Childhood antecedents of personality disorder

A developmental approach to youth maladaptive personality traits: Variable- versus person-centered change in the transition from childhood to adolescence

Increasing evidence shows that personality pathology starts to develop from (late) childhood onwards. The current study extends previous research by examining maladaptive personality change using both a variable-centered approach (i.e., mean-level changes) and a person-centered approach (i.e., latent profile transitions). Data were used from a 3-wave longitudinal study on Dutch youth (at T1: N = 492, mean age = 10.1). Maladaptive personality traits (i.e., Emotional Instability, Disagreeableness, Introversion, and Compulsivity) were assessed yearly using the Dimensional Personality Symptom Item Pool (DIPSI). A Factor of Curves model indicated presence of a higher-order developmental factor, reflecting low initial levels and small decreases over time, which explained change in all DIPSI traits. Latent profile analyses revealed three quantitatively different maladaptive personality trait profiles. Latent Transition Analysis demonstrated substantial stability in profiles over time. Small groups showed a transition toward another (often more adaptive) profile. Although a person-centered approach may have some merit when aiming to detect high-risk subgroups, the current results suggest that a variable-centered approach—and a Factor of Curves model capturing shared underlying developmental processes in particular—is favorable over a person-centered approach.

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.

Exploring mentalizing in adolescents with anorexia nervosa and borderline personality disorder: A comparative study of psychiatric inpatients and healthy controls

Background:

Impaired mentalizing, i.e., difficulties in understanding oneself and others in terms of mental states, has been associated with the development of Anorexia Nervosa (AN), mainly among adults. However, few studies have addressed this question in clinical samples of adolescents with AN. Moreover, no study has explored mentalizing abilities among inpatient adolescents presenting with AN and Borderline Personality Disorder (BPD), despite their high comorbidity in a highly relevant age group.

Objective:

This study attempted, for the first time, to further examine differences in mentalizing abilities and to identify specific mentalizing impairments in different psychiatric inpatient groups and healthy adolescents.

Methods:

Using samples of female adolescents aged 12–17, comparison analyses were performed between psychiatric inpatient adolescents with AN (n = 44), BPD (n = 101), AN+BPD (n = 48), other psychopathology (n = 163) and healthy adolescents (n = 129). Structured and semi-structured clinical interviews, and two experimental tasks were administered to assess AN, BPD and mentalizing, respectively.

Results:

Comparison analyses showed that patients with BPD and other psychiatric disorders evidenced higher levels of hypermentalizing compared to healthy adolescents. Hypermentalizing was also reported among inpatients with AN+BPD, although to a lesser extent. BPD and AN scores were positively correlated with hypermentalizing responses.

Conclusions:

Our results suggest that hypermentalizing is a specific mentalization impairment in inpatient adolescents, particularly with BPD and both AN+BPD. Further investigation into the efficacy of mentalization based treatments for adolescents with BPD and AN+BPD is recommended. Prospective studies are needed to assess mentalizing using experimental tasks among adolescents with AN, taking into account the potential influence of temporality and severity of the disorders’ symptoms.

A meta‐analysis of psychopathy‐, antisocial PD‐ and FFM associations

This research meta‐analytically summarizes the relationships of the Five‐Factor Model (FFM) with psychopathy and Antisocial Personality Disorder (APD). Effect sizes of the associations between psychopathy, APD and the FFM were compiled from 26 independent samples (N = 6913) for psychopathy and 57 independent samples (N = 16 424) for APD. The results revealed predominantly points of similarity and some differences in the FFM associations of both disorders. Symptoms of psychopathy and APD were negatively associated with Conscientiousness and Agreeableness facets and positively with scores on Angry–Hostility (N2), Impulsiveness (N5), Excitement Seeking (E5) and negatively with Warmth (E1). Only psychopathy had a small negative association with Anxiety (N1) and was characterized by stronger negative associations with Agreeableness and Straightforwardness (A2), Compliance (A4) and Modesty (A5) compared to APD. The moderator analyses showed that sample type, use of the NEO‐PI‐R and APD instrument moderated the APD FFM associations, while psychopathy instrument and age group were moderators in the psychopathy MA. Implications of this research for the assessment of APD and psychopathy relying on dimensional models of personality pathology are discussed. Copyright © 2009 John Wiley & Sons, Ltd.

Psychotropic medication use among personality disordered young adults. A follow-up study among former adolescent psychiatric inpatients

OBJECTIVE

To analyze the use of prescribed psychotropic medication in subjects with personality disorder (PD) diagnosed in early adulthood.

METHODS

The study population consisted of former adolescent psychiatric inpatients (N=508). 63 had a diagnosis of PD, including with borderline PD (BPD) (N=38) and other PD (OPD) (N=25). DSM IV-based psychiatric diagnoses in adolescence were based on the Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL). The information on in-or outpatient hospital treatments until the end of 2016 were extracted from the National Care Register for Health Care. Lifetime data on purchases of physician-prescribed psychotropic medications was obtained from the Social Insurance Institution of Finland.

RESULTS

98.4% (N=62) of subjects with PD had purchased at least one type of psychotropic medication during the follow-up period. The use of non-opioid analgesics and antipyretics was over twice as common among subjects with BPD than subjects with OPD (57.9% vs.28.0%, p=0.020). Anxiolytic use was 1.5 times more common among subjects with BPD than subjects with OPD (65.8% vs. 40.0%, p=0.044) CONCLUSIONS: Psychotropic medication use was common among subjects with PD. The use of non-opioid analgesics, antipyretics and anxiolytics was more common among subjects with BPD.

Personality disorders of drivers killed in fatal motor vehicle accidents in Finland during 1990-2011

OBJECTIVE

To examine the association of personality disorders (PDs) to deaths of drivers in fatal motor vehicle accidents (FMVAs) and analyze gender differences in lifetime psychiatric disorders and medico-legal findings at the time of accident.

METHOD

The study sample consisted of 4810 Finnish drivers killed in FMVAs in Finland between 1990 and 2011. Doctor-diagnosed PD was found in 146 drivers (118 men and 28 women). The information of psychiatric morbidity was obtained from the Finnish Care Register for Health Care.

RESULTS

The proportion of deceased drivers with PDs had increased significantly over the study period, particularly among females and those with PD not otherwise specified (NOS). Suicidality and use of medication affecting driving ability were more common among females with PD compared to males with PD. 88% of all deceased drivers with PD had comorbid psychiatric disorders.

CONCLUSION

Our findings indicate that PDs may predispose drivers to FMVAs, particularly females. This study emphasizes the importance of evaluating the fitness-to-drive of subjects with PD and especially comorbid substance use disorders, which may relate to an increased risk of fatal motor accidents.

L’enfant borderline en devenir II : validation préliminaire de l’Échelle de traits de personnalité limite pour enfants

Le trouble de personnalité limite (TPL) est une psychopathologie sévère qui engendre une grande détresse personnelle et familiale et dont l’étiologie remonte à l’enfance. Les données empiriques appuyant une certaine stabilité temporelle des traits de personnalité de l’enfance à l’adolescence et à l’âge adulte, plusieurs auteurs soutiennent qu’il est possible d’observer chez des enfants et des adolescents des traits de personnalité pouvant être associés aux caractéristiques du TPL à l’âge adulte. Peu d’instruments permettent toutefois d’identifier chez les enfants et les adolescents des traits associés au TPL, d’où l’intérêt du Borderline Personality Features Scale for Children (BPFS-C). Basé sur une perspective développementale, cet instrument mesure les traits de personnalité limite chez les enfants de neuf ans et plus par un questionnaire autorapporté. Une première étude de validation de la version française de l’instrument démontre une cohérence interne très satisfaisante. Les corrélations entre les deux versions de l’instrument (en anglais et en français) sont significatives. L’analyse en composantes principales révèle un modèle en quatre composantes qui présente des similarités avec les quatre sous-échelles de la version anglaise, mais diffère quant à la répartition des énoncés appartenant initialement à la sous-échelle « problèmes d’identité » du BPFS-C. La poursuite de la validation de cet instrument permettrait d’identifier des traits de personnalité et des comportements associés au développement du TPL dans l’enfance et favoriserait la réalisation d’études prospectives afin d’augmenter les connaissances sur l’étiologie du TPL, ses manifestations et sa trajectoire au cours du développement.

Who is becoming personality disordered? A register-based follow-up study of 508 inpatient adolescents

BACKGROUND

Our aim was to investigate which clinical and socio-demographic factors among adolescent psychiatric patient aged 13-17 are associated with a diagnosis of personality disorder (PD) in young adulthood after discharge from psychiatric hospitalization.

METHODS

The study sample consisted of 508 adolescents (ages 13-17) admitted to acute psychiatric impatient care between April 2001 and March 2006. DSM IV-based psychiatric diagnoses were obtained from the Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL). The information on hospital treatments either in out- or inpatient settings until the end of 2012 was extracted from the national Care Register for Health Care provided by the Finnish National Institute for Health and Welfare. The follow-up time was 9.2 years (mean, 95% CI 9.0-9.3 yrs).

RESULTS

Altogether 57 (11.2%) of subjects were diagnosed PD in adulthood. Among girls with anxiety disorders in adolescence the risk for PD in adulthood increased to 4.39-fold (95% CI 2.02-9.53). Males with later PD were more likely to be admitted for hospital treatment from child welfare placements (OR 3.23, 95% CI 1.21-8.61). However, axis I disorders in adolescence was not associated with risk for PD among boys.

CONCLUSIONS

The results indicate that risk of PD developing later in life is increased among girls with anxiety disorders. A child welfare placement associated with PD in males later in life. These associations in adolescents should be considered in clinical work.

Youth services: meeting the mental health needs of adolescents

Objectives

Youth mental health services are poised for a paradigm shift. Recent epidemiological evidence confirms the seriousness of adolescence as a risk period for mental ill-health - 50% of all adult mental disorders begin before the age of 16% and 75% before the age of 25. Here, we identify issues with transition of care between CAMHS-AMHS service, and effectiveness of early intervention services.

Methods

We provide a selective review providing evidence of adolescence as a risk period, discuss CAMHS-AMHS service transition problems, and discuss avenues for change to implement the early intervention model across youth mental health.

Results

Traditional service structures,with paediatric -adult split at 16–18 years increasingly appear not fit for purpose. A radical redesign of youth mental health services is not only necessary, it is also feasible and achievable, as illustrated by a pilot Birmingham youth service – Youthspace.

Conclusions

Pilot youth mental projects currently underway can help radically redesign the existing child and adolescent services. This will in turn lead to an improvement in the young people's experience of engagement with the services so that they too have a positive future.

Callous-Unemotional traits in youth from a DSM-5 trait perspective

The current study investigated how the Callous-Unemotional (CU) trait specifier is empirically associated with the proposed trait system for personality pathology in DSM-5, and addressed the use of multiple raters in the assessment of CU traits and additional maladaptive traits in an adolescent community sample. Both mothers and adolescents (N = 197) participated in the present study. Results showed that CU traits are located in different parts of the personality space, and are significantly associated with four broad maladaptive trait dimensions, Negative Affect, Detachment, Antagonism, and Disinhibition. Despite moderate agreement between raters, self- and maternal-rated CU traits were related in a congruent manner with PID-5 traits, and adolescents provided incremental information in CU trait assessment above maternal ratings. The present results have clear implications for the conceptualization of CU traits within the overarching model of personality pathology, proposed in DSM-5, and partially supported the application of a multi-informant approach in CU trait assessment.

The influence of personality disorders on the use of mental health services in adolescents with psychiatric disorders

OBJECTIVE

The aims of this study were to explore the influence of personality disorders (PDs) in Spanish adolescents with Axis I psychiatric disorders on their use of mental health services and to analyze the risk of having a comorbid PD in relation to psychiatric service use.

METHODS

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and International Classification of Diseases, Tenth Revision (ICD-10) modules of the semistructured interview International Personality Disorders Examination were administered to a sample of 112 adolescent psychiatric patients (mean age = 15.8 years; SD, 0.8; range, 15-17; 79% women) at the point of initiating treatment. On the basis of the interview, subjects were divided into two groups: a PD group (PDG) and a non-PD group (NPDG). After 3 years of treatment, clinical records were retrospectively analyzed.

RESULTS

The PDG showed a significantly higher number of psychiatric admissions (P < .001), days per psychiatric admission (P < .001), and psychiatric emergencies (P < .010) than the NPDG, although the number of outpatient consultations was not significantly higher. Logistic regression analysis showed that the probability of belonging to the PDG rather than the NPDG increased with each psychiatric admission (odds ratio [OR] = 1.67 for DSM-IV criteria and OR = 1.59 for ICD-10 criteria), after controlling by sex, age, and comorbidity (Axis I disorders).

CONCLUSIONS

Patients with comorbid PD used more inpatient and emergency psychiatric services than did patients without a PD. Large number of psychiatric hospitalizations suggests the likelihood of a PD being present.

Exploring depressive personality traits in youth: origins, correlates, and developmental consequences

Research suggests that depressive personality (DP) disorder may represent a persistent, trait-based form of depression that lies along an affective spectrum ranging from personality traits to diagnosable clinical disorders. A significant gap in this area of research concerns the development of DP and its applicability to youth. The present research explored the construct of DP traits in youth. Specifically, this study examined the reliability, stability, and validity of the construct, potential origins of DP traits, and the developmental consequences of DP traits. A sample of 143 youth (mean age = 12.37 years, SD = 1.26) and their caregivers completed semistructured interviews and questionnaires on two occasions, separated by a 12-month interval. The measure of DP traits was reliable and moderately stable over time. Providing evidence of construct validity, DP traits were associated with a network of constructs, including a negative self-focus, high-negative and low-positive emotionality, and heightened stress reactivity. Moreover, several potential origins of DP traits were identified, including a history of family adversity, maternal DP traits, and maternal depression. Consistent with hypotheses regarding their developmental significance, DP traits predicted the generation of stress and the emergence of depression (but not nondepressive psychopathology) during the pubertal transition. Finally, depression predicted subsequent DP traits, suggesting a reciprocal process whereby DP traits heighten risk for depression, which then exacerbates these traits. These findings support the construct of DP traits in youth, and suggest that these traits may be a useful addition to developmental models of risk for youth depression.

Multifinality in the development of personality disorders: a Biology x Sex x Environment interaction model of antisocial and borderline traits

Although antisocial personality disorder (ASPD) is more common among males and borderline PD (BPD) is more common among females, some authors have suggested that the two disorders reflect multifinal outcomes of a single etiology. This assertion is based on several overlapping symptoms and features, including trait impulsivity, emotional lability, high rates of depression and suicide, and a high likelihood of childhood abuse and/or neglect. Furthermore, rates of ASPD are elevated in the first degree relatives of those with BPD, and concurrent comorbidity rates for the two disorders are high. In this article, we present a common model of antisocial and borderline personality development. We begin by reviewing issues and problems with diagnosing and studying PDs in children and adolescents. Next, we discuss dopaminergic and serotonergic mechanisms of trait impulsivity as predisposing vulnerabilities to ASPD and BPD. Finally, we extend shared risk models for ASPD and BPD by specifying genetic loci that may confer differential vulnerability to impulsive aggression and mood dysregulation among males and impulsive self-injury and mood dysregulation among females. Although the precise mechanisms of these sex-moderated genetic vulnerabilities remain poorly understood, they appear to interact with environmental risk factors including adverse rearing environments to potentiate the development of ASPD and BPD.

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.

Child maltreatment and trajectories of personality and behavioral functioning: implications for the development of personality disorder

This study investigated the longitudinal impact of maltreatment parameters on personality processes and maladjustment and prospective relationships between personality trajectory classes and subsequent maladjustment outcomes. The sample involved maltreated (n = 249) and nonmaltreated (n = 200) children followed longitudinally between ages 6 and 10. Growth mixture modeling indicated multifinality in personality development depending on the risk status (i.e., maltreated vs. nonmaltreated). Two trajectory classes of ego resiliency were identified for maltreated children: those who showed a declining trajectory exhibited greater maladjustment. In contrast, three trajectory classes of ego control were identified for nonmaltreated children; the subgroups showing increases in ego undercontrol or dramatic changes from high ego undercontrol to high ego overcontrol exhibited poor adjustment. Experiencing multiple maltreatment subtypes and physical/sexual abuse were related to higher levels of ego undercontrol and externalizing symptomatology, whereas early onset of maltreatment was associated with the low and decreasing trajectory of ego resiliency and higher levels of internalizing symptomatology. The findings suggest that ego resiliency and ego control, personality processes related to self-regulation, may be important factors in identifying distinct pathways to later personality disorders as well as pathways to resilient functioning.

Transition of care from child to adult mental health services: the great divide

PURPOSE OF REVIEW

Adolescents with mental health problems often require transition of care from child and adolescent to adult mental health services. This review is a synthesis of current research and policy literature on transition to describe the barriers at the interface between child and adolescent mental health services and adult mental health services and outcomes of poor transition.

RECENT FINDINGS

Adolescence is a risk period for emergence of serious mental disorders. Child and adolescent mental health services and adult mental health services use rigid age cut-offs to delineate service boundaries, creating discontinuities in provision of care. Adolescent mental health services are patchy across the world. Several recent studies have confirmed that problems occur during transition in diverse settings across several countries. In physical health, there are emerging models of practice to improve the process and outcomes of transition, but there is very little comparable literature in mental healthcare.

SUMMARY

Poor transition leads to disruption in continuity of care, disengagement from services and is likely to lead to poorer clinical outcomes. Some young people, such as those with neurodevelopmental disorders and complex needs, are at a greater risk of falling through the care gap during transition. Services need robust and high-quality evidence on the process and outcomes of transition so that effective intervention strategies can be developed.

Entwicklungspsychopathologie der Persönlichkeitsstörungen

Störungen der Persönlichkeitsentwicklung finden sich schon im Kindes- und Jugendalter. So zeigen kindliche Temperamentsmerkmale eine hohe Übereinstimmung mit Persönlichkeitszügen des Erwachsenenalters. Normale Persönlichkeitsvarianten gehen fließend in klinisch relevante Persönlichkeitsstörungen über. Die Kategorialen Diagnosen weisen eine relativ geringe longitudinale Stabilität auf. Die Entwicklung von Persönlichkeitsstörungen ist als Risikoprozess aufzufassen, wobei unterschiedliche Vulnerabilitäten und dysfunktionale Kommunikationsprozesse in einen Teufelskreis sich selbst verstärkender ungünstiger Wechselwirkungen münden. Paradigmatisch werden die Entwicklungswege der Borderline-Persönlichkeitsstörung sowie der Antisozialen Persönlichkeitsstörung aufgezeigt.

Child development and personality disorder

The evidence is surprisingly strong that even early adolescent personality disorders or elevated personality disorder symptoms have a broad range of negative effects well into adulthood, for the most part comparable to or even larger than those of Axis I disorders. Current evidence suggests that the most severe long-term prognosis is associated with borderline and schizotypal PDs and elevated symptoms. And of course, childhood conduct disorder is in a peculiar status, disappearing in adulthood to be manifest as a very severe disorder-antisocial PD-in a minority of those with the adolescent disorder.

Does the treatment of mental disorders in childhood lead to a healthier adulthood?

PURPOSE OF REVIEW

To review mechanisms by which intervention for childhood mental disorders may exert an influence on mental health and wellbeing in adulthood, the challenges to demonstrating long-term benefit or harm from such intervention, existing evidence of long-term benefit, and strategies for improving the long-term benefit of treatment.

RECENT FINDINGS

Intervention may improve long-term outcome through the promotion of protective interpersonal relationships, by enhancing scholastic and later occupational functioning, by arresting the progression of disorder, and by improving general health. Challenges to demonstrating benefits or harms in the long term include variability in the natural course of childhood mental disorders, heterotypic outcomes, and the influence of other variables over time on long-term functioning. Examples of demonstrated benefit include the lowering of risk for substance abuse seen with psychostimulant treatment for attention-deficit/hyperactivity disorder, improved outcomes for autism since the introduction of early interventions to address language impairment, and reduced mortality in anorexia nervosa.

SUMMARY

There are feasible enduring benefits of treatment for childhood mental disorders. Treatment of complex problems may have a greater long-term impact than in conditions that follow a benign natural course. Success requires more assertive approaches to treatment than are traditionally employed by child and adolescent mental health services.