Comorbid personality disorders in subjects with bipolar I disorder

Abstract

Unlabelled:
Objective. The purpose of this study was to present the frequencies of personality disorders in a sample of bipolar I patients and to investigate whether the presence of comorbid personality disorders affect the course of bipolar illness.

Methods:
Seventy euthymic bipolar I patients were assessed using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID II). Bipolar patients with comorbid personality disorder were compared with those of without personality disorder comorbidity on demographic and clinical variables.

Results:
Forty bipolar I patients (57%) had at least one comorbid personality disorder. The most common personality disorder cluster was cluster C (36%), followed by cluster B (17%) and cluster A (17%) personality disorders. The most prevalent personality disorder in the whole group was obsessive-compulsive personality disorder (21%). Patients with comorbid personality disorders had an earlier age of onset than those of without comorbidity.

Conclusion:
Although the rates of comorbid personality disorders are high in bipolar I patients, the presence of comorbidity has no relevant impact on the course of bipolar I patients except for earlier age of onset of bipolar I disorder.

Full text

ORIGINAL ARTICLE
Comorbid personality disorders in subjects with bipolar I disorder
ABDURRAHMAN ALTINDAG, MEDAIM YANIK & MELIKE NEBIOGLU
Department of Psychiatry, Harran University Faculty of Medicine, Sanliurfa, Turkey
Abstract
Objective. The purpose of this study was to present the frequencies of personality disorders in a sample of bipolar I patients
and to investigate whether the presence of comorbid personality disorders affect the course of bipolar illness. Methods.Seventy
euthymic bipolar I patients were assessed using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders
(SCID II). Bipolar patients with comorbid personality disorder were compared with those of without personality disorder
comorbidity on demographic and clinical variables. Results. Forty bipolar I patients (57%) had at least one comorbid
personality disorder. The most common personality disorder cluster was cluster C (36%), followed by cluster B (17%) and
cluster A (17%) personality disorders. The most prevalent personality disorder in the whole group was obsessive-compulsive
personality disorder (21%). Patients with comorbid personality disorders had an earlier age of onset than those of without
comorbidity. Conclusion. Although the rates of comorbid personality disorders are high in bipolar I patients, the presence of
comorbidity has no relevant impact on the course of bipolar I patients except for earlier age of onset of bipolar I disorder.
Key Words: Bipolar, comorbidity, personality disorders, prevalence, age of onset
Introduction
The comorbidity of personality disorders is a com-
mon phenomenon among bipolar patients. There
have been many studies examining the prevalence of
personality disorder in patients with bipolar disorder
[1/7]. In these studies, the co-occurrence of person-
ality disorder and bipolar disorder has ranged from
9 to 89% of patients [6,7]. The variability in
prevalence rates may be related to methodological
differences with regard to population assessed, the
measures used and the patients’ symptomatic states
at the time of personality disorder assessment.
Impact of comorbid personality disorders on the
course of bipolar disorder has received considerable
attention in recent years [2,3,8 /11]. In these stu-
dies, personality disorders were associated with
noncompliance with treatment, decreased response
to lithium treatment, poor treatment outcome,
increased rates of alcohol and substance abuse, and
increased severity of residual mood symptoms.
Bipolar patients with comorbid personality disorders
also spend more days in the hospital in a given year
[12], are more likely to have suicidal ideation and
behavior [4,13], and have more severe mood dis-
order symptoms and function at a lower level [14]
than those without comorbid personality disorders.
The purpose of this study was to present the
frequencies of personality disorders in a sample of
bipolar I patients and to investigate whether the
presence of comorbid personality disorders affect the
course of bipolar illness. This study provides a view
on personality disorder comorbidity in bipolar I
patients in Sanliurfa, Turkey. To avoid potential
overlap between the symptoms of acute episodes of
bipolar illness and comorbid personality disorders
we examined patients in states of clinical remission.
Methods
Participants
All patients presenting at the Bipolar Disorder Out-
patients Clinics of the Harran University, located in
Sanliurfa, Southeastern Turkey between 2002 and
2004 were considered for inclusion in the present
study. Patients diagnosed with bipolar disorder in
the psychiatry clinics of Harran University Research
Hospital (a tertiary level health institute which
receives referrals from the southeastern part of
Turkey) were recruited for the study. Among
patients enrolled in this unit, the ones who met the
following criteria were included in the study: (1) age
at least 18 years; (2) DSM-IV diagnosis of bipolar I
Correspondence: Dr Abdurrahman Altindag, Harran Universitesi Tip Fakultesi, Psikiyatri AD Arastirma Hastanesi, 63100 Sanliurfa, Turkey. Tel: /90 414
3128456 2319. Fax: 
/90 414 3139615. E-mail: aaltindag@yahoo.com
International Jour nal of Psychiatry in Clinical Practice, 2006; 10(1): 33 /37
(Received 8 March 2005; accepted 18 July 2005)
ISSN 1365-1501 print/ISSN 1471-1788 online #2006 Taylor & Francis
DOI: 10.1080/13651500500305481

disorder; (3) being clinically in remission for at least
1 month before inclusion in this study as corrobo-
rated with routinely administered scales during
follow-up visits (17-item Hamilton Rating Scale for
Depression score of B
/7 and Young Mania Rating
Scale score of B
/5 for at least 1 month in two
consecutive visits were used as confirmative scores
for remission); and (4) written informed consent
obtained before participation in the study. The
diagnosis of bipolar I disorder was made clinically
according to DSM-IV criteria on admission of the
patient to the follow-up routine of outpatient clinics
and later confirmed by interviews conducted by the
first and the second authors. Exclusion criteria were:
(1) history of seizure, head injury with loss of
consciousness, or other neurological disorder; (2)
concurrent active medical disorder; (3) unwilling-
ness to cooperate with investigators; and (4) contact
loss.
Among 116 cases who were enrolled in our bipolar
disorder outpatient clinic, 70 patients (30 females,
and 40 males), aged between 18 and 59 years,
fulfilled the inclusion criteria for the study. Out of
116 patients, 17 had other subtypes of bipolar
disorder (i.e. bipolar II disorder, bipolar disorder
not otherwise specified and schizoaffective disorder,
bipolar type), four had a history of seizure, head
injury with loss of consciousness, or other neurolo-
gical disorders, two had concurrent active medical
disorders, 19 did not wish to be interviewed, and
four were later out of reach. These cases, therefore,
were excluded from the study.
Measures
1. Sociodemographic and clinical variables of the
subjects including previous hospitalizations,
number and type of previous episodes, presence
of psychotic features, suicide attempts and age
at onset of the disorder were obtained from
inpatient and outpatient medical records of the
cases, patient interviews, and from first-degree
relatives when available.
2. The Structured Clinical Interview for DSM-IV
Axis II Personality Disorders (SCID-II) [15]
was used to diagnose comorbidities of person-
ality disorders. All patients were interviewed by
the first author, trained in the use of the SCID-
II. A complete interview was done for all
patients in SCID-II interview. Individuals who
were found to present at least one personality
disorder were included in the group ‘‘with
comorbid personality disorder’’, and those
without any comorbid personality disorder,
in the group ‘‘without comorbid personality
disorder’’.
3. Hamilton Rating Scale for Depression (HAM-D),
a 17-item clinician-rated instrument [16,17],
was used to determine the level of depression.
4. Young Mania Rating Scale (YMRS) is a clinical
rating scale containing 11 items assessing manic
symptoms [18]. Reliability ratings have been
high in Turkish version [19].
Statistical analysis
The Statistical Package for Social Sciences (SPSS
11.5, SPSS Inc, Chicago, IL) was used for all
statistical analyses. Mann /Whitney test, Chi-
squared test and Fisher’s exact test were used to
examine the statistical differences between bipolar
patients with an axis II diagnosis (n
/40) and those
without an axis II diagnosis (n
/30) on demo-
graphic, clinical and course of illness variables. The
two-tailed significance level was set at 0.05.
Results
Table I shows the personality disorder comorbidity
of the sample. Of the 70 bipolar I patients, 40 (57%)
had at least one comorbid personality disorder.
Fourteen patients (20%) were diagnosed with two
comorbid personality disorders, and two (3%) with
three personality disorders. The most common
personality disorder cluster was cluster C (36%),
followed by cluster B (17%) and cluster A (17%)
personality disorders. Two (3%) bipolar I patients
met criteria for a personality disorder in both cluster
A and B, two (3%) for a disorder in cluster B and C,
and five (7%) for a disorder in cluster A and C. The
most prevalent personality disorder in the whole
group was obsessive-compulsive personality disorder
(21%). Avoidant (17%), paranoid (17%), and his-
trionic (10%) followed in decreasing order.
Tables II and III show the comparisons of patients
with and without comorbid personality disorder with
respect to demographic and clinical variables. Mean
age of bipolar I patients with comorbid personality
Table I. Prevalence of comorbid personality disorders in bipolar I
patients.
Personality disorder n%
Any personality disorder 40 57
Cluster A 12 17
Paranoid 12 17
Schizoid //
Schizotypal //
Cluster B 12 17
Histrionic 7 10
Narcissistic 1 1
Borderline 5 7
Antisocial 1 1
Cluster C 25 36
Avoidant 12 17
Dependent 3 4
Obsessive /compulsive 15 21
Cluster A
/B23
Cluster B/C23
Cluster A/C57
34 A. Altindag et al.

disorders was significantly lower than those of with-
out comorbidity (P
/0.02). Neither were there
significant differences regarding most clinical vari-
ables such as psychotic symptoms, rapid cycling,
seasonality, familial psychiatric history, suicidal idea-
tion and behavior, and total number of episodes.
Patients with comorbid personality disorder had an
earlier age of onset than those of without personality
disorder comorbidity (P
/0.04).
Discussion
This study examined the prevalence of comorbid
personality disorders in a sample of bipolar I
patients. It also examined the clinical correlates of
personality disorder comorbidity. It appears that
comorbid personality disorder occurs in more than
half of the subject with bipolar I disorder (57%).
This prevalence rate is comparable with rates found
in other studies that used structured interviews
Table II. Differential quantitative features between bipolar I patients with and without personality disorder comorbidity.
BD with personality
disorder comorbidity
(n
/40)
BD without personality
disorder comorbidity
(n/30) Analysis
Mean (SD) Mean (SD) U
a
P
Age 31.8 (8.7) 37.1(10.0) 
/2.12 0.03
Age of onset 21.9 (6.6) 25.7 (8.6) 
/1.97 0.04
Total number of episodes 7.9 (5.7) 5.7 (15.9) 
/1.22 NS
Number of manic episodes 5.4 (6.5) 4.8 (7.1) 
/0.72 NS
Number of depressive episodes 4.3 (8.7) 4.0 (9.0) /0.76 NS
Number of hospitalizations 1.4 (2.1) 1.3 (1.6) 
/0.12 NS
BD, bipolar I disorder; SD, standard deviation.
a
Mann /Whitney test. NS, not significant.
Table III. Differential qualitative features between bipolar I patients with and without personality disorder comorbidity.
BD with personality
disorder comorbidity
(n
/40)
BD without personality
disorder comorbidity
(n/30)
n(%) n(%) df x2P
Sex 1 1.94 NS
Female 20 (50) 10 (33)
Male 20 (50) 20 (67)
First episode 1 0.26 NS
Manic 25 (63) 21 (70)
Depressive 14 (35) 9 (30)
Rapid cycling **NS
Present 1 (3) 2 (7)
Absent 39 (97) 28 (93)
Seasonal pattern 1 0.13 NS
Present 13 (33) 11 (37)
Absent 27 (67) 19 (63)
Psychotic symptoms 1 2.04 NS
Yes 28 (70) 16 (53)
No 12 (30) 14 (47)
Suicidal ideation 1 0.32 NS
Yes 16 (40) 10 (33)
No 24 (60) 20 (67)
Suicide attempts 1 0.21 NS
Yes 10 (25) 9 (30)
No 30 (75) 21 (70)
Family history of suicide 1 0.78 NS
Yes 7 (16) 3 (14)
No 33 (84) 27 (86)
Affective disorder in first-degree relatives 1 0.49 NS
Yes 18 (45) 11 (37)
No 22 (55) 19 (63)
Treatment 1 3.14 NS
Mood-stabilizer monotherapy 13 (33) 15 (50)
Polymedicated 24 (60) 11 (37)
BD, bipolar I disorder; NS, not significant.
*Fisher’s exact test.
Comorbid personality disorders in bipolar I patients 35

[4,5,12,20,21]. In two of the recent studies with
similar methodology and sample structure, Tamam
et al [5] found that 62% of bipolar I patients in
remission have at least one comorbid personality
disorder, whereas Ucok et al [6] reported a person-
ality disorder comorbidity rate of 48% among
euthymic bipolar I patients.
In the present study, we found that the majority of
bipolar I patients with axis II comorbidity had cluster
C personality disorders. This finding is consistent
with results of several recent studies [3 /5,21,22].
However, previous studies found that cluster B
diagnoses, specifically borderline personality disor-
der, are the most common comorbid axis II condi-
tions in subjects with bipolar disorder [23,24].
In this study, obsessive-compulsive personality
disorder (21%) was the most frequent comorbid
personality disorder in bipolar I patients. Similar
results have been reported in four studies conducted
in Europe [4,5,22,25]. One might speculate that
social factors such as cultural differences between
different societies (e.g., Turkey or Europe versus
North America) from which the result stem may
have exerted an influence, but we are not aware
of any empirical study testing such a hypothesis
adequately.
In our study group, we observed that bipolar
patients with personality disorder comorbidity have
earlier age of onset of bipolar disorder than those of
without comorbidity. It has been suggested that
personality disorders could lead patients to be
more vulnerable to affective disorders [5,24].
In the present contribution, we found that
younger bipolar I patients had more comorbid
personality disorders than those of older patients.
Brieger et al [25] reported that a longer duration of
affective disorders led to a lower frequency of
personality disorders. They suggested that a longer
duration of an affective illness makes it more difficult
to decide whether a patient has a personality
disorder or not may be clinically justified: a long-
standing affective illness may lead to ‘‘residual’’
personality changes in the form of ‘‘persisting
alterations’’ [26] which may be phemonenologically
different from the ‘‘standard’’ personality disorder
diagnoses, while in first-episode patients such per-
sonality disorder diagnoses may be easier to make.
This might lead to the seemingly paradoxical con-
sequence that patients with a chronic affective
disorder may exhibit more personality pathology
than first-episode patients, but at the same time
they do not fulfill the DSM-IV criteria for a
diagnosis of personality disorder as often as first
episode patients.
There is discussion that the mere presence of a
personality disorder is not highly relevant for course
and outcome, while the presence of specific person-
ality disorders is important. Bieling et al [9] reported
that Cluster A personality disorders were the stron-
gest predictor of poor outcome. The Cluster B
comorbidity was found to be associated with sig-
nificantly more lifetime suicide attempts and current
depression in bipolar patients [27]. The sample size
of this study was too small to test such a hypothesis.
It should be noted that our findings may not be
generalizable to all bipolar patients. First, the sample
size of this study is relatively small. Second, we
screened only a given sample in a tertiary level
university hospital. Another limitation of this study
lays on the retrospective recall of some variables,
which may certainly bias some results.
In summary, personality disorders are prevalent in
patients with bipolar I disorder. Besides, the pre-
sence of comorbidity has no relevant impact on the
course of bipolar I patients except for earlier age of
onset of bipolar I disorder. Future studies with larger
number of subjects will be needed to identify the
relationship between personality disorders and bipo-
lar disorders, and to help develop treatment strate-
gies for subjects who have comorbid bipolar and
personality disorders.
Key points
.Comorbid personality disorders are prevalent in
patients with bipolar I disorder
.Patients with comorbid personality disorders
had an earlier age of onset than those of without
comorbidity
.The presence of personality disorder comorbid-
ity has no relevant impact on the course of
bipolar I patients except for earlier age of onset
of bipolar I disorder
Statement of interest
The authors have no conflict of interest with any
commercial or other associations in connection with
the submitted article.
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Comorbid personality disorders in bipolar I patients 37