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Partial seizure-like symptoms in borderline personality disorder
Epilepsy & Behavior Epilepsy & Behavior 3 (2002) 433–438 www.academicpress.com
Partial seizure-like symptoms in borderline personality disorder Catherine L. Harris,a Wayne M. Dinn,a,* and Jonathan A. Marcinkiewiczb a
Department of Psychology, Brain, Behavior and Cognition Program, Boston University, 64 Cummington Street, Boston, MA 02215, USA b Department of Psychiatry, Heywood Hospital, Gardner, MA, USA Received 26 March 2002; accepted 21 August 2002
Abstract The clinical presentation of borderline personality disorder (BPD) bears a striking resemblance to the behavioral alterations associated with temporal lobe epilepsy. Using the Limbic System Checklist-33, we found that BPD subjects reported more symptoms associated with partial seizures than did control subjects. BPD patients also exhibited deficits on immediate and delayed recall of the Rey–Osterrieth Complex Figure and produced distorted drawings of the Rey Figure. Their degree of impairment correlated with their report of temporolimbic symptoms. Results are consistent with the proposal that temporolimbic dysfunction underlies the behavioral dyscontrol and affective dysregulation present in BPD. Ó 2002 Elsevier Science (USA). All rights reserved. Keywords: Borderline personality disorder; Temporolimbic; Neuropsychological; Interictal; Partial seizures
1. Introduction The integrity of neural systems involved in affect regulation and impulse control may be compromised in borderline personality disorder (BPD). Clinical features include intense affect, rapidly shifting mood states, irritability, impulsivity and behavioral dyscontrol, unstable personal relationships, self-destructive behavior, brief psychotic episodes, dissociative states, and identity disturbance [1–9]. Episodes of uncontrollable rage are a particularly salient feature. Millon [6] suggested that the most striking characteristic of BPD patients is the intensity and variability of their emotions. The current article focuses on the proposal that temporolimbic dysfunction underlies the behavioral dyscontrol and affective dysregulation exhibited by BPD patients. The starting point for this proposal is the observation that diagnostic criteria for BPD resemble classic descriptions of the interictal behavioral syndrome (i.e., the temporal lobe personality). Patients with temporal lobe epilepsy (TLE) may present with diverse characteristics including explosive emotionality,
*
Corresponding author. E-mail address: [email protected] (W.M. Dinn).
unstable personal relationships, obsessionalism, dependence, hypergraphia, hyperreligiosity and philosophic interests, irritability, impulsivity, rage followed by self-recrimination, psychotic episodes, anxiety, depression, and dissociative states [10–22]. Bear [10] suggested that temporal lobe seizures generate a sensory–limbic hyperconnection syndrome. The intensification of emotion and volatile interactional style associated with TLE may reflect enhanced limbic responsivity. Patients with temporal lobe epilepsy demonstrate an increased incidence of mental disorders [23] and TLE is associated with a broad spectrum of neuropsychiatric symptoms/syndromes including affective illness [19,20,24–26], panic attacks [27,28], posttraumatic stress disorder [29], obsessive–compulsive disorder [30,31], and schizophrenia-like psychosis [19,32–34]. However, the contention that focal seizures originating in temporolimbic structures generate a well-defined neurobehavioral syndrome is controversial [35,36]. Several studies on temporal lobe epilepsy failed to observe the classic interictal behavioral profile, an increased incidence of psychopathology, or differences between patients with TLE and patients with other forms of epilepsy [36–40]. Nevertheless, a considerable body of research suggests that a significant subset of patients with TLE demonstrate behavioral alterations,
1525-5050/02/$ - see front matter Ó 2002 Elsevier Science (USA). All rights reserved. PII: S 1 5 2 5 - 5 0 5 0 ( 0 2 ) 0 0 5 2 1 - 8
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C.L. Harris et al. / Epilepsy & Behavior 3 (2002) 433–438
including intense and unstable affect, behavioral dyscontrol, interpersonal viscosity and dependence, and volatile personal relationships. Patients with BPD demonstrate symptoms and behavioral phenomena associated with the interictal behavioral syndrome, including irritability, impulsivity, affective instability, paroxysmal rage, interpersonal viscosity and dependence, transient psychotic episodes, self-destructive behavior (e.g., self-mutilation) and multiple suicide attempts, and dissociative states. Behavioral changes associated with TLE resemble the clinical features of BPD. This raises the question of whether at least a subset of BPD patients have an undiagnosed seizure disorder (e.g., temporolimbic epilepsy). Cowdry and colleagues [41] documented an increased incidence of symptoms associated with complex partial seizures (CPS) among BPD subjects in comparison to psychiatric controls. Clearly, the relationship between BPD and temporolimbic seizure activity merits further study. While overlapping symptomatology does not establish a shared etiology, neurocognitive testing in BPD patients implicates the temporal lobes [42,43]. Medication-free BPD patients have demonstrated performance deficits on tests of complex memory function and visual discrimination [42]. Patients with temporal lobe epilepsy also exhibit performance deficits on tests assessing verbal or spatial memory [13,18,44,45]. TLE patients presenting with a left temporal lobe seizure focus demonstrate verbal memory deficits [45,46], while patients presenting with a right seizure focus exhibit performance deficits on tests of visual and spatial learning and memory function [45,47–49]. Several case reports have appeared describing patients with seizure disorders who also fulfilled diagnostic criteria for BPD [50–52] or presented with symptoms similar to those of BPD [53]. Schmid and colleagues [52] described the case history of a patient who originally received a BPD diagnosis; however, subsequent neurological examination revealed an atypical seizure disorder. Anticonvulsant drugs are frequently helpful in treating BPD patients even in the absence of documented seizures [54–57]. The present article tests the hypothesis that the emotional dysregulation and behavioral dyscontrol of at least some BPD patients may be associated with temporolimbic seizures and may represent interictal phenomena. A helpful step toward investigating the interictal hypothesis is to document whether BPD patients report an increased incidence of symptoms associated with temporal lobe epilepsy. We employed the Limbic System Checklist-33 [58] to assess these symptoms. In a follow-up study, we explored the relation between Limbic System Checklist scores and performance on a neuropsychological task considered sensitive to temporal lobe dysfunction among BPD patients and control subjects.
2. Study I 2.1. Method Subjects were 25 consecutive admissions to an acute care inpatient psychiatric ward at a general hospital (Heywood Memorial Hospital) who met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic criteria for borderline personality disorder (BPD) [1]. The BPD group comprised 16 female and 9 male inpatients. Their ages ranged from 19 to 48 years (mean SD ¼ 30:2 8:1). A psychiatric control group consisted of 12 consecutive admissions who met DSMIV criteria for major depressive disorder (MDD). The MDD group comprised 7 female and 5 male inpatients. Their ages ranged from 17 to 49 years (mean SD ¼ 32:6 10:4). Diagnoses were made by a board-certified psychiatrist experienced in the differential diagnosis of Axis II disorders. A second psychiatric control group consisted of 10 consecutively evaluated outpatients seen at an anxiety disorders clinic. The anxiety disorders group comprised 5 male and 5 female outpatients diagnosed with panic disorder (n ¼ 5), posttraumatic stress disorder (n ¼ 2), and obsessive–compulsive disorder (n ¼ 3). Their ages ranged from 21 to 51 years (mean SD ¼ 35:8 11:3). Diagnoses were made by a licensed clinical psychologist. A nonpatient control group (n ¼ 25) comprised 16 female and 9 male hospital employees and their ages ranged from 20 to 48 years (mean SD ¼ 31:3 7:7). After giving informed consent, subjects completed the Limbic System Checklist-33 [58]. The Limbic System Checklist is a 33-item, self-report symptom inventory developed by Teicher and colleagues [58]. Respondents indicate how frequently they experience symptoms suggestive of partial seizures that arise in temporolimbic structures, including ‘‘paroxysmal somatic disturbances, brief hallucinatory events, visual disturbances, automatisms, and dissociative disturbances’’ [58, p. 302]. Ictal phenomena include: Somatosensory symptoms (e.g., ‘‘How often have you experienced the sudden, abrupt, and unexplained onset of sensation of something crawling under your skin? or ‘‘a rising or sinking feeling in your stomach—like you were in an elevator?’’). Complex stereotyped motor behavior (e.g., ‘‘How frequently have you had unexplained or uncontrolled episodes in which you experienced or engaged in complex automatic behavior—such as purposeless running in circles, closing windows, or picking at your clothes?’’). Olfactory or visual hallucinations (e.g., ‘‘How often have you experienced, for no particular reason, smelling an odor such as ammonia, burning rubber, decaying waste, or garbage?’’ or ‘‘seeing fully formed images— such as a person in a doorway, a demon, a God-like image?’’).
C.L. Harris et al. / Epilepsy & Behavior 3 (2002) 433–438 Table 1 Study I: Limbic System Checklist-33 Group
n
Mean
SD
Range
BPD MDD AD Control
25 12 10 25
46.6 21.7 18.4 16.5
19.3 6.5 6.7 7.5
15–89 13–36 10–32 1–31
Note. BPD, borderline personality disorder; MDD, major depressive disorder; AD, anxiety disorders; Control, nonpatient volunteers.
Perceptual distortions (e.g., ‘‘How frequently have you had the visual illusion that an object or person suddenly became distorted or transformed’’ or ‘‘an object or person suddenly looked smaller, farther away, or out of reach?’’). Distortions of consciousness (e.g., ‘‘How often have you experienced the sensation that your mind has left your body, or that you are watching yourself as a detached observer’’ or ‘‘how often have you experienced the sudden feeling that you are no longer real, or not the same person?’’). The Limbic System Checklist possesses adequate psychometric properties [58]. The checklist showed acceptable construct validity and demonstrated high test– retest reliability. 2.2. Results As shown in Table 1, the BPD group had the highest mean score on the Limbic System Checklist. This mean score was significantly greater than the mean of the next highest scoring group, inpatients with major depressive disorder, F ð1; 35Þ ¼ 18:5, P < 0:0001. Limbic System Checklist scores did not differ between the nonpatient control, anxiety disorder, and major depressive disorder groups, as verified by a one-way analysis of variance, F ð2; 44Þ ¼ 2:1, P > 0:12. Scores did not vary as a function of gender (mean for males ¼ 27.6; mean for females ¼ 28.4; tð70Þ ¼ 0:174, P > 0:85) or age (r ¼ 0:05, ns). The BPD group mean on the Limbic System Checklist was more than double the psychiatric and control group means. This is consistent with the hypothesis that BPD symptoms reflect interictal behavioral changes secondary to recurrent partial seizures. However, BPD symptoms may have a distinct etiology unrelated to temporolimbic seizures. It would be useful to correlate performance on the Limbic System Checklist with an established measure of temporal lobe dysfunction.
3. Study II In Study II, we replicated our finding of an increased incidence of seizure-like symptoms among BPD patients, and examined the relationship between Limbic
435
System Checklist scores and performance on the Rey– Osterrieth Complex Figure (ROCF) test, a neuropsychological measure considered sensitive to temporal lobe dysfunction. During the ROCF test, participants copy a complex geometric figure consisting of 18 separate elements [59]. Subjects are then required to reproduce the figure from memory after 1- and 30-min delays. Impaired performance on the ROCF may reflect visuoconstructive, executive function, and nonverbal memory deficits. Poor performance on the recall components of the ROCF test has been associated with right temporal lobe dysfunction [60,61]. Efficient copy performance depends on the use of organizational strategies. Thus, performance deficits may reflect a failure to impose efficient organizational strategies at encoding (implicating frontal-executive circuitry) [62] or a retention/retrieval deficit (implicating temporolimbic systems). 3.1. Method Subjects were 15 consecutive admissions (10 female and 5 male) to an acute care inpatient psychiatric ward at Heywood Memorial Hospital who fulfilled DSM-IV diagnostic criteria for BPD [1]. Their ages ranged between 19 and 42 years (mean SD ¼ 31:1 6:4). Diagnoses were made by a board-certified psychiatrist experienced in the differential diagnosis of Axis II disorders. Fifteen control subjects were recruited from the general population via flyers seeking individuals interested in participating in research examining the neuropsychology of personality. Control subjects (10 females and 5 males) were matched to BPD subjects for educational level, handedness, and gender. Their ages ranged between 18 and 40 years (mean SD ¼ 29:4 5:5). None of the subjects participated in Study I. After obtaining informed consent, we administered the Limbic System Checklist and the ROCF. We employed the 36point itemized scoring system described by Lezak [59] to evaluate constructional accuracy. Drawings were scored by raters blind to subjectsÕ clinical status. 3.2. Results Independent-sample t tests were performed to assess between-group differences. Effect sizes (Omega2 ) were calculated to ascertain the strength of group differences. As shown in Table 2, participants with BPD obtained significantly lower copy accuracy scores in comparison to controls, with tð28Þ ¼ 4:34, P < 0:001, effect size ¼ 0.37. The BPD patient group also exhibited significant deficits on immediate (1-min) and delayed (30-min) recall of the Rey–Osterrieth Complex Figure relative to control subjects, with tð28Þ ¼ 3:30, P < 0:003, effect size ¼ 0.24, and tð28Þ ¼ 5:61, P < 0:001, effect size ¼ 0.50, respectively. Analysis of Limbic System Checklist scores also revealed marked group differences. The BPD group
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Table 2 Study II: Limbic System Checklist-33 and the Rey–Osterrieth Complex Figure task
n LSCL ROCF copy ROCF 1-min 30-min
BPD
Control
t
P
esa
15 50.1 (17.4)b 31.3 (3.9)
15 23.2 (9.4) 35.9 (0.3)
5.23 )4.34
0.001 0.001
0.46 0.37
15.6 (9.1) 12.2 (4.5)
24.6 (5.2) 23.4 (6.2)
)3.30 )5.61
0.003 0.001
0.24 0.50
Note. LSCL, Limbic System Checklist-33; ROCF, Rey–Osterrieth Complex Figure test; BPD, borderline personality disorder; Control, control subjects recruited from the general population. a Effect size (Omega2 ). b Mean (SD).
differed significantly from the nonpatient control group, tð28Þ ¼ 5:23, P < 0:001, effect size ¼ 0.46. In addition, Limbic System Checklist scores correlated strongly with performance on the immediate and delayed recall components of the ROCF among BPD subjects, with r ¼ 0:63, P < 0:05, and r ¼ 0:70, P < 0:05.
4. General discussion BPD patients scored significantly higher on a selfreport measure of temporolimbic dysfunction and exhibited performance deficits on the Rey–Osterrieth Complex Figure test in comparison to psychiatric and nonclinical control subjects. Poor performance on the recall components of the Rey–Osterrieth task is associated with right temporal lobe dysfunction [60,61]. Performance on the ROCF correlated strongly with Limbic System Checklist scores. Results suggest that items on the Limbic System Checklist may reflect nondominant temporal lobe dysfunction. In Studies I and II, Limbic System Checklist scores obtained by BPD patients were comparable to scores obtained by patients with temporal lobe epilepsy (TLE) reported in Teicher et al. [58]. The impaired visuoconstructive and nonverbal recall skills of these BPD patients suggest right-hemisphere dysfunction. Interestingly, behavioral effects associated with TLE vary according to the hemisphere of seizure focus. Epilepsy with a right temporal lobe focus is associated with affective instability and impulsivity [25,63,64]. Seizures originating in left temporal regions are associated with a schizophrenia-like psychosis [19,32,64] and depressive and anxiety symptoms [24,65,66]. However, not all studies have found that seizure focus (i.e., right vs left hemisphere focus) is associated with a specific personality syndrome or distinct patterns of interictal psychopathology [67,68]. How specific is the relation between BPD and partial seizure-like phenomena? It is worth comparing our results with a prior study that investigated cognitive and sensory distortions in mood disorder and epilepsy patients. Silberman et al. [69] interviewed patients with
affective illness, patients presenting with complex partial seizures (CPS), and control subjects free of psychiatric and neurologic disease. They conducted structured psychiatric interviews during which subjects indicated the frequency with which they experienced symptoms associated with CPS. Both mood disorder and epilepsy patients demonstrated an increased incidence of CPS-like symptoms relative to control subjects. However, there were notable differences in the symptom profiles of epilepsy and mood disorder patients. Epilepsy patients reported a significantly greater number of classic CPS symptoms relative to control subjects, including motor automatisms; speech arrest; vestibular, gustatory, and epigastric hallucinations; tactile distortions; amnestic episodes; time disorientation; and body part dissociation [69]. The incidence of the aforementioned symptoms was not significantly greater among mood disorder patients in comparison to control subjects, although group differences for epigastric hallucinations and amnestic episodes did approach significance (P < 0:1). Mood disorder patients reported an increased incidence of CPS-like symptoms relative to controls, including speeded thoughts; slowed thoughts; sudden, intense, unexplained depression, pleasurable sensations, and sexual sensations; formed visual hallucinations; autoscopic states; and altered sound quality. The incidence of these symptoms was not significantly greater among epilepsy patients than among control subjects. Relative to controls, both affective and epilepsy patients reported an increased incidence of the following symptoms: illusions of significance; jumbled thoughts; altered sound and color intensity; and olfactory hallucinations. Patients with affective illness demonstrated an increased incidence of CPS-like symptoms relative to control subjects, including derealization, metamorphopsia, epigastric hallucinations, and amnestic episodes; however, group differences were not statistically significant (P < 0:1). In our study, BPD patients reported a greater number of classic partial seizure-like symptoms relative to mood disorder, anxiety disorder, and nonclinical control subjects. That is, their symptom profile resembled the profile of patients presenting with EEG-verified CPS
C.L. Harris et al. / Epilepsy & Behavior 3 (2002) 433–438
described in Silberman et al. [69], rather than the profile exhibited by patients with affective illness.
5. Conclusion In the present study, BPD patients achieved higher scores on the Limbic System Checklist relative to psychiatric and nonpatient controls. Of course, overlapping symptomatology does not necessarily imply a common etiology and we are not suggesting that we have obtained evidence of partial seizure activity among BPD patients. An alternative explanation is that partial seizure-like symptoms among BPD patients mirror classic symptoms of TLE, but possess a distinct etiology. However, the fact that BPD patients, in two separate studies, achieved relatively high scores on the Limbic System Checklist is noteworthy. One hypothesis to be tested is that the explosive emotionality and behavioral dyscontrol displayed by BPD patients are, at least in some cases, associated with temporolimbic dysfunction and may possibly represent interictal phenomena.
References [1] Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. [2] Gunderson J. Empirical studies of the borderline diagnosis. In: Grinspoon L, editor. Psychiatry, vol. 1. Washington, DC: American Psychiatric Press; 1982. p. 414–37. [3] Gunderson J. Borderline personality disorder. Washington, DC: APA Press; 1984. [4] Gunderson J, Kolb J. Discriminating features of borderline patients. Am J Psychiatry 1978;135:792–6. [5] Gunderson J, Singer M. Defining borderline patients: an overview. Am J Psychiatry 1975;132:1–10. [6] Millon T. Disorders of personality: DSM-III, axis-II. New York: Wiley–Interscience; 1981. [7] Pollack WS. Psychotherapy. In: Bellack AS, Hersen M, editors. Handbook of comparative treatments for adult disorders. New York: Wiley; 1990. p. 393–419. [8] Stone MH. Toward a psychobiological theory of borderline personality disorder: is irritability the red thread that runs through borderline conditions? Dissociation Progr Dissociative Disord 1988;1(2):2–15. [9] Rusch KM, Guastello SJ, Mason PT. Differentiating symptom clusters of borderline personality disorder. J Clin Psychol 1992;48:730–8. [10] Bear DM. Temporal lobe epilepsy: a syndrome of sensory–limbic hyperconnection. Cortex 1979;15:357–84. [11] Bear DM, Fedio P. Quantitative analysis of interictal behavior in temporal lobe epilepsy. Arch Neurol 1977;34:454–67. [12] Waxman SG, Geschwind N. Hypergraphia in temporal lobe epilepsy. Neurology 1974;24:629–36. [13] Blumer D. Temporal lobe epilepsy and its psychiatric significance. In: Benson DF, Blumer D, editors. Psychiatric aspects of neurologic disease. New York: Grune & Stratton; 1975. p. 171–98. [14] Blumer D. Evidence supporting the temporal lobe personality syndrome. Neurology 1999;53(5, Suppl 2):S9–S12. [15] Geschwind N. Behavioral changes in temporal lobe epilepsy. Psychol Med 1979;9:217–9.
437
[16] Waxman SG, Geschwind N. The interictal behavior syndrome of temporal lobe epilepsy. Arch Gen Psychiatry 1975;32: 1580–6. [17] Bear D, Levin K, Blumer D, Chetham D, Ryder J. Interictal behaviour in hospitalised temporal lobe epileptics: relationship to idiopathic psychiatric syndromes. J Neurol Neurosurg Psychiatry 1982;45:481–8. [18] Bear DM, Freeman R, Greenberg M. Behavioral alterations in temporal lobe epilepsy. In: Blumer D, editor. Psychiatric aspects of epilepsy. Washington, DC: American Psychiatric Press; 1984. p. 197–227. [19] Flor-Henry P. Schizophrenic-like reactions and affective psychoses associated with temporal lobe epilepsy: etiological factors. Am J Psychiatry 1969;126:148–52. [20] Perini G, Tosin C, Carraro C, Bernasconi G. Interictal mood and personality disorders in temporal lobe epilepsy and juvenile myoclonic epilepsy. J Neurol Neurosurg Psychiatry 1996;61:601– 5. [21] Schenk L, Bear D. Multiple personality and related dissociative phenomena in patients with temporal lobe epilepsy. Am J Psychiatry 1981;138:1311–26. [22] Spiers PA, Schomer DL, Blume HW, Hochanadel GS. Behavioral alterations in temporolimbic epilepsy. In: Bennett TL, editor. The neuropsychology of epilepsy: critical issues in neuropsychology. New York: Plenum Press; 1992. p. 97–138. [23] Glosser G, Zwil AS, Glosser DS, OÕConnor MJ, Sperling MR. Psychiatric aspects of temporal lobe epilepsy before and after anterior temporal lobectomy. J Neurol Neurosurg Psychiatry 2000;68:53–8. [24] Carrieri PB, Provitera V, Iacovitti B, Iachetta C, Nappi C, Indaco A. Mood disorders in epilepsy. Acta Neurol 1993;15:62–7. [25] Gillig P, Sackellares JC, Greenberg HS. Right hemisphere partial complex seizures: mania, hallucinations, and speech disturbances during ictal events. Epilepsia 1988;29:26–9. [26] Himmelhoch JM. Major mood disorders related to epileptic changes. In: Blumer D, editor. Psychiatric aspects of epilepsy. Washington, DC: American Psychiatric Press; 1984. [27] Meyer MA, Zimmerman AW, Miller CA. Temporal lobe epilepsy presenting as panic attacks: detection of interictal hypometabolism with positron emission tomography. J Neuroimaging 2000;10:120–2. [28] Wall M, Tuchman M, Mielke D. Panic attacks and temporal lobe seizures associated with a right temporal lobe arteriovenous malformation: case report. J Clin Psychiatry 1985;46:143–5. [29] Bennett TL, Curiel MP. Complex partial seizures presenting as a psychiatric illness: a case study. Int J Clin Neuropsychol 1988;10:41–4. [30] Kanner AM, Morris HH, Stagno S, Chelune G, Lunders H. Remission of an obsessive–compulsive disorder following a right temporal lobectomy. Neuropsychiatry Neuropsychol Behav Neurol 1993;6:126–9. [31] Kroll L, Drummond LM. Temporal lobe epilepsy and obsessive– compulsive symptoms. J Nerv Ment Dis 1993;181:457–8. [32] Sherwin I. The effect of the location of an epileptogenic lesion on the occurrence of psychosis in epilepsy. Adv Biol Psychiatry 1982;8:81–97. [33] Shukla GD, Srivastava ON, Katiyar BC, Joshi V, Mohan PK. Psychiatric manifestations in temporal lobe epilepsy: a controlled study. Br J Psychiatry 1979;135:411–7. [34] Stoudemire A, Nelson A, Houpt JL. Interictal schizophrenia-like psychoses in temporal lobe epilepsy. Psychosomatics 1983;24:331– 9. [35] Devinsky O, Najjar S. Evidence against the existence of a temporal lobe epilepsy personality syndrome. Neurology 1999;53(5, Suppl 2):S13–25. [36] Dodrill CB, Batzel LW. Interictal behavioral features of patients with epilepsy. Epilepsia 1986;27(Suppl 2):S64–76.
438
C.L. Harris et al. / Epilepsy & Behavior 3 (2002) 433–438
[37] Hermann BP, Riel P. Interictal personality and behavioral traits in temporal lobe and generalized epilepsy. Cortex 1981;17:125–8. [38] Mungas D. Interictal behavior abnormality in temporal lobe epilepsy: a specific syndrome or nonspecific psychopathology? Arch Gen Psychiatry 1982;39:108–11. [39] Rodin E, Schmaltz S. The Bear–Fedio personality inventory and temporal lobe epilepsy. Neurology 1984;34:591–6. [40] Stevens JR. Psychiatric implications of psychomotor epilepsy. Arch Gen Psychiatry 1966;14:461–71. [41] Cowdry RW, Pickar D, Davies R. Symptoms and EEG findings in the borderline syndrome. Int J Psychiatry Med 1985–1986;15:201– 11. [42] OÕLeary KM, Brouwers P, Gardner DL, Cowdry RW. Neuropsychological testing of patients with borderline personality disorder. Am J Psychiatry 1991;148:106–11. [43] Swirsky-Sacchetti T, Gorton G, Samuel S, Sobel R, GenettaWadley A, Burleigh B. Neuropsychological function in borderline personality disorder. J Clin Psychol 1993;49:385–96. [44] Blumer D, Walker AE. Memory in temporal lobe epileptics. In: Talland G, Waugh N, editors. The pathology of memory. New York: Academic Press; 1969. p. 65–73. [45] Falk MC, Cole LC, Glosser G. Pseudoword and real word memory in unilateral temporal lobe epilepsy. J Clin Exp Neuropsychol 2002;24:327–34. [46] Wegesin DJ, Nelson CA. Effects of inter-item lag on recognition memory in seizure patients preceding temporal lobe resection: evidence from event-related potentials. Int J Psychophysiol 2000;37:243–55. [47] Abrahams S, Morris RG, Polkey CE, et al. Hippocampal involvement in spatial and working memory: a structural MRI analysis of patients with unilateral mesial temporal lobe sclerosis. Brain Cogn 1999;41:39–65. [48] Baxendale SA, Thompson PJ, Van Paesschen W. A test of spatial memory and its clinical utility in the pre-surgical investigation of temporal lobe epilepsy patients. Neuropsychologia 1998;36:591– 602. [49] Helmstaedter C, Pohl C, Hufnagel A, Elger CE. Visual learning deficits in nonresected patients with right temporal lobe epilepsy. Cortex 1991;27:547–55. [50] Genton P, Gelisse P. Premature death in juvenile myoclonic epilepsy. Acta Neurol Scand 2001;104:125–9. [51] Hansen LM, Trudeau DL, Grace DL. Neurotherapy and drug therapy in combination for adult ADHD, personality disorder, and seizure disorder: a case report. J Neurother 1996;2(1):6–14. [52] Schmid EM, Handleman MJ, Bidder TG. Seizure disorder misdiagnosed as borderline syndrome. Am J Psychiatry 1989; 146:400–1.
[53] Hellekson C, Buckland R, Price TR. Organic personality disturbance: a case of apparent atypical cyclic affective disorder. Am J Psychiatry 1979;136:833–5. [54] Freinhar JP, Alvarez WA. Clonazepam: a novel therapeutic adjunct. Int J Psychiatry Med 1985–1986;15:321–8. [55] Hollander E, Allen A, Lopez RP, et al. A preliminary doubleblind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001;62:199–203. [56] Pinto OC, Akiskal HS. Lamotrigine as a promising approach to borderline personality: an open case series without concurrent DSM-IV major mood disorder. J Affect Disord 1998;51:333–43. [57] Stein DJ, Simeon D, Frenkel M, Islam MN, Hollander E. An open trial of valproate in borderline personality disorder. J Clin Psychiatry 1995;56:506–10. [58] Teicher MH, Glod CA, Surrey J, Swett C. Early childhood abuse and limbic system ratings in adult psychiatric outpatients. J Neuropsychiatry Clin Neurosci 1993;5:301–6. [59] Lezak MD. Neuropsychological assessment. 3rd ed. New York: Oxford University Press; 1995. [60] Kolb B, Whishaw IQ. Fundamentals of human neuropsychology. 4th ed. New York: Freeman; 1996. [61] Taylor L. Localization of cerebral lesions by psychological testing. Clin Neurosurg 1969;16:269–87. [62] Savage CR, Baer L, Keuthen NJ, Brown HD, Rauch SL, Jenike MA. Organizational strategies mediate nonverbal memory impairment in obsessive–compulsive disorder. Biol Psychiatry 1999;45:905–16. [63] McIntyre M, Pritchard PB, Lombroso CT. Left and right temporal lobe epileptics: a controlled investigation of some psychological differences. Epilepsia 1976;17:377–86. [64] Trimble MR. Interictal psychoses of epilepsy. Acta Psychiatr Scand 1984;69:9–18. [65] Perini G. Emotions and personality in complex partial seizures. Psychother Psychosom 1986;45:141–8. [66] Perini G, Mendius R. Depression and anxiety in complex partial seizures. J Nerv Ment Dis 1984;172:287–90. [67] Gainotti G, Azzoni A, Bartocci A, Mazza S. Interictal psychopathology in temporal lobe epilepsy: the role of laterality of the epileptic focus. Funct Neurol 1986;1:225–33. [68] Manchanda R, Schaefer B, McLachlan RS, et al. Psychiatric disorders in candidates for surgery for epilepsy. J Neurol Neurosurg Psychiatry 1996;61:82–9. [69] Silberman EK, Post RM, Nurnberger J, Theodore W, Boulenger JP. Transient sensory, cognitive, and affective phenomena in affective illness: a comparison with complex partial epilepsy. Br J Psychiatry 1985;146:81–9.
Partial seizure-like symptoms in borderline personality disorder Catherine L. Harris,a Wayne M. Dinn,a,* and Jonathan A. Marcinkiewiczb a
Department of Psychology, Brain, Behavior and Cognition Program, Boston University, 64 Cummington Street, Boston, MA 02215, USA b Department of Psychiatry, Heywood Hospital, Gardner, MA, USA Received 26 March 2002; accepted 21 August 2002
Abstract The clinical presentation of borderline personality disorder (BPD) bears a striking resemblance to the behavioral alterations associated with temporal lobe epilepsy. Using the Limbic System Checklist-33, we found that BPD subjects reported more symptoms associated with partial seizures than did control subjects. BPD patients also exhibited deficits on immediate and delayed recall of the Rey–Osterrieth Complex Figure and produced distorted drawings of the Rey Figure. Their degree of impairment correlated with their report of temporolimbic symptoms. Results are consistent with the proposal that temporolimbic dysfunction underlies the behavioral dyscontrol and affective dysregulation present in BPD. Ó 2002 Elsevier Science (USA). All rights reserved. Keywords: Borderline personality disorder; Temporolimbic; Neuropsychological; Interictal; Partial seizures
1. Introduction The integrity of neural systems involved in affect regulation and impulse control may be compromised in borderline personality disorder (BPD). Clinical features include intense affect, rapidly shifting mood states, irritability, impulsivity and behavioral dyscontrol, unstable personal relationships, self-destructive behavior, brief psychotic episodes, dissociative states, and identity disturbance [1–9]. Episodes of uncontrollable rage are a particularly salient feature. Millon [6] suggested that the most striking characteristic of BPD patients is the intensity and variability of their emotions. The current article focuses on the proposal that temporolimbic dysfunction underlies the behavioral dyscontrol and affective dysregulation exhibited by BPD patients. The starting point for this proposal is the observation that diagnostic criteria for BPD resemble classic descriptions of the interictal behavioral syndrome (i.e., the temporal lobe personality). Patients with temporal lobe epilepsy (TLE) may present with diverse characteristics including explosive emotionality,
*
Corresponding author. E-mail address: [email protected] (W.M. Dinn).
unstable personal relationships, obsessionalism, dependence, hypergraphia, hyperreligiosity and philosophic interests, irritability, impulsivity, rage followed by self-recrimination, psychotic episodes, anxiety, depression, and dissociative states [10–22]. Bear [10] suggested that temporal lobe seizures generate a sensory–limbic hyperconnection syndrome. The intensification of emotion and volatile interactional style associated with TLE may reflect enhanced limbic responsivity. Patients with temporal lobe epilepsy demonstrate an increased incidence of mental disorders [23] and TLE is associated with a broad spectrum of neuropsychiatric symptoms/syndromes including affective illness [19,20,24–26], panic attacks [27,28], posttraumatic stress disorder [29], obsessive–compulsive disorder [30,31], and schizophrenia-like psychosis [19,32–34]. However, the contention that focal seizures originating in temporolimbic structures generate a well-defined neurobehavioral syndrome is controversial [35,36]. Several studies on temporal lobe epilepsy failed to observe the classic interictal behavioral profile, an increased incidence of psychopathology, or differences between patients with TLE and patients with other forms of epilepsy [36–40]. Nevertheless, a considerable body of research suggests that a significant subset of patients with TLE demonstrate behavioral alterations,
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including intense and unstable affect, behavioral dyscontrol, interpersonal viscosity and dependence, and volatile personal relationships. Patients with BPD demonstrate symptoms and behavioral phenomena associated with the interictal behavioral syndrome, including irritability, impulsivity, affective instability, paroxysmal rage, interpersonal viscosity and dependence, transient psychotic episodes, self-destructive behavior (e.g., self-mutilation) and multiple suicide attempts, and dissociative states. Behavioral changes associated with TLE resemble the clinical features of BPD. This raises the question of whether at least a subset of BPD patients have an undiagnosed seizure disorder (e.g., temporolimbic epilepsy). Cowdry and colleagues [41] documented an increased incidence of symptoms associated with complex partial seizures (CPS) among BPD subjects in comparison to psychiatric controls. Clearly, the relationship between BPD and temporolimbic seizure activity merits further study. While overlapping symptomatology does not establish a shared etiology, neurocognitive testing in BPD patients implicates the temporal lobes [42,43]. Medication-free BPD patients have demonstrated performance deficits on tests of complex memory function and visual discrimination [42]. Patients with temporal lobe epilepsy also exhibit performance deficits on tests assessing verbal or spatial memory [13,18,44,45]. TLE patients presenting with a left temporal lobe seizure focus demonstrate verbal memory deficits [45,46], while patients presenting with a right seizure focus exhibit performance deficits on tests of visual and spatial learning and memory function [45,47–49]. Several case reports have appeared describing patients with seizure disorders who also fulfilled diagnostic criteria for BPD [50–52] or presented with symptoms similar to those of BPD [53]. Schmid and colleagues [52] described the case history of a patient who originally received a BPD diagnosis; however, subsequent neurological examination revealed an atypical seizure disorder. Anticonvulsant drugs are frequently helpful in treating BPD patients even in the absence of documented seizures [54–57]. The present article tests the hypothesis that the emotional dysregulation and behavioral dyscontrol of at least some BPD patients may be associated with temporolimbic seizures and may represent interictal phenomena. A helpful step toward investigating the interictal hypothesis is to document whether BPD patients report an increased incidence of symptoms associated with temporal lobe epilepsy. We employed the Limbic System Checklist-33 [58] to assess these symptoms. In a follow-up study, we explored the relation between Limbic System Checklist scores and performance on a neuropsychological task considered sensitive to temporal lobe dysfunction among BPD patients and control subjects.
2. Study I 2.1. Method Subjects were 25 consecutive admissions to an acute care inpatient psychiatric ward at a general hospital (Heywood Memorial Hospital) who met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic criteria for borderline personality disorder (BPD) [1]. The BPD group comprised 16 female and 9 male inpatients. Their ages ranged from 19 to 48 years (mean SD ¼ 30:2 8:1). A psychiatric control group consisted of 12 consecutive admissions who met DSMIV criteria for major depressive disorder (MDD). The MDD group comprised 7 female and 5 male inpatients. Their ages ranged from 17 to 49 years (mean SD ¼ 32:6 10:4). Diagnoses were made by a board-certified psychiatrist experienced in the differential diagnosis of Axis II disorders. A second psychiatric control group consisted of 10 consecutively evaluated outpatients seen at an anxiety disorders clinic. The anxiety disorders group comprised 5 male and 5 female outpatients diagnosed with panic disorder (n ¼ 5), posttraumatic stress disorder (n ¼ 2), and obsessive–compulsive disorder (n ¼ 3). Their ages ranged from 21 to 51 years (mean SD ¼ 35:8 11:3). Diagnoses were made by a licensed clinical psychologist. A nonpatient control group (n ¼ 25) comprised 16 female and 9 male hospital employees and their ages ranged from 20 to 48 years (mean SD ¼ 31:3 7:7). After giving informed consent, subjects completed the Limbic System Checklist-33 [58]. The Limbic System Checklist is a 33-item, self-report symptom inventory developed by Teicher and colleagues [58]. Respondents indicate how frequently they experience symptoms suggestive of partial seizures that arise in temporolimbic structures, including ‘‘paroxysmal somatic disturbances, brief hallucinatory events, visual disturbances, automatisms, and dissociative disturbances’’ [58, p. 302]. Ictal phenomena include: Somatosensory symptoms (e.g., ‘‘How often have you experienced the sudden, abrupt, and unexplained onset of sensation of something crawling under your skin? or ‘‘a rising or sinking feeling in your stomach—like you were in an elevator?’’). Complex stereotyped motor behavior (e.g., ‘‘How frequently have you had unexplained or uncontrolled episodes in which you experienced or engaged in complex automatic behavior—such as purposeless running in circles, closing windows, or picking at your clothes?’’). Olfactory or visual hallucinations (e.g., ‘‘How often have you experienced, for no particular reason, smelling an odor such as ammonia, burning rubber, decaying waste, or garbage?’’ or ‘‘seeing fully formed images— such as a person in a doorway, a demon, a God-like image?’’).
C.L. Harris et al. / Epilepsy & Behavior 3 (2002) 433–438 Table 1 Study I: Limbic System Checklist-33 Group
n
Mean
SD
Range
BPD MDD AD Control
25 12 10 25
46.6 21.7 18.4 16.5
19.3 6.5 6.7 7.5
15–89 13–36 10–32 1–31
Note. BPD, borderline personality disorder; MDD, major depressive disorder; AD, anxiety disorders; Control, nonpatient volunteers.
Perceptual distortions (e.g., ‘‘How frequently have you had the visual illusion that an object or person suddenly became distorted or transformed’’ or ‘‘an object or person suddenly looked smaller, farther away, or out of reach?’’). Distortions of consciousness (e.g., ‘‘How often have you experienced the sensation that your mind has left your body, or that you are watching yourself as a detached observer’’ or ‘‘how often have you experienced the sudden feeling that you are no longer real, or not the same person?’’). The Limbic System Checklist possesses adequate psychometric properties [58]. The checklist showed acceptable construct validity and demonstrated high test– retest reliability. 2.2. Results As shown in Table 1, the BPD group had the highest mean score on the Limbic System Checklist. This mean score was significantly greater than the mean of the next highest scoring group, inpatients with major depressive disorder, F ð1; 35Þ ¼ 18:5, P < 0:0001. Limbic System Checklist scores did not differ between the nonpatient control, anxiety disorder, and major depressive disorder groups, as verified by a one-way analysis of variance, F ð2; 44Þ ¼ 2:1, P > 0:12. Scores did not vary as a function of gender (mean for males ¼ 27.6; mean for females ¼ 28.4; tð70Þ ¼ 0:174, P > 0:85) or age (r ¼ 0:05, ns). The BPD group mean on the Limbic System Checklist was more than double the psychiatric and control group means. This is consistent with the hypothesis that BPD symptoms reflect interictal behavioral changes secondary to recurrent partial seizures. However, BPD symptoms may have a distinct etiology unrelated to temporolimbic seizures. It would be useful to correlate performance on the Limbic System Checklist with an established measure of temporal lobe dysfunction.
3. Study II In Study II, we replicated our finding of an increased incidence of seizure-like symptoms among BPD patients, and examined the relationship between Limbic
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System Checklist scores and performance on the Rey– Osterrieth Complex Figure (ROCF) test, a neuropsychological measure considered sensitive to temporal lobe dysfunction. During the ROCF test, participants copy a complex geometric figure consisting of 18 separate elements [59]. Subjects are then required to reproduce the figure from memory after 1- and 30-min delays. Impaired performance on the ROCF may reflect visuoconstructive, executive function, and nonverbal memory deficits. Poor performance on the recall components of the ROCF test has been associated with right temporal lobe dysfunction [60,61]. Efficient copy performance depends on the use of organizational strategies. Thus, performance deficits may reflect a failure to impose efficient organizational strategies at encoding (implicating frontal-executive circuitry) [62] or a retention/retrieval deficit (implicating temporolimbic systems). 3.1. Method Subjects were 15 consecutive admissions (10 female and 5 male) to an acute care inpatient psychiatric ward at Heywood Memorial Hospital who fulfilled DSM-IV diagnostic criteria for BPD [1]. Their ages ranged between 19 and 42 years (mean SD ¼ 31:1 6:4). Diagnoses were made by a board-certified psychiatrist experienced in the differential diagnosis of Axis II disorders. Fifteen control subjects were recruited from the general population via flyers seeking individuals interested in participating in research examining the neuropsychology of personality. Control subjects (10 females and 5 males) were matched to BPD subjects for educational level, handedness, and gender. Their ages ranged between 18 and 40 years (mean SD ¼ 29:4 5:5). None of the subjects participated in Study I. After obtaining informed consent, we administered the Limbic System Checklist and the ROCF. We employed the 36point itemized scoring system described by Lezak [59] to evaluate constructional accuracy. Drawings were scored by raters blind to subjectsÕ clinical status. 3.2. Results Independent-sample t tests were performed to assess between-group differences. Effect sizes (Omega2 ) were calculated to ascertain the strength of group differences. As shown in Table 2, participants with BPD obtained significantly lower copy accuracy scores in comparison to controls, with tð28Þ ¼ 4:34, P < 0:001, effect size ¼ 0.37. The BPD patient group also exhibited significant deficits on immediate (1-min) and delayed (30-min) recall of the Rey–Osterrieth Complex Figure relative to control subjects, with tð28Þ ¼ 3:30, P < 0:003, effect size ¼ 0.24, and tð28Þ ¼ 5:61, P < 0:001, effect size ¼ 0.50, respectively. Analysis of Limbic System Checklist scores also revealed marked group differences. The BPD group
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Table 2 Study II: Limbic System Checklist-33 and the Rey–Osterrieth Complex Figure task
n LSCL ROCF copy ROCF 1-min 30-min
BPD
Control
t
P
esa
15 50.1 (17.4)b 31.3 (3.9)
15 23.2 (9.4) 35.9 (0.3)
5.23 )4.34
0.001 0.001
0.46 0.37
15.6 (9.1) 12.2 (4.5)
24.6 (5.2) 23.4 (6.2)
)3.30 )5.61
0.003 0.001
0.24 0.50
Note. LSCL, Limbic System Checklist-33; ROCF, Rey–Osterrieth Complex Figure test; BPD, borderline personality disorder; Control, control subjects recruited from the general population. a Effect size (Omega2 ). b Mean (SD).
differed significantly from the nonpatient control group, tð28Þ ¼ 5:23, P < 0:001, effect size ¼ 0.46. In addition, Limbic System Checklist scores correlated strongly with performance on the immediate and delayed recall components of the ROCF among BPD subjects, with r ¼ 0:63, P < 0:05, and r ¼ 0:70, P < 0:05.
4. General discussion BPD patients scored significantly higher on a selfreport measure of temporolimbic dysfunction and exhibited performance deficits on the Rey–Osterrieth Complex Figure test in comparison to psychiatric and nonclinical control subjects. Poor performance on the recall components of the Rey–Osterrieth task is associated with right temporal lobe dysfunction [60,61]. Performance on the ROCF correlated strongly with Limbic System Checklist scores. Results suggest that items on the Limbic System Checklist may reflect nondominant temporal lobe dysfunction. In Studies I and II, Limbic System Checklist scores obtained by BPD patients were comparable to scores obtained by patients with temporal lobe epilepsy (TLE) reported in Teicher et al. [58]. The impaired visuoconstructive and nonverbal recall skills of these BPD patients suggest right-hemisphere dysfunction. Interestingly, behavioral effects associated with TLE vary according to the hemisphere of seizure focus. Epilepsy with a right temporal lobe focus is associated with affective instability and impulsivity [25,63,64]. Seizures originating in left temporal regions are associated with a schizophrenia-like psychosis [19,32,64] and depressive and anxiety symptoms [24,65,66]. However, not all studies have found that seizure focus (i.e., right vs left hemisphere focus) is associated with a specific personality syndrome or distinct patterns of interictal psychopathology [67,68]. How specific is the relation between BPD and partial seizure-like phenomena? It is worth comparing our results with a prior study that investigated cognitive and sensory distortions in mood disorder and epilepsy patients. Silberman et al. [69] interviewed patients with
affective illness, patients presenting with complex partial seizures (CPS), and control subjects free of psychiatric and neurologic disease. They conducted structured psychiatric interviews during which subjects indicated the frequency with which they experienced symptoms associated with CPS. Both mood disorder and epilepsy patients demonstrated an increased incidence of CPS-like symptoms relative to control subjects. However, there were notable differences in the symptom profiles of epilepsy and mood disorder patients. Epilepsy patients reported a significantly greater number of classic CPS symptoms relative to control subjects, including motor automatisms; speech arrest; vestibular, gustatory, and epigastric hallucinations; tactile distortions; amnestic episodes; time disorientation; and body part dissociation [69]. The incidence of the aforementioned symptoms was not significantly greater among mood disorder patients in comparison to control subjects, although group differences for epigastric hallucinations and amnestic episodes did approach significance (P < 0:1). Mood disorder patients reported an increased incidence of CPS-like symptoms relative to controls, including speeded thoughts; slowed thoughts; sudden, intense, unexplained depression, pleasurable sensations, and sexual sensations; formed visual hallucinations; autoscopic states; and altered sound quality. The incidence of these symptoms was not significantly greater among epilepsy patients than among control subjects. Relative to controls, both affective and epilepsy patients reported an increased incidence of the following symptoms: illusions of significance; jumbled thoughts; altered sound and color intensity; and olfactory hallucinations. Patients with affective illness demonstrated an increased incidence of CPS-like symptoms relative to control subjects, including derealization, metamorphopsia, epigastric hallucinations, and amnestic episodes; however, group differences were not statistically significant (P < 0:1). In our study, BPD patients reported a greater number of classic partial seizure-like symptoms relative to mood disorder, anxiety disorder, and nonclinical control subjects. That is, their symptom profile resembled the profile of patients presenting with EEG-verified CPS
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described in Silberman et al. [69], rather than the profile exhibited by patients with affective illness.
5. Conclusion In the present study, BPD patients achieved higher scores on the Limbic System Checklist relative to psychiatric and nonpatient controls. Of course, overlapping symptomatology does not necessarily imply a common etiology and we are not suggesting that we have obtained evidence of partial seizure activity among BPD patients. An alternative explanation is that partial seizure-like symptoms among BPD patients mirror classic symptoms of TLE, but possess a distinct etiology. However, the fact that BPD patients, in two separate studies, achieved relatively high scores on the Limbic System Checklist is noteworthy. One hypothesis to be tested is that the explosive emotionality and behavioral dyscontrol displayed by BPD patients are, at least in some cases, associated with temporolimbic dysfunction and may possibly represent interictal phenomena.
References [1] Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. [2] Gunderson J. Empirical studies of the borderline diagnosis. In: Grinspoon L, editor. Psychiatry, vol. 1. Washington, DC: American Psychiatric Press; 1982. p. 414–37. [3] Gunderson J. Borderline personality disorder. Washington, DC: APA Press; 1984. [4] Gunderson J, Kolb J. Discriminating features of borderline patients. Am J Psychiatry 1978;135:792–6. [5] Gunderson J, Singer M. Defining borderline patients: an overview. Am J Psychiatry 1975;132:1–10. [6] Millon T. Disorders of personality: DSM-III, axis-II. New York: Wiley–Interscience; 1981. [7] Pollack WS. Psychotherapy. In: Bellack AS, Hersen M, editors. Handbook of comparative treatments for adult disorders. New York: Wiley; 1990. p. 393–419. [8] Stone MH. Toward a psychobiological theory of borderline personality disorder: is irritability the red thread that runs through borderline conditions? Dissociation Progr Dissociative Disord 1988;1(2):2–15. [9] Rusch KM, Guastello SJ, Mason PT. Differentiating symptom clusters of borderline personality disorder. J Clin Psychol 1992;48:730–8. [10] Bear DM. Temporal lobe epilepsy: a syndrome of sensory–limbic hyperconnection. Cortex 1979;15:357–84. [11] Bear DM, Fedio P. Quantitative analysis of interictal behavior in temporal lobe epilepsy. Arch Neurol 1977;34:454–67. [12] Waxman SG, Geschwind N. Hypergraphia in temporal lobe epilepsy. Neurology 1974;24:629–36. [13] Blumer D. Temporal lobe epilepsy and its psychiatric significance. In: Benson DF, Blumer D, editors. Psychiatric aspects of neurologic disease. New York: Grune & Stratton; 1975. p. 171–98. [14] Blumer D. Evidence supporting the temporal lobe personality syndrome. Neurology 1999;53(5, Suppl 2):S9–S12. [15] Geschwind N. Behavioral changes in temporal lobe epilepsy. Psychol Med 1979;9:217–9.
437
[16] Waxman SG, Geschwind N. The interictal behavior syndrome of temporal lobe epilepsy. Arch Gen Psychiatry 1975;32: 1580–6. [17] Bear D, Levin K, Blumer D, Chetham D, Ryder J. Interictal behaviour in hospitalised temporal lobe epileptics: relationship to idiopathic psychiatric syndromes. J Neurol Neurosurg Psychiatry 1982;45:481–8. [18] Bear DM, Freeman R, Greenberg M. Behavioral alterations in temporal lobe epilepsy. In: Blumer D, editor. Psychiatric aspects of epilepsy. Washington, DC: American Psychiatric Press; 1984. p. 197–227. [19] Flor-Henry P. Schizophrenic-like reactions and affective psychoses associated with temporal lobe epilepsy: etiological factors. Am J Psychiatry 1969;126:148–52. [20] Perini G, Tosin C, Carraro C, Bernasconi G. Interictal mood and personality disorders in temporal lobe epilepsy and juvenile myoclonic epilepsy. J Neurol Neurosurg Psychiatry 1996;61:601– 5. [21] Schenk L, Bear D. Multiple personality and related dissociative phenomena in patients with temporal lobe epilepsy. Am J Psychiatry 1981;138:1311–26. [22] Spiers PA, Schomer DL, Blume HW, Hochanadel GS. Behavioral alterations in temporolimbic epilepsy. In: Bennett TL, editor. The neuropsychology of epilepsy: critical issues in neuropsychology. New York: Plenum Press; 1992. p. 97–138. [23] Glosser G, Zwil AS, Glosser DS, OÕConnor MJ, Sperling MR. Psychiatric aspects of temporal lobe epilepsy before and after anterior temporal lobectomy. J Neurol Neurosurg Psychiatry 2000;68:53–8. [24] Carrieri PB, Provitera V, Iacovitti B, Iachetta C, Nappi C, Indaco A. Mood disorders in epilepsy. Acta Neurol 1993;15:62–7. [25] Gillig P, Sackellares JC, Greenberg HS. Right hemisphere partial complex seizures: mania, hallucinations, and speech disturbances during ictal events. Epilepsia 1988;29:26–9. [26] Himmelhoch JM. Major mood disorders related to epileptic changes. In: Blumer D, editor. Psychiatric aspects of epilepsy. Washington, DC: American Psychiatric Press; 1984. [27] Meyer MA, Zimmerman AW, Miller CA. Temporal lobe epilepsy presenting as panic attacks: detection of interictal hypometabolism with positron emission tomography. J Neuroimaging 2000;10:120–2. [28] Wall M, Tuchman M, Mielke D. Panic attacks and temporal lobe seizures associated with a right temporal lobe arteriovenous malformation: case report. J Clin Psychiatry 1985;46:143–5. [29] Bennett TL, Curiel MP. Complex partial seizures presenting as a psychiatric illness: a case study. Int J Clin Neuropsychol 1988;10:41–4. [30] Kanner AM, Morris HH, Stagno S, Chelune G, Lunders H. Remission of an obsessive–compulsive disorder following a right temporal lobectomy. Neuropsychiatry Neuropsychol Behav Neurol 1993;6:126–9. [31] Kroll L, Drummond LM. Temporal lobe epilepsy and obsessive– compulsive symptoms. J Nerv Ment Dis 1993;181:457–8. [32] Sherwin I. The effect of the location of an epileptogenic lesion on the occurrence of psychosis in epilepsy. Adv Biol Psychiatry 1982;8:81–97. [33] Shukla GD, Srivastava ON, Katiyar BC, Joshi V, Mohan PK. Psychiatric manifestations in temporal lobe epilepsy: a controlled study. Br J Psychiatry 1979;135:411–7. [34] Stoudemire A, Nelson A, Houpt JL. Interictal schizophrenia-like psychoses in temporal lobe epilepsy. Psychosomatics 1983;24:331– 9. [35] Devinsky O, Najjar S. Evidence against the existence of a temporal lobe epilepsy personality syndrome. Neurology 1999;53(5, Suppl 2):S13–25. [36] Dodrill CB, Batzel LW. Interictal behavioral features of patients with epilepsy. Epilepsia 1986;27(Suppl 2):S64–76.
438
C.L. Harris et al. / Epilepsy & Behavior 3 (2002) 433–438
[37] Hermann BP, Riel P. Interictal personality and behavioral traits in temporal lobe and generalized epilepsy. Cortex 1981;17:125–8. [38] Mungas D. Interictal behavior abnormality in temporal lobe epilepsy: a specific syndrome or nonspecific psychopathology? Arch Gen Psychiatry 1982;39:108–11. [39] Rodin E, Schmaltz S. The Bear–Fedio personality inventory and temporal lobe epilepsy. Neurology 1984;34:591–6. [40] Stevens JR. Psychiatric implications of psychomotor epilepsy. Arch Gen Psychiatry 1966;14:461–71. [41] Cowdry RW, Pickar D, Davies R. Symptoms and EEG findings in the borderline syndrome. Int J Psychiatry Med 1985–1986;15:201– 11. [42] OÕLeary KM, Brouwers P, Gardner DL, Cowdry RW. Neuropsychological testing of patients with borderline personality disorder. Am J Psychiatry 1991;148:106–11. [43] Swirsky-Sacchetti T, Gorton G, Samuel S, Sobel R, GenettaWadley A, Burleigh B. Neuropsychological function in borderline personality disorder. J Clin Psychol 1993;49:385–96. [44] Blumer D, Walker AE. Memory in temporal lobe epileptics. In: Talland G, Waugh N, editors. The pathology of memory. New York: Academic Press; 1969. p. 65–73. [45] Falk MC, Cole LC, Glosser G. Pseudoword and real word memory in unilateral temporal lobe epilepsy. J Clin Exp Neuropsychol 2002;24:327–34. [46] Wegesin DJ, Nelson CA. Effects of inter-item lag on recognition memory in seizure patients preceding temporal lobe resection: evidence from event-related potentials. Int J Psychophysiol 2000;37:243–55. [47] Abrahams S, Morris RG, Polkey CE, et al. Hippocampal involvement in spatial and working memory: a structural MRI analysis of patients with unilateral mesial temporal lobe sclerosis. Brain Cogn 1999;41:39–65. [48] Baxendale SA, Thompson PJ, Van Paesschen W. A test of spatial memory and its clinical utility in the pre-surgical investigation of temporal lobe epilepsy patients. Neuropsychologia 1998;36:591– 602. [49] Helmstaedter C, Pohl C, Hufnagel A, Elger CE. Visual learning deficits in nonresected patients with right temporal lobe epilepsy. Cortex 1991;27:547–55. [50] Genton P, Gelisse P. Premature death in juvenile myoclonic epilepsy. Acta Neurol Scand 2001;104:125–9. [51] Hansen LM, Trudeau DL, Grace DL. Neurotherapy and drug therapy in combination for adult ADHD, personality disorder, and seizure disorder: a case report. J Neurother 1996;2(1):6–14. [52] Schmid EM, Handleman MJ, Bidder TG. Seizure disorder misdiagnosed as borderline syndrome. Am J Psychiatry 1989; 146:400–1.
[53] Hellekson C, Buckland R, Price TR. Organic personality disturbance: a case of apparent atypical cyclic affective disorder. Am J Psychiatry 1979;136:833–5. [54] Freinhar JP, Alvarez WA. Clonazepam: a novel therapeutic adjunct. Int J Psychiatry Med 1985–1986;15:321–8. [55] Hollander E, Allen A, Lopez RP, et al. A preliminary doubleblind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001;62:199–203. [56] Pinto OC, Akiskal HS. Lamotrigine as a promising approach to borderline personality: an open case series without concurrent DSM-IV major mood disorder. J Affect Disord 1998;51:333–43. [57] Stein DJ, Simeon D, Frenkel M, Islam MN, Hollander E. An open trial of valproate in borderline personality disorder. J Clin Psychiatry 1995;56:506–10. [58] Teicher MH, Glod CA, Surrey J, Swett C. Early childhood abuse and limbic system ratings in adult psychiatric outpatients. J Neuropsychiatry Clin Neurosci 1993;5:301–6. [59] Lezak MD. Neuropsychological assessment. 3rd ed. New York: Oxford University Press; 1995. [60] Kolb B, Whishaw IQ. Fundamentals of human neuropsychology. 4th ed. New York: Freeman; 1996. [61] Taylor L. Localization of cerebral lesions by psychological testing. Clin Neurosurg 1969;16:269–87. [62] Savage CR, Baer L, Keuthen NJ, Brown HD, Rauch SL, Jenike MA. Organizational strategies mediate nonverbal memory impairment in obsessive–compulsive disorder. Biol Psychiatry 1999;45:905–16. [63] McIntyre M, Pritchard PB, Lombroso CT. Left and right temporal lobe epileptics: a controlled investigation of some psychological differences. Epilepsia 1976;17:377–86. [64] Trimble MR. Interictal psychoses of epilepsy. Acta Psychiatr Scand 1984;69:9–18. [65] Perini G. Emotions and personality in complex partial seizures. Psychother Psychosom 1986;45:141–8. [66] Perini G, Mendius R. Depression and anxiety in complex partial seizures. J Nerv Ment Dis 1984;172:287–90. [67] Gainotti G, Azzoni A, Bartocci A, Mazza S. Interictal psychopathology in temporal lobe epilepsy: the role of laterality of the epileptic focus. Funct Neurol 1986;1:225–33. [68] Manchanda R, Schaefer B, McLachlan RS, et al. Psychiatric disorders in candidates for surgery for epilepsy. J Neurol Neurosurg Psychiatry 1996;61:82–9. [69] Silberman EK, Post RM, Nurnberger J, Theodore W, Boulenger JP. Transient sensory, cognitive, and affective phenomena in affective illness: a comparison with complex partial epilepsy. Br J Psychiatry 1985;146:81–9.