Lecture 7 Personality Disorders

Transcription

1 Lecture 7 Personality Disorders David Saffen, Ph.D. Principal Investigator Department of Cellular and Genetic Medicine Fudan University, Shanghai, China saffen@fudan.edu.cn

2 Outline A. Introduction B. Antisocial Personality Disorder, Psychopathy and Conduct Disorder: Neurobiology, early life influences, environment and genetics C. Future directions: a shift to dimensional classifications? D. References, journal presentations, internet resources, extra slides

3 A. Introduction Definition: an enduring pattern of inner experience and behavior in the realm of cognition, mood, interpersonal functioning or impulse control that deviates from the norms of ones culture, is inflexible and pervasive, and produces significant distress or impairment in daily life. Prevalence: ~10% - 20% in the population; 30% - 50% among psychiatric outpatients Onset in adolescence and establishment in early adulthood Large impact on individuals and society

4 History Hippocrates: four humors embodying the elements of air, fire, earth and water: sanguine (optimistic), choleric (irritable), melancholic (sad), phlegmatic (calm) Kraepelin: personalities among manic-depressive patients and their relatives: hypomanic (~ sanguine), irritable (~ choleric), depressive (~ melancholic). DSM-I (1952): seven types of personality disturbances DSM-III (1980): eleven personality disorders on a separate axis from mental illnesses DSM-IV (1994): ten personality disorders in three clusters: DSMIV-TR (2000) ten personality disorders in three clusters: Cluster A ( Eccentric disorders), Cluster B ( Dramatic disorder). Cluster C ( Anxious disorders), plus: Personality disorder not otherwise specified. Alternative classification scheme: five main factors that determine personality: - Extraversion - Agreeableness - Conscientiousness - Neuroticism - Openness to experience.

5 Personality disorders General Definition (DSM5): A. An enduring pattern of inner experience and behavior that deviates from the expectations of the individuals culture. This pattern is manifested in two (or more) of the following areas: 1. Cognition, 2. Affectivity 3. Interpersonal functioning 4. Impulse control B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. C. The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning. D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder F. The enduring pattern is not attributable to the physiological effects of an substance or another medical condition.

6 Personality Disorders (DSM-5) A. Cluster A ( Eccentric ) - Paranoid Personality Disorder - Schizoid Personality Disorder - Schizotypal Personality Disorder B. Cluster B ( Dramatic ) - Antisocial Personality Disorder - Borderline Personality Disorder - Histrionic Personality Disorder - Narcissistic Personality Disorder C. Cluster C ( Anxious ) - Avoidant Personality Disorder - Dependent Personality Disorder - Obsessive-Compulsive Personality Disorder Also: Personality change due to another medical condition Other specified personality disorder Unspecified personality disorder

7 Paranoid Personality Disorder A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning in early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Suspects, without sufficient basis, that others are exploiting, harming or deceiving him or her. 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. 3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. 4. Reads hidden demeaning or threatening meanings into benign remarks or events. 5. Persistently bears grudges. 6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. 7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to physiological effects of another medical condition.

8 Schizoid Personality Disorder A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning in early childhood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Neither desires nor enjoys close relationships, including being part of a family. 2. Almost always chooses solitary activities. 3. Has little, if any, interest in having sexual experiences with another person. 4. Takes pleasure in few, if any, activities. 5. Lacks close friends or confidants other than first-degree relatives. 6. Appears indifferent to the praise or criticisms of others. 7. Shows emotional coldness, detachment or flattened affectivity. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to physiological effects of another medical condition.

9 Schizotypal Personality Disorder A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Ideas of reference (excluding delusions of reference). 2. Odd beliefs of magical thinking that influences behavior and is inconsistent with subcultural norms. 3. Unusual perceptual experiences, including bodily illusions. 4. Odd thinking and speech. 5. Suspiciousness or paranoid ideation. 6. Inappropriate or constricted affect. 7. Behavior or appearance that is odd, eccentric or peculiar. 8. Lack of close friends or confidants other than first-degree relatives. 9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder or autism spectrum disorder.

10 Antisocial Personality Disorder A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. 3. Impulsivity or failure to plan ahead. 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. 5. Reckless disregard for safety of others. 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated or stolen from others. B. The individual is at least age 18 years. C. There is evidence of conduct disorder with onset before age 15 years D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder

11 Borderline Personality Disorder A. A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, reckless driving, binge eating). 5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior. 6. Affective instability due to marked reactivity of mood. 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger. 9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

12 Histrionic Personality Disorder A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Is uncomfortable in situations in which he or she is not the center of attention. 2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. 3. Displays rapidly shifting and shallow expression of emotions. 4. Consistently uses physical appearance to draw attention to self. 5. Has a style of speech that is excessively impressionistic and lacking in detail 6. Shows self-dramatization, theatricality, and exaggerated expression of emotion. 7. Is suggestible (i.e., easily influenced by others or circumstances). 8. Considers relationships to be more intimate than they actually are.

13 Narcissistic personality disorder A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has a grandiose sense of self-importance. 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love. 3. Believes that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). 4. Requires excessive admiration. 5. Has a sense of entitlement. 6. Is interpersonally exploitative. 7. Lacks empathy 8. Is often envious or others or believes that others are envious of him or her. 9. Shows arrogant, haughty behaviors or attitudes.

14 Avoidant Personality Disorder A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection. 2. Is unwilling to get involved with people unless certain of being liked. 3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. 4. Is preoccupied with being criticized or rejected in social situations. 5. Is inhibited in new interpersonal situations because of feelings of inadequacy. 6. Views self as socially inept, personally unappealing, or inferior to others. 7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

15 Dependent Personality Disorder A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. 2. Needs others to assume responsibility for most major areas of his or her life. 3. Has difficulty expressing disagreement with others because of fear or loss of support or approval. 4. Has difficulty initiating projects or doing thins on his or her own. 5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do this that are unpleasant. 6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. 7. Urgently seeks another relationship as a source of care and support when a close relationship ends. 8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

16 Obsessive-Compulsive Personality Disorder A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. 2. Shows perfectionism that interferes with task completion. 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships. 4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics or values. 5. Is unable to discard worn-out or worthless objects even when they have no sentimental value. 6. Is reluctant to delegate task or to work with others unless they submit to exactly his or her way of doing things. 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. 8. Shows rigidity and stubbornness.

17 Famous (notorious!) individuals diagnosed with personality disorders Ted Bundy Rapist, kidnapper, serial killer (~35 women) Antisocial Personality Disorder Executed at Florida State Prison, 1989 (age 43) Jodi Arias Murderer Borderline Personality Disorder Convicted of first-degree murder; sentenced to life in Arizona state prison John Hinckley Would-be assassin of President Ronald Regan Schizoid Personality Disorder, Narcissistic Personality disorder; found not guilty by reason of insanity; confined to a mental hospital ( )

18 B. Antisocial Personality Disorder, Psychopathy and Conduct Disorder: Neurobiology, early life influences environment and genetics

19 Antisocial Personality Disorder (Source: MedlinePlus, NLM, NIH) Antisocial personality disorder is a mental health condition in which a person has a long-term pattern of manipulating, exploiting, or violating the rights of others. This behavior is often criminal. Causes: The causes of antisocial personality disorder are unknown. Genetic factors and environmental factors, such as child abuse, are believed to contribute to the development of this condition. People with an antisocial or alcoholic parent are at increased risk. Far more men than women are affected. The condition is common among people who are in prison. Fire-setting and cruelty to animals during childhood are linked to the development of antisocial personality. Some doctors believe that psychopathic personality (psychopathy) is the same disorder. Others believe that psychopathic personality is a similar but more severe disorder.

20 A person with antisocial personality disorder may: Be able to act witty and charming Be good at flattery and manipulating other people's emotions Break the law repeatedly Disregard the safety of self and others Have problems with substance abuse Lie, steal, and fight often Not show guilt or remorse Often be angry or arrogant Exams and tests: Antisocial personality disorder is diagnosed based on a psychological evaluation that assesses the history and severity of symptoms. To be diagnosed with antisocial personality disorder, a person must have had conduct disorder during childhood.

21 Treatment: Antisocial personality disorder is one of the most difficult personality disorders to treat. People with this condition rarely seek treatment on their own. They may only start therapy when required to by a court. Behavioral treatments, such as those that reward appropriate behavior and have negative consequences for illegal behavior, may hold the most promise. Certain forms of talk therapy are also being explored. Persons with antisocial personality who have other disorders, such as a mood or substance disorder, are often treated for those problems as well. Prognosis: Symptoms tend to peak during the late teenage years and early 20s. They sometimes improve on their own by a person's 40s Possible complications Complications can include imprisonment, drug abuse, violence, and suicide.

22 Antisocial Personality Disorder: a case history

23 Source: NC Andreasen and DW Black, Introductory Textbook of Psychiatry, Fourth Edition, American Psychiatric Publishing, Inc, Washington DC, 2006, pp

24 Antisocial Personality Disorder and Psychopathy (aka sociopathy) Psychopathy and sociopathy are not explicitly defined in DSMIV or DSM5; Subsumed under Antisocial Personality Disorder diagnosis. A widely used measure of psychopathy: Robert Hare s Psychopathy Checklist (PCL) -revised (1991): Each of the 20 items scored 0, 1 or 2; Total score > 30 (US) or > 25 (UK): psychopathy

25 Psychopathology may be common in modern societies 2008 study using PCL (screening version; maximum score = 20) found 1.2% of US population scored > study using PCL:SV found 0.6 of UK population scored > 13. Many recent books in the popular press give higher estimates, and speculate that psychopaths/ sociopaths may be over represented among certain professionals, such as company CEOs and other high-achievers.

26 Neuroscientist discovers that he is a borderline psychopath Family history (many generations) includes eight murderers, including the infamous Lizzie Borden who allegedly killed her father and step-mother with an ax in Harbors MAOA alleles linked to aggression PET brain scans show low activity in prefrontal cortex and limbic system Claims to lacks empathy Claims to be highly competitive, harbor grudges, be manipulative Experienced panic attacks, obsessive-compulsive tendencies, social anxieties in youth

27 Conduct Disorder (DSM5) A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifest by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: Aggression to People and Animals 1. Often bullies, threatens, or intimidates others. 2. Often initiates physical fights. 3. Has used a weapon that can cause serious physical harm to others. 4. Has been physically cruel to people. 5. Has been physically cruel to animals. 6. Has stolen while confronting a victim. 7. Has forced someone into sexual activity. Destruction of Property 8. Has deliberately engaged in fire setting with the intention of causing serious damage. 9. Has deliberately destroyed others property (other than by fire setting).

28 Deceitfulness or Theft 10. Has broken into someone else s house, building or car. 11. Often lies to obtain goods or favors or to avoid obligations (i.e., cons others). 12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting without breaking and entering; forgery). Serious Violation of Rules 13. Often stays out at night despite parental prohibitions, beginning before age Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period. 15. Is often truant from school, beginning before age 13 years. B.The disturbance in behavior causes clinically significant impairment in social, academic or occupational functioning. C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

29 Specification (1) Onset: Childhood-onset type Adolescent-onset type Unspecified onset Specification (2) With limited prosocial emotions (two or more of the following): Lack of remorse or guilt Callous-lack of empathy Unconcerned about performance Shallow or deficit affect Specification (3) Current severity: Mild Moderate Severe

30 Two proposed subtypes of conduct disorders: 1. Characterized by presence of psychopathy: impairments related to decreased amygdala responsiveness to distress cues and decreased ventromedial prefrontal cortex (vmpfc) sensitivity to reinforcement signals critical for decision making. 2. Characterized by exaggerated reactive aggression: impairments related to hyperactivation of a neural circuit that connects the medial amygdala to the hypothalamus and then to the dorsal pariaqueductal grey (PAG). This circuit is proposed to be regulated by the vmpfc and anterior cingulate cortex (ACC). This subtype of conduct disorder is also associated with increased comorbidity of a mood or anxiety disorder. Blair RJ, Nat Rev Neurosci, 2013

31 Cognitive-neuroscience analysis of conduct disorder with psychopathic traits A. Callous-unemotional component (e.g., lack of guilt and emotional empathy): reduced amygdala response to distress cues (fear, sadness, pain) and happy expressions in others; normal response to expressions of anger and disgust. B. Impulsive-antisocial component (e.g., deficits in the ability to forego actions that invite punishment) dysfunction in vmpfc and striatum (caudate and n. accumbens) (Note: children with non-psychopathic forms of conduct disorder also display an impulsive-antisocial component and decreased vmpfc and striatal responsiveness) Note: Individuals diagnosed with psychopathy do not show deficits in cognitive empathy, which involves the ability to intellectually ascribe intentions and beliefs to others (aka theory of mind ). MRI studies show normal recruitment of brain regions implicated in cognitive empathy, including: vmpfc, temporal-parietal junction, posterior cingulate cortex, and temporal pole.

32 Circuits underlying a willful change in behavior (intact) Emotional empathy related learningcircuits (defective) Impaired learning about actions that harm others, (due to dysfunctional amygdalastriatum-vmpfc circuits) results in poor decision-making concerning changing those actions Blair RJ, Nat Rev Neurosci, 2013

33 Functional and structural MRI imaging studies fmri studies consistently show reduced amygdala activity in response to fearful expressions in individuals with psychopathic traits and reduced striatal and vmpfc activities in youths with conduct disorder and with our without psychopathic traits. Structural MRI studies have mostly reported smaller amygdala volumes and reduced temporal cortex volumes and cortical thicknesses in youths with conduct disorders. Evidence is less clear concerning structural changes in vmpfc. A study of over 200 adolescents in a maximum security facility identified reduced volumes of vmpfc, amygdala, temporal cortex and caudate (areas associated with the emotion dysfunction component of psychopathy).

34 Reduced response of amygdala to fearful expression in youths with behavior disorders and psychopathic traits Blair RJ, 2015

35 Reduced activation of striatum and vmpfc during stimulusreinforcement learning in individuals with disruptive behavior disorders Blair RJ, 2015

36 Environmental factors Childhood stress (including physical and sexual abuse; family violence; neglect) is reported associate with heighten amygdala responsiveness and increased risk for reactive aggression in adults. Maternal drug use has been associated with decreased amygdala responsiveness and callous-unemotional traits in adults. Low socioeconomic status and/or exposure to criminal environments can have a large influence on the behavioral repertoires that individuals with psychopathic tendencies develop: CEO or incarcerated criminal?

37 Genetics Twin studies indicate a large genetic component for callous-unemotional traits (H 2 = 0.58). A recent GWA of 370 cases and 5850 controls (discovery sample) cases and 3766 controls (replication sample) selected from the Finnish population identified SNPs at 6p21.2 and 6p21.32 that associated with antisocial personality disorder (ASPD) at genomewide or near genomewide significance. Probable ASPD in these regions have not yet been identified. (Rautiainen M-R et al, Translational Psychiatry, 2016) Small-scale, candidate gene studies have implicated variants of monoamine oxidase A (MAOA), serotonin transporter promoter region (5-HTTLPR), catecholamine O-methyltransferase (COMT) in increased amygdala responsiveness to treats and increased risk of aggression. One study found an association between the high-expression 5-HTTLPR variant and reduced amygdala responsiveness and callous-unemotional traits in individuals with low family socioeconomic backgrounds. Also reports of associations between variants of serotonin receptors 1B and 2A genes and the oxytocin receptor gene and callous-unemotional traits.

38 Comorbidity of psychopathy with other psychiatric disorders Mood disorders, including major depression and bipolar disorder Anxiety disorders, including PTSD Substance abuse

39 C. Future directions: A shift to dimensional classifications?

40 Widiger TA Mullins-Sweatt SN, 2009

41 Diagnostic instruments for Five-Factor Model of personality: 1) NEO PI-R (Neuroticism Extroversion, Openness-Personality Interview-Revised 2) Structured Interview Assessment of the Five Factor Model 3) FFMRF (Five-Factor Model Rating Form)

42 Widiger TA Mullins-Sweatt SN, 2009

43 Widiger TA Mullins-Sweatt SN, 2009

44 Research Domain Criteria (RDoC)

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47 References (1) Blair RJ, Leibenluft E and Pine DS, Conduct disorder and callous-unemotional traits in youth, New England Journal of Medicine 371, , 2014 Blair RJ, The neurobiology of psychopathic traits in youths, Nature Review Neuroscience 14, , 2013 ;Blair RJ, Psychopathic traits from a RDoC perspective, Current Opinion in Neurobiology 30, 79-84, 2015 Burt SA, How do we optimally conceptualize the heterogeneity within antisocial behavior? An argument for aggressive versus non-aggressive behavioral dimensions, Clinical Psychology Reviews 32, , 2012 Price JL and Drevets WC, Neural circuits underlying the pathophysiology of mood disorders, Trends in Cognitive Sciences 16, 61-71, 2012 Lesch KP et al, Targeting serotonin synthesis: insights into neurodevelopmental outcomes related to negative emotionality, aggression and antisocial behavior, Philos. Trans. Lond. B Biol. Sci. 367, , 2012 Niederholfer V et al, Identification of serotonergic neuronal modules that affect aggressive behavior, Cell Reports 17, , 2016

48 References (2) Buckholtz JW and Meyr-Lindenberg A, MAOA and the neurogenetic architecture of human aggression, Trends in Neuroscience 31, , 2007 Anderson NE and Kiehl KA, The psychopath magnetized: insights from brain imaging, Trends in Cognitive Sciences 16, 52-60, 2012 Hengartener MP, et al, Childhood adversity in association with personality disorder dimensions: new findings in an old debate, European Psychiatry 28, , 2013 Afifi TO, et al., Childhood adversity and personality disorders: results from a nationally representative population-based study, Journal of Psychiatry Research 45, , 2011 Viding E and McCroy EJ, Genetic and neurocognitive contributions to the development of psychopathy, Development and Psychopathy 24, , 2012 Rautiainen M-R, et al Genome-wide association study of antisocial behavior, Translational Psychiatry 6, July 2016 Widiger TA and Mullins-Sweatt SN, Five-factor model of personality disorder: a proposal for DSM-V, Annual Review Clinical Psychology 5, , 2009

49 Journal Presentations Background paper Viding E, McCrory E and Seara-Cardoso A, Psychopathy, Current Biology 24 (18) RB871-RB874, 2014 Research papers Viding E et al, Amygdala response to preattentive masked fear in children With conduct problems: the role of callous-unemotional traits, American Journal of Psychiatry 169, , 2012 Buckholtz IW et al, Mesolimbic dopamine reward system hypersensitivity In individuals with psychopathic traits, Nature Neuroscience 13, , 2010

50 Internet resources National Institute of Mental Health (NIMH) National Institutes of Health (NIH)

51 Additional Slides

52 Borderline Personality Disorder (Source: MedlinePlus, NLM, NIH) Borderline personality disorder (BPD) is a mental health condition in which a person has long-term patterns of unstable or turbulent emotions. These inner experiences often result in impulsive actions and chaotic relationships with other people. The causes of borderline personality disorder are unknown. Genetic, family, and social factors are thought to play roles. Risk factors for BPD include: Abandonment in childhood or adolescence Disrupted family life Poor communication in the family Sexual, physical, or emotional abuse This personality disorder tends to occur more often in women and among hospitalized psychiatric patients.

53 Symptoms: Persons with BPD are often uncertain about their identity. As a result, their interests and values can change rapidly. They also tend to view things in terms of extremes, such as either all good or all bad. Their views of other people can change quickly. A person who is looked up to one day may be looked down on the next day. These suddenly shifting feelings often lead to intense and unstable relationships. Other symptoms of BPD include: Intense fear of being abandoned Intolerance being alone Frequent feelings of emptiness and boredom Frequent displays of inappropriate anger Impulsiveness, such as with substance abuse or sexual relationships Repeated crises and acts of self-injury, such as wrist cutting or overdosing.

54 Exams and tests: BPD is diagnosed based on a psychological evaluation that assesses the history and severity of the symptoms. Treatment Individual talk therapy may successfully treat BPD. In addition, group therapy can sometimes be helpful. Medications have less of a role in the treatment of BPD. But in some cases, they can improve mood swings and treat depression or other disorders that may occur with this condition. Prognosis Outlook of treatment depends on how severe the condition is and whether the person is willing to accept help. With long-term talk therapy, the person often gradually improves.

55 Borderline Personality Disorder: a case history

56 Source: NC Andreasen and DW Black, Introductory Textbook of Psychiatry, Fourth Edition, American Psychiatric Publishing, Inc, Washington DC, 2006, p 293

57 Individuals diagnosed with psychopathy show deficits in emotional learning and decision making Specifically, deficits in: Stimulus-reinforcement of expected values (amygdala) The ability to associate an adverse emotional response of a victim with the action that caused this distress. For example, the association between threatening a person with harm and the emotional response of that person Prediction error signaling (striatum: caudate and n. accumbens) The ability to detect differences between expected and observed events. For example, the difference between an expected and observed emotional response or between an expected and observed punishment. The inability to detect these differences reduces associative learning. Response-outcome learning; i.e., adverse conditioning (striatum: caudate and n. accumbens) The ability to associate the emotional response of a victim with adverse consequences to oneself. For example, the ability to associate punishment received with actions that produce emotional distress in another person. Expected value representation (vmpfc) The ability to imagine a reward or punishment following the commission of a specific response. For example, the ability to imagine punishment for causing emotional distress to another person by making treats

58 Framework for understanding conduct disorder Conduct disorder with psychopathic traits Conduct disorder with anxiety and emotional lability Blair RJ, Nat Rev Neurosci, 2013

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60 Blair RJ, Leibenluft E and Pine DS, 2014

61 Blair RJ, Leibenluft E and Pine DS, 2014

62 Blair RJ, Leibenluft E and Pine DS, 2014

63 Blair RJ, Leibenluft E and Pine DS, 2014