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Are Atypical Depression, Borderline Personality Disorder and Bipolar II Disorder Overlapping Manifestations of a Common Cyclothymic Diathesis?

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Are Atypical Depression, Borderline Personality Disorder and Bipolar II Disorder Overlapping Manifestations of a Common Cyclothymic Diathesis? View metadata,RESEARCH citation and similar REPORT papers at core.ac.uk brought to you by CORE provided by Archivio della ricerca - Università degli studi di Napoli Federico II Are atypical depression, borderline personality disorder and bipolar II disorder overlapping manifestations of a common cyclothymic diathesis? GIULIO PERUGI1, MICHELE FORNARO2, HAGOP S. AKISKAL3 1Department of Psychiatry, University of Pisa, via Roma 67, Pisa, Italy 2Department of Neuroscience, Section of Psychiatry, University of Genoa, Italy 3International Mood Center, Department of Psychiatry, University of California at San Diego, La Jolla, CA, USA 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 fac- tors. 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 sensi- tivity (among atypical depressive patients) appear to be related as part of an underlying cyclothymic temperamental matrix. Key words: Atypical depression, borderline personality disorder, bipolar II disorder, cyclothymic temperament (World Psychiatry 2011;10:45-51) The relationship between atypical depression, borderline major depressive patients with DSM-IV atypical features met personality disorder (BPD) and bipolar II disorder (BP-II) criteria for strictly defined BP-II and 72% met our criteria for remains understudied. Previous work by us (1,2) and others bipolar spectrum disorder (major depression plus hypoma- (3-6) suggests a considerable overlap in both clinical mani- nia and/or cyclothymic or hyperthymic temperament). Fam- festations and long-term traits of patients within this broad ily history for bipolar disorder validated these clinical obser- realm. vations. Lifetime comorbidity with anxiety disorders (panic The rubric “atypical depression” includes a large subset disorder-agoraphobia, social phobia and obsessive-compul- (7,8) of depressive states characterized by reactive mood, a sive disorder) and both cluster B (dramatic, emotional or pattern of stable interpersonal sensitivity (exaggerated vul- erratic) and C (anxious or fearful) personality disorders was nerability to feeling hurt by criticism or rejection) and re- very common. These findings suggested that the “atypicality” verse vegetative symptoms such as increased appetite and of depression is related to an affective temperamental dys- hypersomnia. In its original description, atypical depression regulation, which could explain why atypical depressive pa- was also invariably associated with phobic-anxious symp- tients are often given “borderline” diagnoses (18). tomatology and preferential response to monoamine oxi- In the present report, we expand our sample size and ex- dase inhibitors (9). tend the aim of our analyses to compare previous course, The related concept of “hysteroid dysphoria” (10) has symptomatic features, family history, and axis I and axis II been used to describe a subgroup of depressed patients, usu- comorbidity in atypical depressive patients with (BPD+) or ally women, whose hallmark is an extreme intolerance of without (BPD-) a concomitant diagnosis of BPD. Moreover, personal rejection, with a particular vulnerability to loss of in order to better characterize this personality profile in romantic relationships. The stormy lifestyle of these patients atypical depressives, we explore its temperamental under- suggests a link to BP-II and related cyclothymic or “soft” pinnings and links with other personality disorders. bipolar conditions (11-13). Regrettably, most clinical studies of atypical depression exclude definite bipolar disorder (9,10,14). Such exclusion METHODS appears unjustified on the basis of the observation of similar rates of atypicality in unipolar and bipolar I depressives (15) A consecutive sample of 107 patients who met DSM-IV and of higher rates in BP-II compared to unipolar patients criteria for major depressive episode with atypical features (16). Follow-up data also show a frequent bipolar outcome (14 males and 93 females, mean age 31.5±8.8 years, range in atypical depressives (15,17). 16-55 years), was recruited in a three-year period at the In- In a previous study (2), we observed that 32.6% of 86 stitute of Psychiatry of the University of Pisa. The subjects 45 WPA1_2011_45_51.indd 45 02/02/11 11:24 came from a variety of sources, about equally divided be- tivity (i.e., mood brightens in response to actual or potential tween self-referrals, referrals from general practitioners and positive events), plus two or more of the following features: various medical specialists and psychiatrists. Exclusion cri- significant weight gain or increase in appetite, hypersomnia, teria were a lifetime history of schizophrenia or other psy- leaden paralysis, long-standing pattern of interpersonal re- chotic disorder, organic mental syndrome and serious or jection sensitivity (not limited to episodes of mood distur- uncontrolled medical diseases. All patients provided written bance) resulting in significant social or occupational impair- informed consent for participation in the study. ment, and absence of melancholic and catatonic features The Axis I diagnostic evaluation was conducted by the during the same episode. For the diagnosis of major depres- Structured Clinical Interview for DSM III-R (19) and the sion with atypical features, we attained excellent inter-rater Semi-structured Interview for Depression (SID, 20). The reliability (kappa = 0.94). SID, developed as part of the Pisa-San Diego Collaborative For the current and lifetime diagnosis of body dysmor- Study on Affective Disorders, has been used with 2500 pa- phic disorder (BDD), we used a semi-structured interview tients at the time of this writing: its reliability for diagnostic (30). The diagnosis of borderline, histrionic, narcissistic, assessment of patients and their temperaments has been avoidant, dependent and obsessive-compulsive personality documented elsewhere (21,22). Family history data were disorders was performed by the corresponding sections of collected by the Family History Research Diagnostic Criteria the Structured Clinical Interview for DSM-IV Axis II Per- (23). Temperaments were defined by our operational crite- sonality Disorders, Version 2.0 (SCID-II, 31). ria, reported elsewhere (2, 24), which represent the Univer- For symptomatological assessment, psychiatrists com- sity of Tennessee (25) modification of the Schneiderian de- pleted the following rating scales: the Atypical Depression scriptions (26). Cyclothymic temperament was defined ac- Diagnostic Scale (ADDS, 32), a semi-structured interview cording to Akiskal (27). designed to determine the presence and the severity, on a We considered two levels for the diagnosis of BP-II, based scale ranging from 1 to 6, of atypical features during the cur- respectively on the “conservative” DSM-IV threshold of ≥ 4 rent depressive episode, the Hamilton Rating Scale for De- days for hypomania, and the ≥ 2 days threshold embodied pression (HRSD, 33) and its modified form for reverse veg- in the SID, which has been validated in large clinical and etative features (34). Patients also completed the Hopkins epidemiologic populations (28,29). Symptoms Check List (HSCL-90, 35). The diagnosis of atypical depression required mood reac- Comparative analyses for familial, epidemiological, clini- Table 1 Demographic and clinical features in patients with atypical depression with (BDP+) or without (BDP-) borderline personality disorder BDP+ BDP- (n=46) (n=61) t or b2 (df=2) p Gender (% females) 87.0 86.7 0 0.99 Age (years, mean±SD) 30.0±7.7 32.7±9.4 -1.61 0.11 Age at onset (years, mean±SD) 22.2±7.8 23.2±8.2 -0.6 0.54 Age at first treatment (years, mean±SD) 24.6±8.9 26.3±10 -1 0.3 Age at first hospitalization (years, mean±SD) 18.2±15.0 18.3±17 0 0.98 Duration of current episode (months, mean±SD) 7.3±7.3 14.0±17.8 -2.41 0.02 Duration of illness (years, mean±SD) 7.7±6.0 9.5±7.6 -1.28 0.2 No. previous depressive episodes (mean±SD) 3.3±2.8 4.0±4.0 -1.02 0.32 No. hospitalizations (mean±SD) 1.1±1.8 1.5±2.8 -0.82 0.42 Residual (interepisodic) symptoms (%) 84.4 77.6 0.76 0.4 No. lifetime suicide attempts (mean±SD) 1.1±1.6 0.9±1.9 0.38 0.7 Suicide attempts in current episode (%) 32.6 15±24.6 0.84 0.04 Family history in first-degree relatives (%) Major depression 52.2 50.8 0.06 0.8 Bipolar disorder 10.9 9.9 0.22 0.73 Panic disorder-agoraphobia 8.7 16.4 1.37 0.24 Obsessive-compulsive disorder 4.3 5.0 0.55 0.46 Generalized anxiety disorder 4.3 0 2.7 0.1 Eating disorders 4.3 4.9 0.08 0.77 Alcohol abuse 2.2 5.0
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