Descriptive and longitudinal observations on the relationship of borderline personality disorder and bipolar disorder

OBJECTIVE: The purpose of this study was to test whether borderline personality disorder is a variant of bipolar disorder by examining the rates of co-occurrence in both disorders, the effects of co-occurrence on a longitudinal course, and whether the presence of either disorder confers the risk for new onsets of the other. METHOD: A prospective repeated-measures design with reliable independent diagnostic measures and 4 years of follow-up was used to assess 196 patients with borderline personality disorder and 433 patients with other personality disorders. RESULTS: Patients with borderline personality disorder had a significantly higher co-occurrence of bipolar disorder (19.4%) than did patients with other personality disorders. However, this co-occurrence did not appear to affect the subsequent course of borderline personality disorder. Although only 8.2% of the borderline personality disorder patients developed new onsets of bipolar disorder, this rate was higher than in patients with other personality disorders. Patients with other personality disorders with co-occurring bipolar disorder generally had more new onsets of borderline personality disorder (25%) than did patients with other personality disorders without co-occurring bipolar disorder (10%). CONCLUSIONS: A modest association between borderline personality disorder and bipolar disorder is reported.     

Exploratory factor analysis of borderline personality disorder criteria in hospitalized adolescents

OBJECTIVE: The authors examined the factor structure of borderline personality disorder (BPD) in hospitalized adolescents and also sought to add to the theoretical and clinical understanding of any homogeneous components by determining whether they may be related to specific forms of Axis I pathology. METHOD: Subjects were 123 adolescent inpatients, who were reliably assessed with structured diagnostic interviews for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition Axes I and II disorders. Exploratory factor analysis identified BPD components, and logistic regression analyses tested whether these components were predictive of specific Axis I disorders. RESULTS: Factor analysis revealed a 4-factor solution that accounted for 67.0% of the variance. Factor 1 ("suicidal threats or gestures" and "emptiness or boredom") predicted depressive disorders and alcohol use disorders. Factor 2 ("affective instability," "uncontrolled anger," and "identity disturbance") predicted anxiety disorders and oppositional defiant disorder. Factor 3 ("unstable relationships" and "abandonment fears") predicted only anxiety disorders. Factor 4 ("impulsiveness" and "identity disturbance") predicted conduct disorder and substance use disorders. CONCLUSIONS: Exploratory factor analysis of BPD criteria in adolescent inpatients revealed 4 BPD factors that appear to differ from those reported for similar studies of adults. The factors represent components of self-negation, irritability, poorly modulated relationships, and impulsivity--each of which is associated with characteristic Axis I pathology. These findings shed light on the nature of BPD in adolescents and may also have implications for treatment.     

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.     

Altered age-related trajectories of amygdala-prefrontal circuitry in adolescents at clinical high risk for psychosis: a preliminary study

Emotion processing deficits are prominent in schizophrenia and exist prior to the onset of overt psychosis. However, developmental trajectories of neural circuitry subserving emotion regulation and the role that they may play in illness onset have not yet been examined in patients at risk for psychosis. The present study employed a cross-sectional analysis to examine age-related functional activation in amygdala and prefrontal cortex, as well as functional connectivity between these regions, in adolescents at clinical high risk (CHR) for psychosis relative to typically developing adolescents. Participants (n=34) performed an emotion processing fMRI task, including emotion labeling, emotion matching, and non-emotional control conditions. Regression analyses were used to predict activation in the amygdala and ventrolateral prefrontal cortex (vlPFC) based on age, group, sex, and the interaction of age by group. CHR adolescents exhibited altered age-related variation in amygdala and vlPFC activation, relative to controls. Controls displayed decreased amygdala and increased vlPFC activation with age, while patients exhibited the opposite pattern (increased amygdala and decreased vlPFC activation), suggesting a failure of prefrontal cortex to regulate amygdala reactivity. Moreover, a psychophysiological interaction analysis revealed decreased amygdala-prefrontal functional connectivity among CHR adolescents, consistent with disrupted brain connectivity as a vulnerability factor in schizophrenia. These results suggest that the at-risk syndrome is marked by abnormal development and functional connectivity of neural systems subserving emotion regulation. Longitudinal data are needed to confirm aberrant developmental trajectories intra-individually and to examine whether these abnormalities are predictive of conversion to psychosis, and of later deficits in socioemotional functioning.     

A comparison of adolescent- and adult-onset first-episode, non-affective psychosis: 2-year follow-up

This study aimed to compare 2-year outcome among individuals with early-onset (EO; <18?years) versus adult-onset (AO) first-episode, non-affective psychosis. We compared clinical and treatment characteristics of 43 EO and 189 AO patients 2 years after their inclusion in a clinical epidemiologic population-based cohort study of first-episode psychosis. Outcome variables included symptom severity, remission status, drug abuse, treatment utilization, cognition and social functioning. At baseline, EO patients were more symptomatically compromised. However, these initial baseline differences were no longer significant at the 2-year follow-up. This study challenges the findings of a larger and older literature base consisting primarily of non-comparative studies concluding that teenage onset indicates a poor outcome. Our results indicate that adolescent-onset and adult-onset psychosis have similar prognostic trajectories, although both may predict a qualitatively different course from childhood-onset psychosis.     

Guidelines for timely initiation of chemotherapy: a proposed framework for access to medical oncology and haematology cancer clinics and chemotherapy services

These guidelines, informed by the best available evidence and consensus expert opinion, provide a framework to guide the timely initiation of chemotherapy for treating cancer. They sit at the intersection of patient experience, state‐of‐the‐art disease management and rational efficient service provision for these patients at a system level. Internationally, cancer waiting times are routinely measured and publicly reported. In Australia, there are existing policies and guidelines relating to the timeliness of cancer care for surgery and radiation therapy; however, until now, equivalent guidance for chemotherapy was lacking. Timeliness of care should be informed, where available, by evidence for improved patient outcomes. Independent of this, it should be recognised that shorter waiting periods are likely to reduce patient anxiety. While these guidelines were developed as part of a proposed framework for consideration by the Victorian Department of Health, they are clinically relevant to national and international cancer services. They are intended to be used by clinical and administrative staff within cancer services. Adoption of these guidelines, which are for the timely triage, review and treatment of cancer patients receiving systemic chemotherapy, aims to ensure that patients receive care within a timeframe that will maximise health outcomes, and that access to care is consistent and equitable across cancer services. Local monitoring of performance against this guideline will enable cancer service providers to manage proactively future service demand.