Attachment and body representations in adolescents with personality disorder

BACKGROUND

Attachment theory has served as an influential framework for understanding psychopathology, partly due to reliable assessment methodology. The influence of insecure attachment on attitudes toward the body and the impact this might have for the development of psychopathology is however less well elucidated.

METHOD

A total of 123 adolescents (35 with borderline personality disorder or BPD, 25 with other personality disorders [OPD] and 63 comprising a normative control group) were interviewed with the Adult Attachment Interview (AAI) and the Mirror Interview (MI). The MI questions respondents about how they feel about their bodies, as they look in the mirror.

RESULTS

The AAIs from the Borderline group were predominantly insecure-preoccupied and unresolved. These adolescents had significantly lower levels of a positive and integrated sense of self and body than the other groups. Regression results revealed a high loving relationship with fathers, low involving anger with father, high coherence of mind, slight derogation of mother & low levels of unresolved loss uniquely and additively predicted 55% of variance in the summary score assigned to MI responses, that is, the summary score for a Positive and Integrated Body Representation (PIBR).

CONCLUSION

Unfavorable attachment experiences and current states of mind regarding attachment may give rise to problems with establishing PIBRs, and thus play a role in the development of psychopathology, especially BPD.

Social and Monetary Reward Processing in Youth with Early Emerging Personality Pathology: An RDoC-Informed Study

Very little is known about the mechanisms underlying the development of personality disorders, hindering efforts to address early risk for these costly and stigmatized disorders. In this study, we examined associations between social and monetary reward processing, measured at the neurophysiological level, and personality pathology, operationalized through the Level of Personality Functioning (LPF), in a sample of early adolescent females (Mage = 12.21 years old, SD = 1.21). Female youth with (n = 80) and without (n = 30) a mental health history completed laboratory tasks assessing social and monetary reward responsiveness using electroencephalogram (EEG) and completed ratings of personality pathology. Commonly co-occurring psychopathology, including depression, anxiety, attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) were also assessed. At the bivariate level, significant associations did not emerge between psychopathology and reward processing variables. When covarying symptoms of depression, anxiety, ADHD, ODD, and CD, an enhanced reward positivity (RewP) component to social reward feedback (accounting for response to social rejection) was associated with higher levels of personality impairment. Results were specific to social rather than monetary reward processing. Depression, anxiety, and ODD also explained unique variance in LPF. These findings suggest that alterations in social reward processing may be a key marker for early emerging personality pathology. Future work examining the role of social reward processing on the development of LPF across adolescence may guide efforts to prevent the profound social dysfunction associated with personality pathology.

Capturing Between- and Within-Person Variability of Borderline Traits in Youth from a Developmentally Sensitive Situational Judgment Perspective

The significance of early maladaptive traits for understanding the roots of borderline personality disorder (BPD) is increasingly endorsed. Given the interpersonal nature of BPD and fluctuations in phenotypic symptomatology, this study aims to test the assumption that a situation-contingent contextualized assessment of borderline traits is a viable avenue to more fully capture the way underlying traits are reflected in socioaffective behavior that occurs in age-relevant situations. We aimed to explore the extent to which the variability on these responses represents a meaningful construct for understanding the clinical richness of BPD. Toward this end, a contextualized measure of DSM-5 BPD traits was developed along a situational judgment test (SJT) format, allowing us to explore both between-person and within-person variability in a more economic format than repeated measurement does. Examination of the psychometric properties of the SJT revealed distinctive correlational patterns of the situation-based traits with symptom scales of a youth BPD measure, but also indicated that for certain traits consistency in trait level across different situations is more maladaptive, whereas for other traits a greater degree of variability in trait expression is more maladaptive. Overall, this work could set the stage for further research on the potential of SJTs for understanding personality vulnerabilities both at the dispositional and the dynamic level.

Key insights from studies on the stability of personality disorders in different age groups

While for decades, temporal stability has been conceived as a defining feature of personality disorders (PDs), cumulative findings appear to question the stability of PDs and PD symptoms over time. However, stability itself is a complex notion and findings are highly heterogenous. Building upon a literature search from a systematic review and meta-analysis, this narrative review aims to capture key findings in order to provide critical implications, both for clinical practice and future research. Taken together, this narrative review revealed that unlike previous assumptions, stability estimates in adolescence are comparable to stability estimates in adulthood and PDs and PD symptoms are not that stable. The extent of stability itself depends yet on various conceptual, methodological, environmental, and genetic factors. While findings were thus highly heterogenous, they all seem to converge in a notable trend towards symptomatic remission, except for high-risk-samples. This challenges the current understanding of PDs in terms of disorders and symptoms and argues instead in favor of the AMPD and ICD-11 reintroducing the idea of self and interpersonal functioning as the core feature of PDs.

Maladaptive Self- and Interpersonal Functioning Increments General Psychiatric Severity in the Association with Adolescent Personality Pathology

Dimensionalized diagnostic systems, especially the entry criterion of maladaptive self and interpersonal functioning, hold particular advantages for the downward extension of personality pathology to young persons, but require conceptual clarification. The current study evaluated the distinctiveness of maladaptive self and interpersonal functioning by examining its incremental value over and above general psychiatric severity in the association with personality pathology. A community sample of N = 419 youth (50.4% female; M_age = 11.91, SD = 1.19) between the ages of 10 and 14 completed measures of maladaptive self- and interpersonal functioning, general psychiatric severity (internalizing-externalizing spectrum), and personality pathology. Results showed that, as expected, maladaptive self- and interpersonal functioning incremented general psychiatric severity in the association with personality pathology in adolescents. Results contribute to the literature base illustrating the value of the entry criterion of the ICD-11 and AMPD diagnostic system.

Prevalence and 10-Year Stability of Personality Disorders From Adolescence to Young Adulthood in a High-Risk Sample

Background

With the implementation of the 11th edition of the International Classification of Diseases (ICD-11) in early 2022, there will be a radical change in the framework and process for diagnosing personality disorders (PDs), indicating a transition from the categorical to the dimensional model. Despite increasing evidence that PDs are not as stable as previously assumed, the long-term stability of PDs remains under major debate. The aim of the current paper was to investigate the categorical and dimensional mean-level and rank-order stability of PDs from adolescence into young adulthood in a high-risk sample.

Methods

In total, 115 young adults with a history of residential child welfare and juvenile-justice placements in Switzerland were included in the current study. PDs were assessed at baseline and at a 10-year follow-up. On a categorical level, mean-level stability was assessed through the proportion of enduring cases from baseline to follow-up. Rank-order stability was assessed through Cohen's κ and tetrachoric correlation coefficients. On a dimensional level, the magnitude of change between the PD trait scores at baseline and at follow-up was measured by Cohen's d. Rank-order stability was assessed through Spearman's ρ.

Results

The prevalence rate for any PD was 20.0% at baseline and 30.4% at follow-up. The most frequently diagnosed disorders were antisocial, borderline, and obsessive-compulsive PDs, both at baseline and at follow-up. On a categorical level, the mean-level stability of any PD was only moderate, and the mean-level stability of specific PDs was low, except of schizoid PD. Likewise, the rank-order stability of any PD category was moderate, while ranging from low to high for individual PD diagnoses. On a dimensional level, scores increased significantly for most PDs, except for histrionic traits, which decreased significantly from baseline to follow-up. Effect sizes were generally low. The rank-order stability for dimensional scores ranged from low to moderate.

Conclusion

The findings indicate low to moderate stability of Pds and Pd traits from adolescence to adulthood, which supports the growing evidence that categorical diagnoses of Pds are quite unstable. This in turn, emphasizes the use of the upcoming ICD-11 that Acknowledgments Pds to be only "relatively" stable.

The Hierarchical Structure and Predictive Validity of the Personality Inventory for DSM-5 in Chinese Nonclinical Adolescents

To evaluate the factor structure, reliability, and validity of the Personality Inventory for DSM-5 (PID-5) in Chinese nonclinical adolescents, a total of 1,442 Chinese middle school youths (M_age = 14.85, girls = 52.4%) were recruited in the present study. All the participants completed the full-length 220-item PID-5. Some participants (n = 1,003) were administered adolescents' social adjustment as a criterion measure at the same time and 236 participants took part in longitudinal assessment of the PID-5 and adolescents' social adjustment 6 months later. First, exploratory structural equation modeling analyses supported a six-factor structure of the PID-5 in our present sample. Second, Negative Affectivity, Detachment, Antagonistic, and Disinhibition domains had positive correlations with negative social adjustment, and negative correlations with positive social adjustment concurrently and longitudinally, with the exception of Constraint and Psychoticism. Third, Cronbach's alpha for the PID-5 traits ranged from .57 to .91 in the full sample. The 6-month test-retest reliability by indexes of interclass correlation coefficient showed poor to good stability. As a whole, our findings provided preliminary evidence of the PID-5 as a reliable and valid measure of adolescents' maladaptive personality traits in mainland China.

At the Junction of Clinical and Developmental Science: Associations of Borderline Identity Disturbance Symptoms With Identity Formation Processes in Adolescence

Developmental scientists describe the role confusion that can occur for adolescents as they are forming a personal identity. Clinical psychologists describe low self-worth, lack of self-clarity, feelings of emptiness, and dissociation as the key elements of identity disturbance, and they link these to borderline personality disorder. In this study, the authors aimed to work at the juncture of these approaches by considering interrelations between four elements of identity disturbance, typical identity formation processes reflective of identity commitment and confusion, and borderline features. Australian youth (N = 505, 63% female and aged 12-20 years) recruited from clinical and community settings reported on identity commitment, exploration and reconsideration, four elements of identity disturbance, and borderline features. Identity confusion (especially reconsideration) and disturbance were associated with elevated borderline symptoms. Emptiness stood out as the strongest correlate of borderline symptoms. Youth reporting greater emptiness were nearly twice as likely to report a high borderline symptom profile.

Therapeutic Relationship and Dropout in High-Risk Adolescents' Intensive Group Psychotherapeutic Programme

Objective

Dropout rates are a prominent problem in youth psychotherapy. An important determinant of dropouts is the quality of the therapeutic relationship. This study aimed to evaluate the association between the therapeutic relationship and dropouts in an intensive mentalization-based treatment (MBT) for adolescents with personality disorders.

Methods

Patients (N = 105) included were either dropouts (N = 36) or completers (N = 69) of an intensive MBT. The therapeutic relationship was measured with the child version of the Session Rating Scale (C-SRS), which was completed by the patient after each group therapy session. For each patient, the treatment termination status (dropout or completer) was indicated by the treatment staff. The reliable change index (RCI) was calculated for the C-SRS to determine significant changes in the therapeutic relationship.

Results

While both groups started with similar scores on the C-SRS, the scores between dropouts and completers differed significantly at the end of the treatment period. On average, during therapy, an increase was seen in the scores of completers, and a decrease was seen in the scores of dropouts. While dropouts could not be predicted based on the C-SRS scores, a significant decrease (RCI) in C-SRS scores during the last two sessions occurred more often for dropouts than for completers.

Conclusion

Our findings show that to prevent dropouts, the patient’s judgment of the quality of the therapeutic relationship should be monitored continuously, and decreases discussed with the patient and the group.

The relationship between prototype ratings of personality and self and interpersonal functioning with an adolescent inpatient sample

Personality pathology is conceptualized, in part, as impairments in self and interpersonal functioning. Although most of the research has focused on adult samples, fewer have looked at this relationship in adolescent samples. This paper investigates the relationship between clinician-rated personality prototypes, the Shedler-Westen Assessment Procedure-Prototype Matching Adolescent Version (SWAP-A-P) derived from the SWAP-II-A, and a measure of self and interpersonal functioning, the Social Cognition and Object Relation Scale-Global Rating (SCORS-G). Clinicians rated 66 adolescents hospitalized at a safety net teaching hospital in the northeast. The patient's individual and group therapist rated the patients at discharge using the SWAP-A-P and the SCORS-G at discharge blind to each other's ratings. Results showed that more severe personality pathology was linked with more impairments in self and interpersonal functioning.

Borderline Symptoms at Age 12 Signal Risk for Poor Outcomes During the Transition to Adulthood: Findings From a Genetically Sensitive Longitudinal Cohort Study

OBJECTIVE

Borderline personality disorder in adolescence remains a controversial construct. We addressed concerns about the prognostic significance of adolescent borderline pathology by testing whether borderline symptoms at age 12 years predict functioning during the transition to adulthood, at age 18 years, in areas critical to life-course development.

METHOD

We studied members of the Environmental Risk (E-Risk) Longitudinal Twin Study, which tracks the development of a birth cohort of 2,232 British twin children. At age 12, study members' borderline symptoms were measured using mothers' reports. At age 18, study members' personality, psychopathology, functional outcomes, and experiences of victimization were measured using self-reports, coinformant reports, and official records.

RESULTS

At age 18, study members who had more borderline symptoms at age 12 were more likely to have difficult personalities, to struggle with poor mental health, to experience poor functional outcomes, and to have become victims of violence. Reports of poor outcomes were corroborated by coinformants and official records. Borderline symptoms in study members at 12 years old predicted poor outcomes over and above other behavioral and emotional problems during adolescence. Twin analyses showed that borderline symptoms in 12-year-olds were influenced by familial risk, particularly genetic risk, which accounted for associations with most poor outcomes at age 18.

CONCLUSION

Borderline symptoms in 12-year-olds signal risk for pervasive poor functioning during the transition to adulthood. This association is driven by genetic influences, suggesting that borderline symptoms and poor outcomes are manifestations of shared genetic risk.

A Psychometric Evaluation of a Reduced Version of the PID-5 in Clinical and Non-Clinical Adolescents

Abstract. A dimensional perspective on personality pathology in which trait assessment plays an important role has been proposed in the DSM-5, as represented in the PID-5 measure. In an attempt to increase the feasibility of the personality disorder (PD) assessment process, Maples and colleagues constructed a reduced, 100-item version of the PID-5. This study aimed to replicate and extend previous findings on the psychometric properties of this 100-item PID-5 relying on a non-clinical ( N = 100) and a clinical ( N = 101) sample of mid-adolescents, as well as a non-clinical ( N = 218) and a clinical ( N = 212) sample of late-adolescents. Results indicate that the psychometric properties of the 100-item PID-5 are adequate and similar to the original PID-5 in all samples. Our study provides evidence for extended applicability of the 100-item PID-5 for both clinical and non-clinical adolescents.

The Network Structure of Personality Pathology in Adolescence With the 100-Item Personality Inventory for DSM-5 Short-Form (PID-5-SF)

There is currently a lack of understanding of the structure of personality disorder (PD) trait facets. The network approach may be useful in providing additional insights, uncovering the unique association of each PD trait facet with every other facet. A unique feature of network analysis is centrality, which indicates the importance of the role a trait facet plays in the context of other trait facets. Using data from 1,940 community Dutch adolescents, we applied network analysis to the 25 trait facets from the 100-item Personality Inventory for DSM-5 Short-Form (PID-5-SF) to explore their associations. We found that some trait facets only seem to be core indicators of their pre-ordained domains, whereas we observed that other trait facets were strongly associated with trait facets outside of their hypothesized domains. Importantly, anxiousness and callousness were identified as highly central facets, being uniquely associated with many other trait facets. Future longitudinal network studies could therefore further examine the possibility of anxiousness and callousness as risk marker trait facets among other PD trait facets.

Assessing Personality Disorders in Adolescence: A Validation Study of the IPOP-A

Background:

The need to develop clinical and empirically-based tools for assessing personality development in adolescence led to the proposal of the IPOP-A (Ammaniti, Fontana, Kernberg, Clarkin, & Clarkin, 2011), a semi-structured interview for adolescents that aims to differentiate personality organization processes from characteristics that may reflect a personality disorder.

Objective and Methods:

This research aimed to evaluate the adaptation of the IPOP-A to the Portuguese population, attending to its diagnostic properties and its discriminant validity by comparing a clinical group with a nonclinical one. A total sample of 44 adolescents from 13 to 18 years old has taken part in this study, 22 of whom had a previous personality disorder diagnosis. The content of the interviews was transcribed and codified according to the coding manual.

Results:

Acceptable internal consistency values across the dimensions of the IPOP-A are found and statistically significant differences are revealed between the clinical group and nonclinical group, with the clinical group revealing values that suggest higher impairment in the dimensions of the personality functioning in comparison with the nonclinical one.

Conclusion:

Our study supports that the Portuguese version of the IPOP-A can be considered a valid instrument to identify adolescents with a personality disorder.

A whole of school intervention for personality disorder and self-harm in youth: a pilot study of changes in teachers' attitudes, knowledge and skills

BACKGROUND

The school environment offers an ideal opportunity for early identification and intervention for youth with self-harm and complex mental health issues, such as borderline personality disorder (BPD). Yet, class teachers often report minimal knowledge, feeling ill-equipped to respond, and experience high levels of stress when exposed to such challenges. Research is required to understand how training and development activities led by school counsellors may enhance teacher attitudes, confidence and knowledge of self-harm and complex mental health issues, such as BPD. We aimed to explore the extent that a whole of school initiative might enhance capacity for early identification and intervention.

METHOD

18 secondary schools implemented a manualised program, Project Air Strategy for Schools. N = 400 class teachers (71.3% female, mean age 42 years) across city and rural locations were evaluated before and after program implementation on attitudes, knowledge and skills.

RESULTS

Providing class teachers with additional training on complex mental health issues and associated behaviours such as self-harm was well received. Participants reported post-program improvements in their optimism (d = .35), confidence (d = .63), knowledge (d = .73) and skills (d = 0.67) in working with young people with complex mental health issues, such as BPD.

CONCLUSIONS

Providing school counsellor led structured approaches, to help class teachers identify and respond to youth in distress, closed identified gaps. Results indicated improvements in class teachers' knowledge and attitudes towards self-harm and BPD. The intervention also improved the capacity of schools to plan and implement strategies to reduce the impact of mental health problems on the young person and their peers. A stay-at-school psychological care approach was fostered by enhancing partnerships between class teachers and school counsellors.

Understanding adolescent personality pathology from growth trajectories of childhood oddity

Research on developmental trajectories of early maladaptive features for understanding later personality disorders (PDs) is increasingly recognized as an important study area. The course of early odd features is highly relevant in this regard, as only a few researchers have addressed childhood oddity in the context of emerging PDs. Using latent growth modeling, the current study explores growth parameters of odd features in a mixed sample of Flemish community and referred children (N = 485) across three measurement waves with 1-year time intervals. Personality pathology was assessed at a fourth assessment point in adolescence. Beyond a general declining trend in oddity characteristics, the results demonstrated that both an early onset and an increasing trend of oddity-related characteristics over time are independent predictors of adolescent PDs. Childhood oddity tends to be the most manifest precursor for PDs with a core oddity feature (i.e., the schizotypal and borderline PD), but also appears to predict most of the other DSM-5 PDs. Results are discussed from an overarching developmental framework on PDs (Cicchetti, 2014), specifically focusing on the principle of multifinality. From a clinical perspective, the significance of increasing or steady-high childhood oddity trajectories for adolescent PDs highlights the relevance of systematic screening processes across time.

Optimizing Prediction of Psychosocial and Clinical Outcomes With a Transdiagnostic Model of Personality Disorder

Transdiagnostic models hold promise for transforming research and treatment practices for personality disorders (PDs), but widespread acceptance and implementation of such approaches will require persuasive evidence of construct validity and clinical utility. Toward that end, the authors examined the criterion-related validity of a transdiagnostic PD model in relation to psychosocial and clinical outcomes in a high-risk community sample of 700 young adults. Participants and their mothers completed semistructured interviews to assess young adults' PD symptomatology, psychosocial functioning, suicidality, and mental health treatment use. Bifactor modeling revealed an overarching dimension of PD severity-capturing symptoms across all PD categories-that strongly predicted all functional and clinical outcomes in multivariate analyses. Effect sizes for lower-order, specific PD processes were comparatively modest for functional outcomes; however, they provided clinically significant information about suicide risk and treatment use. The authors discuss implications of a transdiagnostic perspective for research on PD etiology, classification, and treatment.

ESCAP Expert Article: borderline personality disorder in adolescence: an expert research review with implications for clinical practice

Borderline personality disorder (BPD) has onset in adolescence, but is typically first diagnosed in young adulthood. This paper provides a narrative review of the current evidence on diagnosis, comorbidity, phenomenology and treatment of BPD in adolescence. Instruments available for diagnosis are reviewed and their strengths and limitations discussed. Having confirmed the robustness of the diagnosis and the potential for its reliable clinical assessment, we then explore current understandings of the mechanisms of the disorder and focus on neurobiological underpinnings and research on psychological mechanisms. Findings are accumulating to suggest that adolescent BPD has an underpinning biology that is similar in some ways to adult BPD but differs in some critical features. Evidence for interventions focuses on psychological therapies. Several encouraging research studies suggest that early effective treatment is possible. Treatment development has just begun, and while adolescent-specific interventions are still in the process of evolution, most existing therapies represent adaptations of adult models to this developmental phase. There is also a significant opportunity for prevention, albeit there are few data to date to support such initiatives. This review emphasizes that there can be no justification for failing to make an early diagnosis of this enduring and pervasive problem.

Personality disorder classification: stuck in neutral, how to move forward?

An "Alternative DSM-5 Model for Personality Disorders" was published in Sect. III of DSM-5, while the identical categories and criteria from DSM-IV for the personality disorders (PDs) are in Sect. II. Given strong shifts from categorical diagnoses toward dimensional representations in psychiatry, how did the PDs end up "stuck in neutral," with the flawed DSM-IV model perpetuated? This article reviews factors that influenced the development of the new model and data to encourage and facilitate its use by clinicians. These include recognizing 1) a dimensional structure for psychopathology for which personality may be foundational; 2) a consensus on the structure of normal and abnormal personality; 3) the clinical significance of personality; 4) PD-specific severity required to establish disorder; 5) disruption, discontinuity, and perceived clinical utility of the Alternative Model may not be problems; and 6) a way forward involving collaborative research on neurobiological and psychosocial processes, treatment planning, and outcomes.

Clinical validity of a dimensional assessment of self- and interpersonal functioning in adolescent inpatients

The Social Cognition and Object Relations Scale-Global Version (SCORS-G) is a clinical rating system assessing 8 domains of self- and interpersonal relational experience that can be applied to narrative response data (e.g., Thematic Apperception Test [TAT; Murray, 1943], early memories narratives) or oral data (e.g., psychotherapy narratives, relationship anecdotal paradigms). In this study, 72 psychiatrically hospitalized adolescents consented and were rated by their individual and group therapist using the SCORS-G. Clinicians also rated therapy engagement, personality functioning, quality of peer relationships, school functioning, global assessment of functioning (GAF), history of eating-disordered behavior, and history of nonsuicidal self-injury. SCORS-G composite ratings achieved an acceptable level of interrater reliability and were associated with theoretically predicted variables (e.g., engagement in therapy, history of nonsuicidal self-injury). SCORS-G ratings also incrementally improved the prediction of therapy engagement and global functioning beyond what was accounted for by GAF scores. This study further demonstrates the clinical utility of the SCORS-G with adolescents.