MEDLINE Citations on The Borderline-Bipolar Connection

MEDLINE Search by, Ivan Goldberg, MD

Psychol Med. 2011 Aug 16:1-13. [Epub ahead of print]

The lifetime impact of attention deficit hyperactivity disorder: results from the
National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

Bernardi S, Faraone SV, Cortese S, Kerridge BT, Pallanti S, Wang S, Blanco C.

Department of Psychiatry, Columbia University/New York State Psychiatric
Institute, New York, NY, USA.

BACKGROUND: The aim of the study was to present nationally representative data on
the lifetime independent association between attention deficit hyperactivity
disorder (ADHD) and psychiatric co-morbidity, correlates, quality of life and
treatment seeking in the USA.MethodData were derived from a large national sample
of the US population. Face-to-face surveys of more than 34 000 adults aged 18
years and older residing in households were conducted during the 2004-2005
period. Diagnoses of ADHD, Axis I and II disorders were based on the Alcohol Use
Disorder and Associated Disabilities Interview Schedule-DSM-IV version. RESULTS:
ADHD was associated independently of the effects of other psychiatric
co-morbidity with increased risk of bipolar disorder, generalized anxiety
disorder, post-traumatic stress disorder, specific phobia, and narcissistic,
histrionic, borderline, antisocial and schizotypal personality disorders. A
lifetime history of ADHD was also associated with increased risk of engaging in
behaviors reflecting lack of planning and deficient inhibitory control, with high
rates of adverse events, lower perceived health, social support and higher
perceived stress. Fewer than half of individuals with ADHD had ever sought
treatment, and about one-quarter had ever received medication. The average age of
first treatment contact was 18.40 years. CONCLUSIONS: ADHD is common and
associated with a broad range of psychiatric disorders, impulsive behaviors,
greater number of traumas, lower quality of life, perceived social support and
social functioning, even after adjusting for additional co-morbidity. When
treatment is sought, it is often in late adolescence or early adulthood,
suggesting the need to improve diagnosis and treatment of ADHD.
PMID: 21846424 [PubMed – as supplied by publisher] ———-
Compr Psychiatry. 2011 Aug 8. [Epub ahead of print]

Looking for bipolar spectrum psychopathology: identification and expression in
daily life.

Walsh MA, Royal A, Brown LH, Barrantes-Vidal N, Kwapil TR.

University of North Carolina at Greensboro, PO Box 26170, Greensboro, NC

OBJECTIVES: Current clinical and epidemiological research provides support for a
continuum of bipolar psychopathology: a bipolar spectrum that ranges from
subclinical manifestations to full-blown bipolar disorders. Examining
subthreshold bipolar symptoms may identify individuals at risk for clinical
disorders, promote early interventions and monitoring, and increase the
likelihood of appropriate treatment. The present studies examined the construct
validity of bipolar spectrum psychopathology using the Hypomanic Personality
Scale. METHODS: Study 1 used interview and questionnaire measures of bipolar
spectrum psychopathology in a sample of 145 nonclinically ascertained young
adults. Study 2 assessed the expression of the bipolar spectrum in daily life
using experience sampling methodology in the same sample. RESULTS: In study 1,
Hypomanic Personality Scale scores were positively associated with clinical
bipolar disorders, bipolar spectrum disorders, the presence of hypomania or
hyperthymia, depressive symptoms, poor psychosocial functioning, cyclothymia,
irritability, and symptoms of borderline personality disorder. In study 2,
bipolar spectrum psychopathology was associated with negative affect, thought
disturbance, risky behavior, and measures of grandiosity. These findings remained
independent of clinical bipolar disorders. CONCLUSIONS: In the present studies,
bipolar-like disruptions in cognition, affect, and behavior were not limited to
clinical diagnoses or mood episodes, providing further validation of the bipolar
spectrum construct. The bipolar spectrum model appears to provide a conceptually
richer basis for understanding and ultimately treating bipolar psychopathology
than current diagnostic formulations.
PMID: 21831368 [PubMed – as supplied by publisher] ———-
J Intellect Disabil Res. 2011 Jul;55(7):636-49. doi:
10.1111/j.1365-2788.2011.01418.x. Epub 2011 Apr 15.

Association of aggressive behaviours with psychiatric disorders, age, sex and
degree of intellectual disability: a large-scale survey.

Tsiouris JA, Kim SY, Brown WT, Cohen IL.

George A. Jervis Clinic, New York State Institute for Basic Research in
Developmental Disabilities, Staten Island, NY, USA.

BACKGROUND: The link between aggression and mental disorders has been the focus
of diverse studies in persons with and without intellectual disabilities (ID).
Because of discrepancies in the finding of studies in persons with ID to date,
and because of differences in research design, instruments used and the
population studied, more research is needed. The purpose of this study was to
delineate any significant association between certain psychiatric disorders and
specific domains of aggressive behaviours in a large sample of persons with ID
controlling for sex, age, autism and degree of ID.
METHOD: Data from the present study were obtained from 47% of all persons with ID
receiving services from New York State agencies, using the Institute for Basic
Research – Modified Overt Aggression Scale (IBR-MOAS between 2006 and 2007). The
IBR-MOAS was completed by the chief psychologists of 14 agencies based on
information from the participants’ files. Demographic information obtained
included the psychiatric diagnosis made by the treating psychiatrist as well as
information on age, sex and degree of ID. Data from 4069 participants were
RESULTS: Impulse control disorder and bipolar disorder were strongly associated
with all five domains of aggressive behaviour in the IBR-MOAS. Psychotic disorder
was highly associated with four domains except for physical aggression against
self (PASLF), which was of borderline significance. Anxiety was most associated
with PASLF and verbal aggression against self (VASLF); depression with VASLF;
obsessive compulsive disorder with physical aggression against objects (PAOBJ);
personality disorders with verbal aggression against others (VAOTH), VASLF and
PASLF; and autism with physical aggression against others (PAOTH), PAOBJ and
PASLF. Mild to moderate ID was associated with VAOTH and VASLF and severe to
profound ID with PAOBJ and PASLF. Female sex was most associated with VASLF.
CONCLUSIONS: Impulse control, mood dysregulation and perceived threat appear to
underlie most of the aggressive behaviours reported. Psychosis and depression
appeared to have been over-diagnosed in persons with mild to moderate ID and
under-diagnosed in persons with severe and profound ID. These findings replicate
and extend findings from previous studies. The pattern of associations reported
can be used as helpful indicators by professionals involved in the treatment of
aggressive behaviours in persons with ID.
PMID: 21492292 [PubMed – in process] ———-
Psychiatry Res. 2011 Jun 30;188(1):40-4. Epub 2010 Dec 4.

Impulsivity and aggressiveness in bipolar disorder with co-morbid borderline
personality disorder.

Carpiniello B, Lai L, Pirarba S, Sardu C, Pinna F.

Department of Public Health, University of Cagliari, Italy.

Few studies to date have been performed to investigate impulsivity and
aggressivity in patients with bipolar disorder (BD) and borderline personality
disorder (BPD); the primary aim of the present study was to evaluate the impact
of co-morbidity of BPD on impulsivity and aggressivity in patients affected by
BD. A total of 57 patients (male=20, female=37) affected by BD (BD-I 51%; BD-II
49%) in clinical stable remission were recruited; 28 patients were affected by BD
(49.1%), 18 by BD and BPD (31.6%) and 11 (19.3%) by BD plus other personality
disorders (OPD) (19.3%). They were assessed with the Structured Clinical
Interview for DSM-IV (SCID)-I and SCID-II, and were evaluated by means of the
Clinical Global Impression (CGI)-severity and Global Assessment Functioning (GAF)
scales, the Barratt Impulsivity Scale (BIS-11) and the Aggression Questionnaire
(AQ). Mean total scores were significantly higher among BD/BPD patients with
respect to BD and to BD/OPD, both on the BIS-11 and the AQ; the rate of attempted
suicides was approximately three times higher in BD/BPD patients with respect to
BD and 7.6 times higher than in BD/OPD patients. The results of our study suggest
that patients with co-morbid BD and BPD are more impulsive and aggressive.
Furthermore, this co-morbid condition may be a risk factor for suicidality.
PMID: 21131058 [PubMed – indexed for MEDLINE] ———-
J Affect Disord. 2011 Jun 8. [Epub ahead of print]

Timing, quantity and quality of stressful life events in childhood and preceding
the first episode of bipolar disorder.

Horesh N, Apter A, Zalsman G.

Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel.

BACKGROUND: A large body of evidence supports the importance of genetic risk
factors in bipolar disorder (BPD), but less is known about the role of stressful
life events (SLE). This study assessed the role of SLE in childhood, adulthood
and one year prior to first episodes of both depression and mania in BPD.
METHODS: Three groups of 50 matched subjects each were assessed: patients with
BPD, with borderline personality disorder (BLPD) and healthy controls. Structured
clinical interviews were used for diagnoses. The Coddington Life Events Schedule
and the Israel Psychiatric Epidemiology Research Interview Life Event Scale
measured life events and were confirmed with a semi-structured interview for
subjective experience for each SLE. RESULTS: In BPD, the total number of SLE was
lower during childhood and higher in the year preceding the first depression
compared to controls and the proportion of loss-related events in childhood was
higher. In the year preceding the first depressive episode, BPD subjects had more
total, negative uncontrolled and independent but not positive SLE. In the year
preceding the first episode of mania, the total number of uncontrolled, negative
SLE were higher in BPD, whereas positive and separation-related SLE were not.
After the first episode, BPD subjects had less SLE than controls. CONCLUSIONS:
Negative and loss-related SLE are common in BPD subjects, occur in the year
preceding the first episodes of depression and mania and are less common in
childhood or after the onset of the disorder.
PMID: 21658777 [PubMed – as supplied by publisher] ———-
Compr Psychiatry. 2011 May 30. [Epub ahead of print]

Affective lability in bipolar disorder and borderline personality disorder.

Reich DB, Zanarini MC, Fitzmaurice G.

BACKGROUND: The boundaries between the affective instability in bipolar disorder
and borderline personality disorder have not been clearly defined. Using
self-report measures, previous research has suggested that the affective lability
of patients with bipolar disorder and borderline personality disorder may have
different characteristics. METHODS: We assessed the mood states of 29 subjects
meeting Revised Diagnostic Interview for Borderlines and Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for BPD
and 25 subjects meeting DSM-IV criteria for bipolar II disorder or cyclothymia
using the Affective Lability Scale (ALS), the Affect Intensity Measure (AIM), and
a newly developed clinician-administered instrument, the Affective Lability
Interview for Borderline Personality Disorder (ALI-BPD). The ALI-BPD measures
frequency and intensity of shifts in 8 affective dimensions. Subjects in the
borderline group could not meet criteria for bipolar disorder; subjects in the
bipolar/cyclothymia group could not meet criteria for BPD. RESULTS: Patients in
the bipolar group had significantly higher scores on the euthymia-elation
subscale of the ALS; patients in the BPD group had significantly higher scores on
the anxiety-depression subscale of the ALS. Patients with bipolar disorder had
significantly higher total AIM scores and significantly higher score on the AIM
positive emotion subscale. In terms of frequency, patients in the borderline
group reported the following: (1) significantly less frequent affective shifts
between euthymia-elation and depression-elation on the ALI-BPD and (2)
significantly more frequent shifts between euthymia-anger, anxiety-depression,
and depression-anxiety. In terms of intensity, borderline patients reported the
following: (1) significantly less intense shifts between euthymia-elation and
depression-elation on the ALI-BPD and (2) significantly more intense shifts
between euthymia-anxiety, euthymia-anger, anxiety-depression, and
depression-anxiety. CONCLUSION: The affective lability of patients with
borderline and bipolar II/cyclothymic can be differentiated with respect to
frequency and intensity using both self-report and clinician-administered

PMID: 21632042 [PubMed – as supplied by publisher] ———-
J Forensic Sci. 2011 May;56(3):679-82. doi: 10.1111/j.1556-4029.2010.01691.x.
Epub 2011 Feb 9.

The prevalence of mental disorders in prisoners in the city of Salvador, Bahia,

Pondé MP, Freire AC, Mendonça MS.

Bahia School of Medicine and Public Health (EBMSP), Salvador, Bahia, Brazil.

The number of individuals affected by serious psychiatric disorders in Brazilian
prisons is unknown. This cross-sectional study was conducted in prison complexes
within the city of Salvador, Bahia, Brazil. The sample consisted of 497
prisoners, and the outcome measure was the Brazilian Portuguese version of the
Mini International Neuropsychiatric Interview. The prevalence rates found in the
closed and semi-open prison systems, respectively, were as follows: depression
17.6% and 18.8%; bipolar mood disorder 5.2% and 10.1%; anxiety disorders 6.9% and
14.4%; borderline personality disorder 19.7% and 34.8%; antisocial personality
disorder 26.9% and 24.2%; alcohol addiction 26.6% and 35.3%; drug addiction 27.9%
and 32.4%; psychosis 1.4% and 12.6%; attention deficit/hyperactivity disorder
(ADHD) in childhood 10.3% and 22.2%; and ADHD in adulthood 4.1% and 5.3%. This
study revealed higher rates of substance-related disorders and lower rates of
psychotic and mood disorders compared to other prevalence studies carried out in
prison populations.

PMID: 21306379 [PubMed – in process] ———-
Australas Psychiatry. 2011 Apr;19(2):107-9. Epub 2011 Feb 15.

Undiagnosis: an important new role for psychiatry.

Patfield M.

Greater Western Area Health Service and School of Rural Health, University of
Sydney, Orange, NSW, Australia.

OBJECTIVE: This paper discusses an activity, hitherto inadequately identified,
which is an increasingly important part of contemporary practice. CONCLUSION:
Iatrogenesis presents today in new guises but can be satisfying and productive to

PMID: 21320037 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2011 Mar;13(2):173-81. doi: 10.1111/j.1399-5618.2011.00900.x.

Criminal conviction, impulsivity, and course of illness in bipolar disorder.

Swann AC, Lijffijt M, Lane SD, Kjome KL, Steinberg JL, Moeller FG.

Department of Psychiatry and Behavioral Sciences, The University of Texas Health
Science Center at Houston, 1941 East Road, Houston, TX 77054, USA.

OBJECTIVE: Criminal behavior in bipolar disorder may be related to substance use
disorders, personality disorders, or other comorbidities potentially related to
impulsivity. We investigated relationships among impulsivity, antisocial
personality disorder (ASPD) or borderline personality disorder symptoms,
substance use disorder, course of illness, and history of criminal behavior in
bipolar disorder.
METHODS: A total of 112 subjects with bipolar disorder were recruited from the
community. Diagnosis was by Structured Clinical Interview for DSM-IV (SCID-I and
SCID-II); psychiatric symptom assessment by the Change version of the Schedule
for Affective Disorders and Schizophrenia (SADS-C); severity of Axis II symptoms
by ASPD and borderline personality disorder SCID-II symptoms; and impulsivity by
questionnaire and response inhibition measures.
RESULTS: A total of 29 subjects self-reported histories of criminal conviction.
Compared to other subjects, those with convictions had more ASPD symptoms, less
education, more substance use disorder, more suicide attempt history, and a more
recurrent course with propensity toward mania. They had increased impulsivity as
reflected by impaired response inhibition, but did not differ in
questionnaire-measured impulsivity. On logit analysis, impaired response
inhibition and ASPD symptoms, but not substance use disorder, were significantly
associated with criminal history. Subjects convicted for violent crimes were not
more impulsive than those convicted for nonviolent crimes.
CONCLUSIONS: In this community sample, a self-reported history of criminal
behavior is related to ASPD symptoms, a recurrent and predominately manic course
of illness, and impaired response inhibition in bipolar disorder, independent of
current clinical state.

PMID: 21443571 [PubMed – indexed for MEDLINE] ———-
Rev Prat. 2011 Feb;61(2):202-3, 206-7.

[What can we do to prevent the suicide re-attempts?].

[Article in French]

Vaiva G, Jardon V, Vaillant A, Ducrocq F.

Pôle de psychiatrie, université Lille-Nord de France, CHRU de Lille, hôpital
Michel-Fontan, 59037 Lille Cedex.

A subject surviving a suicide attempt (SA) belongs in fact to a group at risk for
suicide (40% of lifetime repetition including 20 to 25% over the 12 months
following the initial gesture). To prevent the risk of suicide in general is thus
effective on the prevention of the repetition. It initially seems important to
treat a somatic or psychiatric pathology having taken part in the initial
suicidal context: treating a mood depression disorder, prescribing a mood
stabilizer to a bipolar patient, managing the global treatment of a borderline
personality disorder, etc. Some strategies have been proposed with a specific aim
to reduce this rate of suicidal repetition. Certain devices very interventionists
appear expensive and difficult to generalize (at home interventions, intensive
short psychotherapies carried out starting from the Emergency Rooms…). In a
parallel way, “connectedness” devices, which are careful not to invade the
suicide attempter life, which does not aim to replace a treatment, but try to
propose effective recourse in case of crisis, tend to currently develop on the
whole territory.

PMID: 21618769 [PubMed – indexed for MEDLINE] ———-
World Psychiatry. 2011 Feb;10(1):45-51.

Are atypical depression, borderline personality disorder and bipolar II disorder
overlapping manifestations of a common cyclothymic diathesis?

Perugi G, Fornaro M, Akiskal HS.

The constructs of atypical depression, bipolar II disorder and borderline
personality disorder (BPD) overlap. We explored the relationships between these
constructs and their temperamental underpinnings. We examined 107 consecutive
patients who met DSM-IV criteria for major depressive episode with atypical
features. Those who also met the DSM-IV criteria for BPD (BPD+), compared with
those who did not (BPD-), had a significantly higher lifetime comorbidity for
body dysmorphic disorder, bulimia nervosa, narcissistic, dependent and avoidant
personality disorders, and cyclothymia. BPD+ also scored higher on the Atypical
Depression Diagnostic Scale items of mood reactivity, interpersonal sensitivity,
functional impairment, avoidance of relationships, other rejection avoidance, and
on the Hopkins Symptoms Check List obsessive-compulsive, interpersonal
sensitivity, anxiety, anger-hostility, paranoid ideation and psychoticism
factors. Logistic regression revealed that cyclothymic temperament accounted for
much of the relationship between atypical depression and BPD, predicting 6 of 9
of the defining DSM-IV attributes of the latter. Trait mood lability (among BPD
patients) and interpersonal sensitivity (among atypical depressive patients)
appear to be related as part of an underlying cyclothymic temperamental matrix.

PMID: 21379356 [PubMed] ———-
J Pers Disord. 2010 Dec;24(6):763-72.

A comparison of depressed patients with and without borderline personality
disorder: implications for interpreting studies of the validity of the bipolar

Galione J, Zimmerman M.

Department of Psychiatry and Human Behavior, Brown University School of Medicine,
Rhode Island Hospital, Providence, RI, USA.

The nosological status of borderline personality disorder as it relates to the
bipolar disorder spectrum has been controversial. Studies have supported, in
part, the validity of the bipolar spectrum by demonstrating that these patients,
compared to patients with nonbipolar depression, are characterized by earlier age
of onset of depression, recurrent depressive episodes, comorbid anxiety and
substance use disorders and increased suicidality. However, all of these factors
have likewise been found to distinguish depressed patients with and without
borderline personality disorder. A family history of bipolar disorder is one of
the few disorder specific validators. In the present study from the Rhode Island
Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we
compared the demographic and clinical characteristics of depressed patients with
and without borderline personality disorder. We hypothesized that many of the
factors used to validate the bipolar spectrum will also distinguish depressed
patients with and without borderline personality disorder except, however, a
family history of bipolar disorder. Two thousand nine hundred psychiatric
outpatients at Rhode Island Hospital were evaluated with the Structured Clinical
Interview for DSM-IV (SCID) and Structured Interview for DSM-IV Personality
Disorders (SIDP-IV). Family history information regarding first-degree relatives
was obtained from the patient using the Family History Research Diagnostic
Criteria. One hundred and one patients with borderline personality disorder plus
major depressive disorder were compared to 947 patients with major depressive
disorder alone on the prevalence of bipolar disorder validators. Compared to
depressed patients without borderline personality disorder, depressed patients
with borderline personality disorder had a younger age of onset, more depressive
episodes, a greater likelihood of experiencing atypical symptoms and had a higher
prevalence of comorbid anxiety disorders, substance use disorders, and number of
previous suicide attempts. The depressed patients with borderline personality
disorder did not significantly differ from the patients without borderline
personality disorder on morbid risk for bipolar disorder in first degree
relatives. In addition, patients with a diagnosis of bipolar disorder had a
significantly higher morbid risk of bipolar disorder in first degree relatives
than the borderline personality disorder group. The findings indicate that many
factors used to validate the bipolar spectrum are not disorder specific. These
results raise questions about studies of the validity of the broad bipolar
spectrum that do not assess borderline personality disorder. Our results do not
support inclusion of borderline personality disorder as part of the bipolar

PMID: 21158598 [PubMed – indexed for MEDLINE] ———-
Psychiatr Danub. 2010 Nov;22 Suppl 1:S26-32.

Assessment of self harm in an accident and emergency service – the development of
a proforma to assess suicide intent and mental state in those presenting to the
emergency department with self harm.

Haq SU, Subramanyam D, Agius M.

South Essex University Partnership NHS Trust, UK.

INTRODUCTION: the UK has one of the highest rates of self harm in Europe, around
400 per 100,000 people (Horrocks et al. 2002). It accounts for 150,000
attendances to the Emergency department each year and is one of the top five
causes of acute medical admissions in the UK (NICE 2002).
AIMS: objectives included to explore the method of self harm and the demographic
factors of those presenting the Emergency department with self harm. In addition
we wanted to review the exploration of suicide risk factors and suicide intent by
the Emergency department doctor and ascertain whether a psychiatric assessment
with full mental state examination had been conducted with referral to
psychiatric services if deemed necessary. We wanted to explore the current
practice around self harm presentations in the Emergency department accordance
with NICE guidelines.
METHODS: data was collected retrospectively from February to August 2009.
Twenty-five sets of medical notes were collated at random for patients who had
presented with self harm to the Emergency department. Notes were reviewed for
evidence of exploration of the event, psychiatric assessment, risk factors for
suicide and further referral.
RESULTS: 14 of the 25 patients presented having taken an overdose. 9 had
inflicted some other form of self injury, namely lacerations to self. In 2 cases
a mixed presentation was found. Previous psychiatric history was documented in 16
cases. 11 had a previous history of depression or anxiety disorder; 1 was known
to have bipolar affective disorder; 1 was diagnosed in the past with borderline
personality disorder; and 3 patients had no previous history. In 9 cases previous
history was not documented.
DISCUSSION: twenty-five sets of medical notes were reviewed from February to
August 2009 for individuals presenting to the Emergency department with self
harm. Of those, 12 fell into the over 25 age group. 17 were female and 8 were
male. The majority of patients were of white British ethnicity. 14 had taken an
overdose; 9 had inflicted some other form of self injury; and 2 had a mixed
presentation. Suicide risk factors and suicidal intent was poorly documented with
mental state examination found not to be documented in all 25 cases reviewed. 18
were deemed medically fit in the Emergency department and were referred for
psychiatric review. These unfortunate findings may be a reflection on the time
pressures faced by Emergency department doctors, namely the four hour targets,
and perhaps lack of adequate training in psychosocial risk assessment. With such
poor documentation made by the Emergency department doctors, a proforma was
produced which incorporates suicide risk factors and assessment of suicide intent
in addition to a brief version of the mental state examination.
CONCLUSION: concerns have been raised by the recent Royal College of
Psychiatrists report on self harm, that current level of care provided to service
users fall short of the standards set out in policies and guidelines, with poor
assessments, unskilled staff and insufficient care pathways (Royal College of
Psychiatrists. Report CR 158. 2010). Indeed evidence suggest that appropriate
training and intervention given to A&E staff can lead to improvements in the
quality of psychosocial assessment of patients with deliberate self harm
(Crawford et al. 1998).

PMID: 21057397 [PubMed – indexed for MEDLINE] ———-
Psychoneuroendocrinology. 2010 Nov;35(10):1565-72. Epub 2010 Jul 13.

Increased psychological and attenuated cortisol and alpha-amylase responses to
acute psychosocial stress in female patients with borderline personality

Nater UM, Bohus M, Abbruzzese E, Ditzen B, Gaab J, Kleindienst N, Ebner-Priemer
U, Mauchnik J, Ehlert U.

University of Zurich, Institute of Psychology, Dept. of Clinical Psychology &
Psychotherapy, Switzerland.

OBJECTIVE: Borderline personality disorder (BPD) is characterized by increased
self-reported stress and emotional responding. Knowledge about the psychological
and physiological mechanisms that underlie these experiences in BPD patients is
scarce. The objective was to assess both psychological and endocrinological
responses to a standardized psychosocial stressor in female BPD patients and
healthy controls.
METHODS: A total of 15 female BPD patients and 17 healthy control subjects were
included in a case-control study. All subjects were free of any medication, had a
regular menstrual cycle, and were investigated during the luteal phase of their
menstrual cycle. Co-occurring current major depression, current substance
abuse/dependence, and lifetime schizophrenia or bipolar I disorder were excluded.
Psychological measures of stress, salivary cortisol, salivary alpha-amylase,
plasma ACTH, plasma norepinephrine and epinephrine concentrations were measured
before, during, and after exposure to a standardized psychosocial stress
RESULTS: BPD patients displayed maladaptive cognitive appraisal processes
regarding the upcoming stressor as well as significantly higher subjective
stress, coupled with a substantial cortisol and alpha-amylase hyporeactivity to
the stressor in comparison to the controls. No significant differences for ACTH
and catecholaminergic responses were observed, while the ACTH:cortisol ratio was
higher in BPD patients than in controls.
CONCLUSIONS: Attenuated cortisol responsiveness in BPD patients might in part be
explained by decreased adrenal responsiveness to endogenous ACTH and altered
central noradrenergic activation as reflected by alpha-amylase.

PMID: 20630661 [PubMed – indexed for MEDLINE] ———-
Compr Psychiatry. 2010 Sep-Oct;51(5):486-91. Epub 2010 Mar 29.

Severity of affective temperament and maladaptive self-schemas differentiate
borderline patients, bipolar patients, and controls.

Nilsson AK, Jørgensen CR, Straarup KN, Licht RW.

Department of Psychology, Aarhus University, Aarhus 8000, Denmark.

OBJECTIVES: There is an unsettled debate on whether borderline personality
disorder and bipolar disorder should be considered related or distinct. This
study aimed to further the understanding of the similarities and differences
between the 2 disorders by comparing borderline patients, bipolar patients, and
controls in terms of various affective temperaments and maladaptive self-schemas.
METHODS: The sample consisted of 85 participants (31 borderline patients, 25
bipolar patients and 29 student controls) who completed 2 questionnaires: The
Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego
Autoquestionnaire and the Young Schema Questionnaire. All of the patients were in
remission from affective episodes.
RESULTS: Compared to the bipolar patients and the controls, the borderline
patients were characterized by significantly higher mean scores on most of the
maladaptive self-schemas and affective temperaments. The bipolar patients
differed significantly from controls by higher mean scores on the cyclothymic
temperament and insufficient self-control.
CONCLUSIONS: The study suggests that affective temperaments and maladaptive
self-schemas are more severe in borderline patients than in bipolar patients.
These findings point to phenomenological differences between the 2 disorders and
therefore question their degree of kinship.

PMID: 20728005 [PubMed – indexed for MEDLINE] ———-
J Affect Disord. 2010 Sep;125(1-3):98-102. Epub 2010 Jan 21.

Is the serotonin transporter polymorphism (5-HTTLPR) a potential marker for
suicidal behavior in bipolar disorder patients?

Neves FS, Malloy-Diniz LF, Romano-Silva MA, Aguiar GC, de Matos LO, Correa H.

Department of Mental Health, Universidade Federal de Minas Gerais, Belo
Horizonte, Brazil.

BACKGROUND: Suicide prediction is a huge challenge for mental health workers.
Structured interviews based on epidemiological and clinical factors don’t show
effectiveness for suicide prevention. Biological markers, such as 5-HTTLPR, could
help for identification of potential suicide attempters.
METHODS: We evaluated 198 bipolar patients and 103 health controls, using a
structured interview according to DSM-IV criteria. Genotyping, blind of clinical
assessment for identification of S carriers and structured interviews were
performed in order to describe clinical and epidemiological factors which could
be associated with suicide behavior. Statistical analyses were calculated by the
x(2) test and logistic regression model.
RESULTS: We found that 26.77% and 16.67% had a lifetime history of non violent
suicide attempt and violent suicide attempt, respectively. The clinical factors
associated with violent and non violent suicide attempt had several differences.
Violent suicide attempters had an earlier illness onset and had a higher number
of psychiatric comorbidities (borderline personality disorder, panic disorder and
alcoholism). The frequency of S allele carriers was higher only in those patients
who had made a violent suicide attempt in their lifetime (x(2)=16.969; p=0.0001).
In a logistic regression model including these factors, S allele carrier
(5-HTTLPR) was the only factor associated with violent suicide attempt.
LIMITATIONS: Sample size and retrospective assessment of suicide behavior history
are the limitations of this study.
CONCLUSIONS: Our study showed that serotonin polymorphism (5-HTTLPR) is strongly
associated with violent suicidal behavior in BD patients. If confirmed, our
results could be an important step to create a genetic tool for long-term suicide

PMID: 20096463 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2010 Sep;71(9):1212-7. Epub 2010 Mar 23.

Screening for bipolar disorder and finding borderline personality disorder.

Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, Young D, Dalrymple K,
McGlinchey JB.

Department of Psychiatry and Human Behavior, Brown Medical School, Department of
Psychiatry Rhode Island Hospital, Providence, USA.

OBJECTIVE: Bipolar disorder and borderline personality disorder share some
clinical features and have similar correlates. It is, therefore, not surprising
that differential diagnosis is sometimes difficult. The Mood Disorder
Questionnaire (MDQ) is the most widely used screening scale for bipolar disorder.
Prior studies found a high false-positive rate on the MDQ in a heterogeneous
sample of psychiatric patients and primary care patients with a history of
trauma. In the present report from the Rhode Island Methods to Improve Diagnostic
Assessment and Services project, we examined whether psychiatric outpatients
without bipolar disorder who screened positive on the MDQ would be significantly
more often diagnosed with borderline personality disorder than patients who did
not screen positive.
METHOD: The study was conducted from September 2005 to November 2008. Five
hundred thirty-four psychiatric outpatients were interviewed with the Structured
Clinical Interview for DSM-IV and Structured Interview for DSM-IV Personality
Disorders and asked to complete the MDQ. Missing data on the MDQ reduced the
sample size to 480. Approximately 10% of the study sample were diagnosed with a
lifetime history of bipolar disorder (n = 52) and excluded from the initial
RESULTS: Borderline personality disorder was 4 times more frequently diagnosed in
the MDQ positive group than the MDQ negative group (21.5% vs 4.1%, P < .001). The
results were essentially the same when the analysis was restricted to patients
with a current diagnosis of major depressive disorder (27.6% vs 6.9%, P = .001).
Of the 98 patients who screened positive on the MDQ in the entire sample of
patients, including those diagnosed with bipolar disorder, 23.5% (n = 23) were
diagnosed with bipolar disorder, and 27.6% (n = 27) were diagnosed with
borderline personality disorder.
CONCLUSIONS: Positive results on the MDQ were as likely to indicate that a
patient has borderline personality disorder as bipolar disorder. The clinical
utility of the MDQ in routine clinical practice is uncertain.

PMID: 20361913 [PubMed – indexed for MEDLINE] ———-
Psychiatr Q. 2010 Sep;81(3):239-51.

Aggression in borderline personality disorder.

Látalová K, Prasko J.

Department of Psychiatry, Faculty of Medicine and Dentistry, Palacký University
Olomouc, Olomouc, Czech Republic.

This review examined aggressive behavior in Borderline Personality Disorder (BPD)
and its management in adults. Aggression against self or against others is a core
component of BPD. Impulsiveness is a clinical hallmark (as well as a DSM-IV-TR
diagnostic criterion) of BPD, and aggressive acts by BPD patients are largely of
the impulsive type. BPD has high comorbidity rates with substance use disorders,
Bipolar Disorder, and Antisocial Personality Disorder; these conditions further
elevate the risk for violence. Treatment of BDP includes psychodynamic, cognitive
behavioral, schema therapy, dialectic behavioral, group and pharmacological
interventions. Recent studies indicate that many medications, particularly
atypical antipsychotics and anticonvulsants, may reduce impulsivity, affective
lability as well as irritability and aggressive behavior. But there is still a
lack of large, double blind, placebo controlled studies in this area.

PMID: 20390357 [PubMed – indexed for MEDLINE] ———-
Australas Psychiatry. 2010 Aug;18(4):303-8.

The clinician’s dilemma: borderline personality disorder or bipolar spectrum

Little J, Richardson K.

Bodmin Hospital, Bodmin, Cornwall, United Kingdom.

OBJECTIVES: This paper aims to explore the use of science as a basis for
introducing bipolar spectrum disorder to conceptualize people who may otherwise
be described as having borderline personality disorder, and offer suggestions for
the management of clinical dilemmas. CONCLUSIONS: Testable observations,
thoughtfulness and humility are helpful in clinical practice.

PMID: 20645894 [PubMed – indexed for MEDLINE] ———-
Ann Clin Psychiatry. 2010 May;22(2):121-8.

Impact on suicidality of the borderline personality traits impulsivity and
affective instability.

Rihmer Z, Benazzi F.

Department of Clinical and Theoretical Mental Health, Faculty of Medicine,
Semmelweis University, Budapest, Hungary.

BACKGROUND: The aim of this study was to test the impact on suicidality (suicide
threats, attempts) of the borderline personality disorder (BPD) traits
impulsivity and affective instability in mood disorders.
METHODS: In a general psychiatry private practice (nontertiary care), consecutive
remitted, non-substance-abusing outpatients–138 with bipolar II disorder (BP II)
and 71 with major depressive disorder (MDD)–self-assessed using the Structured
Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II)
RESULTS: The frequency (higher in BP II) of suicidality was 14%; impulsivity,
37%; and affective instability, 58%. The suicidality-positive patients (n = 30),
when compared with the suicidality-negative patients (n = 179), had more BP II,
more impulsivity (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.3 to
13.3), and more affective instability (OR, 2.4; 95% CI, 0.99 to 6.0). Logistic
regression of suicidality vs impulsivity and affective instability (controlled
for BP II; age; and interactions among BP II, age, impulsivity, and affective
instability), showed that impulsivity was a strong independent predictor of
suicidality (OR, 4.3; 95% CI, 1.7 to 10.6), and that affective instability was
not an independent predictor of suicidality (OR,1.6; 95% 0.6 to 4.1). BP II
showed neither confounding nor interactions.
CONCLUSION: Results showed a strong independent impact of impulsivity-but not
affective instability-on suicidality in BPD. No confounding by mood and substance
disorders supported the BPD nature of these associations.

PMID: 20445839 [PubMed – indexed for MEDLINE] ———-
Vertex. 2010 May-Jun;21(91):294-300.

[Differential diagnosis between borderline personality disorder and bipolar

[Article in Spanish]

Herbst L.

Servicio de Consultorios Externos, Hospital José T. Borda, Buenos Aires.

The relationship between bipolar disorder and borderline personality disorder
remains controversial since in both conditions there are overlapping and similar
symptomatic dimensions. Symptomatic dimensions suitable to subserve differential
diagnosis are: mood, mood variability mode, and personal and family history.
Characteristics of psychotic symptoms may also be useful in the differentiation.
On the other hand, anxiety symptoms, neuropsychological profiles, neuro-imaging
procedures and biomarkers seem not to contribute to differentiate between both
diseases. The presentation of nonsuicidal self mutilation behavior can offer some
differences between bipolar and borderline personality disorders, but both can
coexist in clinical comorbid forms and do not significantly contribute to the
differential diagnosis. Differential diagnosis is complicated by the fact that a
low percentage of patients can experience comorbidity of both conditions. In this
work we review all these issues, and particularly emphasize the importance of
sitematically take into account the patient background, the course that follows
his or her disorder, together with the outcome in response to medical decisions.

PMID: 21188307 [PubMed – indexed for MEDLINE] ———-
J Psychiatr Res. 2010 Apr;44(6):405-8. Epub 2009 Nov 3.

Borderline personality disorder and the misdiagnosis of bipolar disorder.

Ruggero CJ, Zimmerman M, Chelminski I, Young D.

Department of Psychology, University of North Texas, Denton, TX, USA.

Recent reports suggest bipolar disorder is not only under-diagnosed but may at
times be over-diagnosed. Little is known about factors that increase the odds of
such mistakes. The present work explores whether symptoms of borderline
personality disorder increase the odds of a bipolar misdiagnosis. Psychiatric
outpatients (n=610) presenting for treatment were administered the Structured
Clinical Interview for DSM-IV (SCID) and the Structured Interview for DSM-IV
Personality for DSM-IV axis II disorders (SIDP-IV), as well as a questionnaire
asking if they had ever been diagnosed with bipolar disorder by a mental health
care professional. Eighty-two patients who reported having been previously
diagnosed with bipolar disorder but who did not have it according to the SCID
were compared to 528 patients who had never been diagnosed with bipolar disorder.
Patients with borderline personality disorder had significantly greater odds of a
previous bipolar misdiagnosis, but no specific borderline criterion was unique in
predicting this outcome. Patients with borderline personality disorder,
regardless of how they meet criteria, may be at increased risk of being
misdiagnosed with bipolar disorder.

PMID: 19889426 [PubMed – indexed for MEDLINE] ———-
Psychiatry (Edgmont). 2010 Apr;7(4):21-30.

Accurately diagnosing and treating borderline personality disorder: a
psychotherapeutic case.

Johnson AB, Gentile JP, Correll TL.

Dr. Johnson is a Fourth Year Resident, Department of Psychiatry, Boonshoft School
of Medicine, Wright State University, Dayton, Ohio.

The high prevalence of comorbid bipolar and borderline personality disorders and
some diagnostic criteria similar to both conditions present both diagnostic and
therapeutic challenges. This article delineates certain symptoms which, by
careful history taking, may be attributed more closely to one of these two
disorders. Making the correct primary diagnosis along with comorbid psychiatric
conditions and choosing the appropriate type of psychotherapy and pharmacotherapy
are critical steps to a patient’s recovery. In this article, we will use a case
example to illustrate some of the challenges the psychiatrist may face in
diagnosing and treating borderline personality disorder. In addition, we will
explore treatment strategies, including various types of therapy modalities and
medication classes, which may prove effective in stabilizing or reducing a broad
range of symptomotology associated with borderline personality disorder.

PMID: 20508805 [PubMed] ———-
Aust N Z J Psychiatry. 2010 Mar;44(3):250-7.

Self-mutilation and suicide attempts: relationships to bipolar disorder,
borderline personality disorder, temperament and character.

Joyce PR, Light KJ, Rowe SL, Cloninger CR, Kennedy MA.

Department of Psychological Medicine, University of Otago, Christchurch, PO Box
4345, Christchurch, New Zealand.

Comment in
Aust N Z J Psychiatry. 2010 Jul;44(7):677.

OBJECTIVE: Self-mutilation has traditionally been associated with borderline
personality disorder, and seldom examined separately from suicide attempts.
Clinical experience suggests that self-mutilation is common in bipolar disorder.
METHODS: A family study was conducted on the molecular genetics of depression and
personality, in which the proband had been treated for depression. All probands
and parents or siblings were interviewed with a structured interview and
completed the Temperament and Character Inventory.
RESULTS: Fourteen per cent of subjects interviewed reported a history of
self-mutilation, mostly by wrist cutting. Self-mutilation was more common in
bipolar I disorder subjects then in any other diagnostic groups. In multiple
logistic regression self-mutilation was predicted by mood disorder diagnosis and
harm avoidance, but not by borderline personality disorder. Furthermore, the
relatives of non-bipolar depressed probands with self-mutilation had higher rates
of bipolar I or II disorder and higher rates of self-mutilation. Sixteen per cent
of subjects reported suicide attempts and these were most common in those with
bipolar I disorder and in those with borderline personality disorder. On multiple
logistic regression, however, only mood disorder diagnosis and harm avoidance
predicted suicide attempts. Suicide attempts, unlike self-mutilation, were not
CONCLUSIONS: Self-mutilation and suicide attempts are only partially overlapping
behaviours, although both are predicted by mood disorder diagnosis and harm
avoidance. Self-mutilation has a particularly strong association with bipolar
disorder. Clinicians need to think of bipolar disorder, not borderline
personality disorder, when assessing an individual who has a history of

PMID: 20180727 [PubMed – indexed for MEDLINE] ———-
J Affect Disord. 2010 Feb 1. [Epub ahead of print]

The influence of affective temperaments and psychopathological traits on the
definition of bipolar disorder subtypes: A study on Bipolar I Italian National

Perugi G, Toni C, Maremmani I, Tusini G, Ramacciotti S, Madia A, Fornaro M,
Akiskal HS.

Department of Psychiatry, University of Pisa, Pisa, Italy; Institute of
Behavioural Sciences, “G. De Lisio”, Pisa, Italy.

Affective temperament and psychopathological traits such as separation anxiety
(SA) and interpersonal sensitivity (IPS) are supposed to impact on the clinical
manifestation and on the course of Bipolar Disorder (BD); in the present study we
investigated their influence on the definition of BD subtypes. METHOD:: Among 106
BD-I patients with DSM-IV depressive, manic or mixed episode included in a
multi-centric Italian study and treated according to the routine clinical
practice, 89 (84.0%) were in remission after a follow-up period ranging from 3 to
6months (Clinical Global Impression-BP [CGI-BP] <2). Remitting patients underwent
a comprehensive evaluation including self-report questionnaires such as the
Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A) scale,
Separation Anxiety Symptom Inventory (SASI), Interpersonal Sensitivity Measure
(IPSM) and the Semi-structured interview for Mood Disorder (SIMD-R) administered
by experienced clinicians. Correlation and factorial analyses were conducted on
temperamental and psychopathological measures. Comparative analyses were
conducted on different temperamental subtypes based on the TEMPS-A, SASI and IPSM
profile. RESULTS:: Depressive, cyclothymic and irritable TEMPS-A score and SASI
and IPSM total scores were positively and statistically correlated with each
other. On the contrary, hyperthymic temperament score was negatively correlated
with depressive temperament and not significantly correlated with the other
temperamental and psychopathological dimensions. The factorial analysis of the
TEMPS-A subscales and SASI and IPSM total scores allowed the extraction of 2
factors: the cyclothymic-sensitive (explaining 46% of the variance) that
included, as positive components, depressive, cyclothymic, irritable temperaments
and SASI and IPSM scores; the hyperthymic (explaining the 19% of the variance)
included hyperthymic temperament as the only positive component and depressive
temperament and IPSM, as negative components. Dominant cyclothymic-sensitive
patients (n=49) were more frequently females and reported higher number of
depressive, hypomanic and suicide attempts when compared to the dominant
hyperthymic patients (n=40). On the contrary, these latter showed a higher number
of manic episodes and hospitalizations than cyclothymic-sensitive patients. The
rates of first-degree family history for both mood and anxiety disorders were
higher in cyclothymic-sensitive than in hyperthymic patients. Cyclothymic
sensitive patients also reported more axis I lifetime co-morbidities with Panic
Disorder/Agoraphobia and Social Anxiety Disorder in comparison with hyperthymics.
As concerns axis II co-morbidity the cyclothymic-sensitive patients met more
frequently DSM-IV criteria 1, 5 and 7 for borderline personality disorder than
the hyperthymics. On the contrary, antisocial personality disorder was more
represented among hyperthymic than cyclothymic patients, in particular for DSM-IV
criteria 1 and 6. LIMITATION:: No blind evaluation and uncertain validity of
personality inventory. CONCLUSION:: Our results support the view that affective
temperaments influence the clinical features of BD in terms of both clinical and
course characteristics, family history and axis I and II co-morbidities.
Hypothetical temperamental subtypes as measured by TEMPS-A presented important
interrelationships that permit to reliably isolate two fundamental temperamental
disposition: the first characterized by rapid fluctuations of mood and emotional
instability, and the second by hyperactivity, high level of energy and emotional
intensity. Dominant cyclothymic and hyperthymic bipolar I patients reported
important differences in terms of gender distribution, number and polarity of
previous episodes, hospitalizations, suicidality, rates of co-morbid anxiety and
personality traits and disorders. Our data are consistent with the hypothesis
that affective temperaments, and in particular cyclothymia, could be utilized as
quantitative, intermediate phenotypes in order to identify BD susceptibility

PMID: 20129674 [PubMed – as supplied by publisher] ———-
Behav Brain Funct. 2010 Jan 12;6:4.

Association between dopaminergic polymorphisms and borderline personality traits
among at-risk young adults and psychiatric inpatients.

Nemoda Z, Lyons-Ruth K, Szekely A, Bertha E, Faludi G, Sasvari-Szekely M.

Institute of Medical Chemistry, Molecular Biology and Pathobiochemistry,
Semmelweis University, Budapest, Hungary.

BACKGROUND: In the development of borderline personality disorder (BPD) both
genetic and environmental factors have important roles. The characteristic
affective disturbance and impulsive aggression are linked to imbalances in the
central serotonin system, and most of the genetic association studies focused on
serotonergic candidate genes. However, the efficacy of dopamine D2 receptor
(DRD2) blocking antipsychotic drugs in BPD treatment also suggests involvement of
the dopamine system in the neurobiology of BPD.
METHODS: In the present study we tested the dopamine dysfunction hypothesis of
impulsive self- and other-damaging behaviors: borderline and antisocial traits
were assessed by Structured Clinical Interview for Diagnosis (SCID) for DSM-IV in
a community-based US sample of 99 young adults from low-to-moderate income
families. For the BPD trait analyses a second, independent group was used
consisting of 136 Hungarian patients with bipolar or major depressive disorder
filling out self-report SCID-II Screen questionnaire. In the genetic association
analyses the previously indicated polymorphisms of the
catechol-O-methyl-transferase (COMT Val158Met) and dopamine transporter (DAT1 40
bp VNTR) were studied. In addition, candidate polymorphisms of the DRD2 and DRD4
dopamine receptor genes were selected from the impulsive behavior literature.
RESULTS: The DRD2 TaqI B1-allele and A1-allele were associated with borderline
traits in the young adult sample (p = 0.001, and p = 0.005, respectively). Also,
the DRD4 -616 CC genotype appeared as a risk factor (p = 0.02). With severity of
abuse accounted for in the model, genetic effects of the DRD2 and DRD4
polymorphisms were still significant (DRD2 TaqIB: p = 0.001, DRD2 TaqIA: p =
0.008, DRD4 -616 C/G: p = 0.002). Only the DRD4 promoter finding was replicated
in the independent sample of psychiatric inpatients (p = 0.007). No association
was found with the COMT and DAT1 polymorphisms.
CONCLUSIONS: Our results of the two independent samples suggest a possible
involvement of the DRD4 -616 C/G promoter variant in the development of BPD
traits. In addition, an association of the DRD2 genetic polymorphisms with
impulsive self-damaging behaviors was also demonstrated.

PMID: 20205808 [PubMed – in process] ———-
Front Neurol Neurosci. 2010;27:174-206. Epub 2010 Apr 6.

‘A man can be destroyed but not defeated’: Ernest Hemingway’s near-death
experience and declining health.

Dieguez S.

Laboratory of Cognitive Neuroscience, Ecole Polytechnique Fédérale de Lausanne,
Lausanne, Switzerland. sebastian.dieguez@epfl .ch

Ernest Hemingway is one of the most popular and widely acclaimed American writers
of the 20th century. His works and life epitomize the image of the
hyper-masculine hero, facing the cruelties of life with ‘grace under pressure’.
Most of his writings have a quasi-autobiographical quality, which allowed many
commentators to draw comparisons between his personality and his art. Here, we
examine the psychological and physical burdens that hindered Hemingway’s life and
contributed to his suicide. We first take a look at his early years, and review
his psychopathology as an adult. A number of authors have postulated specific
diagnoses to explain Hemingway’s behavior: borderline personality disorder,
bipolar disorder, major depression, multiple head trauma, and alcoholism. The
presence of hemochromatosis, an inherited metabolic disorder, has also been
suggested. We describe the circumstances of his suicide at 61 as the outcome of
accumulated physical deterioration, emotional distress and cognitive decline.
Special attention is paid to the war wound he suffered in 1918, which seemed to
involve a peculiar altered state of consciousness sometimes called ‘near-death
experience’. The out-of-body experience, paradoxical analgesia and conviction
that dying is ‘the easiest thing’ seemed to infl uence his future work. The
constant presence of danger, death, and violence in his works, as well as the
emphasis on the typical Hemingway ‘code hero’, can all be traced to particular
psychological and neurological disorders, as well as his early brush with death.

PMID: 20375531 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2010 Jan;71(1):26-31. Epub 2009 Jul 28.

Psychiatric diagnoses in patients previously overdiagnosed with bipolar disorder.

Zimmerman M, Ruggero CJ, Chelminski I, Young D.

Department of Psychiatry and Human Behavior, Brown University School of Medicine,
Providence, Rhode Island, USA.

OBJECTIVE: In a previous article from the Rhode Island Methods to Improve
Diagnostic Assessment and Services (MIDAS) project, we reported that bipolar
disorder is often overdiagnosed in psychiatric outpatients. An important question
not examined in that article was what diagnoses were given to the patients who
had been overdiagnosed with bipolar disorder. In the present report from the
MIDAS project, we examined whether there was a particular diagnostic profile
associated with bipolar disorder overdiagnosis.
METHOD: Eighty-two psychiatric outpatients reported having been previously
diagnosed with bipolar disorder that was not confirmed when they were interviewed
with the Structured Clinical Interview for DSM-IV (SCID). Psychiatric diagnoses
were compared in these 82 patients and in 528 patients who were not previously
diagnosed with bipolar disorder. Patients were interviewed by a highly trained
diagnostic rater who administered a modified version of the SCID for DSM-IV Axis
I disorders and the Structured Interview for DSM-IV Personality for DSM-IV Axis
II disorders. This study was conducted from May 2001 to March 2005.
RESULTS: The most frequent lifetime diagnosis in the 82 patients previously
diagnosed with bipolar disorder was major depressive disorder (82.9%, n = 68).
The patients overdiagnosed with bipolar disorder were significantly more likely
to be diagnosed with borderline personality disorder compared to patients who
were not diagnosed with bipolar disorder (24.4% vs 6.1%; P < .001). A previous
diagnosis of bipolar disorder was also associated with significantly higher
lifetime rates of major depressive disorder (P < .01), posttraumatic stress
disorder (P < .05), impulse control disorders (P < .05), and eating disorders (P
< .05), although only the association with impulse control disorders remained
significant after controlling for the presence of borderline personality
CONCLUSIONS: Psychiatric outpatients overdiagnosed with bipolar disorder were
characterized by more Axis I and Axis II diagnostic comorbidity in general, and
borderline personality disorder in particular.

PMID: 19646366 [PubMed – indexed for MEDLINE] ———-
Seishin Shinkeigaku Zasshi. 2010;112(1):3-22.

[The modern concept of atypical depression: four definitions].

[Article in Japanese]

Ohmae S.

Department of Psychiatry, Toranomon Branch Hospital.

This report describes and compares four current concepts and definitions of
atypical depression. Since its emergence, atypical depression has been considered
a depressive state that can be relieved by MAO inhibitors. Davidson classified
the symptomatic features of atypical depression into type A, which is
predominated by anxiety symptoms, and type V, which is represented by atypical
vegetative symptoms, such as hyperphagia, weight gain, oversleeping, and
increased sexual drive. Features that are shared by both subtypes include: early
onset, female predominance, outpatient predominance, mildness, few suicide
attempts, nonbipolarity, nonendogeneity, and few psychomotor changes. Based on
these features, bipolar depression can also be defined as atypical depression
type V. Herein, we examine and classify four concepts of atypical depression
according to the endogenous-nonendogenous (melancholic-nonmelancholic) and
unipolar-bipolar dichotomies. The Columbia University group (see Quitkin,
Stewart, McGrath, Klein et al.) and the New South Wales University group (see
Parker) consider atypical depression to be chronic, mild, nonendogenous
(nonmelancholic), unipolar depression. The former group postulates that mood
reactivity is necessary, while the latter asserts the structural priority of
anxiety symptoms over mood symptoms and the significance of interpersonal
rejection sensitivity. For the Columbia group, the significance of mood
reactivity reflects the theory that mood nonreactivity is the essential symptom
of “endogenomorphic depression”, which was proposed by Klein as typical
depression. Thus, mood reactivity is not related to overreactivity or
hyperactivity, which are often observed in atypical depressives. However, Parker
postulates that psychomotor symptoms are the essential features of melancholia,
which he recognizes as typical depression; therefore, the New South Wales group
does not recognize the significance of mood reactivity. The New South Wales group
accepts the relationship between anxiety symptoms and interpersonal rejection
sensitivity, while the Columbia group does not recognize the importance of
anxiety symptoms because they could not identify a relationship between such
symptoms and the efficacy of MAO inhibitors. The concept of atypical depression
proposed by the New South Wales group overlaps considerably with that of
hysteroid dysphoria, which was proposed by Klein et al., and was the progenitor
of Columbia group’s concept of atypical depression. The Pittsburgh University
group (see Himmelhoch, Kupfer, Thase et al.) and the soft bipolar spectrum group
(see Akiskal, Perugi, Benazzi et al.) regard atypical depression as a depressive
state that can be observed in bipolar disorder. The former groups takes into
account reversed vegetative symptoms and lethargy as signs of bipolar disorder,
while the latter recognizes that atypical depression shares features with bipolar
II disorder or soft bipolar spectrum disorder. The soft bipolar spectrum group
maintains their unique concept of bipolar disorder, which regards some unipolar
depressions as bipolar disorder, while the Pittsburg group continues to share the
conventional concept of a unipolar-bipolar dichotomy with other groups. The
fundamental pattern of atypical depression is represented by chronic mild
depressions, which are characterized by a younger age at onset, female
predominance, interpersonal rejection sensitivity, and mood lability, which are
difficult to distinguish from a characterological pathology. Patients who present
with such patterns are frequently diagnosed with borderline, histrionic, or
avoidant personality disorders; therefore, we must recognize the significance of
atypical depression as a concept that can suggest the utility of medication for
these patients. For such patients, however, various groups have proposed
different kinds of definition and therapeutic guidelines that are difficult to
synthesize and utilize in clinical settings. Moreover, some features of atypical
depression outlined in the Columbia University criteria, such as a younger age at
onset, chronicity, mildness, and female predominance, were excluded from DSM-IV.
Consequently, the concept of atypical depression has become overextended and
gradually lost its construct validity. Therefore, the diagnostic criteria for
atypical depression should be reconsidered in reference to various definitions
and concepts and refined through accumulated clinical research.

PMID: 20184236 [PubMed – indexed for MEDLINE] ———-
Turk Psikiyatri Derg. 2010 Winter;21(4):309-18.

[The relationship between attachment style, and temperament, personality and
bipolar symptoms: a controlled study on bipolar patients and their children].

[Article in Turkish]

Kökçü F, Kesebir S.

OBJECTIVE: This study aimed to identify the attachment style of bipolar patients
and their children, and to investigate the relationship between attachment style,
and temperament, personality characteristics, and clinical features of bipolar
METHOD: The study included 44 euthymic bipolar patients, 35 of their healthy
children (>16 years old), and 84 healthy controls (matched in terms of age,
gender, and sociocultural background with the patients and their children).
Diagnostic interviews were conducted using SCID-I, SCID-II, and SCID-NP. Bipolar
symptoms were evaluated using SCIP-TURK. Temperament and attachment style were
measured using TEMPS-A and AAS.
RESULTS: More of the bipolar patients had an avoidant attachment style and more
of their children had an anxious/ambivalent attachment style than did the healthy
controls (p < 0.001 and p << 0.001). There was a negative correlation between
insecure attachment and hyperthymic temperament (p = 0.008 and r = -0.623, and p
= 0.049, r = -0.386). Insecure attachment style in the bipolar patients was
predicted by borderline personality disorder, the severity of manic/depressive
episodes, and depressive temperament. Insecure attachment in their children was
predicted by anxious-avoidant and anxious-ambivalent attachment styles, the
number of depressive episodes, irritable temperament (children), low-level social
functioning, and a depression-mania-remission pattern.
CONCLUSION: We observed a reciprocal relationship between insecure attachment
style and mood disorders. This study shows that depressive temperament in bipolar
patients and irritable temperament in their children predicted insecure
attachment in both patients and their children.

PMID: 21125506 [PubMed – indexed for MEDLINE] ———-
Behav Brain Res. 2009 Dec 1;204(1):32-66. Epub 2009 Jun 10.

In vivo imaging of synaptic function in the central nervous system: II. Mental
and affective disorders.

Nikolaus S, Antke C, Müller HW.

Clinic of Nuclear Medicine, University Hospital Düsseldorf, Heinrich-Heine
University, Moorenstr. 5, 40225 Düsseldorf, Germany.

This review gives an overview of those in vivo imaging studies on synaptic
neurotransmission, which so far have been performed on patients with mental and
affective disorders. Thereby, the focus is on disease-related deficiencies within
the functional entities of the dopaminergic, serotonergic, cholinergic,
histaminergic, glutamatergic, or GABAergic synapse. So far, in vivo
investigations have yielded rather inconsistent results on the dysfunctions of
specific synaptic constituents in the pathophysiology of the diseases covered by
this overview. Among the more congruent results are the findings of increased
synthesis (8 out of a total of 12 reports) and release of dopamine (4 out of 4
reports) in the striatum of schizophrenic patients, which supports the dopamine
hypothesis of schizophrenia. Results on both dopaminergic and serotonergic
neurotransmission are inconsistent in both major depressive disorder and bipolar
illness, and fail to clearly agree with the dopamine and/or serotonin hypothesis
of depression. The majority of in vivo findings suggest no alterations (25 out of
a total of 50 reports on serotonin synthesis, transporter as well as receptor
binding) rather than a deficiency (merely 13 out of these 50 reports) of cortical
serotonergic neurotransmission in major depression, whereas a decrease of
cortical serotonergic neurotransmission (3 out of a total on 5 reports) can be
assumed in bipolar illness. In borderline personality disorder, an increased
binding of serotonin transporter binding was observed (merely 1 report). Due to
the limited evidence, this result only with due caution may be interpreted as an
indication for increased availability of serotonin in the synaptic cleft.
Patients with Tourette syndrome exhibited increases of DAT binding in the
neostriatum (5 out of 10 reports) increases of dopamine storage and dopamine
release in the ventral striatum (1 report, each). Moreover, striatal D2 receptor
binding was found to be decreased in advanced stages of the disease. Results,
tentatively, may be interpreted in terms of an increased dopaminergic
neurotransmission in the mesolimbic system. There is limited evidence of
decreased dopamine synthesis in both children and adults with
attention-deficit/hyperactivity disorder (4 out of a total of 10 reports). These
findings as well as the reduction of striatal dopamine release observed in adults
(merely 1 report) are in line with the notion of mesocortical dopaminergic
hypofunction in attention-deficit/hyperactivity disorder. Thereby, however, in
children, results on dopamine synthesis indicate a deficiency in the ventral
tegmentum rather than in the prefrontal cortex, whereas, with increasing age, the
prefrontal cortex rather than the sites of origin of DAergic innervation become
predominantly affected (merely 1 report, each). In anxiety disorders, varying
results have been obtained for both pre- and/or postsynaptic dopaminergic,
serotonergic and GABAergic binding sites. Thereby, results on posttraumatic
stress disorder are homogenous reporting a decrease of GABA A receptor binding in
all investigated brain regions including striatum, thalamus, neocortex and limbic
system (2 out of 2 reports, each). Moreover, patients with obsessive-compulsive
disorder displayed increases of dopamine transporter binding (2 out of 4 reports)
and decreases of both D1 (merely 1 report) and D2 receptor binding (4 out of 5
reports), respectively. These findings, tentatively, may be interpreted in terms
of an increased availability of synaptic dopamine in the neostriatum, which is
compensated for both pre- and postsynaptically by increasing dopamine reuptake
into the presynaptic terminal, and decreasing (inhibitory) signal transduction of
efferent fibers. The observed reduction of GABA A receptor binding in
frontocortical neurons (in 11 out of a total of 21 reports on anxiety disorders)
is in line with this assumption. The inconsistency (and, partially, also
incompleteness) of in vivo findings on mental and affective disorders constitutes
a major result of this overview. Discrepancies indicate that the regulation state
of synaptic constituents may not only vary between the subtypes of disorders but
also between subject cohorts and, even, individual patients depending on
variables such as the predominance of symptoms, medication status or onset and
duration of disease. This, for the time being, limits the application of in vivo
imaging methods for differential diagnosis of mental and affective disorders. In
vivo imaging results on anxiety disorders, however, are of possible interest with
regard to psychoanalysis, as they offer a neurochemical correlate for Freud’s
theories on the pathogenesis of anxiety- and compulsion-related disorders.

PMID: 19523495 [PubMed – indexed for MEDLINE] ———-
Psychol Assess. 2009 Dec;21(4):463-75.

Ecological momentary assessment of mood disorders and mood dysregulation.

Ebner-Priemer UW, Trull TJ.

House of Competence, Karlsruhe Institute of Technology (KIT), 76187 Karlsruhe,

In this review, we discuss ecological momentary assessment (EMA) studies on mood
disorders and mood dysregulation, illustrating 6 major benefits of the EMA
approach to clinical assessment: (a) Real-time assessments increase accuracy and
minimize retrospective bias; (b) repeated assessments can reveal dynamic
processes; (c) multimodal assessments can integrate psychological, physiological,
and behavioral data; (d) setting- or context-specific relationships of symptoms
or behaviors can be identified; (e) interactive feedback can be provided in real
time; and (f) assessments in real-life situations enhance generalizability. In
the context of mood disorders and mood dysregulation, we demonstrate that EMA can
address specific research questions better than laboratory or questionnaire
studies. However, before clinicians and researchers can fully realize these
benefits, sets of standardized e-diary questionnaires and time sampling protocols
must be developed that are reliable, valid, and sensitive to change.

PMID: 19947781 [PubMed – indexed for MEDLINE] ———-
Mol Psychiatry. 2009 Nov;14(11):1051-66. Epub 2008 Apr 22.

Sociodemographic and psychopathologic predictors of first incidence of DSM-IV
substance use, mood and anxiety disorders: results from the Wave 2 National
Epidemiologic Survey on Alcohol and Related Conditions.

Grant BF, Goldstein RB, Chou SP, Huang B, Stinson FS, Dawson DA, Saha TD, Smith
SM, Pulay AJ, Pickering RP, Ruan WJ, Compton WM.

Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and
Biological Research, National Institute on Alcohol Abuse and Alcoholism, National
Institutes of Health, Bethesda, MD 20892-9304, USA.

The objective of this study was to present nationally representative findings on
sociodemographic and psychopathologic predictors of first incidence of Diagnostic
and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) substance, mood and
anxiety disorders using the Wave 2 National Epidemiologic Survey on Alcohol and
Related Conditions. One-year incidence rates of DSM-IV substance, mood and
anxiety disorders were highest for alcohol abuse (1.02), alcohol dependence
(1.70), major depressive disorder (MDD; 1.51) and generalized anxiety disorder
(GAD; 1.12). Incidence rates were significantly greater (P<0.01) among men for
substance use disorders and greater among women for mood and anxiety disorders
except bipolar disorders and social phobia. Age was inversely related to all
disorders. Black individuals were at decreased risk of incident alcohol abuse and
Hispanic individuals were at decreased risk of GAD. Anxiety disorders at baseline
more often predicted incidence of other anxiety disorders than mood disorders.
Reciprocal temporal relationships were found between alcohol abuse and
dependence, MDD and GAD, and GAD and panic disorder. Borderline and schizotypal
personality disorders predicted most incident disorders. Incidence rates of
substance, mood and anxiety disorders were comparable to or greater than rates of
lung cancer, stroke and cardiovascular disease. The greater incidence of all
disorders in the youngest cohort underscores the need for increased vigilance in
identifying and treating these disorders among young adults. Strong common
factors and unique factors appear to underlie associations between alcohol abuse
and dependence, MDD and GAD, and GAD and panic disorder. The major results of
this study are discussed with regard to prevention and treatment implications.

PMID: 18427559 [PubMed – indexed for MEDLINE] ———-
Adv Emerg Nurs J. 2009 Oct-Dec;31(4):298-308.

Psychiatric crash cart: treatment strategies for the emergency department.

Gilbert SB.

Cheshire Medical Center, Keene, New Hampshire, USA.

Emergency department staff are often frustrated when treating patients with
psychiatric disorders. Nurses may feel that these patients are taking time away
from the truly sick and may react by avoiding, ignoring, or using force with
patients with psychiatric disorders. Psychiatric patients will often present with
exacerbations of their illnesses, as do our patients with medical conditions.
Ignoring or disregarding these symptoms will worsen them, much like ignoring
dyspnea will cause a patient to deteriorate physically. Instead, it is important
to understand the common psychiatric diagnoses and their associated symptomology.
Symptom management is critical in the treatment of patients with psychiatric
disorders; it reduces anxiety, builds trust, and allows the patients to feel
safer. The staff is able to enlist the cooperation of the patients to stay in
control, not only reducing disruption in the ED but also creating a better
patient experience. Establishing a therapeutic relationship with patients also
furthers this goal.

PMID: 20118883 [PubMed – indexed for MEDLINE] ———-
Int Clin Psychopharmacol. 2009 Sep;24(5):270-5.

A preliminary study of lamotrigine in the treatment of affective instability in
borderline personality disorder.

Reich DB, Zanarini MC, Bieri KA.

Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA
02478, USA.

The objective of this study was to evaluate the effectiveness of lamotrigine in
reducing affective instability in borderline personality disorder (BPD). We
conducted a 12-week, double-blind, placebo-controlled study of 28 patients who
met Revised Diagnostic Interview for Borderlines and Diagnostic and Statistical
Manual of Mental Disorders, fourth edition criteria for BPD. Patients could not
meet Diagnostic and Statistical Manual of Mental Disorders, fourth edition
criteria for bipolar disorder. Patients could be taking one antidepressant during
the study. Patients were randomly assigned to treatment with flexible-dose
lamotrigine or placebo in a 1 : 1 manner. The primary outcome measures were: (i)
the Affective Lability Scale total score; and (ii) the Affective Instability Item
of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). The
study randomized 15 patients to receive lamotrigine and 13 patients to receive
placebo. Patients in the lamotrigine group had significantly greater reductions
in the total Affective Lability Scale scores (P<0.05) and significantly greater
reductions in scores on the affective instability item of the ZAN-BPD (P<0.05). A
secondary finding was that patients in the lamotrigine group had significantly
greater reductions in scores on the ZAN-BPD impulsivity item (P = 0.001). Results
from the study suggest that lamotrigine is an effective treatment for affective
instability and for the general impulsivity characteristic of BPD.

PMID: 19636254 [PubMed – indexed for MEDLINE] ———-
Psychiatr Danub. 2009 Sep;21(3):386-90.

Borderline personality disorder and bipolar disorder comorbidity in suicidal
patients: diagnostic and therapeutic challenges.

Marcinko D, Vuksan-Cusa B.

Department of Psychiatry, Clinical Hospital Center Zagreb, 10000 Zagreb, Croatia.

Suicidality is one of the great challenges in contemporary psychiatry. Suicidal
patients are often misdiagnosed in clinical practice. It is very important to
evaluate possible comorbidity in diagnostic assessment of suicidal patients. The
high prevalence of comorbid bipolar (BD) and borderline personality disorders
(BPD) presents both a diagnostic and a therapeutic challenge. Although the
primary treatment for patients with BPD is psychotherapy, pharmacotherapy is a
core component for the treatment of comorbid conditions such as bipolar disorder.
Because of heterogeneity of the BPD, pharmacologic treatment has evolved to some
particular dimensions of BPD rather than the disorder in its entirety. The
dimensions include affective instability, impulsive aggression and identity
disturbance. Effective medication management reduces the overall suffering of the
patient and enables to make greater use of psychotherapeutic interventions which
is very important for BPD patients with BD comorbidity.

PMID: 19794362 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2009 Aug;70(8):e29.

Bipolar disorder and concurrent psychiatric and medical disorders.

Gentil V.

Instituto de Psiquiatria, Hospital das Clinicas, and the Faculdade de Medicina da
Universidade de Sao Paulo, Brazil.

A correct diagnosis of bipolar disorder is crucial to determining appropriate
treatment strategies, but the majority of patients with this illness are
initially misdiagnosed. Bipolar presentations share features with other
psychiatric disorders such as unipolar depression and borderline personality
disorder, and comorbid medical conditions further complicate diagnosis.
Clinicians may minimize diagnostic and treatment issues by focusing on
differential diagnosis and dual treatment of bipolar disorder and co-occurring
conditions. The physical health of patients with bipolar disorder should be
monitored, because this population is at risk for obesity, metabolic syndrome,
and associated conditions.

PMID: 19758518 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2009 Aug;70(8):e26.

Bipolar disorder: diagnostic conundrums and associated comorbidities.

Young AH.

Department of Psychiatry, University of British Columbia, Vancouver, British
Columbia, Canada.

Many patients with bipolar disorder are initially misdiagnosed. Clinicians may
incorrectly diagnose bipolar disorder as unipolar depression, borderline
personality disorder, schizophrenia, anxiety, or substance use disorder. The
consequences of misdiagnosis can include intensified manic symptoms, reduced
quality of life, and increased risk of suicide. To correctly diagnose patients
with bipolar disorder, clinicians must be aware of associated comorbidities and
methods of differentiating bipolar disorder from other illnesses.

PMID: 19758515 [PubMed – indexed for MEDLINE] ———-
J Pers Disord. 2009 Aug;23(4):357-69.

Family history study of the familial coaggregation of borderline personality
disorder with axis I and nonborderline dramatic cluster axis II disorders.

Zanarini MC, Barison LK, Frankenburg FR, Reich DB, Hudson JI.

Laboratory for the Study for Adult Development and the Psychiatric Epidemiology
Research Program, McLean Hospital, and the Department of Psychiatry, Harvard
Medical School, USA.

The purpose of this study was to assess the familial coaggregation of borderline
personality disorder (BPD) with a full array of axis I disorders and four axis II
disorders (antisocial personality disorder, histrionic personality disorder,
narcissistic personality disorder, and sadistic personality disorder) in the
first-degree relatives of borderline probands and axis II comparison subjects.
Four hundred and forty-five inpatients were interviewed about familial
psychopathology using the Revised Family History Questionnaire-a semistructured
interview of demonstrated reliability. Of these 445 subjects, 341 met both DIB-R
and DSM-III-R criteria for BPD and 104 met DSM-III-R criteria for another type of
personality disorder (and neither criteria set for BPD). The psychopathology of
1,580 first-degree relatives of borderline probands and 472 relatives of axis II
comparison subjects was assessed. Using structural models for familial
coaggregation, it was found that BPD coaggregates with major depression,
dysthymic disorder, bipolar I disorder, alcohol abuse/dependence, drug
abuse/dependence, panic disorder, social phobia, obsessive-compulsive disorder,
generalized anxiety disorder, posttraumatic stress disorder, somatoform pain
disorder, and all four axis II disorders studied. Taken together, the results of
this study suggest that common familial factors, particularly in the areas of
affective disturbance and impulsivity, contribute to borderline personality

PMID: 19663656 [PubMed – indexed for MEDLINE] ———-
Psychiatry (Edgmont). 2009 Aug;6(8):29-32.

Misdiagnosed Bipolar Disorder Reveals Itself to be Posttraumatic Stress Disorder
with Comorbid Pseudotumor Cerebri: A Case Report.

Salzbrenner S, Conaway E.

Dr. Salzbrenner is USN at Naval Medical Center Portsmouth.

We present the case of a patient with a reported history of bipolar II and
borderline personality disorders who presented to our inpatient psychiatry
department following a suicidal gesture. We determined that she was not suffering
from bipolar disorder at all, and we diagnosed her with posttraumatic stress
disorder and pseudotumor cerebri. This paper describes the overlap of symptoms of
bipolar disorder and posttraumatic stress disorder, which may lead to an
incorrect diagnosis. Additionally, the patient had the complicating factor of
comorbid pseudotumor cerebri, which we feel contributed to her psychiatric
symptoms. Once the patient was properly diagnosed and placed on appropriate
treatment, she responded well.

PMID: 19763205 [PubMed] ———-
Expert Rev Neurother. 2009 Jul;9(7):949-55.

Corpus callosum abnormalities in pediatric bipolar disorder.

Baloch HA, Brambilla P, Soares JC.

Department of Psychiatry, 10616 Neuroscience Hospital CB#7160, UNC School of
Medicine, Chapel Hill, NC 27599-7160, USA.

The corpus callosum (CC) is a midline white matter brain region that is important
in interhemispheric communication and coordination. CC abnormalities are
associated with a variety of psychiatric conditions, including increased
vulnerability for psychotic illness, stressful early-life experiences, marijuana
use, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder,
borderline personality disorder, dementia, schizophrenia and bipolar disorder. CC
abnormalities in bipolar disorder have been identified in both pediatric and
adult populations. In adults, a consistent finding has been a reduction in CC
size, as well as abnormal axonal orientation or structure. Axonal abnormalities
have also been noted in pediatric populations, but overall CC size reductions
have not thus far been demonstrated. Furthermore, there are unique gender
differences in the expression of CC abnormalities in pediatric populations,
possibly related to androgen changes during puberty. The protean number of
conditions in which the CC is involved is reflective of its central role in
normal brain function and its potential as an early marker of neuropathology in
psychiatric illness. Specifically, in bipolar disorder it has the potential to be
useful as an early preclinical marker of disease or disease risk.

PMID: 19589045 [PubMed – indexed for MEDLINE] ———-
Acad Psychiatry. 2009 May-Jun;33(3):204-11.

Student experiences with competency domains during a psychiatry clerkship.

West DA, Nierenberg DW.

Dartmouth Medical School, Psychiatry, DHMC -Psychiatry Level 2, # 1 Medical
Center Dr., Lebanon, NH 03756, USA.

OBJECTIVES: The authors reviewed medical student encounters during 3 years of a
required psychiatry clerkship that were recorded on a web-based system of six
broad competency domains (similar to ACGME-recommended domains). These were used
to determine diagnoses of patients seen, clinical skills practiced, and
experiences in interpersonal and communications skills, professionalism,
practice-based learning and improvement, and system-based practice. The authors
aim to understand how students are learning and growing in these domains and to
modify the clerkship in an ongoing manner.
METHODS: Data were collected from the Dartmouth Medical Encounter Documentation
System (DMEDS) for all student encounters in required third-year psychiatry
clerkships during academic years 2004-2007, in which students had intensive
involvement in patient care.
RESULTS: One hundred seventy three students reported a total of 4,676 patient
encounters, averaging 27.2 encounters per student and 1.8 psychiatric diagnoses
per patient. Students met “learning targets” for anxiety disorder, bipolar
affective disorder, depression, personality disorder (borderline), posttraumatic
stress disorder, psychosis, schizophrenia, and substance abuse (alcohol), but not
for disorders more likely seen in outpatient settings. For the 10 counseling
skills learning targets, students only met those for family issues. In the four
“newer” competency domains, students reported struggling with issues in 0.3% to
12.6% of encounters. Students documented being challenged by professionalism
issues most often and recorded examples of how these competencies played out for
them during the clerkship.
CONCLUSION: Use of a required web-based medical encounter reporting system for
student-patient-faculty encounters during a psychiatry clerkship can be of
significant value in assessing what students are seeing, doing, and learning on
this required third-year experience. The results provide helpful current
information to the clerkship director and data that help the director modify the
clerkship on an ongoing basis to better meet students’ educational needs.

PMID: 19574516 [PubMed – indexed for MEDLINE] ———-
Expert Opin Drug Metab Toxicol. 2009 May;5(5):539-51.

A review of valproate in psychiatric practice.

Haddad PM, Das A, Ashfaq M, Wieck A.

Greater Manchester West Mental Health, NHS Foundation Trust, Cromwell House,
Cromwell Road, Eccles, Salford, Manchester M300GT, UK.

Valproate (2-propylpentanoate) is available as valproic acid, sodium valproate
and semisodium valproate. It has actions on dopamine, GABA and glutamate
neurotransmission and intracellular signaling. Its main psychiatric use is to
treat bipolar disorder. It has been used in other psychiatric disorders,
including schizophrenia and borderline personality disorder, but data are
insufficient to recommend this. In acute mania, valproate monotherapy has similar
efficacy to antipsychotic drugs and lithium whereas the combination of valproate
and an antipsychotic is more effective than either drug alone. In maintenance
treatment of bipolar disorder, valproate monotherapy has comparable efficacy to
olanzapine although placebo-controlled evidence is limited. Maintenance treatment
with valproate and quetiapine or olanzapine is more efficacious than valproate
alone when an acute episode responds to the combination. Common adverse effects
of valproate include weight gain, gastrointestinal symptoms, sedation, tremor and
mild elevation of hepatic enzymes. Serious hepatic toxicity is rare in adults.
Many adverse effects are dose related and resolve with dose reduction. Valproate
is teratogenic and specifically associated with neural tube defect. Preliminary
evidence has linked in utero exposure to decreased verbal intelligence in the
offspring. These effects, plus a probable increased risk of polycystic ovary
syndrome, limit valproate’s use in women of childbearing potential.

PMID: 19409030 [PubMed – indexed for MEDLINE] ———-
Psychiatry Clin Neurosci. 2009 Apr;63(2):186-94.

Anger and functioning amongst inpatients with schizophrenia or schizoaffective
disorder living in a therapeutic community.

Fassino S, Amianto F, Gastaldo L, Leombruni P.

Neurosciences Department, Psychiatry Section, University of Turin, Turin, Italy.

AIMS: This study explored the functional correlates of anger amongst therapeutic
community inpatients.
METHODS: The sample consisted of 44 subjects diagnosed with
schizophrenic/schizoaffective disorder who were involved in a community treatment
program. Assessment involved administration of the Health of Nation Outcome
Scales and the Global Assessment of Functioning as well as self-evaluations using
the Social Adaptation Self-evaluation Scale. Psychopathology was assessed with
the Positive and Negative Symptoms Scale. Angry feelings and coping skills were
self-assessed with the State-Trait Anger Expression Inventory and the Symptom
Checklist-90 Hostility Scale. Multiple regression analyses correlated anger with
functioning, controlling for psychopathology.
RESULTS: Angry feelings related to self-harm, hyperactivity, physical problems,
and to global weight independently from Positive and Negative Symptoms Scale
scores. They also predicted interest and pleasure in housekeeping, quality of
social relationships and relational exchanges.
CONCLUSIONS: Results showed that angry feelings were not merely derivations of
schizophrenic psychopathology; rather, they were independently related to
self-damaging behaviors, to attentional demands towards the staff, to agreement
to community tasks and to low quality of social relationships. Indeed, anger was
related to adaptation’s level in a therapeutic community setting demonstrated by
subjects with psychoses and it may represent an indirect measure of their
experienced quality of life. Therapeutic and management approaches to anger
amongst subjects with schizophrenia are discussed.

PMID: 19335389 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2009 Mar;11(2):205-8.

Age at onset of bipolar disorder and risk for comorbid borderline personality

Goldberg JF, Garno JL.

Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA.

OBJECTIVES: The relationship between bipolar disorder and cluster B personality
disorders remains phenomenologically complex and controversial. We sought to
examine the relationship between early age at onset of bipolar disorder and
development of comorbid borderline personality disorder.
METHODS: A total of 100 adults in an academic specialty clinic for bipolar
disorder underwent structured diagnostic interviews and clinical assessments to
determine lifetime presence of comorbid borderline personality disorder,
histories of childhood trauma, and clinical illness characteristics.
RESULTS: Logistic regression indicated that increasing age at onset of bipolar
disorder was associated with a lower probability of developing comorbid
borderline personality disorder (odds ratio = 0.91, 95% confidence interval:
0.83-0.99) while controlling for potential confounding factors, including a
history of severe child trauma/abuse.
CONCLUSION: Early onset of bipolar disorder increases the probability of
developing comorbid borderline personality disorder, independent of the effects
of severe childhood trauma/abuse. In patients with borderline personality
disorder, prospective studies of new-onset bipolar disorder may underestimate the
prevalence of true comorbidity unless they capture the primary risk window for
first-episode mania arising before the end of adolescence.

PMID: 19267703 [PubMed – indexed for MEDLINE] ———-
Med J Aust. 2009 Feb 16;190(4):176-9.

Prevalence of metabolic syndrome among Australians with severe mental illness.

John AP, Koloth R, Dragovic M, Lim SC.

Mental Health, Bentley Health Service, Perth, WA, Australia.

Comment in
Med J Aust. 2009 Feb 16;190(4):171-2.

OBJECTIVE: To assess the prevalence of metabolic syndrome and its association
with sociodemographic, clinical and lifestyle variables among Australian patients
with a variety of psychiatric disorders.
DESIGN AND SETTING: Cross-sectional study of patients attending a public mental
health service in Western Australia between July 2005 and September 2006.
PARTICIPANTS: Patients who were aged 18-65 years; diagnosed with schizophrenia,
schizoaffective disorder, bipolar disorder, major depressive disorder with
psychotic symptoms, drug-induced psychosis or borderline personality disorder;
and currently taking at least one antipsychotic drug for a minimum of 2 weeks.
MAIN OUTCOME MEASURES: Prevalence of metabolic syndrome diagnosed with
International Diabetes Federation criteria; fasting blood glucose and lipid
levels; sociodemographic and lifestyle characteristics.
RESULTS: Of 219 patients invited to participate, 203 agreed and had complete
data. Prevalence of metabolic syndrome was 54% overall, and highest among
patients with bipolar disorder or schizoaffective disorder (both 67%), followed
by schizophrenia (51%). Sociodemographic variables, including age and ethnic
background, were not significantly associated with metabolic syndrome, but a
strong association was seen with mean body mass index. Other cardiovascular risk
factors, such as smoking and substance misuse, were common among participants.
CONCLUSIONS: Prevalence of metabolic syndrome in this population was almost
double that in the general Australian population, and patients with schizophrenia
had a prevalence among the highest in the developed world. Prevalence was also
high in patients with a variety of other psychiatric disorders.

PMID: 19220180 [PubMed – indexed for MEDLINE] ———-
J Nerv Ment Dis. 2009 Feb;197(2):92-7.

The association between self-reported anxiety symptoms and suicidality.

Diefenbach GJ, Woolley SB, Goethe JW.

Anxiety Disorders Center, Institute of Living/Hartford Hospital, Hartford, CT
06106, USA.

This cross-sectional study assessed the association between self-reported anxiety
symptoms and self-reported suicidality among a mixed diagnostic sample of
psychiatric outpatients. Data were obtained from chart review of 2,778
outpatients who completed a routine diagnostic clinical interview and a
standardized self-report of psychiatric symptoms on admission. Bivariate analyses
indicated that those with >or= moderate anxiety symptoms were over three times as
likely to report >or= moderate difficulty with suicidality. Self-reported anxiety
symptoms were associated with a 2-fold increased likelihood of reporting
suicidality after controlling for confounding (demographics, depressive symptoms,
and diagnoses). These data are consistent with a growing literature demonstrating
an association between anxiety symptoms and suicidality, and suggest that this
association is not accounted for by coexisting mood symptoms or diagnoses. A
single item, self-report may be a useful screening tool for symptoms that are
pertinent to assessment of suicide risk.

PMID: 19214043 [PubMed – indexed for MEDLINE] ———-
Acta Med Port. 2009 Jan-Feb;22(1):59-70. Epub 2009 Mar 25.

[Liaison psychiatry in a general hospital: seven paradigmatic cases].

[Article in Portuguese]

Guerreiro DF, Barrocas D, Fernandes S, Coentre R, Navarro R, Santos N.

Departamento de Psiquiatria e Saúde Mental, Hospital de Santa Maria, Lisboa.

Through the use of case reports, this article reviews frequent causes that origin
the need for psychiatric intervention in patients hospitalized in medical and
surgical wards. Particular diagnosis aspects are focused, so is the necessity of
integration of the biological, psychological and social dimensions of the
patient. The integrated approach by the various members of the medical staff is
also emphasised. The cases presented were observed in the Liaison Psychiatry
Consult of the Psychiatry Service of Hospital Santa Maria, in Lisbon, between
November 2007 and January 2008. Seven cases were selected because they reflect
paradigms in the intervention of the Liaison Psychiatrist, and reflect the
following psychiatric diagnosis: Panic Disorder; Paranoid Schizophrenia; Bipolar
Disorder; Personality Disorder; Major Depression, Dementia and Abstinence

PMID: 19341594 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2009 Jan;70(1):13-8. Epub 2008 Nov 18.

Suicidal behavior in bipolar disorder: what is the influence of psychiatric

Neves FS, Malloy-Diniz LF, Corrêa H.

Instituto dos Servidores da Previdência Social de Minas Gerais, Belo Horizonte,

OBJECTIVE: To assess the frequency of some psychiatric comorbidities found to be
associated with suicidal behavior in previous studies and to evaluate their
influence on suicidal behavior in a sample of patients with bipolar disorder.
METHOD: We assessed 239 bipolar patients from January 2005 to January 2007. Axis
I diagnosis was performed according to the DSM-IV using a structured interview
(the Mini-International Neuropsychiatric Interview-Plus), and borderline
personality disorder was assessed using the Structured Clinical Interview for
DSM-IV Axis II Personality Disorders. Lifetime suicide history was assessed using
a semistructured interview in addition to a review of medical records.
RESULTS: There were 99 patients (41.4%) with a history of previous suicide
attempts. The psychiatric comorbidities associated with suicidal behavior were
borderline personality disorder (chi(2) = 36.008, p = .0001), panic disorder
(chi(2) = 5.537, p = .019), alcoholism (chi(2) = 12.820, p = .001), other drug
addictions (chi(2) = 10.055, p = .02), generalized anxiety disorder (chi(2) =
10.216, p = .001), and smoking (chi(2) = 9.070, p = .003). However, when logistic
regression analyses were used, only the diagnosis of border-line personality
disorder remained significant (Wald chi(2) = 19.13, p = .0001). When analyzing
the subtypes of suicide attempts, we found that borderline personality disorder
and alcoholism were associated with violent suicide attempts.
CONCLUSION: A diagnosis of borderline personality disorder or alcoholism (only
for violent sub-type of suicidal behavior) was the only comorbidity independently
associated with suicide in patients with bipolar disorder. For suicide
prevention, screening to identify patients at high risk for suicidal behavior
should be performed routinely in patients with bipolar disorder.

PMID: 19026263 [PubMed – indexed for MEDLINE] ———-
Prim Care Companion J Clin Psychiatry. 2009;11(2):53-67.

Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Schizotypal
Personality Disorder: Results From the Wave 2 National Epidemiologic Survey on
Alcohol and Related Conditions.

Pulay AJ, Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Saha TD, Smith
SM, Pickering RP, Ruan WJ, Hasin DS, Grant BF.

Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and
Biological Research, National Institute on Alcohol Abuse and Alcoholism, National
Institutes of Health, Bethesda, Md. ; and the Mailman School of Public Health and
Department of Psychiatry, College of Physicians and Surgeons of Columbia
University, New York, N.Y.

OBJECTIVE: To present nationally representative findings on the prevalence,
correlates, and comorbidity of and disability associated with DSM-IV schizotypal
personality disorder (SPD). METHOD: This study used the 2004-2005 Wave 2 National
Epidemiologic Survey on Alcohol and Related Conditions, which targeted a
nationally representative sample of the adult civilian population of the United
States aged 18 years and older and residing in households and group quarters. In
Wave 2, attempts were made to conduct face-to-face reinterviews with all
respondents to the Wave 1 interview. RESULTS: Lifetime prevalence of SPD was
3.9%, with significantly greater rates among men (4.2%) than women (3.7%) (p <
.01). Odds for SPD were significantly greater among black women, individuals with
lower incomes, and those who were separated, divorced, or widowed; odds were
significantly lower among Asian men (all p < .01). Schizotypal personality
disorder was associated with substantial mental disability in both sexes.
Co-occurrence rates of Axis I and other Axis II disorders among respondents with
SPD were much higher than rates of co-occurrence of SPD among respondents with
other disorders. After adjustment for sociodemographic characteristics and
additional comorbidity, associations remained significant in both sexes between
SPD and 12-month and lifetime bipolar I disorder, social and specific phobias,
and posttraumatic stress disorder, as well as 12-month bipolar II disorder,
lifetime generalized anxiety disorder, and borderline and narcissistic
personality disorders (all p < .01). CONCLUSIONS: Common and unique factors may
underlie associations of SPD with narcissistic and borderline personality
disorders, whereas much of the comorbidity between SPD and most mood and anxiety
disorders appears to reflect factors common to these disorders. Some of the
associations with SPD were sex specific. Schizotypal personality disorder and
dependent, avoidant, and borderline personality disorders were associated with
the occurrence of schizophrenia or psychotic episode. Schizotypal personality
disorder is a prevalent, fairly stable, highly disabling disorder in the general
population. Sex differences in associations of SPD with other specific Axis I and
II disorders can inform more focused, hypothesis-driven investigations of factors
underlying the comorbid relationships. Schizotypal as well as borderline,
dependent, and avoidant personality disorders may be components of the
schizophrenia spectrum.

PMID: 19617934 [PubMed – as supplied by publisher] ———-
Psychopathology. 2009;42(4):257-63. Epub 2009 Jun 12.

Gender differences in axis I and axis II comorbidity in patients with borderline
personality disorder.

Tadi? A, Wagner S, Hoch J, Ba?kaya O, von Cube R, Skaletz C, Lieb K, Dahmen N.

Department of Psychiatry, University of Mainz, Germany.

BACKGROUND/AIMS: Differences in the clinical presentation of men and women with
borderline personality disorder (BPD) are of potential interest for
investigations into the neurobiology, genetics, natural history, and treatment
response of BPD. The purpose of this study was to investigate gender differences
in axis I and axis II comorbidity and in diagnostic criteria in BPD patients.
METHODS: 110 women and 49 men with BPD were assessed with the computer-based
version of the Munich-Composite International Diagnostic Interview and the
Structured Clinical Interview for DSM-IV Personality Disorders. Gender
differences were investigated for the following outcomes: (a) lifetime, 12-month
and 4-week prevalence of axis I disorders; (b) axis II disorders, and (c) DSM-IV
BPD diagnostic criteria.
RESULTS: With regard to lifetime prevalence of axis I disorders, men more often
displayed a substance use disorder, in particular alcohol dependency (65 vs.
43%); on the other hand, women more frequently had an affective (94 vs. 82%),
anxiety (92 vs. 80%) or eating disorder (35 vs. 18%), in particular anorexia
nervosa (21 vs. 4%). Regarding the 12-month prevalence, we found significantly
more women suffering from anorexia nervosa (13 vs. 0%). Considering the 4-week
prevalence, there were no significant gender differences. With regard to axis II
disorders, men had a higher frequency of antisocial personality disorder (57 vs.
26%). Regarding the BPD diagnostic criteria, men more often displayed ‘intensive
anger’ (74 vs. 49%), whereas women more frequently showed ‘affective instability’
(94 vs. 82%).
CONCLUSION: In this German study, we could replicate and extend the findings from
previous US studies, where men and women with BPD showed important differences in
their pattern of psychiatric comorbidity. The implications for clinicians and
researchers are discussed.

PMID: 19521142 [PubMed – indexed for MEDLINE] ———-
Psychopathology. 2009;42(4):219-28. Epub 2009 May 16.

Concept of representation and mental symptoms. The case of theory of mind.

Rejón Altable C, Vidal Castro C, López Santín JM.

Hospital de Día Hospital Universitario de la Princesa, Madrid, Spain.

BACKGROUND: Most current theories explaining theory of mind (ToM) rely on the
concept of ‘representation’, as it is usually employed in cognitive science, and
is thus affected by its epistemic shortcoming, namely its incapacity to use
‘sub-signifier’ level information. This shortcoming is responsible for the lack
of specificity of ToM deficits, which are now found in very different syndromes,
from schizophrenia to bipolar disorder or borderline personality disorder, in
spite of its original formulation being restricted to childhood autism.
METHOD: Representation, its shortcomings and the way they may affect
clinical/research programs undergo a conceptual analysis, which shows how
representational-founded semiology leave out information that is essential for
symptom specificity and correct symptom assessment. Schizophrenic autism,
delusional perception and axial syndromes are studied as examples of both the
difficulties that have arisen and possible ways of dealing with them.
RESULTS: Transfers of properties between different meanings of ‘representation’
together with a systematic ambiguity in the use of ‘representation’ are proposed
as the main ways for representational approaches to assure stability to their
proposals in spite of the violence exerted on clinical phenomena.
CONCLUSIONS: It is exposed how systematic ambiguity and epistemic shortcomings
both affect Leslie’s formulation of ToM and, further, the importance of these
characteristics of the concept of ‘representation’ for general issues in
psychiatric semiology.

PMID: 19451754 [PubMed – indexed for MEDLINE] ———-
Psychopharmacol Bull. 2009;42(4):23-39.

Early predictors of weight gain risk during treatment with olanzapine: analysis
of pooled data from 58 clinical trials.

Lipkovich I, Jacobson JG, Caldwell C, Hoffmann VP, Kryzhanovskaya L, Beasley CM.

Lilly Corporate Center, Eli Lilly and Company, Indianapolis, IN.

This analysis evaluated the usefulness of different predictors in identifying
patient risk of substantial weight gain (SWG) during olanzapine treatment. Data
were from 58 studies with 3826 patients diagnosed with schizophrenia,
schizophrenia spectrum disorders, bipolar mania, bipolar depression, or
borderline personality disorder. The primary definition for SWG was gaining
>/=12% of baseline weight by endpoint (30 weeks +/-5 weeks); other definitions of
SWG were also examined. Potential predictors of SWG included baseline patient
characteristics, weight change, and percent weight change at Weeks 1, 2, 3, and 4
after olanzapine initiation. To facilitate model building and validation, the
data set was randomly partitioned into training (N = 1912), validation (N =
1149), and test (N = 765) sets and 2 complementary analytic techniques were used:
logistic regression with stepwise variable selection followed by receiver
operating characteristic analysis for evaluation of resulting candidate models
and decision trees. Approximately 24% of patients gained >/=12% of their initial
weight, about 30% gained >/=10%, and 45% gained >/=7% or >/=5 kg by the 30-week
endpoint. Baseline covariates significantly and positively associated with
probability of SWG were lower baseline body mass index, younger age, female sex,
United States residency, and African ethnicity. Early weight changes
substantially improved the prediction of the risk for longer-term SWG. These
results confirm that cut-offs for weight gain during the first 4 weeks of
treatment may be useful in evaluating SWG risk for an individual patient.

PMID: 20581791 [PubMed – in process] ———-
Tijdschr Psychiatr. 2009;51(1):31-41.

[Dialectical behaviour therapy for adolescents; a literature review].

[Article in Dutch]

Backer HS, Miller AL, van den Bosch LM.

Rijks Inrichting voor Jeugdigen de Doggershoek te DenHelder.

BACKGROUND: According to several randomised controlled trials (rct’s) dialectical
behaviour therapy (dbt) is effective in treating adults diagnosed with borderline
personality disorder (bpd) who present with self-injurious and suicidal
behaviour. In recent years there have been several studies about dbt in
adolescents with varying problems and disorders.
AIM: To review the literature for evidence of the effectiveness of dbt in
adolescents aged 12 to 18.
METHOD: With the help of PubMed and Medline and using the search-terms
‘dialectical’, ‘adolescent’, ‘suicide attempt’ and ‘deliberate self harm’, we
searched the literature for references to dbt in adolescents.
RESULTS: There were no rct’s involving dbt in adolescents, but we did find one
quasi-experimental design and several other studies with a pre-post treatment
design. However, the studies were difficult to compare. In some cases it was
doubtful whether the treatment could still be called dbt. The results suggested
that dbt may be just as effective with adolescents as it is with adults in
reducing bpd symptoms, suicidal ideation, and comorbid depressive disorder
symptoms, and in reducing the need for hospitalisation. The results also
indicated that dbt might be effective in treating eating disorders, bipolar
disorder, oppositionality, aggression and nonsuicidal self-injurious behaviour
(nsib) in a variety of treatment settings.
CONCLUSION: dbt is possibly effective for treating adolescents with nsib and/or
bpd symptoms. It may also be an effective treatment for various other affective
and behavioural disorders. rct’s are needed.

PMID: 19194844 [PubMed – indexed for MEDLINE] ———-
World J Biol Psychiatry. 2009;10(4 Pt 2):612-5.

Misdiagnosis of bipolar disorder as borderline personality disorder: clinical and
economic consequences.

John H, Sharma V.

Department of Psychiatry, University of Western Ontario, London, Ontario, Canada.

We report the case of a 26-year-old patient with bipolar spectrum disorder who
was misdiagnosed with borderline personality disorder. In spite of trials of
various psychotropic drugs and frequent, prolonged hospitalizations, the patient
had remained chronically symptomatic. Following a detailed examination of the
longitudinal illness course and confirmation of the diagnosis of bipolar spectrum
disorder, antidepressants were discontinued and the patient was treated with
lamotrigine and quetiapine. This treatment resulted in sustained euthymia and
cessation of deliberate self-harm in addition to a significant reduction in
utilization of health resources.

PMID: 19224409 [PubMed – indexed for MEDLINE] ———-
Psychol Methods. 2008 Dec;13(4):354-75.

Analysis of affective instability in ecological momentary assessment: Indices
using successive difference and group comparison via multilevel modeling.

Jahng S, Wood PK, Trull TJ.

Department of Psychological Sciences, University of Missouri, Columbia, MO 65211,

Temporal instability of affect is a defining characteristic of psychological
disorders such as borderline personality disorder (BPD) and mood cycling
disorders. Ecological momentary assessment (EMA) enables researchers to directly
assess such frequent and extreme fluctuations over time. The authors examined 4
operationalizations of such temporal instability: the within-person variance
(WPV), the first-order autocorrelation, the mean square successive difference
(MSSD), and the probability of acute change (PAC). It is argued that the MSSD and
PAC measures are preferred indices of affective instability because they capture
both variability and temporal dependency in a time series. Additionally, the
performance of these 2 measures in capturing within- and between-day instability
is discussed. To illustrate, the authors present EMA data from a study of
negative mood in BPD and major depressive disorder patients. In this study, MSSD
and PAC captured affective instability better than did WPV. Given that MSSD and
PAC are individual difference measures, the authors propose that group
differences on these indices be explored using generalized multilevel models.
Versions of MSSD and PAC that adjust for randomly elapsed time interval between
assessments are also presented.

PMID: 19071999 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2008 Nov;69(11):1794-803. Epub 2008 Nov 4.

Bipolar disorder and comorbid personality psychopathology: a review of the

Fan AH, Hassell J.

Department of Psychiatry, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

OBJECTIVE: To examine the prevalence of personality disorder comorbidity in
bipolar disorder and examine the effects of this comorbidity on bipolar disorder
DATA SOURCES: All the studies reviewed were found through an online literature
search through the Web site PubMed. The studies were published between 1980 and
2006. The following keywords were used to search articles: bipolar, mania, mood,
personality, Axis II, borderline, and lithium. Only articles in English were
included in this literature review.
STUDY SELECTION: A total of 32 studies that reported data on the prevalence and
effect of comorbid personality disorders or abnormal personality traits in
bipolar disorder patients were reviewed.
DATA EXTRACTION: The data abstracted from the prevalence studies included sample
size, mood state of the study population, research instruments used to determine
personality psychopathology, prevalence rates of personality disorders, and
abnormalities. Other data collected included response to medications and course
of illness.
DATA SYNTHESIS: The prevalence studies were categorized into outpatient and
inpatient studies to facilitate data analysis. The prevalence studies were also
analyzed according to the research instrument used to measure personality
pathology. Studies that used non-DSM personality measures were analyzed
CONCLUSIONS: Bipolar disorder patients have significantly higher prevalence of
personality disorder than the general population. Several studies reviewed
indicate a higher prevalence of Axis II disorders in bipolar patients with
unstable mood. However, this finding was not confirmed in comparison of inpatient
and outpatient comorbidity rates. Bipolar patients with personality
psychopathology have poorer response to medications and a more virulent course of

PMID: 19026249 [PubMed – indexed for MEDLINE] ———-
J Psychiatr Res. 2008 Sep;42(11):920-9. Epub 2007 Dec 21.

Hypomanic, cyclothymic and hostile personality traits in bipolar spectrum
illness: a family-based study.

Savitz J, van der Merwe L, Ramesar R.

Division of Human Genetics, Institute of Infectious Disease and Molecular
Medicine, University of Cape Town, South Africa.

OBJECTIVES: To examine hypomanic, cyclothymic and hostile personality traits in a
large, euthymic, family-based group of individuals with bipolar disorder (BPD)
and their affectively ill and healthy relatives. To test whether these traits
follow a distribution with the most “pathological” scores in the bipolar disorder
I (BPD I) group and the least “pathological” scores in the unaffected relatives.
METHODS: Two-hundred and ninety-six individuals from 47 bipolar disorder families
were administered a battery of personality questionnaires (Temperament Evaluation
of Memphis, Pisa, Paris, and San Diego; Temperament and Character Inventory;
Affective Neuroscience Personality Scale; Hypomanic Personality Scale; Borderline
Traits Questionnaire) as well as a self-rating depression (Beck Depression
Inventory) and mania (Altman Self-Rating Mania) scale. Out of the 296
participants, 57 were diagnosed with BPD I, 24 with bipolar disorder II (BPD II),
58 with recurrent major depression (MDE-R), 45 had one previous depressive
episode (MDE-S), and 86 were unaffected. Twenty six individuals had another
DSM-IV diagnosis.
RESULTS: The BPD I group displayed elevated hypomanic, cyclothymic and hostile
traits. These traits were also characteristic of the BPD II group but were less
salient in the MDE-R group. The MDE-S group did not differ significantly from
unaffected relatives. Hypomanic personality characteristics were clearly elevated
in both BPD groups and differentiated BPD from major depressive disorder (MDD)
CONCLUSIONS: Our results provide preliminary support for the hypothesis that
temperament is a genetically quantitative trait.

PMID: 18082182 [PubMed – indexed for MEDLINE] ———-
Psychiatr Serv. 2008 Sep;59(9):1038-45.

Psychiatric rehospitalization among elderly persons in the United States.

Prince JD, Akincigil A, Kalay E, Walkup JT, Hoover DR, Lucas J, Bowblis J,
Crystal S.

School of Social Work, Rutgers University, 536 George St., New Brunswick, NJ
08901-1167, USA.

OBJECTIVE: This study examined predictors of psychiatric rehospitalization among
elderly persons.
METHODS: Readmission within six months of an index hospitalization was modeled by
using Medicare data on all hospitalizations with a primary psychiatric diagnosis
in the first half of 2002 (N=41,839). Data were linked with state and
community-level information from the U.S. census.
RESULTS: Twenty-two percent of beneficiaries were rehospitalized for psychiatric
reasons within six months of discharge. After the analyses adjusted for
sociodemographic factors, readmission was most likely among persons with a
primary diagnosis of schizophrenia (hazard ratio [HR]=2.63), followed by bipolar
disorder (HR=2.51), depression (HR=1.75), and substance abuse (HR=1.38)
(reference group was “other” psychiatric conditions). A baseline hospital stay of
five or more days for an affective disorder was associated with a reduced
readmission hazard (HR=.68, relative to shorter stays), yet the opposite was true
for a nonaffective disorder (HR=1.26). For persons with nonaffective disorders,
an elevated hazard of readmission was associated with comorbid alcohol dependence
(HR=1.32), panic disorder (HR=1.76), borderline personality disorder (HR=2.33),
and drug dependence (HR=1.17). However, for persons with affective disorders,
having a personality disorder other than borderline personality disorder or
dependent personality disorder (HR=1.27) and having an “other” anxiety disorder
(HR=1.15) were significantly associated with an increased risk of
rehospitalization. Obsessive-compulsive disorder increased the readmission hazard
in both groups.
CONCLUSIONS: Readmission risk factors may differ for affective disorders and
nonaffective disorders. Very short hospitalizations were associated with
increased risk of rehospitalization among persons with an affective disorder,
which underscores the need for adequate stabilization of this group of patients
during hospitalization. Results also highlight the specific types of
comorbidities associated most strongly with rehospitalization risk.

PMID: 18757598 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2006 Feb;8(1):1-14.

Affective instability as rapid cycling: theoretical and clinical implications
for borderline personality and bipolar spectrum disorders.

Mackinnon DF, Pies R.

Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University
School of Medicine, Baltimore, MD, USA.

Objectives: The Diagnostic and Statistical Manual of Mental Disorders guidelines
provide only a partial solution to the nosology and treatment of bipolar
disorder in that disorders with common symptoms and biological correlates may be
categorized separately because of superficial differences related to behavior,
life history, and temperament. The relationship is explored between extremely
rapid switching forms of bipolar disorder, in which manic and depressive
symptoms are either mixed or switch rapidly, and forms of borderline personality
disorder in which affective lability is a prominent symptom. Methods: A MedLine
search was conducted of articles that focused on rapid cycling in bipolar
disorder, emphasizing recent publications (2001-2004). Results: Studies examined
here suggest a number of points of phenomenological and biological overlap
between the affective lability criterion of borderline personality disorder and
the extremely rapid cycling bipolar disorders. We propose a model for the
development of ‘borderline’ behaviors on the basis of unstable mood states that
sheds light on how the psychological and somatic interventions may be aimed at
‘breaking the cycle’ of borderline personality disorder development. A review of
pharmacologic studies suggests that anticonvulsants may have similar stabilizing
effects in both borderline personality disorder and rapid cycling bipolar
disorder. Conclusions: The same mechanism may drive both the rapid mood
switching in some forms of bipolar disorder and the affective instability of
borderline personality disorder and may even be rooted in the same genetic
etiology. While continued clinical investigation of the use of anticonvulsants
in borderline personality disorder is needed, anticonvulsants may be useful in
the treatment of this condition, combined with appropriate psychotherapy.

PMID: 16411976 [PubMed – in process] ———-
J Affect Disord. 2005 Jul;87(1):17-23.

Borderline personality disorder characteristics in young adults with recurrent
mood disorders: a comparison of bipolar and unipolar depression.

Smith DJ, Muir WJ, Blackwood DH.

Division of Psychiatry, School of Molecular and Clinical Medicine, University of
Edinburgh, Royal Edinburgh Hospital, Morningside Park, Edinburgh EH10 5HF, UK.

BACKGROUND: In young adults it can be difficult to differentiate between an
early bipolar illness and borderline personality disorder. There are
considerable areas of clinical overlap between cyclothymic temperament,
bipolar-spectrum disorders and borderline characteristics. The aim of this study
was to measure borderline characteristics in young adults during an index
depressive episode and to compare three diagnostic groups: DSM-IV bipolar
affective disorder (BPAD); bipolar spectrum disorder (BSD); and DSM-IV recurrent
major depressive disorder (MDD). METHODS: Eighty-seven young adults with a
current episode of major depression and at least one previous episode of
depression were recruited from consecutive referrals to a psychiatric clinic.
Diagnoses were based on the Structured Clinical Interview for DSM-IV (SCID-1)
and recently proposed structured diagnostic criteria for BSD. All patients also
completed the borderline questions from the screening questionnaire of the
International Personality Disorders Examination (IPDE). RESULTS: Diagnostically,
the cohort of 87 patients divided into three groups: 14 with BPAD; 27 with BSD;
and 46 with MDD. None of the subjects fulfilled DSM-IV or ICD-10 diagnostic
criteria for personality disorder and all three groups were well matched in
terms of age, gender distribution, ethnicity, socioeconomic and educational
status, age at onset of illness, and severity of index depressive episode. Both
of the bipolar-depressed groups reported significantly higher median levels of
borderline characteristics than the MDD group (p<0.0001). Three of the
borderline characteristics emerged as potentially useful in differentiating
bipolar depression from unipolar depression: ‘I’ve never threatened suicide or
injured myself on purpose’ (sensitivity=0.93; positive predictive value
[PPV]=56.7); ‘I have tantrums or angry outbursts’ (sensitivity 0.66; PPV=65.6%);
and ‘Giving in to some of my urges gets me into trouble’ (sensitivity=0.76;
PPV=59.6%). LIMITATIONS: All of the subjects were recruited from a university
health service clinic and as such are unlikely to be representative of patients
from more diverse socio-economic backgrounds. No structured diagnostic
assessment of personality disorder was administered. The diagnostic criteria for
BSD are not yet fully validated. CONCLUSIONS: Young adults with bipolar
depression exhibit significantly higher levels of borderline personality
pathology than those with unipolar depression. Those borderline screening
questions that reflect cyclothymic characteristics or depressive mixed states
may be of practical use to clinicians in helping to differentiate between
bipolar depression and unipolar depression in young adults.

PMID: 15967232 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2005 Apr;7(2):192-7.

Acute treatment outcomes in patients with bipolar I disorder and co-morbid
borderline personality disorder receiving medication and psychotherapy.

Swartz HA, Pilkonis PA, Frank E, Proietti JM, Scott J.

Department of Psychiatry, University of Pittsburgh School of Medicine, Western
Psychiatric Institute and Clinic, Pittsburgh, PA 15213, USA.

OBJECTIVE: Patients suffering from both bipolar I disorder and borderline
personality disorder (BPD) pose unique treatment challenges. The purpose of this
matched case-control study was to compare acute treatment outcomes of a sample
of patients who met standardized diagnostic criteria for both bipolar I disorder
and BPD (n = 12) to those who met criteria for bipolar I disorder only (n = 58).
METHOD: Subjects meeting criteria for an acute affective episode were treated
with a combination of algorithm-driven pharmacotherapy and weekly psychotherapy
until stabilization (defined as four consecutive weeks with a calculated average
of the 17-item version of the Hamilton Rating Scale for Depression and
Bech-Rafaelsen Mania scale totaling < or = 7). RESULTS: Only three of 12 (25%)
bipolar-BPD patients achieved stabilization, compared with 43 of 58 (74%)
bipolar-only patients. Two of the three bipolar-BPD patients who did stabilize
took over 95 weeks to do so, compared with a median time-to-stabilization of 35
weeks in the bipolar-only group. The bipolar-BPD group received significantly
more atypical mood-stabilizing medications per year than the bipolar-only group
(Z = 4.3, p < 0.0001). Dropout rates in the comorbid group were high.
CONCLUSIONS: This quasi-experimental study suggests that treatment course may be
longer in patients suffering from both bipolar I disorder and BPD. Some patients
improved substantially with pharmacotherapy and psychotherapy, suggesting that
this approach is worthy of further investigation.

PMID: 15762861 [PubMed – indexed for MEDLINE] ———-
Psychosom Med. 2005 Jan-Feb;67(1):1-8.

Psychiatric and medical comorbidities of bipolar disorder.

Krishnan KR.

Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
(3050A), 4584 Hospital South, Box 3950, Durham, NC 27710, USA.

OBJECTIVES: This review summarizes the literature on psychiatric and medical
comorbidities in bipolar disorder. The coexistence of other Axis I disorders
with bipolar disorder complicates psychiatric diagnosis and treatment.
Conversely, symptom overlap in DSM-IV diagnoses hinders definition and
recognition of true comorbidity. Psychiatric comorbidity is often associated
with earlier onset of bipolar symptoms, more severe course, poorer treatment
compliance, and worse outcomes related to suicide and other complications.
Medical comorbidity may be exacerbated or caused by pharmacotherapy of bipolar
symptoms. METHODS: Articles were obtained by searching MEDLINE from 1970 to
present with the following search words: bipolar disorder AND, comorbidity,
anxiety disorders, eating disorder, alcohol abuse, substance abuse, ADHD,
personality disorders, borderline personality disorder, medical disorders,
hypothyroidism, obesity, diabetes mellitus, multiple sclerosis, lithium,
valproate, lamotrigine, carbamazepine, atypical antipsychotics. Articles were
prioritized for inclusion based on the following considerations: sample size,
use of standardized diagnostic criteria and validated methods of assessment,
sequencing of disorders, quality of presentation. RESULTS: Although the
literature establishes a strong association between bipolar disorder and
substance abuse, the direction of causality is uncertain. An association is also
seen with anxiety disorders, attention-deficit/hyperactivity disorder, and
eating disorders, as well as cyclothymia and other axis II personality
disorders. Medical disorders accompany bipolar disorder at rates greater than
predicted by chance. However, it is often unclear whether a medical disorder is
truly comorbid, a consequence of treatment, or a combination of both.
CONCLUSION: To ensure prompt, appropriate intervention while avoiding iatrogenic
complications, the clinician must evaluate and monitor patients with bipolar
disorder for the presence and the development of comorbid psychiatric and
medical conditions. Conversely, physicians should have a high index of suspicion
for underlying bipolar disorder when evaluating individuals with other
psychiatric diagnoses (not just unipolar depression) that often coexist with
bipolar disorder, such as alcohol and substance abuse or anxiety disorders.
Anticonvulsants and other mood stabilizers may be especially helpful in treating
bipolar disorder with significant comorbidity.

Publication Types:

PMID: 15673617 [PubMed – in process] ———-
Can J Psychiatry. 2004 Aug;49(8):551-6.

The boundary between borderline personality disorder and bipolar disorder:
current concepts and challenges.

Magill CA.

Department of Psychiatry, McGill University, Montreal, Quebec.

OBJECTIVE: The boundary between borderline personality disorder (BPD) and
bipolar disorder (BD) is a controversial subject. Clinically, it can be
difficult to diagnose patients who present with both affective instability and
impulsivity. This paper reviews concepts and challenges related to the overlap
of these disorders. METHODS: A Medline search was conducted, using the key words
borderline personality disorder, bipolar disorder, affective disorder, and
personality disorder. Reference lists from articles generated were also used.
Publications from the last 20 years were considered. RESULTS: Studies
demonstrate a greater cooccurrence between these 2 disorders than between BPD
and other Axis I disorders or between BD and other Axis II disorders. Some
authors suggest that many patients diagnosed with BPD are better described as
having BD, that the bipolar classification is too narrow, or that BPD should be
considered a variant of affective disorders. Others present evidence supporting
BPD as a valid construct. Hypotheses about the relation between the 2 disorders
and suggestions for clinical practice are offered. CONCLUSIONS: There appears to
be sufficient evidence to consider BPD to be a valid diagnosis. Both disorders
apply to heterogeneous populations, and their characteristics require further
clarification. In diagnostically challenging situations, careful consideration
of a patient’s longitudinal history is essential. Future research will be
important to ensure that our diagnostic classifications reflect clinically
useful entities.

Publication Types:

PMID: 15453104 [PubMed – indexed for MEDLINE] ———-
Harv Rev Psychiatry. 2004 May-Jun;12(3):140-5.

Comment in:
Harv Rev Psychiatry. 2004 May-Jun;12(3):146-9.

Borderline or bipolar? Distinguishing borderline personality disorder from
bipolar spectrum disorders.

Paris J.

Department of Psychiatry, McGill University, Institute of Community and Family
Psychiatry, Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec,

This article addresses the question whether borderline personality disorder
(BPD) can be understood as a variant of bipolar disorder. In the past,
borderline pathology has been seen as a variant of psychosis, depression, or
posttraumatic stress disorder, but there are important differences between all
of these conditions and BPD. The proposal that BPD falls within the bipolar
spectrum depends on the assumption that affective instability develops through
the same mechanism in both diagnostic categories. There are major differences in
phenomenology, family history, longitudinal course, and treatment response
between BPD and bipolar disorder, and the findings of comorbidity studies are
equivocal. Thus, existing evidence is insufficient to support the concept that
BPD falls in the bipolar spectrum.

Publication Types:

PMID: 15371068 [PubMed – indexed for MEDLINE] ———-
Harv Rev Psychiatry. 2004 May-Jun;12(3):133-9.

Comment in:
Harv Rev Psychiatry. 2004 May-Jun;12(3):146-9.

Is borderline personality disorder part of the bipolar spectrum?

Smith DJ, Muir WJ, Blackwood DH.

Division of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital,
Edinburgh, Scotland.

In recent years, advances in the areas of both bipolar and borderline
personality disorders have generated considerable interest in the clinical
interface between these two conditions. Developments in the study of the
neurobiology of borderline personality disorder suggest that many patients with
this diagnosis have etiological features in common with those diagnosed with
bipolar disorders. This claim is supported by new insights into the
phenomenology of both disorders and by evidence that mood stabilizers are
efficacious in the pharmacological management of borderline patients. This area
of research is an important one because of the considerable morbidity and public
health costs associated with borderline personality disorder. Since borderline
patients can be so challenging to care for, it may be that a reframing of the
disorder as belonging to the broad clinical spectrum of bipolar disorders holds
benefits for patients and clinicians alike.

Publication Types:

PMID: 15371067 [PubMed – indexed for MEDLINE] ———
J Affect Disord. 2004 Apr;79(1-3):297-303.

Borderline personality disorder in patients with bipolar disorder and response
to lamotrigine.

Preston GA, Marchant BK, Reimherr FW, Strong RE, Hedges DW.

Department of Psychiatry, Mood Disorders Clinic, University of Utah School of
Medicine, Salt Lake City, UT, USA.

BACKGROUND: Recent reports suggesting lamotrigine as an effective treatment in
bipolar disorder, and perhaps borderline personality disorder, a common comorbid
personality disorder in bipolar patients, led us to retrospectively examine
patients from two bipolar studies to investigate this pattern of comorbidity,
and to determine whether lamotrigine effected the dimensions of borderline
personality. Methods: Fifteen months following entry into either study, we
retrospectively assessed DSM-IV dimensions of borderline personality disorder
pre- and post-treatment with lamotrigine in 35 bipolar patients. RESULTS: Forty
percent met criteria for borderline personality disorder; this subgroup had a
more frequent history of substance abuse and childhood symptoms of attention
deficit hyperactivity disorder (ADHD). Dimensions of borderline personality
improved significantly with treatment in both patient groups, and corresponded
with response of bipolar symptoms. Six (43%) comorbid bipolar patients endorsed
three or fewer criteria of borderline personality during treatment with
lamotrigine. There was a trend for comorbid bipolar patients to require a second
psychoactive medication in addition to lamotrigine during extended treatment.
LIMITATIONS: Criteria for borderline personality and improvement were assessed
retrospectively in an open manner. CONCLUSIONS: Dimensions of borderline
personality disorder may respond to lamotrigine in comorbid bipolar patients;
controlled studies appear warranted. Bipolar studies should assess and specify
the number of patients with personality disorders in the trial.

PMID: 15023511 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2004 Jan;65(1):104-9.

Olanzapine versus placebo in the treatment of borderline personality disorder.

Bogenschutz MP, George Nurnberg H.

Department of Psychiatry, University of New Mexico School of Medicine,
Albuquerque, NM 87131, USA.

BACKGROUND: Atypical antipsychotics are increasingly used in clinical practice
in the management of borderline personality disorder (BPD), and a small but
growing body of literature supports their efficacy. Here, we report the results
of a double-blind, placebo-controlled study of olanzapine as a treatment for
BPD. METHOD: Forty BPD patients (25 female, 15 male) were randomly assigned in
equal numbers to olanzapine and placebo. Diagnoses were made using the
Structured Clinical Interview for DSM-IV Axis II Personality Disorders and the
Mini-International Neuropsychiatric Interview. Patients with schizophrenia,
bipolar disorder, or current major depression were excluded. Olanzapine dosage
was flexible, and the dose range was 2.5 to 20 mg/day, with most patients
receiving 5 to 10 mg/day. No concomitant psychotropic medications were allowed.
Patients were assessed at baseline and at 2, 4, 8, and 12 weeks. The primary
outcome was change in the total score for the 9 BPD criteria on a 1-to-7 Likert
scale, the Clinical Global Impressions scale modified for borderline personality
disorder (CGI-BPD), using an analysis of covariance model including baseline
score as covariate. Data were collected from July 2000 to April 2002. RESULTS:
Olanzapine was found to be significantly (p <.05) superior to placebo on the
CGI-BPD at endpoint, with separation occurring as early as 4 weeks. Similar
results were found for the single-item Clinical Global Impressions scale. Weight
gain was significantly (p =.027) greater in the olanzapine group. CONCLUSIONS:
This study supports the efficacy of olanzapine for symptoms of BPD in a mixed
sample of women and men. Further studies with olanzapine and other atypical
antipsychotics are needed.

Publication Types:
Clinical Trial
Randomized Controlled Trial

PMID: 14744178 [PubMed – indexed for MEDLINE] ———-
Zh Nevrol Psikhiatr Im S S Korsakova. 2004;104(8):18-23.

[Affective phases in dynamics of personality disorders (on a model of borderline
personality disorder)] [Article in Russian]

Smulevich AB, Dubnitskaia EB, Koliutskaia EV.

Affective phases developing in personality disorder (index-sample–98 patients)
were compared to those in cyclothymia (85 patients–control group). A preference
of phase dynamics in the group of abnormalities relating to ICD-10 item
“Borderline personality disorder” was confirmed. In line with a concept
considering personality disorders as clinical syndromes, patients of the
index-group have personality disorders with the signs of psychopathological
diathesis determined by vulnerability to affective disorders. Affective phases
are interpreted not only as an expression of a specific type of personality
disorders dynamics but as an emergence of affective pathology, which is
alternative to endogenous one both by modus of constitutional predisposition and
clinical parameters (egosyntonic moderating of the phase, domination of negative
affectivity in its structure, amphitymic duality of pathologically altered

PMID: 15554137 [PubMed – indexed for MEDLINE] ———-
Int J Neuropsychopharmacol. 2003 Jun;6(2):139-44.

Bipolar comorbidity: from diagnostic dilemmas to therapeutic challenge.

Sasson Y, Chopra M, Harrari E, Amitai K, Zohar J.

Chaim Sheba Medical Centre, Division of Psychiatry, Tel Hashomer, Israel.

Comorbidity in bipolar disorder is the rule rather than the exception more than
60% of bipolar patients have a comorbid diagnosis and is associated with a mixed
affective or dysphoric state; high rates of suicidality; less favourable
response to lithium and poorer overall outcome. There is convincing evidence
that rates of substance use and anxiety disorders are higher among patients with
bipolar disorder compared to their rates in the general population. The
interaction between anxiety disorders and substance use goes both ways: patients
with bipolar disorder have a higher rate of substance use and anxiety disorder,
and vice versa. Bipolar disorder is also associated with borderline personality
disorder and ADHD, and to a lesser extent with weight gain. As more than 40% of
bipolar patients have anxiety disorder, it is indicated that while diagnosing
bipolar patients, systematic enquiry about different anxiety disorders is called
for. This also presents a therapeutic challenge, since agents that effectively
treat anxiety disorders are associated with the risk of induced mania.
Therefore, the treating psychiatrist needs to carefully evaluate the potential
benefit of treating the anxiety against the potential cost of inducing a manic
episode. A possible solution would be to use, when possible, a
non-pharmacological intervention, such as a cognitivebehavioural approach.
Alternately, it is suggested that the clinician attempts to ensure that the
patient receives adequate treatment with mood stabilizers before slowly and
carefully attempting the addition of anti-anxiety compounds with a relatively
lower risk of mania induction (e.g. SSRIs compared to TCAs).

PMID: 12890307 [PubMed – indexed for MEDLINE] ———-
J Affect Disord 2003 Jan;73(1-2):49-57

Bipolar II with and without cyclothymic temperament: “dark” and “sunny”
expressions of soft bipolarity.

Akiskal HS, Hantouche EG, Allilaire JF.

International Mood Center, UCSD Department of Psychiatry, 9500 Gilman Drive, La
Jolla, 92093-0603, San Diego, CA, USA

BACKGROUND: In the present report deriving from the French national multi-site
EPIDEP study, we focus on the characteristics of Bipolar II (BP-II), divided on
the basis of cyclothymic temperament (CT). In our companion article (, this
issue), we found that this temperament in its self-rated version correlated
significantly with hypomanic behavior of a risk-taking nature. Our aim in the
present analyses is to further test the hypothesis that such patients-assigned
to CT on the basis of clinical interview-represent a more “unstable” variant of
BP-II. METHODS: From a total major depressive population of 537 psychiatric
patients, 493 were re-examined on average a month later; after excluding 256
DSM-IV MDD and 41 with history of mania, the remaining 196 were placed in the
BP-II spectrum. As mounting international evidence indicates that hypomania
associated with antidepressants belongs to this spectrum, such association per
se did not constitute a ground for exclusion. CT was assessed by clinicians
using a semi-structured interview based on in its French version; as two files
did not contain full interview data on CT, the critical clinical variable in the
present analyses, this left us with an analysis sample of 194 BP-II.
Socio-demographic, psychometric, clinical, familial and historical parameters
were compared between BP-II subdivided by CT. Psychometric measures included
self-rated CT and hypomania scales, as well as Hamilton and Rosenthal scales for
depression. RESULTS: BP-II cases categorically assigned to CT (n=74) versus
those without CT (n=120), were differentiated as follows: (1) younger age at
onset (P=0.005) and age at seeking help (P=0.05); (2) higher scores on HAM-D
(P=0.03) and Rosenthal (atypical depressive) scale (P=0.007); (3) longer delay
between onset of illness and recognition of bipolarity (P=0.0002); (4) higher
rate of psychiatric comorbidity (P=0.04); (5) different profiles on axis II
(i.e., more histrionic, passive-aggressive and less obsessive-compulsive
personality disorders). Family history for depressive and bipolar disorders did
not significantly distinguish the two groups; however, chronic affective
syndromes were significantly higher in BP-II with CT. Finally, cyclothymic BP-II
scored significantly much higher on irritable-risk-taking than “classic”
driven-euphoric items of hypomania. CONCLUSION: Depressions arising from a
cyclothymic temperament-even when meeting full criteria for hypomania-are likely
to be misdiagnosed as personality disorders. Their high familial load for
affective disorders (including that for bipolar disorder) validate the bipolar
nature of these “cyclothymic depressions.” Our data support their inclusion as a
more “unstable” variant of BP-II, which we have elsewhere termed “BP-II 1/2.”
These patients can best be characterized as the “darker” expression of the more
prototypical “sunny” BP-II phenotype. Coupled with the data from our companion
paper (, this issue), the present findings indicate that screening for
cyclothymia in major depressive patients represents a viable approach for
detecting a bipolar subtype that could otherwise be mistaken for an erratic
personality disorder. Overall, our findings support recent international
consensus in favoring the diagnosis of cyclothymic and bipolar II disorders over
erratic and borderline personality disorders when criteria for both sets of
disorders are concurrently met.

PMID: 12507737 [PubMed – in process] ———-
Psychiatr Clin North Am 2002 Dec;25(4):713-37

The soft bipolar spectrum redefined: focus on the cyclothymic, anxious-sensitive,
impulse-dyscontrol, and binge-eating connection in bipolar II and related conditions.

Perugi G, Akiskal HS.

Institute of Behavioral Sciences G. De Lisio, Viale Monzone 3, 54031 Carrara,

The bipolar II spectrum represents the most common phenotype of bipolarity.
Numerous studies indicate that in clinical settings this soft spectrum might be
as common–if not more common than–major depressive disorders. The proportion
of depressive patients who can be classified as bipolar II further increases if
the 4-day threshold for hypomania proposed by the DSM-IV is reconsidered. The
modal duration of hypomanic episodes is 2 days; highly recurrent brief hypomania
is as short as 1 day, and when complicated by major depression, it should be
classified as a variant of bipolar II. Another variant of the bipolar II pattern
is represented by major depressive episodes superimposed on cyclothymic or
hyperthymic temperamental characteristics. The literature is unanimous in
supporting the idea that depressed patients who experience hypomania during
antidepressant treatment belong to the bipolar II spectrum. So-called alcohol-
or substance-induced mood disorders may have much in common with bipolar II
spectrum disorders, in particular when mood swings outlast detoxification.
Finally, many patients within the bipolar II spectrum, especially when
recurrence is high and the interepisodic period is not free of affective
manifestations, may meet criteria for personality disorders. This is
particularly true for cyclothymic bipolar II patients, who are often
misclassified as borderline personality disorder because of their extreme mood
instability. Subthreshold mood lability of a cyclothymic nature seems to be the
common thread that links the soft bipolar spectrum. The authors submit this to
represent the endophenotype likely to be informative in genetic investigations.
Mood lability can be considered the core characteristics of the bipolar II
spectrum, and it has been validated prospectively as a sensitive and specific
predictor of bipolar II outcome in major depressives. In a more hypothetical
vein, cyclothymic-anxious-sensitive temperamental disposition might represent
the mediating underlying characteristic in the complex pattern of anxiety, mood,
and impulsive disorders that bipolar II spectrum patients display throughout
much of their lifetimes. The foregoing conclusions, based on clinical experience
and the research literature, challenge several conventions in the formal
classificatory system (i.e., ICD-10 and DSM-IV). The authors submit that the
enlargement of classical bipolar II disorders to include a spectrum of
conditions subsumed by a cyclothymic-anxious-sensitive disposition, with mood
reactivity and interpersonal sensitivity, and ranging from mood, anxiety,
impulse control, and eating disorders, will greatly enhance clinical practice
and research endeavors. Prospective studies with the requisite methodologic
sophistication are needed to clarify further the relationship of the putative
temperamental and developmental variables to the complex syndromic patterns
described herein. The authors believe that viewing these constructs as related
entities with a common temperamental diathesis will make patients in this realm
more accessible to pharmacologic and psychological approaches geared to their
common temperamental attributes. The authors submit that the use of the term
“spectrum” is distinct from a simple continuum of subthreshold and threshold
cases. The underlying temperamental dimensions postulated by the authors define
the disposition for soft bipolarity and its variation and dysregulation in
anxious disorders and dyscontrol in appetitive, mental, and behavioral
disorders, much beyond affective disorders in the narrow sense.

Publication Types:
Review, Tutorial

PMID: 12462857 [PubMed – indexed for MEDLINE] ———-
Suicide Life Threat Behav 2002 Summer;32(2):167-75

Situational determinants of inpatient self-harm.

Nijman HL, a Campo JM.

De Kijvelanden forensic psychiatric hospital, Poortugaal, The Netherlands.

Auto-aggressive individuals have a higher likelihood of engaging in
interpersonal violence, and vice versa. It is unclear, however, whether ward
circumstances are involved in determining whether aggression-prone patients will
engage in auto-aggressive or outwardly directed aggressive behavior. The current
study focuses on the situational antecedents of self-harming behavior and
outwardly directed aggression of psychiatric inpatients. Inwardly and outwardly
aggressive behavior were monitored on a locked 20-bed psychiatric admissions
ward for 3.5 years with the Staff Observation Aggression Scale-Revised (SOAS-R).
A map of the ward was attached to each SOAS-R form, enabling staff members to
specify locations of aggressive incidents. Time of onset, location, and
provoking factors of auto-aggressive incidents were compared to those connected
to aggression against others or objects. Of a total of 774 aggressive incidents,
154 (20%) concerned auto-aggressive behavior. Auto-aggression was significantly
more prevalent during the evening (i.e., 50% compared to 32%), and reached its
highest level between 8 and 9 P.M. (17% compared to 7%). The majority of
self-harming acts (66%) were performed on patients’ bedrooms. Outwardly directed
aggression was particularly common in the day-rooms (24%), the staff office
(19%), the hallways of the ward (14%), and the dining rooms (10%). Provoking
factors of auto-aggressive behavior are less often of an interactional nature
compared to outwardly directed aggression. The results suggest that a lack of
stimulation and interaction with others increases the risk of self-injurious
behavior. Practical and testable measures to prevent self-harm are proposed.

PMID: 12079033 [PubMed – indexed for MEDLINE] ———-
Can J Psychiatry 2002 Mar;47(2):195-6

Borderline personality disorder comorbidity in early- and late-onset bipolar II

Benazzi F.

Publication Types:

PMID: 11926084 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry 2002 May;63(5):442-6

Divalproex sodium treatment of women with borderline personality disorder and
bipolar II disorder: a double-blind placebo-controlled pilot study.

Frankenburg FR, Zanarini MC.

Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA
02478, USA.

BACKGROUND: The intent of this study was to compare the efficacy and safety of
divalproex sodium and placebo in the treatment of women with borderline
personality disorder and comorbid bipolar II disorder. METHOD: We conducted a
placebo-controlled double-blind study of divalproex sodium in 30 female subjects
aged 18 to 40 years who met Revised Diagnostic Interview for Borderlines and
DSM-IV criteria for borderline personality disorder and DSM-IV criteria for
bipolar II disorder. Subjects were randomly assigned to divalproex sodium or
placebo in a 2:1 manner. Treatment duration was 6 months. Primary outcome
measures were changes on the interpersonal sensitivity, anger/hostility, and
depression scales of the Symptom Checklist 90 (SCL-90) as well as the total
score of the modified Overt Aggression Scale (MOAS). RESULTS: Twenty subjects
were randomly assigned to divalproex sodium; 10 subjects to placebo. Using a
last-observation-carried-forward paradigm and controlling for baseline severity,
divalproex sodium proved to be superior to placebo in diminishing interpersonal
sensitivity and anger/hostility as measured by the SCL-90 as well as overall
aggression as measured by the MOAS. Adverse effects were infrequent. CONCLUSION:
The results of this study suggest that divalproex sodium may be a safe and
effective agent in the treatment of women with criteria-defined borderline
personality disorder and comorbid bipolar II disorder, significantly decreasing
their irritability and anger, the tempestuousness of their relationships, and
their impulsive aggressiveness.

PMID: 12019669
Can J Psychiatry 2002 Mar;47(2):195-6

Borderline personality disorder comorbidity in early- and late-onset bipolar II

Benazzi F.

Publication Types:

PMID: 11926084
J Affect Disord 2001 Dec;67(1-3):221-8

Do patients with borderline personality disorder belong to the bipolar spectrum?

Deltito J, Martin L, Riefkohl J, Austria B, Kissilenko A, Corless C Morse P.

Anxiety and Mood Disorders Program, The New York Hospital-Cornell Medical
Center, Westchester Division, USA.

BACKGROUND: This report examines clinical indicators for bipolarity in a cohort
of patients suffering from Borderline Personality Disorder (BPD). METHODS: The
study was conducted in the Cornell-Westchester Hospital, famed for its expertise
in BPD. To avoid biasing our sample, we excluded all BPD patients who were
active patients in our anxiety and mood disorders program. Through the use of
both open clinical interviews and standardized diagnostic interviews (SCID),
borderline patients were examined for evidence of bipolarity by five indicators:
history of spontaneous mania, history of spontaneous hypomania, bipolar
temperaments, pharmacologic response typical of bipolar disorder, and a positive
bipolar family history. RESULTS: Depending on the level of bipolar disorder from
the most rigorous (mania) to the most ‘soft’ (bipolar family history), between
13 and 81% of borderline patients showed signs of bipolarity. Based on what the
emerging literature supports as rigorously defined bipolar spectrum (bipolar I
and II), we submit that at least 44% of BPD belong to this spectrum; adding
hypomanic switches during antidepressant pharmacotherapy, the rate of bipolarity
in BPD reaches 69%. As expected from this formulation, most responded negatively
to antidepressants (e.g. hostility and agitation) and positively to mood
stabilizers. LIMITATIONS: Small sample size and retrospective gathering of data
on treatment response. CCONCLUSION: Patients with BPD more often than not
exhibit clinically ascertainable evidence for bipolarity and may benefit from
known treatments for Bipolar Spectrum Disorders. Large scale, systematic
treatment studies with mood stabilizers are indicated.

PMID: 11869772
J Psychiatr Res 2001 Nov-Dec;35(6):307-12

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

Henry C, Mitropoulou V, New AS, Koenigsberg HW, Silverman J, Siever LJ.

Service Universitaire de Psychiatrie, Centre Hospitalier Charles Perrens, 121
rue de la Bechade, 33076, Bordeaux, France.

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.

PMID: 11684137
Encephale 2001 Mar-Apr;27(2):120-7

[Symptoms of DSM IV borderline personality disorder in a nonclinical population
of adolescents: study of a series of 35 patients] [Article in French]

Chabrol H, Chouicha K, Montovany A, Callahan S.

Centre d’Etude et de Recherche en Psychopathologie, Universite de Toulouse-Le
Mirail, 5, allee Antonio Machado, 31058 Toulouse.

1,363 high school students were solicited to complete a personality disorder
questionnaire and were encouraged to continue in the study by signing up for
interviews with Master’s level psychology students. 107 students (7.8%, 34
males, 73 females, mean age = 16.7 +/- 1.8) manifested themselves for the
interview and were assessed by using structured diagnostic interviews for
borderline personality disorder and major depressive disorder (DIB-R, Revised
Diagnostic Interview for Borderlines; MINI, Mini International Neuropsychiatric
Interview). The interviews were audiotaped. Interrater reliability was
determined by independent ratings of 12 borderline subjects and 12
non-borderline subjects (kappa: 0.795). The distribution of the 107 subjects
based on the number of DSM IV borderline personality disorder criteria indicated
a gradual dispersion suggesting a continuum from normality to borderline
personality disorder: 8% of the subjects met none of the criteria; 16% met one
criterion; 17% met two; 12.5%, three; 13.7%, four; 8.4%, five; 5.6%, six; 9.3%,
seven; 4.6%, eight; 4.6%, nine. Thirty-five of these 107 subjects (32.7%, 6
males, 29 females, mean age = 16.7 +/- 1.7) received a diagnosis of borderline
personality disorder according to DSM IV criteria. The most frequent symptoms
were paranoid ideation or dissociative symptoms (97.1%), affective instability
(88.6%), inappropriate, intense anger (85.6%), suicidal gestures or
automutilation (82.9%), followed by frantic efforts to avoid abandonment (77%),
impulsivity (65.7%), unstable and intense relationships (62.9%), identity
disturbance (60%), and emptiness (57.1%). The comparison between borderline and
non-borderline subjects showed that all borderline personality disorder criteria
discriminated significantly between the two groups. The high incidence of
paranoid ideation (97.1%) and dissociative experiences (65.7%) in the borderline
group suggests the pertinence of criterion 9 in the diagnosis of borderline
personality disorder in adolescents. Two criteria of schizotypal personality
disorder were also frequent in this group: 68.6% of the borderline group
reported odd beliefs or magical thinking, in particular beliefs in clairvoyance
or telepathy and 88.6% reported unusual perceptual experiences, in particular
sensing the presence of a force or person and bodily illusions. Moreover, 31.4%
of the borderline group reported transient “quasi” psychotic experiences, mainly
“quasi” visual hallucinations. Auditory hallucinations or delusional ideas were
not observed. This symptomatology suggests a “quasi” psychotic dimension of
adolescent borderline personality disorder. Affective instability was the next
most frequent symptom which was usually marked by a cyclothymic appearance.
Comorbidity with major depressive disorder was high: 85.7% of the borderline
subjects had a concurrent diagnosis of major depression versus 45.8% of the
non-borderline subjects. Thus, major depression is more frequent than most of
the borderline personality disorder criteria, with the exception of the already
noted paranoid ideation and affective instability. Hypomanic symptoms were
frequent in the borderline group (65.7%) as well as in the non-borderline group
(38.8%). This symptomatology suggests that adolescent borderline personality
disorder is linked to an attenuated bipolar spectrum characterised by major
depressive episodes and soft signs of bipolarity. However, hypomanic symptoms,
which were quite frequent in non-borderline subjects, might also be due to a
mechanism of defence, i.e. the denial of depression. Comorbidity with anxiety
disorders appeared also to be high: anxiety symptoms were found in 91.4% of the
borderline subjects who reported symptoms of generalised anxiety disorder, panic
disorder, and somatoform disorders. The overall clinical appearance of these
borderline adolescents not referred for treatment seemed to be quite similar to
that of borderline adolescents in clinical samples. This study shows that
adolescent borderline personality disorder in non-clinical population is a
serious disorder characterised by the importance of mental suffering and
behavioural disturbances the disorganising power of which may fix the
developmental process in a pathological pathway. Adolescent borderline
personality disorder appears in this study to be strongly associated with major
depressive disorder and at-risk behaviours linked to impulsivity, affective
instability, and suicidal ideation. However, this study found an absence of
precise cut-off between borderline and non-borderline subjects. Two factors
might have contributed to the appearance of a continuum. First, some degree of
impulsivity and instability in affectivity, self-images and interpersonal
relationships is part of normal adolescence. (ABSTRACT TRUNCATED)

PMID: 11407263
Bipolar Disord 2000 Sep;2(3 Pt 2):281-93

Bipolar disorder during adolescence and young adulthood in a community sample.

Lewinsohn PM, Klein DN, Seeley JR.

Oregon Reserch Institute, Eugene, 97403-1983, USA.

OBJECTIVES: To compare the incidence and prevalence of bipolar disorder (BD)
between adolescence and young adulthood; to explore the stability and
consequences of adolescent BD in young adulthood; to determine the rate of
switching from major depressive disorder (MDD) to BD; and to evaluate the
significance of subsyndromal BD (SUB). METHODS: A large, randomly selected
community sample (n = 1,507) received diagnostic assessments twice during
adolescence, and a stratified subset (n = 893) was assessed again at 24 years of
age. In addition, direct interviews were conducted with all available
first-degree relatives. Five mutually exclusive groups, based on diagnoses in
adolescence, were compared: BD (n = 17), SUB (n = 48), MDD (n = 275), disruptive
behavior disorder (n = 49), and no-disorder (ND) controls (n = 307). RESULTS:
Lifetime prevalence of BD was approximately 1% during adolescence and 2%, during
young adulthood. Lifetime prevalence for SUB was approximately 5%. Less than 1%,
of adolescents with MDD ‘switched’ to BD by age 24. Adolescents with BD had an
elevated incidence of BD from 19 to 23 years, while adolescents with SUB
exhibited elevated rates of MDD and anxiety disorders in young adulthood. BD and
SUB groups both had elevated rates of antisocial symptoms and borderline
personality symptoms. Compared to the ND group, adolescents with BD and SUB both
showed significant impairment in psychosocial functioning and had higher
mental-health treatment utilization at age 24 years of age. The relatives of
adolescents with BD and SUB had elevated rates of MDD and anxiety disorders. The
relatives of SUB probands had elevated BD, while the relatives of BD had
elevated rates of SUB and borderline symptoms. CONCLUSIONS: Adolescent BD showed
significant continuity across developmental periods and was associated with
adverse outcomes during young adulthood. Adolescent SUB was also associated with
adverse outcomes in young adulthood, but was not associated with an increased
incidence of BD. Due to high rates of comorbidity with other disorders,
definitive conclusions regarding the specific clinical significance of SUB must
await studies with larger numbers of ‘pure’ SUB cases.

PMID: 11249806
Am J Psychiatry 2001 Feb;158(2):295-302

Treatment utilization by patients with personality disorders.

Bender DS, Dolan RT, Skodol AE, Sanislow CA, Dyck IR, McGlashan TH, Shea MT,
Zanarini MC, Oldham JM, Gunderson JG.

Department of Psychiatry and Human Behavior, Brown University, Providence, RI,

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.

PMID: 11156814
J Abnorm Psychol 2000 May;109(2):222-6

A longitudinal study of high scorers on the hypomanic personality scale.

Kwapil TR, Miller MB, Zinser MC, Chapman LJ, Chapman J, Eckblad M.

Department of Psychology, University of Wisconsin-Madison, USA.

Former college students (n = 36) identified by high scores on the Hypomanic
Personality Scale (HYP; Eckblad & Chapman, 1986) were compared with control
participants (n = 31) at a 13-year follow-up assessment. As hypothesized, the
HYP group reported more bipolar disorders and major depressive episodes than the
control group. The HYP group also exceeded the control group on the severity of
psychotic-like experiences, symptoms of borderline personality disorder, and
rates of substance use disorders. HYP group members with elevated scores on the
Impulsive-Nonconformity Scale (Chapman et al., 1984) experienced greater rates
of bipolar mood disorders, poorer overall adjustment, and higher rates of arrest
than the remaining HYP or control participants.

PMID: 10895560
Compr Psychiatry 2000 Mar-Apr;41(2):106-10

Borderline personality disorder and bipolar II disorder in private practice
depressed outpatients.

Benazzi F.

Department of Psychiatry, Public Hospital Morgagni, Forli, Italy.

Bipolar II disorder (BDII) may be confused with borderline personality disorder
(BPD) when it is cyclothymic between episodes. The aim of the present study was
to determine the prevalence of BPD and to test whether BDII can be distinguished
from BPD without difficulty in private practice mood disorder outpatients.
Private practice was chosen because it is often the first or second line of
treatment of mood disorders in Italy, and many “soft” patients can be found in
this setting. Among 63 consecutive unipolar and 50 bipolar II major depressive
episode (MDE) outpatients interviewed with the Structured Clinical Interviews
for DSM-IV axis I/II disorders (SCIDs), the prevalence of BPD was 6.1% and was
significantly higher in BDII patients (12% v. 1.5%). Overall, the rate of BPD
diagnosis was very low. BDII was distinguished from BPD without difficulty by
DSM-IV criteria. The results suggest that there may be a subgroup of BDII
patients with a relatively stable course between episodes (or at least not so
unstable as to suggest a BPD diagnosis or comorbidity) and a low comorbidity
with BPD, in a setting closer to community patients than university settings.
The “usual” BDII patient can be distinguished from the BPD patient.

PMID: 10741888
Compr Psychiatry 1999 Jul-Aug;40(4):245-52

Axis I diagnostic comorbidity and borderline personality disorder.

Zimmerman M, Mattia JI.

Department of Psychiatry and Human Behavior, Brown University School of
Medicine, Rhode Island Hospital, Providence, USA.

Borderline personality disorder (PD) has been the most studied PD. Research has
examined the relationship between borderline PD and most axis I diagnostic
classes such as eating disorders, mood disorders, and substance use disorders.
However, there is little information regarding the relationship of borderline PD
and overall comorbidity with all classes of axis I disorders assessed
simultaneously. In the present study, 409 patients were evaluated with
semistructured diagnostic interviews for axis I and axis II disorders. Patients
with a diagnosis of borderline PD versus those who did not receive the diagnosis
were assigned significantly more current axis I diagnoses (3.4 v 2.0).
Borderline PD patients were twice as likely to receive a diagnosis of three or
more current axis I disorders (69.5% v 31.1%) and nearly four times as likely to
have a diagnosis of four or more disorders 147.5% v 13.7%). In comparison to
nonborderline PD patients, borderline PD patients more frequently received a
diagnosis of current major depressive disorder (MDD), bipolar I and II disorder,
panic disorder with agoraphobia, social and specific phobia, posttraumatic
stress disorder (PTSD), obsessive-compulsive disorder (OCD), eating disorder
NOS, and any somatoform disorder. Similar results were observed for lifetime
diagnoses. Overall, borderline PD patients were more likely to have multiple
axis I disorders than nonborderline PD patients, and the differences between the
two groups were present across mood, anxiety, substance use, eating, and
somatoform disorder categories. These findings highlight the importance of
performing thorough evaluations of axis I pathology in patients with borderline
PD in order not to overlook syndromes that are potentially treatment-responsive.

PMID: 10428182
J Nerv Ment Dis 1999 May;187(5):313-5

Borderline personality disorder and bipolar mood disorder: two distinct
disorders or a continuum?

Atre-Vaidya N, Hussain SM.

Department of Psychiatry and Behavioral Sciences, Finch University of Health
Sciences/The Chicago Medical School, North Chicago, Illinois 60064, USA.

PMID: 10348089
J Affect Disord 1998 Dec;51(3):333-43

Lamotrigine as a promising approach to borderline personality: an open case
series without concurrent DSM-IV major mood disorder.

Pinto OC, Akiskal HS.

International Mood Center, University of California at San Diego, La Jolla
92093-0603, USA.

BACKGROUND: Borderline personality disorder (BPD) has long defined definitive
treatment. Such failure is reflected in repeated suicidal crises, often
associated with dysphoric symptoms of a chronic fluctuating nature, whose labile
intermittent character does suggest a subthreshold bipolar depressive mixed
state. For all these reasons, we hypothesized that the anticonvulsant
lamotrigine, touted to be a mood stabilizer with antidepressant properties,
might be uniquely beneficial for these patients. METHODS: From a base rate of
about 300 patients in a community mental health center, we identified eight
patients meeting seven or more of the DSM-IV criteria for BPD without concurrent
major mood disorders. All patients presented with history of severe suicidal
behavior, hostile depression and/or labile moods, stimulant and alcohol abuse,
as well as multiple unprotected sexual encounters; one patient was actually HIV
positive. All had failed previous trials with different antidepressants and mood
stabilizers. All current medications were gradually withdrawn–and when
necessary–patients kept on a low dose of a conventional neuroleptics for a few
weeks, while lamotrigine was being gradually introduced in 25-mg weekly
increments until the patient responded (up to 300 mg/day maximum). RESULTS:
Consistent with previous work by us and others, bipolar family history could be
documented in three of eight BPD patients, and worsening on antidepressants in
four of eight, providing indirect support to our conceptualization of BPD as a
bipolar variant. One patient developed a rash on 25 mg and was dropped from the
lamotrigine trial, while another patient was noncompliant. Three who failed
lamotrigine, subsequently responded, respectively, to sertraline,
lithium-thioridazine combination, and valproate. The remaining three patients
showed a robust response to lamotrigine, ranging from 75 to 300 mg/day: their
functioning jumped from a mean baseline DSM-IV GAF score in the 40’s to the 80’s
during 3-4 months. Among all responders impulsive sexual, drug-taking and
suicidal behaviors disappeared and no longer met the criteria for BPD. At an
average follow-up of 1 year, they no longer meet criteria for BPD. LIMITATIONS:
Open uncontrolled results on a small number of patients in a tertiary care
center may not generalize to BPD patients at large. CONCLUSIONS: Overall, the
BPD response to pharmacotherapy in the present case series was 75%. The fact
that five of six pharmacotherapy responders required mood stabilizers, argues
against the prevalent view that the depressions of borderline patients belong to
unipolarity. Of BPD patients who completed the trial, 50% achieved sustained
remission from their personality disorder with lamotrigine monotherapy. The
dramatic nature of the response in patients refractory to all previous
medication trials and maintenance of a robust response over 1 year, argue
against a placebo effect. Controlled systematic investigation of lamotrigine in
BPD is indicated.

PMID: 10333987
J Am Acad Child Adolesc Psychiatry 1999 Jan;38(1):56-63

Natural course of adolescent major depressive disorder: I. Continuity into young

Lewinsohn PM, Rohde P, Klein DN, Seeley JR.

Oregon Research Institute, Eugene 97403-1983, USA.

OBJECTIVE: To examine the course of adolescent major depressive disorder (MDD)
by comparing rates of mood and non-mood disorders between age 19 and 24 years in
participants with a history of adolescent MDD versus participants with
adolescent adjustment disorder with depressed mood, nonaffective disorder, and
no disorder. METHOD: Participants from a large community sample who had been
interviewed twice during adolescence completed a third interview assessing Axis
I psychopathology and antisocial and borderline personality disorders after
their 24th birthday: 261 participants with MDD, 73 with adjustment disorder, 133
with nonaffective disorder, and 272 with no disorder through age 18. RESULTS:
MDD in young adulthood was significantly more common in the adolescent MDD group
than the nonaffective and no disorder groups (average annual rate of MDD = 9.0%,
5.6%, and 3.7%, respectively). Adolescents with MDD also had a high rate of
nonaffective disorders in young adulthood (annual nonaffective disorder rate =
6.6%) but did not differ from adolescents with nonaffective disorder (7.2%).
Prevalence rates of dysthymia and bipolar disorder were low (< 1%). Adolescents
with adjustment disorder exhibited similar rates of MDD and nonaffective
disorders in young adulthood as adolescents with MDD. CONCLUSIONS: This study
documents the significant continuity of MDD from adolescence to young adulthood.
Public health implications of the findings are discussed.

PMID: 9893417
J Nerv Ment Dis 1999 May;187(5):313-5

Borderline personality disorder and bipolar mood disorder: two distinct
disorders or a continuum?

Atre-Vaidya N, Hussain SM

Department of Psychiatry and Behavioral Sciences, Finch University of Health
Sciences/The Chicago Medical School, North Chicago, Illinois 60064, USA.

PMID: 10348089, UI: 99275845
J Nerv Ment Dis 1998 Oct;186(10):616-22

Comorbid mood disorders as modifiers of treatment response among inpatients
with borderline personality disorder.

Goodman G, Hull JW, Clarkin JF, Yeomans FE

Department of Psychiatry, Cornell University Medical College, White Plains, New
York 10605, USA.

Structured clinical interviews of 63 female inpatients diagnosed with
borderline personality disorder were used to study the relations of comorbid
mood disorders to treatment response. Diagnostic information was gathered using
the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II)
and the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P).
Information about psychotic symptoms was also based upon responses to the
SCID-P. Treatment response was assessed through weekly ratings on the Symptom
Checklist-90-Revised over 25 weeks of hospitalization. Initial depression but
not initial or previous bipolar disorder was found to predict treatment course.
Initial psychotic symptoms were also found to predict treatment course among
patients with initial bipolar disorder and tended to modify the trajectory of
symptoms over time among patients with initial depression. Possible
explanations for these findings are explored and discussed.
Compr Psychiatry 1998 Mar-Apr;39(2):72-4

Comorbidity of personality disorders with bipolar mood disorders.

Ucok A, Karaveli D, Kundakci T, Yazici O

Department of Psychiatry, Istanbul Medical Faculty, Turkey.

The aim of the study was to assess the prevalence of personality disorders in a
group of outpatients with bipolar I disorder. The Structured Clinical Interview
for DSM-III-R Personality Disorders (SCID-II) was administered to 90 bipolar
outpatients who met the DSM-III-R criteria and 58 control subjects. Of the
patients and controls, 47.7% and 15.5%, respectively, had at least one
personality disorder. At least one personality disorder in clusters A, B, and C
and obsessive-compulsive, paranoid, histrionic, and borderline personality
disorders were significantly more prevalent in bipolars. Suicide attempts were
more frequent in patients with a history of personality disorder.
Ned Tijdschr Geneeskd 1997 Mar 1;141(9):409-12

[Borderline or bipolar disorder after all]?
[Article in Dutch]

Knoppert-van der Klein EA, Hoogduin CA, Nolen WA, Kolling P

Psychiatrisch Ziekenhuis Endegeest, afd. Jelgersmapolikliniek, Oegstgeest.

In two women aged 35 and 21 years, the initial diagnosis ‘borderline
personality disorder’ was changed to ‘bipolar disorder’. These disorders are
separate entities with different therapy, but may resemble each other very
much. It may be necessary to use heteroanamnesis and family anamnesis and to
follow the patient for some time in order to establish whether there are mood
J Clin Psychopharmacol 1996 Apr;16(2 Suppl 1):4S-14S

The prevalent clinical spectrum of bipolar disorders: beyond DSM-IV.

Akiskal HS

International Mood Clinic, University of California at San Diego, La Jolla,

Based on the author’s work and that of collaborators, as well as other
contemporaneous research, this article reaffirms the existence of a broad
bipolar spectrum between the extremes of psychotic manic-depressive illness and
strictly defined unipolar depression. The alternation of mania and melancholia
beginning in the juvenile years is one of the most classic descriptions in
clinical medicine that has come to us from Greco-Roman times. French alienists
in the middle of the nineteenth century and Kraepelin at the turn of that
century formalized it into manic-depressive psychosis. In the pre-DSM-III era
during the 1960s and 1970s, North American psychiatrists rarely diagnosed the
psychotic forms of the disease; now, there is greater recognition that most
excited psychoses with a biphasic course, including many with schizo-affective
features, belong to the bipolar spectrum. Current data also support Kraepelin’s
delineation of mixed states, which frequently take on psychotic proportions.
However, full syndromal intertwining of depressive and manic states into
dysphoric or mixed mania–as emphasized in DSM-IV–is relatively uncommon;
depressive symptoms in the midst of mania are more representative of mixed
states. DSM-IV also does not formally recognize hypomanic symptomatology that
intrudes into major depressive episodes and gives rise to agitated depressive
and/or anxious, dysphoric, restless depressions with flight of ideas. Many of
these mixed depressive states arise within the setting of an attenuated bipolar
spectrum characterized by major depressive episodes and soft signs of
bipolarity. DSM-IV conventions are most explicit for the bipolar II subtype
with major depressive and clear-cut spontaneous hypomanic episodes;
temperamental cyclothymia and hyperthymia receive insufficient recognition as
potential factors that could lead to switching from depression to bipolar I
disorder and, in vulnerable subjects, to predominantly depressive cycling. In
the main, rapid-cycling and mixed states are distinct. Nonetheless, there exist
ultrarapid-cycling forms where morose, labile moods with irritable, mixed
features constitute patients’ habitual self and, for that reason, are often
mistaken for “borderline” personality disorder. Clearly, more formal research
needs to be conducted in this temperamental interface between more classic
bipolar and unipolar disorders. The clinical stakes, however, are such that a
narrow concept of bipolar disorder would deprive many patients with lifelong
temperamental dysregulation and depressive episodes of the benefits of
mood-regulating agents.
Encephale 1995 Mar;21 Spec No 2:47-9

[Pathologic personality, temperament and treatment].
[Article in French]

Akiskal HS

The relationships between affective disorders and personality disorders remain
controversial. The inefficacy of therapeutics in depressed subjects with a
personality disorder is often due to an inadequate therapeutic. A few clinical
arguments and experimental data corroborate the hypothesis of a commun
substratum for affective disorders and personality disorders. A few studies
demonstrate an efficacy in specific cases of lithium, neuroleptics and
antidepressants (particularly MAOI) in borderline subjects with an affective
disorder. We may too use pragmatic psychotherapies targeted on specific
problems of each patient.
J Abnorm Psychol 1994 Nov;103(4):610-24

Social perceptions and borderline personality disorder: the relation to mood

Benjamin LS, Wonderlich SA

Department of Psychology, University of Utah.

We used the Structural Analysis of Social Behavior (SASB) to compare the social
perceptions of borderline, unipolar, and bipolar-depressed inpatients. As
predicted, borderline subjects differed from bipolar-depressed and unipolar
subjects in their social perceptions. Borderline subjects viewed their
relationships to their mother, hospital staff, and other patients as more
hostile and autonomous than did mood disordered subjects. The results are
discussed in terms of an integrative theory of borderline personality that
considers the psychobiology of interpersonal relationships and attachment
Can J Psychiatry 1994 Jun;39(5):315

Re: Misdiagnosis of bipolar affective disorder as personality disorder.

Paris J

Comment on: Can J Psychiatry 1993 Nov;38(9):587-9
Comment in: Can J Psychiatry 1995 Mar;40(2):109-10
Acta Psychiatr Scand Suppl 1994;379:45-9

The borderline syndromes of depression, mania and schizophrenia: the coaxial or
temperamental approach.

Bech P

Department of Psychiatry, Frederiksborg General Hospital, Hillerod, Denmark.

When analyzing the diagnostic position of “neurosis”, Akiskal found it
clinically meaningless because it lacks sufficient phenomenological
characterization. In contrast, Tyrer found it meaningful because it explains
the heterogeneity of neurotic symptoms. The diagnostic position of “borderline”
has been treated analogically by Akiskal and Tyrer. Thus, Tyrer uses the term
borderline in a very broad and general sense, while Akiskal again has found it
without sufficient phenomenological characterization. Hence, the DSM-III
concept of borderline personality disorder includes the temperament borders of
affective disorders (melancholic, choleric and sanguine). A closer look at the
Tyrer concept of neurosis places it within the melancholic temperament. The
choleric temperament covers cyclothymia and the sanguine temperament the
subclinical manifestations of mania. The term borderline personality disorders
should, then, be restricted to cover the phlegmatic temperament or mild degrees
of the schizophrenic spectrum disorders, which is in accordance with ICD-10.
Acta Psychiatr Scand Suppl 1994;379:32-7

The temperamental borders of affective disorders.

Akiskal HS

Department of Psychiatry, University of California at San Diego, La Jolla

Depending on the population studied, anywhere from half to two-thirds of
DSM-III borderline disorders seem to represent subaffective expressions,
principally on the border of bipolar disorder. “Borderland” may actually be a
better characterization of this large temperamentally unstable terrain with a
population prevalence of 4-6% (as compared with 1% for classical bipolar
disorder). The temperaments include the dysthymic, irritable, and cyclothymic
types which, respectively, coexist with “double depressive”, mixed bipolar, and
bipolar II disorders; others conform to an anxious-sensitive temperament in
continuum with hysteroid dysphoric and atypical depressive disorders.
Borderline “stable instability” in these patients appears secondary to
affective temperamental dysregulation, which has exacerbated into a protracted
emotional storm during a difficult maturational phase in the biography of a
given patient.
Am J Psychiatry 1992 Nov;149(11):1473-83

Contested boundaries of bipolar disorder and the limits of categorical
diagnosis in psychiatry.

Blacker D, Tsuang MT

Program in Psychiatric Epidemiology, Harvard School of Public Health, Boston,

The authors’ primary objective is to outline the phenomenology, importance, and
available data on issues concerning the boundaries between bipolar disorder and
diagnoses such as schizophrenia, unipolar depression, and personality
disorders. In addition, by illuminating the many difficulties with the
boundaries of one of psychiatry’s more robust diagnoses, they hope to awaken in
the reader a healthy skepticism about current psychiatric nosology. For a topic
of this scope, a literature review must be selective. For each boundary area, a
mixture of classic and recent papers covering a range of validating criteria is
included whenever possible. Good summary data are cited when available, as are
a selection of relevant theoretical papers. The review indicates that current
diagnostic criteria for bipolar disorder are generally reasonable, but there
are many problem areas, most of which cannot be solved by changes in criteria.
Notable among these are 1) the possibility of future manic episodes in unipolar
disorder, 2) schizoaffective disorder, bipolar type, and 3) borderline
personality disorder with prominent mood swings. The disputes concerning the
boundaries of bipolar disorder illustrate the limitations of categorical
diagnosis which result from the implementation of diagnostic criteria, the
criteria themselves, the fundamental nosologic process, and the phenomena
themselves. If these limitations are to be extended, it may be necessary to
explore alternative ways of defining psychiatric diagnoses for different
settings in research and clinical practice.

Comment in: Am J Psychiatry 1993 Oct;150(10):1568-9
Encephale 1992 Jan;18 Spec No 1:78-82

[Clinical study of 5 families with bipolar disorder].
[Article in French]

Amadeo S, Abbar M, Fourcade ML, Scharbach H, Selin D, Bretome A, Madec A,
Castelnau D, Besancon G

Service de Psychiatrie Adulte, Hopital Saint-Jacques, CHRU, Nantes.

Five pedigrees of bipolar patients with at least two bipolar subjects on two
generations have been identified in psychiatric departments of Nantes,
Montpellier and Challans for linkage studies. In each pedigree, it was found
one or more patients suffering from other conditions, like Borderline
personality, Anorexia-bulimia, Mental retardation with dysmorphia, and Panic
disorders. Mood disorders spectrum and therapeutic implications are discussed.
J Psychiatr Res 1992 Jan;26(1):1-16

Mood and global functioning in borderline personality disorder: individual
regression models for longitudinal measurements.

Hoke LA, Lavori PW, Perry JC

Beth Israel Hospital, Department of Psychiatry, Boston, MA 02215.

This report addresses the need for prospective studies of personality
disorders, as well as some of the difficulties encountered in longitudinal
studies when missing data occur due to subject attrition and variable follow-up
intervals. Various statistical methods for handling repeated measurements data
are reviewed. Many of these methods are quite complex and require expert
statistical skills. A simpler way to handle multivariate data using
single-number summary scores is proposed as an alternative which is efficient
and more readily understood by professionals in many disciplines. Findings are
presented from a prospective study of borderline personality disorder which
utilized repeated observations over time. Individual regression models were
applied to each subject’s repeated measurements to obtain a summary of his or
her trend on measures of mood and global functioning. The individual
regressions produced separate statistics, slopes summarizing rates of change
and intercepts which estimated initial levels of functioning. These summaries
were then used in group analyses. Findings indicated that subjects showed mild
to moderate impairment in mood and moderate impairment in overall functioning.
The individual slopes indicated that little overall change was observed during
the 5-year period after initial assessment. Neither presence of borderline
diagnosis (definite vs. trait vs. no borderline diagnosis) nor gender predicted
initial levels of functioning or rates of change. Further examination of other
predictors which may influence longterm outcome, such as history of childhood
trauma or presence of schizotypal personality features, is suggested. It is
concluded that prospective studies are essential in establishing the validity
of personality disorders and in understanding individual variation in outcomes.
J Affect Disord 1991 Apr;21(4):265-72

Morbidity risk for mood disorders in the families of borderline patients.

Gasperini M, Battaglia M, Scherillo P, Sciuto G, Diaferia G, Bellodi L

Department of Neuropsychiatric Sciences, School of Medicine, University of
Milan, Italy.

We analyzed the familial morbidity risk for mood disorders (MR) and the
presence of a family history of alcoholism in a group of 58 patients with
DSM-III borderline personality disorder (PD). The MR in the families of
borderline subjects was not significantly different from that found in a
control group of affective patients with other cluster II PD, or without PD.
The MR in the families of borderline subjects who had never developed an
affective episode was not significantly different from that found in the
families of borderline PD with a history of mood disorders. Borderline subjects
with mood disorders had higher rates of alcoholism in their families, mainly
among parents. Our results support the hypothesis that borderline PD, even in
absence of the codiagnosis of a mood disorder in the subject, may be a
predictor of higher familial liability to mood disorders, although it may be
more informative for the familial clustering of specific subgroups than for
mood disorders as a whole.
J Clin Psychiatry 1990 Aug;51(8):335-9

The prevalence of cyclothymia in borderline personality disorder.

Levitt AJ, Joffe RT, Ennis J, MacDonald C, Kutcher SP

University of Toronto, Ontario, Canada.

Sixty patients with personality disorders were evaluated by several different
diagnostic instruments to determine the prevalence of cyclothymia in borderline
personality disorder (BPD) and in other personality disorders (OPD).
Cyclothymia occurred more frequently in BPD than in OPD, regardless of which
diagnostic system was used. In contrast, the prevalence of major, minor, and
intermittent depression, hypomania, and bipolar disorder was not significantly
different in BPD as compared with OPD. Cyclothymic borderlines and
noncyclothymic borderlines could not be distinguished on behavioral or
functional measures. These results have implications for the diagnostic
validity of both BPD and cyclothymia.
J Am Acad Child Adolesc Psychiatry 1990 May;29(3):355-8

Adolescent bipolar illness and personality disorder.

Kutcher SP, Marton P, Korenblum M

Department of Psychiatry, Sunnybrook Medical Centre, University of Toronto,
Ontario, Canada.

The relationship between adolescent bipolar illness and personality disorder
has not been explored. Studies of adult bipolars suggest a bipolar
illness/borderline personality disorder (BPD) association. Twenty euthymic
bipolar teens were assessed using the Personality Disorders Examination.
Thirty-five percent met DSM-III-R criteria for at least one personality
disorder. Three of the 20 (15%) had a borderline personality disorder
diagnosis. The bipolar illness with personality disorder group differed
significantly from the bipolar illness without personality disorder group in
terms of increased lithium unresponsiveness (p less than 0.05) and neuroleptic
treatment at time of personality assessment (p less than 0.01), but not in
terms of age, sex, age of illness onset, serum lithium level, rapid cycling,
substance abuse history, alcohol abuse history, or number of suicide attempts.
Issues regarding the study of personality disorder in adolescent bipolars are
J Affect Disord 1990 Apr;18(4):267-73

Sleep patterns in borderline personality disorder.

Benson KL, King R, Gordon D, Silva JA, Zarcone VP Jr

Department of Psychiatry, VA Medical Center, Palo Alto, CA 94304.

Sleep patterns of borderline patients with and without a history of affective
disorder were compared to each other and to normal reference data. The three
groups could not be distinguished in terms of REM latency because a wide spread
of values was seen within each group. Borderlines were different from normal
controls in other aspects of sleep architecture; they had less total sleep,
more stage 1 sleep, and less stage 4 sleep. If one assumes that REM latency is
a biological marker for mood disorder, then our results do not support the
hypothesis that borderline personality disorder is a variant of affective
illness. However, other data suggest that REM latency should not be used to
validate the presence of affective illness.
Psychiatr J Univ Ott 1990 Mar;15(1):22-7

Associated diagnoses (comorbidity) in patients with borderline personality

Prasad RB, Val ER, Lahmeyer HW, Gaviria M, Rodgers P, Weiler M, Altman E

University of Illinois Medical Center, Illinois.

The authors administered the Diagnostic Interview Schedule to 21 patients with
borderline personality disorder. The patients met criteria for various other
DSM-III diagnoses, meeting exclusion criteria in some cases, and not in other
cases. Frequency distribution of each diagnosis and the diagnoses of each
individual patient, are presented. Affective disorder was the most common
diagnosis (85%). Of these, 62% had primary major depression, and 23% had
secondary depression. Other diagnoses include bipolar disorder, dysthymia,
panic, agoraphobia, alcohol and Drug abuse, somatization disorder, and many
others. The authors conclude that while borderline disorder may be a
sub-affective disorder, a specific diagnostic profile for this disorder that
accounts for the presence of other Axis I and Axis II syndromes has yet to be
Am J Psychiatry 1986 Aug;143(8):1068-9

The overlap of affective and borderline disorders.

Fein S
Am J Psychiatry 1985 Jul;142(7):855-8

Comparison of three systems for diagnosing borderline personality disorder.

Nelson HF, Tennen H, Tasman A, Borton M, Kubeck M, Stone M

The authors assessed three systems for diagnosing borderline personality
disorder: DSM-III, the checklist criteria of Spitzer et al., and the Diagnostic
Interview for Borderline Patients. In an inpatient sample of 51 patients, 43
(84%) met the criteria of at least one of these systems; analyses were carried
out on 28 of these patients. Twelve (43%) of these 28 patients met criteria for
all three systems, seven (25%) for two systems, and nine (32%) for only one
system. Kernberg’s structural criteria showed reasonable overlap with the other
diagnostic criteria. Affective disorders were prominent across diagnostic
measures in this sample of borderline patients.
J Clin Psychiatry 1985 Feb;46(2):41-8

Borderline: an adjective in search of a noun.

Akiskal HS, Chen SE, Davis GC, Puzantian VR, Kashgarian M, Bolinger JM

Outpatients diagnosed as borderline (N = 100) were prospectively followed for
6-36 months and examined from phenomenologic developmental, and family history
perspectives. At index evaluation, 66 met criteria for recurrent depressive,
dysthymic, cyclothymic, or bipolar II disorders, and 16 for those of
schizotypal personality. Other subgroups included sociopathic, somatization,
panic-agoraphobic, attention deficit, epileptic, and identify disorders.
Compared with nonborderline personality controls, borderlines had a
significantly elevated risk for major affective but not for schizophrenic
breakdowns during follow-up. Prominent substance abuse history, tempestuous
biographies, and unstable early home environment were common to all diagnostic
subgroups. In family history, borderlines were most like bipolar controls, and
differed significantly from schizophrenic, unipolar, and personality controls.
It is concluded that, despite considerable overlap with subaffective disorders,
the current adjectival use of this rubric does not identify a specific
psychopathologic syndrome.
Am J Psychiatry 1985 Jan;142(1):15-21

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

Perry JC

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.
Arch Gen Psychiatry 1983 Dec;40(12):1319-23

The borderline syndrome. II. Is it a variant of schizophrenia or affective

McGlashan TH

Recent studies question whether the borderline syndrome represents two
entities: borderline schizophrenia (or schizotypal personality) as a variant of
schizophrenia and borderline personality disorder as a variant of primary
affective disorder. Relevant data are presented from the long-term follow-up of
patients at the Chestnut Lodge, Rockville, Md, receiving systematic diagnoses
by the retrospective application of diagnostic criteria. Studied were (1)
diagnostic overlap at index admission, (2) diagnostic change over follow-up
period, and (3) comparative long-term functional outcome between borderline
samples and other diagnostic groups. Findings supported the hypothesis that
schizotypal personality (as defined by DSM-III) is a variant of schizophrenia
but borderline personality disorder (as defined by the DSM-III and Gunderson et
al criteria) is not. An affiliation of borderline personality disorder with
primary affective disorder is suggested although not conclusive.
Schizophr Bull 1980;6(4):549-51

The borderline syndrome and affective disorders: a comment on the Wolf-man.

Abrahamson D

The famous Wolf-Man case described by Freud is re-examined. Evidence of a
recurrent affective disorder, which appears to have been neglected in previous
assessments, is presented. The evidence is derived from the patient’s own
memoirs, comments by therapists and others, and from the family history. A plea
is made for a multidimensional conceptualization of this and other complex and
influential cases.