Sleep-Wake Patterns of Adolescents with Borderline Personality Disorder and Bipolar Disorder

Physical Activity, Sleep and Eating in Young People With Borderline Personality Disorder

Previous research suggests a connection between borderline personality disorder (BPD) and somatic comorbidities, underscoring the importance of lifestyle and health-related behaviour (LHRB) in the emergence of BPD. We investigated LHRBs-physical activity, sleeping and overeating-among young people at different BPD stages compared to a matched community sample. Furthermore, we explored whether problematic LHRBs intensify in later BPD stages. Participants included 55 young people exhibiting BPD features from a specialized mental health care institution, matched with a community control group based on age, self-reported and education. A MANOVA assessed differences in physical activity, sleep disturbance, sleep-related impairment and emotional overeating between the BPD and control group. A second MANOVA explored these behaviours across BPD stages within the clinical group. Results revealed significantly higher levels of sleep-related problems among young people with BPD features compared to controls. However, no significant differences were found in physical activity or emotional overeating. Furthermore, problematic LHRBs did not show a significant association with BPD stage. These findings contribute to a better understanding of the relationship between BPD and problematic LHRBs, emphasizing the importance of early intervention targeting sleep-related problems in young people with BPD, alongside addressing other aspects of BPD and associated LHRBs.

Imagery rehearsal therapy for the treatment of nightmares in individuals with borderline personality disorder - A pilot study

Insomnia and nightmares are present in up to 45 % of individuals with borderline personality disorder (BPD) and can contribute to challenges with emotion regulation, low sleep quality, dream anxiety, increased arousal and self-control. Despite their prevalence, nightmares are usually not addressed in classical BPD treatment. Imagery rehearsal therapy (IRT) is considered first in line treatment for nightmares, however, there are no studies to date that investigate its effects in individuals with BPD. Here we investigated a) whether IRT can be used to treat nightmares in individuals with BPD and b) whether there is an additional benefit of the intervention on symptoms associated with BPD. In a between-subjects design, 22 individuals with BPD completed eight sessions of group-IRT as an add-on to their inpatient treatment and were compared to 22 gender and age matched control participants regarding nightmares, trauma, depression and anxiety symptoms. Nightmare symptoms improved significantly during the intervention as indicated by subjective ratings. Moreover, participants in the IRT group showed a more pronounced decrease in intrusions, hyperarousal and anxiety compared to the control group. This pilot study gives a first glimpse into the feasibility and benefits of imagery rehearsal therapy in individuals with BPD. Our findings suggest that IRT may not only help treat nightmare symptoms but also reduce anxiety and trauma symptoms in BPD. Future studies should include randomized controlled trials of IRT in individuals with BPD with larger sample sizes and polysomnography in both groups.

The influence of sleep on emotion dysregulation in borderline personality disorder, generalized anxiety disorder, and healthy controls

Emotion dysregulation is central to borderline personality disorder (BPD) and exacerbated by sleep disruptions. This study investigated whether homeostatic (i.e., sleep efficiency), circadian (i.e., chronotype), and subjective (i.e., sleep quality) sleep elements predict emotion dysregulation in BPD, healthy controls (HCs), and a generalized anxiety disorder (GAD) group. Participants (N = 120) with BPD, GAD, and HCs completed daily sleep measures for seven days prior to an experiment wherein baseline emotion, emotional reactions to stressors (i.e., reactivity), and the extent to which they can decrease their emotion using mindfulness and distraction (i.e., emotion regulation) were measured across self-reported, sympathetic, and parasympathetic emotion. Across groups, earlier chronotypes and higher sleep quality predicted less self-reported baseline negative emotion, and higher sleep quality predicted better parasympathetic emotion regulation. For HCs, higher sleep efficiency and lower sleep quality predicted higher parasympathetic baseline emotion, and higher sleep efficiency predicted more self-reported baseline negative emotion. Also in HCs, earlier chronotype predicted better sympathetic emotion regulation, and there was a quadratic relationship between sleep efficiency and self-reported emotion regulation. Optimizing sleep quality and improving alignment between chronotype and daily living may improve baseline emotion and emotion regulation. Healthy individuals may be particularly vulnerable to high or low sleep efficiency.

The Impact of Homeostatic and Circadian Sleep Processes on Non-Suicidal Self-Injury and Suicide Urges in Borderline Personality Disorder

OBJECTIVE

Borderline personality disorder (BPD) involves high rates of non-suicidal self-injury (NSSI) and suicidal behaviors, which are often preceded by urges. Disrupted sleep processes have been linked to NSSI and suicidal behaviors. However, it is unclear which specific sleep processes influence NSSI and suicide urges at rest (i.e., baseline) or in response to distress (i.e., reactivity) in BPD, and thus require targeting in BPD-specific interventions. This study examined whether two distinct homeostatic sleep processes (i.e., total sleep time [TST] and time in bed [TIB]), and one circadian sleep process (i.e., chronotype, or tendencies toward early versus late bed and rise times) predict baseline NSSI and suicide urges and urge reactivity in BPD.

METHODS

Forty adults with BPD completed a seven-day sleep diary to measure average TST and TIB. They then completed a questionnaire to measure chronotype and underwent an experiment wherein they rated NSSI and suicide urges at baseline and following an emotion induction.

RESULTS

Generalized estimating equations revealed that higher TST was associated with lower baseline NSSI urges, and lower suicide urge reactivity. Additionally, higher TIB predicted higher NSSI urge reactivity.

CONCLUSIONS

Sleep deprivation and extended time in bed may increase proclivity toward NSSI and/or suicide. Targeting these variables in BPD interventions may ultimately facilitate the reduction of NSSI and suicidal acts. HighlightsHigher total sleep time predicts lower baseline NSSI urges, suicide urge reactivityHigher time in bed predicts higher NSSI urge reactivityReducing sleep deprivation in BPD may facilitate reductions in suicide, NSSI urges.

A systematic review and meta-analysis of sleep and circadian rhythms disturbances in individuals at high-risk of developing or with early onset of bipolar disorders

Sleep and circadian rhythms disturbances (SCRD) in young people at high risk or with early onset of bipolar disorders (BD) are poorly understood. We systematically searched for studies of self, observer or objective estimates of SCRD in asymptomatic or symptomatic offspring of parents with BD (OSBD), individuals with presentations meeting recognised BD-at-risk criteria (BAR) and youth with recent onset of full-threshold BD (FT-BD). Of 76 studies eligible for systematic review, 35 (46%) were included in random effects meta-analyses. Pooled analyses of self-ratings related to circadian rhythms demonstrated greater preference for eveningness and more dysregulation of social rhythms in BAR and FT-BD groups; analyses of actigraphy provided some support for these findings. Meta-analysis of prospective studies showed that pre-existing SCRD were associated with a 40% increased risk of onset of BD, but heterogeneity in assessments was a significant concern. Overall, we identified longer total sleep time (Hedges g: 0.34; 95% confidence intervals:.1, .57), especially in OSBD and FT-BD and meta-regression analysis indicated the effect sizes was moderated by the proportion of any sample manifesting psychopathology or receiving psychotropic medications. This evolving field of research would benefit from greater attention to circadian rhythm as well as sleep quality measures.

Potential mechanisms underlying sleep disturbance in young people with borderline personality disorder features: an exploratory study

BACKGROUND

Sleep disturbance is common among young people (15-25 years) with features of borderline personality disorder (BPD). However, the mechanisms underlying sleep disturbance in BPD remain unknown. Understanding these underlying processes is essential to guide the development of sleep-improvement interventions and to optimise their efficacy through identifying beneficial treatment targets. This exploratory study aimed to investigate potential underlying mechanisms to inform future hypotheses, research development, and provide insight into potential treatment targets to improve sleep in young people with BPD. This study explored the indirect roles of emotion regulation difficulties, depression, anxiety and stress in the relationship between BPD features and sleep disturbance in young people.

METHODS

Sleep was measured subjectively (self-report questionnaires) and objectively (10 days wrist actigraphy) in 40 young people with BPD features and 38 healthy young people. Participants also completed the Difficulties in Emotion Regulation Scale and the Depression, Anxiety and Stress Scale.

RESULTS

Mediation analyses revealed that impulse control difficulties, limited emotion regulation strategies and anxiety indirectly affected the relationship between group (BPD vs. healthy) and subjective sleep disturbance in young people. Lack of emotional awareness and anxiety contributed to associations between group and objectively longer time in bed and bedtime variability, respectively.

CONCLUSIONS

These preliminary findings suggest that targeting emotional dysregulation (impulse control, strategies, emotional awareness) and anxiety might be beneficial for improving sleep in this population.

Interactions between Sleep and Emotions in Humans and Animal Models

Recently, increased interest and efforts were observed in describing the possible interaction between sleep and emotions. Human and animal model studies addressed the implication of both sleep patterns and emotional processing in neurophysiology and neuropathology in suggesting a bidirectional interaction intimately modulated by complex mechanisms and factors. In this context, we aimed to discuss recent evidence and possible mechanisms implicated in this interaction, as provided by both human and animal models in studies. In addition, considering the affective component of brain physiological patterns, we aimed to find reasonable evidence in describing the two-way association between comorbid sleep impairments and psychiatric disorders. The main scientific literature databases (PubMed/Medline, Web of Science) were screened with keyword combinations for relevant content taking into consideration only English written papers and the inclusion and exclusion criteria, according to PRISMA guidelines. We found that a strong modulatory interaction between sleep processes and emotional states resides on the activity of several key brain structures, such as the amygdala, prefrontal cortex, hippocampus, and brainstem nuclei. In addition, evidence suggested that physiologically and behaviorally related mechanisms of sleep are intimately interacting with emotional perception and processing which could advise the key role of sleep in the unconscious character of emotional processes. However, further studies are needed to explain and correlate the functional analysis with causative and protective factors of sleep impairments and negative emotional modulation on neurophysiologic processing, mental health, and clinical contexts.

Sleep in Young People With Features of Borderline Personality Disorder: A Scoping Review

Sleep disturbance is commonly reported in young people with features of borderline personality disorder (BPD). Examining sleep quality and sleep-wake patterns in young people with features of BPD is essential to inform the development of sleep-improvement interventions. A scoping review was conducted according to the Joanna Briggs Institute methodology. The objectives were to map the literature regarding sleep in young people with features of BPD, highlight areas for further investigation, and provide methodological recommendations for future research. Seven data sets were included in the review. Young people with features of BPD had poorer objective and subjective sleep quality, disturbed sleep architecture (particularly rapid-eye-movement sleep), an increased vulnerability to delayed sleep phase syndrome, and more nightmares and dream anxiety, compared with healthy individuals. Future research should use both objective and subjective sleep measures, include clinical comparison groups, and focus specifically on young people with BPD.

Cardiovascular reactivity as a measure of irritability in a transdiagnostic sample of youth: Preliminary associations

OBJECTIVES

Irritability is a transdiagnostic symptom in developmental psychopathology, conceptualized as a low threshold for frustration and increased proneness to anger. While central to emotion regulation, there is a vital need for empirical studies to explore the relationship between irritability and underlying physiological mechanisms of cardiovascular arousal.

METHODS

We examined the relationship between irritability and cardiovascular arousal (i.e., heart rate [HR] and heart rate variability [HRV]) in a transdiagnostic sample of 51 youth (M = 12.63 years, SD = 2.25; 62.7% male). Data was collected using the Empatica E4 during a laboratory stop-signal task. In addition, the impact of motion activity, age, medication, and sleep on cardiovascular responses was explored.

RESULTS

Main findings showed that irritability was associated with increased HR and decreased HRV during task performance.

CONCLUSIONS

Findings support the role of peripheral physiological dysregulation in youth with emotion regulation problems and suggest the potential use of available wearable consumer electronics as an objective measure of irritability and physiological arousal in a transdiagnostic sample of youth.

Prevalence and comorbidity of borderline personality traits in the Quebec general population aged 12-14 years

PURPOSE

The early identification of borderline personality traits (BPT) in adolescents helps to prevent their progression. Data are available for the clinical population, but little has been published on the general population, especially regarding age and sex distribution in adolescence. Even less is known about the comorbidity of BPT with other mental disorders.

METHODS

We estimated the prevalence of BPT, by sex, age, and comorbidity, in a sample of adolescents aged 12-14 years (n = 799) from the Quebec Mental Health Survey. A complex sampling design was used to ensure representativeness. BPT was assessed with the abbreviated-diagnostic interview for borderlines-revised, with the adolescent as an informant. Reliability coefficients were above 0.80. Several levels of severity were explored using an independent criterion, defined by impairment according to the Columbia impairment scale.

RESULTS

The overall prevalence of BPT was 6.3%. Prevalence estimates for the most impaired were 3.2% for the entire sample and 1.3% for 12-year-olds. Prevalence increased significantly with age for most impairment levels but did not differ significantly between the sexes. In adolescents, BPT displayed moderate-to-strong comorbidity with anxiety (AD) and insomnia disorders, and very strong comorbidity with depressive (DD), attention deficit hyperactivity (ADHD), and oppositional defiant/conduct disorders (ODD/CD).

CONCLUSION

We, therefore, make two clinical recommendations for child psychiatry practice: (1) with respect to the lower rate of male adolescents attending BPT Health Programs, increase BPT screening in male adolescents; (2) evaluate BPT when children with ADHD or ODD/CD develop AD or DD during adolescence.

Subjective and objective sleep in young people with borderline personality disorder features

Characterising sleep in young people (aged 15-25 years) with borderline personality disorder (BPD) features is crucial given the association between BPD features and sleep disturbance, negative consequences of poor sleep, and normative developmental sleep changes that occur in this age group. The present study aimed to characterise the sleep profile of young people with BPD to determine whether this profile is non-normative and specific to BPD. Participants were 96 young people (40 with BPD features, 38 healthy individuals, and 18 young people seeking help for mental health difficulties without BPD). Sleep was measured subjectively (self-report questionnaires) and objectively (10 days of actigraphy). Young people with BPD features reported poorer subjective sleep quality, greater insomnia symptoms and later chronotype than same-age healthy and clinical comparison groups. Young people with BPD features also displayed irregular sleep timing, later rise times, greater time in bed and longer sleep durations than healthy young people. Those with BPD features had superior sleep quality (greater sleep efficiency, less wake after sleep onset) and longer sleep durations than the clinical comparison group. Sleep profiles were similar across young people with BPD features with and without co-occurring depression. Overall, the findings revealed a subjective-objective sleep discrepancy and suggest that sleep-improvement interventions might be beneficial to improve subjective sleep in young people with BPD features.

The Emerging Circadian Phenotype of Borderline Personality Disorder: Mechanisms, Opportunities and Future Directions

PURPOSE OF REVIEW

We review the recent evidence suggesting that circadian rhythm disturbance is a common unaddressed feature of borderline personality disorder (BPD); amelioration of which may confer substantial clinical benefit. We assess chronobiological BPD studies from a mechanistic and translational perspective and highlight opportunities for the future development of this hypothesis.

RECENT FINDINGS

The emerging circadian phenotype of BPD is characterised by a preponderance of comorbid circadian rhythm sleep-wake disorders, phase delayed and misaligned rest-activity patterns and attenuated amplitudes of usually well-characterised circadian rhythms. Such disturbances may exacerbate symptom severity, and specific maladaptive personality dimensions may produce a liability towards extremes in chronotype. Pilot studies suggest intervention may be beneficial, but development is limited. Endogenous and exogenous circadian rhythm disturbances appear to be common in BPD. The interface between psychiatry and chronobiology has led previously to novel efficacious strategies for the treatment of psychiatric disorders. We believe that better characterisation of the circadian phenotype in BPD will lead to a directed biological target for treatment in a condition where there is a regrettable paucity of accessible therapies.

Borderline personality disorder and prior suicide attempts define a severity gradient among hospitalized adolescent suicide attempters

BACKGROUND

Borderline personality disorder (BPD) and history of prior suicide attempt (SA) have been shown to be high predictors for subsequent suicide. However, no previous study has examined how both factors interact to modify clinical and suicide severity among adolescents.

METHODS

This study presents a comprehensive assessment of 302 adolescents (265 girls, mean age = 14.7 years) hospitalized after a SA. To test clinical interactions between BPD and history of prior SA, the sample was divided into single attempters without BPD (non-BPD-SA, N = 80), single attempters with BPD (BPD-SA, N = 127) and multiple attempters with BPD (BPD-MA, N = 95).

RESULTS

Univariate analyses revealed a severity gradient among the 3 groups with an additive effect of BPD on the clinical and suicide severity already conferred by a history of SA. This gradient encompassed categorical (anxiety and conduct disorders and non-suicidal-self-injury [NSSI]) and dimensional comorbidities (substance use and depression severity) and suicide characteristics (age at first SA). According to regression analyses, the BPD-MA group that was associated with the most severe clinical presentation also showed specific features: the first SA at a younger age and a higher prevalence of non-suicidal self-injury (NSSI) and anxiety disorders. The BPD-MA group was not associated with higher impulsivity or frequency of negative life events.

CONCLUSIONS

Based on these findings and to improve youth suicide prevention, future studies should systematically consider BPD and the efficacy of reinforcing early interventions for anxiety disorders and NSSI.

Adolescent Sleep Disturbance, Emotion Regulation and Borderline Features in an Inpatient Setting

OBJECTIVE

The current study aimed to examine the relation between sleep disturbance, emotion dysregulation and borderline personality features in adolescent inpatients.

METHOD

N = 217 adolescents (67.1% female; ages 12-17) with the following racial/ethnic breakdown: 67.4% White, 3.7% Hispanic, 2.8% Asian, 1.8% African American, and 6.4% multiracial) completed self-report measures of sleep disturbance, emotion dysregulation and borderline personality symptoms at admission to, discharge from, and at 6-months-post discharge from an inpatient psychiatric hospital. Group comparison and path analyses were conducted to examine differences in sleep disturbance between those with and without borderline personality disorder and the mediating role of emotion dysregulation in the relation between sleep disturbance and borderline personality features.

RESULTS

Borderline personality features and emotion dysregulation were significantly related to indices of sleep disturbance. Path models revealed that some sleep disturbance indices at admission directly predicted levels of borderline features at discharge and at 6-months-post-discharge. However, none of the indirect pathways between sleep disturbance at admission, emotion dysregulation at discharge, and borderline features at discharge or 6-months post-discharge were significant.

CONCLUSIONS

Findings are consistent with prior literature which suggest that a unique relation exists between sleep disturbance and BPD, beyond comorbid depression symptoms. However, contrary to our hypotheses, the current study did not provide empirical support for the mediating role of emotion regulation in this relation. These findings have implications for existing personality disorder and sleep interventions and suggest further research into the mechanisms underlying the relation between sleep disturbance and borderline personality pathology is necessary.

Actigraphic patterns, impulsivity and mood instability in bipolar disorder, borderline personality disorder and healthy controls

OBJECTIVES

To differentiate the relation between the structure and timing of rest-activity patterns and symptoms of impulsivity and mood instability in bipolar disorder (BD), borderline personality disorder (BPD) and healthy controls (HC).

METHODS

Eighty-seven participants (31 BD, 21 BPD and 35 HC) underwent actigraph monitoring for 28 days as part of the Automated Monitoring of Symptom Severity (AMoSS) study. Impulsivity was assessed at study entry using the BIS-11. Mood instability was subsequently longitudinally monitored using the digital Mood Zoom questionnaire.

RESULTS

BPD participants show several robust and significant correlations between non-parametric circadian rest-activity variables and worsened symptoms. Impulsivity was associated with low interdaily stability (r = -0.663) and weak amplitude (r = -0.616). Mood instability was associated with low interdaily stability (r = -0.773), greater rhythm fragmentation (r = 0.662), weak amplitude (r = -0.694) and later onset of daily activity (r = 0.553). These associations were not present for BD or HCs. Classification analysis using actigraphic measures determined that later L5 onset reliably distinguished BPD from BD and HC but did not sufficiently discriminate between BD and HC.

CONCLUSIONS

Rest-activity pattern disturbance indicative of perturbed sleep and circadian function is an important predictor of symptom severity in BPD. This appears to validate the greater subjective complaints of BPD individuals that are sometimes regarded as exaggerated by clinicians. We suggest that treatment strategies directed towards improving sleep and circadian entrainment may in the future be investigated in BPD.

Circadian rest-activity patterns in bipolar disorder and borderline personality disorder

Bipolar disorder (BD) and borderline personality disorder (BPD) are two psychiatric disorders with overlapping features that can be challenging to separate diagnostically. Growing evidence suggests that circadian rhythm disturbances are associated with psychiatric illness, however circadian patterns of behaviour have not been elucidated in BPD or differentiated from BD. This study compared the circadian structure and timing of rest-activity patterns in BPD with BD and healthy volunteers. Participants with BD (N = 31) and BPD (N = 21) and healthy controls (HC, N = 35) wore an actigraph on their non-dominant wrist for 28 day periods as part of the Automated Monitoring of Symptom Severity (AMoSS) study. Non-parametric circadian rhythm analysis of rest-activity patterns and cosinor analysis of distal temperature rhythms were conducted to elucidate circadian function between groups. Covariates controlled for included employment status, BMI and gender. Compared with HC and BD, individuals with BPD showed significantly delayed phase of night-time rest patterns ("L5 onset") (mean difference = 1:47 h, P < 0.001; mean difference = 1:38 h, P = 0.009, respectively), and relative to HC showed delayed daytime activity onset ("M10 onset") (mean difference = 2:13 h, P = 0.048) and delayed temperature phase (mean difference = 1:22 h, P = 0.034). These findings suggest that delayed circadian function may be a clinically important phenotype in individuals with BPD. Future work should interrogate the causality of this association and examine interventions which target delayed circadian function in the treatment of BPD.

Borderline personality disorder traits and suicide risk: The mediating role of insomnia and nightmares

BACKGROUND

Borderline personality disorder (BPD) is associated with high rates of suicide risk and problems related to sleep, including insomnia and nightmares. The purpose of the current study was to assess the potential indirect effect of BPD traits on suicide risk through both/either insomnia and nightmares.

METHODS

Participants (N = 281) were recruited via Amazon's Mechanical Turk to complete the study remotely online. Participants completed measures of BPD traits and symptoms, suicide risk (history of suicidal thoughts and behaviors), insomnia symptoms, and distress and impairment related to nightmares.

RESULTS

BPD traits and symptoms were moderately to highly correlated to suicide risk, insomnia, and nightmares. In parallel mediation models, BPD traits had a significant indirect effect on suicide risk through insomnia symptoms but not nightmares.

LIMITATIONS

The current study assessed problems within the general population and not in a clinical sample. Second, the study relied solely on self-report measures. Futures studies would benefit from investigating these relations in clinical samples utilizing observer-report and interview methods.

CONCLUSIONS

BPD traits appear to relate to increased risk for suicide through the relation with sleep concerns, particularly insomnia symptoms. Therefore, assessing and treating sleep problems within individuals with BPD may result in a lower risk for suicide.

Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies

Using the same Diagnostic and Statistical Manual of Mental Disorders, fifth version (DSM-V) criteria as in adults, borderline personality disorder (BPD) in adolescents is defined as a 1-year pattern of immature personality development with disturbances in at least five of the following domains: efforts to avoid abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, suicidal and self-mutilating behaviors, affective instability, chronic feelings of emptiness, inappropriate intense anger, and stress-related paranoid ideation. BPD can be reliably diagnosed in adolescents as young as 11 years. The available epidemiological studies suggest that the prevalence of BPD in the general population of adolescents is around 3%. The clinical prevalence of BPD ranges from 11% in adolescents consulting at an outpatient clinic to 78% in suicidal adolescents attending an emergency department. The diagnostic procedure is based on a clinical assessment with respect to developmental milestones and the interpersonal context. The key diagnostic criterion is the 1-year duration of symptoms. Standardized, clinician-rated instruments are available for guiding this assessment (eg, the Diagnostic Interview for Borderlines-Revised and the Childhood Interview for DSM-IV-TR BPD). The assessment should include an evaluation of the suicidal risk. Differential diagnosis is a particular challenge, given the high frequency of mixed presentations and comorbidities. With respect to clinical and epidemiological studies, externalizing disorders in childhood constitute a risk factor for developing BPD in early adolescence, whereas adolescent depressive disorders are predictive of BPD in adulthood. The treatment of adolescents with BPD requires commitment from the parents, a cohesive medical team, and a coherent treatment schedule. With regard to evidence-based medicine, psychopharmacological treatment is not recommended and, if ultimately required, should be limited to second-generation antipsychotics. Supportive psychotherapy is the most commonly available first-line treatment. Randomized controlled trials have provided evidence in favor of the use of specific, manualized psychotherapies (dialectic-behavioral therapy, cognitive analytic therapy, and mentalization-based therapy).

Sleep and disruptive mood dysregulation disorder: A pilot actigraphy study

OBJECTIVE

To explore the clinical characteristics and motor activity profile during sleep periods of children and adolescents presenting with disruptive mood dysregulation disorder (DMDD).

METHOD

Twenty-one youths (mean age±standard deviation, 11.7±3 years) wore a wrist actigraph for 9 consecutive days (including both school days and non-school days), to measure sleep parameters: sleep latency, sleep efficiency and the number and duration of periods of wakefulness after sleep onset (WASO). We divided the night-time actigraphy recording sessions into three sections and compared the first and last thirds of the night.

RESULTS

All the study participants had a psychiatric comorbidity (primarily attention deficit hyperactivity disorder, depressive disorder or anxiety disorder). On non-school days, bedrest onset and activity onset were shifted later by about 1h. There was no significant difference between school days and non-school days with regard to the total sleep time. Sleep efficiency was significantly greater on non-school days. Sleep was fragmented on both school days and non-school days. The mean number of episodes of WASO was 24.9 for school days and 30.9 for non-school days. Relative to the first third of the night, we observed a significantly greater number of episodes of WASO during the last third of the night, a period associated with a larger proportion of rapid eye movement (REM) sleep.

DISCUSSION

Sleep appeared to be fragmented in the study population of youths with DMDD. The greater frequency of WASO in the last third of the night points to a possible impairment of the motor inhibition normally associated with REM sleep.

Desynchronization of diurnal rhythms in bipolar disorder and borderline personality disorder

It has long been proposed that diurnal rhythms are disturbed in bipolar disorder (BD). Such changes are obvious in episodes of mania or depression. However, detailed study of patients between episodes has been rare and comparison with other psychiatric disorders rarer still. Our hypothesis was that evidence for desynchronization of diurnal rhythms would be evident in BD and that we could test the specificity of any effect by studying borderline personality disorder (BPD). Individuals with BD (n = 36), BPD (n = 22) and healthy volunteers (HC, n = 25) wore a portable heart rate and actigraphy device and used a smart-phone to record self-assessed mood scores 10 times per day for 1 week. Average diurnal patterns of heart rate (HR), activity and sleep were compared within and across groups. Desynchronization in the phase of diurnal rhythms of HR compared with activity were found in BPD (+3 h) and BD (+1 h), but not in HC. A clear diurnal pattern for positive mood was found in all subject groups. The coherence between negative and irritable mood and HR showed a four-cycle per day component in BD and BPD, which was not present in HC. The findings highlight marked de-synchronisation of measured diurnal function in both BD but particularly BPD and suggest an increased association with negative and irritable mood at ultradian frequencies. These findings enhance our understanding of the underlying physiological changes associated with BPD and BD, and suggest objective markers for monitoring and potential treatment targets. Improved mood stabilisation is a translational objective for management of both patient groups.

Variability in phase and amplitude of diurnal rhythms is related to variation of mood in bipolar and borderline personality disorder

Variable mood is an important feature of psychiatric disorders. However, its measurement and relationship to objective measureas of physiology and behaviour have rarely been studied. Smart-phones facilitate continuous personalized prospective monitoring of subjective experience and behavioural and physiological signals can be measured through wearable devices. Such passive data streams allow novel estimates of diurnal variability. Phase and amplitude of diurnal rhythms were quantified using new techniques that fitted sinusoids to heart rate (HR) and acceleration signals. We investigated mood and diurnal variation for four days in 20 outpatients with bipolar disorder (BD), 14 with borderline personality disorder (BPD) and 20 healthy controls (HC) using a smart-phone app, portable electrocardiogram (ECG), and actigraphy. Variability in negative affect, positive affect, and irritability was elevated in patient groups compared with HC. The study demonstrated convincing associations between variability in subjective mood and objective variability in diurnal physiology. For BPD there was a pattern of positive correlations between mood variability and variation in activity, sleep and HR. The findings suggest BPD is linked more than currently believed with a disorder of diurnal rhythm; in both BPD and BD reducing the variability of sleep phase may be a way to reduce variability of subjective mood.

Sleep-wake cycle phenotypes in young people with familial and non-familial mood disorders

OBJECTIVES

Converging evidence identifies that the offspring of parents with bipolar disorder (BD), individuals at clinical high risk of BD, and young people with recent onset BD may differ from other clinical cases or healthy controls in terms of sleep-wake profiles. However, it is possible that these differences may reflect current mental state, subtype of mood disorder, or familial traits. This study aimed to determine objective and subjective sleep-wake profiles in individuals aged 15-25 years with a current major depressive episode, in relation to familial traits.

METHODS

Frequency matching was employed to ensure that each individual with a confirmed family history of BD (FH+) could be compared to four controls who did not have a familial mood disorder (FH-). Pre-selected objective actigraphy and subjective Pittsburgh Sleep Quality Index (PSQI) ratings were compared using one-way analysis of variance (ANOVA) and applying the Benjamini-Hochberg (BH) correction for false discoveries.

RESULTS

The sample comprised 60 individuals with a mean age of 19 years. The FH+ (n=12) and FH- groups (n=48) differed on three key sleep parameters: mean sleep duration on week nights (P=.049), variability in waking after sleep onset (P=.038), and daily disturbances (PSQI dimension of sleep disturbance and daytime dysfunction; P=.01).

CONCLUSIONS

The sleep profiles we identified in this study, especially the daily disturbances phenotype, provide support for research into endophenotypes for BD. Also, the findings may offer the opportunity for more tailored, personalized interventions that target specific components of the sleep-wake cycle in individuals with a family history of BD.

Familial and Clinical Correlates in Depressed Adolescents with Borderline Personality Disorder Traits

INTRODUCTION

Chart review is a low-cost, but highly informative, method to describe symptoms, treatment, and risk factors associated with borderline personality disorder (BPD) and to adapt screening and intervention to clinical reality. Previous chart review studies report more aggressiveness/anger and psychotic features in youths with BPD. They show that adverse family environment and parental psychopathology constitute important factors for BPD pathology.

OBJECTIVES

To examine clinical characteristics of depressed BPD adolescents (12-17 years old) outpatients according to gender and to explore variables which are associated with BPD traits.

METHODS

A retrospective chart review using the child and adolescent version of the retrospective diagnostic instrument for borderlines was conducted on 30 depressed adolescents with BPD traits and 28 depressed patients without BPD traits. Participants who reached the retrospective diagnostic instrument for borderlines threshold for BPD were included in the BPD traits group. Comparison analyses were performed using Pearson's Chi-square test. Associated factors were determined using regression analyses.

RESULTS

BPD traits participants were characterized by higher family problems (parental psychopathology, parent disagreement/argument, and parent-child relational problem), more aggressive symptoms, and higher rates of family intervention and hospitalization. A number of familial factors (parental history of delinquency, substance use, personality disorders, having siblings, or parental disagreement/argument in boys) were associated with BPD traits. Attention seeking and problematic functioning (does not adapt well to group activities) were also associated with BPD traits.

DISCUSSION

Our study stresses the need to assess BPD traits in adolescent psychiatric evaluation, especially in the presence of aggressive behaviors, family problems and attention seeking. Our results also highlight the importance of exploring family characteristics intervention in adolescents with BPD traits.