Parenting and personality disorder: An overview and meta-synthesis of systematic reviews

Attachment security and disorganization in infants of mothers with severe psychiatric disorder: Exploring the role of comorbid personality disorder

The aim of this preliminary study was to explore infant-mother attachment quality in a Dutch clinical sample of mothers with severe psychiatric disorder, with or without comorbid personality disorder. Thirty-two mothers were recruited through specialized secondary and tertiary outpatient clinics and mental health institutions. Maternal psychiatric and personality diagnoses were verified with structured clinical interviews during pregnancy. Maternal concurrent level of psychiatric symptoms was assessed by self-report and infant-mother attachment quality by observation in the Strange Situation Procedure at 14 months postpartum. In the full sample, almost half of the infants were classified as disorganized. All infants of mothers with a comorbid personality disorder were classified as either insecure or disorganized. Infants of mothers with a comorbid personality disorder had a significantly higher disorganization score than infants of mothers with a psychiatric disorder only. Continuous attachment security scores did not differ significantly between groups. In the full sample, continuous infant attachment security and disorganization score were not significantly correlated with the level of maternal concurrent psychiatric symptoms. Our exploratory findings suggest a specific link between maternal psychiatric and comorbid personality disorder and attachment disorganization. Moreover, chronicity of symptoms appears more relevant for attachment behaviors than the severity of concurrent psychiatric symptoms. Maternal personality disorder may have a strong formative impact on infant attachment security and disorganization, which warrants further research to inform clinical practice, in order to reduce the risk of intergenerational transmission of maternal psychopathology.

Association of maternal and paternal personality disorders with risk of mental disorders in children: A nationwide, register-based cohort study of 1,406,965 children

BACKGROUND

Knowledge of the association between parental personality disorders and mental disorders in children is limited. To examine the association between parental personality disorders and the risk of mental disorders in offspring.

METHODS

We linked Danish health registers to create a cohort of children born from January 1, 1995, to December 31, 2016. Children were followed until their 18th birthday, diagnosis set, emigration, death, or December 31, 2016. Parental personality disorders according to the International Classification of Diseases (ICD) Eighth or 10th Revision. Poisson regression analyses were used to estimate the incidence risk ratio (IRR) and cumulative incidence of ICD 10th mental disorders in offspring (age 0-17).

RESULTS

The study cohort included 1,406,965 children. For girls, maternal or paternal personality disorder (MPD/PPD) was associated with mental disorders: MPD girls (IRR, 2.74; 95% CI, 2.59-2.89) and PPD girls (IRR, 2.10; 95% CI, 1.94-2.27). Likewise, the risk was increased for both MPD boys (IRR, 2.44; 95% CI, 2.33-2.56) and PPD boys (IRR, 2.04; 95% CI, 1.91-2.18). For girls and boys combined, exposure to two parents with a personality disorder was associated with the highest risk (IRR, 3.69; 95% CI, 3.15-4.33). At age 18, the cumulative incidence of any mental disorder in children of one or two parents with a personality disorder was 34.1% (95% CI, 33.0-35.1), which was twice the cumulative incidence of mental disorders in nonexposed children (15.2% [95% CI, 15.1-15.3]).

CONCLUSION

Children of parents with a personality disorder were at a 2 to 3.5 times higher risk of mental disorders compared with nonexposed offspring. Possible mechanisms of transmission of mental disorders from parent to child involve genetic, environmental, and gene-environment pathways. More research into these mechanisms and research into preventive interventions is warranted.

Emotion Regulation, Parenting, and Psychopathology: A Systematic Review

The presence of a parental mental disorder can lead to adverse outcomes for children. Difficulties in emotion regulation are observed across a range of mental health problems and may play a crucial role in this context. Following PRISMA guidelines, we systematically searched Medline, PsycINFO, Embase, and Web of Science for studies examining the association between emotion regulation in parents with psychopathology at a clinical or subclinical level and their parenting. The protocol was registered with the PROSPERO international prospective register of systematic reviews (CRD42021224954; January 2021). A total of 23 studies were included in the qualitative synthesis. Emotion regulation was predominantly assessed using self-report on the general ability (e.g., Difficulties in Emotion Regulation Scale). The assessment of parenting encompassed a broad range of aspects and operationalizations. Across psychopathology in parents, several aspects of difficulties in emotion regulation were associated with unfavorable emotion socialization, more negative parenting, and partially with less positive parenting. Slightly different effects were observed for posttraumatic stress disorder and anxiety disorders. For parents with depressive disorders, specific emotion regulation strategies (suppression, reappraisal) seem to buffer against negative parenting. Since the majority of studies refer only to mothers, generalization to fathers is limited. Furthermore, conclusions are limited due to study heterogeneity and lack of prospective studies. Nevertheless, findings suggest that interventions should target the improvement of emotion regulation in parents with psychopathology.

Early maladaptive schema, attachment style, and parenting style in a clinical population with personality disorder and normal individuals: a discriminant analysis model

INTRODUCTION

Researchers have shown various variables' role in forming personality disorders (PD). This study aimed to assess the role of early maladaptive schema (EMS), attachment style (AS), and parenting style (PS) in discriminating between personality disorders and normal individuals.

METHODS

In this study, 78 personality disorder patients and 360 healthy volunteers aged 18-84 were selected using convenience sampling. They completed the Schema Questionnaire-Short Form (SQ-SF), Revised Adult Attachment Scale (RAAS), and Baumrind's Parenting Styles Questionnaire (PSI). Data were analyzed using discriminant analysis with IBM SPSS 25.

RESULTS

The results showed higher mean scores in all early maladaptive schema domains, insecure attachment styles, and authoritarian parenting in the personality disorder group than in the normal group. Also, discriminant analyses revealed that the function was statistically significant and could distinguish between the two groups and a compound of essential variables, disconnection, impaired autonomy, and secure attachment, respectively, discriminating two groups. Given that all components were able to distinguish between the two groups.

CONCLUSION

Therefore, intervention based on these factors early in life may help reduce the characteristics of personality disorders. Also, considering the role of these factors, treatment protocols can be prepared.

Fathers' mental Ill-health and child maltreatment: A systematic review of the literature

Background

Parental mental ill-health is often described as a risk factor for child maltreatment. Yet the literature commonly foregrounds maternal mental ill-health. To obtain a more complete picture, it is crucial to also understand the associations between fathers' mental health and child maltreatment.

Aim

To provide a narrative synthesis of evidence about the relationship between fathers' mental health and child maltreatment.

Method

Four electronic databases were searched, identifying 5479 citations. 151 studies were brought to full-text review. 37 were included in the study.

Results

Studies revealed mixed evidence for associations between forms of paternal mental ill health and child maltreatment, with stronger evidence for paternal depression and weak or no evidence for PTSD and anxiety. Many confounding factors were identified across the papers.

Discussion

The small number and limited range of good quality studies indicate the need to correct the relative invisibility of fathers within research about mental health and child maltreatment. At present, the available evidence is not sufficient to draw firm conclusions about the association between fathers' mental health and child maltreatment or appropriate policy and practice responses.

Mentalizing in Adolescents with Borderline Personality Disorder

Mentalizing, recognized as the capacity to understand behaviors in the context of our own mental states and those of other people, is being researched more and more commonly in regard to various mental disorders. The research on mentalization focuses on, among other things, borderline personality disorder, which is at present perceived as an emerging problem in the population of adolescents. In order to summarize the currently accessible knowledge of mentalizing in adolescents with borderline personality disorder, we thoroughly analyzed relevant publications. Based on the available literature, it can be concluded that the mentalizing ability of adolescents with borderline personality disorder can be impaired. The evidence demonstrates that they are prone to hypermentalizing, defined as an overattribution of mental states to other people. However, this tendency has not been proven to be specific to teenagers with this disorder. Moreover, the existing data suggest that young people with borderline personality exhibit a reduced capacity to mentalize their own inner states.

Reflective functioning and mother-infant relationships among mothers with Borderline Personality Disorder post-therapy

The stressful nature of parenting infants exacerbates the characteristics of Borderline Personality Disorder (BPD). Consequently, mothers with BPD tend to be emotionally dysregulated, respond impulsively to their infants, and have poorer mother-infant relationships. Few parenting interventions target the specific skill deficits observed in mothers with BPD. This study explored the differences in parental reflective functioning (PRF) and mother-infant relationship quality at baseline and following a 24-week, group parenting intervention for mothers with BPD. PRF and mother-infant relationship quality were assessed from quantitative (N = 23) and qualitative (N = 32) perspectives. Quantitative data (Parental Reflective Functioning Questionnaire) showed a significant improvement in one of the three subscales, Interest and Curiosity, between baseline and post-intervention, and a significant moderate positive association between the subscale Certainty of Mental States and maternal-infant interaction quality post-intervention. Improvements in mother-infant relationship quality were not evident from the observational measure, Nursing Child Assessment Satellite Teaching scale. In contrast, semi-structured interview qualitative data found maternal improvements in parental reflection, coping strategies implemented post-intervention, and quality of mother-infant relationships. Overwhelmingly positive intervention feedback suggested perceived maternal benefits of group format and skills taught. Future studies with larger sample sizes would allow further clarification of such parenting interventions for mothers with BPD.

Mother-child interactions in adolescents with borderline personality disorder traits and the impact of early life maltreatment

BACKGROUND

Early detection and intervention of borderline personality disorder (BPD) in adolescence has become a public health priority. Theoretical models emphasize the role of social interactions and transgenerational mechanisms in the development of the disorder suggesting a closer look at caregiver-child relationships.

METHODS

The current study investigated mother-adolescent interactions and their association with adolescent BPD traits by using a case-control design. Thirty-eight adolescent patients with ≥ 3 BPD traits and their mothers (BPD-G) were investigated in contrast to 35 healthy control dyads (HC-G). Maternal, adolescent and dyadic behavior was coded using the Coding Interactive Behavior Manual (CIB) during two interactions: a fun day planning and a stress paradigm. Additional effects of maternal and/or adolescent early life maltreatment (ELM) on behavior were also explored.

RESULTS

BPD-G displayed a significantly lower quality of maternal, adolescent and dyadic behavior than the HC-G during both interactions. Maternal and adolescent behavior was predicted by BPD traits alone, whilst dyadic behavior was also influenced by general adolescent psychopathology. Exploratory analyses of CIB subscales showed that whilst HC-G increased their reciprocal behavior during stress compared to the fun day planning, BPD-G dyads decreased it. Maternal ELM did not differ between groups or have any effect on behavior. Adolescent ELM was correlated with behavioral outcome variables, but did not explain behavioral outcomes above and beyond the effect of clinical status.

DISCUSSION/CONCLUSION

Our data suggest a stronger focus on parent-child interactions in BPD-specific therapies to enhance long-term treatment outcomes in adolescent BPD patients. Further research employing study designs that allow the analyses of bidirectional transactions (e.g. longitudinal design, behavioral microcoding) is needed.

Thinking about the next generation: The case for a mentalization-informed approach to perinatal and intergenerational mental health

BACKGROUND

There has been substantial progress made across multiple disciplines to emphasize the importance of perinatal mental health both for parents and offspring. This focuses on what has been termed the 'First 1000 Days' from conception to the child's second birthday. We argue that our understanding of this issue can go further to create an intergenerational approach to mental health. Despite the existence of theoretical frameworks and practical approaches to implementation, there are gaps in the understanding of perinatal and intergenerational mental health including which psychological mechanisms are implicated in the transmission of risk and resilience within the perinatal period; and how to leverage these into treatment approaches.

AIMS AND METHODS

In this paper, we explore the potential for mentalization as a candidate psychological approach to intergenerational mental health.

RESULTS

We contextualize this issue in terms of the points of contact between mentalization and broader theoretical models such as the social determinants of health and the Developmental Origins of Health and Disease (DoHaD) model. Further, we provide an overview of the existing evidence base for the relevance of mentalization to perinatal mental health.

DISCUSSION

Finally, we sketch out an outline model for integrating mentalization into perinatal and intergenerational mental health, highlighting several areas of opportunity to develop research and practice from diverse geographies and demographics. Here, we suggest that integration of mentalization with other conceptual frameworks such as DoHaD can mutually enrich the understanding of each model, pointing the way towards more effective early and preventative interventions.

Childhood family environment predicting psychotic disorders over a 37-year follow-up - A general population cohort study

BACKGROUND

Childhood adverse effects and traumatic experiences increase the risk for several psychiatric disorders. We now investigated whether prospectively assessed childhood family environment per se contributes to increased risk for psychotic disorders in adulthood, and whether these family patterns are also relevant in the development of affective disorders.

METHODS

We used the Young Finns Data (n = 3502). Childhood family environment was assessed in 1980/1983 with previously constructed risk scores: (1) disadvantageous emotional family atmosphere (parenting practices, parents' life satisfaction, parents' mental disorder, parents' alcohol intoxication), (2) adverse socioeconomic environment (overcrowded apartment, home income, parent's employment, occupational status, educational level), and (3) stress-prone life events (home movement, school change, parental divorce, death, or hospitalization, and child's hospitalization). Psychiatric diagnoses (ICD-10 classification) over the lifespan were collected up to 2017 from the national registry of hospital care. Non-affective psychotic disorder and affective disorder groups were formed.

RESULTS

Frequent stress-prone life events predicted higher likelihood of non-affective psychotic disorders (OR = 2.401, p = 0.001). Adverse socioeconomic environment or emotional family atmosphere did not predict psychotic disorders. Only disadvantageous emotional family atmosphere predicted modestly higher likelihood of affective disorders (OR = 1.583, p = 0.013).

CONCLUSIONS

Our results suggest that childhood family environment and atmosphere patterns as such contribute to the risk for developing adulthood mental disorders with relative disorder specificity. The results emphasize the importance of both individual and public health preventive initiatives, including family support interventions.

Effects of BPD tendencies and subjective well-being on NSSI in adolescents with PTSD

Background

Severe posttraumatic stress disorder (PTSD) may lead to non-suicidal self-injury (NSSI), and borderline personality disorder (BPD) tendencies may play a role in this process. Secondary vocational students experience more social, familial and other pressures and are more vulnerable to psychological problems. Thus, we explored the effect of BPD tendencies and subjective well-being (SWB) on NSSI in secondary vocational students with PTSD.

Methods

A total of 2,160 Chinese secondary vocational students in Wuhan participated in our cross-sectional investigation. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), criteria for PTSD, NSSI Questionnaire, Personality Diagnostic Questionnaire-4+, subjective well-being scale, and family adaptation, partnership, growth, affection, and resolve (APGAR) Index were used. We conducted a binary logistic regression model and linear regression analysis.

Results

Sex (odds ratio [OR] = 0.354, 95% confidence interval [CI] = 0.171-0.733), BPD tendencies (OR = 1.192, 95% CI = 1.066-1.333) and SWB (OR = 0.652, 95% CI = 0.516-0.824) were independent factors that predicted NSSI in secondary vocational students with PTSD. Spearman's correlation analysis showed that BPD tendencies were positively correlated with NSSI frequency (r = 0.282, P < 0.01). SWB was negatively correlated with NSSI frequency (r = -0.301, P < 0.01). The linear regression showed that BPD tendencies (β = 0.137, P < 0.05 and β = -0.230, P < 0.001) were significantly correlated with NSSI frequency. Spearman's correlation analysis showed that family functioning was positively correlated with SWB (r = 0.486, P < 0.01) and negatively correlated with BPD tendencies (r = -0.296, P < 0.01).

Conclusion

In adolescents, PTSD in response to stressful events could lead to NSSI, and BPD tendencies promote the intensity of NSSI, while SWB diminishes its intensity. Improvement in family functioning may actively guide the development of mental health and improve SWB; such steps may constitute interventions to prevent or treat NSSI.

Parental personality disorder and child maltreatment: A systematic review and meta-analysis

BACKGROUND

Parental pathology may affect parenting capacity and is deemed a risk factor for child maltreatment. Especially parental personality disorder (PD) can significantly burden the relationship and interaction between parents and their children.

OBJECTIVE

This meta-analytic review aims to summarize and quantify the influence of parental PD on the occurrence / the risk of child maltreatment.

PARTICIPANTS AND SETTING

Studies had to meet the following inclusion criteria: They had to analyze a sample of parents with a diagnosed PD and the occurrence / risk of maltreating their children. To be included in the narrative synthesis and/or meta-analysis, they had to be case-control, cross-sectional, or longitudinal studies. Literature research was conducted in the databases Web of Science, Psychinfo, and Google Scholar up to January 2023.

METHODS

First, studies were analyzed on a narrative level, and eligible studies for the meta-analysis were identified. Studies were grouped according to the diagnosed PDs. Five different groups were included: borderline PD, antisocial PD, narcissistic PD, nondifferentiated PDs, and Cluster B PDs. Three different random-effects meta-analyses were computed (borderline PD, antisocial PD, Cluster B PDs). Meta-analyses were controlled for publication bias and different covariates (e.g., study quality, sample size).

RESULTS

After screening 41 full texts, 17 studies were included in the narrative synthesis, out of which 14 samples from 11 studies were included in the meta-analysis. Analysis of borderline PD showed an association with the occurrence / risk of child maltreatment (OR = 8.08; 95 % CI [2.51, 25.93]). However, after taking into account possible publication bias, this association was no longer significant. We found a significant and stable association between antisocial PD and the occurrence of / risk of child maltreatment (OR = 4.92; 95 % CI [3.26, 7.43]). Analysis of Cluster B PDs (antisocial, borderline, histrionic, narcissistic) revealed a significant overall association (OR = 4.23; 95 % CI [2.75, 6.5]), indicating that the presence of Cluster B PDs in parents significantly increases the occurrence of / the risk of child maltreatment.

CONCLUSIONS

Analyses indicated a significant association between of Cluster B PDs, and specifically between antisocial and borderline PD, with the occurrence of / the risk of child maltreatment. However, methodological limitations have to be taken into account, because results for borderline PD were no longer significant after controlling for possible publication bias. Moreover, the number of studies included was rather small, and results showed a substantial amount of heterogeneity.

OTHER

This work was not supported by any funding.

Parental personality traits and emotion regulation: Its relationship with infants' socioemotional development during the perinatal period

Socioemotional development is central throughout life, and it unfolds in an interpersonal context in which each significant caregiver has an impact, particularly during infancy. However, only a relatively small number of studies have investigated associations between mothers and fathers' personality and emotional characteristics with their infant's socioemotional development during the perinatal period. Therefore, the present article examines the relationship between maternal and paternal personality traits and emotion regulation difficulties during the prenatal period with offspring's socioemotional development. This was a non-experimental and longitudinal study that included a community sample of 55 mother-father-baby triads. Parental assessments were carried out between the second and third trimester of pregnancy, and baby's socio-emotional development was assessed during their 2nd month after birth. Results evidenced differences between maternal and paternal personality traits and emotion regulation difficulties during the perinatal period as well as distinct contributions on infant's socioemotional development.

Mother and clinician experiences of a trial of a video feedback parent-infant intervention for mothers experiencing difficulties consistent with 'personality disorder': A qualitative interview study

OBJECTIVES

We explored mothers' and clinicians' experiences of a video feedback intervention adapted for perinatal 'personality disorder' (VIPP-PMH) and the acceptability of a randomised controlled trial (RCT) examining its effectiveness.

DESIGN

In-depth qualitative interviews with participants from a two-phase feasibility study of the VIPP-PMH intervention. Participants were mothers experiencing enduring difficulties in managing emotions and relationships, consistent with a 'personality disorder', and their 6- to 36-month-old children.

METHODS

Forty-four qualitative interviews were conducted, including all nine mothers receiving VIPP-PMH during the pilot phase, 25 of the 34 mothers participating in the RCT (14 allocated to the VIPP-PMH arm and 9 from the control arm), 11 of the 12 clinicians delivering VIPP-PMH and one researcher. Interview data were thematically analysed.

RESULTS

Mothers described feeling motivated to take part in the research and understood the need for randomisation. Research visits were largely experienced positively, with some suggestions for improvement in questionnaire timing and accessibility. Almost all mothers initially felt anxious about being filmed, but reported positive experiences of the intervention, particularly valuing its non-judgemental, positive and child-focussed nature, their supportive relationship with the therapist and the insights they gained on their child.

CONCLUSIONS

The findings indicate the likely feasibility and acceptability of undertaking a future definitive RCT of the VIPP-PMH intervention in this population. In designing a future trial, a positive and non-judgemental therapeutic relationship will be important to allay mothers' anxieties about being filmed, and careful consideration should be given to the timing and accessibility of questionnaires used.

Early Maladaptive Schemas and Their Impact on Parenting: Do Dysfunctional Schemas Pass Generationally?-A Systematic Review

There are several factors that play a key role in the development of early maladaptive schemas, i.e., temperament, unmet core emotional needs, and adverse childhood events (e.g., traumatization and victimization, overindulgence, overprotection). Thus, the parental care that a child experiences has a substantial impact on the potential development of early maladaptive schemas. Negative parenting can range from unconscious neglect to overt abuse. Previous research supports the theoretical concept that there is a clear and close relationship between adverse childhood experiences and the development of early maladaptive schemas. Maternal mental health problems have been proven to be a factor that has strengthened the link between a mother's history of negative childhood experiences and subsequent negative parenting. Consistent with the theoretical background, early maladaptive schemas are associated with a wide variety of mental health problems. Clear links have been found for EMSs and personality disorders, depression, eating disorders, anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder. In light of these theoretical and clinical connections, we decided to summarize the available literature on the multigenerational transmission of early maladaptive schemas, which is also an introduction to our research project.

Contextualizing motherhood in persons with borderline personality vulnerabilities: cultural adaptation of the parent development interview-revised in an Indian context

An understanding of the complex intersection of borderline personality vulnerabilities and motherhood calls for an integrative and culture-sensitive lens in assessment and therapeutic interventions. The aim of the study was to explore constructions of motherhood in an Indian context to inform the adaptation of the Parent Development Interview-Revised (PDI-R) for use with mothers with borderline personality vulnerabilities. A stepwise framework was followed to obtain conceptual, semantic, and operational equivalences for the PDI-R adaptation. Interviews on contextualised aspects of motherhood were conducted with a sample of eight mental health practitioners specializing in borderline personality disorders, women's mental health or child psychology, two cultural psychologists, one gynaecologist and one paediatrician. Six emergent themes were identified through thematic analysis, 'The ideal mother and her search for identity,' 'Mothering the mother and the vicissitudes of care,' 'Not just mine - negotiating boundaries,' 'Mother knows best,' 'Food, feeding and embodied nurturing,' and 'Approaching motherhood in the clinic.' The proposed adaptations to the PDI-R were further reviewed by two experts, a clinical psychologist and a psychiatrist specialised in perinatal services. This was followed by the process of operational equivalence through administration of PDI-R with two mothers with borderline personality vulnerabilities and two mothers from the community. The expert review and the administration informed the final adaptation of the PDI-R. A systematic process of adaptation can support the use of measures like the PDI-R in different cultures. A contextual understanding of constructions of motherhood and borderline personality has potential to support meaningful assessment and targeted parenting interventions.

Protocol for the Feasibility Randomised Controlled Trial of Being a Parent- Enjoying Family Life (BAP-EFL): A peer-led group intervention for parents and caregivers with significant emotional and interpersonal difficulties

Group-format parenting interventions are well-established at reducing challenging child behavior and risk for psychopathology. However, there is significantly less evidence about the performance of these interventions for parents with significant emotional and interpersonal difficulties, including personality disorder. This protocol presents the rationale and design of a two-arm parallel group feasibility Randomised Controlled Trial and nested process evaluation of Being a Parent (BaP)- Enjoying Family Life, a novel peer-led intervention. The trial compares BaP-Enjoying Family Life to the well-established Empowering Parents Empowering Communities-Being a Parent (EPEC-Being a Parent) in a sample of parents who experience significant emotional and interpersonal difficulties and who are concerned about their child's, aged 2-11 years, behavior. 72 parents will be recruited and randomised to receive either BaP-Enjoying Family Life or EPEC-Being a Parent group-format interventions. The primary aim of this study is to examine the feasibility and acceptability of BaP-Enjoying Family Life and the proposed trial methods. Secondary clinical outcomes include child behavioral difficulties, parenting, parental reflective function, parent wellbeing, satisfaction and self-efficacy. An observational assessment of parent and index child will also assess changes in the home environment. Outcome measures will be collected pre-intervention, post-intervention and at 6-month follow up. A parallel process evaluation will use qualitative data from interviews to assess parents' experience of the intervention delivery and trial methods. Findings will be evaluated against pre-determined feasibility criteria. The results will be used to determine the planning of a definitive clinical trial. The wider methodological and clinical implications are also discussed.

Parenting Role in the Development of Borderline Personality Disorder

The progressively improving understanding of the borderline personality disorder (BPD) has led to an increased interest in the better clarification of the integrated role of biological and psychosocial factors in the underlying pathophysiology of this condition. The influence of early childhood interactions and stress exposure in shaping our personalities during adulthood cannot be emphasized enough. In this review, we discuss the critical role of parenting-related factors including maladaptive parenting, parenting styles, and parenting psychopathology as early childhood influences in the developmental psychopathology of BPD. Protective factors that may impact the development of this disorder and possible preventive interventions are also briefly reviewed.

Different Effects of Perceived Social Support on the Relationship between Perceived Stress and Depression among University Students with Borderline Personality Disorder Symptoms: A Multigroup Mediation Analysis

Background: While perceived social support can mediate the relationship between perceived stress and depression, little is known about the differences between individuals with high and low borderline personality disorder symptoms (BPDS). This study aimed to investigate the associations among perceived stress, perceived social support, and depression, and compare low and high levels of BPDS. Methods. This cross-sectional analysis was a secondary analysis of data from the SI-Bord study. University students across Thailand completed a screening instrument for borderline personality disorder, the Perceived Stress Scale (PSS), the Revised Thai Multi-dimensional Scales of Perceived Social Support (MSPSS), and the Patient-Health Questionnaire (PHQ)-9. Mediation analysis using PROCESS was applied to test the direct and indirect effects of perceived stress on depression. Multigroup mediational analysis was adopted to compare low and high levels of BPDS. Results. The mean age of the 330 participants was 20.27 (SD, 1.4) and 80% were female. Significant correlations were observed between the PSS, MSPSS, and PHQ scores, with greater magnitude among the high-level BPDS group (p < 0.001). A significant direct effect on perceived stress and a significant indirect effect on depression through perceived social support were noted. Of all the sources of social support, only the significant others variable significantly differed between the two groups (p < 0.05). Conclusion. Perception of social support had a significant mediating role in perceived stress and depression. The magnitude of associations was remarkably high for individuals with high BPDS compared to those with low BPDS. Unlike those with low BPDS, all sources of social support were significant mediators between the two groups.

Video feedback parent-infant intervention for mothers experiencing enduring difficulties in managing emotions and relationships: A randomised controlled feasibility trial

OBJECTIVES

Parents experiencing mental health difficulties consistent with "personality disorder", often related to a history of complex trauma, may face increased challenges in parent-child relationships and child socioemotional development. There are no published randomised controlled trials (RCTs) evaluating perinatal parent-child interventions for this population. We evaluated the feasibility and acceptability of undertaking an RCT of the video feedback intervention for positive parenting adapted for perinatal mental health (VIPP-PMH).

DESIGN

Feasibility study incorporating a pilot RCT.

METHODS

Mothers with enduring difficulties in managing emotions and relationships, consistent with a "personality disorder", and their 6- to 36-month old infants were randomly allocated to receive six sessions of VIPP-PMH (n = 20) or usual care alone (n = 14).

RESULTS

76% of eligible mothers consented to participate. Intervention uptake and completion rates were 95% (≥1 VIPP-PMH session) and 70% (6 sessions), respectively. Follow-up rates were 85% at month 5 and 65% at month 8 post-baseline. Blinded observer-ratings of maternal sensitivity in parent-child interaction favoured the intervention group at month 5 (RR = 1.94, 95% CI 0.67-5.63) and month 8 (RR = 1.91, 95% CI 0.68-5.33). Small changes over time in self-rated parenting confidence and stress favoured the intervention group. There were no clear intervention effects on maternal non-intrusiveness or mental health, or on child behaviour problems, emotional functioning, or self-regulation.

CONCLUSIONS

An RCT of VIPP-PMH is feasible and acceptable to implement with mothers experiencing difficulties consistent with perinatal "personality disorder". A fully powered definitive RCT should be undertaken.

Maladaptive personality traits may link childhood trauma history to current internalizing symptoms

Research supports a strong relationship between childhood maltreatment and internalizing psychopathology (e.g., anxiety and depression), and features of personality are assumed to explain some of this relationship. In this study, we proposed a model in which maladaptive traits mediate the effect of childhood trauma history on internalizing symptoms in adult individuals. A mixed sample (N = 462) composed of 142 psychiatric patients and 320 community-dwelling individuals completed the Childhood Trauma Questionnaire (CTQ), the Personality Inventory for DSM-5 (PID-5), and the Symptom Checklist (SCL-27) for internalizing psychopathology. The effect of childhood traumas explained 34% of the variance in internalizing symptoms while controlling for the influence of age and gender. The traits accounted for 78% of this effect, which was predominantly exerted through the domains of Negative Affectivity, Detachment, and Psychoticism, and specifically through the facets of Depressivity, Suspiciousness, Anxiousness, Perceptual Dysregulation, and Distractibility. This finding provides preliminary support for the proposed model indicating that the aforementioned maladaptive trait domains potentially function as mediating links by which childhood traumas are translated into internalizing symptoms in adulthood. However, these findings must be interpreted with caution due to the cross-sectional and retrospective mono-method design of this study. Clinical implications are discussed in relation to transdiagnostic treatment and the potential value of specifying trait domain specifiers in ICD-11 and DSM-5 models of personality disorders.

How childhood maltreatment alters perception and cognition - the predictive processing account of borderline personality disorder

Borderline personality disorder (BPD) is a severe mental disorder, comprised of heterogeneous psychological and neurobiological pathologies. Here, we propose a predictive processing (PP) account of BPD to integrate these seemingly unrelated pathologies. In particular, we argue that the experience of childhood maltreatment, which is highly prevalent in BPD, leaves a developmental legacy with two facets: first, a coarse-grained, alexithymic model of self and others - leading to a rigidity and inflexibility concerning beliefs about self and others. Second, this developmental legacy leads to a loss of confidence or precision afforded beliefs about the consequences of social behavior. This results in an over reliance on sensory evidence and social feedback, with concomitant lability, impulsivity and hypersensitivity. In terms of PP, people with BPD show a distorted belief updating in response to new information with two opposing manifestations: rapid changes in beliefs and a lack of belief updating despite disconfirmatory evidence. This account of distorted information processing has the potential to explain both the instability (of affect, self-image, and interpersonal relationships) and the rigidity (of beliefs about self and others) which is typical of BPD. At the neurobiological level, we propose that enhanced levels of dopamine are associated with the increased integration of negative social feedback, and we also discuss the hypothesis of an impaired inhibitory control of the prefrontal cortex in the processing of negative social information. Our account may provide a new understanding not only of the clinical aspects of BPD, but also a unifying theory of the corresponding neurobiological pathologies. We conclude by outlining some directions for future research on the behavioral, neurobiological, and computational underpinnings of this model, and point to some clinical implications of it.

Buffering Effect of Perseverance and Meditation on Depression among Medical Students Experiencing Negative Family Climate

Background and objective: Thirty percent of Thai medical students experienced depression. Two of the crucial factors related to depression involved borderline personality disorder symptoms and adverse family experiences, while positive strengths were documented to prevent depression. This study aimed to investigate the role of perseverance and meditation on depression; Methods: Two hundred and forty−three medical student participants completed the following measurements: the core symptom index (CSI−D) to measure depression, the family climate questionnaire to measure family experience, the personality disorder questionnaire to measure borderline personality disorder symptoms, and the inner strength−based inventory to measure perseverance and meditation. In the analysis, depression served as an outcome, adverse family climate as a predictor and borderline personality disorder symptoms as a mediator. In contrast, perseverance and meditation were moderators in the mediation model. Mediation and moderation analysis using PROCESS was applied for testing the direct and indirect effects; Results: Among all, 49.38% were male, and the mean age was 22.76 years. Borderline personality disorder symptoms significantly mediated the relationship between adverse family climate and depression, B = 0.0608 (95%CI, 0.0301 to 0.1052). The variance explained by the mediation model was 43%. Meditation moderated the relationship between adverse family climate and borderline personality symptoms, whereas perseverance and meditation were found to be significant moderators for borderline personality disorder symptoms and depression. With two moderators in the mediation model, the indirect effect index was B = 0.0072 (95%CI, 0.0002 to 0.0160). The 49% of variances of depression were explained by the moderated mediation model; Conclusion: Borderline personality disorder symptoms are a crucial variable involving depression. Meditation practice has been demonstrated to be a buffer between negative family climate to borderline personality disorder symptoms and depressive symptoms, whereas perseverance buffers the effect of borderline personality disorder symptoms of depression. Further research on cultivating meditation and perseverance should be encouraged among those with negative family experiences.

Screening for media use in the ED among young Australians: a cross-sectional study (Preprint)

BACKGROUND

Research on problematic internet use has largely adhered to addiction paradigms, possibly impeding the identification of specific internet behaviors related to psychopathology. This study presents a novel approach to screening for specific problematic internet behaviors by using a new measure, the emergency department media use screener (EDMUS).

OBJECTIVE

The purpose of this study was to identify patterns of internet use in young people presenting with mental health concerns to the emergency department (ED), ascertain associations with their mental health, and evaluate whether the EDMUS can be used to predict subsequent ED presentations within 3 months.

METHODS

This cross-sectional retrospective study of Australian young people (N=149, aged 11-25 years; female: n=92, 61.7%) sought to use the EDMUS, a 24-item questionnaire, to identify problematic internet behaviors, including accessing or posting prosuicidal or proeating disorder content, cyberbullying, and inappropriate digital content. Data on each person's mental health were extracted from electronic medical records to look for associations with EDMUS responses and ED re-presentation over 3 months. EDMUS items were grouped into clusters for analysis using chi-square tests, binary logistic regression, and path analyses.

RESULTS

Sharing suicidal digital content was the most common problematic internet use pattern identified by the EDMUS. However, this did not correlate with having a prior mental health diagnosis or predict readmission. Most participants had families with a concern for their internet use; however, this was less likely in participants with a diagnosis of personality disorder. Diagnoses of personality disorder or posttraumatic stress disorder were independent predictors of readmission (P=.003; P=.048).

CONCLUSIONS

Although a history of complex psychopathology increases the likelihood of subsequent ED presentations, its links to internet use-related behaviors are still unclear. The EDMUS has potential for identifying young people who are most vulnerable to problematic internet behaviors and offers the opportunity for early intervention and potential prevention of more entrenched difficulties.

The Dutch Infant Caregiving Assessment Scales: Psychometric properties in mothers with and without a severe psychiatric disorder

OBJECTIVES

This study examines the psychometric properties of the Dutch adaptation of the Infant Caregiving Assessment Scales (INCAS). This standardized observation procedure is the first to assess both emotional and instrumental caregiving skills of mothers with a severe psychiatric disorder, during the postpartum period.

METHODS

Mothers with and without a severe psychiatric disorder (N = 123) were observed at home at the infant age of 6 weeks during daily caregiving; changing a diaper, bathing, dressing, and feeding. Recordings of observations were coded independently by trained coders, blind for group membership. Subsequently, the component structure, internal consistency, interrater reliability, and concurrent validity of the INCAS were examined.

RESULTS

Principal component analysis largely confirmed the two a priori defined caregiving domains. The internal consistencies of the emotional and instrumental domains were deemed excellent and good, respectively. The interrater reliability was substantial for the emotional domain and moderate for the instrumental domain. Furthermore, evidence for good concurrent validity of the emotional domain was found. Lastly, significant correlations were found between specific instrumental caregiving skills and maternal neuropsychological functioning.

CONCLUSION

Psychometric findings support the INCAS as a comprehensive and reliable instrument for standardized assessment of caregiving by mothers with a severe psychiatric disorder.

Childhood Maltreatment, Mental Well-Being, and Healthy Lifestyle in Patients With Chronic Thromboembolic Pulmonary Hypertension

Introduction

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially life-threatening condition associated with high morbidity and mortality. However, advances in medical, surgical and interventional treatment have markedly improved the outcome of patients with CTEPH. Additional factors potentially influencing quality of life (QoL) and outcome in CTEPH are yet to be defined. Child maltreatment is a major risk factor for unfavorable behavioral, mental as well as physical health outcomes and has been associated with decreased QoL. To date, no study assessed the impact of childhood trauma in patients with CTEPH.

Methods

Patients with CTEPH were invited to complete the Childhood Trauma Questionnaire (CTQ). Data were compared to prevalence data from the German population. Mental well-being was assessed using the Hospital Anxiety and Depression Scale (HADS) and quality of life was measured using the WHO Quality of Life Questionnaire (WHOQOL). Furthermore, lifestyle factors and physical health parameters were studied.Logistic regression analysis was used to investigate a possible impact of child maltreatment on markers of disease severity.

Results

One-hundred and seven patients with CTEPH completed the CTQ. These patients reported higher rates of emotional abuse and physical abuse and emotional neglect compared to the German population while rates of physical neglect and sexual abuse did not differ between patients and German population with prevalence of 20.6% for emotional abuse, 20% for physical abuse, 22% for emotional neglect, 46% for physical neglect, and 6% for sexual abuse in patients with CTEPH. Higher CTQ scores were associated with anxiety symptoms as well as negatively associated with QoL. No direct impact of childhood trauma on CTEPH severity was found.

Conclusion

We found a higher rate of child maltreatment in patients with CTEPH in comparison to the German population. Correlations suggest moderate associations between CTQ scores and mental health and QoL. Child maltreatment had no significant impact on disease severity. Further investigation on proper interventions to support affected patients is needed.

Patients With Personality Disorders in Everyday Clinical Practice–Implications of the ICD-11

BACKGROUND

Patients with difficult personalities or personality disorders are a special challenge for primary care physicians. Their style of interpersonal interaction is often difficult. As the ICD-11 classification comes into use, a new systematic approach to diagnosis is being introduced that focuses on the patient's functional impairments in everyday life. We describe the implications for the diagnosis and treatment of patients of this type.

METHODS

This review is based on pertinent publications retrieved by a selective search, with particular attention to primary care and to somatic morbidity and mortality.

RESULTS

10-12% of the population suffers from personality disorders. A high degree of psychiatric comorbidity is typical; somatic diseases are also more than twice as common as in the general population. In emergency medicine, persons with personality disorders are more likely than others to present with a suicide attempt. Their lifetime risk of suicide is between 1.4% and 4.5% (the latter for persons with borderline personality disorder).

CONCLUSION

Primary care physicians have an important role in the initial diagnosis of patients with personality disorders and in the planning of their treatment. Such patients require special care and attention from their physicians in view of their elevated somatic morbidity and mortality. In everyday clinical practice, physicians who encounter patients with complex and persistent mental problems, or just with a difficult style of interpersonal interaction, should consider the possibility of a personality disorder and motivate such patients to undergo psychotherapy, if indicated.

Parental Mental Illness, Borderline Personality Disorder, and Parenting Behavior: The Moderating Role of Social Support

PURPOSE OF REVIEW

Parental mental disorders, particularly borderline personality disorder (BPD), impair parenting behavior. Consequently, the children exhibit an elevated risk for psychopathology across their lifespan. Social support for parents is thought to moderate the relationship between parental mental illness and parenting behavior. It may dampen negative effects and serve as starting point for preventive interventions. This paper provides a literature overview regarding the impact of social support on the sequelae of parental mental illness and BPD for parenting behavior.

RECENT FINDINGS

Current literature highlights the increased burden of families with a mentally ill parent and associated changes in parenting behavior like increased hostility and affective dysregulation, especially in the context of parental BPD. Literature further demonstrates the powerful impact of social support in buffering such negative outcomes. The effect of social support seems to be moderated itself by further factors like socioeconomic status, gender, or characteristics of the social network. Social support facilitates positive parenting in mentally ill parents and may be particularly important in parents with BPD. However, social support is embedded within a framework of influencing factors, which need consideration when interpreting scientific results.

Complex PTSD and personality disorder in ICD-11: when to assign one or two diagnoses?

OBJECTIVE

To outline overlap and boundaries between ICD-11 definitions of complex post-traumatic stress disorder (C-PTSD) and personality disorder (PD) and propose guiding principles that may assist practitioners in assigning one or both of the two diagnoses.

CONCLUSIONS

The ICD-11 definitions for C-PTSD and PD are substantially comparable in terms of self- and interpersonal problems, and childhood trauma may be at the root of both disorders. The ICD-11 formally recognizes this overlap and allows the assignment of both diagnoses at the same time. The C-PTSD diagnosis essentially differs from a PD diagnosis by requiring a history of trauma and PTSD symptoms. Moreover, C-PTSD typically involves stable and persistent patterns of negative self-perception while emphasizing avoidant interpersonal patterns. In comparison, the PD diagnosis may differ from C-PTSD by allowing an unstable or internally contradictory sense of self, which may involve both overly negative and overly positive self-views. When the diagnostic requirements for both C-PTSD and PD are met, only the C-PTSD diagnosis should be assigned, unless the PD diagnosis may contribute with clinically useful information that is not sufficiently covered by the C-PTSD diagnosis. The outlined similarities and boundaries must be further corroborated by future empirical studies.

Borderline Personality Disorder: Risk Factors and Early Detection

Personality disorders (PDs) exert a great toll on health resources, and this is especially true for borderline personality disorder (BPD). As all PDs, BPD arises during adolescence or young adulthood. It is therefore important to detect the presence of this PD in its earlier stages in order to initiate appropriate treatment, thus ameliorating the prognosis of this condition. This review aims to highlight the issues associated with BPD diagnosis in order to promote its early detection and treatment. To do so, we conducted a search on PubMed database of current evidence regarding BPD early diagnosis, focusing on risk factors, which represent important conditions to assess during young patient evaluation, and on diagnostic tools that can help the clinician in the assessment process. Our findings show how several risk factors, both environmental and genetic/neurobiological, can contribute to the onset of BPD and help identify at-risk patients who need careful monitoring. They also highlight the importance of a careful clinical evaluation aided by psychometric tests. Overall, the evidence gathered confirms the complexity of BDP early detection and its crucial importance for the outcome of this condition.

Parental Mental Health Problems and the Risk of Child Maltreatment: The Potential Role of Psychotherapy

Parental mental health is a risk factor for numerous issues affecting a child’s physical and psychological development, especially the perpetration of child maltreatment. This paper aims to contribute a theoretical review of the risks faced by some children living in families with parental mental health problems and argues that psychotherapy has an essential role in resolving emotional and interpersonal difficulties, based on the example of Emotion Focused Therapy (EFT). This model has revealed benefits in interventions with several types of patients and is consequently a promising model for preventing the risk of aggressive behaviors. The programs addressing both parents and children have been proven to contribute to more informed and effective interventions.

Prevalence and characteristics of women with borderline personality pathology referred to a perinatal consultation liaison service

OBJECTIVE

To examine the prevalence and characteristics of pregnant women with borderline personality pathology (defined as borderline personality disorder and borderline personality traits) referred to a perinatal consultation-liaison psychiatry service.

METHOD

Socio-demographic and clinical data, and diagnoses made according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria were recorded for all women referred to and seen by the perinatal consultation-liaison psychiatry service over an 18-month period. Data were analysed using descriptive statistics and logistic regression analysis.

RESULTS

A total of 318 women were seen. The most common diagnoses found were depressive disorder (25.5%) and anxiety disorder (15.1%). Borderline personality disorder was found in 10.1% of women and almost one in five women had two or more borderline personality traits (19.5%). When compared to women with other diagnoses, women with borderline personality pathology had higher rates of unplanned pregnancy, being unpartnered, substance use during pregnancy and higher rates of child safety services involvement as a child or in a previous pregnancy. Over 40% of women with borderline personality pathology were referred to child safety services in the current pregnancy and a diagnosis of borderline personality pathology increased the risk of child safety services involvement by almost sixfold (odds ratio: 5.5; 95% confidence interval = [1.50, 20.17]).

CONCLUSION

The prevalence of borderline personality pathology in antenatal women identified at antenatal screening and the recognition that women with borderline personality pathology are 'high-risk' caregivers argue for borderline personality pathology to be recognised as a high priority for investment in service development.

Maternal Mental Disorders and Pediatric Infectious Diseases: A Retrospective Cohort Study

BACKGROUND

Maternal stress and depression are associated with infections in offspring, but there is a paucity of data for other mental disorders.

METHODS

We conducted a retrospective cohort study of 832,290 children born between 2006 and 2016 in hospitals of Quebec, Canada. We identified maternal mental disorders before and during pregnancy, and admissions for otitis media, pneumonia, infectious enteritis and other infections in children before 13 years of age. We used Cox proportional hazards regression to estimate hazard ratios (HRs) with 95% confidence intervals (CI) for the association between maternal mental disorders and the risk of pediatric infectious diseases, adjusted for maternal age, comorbidity, socioeconomic disadvantage, and other confounders.

RESULTS

The incidence of pediatric infection hospitalization was higher for maternal mental disorders compared with no disorder (66.1 vs. 41.1 cases per 1000 person-years). Maternal mental disorders were associated with 1.38 times the risk of otitis media (95% CI: 1.35-1.42), 1.89 times the risk of bronchitis (95% CI: 1.68-2.12), and 1.65 times the risk of infectious enteritis in offspring (95% CI: 1.57-1.74). Stress and anxiety disorders (HR 1.49, 95% CI: 1.46-1.53) and personality disorders (HR 1.55, 95% CI: 1.49-1.61) were more strongly associated with the risk of pediatric infection hospitalization than other maternal mental disorders. Associations were prominent in the first year of life and weakened with age.

CONCLUSIONS

Maternal mental disorders are risk factors for infectious disease hospitalization in offspring. Women with mental disorders may benefit from psychosocial support to reduce the risk of serious infections in their children.

Changing intergenerational patterns of emotional dysregulation in families with perinatal borderline personality disorder

A pilot study with women with borderline personality disorder (BPD) and their infants showed promising results. This clinical research program sought to discover whether ongoing implementation confirmed preliminary results in relation to maternal mental health and, in addition, whether parenting and the mother-infant relationship showed sufficient improvement. Women with BPD and their infants were referred to a 25-week group program of Mother-Infant Dialectical Behavior Therapy (MI-DBT). During groups, infants were provided care by childcare workers while mothers took part in a skills training session. Mothers and infants then reunited and took part in an activity together that incorporated skills taught in the teaching session. Sixty-nine of 98 women commencing MI-DBT completed the program, demonstrating a 71% completion rate. Women showed improvement on all measures of mental health including depression, anxiety, and BPD symptoms. While women reported improvement in parenting confidence, an objective measure of the mother-infant relationship showed continuation of concerning relationships in a significant percentage. MI-DBT was found to be effective at improving mothers' mental health, both at the initial site and in community settings, with different clinicians and with different childcare options. While there were some improvements found in measures of the mother's perception of the infant-parent relationship, there were no significant improvements in currently used observational measures of the interaction or the infant's social-emotional development, suggesting that additional intervention such as infant-parent therapy may be needed to augment the benefits of MI-DBT to improve outcomes in these areas.

Unraveling Prospective Reciprocal Effects between Parental Invalidation and Pre-Adolescents' Borderline Traits: Between- and Within-Family Associations and Differences with Common Psychopathology-Parenting Transactions

The etiology of borderline personality pathology has consistently been framed as an interactional process between child vulnerability (i.e. emotional sensitivity and reactivity; Linehan, 1993) and invalidating parenting strategies, which evolves into increased emotion dysregulation and disinhibited behavior of the child and in turn activates more parental invalidation. Despite the strong theoretical base in support of these high-risk parent-child transactions, invalidating parenting behaviors have mostly been explored as a cause of child dysregulation and disinhibition, rather than as a result of child-driven effects. Also, most transactional research in this regard focused at differences between families, thereby not addressing potential changes within families across time. The current study therefore examines bidirectional between- and within-family effects of childhood borderline-related traits and maternal invalidation in the sensitive developmental phase of pre-adolescence (n = 574; 54.4% girls) along three assessment points. Cross-Lagged Panel Models and Random-Intercept Cross-Lagged Panel Models indicated detrimental parenting effects of invalidation on subsequent development in borderline-related traits of the child both between and within families, and additional child-driven effects for subsequent invalidating parenting strategies within families. Beyond these transactions between borderline-related traits and parenting, the current study also indicates significant differences in the direction of effects when exploring transactions between more common dimensions of child internalizing/externalizing symptomatology and parental invalidation, suggesting a more substantial parenting etiology in the developmental process of borderline traits throughout pre-adolescence. Future longitudinal research may explore to what extent the transactional nature of borderline personality traits during important developmental stages indeed holds unique aspects compared to more common manifestations of symptomatology at young age.

Parental eating disorders: A systematic review of parenting attitudes, behaviours, and parent-child interactions

A substantial proportion of adults with eating disorders are parents. Studies suggest these parents may experience a range of parenting challenges, and their children may be at an increased risk for the development of eating disorders themselves. With parenting practices being one potential environmental mechanism for the intergenerational transmission of eating disorders, we systematically searched Scopus, Web of Science, PubMed, MEDLINE, PsychINFO, and PsychArticles for controlled studies in which parenting attitudes, behaviours, and parent-child interactions were examined for parents with and without probable eating disorders. 26,512 abstracts were screened, and 167 full-text manuscripts were retrieved, with 33 studies meeting the review inclusion criteria. Studies suggest that parents with eating disorders experience higher levels of parenting stress than control parents, and may on average be more intrusive, less sensitive, and provide less structuring/facilitation in non-feeding interactions with their children. These parents also appear, on average, to experience increased concern about their children's weight, and parent-child mealtime interactions may be problematic and characterised by high levels of conflict. Suggestions for future research are made with a view to enhancing understandings of the intergenerational transmission of eating disorders, which may lead to the identification of intervention targets for parents with eating disorders and their children.

Future directions in personality pathology development research from a trainee perspective: Suggestions for theory, methodology, and practice

Research on personality disorder (PD) development has received increased attention in the last two decades, spurring reconceptualization in theoretical models of etiology, use of advanced methods, and development of effective treatments. The current manuscript briefly reviews the state of the field and proposes avenues of new research on the development of personality pathology in theoretical, methodological, and clinical veins. We identify the need to adopt a unifying and comprehensive theory to describe PD development across the lifespan, novel statistical methods to complement traditional methods relied on thus far, and the adoption of developmentally sensitive interventions that are disseminated to professionals and trainees alike. These directions for future research aim to augment prevention efforts to reduce the burden of PDs earlier in life.

Risk and Protective Factors for Personality Disorders: An Umbrella Review of Published Meta-Analyses of Case-Control and Cohort Studies

The putative risk/protective factors for several personality disorders remain unclear. The vast majority of published studies has assessed personality characteristics/traits rather than disorders. Thus, the current umbrella review of meta-analyses (MAs) aims to systematically assess risk or protective factors associated with personality disorders. We searched PubMed-MEDLINE/PsycInfo databases, up to August 31, 2020. Quality of MAs was assessed with AMSTAR-2, while the credibility of evidence for each association was assessed through standard quantitative criteria. Out of 571 initial references, five meta-analyses met inclusion criteria, encompassing 56 associations of 26 potential environmental factors for antisocial, dependent, borderline personality disorder, with a median of five studies per association, and median 214 cases per association. Overall, 35 (62.5%) of the associations were nominally significant. Six associations met class II (i.e., highly suggestive) evidence for borderline personality disorder, with large effect sizes involving childhood emotional abuse (OR = 28.15, 95% CI 14.76-53.68), childhood emotional neglect (OR = 22.86, 95% CI 11.55-45.22), childhood any adversities (OR = 14.32, 95% CI 10.80-18.98), childhood physical abuse (OR = 9.30, 95% CI 6.57-13.17), childhood sexual abuse (OR = 7.95, 95% CI 6.21-10.17), and childhood physical neglect (OR = 5.73, 95% CI 3.21-10.21), plus 16 further associations supported by class IV evidence. No risk factor for antisocial or dependent personality disorder was supported by class I, II, and III, but six and seven met class IV evidence, respectively. Quality of included meta-analyses was rated as moderate in two, critically low in three. The large effect sizes found for a broad range of childhood adversities suggest that prevention of personality disorders should target childhood-related risk factors. However, larger cohort studies assessing multidimensional risk factors are needed in the field.

Trauma and psychopathology associated with early onset BPD: an empirical contribution

Prodromal symptoms of borderline personality disorder (BPD) often arise in young age, especially in early adolescence. Several factors for early BPD onset have been identified to consent a precocious detection of high-risk population. The present study is aimed: (1) to identify what psychopathological, traumatic, and functional factors are significantly associated to early onset in a sample of BPD patients and (2) to evaluate what factors are associated to the time interval between symptoms onset and first psychiatric visit (Δ age). Participants were enrolled from BPD outpatients attending the Center for Personality Disorder of the University of Turin, Italy. Patients were tested with assessment instruments for specific BPD symptoms, exposure to traumatic experiences, global functioning, and perception of quality of life. All variables that were found significant at a bivariate analysis were included in two multiple regressions (stepwise backward), with the age of onset and the Δ age as dependent variables. Significance level was P ≤ 0.05. Seventy patients were included in the study (68 completers). Factors that were found related to age of onset were: CTQ-SF emotional abuse (P = 0.001); ACE-IQ bully victimization (P = 0.005), alcohol/drug abuser in the household (P = 0.001), and physical neglect (P = 0.006); BIS non-planning impulsivity (P = 0.005); and SOFAS score (P = 0.033). Factors that were found related to Δ age were: ACE-IQ total score (P = 0.001) and BIS total score (P = 0.001). Earlier onset of BPD is mainly associated to traumatic events, including abuse, neglect, dysfunction in household environment, and bullying. Earlier onset is also related to a worse social functioning. Among BPD symptoms only non-planning impulsivity was found associated to early onset. A higher number of traumatic events and worse impulsive dyscontrol induce a significant reduction of the time interval between onset and first psychiatric observation.

The Parenting Experience of Those With Borderline Personality Disorder Traits: Practitioner and Parent Perspectives

Background

Borderline Personality Disorder (BPD) is associated with challenges around emotional intensity and interpersonal difficulties. The children of parents with BPD are at risk of poorer outcomes in terms of their own mental health, educational outcomes and wellbeing. The challenges of being a parent can also exacerbate the symptoms of those with BPD traits. There is a pressing need to understand the experience of these parents and to determine what support would be appropriate and useful.

Aim

To explore and compare the experiences and support needs of parents with BPD traits with the experiences and understanding of practitioners who work with them.

Methods

Interviews with 12 parents with BPD traits and 21 practitioners with experience of working with individuals with BPD. The two strands of interviews were analyzed independently using a thematic framework approach, after which the superordinate and subordinate themes were subject to comparison.

Results

Parents with BPD traits represent themselves as experiencing considerable challenges in their role as a parent. These included the impact of emotional intensity, social isolation and lack of a positive parenting models to draw upon. Practitioners demonstrated a strong degree of shared understanding into these difficulties. Both groups highlighted a lack of appropriate support for these parents.

Conclusion

This research highlights the clinical need for parenting-focused support for individuals with BPD traits. Preliminary suggestions for format and content are given.

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.

Familiäre Transmission der Borderline-Persönlichkeitsstörung

Hintergrund

Forschungsergebnisse weisen übereinstimmend darauf hin, dass Kinder von Müttern mit einer Borderline-Persönlichkeitsstörung (BPS) ein erhöhtes Risiko aufweisen, emotionale und verhaltensbezogene Auffälligkeiten zu entwickeln und/oder im Jugendalter selbst BPS-spezifische Symptomausprägungen zu zeigen.

Fragestellung

Welche Faktoren sind bei der familiären Transmission der BPS involviert, und welche Implikationen für die Praxis können darauf aufbauend abgeleitet werden?

Material und Methode

Auf der Basis einer umfassenden Literaturrecherche wurden aktuelle Forschungsbefunde zur familiären Transmission der BPS von Müttern zu ihren Kindern zusammengetragen und Kernbefunde in einem Transmissionsmodell integriert.

Ergebnisse

Das hier postulierte Transmissionsmodell bildet ein komplexes Zusammenspiel verschiedener Einflussfaktoren und Übertragungsmechanismen ab. Neben Faktoren aufseiten der Mutter und des Kindes werden externe Faktoren in das Modell integriert. Darüber hinaus werden (epi-)genetische und pränatale Einflüsse, die Bedeutung der Mutter-Kind-Interaktion und familiäre sowie soziale bzw. gesellschaftliche Einflüsse als Übertragungsmechanismen betont. Zudem wird eine potenziell präventive Wirkung der Hilfesysteme angenommen.

Schlussfolgerung

Aus dem Modell werden Ansatzpunkte abgeleitet, die dazu beitragen könnten, die Vulnerabilität sowie Belastungsfaktoren zu reduzieren und somit eine gesunde kindliche Entwicklung in dieser Risikogruppe zu fördern.

Parenting stress and competence in borderline personality disorder is associated with mental health, trauma history, attachment and reflective capacity

BACKGROUND

Individuals with borderline personality disorder (BPD) may experience additional challenges in their parenting role, including increased stress and lower self-efficacy and satisfaction. These difficulties have been shown to impact their children, and may be implicated in the potential intergenerational transmission of personality vulnerabilities.

METHODS

Parental stress and competence variables were examined in a cross-sectional study of 284 parents (94.72% female, M = 37.37, SD = 8.04 years), of which 69 (24.30%) met caseness for BPD criteria. We completed a multivariate analysis of variance to test how parents with 'high BPD features' (meeting caseness for BPD) compared to those with 'low BPD features' on a range of parenting and mental health variables. Multivariate linear regression modelling was then utilised to explore whether these parenting variables were associated with personality and psychological wellbeing, recalled trauma history, orientation to attachment relationships and reflective capacity.

RESULTS

Individuals high in BPD features experienced more stress and lower competence in their parenting role than those low in BPD features. These parents also reported more personality vulnerabilities, poorer psychological wellbeing, recalled more traumatic experiences in their childhood, were more likely to endorse insecure attachment styles and had poorer reflective capacity. In the regression model, parenting stress and competence was associated with personality traits, general psychological wellbeing, recalled trauma history, attachment style and reflective capacity variables. Parental reflective capacity had the strongest association with parenting stress, satisfaction, efficacy, the perception of having a difficult child and a difficult parent-child relationship, and psychological wellbeing had the greatest association with parenting distress.

CONCLUSIONS

Parents who were able to imaginatively enter the subjective world of the child and hold the child's mind in mind with less certainty, reported reduced parenting stress and greater parenting satisfaction and efficacy. Helping to improve personality and mental health functioning, increasing parental reflective capacity and strengthening parent-child attachment relationships, may reduce parenting stress and increase parenting competence in individuals with BPD.