Families with Mentally Ill Parents and Their Partners: Overlaps in Psychiatric Symptoms and Symptom Coping.

Partners in families with a mentally ill parent often experience psychiatric symptoms themselves. Recent studies indicate that there might be overlaps in disorder-specific symptom areas between partners and spouses. This study aimed at examining associations in psychiatric symptoms and symptom coping in partners in families with a mentally ill parent, e.g., having a psychiatric diagnosis according to the International Classification of Diseases (ICD-10). Furthermore, a moderation of the psychiatric symptoms of the parent with a mental illness on the association in symptom coping was assumed. Families with at least one parent with a mental illness were recruited into the longitudinal "Children of Mentally Ill Parents" (CHIMPS) trial at seven clinical centers in Germany and Switzerland. In total, 139 families were included in the current study. Psychiatric symptoms were assessed using the Brief Symptom Inventory (BSI), Clinical Global Impression scale (CGI), Global Assessment of Functioning (GAF), and Patient Health Questionnaire (PHQ), while symptom coping strategies were measured using the Freiburger Fragebogen zur Krankheitsverarbeitung (FKV). Regression analyses have indicated an association in psychiatric symptoms between mentally ill parents and their partners concerning psychosocial functioning, somatic, and stress-related symptoms. Additionally, one symptom coping strategy of the partners was predicted by the same strategy of the parent with a mental illness. The results emphasize the importance of screening and providing support to parents burdened by the mental disorder of their partners, especially regarding the children in these partnerships.

Clinical Trial Data: Both Parents Having Psychiatric Symptoms as Risk Factor for Children's Mental Illness.

Children of mentally ill parents represent a particularly vulnerable risk group for the development of mental illness. This study examines whether there is a predictive association between children's psychiatric symptomatology and (1) the clinical diagnosis according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10) of their mentally ill parent as well as (2) to families both parents showing psychiatric symptoms. The study is part of the multicenter controlled trial project "Children of Mentally Ill Parents" (CHIMPS). For this purpose, the psychiatric symptomatology of the mentally ill parent (N = 196) and his or her partner (N = 134) as well as the psychiatric symptomatology of their children aged 4 to 18 years (N = 290) was measured using clinical rated ICD-10-diagnosis, self-rated Brief Symptom Inventory (BSI), and Child Behavior Checklist (CBCL). Using multilevel analyses, the severity of the parental psychiatric symptomatology (BSI) was identified as a significant predictor of children's psychiatric symptomatology (CBCL). Children of parents with a personality disorder (ICD-10) were not more affected than children of parents with another ICD-10-diagnosis. However, children with two parents showing psychiatric symptoms (CBCL) were significantly more affected than children with one mentally ill parent. The results of this study support the well-known view that parental mental illness is a risk factor for children's psychiatric symptoms. Therefore, increased support, especially in high-risk families, both parents having psychiatric symptoms, is highly necessary and should be implemented in the future psychotherapeutic family care.

Risk and Protective Factors Associated With Health-Related Quality of Life of Parents With Mental Illness.

Purpose: Health-related quality of life (HRQoL) can be reduced in parents with mental illness (mental illness) who face the dual demands of disabling symptoms and their impact on family, social, and occupational life. This study aimed at analyzing the influence of various factors on HRQoL in parents with mental illness. Method: Baseline data of the German randomized controlled multicenter project CHIMPS (children of parents with mental illness) was used for analyses. The final sample consisted of n = 208 parents with mental illness and n = 197 children and adolescents aged 8-18 years. HRQoL was assessed with the EQ-5D. Results: Parents with mental illness reported significantly lower global and specific HRQoL than the German reference population. They were least satisfied with aspects that relate to anxiety and depression followed by usual activities, pain and discomfort. Better global HRQoL was primarily associated with self-reported physical and mental health, as well as adaptive coping behavior. Associations with mobility, self-care, usual activity, pain and discomfort, anxiety and depression were analyzed and discussed. Conclusions: HRQoL in parents with mental illness is reduced. Clinical interventions should focus on the alleviation of mental health symptoms and probably somatic symptoms and promote adaptive coping skills.

Parents With Mental Illness: Parental Coping Behavior and Its Association With Children's Mental Health.

The relevance of coping behavior for the individual's own mental health has been widely investigated. However, research on the association between coping of parents with a mental illness and their children's mental health is scarce. In the current study, we address the role of several parental coping strategies and their relation to child psychological symptoms. As part of the German randomized controlled multicenter study CHIMPS (children of mentally ill parents), parents with mental illness completed questionnaires on illness-related coping and child mental health symptoms. Children's diagnoses of a mental disorder were assessed with diagnostic interviews. The sample comprised n = 195 parents with mental illness and n = 290 children and adolescents aged 4-18 years. We conducted mixed models to investigate the associations of parental coping strategies with internalizing and externalizing symptoms as well as the diagnosis of a mental disorder in children controlling for sociodemographic factors and parental symptom severity. Parental coping characterized by religiosity and quest for meaning was significantly associated with fewer mental health symptoms and lower odds of a mental disorder in children, whereas a depressed processing style was related to increased internalizing problems in the children. Coping behavior in parents with mental illness is a relevant factor for the mental health of their children and should be considered in preventive interventions.

Associations of Family Functioning and Social Support With Psychopathology in Children of Mentally Ill Parents: Multilevel Analyses From Different Rating Perspectives.

Offspring of mentally ill parents is at heightened risk for psychological symptoms. The identification of environmental factors that predict their mental health is crucial for the development of preventive and therapeutic measures. In the current study, we addressed the combined role of family functioning and social support by taking mentally ill patients', their partners', and children's perspectives into account. The cross-sectional sample included n=195 families (195 patients, 127 partners, and 295 children). Family members completed questionnaires related to family functioning, social support as well as parental and child psychopathology. We conducted multilevel analyses to investigate the associations with internalizing and externalizing problems in children. Family functioning and social support were significantly associated with child internalizing and externalizing problems. However, results varied depending on the rating perspective. We found significant interaction effects of family functioning and social support on child psychopathology. The findings point to the importance of family functioning and social support as potential targets for interventions. Findings should be replicated in future longitudinal studies.

Family Functioning in Families Affected by Parental Mental Illness: Parent, Child, and Clinician Ratings.

Family functioning is often impaired in families with a parent with mental illness and is linked to child mental health. This study aims to gain a better understanding of family functioning in affected families by comparing ratings among family members and by analyzing associations with clinician-rated family functioning. The cross-sectional sample comprised 210 families with ratings of 207 patients, 139 partners, and 100 children. Parents with a mental illness as well as their partners and children completed the German version of the Family Assessment Measure (FAM). Clinician ratings were obtained by the Global Assessment of Relational Functioning Scale (GARF). We conducted several mixed models to compare ratings of family functioning while accounting for family cluster. Family dysfunction was consistently elevated compared to a normative sample. On several domains, parents with a mental illness perceived family functioning to be worse compared to their partners and children. Partners and children did not differ in their perceptions of family functioning. Ratings of family members were moderately associated with clinician ratings. We discuss the importance of multi-informant assessment of family functioning and the implementation of family-based interventions for families with a parent with mental illness.

Vulnerable narcissism as beneficial factor for the therapeutic alliance in borderline personality disorder.

Evidence suggests that narcissism and borderline personality disorder are associated with each other. This naturalistic study investigated the predictive value of grandiose and vulnerable narcissism on the development of the therapeutic alliance in short-term psychodynamic treatment across 12 weeks. The sample consisted of 99 patients with borderline personality disorder. Narcissism was assessed with the Pathological Narcissism Inventory at treatment onset. The therapeutic alliance was rated with the Scale to Assess Therapeutic Relationships by both patient and therapist at four time points during treatment. Results showed a significant predictive value of vulnerable narcissism on the therapeutic alliance, revealing a more beneficial progression for patients with higher vulnerable narcissism. Grandiose narcissism had no predictive value on the therapeutic alliance. The study strengthens the clinical utility of the concept of vulnerable narcissism towards the evaluation of treatment processes in borderline personality disorder.

Costs of health and social services use in children of parents with mental illness.

BACKGROUND: Children of parents with mental illness have a higher risk of developing mental health problems when compared with the general population. Therefore, families with parents with mental illness are a suitable target group for selective prevention. In order to plan and evaluate the health economic consequences of preventive interventions for this target group, data on the societal costs related to parenthood under the condition of mental disorders are needed. To date, within Germany there has been a lack of research evaluating the costs of mental health treatment and use of social services by children and adolescents with parents with mental illness. METHODS: As part of a multicentre randomised controlled trial, use and costs of health and social services were assessed for a sample of 332 children and adolescents with parents with mental illness in six regions of Germany. Service use at baseline was assessed by the German version of the Children and Adolescent Mental Health Service Receipt Inventory. Costs were calculated for 12 months based on diagnosis and service user status and described separately. Cost drivers were identified by means of a two-part regression model. RESULTS: Total mean costs for 12 months for the total sample amount of € 3736.35 (95% CI: € 2816.84-4813.83) per person. Children with a psychiatric diagnosis generated a total of € 5691.93 (95% CI: € 4146.27-7451.38) of costs per person, compared to € 1245.01 (95% CI: € 657.44-1871.49) for children without a psychiatric diagnosis. The logit part indicates significant odds ratios for individual functioning and diagnosis of the child as well as for family functioning. The linear part reveals that increasing individual functioning in the child is related to decreasing costs. CONCLUSIONS: Children of families with parents with mental illness use a broad spectrum of mental health care, school-based support and youth welfare services even if they are not yet diagnosed as having a mental disorder. Further research should examine whether these institutions are sufficiently qualified and interlinked to meet the support needs of this vulnerable group. Trial registration The study was registered at the 07/10/2014 before the start of data collection (04/11/2014) at the German clinical trials register (Deutsches Register Klinischer Studien, DRKS, nr: DRKS00006806, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00006806 ).

Impulsiveness in borderline personality disorder predicts the long-term outcome of a psychodynamic treatment programme.

Despite the preponderance of treatment outcome predictors in patients with borderline personality disorder (BPD), the predictive value of measures of impulsiveness is inconclusive. This naturalistic study consecutively included hospitalized patients with BPD (N = 99) who underwent a standardized and structured 12-week inpatient treatment programme, which integrated cognitive-behavioural and psychodynamic elements. The Brief Symptom Checklist (BSCL) was applied as outcome measure over four time points: pretreatment, posttreatment, first follow-up at 6 to 8 weeks and second follow-up at 1 year after discharge. Impulsiveness was measured using the Barratt Impulsiveness Scale (BIS) at the pretreatment time point. The BSCL significantly decreased between pretreatment and posttreatment, followed by an increase after posttreatment without reaching pretreatment extent. The temporal course of the BSCL significantly varied with pretreatment BIS in that patients with higher impulsiveness revealed a stronger re-increase of symptom severity from posttreatment to end of follow-up than those with lower impulsiveness. The least impulsive patients thereby showed no rebound effect. The robustness of the results was examined by cross-validation. The results indicate that irrespective of the level of impulsiveness, patients with BPD profit from a structured inpatient treatment. However, long-term treatment success was impaired in patients with high level of impulsiveness at pretreatment. Thus, self-ratings of impulsiveness in BPD patients can be utilized for treatment planning. After discontinuation of interventions, relapse prevention should be implemented early in high impulsive patients as symptoms recrudesce in the course after discharge.

Evaluation of a Family-Based Intervention Program for Children of Mentally Ill Parents: Study Protocol for a Randomized Controlled Multicenter Trial.

Background: Children of mentally ill parents have a three to seven times higher risk of developing mental disorders compared to the general population. For this high-risk group, specialized prevention and intervention programs have already been developed. However, there has been insufficient sytematic evaluation to date. Moreover, effectiveness and the cost-effectiveness data of the respective programs until today is very scarce and at the same time constitutes the pre-condition for the program's implementation into regular health care. Methods: The study consists of a two-group randomized controlled multicenter trial conducted at seven study sites throughout Germany and Switzerland. Participants are families with mentally ill parents and their children aged from 3 to 19 years. The intervention comprises 6 to 8 semi-structured sessions over a period of about 6 months. Topics discussed in the intervention include parental mental illness, coping, family relations and social support. Families in the control condition will receive treatment as usual. The children's mental health, assessed using the K-SADS-PL by blinded external raters will constitute the primary efficacy outcome. Further outcomes will be assessed from the parents' as well as from the children's perspectives. Participants are investigated at baseline, 6, 12, and 18 months after baseline assessment. In addition to the assessment of various psychosocial outcomes, a comprehensive health-economic evaluation will be performed. Discussion: This paper describes the evaluation of a family-based intervention program for children of mentally ill parents (CHIMPs) in the regular health care system in Germany and Switzerland. A methodically sophisticated study design has been developed to reflect the complexity of the actual health care situation. This trial will contribute to the regular health care for the high-risk group of children of mentally ill parents. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02308462; German Clinical Trials Register: DRKS00006806.

Negative affect moderates the effect of social rejection on frontal and anterior cingulate cortex activation in borderline personality disorder.

Patients with borderline personality disorder (BPD) have a heightened sensitivity to social exclusion. Experimental manipulations have produced inconsistent findings and suggested that baseline negative affect (NA) might influence the experience of exclusion. We administered a standardized social exclusion protocol (Cyberball paradigm) in BPD (n = 39) and age-matched and sex-matched healthy controls (n = 29) to investigate the association of NA on social exclusion and activation in brain regions previously implicated in this paradigm. Compared with controls, patients with BPD showed higher activation during social exclusion in the anterior cingulate cortex (ACC), the medial prefrontal cortex (mPFC), and in the right precuneus. Prescan NA ratings were associated with higher brain activation in the ACC and mPFC over all conditions, and post hoc t tests revealed that differences between the groups were only significant when controlling for NA. Brain activation during exclusion was correlated with NA separately for each group. Only BPD patients showed a significant association of NA and exclusion related precuneus activation (r = .52 p = .001). Additionally, BPD patients experienced less feelings of belonging compared with a healthy control (HC) group during inclusion and exclusion, although they estimated their ball possessions significantly higher than did the HC. These findings suggest that baseline NA has a crucial impact on Cyberball-related brain activation. The results underscore the importance of considering levels of NA in social exclusion protocols for participants high in this trait.

Alternative Model of Personality Disorders (DSM-5) Predicts Dropout in Inpatient Psychotherapy for Patients With Personality Disorder.

OBJECTIVE: Criterion A serves as the fundamental diagnostic criterion of the Alternative Model of Personality Disorders in section III of the Diagnostic and Statistical Manual 5. Consisting of a self- and an interpersonal dimension, it defines the construct of personality functioning as a general and dimensional factor of personality disorders. This study aimed to explore criterion A along with well-established treatment dropout predictors, e.g., sociodemographic factors, personality disorder diagnosis, symptom severity, and the therapeutic alliance. METHODS: The sample consisted of 132 patients diagnosed with personality disorder in a psychotherapeutic inpatient treatment. Cox proportional hazard regression models and a lasso model were applied. RESULTS: 28% of the sample prematurely discontinued treatment. The risk for dropout was 2.3 times higher for patients with high impairments in self-functioning as assessed with criterion A. Moreover, a positive therapist-rated therapeutic alliance was associated with a lower dropout risk. CONCLUSION: The study suggests criterion A is a useful clinical indicator by identifying patients with personality disorder with a higher risk for dropout. An individualized therapeutic approach for such patients might be required.

Exclusion-Proneness in Borderline Personality Disorder Inpatients Impairs Alliance in Mentalization-Based Group Therapy.

Interpersonal sensitivity, particularly threat of potential exclusion, is a critical condition in borderline personality disorder (BPD) which impairs patients' social adjustment. Current evidence-based treatments include group components, such as mentalization-based group therapy (MBT-G), in order to improve interpersonal functioning. These treatments additionally focus on the therapeutic alliance since it was discovered to be a robust predictor of treatment outcome. However, alliance is a multidimensional factor of group therapy, which includes the fellow patients, and may thus be negatively affected by the exclusion-proneness of BPD patients. The aim of this pilot study was to examine the predictive value of threat of social exclusion for the therapeutic alliance in MBT-G. In the first part of the study, social exclusion was experimentally induced in 23 BPD inpatients and 28 healthy subjects using the Cyberball paradigm, a virtual ball tossing game. The evoked level of threat was measured with the Need-Threat Scale (NTS) which captures four dimensions of fundamental human needs, i.e., the need for belongingness, for self-esteem, for control, and for a meaningful existence. In the second part of the study, therapeutic alliance was measured on three dimensions, the therapists, the fellow patients and the group as a whole, using the Group-Questionnaire (GQ-D). BPD patients scored higher in their level of threat according to the NTS in both, the inclusion and the exclusion condition. The level of threat after exclusion predicted impairments of the therapeutic alliance in MBT-G. It was associated with more negative relationships, lower positive bonding and a lower positive working alliance with the fellow patients and lower positive bonding to the group as a whole whilst no negative prediction of the alliance to the therapists was found. Consequently, our translational study design has shown that Cyberball is an appropriate tool to use as an approach for clinical questions. We further conclude that exclusion-proneness in BPD is a critical feature with respect to alliance in group treatments. In order to neutralize BPD patients' exclusion bias, therapists may be advised to provide an "inclusive stance," especially in initial sessions. It is also recommendable to strengthen patient to patient relations.

Functional characteristics of control adaptation in intermodal sensory processing.

The present work investigated functional characteristics of control adjustments in intermodal sensory processing. Subjects performed an interference task that involved simultaneously presented visual and auditory stimuli which were either congruent or incongruent with respect to their response mappings. In two experiments, trial-by-trial sequential congruency effects were analysed for specific conditions that allowed ruling out "non-executive" contributions of stimulus or response priming to the respective RT fluctuations. In Experiment 1, conflict adaptation was observed in an oddball condition in which interference emanates from a task-irrelevant and response-neutral low-frequency stimulus. This finding characterizes intermodal control adjustments to be based - at least partly - on increased sensory selectivity, which is able to improve performance in any kind of interference condition which shares the same or overlapping attentional requirements. In order to further specify this attentional mechanism, Experiment 2 defined analogous conflict adaptation effects in non-interference unimodal trials in which just one of the two stimulus modalities was presented. Conflict adaptation effects in unimodal trials exclusively occurred for unimodal task-switch trials but not for otherwise equivalent task repetition trials, which suggests that the observed conflict-triggered control adjustments mainly consist of increased distractor inhibition (i.e., down-regulation of task-irrelevant information), while attributing a negligible role to target amplification (i.e., enhancement of task-relevant information) in this setup. This behavioral study yields a promising operational basis for subsequent neuroimaging investigations to define brain activations and connectivities which underlie the adaptive control of attentional selection.