Borderline personality disorder , childhood trauma and structural dissociation of the personality

Borderline personality disorder and dissociation are strongly related. DSM-IV-TR criteria of BPD, for instance, include isolated dissociative symptoms (APA, 1994). Two thirds of BPD may be diagnosed of a dissociative disorder (Korzekwa, Dell and Pain, 2009). Both diagnoses have been related with high rates of childhood trauma. The close relationship between trauma, dissociation and borderline features can be understood from the perspective of the theory of structural dissociation of the personality (Van der Hart, Nijenhuis & Steele, 2006/2008) which transcends the traditional approach of describing "comorbidity". In this article we will review the empirical data which support the relation between early traumatizing and attachment disruption situations, and both borderline and dissociative symptoms. Borderline personality disorder will be explained in terms of structural dissociation of the personality. event and its characteristics: a threat to the physical integrity of oneself or other people. But in childhood, many perceived threats stem more from caregivers’ affective signals and caregiver availability than from the actual level or physical danger or risk for survival (Schuder & Lyons-Ruth, 2004). An often overlooked form of traumatization pertains to the so-called “hidden traumas,” that are related to the caregiver’s inability to modulate the affective dysregulation (Schuder & Lyons-Ruth (2004). Different studies have described a frequent comorbidity between PTSD and BPD (Driessen et al, 2002; McLean & Gallop, 2003; Harned, Rizvi, & Linehan 2010; Pagura et al, 2010; Pietrzak et al, 2010). Others found a relationship between BPD and emotional abuse (Kingdon et al, 2010) and different kinds of abuse (Grover, 2007; Tyrka et al, 2009). A history of childhood trauma predicts a poor outcome in borderline patients (Gunderson, 2006). PTSD symptoms together with dissociative symptomatology predict self-destructive behaviors (Spitzer et al, 2000; Sansone et al, 1995). Zanarini (2000a) reviewed the empirical literature that described estimates of childhood sexual abuse in BPD ranging between 40 to 70% compared with the rate of childhood sexual abuse in other Axis II disorder patients (19% to, 26%). While many of these studies were retrospective, some studies included prospective measures, and all showed a significant relationship between sexual abuse, childhood maltreatment, BPD precursors and BPD (Battle, Shea, Johnson et al, 2004; Cohen, Crawford, Johnson & Kasen, 2005; Rogosch & Chiccetti, 2005; Yen, Shea, Battle et al, 2002). Early maltreatment has been related not only to BPD, but to other mental disorders. However, these studies show that the relation is strongest with BPD as compared to other personality disorders. The severity of sexual abuse has also been related with the severity of BPD features (Silk, Lee, Hill &Lohr, 1995; Zanarini, Yong, Frankenburg et al, 2002) and self-harming behaviors (Sansone et al, 2002). Battle, Shea, Johnson, DM et al. (2004) developed a multisite investigation in which self-reported history of abuse and neglect experiences were assessed among 600 patients diagnosed with either a PD (borderline, schizotypal, avoidant, or obsessivecompulsive) or major depressive disorder without PD. They found that rates of childhood maltreatment among individuals with PDs are generally high (73% reporting abuse and 82% reporting neglect). BPD was more consistently associated with childhood abuse and neglect than other PD diagnoses. Graybar and Boutilier (2002) reviewed the empirical literature on BPD and various childhood traumas. They concluded that the reported rates of physical, sexual, and verbal abuse and neglect among BPD patients ranged from 60–80%. Laporte and Guttman (1996) also studied a range of childhood experiences in female patients with BPD and those with other personality disorders. They found that the patients with BPD were more likely to report a history of adoption, paternal alcoholism, parental divorce, parental desertion, leaving home before age 16, verbal abuse, physical abuse, sexual abuse, and witnessing more abuse than patients with other personality disorders. Furthermore, a significantly higher percentage of BPD patients than non-BPD patients reported multiple occurrences and more than one type of abuse. Paris and ZweigFrank (1997) found that the degree of severity of the abuse could distinguish individuals with BPD from those without BPD. Ball and Links (2009) review the literature on trauma and BPD in the context of Hill ́s classic criteria (1965) for demonstrating causation (strength, consistency, specificity, temporality, biological gradient, plausibility, coherence, experimental evidence and analogy). These authors demonstrated that trauma can be considered a causal factor in the development of BPD, as part of a multifactorial etiologic model. Goodman and Yehuda (2002) reviewed a number of empirical studies and concluded that the frequency of the overall rate of childhood sexual abuse among BPD patients ranged from 40–70% compared to 19–26% among patients with other personality disorders. However, in recent years, many researchers have pointed out that the association between (remembered) childhood sexual abuse and BPD might not be as strong as the previous studies indicated. Golier et al (2003) found high rates of early and lifetime trauma in a sample of personality disorders. Borderline patients had significantly higher rates of childhood/adolescent physical abuse (52.8% versus 34.3%) and were twice as likely to develop PTSD. Yen et al. (2002) found that between different personality disorders, BPD participants reported the highest rate of traumatic exposure (particularly sexual trauma, including childhood sexual abuse), the highest rate of posttraumatic stress disorder, and youngest age of first traumatizing event. FUNDAP | ex IAEPD | PERSONA 45