Child development and personality disorder

Do self and interpersonal dysfunction cross-sectionally mediate the association between adverse childhood experiences and personality pathology?

Two primary limitations of research on the association between adverse childhood experiences (ACEs) and personality disorder (PD) are (1) failure to consider mechanisms of association and (2) inconsistent results due, in part, to inconsistent approaches to quantifying ACE exposure. The current study will address these limitations by examining the cross-sectional mediating role of self- and interpersonal dysfunction on the association between ACE and three PDs (antisocial, schizotypal, and borderline) using three quantifications of ACE exposure (cumulative, individual, and unique risk). Participants were 149 current or recent psychiatric patients, and data analyses were performed through estimation of a series of cross-sectional mediation models. Taken together, results suggest that (1) the association between ACE and PD is moderate, (2) self- and interpersonal dysfunction cross-sectionally mediate this association, (3) after accounting for variance shared among ACEs, associations between specific ACE subtypes and PD were negligible, (4) much of the association between ACE and PD is accounted for by general processes impacted by all forms of ACE and implicated in all forms of PD, and (5) emotional neglect may uniquely contribute to self- and interpersonal dysfunction and thereby, PD risk.

Dissociation of basolateral and central amygdala effective connectivity predicts the stability of emotion-related impulsivity in adolescents and emerging adults with borderline personality symptoms: a resting-state fMRI study

BACKGROUND

Borderline personality disorder (BPD) is associated with altered activity in the prefrontal cortex (PFC) and amygdala, yet no studies have examined fronto-limbic circuitry in borderline adolescents and emerging adults. Here, we examined the contribution of fronto-limbic effective connectivity (EC) to the longitudinal stability of emotion-related impulsivity, a key feature of BPD, in symptomatic adolescents and young adults.

METHODS

We compared resting-state EC in 82 adolescents and emerging adults with and without clinically significant borderline symptoms (n BPD = 40, ages 13-30). Group-specific directed networks were estimated amongst fronto-limbic nodes including PFC, ventral striatum (VS), central amygdala (CeN), and basolateral amygdala (BLA). We examined the association of directed centrality metrics with initial levels and rates of change in emotion-related impulsivity symptoms over a one-year follow-up using latent growth curve models (LGCMs).

RESULTS

In controls, ventromedial prefrontal cortex (vmPFC) and dorsal ACC had a directed influence on CeN and VS, respectively. In the BPD group, bilateral BLA had a directed influence on CeN, whereas in the healthy group CeN influenced BLA. LGCMs indicated that emotion-related impulsivity was stable across a one-year follow-up in the BPD group. Further, higher EC of R CeN to other regions in controls was associated with stronger within-person decreases in emotion-related impulsivity.

CONCLUSIONS

Functional inputs from BLA and vmPFC appear to play competing roles in influencing CeN activity. In borderline adolescents and young adults, BLA may predominate over CeN activity, while in controls the ability of CeN to influence BLA activity predicted more rapid reductions in emotion-related impulsivity.

Comparing Differences between Two Groups of Adolescents Hospitalized for Self-Harming Behaviors with and without Personality Disorders

Self-harm (non-suicidal self-injury (NSSI) and suicidal behavior (SB)) is frequent display during adolescence. Patients with personality disorders (PDs) frequently self-harm. However, few studies have focused on the role of PDs in self-harming adolescents. In this study, we collected 79 adolescents hospitalized due to self-harm (88.6% female; 78.5% Caucasian) and divided them into two groups, with or without a diagnosis of PD. The socio-demographic and psychological-clinical data were collected through a structured interview by clinicians. Univariate, subgroup, and multiple logistic regression analyses were performed. Univariate analysis showed that adolescents with a PD and self-harm had (1) an older age at hospitalization (p < 0.01); (2) experienced physical and sexual abuse (p = 0.05, and p < 0.01, respectively); (3) ADHD (p = 0.05); (4) a greater number of SA (p < 0.01); and (5) probability of being a major NSSI patient (>20 lifetime NSSI episodes) (p < 0.01). After multivariate stratified analysis, the results indicated that an older age, and particularly major NSSI status were predictors of PD diagnosis. Early identification and a better understanding of the characteristics of adolescent PDs can assist clinicians in intervening earlier and developing more rational treatment strategies to reduce the long-term effects of PDs.

Parental Reports of Physically Self-Destructive Behavior in the Offspring of Patients With Borderline Personality Disorder and Other Personality Disorders

The main aim of this article is to compare the prevalence of four forms of physically self-destructive behavior in the offspring of parents with borderline personality disorder (BPD) and compare them to the offspring of parents with other personality disorders (OPD). At the 4- and 6-year waves in a prospective study of the long-term course of BPD, participants were asked to report on the self-destructive behaviors of their children using the Childhood Self-Destructiveness Scale. A total of 68 parents were interviewed regarding 131 children, 104 of whom were offspring of parents with BPD (n = 55) and 27 were offspring of parents with OPD (n = 13). BPD parents reported significantly more self-injury and substance abuse in their children than OPD parents. The results from this study suggest that both direct and indirect forms of self-destructive behavior are both more common and quite specific for the children of parents with BPD.

Emotional abuse interacts with borderline personality in adolescent inpatients with binge-purging eating disorders

PURPOSE

Childhood abuse is associated with an increased risk of developing eating disorders (EDs) as well as personality disorders (PDs). However, their interaction is still uncertain, particularly in adolescents. This study investigates the correlations between childhood emotional neglect (CEN), childhood emotional abuse (CEA), and obsessive-compulsive and borderline personality styles in female adolescent inpatients with eating disorders (EDs).

METHODS

One hundred and twenty-eight inpatients (ages 14-18) were assessed, 54 were diagnosed with restricting-type anorexia nervosa (AN-R) and 33 with a binge-purging ED [BP-ED; comprising patients with binge-purging type anorexia nervosa (AN-BP), n = 15, and bulimia nervosa (BN), n = 18]. Fifty healthy participants made up the control group (CG). CEN and CEA were assessed with the Childhood Trauma Questionnaire, while the Personality Style and Disorder Inventory was implemented to determine personality styles.

RESULTS

A MANOVA revealed a significant main effect of CEA on spontaneous-borderline personality style [F(8,119) = 17.1, p < 0.001, η² = 0.126], as well as a main effect of ED group on spontaneous-borderline [F(2,119) = 3.1, p = 0.048, η² = 0.050]. A significant interaction between ED group, CEA, and spontaneous-borderline was found [F(2,119) = 3.5, p = 0.034, η² = 0.055] with BP-ED showing significantly higher scores in CEA (9.3 ± 4.0) and in spontaneous-borderline (14.2 ± 6.2).

CONCLUSIONS

Considering CEA and borderline personality style in adolescent inpatients with BN or AN-BP may help improve the understanding of the etiology and maintenance of BP-ED and provide more effective treatment targets.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Exposure to interparental intimate partner violence and the development of borderline features in adolescents

BACKGROUND

Due to associated trauma, exposure to intimate partner violence (IPV) is considered a form of child maltreatment, and is associated with heightened risk for mental health problems.

OBJECTIVE

To evaluate associations between exposure to interparental IPV and the prospective development of borderline features in adolescents.

PARTICIPANTS AND SETTING

A diverse sample of 1,042 adolescents were recruited from public high schools throughout southeastern United States and followed annually for 5 years. Baseline mean age was 15.09 (SD = .79; range 13-18), and 56 % of the sample was female; 31.4 % (n = 327) were Hispanic, 29.4 % (n = 306) were White/not Hispanic, 27.9 % (n = 291) were African American, 3.6 % (n = 38) were Asian or Pacific Islander, and 7.7 % (n = 80) were mixed or another race.

METHODS

Exposure to interparental IPV and the quality of the parent-child relationship were assessed at baseline. Borderline features were assessed annually for the each of the five follow-up timepoints. Latent growth curve modeling was used to estimate the course of change of BPD features over time.

RESULTS

Consistent with expectations, and controlling for quality of parent-child relationships and sociodemographic confounds, findings demonstrated that IPV exposure related to both cross-sectional association between interparental IPV and adolescents' borderline features and change in borderline features over a 5-year period.

CONCLUSION

Adolescents who had witnessed interparental IPV were more likely to have higher levels of BPD features at baseline and to deviate from the typically observed normative decline in BPD features over the 4-year follow-up period.

Personality profiles as potential targets for intervention: Identification and replication

The alternative dimensional model of personality disorder (PD) diagnosis, based on personality-functioning impairment and pathological traits, opens the door for tailoring treatments to individuals with more homogeneous personality profiles than diagnostic categories. Such a transdiagnostic PD treatment approach requires robust, replicable, personality-relevant dimensions, which we found using a large battery of self-report measures: Self-pathology and negative affectivity (NA) traits, interpersonal pathology and detachment traits, and interpersonal pathology and antagonism traits. Using these dimensions, we identified three groups that had, respectively, elevations on (1) all three dimensions, (2) self-pathology/NA (with/without interpersonal-pathology elevation(s)) and (3) either or both interpersonal-pathology dimensions, without elevated self-pathology/NA. Using the same personality-functioning measures and a half-overlapping trait set, we replicated these profiles in an additional sample. Interview-based measures of functioning and personality pathology provided external validity evidence for the method, suggesting it represents a critical first step towards treatment research targeting transdiagnostic processes rather than diagnoses. For example, two groups might benefit from treatments focused, respectively, on emotional dysregulation and interpersonal relations, whereas the multiple-problem group may need a sequenced treatment approach. Research is needed to test these hypotheses and to expand the method to include a wider range of pathological personality traits. © 2019 John Wiley & Sons, Ltd.

Childhood malnutrition and maltreatment are linked with personality disorder symptoms in adulthood: Results from a Barbados lifespan cohort

Both childhood malnutrition and maltreatment are associated with mental health problems that can persist into adulthood. Previously we reported that in Barbados, those with a history of infant malnutrition were more likely to report having experienced childhood maltreatment. Few studies, however, address the long-term outcomes of those who have been exposed to both. We assessed the unique and combined associations of a history of early malnutrition and childhood maltreatment with personality pathology in mid-adulthood in participants of the 47-year longitudinal Barbados Nutrition Study. We used the Structured Clinical Interview for DSM-IV-TR Axis II Personality Disorders Personality Questionnaire (SCID-II-PQ) and NEO Personality Inventory-Revised derived Five-Factor Model (NEO PI-R FFM) personality disorder (PD) scores to assess personality pathology, the Childhood Trauma Questionnaire-Short Form (CTQ-SF) to assess childhood maltreatment, and clinical documentation of malnutrition in infancy. We tested the associations of malnutrition and maltreatment with PD scores using linear regression models, unadjusted and adjusted for other childhood adversities. We found increased scores for paranoid, schizoid, avoidant, and dependent PDs among those who had been malnourished and increased scores for paranoid, schizoid, schizotypal, and avoidant PDs among those with higher childhood maltreatment scores. Overall, those exposed to both adversities had even greater PD scores.

Prevalence and severity of childhood adversity in adolescents with BPD, psychiatrically healthy adolescents, and adults with BPD

OBJECTIVE

Existing research has demonstrated that both adolescents and adults with borderline personality disorder (BPD) report higher rates of childhood adversity than their same-age peers; no studies have examined if adolescents and adults with BPD differ based on the extent of these experiences. In the present study, we compared the prevalence rates and severity of multiple forms of abuse and neglect in adolescents and adults with BPD and in psychiatrically healthy adolescents.

METHODS

Participants included 104 adolescent (aged 13-17 years) inpatients with BPD, 60 age-matched, psychiatrically healthy adolescents, and 290 adult inpatients with BPD. All participants completed an interview that assessed the presence and severity of multiple forms of childhood abuse and neglect.

RESULTS

A significantly higher percentage of adolescents with BPD reported 5 of 12 pathological childhood experiences and described more severe abusive experiences than their psychiatrically healthy peers. In comparison with adolescents with BPD, a significantly higher percentage of adults with BPD reported nearly all forms of childhood adversity and rated these experiences as more severe.

CONCLUSIONS

Taken together, these results suggest that adults with BPD report more severe profiles of abuse and neglect than adolescents with the disorder, even though adolescents with BPD differ from healthy peers. Copyright © 2017 John Wiley & Sons, Ltd.

Prevalence rates of childhood protective factors in adolescents with BPD, psychiatrically healthy adolescents and adults with BPD

OBJECTIVE

Existing literature on the aetiology of borderline personality disorder (BPD) has primarily focused on pathological childhood experiences, while little to no research has been conducted on protective factors that may serve to ameliorate these symptoms. The current study attempts to fill this gap in the literature by comparing the rates of childhood protective factors among adolescents with BPD, psychiatrically healthy adolescents and adults with BPD.

METHODS

One hundred and four subjects were adolescent inpatients between the ages of 13 and 17 who met Revised Diagnostic Interview for Borderlines and Diagnostic and Statistical Manual of Mental Disorders Fourth Edition criteria for BPD. Sixty were age-matched psychiatrically healthy comparison subjects. Two hundred and ninety subjects were adult inpatients between the ages of 18 and 35 who met Revised Diagnostic Interview for Borderlines and Revised Diagnostic and Statistical Manual of Mental Disorders Third Edition criteria for BPD. All three groups were interviewed by using the Revised Childhood Experiences Questionnaire, a semi-structured interview that assesses pathological and protective childhood experiences.

RESULTS

Psychiatrically healthy adolescents reported significantly higher rates of 4 out of 18 protective factors than adolescents with BPD. Adolescents with BPD reported significantly higher rates of 5 of these 18 protective factors than adults with BPD. Adults with BPD were significantly more likely to endorse having a steady after school or weekend work record than adolescents with BPD.

CONCLUSIONS

Taken together, the results of this study suggest that adolescents meeting criteria for BPD report lower rates of some protective factors than psychiatrically healthy adolescents. They also suggest that they have higher rates of some protective factors than adults with BPD. Copyright © 2017 John Wiley & Sons, Ltd.

Transactional processes in the development of adult personality disorder symptoms

The development of adult personality disorder symptoms, including transactional processes of relationship representational and behavioral experience from infancy to early adolescence, was examined using longitudinal data from a risk sample (N = 162). Significant preliminary correlations were found between early caregiving experience and adult personality disorder symptoms and between representational and behavioral indices across time and adult symptomatology. Significant correlations were also found among diverse representational assessments (e.g., interview, drawing, and projective narrative) and between concurrent representational and observational measures of relationship functioning. Path models were analyzed to investigate the combined relations of caregiving experience in infancy; relationship representation and experience in early childhood, middle childhood, and early adolescence; and personality disorder symptoms in adulthood. The hypothesized model representing interactive contributions of representational and behavioral experience represented the data significantly better than competing models representing noninteractive contributions. Representational and behavioral indicators mediated the link between early caregiving quality and personality disorder symptoms. The findings extend previous studies of normative development and support an organizational developmental view that early relationship experiences contribute to socioemotional maladaptation as well as adaptation through the progressive transaction of mutually informing expectations and experience.

Association between childhood adversity and a diagnosis of personality disorder in young adulthood: a cohort study of 107,287 individuals in Stockholm County

Childhood adversity (CA) may increase the risk for later developing of personality disorder (PD). However, less is known about the association between cumulative CA and PD, and the role of childhood psychopathology and school performance. The current study examined the relationship between a range of CAs and a diagnosis of PD in young adulthood, and the roles of childhood psychopathology and school performance in this relationship. All individuals born in Stockholm County 1987–1991 (n = 107,287) constituted our cohort. Seven CAs were measured between birth and age 14: familial death, parental criminality, parental substance abuse and psychiatric morbidity, parental separation and/or single-parent household, household public assistance and residential instability. Individuals were followed from their 18th birthday until they were diagnosed with PD or until end of follow-up (December 31st 2011). Adjusted estimates of risk of PD were calculated as hazard ratios (HR) with 95% confidence intervals (CI). Associations were observed between cumulative CA and PD. During the follow-up 770 individuals (0.7%) were diagnosed with PD. Individuals exposed to 3+ CAs had the highest risks of being diagnosed with PD (HR 3.0, 95% CI 2.4–3.7). Childhood psychopathology and low school grades further increased the risk of PD among individuals exposed to CA. Cumulative CA is strongly associated with a diagnosis of PD in young adulthood. Our findings indicate that special attention should be given in schools and health services to children exposed to adversities to prevent decline in school performance, and to detect vulnerable individuals that may be on negative life-course trajectories.

Self-reported patterns of impairments in mentalization, attachment, and psychopathology among clinically referred adolescents with and without borderline personality pathology

BACKGROUND

Previous research, which primarily focused on adult samples, suggests that individuals with borderline personality disorder (BPD) display high levels of psychopathology, dysfunctional mentalization and problematic attachment to others. The current study investigated whether impairments in mentalization, attachment, and psychopathology are more severe in outpatient adolescents with BPD than in a clinical comparison group.

METHODS

Consecutive referrals to a child and adolescent psychiatric clinic were clinically assessed with a battery of self-report instruments to assess mentalization, attachment, and psychopathology. Specifically, in regard to BPD a self-report questionnaire was employed to decide if patients were classified into the BPD or the clinical comparison group. The main outcome variables of adolescents with a primary diagnosis of BPD were then compared with those of a clinical comparison group comprising patients receiving psychiatric diagnoses other than BPD.

RESULTS

Relative to the clinical group without BPD, and after controlling for sociodemographic variables, the BPD group displayed poorer mentalizing abilities, more problematic attachments to parents and peers, and higher self-reported levels of psychopathology.

CONCLUSIONS

The results of this study suggest that BPD is a severe mental condition in adolescents and is characterized by poor mentalizing abilities, attachment problems and high levels of psychopathology compared to adolescents with psychiatric disorders other than BPD. Hence, clinicians should consider BPD when conducting diagnostic assessments, and evidence-based treatments for this vulnerable group should be developed.

Mentalization-based treatment in groups for adolescents with borderline personality disorder (BPD) or subthreshold BPD versus treatment as usual (M-GAB): study protocol for a randomized controlled trial

Background

Evidence-based outpatient psychotherapeutic programs are first-line treatment of borderline personality disorder (BPD). Early and effective treatment of BPD is crucial to the prevention of its individual, psychosocial, and economic consequences. However, in spite of recent advantages in diagnosing adolescent BPD, there is a lack of cost-effective evidence-based treatment programs for adolescents. Mentalization-based treatment is an evidence-based program for BPD, originally developed for adults.

Methods/Design

Aims/hypotheses: We will investigate whether a specifically designed mentalization-based treatment in groups is an efficacious treatment for adolescents with BPD or subthreshold BPD compared to treatment as usual. The trial is a four-center, two-armed, parallel-group, assessor-blinded randomized clinical superiority trial. One hundred twelve patients aged 14 to 17 referred to Child and Adolescent Psychiatric Clinics in Region Zealand are randomized to 1 year of either mentalization-based treatment in groups or treatment as usual. Patients will be included if they meet at least four DSM-5 criteria for BPD. The primary outcome is self-reported borderline features at discharge. Secondary outcomes will include self-harm, depression, BPD criteria, externalizing and internalizing symptoms, and social functioning, together with parental reports on borderline features, externalizing and internalizing symptoms. Measures of attachment and mentalization will be included as mediational variables. Follow-up assessment will take place at 3 and 12 months after end of treatment.

Discussion

This is the first randomized controlled trial to test the efficacy of a group-based mentalization-based treatment for adolescents with BPD or subthreshold BPD. If the results confirm our hypothesis, this trial will add to the treatment options of cost-effective treatment of adolescent BPD.

Trial registration

Clinicaltrials.gov NCT02068326, February 19, 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1431-0) contains supplementary material, which is available to authorized users.

Practitioner Review: Borderline personality disorder in adolescence--recent conceptualization, intervention, and implications for clinical practice

BACKGROUND

The past decade has seen an unprecedented increase in research activity on personality disorders (PDs) in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners.

SCOPE

In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim was to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of PDs in adolescents.

FINDINGS AND CONCLUSION

Alongside providing up-to-date information on the phenomenology, prevalence, and etiology, we also report on associated clinical problems and interventions for adolescent BPD. It is only through early active assessment and identification of youngsters with these problems that a lifetime of personal suffering and health system burden can be reduced or altogether avoided. A variety of evidence-based approaches are now available to treat BPD and related clinical problems in young people. Future research should focus on establishing optimal precision in the diagnostic processes in different treatment settings.

A longitudinal twin study of borderline and antisocial personality disorder traits in early to middle adulthood

BACKGROUND

Antisocial personality disorder (ASPD) and borderline personality disorder (BPD) share genetic and environmental risk factors. Little is known about the temporal stability of these etiological factors in adulthood.

METHOD

DSM-IV criteria for ASPD and BPD were assessed using structured interviews in 2282 Norwegian twins in early adulthood and again approximately 10 years later. Longitudinal biometric models were used to analyze the number of endorsed criteria.

RESULTS

The mean criterion count for ASPD and BPD decreased 40% and 28%, respectively, from early to middle adulthood. Rank-order stability was 0.58 for ASPD and 0.45 for BPD. The best-fitting longitudinal twin model included only genetic and individual-specific environmental factors. Genetic effects, both those shared by ASPD and BPD, and those specific to each disorder remained completely stable. The unique environmental effects, however, changed substantially, with a correlation across time of 0.19 for the shared effects, and 0.39 and 0.15, respectively, for those specific to ASPD and BPD. Genetic effects accounted for 71% and 72% of the stability over time for ASPD and BPD, respectively. The genetic and environmental correlations between ASPD and BPD were 0.73, and 0.43, respectively, at both time points.

CONCLUSION

ASPD and BPD traits were moderately stable from early to middle adulthood, mostly due to genetic risk factors which did not change over the 10-year assessment period. Environmental risk factors were mostly transient, and appear to be the main source of phenotypic change. Genetic liability factors were, to a large extent, shared by ASPD and BPD.

Covariance and specificity in adolescent schizotypal and borderline trait expression

AIMS

The first aim of the present study is to assess the overlap between borderline and schizotypal traits during adolescence. The second objective is to examine whether some psychological factors (i.e. cognitive coping mechanisms, impulsivity and encoding style) are differentially related to borderline and schizotypal traits and may therefore improve the efficiency of clinical assessments.

METHODS

One hundred nineteen community adolescents (57 male) aged from 12 to 19 years completed a set of questionnaires evaluating the expression of borderline and schizotypal traits as well as cognitive emotion regulation (CER), impulsivity and encoding style.

RESULTS

Our data first yielded a strong correlation between borderline and schizotypal scores (r = 0.70, P < 0.001). Secondly, linear regression models indicated that the 'catastrophizing' CER strategy and the 'lack of premeditation' impulsivity facet accounted for the level of borderline traits, whereas an internal encoding style predominantly explained schizotypal traits.

CONCLUSIONS

Our results support the abundant literature showing that borderline and schizotypal traits frequently co-occur. Moreover, we provide original data indicating that borderline and schizotypal traits during adolescence are linked to different specific psychological mechanisms. Thus, we underline the importance of considering these mechanisms in clinical assessments, in particular to help disentangle personality disorder traits in youths.

Adolescent precursors of adult borderline personality pathology in a high-risk community sample

Longitudinal studies of the exact environmental conditions and personal attributes contributing to the development of borderline personality disorder (BPD) are rare. Furthermore, existing research typically examines risk factors in isolation, limiting our knowledge of the relative effect sizes of different risk factors and how they act in concert to bring about borderline personality pathology. The present study investigated the prospective effects of diverse acute and chronic stressors, proband psychopathology, and maternal psychopathology on BPD features in a high-risk community sample (N = 700) of youth followed from mid-adolescence to young adulthood. Multivariate analyses revealed significant effects of maternal externalizing disorder history, offspring internalizing disorder history, family stressors, and school-related stressors on BPD risk. Contrary to expectations, no interactions between chronically stressful environmental conditions and personal characteristics in predicting borderline personality features were detected. Implications of these findings for etiological theories of BPD and early screening efforts are discussed.

Personality disorder across the life course

The pervasive effect of personality disorder is often overlooked in clinical practice, both as an important moderator of mental state and physical disorders, and as a disorder that should be recognised and managed in its own right. Contemporary research has shown that maladaptive personality (when personality traits are extreme and associated with clinical distress or psychosocial impairment) is common, can be recognised early in life, evolves continuously across the lifespan, and is more plastic than previously believed. These new insights offer opportunities to intervene to support more adaptive development than before, and research shows that such intervention can be effective. Further research is needed to improve classification, assessment, and diagnosis of personality disorder across the lifespan; to understand the complex interplay between changes in personality traits and clinical presentation over time; and to promote more effective intervention at the earliest possible stage of the disorder than is done at present. Recognition of how personality disorder relates to age and developmental stage can improve care of all patients.

Clinical validity of prototype personality disorder ratings in adolescents

A growing body of research shows that personality pathology in adolescents is clinically distinctive and frequently stable into adulthood. A reliable and useful method for rating personality pathology in adolescent patients has the potential to enhance conceptualization, dissemination, and treatment effectiveness. The aim of this study is to examine the clinical validity of a prototype matching approach (derived from the Shedler Westen Assessment Procedure-Adolescent Version) for quantifying personality pathology in an adolescent inpatient sample. Sixty-six adolescent inpatients and their parents or legal guardians completed forms of the Child Behavior Checklist (CBCL) assessing emotional and behavioral problems. Clinical criterion variables including suicide history, substance use, and fights with peers were also assessed. Patients' individual and group therapists on the inpatient unit completed personality prototype ratings. Prototype diagnoses demonstrated substantial reliability (median intraclass correlation coefficient =.75) across independent ratings from individual and group therapists. Personality prototype ratings correlated with the CBCL scales and clinical criterion variables in anticipated and meaningful ways. As seen in prior research with adult samples, prototype personality ratings show clinical validity across independent clinician raters previously unfamiliar with the approach, and they are meaningfully related to clinical symptoms, behavioral problems, and adaptive functioning.

If It Looks Like a Duck and Quacks Like a Duck: Evaluating the Validity of Borderline Personality Disorder in Adolescents

Background:

The validity of borderline personality disorder (BPD) has been a topic of much controversy in psychiatry. Over the last two decades, a wealth of empirical work has challenged long-held concerns regarding the validity of adolescent BPD. However, this research has been conducted within a traditional approach to psychiatric nosology.

Objective:

In this article, we aim to evaluate the validity of adolescent BPD as guided by both the Robins and Guze criteria for the validity of psychiatric constructs and the new National Institute of Mental Health Research Domain Criteria (NIMH RDoC).

Method:

We used the five principles of the Robins and Guze approach to evaluate selected research from our own and other groups regarding the validity of adolescent BPD. These principles include clinical description studies, laboratory studies, studies that delimitate the disorder from other related syndromes, follow-up studies, and family studies.

Results:

Within the Robins and Guze criteria framework, evidence to date supports the validity of adolescent BPD to some extent. However, limitations of the research about the construct validity of adolescent BPD have also been identified, most notably regarding the delimitation of adolescent BPD from other disorders as well as a lack of longitudinal and family studies.

Conclusions:

Given these limitations and the limitations of the Robins and Guze approach to psychiatric nosology, we recommend exploring the potential of the National Institute of Mental Health Research Domain Criteria as a complement to previous work.

Disparate plasma cortisol concentrations in sexually abused female children from Johannesburg, South Africa

A growing body of research indicates that a bidirectional response to a stressor may occur in maltreated children and may be associated with later life psychopathology. However, few studies have investigated stress reactivity in children when they first present to a sexual abuse clinic. Thus, in order to evaluate whether HPA axis dysregulation would be evident at first presentation to a sexual abuse clinic in young girls (n = 26), between the ages of 6-12 years old, blood samples were obtained immediately following examination at a forensic sexual abuse clinic and from the matched control group of children (n = 14; 10.1 ± 0.8) immediately following a bone density scan. Stratification of the sexually abused group into those children who were reportedly abused by a stranger and had no other family stressors (n = 15, 10.4 ± 1.8) and those children whose parents reported abuse of the child by a stranger and other family stressors (n = 11; 9.5 ± 1.8) revealed differences in stress reactivity. Plasma concentrations, of the children from the forensic clinic, were significantly increased in children who reported abuse by a stranger only (322.3 ± 117.4 nmol/l) and significantly decreased in children whose histories indicated sexual abuse by a stranger and other family stressors (149.6 ± 39.7 nmol/l) when compared to the control group (225.5 ± 47.5 nmol/l). In conclusion, following sexual abuse and a secondary stressor, the forensic examination, there is evidence of divergent cortisol responses in the stratified clinical group of children.

[Prevalence of emotional and behavioral symptomatology in Spanish adolescents]

INTRODUCTION

The main purpose of this study was to examine the prevalence of symptoms of an emotional and behavioral nature, as well as prosocial type capabilities, measured using the Strengths and Difficulties Questionnaire, in non-clinical adolescents.

METHOD

The final sample was composed of a total of 508 students, 208 male (40.9%). The age of participants ranged from 11 to 18 years (M=13.91 years; SD=1.71).

RESULTS

The results show that a significant number of adolescents self-reported emotional and behavioral problems. The mean scores of the Strengths and Difficulties Questionnaire subscales varied according the gender and age of the adolescents.

CONCLUSIONS

In the present study, the prevalence of psychological difficulties among adolescents was similar to that reported in other national and international studies. In view of these results, there is a need to develop programs for the early detection of these types of problems in schools in children and adolescents ages.

Prevention and early intervention for borderline personality disorder: current status and recent evidence

Borderline personality disorder (BPD) is a leading candidate for developing empirically based prevention and early intervention programmes because it is common in clinical practice, it is among the most functionally disabling of all mental disorders, it is often associated with help-seeking, and it has been shown to respond to intervention, even in those with established disorder. Moreover, it can be reliably diagnosed in its early stages and it demarcates a group with high levels of current and future morbidity and mortality. Data also suggest considerable flexibility and malleability of BPD traits in youth, making this a key developmental period during which to intervene. Novel indicated prevention and early intervention programmes have shown that BPD in young people responds to intervention. Further work is required to develop appropriate universal and selective preventive interventions.

A Five-Factor Model framework for understanding childhood personality disorder antecedents

The present contribution reviews evidence that supports the relevance of childhood antecedents of personality disorders, and advocates that the validity of a Five-Factor Model framework for describing general trait differences in childhood can be extended towards the field of developmental personality difficulties. In addition, we suggest that several traditional childhood Axis I conditions include a substantial trait component that may be responsible for the recurring finding that childhood Axis I disorders are predictive for adult Axis II disorders. Given the valuable information provided by a trait assessment, we further propose to integrate dimensional personality and personality pathology measures as standard tools in mental health assessments at a young age.

Using electronic health records data to assess comorbidities of substance use and psychiatric diagnoses and treatment settings among adults

OBJECTIVE

To examine prevalences of substance use disorders (SUD) and comprehensive patterns of comorbidities among psychiatric patients ages 18-64 years (N = 40,099) in an electronic health records (EHR) database.

METHOD

DSM-IV diagnoses among psychiatric patients in a large university system were systematically captured: SUD, anxiety (AD), mood (MD), personality (PD), adjustment, childhood-onset, cognitive/dementia, dissociative, eating, factitious, impulse-control, psychotic (schizophrenic), sexual/gender identity, sleep, and somatoform diagnoses. Comorbidities and treatment types among patients with a SUD were examined.

RESULTS

Among all patients, 24.9% (n = 9984) had a SUD, with blacks (35.2%) and Hispanics (32.9%) showing the highest prevalence. Among patients with a SUD, MD was prevalent across all age groups (50.2-56.6%). Patients aged 18-24 years had elevated odds of comorbid PD, adjustment, childhood-onset, impulse-control, psychotic, and eating diagnoses. Females had more PD, AD, MD, eating, and somatoform diagnoses, while males had more childhood-onset, impulse-control, and psychotic diagnoses. Blacks had greater odds than whites of psychotic and cognitive/dementia diagnoses, while whites exhibited elevated odds of PA, AD, MD, childhood-onset, eating, somatoform, and sleep diagnoses. Women, blacks, and Native American/multiple-race adults had elevated odds of using inpatient treatment; men, blacks, and Hispanics had increased odds of using psychiatric emergency care. Comorbid MD, PD, adjustment, somatoform, psychotic, or cognitive/dementia diagnoses increased inpatient treatment.

CONCLUSION

Patients with a SUD, especially minority members, use more inpatient or psychiatric emergency care than those without. Findings provide evidence for research on understudied diagnoses and underserved populations in the real-world clinical settings.

Cluster B maladaptive personality traits in Spanish adolescents

INTRODUCCTION

The prevalence and expression of Cluster B personality disorders during adolescence have been poorly analyzed. The main aim of this research was to analyze the rate of Cluster B maladaptive personality traits in Spanish adolescents. We also examined dimensional structure underlying the influence of sex and age in its phenotypic expression, was also examined.

METHOD

The sample consisted of a total of 1440 participants (Mean=15.9 years, SD=1.2). The self-reporting questionnaire used was the Personality Diagnostic Questionnaire-4 + (PDQ-4 +).

RESULTS

Maladaptative «dramatic» or «erratic» personality traits are common among adolescents, particularly antisocial and borderline facets. Using the PDQ-4+ cut-off points, 20.3% of the sample submitted had a Cluster B personality disorder. The analysis of the internal structure of the Cluster B items of the PDQ-4 + yielded a factorial solution centred on three interrelated factors, including: Antisocial, Borderline and Histrionic/Narcissistic. There were differences by gender in the subscales of Cluster B, but not in function of age.

CONCLUSIONS

These data yield new insights that improve the understanding of the Cluster B personality disorders and traits in this sector of the population. Future studies should use measurement tools that take into account the concern, conviction and distress associated with such experiences.

Screening for personality disorder in incarcerated adolescent boys: preliminary validation of an adolescent version of the standardised assessment of personality - abbreviated scale (SAPAS-AV)

BACKGROUND

Personality disorder (PD) is associated with significant functional impairment and an elevated risk of violent and suicidal behaviour. The prevalence of PD in populations of young offenders is likely to be high. However, because the assessment of PD is time-consuming, it is not routinely assessed in this population. A brief screen for the identification of young people who might warrant further detailed assessment of PD could be particularly valuable for clinicians and researchers working in juvenile justice settings.

METHOD

We adapted a rapid screen for the identification of PD in adults (Standardised Assessment of Personality - Abbreviated Scale; SAPAS) for use with adolescents and then carried out a study of the reliability and validity of the adapted instrument in a sample of 80 adolescent boys in secure institutions. Participants were administered the screen and shortly after an established diagnostic interview for DSM-IV PDs. Nine days later the screen was readministered.

RESULTS

A score of 3 or more on the screening interview correctly identified the presence of DSM-IV PD in 86% of participants, yielding a sensitivity and specificity of 0.87 and 0.86 respectively. Internal consistency was modest but comparable to the original instrument. 9-days test-retest reliability for the total score was excellent. Convergent validity correlations with the total number of PD criteria were large.

CONCLUSION

This study provides preliminary evidence of the validity, reliability, and usefulness of the screen in secure institutions for adolescent male offenders. It can be used in juvenile offender institutions with limited resources, as a brief, acceptable, staff-administered routine screen to identify individuals in need of further assessment of PD or by researchers conducting epidemiological surveys.

Developmental pathways to borderline personality disorder

This paper reviews recent studies of biological and environmental risk and protective factors and patterns of continuity leading to borderline personality disorder (BPD). It focuses on prospective studies of children and adolescents and studies of young people with borderline pathology, reporting findings from genetics, neurobiology, experimental psychopathology, environmental risk, and precursor signs and symptoms. Studies of individuals earlier in the course of BPD demonstrate relatively consistent environmental risk factors, but neurobiological and experimental psychopathology findings are still inconsistent. Also, temperamental and mental state abnormalities that resemble aspects of the BPD phenotype emerge in childhood and adolescence and presage the BPD syndrome in adolescence or adulthood. Further work is required to better understand the roles that all these factors play in the developmental pathways to BPD and to increase their specificity for BPD in order to facilitate prevention and early intervention.

Childhood Maltreatment and Prospectively Observed Quality of Early Care as Predictors of Antisocial Personality Disorder Features

Few studies have evaluated the separate contributions of maltreatment and ongoing quality of parent-child interaction to the etiology of antisocial personality features using a prospective longitudinal design. 120 low-income young adults (aged 18-23) were assessed for extent of ASPD features on the Structured Clinical Interview for Diagnosis-Axis II, for presence of maltreatment on the Conflict Tactics Scale, Traumatic Experiences Scale, and Adult Attachment Interview, and for referral in infancy to parent-infant clinical services. Fifty-six of these families had been studied longitudinally since the first year of life. In infancy, attachment disorganization and disrupted mother-infant interaction were assessed; in middle childhood, disorganized-controlling attachment behaviors were reliably rated. In kindergarten and second grade, behavior problems were assessed by teacher report. In cross-sectional analyses, maltreatment was significantly associated with ASPD features but did not account for the independent effect of early referral to parent-infant services on ASPD features. In longitudinal analyses, maternal withdrawal in infancy predicted the extent of ASPD features twenty years later, independently of childhood abuse. In middle childhood, disorganized attachment behavior and maladaptive behavior at school added to prediction of later ASPD features. Antisocial features in young adulthood have precursors in the minute-to-minute process of parent-child interaction beginning in infancy.

Schizotypy, emotional-behavioural problems and personality disorder traits in a non-clinical adolescent population

The main goal of the present study was to examine the relationship between the schizotypy dimensions, emotional-behavioural problems and personality disorder traits in non-clinical general adolescent population. A total of 1455 participants (M=15.9years; S.D.=1.2) were administered the Oviedo Schizotypy Assessment Questionnaire (ESQUIZO-Q), the Strengths and Difficulties Questionnaire (SDQ) and the Personality Diagnostic Questionnaire-4+ (PDQ-4+). Correlation analyses revealed significant associations between the schizotypy and emotional-behavioural problems self-reported by adolescents. Participants with high scores in schizotypy dimensions, reported higher rates of affective and behavioural problems than those with low scores. Also, schizotypy dimensions and personality disorder traits were closely related in adolescent population. These data indicate, as occurs in clinical samples, the high overlap between schizotypy and personality disorder traits. Affective dysregulation and behavioural problems are present at the subclinical level in non-clinical adolescent population. These results have implications for the integration of schizotypy studies within the paradigms of developmental psychology and dimensional models of personality.

Substance use disorders and comorbid Axis I and II psychiatric disorders among young psychiatric patients: findings from a large electronic health records database

This study examined the prevalence of substance use disorders (SUDs) among psychiatric patients aged 2-17 years in an electronic health records database (N=11,457) and determined patterns of comorbid diagnoses among patients with a SUD to inform emerging comparative effectiveness research (CER) efforts. DSM-IV diagnoses of all inpatients and outpatients at a large university-based hospital and its associated psychiatric clinics were systematically captured between 2000 and 2010: SUD, anxiety (AD), mood (MD), conduct (CD), attention deficit/hyperactivity (ADHD), personality (PD), adjustment, eating, impulse-control, psychotic, learning, mental retardation, and relational disorders. The prevalence of SUD in the 2-12-year age group (n=6210) was 1.6% and increased to 25% in the 13-17-year age group (n=5247). Cannabis diagnosis was the most prevalent SUD, accounting for more than 80% of all SUD cases. Among patients with a SUD (n=1423), children aged 2-12 years (95%) and females (75-100%) showed high rates of comorbidities; blacks were more likely than whites to be diagnosed with CD, impulse-control, and psychotic diagnoses, while whites had elevated odds of having AD, ADHD, MD, PD, relational, and eating diagnoses. Patients with a SUD used more inpatient treatment than patients without a SUD (43% vs. 21%); children, females, and blacks had elevated odds of inpatient psychiatric treatment. Collectively, results add clinical evidence on treatment needs and diagnostic patterns for understudied diagnoses.

Personality disorders in later life: questions about the measurement, course, and impact of disorders

Lifespan perspectives have played a crucial role in shaping our understanding of many forms of psychopathology. Unfortunately, little attention has been given to personality disorders in middle adulthood and later life. Several issues are responsible for this deficiency, including difficulty applying the diagnostic criteria for personality disorders to older people and challenges in identifying appropriate samples of older participants. The goal of this review is to explore the benefits of considering older adults in the study of personality disorders. Later life offers a unique opportunity for investigators to consider links between personality pathology and consequential outcomes in people's lives. Many domains are relevant, including health, longevity, social adjustment, marital relationships, and the experience of major life events. We review each domain and consider ways in which the study of middle-aged and older adults challenges researchers to evaluate how personality disorders in general are defined and measured.

Childhood adversity and personality disorders: results from a nationally representative population-based study

BACKGROUND

Although, a large population-based literature exists on the relationship between childhood adversity and Axis I mental disorders, research on the link between childhood adversity and Axis II personality disorders (PDs) relies mainly on clinical samples. The purpose of the current study was to examine the relationship between a range of childhood adversities and PDs in a nationally representative sample while adjusting for Axis I mental disorders.

METHODS

Data were from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; n=34,653; data collection 2004-2005); a nationally representative sample of the United States population aged 20 years and older.

RESULTS

The results indicated that many types of childhood adversity were highly prevalent among individuals with PDs in the general population and childhood adversity was most consistently associated with schizotypal, antisocial, borderline, and narcissistic PDs. The most robust childhood adversity findings were for child abuse and neglect with cluster A and cluster B PDs after adjusting for all other types of childhood adversity, mood disorders, anxiety disorders, substance use disorders, other PD clusters, and sociodemographic variables (Odd Ratios ranging from 1.22 to 1.63). In these models, mood disorders, anxiety disorders, and substance use disorders also remained significantly associated with PD clusters (Odds Ratios ranging from 1.26 to 2.38).

CONCLUSIONS

Further research is necessary to understand whether such exposure has a causal role in the association with PDs. In addition to preventing child maltreatment, it is important to determine ways to prevent impairment among those exposed to adversity, as this may reduce the development of PDs.

Integrating normal and abnormal personality structure: a proposal for DSM-V

The personality disorders section of the American Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is currently being developed. The purpose of the current paper is to encourage the authors of DSM-V to integrate normal and abnormal personality structure within a common, integrative model, and to suggest that the optimal choice for such an integration would be the five-factor model (FFM) of general personality structure. A proposal for the classification of personality disorder from the perspective of the FFM is provided. Discussed as well are implications and issues associated with an FFM of personality disorder, including validity, coverage, feasibility, clinical utility, and treatment implications.

Cluster A Personality Disorders: Schizotypal, Schizoid and Paranoid Personality Disorders in Childhood and Adolescence

Cluster A personality disorders (PD), including schizotypal personality disorder (SPD), paranoid personality disorder (PPD), and schizoid PD, are marked by odd and eccentric behaviors, and are grouped together because of common patterns in symptomatology as well as shared genetic and environmental risk factors. The DSM-IV-TR describes personality disorders as representing stable and enduring patterns of maladaptive traits, and much of what is understood about Cluster A personality disorders in particular stems from research with adult populations. Less in known about these disorders in children and adolescents, and controversy remains regarding diagnosis of personality disorders in general in youth. The current paper reviews the available research on Cluster A personality disorders in childhood and adolescence; specifically, we discuss differentiating between the three disorders and distinguishing them from other syndromes, measuring Cluster A disorders in youth, and the nature and course of these disorders throughout childhood and adolescence. We also present recent longitudinal data from a sample of adolescents diagnosed with Cluster A personality disorders from our research laboratory, and suggest directions for future research in this important but understudied area.

Early maternal separation and the trajectory of borderline personality disorder symptoms

Extended maternal separations before age 5 were evaluated as a predictor of long-term risk for offspring borderline personality disorder (BPD) symptoms in longitudinal data from a large random community sample. Early separations from mother predicted elevations in BPD symptoms assessed repeatedly from early adolescence to middle adulthood. Early separations also predicted a slower than normal rate of decline in symptoms with age. Other theoretically grounded risks were examined and shown to predict elevated BPD symptoms over the developmental trajectory. Long-term effects of early separations were largely independent of childhood temperament, child abuse, maternal problems, and parenting risks. These data provide the first prospectively collected data on the developmental course of BPD symptoms and suggest a series of environmental and other influences on these very disabling problems.

Childhood personality pathology: dimensional stability and change

Studies on the developmental course of personality disorders have suggested that adult personality disorders enclose both features with a natural plasticity over time, as well as stable components represented by underlying trait dimensions. The current study broadens this dimensional stability perspective toward an earlier developmental stage, and describes with different indices of stability the longitudinal behavior of basic childhood maladaptive trait dimensions in a community sample of 477 Flemish children. The results underscore structural, rank-order, and within-person stability for the disagreeableness, emotional instability, introversion, and compulsivity dimensions and suggest a similar maturation principle as has been proposed for adults. Individual growth curve analyses indicate that children's maladaptive trait scores generally decrease as they grow older, with a smaller decline for high-scoring individuals. Childhood maladaptive traits and general psychopathology dimensions show similar longitudinal patterns in terms of shape and change over time, supporting a spectrum conceptualization of Axis I related pathology and personality disorder precursors at young age. The implications of these findings for a developmental perspective on dimensional conceptualizations of personality disorders are discussed.

Childhood antecedents of personality disorder: an alternative perspective

One of the fundamental limitations of the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, Text Revision (DSM-IV-TR) categorical model of personality disorder classification has been the lack of a strong scientific foundation, including an understanding of childhood antecedents. The DSM-IV-TR personality disorders, however, do appear to be well understood as maladaptive variants of the domains and facets of the general personality structure as conceptualized within the five-factor model (FFM). Integrating the classification of personality disorder with the FFM brings to an understanding of the personality disorders a considerable body of scientific research on childhood antecedents. The temperaments and traits of childhood do appear to be antecedent to the FFM of adult personality structure, and these temperament and traits of childhood and adolescence are the likely antecedents for adult personality disorder, providing further support for the conceptualization of the adult personality disorders as maladaptive variants of the domains and facets of the FFM. Conceptualizing personality disorders in terms of the FFM thereby provides a basis for integrating the classification of abnormal and normal personality functioning across the life span.

A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder

The precise nature and etiopathogenesis of borderline personality disorder (BPD) continues to elude researchers and clinicians. Yet, increasing evidence from various strands of research converges to suggest that affect dysregulation, impulsivity, and unstable relationships constitute the core features of BPD. Over the last two decades, the mentalization-based approach to BPD has attempted to provide a theoretically consistent way of conceptualizing the interrelationship between these core features of BPD, with the aim of providing clinicians with a conceptually sound and empirically supported approach to BPD and its treatment. This paper presents an extended version of this approach to BPD based on recently accumulated data. In particular, we suggest that the core features of BPD reflect impairments in different facets of mentalization, each related to impairments in relatively distinct neural circuits underlying these facets. Hence, we provide a comprehensive account of BPD by showing how its core features are related to each other in theoretically meaningful ways. More specifically, we argue that BPD is primarily associated with a low threshold for the activation of the attachment system and deactivation of controlled mentalization, linked to impairments in the ability to differentiate mental states of self and other, which lead to hypersensitivity and increased susceptibility to contagion by other people's mental states, and poor integration of cognitive and affective aspects of mentalization. The combination of these impairments may explain BPD patients' propensity for vicious interpersonal cycles, and their high levels of affect dysregulation and impulsivity. Finally, the implications of this expanded mentalization-based approach to BPD for mentalization-based treatment and treatment of BPD more generally are discussed.