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. 2026 Sep 30;17(1):2699494. doi: 10.1080/20008066.2026.2699494

The mediating role of personality functioning impairment between childhood maltreatment and adult mental health problems

El papel mediador del deterioro del funcionamiento de la personalidad entre el maltrato infantil y los problemas de salud mental en la edad adulta

Delfine d'Huart a,b,c,*, Sofie Frey a,*, Gresa Mazreku a,b,c, Isabel Hauri a, Dorothée Bentz b, Marc Birkhölzer a,b,d,CONTACT
PMCID: PMC13629795  PMID: 42812003

ABSTRACT

Background: Childhood maltreatment is a critical societal and public health concern significantly associated with adult mental health outcomes. Recent research suggests that impaired personality functioning may mediate this association.

Objective: The aim of the present study was to examine personality functioning impairment (PFI) as a potential mediator between different types of childhood maltreatment and self-reported adult mental health problems in a large community-based sample. In addition, this study sought to identify the domains and subdomains of PFI that have the strongest mediating effects between different types of childhood maltreatment and adult mental health problems.

Method: 1,148 adults, with a mean age of 43.49 years (SDage = 5.80; 85.89% female) were included in the analysis. Childhood maltreatment was measured with the Childhood Trauma Questionnaire (CTQ-SF), PFI with the Levels of Personality Functioning Questionnaire – Adult (LoPF-Q Adult), and mental health problems with the Brief Symptom Inventory (BSI-18). Mediation analyses were conducted through structural equation modelling.

Results: A total of 352 (30.69%) reported at least one type of childhood maltreatment, with emotional abuse being most common (14.48%). Emotional abuse and neglect showed the strongest association with PFI (r = 0.41 and r = 0.45, p < .001) and adult mental health problems (r = 0.32 and r = 0.30, p < .001). Overall, PFI significantly mediated the effects of all types of childhood maltreatment, but when self- and interpersonal functioning were considered separately, only self-functioning remained a significant mediator.

Conclusions: Taken together, the present findings suggest that PFI, particularly self-functioning, may present an important pathway linking childhood maltreatment to adult mental health outcomes. In addition, findings revealed emotional maltreatment to be particularly important in the context of PFI and adult mental health. Integrating trauma-informed practices within community-based child programmes may foster resilience and counteract unfavourable mental health outcomes.

KEYWORDS: Childhood maltreatment, personality functioning, adult mental health, self-functioning, mediation analysis

HIGHLIGHTS

  • Personality functioning impairment significantly mediates the association between childhood maltreatment and adult mental health problems.

  • When both self- and interpersonal functioning were considered, only impaired self-functioning remained a significant mediator.

  • Both identity and self-direction impairments mediated the association, with self-direction showing slightly stronger effects.

1. Introduction

Childhood maltreatment (i.e. emotional, physical and sexual abuse and neglect) is a significant societal and public health concern, affecting hundreds of millions worldwide. The World Health Organization (WHO, 2026) defines childhood maltreatment as any form of physical, sexual or emotional abuse and neglect of individuals aged 0–17 years by parents, caregivers or other authority figures. In a series of meta-analyses, Stoltenborgh et al. (2015) found that more than a third of children globally experience childhood maltreatment. Self-report studies indicated prevalence rates of 36.3% for emotional abuse, 22.6% for physical abuse, 12.7% for sexual abuse, 16.3% for physical neglect, and 18.4% for emotional neglect (Stoltenborgh et al., 2015). It is well established that various forms of childhood maltreatment are significantly associated with poor mental health outcomes in childhood (Maguire-Jack et al., 2022) and adulthood (Hughes et al., 2017). Recent systematic reviews and meta-analyses, for instance, have linked childhood maltreatment to adult mental health disorders, including depression and anxiety (Li et al., 2016), suicidality (Angelakis et al., 2019), substance abuse (Halpern et al., 2018; Zhu et al., 2023) and borderline personality disorder (Porter et al., 2020). However, not all individuals exposed to childhood maltreatment develop mental health problems in adulthood, highlighting the role of resilience in promoting positive adaptation (Lang et al., 2020). Resilience factors, such as caregiver warmth, positive peer relationships and social support, may buffer against adverse outcomes (Austin et al., 2020; Yoon et al., 2021). Fritz et al. (2018) found protective factors at the individual, family- and community-level, with resilience at the individual level being linked to cognitive reappraisal, mental flexibility, effective emotion regulation, social connectedness, and a strong sense of self. The construct of personality functioning encompasses similar abilities, such as self-reflection, emotion regulation, adaptive interpersonal behaviour and self-direction (Sharp & Wall, 2021). This conceptual overlap suggests that personality functioning may be considered as an important aspect of resilience (d’Huart et al., 2022), while PFI then reflects a reduced resilience. This may point to the potential role of personality functioning as a mediator, partially explaining why some individuals experience greater mental health burden in association with childhood maltreatment than others.

With the introduction of the Alternative Model of Personality Disorders (AMPD) in Section III of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) and the eleventh edition of the International Classification of Diseases (ICD-11; WHO, 2026), the concept of personality functioning gained increasingly attention (Zimmermann et al., 2019). Both models define PFI as the core feature of PD (Sharp & Wall, 2021). In the DSM-5, Criterion A of the AMPD conceptualises personality functioning as self- (i.e. identity and self-direction) and interpersonal functioning (i.e. empathy and intimacy), ranging from healthy functioning to extreme impairment. Given that personality functioning may be impaired in various ways, Criterion B describes 25 pathological trait facets, organised into the five broader domains of Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. Using the AMPD, a PD diagnosis is assigned when there is at least moderate impairment in Criterion A, that it is relatively stable, pervasive and not better explained by another mental disorder, substance use, medical condition, developmental stage, or socio-cultural context (APA, 2013). Unlike the DSM-5, the ICD-11 does not mandate the presence of pathological traits, but rather emphasises PFI as the defining feature of PD (WHO, 2026).

A growing body of research has shown that childhood maltreatment is linked to PFI (Back et al., 2021). Emotional abuse, for instance, has been found to be associated with impaired identity and impaired interpersonal functioning, while emotional neglect has been found to be associated with impaired intimacy functioning (Gander et al., 2020). In addition, overall childhood maltreatment has been found to be significantly associated with overall PFI (Back et al., 2020), with multiple childhood maltreatment increasing the risk for PFI in multiple domains (Granieri et al., 2018). From a theoretical perspective, impairments in core aspects of personality functioning – such as difficulties in identity integration, emotion regulation, and/or the capacity to develop and maintain close relationships – may, in turn, undermine an individual’s ability to cope with emotional distress, thereby predisposing the individual to the development of mental health problems. This notion is supported by a growing body of evidence indicating that PFI is significantly linked to mental health problems (Buer Christensen et al., 2020; Kerber et al., 2024; Veenstra et al., 2022). Accordingly, Doubková et al. (2022) suggested that the level of personality functioning may serve as a global indicator of both, the presence and the severity of mental health symptoms. In addition, individuals with PFI have been found to be at increased risk for depressive and anxiety disorders (Crempien et al., 2017; Dagnino et al., 2020; Doering et al., 2018). Taken together, this suggests that PFI might be an important mechanism through which childhood maltreatment exerts its long-term effects on adult mental health, rather than merely amplifying the impact of childhood maltreatment, as would be expected in a moderating role.

Indeed, previous work supports the idea that PFI may serve as a mediator for the long-term consequences of childhood maltreatment. As such, PFI has been identified as a significant mediator in the association between childhood maltreatment and overall mental health problems (d’Huart et al., 2022; Krakau et al., 2021), depressive disorders (Freier et al., 2022; Vaccarezza et al., 2025), as well as anxiety and depressive symptoms (Dagnino et al., 2020). Interestingly, emotional abuse and neglect consistently showed the strongest associations with PFI and subsequent mental health problems (d’Huart et al., 2022; Freier et al., 2022; Vaccarezza et al., 2025). Likewise, self-functioning showed a stronger mediating effect when both self-functioning and interpersonal functioning were included as potential mediators in the association between childhood maltreatment and adult mental health problems (d’Huart et al., 2022; Krakau et al., 2021; Vacarezza et al., 2025).

Thus, there is evidence that the association between childhood maltreatment and mental health problems might be mediated by PFI with self-functioning impairment having the strongest mediating effect. However, current findings are mostly limited to overall personality functioning, either assessed with the operationalised psychodynamic diagnosis structure questionnaire (i.e. OPD Structure Questionnaire [OPD-SQ]; Ehrenthal et al., 2012, 2015), the Semi-structured Interview for Personality Functioning DSM-5 (STiP-5.1; Hutsebaut et al., 2017) or with the brief form of the Level of Personality Functioning Scale (LPFS-BF; Hutsebaut et al., 2016). A study in a large community-based sample with detailed measures of childhood maltreatment, PFI, and self-reported mental health problems is thus needed to extend current evidence by investigating the subdomains of self-functioning (e.g. identity and self-direction) as potential mediators. To the best of our knowledge, no such study to date has done so.

To this end, the aim of the present study was to examine PFI as a potential mediator between different types of childhood maltreatment and self-reported adult mental health problems in a large community-based sample. In addition, this study sought to identify the domains and subdomains of PFI that have the strongest mediating effects between different types of childhood maltreatment and adult mental health problems. Based on the aforementioned findings, we hypothesised: (1) that PFI would partially mediate the relationship between various types of childhood maltreatment and adult mental health problems; (2) that self-related PFI (i.e. identity and self-direction) would mediate the relationship between various types of childhood maltreatment and mental health problems significantly stronger than interpersonal personality functioning impairment (i.e. empathy and intimacy) and (3) that identity impairment would mediate the relationship between childhood maltreatment and mental health problems significantly stronger than self-direction impairment. By differentiating these pathways, the present paper aims to clarify how distinct domains of PFI mediate the long-term effects of childhood maltreatment on mental health problems, providing insights that may inform targeted clinical interventions.

2. Methods

2.1. Study design and participants

Data was obtained from the longitudinal, international and multi-centered EARLY study (Investigating Early Signs and Developmental Course of Impaired Personality Functioning in Young People, https://osf.io/45etz/overview), which assess the mental health of parents and their children aged five to 19 years in both the general population and clinical inpatient and out-patient settings. The present study focuses on Swiss parents’ self-reported data, collected at baseline between August 2023 and July 2025. Recruitment was conducted by the Department of Youth Forensics at the Psychiatric University Hospitals (UPK) Basel as well as the Faculty of Psychology at the University of Basel (Department of Clinical Psychology and Translational Psychotherapy Research Lectureship). Participants were recruited through public schools and social media platforms across Basel and surrounding regions. After providing written informed consent, participants received a link to complete online questionnaires. Upon competition, they were compensated with a CHF 20 voucher, redeemable at a broad range of retails stores across Switzerland. Inclusion criteria were sufficient German proficiency and being a parent of a child aged five to 19 years. The study was approved by the Ethics Committee Northwestern and Central Switzerland (EKNZ; Ref. 2023-00877). The present hypotheses were preregistered at: https://osf.io/4esm3/overview.

The final sample comprised N = 1,148 adults, of which 85.89% (n = 986) were female with a mean age of 42.49 years (SDage = 5.80; age range = 25–70 years).

2.2. Measures

2.2.1. Childhood Trauma Questionnaire – Short Form (CTQ-SF)

Childhood maltreatment was assessed using the Childhood Traum Questionnaire – Short Form (CTQ-SF; Bernstein et al., 2003), a 25-item retrospective self-report questionnaire assessing childhood maltreatment histories. Three additional items compose the Minimalization/Denial scale specifically designed to identify individuals who may be underreporting traumatic events. The CTQ-SF includes five subscales: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. Items are rated on a 5-point Likert scale (‘never true’ [1] to ‘very often true’ [5]), with subscale scores ranging from 5 (no childhood maltreatment) to 25 (extreme childhood maltreatment). A total score is calculated by summing up the score of each subscale. Clinical relevance is determined using the severity classification by Bernstein and Fink (1998), which categorises each subscale into four levels: none/low, low/moderate, moderate/severe, and severe/extreme. For the present analysis, participants scoring in the moderate/severe, and severe/extreme range were considered to having experienced childhood maltreatment. The CTQ-SF shows strong reliability and validity, with interclass correlation coefficients ranging from 0.76 to 0.86 (Bernstein et al., 2003). For the present study, the German version of the CTQ-SF was used (Klinitzke et al., 2011). Internal consistency in the present sample ranged from acceptable to excellent (α = 0.78–0.90), except for the physical neglect subscale, which showed poor reliability (α = 0.51). The total scale, however, indicated excellent internal consistency (α = 0.92, see Table S1 in the Supplement).

2.2.2. Levels of Personality Functioning Questionnaire – Adult (LoPF-Q Adult)

Personality functioning was assessed using the Levels of Personality Functioning Questionnaire – Short Version (LoPF-Q Adult; Goth & Schmeck, 2023). The LoPF-Q Adult is a 36-item self-report questionnaire, originally adapted from the adolescent version (LoPF-Q 12–18; Goth et al., 2018). Items are rated on a 5-point scale ranging from ‘strongly disagree’ (0) to ‘strongly agree’ (4), with higher scores indicating greater impairment. The LoPF-Q Adult provides both a total score and four scale scores referring to the domains of self-functioning (i.e. identity and self-direction) and interpersonal functioning (i.e. empathy and intimacy). T-scores ≥ 60 indicate clinically relevant impairment. The LoPF-Q demonstrates excellent reliability (α = 0.98 total; 0.89–0.96 for domains) and discriminates clinical from non-clinical samples (d = 3.1; Goth & Schmeck, 2023). For the present study, the German version of the LoPF-Q 12–18 was used (Goth & Schmeck, 2023). In the present sample, internal consistency for the domain scales ranged from acceptable to good (α = 0.74–0.85), while the total scale showing excellent internal consistency (α = 0.93, see Table S1 in the Supplement).

2.2.3. Brief Symptom Inventory – 18 (BSI-18)

Mental health problems were assessed with the German version of the Brief Symptom Inventory – 18 (BSI-18; Derogatis, 2017; Spitzer et al., 2011) which originally derives from the Symptom Checklist (SCL-90-R; Franke, 1992). The BSI-18 includes 18 items across three symptom dimensions (i.e. somatisation, depression and anxiety), as well as a Global Severity Index (GSI). Items are rated on a 5-point scale (‘not at all’ [0] to ‘very strongly’ [4]) based on the past seven days. The GSI ranges between 0–72 and the three scale scores between 0–24. T-scores ≥ 63 indicate clinically significant mental health problems. The German version of the BSI-18 shows high reliability (α = .82–.93) and strong internal consistency (Franke et al., 2017). In the present sample, internal consistency for the symptom dimensions ranged from acceptable to good (α = 0.66–0.82), with excellent reliability found for the total GSI (α = 0.87, see Table S1 in the Supplement).

2.3. Statistical analysis

All analyses were conducted using RStudio (Version 2025.05.1 + 513; R Core Team, 2020). Descriptive statistics were calculated for sociodemographic variables, childhood maltreatment, personality functioning and mental health problems. Clinically relevant PFI was described using T-scores (i.e. T-scores from 60 to 70: mild to moderate impairment; T-scores ≥70: severe impairment), while raw scores were used for correlations and mediation models. Bonferroni-corrected Spearman correlation coefficients were calculated to investigate the associations between childhood maltreatment, PFI and mental health problems. In order to classify the magnitude of the correlations, we followed Cohen's (1988) conventions, whereby coefficients of .10, .30, and .50 were considered small, moderate, and large effects, respectively. Mediation models were tested using structural equation modelling (SEM), adjusted for age, in order to explore the mediating role of PFI between childhood maltreatment and mental health problems (i.e. hypotheses 1, 2 and 3). The mediation effect is referred to as the indirect effect, while the portion of childhood maltreatment that does not go through PFI is referred to as the direct effect. Summing up the direct and indirect effect results in the total effect of childhood maltreatment on mental health problems. First, we calculated the indirect effect of PFI (i.e. LoPF-Q total score) between different types of childhood maltreatment (i.e. CTQ-SF total score, emotional abuse, physical abuse, sexual abuse, physical neglect, and emotional neglect) and mental health problems to test hypothesis 1. We, then excluded the LoPF-Q total score as potential mediator and simultaneously incorporated the domains of self-functioning and interpersonal functioning to test hypothesis 2. Finally, we excluded the LoPF-Q domains of self- and interpersonal functioning and simultaneously incorporated the subdomains of identity and self-direction to test hypothesis 3. The proportion of the mediating effect indicates the proportion of the total effect that occurs through the mediating effect (i.e. indirect effect). A bootstrapping sampling procedure with 5′000 bootstrapped samples was applied to estimate indirect effects and confidence intervals (Hayes, 2013). All mediation models were just-identified (df = 0), meaning that the number of estimated parameters equals the number of observed variances and covariances. As a results, fit indices such as the Comparative Fix Index (CFI), the Root Mean Square Error of Approximation (RMSEA), and the Standardized Root Mean Square Residual (SRMR) are not informative for evaluating model fit. The focus of the present analyses was therefore on testing specific mediation hypotheses following conventional guidelines (Hayes, 2013) rahter than evaluating overall model fit. Multicollinearity of independent variables was assessed and had not to be considered (see Additional file 1: Table S1). The SEM models were conducted using the lavaan package (Rosseel, 2012). Statistical significance was set to p < .05. Complete case analyses were performed.

3. Results

3.1. Sample characteristics

Descriptive measures are displayed in Table 1. Overall, 30.69% (n = 352) reported at least one type of childhood maltreatment. Emotional abuse was most commonly reported (14.48%), followed by emotional neglect (13.43%), and physical neglect (13.07%). A total of 13.51% (N = 155) participants reported clinically relevant mental health problems, with most individuals showing anxiety symptoms (20.05%), followed by depressive symptoms (12.55%) and somatisation symptoms (9.42%). Overall, 16.3% (n = 187) participants showed significant PFI, with 4.53% (n = 53) exhibiting mild-to-moderate, and 11.77% (n = 135) exhibiting severe-to-extreme impairments. A total of 18.49% (n = 212) showed impairments in identity, 20.31% (n = 233) in self-direction, 8.02% (N = 92) in empathy and 14.82% (N = 170) showed impairments in intimacy.

Table 1.

Descriptive characteristics (N = 1,148).

  M (SD)
Age (years) 42.49 (5.8)
  N (%)
Gender (female) 986 (85.89)
Childhood maltreatment  
 Overall childhood maltreatment 352 (30.69)
 Emotional abuse 166 (14.48)
 Physical abuse 62 (5.4)
 Sexual abuse 137 (11.94)
 Emotional neglect 118 (13.43)
 Physical neglect 150 (13.07)
Impaired personality functioning  
 Overall Impairment 187 (16.3)
 Identity 212 (18.49)
 Self-direction 233 (20.31)
 Empathy 92 (8.02)
Intimacy 170 (14.6)
Mental health problems  
 Overall mental health problems 155 (13.51)
 Depressive symptoms 144 (12.55)
 Anxiety symptoms 230 (20.05)
 Somatisation symptoms 108 (9.42)
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3.2. Associations between childhood maltreatment, personality functioning and mental health problems

Findings regarding the associations between childhood maltreatment, personality functioning, and mental health problems are presented in Table 2. All types of childhood maltreatment were significantly positively associated with PFI, with effect sizes ranging from small (i.e. r = 0.17, sexual abuse) to moderate (i.e. r = 0.45, emotional neglect), indicating that higher levels of childhood maltreatment are associated with higher levels of PFI in adulthood. Likewise, all types of childhood maltreatment were significantly positively associated with mental health problems, ranging from small (i.e. r = 0.13, sexual abuse) to moderate (i.e. r = 0.33, emotional abuse), indicating that higher levels of childhood maltreatment were associated with higher levels of mental health problems in adulthood. Finally, impaired personality functioning was significantly positively associated with mental health with a large effect size of r = 0.62. A comprehensive correlation matrix including all CTQ types, PFI domains, and mental health outcomes, is provided in Table S2 in the Supplement.

Table 2.

Associations between childhood maltreatment, impaired personality functioning and mental health problems (N = 1,148).

  Overall personlaity functioning Mental health problems
Overall childhood maltreatment 0.43*** 0.30***
Emotional abuse 0.41*** 0.32***
Physical abuse 0.20*** 0.14***
Sexual abuse 0.17*** 0.13***
Emotional neglect 0.45*** 0.30***
Physical neglect 0.28*** 0.18***
Overall personlaity functioning – 0.62***
 Identity – 0.62***
 Self-direction – 0.63***
 Empathy – 0.48***
 Intimacy – 0.42***
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Note: Pearson’s r is reported. *p < .05; **p < .01; ***p < .001.

3.3. Mediation analyses

Findings regarding hypothesis 1, predicting that PFI would partially mediate the relationship between various types of childhood maltreatment and adult mental health problems, are presented in Figure 1. First, all types of childhood maltreatment were significantly associated with PFI in adulthood, ranging from β = 0.167 (p < .001) for sexual abuse to β = 0.440 (p < .001) for emotional neglect. Second, across all models, PFI was significantly associated with mental health problems, ranging from β = 0.582 to β = 0.611 (p < .001). Third, significant total effects were found for all types of childhood maltreatment, ranging from β = 0.121 (p = .001) for sexual abuse to β = 0.309 (p < .001) for emotional abuse. Fourth, PFI showed a significant indirect effect for all types of childhood maltreatment (p < .001). Specifically, indirect effects were β =  0.248 (95%-CI [ 0.326, 0. 0.491]) for emotional abuse, β =  0.270 (95% CI [0.271, 0.552]) for physical abuse, β = 0.102 (95%-CI [0.179, 0.410]) for sexual abuse, β = 0.263 (95% CI [0.339, 0.499]) for emotional neglect, and β = 0.168 (95%-CI [0.348, 0.557]) for physical neglect. Fifth, a significant direct effect was found only for emotional abuse (β = 0.077; p = .012).

Figure 1.

Six path diagrams showing childhood maltreatment types predicting adult mental health problems via personality functioning. All data are approximate.

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Mediation Models of impaired personality functioning in the association between childhood maltreatment and adult mental health problems, adjusted for age (N = 1,148).

Findings regarding hypothesis 2, predicting that self-related PFI (i.e. identity and self-direction) would mediate the relationship between various types of childhood maltreatment and adult mental health problems significantly stronger than interpersonal PFI (i.e. empathy and intimacy), are displayed in Figure S1 in the Supplement. First, all types of childhood maltreatment were significantly associated with self-related PFI, ranging from β = 0.171 (p < .001) for sexual abuse to β = 0.416 (p < .001) for emotional neglect, as well as interpersonal PFI, ranging from β = 0.142 (p < .001) for sexual abuse to β = 0.412 (p < .001) for emotional neglect. Second, across all models, only self-related PFI was significantly associated with mental health problems, ranging from β = 0.650 to β = 0.668 (p < .001). Third, significant total effects were found for all types of childhood maltreatment, ranging from β = 0.114 (p < .001) for sexual abuse to β = 0.309 (p < .001) for emotional abuse. Fourth, only self-related PFI significantly mediated the association between all types of childhood maltreatment and mental health problems when both, self- and interpersonal functioning were included as potential mediators (p < .001). Specifically, indirect effects were β =  0.254 (95%-CI [ 0.200, 0.311]) for emotional abuse, β =  0.125 (95%-CI [0.083, 0.175]) for physical abuse, β = 0.114 (95%-CI [0.072, 0.162]) for sexual abuse, β = 0.275 (95%-CI [0.221, 0.332]) for emotional neglect, and β = 0.166 (95%-CI [0.123, 0.213]) for physical neglect. Fifth, a significant direct effect was found only for emotional abuse (β = 0.064; p = .032). Figure 2 displays forest plots for the indirect effects for self-related and interpersonal impaired functioning in the association between childhood maltreatment types and mental health problems.

Figure 2.

A forest plot chart showing standardized indirect effects of childhood maltreatment types on mental health via self and interpersonal functioning. The figure shows a forest plot chart with 6 grouped sections labeled Overall Maltreatment, Emotional Abuse, Physical Abuse, Sexual Abuse, Emotional Neglect, and Physical Neglect. Each section contains 2 horizontal effect lines representing mediators: self functioning and interpersonal functioning. The horizontal axis is labeled Standardized Indirect Effect, 95 percent confidence interval, with numeric tick marks running from 0.0 to about 0.35 in steps of 0.05 for the top row, and from 0.0 to about 0.20 in steps of 0.05 for the lower rows. For each maltreatment type, a point marker indicates the indirect effect and a horizontal line shows its 95 percent confidence interval. A dashed vertical reference line at 0.0 appears in each section. For Overall Maltreatment, Emotional Abuse, Physical Abuse, Sexual Abuse, Emotional Neglect, and Physical Neglect, the self functioning lines extend to the right of 0.0 with nonzero point estimates, while the interpersonal functioning lines cluster around 0.0. A legend below the chart identifies self functioning and interpersonal functioning as the 2 mediators and uses different line styles and colors to distinguish them. All data are approximate.

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Indirect effects for self-related and interpersonal impaired functioning in the association between overall childhood maltreatment and mental health problems (N = 1,148).

Note: Error bars indicate 95% confidence intervals. The self-related functioning path was significant, while the interpersonal functioning path was not. The red dashed line marks the threshold for non-significance.

Findings regarding hypothesis 3, predicting that identity impairment would mediate the relationship between childhood maltreatment and mental health problems significantly stronger than self-direction impairment, are displayed in Figure S2 in the Supplement. First, all types of childhood maltreatment were significantly associated with identity impairment, ranging from β = 0.171 (p < .001) for sexual abuse to β = 0.410 (p < .001) for emotional neglect, as well as self-direction impairment, ranging from β = 0.154 (p < .001) for sexual abuse to β = 0.381 (p < .001) for emotional neglect. Second, identity impairment was significantly associated with mental health problems for all types of childhood maltreatment, ranging from β = 0.286 (p < .001) for emotional abuse to β = 0.301 (p < .001) for physical abuse. Likewise, self-direction impairment was significantly associated with mental health problems for all types of childhood maltreatment, ranging from β = 0.377 (p < .001) for emotional abuse to β = 0.387 (p < .001) for physical abuse, sexual abuse and physical neglect. Third, significant total effects were found for all types of childhood maltreatment, ranging from β = 0.121 (p < .001) for sexual abuse to β = 0.309 (p < .001) for emotional abuse. Fourth, both identity impairment and self-direction impairment significantly mediated the association between all types of childhood maltreatment and mental health problems when they were included as potential mediators (p < .001). The mediating effect of self-direction impairment was slightly stronger for all types of childhood maltreatment than that of identity impairment (p < .001). Figure 3 displays a line plot with error bars for the indirect effects for impaired identity and impaired self-direction in the association between childhood maltreatment types and mental health problems.

Figure 3.

A line graph comparing identity and self direction indirect effects across childhood maltreatment types, with values mostly decreasing. The figure shows a line graph with error bars illustrating approximate standardized indirect effects for 2 mediators across childhood maltreatment types. The horizontal axis is labeled Childhood Maltreatment Type and lists Overall Maltreatment, Emotional Abuse, Emotional Neglect, Physical Neglect, Physical Abuse, and Sexual Abuse. The vertical axis is labeled Standardized Indirect Effect, 95 percent confidence interval, with a numeric scale from 0.00 to 0.20 marked at intervals of 0.05. One line represents identity impairment and one line represents self direction impairment. For each maltreatment type, both mediators have positive indirect effects with overlapping confidence intervals. For Overall Maltreatment, both mediators are around 0.13 to 0.16. For Emotional Abuse and Emotional Neglect, the lines stay at similar levels near 0.11 to 0.15. At Physical Neglect, values begin to decline, roughly 0.08 to 0.12. For Physical Abuse, values fall further to about 0.05 to 0.08. For Sexual Abuse, both mediators are lowest, near 0.05 to 0.07. Across maltreatment types, self direction impairment appears slightly higher than identity impairment. All data are approximate.

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Indirect effects for impaired identity and impaired self-direction in the association between overall childhood maltreatment and mental health problems (N = 1,148).

Note: Bars represent standardised indirect effects from the mediation for impaired identity and impaired self-direction in the association between overall childhood maltreatment and mental health problems. Error bars indicate 95% bootstrap confidence intervals based on 5,000 samples. Higher bar values reflect stronger mediation effects.

4. Discussion

The aim of the present study was to examine PFI as a potential mediator between different types of childhood maltreatment and self-reported adult mental health problems in a large community-based sample. In addition, this study sought to identify the domains and subdomains of PFI that have the strongest mediating effects between different types of childhood maltreatment and adult mental health problems. Overall, about one-third (30.7%) reported at least one type of childhood maltreatment, which aligns with the prevalence rate reported by Witt et al., 2017 in a large, representative sample of the German general population (31.0%). A total of 13.5% participants reported clinically relevant adult mental health problems, a prevalence rate that is somewhat lower, yet broadly consistent with the 18.1% recently reported by (Michel et al., 2024) in the Swiss general population. Finally, about 16.3% participants showed significant PFI, with most participants showing self-direction impairment (20.3%), followed by impairments in identity (18.5%), intimacy (14.8) and empathy (8.0%).

First, and in line with hypothesis 1, PFI was a significant mediator in the association between various types of childhood maltreatment and adult mental health problems. This is consistent with previous findings in community studies (Freier et al., 2022; Kampling et al., 2022; Krakau et al., 2021; Vaccarezza et al., 2025), suggesting that childhood maltreatment negatively affects personality functioning, which in turn leads to higher levels of adult mental health problems. A significant mediating effect was found for all types of childhood maltreatment, which is consistent with the findings from Freier et al. (2022). In our study, the strongest mediating effect was found for emotional neglect, followed by overall childhood maltreatment and emotional abuse, in relation to adult mental health problems. In contrast, Freier et al. (2022) reported the strongest mediating effects for emotional, physical and sexual abuse, with somewhat weaker effects for emotional and physical neglect and adult symptoms of depression and anxiety. Thus, whereas Freier et al. (2022) emphasised that PFI most strongly mediated the effects of ‘overt abuse’ such as physical abuse and emotional abuse, our findings indicate that this pathway is particularly pronounced for emotional forms of maltreatment (i.e. emotional abuse and emotional neglect). This again, is consistent with the findings of Vacarrezza et al. (2025), who reported significant mediating effects only for emotional abuse and emotional neglect in relation to adult depressive symptoms. Moreover, emotional abuse and neglect were more strongly associated with PFI than other types of childhood maltreatment in our sample. This is in line with findings from a clinical sample reported by Gander et al. (2020) and a high-risk sample reported by d’Huart et al. (2022), that support the growing evidence that emotional abuse and neglect may be more relevant in the context of PFI than other forms of childhood maltreatment (Back et al., 2021). Notably, in our study, PFI mediated about 75% and 89% of the total effect of emotional abuse and neglect on adult mental health problems, indicating that only about 25% and 11% of these effects operated through a direct pathway from emotional abuse and neglect to adult mental health problems. This may reflect the central role of positive emotional experiences such as being taken care for and a validating environment in the development of personality and personality functioning. Both forms of childhood maltreatment appear to directly undermine the child’s self-concept and emotion regulation (Kim et al., 2023; Pereira et al., 2021) – core components of personality functioning. Thus, impairments in these abilities may explain why PFI mediates the link between emotional abuse and neglect and adult mental health problems more strongly than for other forms of childhood maltreatment (d’Huart et al., 2022; Krakau et al., 2021; Vacarezza et al., 2025)). In contrast, the mediating effects for physical and sexual abuse were considerably smaller, consistent with the weaker bivariate associations observed for these childhood maltreatment types (see Table 2). While PFI still significantly mediated these associations, its contribution to explaining the long-term effects of physical and sexual abuse appear more limited, and other mechanisms may play a more prominent role.

Second, consistent with hypothesis 2, our findings revealed a significant mediating effect of self-functioning impairment when both self-functioning and interpersonal functioning were included as potential mediators in the association between all types of childhood maltreatment and adult mental health problems. This is in line with previous findings (d’Huart et al., 2021; Krakau et al., 2021; Vacarezza et al., 2025) highlighting the central role of self-functioning in relation to childhood maltreatment and adult mental health outcomes. Notably, self-functioning showed the strongest mediating effect for emotional abuse and neglect. Prior meta-analyses and cross-sectional studies suggest that these types of childhood maltreatment may impede the development of self-compassion (Huang & Hou, 2023; Ross et al., 2019; Zhang, Li, et al., 2023), self-esteem (Zhang, Wang, et al., 2023), self-efficacy (Sachs-Ericsson et al., 2011) and reflective functioning (Paetzold & Rholes, 2021) – factors closely linked to self-functioning, which in turn, may lead to adult mental health problems. Indeed, a lack of responsiveness to a child’s needs may encumber the child’s ability to identify and value their own needs, which in turn, may result in a less coherent sense of self and a diminished capacity for self-directed behaviour (d’Huart et al., 2022; Kapeleris & Paivio, 2011).

Third, hypothesis 3, which predicted that identity impairment would more strongly mediate the relationship between various types of childhood maltreatment and adult mental health problems than self-direction impairment, was only partially supported. In fact, both identity and self-direction impairment significantly mediated the effects of all types of childhood maltreatment and adult mental health problems, with slightly stronger effects for self-direction impairment. Mediating effects in the association between physical and sexual abuse and adult mental health problems were again somewhat weaker, although not statistically significant, warranting further investigation. While identity embraces the individual’s ability to perceive a unique, coherent and stable sense of self, and to sustain a stable self-esteem, self-direction refers to the ability to regulate impulses and emotions and adapt one’s behaviour in a goal-oriented manner. This, in turn, requires self-reflection and sufficient agency to recognise one’s own needs and desires, in order to direct behavioural efforts towards a meaningful purpose (Perrini et al., 2024). Although no prior study has directly examined the mediating role of both identity and self-direction impairment in the association between childhood maltreatment and adult mental health, previous literature showed that childhood maltreatment – especially emotional abuse and neglect – significantly increase the risk of impaired identity development in adolescence (Gander et al., 2025; Penner et al., 2019). In addition, emotional abuse and neglect were significantly associated with lower self-direction (Leiting et al., 2024; Perrini et al., 2024). As Perrini et al. (2024) argue, emotional abuse and neglect may interfere with the development of self-direction through self-reflective and meta-reflective processes, as well as altered mental representations of the self, others, and the broader world. Consequently, maltreated children struggle to integrate their experiences, leading to a fragmented identity, ultimately leading to difficulties in forming coherent life goals (Perrini et al., 2024). Moreover, a recent meta-analysis, found that various facets of lower selfhood – such as self-esteem, self-concept, self-compassion, self-awareness, self-efficacy and self-regulation (Baumeister, 1999, 2023) – are significantly associated with depression and anxiety in adolescence (Yeo et al., 2023). Likewise, lower self-control (He et al., 2023; Kim et al., 2022), self-esteem and self-compassion (Muris & Otgaar, 2023) were significantly associated with higher rates of mental health problems in adulthood. This may help explain why both identity and self-direction impairment were significant mediators in the association between childhood maltreatment and adult mental health problems.

Integrating the findings across all three hypotheses, a consistent pattern emerges in which emotional abuse and neglect revealed the strongest mediating effects through PFI (hypothesis 1), driven primary by self-functioning (hypothesis 2) and specifically by impairments in both identity and self-direction (hypothesis 3). This, again, reflects the central role of early emotional experiences in the development of a stable sense of self. Indeed, emotional abuse and neglect appear to directly undermine the child’s self-concept and emotion regulation capacities (Kim et al., 2023; Pereira et al., 2021), which, in turn may interfere with the development of a coherent sense of self and self-directed behaviour (Perrini et al., 2024). This may thus explain, at least in part, why PFI, in particular identity and self-direction, showed the strongest mediating effect for emotional childhood maltreatment relative to other forms of childhood maltreatment. While PFI also significantly mediated the effects of physical and sexual abuse, these effects were considerably weaker, suggesting that other mechanisms may play a more prominent role for these types of childhood maltreatment.

4.1. Strength and limitations

Methodologically, this study has notable strengths, including its large community-based sample and comprehensive assessment of childhood maltreatment and impaired PFI. Nevertheless, findings must be interpreted under the light of some limitations. First, the use of mediation analyses with cross-sectional data has been widely questioned (Maxwell et al., 2011), arguing that they might produce biased estimates due to the lack of temporal data. Although the present study was conducted according to the recommendations of Hayes (2013), findings must be interpreted with caution and further investigations using longitudinal studies are highly needed. Second, childhood maltreatment was assessed through a retrospective self-report questionnaire, which may be prone to recall bias and influenced by current personality functioning. Nonetheless, the CTQ-SF has demonstrated satisfactory validity (Hardt & Rutter, 2004), and comparative research found no significant difference between prospective and retrospective self-reports of childhood maltreatment (Scott et al., 2012). In addition, the physical neglect subscale of the CTQ-SF showed poor internal consistency in the present sample (α = 0.51), which is consistent with meta-analytical evidence, showing that physical neglect consistently shows the lowest internal consistency among CTQ-SF subscales (Badenes-Ribera et al., 2024). Findings related to physical neglect should therefore be interpreted with caution. Third, mental health problems were assessed using a brief self-report questionnaire, prone to social desirability and limited self-awareness. Moreover, the BSI-18 only captures mental health problems related to anxiety, depression and somatisation, and does not assess the full range of potential mental health disorders (e.g. substance use, psychosis). Future studies should therefore consider using more comprehensive measures of mental health outcomes. Nevertheless, the BSI-18 has shown good validity, even when applied in a clinical sample (Michel et al., 2024). Fourth, the present sample was mainly female (85.6%), which considerably limits the generalizability of the findings. Future studies should therefore aim for more balanced samples.

4.2. Clinical implications

From a public mental health perspective, the present findings emphasise the importance to focus on early identification of childhood maltreatment – foremost emotional maltreatment, which, despite being less visible than physical or sexual abuse, was most prevalence and most strongly associated with PFI and adult mental health problems. The findings add to the need to sensitise school- and community-based programmes to the impact of childhood maltreatment and PFI. Preventive practices may include parent-focused interventions that foster sensitive and responsive caregiving, as well as trauma-informed approaches in schools (e.g. Avery et al., 2021) and community-based programmes, in order to strengthen community resilience (King et al., 2022). More specifically, vulnerable children and adolescents should be assisted in developing more adaptive self-concepts, self-direction, and emotion regulation capacities (e.g. Pedrini et al., 2022).

5. Conclusion

The present study adds to the current understanding of PFI, particularly self-functioning impairment, as a key mediator in the association between childhood maltreatment and adult mental health problems. Notably, both identity and self-direction impairment significantly mediated the effects of childhood maltreatment and adult mental health problems, with slightly stronger effects for self-direction impairment. This adds to the need to assist vulnerable children and adolescents in developing healthy self-functioning in order to promote adult mental health. Furthermore, the findings revealed emotional abuse and neglect to be particularly important in the context of PFI and adult mental health problems and, therefore, should not be overlooked compared to the more ‘obvious’ physical forms of childhood maltreatment. Integrating trauma-informed practices within community-based child programmes may foster resilience and counteract the psychopathological outcomes.

Author contributions statement

The initial work was developed for a master’s thesis by SF. All authors contributed to conceiving and designing the present study. SF and DH wrote the original draft of the manuscript. SF, IH, GM, DH collected the data. DH and GM analyzed the data. GM, DB and MB reviewed and edited the original draft. All the authors read and approved the final manuscript and agree to be accountable for all aspects of the work.

Ethics statement

The study was approved by the Regional Ethics Committee of Northwestern and Central Switzerland (EKNZ; Ref. 2023-00877). Written informed consent was obtained from all participants prior to data collection. All procedures followed the principles of the Declaration of Helsinki.

Supplementary Material

Supplemental Material
ZEPT_A_2699494_SM8365.docx (796.8KB, docx)

Funding Statement

This work was supported by the Botnar Research Center for Child Health (BRCCH) Foundation.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Open Scholarship

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This article has earned the Center for Open Science badge for Preregistered. The materials are openly accessible at https://osf.io/4esm3/overview.

Data availability statement

The data that support the findings of this study are available from the corresponding author, [MB], upon reasonable request.

Supplemental Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2026.2699494.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Material
ZEPT_A_2699494_SM8365.docx (796.8KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, [MB], upon reasonable request.

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