Cognitive impairment in patients with bipolar disorder alone versus those with bipolar disorder comorbid with borderline personality disorder

BACKGROUND Bipolar disorder(BD)is a severe mental illness.BD often coexists with borderline personality disorders,making the condition more complex.AIM To explore the differences in cognitive impairment between patients with BD and those with BD comorbid with borderline personality disorder.METHODS Eighty patients with BD and comorbid borderline personality disorder and 80 patients with BD alone were included in groups A and B,respectively,and 80 healthy volunteers were included as controls.Cognitive function in each group was evaluated using the Chinese version of the repeatable battery for the assess-ment of neuropsychological status(RBANS),the Stroop color-word test,and the Wechsler intelligence scale-revised(WAIS-RC).RESULTS The indices of the RBANS,Stroop color-word test,and WAIS-RC in groups A and B were significantly lower than those of the control group(P<0.05).Group A had significantly longer Stroop color-word test times for single-character,single-color,double-character,and double-color,lower scores of immediate memory,visual breadth,verbal function dimensions and total score of the RBANS,as well as lower scores of verbal IQ,performance IQ,and overall IQ of the WAIS-RC compared with group B(P<0.05).Compared to group B,group A exhibited significantly longer single-character time,single-color time,double-character time,and double-color time in the Stroop color-word test(P<0.05).CONCLUSION The cognitive function of patients with BD complicated with borderline personality disorder is lower than that of patients with BD.

White matter abnormalities in young males with antisocial personality disorder Evidence from voxel-based morphometry-diffeomorphic anatomical registration using exponentiated lie algebra analysis

Voxel-based morphometry-diffeomorphic anatomical registration using exponentiated lie algebra analysis was used to investigate the structural characteristics of white matter in young males with antisocial personality disorder （APD） and healthy controls without APD. The results revealed that APD subjects, relative to healthy subjects, exhibited increased white matter volume in the bilateral prefrontal lobe, right insula, precentral gyrus, bilateral superior temporal gyrus, right postcentral gyrus, right inferior parietal Iobule, right precuneus, right middle occipital lobe, right parahippocampal gyrus and bilateral cingulate, and decreased volume in the middle temporal cortex and right cerebellum. The white matter volume in the medial frontal gyrus was significantly correlated with antisocial type scores on the Personality Diagnostic Questionnaire in APD subjects. These experimental findings indicate that white matter abnormalities in several brain areas may contribute to antisocial behaviors in APD subjects.

Autism spectrum disorder and personality disorders: Comorbidity and differential diagnosis

BACKGROUND Differential diagnosis,comorbidities and overlaps with other psychiatric disorders are common among adults with autism spectrum disorder(ASD),but clinical assessments often omit screening for personality disorders(PD),which are especially common in individuals with high-functioning ASD where there is less need for support.AIM To summarize the research findings on PD in adults with ASD and without intellectual disability,focusing on comorbidity and differential diagnosis.METHODS PubMed searches were performed using the key words“Asperger’s Syndrome”,“Autism”,“Personality”,“Personality disorder”and“comorbidity”in order to identify relevant articles published in English.Grey literature was identified through searching Google Scholar.The literature reviews and reference sections of selected papers were also examined for additional potential studies.The search was restricted to studies published up to April 2020.This review is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method.RESULTS The search found 22 studies carried out on ASD adults without intellectual disability that met the inclusion criteria:16 evaluated personality profiles or PD in ASD(comorbidity),five compared ASD and PD(differential diagnosis)and one performed both tasks.There were significant differences in the methodological Cluster A and cluster C PD are the most frequent co-occurring PD,but overlapping features should be considered.Data on differential diagnosis were only found with cluster A and cluster B PD.CONCLUSION ASD in high-functioning adults is associated with a distinct personality profile even if variability exists.Further studies are needed to explore the complex relationship between ASD and PD.

Psychic euosmia among obsessive-compulsive personality disorder patients:A case control study

BACKGROUND Psychic euosmia(PE)has been described as a supposed psychological predisposition for which pleasant smells elicit an immediate sense of pleasure,order and calmness in obsessive-compulsive personality disorder(OCPD).In this study we tried to verify the interpretation that PE is the counterpart of disgust that has been associated to contamination and moral purity.Disgust and morality are significantly associated in people with obsessive-compulsive personality traits.We expected that OCPD patients would experience higher levels of PE.AIM To investigate the PE frequency in OCPD patients and healthy controls(HC)and to evaluate the relationship between PE and disgust.METHODS A single-center,case-control study was conducted in an outpatient service for obsessive-compulsive and related disorders.The sample consisted of 129 subjects:45 OCPD patients and 84 HC.In both groups we submitted the Disgust Scale Revised(DS-R)and the self-report Structured Clinical Interview for DSM-5 Screening Personality Questionnaire to which we added an additional yes or no question to investigate the presence of PE.In order to verify differences between groups,t-test was employed for continuous variables and 2 test for categorical variable;odds ratio was employed to analyze group differences in the PE survey.Correlation was explored with Pearson r correlations.RESULTS No differences were observed between groups in gender composition or education.A slight significant difference was found in mean age(t=1.988;P=0.049).The present study revealed significantly higher proportions of PE among OCPD patients when compared to HC(OR:5.3,2.28-12.46).Patients with OCPD were more likely to report PE(n=36;80%)whereas a much lower proportion endorsed PE in the HC group(n=36;42.9%).Interestingly,no differences were observed between groups in mean score for the Disgust Scale.There was also no difference between the two groups in any of the Disgust Scale Revised subscales.Moreover,no significant correlations were observed in the OCPD group between PE and Disgust Scale Revised subscales.CONCLUSION Results suggested that PE might be part of the clinical spectrum of OCPD,and it does not reflect the counterpart of disgust.This could also indicate that this phenomenon is a manifestation of orderliness or incompleteness.Further studies will need to be undertaken to better understand PE and its significance in OCPD.

Affect regulation in psychoanalytic treatments of patients with a borderline personality disorder–psychoanalysis and psychodynamic psychotherapy–a comparison

BACKGROUND A recent meta-analysis has confirmed that the effects of psychotherapy on patients with borderline personality disorders(BPD)are still insufficiently understood.Evidence of differences between different types of therapies has been questioned.AIM To study repetitive interaction patterns in patients with BPD undergoing either psychoanalysis or psychodynamic therapy.METHODS Psychoanalysis(PSA)or psychodynamic psychotherapy(PDT)was administered to 10 patients each,the two groups were matched.Therapy regimens were applied according to care as usual/manualized including quality control and supervision as usual.Randomization to one of the groups was done after baseline assessment.During classical PSA(n=10)and PDT(n=10),semiannually,recordings(audio or video)of five consecutive therapy sessions were taken over three years for an ex-post analysis.The patients'characteristics,such as affect parameters[Affect regulation and experience Q-sort(AREQ)],quality of object relations(quality of object relations scale)and personality traits[Shedler-Westen Assessment Procedure(SWAP-200)]were analyzed retrospectively by independent raters.Therapeutic action(psychotherapy process Q-sort)and affective(re)actions of the patients(AREQ)were then analyzed in relation to changes found in the patients'characteristics.RESULTS During the first year of therapy(PSA:n=10;PDT:n=9),the therapeutic method PSA was associated with significant improvements in the variable"SWAP Borderline",while in PDT change was not significantly different to baseline(PSA:P=0.04;PDT:P=0.33).Long-term results and follow up was available for seven participants in PSA and for five in PDT after three years;change in SWAP borderline for the whole sample was not significant at this time point when confronting to baseline(P=0.545).However,differences between PSA and PDT were significant when analyzing the“mean change”in the SWAP Borderline variable after one year of therapy(P=0.024):PSA led to slightly increased BPD symptoms,while PDT to a decrease;for the long run,variance of observed change was higher in PSA than in PDT(SDPSA±9.29 vs SDPDT±7.94).Our assumption that transference interpretations,closely followed by affective changes in the patient,could be useful modes of interaction was reproducible in our findings,especially when looking at the descriptive findings in the long-term data.The analysis of repetitive interaction structures demonstrated a very specific"time-lag"between therapeutic intervention and a corresponding increase in positive affect in successful therapy cases.CONCLUSION Exploring the change processes in the patients'characteristics and linking these changes to specific treatment strategies is of clinical importance when starting treatment and for its long-term progress.

Modern Health Worries and the Personality Disorders: Two Studies Using Different Measures

This paper reports on two studies using different measures of both Modern Health Worries (MHW) and the Personality Disorders (PDs) to establish the relationship between the two concepts. Study 1 used the PID-5 which is a measure of maladaptive personality traits and the extended 40 item MHW scale. Study 2 used the original 28 item measure of MHW and PDs as measured by the Coolidge Axis-II Inventory—Short Form: SCATI. In study 1 a regression on the total MHW scale accounted for 14% of the variance: those who scored higher on Antagonism and Negative Affect had higher MHW scores. In the study 2 regressions showed four variables consistently related to MHW: sex (females with higher scores), optimism, political beliefs (left wing liberals with higher scores) and those with Cluster B personality disorders (dramatic, overly emotional, erratic). There was enough overlap in the two studies to conclude that various PDs mainly from Cluster B (Moving Against others) were modestly related to MHW as predicted. Limitations and implications are considered.

A Review of Stressors as Inducer for Personality Disorders and Anxiety Disorders

Personality Disorders(PDs)and Anxiety Disorders(ADs)are common mental disorders.PDs are often more or less related to anxiety and ADs are affected by Personality Functioning(PF).To clarify the pathology of both ADs and PDs,along with their similarities and differences,the literature review by paired keywords search on NCBI PubMed and subsequent analysis are used.The findings support that abnormal stressors can damage the Hypothalamus-Pituitary-Adrenal(HPA)axis time by time throughout life through the epigenetic pathway,lowering down the ability of the stress system to deal with stressors.Biological basis,like the genetic issue,for PDs,is important but after-born experience also matters a lot.Adjoint stressful long-term memory may largely affect normal personality formation,contributing to some kinds of PDs.It seems that early exposure to these stressors influences PDs more,compared to ADs.More researches are needed to explore the effect on ADs from later life stress.This study partially explained the process of ADs and PDs,linked them by abnormal stressors,and emphasized the importance of focusing on the effect of stressful long-term memory formation,which is psychological,and the HPA axis disability,which is biological,on patients having these diseases,reminds psychiatrist to treat disease at the source,to lower down the potential risk of getting PDs in patients who are diagnosed with ADs,to prevent arouse of ADs in patients who are diagnosed with PDs and to combine biological treatment with psychological therapies.

Borderline Personality Disorders by Dialectical Therapy

This study aimed to discover the possibility of reducing the symptoms of borderline personality disorders (BPD) through the dialectical treatment of a sample group of individuals with BPD in Kuwait. To achieve this objective, a quasi-experimental approach was applied by dividing the study sample into two groups;the control group consisted of 75 individuals and the experimental group consisted of 75 individuals. In addition, a borderline personality disorder scale and program were developed based on American psychologist Marsha Linehan’s rules of dialectical behavioral therapy (DBT). Among the results, the study found statistically significant differences between members of the two groups due to the use of the counseling program based on dialectical treatment. This indicates a positive effect of using the counseling program to reduce the level of BPD among the members of the study sample, in favor of the experimental group.

Borderline Personality Disorder: A General Overview

Borderline Personality Disorder(BPD)is a personality disorder marked by unpredictable behaviors,emotional instability,and self-injurious conduct,which typically begins in adolescence.BPD patients are difficult to treat.The majority have had child sexual abuse,and roughly a quarter have experienced sexual abuse by a caregiver.The study is an overview of Borderline Personality Disorder,including current and past understanding of its main features,etiology,impact,treatment,and future directions since the public’s recognition of BPD is only at a beginning stage.The passage would be mainly focused on the part of the discussion,where I would illustrate the possible factors that lead to the development of Borderline Personality Disorder from both biological and social perspectives,its impact on individual’s behavior and social functioning,and the current ways of treatments.The discipline has changed dramatically over the last two decades,with a growing number of specialized psychotherapies and drugs being explored.Since BPD patients are especially hard to treat,an evaluation of multiple therapies should be necessary.Limitations and future directions would be discussed in the conclusion.Overall,the paper is aimed to provide a comprehensive summary for the general public.

The Process of Support by Nursing Professionals for Families Having a Member with Borderline Personality Disorder

The purpose of this study was to explore the process of family support provided by nurses to families with a borderline personality disorder (BPD) patient. Semi-structured interviews were conducted with 16 nurses who had provided care to BPD patients. Data obtained from the interviews were qualitatively analyzed using a modified grounded theory approach. As an overall core category of family support processes practiced by nurses for families with BPD patients, family support practiced without awareness that the nurses were supporting families was extracted. Through this process, nurses held perceptions that were premises for family support, which were formed through their individual nursing experiences and perspectives. Nurses also had diverse perceptions concerning the image of families. Through the integration of perceptions that were premises for family support and perceptions of an image of the family, nurses underwent a process of “determination and ambivalence about the need for family support.” Then, nurses provided “family support practice” when they acknowledged the need for family support. During the “family support practice,” nurses had difficulties in providing family support. When family support was not successfully provided, nurses provided “family support practice with seeking more effective ways through trial and error.” For cases in which nurses did not acknowledge the need for intervention, they intentionally chose “not to provide family support.” Furthermore, during the “family support practice,” nurses had contradictory perspectives of family support. Such family support processes ultimately led to an awareness of the same family support required for the future. Family support was provided with “family support practice” and “family support practice with seeking more effective ways through trial and error.” In some cases, however, the process ended in “not to provide family support intentionally.” Experiences and perspectives in providing family support are important factors in carrying out future family support. Developing the positive implications of these factors and reducing psychological strain on nurses may ensure smooth implementation of family support. Thus, nurses need to recognize that they are supporting the family, which is identified as a core category.

Should borderline personality disorder be included in the fourth edition of the Chinese classification of mental disorders?

Borderline personality disorder （BPD） is a serious personality disorder characterized by a pervasive pattern of disturbances in mood regulation, impulse control, self-image and interpersonal relationships） In the United States, the prevalence of BPD has been estimated at 1%-2% of the general population, 10% of psychiatric outpatients, and 20% of inpatients. According to the 4th text revision of diagnostic and statistical manual of mental disorders （DSM-IV-TR）, about 75% of BPD patients are women. The BPD diagnosis has been associated with heightened risk （8.5% to 10.0% among BPD patients） for completed suicide, a rate almost 50 times higher than in the general population.

Distribution and Risk Factors of Disability Attributed to Personality Disorders： A National Cross-sectional Survey in China

Background： Personality disorders can lead to some disability. However, little is known about the disability prevalence and function impairments. This study aimed to describe the disability prevalence attributed to personality disorders, its distribution, impairments of daily activities and social functions, and risk factors in China. Methods： Using a descriptive and analytic epidemiological method, data from the Second China National Sample Survey on Disability in 2006 were analyzed. The disability prevalence attributed to personality disorders, its distribution in different people and regions, and risk factors were statistically calculated. Results： Respondents included 1,909,205 adults. The disability prevalence rate attributed to personality disorders in China was 5.9/100,000. The disability rate attributed to personality disorders of males was higher than that of females （P 0.012）, while the rate of the unemployed was higher than that of the employed （P 〈 0.001 ）. Furthermore, the rates of unmarried/divorced/widowed people and the illiterate population were higher than those of married and educated people （P 〈 0.001 ）. Regarding the severity of disability attributable to personality disorders, mild disability accounted for a majority or 60% of the respondents. The data showed that disability mainly impaired respondents＇ ability to engage in daily activities, get along with people, and participate in social situations. According to the case-control study, marriage, employment, and higher education were protective factors of disability. Conclusions： The prevalence of disability attributed to personality disorders is low in China and always leads to mild disability. The distribution of disability attributed to personality disorders also varies in the Chinese population.

Genetic and Neuroimaging Features of Personality Disorders:State of the Art

Personality disorders often act as a common denominator for many psychiatric problems,and studies on personality disorders contribute to the etiopathology,diagnosis,and treatment of many mental disorders.In recent years,increasing evidence from various studies has shown distinctive features of personality disorders,and that from genetic and neuroimaging studies has been especially valuable.Genetic studies primarily target the genes encoding neurotransmitters and enzymes in the serotoninergic and dopaminergic systems,and neuroimaging studies mainly focus on the frontal and temporal lobes as well as the limbic-paralimbic system in patients with personality disorders.Although some studies have suffered due to unclear diagnoses of personality disorders and some have included few patients for a given personality disorder,great opportunities remain for investigators to launch new ideas and technologies in the field.

The Narcissistic Dilemma: Exploring NPD Traits in Hamlet from a Beauvoirian Perspective

This research paper explores the intersection of existential philosophy and psychological disorders in William Shakespeare’s Hamlet,with a focus on Narcissistic Personality Disorder(NPD)as viewed through the existentialist lens of Simone de Beauvoir.Drawing upon Beauvoir’s existentialist framework,the study delves into the complexities of identity,agency,and societal expectations as portrayed in the characters of Gertrude and Ophelia.Through an interdisciplinary approach,the paper examines how existential crises intertwine with narcissistic behaviors,shedding light on the psychological intricacies of Shakespeare’s iconic figures.By synthesizing literary analysis with psychological insights,the study offers valuable contributions to our understanding of human psychology,societal dynamics,and the timeless themes of existential authenticity portrayed in literature.

Personality Characteristics among Patients Waiting for Liver or Kidney Transplants

Introduction: Personality characteristics are believed to predict post-transplant adherence and outcome. However, data concerning the prevalence and type of personality disorders (PDs) among transplant populations are sparse. Objectives: To evaluate the prevalence and types of PDs among patients waiting for liver or kidney transplants, to compare the results obtained between the two groups and to identify predictors of the prevalence of PDs. Method: In a prospective cohort study, 629 patients waiting for liver (n = 196) or kidney (n = 433) transplants were assessed by the Personality Diagnostic Questionnaire, fourth edition (PDQ-4+). Results: The 629 pre-transplant patients were 46.1 years old on average (SD: 11.5). The PDQ total score was 25.5 (SD: 13.7). 36.5% had a total score equal to or greater than 30. Paranoid (42.1%), avoidant (31.1%) and obsessive-compulsive (29.8%) were the most common possible PDs identified. Patients waiting for a kidney transplant had a higher total score than those waiting for a liver transplant (p 0.001) and they also had significantly more paranoid (p = 0.001), obsessive-compulsive (p = 0.002) and avoidant (p = 0.001) PDs. Comment: In case of possible PDs, an assessment of other clinical variables for helping patients is needed so that a specific treatment could be offered to patients at the time of their inclusion on the waiting list, during the waiting period and after the organ transplant.

Correlates of Self-Assessed Wellness

Background: This study was concerned with correlates of self-assessed health and wellness on ten dimensions including emotional, financial and physical health. All 10 self-ratings loaded on one factor with high internal reliability. Method: In all 506 adult participants, completed short measures of the bright side, Big Five traits (TIPI) and a short measure of the dark side, personality disorders (PID-5-BF). Results: Correlations and regressions suggested that wellness was related to sex, education and religious beliefs as well as four of five bright- and dark-side traits. Being Sanguine was most positively, and Choleric most negatively, associated with subjective wellness. Detachment and Negative Affect were the highest dark-side correlates. The final regression suggested that over a third of the variance in subjective wellness could be explained by four bright- and two dark-side factors. Conclusions: Personality factors, especially instability and negative affectivity, play a crucial role in all aspects of wellness. Implications and limitations are acknowledged.

The Dark Reflection of Sadism within the Brilliance of the Narcissistic Persona

This double blind randomized clinical trial with 84 participants, revealed that mental patients diagnosed with narcissism, and narcissistic celebrities mirror each other’s paranoid, obsessive and histrionic symptomatology, grandiosity, manipulative charm, and inner emptiness. Elite narcissists manifested insidious sadism in the absence of depressive affect, while the narcissistic patients were differentiated by their depressive and masochistic symptomatology. Elite narcissists demonstrated advanced empathic skills, contradicting past literature. However, their empathic advantage appeared void of compassion, merely employed as a self-serving tactic to exploit, intimidate and subordinate. Both experimental narcissistic groups evidenced more prevalent psychopathology, yet, higher achievement, efficacy and ambition than their reciprocal control groups, confirming the narcissists’ finesse in concealing psychopathology under the brilliance of their pseudosuperiority. The main danger is the affinity between masochism and sadism, bonding low and high functioning narcissistic counterparts to endlessly feed from each-others’ pathology, forming dysfunctional interpersonal relationships, cults or disintegrating societies. This sadomasochistic dependency also reflects several countries’ authoritarian trends, where narcissistic constituents’ unyielding loyalty elevates idolized leaders to power, preluding the establishment of toxic tyrannical governments.

Diagnostic procedures and classification of antisocial behavior in Norwegian inmates in preventive detention

In official Norwegian government reports’ prison statistics, it is claimed that the prevalence of Dissocial Personality Disorder (DPD) or Antisocial Personality Disorder (APD) among inmates in preventive detention is approximately 50%. Furthermore, previous findings have described a practice in which forensic examiners use the DSM SCID axis II for APD to confirm an ICD 10 diagnosis of DPD. Clinical investigation supported by the use of SCID Axis II for quality assurance was performed on almost half the population of inmates (46.4%) in preventive detention at a high security prison. The inmates had all committed severe violent acts including murder. All the information obtained by applying the DSM IV-TR criteria was tested against the ICD-10 Research Criteria (ICD-10-RC) for Dissocial Personality Disorder (ICD-10, DPD). It was found that all inmates met the ICD-10-RC for (DPD) and the DSM-IV-TR definition for Adult Antisocial Behavior (AAB). On the other hand, none met the DSM-IV-TR criteria for (APD). The SCID Axis II failed to identify inmates with APD because the DSM-IV-TR C-criteria, referring to symptoms of childhood Conduct Disorder (CD), were not met. These findings raise important questions since the choice of diagnostic system may influence whether a person’s clinically described antisocial behaviour should be classified as a personality disorder or not. For the inmates, a diagnosis of APD or DPD may compromise their legal rights and affect decisions on prolongation of the preventive detention. Studies have shown that combining the DSM and the ICD diagnostic systems may have consequences for the reliability of the diagnosis.

Innovations in education:A prospective study of storytelling narratives to enhance hepatitis C virus knowledge among substance users

BACKGROUND Even though substance users have the highest hepatitis C virus(HCV)burden,many lack knowledge about the infection.Lack of knowledge is an important obstacle to pursuing HCV care.Although printed materials are conventionally utilized to disseminate HCV-related knowledge,narrative story-telling videos may be an alternative.Data are extremely limited,however,in the ability of storytelling videos to increase HCV knowledge among substance users.In this study,we hypothesized that a story-telling narrative video would increase substance user’s immediate and 1-month HCV-related knowledge compared to a printed format.AIM To assess immediate and 1-month HCV-related knowledge retention among substance users comparing education delivered via a storytelling narrative video compared to a printed format.METHODS We conducted a prospective matched,case-control study among substance users actively prescribed buprenorphine enrolled from two sites.The intervention site received the video and the control site,the brochure.Participants(n=176)were matched on age,gender,and race.We obtained extensive patient and stakeholder input on the video’s design,validated the video’s content,and developed a recruitment plan to guide participant enrollment.Knowledge was assessed by administration of a 25-item instrument immediately before,immediately after,or one month after the intervention.Data were analyzed using nonparametric and generalized linear mixed-effects models.RESULTS We recruited a total of 176 substance users,90 and 86 individuals,from each site,respectively.One-month follow up occurred in 92%and 94%of enrollees in the control and intervention groups,respectively.In comparison with the pre-intervention scores,immediate knowledge recall increased significantly for both the intervention(P<0.0001)and control(P<0.0001)groups.Multivariate modeling revealed a significant improvement in HCV-related knowledge and retention(P=0.033)among participants who viewed the storytelling video.CONCLUSION Storytelling narratives emphasizing HCV education appear to be an effective method to increase HCV-related knowledge among substance users.They should become an educational cornerstone to promote HCV management among this population.

Police Emergency Commitment Powers in Cases of Persons Experiencing Mental Health Crisis in “Public Spaces”: Review of the Commitment Process in England and Wales, in Comparison to the Practice in the United States of America (USA)

Police emergency commitment powers for detention of persons in the community perceived to be seriously mentally ill for further specialist examination in a designated facility have always raised interest in medical and legal circles on both sides of the Atlantic. The objective of this article is to detail the police commitment procedure in England and Wales, as dictated by the mental health act of 1983 (MHA 1983) amended in 2007 (MHA 2007);and compare this with similar legal provisions as prevails under current state mental health statutes in the United States of America (USA). The comparative review of the commitment processes in England and Wales to that of the USA reveals that the process in England and Wales seeks to primarily ensure that persons with mental disorder (PWMD) in crisis are directed to a specialist hospital for evaluation and appropriate specialist care. In the USA such persons in a good number of cases may end up in the criminal justice system due to application of the “dangerousness” standard. Additionally whereas in England and Wales the commitment law is uniform in law and application, the federal system in the USA is such that the commitment law may have minor variations depending on the individual states. The minor variation in state commitment laws may engender a situation where the commitment law in England and Wales may seem relatively equitable and just towards PWMD in crisis, compared to the state commitment laws in the USA.