Personality Disorders
Personality Disorders
Program Transcript
MALE SPEAKER: Tell you the truth, I don't even want to be here. My mother,
she nags. She pushed me to come. Of course she's 86. She nags and complains
about everything. I came just to keep her quiet.
FEMALE SPEAKER: You mentioned that she's concerned about your not having
very many friends.
MALE SPEAKER: I don't have a girlfriend. That's what bothers her. She comes
over to my apartment, starts talking how I don't take care of myself, How I need
to meet someone, get married.
FEMALE SPEAKER: Sounds like you're dealing with some frustration, some
annoyance. What do you think about it when she's talking about these things?
MALE SPEAKER: She's my mom. I know she cares, but a woman. I've been
alone too long to change now. I don't want a relationship. I never have. It's not a
big deal.
FEMALE SPEAKER: What about your other friends? How would you
characterize your social life?
MALE SPEAKER: I mean, I know people. They're friends.
FEMALE SPEAKER: But what do you like to you when you guys get together?
MALE SPEAKER: I don't need other people to do things. I can be my own best
friend. I like my privacy.
FEMALE SPEAKER: What about the rest of your family? Do you spend a lot of
time with them? Are you close with them?
MALE SPEAKER: My mom's my family. I don't care about my father or my sister.
FEMALE SPEAKER: How about when you were in school and college? How
would you describe your social life back then? Students often have opportunities
to socialize, activities, making friends.
MALE SPEAKER: I didn't have much use for all that. I was busy studying. You
don't get on the dean's list by playing around.
FEMALE SPEAKER: No, you don't. And what was your major?
©2013 Laureate Education, Inc.
1
Personality Disorders
MALE SPEAKER: Electrical engineering. I didn't finish, though. I went three
semesters. That was it for me. Trust me, I learned a lot more when I stopped
going to classes. The other students, they were completed idiots. I'm not kidding.
I taught myself everything I do now at my job-- math, statistics, computers, data
analysis.
You want to know how long my commute is? 10 steps. 10 steps, my bedroom to
my desk. I do all my job right there at home. It's perfect.
FEMALE SPEAKER: So besides work, what do you like to do in your free time?
MALE SPEAKER: World of Warcraft, an online role playing game. 20 levels,
incredibly complex. It has the most incredible special effects. I've been playing it
for years, and I still get shivers every time I turn it on and hear that theme music.
FEMALE SPEAKER: What do you like about it so much?
MALE SPEAKER: It's hard to explain if you've never played it. Basically you go
exploring and you get to create your own fantasy world, whatever it is. Sky's the
limit.
FEMALE SPEAKER: And how do you feel as you're playing it?
MALE SPEAKER: You know how they say there's nothing left, nothing more left
to explore or discover on earth except maybe at the bottom of the ocean? But
I've always imagined myself making some great new discovery. You know, like-- I
don't know. Something great. This game lets me do that.
FEMALE SPEAKER: It sounds like you spend a lot of time playing it.
MALE SPEAKER: It's time well spent as far as I'm concerned.
FEMALE SPEAKER: Let's go back to your family a little bit. You had mentioned
some strong feelings about your father, your sister.
MALE SPEAKER: My father. You want to know why I didn't have any friends
when I was young? My old man. I'd be hanging out in the yard with some kids in
the neighborhood, throwing the ball around, goofing off, and he'd come out and
start yelling at me for no reason. He's just make up an excuse. His voice. It was
like having razor blades thrown at you. And after that, nobody would be hanging
out in the yard anymore. Just me. And at night, sometimes I was afraid just to
come out of my room because I didn't know how he was going to be. Was I going
to get a smile or the back of his hand?
©2013 Laureate Education, Inc.
2
Personality Disorders
Personality Disorders
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3
RESEARCH ARTICLE .
Temperament and Maltreatment in the Emergence of
Borderline and Antisocial Personality Pathology
during Early Adolescence
Martina Jovev PhD1,2; Trudi McKenzie MA3; Sarah Whittle PhD3; Julian G. Simmons PhD3;
Nicholas B. Allen PhD1,3; Andrew M. Chanen MBBS, PhD, FRANZCP1,2
██ Abstract
Objective: The present study utilized a prospective, longitudinal design to examine the role of temperament and
maltreatment in predicting the emergence of borderline (BPD) and antisocial (ASPD) personality disorder symptoms during
adolescence. Method: Two hundred and forty-five children aged between 11 and 13 years were recruited from primary
schools in Melbourne, Australia. Participants completed temperament, maltreatment, BPD and ASPD symptom measures,
and approximately two years later, 206 participants were again assessed for BPD and ASPD symptoms. Results:
The findings indicate that childhood neglect is a significant predictor of an increase in BPD symptoms, while childhood
abuse is a significant predictor of an increase in ASPD symptoms. Moreover, abuse and neglect acted as moderators
of the relationship between temperament dimensions and increase in BPD and ASPD symptoms, respectively. Abuse
was associated with an increase in BPD symptoms for children with low Affiliation, while neglect was associated with an
increase in ASPD symptoms for children with low Effortful Control. Conclusions: The current study contributes much
needed prospective, longitudinal information on the early development of symptoms of BPD and ASPD, and supports
importance of both temperamental and environmental factors in predicting the emergence of these mental health problems
early in life.
Key Words: personality, temperament, neglect, abuse, adolescence
██ Résumé
Objectif: La présente étude a utilisé une méthode prospective longitudinale pour examiner le rôle du tempérament et
de la maltraitance dans la prédiction de l’émergence des symptômes d’un trouble de la personnalité limite (TPL) et d’un
trouble de la personnalité antisociale (TPA) durant l’adolescence. Méthode: Deux cent quarante-cinq enfants de 11 à 13
ans ont été recrutés dans des écoles primaires de Melbourne, en Australie. Les participants ont répondu à des mesures
des symptômes du tempérament, de maltraitance, du TPL et du TPA, et environ deux ans plus tard, 206 participants ont
de nouveau été évalués pour les symptômes du TPL et du TPA. Résultats: Les résultats indiquent que la négligence
dans l’enfance est un prédicteur significatif d’une augmentation des symptômes de TPL, alors que l’abus dans l’enfance
est un prédicteur significatif d’une augmentation des symptômes de TPA. En outre, l’abus et la négligence servaient
de modérateurs à la relation entre les dimensions du tempérament et l’augmentation des symptômes de TPL et TPA,
respectivement. L’abus était associé à une augmentation des symptômes de TPL pour les enfants ayant une faible
affiliation, tandis que la négligence était associée à une augmentation des symptômes de TPA pour les enfants ayant
un faible contrôle volontaire. Conclusions: La présente étude apporte une information prospective et longitudinale très
nécessaire sur le développement précoce des symptômes de TPL et de TPA, et confirme l’importance des facteurs du
tempérament et de l’environnement pour prédire l’émergence de ces problèmes de santé mentale en début de vie.
Mots clés: personnalité, tempérament, négligence, abus, adolescent
Jovev et al
1
Orygen Youth Health Research Centre, Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
2
Orygen Youth Health Clinical Program, Northwestern Mental Health, Melbourne, Australia
3
Department of Psychological Sciences, The University of Melbourne, Melbourne, Australia
Corresponding E-Mail: achanen@unimelb.edu.au
Submitted: February 17, 2013; Accepted: May 9, 2013
220
J Can Acad Child Adolesc Psychiatry, 22:3, August 2013
Temperament and Maltreatment in the Emergence of Borderline and Antisocial Personality Pathology during Early Adolescence
Introduction
L
ittle is known about the childhood antecedents of most
personality disorders (PDs) (Cohen & Crawford, 2005).
The Children in the Community (CIC) study remains the
only prospective, longitudinal, community-based study to
examine PD symptoms from childhood through to adulthood (Cohen, Crawford, Johnson, & Kasen, 2005) but this
study did not measure antisocial features until participants
were aged 18 years (Cohen & Crawford, 2005). Even so,
the CIC findings suggest that mean levels of non-antisocial PD traits peak during early adolescence (9-12 years)
and follow a linear decline through to 25-28 years of age
(Johnson et al., 2000a). This is consistent with a normative pattern whereby the transition from adolescence to
adulthood is characterized by decreases in negative affectivity and behavioural disinhibition (Roberts, Caspi, &
Moffitt, 2001; Robins, Fraley, Roberts, & Trzesniewski,
2001). Many individuals, however, exhibit no change from
adolescent levels or may change in a direction opposing
the overall population trend (Johnson, Hicks, McGue, &
Iacono, 2007). Indeed, 21% of the CIC sample exhibited
an increase in PD symptoms over a decade of follow-up
assessments (Johnson et al., 2000b), becoming more deviant relative to their age peers (Crawford et al., 2005). Thus,
as the tide of ‘normative’ PD traits recedes, in part due to
maturational or socialization processes (Cohen et al., 2005),
a group is revealed that perhaps conforms more to descriptions of ‘adult’ PD and is more familiar to practitioners and
researchers in adult mental health settings (Chanen & McCutcheon, 2008).
Temperament is one individual difference variable that
might be a good candidate for predicting such an ‘at risk’
developmental trajectory. Temperament is generally defined as constitutionally based differences in reactivity and
regulation that are observable from early in life and have
strong biological origins (Goldsmith et al., 1987). It has
been implicated in the emergence of a broad range of adolescent mental health problems (Sanson, Letcher, & Smart,
2008). Previous research commonly reports four broad temperament dimensions (Putnam, Ellis, & Rothbart, 2001).
Surgency (SUR) refers to a tendency to seek out and enjoy
intense experiences, together with a lack of shyness and
fear, and is positively associated with the personality factor
of extroversion (Putnam et al., 2001). Negative Affect (NA)
refers to expressed and felt irritability, sadness and frustration in response to limitations, and is associated with the
personality dimension of neuroticism (Rothbart & Ahadi,
1994). Affiliation (AF) relates to a desire for, and pleasure
in, warmth and closeness with others and is aligned with the
personality factor of agreeableness. Effortful Control (EC)
refers to the ability to inhibit a dominant response in order
to produce a more socially appropriate and/or goal-directed,
non-dominant response (Rothbart, Ahadi, & Evans, 2000),
and maps reasonably well onto the adult personality dimension of conscientiousness (Putnam et al., 2001).
J Can Acad Child Adolesc Psychiatry, 22:3, August 2013
Understanding the childhood antecedents of borderline personality disorder (BPD) and antisocial personality disorder
(ASPD) is of particular importance because they are both
associated with severe functional impairments and have
disproportionate effects upon the health and justice systems (Coid et al., 2009; Lenzenweger, Lane, Loranger, &
Kessler, 2007). It is generally agreed that these disorders
emerge during adolescence or early adulthood (APA, 2000)
and contribute to serious psychosocial consequences both
during adolescence and in later in life (APA, 2000; Chanen,
Jovev, & Jackson, 2007; Winograd, Cohen, & Chen, 2008).
Moreover, their temporal stability, functional impairments,
and related characteristics are similar to those observed in
adult populations (Chanen et al., 2004; Chanen et al., 2007;
Chanen, Jovev, McCutcheon, Jackson, & McGorry, 2008).
Research has robustly associated high negative affect, and
low effortful control, agreeableness and conscientiousness
with BPD (Joyce et al., 2003; Paris, 2005; Saulsman & Page,
2004). Although similar traits have been associated with
ASPD, this disorder also appears to be uniquely associated
with low negative affectivity (Liest & Dadds, 2009). While
temperamental extremes have been considered among the
best candidates for developmental antecedents of adult PDs
(Mervielde, De Clercq, De Fruyt, & Van Leeuwen, 2005),
no studies have prospectively assessed the role of early adolescent temperament in the etiology of PD symptoms or
disorders. Adolescent temperament extremes are likely to
confer vulnerability for later personality pathology, at least
in part, via their interaction with other etiological factors.
Aversive life experiences represent an obvious candidate
for such a moderating influence.
Childhood abuse and neglect are specific adverse life experiences that have a robust empirical association with the
development of adult psychopathology in general (Fergusson, Horwood, & Lynskey, 1996; Mullen, Martin, Anderson, Romans, & Herbison, 1993), with some evidence supporting the idea that this relationship is causal (Kendler et
al., 2000). Furthermore, childhood abuse or neglect are both
risk factors for both adolescent and adult PD (Cohen et al.,
2005). Children with documented childhood abuse or neglect have an increased risk for a range of PDs, including
ASPD and BPD, after controlling for offspring age, parental education, and parental psychiatric disorders and symptoms of other PDs (Johnson, Cohen, Brown, Smailes, &
Berstein, 1999a). Childhood physical abuse, sexual abuse,
and neglect might be differentially associated with PDs, and
suggest that it is important to investigate specific etiologic
models for each of the PDs. With regard to ASPD and BPD,
after symptoms of other PDs were accounted for, documented physical abuse was associated with elevated ASPD
symptoms, sexual abuse was associated with elevated BPD
symptoms, and neglect was associated with elevated symptoms of ASPD and BPD.
221
Jovev et al
The present study utilized a community-based, prospective,
longitudinal assessment of both PD symptoms and temperament features beginning early in adolescence. The study
specifically focused upon BPD and ASPD symptoms, with
the primary aim being to examine the influence of early
maltreatment and temperamental antecedents in predicting
the emergence of these PD symptoms. Particularly, the degree to which four dimensions of temperament (NA, SUR,
AFL and EC) predict emerging symptoms of ASPD and
BPD during early adolescence was examined. It was hypothesized that low AFL, low EC and high SUR would be
significant predictors of increases in both BPD and ASPD
symptoms, while high NA would be a predictor of increased
BPD symptoms only. It was further hypothesized that the
levels of abuse and neglect would moderate the relationship between temperament and change in ASPD and BPD
symptoms, such that the presence of early abuse or neglect
would increase the strength of the relationships between
temperament and change in symptoms. Consistent with the
findings of the CIC study, it was expected that across the
sample, measures of BPD and ASPD symptoms would decrease from baseline to follow-up two years later.
Father’s education was utilized as an index of general family
socioeconomic status. Of our sample, 0.5% of fathers were
primary school educated only, 40.1% were high school educated, 18.1% received vocational training (TAFE: Training
And Further Education) and 41.2% were university educated. In regard to ethnicity, 87.3% of the sample self-identified as Australian, 6.9% as Australian-European, 3.7% as
Australian-Asian, 1.6% as Australian-American and 0.5%
as Australian-Middle Eastern.
Method
The BPD and ASPD subscales of the Children in the Community Self Report Scale (CIC-SR) were used to dimensionally assess BPD and ASPD symptoms in the sample.
The CIC-SR was developed as an age-appropriate measure
of PDs for the CIC sample (mean age=13 years). The CIC
study’s original assessment of PDs took place in 1983 and
the scale has been modified on subsequent occasions to reflect the most recent DSM system revisions. The development of the CIC-SR, is described in detail by Crawford and
colleagues (Crawford et al., 2005), and it has been repeatedly validated in longitudinal analyses (Bernstein, Cohen,
Skodol, Bezirganian, & Brook, 1996; Bernstein et al., 1993;
Crawford, Cohen, & Brook, 2001; Johnson et al., 1999a;
Johnson et al., 1999b; Kasen et al., 2001).
Participants: Sampling and Recruitment
Study participants were drawn from a larger study (see Yap
et al., 2008a for details). Children were originally recruited
from a random sample of government, independent and
Catholic primary schools across metropolitan Melbourne.
A large group of children (N=2453), between 10-12 years
of age, were screened using the Early Adolescent Temperament Questionnaire (EATQ; see below) in order to:
(a) select a smaller sample of children for more intensive
assessment that represented the full range of temperament
scores; and, (b) to maximize the inclusion of children with
temperaments associated with both high and low risk of later affect-regulation problems, including PDs. Participants
scoring at both extremes of each temperament dimension
during the school-based screening were over-sampled for
selection into the baseline cohort (N=415).
Of the children selected and asked to participate in the more
intensive assessments, 59% (N=245) consented to participate and completed the baseline assessments. At baseline,
the participants were 11-13 (M=12.5, SD=0.5) years of
age, with 121 (49%) male participants. At follow-up (approximately two years after baseline (M = 2.56 years, SD
= 0.25 years, range = 1.74 - 3.39 years)), participants were
14-16 years of age (M = 14.57, SD = 0.53). Two hundred
and fourteen participants (87%) consented to the followup assessment, but not all completed the assessment. The
final sample consisted of 205 individuals who had usable
follow-up data. Written informed consent was obtained in
accordance with the guidelines of the Human Research Ethics Committee of the University of Melbourne, Australia.
222
Measures
The Early Adolescent Temperament Questionnaire-Revised
(EATQ-R: Ellis & Rothbart, 2001) was used to examine adolescent temperament child self-report forms. The EATQ-R
consists of ten subscales (Activation Control, Affiliation,
Attention, Fear, Frustration, High Intensity Pleasure, Inhibitory Control, Pleasure Sensitivity, Perceptual Sensitivity
and Shyness) loading onto four higher-order temperamental
dimensions: Negative Affect (NA), Surgency (SUR), Affiliation (AFL) and Effortful Control (EC). The EATQ-R has
good internal consistency, test-retest reliability and validity
data (Capaldi & Rothbart, 1992; Ellis & Rothbart, 2001).
The BPD scale (26 items) and the ASPD scale (31 items)
were utilized in the present study, and the subscales were
used to dimensionally assess BPD and ASPD symptoms
rather than for diagnostic purposes. The BPD and ASPD
scores ranged from 1 to 3.92 (mean=1.72, SD=0.56) and
1.01 to 2.96 (mean=1.27, SD=0.27), respectively. This is
comparable to the data reported in the CIC study for BPD
(mean=1.7, SD=1.5); however, ASPD data was not collected until 1992 when participants were 22 years of age (Johnson, Smailes, Cohen, Brown, & Bernstein, 2000c). Both
scales had excellent internal consistency (BPD Cronbach’s
alpha = 0.94; ASPD Cronbach’s alpha = 0.86) and have appropriate convergence with other self-report instruments in
the present sample.
The Childhood Trauma Questionnaire (CTQ: Bernstein,
Ahluvalia, Pogge, & Handelsman, 1997), a 28-item selfreport inventory suitable for use with adolescents, was used
to screen for a history of abuse and/or neglect. The CTQ
J Can Acad Child Adolesc Psychiatry, 22:3, August 2013
Temperament and Maltreatment in the Emergence of Borderline and Antisocial Personality Pathology during Early Adolescence
Table 1. Summary statistics for temperament, maltreatment and
personality disorder symptoms
Minimum
Maximum
Mean
SD
EC (Baseline)
18
68
47.27
10.04
NA (Baseline)
8
35
23.10
6.46
SUR (Baseline)
22
70
46.93
11.10
AFL (Baseline)
22
64
44.25
8.60
Neglect (Baseline)
10
35
14.73
5.06
Abuse (Baseline)
15
43
18.38
4.92
ASPD (Baseline)
1
2.66
1.25
0.24
BPD (Baseline)
1
3.92
1.67
0.53
ASPD (Follow-up)
1
3.00
1.52
0.40
BPD (Follow-up)
1
2.19
1.30
0.26
SUR = surgency; AFL = affiliation; NA = negative affect; EC = effortful control; ASPD
= antisocial personality disorder; BPD = borderline personality disorder
consists of items measuring physical, sexual, and emotional
abuse (‘Abuse’ scale), and items measuring physical and
emotional neglect (‘Neglect’ scale). The CTQ is quick to
administer, and has been shown to have acceptable psychometric properties for use in both clinical and community
based samples (Bernstein et al., 1997; Scher, Stein, Asmundson, McCreary, & Forde, 2001).
Procedure
Interviewers met with the adolescent in their home for administration of baseline and follow-up assessments. Assessments were conducted as part of a larger Adolescent Development Study (Yap, Allen, & Ladouceur, 2008b). CIC-SR
was administered at both baseline and follow-up. EATQ-R
was also administered at both baseline and follow-up assessments, however; only baseline data was utilized, as it
was closest to the baseline CIC-SR assessment. CTQ was
completed at follow-up, and thus measures abuse and neglect that might have occurred between baseline and follow-up assessments.
Data Analysis
Data were analyzed using separate hierarchical regressions
for each of the maltreatment (abuse and neglect) scores separately. The dependent variable in each regression model
was follow-up PD score; with separate analyses conducted
for BPD and ASPD scores. Baseline higher-order temperament scores and one of the maltreatment scores were
entered into the second block of predictors, after first controlling for the effects of gender, baseline PD score, and
SES (father’s highest level of education) in the first block.
All two-way interactions involving second block predictors were entered into the third block. All continuous independent variables were mean-centred before forming any
interaction terms (Aiken & West, 1991). Significant temperament by trauma interactions were probed using Stata
J Can Acad Child Adolesc Psychiatry, 22:3, August 2013
Version 11 (StataCorp., 2009). An alpha level of 0.05 was
used to classify findings as significant for all statistical tests.
Two participants were missing temperament data and five
were missing baseline CIC-SR data. All missing observations were imputed using the EM approach in the SPSS
Missing Values procedure. In addition to the variables of
interest, the imputation model contained all centered variables and two-way interactions. After imputation of missing data, all continuous independent variables were again
mean-centered and interaction terms were re-calculated.
Results
Preliminary Analyses
Summary statistics for temperament, maltreatment and PD
symptoms are presented in Table 1. The pattern of stability
and change of PD symptoms across the study period was
examined. Paired samples t-tests revealed that mean ASPD
symptoms significantly increased over the observed period
(t(204) = -3.01, p =0.003) while mean BPD symptoms significantly decreased (t(204) = 4.48, p
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