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      Risk and Protective Factors for Personality Disorders: An Umbrella Review of Published Meta-Analyses of Case–Control and Cohort Studies

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          Abstract

          The putative risk/protective factors for several personality disorders remain unclear. The vast majority of published studies has assessed personality characteristics/traits rather than disorders. Thus, the current umbrella review of meta-analyses (MAs) aims to systematically assess risk or protective factors associated with personality disorders. We searched PubMed–MEDLINE/PsycInfo databases, up to August 31, 2020. Quality of MAs was assessed with AMSTAR-2, while the credibility of evidence for each association was assessed through standard quantitative criteria. Out of 571 initial references, five meta-analyses met inclusion criteria, encompassing 56 associations of 26 potential environmental factors for antisocial, dependent, borderline personality disorder, with a median of five studies per association, and median 214 cases per association. Overall, 35 (62.5%) of the associations were nominally significant. Six associations met class II (i.e., highly suggestive) evidence for borderline personality disorder, with large effect sizes involving childhood emotional abuse (OR = 28.15, 95% CI 14.76–53.68), childhood emotional neglect (OR = 22.86, 95% CI 11.55–45.22), childhood any adversities (OR = 14.32, 95% CI 10.80–18.98), childhood physical abuse (OR = 9.30, 95% CI 6.57–13.17), childhood sexual abuse (OR = 7.95, 95% CI 6.21–10.17), and childhood physical neglect (OR = 5.73, 95% CI 3.21–10.21), plus 16 further associations supported by class IV evidence. No risk factor for antisocial or dependent personality disorder was supported by class I, II, and III, but six and seven met class IV evidence, respectively. Quality of included meta-analyses was rated as moderate in two, critically low in three. The large effect sizes found for a broad range of childhood adversities suggest that prevention of personality disorders should target childhood-related risk factors. However, larger cohort studies assessing multidimensional risk factors are needed in the field.

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          Most cited references56

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          Measuring inconsistency in meta-analyses.

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            Meta-analysis in clinical trials

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              AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both

              The number of published systematic reviews of studies of healthcare interventions has increased rapidly and these are used extensively for clinical and policy decisions. Systematic reviews are subject to a range of biases and increasingly include non-randomised studies of interventions. It is important that users can distinguish high quality reviews. Many instruments have been designed to evaluate different aspects of reviews, but there are few comprehensive critical appraisal instruments. AMSTAR was developed to evaluate systematic reviews of randomised trials. In this paper, we report on the updating of AMSTAR and its adaptation to enable more detailed assessment of systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. With moves to base more decisions on real world observational evidence we believe that AMSTAR 2 will assist decision makers in the identification of high quality systematic reviews, including those based on non-randomised studies of healthcare interventions.

                Author and article information

                Contributors
                Journal
                Front Psychiatry
                Front Psychiatry
                Front. Psychiatry
                Frontiers in Psychiatry
                Frontiers Media S.A.
                1664-0640
                06 September 2021
                2021
                : 12
                : 679379
                Affiliations
                [1] 1Department of Psychiatry, University of Ottawa , Ottawa, ON, Canada
                [2] 2Department of Mental Health, The Ottawa Hospital , Ottawa, ON, Canada
                [3] 3Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology , London, United Kingdom
                [4] 4Faculty of Environmental and Life Sciences, Center for Innovation in Mental Health, School of Psychology, University of Southampton , Southampton, United Kingdom
                [5] 5Clinical Epidemiology Program, Ottawa Hospital Research Institute , Ottawa, ON, Canada
                [6] 6Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University , Linköping, Sweden
                [7] 7Neurosciences Department, University of Padua , Padua, Italy
                [8] 8Imaging of Mood- and Anxiety-Related Disorders (IMARD) Group, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERSAM , Barcelona, Spain
                [9] 9Department of Clinical Neuroscience, Centre for Psychiatric Research and Education, Karolinska Institutet , Solna, Sweden
                [10] 10Department of Psychiatry, Medical Faculty, University of Basel , Basel, Switzerland
                [11] 11Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck , Lübeck, Germany
                [12] 12Department of Psychiatry, Faculty of Medicine, University of Toronto , Toronto, ON, Canada
                [13] 13Centre for Addiction and Mental Health , Toronto, ON, Canada
                [14] 14Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia , Modena, Italy
                [15] 15Clienia AG, Wetzikon Psychiatric Centre , Wetzikon, Switzerland
                [16] 16Department of General Practice, University Medical Center Würzburg , Würzburg, Germany
                [17] 17Faculty of Education and Health, University of Greenwich , London, United Kingdom
                [18] 18Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton , Southampton, United Kingdom
                [19] 19Solent NHS Trust , Southampton, United Kingdom
                [20] 20Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center , New York, NY, United States
                [21] 21Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham , Nottingham, United Kingdom
                [22] 22Department of Pediatrics, Yonsei University College of Medicine , Seoul, South Korea
                [23] 23Department of Brain and Behavioural Sciences, University of Pavia , Pavia, Italy
                [24] 24Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London , London, United Kingdom
                [25] 25Outreach and Support in South London (OASIS) Service, South London and Maudsley NHS Foundation Trust , London, United Kingdom
                Author notes

                Edited by: Sara Calderoni, Fondazione Stella Maris (IRCCS), Italy

                Reviewed by: Michael Gordon, Monash Health, Australia; Michele Fornaro, New York State Psychiatric Institute (NYSPI), United States

                *Correspondence: Marco Solmi Marco.solmi83@ 123456gmail.com

                This article was submitted to Child and Adolescent Psychiatry, a section of the journal Frontiers in Psychiatry

                †These authors share first authorship

                ‡ORCID: Peter Kurotschka orcid.org/0000-0003-3750-6147

                Article
                10.3389/fpsyt.2021.679379
                8450571
                34552513
                9414f53c-2ea6-46d0-8f3e-68cb5049bc76
                Copyright © 2021 Solmi, Dragioti, Croatto, Radua, Borgwardt, Carvalho, Demurtas, Mosina, Kurotschka, Thompson, Cortese, Shin and Fusar-Poli.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 11 March 2021
                : 06 July 2021
                Page count
                Figures: 1, Tables: 4, Equations: 0, References: 59, Pages: 12, Words: 7485
                Categories
                Psychiatry
                Brief Research Report

                Clinical Psychology & Psychiatry
                umbrella review,personality disorder,prevention,meta-analysis,risk factor,systematic review,psychiatry,mental health

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