A comparison of depressed patients with and without borderline personality disorder: implications for interpreting studies of the validity of the bipolar spectrum

The nosological status of borderline personality disorder as it relates to the bipolar disorder spectrum has been controversial. Studies have supported, in part, the validity of the bipolar spectrum by demonstrating that these patients, compared to patients with nonbipolar depression, are characterized by earlier age of onset of depression, recurrent depressive episodes, comorbid anxiety and substance use disorders and increased suicidality. However, all of these factors have likewise been found to distinguish depressed patients with and without borderline personality disorder. A family history of bipolar disorder is one of the few disorder specific validators. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical characteristics of depressed patients with and without borderline personality disorder. We hypothesized that many of the factors used to validate the bipolar spectrum will also distinguish depressed patients with and without borderline personality disorder except, however, a family history of bipolar disorder. Two thousand nine hundred psychiatric outpatients at Rhode Island Hospital were evaluated with the Structured Clinical Interview for DSM-IV (SCID) and Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Family history information regarding first-degree relatives was obtained from the patient using the Family History Research Diagnostic Criteria. One hundred and one patients with borderline personality disorder plus major depressive disorder were compared to 947 patients with major depressive disorder alone on the prevalence of bipolar disorder validators. Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder had a younger age of onset, more depressive episodes, a greater likelihood of experiencing atypical symptoms and had a higher prevalence of comorbid anxiety disorders, substance use disorders, and number of previous suicide attempts. The depressed patients with borderline personality disorder did not significantly differ from the patients without borderline personality disorder on morbid risk for bipolar disorder in first degree relatives. In addition, patients with a diagnosis of bipolar disorder had a significantly higher morbid risk of bipolar disorder in first degree relatives than the borderline personality disorder group. The findings indicate that many factors used to validate the bipolar spectrum are not disorder specific. These results raise questions about studies of the validity of the broad bipolar spectrum that do not assess borderline personality disorder. Our results do not support inclusion of borderline personality disorder as part of the bipolar spectrum.     

Personal efficacy, external locus of control, and perceived contingency of parental reinforcement among depressed, paranoid, and normal subjects

Bandura (1982) suggested that judgments of personal efficacy and outcome expectancies (i.e., locus of control) jointly affect behavior. We hypothesized that different combinations of these two sets of beliefs would characterize the thought structures of normal subjects and of psychiatric patients suffering from distinctly different disorders. Normal subjects, depressed subjects, and paranoid subjects completed scales with which we measured beliefs in personal efficacy and beliefs that outcomes are controlled either by chance or by powerful others, as well as a scale with which we assessed perceived contingency of parental reinforcement. The major findings were as follows: Normals judged themselves to be more efficacious than did psychiatric subjects; whereas depressives expected outcomes to be controlled by chance, paranoids expected outcomes to be under the control of powerful others; among the normals, outcome expectancies were strongly associated with personal efficacy, but among the psychiatric patients, these beliefs were unrelated; depressives and paranoids equally reported more noncontingent parental reinforcement than did normals; and perceived contingency of parental reinforcement was predictive of outcome expectancies but not of personal efficacy. The data suggest that low personal efficacy may be a distinguishing characteristic of all psychiatric patients, whereas outcome expectancies may determine the specific nature of the psychiatric disorder.     

Clinical features of major depressive disorder in adolescents and their relatives: impact on familial aggregation, implications for phenotype definition, and specificity of transmission

Three questions were addressed using family study data from a community sample: (a) Which clinical features of major depressive disorder (MDD) in adolescents are associated with elevated rates of MDD in relatives? (b) Which features of MDD in relatives distinguish family members of depressed adolescents from relatives of adolescents without mood disorders (NMD)? and (c) Do depressed adolescents with particular features have higher proportions of depressed relatives with the same features? Participants included 268 MDD adolescents, 401 NMD adolescents, and their 2,202 first-degree relatives. Rates of MDD were highest among relatives of depressed adolescents with recurrent episodes and greater impairment. Depression severity best distinguished the relatives of depressed adolescents from relatives of controls. Specific clinical features did not aggregate in families.     

Assessment of fear of fear among Agoraphobic patients: The Agoraphobic Cognitions Scale

A self-report scale for the measurement of fear of fear, the Agoraphobic Cognitions Scale (ACS), was psychometrically evaluated. Two samples of inpatients satisfying DSM-III-R criteria for unipolar depressive and/or anxiety disorder were studied. Intercorrelational and factor analyses indicated that the ACS measured three dimensions of fear of fear: fear of bodily incapacitation, fear of losing control, and fear of acting embarrassingly. Three subscales were constructed to measure these dimensions. The subscales proved to have satisfactory internal consistency and criterion-related validity. However, fear of losing control was related not only to other anxiety symptoms, but also to depressive symptomatology. Agoraphobic patients reported more fear of bodily incapacitation and fear of losing control than social phobic, generally anxious, and nonanxious depressed patients. Fear of embarrassing action was higher among agoraphobic and social phobic patients than among generally anxious and nonanxious depressed patients. These results were obtained after controlling for general anxiety and depression level and, thus, support the validity of the fear of fear construct.     

Agoraphobia and Locus of Control

This study investigated whether external locus of control, as measured with the Rotter Internal-External Locus of Control Scale, is a specific feature of agoraphobia or whether it characterizes neurosis in general. Forty agoraphobic patients, 81 nonagoraphobic neurotic controls, and 49 normal controls completed the Dutch version of the Rotter Internal-External Locus of Control Scale. Agoraphobic patients were found to have a more external orientation as compared to the normal controls, but as a group, they could not be identified as being different from neurotic controls.This study was supported in part by a grant from the Dutch Organization for Fundamental Research (ZWO/Psychon 560-268-001).     

Causal attributions in clinical subtypes of depression: A longitudinal study of inpatients

The study material comprised inpatients who met DSM-III-R criteria for (a) dysthymia without panic and/or agoraphobia (n=20), (b) major depression without panic and/or agoraphobia (n=26), (c) both major depression and panic with agoraphobia (comorbid patients) (n=17), and (d) panic with agoraphobia without any depressive disorder (n=22). The patients completed the Attributional Style Questionnaire and the Beck Depression Inventory and were assessed on the Comprehensive Psychopathological Rating Scale upon admission to the hospital and at discharge. Some of the self-report scales were also administered at 1-year follow-up. It was assumed that dysthymic patients and patients with both major depression and agoraphobia would exhibit more biased attributions for bad events than purely major depressed and purely agoraphobic patients. However, inconsistent with this hypothesis, obtained group differences could be statistically reduced to differences in depressive symptom level. At each assessment, attributions for bad events correlated significantly with depressive symptom level. Attributional bias tended to decrease during treatment. However, most attribution subscales exhibited moderate stability in terms of correlation across assessments. Attributing bad events to global causes proved to predict later depression.This research was supported by grants from the Halldis and Josef Andresen Legacy.     

Prognostic value of implicit and explicit self-associations for the course of depressive and anxiety disorders

Dysfunctional self-beliefs are assumed to play an important role in maintaining depression and anxiety. Current dual-process models emphasize the relevance of differentiating between implicit and explicit self-beliefs. Therefore, this study tested the prognostic value of automatic and explicit self-associations for the naturalistic course of depressive and anxiety disorders over two years follow-up. Both self-depressed and self-anxious associations were measured in unipolar depressed patients (n = 313), anxious patients (n = 566), and patients with comorbid depressive and anxiety disorders (n = 577) as part of the Netherlands Study of Depression and Anxiety. Outcomes showed that in single predictor models specifically automatic self-anxious associations were related to a reduced chance of remission from anxiety, whereas automatic self-depressed associations were related to a reduced chance of remission from depression. Explicit self-anxious associations and fearful avoidance behaviour showed independent predictive validity for remission from anxiety, whereas explicit self-depressed associations and having both major depressive disorder and dysthymia showed independent predictive validity for remission from depression. These findings are not only consistent with the view that both implicit and explicit dysfunctional self-associations are related to the course of anxiety and unipolar depressive disorders, but also suggest that both types of self-beliefs are proper targets for therapeutic interventions.     

Heightened subjective experience of depression in borderline personality disorder

Despite the frequent comorbidity of major depression and borderline personality disorder (BPD), limited research has examined what effect this comorbidity has on the severity, course, and presentation of depression. The purpose of this study was to examine whether the severity of major depressive disorder (MDD) in the context of comorbid borderline personality disorder (BPD) differs from MDD when comorbid BPD is not present and to determine whether different measures of depression yield convergent findings. Sixty patients diagnosed with DSM-IV MDD participated in this study. Twenty-nine were diagnosed with DSM-IV BPD, while the remaining 31 had no Axis II diagnosis. Depression was evaluated with both clinician (Hamilton Rating Scale for Depression) and self-report (Beck Depression Inventory) ratings. While the two groups were rated as similarly depressed by clinicians on the overall rating and the factor scores, the MDD/BPD group reported more severe depressive symptoms on the self-report measure. This difference was significant even after controlling for clinician-rated severity. Gender interacted with diagnosis, males in the BPD group showed the largest discrepancies between clinician ratings and self-reports. Posthoc analyses of HDRS factors with the BDI showed that the clinicianrated cognitive disturbance and retardation factors were correlated with self-rated severity overall. Within subgroups, only the retardation factor was correlated with the BDI. Our results suggest that while depressed individuals with and without BPD may be rated as similarly depressed when assessed with objective rating methods, the subjective experience of the depression may be rated as more intense or severe by patients with comorbid BPD. The mechanism underlying this effect remains unknown, and requires further research.     

Internal health locus of control predicts willingness to track health behaviors online and with smartphone applications

Given rising technology use across all demographic groups, digital interventions offer a potential strategy for increasing access to health information and care. Research is lacking on identifying individual differences that impact willingness to use digital interventions, which may affect patient engagement. Health locus of control, the amount of control an individual believes they have over their own health, may predict willingness to use mobile health (mHealth) applications (‘apps’) and online trackers. A cross-sectional study (n = 276) was conducted to assess college students’ health locus of control beliefs and willingness to use health apps and online trackers. Internal and powerful other health locus of control beliefs predicted willingness to use health apps and online trackers while chance health locus of control beliefs did not. Individuals with internal and powerful other health locus of control beliefs are more willing than those with chance health locus of control beliefs to utilize a form of technology to monitor or change health behaviors. Health locus of control is an easy-to-assess patient characteristic providers can measure to identify which patients are more likely to utilize mHealth apps and online trackers.     

Brief treatment with alprazolam and behavioral guidance in panic disorder

Abstract

Thirty-two patients with panic disorder, with or without agoraphobic limitations, were treated with alprazolam (mean dose 3.5 mg/d) plus brief behavioral guidance in an open study during eight weeks. The sample had a notorious severity in the frequency of panics and phobic avoidance but was only mildly depressed. Before starting treatment the presence of demoralized mood and extensive avoidance were significant indicators of clinical severity, whereas the presence of dizziness as a relevant somatic complaint was not related to higher severity. After eight weeks of treatment a clinical improvement equal to or exceeding 80% of change was obtained in all cases (29) who completed treatment. Ninety-two percent of the patients were panic free at the end of treatment. There were significant reductions in all the scales with comparable declines in the subgroups formed according to the presence or absence of agoraphobic avoidance and demoralization. The data suggested that moderate doses of alprazolam could be a quick and effective treatment for panic-agoraphobic patients in the short term. The behavioral guidance probably helped in reducing agoraphobic avoidance and in obtaining global good effectiveness although this awaits controlled tests. Finally, the similarity in the response to treatment regardless of the presence of extensive avoidance or demoralized mood argues in favor of not considering the different variants of panic-agoraphobic syndrome differently, at least in samples with similar severity to the present one.     

Obsessive-compulsive disorder with comorbid major depression: what is the role of cognitive factors?

Individuals with obsessive-compulsive disorder (OCD) commonly experience comorbid mood disturbances such as major depressive disorder (MDD). Previous studies that have compared OCD patients with and without MDD have revealed differences in demographic characteristics, clinical severity, and symptom presentation between these two patient groups. Previous studies have not, however, examined whether there are differences with respect to cognitive processes. The present study therefore aimed to address this gap in the literature. Eighty patients with OCD and no unipolar mood disorders were compared with 34 OCD patients with comorbid major depression on measures of OCD symptoms, cognitions, and insight, as well as on measures of depression and functional impairment. Whereas depressed OCD patients evidenced higher scores than non-depressed OCD patients on semi-idiographic measures of OCD symptoms and cognitions, this was not the case for nomothetic measures. Functional impairment and the tendency to misinterpret innocuous intrusive thoughts as significant emerged as unique predictors of depression within the entire sample of OCD patients. Results are discussed in terms of (a) the importance of semi-idiographic assessment of OCD, (b) possible explanations for the relationship between OCD symptoms, depression, and cognitive processes, and (c) the psychological treatment of comorbid OCD and MDD.     

Depression and attributions for problems and solutions in college students

50 adult clients at college counseling centers completed scales measuring depression, attributions for their primary problem and its expected improvement, and locus of control. Subjects who were more depressed made relatively internal and stable attributions for their primary problems, were less likely to believe they would improve, and expressed more belief in the importance of chance and powerful others. As a group, subjects tended to view their improvement as more internal and controllable than the cause of their problems. The results suggest that knowledge of clients' attributions for their problems could prove relevant to the treatment of depression.     

Killing Two Birds With One Stone: Exposure Simultaneously Addressing Panic Disorder and Obsessive-Compulsive Disorder

Massed exposure has gained acceptance as an effective method to treat anxiety disorders. When using this intervention in patients presenting with more than one anxiety disorder, specific treatment options need to be discussed. Should exposure be applied in sequential order for each of the comorbid disorders? Or can exposure sessions also be designed to simultaneously target both problem areas? We report on the cognitive-behavioral treatment of a 28-year-old woman with obsessive-compulsive disorder (OCD) and severe panic disorder with agoraphobia (PDA). A series of behavioral experiments based on prolonged exposure was planned. Due to the fact that avoided situations elicited both agoraphobic and contamination fears, we decided to combine exposure for PDA and OCD to optimize therapeutic transfer. Twelve sessions of this exposure resulted in a long-term reduction of both PDA and OCD symptoms. The case illustrates that two comorbid conditions can be effectively combined under one therapeutic rationale. Capabilities and limitations of the method and implications for current theoretical debates on exposure therapy are discussed.     

The relationship between STD locus of control and STD acquisition among adolescent girls

This longitudinal study examined adolescent girls' perception of control over sexually transmitted disease (STD) acquisition. Participants were asked questions regarding their perception of their STD locus of control (internal control; control by parents, partners, peers, and health care providers; and chance) at two waves of data collection. Of the 116 participants (mean age = 17 years), 82% were African-American and 18% were Caucasian. Responses to the measure of locus of control were significantly correlated across a 6-month interval. The responses regarding internal control, control by partner, and chance were not related to the acquisition of an STD in the next 6 months. Further, they were not influenced by an STD in the preceding 6 months. These results indicate that responses to a locus of control measure were stable over a 6-month period, and internal, partner, and chance locus of control perceptions seem to be neither determined by STD experience nor directly related to future STD acquisition. However, understanding an individual's locus of control may be helpful in providing appropriate counseling. Future research could examine how adolescent girls form their perceptions of control over STD acquisition.     

Desire for control, locus of control, and proneness to depression

Two personality constructs, desire for control and locus of control, were related to depression among college students. Measures of levels of depression, desire for control, and locus of control were taken from subjects. Approximately six months later 71% of these subjects returned a questionnaire concerning their experiences with depression during that six-month period. It was found that locus of control scores, particularly the extent to which subjects perceived that their lives were controlled by chance, were significantly related to the depression levels. It was also found that high desire for control subjects who held external perceptions of control were most likely to seek nonprofessional help for depression. In addition, high desire for control subjects who perceived their lives as generally controlled by chance were most likely to have suicidal thoughts. The results are interpreted in terms of a general style that may promote a proneness to depression for certain individuals.     

Agoraphobia and the hyperventilation syndrome

One of the causes of agoraphobic complaints is the fear of having an attack of physical complaints in public places. The Hyperventilation Syndrome (HVS) with its diverse symptoms seems to fit well in this model. Hyperventilation symptoms are threatening, because for most subjects they occur unexpectedly and without a clear reason. An investigation was made into how often the HVS and the agoraphobic syndrome appeared together and into the causal relationship between both syndromes. About 60% of the agoraphobic patients suffered from hyperventilation complaints and about 60% of the HVS patients were agoraphobic. Most patients mentioned the fear of having an attack as an important reason for their agoraphobic complaints, and this applied especially in the case of the HVS.     

Locus of control in aging research: a case for multidimensional and domain-specific assessment

Do locus of control beliefs change in later life? Is locus of control related to aging-relevant outcomes involving intelligence and health? In past research on these topics, the use of unidimensional and generalized measures of locus of control has led to a set of inconsistent findings. Three studies were conducted to examine the usefulness of multidimensional and domain-specific measures of locus of control for examining age differences and correlates. College students and elderly adults were compared on Levenson's multidimensional and generalized (internal, chance, and powerful others) locus of control scales and two domain-specific versions related to intelligence and health. As predicted, no age differences were found with generalized measures, but the elderly were more external on intelligence- and health-specific locus of control dimensions. Age differences were found most often on the chance and powerful others control dimensions, suggesting that the elderly acknowledge the importance of external sources of control and at the same time preserve their sense of internal control. In addition, the domain-specific scales were better predictors of behavioral outcomes within their respective domains for the elderly but not for the young. The findings suggest that multidimensional and domain-specific conceptions of control are advantageous for aging research.     

Frontal brain asymmetry in depression with comorbid anxiety: a neuropsychological investigation

The approach-withdrawal model posits that depression and anxiety are associated with a relative right asymmetry in frontal brain activity. Most studies have tested this model using measures of cortical brain activity such as electroencephalography. However, neuropsychological tasks that differentially use left versus right frontal cortical regions can also be used to test hypotheses from the model. In two independent samples (Study 1 and 2), the present study investigated the performance of currently depressed individuals with or without a comorbid anxiety disorder and healthy controls on neuropsychological tasks tapping primarily left (verbal fluency) or right (design fluency) frontal brain regions. Across both samples, results indicated that comorbid participants performed more poorly than depressed only and control participants on design fluency, while all groups showed equivalent performance on verbal fluency. Moreover, comorbid participants showed "asymmetrical" performance on these two tasks (i.e., poorer design [right frontal] relative to verbal [left frontal] fluency), whereas depressed only and control participants showed approximately symmetrical profiles of performance. Results from these two samples suggest an abnormal frontal asymmetry in neurocognitive performance driven primarily by right frontal dysfunction among anxious-depressed individuals and highlight the importance of considering comorbid anxiety when examining frontal brain functioning in depression.     

The role of personality factors in predicting the reported physical health symptoms of Turkish college students

This study investigates the role of optimism, health control beliefs, perceived health competence, and medical help-seeking variables in predicting the frequency of reported physical symptoms. A total of 345 college students (207 male and 138 female) were presented with the Life Orientation Test, Multidimensional Health Locus of Control, Perceived Health Competence Scale, and Physical Symptom Checklist. Separate stepwise multiple regression analyses were applied to the data obtained from males, females, and the total group of students. Results showed that optimism, medical help seeking, chance health locus of control, and internal health locus of control predicted the reported physical symptom scores of the total sample. Also revealed were the different patterns for males and females. While optimism and internal health locus of control best predicted physical health for males, optimism and chance health locus of control best predicted the physical health symptoms of females.     

Marital systems of agoraphobic women: contributions of husbands' denial and projection

The problems of measuring psychological concepts such as repression and denial are discussed in the context of the marital systems of agoraphobic women and the credibility of a couples approach to treatment. Repression, denial and projection in husbands were inferred from systematic measurement of mood, hostility and symptom changes after intensive behaviour therapy for the agoraphobia. The results suggested that the agoraphobic symptoms of about half of the women were reinforced by their husbands' habitual denial of affect and of personal problems; in this group, worthwhile symptomatic improvement occurred only in those women whose husbands relinquished repression and denial as major defence mechanisms, acknowledging their own personal problems, and allowing the patients to take more responsibility for their agoraphobia. The marital systems of the remaining couples were characterized by incompatible ways of dealing with hostility, with husbands' abnormal extrapunitiveness reinforcing patients' self-blame, which inhibited problem-solving and hence indirectly perpetuated the agoraphobia.