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

Optimizing differential diagnostics and identifying transdiagnostic treatment targets using virtual reality

Accurate diagnosis in psychiatry remains a significant challenge, often delaying appropriate treatment and resulting in poorer clinical outcomes. Identifying precise biomarkers for differential diagnosis is therefore crucial. This study aimed to identify distinct behavioral and psychophysiological markers of emotional reactivity in virtual reality (VR) settings among individuals with bipolar disorder (BD), borderline personality disorder (BPD), schizophrenia spectrum disorders (SSD), and healthy controls (HC). Participants (BD: n = 32, BPD: n = 21, SSD: n = 17, HC: n = 30) aged 19-60 were exposed to six immersive 360-degree social VR scenarios, ranging from neutral to highly emotional contexts (e.g., an elevator ride, a crying baby). Emotional responses were self-rated on a 1-5 scale, while galvanic skin response (GSR) was continuously recorded. Scenarios assessed feelings of unpleasantness, pleasantness, being observed, and the urge to comfort. Across diagnoses, individuals with mental health conditions reported more negative emotional responses (greater unpleasantness) across both neutral and negative scenarios (ps ≤ 0.02) despite similar GSR levels to HC. Specifically, in the elevator scenario, BPD and SSD experienced greater unpleasantness and feelings of being observed, coupled with stronger GSRs compared to BD (ps ≤ 0.03). SSD reported higher unpleasantness in the canteen scenario, less pleasantness in the happy baby scenario, and overall higher GSR than BD (ps ≤ 0.049). Negative emotional reactivity was consistent across BD, BPD, and SSD, with heightened emotional and physiological responses distinguishing SSD and BPD from BD in specific VR contexts. VR-based assessments of emotional and physiological markers show promise for improving differential diagnosis and identifying transdiagnostic treatment targets.

Personality functioning in bipolar 1 disorder and borderline personality disorder

BACKGROUND

Differentiation of borderline personality disorder (BPD) and bipolar I disorder (BD) has been challenging. The assessment of shared symptoms in the context of the overall personality functioning, the patient's sense of self, and the quality of his object (interpersonal) relations is proposed to be valuable for the differential diagnosis of these disorders.

METHODS

We empirically investigated the level of personality organization (PO), identity integration, and quality of object relations in patients suffering from BD or BPD using the Structured Interview of Personality Organization (STIPO) and the Level of Personality Functioning Scale (LPFS) in 34 BPD and 28 BD patients as well as 27 healthy control persons. Group comparisons and a logistic regression model were calculated to analyze group differences.

RESULTS

The BPD group showed significantly greater impairment in several domains of personality functioning, namely "identity", and "self- and other-directed aggression", while showing lower impairment in "moral values". The overall level of PO in the BPD group was significantly lower when excluding not only BPD but any personality disorder (PD) in the BD sample. Severity of impaired personality structure had a major impact on symptom load independent of the main diagnosis BD or BPD.

CONCLUSIONS

Our data show greater impairment in personality functioning in BPD than in BD patients. BD patients present with varying levels of PO, whereas in BPD severe deficits in PO are pathognomonic. The level of PO has a significant impact on symptom severity in both BD and BPD patients. Therefore, careful assessment of PO should be considered for differential diagnosis and adequate treatment planning.

A cluster analysis of attachment styles in patients with borderline personality disorder, bipolar disorder and ADHD

BACKGROUND

Insecure adult attachment has been associated with psychiatric disorders characterized by emotional dysregulation, such as borderline personality disorder (BPD), bipolar disorder (BD) and attention deficit/hyperactivity disorder (ADHD). However, little is known about the differences in attachment patterns between these diagnostic groups. The aim of this study was to identify clusters of adult attachment style in a cross-diagnostic group of patients with BDP and/or BD and/or ADHD and explore the characteristics of these clusters based on temperament profile, childhood trauma and psychiatric diagnoses.

METHODS

K-means cluster analysis was used to identify subgroups, based on the Attachment Style Questionnaire Short Form dimensions, in a clinical cohort of 150 young adults (113 women and 37 men, mean age ± SD = 23.3 ± 2.1) diagnosed with BPD, and/or BD, and/or ADHD.

RESULTS

Three distinct clusters were identified: a secure, an insecure/avoidant-anxious and an insecure/avoidant cluster. These three clusters differed in temperament profile and related psychiatric diagnoses.

CONCLUSIONS

The three clusters of attachment in individuals with BPD, BD and/or ADHD could support differentiation between the disorders as well provide information usable for planning of treatment.

Prior psychiatric morbidity and differential psychopharmacological treatment patterns: Exploring the heterogeneity of bipolar disorder in a nationwide study of 9594 patients

OBJECTIVES

Individuals with bipolar disorders (BD) have heterogenic pre-onset illness courses and responses to treatment. The pattern of illness preceding the diagnosis of BD may be a marker of future treatment response. Here, we examined associations between psychiatric morbidity preceding the diagnosis of BD and pharmacological treatment patterns in the 2 years following diagnosis.

METHODS

In this register-based study, we included all patients with a diagnosis of BD attending Danish Psychiatric Services between January 1, 2012 and December 31, 2016. We examined the association between a diagnosis of substance use disorder, psychosis (other than schizophrenia or schizoaffective disorder), unipolar depression, anxiety/OCD, PTSD, personality disorder, or ADHD preceding BD and pharmacological treatment patterns following the diagnosis of BD (lithium, valproate, lamotrigine, antidepressants, olanzapine, risperidone, and quetiapine) via multivariable Cox proportional hazards regression adjusted for age, sex, and year of BD diagnosis.

RESULTS

We included 9594 patients with a median age of 39 years, 58% of whom were female. Antidepressants, quetiapine, and lamotrigine were the most commonly used medications in BD and were all linked to prior depressive illness and female sex. Lithium was used among patients with less diagnostic heterogeneity preceding BD, while valproate was more likely to be used for patients with prior substance use disorder or ADHD.

CONCLUSION

The pharmacological treatment of BD is linked to psychiatric morbidity preceding its diagnosis. Assuming that these associations reflect well-informed clinical decisions, this knowledge may inform future clinical trials by taking participants' prior morbidity into account in treatment allocation.

The comparison of hot and cold executive functions in patients with bipolar II disorder, borderline personality disorder, and healthy individuals

Background

Differential diagnosis of bipolar II disorder (BD-II) and borderline personality disorder (BPD) has always been challenging for clinicians due to symptoms' overlap. This study aimed to compare hot and cold executive functions (EFs) in BD-II patients, as well as BPD and healthy controls (HCs), in order to differentiate these two disorders.

Methods

In the present study, 30 BD-II and 30 BPD patients undergoing the drug therapy with mood stabilizers, and 30 HC were examined using EFs evaluated tests. The data were then analyzed using ANOVA and Tukey post hoc test.

Results

The BD-II Patients performed significantly less in all cold EFs than the HC. Also, BPD patients had meaningfully lesser performance compared to HC in all cold EFs except sustained attention. No significant difference was perceived between the two patient groups in the cold EFs. In BD-II patients, the risky decision-making as a hot EFs' component was not significantly different from HC; nevertheless, its amount was significantly higher in BPD than in the HC and BD-II patients.

Conclusion

These findings underline the differences between the two mentioned disorders based on the hot EFs, which may indicate further disorder in the emotional information processing system among the BPD patients.

The Management of Perinatal Borderline Personality Disorder

Borderline personality disorder (BPD) is highly prevalent in clinical perinatal mental health settings, although there are few systematic programmes to identify BPD at this time. Retrospective studies show compromised birth outcomes for women with this condition, and several authors have highlighted a significant range of problem outcomes for offspring identifiable from early infancy through the adult years, including the intergenerational transfer of mental health problems from mother to child. A literature review identifies the varying prevalence rates found in non-clinical and clinical settings and the paucity of published studies on the management of perinatal BPD, in particular focused both on the mother and mother-infant relationships. A case study is presented to show both the potential benefits of inpatient mother-baby unit protocols and of specialised longer-term group therapy. Many knowledge gaps can be identified for further clinical research that could potentially benefit families with perinatal BPD, including systematic identification of perinatal BPD and intensive programmes that not only could perhaps improve birth outcomes but also provide skills to mothers to help with their emotional regulation and potentially improve mother-infant relationships and longer-term offspring developmental pathways.

Importance of Longitudinal Assessments in a Case of Comorbid Polysubstance Use Disorder and Borderline Personality Disorder Misdiagnosed As Bipolar I Disorder

Differentiating between borderline personality disorder (BPD) and bipolar disorder (BD) can be difficult. Both may present with altered mood states, deliberate self-harm, suicidality, impulsivity, unstable relationships, and risky behaviors. A manic episode is characterized by at least one week of elevated or irritated mood and at least three of the following: distractibility, impulsivity, grandiosity, flight of ideas, psychomotor activity, decreased need for sleep, and pressured speech. Borderline personality disorder is characterized by unstable mood and relationships, fear of abandonment, impulsivity, self-mutilation, suicidality, and a feeling of emptiness. In combination with polysubstance use, borderline personality disorder can present similarly to a manic episode and lead to an incorrect diagnosis of bipolar I disorder. In this study, we present a 44-year-old female whose psychiatric history highlights the importance of long-term patient observation in making an accurate diagnosis. Over the course of several years, she was given incorrect psychiatric diagnoses, including attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder, and bipolar I disorder. As a result, her interpersonal relationships remained unstable and significantly affected her quality of life. Over the course of consistent, long-term psychiatric appointments, conversations with family members, and notes from previous psychiatrists, it became evident that substance use had also complicated her psychiatric history, leading to the aforementioned diagnoses. Once this was established, she was diagnosed with borderline personality disorder; subsequent correct medical intervention has been integral in helping her maintain a steady job and improve her interpersonal relationships and quality of life.

Altered regional homogeneity and its association with cognitive function in adolescents with borderline personality disorder

BACKGROUND

Adolescents with borderline personality disorder often have cognitive impairment, but the underlying mechanism for this is not clear. This study was aimed at assessing alterations in regional homogeneity using resting-state functional MRI (fMRI) in adolescents with borderline personality disorder, and evaluating the associations between regional homogeneity and cognitive testing scores.

METHODS

We enrolled 50 adolescents with borderline personality disorder (age 12-17 years) and 21 age- and sex-matched healthy controls. We performed regional homogeneity and seed-based functional connectivity analysis for both groups. We also performed correlative analysis for regional homogeneity and cognitive testing scores.

RESULTS

Compared with healthy controls, adolescents with borderline personality disorder had reduced regional homogeneity values in the frontal cortex (including the left inferior orbitofrontal cortex and the bilateral superior frontal cortex) as well as in the left precuneus in the default mode network. Adolescents with borderline personality disorder also had higher regional homogeneity values in several cortical regions: the right middle temporal gyrus, the right cuneus, the right precentral gyrus and the left middle occipital gyrus. Regional homogeneity values in the left middle occipital gyrus, left inferior orbitofrontal cortex and right superior frontal gyrus were associated with cognitive testing scores in adolescents with borderline personality disorder. We also found increased functional connectivity between the left middle occipital gyrus and right superior frontal gyrus in adolescents with borderline personality disorder.

LIMITATIONS

This study had a modest sample size, with a possible case selection bias for patients with more severe illness. This cohort also included patients with comorbidities or taking psychotropic medications, which may have confounded study results.

CONCLUSION

Alterations in regional homogeneity and functional connectivity in brain regions that involve the limbic-cortical circuit could be neural correlates for cognitive impairment in adolescents with borderline personality disorder.

Understanding the development of bipolar disorder and borderline personality disorder in young people: a meta-review of systematic reviews

BACKGROUND

There is ongoing debate on the nosological position of bipolar disorder (BD) and borderline personality disorder (BPD). Identifying the unique and shared risks, developmental pathways, and symptoms in emerging BD and BPD could help the field refine aetiological hypotheses and improve the prediction of the onset of these disorders. This study aimed to: (a) systematically synthesise the available evidence from systematic reviews (SRs) and meta-analyses (MAs) concerning environmental, psychosocial, biological, and clinical factors leading to the emergence of BD and BPD; (b) identify the main differences and common features between the two disorders to characterise their complex interplay and, (c) highlight remaining evidence gaps.

METHODS

Data sources were; PubMed, PsychINFO, Embase, Cochrane, CINAHL, Medline, ISI Web of Science. Overlap of included SRs/MAs was assessed using the corrected covered area process. The methodological quality of each included SR and MA was assessed using the AMSTAR.

RESULTS

22 SRs and MAs involving 249 prospective studies met eligibility criteria. Results demonstrated that family history of psychopathology, affective instability, attention deficit hyperactivity disorder, anxiety disorders, depression, sleep disturbances, substance abuse, psychotic symptoms, suicidality, childhood adversity and temperament were common predisposing factors across both disorders. There are also distinct factors specific to emerging BD or BPD.

CONCLUSIONS

Prospective studies are required to increase our understanding of the development of BD and BPD onset and their complex interplay by concurrently examining multiple measures in BD and BPD at-risk populations.

Prevalence of Comorbid Personality Disorder in Psychotic and Non-psychotic Disorders

Introduction: The burden of personality disorders (PDs) in China is large and the focus on mental health services is increasing. However, there is a lack of sufficient evidence regarding the prevalence of comorbid PD in psychotic and non-psychotic disorders, and whether PDs have different distributions. We aimed to investigate the PD comorbidity distribution pattern between psychotic and non-psychotic disorders using a clinical population-based study. Materials and Methods: We conducted a cross-sectional study of 1,497 patients in Shanghai. PDs were screened using the Personality Diagnostic Questionnaire Fourth Edition Plus (PDQ-4+). All patients were interviewed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) Axis II (SCID-II). We compared the differences in PD comorbidities classified as the 10 types of PDs in the DSM-IV, in 531 patients with psychosis and 966 patients with non-psychotic disorders. Results: More than one-third (37%) of patients with psychotic disorders met the criteria of at least one PD. Approximately half (46%) of patients with non-psychotic disorders met the criteria of at least one PD. Patients with non-psychotic disorders were more likely to meet the criteria of borderline (χ² = 20.154, p < 0.001) and obsessive-compulsive PD (χ² = 21.164, p < 0.001) diagnoses compared to those with psychotic disorders. In contrast, patients with psychotic disorders were more likely to meet the criteria of paranoid (χ² = 11.144, p = 0.001) and schizotypal PD (χ² = 14.004, p < 0.001) diagnoses than those with non-psychotic disorders. Discussion: PD comorbidity is common and comorbidity distribution pattern is varied in patients with psychotic and non-psychotic disorders, implicating the development of specific strategies that could screen and assess PDs in psychiatric clinical practice.