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
mental health impairment that can persist into adulthood. There
are strong associations between adverse childhood experiences
such as abuse, neglect, exposure to intimate partner violence, and
parental divorce and suicidal behavior and adult Axis I mental
disorders such as mood, anxiety, impulse control, and substance
use disorders in representative population-based samples (Afifi
et al., 2006, 2008, 2009, 2010; Bruffaerts et al., 2010; Enns et al.,
2006; Kessler et al., 1997; MacMillan et al., 2001; Scott et al.,
2010). Studies involving nationally representative samples have
* Corresponding author. Department of Community Health Sciences, University
of Manitoba, S113 Medical Services Building, 750 Bannatyne Avenue, Winnipeg,
Manitoba R3E 0W3, Canada. Tel.: þ1 (204) 272 3138; fax: þ1 (204) 789 3905.
E-mail address: t_afifi@umanitoba.ca (T.O. Afifi).
shown a relationship between traumatic events occurring in
childhood and personality traits such as high neuroticism and
openness to experiences (Allen and Lauterbach, 2007). Although,
the relationship between childhood adversity and Axis I mental
health conditions is well established, research on the link between
childhood adversity and Axis II personality disorders (PDs) has
focused mainly on clinical samples (Battle et al., 2004; Johnson
et al., 2004; Rettew et al., 2003; Yen et al., 2002; Luntz and
Widom, 1994; Zanarini et al., 1989, 1997, 2000, 2002; Bierer et al.,
2003). PDs are generally persistent overtime, are often repre-
sented by patterns of behaviors and experiences that can negatively
impact areas of cognition, affect, interpersonal functioning, and
impulse control, and are frequently associated with impairment
(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
have indicated that the childhood experience of physical abuse,
sexual abuse, emotional abuse, physical neglect, and emotional
neglect are common among patients with PDs (Battle et al., 2004;
Johnson et al., 2004; Rettew et al., 2003; Yen et al., 2002; Luntz
and Widom, 1994; Zanarini et al., 1989, 1997, 2000, 2002; Bierer
et al., 2003). Studies involving convenience (Gibb et al., 2001;
Grover et al., 2007; Tyrka et al., 2009) and small community
samples (Johnson et al., 1999, 2000, 2006) have also supported this
association, but it remains unclear whether the relationship
between childhood adversities and all PDs exists in representative
general population samples.
Another important limitation is the narrow examination of child
adversity. To date, collectively, studies have looked at parenting
behaviors and multiple types of child abuse and neglect. However,
some studies have only examined child abuse (Yen et al., 2002;
Gibb et al., 2001), neglect (Johnson et al., 2000), or a have
combined child abuse and neglect together (Grover et al., 2007;
Johnson et al., 1999; Luntz and Widom, 1994; Tyrka et al., 2009;
Zanarini et al., 2000). Collapsing multiple types of child maltreat-
ment is often necessary due to lack of statistical power based on
small sample sizes. However, this approach precludes under-
standing the specific relationship between subtypes of maltreat-
ment and impairment, such as PDs. The limited research involving
community samples has all been based on a study of two New York
State counties. The investigators combined multiple types of child
maltreatment into child abuse and neglect categories (Johnson
et al., 1999, 2000), only examined neglect (Johnson et al., 2000),
and investigated parenting behaviors not including child abuse or
neglect (Johnson et al., 2006).
Another limitation of the current literature is the focus on only
one or limited types of PDs. For example, there are numerous
clinical studies showing a link between exposure to child sexual
abuse and borderline personality disorder (Murray, 1993). Although
this is an important association, less attention has been paid to
other types of childhood adversity and PDs. An examination of
a wider range of adverse childhood events with all PDs in a pop-
ulation-based sample would significantly extend the existing
literature. Finally, only a few studies investigating childhood
adversity and PDs have taken into account the effects of Axis I
mental disorders on this relationship (Tyrka et al., 2009; Grover
et al., 2007; Gibb et al., 2001). This is an important methodolog-
ical consideration since Axis I mental disorders are highly comorbid
with Axis II PDs (McGlashan et al., 2000; Lenzenweger, 2008).
To our knowledge, this study is the first to examine the rela-
tionship between a wide range of adverse childhood experiences
including child maltreatment and household dysfunction with all
types of Axis II PDs in a nationally representative population-
based sample. It builds upon the existing literature, which is
based on clinical and small community samples. Furthermore, we
adjust for Axis I disorders, an important consideration, given the
high prevalence of comorbidity between Axis I and Axis II
disorders.
1. Methods
1.1. Survey
Data were from the second wave of the National Epidemiologic
Survey on Alcohol and Related Conditions (NESARC) collected in
2004 to 2005 (n ¼ 34,653). The NESARC is a representative sample
of the adult (20 years of age or older), civilian, non-institutionalized
population of the United States; it included respondents living in
households and assorted non-institutional group dwellings such as
college quarters, group homes, and boarding houses. The response
rate for Wave 2 was 86.7%. Interviews for both waves of the NESARC
815
were conducted face-to-face by trained lay interviewers. Further
details of the NESARC have been published elsewhere (Ruan et al.,
2008b; Grant et al., 2005).
1.2. Measures
1.2.1. Childhood adversity
1.2.1.1. Child maltreatment: abuse and neglect. Respondents’ expe-
riences of a variety of adverse childhood events (events occurring
before the age of 18) were assessed using questions based on those
from the Adverse Childhood Experiences study (Dong et al., 2003;
Dube et al., 2003). These questions were in turn a subset of the
items from the Conflict Tactics Scale (Straus, 1979; Straus et al.,
1996) and the Childhood Trauma Questionnaire (Bernstein et al.,
1994). Respondents were asked to respond to all questions per-
taining to abuse, neglect (except emotional neglect), and having
a battered mother on a five-point scale (never, almost never,
sometimes, fairly often, or very often). Emotional neglect questions
employed an alternative five-point scale of never true, rarely true,
sometimes true, often true, or very often true. All questions per-
taining to general household dysfunction required yes/no
responding (except questions regarding having a battered mother,
as mentioned above).
From the list of questions, several types of childhood adversity
were coded. Physical abuse was defined as a response of “some-
times” or greater to either question when asked how often a parent
or other adult living in the respondent’s home (1) pushed, grabbed,
shoved, slapped, or hit the respondent; or (2) hit the respondent so
hard it left marks or bruises, or caused an injury. Emotional abuse
was identified as a response of “fairly often” or “very often” to any
question when asked how often a parent or other adult living in the
respondent’s home (1) swore at, insulted, or said hurtful things to
the respondent; (2) threatened to hit or throw something at the
respondent (but did not do it); or (3) acted in any other way that
made the respondent afraid he/she would be physically hurt or
injured. These definitions are consistent with child maltreatment
definitions employed in the Adverse Childhood Experiences study
(Dube et al., 2003; Dong et al., 2003).
Sexual abuse was examined using a series of four questions
(Wyatt, 1985). These questions were adapted for use in the
AUDADIS-IV and were rated on the same five-point scale that was
used for all other abuse and physical neglect questions. The ques-
tions examined the occurrence of sexual touching or fondling,
attempted intercourse, or actual intercourse by any adult or other
person when the respondent did not want the act to occur or was
too young to understand what was happening. Any response other
than “never” on any of the questions was taken to indicate sexual
abuse.
Physical neglect was defined as any response other than “never”
on a series of four relevant questions. These questions explored
respondents’ experiences of being left unsupervised when too
young to care for themselves or going without needed clothing,
school supplies, food, or medical treatment. Other studies using the
Adverse Childhood Experiences Study have defined physical
neglect differently than we have here (Dong et al., 2003; Dube et al.,
2003); however, we were unable to follow the conventions out-
lined by these previous researchers because of the exclusion of one
of the original physical neglect questions by the AUDADIS-IV (the
original series included five questions examining physical neglect).
To compensate for this discrepancy, an alternative definition of
physical neglect was developed. Examination of the distribution of
summed responses to all physical neglect questions in our dataset
indicated a clear break in the distribution between those
responding with “never” to all items versus those responding with
“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-
tioned definition of physical neglect was adopted.
Emotional neglect was defined by five questions regarding
whether the respondent felt a part of a close-knit family or whether
anyone in the respondent’s family of origin made the respondent
feel special, wanted the respondent to succeed, believed in the
respondent, or provided strength and support. Consistent with
previous research all five items were reverse-scored and summed;
scores of 15 or greater were identified as emotional neglect (Dube
et al., 2003; Dong et al., 2003).
1.2.1.2. Household dysfunction. To characterize the experience of
having a battered mother, respondents were asked whether the
respondent’s father, stepfather, foster/adoptive father, or mother’s
boyfriend had ever done any of the following to the respondent’s
mother, stepmother, foster/adoptive mother, or father’s girlfriend:
(1) pushed, grabbed, slapped, or threw something at her; (2)
kicked, bit, hit with a fist, or hit her with something hard; (3)
repeatedly hit her for at least a few minutes; or (4) threatened to
use or actually used a knife or gun on her. Any response of
“sometimes” or greater for questions 1 or 2, or any response except
“never” for questions 3 or 4, was defined as having a battered
mother.
Parental substance abuse was assessed with two questions
regarding whether a parent or other adult living in the home had
a problem with alcohol or drugs. A response of “yes” to either of
these questions was defined as parental substance abuse. To char-
acterize the remaining household dysfunction variables, respon-
dents were asked to answer with either “yes” or “no” whether
a parent or other adult in the home (1) went to jail or prison; (2)
was treated or hospitalized for a mental illness; (3) attempted
suicide; and/or (4) actually committed suicide. Responses of “yes”
for any of these questions defined the corresponding general
household dysfunction variable.
Two variables were derived from each of these abuse, neglect,
and general household dysfunction variables. An “any abuse or
neglect” variable was created that indicated the presence of at least
one type of abuse or neglect in the respondent’s childhood. A
similar “any adverse childhood events” variable was created that
identified respondents who experienced at least one type of
adverse childhood events (abuse, neglect, and general household
dysfunction).
1.2.2. Personality Disorder Diagnoses
Diagnoses of PDs were made using the Alcohol Use Disorder and
Associated Disabilities Interview Schedule-Diagnostic and Statis-
tical Manual of Mental Disorders-Fourth Edition (AUDADIS-IV)
(Grant et al., 2001; Ruan et al., 2008a). The AUDADIS-IV provides
a fully structured interview protocol to assess various Axis I (mood,
anxiety, substance use disorders) and Axis II (PDs) diagnoses.
The reliability of the AUDADIS-IV for PDs has been assessed using
test-retest methods and were determined to be good
(Kappa ¼ 0.67e0.71; ICC ¼ 0.71e0.75; Alpha ¼ 0.75e0.83) (Grant
et al., 2003; Ruan et al., 2008b) and equivalent or better than to
reliabilities from patient samples using semi-structured person-
ality interviews in short-term test-retest studies (Zimmerman,
1994). The authors from the reliability studies aptly concluded
that the AUDADIS-IV diagnostic measures were reliable and useful
research tools (Ruan et al., 2008b). The validity of the AUDADIS-IV
for PDs using mental component summary, social functioning, and
role emotional scores has also been assessed with linear regression
analyses and were found to be highly significant (P < 0.01 to
P < 0.001) (Grant et al., 2004).
All 10 PDs were assessed in either Waves 1 or 2 of the NESARC. In
the first wave, all but schizotypal, borderline, and narcissistic PDs
were assessed; in Wave 2, these three PDs were measured. Anti-
social PD was assessed in both waves, and the diagnostic variable
from Wave 2 is used in our analysis. Although PDs are subject to
change over time, this disparity between the times of assessment of
some of the PDs is not thought to be problematic since PDs are
often persistent in nature for many individuals (American
Psychiatric Association, 2000).
In addition to analyses conducted on individual PD diagnoses,
we also examined PD cluster variables, which included the pres-
ence of one or more PDs within each of cluster A (paranoid,
schizoid, schizotypal), cluster B (antisocial, histrionic, borderline,
narcissistic), and cluster C (avoidant, dependent, obsessive-
compulsive). These derived variables were based on the DSM-IV
classification of PDs into clusters determined by similarities in
symptomatology (American Psychiatric Association, 2000).
1.2.3. Covariates
Sociodemographic covariates included age (continuous),
gender, household income (continuous), years of education
(continuous), marital status (three categories: married/living
common law, separated/divorced/widowed, and never married),
and race/ethnicity (five categories: non-Hispanic White, non-
Hispanic Black, non-Hispanic American Indian/Alaska Native, non-
Hispanic Hawaiian/Pacific Islander, and Hispanic of any race). Three
Axis I mental disorder variables were included in the models: (1)
any lifetime mood disorder (depression, dysthymia, mania, or
hypomania), (2) any lifetime anxiety disorder (panic disorder,
agoraphobia, social phobia, specific phobia, generalized anxiety
disorder, or post-traumatic stress disorder), and (3) any lifetime
substance use disorder (abuse/dependence on alcohol, sedatives,
tranquilizers, opioids, amphetamines, cannabis, cocaine, halluci-
nogens, inhalants/solvents, heroin, or other drugs). These mental
health conditions were diagnosed using the AUDADIS-IV, as
described above.
To account for the effect of inter-cluster PD comorbidity, each
analysis was adjusted for the two cluster variables that represented
the PD clusters other than the cluster currently being examined. For
example, in analyses of avoidant personality disorder, adjustments
were made for any cluster A and any cluster B PDs. Intra-cluster PD
comorbidity was not adjusted for because PDs tend not to present
as distinct entities, and instead exhibit a high degree of overlap
within clusters (Cox et al., 2007). Adjusting for within-cluster PDs
may remove variability that is simply due to the common features
of all PDs within a cluster, thereby perhaps negating effects that
truly exist.
1.3. Statistical methods
All analyses were conducted using the weight and stratification
variables supplied with the Wave 2 NESARC data file. To account for
the complex sampling design of the NESARC, Taylor series lineari-
zation was used as the variance estimation technique using
SUDAAN software (Shah et al., 2004). In addition, due to the
number of comparisons and the large sample size, a conservative
99% confidence interval was used to determine the statistical
significance of the odds ratios.
Crosstabs were calculated to determine the prevalence of
childhood adversity among individuals who met criteria for PDs.
For these analyses, the any general household dysfunction variable
was utilized, instead of individually examining each general
household dysfunction variable. The any general household
dysfunction variable was used in these analyses to increase read-
ability of the table; in all further analyses, the individual general
household dysfunction variables were utilized. Logistic regression
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
further evidence of the link between adverse experiences in
childhood and mental health disorders in adulthood. First, the
results indicate that many types of childhood adversity were highly
prevalent among individuals with PDs in the general U.S. pop-
ulation. Second, childhood adversity was most strongly and
consistently associated with clusters A and B PDs and specifically
schizotypal, antisocial, borderline, and narcissistic PDs. Many of
these findings remained significant even after simultaneously
accounting for the variance of all types of child abuse and neglect,
household dysfunction, mental disorders, and sociodemographic
covariates. Third, childhood adversity in the form of household
dysfunction including exposure to battering of a mother, parental
substance use problems, parental incarceration, parental mental
illness, and parental suicide attempts was associated with
increased likelihood of PDs.
Although all types of childhood adversities were highly preva-
lent among individuals with PDs in the current sample, this
prevalence was lower than estimates based on clinical samples
(Battle et al., 2004; Bierer et al., 2003). For example, 29% of
respondent with borderline PD reported experiencing emotional
abuse in the current sample compared to 66% from a longitudinal
clinical sample (Battle et al., 2004). Our findings suggest that
childhood adversity may not be as prevalent in community samples
of people with PDs compared to clinical samples, but adverse
childhood events remain common among individuals with PD in
the general population.
Significant associations were found between childhood adver-
sity and PDs from all three clusters. Significant relationships
between child abuse and neglect and various PDs from clusters A, B,
and C are consistent with previous research (Battle et al., 2004;
Gibb et al., 2001; Grover et al., 2007; Johnson et al., 1999, 2000).
However, our current findings indicate that childhood adversity
more broadly defined as child abuse, neglect and household
dysfunction was more robustly related to schizotypal PD and most
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
an association between childhood adversity and schizotypal
symptoms (Steel et al., 2009; Berenbaum et al., 2003, 2008). This
connection may be partly explained through the shared variance
between childhood adversity, schizotypal symptoms, and disso-
ciative tendencies (Irwin, 2001). Almost all forms of abuse, neglect,
and household dysfunction were associated with increased odds of
having schizotypal PD, antisocial PD, borderline PD, and narcissistic
PD. This observation is in keeping with the clinical impression of
a particularly strong association between cluster B PDs and child-
hood adversities. Cluster B PDs are characterized by dramatic,
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
emotions and emotion-related experiences beginning in early
childhood (Cohen, 2008). Adverse childhood experiences may, in
part, shape personality and have the potential to negatively influ-
ence the development of personality traits, PD symptoms, and PDs.
Another interesting finding from this research was that many
adverse childhood events were not strongly related to cluster C
disorders. It may be that the nature of the psychopathology asso-
ciated with cluster C PDs (i.e. the anxious, fearful cluster) is more
closely overlapping with the “distress” Axis I disorders (i.e. mood,
anxiety). If etiological factors (or “symptoms” used in making the
diagnoses) are more closely overlapping, then controlling for such
Axis I disorders may more completely account for any association
that might have been seen between cluster C and childhood
adversities.
In the fully adjusted models presented in Table 6, Axis I disor-
ders including mood disorders, anxiety disorders, and substance
use disorders remained significantly associated with cluster A,
cluster B, and cluster C PDs with the exception of substance use
disorders with cluster A PDs. It is noted that mood disorders,
anxiety disorders, and substance use disorders were among the
largest odds ratios associated with cluster A, B, and C PDs meaning
that a history of Axis I mental disorders remains a strong predictor
of PDs. This is in keeping with the high prevalence of comorbid Axis
I and Axis II mental disorders found in this study. These highly
comorbid relationships between Axis I mental disorders and Axis II
PDs have treatment implications; poorer clinical outcomes may
result for some individuals presenting with this comorbidity (Reich,
2007). Although child abuse and neglect significantly increases the
likelihood of cluster A and cluster B PDs, Axis I disorders are also
important correlates.
Of particular note, most individuals who experience childhood
adversity do not develop PDs; it is important in developing
approaches to reduce impairment to understand the mediators and
moderators of this association. As outlined by Bornovalova et al.
(2009), there is a lack of information about the longitudinal
trajectories of PDs; to understand the development of PDs, it is
essential to measure the onset and course of PDs with repeated
assessments from youth and adulthood (indeed we would argue,
beginning in childhood with measurement of environmental
adversity). The investigation by Kim et al. (2009) is one of the few
longitudinal studies to examine the influence of maltreatment on
personality processes and subsequent adjustment in a sample of
children. Ideally, such a sample would be followed through to
young adulthood.
In addition to the need for longitudinal follow-up, future
research should model the genetic and environmental effects on
personality traits, and include gene-environment interactions
(Bornovalova et al., 2009). This might help explain why some
individuals who experience adversity during childhood do not
develop PDs (Paris, 1997, 1998). Perhaps some individuals, based on
their genetic make-up, or other factors that buffer the environ-
mental adversity, such as experiences of nurturing parenting are
protected from the negative impact of child maltreatment. Many
domains of personality are highly heritable (Jang et al., 1996). It may
be that a PD is a result of a specific genotypes interacting with the
adverse environmental factors that leads to expression of
dysfunctional personality traits, PD symptoms, or PDs. Similarly,
not all individuals with PDs have a history of childhood adversity.
Clearly, there are multiple pathways that lead to the development
of PDs. Investigation of pathway models using behavioral-genetics
and molecular study designs including measures of resiliency are
necessary in determining the factors that influence the develop-
ment of PDs, conditions which are associated with major morbidity
and some mortality.
Estimated societal costs associated with child abuse (World
Health Organization, 2006) and PDs (van Asselt et al., 2007) are
substantial. Although some progress has been made in preventing
child maltreatment (MacMillan et al., 2009), it is also important to
determine ways of reducing impairment, as well as recurrence
among those who have suffered maltreatment in childhood. For
example, among sexually abused children who experience PTSD
symptoms, there is evidence that trauma-focused cognitive-
behavior therapy (TF-CBT) can reduce PTSD as well as anxiety and
depression (Macdonald et al., 2006). However, given that most
follow-ups after TF-CBT do not extend beyond 12 months (Stallard,
2006), the long-term effects of such treatment are unknown. Do
interventions shown to be effective in reducing mental health
problems following maltreatment in childhood lead to better
outcomes in adulthood such as reduced risk of PDs? This is a critical
area of research that requires long-term follow-up of patients.
Although it is not ethical to withhold an effective treatment from
one group, it is possible to compare treatments (for example, usual
care and enhanced treatment) and follow patients long-term. We
are not aware of any trials following children to adulthood after
treatment for conditions related to child maltreatment; however,
Olds and colleagues are following participants in each of three
prevention trials of home visitation to determine the long-term
outcome of this intervention (Olds et al., 2007). Prevention strat-
egies that are effective in reducing adverse childhood events may
also help to reduce PDs in the general population, but this is
currently unknown. Furthermore, programs that address one type
of maltreatment or related symptoms, such as PTSD, cannot be
assumed to generalize to other types of maltreatment or impair-
ment. Cohen and colleagues are currently evaluating whether TF-
CBT is effective in reducing symptoms among children exposed to
domestic violence. Such programs have the potential to prevent
a wide range of mental health problems in adulthood, but this is yet
to be determined. Preventing child maltreatment is not a simple
task. Evidence from prevention and intervention research should
be replicated in other samples.
It is also important for clinicians and researchers to be aware of
the types of household dysfunction that are related of PDs. Clini-
cians need to consider the broader range of household dysfunction
when inquiring about child abuse and neglect. Also, researchers
could include these and other household dysfunction variables to
broaden the examination of childhood adversity in future research
on PDs.
Limitations of the current study should be considered. First, the
cross-sectional design precludes determining any causal inferences
in the relationship between childhood adversity and PDs. Second,
data on childhood adversity were collected retrospectively, which
may introduce some sampling error due to recall and reporting
bias. For example, it is possible that individuals with PDs might be
more likely to subjectively recall an experience as abusive or
traumatic. However, there is evidence that supports the validity of
accurate recall of adverse childhood events (Hardt and Rutter,
2004). Additionally, although several items were used to measure
child abuse and neglect, the assessment of other family violence
was limited to violence against a mother or female caregiver.
Although our study included a wide range of adverse childhood
events this is not an exhaustive list; other types of adverse child-
hood should be included in future research. Third, although all
mental disorder diagnoses were made by a reliable structured
interview conducted by trained lay interviews, this assessment
approach may not match the accuracy of an experienced clinician.
Structured clinical interviews for DSM based diagnoses would be
ideal, but is not possible in nationally representative epidemiologic
surveys due to expense. However, the assessment of Axis I and Axis
II PDs included in the NESARC using the AUDADIS-IV provides
 T.O. Afifi et al. / Journal of Psychiatric Research 45 (2011) 814e822
a unique opportunity to study PDs in the general population.
Finally, the existence of numerous Axis I disorders were included as
covariates. However, not all Axis I disorders were assessed in the
data (e.g. psychotic disorders or obsessive-compulsive disorder),
which is an important limitation.
In conclusion, the present findings suggest that childhood
abuse, neglect and household dysfunction are related to PDs in the
general U.S. population. Due to the trauma of childhood adversity
and impairment related to PDs, the present study offers important
policy implications. Reducing childhood adversity may help to
reduce PDs in the general population. These disorders are associ-
ated with a huge burden of suffering and determining approaches
to reduce them should be a priority.
Acknowledgements
The authors had full access to all of the data in the study and
take responsibility for the integrity of the data and the accuracy of
the data analysis. The authors would like to thank Christine Hen-
riksen for editing the manuscript.
Funding
Preparation of this article was supported by a Canadian Insti-
tutes of Health Research (CIHR) Postdoctoral Fellowship award to
the first author.
Contributors
Afifi conducted literature searches, designed the analysis, wrote
sections of the manuscript.
Mather designed the analysis, conducted the statistical analysis,
wrote sections of the manuscript, edited and revised the
manuscript.
Boman designed the analysis, wrote sections of the manuscript,
edited and revised the manuscript.
Fleisher designed the analysis, wrote sections of the manuscript,
edited and revised the manuscript.
Enns designed the analysis, wrote sections of the manuscript,
edited and revised the manuscript.
MacMillan designed the analysis, wrote sections of the manu-
script, edited and revised the manuscript.
Sareen designed the analysis, wrote sections of the manuscript,
edited and revised the manuscript.
All authors contributed to and have approved the final
manuscript.
Conflict of interest
No conflicts of interest to declare.
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