Personality disorders constitute a major challenge for society, as well as psychiatry and psychotherapy [...

Möhler, Eva

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Personality Disorders and Development

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Eva Möhler

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Citation: Möhler, E. PersonalityDisorders and Development. BrainSci. 2022, 12, 983. https://doi.org/10.3390/brainsci12080983Received: 14 July 2022Accepted: 19 July 2022Published: 26 July 2022Publisher’s Note: MDPI stays neutralwith regard to jurisdictional claims inpublished maps and institutional affil-iations.Copyright: © 2022 by the author.Licensee MDPI, Basel, Switzerland.This article is an open access articledistributed under the terms andconditions of the Creative CommonsAttribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).brainsciencesEditorialPersonality Disorders and DevelopmentEva MöhlerDepartment of Child and Adolescent Psychiatry, Saarland University Hospital, G-66421 Homburg, Germany;eva.moehler@uks.euPersonality disorders constitute a major challenge for society, as well as psychiatryand psychotherapy. Specifically, in connection with emotionally unstable personality traits,large and rigorous studies [1] emphasize the high costs for health and other services.Recent research has featured different levels of personality functioning, that canbe measured early in development and result in specific profiles for different types ofpersonality disorders [2]. Even for children as young as school age, diagnostic tools haverecently been developed These novel tools are able to help understand the onset and timingin the development of personality disorders, e.g., a recent study could demonstrate thatespecially emotion dysregulation (ED) contributes to self-injurious behavior in a largegroup of adolescents presenting to a child and adolescent psychiatric emergency service [3].Several authors also mention emotionally dysregulated behavior as one of the leadingsymptoms of Borderline Personality disorder [4].The occurrence of typical phenomena associated with personality dysfunction in earlydevelopment, such as severe tantrums, low frustration tolerance, aggression, negativemood and suicidality is even higher with estimates of about 45% in psychiatric patients [5].30% of adults with emotionally unstable personality report having injured themselvesas early as at primary school age [6]. Therefore a focus on developmental aspects ofpersonality disorders seems to be of crucial importance for elucidating underlying factorsand mechanisms.On the level of the brain, emotional instability has been reported to be correlatedto reduced glucose metabolism in premotoric areas, in the dorsolateral prefrontal cortex,in parts of the anterior prefrontal cortex, in the thalamus, in the caudate nucleus and inthe lenticular nucleus [7] and in the bilateral medial orbitofrontal cortex [8]. CSF tests inemotionally unstable patients and other personality disorders showed particularly lowlevels of 5-hydroxyidol acetic, the degradation product of serotonin. A negative correlationbetween the amount of 5-hydroxyidol acetic acid and the frequency of suicidal behaviourcould be established [9].In addition, a significantly higher serotonin transporter binding was observed [10].From these observations, a serotonergic dysfunction can be concluded as a partial aspectof emotional instability [11]. As further correlates on the neurobiological level, correla-tions between a reduction of serotonergic activity in the brain and subsequent impulsiveaggressiveness, as well as between an increase in cholinergic system reactivity and affec-tive instability have been described [12]. The neuroanatomical correlation to serotonergicdysfunctioning is still unclear. A reduced serotonergic activity in the frontal and cingulatecortex in combination with noradrenergic dysfunction is postulated to lead to an increasein emotional responsiveness of the amygdala and enhances dopaminergic projection ontoorbitofrontal and corticolimbic structures via mutual connection to the ventral tegmentalarea. This disturbed alternating circuit might be associated with impulsive and emotionallydysregulated behavior [9].On the neuroanatomical level, the orbitofrontal cortex seems to play a special rolein emotion regulation. The orbitofrontal cortex takes over the inhibition of aggressionwith the help of the anterior cingulate cortex. Furthermore, the orbitofrontal cortex alsoBrain Sci. 2022, 12, 983. https://doi.org/10.3390/brainsci12080983 https://www.mdpi.com/journal/brainsciBrain Sci. 2022, 12, 983 2 of 4shows a regulatory influence on the amygdala by inhibition [13]. Patients with lesions inthe orbitofrontal cortex were reported to show a significantly higher degree of impulsiv-ity and a higher frequency of inadequate behaviour compared to patients in the healthycontrol group accordingly [9]. Oxytocin has also been postulated to be a major componentaffecting social behavior and perception in personality disorders [13]. The neurobiologicalabnormalities found so far are indirectly associated with personality factors such as neu-roticism, impulsiveness, anxiety, affective instability and uncertain attachment behaviourin conjunction with different expression of these factors via dominance or inactivation ofthe various neurotransmitter systems for an effect on the psychological situation or thepossible development of a borderline personality disorder [14].On another important note, research on personality disorders has stressed the impor-tance of trauma and abusive experiences, as well as adverse childhood experiences forthe development of personality disorders. In general, neurobiology as well as physiologyhas been described to be vastly altered in victims of childhood abuse, e.g., [15]. Generally,a considerable number of studies have pointed out the important role of childhood ad-versities (CA) such as physical and sexual abuse, neglect, parental loss or family conflictin the development of psychopathology in adulthood, emphasizing the need to considerACEs as an influential factor in models examining personality development. Literaturerepeatedly points out that especially the experience of trauma, especially in the form ofsexual abuse and physical abuse, but also emotional neglect in childhood or adolescenceplays a major role in the development of personality disorder [16]. It can be assumedthat a longer-term experience of stress or abuse during the unfinished development ofregulatory and coping mechanisms leads to restrictions of adequate effect control andbehavioural control. In several studies up to 85% of patients with emotional instabilityreported childhood abuse, around 70% of patients with an emotional unstable personalitydisorder report physical abuse and 67% report sexual abuse. Furthermore, in a study ofBohus [17], a large number of patients are massively psychosocially burdened by sexualviolence (65%), physical violence (60%) or neglect (40%). The retrospective evaluation ofpatient histories and data from a structured clinical interview for DSM-IV (SKID) confirmedstressful early life experiences as possible etiological factors. A large proportion of patientsexamined reported traumatic experiences such as sexual and physical violence in childhoodand/or adulthood. In addition, patients with previous experience of sexual violence hadan increased number of suicide attempts compared to the group of patients without suchexperiences in the past.With regard to predictors on the level of relationships, in families with known person-ality disorders, problems with attachment behaviour between children and their parentsare described significantly more frequently in retrospect [18]. According to the basic as-sumptions of attachment theory experience with interpersonal interactions form the basisfor the development of emotional health, disturbed attachment behaviour leads to interac-tional difficulties and disorders with self-control in the child’s development [19]. Dramaticrelationships with disorganized, chaotic, conflictual and sensitive family interactions, achaotic and hostile family atmosphere, as well as an invalidating style in upbringing, inwhich feelings, thoughts and behaviour are neither taken seriously nor accepted, playa special role [20]. With a disabling, disrespectful and hardly supportive or predictableenvironment, traumatic experiences have a stronger impact on the development of a per-sonality in childhood [13]. Particularly early occurrence of abuse, separation or neglecthas been described to be closely related to the development of uncertainties in attachmentbehavior [18]. The available data show that a substantial body of research associates earlylife conditions with later personality disorder, however, to date very few studies have beenconducted prospectively or with regard to targets for treatment or prevention.Therefore, strategies regarding prevention and intervention such as dialectic behav-ioral therapy tend to focus on and target different levels of personality functioning, such asself-control, empathy and interpersonal behavior. Much progress has been made in thisregard, e.g., with mentalization based therapies and other novel treatment approaches.Brain Sci. 2022, 12, 983 3 of 4Specifically, regarding the patients’ frequent mistrust and relationship difficulties, lowthreshold programs need to be developed and evaluated.In summary, research and clinical provider need better equipment with diagnosticand psychotherapeutic tools for characterization of personality disorders and a much morethorough understanding of the developmental pathways through which early experienceshapes personality. In addition, a more dimensional framework respecting the normal vari-ation of human feelings and behavior and regarding it as highly susceptible to environmentand therefore therapeutic interventions is encouraged [21]. Novel insights on these aspectscan help clinicians to tailor intervention efforts more precisely [22].Therefore, studies focusing on pathogenetic aspects of personality disorders by ad-dressing neurobiological underpinnings and childhood adversity are collected in this issue.Furthermore, interventions and therapies that give an overview on established therapeutictools such as DBT and the younger ‘derivatives’ are of interest, as well as articles describingnovel interventions developed from the recent ED-Framework. Together with reviewarticles on state of the art advancements in personality disorders, research in this issuealso explores the adverse childhood experiences framework and aims to describe empiricalresearch on neurobiological associations between trauma and personality disorders.With original articles and reviews on pathogenesis, diagnosis, treatment and classifica-tion of personality disorders our aim is to achieve with this issue a large transdiagnosticlong-term benefit for research as well as clinical aspects. This is of crucial significance, sinceunderstanding and improving personality functioning in all aspects prevents the onset ofmultiple associated psychiatric and physical disorders and severe psychsoscial dysfunction.Intervention and preventive efforts to promote successful social and professional develop-ment will be shown and highly welcomed in this issue. The global alliance for preventionand early intervention of borderline personality disorder has named the development andradnomized controlled evaluation as a novel public health priority [23], which should bevalidated not only, but also by this special issue.Funding: This research received no external funding.Conflicts of Interest: The author declare no conflict of interest.References1. Plener, P.L.; Kapusta, N.D.; Kölch, M.G.; Kaess, M.; Brunner, R. Nichtsuizidale Selbstverletzung als eigenständige Diagnose. Z.Kinder Jugendpsychiatrie Psychother. 2012, 40, 113–120. [CrossRef] [PubMed]2. Birkhölzer, M.; Schmeck, K.; Goth, K. Assessment of Criterion A. Curr. Opin. Psychol. 2021, 37, 98–103. [CrossRef] [PubMed]3. Kandsperger, S.; Jarvers, I.; Ecker, A.; Schleicher, D.; Madurkay, J.; Otto, A.; Brunner, R. Emotional Reactivity and Family-RelatedFactors Associated with Self-Injurious Behavior in Adolescents Presenting to a Child and Adolescent Psychiatric EmergencyService. Front. 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