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Adolescent Bipolar Illness and Personality Disorder
Adolescent Bipolar Illness and Personality Disorder STAN P. KUT CHER, M .D ., F.R.C.P.(C), PETER MAR TON, PH.D., AN D MARSHALL KORENBLUM , M.D., F.R.C. P.(C)
Abstract. Th e rel ationship bet ween ado lesce nt bipolar illness and personality d isorder has not been explored . Studie s of adu lt bipolars suggest a bipo lar illness/borderline personality diso rder (BPD) assoc iatio n. Tw e nty cuthymic bip olar tee ns were assessed using the Personality Disorders Exam ination . Th irty-five perce nt met DSlvf-lJ!-R criteria for at least one person ality disord er. Th ree of the 20 ( 15%) had a borderline persona lity disor der dia gnosis. The bipo lar illne ss wit h person al ity disorder gro up differe d significantly from the bipolar illness wi thou t perso na lity disord er group in term s of increased lithium unresponsi ven ess (p < 0 .05) and ne uro leptic treatm ent at tim e of personality assess me nt (p < 0 .01), but not in terms of age , sex , age of illness onset, serum lith ium le vel , rapid cycl ing, subs tance abuse history , alcoho l abu se histo ry , or numbe r of suicide attempts . Issues rega rding the study of personality disorder in ado lesce nt bipolars arc discussed, J. Alii. Acad. Child /vdolesc, Psychiatry , 1990, 29, 3:355-35 8. Key Words: bip olar , personality , ado lescent. The study of the relation ship betw een affecti ve disorder and personality disord ers has tend ed to focus on unipolar dep ression and not bipolar illness (Docher ty et £11., 1986). Person ality studies of adult s with bipo lar disorder are few , and no spec ific studies of person ality disorder in adolescent s with bipolar disorder have , to the authors' knowl edge , been publi shed . The sma ll number of adult studies , however, does suggest that an association betw een bipolar disorder and pers on ality disord er-- specifically, borderline person ality (BPD )-may exist. In examining samples of bord erl ine patients for the presence of bipolar disorder, Val et £II. (1983) found two of JO (20%) to have a bipolar illness. Th is figure is slightl y higher than those reported by Friedman et £II. (1983)- 5.6%; Pope et £II. ( 1983)- 10%; and McGlashan et al. (1983)-1 2% . On the other hand , studies which have assessed samples of bipolar patients have found that 3 .8 (Ba xter et £II . , 1984) to 14.7% (Ga viria ct aI., 1982) have met criteria for BPD. The concurrence of BPD with bip olar illness has also been associated with increased suicidal behavior, poo rer treatm ent outcome , more psychoti c symptomatology , and poorer social, academic, and vocational functioning; (Gaviria et aI., 1982 ; Friedm an et £11. , 1983; McGlashan , 1983; Docherty et £11., 1986). Th ese studies , however , share a numb er of methodological limitations which make the findings of a possibl e bipolar-borderlin e personalit y disord er relation ship difficult to interpret. In most cases, they did not use stru ctured di-
agnostic intervi ews to assess person ality disord er nor did they attempt to eva luate the full spec trum of personal ity disorders , and by focu sing only on the bord erline diagno sis may have give n the impre ssion of a specific bipolarborderlin e relation ship when one does not ex ist (Gavi ria et £11. , 1982; Friedman et £II. , 1983; McGlashan , 1983; Pope et £11., 1983; Val et al., 1983; Baxter et £11. , (984) . The study of Charney et al. ( 198 1), wh ich assessed a wider range of personality disord ers, unfortunately, failed to report the various types of person ality disorders found, thu s , not allowin g eva luation of the relationship between bip olar illness and anyone specific personality disord er. Further , samp le sizes in the studies cited above have generally been sma ll. Val et £II. (1983) described two bipolars, Friedma n et al. (1983), reported on three bipolars, as did Pope et £II. (198 3). Onl y the studie s by Baxter et £I I. ( 1984) and Gaviria ct £I I. (19 82) report ed on suffic ient probands to allow for a wider assessment of personality disorders, but this was not undertaken . Additionally , in all thc studies noted abov e, assessment of personality disord er was based on data coll ected at the time of index presentation when the patient was suffering from an affective disorder or other acute psych iatric disturbance . Thi s approac h biases findings toward increas ing person ality disord er diagnoses as numerou s inves tigators have shown that many patient s who met diagnostic cr iteria for person ality disorder dur ing an acute affective episo de no longer met those criteria when euthymic (Liebowitz et £11., 1979; Hirschfield ct '11. , 1983a,b , 1986; Joffe and Regan , 1988; Ko renblurn et £11. , 198 8). Wh ile some studies describing the relationsh ip between unipol ar affective di sorder and per sonality disorder s in ad-
olescents have been reported (Robbins et aI., 1983; Clarkin et aI. , 1984; Yanchyshyn ct al., 1986 ; Korcnblum et a!., 1988; Marton et £11., 1989); to the authors' knowl edge no published studies have spec ifica lly described the relationship between bipolar disord er and personality disord ers in ado lesce nts . Thi s study was des igned to pro vide an initial descripti ve pro file of the bipol ar disorder/p erson alit y disorder relationship in teenager s and to assess if any specific personality disorder (particularly borderline personality) was more likely to be associated with bipolar illne ss.
Acc epted July 3, 1989. Drs . Kutcher and Korcnb lum are from the Department of Psychiatry and Dr . Marton is fr o m the Depa rtment of Psycho logy , Sunnybrook Medica! Centre, Uni versity of Toront o. Our appreciation to Ms. J . Stewart for manu script pr eparation and the nursing staff of the Adolescent Inpatient and Outpatient Services at Sunnybrook Medi cal Cent re f or Patient Care . Request reprintsfromDr. Kut cher, Department of Psychia try, 51111nybrook Medical Cent re, 20 75 Bay view Ave llue, Toronto . Ontario, Canada M4N 3M5 . 0890-R567/9012903·0 355$02 .00/0© 1990 by the American Acade my of Child and Adole scent Psych iatry.
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K UTC I WR ET A I. .
Method Twenty adolescent s ( I I male , nine female; average age 17.5 years) meetin g DSM -III-R criteria for bipolar disorder following a full inpatient assessment which included the affective disorders section of the Schedule for Affective Disorders and Sch izophrenia (Endicott and Spit zer , (97 8) were assessed when euthymic by an experienced intervie wer not involved in their care, using the Personality Disorders Examination (PD E) (Loranger et al., 1987) . Personality disorder diagnoses were assigned on the basis of the PDE interview . All probands had experienced at least one manic and one depressive episode . Euthymia was defined as a score of 10 or less on the Brief Psychiatri c Rat ing Sca le (Ove rall and Gorham , 1962) plus a self-report assessment of less than or equal to 2 em from midlin e on a 10 ern visual analogue scale. At the time of the PDE assess me nt, 19 of the subjects were outpatients atte nding an adolescent medications clini c and one was an inpatient in the process of discharge .
Results Seven of the 20 adolescent bipolars (35%) met DSM-III criteria for at least one person ality diso rder and three of the 20 ( 15%) met criter ia for more than one personality disorder. Personali ty diagnoses were: borderline- 3; nareissistie- 3; passive aggressi ve- 2; schizotypal - I; avoidant- I; and dependent- I . There were no significant differences between personalit y disordered and nonperson ality disord ered grou ps in age , sex, age of illness onset , seru m lithium level, rap id cycling, history of substance abuse, number of suicide attempts, or history of alcohol abuse . The bipolar group without personality disorder was significa ntly more responsive to lithium eabonate alone (X2 P < 0 .05 ) and had significantly less neurol eptic treatment at the lime of PDE assess ment (p < 0 .0 I) than the bipolar gro up with personality disorder (Ta ble I ).
Discussion The present findin g that 35% of a sample of euthymic ado lescent bipolars met criteria for a personalit y disorder is higher than that reported in adult studies (Gaviria et al ., 1982; Baxter et al ., 1984; Dochert y el al . , 1986). The reason for this is uncle ar , but it may reflect sample bias, illness onset effects, or the " selective" report ing of symptoms by adolesce nts. The current sample is from a tertiary refe rral unit at a university teaching hospital. All probands had been inpatients at least once and most were being followed in a specialized med ications cli nic. Th is population may thus be more disturbed than those reported on in the adult studies and may therefore preselect for an Axis IIAxis II co-m orbidity. Alternati vely, the mean age of bipol ar illness ons et in the group was quite young- 16.4 years. The onset of an affecti ve disorder this early in the life cycle may have greater effects on personality development than disorders with a later onset. Thi s early onset may explain the higher prevalence of personality disord er diagno ses in this populat ion .
356
T A BLE
I. Bipolar Adol escents with and without Personality
Disorder: Associated Features
Agc Sc x Ag c of o nse t Rapid cycling Substan ce ab use Suicide atte mpts Alco ho l abuse Lithium res ponders Neur olep tic treated at PDE asses sme nt
Bipo lars W ithou t
Bip olars With
(N = ( 3)
(N = 7)
S ign ificance
17 .2
17.8
6F17M 16.3
3F/4M 16.5 1 4 2
NS NS NS
3 4 I 2
6 4
I
o 7
NS NS NS NS 0 .05 0 .0 1
A further possib ility is that " selective " reporting of symptoms by adolescent s may lead to person ality dia gnoses rather than Axi s I diagnoses. Alth ough this sample was euthymic using Brief Psychi atric Ratin g Scale and Visual Analogue Scale criteria at the time of PDE testin g , clin ical experience indicates that adolescent bipolars , particularly those who have residual affective symptomatology of the irritable " hypomanic " type tend to deny those mood and cognitive symptoms which they know are the foc us of diagnostic inqu iry. A PD E assessment may allow for freer sharing of distress becau se it does not focus so specifically on manic syndro me symptoms. A co ncurrent parental report to assess the full range of Axis I and Axis II symptoms will be added in future studies. This group of personality disord ered adolescent bipolars was hetero genou s in its personality diagnos is. Thi s does not support the sugges tion in the adult literatu re that there is a unique bipolar/borderlin e personal ity disord er relationship (Gaviria et al. , 1982; Val ct al . , 1983; Dochert y et al. , 1986). This heterogeneit y of person ality disorder dia gnoses is also consistent with find ings in unipolar adol escents (Robbins et al. , 1983; Korenblurn et al . , 1988; Marton et al . , 1988) and may reflect nonspecific effects of affecti ve illness on personalit y developm ent or , alternatively, may suggest that there is no one specific person ality constell ation that pred isposes to affective illness. A deta iled reassessment of the three adolescent s ass igned a BPD diagnosis found that two of the thre e were felt by the treating physician to be not fully clinicall y recovered from a manic episode . These two teens exh ibited anger outbursts. interp ersonal hypersensiti vity, irrit ab ility, defensive ness, impul sivity, and failure to ass ume person al responsibility for daily tasks- all behavi ors whic h have been described by Davis et al. (1986) as characteristic of the hypom anic state and which may impro ve with successful pharm acologi cal treatmen t. Thus, the Axis IJ diagnosi s of borderline pers onality in some of these adol escents with bipolar illness may possibly be a subclinical presentation of an Axis I bipolar disorder. Support for this possibility is found in the only featur es which significantly differentiated bipol ar with personality disorder from bipol ar without personality disord er groups-lithium nonresp onsiveness (p < l.Am .A cad. Chil d Adolesc . Psy chiatry, 29 :3, May 1990
PE RSONALIT Y DISO RDER IN ADO LESC ENT BI PO LARS
0.05) and neuroleptic treatment at the time of PDE asse ssment (p < 0 .0 1). Although the diagnosis of adolescent perso nality disorder is diffic ult, DSM-II/ -R criter ia ca n be appli ed to adolescents as well as to adult s. Perv asive and per sistent disturbances of personality functio ning in ado lesce nce whic h meet threshold criteria for " adult" perso nality disorder diagnoses should be so classified if the clin ician is reaso nabl y certain that the disturbances are stable over time and do not reflect e ither a transient situatio nal pert urbation or a life-ph ase specific variation of an Axis I disorder (Friedman et al ., 1982 ; Marton et ai., 1989). Given this approach, however, there is little empir ical evid ence about the incid ence or preva lence of persona lity disorders in ado lesce nce or the stability of disturbance in person ality traits from ado lescence to adulthood . Alth ough some dat a are availabl e reg arding the fre quency of personality disorder in samples of adolescent psychiatric patients (Hudgens , 1974 , Friedman et al. , 1982) , they arc insufficient to pro vide a mean ingful estimate since the samples are rela tive ly small and probably unrepresentative . A few longitudin al studies indicate that some characteristics of per sonality disorder such as aggressio n, antisocial behav ior, and inh ibited , shy, wit hdrawn behav ior are persis ten t over long periods of time in chi ldhoo d and adole sce nce (Kazdin, 1987; Rubi n & Loll is , 1988; Go lornbek et a!., 1989). Much yet needs to be known abo ut the development of personality dys fun ction and disorder from adolescence to adul thood, and the current study needs to be understood within these constraints . Further studies of personali ty disturbances in the adolescent bipo lar pop ulatio n wi ll have to take four issues into account. First, def ining euthyrnia is crucia l to excl ude partiall y treat ed Axi s I cases as they ma y be diagnosed as personality disor dered . The uses of multi ple asses sme nt instruments incl ud ing mani a rating scales (yet to be specifica lly des igned for adolescents), concurrent pare nta l rep orts , and detailed cli nician eva luation arc necessary to minimize the effect of state spe cific symptoms on the assessment of personality . Second, the deve lopm ent of bio logical markers that co uld differentia te state from trait wo uld improve asses sment specificit y (Whalley et al., 1987). Th ird , longitudinal studie s of high-risk groups (children of bipo lar parents) first assessed prior to any reco gnizab le ma nic or depressiv e episode are essential to det er mine the pos sible effect of pre rn orbi d persona lity on illness onset. Fina lly , the assessme nt of specific person ality traits such a neurotici sm and extraversion or other dimensional measures should be incl uded in future studies as the curre nt syndrorn al DSM III -I? p ers on al it y di sorde r diagno se s may no t provi de t he
" fine tuni ng" needed to ide ntify specific personality traits which may be associated with adolescent bipo lar illness . In summa ry, much work needs to be done in the area of adolesce nt bipo lar illness and perso nality disturb ance .
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chiatr. Res. , 22 :279-2 86 . Ka zdin , A . ( I( 87) , Treatm e nt o f an tiso cial beh a vior in c h ild re n: c urrent status and future direct ion s . l' sychol . Hull ., 102 : 187- 20:1. Kore nblum, M., M arton, P . , Kut ch er , S . ct a!' (October , )9 88) , 1'1'1'so nality dysfunction ill depressed adolcsccnts-s-statc or trail ? Prese nted at the Joint Meeting of the A me rica n Academ y o f C hild a nd Ado lescen t Psychi atr y an d the Canadi an Ac ade my o f Ch ild Psychiatry , Se attle . Lieb owit z , M . R . , Stal on e, F. , Du nner, D . L. e t a l. ( 19 79), Pe rsona lity features of patie nts with primary affective di sorder. Acta Psychiatr, Scand. , 60 :2 14-244 . Loranger, A. , Su sman , V . , Ol dham , 1. ct a l.(1987 ) , Th e per sonality disorder ex ami nat ion (PD E) : a structured int erview [or U SM -If / -R personality dis orders . Wh ite Pla ins , NY : Th e New Yo rk Hospital-Co rnell Medica l Centre , Westch ester Di visio n. Ma rton , P. , Korcn blum , ivI. , Kutch er , S . e t al. (Oc tobe r, 1( 88) , Comorbidity ofpersonality d isorde rs and depressi ve dis ord ers ill adolescent s. Pre se nted at the Jo int Mee ting of the A me rican Academy of Ch ild and Ad olescent Psychiatry a nd the Canadi a n Aca dem y of Child Psych iatry , Sea ttle . - - - -- - - c t a!' (I (89 ) , Persona lity dysfunctio n in depressed ado lescents . Call . J . Psychiat ry, :14 :8 10--8 13. McG lasha n, T . H . ( 198 3) , Th e bo rderline sy ndro me . Arch . Gcn. Psy ch ia lry,40 :11 19 1121 Ove rall , J . E., Go rham , D . R., (196 2), T he b rief psyc h iatric rat ing sca le. Psych ol , Rcp . ; 10:799-812 . Pop e , H. G . , Jonas ,.I . M . , Hud so n ,.I . I. c t a!' (19 83 ), The va lid ity of USM -If I borde rline per sona lity disorder. Arch . Gen . Psvchiatry, 40 :23 -30. Robbi ns , D. , Al essi , N. , Yan ch ysh yn , G . c t a l. ( 1983) , Psyc ho dyna mic and charac terologica l he tero ge neit y among ado lesce nts with maj or depressive di sorder s . J. A m . A ca d. Child Ps ychiatry, 22:487· 491. Rubin , K . , Lollis , S . ( 1988) , O rigin s and co nse q ue nces of soc ia l withdrawal. In : Clinical Implications oIA ttachm ent , cd . .I. Bel sky & T . Nezwa rsk i. H illsda le , NJ : Law ren ce Erlbau m Asocs ., Inc .
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KUTC IIER liT J\L. Val, E. , Nasr, S . .I. , Gaviria , F. M . et ul. ( 1983), Depression , borderline disord er , and the DST JIm . J . Psychi at ry 140 :819. Wha lley , L. .I. , Kutch er , S . P. , Blackwood . D . J-l. R. ct al. ( 198 7), Increa sed plasma LH in ma nic de pressive illness: evid ence of a state
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inde pende nt abnor mality . Br. J . Psy chiatry; 150 :682- 684. Yanchysh yn , G . , Kut cher , S ., Co hen , C . ( 1986) , The dia gnostic interview for borderline : rel iability and va lidity in ado les cen ts . .I . Am . Acad . Child lido/es c. Psychiatry , 25:427- 429 .
.I.Am. Acad . Child Adole sc. Psychiatry , 29:3, May 1990
Abstract. Th e rel ationship bet ween ado lesce nt bipolar illness and personality d isorder has not been explored . Studie s of adu lt bipolars suggest a bipo lar illness/borderline personality diso rder (BPD) assoc iatio n. Tw e nty cuthymic bip olar tee ns were assessed using the Personality Disorders Exam ination . Th irty-five perce nt met DSlvf-lJ!-R criteria for at least one person ality disord er. Th ree of the 20 ( 15%) had a borderline persona lity disor der dia gnosis. The bipo lar illne ss wit h person al ity disorder gro up differe d significantly from the bipolar illness wi thou t perso na lity disord er group in term s of increased lithium unresponsi ven ess (p < 0 .05) and ne uro leptic treatm ent at tim e of personality assess me nt (p < 0 .01), but not in terms of age , sex , age of illness onset, serum lith ium le vel , rapid cycl ing, subs tance abuse history , alcoho l abu se histo ry , or numbe r of suicide attempts . Issues rega rding the study of personality disorder in ado lesce nt bipolars arc discussed, J. Alii. Acad. Child /vdolesc, Psychiatry , 1990, 29, 3:355-35 8. Key Words: bip olar , personality , ado lescent. The study of the relation ship betw een affecti ve disorder and personality disord ers has tend ed to focus on unipolar dep ression and not bipolar illness (Docher ty et £11., 1986). Person ality studies of adult s with bipo lar disorder are few , and no spec ific studies of person ality disorder in adolescent s with bipolar disorder have , to the authors' knowl edge , been publi shed . The sma ll number of adult studies , however, does suggest that an association betw een bipolar disorder and pers on ality disord er-- specifically, borderline person ality (BPD )-may exist. In examining samples of bord erl ine patients for the presence of bipolar disorder, Val et £II. (1983) found two of JO (20%) to have a bipolar illness. Th is figure is slightl y higher than those reported by Friedman et £II. (1983)- 5.6%; Pope et £II. ( 1983)- 10%; and McGlashan et al. (1983)-1 2% . On the other hand , studies which have assessed samples of bipolar patients have found that 3 .8 (Ba xter et £II . , 1984) to 14.7% (Ga viria ct aI., 1982) have met criteria for BPD. The concurrence of BPD with bip olar illness has also been associated with increased suicidal behavior, poo rer treatm ent outcome , more psychoti c symptomatology , and poorer social, academic, and vocational functioning; (Gaviria et aI., 1982 ; Friedm an et £11. , 1983; McGlashan , 1983; Docherty et £11., 1986). Th ese studies , however , share a numb er of methodological limitations which make the findings of a possibl e bipolar-borderlin e personalit y disord er relation ship difficult to interpret. In most cases, they did not use stru ctured di-
agnostic intervi ews to assess person ality disord er nor did they attempt to eva luate the full spec trum of personal ity disorders , and by focu sing only on the bord erline diagno sis may have give n the impre ssion of a specific bipolarborderlin e relation ship when one does not ex ist (Gavi ria et £11. , 1982; Friedman et £II. , 1983; McGlashan , 1983; Pope et £11., 1983; Val et al., 1983; Baxter et £11. , (984) . The study of Charney et al. ( 198 1), wh ich assessed a wider range of personality disord ers, unfortunately, failed to report the various types of person ality disorders found, thu s , not allowin g eva luation of the relationship between bip olar illness and anyone specific personality disord er. Further , samp le sizes in the studies cited above have generally been sma ll. Val et £II. (1983) described two bipolars, Friedma n et al. (1983), reported on three bipolars, as did Pope et £II. (198 3). Onl y the studie s by Baxter et £I I. ( 1984) and Gaviria ct £I I. (19 82) report ed on suffic ient probands to allow for a wider assessment of personality disorders, but this was not undertaken . Additionally , in all thc studies noted abov e, assessment of personality disord er was based on data coll ected at the time of index presentation when the patient was suffering from an affective disorder or other acute psych iatric disturbance . Thi s approac h biases findings toward increas ing person ality disord er diagnoses as numerou s inves tigators have shown that many patient s who met diagnostic cr iteria for person ality disorder dur ing an acute affective episo de no longer met those criteria when euthymic (Liebowitz et £11., 1979; Hirschfield ct '11. , 1983a,b , 1986; Joffe and Regan , 1988; Ko renblurn et £11. , 198 8). Wh ile some studies describing the relationsh ip between unipol ar affective di sorder and per sonality disorder s in ad-
olescents have been reported (Robbins et aI., 1983; Clarkin et aI. , 1984; Yanchyshyn ct al., 1986 ; Korcnblum et a!., 1988; Marton et £11., 1989); to the authors' knowl edge no published studies have spec ifica lly described the relationship between bipolar disord er and personality disord ers in ado lesce nts . Thi s study was des igned to pro vide an initial descripti ve pro file of the bipol ar disorder/p erson alit y disorder relationship in teenager s and to assess if any specific personality disorder (particularly borderline personality) was more likely to be associated with bipolar illne ss.
Acc epted July 3, 1989. Drs . Kutcher and Korcnb lum are from the Department of Psychiatry and Dr . Marton is fr o m the Depa rtment of Psycho logy , Sunnybrook Medica! Centre, Uni versity of Toront o. Our appreciation to Ms. J . Stewart for manu script pr eparation and the nursing staff of the Adolescent Inpatient and Outpatient Services at Sunnybrook Medi cal Cent re f or Patient Care . Request reprintsfromDr. Kut cher, Department of Psychia try, 51111nybrook Medical Cent re, 20 75 Bay view Ave llue, Toronto . Ontario, Canada M4N 3M5 . 0890-R567/9012903·0 355$02 .00/0© 1990 by the American Acade my of Child and Adole scent Psych iatry.
355
K UTC I WR ET A I. .
Method Twenty adolescent s ( I I male , nine female; average age 17.5 years) meetin g DSM -III-R criteria for bipolar disorder following a full inpatient assessment which included the affective disorders section of the Schedule for Affective Disorders and Sch izophrenia (Endicott and Spit zer , (97 8) were assessed when euthymic by an experienced intervie wer not involved in their care, using the Personality Disorders Examination (PD E) (Loranger et al., 1987) . Personality disorder diagnoses were assigned on the basis of the PDE interview . All probands had experienced at least one manic and one depressive episode . Euthymia was defined as a score of 10 or less on the Brief Psychiatri c Rat ing Sca le (Ove rall and Gorham , 1962) plus a self-report assessment of less than or equal to 2 em from midlin e on a 10 ern visual analogue scale. At the time of the PDE assess me nt, 19 of the subjects were outpatients atte nding an adolescent medications clini c and one was an inpatient in the process of discharge .
Results Seven of the 20 adolescent bipolars (35%) met DSM-III criteria for at least one person ality diso rder and three of the 20 ( 15%) met criter ia for more than one personality disorder. Personali ty diagnoses were: borderline- 3; nareissistie- 3; passive aggressi ve- 2; schizotypal - I; avoidant- I; and dependent- I . There were no significant differences between personalit y disordered and nonperson ality disord ered grou ps in age , sex, age of illness onset , seru m lithium level, rap id cycling, history of substance abuse, number of suicide attempts, or history of alcohol abuse . The bipolar group without personality disorder was significa ntly more responsive to lithium eabonate alone (X2 P < 0 .05 ) and had significantly less neurol eptic treatment at the lime of PDE assess ment (p < 0 .0 I) than the bipolar gro up with personality disorder (Ta ble I ).
Discussion The present findin g that 35% of a sample of euthymic ado lescent bipolars met criteria for a personalit y disorder is higher than that reported in adult studies (Gaviria et al ., 1982; Baxter et al ., 1984; Dochert y el al . , 1986). The reason for this is uncle ar , but it may reflect sample bias, illness onset effects, or the " selective" report ing of symptoms by adolesce nts. The current sample is from a tertiary refe rral unit at a university teaching hospital. All probands had been inpatients at least once and most were being followed in a specialized med ications cli nic. Th is population may thus be more disturbed than those reported on in the adult studies and may therefore preselect for an Axis IIAxis II co-m orbidity. Alternati vely, the mean age of bipol ar illness ons et in the group was quite young- 16.4 years. The onset of an affecti ve disorder this early in the life cycle may have greater effects on personality development than disorders with a later onset. Thi s early onset may explain the higher prevalence of personality disord er diagno ses in this populat ion .
356
T A BLE
I. Bipolar Adol escents with and without Personality
Disorder: Associated Features
Agc Sc x Ag c of o nse t Rapid cycling Substan ce ab use Suicide atte mpts Alco ho l abuse Lithium res ponders Neur olep tic treated at PDE asses sme nt
Bipo lars W ithou t
Bip olars With
(N = ( 3)
(N = 7)
S ign ificance
17 .2
17.8
6F17M 16.3
3F/4M 16.5 1 4 2
NS NS NS
3 4 I 2
6 4
I
o 7
NS NS NS NS 0 .05 0 .0 1
A further possib ility is that " selective " reporting of symptoms by adolescent s may lead to person ality dia gnoses rather than Axi s I diagnoses. Alth ough this sample was euthymic using Brief Psychi atric Ratin g Scale and Visual Analogue Scale criteria at the time of PDE testin g , clin ical experience indicates that adolescent bipolars , particularly those who have residual affective symptomatology of the irritable " hypomanic " type tend to deny those mood and cognitive symptoms which they know are the foc us of diagnostic inqu iry. A PD E assessment may allow for freer sharing of distress becau se it does not focus so specifically on manic syndro me symptoms. A co ncurrent parental report to assess the full range of Axis I and Axis II symptoms will be added in future studies. This group of personality disord ered adolescent bipolars was hetero genou s in its personality diagnos is. Thi s does not support the sugges tion in the adult literatu re that there is a unique bipolar/borderlin e personal ity disord er relationship (Gaviria et al. , 1982; Val ct al . , 1983; Dochert y et al. , 1986). This heterogeneit y of person ality disorder dia gnoses is also consistent with find ings in unipolar adol escents (Robbins et al. , 1983; Korenblurn et al . , 1988; Marton et al . , 1988) and may reflect nonspecific effects of affecti ve illness on personalit y developm ent or , alternatively, may suggest that there is no one specific person ality constell ation that pred isposes to affective illness. A deta iled reassessment of the three adolescent s ass igned a BPD diagnosis found that two of the thre e were felt by the treating physician to be not fully clinicall y recovered from a manic episode . These two teens exh ibited anger outbursts. interp ersonal hypersensiti vity, irrit ab ility, defensive ness, impul sivity, and failure to ass ume person al responsibility for daily tasks- all behavi ors whic h have been described by Davis et al. (1986) as characteristic of the hypom anic state and which may impro ve with successful pharm acologi cal treatmen t. Thus, the Axis IJ diagnosi s of borderline pers onality in some of these adol escents with bipolar illness may possibly be a subclinical presentation of an Axis I bipolar disorder. Support for this possibility is found in the only featur es which significantly differentiated bipol ar with personality disorder from bipol ar without personality disord er groups-lithium nonresp onsiveness (p < l.Am .A cad. Chil d Adolesc . Psy chiatry, 29 :3, May 1990
PE RSONALIT Y DISO RDER IN ADO LESC ENT BI PO LARS
0.05) and neuroleptic treatment at the time of PDE asse ssment (p < 0 .0 1). Although the diagnosis of adolescent perso nality disorder is diffic ult, DSM-II/ -R criter ia ca n be appli ed to adolescents as well as to adult s. Perv asive and per sistent disturbances of personality functio ning in ado lesce nce whic h meet threshold criteria for " adult" perso nality disorder diagnoses should be so classified if the clin ician is reaso nabl y certain that the disturbances are stable over time and do not reflect e ither a transient situatio nal pert urbation or a life-ph ase specific variation of an Axis I disorder (Friedman et al ., 1982 ; Marton et ai., 1989). Given this approach, however, there is little empir ical evid ence about the incid ence or preva lence of persona lity disorders in ado lesce nce or the stability of disturbance in person ality traits from ado lescence to adulthood . Alth ough some dat a are availabl e reg arding the fre quency of personality disorder in samples of adolescent psychiatric patients (Hudgens , 1974 , Friedman et al. , 1982) , they arc insufficient to pro vide a mean ingful estimate since the samples are rela tive ly small and probably unrepresentative . A few longitudin al studies indicate that some characteristics of per sonality disorder such as aggressio n, antisocial behav ior, and inh ibited , shy, wit hdrawn behav ior are persis ten t over long periods of time in chi ldhoo d and adole sce nce (Kazdin, 1987; Rubi n & Loll is , 1988; Go lornbek et a!., 1989). Much yet needs to be known abo ut the development of personality dys fun ction and disorder from adolescence to adul thood, and the current study needs to be understood within these constraints . Further studies of personali ty disturbances in the adolescent bipo lar pop ulatio n wi ll have to take four issues into account. First, def ining euthyrnia is crucia l to excl ude partiall y treat ed Axi s I cases as they ma y be diagnosed as personality disor dered . The uses of multi ple asses sme nt instruments incl ud ing mani a rating scales (yet to be specifica lly des igned for adolescents), concurrent pare nta l rep orts , and detailed cli nician eva luation arc necessary to minimize the effect of state spe cific symptoms on the assessment of personality . Second, the deve lopm ent of bio logical markers that co uld differentia te state from trait wo uld improve asses sment specificit y (Whalley et al., 1987). Th ird , longitudinal studie s of high-risk groups (children of bipo lar parents) first assessed prior to any reco gnizab le ma nic or depressiv e episode are essential to det er mine the pos sible effect of pre rn orbi d persona lity on illness onset. Fina lly , the assessme nt of specific person ality traits such a neurotici sm and extraversion or other dimensional measures should be incl uded in future studies as the curre nt syndrorn al DSM III -I? p ers on al it y di sorde r diagno se s may no t provi de t he
" fine tuni ng" needed to ide ntify specific personality traits which may be associated with adolescent bipo lar illness . In summa ry, much work needs to be done in the area of adolesce nt bipo lar illness and perso nality disturb ance .
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