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Findings from several studies concur that most patients with borderline personality disorder (BPD) have comorbid Axis I disorders during their lifetime (1–3). Comorbidity with major depressive disorder (MDD) is generally considered the most common, with rates ranging from 53% to 83%. The reasons for this frequent coexistence remain controversial. Some authors have suggested that MDD and BPD may be the expression of a common underlying pathological process, while others have objected that these disorders may simply coexist without sharing any physio- pathological mechanism (4–8). The following clinical characteristics of depression patients with a codiagnosis of BPD have been described: lower age at onset of MDD; higher severity of depressive symptoms; lower level of social functioning; chronic MDD and repeated hospitalization; more common suicidal ideation and behaviour; history of physical or sexual abuse in childhood; and higher cooccurrence of phobias, eating disorders, and alcohol and cannabis abuse (2,9–17). Replication of these findings is needed to determine whether the clinical picture of MDD is significantly influenced by concomitant BPD. If this is the case, careful identification of personality disorders should be considered in the diagnostic assessment of depressive disorders. The present study aimed to further analyze data on this topic by comparing 2 groups of depression patients: those with concomitant BPD and those with other Axis II codiagnoses. Material and MethodsWe included in this study 119 consecutive outpatients (aged 18 years and over) who had a diagnosis of personality disorder and a codiagnosis of MDD. Patients attended the Service for Personality Disorders, Unit of Psychiatry, at the University of Turin. Diagnoses were made by an expert clinician according to DSM-IV-TR criteria (18) and were confirmed with the Structured Clinical Interview for DSM-IV disorders (SCID, 19,20). Subjects were excluded if they had a current or previous diagnosis of delirium, dementia, amnestic disorder, or other cognitive disorders; schizophrenia or other psychotic disorders; or bipolar disorders. Each patient participated voluntarily in this study after providing written informed consent. Patients were divided into 2 subgroups: those with a diagnosis of BPD and those with a different Axis II diagnosis. Patients were tested with the following instruments:
Rating scales were administered by 2 investigators who were blind to the Axis I and II diagnoses. Pearson’s chi-square test and Student’s t test for independent samples were used to compare categorical and continuous variables between subgroups. We included all factors found to be significantly different between subgroups in a regression model (stepwise), choosing the number of SCID criteria for BPD as the dependent variable. ResultsThe patient sample had a mean age of 37.23 years, SD 14.67; there were 74 women (62.2%) and 45 men (37.8%). In total, 45 patients (37.8%) had a diagnosis of BPD, while 74 patients (62.2%) met criteria for the following other personality disorders: obsessive–compulsive (n = 20, 16.8%), avoidant (n = 17, 14.3%), dependent (n = 13, 10.9%), histrionic (n = 11, 9.2%), narcissistic (n = 10, 8.4%), paranoid (n = 8, 6.7%), schizotypal (n = 6, 5%), and schizoid (n = 4, 3.4%). Table 1 reports Pearson’s chi-square test comparisons of categorical variables between subgroups. In the BPD subgroup, we found more common occurrence of Axis I comorbidity (P = 0.042), mood and anxiety disorders in first-degree relatives (P = 0.016), self-mutilating behaviours (P = 0.0005), substance abuse (P = 0.008), verbal or emotional abuse in childhood (P = 0.008), and physical abuse in childhood (P = 0.049).
Table 2 shows mean (SD) values of continuous variables and comparisons of the 2 subgroups with Student’s t test. Patients with BPD had a lower mean age (P = 0.019), an earlier age at onset of MDD (P = 0.025), a lower SOFAS score (P = 0.0005), and higher scores on the HARS (P = 0.021), ZSDS (P = 0.007), and SDS (P = 0.0005).
Multiple regression showed that 5 variables were significantly related to the number of criteria for BPD: the ZSDS score (P = 0.0005), self-mutilating behaviours (P = 0.001), and occurrence of mood disorders in first-degree relatives (P = 0.01) were positively related, whereas the SOFAS score (P = 0.0005) and age at onset of MDD (P = 0.006) were negatively related (Table 3).
DiscussionOur data contribute to outlining differential characteristics of patients with coexisting MDD and BPD, compared with depression patients with other Axis II codiagnoses. Results of regression analysis indicate that the number of BPD criteria is related to earlier age at onset of MDD, more serious patient-rated depressive symptoms, worse clinician-rated global functioning, more common history of self-mutilating behaviours, and higher occurrence of mood disorders in first-degree relatives. Our findings concerning age at onset of MDD, level of global functioning, and frequency of self-mutilating behaviours are consistent with previous studies (9–11,15,16). The association we found between number of BPD criteria and prevalence of mood disorders in the families of our depression patients can also be considered a substantial confirmation of preceding reports. For example, several authors have reported an increased rate of mood disorders in the relatives of BPD patients (1,27,28) and have suggested that it could be the consequence of coexisting affective syndromes. Riso and colleagues pointed out that the rates of mood disorders in the relatives of BPD probands were similar to rates found in a mood disorder control group (29). Similarly, our investigation of a sample of patients with a diagnosis of MDD found that coexisting BPD features were related to a family history of mood disorders. Despite some differences in methods among studies, available data implicate a strong familial link between BPD and mood disorders, suggesting that overlapping etiologic factors be considered. A notable finding in our study is that the number of BPD criteria is only significantly related to the severity of depressive symptoms when measured by the patient, not by the clinician. This result appears discordant with a previous investigation by Comtois and colleagues, who reported that both a clinician-rated scale and a self-report measure of depressive symptoms were significantly related to BPD (2). If the difference that we found between the 2 types of scale is confirmed, a possible explanation could be that BPD patients experience and express depression with a dramatic and emphasized modality. In conclusion, results of our study indicate that, compared with MDD patients having other Axis II codiagnoses, MDD patients with coexisting BPD are characterized by distinct clinical features. These include earlier onset and more severe depression, worse social impairment, more pronounced self-aggressiveness, and a stronger familial association with mood disorders. These differential characteristics may have diagnostic and therapeutic implications. They indicate the need for an accurate assessment of personality disorders in depression patients to identify cases with concomitant BPD and to reduce the incidence of complications such as self- mutilating behaviours or suicide attempts and loss of social abilities. The search for BPD should be particularly recommended in depression patients with a family history of mood disorders. Moreover, detection of BPD could be considered a predictive factor for early-onset MDD and induce clinicians to provide adequate preventive treatment. A limitation of our study is that we collected clinical data retrospectively by interviewing patients on their psychiatric history. In particular, childhood abuse was identified from patients’ memories. The validity of retrospective methods to collect data on autobiographical events remains controversial, although some authors regard patients’ reports as sufficiently accurate (30,31). Another limitation is that data concerning previous and ongoing treatments were not analyzed, because there was considerable heterogeneity in drug and psycho-social interventions. References1. Zanarini MC, Gunderson JG, Marino MF, Schwartz EO, Frankenburg FR. DSM-III disorders in the families of borderline patients. J Personal Disord 1998;2:292–302. 2. Comtois KA, Cowley DS, Dunner DL, Roy-Byrne PP. Relationship between borderline personality disorder and Axis I diagnosis in severity of depression and anxiety. J Clin Psychiatry 1999;60:752–8. 3. Zimmerman M, Mattia JI. Axis I diagnostic comorbidity and borderline personality disorder. Compr Psychiatry 1999;40:245–52. 4. Gunderson JG, Phillips KA. A current view of the interface between borderline personality disorder and depression. Am J Psychiatry 1991;148:967–75. 5. Rogers JH, Widiger TA, Krupp A. Aspects of depression associated with borderline personality disorder. Am J Psychiatry 1995;152:268–70. 6. 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Br J Med Psychol 1959;32:50. 22. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56–62. 23. Zung WK. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63–7. 24. Goldman HH, Skodol AE, Lave TR. Revising Axis V for DSM-IV: a review of measures of social functioning. Am J Psychiatry 1992;149:1148–56. 25. Sheehan DV, Harnett Sheehan K, Ray BA. The measurement of disability. Int Clin Psychopharmacol 1996;11(Suppl):89–95. 26. Zanarini MC, Gunderson JG, Marino MF, Schwartz EO, Frankenburg FR. Childhood experiences of borderline patients. Compr Psychiatry 1989;30:18–25. 27. Pope GP, Jonas JM, Hudson JI, Cohen BM, Gunderson JG. Borderline personality disorder: a phenomenologic, family history, treatment response, and long-term follow-up study. Arch Gen Psychiatry 1983;40:23–30. 28. Silverman JM, Pinkham L, Horvath TB, Coccaro EF, Klar H, Schear S, and others. Affective and impulsive personality disorder traits in the relatives of patients with borderline personality disorder. Am J Psychiatry 1991;148:1378–85. 29. Riso LP, Klein DN, Anderson RL, Ouimette PC. A family study of outpatients with borderline personality disorder and no history of mood disorder. J Personal Disord 2000;14:208–17. 30. Perugi G, Toni C, Traverso MC, Akiskal HS. The role of cyclothymia in atypical depression: toward a data-based reconceptualization of the borderline-bipolar II connection. J Affect Disord 2003;73:87–98. 31. Brewin CR, Andrews B, Gotlib IH. Psychopathology and early experience: a reappraisal of retrospective reports. Psychol Bull 1993;113:82–98. Author(s)Manuscript received September 2003, revised, and accepted July 2004. 1. Assistant Professor, Unit of Psychiatry, Department of Neuroscience, University of Turin, Italy. 2. Psychiatrist, Unit of Psychiatry, Department of Neuroscience, University of Turin, Italy. 3. Psychiatry Resident, Unit of Psychiatry, Department of Neuroscience, University of Turin, Italy. 4. Clinical Psychologist, Unit of Psychiatry, Department of Neuroscience, University of Turin, Italy. 5. Professor, Unit of Psychiatry, Department of Neuroscience, University of Turin, Italy. Address for correspondence: Dr S Bellino, Unit of Psychiatry, Department of Neuroscience, University of Turin, via Cherasco 11, 10126 Torino, Italy e-mail: silvio.bellino@unito.it
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