Differentiating borderline personality disorder (BPD) from bipolar disorder: diagnostic efficiency of DSM BPD criteria

OBJECTIVE

We sought to determine the differential diagnostic efficiency of all DSM-IV borderline personality disorder (BPD) criteria by studying a sample of those with BPD and a contrast group with a bipolar disorder (BP).

METHOD

Participants were clinically assessed and assigned diagnoses based on DSM criteria - with prevalence rates and diagnostic efficiency values calculated.

RESULTS

Fifty-three participants were assigned a BPD diagnosis, 83 a BP diagnosis, with comorbid participants excluded. The mean number of DSM BPD criteria assigned was 6.6 (SD = 1.0) in the BPD group and 1.9 (SD = 1.3) in the BP group. The most prevalent criterion in the BPD group was 'affective instability' (AI) (92.5%), with 'inappropriate anger' least endorsed (49%). The highest specificity criterion was 'abandonment fears', which displayed the greatest positive predictive value (PPV) = 0.9, and with AI offering the lowest specificity. 'Unstable relationships' had the highest overall negative predictive value (NPV) = 0.91. The highest percentage accuracy of classification was provided by 'identity disturbance' and 'abandonment fears' criteria, both 85%.

CONCLUSION

The transdiagnostic nature of 'affective instability' means it is less useful for diagnostic decisions, whereas 'abandonment fears' and 'identity disturbance' offer superior diagnostic efficiency in distinguishing BPD from BP.

Comparison of guidelines for the treatment of unipolar depression: a focus on pharmacotherapy and neurostimulation

OBJECTIVE

To determine the level of agreement across a set of evidence-based guidelines for management of the unipolar depressive disorders and with a focus on physical treatments.

METHOD

A literature search was undertaken using the terms 'depression', 'depressive' and 'guidelines', using PubMed, Cochrane Database of Systematic Reviews and the National Guideline Clearinghouse. Twelve national psychiatric or professional guideline-producing organizations were identified from the period 2007-2017, with guidelines qualitatively reviewed by two assessors.

RESULTS

For major depressive disorder (MDD), there was general consensus to use an antidepressant (AD) in cases of greater severity, although disagreement on AD use in mild to moderate depression. There was some agreement on choice of AD class in first-line treatment recommendations, though great variability in second- and third-line management particularly in recommended augmentation and combined AD strategies. Electroconvulsive therapy was considered in all but one guideline, with other neurostimulation treatments being less consistently covered and with variable recommendations. Finally, there was low consistency in the management of dysthymia, persistent depressive disorder and treatment resistant depression.

CONCLUSION

Our review identifies varying levels of consistency in guideline recommendations. Strategies to improve reliability in guideline formulation should also improve their validity.

Clinical vs. DSM diagnosis of bipolar disorder, borderline personality disorder and their co-occurrence

OBJECTIVE

To investigate the extent and reasons contributing to discrepancies between those receiving a DSM as against a clinical diagnosis of a bipolar disorder (BP) and/or a borderline personality disorder (BPD).

METHOD

We interviewed participants previously receiving a BP or BPD diagnosis, studying those who met DSM or clinical criteria for one or both conditions. We compared the numbers of participants allocated to the three diagnostic categories according to rater strategy to calculate concordance rates and determine reasons for discordance.

RESULTS

Rates of assignment to BP, BPD and comorbid BP/BPD varied according to the diagnostic strategy. Concordance rates were reduced as BP disorder duration criteria were relaxed, with discordance mainly arising from clinical allocation of a BP disorder for those DSM assigned as unipolar depression. Rates of BPD allocation varied marginally, with discordance mostly arising from so clinically diagnosed receiving a comorbid BP/BPD DSM diagnosis. Finally, DSM overestimated comorbidity compared with clinician diagnoses. Of central importance, not imposing the DSM duration criteria for BP did not increase the prevalence of misdiagnosing BPD, a finding at variance with the literature.

CONCLUSION

Rates and reasons for discordance between clinical and DSM diagnosis are detailed, which should assist clinical decision-making.

Differentiating the bipolar disorders from borderline personality disorder

OBJECTIVE

To identify features differentiating bipolar disorder (BP) from borderline personality disorder (BPD) and with each condition variably defined.

METHOD

Participants were assigned a BP or BPD diagnosis on the basis of DSM criteria and, separately, by clinical judgment, and undertook a diagnostic interview and completed self-report measures.

RESULTS

Predictors of BPD status varied according to diagnostic decisions, but with the most consistent items being childhood sexual abuse, childhood depersonalization, personality variables relating to relationship difficulties and sensitivity to criticism, and the absence of any BP family history. Across diagnostic groups, personality measure items alone predicted diagnostic allocation with an accuracy of 81-84%, the refined study variables other than hypo/manic features improved the classification rates to 88%, and when the presence or absence of hypo/manic features was added, classification rates increased to 92-95%.

CONCLUSION

Study findings indicate that BPD can be differentiated from BP with a high degree of accuracy.

Preconditioning prevents myocardial stunning after cardiac transplantation

BACKGROUND

Preconditioning has been shown to reduce myocardial stunning after reversible global ischemia. To determine whether preconditioning improves functional recovery after cardiac transplantation, 16 sheep were randomly assigned to a preconditioning protocol or to a control group.

METHODS

Preconditioning was achieved with 5 minutes of global ischemia followed by 10 minutes of reperfusion. The heart was then arrested with 1 L of crystalloid cardioplegia, explanted, stored in a transport cooler, and then transplanted into recipient sheep. The total ischemia time was 2 hours. Pressure-volume loops were used to calculate preload recruitable stroke work, the maximum elastance, and diastolic compliance. Linear regression analysis was used to determine the preload recruitable stroke work, maximum elastance, and diastolic compliance-and end-diastolic volume relationship. The area under the regression curve for preload recruitable stroke work was defined as the preload recruitable stroke work area. Biopsies were taken for high-energy phosphates.

RESULTS

Systolic function, represented by preload recruitable stroke work area, was preserved after cardiac transplantation in preconditioned animals. Maximum elastance and diastolic compliance were unaffected by preconditioning or ischemia. High-energy phosphates were better preserved in preconditioned animals.

CONCLUSION

Preconditioning prevented myocardial stunning and preserved high-energy phosphates after experimental cardiac transplantation.

Clagett open-window thoracostomy in patients with empyema who had and had not undergone pneumonectomy

Patients with empyema not responding to simple chest-tube drainage and antibiotic therapy have been managed by a "Clagett"-type procedure that consists of open-window thoracostomy, antibiotic irrigation and closure of the window. The results of such treatment were reviewed. Of the 103 patients with empyema treated between 1967 and 1983, 41 underwent open-window thoracostomy. Twenty-eight (group 1) had empyema after pneumonectomy, 13 (group 2) did not; however, 9 of the 13 in group 2 had undergone lobectomy. The mean follow-up was 46 months for group 1 and 42 months for group 2. When surgical closure of the open-window thoracostomy was attempted, the success rate in group 1 was 85% for those without concomitant bronchopleural fistula, but only 36% in patients with a fistula. In group 2 the respective success rates were 50% and 57%. Unsuccessful closure resulted in chronic fistulas in four patients in each of the two groups. Six deaths in group 1 and two in group 2 were related to the original disease, but one was an operative death. These results demonstrate both the effectiveness and limitations of open-window thoracostomy in the management of these difficult cases.