Bipolar vs. borderline - diagnosis is prognosis once again

Number of episodes in bipolar disorder: The case for more thoughtful conceptualization and measurement

OBJECTIVES

Number of mood episodes (NoE) may be an important prognostic indicator in bipolar disorder, with implications for treatment. However, NoE has been conceptualized and measured inconsistently throughout the literature. This review examines the construct of NoE in bipolar disorder, with the aim of enhancing its conceptualization and measurement.

METHODS

A critical evaluation of literatures on important correlates of NoE, conceptually and phenomenologically overlapping features, and previous studies considering and measuring this construct was undertaken.

RESULTS

The literature indicates that despite frequent use, NoE has been inconsistently defined and measured. Multiple studies have linked NoE with important clinical factors, including relapse, functioning, cognitive impairment and the effectiveness of both pharmacological and psychosocial interventions, yet conclusions are limited by its inconsistent treatment. Additionally, it seems evident that that NoE may best be treated as a fuzzy construct (rather than precise figure), with yet to be defined overlaps with clinical variables such as age at onset and severity. Attempts to measure this construct have varied in comprehensiveness and structure.

CONCLUSIONS

The NoE construct may have important implications for individuals with bipolar disorders. However, more consistent and systematic definition and assessment of NoE is required to advance this literature and clarify its role. Recommendations aimed at advancing the conceptualization and the measurement of NoE are provided. Conceptualization may be advanced by considering and exploring relationships between NoE and factors with which it overlaps, while measurement may best be improved with increased consistency and balancing accuracy with feasibility.

Patterns of response to antidepressants in major depressive disorder: Drug resistance or worsening of depression are associated with a bipolar diathesis

Resistance and worsening of depression in response to antidepressants (ADs) are major clinical challenges. In a large international sample of patients with major depressive disorder (MDD), we aim to explore the possible associations between different patterns of response to ADs and bipolarity. A total of 2811 individuals with a major depressive episode (MDE) were enrolled in the BRIDGE-II-MIX study. This post-hoc analysis included only 1329 (47%) patients suffering from MDD. Patients with (TRD-MDD, n = 404) and without (NTRD-MDD, n = 925) history of resistance to AD treatment and with (n = 184) and without (n = 1145) previous AD-induced irritability and mood lability (AIM) were compared using Chi-square, t-Student's test and logistic regression models. TRD-MDD patients resulted significantly associated with higher rates of AIM, psychotic features, history of suicide attempts, emotional lability and impulsivity, comorbid borderline personality disorder and polipharmacological treatment, compared to NTRD-MDD group. In comparison to NAIM-MDD patients, subjects in the AIM-MDD group showed significantly higher rates of first-degree family history for BD, previous TRD, atypical features, mixed features, psychiatric comorbidities, lifetime suicide attempts and lower age at first psychiatric symptoms. In addition, patients with AIM presented more often almost all the hypomanic symptoms evaluated in this study. Among these latter symptoms, logistic regressions showed that distractibility, impulsivity and hypersexuality were significantly associated with AIM-MDD. In conclusion, in MDD patients, a lifetime history of resistance and/or irritability/mood lability in response to ADs was associated with the presence of mixed features and a possible underlying bipolar diathesis.

Unblending Borderline Personality and Bipolar Disorders

Borderline Personality (BPD) and Bipolar (BP) disorders stimulate an academic debate between their distinction and the inclusion of Borderline in the Bipolar spectrum. Opponents to this inclusion attribute the important differences and possible diagnostic incomprehension to overlapping symptoms. We tested 248 Borderline and 113 Bipolar patients, consecutively admitted to the Psychiatric Unit, through DSM-IV Axis I and II Disorders (SCID-I/II), Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Young Mania Rating Scale (YMRS) and Borderline Personality Disorder Severity Index-IV (BPDSI-IV). All the tests statistically discriminated the disorders (p < 0.0001). Overlapping symptoms resulted significantly different (impulsivity = 5.32 in BPD vs 1.55 in BP, p < 0.0001; emotional instability = 7.11 in BPD vs 0.55 in BP, p < 0.0001) and the range of their scores gives the opportunity for an even more precise discrimination. Distinctive traits (e.g. irritability or sexual arousal) are also discussed in order to try to qualify the core of these disorders to a higher degree. Comorbidity proves to be extremely small (3.6%). However, Borderline patients with manic features offer a privileged point of view for a deeper analysis. This allows for the possibility of a more precise examination of the nature and load of each symptom. Borderline Personality and Bipolar Disorders can be distinguished with high precision using common and time-sparing tests. The importance of discriminating these clinical features may benefit from this evidence.