Childhood sexual and physical abuse in adult patients with borderline personality disorder

Childhood abuse as a risk factor for suicidal behavior in borderline personality disorder

A childhood history of sexual or physical abuse is highly prevalent in borderline personality disorder (BPD) and is associated with self-destructive behavior in clinical and nonclinical samples. Viewing BPD as a "high risk" disorder, we asked if childhood abuse was a risk factor for adult suicidal behavior or if it was related to other known risk factors for suicide in BPD. A semistructured Abuse History was obtained in 61 criteria-defined BPD patients, who were characterized by structured interviews and self-reports for Axis I disorders, Suicide History, BPD severity, hopelessness, impulsivity, impulsive-aggression, and antisocial traits. Occurrence and severity of childhood sexual abuse, but not physical abuse, predicted adult suicidal behavior independent of other known risk factors. The odds of a sexually abused patient attempting suicide in adulthood was over 10 times that of a patient who was never sexually abused. Given a history of childhood sexual abuse, the risk of adult suicidal behavior in BPD was increased by antisocial traits, severity of BPD, hopelessness, or comorbid major depressive episode (MDE).

Attachment, parental bonding and borderline personality disorder features in young adults

The relations between parental bonding and attachment constructs and borderline personality disorder features were examined in a sample of 393 18-year-old participants. Hierarchical regression analyses revealed that parental bonding and attachment scores (especially insecure attachment, anxious or ambivalent attachment, and a perception of a relative lack of caring from one's mother) were uniquely associated with borderline features beyond what could be accounted for by gender, childhood adversity experiences, Axis I disorder, and nonborderline Axis II symptoms. Although relatively modest, these relations suggest that bonding and attachment constructs might be considered in comprehensive etiological models of borderline personality disorder.

Early physical and sexual abuse associated with an adverse course of bipolar illness

BACKGROUND

There is growing awareness of the association between physical and sexual abuse and subsequent development of psychopathology, but little is known, however, about their relationship to the longitudinal course of bipolar disorder.

METHODS

We evaluated 631 outpatients with bipolar I or II disorder for general demographics, a history of physical or sexual abuse as a child or adolescent, course of illness variables, and prior suicide attempts, as well as SCID-derived Axis I and patient endorsed Axis II comorbidity.

RESULTS

Those who endorsed a history of child or adolescent physical or sexual abuse, compared with those who did not, had a history of an earlier onset of bipolar illness, an increased number of Axis I, II, and III comorbid disorders, including drug and alcohol abuse, faster cycling frequencies, a higher rate of suicide attempts, and more psychosocial stressors occurring before the first and most recent affective episode. The retrospectively reported associations of early abuse with a more severe course of illness were validated prospectively.

CONCLUSIONS

Greater appreciation of the association of early traumatic experiences and an adverse course of bipolar illness should lead to preventive and early intervention approaches that may lessen the associated risk of a poor outcome.

The relationships among childhood abuse, borderline personality, and self-harm behavior in psychiatric inpatients

The current study was undertaken to explore the relationships among childhood abuse subtypes (sexual, physical, and emotional abuse; witnessing violence), three diagnostic screenings for borderline personality disorder (BPD), and self-harm behavior. Psychiatric inpatients (N = 77) were evaluated for childhood abuse histories through a survey. Participants also underwent assessment for BPD using a self-report measure, clinical diagnosis, and a DSM-IV checklist. Finally, each was assessed for self-harm behavior using the 22-item Self-Harm Inventory (SHI). Compared with non-abused participants, those with abuse histories (with the exception of witnessing violence) had a significantly greater number of BPD confirmations (i.e., self-report, clinical diagnosis, DSM-IV checklist) as well as self-harm behaviors. When examining the total number of endorsed abuse subtypes, there was a significant correlation with the number of self-harm behaviors, but not the number of BPD diagnoses. Among psychiatric inpatients, childhood abuse demonstrates a complex relationship to BPD diagnoses and self-harm behavior.

The epigenesis of the family system as a context for individual development

In this article, the concept introduced by Lyman Wynne, that the individual develops epigenetically within the family system, is discussed and validated with data from a study of the characteristics and relationships of 27 women with borderline personality disorder and their parents. Each stage of the epigenetic process is impaired in one way or another, adversely affecting subsequent stages. Early impairment of attachment-care-giving processes is at least partly attributable to a lack of empathic parenting; effective communication is married by family members' inability to experience or express feelings (alexithymia); this, in turn, makes it difficult to engage in joint family problem solving. Mutuality between family members does not occur in such a context, and there is an absence of intimacy between family members. These are often abusive family systems, with multiple abuse and intrafamilial sexual abuse more specifically directed at the daughter with BPD. The symptoms of the daughter can be understood systemically, as representing both predispositional characteristics and reactions to the family system. It is suggested that the epigenetic paradigm could be used to characterize the specific failure of developmental processes in many different disorders.

Structural relations between borderline personality disorder features and putative etiological correlates

This study assessed the structural relations between borderline personality disorder (BPD) features and purported etiological correlates. Approximately 5,000 18-year-old nonclinical young adults were screened for BPD features, and 2 cohorts of participants (total N = 421; approximately one half of whom endorsed significant borderline features) completed the laboratory phase of the study. Measures included self-report and interview-based assessments of BPD psychopathology, personality, psychopathology in biological parents, and childhood physical and sexual abuse. Significant relations between BPD features and purported etiological correlates of BPD were found. A multivariate model that included parental psychopathology, childhood abuse, and personality factors provided an adequate fit to the data and supported the contention that the personality traits disinhibition and negative affectivity underlie BPD features.

Childhood trauma and hostility as an adult: relevance to suicidal behavior

The objective of this study is to look for a relationship between childhood trauma and hostility as an adult. Toward this end, 294 recently abstinent cocaine or opiate dependent patients were asked to complete two questionnaires: the Childhood Trauma Questionnaire (CTQ) and the Hostility and Direction of Hostility Questionnaire (HDHQ). It was found that there were significant correlations between the HDHQ total hostility score and scores on the CTQ for childhood emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. Thus, these results suggest the possibility that childhood trauma may be a determinant of the personality dimension of hostility as an adult.

Development of a depersonalization severity scale

Our aim was to develop a clinician-rated scale assessing depersonalization severity for use in clinical trials of Depersonalization Disorder and trauma-related disorders in general. The 6-item Depersonalization Severity Scale (DSS) was administered to 63 participants with DSM-IV Depersonalization Disorder as diagnosed by the SCID-D, and its psychometric properties were examined. The sensitivity of the DSS and of the Dissociative Experiences Scale (DES) to treatment change was assessed in blinded, controlled settings. Individual items were widely distributed across the severity range. Interrater reliability was excellent and internal consistency was moderate. The DSS had high convergent and discriminant validity and was sensitive to treatment change. The DES was also sensitive to treatment change. We recommend piloting the DSS in future treatment trials of trauma-spectrum disorders.

The "A-B-C's" of the cluster B's: identifying, understanding, and treating cluster B personality disorders

This article is a summary of some of the more recent research on the diagnosis, etiology, and treatment of Cluster B personality disorders (antisocial, histrionic, borderline, and narcissistic). Research on psychological, psychosocial, and biological perspectives of these disorders is presented. Individual psychotherapy, group psychotherapy, and other forms of multi-person therapies are also discussed. Finally, perspectives on issues of countertransference when treating these personality-disordered patients are addressed.

Clinical features of survivors of sexual abuse with major depression

OBJECTIVE

This study examined differences in rates of trauma-related disorders between patients with histories of childhood sexual abuse and those without such histories in a sample of depressed outpatients. Another aim of this study was to determine whether childhood sexual abuse is associated with recent suicidal attempts, affect dysregulation and duration of index depressive episode, independent of posttraumatic stress disorder and borderline personality disorder.

METHOD

Subjects were 235 treatment-seeking outpatients with major depression. Structured interviews were administered to assess for Axis I and Axis II disorders, childhood sexual abuse, and various clinical features.

RESULTS

Patients with sexual abuse compared to those without sexual abuse histories had higher rates of comorbidity, primarily borderline personality disorder, posttraumatic stress disorder and multiple Axis I diagnoses. Childhood sexual abuse status was linked to a longer duration of the index depressive episode, independent of borderline personality disorder and/or posttraumatic stress disorder. However, childhood sexual abuse status was not independently related to affect dysregulation and suicidal attempts.

CONCLUSION

The findings suggest that patients with histories of sexual abuse represent a subgroup of depressed patients who are at especially high risk for psychiatric morbidity and a prolonged episode of depression.

Biparental failure in the childhood experiences of borderline patients

The purpose of this study was to assess the role of biparental abuse and neglect in the development of borderline personality disorder (BPD). A semistructured research interview was used to blindly assess the childhood experiences of biparental abuse and neglect reported by 358 borderline inpatients and 109 axis II controls. Eighty-four percent of borderline patients reported having experienced some type of biparental abuse or neglect before the age of 18; 55% reported a childhood history of biparental abuse; 77% reported a childhood history of biparental neglect. These experiences were also reported by a substantial percentage of Axis II controls (biparental abuse or neglect [61%], biparental abuse [31%], and biparental neglect [55%]). However, borderline patients were significantly more likely than axis II controls to report having been verbally, emotionally, and physically but not sexually abused by caretakers of both sexes. They were also significantly more likely than controls to report having caretakers of both sexes deny the validity of their thoughts and feelings, fail to provide them with needed protection, neglect their physical care, withdraw from them emotionally, and treat them inconsistently. It was also found that female borderlines who reported a previous history of neglect by a female caretaker and abuse by a male caretaker were at significantly higher risk for having been sexually abused by a noncaretaker. Taken together, the results of this study suggest that biparental failure may be a significant factor in the etiology of BPD. They also suggest that biparental failure may significantly increase a preborderline girl's risk of being sexually abused by someone other than her parents.

Development and preliminary psychometric properties of an instrument for the measurement of childhood trauma: the Early Trauma Inventory

Research on the effects of childhood trauma has been limited by the lack of a comprehensive, reliable, and valid instrument that assesses the occurrence of early traumatic experiences. This paper presents the development and preliminary psychometric properties of an instrument, the Early Trauma Inventory (ETI), for the assessment of reported childhood trauma. The clinician-administered ETI is a 56-item interview for the assessment of physical, emotional, and sexual abuse, as well as general traumatic experience (including items which range from parental loss to natural disaster). For each item of the ETI, frequency of abuse/trauma by developmental stage, onset and termination of abuse/trauma, perpetrator of the abuse/trauma, and impact on the individual are assessed. Initial analyses indicate acceptable inter-rater reliability, test-retest reliability, and internal consistency for the ETI. Comparisons between the ETI and other instruments for the assessment of trauma, as well as instruments for the measurement of symptoms related to abuse, such as dissociation and PTSD, demonstrated good convergent validity. Validity was also demonstrated based on the ability of the ETI to discriminate patients with PTSD from comparison subjects. Based on these findings, the ETI appears to be a reliable and valid instrument for the measurement of reported childhood trauma.

Recent developments in research of trauma and personality disorders

Although the association between trauma and personality disorders, particularly borderline personality disorder (BPD), has been well established, the etiologic role of trauma in the development of personality disorders has been a topic of debate. Numerous mediation models have been put forth to explain how trauma can serve as a risk factor for the subsequent development of BPD. The symptomatic overlap between the proposed complex post-traumatic stress disorder diagnosis and BPD has fueled research efforts aimed at determining whether these are distinct disorders or should both be considered as trauma spectrum disorders. Treatment implications of this diagnostic differentiation are discussed.

Relationships of borderline features to parental mental illness, childhood abuse, Axis I disorder, and current functioning

Although a number of studies have investigated single, putative etiological factors for borderline personality disorder (BPD), few studies have assessed the relations between multiple etiological factors and borderline features within the same study. Borderline features, parental psychopathology, childhood physical and sexual abuse, lifetime Axis I disorder, and current functioning were assessed in 65 nonclinical participants, a portion of which exhibited significant BPD features. Multivariate models were tested and results indicated that parental mental illness and lifetime Axis I disorder were significant and unique predictors of borderline scores. Borderline features accounted for significant variance in current functioning beyond what was accounted for by other predictors; borderline scores mediated the relations between lifetime Axis I disorder and current functioning.

Diatheses and stressors in borderline pathology of childhood: the role of neuropsychological risk and trauma

OBJECTIVE

To determine the relative contributions of neuropsychological deficits and psychosocial stressors to the presence of borderline pathology in children.

METHOD

The subjects were 86 school-age children (75 males, 11 females) referred for psychiatric day treatment. Thirty-five of the children met criteria for borderline pathology. Data on psychosocial risk factors were obtained for each child from a questionnaire completed by members of the child's clinical team and were based on interviews with parents and children, as well as reports from schools and social agencies. Neuropsychological measures included computerized versions of the Wisconsin Card Sorting Test and the Continuous Performance Test.

RESULTS

Both deficits in executive function and psychological trauma made significant and independent contributions to the variance in borderline pathology. Inclusion of both sets of risk factors produced a model that explained 48% of the variance in borderline diagnosis.

CONCLUSIONS

Both environmental risks and neurobiological vulnerability should be taken into account to understand the etiology of borderline pathology in children.

A comparison of posttraumatic stress disorder with and without borderline personality disorder among women with a history of childhood sexual abuse: etiological and clinical characteristics

The overlap in definition and presentation between posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) has raised questions about the relationship of these disorders. Are they separate disorders, variants of the same disorder, or comorbid conditions? The present study examined etiological variables and current functioning among two groups of outpatient women with a history of childhood sexual abuse: those with PTSD only (N = 45) and those with PTSD and BPD (N = 26). The groups did not differ in severity, frequency, or number of perpetrators of their childhood sexual abuse, or whether the perpetrator was a family member or not. The additional diagnosis of BPD was associated with earlier age of abuse onset and significantly higher rates of physical and verbal abuse by mother. Severity and frequency of PTSD symptoms were not affected by BPD diagnosis, suggesting that the personality disorder and PTSD are independent symptom constructs. The PTSD+BPD group scored higher on several other clinical measures including anger, dissociation, anxiety, and interpersonal problems. They did not differ in their frequency of use of mental health services but tended to be less compliant in their treatment. These and other findings are discussed, and implications for treatment are considered.

Prevalence of personality disorders among combat veterans with posttraumatic stress disorder

Many combat veterans with PTSD have co-occurring symptoms of other forms of psychopathology; however, there have been limited studies examining personality disorders among this population. The few extant studies typically have assessed only two or three personality disorders or examined a small sample, resulting in an incomplete picture and scope of comorbidity. This study assessed all DSM-III-R personality disorders in 107 veterans in a specialized, inpatient unit. Using the Structured Clinical Interview for DSM-III-R Personality Disorders, 79.4% of the participants were diagnosed with at least one personality disorder: 29.9% received only one diagnosis, 21.5% had two, 15.9% had three, and 12.1% had four or more. The most frequent single diagnoses were Avoidant (47.2%), Paranoid (46.2%), Obsessive-Compulsive (28.3%), and Antisocial (15.1%) personality disorders.

Serotonergic blunting to meta-chlorophenylpiperazine (m-CPP) highly correlates with sustained childhood abuse in impulsive and autoaggressive female borderline patients

BACKGROUND

Disturbances of affect, impulse regulation, and autoaggressive behavior, which are all said to be related to an altered function of the central serotonergic (5-HT) system, are prominent features of borderline personality disorder (BPD). A high coincidence of childhood physical and sexual abuse is reported in these patients. Animal studies indicate that early, sustained stress correlates with a dysfunctional central 5-HT system. Therefore, we hypothesize that sustained traumatic stress in childhood affects the responsivity of the postsynaptic serotonergic system of traumatized BPD patients.

METHODS

Following Axis I, Axis II, and trauma assessment, a neuroendocrine challenge test was performed with the postsynaptic serotonergic agonist meta-chlorophenylpiperazine (m-CPP) in 12 impulsive and autoaggressive female patients with BPD and 9 matched healthy volunteers.

RESULTS

The cortisol and prolactin responses to the m-CPP challenge in BPD patients were significantly lower compared to those in controls. Within the group of patients with BPD, the net prolactin response showed a high inverse correlation with the frequency of the physical (r = -.77) and sexual abuse (r = -.60).

CONCLUSIONS

Our data suggest that severe and sustained traumatic stress in childhood affects the 5-HT system and especially 5-HT(1A) receptors. This finding confirms the data from animal research. The blunted prolactin response to m-CPP appears to be the result of severe traumatization and independent of the BPD diagnosis.

Personality traits of women with a history of childhood sexual abuse

This study examined relationships between specific dimensions of childhood sexual abuse and personality traits in adulthood. Study participants were 74 hospitalized female psychiatric patients with a self-reported history of childhood sexual abuse. Characteristics of childhood sexual abuse were obtained from a structured life-events interview. Personality was measured with the NEO-Five-Factor Inventory (NEO-FFI), which yields scores on neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. We hypothesized that parental abuse, intercourse, and the combination of these two childhood sexual abuse characteristics would be associated with personality traits. Supporting this hypothesis, women who were abused by a parent had lower scores on openness to experience than women who were abused by someone else. Patients whose abuse history included both parental abuse and intercourse had very low extraversion scores. Our findings suggest that there are associations between personality traits and childhood sexual abuse characteristics in psychiatric patients. Specifically, women who experienced intercourse by a parent may be more introverted and less open to experience than women whose sexual abuse history does not include parental incest.

Childhood experiences associated with the development of borderline personality disorder

In time, mental health professionals will understand the etiology of BPD more fully. Although enormous strides have been made in the past decade, research into the multifactorial basis of BPD is still in its infancy. In particular, studies of children at high risk for developing BPD are needed. For now, the author suggests that one can admire patients with BPD for the integrity with which they have dealt with their pain. After all, not many people remain so loyal to and so respectful of such disheartening childhood experiences.

Predictors of comorbid personality disorders in patients with panic disorder with agoraphobia

The aim of this study was to ascertain predictors of comorbid personality disorders in patients with panic disorder with agoraphobia (PDAG). Sixty consecutive outpatients with PDAG were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) for the purpose of diagnosing personality disorders. Logistic regressions were used to identify predictors of any comorbid personality disorder, any DSM-IV cluster A, cluster B, and cluster C personality disorder. Independent variables in these regressions were gender, age, duration of panic disorder (PD), severity of PDAG, and scores on self-report instruments that assess the patient's perception of their parents, childhood separation anxiety, and traumatic experiences. High levels of parental protection on the Parental Bonding Instrument (PBI), indicating a perception of the parents as overprotective and controlling, emerged as the only statistically significant predictor of any comorbid personality disorder. This finding was attributed to the association between parental overprotection and cluster B personality disorders, particularly borderline personality disorder. The duration of PD was a significant predictor of any cluster B and any cluster C personality disorder, suggesting that some of the cluster B and cluster C personality disorders may be a consequence of the long-lasting PDAG. Any cluster B personality disorder was also associated with younger age. In conclusion, despite a generally nonspecific nature of the relationship between parental overprotection in childhood and adult psychopathology, the findings of this study suggest some specificity for the association between parental overprotection in childhood and personality disturbance in PDAG patients, particularly cluster B personality disorders.

Risk factors associated with the dissociative experiences of borderline patients

The objective of this study was to identify the risk factors associated with the dissociative symptomatology of borderline patients. The Dissociative Experiences Scale--a 28-item self-report measure that has well documented reliability and validity--was administered to 290 criteria-defined borderline patients and 72 axis II comparison subjects. Semistructured interviews pertaining to difficult childhood experiences and adult experiences of being a victim of violence were administered to these patients blind to diagnostic status. In the sample of borderline patients alone, multiple regression analyses revealed that four risk factors were found to be significantly associated with the level of dissociation reported by these 290 patients: inconsistent treatment by a caretaker, sexual abuse by a caretaker, witnessing sexual violence as a child, and adult rape history. In the combined sample of axis II patients, the borderline diagnosis joined these four "traumatic" factors as a significant predictor of the overall level of dissociation reported by these 362 personality-disordered inpatients. The results of this study suggest that both sexual trauma and something intrinsic to the borderline diagnosis itself are risk factors for dissociative phenomena among borderline patients.

A Jacksonian and biopsychosocial hypothesis concerning borderline and related phenomena

OBJECTIVE

The aim of this paper is to develop an aetiological model for borderline personality disorder.

METHOD

The postulates of Hughlings Jackson are used to provide a preliminary explanatory framework for borderline phenomena. As a necessary background to this discussion, the findings concerning abuse in the early history of borderline personality disorder (BPD) and other conditions, notably somatisation disorder and dissociative states, are briefly reviewed. Other data, including family studies, which might have significance in the aetiology of BPD are also reviewed.

RESULTS

The hypothesis is put forward that the symptoms of BPD are due to the failure of 'experience-dependent' maturation of a cascade of neural networks, with prefrontal connections, which become active relatively late in development and which coordinate disparate elements of central nervous system function. These networks subserve higher psychological functions, including attentional focus and affect regulation. They also underpin the reflective function necessary to the emergence of self as the stream of consciousness, which appears at about the age of 4 years.

CONCLUSION

Adverse developmental circumstances may produce an interrelated set of symptom clusters, with associated neural network disturbances that are amenable to investigation with psychometric and brain imaging techniques. Since these disturbances are seen as 'experience-dependent', they are considered reversible, at least in part.

Reality testing in adult women who report childhood sexual and physical abuse

OBJECTIVE

To better understand how neighborhood and individual factors are related to child maltreatment.

METHOD

Using an ecological framework, a multi-level model (Hierarchical Linear Modeling) was used to analyze neighborhood structural conditions and individual risk factors for child abuse and neglect. Parents (n = 400) of children under the age of 18 were systematically selected from 20 randomly selected census-defined block groups with different risk profiles for child maltreatment report rates. Parents were administered the Neighborhood Environment for Children Rating Scales, the Child Abuse Potential Inventory, the Zimet measure of social support, and the Conflict Tactics Scales as a measure of childhood experience with violence.

RESULTS

Neighborhood factors of improverishment and child care burden significantly affect child abuse potential after controlling for individual risk factors. However, neighborhood effects are weaker than they appear to be in aggregate studies of official child maltreatment reports. Variation in child abuse potential within neighborhoods is greater than between neighborhoods. However, adverse neighborhood conditions weakened the effects of known individual risk and protective factors, such as violence in the family of origin.

CONCLUSIONS

If individual potential for child maltreatment is more evenly distributed across neighborhoods than reported maltreatment, then neighborhood and community play an important, if as yet unspecified, role in child maltreatment. Multi-level models are a promising research strategy for disentangling the complex interactions of individual and contextual factors in child maltreatment.

Assumptions in borderline personality disorder: specificity, stability and relationship with etiological factors

The specificity and stability of a set of assumptions hypothesized to be characteristic of Borderline Personality Disorder (BPD) was investigated. BPD patients (n = 16) were compared to cluster-C personality disorder patients (n = 12) and to normal controls (n = 15). All subjects were female and diagnosed with SCID-I and -II. Subjects rated a short version of the Personality Disorder Beliefs Questionnaire (PDBQ), with six sets of 20 assumptions each, hypothesized to be characteristic of avoidant, dependent, obsessive-compulsive, paranoid, histrionic and borderline personality disorder. The BPD assumptions (Cronbach alpha = 0.95) proved to be the most specific to BPD patients. Subjects rated the shortened PDBQ again after viewing an emotional video fragment one week later. Despite increased negative emotions, the PDBQ ratings remained relatively stable. Confirming the cognitive hypothesis, regression analyses indicated that the BPD assumptions mediate the relationship between self-reported etiological factors from childhood (sexual abuse and emotional/physical abuse) and BPD pathology assessed with the SCID-II. It is suggested that a set of assumptions is characteristic of BPD, and is relatively stable despite the instability of the behaviour of people diagnosed as having BPD.

Violence in the lives of adult borderline patients

The purpose of this study was to assess the experiences of adult violence reported by a sample of criteria-defined borderline patients and axis II controls. The experiences of having had a physically abusive partner and/or having been raped reported by 362 personality-disordered inpatients were assessed blind to diagnostic status using a semistructured research interview. Forty-six percent of borderline patients reported having been a victim of violence since the age of 18. Borderline patients (N = 290) were significantly more likely than axis II controls (N = 72) to report having had a physically abusive partner, having been raped, having been raped multiple times, having been raped by a known perpetrator, and having been both physically assaulted by a partner and raped. Female borderline patients were significantly more likely than male borderline patients to have been physically and/or sexually assaulted as adults (50% vs. 26%). However, a significantly higher percentage of borderline patients of both genders reported experiences of adult violence than controls of the same gender. Four risk factors were found to significantly predict whether borderline patients had an adult history of being a victim of violence: female gender, a substance use disorder that began before the age of 18, childhood sexual abuse, and emotional withdrawal by a caretaker. The results of this study suggest that both male and female borderline patients are at substantial risk for being physically and/or sexually victimized as adults.

Does childhood sexual abuse cause borderline personality disorder?

Several studies have found that women with borderline personality disorder are more likely than controls to report a history of childhood sexual abuse. Researchers have generally assumed that childhood sexual abuse causes borderline personality disorder, but there are other possible interpretations of the association. We surveyed psychologists about the likelihood that patients with various personality disorders would engage in behaviors relevant to several alternative interpretations. Relative to patients with other personality disorders and to the "typical outpatient," patients with borderline personality disorder were rated as especially likely to misinterpret or misremember social interactions, to lie manipulatively and convincingly, and to have voluntarily entered destructive sexual relationships, possibly even at young ages. We discuss the plausibility of relevant alternative interpretations of the association between childhood sexual abuse and borderline personality disorder.

Twin study of dissociative experience

The relative influence of genetic and environmental influences on measures of pathological and nonpathological dissociative experience was estimated using a classic twin-study design. Subjects were 177 monozygotic and 152 dizygotic volunteer general population twin pairs who completed two measures of dissociative capacity identified from the items comprising the Dissociative Experiences Scale (DES). Additive genetic influences accounted for 48% and 55% of the variance in scales measuring pathological and nonpathological dissociative experience, respectively. Heritability estimates did not differ by gender. The genetic correlation between these measures was estimated at .91, suggesting common genetic factors underlying pathological and nonpathological dissociative capacity. Genetic and environmental correlations between the DES scales and measures of personality disorder traits (Dimensional Assessment of Personality Pathology-Basic Questionnaire; DAPP-BQ) were also estimated. Significant genetic correlations (median = .38) were found between the DES scales and DAPP-BQ cognitive dysregulation, affective lability, and suspiciousness, suggesting that the genetic factors underlying particular aspects of personality disorder also influence dissociative capacity.

Possible antecedents of DSM-III-R personality disorders

In order to extend our knowledge of the effects of environmental influences upon personality disorder (PD) pathology, childhood traumatic events and parental bonding were studied in 90 PD in-patients of both sexes. Childhood traumatic experiences (primarily physical and/or sexual abuse) and parental bonding dimensions were correlated with PD pathology depending on PD type and cluster. Important differences were found between the sexes. The quality of the paternal relationship (high control, low care) was significantly associated with PD pathology in men, whereas childhood traumatic experiences and the quality of maternal parenting were associated with PD pathology in women. The study of traumatic events such as childhood abuse has recently been the focus of considerable attention. More emphasis in empirical research needs to be given to parental relationships, especially in the case of men.

Does childhood trauma cause personality disorders in adults?

OBJECTIVE

To examine the relationship between trauma in childhood and personality disorders in adulthood.

METHOD

A review of the literature was conducted.

RESULTS

The reported associations between trauma and personality pathology are illuminated by the following research findings: 1) personality is heritable; 2) only a minority of patients with severe personality disorders report childhood trauma; and 3) children are generally resilient, and traumatic experiences do not consistently lead to psychopathology.

CONCLUSIONS

The role of trauma in the personality disorders is best understood in the context of gene-environment interactions.

The long term effects of childhood sexual abuse: rationale for and experience of pharmacotherapy with nefazodone

Studies estimate that 1 in 6 women and 1 in 10 men experience childhood sexual abuse (CSA). Whilst ill-health is not an inevitable consequence, approximately 20% of victims go on to have serious long-term pathology. This is reflected in an excess incidence of CSA survivors in problem populations, be they medical, forensic or psychiatric. Four groups of research studies suggest that PTSD-related mechanisms might be a major mediating factor in the development of symptoms: 1. There is high incidence of PTSD following sexual trauma; 2. Psychometric studies show evidence of impaired limbic functions; 3. There is evidence of neuroendocrine disturbances similar to those seen in war veterans with PTSD; 4. MRI studies show evidence of hippocampal atrophy. There is a growing database of studies showing that drugs that act as seroionergic modulators are effective in the treatment of PTSD. Drugs such as nefazodone which block 5HT2 receptors and inhibit the uptake of serotonin may be of particular value. Studies suggest that trauma-related issues are not always addressed in patients with a history of abuse. Given the problems posed, there is a need to review their treatment in the light of emergent knowledge. Further research is needed to validate these findings.

Psychiatric staff as attachment figures. Understanding management problems in psychiatric services in the light of attachment theory

BACKGROUND

Attachment theory argues that psychological development and functioning are affected by our earliest attachments to care-givers. Failed or pathological attachment in childhood may give rise to repetition of maladaptive attachment patterns in adulthood.

METHOD

Analysis of therapeutic relationships in the light of attachment theory.

RESULTS

Relationships between patients and both psychiatric care-givers and institutions may resemble attachment relationship.

CONCLUSION

An attachment perspective may be useful for understanding common behavioural disturbances in general psychiatric settings, and support the use of clinical strategies which focus on containment of arousal and the management of anxiety states.

Hand Test scores of panic disordered outpatients sexually abused as children

A history of childhood sexual abuse has been implicated in a variety of adult psychiatric disorders as more frequent in females than in males and in subjects with more prominent dissociative symptoms such as panic disorder. Previous research has varied greatly in terms of methods, measurement instruments, and reported findings. Recent studies, however, suggest that projective techniques may be useful in resolving some of these inconsistencies. The present study utilized the Hand Test to investigate the late effects of childhood sexual trauma in a group of authenticated cases of panic disordered adult outpatients sexually abused as children compared to a matched sample of presumably nonabused patients. No statistically significant differences on quantitative variables were obtained between the two groups, but the group of outpatients (n = 16) sexually abused as children showed a larger latency to the ninth card of the Hand Test (shock reaction). This may be a potentially useful index in investigating cases of suspected abuse and confirms Wagner's (1983) contention that Card IX has a psychosexual "pull" as documented also by Italian studies.

History of childhood sexual abuse and general psychopathology

Reported history of childhood sexual abuse (CSA) was correlated with general measures of psychopathology on the SCL-90-R in a sample that included inpatients with borderline personality disorder (BPD), inpatients with major depression, and a nonpatient control group. When subjects who reported abuse were compared with those who did not, scores for the Global Severity Index (GSI) and all subscales of the SCL-90-R, except for the obsessive-compulsive and somatization subscales, were significantly-higher. When only those subjects who reported CSA were studied and when specific measures of CSA were the independent variables and SCL-90-R subscales were the dependent variables, scores on the hostility, interpersonal sensitivity, and paranoia subscales of the SCL-90-R were significantly higher. Because a large proportion of the sample consisted of borderline patients, and because both the specific measures of CSA and the borderline diagnosis could predict similar SCL-90-R subscale results, a series of stepwise regressions were performed. In the first regression, diagnosis, gender, and specific measures of CSA were the predictor variables and SCL-90-R subscale scores were the dependent variables; in the second regression, SCL-90-R subscales and specific measures of CSA were the predictor variables and diagnosis was the dependent variable. Interpersonal sensitivity was the only significant predictor of the borderline diagnosis. We suggest that, at least in some cases, interpersonal sensitivity may be the constitutional/environmental substrate on which traumatic experiences interact to arrive at the borderline diagnosis.

Histories of childhood trauma and complex post-traumatic sequelae in women with eating disorders

The profound self-destructiveness and tenacity of eating disorders found among women abused and neglected in childhood become comprehensible when understood within a complex posttraumatic conceptualization as desperate attempts to regulate overwhelming affective states and construct a coherent sense of self and system of meaning. Trauma leads to the predictable consequences of dysregulation of the arousal system, avoidance, and constriction of affect; coherence of self and world are shattered. Abused patients' childhood experiences teach them that to need is to expose oneself to the pain of abandonment and betrayal at the hands of individuals responsible for their care. Consequently, needs-psychological, physical, and spiritual-come to be perceived as dangerous, and human relationships are simultaneously yearned for and feared. Robbed of the opportunity to develop a cohesive self and a coherent system of meaning and faith to sustain from within, the traumatized eating-disorder patient turns to the culture to tell her who to be and how to live; she learns that to conquer rather than satisfy needs and to be "in control" (an internal state of equanimity manifested externally in a thin body) will bring meaning and purpose. Binge eating, purging, and starving become apt metaphors for the boundless hunger, the wish to fulfill needs together with the wish to rid oneself forever of need, the desire to "purify" the damaged psychic and physical self, and the hope of restoring meaning. The treatment of the traumatized eating disorder patient is complex. Individual therapy provides the opportunity for intensive relational work that begins to restore faith in human connection and that provides a "safe base" from which to examine the trauma and separate past from present. Therapy groups for eating-disordered women and trauma survivors provide relief from isolation, valuable perspectives from others who have "been there," and the opportunity to contribute to others' healing as one heals. Ultimately, these patients must be willing to leave the world of obsession with food and weight, which guarantees safety from interpersonal hurt while it simultaneously guarantees that hope will not be restored. Though reconnecting with humanity carries the risk of further pain, it opens up the opportunity for connection, healing, and growth.

Victims and perpetrators of child sexual abuse

BACKGROUND

This article aims to inform clinicians of current thinking in the area of victims and perpetrators of child sexual abuse. It covers prevalence data as well as identification, effects and interventions with victims, and also characteristics, assessment and treatment of perpetrators.

METHOD

The review is based on manual searches and the authors' own clinical experience.

RESULTS

All clinicians should be aware of signs and symptoms that raise the possibility that someone has been or is being sexually abused, and also of the possibilities of abuse of boys and of women as abusers. Methods of intervening are discussed, both in relation to victims and perpetrators. The importance of thoroughness when assessing perpetrators is emphasised because of their tendency to deny and/or minimise their offending. The demands of this work are underlined in a section on the necessary qualifications and characteristics of therapists working in this area.

CONCLUSIONS

Despite the lack of agreement in definitions and outcome measures used in research there are some positive findings in relation to clinical efficacy. In particular, the need for long-term treatment with those offenders who are more seriously deviant has been supported by recent research. There is a need for continuing attempts to standardise definitions and measures to aid realistic comparison of research results.

A critical review of recovered memories in psychotherapy: Part I--Trauma and memory

OBJECTIVE

The theoretical basis of the use of recovered memories in psychotherapy will be critically examined.

METHOD

Literature will be reviewed on the nature of normal memory, and on the relationship of trauma to memory.

RESULTS

Normal memories are surprisingly inaccurate. There is little evidence that normal memories can be repressed. There is no evidence that trauma makes repression more likely.

CONCLUSIONS

"Recovery" of repressed memories is not consistent with the findings of empirical research.

Borderline personality disorder: study in adolescence

The study of the presentation, symptomatology and family characteristics of an exclusively adolescent sample of patients with borderline personality disorder (BPD) was undertaken. Twenty-four cases of borderline personality disorder, 20 females, 4 males, identified using chart review and meeting the criteria of the Diagnostic Interview for Borderlines (DIB) and DSM III-R, were matched with psychiatric controls. Adolescents with borderline personality disorder were found to have high rates of affective symptomatology with Axis I diagnosis of major depressive disorder MDD (DSM-III-R), and high rates of interpersonal psychopathology, i.e., manipulation, devaluation, and a pervasive sense of boredom. The latter seem to be characteristic as for adults with borderline personality disorder. The families were particularly angry and volatile.

Lifetime axis I and II comorbidity and childhood trauma history in dissociative identity disorder

According to DSM-IV, dissociative identity disorder is characterized by the existence within the person of two or more distinctly different identities or personality states that from time to time take executive control of the person's body and behavior, with accompanying amnesia (American Psychiatric Association, 1994). By retrospective patient report, dissociative identity disorder usually occurs in conjunction with severe childhood trauma (Kluft 1985; Putnam et al. 1986; Ross 1989; Ross et al. 1989a, 1990a). The disorder appears to be the most severe form of disturbance on the dissociative disorders continuum (Boon and Draijer 1993; Coons 1992; Ross 1985; Ross et al. 1992). There is evidence that dissociative identity disorder may be more prevalent than once believed in the general population (Ross 1991) and among general adult psychiatric inpatients (Latz et al. 1995; Ross et al. 1991; Saxe et al. 1993).

Family relationships of adults with borderline personality disorder

Current, ongoing interactions between adults exhibiting borderline personality disorder (BPD) traits and their families of origin may influence and maintain self-destructive behavior. Family interactions in such patients are often characterized by coexisting extremes of overinvolvement and underinvolvement by parental figures. Such parental behavior may trigger preexisting role relationship schemata in vulnerable individuals. Negative family reactions to new behavior patterns may make change difficult. A model for how present-day interpersonal patterns lead to self-destructive behavior, based on clinical observations, is proposed and case examples are presented.

Risk factors for borderline pathology in children

OBJECTIVE

To examine risk factors associated with borderline pathology in latency-age children.

METHOD

The subjects were 98 children assessed for day treatment. Borderline subjects were identified in a chart review using the Child Diagnostic Interview for Borderlines, which divided the sample into borderline (n = 41) and nonborderline (n = 57) groups. Functional levels were assessed by Children's Global Assessment Scale scores. The risk factors were also rated by chart review; all subjects were given a cumulative abuse score and a cumulative parental dysfunction score.

RESULTS

Both groups demonstrated severe functional impairment. The risk factors that differentiated the borderline group were sexual abuse, physical abuse, severe neglect, and parental substance abuse or criminality. Sexual abuse and severe neglect were significant in multivariate analysis. Cumulative abuse and cumulative parental dysfunction scores were both higher in the borderline group.

CONCLUSIONS

The findings indicate that the risk factors in borderline children are similar to those found in adults.

Relationship of borderline symptoms to histories of abuse and neglect: a pilot study

Axis II diagnoses of 50 applicants for long-term inpatient treatment were obtained using the Personality Diagnostic Questionnaire, Revised. Clinical records were coded for evidence of a history of childhood abuse or neglect. Seventy-five percent of patients with a diagnosis of Borderline Personality Disorder (BPD) had histories of some type of abuse, compared with 33 percent of the nonborderline patients. A principal components analysis of the eight DSM-III-R criteria for BPD and histories of abuse and neglect showed that abuse history is correlated with the criteria of unstable relationships, feelings of emptiness, and abandonment fears, whereas neglect history is correlated with suicidal behavior. Affective instability, intense anger, and identity disturbance were uncorrelated with abuse or neglect. Thus, the affective symptoms of BPD appear to be unrelated to aversive childhood events, consistent with the concept of a subtype of BPD dominated by affective dysregulation.

Deficits in short-term memory in adult survivors of childhood abuse

Exposure to stress has been associated with alterations in memory function, and we have previously shown deficits in short-term verbal memory in patients with a history of exposure to the stress of combat and the diagnosis of posttraumatic stress disorder (PTSD). Few studies of any kind have focused on adult survivors of childhood physical and sexual abuse. The purpose of this study was to investigate short-term memory function in adult survivors of childhood abuse. Adult survivors of severe childhood physical and sexual abuse (n = 21), as defined by specific criteria derived from the Early Trauma Inventory (ETI), who were presenting for psychiatric treatment were compared with healthy subjects (n = 20) matched for several variables including age, alcohol abuse, and years of education. All subjects were assessed with the Wechsler Memory Scale (WMS) Logical (verbal memory) and Figural (visual memory) components, the Verbal and Visual Selective Reminding Tests (SRT), and the Wechsler Adult Intelligence Scale-Revised (WAIS-R). Adult survivors of childhood abuse had significantly lower scores on the WMS Logical component for immediate and delayed recall in comparison to normal subjects, with no difference in visual memory, as measured by the WMS or the SRT, or IQ, as measured by the WAIS-R. Deficits in verbal memory, as measured by the WMS, were associated with the severity of abuse, as measured by a composite score on the ETI. Our findings suggest that childhood physical and sexual abuse is associated with long-term deficits in verbal short-term memory. These findings of specific deficits in verbal (and not visual) memory, with no change in IQ, are similar to the pattern of deficits that we have previously found in patients with combat-related PTSD.