Decreased oxytocin levels related to social cognition impairment in borderline personality disorder

INTRODUCTION

Dysfunctions in the oxytocin system have been reported in patients with borderline personality disorder (BPD). Deficits could be related to interpersonal hypersensitivity, which has been previously associated with failures in social cognition (SC) in this disorder, especially in Theory of Mind (ToM) skills. The aim of this work is to study the links between the oxytocin system and SC impairments in patients with BPD.

METHOD

Plasma oxytocin levels (OXT) and protein expression of oxytocin receptors in blood mononuclear cells (OXTR) were examined in 33 patients with a diagnosis of BPD (age: M 28.85, DT = 8.83). Social cognition was assessed using the Movie for the Assessment of Social Cognition (MASC). Statistical associations between biochemical factors and different response errors in MASC were analyzed through generalized linear regression controlling for relevant clinical factors.

RESULTS

Generalized linear regression showed a significant relationship between lower OXTR and overmentalization in BPD patients (OR = 0.90).

CONCLUSIONS

This work supports the relationship between alterations in the oxytocin system and ToM impairments observed in BPD patients, enhancing the search for endophenotypes related to the phenotypic features of the disorder to improve current clinical knowledge and address more specific therapeutic targets.

Hypothalamic-pituitary-thyroid axis function in female adolescent nonsuicidal self-injury and its association with comorbid borderline personality disorder and depression

OBJECTIVES

Behavioral disturbances in adolescence are potentially linked to aberrant functioning of the thyroid gland. Accordingly, alterations of the hypothalamic-pituitary-thyroid (HPT) axis might impact psychopathological development. Yet corresponding research in adolescents with nonsuicidal self-injury (NSSI) and comorbid mental disorders is scarce.

METHODS

The present study examined HPT axis functioning in adolescents with NSSI compared to healthy controls (HC) using blood-based assays of thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), and the ratio of these hormones (fT3/fT4 ratio). Cortisol was additionally examined to contrast HPT axis functioning with a well-established biomarker of stress responsivity. Moreover, associations between clinical characteristics, HPT axis and HPA axis functioning were investigated. Female adolescents meeting NSSI criteria according to DSM-5 criteria (n = 117) were compared to adolescent HC (n = 41). Standardized serum-based endocrinological assays and interview- and questionnaire-based psychiatric assessments were used. Smoking status was included as covariate for all analyses.

RESULTS

NSSI patients displayed altered HPT axis functioning as fT3/fT4 ratio values were blunted in comparison to HC. Negative correlations were further present between fT3, fT3/fT4 ratio and severity of BPD symptoms, depression scores and symptomatic distress. TSH correlated negatively with severity of BPD symptoms and symptomatic distress exclusively. Cortisol values differed neither significantly between experimental groups nor correlated significantly with clinical characteristics.

CONCLUSIONS

Longitudinal examinations, assessing links between psychopathology and endocrinological alterations, are warranted to address potential clinical implications of thyroid markers in child and adolescent psychiatry.

Inflammatory and antioxidant pathway dysfunction in borderline personality disorder

INTRODUCTION

This study investigates the alteration of the inflammatory/oxidative pathway in patients with borderline personality disorder (BPD) and its relationship with clinical features of the disorder.

METHODS

49 BPD patients and 33 healthy control subjects were studied. Plasma levels of TBARS, nitrites, and the antioxidant enzymes CAT, GPx and SOD were measured. In addition, peripheral blood mononuclear cells were obtained to investigate levels of intracellular components of the inflammatory/oxidative pathway including the IκBα, NFκB, iNOS, COX2, Keap1, NQO1, and HO1. Western Blot and ELISA were used to measure protein expression. Patients were assessed for different clinical dimensions of BPD with scales for depression, anxiety, impulsivity and functioning.

RESULTS

A significant decrease of IκBα levels and a significant increase of inflammatory factors, including NFκB, COX2 and iNOS levels were found in patients. On the other hand, a significant decrease was observed for all antioxidant enzymes in patients with BPD, except for HO1. The inflammatory factor NFκB showed a significant positive correlation with impulsivity scores.

CONCLUSIONS

Patients with BPD presented an increased activation of several components of the inflammatory pathways, as well as an inhibition of the antioxidant path. These alterations appear partially correlated with the impulsivity scores in these patients.

Bipolar affective disorder and borderline personality disorder: Differentiation based on the history of early life stress and psychoneuroendocrine measures

INTRODUCTION

Borderline Personality Disorder (BPD) and Bipolar Affective Disorder (BD) have clinical characteristics in common which often make their differential diagnosis difficult. The history of early life stress (ELS) may be a differentiating factor between BPD and BD, as well as its association with clinical manifestations and specific neuroendocrine responses in each of these diagnoses.

OBJECTIVE

Assessing and comparing patients with BD and BPD for factors related to symptomatology, etiopathogenesis and neuroendocrine markers.

METHODOLOGY

The study sample consisted of 51 women, divided into 3 groups: patients with a clinical diagnosis of BPD (n = 20) and BD (n = 16) and healthy controls (HC, n = 15). Standardized instruments were used for the clinical evaluation, while the history of ELS was quantified with the Childhood Trauma Questionnaire (CTQ), and classified according to the subtypes: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. The functioning of the hypothalamic-pituitary-adrenal (HPA) axis was evaluated by measuring a single plasma cortisol sample.

RESULTS

Patients with BPD presented with more severe psychiatric symptoms of: anxiety, impulsivity, depression, hopelessness and suicidal ideation than those with BD. The history of ELS was identified as significantly more prevalent and more severe in patients (BPD and BP) than in HC. Emotional abuse, emotional neglect and physical neglect also showed differences and were higher in BPD than BD patients. BPD patients had greater severity of ELS overall and in the subtypes of emotional abuse, emotional neglect and physical neglect than BD patients. The presence of ELS in patients with BPD and BP showed significant difference with lower cortisol levels when compared to HC. The endocrine evaluation showed no significant differences between the diagnoses of BPD and BD. Cortisol measured in patients with BPD was significantly lower compared to HC in the presence of emotional neglect and physical neglect. A significant negative correlation between the severity of hopelessness vs cortisol; and physical neglect vs cortisol were found in BPD with ELS. The single cortisol sample showed a significant and opposite correlations in the sexual abuse diagnosis-related groups, being a negative correlation in BD and positive in BPD.

DISCUSSION

Considering the need for a multi-factorial analysis, the differential diagnosis between BPD and BD can be facilitated by the study of psychiatric symptoms, which are more severe in the BPD patients with a history of early life stress. The function of the HPA axis assessed by this cortisol measure suggests differences between BPD and BP with ELS history.

CONCLUSION

The integrated analysis of psychopathology, ELS and neuroendocrine function may provide useful indicators to differentiate BPD and BD diagnoses. These preliminary data need to be replicated in a more significant sample with improved and multiple assessments of HPA axis activity.

Fatty acid ethanolamide levels are altered in borderline personality and complex posttraumatic stress disorders

Borderline personality (BPD) and complex posttraumatic stress disorders (PTSD) are both powerfully associated with the experience of interpersonal violence during childhood and adolescence. The disorders frequently co-occur and often result in pervasive problems in, e.g., emotion regulation and altered pain perception, where the endocannabinoid system is deeply involved. We hypothesize an endocannabinoid role in both disorders. We investigated serum levels of the endocannabinoids anandamide and 2-arachidonoylglycerol and related fatty acid ethanolamides (FAEs) in BPD, PTSD, and controls. Significant alterations were found for both endocannabinoids in BPD and for the FAE oleoylethanolamide in PTSD suggesting a respective link to both disorders.

Reduced plasma oxytocin levels in female patients with borderline personality disorder

The neuropeptide oxytocin is involved in social cognition and interaction across species and plays a crucial role in the regulation of affiliative behaviors. Oxytocin levels in cerebrospinal fluid (CSF), but also in plasma or urine, have been shown to be negatively associated with childhood traumata, aggressive behavior, and suicide attempts. Recently, an altered activity of the oxytocin system has been discussed to play a prominent role in borderline personality disorder (BPD), which is thought to be closely related to traumatic experiences in childhood and is characterized by (para)suicidal behaviors as well as aggressive outbursts. In the present study, we compared plasma oxytocin levels of women with and without BPD in the follicular phase and assessed the relationship between oxytocin concentrations and childhood traumata. Women diagnosed with BPD had significantly reduced oxytocin concentrations, even after controlling for estrogen, progesterone, and contraceptive intake. In addition, plasma oxytocin correlated negatively with experiences of childhood traumata, in particular with emotional neglect and abuse. The results of mediation analyses do not support a model of oxytocin being a prominent mediator in the link between childhood trauma and BPD. Thus, the findings indicate dysregulations in the oxytocin system of patients diagnosed with BPD with more longitudinal research being necessary to disentangle the relationship between childhood adversities, oxytocin system, and psychopathology.

Serum cholesterol concentration and structured individual psychoanalytic psychotherapy in suicidal and non-suicidal male patients suffering from borderline personality disorder

Findings from numerous studies suggest an association between low cholesterol levels and suicidal behavior in patients with different psychiatric diagnoses. The aims of this case-control study were to test whether cholesterol levels in male suicidal patients (N=20) with borderline personality disorder (BPD) are lower than in male non-suicidal patients (N=20) with BPD and male healthy control group (N=20), and to evaluate the influence of structured individual psychoanalytic psychotherapy on suicidal behavior. The groups were matched for age and body mass index (BMI). Results showed that serum cholesterol levels did not differ significantly between suicidal and non-suicidal BPD patients and healthy controls. The level of psychopathology (measured by Brief Psychiatric Rating Scale and Hamilton Depression Rating Scale) was significantly higher in the group of suicidal patients, which indicates the importance of evaluating particular clinical symptoms in BPD, in order to prevent suicidal behavior. Non-suicidal male patients suffering from BPD received more frequently structured individual psychoanalytic psychotherapy prior to the hospitalization than suicidal group. These results emphasized the role of this type of psychotherapy in preventing suicidal behavior in BPD patients.

Cortisol response to interpersonal stress in young adults with borderline personality disorder: a pilot study

Hypothalamic-pituitary-adrenal axis dysregulation after stress was found to be associated with borderline personality disorder (BPD). Nine female BPD young adults and 12 control subjects were investigated for stress reactivity and recovery after an interpersonal conflict discussion with their mothers. BPD subjects showed a delayed cortisol response after psychosocial stress.

Cortisol response to interpersonal stress in young adults with borderline personality disorder: a pilot study

Hypothalamic-pituitary-adrenal axis dysregulation after stress was found to be associated with borderline personality disorder (BPD). Nine female BPD young adults and 12 control subjects were investigated for stress reactivity and recovery after an interpersonal conflict discussion with their mothers. BPD subjects showed a delayed cortisol response after psychosocial stress.

Stability of the dexamethasone suppression test in borderline personality disorder with and without comorbid PTSD: a one-year follow-up study

Alterations in hypothalamic-pituitary-adrenal axis feedback regulation have been repeatedly reported in patients with borderline personality disorder (BPD). Due to the cross-sectional design of these studies, little is known about the longitudinal course of HPA axis functioning. In a sample of 13 patients with BPD, the dexamethasone suppression test (DST) has been used in a one-year follow-up study. There were no changes of cortisol concentrations before or after dexamethasone intake between baseline and follow-up examination. Patients with comorbid posttraumatic stress disorder (PTSD) showed more pronounced cortisol suppression compared to those without PTSD. The DST seems to be a stable marker of alterations in HPA axis feedback regulation in BPD, which is also reflected by substantial correlations between percentage of cortisol suppression at baseline and follow-up examination.

Hypothalamic-pituitary-adrenal axis response in borderline personality disorder without post-traumatic features

Hypothalamic-pituitary-adrenal (HPA) axis sensitivity was investigated in 32 non-medicated patients with borderline personality disorder without comorbid post-traumatic syndromes and in 18 normal individuals using a modified dexamethasone suppression test (0.25 mg). Enhanced cortisol suppression was found in the patients v. controls (P<0.05) and the percentage of participant's with non-suppression was smaller in the patient (34%) than in the control group (89%) (P<0.01). Baseline cortisol levels in the patients were also lower than in the controls (P<0.05). The 0.25 mg dexamethasone suppression test reveals increased feedback inhibition of the HPA in borderline personality disorder.

Dexamethasone suppression test in borderline personality disorder--effects of posttraumatic stress disorder

BACKGROUND

Divergent findings of hypothalamic-pituitary-adrenal (HPA) axis functioning in borderline personality disorder (BPD) may be caused by a different degree of comorbid posttraumatic stress disorder (PTSD), in which alterations of the HPA axis are well known. Here we investigate alterations of the HPA axis in BPD patients with and without comorbid PTSD compared to healthy controls. Considering previous findings current major depression (MDD) was taken into account as a confounding variable.

METHODS

Apart from clinical assessment the 0.5 mg dexamethasone suppression test (DST) was performed in 21 female borderline patients and 23 healthy controls.

RESULTS

Twelve BPD patients suffered from comorbid PTSD. Relative suppression (%) did not differ between healthy controls and the total BPD group, but BPD patients with comorbid PTSD showed increased suppression compared to those without. Comorbid MDD was not associated with suppression.

CONCLUSIONS

Our results do not indicate a dysfunction of the HPA axis in BPD. However, comorbid PTSD seems to be associated with a relative hypersuppression in the 0.5 mg DST.

Visceral fat deposition and insulin sensitivity in depressed women with and without comorbid borderline personality disorder

OBJECTIVE

Major depressive disorder (MDD) is associated with increased intra-abdominal fat, an important antecedent of noninsulin-dependent diabetes mellitus (NIDDM) and cardiovascular disorders. Furthermore, MDD is commonly accompanied by endocrine and immune dysregulation that has also been discussed in connection with the pathogenesis of NIDDM and ischemic heart disease. In borderline personality disorder (BPD), a dysregulation of the hypothalamic-pituitary-adrenal system has also been described. Therefore, our study aimed at examining visceral fat, insulin resistance, and alterations of cortisol and cytokines in young depressed women with and without comorbid BPD.

METHODS

Visceral fat was measured in 18 premenopausal women with MDD and in 18 women comorbid with MDD and BPD by means of magnetic resonance tomography at the level of the first lumbar vertebral body. Twelve BPD patients without MDD and 20 healthy women served as the comparison groups. Concentrations of fasting cortisol, tumor necrosis factor-alpha, and interleukin-6 were measured, and indicators of insulin resistance and beta-cell sensitivity were calculated according to the homeostasis assessment model.

RESULTS

We found increased visceral fat in women comorbid with MDD and BPD, and to a lesser extent, in women with MDD but without BPD. Insulin sensitivity was reduced in comorbid patients. Serum interleukin-6 (IL-6) and tumor necrosis factor-alpha concentrations were significantly increased in both groups of depressed patients. Reduced insulin sensitivity correlated with the amount of visceral fat and with serum concentrations of IL-6.

CONCLUSION

Young depressed women with and without comorbid BPD display increased visceral fat and may constitute a risk group for the development of NIDDM and the metabolic syndrome. Our data support the hypothesis that the immune and endocrine alterations associated with MDD and BPD may contribute to the pathophysiologic processes associated with NIDDM.

Enhanced serum cholesterol and triglyceride levels in bulimia nervosa: relationships to psychiatric comorbidity, psychopathology and hormonal variables

Increased levels of cholesterol have been reported in patients with bulimia nervosa (BN), but all but one of the published studies were performed on non-fasting subjects, which limits the interpretation of this finding. Moreover, the relationships between serum lipids and comorbid psychiatric disorders or bulimic psychopathology have scarcely been investigated. We measured serum levels of total cholesterol, triglycerides, glucose, 17beta-estradiol and thyroid hormones in 75 bulimic women and 64 age-matched healthy females after an overnight fast. Compared with healthy women, bulimic patients exhibited significantly enhanced serum levels of cholesterol and triglycerides, but similar values of glucose, 17beta-estradiol, FT3 and FT4. No significant differences emerged in these variables between patients with or without comorbid depression, borderline personality disorder or lifetime anorexia nervosa. Circulating cholesterol was positively correlated to the patients' drive for thinness, ineffectiveness, enteroceptive awareness and impulse regulation sub-item scores of the Eating Disorder Inventory-2. These findings confirm that BN is associated with increased levels of serum lipids. This alteration may be involved in the pathophysiology of certain psychopathological characteristics of BN and cannot be explained by the co-occurrence of other psychiatric disorders.

A possible effect of amisulpride on a prolactinoma growth in a woman with borderline personality disorder

The authors report the case of a woman with borderline personality disorder who developed a prolactinoma probably induced by amisulpride. This patient was treated with 300 mg of amisulpride per day for a delirium. Her brain MRI was normal. Four months later this patient developed a micro-adenoma (5mm) on the right side of the pituitary gland with amenorrhea and galactorrhea. Amisulpride treatment was withdrawn and replaced by a treatment of quetiapine 100 mg day(-1). The hyperprolactinemia symptoms disappeared. This report shows that the short-term use of amisulpride treatment was linked to an elevation in the PRL level with a possible induction of a pituitary adenoma.

Antithyroid antibody-linked symptoms in borderline personality disorder

Circulating thyroid autoantibodies are more prevalent in patients with mood disorders than in the general population, but longitudinal clinical data that establish a relationship between thyroid antibody status and the course of any psychiatric syndrome have been lacking. In addition, scant attention has been paid to thyroid hormones and autoimmunity in borderline personality disorder (BPD). We report a case of a patient with classic BPD whose fluctuating mood and, especially, psychotic symptoms-rated using a double-blind method-were directly linked to antithyroglobulin antibody titers serially determined over an inpatient period of 275 d. Significantly lower psychosis and depression ratings were seen during a 4-wk period of relatively low antithyroid antibody titers, during blinded treatment with carbamazepine, than were observed during two high autoantibody epochs. The significant positive correlations between nurse- and patient-rated depression and thyroid autoantibodies over the entire period of inpatient study were similar to those also observed between urinary free cortisol levels and depression; the positive correlation between antithyroglubulin antibody titers and psychotic symptoms was stronger (r = +0.544; p < 0.002). Although this patient had biochemical indices of primary hypothyroidism, she showed only marginal improvement to triiodothyronine (T3) and no apparent clinical response to sustained levorotatory thyroxine (T4) administration; neither were antithyroid antibody titers significantly associated with changes in T3, free T4, or thyroid-stimulating hormone concentrations. She clinically deteriorated during a 50-d fluoxetine trial. The present data demonstrate a clinically significant, longitudinal correlation between fluctuating antithyroid antibody titers and symptoms of borderline psychopathology in our patient. It will be of interest to determine the prevalence, pathophysiologic mechanisms, and treatment implications of this putative autoimmune- BPD link.

Dexamethasone suppression test findings in subjects with personality disorders: associations with posttraumatic stress disorder and major depression

OBJECTIVE

Previous studies using the 1.0-mg dexamethasone suppression test (DST) in subjects with personality disorders have produced mixed results. However, these studies focused on major depression and did not consider the possible effects of the comorbidity of posttraumatic stress disorder (PTSD). PTSD has been shown to be associated with increased cortisol suppression. To investigate the effect of PTSD, the authors conducted a 0.5-mg DST, which is more sensitive than the 1.0-mg DST for detection of increased cortisol suppression, in a group of subjects with personality disorders.

METHOD

Subjects with personality disorders (N=52) ingested 0.5 mg of dexamethasone. Pre- and postfasting blood samples were drawn for measurement of cortisol levels. A three-way analysis of covariance was used to test for the main effects of major depression, PTSD, and gender on percent cortisol suppression, with plasma dexamethasone concentration as a covariate. Secondary analyses assessed for main and interaction effects of age at which trauma(s) occurred and a diagnosis of borderline personality disorder.

RESULTS

Neither major depression nor gender had a significant effect on percent cortisol suppression. Subjects with PTSD had significantly higher percent cortisol suppression than subjects with major depression. Age at which trauma(s) occurred and a borderline personality disorder diagnosis had no significant main or interaction effects on cortisol suppression.

CONCLUSIONS

A high level of cortisol suppression was associated with PTSD in subjects with personality disorder. This finding is similar to published findings for PTSD subjects without personality disorders. Major depression, gender, age when trauma(s) occurred, and a diagnosis of borderline personality disorder did not have significant main or interaction effects on cortisol suppression.

Human impulsive aggression: a sleep research perspective

Impulsive aggression is commonly associated with personality disorders, in particular antisocial and borderline personality disorders as well as with conduct disorder and intermittent explosive disorder. The relationship between impulsive aggression and testosterone is well established in many studies. One of the aims of this study was to characterize the relationship between earlier-mentioned different categorical psychiatric diagnosis describing human impulsive aggression and sleep using polysomnography and spectral power analysis. Another aim was to study the relationship between serum testosterone and sleep in persons with severe aggressive behaviour. Subjects for the study were 16 males charged with highly violent offences and ordered for a pretrial forensic psychiatric examination. The antisocials with borderline personality disorder comorbidity had significantly more awakenings and lower sleep efficiency compared with the subjects with only antisocial personality disorder. The subjects with severe conduct disorder in childhood anamnesis had higher amount of S4 sleep and higher relative theta and delta power in this sleep stage compared with males with only mild or moderate conduct disorder. The same kind of sleep architecture was associated with intermittent explosive disorder. In subgroups with higher serum testosterone levels also the amount of S4 sleep and the relative theta and delta power in this sleep stage were increased. The study gives further support to the growing evidence of brain dysfunction predisposing to severe aggressive behaviour and strengthens the view that there are different subpopulations of individuals with antisocial personality varying in impulsiveness. The differences in impulsiveness are reflected in sleep architecture as well.

Serum cholesterol and leptin levels in patients with borderline personality disorder

The association between low or lowered cholesterol and impulsivity, aggressive behaviours and suicide remains controversial. In the present study, cholesterol and leptin levels of patients with borderline personality disorder in whom impulsivity, aggressive behaviours and suicide attempts are clearly established have been compared with those of healthy controls. The study group consisted of 16 patients with borderline personality disorder and 16 healthy controls. All patients were assessed with the Barratt Impulsivity Scale (BIS), Buss-Durkee Hostility Inventory (BDHI) and Hamilton Depression Rating Scale (HDRS). Fasting serum cholesterol and leptin levels were measured. The mean cholesterol and leptin levels of the patient group were significantly lower than those of the controls. Likewise, the patients with current suicidal thoughts and a history of suicide attempt had statistically significantly lower cholesterol and leptin levels compared with the patients without those features. There was an inverse correlation between both cholesterol and leptin levels, and impulsivity as determined by the BIS or aggression as determined by the BDHI, but no correlation between both cholesterol and leptin levels and the HDRS was found in the patients. In conclusion, the present study demonstrates that the patients with borderline personality disorder have lower cholesterol and leptin levels than healthy controls. Low serum cholesterol and leptin levels are associated with all dimensions of the disorder - impulsivity, aggression and suicidality - but are not associated with the presence and the severity of comorbid depression.

Serum leptin and cholesterol values in suicide attempters

The growing number of studies examining the relationship between suicide and lipid metabolism are based upon studies suggesting that cholesterol-lowering procedures may increase the risk of death due to suicide or impulsive-aggressive behavior. Leptin seems to be strongly associated with lipid metabolism. In the present study, serum total cholesterol and leptin levels were compared in 24 suicide attempters and 24 healthy controls. The patients with suicide attempts had significantly lower serum cholesterol and leptin levels than controls. There was a positive correlation between cholesterol and leptin levels in both groups. Our results suggest that suicide attempts seem to be associated with decreased serum cholesterol and leptin levels.

Prevalence of acute intermittent porphyria in a Mexican psychiatric population

BACKGROUND

Acute intermittent porphyria is a hereditary error of porphyrin metabolism in which the main metabolic defect is caused by a decrease in porphobilinogen deaminase activity. Previous work has demonstrated a higher prevalence of acute intermittent porphyria in the psychiatric patient population than in the general population. The goal of this study was evaluate 300 psychiatric patients and 150 control subjects to detect acute intermittent porphyria by measurement of porphobilinogen (PBG) deaminase activity in blood.

METHODS

Screening for porphobilinogen deaminase activity was carried out by fluorometric measurement of porphyrins synthesized during 1 h in blood and the measurement of delta-aminolevulinic acid and porphobilinogen in urine.

RESULTS

We found two psychiatric patients, one male and one female, with decreased porphobilinogen deaminase activity. When the families of these patients were studied, one brother was found to have an abnormality. Among controls, a woman was found to have the abnormality and her father was found to have typical features of the disease.

CONCLUSIONS

These results indicate a prevalence of porphyria in Mexican psychiatric patients similar to controls, and that measurement of PBG deaminase activity is a good tool for defining acute intermittent porphyria carriers.

Childhood abuse and platelet tritiated-paroxetine binding in bulimia nervosa: implications of borderline personality disorder

BACKGROUND

Co-occurrence of bulimia nervosa and borderline personality disorder has been attributed to shared factors, including childhood abuse and disturbances in central serotonin (5-hydroxytryptamine; 5-HT) mechanisms. To explore this notion, we conducted a controlled assessment of childhood abuse and 5-HT function in bulimics with and without borderline personality disorder.

METHOD

Forty patients with bulimia nervosa, confirmed with the Eating Disorders Examination interview (14 with borderline personality disorder and 26 without), and 25 normal-eater controls were assessed for clinical symptoms (eating disturbances, mood lability, impulsivity, and dissociation) and childhood sexual and physical abuse. We also conducted tests of platelet tritiated-paroxetine binding in blood samples from 27 of the bulimics (11 with borderline personality disorder and 16 without) and 16 of the controls.

RESULTS

Relative to normal eaters, bulimics showed greater affective instability, overall impulsivity, and a history of physical abuse. However, borderline bulimics alone showed elevated motor impulsivity, dissociation, and rates of sexual abuse. Paroxetine-binding tests indicated no differences attributable to comorbid borderline personality disorder, instead linking bulimia nervosa with or without borderline personality disorder to substantially reduced 5-HT transporter density.

CONCLUSION

Results suggest relatively autonomous pathologic entities: one, relevant to bulimia nervosa, being associated with abnormal 5-HT transporter function and affective instability, but relatively independent of childhood sexual abuse; another, relevant to borderline personality disorder, onto which sexual abuse, dissociative symptoms, and behavioral impulsivity converge. We propose that abnormal 5-HT function may, however, constitute one basis for the frequent co-occurrence of bulimic and borderline disturbances.

Serum cholesterol and impulsivity in personality disorders

Decreased serum cholesterol has been associated with impulsive aggressive behaviors. This study was designed to explore the relationship between serum cholesterol levels and measures of impulsive aggression in personality disordered patients. Forty-two personality disordered patients (14 borderline personality disorder, 28 other personality disorders) were included. Fasting serum cholesterol was measured by standard enzymatic assay. An ANOVA was performed with factors of gender and diagnosis, looking at two-way interactions between the factors and serum cholesterol. Patients with borderline personality disorder were found to have significantly lower serum cholesterol than non-borderline personality disorders. A significant interaction effect was also seen between gender and diagnosis with the male patients having lower cholesterol levels. This study suggests there may be a relationship between borderline personality disorder and low serum cholesterol.

Borderline personality, impulsiveness, and platelet monoamine measures in bulimia nervosa and recurrent suicidal behavior

This study examined the relationship between borderline and impulsive personality traits on the one hand, and monoamine function on the other in 15 women with bulimia nervosa and 15 women with recurrent suicidal behavior. Platelet serotonin (5-HT) and platelet monoamine oxidase (MAO) activity were used as peripheral measures of monoaminergic function. All suicide attempters were diagnosed as having a borderline personality disorder, whereas this diagnosis was less frequent in bulimics. Bulimics with borderline comorbidity resembled recurrent suicide attempters with borderline personality disorder more closely in both psychological (anger, impulsive behavior) and biochemical characteristics (platelet 5-HT) than bulimics without borderline personality disorder. Platelet 5-HT was higher in patients with borderline personality than in normal female controls and was positively correlated with the disposition to experience anger. Impulsive personality traits were consistently negatively correlated with platelet MAO activity. Our findings support the subdivision of bulimics according to the presence of borderline or "multi-impulsive" personality disorder.

The relationship of platelet 5-HT2 receptor indices to major depressive disorder, personality traits, and suicidal behavior

Previous research has suggested that major depression and suicidal behavior may be associated with altered serotonin receptor function. In this study, platelet serotonin2 (5-HT2) receptor binding indices were measured in conjunction with serotonin-amplified platelet aggregation, a response mediated by the platelet 5-HT2 receptor complex, in depressed patients and normal controls. The magnitude of serotonin-amplified platelet aggregation was positively correlated with the number of platelet 5-HT2 receptor sites in both groups. Mean values for the receptor binding indices and the receptor-mediated response did not differ significantly between patients and controls, although patients exhibited a wider range of values for each parameter compared with controls. Exploratory analyses were undertaken to determine clinical variables that might contribute to the increased variance in depressed individuals. These analyses failed to reveal a statistically significant relationship between any of the platelet 5-HT2 receptor measures and the subtype or severity of depressive illness, or the presence of comorbid borderline personality disorder. Although the mean number of receptor sites did not differ between patients who had recently attempted suicide and those who had never attempted suicide, a strong positive correlation (p = 0.002) was found between receptor number and the degree of medical damage resulting from the suicidal act. Furthermore, the ratio of the serotonin-amplified platelet aggregation response to platelet 5-HT2 receptor number, an index of the mean responsivity of an individual receptor complex, was lower in suicide attempters versus nonattempters (p = 0.06) and normal controls (p = 0.01). Exploratory analyses also suggested that recent exposure to psychotropic medication may result in a significant increase in platelet 5-HT2 receptor number (p = 0.03). Thus, although the study did not show a consistent alteration in platelet 5-HT2 receptor indices in major depression, the data suggest that specific factors such as suicidality and drug exposure may explain some of the variance in depressed patients.

Hemodialysis for lithium intoxication: preliminary guidelines for emergency

In Japan, 9 cases of severe lithium intoxication have been treated by hemodialysis so far, and the usefulness and indications of this procedure are not yet understood fully. We have recently experienced a case of lithium intoxication treated by hemodialysis. Considering this case together with those reported previously, we have prepared some preliminary guidelines for the application of hemodialysis to patients with lithium intoxication. The blood concentration of lithium, renal function, the severity of consciousness disturbance and clinical symptoms such as somatic complications are, of course, important indices for the application of this therapy. We think that the signs of intoxication and the time interval between the onset and the beginning of treatment also serve as useful indices for application of hemodialysis.

Tryptophanemia and tyrosinemia in adolescents with impulsive behavior

Tryptophan (TRP) and tyrosine (TYR), respectively the circulating precursors of the central serotonergic (5-HT) and catecholamine systems, were measured in eight adolescents with impulsive behavior regardless of the exact type of disorder. The 6 week study period included weekly blood sampling and clinical evaluation. The ratios of TRP and TYR to large neutral amino acids (LNAA), which indicate the availability for the synthesis of neurotransmitters, were calculated. Comparison of results with eight hospitalized controls of the same age (12.5 to 18 years) revealed lower total TRP levels in four adolescent patients, a lower TRP/LNAA ratio in three adolescents, and a lower free TRP concentration in six adolescents with discretely enhanced albuminemia. A slight increase in TYR and the TYR/LNAA ratio was noted in nearly all of the adolescent patients. Despite the heterogeneity of individual biological results, the impulsive behavior subjects in this study seemed to present abnormalities in neurotransmitter precursors.

Platelet and whole blood serotonin content in depressed inpatients: correlations with acute and life-time psychopathology

Platelet or whole blood serotonin content did not differ significantly in patients with major depression compared to healthy controls, but within the patient group, platelet serotonin levels correlated negatively with severity of depression (r = -0.49, p = 0.007). Levels were 39% lower in patients who had made a suicide attempt compared to nonattempter patients (47.2 +/- 27.3 versus 77.6 +/- 41.7 ng/10(8) platelets, p = 0.04). Conversely, comorbid borderline personality disorder (85.3 +/- 41.5 ng/10(8) platelets) was associated with 31% greater platelet serotonin content than nonborderline patients (58.9 +/- 31.1 ng/10(8) platelets) and 27% greater than healthy controls (62.4 +/- 19.8 ng/10(8) platelets). A pronounced seasonal variation in whole blood and platelet serotonin content was found in both patients and controls, largely due to lower levels in summer. Excluding cases tested in the summer abolished the statistically significant differences in patients with and without comorbid borderline personality disorder (BPD). Nevertheless, BPD attempters had lower serotonin levels than BPD nonattempters but higher serotonin levels than non-BPD attempters. Current hostility and a life-time history of aggression were positively correlated with platelet serotonin content (r = 0.44, p = 0.04 and r = 0.41, p = 0.06). This study provides evidence for an association between lower platelet serotonin content and depression and suicidal behavior, and association of higher platelet serotonin content and comorbid borderline personality disorder and behavior traits such as aggressivity.

Interaction between carbamazepine and fluvoxamine

In 3 patients the addition of fluvoxamine to a constant dosage of carbamazepine (CZP) caused a substantial rise of plasma CZP accompanied by symptoms of intoxication. As this drug combination may occur increasingly in the future, this probably pharmacokinetic interaction is of practical relevance.

The dexamethasone suppression test in borderlines: is it useful?

The relationship between borderline personality disorders (BPD) and major depressive disorder (MDD) continues to be controversial. A reliable biological marker for depressed BPD patients would not only support the diagnosis but could also help in predicting treatment outcome. A large sample of psychiatric patients was screened and data on the Dexamethasone Suppression Test (DST) were obtained for 67 patients who met the criteria for BPD by scoring 7 or greater on the Diagnostic Interview for Borderlines. The DST was positive in 23.9% of the cases. Fifty cases of BPD also met the Research Diagnostic Criteria for MDD. The DST was positive in 26.0%. Of the 50 patients with MDD, 34 also met the criteria for endogenous depression. Only 17.6% of this subgroup had positive results on the DST. The low sensitivity and specificity of the DST for depression in BPD patients suggests that the DST is not a useful test in differentiating BPD patients with MDD from those without MDD. The possible reasons for the DST not being useful in this population are discussed. These findings raises further questions about the nature of the depression suffered by BPD patients.

Platelet alpha 2-adrenergic receptor binding sites in major depressive disorder and borderline personality disorder

Platelet alpha 2-adrenergic receptor binding sites were measured in a group of patients with major depressive disorder (MDD) (n = 23) and in normal controls (n = 25). When all depressed subjects were compared to controls, there were no differences in either Kd (affinity of the ligand) or total binding site (number/platelet), although a significant change in the ratio of high to low affinity states was observed in the depressed group. When the depressed patients were subdivided into those with and without a co-occurring borderline personality disorder (BPD), the BPD group had significantly fewer alpha 2 high affinity binding sites, while the group with depression alone had significantly more binding sites (both low and high affinity) than the control group. The results support the concept that assessment of comorbid diagnoses may be essential to biological studies of depression.

Altered platelet alpha 2-adrenergic receptor binding sites in borderline personality disorder

The authors found significantly fewer total platelet alpha 2-adrenergic receptor binding sites in 13 nonmedicated patients with borderline personality disorder than in 11 patients with borderline personality disorder who were receiving low doses of benzodiazepines and 18 nonpsychiatric control subjects. The two patient groups showed comparable degrees of depression as assessed by the Hamilton Rating Scale for Depression. However, nonmedicated borderline patients were considerably more anxious than medicated patients, raising the possibility that lower alpha 2-adrenergic receptor binding in borderline personality disorder is related to anxiety.

Serotonin uptake by platelets of suicidal and aggressive adolescent psychiatric inpatients

Thirty-four adolescent psychiatric inpatients were studied in order to find out whether there is a correlation between serotonin platelet uptake (SPU), suicidality and aggression. The patients were divided into four main diagnostic groups according to clinical data: borderline personality disorder, affective disorder (unipolar) including schizoaffective disorder, schizophrenia and 'others'. These patients were also characterized by the quantitative symptoms profile from K-SADS scale (Children's Version of the Schedule of Affective Disorders and Schizophrenia) and by their behavior: aggression, suicide attempts and violent suicide attempts. In the schizophrenic group, a correlation was found between low Vmax values of SPU and aggressive behavior (p less than 0.05). In addition, in the 'other' group a correlation was found between low Vmax values of SPU and conduct disorder (p less than 0.05). On the other hand, in 'other' patients a correlation was found between low Km values of SPU and violent suicide attempt (p less than 0.05). It is noteworthy that the lowest (20-35%) Vmax values of SPU were found in the patients of the affective group as compared to values of the three other diagnostic groups. These findings are similar to those concerning unipolar depressive adults. It is assumed that there are less binding sites for serotonin on platelets of depressive adolescents than was suggested for depressive adults.

Lack of effect of dopamine receptor blockade on the TSH response to TRH in borderline personality disorder

We recently reported that some patients with borderline personality disorder (BPD) exhibit a blunted thyrotropin (thyroid-stimulating hormone; TSH) response to thyrotropin-releasing hormone (TRH). Because it is known that dopamine can inhibit the TSH response to TRH and that some patients with BPD show improvement with antipsychotic (dopamine-blocking) medication, we investigated whether haloperidol could reverse the blunted TSH response in BPD. Of 12 patients with BPD, three showed a blunted TSH response that did not normalize with haloperidol. Furthermore, there were no overall group changes in TSH response with haloperidol. The present study suggests that reductions in TSH response in BPD are not secondary to dopamine.

[New diagnostic and neuroendocrine approaches to the borderline syndrome]

The recent literature reflects a growing interest in Borderline Disorders. This paper summarizes the recent developments on nosological, genetical and biological aspects of the Borderline syndrome. Original neuroendocrine results from our group are presented and discussed. They suggest that an endogenomorphic depressive spectrum may be associated with the Borderline personality disorders.

Dexamethasone suppression test in hospitalized depressed patients with borderline personality disorder

There is considerable disagreement about the relationship between borderline personality disorder and the affective disorders. The authors report the results of a study of the relationship between dexamethasone suppression and depressive subtype in hospitalized depressed borderline patients. Twenty-three patients met research criteria for unipolar major depressive episode without psychosis of at least moderate severity. Thirteen patients also met criteria for borderline personality disorder. Dexamethasone suppression test (DST) results showed no significant correlation with either melancholia or borderline personality disorder alone. However, of the 13 borderlines, eight failed to suppress and six of those eight were not melancholic. The authors conclude that abnormal response to dexamethasone in nonmelancholic borderlines casts some doubt on the specificity of the DST for melancholia.

Plasma cortisol and beta-endorphin immunoreactivity in nonmajor and major depression

Plasma cortisol levels of 28 hospitalized patients meeting Research Diagnostic Criteria for major or nonmajor (minor or intermittent) depression were significantly higher than those of eight normal subjects. In contrast, plasma beta-endorphin immunoreactivity was significantly lower in patients with nonmajor depression than in those with major depression or in normal subjects. A low ratio of plasma beta-endorphin to cortisol immunoreactivity was found to characterize patients in both groups. Through the use of only this ratio, a post-hoc analysis identified 25 depressed patients and seven controls. These findings have implications for psychiatric diagnosis and the involvement of the endogenous opioid system in the pathogenesis of depression.

The TRH test in patients wih borderline personality disorder

Fifteen patients with a primary diagnosis of borderline personality disorder were studied with the thyrotropin-releasing hormone (TRH) test. Twelve carried the additional diagnosis of depression, substance abuse, or both. A blunted thyroid-stimulating hormone (TSH) response to TRH was found in seven patients, two of whom were neither depressed nor had the additional diagnosis of depression and/or substance abuse. TSH blunting was unrelated to such factors as thyroid status, serum cortisol, weight, height, or body surface. Since TSH blunting occurs in about 25% of patients with major depression but not in schizophrenia, the findings suggest that some patients with borderline personality disorder share a neuroendocrine abnormality with some affective disorder patients.

Use of TSH response to TRH as an independent variable

The thyrotropin (TSH) response to thyrotropin-releasing hormone (TRH) was assessed in 35 consecutive male admissions. Patients with TSH blunting were identified; they were compared with patients without blunting and with normal subjects. Patients without TSH blunting were normal as regards all endocrine variables. Patients with TSH blunting showed reduced TSH (but normal prolactin) levels before and after TRH administration, although their thyroid hormone levels and cortisol levels were normal. Height, weight, and body surface were unrelated to TSH blunting. The test-retest reliability of a blunted TSH response was acceptable.

The dexamethasone suppression and thyrotropin-releasing hormone tests in depressed borderline patients

Borderline patients can be both a diagnostic and a therapeutic enigma. We investigated a group of 24 depressed women with borderline personality disorder or strong borderline features by DSM III criteria for the presence of either an abnormal dexamethasone suppression test (DST) or a blunted TSH response to TRH, abnormalities which have been reported in major depression. Thirteen of the 24 borderlines failed to suppress on the DST, compared with one of 14 normal women (p less than 0.01). Nine of the 24 borderlines had a blunted TSH response to TRH, compared with one of 11 normal women. Neuroendocrine abnormalities were found in a total of 75% of the borderline women, independent of whether or not they met DSM III criteria for major depressive disorder. The results of this study support the notion that many borderline patients with depression have a genuine affective component to their illness, perhaps biologically similar to major depression in non-borderlines.