Borderline personality features in depressed or anxious patients
Introduction
Depressive and anxiety disorders are among the most prevalent psychiatric disorders with life time prevalence rates around 20% (Kessler et al., 2005; De Graaf et al., 2012). Comorbidity with Borderline Personality Disorder (BPD) is high ranging from 13 to 14% for depressive disorders (Friborg et al., 2014) and from 6 to 10% for anxiety disorders, excluding Post-Traumatic Stress Disorder (Friborg et al., 2013). The other way around, rates of lifetime depressive and anxiety disorders in BPD patients both go up to around 85% (Gunderson et al., 2008, Silverman et al., 2012, Tomko et al., 2014). BPD is characterized by instability in several domains including affective functioning, relationships, identity and cognition. BPD patients often engage in problematic behavior such as substance abuse, binge eating, suicide attempts and other self-harm behavior, making it a highly disturbing disorder (American Psychiatric Association, 2000, Skodol et al., 2002).
Patients with comorbid major depressive disorder and BPD are more actively suicidal (Soloff et al., 2000, Soloff and Chiappetta, 2012, Amore et al., 2014), have earlier age of onset of their depression and are more often chronically depressed (Joyce et al., 2003, Amore et al., 2014). A large recent meta-analyses revealed that BPD patients with an additional comorbid depressive disorder were more severely depressed than patients with a depressive disorder only (Kohling et al., 2015). Studies into the clinical presentation of patients with anxiety disorders and comorbid BPD are scarce. The comorbidity with personality disorders in general is associated with higher levels of anxiety, lower levels of general functioning and stronger associations with suicide attempts (Ozkan and Altindag, 2005, Nepon et al., 2010). For BPD specific, Ozkan and Altindag (2005) showed that BPD predicted suicide attempts and an earlier age of onset of the anxiety disorder in panic disorder patients. Skodol et al. (1995) showed that patients with comorbid anxiety disorder and BPD had lower levels of functioning than patients with anxiety disorders alone.
Knowledge of borderline personality features in patients with anxiety and depression is thus of great clinical relevance. We will add to the available literature in several ways. First, most available studies on the comorbidity of depression and anxiety and BPD used a categorical classification of the disorders. Often however, borderline personality features are apparent at subthreshold level where they may already have a significant unfavorable impact on the presentation of psychiatric disorders. The present study therefore uses a dimensional measure of borderline personality features to study the association with depression and anxiety. In addition, we will take into account that BPD is a very heterogeneous disorder. We will study whether associations between anxiety and depression and borderline personality features are consistent across four main domains of BPD: affective instability, identity problems, negative relationships and self-harm.
A total of 50–70% of the patients with anxiety or depression are exposed to both disorders (De Graaf et al., 2003a, Penninx, 2015). Although this comorbidity is substantial, most studies on the comorbidity with BPD focus on one of the two disorders. The present study focuses on both disorders. This way, the unique and common association with borderline personality features and its main domains can be determined. The presence of borderline personality features will be compared between healthy controls and subjects with remitted, current and comorbid anxiety and depression. Finally, in addition to clinical diagnoses, the strength of the relationship between specific clinical characteristics of depression and anxiety and borderline personality features will be examined.
Section snippets
Sample
Data were drawn from the Netherlands Study of Depression and Anxiety (NESDA). NESDA is an ongoing cohort study designed to investigate the course and consequences of depressive and anxiety disorders. A total of 2981 participants with a current or past anxiety or depressive disorder and healthy controls were recruited from the community, primary care and secondary mental health care. Participants were all aged between 18 and 65 years at the baseline assessment in 2004–2007. During the baseline
Sociodemographic and clinical characteristics
The total study sample consisted of 2143 participants with a remitted (N=1115) or current (N=597) depressive and/or anxiety disorder and healthy controls (N=431). The mean age of the total study sample was 48.1 years (range 23–72), 66.2% were females and the mean years of attained education was 12.9 years. Table 1 shows the sociodemographic and clinical characteristics across the diagnostic groups. The severity of the symptoms differed significantly across the diagnostic groups depending on the
Discussion
To our knowledge, this was the first study examining associations between anxiety and depressive disorders and borderline personality features using a dimensional measure for borderline personality and four main domains of BPD. Dimensional measures for personality disorders are generally considered as more reliable, more stable and more highly associated with measures of severity than categorical classifications (Zanarini et al., 2000, Verheul, 2005, Durbin and Klein, 2006, Morey et al., 2007).
Acknowledgements
The infrastructure for the NESDA study (www.nesda.nl) is funded through the Geestkracht Program of the Netherlands Organisation for Health Research and development (Zon-Mw, grant number 10-000-1002) and is supported by participating universities and mental health care organizations (VU University Medical Center, GGZ ingest, Arkin, Leiden university medical center, GGZ Rivierduinen, University Medical Center Groningen, Lentis, GGZ Friesland, GGZ Drenthe, Scientific Institute for Quality of
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