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The Diagnosis and Treatment for Depression Co-Occurring with Borderline Disorder

The majority of people with borderline disorder suffer from episodes of major depression. Treatment for depression is vital in these individuals. There are two categories of major depressive episodes, those associated with bipolar I and II disorder-depressed*, and those referred to as major depressive disorder. Bipolar depressions are more frequent with borderline disorder, and are commonly associated with atypical features (see below).

Therefore, if you have borderline disorder, it is important that you know and recognize the symptoms of these disorders. If they occur, you should alert your physician so that you may receive prompt treatment for depression.

Symptoms of a Major Depressive Episode:
•persistently depressed or irritable mood
•diminished interest or pleasure in activities
•significant decrease or increase in appetite, or weight loss or weight gain
•increased or decreased sleep
•decreased mental and physical activity, or increase in such activity as demonstrated by excessive worrying and agitated behavior
•fatigue, or loss of energy
•feelings of worthlessness or excessive or inappropriate guilt
•diminished ability to think or concentrate, or indecisiveness
•recurrent thoughts of death and dying, recurrent suicidal thoughts with a specific plan, or a suicide attempt

Understand the differences in symptoms of Borderline Disorder, Bipolar Disorder-Depressed and Major Depressive Disorder, and learn about the various plans for treatment for depression.

In order to initiate the proper treatment for depression, it is necessary to determine if you are experiencing a decrease in mood associated with borderline disorder, or if you have developed a bipolar II disorder- depressed or major depressive disorder.

Depressed Mood in Borderline Disorder

In borderline disorder alone, depressed mood often occurs as follows:
•sad, depressed, and lonely feelings are frequently triggered by some life event and are often associated with strong feelings of emptiness, loneliness and fears of abandonment.
•symptoms readily improve if the situation causing them improves
•sleep, appetite and energy disturbances (if present) are usually related to an identifiable life stress and stop when the stress is managed successfully.
•acute suicidal thoughts and self-injurious behavior are usually the direct result of a personal problem (for example, an argument with a parent, boyfriend, spouse, or boss)

Bipolar II Disorder-Depressed*

In bipolar disorder-depressed, the symptoms of a major depressive episode listed above are often characterized by:
•increased appetite or weight gain
•increased sleep and napping
•marked decrease in mental and physical activity
•marked fatigue and loss of energy

Major Depressive Disorder

In major depressive disorder, the symptoms of a major depressive episode listed above are often characterized by:
•decreased appetite or weight loss
•decreased sleep with early morning awakening
•increased mental and physical activity as demonstrated by excessive worrying and agitated behavior

Atypical Features

The essential characteristics of atypical features are the capacity to be cheered up when experiencing positive events and two of the following: increased appetite and weight gain, nighttime sleep and napping of at least ten hours duration, or two hours more than usual, feeling heavy, leaden, or weighted down, usually in the arms and legs, and moderate to severe sensitivity to rejection.

Treatment for Depression Co-occurring with Borderline Disorder

If you think you have the symptoms of either type of depression, immediately alert your psychiatrist. If appropriate, the treatment for depression frequently involves the addition of an antidepressant, an increase in dosage if one is already being used, and/or the use of behavioral techniques.

There are no controlled studies on the relative effectiveness of different antidepressants for the treatment for depression in people with borderline disorder. However, studies of these disorders in people without borderline disorder, and experience, suggest that the following initial treatment strategies may have merit:

Treatment for Depression in Bipolar Disorder-Depressed and Major Depression with Atypical Features
•Bupropion (Wellbutrin&orig;)* drug of choice
•Lamotrigine (Lamictal&orig;)
•SSRIs such as fluoxetine (Prozac&orig;) or sertraline (Zoloft&orig;) if bupropion and lamotrigine are ineffective

Treatment for Depression in Major Depressive Disorder without Atypical Features
•SSRIs such as fluoxetine or sertraline* drug of choice
•Bupropion and lamotrigine if SSRIs are ineffective

Note: It is important in the treatment for depression to recognize that some antidepressants may cause an episode of mania or hypomania in patients with depression who have never experienced such episodes in the past.

Cognitive Behavioral Therapy focused on
treatment for depression may also prove useful to help identify thought patterns and behaviors that operate as risk factors for mood disorders, and to encourage new, more successful behaviors.

* Bipolar I and II, and major depressive disorders occur more commonly in patients with borderline disorder than they do in the general population. Bipolar II disorder is the most common type of bipolar disorder that occurs with borderline disorder. People with bipolar II disorder do not experience manic episodes as do those with bipolar I disorder, but do experience brief hypomanic periods and recurring episodes of depression. Depressions associated with bipolar disorder appear to be related to depressions referred to as atypical depression and seasonal affective disorder (SAD).

Have you or a loved one been diagnosed with borderline disorder and are suffering from anxiety and panic attack symptoms?

Read the following article and learn more about these symptoms and how they are treated.

Anxiety and panic attack symptoms are common in people with borderline disorder. Symptoms of anxiety occur in almost 90% of people with borderline disorder. If you have borderline disorder, you may experience heightened levels of anxiety and panic attack symptoms, especially at times of stress. For example, this may occur when you feel you are personally criticized and rejected, or during periods of separation from people who are very important to you. Moderate to severe anxiety may also lead to physical symptoms, such as migraine headaches, abdominal pain and irritable bowel syndrome.

Panic Attacks

A panic attack is an acute and severe form of anxiety that occurs in about 50% of people with borderline disorder. Panic attacks are characterized by a discrete period of intense fear in which four or more of the following symptoms develop abruptly and reach a peak within 10 minutes:
◾palpitations, pounding heart, or increased heart rate
◾sweating
◾trembling or shaking
◾sensations of shortness of breath or smothering
◾feeling of choking
◾chest pain or discomfort
◾nausea or abdominal distress
◾feeling dizzy, unsteady, lightheaded, or faint
◾feelings of unreality or being detached from oneself
◾fear of losing control or going crazy
◾fear of dying
◾numbness or tingling sensations
◾chills or hot flashes

Symptoms can appear unexpectedly and suddenly, or for no apparent reason, and disappear either rapidly or slowly. People who suffer from anxiety and panic attack symptoms may also be fearful of placing themselves in circumstances from which escape may be difficult or embarrassing such as elevators, shopping malls and movie theaters. This is referred to as agoraphobia.

Treatment of Anxiety and Panic Attack Symptoms in Borderline Disorder

Effective treatment of disabling anxiety and panic attack symptoms in people with borderline disorder should be initiated promptly when these disorders occur. Such treatment usually consists of the use of medications and behavioral techniques.

The use of medications to treat anxiety and panic attack symptoms in patients with borderline disorder must proceed with care. This is so because these disorders are commonly treated with benzodiazepines (Xanax, Klonopin, Valium, etc.) that have been found to be harmful in most patients with borderline disorder because they increase impulsivity and have addictive potential. Therefore, in borderline disorder, other classes of medications are often required such as a temporary increase in the antipsychotic or mood stabilizer being used to treat the disorder. Initiating the use of an antipsychotic agent or a mood stabilizer may prove effective for moderate to severe anxiety and panic attack symptoms if one is not already prescribed.

In addition, a course of cognitive behavioral therapy or of biofeedback specifically tailored to target anxiety and panic attack symptoms are often considered as part of the long-term treatment of these problems.

Co- occuring Disorders

If you suffer from borderline disorder, you are more prone to develop certain other mental disorders than those who do not have borderline disorder.13,14 One of the most likely explanations of this is that some of the genes that increase the risk of developing borderline disorder also increase the risk for developing these other disorders as well.

The disorders that most often occur with borderline disorder include the following:
◾mood disorders: major depressive disorder; dysthymia; bipolar disorder (depressive disorders)
◾substance use disorders
◾anxiety/panic disorders
◾post-traumatic stress disorder (PTSD)
◾eating disorders: bulimia; anorexia nervosa
◾attention deficit hyperactivity disorder (ADHD)
◾other personality disorders

Often, the diagnosis of these disorders is made correctly in patients with borderline disorder, but the diagnosis of borderline disorder is missed. When this occurs, treatment for the other condition is typically less successful than it might otherwise be, mainly because the appropriate treatments for borderline disorder have not been utilized.

Conversely, the effective treatment of borderline disorder requires the prompt recognition of other disorders if they are also present and, if so, the appropriate additional treatment.

The early detection and effective treatment of a mental disorder co-occurring with borderline disorder may result in rapid improvement of the symptoms of borderline disorder if it is being properly treated itself. This is an added incentive to consider the presence of these disorders along with borderline disorder, and to treat them when present.

For these reasons, you and your psychiatrist should attempt to determine the presence of these co-occurring conditions, and to initiate promptly the appropriate additional treatments if indicated.

Causes

For many years, it was commonly believed that the main cause of borderline personality disorder was poor or uninformed parenting. It now seems most likely that both environmental and biological factors, especially genetic ones, place a person at risk for developing the disorder.4,9-12

For example, psychological and social (environmental) factors, including but not limited to poor parenting, increase the risk of developing the disorder in those people biologically predisposed to it.9 It appears that no single cause, or risk factor, is responsible by itself for causing the disorder. In fact, it now appears that a genetic predisposition for developing the disorder is necessary, and that environmental factors may increase the risk but are not essential.

Finally, it is generally held that biological and environmental risk factors interact to reach a certain critical level of brain dysfunction in order for the symptoms of borderline personality disorder to become apparent. It appears that this critical degree of disturbance of brain function can be achieved by a large amount of biological risk which requires only a low amount of environmental risk, low biological risk coupled with high environmental risk, or intermediate levels of both.

Biological Risk Factors

Research studies now suggest that 60% of the risk of developing borderline disorder is conveyed by genetic abnormalities.10 These abnormalities appear to affect the proper functioning of those brain pathways or circuits that serve the behavioral functions of emotion information processing, impulse control and cognitive activity such as perception and reasoning. Current research suggests that there is not a single, specific gene for borderline disorder. It appears that the genes that increase risk for the disorder may be passed on by people who have the disorder itself, or a related disorder, such as bipolar disorder, depression, substance use disorders, ADHD and posttraumatic stress disorder.

Environmental Risk Factors

Of all environmental factors that place a person at risk for developing borderline disorder, those associated with poor or uninformed parenting appear to be the most critical.9,11,12 These include early separation from one or both parents, repeated emotional, physical or sexual abuse by someone within or outside of the family itself, and inconsistent, unsupportive care. Poor parenting can also include failing to protect the child from repeated abuse by the other parent, another member of the family, or an outsider.

It is important to understand that children who have not been exposed to such environmental traumas can still develop borderline disorder. This suggests that in some people the biological risk of developing the disorder is very high, and may be sufficient in the absence of environmental traumas