Childhood adversity in association with personality disorder dimensions: New findings in an old debate

Inadequate Coping Strategies of Men who Have Committed Sexual Aggression Against Women: A Study of Their Developmental Antecedents

Several researchers have found that men who have committed sexual aggression have inadequate coping strategies (e.g., paraphilic sexual fantasies, substance abuse). However, very few researchers have empirically examined the factors potentially associated with the development of these strategies. In 2011, Maniglio hypothesized that the inadequate coping strategies of men who have committed sexual aggression are the result of childhood victimization, mediated by internalized psychological problems. The present study therefore empirically tested this hypothesis in a Canadian sample of 205 men who had committed sexual aggression against women, of whom 37 committed sexual murder. Structural equation modeling (SEM) resulted in the identification of several direct and indirect trajectories leading from childhood victimization (psychological, physical, sexual) to the development of inadequate coping strategies (paraphilic sexual fantasies, alcohol and drug use) mediated by internalized psychological problems (e.g., anxiety, depression, social isolation). The theoretical and clinical implications of these developmental trajectories are discussed.

Differentiating between intrapsychic symptoms and behavioral expressions of borderline personality disorder in relation to childhood emotional maltreatment and emotion dysregulation: an exploratory investigation

BACKGROUND

Borderline personality disorder (BPD) is a severe mental disorder, characterized by pronounced instability in emotions, self-image, and interpersonal relationships. Experiences of childhood maltreatment are among the risk factors for BPD. While self-damaging and aggressive acts often occur, not every person with the disorder shows markedly dysregulated behaviour. Internalized symptoms, such as shame, loneliness, and self-disgust tend to be more pervasive and persist after clinical remission.

OBJECTIVE

Here we investigated associations between BPD symptom severity, childhood maltreatment, and emotion regulation difficulties. We further explored if the Borderline Symptom List (BSL) could potentially be used to differentiate between internalized symptoms (intrapsychic strain) and externalized symptoms (dysregulated behaviours) in future research.

METHOD

187 women with at least mild BPD symptoms (65% having a diagnosis of BPD) completed the BSL 23 including its 11-item supplement (BSL-S), the Childhood Trauma Questionnaire (CTQ), and Difficulties in Emotion Regulation Scale (DERS). Participants further underwent a semi-structured clinical interview to assess BPD criteria (International Personality Disorder Examination, IPDE). Multivariate models and regression-based bootstrapping analyses were performed to test direct and indirect effects.

RESULTS

Childhood trauma severity, especially emotional abuse, positively predicted BPD symptom severity. A significant indirect effect through emotion regulation difficulties was found (k2=.56). When exploring associations with BPD criteria (IPDE), the BSL-23 mean significantly correlated with separation anxiety, identity and mood problems, chronic emptiness, suicidal ideation, and dissociation, while the BSL-S correlated with self-harming impulsive behaviour and anger outbursts.

CONCLUSIONS

Findings complement previous research, highlighting the role of childhood maltreatment and emotion regulation difficulties in BPD. While our findings need to be seen as preliminary and interpreted with caution, they suggest that the BSL may be used to differentiate between internalized symptoms and behavioural expressions of BPD in future research. Such a distinction might help to deepen the understanding of this complex heterogenous disorder.

Differential associations between childhood maltreatment types and borderline personality disorder from the perspective of emotion dysregulation

BACKGROUND

Borderline Personality Disorder (BPD) is characterized by pervasive instability in a range of areas including interpersonal relationships, self-image, and affect. Extant studies have consistently identified significant correlations between childhood maltreatment (CM) and BPD. While exploring this CM-BPD link, a number of cross-sectional studies commonly emphasize the role of emotion dysregulation (ED). A better understanding of the associations between BPD and (1) CM and (2) ED are essential in formulating early, effective intervention approaches, and in addressing varied adverse impacts.

METHODS

This cross-sectional study analyzed a subset of baseline data collected for a larger community-based longitudinal study. Given that our current focus on CM and ED, only those participants who completed the baseline CM assessment and ED measure (N = 144) were included for the primary analyses. We conducted stepwise multivariate linear models to examine the differential relationships between BPD features, ED, and multiple CM types. A path analysis with latent factors using the structural equation modeling (SEM) method was performed to test the indirect effect from CM to BPD features via ED.

RESULTS

Linear regression models revealed that only emotional abuse (relative to other trauma types) was significantly associated with high BPD features. The SEM, by constructing direct and indirect effects simultaneously, showed that (1) ED partially mediated the path from CM to BPD features; and (2) CM played an important role in which the direct effect remained significant even after accounting for the indirect effect through ED.

CONCLUSIONS

Our results highlight a most consistent association between emotional abuse and BPD, indicating its unique role in understanding BPD features in the context of CM. Further, shame-related negative appraisal and ED were found critical when examining the association between CM and BPD, possibly providing promising treatment targets for future practices.

A Systematic Review of the Association Between Early Childhood Trauma and Borderline Personality Disorder

Borderline personality disorder (BPD) is a debilitating clinical disorder associated with adverse impacts on multiple levels. While a high prevalence of childhood trauma has been noted, the ways such trauma impacts the development of BPD symptomatology remain unclear. In this systematic review, the authors examine the literature from 2000 to 2020, focusing on the association between trauma and BPD, and offer a comprehensive synthesis of possible etiological implications related to either one specific or multiple trauma types. In addition, results are analyzed based on commonly tested trauma parameters, including repeated exposure, polytrauma, onset, perpetrators, and gender. The authors also note some limitations in areas of sampling, measurement, causal inference methods, and data analyses. Results of this review point to several parameters of trauma that can be used to inform training for practitioners as well as enhance current interventions.

Childhood emotional abuse and motor impulsiveness among male violent inmates with antisocial personality disorder

This study aimed to explore the relationship among childhood maltreatment, impulsiveness and antisocial personality through a questionnaire survey of violent male inmates. We found that the scores of inmates with Antisocial Personality Disorder (ASPD) in Childhood Trauma Questionnaire-28 item Short Form (CTQ-SF) and Barratt Impulsive Scale-11 (BIS-11) were higher than those in the Non-Antisocial personality group, and there was a significant correlation between the scores of CTQ-SF and BIS-11. We found that the interaction between impulsivity and childhood abuse predicts ASPD levels. Moreover, motor and non-planning impulsiveness played important roles in the observed differences in antisocial personality scores among the inmates who had experienced childhood maltreatment; motor impulsiveness was mainly related to emotional abuse, physical abuse, and sexual abuse, while non-planning impulsiveness was mainly related to emotional neglect and physical neglect. These findings suggest that identifying and providing timely intervention for inmates with high impulsiveness who experienced maltreatment in childhood may also contribute to the prevention of violent behavior and to better prison management.

Are Children Harmed by Being Locked up at Home? The Impact of Isolation during the COVID-19 Pandemic on the Phenomenon of Domestic Violence

The phenomenon of violence against children is a very complex one. There are many types of child abuse, and they are culturally dependent to a significant degree. Although studies show that children generally only suffer from mild COVID-19 infection, some social restrictions introduced during the pandemic, such as home isolation, may have many severe consequences on the population's mental health. Studies on this topic suggest that violence against children increased during lockdown due to the COVID-10 pandemic. This narrative review summarizes this available literature on the subject and discusses the different forms of violence against children, their cultural aspects, the impact of the COVID-19 pandemic on the phenomenon of violence, the long-term consequences of the above, and forms of assistance for abused minors.

Narcissistic Personality Disorder: Progress in Understanding and Treatment

This review summarizes current knowledge about narcissistic personality disorder (NPD). Each section brings the reader up to date on advances in our knowledge during the last decade. In terms of NPD diagnosis, this review describes the addition of the dimensional model to the categorical model. The accumulating knowledge has led to the description of grandiose and vulnerable narcissism as well as their complex interrelationship. Strong support exists for co-occurrence of these presentations among people with high levels of grandiose narcissism. Studies have identified mechanisms, in domains such as self-esteem dysregulation, emotion dysregulation, cognitive style, interpersonal relations, and empathy, and possible developmental and temperamental antecedents of the disorder. Thus, it appears that NPD has a multifactorial etiology and pathogenesis, with numerous mechanisms associated with each area of dysfunction. Longitudinal studies support the view that these patients can improve, but such improvement is gradual and slow. Several treatments have been developed for the disorder, and a majority share commonalities, including clear goals, attention to treatment frame, attention to relationships and self-esteem, alliance building, and monitoring of countertransference.

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.

Below average motor skills predict victimization from childhood bullies: A study of adults with ADHD

Children with ADHD are frequently clumsy and involved in bullying, both as victims and perpetrators. The relationship between motor skills and bully status is poorly understood. The aim of the current study was to evaluate the effect of motor skills in childhood on bully victimization/perpetration in those with ADHD. In this cross-sectional study, 403 adults diagnosed with ADHD filled out a questionnaire on their recall of bully victimization, bully perpetration, performance in physical education (PE) (defined as performance below average in i.e., ball dexterity, coordination or agility) as a proxy for motor skills, and academic skills at age 12, as compared to their peers. Of the current sample, 63% remembered being victimized and 31% noted they were perpetrators. Thirty-two percent recalled that they performed below average in PE. Being diagnosed with ADHD and having poor motor skills was strongly associated with bully victimization (OR = 2.63; 95% CI:1.62, 4.27, p < .001). Victimization was more common during all measured time periods, from nursery school until the age of 15, among those with poor performance in PE as compared to those without poor performance. No relationship was found between poor motor skills and bully perpetration. CONCLUSION: A crucial role of the cerebellum is coordination and the linking of sequenced motor actions through milli-second timing. Aberrations in this ability makes a person present as "different", which was stated as the most common reason for social exclusion by other children. Therefore, subtle clumsiness (presumed by poor performance in PE class) is suggested to mirror deficits in social skills, which is intuitively observed by peers, leading to victimization.

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.

The mediation effect of personality functioning between different types of child maltreatment and the development of depression/anxiety symptoms - A German representative study

BACKGROUND

Child maltreatment (CM) is associated with an increased risk to develop symptoms of depression/anxiety across an individual's lifespan. Recent studies indicated that impairments in personality functioning might mediate this association. The purpose of this study is to add evidence of this mediating effect by regarding different types of CM (emotional, physical and sexual abuse as well as emotional and physical neglect) in the general population.

METHODS

A representative sample of the German population (N = 2,354) completed a set of standardized measures (OPD-SQS: Operationalized Psychodynamic Diagnosis - Structure Questionnaire Short, PHQ-4: Patient Health Questionnaire, CTQ: Childhood Trauma Questionnaire). Mediation analyses were carried out to examine the association between CM types, symptoms of depression/anxiety, and personality functioning.

RESULTS

Up to two-thirds of the associations between CM types and symptoms of depression/anxiety are mediated by personality functioning [indirect effect: emotional abuse (β = 0.219, 95%-CI: 0.187-0.251, p < .001), physical abuse (β = 0.151, 95%-CI: 0.123-0.178, p < .001), sexual abuse (β = 0.163, 95%-CI: 0.138-0.188, p < .001), emotional neglect (β = 0.131, 95%-CI: 0.104-0.159, p < .001) and physical neglect (β = 0.102, 95%-CI: 0.078-0.127, p < .001)].

LIMITATIONS

Symptoms of depression/anxiety were measured with screening instruments and results are based on cross-sectional data.

CONCLUSIONS

The present investigation expands the evidence on the mediating effect of personality functioning in the association between CM and depression/anxiety symptoms based on data of the general population. Our results show the relevance of types, as the mediating effects are slightly stronger in CM abuse types than in CM neglect types. Knowledge about impaired personality might be an angle for clinical interventions and inspire future research.

The Association Between Childhood Trauma and Attachment Functioning in Patients With Personality Disorders

Attachment (mal)functioning and a history of childhood trauma (CT) are both considered psychological determinants of personality disorders (PDs). Their interaction, however, remains largely uninvestigated. In this study, the authors assessed adult and childhood attachment style in a sample of patients with diverse PDs (N = 75) and determined the relation with both occurrence and severity of CT. The authors found that the sample was characterized by severe attachment malfunctioning and high levels of CT. Using cross-tabulations and analysis of variance, the authors showed that patients with a fearful or dismissive attachment style experienced more severe CT than patients with a preoccupied attachment style. Patients reporting an affectionless control bonding style to either parent suffered frequent and severe CT. Although temporal causality cannot be determined, these findings stress the necessity to screen for CT in PDs and suggest that attachment-centered psychotherapy for these patients may benefit from preceding or concurrent trauma treatment.

Personality Disorders, Risky Behaviors, and Adversity: The Moderating Role of Resilience

Individuals with personality disorders (PDs) comprise 30% to 40% of individuals receiving mental health treatment. Treatment of PDs is exceedingly difficult; therefore, research has focused on PD etiology and preventative factors. One known influence on PD etiology is adverse childhood experiences (ACEs). ACEs are associated with increased prevalence of several health risk behaviors (HRBs), including engagement in substance use, criminal, and risky sexual behavior. One protective factor, childhood resiliency, predicts lower prevalence of PDs and engagement in HRBs. We hypothesized that increased prevalence of ACEs would predict higher levels of PD symptoms and HRBs engagement. Furthermore, we predicted that childhood resiliency would moderate the relation between ACEs, PD symptoms, and HRBs. In the present study, students (N = 531) completed the Adverse Childhood Experiences survey, the Self-Administered - Standardized Assessment of Personality Abbreviated Scale, and the Childhood Youth and Resiliency Measure-28. They also responded to questions about substance use, criminal, and sexual behavior which were used to define a latent HRB variable. Structural equation modeling was conducted to examine study hypotheses. As hypothesized, we found positive relations between ACEs, PD symptoms, and our HRB latent variable. Childhood resiliency moderated both ACE and PD symptom paths. At lower levels of reported ACEs, individuals high in childhood resiliency reported fewer PD symptoms and HRBs than individuals low in childhood resiliency. At high levels of ACEs, childhood resiliency did not serve as a protective factor. Additionally, study findings suggest that childhood resiliency factors are integral for protecting against the development of these disorders.

Adverse childhood experiences and trajectories of internalizing, externalizing, and prosocial behaviors from childhood to adolescence

BACKGROUND

Adverse childhood experiences (ACEs) predict poorer mental health across the life course but most of the extant research has employed ACE scores or individual adversities using retrospective data.

OBJECTIVES

To study the impact of ACEs on later mental health using not only ACEs scores and individual ACEs, but also latent class analysis (LCA), which respects the clustering of adversities.

PARTICIPANTS AND SETTING

8823 members from the UK Millennium Cohort Study.

METHODS

We investigated the impact of prospectively reported ACEs on mental health trajectories derived using the Strengths and Difficulties Questionnaire at age 3, 5, 7, 11 and 14. Associations between LCA-derived ACE clusters, ACE scores, individual ACEs and mental health trajectories were tested using linear mixed effects models.

RESULTS

With statistical significance set at 5% level, ACE scores showed a graded association with internalizing (ACE score of 1: β = 0.057; ACE score of 2: β = 0.108; ACE score of 3: β = 0.202), externalizing (ACE score of 1: β = 0.142; ACE score of 2: β = 0.299; ACE score of 3: β = 0.415) and prosocial behaviors (ACE score of 1: β=-0.019; ACE score of 2: β=-0.042; ACE score of 3: β=-0.059). Harsh parenting and physical punishment were particularly strongly associated with externalizing (β = 0.270 and β = 0.256) and negatively associated with prosocial behaviors (β=-0.046 and β=-0.058). Parental discord and parental depression showed the strongest associations with internalizing problems (β = 0.125 and β = 0.113). LCA did not discriminate ACE clusters in this dataset.

CONCLUSIONS

ACEs have an important impact on mental health from childhood to adolescence. ACEs score approach yielded useful results, which were further enhanced by exploring individual ACEs.

How to understand and help a person with borderline personality. Case report and literature review on the therapeutic possibilities

Introduction: The study aims to present 1) a case report of an 18-year-old female patient with borderline personality disorder (BPD) 2) the diagnostic and treatment difficulties in BPD patients.

Materials and methods: The review of the literature from the years 1953-2020 searched from PubMed, Google Scholar, and Web of Science databases.

Discussion: Patient, 18-years old, hospitalized five times for psychiatric care, presenting self-injurious behaviours, hurting herself within forearms. A patient attempted suicide eight times. She is living with her divorced parents. The patient’s father has a new partner with whom he has children. The patient used marijuana and she was experiencing psychotic symptoms under its influence. She smokes 10 cigarettes per day and drinks alcohol once a week since she was 16 years old. Psychiatric problems appeared when the patient started learning in high school.

Conclusions:

1. Borderline personality disorder (BPD) is a serious psychiatric condition of a difficult diagnosis that should be differentiated with many other psychiatric disorders such as an atypical or subclinical course of psychosis, affective disorders, or dissocial personality.

2. A therapeutic process of a person with BPD is based on psychotherapy and personalized treatment strategies, whereas, pharmacological treatment plays only a supporting role during BPD treatment.

Association between different types of childhood trauma and parental bonding with antisocial traits in adulthood: A systematic review

BACKGROUND

ASPD describes individuals with a pervasive pattern of disregard for the rights of others that begins in childhood and continues into adulthood. The relationship between parental bonding, trauma, and ASPD is well established, however, it remains unclear what types of trauma or which patterns of bonding are more associated with ASPD.

OBJECTIVES

Review the literature regarding what types of trauma and bonding characteristics were related to antisocial personality traits.

METHOD

Systematic searches of PubMed, Embase, Web of Science, and Scielo for studies about the relationship between antisocial personality traits and the Childhood Trauma Questionnaire (CTQ) and/or the Parental Bonding Instrument (PBI).

RESULTS

357 abstracts were selected, and 18 studies met the inclusion criteria. Regarding CTQ, the most consistent finding was the association between physical abuse and neglect to antisocial traits. Sexual abuse was the variable least related to antisocial traits. Regarding PBI, the most consistent finding was the inverse relationship between maternal and paternal care and antisocial traits. Concerning overprotection, the data is less consistent. Also, there was a considerable heterogenity between studies.

CONCLUSIONS

The literature little explores how these variables interact with each other. Thus, more studies are important to aidpolitical,educational, and public health programs to create preventive initiatives for ASPD.

Schema modes mediate the effect of emotional abuse in childhood on the differential expression of personality disorders

BACKGROUND

There is sound evidence that childhood maltreatment increases the likelihood of developing personality disorders (PDs). However, research on the possible mechanisms involved in the relationship between childhood maltreatment and PDs is scarce. One potential mediator of the maltreatment-PD relationship are schema modes, reflecting dynamic states of cognition, emotion, and behaviour.

AIMS

The current study aimed to explore the mediating effect of schema modes on the association between childhood maltreatment and the expression of Cluster B (borderline and antisocial) and C (avoidant and dependent) PDs.

METHOD

Within a mixed sample of N = 120 clinical PD patients and non-clinical participants, a multivariate path model including interview-assessed childhood maltreatment (emotional abuse, emotional neglect, sexual abuse, and physical abuse), schema modes (child, parent, coping and healthy modes), and borderline, antisocial, avoidant and dependent PDs was explored.

RESULTS

The path model depicted five significant indirect links from emotional abuse on PDs via distinct schema modes. The impact of emotional abuse on borderline PD was mediated by child and coping modes, while parent modes mediated the link to antisocial PD. Healthy modes acted as a mediator on dependent and avoidant PDs.

CONCLUSIONS

The results indicate emotional abuse as a main predictor of schema mode clusters and emphasize the mediating role of schema modes on the maltreatment-related pathways towards PDs. Therapeutic implications are discussed with a special focus on healthy modes.

Mentalization-Based Treatment for Pathological Narcissism

Despite the growing cultural and empirical interest in pathological narcissism (PN), effective treatment guidelines for PN have not yet been established. This article develops mentalization-based treatment (MBT), a leading evidence-based therapy for borderline personality disorder, as a primary intervention for PN. Synthesizing research on parenting styles, attachment patterns, and empathy in PN, the authors propose a developmental model of narcissism centering on impairments in mentalization. Core therapeutic techniques of MBT for PN are outlined, including clinical examples to illustrate practical implementation. As an accessible, easy-to-operationalize, and resource-sensitive therapeutic approach, MBT offers considerable promise for future empirical investigation and clinical applications in the treatment of patients with pathological narcissism.

Transdiagnostic Dimensions towards Personality Pathology and Childhood Traumatic Experience in a Clinical Sample: Subtype Classification by a Cross-sectional Analysis

Psychiatric disorders are highly heterogeneous syndromes often explained by underlying and internalized personality disorder(PD) traits that are affected by externalized childhood trauma experiences(CTE). The present study investigated the differential subtype model by examining the association between PD traits and CTE in a clinical sample with transdiagnostic psychopathology. Outpatients(n = 2090) presenting for psychiatric treatment completed self-reported measures of PD traits(Personality Diagnostic Questionnaire) and the childhood adversity(Child Trauma Questionnaire). Canonical variates were generated by canonical correlation analysis(CCA) and then used for hierarchical cluster analysis to produce subtypes. A support vector machine(SVM) model was used and validated using a linear kernel to assess the utility of the extracted subtypes of outpatients in clinical diagnosis classifications. The CCA determined two linear combinations: emotional abuse related dissociality PD traits(antisocial and paranoid PD) and emotional neglect related sociality PD traits(schizoid, passive-aggressive, depressive, histrionic, and avoidant PD). A cluster analysis revealed three subtypes defined by distinct and relatively homogeneous patterns along two dimensions, and comprising 17.5%(cluster-1, n = 365), 34.8%(cluster-2, n = 727), and 47.8%(cluster-3, n = 998) of the sample, each with distinctive features of PD traits and CTE. These subtypes suggest more distinct PD trait correlates of CTE manifestations than were captured by clinical phenomenological diagnostic definitions. Our results highlight important subtypes of psychiatric patients that highlight PD traits and CTE that transcend current diagnostic boundaries. The three different subtypes reflect significant differences in PD and CTE characteristics and lend support to efforts to develop PD and childhood trauma targeted psychotherapy that extends to clinical diagnosis-based interventions.

The possible mediating effect of alcohol dependence on the relationship between adverse childhood experiences and attempted suicide

Adverse childhood experiences (ACEs) and alcohol dependence (AD) carry independent risks for suicidal behavior. While the strength of the association between ACEs and attempted suicide is weakened following adjustment for AD, no study to date has directly been performed to determine whether AD affects the risk of suicide attributable to ACEs. The study aimed to examine the possible role of alcohol dependence (AD) in the relationship between various ACEs and attempted suicide. This cross-sectional study assessed history of ACEs among 184 AD patients and 205 control participants using the Family Health Questionnaire. Lifetime history of attempted suicide was collected using the Chinese version of the Composite International Diagnostic Interview. We used the Sobel test to examine the mediating effects of AD on the relationship between ACEs and attempted suicide. Results showed that the suicide attempters were associated with higher rates of AD and ACEs. The regression analysis showed that AD and multiple ACEs exposure are independently associated with attempted suicide. AD appears as a partial mediator in the relationship between attempted suicide and the specific type of ACE (exposure to a battered mother or sexual abuse) or exposure to ≥3 types of ACEs. We conclude that AD might partially mediate the associations detected between attempted suicide and exposure to a battered mother, sexual abuse, and ≥3 types of ACEs. These observations may provide important insight for intervention strategies aimed at reducing the risk of suicide attempts.

Borderline Personality Disorder (BPD): In the Midst of Vulnerability, Chaos, and Awe

Borderline personality disorder (BPD) is a chronic psychiatric disorder characterized by pervasive affective instability, self-image disturbances, impulsivity, marked suicidality, and unstable interpersonal relationships as the core dimensions of psychopathology underlying the disorder. Across a wide range of situations, BPD causes significant impairments. Patients with BPD suffer considerable morbidity and mortality compared with other populations. Although BPD is more widely studied than any other personality disorder, it is not understood sufficiently. This paper briefly reviews the recent evidence on the prevalence, etiology, comorbidity, and treatment approaches of borderline personality disorder (BPD) by examining published studies, and aims to offer a more coherent framework for the understanding and management of borderline personality disorder.

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

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Borderline personality disorder

Caretakers are often intimidated or alienated by patients with borderline personality disorder (BPD), compounding the clinical challenges posed by the severe morbidity, high social costs and substantial prevalence of this disorder in many health-care settings. BPD is found in ∼1.7% of the general population but in 15-28% of patients in psychiatric clinics or hospitals and in a large proportion of individuals seeking help for psychological problems in general health facilities. BPD is characterized by extreme sensitivity to perceived interpersonal slights, an unstable sense of self, intense and volatile emotionality and impulsive behaviours that are often self-destructive. Most patients gradually enter symptomatic remission, and their rate of remission can be accelerated by evidence-based psychosocial treatments. Although self-harming behaviours and proneness to crisis can decrease over time, the natural course and otherwise effective treatments of BPD usually leave many patients with persistent and severe social disabilities related to depression or self-harming behaviours. Thus, clinicians need to actively enquire about the central issues of interpersonal relations and unstable identity. Failure to correctly diagnose patients with BPD leads to misleading pharmacological interventions that rarely succeed. Whether the definition of BPD should change is under debate that is linked to not fully knowing the nature of this disorder.

Childhood Maltreatment as Predictor of Pathological Personality Traits Using PSY-5 in an Adult Psychiatric Sample

Extant literature indicates that childhood maltreatment is significantly associated with personality disorders. With the recent call for a more dimensional approach to understanding personality and pathological personality traits, the aim of the present study was to examine whether the experience of childhood maltreatment is associated with pathological personality traits as measured by the Personality Psychopathology Five (PSY-5). We analyzed data from 557 adult psychiatric patients with diverse psychiatric diagnoses, including mood disorders, schizophrenia spectrum disorders, and anxiety disorders. Hierarchical multiple regression analyses were conducted to determine the degree to which childhood maltreatment explained the five trait dimensions after controlling for demographic variables, presence of psychotic symptoms, and degree of depressive symptoms. Childhood maltreatment significantly predicted all of the five trait dimensions of the PSY-5. This suggests that childhood maltreatment may negatively affect the development of an adaptive adjustment system, thereby potentially contributing to the emergence of pathological personality traits.

The Nexus of Trauma, Victimization, and Mental Health Disorders Among Incarcerated Adults in Spain

Victimization and exposure to trauma, commonly linked to co-occurring mental health disorders, are prevalent among prison populations. The purpose of this study is to shed light on the prevalence of various kinds of victimization and trauma exposure at distinct life stages (childhood, adulthood and during prison) among incarcerated persons in Spain. The research team surveyed a random sample of 453 male and female inmates, serving time in two Spanish prisons, to gather information on experiences of physical and sexual victimization in both childhood and adulthood along with the presence or absence of in-prison treatment for a mental health disorder(s). More than 80% of participants reported experiencing some kind of traumatic/shocking life event - and this was significantly higher for those receiving in-prison mental health treatment than their non-treated counterparts (96.3 versus 83.3%, respectively). Logistic regression analyses revealed that inmates who were receiving in-prison treatment for a mental health disorder reported significantly higher rates of both physical and sexual victimization in prison, prior to prison, and during childhood. The results of this study strongly suggest the importance of comprehensive and accurate identification of inmates' traumatic, victimization, and mental health histories that necessitate treatment during incarceration. We discuss the implications of our study for correctional practice, policy and future research in order to reduce victimization in the Spanish Prison System.

Bullying involvement in relation to personality disorders: a prospective follow-up of 508 inpatient adolescents

We examined the association of bullying behavior in adolescence to personality disorder (PD) diagnosed in early adulthood. The study sample consisted of 508 adolescents (300 girls, 208 boys) who were admitted to psychiatric inpatient treatment between April 2001 and March 2006. Data were based on semi-structured K-SADSPL-interviews and hospital treatments extracted from the Care Register for Health Care (CRHC). At the end of 2013, details of psychiatric diagnoses recorded on hospital discharges and outpatient visits were extracted from the CRHC. This study showed that female victims of bullying have an almost fourfold likelihood of developing a PD later in life compared to adolescents with no involvement in bullying behavior. Most of the females had Borderline PD. Female adolescents diagnosed with anxiety disorder during adolescence had an over threefold risk of developing a PD during late adolescence or early adulthood. Conversely, we found no associations between bullying involvement among men in adolescence and subsequent PDs. Bullying victimization may influence the development of PDs among females. Adolescent services should pay particular attention to female victims of bullying and those displaying symptoms of anxiety disorders.

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

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

Neonatal isolation augments social dominance by altering actin dynamics in the medial prefrontal cortex

Social separation early in life can lead to the development of impaired interpersonal relationships and profound social disorders. However, the underlying cellular and molecular mechanisms involved are largely unknown. Here, we found that isolation of neonatal rats induced glucocorticoid-dependent social dominance over nonisolated control rats in juveniles from the same litter. Furthermore, neonatal isolation inactivated the actin-depolymerizing factor (ADF)/cofilin in the juvenile medial prefrontal cortex (mPFC). Isolation-induced inactivation of ADF/cofilin increased stable actin fractions at dendritic spines in the juvenile mPFC, decreasing glutamate synaptic AMPA receptors. Expression of constitutively active ADF/cofilin in the mPFC rescued the effect of isolation on social dominance. Thus, neonatal isolation affects spines in the mPFC by reducing actin dynamics, leading to altered social behavior later in life.

Anxious adult attachment may mediate the relationship between childhood emotional abuse and borderline personality disorder

BACKGROUND

Childhood trauma has been associated with borderline personality disorder (BPD). However, research has not yet provided conclusive evidence concerning the mediating mechanisms.

METHODS

Seventy women diagnosed with BPD were compared with other 60 women who met DSM-IV criteria for other personality disorders on measures of childhood trauma and attachment.

RESULTS

Patients with BPD reported higher severity of emotional, physical and sexual abuse than patients with other personality disorders. Moreover, BPD patients also showed greater preoccupied-anxious adult attachment. At model 1, logistic regression analysis revealed that only childhood emotional abuse predicted the occurrence of BPD. At model 2, this association was no longer significant, and the addition of preoccupied-anxious adult attachment was significantly associated with a greater likelihood of BPD diagnosis.

CONCLUSIONS

These findings support a specific relationship between childhood emotional abuse and the occurrence of BPD, which may be accounted for by preoccupied-anxious adult attachment. Copyright © 2016 John Wiley & Sons, Ltd.

Sexuality-related issues in borderline personality disorder: A comprehensive review

OBJECTIVE

Sexuality is somewhat neglected in clinical research on borderline personality disorder (BPD).

METHOD

We performed a systematic review from 1980 to November 2014 through PubMed and PsycINFO.

RESULTS

Empirical evidence underscores that childhood sexual trauma may be considered a non-specific risk factor for BPD. Furthermore, individuals with BPD also display higher sexual identity disturbances and homosexual relationships than non-BPD individuals. Moreover, patients with BPD also exhibit higher sexual impulsivity than non-BPD. In addition, sexual risk behaviours among individuals with BPD are related to increased rates of sexually transmitted diseases, unwanted pregnancies, rape and commercial sexual relationships, especially among drug abusers. Although psychotherapy is widely recommended for BPD, there has been little systematic research on the effect of these treatments with respect to co-morbid post-traumatic symptoms related to childhood sexual trauma.

CONCLUSIONS

Sexuality-related issues represent a major clinical topic within this population. Findings are discussed concerning their methodological limitations and clinical implications. Copyright © 2016 John Wiley & Sons, Ltd.

A retrospective chart review: adolescents with borderline personality disorder, borderline personality traits, and controls

With an estimated lifetime prevalence as high as 5.9% in the general population, borderline personality disorder (BPD) is a psychiatric disorder characterized by marked impulsivity as well as difficulties in interpersonal relationships, self-image, and affects. The burden on the health care system is immense with BPD patients accounting for 10%-20% of the patients in mental health outpatient facilities and 15%-40% in mental health inpatient facilities. Further, while 75%-80% of BPD patients attempt to commit suicide, 10% succeed; this mortality rate exceeds even that of anorexia nervosa which, with a weighted mortality rate of 5.1%, has often been considered to have the highest mortality rate of any mental disorder. In order to provide treatment and to implement preventative measures, a risk profile as well as clinical features must be identified within the adolescent population. This is presently crucial, as the current criteria for BPD are not developmentally focused, and as a result, criteria initially developed for the adult population are being applied in diagnoses of adolescents. A population of adolescents (n=80) between 16 and 19 years of age meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria either for BPD traits (n=46) or for BPD (n=36) were included in a retrospective chart review; a control group consisting of n=30 mood and anxiety control subjects were included to allow for further comparisons. Complex significant differences were discovered between the three groups in the following areas: history of sexual abuse, suicidal ideation, internalizing/externalizing symptoms, interpersonal difficulties, impulsivity, pre-perinatal stress, bullying, substance abuse, anxiety disorders, disruptive disorders, and finally, learning disorders.

Birth experiences in adult women with a history of childhood sexual abuse

OBJECTIVE

Although childhood sexual abuse (CSA) may seriously impair childbirth experiences, few systematic evaluations on associations, mediating influences, risk and protective factors are available. As such information is mandatory to improve obstetric care, the present study aimed to provide such data.

METHODS

The study compared childbirth experiences from 85 women after CSA and at least one pregnancy resulting in a life birth with those from 170 control women matched for nationality, personal age and children's age. Trained specialists from support centers investigated CSA. Obstetrical data were collected from the official personal clinical record of each pregnancy (Mutterpass) and data on CSA as well as childbirth experiences were examined by questionnaires.

RESULTS

Childbirth was more often highly frightening (24.7 vs. 5.3%; p<0.01) and a negative experience (40.7 vs. 19.6%, p<0.01) in women with a history of CSA than in controls. Multivariate regression models support the hypothesis that at least part of this association was mediated by covariates (specifically, birth preparation classes, presence of a trusted person, participation in medical decision-making, pain relief, emergency during labor and extreme duration of labor), which represent important resources in improving obstetric care. In 41% of women with CSA, memories of traumatic experiences intruded during childbirth, whereas about 58% experienced dissociation. While dissociation may result in loss of contact with obstetric staff, it was also used to reduce labor pain.

CONCLUSION

Childbirth following a history of CSA is associated with particular challenges. Creating a trusting environment by evaluating and integrating individual needs could ameliorate birth experiences.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Severity of personality disorders and domains of general personality dysfunction related to attachment

This is the first study to link attachment to both severity of total DSM-IV personality disorder (PD) traits and domains of general personality dysfunction, using a sample of 72 inpatients from New York City. We assessed a measure of global PD severity and the core domains of personality functioning using the severity indices of personality problems (SIPP-118). Attachment was measured with the experience in close relationships-revised (ECR-R) and the relationship style questionnaire (RSQ). Global PD severity correlated most strongly with attachment anxiety (r = 0.65). Regression of the SIPP-118 domains on attachment produced models that accounted for a substantial proportion of variance in those scales (R(2) ranging from 28.2 to 54.2%). SIPP-118 relational capacities were the strongest predictor of ECR-R avoidance (β = -0.88) and anxiety (β = -0.58), as well as RSQ secure (β = 0.53) and fearful (β = -0.65). In conclusion, insecure attachment strongly related to the severity of global PD traits and specifically to relational capacities, which are a higher-order domain of general personality dysfunction. These findings provide further evidence that interpersonal problems are at the core of PDs and that attachment could constitute an important mediator of the social dysfunction in persons with personality pathology.

The role of schizotypy in the study of the etiology of schizophrenia spectrum disorders

Schizotypy provides a useful construct for understanding the development of schizophrenia spectrum disorders. As research on the epidemiology of psychotic symptoms and clinical risk for psychosis has expanded, conceptual challenges have emerged to comprehend the nature and borders of the space comprised between personality variation and psychosis. Schizotypy is considered in light of these more recent constructs. It is suggested that rather than being superseded by them due to their higher specificity and predictive power for transition to psychosis, schizotypy integrates them as it constitutes a dynamic continuum ranging from personality to psychosis. The advantages of schizotypy for studying schizophrenia etiology are discussed (eg, it facilitates a developmental approach and the identification of causal, resilience, and compensating factors and offers a multidimensional structure that captures etiological heterogeneity). An overview of putative genetic, biological, and psychosocial risk factors is presented, focusing on communalities and differences between schizotypy and schizophrenia spectrum disorders. The found notable overlap supports etiological continuity, and, simultaneously, differential findings appear that are critical to understanding resilience to schizophrenia. For example, discrepant findings in genetic studies might be interpreted as suggestive of sets of independent genetic factors playing a differential role in schizotypy and schizophrenia: some would influence variation specifically on schizotypy dimensions (ie, high vs low schizotypy, thereby increasing proneness to psychosis), some would confer unspecific liability to disease by impacting neural properties and susceptibility to environmental factors (ie, high vs low resilience to disorder) and some might contribute to disease-specific characteristics. Finally, schizotypy's promise for studying gene-environment interactions is considered.

Association between childhood maltreatment and normal adult personality traits: exploration of an understudied field

We assessed normal personality traits and childhood trauma in approximately 1170 subjects from a general population-based community sample. In bivariate analyses emotional abuse was most pervasively related to personality, showing significant detrimental associations with neuroticism, extraversion, openness, conscientiousness, and agreeableness. Neuroticism was significantly related to emotional abuse and neglect, physical abuse and neglect, and sexual abuse. Emotional abuse was related to neuroticism in men more profoundly than in women (β = 0.095). Adjusting for the covariance between childhood maltreatment variables, neuroticism was mainly related to emotional abuse (β = 0.193), extraversion to emotional neglect (β = -0.259), openness to emotional abuse (β = 0.175), conscientiousness to emotional abuse (β = -0.110), and agreeableness to emotional neglect (β = -0.153). The proportion of variance explained was highest in neuroticism (5.6%) and lowest in openness (1.9%) and conscientiousness (1.8%). These findings help to understand the complex association between childhood maltreatment and both normal and pathological personality.

Comorbidity between post-traumatic stress disorder and borderline personality disorder: a review

BACKGROUND

Traditionally, the presence of post-traumatic stress disorder (PTSD) in subjects diagnosed with borderline personality disorder (BPD) has been the object of scant empirical research. The clarification of issues related to the different areas of study for this comorbidity is not only significant from a theoretical point of view but also relevant for clinical practice. The aim of this review is to describe the main theoretical findings and research conclusions about the comorbidity between PTSD and BPD.

METHODS

A literature review was carried out via PubMed and PsycINFO for the period between 1990 and September 2013. The descriptors used were 'post-traumatic stress disorder', 'borderline personality disorder', 'PTSD', 'complex PTSD' and 'BPD'.

RESULTS

Epidemiological studies show that the risk of PTSD among BPD subjects is not regularly higher than in subjects with other personality disorders. Furthermore, there is no conclusive evidence about the main aetiopathogenic mechanism of this comorbidity, either of one disorder being a risk factor for the other one or of common underlying variables. Concerning comparative studies, several studies with PTSD-BPD subjects have found a higher severity of psychopathology and psychosocial impairment than in BPD subjects. With regard to nosological status, the main focus of controversy is the validation of 'complex PTSD', a clinical entity which may comprise a subgroup of PTSD-BPD subjects. With regard to treatment, there are preliminary evidences for the efficient treatment of psychopathology in both PTSD and BPD.

CONCLUSIONS

These findings are remarkable for furthering the understanding of the link between PTSD and BPD and their implications for treatment. The results of this review are discussed, including methodological constraints that hinder external validity and consistency of referred findings.

Suicidality in the prospective Zurich study: prevalence, risk factors and gender

Our prospective Zurich study (1978-2008) found that suicidal ideation had occurred in 40.5% and suicide attempts in 6.6% of the population by age 50. Important gender differences were found in both suicidality and its risk factors. Suicide attempts were earlier and more frequent among women than among men: 70 versus 44% reported their first suicide attempt before 20. For women, the relative risk of suicide attempts was 1.6, but the relative risk of suicidal ideation was about equal (1.1 for women). The main risk factors for suicidal ideation in women were low social support (OR 4.0) and frequent punishment in childhood (OR 3.7), and in men, a depressive (OR 6.5) and an anxious personality (OR 4.6). The main risk factors for suicide attempts in women were a broken home (OR 10.2) and sexual abuse/violence (OR 7.9) in childhood; in men, no multivariate analyses of suicide attempt were conducted because of insufficient statistical power.

Prevalence and impact of childhood abuse in people with a psychotic illness. Data from the second Australian National Survey of Psychosis

Child abuse has been associated with risk of mental illness, including schizophrenia and other psychotic disorders and, among those with mental illness, with a more severe clinical profile. Using an extensively characterised and epidemiologically representative sample of 1825 Australians with a psychotic illness aged 18-64 years and in contact with mental health services, we estimated the proportion of individuals with psychotic disorders who self-reported child abuse and examined its relationship with clinical and other characteristics. The prevalence of child abuse in this nationally representative sample of people with psychotic illness was 30.6%. Women were almost three times more likely to report child abuse compared to males (OR, 2.8, 95% CI 2.3-3.4). When adjusted for age at interview and socio-economic status, there was no significant relationship between self-reported child abuse and type of psychosis or course of illness. Participants with child abuse were significantly more likely to have subjective thought disorder, lifetime suicide attempt and premorbid personality disorder (females only) and anxiety (males only). Our findings demonstrate that child abuse is relatively common across the range of psychotic disorders, with an elevated risk for women in particular, compounding the already high burden associated with psychotic illness. Clinicians need to inquire routinely about child abuse in order to develop appropriate treatment plans tailored to individual needs.

Impact of childhood adversity on the onset and course of subclinical psychosis symptoms--results from a 30-year prospective community study

The study objective was to examine childhood adversity in association with intra-individual changes and inter-individual differences in subclinical psychosis in a representative community cohort over a 30-year period of observation. We analyzed two psychosis syndromes derived from the SCL-90-R - schizotypal signs and schizophrenia nuclear symptoms - in 335 participants. Participants were repeatedly assessed between 1978 (around age 20) and 2008 (around age 50). We focused specifically on inter-individual differences and intra-individual changes over time by applying structural equation modeling, generalized linear models, and generalized estimating equations. Several weak inter-individual differences revealed that increased schizotypal signs are related to various childhood adversities, such as being repeatedly involved in fights and parents having severe conflicts among themselves. We also found a significant positive association between schizotypal signs and the total number of adversities a subject experienced. This pointed toward a modest dose-response relationship. The intra-individual change in schizotypal signs over time was rather weak, although some adjustment did occur. In contrast, inter-individual schizophrenia nuclear symptoms were mainly unrelated to childhood adversity. However, some striking intra-individual changes in distress were noted over time, especially those linked with severe punishment and the total adversity score. In conclusion, we have confirmed previous positive findings about the association between childhood adversity and subsequent subclinical psychosis symptoms: An increase in adversity is weakly related to an increase of the psychosis symptom load. However, depending on the kind of adversity experienced the psychosis symptom load decreases gradually in adult life.

Interpersonal functioning deficits in association with DSM-IV personality disorder dimensions

PURPOSE

According to DSM, interpersonal functioning deficits are a main criterion for the general definition of personality disorders (PDs), but some PD diagnoses do not appear to be related to impaired interpersonal functioning. Social deficits have rarely been studied in all PD dimensions to date.

METHODS

We analyzed 511 adults aged 20-41 years from the general population of the canton of Zurich, Switzerland, using data from the Epidemiology Survey of the Zurich Programme for Sustainable Development of Mental Health Services (ZInEP). PD dimensions were measured with a questionnaire and indicators of interpersonal functioning with a semi-structured interview. Associations were analyzed with generalized linear models.

RESULTS

All PD dimensions were significantly associated with various indicators of interpersonal functioning deficits, such as distress and conflicts in friendships and partnership, feeling lonely, few close friends, and reduced social support. Schizotypal and borderline PD were relatively strongly associated with distress in friendships when compared with other PD dimensions. Furthermore, both dimensions were significantly related to all indicators of interpersonal functioning deficits.

CONCLUSIONS

Subjects scoring high on any PD dimension reported considerable deficits in interpersonal functioning as characterized by a solitary lifestyle, conflictual and distressful social relations, and lack of social support. All DSM-IV PDs are associated with poor interpersonal functioning, but there is some evidence that schizotypal and borderline symptomatology affects deficits in social interactions even more profoundly and pervasively than other PD dimensions.

Occupational functioning and work impairment in association with personality disorder trait-scores

PURPOSE

According to the DSM, functional impairment is a main criterion for the general definition of personality disorders (PDs), but research suggests that some PDs might not be related to impaired functioning. Occupational functioning has rarely been examined in all ten DSM PDs.

METHODS

We analysed 511 adults aged 20-41 years from the general population of the canton of Zurich, Switzerland, using data from the Epidemiology Survey of the Zurich Programme for Sustainable Development of Mental Health Services. All PDs were assessed with dimensional trait-scores and associations with indicators of occupational functioning were analysed with generalised linear models.

RESULTS

Each PD revealed at least a weak association with some form of occupational impairment. Most PDs, especially from cluster A and B, were significantly related to occupational dysfunction, in particular low education level, conflicts in the workplace, dismissal or demotion, and unemployment. In contrast, obsessive-compulsive PD was mostly unrelated to occupational functioning. A total personality pathology dose-response relationship was observed for low education level, conflicts in the workplace, dismissal or demotion, and unemployment.

CONCLUSIONS

Impairment in occupational functioning is an important aspect particularly of cluster A and B PDs. Assuming that functional impairment is a predictor of illness severity, we advocate that clinicians should carefully explore indicators of occupational functioning in the diagnosis, prognosis, and treatment of PDs. The findings discussed herein have implications for general treatment, interventions in the work environment, or re-integration of patients into the labour force.

Can protective factors moderate the detrimental effects of child maltreatment on personality functioning?

OBJECTIVE

The aim of this study was to examine whether, and if so, to what extent, education and coping strategies may reduce the detrimental effects of childhood maltreatment on personality functioning.

METHODS

We assessed dimensional trait-scores of all 10 DSM-IV personality disorders (PDs), childhood maltreatment, education and three coping styles in 511 subjects of the general population of Zurich, Switzerland, using data from the ZInEP Epidemiology Survey.

RESULTS

Childhood maltreatment was associated with all 10 PDs. Low education was related to antisocial, borderline and histrionic PD. Low emotion-focused coping was associated with paranoid, schizoid, borderline, avoidant, and obsessive-compulsive PD. Low problem-focused coping was related to schizoid PD and high problem-focused coping to histrionic PD. High dysfunctional coping was significantly related to all 10 PD dimensions. Obsessive-compulsive trait scores were significantly lower in maltreated subjects with high emotion-focused coping. Antisocial, borderline and narcissistic trait scores were significantly higher in maltreated subjects with high dysfunctional coping.

CONCLUSION

Education and adaptive coping may have a protective effect on PD symptomatology. Promotion of adaptive coping and suppression of dysfunctional coping may additionally reduce PD symptoms specifically in maltreated subjects. Those findings have important clinical implications. Longitudinal research is needed to address questions of causality and to evaluate potential effects of treatment and intervention.