Borderline personality disorder criteria associated with prospectively observed suicidal behavior

OBJECTIVE: The authors prospectively examined associations between each DSM-IV borderline personality disorder criterion and suicidal behaviors. METHOD: Borderline personality disorder diagnosis and criteria, major depressive disorder, substance use disorders, and history of childhood sexual abuse were assessed with semistructured interviews. Participants (N=621) were followed for 2 years with repeated structured evaluations that included assessments of suicidality. RESULTS: With the self-injury criterion excluded, the borderline personality disorder criteria of affective instability, identity disturbance, and impulsivity significantly predicted suicidal behaviors. Only affective instability and childhood sexual abuse were significantly associated with suicide attempts (i.e., behavior with some intent to die). CONCLUSIONS: Affective instability is the borderline personality disorder criterion (excluding self-injury) most strongly associated with suicidal behaviors. Since major depressive disorder did not significantly predict suicidal behaviors, the reactivity associated with affective instability (more so than negative mood states) appears to be a critical element in predicting suicidal behaviors.     

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.     

Comorbid personality disorders in subjects with panic disorder: do personality disorders increase clinical severity?

Personality disorders are common in subjects with panic disorder. Personality disorders have been shown to affect the course of panic disorder. The purpose of this study was to examine which personality disorders affect clinical severity in subjects with panic disorder. This study included 122 adults (71 women, 41 men) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for panic disorder (with or without agoraphobia). Clinical assessment was conducted by using the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and the Panic and Agoraphobia Scale, Global Assessment Functioning Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Patients who had a history of sexual abuse were assessed with Sexual Abuse Severity Scale. Logistic regressions were used to identify predictors of suicide attempts, suicidal ideation, sexual abuse, and early onset of disorder. The rates of comorbid Axes I and II psychiatric disorders were 80.3% and 33.9%, respectively, in patients with panic disorder. Patients with panic disorder with comorbid personality disorders had more severe anxiety, depression, and agoraphobia symptoms, had earlier ages at onset, and had lower levels of functioning. The rates of suicidal ideation and suicide attempts were 34.8% and 9.8%, respectively, in subjects with panic disorder. The rate of patients with panic disorder and a history of childhood sexual abuse was 12.5%. The predictor of sexual abuse was borderline personality disorder. The predictors of suicide attempt were comorbid paranoid and borderline personality disorders, and the predictors of suicidal ideation were comorbid major depression and avoidant personality disorder in subjects with panic disorder. In conclusion, this study documents that comorbid personality disorders increase the clinical severity of panic disorder. Borderline personality disorder may be the predictor of a history of sexual abuse and early onset in patients with panic disorder. Paranoid and borderline personality disorders may be associated with a high frequency of suicide attempts in patients with panic disorder.     

Dissociation and fantasy proneness in psychiatric patients: a preliminary study

Nonclinical studies found that dissociative experiences are intimately linked to a trait known as fantasy proneness. We examined the links among dissociative symptoms, fantasy proneness, and impulsivity in psychiatric outpatients. Our sample consisted of 22 patients with schizophrenia, 20 patients with a diagnosis of borderline personality disorder, and 19 patients with a major depressive disorder. For the whole sample, levels of dissociation were found to be related to fantasy proneness and impulsivity. There were group differences in dissociative symptoms, with patients with borderline personality disorder reporting more such symptoms than patients with either schizophrenia or major depressive disorder. The overlap between dissociation and fantasy proneness may have important ramifications for studies addressing comorbid phenomena of dissociative symptoms.     

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

BACKGROUND: Co-occurrence of bulimia nervosa and borderline personality disorder has been attributed to shared factors, including childhood abuse and disturbances in central serotonin (5-hydroxytryptamine; 5-HT) mechanisms. To explore this notion, we conducted a controlled assessment of childhood abuse and 5-HT function in bulimics with and without borderline personality disorder. METHOD: Forty patients with bulimia nervosa, confirmed with the Eating Disorders Examination interview (14 with borderline personality disorder and 26 without), and 25 normal-eater controls were assessed for clinical symptoms (eating disturbances, mood lability, impulsivity, and dissociation) and childhood sexual and physical abuse. We also conducted tests of platelet tritiated-paroxetine binding in blood samples from 27 of the bulimics (11 with borderline personality disorder and 16 without) and 16 of the controls. RESULTS: Relative to normal eaters, bulimics showed greater affective instability, overall impulsivity, and a history of physical abuse. However, borderline bulimics alone showed elevated motor impulsivity, dissociation, and rates of sexual abuse. Paroxetine-binding tests indicated no differences attributable to comorbid borderline personality disorder, instead linking bulimia nervosa with or without borderline personality disorder to substantially reduced 5-HT transporter density. CONCLUSION: Results suggest relatively autonomous pathologic entities: one, relevant to bulimia nervosa, being associated with abnormal 5-HT transporter function and affective instability, but relatively independent of childhood sexual abuse; another, relevant to borderline personality disorder, onto which sexual abuse, dissociative symptoms, and behavioral impulsivity converge. We propose that abnormal 5-HT function may, however, constitute one basis for the frequent co-occurrence of bulimic and borderline disturbances.     

Comorbidity for borderline and schizotypal personality disorders. A study of alcoholic women

Twenty-six women alcoholics who fulfilled the criteria for a pure borderline personality disorder (BPD) were compared with 16 women alcoholics who also fulfilled the criteria of a schizotypal personality disorder (called mixed borderline disorder, MBD) based on personal interviews including SADS, SIB, Childhood Environment Scale (CES), and the Premorbid Adjustment Scale (PAC). The MBD women had fewer alcoholic relatives, poorer relationships with parents and siblings, a more deviant score on CES and PAC, a higher incidence of nervous children, and a poorer social network. They also reported more losses and a greater frequency of depressive symptoms during childhood and adolescence, earlier contact with psychiatry, and more frequent hospitalizations. They had a higher frequency of a nonalcoholic axis I disorder (mainly depressive and anxiety disorders), as well as a greater frequency of a paranoid personality disorder. The results show that the MBD women were more psychopathologically disturbed and support a possible link between MBD and affective disorders. The findings also indicate that MBD may be a clinical entity that should be differentiated from the pure BPD group both in clinical work and forthcoming research.     

Lifetime rhythmicity and mania as correlates of suicidal ideation and attempts in mood disorders

BACKGROUND: The aim of this study is to establish to what degree variation in lifetime experience of rhythmicity and manic-hypomanic features correlates with suicidality in individuals with mood disorders and other major psychiatric diagnoses and in a comparison group of controls. METHOD: Suicidal ideation and attempts were investigated in a clinical sample, including 77 patients with schizophrenia, 60 with borderline personality disorder, 61 with bipolar disorder, 88 with unipolar depression, and 57 with panic disorder, and in a comparison group of 102 controls. Using information derived from the diagnostic interview and a self-report assessment of mood spectrum symptoms, subjects were assigned to 3 categories according to the maximum level of suicidality achieved in the lifetime (none, ideation/plans, and suicide attempts). The association of categorical and continuous variables with suicidality levels was investigated using multinomial logistic regression models. RESULTS: Suicidal ideation and plans were more common in unipolar depression (50%) and bipolar disorder (42.4%) than in borderline personality disorder (30%), whereas the reverse was true for suicidal attempts. In each of the study groups, the number and the type of mood spectrum items endorsed, including depressive and manic-hypomanic items and rhythmicity and vegetative symptoms, were associated with increased levels of suicidality. CONCLUSIONS: Our results suggest that the assessment of lifetime rhythmicity and manic-hypomanic features may be clinically useful to identify potential suicide attempters in high-risk groups.     

Two-year prevalence and stability of individual DSM-IV criteria for schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: toward a hybrid model of axis II disorders

OBJECTIVE: This study tracked the individual criteria of four DSM-IV personality disorders-borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders-and how they change over 2 years. METHOD: This clinical sample of patients with personality disorders was derived from the Collaborative Longitudinal Personality Disorders Study and included all participants with borderline, schizotypal, avoidant, or obsessive-compulsive personality disorder for whom complete 24-month blind follow-up assessments were obtained (N=474). The authors identified and rank-ordered criteria for each of the four personality disorders by their variation in prevalence and changeability (remission) over time. RESULTS: The most prevalent and least changeable criteria over 2 years were paranoid ideation and unusual experiences for schizotypal personality disorder, affective instability and anger for borderline personality disorder, feeling inadequate and feeling socially inept for avoidant personality disorder, and rigidity and problems delegating for obsessive-compulsive personality disorder. The least prevalent and most changeable criteria were odd behavior and constricted affect for schizotypal personality disorder, self-injury and behaviors defending against abandonment for borderline personality disorder, avoiding jobs that are interpersonal and avoiding potentially embarrassing situations for avoidant personality disorder, and miserly behaviors and strict moral behaviors for obsessive-compulsive personality disorder. CONCLUSIONS: These patterns highlight that within personality disorders the relatively fixed criteria are more trait-like and attitudinal, whereas the relatively intermittent criteria are more behavioral and reactive. These patterns suggest that personality disorders are hybrids of traits and symptomatic behaviors and that the interaction of these elements over time helps determine diagnostic stability. These patterns may also inform criterion selection for DSM-V.     

Psychotic symptoms and paranoid ideation in a population-based sample of 95-year-olds.

OBJECTIVE: To examine the 1-year prevalence of psychotic symptoms and schizophrenia in nondemented 95-year-olds, and to examine the relation between psychotic symptoms and other psychiatric symptoms, sensory impairments, and cognitive functioning. PARTICIPANTS: The representative sample was 95-year-olds living in G?teborg, Sweden (N = 338). Individuals with dementia were excluded (N = 175), leaving 163 subjects for this study. DESIGN: This was a cross-sectional population study, including psychiatric and physical examinations, cognitive tests, and interviews with close informants. MEASUREMENTS: Diagnosis of schizophrenia, psychotic symptoms, paranoid ideation and dementia according to Diagnostic and Statistical Manual of Mental Disorders, Third Revision (DSM-III) were measured. Cognitive function was tested with the Mini-Mental State Exam. Other psychiatric symptoms were measured by the Comprehensive Psychopathological Rating Scale. RESULTS: The one-year prevalence of any psychotic symptom was 7.4% (95% confidence interval [CI] 3.8-12.5); including hallucinations 6.7% (95% CI 3.4-11.8) and delusions 0.6% (95% CI 0.0-3.4). Four (2.4%) individuals fulfilled DSM-III-R criteria for schizophrenia. Individuals with psychotic symptoms or paranoid ideation did not differ regarding cognitive functioning compared with individuals without these symptoms. Individuals with hallucinations and paranoid ideation had an increased frequency of previous paranoid personality traits compared with individuals without psychotic symptoms and paranoid ideation. No individuals with psychotic symptoms had a formal thought disorder, incoherence of speech, or flat affect. CONCLUSION: The authors found a high prevalence of psychotic symptoms, paranoid ideation, and schizophrenia in the very old. Most of the symptoms were elucidated by information from key informants, illustrating the importance of including relatives in the evaluation of elderly persons.     

Sex differences in clinical predictors of suicidal acts after major depression: a prospective study

OBJECTIVE: Whether sex differences exist in clinical risk factors associated with suicidal behavior is unknown. The authors postulated that among men with a major depressive episode, aggression, hostility, and history of substance misuse increase risk for future suicidal behavior, while depressive symptoms, childhood history of abuse, fewer reasons for living, and borderline personality disorder do so in depressed women. METHOD: Patients with DSM-III-R major depression or bipolar disorder seeking treatment for a major depressive episode (N=314) were followed for 2 years. Putative predictors were tested with Cox proportional hazards regression analysis. RESULTS: During follow-up, 16.6% of the patients attempted or committed suicide. Family history of suicidal acts, past drug use, cigarette smoking, borderline personality disorder, and early parental separation each more than tripled the risk of future suicidal acts in men. For women, the risk for future suicidal acts was sixfold greater for prior suicide attempters; each past attempt increased future risk threefold. Suicidal ideation, lethality of past attempts, hostility, subjective depressive symptoms, fewer reasons for living, comorbid borderline personality disorder, and cigarette smoking also increased the risk of future suicidal acts for women. CONCLUSIONS: These findings suggest that the importance of risk factors for suicidal acts differs in depressed men and women. This knowledge may improve suicide risk evaluation and guide future research on suicide assessment and prevention.     

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.     

Risk of schizophrenia in character disordered patients

Inpatients from the Chestnut Lodge follow-up study diagnosed with character disorder were studied to predict future schizophrenic decompensation. Individually, three DSM-III criteria for schizotypal personality disorder predicted schizophrenia at long-term follow-up: magical thinking, suspiciousness or paranoid ideation, and social isolation. Additionally, lower IQ, poorer premorbid quality of work, and transient delusional experiences were predictive. No borderline personality disorder criterion was predictive. This suggests that schizotypal but not borderline personality disorder belongs in the schizophrenic spectrum. Within schizotypal personality disorder, criteria from both familial and clinical traditions appear to be dimensions of vulnerability to psychosis.     

Suicidal ideation and suicide attempts among patients with panic disorder: a survey of two outpatient clinics.

OBJECTIVE: Recent epidemiologic studies found that 20% of subjects with the diagnosis of panic disorder had attempted suicide. This study sought to determine the prevalence of suicidal ideation and suicide attempts among patients with panic disorder and whether the presence of comorbid borderline personality disorder influenced the prevalence of suicidal thoughts and behavior. METHOD: At two outpatient clinics, experienced clinicians conducted retrospective reviews of data from the intake interviews and charts of 59 patients with panic disorder and comorbid borderline personality disorder and 234 patients with panic disorder with or without axis II disorders other than borderline personality disorder. RESULTS: Suicide attempts were reported by 2% of the patients with panic disorder, compared to 25% of the patients with both panic disorder and borderline personality disorder. In addition, 2% of the patients with panic disorder, compared to 27% of the patients with panic disorder and borderline personality disorder, reported suicidal ideation that was judged to be of clinical significance. CONCLUSIONS: The rate of suicidal ideation and suicide attempts for psychiatric outpatients with panic disorder was discrepant with the findings of the earlier studies. The increased suicide risk in this group of patients was associated with borderline personality disorder, increased substance abuse, and affective instability. While 61% of the panic disorder patients and 78% of the patients with both panic disorder and borderline personality disorder reported thinking about death, this must be distinguished from actual suicidal ideation and clinical risk of suicide.     

Effects of Personality Disorder and Impulsivity on Emotional Adaptations in Prison Among Women Offenders

The present study sought to better understand the influence of personality disorders and impulsivity on women??s ability to adapt to incarceration. We analyzed the influence of personality disorders as screened with the Structured Clinical Interview for Personality Disorders, and impulsivity as assessed with the Barratt Impulsivity Scale on depression and anxiety, sleeping problems, and feeling afraid of being attacked in prison among a large sample of women incarcerated in a Virginia prison. Results from regression models indicated that schizotypal, borderline, avoidant and dependent personality disorders and cognitive impulsivity were significant predictors of symptoms of anxiety and depression net of demographic covariates. Women possessing a diagnosis of paranoid personality disorder were at increased odds of having difficulty sleeping in prison and borderline, dependent, and paranoid personality disorder were at increased odds of experiencing fear in prison. Women who had been in prison before were significantly less likely to experience these problems. Implications of study findings for policies and practices involving women offenders are discussed.     

A longitudinal view of triggers and thresholds of suicidal behavior in depression

BACKGROUND: Recurrent brief depressive disorder (RBD) and major depressive disorder (MDD) share the same diagnostic picture of full-blown depression and are both associated with increased suicide attempt rates. However, longitudinal diagnostic shifts from RBD to MDD or vice versa, called "combined depression" (CD), have demonstrated a substantially higher risk of suicide attempts in epidemiologic and clinical studies. Following the stress-diathesis model of suicidal behavior, we compared possible triggers and thresholds for suicidal behavior among patients with RBD, MDD, and CD. RBD and MDD diagnoses were based on DSM-IV criteria. Furthermore, the goal of this study was to determine if impulsivity as an underlying factor could explain high suicide attempt rates in CD. METHOD: A structured clinical interview evaluating comorbid Axis I and II disorders and RBD and a battery of instruments assessing suicidal behavior were administered to 101 patients with RBD (N = 27), MDD (N = 33), or CD (N = 41). RESULTS: Patients with CD showed significantly higher (p < .05) scores on measures of suicidal behavior in comparison with RBD and MDD patients. Together with comorbid substance abuse and marital status, CD was among the highest-ranking risk factors for suicide attempts. Impulsivity was identified as a major underlying factor, predicting 80.7% of suicide attempts. CONCLUSION: CD seems to be an important clinical risk factor for the prediction of suicide attempts, similar to risk factors such as substance use disorders and borderline personality disorder. All of these factors share the same diathesis for increased impulsivity and suicidal ideation, which could explain comorbidity and suicidal behavior. The coexistence of a greater propensity for suicidal ideation and impulsivity in RBD might also explain why such patients are more prone to attempt suicide, even if they do not, in the case of RBD, meet the duration criteria for MDD.     

Depression in borderline personality disorder: lifetime prevalence at interview and longitudinal course of symptoms

The author compared a group of patients with borderline personality disorder with groups of subjects with antisocial personality and bipolar II illness. The lifetime prevalence at interview of DSM-III major depression was high in all groups. Chronic depression demonstrated a specific relationship to borderline psychopathology. Prospectively, borderline psychopathology predicted high levels of depressive and anxiety symptoms. This relationship was reversed for depressive symptoms in patients with antisocial personality disorder, suggesting that when borderline and antisocial personality disorders occur together, some features may arise that differentiate patients with both disorders from those with either disorder alone.     

Impact of trait impulsivity and state aggression on divalproex versus placebo response in borderline personality disorder

OBJECTIVE: The authors' goal was to determine whether specific pretreatment clinical characteristics differentially predict favorable treatment response to divalproex versus placebo for impulsive aggression in patients with borderline personality disorder. METHOD: Fifty-two outpatients with DSM-IV borderline personality disorder were randomly assigned to receive divalproex (N=20) or placebo (N=32), double-blind, for 12 weeks. Trait impulsivity symptoms were determined by using the Barratt Impulsiveness Scale, and state aggression symptoms were determined by using the Overt Aggression Scale modified for outpatients. Affective stability was determined by using the Young Mania Rating Scale and the Hamilton Depression Rating Scale. Analyses were performed to identify possible baseline symptom domains that predict treatment response. RESULTS: Divalproex was superior to placebo in reducing impulsive aggression in patients with borderline personality disorder. Divalproex-treated patients responded better than placebo-treated patients among those with higher baseline trait impulsivity symptoms and state aggression symptoms. The effects of baseline trait impulsivity and state aggression appear to be independent of one another. However, baseline affective instability did not influence differential treatment response. CONCLUSIONS: Both pretreatment trait impulsivity symptoms and state aggression symptoms predict a favorable response to divalproex relative to placebo for impulsive aggression in patients with borderline personality disorder.     

Testing DSM-III symptom criteria for schizotypal and borderline personality disorders

Schizotypal and borderline personality disorders (SPD and BPD, respectively) appear to be different at follow-up, yet they are poorly discriminated from each other by current DSM-III symptom criteria. In the Chestnut Lodge Follow-up Study, three axis II study cohorts (pure SPD, n = 10; pure BPD, n = 81; mixed SPD/BPD, n = 18) with distinctive outcomes are defined using current borderline systems. This study compares the relative frequency with which individual symptom criteria from each system discriminate across study cohorts. Findings suggest that for SPD, the most characteristic (core) DSM-III symptoms are odd communication, suspiciousness/paranoid ideation, and social isolation, while the least discriminating symptom is illusions/depersonalization/derealization; the core DSM-III symptoms for BPD are unstable relationships, impulsivity, and self-damaging acts, while the least discriminating symptoms are inappropriate anger and intolerance of aloneness; depression as a symptom does not discriminate between SPD and BPD; and transient psychoses and brief paranoid experiences and/or regression in treatment discriminate for SPD but against BPD and therefore fit better as SPD criteria. Results support the retention of some, but the elimination of other, DSM-III symptom criteria for the diagnosis of SPD and BPD.     

Borderline personality disorder in major depression: symptomatology,temperament, character,differential drug response,and 6-month outcome

Among 183 depressed patients participating in a randomized long-term treatment trial of fluoxetine and nortriptyline, 30 patients had borderline personality disorder (BPD), 53 had other personality disorders (OPD), and 100 had no personality disorders (NPD). The borderline depressed patients had earlier age of onset of their depressions, more chronic depressions, more alcohol and cannabis comorbidity, and were more likely to have histories of suicide attempts and of self-mutilation. On self-report, patients with BPD and OPD reported more phobic symptoms, greater interpersonal sensitivity, and more paranoid ideation. Uniquely, BPD patients were more angry than OPD patients. BPD patients had high novelty seeking, high harm avoidance, low self-directedness, and low cooperativeness. Depressed patients with BPD did poorly in the short term if treated with nortriptyline rather than fluoxetine. After 6 months, those with BPD had a favorable outcome in regard to depressive symptoms, social adjustment, and even improvement in the character measure of self-directedness. Those with the poorest outcome were those with OPD.     

Natural course of adolescent major depressive disorder in a community sample: predictors of recurrence in young adults

OBJECTIVE: The primary purpose was to identify factors related to the recurrence of major depressive disorder during young adulthood (19-23 years of age) in a community sample of formerly depressed adolescents. METHOD: A total of 274 participants with adolescent-onset major depressive disorder were assessed twice during adolescence and again after their 24th birthday. Lifetime psychiatric information was obtained from their first-degree relatives. Adolescent predictor variables included demographic characteristics, psychosocial variables, characteristics of adolescent major depressive disorder, comorbidity, family history of major depressive disorder and nonmood disorder, and antisocial and borderline personality disorder symptoms. RESULTS: Low levels of excessive emotional reliance, a single episode of major depressive disorder in adolescence, low proportion of family members with recurrent major depressive disorder, low levels of antisocial and borderline personality disorder symptoms, and a positive attributional style (males only) independently predicted which formerly depressed adolescents would remain free of future psychopathology. Female gender, multiple major depressive disorder episodes in adolescence, higher proportion of family members with recurrent major depressive disorder, elevated borderline personality disorder symptoms, and conflict with parents (females only) independently predicted recurrent major depressive disorder. Comorbid anxiety and substance use disorders in adolescence and elevated antisocial personality disorder symptoms independently distinguished adolescents who developed recurrent major depressive disorder comorbid with nonmood disorder from those who developed pure major depressive disorder. CONCLUSIONS: Formerly depressed adolescents with the risk factors identified in this study are at elevated risk for recurrence of major depressive disorder during young adulthood and therefore warrant continued monitoring and preventive or prophylactic treatment.