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This chapter focuses on advancements in the understanding of personality pathology gained from structural and functional neuroimaging studies. It draws from the literature on the most widely researched personality disorders including schizotypal, borderline, and antisocial personality disorder. Prominent findings in schizotypal personality disorder include abnormalities in temporal and frontal lobe volumes, decreased structural connectivity of temporal lobe regions, and inefficient recruitment of brain areas during task performance. In borderline personality disorder, neuroimaging findings are characterized by aberrant volume and activity of limbic and prefrontal brain areas that suggest diminished top-down control of affective responsivity. Studies in antisocial personality disorder reveal reduced volume in prefrontal and temporal lobe structures, white matter structure compromise, and altered brain network functional connectivity. Significant challenges in studying this complex population and limitations of current methodology are discussed. Suggestions for future directions of research in this field are provided.
This rejoinder uses the neuroimaging literature on affect regulation to exemplify how integration of complementary methods suggested by the commentaries could advance neurobiological understanding of personality disorders. It illustrates progressive insights gained from incorporating multiple sources of evidence including neuroimaging, genetics, and behavioral data associated with affect regulation. It also demonstrates the use of brain pattern activation analysis in addition to studying individual regions of interest to better understand the complex relationships between biological genotype, brain activity, and behavioral phenotype. The ways in which neuroimaging can serve as an endophenotype to bridge the gap between genes and distant phenotypes are highlighted.
There is a substantial proportion of patients who drop out of treatment before they receive minimally adequate care. They tend to have worse health outcomes than those who complete treatment. Our main goal is to describe the frequency and determinants of dropout from treatment for mental disorders in low-, middle-, and high-income countries.
Respondents from 13 low- or middle-income countries (N = 60 224) and 15 in high-income countries (N = 77 303) were screened for mental and substance use disorders. Cross-tabulations were used to examine the distribution of treatment and dropout rates for those who screened positive. The timing of dropout was examined using Kaplan–Meier curves. Predictors of dropout were examined with survival analysis using a logistic link function.
Dropout rates are high, both in high-income (30%) and low/middle-income (45%) countries. Dropout mostly occurs during the first two visits. It is higher in general medical rather than in specialist settings (nearly 60% v. 20% in lower income settings). It is also higher for mild and moderate than for severe presentations. The lack of financial protection for mental health services is associated with overall increased dropout from care.
Extending financial protection and coverage for mental disorders may reduce dropout. Efficiency can be improved by managing the milder clinical presentations at the entry point to the mental health system, providing adequate training, support and specialist supervision for non-specialists, and streamlining referral to psychiatrists for more severe cases.
Traumatic events are associated with increased risk of psychotic experiences, but it is unclear whether this association is explained by mental disorders prior to psychotic experience onset.
To investigate the associations between traumatic events and subsequent psychotic experience onset after adjusting for post-traumatic stress disorder and other mental disorders.
We assessed 29 traumatic event types and psychotic experiences from the World Mental Health surveys and examined the associations of traumatic events with subsequent psychotic experience onset with and without adjustments for mental disorders.
Respondents with any traumatic events had three times the odds of other respondents of subsequently developing psychotic experiences (OR=3.1, 95% CI 2.7–3.7), with variability in strength of association across traumatic event types. These associations persisted after adjustment for mental disorders.
Exposure to traumatic events predicts subsequent onset of psychotic experiences even after adjusting for comorbid mental disorders.
Depression is expensive to treat, but providing ineffective treatment is more expensive. Such is the case for many patients who do not respond to antidepressant medication.
To assess the cost-effectiveness of cognitive–behavioural therapy (CBT) plus usual care for primary care patients with treatment-resistant depression compared with usual care alone.
Economic evaluation at 12 months alongside a randomised controlled trial. Cost-effectiveness assessed using a cost-consequences framework comparing cost to the health and social care provider, patients and society, with a range of outcomes. Cost-utility analysis comparing health and social care costs with quality-adjusted life-years (QALYs).
The mean cost of CBT per participant was £910. The difference in QALY gain between the groups was 0.057, equivalent to 21 days a year of good health. The incremental cost-effectiveness ratio was £14 911 (representing a 74% probability of the intervention being cost-effective at the National Institute of Health and Care Excellence threshold of £20 000 per QALY). Loss of earnings and productivity costs were substantial but there was no evidence of a difference between intervention and control groups.
The addition of CBT to usual care is cost-effective in patients who have not responded to antidepressants. Primary care physicians should therefore be encouraged to refer such individuals for CBT.