Article
Increased serum prolactin in borderline personality disorder
The International Journal of Psychiatry in Medicine 2015, Vol. 49(3) 169–175 ß The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0091217415582172 ijp.sagepub.com
Murad Atmaca1, Sevda Korkmaz2, Bilal Ustundag3, and Yusuf Ozkan4
Abstract Although there is an important interaction between serotonergic system, prolactin and suicidal behavior, and impulsivity, no investigation examined the prolactin values in borderline personality disorder in which suicidal behavior and impulsivity are core symptom dimensions. In this context, in the present investigation, we planned to measure serum prolactin levels in the patients with borderline personality disorder. The study comprised 15 patients with borderline personality disorder and 15 healthy controls. Prolactin values were measured in both patients and control subjects. The patients had abnormally higher mean value of prolactin compared to those of healthy controls (48.66 36.48 mg/dl for patients vs. 15.20 7.81 mg/dl for healthy controls). There was no correlation between prolactin values and any demographic variables for both the patients and control subjects. In conclusion, our present results suggest that prolactin values increased in the patients with borderline personality disorder and are required to be replicated by more comprehensive and detailed further studies to decipher the exact roles of prolactin increase. Keywords Prolactin, borderline personality disorder, serotonin
Introduction DSM 51 describes the borderline personality disorder as moderate or greater impairment in personality functioning, manifest by characteristic difficulties in 1
Department of Psychiatry, School of Medicine, Firat University, Elazig, Turkey Elazig Mental Health Hospital, Elazig, Turkey 3 Department of Clinical Biochemistry, School of Medicine, Firat University, Elazig, Turkey 4 Department of Endocrinology, School of Medicine, Firat University, Elazig, Turkey 2
Corresponding author: Murad Atmaca, Psikiyatri Anabilim Dali, Firat Tip Merkezi, Firat (Euphrates) Universitesi, 23119 Elazig, Turkey. Email: [email protected]
170
The International Journal of Psychiatry in Medicine 49(3)
two or more of the following four areas: identity, self-direction, empathy, and intimacy. Apart from this, emotional lability, anxiousness, seperation insecurity, depressiveness, impulsivity, risk taking, and hostility are important clinical features. The other main features of clinical presentation are aggression in determining self-harm and suicidal risk in these patients. Clinicians have to pay attention to prevent suicide and social impairment associated with impulsivity and aggression.2 The etiopathogenesis of borderline personality disorder has not been established. However, among the main symptoms of the disorder, it has been suggested emotional dysregulation and impulsivity develop via the interaction of multiple genetic factors and distressing childhood experiences.3 The core symptoms of borderline personality disorder, such as impulsivity, aggressive behaviors, and suicide, have been linked to low or lowered by pharmacologically reduced serum cholesterol.4 On the other hand, an association between violence and reduced cholesterol values has been reported in the criminal patients such as antisocial personality disorder.5 In this context, we evaluated serum cholesterol and leptin levels in the patients with borderline personality disorder and healthy controls.6 In that study, we found that cholesterol and leptin values of the patients with borderline personality disorder were decreased and that there was an inverse correlation between cholesterol values and Barratt Impulsivity Scale and Buss Durkee Hostility Scale. We concluded that low serum cholesterol and leptin levels might be associated with all dimensions of the borderline personality disorder, such as impulsivity, aggression, and suicidality, but for the presence or severity of comorbid depression. As observed indirectly via measuring cerebrospinal fluid 5-hydroxy indole acetic acid, or by neuroendocrinologic responses to challenge with serotonergic agonists such as d-fenfluramine and meta-chlorophenylpiperazine, core dimensions of borderline personality disorder such as impulsivity and suicidal behavior are related to the indices of diminished central serotonergic function.7–9 It has been shown that lower serotonergic functioning may be a marker of increased suicide risk in patients with major depression10 and schizophrenia11 by using a prolactin response to the d-fenfluramine test. Pompili et al.12 reported that both prolactin and thyroid hormones might be involved in a complex compensatory mechanism to correct reduced central serotonin activity. Prolactin is a hormone that is released from the anterior part of the pituitary gland. The level of prolactin is determined by dopamine which is secreted by neuron terminals in the hypothalamus median eminence to veins of the pituitary.3 Thus, prolactin is controlled by the dopaminergic system. Although there is an important interaction between serotonergic system, prolactin and suicidal behavior, and impulsivity, no investigation examined the prolactin values in borderline personality disorder in which suicidal behavior and impulsivity are core symptom dimensions. In this context, in the present investigation, we planned to measure serum prolactin levels in the patients with borderline personality disorder and hypothesized that prolactin values might
Atmaca et al.
171
be changed because of the complex mechanisms and associations aforementioned12 in the patients with borderline personality disorder.
Materials and methods The present study included inpatients or outpatients by chart review who had had borderline personality disorder according to DSM-IV and had been evaluated in terms of prolactin values for a variety of reasons at the Department of Psychiatry or Endocrionology Departments, Firat University Hospital, Elazig. The patients were consecutively recruited. Chart review was done by one senior psychiatrist (SK). Initially, there were 19 patients with borderline personality disorder. But four were not included into the investigation because of a variety of reasons such as endocrinologic disorder (prolactinoma in one patient), severe organic disease (diabetes mellitus in one patient and romatoid arthritis in another one), and finally, use of hormone preparat (oral contraceptive for medical reasons in one patient). All patients were females. Only the patients without any axis I disorder were included into the study. Diagnosing borderline personality disorder had been done by using Turkish version of the Structured Clinical Interview13 performed by one senior psychiatrist. Control group comprised 15 age- and sex-matched healthy female subjects according to exclusion criteria among the people who had applied to our hospital and were not determined any medical and psychiatric illness via chart review. In addition, control subjects were age- and gender matched with the patients. In the present investigation, the patients were excluded if they had (1) alcohol and substance abuse or dependence, (2) an important medical problem such as prolactinoma, pheochromocytoma, carsinoid tumor, any other endocrinopathy, (3) use of glucocorticoids and oral contraceptives, (4) use of any psychotropic drugs, and (5) excessive obesity. In addition to all above, all patients and controls were subjectto free of all medications at least in the previous two weeks. Subjects having normal results and without any exclusion criteria were admitted to the study. Hamilton Depression Rating Scale (HDRS)14 was administered to the subjects. The study was approved by the Local Ethics Committee. All venous blood samples had been obtained between 8:00 a.m. and 10:00 a.m. in order to detect the prolactin oncentrations. The samples obtained had been immediately centrifuged, and the serum samples had been stored at 20 C until thawing for the analysis. Blood samples were sent to a centralized laboratory that performed analysis following standard procedures. The prolactin values had been measured by using chemiluminoassay method using BIODPC kit (Immulyte 2000, Diagnostic Product Co., Los Angeles, CA, USA). Sensitivity of this assay is 0.60 ng/ mL; upper limits of prolactin are 15 ng/mL for males and 20 ng/mL for females.15 All the analyses were performed with the Statistical Package for Social Sciences (SPSS) for Windows 13.0; t-tests for independent samples were performed to identify differences in biochemical and sociodemographic variables
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The International Journal of Psychiatry in Medicine 49(3)
Table 1. Demographic and clinical characteristics of the patients and healthy controls. Borderline patients (n ¼ 20) Demographic and clinical parameters Age 30.00 7.42 Gender (female/male) 15/0 Ethnicity Caucasian 15 Socioeconomic status Good 4 Moderate 6 Poor 5 HDRS scores 11.07 5.48
Controls (n ¼ 20) 32.27 5.13 15/0 15 3 7 5 6.47 2.64*
HDRS: Hamilton Depression Rating Scale. *p < 0.01.
measured on the dimensional scale, and one-way Fisher exact tests and chisquared tests were performed to identify associations between variables measured on nominal scales. Pearson’s method of correlation was also used. Differences were considered significant at p < 0.05 for all these tests.
Results The mean age was 30.00 7.42 for patients with borderline personality disorder and 32.27 5.13 for healthy controls. All subjects were females. There were no statistically significant differences between groups with respect to the demographic characteristics including socioeconomical status, gender, or age (p > 0.05). The mean HDRS score was 11.07 5.48 for the patients with borderline personality disorder and 6.47 2.64 for the control subjects (p ¼ 0.007) (Table 1). The prolactin levels were increased in 10 patients (66.7%) and in two control subjects (13.3%), when individually compared with normal range of prolactin values. The patients had abnormally higher mean value of prolactin compared to those of healthy controls (48.66 36.48 mg/dl for patients vs. 15.20 7.81 mg/dl for healthy controls; p ¼ 0.002) (Figure 1). There was no correlation between prolactin values, HDRS, or and any demographic variables for both the patients and control subjects (p > 0.05).
Discussion In the present investigation, we examined serum prolactin values in the patients with borderline personality disorder. Consequently, we found that the prolactin levels were increased in nine patients (66.6%) and in one control subject, when
Atmaca et al.
173
120,00
PRL
80,00
40,00
0,00 P a tie n ts
Co nt ro ls
Groups Figure 1. Boxplot of prolactin values of the groups.
individually compared with normal range of prolactin values and that the patients had abnormally higher mean value of prolactin compared to those of healthy controls, without any correlation between prolactin values and any demographic variables, age, or HDRS scores for both the patients and control subjects. In many investigations, reduced indices of central serotonergic function have been found to be associated with attempted or completed suicide, moreover, with suicide attempt consisting of violent components.16 Furthermore, it has been described that independent of history of suicidal behavior, there has been a blunted prolactin response to serotonergic agonists, and an inverse relationship between prolactin response and behavioral impulsivity, in patients with borderline personality disorder.17–19 On the other hand, Pompili et al.12 examined a group of patients with major depressive disorder, bipolar disorder, and psychotic disorders in regard to the values of free triiodothyronine and prolactin, dividing the whole group into two subgroups as suicide attempters and no-attempters and found a significant effect of sex and suicidal status and the interaction between sex and suicidal status on prolactin levels. They concluded that both prolactin and thyroid hormones might be involved in a complex compensatory mechanism to correct
174
The International Journal of Psychiatry in Medicine 49(3)
reduced central serotonin activity. We do not know the exact mechanism of increased prolactin values in the patients with borderline personality disorder, which is found in the present study. It is probably a complex nature. The finding of our present investigation that the patients with borderline personality disorder had abnormally higher mean value of prolactin compared to those of healthy controls led us to consider that altered 5-HT function might have provoked a cascade of biological modifications, resulting in increased prolactin levels. There are some methodological limitations of the present study that must be acknowledged. First, the relatively small sample size might not be representative of the patients with borderline personality disorder. Second, the fact that all patients were female is another main limitation. Third, the present investigation has a relatively simple design. We did not evaluate related factors affecting prolactin values. Fourth, in the present investigation, a link between prolactin values and symptom dimensions such as impulsivity and suicidality was not examined. Fifth, the inclusion of a mixed sample of patients, both inpatients and outpatients, is another relevant limitation of the present study. Sixth, all subjects were female, and this may further limit the relevance of the main findings. Finally, a scale for impulsivity and suicidality and their relationships with prolactin values were not obtained in the present study. This was another limitation. In conclusion, our present results suggest that prolactin values were increased in the patients with borderline personality disorder. So, our hypothesis that prolactin values might be changed because of the complex mechanisms and associations mentioned in the Introduction section12 in the patients with borderline personality disorder was correct. However, our results are required to be replicated by more comprehensive and detailed further studies to decipher the exact roles of prolactin increase. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing, 2013. 2. Pompili M, Serafini G, Innamorati M, et al. Impulsivity, aggression, and suicide risk in patients with schizophrenia. Psychiatr Ann 2013; 43: 458–462. 3. Nemoda Z, Lyons-Ruth K, Szekely A, et al. Association between dopaminergic polymorphisms and borderline personality traits among at-risk young adults and psychiatric inpatients. Behav Brain Funct 2010; 6: 4.
Atmaca et al.
175
4. Muldoon MF, Manuck SB and Matthews KA. Lowering cholestrol concentraion and mortality: a quantitative review of primary prevantion trials. BMJ 1990; 301: 309–314. 5. Virkunnen M. Serum cholestrol in antisocial personality disorder. Neuropsychobiology 1979; 5: 27–30. 6. Atmaca M, Kuloglu M, Tezcan E, et al. Serum cholesterol and leptin levels in patients with borderline personality disoerder. Neuropsychobiology 2002; 45: 167–171. 7. Oquendo MA and Mann JJ. The biology of impulsivity and suicidality. Psychiatr Clin N Am 2000; 23: 11–25. 8. Coccaro EF, Gabriel S, Mahon T, et al. Preliminary evidence of a serotonin (5-HT-1like) component to the prolactin response to buspirone challenge in humans. Arch Gen Psychiatr 1990; 47: 594–595. 9. Stanley M, Mann JJ and Cohen LS. Serotonin and serotonergic receptors in suicide. Ann New York Acad Sci 1986; 487: 122–127. 10. Correa H, Duval F, Mokrani M, et al. Prolactin response to D-fenfluramine and suicidal behavior in depressed patients. Psychiatr Res 2000; 10: 189–199. 11. Correa H, Duval F, Mokrani MC, et al. Serotonergic function and suicidal behavior in schizophrenia. Schizophr Res 2002; 56: 75–85. 12. Pompili M, Gibiino S, Innamorati M, et al. Prolactin and thyroid hormone levels are associated with suicide attempts in psychiatric patients. Psychiatr Res 2012; 30: 389–394. 13. Sorias S, Saygılı R and Elbi H. DSM-III-R Yapılandırılmıs¸ Klinik Go¨ru¨s¸mesi Tu¨rkc¸e versiyonu, Kis¸ilik Bozuklukları Formu: SCID-IIIzmir: Ege U¨niversitesi Basımevi. 14. Hamilton M. The assesment of anxiety states by rating. Br J Med Psychol 1959; 32: 50–55. 15. Kuruvilla A, Peedicayil J, Srikrishna G, et al. A study of serum prolactin levels in schizophrenia: comparison of males and females. Clin Exp Pharmacol Physiol 1992; 19: 603–606. 16. Asberg M, Traskman L and Thoren P. 5-HIAA in the cerebrospinal fluid A biochemical suicide predictor? Arch Gen Psychiatr 1976; 33: 1193–1197. 17. Coccaro EF, Siever LJ, Klar HM, et al. Serotonergic studies in patients with affective and personality disorders. Correlates with suicidal and impulsive aggressive behavior. Arch Gen Psychiatr 1989; 46: 587–599. 18. O’Keane V, Moloney E, O’Neill H, et al. Blunted prolactin responses to d-fenfluramine in sociopathy. Evidence for subsensitivity of central serotonergic function. Br J Psychiatr 1992; 160: 643–646. 19. Moss HB, Yao JK and Panzak GL. Serotonergic responsivity and behavioral dimensions in antisocial personality disorder with substance abuse. Biol Psychiatr 1990; 15: 325–338.
Increased serum prolactin in borderline personality disorder
The International Journal of Psychiatry in Medicine 2015, Vol. 49(3) 169–175 ß The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0091217415582172 ijp.sagepub.com
Murad Atmaca1, Sevda Korkmaz2, Bilal Ustundag3, and Yusuf Ozkan4
Abstract Although there is an important interaction between serotonergic system, prolactin and suicidal behavior, and impulsivity, no investigation examined the prolactin values in borderline personality disorder in which suicidal behavior and impulsivity are core symptom dimensions. In this context, in the present investigation, we planned to measure serum prolactin levels in the patients with borderline personality disorder. The study comprised 15 patients with borderline personality disorder and 15 healthy controls. Prolactin values were measured in both patients and control subjects. The patients had abnormally higher mean value of prolactin compared to those of healthy controls (48.66 36.48 mg/dl for patients vs. 15.20 7.81 mg/dl for healthy controls). There was no correlation between prolactin values and any demographic variables for both the patients and control subjects. In conclusion, our present results suggest that prolactin values increased in the patients with borderline personality disorder and are required to be replicated by more comprehensive and detailed further studies to decipher the exact roles of prolactin increase. Keywords Prolactin, borderline personality disorder, serotonin
Introduction DSM 51 describes the borderline personality disorder as moderate or greater impairment in personality functioning, manifest by characteristic difficulties in 1
Department of Psychiatry, School of Medicine, Firat University, Elazig, Turkey Elazig Mental Health Hospital, Elazig, Turkey 3 Department of Clinical Biochemistry, School of Medicine, Firat University, Elazig, Turkey 4 Department of Endocrinology, School of Medicine, Firat University, Elazig, Turkey 2
Corresponding author: Murad Atmaca, Psikiyatri Anabilim Dali, Firat Tip Merkezi, Firat (Euphrates) Universitesi, 23119 Elazig, Turkey. Email: [email protected]
170
The International Journal of Psychiatry in Medicine 49(3)
two or more of the following four areas: identity, self-direction, empathy, and intimacy. Apart from this, emotional lability, anxiousness, seperation insecurity, depressiveness, impulsivity, risk taking, and hostility are important clinical features. The other main features of clinical presentation are aggression in determining self-harm and suicidal risk in these patients. Clinicians have to pay attention to prevent suicide and social impairment associated with impulsivity and aggression.2 The etiopathogenesis of borderline personality disorder has not been established. However, among the main symptoms of the disorder, it has been suggested emotional dysregulation and impulsivity develop via the interaction of multiple genetic factors and distressing childhood experiences.3 The core symptoms of borderline personality disorder, such as impulsivity, aggressive behaviors, and suicide, have been linked to low or lowered by pharmacologically reduced serum cholesterol.4 On the other hand, an association between violence and reduced cholesterol values has been reported in the criminal patients such as antisocial personality disorder.5 In this context, we evaluated serum cholesterol and leptin levels in the patients with borderline personality disorder and healthy controls.6 In that study, we found that cholesterol and leptin values of the patients with borderline personality disorder were decreased and that there was an inverse correlation between cholesterol values and Barratt Impulsivity Scale and Buss Durkee Hostility Scale. We concluded that low serum cholesterol and leptin levels might be associated with all dimensions of the borderline personality disorder, such as impulsivity, aggression, and suicidality, but for the presence or severity of comorbid depression. As observed indirectly via measuring cerebrospinal fluid 5-hydroxy indole acetic acid, or by neuroendocrinologic responses to challenge with serotonergic agonists such as d-fenfluramine and meta-chlorophenylpiperazine, core dimensions of borderline personality disorder such as impulsivity and suicidal behavior are related to the indices of diminished central serotonergic function.7–9 It has been shown that lower serotonergic functioning may be a marker of increased suicide risk in patients with major depression10 and schizophrenia11 by using a prolactin response to the d-fenfluramine test. Pompili et al.12 reported that both prolactin and thyroid hormones might be involved in a complex compensatory mechanism to correct reduced central serotonin activity. Prolactin is a hormone that is released from the anterior part of the pituitary gland. The level of prolactin is determined by dopamine which is secreted by neuron terminals in the hypothalamus median eminence to veins of the pituitary.3 Thus, prolactin is controlled by the dopaminergic system. Although there is an important interaction between serotonergic system, prolactin and suicidal behavior, and impulsivity, no investigation examined the prolactin values in borderline personality disorder in which suicidal behavior and impulsivity are core symptom dimensions. In this context, in the present investigation, we planned to measure serum prolactin levels in the patients with borderline personality disorder and hypothesized that prolactin values might
Atmaca et al.
171
be changed because of the complex mechanisms and associations aforementioned12 in the patients with borderline personality disorder.
Materials and methods The present study included inpatients or outpatients by chart review who had had borderline personality disorder according to DSM-IV and had been evaluated in terms of prolactin values for a variety of reasons at the Department of Psychiatry or Endocrionology Departments, Firat University Hospital, Elazig. The patients were consecutively recruited. Chart review was done by one senior psychiatrist (SK). Initially, there were 19 patients with borderline personality disorder. But four were not included into the investigation because of a variety of reasons such as endocrinologic disorder (prolactinoma in one patient), severe organic disease (diabetes mellitus in one patient and romatoid arthritis in another one), and finally, use of hormone preparat (oral contraceptive for medical reasons in one patient). All patients were females. Only the patients without any axis I disorder were included into the study. Diagnosing borderline personality disorder had been done by using Turkish version of the Structured Clinical Interview13 performed by one senior psychiatrist. Control group comprised 15 age- and sex-matched healthy female subjects according to exclusion criteria among the people who had applied to our hospital and were not determined any medical and psychiatric illness via chart review. In addition, control subjects were age- and gender matched with the patients. In the present investigation, the patients were excluded if they had (1) alcohol and substance abuse or dependence, (2) an important medical problem such as prolactinoma, pheochromocytoma, carsinoid tumor, any other endocrinopathy, (3) use of glucocorticoids and oral contraceptives, (4) use of any psychotropic drugs, and (5) excessive obesity. In addition to all above, all patients and controls were subjectto free of all medications at least in the previous two weeks. Subjects having normal results and without any exclusion criteria were admitted to the study. Hamilton Depression Rating Scale (HDRS)14 was administered to the subjects. The study was approved by the Local Ethics Committee. All venous blood samples had been obtained between 8:00 a.m. and 10:00 a.m. in order to detect the prolactin oncentrations. The samples obtained had been immediately centrifuged, and the serum samples had been stored at 20 C until thawing for the analysis. Blood samples were sent to a centralized laboratory that performed analysis following standard procedures. The prolactin values had been measured by using chemiluminoassay method using BIODPC kit (Immulyte 2000, Diagnostic Product Co., Los Angeles, CA, USA). Sensitivity of this assay is 0.60 ng/ mL; upper limits of prolactin are 15 ng/mL for males and 20 ng/mL for females.15 All the analyses were performed with the Statistical Package for Social Sciences (SPSS) for Windows 13.0; t-tests for independent samples were performed to identify differences in biochemical and sociodemographic variables
172
The International Journal of Psychiatry in Medicine 49(3)
Table 1. Demographic and clinical characteristics of the patients and healthy controls. Borderline patients (n ¼ 20) Demographic and clinical parameters Age 30.00 7.42 Gender (female/male) 15/0 Ethnicity Caucasian 15 Socioeconomic status Good 4 Moderate 6 Poor 5 HDRS scores 11.07 5.48
Controls (n ¼ 20) 32.27 5.13 15/0 15 3 7 5 6.47 2.64*
HDRS: Hamilton Depression Rating Scale. *p < 0.01.
measured on the dimensional scale, and one-way Fisher exact tests and chisquared tests were performed to identify associations between variables measured on nominal scales. Pearson’s method of correlation was also used. Differences were considered significant at p < 0.05 for all these tests.
Results The mean age was 30.00 7.42 for patients with borderline personality disorder and 32.27 5.13 for healthy controls. All subjects were females. There were no statistically significant differences between groups with respect to the demographic characteristics including socioeconomical status, gender, or age (p > 0.05). The mean HDRS score was 11.07 5.48 for the patients with borderline personality disorder and 6.47 2.64 for the control subjects (p ¼ 0.007) (Table 1). The prolactin levels were increased in 10 patients (66.7%) and in two control subjects (13.3%), when individually compared with normal range of prolactin values. The patients had abnormally higher mean value of prolactin compared to those of healthy controls (48.66 36.48 mg/dl for patients vs. 15.20 7.81 mg/dl for healthy controls; p ¼ 0.002) (Figure 1). There was no correlation between prolactin values, HDRS, or and any demographic variables for both the patients and control subjects (p > 0.05).
Discussion In the present investigation, we examined serum prolactin values in the patients with borderline personality disorder. Consequently, we found that the prolactin levels were increased in nine patients (66.6%) and in one control subject, when
Atmaca et al.
173
120,00
PRL
80,00
40,00
0,00 P a tie n ts
Co nt ro ls
Groups Figure 1. Boxplot of prolactin values of the groups.
individually compared with normal range of prolactin values and that the patients had abnormally higher mean value of prolactin compared to those of healthy controls, without any correlation between prolactin values and any demographic variables, age, or HDRS scores for both the patients and control subjects. In many investigations, reduced indices of central serotonergic function have been found to be associated with attempted or completed suicide, moreover, with suicide attempt consisting of violent components.16 Furthermore, it has been described that independent of history of suicidal behavior, there has been a blunted prolactin response to serotonergic agonists, and an inverse relationship between prolactin response and behavioral impulsivity, in patients with borderline personality disorder.17–19 On the other hand, Pompili et al.12 examined a group of patients with major depressive disorder, bipolar disorder, and psychotic disorders in regard to the values of free triiodothyronine and prolactin, dividing the whole group into two subgroups as suicide attempters and no-attempters and found a significant effect of sex and suicidal status and the interaction between sex and suicidal status on prolactin levels. They concluded that both prolactin and thyroid hormones might be involved in a complex compensatory mechanism to correct
174
The International Journal of Psychiatry in Medicine 49(3)
reduced central serotonin activity. We do not know the exact mechanism of increased prolactin values in the patients with borderline personality disorder, which is found in the present study. It is probably a complex nature. The finding of our present investigation that the patients with borderline personality disorder had abnormally higher mean value of prolactin compared to those of healthy controls led us to consider that altered 5-HT function might have provoked a cascade of biological modifications, resulting in increased prolactin levels. There are some methodological limitations of the present study that must be acknowledged. First, the relatively small sample size might not be representative of the patients with borderline personality disorder. Second, the fact that all patients were female is another main limitation. Third, the present investigation has a relatively simple design. We did not evaluate related factors affecting prolactin values. Fourth, in the present investigation, a link between prolactin values and symptom dimensions such as impulsivity and suicidality was not examined. Fifth, the inclusion of a mixed sample of patients, both inpatients and outpatients, is another relevant limitation of the present study. Sixth, all subjects were female, and this may further limit the relevance of the main findings. Finally, a scale for impulsivity and suicidality and their relationships with prolactin values were not obtained in the present study. This was another limitation. In conclusion, our present results suggest that prolactin values were increased in the patients with borderline personality disorder. So, our hypothesis that prolactin values might be changed because of the complex mechanisms and associations mentioned in the Introduction section12 in the patients with borderline personality disorder was correct. However, our results are required to be replicated by more comprehensive and detailed further studies to decipher the exact roles of prolactin increase. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing, 2013. 2. Pompili M, Serafini G, Innamorati M, et al. Impulsivity, aggression, and suicide risk in patients with schizophrenia. Psychiatr Ann 2013; 43: 458–462. 3. Nemoda Z, Lyons-Ruth K, Szekely A, et al. Association between dopaminergic polymorphisms and borderline personality traits among at-risk young adults and psychiatric inpatients. Behav Brain Funct 2010; 6: 4.
Atmaca et al.
175
4. Muldoon MF, Manuck SB and Matthews KA. Lowering cholestrol concentraion and mortality: a quantitative review of primary prevantion trials. BMJ 1990; 301: 309–314. 5. Virkunnen M. Serum cholestrol in antisocial personality disorder. Neuropsychobiology 1979; 5: 27–30. 6. Atmaca M, Kuloglu M, Tezcan E, et al. Serum cholesterol and leptin levels in patients with borderline personality disoerder. Neuropsychobiology 2002; 45: 167–171. 7. Oquendo MA and Mann JJ. The biology of impulsivity and suicidality. Psychiatr Clin N Am 2000; 23: 11–25. 8. Coccaro EF, Gabriel S, Mahon T, et al. Preliminary evidence of a serotonin (5-HT-1like) component to the prolactin response to buspirone challenge in humans. Arch Gen Psychiatr 1990; 47: 594–595. 9. Stanley M, Mann JJ and Cohen LS. Serotonin and serotonergic receptors in suicide. Ann New York Acad Sci 1986; 487: 122–127. 10. Correa H, Duval F, Mokrani M, et al. Prolactin response to D-fenfluramine and suicidal behavior in depressed patients. Psychiatr Res 2000; 10: 189–199. 11. Correa H, Duval F, Mokrani MC, et al. Serotonergic function and suicidal behavior in schizophrenia. Schizophr Res 2002; 56: 75–85. 12. Pompili M, Gibiino S, Innamorati M, et al. Prolactin and thyroid hormone levels are associated with suicide attempts in psychiatric patients. Psychiatr Res 2012; 30: 389–394. 13. Sorias S, Saygılı R and Elbi H. DSM-III-R Yapılandırılmıs¸ Klinik Go¨ru¨s¸mesi Tu¨rkc¸e versiyonu, Kis¸ilik Bozuklukları Formu: SCID-IIIzmir: Ege U¨niversitesi Basımevi. 14. Hamilton M. The assesment of anxiety states by rating. Br J Med Psychol 1959; 32: 50–55. 15. Kuruvilla A, Peedicayil J, Srikrishna G, et al. A study of serum prolactin levels in schizophrenia: comparison of males and females. Clin Exp Pharmacol Physiol 1992; 19: 603–606. 16. Asberg M, Traskman L and Thoren P. 5-HIAA in the cerebrospinal fluid A biochemical suicide predictor? Arch Gen Psychiatr 1976; 33: 1193–1197. 17. Coccaro EF, Siever LJ, Klar HM, et al. Serotonergic studies in patients with affective and personality disorders. Correlates with suicidal and impulsive aggressive behavior. Arch Gen Psychiatr 1989; 46: 587–599. 18. O’Keane V, Moloney E, O’Neill H, et al. Blunted prolactin responses to d-fenfluramine in sociopathy. Evidence for subsensitivity of central serotonergic function. Br J Psychiatr 1992; 160: 643–646. 19. Moss HB, Yao JK and Panzak GL. Serotonergic responsivity and behavioral dimensions in antisocial personality disorder with substance abuse. Biol Psychiatr 1990; 15: 325–338.
