Clinical status of comorbid bipolar disorder and borderline personality disorder.

BACKGROUND: The status and differentiation of comorbid borderline personality disorder and bipolar disorder is worthy of clarification. AIMS: To determine whether comorbid borderline personality disorder and bipolar disorder are interdependent or independent conditions. METHOD: We interviewed patients diagnosed with either a borderline personality disorder and/or a bipolar condition. RESULTS: Analyses of participants grouped by DSM diagnoses established that those with comorbid conditions scored similarly to those with a borderline personality disorder alone on all key variables (i.e. gender, severity of borderline personality scores, developmental stressors, illness correlates, self-injurious behaviour rates) and differed from those with a bipolar disorder alone on nearly all non-bipolar item variables. Similar findings were returned for groups defined by clinical diagnoses. CONCLUSIONS: Comorbid bipolar disorder and borderline personality disorder is consistent with the formal definition of comorbidity in that, while coterminous, individuals meeting such criteria have features of two independent conditions.

Melancholia and catatonia: disorders or specifiers?

The fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 defines mental disorders as syndromes and also introduced disorder "specifiers" with the aim of providing increased diagnostic specificity by defining more homogeneous subgroups of those with the disorder and who share certain features. While the majority of specifiers in DSM-5 define a specific aspect of the disorder such as age at onset or severity, some define syndromes that appear to meet the DSM-5 definition of a mental disorder. Specifically, melancholia is positioned in DSM-5 as a major depressive disorder (non-coded) specifier, while catatonia is listed as both a disorder secondary to a medical condition and as a specifier associated with other mental disorders such as schizophrenia, major depressive disorder, and bipolar disorder. Despite decades of research supporting melancholia's status as a categorical "disorder" (a higher-order construct than a specifier), failure to provide convincing support for its disorder status has contributed to its current positioning in DSM-5. As DSM-5 has similar symptom criteria for major depression and for its melancholia specifier, research seeking to differentiate melancholic and non-melancholic depression according to DSM-5 criteria will have limited capacity to demonstrate "melancholia" as a separate disorder and risks melancholia continuing to be reified as a low-order specifier and thus clinical marginalization. There have been few advances in catatonia research in recent years with its positioning largely relying on opinion and clinical observation rather than on empirical studies.

The validity of a food frequency questionnaire as a measure of PUFA status in pregnancy.

BACKGROUND: Nutritional studies have found conflicting evidence regarding the ability of Food Frequency Questionnaires (FFQs) to demonstrate convergent validity with tissue content of omega-3 and omega-6 polyunsaturated fatty acids (PUFAs). We therefore sought to assess the convergent validity of a FFQ strategy when compared with a blood biomarker of PUFA levels in a sample of pregnant women. METHOD: A previously validated PUFA FFQ was completed by 895 pregnant women and compared to erythrocyte membrane of six PUFA variables. RESULTS: Four of the six correlations were found to be formally significant, however two of these demonstrated minimal associational strength. Moderate-high correlations between the FFQ-derived PUFA intake estimates and blood biomarker PUFA levels were shown only for eicosapentaenoic acid (EPA; 0.55) and docosahexaenoic acid (DHA; 0.61). CONCLUSIONS: Overall, the correlations were lower than those found in general population studies. Findings suggest biological estimates, such as blood samples, may be most appropriate to measure PUFA levels above indirect strategies such as an FFQ in this population. The results, if an indirect strategy is unavoidable, indicate specific PUFAs where an FFQ strategy may be most informative.

Construct validity of the Experiences of Therapy Questionnaire (ETQ).

BACKGROUND: The Experiences of Therapy Questionnaire (ETQ) is a reliable measure of adverse effects associated with psychotherapy. The measure has not been subject to validity analyses. This study sought to examine the validity of the ETQ by comparison against a measure of therapist satisfaction. METHODS: Participants were recruited from the Black Dog Institute's website and completed all measures online, at two time points (two weeks apart). Correlational analyses compared scale scores on the ETQ with related constructs of the Therapist Satisfaction Scale (TSS). To exclude any impact of current depression on ratings, we examined correlations between salient ETQ and TSS scales after controlling for depression severity. RESULTS: Forty-six participants completed all the measures at both time points. Hypothesised associations between the ETQ and TSS scales were supported, irrespective of current depression severity. CONCLUSIONS: The validity of the ETQ is supported; however limitations of the study are noted, including generalizability due to sample characteristics.

The co-occurrence of neurodevelopmental disorders in gender dysphoria: Characteristics within a paediatric treatment-seeking cohort and factors that predict distress pertaining to gender.

Gender dysphoria, characterised by distress associated with an incongruence between an individual's assigned and experienced gender, is encountered in 1%-2% of children and adolescents. Recent findings suggest neurodevelopmental disorders (NDDs), including Autism, are frequently reported among youth with Gender Dysphoria. This study aims to explore the frequency of NDDs in children and adolescents presenting to a hospital-based gender service, and to investigate the contribution of autistic traits and general psychological distress to distress pertaining to gender. Sixty-four participants (mean age = 12.91 years) with Gender Dysphoria were recruited to this study. Self- and caregiver-report questionnaires were used to evaluate psychological distress, autistic traits, and distress pertaining to gender. Relative to the rest of the participants, the 13 (20.31%) with a co-occurring NDD diagnosis reported elevated autistic traits (p < .001). They did not differ in terms of psychological distress or distress pertaining to gender. A hierarchical linear regression revealed autistic traits alone did not contribute to the variability in distress pertaining to gender, whereas general psychological distress accounted for 9.9% of the variability in distress pertaining to gender (p = .012). The current findings indicate that NDD diagnoses are common in children and adolescents with Gender Dysphoria who attend hospital-based services. Psychological distress, rather than autistic traits, contributes more variability in distress pertaining to gender. Taken together, these findings indicate the need to consider NDDs in treatment plans but also to focus on the important relationship between psychological distress and Gender Dysphoria.

Attachment Patterns in Children and Adolescents With Gender Dysphoria.

The current study examines patterns of attachment/self-protective strategies and rates of unresolved loss/trauma in children and adolescents presenting to a multidisciplinary gender service. Fifty-seven children and adolescents (8.42-15.92 years; 24 birth-assigned males and 33 birth-assigned females) presenting with gender dysphoria participated in structured attachment interviews coded using dynamic-maturational model (DMM) discourse analysis. The children with gender dysphoria were compared to age- and sex-matched children from the community (non-clinical group) and a group of school-age children with mixed psychiatric disorders (mixed psychiatric group). Information about adverse childhood experiences (ACEs), mental health diagnoses, and global level of functioning was also collected. In contrast to children in the non-clinical group, who were classified primarily into the normative attachment patterns (A1-2, B1-5, and C1-2) and who had low rates of unresolved loss/trauma, children with gender dysphoria were mostly classified into the high-risk attachment patterns (A3-4, A5-6, C3-4, C5-6, and A/C) (χ2 = 52.66; p < 0.001) and had a high rate of unresolved loss/trauma (χ2 = 18.64; p < 0.001). Comorbid psychiatric diagnoses (n = 50; 87.7%) and a history of self-harm, suicidal ideation, or symptoms of distress were also common. Global level of functioning was impaired (range 25-95/100; mean = 54.88; SD = 15.40; median = 55.00). There were no differences between children with gender dysphoria and children with mixed psychiatric disorders on attachment patterns (χ2 = 2.43; p = 0.30) and rates of unresolved loss and trauma (χ2 = 0.70; p = 0.40). Post hoc analyses showed that lower SES, family constellation (a non-traditional family unit), ACEs-including maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence)-increased the likelihood of the child being classified into a high risk attachment pattern. Akin to children with other forms of psychological distress, children with gender dysphoria present in the context of multiple interacting risk factors that include at-risk attachment, unresolved loss/trauma, family conflict and loss of family cohesion, and exposure to multiple ACEs.

Use of respiratory rates and heart rate variability in the assessment and treatment of children and adolescents with functional somatic symptoms.

Functional somatic symptoms (FSS) emerge when the stress system is activated in response to physical or emotional stress that is either chronic or especially intense. In such cases, the heightened state of physiological arousal and motor activation can be measured through biological markers. Our team have integrated the use of biological markers of body state - respiratory rate, heart rate (HR) and heart rate variability (HRV) measurements - as a way of helping families to understand how physical symptoms can signal activation of the body's stress systems. This study measured respiratory rates, HR and HRV in children and adolescents with FSS (and healthy controls) during baseline assessment to determine whether these biological markers were effective at differentiating patients with FSS. The study also implemented a biofeedback intervention during the assessment to determine whether patients with FSS were able to slow their respiratory rates and increase HRV. Patients with FSS had faster respiratory rates, faster HR, and lower HRV, suggesting activation of the autonomic nervous system coupled with activation of the respiratory motor system. Like controls, patients were able to slow their respiratory rates, but in contrast to controls, they were unable to increase their HRV. Our findings suggest that patients with FSS present in a state of physiological activation and struggle to regulate their body state. Patients with FSS are likely to need ongoing training and practice to regulate body state coupled with interventions that target regulatory capacity across multiple systems.

Psychogenic non-epileptic seizures in children and adolescents: Part I - Diagnostic formulations.

Psychogenic non-epileptic seizures (PNES) are a nonspecific, umbrella category that is used to collect together a range of atypical neurophysiological responses to emotional distress, physiological stressors and danger. Because PNES mimic epileptic seizures, children and adolescents with PNES usually present to neurologists or to epilepsy monitoring units. After a comprehensive neurological evaluation and a diagnosis of PNES, the patient is referred to mental health services for treatment. This study documents the diagnostic formulations - the clinical formulations about the probable neurophysiological mechanisms - that were constructed for 60 consecutive children and adolescents with PNES who were referred to our Mind-Body Rehabilitation Programme for treatment. As a heuristic framework, we used a contemporary reworking of Janet's dissociation model: PNES occur in the context of a destabilized neural system and reflect a release of prewired motor programmes following a functional failure in cognitive-emotional executive control circuitry. Using this framework, we clustered the 60 patients into six different subgroups: (1) dissociative PNES (23/60; 38%), (2) dissociative PNES triggered by hyperventilation (32/60; 53%), (3) innate defence responses presenting as PNES (6/60; 10%), (4) PNES triggered by vocal cord adduction (1/60; 2%), (5) PNES triggered by activation of the valsalva manoeuvre (1/60; 1.5%) and (6) PNES triggered by reflex activation of the vagus (2/60; 3%). As described in the companion article, these diagnostic formulations were used, in turn, both to inform the explanations of PNES that we gave to families and to design clinical interventions for helping the children and adolescents gain control of their PNES.

Psychogenic non-epileptic seizures in children and adolescents: Part II - explanations to families, treatment, and group outcomes.

Psychogenic non-epileptic seizures (PNES) - time-limited disturbances of consciousness and motor-sensory control, not accompanied by ictal activity on electroencephalogram (EEG) - are best conceptualized as atypical neurophysiological responses to emotional distress, physiological stressors and danger. Patients and families find the diagnosis of PNES difficult to understand; the transition from neurology (where the diagnosis is made) to mental health services (to which patients are referred for treatment) can be a bumpy one. This study reports how diagnostic formulations constructed for 60 consecutive children and adolescents with PNES were used to inform both the explanations about PNES that were given to them and their families and the clinical interventions that were used to help patients gain control over PNES. Families were able to accept the diagnosis of PNES and engage in treatment when it was explained how emotional distress, illness and states of high arousal could activate atypical defence responses in the body and brain - with PNES being an unwanted by-product of this process. Patients and their families made good use of therapeutic interventions. A total of 75% of children/adolescents (45/60) regained normal function and attained full-time return to school. Global Assessment of Functioning scores increased from 41 to 67 ( t(54) = 10.09; p < .001). Outcomes were less favourable in children/adolescents who presented with chronic PNES and in those with a chronic, comorbid mental health disorder that failed to resolve with treatment. The study highlights that prompt diagnosis, followed by prompt multidisciplinary assessment, engagement, and treatment, achieves improved outcomes in children/adolescents with PNES.

Emotional dysregulation in those with bipolar disorder, borderline personality disorder and their comorbid expression.

BACKGROUND: Differentiation of the bipolar disorders (BP) from a borderline personality disorder (BPD) can be challenging owing to shared features, with emotional dysregulation being the likely principal one. AIM: To assess differences in emotion regulation strategies in those with BP alone, BPD alone and those comorbid for both. METHODS: We interviewed participants previously receiving a BP or BPD diagnosis, studying those who met DSM criteria for one or both conditions. RESULTS: The sample comprised 83 with bipolar disorder, 53 with BPD and 54 comorbid for both. Analyses established linear trends, with the greatest impairment in emotion regulation strategies in the comorbid group followed by the BPD group, and with the lowest in the BP group. Specific deficits in the comorbid group included impulsivity, difficulties with goal directed behaviour, and accessing strategies. A similar linear profile was quantified for maladaptive cognitive emotion regulation strategies, weighted to catastrophizing and rumination. Adaptive emotion regulation strategies were superior in the bipolar group, without significant differences observed between the comorbid and BPD groups. LIMITATIONS: Reliance on self-report measures; combined BP I and II participants limits generalisability of results to each bipolar sub-type; use of DSM diagnoses risking artefactual comorbidity; while there was an over-representation of females in all groups. CONCLUSIONS: Differences in emotion regulation strategies advance differentiation of those with either BP or BPD, while we identify the specificity of differing strategies to each condition and their synergic effect in those comorbid for both conditions. Study findings should assist the development and application of targeted strategies for those with either or both conditions.

Borderline personality disorder and neuropsychological measures of executive function: A systematic review.

The notion that neurocognitive deficits may be core to the development of borderline personality disorder (BPD) has received considerable attention in recent years, with growing evidence pointing to cognitive deficits in executive function (EF). A relationship between EF and BPD has long been suggested by evidence of high comorbidity between BPD and disorders characterized by poor EF (e.g. attention-deficit/hyperactivity disorder); however, despite a marked increase in studies of EF and BPD in recent years, the precise nature of this relationship remains unclear. We provide a systematic review of this emerging evidence base, with respect to (1) studies of participants diagnosed with BPD in which EF has been indexed in isolation from broader cognitive processes; (2) the specific domains of EF that have been most robustly associated with BPD; and (3) whether deficits in EF are uniquely associated with BPD, independent of comorbid psychopathology. Key directions for future research are discussed with respect to strategies for measuring EF and the need for research designs that control for phenotypic overlap between BPD and related forms of psychopathology.

Emotion regulation strategies in bipolar II disorder and borderline personality disorder: differences and relationships with perceived parental style.

BACKGROUND: Bipolar II disorder (BP II) and Borderline Personality Disorder (BPD) share common features and can be difficult to differentiate, contributing to misdiagnosis and inappropriate treatment. Research contrasting phenomenological features of both conditions is limited. The current study sought to identify differences in emotion regulation strategies in BP II and BPD in addition to examining relationships with perceived parental style. METHOD: Participants were recruited from a variety of outpatient and community settings. Eligible participants required a clinical diagnosis of BP II or BPD, subsequently confirmed via structured diagnostic interviews assessing DSM-IV criteria. Participants completed a series of self-reported questionnaires assessing emotion regulation strategies and perceived parental style. RESULTS: The sample comprised 48 (n=24 BP II and n=24 BPD) age and gender-matched participants. Those with BPD were significantly more likely to use maladaptive emotion regulation strategies, less likely to use adaptive emotion regulation strategies, and scored significantly higher on the majority of (perceived) dysfunctional parenting sub-scales than participants with BP II. Dysfunctional parenting experiences were related to maladaptive emotion regulation strategies in participants with BP II and BPD, however differential associations were observed across groups. LIMITATIONS: Relatively small sample sizes; lack of a healthy control comparator group; lack of statistical control for differing sociodemographic and clinical characteristics, medication and psychological treatments; no assessment of state or trait anxiety; over-representation of females in both groups limiting generalisability of results; and reliance on self-report measures. CONCLUSIONS: Differences in emotion regulation strategies and perceived parental style provide some support for the validity of distinguishing BP II and BPD. Development of intervention strategies targeting the differing forms of emotion regulatory pathology in these groups may be warranted.

Psychostimulants for managing unipolar and bipolar treatment-resistant melancholic depression: a medium-term evaluation of cost benefits.

BACKGROUND: We earlier reported an open study of 50 unipolar and bipolar treatment resistant depressed patients indicating that psychostimulants may have differential superiority for the melancholic depressive sub-type. We designed an extension study to examine cost benefits of psychostimulants more closely for those only with melancholic depression. METHOD: The sample comprised patients clinically diagnosed with melancholic depression who had failed to respond to and/or experienced significant side-effects with at least two antidepressants. Data were collected for 61 unipolar and 51 bipolar II patients receiving a psyschostimulant for a mean interval of 69 weeks. Benefits and side-effects were assessed. RESULTS: Effectiveness ratings were similar across unipolar and bipolar sub-sets. Psychostimulants were judged as 'very' effective for 20% of patients and 'somewhat' effective for 50%. Forty percent judged the psychostimulant as being 'as effective' or as 'superior' to previously prescribed antidepressants, and worthy of being maintained. Significant side-effects were experienced by 40% of patients, requiring medication to be ceased in 12%. Twenty percent of the bipolar patients experienced a worsening of highs. LIMITATIONS: The study was uncontrolled and retrospective, no formal rater-completed or patient-completed interval measures of severity were completed, while diagnostic judgments about melancholic depression and bipolar disorder were clinically judged. CONCLUSIONS: This open study suggests that psychostimulants may be efficacious antidepressant options for managing unipolar and bipolar melancholia, often seemingly having very rapid onset and generally requiring only low doses, and arguing the need for controlled studies in melancholic patients.