The bipolar spectrum: diagnostic and pharmacologic considerations

Epilepsy and bipolar disorder

It is well recognized that mood disorders and epilepsy commonly co-occur. Despite this, our knowledge regarding the relationship between epilepsy and bipolar disorder is limited. Several shared features between the two disorders, such as their episodic nature and potential to run a chronic course, and the efficacy of some antiepileptic medications in the prophylaxis of both disorders, are often cited as evidence of possible shared underlying pathophysiology. The present paper aims to review the bidirectional associations between epilepsy and bipolar disorder, with a focus on epidemiological links, evidence for shared etiology, and the impact of these disorders on both the individual and wider society. Better recognition and understanding of these two complex disorders, along with an integrated clinical approach, are crucial for improved evaluation and management of comorbid epilepsy and mood disorders.

Psychosocial morbidity associated with bipolar disorder and borderline personality disorder in psychiatric out-patients: comparative study

BACKGROUND

The morbidity associated with bipolar disorder is, in part, responsible for repeated calls for improved detection and recognition. No such commentary exists for the improved detection of borderline personality disorder. Clinical experience suggests that it is as disabling as bipolar disorder, but no study has directly compared the two disorders.

AIMS

To compare the levels of psychosocial morbidity in patients with bipolar disorder and borderline personality disorder.

METHOD

Patients were assessed with semi-structured interviews. We compared 307 patients with DSM-IV borderline personality disorder but without bipolar disorder and 236 patients with bipolar disorder but without borderline personality disorder.

RESULTS

The patients with borderline personality disorder less frequently were college graduates, were diagnosed with more comorbid disorders, more frequently had a history of substance use disorder, reported more suicidal ideation at the time of the evaluation, more frequently had attempted suicide, reported poorer social functioning and were rated lower on the Global Assessment of Functioning. There was no difference between the two patient groups in history of admission to psychiatric hospital or time missed from work during the past 5 years.

CONCLUSIONS

The level of psychosocial morbidity associated with borderline personality disorder was as great as (or greater than) that experienced by patients with bipolar disorder. From a public health perspective, efforts to improve the detection and treatment of borderline personality disorder might be as important as efforts to improve the recognition and treatment of bipolar disorder.

Borderline personality disorder: a disorder in search of advocacy

Compared with bipolar disorder, borderline personality disorder (BPD) is as frequent (if not more frequent), as impairing (if not more impairing), and as lethal (if not more lethal). Yet, BPD has received less than one-tenth the funding from the National Institutes of Health than has bipolar disorder. More than other reviewers of the literature on the interface between bipolar disorder and BPD, Paris and Black (Paris J and Black DW (2015) Borderline Personality Disorder and Bipolar Disorder: What is the Difference and Why Does it Matter? J Nerv Ment Dis 203:3-7) emphasize the clinical importance of correctly diagnosing BPD and not overdiagnosing bipolar disorder, with a focus on the clinical feature of affective instability and how the failure to recognize the distinction between sustained and transient mood perturbations can result in misdiagnosing patients with BPD as having bipolar disorder. The review by Paris and Black, then, is more of an advocacy for BPD than other reviews in this area have been. In the present article, the author will illustrate how the bipolar disorder research community has done a superior job of advocating for and "marketing" their disorder compared with researchers of BPD. Specifically, researchers of bipolar disorder have conducted multiple studies highlighting the problem with underdiagnosis, written commentaries about the problem with underdiagnosis, developed and promoted several screening scales to improve diagnostic recognition, published numerous studies of the operating characteristics of these screening measures, attempted to broaden the definition of bipolar disorder by advancing the concept of the bipolar spectrum, and repeatedly demonstrated the economic costs and public health significance of bipolar disorder. In contrast, researchers of BPD have almost completely ignored each of these issues and thus have been less successful in highlighting the public health significance of the disorder.

Clinical differentiation of bipolar II disorder from borderline personality disorder

PURPOSE OF REVIEW

Differentiating bipolar II disorder (BP II) from borderline personality disorder (BPD) is a common diagnostic dilemma. The purpose of this review is to focus on recent studies that have considered clinical differences between the conditions including family history, phenomenology, longitudinal course, comorbidity and treatment response, and which might advance their clinical distinction.

RECENT FINDINGS

Findings suggest key differentiating parameters to include family history, onset pattern, clinical course, phenomenological profile of depressive and elevated mood states, and symptoms of emotional dysregulation. Less specific differentiation is provided by childhood trauma history, deliberate self-harm, comorbidity rates, neurocognitive features, treatment response and impulsivity parameters.

SUMMARY

This review refines candidate variables for differentiating BP II from BPD, and should assist the design of studies seeking to advance their phenomenological and clinical distinction.

Sustained unemployment in psychiatric outpatients with bipolar depression compared to major depressive disorder with comorbid borderline personality disorder

OBJECTIVES

The morbidity associated with bipolar disorder is, in part, responsible for repeated calls for improved detection and recognition. No such clinical commentary exists for improved detection of borderline personality disorder in depressed patients. Clinical experience suggests that borderline personality disorder is as disabling as bipolar disorder; however, no studies have directly compared the two disorders. For this reason we undertook the current analysis from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project comparing unemployment and disability rates in patients with bipolar disorder and borderline personality disorder.

METHODS

Patients were interviewed with semi-structured interviews. We compared three non-overlapping groups of depressed patients: (i) 181 patients with DSM-IV major depressive disorder and borderline personality disorder, (ii) 1068 patients with major depressive disorder without borderline personality disorder, and (iii) 84 patients with bipolar depression without borderline personality disorder.

RESULTS

Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder were significantly more likely to have been persistently unemployed. A similar difference was found between patients with bipolar depression and major depressive disorder without borderline personality disorder. No differences were found between patients with bipolar depression and depression with borderline personality disorder.

CONCLUSIONS

Both bipolar disorder and borderline personality disorder were associated with impaired occupational functioning and thus carry a significant public health burden. Efforts to improve detection of borderline personality disorder in depressed patients might be as important as the recognition of bipolar disorder.

Decreased Serum Hepatocyte Growth Factor (HGF) in Individuals with Bipolar Disorder Normalizes after Zinc and Anti-oxidant Therapy

Aim:

To assess serum HGF concentration in individuals with bipolar disorder and investigate the efficacy of zinc therapy on these levels.

Subjects and methods:

Serum from 35 individuals diagnosed with bipolar disorder and 19 age and gender similar controls were tested for HGF concentration using ELISAs, and copper and zinc plasma levels using inductively-coupled plasma-mass spectrometry.

Results:

HGF serum levels of individuals with bipolar disorder were significantly lower than age and gender similar controls (P = 0.0021). HGF serum concentration was significantly lower in Bipolar patients pre-therapy (P = 0.0009) and HGF levels normalized post-therapy. Zinc levels in these same individuals also normalized (P = 0.0046) and patient’s perceived severity of Bipolar symptoms significantly decreased after therapy (P = 0.0003). We also found a significant direct correlation between Zinc and HGF serum concentration in the bipolar patients (P = 0.04).

Discussion:

These results suggest an association between low HGF levels and bipolar disorder and also demonstrate that zinc therapy may be associated with the normalization of HGF levels and decrease in severity of disease.

Increased Serum Cu/Zn SOD in Individuals with Bipolar Disorder

Aim

To assess serum Cu/Zn SOD (Superoxide Dismutase) concentration in individuals with bipolar disorder.

Subjects and methods

Serum from 20 individuals diagnosed with bipolar disorder and 20 age and gender similar controls were tested for Cu/Zn SOD serum concentration using ELISAs.

Results

Serum Cu/Zn SOD levels of individuals with bipolar disorder were significantly higher than age and gender matched controls.

Discussion

These results suggest an association between Cu/Zn SOD serum levels and bipolar disorder.

Validity and utility of bipolar spectrum models

The bipolar spectrum model suggests that several patient presentations not currently recognized by the DSM warrant consideration as part of a mood disorders continuum. These include hypomania or mania associated with antidepressants; manic symptoms which fall short of the current DSM threshold for hypomania; and depression attended by multiple non-manic markers that are associated with bipolar course. Evidence supporting the inclusion of these groups within the realm of bipolar disorder (BP) is examined. Several diagnostic tools for detecting and characterizing these patient groups are described. Finally, options for altering DSM-IV criteria to allow some of the above patient presentations to be recognized as bipolar are considered. More data on the validity and utility of these alterations would be useful, but limited changes appear warranted now. We describe an additional BP Not Otherwise Specified (BP NOS) example which creates a subthreshold hypomanic analogue to cyclothymia, consistent with existing BP NOS criteria. This change should be accompanied by additional requirements for the assessment and reporting of non-manic bipolar markers.