The influence of borderline personality traits on clinical outcomes in bipolar disorder

Comparing suicide completion rates in bipolar I versus bipolar II disorder: A systematic review and meta-analysis

BACKGROUND

Bipolar disorder (BD) has a high disease burden and the highest mortality risk in BD comes from suicide. Bipolar disorder type II (BD-II) has been described as a milder form of bipolar disorder; however, extant literature is inconsistent with this description and instead describe illness burden and notably suicidality comparable to persons with bipolar I disorder (BD-I). Towards quantifying the hazard of BD-II, herein we aim via systematic review and meta-analysis to evaluate the rates of completed suicide in BD-I and BD-II.

METHOD

We conducted a literature search on PubMed, OVID (Embase, Medline) and PsychINFO databases from inception to June 30th, 2023, according to PRISMA guidelines. Articles were selected based on the predetermined eligibility criteria. A meta-analysis was performed, comparing the risk of completed suicide between individuals diagnosed with BD-I to BD-II.

RESULTS

Four out of eight studies reported higher suicide completion rates in persons living with BD-II when compared to persons living with BD-I; however, two of the studies reported non-significance. Two studies reported significantly higher suicide completion rates for BD-I than BD-II. The pooled odds ratio of BD-II suicide rates to BD-I was 1.00 [95 % CI = 0.75, 1.34].

LIMITATIONS

The overarching limitation is the small number of studies and heterogeneity of studies that report on suicide completion in BD-I and BD-II.

CONCLUSION

Our study underscores the severity of BD-II, with a risk for suicide not dissimilar from BD-I. The greater propensity to depression, comorbidity and rapid-cycling course reported in BD-II are contributing factors to the significant mortality hazard in BD-II.

The Epidemiological, Clinical, and Therapeutic Profile of Bipolar Patients in Eastern Morocco

INTRODUCTION

 Bipolar disorder is a severe psychiatric disorder. The objective of our study is to describe the epidemiological, clinical, and therapeutic profile of patients followed for bipolar disorder in this hospital.

MATERIALS AND METHODS

This is a cross-sectional, descriptive study conducted over a period of two years within the mental health and psychiatric diseases department of the Mohammed VI University Hospital in Oujda, Morocco, including 206 patients followed for bipolar disorder on an outpatient basis or hospitalized in one of the departments of the hospital.

RESULTS

We included in our study 206 patients with an average age of 37.34+/-12.53 and a male predominance. About 17% of our patients reported a personal medical history and 18.4%, a personal surgical history. Regarding the family history, 40.3% have a medical and surgical history and 63.1%, a psychiatric family history. The consumption of psychoactive substances is present in 49.5% of our patients. About 26.7% reported psychological trauma during childhood. Our patients have reported a history of suicide attempts with a prevalence of 26.6% in several settings: depressive (15%), delusional (5.8%), hallucinatory (3.9%), and anxious (1.9%). Several means were used during these suicide attempts, in particular, defenestration (40%), drug ingestion (36.4%), caustic ingestion (16.4%), strangulation (16.4%), and hanging (10.9%).

CONCLUSION

 It is important to develop a personalized approach to the patient wherever possible and, if necessary, to involve other specialists in diagnosis and treatment.

Brexpiprazole Attenuates Aggression, Suicidality and Substance Use in Borderline Personality Disorder: A Case Series

Background: Borderline personality disorder (BPD) is a heterogeneous and highly comorbid disorder. Suicidality, aggression and substance abuse are common presentations of BPD. Our case series is the first to highlight the role of brexpiprazole in improving these symptoms in patients with BPD. Case presentation: We describe three cases demonstrating the role of brexpiprazole in improving BPD's prominent features and comorbidities. All cases improved when brexpiprazole was added to their treatment regime. Case 1: A 26-year-old woman who was diagnosed with BPD and cyclothymia, presented to the psychiatric emergency unit with impulsive suicidal behaviour. Case 2: A 43-year-old woman suffering from BPD sought help due to her violent behaviour and emotional dysregulation. Case 3: A 22-year-old woman with underlying attention deficit and hyperactivity disorder, polysubstance use disorder and BPD presented with dysregulated emotions. Conclusions: Our case series provides anecdotal evidence of the potential role of brexpiprazole in attenuating suicidality, aggression and substance abuse in patients with BPD. We postulate that brexpiprazole's high affinity for the 5HT1A/5HT2A receptors, coupled with its low intrinsic effect on the D2/D3 receptor system, is fundamental in its actions to stabilise the aberrant dopaminergic and serotonergic signalling in BPD. Future research should focus on well-designed clinical trials investigating the efficacy of brexpiprazole in patients with BPD.

Endoxifen in Treatment of Individuals with Borderline Personality Disorder with Predominant Impulsivity: A Case Series

Endoxifen, a protein kinase C inhibitor, has been approved for use in manic episodes in India. One of the symptom traits that it predominantly targets is impulsivity. Impulsivity can also be a symptom dimension of other mental health conditions, one of which is Borderline Personality Disorder (BPD). Management of BPD is challenging, with limited pharmacological options that are symptom-directed and psychotherapy sessions that are fraught with early dropouts and lack of compliance. Impulsive behaviors represent a major reason for seeking help in BPD, especially with regard to non-suicidal self-injury, substance abuse, high-risk sexual behavior, aggression, etc. Here, we present a case series comprising five individuals with a diagnosis of BPD whose treatment regimens were changed and endoxifen added at a dose of 8 mg once daily. Clinical improvement was monitored using the Borderline Evaluation of Severity Over Time (BEST). All the subjects improved in the impulsivity domains as well as with regard to attention deficits, mood fluctuations, and overall functioning. Endoxifen is thus potential promising in terms of the management of BPD, but needs more extensive study to fully substantiate its clinical benefits.

Short term ketamine treatment in patient with bipolar disorder with comorbidity with borderline personality disorder: Focus on impulsivity

OBJECTIVES

Borderline personality disorder (BPD) and bipolar disorder (BD) often co-occur and frequently do not respond adequately to traditional antidepressant treatments. Ketamine has shown rapid antidepressant and anti-suicidal effects. However, there is limited literature on the safety and tolerance of using ketamine to treat patients with comorbid BD and BPD.

METHODS

This case presents a female patient diagnosed with both Bipolar Disorder (BD) and Borderline Personality Disorder (BPD) who received intravenous ketamine treatment to alleviate acute depressive symptoms.

RESULTS

Initially, ketamine ameliorated depressed symptoms. However, as the ketamine treatment continued, the patient showed an increase in nonsuicidal self-injury (NSSIs) and impulsive conduct with a aggravation of dissociative symptoms. As a result, intravenous ketamine was discontinued, and the patient received the medication, which proved helpful.

CONCLUSIONS

Although ketamine presents antidepressant properties, reports on its impact on emotional dysregulation and impulsive conduct are unclear and not alike to its antidepressant effect. Therefore, there is a need for more studies investigating the effectiveness and safety of this rapid-acting medicine in this patient population.

Heterogeneous early illness courses of Korean patients with bipolar disorders: replication of the staging model

BACKGROUND

Clinical staging of bipolar disorder (BD) requires application of real-world data, as the next step in hypothesis. This study used the staging model to analyze the long-term course of BD in Korean patients based on clinical features and treatment responses to map the progression of bipolar illness from its early phase after the onset of illness.

METHODS

A total of 136 patients diagnosed with BD-I (n = 62) or BD-II (n = 74) were recruited. Their progressive stages were retrospectively evaluated. A multi-state model was used to calculate the probability of progression to each stage. Hazard ratios of covariates expected to influence different courses of BD were calculated. Using the Alda score, long-term responses to mood stabilizers depending on the current stage were compared.

RESULTS

Several sub-populations showed varied courses during the first five years after the onset of illness, with 41.5% remaining in stage 2 and 53% progressing to higher stages with shortened time for transition. Profiles of patients with BD-I and BD-II were different, suggesting biologically distinct groups. Comorbid psychiatric disorders, such as obsessive-compulsive disorder (OCD) and bulimia nervosa (BN) were associated with a recurrent course (stage 3a or 3b) or a malignant course (stage 3c or 4). Early age of onset, shorter duration of illness, older age at the start of medication, and poor response to lithium affected the illness progression.

CONCLUSION

We were able to apply the stage model based on episode recurrence patterns in early illness courses of Korean patients with BD. The stage progression pattern differed from the early phase in BD-I and BD-II patients. Psychotic comorbidity, age at onset, age at starting psychiatric treatment showed associations with the illness progression.

The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management

Bipolar disorder is heterogeneous in phenomenology, illness trajectory, and response to treatment. Despite evidence for the efficacy of multimodal-ity interventions, the majority of persons affected by this disorder do not achieve and sustain full syndromal recovery. It is eagerly anticipated that combining datasets across various information sources (e.g., hierarchical "multi-omic" measures, electronic health records), analyzed using advanced computational methods (e.g., machine learning), will inform future diagnosis and treatment selection. In the interim, identifying clinically meaningful subgroups of persons with the disorder having differential response to specific treatments at point-of-care is an empirical priority. This paper endeavours to synthesize salient domains in the clinical characterization of the adult patient with bipolar disorder, with the overarching aim to improve health outcomes by informing patient management and treatment considerations. Extant data indicate that characterizing select domains in bipolar disorder provides actionable information and guides shared decision making. For example, it is robustly established that the presence of mixed features - especially during depressive episodes - and of physical and psychiatric comorbidities informs illness trajectory, response to treatment, and suicide risk. In addition, early environmental exposures (e.g., sexual and physical abuse, emotional neglect) are highly associated with more complicated illness presentations, inviting the need for developmentally-oriented and integrated treatment approaches. There have been significant advances in validating subtypes of bipolar disorder (e.g., bipolar I vs. II disorder), particularly in regard to pharmacological interventions. As with other severe mental disorders, social functioning, interpersonal/family relationships and internalized stigma are domains highly relevant to relapse risk, health outcomes, and quality of life. The elevated standardized mortality ratio for completed suicide and suicidal behaviour in bipolar disorder invites the need for characterization of this domain in all patients. The framework of this paper is to describe all the above salient domains, providing a synthesis of extant literature and recommendations for decision support tools and clinical metrics that can be implemented at point-of-care.

Why might bipolar disorder and borderline personality disorder be bonded?

The prevalence of comorbid bipolar disorder (BD) and borderline personality disorder (BPD) is distinctly higher in community samples than would be expected if the two conditions are independent. While there have been multiple explanations suggested for their interdependence, no clear model has been established. This paper reviews a broader set of explanations than considered previously, where relevant prevalence studies of the conditions are reported, previous explanations overviewed, and additional potential linkage causes are considered. It was found that there is unlikely to be any single determinant of the comorbid presence of BD and BPD. The most likely candidates are the artefactual impact of transdiagnostic features, with true comorbid status reflecting both pleiotropic genetic influences and environmental factors. Measurement errors in diagnostic assignment emerging from transdiagnostic features are likely to have clouded previous studies and therefore the interpretations. Comorbid BD/BPD is likely to be distinctly more common than estimated by clinicians, and clarification of the reasons why this is may well assist clinical management.

Are personality disorders in bipolar patients more frequent in the US than Europe?

OBJECTIVE

Bipolar patients in the United States (US) compared to those from the Netherlands and Germany (here abbrev. as "Europe") have more Axis I comorbidities and more poor prognosis factors such as early onset and psychosocial adversity in childhood. We wished to examine whether these differences also extended to Axis II personality disorders (PDs).

METHODS

793 outpatients with bipolar disorder diagnosed by SCID gave informed consent for participating in a prospective longitudinal follow up study with clinician ratings at each visit. They completed detailed patient questionnaires and a 99 item personality disorder inventory (PDQ-4). US versus European differences in PDs were examined in univariate analyses and then logistic regressions, controlling for severity of depression, age, gender, and other poor prognosis factors.

RESULTS

In the univariate analysis, 7 PDs were more prevalent in the US than in Europe, including antisocial, avoidant, borderline, depressive, histrionic, obsessive compulsive, and schizoid PDs. In the multivariate analysis, the last 4 of these PDs remained independently greater in the US than Europe.

CONCLUSIONS

Although limited by use of self report and other potentially confounding factors, multiple PDs were more prevalent in the US than in Europe, but these preliminary findings need to be confirmed using other methodologies. Other poor prognosis factors are prevalent in the US, including early age of onset, more childhood adversity, anxiety and substance abuse comorbidity, and more episodes and rapid cycling. The interactions among these variables in relationship to the more adverse course of illness in the US than in Europe require further study.

Characterization of affective lability across subgroups of psychosis spectrum disorders

BACKGROUND

Affective lability is elevated and associated with increased clinical burden in psychosis spectrum disorders. The extent to which the level, structure and dispersion of affective lability varies between the specific disorders included in the psychosis spectrum is however unclear. To have potential value as a treatment target, further characterization of affective lability in these populations is necessary. The main aim of our study was to investigate differences in the architecture of affective lability in different psychosis spectrum disorders, and if putative differences remained when we controlled for current symptom status.

METHODS

Affective lability was measured with The Affective Lability Scale Short Form (ALS-SF) in participants with schizophrenia (SZ, n = 76), bipolar I disorder (BD-I, n = 105), bipolar II disorder (BD-II, n = 68) and a mixed psychosis-affective group (MP, n = 48). Multiple analyses of covariance were conducted to compare the ALS-SF total and subdimension scores of the diagnostic groups, correcting for current psychotic, affective and anxiety symptoms, substance use and sex. Double generalized linear models were performed to compare the dispersion of affective lability in the different groups.

RESULTS

Overall group differences in affective lability remained significant after adjusting for covariates (p = .001). BD-II had higher affective lability compared to SZ and BD-I (p = .004), with no significant differences between SZ and BD-I. There were no significant differences in the contributions of ALS-SF dimensions to the total affective lability or in dispersion of affective lability between the groups.

CONCLUSIONS

This study provides the construct of affective lability in psychosis spectrum disorders with more granular details that may have implications for research and clinical care. It demonstrates that despite overlap in core symptom profiles, BD-I is more similar to SZ than it is to BD-II concerning affective lability and the BD groups should consequently be studied apart. Further, affective lability appears to be characterized by fluctuations between depressive- and other affective states across different psychosis spectrum disorders, indicating that affective lability may be related to internalizing problems in these disorders. Finally, although the level varies between groups, affective lability is evenly spread and not driven by extremes across psychosis spectrum disorders and should be assessed irrespective of diagnosis.

Clinical Features, Neuropsychology and Neuroimaging in Bipolar and Borderline Personality Disorder: A Systematic Review of Cross-Diagnostic Studies

Background: Bipolar Disorder (BD) and Borderline Personality Disorder (BPD) have clinically been evolving as separate disorders, though there is still debate on the nosological valence of both conditions, their interaction in terms of co-morbidity or disorder spectrum and their distinct pathophysiology. Objective: The objective of this review is to summarize evidence regarding clinical features, neuropsychological performance and neuroimaging findings from cross-diagnostic studies comparing BD and BPD, to further caracterize their complex interplay. Methods: Using PubMed, PsycINFO and TripDataBase, we conducted a systematic literature search based on PRISMA guidelines of studies published from January 1980 to September 2019 which directly compared BD and BPD. Results: A total of 28 studies comparing BD and BPD were included: 19 compared clinical features, 6 neuropsychological performance and three neuroimaging abnormalities. Depressive symptoms have an earlier onset in BPD than BD. BD patients present more mixed or manic symptoms, with BD-I differing from BPD in manic phases. BPD patients show more negative attitudes toward others and self, more conflictive interpersonal relationships, and more maladaptive regulation strategies in affective instability with separate pathways. Impulsivity seems more a trait in BPD rather than a state as in BD. Otherwise, BD and BPD overlap in depressive and anxious symptoms, dysphoria, various abnormal temperamental traits, suicidal ideation, and childhood trauma. Both disorders differ and share deficits in neuropsychological and neuroimaging findings. Conclusion: Clinical data provide evidence of overlapping features in both disorders, with most of those shared symptoms being more persistent and intense in BPD. Thus, categorical classifications should be compared to dimensional approaches in transdiagnostic studies investigating BPD features in BD regarding their respective explanatory power for individual trajectories. Systematic Review Registration: The search strategy was pre-registered in PROSPERO: CRD42018100268.