This issue of Psychiatric Annals, guest edited by James Reich, MD, reviews personality disorders and their treatment. The series discusses the importance of learned negative schémas from child neglect and abuse as well as the possibility of traumatic experience resulting from psychiatric disorders. Also discussed is the issue of traits that could be genetically hardwired into brain function or created by negative experience. The treatments that derive from these models as well as empirical results, very much as in the case of the treatment of depression, can be conceptualized as "top down" or "bottom up" strategies.
Top down treatments can be conceptualized as employing learning therapies (dialectical behavior therapy, cognitive behavior therapy) to enhance cortical influences on subcortical or limbic circuits, and to undo negative learning or schémas and increase modulating effects. Bottom Up approaches involve the use of psychotropics for the purpose of modulating harmful traits or states that undennine adaptation to life stresses by "normalizing" the function of lower limbic structures.
In the case of depression, recent studies are suggesting that tools such as functional magnetic resonance imaging and other techniques may allow us to visualize and monitor the activity of the circuits that are substrates of some maladaptive states and traits. An example would be recent studies revealing prolonged activation oí the amygdala and anterior cingulate regions in some patients with depression. When these techniques allow more resolution and with the use of provocative psychological techniques (the induction of various negative moods by suggestive techniques such as the suggestion of painful past experiences or critical phrases), it may be possible to visualize responses of higher and lower circuits at base line and as treatment (top down, bottom up, or both) progresses. Maybe then, at last, we will have clinically useful tests to guide our treatment efforts. Wouldn't it be great to get some guidance as to which approaches are likely to be most helpful at a particular point in our treatment of patients suffering from these disorders?