Shame and implicit self-concept in women with borderline personality disorder

OBJECTIVE: Shame is considered to be a central emotion in borderline personality disorder and to be related to self-injurious behavior, chronic suicidality, and anger-hostility. However, its level and impact on people with borderline personality disorder are largely unknown. The authors examined levels of self-reported shame, guilt, anxiety, and implicit shame-related self-concept in women with borderline personality disorder and assessed the association of shame with self-esteem, quality of life, and anger-hostility. METHOD: Sixty women with borderline personality disorder completed self-report measures of shame- and guilt-proneness, state shame, anxiety, depression, self-esteem, quality of life, and clinical symptoms. Comparison groups consisted of 30 women with social phobia and 60 healthy women. Implicit shame-related self-concept (relative to anxiety) was assessed by the Implicit Association Test. RESULTS: Women with borderline personality disorder reported higher levels of shame- and guilt-proneness, state shame, and anxiety than women with social phobia and healthy comparison subjects. The implicit self-concept in women with borderline personality disorder was more shame-prone (relative to anxiety-prone) than in women in the comparison groups. After depression was controlled for, shame-proneness was negatively correlated with self-esteem and quality of life and positively correlated with anger-hostility. CONCLUSIONS: Shame, an emotion that is prominent in women with borderline personality disorder, is associated with the implicit self-concept as well as with poorer quality of life and self-esteem and greater anger-hostility. Psychotherapeutic approaches to borderline personality disorder need to address explicit and implicit aspects of shame.     

Clinical outcome of ECT in patients with major depression and comorbid borderline personality disorder

OBJECTIVE: Previous research suggests that the comorbidity of major depression with a personality disorder, especially borderline personality disorder, is associated with a poorer response to ECT. The authors compared the acute outcome of ECT in depressed patients with borderline personality disorder, with personality disorders other than borderline personality disorder, and with no personality disorder. METHOD: The study subjects were 139 patients with a primary diagnosis of unipolar major depression and scores of at least 20 on the 24-item Hamilton Depression Rating Scale. Patients were treated with suprathreshold right unilateral or bilateral ECT in a standardized manner and were assessed with the Hamilton depression scale within 3 days and 4-8 days after completing ECT. RESULTS: Compared to patients with personality disorders other than borderline personality disorder (N=42) and those with no personality disorder (N=77), patients with borderline personality disorder (N=20) had less symptomatic improvement assessed up to 8 days after ECT. Patients with personality disorders other than borderline personality disorder responded as well to ECT as those with no personality disorder. Borderline personality disorder patients were more likely to be female and to have medication-resistant depression than the patients in the two comparison groups; they were also younger. However, none of these differences accounted for the borderline personality disorder patients' poorer response to ECT. CONCLUSIONS: Patients with borderline personality disorder have a poorer acute response to ECT, but explanations for this finding remain elusive.     

Tobacco smoking behaviors in bipolar disorder: a comparison of the general population,schizophrenia, and major depression

Objectives: This study compared the prevalence of tobacco smoking behaviors in patients with bipolar disorder with normal and psychiatric (schizophrenia and major depression) controls. The main goal was to establish that bipolar patients smoke more than normal controls. Differences with psychiatric controls were explored. Methods: Samples of 424 patients (99 bipolar, 258 schizophrenia and 67 major depression) and 402 volunteer controls were collected in Central Kentucky. Smoking data for Kentucky’s general population were available. Odds ratios (ORs) and their 95% confidence intervals (CIs) were used to establish the strength of associations. Logistic regression was used to adjust ORs for confounding variables. Results: Using epidemiological definitions of smoking behaviors and the general population as controls provided bipolar disorder unadjusted ORs of 5.0 (95% CI: 3.3–7.8) for current cigarette smoking, 2.6 (95% CI: 1.7–4.4) for ever cigarette smoking, and 0.13 (95% CI: 0.03–0.24) for smoking cessation. Using a clinical definition and volunteers as controls provided respective bipolar disorder adjusted ORs of 7.3 (95% CI: 4.3–12.4), 4.0 (95% CI: 2.4–6.7), and 0.15 (95% CI: 0.06–0.36). Prevalences of current daily smoking for patients with major depression, bipolar disorder, and schizophrenia were 57%, 66%, and 74%, respectively. Conclusions: Bipolar disorder was associated with significantly higher prevalences of tobacco smoking behaviors compared with the general population or volunteer controls, independently of the definition used. It is possible that smoking behaviors in bipolar disorder may have intermediate prevalences between major depression and schizophrenia, but larger samples or a combination of multiple studies (meta‐analysis) will be needed to establish whether this hypothesis is correct.     

My Body and Me: Self-Injurious Behaviors and Body Modifications in Eating Disorders—Preliminary Results

We investigated self-injurious behaviors and body modification practices in eating disorder patients, considering different ED diagnoses and illness severities. Of the total sample, 50.9% showed at least one form of self-injury and 50.9% reported at least one tattoo, piercing, or both. Patients reporting only body modifications showed more positive feelings toward their bodies, higher levels of self-esteem, less impulsivity, depression, and anxiety, and lower levels of social dysfunction than those reporting only self-injury or both self-injury and body modifications. Self-injury was influenced by both diagnosis and severity of disorders.     

The relative influences of symptoms, insight, and neurocognition on social adjustment in schizophrenia and schizoaffective disorder

Impaired insight and neurocognitive deficits are commonly seen in schizophrenia. No study to date, however, has documented the relative influences of insight deficits, neurocognitive functioning, and psychotic symptoms on overall social adjustment in this population. This was done in a cohort of individuals recovering from acute exacerbations. Forty-six individuals with schizophrenia or schizoaffective disorder were recruited upon discharge from an inpatient unit. Symptom levels, neurocognitive functioning (information processing, memory, and executive functioning), and symptom awareness were documented, and social adjustment was assessed in three domains: treatment compliance, social behavior, and subjective quality of life. Cross-sectional data from initial assessments are reported. Sequential linear regression analyses identified differential associations between illness characteristics and outcome domains. Treatment compliance was most influenced by insight; social behavior deficits were associated with thought disorder and neurocognitive (working memory and visuo-spatial) impairments; and quality of life was associated with mood disturbances. Outcome is multidimensional in schizophrenia, and there are differential patterns of associations between illness characteristics and domains of social adjustment. Studies such as this can guide clinicians in determining the most appropriate treatments for specific individuals and should also guide researchers in efforts to clarify the processes that underlie treatment response and recovery in schizophrenia.     

A comparison of neuropsychological dysfunction in first-episode psychosis patients with unipolar depression, bipolar disorder, and schizophrenia

The severity and profile of cognitive dysfunction in first episode schizophrenia and psychotic affective disorders were compared before and after antipsychotic treatment. Parallel recruitment of consecutively admitted study-eligible first-episode psychotic patients (30 schizophrenia, 22 bipolar with psychosis, and 21 psychotic depression) reduced confounds of acute and chronic disease/medication effects as well as differential treatment and course. Patient groups completed a neuropsychological battery and were demographically similar to healthy controls (n = 41) studied in parallel. Prior to treatment, schizophrenia patients displayed significant deficits in all cognitive domains. The two psychotic affective groups were also impaired overall, generally performing intermediate between the schizophrenia and healthy comparison groups. No profile differences in neuropsychological deficits were observed across patient groups. Following 6 weeks of treatment, no patient group improved more than practice effects seen in healthy individuals, and level of performance improvement was similar for affective psychosis and schizophrenia groups. Although less severe in psychotic affective disorders, similar profiles of generalized neuropsychological deficits were observed across patient groups. Recovery of cognitive function after clinical stabilization was similar in mood disorders and schizophrenia. To the extent that these findings are generalizable, neuropsychological deficits in psychotic affective disorders, like schizophrenia, may be trait-like deficits with persistent functional implications.     

Mood symptoms, cognition, and everyday functioning: in major depression, bipolar disorder, and schizophrenia

People with depression, bipolar disorder, and schizophrenia manifest considerable cognitive deficits and impairments in everyday functional outcomes. The severity of current mood symptoms is associated with the severity of cognitive deficits in people with unipolar and bipolar disorder, but impairments are clearly still present in cases with minimal current mood symptoms. In people with schizophrenia, depression is less strongly associated with cognitive deficits on a cross-sectional basis, and some evidence suggests that depression and cognitive impairments are inversely related. Furthermore, in schizophrenia, mood symptoms seem to affect everyday functioning in a way that is unassociated with the severity of deficits in cognition and functional capacity. In contrast, in bipolar disorder, mood symptoms seem to affect real-world functioning through an adverse effect on the ability to perform critical functional skills. In both mood disorders and schizophrenia, depression appears to impact the motivation to perform potentially reinforcing acts, possibly through the induction of anhedonia. Clearly, depression has a major adverse impact on everyday functioning in all variants of severe mental illness, and improving its recognition (in the case of schizophrenia) and management has the potential to reduce the adverse impact of severe mental illness on everyday functioning. Reducing disability has the potential to have positive impacts in multiple objective and subjective aspects of functioning in severe mental illness.     

Characteristics of patients with major depression in combination with dysthymic or cyclothymic disorders. Childhood and precipitating events

The relationship between patients with acute major depression and chronic affective disorders was investigated in 298 nonpsychotic outpatients. The patients were categorized into 4 groups: major depression only, major depression with dysthymic or cyclothymic disorders, dysthymic or cyclothymic disorder without major depression and one group of other psychiatric disorders. The patients were interviewed about childhood losses, relationship to parents and siblings and family atmosphere, their personality characteristics as children, as well as precipitating events. The reports in the various diagnostic groups were compared. Patients in the mixed group reported somewhat more traumatic childhood experiences compared with patients in the pure major depression group and pure dysthymic-cyclothymic group, and much more traumatic childhood experiences compared with patients in the group of other disorders. Precipitating events among patients in the acute major depression group consisted of more acute external stressors compared with the events of the patients in the group of chronic affective disorders. Patients with major depression in combination with pure dysthymic-cyclothymic disorder generally remembered their childhood as having been more traumatic, with a less satisfying relationship to their parents.     

Personality and personality disorders among patients with major depression in combination with dysthymic or cyclothymic disorders

Personality traits and personality disorders in 298 consecutive outpatients with pure major depression, major depression with dysthymic or cyclothymic disorder, pure dysthymic or cyclothymic disorder and other disorders were investigated. Patients with dysthymic or cyclothymic disorders alone or in combination with major depression showed more self-doubt, insecurity, sensitivity, compliance, rigidity and emotional instability. They were more schizoid, schizotypal, borderline and avoidant according to MCMI and had a higher prevalence of DSM-III Axis II diagnoses, and more borderline, avoidant, and passive-aggressive personality disorders, as measured by SIDP. All in all, dramatic and anxious clusters of personality disorders were more frequent among patients with dysthymic-cyclothymic disorders in addition to major depression than among patients with major depression only. The findings elucidated the close connection between the more chronic affective disorders and the personality disorders, irrespective of any concomitant diagnosis of major depression.     

Neurocognitive Graphs of First-Episode Schizophrenia and Major Depression Based on Cognitive Features

Neurocognitive deficits are frequently observed in patients with schizophrenia and major depressive disorder (MDD). The relations between cognitive features may be represented by neurocognitive graphs based on cognitive features, modeled as Gaussian Markov random fields. However, it is unclear whether it is possible to differentiate between phenotypic patterns associated with the differential diagnosis of schizophrenia and depression using this neurocognitive graph approach. In this study, we enrolled 215 first-episode patients with schizophrenia (FES), 125 with MDD, and 237 demographically-matched healthy controls (HCs). The cognitive performance of all participants was evaluated using a battery of neurocognitive tests. The graphical LASSO model was trained with a one-vs-one scenario to learn the conditional independent structure of neurocognitive features of each group. Participants in the holdout dataset were classified into different groups with the highest likelihood. A partial correlation matrix was transformed from the graphical model to further explore the neurocognitive graph for each group. The classification approach identified the diagnostic class for individuals with an average accuracy of 73.41% for FES vs HC, 67.07% for MDD vs HC, and 59.48% for FES vs MDD. Both of the neurocognitive graphs for FES and MDD had more connections and higher node centrality than those for HC. The neurocognitive graph for FES was less sparse and had more connections than that for MDD. Thus, neurocognitive graphs based on cognitive features are promising for describing endophenotypes that may discriminate schizophrenia from depression.     

Working memory in schizophrenia and mania: correlation with symptoms during the acute and subacute phases

OBJECTIVE: The aims of this study were to examine working memory in the acute subacute phase of schizophrenia and mania and to examine correlations between working memory and specific symptom domains. METHOD: Visuospatial working memory and symptom profiles were assessed in three groups (schizophrenia group, n= 19; mania, n= 12; controls, n= 19) on two occasions separated by 4 weeks. RESULTS: Both patient groups had significant deficits on working memory compared to the well controls and the schizophrenia and mania groups were equally impaired. All groups showed equivalent improvement over time. In the patient groups, impaired working memory was significantly correlated with the presence of both negative symptoms and positive thought disorder. CONCLUSION: Impaired working memory is found in both schizophrenia and mania during the acute subacute phases. Further research is required in order to clarify the neurocognitive mechanisms linking impaired working memory with both negative symptoms and positive thought disorder.     

Psychosocial situations, quality of depression and schizophrenia in adolescents

The relationships between acute life events and type of depression were evaluated among inpatient adolescents with schizophrenia. Forty-two adolescent inpatients were assessed, 25 with schizophrenia and 17 with personality disorder. Acute life events and other psychosocial situations were identified with the ICD-10 Axis V semistructured interviews. The Depression Equivalent Questionnaire for Adolescents (DEQ-A) and the Positive and Negative Symptom Scale (PANSS) were used to measure quality and severity of depression. In the patients with schizophrenia, psychosocial situations were related to the anaclitic type of depression, whereas in the subjects with personality disorder, they were highly correlated with introjective depression. In the schizophrenic group, the psychosocial situations related to depression were of a more intrapersonal nature and, in the personality-disordered group, they were more interpersonal. Environmental factors play an important role in the course of schizophrenia in adolescents and should remain a focus of study. Object relations theory may be of heuristic value in the investigation of these factors.     

Recovery from psychosis in schizophrenia and schizoaffective disorder: symptoms and neurocognitive rate-limiters for the development of social behavior skills

Neurocognitive deficits are believed to be important predictors of functional outcome in chronic psychotic disorders, but few supporting studies have utilized prospective designs and adequate control. The aim of this study was to estimate the relative influence of symptoms and neurocognitive deficits on the development of social behavior skills in a cohort of individuals with schizophrenia or schizoaffective disorder recovering from acute symptom exacerbations. Forty-six individuals were recruited upon discharge from an inpatient unit and completed assessments of symptoms, neurocognitive function, and social behavior at 3-month intervals for 1 year. Correlational analyses and random regression models were used to model social behavioral capacities longitudinally. Social behavior improved modestly (10% improvements in ratings) over the follow-up period for the group as a whole. Disorganized and negative symptoms, as well as neurocognitive deficits in short-term and working memory predicted changes in social behavior over time. Individuals with better working memory function showed significantly greater abilities to recover social behavior skills, whereas those with working memory deficits showed no functional improvement over time. Both symptoms and neurocognitive deficits are important determinants of functional outcome in schizophrenia. It is proposed that clinicians should consider neurocognitive thresholds for treatment response when developing rehabilitation plans.     

Clonidine in acute aversive inner tension and self-injurious behavior in female patients with borderline personality disorder

BACKGROUND: States of strong aversive inner tension and dissociative symptoms are clinical hallmarks of borderline personality disorder and major reasons for self-injurious behavior, a severe clinical condition for which there are no established pharmacologic treatment options. METHOD: The acute effect of 75 and 150 microg of clonidine administered orally in acute states of strong aversive inner tension and urge to commit self-injurious behavior was examined in 14 female patients meeting DSM-IV criteria for borderline personality disorder. Before and 30, 60, and 120 minutes after administration of clonidine, aversive inner tension and dissociative symptoms were assessed using a self-rating instrument for aversive inner tension and dissociation (Dissociation-Tension-Scale acute), and the urge to commit self-injurious behavior and suicidal ideations were assessed using self-rating Likert scales. Blood pressure and heart rate were monitored during the trial. RESULTS: Aversive inner tension and urge to commit self-injurious behavior before administration of clonidine were strong. After administration of clonidine in both doses, aversive inner tension, dissociative symptoms, urge to commit self-injurious behavior, and suicidal ideations significantly decreased. The strongest effects were seen between 30 and 60 minutes after drug intake and correspond to the pharmacokinetics of clonidine with maximum plasma concentrations after 1 hour. Blood pressure and aversive inner tension and dissociative symptoms were positively correlated before and after administration of clonidine. CONCLUSION: Orally given clonidine may be effective for treatment of acute states of aversive inner tension, dissociative symptoms, and urge to commit self-injurious behavior in female patients with borderline personality disorder. Further placebo-controlled studies with larger populations are needed to confirm this finding.     

Differential impairments of facial affect recognition in schizophrenia subtypes and major depression

The goal of this study was to assess facial affect recognition abilities in subjects with various schizophrenia subtypes and subjects with major depression. A total of six disorganized, 21 paranoid and 18 residual subjects with schizophrenia (DSM-IV criteria) were compared with 21 subjects with major depression (DSM-IV criteria) and 30 matched healthy control subjects. Two experimental tasks requiring the sorting and rating of emotional facial expressions were applied. Disorganized and paranoid subjects showed strong impairments in the sorting of emotional facial expressions. Depressive subjects displayed only minor deficits, and residual subjects were unimpaired. Subjects with disorganized schizophrenia rated emotional facial expressions as more aroused, and depressive subjects rated them as less aroused, than the other study groups. Our study demonstrates strong deficits in facial affect recognition in subjects with schizophrenia and pronounced disorganized or psychotic symptoms. Deficits in facial affect recognition are specific to schizophrenia. They may be considered as a state marker of schizophrenia.     

Differential regional N-acetylaspartate deficits in postmortem brain in schizophrenia, bipolar disorder and major depressive disorder

There is substantial evidence for the involvement of the hippocampus and subcortical regions in the neuropathology of schizophrenia. Deficits of N-acetylaspartate (NAA) have been found in schizophrenia and bipolar disorder which may reflect neuronal loss and/or dysfunction. N-acetylaspartylglutamate (NAAG) is the most abundant peptide transmitter in the mammalian nervous system. It is an agonist at presynaptic metabotropic glutamate receptors mGluR3, inhibiting glutamate release. NAA and NAAG and were measured in hippocampal, striatal, amygdala and cingulate gyrus regions of human postmortem tissue from controls and subjects with schizophrenia, bipolar disorder and major depressive disorder. There are significant deficits in hippocampal NAA concentrations in all patient groups. In the amygdala there are significant NAA deficits in schizophrenia and depression and significant deficits of NAAG in the amygdala in the depression group. The deficits in NAA reported in this study confirm the importance of hippocampal and other subcortical structures in the neuropathology of the major psychiatric disorders.     

Working memory and prefrontal cortex dysfunction: specificity to schizophrenia compared with major depression.

BACKGROUND: A large number of studies suggest the presence of deficits in dorsolateral prefrontal cortex function during performance of working memory tasks in individuals with schizophrenia. However, working memory deficits may also present in other psychiatric disorders, such as major depression. It is not clear whether people with major depression also demonstrate impaired prefrontal activation during performance of working memory tasks. METHODS: We used functional magnetic resonance imaging to assess the patterns of cortical activation associated with the performance of a 2-back version of the N-Back task (working memory) in 38 individuals with schizophrenia and 14 with major depression. RESULTS: We found significant group differences in the activation of dorsolateral prefrontal cortex associated with working memory performance. Consistent with prior research, participants with schizophrenia failed to show activation of right dorsolateral prefrontal cortex in response to working memory tasks demands, whereas those with major depression showed clear activation of right and left dorsolateral prefrontal cortex as well as bilateral activation of inferior and superior frontal cortex. CONCLUSIONS: During performance of working memory tasks, deficits in prefrontal activation, including dorsolateral regions, are more severe in participants with schizophrenia (most of whom were recently released outpatients) than in unmedicated outpatients with acute nonpsychotic major depression.     

DSM-III personality disorders among patients with major depression, anxiety disorders, and mixed conditions

Of 298 mainly nonpsychotic psychiatric outpatients between 19 and 59 years of age, a group of patients having either pure major depression, major depression in combination with anxiety disorders, or pure anxiety disorders was extracted. The anxiety disorders were further differentiated in panic and nonpanic anxiety disorders. The groups were compared as to differences in frequency of personality disorders assessed by means of the Structured Interview for DSM-III Personality Disorders. The mixed major depression/anxiety disorder group appeared to be the most deviant with more severe personality disorders such as paranoid and borderline in addition to avoidant and dependent personality disorder. The differentiation between panic and nonpanic anxiety showed that it was patients with nonpanic anxiety features in addition to major depression who had this higher frequency of personality disorders. These findings imply that it is important to distinguish between major depression cases with and without anxiety disorders both in forthcoming research and in clinical practice.     

Do neuroleptics cause depression?

To investigate the etiology of depression occurring in the course of schizophrenia, 18 chronic schizophrenic outpatients with a major depressive episode were matched with nondepressed schizophrenic outpatient controls. There was no significant difference on mean equivalent daily dosage of chlorpromazine between the depressed and nondepressed schizophrenic groups. Thus, neuroleptics do not appear to induce depressive disorder in chronic schizophrenic patients.     

Depressive factors and their relationships with other symptom domains in schizophrenia, schizoaffective disorder, and psychotic depression

Relationships among different symptom domains were investigated in patients with acute exacerbation of schizophrenia with depressive symptoms, psychotic depression, or schizoaffective disorder, depressive subtype. Scores for depression and depressive factors were correlated with positive, negative, and extrapyramidal symptoms within diagnostic categories. No between-group differences in the relationship of different symptom domains could be found, and no substantial relationship between depression and positive symptoms could be revealed in any diagnostic subgroup. Only the retardation factor of depression showed a significant overlap with negative symptoms; depressive core symptoms did not. Core symptoms of depression were independent from other symptoms in all investigated diagnostic groups. Depression seems to represent a heterogeneous symptom domain with unique relationships of components to positive and negative symptoms across nosological borders. A more differentiated assessment, analysis, and treatment of depressive symptoms is therefore recommended for patients with combined depressive and psychotic symptoms.