Does childhood trauma cause personality disorders in adults?

Towards the understanding of the core of general personality disorder factor: g-PD and its relation to hostile attributions

There is a general consensus that personality disorders (PDs) share a general factor (g-PD) overlapping with the general factor of psychopathology (p-factor). The general psychopathology factor is related to many social dysfunctions, but its nature still remains to some extent ambiguous. We posit that hostile attributions may be explanatory for the factor common for all PDs, i.e., interpersonal problems and difficulty in building long-lasting and satisfying relationships of all kinds. Thus, the main objective of the current project was to expand the existing knowledge about underlying factors of g-PD with regard to hostile attributions. We performed a cross-sectional study on a representative, community sample of Poles (N = 1031). Our hypotheses were primarily confirmed as hostile attributions predicted p-factor. However, the relation was positive only for hostile attributions related to ambiguous situations involving relational harm and physical harm done by female authorities and negative in case of hostile attributions in situations involving physical harm done by peers. Additionally, paranoia-like thoughts strongly related to hostile attributions and independently predicted g-PD. The results contribute to the current discussion on the nature of the g-PD, confirm that hostile attributions and paranoia are a crucial aspect of personality pathology, and indicate the importance of working on these cognitions in the course of therapeutic work.

On the interplay of borderline personality features, childhood trauma severity, attachment types, and social support

BACKGROUND

Adverse childhood experiences (ACE) have consistently been associated with borderline personality disorder (BPD). Still, it is not yet entirely understood if and how different types of ACE (emotional, physical, sexual abuse, neglect) relate to different BPD subdomains (affective instability, identity disturbance, negative relationships, self-harm). Insecure attachment and lower perceived social support are associated with both ACE and BPD and may therefore contribute to their relationship. No study so far integrated all these variables in one model, while accounting for their mutual influence on each other. We investigated the interplay of BPD subdomains, ACE, attachment, and perceived social support using a graph-theoretical approach.

METHODS

An international sample of 1692 participants completed the Childhood Trauma Questionnaire (CTQ), the Borderline Feature Scale from the Personality Assessment Inventory (PAI-BOR), the Adult Attachment Scale (AAS), and Multidimensional Scale of Perceived Social Support (MSPSS) via an online survey. We estimated a partial correlation network including subscales of the CTQ and the PAI-BOR as nodes. We extended the network by including subscales of the AAS and MSPSS as additional nodes.

RESULTS

Emotional abuse was the most central node in both networks and a bridge between other types of ACE and BPD features. All domains of BPD except affective instability were associated with emotional abuse. Identity disturbances was the most central node in the BPD network. The association between ACE and BPD features was partly but not fully explained by attachment and social support.

CONCLUSION

Our findings suggest that emotional abuse is an important link in the association between ACE and BPD features, also when taking attachment and social support into account. Findings further suggest an outstanding role of identity disturbance, linking emotional abuse to affective instability and being strongly associated with attachment anxiety.

Early Intervention for Personality Disorder

Both the DSM-5 Section III Alternative Model for Personality Disorders and the ICD-11 have introduced a genuinely developmental approach to personality disorder. Among young people with personality disorder, compelling evidence demonstrates a high burden of disease, substantial morbidity, and premature mortality, as well as response to treatment. Yet, early diagnosis and treatment for the disorder have struggled to emerge from its identity as a controversial diagnosis to a mainstream focus for mental health services. Key reasons for this include stigma and discrimination, lack of knowledge about and failure to identify personality disorder among young people, along with the belief that personality disorder must always be addressed through lengthy and specialized individual psychotherapy programs. In fact, evidence suggests that early intervention for personality disorder should be a focus for all mental health clinicians who see young people and is feasible by using widely available clinical skills.

Personality functioning as a mediator of adult mental health following child maltreatment

BACKGROUND

The broad range of adverse health outcomes following child maltreatment (child maltreatment) underscores the need to investigate shared trajectories that contribute to associated physical and mental health problems. Previous research focused on different mechanisms, such as emotion regulation or attachment. In the present study, we propose personality functioning, comprising self- and interpersonal regulation and perception, to mediate between child maltreatment and mental and physical health.

METHODS

In a German representative sample (N = 2,508), we assessed remembered child maltreatment, levels of personality functioning, and different health outcomes in adulthood, namely somatic symptoms, general mental distress, and body dysmorphic concern. We conducted path analyses to investigate mediation effects in the total sample as well as in female and male subsamples.

RESULTS

Child maltreatment significantly predicted the assessed health outcomes and showed significant associations with lower levels of personality functioning. Personality functioning partially mediated all health outcomes assessed by significant indirect effects and lowered direct effects of child maltreatment on health outcomes. An exploratory analysis of different facets of personality functioning revealed a pronounced impact of identity perception and self-reflective capacities in mediating between child maltreatment and physical and mental health. Comparable results were found in female and male participants.

LIMITATIONS

Major limitations of the study are the reliance on cross-sectional data and the use of a screening measure to assess experienced child maltreatment.

CONCLUSION

Personality functioning may represent a transdiagnostic link to different somatic and psychological symptoms in the aftermath of child maltreatment.

Nature and nurture? A review of the literature on childhood maltreatment and genetic factors in the pathogenesis of borderline personality disorder

BACKGROUND

Borderline Personality Disorder (BPD) is a psychiatric disorder associated with significant morbidity and mortality. However, the neurobiological alterations underlying the condition remain poorly understood. As a result, existing treatments remain inadequate. One of the main risk factors for the development of BPD is a history of childhood maltreatment. However, it is considered neither causative nor specific to the condition. Current theory is therefore increasingly moving toward a 'Gene x Environment' (GxE) model of the condition. The purpose of the current work was to conduct a systematic literature review, which comprehensively identifies all published molecular level GxE studies that have explored the role of specific genetic loci, in influencing the risk of BPD following exposure to childhood abuse or neglect.

METHODS

Four electronic databases were used to systematically search for molecular level GxE studies of any design, which focused on the development of BPD following exposure to childhood abuse or neglect, without language or date restrictions. Articles were screened independently by two reviewers and results were synthesized narratively.

RESULTS

A total of 473 articles were screened of which sixteen were selected for inclusion in our review. Implicated genes were categorised according to their influence on; Neurotransmitter Systems, Neurodevelopment and Neuroendocrine Systems.

CONCLUSIONS

The identified studies have produced several relevant and statistically significant results. Of particular note, is the repeated finding that genes involved in HPA axis regulation, may be altered by exposure to childhood maltreatment, influencing subsequent susceptibility to BPD. This is both biologically plausible and of potential clinical significance.

Latent classes of posttraumatic psychiatric comorbidity in the general population

Some narrow patterns of posttraumatic psychiatric comorbidity are well-established (e.g., posttraumatic stress disorder and substance use). However, broad multi-diagnosis profiles of posttraumatic comorbidity are poorly characterized. The goal of the current study was to use latent class analysis (LCA) to identify profiles of posttraumatic psychopathology from 11 International Classification of Diseases (ICD-10) diagnostic categories (e.g., stress, substance, depressive, psychosis, personality). Danish national registries were used to identify 166,539 individuals (median age = 41 years, range = <1 to >100) who experienced a traumatic event between 1994 and 2016 and were diagnosed with one or more mental disorders within 5 years. Two through 14-class LCA solutions were evaluated. A 13-class solution (a) provided the best fit, with the Bayes and Akaike Information Criteria reaching a minimum, (b) was broadly consistent with prior LCA studies, and (c) included several novel classes reflecting differential patterns of posttraumatic psychopathology. Three classes were characterized by high comorbidity: broad high comorbidity (M # diagnoses = 4.3), depression with stress/substance use/personality/neurotic disorders (M# diagnoses = 3.8), and substance use with personality/stress/psychotic disorders (M # diagnoses = 3.1). The other 10 classes were characterized by distinct patterns of mild comorbidity or negligible comorbidity. Compared to the mild and negligible comorbidity classes, individuals in high comorbidity classes were younger, had lower income, and had more pre-event psychiatric disorders. Results suggest that several different comorbidity patterns should be assessed when studying and treating posttraumatic psychopathology.

Familial risk and heritability of diagnosed borderline personality disorder: a register study of the Swedish population

Family and twin studies of Borderline Personality Disorder (BPD) have found familial aggregation and genetic propensity for BPD, but estimates vary widely. Large-scale family studies of clinically diagnosed BPD are lacking. Therefore, we performed a total-population study estimating the familial aggregation and heritability of clinically diagnosed BPD. We followed 1,851,755 individuals born 1973-1993 in linked Swedish national registries. BPD-diagnosis was ascertained between 1997 and 2013, 11,665 received a BPD-diagnosis. We identified relatives and estimated sex and birth year adjusted hazard ratios, i.e., the rate of BPD-diagnoses in relatives to individuals with BPD-diagnosis compared to individuals with unaffected relatives, and used structural equation modeling to estimate heritability. The familial association decreased along with genetic relatedness. The hazard ratio was 11.5 (95% confidence interval (CI) = 1.6-83.8) for monozygotic twins; 7.4 (95% CI = 1.0-55.3) for dizygotic twins; 4.7 (95% CI = 3.9-5.6) for full siblings; 2.1 (95% CI = 1.5-3.0) for maternal half-siblings; 1.3 (95% CI = 0.9-2.1) for paternal half-siblings; 1.7 (95% CI = 1.4-2.0) for cousins whose parents were full siblings; 1.1 (95% CI = 0.7-1.8) for cousins whose parents were maternal half-siblings; and 1.9 (95% CI = 1.2-2.9) for cousins whose parents were paternal half-siblings. Heritability was estimated at 46% (95% CI = 39-53), and the remaining variance was explained by individually unique environmental factors. Our findings pave the way for further research into specific genetic variants, unique environmental factors implicated, and their interplay in risk for BPD.

Kindheitstraumatisierungen bei Patienten mit Borderline-Persönlichkeitsstörung

Während Kindheitstraumatisierungen zentrale psychosoziale Risikofaktoren für die Entwicklung einer Borderline-Persönlichkeitsstörung (BPS) darstellen, ist ihre Relevanz für die Symptomschwere der Erkrankung und das Therapieergebnis bisher unzureichend und mit inkonsistenten Ergebnissen untersucht worden. In dieser naturalistischen Studie an 482 stationären Psychotherapiepatienten mit einer BPS wurde daher der differenzielle Einfluss verschiedener Kindheitstraumatisierungen (gemessen mit dem Childhood Trauma Questionnaire, CTQ) auf die selbstberichtete Psychopathologie hinsichtlich Depressivität (Beck-Depressions-Inventar II [BDI-II], Gesundheitsfragebogen für Patienten [PHQ]), Ängstlichkeit und Somatisierung (PHQ), BPS-spezifischer Symptomatik (Borderline-Symptom-Liste, BSL) sowie gesundheitsbezogener Lebensqualität (Kurzform des Fragebogens zum Gesundheitszustand, SF-12) zu Behandlungsbeginn und bei Abschluss einer Dialektisch-Behavioralen Therapie analysiert. Weil sich Frauen und Männer in Symptomschwere und Häufigkeit verschiedener Kindheitstraumatisierungen unterscheiden, erfolgten geschlechtsdifferenzielle Analysen. Bei Patientinnen trugen Kindheitstraumatisierungen bis maximal knapp 7 % zur Varianzaufklärung der Symptombelastung bei Aufnahme bei; lediglich emotionaler Missbrauch hatte einen signifikanten und unabhängigen Einfluss. Bei Männern fanden sich keine relevanten Zusammenhänge zwischen dem CTQ und den Ergebnismaßen. Weder bei Männern noch bei Frauen wirkten sich Kindheitstraumatisierungen auf das symptombezogene Behandlungsergebnis aus. Die Ergebnisse werden im Kontext der bisherigen Befundlage zum Zusammenhang zwischen Kindheitstraumatisierungen, Symptomschwere und Therapieergebnis bei psychischen Störungen im Allgemeinen und der BPS im Besonderen diskutiert.

Features of borderline personality disorder as a mediator of the relation between childhood traumatic experiences and psychosis-like experiences in patients with mood disorder

Background

Psychosis-like experiences (PEs) are common in patients with non-psychotic disorders. Several factors predict reporting of PEs in mood disorders, including mood-associated cognitive biases, anxiety and features of borderline personality disorder (BPD). Childhood traumatic experiences (CEs), often reported by patients with BPD, are an important risk factor for mental disorders. We hypothesized that features of BPD may mediate the relationship between CEs and PEs. In this study, we investigated the relationships between self-reported PEs, CEs and features of BPD in patients with mood disorders.

Methods

As part of the Helsinki University Psychiatric Consortium study, McLean Screening Instrument (MSI), Community Assessment of Psychic Experiences (CAPE-42) and Trauma and Distress Scale (TADS) were filled in by patients with mood disorders (n = 282) in psychiatric care. Correlation coefficients between total scores of scales and their dimensions were estimated, multiple regression and mediation analyses were conducted.

Results

Total scores of MSI correlated strongly with scores of the CAPE-42 dimension “frequency of positive symptoms” (rho = 0.56; p ≤ 0.001) and moderately with scores of TADS (rho = 0.4; p ≤ 0.001). Total score of MSI and its dimension “cognitive symptoms”, including identity disturbance, distrustfulness and dissociative symptoms, fully mediated the relation between TADS and CAPE-42. Each cognitive symptom showed a partial mediating role (dissociative symptoms 43% (CI = 25–74%); identity disturbance 40% (CI = 30-73%); distrustfulness 18% (CI = 12-50%)).

Conclusions

Self-reported cognitive-perceptual symptoms of BPD fully mediate, while affective, behavioural and interpersonal symptoms only partially mediate the relationships between CEs and PEs. Recognition of co-morbid features of BPD in patients with mood disorders reporting PEs is essential.

Relationships between self-reported childhood traumatic experiences, attachment style, neuroticism and features of borderline personality disorders in patients with mood disorders

BACKGROUND

Co-occurring borderline personality disorder (BPD) features have a marked impact on treatment of patients with mood disorders. Overall, high neuroticism, childhood traumatic experiences (TEs) and insecure attachment are plausible aetiological factors for BPD. However, their relationship with BPD features specifically among patients with mood disorders remains unclear. We investigated these relationships among unipolar and bipolar mood disorder patients.

METHODS

As part of the Helsinki University Psychiatric Consortium study, the McLean Screening Instrument (MSI), the Experiences in Close Relationships-Revised (ECR-R), the Short Five (S5) and the Trauma and Distress Scale (TADS) were filled in by patients with mood disorders (n=282) in psychiatric care. Correlation coefficients between total scores of scales and their dimensions were estimated, and multivariate regression (MRA) and mediation analyses were conducted.

RESULTS

Spearman's correlations were strong (rho=0.58; p<0.001) between total scores of MSI and S5 Neuroticism and moderate (rho=0.42; p<0.001) between MSI and TADS as well as between MSI and ECR-R Attachment Anxiety. In MRA, young age, S5 Neuroticism and TADS predicted scores of MSI (p<0.001). ECR-R Attachment Anxiety mediated 33% (CI=17-53%) of the relationships between TADS and MSI.

LIMITATIONS

Cross-sectional questionnaire study.

CONCLUSIONS

We found moderately strong correlations between self-reported BPD features and concurrent high neuroticism, reported childhood traumatic experiences and Attachment Anxiety also among patients with mood disorders. Independent predictors for BPD features include young age, frequency of childhood traumatic experiences and high neuroticism. Insecure attachment may partially mediate the relationship between childhood traumatic experiences and borderline features among mood disorder patients.

Exploring the effectiveness of combined mentalization-based group therapy and dialectical behaviour therapy for inpatients with borderline personality disorder - A pilot study

OBJECTIVES

Borderline personality disorder (BPD) is characterized by emotional instability, interpersonal dysfunction, and other features that typically develop before a background of insecure attachment and traumatic experiences. Dialectical behaviour therapy (DBT) has proven highly effective in reducing self-harm and improving emotion regulation, whereby problems concerning social cognition, which are also characteristic of BPD, may need additional approaches such as mentalization-based treatment (MBT).

METHODS

Here, we examined, in a pilot study, the effectiveness of MBT given adjunct to DBT, compared to DBT alone, in an inpatient sample with BPD, whereby mentalization was measured using a novel cartoon-based task.

RESULTS

Both treatments were highly effective in reducing symptom severity. The combination of DBT and MBT was superior in reducing fearful attachment and in improving affective mentalizing.

CONCLUSIONS

Mentalization-based treatment in combination with DBT may improve certain aspects of social cognitive skills and attachment security, as compared to DBT alone, although the exact mechanisms that led to these changes need to be studied further.

PRACTITIONER POINTS

Clinical implications Dialectical behaviour therapy (DBT) can usefully be combined with mentalization-based treatment (MBT). The combination of DBT and MBT reduces self-harm more than DBT alone. DBT plus MBT may lead to a reduction in fearful attachment and improvement of affective mentalizing. Short-term combinations of evidence-based borderline treatments may enrich psychiatric inpatient care. Therefore, such approaches deserve further research. Limitations The treatment condition was therapeutically more intense than the control condition. The study lacked a follow-up assessment. The impact of comorbid conditions on treatment response was not taken into account. Adherence to the manualized approach was not measured.

An Attachment Theory Approach to the Short-Term Treatment of a Woman With Borderline Personality Disorder and Comorbid Diagnoses

The current case study highlights the treatment of “Thelma,” a 48-year-old woman of African American and Hispanic descent who was diagnosed with borderline personality disorder (BPD), major depressive disorder, post-traumatic stress disorder, and bulimia. An attachment theory approach was used to elicit core structure change in Thelma's BPD symptoms after traditional modern cognitive approaches proved ineffective. It was hypothesized that treating her Axis II disorder would actually serve to reduce her Axis I symptoms. The attachment approach entailed a shift toward second-order change processes, a shift away from problem-solving approaches, a focus on the quality and intensity of the relationship, and a more relaxed approach to boundary setting in the context of treatment. The approach did appear to reduce many Axis I symptoms including self-mutilation, suicidal ideation, and binging and purging behaviors and appeared to improve her interpersonal functioning.

Effect of trauma onset on personality traits of politically persecuted victims

BACKGROUND

The hypothesis that traumatic experiences in early childhood impact personality formation and psychopathology is well known in psychology and psychiatry, but this is difficult to verify statistically in methodological terms. The aim of this study, conducted with politically persecuted Poles, was to establish the influence of the time when trauma is experienced on the development of psychopathological symptoms.

METHODS

The subjects were divided into two groups: those who had experienced trauma before age five (group 1) and those who experienced trauma at an older age (group 2). Subjects in both groups suffered from chronic untreated post-traumatic stress disorder. In order to test the research hypothesis, the Minnesota Multiphasic Personality Inventory-2 profiles of both groups were compared using Student's t-test, and the Mann-Whitney U-test.

RESULTS

Statistically significant between-group differences were found for the F validity scale and the following clinical scales: Hypochondriasis, Depression, Psychopathic deviate, Psychasthenia, Schizophrenia, and Social introversion. All the significantly different scores were higher in the group traumatized in early childhood. People exposed to trauma under age five had profiles similar to those traumatized after age five, but they experienced their symptoms more intensely.

CONCLUSIONS

Of clinical significance, higher scores on the psychasthenia, schizophrenia, and social introversion scales, especially on the psychopathic deviate scale, indicated pathology only in the early childhood trauma group. Taken together, these symptoms lead to withdrawal and hindrance of social functioning. This outcome confirms the hypothesis of the influence of various early childhood factors (such as trauma) on personality formation and personality traits in adulthood.

Cyclothymia reloaded: A reappraisal of the most misconceived affective disorder

Data emerging from both academic centers and from public and private outpatient facilities indicate that from 20% to 50% of all subjects that seek help for mood, anxiety, impulsive and addictive disorders turn out, after careful screening, to be affected by cyclothymia. The proportion of patients who can be classified as cyclothymic rises significantly if the diagnostic rules proposed by the DSM-5 are reconsidered and a broader approach is adopted. Unlike the DSM-5 definition based on the recurrence of low-grade hypomanic and depressive symptoms, cyclothymia is best identified as an exaggeration of cyclothymic temperament (basic mood and emotional instability) with early onset and extreme mood reactivity linked with interpersonal and separation sensitivity, frequent mixed features during depressive states, the dark side of hypomanic symptoms, multiple comorbidities, and a high risk of impulsive and suicidal behavior. Epidemiological and clinical research have shown the high prevalence of cyclothymia and the validity of the concept that it should be seen as a distinct form of bipolarity, not simply as a softer form. Misdiagnosis and consequent mistreatment are associated with a high risk of transforming cyclothymia into severe complex borderline-like bipolarity, especially with chronic and repetitive exposure to antidepressants and sedatives. The early detection and treatment of cyclothymia can guarantee a significant change in the long-term prognosis, when appropriate mood-stabilizing pharmacotherapy and specific psychological approaches and psychoeducation are adopted. The authors present and discuss clinical research in the field and their own expertise in the understanding and medical management of cyclothymia and its complex comorbidities.

Genetics of borderline personality disorder: systematic review and proposal of an integrative model

Borderline personality disorder (BPD) is one of the most common mental disorders and is characterized by a pervasive pattern of emotional lability, impulsivity, interpersonal difficulties, identity disturbances, and disturbed cognition. Here, we performed a systematic review of the literature concerning the genetics of BPD, including familial and twin studies, association studies, and gene-environment interaction studies. Moreover, meta-analyses were performed when at least two case-control studies testing the same polymorphism were available. For each gene variant, a pooled odds ratio (OR) was calculated using fixed or random effects models. Familial and twin studies largely support the potential role of a genetic vulnerability at the root of BPD, with an estimated heritability of approximately 40%. Moreover, there is evidence for both gene-environment interactions and correlations. However, association studies for BPD are sparse, making it difficult to draw clear conclusions. According to our meta-analysis, no significant associations were found for the serotonin transporter gene, the tryptophan hydroxylase 1 gene, or the serotonin 1B receptor gene. We hypothesize that such a discrepancy (negative association studies but high heritability of the disorder) could be understandable through a paradigm shift, in which "plasticity" genes (rather than "vulnerability" genes) would be involved. Such a framework postulates a balance between positive and negative events, which interact with plasticity genes in the genesis of BPD.

Parental care-giving and home environment predicting offspring's temperament and character traits after 18 years

Although many personality theories emphasize the role of parental behaviors in shaping personality development, empirical data from longitudinal studies remain scarce. It is also not known, if parental behaviors affect character development more strongly than temperament or vice versa. In a prospective study, 1083 volunteer participants of the Young Finns study completed the Temperament and Character Inventory (TCI). Parents of the participants had answered questions about parenting attitudes, socioeconomic status, health behaviors, and role satisfaction 18 years before. We studied the univariate and the cumulative effects of parental care-giving and family environment on offspring's personality traits. Parental care-giving and home-environment were more strongly associated with offspring character traits reflecting personality maturity (Self-directedness and Cooperativeness) than with offspring temperament traits (Novelty seeking, Harm avoidance, Reward dependence and Persistence) reflecting emotional and behavioral tendencies. The differences were most evident in the cumulative effects model. Maternal variables were stronger predictors than paternal variables. The present findings suggest that not all personality traits are similarly predicted by parental care-giving and home-environment. In particular, character development is more strongly related to such measures than temperament. Parental care-giving and home-environment are more strongly related to psychological maturity (character) than emotional and behavioral tendencies (temperament).

Borderline personality disorder features and history of childhood maltreatment in mothers involved with child protective services

This study examines the history of childhood maltreatment and Borderline Personality Disorder (BPD) symptoms in mothers whose children were removed from the home by Child Protective Services (CPS) to identify potential targets for future intervention efforts. Forty-one mothers of children removed from the home due to abuse and/or neglect and 58 community-control mothers without CPS involvement were assessed for history of childhood maltreatment, alcohol and drug use, and BPD features. CPS-involved mothers scored significantly higher on measures of childhood maltreatment history and BPD features than did control mothers. The highest BPD scores were associated with the most severe histories of mothers' childhood maltreatment. In total, 50% of CPS-involved mothers reported elevated BPD features, compared with 15% of control mothers. Further, 19% of CPS-involved mothers had self-reported scores consistent with a BPD diagnosis, compared with 4% of control mothers. BPD features rather than maltreatment history per se predicted maternal involvement with CPS, controlling for alcohol and drug use predictors. The present data suggest that evidence-based treatments to address BPD symptoms may be indicated for some CPS-involved parents.

From traumatic attachment to somatization disorder

OBJECTIVE

This paper emphasizes attachment trauma as an important etiological factor in somatization disorder and psychoanalytic psychotherapy as an effective treatment.

METHOD

Weekly psychotherapy with an 18 year old with somatization disorder, using the Conversational Model, is described.

CONCLUSION

Early cumulative trauma has far-reaching health consequences. Brief psychotherapy produces symptom relief, and long-term analytic therapy is necessary for sustained improvement.

Negative life experiences and the development of cluster C personality disorders: a cognitive perspective

Early negative experiences have long been thought to play an important role in the development of personality disorders. Most of the literature regarding these early life experiences has focused on borderline personality disorder, with only occasional focus on other personality disorders. Utilizing cognitive theory of personality disorders (Beck et al., 2004), the authors conceptualize cluster C personality disorders (avoidant, dependent, and obsessive-compulsive). They then critically review the relevant literature on early negative life experiences and later development of these disorders to determine whether the theory is supported by the empirical data. The theory regarding avoidant and dependent personality disorders has limited support, whereas data relating to obsessive-compulsive personality disorder are much weaker. Implications and future research suggestions are discussed.

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.

Borderline personality disorder: considerations for inclusion in the Massachusetts parity list of "biologically-based" disorders

Borderline Personality Disorder (BPD) is a common and severe mental illness that is infrequently included under state mental health parity statutes. This review considers BPD parity, using the Massachusetts mental health parity statute as a model. While BPD can co-occur with other disorders, studies of its heritability, diagnostic validity/reliability, and response to specific treatments indicate it is best considered an independent disorder, one that negatively impacts the patient's treatment response to comorbid disorders, particularly mood disorders. Persons with BPD are high utilizers of treatment, especially emergency departments and inpatient hospitalizations-the most expensive forms of psychiatric treatment. While some patients remain chronically symptomatic, the majority improve. The findings from psychopharmacologic and other biologic treatment data, coupled with associated brain functioning findings, indicate BPD is a biologically-based disorder. Clinical data indicate that accurately diagnosing and treating BPD conserves resources and improves outcomes. Based on this analysis, insuring BPD in the same manner as other serious mental illnesses is well-founded and recommended.

Emotional instability, poor emotional awareness, and the development of borderline personality

Emotional instability and poor emotional awareness are cardinal features of the emotional dysregulation associated with borderline personality disorder (BPD). Most models of the development of BPD include child negative emotional reactivity and grossly inadequate caregiving (e.g., abuse, emotional invalidation) as major contributing factors. However, early childhood emotional reactivity and exposure to adverse family situations are associated with a diverse range of long-term outcomes. We examine the known effects of these risk factors on early childhood emotional functioning and their potential links to the emergence of chronic emotional instability and poor emotional awareness. This examination leads us to advocate new research directions. First, we advocate for enriching the developmental assessment of children's emotional functioning to more closely capture clinically relevant aspects. Second, we advocate for conceptualizing children's early family experiences in terms of the proximal emotional environment to which young children may be or become sensitive. Such approaches should contribute to our ability to identify risk for BPD and guide preventive intervention.

Childhood maltreatment and adult personality disorder symptoms: influence of maltreatment type

The present study examines the effects of different types of childhood maltreatment on personality disorder symptoms in a sample of adults with no Axis I psychopathology. Participants reporting a history of moderate to severe maltreatment on the Childhood Trauma Questionnaire (n = 70) were grouped by type of abuse and compared with a non-abused group (n = 35) with regard to the number of personality disorder symptoms endorsed. Physical/sexual abuse and emotional abuse/neglect each were associated with elevated symptoms of all three personality disorder clusters. Elevated symptoms of several specific personality disorders were also seen, including paranoid, borderline, avoidant, dependent, obsessive-compulsive, and depressive personality disorder. There were no significant differences between the maltreatment groups. These findings indicate that emotional abuse/neglect and physical/sexual abuse are risk factors for a broad array of personality outcomes in a non-clinical sample.

Borderline personality disorder and childhood trauma: evidence for a causal relationship

The debate over whether childhood trauma is a causative factor in the development of borderline personality disorder continues in the literature despite decades of research. This review examines this body of literature published from 1995 through 2007 to assess the strength of evidence for such a causal relationship. A unique conceptual approach was used, as we considered the literature in the context of Hill's classic criteria for demonstrating causation. Results of this review suggest that evidence supports the causal relationship, particularly if the relationship is considered as part of a multifactorial etiologic model. Directions for future research and clinical implications are discussed.

A comparison of the family and childhood backgrounds of hospitalised offenders with schizophrenia or personality disorder

BACKGROUND

Previous studies have demonstrated high levels of childhood adversity and familial criminality in offender patients with schizophrenia and/or personality disorder, but few have directly compared these groups.

AIMS

To compare the parenting histories of offender patients with schizophrenia with those with personality disorder. We hypothesised that rates of family criminality and experiences of disrupted parenting would be higher in the personality disorder group than the schizophrenia group.

METHOD

A retrospective case-control methodology compared the family background and childhood experiences of patients with either schizophrenia or personality disorder (n = 3088) admitted to any of the English high-security hospitals.

RESULTS

Compared with those with schizophrenia, patients with personality disorder had experienced higher rates of family criminality, parental separation, and multiple changes of caregiver and institutional care. There was no significant difference in the prevalence of family psychiatric history between the groups.

DISCUSSION

Although our hypotheses were sustained, we were impressed that rates of disruption to parenting were high in the schizophrenia group as well as in the personality disorder group. Less than a third of the personality disorder group had survived childhood without a change in parenting, but this was true for about half of the schizophrenia group, too. Family work tailored for people with schizophrenia is needed, even though within personality disorder services, a greater demand for disorder-sensitive family work is likely to be encountered.

The case for shifting borderline personality disorder to Axis I

Through reviewing what is known about the nature, course, and heritability of borderline personality disorder (BPD), we argue for a reconceptualization of this disorder that would lead to its placement on Axis I. Borderline personality disorder is a prevalent and disabling condition, and yet the empirical research into its nature and treatment has not been commensurate with the seriousness of the illness. We not only review empirical evidence about the etiology, phenomenology, and course of the disorder in BPD but we also address fundamental misconceptions about BPD that we believe have contributed to misunderstanding and stigmatization of the disease. Finally, we suggest future directions for research that might permit the identification of core features of this disorder, with a focus on the importance of naturalistic assessments and of assessments through the course of development.

Borderline Personality Disorder: What do We Know? Diagnosis, Course, Co-Morbidity, and Aetiology

Evidence regarding the diagnostic dilemmas, course, co-morbidity, and aetiology of Borderline Personality Disorder (BPD) is reviewed. After considering problems that the clinician and researcher face in using BPD as a diagnostic category, I argue that current evidence indicates that there is reason to be more optimistic about the course of BPD. Emerging dilemmas in considering co-morbidity in the BPD patient are considered. Aetiological factors are presented in support of a ‘multiple pathways’ model of aetiology where characterological and temperamental characteristics interact in complex idiosyncratic ways.

Prevention and early intervention for borderline personality disorder

Borderline personality disorder (BPD) is a severe mental disorder that is associated with substantial psychosocial impairment and morbidity, disproportionate use of health resources, a high suicide rate, and a reputation for being "untreatable". A diagnosis of BPD in young people has similar reliability, validity and prevalence to BPD in adults, and almost certainly has serious and pervasive negative repercussions over subsequent decades. Current data are inadequate to inform specific universal or selective prevention programs for BPD. However, they do support including BPD prevention as an outcome when evaluating universal and/or selective interventions for a variety of mental health problems and adverse psychosocial outcomes. The strongest data support early intervention for the emerging BPD phenotype. Early intervention programs will need to be realistic in their aims, require change in clinician attitudes and service systems, and must be mindful of the risk of iatrogenic harm.

Personality characteristics of adult survivors of childhood trauma

Lenore Terr (1991) proposed a framework for childhood trauma that distinguishes between single-incident trauma (Type I) and repeated or prolonged trauma (Type II). Terr's framework and data collected from the National Comorbidity Survey (NCS) are used to examine differences in personality between adult survivors of childhood Type I trauma, childhood Type II trauma, and a control group of adults not traumatized as children. Groups were compared on five personality scales. Results indicate that individuals in the trauma categories scored higher in neuroticism and openness to new experiences than individuals in the control group. The Type I group was lower than the control group on interpersonal dependency, whereas the Type II group scored higher than the control group on this measure.

Non-epileptic seizures and child sexual abuse: A critical review of the literature

Non-epileptic seizures have received a substantial amount of attention in the psychiatric and medical literature, but comparatively little attention from psychologists. Non-epileptic seizures resemble epileptic seizures but lack the physiological symptoms of genuine epilepsy and are psychological in origin. Many authors have emphasized the role that child sexual abuse may play in the etiology of this disorder. In the present paper, we provide a review of 34 studies examining this relationship, followed by a meta-analysis of 19 effect sizes. While our statistical results support the professed link between child sexual abuse and non-epileptic seizures, we suggest that because of research design limitations, it is premature to draw any definitive conclusions regarding a relationship. Eight of these research design limitations are identified and discussed (e.g., the absence of comparison groups; an explicit and public definition of child sexual abuse). Alternatives to a traditional psychoanalytic perspective that emphasizes the role of child sexual abuse in the etiology of NES are presented. Specific recommendations for future research are made and psychologists are strongly encouraged to play a more active role in both researching and treating non-epileptic seizures.

A Multi-Dimensional Perspective of Adolescents' Self-Cutting

Adolescent self-cutting behaviours has a long been a problem in modern society. In this paper, the writer tries review six perspectives in interpreting adolescent self-cutting behaviours. Based on these six perspectives, the writer tries to re-conceptualise a multidimensional model on adolescent self-cutting behaviours. This model tries to include the family system, peer system and socio-cultural context in perceiving the antecedents, process and aftermath in adolescents' self cutting behaviours. The implications of this perspective to intervention with adolescents are also discussed.

Childhood sexual abuse predicts poor outcome seven years after parasuicide

BACKGROUND

There is substantial empirical research linking borderline personality disorder with prolonged mental instability and recurrent suicidality. At the same time, a growing body of observations links borderline personality disorder to sexual abuse and other forms of abuse and trauma in childhood. The aim of this study was to investigate among patients admitted for parasuicide the predictive value for outcome 7 years after the parasuicide of a diagnosis of borderline personality disorder compared to the predictive value of a history of childhood sexual abuse.

METHODS

Semi-structured interviews were conducted at the time of the index parasuicide, with follow-up interviews 7 years later. In addition, information was collected from medical records at the psychiatric clinic. A logistic regression analysis was used to assess the specific influence of the covariates borderline personality disorder, gender and reported childhood sexual abuse on the outcome variables.

RESULTS

Univariate regression analysis showed higher odds ratios for borderline personality disorder, female gender and childhood sexual abuse regarding prolonged psychiatric contact and repeated parasuicides. A combined logistic regression model found significantly higher odds ratios only for childhood sexual abuse with regard to suicidal ideation, repeated parasuicidal acts and more extensive psychiatric support.

CONCLUSION

The findings support the growing body of evidence linking the characteristic symptoms of borderline personality disorder to childhood sexual abuse, and identify sexual abuse rather than a diagnosis of borderline personality disorder as a predictor for poor outcome after a parasuicide. The findings are relevant to our understanding and treatment of parasuicide patients, especially those who fulfil the present criteria for borderline personality disorder.

Borderline pathology in children and adolescents

Mental health nurses have historically been pessimistic about and often unsympathetic towards clients diagnosed with borderline personality disorder. By the time these clients reach adult mental health services their behaviours are often difficult to manage and they often suffer significant re-victimization by health services. Questions need to be raised about how best to avert the consolidation of the problems associated with the disorder. This paper explores the concept of "borderline pathology" in children and adolescents and examines the best available evidence for utilizing an early identification and intervention model for children and adolescents who exhibit this constellation of symptoms.

Life events, motives, and precipitating factors in parasuicide among borderline patients

The high prevalence of borderline personality disorder in parasuicide raises the question whether there are differences in motives, precipitating factors, and life events as compared to other clinical groups. Consecutive hospital admitted parasuicide patients were therefore investigated for personality disorders by a structured clinical interview (SCID-II), a structured interview concerning precipitating factors and a self-report questionnaire on motives and life events. Out of a total of 64 patients, 55% met the criteria for a borderline personality disorder. While the parasuicidal motives and precipitating factors did not differ between the borderline group and the others, the borderline group reported significantly more adverse life events. Our findings suggest that the overrepresentation of borderline personality disorder in parasuicide might be related to accumulated adverse life events rather than to manipulative motives.

Personality disorders and posttraumatic stress disorder in motor vehicle accident survivors

This study examined the impact of a co-occurring personality disorder on the development and remission of posttraumatic stress disorder (PTSD) in 158 motor vehicle accident (MVA) survivors followed prospectively for 1 year. Participants were assessed 1 to 4 months after trauma and at 6-month and 1-year follow-up evaluations during 1991 through 1993. These archival data were analyzed in the present study. The prevalence of at least one personality disorder was 13.3%, with the majority (52.4%) presenting with obsessive-compulsive personality disorder. Persons with a personality disorder were significantly more likely to be diagnosed with PTSD at 1-year follow-up evaluation. For persons diagnosed with PTSD at the initial assessment, those with a personality disorder were significantly less likely to remit by 1 year. The presence of a preexisting personality disorder may increase the risk of chronic PTSD and impede remission.

Associação entre trauma por perda na infância e depressão na vida adulta

Observações clínicas efetuadas por psicanalistas sugerem que psicopatologias da idade adulta podem ter sido originadas na infância. Estudos publicados na última década identificaram associação entre trauma na infância e depressão na vida adulta. Vivências traumáticas na infância, como a perda de vínculos afetivos devido à morte de pais ou de irmãos ou, ainda, a privação de um ou de ambos os pais por separação ou abandono constituem importantes fatores associados à depressão na vida adulta. O objetivo do presente artigo é revisar a literatura dos últimos dez anos, considerando os fatores associados à depressão, particularmente aqueles relacionados aos estressores presentes na infância. A metodologia utilizada foi de busca on-line nas bases de dados Medline, PsycINFO, Cochrane e Lilacs, referentes ao período de maio de 1991 a maio de 2001. A maioria dos estudos incluídos nesta revisão encontrou uma associação significativa entre trauma por perdas na infância e depressão na vida adulta, com variação na intensidade das associações observadas.

Recent developments in research of trauma and personality disorders

Although the association between trauma and personality disorders, particularly borderline personality disorder (BPD), has been well established, the etiologic role of trauma in the development of personality disorders has been a topic of debate. Numerous mediation models have been put forth to explain how trauma can serve as a risk factor for the subsequent development of BPD. The symptomatic overlap between the proposed complex post-traumatic stress disorder diagnosis and BPD has fueled research efforts aimed at determining whether these are distinct disorders or should both be considered as trauma spectrum disorders. Treatment implications of this diagnostic differentiation are discussed.

Predictors of comorbid personality disorders in patients with panic disorder with agoraphobia

The aim of this study was to ascertain predictors of comorbid personality disorders in patients with panic disorder with agoraphobia (PDAG). Sixty consecutive outpatients with PDAG were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) for the purpose of diagnosing personality disorders. Logistic regressions were used to identify predictors of any comorbid personality disorder, any DSM-IV cluster A, cluster B, and cluster C personality disorder. Independent variables in these regressions were gender, age, duration of panic disorder (PD), severity of PDAG, and scores on self-report instruments that assess the patient's perception of their parents, childhood separation anxiety, and traumatic experiences. High levels of parental protection on the Parental Bonding Instrument (PBI), indicating a perception of the parents as overprotective and controlling, emerged as the only statistically significant predictor of any comorbid personality disorder. This finding was attributed to the association between parental overprotection and cluster B personality disorders, particularly borderline personality disorder. The duration of PD was a significant predictor of any cluster B and any cluster C personality disorder, suggesting that some of the cluster B and cluster C personality disorders may be a consequence of the long-lasting PDAG. Any cluster B personality disorder was also associated with younger age. In conclusion, despite a generally nonspecific nature of the relationship between parental overprotection in childhood and adult psychopathology, the findings of this study suggest some specificity for the association between parental overprotection in childhood and personality disturbance in PDAG patients, particularly cluster B personality disorders.

Psychopathological characteristics of recovered bulimics who have a history of physical or sexual abuse

We sought to clarify the influence of a history of sexual or physical abuse on a variety of psychopathologies in subjects with bulimia nervosa (BN). To avoid confounding effects, the presence of a history of sexual or physical abuse, lifetime axis I disorders, and personality disorders were assessed through direct structured interviews in 44 subjects recovered from BN for at least 1 year. Twenty abused subjects (45%) were significantly more likely than 24 subjects without abuse to have severe general psychopathology and eating disturbance. Compared with nonabused subjects, abused subjects showed a trend toward more frequent lifetime diagnoses of posttraumatic stress disorder and substance dependence. These results suggest that abusive experiences may be associated with some psychopathology of BN, particularly related to anxiety, substance abuse, and more severe core eating disorder pathology.

Acute and chronic posttraumatic stress disorder in motor vehicle accident victims

OBJECTIVE

This study reports the rates of acute and chronic posttraumatic stress disorder (PTSD) in a suburban community study group of 122 victims of serious motor vehicle accidents and a comparison group of 42 (who had been involved in minor, non-motor-vehicle accidents) followed over 12 months.

METHOD

Motor vehicle accident victims were systematically recruited and examined with comparison subjects at 1, 3, 6, 9, and 12 months after the accident. The authors used the Structured Clinical Interview for DSM-III-R to assess DSM-III-R axis I disorders including PTSD.

RESULTS

One month after the accident, 34.4% of the motor vehicle accident victims met criteria for PTSD (versus 2.4% of the comparison subjects). Similarly, at 3 and 6 months, rates of PTSD were higher (25.2% and 18.2%) in the motor vehicle accident victims than in the comparison group. Female victims were 4.64 times more likely than male victims to have PTSD at 1 month. Victims with a history of PTSD were 8.02 times more likely at 1 month and 6.81 times more likely at 3 months to have PTSD than those without a history of PTSD. Having an axis II disorder increased the risk for PTSD at 6 months. After adjustment for a history of PTSD and potentially confounding variables, women were 4.39 times more likely than men to develop PTSD at 1 month but did not have a higher risk for chronic PTSD; at 6 months, those with an axis II disorder were at greater risk of PTSD.

CONCLUSIONS

Rates of PTSD are high in victims of serious motor vehicle accidents and remain high 9 months later. Female victims have an increased risk of acute but not chronic PTSD. Individuals with a history of PTSD are at risk of acute and chronic PTSD. An axis II disorder increases the risk for chronic but not acute PTSD.

A comparison of short-term group and individual therapy for sexually abused women

OBJECTIVE

To compare the effectiveness of 10 sessions of group therapy with that of 10 sessions of individual therapy in a sample of 86 adult women seeking treatment for the effects of childhood sexual abuse.

METHOD

Participants were randomly assigned to the 2 treatment modalities and tested at assessment, pretherapy following a 10-week wait condition, posttherapy, and 6-month and 12-month follow-up.

RESULTS

Participants had fewer symptoms and better psychosocial functioning posttherapy and were further improved at the 6- and 12-month follow-up. Neither treatment modality was superior to the other. Approximately one-half of the sample sought further treatment during the follow-up periods.

CONCLUSIONS

Improvement in symptoms and functioning was associated with short-term treatment in both modalities, but many patients remained distressed and required further treatment. Future research should investigate whether sexually abused women who meet criteria for specific diagnoses require more focused and/or longer-term therapy.