JOURNAL CLUB

PRESENTATION

Supervisor: Presented By:

Dr. Shweta Singh Ms. Huma Fatima
Associate Professor M. Phil 1st year
Dept. Of Psychiatry Dept. Of Psychiatry
KGMU, Lucknow KGMU, Lucknow
 OUTLINE OF THE PRESENTATION

 About the Paper

 Abstract

 Introduction

 Method

 Results

 Discussion

 Conclusion

 Critical appraisal of the study

 ABOUT THE PAPER

 Title
Psychopathology of Emotionally Unstable Personality Disorder: A
Neuropsychosocial Perspective
 Authors
Dinaz D. Bilimoria, Assistant professor, Pritha Mukhopadhyay, Professor, Loreto College, Kolkata.
Sanjukta Das, Associate Professor, Department of Psychology, University of Calcutta, Kolkata.

 Published in
Indian Journal of Clinical Psychology, 2015, Vol. 42, No. 1, 25-34
ABSTRACT
 Abstract
 Emotionally Unstable Personality Disorder (EUPD) is a complex and serious mental disorder
characterized by intense and rapidly changing mood states as well as by impulsivity, self
injurious behaviors, fear of abandonment, unstable relationships, and unstable self image.
 The study aimed to identify the underlying psychosocial factors that may contribute to the
psychopathology of two groups (namely, EUPD and EUPD comorbid with another disorders;
EUPD Co) and also to assess the executive functions of the groups in comparison to their
normal counterparts (CG).
 The study groups comprised of EUPD (n=30), EUPD Co (n=20) along with the matched
control group (n=30).
 The study groups assessed on International Personality Assessment Examination, General
Health Questionnaire, Standardized Assessment of Personality Abbreviated Scale, Beck
Depression Inventory, Aggression Orientation Scale, Family Environment Scale and Tower of
London Test, Drexel University.
 Abstract cont’…
 One way analysis of variance (one-way ANOVA) was used for obtaining differences of means
between the three groups.
 Principal Component Analysis (PCA) was done to identify a pattern or structural analysis of the
variables amongst the three groups for two constructs namely, neuropsychological and
psychosocial.
 Result indicated that the EUPD and EUPD Comorbid groups significantly differed from the
Control Group in terms of Subjective Depression, Aggression Orientation, and the Executive
Function of the Planning.
 PCA showed different structures for the groups. It is seen that there is substantial dysfunction in
the interpersonal sphere as well as executive functioning in both the patient groups and when
psychopathology is complex as in the comorbid group the dysfunction is greater.
 Key words
Emotionally Unstable, Depression, Aggression, Family, Executive Functions, Planning
INTRODUCTION
 Introduction
 Emotionally Unstable Personality Disorder (EUPD) as described in the International
Classification Of Diseases (ICD) or Borderline Personality Disorder (BPD) as
described in the Diagnostic And Statistical Manual Of Mental Disorders (DSM) is one
of the most enunciated and written about conditions in modern psychiatry.
 EUPD is a condition that is thought to occur globally (Pinto et al., 2000).
 The prevalence of EUPD has been estimated to occur in approximately 2% of
general population, 10% of psychiatric outpatients and up to 20% of psychiatric
inpatients (Wingenfeld et al., 2009).
 The gender proportion in EUPD is clearly dominated by the female population with
females accounting for approximately four-fifth of the cases (Swartz, Blazer,
George, and Winfield 1990).
 Intro. Cont’…
 Individuals with EUPD are commonly diagnosed with other comorbid Axis I disorders
such as mood disorders (96.3%) and anxiety disorders (88.4 %) being the best
prominent ones (Zanarini et al., 1998).
 Indian studies indicated that personality disorder diagnoses are found to be common
among untreated Axis-1 disorders, particularly, in untreated outpatients with major
depressive disorder (Laha, 2013).
 Linehan (1993) closely researched on the specific features of EUPD.
 It was found that five major areas of dysregulation were present in affected
individuals.
 These characteristics were divided into five categories: Emotional dysregulation
was the most significant problem faced by individuals with this disorder and refers to
the intense and labile emotions and extreme sensitivity resulting in frustration and
anger outbursts that may be verbal or physical.
 Intro. Cont’…
 Interpersonal dysregulation refers to major difficulties in maintaining relationships and
interpersonal conflicts. The relationships of affected individuals would rapidly change
from infatuation and joy to fury, resentment, and hatred.
 Behavioral dysregulation refers to indulgence in dangerous and impulsive behaviors,
which are followed by harm to self and to others.
 Cognitive dysregulation includes the experience of a disconnection from reality when
faced with extreme stress. They also display dichotomous or “black or white” thinking in
which they only consider their interpretation of the event.
 Self dysregulation is where affected individuals often report a dearth of knowledge
about oneself and feelings of hollowness. Confusion about self identity is common.
 Impulsivity (Critchfield et al., 2004; Svrakic et al., 2002; Trull, 1992) and
aggressiveness (Skodol et al., 2002) have been hypothesized recently to represent core
features of EUPD.
 Intro. Cont’…
 Likelihood of aggression in EUPD is increased by environmental overstimulation and stress
(Nickel et al., 2004).
 Patient mainly with impulsive-behavioral dyscontrol symptoms, exhibit impulsive aggression,
self-mutilation, or self-damaging behavior ( e.g., promiscuous sex, substance abuse, reckless
spending etc).
 EUPD patients often sensitive to relationship dynamics, fearing abandonment or rejection
and engaging in frantic attempts to avoid it.
 Ambivalence has also been observed to be an important theme in EUPD and is defined as
the coexistence of confusing and contradictory feelings and thoughts.
 Redundant communication and interaction pattern have emerged as significant factors in
families with a EUPD patient.
 All of the patients reported that they did not feel as if they had received positive affective
messages.
 Instead, they experienced certain communication as being delivered in an ineffective,
destructive, devaluative and directly abusive manner.
 Intro. Cont’…
 Impaired anticipatory planning in EUPD has been confirmed in some studies
(Bazanis et al., 2002; Dinn et al., 2004; Dowson et al., 2004).
 Planning deficits have been reported in EUPD sample reviewed and these
studies indicated longer deliberation times, more attempts and longer latency.
 Bazanis described these deficits as localized to the orbito-frontal and dorso-
lateral frontal brain regions and speculated that a general aversion to delay
might be an important feature of EUPD (Bazanis et al., 2002).
 This study is an endeavor to understand personality disorder in a holistic
approach, taking into consideration the various dimensions of the individual’s
life aspect which may lead to the formation of such psychopathology.
METHOD
 Method
Study design
 Present study is a cross sectional comparative study.
Aim
 The study aims to explore subjective level of depression, aggression orientation, familial
environment and the executive functions of planning.
Participants
 Participant are divided in three groups; patients with EUPD (n=30; male=8; female=22)
comprised of Group A, EUPD co-morbid with another mental disorders (Adjustment disorder or
Depressive disorder or Anxiety disorder) (n=20; male=6; female=14) comprised of Group B
and last group was drawn from the community and was considered as the control group (CG)
(n=30) (Group C).
Sampling type
 Purposive sampling
 Method Cont’…
Matching
 The patient group was matched with healthy controls for age, sex, education and
handedness.
Place of conducting study
 The study was conducted at the Department of Psychology, University of Calcutta, Kolkata.

 Participants were selected only on the basis of agreement between Psychiatrist and the
Clinical Psychologist.

 Diagnosis was based on International Classification of Mental and Behavioral diseases (ICD-
10).
 Method cont’…
Inclusion criteria for group A and B
 Persons of either sex within the age range of 18-48 (age 48 was chosen to avoid possible
cognitive decline/changes in neuropsychological assessment).

 The minimum level of education was fixed at standard 10th to aid in neuropsychological
assessment.

 Subjects who were not acquainted with this type of testing, i.e. naïve subjects, were chosen.

 Only right-handed subjects were chosen.

 Those who agreed to partake in the study were chosen.

 Method Cont’…
Exclusion criterion for group A and B
 Subjects with the history of co-morbid psychological disorders were

excluded (only applicable for Group A, Group B could include

Adjustment disorder or Depressive episode or Anxiety Disorder).
 Subjects with current serious/acute/chronic medical illness diagnosed

were excluded.
 Subjects with physical disability/neurological condition were excluded.

 Subjects with the history of developmental disorders were excluded.

 Method Cont’…
Inclusion Criteria for Group C
 Subjects with no history of any psychological disorders were
included.
 Subjects who scored 4 or less on General Health Questionnaire
a screening questionnaire for psychiatric morbidity were
included.
 Subjects who were not acquainted with this type of testing, i.e.
naïve subjects were included.
 Those who agreed to partake in the study were included.
 Method Cont’…
Exclusion criteria for Group C
 Subjects with current serious/acute/chronic medical illness diagnosed

were excluded.
 Subjects with physical disability/ neurological condition were excluded.

 Subjects with the history of developmental disorders were excluded.

 Method Cont’…
Tools
 Semi-Structured Socio-Demographic and Clinical Data Sheet
 Edinburgh Handedness Inventory (Oldfield, 1971) was used to assess handedness
 International Personality Disorder Examination (IPDE; Loranger, Janca, & Sartorius, 1997) was
used to screen patients with EUPD.
 General Health Questionnaire (GHQ, Goldberg and Miller, 1979) was assessed as a screening tool
for the control group.
 Standardized Assessment of Personality Abbreviated Scale (SAPAS; Moran et al., 2003) was used
as a screening tool for the CG.
 Beck Depression Inventory (BDI; Beck et al., 1961) was used to assess subjective level of depression.
 Aggression Orientation Scale (AOS; Basu,2001) was administered to assess the level of aggression.
 Family Environment Scale(FES; Bhatia And Chadha, 1993) was used to assess the perception of the
familial environment.
 TOWER OF LONDON TEST (TOL; Culberston & Zilmer, 2001) was used to assess the executive
function of planning.
 Method Cont’…
Analysis
 Statistical analysis was done with the help of Statistical Package for
Social Sciences, Version 21.
 Levene’s test was used for homogeneity of variances.
 One way analysis of variance (ANOVA) was used for obtaining
differences of means between the EUPD, EUPD Co-morbid and their
corresponding community sample.
 0.05 and 0.01 level of significance was accepted as critical level.
 A structure analysis using Principal Component Analysis (PCA) was done
to see in which way the groups differed amongst each other in terms of
the psychosocial variables and the neuropsychological variable.
RESULTS
 Results
 The results revealed that the EUPD and EUPD Co-morbid significantly differed from the Control group
in terms of subjective depression, aggression orientation, their perception of familial environment and
the executive function of planning.
Table 1 : Comparison between EUPD, EUPD Co-morbid and the Control Group (CG) on Beck
Depression Inventory and Aggression Orientation.

Variables EUPD EUPD CG Mean Diff.

Comorbid
M SD M SD M SD F
Depression (BDI) 27.90 13.58 31.00 8.83 5.97 3.67 60.71***

Aggression orientation 42.13 12.59 46.6 9.22 16.66 7.72 77.31***

*p<0.05 level, **p<0.01 level, ***p<0.001 level

 Results Cont’…
Table 1 indicates that the two groups-EUPD and EUPD
Comorbid showed significant difference in experience of
subjective depression and aggression orientation as
compared to the Control Group, with greater
impairment being shown in the EUPD and EUPD
Comorbid against their normal controls.
Table-2 : Comparison between EUPD, EUPD Comorbid and the Control Group (CG) on Family
Environment Scale.
Variables EUPD EUPD CG Mean
Comorbid Differences
M SD M SD M SD F
Cohesion 45.53 10.35 39.10 9.12 55.17 6.54 25.24***
Expressiveness 29.23 6.62 23.20 6.68 34.83 6.64 22.97**
Conflict 37.80 10.35 30.20 6.67 51.2 6.59 102.87***
Acceptance and caring 41.43 8.27 30.80 8.01 54.03 4.27 80.69***
Active recreational orientation 28.00 4.73 24.00 5.91 35.80 3.20 47.89***
Independence 31.33 6.32 25.60 6.00 33.60 3.66 17.11***
Organization 7.46 2.41 5.9 2.15 8.33 1.12 11.65***
Control 15.56 2.43 12.6 3.31 15.90 1.84 14.62***
* p < 0.05 level, ** p < 0.01 level, *** p < 0.001 level
 Results Cont’…
 Table 2 indicates that the three groups – EUPD, EUPD Comorbid and
Control Groups showed significant differences on all the domains of
FES as the EUPD and EUPD Comorbid groups being worse off in their
perception of their family environment than the Control Group.
 It is further seen that the EUPD and the EUPD Comorbid perceive low
cohesion, low expressiveness, high conflicts, low acceptance and caring
and low active recreational orientation than the Control Group.
 The EUPD Comorbid group perceives low independence, low
organization and low control and differs significantly with the other
two groups.
Table 3 : Comparison between EUPD, EUPD Comorbid and the Control Group (CG) on Tower Of
London Test.
Variables EUPD EUPD Comorbid Control Group Mean Diff.
M SD M SD M SD F
Correct Score
Bn,m, 9.33 1.76 35.20 14.37 51.16 21.30 60.44***

Move Score 18.56 6.10 11.40 17.75 30.01 21.84 7.07***

Initiation Time 39.00 25.26 37.50 25.40 56.36 27.67 4.83**

Execution Time 20.13 17.07 15.50 12.35 22.96 18.03 1.66

Total Time 25.36 19.49 21.60 16.73 29.16 21.08 1.16

Time Violations 65.26 41.57 43.00 38.46 77.06 36.36 5.95**

Rule Violations 56.23 41.20 43.70 46.40 92.67 19.88 13.71***

* p < 0.05 level, ** p < 0.01 level, *** p < 0.001 level
 Results Cont’…
 Table 3 indicates that the EUPD, EUPD Comorbid and Control Group
differ significantly on the correct score domain of planning and goal
directed behaviour, with the EUPD and EUPD Comorbid performing
worse than the Control Group.
 The EUPD, EUPD Comorbid and CG also differ significantly on initiation
time and rule violation domain of planning and goal directed behavior
as CG performing better with respect to both groups on said domains.
 Further, the EUPD Comorbid and CG differ significantly on the domains
of move score and time violation as the EUPD Comorbid group
performing poorly on these measures.
DISCUSSION
 Discussion
 The present study indicates that the patient groups (EUPD and
EUPD Comorbid) experience greater amount of subjective
depression and have a greater aggression orientation than the
control group.
 The frustration that they experience may be externalized
through aggression and internalized through depression.
 The frustration they experience may be rapidly transformed
into actions, like, temper outbursts and prolonged verbal
battles, can destabilize and even destroy close relationships
(Linehan, 1993).
 Discussion Cont’…
 The inability to reach their goal, perceived rejection from a
loved one or a prevented impulse may lead to frustration
culminating aggression as it is a well established notion that
frustration leads to aggression.
 Significantly higher scores on the aggression scale found in the
patient groups in this study are comparable to that of the
existing literature as well, where aggression has been
identified as one of the core features of EUPD (Dougherty et
al., 1999; Links et al., 1999; Hansenne et al., 2002; Skodol et
al., 2002).
 Discussion cont…
 Dutton (2002) in his study found that some individuals may also use
aggression in attempt to control a significant other and avoid
feared abandonment.
 The aggressive reaction may be because of their perceived
rejection from the significant other who probably moves away
because of their clinging behavior.
 Their perception of being rejected by the other may result in
depression as indicated by greater scores on the measures of
subjective depression (BDI).
 Threats to positive self-esteem in terms of negative social feedback
may give rise to anger and hostility (Baumeister et al., 2000).
 Discussion Cont’…
 If negative feedback is encountered that challenges
established positive self-perceptions, the individual may either
accept the external appraisal without rationally evaluating it
and thereby experience dysphoric feelings as indicated by
significantly high scores on the BDI, or may reject the
unfavorable feedback which may result in feelings of anger
and resentment toward the source of the threat as reflected in
this study by scores on AOS
 Therefore, their sense of self is dependent on others evaluation.
 Discussion cont’…
 Escalating demands for attention, love and care (perception of
poor acceptance and caring on FES) by the individual may not be
catered to because of its excessive nature which may result in
their perception of a dysfunctional family environment as in the
present study.
 The initial exchange of love, care and acceptance attract them
to a significant other and perhaps consequently their sense of
self is somewhat fused with the significant other, where they
want this other to understand and adjust with them perfectly
and as per their expectations.
 Discussion cont’…
 When there is a slightest mismatch it leads to negative emotions
in self that may be projected toward this significant other.
Interpersonal dysregulation (as seen in the present study) may
also be explained through their continuous evaluation of the
other which is extreme, i.e. the individual is either very good or
very bad with nothing in between. These relationship often shift
between the unrealistic views of the important other as all
good or perfect, and all bad and not worth knowing (FES
domain of conflict).
 Discussion cont’…
 This black and white thinking further estranges the other in the
relationship . It has also been reported in literature that EUPD
patients have a tendency to distort their relationships by
categorizing peoples (including themselves) as either ‘all good’
or ‘all bad’- a process called splitting (Stern, et al, 1997).
 As a result of splitting, interpersonal relations are paradoxical
by nature because the good person is idealized and the bad
person devalued. Shift in loyalty from the one person to other
are therefore common (Kaplan & Sadock , 1997).
 Discussion cont’…
 EUPD patients can feel both dependent upon and hostile
towards objects (people) at the same time (Kernberg, 1975).
 Poor perception of their relationships within their familial set up
may be extended to the outer environment where they seek the
company of others but are unable to maintain most
relationships.
 This may be a result of their self set standards for receiving
acceptance and care which are so high because of their own
emptiness and vacuum that they probably perceive a lack of it
because of the gap in their expectation what is actually
available as seen in this study.
 Discussion cont’…
 Their risk taking and impulsive behavior have also been supported
by increased percentiles on initiation time on planning task of TOL
in this study. This may make family members vary of their
interaction with their external world which may lead to decreased
scope for social and recreational activities (active recreational
domain of FES) within the family set up as identified by them.
 On the other hand, emotional under-involvement by parents may
also be a factor that impairs the child’s ability to socialize
effectively (Linehan, 1993) and perhaps thwarts independence. This
entire cycle may further reflect in the perception of poor
organization and control in the family system (FES).
 Discussion cont’…
 Bazanis cribbed these deficits as localized to the orbitofrontal and
dorsolateral frontal brain and speculated that a general aversion
to delay might be an important feature of EUPD (Bazanis et al.,
2002).
 EUPD patients have shown to display deficient executive functioning
as compared to healthy controls in the domains of cognitive
planning, sustained attention, and working memory in other studies
as well (Gvirts et al., 2012).
 This indicates poor development of an overall action plan, the
inability to identify sub goals and their organization into a
sequence of moves in order to reach the required goal state.
 Discussion cont’…
 Impaired anticipatory planning in EUPD have been confirmed in
some studies (Travers & King, 2005; Dinn et al., 2004; Dowson et
al., 2004; Bazanis et al., 2002).
 Poor scores on planning reflect poor monitoring of sub goal
attainment while maintaining a solution schema in the spatial
working memory.
 This attention seeking behavior may push the individual toward
engaging in behavior that can be impulsive. When this impulsivity is
met with resistance by family members, it may create a ground for
such individuals to perceive that are not encouraged to act openly
and express their thoughts and feelings directly and thus perceive
low expressiveness within the familial environment as seen in the
present study.
 Discussion cont’…
 Consequently, this may lead to confrontations and conflicts
within the family (as indicated by perception of high conflict in
the present study) resulting in the perception of absence of
unconditional acceptance and caring in the family set up.
 Further it has been seen that the clinical groups have a poorer
percentile for initiation time which indicates an undercontrolled
impulsive response which results in early incorrect moves making
the task unsolvable in the minimum number of moves indicating
the lack of a ‘think ahead’ strategy and greater number of
erroneous moves.
 Discussion cont’…
 The EUPD and EUPD Comorbid group show increased rule violations
which is an index of their deficit in adherence to rule governed
behavior. It is not that they do not know the rule or they are
forgetting it, rather they are violating the rule despite its
knowledge and correction. Thus, they reflect poor feedback
utilization reflecting their impulsivity in situations.
 Furthermore, the EUPD comorbid group also show increased time
violations when compared to the EUPD group or CG.
 It may be postulated that initial impulsivity of comorbid group
results in early incorrect moves and leads to a confused order of
steps to solve the problem and also more number of moves will be
required to solve the task at hand.
 Discussion cont’…
 Consequently, the task becomes unsolvable unless previous
moves are corrected and therefore more time is required for
problem solving, ultimately leading to time violation. The
finding of greater time violation on TOL reflects poor response
inhibition.
 It is seen that both the groups EUPD and EUPD Comorbid show
a deficit in working memory where it is difficult to generate
and select alternatives. This may be attributed to their
impulsivity.
 Discussion cont’…
 Poor attentional allocation to all the relevant variables indicates the
inability to use the ‘think ahead’ strategy which although may result
in completion of the task but is flawed with error components
indicating an overall deficit in problem solving ability.
 Some previous studies have suggested that individuals with EUPD
may show a possible dysfunction in the inhibitory control (Grootens
et al., 2008; Rcuhshow et al., 2008).
 They mostly act on the basis of their ‘here and now’ feeling and in
combination with their impulsivity display poor response inhibition
which is further reflected through violations in rules that indicates a
gap between their knowledge and action.
 Discussion cont’…
 Impulsive aggression seems to be related to an unplanned aggressive
behavior generally defined as a trigger aggressive response to
provocation with loss of behavioral control (Dougherty et al., 1999).
 The principal component analysis indicates that perception of familial
environment and experiences within the family set up contribute to the
first component in the EUPD group while planning variables to the
second component. This may indicate that perceived deprivation in terms
of a well knit, emotionally balanced family that allows freedom of
expression principally contribute to the formation of the
psychopathology within this group and planning dysfunction that is
characterized by impulsivity, response disinhibition and non rule
governed behavior is seen to contribute to the second component.
 Discussion cont’…
 The EUPD comorbid group primarily comprised of OCD and
depression as comorbidities and it was seen through principal
component analysis that planning variables contributed
principally to the first component of this group. OCD is now a
neurobiological disorder (Saxena & Rauch, 2000) and here too
it has been seen that executive dysfunction contributes to the
psychopathology of this group. Furthermore, slowing of
executive dysfunction has also been reported in patients with
depression (Snyder, 2013).
 Discussion cont’…
 Both OCD and depression are internalizing disorders, where
because of their functional fixedness they may find it difficult to
assimilate information coming from the external environment
into an existing mental schema.
 Consequently, accommodating or developing new schemata
becomes difficult for them. They seem to be conditioned only to
one particular way of thinking and thus cannot think differently
even in the face of changing external contingencies. It further
reflects an inability of top-down processing to assimilate
bottom-up information.
CONCLUSION
 Conclusion
 In conclusion, it can be stated that EUPD may not only be the result of
elevated subjective levels of depression, aggression and dysfunctional
home environment but also of executive dysfunction which work in
synchrony with each-other leading to symptom formation.
 Furthermore, when EUPD is comorbid with another disorder it worsens
the psychopathology and makes the individual more dysfunctional.
 CRITICAL
APPRAISAL
 Critical Appraisal
Title of the paper
 The title of the article is well defined and in descriptive form.

 It clearly represents the purpose of the study.

Authors
 Contact details and academic profile of the first author has been mentioned.

 Details of affiliating institution has been mentioned.

Topic
 Topic of the paper is relevant to clinical practice and a subject to future
research.
 The findings of the study give an insight to understand the neuropsychosocial
perspective in EUPD.
 Critical Appraisal
Abstract
 The content of the abstract has not been divided in sub-
headings which would have aided in better understanding.
 Background of the study has not been mentioned.

 Psychopathology of EUPD has been clearly defined.

 Aim of the study has been mentioned.

 Rationale of the study has not been mentioned.

 Sample size of each group has been mentioned but male-

female ratio and other characteristics were not mentioned.

 Critical appraisal
 Selection criteria of sample groups has not been mentioned.
 The place from where sample has drawn has not been mentioned.

 Design of the study has not been mentioned.

 Measures used for assessment have been mentioned.

 The statistical methods used to analyze the obtained data have

not been mentioned.
 Conclusion is in keeping with results obtained.

 Limitations of the study has not been mentioned.

 Further implication of the findings have not been mentioned.

 Critical appraisal
Introduction
 Psychopathology of EUPD has been clearly defined.

 Epidemiology of the EUPD has been mentioned in detail.

 Background of the study has not been mentioned.

 Aims and objectives of the study have not been mentioned.

 A good detail of related previous literature have been

provided.
 Language of the article was simple and clear.
 Critical appraisal
Method
 Design of the study has been mentioned.
 Objective of the study has been mentioned.
 Ethical concerns have not been mentioned.
 Informed consent, if taken, has not been mentioned.
 Some details about each group have been included which are not sufficient
for better understanding.
 Sampling type has been mentioned.
 Criteria of matching of patient groups with healthy controls have been
mentioned.
 The place of the conduction of the study has been mentioned.
 Critical appraisal
 Basis of diagnosing EUPD has been mentioned; [IPDE, ICD-10]
 Inclusion and exclusion criteria for all the groups have been mentioned.
 The socio-demographic details of all the groups have not been
mentioned.
 Clinical considerations for group B e.g. EUPD Comorbid group, like
duration of illness, and treatment history have not been mentioned.
 Relevant details of screening tools have been mentioned.
 The names of some original authors of applied screening tools have not
been mentioned.
 Details of statistical analysis have been mentioned.
 Critical appraisal
Results
 The results have been presented in tabular form.

 The results have been well discussed.

 On measures, there is no mention about which clinical group is

more impaired.

 In the measure of executive functioning on planning, there have

been different level of significance which were confusing.
 Critical appraisal
Discussion
 Importance of the study has been mentioned.
 Support of earlier related literature have been mentioned.
 Results of present study has been related with previous related studies.
 Interpretation made were consistent with obtained results.
 Applications of the study has not been mentioned.
 Limitations of the study has not been mentioned.
 Suggestions for future research have not been mentioned.
 Critical appraisal
References
 References of the study were correctly formatted, well organized and
properly placed as per APA format.

Miscellaneous
 There are some grammatical mistakes i.e. International Classification
Of Disorders instead of Diseases for ICD, assessed for assess etc.
 Points To Take Home
 Although there are some weaknesses present in the study but
this study give us new insight to understand the
psychopathology of EUPD.
 EUPD is not only result of dysfunctional home environment, as

we understood earlier, but it also a result of executive

dysfunction as proven in this study.
 This study open many doors for further researches to

understand the psychopathology of EUPD and EUPD with co-

morbid conditions more accurately.
Thank you