OBJECTIVE: Patients with borderline personality disorder (BPD) fare better clinically if their families are rated as being high in emotional overinvolvement, which is characterized by marked emotionality, anxious concern, and protective behavior. This is not true of patients with disorders such as schizophrenia or major depression. We used functional magnetic resonance imaging methods to explore the link between emotional overinvolvement (EOI) and better clinical outcome in BPD. Specifically, we tested the hypothesis that, unlike healthy controls or people with other psychiatric problems, people with BPD process EOI as an approach-related stimulus. METHOD: Participants with BPD (n = 13) and dysthymia (n = 10) (DSM-IV criteria for both) and healthy controls (n = 11) were imaged using a high field strength (3T) scanner while they listened to a standardized auditory stimulus consisting of either 4 neutral or 4 EOI comments. Participants also rated their mood before and after exposure to the comments. RESULTS: All participants reported increased negative mood after hearing EOI and rated the EOI comments as negative stimuli. However, after subtracting activation to neutral comments, participants with BPD showed higher activation in left prefrontal regions during EOI compared to the other groups. Increased left prefrontal activation during EOI was also correlated with clinical measures indicative of borderline pathology. Participants with dysthymia showed increased amygdala activation during EOI. This was not true for the healthy controls or participants with BPD. CONCLUSIONS: For people with BPD, EOI may be activating neural circuitry implicated in the processing of approach-related stimuli. Increased left prefrontal activation to EOI may be a vulnerability marker for BPD. These findings may also help explain why BPD patients do better clinically in high EOI family environments.
People vulnerable to depression are at increased risk of relapse if they live in highly critical family environments. To explore this link, we used neuroimaging methods to examine cortico-limbic responding to personal criticisms in healthy participants and participants with known vulnerability to major depression. Healthy controls and fully recovered participants with a past history of major depression were scanned while they heard praising, critical, and neutral comments from their own mothers. Prior to scanning, the formerly depressed and the control participants were indistinguishable with respect to self-reported positive, negative, or anxious mood. They also reported similar mood changes after being praised or criticized. However, formerly depressed participants responded to criticism with greater activation in the amygdala and less activation in the dorsolateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC) than did controls. During praise and neutral commentary, amygdala activation was comparable in both groups, although lower levels of activation in the DLPFC and ACC still characterized formerly depressed participants. Vulnerability to depression may be associated with abnormalities in cortico-limbic activation that are independent of mood state and that remain even after full recovery. Criticism may be a risk factor for relapse because it activates the amygdala and perturbs the affective circuitry that underlies depression.
Suicide and non-suicidal self-injury (NSSI) lie along a continuum of self-harming behaviors. Highly prevalent, NSSI is a serious public health concern. It also increases risk for suicide. The present article reviews recent research on NSSI and provides an introduction to the articles in this special edition of the journal.
The construct of expressed emotion (EE) is a highly reliable and valid predictor of poor clinical outcomes in patients with major psychopathology. Patients are at early risk for relapse if they live with family members who are classified as high in EE. Conventionally, EE is assessed with the Camberwell Family Interview (CFI), a semistructured interview that is conducted with the patient's key relatives. Unfortunately, training in the CFI is difficult to obtain. The CFI is also time-consuming to administer and labor intensive to rate. In this article, the authors discuss alternative ways of assessing EE. They also evaluate the predictive validity of these measures and make recommendations for researchers and clinicians interested in using these assessments.
Background: High family levels of expressed emotion reliably predict relapse in patients with schizophrenia and mood disorders; however, the neural mechanisms linking expressed emotion and relapse are unexplored. Dysfunctional activity in the dorsolateral prefrontal cortex (DLPFC) has been implicated in the pathophysiology of depression. Functional magnetic resonance imaging (fMRI) was used to assess focal activation changes in DLPFC in response to a novel psychosocial challenge stimulus developed from the expressed emotion construct. Methods: Healthy control subjects and fully remitted unipolar depressed participants completed blood oxygen level–dependent fMRI while they heard their own mothers making critical and praising comments about them. Results: Relative to control subjects, participants with a history of depression failed to activate DLPFC when they heard critical remarks. There were no differences between the two groups in their DLPFC responses to maternal praise. Conclusions: Even if fully well at the time of testing, participants with a known vulnerability to depression respond differently to the psychosocial challenge of being criticized. These findings might have implications for our understanding of vulnerability to depression and to depressive relapse.
The psychiatric literature contains anecdotal reports of diminished pain sensitivity in schizophrenia that date back to Kraepelin. Yet, the phenomenon of pain insensitivity in schizophrenia remains largely unstudied. For example, it is not clear if pain insensitivity is a consequence of the illness or if it is also present in the well relatives of schizophrenia patients. To explore this issue, we examined pain thresholds and pain tolerances in healthy young adults. Compared with controls with no family history of psychopathology (n=21), participants with a family history of schizophrenia (n=32) showed elevated pain thresholds and pain tolerances to finger pressure. Pain insensitivity was also significantly correlated with elevated scores on measures of self-referential thinking, magical ideation, and perceptual disturbances. Finally, a sizeable minority (19%) of well relatives of schizophrenia patients showed extreme pain insensitivity compared to other participants. The pattern of findings suggests that pain insensitivity may warrant further exploration as a potential marker of underlying liability to psychosis.
A sizeable body of research has demonstrated that expressed emotion (EE) predicts clinical relapse in a number of distinct psychiatric disorders. These findings have provided the impetus for the development of interventions that attempt to reduce patients' relapse rates by modifying aspects of the family environment believed to be associated with high levels of EE. Despite the efficacy of these treatments, however, we know little about how EE develops in relatives of psychiatric patients or about the mechanisms through which high EE leads to relapse. Moreover, there is not a coherent theory that attempts to integrate findings concerning the impact of high EE on relapse in different disorders. The purpose of this article is to elucidate a diathesis-stress conceptualization of EE to explain both the development and manifestation of high EE in relatives of disordered patients and the impact of high EE on the course of patients' disorders. In this context, we use a diathesis-stress perspective to examine why EE predicts symptom relapse and poor clinical outcome in schizophrenia, depressive disorders, and borderline personality disorder. We conclude by discussing treatment implications of the diathesis-stress perspective and by outlining what we believe are fruitful directions for future research.
OBJECTIVE: This longitudinal follow-up study examined the predictive validity of relatives' expressed emotion in a group of patients diagnosed with borderline personality disorder. METHOD: Thirty-five patients with DSM-III-R-diagnosed borderline personality disorder were followed up 1 year after they were discharged from a psychiatric hospital. Clinical outcome was assessed through interviews with patients and their family members. Expressed emotion in the patients' relatives, assessed at the time of the index admission, was then used to predict patients' subsequent clinical outcomes. RESULTS: Contrary to prediction, relatives' criticism and hostility did not predict how well patients did in the year after discharge. Neither did they predict rates of rehospitalization. Clinical outcome was strongly associated with family levels of emotional overinvolvement, however. Patients whose families scored higher on emotional overinvolvement had better clinical outcomes over the course of the follow-up period. CONCLUSIONS: These findings suggest that the association between expressed emotion and patient outcome may be different for patients with borderline personality disorder than it is for patients with schizophrenia or mood disorders.