The Relationship Between ACEs and Personality Disorders - A Case for Early Intervention | Norwescap Parenting SEAS (NJ)

When we think of Adverse Childhood Experiences, we often think of the fallout being chronic illness, post-traumatic stress disorder, and generalized symptoms of anxiety or depression. One additional, potential consequence of ACEs is the development of a personality disorder (PD), which are quite common as approximately 9% of adults in the United States, or about 30 million, experience them. Defined as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture” (American Psychiatric Association, 2013), some of the features of these psychiatric conditions include emotional dysregulation, distorted thinking, poor impulse control, and social and functional impairments. PDs tend to co-occur with other psychiatric diagnoses such as anxiety and depression, substance abuse, and PTSD, all of which have been linked to Adverse Childhood Experiences.

While the connection between ACEs and PDs is still being explored and has yet to be fully proven for the full spectrum of PDs, there is mounting evidence indicating that childhood adversity plays a role in their development. Links have been found between borderline, anti-social and schizotypal personality disorders and childhood trauma, most notably with borderline. In the case of schizotypal, a key genetic variable in combination with environmental factors is what is thought to be the cause. Dr. Jeffrey Magnavita, an internationally recognized expert in personality disorders and personality theory, offers anecdotal evidence of the ACEs-PD connection: “I have specialized in the treatment of personality disorders for over three decades. I have learned what I consider to be the most critical commonality among these patients: almost every patient I have evaluated and/or treated has suffered from early traumatic experiences in childhood or adolescence. And yet, most medical and mental health clinicians do not recognize or acknowledge the prevalence of trauma most of the time” (Magnavita, 2022). Numerous empirical studies corroborate similar findings. A 2021 Taiwanese study published in the Journal of Affective Disorders found that childhood maltreatment was a significant risk factor in PD development, concluding with a recommendation that “In order to reduce the risk of personality disorders, interventions should be implemented, identifying and supporting economically disadvantaged families and vulnerable children as early as possible” (Wang, 2021). Diagnoses for these psychiatric disorders have historically not come until adulthood, but recent research on borderline PD, which affects about 4 million people in the United States, may offer some insight into the efficacy of early diagnosis and intervention.

Borderline PD has been shown by research to be significantly associated with ACEs and is a serious, often debilitating condition that is typically diagnosed once it has fully developed. Nearly two-thirds of borderline patients reported experiencing at least one ACE, with a higher number of ACEs being correlated with more severe clinical outcomes. They were also fourteen times as likely to report childhood adversity compared to those with no clinical psychiatric history. Borderline is characterized by significant challenges including intense fear of abandonment, relationship instability, impulsivity, unstable self-image, and many more, often co-occurring with depression and/or substance abuse disorder. Borderline patients are also prone to higher-than-average risk of self-harm and suicide as 75% of patients will try ending their life at some point; 10% will successfully complete an attempt. Due to the nature of this condition, there has been growth in advocacy for early intervention.

Early diagnosis in teenage females has steadily increased in Denmark since 1970 and showed an increase from 2000-2012 in Canada. The clinical protocol for diagnosis requires that adolescents meet five of the nine criteria known to be associated with borderline and must display this symptomatology continuously for at least one year. Some of the precursor indicators of BPD include oppositional-defiant disorder, conduct disorder, ADHD, and substance use. Perhaps the most telling indicator is self-harm. A 2018 study states that “58% of suicidal adolescents reported non-suicidal self-injury (NSSI), whereas 51.7% of female adolescents engaging in NSSI met criteria for BPD. Suicidal and NSSI behaviors should always prompt the clinician to screen for BPD.” (Guile, 2018) With a clearer picture of how BPD manifests in developing youth, clinical protocols for adolescents are in the process of being explored.

To date, there is a limited amount of research and overall literature addressing effective treatments for adolescents experiencing BPD, however, there is some emerging evidence that certain intervention strategies are effective. Three psychotherapeutic interventions stand out as having the most promise: dialectical behavior therapy (DBT), cognitive analytic therapy (CAT), and mentalization-based therapy (MBT). DBT showed efficacy in targeting suicidal ideation, feelings of hopelessness, and depressive symptoms, and showed superior efficacy in easing self-harm behaviors as compared to treatment-as-usual. Similarly, MBT was effective in treating the same symptoms throughout a year-long therapeutic program designed for 12–17-year-olds as compared to a control arm receiving treatment-as-usual. Last, CAT is a time-limited therapy tool lasting anywhere from 4-24 weeks that focuses on identifying relationship patterns in how the patients relate to oneself and others, and the ensuing outcomes. This technique is utilized in all adolescent BPD treatment at the Helping Young People Early (HYPE) clinic in Melbourne Australia in combination with case management, general psychiatric care, active engagement of family members, and pharmacotherapy when necessary. Research suggests that family commitment to active participation in the treatment process, and the patient working towards improving the nature of relationships more generally, are an important aspect of increasing the likelihood of positive outcomes. Research also suggests that pharmacotherapy is not an effective intervention in most cases. Despite the evidence for treatment that has been cited, long-terms studies have not been conducted to provide a window into long-term outcomes for adolescents diagnosed and treated for BPD.

Given the extensive effort that has been put into studying BPD in many dimensions, from its connection to ACEs to the evidence-based therapeutic approaches in early intervention, there is hope that more can be learned about the relationship between PDs and childhood adversity. Those who have advocated for early intervention in borderline patients have done a great service to all youth who are in the throes of struggling with an emerging personality disorder. The early intervention research and strategic model for BPD can be used as a blueprint for addressing other emerging personality disorders that do not yet have a clinical protocol in the youth population. Andrea Rosenhaft, LCSW, wrote about her personal experience in which she expressed the following: “When I was in my twenties… I destroyed a promising career in marketing due to multiple long-term hospitalizations for severe anorexia. After I was discharged from the eating disorder unit for the second time, my company dismissed me, and I collapsed into a severe depression and attempted suicide. After even more suffering, and another attempt at my life, I was diagnosed with borderline personality disorder (BPD). By then, I was 29 years old. I’d like to think if I’d been diagnosed ten years earlier, I could have avoided decades of self-destruction and emotional pain.” (Rosenhaft, 2021) The earlier these psychiatric conditions are caught, the more likely our youth and young adults will live to their potential and lead a fulfilling, successful life.

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