Major Depression in Patients With Borderline Personality Disorder: A Clinical Investigation

Objective: Borderline personality disorder (BPD) is characterized by a high frequency of comorbidity with major depressive disorder (MDD). This study aimed to compare the clinical characteristics of 2 groups of patients with MDD: those with concomitant BPD and those with other concomitant personality disorders.

Methods: We assessed 119 outpatients, using a semistructured interview for demographic and clinical features, the Structured Clinical Interview for DSM-IV, Hamilton anxiety and depression scales, the Zung Self-Rating Depression Scale (ZSDS), the Social and Occupational Functioning Assessment Scale (SOFAS), the Sheehan Disability Scale, and the Revised Childhood Experiences Questionnaire. We performed a regression analysis, using the number of criteria for BPD as the dependent variable.

Results: Severity of BPD was positively related to the ZSDS score, to self-mutilating behaviours, and to the occurrence of mood disorders in first-degree relatives; it was negatively related to the SOFAS score and age at onset of MDD.

Conclusions: Patients with comorbid MDD and BPD present differential characteristics that indicate a more serious and impairing condition with a stronger familial link with mood disorders than is shown by depression patients with other Axis II codiagnoses.

(Can J Psychiatry 2005;50:234-238)

Information on author affiliations appears at the end of the article.

Key Words: borderline personality disorder, major depressive disorder, comorbidity, familial mood disorders

Clinical Implications

* Coexisting personality disorders should be carefully assessed in patients with major depressive disorder (MDD).

* Borderline personality disorder (BPD) should be particularly investigated in depression patients with a family history of mood disorders.

* BPD could be considered a predictive factor of early-onset MDD.

Limitations

* The sample size was relatively small for conclusive statements.

* We used a retrospective method to collect data.

* Data concerning previous and ongoing treatments were not analyzed.

Findings from several studies concur that most patients with borderline personality disorder (BPD) have comorbid Axis I disorders during their lifetime (1-3). Comorbidity with major depressive disorder (MDD) is generally considered the most common, with rates ranging from 53% to 83%. The reasons for this frequent coexistence remain controversial. Some authors have suggested that MDD and BPD may be the expression of a common underlying pathological process, while others have objected that these disorders may simply coexist without sharing any physiopathological mechanism (4-8).

The following clinical characteristics of depression patients with a codiagnosis of BPD have been described: lower age at onset of MDD; higher severity of depressive symptoms; lower level of social functioning; chronic MDD and repeated hospitalization; more common suicidal ideation and behaviour; history of physical or sexual abuse in childhood; and higher cooccurrence of phobias, eating disorders, and alcohol and cannabis abuse (2,9-17).

Replication of these findings is needed to determine whether the clinical picture of MDD is significantly influenced by concomitant BPD. If this is the case, careful identification of personality disorders should be considered in the diagnostic assessment of depressive disorders. The present study aimed to further analyze data on this topic by comparing 2 groups of depression patients: those with concomitant BPD and those with other Axis II codiagnoses.

Material and Methods

We included in this study 119 consecutive outpatients (aged 18 years and over) who had a diagnosis of personality disorder and a codiagnosis of MDD. Patients attended the Service for Personality Disorders, Unit of Psychiatry, at the University of Turin. Diagnoses were made by an expert clinician according to DSM-IV-TR criteria (18) and were confirmed with the Structured Clinical Interview for DSM-IV disorders (SCID, 19,20). Subjects were excluded if they had a current or previous diagnosis of delirium, dementia, amnestic disorder, or other cognitive disorders; schizophrenia or other psychotic disorders; or bipolar disorders. Each patient participated voluntarily in this study after providing written informed consent. Patients were divided into 2 subgroups: those with a diagnosis of BPD and those with a different Axis II diagnosis.

Patients were tested with the following instruments:

* A semistructured interview to assess demographic and clinical features (age, sex, age at onset and duration of MDD, number of major depressive episodes, history of self-mutilating behaviours and substance abuse, and occurrence of mood and anxiety disorders in first-degree relatives). All data were confirmed by clinical chart review and by a close informant, when available.

* The SCID, to determine Axis I comorbidity.

* The Hamilton Anxiety Rating Scale (HARS, 21), the Hamilton Depression Rating Scale (HDRS, 22), and the Zung Depression Self-rating Scale (ZSDS, 23).

* The Social and Occupational Functioning Assessment Scale (SOFAS, 24) and the Sheehan Disability Scale (SDS, 25).

* The Revised Childhood Experiences Questionnaire (CEQ-R, 26), to search for verbal or emotional, physical, or sexual abuse in childhood.

Rating scales were administered by 2 investigators who were blind to the Axis I and II diagnoses.

Pearson's chi-square test and Student's t test for independent samples were used to compare categorical and continuous variables between subgroups. We included all factors found to be significantly different between subgroups in a regression model (stepwise), choosing the number of SCID criteria for BPD as the dependent variable.

Results

The patient sample had a mean age of 37.23 years, SD 14.67; there were 74 women (62.2%) and 45 men (37.8%).

In total, 45 patients (37.8%) had a diagnosis of BPD, while 74 patients (62.2%) met criteria for the following other personality disorders: obsessive-compulsive (n = 20, 16.8%), avoidant (n = 17, 14.3%), dependent (n = 13, 10.9%), histrionic (n = 11, 9.2%), narcissistic (n = 10, 8.4%), paranoid (n = 8,6.7%), schizotypal (n = 6,5%), and schizoid (n = 4,3.4%).

Table 1 reports Pearson's chi-square test comparisons of categorical variables between subgroups. In the BPD subgroup, we found more common occurrence of Axis I comorbidity (P = 0.042), mood and anxiety disorders in first-degree relatives (P = 0.016), self-mutilating behaviours (P = 0.0005), substance abuse (P = 0.008), verbal or emotional abuse in childhood (P = 0.008), and physical abuse in childhood (P = 0.049).

Table 2 shows mean (SD) values of continuous variables and comparisons of the 2 subgroups with Student's t test. Patients with BPD had a lower mean age (P = 0.019), an earlier age at onset of MDD (P = 0.025), a lower SOFAS score (P = 0.0005), and higher scores on the HARS (P = 0.021), ZSDS (P = 0.007), and SDS (P = 0.0005).

Multiple regression showed that 5 variables were significantly related to the number of criteria for BPD: the ZSDS score (P = 0.0005), self-mutilating behaviours (P = 0.001), and occurrence of mood disorders in first-degree relatives (P = 0.01) were positively related, whereas the SOFAS score (P = 0.0005) and age at onset of MDD (P = 0.006) were negatively related (Table 3).

Discussion

Our data contribute to outlining differential characteristics of patients with coexisting MDD and BPD, compared with depression patients with other Axis II codiagnoses. Results of regression analysis indicate that the number of BPD criteria is related to earlier age at onset of MDD, more serious patient-rated depressive symptoms, worse clinician-rated global functioning, more common history of self-mutilating behaviours, and higher occurrence of mood disorders in first-degree relatives.

Our findings concerning age at onset of MDD, level of global functioning, and frequency of self-mutilating behaviours are consistent with previous studies (9-11,15,16). The association we found between number of BPD criteria and prevalence of mood disorders in the families of our depression patients can also be considered a substantial confirmation of preceding reports. For example, several authors have reported an increased rate of mood disorders in the relatives of BPD patients (1,27,28) and have suggested that it could be the consequence of coexisting affective syndromes. Riso and colleagues pointed out that the rates of mood disorders in the relatives of BPD probands were similar to rates found in a mood disorder control group (29). Similarly, our investigation of a sample of patients with a diagnosis of MDD found that coexisting BPD features were related to a family history of mood disorders. Despite some differences in methods among studies, available data implicate a strong familial link between BPD and mood disorders, suggesting that overlapping etiologic factors be considered.

A notable finding in our study is that the number of BPD criteria is only significantly related to the severity of depressive symptoms when measured by the patient, not by the clinician. This result appears discordant with a previous investigation by Comtois and colleagues, who reported that both a clinician-rated scale and a self-report measure of depressive symptoms were significantly related to BPD (2). If the difference that we found between the 2 types of scale is confirmed, a possible explanation could be that BPD patients experience and express depression with a dramatic and emphasized modality.

In conclusion, results of our study indicate that, compared with MDD patients having other Axis II codiagnoses, MDD patients with coexisting BPD are characterized by distinct clinical features. These include earlier onset and more severe depression, worse social impairment, more pronounced self-aggressiveness, and a stronger familial association with mood disorders. These differential characteristics may have diagnostic and therapeutic implications. They indicate the need for an accurate assessment of personality disorders in depression patients to identify cases with concomitant BPD and to reduce the incidence of complications such as self-mutilating behaviours or suicide attempts and loss of social abilities. The search for BPD should be particularly recommended in depression patients with a family history of mood disorders. Moreover, detection of BPD could be considered a predictive factor for early-onset MDD and induce clinicians to provide adequate preventive treatment.

A limitation of our study is that we collected clinical data retrospectively by interviewing patients on their psychiatric history. In particular, childhood abuse was identified from patients' memories. The validity of retrospective methods to collect data on autobiographical events remains controversial, although some authors regard patients' reports as sufficiently accurate (30,31). Another limitation is that data concerning previous and ongoing treatments were not analyzed, because there was considerable heterogeneity in drug and psychosocial interventions.

R�sume : La d�pression majeure chez les patients souffrant du trouble de la personnalit� limite : une investigation clinique

Objectif : Le trouble de la personnalit� limite (TPL) se caract�rise par une fr�quence �lev�e de trouble d�pressif majeur (TDM) comorbide. Cette �tude visait � comparer les caract�ristiques cliniques de 2 groupes de patients souffrant de TDM : ceux ayant un TPL concomitant et ceux souffrant d'autres troubles de la personnalit� concomitants.

M�thodes : Nous avons �valu� 19 patients externes, � l'aide d'une entrevue semi-structur�e pour obtenir les donn�es d�mographiques et cliniques, de l'entrevue structur�e clinique pour le DSM-IV, des �chelles de d�pression et d'anxi�t� d'Hamilton, de l'�chelle de d�pression auto-�valu�e de Zung (ZSDS), de l'�chelle d'�valuation du fonctionnement professionnel (SOFAS), de l'�chelle d'incapacit� de Sheehan et du questionnaire sur les exp�riences d'enfance revues. Nous avons ex�cut� une analyse de r�gression, � l'aide du nombre de crit�res du TPL comme variable d�pendante.

R�sultats : La gravit� du TPL �tait positivement reli�e au score � la ZSDS, aux comportements d'automutilation, et � la pr�sence de troubles de l'humeur chez des parents du premier degr�; elle �tait n�gativement reli�e au score � la SOFAS et � l'�ge de l'apparition du TDM.

Conclusions : Les patients souffrant de TDM et de TPL comorbides pr�sentent des caract�ristiques diff�rentielles qui indiquent un �tat plus s�rieux et incapacitant, et un fort lien familial avec des troubles de l'humeur, que ne le font les patients d�pressifs pr�sentant d'autres co-diagnostics de l'axe II.

[Reference]

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[Author Affiliation]

Silvio Bellino, MD1, Luca Patria, MD2, Erika Paradiso, MD3, Rossella Di Lorenzo, PhD4, Caterina Zanon, MD3, Monica Zizza, PhD4, Filippo Bogetto, MD5

[Author Affiliation]

Manuscript received September 2003, revised, and accepted July 2004.

1 Assistant Professor, Unit of Psychiatry, Department of Neuroscience, University of Turin, Italy.

2 Psychiatrist, Unit of Psychiatry, Department of Neuroscience, University of Turin, Italy.

3 Psychiatry Resident, Unit of Psychiatry, Department of Neuroscience, University of Turin, Italy.

4 ClinicaI Psychologist, Unit of Psychiatry, Department of Neuroscience, University of Turin, Italy.

5 Professor, Unit of Psychiatry, Department of Neuroscience, University of Turin, Italy.

Address for correspondence: Dr S Bellino, Unit of Psychiatry, Department of Neuroscience, University of Turin, via Cherasco 11, 10126 Torino, Italy

e-mail: silvio.bellino@unito.it