The Impact of Impulsivity and Emotional Dysregulation on Comorbid Bipolar Disorder and Borderline Personality Disorder

Emotion dysregulation, impulsivity and anger rumination in borderline personality disorder: the role of amygdala and insula

Borderline Personality Disorder (BPD) is a severe mental disorder, characterized by deficits in emotion regulation, interpersonal dysfunctions, dissociation and impulsivity. Brain abnormalities have been generally explored; however, the specific contribution of different limbic structures to BPD symptomatology is not described. The aim of this study is to cover this gap, exploring functional and structural alterations of amygdala and insula and to highlight their contribution to neuropsychiatric symptoms. Twenty-eight BPD patients (23.7 ± 3.42 years; 6 M/22F) and twenty-eight matched healthy controls underwent a brain MR protocol (1.5 T, including a 3D T1-weighted sequence and resting-state fMRI) and a complete neuropsychiatric assessment. Volumetry, cortical thickness and functional connectivity of amygdala and insula were evaluated, along with correlations with the neuropsychiatric scales. BPD patients showed a lower cortical thickness of the left insula (p = 0.027) that negatively correlated with the Anger Rumination Scale (p = 0.019; r = - 0.450). A focused analysis on female patients showed a significant reduction of right amygdala volumes in BPD (p = 0.037), that correlate with Difficulties in Emotion Regulation Scale (p = 0.031; r =  - 0.415), Beck Depression Inventory (p = 0.009; r =  - 0.50) and Ruminative Response Scale (p = 0.045; r =  - 0.389). Reduced functional connectivity was found in BPD between amygdala and frontal pole, precuneus and temporal pole. This functional connectivity alterations correlated with Anger Rumination Scale (p = .009; r = - 0.491) and Barratt Impulsiveness Scale (p = 0.020; r = - 0.447). Amygdala and insula are altered in BPD patients, and these two limbic structures are implicated in specific neuropsychiatric symptoms, such as difficulty in emotion regulation, depression, anger and depressive rumination.

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.

Development of a screening algorithm for borderline personality disorder using electronic health records

Borderline personality disorder (BoPD or BPD) is highly prevalent and characterized by reactive moods, impulsivity, behavioral dysregulation, and distorted self-image. Yet the BoPD diagnosis is underutilized and patients with BoPD are frequently misdiagnosed resulting in lost opportunities for appropriate treatment. Automated screening of electronic health records (EHRs) is one potential strategy to help identify possible BoPD patients who are otherwise undiagnosed. We present the development and analytical validation of a BoPD screening algorithm based on routinely collected and structured EHRs. This algorithm integrates rule-based selection and machine learning (ML) in a two-step framework by first selecting potential patients based on the presence of comorbidities and characteristics commonly associated with BoPD, and then predicting whether the patients most likely have BoPD. Leveraging a large-scale US-based de-identified EHR database and our clinical expert’s rating of two random samples of patient EHRs, results show that our screening algorithm has a high consistency with our clinical expert’s ratings, with area under the receiver operating characteristic (AUROC) 0.837 [95% confidence interval (CI) 0.778–0.892], positive predictive value 0.717 (95% CI 0.583–0.836), accuracy 0.820 (95% CI 0.768–0.873), sensitivity 0.541 (95% CI 0.417–0.667) and specificity 0.922 (95% CI 0.880–0.960). Our aim is, to provide an additional resource to facilitate clinical decision making and promote the development of digital medicine.

Emotional Dysregulation, Temperament and Lifetime Suicidal Ideation among Youths with Mood Disorders

Background: Psychopathological dimensions contributing to suicidal ideation in young age are poorly understood. We aimed to investigate the involvement of emotional dysregulation and temperament in suicide risk in a sample of accurately selected young patients with mood disorders and a matched sample of healthy controls (HC). Methods: We assessed 50 young patients (aged 14–25 years) with DSM-5 bipolar or depressive disorders for clinical and psychopathological characteristics and 82 age and sex, educational level, and smoking habits-matched HC. Emotional dysregulation and temperament were assessed using the Difficulties in Emotion Regulation Scale (DERS) and the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire (TEMPS-A-39), respectively. We tested their associations with suicidal ideation, using standard univariate/bivariate methods, preceded by overall multivariate analysis. Results: In the group of patients, 24 (48%) reported lifetime suicide ideation (LSI). Patients with LSI scored higher on emotional dysregulation (p < 0.001) and cyclothymic (p < 0.001), irritable (p = 0.01), and hyperthymic temperaments (p = 0.003) than HC. Patients with LSI specifically presented with more emotional dysregulation (p < 0.001) and cyclothymic temperament (p = 0.001), than patients without LSI (N = 26). Conclusions: Temperamental features, in particular cyclothymic temperament, and emotion dysregulation may represent independent factors for increased vulnerability to lifetime suicidal ideation in young adults with mood disorders.

Moderators of the association between depressive, manic, and mixed mood symptoms and suicidal ideation and behavior: An analysis of the National Network of Depression Centers Mood Outcomes Program

BACKGROUND

It has not been established that suicide risk with mixed symptoms is any greater than the depressive component or if there is synergy between depressive and manic symptoms in conveying suicide risk.

METHODS

The National Network of Depression Centers Mood Outcomes Program collected data from measurement-based care for 17,179 visits from 6,105 unique individuals with clinically diagnosed mood disorders (998 bipolar disorder, 5,117 major depression). The Patient Health Questionaire-8 (PHQ-8) captured depressive symptoms and the Altman Self-Rating Mania scale (ASRM) measured hypomanic/manic symptoms. Generalized linear mixed models assessed associations between depressive symptoms, manic symptoms, and their interaction (to test for synergistic effects of mixed symptoms) on the primary outcome of suicidal ideation or behavior (secondarily suicidal behavior only) from the Columbia-Suicide Severity Rating Scale (C-SSRS). Moderation was assessed.

RESULTS

PHQ-8 scores were strongly associated with suicide-related outcomes across diagnoses. ASRM scores showed no association with suicidal ideation/behavior in bipolar disorder and an inverse association in major depression. There was no evidence of synergy between depressive and manic symptoms. There was no moderation by sex, race, or mood disorder polarity. Those over 55 years of age showed a protective effect of manic symptoms, which was lost when depressive symptoms were also present (mixed symptoms).

DISCUSSION

Mixed depressive and manic symptoms convey no excess risk of suicidal ideation or behavior beyond the risk conveyed by the depressive symptoms alone. Depressive symptoms are strongly linked to suicidal ideation and suicidal behavior and represent an important and potentially modifiable risk factor for suicide.