Association between childhood maltreatment, psychopathology and DNA methylation of genes involved in stress regulation: Evidence from a study in Borderline Personality Disorder

Previous research suggests that childhood maltreatment is associated with epigenetic modification of genes involved in hypothalamic-pituitary-adrenal (HPA) functioning, which could cause dysregulation of the stress response system. If pervasive, this may be associated with the development of stress-related disorder in adults, including affective disorders, anxiety disorders, post-traumatic stress disorder (PTSD) or borderline-personality disorder (BPD). The majority of studies have focused on DNA methylation of the glucocorticoid receptor gene (NR3C1) and the FKBP5 encoding gene, which regulates the sensitivity of the glucocorticoid receptor (GR). How methylation of NR3C1 and FKBP5 interferes with childhood adversity and psychopathology as well as empathy is an under-researched issue. Here, we sought to investigate the association of childhood maltreatment in a sample of 89 individuals (44 healthy participants and 45 patients diagnosed with BPD) with the methylation of the 1_F promoter region of NR3C1 and the intron 7 of FKBP5 as well as with different measures of psychopathology and empathy. Methylation of FKBP5 (bin 2) correlated with anxiety (SCL-90-R) and the global psychopathological symptom load index (GSI), as well as with lower empathic perspective-taking abilities. Psychopathology and empathy impairments correlated with the level of childhood maltreatment. No difference in FKBP5 methylation was observed between the clinical and the non-clinical group. Methylation of NR3C1 was lower in BPD patients compared to controls, yet with small differences. The results are discussed regarding their biological relevance, including possible evolutionary explanations. In short, the regulation of the GR sensitivity by methylation of FKBP5 correlated with psychopathology and empathy scores, while no correlation emerged with the severity of childhood adversity.

Ovarian Hormones as a Source of Fluctuating Biological Vulnerability in Borderline Personality Disorder

PURPOSE OF REVIEW

To examine the potential role of ovarian hormones in biological vulnerability to borderline personality disorder (BPD). The review focuses primarily on research examining the menstrual cycle as a source of short-term lability of BPD symptom expression, while discussing the currently understudied possibility of ovarian hormone influence in the developmental course of BPD.

FINDINGS

Several patterns of menstrual cycle effects on BPD symptoms and relevant features in non-clinical samples have been observed in empirical studies. Most symptoms demonstrated patterns consistent with perimenstrual exacerbation; however, timing varied between high and low arousal symptoms, potentially reflecting differing mechanisms. Symptoms are typically lowest around ovulation, with an exception for proactive aggression and some forms of impulsive behaviors. Preliminary evidence suggests ovarian hormones may exert strong effects on BPD symptom expression, and further research is warranted examining mechanisms and developing interventions. Recommendations for researchers and clinicians working with BPD are provided.

Perimenstrual exacerbation of symptoms in borderline personality disorder: evidence from multilevel models and the Carolina Premenstrual Assessment Scoring System

BACKGROUND

Individuals with a borderline personality disorder (BPD) suffer from a constellation of rapidly shifting emotional, interpersonal, and behavioral symptoms. The menstrual cycle may contribute to symptom instability among females with this disorder.

METHODS

Fifteen healthy, unmedicated females with BPD and without dysmenorrhea reported daily symptoms across 35 days. Urine luteinizing hormone and salivary progesterone (P4) were used to confirm ovulation and cycle phase. Cyclical worsening of symptoms was evaluated using (1) phase contrasts in multilevel models and (2) the Carolina Premenstrual Assessment Scoring System (C-PASS), a protocol for evaluating clinically significant cycle effects on symptoms.

RESULTS

Most symptoms demonstrated midluteal worsening, a perimenstrual peak, and resolution of symptoms in the follicular or ovulatory phase. Post-hoc correlations with person-centered progesterone revealed negative correlations with most symptoms. Depressive symptoms showed an unexpected delayed pattern in which baseline levels of symptoms were observed in the ovulatory and midluteal phases, and exacerbations were observed during both the perimenstrual and follicular phases. The majority of participants met C-PASS criteria for clinically significant (⩾30%) symptom exacerbation. All participants met the emotional instability criterion of BPD, and no participant met DSM-5 criteria for premenstrual dysphoric disorder (PMDD).

CONCLUSIONS

Females with BPD may be at elevated risk for perimenstrual worsening of emotional symptoms. Longitudinal studies with fine-grained hormonal measurement as well as hormonal experiments are needed to determine the pathophysiology of perimenstrual exacerbation in BPD.

Reduced levels of the endocannabinoid arachidonylethanolamide (AEA) in hair in patients with borderline personality disorder - a pilot study

Endocannabinoids are involved in depressive and anxious symptoms and might play a role in stress-associated psychiatric disorders. While alterations in the endogenous cannabinoid system have been repeatedly found in patients with posttraumatic stress disorder (PTSD), this system has been mostly neglected in borderline personality disorder (BPD). However, there is first evidence for elevated serum levels of the endocannabinoids arachidonylethanolamide (AEA) and 2-arachidonyl-sn-glycerol (2-AG) in BPD patients compared to healthy controls and PTSD patients. In this study, hair endocannabinoids were analyzed, reflecting long-term endocannabinoid concentrations. We assessed AEA concentrations as well as 2-AG and the 2-AG main isomer 1-AG (1-AG/2-AG) in hair in women with BPD (n = 15) and age- and education-matched healthy women (n = 16). We found significantly reduced log AEA in BPD patients compared to healthy women (p = .03) but no differences in log 1-AG/2-AG concentrations. In addition, there was no association between 1-AG/2-AG and hair cortisol, but we found a non-significant correlation between hair concentrations of AEA and cortisol (p = .06). Our data indicate altered long-term release of endogenous cannabinoids in women with BPD depending on type of endocannabinoid. AEA has been suggested to modulate the basal activity of the endocannabinoid system and seems to attenuate depressive and anxious symptoms. Thus, chronically reduced AEA might contribute to psychiatric symptoms in BPD.

Attachment-Related Regulatory Processes Moderate the Impact of Adverse Childhood Experiences on Stress Reaction in Borderline Personality Disorder

In this study, the authors explored whether attachment insecurity moderates the effects of adverse childhood experiences on stress reactivity in the context of borderline personality disorder (BPD). Participants were 113 women (39 with BPD, 15 with some BPD criteria present, 59 without any BPD symptoms) who participated in the Trier Social Stress Test. Saliva samples were collected before and after the stressor and assayed for salivary alpha-amylase (sAA) and cortisol. Adverse childhood experiences were measured using the Childhood Trauma Questionnaire, and attachment by the Experiences in Close Relationships-Revised questionnaire. Results revealed that attachment avoidance and a combination of more adverse childhood experiences and attachment insecurity resulted in higher sAA levels and differences in reactivity to the stressor. Interactions between attachment anxiety and adverse childhood experiences were related to blunted cortisol reactivity. The results suggest that the influence of adverse childhood experiences on stress regulation in BPD may be moderated by attachment-related regulatory processes.

Brain activity to transitional objects in patients with borderline personality disorder

Adult patients with borderline personality disorders (BPD) frequently have attachments to inanimate transitional objects (TOs) such as stuffed animals. Using event-related potential (ERP) recordings, we determined in patients with BPD the neural correlates of the processing of these attachment-relevant objects and their functional significance. Sixteen female patients with BPD viewed pictures of their TOs, other familiar stuffed toys (familiar objects, FOs), and unfamiliar objects (UOs). ERPs in the patients were compared to those in 16 matched healthy controls who possessed a stuffed animal of comparably high familiarity. Here, we found a specific increase of frontal P3/LPP amplitude in patients with BPD, which was related to attachment anxiety and depression scores. Attachment-related TO stimuli in patients with BPD specifically modulated stages of emotional stimulus evaluation reflecting processing of self-relevance. The relation of the frontal ERP effect to patients' attachment anxiety and depression highlights the function of TOs for coping with anxiety about being abandoned by significant others and for dealing with depressive symptoms.

Increased testosterone levels and cortisol awakening responses in patients with borderline personality disorder: gender and trait aggressiveness matter

BACKGROUND

Borderline personality disorder (BPD) is characterized by antagonism, negative affectivity, disinhibition, and impairments in interpersonal functioning, including enhanced impulsive aggression. Interpersonal dysfunctions may be related to alterations in endocrine systems. The current study investigated alterations in basal activity of the hypothalamus-pituitary-gonadal (HPG) reproductive and the hypothalamus-pituitary-adrenal (HPA) stress system in BPD patients and their association to anger-related aggression with a particular focus on effects of gender and comorbid conditions of depression and posttraumatic stress disorder (PTSD).

METHOD

Saliva testosterone levels as well as cortisol awakening responses were assessed in 55 medication-free female and male patients with BPD and compared to 47 gender-, age-, and intelligence-matched healthy volunteers. In addition, analyses controlling for current depression and PSTD and bivariate correlations between testosterone and cortisol levels on the one hand and anger and aggressiveness on the other hand were performed.

RESULTS

The results revealed increased saliva testosterone levels in female and male patients with BPD as well as elevated cortisol awakening responses in female, but not male patients with BPD compared to healthy volunteers. Cortisol awakening responses were positively related to anger and aggressiveness in female patients with BPD, but no associations were found with testosterone levels.

CONCLUSION

In line with previous reports, the present results suggest endocrine alterations in BPD which may be associated with interpersonal impairments, such as increased anger-related aggressive behavior and could have implications for the development of new (psychopharmaco-) therapeutic interventions that may help to restore the alterations in the HPA and HPG systems.

Steroid regulation of T cell function appears unaltered in borderline personality disorder

Borderline personality disorder (BPD) is characterized by instability of interpersonal relationships and affection, impulsivity, and cognitive disruptions. Increasing evidence suggests hypothalamic-pituitary-adrenal (HPA) axis alterations in BPD. Changed glucocorticoid sensitivity of peripheral blood mononuclear cells is known in mood and posttraumatic stress disorders, representing frequent comorbidities in BPD. However, to the authors' knowledge, in BPD glucocorticoid sensitivity at the receptor level remains unexplored. Sixteen age-matched female BPD patients were compared to sixteen female healthy controls. In vitro steroid sensitivity of T cell proliferation was tested using aldosterone, dexamethasone, and hydrocortisone. Steroid sensitivity of BPD patients and healthy controls appeared comparable. Psychiatric comorbidities such as major depressive disorder or posttraumatic stress disorder and early life stress seemed to have had no influence on steroid sensitivity parameters. The data suggest unaltered GC sensitivity of T cell function in BPD.

[Neurobiology in borderline personality disorder]

Borderline personality disorder (BPD) is a severe psychiatric disorder characterised by instability of affect regulation, impulse control, interpersonal relationships, and self-image. The aim of this status article is to provide a brief overview of the neurobiological underpinnings of the core dimensions in BPD, as well as of the potential clinical implications. The latest results from genetic, endocrinologic, neuropsychologic, and neuroimaging research in identifying the dysfunctional neurobiological systems that could play a role in diathesis to BPD are presented.

Modeling borderline personality disorder based on the neurobehavioral foundation of major personality traits

Borderline personality disorder (BPD) is an exceedingly complex behavioral phenomenon that is in need of conceptual clarification within a larger model of personality disorders (PDs). The association of personality traits to BPD is discussed initially as a means of introducing a dimensional personality approach to understanding BPD. While this model suggests that PDs emerge at the extremes of personality dimensions, attempts to demonstrate such an association have been empirically disappointing and conceptually unilluminating. Therefore, in this article, we attempt to extend such models by outlining the neurobehavioral systems that underlie major personality traits, and highlight the evidence that they are subject to experience-dependent modification that can be enduring through effects on genetic expression, mainly through processes known as epigenetics. It is through such processes that risk for personality disorder may be modified by experience at any point in development, but perhaps especially during early critical periods of development. We conclude by presenting a multidimensional model of PDs, in general, and BPD, in particular, that relies on the concepts developed earlier in the article. Our goal is to provide a guide for novel clinical conceptualization and assessment of PDs, as well as research on their psychobiological nature and pharmacological treatment.

Fronto-limbic dysfunction in borderline personality disorder: a 18F-FDG positron emission tomography study

INTRODUCTION

Several functional neuroimaging studies have demonstrated abnormalities in fronto-limbic pathways when comparing borderline personality disorder (BPD) patients with controls. The present study aimed to evaluate regional cerebral metabolism in euthymic BPD patients with similar measured impulsivity levels by means of 18F-FDG PET during resting state and to compare them against a control group.

METHODS

The present study evaluates regional cerebral metabolism in 8 euthymic BPD patients with 18F-FDG PET during resting state as compared to 8 controls with similar socio-geographic characteristics.

RESULTS

BPD patients presented a marked hypo-metabolism in frontal lobe and showed hyper-metabolism in motor cortex (paracentral lobules and post-central cortex), medial and anterior cingulus, occipital lobe, temporal pole, left superior parietal gyrus and right superior frontal gyrus. No significant differences appeared in basal ganglia or thalamus.

CONCLUSIONS

Results reveal a dysfunction in patients' frontolimbic network during rest and provide further evidence for the importance of these regions in relation to BPD symptomatology.

Borderline personality disorder: a dysregulation of the endogenous opioid system?

The neurobiology of borderline personality disorder (BPD) remains unclear. Dysfunctions of several neurobiological systems, including serotoninergic, dopaminergic, and other neurotransmitter systems, have been discussed. Here we present a theory that alterations in the sensitivity of opioid receptors or the availability of endogenous opioids constitute part of the underlying pathophysiology of BPD. The alarming symptoms and self-destructive behaviors of the affected patients may be explained by uncontrollable and unconscious attempts to stimulate their endogenous opioid system (EOS) and the dopaminergic reward system, regardless of the possible harmful consequences. Neurobiological findings that support this hypothesis are reviewed: Frantic efforts to avoid abandonment, frequent and risky sexual contacts, and attention-seeking behavior may be explained by attempts to make use of the rewarding effects of human attachment mediated by the EOS. Anhedonia and feelings of emptiness may be an expression of reduced activity of the EOS. Patients with BPD tend to abuse substances that target mu-opioid receptors. Self-injury, food restriction, aggressive behavior, and sensation seeking may be interpreted as desperate attempts to artificially set the body to survival mode in order to mobilize the last reserves of the EOS. BPD-associated symptoms, such as substance abuse, anorexia, self-injury, depersonalization, and sexual overstimulation, can be treated successfully with opioid receptor antagonists. An understanding of the neurobiology of BPD may help in developing new treatments for patients with this severe disorder.

5HT2A receptor binding is increased in borderline personality disorder

BACKGROUND

Postmortem studies in suicide victims demonstrate an increase in the number of post-synaptic 5-HT(2A) receptor binding sites in ventral lateral and orbital frontal cortex. Diminished metabolic responses to serotonergic activation are noted in these areas in impulsive subjects with borderline personality disorder (BPD), a group at high risk for suicidal behaviors. We examined 5HT(2A) receptor binding potential (BP) in impulsive subjects with BPD, with positron emission tomography neuroimaging with [(18)F] altanserin.

METHODS

Fourteen female subjects with BPD were assessed for Axis I comorbidity, depressed mood, impulsivity, aggression, suicidality, childhood abuse, and compared with 11 healthy female control subjects. The 5HT(2A) receptor binding was evaluated in prefrontal cortex, anterior cingulate, hippocampus, temporal lobe, occipital cortex, and thalamus. Data were analyzed with Logan graphical analysis and a four-compartment (4C) model.

RESULTS

Hippocampal 5HT(2A) receptor binding was significantly increased in BPD subjects compared with control subjects in both Logan and 4C analyses, covarying for age. Hippocampal BP values were related to comorbid major depressive episode, with highest values found in non-depressed BPD subjects and lowest in healthy control subjects. The BP values were not related to depressed mood, impulsivity, aggression, suicidality, or childhood abuse.

CONCLUSIONS

5HT(2A) receptor binding is increased in the hippocampus of BPD subjects independent of depressed mood, impulsivity, aggression, suicidality, or childhood abuse. Dysregulation of serotonergic function in hippocampus might contribute to affective and behavioral symptoms in BPD.

Amygdala-prefrontal disconnection in borderline personality disorder

Abnormal fronto-amygdala circuitry has been implicated in impulsive aggression, a core symptom of borderline personality disorder (BPD). We examined relative glucose metabolic rate (rGMR) at rest and after m-CPP (meta-chloropiperazine) with (18)fluorodeoxyglucose (FDG) with positron emission tomography (PET) in 26 impulsive aggressive (IED)-BPD patients and 24 controls. Brain edges/amygdala were visually traced on MRI scans co-registered to PET scans; rGMR was obtained for ventral and dorsal regions of the amygdala and Brodmann areas within the prefrontal cortex (PFC). Correlation coefficients were calculated between rGMR for dorsal/ventral amygdala regions and PFC. Additionally, amygdala volumes and rGMR were examined in BPD and controls. Correlations PFC/amygdala Placebo: Controls showed significant positive correlations between right orbitofrontal (OFC) and ventral, but not dorsal, amygdala. Patients showed only weak correlations between amygdala and the anterior PFC, with no distinction between dorsal and ventral amygdala. Correlations PFC/amygdala: m-CPP response: Controls showed positive correlations between OFC and amygdala regions, whereas patients showed positive correlations between dorsolateral PFC and amygdala. Group differences between interregional correlational matrices were highly significant. Amygdala volume/metabolism: No group differences were found for amygdala volume, or metabolism in the placebo condition or in response to meta-chloropiperazine (m-CPP). We demonstrated a tight coupling of metabolic activity between right OFC and ventral amygdala in healthy subjects with dorsoventral differences in amygdala circuitry, not present in IED-BPD. We demonstrated no significant differences in amygdala volumes or metabolism between BPD patients and controls.

Evidence of disturbed amygdalar energy metabolism in patients with borderline personality disorder

In order to detect possible links between structural and neurochemical brain abnormalities we applied high resolution morphometric imaging and short-echo time absolute-quantification magnetic resonance spectroscopy (MRS) at the left hand side to the amygdala in 12 patients with borderline personality disorder (BPD) and 10 group-matched healthy controls. Confirming earlier reports we found a significant 11-17% reduction of amygdalar volumes in patients with BPD. In addition there was a significant 17% increase of left amygdalar creatine concentrations in BPD patients. Left amygdalar creatine concentration correlated positively with measures of anxiety and negatively with amygdalar volume. This pilot study of simultaneous amygdalar morphometry and spectroscopy in BPD reveals a possible link between amygdalar volume loss, psychopathology and neurochemical abnormalities in terms of creatine signals.

Bone mineral density, bone turnover, and osteoprotegerin in depressed women with and without borderline personality disorder

OBJECTIVE

Low bone mineral density has repeatedly been reported in patients with major depressive disorder (MDD), and MDD has been discussed as a risk factor for the development of osteoporosis. MDD in young adults often occurs in the context of borderline personality disorder (BPD), and both MDD and BPD have been associated with a dysregulation of the hypothalamic-pituitary-adrenal system and subsequent hypercortisolemia. To date, it is unclear whether comorbid BPD in depressed patients modulates the extent of bone mass reduction. Therefore, we examined bone density, markers of bone turnover, and proinflammatory cytokines in depressed patients with and without BPD. Patients with BPD alone and healthy women served as comparison groups.

METHOD

Twenty-four patients with MDD and 23 patients with comorbid MDD and BPD were included. Sixteen patients with BPD and 20 healthy women of similar body mass index served as the comparison group. BMD was assessed by means of dual-energy x-ray absorptiometry. Markers of bone turnover, endocrine and immune parameters were determined. For data analysis, the group of depressed patients without comorbid BPD was divided according to age into two groups (younger depressed patients with a mean age of 30 years and older patients with a mean age of 42.9 years).

RESULTS

BMD at the lumbar spine was significantly reduced in a) depressed women with comorbid BPD (mean age, 28.6 years) and in b) older depressed patients without BPD (mean age, 42.9 years). Osteocalcin, a marker of osteoblastic activity, and crosslaps, a marker of bone loss, were significantly different between the study groups. Tumor necrosis factor-alpha was increased in depressed patients when compared with healthy women. Furthermore, TNF-alpha was positively correlated with serum crosslaps, a marker for osteoclastic activity.

CONCLUSION

Depression is associated with reduced bone mass, in particular in patients with comorbid BPD. Possible factors contributing to BMD reduction include endocrine and immune alterations associated with either MDD or BPD. We conclude from our data that a history of MDD with and without comorbid BPD should be considered as a risk factor in clinical assessment instruments for the identification of persons prone to osteoporosis.

Cortisol, the cortisol-dehydroepiandrosterone ratio, and pro-inflammatory cytokines in patients with current major depressive disorder comorbid with borderline personality disorder

BACKGROUND

Major depression in young women is often comorbid with borderline personality disorder (BPD); however, adrenal steroids and pro-inflammatory cytokines in patients with comorbid current major depressive disorder and BPD (MDD/BPD) have not been systematically examined. Therefore, our study aimed at examining serum profiles of cortisol, cytokines, and the cortisol/dehydroepiandrosterone (cortisol/DHEA) ratio in MDD/BPD patients and a healthy comparison group.

METHODS

Twelve medication-free female patients with MDD/BPD and 12 healthy women were included. Serum profiles of cortisol, DHEA, tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and interleukin-1beta were sampled, and the molar cortisol/DHEA ratio was determined.

RESULTS

Concentrations of serum cortisol, TNF-alpha, and IL-6, as well as the cortisol/DHEA ratios were significantly increased in MDD/BPD patients as compared with the healthy comparison group.

CONCLUSIONS

Depressed patients with comorbid BPD display endocrine and immune alterations similar to those observed in cases of melancholic MDD without BPD. Elevated concentrations of serum cortisol, cortisol/DHEA ratios, and pro-inflammatory cytokines might indicate a state marker in these patients and might contribute to long-term metabolic alterations that have also been associated with MDD.

Impaired platelet [3H]paroxetine binding in female patients with borderline personality disorder

RATIONALE

There have been few studies of platelet paroxetine binding in borderline personality disorder (BPD).

OBJECTIVE

Our aim was to determine whether female BPD subjects show abnormalities in platelet paroxetine binding.

METHODS

Twenty-one female BPD subjects and 16 age- and gender-matched normal control subjects were assessed using the following: (1) Diagnostic Interview for Borderlines, Revised, (2) Diagnostic Assessment for Personality Pathology: Brief Questionnaire, and (3) Barratt Impulsivity Scale. Platelets were collected and assayed for platelet paroxetine binding.

RESULTS

Bmax was lower in the BPD group (p < 0.0001), but differences in Kd only reached a trend level. There were no associations with trait dimensions independent of diagnosis.

CONCLUSIONS

Reduced platelet paroxetine binding in female BPD patients may reflect presynaptic serotonin dysfunction.

Reduced glucose metabolism in temporo-parietal cortices of women with borderline personality disorder

Individuals with borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) often experience dissociative symptoms. Evidence is increasing that stress-related hyperglutamatergic states may contribute to dissociative symptoms and neurodegeneration in temporo-parietal cortical areas. Seventeen young women with BPD who had been exposed to severe childhood physical/sexual abuse and presented with pronounced dissociative symptoms underwent (18)fluoro-2-deoxyglucose positron emission tomography (FDG-PET). Nine healthy, matched volunteers served as comparison subjects. Borderline subjects displayed reduced FDG uptake (as analyzed by SPM) in the right temporal pole/anterior fusiform gyrus and in the left precuneus and posterior cingulate cortex. Impaired memory performance among borderline subjects was significantly correlated with metabolic activity in ventromedial and lateral temporal cortices. Our results demonstrate regional hypometabolism in temporal and medial parietal cortical regions known to be involved in episodic memory consolidation and retrieval. Currently, the precuneus/posterior cingulate cortex is modeled as part of a network of tonically active brain regions that continuously gather information about the world around and within us. Decreased resting metabolic rate of these regions may reflect dissociative symptoms and possibly also identity disturbances and interpersonal difficulties of individuals with BPD.

Positron emission tomography of regional brain metabolic responses to a serotonergic challenge in major depressive disorder with and without borderline personality disorder

Previous neuroimaging studies of major depression have not controlled for the presence of personality disorders characterized by impulsive aggressive behavior, such as borderline personality disorder (BPD). Using positron emission tomography (PET), we studied regional glucose uptake in response to fenfluramine (FEN) in depressed subjects with BPD (n=11) and depressed patients without Cluster B Axis II disorders (n=8). Subjects were scanned while medication-free after a single blind placebo administration and after FEN on a second day. Brain responses were measured by PET imaging of [18F]fluorodeoxyglucose (FDG) and serial prolactin levels. Scans were compared at a voxel level using statistical parametric mapping. Correlations of changes in relative regional cerebral uptake (rCMRglu) with clinical measures were assessed. Depressed borderline patients had greater relative activity in parietotemporal cortical regions (BA 40, BA 22, and BA 42) before and after FEN activation compared to those without BPD. They also had less relative uptake in the anterior cingulate cortex (BA 32) at baseline compared to depressed patients without BPD and FEN abolished this difference. Impulsivity was positively correlated with rCMRglu in superior and middle frontal cortex (BA 6 and 44). Hostility was positively correlated with rCMRglu in temporal cortical regions (BA 21 and 22). In conclusions, borderline pathology in the context of a Major Depressive Disorder is associated with altered activity in parietotemporal and anterior cingulate cortical regions. Controlling for the presence of BPD in future imaging studies of mood disorders may elucidate similarities and differences in regional serotonergic function in these two often comorbid disorders.

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.

Gender differences in a fenfluramine-activated FDG PET study of borderline personality disorder

Neuroimaging studies of impulsive-aggressive subjects with borderline personality disorder (BPD) demonstrate hypometabolism in areas of prefrontal and frontal cortex, and a blunted cortical metabolic response to challenge with serotonergic agonists. Neuroendocrine responses to serotonergic challenge are known to vary greatly by gender, and may be related to sex differences in expression of impulsive aggression. We conducted single-blind, placebo-controlled fenfluramine-activated positron emission tomography (PET) studies in impulsive male and female subjects with BPD to look for gender differences in cortical response. The sample comprised 22 BPD (15 female, 7 male) and 24 control subjects (10 female, 14 male) who received placebo on Day 1 and d,l-fenfluramine on Day 2 before PET neuroimaging. In response to placebo, female, but not male, controls had areas of increased uptake of fluorodeoxyglucose-F18 in prefrontal cortex compared with BPD subjects, with greatest uptake in the medial orbital frontal cortex, bilaterally. Male, but not female, BPD subjects, showed areas of increased glucose utilization compared with controls in large areas of parietal and occipital cortex, bilaterally. In response to fenfluramine (relative to placebo), significant decreases in glucose uptake were found in male, but not female, BPD subjects, centered in the left temporal lobe. Female, but not male, control subjects showed significantly decreased uptake in areas of right frontal and temporal cortex. Covarying for impulsive-aggression rendered nonsignificant the gender differences in responses to placebo or fenfluramine. Gender differences in serotonergic function may mediate differences in behavioral expression of impulsive aggression in subjects with BPD.

Bone mineral density, markers of bone turnover, and cytokines in young women with borderline personality disorder with and without comorbid major depressive disorder

OBJECTIVE

The pathogenesis of bone loss in major depressive disorder is a matter of debate. Studies of bone loss in nonpsychiatric medical disorders have found an association between the activation of osteoclastic cells and an imbalance of pro- and antiinflammatory cytokines. Since major depressive disorder is also associated with alterations in serum cytokine concentrations, the authors hypothesized that bone loss in patients with major depressive disorder and comorbid borderline personality disorder may be associated with cytokines capable of activating osteoclastic cells.

METHOD

Twenty-two patients with borderline personality disorder and comorbid current or lifetime major depressive disorder were compared with 16 patients with borderline personality disorder who did not have major depressive disorder and 20 healthy volunteers. Bone mineral density was assessed by means of dual-energy x-ray absorptiometry. Markers of bone turnover as well as endocrine and immune measures were determined.

RESULTS

The bone mineral density of 10 patients with borderline disorder plus current major depressive episode was significantly lower than that of the healthy subjects and the patients with borderline personality disorder without depression. Values of crosslaps, osteocalcin, serum cortisol, tumor necrosis factor-alpha (TNF-alpha), and interleukin-6 were significantly higher in the patients with borderline disorder plus current major depressive episode than in the healthy subjects. Crosslaps correlated positively with TNF-alpha but negatively with bone mineral density at the lumbar spine. Patients with borderline personality disorder who did not have current or lifetime depression displayed no alterations of either bone mineral density or the immunological and hormonal measures examined.

CONCLUSIONS

Young women with comorbid borderline personality disorder and major depressive disorder have an elevated risk for osteoporosis. Borderline personality disorder per se is not associated with low bone mineral density. These data suggest that the immune and endocrine disturbances associated with depressive disorders in the context of borderline personality disorder may play a role in the pathophysiological process underlying bone loss in the patients studied.

Dopamine dysfunction in borderline personality disorder: a hypothesis

Research on the biological basis of borderline personality disorder (BPD) has focused primarily on the serotonin model of impulsive aggression. However, there is evidence that dopamine (DA) dysfunction may also be associated with BPD. Pertinent research and review articles, identified by Medline searches of relevant topics, books, references from bibliographies, and conference proceedings from 1975 to 2003, were reviewed. Evidence of DA dysfunction in BPD derives from the efficacy of traditional and atypical antipsychotic agents in BPD, and from provocative challenges with amphetamine and methylphenidate of subjects with the disorder. In addition, human and animal studies indicate that DA activity plays an important role in emotion information processing, impulse control, and cognition. The results of this review suggest that DA dysfunction is associated with three dimensions of BPD, that is, emotional dysregulation, impulsivity, and cognitive-perceptual impairment. The main limitation of this hypothesis is that the evidence reviewed is circumstantial. There is no study that directly demonstrates DA dysfunction in BPD. In addition, the therapeutic effects of antipsychotic agents observed in BPD may be mediated by non-DA mechanisms of action. If the stated hypothesis is correct, DA dysfunction in BPD may result from genetic, developmental, or environmental factors directly affecting specific DA pathways. Alternatively, DA dysfunction in BPD may be a compensatory response to alterations in the primary neural systems that control emotion, impulse control, and cognition, and that are mediated by the brain's main neurotransmitters, glutamate, and GABA, or in one or more other neuromodulatory pathways such as serotonin, acetylcholine, and norepinephrine.

Estrogen fluctuations, oral contraceptives and borderline personality

Results from three studies suggest fluctuation in estrogen level may influence the expression of borderline personality disorder (BPD) symptoms. In the first study, 226 women were administered the Personality Assessment Inventory, borderline scales (PAI-BOR; L.C. Morey, The Personality Assessment Inventory, Professional Manual, 1991) and a questionnaire that assessed time in menstrual cycle and use of oral contraceptives, that is synthetic estrogens. BPD symptoms were most common in women using oral contraceptives and during times in the menstrual cycle when estrogen level is rising. In Study 2, 52 women were measured four times across one menstrual cycle and provided salivary samples at each test session. The samples were assayed and estrogen levels were obtained. The principle finding was that variation in estrogen levels predicted the presence of BPD symptoms (r=0.4, p<0.01). This relationship remained significant when a general increase in negative affect was statistically controlled. Study 3 employed a pre-post Oral Contraceptive (OC) design with a control group. It was found that for women with high pre-existing levels of BPD, symptoms became significantly worse after starting pill use (F (3,42)=4.7; p<0.01). Research findings that link the serotonin system and estrogen are reviewed and theoretical and practical implications are discussed.

Impulsivity and prefrontal hypometabolism in borderline personality disorder

Prefrontal hypoperfusion and decreased glucose uptake in the prefrontal cortex (PFC) are found in violent criminal offenders, murderers and aggressive psychiatric patients. These abnormalities may be independent of diagnosis and associated with impulsive-aggression as a personality trait. Impulsive-aggression is a clinical characteristic of borderline personality disorder (BPD) where it is associated with assaultive and suicidal behaviors. We conducted FDG-PET studies in 13 non-depressed, impulsive female subjects with BPD and 9 healthy controls to look for abnormalities in glucose metabolism in areas of the PFC associated with regulation of impulsive behavior. Statistical Parametric Mapping-99 (SPM99) was used to analyze the PET data with Hamilton depression scores as covariate. Significant reductions in FDG uptake in BPD subjects relative to healthy controls were found bilaterally in medial orbital frontal cortex, including Brodmann's areas 9, 10 and 11. There were no significant areas of increased uptake in BPD subjects compared to control subjects. Covarying for measures of impulsivity or impulsive-aggression rendered insignificant the differences between groups. Decreased glucose uptake in medial orbital frontal cortex may be associated with diminished regulation of impulsive behavior in BPD.

Impulsivity, gender, and response to fenfluramine challenge in borderline personality disorder

Behavioral impulsivity in borderline personality disorder (BPD) is associated with indices of diminished central serotonergic function, independent of suicidal behavior, depression or alcohol use disorder. Many of these studies have been conducted among males in specialized settings. Studies of BPD females, who constitute the majority of BPD patients, are generally conducted in community settings and report inconsistent findings. We studied gender differences in behavioral impulsivity and the prolactin response to D,L-fenfluramine (FEN) in BPD subjects in a community setting. A FEN challenge study was conducted with 64 BPD subjects (20 male, 44 female), and 57 controls (36 male, 21 female). Axis I and II disorders, including BPD, and suicidal histories were assessed by structured interviews. Controls were free of Axis I and II disorders. Impulsivity and aggression were assessed by the Buss-Durkee Hostility Inventory, Barratt Impulsiveness Scale, Minnesota Multiphasic Personality Inventory-Psychopathic Deviate subscale, and the Brown-Goodwin Lifetime History of Aggression. Male, but not female, BPD subjects had significantly diminished prolactin responses compared to controls. Impulsivity and aggression each predicted prolactin responses. A significant effect of BPD diagnosis on prolactin response was eliminated when impulsivity was co-varied. Impulsivity and aggression were inversely related to delta-prolactin and peak-prolactin responses among male but not female subjects. Gender differences in central serotonergic function may contribute to variations in impulsivity in BPD.

[Enhanced suppression of cortisol after dexamethasone in borderline personality disorder. A pilot study]

INTRODUCTION

Some studies have suggested the etiological role of childhood traumatic events in borderline personality disorder (BPD), involving the stress response mechanisms and the activity of hypothalamic-pituitary adrenal (HPA) axis. Recent preliminary results show that BPD, similar to that found in post-traumatic stress disorder (PSD), might have a hypersensitive response to the dexamethasone test.

METHODS

Fourteen BPD patients, diagnosed according to DSM-IV criteria, without a major depressive episode or history of bipolar or psychotic disorder, were compared with 10 patients with other personality disorders (OPD). Plasma cortisol was measured at baseline and following an oral test with 0.25 mg of dexamethasone.

RESULTS

Nine out of 14 (64%) BPD patients were cortisol suppressors in the test versus only 2 out of 10 (20%) patients with other personality disorders (chi square 4.6, degree factors [df] 18, p<0.05). The degree of cortisol suppression was significantly greater for BPD patients (73% ) than for patients with other personality disorder (34 %). Baseline cortisol concentrations, although lower in BPD patients, were not significantly different among groups.

CONCLUSIONS

BPD could be associated with hypersensitivity of feedback mechanisms of the HPA axis similar to PSD, which suggests a possible role for traumatic experiences in the pathogenesis of the disorder.

Positron emission tomography in female patients with borderline personality disorder

The pathology of Borderline personality disorder (BPD) is poorly understood and its biological basis remains largely unknown. One functional brain imaging study using [(18)F]Deoxyglucose-PET previously reported frontal and prefrontal hypometabolism. We studied brain metabolism at baseline in 12 medication-free female patients with BPD without current substance abuse or depression and 12 healthy female controls by [(18)F]Deoxyglucose-PET and statistical parametric mapping. We found significant frontal and prefrontal hypermetabolism in patients with BPD relative to controls as well as significant hypometabolism in the hippocampus and cuneus. This study demonstrated limbic and prefrontal dysfunction under resting conditions in patients with BPD by FDG-PET. Dysfunction in this network of brain regions, which has been implicated in the regulation of emotion, may underlie symptoms of BPD.

Brain Regional alpha-[11C]methyl-L-tryptophan trapping in impulsive subjects with borderline personality disorder

OBJECTIVE

Neurotransmission of serotonin (or 5-hydroxytryptamine [5-HT]) is thought to be disturbed in patients exhibiting impulsive behaviors. However, until recently it has not been possible to test this hypothesis in the brains of living humans.

METHOD

Unidirectional trapping of the 5-HT precursor analog alpha-[(11)C]methyl-L-tryptophan (alpha-[(11)C]MTrp) has been proposed as an index of 5-HT synthesis capacity. The authors measured brain regional alpha-[(11)C]MTrp trapping with positron emission tomography in medication-free subjects with borderline personality disorder (N=13) and a healthy comparison group (N=11). Impulsivity was assessed by using a laboratory measure of behavioral disinhibition, go/no-go commission errors.

RESULTS

Compared to healthy men, the men with borderline personality disorder had significantly lower alpha-[(11)C]MTrp trapping in corticostriatal sites, including the medial frontal gyrus, anterior cingulate gyrus, superior temporal gyrus, and corpus striatum. In the women with borderline personality disorder, significantly lower alpha-[(11)C]MTrp trapping was seen in fewer regions, but in both men and women, negative correlations with impulsivity scores were identified in the medial frontal gyrus, anterior cingulate gyrus, temporal gyrus, and striatum.

CONCLUSIONS

Low 5-HT synthesis capacity in corticostriatal pathways may contribute to the development of impulsive behaviors in persons with borderline personality disorder.

Relationship between depression and borderline personality disorder

The frequent occurrence of depressive symptoms in patients with borderline personality disorder has generated considerable interest in the nature of the relationship between borderline personality disorder and the depressive disorders. Data from the perspectives of phenomenology, biology, family history, course of illness, comorbidity patterns, and treatment response have been brought to bear on the question. Reviews based on research available by 1985 and 1991, respectively, arrived at differing conclusions: (1) that both disorders shared common but non-specific sources, and (2) that the two disorders were unrelated but co-occurred because of the high prevalence of each. Since the time of these reviews, additional evidence has become available from a wider range of biological investigations, better controlled comorbidity studies, studies of the relationship of psychosocial stressors to the course of each disorder and neuroimaging studies. In reviewing the more recent findings, we propose the less parsimonious hypothesis that the disorders co-occur, both because they share some common biological features and because the psychosocial sequella of each can contribute to the development of the other.

Serotonergic blunting to meta-chlorophenylpiperazine (m-CPP) highly correlates with sustained childhood abuse in impulsive and autoaggressive female borderline patients

BACKGROUND

Disturbances of affect, impulse regulation, and autoaggressive behavior, which are all said to be related to an altered function of the central serotonergic (5-HT) system, are prominent features of borderline personality disorder (BPD). A high coincidence of childhood physical and sexual abuse is reported in these patients. Animal studies indicate that early, sustained stress correlates with a dysfunctional central 5-HT system. Therefore, we hypothesize that sustained traumatic stress in childhood affects the responsivity of the postsynaptic serotonergic system of traumatized BPD patients.

METHODS

Following Axis I, Axis II, and trauma assessment, a neuroendocrine challenge test was performed with the postsynaptic serotonergic agonist meta-chlorophenylpiperazine (m-CPP) in 12 impulsive and autoaggressive female patients with BPD and 9 matched healthy volunteers.

RESULTS

The cortisol and prolactin responses to the m-CPP challenge in BPD patients were significantly lower compared to those in controls. Within the group of patients with BPD, the net prolactin response showed a high inverse correlation with the frequency of the physical (r = -.77) and sexual abuse (r = -.60).

CONCLUSIONS

Our data suggest that severe and sustained traumatic stress in childhood affects the 5-HT system and especially 5-HT(1A) receptors. This finding confirms the data from animal research. The blunted prolactin response to m-CPP appears to be the result of severe traumatization and independent of the BPD diagnosis.

A fenfluramine-activated FDG-PET study of borderline personality disorder

BACKGROUND

Impulsive aggression in patients with personality disorders is associated with diminished levels of cerebrospinal fluid (CSF) 5-HIAA, blunted neuroendocrine responses to serotonergic agonists, and decreased glucose utilization in the prefrontal cortex. We tested the hypothesis that impulsive aggression in borderline personality disorder (BPD) may be associated with diminished serotonergic regulation in the prefrontal cortex, using positron-emission tomography (PET) neuroimaging during pharmacologic challenge with d,l fenfluramine (FEN).

METHODS

A 2-day, single-blind, placebo-controlled FEN challenge study was conducted in five patients with BPD (and no Axis I MDD) and eight healthy control participants. On Day 1, 4 mCi [(18)F]-fluorodeoxyglucose (FDG) was injected 3 hours after ingestion of placebo; on Day 2, FDG was injected 3 hours after ingestion of.8 mg/kg to 60 mg of d,l fenfluramine. After 30 min, a 45-min emission scan was acquired on the Siemans/CTI 951r/31 scanner. PET data were aligned to MR images and analyzed by Statistical Parametric Mapping (SPM96).

RESULTS

In response to placebo, uptake of FDG was greater in control participants than patients in large areas of the prefrontal cortex including medial and orbital regions bilaterally (BA 10-11), left superior temporal gyrus, and right insular cortex. There were no areas in which patients had greater relative regional uptake than control participants. In response to FEN, relative regional uptake of FDG (relative to placebo) was greater in control participants compared to patients in medial and orbital regions of right prefrontal cortex (BA 10), left middle and superior temporal gyri (BA 22-23), left parietal lobe (BA 40), and left caudate body.

CONCLUSIONS

Patients with BPD have diminished response to serotonergic stimulation in areas of prefrontal cortex associated with regulation of impulsive behavior.

Borderline personality disorder. Overview of biologic factors

Exploring the biology of neurotransmitters and polymorphic genes that influence behavior most certainly will increase understanding of the complexity of personality disorders and the people who suffer with them. Continuing biologic exploration of the personality disorders will also provide new and valuable information that will inform and direct ever more sophisticated and specific psychiatric treatments. Further, it will supply knowledge that might begin to erode the strong biases and negative labels that have for too long been applied to these patients. These labels may have been applied not because these patients are bad people, but because of ignorance in understanding their complexity and limited ability to improve their condition. Nonetheless, clinicians must refrain from concluding that the answers to all problems in psychiatric treatment can be answered by the molecular geneticist or biologic researcher. As Reiss et al have written when speaking about nonshared environmental effects and its role in the development of psychopathology: "Psychiatry has been forced into the chronically uncomfortable position of straddling biomedicine and the social sciences and seems always to hunger for relief.... [Yet] the data simply do not permit a conception of the future centered on a straightforward biomedical answer to the fundamental question of the pathogenesis of major disorders. Indeed, a balanced image of the future contains a growing and equal partnership of the social sciences and molecular biology."

The biology of impulsivity and suicidality

Abnormalities of 5-HT and noradrenergic functioning have been implicated in aggressive impulsivity, SIB, and suicidal behavior. The role of DA and GABA in human studies of these behaviors requires further investigation. Most studies suggest that impulsive aggression is related to lower levels of CNS 5-HT. Some studies demonstrate that increasing NE correlates to impulsive aggression, whereas other studies demonstrate an opposite relationship. The role of NE in impulsive aggressive behavior is still unclear. Self-injurious behavior is similar to impulsive aggression in that it seems to be mediated by the neurotransmitter systems previously mentioned. For example, the presence of lower levels of 5-HT and abnormalities in the DA system are related to SIB in patients with BPD and depression. SIB severity also seems to be influenced by neglect (e.g., severe isolation during rearing). As animal studies suggest, increasing the amount of isolation and an earlier onset of isolation increase the severity of SIB. Suicidal behaviors and the lethality of suicide attempts may also be linked to the abnormalities in neurotransmitter systems similar to those found in patients with impulsive aggression and SIB, namely, lowered 5-HT transmission and enhanced DA and NE functioning. Understanding the biological triggers of impulsive aggression or SIB may allow for the evaluation of suicidal attempts and completion from a different perspective and, in conjunction with genetic predictors, may eventually help with the early prediction and prevention of suicidal behaviors. Additional studies of live subjects and postmortem brains will assist in clarifying the neurobiology of suicidal behaviors that are common to many disorders and are clinically relevant to BPD.

Neurotransmitter dysfunction in patients with borderline personality disorder

Neurotransmitter system dysfunction may contribute to the borderline personality disorder traits of impulsive aggression and affective instability. This article reviews evidence from neurochemical assays, receptor-density studies, neuroendocrine-challenge paradigms, functional neuroimaging studies, and candidate-gene research, which converge to identify particular neurotransmitter systems that seem to be dysregulated in patients with borderline personality disorder.

Brain glucose metabolism in borderline personality disorder

We searched for regional cerebral metabolic disturbances in patients with borderline personality disorder (BPD). Ten inpatients with BPD, no current DSM-IIIR Axis I diagnosis and free of any psychotropic substances, were compared with 15 age-matched control subjects using positron emission tomography with 2-deoxy-2-[18F]fluoro-D-glucose and semiquantitative analysis of regional glucose metabolic activity. We found relative hypometabolism in patients with borderline personality disorder at the level of the premotor and prefrontal cortical areas, the anterior part of the cingulate cortex and the thalamic, caudate and lenticular nuclei. This study shows significant cerebral metabolic disturbances in patients with borderline personality disorder. These metabolic disturbances, which are similar to some of those described in other psychiatric entities, may help to understand the characteristic clinical aspects of this disorder.

Temporal glucose metabolism in borderline personality disorder

The pathophysiology of borderline personality disorder (BPD) is obscure. Underlying organic factors such as epilepsy are suspected because clinical characteristics of the syndrome are similar to some manifestations of patients with complex partial seizures (CPS). Positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) reveals hypometabolism in the area surrounding epileptic foci. To test the epilepsy hypothesis in BPD, we have explored 10 patients with BPD and compared them with 15 control subjects using PET with FDG. We conclude that PET provides no metabolic indication of temporal lobe epilepsy in BPD.

The measurement of endorphins in body fluids

The measurement of endorphins in body fluids has been an important advance in clinical research attempting to link the endogenous opioid system to psychiatric illness and symptomatology. The consideration of methodologic differences in assay technique and in clinical methods is important in evaluating results of studies. Whereas findings in early clinical studies supported the notion of increased endorphin system function in patients with schizophrenia, cumulative data from the considerable number of studies carried out throughout world centers have been unable to demonstrate a consistent abnormality in levels of endorphins in CSF or plasma of patients with schizophrenia. Among the affective disorders, data suggest the possibility of relative changes in levels of opioids within individual manic-depressive patients when studied across state change from depression to mania. In studies of depressive illness there is accumulating evidence that the endogenous opioid system may relate or contribute to abnormality of the HPA axis. In our work measuring opioids in CSF we have observed relationships between anxiety and CSF opioids in normals and psychiatric patients and changes in CSF opioid activity in patients with anorexia nervosa accompanying weight change. These data are consistent with other evidence linking endorphins to CNS noradrenergic systems and to biologic response to stress.

Clinical utility of salivary lithium concentration

Saliva, plasma and erythrocyte lithium concentrations were studied in 40 long-term lithium users. Intersubject variation in saliva to plasma lithium ratio was too great for clinical utility, when based on a group linear regression equation. By contrast, intrasubject data from 8 patients studied on three or more occasions indicated a higher linear correlation (r = 0.91 to 1.00 for 7 of 8 patients). For individual patients the ratio remained stable over varying concentration ranges, and was not affected by time from last dose or length of use of lithium. Based on these data, use of saliva concentrations of lithium for routine monitoring appears feasible after several blood and saliva concentrations are obtained to establish a relationship for a particular patient. Saliva monitoring may facilitate accurate analysis and convenience for some patients.