Temperament, childhood environment and psychopathology as risk factors for avoidant and borderline personality disorders

OBJECTIVE: To evaluate childhood experiences (neglect and abuse), temperament and childhood and adolescent psychopathology as risk factors for avoidant and borderline personality disorders in depressed outpatients. METHOD: One hundred and eighty depressed outpatients were evaluated for personality disorders. Risk factors of childhood abuse, parental care, temperament, conduct disorder symptoms, childhood and adolescent anxiety disorders, depressive episodes, hypomania and alcohol and drug dependence were obtained by questionnaires and interviews. RESULTS: Avoidant personality disorder can be conceptualized as arising from a combination of high harm avoidance (shy, anxious), childhood and adolescent anxiety disorders and parental neglect. Borderline personality disorder can be formulated as arising from a combination of childhood abuse and/or neglect, a borderline temperament (high novelty seeking and high harm avoidance), and childhood and adolescent depression, hypomania, conduct disorder and alcohol and drug dependence. CONCLUSIONS: Combinations of risk factors from the three domains of temperament, childhood experiences and childhood and adolescent psychopathology make major contributions to the development of avoidant and borderline personality disorders.     

Stressful life events as predictors of functioning: findings from the collaborative longitudinal personality disorders study

OBJECTIVE: Although much attention has been given to the effects of adverse childhood experiences on the development of personality disorders (PDs), we know far less about how recent life events influence the ongoing course of functioning. We examined the extent to which PD subjects differ in rates of life events and the extent to which life events impact psychosocial functioning. METHOD: A total of 633 subjects were drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS), a multi-site study of four personality disorders--schizotypal (STPD), borderline (BPD), avoidant (AVPD), obsessive-compulsive (OCPD)--and a comparison group of major depressive disorders (MDD) without PD. RESULTS: Borderline personality disorder subjects reported significantly more total negative life events than other PDs or subjects with MDD. Negative events, especially interpersonal events, predicted decreased psychosocial functioning over time. CONCLUSION: Our findings indicate higher rates of negative events in subjects with more severe PDs and suggest that negative life events adversely impact multiple areas of psychosocial functioning.     

The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events

OBJECTIVE: The authors examined the relationship of borderline personality disorder to posttraumatic stress disorder (PTSD) with respect to the role of trauma and its timing. METHOD: The Trauma History Questionnaire and the PTSD module of the Structured Clinical Interview for DSM-III-R were administered to 180 male and female outpatients with a diagnosis of one or more DSM-III-R personality disorders. Path analysis was used to evaluate the relationship between borderline personality disorder and PTSD. RESULTS: High rates of early and lifetime trauma were found for the subject group as a whole. Compared to subjects without borderline personality disorder, subjects with borderline personality disorder had significantly higher rates of childhood/adolescent physical abuse (52.8% versus 34.3%) and were twice as likely to develop PTSD. In the path analysis of the relationship between borderline personality disorder and PTSD, none of the different types of paths (direct path, indirect paths through adulthood traumas, paths sharing the antecedent of childhood abuse) was significant. The associations with both trauma and PTSD were not unique to borderline personality disorder; paranoid personality disorder subjects had an even higher rate of comorbid PTSD than subjects without paranoid personality disorder, as well as elevated rates of physical abuse and assault in childhood/adolescence and adulthood. CONCLUSIONS: The associations of personality disorder with early trauma and PTSD were evident, but modest, in borderline personality disorder and were not unique to this type of personality disorder. The results do not appear substantial or distinct enough to support singling out borderline personality disorder from the other personality disorders as a trauma-spectrum disorder or variant of PTSD.     

Attention-deficit hyperactivity disorder as a potentially aggravating factor in borderline personality disorder

BACKGROUND: Clinical experience suggests that people with borderline personality disorder often meet criteria for attention-deficit hyperactivity disorder (ADHD). However, empirical data are sparse. AIMS: To establish the prevalence of childhood and adult ADHD in a group of women with borderline personality disorder and to investigate the psychopathology and childhood experiences of those with and without ADHD. METHOD: We assessed women seeking treatment for borderline personality disorder (n=118) for childhood and adult ADHD, co-occurring Axis I and Axis II disorders, severity of borderline symptomatology and traumatic childhood experiences. RESULTS: Childhood (41.5%) and adult (16.1%) ADHD prevalence was high. Childhood ADHD was associated with emotional abuse in childhood and greater severity of adult borderline symptoms. Adult ADHD was associated with greater risk for co-occurring Axis I and II disorders. CONCLUSIONS: Adults with severe borderline personality disorder frequently show a history of childhood ADHD symptomatology. Persisting ADHD correlates with frequency of co-occurring Axis I and II disorders. Severity of borderline symptomatology in adulthood is associated with emotional abuse in childhood. Further studies are needed to differentiate any potential causal relationship between ADHD and borderline personality disorder.     

The borderline diagnosis in adolescents: symptoms and developmental history

Adult criteria for borderline personality disorder distinguished a group of 27 inpatient adolescent girls from 23 nonborderline inpatient female comparison subjects. The two groups were compared on retrospectively assessed variables measuring psychological, familial, and constitutional factors. Variables most likely to predict borderline personality disorder included history of disrupted attachments, maternal neglect, maternal rejection, grossly inappropriate parental behavior, number of mother and father surrogates, physical abuse, and sexual abuse. Families of borderline adolescents were chronically disrupted, particularly during the patients' early childhoods. The traumatic childhood experiences of the borderline adolescents were similar to those of adults with borderline personality disorder in recent studies.     

A comparison of posttraumatic stress disorder with and without borderline personality disorder among women with a history of childhood sexual abuse: etiological and clinical characteristics

The overlap in definition and presentation between posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) has raised questions about the relationship of these disorders. Are they separate disorders, variants of the same disorder, or comorbid conditions? The present study examined etiological variables and current functioning among two groups of outpatient women with a history of childhood sexual abuse: those with PTSD only (N = 45) and those with PTSD and BPD (N = 26). The groups did not differ in severity, frequency, or number of perpetrators of their childhood sexual abuse, or whether the perpetrator was a family member or not. The additional diagnosis of BPD was associated with earlier age of abuse onset and significantly higher rates of physical and verbal abuse by mother. Severity and frequency of PTSD symptoms were not affected by BPD diagnosis, suggesting that the personality disorder and PTSD are independent symptom constructs. The PTSD+BPD group scored higher on several other clinical measures including anger, dissociation, anxiety, and interpersonal problems. They did not differ in their frequency of use of mental health services but tended to be less compliant in their treatment. These and other findings are discussed, and implications for treatment are considered.     

Personality Compensates for Impaired Quality of Life and Social Functioning in Patients With Psychotic Disorders Who Experienced Traumatic Events

Background: Patients with psychotic disorders who experienced childhood trauma show more social dysfunction than patients without traumatic experiences. However, this may not hold for all patients with traumatic experiences. Little is known about the potential compensating role of Five-Factor Model personality traits within this group, despite their strong predictive value for social functioning and well-being in the general population. Methods: Our sample consisted of 195 patients with psychotic disorders (74% diagnosed with schizophrenia) and 132 controls. Cluster analyses were conducted to identify and validate distinct personality profiles. General linear model analyses were conducted to examine whether patients with different profiles differed in social functioning and quality of life (QoL), while controlling for possible confounders. Mediation models were tested to assess potential causal links. Results: In general, patients with higher levels of self-reported traumatic experiences (PT+) showed lower QoL and more social withdrawal compared with patients with lower traumatic experiences (PT−). Two clusters reflecting personality profiles were identified. PT+ with the first profile (lower neuroticism and higher extraversion, openness, agreeableness, and conscientiousness) presented higher levels of QoL and better social functioning in several areas, including less withdrawal, compared with both PT+ and PT− with the second profile. PT+ and PT− with the first personality profile did not differ in QoL and social functioning. Mediation analyses suggested that personality traits mediate the relation between traumatic experiences and QoL and social withdrawal. Conclusions: Our findings indicate that personality may “buffer” the impact of childhood traumatic experiences on functional outcome in patients with psychotic disorders.Key words: Five-Factor Model, psychosis, trauma, well-being, resilience     

Genetic, developmental and personality correlates of self-mutilation in depressed patients

OBJECTIVE: To examine whether the T allele of G protein beta3 (GNbeta3) is associated with self-mutilation in depressed patients. METHOD: A history of self-mutilation was systematically inquired about when recruiting depressed patients for a long-term treatment trial. Risk factors such as borderline personality disorder and childhood abuse experiences were systematically assessed, and patients were genotyped for polymorphisms of GNbeta3. RESULTS: The T allele of GNbeta3, borderline personality disorder and childhood sexual abuse were all significantly associated with self-mutilation in depressed patients. These associations were significant in both univariate and multivariate analyses, and as predicted were stronger in young depressed patients than in depressed patients of all ages. CONCLUSIONS: If the association between the T allele of GNbeta3 and self-mutilation can be replicated, this may provide clues to understanding the neurobiology of self-mutilation.     

P3 event-related potential amplitude and the risk for disinhibitory disorders in adolescent boys

BACKGROUND: The children of parents who abuse alcohol typically show reduced amplitude of the P3 event-related potential wave. We determined if this effect was present in a population-based sample of older adolescent boys, whether it was associated with paternal antisocial personality and drug use, and whether it appeared in youth with childhood externalizing and substance use disorders. METHODS: A statewide sample of 502 male youth, identified from Minnesota birth records as members of twin pairs, had their P3 amplitude measured, using a visual oddball paradigm when they were approximately 17 years old. Structured clinical interviews covering attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, antisocial personality disorder, and substance use disorders were administered in person to the youth and his parents at the time of the P3 assessment and again to the youth 3 years later. RESULTS: Reduced P3 was associated with disorders and paternal risk for disorders, reflecting a behavioral disinhibition spectrum that included attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, antisocial personality disorder, alcoholism, nicotine dependence, and illicit drug abuse and dependence. Reduced P3 at age 17 predicted the development of substance use disorders at age 20. Most effect sizes associated with these group differences exceeded 0.70, indicating medium to moderately large group differences. Maternal alcoholism and substance use during pregnancy were unrelated to P3 amplitude in offspring. CONCLUSION: Small amplitude P3 may indicate genetic risk for a dimension of disinhibiting psychiatric disorders, including childhood externalizing, adult antisocial personality disorder, and substance use disorders.     

Substance abuse and personality disorders in homeless drop-in center clients: symptom severity and psychotherapy retention in a randomized clinical trial

This study evaluated the psychiatric symptoms, psychosocial problems, and treatment response of personality-disordered substance abusers receiving services within a homeless drop-in center. Fifty-two homeless clients were assessed after program admission and randomly assigned to receive either individual psychotherapy focused on personality disorder and substance abuse relapse prevention (dual-focus schema therapy [DFST]) or standard group substance abuse counseling (SAC). Client functioning was assessed using measures of personality disorder, psychiatric symptoms, early maladaptive schemas, interpersonal problems, and addiction-related psychosocial impairment. Therapy retention (total weeks in treatment) and utilization (number of weeks in which sessions were attended) were the primary outcomes. Although rates of cluster B personality disorders were comparable to other substance dependent samples, clusters A and C disorders were disproportionately more common. Clients reported significant psychiatric symptoms, criminality, and psychosocial impairment, yet made limited lifetime use of mental health services. Overall, there was greater utilization of individual DFST than group SAC. However, clients with more severe personality disorder symptoms demonstrated better utilization of SAC than DFST.     

Fourteen-year follow-up of speech/language-impaired and control children: psychiatric outcome

OBJECTIVE: To examine the association between early childhood speech and language disorders and young adult psychiatric disorders. METHOD: In a longitudinal community study conducted in the Ottawa-Carleton region of Ontario, Canada, interviewers administered structured psychiatric interviews to age 19 participants who were originally identified as speech-impaired only, language-impaired, or nonimpaired at age 5. The first stage of the study took place in 1982 when participants were 5 years old, and the latest stage of the study took place between 1995 and 1997 when participants had a mean age of 19 years. This report examines the association between early childhood speech/language status and young adult psychiatric outcome. RESULTS: Children with early language impairment had significantly higher rates of anxiety disorder in young adulthood compared with nonimpaired children. The majority of participants with anxiety disorders had a diagnosis of social phobia. Trends were found toward associations between language impairment and overall and antisocial personality disorder rates. Males from the language-impaired group had significantly higher rates of antisocial personality disorder compared with males from the control group. Age of onset and comorbidity did not differ by speech/language status. The majority of participants with a disorder had more than one. CONCLUSIONS: Results support the association between early childhood speech and language functioning and young adult psychiatric disorder over a 14-year period. This association underscores the importance of effective and early interventions.     

Factors differentiating personality-disordered individuals with and without a history of unipolar mood disorder

The relationship between mood disorders and personality disorders has been of longstanding interest to clinicians. Despite theoretical reasons to do so, virtually no studies have examined factors that discriminate personality-disordered subjects with a history of mood disorder (PD/HMD) from personality-disordered subjects without a history of mood disorder (PD). This study examined demographic variables, patterns of comorbidity, measures of life functioning, personality traits, and early life experiences differentiating PD/HMD (n = 83) from PD (n = 214). Diagnoses were assigned using structured clinical interviews and a best-estimate procedure. The results suggest that subjects with borderline personality disorder are more likely to have a life history of mood disorder than are subjects with other personality disorders. In addition, PD/HMDs are more likely to receive a diagnosis of anxiety disorder or alcoholism, to have lower Global Assessment of Functioning (GAF) scores, and to have sought treatment than PDs. On self-report measures of personality, PD/HMDs endorse higher levels of trait anxiety and affective lability (e.g., Harm Avoidance, Neuroticism) than do PDs. PD/HMDs are also more likely to report childhood physical and emotional abuse than are PDs, and to describe their parents as using affectionless control. No differences were found between Axis II clusters as a function of mood disorder history. The discussion suggests a potential model in which early environmental stress interacts with constitutional vulnerabilities to put individuals at an increased risk for both mood and anxiety disorders as well as personality disorders.     

Gender differences in depression risk and coping factors in a clinical sample

OBJECTIVE: To examine gender differences in depression risk and coping factors in a clinical sample of patients with a diagnosis of DSM-IV major depression. METHOD: Patients were assessed for substance use and abuse, family history of psychiatric disorder, interpersonal depressogenic factors and lifetime history of anxiety disorders. Trait anxiety, coping styles when depressed, parental bonding, marital features and personality style were also measured. Patients were reassessed at 12-month follow-up. RESULTS: There were few gender differences in experience of depression (either in duration, type or severity prior to treatment) in a group with established episodes of major depression but women reported more emotional arousability when depressed. Women reported higher rates of dysfunctional parenting and childhood sexual abuse, and rated their partners as less caring and as more likely to be a depressogenic stressor. Men were more likely to have a generalized anxiety disorder at assessment, to use recreational drugs prior to presentation. Men were rated as having a more rigid personality style and 'Cluster A' personality traits both at assessment and follow-up. CONCLUSION: There were few gender differences in severity or course of established episodes of major depression. Gender differences were related to levels of arousal, anxiety disorders, and repertoires for dealing with depression, rather than depressive symptoms per se.     

Characteristics of patients with major depression in combination with dysthymic or cyclothymic disorders. Childhood and precipitating events

The relationship between patients with acute major depression and chronic affective disorders was investigated in 298 nonpsychotic outpatients. The patients were categorized into 4 groups: major depression only, major depression with dysthymic or cyclothymic disorders, dysthymic or cyclothymic disorder without major depression and one group of other psychiatric disorders. The patients were interviewed about childhood losses, relationship to parents and siblings and family atmosphere, their personality characteristics as children, as well as precipitating events. The reports in the various diagnostic groups were compared. Patients in the mixed group reported somewhat more traumatic childhood experiences compared with patients in the pure major depression group and pure dysthymic-cyclothymic group, and much more traumatic childhood experiences compared with patients in the group of other disorders. Precipitating events among patients in the acute major depression group consisted of more acute external stressors compared with the events of the patients in the group of chronic affective disorders. Patients with major depression in combination with pure dysthymic-cyclothymic disorder generally remembered their childhood as having been more traumatic, with a less satisfying relationship to their parents.     

人格障碍倾向者的童年创伤经历研究

目的 研究人格障碍和童年创伤经历的相互关系,探索与人格障碍关系比较密切的童年创伤经历。方法 在1402例咨客中,对其中人格障碍诊断问卷第四版（Personality Diagnostic Questionnaire,PDQ^4＋）筛查阳性的987例人格障碍高危人群进行童年期创伤性经历问卷的评分,并利用SAS（Statistics Analysis System）统计软件包对资料进行典型相关分析。结果 典型相关分析的男女结果有所差异,男性组第1、2对典型变量（相关系数：0．4528和0．2568）、女性组第1对典型变量（相关系数：0．4395）的相关性有统计学意义。男性被试人格障碍的典型变量W1主要由反社会型和分裂型决定,创伤经历的典型变量V1主要由情感虐待和躯体虐待决定;女性被试人格障碍的典型变量W1主要由反社会型和边缘型决定,创伤经历的典型变量V1主要由情感虐待和性虐待决定。结论 男性被试童年时期的情感虐待和躯体虐待的经历对其成年后反社会型和分裂型人格障碍倾向的影响较明显。女性被试童年时期的情感虐待和性虐待的经历对其成年后反社会型和边缘型人格障碍倾向的影响较明显。     

The relationship between social functioning and psychiatric symptomatology in primary care

Summary The relationship between social functioning measured by an interview schedule, psychiatric symptoms, alcohol abuse and personality was examined in 171 patients with conspicuous psychiatric morbidity seen in primary care. Social functioning was significantly better in older patients and in those with no alcohol abuse or personality disorder. A close relationship was shown between social functioning and psychiatric diagnosis, social impairment increasing with severity of disorder. This relationship was not obtained for depressive disorders in which social functioning was similar across all diagnostic groups. There was a high correlation between social functioning score and total psychiatric symptomatology, although social functioning appeared to be a more important determinant of referral to psychiatric services than Present State Examination (PSE) total score. The results support the view that social functioning measures can convey additional useful information to that of symptom measures, and might be of use in a multiaxial classification.     

Child and adolescent psychiatric disorders predicting adult personality disorder: a follow-up study

The objective of this study was to examine associations between childhood and adolescent psychiatric disorders and adult personality disorders in a group of former child psychiatric inpatients. One hundred and fifty-eight former inpatients with a mean age of 30.5 +/- 7.1 years at investigation had their childhood and adolescent Axis I disorders, obtained from their medical records, coded into DSM-IV diagnoses. Personality disorders in adulthood were assessed by means of the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q). The predictive effects of child and adolescent Axis I disorders on adult personality disorders were examined with logistic regression analyses. The odds of adult schizoid, avoidant, dependent,borderline and schizotypal personality disorders increased by almost 10, five, four, three and three times, respectively, given a prior major depressive disorder. Those effects were independent of age, sex and other Axis I disorders. In addition, the odds of adult narcissistic and antisocial personality disorders increased by more than six and five times, respectively, given a prior disruptive disorder, and the odds of adult borderline, schizotypal, avoidant and paranoid personality disorders increased between two and three times given a prior sub-stance-related disorder. The results illustrate an association between mental disorders in childhood and adolescence and adult personality disorders. Identification and successful treatment of childhood psychiatric disorders may help to reduce the risk for subsequent development of an adult personality disorder.     

Differences between multiple personality disorder and other diagnostic groups on structured interview

The Dissociative Disorders Interview Schedule was administered to 20 subjects with multiple personality disorder, 20 with schizophrenia, 20 with panic disorder, and 20 with eating disorders. The findings showed that multiple personality can be differentiated from the other groups on variables such as history of physical abuse, sexual abuse, substance abuse, sleepwalking, childhood imaginary playmates, secondary features of multiple personality and extrasensory and supernatural experiences. Those with multiple personality also differ from the other groups on DSM-III criteria for multiple personality, psychogenic amnesia, and psychogenic fugue. The groups did not differ on the number of subjects who had had a major depressive episode.     

Comorbid personality disorders in subjects with panic disorder: do personality disorders increase clinical severity?

Personality disorders are common in subjects with panic disorder. Personality disorders have been shown to affect the course of panic disorder. The purpose of this study was to examine which personality disorders affect clinical severity in subjects with panic disorder. This study included 122 adults (71 women, 41 men) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for panic disorder (with or without agoraphobia). Clinical assessment was conducted by using the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and the Panic and Agoraphobia Scale, Global Assessment Functioning Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Patients who had a history of sexual abuse were assessed with Sexual Abuse Severity Scale. Logistic regressions were used to identify predictors of suicide attempts, suicidal ideation, sexual abuse, and early onset of disorder. The rates of comorbid Axes I and II psychiatric disorders were 80.3% and 33.9%, respectively, in patients with panic disorder. Patients with panic disorder with comorbid personality disorders had more severe anxiety, depression, and agoraphobia symptoms, had earlier ages at onset, and had lower levels of functioning. The rates of suicidal ideation and suicide attempts were 34.8% and 9.8%, respectively, in subjects with panic disorder. The rate of patients with panic disorder and a history of childhood sexual abuse was 12.5%. The predictor of sexual abuse was borderline personality disorder. The predictors of suicide attempt were comorbid paranoid and borderline personality disorders, and the predictors of suicidal ideation were comorbid major depression and avoidant personality disorder in subjects with panic disorder. In conclusion, this study documents that comorbid personality disorders increase the clinical severity of panic disorder. Borderline personality disorder may be the predictor of a history of sexual abuse and early onset in patients with panic disorder. Paranoid and borderline personality disorders may be associated with a high frequency of suicide attempts in patients with panic disorder.     

Associations of anxiety-related symptoms with reported history of childhood sexual abuse in schizophrenia spectrum disorders

OBJECTIVE: Research suggests that persons with schizophrenia tend to experience significant levels of anxiety and that history of childhood sexual abuse may predispose some with schizophrenia to experience significant levels of persistent anxiety. It is unclear whether childhood sexual abuse is more closely linked to specific forms of anxiety including symptoms of post-traumatic stress disorder (PTSD). METHOD: Data were gathered from April 2004 through November 2004 on trauma history, PTSD symptoms, social anxiety, and state and trait anxiety from 45 men with a SCID-I-confirmed diagnosis of schizophrenia or schizoaffective disorder and 11 with a SCID-I-confirmed diagnosis of PTSD with no history of psychosis. Participants with schizophrenia spectrum disorders (schizophrenia group) were divided into those with and without history of childhood sexual abuse. Five participants in the schizophrenia group with a history of adult but not childhood sexual assault were excluded from analyses. RESULTS: Analysis of variance comparing the childhood sexual abuse (N = 21) and non-abused (N = 19) schizophrenia groups and the PTSD group on all anxiety assessments revealed that the sexually abused schizophrenia group had significantly higher levels of dissociation, intrusive experiences, and state and trait anxiety than the non-abused schizophrenia group. The schizophrenia groups did not differ statistically on levels of anxious arousal, defensive avoidance, or social anxiety. When compared with participants with PTSD and no psychosis, the sexually abused schizophrenia group had significantly lower levels of state anxiety, anxious arousal, intrusive experiences, and fearful social avoidance but failed to differ statistically on other scores. CONCLUSION: These results, if replicated, could lead to identification of those at risk for anxiety and PTSD and to targeted interventions.