Psychiatry Research, 9, I 15 I23 Elsevier

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Effect of Preexisting Borderline Personality Disorder on Clinical and EEG Sleep Correlates of Depression

Jesse Bell, Helene Lycaki, Don Jones, Surendra Kelwala, and Natraj Sitaram

Abstract. Two groups of depressed patients were studied: (I) The first group comprised 15 inpatients who were diagnosed aspredominant!,~“borderline person- ality disorders” based on DSM-III and psychometric test criteria; these patients were also clinically depressed. (2) The second group consisted of 18 inpatients who met Research Diagnostic Criteria (RDC) for major depressive disorder (MDD) but who failed to meet the above criteria for borderline personality disorder. Subsequent to the selection of patients for study. an independent diagnostic evaluation revealed that MDD patients with borderline personality disorder had higher ratings than nonborderline MDD patients on items from the Schedule for Affective Disorders and Schizophrenia such as total anxiety, anger, schizotypal features, miscellaneous psychopathology, and alcohol and drug abuse. A further breakdown of miscellaneous psychopathology items revealed greater subjective anger, self-pity, and demandingness in borderline patients. A comparison of RDC subtypes in the two groups revealed a significant increase in bipolar II diagnoses in

the borderline MDD group. Electroencephalographic (EEG) sleep studies carried out in a subsample of M DD borderline (n= 8) and primary M DD nonborderline (n = I I) patients revealed no significant differences between the two groups. Thus, in contrast to the EEG sleep findings reported for secondary depression with other antecedent psychiatric disorders, the present study indicated that a preexisting diagnosis of borderline personality disorder in MDD patients did not alter the characteristic short latency of rapid eye movement (REM) sleep and the sleep continuity disturbances reported in primary MDD. These data confirm earlier reports by Akiskal (1981) Carroll et al. (1981) and McNamara et al. (1982) concerning the phenomenological and EEG sleep profiles of borderline patients.

Key Words. Borderline personality disorder, major depressive disorder, sleep, rapid eye movement (REM) latency.

The group of patients diagnosed as borderline personality disorders have attracted the

attention of both psychoanalytic theorists and biological scientists. Numerous

attempts have been made to understand borderline personality as a diagnostic entity, as well as to define its relationship to the two major psychiatric syndromes with which it shares several overlapping features-namely, schizophrenia and the affective disorders.

Formulations of the borderline concept by Gunderson and Singer (1975), as well as the recent classification of the disorder along Axis II in DSM-/I/(Spitzeret al., 1980)

Jesse Bell. Ph.D.. Don Jones. M.D., Surendra Kelwala, M.D.. and Natraj Sitaram, M.D., are in the Affective Disorders Unit, and H. Lycaki is in the Department of Psychology, LafayetteClinic. Detroit, MI. Dr. Sitaram is also Associate Professor of Psychiatry. Wayne State University. Detroit, Ml. (Reprint requests to Dr. J. Bell. Dept. of Psychology. Lafayette Clinic, 951 E. Lafayette. Detroit. MI 48207, USA.)

0 165 I78 I 83 $03.00 Q 1983 Elsevier Science Publishers B.V.

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suggest that borderline patients suffer from a severe “personality” disorder. The Research Diagnostic Criteria (RDC) developed by Spitzer et al. (1978) omit this diagnostic entity altogether, presumably because of difficulties in arriving at specific operational criteria to define the disorder.

There are converging lines of evidence, however, that a large proportion of border- line patients may suffer from intermittent or lifelong affective illness: (1) Akiskal (1980), in a followup study of 100 consecutive cases of borderline patients, found that approximately two thirds of the cohort would qualify for a diagnosis of bipolar 11 (major depressive disorder with hypomania not requiring hospitalization), cyclo- thymic or dysthymic disorder. Lithium also reportedly attenuated the unpredictable affective swings in many of these patients. (2) Stone (1977) reported a significant loading of affective disorders in the families of borderline probands. (3) Carroll et al. (1981) found that patients with depression superimposed on a chronic borderline personality disorder often have abnormal dexamethasone suppression test (DST) results similar to those found in major depression (Carroll et al., 1976). (4) Akiskal (198 1) and McNamara et al. (1982) have also reported that borderline patients show an abnormally early onset of rapid eye movement (REM) sleep that is comparable to observations in primary major depressive illness.

The current study, which attempted to delineate the relationship between borderline and affective disorders, had the following objectives: (1) to quantitate the specific type and degree of distortions produced by a preexisting borderline personality disorder on the clinical picture of a superimposed depressive episode; (2) to determine the effect of a preexisting borderline condition on a specific biological marker, REM sleep latency, and other electroencephalographic (EEG) sleep abnormalities that have been asso- ciated with primary depressive illness (Kupfer et al., 1978).

Methods

The study protocol consisted of two phases. First, all new consecutive inpatient admissions with a DSM-III (American Psychiatric Association, 1980) diagnosis of major depressive disorder (MDD) were independently evaluated by a senior clinical psychologist (H.L.) for the presence or absence of a preexisting borderline personality disorder. A group of I5 patients with unequivocal borderline personality disorder antecedent to the current depressive episode and another group of I8 depressed patients without current or past borderline features were selected for study’ and referred to the affective disorders research team. Phase 2 of the study. coordi- nated by the research team, consisted of the administration of a Schedule for Affective Disorders and Schizophrenia (SADS) interview (Endicott and Spitzer, 1978) assignment of a diagnosis of major depressive disorder (MDD) and subtype by RDC criteria, and 3 nights of EEG sleep recordings.

The research team responsible for the SADS interview and EEG sleep recordings had no knowledge of the borderline/ nonborderline assignment of the referred patients. Conversely. the clinical psychologist (H.L.) who determined borderline status was unaware of the subsequent

clinical ratings and the EEG sleep data. Borderline personality disorder is not included as an RDC diagnosis by Spitzer et al. (1978) and the SADS interview does not contain specific items aimed at diagnosing this disorder.

I. Five additional patients (three borderline, two nonborderline) who were referred did not enter the stud) either because changes in clinical state resulted in failure to meet RDC criteria for M DD (n = 2) or because of refusal to undergo a structured diagnostic interview 01 = 3).

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Diagnostic Criteria. During phase I, the diagnosis of borderline personality disorder was made as follows: (I) All patients fulfilled DSM-IIIcriteria for the diagnosis, showing five of the eight characteristics specified. (2) In all cases, borderline symptomatology was required to have preceded (chronologically) the onset of depressive symptoms. Symptoms included a clear history of premorbid borderline pathology, longstanding difficulties in the management of impulse and affect (perceived most characteristically in interpersonal relationships which tended to be intense and unstable), pronounced affective instability, mood swings, and severe identity disturbances. In the global judgment of the referring clinician, the borderline syndrome was the predominant and most severe psychoparholog,v of the individual, even though all patients were also depressed. (3) All patients underwent a full psychological testing battery consisting of the Wechsler Adult Intelligence Scale-Revised (WAIS-R), Minnesota Multiphasic Personality Inventory (M MPI), Thematic Apperception Test (TAT), and Rorschach test. Items that were consistent with and lent weight to a borderline classification were the following: (I) predominance of projective identification and splitting of ego states on both the TAT and the Rorschach test, as indicated by the presence of excessive oral-incorporative and oral-aggressive content, and the coexistence of contradictory opposite affective states (e.g., love and hate, good and bad); (2) intact intellectual function on the WAIS-R; (3) absence of attentional or associa- tive disturbances of cognition on the WAIS-R; (4) significant elevations on the depression, anxiety (psychasthenia), and schizophrenia scales of the MM PI with T scores > 70 on scales l-9, regardless of the validity scales configuration (Newmark and Sines, 1972; Snyder et al., 1982). The above operationalized criteria are consistent with the findings of borderline pathology reported by Rapaport et al. (1946) Schafer (1954) and Gorney and Weinstoch (1979).

During phase 2 the affective disorders research team confirmed the DSM-If/ M DD diagnosis using RDC after the SADS interview. All SADS interviews were conducted by two experienced clinicians (J.B. and D.J.) who had participated in the standardized SADS training program. All diagnoses of MDD required a minimum of 2 weeks’ duration of depressed mood and the presence of five of the eight items specified, i.e., definite MDD (RDC). Diagnoses of bipolar I and II were distinguished by the requirement of documented evidence of hospitalization for mania in bipolar I patients and evidence of a hypomanic episode not requiring hospitalization in bipolar II patients.

Sleep Studies. A subsample of primary MDD borderline (n = 8) and primary MDD nonbor- derline (n = I 1) patients underwent EEG sleep recording after a 2-week drug-free period. Only the sleep data from primary depressives were included for analysis in view of reports that primary and secondary depressives have significantly different REM latencies (Coble et al., 1976).

Sleep polygraphic recording and scoring of sleep stages followed standard criteria (Recht- schaffen and Kales, 1968) and consisted of all-night monitoring of EEG (C,-A,), submental electromyogram (EMG). electro-oculogram (EOG), and electrocardiogram (EKG) (lead II). The subjects underwent 3 nights of study: an initial adaptation night and 2 additional nights. Sleep recordings were unfortunately not obtained on the first (adaptation) night. There were no differences between the sleep parameter values for night 2 alone, night 3 alone, and the mean of nights 2 and 3. In this article, we present data from the mean of nights 2 and 3. All subjects were prepared for sleep study between IO and I I p.m. and generally retired between I I:30 p.m. and midnight. They were awakened between 6:30 and 6:45 a.m.

Results

Interrater Reliability. Reliability between two raters (J.B. and D.J.) was good (see

Table 1); intraclass (r) concordance correlations (Kramer and Feilstein, 198 1) ranged

from 0.6 to 1.0 on the SADS scale scores.

Demographic and Diagnostic Subtype Distribution. As shown in Table 2, there

were no sex or age differences between the two groups. There were also no significant

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Table 1. Interrater reliability among two raters on SADS summary scores (n=6)

SADS scales lntraclass r

Depressed mood and ideatron 0.76

Endogenous features 0.65

Depressive assocrated features 0.93

Suicidal rdeatron and behavior 0.88

Anxiety phobias and panic attacks , 0.85

Alcohol, drug abuse 0.99

Delusions-hallucinations 1 .oo

Formal thought disorder 1 .oo

Miscellaneous psychopathology 0 93

GAS 0.63

Extracted Hamrlton 0.60

Impaired functionrng 0.98

Manic syndrome 0.90

Table 2. Age, sex and frequency of diagnostic sub- type associated with borderline and nonborder- line depressed patients.

Borderline Nonborderline (n=15) (n=18)

Age mean + SD) 29.7 t 3.9 36.5 i 13.2

Sex

Males 5 8

Females 10 IO

Subtypes

Endogenous 9 10

Nonendogenous 6 a

Primary a 11

Secondary 7 7

Unrpolar 9 15

Bipolar I 1 2

Unipolarl 9 15

Bipolar II 5 1 L

Psychotic 1 3

Nonpsychotrc 14 15

1. pc.0 05. Fisher’s exact probability test All other entrles, NS

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differences in frequency of endogenous vs. nonendogenous, unipolar vs. bipolar I, or psychotic vs. nonpsychotic subtypes between the borderline and nonborderline depressed groups by Fisher’s exact probability test. There was, however, a significant increase in the frequency of bipolar II diagnoses among the borderline group.

SADS Depressive Symptomatology and Ratings. Each of the SADS total scale scores is a composite of several related items/ symptoms which are rated on severity. Each item has a range of O-7 or O-6, with O-2 representing the absence or presence of a minimally clinically significant level of the symptom, and 6-7 representing its greatest level of severity. The total scale score of depressed mood and ideation, for example, is a summation of the severity ratings on items such as depressed mood, self-reproach, worrying/ brooding, negative self-evaluation, and discouragement/ pessimism. Thus, the total scale scores presented in Table 3 are a summation of severity ratings taken from a group of ordinal level items.

Results from Table 3 indicate that borderline and nonborderline patients are basically similar on most of the core depressive symptomatology during the worst week of the current episode (e.g., endogenous features, mood and ideation, and suicidal behavior). The parameters that emerged as significantly different were greater schizotypal features, total anxiety, anger, miscellaneous psychopathology (i.e., self- pity, demandingness), and alcohol and drug use in borderline as compared to nonbor- derline depressed patients.

EEG Sleep Variables. Results indicate that the EEG sleep patterns of our primary borderline MDD patients were basically similar to those of primary nonborderline MDD patients, especially with regard to abnormally shortened REM latency and sleep continuity disturbances (Table 4). It is unlikely that age was a significant factor in our failure to find differences between the two groups, since there were no significant age differences between borderline and nonborderline patients. These results indicate that the sleep abnormalities found in depressed borderline patients closely resemble many of those reported in primary MDD patients (Kupfer et al., 1978). These findings are not surprising since the two groups being compared both received diagnoses of major depressive illness and moreover had comparable depressive scale item scores on the SADS interview. However, in an attempt to partial out the contribution of depression to the EEG sleep findings, an analysis of covariance (ANCOVA) between the two groups was performed holding various depressive scale scores constant and using REM latency as the dependent variable. This analysis would provide statistical control for the contribution of depression in the absence of a nondepressed borderline control group in our study.

The results shown in Table 5 indicate a significant difference in REM latency between borderline and nonborderline patients when Hamilton (mean of two raters) rating scores were held constant. In this analysis, borderline depressed patients had shorter REM latencies than nonborderline depressed patients. However, ANCOVA with other SADS depression scales (such as depressed ideation and mood, depressive associated features, and endogenous features) as covariates did not reach significance. In view of the small sample involved and the fact that the ANCOVA was significant only for Hamilton ratings, the preliminary nature of this finding should be emphas-

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Table 3. Major differences in clinical and personality variables between borderline (n=15) and nonborderline (n=18) depres- sed Datients.

Borderline Nonborderline

Mean SD Mean SD Variable (score range)

Total

anxiety I 4-30 ) Schizotypal

features I O-6 1 Behavioral

disorganization I 5-35 I Anger 10-121

GAS tl-99i

Depressed mood

& ideation (5-31 ! Endogenous

features (7-621

Depressive associated

features ( 14-88)

Suicidal ideation

& behavior I 1-281

Delusions-

hallucinations I 18-73)

Extracted Hamilton 10-63 I Miscellaneous

psychopathology I 13-71 I Alcohol, drug

abuse 12-121

Manic syndrome 5-301

16.7 6.6 11.91 5.2

1.1 0.6 0.1’ 0.2

8.0 2.1 7.1 3.1

7.2 2.2 5.51 3.1

37.2 5.9 39.4 14.8

25.0 3.6 21.8 6.8

38.6 9.4 36.5 7.9

52.2 9.8 48.2 8.9

12.7 3.6 12.1 7.8

21.1 4.2

23.1 7.6

21.4

26.7

7.3

7.9

30.0

4.1

6.9 24.61 6.3

2.5 2.71 1.1

20.3 15.6 13.5 10.1

1. ~0.05, two-tailed t test. All other comparrsons, NS

ized. A prospective study (currently underway) with a larger sample would be more definitive in determining whether borderline status has independent additive effects on the shortened REM latency seen in primary depression.

Discussion

Given the small sample size and the large number of variables used in the present study, the reliability and generalizability of its results can be questioned. However, our data suggest that a premorbid history of borderline personality disorder lends a distinctive flavor to the clinical presentation of a superimposed depressive episode. Depressed borderline patients appear to be very similar to major depressives in mood and ideation, endogenous features, suicidal ideation and behavior, and ratings on the Hamilton Scale and the Global Assessment Scale (GAS). The SADS items that

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Table 4. Comparison of primary borderline (n=8) and nonborderline (n=9) depressed patients on EEG sleep variables (mean of nights 2 and 3)

Borderline Nonborderline

Variables Mean SD Mean SD

Sleep latency1 36.2 22.3 25.0 20.3

Intermittent awakening 48.4 26.5 63.7 34.5

Early morning

awakening 12.9 15.5 10.6 13.6

Sleep efficiency 84.4 10.5 78.9 15.7

Sleep changes 47.8 17.9 48.5 12.4

1st REM latency2 41.3 17.2 49.1 18.1

Total REM % 30.3 9.2 28.8 10.8

Total REM density 1.9 0.5 1.7 0.6

1st REM density3 1.7 0.8 1.6 1.1

1st REM period duration 24.0 17.6 21.0 16.0

% Delta sleep 9.2 8.5 9.7 9.2

Total sleep time 339.6 48.2 342.6 59.6

Total recording time 423.8 40.3 433.0 36.3

1. Sleep latency is the elapsed time in mrnutesfrom “lights o&to the first onset of sleep, whrch in turn is defined by the first minuteof stage 2 sleep whrch IS followed by 9 mmutes containing not more than 1 minute of awake time. Sleep begmnmg with a REM period must have at least 3or more minutesof REM sleep isleep-onset REMI. 2 Includes intermittent awakenings. 3. REM densrty is a measure of the intensity of rapid eye movements occurnng withm a REM sleep episode. Each 30-second epoch of REM sleep IS scored on a scale of O-4 and the total eye movement score is divrded by the number of 30.second REM sleep epochs. All tabled comparisons are NS.

Table 5. Comparison of REM sleep latency between primary borderline (n=8) and nonborderline (n=ll) depressed patients by ANCOVA with Hamilton depressive mood ratings as covariate

Patient groups Hamilton’ REM lat.1

Borderlme depressed 23.8 + 5.2 41.3 2 17.2

Nonborderline dep. 27.8 k8.1 49.1 + 18.1

ANCOVA table Residuals

df Sslxr SSIV, df SstvI MS(v) F

Among 1 76.7

Within 17 907.7

Total 983.8

1 Values expressed as mean t SD. 2 p<oo25

280.2 1 1032.5 1032.5 6.972

5680.9 16 2371.3 148.2

5961.1 3403.8

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distinguished borderline from nonborderline depressed patients were total anxiety, anger, miscellaneous psychopathology (i.e., self-pity. demandingness), and alcohol, drug abuse. These personality and behavioral traits make the clinical presentation of borderlines quite different from the typical endogenous presentation and could poten- tially lead to diagnostic confusion and ambiguity. With regard to the EECi sleep findings, borderline patients appear to be biologically similar to primary major depressive patients in their sleep patterns. These results are consistent with the findings of Akiskal(l98 I) and McNamara et al. (1982), and indicate that depressed borderline patients share, and possibly amplify the degree of abnormality of. this critical biologi- cal marker of major depression.

Acknowledgment. The authors thank Ms. Mar) Rat/a for assistance in the preparation ot this report.

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