Journal of Affective Disorders 170 (2015) 104–111

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Research report

Different impulsivity profiles in borderline personality disorder and bipolar II disorder Erlend Bøen a,b,c,n, Benjamin Hummelen d,e, Torbjørn Elvsåshagen a,c, Birgitte Boye a, Stein Andersson a,f, Sigmund Karterud c,d, Ulrik F. Malt a,b,c a

Department of Psychosomatic Medicine, Oslo University Hospital, Post Box 4950 Nydalen, Oslo 0424, Norway Norwegian Research Network on Mood Disorders (NORMOOD), Oslo, Norway c Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway d Department for Personality Psychiatry, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway e Division of Mental Health and Addiction, Department for Research and Education, Oslo University Hospital, Norway f Department of Psychology, University of Oslo, Oslo, Norway b

art ic l e i nf o

a b s t r a c t

Article history: Received 4 July 2014 Received in revised form 21 August 2014 Accepted 22 August 2014 Available online 29 August 2014

Introduction: Borderline personality disorder (BPD) and bipolar II disorder (BP II) share clinical characteristics including impulsivity. Their relationship is disputed. In this study, we investigated selfreported impulsivity in these patient groups and in a healthy control group. Effects of current mood state and of traumatic childhood experiences were explored. Methods: Twenty-five patients with BPD without comorbid bipolar disorder; 20 patients with BP II without comorbid BPD; and 44 healthy control subjects completed the UPPS questionnaire which yields assessments of four components of impulsivity: Urgency, Lack of Premeditation, Lack of Perseverance, and Sensation Seeking. Current mood state was rated using the Montgomery Asberg Depression Rating Scale (MADRS), and the Young Mania Rating Scale (YMRS). Traumatic childhood experiences were assessed using the Childhood Trauma Questionnaire (CTQ). Group differences in UPPS levels; and effects of mood state and CTQ score on UPPS scores in patients were investigated. Results: BPD patients showed significantly higher levels of Urgency and Lack of Perseverance than BP II patients and controls, and a significantly higher level of Lack of Premeditation than controls. BP II patients showed higher levels of Urgency and Lack of Perseverance than controls. In BP II, higher MADRS scores were associated with higher impulsivity scores. Also, higher CTQ scores were associated with higher Urgency scores in BP II. Limitations: Relatively small sample size; cross-sectional assessment of influence of mood state. Conclusions: BPD patients exhibited markedly elevated UPPS impulsivity scores compared with healthy controls and BP II patients, and the elevations were not related to current mood state. BP II patients showed moderately elevated impulsivity scores which were associated with a depressed mood state and to some extent with a history of childhood trauma. The findings suggest that BPD and BP II have different impulsivity profiles. & 2014 Elsevier B.V. All rights reserved.

Keywords: Impulsivity Borderline personality disorder Bipolar II disorder UPPS

1. Introduction Borderline personality disorder (BPD) and bipolar disorder have several commonalities. For years, there has been a debate about how the two conditions are related (Zanarini et al., 1998; Ruggero et al., 2010; Paris, 2013; Fletcher et al., 2014; Ghaemi et al., 2014). Some have argued that BPD may represent a subgroup of the bipolar spectrum disorders (Akiskal et al., 1985), or that BPD and

n Corresponding author at: Department of Psychosomatic Medicine, Oslo University Hospital, Post Box 4950 Nydalen, 0424, Oslo, Norway. E-mail address: [email protected] (E. Bøen).

http://dx.doi.org/10.1016/j.jad.2014.08.033 0165-0327/& 2014 Elsevier B.V. All rights reserved.

bipolar disorder may share a genetic predisposition to temperamental instability, which may develop into either BPD or bipolar disorder (Mackinnon and Pies, 2006). Others acknowledge that BPD and bipolar disorder have a certain reciprocal comorbidity, but maintain that they represent distinct diagnostic entities (Zimmerman and Morgan, 2013). The manias of bipolar I disorder are qualitatively distinct and easily recognizable; therefore, recent research has focused on the relationship between BPD and bipolar II disorder (BP II) (Perugi et al., 2011). Present data support that the disorders differ on central aspects such as etiology, course of illness, emotion dysregulation profile, and treatment response (Bayes et al., 2014; Ghaemi et al., 2014; Parker, 2011). However, direct comparisons of BPD and BP II

E. Bøen et al. / Journal of Affective Disorders 170 (2015) 104–111

patients are few, and there are still unresolved questions regarding their relationship. For example, it is not fully clarified whether and how the disorders are separated on measures of impulsivity (Bayes et al., 2014; Ghaemi et al., 2014). 1.1. Impulsivity in BPD and BP II Impulsivity is a defining feature of the BPD diagnosis, but has also been shown to be associated with bipolar disorder (Lewis et al., 2009; Swann et al., 2009; Strakowski et al., 2010). To our knowledge, only two studies have compared impulsivity in BPD and BP II. Both studies assessed impulsivity by means of the Barratt Impulsiveness Scale (BIS) (Henry et al., 2001; Wilson et al., 2007). Both studies compared four patient groups classified by different comorbidity combinations, and both found that BPD was associated with higher impulsivity than BP II. However, neither study compared BPD and BP II groups directly, but instead conducted two-way analyses of variance with the presence or absence of BPD and BP II or mood disorder as factor. Nor did any of them include a healthy control group. Those study limitations impeded determinations of whether and how impulsivity might differ between these two diagnostic groups (Zimmerman et al., 2013). 1.2. Self assessment of impulsivity BIS is probably the most commonly used self-assessment measurement of impulsivity in psychiatry, and elevated BIS scores have been shown repeatedly in BPD (Herpertz et al., 1999; Paris et al., 2004; Domes et al., 2006) and in BP II (Lewis et al., 2009; Swann et al., 2009; Etain et al., 2013). However, a large factor analysis study suggested that BIS and other questionnaires do not capture all facets of impulsivity (Whiteside and Lynam, 2001). Importantly, impulsivity related to negative affect is not well evaluated by the BIS scale, which might limit the assessment of impulsivity related to psychiatric disorders. Therefore, Whiteside and Lynam wanted to create a more comprehensive self assessment scale to measure impulsivity (Whiteside and Lynam, 2001). This new scale, known as UPPS, includes four components and corresponding subscales. The first component, Urgency, refers to a tendency to act impulsively under experiences of negative effect. The second component, Lack of Premeditation, refers to a difficulty to reflect on the consequences of an act before engaging in it, and corresponds closely with several previous measures of impulsivity including the BIS. The third component, Lack of Perseverance, refers to an inability to remain focused on boring or difficult tasks. The fourth component, Sensation Seeking, refers to a tendency to engage in exciting, new, and sometimes dangerous activities. Accordingly, the UPPS might have the potential to capture a broad range of aspects involved in impulsivity. The clinical usefulness of the questionnaire has been demonstrated in a variety of samples (Smith et al., 2007; Verdejo-Garcia et al., 2007; Tragesser and Robinson, 2009; Jacob et al., 2010; Miller et al., 2010; Mobbs et al., 2010; Claes and Muehlenkamp, 2013). Notably, UPPS has also proven useful to differentiate between disorders and traits; for example between variants of ADHD (Miller et al., 2010) and between borderline and antisocial traits (DeShong and Kurtz, 2013). 1.3. Aims and hypotheses The present study aimed to compare UPPS impulsivity among BPD, BP II, and healthy control groups. Our main hypothesis was that BPD and BP II represent distinct diagnostic categories, and thus would display different UPPS profiles. Based on a previous study that used UPPS in the assessment of impulsivity in BPD (Jacob et al., 2010), we expected that patients with BPD would exhibit higher levels of impulsivity compared to healthy controls

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on all UPPS subscales, except for the Sensation Seeking scale. Based on studies of bipolar disorder that used the BIS scale, we expected that BP II patients, compared to healthy controls, would exhibit elevations on the UPPS subscales that correspond most closely to BIS; i.e., Lack of Premeditation and to a certain extent Urgency (Whiteside and Lynam, 2001). Furthermore, based on studies that used the Zuckerman Sensation Seeking scale (Fornaro et al., 2013), we expected patients with BP II to exhibit elevated UPPS Sensation Seeking compared to controls. We hypothesized that patients with BP II would not differ significantly from healthy controls on the UPPS Lack of Perseverance scale. In the direct comparison between BPD and BP II, we hypothesized that the BPD group would exhibit higher impulsivity scores than the BP II group on all subscales, except for Sensation Seeking, where the BP II group was expected to exhibit the highest scores. To highlight differences between the diagnostic categories, we focused on including patients without reciprocal comorbidity (i.e. BPD patients without BP II; BP II patients without BPD). In addition, comorbid ADHD (Attention Deficit Hyperactivity Disorder) was an exclusion criterion, due to the potential confounding role of this disorder in a study of impulsivity (Miller et al., 2010). Mood state has in some studies been shown to influence BIS impulsivity in bipolar disorder, but those results have been equivocal (Lewis et al., 2009; Strakowski et al., 2010). In exploratory analyses in each patient group, we aimed to investigate the relationship between UPPS impulsivity and depressive state, measured with the Montgomery–Asberg Depression Rating Scale (MADRS), and the relationship between UPPS impulsivity and the degree of hypomania, measured with the Young Mania Rating Scale (YMRS). Childhood traumatic experiences are frequent among BPD patients (Battle et al., 2004). Also, such experiences have been shown to increase impulsivity in adult bipolar patients (Leverich et al., 2002). Thus, we also wanted to explore the association between self-reported childhood trauma, assessed by of the Childhood Trauma Questionnaire (CTQ), and UPPS impulsivity in the patient groups.

2. Methods 2.1. Subjects The Regional Ethics Committee of Southeastern Norway (REK Sør-Øst) approved the study (REK no 6.2008.158). After the subjects were informed about the study, written informed consent was obtained. Twenty-five patients meeting the DSM-IV criteria for BPD were recruited from the Department for Personality Psychiatry at Oslo University Hospital. Twenty patients meeting the DSM-IV criteria for BP II were recruited from outpatient psychiatric clinics in the greater Oslo area and from the Department of Psychosomatic medicine at Oslo University Hospital. Forty-four healthy control subjects were recruited through local advertising. Patients with BPD were excluded if they met the criteria for bipolar I or II disorder. To avoid including BPD patients with subthreshold bipolarity, we excluded patients with a history of hypomanic symptoms that lasted more than 24 h. BPD patients were also excluded if they had a schizotypal or schizoid personality disorder. Patients with BP II were excluded if they met the criteria for any cluster A or B personality disorder. Patients in both diagnostic categories were excluded if they had a lifetime psychotic disorder, or ADHD. Healthy control subjects were excluded if they had any previous or present psychiatric disorder. All participants were excluded if they were under age 18 or above age 50; if they had a history of a neurological or other severe chronic

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somatic disorder, or if they had a history of head injury with loss of consciousness for more than 5 min. 2.2. Diagnosis, mood state, demographics, and supplementary information Axis I and axis II assessments of patients were based on the Mini-International Neuropsychiatric Interview, version 5.0.0 (MINI) (Sheehan et al., 1998) and the Structured Clinical Interview for Personality Disorders (SCID-II) (First, 1997), respectively. All patients were interviewed by two clinicians; MINI interviews were carried out by a psychiatrist specializing in mood disorders (EB), and SCID-II interviews were carried out by a psychiatrist specializing in personality disorders (BH). The reliability of each patient's diagnosis was ascertained with the LEAD principle (“Longitudinal, Expert, All Data“) (Spitzer, 1983). All available information was used. Interviews with relatives were conducted, when necessary, to facilitate the diagnostic evaluation. In cases of doubt, senior authors UFM and SK were consulted concerning axis I and axis II cases, respectively. Mood state was assessed by EB with the MADRS (Montgomery and Asberg, 1979) and the YMRS (Young et al., 1978) for depressive and hypomanic symptoms, respectively. EB's credentials included MADRS reliability training, with the result of an intraclass correlation coefficient ¼0.98 (95% CI: 0.90– 0.99). Traumatic childhood experiences were assessed using the short version of the CTQ (Bernstein et al., 2003). This self report inventory comprises 25 items assessing 5 different types of childhood trauma: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. Control subjects were screened for axis I disorders with the MINI interview. Axis II disorder assessment was based on a clinical interview, combined with either the self-report Personality Disorder Questionnaire, version 4 (PDQ-4) (Hyler et al., 1992) or the IOWA self report questionnaire (Langbehn et al., 1999). For all participants, demographic and supplementary information were obtained with the Stanley Foundation Network Entry Questionnaire (NEQ) (Suppes et al., 2001). Alcohol and substance use were assessed with the clinical Alcohol Use Scale (AUS) and Drug Use Scale (DUS) (Drake et al., 1996).

statistically significant. In group comparisons of demographic and clinical data, analyses of variance (ANOVAs) and Student's t-tests were performed to test for differences in continuous variables; and Fischer's exact tests were performed to test for differences in categorical variables. ANOVA post-hoc pairwise comparisons of UPPS subscale scores used the Bonferroni correction for multiple comparisons. Explorative analyses of the effects of MADRS score were carried out in each patient group separately using two different approaches. First, linear regression analyses were performed with each UPPS subscale as the dependent variable, and MADRS score as the independent variable. Second, each diagnostic group was split into two equally sized groups; those with a MADRS score higher than the group median, and those with a MADRS score lower than the group median. The UPPS scores in these groups were compared using Student's t-tests. Explorative analyses of the effects of YMRS score were carried out using linear regression analyses in a similar way as described for MADRS. Bivariate correlation analyses were run in each patient group separately to explore whether CTQ total or subscale scores were associated with UPPS scores. The ANOVAs of UPPS subscales were rerun to investigate whether group effects remained significant while excluding patients with alcohol or substance abuse or dependence. Pairwise analyses (BPD vs. controls, BP II vs. controls, and BPD vs. BP II) of covariance (ANCOVAs) were employed to investigate whether group differences in UPPS scores remained significant when controlling for age, gender, and educational level. To assess whether the use of medication influenced UPPS scores in the patient groups, we included psychotropic medication (use vs. no use) as a covariate in ANCOVAs of UPPS scores for the patient groups. Similarly, ANCOVAs with lamotrigine use as a covariate (use vs. no use) were carried out for the patient groups. Because of the much higher prevalence of lamotrigine and benzodiazepine use in the BP II than the BPD group, t-tests comparing BP II patients using lamotrigine with those not using lamotrigine, and comparing BP II patients using benzodiazepines with those not using benzodiazepines, were also carried out.

2.3. Impulsivity

3. Results

Impulsivity was assessed with the 45-item UPPS self report questionnaire (Whiteside and Lynam, 2001). The UPPS was based on an exploratory factor analysis that included around 700 items potentially associated with impulsivity from a series of impulsivity scales. The exploratory factor analysis identified four distinct components of impulsivity; Urgency, Lack of Premeditation, Lack of Perseverance, and Sensation Seeking. Each item is ranked from 1 (strongly agree) to 4 (strongly disagree). Higher scores represent higher levels of impulsivity.

3.1. Demographic and clinical characteristics

2.4. Statistics The sample size needed to detect clinically significant differences was calculated online (http://www.dssresearch.com/toolkit/ sscalc/size_a2.asp). This analysis was based on our intention to identify differences between the two patient groups. A UPPS mean subscale group difference of 0.4 was considered clinically meaningful. Assuming a mean subscale score of 2.8 in one patient group and 2.4 in the other, and a SD ¼0.5 in each group, with an α error of 5% and β error of 20%, we calculated that a sample size of around 20 in each patient group was sufficient for detecting statistically significant differences. Statistical analyses were conducted with SPSS, version 18.0 (Chicago, Illinois). A two-tailed P-value of p o0.05 was considered

Demographic and clinical data are shown in Table 1. The groups differed in age; the BP II group was significantly older than the other groups. Significantly more BP II patients than BPD patients used psychotropic medication (lamotrigine, benzodiazepines). MADRS scores were significantly higher in the BPD group than in the BP II group. CTQ scores were significantly higher in the BPD group with the exception of the emotional abuse score. The patient groups exhibited comparable comorbidity profiles. 3.2. UPPS scores ANOVAs showed significant group differences for three UPPS subscales; Urgency (F ¼95.3; p o0.001), Lack of Premeditation (F¼9.7, p o0.001), and Lack of Perseverance (F¼47.3, po 0.001). There was no significant group difference for the Sensation Seeking subscale (F¼2.4; p ¼0.104). Mean UPPS subscale scores for each group and pairwise post-hoc comparisons are shown in Table 2. BPD patients showed significantly higher impulsivity scores than healthy controls on all UPPS subscales except Sensation Seeking, and significantly higher impulsivity than BP II patients on the Urgency and Lack of Perseverance subscales.

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Table 1 Demographic and clinical characteristics in BPD, BP II, and healthy controls. Variable Demographics Age in years, mean (SD) Female gender, n (%) Educational level, n (%) 0–10 years 11–13 years 14–17 years 417 years Age at first disabling symptoms, years, mean (SD) Current mood state MADRS score, mean (SD) YMRS score, mean (SD) Lifetime major depression, n (%) Childhood Trauma Questionnairea Total score, mean (SD)b Emotional abuse score, mean (SD)b Physical abuse score, mean (SD)b Sexual abuse score, mean (SD)b Emotional neglect score, mean (SD)b Physical neglect score, mean (SD)b Current medication, n (%) Any psychotropic medication Lamotrigine Valproic acid Lithium Antidepressant Antipsychotic Benzodiazepine Alcohol or substance abuse/dependence, n (%) No alcohol or substance abuse/dependence Alcohol abuse/dependence Substance abuse/dependencec Current PD, social phobia or GAD, n (%) Current PTSD, n (%) Current eating disorder, n (%)

BPD (n¼ 25)

BP II (n ¼20)

Healthy controls (n¼ 44)

26.8 (6.1) 22 (88.0%)

33.6 (5.7) 15 (75.0%)

28.8 (7.7) 35 (77.8%)

1 (4.0%) 12 (48.0%) 8 (32.0%) 4 (16.0%) 15.2 (3.7)

1 (5.0%) 3 (15.0%) 8 (40.0%) 8 (40.0%) 15.8 (5.1)

0 14 (31.8%) 17 (38.6%) 13 (29.5%)

17.0 (5.5) 2.7 (2.3) 23 (92%)

11.6 (6.6) 3.2 (2.7) 20 (100%)

0.6 (1.1) 0.1 (0.4)

55.7 (18.5) 13.0 (5.5) 7.8 (4.0) 7.9 (3.8) 17.0 (5.8) 9.9 (4.3)

40.9 (10.6) 10.2 (4.3) 5.2 (0.5) 5.2 (1.5) 12.8 (4.6) 7.5 (2.2)

0.003 0.074 0.003 0.003 0.013 0.037

13 (52.0%) 2 (8.0%) 0 0 10 (40.0%) 1 (4.0%) 1 (4.0%)

17 (85.0%) 12 (60.0%) 1 (5.0%) 0 8 (40.0%) 2 (10.0%) 5 (25.0%)

0.013 o0.001 0.444

18 (72%) 5 (20%) 4 (16%) 12 (48%) 2 (8.0%) 2 (8.0%)

18 (90%) 1 (5%) 1 (5%) 7 (35%) 0 (0%) 0 (0%)

All groups compared, p

Patients compared, p

o0.001

0.005 0.516 0.139

0.631 o 0.001 o 0.001

0.005 0.530 0.495

1.000 0.577 0.074 0.260 0.205 0.362 0.545 0.495 0.495

BPD¼ borderline personality disorder. BP II ¼ bipolar II disorder. MADRS ¼ Montgomery Asberg Depression Rating Scale. YMRS¼ Young Mania Rating Scale. PD ¼panic disorder. GAD ¼generalized anxiety disorder. PTSD ¼post-traumatic stress disorder. a b c

Child trauma questionnaire available for 19 BP II patients. Childhood Trauma Questionnaire: total score range 25–125; subscale score range 5–25. Substances: cannabis(2), amphetamine(1), cocaine(2).

Table 2 UPPS subscales. Mean scores (SD) and Bonferroni corrected post-hoc pairwise comparisons in BPD, BP II, and HC. UPPS subscale

BPD (n¼ 25)

BP II (n¼ 20)

HC (n ¼44)

BPD vs HC p

Bp II vs HC p

BPD vs BP II p

Urgency Lack of Premeditation Lack of Perseverance Sensation Seeking

3.24 2.70 2.76 2.56

2.76 2.40 2.21 2.29

1.70 2.16 1.76 2.67

o 0.001 o 0.001 o 0.001 1.000

o 0.001 0.223 o 0.001 0.102

0.003 0.134 o0.001 0.501

(0.52) (0.44) (0.35) (0.69)

(0.56) (0.68) (0.65) (0.73)

(0.39) (0.40) (0.31) (0.58)

BPD¼ borderline personality disorder. BP II ¼ bipolar II disorder. HC ¼healthy controls.

BP II patients showed significantly higher impulsivity than healthy controls on the Urgency and Lack of Perseverance subscales. 3.3. Explorative analyses of effect of mood state on impulsivity In the BPD group, linear regression analyses showed no significant effects of the MADRS score on any UPPS subscale (all p 40.47). When the BPD patients with the highest MADRS scores (n ¼13, MADRS Z18) were compared with those with the lowest MADRS scores (n ¼12, MADRS r17), there were no group differences on any UPPS subscale (all p 40.27). In the BP II group, linear regression with the MADRS score as the independent variable showed a statistically significant effect of

MADRS score on the Lack of Premeditation score. An increase in MADRS score corresponded to an increase in the Lack of Premeditation score (β ¼0.54, t¼ 2.73, p¼ 0.014, r2 ¼0.29). There was a trend significant effect of MADRS score on the Lack of Perseverance score (β ¼ 0.41, t¼1.92, p ¼0.070, r2 ¼0.17), with higher MADRS score corresponding to higher Lack of Perseverance score. There were no significant effects of MADRS on the remaining subscales. When the BP II patients with the highest MADRS scores (n ¼10, MADRS Z12) were compared with those with the lowest MADRS scores (n ¼10, MADRS r11), the group with the highest MADRS scores had significantly higher scores on the Urgency (p ¼0.019); Lack of Premeditation (p ¼ 0.049); and Lack of Perseverance (p¼ 0.014) subscales.

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Linear regression showed that the YMRS scores did not have any significant effects on the UPPS subscales for any diagnostic group (all p 40.17).

3.4. Explorative analyses of effect of self reported childhood trauma on impulsivity In the BPD group, there were no significant associations between CTQ total score and UPPS scores (all p 40.42). There was a trend towards a significant negative correlation between physical neglect score and Lack of Premeditation (r ¼  0.34, p ¼0.91) (higher neglect score corresponding to lower impulsivity), otherwise there were no significant associations between any CTQ subscale score and UPPS scores. In the BP II group, there was a significant positive correlation between CTQ total score and Urgency (r ¼0.68, p ¼0.001). There were no significant associations between CTQ total score and any other UPPS subscale score (all p 40.21). It appeared that three CTQ subscales were responsible for the positive correlation between CTQ total score and Urgency: emotional abuse (r ¼ 0.65, p¼ 0.003); emotional neglect (r ¼0.69, p ¼0.001); and physical neglect (r ¼0.48, p ¼ 0.04). There were no other significant associations between CTQ subscale scores and UPPS scores.

3.5. Effects of other clinical variables on impulsivity When ANOVAs were rerun after excluding patients with alcohol or substance abuse or dependence, the group differences, included post-hoc comparisons, in UPPS subscale scores remained significant (all p o0.004). Pairwise ANCOVAs controlling for age, gender, and educational level showed results similar to the main analyses. In the comparison between the BPD and healthy control groups, the three subscales that showed significant differences in the main analyses still showed significant differences (all po 0.011). In the comparison between the BP II and healthy control groups, the differences in Urgency and Lack of Perseverance remained significant (all p o0.012). In the comparisons between the BPD and BP II groups, the difference in Lack of Perseverance remained significant (p ¼0.007). However; the difference in Urgency did not longer reach significance (p ¼0.158). In ANCOVAs including the use of psychotropic medication as a covariate, the differences between BPD and BP II groups remained significant for Urgency (p ¼0.004) and Lack of Perseverance (p ¼0.005), with no significant effect of medication use. In ANCOVAs including lamotrigine use as a covariate, the group difference for Urgency score was not longer significant (p¼ 0.255), while there were significant group differences for Lack of Premeditation (p ¼0.023) and Lack of Perseverance (p ¼0.006). There was a significant lamotrigine x diagnosis interaction on Urgency score (p ¼0.021). Lamotrigine use was associated with lower score in BPD patients and higher score in BP II patients. Similarly, there was a significant lamotrigine x diagnosis interaction (p ¼0.005) on the Lack of Premeditation scores but in the reverse direction: use of lamotrigine was associated with higher scores in the BPD group, and with lower scores in the BP II group. There was a significant difference in Lack of Premeditation score between BP II patients using lamotrigine vs those not using lamotrigin, with those using lamotrigine exhibiting lower scores (p¼ 0.036). However, there was also a trend significant difference in the opposite direction for Urgency scores, with those BP II patients using lamotrigine showing the highest scores (p ¼0.091). There were no significant effects of benzodiazepine use in the BP II group.

4. Discussion In this study of self-reported impulsivity, the BPD group exhibited higher levels of impulsivity than healthy controls on all UPPS subscales except Sensation Seeking. On the Urgency and Lack of Perseverance subscales; the BPD group showed higher impulsivity levels than the BP II group, while the BP II group was situated in an intermediate position with higher levels than healthy controls. Exploratory analyses indicated that a depressive mood state was associated with increased impulsivity in the BP II group, but not in the BPD group. Furthermore, Urgency score was associated with experiences of childhood neglect and emotional abuse in BP II patients. In summary, the results suggest that BPD is associated with a high level of broadly defined impulsivity which is not related to current mood state. In contrast, BP II may be associated with moderately elevated levels of impulsivity, and these elevations may be partly related to current depressive symptoms. Adverse childhood experiences may increase impulsivity related to negative emotions in BP II patients. 4.1. Urgency Both patient groups exhibited elevated scores on the Urgency component compared with healthy control subjects. The patients with BPD had significantly higher scores than those with BP II. Regarding the BPD group, this elevation is consistent with results from a previous study which showed that BPD was associated with a pronounced elevation on this UPPS subscale (Jacob et al., 2010). The finding is also consistent with research suggesting that impulsive behaviors, such as self-mutilation, substance abuse, and promiscuity, may be used to alleviate and express intense psychic pain in BPD (Paris, 2005; Zanarini, 2008; Zanarini et al., 2013). In contrast, little is known about the UPPS Urgency component in patients with BP II. Previously used measures of impulsivity, like the BIS, do only to a small degree assess this kind of impulsivity. However, behaviors that may be related to this emotional component of impulsivity are also observed in bipolar disorder. For example, high rates of self mutilation to alleviate tension have been demonstrated in BP II (Joyce et al., 2010), although this has not been a universal finding (Large et al., 2010). Moreover, the high prevalence of substance abuse in bipolar disorder could be related to this kind of impulsivity. Previous studies using the BIS questionnaire have suggested a link between impulsivity and substance abuse in bipolar disorder (Swann, 2010, Nery et al., 2013). Urgency is linked to neuroticism (Whiteside and Lynam, 2001), and high levels of neuroticism are features of both disorders in question. Elevated Urgency scores are thus to be expected for both patient groups. Still, there were notable group differences. First, the mean Urgency score was about one standard deviation higher in the BPD group than in the BP II group. Second, the analyses of MADRS effects suggest that Urgency in BP II may be partly related to a depressive mood state. Third, there were strong positive correlations between CTQ score and Urgency in BP II patients. This last finding is in line with previous studies that found increased impulsivity and suicidality in bipolar disorder patients with histories of childhood abuse (Leverich et al., 2002; Carballo et al., 2008). The results suggest that impulsivity associated with negative affect is permanently and strongly elevated in BPD. In contrast, this kind of impulsivity may occur mainly in those BP II patients with histories of adverse childhood experiences, and may be particularly pronounced during depressive states. 4.2. Lack of premeditation The Lack of Premeditation component may represent dysfunctional decision-making processes, and it is the UPPS component

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which corresponds most closely to total BIS score, as well as to all BIS subscales (Whiteside and Lynam, 2001). Therefore, it is reasonable to make cautious comparisons with studies that assessed impulsivity with BIS. Our finding of elevated scores on this subscale in the BPD group is consistent with a similar finding in a previous UPPS study (Jacob et al., 2010), and with findings from several studies demonstrating elevated BIS scores in this patient group (Herpertz et al., 1999; Wilson et al., 2007; Lawrence et al., 2010). In contrast, no significant elevation in Lack of Premeditation was identified in the BP II group. Furthermore, our explorative assessments of associations with mood state suggest that depressive symptoms might be associated with an elevated Lack of Premeditation score in these patients. These findings are in accordance with those from Lewis et al., who failed to identify elevations in BIS scores in euthymic patients with bipolar I and II disorder, while patients in syndromal and subsyndromal states exhibited BIS elevations (Lewis et al., 2009). Also, in a study of alcohol abuse in a mixed bipolar I and II sample; positive correlations between depressive symptoms and BIS impulsivity were noted (Nery et al., 2013). However, several studies –using either cross-sectional (Peluso et al., 2007; Swann et al., 2009) or longitudinal (Strakowski et al., 2010) designs – have observed elevated BIS impulsivity in patients with bipolar disorder regardless of mood state. One possible explanation for these conflicting results could be that the latter studies investigated bipolar I or not specified bipolar disorders; thus, those results may not be applicable to BP II. Alternatively, the discrepancy could be related to comorbidity issues. For example, comorbid BPD is common in BP II (Benazzi, 2000; Angst et al., 2011). Several studies of impulsivity in bipolar disorder did not report assessment of personality pathology, or did not exclude patients with such comorbidity (Peluso et al., 2007; Swann et al., 2009; Strakowski et al., 2010). While including patients with a variety of comorbidities could arguably increase the generalizability of the results, the presence of comorbidity – including personality pathology – could nevertheless have influenced the observed impulsivity scores.

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4.4. Sensation seeking No group differences were observed in the Sensation Seeking component. Regarding BPD, our finding is consistent with the study from Jacob et al. (2010), although it is in contrast with the DSM-IV impulsivity criterion for BPD which mentions reckless driving as an example of impulsive behavior. Our result may also seem to contradict previous notions of an association between bipolar disorder and sensation seeking behavior (Fornaro et al., 2013). It is possible that the UPPS scale to a larger degree than previous measurements of impulsivity discriminates between sensation seeking behavior that is motivated by a genuine search for exciting experiences, and similar behavior which is motivated by other factors. For example, behavior motivated by a wish to alleviate negative emotions could superficially resemble “true” sensation seeking behavior, but may translate to high Urgency rather than high Sensation Seeking when assessed by the UPPS questionnaire. 4.5. Medication effects The use of psychotropic medication in general did not have any significant influence on the UPPS scores. However, the analyses of lamotrigine effects yielded conflicting results. Lamotrigine use seemingly affected Urgency and Lack of Premeditation scores, but in opposite directions for the two patient groups and for the two subscales. The results have to be interpreted very cautiously for several reasons. First, only two BPD patients were using this medication. Also, among the 12 BP II patients using lamotrigine, 8 started using the drug less than 3 months before the study and were still on a titration schedule with a current mean dosage of 94 mg lamotrigine. Thus, it is unlikely that lamotrigine would have had major influence on these patients’ impulsivity scores. Furthermore, the potential effects of lamotrigine on UPPS scores may include a direct effect on impulsivity, but also an indirect effect via reduction of depressive symptoms. Held together, the effects of lamotrigine are subject to great uncertainty, and would need to be explored in larger studies.

4.3. Lack of perseverance 4.6. Impulsivity profiles in BPD and BP II The Lack of Perseverance component has not been well represented in previous measures of impulsivity (Whiteside and Lynam, 2001). Consistent with previous findings (Jacob et al., 2010), the BPD group displayed considerably elevated scores compared to controls. This elevation could be related to several clinical aspects of BPD. For example, patients with BPD often experience difficulties with vocational functioning (Zanarini et al., 2010) and with treatment adherence (Martino et al., 2012). Notably, Lack of Perseverance was shown to be elevated in ADHD (Miller et al., 2010). Given the considerable comorbidity between ADHD and BPD (Fossati et al., 2002; Miller et al., 2010), the exclusion of ADHD in the present study strengthens our findings and our conclusion that the elevation in Lack of Perseverance is related to BPD per se. The BP II patients also exhibited significantly elevated Lack of Perseverance scores compared with controls. One could speculate that difficulties associated with high scores on this UPPS component could contribute to the reduced psychosocial functioning associated with bipolar disorder (Sanchez-Moreno et al., 2009). Notably, the scores were significantly lower than the BPD patients ‘scores. In Addition, the explorative analyses of mood state effects suggested that the elevations in the BP II group were at least partly related to depressed mood, and thus might not represent a strong enduring trait in these patients.

Our findings suggest that patients with BPD have elevated levels of traits that correspond to a broadly defined concept of impulsivity. Importantly, our results suggest that this impulsivity is associated with the BPD diagnosis in itself, regardless of traumatic childhood experiences; concomitant bipolar spectrum disorder, ADHD or substance abuse; or current mood state. In contrast, elevations in impulsivity in the BP II group were less pronounced and manifested on the Urgency and Lack of Perseverance subscale. There was no significant elevation in Lack of Premeditation, which is the subscale most closely related to BIS, and hence most comparable to previous studies of impulsivity in bipolar disorder. The analyses of the relationship between UPPS and MADRS scores suggest that impulsivity in BP II patients may be at least partly related to depression. Furthermore, Urgency impulsivity may be related to childhood traumatic experiences in this patient group. Thus, the present study indicates that BP II is associated with less pronounced trait-like impulsivity than suggested by several previous studies. This finding may be related to our pure BP II group (in contrast to the bipolar I or mixed bipolar samples in most previous studies), to the absence of ADHD and personality disorder comorbidity, and to the low prevalence of substance use or dependence in the BP II sample.

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Our finding of associations between MADRS and UPPS scores in BP II but not in BPD could reflect group differences regarding the relation between depressive state and impulsivity. However, our results could also reflect qualitative differences in mood symptoms between BPD and BP II (Parker, 2014). Such differences could influence MADRS scores, which may reflect genuine mood disorder swings to a larger extent in BP II than in BPD. Whether impulsivity in BP II is primarily trait or state related may be of less clinical importance. BP II patients may spend as much as half of their time in syndromal and subsyndromal depressive states (Judd et al., 2003). Accordingly, impulsive traits and behavior could have a major impact even if primarily related to a depressive state. Significant associations between CTQ score and impulsivity in BP II patients were limited to the Urgency component, which is strongly linked to neuroticism. This selective association between childhood trauma and adult impulsivity could be related to childhood trauma-related increases in neuroticism, which previously was demonstrated in a large clinical sample (Roy, 2002). Notably, the BPD patients reported more childhood traumatic experiences than BP II patients, including physical and sexual abuse. A direct association between degree of trauma and impulsivity were not identified in these patients. However, our small sample carries a risk of false negative findings, and the results do not exclude that childhood traumatic experiences may be related to the generally high levels of impulsivity observed in these patients. Nevertheless, we consider that our findings are supportive of impulsivity as a highly integral part of BPD, which only to a limited degree is directly affected by underlying factors such as traumatization history or current factors such as mood state. In contrast, impulsivity in BP II may be less genuinely associated with the disorder in itself, and to a larger degree associated with modulating factors including mood state.

our BP II sample (see Table 1), meaning that our study cannot inform us about the potential consequences of these kinds of abuse for impulsivity in BP II. 4.9. Conclusions In conclusion, this study demonstrated markedly elevated impulsivity levels on three of the four UPPS subscales in BPD patients. The elevations were not related to current mood state or to self reported childhood trauma. The findings indicate that high, trait-like, broadly defined impulsivity is a central feature of BPD. In contrast, patients with BP II exhibited moderately elevated levels of impulsivity on the Urgency and Lack of Perseverance subscales. UPPS impulsivity was related to a depressed mood state; the Urgency component was also linked to childhood trauma. The findings indicate that impulsivity in “pure” BP II without comorbid personality pathology may be less trait-like than suggested by some previous studies. Role of funding source Funding for this study was provided by the South-Eastern Norway Regional Health Authority through the Norwegian Research Network On Mood Disorders, Oslo University Hospital. The funding source had no influence on study design; data collection, analysis and interpretation of data; in the writing of the paper, or in the decision to submit the article for publication.

Conflict of interest E. Bøen has received honoraria from Lundbeck and AstraZeneca for lecturing to psychiatrists and psychologists about clinical and biological aspects of mood and personality disorders. T. Elvsåshagen has received honoraria for lecturing from Glaxo SmithKline and Pfizer. S. Karterud is on the board of directors and is a shareholder of the Norwegian Institute for Mentalization. U.F. Malt has received honoraria from AstraZeneca, Bristol Myers Squibb, Eli Lilly, Glaxo Smith Kline, Schering-Plough and Lundbeck for lectures about the diagnostic assessment and treatment of mood disorders. No conflicts of interest declared by B. Hummelen, B. Boye and S. Andersson.

4.7. Study strengths Our study has three main strengths. First, the assessment of these two different patient categories and a control group provides valuable information regarding diagnostic specificity, compared with studies that included only one of the patient categories. Second, the careful clinical assessment and the exclusion of patients with reciprocal comorbidity and ADHD comorbidity; as well as the relatively low frequency of patients with alcohol and substance misuse; emphasize that our findings are likely to be related to the diagnostic categories in question. Third, our use of the UPPS questionnaire may potentially capture impulsivity in a broader and more nuanced sense than other self-report measures of impulsivity. 4.8. Study limitations There were also limitations to the study. First, the sample size was relatively small. Second, group differences in demographic and medicational status could have influenced the results, although analyses controlling for these factors mainly showed similar results as the main analyses. Third, our assessment of the effects of mood state was based on a cross-sectional design. It would have been preferable to assess the subjects’ mood state at different time-points. Longitudinal studies of larger samples are needed. Fourth, the study does not inform us about the relationship between elevated mood and impulsivity because of the low degree of hypomanic symptoms in our sample. Fifth, the use a selfreport instrument only for the assessment of childhood trauma cannot substitute a more thorough clinical evaluation. Lastly, reports of physical and sexual abuse were almost non-existent in

Acknowledgments The authors would like to thank all participants for their time and effort.

References Akiskal, H.S., Chen, S.E., Davis, G.C., Puzantian, V.R., Kashgarian, M., Bolinger, J.M., 1985. Borderline: an adjective in search of a noun. J. Clin. Psychiatry 46, 41–48. Angst, J., Azorin, J.M., Bowden, C.L., Perugi, G., Vieta, E., Gamma, A., Young, A.H., 2011. Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: the BRIDGE study. Arch. Gen. Psychiatry 68, 791–798. Battle, C.L., Shea, M.T., Johnson, D.M., Yen, S., Zlotnick, C., Zanarini, M.C., Sanislow, C.A., Skodol, A.E., Gunderson, J.G., Grilo, C.M., McGlashan, T.H., Morey, L.C., 2004. Childhood maltreatment associated with adult personality disorders: findings from the collaborative longitudinal personality disorders study. J. Personal. Disord. 18, 193–211. Bayes, A., Parker, G., Fletcher, K., 2014. Clinical differentiation of bipolar II disorder from borderline personality disorder. Curr. Opin. Psychiatry 27, 14–20. Benazzi, F., 2000. Borderline personality disorder and bipolar II disorder in private practice depressed outpatients. Compr. Psychiatry 41, 106–110. Bernstein, D.P., Stein, J.A., Newcomb, M.D., Walker, E., Pogge, D., Ahluvalia, T., Stokes, J., Handelsman, L., Medrano, M., Desmond, D., Zule, W., 2003. Development and validation of a brief screening version of the childhood trauma questionnaire. Child Abuse Negl. 27, 169–190. Carballo, J.J., Harkavy-Friedman, J., Burke, A.K., Sher, L., Baca-Garcia, E., Sullivan, G. M., Grunebaum, M.F., Parsey, R.V., Mann, J.J., Oquendo, M.A., 2008. Family history of suicidal behavior and early traumatic experiences: additive effect on suicidality and course of bipolar illness? J. Affect Disord. 109, 57–63. Claes, L., Muehlenkamp, J., 2013. The relationship between the UPPS-P impulsivity dimensions and nonsuicidal self-injury characteristics in male and female highschool students. Psychiatry J. 2013, 654847. DeShong, H.L., Kurtz, J.E., 2013. Four factors of impulsivity differentiate antisocial and borderline personality disorders. J. Personal. Disord. 27, 144–156. Domes, G., Winter, B., Schnell, K., Vohs, K., Fast, K., Herpertz, S.C., 2006. The influence of emotions on inhibitory functioning in borderline personality disorder. Psychol. Med. 36, 1163–1172.

E. Bøen et al. / Journal of Affective Disorders 170 (2015) 104–111

Drake, R., Mueser, K., McHugo, G, 1996. Clinical rating scales: Alcohol Use Scale (AUS), Drug Use Scale (DUS), and Substance Abuse Treatment Scale (SAYS). In: Sederer, L., Dickey, B. (Eds.), Outcomes Assessment in Clinical Practice. Williams & Wilkins, Maryland, pp. 113–116. Etain, B., Mathieu, F., Liquet, S., Raust, A., Cochet, B., Richard, J.R., Gard, S., Zanouy, L., Kahn, J.P., Cohen, R.F., Bougerol, T., Henry, C., Leboyer, M., Bellivier, F., 2013. Clinical features associated with trait-impulsiveness in euthymic bipolar disorder patients. J. Affect. Disord. 144, 240–247. First, M.B., 1997. User’s Guide for the Structured Clinical Interview for DSM-IV Axis II Personality Disorders: SCID-II. American Psychiatric Press, Inc, Washington, DC. Fletcher, K., Parker, G., Bayes, A., Paterson, A., McClure, G., 2014. Emotion regulation strategies in bipolar II disorder and borderline personality disorder: differences and relationships with perceived parental style. J. Affect. Disord. 157, 52–59. Fornaro, M., Ventriglio, A., De Pasquale, C., Pistorio, M.L., De Berardis, D., Cattaneo, C.I., Favaretto, E., Martinotti, G., Tomasetti, C., Elassy, M., D’Angelo, E., Mungo, S., Del Debbio, A., Romano, A., Ciampa, G., Colicchio, S., 2013. Sensation seeking in major depressive patients: relationship to sub-threshold bipolarity and cyclothymic temperament. J. Affect. Disord. 148, 375–383. Fossati, A., Novella, L., Donati, D., Donini, M., Maffei, C., 2002. History of childhood attention deficit/hyperactivity disorder symptoms and borderline personality disorder: a controlled study. Compr. Psychiatry 43, 369–377. Ghaemi, S.N., Dalley, S., Catania, C., Barroilhet, S., 2014. Bipolar or borderline: a clinical overview. Acta Psychiatr. Scand. 2014, 1–10. Henry, C., Mitropoulou, V., New, A.S., Koenigsberg, H.W., Silverman, J., Siever, L.J., 2001. Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences. J. Psychiatr. Res. 35, 307–312. Herpertz, S.C., Kunert, H.J., Schwenger, U.B., Sass, H., 1999. Affective responsiveness in borderline personality disorder: a psychophysiological approach. Am. J. Psychiatry 156, 1550–1556. Hyler, S.E., Skodol, A.E., Oldham, J.M., Kellman, H.D., Doidge, N., 1992. Validity of the personality diagnostic questionnaire-revised: a replication in an outpatient sample. Compr. Psychiatry 33, 73–77. Jacob, G.A., Gutz, L., Bader, K., Lieb, K., Tuscher, O., Stahl, C., 2010. Impulsivity in borderline personality disorder: impairment in self-report measures, but not behavioral inhibition. Psychopathology 43, 180–188. Joyce, P.R., Light, K.J., Rowe, S.L., Cloninger, C.R., Kennedy, M.A., 2010. Selfmutilation and suicide attempts: relationships to bipolar disorder, borderline personality disorder, temperament and character. Aust. N. Z. J. Psychiatry 44, 250–257. Judd, L.L., Akiskal, H.S., Schettler, P.J., Coryell, W., Endicott, J., Maser, J.D., Solomon, D.A., Leon, A.C., Keller, M.B., 2003. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch. Gen. Psychiatry 60, 261–269. Langbehn, D.R., Pfohl, B.M., Reynolds, S., Clark, L.A., Battaglia, M., Bellodi, L., Cadoret, R., Grove, W., Pilkonis, P., Links, P., 1999. The Iowa personality disorder screen: development and preliminary validation of a brief screening interview. J. Personal. Disord. 13, 75–89. Large, M.M., Nielssen, O.B., Babidge, N., 2010. Self-mutilation is strongly associated with schizophrenia, but not with bipolar disorder. Aust. N. Z. J. Psychiatry 44, 677. Lawrence, K.A., Allen, J.S., Chanen, A.M., 2010. Impulsivity in borderline personality disorder: reward-based decision-making and its relationship to emotional distress. J. Personal. Disord. 24, 786–799. Leverich, G.S., McElroy, S.L., Suppes, T., Keck Jr., P.E., Denicoff, K.D., Nolen, W.A., Altshuler, L.L., Rush, A.J., Kupka, R., Frye, M.A., Autio, K.A., Post, R.M., 2002. Early physical and sexual abuse associated with an adverse course of bipolar illness. Biol. Psychiatry 51, 288–297. Lewis, M., Scott, J., Frangou, S., 2009. Impulsivity, personality and bipolar disorder. Eur. Psychiatry 24, 464–469. Mackinnon, D.F., Pies, R., 2006. Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders. Bipolar Disord. 8, 1–14. Martino, F., Menchetti, M., Pozzi, E., Berardi, D., 2012. Predictors of dropout among personality disorders in a specialist outpatients psychosocial treatment: a preliminary study. Psychiatry Clin. Neurosci. 66, 180–186. Miller, D.J., Derefinko, K.J., Lynam, D.R., Milich, R., Fillmore, M.T., 2010. Impulsivity and attention deficit-hyperactivity disorder: subtype classificationusing the UPPS impulsive behavior scale. J. Psychopathol. Behav. Assess. 32, 323–332. Mobbs, O., Crepin, C., Thiery, C., Golay, A., Van der Linden, M., 2010. Obesity and the four facets of impulsivity. Patient Educ. Couns. 79, 372–377. Montgomery, S.A., Asberg, M., 1979. A new depression scale designed to be sensitive to change. Br. J. Psychiatry 134, 382–389. Nery, F.G., Hatch, J.P., Monkul, E.S., Matsuo, K., Zunta-Soares, G.B., Bowden, C.L., Soares, J.C., 2013. Trait impulsivity is increased in bipolar disorder patients with comorbid alcohol use disorders. Psychopathology 46, 145–152. Paris, J., Zweig-Frank, H., Kin, N.M., Schwartz, G., Steiger, H., Nair, N.P., 2004. Neurobiological correlates of diagnosis and underlying traits in patients with borderline personality disorder compared with normal controls. Psychiatry Res. 121, 239–252.

111

Paris, J., 2005. Understanding self-mutilation in borderline personality disorder. Harv. Rev. Psychiatry 13, 179–185. Paris, J., 2013. Borderline personality and bipolar disorder: the limits of phenomenology. Acta Psychiatr. Scand. 128 (5), 384. Parker, G., 2011. Clinical differentiation of bipolar II disorder from personalitybased “emotional dysregulation“ conditions. J. Affect. Disord. 133, 16–21. Parker, G., 2014. Is borderline personality disorder a mood disorder? Br. J. Psychiatry 204, 252–253. Peluso, M.A., Hatch, J.P., Glahn, D.C., Monkul, E.S., Sanches, M., Najt, P., Bowden, C.L., Barratt, E.S., Soares, J.C., 2007. Trait impulsivity in patients with mood disorders. J. Affect. Disord. 100, 227–231. Perugi, G., Fornaro, M., Akiskal, H.S., 2011. Are atypical depression, borderline personality disorder and bipolar II disorder overlapping manifestations of a common cyclothymic diathesis? World Psychiatry 10, 45–51. Roy, A., 2002. Childhood trauma and neuroticism as an adult: possible implication for the development of the common psychiatric disorders and suicidal behaviour. Psychol. Med. 32, 1471–1474. Ruggero, C.J., Zimmerman, M., Chelminski, I., Young, D., 2010. Borderline personality disorder and the misdiagnosis of bipolar disorder. J. Psychiatr. Res. 44, 405–408. Sanchez-Moreno, J., Martinez-Aran, A., Tabarés-Seisdedos, R., Torrent, C., Vieta, E., Ayuso-Mateos, J.L., 2009. Functioning and disability in bipolar disorder: an extensive review. Psychother. Psychosom. 78, 285–297. Sheehan, D.V., Lecrubier, Y., Sheehan, K.H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., Dunbar, G.C., 1998. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J. Clin. Psychiatry 59 (Suppl. 20), S22–S33 (quiz 34-57). Smith, G.T., Fischer, S., Cyders, M.A., Annus, A.M., Spillane, N.S., McCarthy, D.M., 2007. On the validity and utility of discriminating among impulsivity-like traits. Assessment 14, 155–170. Spitzer, R.L., 1983. Psychiatric diagnosis: are clinicians still necessary? Compr. Psychiatry 24, 399–411. Strakowski, S.M., Fleck, D.E., DelBello, M.P., Adler, C.M., Shear, P.K., Kotwal, R., Arndt, S., 2010. Impulsivity across the course of bipolar disorder. Bipolar Disord. 12, 285–297. Suppes, T., Leverich, G.S., Keck, P.E., Nolen, W.A., Denicoff, K.D., Altshuler, L.L., McElroy, S.L., Rush, A.J., Kupka, R., Frye, M.A., Bickel, M., Post, R.M., 2001. The Stanley foundation bipolar treatment outcome network. II. Demographics and illness characteristics of the first 261 patients. J. Affect. Disord. 67, 45–59. Swann, A.C., Lijffijt, M., Lane, S.D., Steinberg, J.L., Moeller, F.G., 2009. Increased traitlike impulsivity and course of illness in bipolar disorder. Bipolar Disord. 11, 280–288. Swann, A.C., 2010. The strong relationship between bipolar and substance-use disorder. Ann. N Y Acad. Sci. 1187, 276–293. Tragesser, S.L., Robinson, R.J., 2009. The role of affective instability and UPPS impulsivity in borderline personality disorder features. J. Personal. Disord. 23, 370–383. Verdejo-Garcia, A., Bechara, A., Recknor, E.C., Perez-Garcia, M., 2007. Negative emotion-driven impulsivity predicts substance dependence problems. Drug Alcohol Depend. 91, 213–219. Whiteside, S.P., Lynam, D.R., 2001. The five factor model and impulsivity: using a structural model of personality to understand impulsivity. Personal. Individ. Differ. 30, 669–689. Wilson, S.T., Stanley, B., Oquendo, M.A., Goldberg, P., Zalsman, G., Mann, J.J., 2007. Comparing impulsiveness, hostility, and depression in borderline personality disorder and bipolar II disorder. J. Clin. Psychiatry 68, 1533–1539. Young, R.C., Biggs, J.T., Ziegler, V.E., Meyer, D.A., 1978. A rating scale for mania: reliability, validity and sensitivity. Br. J. Psychiatry 133, 429–435. Zanarini, M.C., Frankenburg, F.R., Dubo, E.D., Sickel, A.E., Trikha, A., Levin, A., Reynolds, V., 1998. Axis I comorbidity of borderline personality disorder. Am. J. Psychiatry 155, 1733–1739. Zanarini, M.C., 2008. Reasons for change in borderline personality disorder (and other axis II disorders). Psychiatr. Clin. N. Am. 31, 505–515 (viii). Zanarini, M.C., Frankenburg, F.R., Reich, D.B., Fitzmaurice, G., 2010. The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects. Acta Psychiatr. Scand. 122, 103–109. Zanarini, M.C., Laudate, C.S., Frankenburg, F.R., Wedig, M.M., Fitzmaurice, G., 2013. Reasons for self-mutilation reported by borderline patients over 16 years of prospective follow-up. J. Personal. Disord. 27, 783–794. Zimmerman, M., Martinez, J.H., Morgan, T.A., Young, D., Chelminski, I., Dalrymple, K., 2013. Distinguishing bipolar II depression from major depressive disorder with comorbid borderline personality disorder: demographic, clinical, and family history differences. J. Clin. Psychiatry 74, 880–886. Zimmerman, M., Morgan, T.A., 2013. Problematic boundaries in the diagnosis of bipolar disorder: the interface with borderline personality disorder. Curr. Psychiatry Rep. 15, 422.

Different impulsivity profiles in borderline personality disorder and bipolar II disorder.

Borderline personality disorder (BPD) and bipolar II disorder (BP II) share clinical characteristics including impulsivity. Their relationship is disp...
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