Theresa A. Morgan

Distinguishing bipolar II depression from major depressive disorder with comorbid borderline personality disorder: demographic, clinical, and family history differences.

OBJECTIVE To (1) identify long-term trajectories of combat-induced posttraumatic stress disorder (PTSD) symptoms over a 20-year period from 1983 to 2002 in veterans with and without combat stress reaction (CSR) and (2) identify social predictors of these trajectories. METHOD A latent growth mixture modeling analysis on PTSD symptoms was conducted to identify PTSD trajectories and predictors. PTSD was defined according to DSM-III and assessed through the PTSD Inventory. Israeli male veterans with (n = 369) and without (n = 306) CSR were queried at 1, 2, and 20 years after war about combat exposure, military unit support, family environment, and social reintegration. RESULTS For both study groups, we identified 4 distinct trajectories with varying prevalence across groups: resilience (CSR = 34.4%, non-CSR = 76.5%), recovery (CSR = 36.3%, non-CSR = 10.5%), delayed onset (CSR = 8.4%, non-CSR = 6.9%), and chronicity (CSR = 20.9%, non-CSR = 6.2%). Predictors of trajectories in both groups included perception of war threat (ORs = 1.59-2.47, P values ≤ .30), and negative social reintegration (ORs = 0.24-0.51, P values ≤ .047). Social support was associated with symptomatology only in the CSR group (ORs = 0.40-0.61, P values ≤ .045), while family coherence was predictive of symptomatology in the non-CSR group (OR = 0.76, P = .015) but not in the CSR group. CONCLUSIONS Findings confirmed heterogeneity of long-term sequelae of combat, revealing 4 trajectories of resilience, recovery, delay, and chronicity in veterans with and without CSR. Symptomatic trajectories were more prevalent for the CSR group, suggesting that acute functional impairment predicts pathological outcomes. Predictors of symptomatic trajectories included perceived threat and social resources at the family, network, and societal levels.

Comorbid bipolar disorder and borderline personality disorder and history of suicide attempts.

Both bipolar disorder and borderline personality disorder are associated with elevated rates of attempted suicide; however, no studies have examined whether there is an independent, additive risk for suicide attempts in patients diagnosed with both disorders. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, 3,465 psychiatric outpatients were interviewed with semistructured interviews. Compared to the bipolar patients without borderline personality disorder, the patients diagnosed with both bipolar and borderline personality disorder were significantly more likely to have made a prior suicide attempt. The patients with borderline personality disorder and bipolar disorder were nonsignificantly more likely than the borderline patients without bipolar disorder to have made a prior suicide attempt. Bipolar disorder and borderline personality disorder were each associated with an increased rate of suicide attempts. The co-occurrence of these disorders conferred an additive risk, although the influence of borderline personality disorder was greater than that of bipolar disorder.

Differences between older and younger adults with Borderline Personality Disorder on clinical presentation and impairment

BACKGROUND Borderline Personality Disorder (BPD) is well-known to be a clinically severe and impairing diagnosis. Research shows that BPD symptoms decrease in severity over time. However, a subset of patients with BPD continue to meet criteria for the disorder in older adulthood. Little is known about this subset. Perception of BPD as a young-persons diagnosis could lead to under recognition in older patients. As such, the objective of the present report is to provide the first direct comparison between older and younger adults with BPD on demographics, clinical presentation, and functional impairment. METHOD Over 3000 psychiatric outpatients were evaluated with semi-structured diagnostic interviews. Forty-six older adults (age 45-68) and 97 younger adults (age 18-25) met criteria for BPD. RESULTS Both groups reported high levels of functional impairment and Axis I comorbidity. Older adults were more likely to endorse chronic emptiness, and less likely to endorse impulsivity, self-harm, and affective instability. Older adults also reported fewer substance use disorders, more lifetime hospitalizations and higher social impairment. CONCLUSION Older adults with BPD had a significantly different clinical presentation from younger adults with BPD, including differences in likelihood of endorsing specific BPD criteria, social impairment, and comorbid substance use. It is important to assess less prototypic features of BPD to avoid overlooking borderline personality features in this population.

An Integrated, Acceptance-Based Behavioral Approach for Depression With Social Anxiety: Preliminary Results.

Depression and social anxiety disorder (SAD) are highly comorbid, resulting in greater severity and functional impairment compared with each disorder alone. Although recently transdiagnostic treatments have been developed, no known treatments have addressed this comorbidity pattern specifically. Preliminary support exists for acceptance-based approaches for depression and SAD separately, and they may be more efficacious for comorbid depression and anxiety compared with traditional cognitive-behavioral approaches. The aim of the current study was to develop and pilot test an integrated acceptance-based behavioral treatment for depression and comorbid SAD. Participants included 38 patients seeking pharmacotherapy at an outpatient psychiatry practice, who received 16 individual sessions of the therapy. Results showed significant improvement in symptoms, functioning, and processes from pre- to post-treatment, as well as high satisfaction with the treatment. These results support the preliminary acceptability, feasibility, and effectiveness of this treatment in a typical outpatient psychiatry practice, and suggest that further research on this treatment in larger randomized trials is warranted.

A clinically useful social anxiety disorder outcome scale

Increasingly, emphasis is being placed on measurement-based care to improve the quality of treatment. Although much of the focus has been on depression, measurement-based care may be particularly applicable to social anxiety disorder (SAD) given its high prevalence, high comorbidity with other disorders, and association with significant functional impairment. Many self-report scales for SAD currently exist, but these scales possess limitations related to length and/or accessibility that may serve as barriers to their use in monitoring outcome in routine clinical practice. Therefore, the aim of the current study was to develop and validate the Clinically Useful Social Anxiety Disorder Outcome Scale (CUSADOS), a self-report measure of SAD. The CUSADOS was designed to be reliable, valid, sensitive to change, brief, easy to score, and easily accessible, to facilitate its use in routine clinical settings. The psychometric properties of the CUSADOS were examined in 2415 psychiatric outpatients who were presenting for treatment and had completed a semi-structured diagnostic interview. The CUSADOS demonstrated excellent internal consistency, and high item-total correlations and test-retest reliability. Within a sub-sample of 381 patients, the CUSADOS possessed good discriminant and convergent validity as it was more highly correlated with other measures of SAD than with other psychiatric disorders. Furthermore, scores were higher in outpatients with a current diagnosis of SAD compared to those without a SAD diagnosis. Preliminary support also was obtained for the sensitivity to change of the CUSADOS in a sample of 15 outpatients receiving treatment for comorbid SAD and depression. Results from this validation study in a large psychiatric sample show that the CUSADOS possesses good psychometric properties. Its brevity and ease of scoring also suggest that it is feasible to incorporate into routine clinical practice.

Is Borderline Personality Disorder Underdiagnosed and Bipolar Disorder Overdiagnosed

Both borderline personality disorder (BPD) and bipolar disorder are considered clinically severe, chronic conditions associated with high functional impairment and public health costs. These disorders also share clinical features, most predominantly mood fluctuations and impulsivity across several areas. In this chapter we report research showing that BPD is chronically under-assessed and, as a result, underdiagnosed in clinical populations. Conversely, we also document literature showing the overdiagnosis of bipolar disorder, particularly in cases where, after careful interviewing, patients actually meet criteria for BPD. Reasons for this pattern vary and include insufficient diagnostic rigor, stigma associated with BPD, unfamiliarity with BPD as compared to bipolar disorder, the promotion of bipolar disorder (and not BPD) by pharmaceutical companies, and perceived difficulty in treating BPD as compared to bipolar disorder, among others. Nonetheless, diagnosing BPD and/or bipolar disorder has significant consequences for treatment planning and patient care, and close attention should be paid to making this differential diagnosis in clinical settings.

Psychosocial morbidity associated with bipolar disorder and borderline personality disorder in psychiatric out-patients: comparative study

BACKGROUND The morbidity associated with bipolar disorder is, in part, responsible for repeated calls for improved detection and recognition. No such commentary exists for the improved detection of borderline personality disorder. Clinical experience suggests that it is as disabling as bipolar disorder, but no study has directly compared the two disorders. AIMS To compare the levels of psychosocial morbidity in patients with bipolar disorder and borderline personality disorder. METHOD Patients were assessed with semi-structured interviews. We compared 307 patients with DSM-IV borderline personality disorder but without bipolar disorder and 236 patients with bipolar disorder but without borderline personality disorder. RESULTS The patients with borderline personality disorder less frequently were college graduates, were diagnosed with more comorbid disorders, more frequently had a history of substance use disorder, reported more suicidal ideation at the time of the evaluation, more frequently had attempted suicide, reported poorer social functioning and were rated lower on the Global Assessment of Functioning. There was no difference between the two patient groups in history of admission to psychiatric hospital or time missed from work during the past 5 years. CONCLUSIONS The level of psychosocial morbidity associated with borderline personality disorder was as great as (or greater than) that experienced by patients with bipolar disorder. From a public health perspective, efforts to improve the detection and treatment of borderline personality disorder might be as important as efforts to improve the recognition and treatment of bipolar disorder.

DOES BORDERLINE PERSONALITY DISORDER MANIFEST ITSELF DIFFERENTLY IN PATIENTS WITH BIPOLAR DISORDER AND MAJOR DEPRESSIVE DISORDER

Perugi and colleagues (2013) recently reported that some features of borderline personality disorder (BPD) significantly predicted a diagnosis of bipolar disorder among depressed patients. They interpreted these findings as indicating that some BPD criteria are nonspecific and are indicators of bipolar disorder rather than BPD, whereas other criteria are more specific to BPD. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, the authors tested the hypothesis that BPD presents itself differently in psychiatric outpatients diagnosed with bipolar disorder or major depressive disorder. The authors found that the patients with bipolar disorder were significantly more likely to report impulsive behavior and transient dissociation. No criterion was significantly more common in the BPD patients with MDD. The authors therefore do not consider the BPD criteria to be nonspecific with regard to the distinction between BPD and bipolar disorder.

The severity of psychiatric disorders: World Psychiatry

The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM‐5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom‐defined disorders depends on factors extrinsic to those disorders, such as self‐efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to ones primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.

Community and Clinical Epidemiology of Borderline Personality Disorder

Several studies of the prevalence of borderline personality disorder in community and clinical settings have been carried out to date. Although results vary according to sampling method and assessment method, median point prevalence is roughly 1%, with higher or lower rates in certain community subpopulations. In clinical settings, the prevalence is around 10% to 12% in outpatient psychiatric clinics and 20% to 22% among inpatient clinics. Further research is needed to identify the prevalence and correlates of borderline personality disorder in other clinical settings (eg, primary care) and to investigate the impact of demographic variables on borderline personality disorder prevalence.