Elsevier

Psychiatry Research

Volume 241, 30 July 2016, Pages 224-231
Psychiatry Research

Borderline personality features in depressed or anxious patients

https://doi.org/10.1016/j.psychres.2016.05.007Get rights and content

Highlights

  • Borderline personality features are more common in depression than in anxiety.

  • Anxiety and depression explain a significant amount of variance in borderline features.

  • Anxiety and depression explain 3.8–31% of the variance in the four borderline domains.

  • Variance in borderline features is partly shared and partly unique for anxiety and depression.

  • Borderline features are associated with greater anxiety and depression severity.

Abstract

Anxiety and depression frequently co-occur with borderline personality disorder. Relatively little research examined the presence of borderline personality features and its main domains (affective instability, identity problems, negative relationships and self-harm) in individuals with remitted and current anxiety and depression. Participants with current (n=597) or remitted (n=1115) anxiety and/or depression and healthy controls (n=431) were selected from the Netherlands Study of Depression and Anxiety. Assessments included the Personality Assessment Inventory – Borderline Features Scale and several clinical characteristics of anxiety and depression.

Borderline personality features were more common in depression than in anxiety. Current comorbid anxiety and depression was associated with most borderline personality features. Anxiety and depression status explained 29.7% of the variance in borderline personality features and 3.8% (self-harm) to 31% (identity problems) of the variance in the four domains. A large part of the variance was shared between anxiety and depression but both disorders also explained a significant amount of unique variance. The severity of anxiety and depression and the level of daily dysfunctioning was positively associated with borderline personality features. Individuals with a longer duration of anxiety and depression showed more affective instability and identity problems. These findings suggest that patients with anxiety and depression may benefit from an assessment of personality pathology as it may have implications for psychological and pharmacological treatment.

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

References (58)

  • T.J. Meyer et al.

    Development and validation of the Penn State Worry Questionnaire

    Behav. Res. Ther.

    (1990)
  • M. Ozkan et al.

    Comorbid personality disorders in subjects with panic disorder: do personality disorders increase clinical severity?

    Compr. Psychiatry

    (2005)
  • B.W. Penninx

    Depression and anxiety: their insidious dance

    Lancet Psychiatry

    (2015)
  • A.E. Skodol et al.

    The borderline diagnosis I: psychopathology, comorbidity, and personality structure

    Biol. Psychiatry

    (2002)
  • A.E. Skodol et al.

    Patterns of anxiety and personality-disorder comorbidity

    J. Psychiatr. Res.

    (1995)
  • H.U. Wittchen

    Reliability and validity studies of the WHO - Composite International Diagnostic Interview (CIDI): a critical review

    J. Psychiatr. Res.

    (1994)
  • M.G. Warshaw et al.

    Reliability and valisity of the longitudinal interval follow-up evalaution for assessing outcome of anxiety disorders

    J. Psychiatr. Res.

    (1994)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders 4th (Text Revision)

    (2000)
  • M. Amore et al.

    Suicide attempts in major depressed patients with personality disorder

    Suicide Life-Threat. Behav.

    (2014)
  • D.H. Barlow et al.

    Unified Protocol for Transdiagnostric Treatment of Emotional Disorders: Therapist Guide

    (2011)
  • D.H. Barlow et al.

    The nature, diagnosis, and treatment of neuroticism: back to the future

    Clin. Psychol. Sci.

    (2014)
  • A.T. Beck et al.

    An inventory for measuring clinical anxiety: psychometric properties

    J. Consult. Clin. Psychol.

    (1988)
  • V.J. BellPringle et al.

    Assessment of borderline personality disorder using the MMPI-2 and the personality assessment inventory

    Assessment

    (1997)
  • T.A. Brown et al.

    A proposal for a dimensional classification system based on the shared features of the DSM-IV anxiety and mood disorders: implications for assessment and treatment

    Psychol. Assess.

    (2009)
  • K.M. Davidson et al.

    Impact of treatment intensity on suicidal behavior and depression in borderline personality disorder: a critical review

    J. Personal. Disord.

    (2014)
  • R. De Graaf et al.

    Temporal sequencing of lifetime mood disorders in relation to comorbid anxiety and substance use disorders--findings from the Netherlands mental health survey and incidence study

    Soc. Psychiatry Psychiatr. Epidemiol.

    (2003)
  • R. De Graaf et al.

    Prevalence of mental disorders and trends from 1996 to 2009. Results from the Netherlands Mental Health Survey and Incidence Study-2

    Soc. Psychiatry Psychiatr. Epidemiol.

    (2012)
  • M.H.M. De Moor et al.

    Assessment of borderline personality disorder features in population samples: is the personality assessment inventory-borderline scale measurement invariant across sex and age?

    Psychol. Assess.

    (2009)
  • M.A. Distel et al.

    Nederlandse vertaling van de personality assessment inventory - borderline kenmerken schaal (PAI-BOR): normgegevens, factorstructuur en betrouwbaarheid

    Psychol. Gezondh.

    (2009)
  • Cited by (18)

    • Depressive and anxiety disorders in concert–A synthesis of findings on comorbidity in the NESDA study

      2021, Journal of Affective Disorders
      Citation Excerpt :

      To further advance the ontological comprehension of comorbidity of depressive and anxiety disorders, some have suggested that comorbidity is just an artefact (Maj, 2005), while others stated that comorbidity of depressive and anxiety disorders is more than a sum of the parts (Kleiman and Riskind, 2012). In NESDA, the association between comorbidity and several vulnerability, functional, and mental health indicators remained when clinical factors such as symptom severity (Hendriks et al., 2015; Lamers et al., 2011b) or disease status (current versus remitted; (Distel et al., 2016; Hofmeijer-Sevink et al., 2018)) were taken into account. Hence, severity and disease status may be part, but not all, of the explanation why almost all outcomes tended to be more adverse and protruded in comorbid as compared to the single disorders.

    View all citing articles on Scopus
    View full text