Article

The role of cyclothymia in atypical depression: Toward a data-based reconceptualization of the borderline-bipolar II connection

Department of Psychiatry, University of Pisa, Via Roma 67, 56100, Pisa, Italy.
Journal of Affective Disorders (Impact Factor: 3.38). 02/2003; 73(1-2):87-98. DOI: 10.1016/S0165-0327(02)00329-4
Source: PubMed

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.
Correlational study.
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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    • "Nevertheless, the HAMD 17 failed to evidence difference for severity of depressive symptomatology and recent suicidality between groups, although patients with unipolar depression and cyclothymic temperament reported tendentially higher depression and more frequent suicidal ideation and attempts in the recent past than other patients. Thus, these results are only partly consistent with the results of Kochman et al. (2005) and Perugi et al. (2003) which indicated that adult patients with unipolar depression and cyclothymic temperament may be potentially at higher risk of suicide than other patients with major mood disorders. Our finding is in good agreement with those results showing that cyclothymic temperament is significantly overrepresented among suicide attempters (Pompili et al., 2008; Rihmer et al., 2009). "

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    • "Nevertheless, the HAMD 17 failed to evidence difference for severity of depressive symptomatology and recent suicidality between groups, although patients with unipolar depression and cyclothymic temperament reported tendentially higher depression and more frequent suicidal ideation and attempts in the recent past than other patients. Thus, these results are only partly consistent with the results of Kochman et al. (2005) and Perugi et al. (2003) which indicated that adult patients with unipolar depression and cyclothymic temperament may be potentially at higher risk of suicide than other patients with major mood disorders. Our finding is in good agreement with those results showing that cyclothymic temperament is significantly overrepresented among suicide attempters (Pompili et al., 2008; Rihmer et al., 2009). "
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    ABSTRACT: Background The aim of the present study was to assess sociodemographic and clinical differences between inpatients with major mood disorders (bipolar disorder – BD – and major depression – MDD) and the cyclothymic phenotype (CYC), and pure BDs or MDDs. Methods Participants were 281 adult inpatients (134 men and 147 women) consecutively admitted to the Department of Psychiatry of the Sant׳Andrea University Hospital in Rome, Italy, between January 2008 and June 2010. The patients completed the Hamilton Scale for Depression (HAMD17), the Young Mania Rating Scale, the TEMPS-A (Temperament Evaluation of the Memphis, Pisa, Paris and San Diego—Autoquestionnaire), and the Beck Hopelessness Scale. Results 38.7% of the MDD patients and 48.3% of the BD patients satisfied criteria to be included in the cyclothymic groups. Above 92% of the patients with the cyclothymic phenotype reported suicidal ideation at the item #3 of the HAMD17. Furthermore, patients with the cyclothymic phenotype reported higher hopelessness than other patients. Limitations Our results are potentially limited by the small number of MDD-CYC patients included in the sample. Conclusions Our results support the clinical usefulness of the concept of soft bipolar spectrum. Patients with the cyclothymic phenotype differ from pure MDD patients and BD patients for temperamental profile and clinical variables.
    Full-text · Article · Jan 2015
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    • "Some studies argue that BPD is best reframed as part of the BP spectrum due to symptomatic and familial genetic overlap between these diagnostic phenotypes. (Akiskal, 2004; Akiskal et al., 1985; Perugi et al., 2003; Smith et al., 2004). For example, both BPD and BP are associated with emotional lability, impulsivity, irritability and anger, unstable interpersonal relationships, feelings of emptiness, and suicidality (Akiskal, 2004; Bowden and Maier, 2003; Henry et al., 2001; Perugi and Akiskal, 2002). "
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    ABSTRACT: Background Little is known regarding correlates of borderline personality-spectrum symptoms (BPSS) among adolescents with bipolar disorder (BP). Methods Participants were 90 adolescents, 13–19 years of age, who fulfilled DSM-IV-TR criteria for BP using semi-structured diagnostic interviews. BPSS status was ascertained using the Life Problems Inventory which assessed identity confusion, interpersonal problems, impulsivity, and emotional lability. Analyses compared adolescents with “high” versus “low” BPSS based on a median split. Results Participants with high, relative to low, BPSS were younger, and had greater current and past depressive episode severity, greater current hypo/manic episode severity, younger age of depression onset, and reduced global functioning. High BPSS participants were more likely to have BP-II, and had higher rates of social phobia, generalized anxiety disorder, conduct disorder, oppositional defiant disorder, homicidal ideation, assault of others, non-suicidal self-injury, suicidal ideation, and physical abuse. Despite greater illness burden, high BPSS participants reported lower rates of lithium use. The most robust independent predictors of high BPSS, identified in multivariate analyses, included lifetime social phobia, non-suicidal self-injury, reduced global functioning, and conduct and/or oppositional defiant disorder. Limitations The study design is cross-sectional and cannot determine causality. Conclusions High BPSS were associated with greater mood symptom burden and functional impairment. Presence of high BPSS among BP adolescents may suggest the need to modify clinical monitoring and treatment practices. Future prospective studies are needed to examine the direction of observed associations, the effect of treatment on BPSS, and the effect of BPSS as a moderator or predictor of treatment response.
    Full-text · Article · Jan 2015
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