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Dissertation for the Degree of Doctor of Philosophy (Faculty of Medicine) in Child and
Adolescent Psychiatry presented at Uppsala University in 2002.
ABSTRACT
Ramklint, M. 2002. Influence of Child and Adolescent Psychopathology on Adult Personality
Disorder. Acta Universitatis Upsaliensis. Comprehensive Summaries of Uppsala Dissertations
from the Faculty of Medicine 1163. 54 pp. Uppsala. ISBN 91-554-5338-4.
Individuals afflicted with childhood and adolescent mental disorders have an increased
risk for poor outcome in adulthood. The progression of psychopathology from childhood to
adult life may be influenced by a multitude of interacting variables, both biological and
psychosocial. There is limited information on the relationships between child
psychopathology and adult personality and personality disorders. The main aim of this thesis
was therefore to gain better knowledge concerning adult personality outcome in patients with
early onset of mental disorders.
Former child psychiatric patients as compared to controls had a significantly higher
prevalence of all DSM-IV personality disorders (38.0 vs. 10.9 percent, p<0.001) and also a
considerably higher personality disorder co-morbidity. They also had more psychosocial and
environmental problems. This was exaggerated in those diagnosed with a personality
disorder. Major depression, disruptive disorders and substance use disorders at a young age
were strong predictors for adult personality disorder.
Patients with an early onset major depression had more personality disorders and more
deviant personality traits than those with a late onset.
Forensic psychiatric male patients diagnosed with a previous conduct disorder as
compared to those without had more cluster B personality disorders, and more repeated
violent criminality and mixed abuse. They also exhibited more deviant personality traits and
higher psychopathy scores.
The instrument "Child and Adolescent Psychiatric Screening Inventory-Retrospect" had
acceptable sensitivity and specificity for assessment of child psychiatric disorders. Subscales
demonstrated good internal reliability (Crohnbach´s alpha = 0.76-0.93).
The results suggest that adult personality disturbances are prevalent in individuals
affected with mental problems at young ages. A better understanding of the transition of
psychopathology from childhood to adulthood and a better identification of those at risk will
be of help in attempts to prevent permanent impact on the adult personality.
Key words: child psychiatry, personality, major depressive disorder, disruptive disorder,
conduct disorder, retrospective analysis, self-assessment
Mia Ramklint, Department of Neuroscience, Psychiatry and Child and Adolescent Psychiatry,
University Hospital, SE-751 85 Uppsala, Sweden
 Mia Ramklint, 2002
ISSN 0282-7476
ISBN 91-554-5338-4
Printed in Sweden by Uppsala University, Tryck&Medier, Uppsala, 2002
2
The childhood shows the man,
as morning shows the day
Paradise Regained, 1671
John Milton (1608–1674)
3
LIST OF PAPERS
This thesis is based on the following original papers, which will be referred to in the
text by their Roman numerals:
I Ramklint M, von Knorring A-L, von Knorring L, Ekselius L. Personality
disorders in former child psychiatric patients. Submitted.
II Ramklint M, von Knorring A-L, von Knorring L, Ekselius L. Child and
adolescent psychiatric disorders predicting personality disorders: A follow-up
study. Nordic Journal of Psychiatry, 2002. In press.
II Ramklint M, Ekselius L. Personality disorders and personality traits in early
onset versus late onset major depression. Journal of Affective Disorders, 2002.
In press.
IV Ramklint M, Stålenheim EG, von Knorring A-L, von Knorring L. Conduct
disorder and personality in a forensic psychiatric population. The European
Journal of Psychiatry, 2001:15:245-254.
V Ramklint M, von Knorring A-L, von Knorring L, Ekselius L. Child and
Adolescent Psychiatric Screening Inventory-Retrospect (CAPSI-R): a
questionnaire for adults concerning child and adolescent mental disorders.
European Psychiatry, 2002:17:61-68.
Reprints were made with the permission of the publishers.
4
CONTENTS
ABSTRACT
LIST OF PAPERS
CONTENTS
ABBREVIATIONS
INTRODUCTION
Psychopathology in childhood and adult outcome
Temperament, personality traits and personality
Mental disorders and diagnostic classification
Models of the relationship between clinical syndromes and
personality disorders
Epidemiology
Developmental pathways
Assessments
AIMS OF THE PRESENT THESIS
METHODOLOGY
Subjects and Methods Papers I, II and V
Subjects and Methods Paper III
Subjects and Methods Paper IV
Ethics
RESULTS
Personality disorders in former child psychiatric patients (paper I)
Predictive value of child and adolescent psychiatric disorders for
adult personality disorder (paper II).
Personality traits and personality disorders in early onset vs. late
onset major depression (paper III)
Personality traits and personality disorders in early onset vs. late
onset of antisocial behaviour (paper IV)
The Child and Adolescent Psychiatric Screening InventoryRetrospect (Paper V)
DISCUSSION
Methodological considerations
Adult personality disorders
Personality traits
Major depression and personality characteristics
Substance use disorders and personality characteristics
Disruptive disorders and personality characteristics
The CAPSI-R
CONCLUSIONS
ACKNOWLEDGEMENTS
REFERENCES
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2
4
5
6
7
7
7
9
12
13
13
16
18
18
19
23
25
26
26
26
27
28
29
30
32
32
34
35
36
38
38
40
41
42
44
ABBREVIATIONS
ADHD
Attention deficit hyperactivity disorder
APA
American Psychiatric Association
CAPSI-R
The Child and Adolescent Psychiatric Screening InventoryRetrospect
CI
Confidence interval
DIP-Q
The DSM-IV and ICD-10 Personality Questionnaire
DSM
Diagnostic and Statistical Manual of Mental Disorders
DSM-III-R
Diagnostic and Statistical Manual of Mental Disorders, 3rd edition
revised
DSM-IV
Diagnostic and Statistical Manual of Mental Disorders, 4th
edition.
GAF
Global Assessment of Functioning
ICD-10
International Classification of Diseases and Related Health
Problems, 10th revision
KSP
Karolinska Scales of Personality
MADRS
Montgomery Åsberg Depression Rating Scale
OR
Odds ratio
PCL-R
The Psychopathy Checklist-Revised
SCID I
Structured Clinical Interview for DSM for Clinical Syndromes
SCID II
Structured Clinical Interview for DSM for Personality Disorders
SD
Standard deviation
WHO
World Health Organization
6
INTRODUCTION
Psychopathology in childhood and adult outcome
Individuals afflicted with childhood and adolescent mental disorders have an increased
risk for poor outcome in adulthood. Thus, there are significantly higher rates of
delinquency, disability and mortality in former adolescent psychiatric patients
followed-up decades after hospitalisation as compared to the general population (38,
58, 70, 86-89, 93, 95, 138, 160, 177).
Several studies of child psychiatric symptomatology using prospective designs have
been conducted (2, 28, 55, 56, 112, 122). Results generally indicate moderate stability
of problem behaviour from childhood to adolescence (106). However, specific styles
of behaviour in early childhood have been associated with specific deviant personality
traits in young adulthood (28, 76). Furthermore, anxious/depressed, disruptive and
aggressive syndromes in young adults have been strongly predicted by corresponding
adolescent syndromes (2, 122).
Knowledge about the continuity and discontinuity of psychopathology from childhood
to adulthood is indispensable for answering questions concerning the origins of adult
psychopathology and thus providing possibilities for preventive actions. The course of
pathology with respect to both clinical disorders (Axis I) and personality disorders
(Axis II) across the child-to-adult transition is, however, still largely unclear (53, 136).
Furthermore, there is a considerable lack of understanding about the causal
relationship between childhood and adolescent mental disorders and adult clinical
disorders and personality disorders. This work consequently focuses upon the
relationship between child and adolescent mental disorders and adult personality
disorders.
Temperament, personality traits and personality
Temperament refers to the raw biological materials from which personality emerges. It
reflects the "constitutional soil, the biochemistry, endocrinology, and neurological
structure that underlie the way we respond to stimulation in particular areas" (59). The
7
functional thinking that applies to the internal regulatory roles of temperament derives
from psychophysiology, the Pavlovian tradition, and the works of Eysenck (49), Gray
(61), Sjöbring (147) and Schalling (141). It is abundantly clear that individual children
differ markedly from one another in a host of different ways, and that these differences
can be measured with reasonable reliability (23, 24, 42). There is consensus that
activity level and emotionality are considered to be temperamental dimensions. In
addition, some theorists regard reactivity and sociability as temperamental (59). In the
first weeks of life, temperamental dimensions constitute nearly the entire personality
of the newborn, which makes the infant a prototypical or model system for the study of
temperament. As development proceeds, the expression of temperament becomes
more influenced by experience and context. It has been well demonstrated that
temperamental differences matter in terms of their implications for later development
and the risk of psychiatric morbidity (158, 159).
Temperamental traits refer to correlated patterns of reactions, while personality traits
refer to a conglomerate of habits. Washing one’s hands repeatedly is a habit, while
cleanliness is a trait. Cross-situational consistency is more likely to be assumed for
traits than for habits (25). Personality traits are distributed according to a normal bellshaped curve. The behaviour of people in the middle range would be expected to be
less predictable than the behaviour of those scoring in the upper or lower quartiles.
Personality is a much broader concept than the collection of temperamental or
personality traits. It involves processing of information, the synthesising and
integrative functions of the mind, such as motivation and recognition. Personality is
more than temperament; it also includes self-concept, attitudes, specific expectations,
perceptual dispositions, motivations, values, standards and defence mechanisms.
Allport (7), one of the most influential personality theorists, referred to ”dynamic
organisation”, a phrase that emphasises both an active mental role and also the
importance of developmental changes. Personality is, in a sense, the patterning that
each person, as a thinking being, develops as a way of dealing with the traits with
which he/she is endowed, the social contexts that he/she encounters, and the
8
experiences he/she has had. The various characteristics comprising our personality do
not display equal degrees of consistency and stability (84).
Mental disorders and diagnostic classification
A mental disorder is conceptualised as a clinically significant behavioural or
psychological syndrome or pattern that occurs in an individual and is associated with
present distress or disability or with a significantly increased risk of suffering death,
pain, disability, or an important loss of freedom (10). Mental disorders refer both to
clinical disorders and personality disorders. Classification constitutes a means of
ordering information, of grouping phenomena, and of providing a language by which
to communicate with other people (77). The need for a classification of mental
disorders has been obvious throughout the history of medicine. However, there has
been little agreement among psychiatrists regarding theoretical concepts, although
there has been fairly good agreement on broadly defined, simple phenomenological
diagnoses (103). Thus it has become more accepted that psychiatric classifications
need to be based on patterns of symptomatology rather than on theories (10). Although
the classification of mental illnesses had much earlier origins, modern empiricallybased schemes started with Kraepelin’s use of outcome differences to differentiate
between schizophrenia and manic-depressive disorder (91). The two classification
systems most commonly used today are the International Classification of Diseases,
tenth version (ICD-10) (167), and the Diagnostic and Statistical Manual of Mental
Disorders, fourth version (DSM-IV) (10).
Some disorders, such as attention deficit hyperactivity disorder (ADHD), are already
evident in childhood or adolescence, while others, such as panic disorder, may not
come to clinical attention until late adolescence or adulthood. The division between
child and adult mental disorders according to age of onset is for convenience only, and
is not absolute.
9
The DSM system
In 1952 the American Psychiatric Association’s Committee on Nomenclature and
Statistics published the first edition of DSM (DSM-I). Four editions have been
published since then, the latest in 1994. The approach of DSM is atheoretical with
regard to aetiology. The definitions of the disorders usually consist of descriptions of
clinical features. DSM-IV is a multiaxial system that evaluates the patient along
several variables and that contains five axes (10). Axis I and Axis II comprise the
entire classification of mental disorders, including 17 major classifications and more
than 300 specific disorders. Axis I consists of clinical disorders, and axis II of
personality disorders and mental retardation. In many instances a patient may have
more than one disorder and may have disorders on both axes. Axis III is for reporting
current general medical conditions that are potentially relevant to the understanding or
management of the individual’s mental disorder. Axis IV is used to code the
psychosocial and environmental problems that significantly contribute to the
development or the exacerbation of the current disorder. Finally, Axis V is the Global
Assessment of Functioning (GAF) scale, assessing functioning as a composite of three
major areas, social functioning, occupational functioning and psychological
functioning. The GAF scale is based on a continuum of mental health and mental
illness and is a 100-point scale, with 100 representing the highest level of functioning
in all areas.
Dimensions or categories
DSM-IV is a categorical classification. Categories assume the existence of discrete
boundaries both between different disorders and between normality and abnormality
(79). The categorical approach is mainly based on clinical tradition and anchors the
system within psychiatry and medicine (62). Much indicates that a categorical concept
is a considerable simplification of the underlying biology, and that many symptoms
and underlying processes operate in a continuous spectrum. Thus, many of the
symptoms that are associated with clinical conditions are observed, but in a milder
form, in individuals who do not fulfil the necessary criteria for disease. There are, for
example, obvious similarities between social phobia and what can be considered
10
"normal" shyness, between conduct disorder and ”normal” disruptive behaviour, and
certainly between personality disorders and ”normal” personalities. Thus, there is
empirical support for a dimensional approach, especially with respect to personality
disorders and in studies on underlying mechanisms (34, 44). Furthermore, in a study of
the adolescent consequences of clinical and threshold-level childhood psychiatric
disorders, there was a considerable continuity of psychopathology for those who
received a childhood diagnosis, not only in those with distinct disorders but also in
those with threshold-level disorders with functional impairment (35).
Personality disorders
Personality pathology comprises stable and consistent traits that persist inflexibly, are
exhibited inappropriately, and foster vicious circles that perpetuate and intensify
already present difficulties. According to the DSM-IV (10), a personality disorder is
"an enduring pattern of inner experience and behaviour that deviates markedly from
the expectations of the individual’s culture". This pattern has an onset in adolescence
or early adulthood, is stable over time, and leads to distress and impairment.
Personality disorders can be organised in three distinct clusters based on
characteristics common to each cluster. The cluster organisation was largely the end
result of a committee process (108). Cluster A, the odd and eccentric cluster, consists
of the paranoid, schizoid and schizotypal personality disorders. Common features of
this cluster are constricted emotions, a reduced range of affect, mistrust of others,
aloofness and social withdrawal (10, 108). Schizotypal personality disorder also
includes psychotic-like symptoms and has been linked genetically and
phenomenologically to schizophrenia (83). Cluster B includes antisocial, borderline,
histrionic and narcissistic personality disorders. Individuals with a cluster B diagnosis
are often described as dramatic, emotional and erratic. Impulsiveness is a core
characteristic of at least three of the diagnoses in this cluster (10, 108). Cluster C, the
anxious cluster, includes avoidant, dependent, and obsessive-compulsive personality
disorders. Individuals with a cluster C personality disorder tend to manifest anxious
and fearful behaviour (10, 108).
11
Psychopathy
Psychopathy, as defined by Cleckley (30) and subsequently by Hare (67), offers an
alternative conceptualisation to the DSM antisocial personality disorder. Hare defined
psychopaths as grandiose, egocentric, manipulative and cold-hearted (67). The
Psychopathy Checklist-Revised (PCL-R) was explicitly constructed as a basis for a
reliable assessment (66). Factor analysis has given a two-factor solution, with one
factor that appears to represent a narcissistic personality variant of the psychopathic
pattern, including callous-unemotional interpersonal traits, and another factor that
appears more directly related to those with an overtly antisocial lifestyle (68). A
significant correlation between antisocial personality disorder and psychopathy has
been reported in male prisoners (67) and in female methadone patients (133).
Psychopathy has been shown to be a robust predictor of violence and violent
recidivism (71).
Models of the relationship between clinical syndromes and personality
disorders
Personality disorders and clinical syndromes are related in several ways (37, 76, 108,
168). Quantitative descriptions of clinical and general populations have revealed
substantial co-morbidity between classes of child and adolescent psychiatric disorders
(9, 107). Co-morbidity is also common between adult clinical syndromes (85), among
personality disorders (45), and between clinical syndromes and personality disorders
(33, 113, 149). Different models for these relationships have been suggested (41, 108).
According to the vulnerability model, personality disorders dispose the individual to
the development of an axis I disorder. When coping strategies are limited or
impoverished, the probability of developing an axis I disorder such as anxiety or
depression is greatly increased. Personality-disordered patients often evoke the very
stressors under which these disorders will be developed. In the complication model,
the causality of the vulnerability model is reversed. Axis I conditions create a
predisposition to personality change. For example, patients who experience a severe
and long-lasting depression may internalise pessimism and hopelessness, creating a
personality change at the trait level. In the spectrum model, personality disorders and
12
axis I conditions are seen as developing from the same constitutional soil and therefore
as existing on a continuum. This model has been used to describe the nature of
relationships between e.g. the cluster A personality disorders and psychotic disorders,
most typically schizophrenia. The pathoplasty model holds that personality influences
the course of an axis I disorder but does not itself dispose to the development of the
disorder. All these models are possible and likely to be true for different individuals. In
fact, it is possible that all are applicable to some degree in a single individual (41,
108).
Epidemiology
A systematic review (129) of epidemiological studies done over the past four decades
has found prevalence estimates of psychopathology during childhood and adolescence
ranging from one to nearly 51 percent (mean =15.8). The high variability in prevalence
rates obtained in previous studies reflects differences in sampling, diagnostic methods
and case definitions. The cumulative incidence of psychiatric disorders (meeting
DSM-III criteria) in a total population under 25 years of age in Sweden was 13.9
percent for boys and 14.2 percent for girls. These figures comprise those applying for
professional help who are therefore registered at a hospital or at a clinic (170). The
prevalence of personality disorders in the adult general population is estimated to be
between six and 14 percent depending on the diagnostic criteria and methods of
assessments used (47, 139, 161, 165). Research results indicate that the prevalence of
personality disorders varies between different age groups, with a slight decrease in
older groups (102). Among psychiatric patients the prevalence is much higher, with
frequencies between 30 and 80 percent (8, 19, 78, 92).
Developmental pathways
Biological and psychosocial factors influence development. The biological substrate
(genetic and non-genetic), the interactive shaping of the environment, cognitive and
social skills, self-esteem and self-efficacy, habits, cognitive sets and coping styles are
all possible mediating factors. The timing as well as the nature of experiences is likely
to influence their impact (136). There are both risk and protective factors and
13
interactions between them (134, 135, 173). Mental disorders are much more common
in adults who have been treated for such disorders in childhood or adolescence (69,
131, 177). In a 22 to 25-year follow-up study of former child psychiatric in-patients,
Thomsen (160) found that approximately one-third of the sample had at least one
readmission after the age of 18 years. Childhood emotional and behaviour problems
are associated with a greater risk of developing adolescent personality disorder (14).
Furthermore, childhood mental disorders increase the risk of personality disorders in
young adulthood (1, 127, 128, 160). Finally, both adolescent clinical disorders and
adolescent personality disorders are independent risk factors for young adult
personality disorders (81). An increased number of adolescent mental disorders has
also been shown to be associated with an elevated personality disorder dimensional
score in young adults (97).
Many individuals fulfilling criteria for one Axis I and/or Axis II diagnosis also fulfil
criteria for one or more independent diagnosis(es). Such co-morbidity (see above) has
been extensively studied, as it offers a possibility of understanding underlying
developmental processes (9). Although there is little evidence that any one disorder
directly causes any other disorder, the presence of shared risk factors is likely to be an
important component in the causation of co-morbidity. It is also likely that some comorbid patterns, such as depression with dysthymia and oppositional defiant disorder
with conduct disorder, represent developmental sequences of unitary underlying
developmental psychopathological processes. Furthermore, certain patterns of comorbidity may represent separate subtypes of their component diagnoses that might
have different outcomes (9). Moreover, co-morbidity is of considerable clinical
importance, as it is associated with a higher level of impairment and service utilisation
(17).
Disruptive disorders and personality disorders
Using a sociological approach, Robins (130) showed a convincing link between
childhood conduct problems and adult sociopathy (later named antisocial personality
disorder). This link has been confirmed in several studies (73, 100). However, among
14
children defined as aggressive, antisocial or delinquent on one occasion, only 30 to
50 percent develop adult criminality (130, 153). Children with conduct problems
constitute a very heterogeneous group (73, 94). They develop various patterns of
offending. It seems that the chronic offenders represent a distinct subgroup, with an
early onset of symptoms and a pattern where minor antisocial behaviours are
followed by more serious ones (51, 99).
In both clinical and epidemiological populations there is an overlap between the
diagnoses of conduct disorder and ADHD in 30 to 50 percent of cases (157).
Children with both ADHD and conduct disorder are considered to be at the greatest
risk for developing antisocial personality in adulthood, particularly psychopathy
(99). Consistent with findings in adults, Frick (57) found two separable
psychological dimensions in clinically referred children with conduct disorder. The
first involved a callous-unemotional interpersonal style. The second dimension
involved poor impulse control and antisocial behaviour. The presence of both
callous-unemotional traits and significant conduct problems characterises a subgroup
of antisocial children who show a very severe pattern of antisocial behaviour that
corresponds closely to the adult conceptualisation of psychopathy (29). Finally, there
is an association between childhood disruptive behaviours and personality disorders
in all clusters, particularly between conduct disorder and adult antisocial personality
disorder (81, 128, 131, 176).
Mood disorders and personality disorders
Studies have demonstrated that subjects with early onset major depression are more
likely than those with late onset major depression to have co-morbid personality
disorders (52, 140). Personality disorders from cluster B and cluster C are most
commonly associated with major depression (113, 119, 120, 149). The co-morbidity
between personality disorders and mood disorders has raised questions about
etiological factors (146) and developmental pathways (5). Mood disorders with onset
in childhood or adolescence are common, with prevalence rates for major depressive
disorder ranging between 0.4 and 2.5 percent in children and between 0.4 and 8.3
15
percent in adolescents (for review see (18)). Early onset major depression is a
condition with estimated recurrence rates of 60 to 70 percent (69, 126). Youths with
major depressive disorder convert to bipolar illness more frequently than do adults
(90), which was taken as an argument indicating that early onset major depression is a
particularly serious form of affective illness. On the other hand, a recent genetic
aggregation study suggests a separation of the genetic linkage for early onset major
depression from that of bipolar disorder (101).
Assessments
Diagnostic instruments such as interviews and questionnaires are based on diagnostic
criteria. An assessment instrument must be safe, feasible and have good psychometric
properties (for review see (32)). It should be reliable, i.e. give consistent results when
used by different examiners (inter-rater reliability) or at different times (test-retest
reliability). It should be valid, i.e. measure what it purports to measure. The three most
central aspects of validity are termed content validity, criterion-related validity and
construct validity. Content validity reflects how well a test as such covers the aspects
of a person, situation, behaviour, life, etc., it is meant to cover. Criterion-related
validity, or empirical validity, is a judgement regarding how adequately a test score
can be used to infer information about an individual’s most probable standing with
respect to a defined measure of interest. Construct validity refers to a demonstration
that an instrument does measure what it intends to measure with respect to certain
“constructs”. The test should also be sensitive, i.e. be able to detect all the true cases of
the disorder identified by the criterion instrument, and specific, i.e. identify the true
non-cases identified by the criterion instrument.
The diagnostic method most often recommended in epidemiological child psychiatric
research is the structured interview (75), e.g. the Diagnostic Interview Schedule for
Children (144). One reason for this is that there have been arguments against the
adequacy of using questionnaires, or checklists, for classifying childhood psychiatric
disorders (137). In a recent study, however, Boyle et al. (21) found only small
differences in reliability and validity between structured interviews and checklists. A
16
consensus has evolved that multiple measures are required, preferably involving
different informants and repeated measures over time, a routine that has led to more
robust findings (54, 137).
Retrospective reporting
Studies addressing complex issues, like the long-term course of mental disorders in
this project, require reliable information on all parameters under study. In order to
assure this, some investigators have used a longitudinal approach, where up-to date
information has been obtained from the subjects under study at various time points
(81, 176). Such studies are cumbersome, require a long time, and are often associated
with a very high attrition rate. This approach has been supported by a widespread
claim that alternative strategies such as retrospective reporting are unreliable. A
number of recent reports, however, suggest that such problems have been exaggerated
(22, 104). In an epidemiological longitudinal study (72), retrospective reports thus
showed good agreement with earlier measures of factual issues, such as family
residence changes, and also for the subject’s reporting of some aspects of his/her own
performance and characteristics in childhood. Bernstein et al. (15) found strong
support for the reliability and validity of the Childhood Trauma Questionnaire that
retrospectively measures child abuse and neglect. However, it is possible that different
life events are more easily recalled than problems of behaviour and emotional
regulation. In the study by Henry et al. (72), agreement was much poorer on questions
dealing with hyperactivity or depressed mood at particular ages. In a study by Fendrich
et al. (54), both mothers and children showed good recall of a child's major depression,
whereas the recall of both mothers and children regarding any anxiety disorder was
less satisfactory. The Wender Utah Rating Scale (WURS) (164) was constructed to
retrospectively establish a childhood diagnosis of an ADHD. In a recent study (105),
the WURS was found to be sensitive in detecting ADHD, but it miss-classified
approximately half of those who did not have this disorder.
17
AIMS OF THE PRESENT THESIS
The progression of psychopathology from childhood to adult life may be influenced by
a multitude of interacting variables, both biological and psychosocial. The objective in
most studies has been to address the relationship between child psychopathology and
clinical disorders in adulthood, while there is limited information available on what
characteristics presage adult personality disorders. The principal aim of this thesis was
therefore to gain better knowledge concerning adult personality outcome in patients
with early onset of mental disorders.
The specific aims were:
• To investigate the long-term outcome with respect to DSM-IV personality
disorders in former child psychiatric in-patients as compared to matched controls from
the general population.
• To examine the predictive value of different child or adolescent mental disorders
for adult personality disorders in former child psychiatric patients.
• To determine whether early onset major depression is related to certain personality
traits and personality disorders.
• To examine differences between subjects with early onset vs. late onset of
antisocial behaviour concerning personality disorders and personality traits.
• To describe the construction and initial validation results of a self-report instrument
for retrospective assessment of child and adolescent psychopathology in adults.
METHODOLOGY
This thesis is based on three separate patient populations. Papers I, II and V comprise
investigations of a group of former child psychiatric patients who are compared to
controls from the general population. In paper III, major depressed primary care
18
patients are examined, and paper V comprises an investigation of a group of forensic
psychiatric patients. The patient series and the healthy subjects are described in Table
1, and the assessments and statistical methods used are presented in Table 2.
Table 1. Characteristics of participants in papers I – V
Paper
N
M/F
Age mean (SD) Sample
I
137
59/78
30.7 (6.8)
Former child psychiatric patients
137
59/78
30.7 (6.8)
Controls
II
158
63/95
30.5 (7.1)
Former child psychiatric patients
III
400
113/287
47.2 (12.4)
Depressed primary care patients
IV
61
61/0
34.0 (11.0)
Forensic psychiatric patients
V
164
66/98
30.6 (7.0)
Former child psychiatric patients
193
91/102
30.5 (6.8)
Controls
Note: M/F = males/females
Subjects and Methods Papers I, II and V
Subjects
Former patient group
Four hundred and seven former inpatients at the Department of Child and Adolescent
Psychiatry, University Hospital, Uppsala, Sweden, admitted for care during 1972,
1984, 1987 or 1992, could be completely identified retrospectively. The civil
population register could not identify addresses for 29 of these 407 subjects, and
another 19 persons had died, leaving 359 subjects who were contacted.
Self-report instruments (see below) were mailed to each of these 359 former patients
together with a stamped, self-addressed envelope and an explanatory letter in which
the aim of the study was described and participant anonymity was guaranteed. Two
reminders were sent to non-responders only. Seventy-nine subjects (22.0 %) returned
their questionnaires but refused to participate and 116 (32.3 %) did not respond. Thus,
a total of 164 subjects (45.7 %) were eligible for analysis in paper V (Table 1).
19
Another six subjects were excluded from analyses in paper II due to incomplete
enquiries.
Control group
Three hundred and fifty-nine age and sex-matched individuals selected from the civil
population register were asked to participate as the control group. The same procedure
was used for collecting data as in the former patient group. Seventy-five subjects (20.9
%) returned their questionnaires but refused to participate, and 91 (25.3 %) did not
respond at all. One person answered the questions by telephone. Thus, a total of 193
subjects (53.8 %) were eligible for analysis in paper V (Table 1).
Matched pairs
Out of the 164 former patients and 193 controls, 137 age and sex- matched pairs were
eligible for analysis in paper I (Table 1). There were no differences regarding age, sex
or presence of any personality disorder between the matched subjects and the
unmatched remaining participants.
Assessments
Childhood psychiatric diagnoses
Based on information from the medical records, all participants in the former patient
group had their childhood psychiatric diagnoses coded according to the DSM-IV. The
diagnostic procedure was performed in a structured way using checklists of the DSMIV criteria. All symptoms mentioned in the records were regarded as being of clinical
importance. In a previous work, using the same procedure, good diagnostic agreement
between two of the authors (M.R. and A-L.v.K.) was achieved (for detailed
information see (125)). In paper II, a diagnosis of ADHD, conduct disorder and
oppositional defiant disorder were referred to as a disruptive disorder. Furthermore,
substance abuse and substance dependence were referred to as a substance-related
disorder.
20
Table 2. Assessment methods and statistics.
Paper
Assessments
Statistics
I
DSM-IV Checklist
McNemar’s test
DIP-Q
Paired t-test
GAF
Student’s t-test
Wilcoxon’s matched-pairs signed-rank test
II
III
DSM-IV Checklist
Chi-square test
DIP-Q
Logistic regression analysis
DSM-III-R diagnostic criteria
Chi-square test
MADRS
Fischer’s Exact test
KSP
Logistic regression analysis
SCID-II Screen
Mann-Whitney U-test
Student’s t-test
IV
SCID I and II
Chi-square test
KSP
Discriminant analysis
PCL-R
Student’s t-test
Registered criminality
V
DSM-IV Checklist
Cohen’s kappa coefficient
CAPSI-R
Cronbach’s alpha
Sensitivity/Specificity
The DSM-IV and ICD-10 personality questionnaire
Personality disorders were assessed by means of the DSM-IV and ICD-10 Personality
Questionnaire (DIP-Q). The DIP-Q is a true/false self-report questionnaire designed to
measure all DSM-IV and all ICD-10 personality disorders (115). Out of a total of 140
items in the questionnaire, 135 items reflect the diagnostic criteria of the DSM-IV and
ICD-10 personality disorders. The items consist of brief statements reflecting the main
aspect of the corresponding criterion, and the respondent is asked to score the
statement as ‘true’ or ‘false’. The remaining five items constitute the impairment and
distress scale (ID-scale) and reflect aspects of the general criteria for personality
disorders (10). A self-report version of the Global Assessment of Functioning (GAF)
21
scale (20) is also included. This scale consists of the original 0-100 point GAF scale
included in DSM-IV (10), but with fewer defining characteristics than in the original
version. A short scale, comprising 11 ‘yes’ or ‘no’ questions concerning psychosocial
and environmental problems according to axis IV in the DSM-IV, is included as a
separate part of the DIP-Q.
The DIP-Q has been validated by comparing results from the questionnaire with those
from a structured clinical interview (114, 116). Agreement was acceptable on both the
global and cluster levels. The agreement between DIP-Q and the structured interview
for any DSM-IV personality disorder as measured by Cohen’s Kappa was 0.61, and
the sensitivity and specificity were 0.84 and 0.77, respectively. In papers I and II, a
categorical personality disorder diagnosis was based on trait criteria for the specific
personality disorder and a score of two or higher on the ID scale. A dimensional score
was obtained from the proportion of fulfilled trait criteria for each personality disorder
diagnosis.
Child and Adolescent Psychiatric Screening Inventory-Retrospect
The Child and Adolescent Psychiatric Screening Inventory-Retrospect (CAPSI-R)
questionnaire was constructed with the intention of retrospectively assessing perceived
psychiatric psychopathology during childhood and adolescence. It consists of 146
items, of which 140 correspond to the following DSM-IV standardised diagnostic
categories: reading disorder, mathematics disorder, disorder of written expression,
developmental co-ordination disorder, expressive language disorder, stuttering,
autistic disorder, Asperger´s disorder, attention deficit/hyperactivity disorder, conduct
disorder, oppositional defiant disorder, Tourette´s disorder, separation anxiety
disorder, selective mutism, panic disorder, obsessive-compulsive disorder,
posttraumatic stress disorder, anorexia nervosa, bulimia nervosa, substance
dependence, substance abuse, major depressive episode, manic episode and psychotic
episode. The remaining six items reflect aspects of impairment.
22
Subjects and Methods Paper III
Subjects
Eligible subjects were 400 depressed primary care patients participating in a
randomised, double-blind, multicenter study (48) (Table 1). Included patients were
required to meet the DSM-III-R criteria for major depressive disorder and to have a
minimum score of 21 on the Montgomery Åsberg Depression Rating Scale (MADRS)
(described below) (109).
A clinical diagnosis of a major depressive disorder was set using the DSM-III-R
criteria. The age at onset of the first major depressive episode was established by
interview examination, and the cut-off for early onset major depression was set at 26
years of age.
Assessments
Montgomery-Åsberg Depression Rating Scale
Severity of depression was assessed by means of the MADRS, a depression rating
scale designed to be particularly sensitive to treatment changes. The MADRS is a
subscale constructed from the Comprehensive Psychopathological Rating Scale (11). It
consists of 10 items concerning depressive symptomatology. Each item can be scored
within a range from 0 to 6. The MADRS has been shown to have good psychometric
properties (109).
SCID screen
Personality disorders were assessed by the use of the Swedish modified version of the
SCID screen questionnaire (46). The questions in this self-report are similar to the
questions in the Structured Clinical Interview for DSM-III-R personality disorders
(SCID II) (152). The SCID screen has been validated by comparing the results
obtained from clinically performed SCID II interviews. By adjusting the cut-off level
for diagnosis (one more criterion required for each of the personality disorders), the
overall Kappa coefficient of agreement was 0.78 and the sensitivity and specificity
were 0.87 and 0.75, respectively (46).
23
Karolinska Scales of Personality
The Karolinska Scales of Personality (KSP) was used to assess personality traits (63,
142). The inventory comprises 135 items with a four-point response format grouped in
15 scales. Four scales are related to anxiety proneness: Somatic anxiety (autonomic
disturbances, vague distress and panic attacks), Psychic anxiety (cognitive, social
anxiety, worrying, insecurity), Muscular tension (subjective muscular tenseness and
aches, difficulties in relaxing), and Psychasthenia (low degree of mental energy, easily
fatigued). Three scales are related to vulnerability to non-inhibitory psychopathology:
Impulsiveness (non-planning, impulsive), Monotony avoidance (need for change and
action), and Socialisation (positive childhood experiences, good school and family
adjustment). Six scales are related to aggression and hostility: Verbal aggression
(aggressive feelings expressed in style and content of speech), Indirect aggression
(undirected expressive aggression), Irritability (irritable, lacking patience), Suspicion
(distrusting people’s motives), Guilt (remorseful), and Inhibition of aggression (nonassertive, sad rather than angry). Also included are: Detachment, which is related to
social withdrawal, and Social desirability, which refers to conformity and control.
The scales were composed for the purpose of operationalising and measuring
constructs defining vulnerability for different forms of psychopathology. Most of the
scales are based on hypotheses of biologically relevant temperament dimensions. In
most scales, items were primarily selected based on rational-theoretical considerations
rather than by using factor-analytical or empirical techniques. The scales have later
been subjected to psychometric analyses (63). Personality traits, as assessed by the
KSP in a non-patient sample, have been found to be stable over nine years, both with
regard to absolute and relative stability (64). The mean scores for the different scales
have been transformed into normative T scores (mean=50, SD=10), based on a
Swedish age and gender-stratified, non-patient sample (13).
24
Subjects and Methods Paper IV
Subjects
Research subjects were 61 consecutive men who were referred by the courts to the
Department of Forensic Psychiatry in Uppsala for major forensic examinations
between 1992 and 1994 (Table 1). All subjects were detoxified from drugs and alcohol
when investigated. Criminal behaviour was described in accordance with the subjects’
registered criminality. Subjects sentenced three or more times were regarded as
repeatedly criminal.
Assessments
The Structured Clinical Interview for DSM-III-R
Assessment of psychiatric disorders was based on the use of the Structured Clinical
Interview for DSM-III-R (SCID), a semi-structured interview which was designed to
be administered by a clinician or researcher familiar with the diagnostic criteria used
in the DSM-III-R. The SCID has two parts, one for axis I disorders (151) and another
for axis II personality disorders (152). The interview starts with a set of overview
questions, after which it systematically covers each criterion of all included diagnoses.
Based on the answers given by the patient, the interviewer makes a clinical rating of
each criterion. The scoring categories are: ”?” (inadequate information), 1 (the
criterion is absent), 2 (the criterion is doubtful), and 3 (the criterion is present). The
reliability of the SCID has been found to be adequate (150, 174).
Psychopathy Checklist-Revised
Psychopathy traits were assessed by means of the Psychopathy Checklist-Revised
(PCL-R), which is a 20-item, 40-point rating scale. The scoring is based on a semistructured clinical interview and review of file information (66). Each PCL-R item is
rated 0 (definitely absent), 1 (some or contradicting data), 2 (definitely present), or
omitted (insufficient information). The score represents the extent to which a person
matches the clinical construct of psychopathy.
25
KSP personality traits
Personality traits were assessed using the KSP (see above).
Ethics
All studies were approved by the Uppsala University Ethics Committee.
RESULTS
Personality disorders in former child psychiatric patients (paper I)
Former patients had a significantly higher prevalence of all DSM-IV personality
disorders than controls (38.0 vs. 10.9 %, p<0.001) (Table 3). There was also a
considerably higher personality disorder co-morbidity among the former patients
(mean values 1.7 vs. 0.3, p<0.001). Furthermore, former patients had a greater number
of fulfilled personality disorder criteria than controls (median 23 vs.11 out of 79
possible criteria, p<0.001). In the former patient group there were also significantly
more fulfilled criteria for all specific personality disorders as compared to the control
group.
Table 3. Prevalence of personality disorders in former child psychiatric patients as
adults and in sex and age-matched controls (N=137 pairs).
Former patients
Controls
χ2
n (M/F)
%
n (M/F)
%
p
Any Cluster A PD
40 (14/26)
29.2
7 (6/1)
5.1
22.76 ∗∗∗
Any Cluster B PD
43 (13/30)
31.4
7 (5/2)
5.1
26.63 ∗∗∗
Any Cluster C PD
47 (15/32)
34.3
14 (7/7) 10.2
19.32 ∗∗∗
Any PD
52 (17/35)
38.0
15 (7/8) 10.9
22.74 ∗∗∗
Note: PD = personality disorder; M = male, F = female
There were also significantly lower self-reported GAF scores in former patients than in
controls (mean values 73.4 vs. 82.3; p<0.001). Moreover, the former patients
diagnosed with a personality disorder had lower GAF scores than those former patients
without such a diagnosis (mean values 63.3 vs. 79.3, p<0.001). This was also true in
26
the control group (mean values 69.2 vs. 83.5, p<0.01).
Finally, former patients had more psychosocial and environmental problems than
controls (mean values 4.1 vs. 1.9, p<0.001). Those former patients also diagnosed with
a personality disorder had more psychosocial and environmental problems than former
patients without such a diagnosis (mean values 4.7 vs. 3.7, p<0.01). This was also true
in controls (mean values 3.5 vs. 1.8, p<0.001). Former patients without a personality
disorder also had significantly more psychosocial problems than controls without a
personality disorder (mean values 3.7 vs. 1.8, p<0.001).
Predictive value of child and adolescent psychiatric disorders for adult
personality disorder (paper II)
Out of the 158 former patients, 28 (17.7 %) had a childhood onset of major depression,
75 (47.5 %) a disruptive disorder, and 43 (27.2 %) a substance related disorder. Sixtytwo out of the 158 former patients (39.2 %) received a personality disorder diagnosis.
After controlling for demographic variables and other axis I pathology, former patients
with a childhood onset of a major depressive disorder were more than ten times as
likely to have a schizoid personality disorder than those without (OR=10.4; CI = 2.2348.4). Furthermore, those with a major depressive disorder were almost five times as
likely to have an avoidant personality disorder (OR=4.71; CI=1.83-12.1). In addition,
they were also almost four times as likely to have a dependent personality disorder
(OR=3.71; CI=1.22-11.3), and about three times as likely to have a borderline
(OR=2.91; CI=1.17-7.25) and a schizotypal personality disorder (OR=2.94; CI=1.107.88). Participants with a disruptive disorder at a young age were almost seven times
as likely to have a narcissistic disorder (OR=6.78; CI=1.56-29.4) and more than five
times as likely to have an antisocial disorder (OR=5.62, CI=1.96-16.2)). A substancerelated disorder in childhood or adolescence was a risk factor for paranoid (OR=2.42;
CI=1.04-5.65), schizotypal (OR=3.09; CI=1.25-7.67), borderline (OR=3.00; CI=1.306.92) and avoidant (OR=2.82; CI=1.15-6.92) personality disorders.
27
Personality traits and personality disorders in early onset vs. late onset
major depression (paper III)
Out of the 400 primary care patients with major depression, 104 (24 men and 80
women) were classified as having an early onset depression with a cut-off at 26 years,
and 296 (89 men and 207 women) as having a late onset depression. There were no
significant differences in gender or education between the two groups. The severity of
current illness was similar as determined by the MADRS instrument (mean scores 28.9
vs. 28.1). The early onset group were younger (mean age 40.1 vs. 49.7, p<0.001), had
experienced more depressive episodes (mean values 6.2 vs. 2.6, p<0.001), and had
more hospitalisations due to depression (15.4 vs. 4.1 %; p<0.001). Furthermore, this
group had a significantly higher proportion of family members with depressive
disorders (46.7 vs. 22.0 %; p<0.001).
There were co-existing personality disorders in 249 of the 400 depressed patients (62.3
%). In those with an early onset major depression, 81 (77.9 %) had a personality
disorder, and in those with a late onset there were 168 (56.8 %) subjects with such a
diagnosis (p<0.001). Avoidant and paranoid personality disorders were the most
common axis II disorders in the entire patient population, while borderline personality
disorder was also common in those with an early onset, and obsessive-compulsive
personality disorder occurred frequently in those with a late onset. Those with an early
onset major depression had significantly higher frequencies of all personality disorders
except for schizoid, schizotypal and dependent personality disorders. However, after
adjustment for age, gender and number of previous depressive disorders, the difference
was statistically significant only for the paranoid, borderline and avoidant personality
disorders.
There were significant differences between the early onset and the late onset groups
with respect to the KSP personality traits. Thus, those with an early onset major
depression had higher scores in all anxiety-related scales, i.e. Somatic anxiety, Psychic
anxiety, Muscular tension and Psychasthenia. In addition, they scored higher on four
out of six aggression and hostility-related scales, i.e. Indirect aggression, Guilt,
28
Suspicion and Irritability. Finally, those with an early onset rated themselves as having
a lower level of Socialisation. In a logistic regression with the age and sex-corrected
KSP scales dichotomised at the median value, it was demonstrated that age at onset
was independently related to three anxiety-related scales, Psychic anxiety,
Psychasthenia and Muscular tension, and also to Suspicion, Irritability and
Socialisation.
The entire spectrum of analyses was repeated after dichotomisation of the group using
18 years as the cut-off for early onset depression. Here, 28 of the 400 patients were
defined as having an early onset. Those with an early onset exhibited more paranoid,
borderline, histrionic and avoidant personality disorders, i.e. observations that were
very similar to those when the original cut-off level was used. After correction for age,
sex and number of previous episodes, early onset was related only to avoidant
personality disorder. Early onset was also related to the KSP-scales Psychic anxiety,
Psychasthenia, Suspicion, Socialisation, Irritability and Social desirability. After
correction for number of previous episodes, a relationship to Psychic anxiety,
Psychasthenia, Suspicion, Irritability and Socialisation was found.
Personality traits and personality disorders in early onset vs. late onset of
antisocial behaviour (paper IV)
Out of the 61 forensic psychiatric male subjects, 27 were diagnosed as having a
previous conduct disorder and 34 had not had a previous conduct disorder. Those with
a conduct disorder had more cluster B personality disorders than those without (96.3 %
vs. 32.4 %, p<0.001). Those with a previous conduct disorder had significantly more
repeated violent criminality (78 vs. 21 %; p<0.001). This group of patients also
showed significantly more mixed abuse (56 vs. 3 %; p<0.001), but not significantly
more pure alcohol abuse or dependence.
Personality traits assessed by means of the KSP revealed that subjects with a previous
conduct disorder had higher scores on the scales measuring Impulsiveness, Monotony
avoidance, Verbal aggression and Irritability, Suspicion and lower scores on Social
29
desirability and Socialisation. They also had significantly higher scores on the KSP
Psychopathy factor and the Aggression factor. Finally, the total PCL-R score was
significantly higher in the conduct disorder group as compared to those without such a
previous diagnosis (mean values 29.4 vs. 10.2, p<0.001).
The Child and Adolescent Psychiatric Screening Inventory-Retrospect
(Paper V)
Internal reliability measured by means of Cronbach´s alpha ranged between 0.62 and
0.93 for the different subscales covering the CAPSI-R diagnoses. Autistic disorder
demonstrated the lowest alpha correlation coefficient (0.62). After exclusion of one
item (”As a child, did you often take part in make-believe plays?”) the alpha
correlation coefficient increased to 0.76. This motivated the exclusion of this item
from all subsequent analyses.
Data retrieval from the medical records showed that 140 of the 164 former patients
fulfilled diagnostic criteria for at least one of the mental disorders covered in the
CAPSI-R. Data from the CAPSI-R revealed that a total of 144 of the 164 patients
reached the threshold for at least one mental disorder during their childhood or teenage
years. One hundred and twenty-six of these subjects also reported functional
impairment defined as the need for professional help.
In the control group a total of 96 (49.7 %) of the 193 subjects fulfilled criteria for a
psychiatric disorder according to the CAPSI-R. Twenty of these subjects (10.4 %) also
experienced functional impairment. Another five individuals reported the need for
professional help but did not reach the diagnostic threshold for a CAPSI-R diagnosis.
The sensitivity and the specificity of the CAPSI-R were investigated using diagnoses
from the medical records as “true” diagnoses. Determinations were made in two
different populations: in the whole group of former patients and in the former patient
group who had fulfilled the impairment criterion (Table 4). Sensitivity in the group of
all former patients ranged from 33.3% to 83.3 %, and the specificity varied between
30
54.1 % and 95.5 %. In the 126 former patients who had fulfilled the impairment
criterion, i.e. contact with health professionals, the sensitivity ranged from 47.4 % to
100 %, and the specificity ranged from 44.6 % to 94.8 %. The overall Kappa value
between CAPSI-R diagnoses and those from medical records was 0.79.
Table 4. Sensitivity and specificity of the CAPSI-R. The sensitivity and the specificity
were calculated in two separate populations, i.e. in all former patients and in the
patients who fulfilled the impairment criterion in the CAPSI-R. Sensitivity and
specificity were only calculated if five of more subjects fulfilled diagnostic criteria for
a specific disorder according to the medical records.
All former patients
Former patients who
fulfilled the
impairment criterion
n=164
n=126
DSM-IV Diagnoses
Sensitivity Specificity
Sensitivity Specificity
%
%
%
%
Reading dis.1
75.0
81.8
100
80.9
Mathematics dis.
62.5
82.1
–
–
Dis. of written expression
72.2
76.7
83.3
73.7
Developmental coordination dis
33.3
80.3
47.4
78.5
Expressive language dis.
65.0
90.3
64.7
90.8
Stuttering
50.0
95.5
50.0
94.8
Asperger´s dis.
40.0
83.6
–
–
ADHD
55.6
76.8
62.5
72.9
Conduct dis.
73.5
60.0
78.6
52.4
Oppositional defiant dis.
50.9
64.0
63.4
56.5
Obsessive compulsive dis.
80.0
81.0
–
–
Eating dis.2
83.3
90.5
83.3
87.5
Substance dependence
66.7
84.2
70.0
79.8
Substance abuse
62.5
82.8
66.7
81.4
Major depressive episode
82.1
54.1
88.0
44.6
Notes: 1dis. = disorder, 2anorexia nervosa and bulimia nervosa are collapsed into an
eating disorder group.
31
DISCUSSION
The present studies constitute an attempt to discern the relationship between child and
adolescent psychopathology, above all depression and disruptive disorders, and adult
personality pathology determined as deviant personality traits and personality
disorders.
Methodological considerations
A common limitation in all the papers is that central assessments were performed in
the form of self-reports. Self-reports are frequently used for assessment of a number of
psychosocial issues, including personality and personality disorders. They are time
saving and easily administered. They are also free from systematic biases and
tendencies on the part of interviewers (174). It has, however, been suggested that some
individuals with personality disorders may not adequately describe their personality
because they do not possess sufficient insight into their own behaviour (175). With
respect to the present study, however, the fact that the prevalence of any personality
disorder in the controls is similar to the figures previously reported in the general
population using a multitude of instruments (47, 161, 165) suggests that the abovementioned shortcomings play a subordinate role regarding the results.
With respect to child and adolescent psychopathology, the study was retrospective.
One issue of special importance here is the possibility of an effect of memory on the
reported results. A number of factors influence memory. Developments in cognitive
psychology have recently increased our understanding of the ways in which memories
are encoded, stored and retrieved. Episodic autobiographic memory is part of
declarative memory, i.e. the memory that is accessible for verbalisation. In general, it
is this memory that is of prime concern in the recall of childhood experiences. Its
function depends on the function, and thus on the development, of the sensory cortices,
the limbic system, especially the hippocampal formation, and the functional circuitry
32
between them (110). Studies of adults have found a marked fall-off in the recall of
experiences that took place before the age of five (121).
A central issue in an attempt to evaluate an instrument for assessing child and
adolescent psychiatric problems is to have a “golden standard” that represents a
measure of all possible lifetime mental disorders. This was not possible in the present
study, since objective information on psychiatric morbidity was only obtained for
those periods the former patients were admitted for psychiatric care. This fact has most
likely influenced the figures for the specificity of the CAPSI-R reported in the present
study. Another issue is that the “golden standard” should be interpretable in the same
context as the instrument. Here, the DSM-IV diagnoses in the former patients were
coded from medical records up to almost three decades after treatment, a time period
during which diagnostic classification routines have changed, which might have
influenced the phenomenological reporting of psychiatric symptoms. Such an effect
would possibly have made the diagnostic categories less valid and thereby have
influenced the specificity measurement.
A critical question in all studies is the representativity of the sample studied. In the
retrospective evaluation of former child and adolescent psychiatric patients, one
problem was that the response rate was somewhat low, which means that even
moderate differences between the responders and the non-responders may affect the
results obtained. The response rate was around 50 percent, with a dropout frequency
that was higher among males and more pronounced in the former patients. The
estimated effect of such non-representativity on the present results would be that the
true frequency of personality disorder among the former patients could be even higher
than reported. Thus, other investigators have noted that the prevalence of a disorder is
over-represented, if anything, among non-responders (6, 85). It is therefore reasonable
to suppose that there was a high frequency of disruptive behaviour among the male
dropouts, and that this is associated with a very high frequency of personality disorders
as adults (127, 131).
33
Another methodological issue is that there is no agreed-upon definition for early onset
major depression. Fava et al. (52) classified early onset as occurrence of the first
episode before the age of 18, while Sato et al. (140) used 23 years as a cut-off, and
Parker et al. (117) used 26 years. It was recently suggested that a major genetic locus
contributes to the expression of early onset major depression, where 26 years was used
as a cut-off (101), and this provides certain biological support that this cut-off is
appropriate. In any case, the similarity to the results in our study group, with two
different cut-off levels, 18 and 26 years, suggests that the observations are possible to
generalise. In this perspective, one interpretation is that the underlying processes
operate in a dimensional perspective, also slightly after adolescence.
The definite strengths of this study are the length of the follow-up period and the focus
on individuals with severe childhood or adolescent psychiatric problems, a group that
reasonably offers the best chance for detecting psychopathology retrospectively.
Furthermore, the design used was optimised to reveal differences between afflicted
individuals and representative controls. The control group was sampled from the
population registry in order to match the former patient population with respect to age
and sex. The control group exhibited similar figures for personality disorders as those
for Swedish controls in previous studies (47), as well as a similar extent of contact
with professionals because of symptoms they had experienced (13 vs. 14 percent in a
previous study) (170).
Adult personality disorders
Personality disorders are common conditions with a major impact on health and social
and occupational functioning (139, 148). The prevalence of personality disorders in
the former child psychiatric patients was 38 percent (paper I), a somewhat higher
figure than the 28 percent prevalence rate reported in former referrals to an adolescent
psychiatric unit (128). Moreover, the occurrence of an adult personality disorder was
strongly predicted by a former child psychiatric problem (paper II). The increased risk
34
for an adult personality disorder was similar in the present study and in a previous
community-based group with a much shorter follow-up (81, 82). This suggests that the
predictive values of Axis I disorders at a young age on the occurrence of adult
personality disorders are not dependent on length of follow-up.
In the depressed primary care patients the prevalence of personality disorders was 62
percent (paper III), which is in line with the figures reported earlier in depressed
samples (for review see (33)). However, the most striking observation was that the
depressed individuals with an early onset of their first depressive episode showed
significantly more Axis II personality pathology than those with a late onset. This is
consistent with previous findings that major depression with an onset at younger ages
is related to greater personality pathology in adult ages (52, 81, 82, 97, 117, 140, 149).
The early onset group also showed signs of a more debilitating course of their mood
disorder, seen in the form of more depressive episodes and previous hospitalisations in
spite of their younger age.
Finally, 53 out of the 61 males undergoing forensic psychiatric investigations were
diagnosed with a personality disorder (paper IV) (154). Furthermore, in those
diagnosed with a previous conduct disorder, personality disturbances were more
exaggerated. This was seen in the form of more cluster B personality disorders and a
higher psychopathy score. This group also exhibited more repeated violent criminality
and had more mixed drug abuse.
Personality traits
At present, personality disorders are organised as categories with defined cut-off
points, although evidence suggests that whenever the category versus dimension
distinction has been subjected to empirical validation, the results almost invariably
support a dimensional representation of personality pathology (98). Alternative
approaches for conceptualising and classifying personality disorders have therefore
been suggested (34, 98, 156). The core of these conceptualisations is that personality
disorders can be viewed as more extreme aggregations of different continuous
35
personality traits that have reached such deviance that they are associated with an
impact on global functioning. Viewed in this way, assessment of such personality traits
would aid our understanding of the transition from normality to disordered personality.
In the present study the KSP instrument was used to assess personality traits. The KSP
was constructed for the purpose of operationalising and measuring constructs defining
vulnerability to different forms of psychopathology. Most of the KSP scales, i.e. the
anxiety-related and the aggressiveness-related scales and the Socialisation scale, are
correlated with the separate personality disorders in the DSM (43, 63, 155).
Major depression and personality characteristics
Both individuals with early and with late onset major depression (paper III) could be
characterised by elevated scores in several of the KSP scales. This is analogous to
previous results suggesting that individuals with a lifetime history of depression can be
characterised by certain personality traits, e.g. high levels of neuroticism and
introversion (74, 118, 145, 172). However, a more striking result of the present study
was that individuals who experienced their first depressive episode at young ages
exhibited more deviant personality traits than those with a late onset. These results can
be explained in a number of ways. Early onset major depression may lead to
maladaptive interpersonal functioning that eventually results in the development of
personality disturbances. Alternatively, personality dysfunction (or maladaptiveness)
could cause or contribute to early onset major depression and an increased risk for
recurrent depressive episodes. A third, balanced explanation may be that both
developmental pathways reciprocally affect one another, or else operate separately
from one another.
Psychobiological differences between patients with early onset and late onset major
depression have been suggested. Thus, genetic segregation analysis has recently
provided evidence for a single major locus of genetic transmission of susceptibility for
early-onset major depression (101). The concept of affective instability has been given
a role as a predisposing factor. Affective instability can be defined as a predisposition
36
to marked, rapidly reversible shifts in affective state (146). Such shifts are extremely
sensitive to meaningful environmental events such as separation, frustration regarding
expectations or criticism, which in other people might induce more modest emotional
responses. Such sensitivity might explain why life events in adolescence predispose to
adult major depression (123). Affective instability may also interfere with the
development of stable relationships and self-image (146). Furthermore, there is some
evidence that the impact of experiencing a depressive episode on personality might be
stronger in young individuals who are in the process of establishing their self-identity
in society (132). This is supported by prospective studies suggesting that after
recovery, young persons may continue to show sub-clinical symptoms of depression,
negative attributions, impairment in interpersonal relationships, impairment in global
functioning, early pregnancy and increased physical problems (80, 111, 124, 126,
132). Depression has also been associated with a negative cognitive style including
low self-esteem, high self-criticism, significant cognitive distortions and a feeling of
lack of control over negative events (12).
The observation that major depressive disorder is a risk factor for the development of
schizoid and schizotypal personality disorders (paper II) can be explained in the
context of two earlier observations. First, there is an association between cluster A
personality disorders and schizophrenic disorders (113). Second, a certain proportion
of individuals with depression in childhood and adolescence will later develop a
schizophrenic disorder (36). Taken together, these observations suggest that for a
small subgroup of children and adolescents there may be a developmental transition
from a major depression-like picture into the adult schizophrenic spectrum. A similar
finding has in fact been reported in a community sample, where participants with a
lifetime history of major depression were almost four times as likely to have an
elevated rate of schizoid dimensional scores (97). However, in contrast to our study,
Kasen et al. (82) did not observe major depression to be a risk factor for the
development of schizoid and schizotypal personality disorders. The most probable
explanation for the discrepancy between these studies is that the group investigated by
37
Kasen and colleagues was a community-based sample, while the present results were
based on a group of former severely affected psychiatric in-patients.
Substance use disorders and personality characteristics
Psychiatric research workers have studied the reasons for addiction to alcohol over a
long period of time. There is a general consensus that addicted persons exhibit an
overrepresentation of criteria for both clinical and personality disorders. As general
diagnostic criteria for personality disorders include a requirement that the enduring
pattern is not due to the direct physiological effects of a substance, e.g. a drug abuse
(10), it is difficult to make assumptions about the relationship between drug abuse and
personality. However, there is clear evidence that certain personality features are
present at an early stage in those prone to alcohol and drug abuse (26, 27, 31, 76, 166).
Thus, in the present investigation individuals diagnosed with a substance-related
disorder at an early age were found to be at risk for paranoid, schizotypal, borderline
and avoidant personality disorders (papers I and II). Furthermore, evidence from crosssectional studies is convincing, and shows a strong link between substance-related
disorders and all forms of personality disorders (39, 65), particularly antisocial and
borderline personality disorders (163). In the study by Lewinsohn et al. (97), substance
use disorders in adolescence were significantly associated with antisocial personality
disorder dimensional scores when re-assessed at age 24. In the present study, however,
there was no association between substance-related disorders and antisocial
personality disorder. This might be explained by a high attrition rate in males.
Disruptive disorder and personality characteristics
Former patients diagnosed with a disruptive disorder were observed to have an
increased risk for antisocial and narcissistic personality disorders in adulthood (papers
I and II). This observation was also made by Kasen et al. (82) and Lewinsohn et al.
(97), and is also supported by earlier observations of well-established associations
between disruptive disorders and cluster B personality disorders (131, 176). Although
there are characteristics that differentiate antisocial and narcissistic personality
38
disorders, there is also a considerable overlap, particularly for careless behaviour and
interpersonal relationships that denote indifference to or exploitation of others.
Individuals afflicted with a previous conduct disorder exhibited significantly higher
levels of Impulsiveness (paper IV). This is suggested to represent a specific
vulnerability to disruptive behaviours and criminality, with a strong hereditary factor
(3, 4). In fact, impulsivity is a major predictor for antisocial, delinquent behaviour (50,
162, 169). Impulsivity has also been related to different kinds of mental morbidity
such as borderline personality disorder and type II alcoholism (146, 171). Moreover,
highly impulsive individuals exhibit impaired neuropsychological functions
determined in the form of disturbed sorting perceptions and an inability to show
foresight and to inhibit their behaviour (3, 40).
An intriguing observation (paper IV) was that the forensic patients were characterised
by a very low Socialisation score, considerably lower than the scores of those with a
depressive disorder (paper III). A striking feature was that this was significantly more
pronounced in those with a previous conduct disorder, who on average exhibited a
socialisation score more than three standard deviations lower than that in a general
population control group. The KSP Socialisation scale reflects dimensions of
alienation, victimisation, resentment and dysphoria, and was originally constructed to
assess psychopathic personality features (63). Later studies, however, suggest that a
low score in Socialisation not only characterises psychopathic personality but is also
strongly and broadly associated with the clinical severity of personality pathology and
maladaptiveness (43, 155). As the scale has very little genetic origin (63), it is
probable that environmental factors during development of socialised behaviour play a
dominant role with respect to this personality trait. Here, socially oriented theories
emphasise interpersonal interactions and cognitive processes in the development of
socialised behaviour, and assume that socialisation is dependent on appropriate roletaking experiences (60). In this context, the impact of experiencing psychopathology
39
on personality might be stronger in young individuals who are in the process of
establishing their sense of self-identity in society (132).
The CAPSI-R
The development of the CAPSI-R (paper V) was initiated by the fact that there are no
comprehensive instruments currently available for retrospective self-report assessment
of child and adolescent psychopathology in adults. Such an instrument could serve as a
research tool, but also as a screening instrument in adult patients presenting for a first
time psychiatric consultation.
The internal reliability, as determined by means of Cronbach´s alpha, was satisfactory
for all diagnoses included in the CAPSI-R, and the sensitivity was generally
acceptable to good. The lifetime prevalence rate of any particular DSM-IV psychiatric
disorder in the former patients was very similar to the rate obtained from coded
medical records. The corresponding figure for a CAPSI-R diagnosis was close to 50
percent in the control group, but dropped to 10 percent after incorporation of the
impairment criterion defined as the need for professional help. Others have made the
same observation (16, 96, 143). Despite the fact that the validation procedure was
hampered by methodological shortcomings, sensitivity and specificity were
satisfactory, at least in individuals who met the impairment criterion. The CAPSI-R
therefore shows promise for further evaluation.
40
CONCLUSIONS
The progression of psychopathology from childhood to adulthood may be influenced
by a multitude of intervening variables, both biological and psychosocial. Increased
knowledge concerning intervening variables is necessary in order to get a better
understanding of the connections between child and adult psychopathology. The
results of the present investigations suggest that
•
personality disorders are prevalent in former child psychiatric patients,
•
the presence of psychiatric disorders in childhood and adolescence
significantly increases the risk of an adult personality disorder,
•
there is an association between early onset major depression and adult
personality pathology,
•
early onset antisocial behaviour is related to a more deviant personality, more
repeated violent criminality and mixed abuse,
•
the CAPSI-R shows promise for further evaluation, and it may be useful in
recognising previous child and adolescent mental disorders in adults.
41
ACKNOWLEDGEMENTS
This thesis was completed with the help and support of supervisors, colleagues and
friends. I would like to express my sincere gratitude to:
Lisa Ekselius, Associate Professor, Department of Neuroscience, Psychiatry,
University Hospital, Uppsala, my main supervisor, for all the hard work and
uncountable hours you have spent on this thesis and on me. You have provided me
with scientific guidance, engaging collaboration and warm and generous friendship.
Thank You!!
Anne-Liis von Knorring, Professor, Department of Neuroscience, Child and
Adolescent Psychiatry, University Hospital, Uppsala, my supervisor, for firmly
establishing my work and scientific education in the field of Child and Adolescent
Psychiatry. Thank you for sharing your professional knowledge with me and for
encouraging me to start this project.
Lars von Knorring, Professor, Department of Neuroscience, Psychiatry, University
Hospital, Uppsala, my supervisor, for enthusiasm and great support. You have
provided me with solutions to all the practical and financial problems that have arisen.
I am also grateful that as part of my scientific education, you introduced me to and
involved me in teaching.
Gunilla Stålenheim, M.D., senior colleague at the Clinical Department of Psychiatry,
University Hospital, Uppsala. Thank you for inviting me to collaborate with you and
for sharing your data with me. You gave me a much useful advice during the time we
wrote two scientific papers together.
Hans Arinell, B.Sc., Department of Neuroscience, Child and Adolescent Psychiatry,
University Hospital, Uppsala, for teaching me statistics and how to work with
computers. You have provided me with continual support regarding all statistical and
technical problems, and you have been an excellent teacher.
Lena Bohlin, Department of Neuroscience, Psychiatry, University Hospital, Uppsala.
Thanks for efficient secretarial help and for supportive friendship.
42
Ulises Penayo, M.D., Head of the Clinical Department of Psychiatry at Uppsala
University Hospital, for providing me with financial support in order to complete this
thesis.
Jane Wigertz, for linguistic revision.
Mimmie Willebrand and Johan Dyster-Aas, my fellow Ph.D. students, for scientific
guidance and interesting discussions.
Gösta Lyttkens and Lars-Olof Janols, my clinical tutors, for introducing me to child
and adolescent psychiatry and for your great contributions to my clinical training.
Goldy and Lars Ramklint, my parents, for never-ending support in all areas of life,
including this scientific work. My mother Goldy, for helping me create the database,
and my father Lars, for linguistic revision of several manuscripts.
Anders Holmberg, my husband and life companion, for giving me the idea to become
a Ph.D. student, and for providing me with the encouragement and practical support
that I needed to complete this thesis. But most of all for all the warm and generous
love you give me every day.
Staffan, Håkan, Sara, Calle and Olle, our beloved children, for being part of my life,
and with respect to this thesis for your positive attitude towards my Ph.D. work.
Gunilla and Nils Trowald, neighbours and close friends, for taking part in my Ph.D.
project as friends, for listening, asking questions, discussing and, finally, planning the
party.
And last, but not least, all the participants in these studies, who lent us their time and
shared with us their thoughts and feelings. Without them no knowledge would have
been gained and no studies would have been possible.
Generous financial support was given by the Swedish Medical Research Council
(grants no. 9523, 12260 and 13245), the Söderström-Königska Foundation and the
Märta and Nicke Nasvell Foundation.
43
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