Fig. 1

Hypothetical pathogenesis model inspired by Amad et al. [35]. The interplay of environmental factors and the genetic constitution leads to traits (e.g. impulsivity, emotional dysregulation or attention problems). These provoke reactions (supportive or invalidating). In case of adverse events (e.g. parental aggression), a mutual reinforcement (e.g. stress <− > impulsivity) +/− epigenetic effects intensify the symptoms. To reduce stress, individuals develop maladaptive behaviors that are again reinforced and repeated in the case of a predominantly negative environment. Overlapping risk factors, symptoms and behaviors lead to rather imprecise categorial diagnoses