Longitudinal outcome in patients with bipolar disorder assessed by life-charting is influenced by DSM-IV personality disorder symptoms

Personality disorder among youth with first episode psychotic mania: An important target for specific treatment?

AIM

Personality disorder is a common co-occurrence ('comorbidity') among patients with bipolar disorder and appears to affect outcome negatively. However, there is little knowledge about the impact of this comorbidity in the early phases of bipolar disorder. We examined the prevalence and effect of personality disorder co-occurrence on outcome in a cohort of youth with first episode mania with psychotic features.

METHODS

Seventy-one first episode mania patients, aged 15-29, were assessed at baseline, 6, 12, and 18 months as part of a randomized controlled trial of olanzapine and chlorpromazine as add-on to lithium in first episode mania with psychotic features. The current study involved secondary analysis of trial data.

RESULTS

A co-occurring clinical personality disorder diagnosis was present in 16.9% of patients. Antisocial and narcissistic personality disorders were the most common diagnoses. Patients with co-occurring personality disorder had higher rates of readmission to hospital, lower rates of symptomatic recovery and poorer functional levels at 6 months, but these differences disappeared after 12 and 18 months.

CONCLUSIONS

In the early phase of bipolar disorder, patients with personality disorder comorbidity display delayed symptomatic and functional recovery and increased likelihood to need hospital readmissions. These observations suggest that routine assessment for personality disorder and specific interventions are important in order to improve short-term treatment efficacy in this subgroup.

Psychoeducation: improving outcomes in bipolar disorder

Background

A relevant paradigm shift in the treatment of bipolar disorder started a few years ago; crucial findings on the usefulness of psychological interventions clearly support switching from an exclusively pharmacological therapeutic approach to a combined yet hierarchical model in which pharmacotherapy plays a central role, but psychological interventions may help cover the gap that exists between theoretical efficacy and “real world” effectiveness. Hereby we review the efficacy of several adjunctive psychotherapies in the maintenance treatment of bipolar patients.

Methods

A systematic review of the literature on the issue was performed, using MEDLINE and CURRENT CONTENTS databases. “Bipolar”, “Psychotherapy”, “Psychoeducation”, “Cognitive-behavioral” and “Relapse prevention” were entered as keywords.

Results

Psychological treatments specifically designed for relapse prevention in bipolar affective disorder are useful tools in conjunction with mood stabilizers. Most of the psychotherapy studies recently published report positive results on maintenance as an add-on treatment, and efficacy on the treatment of depressive episodes. Interestingly, several groups from all over the world reported similar positive results and reached very similar conclusions; almost every intervention tested contains important psychoeducative elements including both compliance enhancement and early identification of prodromal signs — stressing the importance of life-style regularity — and exploring patients' health beliefs and illness-awareness.

Conclusions

The usefulness of psychotherapy for improving treatment adherence and clinical outcome of bipolar patients is nowadays unquestionable, and future treatment guidelines should promote its regular use amongst clinicians. As clinicians, it is our major duty, to offer the best treatment available to our patients and this includes both evidence-based psychoeducation programs and newer pharmacological agents.

Comorbid personality disorders in manic bipolar I disorder patients is associated with increased use of long-acting injectable antipsychotic treatment and higher rates of rehospitalization

Personality disorder comorbidity is considered a poor prognostic factor among bipolar disorder patients. However, an evidence-based pharmacological treatment for this sub-population is lacking, and only few studies investigated the impact of personality disorder on bipolar disorder-I course. Here, we studied the effect of comorbid personality disorder on the administrated psychopharmacotherapy and rehospitalization risk among manic bipolar disorder-I patients. A sample of 340 patients with bipolar disorder-I, who were hospitalized with acute manic episode between 2005 and 2013, were retrospectively followed for a mean duration of 1129 days. Drug treatment at discharge and rehospitalization rates during follow-up time were compared between bipolar disorder-I patients with (n = 55) or without (n = 285) personality disorder comorbidity. Multivariate survival analyses adjusted for covariates were conducted. During the study period, 39.4% of bipolar disorder-I patients were rehospitalized due to a mood episode. Comorbid personality disorder was significantly associated with higher rates of long-acting injectable antipsychotics administration at discharge from hospitalization (adjusted odds ratio 2.66, 95% confidence interval: 1.19-5.94, P = 0.017). Comorbid personality disorder significantly increased the adjusted risk of rehospitalization due to a mood episode (hazard ratio = 2.04, 95% confidence interval: 1.29-3.23, P = 0.002). In conclusion, comorbid personality disorder in manic bipolar disorder-I patients is associated with increased use of long-acting injectable antipsychotics and higher rates of rehospitalization.

Efficacy and Safety of Atypical Antipsychotics in Bipolar Disorder With Comorbid Substance Dependence: A Systematic Review

OBJECTIVES

Bipolar disorder (BD) patients with a comorbid substance use disorder (SUD) are notoriously difficult to treat. Atypical antipsychotics (AAPs) are widely prescribed in BD, but their efficacy in patients with comorbid SUD is still debated. The aim of the present article is to systematically review the literature findings on the efficacy and safety of AAPs in BD patients with comorbid SUD.

METHODS

We searched PubMed to identify original studies focused on the treatment of dual diagnosed BD with AAPs.

RESULTS

Ten articles met our inclusion/exclusion criteria, involving a total of 969 subjects, 906 affected by BD and 793 with comorbid SUD: 4 were randomized controlled trials, 4 were open label trials and 2 were observational studies, published between 2002 and 2017. The most commonly abused substances were alcohol and cocaine. The AAPs used to treat patients were quetiapine (n = 337), asenapine (n = 119), olanzapine (n = 80), risperidone (n = 62), and aripiprazole (n = 48). In terms of safety, AAPs were usually well tolerated. Atypical antipsychotics were usually efficacious on acute mood symptoms, whereas their impact on substance-related issues was reported only in those studies without a placebo comparison.

CONCLUSIONS

According to our results, even though AAPs are widely used and efficacious in treating the clinical symptoms of BD, there are not enough data to suggest their adjunctive benefit on craving and substance consumption.

A Preliminary Probe of Personality Predicting Psychotherapy Outcomes: Perspectives from Therapists and Their Clients

BACKGROUND

It is widely established that personality disorder has as broad negative impact on psychotherapy outcomes. Given the increased emphasis on dimensional traits for personality pathology in the DSM-5 and the proposal for the ICD-11, it is important to understand how traits are linked to treatment outcomes. Building on past research with general traits, we hypothesized that more nuanced and specific relations would be apparent. Furthermore, much of the past research has relied upon self-reports of personality and little is known about how ratings from therapists might be related to outcomes.

SAMPLING AND METHODS

The present paper examined how dimensional traits from the Five-Factor Model predicted outcomes in a case series of 54 therapist-client dyads within a doctoral training clinic. Importantly, this extends past research as dimensional traits were rated by both therapists and clients at intake as well as sequentially over the course of therapy.

RESULTS

Correlations and regression analyses indicated that traits predicted a variety of outcomes including initial engagement in treatment as well as overall symptom reduction across therapy. Specifically, preliminary evidence suggests that therapist-rated conscientiousness at intake was positively related to clients' early engagement in therapy. In addition, openness to experience after the 4th session - particularly as rated by the client - was predictive of long-term therapy outcomes.

CONCLUSIONS

Broadly, these results provided preliminary information about the promise of dimensional models for improving the clinical utility of personality disorder diagnoses. More specifically, these results reinforced the relevance of personality assessment during therapy and indicated the potential predictive value of ratings by therapists and their clients.

Personality disorder symptom severity predicts onset of mood episodes and conversion to bipolar I disorder in individuals with bipolar spectrum disorder

Although personality disorders (PDs) are highly comorbid with bipolar spectrum disorders (BSDs), little longitudinal research has been conducted to examine the prospective impact of PD symptoms on the course of BSDs. The aim of this study is to examine whether PD symptom severity predicts shorter time to onset of bipolar mood episodes and conversion to bipolar I disorder over time among individuals with less severe BSDs. Participants (n = 166) with bipolar II disorder, cyclothymia, or bipolar disorder not otherwise specified completed diagnostic interview assessments of PD symptoms and self-report measures of mood symptoms at baseline. They were followed prospectively with diagnostic interviews every 4 months for an average of 3.02 years. Cox proportional hazard regression analyses indicated that overall PD symptom severity significantly predicted shorter time to onset of hypomanic (hazard ratio [HR] = 1.42; p < .001) and major depressive episodes (HR = 1.51; p < .001) and conversion to bipolar I disorder (HR = 2.51; p < .001), after controlling for mood symptoms. Results also suggested that cluster B severity predicted shorter time to onset of hypomanic episodes (HR = 1.38; p = .002) and major depressive episodes (HR = 1.35; p = .01) and conversion to bipolar I disorder (HR = 2.77; p < .001), whereas cluster C severity (HR = 1.56; p < .001) predicted shorter time to onset of major depressive episodes. These results support predisposition models in suggesting that PD symptoms may act as a risk factor for a more severe course of BSDs. (PsycINFO Database Record

A randomized controlled trial of cognitive debiasing improves assessment and treatment selection for pediatric bipolar disorder

OBJECTIVE

This study examined the efficacy of a new cognitive debiasing intervention in reducing decision-making errors in the assessment of pediatric bipolar disorder (PBD).

METHOD

The study was a randomized controlled trial using case vignette methodology. Participants were 137 mental health professionals working in different regions of the United States (M = 8.6 ± 7.5 years of experience). Participants were randomly assigned to a (a) brief overview of PBD (control condition), or (b) the same brief overview plus a cognitive debiasing intervention (treatment condition) that educated participants about common cognitive pitfalls (e.g., base-rate neglect, search satisficing) and taught corrective strategies (e.g., mnemonics, Bayesian tools). Both groups evaluated 4 identical case vignettes. Primary outcome measures were clinicians' diagnoses and treatment decisions. The vignette characters' race or ethnicity was experimentally manipulated.

RESULTS

Participants in the treatment group showed better overall judgment accuracy, p < .001, and committed significantly fewer decision-making errors, p < .001. Inaccurate and somewhat accurate diagnostic decisions were significantly associated with different treatment and clinical recommendations, particularly in cases where participants missed comorbid conditions, failed to detect the possibility of hypomania or mania in depressed youths, and misdiagnosed classic manic symptoms. In contrast, effects of patient race were negligible.

CONCLUSIONS

The cognitive debiasing intervention outperformed the control condition. Examining specific heuristics in cases of PBD may identify especially problematic mismatches between typical habits of thought and characteristics of the disorder. The debiasing intervention was brief and delivered via the Web; it has the potential to generalize and extend to other diagnoses as well as to various practice and training settings.

Five-year outcome of bipolar I and II disorders: findings of the Jorvi Bipolar Study

OBJECTIVES

The long-term outcome of bipolar disorder (BD) has been extensively investigated. However, previous studies may be biased towards hospitalized patients with bipolar I disorder (BD-I), and generalizability to the current treatment era remains uncertain. In this naturalistic study, we followed a secondary-care cohort of patients with BD.

METHODS

In the Jorvi Bipolar Study, 191 patients with BD-I and bipolar II disorder (BD-II) were followed using a life-chart method. Interviews were conducted at six months, 18 months, and five years. Time to full remission, time to first recurrence, total time ill, their predictors, and BD-I versus BD-II differences were investigated among the 151 patients remaining in follow-up.

RESULTS

Nearly all subjects recovered from the index episode, but almost all (90%) had a recurrence, and most had multiple recurrences. The patients spent about one-third of their time in illness episodes and 15% of their time with subthreshold symptoms; half of the time they were euthymic. After controlling for confounders, no difference in time spent in depressive states between patients with BD-I and BD-II persisted. Among patients with a depressive index phase, cluster C personality disorders [hazard ratio (HR) = 0.452, p = 0.040] and higher 17-item Hamilton Depression Scale score (HR = 0.951, p = 0.022) predicted longer time to remission, whereas lifetime psychotic symptoms (HR = 2.162, p = 0.016) predicted shorter time to first recurrence.

CONCLUSIONS

Among patients with BD, chronicity as uninterrupted persistence of illness was rare, but multiple recurrences were the norm. Patients with BD spent only half of their time euthymic. Patients with BD-I and BD-II may differ little in proneness to depressive states. Severity of depression, cluster C personality disorders, and psychotic symptoms predicted outcome.

Extreme cognitions in bipolar spectrum disorders: associations with personality disorder characteristics and risk for episode recurrence

Bipolar spectrum disorders (BSDs) are often characterized by cognitive inflexibility and affective extremities, including "extreme" or polarized thoughts and beliefs, which have been shown to predict a more severe course of illness. However, little research has evaluated factors that may be associated with extreme cognitions, such as personality disorders, which are often characterized by extreme, inflexible beliefs and are also associated with poor illness course in BSDs. The present study evaluated associations among BSDs, personality disorder characteristics, and extreme cognitions (polarized responses made on measures of attributional style and dysfunctional attitudes), as well as links between extreme cognitions and the occurrence of mood episodes, among euthymic young adults with BSDs (n=83) and demographically matched healthy controls (n=89) followed prospectively for 3years. The relationship between personality disorder characteristics and negative and positive extreme cognitions was stronger among BSD participants than among healthy controls, even after statistically accounting for general cognitive styles. Furthermore, extreme negative cognitions predicted the prospective onset of major depressive and hypomanic episodes. These results suggest that extreme cognitive styles are most common in individuals with BSDs and personality disorder characteristics, and they provide further evidence that extreme negative cognitions may confer risk for mood dysregulation.

Significance of borderline personality-spectrum symptoms among adolescents with bipolar disorder

BACKGROUND

Little is known regarding correlates of borderline personality-spectrum symptoms (BPSS) among adolescents with bipolar disorder (BP).

METHODS

Participants were 90 adolescents, 13-19 years of age, who fulfilled DSM-IV-TR criteria for BP using semi-structured diagnostic interviews. BPSS status was ascertained using the Life Problems Inventory which assessed identity confusion, interpersonal problems, impulsivity, and emotional lability. Analyses compared adolescents with "high" versus "low" BPSS based on a median split.

RESULTS

Participants with high, relative to low, BPSS were younger, and had greater current and past depressive episode severity, greater current hypo/manic episode severity, younger age of depression onset, and reduced global functioning. High BPSS participants were more likely to have BP-II, and had higher rates of social phobia, generalized anxiety disorder, conduct disorder, oppositional defiant disorder, homicidal ideation, assault of others, non-suicidal self-injury, suicidal ideation, and physical abuse. Despite greater illness burden, high BPSS participants reported lower rates of lithium use. The most robust independent predictors of high BPSS, identified in multivariate analyses, included lifetime social phobia, non-suicidal self-injury, reduced global functioning, and conduct and/or oppositional defiant disorder.

LIMITATIONS

The study design is cross-sectional and cannot determine causality.

CONCLUSIONS

High BPSS were associated with greater mood symptom burden and functional impairment. Presence of high BPSS among BP adolescents may suggest the need to modify clinical monitoring and treatment practices. Future prospective studies are needed to examine the direction of observed associations, the effect of treatment on BPSS, and the effect of BPSS as a moderator or predictor of treatment response.

Olanzapine is superior to lamotrigine in the prevention of bipolar depression: a naturalistic observational study

BACKGROUND

Bipolar disorder is a highly recurrent disease and has great impact on the function of patients. Depressive symptoms consist of more than 50% of life time during the illness and may lead to self harm or suicidal behaviors. Little is known about the antidepressant effects of olanzapine, an atypical antipsychotic, as monotherapy despite its indication for preventing manic episodes. In contrast, lamotrigine, a mood stabilizer, has been proven to be effective in preventing depression in patients with bipolar disorder. However, no studies have compared the efficacy between lamotrigine and olanzapine in the maintenance treatment of bipolar disorder. This enriched naturalistic study was implemented to assess the effectiveness of olanzapine and lamotrigine as monotherapy in the prevention of recurrence of bipolar disorder.

METHODS

Patients with bipolar disorder in a euthymic state (Young's Mania Rating Scale (YMRS) score <12, and 21-item Hamilton Depression Rating Scale (HAM-D) score <7) for at least two months, having already received either olanzapine or lamotrigine as the maintenance treatment were recruited. The patients maintained with olanzapine (n = 22) were applied to olanzapine group whereas those maintained with lamotrigine (n = 29) were applied to lamotrigine group. They were followed up for 12 months. Differences in the efficacy between olanzapine and lamotrigine in recurrence prevention were analyzed. The Kaplan-Meier method was used to generate time-to-recurrence curves, and differences between the two groups were compared using the log-rank test.

RESULTS

Olanzapine had a significantly lower recurrence rate of depressive episodes than lamotrigine (20.0% vs. 57.7%, χ2 = 6.62, p = .010). However, olanzapine and lamotrigine had similar mania (15.0% vs. 0%, χ2 = 4.17, p = .075, Fisher's exact test) and any mood episode (35.0% vs. 57.7%, χ2 = 2.33, p = .127) recurrence rates. Olanzapine was significantly superior to lamotrigine in the time to recurrence of depressive episodes (χ2 = 4.55, df = 1, p = .033), but there was no difference in the time to recurrence of any mood episode (χ2 = 1.68, df = 1, p = .195).

CONCLUSIONS

This prospective naturalistic study suggests that olanzapine is more effective than lamotrigine in the prevention of depressive episodes in patients with bipolar disorder. Future large-scale randomized studies are warranted to validate our results.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT01864551.

Personality pathology predicts outcomes in a treatment-seeking sample with bipolar I disorder

We conducted a secondary analysis of data from a clinical trial to explore the relationship between degree of personality disorder (PD) pathology (i.e., number of subthreshold and threshold PD symptoms) and mood and functioning outcomes in Bipolar I Disorder (BD-I). Ninety-two participants completed baseline mood and functioning assessments and then underwent 4 months of treatment for an index manic, mixed, or depressed phase acute episode. Additional assessments occurred over a 28-month follow-up period. PD pathology did not predict psychosocial functioning or manic symptoms at 4 or 28 months. However, it did predict depressive symptoms at both timepoints, as well as percent time symptomatic. Clusters A and C pathology were most strongly associated with depression. Our findings fit with the literature highlighting the negative repercussions of PD pathology on a range of outcomes in mood disorders. This study builds upon previous research, which has largely focused on major depression and which has primarily taken a categorical approach to examining PD pathology in BD.

Emotion perception and executive functioning predict work status in euthymic bipolar disorder

Functional recovery, including return to work, in Bipolar Disorder (BD) lags behind clinical recovery and may be incomplete when acute mood symptoms have subsided. We examined impact of cognition on work status and underemployment in a sample of 156 Euthymic-BD and 143 controls (HC) who were divided into working/not working groups. Clinical, health, social support, and personality data were collected, and eight cognitive factors were derived from a battery of neuropsychological tests. The HC groups outperformed the BD groups on seven of eight cognitive factors. The working-BD group outperformed the not working-BD group on 4 cognitive factors composed of tasks of emotion processing and executive functioning including processing speed and set shifting. Emotion processing and executive tasks were predictive of BD unemployment, after accounting for number of mood episodes. Four cognitive factors accounted for a significant amount of the variance in work status among the BD participants. Results indicate that patients with BD who are unemployed/unable to work exhibit greater difficulties processing emotional information and on executive tasks that comprise a set shifting or interference resolution component as compared to those who are employed, independent of other factors. These cognitive and affective factors are suggested as targets for treatment and/or accommodations.

Insight in bipolar disorder

Although there has been interest in insight in bipolar disorder, research has not been as developed as in schizophrenia. The Medline, Embase, and PsychInfo data bases were searched. The key words used in the search were "bipolar", "mania", "manic", "awareness", and "insight". Books, editorials, letters, and reports on pediatric subjects were excluded. Abstracts or full texts were screened for relevance. Better insight is associated with better adherence to treatment and better outcomes. Impairments of executive functions and memory, as well as higher severity of psychotic symptoms, are associated with impairments of insight. Insight is more impaired during an illness episode than during remission, in mixed than in pure manic episodes, in bipolar II than in bipolar I patients, in pure mania than in bipolar or unipolar depression. Psychosocial treatments improve insight and outcomes. There is a need for integration of quantitative assessment methods and their introduction into research and clinical practice.

Long-term impact of the life goals group therapy program for bipolar patients

BACKGROUND

Psychoeducation added to biological treatment enhances overall effectiveness in bipolar disorders. Here, we evaluated the long-term impact of a 2-phase structured psycho-educative group program (Life Goals Program or LGP) for bipolar patients, on parameters such as number and length of hospitalizations, mood stability, relapse prevention and social relationships.

METHODS

Eighty-five patients (55 females, 30 males) with bipolar disorder (48 bipolar I, 37 bipolar II) were included retrospectively. Fifty patients participated in phase 1 and 35 participated in phases 1 and 2 of the LGP. Impact on the number and cumulative length of hospitalization was evaluated by comparing the 3-year period before and after participation in phase 1 (6 weeks) or phases 1 and 2 (median duration 24 months, range 3-74).

RESULTS

Number of hospitalizations significantly decreased from the 3-year period before to the 3-year period after participation in phase 1 only (p=0.017), as well as participation in both phases (p=0.035). After attending phase 1 or phases 1 and 2, a majority of participants reported subjective improvement in mood stability, efficient prevention of relapse and better coping with relapse. Perceived improvement of social relationships was significantly higher for patients who attended phases 1 and 2 than for participants in phase 1 only.

LIMITATIONS

Uncontrolled retrospective study design.

CONCLUSIONS

Results suggest that both phase 1 only and the full 2-phase LGP have long-term positive effects on the number of hospitalizations, mood stability and relapse prevention.

Descriptive study of the occupational outcome of bipolar patients

INTRODUCTION

The purpose of this study was to describe the occupational outcome of bipolar patients 3 years after being hospitalized in a psychiatry department, and the determinants of this outcome.

METHODS

One hundred and one bipolar patients consecutively hospitalized between 1st January 2002 and 31st December 2003, were recruited. Their occupations and medical items were assessed at baseline from the medical records and reassessed 3 years later, using a questionnaire on their work and treatment, and a quality of life scale. Occupational outcome was compared by univariate and multivariate analyses.

RESULTS

Of the 101 patients initially recruited, 36 were excluded and 34 were lost to follow-up. Among the 31 bipolar patients included in the study, 58.1% were working in 2003 and 54.8% were working in 2006. The presence of a personality disorder was significantly associated with a poorer occupational outcome and a lower rate of "return to work".

CONCLUSION

More than half of a population of hospitalized bipolar patients was employed. The presence of a personality disorder appeared to be a pejorative factor for "return to work", although other studies are needed to define the factors that determine the occupational outcome of bipolar patients.

Preliminary results of a fine-grain analysis of mood swings and treatment modalities of bipolar I and II patients using the daily prospective life-chart-methodology

OBJECTIVE

The study aimed to increase the knowledge about the detailed course differences between different forms of bipolar disorder.

METHOD

Using the prospective life-chart-clinician version, we compared the fine-grain analysis of mood swings and treatment modalities of 18 bipolar II with 31 bipolar I patients.

RESULTS

During an observational period of a mean of 26 months we observed an increase of euthymic days, and a decrease of (sub)depressive and (hypo)manic days. Days in a (sub)depressed state were more frequent than days of (hypo)mania as well as days of subdepression or hypomania in comparison to days of full-blown depression or mania. Bipolar II patients showed an increase in hypomanic days receiving more frequently antidepressants. Bipolar I patients, with a decrease of manic days, were significantly taking more often mood stabilizers.

CONCLUSION

Treatment in a specialized bipolar clinic improves the overall outcome, but bipolar II disorder seems to be still treated sub-optimally with a possible iatrogenic increase of hypomanic days.

Commonalities and differences in characteristics of persons at risk for narcissism and mania

Clinicians have long noted overlap in some of the key features of narcissism and bipolar disorder, including excessively high goals and impulsivity. In addition, empirical findings consistently document high levels of comorbidity between the two conditions. To better understand the similarities and differences in psychological qualities associated with mania- and narcissism-related vulnerabilities, we administered to 233 undergraduates a broad range of measures pertaining to goals and affects (both their experience and their dysregulation) and impulsivity. As hypothesized, tendencies toward both narcissism and hypomania related to elevations on measures of affective and goal dysregulation. In addition, hypomania tendencies were related to higher impulsivity, but that association did not appear for narcissistic tendencies. Results highlight key commonalities and differences between those at risk for mania versus narcissism. Future research should examine these relationships in clinically diagnosed samples.

Inter-rater agreement of comorbid DSM-IV personality disorders in substance abusers

BACKGROUND

Little is known about the inter-rater agreement of personality disorders in clinical settings.

METHODS

Clinicians rated 75 patients with substance use disorders on the DSM-IV criteria of personality disorders in random order, and on rating scales representing the severity of each.

RESULTS

Convergent validity agreement was moderate (range for r = 0.55, 0.67) for cluster B disorders rated with DSM-IV criteria, and discriminant validity was moderate for eight of the ten personality disorders. Convergent validity of the rating scales was only moderate for antisocial and narcissistic personality disorder.

DISCUSSION

Dimensional ratings may be used in research studies and clinical practice with some caution, and may be collected as one of several sources of information to describe the personality of a patient.

Clinical variables and implications of the personality on the outcome of bipolar illness: a pilot study

Outcome in bipolar patients is affected by comorbidity. Comorbid personality disorders are frequent and may complicate the course of bipolar illness. This pilot study examined a series of 40 euthymic bipolar patients (DSM-IV criteria) (bipolar I disorder 31, bipolar II disorder 9) to assess the effect of clinical variables and the influence of comorbid personality on the clinical course of bipolar illness. Bipolar patients with a diagnosis of comorbid personality disorder (n = 30) were compared with "pure" bipolar patients (n = 10) with regard to demographic, clinical, and course of illness variables. Comorbid personality disorder was diagnosed in 75% of patients according to ICD-10 criteria, with obsessive-compulsive personality disorder being the most frequent type. Sixty-three per cent of subjects had more than one comorbid personality disorder. Bipolar patients with and without comorbid personality disorder showed no significant differences regarding features of the bipolar illness, although the group with comorbid personality disorder showed a younger age at onset, more depressive episodes, and longer duration of bipolar illness. In subjects with comorbid personality disorders, the number of hospitalizations correlated significantly with depressive episodes and there was an inverse correlation between age at the first episode and duration of bipolar illness. These findings, however, should be interpreted taking into account the preliminary nature of a pilot study and the contamination of the sample with too many bipolar II patients.

Social adjustment based on reported behaviour in bipolar affective disorder

OBJECTIVES

To determine the effects of mood and additional clinical variables on different domains of current interviewer-rated social adjustment reflecting the reported behaviour of patients with bipolar disorder (BD).

METHOD

Multi-center cross-sectional study employing multiple linear regression to investigate whether mood and other clinical features, previously linked to self-rated social adjustment, were associated with eight domains of interviewer-rated social adjustment in 253 BD patients. Baseline variables were entered sequentially in blocks representing current mood, demographic, current other psychiatric, past psychiatric and current treatment variables.

RESULTS

Mood episode or symptoms together with five other variables (borderline/antisocial personality disorder, male gender, living alone, hypnotic drug and drugs for physical illness) were associated with impairment on two or more domains of interviewer-rated social adjustment. They explained up to 31% of the variance in social adjustment, although friction, dependence and overactivity were associated with a different pattern of variables. Hypomanic symptoms were associated with increased friction and worse social adjustment with the extended family in the whole sample but improved performance and social and leisure activities in patients who were not in acute bipolar episode.

CONCLUSION

Clinicians may determine up to about 30% of outcome in current social adjustment in BD patients from the patient's current mood episode or symptoms and a small number of other clinical or demographic variables. Hypomanic episodes and symptoms usually worsen friction and overall social adjustment, but in patients who are not in acute episode, hypomanic symptoms can increase performance and social and leisure activities.

Comorbid personality disorders in subjects with bipolar I disorder

Objective. The purpose of this study was to present the frequencies of personality disorders in a sample of bipolar I patients and to investigate whether the presence of comorbid personality disorders affect the course of bipolar illness.

METHODS

Seventy euthymic bipolar I patients were assessed using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID II). Bipolar patients with comorbid personality disorder were compared with those of without personality disorder comorbidity on demographic and clinical variables.

RESULTS

Forty bipolar I patients (57%) had at least one comorbid personality disorder. The most common personality disorder cluster was cluster C (36%), followed by cluster B (17%) and cluster A (17%) personality disorders. The most prevalent personality disorder in the whole group was obsessive-compulsive personality disorder (21%). Patients with comorbid personality disorders had an earlier age of onset than those of without comorbidity.

CONCLUSION

Although the rates of comorbid personality disorders are high in bipolar I patients, the presence of comorbidity has no relevant impact on the course of bipolar I patients except for earlier age of onset of bipolar I disorder.

Rating of personality disorder features in popular movie characters

BACKGROUND

Tools for training professionals in rating personality disorders are few. We present one such tool: rating of fictional persons. However, before ratings of fictional persons can be useful, we need to know whether raters get the same results, when rating fictional characters.

METHOD

Psychology students at the University of Copenhagen (N = 8) rated four different movie characters from four movies based on three systems: Global rating scales representing each of the 10 personality disorders in the DSM-IV, a criterion list of all criteria for all DSM-IV personality disorders in random order, and the Ten Item Personality Inventory for rating the five-factor model. Agreement was estimated based on intraclass-correlation.

RESULTS

Agreement for rating scales for personality disorders ranged from 0.04 to 0.54. For personality disorder features based on DSM-IV criteria, agreement ranged from 0.24 to 0.89, and agreement for the five-factor model ranged from 0.05 to 0.88. The largest multivariate effect was observed for criteria count followed by the TIPI, followed by rating scales. Raters experienced personality disorder criteria as the easiest, and global personality disorder scales as the most difficult, but with significant variation between movies.

CONCLUSION

Psychology students with limited or no clinical experience can agree well on the personality traits of movie characters based on watching the movie. Rating movie characters may be a way to practice assessment of personality.

Evidence-based research on the efficacy of psychologic interventions in bipolar disorders: a critical review

Although pharmacotherapy is the mainstay of treatment strategies for bipolar disorder, research over the last 5 years suggests that combining psychologic interventions with drug treatment increases overall effectiveness, mostly by further protecting from relapse or recurrence. We aimed at critically examining the relevance and effectiveness of psychosocial approaches to bipolar illness by doing a systematic review of the current literature. Currently, most studies show that patients receiving psychologic treatments have significantly fewer relapses, reduced hospitalization rates, and increased treatment adherence. Psychoeducation, family-focused psychoeducation, and cognitive-behavioral therapy seem to be the most efficacious interventions in the prophylaxis from recurrences in medicated bipolar patients. Recent studies have shown that psychologic approaches do not have the same "weight" in all bipolar patients. Pharmacologic treatment and psychologic interventions are complementary and share many goals, such as avoiding recurrences and improving clinical outcome. A wise combination of these two approaches may help bipolar patients to achieve a better symptomatic and functional recovery. Further research should focus on determining the therapeutic value of each ingredient of the tested psychologic interventions.

Acute treatment outcomes in patients with bipolar I disorder and co-morbid borderline personality disorder receiving medication and psychotherapy

OBJECTIVE

Patients suffering from both bipolar I disorder and borderline personality disorder (BPD) pose unique treatment challenges. The purpose of this matched case-control study was to compare acute treatment outcomes of a sample of patients who met standardized diagnostic criteria for both bipolar I disorder and BPD (n = 12) to those who met criteria for bipolar I disorder only (n = 58).

METHOD

Subjects meeting criteria for an acute affective episode were treated with a combination of algorithm-driven pharmacotherapy and weekly psychotherapy until stabilization (defined as four consecutive weeks with a calculated average of the 17-item version of the Hamilton Rating Scale for Depression and Bech-Rafaelsen Mania scale totaling < or = 7).

RESULTS

Only three of 12 (25%) bipolar-BPD patients achieved stabilization, compared with 43 of 58 (74%) bipolar-only patients. Two of the three bipolar-BPD patients who did stabilize took over 95 weeks to do so, compared with a median time-to-stabilization of 35 weeks in the bipolar-only group. The bipolar-BPD group received significantly more atypical mood-stabilizing medications per year than the bipolar-only group (Z = 4.3, p < 0.0001). Dropout rates in the comorbid group were high.

CONCLUSIONS

This quasi-experimental study suggests that treatment course may be longer in patients suffering from both bipolar I disorder and BPD. Some patients improved substantially with pharmacotherapy and psychotherapy, suggesting that this approach is worthy of further investigation.

Recent developments in the treatment of bipolar disorders

Recently, many new therapeutic options have become available for the treatment of bipolar disorder. Most of these options are agents originally developed to treat other conditions, such as anticonvulsants and antipsychotics. Some older agents have also been rediscovered or reformulated. New drug combinations and treatment strategies have enabled a more comprehensive treatment of the spectrum of bipolar symptoms, as well as bipolar disorder complicated by a range of comorbidities, to be targeted. A growing range of novel therapeutic options for the treatment of bipolar disorder is under investigation. This paper summarises some of the data regarding these potential therapeutic options.

Psychiatric and medical comorbidities of bipolar disorder

OBJECTIVES

This review summarizes the literature on psychiatric and medical comorbidities in bipolar disorder. The coexistence of other Axis I disorders with bipolar disorder complicates psychiatric diagnosis and treatment. Conversely, symptom overlap in DSM-IV diagnoses hinders definition and recognition of true comorbidity. Psychiatric comorbidity is often associated with earlier onset of bipolar symptoms, more severe course, poorer treatment compliance, and worse outcomes related to suicide and other complications. Medical comorbidity may be exacerbated or caused by pharmacotherapy of bipolar symptoms.

METHODS

Articles were obtained by searching MEDLINE from 1970 to present with the following search words: bipolar disorder AND, comorbidity, anxiety disorders, eating disorder, alcohol abuse, substance abuse, ADHD, personality disorders, borderline personality disorder, medical disorders, hypothyroidism, obesity, diabetes mellitus, multiple sclerosis, lithium, valproate, lamotrigine, carbamazepine, atypical antipsychotics. Articles were prioritized for inclusion based on the following considerations: sample size, use of standardized diagnostic criteria and validated methods of assessment, sequencing of disorders, quality of presentation.

RESULTS

Although the literature establishes a strong association between bipolar disorder and substance abuse, the direction of causality is uncertain. An association is also seen with anxiety disorders, attention-deficit/hyperactivity disorder, and eating disorders, as well as cyclothymia and other axis II personality disorders. Medical disorders accompany bipolar disorder at rates greater than predicted by chance. However, it is often unclear whether a medical disorder is truly comorbid, a consequence of treatment, or a combination of both.

CONCLUSION

To ensure prompt, appropriate intervention while avoiding iatrogenic complications, the clinician must evaluate and monitor patients with bipolar disorder for the presence and the development of comorbid psychiatric and medical conditions. Conversely, physicians should have a high index of suspicion for underlying bipolar disorder when evaluating individuals with other psychiatric diagnoses (not just unipolar depression) that often coexist with bipolar disorder, such as alcohol and substance abuse or anxiety disorders. Anticonvulsants and other mood stabilizers may be especially helpful in treating bipolar disorder with significant comorbidity.

[Improving the outcome of bipolar disorder through non-pharmacological strategies: the role of psychoeducation]

The present paper addresses the efficacy of psychoeducation and related strategies in bipolar disorders. Recently, several randomised clinical trials have shown the efficacy of psychological interventions--namely identification of prodromal signs, cognitive-behavioral therapy, psychoeducation and family-focused interventions--as a prophylactic add-on to medication. All these studies are presented hereby, together with the pioneer studies in the field. There are several topics that every psychoeducational program should include to ensure its usefulness, and they will be summarized in twelve points. Roughly, psychoeducation should contain general information about bipolar illness, compliance enhancement elements, teaching on early recognition of relapses and lifestyle regularity issues. Nowadays, several treatment guidelines include psychoeducation as a crucial prophylactic tool. Clinicians should be aware of this and start performing psychoeducation in their everyday clinical practice.

Psychoeducation in bipolar patients with comorbid personality disorders

BACKGROUND

The co-occurrence of personality and bipolar disorders is quite common. Bipolar patients with personality disorders have been described as having poorer outcome than 'pure' bipolar patients. However, from a combined-approach point of view, a little has been done to improve the course of these patients. Psychoeducation has shown its efficacy in the prevention of relapses in the bipolar population but, to date, no data is available on its efficacy in the management of bipolar patients with personality disorders.

METHOD

The present study shows a subanalysis from a single-blind randomized prospective clinical trial on the efficacy of group psychoeducation in bipolar I patients. Bipolar patients fulfilling DSM-IV criteria for any personality disorder were randomized to either psychoeducational treatment or a non-structured intervention. There were 22 patients in the control group and 15 in the psychoeducation group. All patients received naturalistic pharmacological treatment as well. The follow-up phase comprised 2 years where all patients continued receiving naturalistic treatment without psychological intervention and were assessed monthly for several outcome measures.

RESULTS

At the end of the follow-up phase (2 years), a 100% of control group patients fulfilled criteria for recurrence versus a 67% in the psychoeducation group (p < 0.005). Patients included in the psychoeducation group had a higher time-to-relapse and a significantly lower mean number of total, manic and depressive relapses. No significant differences regarding the number of patients who required hospitalization were found but the mean duration of days spent in the hospitalization room was significantly higher for the patients included in the control group.

CONCLUSION

Psychoeducation may be a useful intervention for bipolar patients with comorbid personality disorders. Further studies should address the efficacy of specifically tailored interventions for this common type of patients.

The boundary between borderline personality disorder and bipolar disorder: current concepts and challenges

OBJECTIVE

The boundary between borderline personality disorder (BPD) and bipolar disorder (BD) is a controversial subject. Clinically, it can be difficult to diagnose patients who present with both affective instability and impulsivity. This paper reviews concepts and challenges related to the overlap of these disorders.

METHODS

A Medline search was conducted, using the key words borderline personality disorder, bipolar disorder, affective disorder, and personality disorder. Reference lists from articles generated were also used. Publications from the last 20 years were considered.

RESULTS

Studies demonstrate a greater cooccurrence between these 2 disorders than between BPD and other Axis I disorders or between BD and other Axis II disorders. Some authors suggest that many patients diagnosed with BPD are better described as having BD, that the bipolar classification is too narrow, or that BPD should be considered a variant of affective disorders. Others present evidence supporting BPD as a valid construct. Hypotheses about the relation between the 2 disorders and suggestions for clinical practice are offered.

CONCLUSIONS

There appears to be sufficient evidence to consider BPD to be a valid diagnosis. Both disorders apply to heterogeneous populations, and their characteristics require further clarification. In diagnostically challenging situations, careful consideration of a patient's longitudinal history is essential. Future research will be important to ensure that our diagnostic classifications reflect clinically useful entities.

Is borderline personality disorder part of the bipolar spectrum?

In recent years, advances in the areas of both bipolar and borderline personality disorders have generated considerable interest in the clinical interface between these two conditions. Developments in the study of the neurobiology of borderline personality disorder suggest that many patients with this diagnosis have etiological features in common with those diagnosed with bipolar disorders. This claim is supported by new insights into the phenomenology of both disorders and by evidence that mood stabilizers are efficacious in the pharmacological management of borderline patients. This area of research is an important one because of the considerable morbidity and public health costs associated with borderline personality disorder. Since borderline patients can be so challenging to care for, it may be that a reframing of the disorder as belonging to the broad clinical spectrum of bipolar disorders holds benefits for patients and clinicians alike.