Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences
Introduction
Many studies have reported a high frequency of comorbidity between borderline personality disorder and major mood disorders (bipolar disorder and major depression), from 35 to 51.5% (McGlashan, 1983, Pope et al., 1983, Frances et al., 1984, Perry, 1985, Zanarini et al., 1998). Some family studies have also shown comorbidity between affective disorders including bipolar disorders and borderline personality (Akiskal, 1981, Lorenger et al., 1982, Amadeo et al., 1992). Moreover, in a clinical case conference Bolton and Gunderson (1996) have discussed how it is sometime difficult to establish the differential diagnosis between bipolar disorder and borderline personality.
Some authors have suggested that borderline personality disorder is on the spectrum of affective disorders (Akiskal, 1981, McGlashan, 1983). This has led to the following hypotheses: (1) borderline personality is a variant of affective disorder, (2) borderline personality predisposes the patient to depression, or (3) the two disorders have etiologic features in common (Gunderson and Philips, 1991, Koenigsberg et al., 1999). Biological and treatment studies have shown that borderline personality and affective disorders display similarities and differences in their underlying biology and treatment response (Koenigsberg et al., 1999).
However, most studies assessing the relationship between borderline personality and bipolar disorder raise the question of comorbidity or describe the impact of comorbid borderline personality on the features, progression or treatment response of bipolar disorder. Bipolar patients with a comorbid borderline personality have a less favorable outcome, with more suicide attempts, earlier onset and poorer response to treatment than those without borderline personality (Kutcher et al., 1990, Sato et al., 1999).
To our knowledge, this is the first study to assess dimensional traits in these disorders, identified from a personality disorder cohort, in an adequately large sample, to determine phenomenologically the similarities and differences between these disorders. This dimensional approach may make it possible to elucidate the possible links between these two disorders and to identify the biological features that they share. This approach is based on the model that there are psychobiological dimensions such as affective instability, that predispose individuals and may cut across Axis I/II boundaries (Siever and Davis, 1991).
Affective instability and impulsive behavior appear to be appropriate traits for comparison in the two disorders. Indeed, affective instability is explicitly included as a criterion for borderline personality, whereas “autonomic lability” including a high level of interpersonal sensitivity and a low level of emotional stability has been suggested to be a valid antecedent of unipolar depression and bipolar disorders (Clayton et al., 1994, Lauer et al., 1997). In addition, borderline and bipolar patients (more specifically bipolar II disorder) frequently display suicidal behavior. Moreover, poor impulse control may be a strong risk factor for recurrent suicidal behavior, suggesting that impulsivity is a trait that should be investigated in both disorders. Finally, it has been suggested that both affective instability and impulsive personality disorder traits rather than the personality disorder per se have an heritable component (Silverman et al., 1991, Torgersen, 2000). Thus, affective instability and impulsiveness appear to be appropriate dimensions for investigation in these disorders. We compared bipolar II disorder patients (rather than patients with bipolar I disorder) to borderline personality patients, as these two disorders share similar clinical presentations (Benazzi, 2000).
We hypothesized that (1) both borderline personality disorder and bipolar II patients would display higher levels of affective lability and intensity, as measured by the Affective Lability Scale (ALS) and the Affect Intensity Measure (AIM), than patients without these disorders; (2) borderline personality patients, but not bipolar II patients would display a higher level of impulsiveness compared to patients without these disorders; (3) and bipolar II patients would display affective lability even between major affective episodes.
Section snippets
Subjects
We studied 148 patients with personality disorders from the Mood and Personality Disorder Program at the Mount Sinai Medical Center and the Bronx VA Medical Center. All subjects were healthy outpatients at the time of the study, as evaluated by laboratory tests, physical and neurological examination, and had not taken any medication including psychotropic medication, for at least 14 days.
Patients with bipolar I disorder, schizophrenia, and other Axis I psychotic disorders were excluded from
Statistical analysis
Statistical analysis was performed with SPSS version 9.0 computer software. As no other large studies have assessed borderline personality and bipolar II disorders together, we conducted a two-way analysis of covariance with borderline personality disorder and bipolar disorder diagnoses (presence or absence) as factors, to investigate the contribution of each diagnosis separately and to test for possible interaction effects between these diagnoses, after adjusting for age and sex.
Results
The sample consisted of 29 borderline patients who did not meet the criteria for bipolar II disorder, 14 bipolar II disorder patients who did not meet the criteria for borderline personality disorder, 12 patients who met the criteria for both borderline personality disorder and bipolar II disorder and 93 patients who did not meet the criteria for either (but met criteria for other personality disorders; see Table 1 for description of the study population).
Age and sex distribution differed
Discussion
In this study, we have found affective lability to be a trait shared by both borderline personality and bipolar II patients. However, the two diagnoses presented different patterns of affective lability. Shifts to euthymia from anger and anxiety were associated with borderline personality disorder in the absence of bipolar II disorder diagnosis whereas shifts from euthymia to depression and elation, and shifts to elation from depression were characteristic of bipolar II patients. High scores on
Acknowledgements
This work was supported by the Programme Hospitalier de Recherche Clinique (PHRC 2000) and by grants from the National Institutes of Health; National Center for Research Resources (5 M01 RR00071), for the Mt. Sinai General Clinical Research Center; National Institute of Mental Health grant R01-MH-41131; and Department of Veterans Affairs Merit Award 7609004.
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