Neurocognitive impairment in dramatic personalities: Histrionic, narcissistic, borderline, and antisocial disorders

283

Psychiatry Research. 42:283-290

Elsevier

Neurocognitive Impairment in Dramatic Personalities: Histrionic, Narcissistic, Borderline, and Antisocial Disorders J. Wesley

Burgess

Received August 31, 1990; first revised version received February version received January 9, 1992; accepted May 10, 1992.

4, 1991: second revised

Abstract. Thirty-seven patients with personalities in the dramatic cluster (DSMIII-R histrionic, narcissistic, borderline, and antisocial) and 40 controls matched for age and gender were evaluated on 16 neurocognitive variables. The evaluation screened for deficits in functions of attention, memory, language, abstraction, and behavior planning/sequencing. Analysis of variance revealed significant deficits in neurocognitive performance among patients with dramatic personalities, particularly in subtests requiring multi-step, multi-element associative operations. Key Words. Personality ing, neuropsychology.

disorder,

development,

cognition,

information

process-

deficiencies in information processing have been implicated in schizophrenia, major depression, and other serious psychiatric disorders, neurocognitive problems have not been considered important in dramatic personality, even in the presence of severe symptoms such as chronic depression, anxiety, and impulsivity (Burgess, 1991~). Traditional psychological tests have generally found that persons with dramatic personalities make no more errors in thinking than the general population (Cornelius et al., 1989). However, recent articles have reported a variety of mild cognitive errors in persons with borderline personality (Burgess, 1990, 19914 1991~; O’Leary et al., 1991; Burgess and Zarcone, 1992). The strength and generalizability of this finding to other populations and types of personality disorder is currently unknown. As defined by DSM-III-R (American Psychiatric Association, 1987), the dramatic personalities encompass a collection of interrelated personality characteristics (cluster B) that can be subdivided into histrionic, narcissistic, borderline, and antisocial personalities. Patients with these diagnoses may experience clinical symptoms that include extreme vulnerability to stress; chronic and persistent affective symptoms including depression, anxiety, and anger; recurring problems in interpersonal relationships; and a tendency toward impulsive, maladaptive beAlthough

At the time this work was done, J. Wesley Burgess, Ph.D., M.D., was a Fellow in Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Stanford University Medical Center and Palo Alto Department of Veterans Affairs Medical Center. Dr. Burgess is now Director, Adolescent Division, Los Angeles Center for Mood Disorders. (Reprint requests to Dr. J.W. Burgess, Adolescent Division, Los Angeles Center for Mood Disorders, 1990 S. Bundy Dr., Ste. 790, Los Angeles, CA 90025, USA.) 0165-1781/92/$05:00

@ 1992 Elsevier Scientific

Publishers

Ireland

Ltd.

284

haviors. Such patterns may suggest the presence of underlying problems in the registration and interpretation of internal and external stimuli, perhaps beginning in early development (e.g., Vaillant and Perry, 1985; Vaillant, 1987). Because of these suggestions in the literature, we decided to examine neurocognitive functions in persons with dramatic personalities. Methods Subjects. Seventy-seven adults participated in the study. All were evaluated for alertness and ability to attend to events in the environment; none showed detectable impairment. All denied drug abuse in the week before the evaluation. The personality-disordered group contained 37 persons (mean age = 34.3 years, SD = 8.6; 46% female). These subjects were prospectively drawn from a population of persons who consecutively presented for routine psychiatric evaluation at the Stanford and Palo Alto V.A.

Medical Centers. Inclusion in the personality-disordered diagnosis by at least two recent psychiatric evaluations

group required

agreement

on

that were carried out without knowledge of the patient’s neurocognitive performance; these assessments were based on all available information, including recent clinical examination, past history, and clinical records. Further diagnostic material was obtained from structured clinical interviews and self-report measures (Burgess, 1991b). All diagnoses were made by DSM-III-R criteria (American Psychiatric Association, 1987). The diagnostic breakdown was as follows: histrionic (n = 5) narcissistic (n = I), borderline (n = 15), antisocial (n = I), histrionic/ borderline (n = 4) narcissistic/ borderline (n = 6) and borderline/antisocial (n = 5) personalities. The control group (n = 40; mean age = 34.3 years, SD= 8:O; 50% female) was matched for age and gender to the personality-disordered subjects, and was drawn from clinical and associated mental health personnel without a history of psychiatric diagnosis or treatment. Neurocognitive Examination. Subjects received a 16-item neuropsychiatric battery based on the published examinations of Strub and Black (1987) and Luria (1973, 1980). The examination required approximately 20 minutes to complete. Sixteen subtests, each scored from 0 to 8 points, were administered. The specific items and their presumed functional significance are outlined below: Attention is associated with the function of reticulocortical, thalamic, and brainstem areas (Magoun, 1963; Watson and Heilman, 1979, Watson et al., 1981; Ferro and Kertesz, 1984). We initially screened for level of consciousness and vigilance to the environment/evaluator: these functions were not impaired in any subjects and were not evaluated further. We then tested orientation (to date, day, month, and year). Memory is associated with the functions of the hippocampus, dorsomedial thalamic nuclei, mammillary bodies, and language cortex (Milner, 1968; Scoville and Mimer, 1957; Kandel and Schwartz, 1985). We tested immediate memory spun (for 7 spoken numbers) and cued delayed memory (for 3 objects after 10 minutes). Language functions are associated with the functions of temporal, parietotemporal, and subcortical brain areas (Mohr, 1976; Goodglass and Kaplan, 1983). Verbal repetition is specifically linked to the language cortex surrounding the Sylvian fissure (Geschwind et al., 1968) focal object naming has been linked with lesions of the second and third temporal gyri (Geschwind, 1967) and subcortical lesions have been associated with mild anomia and comprehension errors (Mohr, 1976). We tested repetition of common words (red, ball, blue, car, city, and Chicago) and naming of visually presented objects and their parts (pen: point, cap, clip; watch: band, crystal, winder/ stem). Abstract operations are linked to cortical association areas (Critchley, 1953; Teuber, 1964; Black and Strub, 1976; Anderson, 1987), particularly posterior areas at the intersection of the temporal, parietal, and occipital lobes (the PTO association area of Kandel and Schwartz, 1985). Abstract tasks, which emphasized simultaneous comparison of multiple elements,

285 included similarity comparisons (e.g., truth vs. justice, poverty vs. misery, and daisy vs. flower: Wechsler 1981; Strub and Black, 1987) dependence comparisons (e.g., son of the father and daughter of the mother: Luria, 1973) and proverb interpretation (e.g., “don’t cry over spilt milk”and “let sleeping dogs lie”; scored according to Gorham, 1956). The subtraction of serial sevens emphasized both simultaneous comparative operations and sequential planning. The planning/sequencing of behavioral programs is also linked to cortical association areas, particularly those in the frontal and prefrontal cortex (Luria, 1973; Das et al., 1979; Kandel and Schwartz, 1985; Strub and Black, 1987). Tasks that emphasize the sequential planning and execution of successive steps include the reproduction of nonverbally presented Luria movements (fist-palm-thumb/forefinger ring: Luria, 1973, 1980) and nonverbally presented rhythm reproduction (of hard [T] and soft [t] taps: TTTtttTTT, tttTTTttt, ttTTtt; Luria, 1973, 1980). The following errors of planning and sequencing were also scored: slowing (of responses > 5 sec),perseverution (of previous responses), inversion (of material within a response), addition (of irrelevant material to a response), and omission (of relevant material from a response). Statistical Analysis. Between-group comparisons of neuropsychiatric performance were made by analysis of variance and F tests for nonrepeated, between-subjects effects (Winer, 1971; Snedecor and Cochran, 1980). Within-group comparisons of performance between subtests were made with multifactoral analysis of variance and Hotelling-Lawley tests for repeated effects (Bock, 1975; Morrison, 1976). Tukey’s all-pairs test was used for multiple between-group comparisons of performance on individual subtests (Games, 1978). Programs from the Statistical Analysis Systems were used throughout (SAS Institute, 1988).

Results Levels of overall cognitive performance differed significantly between groups (F = 19.67; df = 1, 75; p < 0.0001; Table 1). A significant overall difference in performance across subtests was found within groups (Hotelling-Lawley T = 3.34;

Table 1. Cognitive performance in dramatic personality and control subjects Dramatic personality Subtest

Control subjects

Mean

SD

Mean

SD

1. Orientation

2. 3. 4. 5. 6. 7. 8. 9.

7.78

0.79

7.80

0.76

Memory

span

7.51

0.77

7.45

0.68

Delayed

memory

6.89

1.31

7.62

0.67

7.78

0.63

7.95

0.32

7.37

1.16

7.90

0.38

6.92

2.14

7.80

0.99

7.46

1.39

8.00

0.00

6.38

1.74

7.78

0.48

Repetition Naming Similarity

comparisons

Dependence Proverb

comparisons

interpretation

Serial sevens

10. Luria movements 11. Rhythm reproduction 12. Slowing errors

6.84

1.40

7.85

0.43

6.38

2.09

7.20

1.09

3.81

3.34

6.95

1.82

3.89

4.05

4.60

4.00

13. Perseveration

4.76

3.98

6.60

3.08

14. Inversion errors 15. Addition errors

4.1 1

4.60

4.00

5.62

4.05 3.71

5.40

3.79

16. Omission

4.32

4.04

6.40

3.24

errors

Significance lTukev test1

p < 0.05 p p p p p p p

< < < < < < <

0.05 0.05 0.05 0.05 0.05 0.05 0.05

p < 0.05

p < 0.05

286 df= 15, 61; p < O.OOOl), and a significant interaction effect revealed group differences in subtest performance (Hotelling-Lawley T = 0.93; df = 15, 6 1; p < 0.000 1). When performance on individual subtests was compared between groups, persons with dramatic personalities made significantly more errors than control subjects on the following measures: delayed memory, naming, similarity comparisons, dependence comparisons, proverb interpretation, serial sevens, Luria movements, rhythm reproduction, perseveration, and omission errors (Tukey test, p < 0.05; Table 1). Discussion The current study indicates that persons with dramatic personalities (histrionic, narcissistic, borderline, and antisocial types) show significant impairment in their performance on tests of cognition and information processing, particularly on subtests requiring multi-step, multi-element associative operations. Cognitive Information Processing in Dramatic Personalities. Recent studies have demonstrated significant levels of cognitive impairment in persons with borderline personality, particularly in tests of planning/ sequencing cognitive functions (Burgess, 1990, 1991a, 1991~; O’Leary et al., 1991; Burgess and Zarcone, 1992). Similar types of cognitive deficits have also been found in persons with major depression (Glass et al., 1981; Shipley et al., 1981; Weingartner et al., 1981; Gruzelier et al., 1988; Cassens et al., 1990; Burgess, 1991a, 1991~). This relationship between depression and cognitive impairment is further strengthened by findings that depressive symptoms are correlated with the severity of cognitive impairment (in planning/ sequencing tasks) in both major depression and dramatic personality disorders (Burgess, 199 la, 199 1c). Different patterns of cognitive information processing are found in schizophrenia (Neale and Oltmanns, 1980; Asarnow and MacCrimmon, 1982; Nuechterlein and Dawson, 1984), mental retardation (Farnham-Diggory, 1976; Burgess, 1981, 1989; Burgess and McMurphy, 1982; Burgess and Fordyce, 1989), and normal controls (Corcoran, 1971; Butler, 1978; Burgess and Spoor, 198 1). Cognitive deficits may point to biologic etiologies in dramatic personality disorders. Current theories relate dramatic personality disorders to psychologically stressful experiences during childhood (Vaillant and Perry, 1985; Vaillant, 1987), but it has been suggested that physical stressors that affect brain development may play a role as well (Burgess, 1990). Physical stressors could include gestational complications, childhood injuries, malnutrition, and illnesses that occur spontaneously or as a result of parental abuse and neglect (Lewis et al., 1979; Soloff and Millard, 1983; Burgess, 1990). A relationship between physical stressors and dramatic personality disorders is supported by numerous past studies that have demonstrated excessive amounts of childhood head trauma, encephalitis, epilepsy, hyperactivity, abnormal electroencephalographic and auditory evoked potential findings, and aberrant sleepcycle architecture in persons with dramatic personalities (Akiskal et al., 1980; Andrulonis et al., 1981, 1982; Bell et al., 1983; McNamara et al., 1984; Cowdry et al., 1985; Reynolds et al., 1985; Kutcher et al., 1987).

287 Implications for Clinical Treatment. Our results encourage the use of neurocognitive testing in the assessment of persons with dramatic personalities. Such testing provides information about thinking style and limitations that may also be related to mood symptoms and behavioral impulsivity (Burgess, 1991a, 1991~). The tests presented here are well suited for such use because they are easily administered in the context of a brief clinical interview and their relevance in this population has been demonstrated. Our findings also support the use of both psychological and biological treatments of mood disorders in dramatic personalities (Brinkley et al., 1979; Leone, 1982; Serban and Siegel, 1984; Gardner and Cowdry, 1986; Goldberg et al., 1986; Soloff et al., 1986; Berger, 1987; Cowdry and Gardner, 1988; Kaplan and Sadock, 1989; Beck and Freeman, 1990). We hope that an increased awareness of different patterns of information processing will aid in our understanding of and communication with patients with dramatic personalities, Acknowledgments. The author thanks Drs. Herbert Leiderman, James Moses, Jr., Brant Wenograt, Vincent P. Zarcone, Jr., and Robert Zeiss for their help and suggestions.

References Akiskal, H.S.; Rosenthal, T.L.; Haykal, R.F.; Lemmi, H.; Rosenthal, R.H.; and ScottStrauss, A. Characterological depressions: Clinical and sleep electroencephalographic findings separating “subaffective dysthymias” from “character-spectrum disorders.” Archives of General Psychiatry, 37:777-783, 1980. American Psychiatric Association. DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, DC: American Psychiatric Press, 1987. Anderson, R.A. Inferior parietal lobule function in spatial perception and visuomotor integration. In: Plum, F., ed. Handbook OfPhysiology. Bethesda, MD: American Physiological Society, 1987. pp. 483-5 18. Andrulonis, P.A.; Glueck, B.C.; Stroebel, C.F.; Vogel, N.G.; Shapiro, A.L.; and Aldridge, D.M. Organic brain dysfunctions and the borderline syndrome. Psychiatric Clinics of North America, 4:47-66, 198 1. Andrulonis, P.A.; Glueck, B.C.; Stroebel, CF.; Vogel, N.G.; Shapiro, A.L.; and Aldridge, D.M. Borderline personality subcategories. Journalof Nervous and Mental Disease, 170:670679, 1982. Asarnow, R.F., and MacCrimmon, D.J. Attention/ information processing, neuropsychological functioning and thought disorder during acute and partial recovery phases of schizophrenia. Psychiatry Research, 7:309-319, 1982. Beck, A.T., and Freeman, A. Cognitive Therapy of Personality Disorders. New York: Guilford Press, 1990. Bell, J.; Lycaki, H.; Jones, D.; Kelwala, S.; and Sitaram, N. Effect of preexisting borderline personality disorder on clinical and EEG sleep correlates of depression. Psychiatry Research, 9:115-123, 1983. Berger, P.A. Pharmacological treatment for borderline personality disorder. Bulletin of the Menninger Clinic, 5 11277-284, 1987. Black, F.W., and Strub, R.L. Constructional apraxia in patients with discrete missile wounds. Cortex, 12:212-220, 1976. Bock, R.D. Multivariate Statistical Methods in Behavioral Research. New York: McGrawHill, Inc., 1975. Brinkley, J.R.; Beitman, B.D.; and Friedel, R.O. Low-dose neuroleptic regimens in the treatment of borderline patients. Archives of General Psychiatry, 36:319-326, 1979.

Burgess, J.W. Development

of social spacing in normal and mentally retarded children.

Journal of Nonverbal Behavior, 6:89-95, 198 1.

288 Burgess, J.W. The development of social group formation in normal and mentally retarded persons from early childhood through old age: Neuropsychiatric, developmental and cognitive implications. Psychiatry Research, 30:3 l-43, 1989, Burgess, J.W. Cognitive information processing in borderline personality disorder: A neuropsychiatric hypothesis. Jefferson Journal of Psychiatry, 8:34-49, 1990. Burgess, J.W. Neurocognition in acute and chronic depression: Personality disorders, major depression and schizophrenia. Biological Psychiatry, 30:305-309, 199la. Burgess, J.W. The Personality Inventory Scales: A self-rating clinical instrument for diagnosis of personality disorders. Psychological Reports, 69:1235-1246, 19916. Burgess, J.W. Relationship of depression and cognitive impairment to self-injury in borderline personality disorder, major depression, and schizophrenia. Psychiatry Research, 38:77-87, 1991~. Burgess, J.W., and Fordyce, W.K. Effects of preschool environments on nonverbal social behavior: Toddlers’ interpersonal distances to teachers and classmates change with environmental density, classroom design and parent-child interactions. Child Psychology and Psychiatry, 30:261-276, 1989. Burgess, J.W., and McMurphy, D. Development of proxemic spacing behavior: Children’s distances to surrounding playmates and adults changes between 6 months and 5 years of age. Developmental Psychobiology, 15:557-567, 1982. Burgess, J.W., and Spoor, D. Seven faces in a crowd: Parallel or serial information processing. International Journal of Neuroscience, 12:93-98, 1981. Burgess, J.W., and Zarcone, V.P. Cognitive impairment in dramatic personality disorders. (Letter) American Journal of Psychiatry, 149: 136, 1992. Butler, B. Sequential and parallel operations in tachistoscopic recognition. Canadian Journal of Psychology, 32:241-256, 1978. Cassens, G.; Wolfe, L.; and Zola, M. The neuropsychology of depressions. Journal of Neuropsychiatry, 21202-213, 1990. Corcoran, D.W.J. Pattern Recognition. Baltimore: Penguin Books, Inc., 1971. Cornelius, J.R.; Soloff, P.H.; George, A.W.A.; Schulz, S.C.;Tarter, R.; Brenner, R.P.; and Schulz, P.M. An evaluation of the significance of selected neuropsychiatric abnormalities in the etiology of borderline personality disorder. Journal of Personality Disorders, 3:19-25, 1989. Cowdry, R.W., and Gardner, D.L. Pharmocotherapy of borderline personality disorder: Alprazolam, carbamazepine, trifluoperazine, and tranylcypromine. Archives of General Psychiatry, 45:11 l-l 19, 1988. Cowdry, R.W.; Pickar, D.; and Davies, R. Symptoms and EEG findings in the borderline syndrome. International Journal of Psychiatric Medicine, 15:201-211, 1985. Critchley, M. The Parietal Lobes. London: Edward Arnold, 1953. Das, J.P.; Kirby, J.R.; and Jarman, R.F. Simultaneous and Successive Cognitive Processes. New York: Academic Press, 1979. Farnham-Diggory, S. Development of logical operations and reasoning. In: Hamilton, V., and Vernon, M.D., eds. The Development of Cognitive Processes. New York: Academic Press, 1976. Ferro, J., and Kertesz, A. Posterior internal capsule infarction associated with neglect. Archives of Neurology, 411422-429, 1984. Games, P.A. A three-factor model encompassing many possible tests on independent groups. Psychological Bulletin, 85: 168-182, 1978. Gardner, D.L., and Cowdry, R.W. Positive effects of carbamazepine on behavioral dyscontrol in borderline personality disorder. American Journal of Psychiatry, 143:5 19-522, 1986. Geschwind, N. The varieties of naming errors. Cortex, 3:97-l 12, 1967. J. Isolation of the speech area. N.; Quadfasel, F.; and Segarra, Geschwind, Neuropsychologia, 6:327-340, 1968.

289 Glass, R.M.; Uhlenhuth, E.H.; Hartel, F.W.; Matuzas, W.; and Fischman, M.W. Cognitive dysfunction and imipramine in outpatient depressives. Archives of General Psychiatry, 38:1048-1051, 1981. Goldberg, SC.; Schulz, S.C.; Schulz, P.M.; Resnick, R.J.; Hamer, R.M.; and Friedel, R.O. Borderline and schizotypal personality disorders treated with low-dose thiothixene vs. placebo. Archives of General Psychiatry, 43:680-686, 1986. Goodglass, H., and Kaplan, E. The Assessment of Aphasia and Related Disorders. Philadelphia: Lea & Febiger, 1983. Gorham, D.R. The Proverbs Test. Missoula, MT: Psychological Test Specialists, 1956. Gruzelier, J.; Seymour, K.; Wilson, L.; Jolley, A.; and Hirsch, S. Impairments on neuropsychologic tests of temporohippocampal and frontohippocampal functions and word fluency in remitting schizophrenia and affective disorders. Archives of General Psychiatry, 45:623-629, 1988. Kandel, E.R., and Schwartz, J.H. Principles of Neural Science. New York: Elsevier Science Publishing Co., Inc., 1985. Kaplan, H.I., and Sadock, B.J., eds. Comprehensive Textbook ofpsychiatry V. Baltimore: Williams & Wilkins Company, 1989. Kutcher, S.P.; Blackwood, D.H.R.; St. Clair, D.; Gaskell, D.F.; and Muir, W.J. Auditory P300 in borderline personality disorder and schizophrenia. Archives of General Psychiatry, 44:645-650, 1987. Leone, F.N. Response of borderline patients to loxapine and chlorpromazine. Journal of Clinical Psychiatry, 43: 148-150, 1982. Lewis, D.O.; Shanok, S.S.; and Balla, D.A. Perinatal difficulties, head and face trauma and child abuse in medical histories of seriously delinquent children. American Journal of Psychiatry, 136:419-423, 1979. Luria, A.R. The Working Brain. New York: Basic Books, 1973. Luria, A.R. Higher Cortical Functions in Man. New York: Basic Books, 1980. Magoun, H. The Waking Brain. Springfield, IL: Charles C Thomas, Publisher, 1963. McNamara, E.; Reynolds, C.F.; Soloff, P.H.; Mathias, R.; Rossi, A.; Spiker, D.; Coble, P.A.; and Kupfer, D.J. EEG sleep evaluation of depression in borderline patients. American Journal of Psychiatry, 141: 182-186, 1984. Mimer, B. Visual recognition and recall after right temporal-lobe excision in man. Neuropsychologia. 6: 191-209, 1968. Mohr, J.P. Broca’s area and Broca’s aphasia. In: Whitaker, H., and Whitaker, H.. eds. Studies in Neurolinguistics. Vol. I. New York: Academic Press, 1976. pp. 201-235. Morrison, D.F. Multivariate Statistical Methods. New York: McGraw-Hill, Inc., 1976. Neale, J.M., and Oltmanns, T.F. Schizophrenia. New York: John Wiley & Sons, 1980. Nuechterlein, K.H., and Dawson, M.E. Information processing and attentional functioning in the developmental course of schizophrenic disorders. Schizophrenia Bulletin, 10: 160-203, 1984. O’Leary, K.M.; Brouwers, P.; Gardner, D.L.; and Cowdry, R.W. Neuropsychological testing of patients with borderline personality disorder. American Journal of Psychiatry, 148:106-111, 1991. Reynolds, C.F.; Soloff, P.H.; Kupfer, D.J.; Taska, L.S.; Restifo, K.; Coble, P.A.; and McNamara, E. Depression in borderline patients: A prospective EEG sleep study. Psychiatry Research, 14:1-15, 1985. SAS Institute. SAS/STAT Users Guide. Cary, NC: SAS Institute, 1988. Scoville, W., and Milner, B. Loss of recent memory after bilateral hippocampal lesions. Journal of Neurology, Neurosurgery, and Psychiatry, 20: I 1-2 I, 1957. Serban, G., and Siegel, S. Response of borderline and schizotypal patients to small doses of thiothixine and haloperidol. American Journal of Psychiatry, 141:1455-1458, 1984. Shipley, J.E.; Kupfer, D.J.; Spiker, D.G.; Shaw, D.H.; Coble, P.A.; Neil, J.F.; and Cofsky, J. Neuropsychological assessment and EEG sleep in affective disorders. Biological Psychiatry, 16:907-918, 1981.

290 Snedecor, G.W., and Cochran, W.G. Statistical Methods. Ames, IA: Iowa State University Press, 1980. Soloff, P.H.; George, A.; Nathan, S.; Schulz, P.M.; Ulrich, R.F.; and Perel, J.M. Progress in pharmacotherapy of borderline disorders. Archives of General Psychiatry, 43:691-697, 1986. Soloff, P.H., and Millard, J.W. Psychiatric disorders in the families of borderline patients. Archives of General Psychiatry, 40137-44, 1983. Strub, R.L., and Black, F.W. The MentalStatus Examination in Neurology. Philadelphia: Davis, 1987. Teuber, H.L. The riddle of frontal lobe function in man. In: Warren, J., and Akert, K., eds. The Frontal Granular Cortex and Behavior. New York: McGraw-Hill, Inc., 1964. pp. 410-444. Vaillant, G.E. A developmental view of old and new perspectives of personality disorders. Journal of Personality Disorders, 1:146-156, 1987. Vaillant , G.E., and Perry, J.C. Personality disorders. In: Kaplan, H.I., and Sadock, B.J., eds. Comprehensive Textbook of Psychiatry IV. Baltimore: Williams & Wilkins Company, 1985. pp. 958-986. Watson, R.T., and Heilman, K.M. Thalamic neglect. Neurology, 29:690-694, 1979. Watson, R.T.; Valenstein, E.; and Heilman, K.M. Thalamic neglect. Archives of Neurology, 38:501-506, 1981. Wechsler, D. Wechsler Adult Intelligence Scale-Revised. New York: Psychological Corporation, 198 1. Weingartner, H.; Cohen, R.M.; Murphy, D.L.; Martello, J.; and Gerdt, C. Cognitive processes in depression. Archives of General Psychiatry, 38:42-47, 198 1. Winer, B.J. Statistical Principles in Experimental Design. New York: McGraw-Hill, Inc., 1971.