Personality disorders and medical comorbidity

PURPOSE OF REVIEW: Personality disorders are not usually thought of as being associated with medical comorbidity. Research shows that medical comorbidity in personality disorders is clinically important. RECENT FINDINGS: In general those with personality disorders do not feel as fit as others do. Also, those with personality disorders in addition to other psychiatric disorders, such as depression and antisocial personality disorder, are likely to have more health problems than those without personality disorders. People with active borderline personality disorder have been shown to have more medical problems than those with remitted borderline personality disorder. Personality disorders can complicate the course of chronic medical illnesses. Finally, the use of psychotropic medications is not unusual in personality disorders and in itself can be associated with medical illnesses. SUMMARY: Clinicians caring for people with personality disorders need to be aware of possible medical comorbidity. More research is needed.     

The relationship of chronic medical illnesses,poor health-related lifestyle choices,and health care utilization to recovery status in borderline patients over a decade of prospective follow-up

Background

The interaction of borderline personality disorder (BPD) with physical health has not been well characterized. In this longitudinal study, we investigated the long-term relationship of chronic medical illnesses, health-related lifestyle choices, and health services utilization to recovery status in borderline patients over a decade of prospective follow-up.

Method

264 borderline patients were interviewed concerning their physical health at 6-year follow-up in a longitudinal study of the course of BPD. This sample was then reinterviewed five times at two-year intervals over the next ten years. We defined recovery from BPD based on a Global Assessment of Functioning score of 61 or higher, which required BPD remission, one close relationship, and full-time competent and consistent work or school attendance. We controlled for potentially confounding effects of time-varying major depressive disorder.

Results

Never-recovered borderline patients were significantly more likely than ever-recovered borderline patients to have a medical syndrome, obesity, osteoarthritis, diabetes, urinary incontinence, or multiple medical conditions (p < 0.0063). They were also significantly more likely to report pack-per-day smoking, weekly alcohol use, no regular exercise, daily sleep medication use, or pain medication overuse (p < 0.0083). In addition, never-recovered borderline patients were significantly more likely than ever-recovered borderline patients to undergo a medical emergency room visit, medical hospitalization, X-ray, CT scan, or MRI scan (p < 0.0063).

Conclusions

Over a decade of prospective follow-up, failure to recover from BPD seems to be associated with a heightened risk of chronic medical illnesses, poor health-related lifestyle choices, and costly health services utilization.     

Variables associated with alcohol, drug, and daily smoking cessation in patients with severe mental illnesses

BACKGROUND: Co-occurrence of substance use disorders and severe mental illnesses (SMIs) is a major U.S. public health issue, although the role of tobacco is usually neglected. This study explored variables associated with alcohol, drug, and smoking cessation in a naturalistic setting. METHOD: Logistic regression was used to study variables associated with cessation of alcohol and drug use disorder and daily smoking in 560 SMI inpatients and outpatients from central Kentucky facilities. Patients with a lifetime history of alcohol or drug use disorder were considered to be in cessation if they had not suffered from abuse or dependence during the last year. Alcohol and drug use disorder diagnoses were determined using the Clinician Rating of Alcohol and Drug Use Disorder. Patients were recruited from July 2000 to March 2003. RESULTS: The cessation rates for alcohol and drug use disorders were, respectively, 44% (95% CI = 39% to 49%) and 46% (CI = 40% to 51%); these were higher than the daily cigarette smoking cessation rate of 10% (CI = 7% to 13%). Drug use disorders (p < or = .02), outpatient status (p < .001), and having a medical complication of obesity (diabetes mellitus, hypertension, or hyperlipidemia; p < .001) were significantly associated with alcohol cessation. Alcohol use disorder (p < .001), starting treatment with psychiatric medications after 33 years of age (p < .001), taking these medications for 14 years or more (p = .02), schizophrenia diagnosis (p < .001), outpatient status (p = .03), and obesity (p = .04) were significantly associated with drug cessation. Cessation of daily smoking was associated with hypertension (p = .02), late start of treatment with psychiatric medications (> 33 years old; p = .01), and lack of lifetime drug abuse (p < .001). CONCLUSIONS: These results are limited by the cross-sectional and naturalistic design but suggest that public health experts, researchers, and clinicians need to mindfully address smoking cessation in patients with SMIs. Clinicians may want to consider that medical illnesses may motivate patients with SMIs to stop substance abuse and that patients with SMIs who abuse both alcohol and drugs rarely stop abusing just one of them.     

Treatment utilization by patients with personality disorders

OBJECTIVE: Utilization of mental health treatment was compared in patients with personality disorders and patients with major depressive disorder without personality disorder. METHOD: Semistructured interviews were used to assess diagnosis and treatment history of 664 patients in four representative personality disorder groups-schizotypal, borderline, avoidant, and obsessive-compulsive-and in a comparison group of patients with major depressive disorder. RESULTS: Patients with personality disorders had more extensive histories of psychiatric outpatient, inpatient, and psychopharmacologic treatment than patients with major depressive disorder. Compared to the depression group, patients with borderline personality disorder were significantly more likely to have received every type of psychosocial treatment except self-help groups, and patients with obsessive-compulsive personality disorder reported greater utilization of individual psychotherapy. Patients with borderline personality disorder were also more likely to have used antianxiety, antidepressant, and mood stabilizer medications, and those with borderline or schizotypal personality disorder had a greater likelihood of having received antipsychotic medications. Patients with borderline personality disorder had received greater amounts of treatment, except for family/couples therapy and self-help, than the depressed patients and patients with other personality disorders. CONCLUSIONS: These results underscore the importance of considering personality disorders in diagnosis and treatment of psychiatric patients. Borderline and schizotypal personality disorder are associated with extensive use of mental health resources, and other, less severe personality disorders may not be addressed sufficiently in treatment planning. More work is needed to determine whether patients with personality disorders are receiving adequate and appropriate mental health treatments.     

Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission

OBJECTIVE: The purpose of this study was to assess the prevalence of axis I disorders among patients with borderline personality disorder over 6 years of prospective follow-up. METHOD: A semistructured interview of demonstrated reliability was used to assess presence or absence of comorbid axis I disorders in 290 patients who met Revised Diagnostic Interview for Borderlines criteria and DSM-III-R criteria for borderline personality disorder and 72 patients who did not meet these criteria but did meet DSM-III-R criteria for another axis II disorder. Over 94% of surviving patients were reinterviewed about their axis I disorders at 2-year, 4-year, and 6-year follow-up periods. RESULTS: Although the patients with borderline personality disorder experienced declining rates of many axis I disorders over time, the rates of these disorders remained high, particularly the rates of mood and anxiety disorders. Patients whose borderline personality disorder remitted over time experienced substantial decline in all comorbid disorders assessed, but those whose borderline personality disorder did not remit over time reported stable rates of comorbid disorders. When the absence of comorbid axis I disorders was used to predict time to remission, the absence of substance use disorders was a far stronger predictor of remission from borderline personality disorder than was the absence of posttraumatic stress disorder, mood disorders, other anxiety disorders, or eating disorders, respectively. CONCLUSIONS: The results of this study suggest that axis I disorders are less common over time in patients with initially severe borderline personality disorder, particularly for patients whose borderline personality disorder remits over time. The findings also suggest that substance use disorders are most closely associated with the failure to achieve remission from borderline personality disorder.     

Axis II comorbidity of borderline personality disorder: description of 6-year course and prediction to time-to-remission

OBJECTIVE: The purpose of this study was to compare the axis II comorbidity of 202 patients whose borderline personality disorder (BPD) remitted over 6 years of prospective follow-up to that of 88 whose BPD never remitted. METHOD: The axis II comorbidity of 290 patients meeting both DIB-R and DSM-III-R criteria for BPD was assessed at baseline using a semistructured interview of demonstrated reliability. Over 96% of surviving patients were reinterviewed about their co-occurring axis II disorders blind to all previously collected information at three distinct follow-up waves: 2-, 4-, and 6-year follow-up. RESULTS: Both remitted and non-remitted borderline patients experienced declining rates of most types of axis II disorders over time. However, the rates of avoidant, dependent, and self-defeating personality disorders remained high among non-remitted borderline patients. Additionally, the absence of these three disorders was found to be significantly correlated with a borderline patient's likelihood-of-remission and time-to-remission; self-defeating personality disorder by a factor of 4, dependent personality disorder by a factor of 3 1/2, and avoidant personality disorder by a factor of almost 2. CONCLUSION: The results of this study suggest that axis II disorders co-occur less commonly with BPD over time, particularly for remitted borderline patients. They also suggest that anxious cluster disorders are the axis II disorders which most impede symptomatic remission from BPD.     

Oxcarbazepine in the treatment of borderline personality disorder: a pilot study

BACKGROUND: According to available studies concerning treatment of patients with borderline personality disorder, mood stabilizers have been found effective in controlling core symptoms of borderline pathology, in particular impulsive behavior and mood instability. Oxcarbazepine, an anticonvulsant structurally related to carbamazepine, has been tested in psychiatric settings for treating patients with bipolar disorders, substance abuse, resistant psychosis, and schizoaffective disorder. The present article is a pilot study on the efficacy and tolerability of oxcarbazepine in the treatment of borderline personality disorder. METHOD: Seventeen outpatients diagnosed with DSM-IV-TR borderline personality disorder were included. Patients were administered oxcarbazepine, 1200 to 1500 mg/day supplied twice daily, and tested at baseline, week 4, and week 12 using the Clinical Global Impressions scale-Severity of Illness item (CGI-S), the Brief Psychiatric Rating Scale (BPRS), the Hamilton Rating Scales for Depression and Anxiety (HAM-D, HAM-A), the Social Occupational Functioning Assessment Scale, and the Borderline Personality Disorder Severity Index (BPDSI). Adverse effects were collected and serum sodium level was measured. Statistics were performed by using the analysis of variance for repeated measures. RESULTS: Four patients discontinued treatment in the first 4 weeks due to noncompliance. A statistically significant response to oxcarbazepine was observed according to CGI-S and BPRS mean score (p = .001), HAM-A mean score (p = .002), BPDSI total score (p = .0005), and 4 BPDSI items, including interpersonal relationships (p = .0005), impulsivity (p = .0005), affective instability (p = .0005), and outbursts of anger (p = .045). No cases of significant hyponatremia or severe adverse effects were reported. Mild to moderate adverse effects included sedation, dizziness, nausea, and headache. Seven patients reported no adverse effects. CONCLUSION: Oxcarbazepine was found an effective and well-tolerated treatment in the management of borderline personality disorder patients.     

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.     

Borderline personality disorder, impulsivity, and the orbitofrontal cortex

OBJECTIVE: Orbitofrontal cortex lesions produce disinhibited or socially inappropriate behavior and emotional irregularities. Characteristics of borderline personality disorder include impulsivity and affective instability. The authors investigated whether aspects of borderline personality disorder, in particular impulsivity, are associated with orbitofrontal cortex dysfunction. METHOD: Measures of personality, emotion, impulsivity, time perception, sensitivity to reinforcers, and spatial working memory were administered to patients with borderline personality disorder (N=19), patients with orbitofrontal cortex lesions (N=23), patients with lesions in the prefrontal cortex but not in the orbitofrontal cortex (N=20), and healthy comparison subjects (N=39). RESULTS: The patients with orbitofrontal cortex lesions and the patients with borderline personality disorder performed similarly on several measures. Both groups were more impulsive and reported more inappropriate behaviors, borderline personality disorder characteristics, and anger and less happiness than the two comparison groups, and both groups were less open to experience and had a faster perception of time (underproduced time) than the healthy comparison subjects. The patients with orbitofrontal cortex lesions and the borderline personality disorder patients performed differently on other measures. The borderline personality disorder patients were less extraverted and conscientious and more neurotic and emotional than all other groups. Patients with orbitofrontal cortex lesions had deficits in reversing stimulus-reinforcer associations and a faster perception of time (overestimated time) than the healthy comparison subjects. CONCLUSIONS: Orbitofrontal cortex dysfunction may contribute to some core characteristics of borderline personality disorder, in particular impulsivity. Other characteristics of borderline personality disorder, such as high levels of emotionality and personality irregularities, do not appear to be related to the type of dysfunction produced by orbitofrontal cortex damage. The similarities and differences found between the borderline personality disorder patients and the patients with orbitofrontal cortex lesions may lead to a better understanding of the etiology of borderline personality disorder and the functions of the orbitofrontal cortex.     

Predictors of trait aggression in bipolar disorder

OBJECTIVES: Although aggressive behavior has been associated with bipolar disorder (BD), it has also been linked with developmental factors and disorders frequently found to be comorbid with BD, making it unclear whether or not it represents an underlying biological disturbance intrinsic to bipolar illness. We therefore sought to identify predictors of trait aggression in a sample of adults with BD. METHODS: Subjects were 100 bipolar I (n = 73) or II (n = 27) patients consecutively evaluated in the Bipolar Disorders Research Program of the New York Presbyterian Hospital-Payne Whitney Clinic. Diagnoses were established using the Structured Clinical Interview for the DSM-IV (SCID-I) and Cluster B sections of the SCID-II. Mood severity was rated by the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS). Histories of childhood maltreatment were assessed via the Childhood Trauma Questionnaire (CTQ), while trait aggression was measured by the Brown-Goodwin Aggression Scale (BGA). RESULTS: In univariate analyses, significant relationships were observed between total BGA scores and CTQ total (r = 0.326, p = 0.001), childhood emotional abuse (r = 0.417, p < 0.001), childhood physical abuse (r = 0.231, p = 0.024), childhood emotional neglect (r = 0.293, p = 0.004), post-traumatic stress disorder (t = -2.843, p = 0.005), substance abuse/dependence (t = -2.914, p = 0.004), antisocial personality disorder (t = -2.722, p = 0.008) and borderline personality disorder (t = -5.680, p < 0.001) as well as current HDRS (r = 0.397, p < 0.001) and YMRS scores (r = 0.371, p < 0.001). Stepwise multiple regression revealed that trait aggression was significantly associated with: (i) diagnoses of comorbid borderline personality disorder (p < 0.001); (ii) depressive symptoms (p = 0.001); and (iii) manic symptoms (p < 0.001). CONCLUSIONS: Comorbid borderline personality disorder and current manic and depressive symptoms each significantly predicted trait aggression in BD, while controlling for confounding factors. The findings have implications for nosologic distinctions between bipolar and borderline personality disorders, and the developmental pathogenesis of comorbid personality disorders as predisposing to aggression in patients with BD.     

Bipolar disorder with comorbid cluster B personality disorder features: impact on suicidality

BACKGROUND: Because of their overlapping phenomenology and mutually chronic, persistent nature, distinctions between bipolar disorder and cluster B personality disorders remain a source of unresolved clinical controversy. The extent to which comorbid personality disorders impact course and outcome for bipolar patients also has received little systematic study. METHOD: One hundred DSM-IV bipolar I (N = 73) or II (N = 27) patients consecutively underwent diagnostic evaluations with structured clinical interviews for DSM-IV Axis I and cluster B Axis II disorders, along with assessments of histories of childhood trauma or abuse. Cluster B diagnostic comorbidity was examined relative to lifetime substance abuse, suicide attempt histories, and other clinical features. RESULTS: Thirty percent of subjects met DSM-IV criteria for a cluster B personality disorder (17% borderline, 6% antisocial, 5% histrionic, 8% narcissistic). Cluster B diagnoses were significantly linked with histories of childhood emotional abuse (p = .009), physical abuse (p = .014), and emotional neglect (p = .022), but not sexual abuse or physical neglect. Cluster B comorbidity was associated with significantly more lifetime suicide attempts and current depression. Lifetime suicide attempts were significantly associated with cluster B comorbidity (OR = 3.195, 95% CI = 1.124 to 9.088), controlling for current depression severity, lifetime substance abuse, and past sexual or emotional abuse. CONCLUSIONS: Cluster B personality disorders are prevalent comorbid conditions identifiable in a substantial number of individuals with bipolar disorder, making an independent contribution to increased lifetime suicide risk.     

Is comorbidity of posttraumatic stress disorder and borderline personality disorder related to greater pathology and impairment?

OBJECTIVE: The authors examined whether patients with comorbid borderline personality disorder and posttraumatic stress disorder (PTSD) have a more severe clinical profile than patients with either disorder without the other. METHOD: Outpatients with borderline personality disorder without PTSD (N=101), PTSD without borderline personality disorder (N=121), comorbid borderline personality disorder and PTSD (N=48), and major depression without PTSD or borderline personality disorder (N=469) were assessed with structured interviews for psychiatric disorders and for degree of impairment. RESULTS: Outpatients with diagnoses of comorbid borderline personality disorder and PTSD were not significantly different from outpatients with borderline personality disorder without PTSD, PTSD without borderline personality disorder, or major depression without PTSD or borderline personality disorder in severity of PTSD-related symptoms, borderline-related traits, or impairment. CONCLUSIONS: The additional diagnosis of PTSD or borderline personality disorder does little to augment the pathology or dysfunction of patients who have either disorder without the other.     

Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years

OBJECTIVE: The purpose of this study was to describe the psychiatric treatment received by a well-defined sample of patients with borderline personality disorder and Axis II comparison subjects over 6 years of prospective follow-up. METHOD: 362 inpatients were interviewed about their treatment histories during their index admission (1992-1995). 290 patients met both Revised Diagnostic Interview for Borderlines and DSM-III-R criteria for borderline personality disorder and 72 met DSM-III-R criteria for at least 1 nonborderline Axis II disorder (and neither criteria set for borderline personality disorder). Over 94% of surviving patients were re-interviewed about their psychiatric treatment histories 2, 4, and 6 years later. RESULTS: Only 33% of borderline patients were hospitalized during the final 2 years of the 6-year follow-up, a substantial decline from the 79% who had prior hospitalizations at baseline. Much the same pattern emerged for day and/or residential treatment (from 55% to 22%). In contrast, about three quarters of borderline patients were still in psychotherapy and taking psychotropic medications after 6 years of follow-up. Additionally, over 70% of borderline patients participating in these outpatient modalities did so for at least 75% of each follow-up period. While rates of intensive psychotherapy declined significantly over time (from 36% to 16%), rates of intensive polypharmacy remained relatively stable over time, with about 40% of borderline patients taking 3 or more concurrent standing medications during each follow-up period, about 20% taking 4 or more, and about 10% taking 5 or more. CONCLUSIONS: The results of this study suggest that the majority of borderline patients continue to use outpatient treatment in a sustained manner through 6 years of follow-up, but only a declining minority use more restrictive and costly forms of treatment.     

Sustained unemployment in psychiatric outpatients with bipolar depression compared to major depressive disorder with comorbid borderline personality disorder

Zimmerman M, Martinez JH, Young D, Chelminski I, Dalrymple K. Sustained unemployment in psychiatric outpatients with bipolar depression compared to major depressive disorder with comorbid borderline personality disorder. Bipolar Disord 2012: 14: 856–862. © 2012 John Wiley & Sons A/S.Published by Blackwell Publishing Ltd. Objectives: The morbidity associated with bipolar disorder is, in part, responsible for repeated calls for improved detection and recognition. No such clinical commentary exists for improved detection of borderline personality disorder in depressed patients. Clinical experience suggests that borderline personality disorder is as disabling as bipolar disorder; however, no studies have directly compared the two disorders. For this reason we undertook the current analysis from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project comparing unemployment and disability rates in patients with bipolar disorder and borderline personality disorder. Methods: Patients were interviewed with semi‐structured interviews. We compared three non‐overlapping groups of depressed patients: (i) 181 patients with DSM–IV major depressive disorder and borderline personality disorder, (ii) 1068 patients with major depressive disorder without borderline personality disorder, and (iii) 84 patients with bipolar depression without borderline personality disorder. Results: Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder were significantly more likely to have been persistently unemployed. A similar difference was found between patients with bipolar depression and major depressive disorder without borderline personality disorder. No differences were found between patients with bipolar depression and depression with borderline personality disorder. Conclusions: Both bipolar disorder and borderline personality disorder were associated with impaired occupational functioning and thus carry a significant public health burden. Efforts to improve detection of borderline personality disorder in depressed patients might be as important as the recognition of bipolar disorder.     

Borderline personality-bipolar spectrum relationship

BACKGROUND: The relationship between borderline personality disorder (BPD) and bipolar disorders, especially bipolar-II disorder (BP-II), is unclear. Several reviews on the topic have come to opposite conclusions, i.e., that BPD is a bipolar spectrum disorder or instead that it is unrelated to bipolar disorders. Study aim was to find which items of BPD were related to BP-II, and which instead had no relationship with BP-II. METHODS: Study setting: An outpatient psychiatry private practice, more representative of mood disorders usually seen in clinical practice in Italy. INTERVIEWER: A senior clinical and mood disorder research psychiatrist. PATIENT POPULATION: A consecutive sample of 138 BP-II and 71 major depressive disorder (MDD) remitted outpatients. ASSESSMENT INSTRUMENTS: The Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version (SCID-CV) was used for diagnosing, the SCID-II Personality Questionnaire was used by patients to self-assess borderline personality traits. Interview methods: Patients were interviewed with the SCID-CV to diagnose BP-II and MDD. The questions of the Personality Questionnaire relative to borderline personality were self-assessed by patients. As clinically significant distress or impairment of functioning was not assessed by the questionnaire, a diagnosis of borderline personality disorder could not be made, but borderline personality traits (BPT) could be assessed (i.e., all DSM-IV BPD items but not the impairment criterion). RESULTS: BPT items were significantly more common in BP-II versus MDD. The best combination of sensitivity and specificity for predicting BP-II was found by using a cutoff number of BPT items > or =5: specificity was 71.4%, sensitivity was 45.9%. BPT (defined by > or =5 items) was present in 29.5% of MDD and in 46.3% of BP-II (p=0.019). Logistic regression of BP-II versus BPT items number found a significant association. Principal component factor analysis of BPT items found two orthogonal factors: "affective instability" including unstable mood, unstable interpersonal relationships, unstable self-image, chronic emptiness, and anger, and "impulsivity" including impulsivity, suicidal behavior, avoidance of abandonment, and paranoid ideation. "Affective instability" was associated with BP-II (p=0.010), but "impulsivity" was not associated with BP-II (p=0.193). Interitem correlation was low. There was no significant correlation between the two factors. DISCUSSION: Study findings suggest that DSM-IV BPD may mix two sets of unrelated items: an affective instability dimension related to BP-II, and an impulsivity dimension not related to BP-II, which may explain the opposite conclusions of several reviews. A subtyping of BPD according to these dimensions is supported by the study findings.     

Low hospital inpatient readmission rate in patients with borderline personality disorder: a naturalistic study at Southern Health, Victoria, Australia

OBJECTIVE: To study how the standard management protocol and the special management contract relate to the clinical profile of patients with borderline personality disorder and their hospital admission pattern. METHOD: A retrospective review was undertaken using naturalistic data from the Client Management Interface over a 2-year period. The standard management protocol patient group and the special treatment contract patient group were compared with respect to variables which included basic demographic data, number of admissions, length of stay and comorbidity. RESULTS: Eighty patients received a diagnosis of borderline personality disorder. The majority (81.2%) were managed with the standard management protocol and only 41.5% had more than one admission. For those who received a special treatment contract (18.8%), 93.3% of them had more than one admission. The special treatment contract group had a significantly higher total number of admissions (p < 0.001), a higher number of admissions when they received (p < 0.001) and did not receive (p = 0.001) a diagnosis of borderline personality disorder, a higher number of comorbidities (p = 0.004) but not more presentations to the emergency department. CONCLUSIONS: Most patients with borderline personality disorder treated with the standard management protocol had a low readmission rate. The small group of patients with comorbidities managed with a special treatment contract had multiple readmissions but not more crisis presentations to the emergency department. Further studies are required to elucidate the therapeutic mechanism of the standard management protocol and special treatment contract and how that impacts on presentations and admissions to a hospital.     

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.     

Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences

Objectives: many studies have reported a high degree of comorbidity between mood disorders, among which are bipolar disorders, and borderline personality disorder and some studies have suggested that these disorders are co-transmitted in families. However, few studies have compared personality traits between these disorders to determine whether there is a dimensional overlap between the two diagnoses. The aim of this study was to compare impulsivity, affective lability and intensity in patients with borderline personality and bipolar II disorder and in subjects with neither of these diagnoses. Methods: patients with borderline personality but without bipolar disorder (n=29), patients with bipolar II disorder without borderline personality but with other personality disorders (n=14), patients with both borderline personality and bipolar II disorder (n=12), and patients with neither borderline personality nor bipolar disorder but other personality disorders (OPD; n=93) were assessed using the Affective Lability Scale (ALS), the Affect Intensity Measure (AIM), the Buss–Durkee Hostility Inventory (BDHI) and the Barratt Impulsiveness Scale (BIS-7B). Results: borderline personality patients had significantly higher ALS total scores (P<0.05) and bipolar II patients tended to have higher ALS scores than patients with OPD (P<0.06). On one of the ALS subscales, the borderline patients displayed significant higher affective lability between euthymia and anger (P<0.002), whereas patients with bipolar II disorder displayed affective lability between euthymia and depression (P<0.04), or elation (P<0.01) or between depression and elation (P<0.01). A significant interaction between borderline personality and bipolar II disorder was observed for lability between anxiety and depression (P<0.01) with the ALS. High scores for impulsiveness (BISTOT, P<0.001) and hostility (BDHI, P<0.05) were obtained for borderline personality patients only and no significant interactions between diagnoses were observed. Only borderline personality patients tended to have higher affective intensity (AIM, P<0.07). Conclusions: borderline personality disorder and bipolar II disorder appear to involve affective lability, which may account for the efficacy of mood stabilizers treatments in both disorders. However, our results suggest that borderline personality disorder cannot be viewed as an attenuated group of affective disorders.     

Prospective assessment of treatment use by patients with personality disorders

OBJECTIVE: This study examined the utilization of mental health treatments over a three-year period among patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorders compared with patients with major depressive disorder and no personality disorder. METHODS: A prospective, longitudinal study design was used to measure treatment use for 633 individuals aged 18 to 45 years during a three-year period. RESULTS: Patients with borderline personality disorder were significantly more likely than those with major depressive disorder to use most types of treatment. Furthermore, all patients continued using high-intensity, low-duration treatments throughout the study period, whereas individual psychotherapy attendance declined significantly after one year. CONCLUSIONS: Although our data showed that patients with borderline personality disorder used more mental health services than those with major depressive disorder, many questions remain about the adequacy of the treatment received by all patients with personality disorders.     

Personality disorders, history of trauma, and posttraumatic stress disorder in subjects with anxiety disorders

The purpose of the study was to examine the association of personality disorders, history of trauma, and posttraumatic stress disorder (PTSD) in a large sample of subjects with anxiety disorders. Categorical and continuous indices of personality disorders were compared in three groups from the Harvard/Brown Anxiety Disorders Research Project (HARP): subjects with no history of trauma (n = 403), subjects with a history of trauma but no history of PTSD (n = 151), and subjects with a current or past diagnosis of PTSD (n = 68). Subjects with PTSD were more likely to meet criteria for borderline or self-defeating personality disorder than subjects in the other two groups. PTSD subjects also had higher scores on the continuous measures (total number of criteria met) for borderline and self-defeating personality disorder than the other two groups. The findings suggest that a diagnosis of PTSD rather than a history of trauma is associated with borderline and self-defeating personality disorder features. Alternative conceptualizations of axis II features in individuals with PTSD are discussed.