New+Findings

=​​​ New Findings = = Bipolar Disorder plus Antisocial Personality Disorder: An Impulsive Storm = =​ Talk about impulsivity! Comorbid bipolar disorder AND Antisocial personality disorder.= Bipolar disorder and antisocial personality disorder (ASPD) are each associated with increased impulsivity. What happens in the course of illness when the two conditions co-occur, as they ofen do? Using careful, structured, clinical interviews and impulsivity rating scales, investigators compared 61 patients with bipolar I disorder without Axis II disorder, 34 with ASPD without bipolar, 24 with both bipolar I disorder and ASPD, and 78 nonpsychiatric comparison subjects.

Patients were assessed when clinically stable (ie., with medication dose changes < 20% in the previous 2 weeks). Of the 85 patients with bipolar illness, 68% and 60% had histories of substance and alcohol use disorders, respectively. Of the patients with both bipolar disorder and ASPD, 62% met criteria for borderline personality disorder. The two ASPD groups had significantly lower educational attainment than the bipolar-only group and healthy comparison groups. Compared with the bipolar-only group, the bipolar-ASPD group had significantly more manic or depressive episodes. The bipolar-ASPD group had higher trait impulsivity and more frequent histories of attempted suicide than the ASPD-only group. Impulsivity was not associated with greater severity of criminal behavior.

In this retrospective study, researchers could not easily tease out the effects of comorbid alcoholism, substance abuse and borderline personality disorder. In other studies, the diagnosis of antisocial personality disorder in patients with preexisting bipolar disorder has in part been attributed to intervening alcoholism and substance abuse. It is not surprising that combinations of these disorders are associated with greater impulsivity and suicidality and more difficult courses of illness than the individual disorders. Clinicians need to comprehensively treat patients with multiple psychiatric and substance abuse diagnoses, and to find strategies for enhancing medication adherance (including the use of depot medications at times), stable social rhythms and sobriety. **- Joel Yager MD**
 * Comment**


 * Swann AC et al Interactions between bipolar and antisocial personality disorder in trait impulsivity and severity of illness.**
 * Acta PsychiatrScand 2010 Jun; 121:453 JournalWatch**

=Endogenous Opiates and Mood Regulation in Borderline Personality Disorder ​= An imaging study uncovers a role for the u-opioid system in these patients' experience of psychic pain.

Multiple endogenous neurotransmitter systems and brain circuits have been implicated in the emotional dysregulation seen in patients with borderline personality disorder (BPD). Of particular interest is the opioid system, because it may affect emotional and stress regulation and because patients with BPD have altered pain thresholds. Using positron emission tomography (PET) and magnetic resonance scans, investigators compared concentrations of u-opioid receptors in several brain regions at baseline and after sustained sadness was induced in 18 female patients with BPD and 14 age-matched comparison women.

At baseline, patients had greater deactivation of u-opioid receptors (ie., higher receptor occupancy by PET ligand) than controls in many brain regions. The evocative stimuli generated greater subjective sadness among patients than among controls. Induced sadness altered receptor activation in the two groups, but in different patterns. After induced sadness, patients showed greater receptor activation than controls in pregenual anterior cingulate and in left-sided orbitofrontal cortex, amygdala, ventral pallidum and inferior temporal cortex. Also after induced sadness, patients had greater endogenous system deactivation than controls in the left nucleus accumbens, left hypothalamus and right hippocampus/parahippocampus.

It is not surprising that the opioid system has a role in the experience of psychic pain, a key BPD feature. These findings may help account for the frequent co-occurrence of pain disorders and the use of opiate medications among patients with BPD. How much do these differences in opioid circuits result from antecedent stressors or from genetic vulnerabilities? This development-related question remains to be answered, probably through animal studies. Whether these findings ultimately translate into clinically useful treatments for patients with BPD (e.g., medications affecting u-opioid receptors) is an open question. -- **Joel Yager, MD**
 * Comment**


 * Prossin AR et al. Dysregulation of regional endogenous opioid function in borderline personality disorder.**
 * Am J Psychiatry 2010 May 13; [e-pub ahead of print] JournalWatch**


 * BORDERLINE PERSONALITY DISORDER **


 * A**lthough the cause of BPD is unknown, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits. Studies show that many, but not all individuals with BPD report a history of abuse, neglect or separation as young children. 40 to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver. Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful as well as impulsivity and poor judgement in choosing partners and lifestyles.

The National Institutes of Mental Health-funded neuroscience research is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. The amygdala, a small almond-shaped structure deep inside the brain, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of drugs like alcohol, or stress. Areas in the front of the brain (pre-frontal area) act to dampen the activity of this circuit. Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.

Serotonin, norepinephrine and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain's major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioural interventions and medications, much like people manage susceptibility to diabetes or high blood pressure.

Studies that translate basic findings about neural basis of temperament, mood regulation and cognition into clinically relevant insights which bear directly on BPD represent a growing area of NIMH-supported research. Research is also underway to test the efficacy of combining medications with behavioural treatments like DBT and guaging the effect of childhood abuse and other stress in BPD on brain hormones. Data from the first prospective, longitudinal study of BPD, which began in the early 1990's, is expected to reveal how treatment affects the course of the illness. It will also pinpoint specific environmental factors and personality traits that predict a more favorable outcome. The Institute is also collaborating with a private foundation to help attract new researchers to develop a better understanding and better treatment for BPD. -http://www.nimh.nih.gov/health/publications/borderline-personality

Personality Disorders Treatable?
There has been so much research, evaluation of treatment, and studies done recently on personality disorders. The progress of treatment is astounding compared to our progress in previous decades. Many personality disorders are being viewed as treatable, and some cases curable. __The Mclean Study of Adult Development__ found that 88% of patients diagnosed with Borderline Personality Disorder severe enough to require hospitalization no longer met diagnostic criteria by the ten year follow up. (Hadjipavlou, G., & Ogrodniczuk, J. 2010.) Furthermore, __The Collaborative Longitudinal Personality Disorders Study__ performed by the McLean Hospital and associates, found that less than half the patients recorded in their study met the diagnostic criteria after 2 years if they received medication and psychotherapy. They estimated that patients receiving psychotherapy experience recovery 7 times faster than those following the natural course of the illness. (Hadjipavlou, G., & Ogrodniczuk, J. 2010) Research studies such as these coupled with Randomized controlled trials and nationwide census's allow us to confidently state that those living with severe personality disorders today have a very good chance of recovery if they are able to seek medical intervention for assistance with their illness.There are many new and promising treatments for personality disorders, and many of them are psychotherapy based. Although many disorders may need medication throughout the patients lives to be manageable, many will be able to be controlled merely with continued psychotherapy and behavioral and cognitive therapy.

Hadjipavlou, G., & Ogrodniczuk, J. (2010). Promising Psychotherapies for Personality Disorders. //Canadian Journal of Psychiatry//, //55//(4), 202-210. Retrieved from Academic Search Premier database.