|Year : 2022 | Volume
| Issue : 2 | Page : 176-181
A study on parental attitudes in patients with personality disorders and healthy controls from a tertiary care hospital in Northern India
Sanjeet Kour, Zaid Ahmad Wani, Haamid Ismail, Waris Ahmad Zargar
Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||09-May-2019|
|Date of Decision||07-Apr-2020|
|Date of Acceptance||13-Sep-2020|
|Date of Web Publication||11-Jun-2022|
Dr. Sanjeet Kour
Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Personality disorders (PDs) comprise deeply ingrained and enduring behavioral patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations. Our aim was to study sociodemographic profile and parental attitudes in patients with PDs and their comparison with healthy controls. Materials and Methods: It was an observational case–control study conducted in Department of Psychiatry, Government Medical College, Srinagar, J and K, India. A total of 41 cases and 163 controls were selected. Patients were diagnosed using Diagnostic and Statistical Manual-5 (DSM-5) criteria. Childhood Trauma Questionnaire was used for parental attitudes. Results: The mean age of patients and controls was 22.41 (standard deviation [SD] = 4.14) and 22.52 (SD = 4.15), respectively. Majority of the participants were females, single, were from nuclear families, and belonged to upper-middle socioeconomic class. Most of the patients were borderline PD (BPD), followed by histrionic PD. The frequency and inappropriateness of punishment by parents was more in patients than controls. Conclusion: A positive correlation was seen between PDs and inappropriate parental attitudes and rearing styles. Therefore, it is required to have a better understanding of PDs and to help parents to develop skills to handle their children with utmost care in distress.
Keywords: Inappropriate parenting, parental attitudes, personality disorders, rearing styles
|How to cite this article:|
Kour S, Wani ZA, Ismail H, Zargar WA. A study on parental attitudes in patients with personality disorders and healthy controls from a tertiary care hospital in Northern India. Indian J Soc Psychiatry 2022;38:176-81
|How to cite this URL:|
Kour S, Wani ZA, Ismail H, Zargar WA. A study on parental attitudes in patients with personality disorders and healthy controls from a tertiary care hospital in Northern India. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Aug 9];38:176-81. Available from: https://www.indjsp.org/text.asp?2022/38/2/176/347281
| Introduction|| |
Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive causing significant functional impairment or subjective distress do they constitute personality disorders (PDs). The prevalence of overall PDs varies from 10% to 20%. According to DSM-5, the PDs are grouped into three clusters based on descriptive similarities. Cluster A includes paranoid, schizoid, and schizotypal PDs. Individuals with these disorders often appear odd or eccentric. Cluster B includes antisocial, borderline, histrionic, and narcissistic PDs. Individuals with these disorders often appear dramatic, emotional, or erratic. Cluster C includes avoidant, dependent, and obsessive-compulsive PDs. Individuals with these disorders are anxious or fearful.
Prevalent estimates for the different clusters suggest 5.7% for disorders in Cluster A, 1.5% for disorders in Cluster B, 6.0% for disorders in Cluster C, and 9.1% for any PD, indicating frequent co-occurrence of disorders from different clusters. Different studies have demonstrated that the history of traumatic events in childhood seems to increase the risk of antisocial behavior, borderline and dependent PD, obsessive compulsive PD, or psychopathological personality traits such as paranoid, histrionic, narcissistic, or dependent, among others. Two studies with nonclinical individuals from representative surveys found that individuals who endorsed borderline features reported more childhood emotional, physical, and supervision neglect., Although comparisons with other psychiatric disorders found a higher rate of environmental risk factors, these studies may have underestimated the relative association of these risk factors with borderline PD (BPD). In addition, the offspring of borderline mothers are at high risk of psychopathology. Family studies do not disentangle genetic from environmental factors, as personality traits may also be transmitted via model learning or due to impaired parenting skills of parents with mood lability, impulsivity, or reality distortion.
A longitudinal study by Johnson et al. found out that childhood emotional neglect, physical neglect, and childhood supervision neglect was found to be associated with increased risk for various PDs and clusters of PDs. Different types of childhood maltreatment entailed the development of different PDs such as BPDs and schizotypal PDs were mostly strongly predicted by sexual abuse, antisocial PDs, and dependent PDs by physical abuse and avoidant PDs and schizoid PDs by emotional neglect. Of the 12 categories of DSM-IV PD symptoms, 10 were associated with childhood abuse or neglect. However according to a review, schizotypal and paranoid PDs were significantly associated with emotional abuse and serious sexual abuse and a positive association can be found between childhood abuse and cluster C PDs.
To our knowledge, the present study is the first comparison of patients with PDs and healthy controls with regard to parental rearing styles in Kashmir. The objective of the study is to determine the relative significance of the various risk factors.
Aims and objectives
The aim and objective was to determine the association of parental attitudes in PDs and their comparison with controls.
| Materials and Methods|| |
The present study entitled “A study on Parental Attitudes in Patients with PDs and Healthy Controls from a tertiary care hospital in Northern India” was conducted from March 2016 to August 2017 in the Institute of Mental Health and Neurosciences, Kashmir, an associated hospital of Government Medical College, Srinagar, J and K, India. This research work was initiated following approval by the Institutional Ethical Committee and Board of Research Studies of Government Medical College, Srinagar. 41 patients presenting mainly with personality-related complaints and seeking treatment for the same were recruited both from OPD and IPD for this purpose. Both the groups were screened using the International PD Examination screening questionnaire and those persons screening positive for PDs were further subjected to confirmation by consultant psychiatrists according to DSM-5 criteria. Convenient sampling method was used for sampling. The patients with a positive diagnosis who gave written informed consent in a language which patient understood and who fulfilled the inclusion and exclusion criteria were subjected to further interview consisting of basic sociodemographic details including revised Kuppuswamy's sociodemographic scale and “childhood trauma questionnaire.” All these questionnaires/interviews have been used and standardized in previous studies regarding PDs.
Patients diagnosed as PDs according to DSM-5 criteria, aged ≥18 years and who gave written informed consent to participate in the study were included. Those aged <18 years, who did not give consent or were suffering from other psychiatric disorders, substance abuse disorders, organic brain disorders, endocrinopathies, or severe medical problems were excluded from the study. 163 age and sex matched healthy controls were recruited from the attendants visiting the patients in our hospital who were not related to the patients, who gave written informed consent and who were screened negative for PDs using same criteria for PDs as for patients and were interviewed in the same settings using the same instruments as cases. The number of healthy controls outnumbered patients because of the fact that prevalence of PDs in India has been much lower (weighted prevalence rate = 0.6%) than the prevalence in Western countries (10%–20%). Therefore in order to extrapolate the results to general population the number of controls had to be around four times the number of patients.
Childhood Trauma Questionnaire
This questionnaire with 203 questions already used and validated in earlier studies by Bandelow et al. with patients with PD. Four types of questions were employed: questions to be answered (1) by “yes” or “ no,” (2) on a 0–4 Likert scale, where 0 = “none” or “very bad,” 1 = “low” or “bad,” 2 = “moderate,” 3 = “high” or “good,” 4 = “very high” or “very good,” (3) by a number (e.g., months of hospitalization); (4) or in the subject's own words. This clinician rated questionnaire contained items concerning parental attitudes toward the subjects. The questionnaire was initially formulated in German language and an English translated version was used in the current study after seeking proper written permission from the original authors.
The data about various parameters were categorized according to age, sex, education, socioeconomic status, clinical phenomenology, psychiatry morbidity, etc., The information thus generated was presented in tables and charts. Statistical analysis was carried out with Epi-Info 7.0 version (CDC, Atlanta, Georgia). For the analysis of two categorical variables, Chi-square test (Fisher's exact test where applicable) was used, and ordinal data were analyzed using Wilcoxon-Mann–Whitney test, and Student's t-test was used to compare continuous variables between two groups and simple logistic regression was done to estimate odds ratio corresponding to various exposure variables. Odds ratio was reported along with their 95% confidence intervals (CI). All tests were two tailed and statistical significance was set at P < 0.05. For better clarity, also for ordinal data, the central tendencies, i.e., means, and standard deviations (SDs) are shown in tables.
Ethical issues of the study
This study was a case–control study and no intervention was required, and there was no interference in the routine clinical management and treatment of these patients. The identity of the patients enrolled in the study was kept confidential.
| Results|| |
The mean age of our cases was 22.41 years (SD = 4.141) and that of healthy controls 22.52 years (SD = 4.159) as shown in [Table 1]. Most of the controls and cases were females and nearly 5% were males. Most of controls and cases were unmarried and were students with nearly three-fourths of both the groups belonging to nuclear families. The maximum number of healthy controls and cases belonged to upper middle class. Most (61%) of the cases had good social support whereas rest had minimal social support, however in the control group almost all (99.4%) enjoyed good social support.
[Table 2] shows the total number of controls to be 163. Forty-one cases were recruited out of which majority (n = 35, 85.37%) had BPD. It was followed by histrionic PD (HPD) (n = 3, 7.31%). Other PDs seen included avoidant/anxious PD (n = 1, 2.44%) and 1 case each (2.44% each) received a dual diagnosis of dependent PD and avoidant PD, and borderline and antisocial PD.
|Table 2: Number of healthy controls and diagnostic distribution of cases|
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[Table 3] reveals the parental attitudes. The punishment by parents was more frequent in cases (mean = 2.10, SD = 1.261) than controls (mean = 1.18, SD =0.793). The inappropriateness of punishment by parents was also more for cases (1.37, SD = 1.624) as compared to controls (mean =0.45, SD =.970). More number of cases were shown sufficient love and care by mother (mean = 2.48, SD = 1.358) than controls (mean = 3.16, SD =.863).
|Table 3: Parental attitudes of personality disorders patients and controls|
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| Discussion|| |
The PDs are seen in 10%–20% of the general population and in about 50% of psychiatric inpatients or outpatients. About 50% of all psychiatric patients have PD, which is frequently comorbid with other clinical syndromes.
Recently a systematic literature review of studies measuring prevalence of PDs done in 2014 in community showed prevalence estimates of 40%–92% in Europe, 45%–51% in the USA, whereas among Asian countries: in Pakistan it was found out to be 60% and 1.07% in India. Methodological shortcomings of surveys preclude direct comparisons with the Western data neglecting co-morbidity and dual diagnosis, and have used screening instruments with low sensitivity and single informants, hence underreporting the prevalence.
Majority of participants in both the groups were females, were single, belonged to student group and were from nuclear families mostly belonging to upper-middle socioeconomic class. BPD which is the most frequently encountered PD in inpatients is more prevalent in younger age groups, females and whites, associated with poor work history and single marital status.
The reason of young participants in this study seems to be emerging difficulties and unhelpful behaviors, e.g., self harm, drug and alcohol use, binge eating, social withdrawal, aggressive, and risky sexual behavior due to which these patients are brought to psychiatric emergencies by their caregivers. BPD which appears to be the most common PD in our study is unequivocally more common in women than men. The number of male to female ratio in our patient group appears skewed as in ASPD, men outnumber women 6:1, whereas, in BPD, women outnumber men 3:1, although this is seen in clinical settings, not in general population, and in our study most patients were BPD which is seen far more commonly in females in clinical population. Gender and age distribution of our patients appear skewed also because of the sampling method used as convenience sampling is highly vulnerable to selection bias resulting in more number of young patients and females. Whisman et al. showed in their study that personality pathology is associated with a significant increase in the likelihood of marital termination. PD patients tend to have chronic impairments in their ability to work and love, and tend to have more marital difficulties, be less educated and unemployed.
In this study, the overall support of the family was much better in control group than in the patient group and the difference was statistically significant. High levels of social support has been linked to more use of active coping strategies and less use of avoidant and self destructive coping strategies. On the other hand, low levels of social support have been linked to grief and suicidal ideation in bereaved samples. According to a study by Cheng-li-na, in which associations between parental rearing patterns and social support in PD were studied in prisoners, positive significant correlations were found between PD and punishment of parental rejection and denial of parental, overprotection of father, and preference of mother and significant inverse correlations were found between PD and warmth of feeling and understanding of parents. Also there were correlations between PD and subjective support and the usage of support. On the other hand, it cannot be excluded that borderline patients may confabulate histories or exaggerate certain events, moreover splitting may make a borderline patient more likely to see the family as all good or bad, concentrating more on few bad events and stating that it was all bad. In general, conflict with parents and a lack of family support are modestly but consistently associated with the PDs.
The mother's unemployment was seen more commonly in patient group than control group which was statistically significant. This is in line with the study by Bandelow et al. in which 42.4% cases had unemployed mothers and only 16.5% controls had unemployed mothers with statistically significant difference. The maternal unemployment from the age groups 0–5 years and 11–15 years lowers adult life satisfaction and adds to childhood psychological trauma (scarring effect) according to a study. It cannot be overemphasized that mother's health and her socioeconomic status as well as household characteristics, are found to be related to her child's mental well being. Although the influence of maternal employment on child development is found to be dependent on the attitudes of the parents, the number of hours the mother is employed, social support and the child's gender.
Among cases, BPD (85.37%) was the most common PD seen followed by HPD (7.31%), followed by anxious PD (2.44%), and 2.44% each received a dual diagnosis of dependent and anxious/avoidant PD, and borderline and antisocial PDs. This is in line with the study by Lana et al. in which BPD was the most prevalent PD among those persons seen in the state public mental health network followed by HPD. The most frequently encountered PD in clinical setting is BPD as these persons have strong tendency to seek psychiatric help. However, in another study carried out by Maanasa et al. in which the prevalence of PD was 21.55% (95% CI 14.07–29.03) among the psychiatric inpatients. The most common type of PD in this study was avoidant (7.7%), followed by anti social (5.17%) and borderline (3.45%) PD. In a study by Gawda and Czubak approximately 9% of the sample had at least one PD (the overall rate was 8.9%) and rates on sex differences in PDs were similar to other European and North American countries. In this study, the most prevalent PDs were obsessive-compulsive (9.6%), narcissistic (7%), and borderline (7%). Results showed the considerable co-morbidity of PDs which meant that about 9% of the adult population have at least one PD and in fact they display features of many specific PDs.
The frequency and inappropriateness of punishment by parents was statistically more significant (P < 0.001) in personality patients (mean = 2.10, SD = 1.261 for frequency and mean = 1.37, SD = 1.624 for inappropriateness) than controls (mean = 1.18, SD =0.793 for frequency and mean = 0.45, SD = 0.970 for inappropriateness). More significant love and affection was shown by mother in control group (mean = 3.16, SD = 0.863) than cases (mean = 2.48, SD = 1.358). Also “care” dimension of parenting style of mothers has a moderate positive correlation with adolescent personality development whereas “overprotection” dimension of parenting style has a weak negative correlation with adolescent personality development. Rest of the parameters show more inappropriate rearing styles and less care and affection from father and other caregivers in patients but the difference was not statistically significant. This is in contrast with the study Bandelow et al. in which all but one question (mother short tempered) regarding parental attitude and rearing styles demonstrated more inappropriate rearing styles and less care and affection among BPD patients. The study confirmed the association of BPD with grossly deranged family environments characterized by inappropriate parental rearing styles and lack of loving care along with separation from parents, growing up in foster care, adoption, and criminality and violence in the family.
According to a study by Timmerman and Emmelkamp in which parental rearing styles and PDs in prisoners and forensic patients, cluster B was significantly associated with less parental care and more protection, cluster C was not significantly related to parental rearing and cluster A was related significantly only to low maternal care. Similar findings were seen in a study by Johnson et al., in which it was seen that aversive parental behavior (e.g., harsh punishment) was associated with elevated risk for offspring borderline, paranoid, passive-aggressive, and schizotypal disorders. Furthermore low parental nurturing also is associated with elevated risk for offspring PDs.
A few longitudinal studies have reported that more common childhood adversities, such as problematic parenting, may have effects on the risk of PD. Nevertheless the role of parenting is of particular interest because PDs have been hypothesized to result in part from maladaptive or deficient socialization during crucial childhood and adolescence and parents typically play a role in rearing and early socialization of the child., Furthermore the overall likelihood of the development of any offspring PD may tend to increase as the number of different types of problematic parenting behaviors increase.
The findings of our study suggest that the more inappropriate and more frequent punishment in childhood was associated with the development of PDs in adolescence, more so BPDs (which is the most common PD presenting in the general psychiatric OPDs in our tertiary care hospital). Also it shows that the maternal love and care was seen less in the PD patients and the results were statistically significant suggesting the importance of maternal affection in the protection against the development of PDs. All these findings suggest that parental attitudes especially punishment have a positive correlation to the development of PDs and the maternal love and care has a negative correlation. These findings support the hypothesis that parenting may play a significant role to the development of PDs.
| Conclusion|| |
It was concluded that the most common PD to present at the tertiary care psychiatric hospital in Kashmir is BPD followed by HPD. Hypothesis that there is significant association between PDs and inappropriate parenting and parental rearing styles in the form of more inappropriate and frequent punishment by parents was found to be true. Healthy controls were showed more love and care by parents (especially by mother). This study will help us understand and give insight into positive and negative influences of parenting style and parental attitudes that affect the personality, behavior, and coping skills of children. It may be possible to reduce the risk for development of PDs by modifying the child-rearing behavior of at-risk youths like those with parental history of psychiatric disorders.
There were various limitations in our study as follows:
- Data were drawn from interviews of adult patients about their memories of childhood experiences, which can never establish causality. To determine causality prospective methodology is needed
- Because of the method of sampling, i.e., convenient sampling, there was a female preponderance in the patient sample and as a result, marked skewedness
- Sampling was done using convenient sampling method and therefore the patient sample did not contain some types of PDs such as paranoid, schizoid, schizotypal, obsessive-compulsive and narcissistic PD. Therefore, it is not the true representation of association between the aforementioned risk factors with all types of PDs
- Furthermore, due to convenient sampling, majority of the participants in both the groups were young, which also resulted in marked skewedness.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]