Research Article ISSN 2641-4317

International Journal of Psychiatry Research

Childhood Adverse Experiences and Personality Disorders in Outpatients

with Addiction
Anna Rita Atti1*, Maurizio Speciani1, Ferdinando Cerrato1, Paola Casadio2, Deanna Olivoni3, Paolo
Scudellari1, Stefano Valente1 and Diana De Ronchi1

Department of Biomedical and Neuromotor Sciences, Psychiatry,

1

Bologna University, Italy. Correspondence:

*

Anna Rita Atti, Department of Biomedical and Neuromotor

Mental Health Center, Mental Health and Pathological Addiction
2
Sciences, Psychiatry, Bologna University, Italy.
Department –AUSL Romagna, Faenza, Italy.

Pathological Addictions Service, Mental Health and Pathological

3 Received: 20 April 2020; Accepted: 12 May 2020
Addiction Department – AUSL Romagna, Faenza, Italy.

Citation: Anna Rita Atti, Maurizio Speciani, Ferdinando Cerrato, et al. Childhood Adverse Experiences and Personality Disorders in
Outpatients with Addiction. Int J Psychiatr Res. 2020; 3(3): 1-7.

ABSTRACT
Introduction: This study aims to disentangle the relationship between childhood adverse experiences (CAE),
personality disorders (PDs) and substance use disorders (SUDs), in patients attending an Italian addiction service.

Materials and Methods: A cross-sectional naturalistic study of 320 consecutive outpatients. Participants were
evaluated by a semi-structured interview including the SCID-II (Structured Clinical Interview for DSM-IV Axis II
PD), and the CECA-Q (Childhood Experience of Care and Abuse - questionnaire). Multivariate Logistic Regression
analyses were used to estimate Odds Ratio (OR) and 95% Confidence Intervals (95%CI).

Results: 65.5% of the sample experienced some kind of CAE (living in an institution before age 17; suffering
of physical punishment; being separated from parents) and the prevalence rate of PDs was 62.2%. PDs were
associated with a history of physical punishment in childhood: OR (95% CI)=1.82 (1.05-3.16), p=0.034, and with
childhood institutionalization: OR (95% CI)=2.15 (1.02-4.54), p=0.041. Three adverse events together increase
the probability of Cluster B PD: OR (95% CI)=5.92 (2.21-15.92), p=0.001.

Conclusion: In outpatients with SUDs, PDs are related to CAE. Regardless of drugs use, CAE have substantial
effects on personality development and occupational functioning.

Keywords fibromyalgia, inflammation, and diabetes with life-long serious

Addiction, Childhood, Personality. consequences [3]. Adverse experiences during childhood, both
physical and psychological, are especially harmful since they
Introduction are known to damage brain development which may result in an
Child maltreatment, sometimes referred to as child abuse and increased lifetime risk of psychiatric disorders [4].
neglect, includes all forms of physical and emotional ill-treatment,
sexual abuse, neglect, and exploitation that results in actual or Relationship between adverse childhood experience (CAE)and
potential harm to the child’s health, development or dignity [1]. mental health has been largely investigated [5,6]. For example,
subjects abused during childhood have about twice the risk of
Around 4–16% of children every year are physically abused, developing depression, anxiety and substance related disorders, and
10% are neglected or psychologically abused, and between fourfold the risk of incurring in post-traumatic stress disorder later
15% and 30% of teen are exposed to any type of sexual abuse in life. It has been also estimated that more than 30% of patients
[2]. Maltreatment during childhood increases the risk of poor with psychotic disorders had childhood experiences of sexual
physical health outcomes, including immune dysfunction, obesity, abuse or physical violence [7,8]. In a study involving 600 patients
Int J Psychiatr Res, 2020 Volume 3 | Issue 3 | 1 of 7
affected by personality disorders (PDs), abuse and physical neglect A detailed description of the objective of the study and personal
frequencies were 73% and 83% respectively [7]. A systematic data handling was provided by a key worker chosen among the
review of international studies, involving 145.407 participants, team members. All participants were clinically assessed by two
showed how sexual or physical abuse and abandonment were consultant psychiatrists and two psychologists and semi-structured
associated with anxiety and mood disorders. Furthermore, questionnaires were administered.
emotional neglect was related with PDs and psychosis whereas
physical violence was specifically associated with PDs [6]. A Inclusion criteria were: age between 15 and 65 years, good
tight relationship between Substance Use Disorders (SUDs) and understanding of Italian language, at least one-month duration of
CAE has also been proved [9]. Many retrospective studies have referring at the Faenza OAS. Exclusion criteria were: seriously
shown family history of addiction [10] or perception of distant, impaired cognition, disabling physical illness such as to compromise
little understanding or claiming and intrusive family members [11] the quality of the interview, condition of temporary incarceration
behind narcotic addiction disorders. Furthermore, among women, or placement in a community outside of the Faenza area, presence
emotional neglect has also been associated with a more frequent of a psychotic disorder in active phase and abandonment of the
substance abuse [12]. treatment program during the assessment phase. Specific details of
this phase are described elsewhere [21].
Several studies show a high prevalence of PDs in people affected by
SUDs [13-18] with a high representation of Antisocial, Borderline Out of the 436 patients referred and invited to participate, 23
and Avoidant PD. Overall, PD prevalence among inpatients with (5.3%) refused and 93 (21.3%) were excluded due to the following
SUDs is about 50-60%, almost four times higher than the general reasons: age older than 65 years (N=11), premature discharged or
population [19-21] suggesting the hypothesis that PD and SUD treatment abandoned treatment (N=34), placement outside Faenza
share a common etiology. area (N=11), cognitive impairment (N=7), active psychosis (N=9),
language difficulties (N=8), serious physical pathologies (N=4)
To our knowledge so far, no studies have investigated by means of and 9 died leaving a study sample of 320 participants.
standardized tools the mutual relationships between CAE, PD and
SUD within an outpatient population who uses public addiction PDs diagnoses – based on DSMIV-TR criteria – [22] were achieved
services and are affected by SUDs. both on the bases of a detailed clinical evaluation and with the
provision of the SCID-II (Structured Clinical Interview for DSM
Objectives IV-TR Axis II Disorders) [23]. In case of co-occurrence of two or
The primary objective of this study was to investigate the more PDs, the PD with the highest number of positive items was
association between a history of CAE and PDs and SUD diagnosis. considered as “primary”.
The secondary aim was to evaluate the socio-demographic
features of participants analyzing the possible association between Assessment
such features, CAE, PDs and SUD in a multi-adjusted logistic The sociodemographic and clinical questionnaires used for
regression model. the present study were extracted from EuropASI. EuropASI
is an adaptation of the European Addiction Severity Index, a
Materials and Methods multidimensional semi-structured tool faced to assess difficulties
Data were collected at the Outpatients Addiction Service (OAS) of of patients with SUDs in seven areas: medical, employment,
Faenza, a wealthy urban area in Romagna (Northern Italy), during alcohol use, drug use, legal, family / social, and psychological.
a 12 months period. The OAS team consists of psychiatrists, Beside collecting a wide range of socio-demographic data, the
psychiatric nurses, psychologists and social workers specifically questionnaire investigated the characteristics of drug addiction
trained for the medical and psychological treatment of addictions. (kind of substances used, mode of use, drug treatment and
The service has a strong attention on the management of alcohol psychotherapy applied) and the physical and psychological
and opiate dependence that constitute the most common reason for conditions of the patient [24].
referring. People with cannabinoids and novel psychoactive drugs
abuse or addiction are not routinely treated in such service [21]. CECA-Q is a self-report questionnaire on adverse childhood
experiences adapted from the Childhood Experience of Care and
According to the Italian law, all participants signed a written Abuse [25]. It concerns several childhood adverse experiences.
consent to personal data handling and an informed consent to We assessed physical abuse by main care-giver (Pun), sexual
study’s participation. Furthermore, this cross-sectional naturalistic harassment by an individual at least 5 years older than the
study was approved by CEAVR (Ethics Committee of the Area recipient (Har), separation from a parent or death of a parent
Vasta Romagna) and IRST (Scientific Institute of Romagna for (Sep), institutional care (Ins), all before 17 years of age. This
Cancer Therapy and study). questionnaire, translated and validated in Italian language [26]
has been shown to have good internal consistency [25,27] and
Sample satisfactory levels of test-retest reliability over 7 years in a similar
During the recruitment phase, all consecutive patients referred psychosis sample [28].
to the addiction service were asked to participate in the study.
Int J Psychiatr Res, 2020 Volume 3 | Issue 3 | 2 of 7
Structured Clinical Interview for DSM IV-TR Axis II (SCID- Single 112 (47.5) 29 (34.5) 141 (44.1)
II) consists of 120 items rated on a scale of 4 levels (from 0 = In a stablerela-
insufficient information 3 = clinically relevant or true); it is 36 (15.3) 12 (14.3) 48 (15.0)
tionship
divided into 11 sections, one for each Personality Disorder so Marital
Married 43 (18.2) 16 (19.0) 59 (18.4) 0.02
Status
as to facilitate the diagnosis of each disorder. The interviewer Separated or
formulates additional questions in order to deepen unclear aspects 42 (17.8) 21 (25.0) 63 (19.7)
Divorced
of the patients' responses; particularly the interviewer should re- Widowed 3 (1.3) 6 (7.1) 9 (2.8)
asses the items that the patient evaluated as "3", or as affirmative, Occupied 153 (64.8) 49 (58.3) 202 (63.1)
Employ-
in order to avoid "false positives". In other cases, it must also re- ment
0.289
Unoccupied 83 (35.2) 35 (41.7) 118 (36.9)
evaluate some of the negative item, for example if there is reason
Cluster A 22 (9.3) 4 (4.8) 26 (8.1)
to think that they are "false negative" depending on the context, or
Cluster B 70 (29.7) 35 (41.7) 105 (32.8)
if the items do not reach the positive enough to make a diagnosis. Personality
Cluster C 29 (12.3) 16 (19) 45 (14.1) 0.056
Disorder
Data analysis Others 19 (8.1) 4 (4.8) 23 (7.2)
Data analysis was carried out in three phases. First the relationships None 96 (40.7) 25 (29.8) 121 (37.8)
between sociodemographic characteristics, PDs, SUDs and
CECA-Q variables were investigated by the Chi square test. Then, Out of 320 participants, 36 individuals who initially accepted
all statistically significant relationships were again tested using to join the study, did not complete the CECA-Q. The remaining
Logistic Regression Analysis that allowed us to estimate the Odds 284 subject with complete data constitutes the population for the
Ratio and the 95% Confidence Intervals (CI). Last, all possible present study. Out of 284 patients, 186 (65.5%) have experienced
confounding factors were included stepwise in a multivariate some kind of childhood adverse events, 36 lived in an institution
Logistic Regression model. Data were processed with SPSS before age 17; 127 suffered of physical punishment; 111 had
version 17th. lost or were separated from parents and 44 underwent to sexual
harassment. 24.6% of these patients were subjected to two or more
Results of the above mentioned conditions.
Out of 320 participants in the study, 236 (73.7%) were male.
Among participants who have had at least one CAE, 72.1% had a
Average age was 39.9 years (SD ± 10.8). The 63.1% were employed
PD while, among participants who did not experienced any CAE,
at the time of data collection. In the 60.6% of cases (N=194), the
47.5% had no PD (p < 0.001).
primary addiction was to opiates, followed by alcohol (27.8%),
gambling (6.9%), and cocaine (4,1%). The 62.2% (N=199) of the
In table 2 are shown correlations between PDs, drugs used and
study population satisfied criteria for PDs distributed as follows:
childhood adverse events. Borderline PD was associated with
13.1% (N=26) Cluster A PD, 52.8% (N=105) Cluster B PD, 22.6%
growing-up in an institution and having had physical punishment.
(N=45) Cluster C PD and 11.6% (N = 23) Not Otherwise Specified
Being in an institution before age 17 and being separated from
PDs. Within Cluster B PD the most represented were Borderline
parents was associated with Antisocial PD. Alcohol and heroin use
(45.7%) and Antisocial (58.1 %) (Table 1). were related to institutionalization and physical punishment.
Table 1: Sociodemographic features of the study population by gender (p Table 2: Personality disorders (PD), drugs, occupation and Childhood
from Chi Squares). Adverse Events at a glance (p from two by two Chi Squares).
Men Women Total Childhood Adverse Events
p
236 (73.7) 84 (26.3) 320 χ2 Institutional- Physical Separation Sexual
<18 4 (1.7) 3 (3.6) 7 (2.2) ization Punishment from parents harassment
18-24 27 (11.4) 8 (9.5) 35 (10.9) Cluster A PD p= 0.166 p= 1.00 p= 0.488 p= 0.217
Age
groups 25-34 55 (23.3) 14 (16.7) 69 (21.6) 0.572 Cluster B PD p= 0.008 p= 0.005 p=0.005 p= 0.229
(years) 35-44 90 (38.1) 36 (42.9) 126 (39.4) Cluster C PD p= 0.322 p= 0.133 p= 0.304 p=0.010
≥45 60 (25.4) 23 (27.4) 83 (25.9) Borderline PD p= 0.053 p= 0.001 p= 0.318 p= 0.116
None 1 (0.4) 1 (1.2) 2 (0.6) Antisocial PD p= 0.049 p= 0.882 p=0.023 p= 0.309
Primary School Alcool Addiction p= 0.050 p= 0.761 p= 0.544 p= 0.968
25 (10.6) 1 (1.2) 26 (8.1)
Diploma Heroin Addiction p= 0.631 p= 0.033 p= 0.277 p= 0.786
Secondary School 125 (53.1) 37 (44.0) 162 (50.6) Being Employed p= 0.017 p=0.051 p=0.018 p= 0.867
Education Professional 0.004
44 (18.6) 18 (21.4) 62 (19.4)
qualification
In the multivariate logistic regression analysis, physical
High School punishment and being in an institute increase the odd of Cluster
31 (13.1) 24 (28.6) 55 (17.2)
Diploma
B PD: OR (95% CI) = 1.82 (1.05-3.16), p=0.034 and 2.15 (1.02-
Graduation 10 (4.2) 3 (3.6) 13 (4.1)
4.54), p=0.041 respectively. Similarly, both current and previous
Int J Psychiatr Res, 2020 Volume 3 | Issue 3 | 3 of 7
heroin abuse increase the probability of Cluster B PD: OR (95% Such estimate is slightly lower than the one measured in the
CI) = 4.34 (1.97-11.8), p=0.004 and OR (95% CI) = 2.93 (1.49- Collaborative Longitudinal Personality Disorders Study. In such
5.75), p=0.002 respectively. In the multivariate logistic regression population-based cohort study, participants reported childhood
model having an occupation halved the probability of Cluster B mistreatment in 73% and abandonment in 83% [7].
PD: OR (CI 95%) = 0.54 (0.31-0.93), p=0.027.
Our findings are in line with previous studies demonstrating that
A stratified analysis by occupational status demonstrated a individuals abused during childhood are more likely to develop
statistically significant association between physical punishment many different mental disorders in adulthood including PDs
and Borderline/Antisocial PD only among unemployed participants [6,29,30]. In our peculiar sample constituted of people searching
(p<0.05). (Data not shown). help for addiction problems, we were able to confirm the strong
link between childhood adverse experiences and PDs.

In addition, an association between specific types of child

maltreatment and personality disorders has more recently been
demonstrated: sexual abuse, emotional and physical abuses are
associated with Borderline Personality disorder and Antisocial
Personality Disorder [31].

The hypotheses behind this strong association are interlinked.

First, CAE might have an effect on the developmental cascade.
Indeed, the first step of the developmental process is the creation of
a secure attachment with the child’s caregiver during the first year
of life. This primary task provides the surrounding for a correct
bio-behavioral organization that addresses and makes easier the
following tasks, helping to create stable internal working models
Figure 1: Childhood Adverse Experiences and Personality Disorders in which will be then used during the entire lifetime. CAE during
Outpatients with Addiction. early life operates a fracture that affects this pattern and contribute
to damage the correct developing of mental functions, such as
In Table 3 is shown the association between different possible emotion regulation, the formation of attachment relationship
combination of adverse events and Cluster B PD. The worst and the creation of an autonomous self. It is clear that all of this
childhood scenario (co-occurrence of Ins, Pun, Sep) versus the function contributes to create a balanced personality and that their
best (no adverse event) is associated to an increased odd of Cluster alterations represent the structural defect that subtend personality
B PD: OR (95% CI) = 5.92 (2.21 -15.9), p<0.001. disorder [3].

Table 3: Childhood Adverse Events and Borderline and Antisocial The second possible causative hypothesis is related to biological
Personality Disorder (Odds Ratio and 95% Confidence Intervals by effects of child maltreatment on brain development on structural
Binary Logistic Regression Analyses). and functional aspects of encephalon. Structures especially affected
p OR (95%CI) are prefrontal cortex, orbitofrontal cortex, hippocampus and
No adverse experience
- Rif. amygdala [32–35]. Changing in these structures can affect mind
Pun 0.011 2.58 (1.24-5.39) functions and ultimately affect personality [36]. In fact, altered
Sep 0.007 3.00 (1.35-6.65) functioning in these brain areas can disturb mental operations like
response inhibition, working memory and emotion processing
Ins 0.123 4.94 (0.65-37.55)
[37]. Moreover, child maltreatment is associated with altered
Pun + Sep 0.099 2.09 (0.87-5.02)
white matter organisation in prefrontal cortex and this is associated
Ins + Pun 0.123 4.94 (0.65-37.55) with impaired cognitive control and behavioural regulation [38].
Ins + Sep 0.438 1.98 (0.35-11.01)
Ins + Pun + Sep <0.001 5.92 (2.21-15.92) Nevertheless, it is necessary to underline that such unfavorable
Pun = Physical Punishment, Sep = Loss or separation from parents, outcome is not obliged for people which had CAE: healthy
Ins = Institutionalization. adaptation is an alternative outcome too. There must be a research
effort focused on protective factors, in order to find interventions
Discussion that could prevent psychopathology development [4].
In our naturalistic study embedded in an outpatient’s addiction
service in Northern Italy childhood adverse experiences occur CAE have been shown to be associated with SUDs, too. A study on
in the 64.4% of participants. Among patients who experienced at 339 patients affected with addiction, comparable to ours for age,
least one CAE, 72.1% developed a PD. PDs rate, and lifetime prevalence of substance abuse demonstrated
that physical punishment and abandonment were closely related
Int J Psychiatr Res, 2020 Volume 3 | Issue 3 | 4 of 7
to Antisocial PD with sadistic traits whereas emotional violence needed to make stronger causal attributions about the effects
were closely related to Borderline PD, suggesting that child of childhood trauma on personality disorders. In addition, our
maltreatment contributes to the co-morbidity of personality findings are generalizable only to treatment seekers SUD patients
disorders in people with problems of addictions [39]. A correlation and replications in community-dwelling population are needed to
between disinhibition, behavioral dyscontrol and SUD’s has been further generalize these findings.
shown [40]. This kind of relation has been recently confirmed: in
particular neuroticism, behavior disinhibition and SUD’s were Finally, prior research has suggested that a range of other factors
shown as associated [41]. may also influence the nature of the impact of the maltreatment,
including perpetrator’s characteristics, duration and chronicity
As we said above child maltreatment can lead to altered functioning of maltreatment and its timing [44,45]. We did not assess any
of specific brain circuits that are related with altered behavior relationship between these factors and their impact on PDs and
regulation, disinhibition and defective emotion processing. SUD.
According to these data and to the ones from our study, it is
possible to hypothesize a psychopathological arc that moves from Conclusion
child maltreatments, passing through altered personality traits or In summary, our findings support the view that CAE contribute to
PD’s, leading to SUD’s. the high prevalence of personality disorders in persons suffering
of addiction. Although there is still more to discover about PDs
For these reasons, it is essential to plan prevention programs for etiology, our findings support the view that all adverse events
early intervention - such as training project for teachers and school occurred in childhood could play a central role in pathological
assistants - in order to stop the process that leads from CAE to personality development and addictive behaviors. Future studies
PDs. Goal of these preventive programs could be the detection with longitudinal designs will allow to enlighten this complex
of prodromal phenomena, in order to operate an effective early phenomenon.
intervention.
References
Finally, in our sample, being employed is inversely related to the 1. https://www.who.int/westernpacific/health-topics/violence-
CECA-Q score and PDs. Many studies validate our hypothesis against-children
that having an occupation within a structured treatment program 2. Gilbert R, Widom CS, Browne K, et al. Burden and
may have a greater therapeutic effect than the pharmacological consequences of child maltreatment in high-income countries.
treatment in itself [42]. An interesting work conducted by Lancet. 2009; 373: 68-81.
Becker [43] attempted to investigate the therapeutic value of 3. Cicchetti D, Doyle C. Child maltreatment, attachment and
job satisfaction on PD. Study participants who had obtained the psychopathology. Mediating relations. World Psychiatry.
desired work were much more satisfied and stayed about twice as 2016; 15: 89-90.
much loyal to it if compared to those who did not get their favorite 4. Morgan C, Gayer-Anderson C. Childhood adversities
occupation. Results regarding employment in our population and psychosis: evidence, challenges, implications. World
appear to be consistent with the hypothesis that occupation could Psychiatry. 2016; 15: 93-102.
exert a protective role. Accurate studies with longitudinal design 5. Bowden-Jones O, Iqbal MZ, Tyrer P, et al. Prevalence
are needed to finally verify this hypothesis. of personality disorder in alcohol and drug services and
associated comorbidity. Addiction. 2004; 99: 1306-1314.
Limitations 6. Carr CP, Martins CMS, Stingel AM, et al. The role of early
Our study acknowledges some advantages as well as some life stress in adult psychiatric disorders: a systematic review
limitations that need to be considered. The main restraint to according to childhood trauma subtypes. JNervMent Dis.
our findings is the retrospective self-report of CAE. Indeed, 2013; 201:1007-1020.
unfortunately we missed the opportunity of having the self-reports 7. Battle CL, Shea MT, Johnson DM, et al. Childhood
corroborated from family members or from registry data. We maltreatment associated with adult personality disorders.
acknowledge that a recall bias might have occurred thus resulting Findings from the Collaborative Longitudinal Personality
both in an under- as well as an over-reporting of CAE. Although Disorders Study. J Pers Disord. 2004; 18: 193-211.
we share this important limitation with most of the other studies 8. Tyrka AR, Wyche MC, Kelly MM, et al. Childhood
on this issue [7], we tried to overcome the problem using a maltreatment and adult personality disorder symptoms:
questionnaire that has been demonstrated to be valid and reliable influence of maltreatment type. Psychiatry Res. 2009; 165:
[24,25] and we spent many efforts in explaining to patients the 281-287.
relevance of filling the questionnaire at their best. A further severe 9. Moran PB, Vuchinich S, Hall NK. Associations between types
concern raises from the gap between the subjective experience of of maltreatment and substance use during adolescence. Child
having been damaged and the objective maltreatment received Abuse Negl. 2004; 28: 565-574.
which remains an unsolved problem. A second concern raises 10. Bernardi E, Jones M, Tennant C. Quality of Parenting in
from the retrospective nature of our study that limits the possibility Alcoholics and Narcotic Addicts. The British Journal of
of identifying causal inference. Future longitudinal studies are Psychiatry. 1989; 154: 677-682.
Int J Psychiatr Res, 2020 Volume 3 | Issue 3 | 5 of 7
11. Schweitzer RD, Lawton PA. Drug Abusers’ Perceptions of 26. Giannone F, Schimmenti A, Caretti V, et al. Validità, attendibilità
their Parents. British Journal of Addiction. 1989; 84: 309-314. e proprietàpsicometrichedellaversioneitalianadell’intervista
12. Axelrod SR, Perepletchikova F, Holtzman K, et al. Emotion CECA (Childhood Experience of Care and Abuse). 2011.
regulation and substance use frequency in women with 27. Smith N, Lam D, Bifulco A, et al. Childhood Experience
substance dependence and borderline personality disorder of Care and Abuse Questionnaire (CECA.Q). Validation of
receiving dialectical behavior therapy. Am J Drug Alcohol a screening instrument for childhood adversity in clinical
Abuse. 2011; 37: 37-42. populations. Soc Psychiatry Psychiatr Epidemiol. 2002; 37:
13. Kleinman PH, Miller AB, Millman RB, et al. Psychopathology 572-579.
among cocaine abusers entering treatment. J NervMent Dis. 28. Fisher HL, Craig TK, Fearon P, et al. Reliability and
1990; 178: 442-447. comparability of psychosis patients’ retrospective reports of
14. Brooner RK, Herbst JH, Schmidt CW, et al. Antisocial childhood abuse. Schizophr Bull. 2011; 37: 546-553.
personality disorder among drug abusers. Relations to other 29. Teicher MH, Samson JA. Childhood maltreatment and
personality diagnoses and the five-factor model of personality. psychopathology. A case for ecophenotypic variants as
J NervMent Dis. 1993; 181: 313-319. clinically and neurobiologically distinct subtypes. Am J
15. Morgenstern J, Langenbucher J, Labouvie E, et al. The Psychiatry. 2013; 170: 1114-1133.
comorbidity of alcoholism and personality disorders in a 30. Fitzhenry M, Harte E, Carr A, et al. Child maltreatment and
clinical population: prevalence rates and relation to alcohol adult psychopathology in an Irish context. Child Abuse Negl.
typology variables. J Abnorm Psychol. 1997; 106: 74-84. 2015; 45: 101-107.
16. Kokkevi A, Stefanis N, Anastasopoulou E, et al. Personality 31. Waxman R, Fenton MC, Skodol AE, et al. Childhood
disorders in drug abusers: prevalence and their association maltreatment and personality disorders in the USA: specificity
with AXIS I disorders as predictors of treatment retention. of effects and the impact of gender. Personal Ment Health.
Addict Behav. 1998; 23: 841-853. 2014; 8: 30-41.
17. Verheul R, Kranzler HR, Poling J, et al. Co-occurrence of Axis 32. De Bellis MD. Developmental traumatology. The
I and Axis II disorders in substance abusers. Acta Psychiatr psychobiological development of maltreated children and
Scand. 2000; 101: 110-118. its implications for research, treatment, and policy. Dev
18. Zikos E, Gill KJ, Charney DA. Personality disorders among Psychopathol. 2001; 13: 539-564.
alcoholic outpatients. Prevalence and course in treatment. Can 33. Hart H, Rubia K. Neuroimaging of child abuse. A critical
J Psychiatry. 2010; 55: 65-73. review. Front Hum Neurosci. 2012; 6: 52.
19. Craig RJ. Prevalence of Personality Disorders among Cocaine 34. McCrory E, Viding E. The neurobiology of maltreatment and
and Heroin Addicts. SubstAbus. 2000; 21: 87-94. adolescent violence. Lancet. 2010; 375: 1856-187.
20. Cohen P, Chen H, Crawford TN, et al. Personality disorders in 35. Teicher MH, Anderson CM, Polcari A. Childhood
early adolescence and the development of later substance use maltreatment is associated with reduced volume in the
disorders in the general population. Drug Alcohol Depend. hippocampal subfields CA3, dentate gyrus, and subiculum.
2007; 88: S71-84. Proc Natl Acad Sci USA. 2012; 109: E563-572.
21. Casadio P, Olivoni D, Ferrari B, et al. Personality Disorders in 36. Edelman GM. Bright air, brilliant fire: On the matter of the
Addiction Outpatients: Prevalence and Effects on Psychosocial mind. New York, NY, US: Basic Books; 1992.
Functioning. Subst Abuse. 2014; 8: 17-24. 37. Blair C, Raver CC, Berry DJ. Family Life Project Investigators.
22. American Psychiatric Association, American Psychiatric Two approaches to estimating the effect of parenting on the
Association, editors. Diagnostic and Statistical Manual development of executive function in early childhood. Dev
of Mental Disorders: DSM-IV-TR. 4th ed., text revision. Psychol. 2014; 50: 554-565.
Washington, DC: American Psychiatric Association. 2000; 38. Hanson JL, Adluru N, Chung MK, et al. Early neglect is
943. associated with alterations in white matter integrity and
23. First MB, Gibbon M, Hoboken NJ, et al. The Structured cognitive functioning. Child Dev. 2013; 84: 1566-1578.
Clinical Interview for DSM-IV Axis I Disorders (SCID- 39. Bernstein DP, Stein JA, Handelsman L. Predicting personality
and the Structured Clinical Interview for DSM-IV Axis pathology among adult patients with substance use disorders:
II Disorders (SCID-II). In: Comprehensive handbook of effects of childhood maltreatment. Addict Behav. 1998; 23:
psychological assessment. 2004; 2: 134–143. 855-868.
24. Weiler D, Coenen M, Küfner H. Use of the European Addiction 40. Sher KJ, Bartholow BD, Wood MD. Personality and substance
Severity Index (Europ ASI) with drug dependants in outpatient use disorders. A prospective study. J Consult Clin Psychol.
treatment [Anwendung des European Addiction Severity 2000; 68: 818-829.
Index (EuropASI) imRahmeneinerambulantenBehandlung 41. Kotov R, Gamez W, Schmidt F, et al. Linking “big” personality
von Drogenabhängigen]. Sucht. 2000; 46: 197-208. traits to anxiety, depressive, and substance use disorders: a
25. Bifulco A, Bernazzani O, Moran PM, et al. The childhood meta-analysis. Psychol Bull. 2010; 136: 768-821.
experience of care and abuse questionnaire (CECA.Q): 42. Lowman RL. Personality disorders and work. In: Counseling
Validation in a community series. British Journal of Clinical and psychotherapy of work dysfunctions. 1993; 177-211.
Psychology. 2005; 44: 563-581. 43. Becker DR, Drake RE, Farabaugh A, et al. Job preferences
Int J Psychiatr Res, 2020 Volume 3 | Issue 3 | 6 of 7
 of clients with severe psychiatric disorders participating in 1083-1093.
supported employment programs. Psychiatr Serv. 1996; 47: 45. Cowell RA, Cicchetti D, Rogosch FA, et al. Childhood
1223-1236. maltreatment and its effect on neurocognitive functioning:
44. Kiser LJ, Stover CS, Navalta CP, et al. Effects of the child- Timing and chronicity matter. Dev Psychopathol. 2015; 27:
perpetrator relationship on mental health outcomes of child 521-33.
abuse: it’s (not) all relative. Child Abuse Negl. 2014; 38:

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