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.     

共病边缘型人格障碍的双相情感障碍患者认知功能状况

背景 双相情感障碍与边缘型人格障碍（BPD）共病率高,共病患者认知功能受损更严重。目的 探讨是否共病BPD的双相情感障碍患者认知功能的差异,为临床诊疗提供参考。方法 采用简单随机抽样,选取2021年4月-2022年4月在河北医科大学第一医院治疗的共病BPD的双相情感障碍患者60例（共病组）,其中双相抑郁患者33例,双相躁狂患者27例。同时选取双相情感障碍患者60例（未共病组）,其中双相抑郁35例,双相躁狂25例。采用中文版神经心理状态测验（RBANS）和Stroop色词测验评估患者的认知功能。结果 共病组RBANS中的即刻记忆、视觉广度、言语功能和总评分均低于未共病组,差异均有统计学意义（t=-2.356、-2.138、-3.306、-2.729,P<0.05或0.01）,Stroop色词测验中的单字时间、单色时间、双字时间和双色时间均长于未共病组,差异均有统计学意义（t=4.808、3.341、5.249、5.167,P均<0.01）。共病BPD的双相抑郁患者RBANS中的即刻记忆、视觉广度、言语功能和总评分均低于未共病BPD的双相抑郁患者（t=-2.446、-2.407、-2.231、-2.078,P均<0.05）,Stroop色词测验中的单字时间、单色时间、双字时间和双色时间均长于未共病组（t=3.652、3.035、4.406、5.016,P均<0.01）。共病组双相躁狂患者RBANS中的言语功能和总评分均高于未共病组（t=-2.777、-2.347,P<0.05或0.01）,Stroop色词测验中的单字时间、单色时间、双字时间和双色时间均长于未共病组（t=3.600、2.658、2.943、4.337,P<0.05或0.01）。结论 相较于未共病BPD的双相情感障碍患者,共病BPD的双相情感障碍患者认知功能受损更严重。     

Electroconvulsive therapy for major depression in borderline personality disorder

Depressive disorder is a serious and frequent complication in borderline personality disorder (BPD), however, its severity tends to be neglected particularly if symptoms are short-lived or inconsistent as is common in patients with BPD. Yet the high frequency in these patients requires especially rapid and effective therapy to reduce the risks of vital endangerment, chronification and psychosocial impairment. Efficient crisis intervention is essential for continuity of the disease-specific multimodal therapy enabling lasting remission and social and vocational rehabilitation in BPD. In particular with regard to the high incidence of poor or failed pharmacological responses in patients with BPD, electroconvulsive therapy (ECT) is of significant relevance among antidepressant treatment options. Despite the wide consensus on its efficacy, there are only few selected trials on ECT for major depression (MD) in BPD. This review summarises the published original studies on this issue, and critically scrutinises indication, benefits and risks of ECT for MD in BPD. It contributes to a focused, discriminating view on ECT and thus enables an optimised patient-oriented, efficient indication for MD in BPD.     

Clinical management for hospital-treated deliberate self-poisoning: comparisons between patients with major depression and borderline personality disorder

OBJECTIVE: To compare the initial clinical management of hospital-treated deliberate self-poisoning patients with major depressive disorder (MDD) or borderline personality disorder (BPD) after controlling for demographic factors and level of suicide ideation. METHOD: This study compared sequential hospital treated deliberate self-poisoning patients (n = 570) with either MDD or BPD (but no major comorbid psychopathology) on four outcomes modelled using logistic regression: (i) length of stay in the general hospital; (ii) discharge to a psychiatric hospital; (iii) psychiatric follow-up; and (iv) general practitioner (GP) follow-up. RESULTS: BPD and MDD patients were discharged to psychiatric inpatient care at very similar rates (33%-35%) and almost all subjects with high levels of suicidal ideation were discharged to psychiatric hospital. However, for mild to moderate levels of suicidal ideation BPD patients were more likely to be discharged to psychiatric hospital than MDD patients. After controlling for demographics and suicidal ideation, BPD patients were more likely to be referred for psychiatric hospitalization on discharge (adjusted OR = 1.79, 95% CI = 1.01-3.18) and less likely to be referred to GPs if discharged to home (adjusted OR = 0.44, 95% CI = 0.24-0.81). There were no differences in general hospital length of stay or arrangements made for psychiatric follow-up for those discharged to home. CONCLUSIONS: This suggests that for mild to moderate suicidal ideation levels clinicians are more likely to choose to send BPD patients, after deliberate self-poisoning, to inpatient psychiatric care than MDD patients. Clinicians are also apparently more likely to choose to manage MDD patients in primary care settings, for those patients discharged to home. This has implications for service planning and clinical guidelines.     

Neural responses to emotional stimuli in comorbid borderline personality disorder and bipolar depression

Borderline personality disorder (BPD) is a severe clinical condition characterised by different maladaptive traits such as impulsivity and affective lability. Mood and emotion dysregulation are core features of affective disorders. Indeed patients affected by mood disorder (MD) have a significantly higher prevalence of comorbid BPD, resulting in more unstable mood and poorer response to medication. Blood oxygen level-dependent functional magnetic resonance imaging has been used to investigate the neural correlates of emotional face processing. Images for each subject were entered into an analysis of variance (ANOVA) dividing participants into three groups (MD, MD+BPD, Controls). MD+BPD patients show lower activations in the dorsolateral prefrontal cortex and higher activations in the cingulate cortex and hippocampus. The present study identifies the neural basis of the interaction between BPD and MD. The lower rate of response to treatment in MD+BPD could be related to a more severe emotional dysregulation syndrome.     

Examining the course and outcome of individuals diagnosed with schizophrenia and comorbid borderline personality disorder

This research examined the prevalence of comorbid borderline personality disorder (BPD) in a sample of schizophrenia inpatients, and then investigated the degree to which BPD comorbidity impacted symptom and functional outcomes after 1-year post-hospital discharge. A sample of 142 individuals with a diagnosis of schizophrenia (n = 100) or schizoaffective disorder (n = 42) from the MacArthur Violence Risk Assessment Study were administered the Structured Interview for DSM-III-R Personality (SIDP-R). Symptom and functional outcome data were gathered during hospitalization and at 1-year follow-up to analyze differences in symptom and functioning characteristics between those diagnosed with and without BPD. Results indicated that comorbid BPD was present in a non-trivial proportion (17.6%, n = 25) of the sample, based on SIDP-R assessment. Baseline analyses indicated that patients with BPD presented with modest elevations in the severity of overall psychiatric symptomatology, and higher levels of anxiety and depression, at hospitalization compared to non-BPD patients. At 1-year follow-up, results revealed that after adjusting for baseline differences, patients with schizophrenia and comorbid BPD showed significantly less improvement in psychiatric symptomatology, particularly hostility and suspiciousness, as well as global functioning, and were re-hospitalized at significantly higher rates than patients without BPD. Our findings indicate that the co-occurrence of schizophrenia and BPD is not infrequent and that BPD has a significant negative longitudinal impact on the course and outcome of patients with schizophrenia.     

Olanzapine safety and efficacy in patients with borderline personality disorder and comorbid dysthymia.

BACKGROUND: Numerous medications have been tested in patients with borderline personality disorder (BPD) and/or schizotypal personality disorder (SPD). Although many of the medications tested have been demonstrated to be useful, no clear main treatment for BPD has emerged. Despite the efficacy of some of the medicines, acceptability and side effects have proven to be barriers to the use of medication. Therefore, an open-label olanzapine trial utilizing objective ratings was performed. METHODS: Patients suffering from BPD and dysthymia were included in an 8-week, open-label study of olanzapine monotherapy. The first 4 weeks of the trial allowed for flexible dosing; during the last 4 weeks, olanzapine dose was held constant. Patients were rated on Hopkins Symptoms Checklist 90 (SCL-90), Brief Psychiatric Rating Scale (BPRS), Global Assessment of Function (GAF), Barratt Impulsivity Scale (BIS 11), and Buss-Durkee Hostility Inventory (BDHI). RESULTS: Eleven patients completed at least 2 weeks; nine of the patients finished the entire trial. There was a robust and statistically significant reduction in the five global ratings. Within the global ratings, symptoms of psychoticism, depression, interpersonal sensitivity, and anger were among the symptoms to be reduced. No movement disorder symptoms were noted for any of the patients. CONCLUSIONS: In this open-label pilot study, patients treated with olanzapine showed statistically significant reduction in self-rated and clinician-rated scales. Symptoms associated with BPD and dysthymia were among those to be substantially reduced. Further studies to explore olanzapine's efficacy versus placebo, as well as comparison to other potential treatments for BPD, are important next steps.     

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

BACKGROUND: Major depression in young women is often comorbid with borderline personality disorder (BPD); however, adrenal steroids and pro-inflammatory cytokines in patients with comorbid current major depressive disorder and BPD (MDD/BPD) have not been systematically examined. Therefore, our study aimed at examining serum profiles of cortisol, cytokines, and the cortisol/dehydroepiandrosterone (cortisol/DHEA) ratio in MDD/BPD patients and a healthy comparison group. METHODS: Twelve medication-free female patients with MDD/BPD and 12 healthy women were included. Serum profiles of cortisol, DHEA, tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and interleukin-1beta were sampled, and the molar cortisol/DHEA ratio was determined. RESULTS: Concentrations of serum cortisol, TNF-alpha, and IL-6, as well as the cortisol/DHEA ratios were significantly increased in MDD/BPD patients as compared with the healthy comparison group. CONCLUSIONS: Depressed patients with comorbid BPD display endocrine and immune alterations similar to those observed in cases of melancholic MDD without BPD. Elevated concentrations of serum cortisol, cortisol/DHEA ratios, and pro-inflammatory cytokines might indicate a state marker in these patients and might contribute to long-term metabolic alterations that have also been associated with MDD.     

Neurochemical alterations in women with borderline personality disorder and comorbid attention-deficit hyperactivity disorder

Background. Borderline personality disorder (BPD) is associated with structural and functional brain changes. Recent models and findings refer to alterations of glutamate and total N-acetylaspartate (tNAA) in this condition. Methods. Absolute quantities of tNAA, creatine, glutamate, glutamine, myoinositol and total choline were measured using 3 Tesla magnetic resonance spectroscopy of the left anterior cingulate cortex and the left cerebellum in 14 unmedicated women with BPD and comorbid attention-deficit hyperactivity disorder (ADHD) and 18 healthy women. Both groups were matched with respect to age, education and premorbid intelligence. Results. In the anterior cingulate, we found significantly higher tNAA and glutamate concentrations and a trend for lower glutamine levels in women with BPD and comorbid ADHD as compared to healthy women. There were no significant group differences in cerebellar metabolite concentrations. Conclusions. Glutamatergic changes in the anterior cingulate may be associated with BPD and comorbid ADHD. Increased anterior cingulate tNAA may indicate disturbed energy metabolism or impaired frontal maturation.     

Combined treatment of major depression in patients with borderline personality disorder: a comparison with pharmacotherapy.

OBJECTIVE: Combined treatment with psychotherapy and antidepressants is more effective than monotherapies. Recent data show that combined therapy has better results in patients with depression and Axis II codiagnosis. The aim of this study was to compare combined treatment using interpersonal psychotherapy (IPT) with pharmacotherapy alone in patients with depression and borderline personality disorder (BPD). METHODS: There were 39 consecutive outpatients diagnosed with BPD who presented with a major depressive episode enrolled in this study. They were randomly assigned to 1 of 2 treatment groups: fluoxetine 20 mg to 40 mg daily or fluoxetine 20 mg to 40 mg daily plus IPT 1 session weekly. Owing to noncompliance, 7 patients dropped out. We assessed the 32 patients who completed the 24 weeks of treatment at baseline, Week 12, and Week 24, using a semistructured interview for clinical characteristics, the Clinical Global Impression Scale (CGI), the Hamilton Depression Rating Scale (HDRS), and the Hamilton Anxiety Rating Scale (HARS), and 2 self-report questionnaires, that is, the Satisfaction Profile (SAT-P) for quality of life and the 64-item Inventory for Interpersonal Problems (IIP-64). We performed statistical analysis, using univariate general linear models with 2 factors: duration and type of treatment. RESULTS: Changes in remission rates, CGI, and HARS score did not differ between treatments. According to changes in the HDRS scores; changes in psychological functioning and social functioning scores on the SAT-P; and changes in vindictive or self-centred, cold or distant, intrusive or needy, and socially inhibited scores on the IIP-64, combined therapy was superior to fluoxetine alone. CONCLUSIONS: Combined therapy with IPT is more effective than antidepressant therapy alone, both in treating symptoms of major depression and in improving dimensions of quality of life and interpersonal functioning.     

Anterior cingulate volume reduction in adolescents with borderline personality disorder and co-morbid major depression

Borderline Personality Disorder (BPD) is a serious illness characterized by emotional dysregulation, impulsivity, and impaired interpersonal relationships. Prior work shows the anterior cingulate gyrus (ACG)—a region primarily involved in assessing the salience of emotional information and regulating emotional responses--is smaller in adults with BPD. We tested the hypothesis that, similar to adults, adolescents with BPD would have reduced Brodmann area (BA)-24 volume. Thirteen adolescent inpatients with co-morbid BPD and Major Depressive Disorder (MDD) and 13 matched healthy controls received 3T-MRI scans. Using a cytoarchitecturally-derived approach measuring gray and white matter volume, we observed a Group × Cingulate BA (25,24,31,23,29) × Matter (gray, white) type interaction indicating the BPD/MDD adolescents had smaller BA24 volume in gray but not white matter. Greater number of suicide attempts and BPD symptom severity measured by the Diagnostic Interview for BPD-revised (DIB-R) total score but not depressive symptoms measured by the Beck Depression Inventory (BDI) was associated with smaller BA24 volume. Our preliminary findings suggest that BPD-related abnormalities in BA24 volume may occur early in the developmental course of BPD with MDD. Future studies examining samples of MDD patients with and without BPD co-morbidity will be needed to clarify whether BA24 volume reductions are specific to BPD.     

Obsessive-compulsive disorder comorbid with borderline personality disorder: A long-term case study

Abstract Three case reports of patients with borderline personality disorder (BPD) and obsessive-compulsive disorder (OCD) for more than 10 years are used to illustrate the relationship between OCD and borderline pathology. The recognizable features of the obsessive-compulsive symptoms in these reports are: (i) pervasiveness, the symptomatic overlap of obsessive-compulsive symptoms; (ii) poor insight and resistance; and (iii) obsessive control evident in personal relationships. These features are manifestations of OCD psychopathology as well as of a personality disorder. The symptoms with these features are located hypothetically towards the severe end of the symptomatic spectrum of OCD. The comorbidity is not a simple relationship, and the symptomatology of the comorbid patient is derived from OCD pathology linked with the personality disorder rather than from independent BPD pathology.     

Predictors of 2-year outcome for patients with borderline personality disorder

OBJECTIVE: The primary purpose of this report was to investigate whether characteristics of subjects with borderline personality disorder observed at baseline can predict variations in outcome at the 2-year follow-up. METHOD: Hypothesized predictor variables were selected from prior studies. The patients (N=160) were recruited from the four clinical sites of the Collaborative Longitudinal Personality Disorders Study. Patients were assessed at baseline and at 6, 12, and 24 months with the Structured Clinical Interview for DSM-IV Axis I Disorders; the Diagnostic Interview for DSM-IV Personality Disorders, a modified version of that instrument; the Longitudinal Interval Follow-Up Evaluation; and the Childhood Experiences Questionnaire-Revised. Univariate Pearson's correlation coefficients were calculated on the primary predictor variables, and with two forward stepwise regression models, outcome was assessed with global functioning and number of borderline personality disorder criteria. RESULTS: The authors' most significant results confirm prior findings that more severe baseline psychopathology (i.e., higher levels of borderline personality disorder criteria and functional disability) and a history of childhood trauma predict a poor outcome. A new finding suggests that the quality of current relationships of patients with borderline personality disorder have prognostic significance. CONCLUSIONS: Clinicians can estimate 2-year prognosis for patients with borderline personality disorder by evaluating level of severity of psychopathology, childhood trauma, and current relationships.     

Corpus callosum abnormalities in women with borderline personality disorder and comorbid attention-deficit hyperactivity disorder

OBJECTIVE: Decreased brain volumes in prefrontal, limbic and parietal areas have been found in women with borderline personality disorder (BPD). Recent models suggest impaired structural and functional connectivity in this condition. To investigate this, we studied the thickness of the corpus callosum, the largest connecting fibre bundle in the human brain. METHODS: We acquired magnetic resonance imaging scans from 20 healthy women and 20 women with BPD and comorbid attention-deficit hyperactivity disorder. A novel computational mesh-based method was applied to measure callosal thickness at high spatial resolution. RESULTS: Women with BPD had a thinner isthmus of the corpus callosum, compared with healthy women. In the patient group, a history of childhood sexual abuse was associated with a thinner posterior body of the corpus callosum. CONCLUSION: Interhemispheric structural connectivity involving parietal and temporal areas may be impaired in women with BPD and comorbid attention-deficit hyperactivity disorder.     

强迫症伴强迫型人格障碍患者的临床表现

目的 评估强迫型人格障碍（OCPD）在强迫症（OCD）中的发病率,探讨伴OCPD的OCD患者的临床特征.方法 采用DSM-Ⅳ人格障碍临床定式检测手册（SCID-Ⅱ）中有关OCPD的诊断项目对260例OCD患者进行评估,据其是否符合OCPD诊断而将患者分为共病组（OCD＋ OCPD）和非共病组（OCD-OCPD）.对两者的临床特征、焦虑、抑郁水平等进行比较.结果 78例（30％）OCD患者符合OCPD的诊断;共病组有更多的物品污染、囤积以及高道德标准强迫思维和更多的检查、囤积和混合强迫行为等强迫症状,且共病组强迫行为严重程度、抑郁及特质焦虑水平显著高于非共病组,但两组首次出现强迫症状的年龄,有精神疾病家族史的比例以及自知力水平、状态焦虑水平等差异无统计学意义.结论 强迫型人格障碍与强迫症的重叠可能增加了其病理心理的严重程度.