Journal of Psychiatric Research 45 (2011) 814e822

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Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/psychires

Childhood adversity and personality disorders: Results from a nationally

representative population-based study
Tracie O. Afifi a, b, *, Amber Mather b, Jonathon Boman b, William Fleisher b, Murray W. Enns b, a,
Harriet MacMillan c, d, Jitender Sareen b, a, e
a
Department of Community Health Sciences, University of Manitoba, S113 Medical Services Building, 750 Bannatyne Avenue, Winnipeg, Manitoba R3E 0W3, Canada
b
Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
c
Department of Psychiatry and Behavioural Neurosciences, McMaster University, Canada
d
Department of Pediatrics, McMaster University, Canada
e
Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Background: Although, a large population-based literature exists on the relationship between childhood
Received 7 July 2010 adversity and Axis I mental disorders, research on the link between childhood adversity and Axis II
Received in revised form personality disorders (PDs) relies mainly on clinical samples. The purpose of the current study was to
8 November 2010
examine the relationship between a range of childhood adversities and PDs in a nationally representative
Accepted 12 November 2010
sample while adjusting for Axis I mental disorders.
Methods: Data were from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC;
Keywords:
n ¼ 34,653; data collection 2004e2005); a nationally representative sample of the United States pop-
Child maltreatment
Child abuse
ulation aged 20 years and older.
Neglect Results: The results indicated that many types of childhood adversity were highly prevalent among
Exposure to intimate partner violence individuals with PDs in the general population and childhood adversity was most consistently associated
Personality disorders with schizotypal, antisocial, borderline, and narcissistic PDs. The most robust childhood adversity find-
Psychiatric disorders ings were for child abuse and neglect with cluster A and cluster B PDs after adjusting for all other types of
childhood adversity, mood disorders, anxiety disorders, substance use disorders, other PD clusters, and
sociodemographic variables (Odd Ratios ranging from 1.22 to 1.63). In these models, mood disorders,
anxiety disorders, and substance use disorders also remained significantly associated with PD clusters
(Odds Ratios ranging from 1.26 to 2.38).
Conclusions: Further research is necessary to understand whether such exposure has a causal role in the
association with PDs. In addition to preventing child maltreatment, it is important to determine ways to
prevent impairment among those exposed to adversity, as this may reduce the development of PDs.
Ó 2010 Elsevier Ltd. All rights reserved.

Exposure to childhood adversity is known to be associated with shown a relationship between traumatic events occurring in
mental health impairment that can persist into adulthood. There childhood and personality traits such as high neuroticism and
are strong associations between adverse childhood experiences openness to experiences (Allen and Lauterbach, 2007). Although,
such as abuse, neglect, exposure to intimate partner violence, and the relationship between childhood adversity and Axis I mental
parental divorce and suicidal behavior and adult Axis I mental health conditions is well established, research on the link between
disorders such as mood, anxiety, impulse control, and substance childhood adversity and Axis II personality disorders (PDs) has
use disorders in representative population-based samples (Afifi focused mainly on clinical samples (Battle et al., 2004; Johnson
et al., 2006, 2008, 2009, 2010; Bruffaerts et al., 2010; Enns et al., et al., 2004; Rettew et al., 2003; Yen et al., 2002; Luntz and
2006; Kessler et al., 1997; MacMillan et al., 2001; Scott et al., Widom, 1994; Zanarini et al., 1989, 1997, 2000, 2002; Bierer et al.,
2010). Studies involving nationally representative samples have 2003). PDs are generally persistent overtime, are often repre-
sented by patterns of behaviors and experiences that can negatively
* Corresponding author. Department of Community Health Sciences, University impact areas of cognition, affect, interpersonal functioning, and
of Manitoba, S113 Medical Services Building, 750 Bannatyne Avenue, Winnipeg, impulse control, and are frequently associated with impairment
Manitoba R3E 0W3, Canada. Tel.: þ1 (204) 272 3138; fax: þ1 (204) 789 3905.
E-mail address: t_afifi@umanitoba.ca (T.O. Afifi).
(American Psychiatric Association, 1994, 2000). Clinical studies

0022-3956/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpsychires.2010.11.008
 T.O. Afifi et al. / Journal of Psychiatric Research 45 (2011) 814e822 815

have indicated that the childhood experience of physical abuse, were conducted face-to-face by trained lay interviewers. Further
sexual abuse, emotional abuse, physical neglect, and emotional details of the NESARC have been published elsewhere (Ruan et al.,
neglect are common among patients with PDs (Battle et al., 2004; 2008b; Grant et al., 2005).
Johnson et al., 2004; Rettew et al., 2003; Yen et al., 2002; Luntz
and Widom, 1994; Zanarini et al., 1989, 1997, 2000, 2002; Bierer 1.2. Measures
et al., 2003). Studies involving convenience (Gibb et al., 2001;
Grover et al., 2007; Tyrka et al., 2009) and small community 1.2.1. Childhood adversity
samples (Johnson et al., 1999, 2000, 2006) have also supported this 1.2.1.1. Child maltreatment: abuse and neglect. Respondents’ expe-
association, but it remains unclear whether the relationship riences of a variety of adverse childhood events (events occurring
between childhood adversities and all PDs exists in representative before the age of 18) were assessed using questions based on those
general population samples. from the Adverse Childhood Experiences study (Dong et al., 2003;
Another important limitation is the narrow examination of child Dube et al., 2003). These questions were in turn a subset of the
adversity. To date, collectively, studies have looked at parenting items from the Conflict Tactics Scale (Straus, 1979; Straus et al.,
behaviors and multiple types of child abuse and neglect. However, 1996) and the Childhood Trauma Questionnaire (Bernstein et al.,
some studies have only examined child abuse (Yen et al., 2002; 1994). Respondents were asked to respond to all questions per-
Gibb et al., 2001), neglect (Johnson et al., 2000), or a have taining to abuse, neglect (except emotional neglect), and having
combined child abuse and neglect together (Grover et al., 2007; a battered mother on a five-point scale (never, almost never,
Johnson et al., 1999; Luntz and Widom, 1994; Tyrka et al., 2009; sometimes, fairly often, or very often). Emotional neglect questions
Zanarini et al., 2000). Collapsing multiple types of child maltreat- employed an alternative five-point scale of never true, rarely true,
ment is often necessary due to lack of statistical power based on sometimes true, often true, or very often true. All questions per-
small sample sizes. However, this approach precludes under- taining to general household dysfunction required yes/no
standing the specific relationship between subtypes of maltreat- responding (except questions regarding having a battered mother,
ment and impairment, such as PDs. The limited research involving as mentioned above).
community samples has all been based on a study of two New York From the list of questions, several types of childhood adversity
State counties. The investigators combined multiple types of child were coded. Physical abuse was defined as a response of “some-
maltreatment into child abuse and neglect categories (Johnson times” or greater to either question when asked how often a parent
et al., 1999, 2000), only examined neglect (Johnson et al., 2000), or other adult living in the respondent’s home (1) pushed, grabbed,
and investigated parenting behaviors not including child abuse or shoved, slapped, or hit the respondent; or (2) hit the respondent so
neglect (Johnson et al., 2006). hard it left marks or bruises, or caused an injury. Emotional abuse
Another limitation of the current literature is the focus on only was identified as a response of “fairly often” or “very often” to any
one or limited types of PDs. For example, there are numerous question when asked how often a parent or other adult living in the
clinical studies showing a link between exposure to child sexual respondent’s home (1) swore at, insulted, or said hurtful things to
abuse and borderline personality disorder (Murray, 1993). Although the respondent; (2) threatened to hit or throw something at the
this is an important association, less attention has been paid to respondent (but did not do it); or (3) acted in any other way that
other types of childhood adversity and PDs. An examination of made the respondent afraid he/she would be physically hurt or
a wider range of adverse childhood events with all PDs in a pop- injured. These definitions are consistent with child maltreatment
ulation-based sample would significantly extend the existing definitions employed in the Adverse Childhood Experiences study
literature. Finally, only a few studies investigating childhood (Dube et al., 2003; Dong et al., 2003).
adversity and PDs have taken into account the effects of Axis I Sexual abuse was examined using a series of four questions
mental disorders on this relationship (Tyrka et al., 2009; Grover (Wyatt, 1985). These questions were adapted for use in the
et al., 2007; Gibb et al., 2001). This is an important methodolog- AUDADIS-IV and were rated on the same five-point scale that was
ical consideration since Axis I mental disorders are highly comorbid used for all other abuse and physical neglect questions. The ques-
with Axis II PDs (McGlashan et al., 2000; Lenzenweger, 2008). tions examined the occurrence of sexual touching or fondling,
To our knowledge, this study is the first to examine the rela- attempted intercourse, or actual intercourse by any adult or other
tionship between a wide range of adverse childhood experiences person when the respondent did not want the act to occur or was
including child maltreatment and household dysfunction with all too young to understand what was happening. Any response other
types of Axis II PDs in a nationally representative population- than “never” on any of the questions was taken to indicate sexual
based sample. It builds upon the existing literature, which is abuse.
based on clinical and small community samples. Furthermore, we Physical neglect was defined as any response other than “never”
adjust for Axis I disorders, an important consideration, given the on a series of four relevant questions. These questions explored
high prevalence of comorbidity between Axis I and Axis II respondents’ experiences of being left unsupervised when too
disorders. young to care for themselves or going without needed clothing,
school supplies, food, or medical treatment. Other studies using the
1. Methods Adverse Childhood Experiences Study have defined physical
neglect differently than we have here (Dong et al., 2003; Dube et al.,
1.1. Survey 2003); however, we were unable to follow the conventions out-
lined by these previous researchers because of the exclusion of one
Data were from the second wave of the National Epidemiologic of the original physical neglect questions by the AUDADIS-IV (the
Survey on Alcohol and Related Conditions (NESARC) collected in original series included five questions examining physical neglect).
2004 to 2005 (n ¼ 34,653). The NESARC is a representative sample To compensate for this discrepancy, an alternative definition of
of the adult (20 years of age or older), civilian, non-institutionalized physical neglect was developed. Examination of the distribution of
population of the United States; it included respondents living in summed responses to all physical neglect questions in our dataset
households and assorted non-institutional group dwellings such as indicated a clear break in the distribution between those
college quarters, group homes, and boarding houses. The response responding with “never” to all items versus those responding with
rate for Wave 2 was 86.7%. Interviews for both waves of the NESARC “almost never” or higher to at least one item (74.4% of respondents
816 T.O. Afifi et al. / Journal of Psychiatric Research 45 (2011) 814e822

answered “never” to all questions). For this reason, the aforemen- were assessed; in Wave 2, these three PDs were measured. Anti-
tioned definition of physical neglect was adopted. social PD was assessed in both waves, and the diagnostic variable
Emotional neglect was defined by five questions regarding from Wave 2 is used in our analysis. Although PDs are subject to
whether the respondent felt a part of a close-knit family or whether change over time, this disparity between the times of assessment of
anyone in the respondent’s family of origin made the respondent some of the PDs is not thought to be problematic since PDs are
feel special, wanted the respondent to succeed, believed in the often persistent in nature for many individuals (American
respondent, or provided strength and support. Consistent with Psychiatric Association, 2000).
previous research all five items were reverse-scored and summed; In addition to analyses conducted on individual PD diagnoses,
scores of 15 or greater were identified as emotional neglect (Dube we also examined PD cluster variables, which included the pres-
et al., 2003; Dong et al., 2003). ence of one or more PDs within each of cluster A (paranoid,
schizoid, schizotypal), cluster B (antisocial, histrionic, borderline,
1.2.1.2. Household dysfunction. To characterize the experience of narcissistic), and cluster C (avoidant, dependent, obsessive-
having a battered mother, respondents were asked whether the compulsive). These derived variables were based on the DSM-IV
respondent’s father, stepfather, foster/adoptive father, or mother’s classification of PDs into clusters determined by similarities in
boyfriend had ever done any of the following to the respondent’s symptomatology (American Psychiatric Association, 2000).
mother, stepmother, foster/adoptive mother, or father’s girlfriend:
(1) pushed, grabbed, slapped, or threw something at her; (2) 1.2.3. Covariates
kicked, bit, hit with a fist, or hit her with something hard; (3) Sociodemographic covariates included age (continuous),
repeatedly hit her for at least a few minutes; or (4) threatened to gender, household income (continuous), years of education
use or actually used a knife or gun on her. Any response of (continuous), marital status (three categories: married/living
“sometimes” or greater for questions 1 or 2, or any response except common law, separated/divorced/widowed, and never married),
“never” for questions 3 or 4, was defined as having a battered and race/ethnicity (five categories: non-Hispanic White, non-
mother. Hispanic Black, non-Hispanic American Indian/Alaska Native, non-
Parental substance abuse was assessed with two questions Hispanic Hawaiian/Pacific Islander, and Hispanic of any race). Three
regarding whether a parent or other adult living in the home had Axis I mental disorder variables were included in the models: (1)
a problem with alcohol or drugs. A response of “yes” to either of any lifetime mood disorder (depression, dysthymia, mania, or
these questions was defined as parental substance abuse. To char- hypomania), (2) any lifetime anxiety disorder (panic disorder,
acterize the remaining household dysfunction variables, respon- agoraphobia, social phobia, specific phobia, generalized anxiety
dents were asked to answer with either “yes” or “no” whether disorder, or post-traumatic stress disorder), and (3) any lifetime
a parent or other adult in the home (1) went to jail or prison; (2) substance use disorder (abuse/dependence on alcohol, sedatives,
was treated or hospitalized for a mental illness; (3) attempted tranquilizers, opioids, amphetamines, cannabis, cocaine, halluci-
suicide; and/or (4) actually committed suicide. Responses of “yes” nogens, inhalants/solvents, heroin, or other drugs). These mental
for any of these questions defined the corresponding general health conditions were diagnosed using the AUDADIS-IV, as
household dysfunction variable. described above.
Two variables were derived from each of these abuse, neglect, To account for the effect of inter-cluster PD comorbidity, each
and general household dysfunction variables. An “any abuse or analysis was adjusted for the two cluster variables that represented
neglect” variable was created that indicated the presence of at least the PD clusters other than the cluster currently being examined. For
one type of abuse or neglect in the respondent’s childhood. A example, in analyses of avoidant personality disorder, adjustments
similar “any adverse childhood events” variable was created that were made for any cluster A and any cluster B PDs. Intra-cluster PD
identified respondents who experienced at least one type of comorbidity was not adjusted for because PDs tend not to present
adverse childhood events (abuse, neglect, and general household as distinct entities, and instead exhibit a high degree of overlap
dysfunction). within clusters (Cox et al., 2007). Adjusting for within-cluster PDs
may remove variability that is simply due to the common features
1.2.2. Personality Disorder Diagnoses of all PDs within a cluster, thereby perhaps negating effects that
Diagnoses of PDs were made using the Alcohol Use Disorder and truly exist.
Associated Disabilities Interview Schedule-Diagnostic and Statis-
tical Manual of Mental Disorders-Fourth Edition (AUDADIS-IV) 1.3. Statistical methods
(Grant et al., 2001; Ruan et al., 2008a). The AUDADIS-IV provides
a fully structured interview protocol to assess various Axis I (mood, All analyses were conducted using the weight and stratification
anxiety, substance use disorders) and Axis II (PDs) diagnoses. variables supplied with the Wave 2 NESARC data file. To account for
The reliability of the AUDADIS-IV for PDs has been assessed using the complex sampling design of the NESARC, Taylor series lineari-
test-retest methods and were determined to be good zation was used as the variance estimation technique using
(Kappa ¼ 0.67e0.71; ICC ¼ 0.71e0.75; Alpha ¼ 0.75e0.83) (Grant SUDAAN software (Shah et al., 2004). In addition, due to the
et al., 2003; Ruan et al., 2008b) and equivalent or better than to number of comparisons and the large sample size, a conservative
reliabilities from patient samples using semi-structured person- 99% confidence interval was used to determine the statistical
ality interviews in short-term test-retest studies (Zimmerman, significance of the odds ratios.
1994). The authors from the reliability studies aptly concluded Crosstabs were calculated to determine the prevalence of
that the AUDADIS-IV diagnostic measures were reliable and useful childhood adversity among individuals who met criteria for PDs.
research tools (Ruan et al., 2008b). The validity of the AUDADIS-IV For these analyses, the any general household dysfunction variable
for PDs using mental component summary, social functioning, and was utilized, instead of individually examining each general
role emotional scores has also been assessed with linear regression household dysfunction variable. The any general household
analyses and were found to be highly significant (P < 0.01 to dysfunction variable was used in these analyses to increase read-
P < 0.001) (Grant et al., 2004). ability of the table; in all further analyses, the individual general
All 10 PDs were assessed in either Waves 1 or 2 of the NESARC. In household dysfunction variables were utilized. Logistic regression
the first wave, all but schizotypal, borderline, and narcissistic PDs analyses were used to determine the association between each
 T.O. Afifi et al. / Journal of Psychiatric Research 45 (2011) 814e822 817

Table 1 highly prevalent among all types of PDs. The results from the
Prevalence of childhood adversity in the general U.S. population. logistic regression models examining the association between each
Type of adverse childhood event N (%) type of adverse childhood event and all cluster A PDs are presented
Abuse in Table 3. The findings indicate that several adverse childhood
Physical 6294 (17.6) experiences were associated with increased odds of having cluster
Emotional 2911 (8.1) A PDs. More specifically, all types of abuse and neglect, having
Sexual 3854 (10.6)
a battered mother, and parental substance use problems were
Neglect associated with an increased likelihood of a cluster A PD. When
Physical 8561 (24.2) examining the individual PDs, childhood adversity had the greatest
Emotional 3413 (9.4)
Any abuse or neglect 10524 (30.1)
link to schizotypal PD.
Any general household dysfunction 14266 (40.3) Table 4 presents the results from the logistic regression models
Any adverse childhood event 18010 (51.5) computing the relationship between childhood adversity and
N (%): number and percentage of respondents who experienced the given adverse cluster B PDs. All adverse childhood events were significantly
childhood event. Ns are for the sample, whereas percentages are weighted to be associated with increased odds of having a cluster B PD with the
representative of the US population. exception of completed parental suicide. When considering each
Any general household dysfunction: indicates whether a respondent has expe- cluster B PD individually, almost all types of child abuse, neglect,
rienced at least one type of general household dysfunction (battered mother/
female caregiver, parent substance use problem, parental incarceration, parent
and household dysfunction were associated with an increased
mental illness, parent suicide attempt, or parent suicide completion). likelihood of having antisocial, borderline, and narcissistic PDs.
Any adverse childhood event: Indicates whether a respondent has experienced at Conversely, strong evidence for a relationship between childhood
least one type of abuse, neglect, or general household dysfunction. adversities and histrionic PD was not found.
Table 5 presents the results from the logistic regression models
adverse childhood event and PDs. These analyses were adjusted for examining the relationship between each adverse childhood event
sociodemographic variables, lifetime mood disorders, lifetime and cluster C PDs. The findings indicate that childhood adversity
anxiety disorders, and lifetime substance use disorders, and out-of- was not strongly associated with cluster C PDs. When looking at
cluster PDs. each cluster C PD individually, only emotional neglect was associ-
ated with avoidant PD, physical neglect with obsessive-compulsive
2. Results PD, and no significant relationships were found between childhood
adversity and dependent PD.
Table 1 presents the prevalence of childhood adversity in the Table 6 presents the results from the logistic regression models
sample. In the entire sample, 30% experienced child abuse and/or computing the relationships between child abuse and neglect,
neglect, 40% experienced household dysfunction, and 52% experi- household dysfunction, mood disorders, anxiety disorders,
enced any childhood adversity. Lifetime Axis I disorders were substance use disorders, out-of-cluster PDs, and sociodemographic
prevalent among those with PDs and any adverse childhood variables with each PD cluster. The findings indicate that several
experiences. Among those with cluster A PDs, 65% had an anxiety forms of child abuse and neglect remained associated with cluster A
disorder, 65% had a mood disorder, and 56% had a substance use and B PDs when simultaneously accounting for the variance of all
disorder. The prevalence of anxiety disorders, mood disorders, other covariates. Notably, the highest associations with PD clusters
substance use disorders was 55%, 57%, and 63%, respectively, among in these models were found for mental disorders including mood
those with Cluster B PDs. Among those with cluster C PDs, 60% had disorders, anxiety disorders, substance use disorders, and out-of-
an anxiety disorder, 59% had a mood disorder, and 53% had cluster PDs.
a substance use disorder. Among individuals experiencing any
childhood adversity, the prevalence of anxiety disorders, mood 3. Discussion
disorders, and substance use disorders was 35%, 34%, and 44%,
respectively. To our knowledge, this is the first study to examine the rela-
Table 2 presents the prevalence of each type of adverse child- tionship between a wide range of childhood adversities and all Axis
hood event among individuals with PDs. Childhood adversity was II PDs using a nationally representative sample controlling for Axis I

Table 2
Prevalence of childhood adversity among those with personality disorders.

Personality disorder Physical abuse Emotional abuse Sexual abuse Physical neglect Emotional neglect Any general household
N (%) N (%) N (%) N (%) N (%) dysfunction N (%)
Cluster A 1208 (34.4) 786 (23.3) 897 (25.6) 1377 (40.6) 664 (19.3) 1659 (48.2)
Paranoid 593 (35.0) 405 (24.9) 442 (25.4) 680 (40.8) 341 (20.1) 820 (49.0)
Schizoid 377 (32.6) 234 (22.2) 249 (22.0) 421 (39.1) 238 (22.1) 505 (46.3)
Schizotypal 639 (40.9) 433 (28.0) 514 (33.4) 717 (47.9) 324 (20.2) 835 (54.5)
Cluster B 1767 (34.9) 1077 (21.7) 1209 (23.8) 2004 (41.4) 853 (17.2) 2382 (48.2)
Antisocial 532 (41.9) 347 (27.1) 308 (23.8) 588 (48.4) 270 (20.6) 653 (52.1)
Histrionic 224 (33.0) 157 (23.7) 166 (24.3) 268 (42.6) 118 (18.1) 315 (49.5)
Borderline 957 (40.5) 649 (28.6) 770 (33.6) 1017 (45.2) 487 (21.0) 1248 (55.0)
Narcissistic 875 (34.1) 492 (19.6) 572 (21.4) 995 (39.5) 363 (14.4) 1164 (46.0)
Cluster C 983 (29.0) 607 (18.0) 699 (21.2) 1174 (35.9) 528 (15.7) 1387 (42.2)
Avoidant 273 (33.5) 201 (25.1) 234 (28.1) 334 (39.7) 208 (24.9) 393 (48.4)
Dependent 52 (34.0) 40 (28.0) 46 (31.3) 71 (45.6) 44 (27.0) 69 (52.0)
Obsessive-Compulsive 830 (28.5) 495 (16.9) 562 (20.1) 993 (35.9) 402 (13.7) 1157 (41.6)

N (%): number and percentage of respondents meeting criteria for the given personality disorder who experienced the given adverse childhood event. Ns are unweighted,
percentages are weighted.
Any general household dysfunction: indicates whether a respondent has experienced at least one type of general household dysfunction (battered mother/female caregiver,
parent substance use problem, parental incarceration, parent mental illness, parent suicide attempt, or parent suicide completion).
818 T.O. Afifi et al. / Journal of Psychiatric Research 45 (2011) 814e822

Table 3
Associations of childhood adversity with Cluster A personality disorders.

Type of adverse childhood event Cluster A personality disorder

Any Cluster A Paranoid Schizoid Schizotypal

Odds ratios (99% CI) Odds ratios (99% CI) Odds ratios (99% CI) Odds ratios (99% CI)
Abuse
Physical 1.39 (1.17e1.66) 1.26 (1.00e1.58) 1.18 (0.91e1.53) 1.62 (1.28e2.03)
Emotional 1.71 (1.38e2.11) 1.52 (1.17e1.98) 1.35 (0.99e1.84) 1.76 (1.35e2.31)
Sexual 1.44 (1.18e1.76) 1.05 (0.80e1.37) 0.99 (0.76e1.28) 2.05 (1.59e2.65)

Neglect
Physical 1.29 (1.11e1.51) 1.15 (0.93e1.43) 1.13 (0.88e1.45) 1.61 (1.26e2.05)
Emotional 1.50 (1.22e1.84) 1.31 (0.98e1.73) 1.68 (1.27e2.23) 1.35 (1.05e1.74)

General household dysfunction

Battered mother/female caregiver 1.27 (1.05e1.54) 1.24 (0.97e1.60) 1.21 (0.91e1.62) 1.33 (1.03e1.70)
Parent substance use problem 1.21 (1.04e1.41) 1.15 (0.93e1.43) 1.13 (0.87e1.45) 1.42 (1.14e1.78)
Parent went to jail 1.26 (0.99e1.61) 1.18 (0.84e1.65) 1.22 (0.86e1.72) 1.48 (1.09e2.00)
Parent mental illness 1.04 (0.78e1.38) 1.02 (0.73e1.42) 1.13 (0.80e1.62) 1.09 (0.74e1.60)
Parent suicide attempt 1.17 (0.84e1.62) 1.05 (0.67e1.66) 0.99 (0.62e1.58) 1.22 (0.81e1.84)
Parent completed suicide 0.85 (0.50e1.47) 0.92 (0.43e1.98) 1.22 (0.54e2.74) 0.95 (0.48e1.86)
Any abuse or neglect 1.40 (1.19e1.64) 1.14 (0.93e1.41) 1.16 (0.89e1.50) 2.01 (1.61e2.52)
Any adverse childhood event 1.54 (1.31e1.81) 1.29 (1.02e1.62) 1.32 (1.01e1.74) 2.28 (1.78e2.92)

Note: all odds ratios adjusted for age, gender, education, income, race/ethnicity, marital status, any cluster B PDs, any cluster C PDs, any Axis I lifetime mood disorders, any Axis
I anxiety disorders, and any Axis I substance use disorders. Bold font indicates significant adjusted odds ratios (p < 0.01).

disorders and sociodemographic covariates. The findings show prevalence was lower than estimates based on clinical samples
further evidence of the link between adverse experiences in (Battle et al., 2004; Bierer et al., 2003). For example, 29% of
childhood and mental health disorders in adulthood. First, the respondent with borderline PD reported experiencing emotional
results indicate that many types of childhood adversity were highly abuse in the current sample compared to 66% from a longitudinal
prevalent among individuals with PDs in the general U.S. pop- clinical sample (Battle et al., 2004). Our findings suggest that
ulation. Second, childhood adversity was most strongly and childhood adversity may not be as prevalent in community samples
consistently associated with clusters A and B PDs and specifically of people with PDs compared to clinical samples, but adverse
schizotypal, antisocial, borderline, and narcissistic PDs. Many of childhood events remain common among individuals with PD in
these findings remained significant even after simultaneously the general population.
accounting for the variance of all types of child abuse and neglect, Significant associations were found between childhood adver-
household dysfunction, mental disorders, and sociodemographic sity and PDs from all three clusters. Significant relationships
covariates. Third, childhood adversity in the form of household between child abuse and neglect and various PDs from clusters A, B,
dysfunction including exposure to battering of a mother, parental and C are consistent with previous research (Battle et al., 2004;
substance use problems, parental incarceration, parental mental Gibb et al., 2001; Grover et al., 2007; Johnson et al., 1999, 2000).
illness, and parental suicide attempts was associated with However, our current findings indicate that childhood adversity
increased likelihood of PDs. more broadly defined as child abuse, neglect and household
Although all types of childhood adversities were highly preva- dysfunction was more robustly related to schizotypal PD and most
lent among individuals with PDs in the current sample, this PDs from cluster B. The relationship between childhood adversity

Table 4
Associations of childhood adversity with Cluster B personality disorders.

Type of adverse childhood event Cluster B personality disorder

Any Cluster B Antisocial Histrionic Borderline Narcissistic

Odds Ratios (99% CI) Odds Ratios (99% CI) Odds Ratios (99% CI) Odds Ratios (99% CI) Odds Ratios (99% CI)
Abuse
Physical 2.00 (1.77e2.27) 2.42 (1.97e2.98) 1.20 (0.90e1.60) 2.04 (1.70e2.45) 1.70 (1.45e1.98)
Emotional 2.27 (1.92e2.68) 2.58 (1.95e3.40) 1.31 (0.92e1.86) 2.31 (1.87e2.87) 1.72 (1.39e2.12)
Sexual 2.14 (1.83e2.51) 2.17 (1.63e2.89) 1.09 (0.76e1.58) 2.47 (2.05e2.97) 1.64 (1.34e2.00)

Neglect
Physical 1.79 (1.55e2.07) 2.02 (1.60e2.54) 1.25 (0.91e1.70) 1.71 (1.45e2.03) 1.49 (1.26e1.77)
Emotional 1.63 (1.38e1.94) 2.00 (1.54e2.60) 1.22 (0.81e1.84) 1.60 (1.25e2.04) 1.23 (0.99e1.54)

General household dysfunction

Battered mother/female caregiver 1.77 (1.49e2.11) 1.84 (1.40e2.43) 1.17 (0.83e1.66) 1.71 (1.42e2.06) 1.57 (1.30e1.89)
Parent substance use problem 1.57 (1.38e1.79) 1.65 (1.32e2.05) 1.12 (0.83e1.51) 1.70 (1.44e2.01) 1.37 (1.15e1.64)
Parent went to jail 1.65 (1.36e2.00) 1.69 (1.25e2.27) 1.14 (0.74e1.76) 1.76 (1.36e2.27) 1.41 (1.09e1.83)
Parent mental illness 1.52 (1.23e1.87) 1.41 (0.99e1.84) 1.37 (0.84e2.23) 1.54 (1.18e2.01) 1.46 (1.12e1.91)
Parent suicide attempt 1.50 (1.14e1.95) 1.57 (1.05e2.36) 0.80 (0.41e1.59) 1.53 (1.08e2.16) 1.43 (1.06e1.93)
Parent completed suicide 1.20 (0.81e1.78) 1.16 (0.60e2.24) 1.20 (0.46e3.12) 1.33 (0.74e2.39) 1.22 (0.75e1.99)
Any abuse or neglect 2.11 (1.86e2.41) 2.26 (1.80e2.83) 1.50 (1.11e2.02) 2.36 (1.99e2.81) 1.81 (1.55e2.12)
Any adverse childhood event 2.04 (1.76e2.36) 2.23 (1.73e2.87) 1.38 (1.00e1.90) 2.35 (1.92e2.86) 1.74 (1.47e2.07)

Note: all odds ratios adjusted for age, gender, education, income, race/ethnicity, marital status, any cluster A PDs, any cluster C PDs, any Axis I lifetime mood disorders, any Axis
I anxiety disorders, and any Axis I substance use disorders. Bold font indicates significant adjusted odds ratios (p < 0.01).
 T.O. Afifi et al. / Journal of Psychiatric Research 45 (2011) 814e822 819

Table 5
Associations of childhood adversity with Cluster C personality disorders.

Type of adverse childhood event Cluster C personality disorder

Any Cluster C Avoidant Dependent Obsessive-compulsive

Odds ratios (99% CI) Odds ratios (99% CI) Odds ratios (99% CI) Odds ratios (99% CI)
Abuse
Physical 1.16 (0.98e1.37) 1.16 (0.98e1.37) 0.81 (0.44e1.47) 1.15 (0.95e1.39)
Emotional 1.19 (0.99e1.43) 1.22 (0.89e1.66) 0.93 (0.47e1.84) 1.11 (0.91e1.36)
Sexual 1.16 (0.95e1.42) 1.13 (0.86e1.48) 0.89 (0.45e1.74) 1.11 (0.90e1.37)

Neglect
Physical 1.17 (1.01e1.36) 1.02 (0.78e1.34) 1.03 (0.61e1.75) 1.20 (1.04e1.40)
Emotional 1.15 (0.96e1.39) 1.60 (1.18e2.16) 1.31 (0.75e2.30) 0.99 (0.79e1.23)

General household dysfunction

Battered mother/female caregiver 1.09 (0.90e1.32) 1.05 (0.78e1.43) 0.81 (0.38e1.73) 1.06 (0.86e1.30)
Parent substance use problem 1.08 (0.92e1.28) 1.08 (0.80e1.45) 0.64 (0.34e1.22) 1.10 (0.92e1.30)
Parent went to jail 0.93 (0.72e1.20) 0.95 (0.65e1.39) 0.97 (0.42e2.25) 0.88 (0.67e1.15)
Parent mental illness 1.14 (0.90e1.43) 1.15 (0.81e1.63) 1.40 (0.63e3.12) 1.11 (0.87e1.43)
Parent suicide attempt 1.07 (0.81e1.41) 0.91 (0.58e1.43) 1.06 (0.42e2.66) 1.04 (0.78e1.39)
Parent completed suicide 1.05 (0.70e1.58) 0.83 (0.35e1.95) 2.02 (0.62e6.53) 1.18 (0.79e1.79)
Any abuse or neglect 1.22 (1.06e1.40) 1.18 (0.91e1.53) 0.78 (0.43e1.40) 1.21 (1.04e1.41)
Any adverse childhood event 1.17 (1.00e1.37) 1.17 (0.86e1.59) 0.98 (0.51e1.86) 1.16 (0.99e1.37)

Note: all odds ratios adjusted for age, gender, education, income, race/ethnicity, marital status, any cluster A PDs, any cluster B PDs, any Axis I lifetime mood disorders, any Axis
I anxiety disorders, and any Axis I substance use disorders. Bold font indicates significant adjusted odds ratios (p < 0.01).

and schizotypal PD is consistent with previous research that found and household dysfunction were associated with increased odds of
an association between childhood adversity and schizotypal having schizotypal PD, antisocial PD, borderline PD, and narcissistic
symptoms (Steel et al., 2009; Berenbaum et al., 2003, 2008). This PD. This observation is in keeping with the clinical impression of
connection may be partly explained through the shared variance a particularly strong association between cluster B PDs and child-
between childhood adversity, schizotypal symptoms, and disso- hood adversities. Cluster B PDs are characterized by dramatic,
ciative tendencies (Irwin, 2001). Almost all forms of abuse, neglect, emotional, and erratic behavior (American Psychiatric Association,

Table 6
Associations of childhood adversity, household dysfunction, and sociodemographic covariates with personality disorders.

Cluster A Cluster B Cluster C

Adjusted Odds ratios (99% CI) Adjusted Odds ratios (99% CI) Adjusted Odds ratios (99% CI)
Child abuse and neglect
Physical abuse 1.08 (0.86e1.35) 1.42 (1.22e1.65) 1.09 (0.87e1.36)
Emotional abuse 1.33 (1.01e1.74) 1.29 (1.03e1.61) 1.08 (0.85e1.37)
Sexual abuse 1.22 (1.00e1.50) 1.63 (1.37e1.93) 1.10 (0.89e1.36)
Physical neglect 1.09 (0.92e1.30) 1.34 (1.14e1.57) 1.12 (0.95e1.32)
Emotional neglect 1.26 (0.99e1.59) 1.09 (0.89e1.33) 1.04 (0.84e1.30)

General household dysfunction

Battered mother/female caregiver 0.98 (0.77e1.25) 1.02 (0.82e1.27) 0.96 (0.75e1.21)
Parent substance use problem 1.04 (0.85e1.28) 1.19 (1.03e1.38) 1.05 (0.87e1.26)
Parent went to jail 1.11 (0.84e1.46) 1.11 (0.88e1.41) 0.81 (0.61e1.08)
Parent mental illness 0.90 (0.64e1.28) 1.23 (0.93e1.62) 1.15 (0.88e1.52)
Parent suicide attempt 1.15 (0.74e1.79) 0.99 (0.66e1.48) 0.93 (0.64e1.37)
Parent completed suicide 0.71 (0.37e1.35) 0.86 (0.49e1.50) 1.12 (0.67e1.88)

Mental disorders
Mood disorders 2.25 (1.90e2.65) 2.20 (1.91e2.53) 2.17 (1.82e2.58)
Anxiety disorders 2.38 (1.98e2.86) 1.83 (1.60e2.08) 2.05 (1.76e2.40)
Substance use disorders 1.17 (0.99e1.37) 2.05 (1.79e2.34) 1.26 (1.07e1.48)
Cluster A Not included 4.84 (4.08e5.74) 5.44 (4.52e6.55)
Cluster B 4.94 (4.16e5.87) Not included 1.58 (1.32e1.88)
Cluster C 5.66 (4.72e6.79) 1.61 (1.35e1.93) Not included

Sociodemographic covariates
Age (continuous) 0.99 (0.99e1.00) 0.98 (0.98e0.98) 1.00 (1.00e1.01)
Gender (female reference) 1.19 (1.01e1.41) 2.00 (1.73e2.32) 1.05 (0.91e1.20)
Household income (continuous) 0.98 (0.96e0.99) 0.98 (0.97e1.00) 1.00 (0.98e1.02)
Education (continuous) 0.94 (0.91e0.98) 0.98 (0.95e1.01) 1.05 (1.01e1.08)
Marital Status (married/common law) 1.00 (e) 1.00 (e) 1.00 (e)
Widowed/separated/divorced 1.34 (1.12e1.59) 1.30 (1.13e1.50) 0.77 (0.64e0.92)
Never married 1.30 (1.08e1.57) 1.19 (1.00e1.41) 0.82 (0.67e0.99)
Ethnicity (White reference) 1.00 (e) 1.00 (e) 1.00 (e)
Black 2.09 (1.71e2.56) 1.71 (1.44e2.03) 0.80 (0.67e0.97)
American Indian/Alaska Native 1.55 (0.99e2.42) 1.38 (0.97e1.98) 0.72 (0.44e1.18)
Hawaiian/Pacific Islander 1.00 (0.61e1.62) 1.10 (0.67e1.81) 0.76 (0.52e1.11)
Hispanic 1.41 (1.11e1.79) 1.10 (0.89e1.36) 0.82 (0.66e1.02)

All independent variables simultaneously entered into each PD cluster model.

820 T.O. Afifi et al. / Journal of Psychiatric Research 45 (2011) 814e822

1994, 2000). Theory suggests that personality develops from Estimated societal costs associated with child abuse (World
emotions and emotion-related experiences beginning in early Health Organization, 2006) and PDs (van Asselt et al., 2007) are
childhood (Cohen, 2008). Adverse childhood experiences may, in substantial. Although some progress has been made in preventing
part, shape personality and have the potential to negatively influ- child maltreatment (MacMillan et al., 2009), it is also important to
ence the development of personality traits, PD symptoms, and PDs. determine ways of reducing impairment, as well as recurrence
Another interesting finding from this research was that many among those who have suffered maltreatment in childhood. For
adverse childhood events were not strongly related to cluster C example, among sexually abused children who experience PTSD
disorders. It may be that the nature of the psychopathology asso- symptoms, there is evidence that trauma-focused cognitive-
ciated with cluster C PDs (i.e. the anxious, fearful cluster) is more behavior therapy (TF-CBT) can reduce PTSD as well as anxiety and
closely overlapping with the “distress” Axis I disorders (i.e. mood, depression (Macdonald et al., 2006). However, given that most
anxiety). If etiological factors (or “symptoms” used in making the follow-ups after TF-CBT do not extend beyond 12 months (Stallard,
diagnoses) are more closely overlapping, then controlling for such 2006), the long-term effects of such treatment are unknown. Do
Axis I disorders may more completely account for any association interventions shown to be effective in reducing mental health
that might have been seen between cluster C and childhood problems following maltreatment in childhood lead to better
adversities. outcomes in adulthood such as reduced risk of PDs? This is a critical
In the fully adjusted models presented in Table 6, Axis I disor- area of research that requires long-term follow-up of patients.
ders including mood disorders, anxiety disorders, and substance Although it is not ethical to withhold an effective treatment from
use disorders remained significantly associated with cluster A, one group, it is possible to compare treatments (for example, usual
cluster B, and cluster C PDs with the exception of substance use care and enhanced treatment) and follow patients long-term. We
disorders with cluster A PDs. It is noted that mood disorders, are not aware of any trials following children to adulthood after
anxiety disorders, and substance use disorders were among the treatment for conditions related to child maltreatment; however,
largest odds ratios associated with cluster A, B, and C PDs meaning Olds and colleagues are following participants in each of three
that a history of Axis I mental disorders remains a strong predictor prevention trials of home visitation to determine the long-term
of PDs. This is in keeping with the high prevalence of comorbid Axis outcome of this intervention (Olds et al., 2007). Prevention strat-
I and Axis II mental disorders found in this study. These highly egies that are effective in reducing adverse childhood events may
comorbid relationships between Axis I mental disorders and Axis II also help to reduce PDs in the general population, but this is
PDs have treatment implications; poorer clinical outcomes may currently unknown. Furthermore, programs that address one type
result for some individuals presenting with this comorbidity (Reich, of maltreatment or related symptoms, such as PTSD, cannot be
2007). Although child abuse and neglect significantly increases the assumed to generalize to other types of maltreatment or impair-
likelihood of cluster A and cluster B PDs, Axis I disorders are also ment. Cohen and colleagues are currently evaluating whether TF-
important correlates. CBT is effective in reducing symptoms among children exposed to
Of particular note, most individuals who experience childhood domestic violence. Such programs have the potential to prevent
adversity do not develop PDs; it is important in developing a wide range of mental health problems in adulthood, but this is yet
approaches to reduce impairment to understand the mediators and to be determined. Preventing child maltreatment is not a simple
moderators of this association. As outlined by Bornovalova et al. task. Evidence from prevention and intervention research should
(2009), there is a lack of information about the longitudinal be replicated in other samples.
trajectories of PDs; to understand the development of PDs, it is It is also important for clinicians and researchers to be aware of
essential to measure the onset and course of PDs with repeated the types of household dysfunction that are related of PDs. Clini-
assessments from youth and adulthood (indeed we would argue, cians need to consider the broader range of household dysfunction
beginning in childhood with measurement of environmental when inquiring about child abuse and neglect. Also, researchers
adversity). The investigation by Kim et al. (2009) is one of the few could include these and other household dysfunction variables to
longitudinal studies to examine the influence of maltreatment on broaden the examination of childhood adversity in future research
personality processes and subsequent adjustment in a sample of on PDs.
children. Ideally, such a sample would be followed through to Limitations of the current study should be considered. First, the
young adulthood. cross-sectional design precludes determining any causal inferences
In addition to the need for longitudinal follow-up, future in the relationship between childhood adversity and PDs. Second,
research should model the genetic and environmental effects on data on childhood adversity were collected retrospectively, which
personality traits, and include gene-environment interactions may introduce some sampling error due to recall and reporting
(Bornovalova et al., 2009). This might help explain why some bias. For example, it is possible that individuals with PDs might be
individuals who experience adversity during childhood do not more likely to subjectively recall an experience as abusive or
develop PDs (Paris, 1997, 1998). Perhaps some individuals, based on traumatic. However, there is evidence that supports the validity of
their genetic make-up, or other factors that buffer the environ- accurate recall of adverse childhood events (Hardt and Rutter,
mental adversity, such as experiences of nurturing parenting are 2004). Additionally, although several items were used to measure
protected from the negative impact of child maltreatment. Many child abuse and neglect, the assessment of other family violence
domains of personality are highly heritable (Jang et al., 1996). It may was limited to violence against a mother or female caregiver.
be that a PD is a result of a specific genotypes interacting with the Although our study included a wide range of adverse childhood
adverse environmental factors that leads to expression of events this is not an exhaustive list; other types of adverse child-
dysfunctional personality traits, PD symptoms, or PDs. Similarly, hood should be included in future research. Third, although all
not all individuals with PDs have a history of childhood adversity. mental disorder diagnoses were made by a reliable structured
Clearly, there are multiple pathways that lead to the development interview conducted by trained lay interviews, this assessment
of PDs. Investigation of pathway models using behavioral-genetics approach may not match the accuracy of an experienced clinician.
and molecular study designs including measures of resiliency are Structured clinical interviews for DSM based diagnoses would be
necessary in determining the factors that influence the develop- ideal, but is not possible in nationally representative epidemiologic
ment of PDs, conditions which are associated with major morbidity surveys due to expense. However, the assessment of Axis I and Axis
and some mortality. II PDs included in the NESARC using the AUDADIS-IV provides
 T.O. Afifi et al. / Journal of Psychiatric Research 45 (2011) 814e822 821

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