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Perimenstrual exacerbation of symptoms in borderline personality disorder: evidence from multilevel models and the Carolina Premenstrual Assessment Scoring System

Published online by Cambridge University Press:  28 May 2018

Tory A. Eisenlohr-Moul ,
Katja M. Schmalenberger ,
Sarah A. Owens ,
Jessica R. Peters ,
Danyelle N. Dawson  and
Susan S. Girdler
Tory A. Eisenlohr-Moul*
Affiliation:
The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA University of Illinois at Chicago, Chicago, IL, USA
Katja M. Schmalenberger
Affiliation:
Heidelberg University, Heidelberg, Germany
Sarah A. Owens
Affiliation:
The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Jessica R. Peters
Affiliation:
Warren Alpert Medical School of Brown University, Providence, RI, USA
Danyelle N. Dawson
Affiliation:
University of Illinois at Urbana-Champaign, Champaign, IL, USA
Susan S. Girdler
Affiliation:
The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
*
Author for correspondence: Tory A. Eisenlohr-Moul, E-mail: [email protected]
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Abstract

Background

Individuals with a borderline personality disorder (BPD) suffer from a constellation of rapidly shifting emotional, interpersonal, and behavioral symptoms. The menstrual cycle may contribute to symptom instability among females with this disorder.

Methods

Fifteen healthy, unmedicated females with BPD and without dysmenorrhea reported daily symptoms across 35 days. Urine luteinizing hormone and salivary progesterone (P4) were used to confirm ovulation and cycle phase. Cyclical worsening of symptoms was evaluated using (1) phase contrasts in multilevel models and (2) the Carolina Premenstrual Assessment Scoring System (C-PASS), a protocol for evaluating clinically significant cycle effects on symptoms.

Results

Most symptoms demonstrated midluteal worsening, a perimenstrual peak, and resolution of symptoms in the follicular or ovulatory phase. Post-hoc correlations with person-centered progesterone revealed negative correlations with most symptoms. Depressive symptoms showed an unexpected delayed pattern in which baseline levels of symptoms were observed in the ovulatory and midluteal phases, and exacerbations were observed during both the perimenstrual and follicular phases. The majority of participants met C-PASS criteria for clinically significant (⩾30%) symptom exacerbation. All participants met the emotional instability criterion of BPD, and no participant met DSM-5 criteria for premenstrual dysphoric disorder (PMDD).

Conclusions

Females with BPD may be at elevated risk for perimenstrual worsening of emotional symptoms. Longitudinal studies with fine-grained hormonal measurement as well as hormonal experiments are needed to determine the pathophysiology of perimenstrual exacerbation in BPD.

Keywords

Borderline personality disordermenstrual cycleovarian steroid hormones
Type
Original Articles
Information
Psychological Medicine , Volume 48 , Issue 12 , September 2018 , pp. 2085 - 2095
Copyright
Copyright © Cambridge University Press 2018 

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References

Aviram, RB, Brodsky, BS and Stanley, B (2006) Borderline personality disorder, stigma, and treatment implications. Harvard Review of Psychiatry 14, 249–256.Google Scholar
Baer, RA and Sauer, SE (2011) Relationships between depressive rumination, anger rumination, and borderline personality features. Personality Disorders 2, 142–150.Google Scholar
Ball, JS and Links, PS (2009) Borderline personality disorder and childhood trauma: evidence for a causal relationship. Springer Current Psychiatry Reports 11, 63–68.Google Scholar
Bateman, AW and Fonagy, P (2004) Mentalization-based treatment of BPD. Journal of Personality Disorders 18, 36–51.Google Scholar
Beck, AT and Steer, RA (1987) Manual for the Revised Beck Depression Inventory. San Antonio, TX: Psychological Corporation.Google Scholar
Bender, DS, Dolan, RT, Skodol, AE, Sanislow, CA, Dyck, IR, McGlashan, TH, Shea, MT, Zanarini, MC, Oldham, JM and Gunderson, JG (2001) Treatment utilization by patients with personality disorders. The American Journal of Psychiatry 158, 295–302.Google Scholar
Ben Dor, R, Harsh, VL, Fortinsky, P, Koziol, DE, Rubinow, DR and Schmidt, PJ (2013) Effects of pharmacologically induced hypogonadism on mood and behavior in healthy young women. The American Journal of Psychiatry 170, 426–433.Google Scholar
Bernstein, DP, Fink, L, Handelsman, L, Foote, J, Lovejoy, M, Wenzel, K, Sapareto, E and Ruggiero, J (1994) Initial reliability and validity of a new retrospective measure of child abuse and neglect. The American Journal of Psychiatry 151, 1132.Google Scholar
Bloch, M, Schmidt, PJ, Danaceau, M, Murphy, J, Nieman, L and Rubinow, DR (2000) Effects of gonadal steroids in women with a history of postpartum depression. The American Journal of Psychiatry 157, 924–930.Google Scholar
DeSoto, MC (2007) Borderline personality disorder, gender and serotonin: does estrogen play a role? In Czerbaska, MT (ed.), Psychoneuroendocrinology Research Trends 2007. New York: Nova Science Publishers Inc., pp. 149–160.Google Scholar
DeSoto, MC, Geary, DC, Hoard, MK, Sheldon, MS and Cooper, L (2003) Estrogen fluctuations, oral contraceptives and borderline personality. Psychoneuroendocrinology 28, 751–766.Google Scholar
Edler, C, Lipson, SF and Keel, PK (2007) Ovarian hormones and binge eating in bulimia nervosa. Psychological Medicine 37, 131–141.Google Scholar
Eisenlohr-Moul, TA, DeWall, CN, Girdler, SS and Segerstrom, SC (2015) Ovarian hormones and borderline personality disorder features: preliminary evidence for interactive effects of estradiol and progesterone. Biological Psychology 109, 37–52.Google Scholar
Eisenlohr-Moul, TA, Rubinow, DR, Schiller, CE, Johnson, JL, Leserman, J and Girdler, SS (2016) Histories of abuse predict stronger within-person covariation of ovarian steroids and mood symptoms in women with menstrually related mood disorder. Psychoneuroendocrinology 67, 142–152.Google Scholar
Eisenlohr-Moul, TA, Girdler, SS, Johnson, JL, Schmidt, PJ and Rubinow, DR (2017 a) Treatment of premenstrual dysphoria with continuous versus intermittent dosing of oral contraceptives: results of a three-arm randomized controlled trial. Depression and Anxiety 34, 908–917.Google Scholar
Eisenlohr-Moul, TA, Girdler, SS, Schmalenberger, KM, Dawson, DN, Surana, P, Johnson, JL and Rubinow, DR (2017b) Toward the reliable diagnosis of DSM-5 premenstrual dysphoric disorder: the Carolina premenstrual assessment scoring system (C-PASS). The American Journal of Psychiatry 174, 51–59.Google Scholar
Endicott, J, Nee, J and Harrison, W (2006) Daily record of severity of problems (DRSP): reliability and validity. Archives of Women's Mental Health 9, 41–49.Google Scholar
Epperson, CN, Steiner, M, Hartlage, SA, Eriksson, E, Schmidt, PJ, Jones, I and Yonkers, KA (2012) Premenstrual dysphoric disorder: evidence for a new category for DSM-5. The American Journal of Psychiatry 169, 465–475.Google Scholar
First, MB, Spitzer, RL, Gibbons, M, Williams, JBW and Benjamin, L (1996) User's Guide for the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). New York: Biometrics Research Dept, New York State Psychiatric Institute.Google Scholar
Freeman, EW, Halberstadt, SM, Rickels, K, Legler, JM, Lin, H and Sammel, MD (2011) Core symptoms that discriminate premenstrual syndrome. Journal of Women's Health 20, 29–35.Google Scholar
Gollenberg, AL, Hediger, ML, Mumford, SL, Whitcomb, BW, Hovey, KM, Wactawski-Wende, J and Schisterman, EF (2010) Perceived stress and severity of perimenstrual symptoms: the BioCycle study. Journal of Women's Health 19, 959–967.Google Scholar
Gordon, JL, Girdler, SS, Meltzer-Brody, SE, Stika, CS, Thurston, RC, Clark, CT, Prairie, BA, Moses-Kolko, E, Joffe, H and Wisner, KL (2015) Ovarian hormone fluctuation, neurosteroids, and HPA axis dysregulation in perimenopausal depression: a novel heuristic model. The American Journal of Psychiatry 172, 227–236.Google Scholar
Gordon, JL, Rubinow, DR, Eisenlohr-Moul, TA, Leserman, J and Girdler, SS (2016) Estradiol variability, stressful life events, and the emergence of depressive symptomatology during the menopausal transition. Menopause 23, 257–266.Google Scholar
Halbreich, U, Endicott, J, Schacht, S and Nee, J (1982) The diversity of premenstrual changes as reflected in the premenstrual assessment form. Acta Psychiatrica Scandinavica 65, 46–65.Google Scholar
Hammarbäck, S, Ekholm, UB and Bäckström, T (1991) Spontaneous anovulation causing disappearance of cyclical symptoms in women with the premenstrual syndrome. Acta Endocrinologica 125, 132–137.Google Scholar
Hartlage, SA and Arduino, KE (2002) Toward the content validity of premenstrual dysphoric disorder: do anger and irritability more than depressed mood represent treatment-seekers' experiences? Psychological Reports 90, 189–202.Google Scholar
Hartlage, SA, Brandenburg, DL and Kravitz, HM (2004) Premenstrual exacerbation of depressive disorders in a community-based sample in the United States. Psychosomatic Medicine 66, 698–706.Google Scholar
Hengartner, MP, Kruger, THC, Geraedts, K, Tronci, E, Mancini, T, Ille, F, Egli, M, Röblitz, S, Ehrig, R, Saleh, L, Spanaus, K, Schippert, C, Zhang, Y and Leeners, B (2017) Negative affect is unrelated to fluctuations in hormone levels across the menstrual cycle: evidence from a multisite observational study across two successive cycles. Journal of Psychosomatic Research 99, 21–27.Google Scholar
Hyler, SE, Skodol, AE, Oldham, JM, Kellman, HD and Doidge, N (1992) Validity of the personality diagnostic questionnaire-revised: a replication in an outpatient sample. Comprehensive Psychiatry 33, 73–77.Google Scholar
Klump, KL, Keel, PK, Racine, SE, Burt, SA, Burt, AS, Neale, M, Sisk, CL, Boker, S and Hu, JY (2013) The interactive effects of estrogen and progesterone on changes in emotional eating across the menstrual cycle. Journal of Abnormal Psychology 122, 131–137.Google Scholar
Leeners, B, Kruger, THC, Geraedts, K, Tronci, E, Mancini, T, Ille, F, Egli, M, Röblitz, S, Saleh, L, Spanaus, K, Schippert, C, Zhang, Y and Hengartner, MP (2017) Lack of associations between female hormone levels and visuospatial working memory, divided attention and cognitive bias across two consecutive menstrual cycles. Frontiers in Behavioral Neuroscience 11, 120.Google Scholar
Linehan, MM (2014) DBT Skills Training Manual, 2nd Edn. New York, NY: Guilford Press.Google Scholar
Linehan, MM, Comtois, KA, Murray, AM, Brown, MZ, Gallop, RJ, Heard, HL, Korslund, KE, Tutek, DA, Reynolds, SK and Lindenboim, N (2006) Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry 63, 757–766.Google Scholar
Löfgren, M, Johansson, I-M, Meyerson, B, Turkmen, S and Bäckström, T (2009) Withdrawal effects from progesterone and estradiol relate to individual risk-taking and explorative behavior in female rats. Physiology & Behavior 96, 91–97.Google Scholar
Lynam, DR and Widiger, TA (2001) Using the five-factor model to represent the DSM-IV personality disorders: an expert consensus approach. Journal of Abnormal Psychology 110, 401–412.Google Scholar
Marschall, D, Sanftner, J and Tangney, JP (1994) The State Shame and Guilt Scale. Fairfax, VA: George Mason University.Google Scholar
Martel, MM, Eisenlohr-Moul, T and Roberts, B (2017) Interactive effects of ovarian steroid hormones on alcohol use and binge drinking across the menstrual cycle. Journal of Abnormal Psychology 126, 1104.Google Scholar
Martinez, PE, Rubinow, DR, Nieman, LK, Koziol, DE, Leslie Morrow, A, Schiller, CE, Cintron, D, Thompson, KD, Khine, KK and Schmidt, PJ (2013) 5α-Reductase inhibition prevents the luteal phase increase in plasma allopregnanolone levels and mitigates symptoms in women with premenstrual dysphoric disorder. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology 41, 1093–1102.Google Scholar
Morey, LC (2007) Personality Assessment Inventory (PAI): Professional Manual. Odessa, FL: Psychological Assessment Resources.Google Scholar
Nillni, YI, Pineles, SL, Patton, SC, Rouse, MH, Sawyer, AT and Rasmusson, AM (2015) Menstrual cycle effects on psychological symptoms in women with PTSD. Journal of Traumatic Stress 28, 1–7.Google Scholar
Paris, J and Zweig-Frank, H (2001) A 27-year follow-up of patients with borderline personality disorder. Comprehensive Psychiatry 42, 482–487.Google Scholar
Pearlstein, T, Yonkers, KA, Fayyad, R and Gillespie, JA (2005) Pretreatment pattern of symptom expression in premenstrual dysphoric disorder. Journal of Affective Disorders 85, 275–282.Google Scholar
Peters, JR, Upton, BT and Baer, RA (2013) Brief report: relationships between facets of impulsivity and borderline personality features. Journal of Personality Disorders 27, 547–552.Google Scholar
Peters, JR, Eisenlohr-Moul, TA, Upton, BT, Talavera, NA, Folsom, JJ, Baer, RA (2017) Characteristics of repetitive thought associated with borderline personality features: a multimodal investigation of ruminative content and style. Journal of Psychopathology and Behavioral Assessment 39, 456–466.Google Scholar
Putnam, KT, Wilcox, M, Robertson-Blackmore, E, Sharkey, K, Bergink, V, Munk-Olsen, T, Deligiannidis, KM, Payne, J, Altemus, M, Newport, J, Apter, G, Devouche, E, Viktorin, A, Magnusson, P, Penninx, B, Buist, A, Bilszta, J, O'Hara, M, Stuart, S, Brock, R, Roza, S, Tiemeier, H, Guille, C, Epperson, CN, Kim, D, Schmidt, P, Martinez, P, Di Florio, A, Wisner, KL, Stowe, Z, Jones, I, Sullivan, PF, Rubinow, D, Wildenhaus, K, Meltzer-Brody, S, Postpartum Depression: Action Towards Causes and Treatment (PACT) Consortium (2017) Clinical phenotypes of perinatal depression and time of symptom onset: analysis of data from an international consortium. The Lancet Psychiatry 4, 477–485.Google Scholar
Roy-Byrne, PP, Rubinow, DR, Hoban, MC, Parry, BL, Rosenthal, NE, Nurnberger, JI and Byrnes, S (1986) Premenstrual changes: a comparison of five populations. Psychiatry Research 17, 77–85.Google Scholar
Saunders, KEA and Hawton, K (2006) Suicidal behaviour and the menstrual cycle. Psychological Medicine 36, 901–912.Google Scholar
Schiller, CE, Schmidt, PJ and Rubinow, DR (2014) Allopregnanolone as a mediator of affective switching in reproductive mood disorders. Psychopharmacology 231, 3557–3567.Google Scholar
Schiller, CE, Johnson, SL, Abate, AC, Schmidt, PJ and Rubinow, DR (2016) Reproductive steroid regulation of mood and behavior. Comprehensive Physiology 6, 1135–1160.Google Scholar
Schmidt, PJ, Nieman, LK, Danaceau, MA, Adams, LF and Rubinow, DR (1998) Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. The New England Journal of Medicine 338, 209–216.Google Scholar
Schmidt, PJ, Keenan, PA, Schenkel, LA, Berlin, K, Gibson, C and Rubinow, DR (2013) Cognitive performance in healthy women during induced hypogonadism and ovarian steroid addback. Archives of Women's Mental Health 16, 47–58.Google Scholar
Schmidt, PJ, Ben Dor, R, Martinez, PE, Guerrieri, GM, Harsh, VL, Thompson, K, Koziol, DE, Nieman, LK and Rubinow, DR (2015) Effects of estradiol withdrawal on mood in women With past perimenopausal depression: a randomized clinical trial. JAMA Psychiatry 72, 714–726.Google Scholar
Schwartz, DH, Romans, SE, Meiyappan, S, De Souza, MJ and Einstein, G (2012) The role of ovarian steroid hormones in mood. Hormones and Behavior 62, 448–454.Google Scholar
Smith, SS, Ruderman, Y, Frye, C, Homanics, G and Yuan, M (2006) Steroid withdrawal in the mouse results in anxiogenic effects of 3α,5β-THP: a possible model of premenstrual dysphoric disorder. Psychopharmacology 186, 323–333.Google Scholar
Snijders, TA (2005) Power and sample size in multilevel linear models. In Everitt, BS and Howell, DC (eds.), Encyclopedia of Statistics in Behavioral Science, Vol. 3. New York: Wiley, pp. 1570–1573.Google Scholar
Spielberger, C, Gorsuch, R, Lushene, R, Vagg, P and Jacobs, G (1983) Manual for the State-Trait Anxiety Inventory (Form Y). Palo Alto, CA: Consulting Psychologists Press.Google Scholar
Stein, MB, Schmidt, PJ, Rubinow, DR and Uhde, TW (1989) Panic disorder and the menstrual cycle: panic disorder patients, healthy control subjects, and patients with premenstrual syndrome. The American Journal of Psychiatry 146, 1299–1303.Google Scholar
Stoffel, EC and Craft, RM (2004) Ovarian hormone withdrawal-induced “depression” in female rats. Physiology & Behavior 83, 505–513.Google Scholar
Sukhodolsky, DG, Golub, A and Cromwell, EN (2001) Development and validation of the anger rumination scale. Personality and Individual Differences 31, 689–700.Google Scholar
Terner, JM and de Wit, H (2006) Menstrual cycle phase and responses to drugs of abuse in humans. Drug and Alcohol Dependence 84, 1–13.Google Scholar
Ziv, B, Russ, MJ, Moline, M, Hurt, S and Zendell, S (1995) Menstrual cycle influences On mood and behavior in women With borderline personality disorder. Journal of Personality Disorders 9, 68–75.Google Scholar
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