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

Patients with borderline personality disorder and bipolar disorder: a descriptive and comparative study

BACKGROUND

Bipolar disorder and borderline personality disorder (BPD) are each significant public health problems. It has been frequently noted that distinguishing BPD from bipolar disorder is challenging. Consequently, reviews and commentaries have focused on differential diagnosis and identifying clinical features to distinguish the two disorders. While there is a burgeoning literature comparing patients with BPD and bipolar disorder, much less research has characterized patients with both disorders. In the current report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compare psychiatric outpatients with both BPD and bipolar disorder to patients with BPD without bipolar disorder and patients with bipolar disorder without BPD.

METHODS

Psychiatric outpatients presenting for treatment were evaluated with semi-structured interviews. The focus of the current study is the 517 patients with both BPD and bipolar disorder (n = 59), BPD without bipolar disorder (n = 330), and bipolar disorder without BPD (n = 128).

RESULTS

Compared to patients with bipolar disorder, the patients with bipolar disorder and BPD had more comorbid disorders, psychopathology in their first-degree relatives, childhood trauma, suicidality, hospitalizations, time unemployed, and likelihood of receiving disability payments. The added presence of bipolar disorder in patients with BPD was associated with more posttraumatic stress disorder in the patients as well as their family, more bipolar disorder and substance use disorders in their relatives, more childhood trauma, unemployment, disability, suicide attempts, and hospitalizations.

CONCLUSIONS

Patients with both bipolar disorder and BPD have more severe psychosocial morbidity than patients with only one of these disorders.

Cortical haemodynamic response during the verbal fluency task in patients with bipolar disorder and borderline personality disorder: a preliminary functional near-infrared spectroscopy study

BACKGROUND

Functional near-infrared spectroscopy (fNIRS) is an emerging neuroimaging modality that provides a direct and quantitative assessment of cortical haemodynamic response during a cognitive task. It may be used to identify neurophysiological differences between psychiatric disorders with overlapping symptoms, such as bipolar disorder (BD) and borderline personality disorder (BPD). Hence, this preliminary study aimed to compare the cerebral haemodynamic function of healthy controls (HC), patients with BD and patients with BPD.

METHODS

Twenty-seven participants (9 HCs, 9 patients with BD and 9 patients with BPD) matched for age, gender, ethnicity and education were recruited. Relative oxy-haemoglobin and deoxy-haemoglobin changes in the frontotemporal cortex was monitored with a 52-channel fNIRS system during a verbal fluency task (VFT). VFT performance, clinical history and symptom severity were also noted.

RESULTS

Compared to HCs, both patient groups had lower mean oxy-haemoglobin in the frontotemporal cortex during the VFT. Moreover, mean oxy-haemoglobin in the left inferior frontal region is markedly lower in patients with BPD compared to patients with BD. Task performance, clinical history and symptom severity were not associated with mean oxy-haemoglobin levels.

CONCLUSIONS

Prefrontal cortex activity is disrupted in patients with BD and BPD, but it is more extensive in BPD. These results provide further neurophysiological evidence for the separation of BPD from the bipolar spectrum. fNIRS could be a potential tool for assessing the frontal lobe function of patients who present with symptoms that are common to BD and BPD.

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.

Enhancing Dialectical Behavior Therapy for the Treatment of Bipolar Disorder

Dialectical behavior therapy (DBT) is a third wave, behavioral therapy that is designed to target emotion dysregulation. The current study investigated whether DBT could be an effective treatment intervention for bipolar disorder and how it could be adapted for this population. Although empirical study of DBT and bipolar disorder is limited, there is evidence to suggest that DBT is a promising treatment for bipolar disorder. In this study, adapted DBT products were created for bipolar disorder, and feedback on the products was elicited from five experts in the field through semi-structured interviews. Interviews were transcribed and coded for analyses. The findings from the interviews were integrated into revised products with the intention to be used in the clinical community. Several experts reported currently using DBT for bipolar disorder treatment. We conclude that a form of DBT using adapted materials could be a promising intervention for the treatment of bipolar disorder, although more research is needed to demonstrate efficacy. Future directions include conducting randomized controlled trials on DBT and bipolar disorder, as well as testing the created product in clinical practice.

Bipolar Disorder and Comorbid Borderline Personality Disorder: Patient Characteristics and Outcomes in US Hospitals

Background and objectives: The quality of life and disease outcomes in bipolar patients, including increased risk of psychiatric hospitalizations and suicide, are adversely affected by the presence of borderline personality disorder (BPD). Our study aims to determine the impact of BPD on the inpatient outcomes of bipolar disorder patients. Methods: We used Nationwide Inpatient Sample from the US hospitals and identified cases with bipolar disorder and comorbid BPD (N = 268,232) and controls with bipolar disorder only (N = 242,379), using the International Classification of Diseases, 9th Revision, and Clinical Modification codes. We used multinomial logistic regression to generate odds ratios (OR) and evaluate inpatient outcomes. Results: The majority of the bipolar patients with BPD were female (84.2%), Caucasian (83.1%) and 18–35 years age (53.9%). Significantly longer inpatient stays, higher inpatient charges, and higher prevalence of drug abuse were noted in bipolar patients with BPD. The suicide risk was higher in bipolar patients with BPD (OR = 1.418; 95% CI 1.384–1.454; p < 0.001). In addition, utilization of electroconvulsive treatment (ECT) was higher in bipolar patients with comorbid BPD (OR = 1.442; 95% CI 1.373–1.515; p < 0.001). Conclusions: The presence of comorbid BPD in bipolar disorder is associated with higher acute inpatient care due to a longer inpatient stay and higher cost during hospitalization, and higher suicide risk, and utilization of ECT. Further studies in the inpatient setting are warranted to develop effective clinical strategies for optimal outcomes and reduction of suicide risk in bipolar patients with BPD.

Associations between mood instability and emotional processing in a large cohort of bipolar patients

BACKGROUND

Aberrant emotional biases have been reported in bipolar disorder (BD), but results are inconsistent. Despite the clinical relevance of chronic mood variability in BD, there is no previous research investigating how the extent of symptom fluctuations in bipolar disorder might relate to emotional biases. This exploratory study investigated, in a large cohort of bipolar patients, whether instability in weekly mood episode symptoms and other clinical and demographic factors were related to emotional bias as measured in a simple laboratory task.

METHOD

Participants (N = 271, BDI = 206, BDII = 121) completed an 'emotional categorization and memory' task. Weekly self-reported symptoms of depression and mania were collected prospectively. In linear regression analyses, associations between cognitive bias and mood variability were explored together with the influence of demographic and clinical factors, including current medication.

RESULTS

Greater accuracy in the classification of negative words relative to positive words was associated with greater instability in depressive symptoms. Furthermore, greater negative bias in free recall was associated with higher instability in manic symptoms. Participants diagnosed with BDII, compared with BDI, showed overall better word recognition and recall. Current antipsychotic use was associated with reduced instability in manic symptoms but this did not impact on emotional processing performance.

CONCLUSIONS

Emotional processing biases in bipolar disorder are related to instability in mood. These findings prompt further investigation into the underpinnings as well as clinical significance of mood instability.

Binge eating and emotional eating behaviors among adolescents and young adults with bipolar disorder

BACKGROUND

This study investigates nutritional behavior among adolescents and young adults with bipolar disorder (BP) in comparison to those without history of major psychiatric disorder.

METHODS

131 participants (82 BP, 49 controls) with a mean age of 16.11 ± 1.61 years were included. The self-reported Quick Weight, Activity, Variety & Excess (WAVE) Screener was used to assess dietary habits, yielding a total nutritional score as well as Excess, Variety, and Household Food Insecurity subscale scores. Specifically, the Variety subscale was used to measure daily consumption of essential nutrients; the Excess subscale measured unhealthy eating behaviors such as binge eating and excessive intake of fat and sugar; and the Household Food Insecurity subscale was used to detect food insecurity. Within-group analysis was conducted on participants with BP to identify correlates of unhealthy diet.

RESULTS

BP participants scored significantly lower than controls on the WAVE (t=2.62, p=0.010), specifically the Excess subscale (t=3.26, p=0.001). This was related to higher prevalence of binge eating and emotional eating behaviors among participants with BP compared to controls. Within-group analyses showed that self-reported emotional dysregulation/impulsivity was associated with maladaptive nutritional behaviors (t=3.38, p=0.035).

LIMITATIONS

Cross-sectional design. Within-group analyses were underpowered. Diet quality was measured using a brief self-report screener.

CONCLUSION

Adolescents and young adults with BP have poorer nutritional behaviors compared to controls, and this difference is related to stress-induced eating. This demonstrates the need to screen for stress-induced eating and to intervene when needed in order to optimize nutritional behaviors among adolescents and young adults with BP.

Differentiating risk for mania and borderline personality disorder: The nature of goal regulation and impulsivity

Researchers and clinicians have long noted the overlap among features and high comorbidity of bipolar disorder and borderline personality disorder. The shared features of impulsivity and labile mood in both disorders make them challenging to distinguish. We tested the hypothesis that variables related to goal dysregulation would be uniquely related to risk for mania, while emotion-relevant impulsivity would be related to risk for both disorders. We administered a broad range of measures related to goal regulation traits and impulsivity to 214 undergraduates. Findings confirmed that risk for mania, but not for borderline personality disorder, was related to higher sensitivity to reward and intense pursuit of goals. In contrast, borderline personality disorder symptoms related more strongly than did mania risk with threat sensitivity and with impulsivity in the context of negative affect. Results highlight potential differences and commonalities in mania risk versus borderline personality disorder risk.

Relationship between personality disorder functioning styles and the emotional states in bipolar I and II disorders

Background

Bipolar disorder types I (BD I) and II (BD II) behave differently in clinical manifestations, normal personality traits, responses to pharmacotherapies, biochemical backgrounds and neuroimaging activations. How the varied emotional states of BD I and II are related to the comorbid personality disorders remains to be settled.

Methods

We therefore administered the Plutchick – van Praag Depression Inventory (PVP), the Mood Disorder Questionnaire (MDQ), the Hypomanic Checklist-32 (HCL-32), and the Parker Personality Measure (PERM) in 37 patients with BD I, 34 BD II, and in 76 healthy volunteers.

Results

Compared to the healthy volunteers, patients with BD I and II scored higher on some PERM styles, PVP, MDQ and HCL-32 scales. In BD I, the PERM Borderline style predicted the PVP scale; and Antisocial predicted HCL-32. In BD II, Borderline, Dependant, Paranoid (-) and Schizoid (-) predicted PVP; Borderline predicted MDQ; Passive-Aggressive and Schizoid (-) predicted HCL-32. In controls, Borderline and Narcissistic (-) predicted PVP; Borderline and Dependant (-) predicted MDQ.

Conclusion

Besides confirming the different predictability of the 11 functioning styles of personality disorder to BD I and II, we found that the prediction was more common in BD II, which might underlie its higher risk of suicide and poorer treatment outcome.

Differences between patients with borderline personality disorder who do and do not have a family history of bipolar disorder

Diagnostic confusion sometimes exists between bipolar disorder and borderline personality disorder (BPD). To improve the recognition of bipolar disorder researchers have identified nondiagnostic factors that point toward bipolar disorder. One such factor is the presence of a family history of bipolar disorder. In the current report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic, clinical, and psychosocial characteristics of patients with BPD who did and did not have a family history of bipolar disorder. A large sample of psychiatric outpatients were interviewed with semi-structured interviews. Three hundred seventeen patients without bipolar disorder were diagnosed with DSM-IV borderline personality disorder. Slightly less than 10% of the 317 patients with BPD (9.5%, n=30) reported a family history of bipolar disorder in their first-degree relatives. There were no differences between groups in any specific Axis I or Axis II disorder. The patients with a positive family history were significantly less likely to report excessive or inappropriate anger, but there was no difference in the frequency of other criteria for BPD such as affective instability, impulsivity, or suicidal behavior. The patients with a positive family history reported a significantly higher rate of increased appetite and fatigue. There was no difference in overall severity of depression, scores on the Global Assessment of Functioning, history of psychiatric hospitalizations, suicide attempts, time unemployed due to psychiatric reasons during the 5 years before the evaluation, and ratings of current and adolescent social functioning. There was no difference on any of the 5 subscales of the childhood trauma questionnaire. Overall, we found few differences between BPD patients with and without a family history of bipolar disorder thereby suggesting that a positive family history of bipolar disorder was not a useful marker for occult bipolar disorder in these patients.

Problematic boundaries in the diagnosis of bipolar disorder: the interface with borderline personality disorder

It is clinically important to recognize both bipolar disorder and borderline personality disorder (BPD) in patients seeking treatment for depression, and it is important to distinguish between the two. The most studied question on the relationship between BPD and bipolar disorder is their diagnostic concordance. Across studies approximately 10 % of patients with BPD had bipolar I disorder and another 10 % had bipolar II disorder. Likewise, approximately 20 % of bipolar II patients were diagnosed with BPD, though only 10 % of bipolar I patients were diagnosed with BPD. While the comorbidity rates are substantial, each disorder is, nonetheless, diagnosed in the absence of the other in the vast majority of cases (80-90 %). In studies examining personality disorders broadly, other personality disorders were more commonly diagnosed in bipolar patients than was BPD. Likewise, the converse is also true: other axis I disorders such as major depression, substance abuse, and post-traumatic stress disorder are more commonly diagnosed in patients with BPD than is bipolar disorder. Studies comparing patients with BPD and bipolar disorder find significant differences on a range of variables. These findings challenge the notion that BPD is part of the bipolar spectrum. While a substantial literature has documented problems with the under-recognition and under-diagnosis of bipolar disorder, more recent studies have found evidence of bipolar disorder over-diagnosis and that BPD is a significant contributor to over-diagnosis. Re-conceptualizing the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, diagnostic criteria for bipolar disorder as a type of test, rather than the final word on diagnosis, shifts the diagnostician from thinking solely whether a patient does or does not have a disorder to considering the risks of false-positive and false-negative diagnoses, and the ease by which each type of diagnostic error can be corrected by longitudinal observation.

Overdiagnosis of bipolar disorder: a critical analysis of the literature

Bipolar disorder (BD) is considered one of the most disabling mental conditions, with high rates of morbidity, disability, and premature death from suicide. Although BD is often misdiagnosed as major depressive disorder, some attention has recently been drawn to the possibility that BD could be overdiagnosed in some settings. The present paper focuses on a critical analysis of the overdiagnosis issue among bipolar patients. It includes a review of the available literature findings, followed by some recommendations aiming at optimizing the diagnosis of BD and increasing its reliability.

Structural brain features of borderline personality and bipolar disorders

A potential overlap between bipolar disorder (BD) and borderline personality disorder (BPD) has been recently proposed. We aimed to assess similarities and differences of brain structural features in BD and BPD. Structural magnetic resonance imaging (MRI) was performed in 26 inpatients with BPD, 14 with BD, and 40 age-and sex-matched healthycontrols (HC). Voxel-based morphometry analysis with Statistical Parametric Mapping (SPM) was used to localize and quantify gray (GM) and white matter (WM) abnormalities in BD and BPD compared to HC and to identify those specifically affected in each patient group. Region of interest (ROI)-based analyses were also performed for confirmation. GM density changes in BD are significantly more diffuse and severe than in BPD, as demonstrated in both SPM- and ROI-based analyses. The topography of GM alterations showed some regions of overlap, but each disorder had specific regions of abnormality (involving both cortical and subcortical structures in BD, confined mainly to fronto-limbic regions in BPD). WM density changes were less pronounced in both conditions and involved completely different regions. Although BPD and BD show a considerable overlap of GM changes, the topography of alterations is more consistent with the separate conditions hypothesis and with the vulnerability of separate neural systems.

Screening for bipolar disorder among patients undergoing a major depressive episode: report from the BRIDGE study in Egypt

BACKGROUND

To estimate the frequency of bipolar disorder (BPD) among patients with a major depressive episode (MDE) and elucidate clinically-relevant factors predictive of bipolarity.

METHODS

We evaluated 306 patients undergoing a MDE at facilities throughout Egypt. Patients were given the HCL-32 R2 questionnaire to assess the presence of manic/hypomanic symptoms; those scoring >14 were considered bipolar. We also investigated how various clinical criteria for bipolarity changed the incidence of bipolar diagnosis. Finally, we examined if demographics, psychiatric history, clinical characteristics, and the incidence of co-morbid conditions differed significantly between bipolar and unipolar patients.

RESULTS

The positive screen rate for BPD based on HCL-32 R2 scores was 62.2% (188/302). However, only 26% (80/306) of patients had been diagnosed previously as bipolar. In contrast, when DSM-IV criteria were used, only 13.7% (42/306) of patients qualified as bipolar. A number of factors were highly predictive of bipolarity including: seasonality, number of past mood episodes, history of psychiatric hospitalization, mixed state, and mood reactivity. Of the comorbidities examined, only borderline personality disorder occurred at a higher rate in bipolar than in unipolar patients.

LIMITATIONS

Participating centers were not randomly selected and there could be a bias if only psychiatrists having specific interest in BPD were included.

CONCLUSIONS

The positive HCL-32-R2-based bipolar screen rate of 62% suggests that a substantial proportion of patients with a MDE may have BPD. Further, a number of factors in the patient's psychiatric history as well as clinical aspects of the episode itself may signal an increased likelihood of bipolarity.

Using the mood disorder questionnaire and bipolar spectrum diagnostic scale to detect bipolar disorder and borderline personality disorder among eating disorder patients

BACKGROUND

Screening scales for bipolar disorder including the Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) have been plagued by high false positive rates confounded by presence of borderline personality disorder. This study examined the accuracy of these scales for detecting bipolar disorder among patients referred for eating disorders and explored the possibility of simultaneous assessment of co-morbid borderline personality disorder.

METHODS

Participants were 78 consecutive female patients who were referred for evaluation of an eating disorder. All participants completed the mood and eating disorder sections of the SCID-I/P and the borderline personality disorder section of the SCID-II, in addition to the MDQ and BSDS. Predictive validity of the MDQ and BSDS was evaluated by Receiver Operating Characteristic analysis of the Area Under the Curve (AUC).

RESULTS

Fifteen (19%) and twelve (15%) patients fulfilled criteria for bipolar II disorder and borderline personality disorder, respectively. The AUCs for bipolar II disorder were 0.78 (MDQ) and 0.78 (BDSD), and the AUCs for borderline personality disorder were 0.75 (MDQ) and 0.79 (BSDS).

CONCLUSIONS

Among patients being evaluated for eating disorders, the MDQ and BSDS show promise as screening questionnaires for both bipolar disorder and borderline personality disorder.

A new look at borderline personality disorder and related disorders: hyper-reactivity in the limbic system and lower centers

Borderline Personality Disorder (BPD) has been often described recently as a condition characterized by emotional dysregulation. Several other conditions share this attribute; namely, Bipolar Disorder (BD), Attention-Deficit/Hyperactivity Disorder (ADHD), Intermittent Explosive Disorder (IED), and Major Depressive Disorder (MDD). The dysregulation is not always in the same direction: BPD, BD, ADHD, and IED, for example, show over-reactivity or "hyperactivity" of emotional responses, whereas patients with MDD show emotional sluggishness and underactivity. At the clinical/descriptive level the "over-reactive" conditions appear separate and distinct. BPD constitutes a large domain within the psychopathological arena, appearing to contain within it a variety of etiologically diverse subtypes. Among the latter is a type of BPD linked closely with Bipolar Disorder; family studies of either condition show an overrepresentation of both: BPD patients with bipolar relatives; Bipolar patients with BPD relatives. A significant percentage of children with ADHD go on to develop either BPD or BD as they approach adulthood. If one shifts the spotlight to neurophysiology, as captured by MRI studies, however, it emerges that an important subtype of BPD, and also BD, ADHD, and IED-share common features of abnormalities and peculiarities in the limbic system and in the cortex, especially the prefrontal cortex. Deeper subcortical regions such as the periaqueductal gray may also be implicated in strong emotional reactions. The diversity of clinical "over-reactive" conditions appear to harken back to a kind of unity at the brain-change level. There are therapeutic implications here, such as the advisability of mood stabilizers in many cases of BPD, not just for Bipolar Disorder.

Differential diagnosis of bipolar affective disorder type II and borderline personality disorder: analysis of the affective dimension

BACKGROUND

Differential diagnosis between bipolar affective disorder type II and borderline personality disorder can be problematic yet a priority for effective treatment planning. Diagnosis is problematic when symptoms do not present enough intensity or duration to clear the issue but also when there is a relative overlap of criteria between both disorders. If for many patients, the diagnosis is more easily differentiated, confounding conditions are found in 20% of cases for which it becomes a significant issue.

METHOD

A research with the key words affective instability, borderline personality disorder, and bipolar disorder on Medline and Psych-Info was done. Other references were found through this review in related articles. Comparison of data about the affective dimensions concerning bipolar disorder and borderline personality disorder was noted.

RESULTS

Affective instability is a confounding factor: quality and intensity of affects, speed of fluctuations, affective response to social stress, and its modulation are core elements of affective instability that need to be analyzed to clarify a proper diagnosis.

LIMITATIONS

There is further necessity for research about affective instability in the 2 diagnoses.

CONCLUSIONS

Making a valid differential diagnosis has an important clinical value in order for the clinician to plan proper treatment. Analysis of the affective experience and its qualitative and quantitative facets can help establish it.

Psychotherapy for Bipolar II Disorder: The Role of Interpersonal and Social Rhythm Therapy

Although bipolar II disorder is a highly prevalent, chronic illness that is associated with burdensome psychosocial impairment, relatively little is known about the best ways to treat the disorder. Moreover, psychosocial interventions for the management of bipolar II disorder have been largely unexplored, leaving psychologists with few evidence-based recommendations for best treatment practices. In this article, we provide information about interpersonal and social rhythm therapy (IPSRT), an empirically supported treatment for bipolar I disorder that has preliminary evidence supporting its efficacy in bipolar II disorder. After reviewing the phenomenology of bipolar II disorder and differentiating it from bipolar I disorder, we summarize the extant empirical support for using psychotherapy in the management of bipolar II disorder. We explore what is known about the role of psychotherapy in the management of bipolar II disorder as well as lacunae in the evidence base. Next, we introduce IPSRT and discuss how it has been adapted for use as a treatment for individuals suffering from bipolar II disorder. Specific strategies of the treatment are detailed, and preliminary evidence for the efficacy of IPSRT in bipolar II disorder is described. Finally, we present a case vignette demonstrating the use of IPSRT for an individual with bipolar II disorder.

Early Maladaptive Schemas in the risk for bipolar spectrum disorders

BACKGROUND

The hypomanic personality style is a risk factor for bipolar spectrum disorders and shares many cognitive and affective features with the bipolar spectrum. Schema theory may serve as a unifying theory that would explain many of these features. This study is an exploratory investigation of Early Maladaptive Schemas (EMSs) in association with the hypomanic personality and bipolar spectrum risk.

METHODS

A sample of 966 participants completed the Young Schema Questionnaire, the Hypomanic Personality Scale and the Patient Health Questionnaire. Associations were investigated using univariate and multivariate analyses. Participants deemed at risk of developing a bipolar disorder (N=107) were compared to low-risk controls (N=681).

RESULTS

The Entitlement/Grandiosity and Insufficient Self-Control/Self-Discipline positively predicted the risk of developing a bipolar disorder, while Emotional Inhibition negatively predicted risk. High-risk participants demonstrated higher mean scores on all EMSs except Emotional Inhibition. These three EMSs, combined with Vulnerability to Harm or Illness, significantly predicted group membership.

CONCLUSIONS

A bipolar spectrum EMS profile was identified, consisting of Entitlement/Grandiosity, Insufficient Self-Control/Self-Discipline and the absence of Emotional Inhibition. These EMSs are highly consistent with characteristics of the bipolar spectrum. This study supports the application of schema theory to the hypomanic personality and bipolar spectrum. Future research should explore the possible interaction between EMSs, life events and affective symptoms and the applicability of schema therapy to the bipolar spectrum.

A (re)-evaluation of the symptom structure of borderline personality disorder

OBJECTIVE

Despite evidence of significant symptom heterogeneity and excessive diagnostic comorbidity, many contend that borderline personality disorder (BPD) is unidimensional, an assumption that rests primarily on results from factor analytic investigations of BPD symptom criteria. We note several limitations in the literature and argue that the symptom structure of BPD can be best clarified by using both factor analytic techniques and examining the BPD symptom dimensions in relation to external criteria (that is, personality traits). Our goals were to: examine if the symptoms of BPD are best conceptualized as unidimensional or multidimensional, and determine the extent to which personality traits account for any symptom dimensions that underlie BPD.

METHOD

All published structural models of the BPD symptom criteria were identified and tested for statistical fit using confirmatory factor analysis in a sample of 373 patients who had completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-Axis II Personality Questionnaire BPD scale. Dimensions from the best fitting model were examined in relation to traits from the Five-Factor Model (FFM) and the Personality Psychopathology Five (PSY-5) using correlational and regression analyses.

RESULTS

Sanislow's 3-factor model, containing affect dysregulation, behavioural dysregulation, and disturbed relations symptom dimensions, provided the best fit; the unidimensional model produced the worst. The symptom dimensions of the 3-factor model were differentiable from one another and had unique associations with the FFM and PSY-5 personality traits.

CONCLUSION

BPD is a multidimensional construct.

Borderline personality disorder: considerations for inclusion in the Massachusetts parity list of "biologically-based" disorders

Borderline Personality Disorder (BPD) is a common and severe mental illness that is infrequently included under state mental health parity statutes. This review considers BPD parity, using the Massachusetts mental health parity statute as a model. While BPD can co-occur with other disorders, studies of its heritability, diagnostic validity/reliability, and response to specific treatments indicate it is best considered an independent disorder, one that negatively impacts the patient's treatment response to comorbid disorders, particularly mood disorders. Persons with BPD are high utilizers of treatment, especially emergency departments and inpatient hospitalizations-the most expensive forms of psychiatric treatment. While some patients remain chronically symptomatic, the majority improve. The findings from psychopharmacologic and other biologic treatment data, coupled with associated brain functioning findings, indicate BPD is a biologically-based disorder. Clinical data indicate that accurately diagnosing and treating BPD conserves resources and improves outcomes. Based on this analysis, insuring BPD in the same manner as other serious mental illnesses is well-founded and recommended.

The clinician's dilemma: borderline personality disorder or bipolar spectrum disorder?

OBJECTIVES

This paper aims to explore the use of science as a basis for introducing bipolar spectrum disorder to conceptualize people who may otherwise be described as having borderline personality disorder, and offer suggestions for the management of clinical dilemmas.

CONCLUSIONS

Testable observations, thoughtfulness and humility are helpful in clinical practice.

Borderline personality disorder and the misdiagnosis of bipolar disorder

Recent reports suggest bipolar disorder is not only under-diagnosed but may at times be over-diagnosed. Little is known about factors that increase the odds of such mistakes. The present work explores whether symptoms of borderline personality disorder increase the odds of a bipolar misdiagnosis. Psychiatric outpatients (n=610) presenting for treatment were administered the Structured Clinical Interview for DSM-IV (SCID) and the Structured Interview for DSM-IV Personality for DSM-IV axis II disorders (SIDP-IV), as well as a questionnaire asking if they had ever been diagnosed with bipolar disorder by a mental health care professional. Eighty-two patients who reported having been previously diagnosed with bipolar disorder but who did not have it according to the SCID were compared to 528 patients who had never been diagnosed with bipolar disorder. Patients with borderline personality disorder had significantly greater odds of a previous bipolar misdiagnosis, but no specific borderline criterion was unique in predicting this outcome. Patients with borderline personality disorder, regardless of how they meet criteria, may be at increased risk of being misdiagnosed with bipolar disorder.

Misdiagnosis of bipolar disorder as borderline personality disorder: clinical and economic consequences

We report the case of a 26-year-old patient with bipolar spectrum disorder who was misdiagnosed with borderline personality disorder. In spite of trials of various psychotropic drugs and frequent, prolonged hospitalizations, the patient had remained chronically symptomatic. Following a detailed examination of the longitudinal illness course and confirmation of the diagnosis of bipolar spectrum disorder, antidepressants were discontinued and the patient was treated with lamotrigine and quetiapine. This treatment resulted in sustained euthymia and cessation of deliberate self-harm in addition to a significant reduction in utilization of health resources.

The borderlines of bipolar affective disorder

This paper provides an overview of the major studies of bipolar affective disorder (BAD) and borderline personality disorder (BPD), and assesses whether the disorders might be better understood as variants of the same basic disorder. There is a shortage of research that delineates the features of both disorders within their representative samples. As a consequence the symptomatic overlap of the disorders, detected by categorical assessment instruments, is often misconstrued as an indication of the disorders' high rates of comorbidity (up to 81%). In paying particular attention to features of both disorders, eg. affective instability and impulsivity, the paper provides evidence that BPD attenuates bipolar disorder along the spectrum of affective disorders, from non-classical bipolar presentation through to severe BAD with borderline features. The paper cites clinical, research and pharmacologic support of the contention that BPD, rather than representing a distinct disorder, is merely an attenuation of Axis I disorders, most especially bipolar affective disorder. Borderline personality is evident across the bipolar spectrum and exacerbates symptomatology and leads to poorer recovery prognosis.

The phenomenology of bipolar disorder: what drives the high rate of medical burden and determines long-term prognosis?

Bipolar disorder (BD) has been classically described as one of episodic mood disturbances. New evidence suggests that a chronic course and multisystem involvement is the rule, rather than the exception, and that together with disturbances of circadian rhythms, mood instability, cognitive impairment, a high rate of medical burden is often observed. The current diagnostic approach for BD neither describes the multisystem involvement that the recent literature has highlighted nor points toward potential predictors of long- term outcome. In light of the new evidence that the long-term course of BD is associated with a high prevalence of psychiatric comorbidity and an increased mortality from medical disease, we propose a multidimensional approach that includes several symptom domains, namely affective instability, circadian rhythm dysregulation, and cognitive and executive dysfunction, presenting in various combinations that give shape to each individual presentation, and offers potential indicators of overall long-term prognosis.

Borderline Personality Disorder Across the Life Span

Borderline personality disorder is characterized by affective dysregulation, intense, unstable interpersonal relationships, impulsivity and unstable identity. It overlaps considerably with both PTSD and bipolar spectrum disorders. Research on true late-life BPD is limited, but suggests that some of the core features of BPD including interpersonal difficulties, unstable affect and anger remain relatively unchanged, while impulsivity and identity disturbance decline or change their mode of expression in late life. Diagnosis of BPD in late life requires both flexible application of the standard diagnostic criteria as well as a thorough longitudinal history. The etiology of BPD is best explained as a combination of genetic, neurobiological vulnerability combined with childhood trauma, abuse or neglect that leads to dysregulated emotions, distorted cognitions, social skills deficits, and few adaptive coping strategies. Treatment options include pharmacotherapy (especially mood stabilizers, SSRIs and atypical antipsychotics) and psychotherapeutic interventions that focus on distress tolerance, affective regulation, changing distorted beliefs, and introducing new social and relationship problem solving skills (especially Dialectical Behavior Therapy and Schema Focused Cognitive Therapy). In late life care environments, such as nursing homes and other residential facilities, staff need to be empowered to set appropriate limits on problematic behavior while maintaining empathy and validating the painful affect patients often experience.

Classification of mood disorders in DSM-V and DSM-VI

For any diagnostic system to be clinically useful, and go beyond description, it must provide an understanding that informs about aetiology and/or outcome. DSM-III and DSM-IV have provided reliability; the challenge for DSM-V and DSM-VI will be to provide validity. For DSM-V this will not be achieved. Believers in DSM-III and DSM-IV have impeded progress towards a valid classification system, so DSM-V needs to retain continuity with its predecessors to retain reliability and enhance research, but position itself to inform a valid diagnostic system by DSM-VI. This review examines the features of a diagnostic system and summarizes what is really known about mood disorders. The review also questions whether what are called mood disorders are primarily disorders of mood. Finally, it provides suggestions for DSM-VI.

Frontolimbic structural changes in borderline personality disorder

OBJECTIVE

Frontolimbic dysfunction is observed in borderline personality disorder (BPD), with responses to emotional stimuli that are exaggerated in the amygdala and impaired in the anterior cingulate cortex (ACC). This pattern of altered function is consistent with animal models of stress responses and depression, where hypertrophic changes in the amygdala and atrophic changes in the ACC are observed. We tested the hypothesis that BPD patients exhibit gross structural changes that parallel the respective increases in amygdala activation and impairment of rostral/subgenual ACC activation.

METHODS

Twelve unmedicated outpatients with BPD by DSM-IV and 12 normal control (NC) subjects underwent a high-resolution T1-weighted structural MRI scan. Relative gray matter concentration (GMC) in spatially-normalized images was evaluated by standard voxel-based morphometry, with voxel-wise subject group comparisons by t test constrained to amygdala and rostral/subgenual ACC.

RESULTS

The BPD group was significantly higher than NC in GMC in the amygdala. In contrast, the BPD group showed significantly lower GMC than the NC group in left rostral/subgenual ACC.

CONCLUSIONS

This sample of BPD patients exhibits gross structural changes in gray matter in cortical and subcortical limbic regions that parallel the regional distribution of altered functional activation to emotional stimuli among these same subjects. While the histological basis for GMC changes in adult clinical populations is poorly-known at present, the observed pattern is consistent with the direction of change, in animal models of anxiety and depression, of neuronal number and/or morphological complexity in both the amygdala (where it is increased) and ACC (where it is decreased).

Borderline Personality Disorder: What do We Know? Diagnosis, Course, Co-Morbidity, and Aetiology

Evidence regarding the diagnostic dilemmas, course, co-morbidity, and aetiology of Borderline Personality Disorder (BPD) is reviewed. After considering problems that the clinician and researcher face in using BPD as a diagnostic category, I argue that current evidence indicates that there is reason to be more optimistic about the course of BPD. Emerging dilemmas in considering co-morbidity in the BPD patient are considered. Aetiological factors are presented in support of a ‘multiple pathways’ model of aetiology where characterological and temperamental characteristics interact in complex idiosyncratic ways.

A relationship between bipolar II disorder and borderline personality disorder?

BACKGROUND

The relationship between DSM-IV-TR borderline personality disorder (BPD) and bipolar disorders, especially bipolar II disorder (BP-II), is still unclear. Many recent reviews on this topic have come to opposite or different conclusions.

STUDY AIM

The aim was to test the association between hypomania symptoms and BPD traits, as hypomania is the defining feature of BP-II in DSM-IV-TR.

METHODS

During follow-up visits in a private practice, consecutive 138 remitted BP-II outpatients were re-diagnosed by a mood disorder specialist psychiatrist, using the Structured Clinical Interview for DSM-IV (as modified by Benazzi and Akiskal for better probing hypomania). Soon after, patients self-assessed (blind to interviewer) the SCID-II Personality Questionnaire for BPD. Associations and confounding were tested by logistic regression, between each criteria symptom of hypomania (apart from "racing thoughts" and "distractibility", not assessed as probing focused mainly on behavioral, observable signs), and the entire set of BPD traits. Multivariate regression was also used to jointly regress the entire set of hypomanic symptoms on the entire set of BPD traits.

RESULTS

Mean (SD) age was 39.0 (9.8) years, females were 76.3%. Frequency of BPD traits ranged between 17% and 66% (e.g. impulsivity trait 41%, affective instability trait 63%), mean (SD) number of traits was 4.2 (2.3). The most common episodic hypomanic symptoms were elevated mood (91%) and overactivity (93%); frequency of excessive risky, impulsive activities (impulsivity) was 62%. By logistic regression the only significant association was between the episodic impulsivity of hypomania and the trait impulsivity of BPD. Multivariate regression of the entire set of hypomanic symptoms jointly regressed on the entire set of BPD traits was not statistically significant.

DISCUSSION

The core feature of BP-II, i.e. hypomania, does not seem to have a close relationship with BDP traits in the study setting, partly running against a strong association between BPD and BP-II and a bipolar spectrum nature of BPD.

Bipolar disorder not otherwise specified: comparison with bipolar disorder I/II and major depression

OBJECTIVE

To compare the personality, clinical and comorbidity characteristics of subjects meeting diagnostic criteria for bipolar disorder not otherwise specified (BDNOS) to those with major depression and bipolar I or II disorder.

METHODS

A family-based study was undertaken on the molecular genetics of depression and personality, in which the proband had been treated for depression, regardless of history, of hypomania or mania.

RESULTS

The 25 subjects with BDNOS were different to the 297 subjects with major depression and similar to 75 subjects with bipolar I or II disorder on social phobia, obsessive-compulsive disorder and substance dependence comorbidity. The BDNOS subjects also had personality traits more akin to the bipolar I or II disorder subjects, especially borderline personality traits and self transcendence.

CONCLUSIONS

Subjects with BDNOS, based on a history of 1-3 day recurrent hypomanias, should be included within a broader bipolar spectrum.

Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open trial

OBJECTIVE

To describe an adapted version of dialectical behavior therapy for adolescents with bipolar disorder.

METHOD

The dialectical behavior therapy intervention is delivered over 1 year and consists of two modalities: family skills training (conducted with individual family units) and individual therapy. The acute treatment period (6 months) includes 24 weekly sessions; sessions alternate between the two treatment modalities. Continuation treatment consists of 12 additional sessions tapering in frequency through 1 year. We conducted an open pilot trial of the treatment, designed as an adjunct to pharmacological management, to establish feasibility and acceptability of the treatment for this population. Participants included 10 patients (mean age 15.8 +/- 1.5 years, range 14-18) receiving treatment in an outpatient pediatric bipolar specialty clinic. Symptom severity and functioning were assessed quarterly by an independent evaluator. Consumer satisfaction was also assessed posttreatment.

RESULTS

Feasibility and acceptability of the intervention were high, with 9 of 10 patients completing treatment, 90% of scheduled sessions attended, and high treatment satisfaction ratings. Patients exhibited significant improvement from pre- to posttreatment in suicidality, nonsuicidal self-injurious behavior, emotional dysregulation, and depressive symptoms.

CONCLUSIONS

Dialectical behavior therapy may offer promise as an approach to the psychosocial treatment of adolescent bipolar disorder.

Clinical features of soft bipolarity in major depressive inpatients

Because of the difficulties of ascertaining episode of hypomania by past history of the patients, it is of clinical value to find variables which predict the development of bipolar II disorder in depressive patients. Taking advantage of relatively long hospitalization, the authors tried to elucidate fine clinical features of the soft bipolarity. The subjects were 39 patients with Major Depressive Episode, diagnosed according to the 4th edition of the Diagnostic and Statistical Manual criteria. Among them, 15 patients were diagnosed as bipolar II disorder (BPII), whereas 24 patients were with unipolar depression (UP), using a structured clinical interview to assess the mood spectrum (SCI-MOODS). In addition to ordinary clinical and demographic variables, the authors studied fine symptomatology of depression, premorbid personality, and interpersonal relationship. Continuous variables were analyzed by t-test. Categorical variables were tested by chi2 analysis. In terms of premorbid personality, manic type (Zerssen) was found more frequently in BPII (UP 2/24, BPII 9/15, P < 0.05). Patients with BPII tended to show apparently quick disappearance of depressive symptoms (UP 2/24, BPII 9/15, P = 0.01). The most prominent result was a high prevalence of comorbidity of borderline personality disorder (BPD) among BPII (UP 0/24, BPII 6/15, P = 0.02). As Akiskal indicated that mood lability represents the most powerful predictor of hypomanias, patients with BPII showed quick response in mood to admission. The current subjects with BPII had high frequency of manic type of premorbid personality, indicating the usefulness of this variable for the prediction of hypomanias. Finally, the authors could observe development of BPD during hospitalization exclusively among BPII, to support the possibility of BPD as a state effect of BPII.

Borderline personality-bipolar spectrum relationship

BACKGROUND

The relationship between borderline personality disorder (BPD) and bipolar disorders, especially bipolar-II disorder (BP-II), is unclear. Several reviews on the topic have come to opposite conclusions, i.e., that BPD is a bipolar spectrum disorder or instead that it is unrelated to bipolar disorders. Study aim was to find which items of BPD were related to BP-II, and which instead had no relationship with BP-II.

STUDY SETTING

An outpatient psychiatry private practice, more representative of mood disorders usually seen in clinical practice in Italy. INTERVIEWER: A senior clinical and mood disorder research psychiatrist.

PATIENT POPULATION

A consecutive sample of 138 BP-II and 71 major depressive disorder (MDD) remitted outpatients. ASSESSMENT INSTRUMENTS: The Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version (SCID-CV) was used for diagnosing, the SCID-II Personality Questionnaire was used by patients to self-assess borderline personality traits. Interview methods: Patients were interviewed with the SCID-CV to diagnose BP-II and MDD. The questions of the Personality Questionnaire relative to borderline personality were self-assessed by patients. As clinically significant distress or impairment of functioning was not assessed by the questionnaire, a diagnosis of borderline personality disorder could not be made, but borderline personality traits (BPT) could be assessed (i.e., all DSM-IV BPD items but not the impairment criterion).

RESULTS

BPT items were significantly more common in BP-II versus MDD. The best combination of sensitivity and specificity for predicting BP-II was found by using a cutoff number of BPT items > or =5: specificity was 71.4%, sensitivity was 45.9%. BPT (defined by > or =5 items) was present in 29.5% of MDD and in 46.3% of BP-II (p=0.019). Logistic regression of BP-II versus BPT items number found a significant association. Principal component factor analysis of BPT items found two orthogonal factors: "affective instability" including unstable mood, unstable interpersonal relationships, unstable self-image, chronic emptiness, and anger, and "impulsivity" including impulsivity, suicidal behavior, avoidance of abandonment, and paranoid ideation. "Affective instability" was associated with BP-II (p=0.010), but "impulsivity" was not associated with BP-II (p=0.193). Interitem correlation was low. There was no significant correlation between the two factors.

DISCUSSION

Study findings suggest that DSM-IV BPD may mix two sets of unrelated items: an affective instability dimension related to BP-II, and an impulsivity dimension not related to BP-II, which may explain the opposite conclusions of several reviews. A subtyping of BPD according to these dimensions is supported by the study findings.

Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies

Since the previous publication of Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines in 1997, there has been a substantial increase in evidence-based treatment options for bipolar disorder. The present guidelines review the new evidence and use criteria to rate strength of evidence and incorporate effectiveness, safety, and tolerability data to determine global clinical recommendations for treatment of various phases of bipolar disorder. The guidelines suggest that although pharmacotherapy forms the cornerstone of management, utilization of adjunctive psychosocial treatments and incorporation of chronic disease management model involving a healthcare team are required in providing optimal management for patients with bipolar disorder. Lithium, valproate and several atypical antipsychotics are first-line treatments for acute mania. Bipolar depression and mixed states are frequently associated with suicidal acts; therefore assessment for suicide should always be an integral part of managing any bipolar patient. Lithium, lamotrigine or various combinations of antidepressant and mood-stabilizing agents are first-line treatments for bipolar depression. First-line options in the maintenance treatment of bipolar disorder are lithium, lamotrigine, valproate and olanzapine. Historical and symptom profiles help with treatment selection. With the growing recognition of bipolar II disorders, it is anticipated that a larger body of evidence will become available to guide treatment of this common and disabling condition. These guidelines also discuss issues related to bipolar disorder in women and those with comorbidity and include a section on safety and monitoring.

Bipolar II disorder: an overview of recent developments

OBJECTIVE

Recent research on the epidemiology, clinical course, diagnosis, and treatment of bipolar II disorder (BD II) stands to have a considerable impact on clinical practice. This paper reviews these developments.

METHOD

We conducted a Pubmed search, focusing on the period from January 1, 1994, to August 31, 2004. Articles deemed directly relevant to the epidemiology, course, diagnosis, and management of BD II were considered.

RESULTS

The prevalence of BD II is likely higher than previously suggested. Systematic probing for particular clinical features and use of screening tools allow for a more timely and accurate detection of the disorder. There is a paucity of good quality data to guide clinicians treating BD II.

CONCLUSION

Significant progress has been made in clarifying diagnostic and treatment issues in BD II. Neither strong nor broad treatment recommendations can be made; a cautious interpretation of available data suggests that lithium or lamotrigine are fairly reasonable first-line choices. More well-designed studies with larger samples are needed to improve the evidence base for managing this disorder.