Category: Borderline Personality Disorder

Research led by a Michigan State University psychologist is playing a key role in the effort to change the way mental health clinicians classify personality disorders.

The study by Christopher Hopwood and colleagues calls for a more scientific and practical method of categorizing personality disorders — a proposal that ultimately could improve treatment, Hopwood said.

"We're proposing a different way of thinking about personality and personality disorders," said Hopwood, MSU assistant professor of psychology and an experienced clinician. "There's widespread agreement among personality disorder researchers that the current way to conceptualize personality disorders is not working."

The study is being cited by the team of experts that currently is developing criteria for the manual used to diagnose personality disorders — the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, slated to come out in 2013.

The study is being considered for inclusion in the DSM-5. The DSM, published by the American Psychiatric Association, is considered the bible of the U.S. mental health industry and is used by insurance companies as the basis for treatment approval and payment. The study also will appear in an upcoming issue of the Journal of Personality Disorders.

The current method of classifying personality disorders, as spelled out in the fourth edition of the DSM, or DSM-IV, breaks personality disorders into 10 categories, Hopwood said. That system is flawed, he said, because it does not take into account severity of personality disorders in an efficient manner and often leads to overlapping diagnoses.

"It's just not true that there are 10 types of personalities disorders, and that they're all categorical — that you either have this personality disorder or you don't," Hopwood said. "Scientifically, it's just not true."

Hopwood and colleagues propose a new three-stage strategy for diagnosing personality disorders:

Stage One: Consider a patient's normal personality traits, such as introversion/extroversion. "If a person is depressed and I'm a clinician, it might make a difference if I think they're extroverted depressive rather than introverted depressive," Hopwood said. "It may dictate the type of recommendations I make for them." These normal personality traits also may indicate patient strengths that could help in overcoming psychiatric difficulties; such strengths are not assessed in the current DSM.

Stage Two: Create a numerical score to represent severity of the disorder. "We're arguing that one single score can represent that severity, so clinicians can easily communicate with one another about how severe a patient is," Hopwood said. "That may indicate decisions such as whether this person should be hospitalized or treated with outpatient care."

Stage Three: Condense the list of 10 personality disorder categories to five dimensional ratings. Under this proposal, clinicians would diagnose how many symptoms of each disorder a patient has, rather than whether they have one or more of 10 disorders as in the current system. Hopwood said this is more reliable, valid and specific than the current system. He added that research has not sufficiently supported the validity of several current personality disorders. The proposed dimensional ratings are:

• Peculiarity. The defining characteristic here is oddness in thought or behavior. This dimension includes the diagnoses of paranoid, schizotypal and schizoid.
• Withdrawal. This includes avoidant personalities. "This may have to do with not wanting to leave the house," Hopwood said.
• Fearfulness. This combines disorders with opposite extremes of harm avoidance, such as antisocial (which involves fearlessness) and dependant or avoidant (which involves fearfulness).
• Unstable. This is similar to the diagnosis of borderline in DSM-IV. The defining characteristic is instability, such as with relationships, identity or emotional experience.
• Deliberate. This includes obsessive-compulsive disorder and other disorders defined by overly methodical behavior. "It's having a rigid sense of how life should happen — how I should behave and how other people should behave," Hopwood said.

Ultimately, Hopwood said, the proposal could improve both the system for diagnosing personality disorders as well as the outcome. "Presumably, if this leads to better clinical efficiency it could lead to better clinical care, and that's in everybody's interest," he said.

Co-authors of the proposal include Andrew Skodol of the Sunbelt Collaborative, New York State Psychiatric Institute and Columbia Medical School, and Leslie Morey of Texas A&M University.

The notion that cutting or burning oneself could provide relief from emotional distress is difficult to understand for most people, but it is an experience reported commonly among people who compulsively hurt themselves.

Individuals with borderline personality disorder experience intense emotions and often show a deficiency of emotion regulation skills. This group of people also displays high prevalence rates of self-injurious behavior, which may help them to reduce negative emotional states.

Niedtfeld and colleagues studied the effects of emotional stimuli and a thermal stimulus in people either with or without borderline personality disorder. They conducted an imaging study using picture stimuli to induce negative, positive, or neutral affect and thermal stimuli to induce heat pain or warmth perception. The painful heat stimuli were administered at an individually-set temperature threshold for each subject.

In patients with borderline personality disorder, they found evidence of heightened activation of limbic circuitry in response to pictures evocative of positive and negative emotions, consistent with their reported emotion regulation problems. Amygdala activation also correlated with self-reported deficits in emotion regulation. However, the thermal stimuli inhibited the activation of the amygdala in these patients and also in healthy controls, presumably suppressing emotional reactivity.

Dr. John Krystal, Editor of Biological Psychiatry, commented, "These data are consistent with the hypothesis that physically painful stimuli provide some relief from emotional distress for some patients with borderline personality disorder because they paradoxically inhibit brain regions involved in emotion. This process may help them to compensate for deficient emotional regulation mechanisms."

The authors note that these results are in line with previous findings on emotional hyperactivity in borderline personality disorder and suggest that these individuals process pain stimuli differently depending on their arousal status.

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Journal Reference:

1. Inga Niedtfeld, Lars Schulze, Peter Kirsch, Sabine C. Herpertz, Martin Bohus, Christian Schmahl. Affect Regulation and Pain in Borderline Personality Disorder: A Possible Link to the Understanding of Self-Injury. Biological Psychiatry, 2010; 68 (4): 383 DOI: 10.1016/j.biopsych.2010.04.015

Personality traits associated with impulsivity normally decrease during emerging and young adulthood, and these decreases are associated with reduced substance use. A new study of "trajectories" of impulsivity and their association with problem alcohol use has found that the 18-to-25-years-of-age group exhibited the largest declines in impulsivity as well as the sharpest decreases in alcohol consumption.

Results will be published in the August 2010 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

"Traits related to impulsivity, such as undirectedness or 'reverse-scored conscientiousness,' tend to normally decrease from late adolescence into early adulthood, approximately from ages 18 to 35," explained Andrew K. Littlefield, a doctoral student in clinical psychology at the University of Missouri and corresponding author for the study.

"This study is unique in examining patterns of impulsive traits across time," added Danielle Dick, assistant professor of psychiatry, psychology, and human and molecular genetics at Virginia Commonwealth University. "It is interesting that the trajectories of impulsivity identified here parallel previous work on trajectories of externalizing behavior — namely, that there is a class of individuals who appear to 'mature out' of impulsive behavior with emerging adulthood, while others do not show this normative maturing out."

"We used a person-centered trajectory approach in order to characterize individual differences in age-related changes in impulsivity," said Littlefield. "This approach allowed us to empirically discover groups of individuals that showed similar stability and change in impulsivity from ages 18 to35."

Littlefield and his colleagues used data drawn from a longitudinal study of individuals at risk for alcohol dependence (AD) because of a family history of alcoholism. Analyses were based on data collected from 489 college students (266 females, 223 males; 51% with a family history of AD) who were first assessed as freshmen at a large, public university and were then assessed six more times during the next 15 years. Initial analyses identified five trajectory groups that differed in baseline levels of impulsivity and developmental patterns of change.

"Our longitudinal trajectory analyses suggested key differences in both initial levels and change in impulsivity from ages 18 to 35," said Littlefield. "Of most importance, our findings suggest that individuals that made the steepest decreases in impulsivity also made the sharpest decreases in alcohol use and alcohol-related problems from ages 18 to 25." The major correlates were alcohol use — typically quantity frequency and a heavy drinking measures — and alcohol problems.

Littlefield said that through identification of distinct trajectory groups, researchers can better understand how different changes in individuals' impulsivity relate to alcohol use and related problems.

"Many researchers and clinicians think of personality as an incredibly stable construct that does not change across time, however, these findings provide clear evidence that at least some individuals undergo significant changes in impulsivity across time," he said. "Future studies could examine why some individuals make significant changes in impulsivity across time whereas other individuals' level of impulsivity remains relatively stable. Identifying factors that enhance or inhibit seemingly beneficial changes in personality may inform treatment approaches that could facilitate decreased impulsivity."

The study was funded by the National Institute on Alcohol Abuse and Alcoholism.

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Journal Reference:

1. Andrew K. Littlefield, Kenneth J. Sher, Douglas Steinley. Developmental Trajectories of Impulsivity and Their Association With Alcohol Use and Related Outcomes During Emerging and Young Adulthood I. Alcoholism: Clinical and Experimental Research, 2010; DOI: 10.1111/j.1530-0277.2010.01224.x

A study from Rhode Island Hospital has shown that a widely-used screening tool for bipolar disorder may incorrectly indicate bipolar disorder for patients suffering from borderline personality disorder. In the article that appears online ahead of print in the Journal of Clinical Psychiatry, the researchers question the effectiveness of the Mood Disorder Questionnaire (MDQ).

The MDQ is the most widely-used and studied screening tool for bipolar disorder. It is a brief questionnaire that assesses whether a patient displays some of the characteristic behaviors of bipolar disorder. It can be administered by clinicians or taken by patients on their own to determine if they screen positively for bipolar disorder. For the purposes of this study, the MDQ was scored by researchers.

Bipolar and borderline personality disorders share some clinical features, including fluctuations in mood and impulsive actions. The treatments, however, will vary depending on the individual and the diagnosis. Principal investigator Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital, conducted a study to test the accuracy of the MDQ.

The research team interviewed nearly 500 patients using the Structured Clinical Interview for Diagnostic Statistical Manual IV (DSM-IV) and the Structured Interview for DSM-IV for personality disorders. The patients were also asked to complete the MDQ. The research team then scored the questionnaires and found that patients with a positive indication for bipolar disorder using the MDQ were as likely to be diagnosed with borderline personality disorder as bipolar disorder when using the structured clinical interview. Further, their findings indicate that borderline personality disorder was four times more frequently diagnosed in the group who screened positive on the MDQ.

Zimmerman says that these findings raise caution for using the MDQ in clinical practice because of how differently the disorders are treated. "An incorrect diagnosis of bipolar disorder will usually lead to a treatment involving medications. If a patient truly has bipolar disorder, that treatment may work. However, at this time there are no approved medications to treat borderline personality disorder.

"Without an accurate diagnosis of borderline personality disorder, we may have many people in treatment who are taking medications that will not work to alleviate the characteristics of the condition from which they really suffer." Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, continues, "In addition, patients with unrecognized borderline personality disorder will not be treated with one of the effective psychotherapies for this condition. It is therefore vital that we develop or identify a more accurate method to distinguish between these two conditions, and adopt it into clinical practice."

— In the future, diagnosing severe personality disorders, evaluating the childhood environment, assessing alcohol consumption and the analysis of the MAOA genotype may provide more accurate means for assessing risk among violent offenders, according to the Finnish research carried out jointly at the University of Helsinki and the Helsinki University Central Hospital Psychiatry Centre.

"The many negative effects of violence could be alleviated by improving the accuracy of predicting violent behaviour. Lack of knowledge about the root causes of violence is, however, an impediment for such predictions," says Roope Tikkanen, MD, who has published his doctoral dissertation on the subject.

Tikkanen analysed the risk factors of violent reconvictions and mortality, using research data collated by Professor Matti Virkkunen based on court-ordered mental status examinations carried out in Finland during 1990-1998. The majority of the 242 men participating in the study suffered from alcoholism and severe personality disorders. The control group comprised 1,210 Finnish males matched by sex, age and place of birth. Following a nine-year follow-up period, the risk analyses were conducted based on criminal register (Legal Register Centre) and mortality (Statistics Finland) data.

Risk variables used in the analyses were antisocial personality disorder (ASPD), borderline personality disorder (BPD), the comorbidity of ASPD and BPD, childhood adversities, alcohol consumption, age, and the monoamine oxidase A (MAOA) genotype. In addition to these factors, the temperament dimensions were also assessed using the Tridimensional Personality Questionnaire (TPQ).

The prevalence of recidivistic acts of violence (32%) and mortality (16%) was high among the offenders. Severe personality disorders and childhood adversities increased the risk of recidivism and mortality both among offenders and in comparison to the controls. Offenders with BPD and a history of childhood maltreatment stood out as having a particularly poor prognosis.

The MAOA genotype was associated with the effects of alcohol consumption and aging on recidivism. With high-activity MAOA(MAOA-H) offenders, alcohol consumption and age affected the risk of violent reconvictions – alcohol increasing it and aging decreasing it – while with low-activity MAOA (MAOA-L) offenders no such link existed.

The temperament dimensions of offenders included high novelty seeking, high harm avoidance, and low reward dependence which correspond to the definition of an explosive personality.

"The risks of violent reconvictions and mortality accumulate in clear subgroups of violent offenders. Diagnosing severe personality disorders, assessing childhood environments and long-term alcohol consumption, and analysing the MAOA genotype may be tools that can in the future be employed in the prevention of recidivism and mortality and improving the accuracy of risk assessment among offenders," says Tikkanen.

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Journal References:

1. Tikkanen R, Holi M, Lindberg N, Virkkunen M. Tridimensional Personality Questionnaire data on alcoholic violent offenders: specific connections to severe impulsive cluster B personality disorders and violent criminality. BMC Psychiatry, 2007; 7 (1): 36 DOI: 10.1186/1471-244X-7-36
2. Tikkanen R, Holi M, Lindberg N, Tiihonen J, Virkkunen M. Recidivistic offending and mortality in alcoholic violent offenders: A prospective follow-up study. Psychiatry Research, 2009; 168 (1): 18 DOI: 10.1016/j.psychres.2008.02.009
3. Tikkanen R, Sjoberg RL, Ducci F, Goldman D, Holi M, Tiihonen J, Virkkunen M. Effects of MAOA-Genotype, Alcohol Consumption, and Aging on Violent Behavior. Alcoholism Clinical and Experimental Research, 2009; 33 (3): 428 DOI: 10.1111/j.1530-0277.2008.00853.x

 A year ago, a study by Rhode Island Hospital and Brown University researchers reported that fewer than half the patients previously diagnosed with bipolar disorder received an actual diagnosis of bipolar disorder after using a comprehensive, psychiatric diagnostic interview tool –the Structured Clinical Interview for DSM-IV (SCID). In this follow-up study, the researchers have determined the actual diagnoses of those patients.

Their study is published in the July 28 ahead of print online edition of The Journal of Clinical Psychiatry.

Under the direction of lead author Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital, the researchers' findings indicate that patients who received a previous diagnosis of bipolar disorder that was not confirmed by a SCID, they were significantly more likely to be diagnosed with borderline personality disorder as well as impulse control disorders.

Their research involved the study of 82 psychiatric outpatients who reported that they received a previous diagnosis of bipolar disorder that was not later confirmed through the use of the SCID. The diagnoses in these patients were compared to 528 patients who were not previously diagnosed with bipolar disorder. The study was conducted between May 2001 and March 2005.

Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, says, "In our study, one quarter of the patients over-diagnosed with bipolar disorder met DSM-IV criteria for borderline personality disorder. Looking at these results another way, nearly 40 percent (20 of 52) of patients diagnosed with DSM-IV borderline personality disorder had been over-diagnosed with bipolar disorder."

The results of the study also indicate that patients who had been over-diagnosed with bipolar disorder were more frequently diagnosed with major depressive disorder, antisocial personality disorder, posttraumatic stress disorder and eating and impulse disorders.

Zimmerman and colleagues note that "we hypothesize that in patients with mood instability, physicians are inclined to diagnose a potentially medication-responsive disorder such as bipolar disorder rather than a disorder such as borderline personality disorder that is less medication-responsive."

In their previously published study that concluded bipolar disorder was over-diagnosed, they studied 700 patients. Of the 700 patients, 145 reported they had been previously diagnosed as having bipolar disorder; however, fewer than half of the 145 patients (43.4 percent) were diagnosed with bipolar disorder based on the SCID. The authors state that the over-diagnosis of bipolar disorder can have serious consequences, because while bipolar disorder is treated with mood stabilizers, no medications have been approved for the treatment of borderline personality disorder. As a result, over-diagnosing bipolar disorder can unnecessarily expose patients to serious medication side effects, including possible impact to renal, endocrine, hepatic, immunologic and metabolic functions.

Zimmerman concludes, "Because evidence continues to emerge establishing the efficacy of certain forms of psychotherapy for borderline personality disorder, over-diagnosing bipolar disorder in patients with borderline personality disorder can result in the failure to recommend the most appropriate forms of treatment."

Along with Zimmerman, other researchers involved in the study include Camile Ruggero, PhD; Iwona Chelminski, PhD and Diane Young, PhD, all of Rhode Island Hospital and Brown University.

According to the National Institute of Mental Health, borderline personality disorder (BPD) is more common than schizophrenia or bipolar disorder and is estimated to affect 2 percent of the population. In a new study, a University of Missouri researcher and Dutch team of research collaborators found that genetic material on chromosome nine was linked to BPD features, a disorder characterized by pervasive instability in moods, interpersonal relationships, self-image and behavior, and can lead to suicidal behavior, substance abuse and failed relationships.

“The results of this study hopefully will bring researchers closer to determining the genetic causes of BPD and may have important implications for treatment programs in the future,” said Timothy Trull, professor of psychology in the MU College of Arts and Science. “Localizing and identifying the genes that influence the development of BPD will not only be important for scientific purposes, but will also have clinical implications.”

In an ongoing study of the health and lifestyles of families with twins in the Netherlands, Trull and colleagues examined 711 pairs of siblings and 561 parents to identify the location of genetic traits that influences the manifestation of BPD. The researchers conducted a genetic linkage analysis of the families and identified chromosomal regions that could contain genes that influence the development of BPD. Trull found the strongest evidence for a genetic influence on BPD features on chromosome nine.

In a previous study, Trull and research colleagues examined data from 5,496 twins in the Netherlands, Belgium and Australia to assess the extent of genetic influence on the manifestation of BPD features. The research team found that 42 percent of variation in BPD features was attributable to genetic influences and 58 percent was attributable to environmental influences, and this was consistent across the three countries. In addition, Trull and colleagues found that there was no significant difference in heritability rates between men and women, and that young adults displayed more BPD features then older adults.

“We were able to provide precise estimates of the genetic influence on BPD features, test for differences between the sexes, and determine if our estimates were consistent across three different countries,” Trull said. “Our results suggest that genetic factors play a major role in individual differences of borderline personality disorder features in Western society.”

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Journal References:

1. Distel et al. Chromosome 9: linkage for borderline personality disorder features. Psychiatric Genetics, 2008; 18 (6): 302 DOI: 10.1097/YPG.0b013e3283118468
2. Distel et al. Heritability of borderline personality disorder features is similar across three countries. Psychological Medicine, 2008; 38 (9): DOI: 10.1017/S0033291707002024

 Palm Pilots already perform a variety of functions, and in the future, they may be used as a therapeutic tool that benefits people with personality disorders.  In a new study, a University of Missouri researcher used Palm Pilots as electronic diaries to record and analyze mood variability in patients with borderline personality disorder (BPD) and found that the devices helped bridge an important communication gap between therapists and patients.

"In the clinical setting, patients are not good at assessing their mood retrospectively," said Tim Trull, professor of psychology in the MU College of Arts and Science. “Previously, we asked BPD patients to recall and describe when a mood change occurred. This description could vary greatly depending on the patient’s current state of mind and how comfortable the patient felt with the therapist.  Electronic diaries help solve this problem by requiring that the patient reflect on and rate the degree to which a specific mood is present at that moment. At the same time, the device does not require that the individual makes a decision about when a mood change has occurred.” 

In the study, patients carried electronic diaries for one month and were prompted randomly to rate their mood on a scale of 1 to 5 up to six times each day. One group of patients had BPD and the other group of patients had depressive disorders. Researchers found that patients with BPD did not have significantly different overall levels of positive or negative moods. However, the patients with BPD displayed significant variability in their positive and negative moods throughout the month, demonstrated more instability, and reported more extreme changes across successive occasions. 

“We may not have known the extent of the mood variability in the BPD patients without the assistance of the Palm Pilots, and the potential use of the device in psychological therapy is very exciting,” Trull said. “Eventually, programmed Palm Pilots may act as proxy therapists and provide patients with advice on coping skills and other therapeutic interventions, as problems occur in patients’ natural environment.” 

According to the National Institute of Mental Health, BPD is more common than schizophrenia or bipolar disorder and is estimated to affect 2 percent of the population. It is characterized by pervasive instability in moods, interpersonal relationships, self-image and behavior, and can lead to suicidal behavior, substance abuse and failed relationships. People with BPD experience mood shifts of depression, irritability, anger, anxiety and fear that can last from a few hours to a few days.  

Trull's study “Affective Instability:  Measuring a Core Feature of Borderline Personality Disorder with Ecological Momentary Assessment,” was published in the Journal of Abnormal Psychology.

— In a game of give and get, the brains of people with borderline personality disorder often don't get it.

In fact, an interactive economic game played between two people in functional magnetic resonance imaging (fMRI) devices revealed a brain malfunction associated with the disorder, a serious but common mental illness that affects a person's perceptions of the world and other people, said researchers from Baylor College of Medicine in a report that appears in the current issue of the journal Science.

"This may be the first time a physical signature for a personality disorder has been identified," said Dr. P. Read Montague, professor of neuroscience at Baylor College of Medicine and director of the BCM Brown Foundation Human Neuroimaging Laboratory.

In the study, directed by Dr. Brooks King-Casas, assistant professor of neuroscience and psychiatry and behavioral sciences at BCM and a member of the College's new Computational Psychiatry Unit, 55 people with borderline personality disorder played a "trust" game with 55 normal people of the same age and social and educational status.

In the game, one player called an investor sends $20 to the other called a trustee. The investment is tripled, and the trustee splits the profits with the investor. The trustee decides how much to send back, thus determining whether the investor recoups a profit or not. Profit requires cooperation between trustee and investor.

Both investor and trustee play the game while their brains are scanned by functional MRI devices through use of software called hyperscanning. The fMRI shows areas of blood flow in parts of the brain during the interaction between two people.

In this study, activity in an area of the brain called the anterior insula, known to respond when "norms" are violated, showed up on the scans. In the normal people, the anterior insula showed activity that responded in direct proportion to the amount of money sent and the money received. However, in people with borderline personality disorder, that part of the brain responded only to sending the money – not to the money received.

The scan casts a new light on the neurobiology of borderline personality disorder, said King-Casas, the study's lead author. Some day, he said, it could be used as a diagnostic tool or even a way to determine the effectiveness of a treatment.

"For the first time, to my knowledge, we have a specific brain association for people with a personality disorder," said Dr. Stuart Yudofsky, chair of the Menninger Department of Psychiatry and Behavioral Sciences at BCM. "It's new and different because it's not a lesion (or injury to the brain) but it is a difference in perceiving information that comes from an interaction." That is the area where people with borderline personality disorder have the most problem.

People with borderline personality disorder suffer from an inability to understand the actions of others. They frequently have unstable relationships, fly into rages inappropriately, or become depressed and cannot trust the actions and motives of other people.

"It's important that this biological signature has been identified," said King-Casas. "It's not just a matter of bad attitudes or a lack of will."

Yudofsky agrees that the finding my help eliminate the stigma associated with such disorders. The finding will help in three areas:

Diagnosis by giving a biologic measure that can be used to determine if a person has the problem.

Treatment using this brain-based difference to devise cognitive interventions or even medications that will affect the brain reactions.

Monitoring the effectiveness of treatment by determining how the brain's dysfunctional responses to the input from others change with treatment.

"We have great strength in the area of personality disorders through our relationship with The Menninger Clinic," said Yudofsky.

Dr. Peter Fonagy of Menninger and the University College London is a pioneer in treating borderline personality disorder using "mentalizing," a technique that helps people understand the mental states of other individuals by analyzing their outward behavior. He is a co-author and is hoping to find funding for a study on evaluating such treatment on patients using the functional MRI device.

Others who took part in this work include Carla Sharp, Laura Lomax and Terry Lohrenz, all of BCM.

Funding for this work came from the Child and Family Program at The Menninger Clinic, the National Institute of Mental Health, the National Institute of Neurological Disorders and Stroke and the National Institute on Drug Abuse.

A study from the Massachusetts General Hospital (MGH) supports previous reports that adolescents with bipolar disorder are at increased risk for smoking and substance abuse. The article appearing in the June Drug and Alcohol Dependence — describing the largest such investigation to date and the first to include a control group — also indicates that bipolar-associated risk is independent of the risk conferred by other disorders affecting study participants.

"This work confirms that bipolar disorder (BPD) in adolescents is a huge risk factor for smoking and substance abuse, as big a risk factor as is juvenile delinquency," says Timothy Wilens, MD, director of Substance Abuse Services in MGH Pediatric Psychopharmacology, who led the study. "It indicates both that young people with BPD need to carefully be screened for smoking and for substance use and abuse and that adolescents known to abuse drugs and alcohol — especially those who binge use — should also be assessed for BPD."

It has been estimated that up to 20 percent of children and adolescents treated for psychiatric problems have bipolar disorder, and there is evidence that pediatric and adolescent BPD may have features, such as particularly frequent and dramatic mood swings, not found in the adult form of the disorder. While elevated levels of smoking and substance abuse previously have been reported in young and adult BPD patients, it has not been clear how the use and abuse of substances relates to the presence of BPD or whether any increased risk could be attributed to co-existing conditions such as attention-deficit hyperactivity disorder (ADHD), conduct disorder or anxiety disorders.

The current study analyzes extensive data — including family histories, information from primary care physicians, and a detailed psychiatric interview — gathered at the outset of a continuing investigation following a group of young BPD patients into adulthood. In addition to 105 participants with diagnosed BPD, who enrolled at an average age of 14, the study includes 98 control participants of the same age, carefully screened to rule out mood disorders.

Incidence of each measure — alcohol abuse or dependence, drug abuse or dependence, and smoking — was significantly higher in participants with BPD than in the control group. Overall, rates of substance use/abuse were 34 percent in the bipolar group and 4 percent in controls. When adjusted to account for co-occurring behavioral and psychiatric conditions, the results still indicated significantly higher risk in the bipolar group. Analyzing how the onset of bipolar symptoms related to when substance abuse began, revealed that BPD came first in most study participants.

The data also indicated that bipolar youth whose symptoms began in adolescence were more likely to abuse drugs and alcohol than were those whose symptoms began in childhood. "It could be that the onset of mood dysregulation in adolescence puts kids at even higher risk for poor judgement and self-medication of their symptoms," Wilens says. "It also could be that some genetic switch activated in adolescence turns on both BPD and substance abuse in these youngsters. That's something that we are currently investigating in genetic and neuroimaging studies of this group."

He adds that clarifying whether bipolar disorder begins before substance abuse starts could have "a huge impact. If BPD usually precedes substance abuse, there may be intervention points where we could reduce its influence on drug and alcohol abuse. Aggressive treatment of BPD could cut the risk of substance abuse, just as we have shown it does in ADHD." Wilens is an associate professor of Psychiatry at Harvard Medical School.

The National Institute of Mental Health is supporting the long-term study of bipolar youth of which this report is one phase. Co-authors of the Drug and Alcohol Dependence article are Joseph Biederman, MD, Joel Adamson, Aude Henin, Stephanie Sgambati, Robert Sawtelle, Alison Santry and Michael Monuteaux, ScD, MGH Pediatric Psychopharmacology; and Martin Gignac, MD, University of Montreal.