 |
|
Childhood Depression and Adult Personality Disorder
Alternative Pathways of Continuity
Stephanie Kasen, PhD;
Patricia Cohen, PhD;
Andrew E. Skodol, MD;
Jeffrey G. Johnson, PhD;
Elizabeth Smailes, MPhil;
Judith S. Brook, EdD
Arch Gen Psychiatry. 2001;58:231-236.
ABSTRACT
| |
Background This study extends previous findings of the risks posed by childhood
major depressive disorder and other psychopathological features for later
personality disorder (PD) in a random sample of 551 youths.
Methods Self-reports and mother reports were used to evaluate DSM-III-R (Axes I and II) psychiatric disorders at mean ages of 12.7,
15.2, and 21.1 years. Logistic regression was used to examine the independent
effects of major depressive disorder in childhood or adolescence on 10 PDs
in young adulthood.
Results Odds of dependent, antisocial, passive-aggressive, and histrionic PDs
increased by more than 13, 10, 7, and 3 times, respectively, given prior major
depressive disorder. Those effects were independent of age, sex, disadvantaged
socioeconomic status, a history of child maltreatment, nonintact family status,
parental conflict, preexisting PD in adolescence, and other childhood or adolescent
Axis I psychopathological features, including disruptive and anxiety disorders.
In addition, odds of schizoid and narcissistic PD increased by almost 6 times
and odds of antisocial PD increased by almost 5 times given a prior disruptive
disorder, and odds of paranoid PD increased by 4 times given a prior anxiety
disorder.
Conclusion Personality disorders may represent alternative pathways of continuity
for major depressive disorder and other Axis I disorders across the child-adult
transition.
INTRODUCTION
STUDIES1, 2, 3, 4, 5, 6, 7
of the long-term sequelae of childhood major depressive disorder (MDD) typically
report increased risk of comorbid and postremission psychosocial disturbance
that may continue into adulthood. Severe and persistent impairment in psychosocial
functioning may place depressed youths at risk for more pervasive and enduring
psychopathological features, as reflected by the Axis II personality disorders
(PDs). However, little attention has been paid to assessing PDs as potential
sequelae of preadult-onset MDD.
Psychosocial deficits8 and high rates
of comorbid PDs9 have been reported among depressed
samples of adults. In addition, several depressive conditions have been linked
to dysfunctional personality traits (dependency, neuroticism, and introversion)
and to cognitive and social styles closely related to those traits.8, 10, 11 Furthermore, prospective
longitudinal studies12, 13, 14, 15
have shown that adolescent depression is associated with persistent maladaptive
functioning in young adulthood, indicative of personality pathologic features.
However, those findings have used personality syndrome scales13, 14
or overall symptom counts of personality pathologic features12
or were based on a small clinical sample.15
It is important to augment that research by examining the association between
childhood MDD and later personality pathologic features at the diagnostic
level in a large representative sample.
Findings from a recent study by our group16
indicated predictive effects of childhood psychopathological features on young
adult PDs. Major depressive disorder increased the odds of a PD in clusters
A, B, and C in young adulthood by 3 (P<.10), 6
(P<.01), and 8 (P<.001)
times, respectively. That approach, grouping specific PDs into the traditional
clusters to maximize statistical power, was prudent in an initial investigation.
However, it may have obscured more specific developmental pathways from childhood
MDD to subsequent Axis II pathologic features in adulthood. Thus, because
it is of significant interest to ascertain which PDs are associated with prior
MDD, specific PD diagnoses are examined in the present study.
Previously, we examined outcomes in youths classified by combinations
of Axes I and II disorders. However, particularly with a general population
sample, insufficient numbers precluded looking at every possible combination
of disorders; thus, youths with comorbid disruptive or anxiety disorders were
not omitted from the depressed group. In the present study, additive effects
of disruptive and anxiety disorders are examined simultaneously to investigate
the independent effects of MDD on later PD. Associations also are adjusted
for preexisting PD in adolescence and for other childhood risks that may be
potential confounders,12, 16, 17
including disadvantaged socioeconomic status, childhood maltreatment, nonintact
family structure, and parental conflict.
We focus herein on the independent effects of MDD in childhood or adolescence
on individual PDs in young adulthood, including antisocial, avoidant, borderline,
dependent, histrionic, narcissistic, obsessive-compulsive, paranoid, passive-aggressive,
and schizoid PDs, measured prospectively in a random sample of 551 youths.
Hypotheses are based on theories of depression that implicate dysfunctional
cognitions, problematic interpersonal relationships, and social deficits18, 19, 20 and on empirical evidence
of comorbid and residual psychosocial impairment among depressed youths.21, 22, 23, 24, 25
Because of reports of negative attributional style, low self-esteem, self-consciousness,
and high dependency and approval needs, we expected an increased risk of avoidant,
dependent, and histrionic PDs. Given the ineffectual coping, irritability,
and interpersonal difficulties also reported, we expected an increased risk
of passive-aggressive PD. Finally, because adolescent depression has been
associated with later antisocial and other externalizing problem behaviors,5, 6, 13 we expected an increased
risk of antisocial PD.
Although examined primarily to adjust for independent effects of MDD,
predictive effects of other childhood Axis I disorders on specific PDs in
young adulthood also are of interest; thus, these results are reported. Because
disruptive disorders imply a failure to meet social demands, low frustration
tolerance, and indifference to the basic rights of others, we expected an
increased risk of antisocial, narcissistic, and schizoid PDs among youths
with a disruptive disorder. Unwarranted fears and concerns is a central feature
of anxiety disorder; based on that and reported associations between anxiety
disorder and personality pathologic features,26
we also predicted an increased risk of avoidant, dependent, obsessive-compulsive,
and paranoid PDs among youths with an anxiety disorder.
PARTICIPANTS AND METHODS
PARTICIPANTS
Subjects were drawn from a longitudinal investigation of childhood risk
and psychopathological features, initiated in 1975 in a random cohort of 976
families with at least one child aged between 1 and 10 years living in 2 upstate
New York counties. Each mother was interviewed about one child randomly selected
from each family. At that time, Axes I and II disorders were not assessed;
however, the protocol included mother and youth diagnostic interviews in 3
follow-up studies, in 1983, 1985, and 1992. In 1983, 722 (74%) of the families
were reinterviewed, 156 (16%) were lost to follow-up, and 49 (5%) refused
to participate; the remaining 49 (5%) were not interviewed because of study
time constraints (n = 44), death of the study child (n = 3), or severe mental
retardation in the study child (n = 2). Fifty-four new families, randomly
sampled from poverty areas in the same 2 counties to replace the low-income
families disproportionately lost to follow-up, were added to the 1983 sample
for a total of 776 families. According to 1980 census data, those families
are representative of families in sampled areas for income, structure, and
residential urbanicity.27 In 1985, 734 families
(94.6%) from the 1983 follow-up and 42 families from the 1975 sample not interviewed
in 1983 participated, for a total of 776 families. In all, 818 families participated
at first or second follow-up or both; of those, 714 were interviewed and had
complete diagnostic information available in 1992. Compared with youths from
those families, the 104 youths not interviewed in 1992 (or with incomplete
diagnostic information) did not differ on any variable examined except for
sex and socioeconomic status: the proportion of males was greater (64.4% vs
49.0%;  21 = 8.62; P =
.003) and the socioeconomic status was lower (t1,816 = -2.31; P = .02).
The present sample is limited to the 551 youths who were aged 16 years
or younger in 1983. Subjects were 52% female and predominantly white (91%)
and Catholic (59%). Their mean age was 12.7 years (SD, 2.1 years) in 1983,
15.2 years (SD, 2.1 years) in 1985, and 21.1 years (SD, 2.2 years) in 1992.
PROCEDURE
After an explanation of study procedures, written consent was obtained
from participants. Mother and youth interviews were conducted simultaneously
but separately in family homes by pairs of trained lay interviewers. Mothers
were interviewed about family background and psychiatric status of the youths.
Youths were interviewed on parallel diagnostic instruments, and responded
to interviews and self-report inventories about school, work, and social relationships.
ASSESSMENT OF AXIS I DISORDERS
In 1983 and 1985, DSM-III-R (Axis I) diagnoses,28 including MDD, attention-deficit/hyperactivity disorder,
conduct disorder, oppositional defiant disorder, overanxious disorder, and
social phobia, were derived from mother and youth responses to the Diagnostic
Interview Schedule for Children.29 Responses
to the Diagnostic Interview Schedule for Children were augmented with other
information from the interview to adequately assess DSM-III-R symptoms. A positive response from either informant was taken as evidence
of symptom presence. The decision to combine information was based on empirical
evidence that parent and child each add unique and valid information to diagnoses.30, 31 To offset known problems of specificity
in diagnostic interviews, only youths who met diagnostic criteria and had
scaled symptom and impairment scores of 2 or more SDs above the sample mean
were considered to have an Axis I disorder. Youths diagnosed as having an
Axis I disorder were identified at the first or the second follow-up. Axis
I predictors were MDD, disruptive disorder (attention-deficit/hyperactivity
disorder, conduct disorder, or oppositional defiant disorder), and anxiety
disorder (overanxious disorder or social phobia). Associations with earlier
risk factors assessed prospectively,32 and with
treatment use,33 support the reliability and
criterion and construct validity of those diagnoses.
ASSESSMENT OF PDs
At all 3 follow-up visits, Axis II PD diagnoses meeting DSM-III-R criteria28 were derived from
mother and youth responses to interview items written for that purpose,34 or adapted for adolescents from the Personality Diagnostic
Questionnaire35 or the Structured Clinical Interview
for DSM-III-R Personality Disorders.36
Specific PDs in clusters A (paranoid and schizoid), B (antisocial, borderline,
histrionic, and narcissistic), and C (avoidant, dependent, obsessive-compulsive,
and passive-aggressive) are examined. Schizotypal PD was not examined herein
due to low prevalences. Antisocial PD was not measured in 1983 or 1985 because
diagnostic age criterion was not met by most of the sample. Passive-aggressive
PD has been classified as a "personality disorder not otherwise specified"
in the DSM-IV taxonomy.37
Relative to Axis I disorders, Axis II disorders are purported to be more inflexible
and chronic; thus, only youths who met the diagnostic criteria for a specific
PD in 1983 and again in 1985 (average interval, 2 years) were identified
as having a PD. The validity of Axis II diagnoses obtained in latency-aged
children and adolescents has been supported by associations with concurrent
social impairment and assaultive and suicidal behaviors.38, 39, 40, 41
As assessed herein, the validity of childhood and adolescent PD has been supported
by associations with adolescent role dysfunction34
and subsequent mental disorders and suicidal behaviors in young adulthood42; the validity of young adult PD has been supported
by associations with childhood maltreatment17
and childhood Axes I and II disorders.16
MEASUREMENT OF OTHER CHILDHOOD RISKS
Analyses were controlled for childhood risks reported to be associated
with later PD, namely, maltreatment, nonintact family structure, parental
conflict, and disadvantaged social status.12, 17
A measure of childhood maltreatment by the age of 18 years (reported indicates
1; and not reported, 0) was derived from official reports of abuse (physical
and sexual) or neglect from the New York State Central Registry of Child Abuse
and Neglect or from retrospective self-reports at the third follow-up. This
measure and consent procedures are discussed in detail elsewhere.43 A measure of family structure (not intact indicates
1; and intact, 0) was derived from 1975, 1983, and 1985 mother reports of
divorce or never marrying (96% and 4%, respectively, of the 164 single parent
mothers in the sample). Mothers responded to a 3-item scale measuring parental
conflict ( = .55) on 5-point Likert-type scales (eg, How often do the
two of you argue? 1 indicates never; 2, less than once or twice a week; 3,
once or twice a week; 4, several times a week; and 5, almost every day)44; an average of the 1983 and 1985 scores was used.
Socioeconomic status was measured in 1983 by an additive scale comprised of
parents' educational levels, fathers' occupational status, and family income.45
STATISTICAL ANALYSES
All analyses controlled for effects of age at outcome, sex, socioeconomic
status, childhood maltreatment, family structure, parental conflict, and corresponding
adolescent PD on young adult PD. Logistic regression was used to examine the
simultaneous effects of MDD, disruptive disorder, and anxiety disorder; interactions
between Axis I disorders and age and sex were examined next. Major depressive
disorder may be a marker for comorbid psychopathological features that may
not meet diagnostic criteria1, 2;
thus, effects of MDD also were adjusted for disruptive, anxiety, and PD symptom
scores, constructed by averaging scores across the 1983 and 1985 assessments.
In the interest of brevity, and because they have been examined elsewhere,16 the effects of adolescent PD on later PD are not included
in the table that notes those effects.
RESULTS
MDD AND OTHER CHILDHOOD DISORDERS: PREVALENCES AND CORRELATIONS
Major depressive disorder, disruptive disorder, and anxiety disorder
were identified in 5.8%, 11.8%, and 11.3% of the sample, respectively, in
the 1983 or 1985 assessment (Table 1).
Significant sex differences included higher rates in females with MDD (8.4%
vs 3.0%; 21 = 6.21; P
= .01) and anxiety disorders (19.2% vs 10.6%; 21
= 7.22; P = .007). Rates of PDs that met diagnostic
criteria in the 1983 and 1985 assessments ranged from 5.6% for obsessive-compulsive
PD to 0.7% for dependent PD (Table 1);
there were no significant sex differences. Major depressive disorder correlated
significantly with 10 of the 11 symptom scales and 8 of the 11 disorders examined
(Table 1). (Prevalences of young
adult PDs ranged from 8.9% for obsessive-compulsive PD to 2.0% for dependent
PD, and are noted in Table 2).
|
|
|
|
Table 1. Prevalences of Disorders and Correlations Between MDD and
Other Disorders in a Community Sample of 551 Youths*
|
|
|
|
|
|
|
Table 2. Simultaneous Consideration of Childhood Axis I Diagnostic
Predictors of Young Adult PDs in a Community Sample of 551 Youths*
|
|
|
CHILDHOOD MDD AND OTHER AXIS I DISORDERS AS A RISK FOR LATER PD
Among youths with MDD, odds of dependent, antisocial, passive-aggressive,
and histrionic PDs in young adulthood increased by about 14, 10, 10, and 4
times, respectively (Table 2);
increased odds remained significant, although they were reduced to about 11,
5, 5, and 3 times, respectively, after simultaneous consideration of concurrent
disruptive, anxiety, and adolescent PD symptoms instead of disorders (Table 3).
|
|
|
|
Table 3. Simultaneous Consideration of the Effects of MDD and Concurrent
Disruptive, Anxiety, and PD Symptoms on Young Adult PD in a Community Sample
of 551 Youths*
|
|
|
Odds of schizoid, narcissistic, and antisocial PDs in young adulthood
increased by about 5 to 6 times among youths with a disruptive disorder (Table 2); in addition, with each SD increase
in disruptive symptoms, the odds of antisocial, avoidant, schizoid, passive-aggressive,
and narcissistic PDs increased by 185%, 111%, 78%, 66%, and 58%, respectively
(Table 3). The odds of paranoid
PD increased by 4 times among youths with an anxiety disorder (Table 2), and the odds of paranoid and obsessive-compulsive PDs
increased by 45% and 42%, respectively, with each SD increase in anxiety symptoms.
There was no differential influence of Axis I disorders by age or sex.
COMMENT
Severe childhood or adolescent MDD heightened the risk of antisocial,
histrionic, dependent, and passive-aggressive PDs in young adulthood, independent
of concurrent disorders or symptoms and other childhood risks. Those outcomes
support results from the Collaborative Longitudinal Personality Disorders
Study,46 which suggest that a history of MDD
with insidious onset in adolescence and recurrence, chronicity, and progressive
severity is particularly likely to be associated with adult PD. Results herein
also are in accord with findings from other long-term prospective investigations2, 4, 5, 6, 7, 13, 14, 15
of adult consequences of childhood depression indicative of personality disturbances,
and with reports9, 26, 47
of comorbid PDs, including antisocial, borderline, histrionic, avoidant, and
dependent PDs, in depressed samples of adults.
Patients with depression who are in remission exhibit high levels of
interpersonal dependency and submissiveness and approval- and attention-seeking
behaviors,8 central features that characterize
dependent and histrionic PDs, respectively. Excessive emotional reliance on
others may be a consequence of the helplessness, low self-esteem, and need
for approval experienced during and following depressive episodes.24 On the other hand, compared with control subjects,
patients with depression who are in remission also are reported to engage
less in social situations and to have fewer close relationships.8, 48
Opposing tendencies may provoke conflict in interpersonal relationships and
foster the pattern of argumentativeness, irritability, and avoidance of social
responsibilities and of demands that characterize passive-aggressive PD. Perhaps,
if conflicts and resistance intensify, that pattern may become more overt
or aggressive in nature, as in antisocial PD. It also is possible that dysfunctional
attitudes and ineffectual coping, noted to be residuals of major depressive
episodes,8 may evolve into a pattern of irresponsible
behaviors that also is characteristic of antisocial PD.
The hypothesized link with avoidant PD did not occur. The central features
of avoidant PD are discomfort in and avoidance of social situations, which
are compatible with problematic interpersonal relationships and social deficits,
concomitants and consequences of MDD. However, avoidance of others is incompatible
with other characteristics of childhood MDD, namely, extreme dependency needs
and approval- and attention-seeking behaviors. Perhaps, as suggested herein,
dealing with social situations in a passive-aggressive or antisocial manner
is preferable to avoiding them completely.
Youths who had a disruptive disorder were at an increased risk of antisocial,
narcissistic, and schizoid PDs in young adulthood. Those results are supported
by others' reports13, 14, 15, 49, 50, 51
of antisocial PD, interpersonal difficulties, and impaired role performance
in adulthood among youths with disruptive disorders. Although there are distinguishing
characteristics among those PDs, there also is substantial overlap, particularly
for irresponsible behavior and disturbed interpersonal relationships, that
denotes indifference to or exploitation of others. Increased risk of a PD
in young adulthood among youths with escalating disruptive symptoms also suggests
that externalizing symptoms in childhood may be a marker for later, more pervasive
psychopathological features.
Youths who had an anxiety disorder or escalating anxiety symptoms were
at increased risk of paranoid PD. It is logical that paranoid personality
formations, namely, anxiety, suspicion, and distrust, could evolve from childhood
anxiety and fears. Youths with escalating anxiety symptoms also were at an
increased risk of obsessive-compulsive PD. Behaviors and thoughts indicative
of perfectionism and inflexibility, characteristics central to obsessive-compulsive
PD, may develop to help control fears and anxieties. That phenomenon may be
observed among high-functioning students who strive for academic perfection
to the exclusion of other activities in an attempt to alleviate unwarranted
fears of failure and to ensure success. Contrary to expectations, childhood
anxiety disorder did not increase the risk of avoidant or dependent PD. Further
exploration revealed that, although there was a significant association between
anxiety disorders and later avoidant and dependent PDs, it was not independent
of other childhood disorders. Moreover, the low prevalence of dependent PD
in the young adults substantially lowered statistical power. Nevertheless,
high rates of comorbid depression and conduct disorder have been reported
in youths diagnosed as having anxiety disorder.52
Thus, effects of anxiety disorder may further complicate the influence of
MDD and disruptive disorders on later personality pathologic features.
Evaluation of Axis II disorders as potential consequences of childhood
disorder, particularly MDD, is warranted. Personality disorders are characterized
by interpersonal difficulties, impaired role performance, social deficits,
and subjective distress, problems strikingly similar to those identified in
depressed youths. The disturbed psychosocial functioning typically reported
to co-occur in depressed youths or to emerge after an episode remits may interfere
with developmental tasks relevant to subsequent role performance in adulthood.
It is plausible that depressed youths may have difficulty in "catching up"
and resuming age-appropriate cognitive, emotional, and social development;
consequently, the risk that mature adult role functioning may be compromised
increases. Postepisode treatment intervention may facilitate the resumption
of normal cognitive, emotional, and social developmental processes and eliminate
or reduce the risk of later more enduring and pervasive disorder.
These findings were based on a predominantly white (91%) and Catholic
(59%) sample; therefore, caution in generalizing to other groups is recommended.
Lifetime disorder was not evaluated; thus, it is probable that some youths
met diagnostic criteria for disorders at other periods of childhood or adolescence.
The absence of that information may have reduced associations between childhood
and adult psychopathological features. On the other hand, diagnoses were obtained
prospectively from multiple informants in a random community sample at 3 points
over 10 years. Rigorous DSM-III-R diagnostic criteria
were imposed, including a 2-SD severity cutoff and diagnosis-specific impairment
for the Axis I disorders and persistence over a 2-year interval for
adolescent PDs. Finally, the present study offers convincing evidence of the
pernicious nature of MDD and other childhood psychopathological features with
regard to the debilitating influence on role functioning and mental well-being
in adulthood, as represented by adult PD.
AUTHOR INFORMATION
Accepted for publication August 4, 2000.
This study was supported by a grant from W. T. Grant Foundation, New
York, NY; grant MH-36971 from the National Institute of Mental Health, Rockville,
Md (Dr Cohen); and grant DA-03188 from the National Institute on Drug Abuse,
Rockville (Dr Brook).
We thank Thomas N. Crawford, PhD, for his careful and highly constructive
review of the revised version of the manuscript.
From the Department of Psychiatry (Drs Kasen, Cohen, Skodol, and Johnson)
and the School of Public Health (Dr Cohen), Columbia University, New York,
NY; the Departments of Epidemiology (Drs Kasen, Cohen, and Johnson and Ms
Smailes) and Personality Studies (Dr Skodol), New York State Psychiatric Institute,
New York; and the Department of Community and Preventive Medicine, Mount Sinai
School of Medicine, New York (Dr Brook).
Corresponding author and reprints: Stephanie Kasen, PhD, New York
State Psychiatric Institute, 1051 Riverside Dr, Unit 47, New York, NY 10032
(e-mail: sk57{at}columbia.edu).
REFERENCES
| |
1. Birmaher B, Ryan ND, Williamson DE, Brent DA, Kaufman J, Dahl RE, Perel J, Nelson B. Childhood and adolescent depression: a review of the last 10 years:
part I. J Am Acad Child Adolesc Psychiatry. 1996;35:1427-1439.
FULL TEXT
|
ISI
| PUBMED
2. Garber J, Kriss MR, Koch M, Lindholm L. Recurrent depression in adolescents: a follow-up study. J Am Acad Child Adolesc Psychiatry. 1988;27:49-54.
FULL TEXT
|
ISI
| PUBMED
3. Harrington R, Fudge H, Rutter M, Pickles A, Hill J. Adult outcomes of childhood and adolescent depression. Arch Gen Psychiatry. 1990;47:465-473.
ABSTRACT
4. Kandel D, Davies M. Adult sequelae of adolescent depressive symptoms. Arch Gen Psychiatry. 1986;43:255-263.
ABSTRACT
5. Lewinsohn PM, Rohde P, Klein DN, Seeley JR. Natural course of adolescent major depressive disorder, I: continuity
into young adulthood. J Am Acad Child Adolesc Psychiatry. 1999;38:56-63.
FULL TEXT
|
ISI
| PUBMED
6. Lewinsohn PM, Rohde P, Seeley JR. Major depressive disorder in older adolescents. Clin Psychol Rev. 1998;18:765-794.
FULL TEXT
|
ISI
| PUBMED
7. Rao U, Ryan ND, Birmaher B, Dahl RE, Williamson DE, Kaufman J, Rao R, Nelson B. Unipolar depression in adolescents: clinical outcome in adulthood. J Am Acad Child Adolesc Psychiatry. 1995;34:566-578.
FULL TEXT
|
ISI
| PUBMED
8. Barnett PA, Gotlib IH. Psychosocial functioning and depression. Psychol Bull. 1988;104:97-126.
FULL TEXT
|
ISI
| PUBMED
9. Farmer R, Nelson-Gray RO. Personality disorders and depression. Clin Psychol Rev. 1990;10:453-476.
FULL TEXT
10. Block JH, Gjerde PF, Block JH. Personality antecedents of depressive tendencies in 18-year-olds: a
prospective study. J Pers Soc Psychol. 1991;60:726-738.
FULL TEXT
|
ISI
| PUBMED
11. Hirschfeld RMA, Klerman GL, Clayton P, Keller M. Personality and depression: empirical findings. Arch Gen Psychiatry. 1983;40:993-998.
ABSTRACT
12. Cohen P. Childhood risks for young adult symptoms of personality disorder: method
and substance. Multivariate Behav Res. 1996;31:121-148.
13. Lewinsohn PM, Rohde P, Seeley JR, Klein DN. Axis II psychopathology as a function of Axis I disorders. J Am Acad Child Adolesc Psychiatry. 1997;36:1752-1759.
FULL TEXT
|
ISI
| PUBMED
14. Lewinsohn PM, Rohde P, Seeley JR. Adolescent psychopathology, III: the clinical consequences of comorbidity. J Am Acad Child Adolesc Psychiatry. 1995;34:510-519.
FULL TEXT
|
ISI
| PUBMED
15. Rey JM, Morris-Yates A, Singh M, Andrews G, Stewart GW. Continuities between psychiatric disorders in adolescents and personality
disorders in adults. Am J Psychiatry. 1995;152:895-900.
FREE FULL TEXT
16. Kasen S, Cohen P, Skodol AE, Johnson JG, Smailes EM, Brook JS. The influence of child and adolescent psychiatric disorders on young
adult personality disorder. Am J Psychiatry. 1999;156:1529-1535.
FREE FULL TEXT
17. Johnson JG, Cohen P, Brown J, Smailes EM, Bernstein DP. Childhood maltreatment increases risk for personality disorders during
early adulthood. Arch Gen Psychiatry. 1999;56:600-606.
FREE FULL TEXT
18. Abramson LY, Seligman LEP, Teasdale JD. Learned helplessness in humans: critique and reformulation. J Abnorm Psychol. 1978;87:49-74.
FULL TEXT
|
ISI
| PUBMED
19. Beck AT. Depression: Clinical, Experimental, and Theoretical
Aspects. New York, NY: Hoeber; 1967.
20. Hirschfeld RM, Klerman GL, Chodoff P, Korchin S, Barrett J. Dependency-self-esteem-clinical depression. J Am Acad Psychoanal. 1976;4:373-388.
PUBMED
21. Gotlib IH, Lewinsohn PM, Seeley JR. Symptoms versus a diagnosis of depression: differences in psychosocial
functioning. J Consult Clin Psychol. 1995;63:90-100.
FULL TEXT
|
ISI
| PUBMED
22. Puig-Antich J, Lukens E, Davies M, Goetz D, Brennan-Quattrock J, Todak G. Psychosocial functioning in prepubertal depressive disorders, I: interpersonal
relationships during the depressive episode. Arch Gen Psychiatry. 1985;42:500-507.
ABSTRACT
23. Puig-Antich J, Lukens E, Davies M, Goetz D, Brennan-Quattrock J, Todak G. Psychosocial functioning in prepubertal depressive disorders, II: interpersonal
relationships after sustained recovery from affective episode. Arch Gen Psychiatry. 1985;42:511-517.
ABSTRACT
24. Rohde P, Lewinsohn PM, Seeley JR. Are adolescents changed by an episode of major depression? J Am Acad Child Adolesc Psychiatry. 1994;33:1289-1298.
ISI
| PUBMED
25. Nolen-Hoeksema S, Girgus JS, Seligman MEP. Predictors and consequences of childhood depressive symptoms. J Abnorm Psychol. 1992;101:405-422.
FULL TEXT
|
ISI
| PUBMED
26. Oldham JM, Skodol AE, Kellman HD, Hyler SE, Doidge N, Rosnick L, Gallagher PE. Comorbidity of Axis I and Axis II disorders. Am J Psychiatry. 1995;152:571-578.
FREE FULL TEXT
27. Cohen P, Cohen J. Life Values and Adolescent Mental Health. Hillsdale, NJ: Lawrence A Erlbaum Associates; 1996.
28. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,
Revised Third Edition. Washington, DC: American Psychiatric Association; 1987.
29. Costello EJ, Edelbrock CS, Dulcan MK, Kalas R, Klaric SK. Testing of the NIMH Diagnostic Interview Schedule
for Children (DISC) in a Clinical Population: Final Report to the Center for
Epidemiological Studies, NIMH. Pittsburgh, Pa: University of Pittsburgh; 1984.
30. Loeber R, Green SM, Lahey BB, Stouthamer-Loeber M. Optimal informants on childhood disruptive behavior. Dev Psychopathol. 1990;1:317-337.
31. Zahner G, Leckman J, Benedict T, Leo-Summers L. The Clinical Process of Assembling Psychodiagnostic
Information From Parents, Children, and Teachers: Recommendations for Multiple
Informant Algorithms for the Diagnostic Interview Schedule for Children: Report
to the Epidemiology and Psychopathology Research Branch, Division of Clinical
Research, NIMH. Washington, DC: National Institute of Mental Health; 1989.
32. Velez CN, Johnson J, Cohen P. A longitudinal analysis of selected risk factors for childhood psychopathology. J Am Acad Child Adolesc Psychiatry. 1989;28:861-864.
ISI
| PUBMED
33. Cohen P, Kasen S, Brook JS, Struening EL. Diagnostic predictors of treatment patterns in a cohort of adolescents. J Am Acad Child Adolesc Psychiatry. 1991;30:989-993.
ISI
| PUBMED
34. Bernstein DP, Cohen P, Velez CN, Schwab-Stone M, Siever LJ, Shinsato L. Prevalence and stability of the DSM-III-R
PDs in a community-based survey of adolescents. Am J Psychiatry. 1993;150:1237-1243.
FREE FULL TEXT
35. Hyler SE, Reider RO, Williams JBW, Spitzer RL, Hendler J, Lyons M. The Personality Diagnostic Questionnaire. J Personal Disord. 1988;2:229-237.
36. Spitzer RL, Williams JBW. Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). New York: New York State Psychiatric Institute; 1986.
37. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition. Washington, DC: American Psychiatric Association; 1994.
38. Pfeffer CR, Plutchik R, Mizruchi MS. Suicidal and assaultive behavior in children. Am J Psychiatry. 1983;140:154-157.
FREE FULL TEXT
39. Brent DA, Johnson B, Bartle S, Bridge J, Rather C, Matta J, Conolly J, Constantine D. Personality disorder, tendency to impulsive violence, and suicidal
behavior in adolescence. J Am Acad Child Adolesc Psychiatry. 1993;32:69-75.
ISI
| PUBMED
40. Brent DA, Johnson BA, Pepper J, Conolly J, Bridge J, Bartle S, Rather C. Personality disorder, personality traits, impulsive violence, and completed
suicide in adolescents. J Am Acad Child Adolesc Psychiatry. 1994;33:1080-1086.
ISI
| PUBMED
41. Westen D, Ludolph P, Lerner H, Ruffins S, Wiss FC. Object relations in borderline adolescents. J Am Acad Child Adolesc Psychiatry. 1990;29:338-346.
PUBMED
42. Johnson JG, Cohen P, Skodol AE, Oldham JM, Kasen S, Brook JS. Personality disorders in adolescence and risk of major mental disorders
and suicidality during adulthood. Arch Gen Psychiatry. 1999;56:805-811.
FREE FULL TEXT
43. Brown J, Cohen P, Johnson JG, Salzinger S. A longitudinal analysis of risk factors for child maltreatment. Child Abuse Negl. 1998;22:1065-1078.
FULL TEXT
|
ISI
| PUBMED
44. Locke HJ, Wallace KM. Short marital-adjustment and prediction tests: their reliability and
validity. Marriage Fam Living. 1959;21:251-255.
FULL TEXT
45. Hollingshead AB, Redlich FC. Social Class and Mental Illness: A Community Study. New York, NY: John Wiley & Sons Inc; 1958.
46. Skodol AE, Stout RL, McGlashan TH, Grilo CM, Gunderson JG, Shea MT, Morey LC, Zanarini MC, Dyck IR, Oldham JM. Co-occurrence of mood and personality disorders. Depress Anxiety. 1999;10:175-182.
FULL TEXT
| PUBMED
47. Skodol AE, Gallaher PE, Oldham JM. Excessive dependency and depression: is the relationship specific? J Nerv Ment Dis. 1996;184:165-171.
PUBMED
|
