Depressed State Increases Self-Reported Personality Disorder Incidence in Bipolar Disorder

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woman sitting on window ledge looking out window
The relationship of baseline mood state and prevalence of axis II personality disorders were examined in patients with bipolar disorder.

Patients with bipolar disorder report a greater number of personality disorders when depressed compared when they are in a euthymic state, according to study findings published in Bipolar Disorders.

Investigators administered the Personality Disorder Questionnaire, 4th edition (PDQ4), to outpatients with bipolar I or II disorder who were enrolled in the Bipolar Treatment Outcome Network (n=966). The self-reported PDQ4 scale, which examines 11 personality disorders, was used to identify axis II pathology.

Patients were seen every 2 weeks and once per month. At each visit, patients rated were on the Inventory of Depressive Symptoms-Clinician version and the Young Mania Rating Scale for depression and mania, respectively.

Researchers also examined 6 poor prognosis factors (PPFs), including onset of bipolar disorder before 19 years of age, history of childhood adversity, substance abuse comorbidity, anxiety disorder comorbidity, presence of rapid cycling, and history of ≥20 prior mood episodes.

When comparing study participants in the depressed vs euthymic state at the time of PDQ4 completion, a greater proportion of patients in depression met the criteria for paranoia (37.7% vs 19.3%, respectively; P <.001), histrionic (17.2% vs 9.4%, respectively; P =.029), obsession (53.0% vs 35.4%, respectively; P =.001), negativistic (48.3% vs 20.8%, respectively; P <.001), schizoid (33.8% vs 11.8%, respectively; P <.001), narcissistic (24.5% vs 11.8%, respectively; P =.002), avoidant (63.6% vs 35.4%, respectively; P <.001), depressive (68.2% vs 29.2%, respectively; P <.001), schizotypal (23.2% vs 9.9%, respectively; P =.001), dependent (21.2% vs 5.7%, respectively; P <.001), and borderline (55.0% vs 22.6%, respectively; P <.001) personality disorders.

The rate of axis II diagnoses increased in a stepwise fashion with increasing severities of depression.

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Participants with a bipolar I diagnosis, physical abuse history, a higher number of manic episodes, and a higher number of the 6 PPFs met the criteria for a cluster A personality disorder (paranoid, schizoid, or schizotypical personality disorders).

In addition, cluster B disorders (antisocial, borderline, histrionic, or narcissistic personality disorders) were associated with a higher number of PPFs, a greater total number of manic episodes, the presence of rapid cycling, and older age. Also, a higher number of PPFs and manic episodes was associated with cluster C personality disorder (avoidant, dependent, or obsessive).

In an effort to attenuate potential challenges in patients with bipolar disorder with axis II comorbidity, the investigators suggest shortening “the duration of the delay to first psychopharmacological treatment for mania and depression and to intervene with appropriate psychotherapies in ill individuals and in those at high risk.”


Post RM, Leverich GS, McElroy S, et al. Prevalence of axis II comorbidities in bipolar disorder: relationship to mood state [published online January 25, 2018]. Bipolar Disord. doi: 10.1111/bdi.12596