Psychiatric Annals

Case Report 

Partial Resolution of Symptomatology in a Patient with Comorbid Bipolar Disorder and Borderline Personality Disorder Through Electroconvulsive Therapy

Melissa Yuan, BA

Abstract

The role of electroconvulsive therapy (ECT) in patients with comorbid mood disorders and borderline personality disorder (BPD) has not been definitively characterized. In the extensive published literature on ECT, there have been few studies examining ECT in patients with BPD, and among these few studies there seems to be no clear consensus. There have been case reports of ECT greatly improving symptomatology (including suicidality and quality of life) in patients with comorbid mood disorders and BPD.1,2 Namely, two case reports show examples of patients with BPD and comorbid depression that improved significantly with ECT, even to the point that they no longer had suicidal thoughts.1,3

Conversely, other studies, including the largest retrospective cohort study to date on the topic, have shown the opposite—that patients with comorbid depression and BPD do not improve to the same extent as patients without BPD, as the borderline traits are not responsive to ECT.4,5 Having BPD, rather than another personality disorder, in addition to depression led to a worse acute response to ECT in one study.5 This may indicate that borderline traits have a uniquely diminished response to ECT, although the mechanism of this phenomenon is unknown.

Given the dearth of guidance about the use of ECT in patients with BPD, the optimal management of patients with both BPD and mood disorders is not always clear. As BPD is frequently comorbid with major depression (85% of women with BPD and 26% of men also have a diagnosis of major depression) and bipolar disorder (about 20% of patients with BPD have a diagnosis of bipolar disorder),4 patients with diagnoses of a mood disorder and BPD frequently present for inpatient psychiatric care. Moreover, there have been no studies describing the use of ECT in patients with comorbid bipolar disorder and BPD.

This case serves as an illustrative example of the management of a patient with severe comorbid mood disorder and BPD. We present the experience of this patient and which of her symptoms were and were not successfully targeted with ECT.

The patient was a 25-year-old woman with an extensive history of bipolar disorder, substance abuse, and BPD dating back to early adolescence. She had made multiple suicide attempts, including two while on the unit during her current hospital stay, in addition to nonsuicidal self-injurious behaviors such as cutting. On her most recent admission, she was brought to the emergency department for a suicide attempt by methamphetamine overdose. She had eloped from an inpatient center, engaged in cutting behaviors, and heavily used substances including alcohol and possibly other drugs.

Biologically, this patient had a significant genetic risk of mental illness, including mood disorders in both parents and substance abuse and mood disorders among her siblings. Psychologically, the patient has had an impulsive, moody temperament since childhood. Socially, she has never been able to maintain long-term friendships, with the only consistent support in her life coming from her husband, with whom she has a chaotic, dependent relationship.

The patient had her first depressive episode at age 13 years in the context of experiencing sexual abuse by a family member. Her mood was consistently unstable throughout her teens and early 20s, with periods of self-described “euphoric” mania interspersed among months of depressive episodes. She was hospitalized at age 24 years on three separate occasions for suicide attempts each time. She also attempted to asphyxiate herself in one of these hospitalizations while on constant one-to-one observation. After her mood had stabilized sufficiently, she was discharged to an outpatient substance abuse program.

The patient maintained sobriety for about 8 months before her behavior began to become erratic and her mood dysregulated.…

The role of electroconvulsive therapy (ECT) in patients with comorbid mood disorders and borderline personality disorder (BPD) has not been definitively characterized. In the extensive published literature on ECT, there have been few studies examining ECT in patients with BPD, and among these few studies there seems to be no clear consensus. There have been case reports of ECT greatly improving symptomatology (including suicidality and quality of life) in patients with comorbid mood disorders and BPD.1,2 Namely, two case reports show examples of patients with BPD and comorbid depression that improved significantly with ECT, even to the point that they no longer had suicidal thoughts.1,3

Conversely, other studies, including the largest retrospective cohort study to date on the topic, have shown the opposite—that patients with comorbid depression and BPD do not improve to the same extent as patients without BPD, as the borderline traits are not responsive to ECT.4,5 Having BPD, rather than another personality disorder, in addition to depression led to a worse acute response to ECT in one study.5 This may indicate that borderline traits have a uniquely diminished response to ECT, although the mechanism of this phenomenon is unknown.

Given the dearth of guidance about the use of ECT in patients with BPD, the optimal management of patients with both BPD and mood disorders is not always clear. As BPD is frequently comorbid with major depression (85% of women with BPD and 26% of men also have a diagnosis of major depression) and bipolar disorder (about 20% of patients with BPD have a diagnosis of bipolar disorder),4 patients with diagnoses of a mood disorder and BPD frequently present for inpatient psychiatric care. Moreover, there have been no studies describing the use of ECT in patients with comorbid bipolar disorder and BPD.

This case serves as an illustrative example of the management of a patient with severe comorbid mood disorder and BPD. We present the experience of this patient and which of her symptoms were and were not successfully targeted with ECT.

Case Presentation

The patient was a 25-year-old woman with an extensive history of bipolar disorder, substance abuse, and BPD dating back to early adolescence. She had made multiple suicide attempts, including two while on the unit during her current hospital stay, in addition to nonsuicidal self-injurious behaviors such as cutting. On her most recent admission, she was brought to the emergency department for a suicide attempt by methamphetamine overdose. She had eloped from an inpatient center, engaged in cutting behaviors, and heavily used substances including alcohol and possibly other drugs.

Biologically, this patient had a significant genetic risk of mental illness, including mood disorders in both parents and substance abuse and mood disorders among her siblings. Psychologically, the patient has had an impulsive, moody temperament since childhood. Socially, she has never been able to maintain long-term friendships, with the only consistent support in her life coming from her husband, with whom she has a chaotic, dependent relationship.

The patient had her first depressive episode at age 13 years in the context of experiencing sexual abuse by a family member. Her mood was consistently unstable throughout her teens and early 20s, with periods of self-described “euphoric” mania interspersed among months of depressive episodes. She was hospitalized at age 24 years on three separate occasions for suicide attempts each time. She also attempted to asphyxiate herself in one of these hospitalizations while on constant one-to-one observation. After her mood had stabilized sufficiently, she was discharged to an outpatient substance abuse program.

The patient maintained sobriety for about 8 months before her behavior began to become erratic and her mood dysregulated. At this time, she endorsed feeling “high and happy” with decreased need for sleep, and she engaged in promiscuous relationships with multiple partners. She stated that she was “just trying to have fun.” Her husband commented that she “did not seem like herself,” as she became much more outgoing and extroverted. Moreover, she was only sleeping for 3 to 4 hours per night.

A few months later, the patient had an altercation with her husband during which she grabbed a knife, punched him, smashed a glass in an attempt to cut him, and self-injured by banging her head on the ground. After that incident, she stayed in the hospital for 3 weeks for inpatient treatment for psychiatric stabilization before being discharged to an inpatient rehabilitation facility, where she stayed until this most recent presentation. At this time, she endorsed depressed mood, sleep and appetite disturbances, decreased energy, feelings of guilt including that the depression was a “punishment,” and suicidality.

After initial evaluation at this presentation, the patient's treatment plan consisted of increasing her dose of quetiapine from 300 mg daily to 400 mg daily for mood disorder symptoms; increasing her dose of venlafaxine to from 150 mg daily to 187.5 mg daily for posttraumatic stress disorder (PTSD) symptoms that included nightmares, flashbacks, and hypervigilance; and beginning lithium at a dose of 600 mg daily for mood stabilization. Importantly, she had been previously diagnosed with PTSD (as well as BPD) due to sexual abuse; however, at the time of this presentation, she was not formally evaluated for PTSD diagnosis. As the lithium dose was being titrated, she had a suicide attempt on the unit, at which time her lithium level was found to be 1.2 mmol/L, which is a therapeutic level. Given the severity of her depressive symptoms despite the therapeutic level of lithium, the lithium was continued at that dose and the patient agreed to ECT. Subsequently, quetiapine was decreased to 300 mg daily and venlafaxine to 150 mg daily. She underwent 12 ECT treatments and endorsed a “much better” mood.

Her hospital course was notable for constant strong desires to hurt herself. About 1 month into her 11-week hospital stay, she had a suicide attempt by asphyxiation with a stocking. Two weeks after that attempt, she punched herself in the eye after a negative family interaction. As she was completing her 9th and 10th ECT treatments, she said she was “more motivated to cut than ever,” and was “thinking about it, dreaming about it.” Just before her 11th ECT treatment, she stated “I just really want to cut. I've been thinking about that a lot.” On several occasions in the week of her 11th and 12th ECT treatments, she scratched and bit herself and needed to be put in 5-point restraints.

However, during the course of her stay, her mood, sleep, and energy improved, her appetite returned, and her affect became much less constricted and sad. Her last Hamilton Depression Rating Scale 17 score was 11, which was an improvement from her score of 22 at 6 weeks prior. She even self-reported that she no longer felt depressed. Clinically, as her depression had improved, her BPD had become more and more pronounced. As noted above, she had more suicide attempts and self-injurious behaviors recently. Additionally, she began to argue more with her husband and “act out” on the unit more frequently.

Differential Diagnosis

Given the patient's life-long course of self-injurious behavior, suicidality, impulsivity, moodiness, and inability to have steady friendships, a diagnosis of BPD is probable. However, other possible diagnoses that would explain these symptoms include narcissistic personality disorder, cyclothymic disorder, bipolar I disorder, and bipolar II disorder.

As the patient had more than 2 weeks of tearfulness, sadness, anhedonia, low energy, decreased appetite, disturbed sleep, and feelings of guilt in addition to suicidal ideation and attempts, she also met criteria for a major depressive episode. However, it is difficult to distinguish whether this major depressive episode occurred as a part of a unipolar or a bipolar depression. She had at least one possible episode of mania in the past, although it is unclear whether this mania was precipitated by substance use or whether substance use was incidentally part of this episode. Thus, bipolar I or II disorder with comorbid borderline personality disorder is the current working diagnosis, although the other diagnoses to be considered are major depressive disorder, substance abuse disorder, and cyclothymic disorder. The diagnosis of bipolar II disorder was favored as the patient was unable to accurately recount the amount of time that she spent in a “high and happy” state and most frequently claimed it was “just a couple of days.” Moreover, the degree of impairment in functioning during this time was unclear and confounded by her substance use.

Discussion

It is not known how and when to use ECT in patients with BPD to give these patients the best outcomes possible. Published case reports have detailed a decrease in suicidality in patients with BPD after treatment with ECT.1,5 However, other case series have indicated that patients with BPD may have suboptimal outcomes with ECT treatment compared to patients with mood disorders alone or with depression comorbid with other personality disorders.2 Also, importantly, the outcomes of patients with bipolar disorder and BPD have not yet been characterized. This case presents a patient with BPD in a major depressive episode that is likely part of bipolar II disorder. It demonstrates the resolution of some of the patient's symptoms including improved mood, sleep, appetite, energy, and concentration. However, her self-injurious behaviors, suicidal ideation, and tendency toward arguments and fear of abandonment by her husband did not improve, and they may have even worsened as she gained more energy.

Suicidality, self-injury, impulsivity, emotional lability, sensitivity to rejection, and chronically chaotic relationships are core features of BPD. Of these, suicidality, emotional lability, sensitivity to rejection, and possibly impulsivity may overlap with mood disorders. ECT has been shown to be efficacious in patients with treatment-resistant mood disorders. However, in this patient, even after 12 treatments of ECT, her impulse control was still lacking, and she continued to express suicidal ideation daily. Thus, this case shows that although ECT improved many of the patient's depressive symptoms, it did not target her suicidality or impulsivity, which may be partially or entirely driven by borderline traits.

Future studies may seek to clarify the role of ECT in patients with bipolar disorder and BPD. Additionally, randomized, controlled treatment studies comparing the efficacy of ECT to other standard treatments, such as dialectical behavior therapy and antidepressant medications, and the long-term outcomes of different treatments will greatly aid in clinical decision-making. It is hoped that this article provides a perspective of a patient with BPD and bipolar depression regarding which symptoms ECT were and were not able to target, to aid in the care of similar patients in the future.

References

  1. Wasiq S, Khan AR, Faquih AE, Saeed H, Mahmood H. Role of electroconvulsive therapy in major depressive disorder with borderline personality disorder: case report and literature review. Cureus.2018;10(8):e3211. https://doi.org/10.7759/cureus.3211 PMID:30405987
  2. Feske U, Mulsant BH, Pilkonis PA, et al. Clinical outcome of ECT in patients with major depression and comorbid borderline personality disorder. Am J Psychiatry.2004;161(11):2073–2080. https://doi.org/10.1176/appi.ajp.161.11.2073 PMID: doi:10.1176/appi.ajp.161.11.2073 [CrossRef]15514409
  3. Gescher DM, Cohen S, Ruttmann A, Malevani J. ECT revisited: impact on major depression in borderline personality disorder. Aust N Z J Psychiatry. 2011;45(11):1003–1004. https://doi.org/10.3109/00048674.2011.617723 PMID: doi:10.3109/00048674.2011.617723 [CrossRef]21981774
  4. DeBattista C, Mueller K. Is electroconvulsive therapy effective for the depressed patient with comorbid borderline personality disorder?J ECT. 2001;17(2):91–98. https://doi.org/10.1097/00124509-200106000-00002 PMID: doi:10.1097/00124509-200106000-00002 [CrossRef]11417933
  5. Kaster TS, Goldbloom DS, Daskalakis ZJ, Mulsant BH, Blumberger DM. Electroconvulsive therapy for depression with comorbid borderline personality disorder or post-traumatic stress disorder: a matched retrospective cohort study. Brain Stimul. 2018;11(1):204–212. https://doi.org/10.1016/j.brs.2017.10.009 PMID: doi:10.1016/j.brs.2017.10.009 [CrossRef]
Authors

Melissa Yuan, BA, is a third-year Medical Student, New York Presbyterian Hospital, Weill Medical College; and a Psychiatry and Clerkship Student, New York Presbyterian Hospital Westchester Division.

Address correspondence to Melissa Yuan, BA, New York Presbyterian Hospital, 1300 York Avenue, New York, NY 10065; email: mey2010@med.cornell.edu.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/00485713-20191118-01

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