of Personality Disorders Unanswered Questions Remain
I N THIS issue of the erable overlap also exists. What are this brings up a question about the ARCHIVES, Johnson et al1 the mechanisms whereby child role of gender and its potential ef- present the findings of a abuse and neglect lead to increased fect on the development of person- longitudinal study demon- risk for personality disorders? Which ality disorders. It is commonly as- strating that abused and ne- mechanisms lead to which specific sumed that men externalize and glected children are more likely than types of personality disorders? Does women internalize their responses nonvictims to develop personality the age of the child at the time of to pain and suffering. Yet, in most disorders in young adulthood. This maltreatment make a difference in samples, women are more likely to article has many strengths: a pro- the development of these personal- have been sexually abused than men, spective longitudinal design, a rep- ity disorders? which would introduce the con- resentative community sample, a Although childhood neglect has found of gender. Also, gender dif- definition of childhood abuse and not received much scholarly atten- ferences exist in the prevalence of neglect based on documented cases, tion, there is an increasing body of different forms of personality and a comprehensive assessment of per- literature on the topic.2-8 Johnson et psychiatric disorders in general com- sonality disorders, and statistical al are to be commended for their ex- munity samples. Thus, an unan- controls for age, gender, childhood amination of findings for the ne- swered question is whether for- temperament, and parental psycho- glected group separately from the merly abused and neglected men and pathology. The authors’ finding that other forms of childhood abuse. Here, women manifest different forms of childhood maltreatment is associ- the findings related to childhood ne- personality disorders and, if so, ated with increased risk for person- glect are the most robust and quite whether these differences conform ality disorders in young adulthood interesting. Neglected children were to gender role stereotypes. is particularly impressive, given the found to be at increased risk for clus- The model for much contem- relatively small number of docu- ter B disorders (antisocial, border- porary thinking about the conse- mented cases of child maltreat- line, and narcissistic personality dis- quences of child maltreatment is ment (31 of a total sample of 639) orders), as well as cluster A (paranoid based on an ecological model, which and even smaller numbers of cases and schizotypal personality disor- stresses the importance of consid- of specific types of abuse and ne- ders), cluster C (avoidant and de- ering the child in the framework of glect (for example, there were 4 pendent personality disorders), and the broader environment in which documented cases of sexual abuse). passive-aggressive personality disor- he or she develops.10 In that con- ders, after controlling for offspring text, it is argued that our under- See also page 600 age, parental education, and paren- standing of the long-term sequelae tal psychopathology. Traditionally, of childhood maltreatment needs to The study raises important the child abuse and neglect litera- take into account characteristics of questions that await answers. For ex- ture has paid relatively little atten- the child (such as difficult tempera- ample, documented child maltreat- tion to many of these forms of per- ment) prior to the abuse or neglect ment was associated with symp- sonality disorders, particularly those experiences. Based on previous re- toms in all 4 clusters of personality in cluster A. Why should neglect lead search, we know that children with disorders. Are abused and ne- to increased risk for paranoid symp- difficult temperaments have been glected youth at risk for all types of toms? One possibility relates to an- consistently found to be at in- personality disorders or just some other body of literature that links creased risk for behavior prob- types? Do differences in kinds of childhood neglect to increased risk lems,11 personality disorders,12 and child maltreatment lead to the de- of violent offending.9 Perhaps devi- Axis I psychiatric disorders during velopment of particular forms of per- ant lifestyles adopted by neglected adolescence.13 The results obtained sonality disorders? What types of children mediate the risk of later de- abuse and/or neglect will lead to velopment of paranoid symptoms? which types of personality disor- As expected, Johnson et al This article is also ders? The findings of Johnson et al found an increase in risk for bor- available on our Web site: suggest that there may be some derline personality disorder associ- www.ama-assn.org/psych. specificity in outcomes, but consid- ated with sexual abuse. However,
by Johnson et al suggest that there and self-reported cases of child- those who succumb. Ultimately, are demonstrable effects of child hood maltreatment. Only 8 cases answering some of these provoca- maltreatment on the development of were both identified from official rec- tive questions may permit us to personality disorders that are inde- ords and self-reports, out of the to- better intervene in the lives of pendent of temperament. This is a tal of 81 documented or self- abused and neglected children and very important finding. Further ex- reported cases. How do we interpret to prevent the development of psy- amination of these data to deter- this result? Given the almost exclu- chiatric disorders. mine the temporal sequence of the sive reliance in the literature on self- assessment of temperament and the reported cases of child maltreat- Cathy Spatz Widom, PhD occurrence of the child maltreat- ment, further research might School of Criminal Justice ment would be informative. investigate factors that influenced State University of New York While the research is impres- the definition of a case—such as at Albany sive in many ways, one of the weaker whether a case was documented or Albany, NY 12222 aspects of this article is its reliance on self-reported. Were there factors in retrospective assessments of earlier these individuals’ lives that differ- child maltreatment. There are 2 ba- entiated those whose cases were re- REFERENCES sic reasons why this is undesirable. ported from those whose cases were First, using information based on ret- not? 1. Johnson JG, Cohen P, Brown J, Smailes EM, Bern- rospective reports in young adult- This brings up a final issue. To stein DP. Childhood maltreatment increases risk hood essentially replicates the nu- what extent do these cases repre- for personality disorders during early adulthood. Arch Gen Psychiatry. 1999;56:600-606. merous cross-sectional studies that sent pure types of physical and sexual 2. Crittenden PM. An information-processing per- already exist in the literature. The abuse and neglect or to what extent spective on the behavior of neglectful parents. Cri- overriding strength of the article by is their overlap? The authors men- min Justice Behav. 1993;20:27-48. Johnson et al is its demonstration of tion the issue of multiple forms of 3. Drotar D. Prevention of neglect and nonorganic a relationship to subsequent person- abuse and neglect (apparently, 59 failure to thrive. In: Willis DJ, Holden EW, Rosen- burg M, eds. 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