Personality Disorder in Childhood and Adolescence comes of Age: a Review of the Current Evidence and Prospects for Future Research

In this article, the authors provide a narrative review of the mounting evidence base on personality disorder in childhood and adolescence. Topics covered include diagnostic validity, prevalence, developmental issues, comorbidity, risk and protective factors, and treatment. Novel indicated prevention and early intervention programs for borderline personality disorder in adolescence are given special priority. To conclude, directions for future research are provided

Personality Disorder in Childhood and Adolescence comes of Age: a Review of the Current Evidence and Prospects for Future Research

In this article, the authors provide a narrative review of the mounting evidence base on personality disorder in childhood and adolescence. Topics covered include diagnostic validity, prevalence, developmental issues, comorbidity, risk and protective factors, and treatment. Novel indicated prevention and early intervention programs for borderline personality disorder in adolescence are given special priority. To conclude, directions for future research are provided

The prevalence of personality disorders in the community: a global systematic review and meta-analysis

Background Personality disorders are now internationally recognised as a mental health priority. Nevertheless, there are no systematic reviews examining the global prevalence of personality disorders. Aims To calculate the worldwide prevalence of personality disorders and examine whether rates vary between high and low and middle-income countries (LAMICs). Method We systematically searched PsycINFO, MEDLINE, EMBASE and PubMed from 1980 to May 2018 to identify articles reporting personality disorder prevalence rates in community populations (PROSPERO registration number: CRD42017065094). Results Forty-six studies (from 21 different countries spanning six continents) satisfied inclusion criteria. The worldwide pooled prevalence of any personality disorder was 7.8 % (95% Confidence Intervals: 6.1-9.5). Rates were greater in high income (9.6%; 95% CI: 7.9-11.3%) compared with LAMI (4.3%; 95% CI =2.6-6.1%) countries. In univariate meta-regressions, significant heterogeneity was partly attributable to study design (two-stage versus one-stage assessment), county income (high versus LAMI) and interview administration (clinician versus trained graduate). In multiple meta-regression analysis, study design remained a significant predictor of heterogeneity. Global rates of Cluster-A, B and C personality disorders were 3.8 % (3.2, 4.4%), 2.8% (1.6, 3.7%) and 5.0% (4.2, 5.9%). Conclusions Personality disorders are prevalent globally. Nevertheless, pooled prevalence rates should be interpreted with caution due to high levels of heterogeneity. More large-scale studies with standardised methodologies are now needed to increase our understanding of population needs and regional variations

Associations of state or trait dissociation with severity of psychopathology in young people with borderline personality disorder.

BACKGROUND State and trait dissociation are associated with borderline personality disorder (BPD) severity and severity of commonly co-occurring mental health symptoms. Although these distinct constructs do not consistently co-occur in experimental settings, they are frequently reported as the same construct, namely dissociation. This study aimed to investigate the co-occurrence of state and trait dissociation among young people with BPD and to examine whether state or trait dissociation were associated with symptom severity in this population. METHODS State dissociation was induced using a stressful behavioural task in a clinical sample of 51 young people (aged 15-25 years) with three or more BPD features. Diagnoses, state and trait dissociation, BPD severity and severity of posttraumatic stress disorder (PTSD), depressive, and stress symptoms were assessed by self-report or research interview. RESULTS A chi-square test of independence showed a strong association between state and trait dissociation. Bonferroni corrected t-tests showed that state dissociation was significantly associated with PTSD symptom severity and likely associated with BPD severity and severity of depressive and stress symptoms. Trait dissociation was not associated with symptom severity or severity of BPD features. CONCLUSIONS These findings highlight the need to distinguish between state and trait dissociation in personality disorder research. They suggest that state dissociation might be an indicator of higher severity of psychopathology in young people with BPD

Clinical and service implications of a cognitive analytic therapy model of psychosis

Cognitive analytic therapy (CAT) is an integrative, interpersonal model of therapy predicated on a radically social concept of self, developed over recent years in the UK by Anthony Ryle. A CAT-based model of psychotic disorder has been developed much more recently based on encouraging early experience in this area. The model describes and accounts for many psychotic experiences and symptoms in terms of distorted, amplified or muddled enactments of normal or ‘neurotic’ reciprocal role procedures (RRPs) and of damage at a meta-procedural level to the structures of the self. Reciprocal role procedures are understood in CAT to represent the outcome of the process of internalization of early, sign-mediated, interpersonal experience and to constitute the basis for all mental activity, normal or otherwise. Enactments of maladaptive RRPs generated by early interpersonal stress are seen in this model to constitute a form of ‘internal expressed emotion’. Joint description of these RRPs and their enactments (both internally and externally) and their subsequent revision is central to the practice of CAT during which they are mapped out through written and diagrammatic reformulations. This model may usefully complement and extend existing approaches, notably recent CBT-based interventions, particularly with ‘difficult’ patients, and generate meaningful and helpful understandings of these disorders for both patients and their treating teams. We suggest that use of a coherent and robust model such as CAT could have important clinical and service implications in terms of developing and researching models of these disorders as well as for the training of multidisciplinary teams in their effective treatment

Psychopathology and psychosocial functioning among young people with first-episode psychosis and/or first-presentation borderline personality disorder.

BACKGROUND One in five young people with first-episode psychosis (FEP) also presents with borderline personality disorder (BPD) features. Among people diagnosed with BPD, auditory verbal hallucinations occur in 29-50 % and delusions in 10-100 %. Co-occurrence of psychotic symptoms and BPD is associated with greater clinical severity and greater difficulty accessing evidence based FEP care. This study aimed to investigate psychotic symptoms and psychosocial functioning among young people presenting to an early intervention mental health service. METHOD According to the presence or absence of either FEP or BPD, 141 participants, aged 15-25 years, were assigned to one of four groups: FEP, BPD, combined FEP + BPD, or clinical comparison (CC) participants with neither FEP nor BPD. Participants completed semi-structured diagnostic interviews and interviewer and self-report measures of psychopathology and psychosocial functioning. RESULTS The FEP + BPD group had significantly more severe psychopathology and poorer psychosocial functioning than the FEP group on every measure, apart from intensity of hallucinations. Comparing the FEP or BPD groups, the BPD group had greater psychopathology, apart from intensity of psychotic symptoms, which was significantly greater in the FEP group. These two groups did not significantly differ in their overall psychosocial functioning. Compared with CC young people, both the FEP + BPD and BPD groups differed significantly on every measure, with medium to large effect sizes. CONCLUSIONS Young people with co-occurring FEP and BPD experience more severe difficulties than young people with either diagnosis alone. This combination of psychosis and severe personality pathology has been longitudinally associated with poorer outcomes among adults and requires specific clinical attention

Prospective progression from high-prevalence disorders to bipolar disorder: exploring characteristics of pre-illness stages

BACKGROUND: Identification of risk factors within precursor syndromes, such as depression, anxiety or substance use disorders (SUD), might help to pinpoint high-risk stages where preventive interventions for Bipolar Disorder (BD) could be evaluated. METHODS: We examined baseline demographic, clinical, quality of life, and temperament measures along with risk clusters among 52 young people seeking help for depression, anxiety or SUDs without psychosis or BD. The risk clusters included Bipolar At-Risk (BAR) and the Bipolarity Index as measures of bipolarity and the Ultra-High Risk assessment for psychosis. The participants were followed up for 12 months to identify conversion to BD. Those who converted and did not convert to BD were compared using Chi-Square and Mann Whitney U tests. RESULTS: The sample was predominantly female (85%) and a majority had prior treatment (64%). Four participants converted to BD over the 1-year follow up period. Having an alcohol use disorder at baseline (75% vs 8%, χ(2)=14.1, p<0.001) or a family history of SUD (67% vs 12.5%, χ(2)=6.0, p=0.01) were associated with development of BD. The sub-threshold mania subgroup of BAR criteria was also associated with 12-month BD outcomes. The severity of depressive symptoms and cannabis use had high effects sizes of association with BD outcomes, without statistical significance. CONCLUSIONS AND LIMITATIONS: The small number of conversions limited the power of the study to identify associations with risk factors that have previously been reported to predict BD. However, subthreshold affective symptoms and SUDs might predict the onset of BD among help-seeking young people with high-prevalence disorders

The prevalence, age distribution and comorbidity of personality disorders in Australian women

OBJECTIVE: We aimed to describe the prevalence and age distribution of personality disorders and their comorbidity with other psychiatric disorders in an age-stratified sample of Australian women aged ⩾25 years. METHODS: Individual personality disorders (paranoid, schizoid, schizotypal, histrionic, narcissistic, borderline, antisocial, avoidant, dependent, obsessive-compulsive), lifetime mood, anxiety, eating and substance misuse disorders were diagnosed utilising validated semi-structured clinical interviews (Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition and Structured Clinical Interview for DSM-IV Axis II Personality Disorders). The prevalence of personality disorders and Clusters were determined from the study population ( n = 768), and standardised to the Australian population using the 2011 Australian Bureau of Statistics census data. Prevalence by age and the association with mood, anxiety, eating and substance misuse disorders was also examined. RESULTS: The overall prevalence of personality disorders in women was 21.8% (95% confidence interval [CI]: 18.7, 24.9). Cluster C personality disorders (17.5%, 95% CI: 16.0, 18.9) were more common than Cluster A (5.3%, 95% CI: 3.5, 7.0) and Cluster B personality disorders (3.2%, 95% CI: 1.8, 4.6). Of the individual personality disorders, obsessive-compulsive (10.3%, 95% CI: 8.0, 12.6), avoidant (9.3%, 95% CI: 7.1, 11.5), paranoid (3.9%, 95% CI: 3.1, 4.7) and borderline (2.7%, 95% CI: 1.4, 4.0) were among the most prevalent. The prevalence of other personality disorders was low (⩽1.7%). Being younger (25-34 years) was predictive of having any personality disorder (odds ratio: 2.36, 95% CI: 1.18, 4.74), as was being middle-aged (odds ratio: 2.41, 95% CI: 1.23, 4.72). Among the strongest predictors of having any personality disorder was having a lifetime history of psychiatric disorders (odds ratio: 4.29, 95% CI: 2.90, 6.33). Mood and anxiety disorders were the most common comorbid lifetime psychiatric disorders. CONCLUSIONS: Approximately one in five women was identified with a personality disorder, emphasising that personality disorders are relatively common in the population. A more thorough understanding of the distribution of personality disorders and psychiatric comorbidity in the general population is crucial to assist allocation of health care resources to individuals living with these disorders

The diagnosis that should speak its name: why it is ethically right to diagnose and treat personality disorder during adolescence

Although national guidelines explicitly state that personality disorder can be diagnosed and treated in young people aged 12 to 18 years (adolescents), most clinicians remain hesitant. This creates a gap between science and practice, which we argue is largely motivated by moral reasons and, therefore, is best challenged by ethical arguments. We provide seven arguments in support of the notion that it is ethically right to diagnose and treat personality disorder when it occurs in adolescents. Central to these arguments is the scientific evidence that features of personality disorder are among the best predictors of a complex cluster of psychopathology leading to impairments in many areas of current and future mental, social and vocational functioning. We argue that intervention during adolescence and young adulthood is not only humane, but also critical for efforts to avert the longstanding psychosocial and health problems that seem refractory to treatment in adults with personality disorder. Moreover, we argue that regular services are often inadequately equipped to meet the needs of young people with personality disorder and that the common ‘stepped-care’ approach should be replaced by a ‘staged-care’ approach. Finally, we argue that early detection and intervention might have anti-stigmatizing effects, similar to other areas of healthcare in which stigmatizing labels have changed meaning when the conditions to which they refer have become more amenable to treatment