The role of cyclothymia in atypical depression: toward a data-based reconceptualization of the borderline–bipolar II connection
ABSTRACT 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.
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).
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.
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.
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ABSTRACT: The aim of the study was to investigate the relationship between the individual pattern of affective temperaments, non-typical symptoms of depression as measured with the Gotland Scale for Male Depression (GSMD), hopelessness and suicidal behavior in major mood disorder patients.Methods Participants were 346 adult inpatients (151 men and 195 women) with major mood disorders consecutively admitted to the Department of Psychiatry of the Sant'Andrea University Hospital in Rome, Italy. All the patients were administered the TEMPS-A, the GSMD, and the Beck Hopelessness Scale (BHS) and the Mini International Neuropsychiatric Interview (MINI).ResultsA Two Step Cluster Analysis procedure, performed to reveal natural groupings within patients' response set, indicated that there were 2-groups: a cyclothymic-depressive-anxious group and a hyperthymic group. More than 81% of the patients with prevailing cyclothymic-depressive-anxious temperament had mild to severe suicidal risk on the MINI vs. only around 42% of the patients with prevailing hyperthymic temperament., Sixty-four percent of patients with prevailing cyclothymic-depressive-anxious temperament had BHS scores of 9 or higher versus only 13% of patients with prevailing hyperthymic temperament. Also, patients with prevailing cyclothymic-depressive-anxious temperament more likely had higher GSMD than patients with prevailing hyperthymic temperament.Discussion and conclusionsOur results indicate that affective temperament measure along with Gotland Scale for Male Depression could be useful tools in screening and identifying those affective disorder patients who are at higher risk of suicidal behavior.European Psychiatry 01/2012; 27:1. DOI:10.1016/S0924-9338(12)74337-7 · 3.21 Impact Factor
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ABSTRACT: Genetic factors are recognized to be involved in the etiology of major psychoses, particularly schizophrenia and bipolar disorder. Nevertheless, little is known about the nature and extent of the specific genetic contribution to disease liability (Kendler et al., 1993; Danese, 2008). Twin studies can provide crucial insights regarding the etiology of sub-threshold and clinical psychosis, and represent an extraordinarily powerful design to establish the role of genes and environment both in the expression of a trait (e.g., development of a disease) and in the co-expression of multiple traits (e.g., comorbidity of multiple diseases). By comparing the correlation for a trait between genetically identical monozygotic (MZ) twins with that between dizygotic (DZ) twins who represent full sibs, and assuming that MZ twins share relevant environmental exposures to the same extent as DZ twins ('equal environments assumption'), it is possible to estimate the contribution of genetic factors (" heritability ") and environmental influences to the expression of the trait. Furthermore, when multiple phenotypes are studied, cross-twin/cross-trait correlation (i.e., between a given phenotype in a twin and another phenotype in his/her co-twin) in MZ and DZ twin pairs provides information on genetic or environmental influences common to the phenotypes (genetic or environmental correlation between the phenotypes), which could play a role in their co-expression (Boomsma et al., 2002; Spector et al., 2000). The potential of the twin design enormously increased after the implementation of population-based registries of data on twins in several countries (Busjahn & Hur, 2006), including Italy (Fagnani et al., 2006; Stazi et al., 2002). A large body of twin studies aimed at unraveling the genetic and environmental architecture of major psy-choses and psychotic symptoms. Although results vary Twin studies in psychotic disordersEpidemiology and Psychiatric Sciences 01/2009; 18(3):195-199. · 3.36 Impact Factor
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ABSTRACT: Temperaments are imperturbable variations of personality, traits and ways of reacting to the environment that characterize individuals and remain constant throughout several different situations. Temperaments usually play a central role in determining emotional reactions, therefore several temperamental models have attempted to establish the potential relationship between temperaments and affective disorders. According to Hagop Akiskal, affective temperaments are subclinical and subaffective trait-like manifestations of affective disorders. Unlike several models of temperament which were exclusively developed theoretically in order to describe healthy human functioning, later extrapolated to capture the pathological domains of mental and behavioral features, the current model of affective temperaments was developed on classical traditions and mainly based on the observation of subjects with mood disorders and their healthy first degree relatives. There is accumulating evidence concerning the development of affective temperaments based on their adaptive evolutionary characteristics and genetic background, and normative data from large national studies on general and healthy samples indicate their universal characteristics. Studies in affective patient populations indicate that the relationship between affective temperaments and affective illness is more complex than a simple extrapolation from psychopathology and mental health, and affective temperaments may represent a latent state of the staging model, playing a pathoplastic role in mood disorders determining their evolution, clinical features, main characteristics and outcome. A large body of data on affective temperaments has been published during the last decade, deserving a critical analysis presented in this overview.