Bpd And Cyclothymia

[lostsoul]

Hi there

I was just reading some articles recently about BPD and its relationship to this other disorder called cyclothymia. Apparently many BPDs get diagnosed with BPD when instead they should be diagnosed with cyclothymia, or vice versa, because they share some similar diagnostic symptoms.

I was just wondering whether any of you have previously been diagnosed with cyclothymia or whether you have wondered if you have cyclothymia, or just even can you tell me anything about it cos i'm still a bit confused about whether it is supposed to be a reactive mood disorder or simply chemical?

i know it is like a mini-version of manic depression, with more rapid cycling of moods that change form mild depression to mild hpomania, and which can change in a short time period, eg, hours, days, weeks. There are also periods of normal functioning which can occur between ups and downs.

Any ideas, information or experiences would be really appreciated... thanks :)

[lostsoul]

This is one of the articles i read it's a bit wordy...

Cyclothymia: Readings from MEDLINE.

Compiled by, Ivan Goldberg, MD

1: J Affect Disord. 2003 Jan;73(1-2):87-98.

The role of cyclothymia in atypical depression: toward a data-based

reconceptualization of the borderline-bipolar II connection.

Perugi G, Toni C, Travierso MC, Akiskal HS.

Department of Psychiatry, University of Pisa, Via Roma 67, 56100, Pisa, Italy.

gperugi@pisco.med.unipi.it

OBJECTIVE: Recent data, including our own, indicate significant overlap between

atypical depression and bipolar II. Furthermore, the affective fluctuations of

patients with these disorders are difficult to separate, on clinical grounds,

from cyclothymic temperamental and borderline personality disorders. The present

analyses are part of an ongoing Pisa-San Diego investigation to examine whether

interpersonal sensitivity, mood reactivity and cyclothymic mood swings

constitute a common diathesis underlying the atypical depression-bipolar

II-borderline personality constructs. METHOD: We examined in a semi-structured

format 107 consecutive patients who met criteria for major depressive episode

with DSM-IV atypical features. Patients were further evaluated on the basis of

the Atypical Depression Diagnostic Scale (ADDS), the Hopkins Symptoms Check-list

(HSCL-90), and the Hamilton Rating Scale for Depression (HRSD), coupled with its

modified form for reverse vegetative features as well as Axis I and SCID-II

evaluated Axis II comorbidity, and cyclothymic dispositions ('APA Review',

American Psychiatric Press, Washington DC, 1992). RESULTS: Seventy-eight percent

of atypical depressives met criteria for bipolar spectrum-principally bipolar

II-disorder. Forty-five patients who met the criteria for cyclothymic

temperament, compared with the 62 who did not, were indistinguishable on

demographic, familial and clinical features, but were significantly higher in

lifetime comorbidity for panic disorder with agoraphobia, alcohol abuse, bulimia

nervosa, as well as borderline and dependent personality disorders. Cyclothymic

atypical depressives also scored higher on the ADDS items of maximum reactivity

of mood, interpersonal sensitivity, functional impairment, avoidance of

relationships, other rejection avoidance, and on the interpersonal sensitivity,

phobic anxiety, paranoid ideation and psychoticism of the HSCL-90 factors. The

total number of cyclothymic traits was significantly correlated with 'maximum'

reactivity of mood and interpersonal sensitivity. A significant correlation was

also found between interpersonal sensitivity and 'usual' and 'maximum'

reactivity of mood. LIMITATION: Correlational study. CONCLUSIONS: Mood lability

and interpersonal sensitivity traits appear to be related by a cyclothymic

temperamental diathesis which, in turn, appears to underlie the complex pattern

of anxiety, mood and impulsive disorders which atypical depressive, bipolar II

and borderline patients display clinically. We submit that conceptualizing these

constructs as being related will make patients in this realm more accessible to

pharmacological and psychological interventions geared to their common

temperamental attributes. More generally, we submit that the construct of

borderline personality disorder is better covered by more conventional

diagnostic entities.

[Lauren]

Hmmm this is why I love you Claire. You want awnsers to things even the pros cant agree on yet.

cyclothymia has similar sypmtoms to some of those associated with BPD. ie the rapid changing thoughts and moods.

The best way ive found to think about is that with bpd the thoughts come before the mood shift with cyclothymia the mood changes then possibly the thoughts follow.

But as you know bpd is often co mormid with the likes of cyclothymia/bipolar and many other disorders.

Thats why its so complicated

Do I have it? it was suggested a few years back.But to be honest the highs it induces are a welcome break (as long as im not near any shops ) and the lows are tollerable when caused by that.

Its so very complicated all this stuff. Keep asking questions though. Helps to keep my mind sharp

L

xxx

[lostsoul]

Almost immediately after my marriage, my husband began to display signs of severe mood swings. One minute he would be completely elated, the next he would plummet into a dark mood. If I asked him if he was okay, he would become aggressive. Some days he would hide in the cupboard when people called round. Other times he'd welcome them in and be the life and soul of the party. The black moods and sulks began to dominate our lives. The more he laughed, the greater we feared the inevitable down side. I began to be on the receiving end of cruel jibes, my husband blamed me for everything that was wrong in his life.

His treatment over the years, ranging from psychotherapy to drugs only seemed to make matters worse. The rages were terrifying; he would smash things up in the house. If I tried to talk to him about how he felt I would be faced with a torrent of abuse or he would simply run off. Other times, he would simply break down into uncontrollable sobs.

Ironically, one of the most difficult things to cope with is my husband's generosity and kindness towards others. He will tread on hot coals to help people he barely knows, but is quite the opposite with his family. He buys relative strangers 'little presents' and sends them hand-drawn postcards and hides his intellect to make others feel superior to him. People frequently comment on how kind my husband is, telling me how lucky I am to be married to him. 'St Peter' one of his former colleagues called him. They rarely see what he's really like and the strain that I'm living under.

A few years ago when 'cyclothymia' [mood disorder] was mentioned to my husband he looked it up and said, 'That's me!' He was happy to find a label that describes how he feels and that helps him to understand his condition. He knows if his mood is manically up one day, he can expect the flip side the next day. Him gaining this insight improved things for both of us.

I am sorry that my husband is ill and unhappy but I cannot do anything about it. I gave up the notion of caring for him a long time ago. We just co-exist now and deal with any problems as they arise. I don't want to end up feeling bitter for the lost years. As soon as I can afford a mortgage, I will leave him and try to get my own life back.

-----------------------

this is a true story written by the wife of a cyclothmic guy. aw what a bitch she must be lol, sounds very sad I reckon he is better off without her. anyway, getting off the point...

thanks lorna for your reply - i can totally see hwere you are coming from with the thoughts either coming before or after the mood shift thing... yeah that's the only way i could understand the essential difference with the reactiveness.

erm, i dunno. it's confusing. there are diagnoses out there like CYCLOTHYMIC BORDERLINE which combines the two. i'm so confused lol. I hope these doctor dudes sort it all out b4 my head explodes :P

[lostsoul]

i have not had a chance to read this yet but looks promising

---------------------------------------------------------

Return to Medscape coverage of: American Psychiatric Association 156th Annual Meeting | Bipolar

Demystifying Borderline Personality: The Cyclothymic-Bipolar II Connection

Disclosures

Hagop S. Akiskal, MD

Introduction

Despite considerable overlap between borderline personality disorder and affective disorders based on methodologically sound studies, as prominent a borderline expert as Gunderson[1] has downplayed such a relationship. Such denial is all the more surprising given the fact that his research team[2] reported that borderline patients at some point in their life met criteria for dysthymia (80%) and/or major depressive disorders (100%). For this reason, it is generally conceded that the nature of affective illness in borderline patients is best described as "atypical." The question of the relationship between borderline and affective disorders then is one of characterizing the nature of "atypicality." The thrust of my argument in this report[3] is that the atypicality of the affective dysregulation of patients given borderline diagnoses can be more precisely delineated in terms of cyclothymic and bipolar II disorders.

Defining the Borderline Terrain

In the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), borderline refers to a discrete operationally defined construct within the "dramatic cluster" of personality disorders. This definition largely derives from the work of Gunderson and Singer.[4] Among its chief merits is the stimulation of a plethora of data-based investigations of borderline conditions since 1980 as well as the development of the Diagnostic Interview for Borderline (DIB) as its structured measurement. Among the limitations of this operationalized approach is that the concept has been oversimplified, even banalized: it has an unwieldy heterogeneity and overlaps significantly, not only with personality disorders within its own cluster, but also with the schizotypal-paranoid and anxious clusters. Of related concern is the fact that DSM-IV criteria, rather than restricting themselves to defining personality attributes, mix traits, symptoms and behaviors -- particularly of an affective nature (Table 1).

Table 1.

Core Characteristics of DSM-IV Borderline Personality Rearranged to Highlight

Affective Loading

Unstable intense relationships - "splitting"

- "object hunger"

- abandonment depression

Affective instability - mercurial moods

- reactive dysphoria

- angry outbursts

Behavioral dyscontrol -impulsivity

- substance abuse

- binge eating

- suicidality

Chronic emptiness -boredom

Unstable sense of self - identity disturbances

Micropsychosis -paranoid sensitivity- dissociation

Of even greater concern is that the operational construct may not coincide with what psychoanalysts mean when they make the clinical diagnosis of borderline personality organization. The latter refers to Kernberg's pioneering contributions[5] in delineating a vulnerable psychic structure, rather than a specific nosologic entity. It refers to a class of personality dysfunctions with common defensive operations, reflecting a vulnerable psychic structure that functions at a "stably unstable" level between the classic neuroses and psychoses. Unlike Gunderson's concept of borderline as a specific personality disorder -- which does not lie on the border of any specific mental disorder -- Kernberg's conceptualization maps a large terrain of psychopathology with affective, neurotic, and paraphiliac disturbances. Kernberg's position appears to be more compatible with psychobiologic formulations of borderline, which place this personality disorder on the borders of such disorders as schizophrenic, manic-depressive, and epileptic psychoses. In this framework,[6] borderline refers to formes frustes of the major endogenous psychoses (ie, subschizophrenic, subaffective, or subictal disorders). This paper updates previous contributions by the present author,[6-10] and integrates them with other emerging trends that emphasize the central role of the cyclothymic constitution in the genesis of borderline, atypical, and bipolar II disorders.

Delineating the Affective Border

Initially, the borderline concept developed as a dilute form of psychosis, and its main usefulness was to exclude such patients from the couch. Working in New York, Stone[11] -- who reported that these patients often came from families with manic-depressive and alcoholic members -- can be credited for having been the first to make a persuasive argument about the need to shift from borderline as a subschizophrenic to a subaffective disorder.

Independently, the present author too arrived at the same conclusion: curiously, our work at the University of Tennessee[6,7] had started off with the hypothesis that many patients with borderline personality had affinity to schizophrenic disorders as defined in the framework of the Danish adoption study of schizophrenia. We studied 100 consecutive outpatients -- in a Memphis mental health center -- meeting the Gunderson and Singer criteria[4] for borderline personality. They were clinically evaluated using a semistructured interview based on a modified version of the Washington University approach to psychiatric diagnosis.[12]

Contradicting our starting hypothesis, only 16% were schizotypal.[6] As for other psychopathology, borderline embraced a broader spectrum than we had anticipated. At index evaluation, 66 met the criteria for recurrent depressive, dysthymic, cyclothymic, or bipolar II disorders; other patients met criteria for sociopathic, panic-agoraphobic, attention-deficit/hyperactivity and epileptic disorders. During prospective observation of up to 3 years, and compared with nonborderline personality subjects, borderline probands had a significantly higher risk for developing major affective disorders than schizophrenia spectrum disorders; furthermore, there were 4 completed suicides. Prominent substance abuse history, stormy biographies, and unstable developmental history marked by repeated object loss were common to all borderline subgroups. From a familial standpoint, borderline probands were closest to the affective, especially the bipolar, comparison group. This familial-genetic bipolar link was reinforced by antidepressant associated switches into irritable-angry hypomanic and mixed states in 20% of our sample during prospective observation. (Of note, "paradoxical" disinhibition on antidepressants in borderline patients has also been observed by others.[13,14])

To summarize, the recurrent nature of affective disorder, coupled with familial bipolarity and spontaneous and pharmacologic excursions into brief periods of elation, places the affective pathology of borderline patients in the soft bipolar realm (that can be broadly defined as bipolar II).

The Nature of "Atypicality"

It is often assumed that micropsychotic and dissociative episodes in patients given borderline diagnoses emanate from psychotic processes. This is a misconception. Grandiose or irritable forms of hypomania occurred in a third of our borderline probands with affective diagnoses.[6] Transient drug-induced psychoses secondary to alcohol, sedative hypnotic, psychedelic or stimulant drug use, or withdrawal were reported in nearly half of all borderline cases. Finally, depersonalization-derealization, as well as brief reactive psychoses, were not uncommon in the borderline probands with concurrent panic-agoraphobic diagnoses. Such data provide a useful beginning framework for understanding the "atypicality" of the affective disorder in borderline patients.

To explain the atypicality of the affective state of borderline patients, Gunderson and Phillips[1] contrasted "empty" depression in this personality with the more classical "guilt" depressions in "classical" affective disorder. Thus, their unstable, hostile, and labile moods -- the unrelenting tension and irritability with superimposed paroxysms of rage -- are relegated by these authors back into the characterologic realm. The thrust of this argument is based on a misconception that only classical affective disorder is a "true" affective disorder. In a forensic population, Coid[15] recently provided a compelling description of the affective storms of borderline patients (restlessness, irritability, explosive anger, tension, psychotic anxiety), which lead to -- and alternate with -- the deceptive "calm" and "emptiness" following self-mutilation. Whatever one ends up calling such patients, one cannot but respect their affectively driven temperamental excesses (lest one becomes victimized by them!). Since 1981, the present author[7] has defended the position that a significant proportion of these patients suffer -- and make their loved ones suffer -- as a result of temperamental dysregulation along dysthymic-irritable-cyclothymic lines. Mood lability and hostile emotional avalanches, which characterize borderline patients, seem to derive from such temperamental dysregulation, which is quintessentially affective in nature.

The Atypical-Bipolar II Connection

Major depressive states with reverse vegetative signs (so-called "atypical features") are commonly encountered in this unstable temperamental terrain. Three recent studies have provided greater clarification about this complex interface of volatile affective temperament and atypical affective states.

In collaboration with clinical researchers in Pisa,[16] we demonstrated that 72% of 80 depressive patients with DSM-IV atypical features simultaneously met the criteria for bipolar II; 60% had antecedent cyclothymic temperament. In addition, 94% were rated as interpersonally sensitive. As expected, using the DSM-IV axis II schema, both cluster B (borderline-histrionic) and cluster C (avoidant) personality disorders were prevalent.

Deltito and colleagues[17] studied 20 consecutive patients diagnosed borderline by experienced clinicians at Westchester-Cornell, "validated" independently by Gunderson's DIB. They then rated them by descending order of certainty of bipolarity: in light of what the current literature indicates as established bipolarity ( bipolar I + bipolar II), the conservative rate for bipolarity in this well-characterized, though small. sample of borderlines was 44%; taking the most liberal definition of bipolarity (including pharmacologic-hypomania, cyclothymic temperament, and family history for bipolar disorder), 81% of borderline patients could be considered lying on the border of within the bipolar spectrum. This provocative work, though preliminary, represents the first head-to-head comparison of borderline personality and bipolarity[11] (and obviously is in need of replication).

The author's research as part of the National Institute of Mental Health Collaborative Study of Depression[18] has shown that clinical features reminiscent of borderline features (SADS Item 12) were strongly predictive of which major depressives would, over a prospective observation period of 11 years, switch to bipolar II (Table 2). The temperament of these patients was a mélange of interpersonal sensitivity and mood lability. This study underscores the importance of temperamental factors in borderline psychopathology, as well as their value in predicting bipolar outcome. Stated more tersely, borderline personality, interpersonal sensitivity, mood labile temperamental traits, and bipolar II seem to represent overlapping expressions of the same diathesis. (That mood lability is not pathognomonic for borderline personality, and occurs in bipolar II as well, has been replicated by Henry and colleagues.[19])

Table 2.

Prospective Prediction of Bipolar II Outcome in 8.6% of 559 Patients With Major Depressive Disorder*

- Younger age at onset

- High depressive recurrence

- Greater marital disruption

- Higher score on phobic anxiety

- More "borderline" clinical features

- Higher score on interpersonal sensitivity

- High on trait energy-activity and daydreaming

- High on trait mood lability

- 42% sensitivity

- 86% specificity

*Summarized from Akiskal et al[18]

Borderline as a Casualty of the Axis I-Axis II Distinction

One of the inadequacies of our current nosologic schema of personality disorders is that the long-term functioning of patients suffering from major mood disorders is described primarily in "characterologic" language (Axis II in DSM-IV), which is conceptually removed from the "temperamental" language that had been used in classical European psychiatry during the first part of this century. For instance, today bipolar patients are often described as "dramatic," "erratic," "unstable," impulsive," "passive-aggressive," "histrionic," "narcissistic," or "borderline," as if affective temperaments had little to contribute to our understanding of these personality disorders. O'Connell and colleagues[20] appropriately pointed out that structured interviews tend to misclassify subthreshold affective disturbances as dramatic personality disorders. The author's work[21] and subsequent research by Levitt and colleagues[22] have actually shown significant overlap between the cyclothymic temperament and borderline personality disorder.

There are advantages to returning to the more natural affective temperamental language of describing the premorbid, intermorbid, and postmorbid phases of major affective disorders. In this framework,[7,21,23] affective temperaments represent the substrate from which the more florid episodes develop. Using the analogy of earthquakes, I have elsewhere[9] compared the predisposing terrain and affective instability in 2 types of depression. In many affective ill patients, the temperamental terrain is not visibly pathologic but refers to a vulnerable fault that can be destabilized periodically, erupting into extreme pathology that could lead to self-destruction. In this more classical affective type, the patient has relatively normal -- or even supernormal or hyperthymic -- functioning between episodes. In other patients, the temperamental terrain is characterized by greater instability and intermittent or nearly continuous emotional "mini-earthquakes"; these patients seem "protected," though not entirely, from major melancholic episodes. The patient with this second type of temperamental dysregulation suffers from protracted intermittent emotional disequilibrium and restlessness without necessarily having full-blown syndromal affective episodes. These are then considered to be "atypical" or "borderline" cases where the terrain is so pathologically unstable that it may be difficult to discern the superimposed episodes that are an accentuation of the basic pathology.

Borderline as the "Darker Side" of Cyclothymia

Our work has actually demonstrated that the temperamental terrain between depression and manic-depression is bridged by a spectrum of subtle bipolar disorders with an extremely variable course.[7,21,23] Mood switches are recurrent, biphasic and abrupt, and may be seasonal and sometimes exacerbated by antidepressants. The term "explosive" captures the abruptness of the affective switches, each phase lasting for hours, days, and, sometimes, weeks. These patients are rarely euthymic. Their mood shifts often follow a circadian pattern (ie, waking up convinced of the futility of existence), but can also be reactive to interpersonal altercations, often rather trivial in nature, but emotionally charged for the patient. Even when provoked by such situations, the resultant emotional outbursts are more like avalanches than understandable reactions proportional to the proximate provoking situation.[23] One must infer an endogenous propensity to extreme emotional reactivity to these patients. Given such emotional tempests, it is no wonder that most clyclothymes accumulate an extreme array of social disturbances by their mid-20s[21]: repeated romantic failure, episodic promiscuity, financial extravagance, uneven work or school record, dilettantism, geographic instability, polysubstance abuse, and joining various eschatologic cults. Such instability appeared to be secondary to lifelong biphasic mood swings below the threshold for full-blown bipolar disorder. Subsequent studies in a community sample[24] have reported similar interpersonal havoc and social disruptions.

The instability in the biography of cyclothymics is especially accentuated in those with predominantly irritable traits.[23] These individuals are habitually dysphoric, prone to anger, hypercritical and complaining, with a penchant for ill-humored joking. They would thus easily offend their loved ones, often leading to verbally abusive behavior when only minutes or hours earlier they had vowed "eternal" love. At other times, interpersonal crises escalate because of their pouting and obtrusive behavior. In brief, the morose temperamentality of the irritable cyclothymic provides the unstable base from which interpersonal tempests arise.

Recent data[25] from a French national collaborative study has shown that the notion of cyclothymia and hypomania as positive "sunny" traits and behaviors represents just one facet of soft bipolarity. This driven-euphoric facet should be contrasted with the irritable-tempestuous or "darker" side of bipolarity. The correlation of cyclothymia reaches significance (.37) only with the latter facet. In brief, depressions arising from a cyclothymic baseline are often characterized by dysphoric hypomanic periods, and are likely to be misdiagnosed as erratic personality disorders. Their high familial load for affective (including bipolar) disorder support their inclusion as a more unstable variant of bipolar II that can be best be characterized as "cyclothymic depressions."

Another study[26] relevant to the "darker" side of bipolarity, which is still unpublished, derives from the author's collaboration with the University of Pisa. In 107 atypical major depressive patients, logistic regression revealed that cyclothymic temperament accounted for much of the relationship between atypicality and borderline personality. The cyclothymic-sensitive disposition seems to represent the common denominator in the complex syndromic pattern of anxiety, mood, and impulse disorders. We explained these findings and considerations as support for the contention that atypical depression, borderline personality, cyclothymia, and bipolar II represent overlapping manifestations of a common underlying psychobiologic diathesis.

Unless their temperamental vulnerabilities are understood properly, the comorbidity and erratic clinical presentations of these borderline patients can baffle clinicians. As a result, some researchers prefer to characterize these vulnerabilities along the lines of sociopathy and related personality disorders.[27] Such characterization, in my opinion, misses the core emotionality of borderline patients that can be observed in both patients and in their biologic kin.[28] I submit that interpersonal sensitivity, mood reactivity, and lability are more germane to the origin of borderline psychopathology and its comorbidities. It is their innate -- and, to some extent, developmentally acquired -- intense reactivity to others that creates their turbulent relationships, and indeed their entire biography.

As discussed elsewhere,[10] the tragedy of borderline patients is that their impulsive drive, which thrusts them into the theater of human interactions -- coupled with their negative affectivity -- accentuates and thereby validates their sense of being rejected emotionally, maltreated, and abused; the more unfortunate among them do get actually abused by psychopathic family members (usually a step-parent).

Concluding Remarks

Discussion of psychopharmacologic and formal psychotherapeutic interventions in borderline personality conceived as a soft bipolar variant are beyond the scope of this paper. Suffice it to say that the affective framework for borderline personality described in this paper has major implications for clinical management. Foremost among them is that affective reconceptualization of borderline pathology may substantially reduce the therapists' countertransference[29] because now the patient is viewed as affectively ill, rather than "character flawed." Treatment should be undertaken with the requisite competence and confidence for a serious mental disorder. The suicide risk -- a potentially fatal consequence of the intense affective dysregulation -- should be conceptualized and clinically managed as rigorously as in any patient with serious mood disorder. The affective dysregulation and the impulsivity that underlies such risk may, in principle, be preventable with mood stabilizers, including carbamazepine and divalproex. This is a vital public health priority.

These patients often come from disturbed families and appear at risk for emotional instability due to both genetic factors (eg, bipolarity, alcoholism) and developmental factors (eg, disruption in early attachment bonds and other traumatic experiences). The neuroendocrine and sleep neurophysiologic correlates of their exquisite affective vulnerabilities have been documented elsewhere.[10] Since borderline patients -- in view of their negative affectivity -- often develop malevolent object representations of significant others in their lives,[30] clinicians must not assume that the parents of borderline patients are or were "monsters." Parents' guidance is often crucial to these patients' mastery of maturational tasks. On the other hand, Kurt Schneider's[31] wise admonition should not be forgotten: "On their bad days, keep out of their way as far as possible."

References

Gunderson JG, Phillips KA. A current view of the interface between borderline personality disorder and depression. Am J Psychiatry. 1991;148:967-975. Abstract

Zanarini MC, Gunderson JG, Frankenburg, FR. Axis I phenomenology of borderline personality disorder. Compr Psychiatry. 1989;30:149-156. Abstract

Akiskal HS. Borderline personality or bipolar II? Program and abstracts of the American Psychiatric Association 156th Annual Meeting; May 17-22, 2003; San Francisco, California. Abstract S100A.

Gunderson JG, Singer MT. Defining borderline patients: an overview. Am J Psychiatry. 1975;132:1-10. Abstract

Kernberg OF. Borderline personality organization. J Am Psychoanal Assoc. 196715:641-685.

Akiskal HS, Chen SE, Davis GC, Puzantian VR, Kashgarian M, Bolinger JM. Borderline: an adjective in search of a noun. J Clin Psychiatry. 1985;46:41-48. Abstract

Akiskal HS. Subaffective disorders: dysthymic, cyclothymic and bipolar II disorders in the "borderline" realm. Psychiatr Clin North Am. 1981;4:25-46. Abstract

Akiskal HS, Yerevanian BI, Davis GC, King D, Lemmi H. The nosologic status of borderline personality: clinical and polysomnographic study. Am J Psychiatry. 1985;142:192-198. Abstract

Akiskal HS. Temperaments on the border of affective disorders. Acta Psychiatr Scand. 1994;89(suppl 379):32-37.

Akiskal HS. Die borderline-personlichkeit: affektive grundlagen symptome und syndrome [borderline personality: affective substrates, symptoms, and syndromes]. In Kernberg OF, Dulz B, Sachsse U, eds. Handbuch der Borderline-Storungen. Stuttgart: Schattauer; 2000:259-270.

Stone MH. The borderline syndrome: constitution, personality and adaptation. New York: McGraw-Hill; 1980.

Feighner JP, Robins E, Guze SB, et al. Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry. 1972;26:57-63. Abstract

Soloff PH, Millward JW. Psychiatric disorders in the families of borderline patients. Arch Gen Psychiatry. 1983;40:37-44. Abstract

Levy D, Kimhi R, Barak Y, Viv A, Elizur A. Antidepressant-associated mania: a study of anxiety disorders patients. Psychopharmacology. 1998;136:243-246. Abstract

Coid JW. An affective syndrome in psychopaths with borderline personality disorder? Br J Psychiatry. 1993;162:641-650.

Perugi G, Akiskal HS, Lattanzi L, et al. The high prevalence of soft bipolar (II) features in atypical depression. Compr Psychiatry. 1998;39:63-71. Abstract

Deltito J, Martin L, Riefkohl J, et al. Do patients with borderline personality disorder belong to the bipolar spectrum? J Affect Disord. 2001;67:221-228.

Akiskal HS, Maser JD, Zeller P, et al. Switching from "unipolar" to bipolar II: an 11-year prospective study of clinical and temperamental predictors in 559 patients. Arch Gen Psychiatry. 1995;52:114-123. Abstract

Henry C, Mitropoulou V, New AS, Koenigsberg HW, Silverman J, Siever LJ. Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences. J Psychiatr Res. 2001;35:307-312. Abstract

O'Connell RA, Mayo JA, Sciutto MS. PDQ-R personality disorders in bipolar patients. J Affect Disord. 1991;23:217-221. Abstract

Akiskal HS, Djenderedjian AM, Rosenthal RH, Khani MK. Cyclothymic disorder: validating criteria for inclusion in the bipolar affective group. Am J Psychiatry. 1977;134:1227-1233. Abstract

Levitt AJ, Joffe RT, Ennis J, MacDonald C, Kutcher SP. The prevalence of cyclothymia in borderline personality disorder. J Clin Psychiatry. 1990;51:335-339. Abstract

Akiskal HS. Delineating irritable and hyperthymic variants of the cyclothymic temperament. J Pers Disord. 1992a;6:326-342.

Depue RA, Slater JF, Wolfstetter-Kausch H, Klein D, Goplerud E, Farr D. A behavioral paradigm for identifying persons at risk for bipolar depressive disorder: a conceptual framework and five validation studies. J Abnorm Psychol. 1981;90:381-437. Abstract

Akiskal HS, Hantouche EG, Lancrenon S. Bipolar II with and without cyclothymic temperament: "dark" and "sunny" expressions of soft bipolarity. J Affect Disord. 2003;73:49-57. Abstract

Perugi G, Akiskal HS. Are bipolar II, atypical depression, and borderline personality overlapping manifestations of a common cyclothymic-sensitive diathesis? J Clin Psychiatry. 2003; In press.

Hudziak JJ, Boffeli TJ, Kriesman JJ, Battaglia MM, Stanger C, Guze SB. Clinical study of the relation of borderline personality disorder to Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorder. Am J Psychiatry. 1996;153:1598-1606. Abstract

Silverman JM, Pinkham L, Horvath TB, Coccaro EF. Affective and impulse personality disorder traits in the relatives of patients with borderline personality disorder. Am J Psychiatry. 1991;148:1378-1385. Abstract

Gardner DL, Cowdry RW. Suicidal and parasuicidal behavior in borderline personality disorder. Special Issue: self-destructive behavior. Psychiatr Clin North Am. 1985;8:389-403. Abstract

Nigg JT, Lohr NE, Western D, Gold LJ, Silk KR. Malevolent object representations in borderline personality disorder and major depression. J Abnorm Psychol. 1992;101:61-67. Abstract

Schneider K. Psychopathic Personalities. Springfield, Ill; Charles C. Thomas: 1958.

[LadyMacbeth]

Hi LostSoul,

I just wanted to say thank you for posting that it was really interesting and I learned a lot from it.

i have not had a chance to read this yet but looks promising

---------------------------------------------------------

Return to Medscape coverage of: American Psychiatric Association 156th Annual Meeting  |  Bipolar

Demystifying Borderline Personality: The Cyclothymic-Bipolar II Connection

Disclosures

Hagop S. Akiskal, MD 

Introduction

Despite considerable overlap between borderline personality disorder and affective disorders based on methodologically sound studies, as prominent a borderline expert as Gunderson[1] has downplayed such a relationship. Such denial is all the more surprising given the fact that his research team[2] reported that borderline patients at some point in their life met criteria for dysthymia (80%) and/or major depressive disorders (100%). For this reason, it is generally conceded that the nature of affective illness in borderline patients is best described as "atypical." The question of the relationship between borderline and affective disorders then is one of characterizing the nature of "atypicality." The thrust of my argument in this report[3] is that the atypicality of the affective dysregulation of patients given borderline diagnoses can be more precisely delineated in terms of cyclothymic and bipolar II disorders.

Defining the Borderline Terrain

In the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), borderline refers to a discrete operationally defined construct within the "dramatic cluster" of personality disorders. This definition largely derives from the work of Gunderson and Singer.[4] Among its chief merits is the stimulation of a plethora of data-based investigations of borderline conditions since 1980 as well as the development of the Diagnostic Interview for Borderline (DIB) as its structured measurement. Among the limitations of this operationalized approach is that the concept has been oversimplified, even banalized: it has an unwieldy heterogeneity and overlaps significantly, not only with personality disorders within its own cluster, but also with the schizotypal-paranoid and anxious clusters. Of related concern is the fact that DSM-IV criteria, rather than restricting themselves to defining personality attributes, mix traits, symptoms and behaviors -- particularly of an affective nature (Table 1).

Table 1.

Core Characteristics of DSM-IV Borderline Personality Rearranged to Highlight

Affective Loading

Unstable intense relationships - "splitting"

- "object hunger"

- abandonment depression

Affective instability - mercurial moods

- reactive dysphoria

- angry outbursts

Behavioral dyscontrol -impulsivity

- substance abuse

- binge eating

- suicidality

Chronic emptiness -boredom

Unstable sense of self - identity disturbances

Micropsychosis -paranoid sensitivity- dissociation

Of even greater concern is that the operational construct may not coincide with what psychoanalysts mean when they make the clinical diagnosis of borderline personality organization. The latter refers to Kernberg's pioneering contributions[5] in delineating a vulnerable psychic structure, rather than a specific nosologic entity. It refers to a class of personality dysfunctions with common defensive operations, reflecting a vulnerable psychic structure that functions at a "stably unstable" level between the classic neuroses and psychoses. Unlike Gunderson's concept of borderline as a specific personality disorder -- which does not lie on the border of any specific mental disorder -- Kernberg's conceptualization maps a large terrain of psychopathology with affective, neurotic, and paraphiliac disturbances. Kernberg's position appears to be more compatible with psychobiologic formulations of borderline, which place this personality disorder on the borders of such disorders as schizophrenic, manic-depressive, and epileptic psychoses. In this framework,[6] borderline refers to formes frustes of the major endogenous psychoses (ie, subschizophrenic, subaffective, or subictal disorders). This paper updates previous contributions by the present author,[6-10] and integrates them with other emerging trends that emphasize the central role of the cyclothymic constitution in the genesis of borderline, atypical, and bipolar II disorders.

Delineating the Affective Border

Initially, the borderline concept developed as a dilute form of psychosis, and its main usefulness was to exclude such patients from the couch. Working in New York, Stone[11] -- who reported that these patients often came from families with manic-depressive and alcoholic members -- can be credited for having been the first to make a persuasive argument about the need to shift from borderline as a subschizophrenic to a subaffective disorder.

Independently, the present author too arrived at the same conclusion: curiously, our work at the University of Tennessee[6,7] had started off with the hypothesis that many patients with borderline personality had affinity to schizophrenic disorders as defined in the framework of the Danish adoption study of schizophrenia. We studied 100 consecutive outpatients -- in a Memphis mental health center -- meeting the Gunderson and Singer criteria[4] for borderline personality. They were clinically evaluated using a semistructured interview based on a modified version of the Washington University approach to psychiatric diagnosis.[12]

Contradicting our starting hypothesis, only 16% were schizotypal.[6] As for other psychopathology, borderline embraced a broader spectrum than we had anticipated. At index evaluation, 66 met the criteria for recurrent depressive, dysthymic, cyclothymic, or bipolar II disorders; other patients met criteria for sociopathic, panic-agoraphobic, attention-deficit/hyperactivity and epileptic disorders. During prospective observation of up to 3 years, and compared with nonborderline personality subjects, borderline probands had a significantly higher risk for developing major affective disorders than schizophrenia spectrum disorders; furthermore, there were 4 completed suicides. Prominent substance abuse history, stormy biographies, and unstable developmental history marked by repeated object loss were common to all borderline subgroups. From a familial standpoint, borderline probands were closest to the affective, especially the bipolar, comparison group. This familial-genetic bipolar link was reinforced by antidepressant associated switches into irritable-angry hypomanic and mixed states in 20% of our sample during prospective observation. (Of note, "paradoxical" disinhibition on antidepressants in borderline patients has also been observed by others.[13,14])

To summarize, the recurrent nature of affective disorder, coupled with familial bipolarity and spontaneous and pharmacologic excursions into brief periods of elation, places the affective pathology of borderline patients in the soft bipolar realm (that can be broadly defined as bipolar II).

The Nature of "Atypicality"

It is often assumed that micropsychotic and dissociative episodes in patients given borderline diagnoses emanate from psychotic processes. This is a misconception. Grandiose or irritable forms of hypomania occurred in a third of our borderline probands with affective diagnoses.[6] Transient drug-induced psychoses secondary to alcohol, sedative hypnotic, psychedelic or stimulant drug use, or withdrawal were reported in nearly half of all borderline cases. Finally, depersonalization-derealization, as well as brief reactive psychoses, were not uncommon in the borderline probands with concurrent panic-agoraphobic diagnoses. Such data provide a useful beginning framework for understanding the "atypicality" of the affective disorder in borderline patients.

To explain the atypicality of the affective state of borderline patients, Gunderson and Phillips[1] contrasted "empty" depression in this personality with the more classical "guilt" depressions in "classical" affective disorder. Thus, their unstable, hostile, and labile moods -- the unrelenting tension and irritability with superimposed paroxysms of rage -- are relegated by these authors back into the characterologic realm. The thrust of this argument is based on a misconception that only classical affective disorder is a "true" affective disorder. In a forensic population, Coid[15] recently provided a compelling description of the affective storms of borderline patients (restlessness, irritability, explosive anger, tension, psychotic anxiety), which lead to -- and alternate with -- the deceptive "calm" and "emptiness" following self-mutilation. Whatever one ends up calling such patients, one cannot but respect their affectively driven temperamental excesses (lest one becomes victimized by them!). Since 1981, the present author[7] has defended the position that a significant proportion of these patients suffer -- and make their loved ones suffer -- as a result of temperamental dysregulation along dysthymic-irritable-cyclothymic lines. Mood lability and hostile emotional avalanches, which characterize borderline patients, seem to derive from such temperamental dysregulation, which is quintessentially affective in nature.

The Atypical-Bipolar II Connection

Major depressive states with reverse vegetative signs (so-called "atypical features") are commonly encountered in this unstable temperamental terrain. Three recent studies have provided greater clarification about this complex interface of volatile affective temperament and atypical affective states.

In collaboration with clinical researchers in Pisa,[16] we demonstrated that 72% of 80 depressive patients with DSM-IV atypical features simultaneously met the criteria for bipolar II; 60% had antecedent cyclothymic temperament. In addition, 94% were rated as interpersonally sensitive. As expected, using the DSM-IV axis II schema, both cluster B (borderline-histrionic) and cluster C (avoidant) personality disorders were prevalent.

Deltito and colleagues[17] studied 20 consecutive patients diagnosed borderline by experienced clinicians at Westchester-Cornell, "validated" independently by Gunderson's DIB. They then rated them by descending order of certainty of bipolarity: in light of what the current literature indicates as established bipolarity ( bipolar I + bipolar II), the conservative rate for bipolarity in this well-characterized, though small. sample of borderlines was 44%; taking the most liberal definition of bipolarity (including pharmacologic-hypomania, cyclothymic temperament, and family history for bipolar disorder), 81% of borderline patients could be considered lying on the border of within the bipolar spectrum. This provocative work, though preliminary, represents the first head-to-head comparison of borderline personality and bipolarity[11] (and obviously is in need of replication).

The author's research as part of the National Institute of Mental Health Collaborative Study of Depression[18] has shown that clinical features reminiscent of borderline features (SADS Item 12) were strongly predictive of which major depressives would, over a prospective observation period of 11 years, switch to bipolar II (Table 2). The temperament of these patients was a mélange of interpersonal sensitivity and mood lability. This study underscores the importance of temperamental factors in borderline psychopathology, as well as their value in predicting bipolar outcome. Stated more tersely, borderline personality, interpersonal sensitivity, mood labile temperamental traits, and bipolar II seem to represent overlapping expressions of the same diathesis. (That mood lability is not pathognomonic for borderline personality, and occurs in bipolar II as well, has been replicated by Henry and colleagues.[19])

Table 2.

Prospective Prediction of Bipolar II Outcome in 8.6% of 559 Patients With Major Depressive Disorder*

- Younger age at onset

- High depressive recurrence

- Greater marital disruption

- Higher score on phobic anxiety

- More "borderline" clinical features

- Higher score on interpersonal sensitivity

- High on trait energy-activity and daydreaming

- High on trait mood lability

      - 42% sensitivity

      - 86% specificity

*Summarized from Akiskal et al[18]

Borderline as a Casualty of the Axis I-Axis II Distinction

One of the inadequacies of our current nosologic schema of personality disorders is that the long-term functioning of patients suffering from major mood disorders is described primarily in "characterologic" language (Axis II in DSM-IV), which is conceptually removed from the "temperamental" language that had been used in classical European psychiatry during the first part of this century. For instance, today bipolar patients are often described as "dramatic," "erratic," "unstable," impulsive," "passive-aggressive," "histrionic," "narcissistic," or "borderline," as if affective temperaments had little to contribute to our understanding of these personality disorders. O'Connell and colleagues[20] appropriately pointed out that structured interviews tend to misclassify subthreshold affective disturbances as dramatic personality disorders. The author's work[21] and subsequent research by Levitt and colleagues[22] have actually shown significant overlap between the cyclothymic temperament and borderline personality disorder.

There are advantages to returning to the more natural affective temperamental language of describing the premorbid, intermorbid, and postmorbid phases of major affective disorders. In this framework,[7,21,23] affective temperaments represent the substrate from which the more florid episodes develop. Using the analogy of earthquakes, I have elsewhere[9] compared the predisposing terrain and affective instability in 2 types of depression. In many affective ill patients, the temperamental terrain is not visibly pathologic but refers to a vulnerable fault that can be destabilized periodically, erupting into extreme pathology that could lead to self-destruction. In this more classical affective type, the patient has relatively normal -- or even supernormal or hyperthymic -- functioning between episodes. In other patients, the temperamental terrain is characterized by greater instability and intermittent or nearly continuous emotional "mini-earthquakes"; these patients seem "protected," though not entirely, from major melancholic episodes. The patient with this second type of temperamental dysregulation suffers from protracted intermittent emotional disequilibrium and restlessness without necessarily having full-blown syndromal affective episodes. These are then considered to be "atypical" or "borderline" cases where the terrain is so pathologically unstable that it may be difficult to discern the superimposed episodes that are an accentuation of the basic pathology.

Borderline as the "Darker Side" of Cyclothymia

Our work has actually demonstrated that the temperamental terrain between depression and manic-depression is bridged by a spectrum of subtle bipolar disorders with an extremely variable course.[7,21,23] Mood switches are recurrent, biphasic and abrupt, and may be seasonal and sometimes exacerbated by antidepressants. The term "explosive" captures the abruptness of the affective switches, each phase lasting for hours, days, and, sometimes, weeks. These patients are rarely euthymic. Their mood shifts often follow a circadian pattern (ie, waking up convinced of the futility of existence), but can also be reactive to interpersonal altercations, often rather trivial in nature, but emotionally charged for the patient. Even when provoked by such situations, the resultant emotional outbursts are more like avalanches than understandable reactions proportional to the proximate provoking situation.[23] One must infer an endogenous propensity to extreme emotional reactivity to these patients. Given such emotional tempests, it is no wonder that most clyclothymes accumulate an extreme array of social disturbances by their mid-20s[21]: repeated romantic failure, episodic promiscuity, financial extravagance, uneven work or school record, dilettantism, geographic instability, polysubstance abuse, and joining various eschatologic cults. Such instability appeared to be secondary to lifelong biphasic mood swings below the threshold for full-blown bipolar disorder. Subsequent studies in a community sample[24] have reported similar interpersonal havoc and social disruptions.

The instability in the biography of cyclothymics is especially accentuated in those with predominantly irritable traits.[23] These individuals are habitually dysphoric, prone to anger, hypercritical and complaining, with a penchant for ill-humored joking. They would thus easily offend their loved ones, often leading to verbally abusive behavior when only minutes or hours earlier they had vowed "eternal" love. At other times, interpersonal crises escalate because of their pouting and obtrusive behavior. In brief, the morose temperamentality of the irritable cyclothymic provides the unstable base from which interpersonal tempests arise.

Recent data[25] from a French national collaborative study has shown that the notion of cyclothymia and hypomania as positive "sunny" traits and behaviors represents just one facet of soft bipolarity. This driven-euphoric facet should be contrasted with the irritable-tempestuous or "darker" side of bipolarity. The correlation of cyclothymia reaches significance (.37) only with the latter facet. In brief, depressions arising from a cyclothymic baseline are often characterized by dysphoric hypomanic periods, and are likely to be misdiagnosed as erratic personality disorders. Their high familial load for affective (including bipolar) disorder support their inclusion as a more unstable variant of bipolar II that can be best be characterized as "cyclothymic depressions."

Another study[26] relevant to the "darker" side of bipolarity, which is still unpublished, derives from the author's collaboration with the University of Pisa. In 107 atypical major depressive patients, logistic regression revealed that cyclothymic temperament accounted for much of the relationship between atypicality and borderline personality. The cyclothymic-sensitive disposition seems to represent the common denominator in the complex syndromic pattern of anxiety, mood, and impulse disorders. We explained these findings and considerations as support for the contention that atypical depression, borderline personality, cyclothymia, and bipolar II represent overlapping manifestations of a common underlying psychobiologic diathesis.

Unless their temperamental vulnerabilities are understood properly, the comorbidity and erratic clinical presentations of these borderline patients can baffle clinicians. As a result, some researchers prefer to characterize these vulnerabilities along the lines of sociopathy and related personality disorders.[27] Such characterization, in my opinion, misses the core emotionality of borderline patients that can be observed in both patients and in their biologic kin.[28] I submit that interpersonal sensitivity, mood reactivity, and lability are more germane to the origin of borderline psychopathology and its comorbidities. It is their innate -- and, to some extent, developmentally acquired -- intense reactivity to others that creates their turbulent relationships, and indeed their entire biography.

As discussed elsewhere,[10] the tragedy of borderline patients is that their impulsive drive, which thrusts them into the theater of human interactions -- coupled with their negative affectivity -- accentuates and thereby validates their sense of being rejected emotionally, maltreated, and abused; the more unfortunate among them do get actually abused by psychopathic family members (usually a step-parent).

Concluding Remarks

Discussion of psychopharmacologic and formal psychotherapeutic interventions in borderline personality conceived as a soft bipolar variant are beyond the scope of this paper. Suffice it to say that the affective framework for borderline personality described in this paper has major implications for clinical management. Foremost among them is that affective reconceptualization of borderline pathology may substantially reduce the therapists' countertransference[29] because now the patient is viewed as affectively ill, rather than "character flawed." Treatment should be undertaken with the requisite competence and confidence for a serious mental disorder. The suicide risk -- a potentially fatal consequence of the intense affective dysregulation -- should be conceptualized and clinically managed as rigorously as in any patient with serious mood disorder. The affective dysregulation and the impulsivity that underlies such risk may, in principle, be preventable with mood stabilizers, including carbamazepine and divalproex. This is a vital public health priority.

These patients often come from disturbed families and appear at risk for emotional instability due to both genetic factors (eg, bipolarity, alcoholism) and developmental factors (eg, disruption in early attachment bonds and other traumatic experiences). The neuroendocrine and sleep neurophysiologic correlates of their exquisite affective vulnerabilities have been documented elsewhere.[10] Since borderline patients -- in view of their negative affectivity -- often develop malevolent object representations of significant others in their lives,[30] clinicians must not assume that the parents of borderline patients are or were "monsters." Parents' guidance is often crucial to these patients' mastery of maturational tasks. On the other hand, Kurt Schneider's[31] wise admonition should not be forgotten: "On their bad days, keep out of their way as far as possible."

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<{POST_SNAPBACK}>

[Lauren]

So wheres the info on 'exausted PMT'ing borderline mother' then?

L

xxx

[lostsoul]

er, not sure lol

i'll have a look later :P