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Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder

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This study sought to document the prevalence of dissociative experiences in adult female inpatients with borderline personality disorder and to explore the relationship between dissociation, self-mutilation, and childhood abuse history. A treatment history interview, the Dissociative Experiences Scale, the Sexual Experiences Questionnaire, and the Hamilton Depression Rating Scale were administered to 60 consecutively admitted female inpatients with borderline personality disorder as diagnosed by the Structured Clinical Interview for DSM-III-R Personality Disorders. Fifty percent of the subjects had a score of 15 or more on the Dissociative Experiences Scale, indicating pathological levels of dissociation. Fifty-two percent reported a history of self-mutilation, and 60% reported a history of childhood physical and/or sexual abuse. The subjects who dissociated were more likely than those who did not to self-mutilate and to report childhood abuse. They also had higher levels of current depressive symptoms and psychiatric treatment. Multiple regression analysis demonstrated that each of these variables predicted dissociation when each of the others was controlled for, and that self-mutilation was the most powerful predictor of dissociation. Female inpatients with borderline personality disorder who dissociate may represent a sizable subgroup of patients with the disorder who are at especially high risk for self-mutilation, childhood abuse, depression, and utilization of psychiatric treatment. The strong correlation between dissociation and self-mutilation independent of childhood abuse history should alert clinicians to address these symptoms first while exercising caution in attributing them to a history of abuse.
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1788 Am JPsychiatry 152:12, December 1995
Relationship of Dissociation to Self-Mutilation
and Childhood Abuse in Borderline Personality Disorder
Beth S. Brodsky, Ph.D., Marylene Cloitre, Ph.D., and Rebecca A. Dulit, M.D.
Objective: This study sought to document the prevalence ofdissociative experiences in adult
female inpatients with borderline personality disorder and to explore the relationship between
dissociation, self-mutilation, and childhood abuse history. Method: A treatment history inter-
view, the Dissociative Experiences Scale, the Sexual Experiences Questionnaire, and the Ham-
ilton Depression Rating Scale were administered to 60 consecutively admitted female inpa-
tients with borderline personality disorder as diagnosed by the Structured Clinical Interview
for DSM-III-R Personality Disorders. Results: Fifty percent of the subjects had a score of IS
or more on the Dissociative Experiences Scale, indicating pathological levels of dissociation.
Fifty-two percent reported a history ofself-mutilation, and 60% reported a history of child-
hood physical and/or sexual abuse. The subjects who dissociated were more likely than those
who did not to self-mutilate and to report childhood abuse. They also had higher levels of
current depressive symptoms and psychiatric treatment. Multiple regression analysis demon-
strated that each of these variables predicted dissociation when each of the others was con-
trolled for, and that self-mutilation was the most powerful predictor ofdissociation. Conclu-
signs: Female inpatients with borderline personality disorder who dissociate may represent a
sizable subgroup ofpatients with the disorder who are at especially high risk for seif-mutila-
tion, childhood abuse, depression, and utilization ofpsychiatric treatment. The strong corre-
lation between dissociation and self-mutilation independent ofchildhood abuse history should
alert clinicians to address these symptoms first while exercising caution in attributing them to
a history of abuse.
(Am JPsychiatry 1995; 152:1788-1792)
Dissociative experiences are being increasingly nec-
ognized as relevant to the diagnosis of borderline
personality disorder, as evidenced by the addition of a
criterion related to depersonalization and derealization
for the diagnosis of borderline personality disorder in
DSM-IV. Dissociation is conceptualized as a pathologi-
cal failure to integrate thoughts, feelings, and memories
into a coherent, unified sense of consciousness ( 1 ). The
dissociative disorders are characterized by disruptions
in memory (amnesia and fugue) and in the experience
of self (depersonalization and dissociative identity dis-
order) and surroundings (demealization).
Presented at the 147th annual meeting of the American Psychiatric
Association, Philadelphia, May 21-26, 1994. ReceivedJan. 30, 1995;
revision received July 5, 1995; accepted Aug. 9, 1995. From the De-
partment of Psychology and the Department of Psychiatry, Cornell
University Medical Center, New York. Address reprint requests to
Dr. Brodsky, New York State Psychiatric Institute at Columbia Uni-
versity, Box 28, 722 West 168th St., New York, NY 10032.
Supported in part by a Reader’s Digest Research Fellowship to Dr.
Dulit.
The authors thank Dr. Herbert Schlesinger, Dr. Jodee Davis, and
Richard Schindledecker for their guidance and assistance.
Dissociation has been found to be associated with
self-mutilation, defined as deliberate self-injury without
suicidal intent, in a variety of psychiatric populations
(2). Surprisingly, although self-mutilation is a behav-
iomal phenomenon especially common in borderline
personality disorder, only one recent study (3) has
documented a significant relation between dissociative
experiences and self-mutilation in patients with this dis-
order. Other clinical correlates of self-mutilation
among patients with borderline personality disorder in-
dude childhood abuse (4-7), depression, and high utili-
zation of psychiatric treatment (8-10). Childhood
abuse, assumed by many to play an etiological mole in
the development of dissociative symptoms (11, 12),
may be a variable that leads to both dissociation and
the propensity to self-mutilation and could account for
their observed comorbidity (2-5, 13). Alternatively,
clinical observations suggest that self-mutilation may
arise directly as a response to dissociative experiences
regardless of the presence or absence of a history of
abuse. For example, it has been proposed that self-mu-
tilation is an attempt to ameliorate the discomfort of
the dissociative phenomena of numbness and identity
BRODSKY, CLOITRE, AND DULIT
Am JPsychiatry 1 52: 1 2, December 199S 1789
diffusion (14, 15), indicating that dissociation and self-
mutilation might be related independent of abuse his-
tony. In the only empirical study that has examined the
relation between dissociation and self-mutilation inde-
pendent ofchildhood abuse history in patients with per-
sonality disorders not limited to borderline personality
disorder (4), dissociation was not found to be come-
lated with self-mutilation when history of abuse was
controlled for. No other study to date has examined
this relationship while controlling for other correlates
such as depression and level of psychopathology.
Our study was undertaken 1 ) to determine the preva-
lence of dissociation, self-mutilation, and a history of
childhood sexual and/or physical abuse in consecutively
admitted female inpatients with borderline personality
disorder and 2) to investigate the relation between dis-
sociation and self-mutilation in borderline personality
disorder, controlling for childhood abuse history, levels
of depression, and psychopathology. We hypothesized
that subjects with borderline personality disorder with
higher levels of dissociation would be more likely to
report a history of childhood abuse as well as higher
levels of depression and global psychopathology. We
further hypothesized that patients with borderline pen-
sonality disorder with higher levels of dissociation
would be more likely to engage in self-mutilation inde-
pendent of abuse history, levels of depression, and psy-
chopathology.
METHOD
This study was conducted as part of a larger investigation of in-
patients with borderline personality disorder, and a more detailed
elaboration of the method has been presented elsewhere (8). The sub-
sects of the present study consisted of 60 women consecutively admit-
ted to the inpatient units at the New York Hospital-Payne Whitney
Psychiatric Clinic from January through December 1992 who gave
written informed consent and fulfilled at least five of the eight DSM-
III-R criteria for borderline personality disorder. The charts of all
newly admitted patients between I 8 and 60 years of age who did not
have a clinician’s diagnosis of organic brain syndrome, major depres-
sion with psychotic features, or schizophrenia were carefully screened
within 3 days of admission. Patients who had a clinician’s diagnosis of
multiple personality disorder were also excluded from the study be-
cause this disorder accounts for an extremely small percentage of all
patients with borderline personality disorder (16) and might have sig-
nificantly skewed the data obtained. Any patient who met at least three
of the DSM-III-R criteria for borderline personality disorder by chart
review was approached for signed informed consent and received the
borderline personality disorder section of the Structured Clinical Inter-
view for DSM-III-R Personality Disorders (SCID-lI) (17). Patients who
did not meet at least five of the eight criteria for DSM-III-R borderline
personality disorder on the interview were excluded from further study.
Our screening method was designed to ensure wide subject sampling.
Patients who met at least five criteria for borderline personality dis-
order on the SCID-lI received the following self-report questionnaires
to complete overnight: 1) the Dissociative Experiences Scale (18) and
2) the Sexual Experiences Questionnaire (unpublished work of Wag-
ncr and Linehan), a measure ofchildhood sexual abuse-before age I 6
by someone at least S years older-according to severity, age at onset,
and perpetrator of the abuse. This latter measure was modified for this
study to include also similar measures of childhood physical abuse.
Sexual abuse was assessed as mild when it involved being forced or
persuaded to kiss or touch or to he kissed or touched by someone when
both parties were fully clothed. The abuse was defined as moderate
TABLE 1. Sociodemographic Characteristics of 60 Consecutively Ad-
mitted Female Inpatients With DSM-lll-R Borderline Personality Dis-
order
Characteristic N %
Race/ethnicity
Caucasian 43 72
Black 6 10
Hispanic 9 15
Asian/other 2 3
Marital status
Single 39 65
Separated/divorced/widowed 12 20
Married 9 15
Hollingshead-Redlich social class
I7 12
II 20 33
III 19 32
IV 9 15
V S 8
when the same activities were performed with clothes off and as severe
when any type of penetration occurred. Physical abuse was defined as
either moderate (when punishment resulted in visible bruises and inju-
nies) or severe (when injuries required medical treatment) (19).
Subjects were also interviewed with several semistructured assess-
ment instruments. The SCID (20) was used to assess current diagno-
ses of major depression and dysthymia. The Hamilton Depression
Rating Scale (2 1 ) was used as a dimensional measure of the severity
of depressive symptoms at the time of the interview. Self-mutilation
was defined as “deliberate self-injury to body tissue without the intent
to die,” and subjects were asked to rate the number of lifetime epi-
sodes of self-mutilating behavior on the following frequency scale:
none, 1-10, 11-20, 21-100, 101-500, and more than 500. Subjects
were categorized as nonmutilators, infrequent mutilatons if they ne-
ported between one and 1 0 lifetime episodes, or frequent mutilatons
if they reported more than 10 lifetime episodes. A treatment history
survey was done to obtain data regarding the number and duration
of previous psychiatric hospitalizations and prior use of psychotropic
medications. These data were used to create a global measure of Se-
verity of psychopathology by merging the three variables into a single
index, with each variable given equal weight in the equation.
Interviews of the patients were conducted by two clinical psychol-
ogy doctoral candidates who had been extensively trained in the use
of the assessment instruments. Twenty random interviews were
audiotaped and independently rated by one of us (R.A.D.) to establish
internaten reliability. Kappas for the individual axis I and II diagnoses
and each of the eight DSM-III-R criteria for borderline personality
disorder were respectable, with a median of 1.00 (nange=0.S7-b .00).
The intraclass correlation coefficient for the Hamilton depression
scale was 0.71.
Means and frequency distributions were used to assess the preva-
lence of dissociative experiences, childhood abuse history, depres-
sion, level of psychopathology, and frequency of self-mutilation
among the study subjects. The raw Dissociative Experiences Scale
scones were highly skewed and kurtotic (skewness=2.08, kurtosis=
6.49). A logarithm was used to transform these scores so that para-
metric statistical analyses would he valid (22) (after transformation,
skewncss=-0.09, kurtosis=-0.22). Pearson’s correlations were used
to determine the relationships between the log transformed Dissocia-
tive Experiences Scale score and severity of childhood abuse history,
Hamilton depression scale score, the global psychopathology index,
and frequency of self-mutilation. Student’s t test was used to compare
the frequency of self-mutilation among patients in the abused and
nonabused subgroups. An analysis of variance (ANOVA) was also
performed to test the relation between log transformed Dissociative
Experiences Scale scones and self-mutilation.
We used a simultaneous-solution, last-entry partial multiple re-
gnession analysis to assess the contribution of each of the hypothe-
sized explanatory variables predicting dissociation (self-mutilation,
abuse history) while controlling for the other variables (level of de-
pression and severity of psychopathology) within the model (23).
TABLE 2. Correlation Matrix of All Study Variables for 60
tients With DSM-lll-R Borderline Personality Disorder’ Consecutively Admitted Female Inpa-
Hamilton
Depression Global
Self- Childhood Scale Psychopathology
Variable Mutilation Abuse Score Index
Dissociative Experiences Scale score 0.4 1    0.36   0.3 1  0.38*
Self-mutilation -0.10 -0.07 0.11
Childhoodahuse 0.32** 0.15
Hamilton depression scale score 0.16
aN59 for correlations that include the self-mutilation variable.
DISSOCIATION IN BORDERLINE PERSONALITY
I 790 Am JPsychiatry 152:12, December 199S
RESULTS
The study subjects were rela-
tively young: their mean age
was 30.0 years (SD=7.2). Other
demographic characteristics of
the subjects are summarized in
table I .The subjects were pre-
dominantly Caucasian, and most
were single. Their socioeco-
nomic status was normally dis-
tnibuted among the five socio- *p<005 **<0#{216}1
economic classes as defined by
the Hollingshead-Redlich social
position indexes.
The mean Dissociative Experiences Scale scone was
19.58 (SD=16.36). One-half (N=30) of the study par-
ticipants had a Dissociative Experiences Scale score of
is or above.
Fifty-two percent (N=3 I ) of the subjects reported a
history of self-mutilation, but one subject refused to dis-
cuss the frequency of her self-mutilation, and her data
were dropped from all further analyses that included
the self-mutilation variable. Of the remaining 30 sub-
jects with histories of self-mutilation, 57% (N=17) ne-
ported between one and 10 lifetime episodes, and 43%
(N=13) reported between 1 1 and 500 lifetime episodes.
Sixty percent (N=36) of the subjects reported that
they had been physically and/on sexually abused. Forty
percent (N=24) reported sexual abuse alone, 15%
(N=9) reported physical abuse alone, and 5% (N=3)
reported both sexual and physical abuse. Of the 36 sub-
jects who reported sexual and/or physical abuse, 6%
(N=2) reported mild abuse, 31 % (N=1 1) reported mod-
emate abuse, and 64% (N=23) reported severe abuse.
Age at onset of abuse was 0-4 years for 28% of the
subjects (N=10), 5-8 years for 56% (N=20), 9-12 years
for 17% (N=6), and 13-15 years for 14% (N=S).
For the 27 subjects who reported sexual abuse, the
most common perpetrator of the abuse was a family
member; 26% (N=7) reported being abused by their fa-
them, 26% (N=7) by their mother, 15% (N=4) by their
grandfather, and 15% (N=4) by their brother. Forty-
four percent (N=12) reported being sexually abused by
a known adult who was not a family member, and 7%
(N=2) by an adult unknown them. For those who me-
ported physical abuse alone, 56% (N=S) reported being
abused by their mother, 11% (N=1) by their father,
22% (N=2) by both parents, and 11% (N=1) by a
known adult other than a parent.
All but 10 study subjects received affective disorder
diagnoses. Forty-seven percent (N=2 8 ) were diagnosed
with major depression, 5% (N=3) with dysthymia
alone, and 32% (N=19) with both disorders. The mean
Hamilton depression scale score among the study sub-
jects was 27.7 (SD=8.9). The mean number of previous
psychiatric hospitalizations was 1.5 (SD=1.9). The
mean number of weeks spent as a psychiatric inpatient
over the past Syears was 4.8 (SD=12.2). A majority of
the subjects (78%, N=47) indicated that they had had
***p=0.001.
at least one trial of psychotropic medications before the
current hospitalization.
There were no statistically significant relationships
between the Dissociative Experiences Scale scores and
the demographic variables of age, race, marital status,
and socioeconomic status. A one-way ANOVA, fol-
lowed by post hoc Newman-Keuls pairwise compani-
sons, compared nonmutilatons (N=29), infrequent mu-
tilatoms (N=18), and frequent mutilators (N=13) on
Dissociative Experiences Scale scores. The scores were
significantly higher for the frequent mutilators than for
the nonmutilatoms (F=6.00, df=2, 57, p<O.OO4). The in-
frequent mutilators did not differ significantly from the
other two groups. The subjects who reported a history
of sexual and/or physical abuse had significantly higher
Dissociative Experiences Scale scores than those who
did not report abuse (for the abused group, mean=23.86,
SD=18.45; for the nonabused group, mean=13.17, SD=
9.83; t=-3.09, df=1, 58, p<O.Ol).
Attest showed no significant difference in frequency
of self-mutilation between the abused and nonabused
groups (t=0.SS, df=58, p<O.S8).
Dissociative Experiences Scale scones were signifi-
candy correlated with frequency of self-mutilation, se-
verity of abuse, Hamilton depression scale scores, and
global psychopathology indexes (table 2). SeIf-mutila-
tion was correlated only with dissociative experiences
and no other variable, including child abuse. Dissocia-
tive Experiences Scale scones were negatively correlated
with age at onset of abuse (n=-0.38, N=58, p<O.OS).
The regression analysis showed that all four variables
entered into the model-frequency of self-mutilation,
abuse history, current level of depression, and global
severity of psychopathology-were correlated with
Dissociative Experiences Scale scores (table 3). This
constellation of variables together accounted for a sub-
stantial 46% of the variance in the scores.
DISCUSSION
Our study resulted in several significant findings.
First, high levels of dissociation, self-mutilation, and
childhood abuse were found among our female inpa-
tients with borderline personality disorder. Second,
subjects who self-mutilated had higher levels of disso-
‘Total R2=0.46.
hN59 for this variable.
BRODSKY, CLOITRE, AND DULIT
Am JPsychiatry 152:12, December 1995 I 791
ciation than those who did not self-mutilate, and a
higher frequency of self-mutilation was correlated with
higher levels of dissociation independent of abuse his-
tory. Third, compared to subjects without abuse histo-
ries, subjects with histories of childhood sexual and/or
physical abuse had higher levels ofdissociation. Fourth,
subjects with more depressive symptoms at the time of
assessment reported more pathological levels of disso-
ciation. Fifth, subjects who were higher utilizers of psy-
chiatric treatment had higher levels of dissociation.
Last, the multiple regression analysis demonstrated that
four variables (frequency of self-mutilation, abuse his-
tory, depressive symptoms, and global severity of psy-
chopathology) were each independently related to dis-
sociation and that self-mutilation was the strongest
predictor of dissociative experiences.
The level of dissociation found among the subjects in
this study is consistent with levels reported in previous
studies of populations with borderline personality dis-
order (3, 24), and this level is within the range of risk
for dissociative pathology (18, 25). It is higher than
that found in subjects with alcoholism, phobias, and
agoraphobia but lower than that found in patients di-
agnosed with schizophrenia, posttraumatic stress dis-
order, or multiple personality disorder (18). This study
confirms that inpatients with borderline personality
disorder have a higher than normal prevalence of dis-
sociative experiences and suggests that clinicians
should carefully assess these patients for pathological
levels of dissociation.
The significantly higher prevalence of dissociative ex-
peniences among the subjects who reported histories of
abuse in this study is consistent with the majority of
studies, which have found that survivors of childhood
abuse are more likely to dissociate (2-4, 11-13, 26).
The fact that we found a positive correlation between
abuse history and dissociation in a group of consecu-
tively admitted female inpatients with borderline per-
sonality disorder strengthens the theoretical argument
that childhood abuse plays an etiological role in the oc-
cumrence of dissociation in adulthood. Our findings that
subjects who reported an earlier age at onset of abuse,
greater severity of abusive experiences, and abuse by a
family member had higher levels of dissociation further
strengthens this argument. If indeed dissociation is a
defense used to mediate the trauma ofchildhood abuse,
a developmental perspective of personality would sug-
gest that the earlier the disruption of development by
trauma, in particular by a family member, and the
greater the severity, the more likely the development of
a personality constellation that includes dissociation as
a defense (27-31).
These findings also implicate the contribution of
other factors associated with childhood abuse to the
development of dissociative symptoms and other types
of psychopathology characteristic of abuse survivors.
For example, Carmen and Rieker (29) and Schultz (30)
have made the point that the family dynamics sun-
rounding incest are potentially more conflictual than
those involved in other forms of abuse. The duration
TABLE 3. Predictors of Dissociative Experiences Scale Scores of 60
Consecutively Admitted Female Inpatients With DSM-lll-R Border-
line Personality Disorder by Multiple Regression
Predictor of Dissociative F
Experiences Scale Score (df= I ) p R2 Beta
Self-mutilation1’ 18.95 0.0001 0.19 0.282
Global psychopathology index 5.92 0.02 0.14 0.095
Childhood abuse 8.68 0.005 0.07 0.474
Hamilton depression scale score 3.94 0.05 0.06 0.158
of the abuse and lack of attachment to a caring adult,
variables not considered in this study, have also been
found to be correlated with severity of pathology (2,
26). Because there is no simple direct cause-and-effect
relation between abuse history and psychopathology,
Cole and Putnam (27) recommended focusing on spe-
cific forms of abuse in order to isolate the many van-
ables involved in assessing the psychological effects of
childhood abuse.
The robust relation between dissociation and self-
mutilation in this study is consistent with the findings
of one previous study (3) that identified such a relation-
ship in individuals with borderline personality disorder
and of one other (2) that found a significant relation
between dissociation and self-mutilation in a group not
limited to subjects with borderline personality disorder.
Of greater significance, however, is the fact that self-
mutilation remained highly correlated with dissociative
experiences when abuse history, depression, and level
of psychopathology were controlled for. Furthermore,
in contrast to previous studies, abuse history, depres-
sion, and level of psychopathology were not correlated
significantly with self-mutilation. Perhaps previously
obtained relationships between self-mutilation and
abuse history were confounded by the high correlation
between childhood abuse and dissociation.
In our study, dissociation was correlated with child-
hood abuse but self-mutilation was not, suggesting that
the relation between dissociation and self-mutilation is
direct. One interpretation of this finding is that self-mu-
tilation is a direct response to dissociative experiences.
As proposed earlier, self-mutilation may constitute an
attempt to ameliorate uncomfortable experiences of
numbness and depersonalization that accompany dis-
sociation. However, because our data are correlational
and do not allow for inference of cause and effect, it is
just as possible that dissociation and self-mutilation co-
occur as ways of dealing with intolerable negative
self/object internalizations and disturbed body images
(I 2, 1 3) that are derived from painful and traumatic life
experiences related to childhood abuse. A biological
vulnerability on traumata other than childhood abuse
may also constitute shared underlying variables. It is
unlikely, in the face of substantial clinical case docu-
mentation to the contrary, that dissociation is a result
of self-injurious behavior.
The major methodological limitation of our study
DISSOCIATION IN BORDERLINE PERSONALITY
1792 AmJ Psychiatry 152:12, December 1995
was its reliance on a retrospective self-report instru-
ment to measure childhood abuse. It is possible that
the rates of abuse found in this study are either anti-
ficially high or artificially low, although most re-
searchers in the field feel that underreporting is the
more prevalent bias ( I 9, 32). Furthermore, it should be
noted that Dissociative Experiences Scale scores have
also been correlated with other types of trauma for
which there is corroboration, for instance, in combat
veterans (33). The experience of research interviewers
suggests that many subjects are reluctant to reveal their
abuse histories, and this was the experience of the in-
vestigators in this study as well. Unfortunately, the
field of childhood abuse research is very complex and
remains vulnerable to many methodological pitfalls.
Results cannot be reduced to monolithic conclusions.
For example, in this study, a subgroup of our subjects
reported an abuse history but no dissociation, suggest-
ing that the experience of abuse in childhood does not
automatically result in the development of dissocia-
tion. Further research is needed to identify the factors
that result in healthy versus pathological adaptation to
childhood abuse. Indeed, van den Kolk et al. (2) con-
cluded that although childhood trauma contributes to
the initiation of self-destructive behavior, the lack of
secure attachments maintains it.
In conclusion, our study indicates that there is a high
prevalence of pathological levels of dissociation, self-
mutilation, and childhood abuse history among female
inpatients with borderline personality disorder, and
that dissociation is correlated with the propensity to
self-mutilate independent of childhood abuse history,
current depressive symptoms, and higher utilization of
psychiatric treatment. Given the current controversy me-
garding repressed memory recall, one clinical treatment
implication of such findings is to address symptoms of
dissociation and self-mutilation first and to exercise
caution in attributing them to a trauma history.
REFERENCES
1. Demitrack MA, Putnam FW, Brewerton TD, Brandt HA, Gold
PW: Relationship ofclinical variables to dissociative phenomena
in eating disorders. Am JPsychiatry I 990; 1 47: 1 1 84-1 188
2. van den Kolk BA, Perry JC, Herman jL: Childhood origins of
self-destructive behavior. Am JPsychiatry 1991; b48:b665-
I 671
3. Shearer SL: Dissociative phenomena in women with borderline
personality disorder. Am JPsychiatry I 994; IS 1: I 324-1328
4. Zweig-Fnank H, Paris J, Guzder J: Psychological risk factors for
dissociation and self-mutilation in female patients with border-
line personality disorder. Can JPsychiatry I 994; 39:259-264
S. Shearer SL, Peter CP, Quaytman MS. Ogden RL: Frequency and
correlates of childhood sexual and physical abuse histories in
adult female borderline inpatients. Am JPsychiatry 1990; 147:
214-216
6. PerryJC, Herman JL, van den Kolk BA, Hoke LA: Psychotherapy
and psychological trauma in borderline personality disorder.
Psychiatr Annals 1990; 20:33-43
7. Wagner AW, Linehan MM: Relationship between childhood
sexual abuse and topography of parasuicide among women with
borderline personality disorder. JPersonality Disorders I 994; 8:
1-9
8. Dulit RA, Fyen MR, Leon AC, Bnodsky BS, Frances AJ: Clinical
correlates of self-mutilation in borderline personality disorder.
AmJ Psychiatry 1994; 151:1305-1311
9. Bennum I, Phil M: Depression and hostility in self-mutilation.
Suicide Life Threat Behav 1983; 13:71-84
10. Roy A: Self-mutilation. BrJ Med Psychol 1978; 51:201-203
11.Chu JA, Dill DL: Dissociative symptoms in relation to childhood
physical and sexual abuse. Am JPsychiatry 1990; 147:887-892
12. Putnam FW Jr: Dissociation as a response to extreme trauma, in
Childhood Antecedents of Multiple Personality Disorder. Edited
by Kluft RP. Washington, DC, American Psychiatric Press, I 985,
pp 65-97
13. Goodwin JM, Cheeves K, Connel V: Borderline and other severe
symptoms in adult survivors of incestuous abuse. Psychiatr An-
nals 1 990; 20:22-32
14. Shapiro 5: Self-mutilation and self-blame in incest victims. Am J
Psychother I 987; 41:46-54
IS. Favazza AR: Why patients mutilate themselves. Hosp Commu-
nity Psychiatry 1989; 40:137-145
16. Honevitz RP, Braun BG: Are multiple personalities borderline?
Psychiatn Clin North Am 1984; 7:69-87
17. Spitzer RL, Williams JBW, Gibbon M, First MB: Structured
Clinical Interview for DSM-III-R Personality Disorders (SCID-
II). Washington, DC, American Psychiatric Press, 1990
18. Bernstein EM, Putnam FW: Development, reliability, and valid-
ity of a dissociation scale. JNerv Ment Dis 1 986; 174:727-735
19. Ogata SN, Silk KR, Goodrich 5, Lohn NE, Westen D, Hill EM:
Childhood sexual and physical abuse in adult patients with bon-
derline personality disorder. Am JPsychiatry 1990; 147:1008-
1013
20. Spitzen RL, Williams JBW, Gibbon M, First MB: User’s Guide
for the Structured Clinical Interview for DSM-III-R (SCID).
Washington, DC, American Psychiatric Press, I 990
21. Hamilton M: A rating scale for depression. JNeurol Neunosung
Psychiatry 1960; 23:56-62
22. Winen BJ: Statistical Principles in Experimental Design. New
York, McGraw-Hill, 1962
23. Cohen J, Cohen P: Applied Multiple Regression/Correlation
Analysis for the Behavioral Sciences. Hillsdale, NJ, Lawrence
Erlbaum Associates, I 975
24. Coons PM: The differential diagnosis of multiple personality: a
comprehensive review. Psychiatr Clin North Am 1984; 7:51-67
25. Steinberg M, Rounsaville B, Cicchetti D: Detection of dissocia-
tive disorders in psychiatric patients by a screening instrument
and a structured diagnostic interview. Am JPsychiatry 1991;
148:1050-1054
26. Roesler TA, McKenzie N: Effects of childhood trauma on psy-
chological functioning in adults sexually abused as children. J
Nerv Ment Dis 1994; 182:145-iSO
27. Cole P. Putnam FW: Effect of incest on self and social function-
ing: a developmental psychopathology perspective. JConsult
Clin Psychol 1992; 60:174-b 84
28. Putnam FW: Dissociative disorders in children and adolescents:
a developmental perspective. Psychiatr Clin North Am 1991; 14:
S I 9-532
29. Carmen EH, Rieker PP: A psychosocial model of the victim to
patient process: implications for treatment. Psychiatr Clin North
Am 1989; 12:431-444
30. Schultz R: Secrets of adolescence: incest and developmental fixa-
tions, in Incest-Related Syndromes of Adult Psychopathology.
Edited by Kluft RP. Washington, DC, American Psychiatric
Press, 1990, pp 133-b 59
3 1 .Putnam FW: Disturbances of “self” in victims of childhood sex-
ual abuse. Ihid, pp 113-131
32. Herman JL, Perry JC, van den Kolk BA: Childhood trauma in
borderline personality. Am JPsychiatry 1989; 146:490-495
33. Bremner JD, Southwick S, Brett E, Fontana A, Rosenheck R,
Charney DS: Dissociation and posttnaumatic stress disorder in
Vietnam combat veterans. Am JPsychiatry 1992; 149:328-332
... While not always clear if sexual abuse actually predicts NSSI (Lang & Sharma-Patel, 2011), the preponderance of the literature suggests the strongest relationship between maltreatment and NSSI is within the sub-type of sexual abuse (Brodsky, Cloitre, & Dulit, 1995;Lang & Sharma-Patel, 2011;WHO, 2017). Tatnell, Hasking, Newman, Taffe, and Martin (2017) reported that youth with recent sexual abuse histories were seven times more likely to endorse NSSI compared to those without a sexual abuse history; Baiden et al. (2017) found that children with a history of sexual abuse were 60% more likely to have NSSI. ...
... Findings related to other types of trauma are less consistent. In comparisons between the outcomes of sexual, physical, and emotional abuse, (Brodsky et al., 1995) determined physical abuse was the only significant variable, (Wan et al., 2019) found emotional abuse to be the only significant variable, and a meta-analysis by Liu et al. (2018) found all but emotional abuse to have significant associations with NSSI. More severe maltreatment and familial association with the abuser/ abusers have been shown to be linked with increased self-injury and persistence of the behavior into adulthood (Brodsky et al., 1995;Yates et al., 2008). ...
... In comparisons between the outcomes of sexual, physical, and emotional abuse, (Brodsky et al., 1995) determined physical abuse was the only significant variable, (Wan et al., 2019) found emotional abuse to be the only significant variable, and a meta-analysis by Liu et al. (2018) found all but emotional abuse to have significant associations with NSSI. More severe maltreatment and familial association with the abuser/ abusers have been shown to be linked with increased self-injury and persistence of the behavior into adulthood (Brodsky et al., 1995;Yates et al., 2008). Richmond-Rakerd et al. (2019) conducted twin studies of the relationship between trauma and NSSI and found that genetic factors, not the type of trauma one experienced, were more predictive of NSSI behaviors. ...
Research
Full-text available
Secondary data analysis using CANS data in Indiana exploring NSSI and DSH in children younger than 10 years of age
... Besides, the heterogeneity of the LOD (see Fig. 1(b)) was consistent with the results obtained by Zanarini et al. [3] and contradicted the findings of previous studies [22][23][24][25]. The earlier investigations as a whole demonstrated that the majority of BPD patients had a relatively high LOD that was not different from the LOD in patients with traumarelated disorders [22][23][24][25][26][27]. By contrast, the results of the present study and Zanarini et al. [3] showed that a large number of BPD patients had moderate LOD. ...
... As the third main finding of the present study, there was no association between SA and dissociative symptomatology among BPD patients. This result was consistent with findings by Zweig-Frank et al. [23,24], Watson et al. [28], Simeon et al. [30], and Sar et al. [31], whereas it was inconsistent with the results obtained by Shearer [22], Brodsky et al. [27], and Van Den Bosch et al. [29], who announced childhood SA was a risk factor for dissociative symptomatology. However, further investigations are needed to reconcile these contradictory findings. ...
Article
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Background: From a developmental and pathogenic perspective, child maltreatment is strongly linked to later dissociative symptoms, as ultimate forms of human response to chronic stress. The present study aimed to investigate the mediating role of early maladaptive schemas (EMSs) in the relationship between child maltreatment and dissociation among patients with borderline personality disorder (BPD). Methods: In this cross-sectional study, a total of 152 BPD patients (men: 52%; women: 48%) with an average age of 29.64 years (standard deviation (SD) = 7.29, range = 18-47) were selected by systematic random sampling from the patients who referred to Baharan psychiatric hospital in Zahedan, Iran, with the sampling interval of 3. The Childhood Trauma Questionnaire-Short Form, Dissociative Experiences Scale, and Young Schema Questionnaire-Short Form 3 were used to assess the patients. Data were analyzed using SPSS v25 software, and the statistical significance level was set at p < 0.05. Results: four main findings were obtained from the present study: (1) Heterogeneity of the levels of dissociation (LOD) in BPD patients; (2) The predicting roles of emotional neglect (EN), vulnerability to harm, and defectiveness/shame schemas in the total DES scores; (3) The vague role of childhood sexual abuse (SA) in developing dissociative symptoms; and (4) The mediating role of the core schemas of vulnerability to harm (β = 0.28, 95% confidence interval (CI): 0.04, 0.61) and defectiveness/shame (β = 0.21, 95% CI: 0.008, 0.45) in the relationship between EN and dissociation. Conclusions: Regarding the heterogeneity of LOD and its crucial role in the successful treatment of BPD patients, it is highly essential to evaluate the present-state dissociation of the patient during the diagnosis process and provide effective interventions to reduce it. The obtained results highlighted the potential role of schema therapy in reducing dissociative responses to emotional stimuli (based on EN), vulnerability to harm, and defectiveness/shame. Nevertheless, psychopathology of dissociation among BPD patients should be further investigated in depth.
... High levels of dissociation are related to many psychological problems. These include; eating disorders Vanderlinden, Van Dyck, Vandereycken, & Vertommen, 1993); self-injurious behavior (Brodsky et al., 1994;van der Kolk, Perry, & Herman, 1991); borderline personality disorder (Herman, Perry, & van der Kolk, 1989;Shearer, 1994); and post-traumatic stress disorder (Branscomb, 1991;Griffin et al., 1997). Although a few studies have not found the above associations (e.g., Favaro & Santonastaso, 1995), these findings are generally robust. ...
Thesis
p>The majority of research on dissociation focuses on adulthood, although adolescence is thought to be a transitional time in the development of dissociation. This dissertation consists of two papers, both of which emphasize the importance of investigating dissociation during adolescence. A literature review of dissociation in adolescence was carried out. Recent conceptualizations of dissociation were firstly evaluated, followed by a review of studies investigating the developmental course of dissociation. The relationship between normal adolescent processes and dissociation was explored and the evidence for a relationship between dissociation and adolescent psychopathology was examined. Subsequently, the empirical evidence and theoretical basis for childhood trauma and disorganized attachment leading to dissociation were evaluated. It was argued that the developmental tasks of adolescence may provoke pathological dissociation in vulnerable young people. Finally, the clinical and research implications of a greater understanding of dissociation in adolescence were outlined. The research paper investigated the psychometric properties of the Adolescent Dissociative Experiences Scale and changes in the frequency of dissociative experiences during adolescence, as well as exploring the relationship between dissociation and psychological symptomatology in adolescence, particularly in females with anorexia. Dissociation was highly correlated with psychological symptomatology in non-clinical, mixed clinical and anorexic adolescent females and appeared to relate in a specific way to symptomatology in anorexia. The clinical and research implications of these findings were discussed.</p
... While the combination of dissociative symptoms and paranoid ideation in the same criterion may be problematic, studies report a high frequency of dissociative symptoms among patients with BPD ( Brodsky, Cloitre & Dulit, 1995 ;Zanarini, Ruser, Frankenburg & Hennen, 2000 ). Roughly two thirds of patients with DSM-III-R BPD (i.e., without the ninth criterion) and three quarters of subjects with DSM-5 BPD have symptoms which are not simply stress-related or transient, and which call for a separate diagnosis ( Ş ar et al., 2003, 2006 ). ...
Chapter
Fragmentation and Beyond Considering the mind as an integrated system, which strives to maintain the biopsychosocial “homeostasis” of the individual, any psychotic condition, per this defi nition, implies some type of “disintegration” of this functional unity. Such disintegration may aff ect one or more mental processes, with a particular emphasis on thinking, because psychosis is characterized by diffi culties determining what is real and what is not. Thus, loss of cognitive insight may occur. Such disintegration may lead to lack of motivation, emotional diffi culties, social withdrawal, diffi culties carrying out daily activities, sleep problems, incoherent speech, and behavior inappropriate to the situation. Psychosis may be associated with a variety of syndromes. Among them are schizophrenia, bipolar disorder, acute and chronic organic mental disorders, and many other psychiatric conditions, which increase proneness to, or may be complicated by, psychosis. Psychosis may be acute and transient or chronic and lifelong. From an etiological point of view in general psychiatry, psychotic disorders have been considered as either “reactive” (trauma- or stress- related) or “endogenous” (constitutional, neurobiological), or “exogenous” (directly related to the eff ects of toxic substances or of medically diagnosable bodily illness).
... Recurrent self-harming behavior was generally positively associated with dissociative symptoms. Eight studies observed an association between dissociation and self-harm, using questionnaires more sensitive to trait dissociation than state dissociation (Brodsky et al., 1995;Colle et al., 2020;Kemperman et al., 1997;Kleindienst et al., 2008;Ludäscher et al., 2009;Navarro-Haro et al., 2015;Shearer, 1994;Zanarini et al., 2011); one study also used a state-sensitive measure (Navarro-Haro et al., 2015). Two studies found dissociation peaked during self-harm and significantly decreased after self-harm was complete (Kemperman et al., 1997;Kleindienst et al., 2008). ...
Article
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Background Borderline Personality Disorder (BPD) is frequently complicated by the presence of dissociative symptoms. Pathological dissociation is linked with earlier and more severe trauma exposure, emotional dysregulation and worse treatment outcomes in Posttraumatic Stress Disorder and Dissociative Disorders, with implications for BPD. Objective A systematic scoping review was conducted to assess the extent of current literature regarding the impact of dissociation on BPD and to identify knowledge gaps. Methods Four electronic databases (MEDLINE, APA PsycINFO, EMBASE, CINAHL Plus) were searched, and English peer-reviewed studies with adults with BPD were included, following Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) extension for scoping reviews (PRISMA-ScR) 2018 guidelines. Results Most of the 70 included studies were observational (98%) with first authors from Germany (59%). Overall, dissociation was associated with increased BPD symptom severity, self-harm and reduced psychotherapy treatment response; findings regarding suicide risk were mixed. Dissociation was associated with working memory and cognitive deficits, decreased pain perception, altered body ownership, no substance abuse or the abuse of sedative substances, increased fantasy proneness, personality fragmentation, fearful attachment, dream anxiety, perceived stress and altered stress responses, increased cumulative body mass index, decreased water consumption, several neurological correlates and changes in gene expression. Conclusion BPD with significant dissociative symptoms may constitute a more severe and at-risk subgroup of BPD patients. However, there are significant research gaps and methodological issues in the area, including the possibility of unrecognized Dissociative Disorders in BPD study populations confounding results. Further studies are needed to better understand the impact of dissociation on BPD course and treatment, and to clarify the most appropriate assessment tools for clinical practice. In addition, interventional studies are needed to develop dissociation-specific BPD treatments to determine whether targeting dissociation in BPD can improve treatment outcomes.
... Dissociation is of clinical relevance not only within the framework of dissociative disorders but also as a transdiagnostic feature across several mental illnesses (Lyssenko et al., 2018). It is well established that dissociation is related to a range of complications such as selfharm and pain threshold abnormalities that could lead to treatment difficulties (Brodsky, Cloitre, & Dulit, 1995;Hoyos et al., 2019). ...
Article
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Dissociation is a debilitating condition often present as comorbidity in patients with eating disorders but to date only mixed data are available. Additionally, very little data exist on the classification of dissociation, namely psychoform and somatoform, in anorexia nervosa (AN). This review aimed to provide an updated view on the literature about dissociation in AN, with a focus on AN subtypes (i.e., restricter and binge-purging) as well as dissociation type (i.e., psychoform and somatoform), when available. We screened 304 studies and, after title and abstract selection and full-text reading, 29 of them were included in the review. Most of the studies investigated psychoform dissociation, while just 4 publications considered somatoform dissociation. Dissociation resulted to be present in AN more than in healthy controls and in individuals with other psychiatric disorders, and it was related mostly to the binge-purging subtype of AN. Moreover, dissociation was linked with traumatic events, self-harm, and negative treatment outcomes, especially in patients affected by the binge-purging subtype of AN. However, results on these topics are scarce and partially discordant. The methodological assessment we performed revealed an overall fair quality of the included studies, although several flaws emerged as well. The present review reported on one hand the relevance of dissociation in AN, but on the other hand the need to stimulate the scientific debate on a) a deeper investigation of somatoform dissociation in AN, and b) the relationship between dissociation and both clinical severity and treatment response/resistance in AN.
Article
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The aim of this study was to investigate the prevalence of dissociative symptoms and the relationship between childhood traumas and clinical variables in individuals who have committed crimes and are followed up in the forensic psychiatry service. 55 patients followed in Elazig City Hospital High Security Forensic Psychiatry (YGAP) service were included in the study. A semi-structured sociodemographic data form, Childhood Trauma Scale (CTQ-28) and Dissociative Experiences Scale (DES) were administered to all participants. The DES total score was 26.7±11.9 in delinquent patients with a diagnosis of mood disorder. A positive and significant correlation was found between DES amnesia, depersonalization/derealization subscores and CTQ-28 physical abuse, physical neglect, sexual abuse and minimalization subscores. According to the research findings, the frequency of having dissociative experiences is low in delinquent mood disorder patients, while it is high in other patient groups. It also suggests that it should be routinely investigated in terms of dissociative symptoms and childhood neglect-abuse in psychiatric patients who have committed crimes.
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Abstract: Background: Mental disorders are one of most common reason for early separation of soldiers from the military service. The purpose of this study was to evaluate the relation of self-mutilation and personality disorder among soldiers. Materials and methods: In this case-control study, 30 soldiers referred to an army psychiatric hospital (cases) and 30 soldiers referred to another military health center (controls) were evaluated for personality disorders by clinical interviews on the basis of DSM-IV criteria. The frequency of self-mutilation and personality disorders were then analyzed by SPSS statistical software. Results: Totally, 63.3% of case group and 6.7% of control group had history of self-mutilation. The frequency of personality disorders was 56.7% and 20% in cases and controls, respectively. In case group, 78.9% and 18.2% of patients, respectively, with and without a history of self-mutilation, had cluster B personality disorder (P=0.002). This difference remain significant among control group (P=0.003). Conclusion: Regarding the relationship between self-mutilation with cluster B personality and impulsivity of these personalities, detection and preventive treatment of patients or exempt in severe cases prior to entering military service may be useful for reducing the incidence of self-mutilation and suicide. Keyword(s): SOLDIERS, PERSONALITY DISORDER, SELF-MUTILATION
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The prevalence of reported subjective paranormal experience (SPE) is at high levels in all populations investigated to date. This article presents a new integrative theory of SPE in light of the brain’s homeostatic response to early trauma. I hold that developmental factors in the brain’s responses to trauma predispose victimized individuals towards SPE and paranormal beliefs. I examine the reported associations between childhood abuse, dissociation, depersonalization, compartmentalization, fantasy generation, homeostasis and SPE. A new integrative theory of psychological homeostasis draws upon the mechanisms of dissociation and fantasy generation to explain the origins of SPE. Twelve hypotheses from the Homeostasis Theory are found to be consistent with the findings of multiple studies and falsifying evidence has yet to be identified. Freezing and associated releases of fantasy, which may take the form of SPE, serve as a survival strategy in the homeostatic regaining of safety and control following childhood abuse. Prospective research is necessary to deepen our understanding of the brain mechanisms required by the system described here.
Presentation
A primer on suicide assessment and treatment in pediatric populations. Discusses validated screening tools for depression, risk/protective factors, suicidal risk levels, safety planning, and potential clinic protocols.
User's Guide for the Structured Clinical Interview for DSM-III-R (SCID)
  • Rl Spitzen
  • Jbw Williams
  • M Gibbon
  • Mb First
Spitzen RL, Williams JBW, Gibbon M, First MB: User's Guide for the Structured Clinical Interview for DSM-III-R (SCID).
Statistical Principles in Experimental Design
  • Bj Winen
Winen BJ: Statistical Principles in Experimental Design. New York, McGraw-Hill, 1962