The construct of effortful control: an approach to borderline personality disorder heterogeneity.

BACKGROUND: The present study investigated the heterogeneity of DSM-IV borderline personality disorder (BPD) diagnosis as a function of the construct of effortful control. We hypothesized 3 subgroups of BPD patients based on effortful control, that would also differ in other areas of functioning, such as symptoms, interpersonal relations and personality organization. SAMPLING AND METHODS: Forty-seven clinically referred individuals were reliably diagnosed as meeting DSM-IV criteria for BPD using semistructured interviews. Effortful control, symptomatology, interpersonal functioning and personality organization were assessed using self-report questionnaires. RESULTS: Cluster and profile analyses were performed and identified 3 subgroups. Subgroup 1, with high effortful control, exhibited the fewest problems in symptoms, interpersonal functioning and personality organization. Subgroup 3, with low ratings of effortful control, had the most problems in these areas, and subgroup 2, a group high in some aspects of effortful control but low in others, ranged midway between groups 1 and 3. DISCUSSION: The findings indicate a relationship between attentional mechanisms and the clinical expression of borderline personality pathology. Effortful control is a valuable construct for identifying subgroups of BPD patients, thus helping to understand the heterogeneity in BPD. Limitations of the study include the exclusive use on self-report of effortful control, as well as the small sample size. Future research should further investigate the associations of neurocognition and borderline pathology, as well as different approaches to treatment of the different BPD subgroups.

Attachment dimensions as predictors of medical hospitalizations in individuals with DSM IV cluster B personality disorders.

This study investigates predictors of health service utilization in individuals with cluster B personality disorders. We hypothesized an association of severity of psychopathology (that is, global psychosocial functioning and psychiatric comorbidity) and attachment style with the length of medical hospitalizations in this population. Forty-one female subjects were interviewed regarding their diagnoses, level of functioning and service utilization. Attachment style was assessed with a self-report questionnaire. Our findings indicate that degree of psychiatric comorbidity and level of psychosocial functioning do not predict length of hospital stays, whereas preoccupied attachment predicted 23.9% of the variance in the length of hospitalizations. We conclude that the quality of interpersonal relatedness appears to be a better predictor of health service use than severity of pathology in patients with cluster B personality disorders.

Insight and recovery from psychosis in chronic schizophrenia and schizoaffective disorder patients.

Impaired insight is an important contributing factor to poor treatment response and outcome in schizophrenia. Prior studies have attempted to identify the illness characteristics that underlie these deficits, with conflicting results regarding associations with symptoms and neurocognitive deficits. These inconsistencies may be a function of a number of methodological issues, which were addressed in this study. In a prospective, longitudinal study, 50 individuals with schizophrenia or schizoaffective disorder underwent baseline assessments upon discharge from an acute inpatient unit, and again at a 6-month follow-up. Unawareness of positive and negative symptoms were studied separately, with analyses focusing on changes in insight over time as well as associations with disorganized symptoms, depression, and card sorting deficits. Subjects showed greater insight for negative symptoms than for positive symptoms. Insight for positive symptoms improved only slightly over the follow-up period, while negative symptom awareness did not change. Insight for negative symptoms showed modest associations with card sorting deficits, while awareness for positive symptoms showed stronger associations with thought disorder, depression, and card sorting deficits. Awareness for positive symptoms in schizophrenia may be distinct from awareness of negative symptoms. Clinicians should also be aware of the multidetermined nature of impaired insight, and future research should aim to isolate distinct mechanisms that give rise to these deficits.

Verbal memory in schizophrenia: sex differences over repeated assessments.

There is conflicting evidence regarding the presence and direction of gender differences in verbal memory capacity in schizophrenia. We examined gender differences in verbal memory performance in schizophrenia and their interactions with repeated assessments and psychiatric symptoms. California Verbal Learning Test (CVLT) data were collected from 28 outpatients diagnosed with schizophrenia. The CVLT was administered on five occasions, 3 months apart. CVLT data were examined using repeated measures analyses, using maximum likelihood estimates, with Brief Psychiatric Rating Scale (BPRS) scores at assessments 1-5 as a time-varying covariate. There were significant main effects of time and gender, with scores improving over time, and women performing better than men. There was also a significant time by gender interaction. The BPRS covariate effect was not significant. Results are discussed in terms of implications for gender-informed approaches to rehabilitation treatments.

Recovery from psychosis in schizophrenia and schizoaffective disorder: symptoms and neurocognitive rate-limiters for the development of social behavior skills.

Neurocognitive deficits are believed to be important predictors of functional outcome in chronic psychotic disorders, but few supporting studies have utilized prospective designs and adequate control. The aim of this study was to estimate the relative influence of symptoms and neurocognitive deficits on the development of social behavior skills in a cohort of individuals with schizophrenia or schizoaffective disorder recovering from acute symptom exacerbations. Forty-six individuals were recruited upon discharge from an inpatient unit and completed assessments of symptoms, neurocognitive function, and social behavior at 3-month intervals for 1 year. Correlational analyses and random regression models were used to model social behavioral capacities longitudinally. Social behavior improved modestly (10% improvements in ratings) over the follow-up period for the group as a whole. Disorganized and negative symptoms, as well as neurocognitive deficits in short-term and working memory predicted changes in social behavior over time. Individuals with better working memory function showed significantly greater abilities to recover social behavior skills, whereas those with working memory deficits showed no functional improvement over time. Both symptoms and neurocognitive deficits are important determinants of functional outcome in schizophrenia. It is proposed that clinicians should consider neurocognitive thresholds for treatment response when developing rehabilitation plans.

Cognitive functioning and social problem-solving skills in schizophrenia.

INTRODUCTION: This study examined the relationships between symptoms, cognitive functioning, and social skill deficits in schizophrenia. Few studies have incorporated measures of cognitive functioning and symptoms in predictive models for social problem solving. METHOD: For our study, 44 participants were recruited from consecutive outpatient admissions. Neuropsychological tests were given to assess cognitive function, and social problem solving was assessed using structured vignettes designed to evoke the participant's ability to generate, evaluate, and apply solutions to social problems. A sequential model-fitting method of analysis was used to incorporate social problem solving, symptom presentation, and cognitive impairment into linear regression models. Predictor variables were drawn from demographic, cognitive, and symptom domains. Because this method of analysis was exploratory and not intended as hierarchical modelling, no a priori hypotheses were proposed. RESULTS: Participants with higher scores on tests of cognitive flexibility were better able to generate accurate, appropriate, and relevant responses to the social problem-solving vignettes. CONCLUSIONS: The results suggest that cognitive flexibility is a potentially important mediating factor in social problem-solving competence. While other factors are related to social problem-solving skill, this study supports the importance of cognition and understanding how it relates to the complex and multifaceted nature of social functioning.

Predictors of risk of nonadherence in outpatients with schizophrenia and other psychotic disorders.

We investigated the course of adherence to medication recommendations in 162 patients with psychotic disorders in ambulatory treatment. Data were collected using the clinic's outcome assessment program, maximizing the generalizability of the study. Patients initially adherent to their medication regimens maintained their adherence for an average of 13.3 months. Patients initially nonadherent developed adherence after an average of 5.6 months of treatment. Demographic factors and illness history were unrelated to adherence. This study replicated previous findings of the concurrent association between adherence and global functioning level, substance use, and working alliance with therapist. Cox regression analyses revealed that working alliance, global functioning, and being prescribed clozapine predicted longer maintenance of adherence. Working alliance was the most significant and consistent predictor of adherence to medication recommendations.