Neurocognitive deficits in decision-making and planning of patients with DSM-III-R borderline personality disorder.

BACKGROUND: Repeated, self-damaging behaviour occurring in the context of borderline personality disorder (BPD) may reflect impairments in decision-making and planning cognition. However, there has been no systematic neuropsychological examination of these particular cognitive functions in patients diagnosed with BPD. Such investigations may improve our understanding of the possible role of brain dysfunction in BPD and improve the characterization of the psychological difficulties associated with this disorder. METHOD: Forty-two psychiatric patients with a diagnosis of DSM-III-R BPD (41 of whom gave a history of self-harm), without a history of specified 'psychoses' or current major affective disorder, were clinically assessed before completing computerized tasks of decision-making and planning previously shown to be sensitive to frontal lobe dysfunction, and tests of spatial and pattern visual recognition memory previously shown to be sensitive to frontal lobe damage and temporal lobe damage respectively. The performance of the BPD patient group was compared with that of a non-clinical control group consisting of 42 subjects. RESULTS: The performance of the BPD patients on the decision-making task was characterized by a pattern of delayed and maladaptive choices when choosing between competing actions, and by impulsive, disinhibited responding when gambling on the outcome of their decisions. BPD patients also showed impairments on the planning task. There was no evidence of impaired visual recognition memory. Additional analyses suggested only limited effects of current medication and history of previous substance use disorder. CONCLUSIONS: These findings suggest that BPD is associated with complex impairments in dissociable cognitive processes mediated by circuitry encompassing the frontal lobes. These impairments may mediate some of the behavioural changes evident in BPD. Further work is needed to examine the specificity of these findings.

The effect of psychopathy on outcome in high security patients.

The study aimed to examine the relationship between the total score on Hare's revised Psychopathy Checklist (PCL-R) and aspects of outcome for a nonrandom sample (n = 89) of male mentally disordered offenders treated in an English high security hospital. The subjects were all legally classified as suffering from "psychopathic disorder" and the majority were followed-up in the community. The methodology was retrospective, using existing case-file data, with follow-up lasting until discharge from statutory supervision. PCL-R scores were dichotomized and related to various outcome factors, including recidivism and aspects of social behavior. The results showed, in contrast to previous North American research, that the PCL-R did not predict any of the outcome factors. Because the PCL-R was able to identify psychopaths in this population but failed to predict their prognosis, it is possible that their outcome may have been improved by the treatment they received in hospital.

Young 'psychopaths' in special hospital: treatment and outcome.

BACKGROUND: The 'Young Persons Unit' (YPU) at Broadmoor Hospital offers psychotherapeutic treatment for young adult male patients. The study objective was to report background details, treatment and outcome of the ward's personality disordered patients. METHODS: The sample consisted of 49 patients, with the legal classification of psychopathic disorder, treated on the unit for at least one year. Data were collected from existing case records. Outcome was recorded until discharge from statutory supervision. Outcome measures were recidivism and a variety of social factors. RESULTS: At follow-up 10 patients had reoffended, with four having committed serious violent or sexual offenses. Two patients had died. A history of sex offending was the strongest predictor of subsequent reoffending. No patients with good social outcome reoffended. CONCLUSION: 'Young patients with personality disorder can be successfully treated on the YPU. The management of sex offenders in this group requires further attention. Successful social integration within the community after discharge may help prevent future reoffending.

The psychopathology of authority and its loss: the effect on a ward of losing a consultant psychiatrist.

A consultant psychiatrist on an in-patient psychiatric unit left temporarily for a four-week visit to Australia. Eight of 11 patients under his care developed disturbed behaviour, although all had been stable for many months before. Of the other 11 patients on the same ward, under the care of another consultant psychiatrist, only one developed similar problems over this time. It has already been well established in previous research that loss events, particularly of attachment figures, contribute to psychopathology. However, what loss events the psychiatric unit itself presents to patients, and furthermore how the loss of perhaps more distant but important figures, like consultants or senior psychiatrists, also affect patients has not been previously explored. The neglected issue of the role of authority in the therapeutic relationship as well as in psychiatric illness is discussed. It is suggested that this has important implications for psychiatric practice.