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The impact of posttraumatic stress disorder on the symptomatology of borderline personality disorder


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Background Previous findings on the impact of co-occurring posttraumatic stress disorder (PTSD) in patients with borderline personality disorder (BPD) have revealed inconsistencies, which may have been related to small sample sizes or differences in the presence of childhood sexual abuse (CSA). In this study, the potentially aggravating impact of PTSD and the role of CSA were examined in a large cohort of BPD patients. Methods BPD patients with current PTSD (n = 142) were compared to BPD patients without PTSD (n = 225) regarding different BPD features such as non-suicidal self-injury. Further, we examined the potentially confounding role of CSA. Results BPD patients with PTSD showed elevated affect dysregulation, intrusions, dissociation, history of suicide attempts and self-mutilation compared to those with only BPD. The effects of PTSD on BPD patients regarding dissociation and the history of suicide attempts were at least partially related to CSA. Conclusions The additional diagnosis of PTSD in BPD patients can aggravate some, but not all BPD features. With respect to dissociation and suicide attempts, at least some of the impact seems to relate to CSA.
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R E S E A R C H A R T I C L E Open Access
The impact of posttraumatic stress disorder
on the symptomatology of borderline
personality disorder
Sylvia Cackowski
, Tamar Neubauer
and Nikolaus Kleindienst
Background: Previous findings on the impact of co-occurring posttraumatic stress disorder (PTSD) in patients with
borderline personality disorder (BPD) have revealed inconsistencies, which may have been related to small sample
sizes or differences in the presence of childhood sexual abuse (CSA). In this study, the potentially aggravating
impact of PTSD and the role of CSA were examined in a large cohort of BPD patients.
Methods: BPD patients with current PTSD (n= 142) were compared to BPD patients without PTSD (n= 225)
regarding different BPD features such as non-suicidal self-injury. Further, we examined the potentially confounding
role of CSA.
Results: BPD patients with PTSD showed elevated affect dysregulation, intrusions, dissociation, history of suicide
attempts and self-mutilation compared to those with only BPD. The effects of PTSD on BPD patients regarding
dissociation and the history of suicide attempts were at least partially related to CSA.
Conclusions: The additional diagnosis of PTSD in BPD patients can aggravate some, but not all BPD features. With
respect to dissociation and suicide attempts, at least some of the impact seems to relate to CSA.
Keywords: Borderline personality disorder, Posttraumatic stress disorder, Childhood sexual abuse, Comorbidity
Borderline personality disorder (BPD) shows high co-
morbidity rates with several psychiatric disorders [14].
The rates of co-occurring posttraumatic stress disorder
(PTSD) within samples of BPD patients range between
30% and 79%, with somewhat higher rates of comorbidity
in clinical populations as compared to field-studies [37].
However, findings on the impact of additional PTSD on
symptomatology in BPD patients remain inconsistent.
Several studies revealed that women with BPD and co-
occurring PTSD had worse general functioning, more
severe BPD symptomatology [810], more frequent
hospitalizations [8, 9, 11], increased dissociation [9],
suicidality and impulsivity [8, 12], as well as increased
self-mutilating behaviour [13, 14]. In a sample of 94
BPD patients, Harned and colleagues found higher
rates of self-injury and suicide attempts based on inter-
personal reasons in BPD patients with co-occurring
PTSD, as well as more pronounced emotion dysregula-
tion [13]. However, there were no differences found in
the number of met BPD criteria and general psycho-
social functioning between BPD patients with or with-
out PTSD. In a longitudinal study by Gunderson and
colleagues, co-occurring PTSD in BPD patients was as-
sociated with poorer 2-year outcomes based on the
Global Assessment of Functioning Scale (GAF) [15, 16].
Furthermore, a 10-year follow-up study showed that
the likelihood of symptom remission in BPD patients
was lower in those with co-occurring PTSD [17]. Previ-
ous studies also revealed that the reported extent of
sexual [4, 8, 13], physical, verbal, and emotional abuse
[3, 8] was higher in patients with a combined diagnosis
of BPD and PTSD. Nonetheless, several other studies
did not find any significant impact of co-occurring
* Correspondence:
Department of Psychosomatic Medicine and Psychotherapy, Central
Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University,
Mannheim, Germany
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Cackowski et al. Borderline Personality Disorder and Emotion
Dysregulation (2016) 3:7
DOI 10.1186/s40479-016-0042-4
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PTSD on BPD symptom severity [11, 13, 18], suicidal-
ity, hospitalizations [13], or physical, emotional and
sexual abuse severity [9].
Independent of ones BPD or PTDS diagnosis, child-
hood sexual abuse (CSA) has been found to relate to
serious aspects such as self-mutilation, suicidality and
dissociation [19, 20]. Although some controversial results
have pointed out that CSA is neither a necessary nor
sufficient factor in the development of BPD [19, 2123],
CSA has been intensely discussed as an etiological factor
for BPD [14, 18]. Several studies have shown that the se-
verity of CSA predicts the severity of BPD symptomatol-
ogy [2, 3, 21, 24, 25]. It has been hypothesized that CSA
may explain the presence and impact of PTSD in BPD
patients, i.e., that CSA, rather than a PTSD diagnosis,
might be predictive of self-mutilating behaviour, as
well as more severe symptomatology in patients with
BPD [13, 18].
Previous research addressing the relationship between
BPD, PTSD and CSA has some noteworthy limitations.
As Nepon and colleagues [26] noticed, samples of highly
symptomatic treatment seeking patients, as studied by
Harned and colleagues [13], may not be representative
of a broader BPD population. On the other hand, it
should also be noted that research on treatment seeking
patients is particularly relevant for therapists, who seek
information about the complexity of conditions of their
clientele. Furthermore there is the assumption that dis-
crepancies between the results of Harned and colleagues
[13] and other (epidemiologic) studies [4] might be a
consequence of different sample sizes. Although the
patients investigated in our study were also treatment
seeking, we aimed to overcome the limitation of a small
sample size. To further enhance representability of our
sample, no specific inclusion criteria were stated con-
cerning the presence or frequency of self-injury and sui-
cide attempts.
We aimed to investigate a large clinical sample of BPD
patients divided in subgroups of patients with versus
without co-occurring PTSD, to clarify whether add-
itional PTSD is related to major aspects of BPD symp-
tomatology such as the number of fulfilled BPD criteria,
as well as suicidal and self-harming behaviour. In a next
step, we analysed the impact of CSA. This seems import-
ant, as CSA affects BPD pathology [2, 3, 21], but does
not necessarily lead to a PTSD diagnosis [27]. For in-
stance, we expect CSA (rather than PTSD) to be predict-
ive of self-mutilating behaviour and general symptom
severity [13, 18].
Participants were treatment-seeking patients, mostly for
a presumed diagnosis of BPD. Criteria for inclusion in
the study were female gender, age between 1865 years
and a diagnosis of BPD according to DSM-IV [28].
Participants were excluded from the study if they met
life-time criteria for schizophrenia, bipolar-I disorder, or
mental disorder due to brain damage. All diagnostic and
observer based assessment instruments were conducted
by trained psychologists and physicians. BPD diagnosis
(according to DSM-IV criteria) was determined by using
the International Personality Disorder Examination
(IPDE) [29]. Apart from the number of met BPD criteria,
a dimensional IPDE score was calculated. Axis-I diagno-
ses, including PTSD were assessed using the Structural
Clinical Interview for DSM-IV (SCID-I) [15]. Besides
assessing whether the diagnostic criteria for PTSD was
currently met (current PTSD), we also assessed whether
PTSD criteria was met in the past. Up to 84% of the
patients with lifetime PTSD met the criteria for a
current PTSD, therefore analyses were based on the
current PTSD diagnosis, which was free of missing
values (the results were almost identical when based on
current or lifetime PTSD). A total of 722 female patients
were assessed for eligibility, whereby 355 (49.2%) of
them were not included in the study, as not all of the
predefined criteria for participation in the study were
met. All of the remaining 367 female patients were in-
cluded in the study.
Assessment of clinical characteristics
To quantify borderline-typical symptomatology, the
Borderline Symptoms List- 95 (BSL) [30] was applied,
which is a self-report scale consisting of seven subscales
(self-perception, affect regulation, auto aggression, dys-
phoria, isolation, intrusions, and hostility) and a general
severity score of BPD symptomatology. The psychomet-
ric criteria of the BSL have been investigated in several
studies and have demonstrated good reliability and
validity [30]. Further clinical assessments comprised
questionnaires on trait dissociation measured by the Dis-
sociative Experiences Scale (DES) [31], childhood trauma
history measured by Childhood Trauma-Questionnaire
(CTQ) [32] and an assessment of the presence and
frequency of previous suicide attempts, as well as the
history of self-mutilation (Have you ever had a suicide
attempt in your life? How many suicide attempts did
you have in your life? Have you ever used self-injuring
behaviour?). Participants were informed about the def-
inition of self-injuring behaviour, which was determined
as any deliberate and self-inflicted behaviour with the
intention to harm or destroy body tissue without
suicidal intent.
The current study is part of an observational study
which was conducted from April 2001 to October 2007
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at two German Departments of Psychiatry specialized in
treatment of BPD: the Department of Psychiatry of the
University in Freiburg and the Central Institute of
Mental Health in Mannheim. The patients included in
the study were treatment-seeking patients, mostly for a
presumed diagnosis of BPD. Definite BPD diagnosis
(according to DSM-IV; [28]) was determined by use of
the International Personality Disorder Examination
(IPDE; [29]). Axis-I diagnoses were established by use of
the structural clinical interview for DSM-IV (SCID-I;
[15]). The following inclusion criteria were required for
study entry:
female gender
age ranging from 18 to 65
established diagnosis of BPD (according to DSM-IV)
written informed consent.
Patients with a lifetime diagnosis of schizophrenia,
bipolar I disorder, or mental disorders due to brain dam-
age were not included in this study. The investigation
was conducted in accordance with GCP guidelines and
the declaration of Helsinki and was approved by the
Ethics committee of the Medical Faculty of Heidelberg
University. The procedure of the study was explained in
detail and a written informed consent was signed by all
participants. Data on the potentially aggravating impact
of attention-deficit hyperactivity disorder for BPD have
been published elsewhere [33].
Statistical analysis
Regression models were used to test whether a diagnosis
of current PTSD was related to continuous data (such as
DES total score). For modelling, binary data logistic
regression was applied. Chi-square tests were used to
compare categorical variables such as education, em-
ployment status and marital status. To compare ordinal
data, such as years of schooling across groups, the
Kolmogorov-Smirnoff test was used. We indicated with
an asterisk which variables would stay significant on the
alpha level of 0.05 (2-tailed) after Bonferroni correction.
To examine whether the relation between PTSD
and BPD psychopathology (BSL, DES, suicidal and
self-harming behaviour) was associated with CSA
(measured by CTQ), we applied a mediational model as
described by Baron and Kenny [34]. When these analyses
referred to continuous dependent variables, regression
coefficient relating PTSD and BPD-psychopathology was
decomposed into two additive components: (a) the indir-
ect effect related to CSA, and (b) the regression coefficient
after controlling for CSA. These two components en-
abled us to determine to which extent the connection
between PTSD and a dependent variable (BSL, DES,
suicidal and self-harming behaviour) was associated
with CSA [35]. As pointed out by Preacher and Hayes
[36], the formal evaluation of statistical significance of
the indirect effect should be based on non-parametric
methods, as the sampling distribution of the indirect
effect is typically skewed. This skewedness violates the
assumption of normality, which is at the base of e.g.,
the Sobel-test. We followed the recommendation by
Hayes [37] and estimated the standard error of the
parameter corresponding to the indirect effect from
bootstrapping using 10,000 bootstrapping samples for
each analysis by applying the macro PROCESS realized
by Hayes in SPSS [37]. The parameters corresponding
to the indirect effect were considered significant if the
95% confidence interval around the point estimate of
the parameter did not include zero.
Demographic and clinical characteristics
Of the 367 BPD patients, 142 (38.7%) met the criteria
for current PTSD. Another 27 patients met the criteria
for lifetime PTSD but not current PTSD. The most com-
monly reported traumatic events were
: sexual abuse or
harassment (76%), physical violence (35%), witness of
traumatic events such as violence against or abuse of
others (28%), accidents (7%) and raid or threat with a
weapon (5%). More than one trauma type was experi-
enced by 54% of these patients.
Patients with and without PTSD did not differ signifi-
cantly on any demographic characteristics (see Table 1).
However, self-reported CSA occurred more frequently
in the subgroup of BPD patients with a co-occurring
diagnosis of PTSD than in BPD patients without co-
occurring PTSD (81.2% vs. 53.1%, p0.01). The cor-
relation between self-reported CSA and a diagnosis of
PTSD was 0.429 (p0.01). Further clinical character-
istics of BPD patients with and without PTSD and
statistical group comparisons are depicted in Table 2.
The role of CSA
As shown in the Table 3, dissociation as assessed by the
DES total scores was significantly related to the diagno-
sis of PTSD (p= 0.02). When one separates the regres-
sion coefficient (b = 5.40) into an indirect component
related to CSA (b = 4.16, p 0.01) and the direct compo-
nent after controlling for CSA (b = 1.24, p= 0.62), the re-
sults suggest that the relationship between the diagnosis
of PTSD and higher DES scores is essentially related to
the presence of CSA (p0.01) and is no longer signifi-
cant after controlling for CSA. Similarly, we detected a
significant relationship between PTSD and the occur-
rence of at least one suicide attempt (p0.01). In per-
centages, 79.5% of BPD patients with co-occurring
PTSD tried to commit suicide, compared to 66.8% of
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Table 2 Clinical characteristics of BPD patients with and without PTSD
Total PTSD absent PTSD present P
M +/- SD M +/- SD M +/- SD
History of CSA 63.3% 53.1% 81.2% 0.01
DES 29.74 +/- 16.19 27.37 +/- 15.37 33.47 +/- 16.81 0.01
Suicide attempts/self-mutilation
Frequency of suicide attempts 4.14 +/- 7.41 4.26 +/- 8.50 3.98 +/- 5.51 0.90
History of suicide attempts 71.92% 66.8% 79.5% 0.02
History of self-mutilation 95.02% 92.7% 98.4% 0.03
BPD severity 206.41 +/- 68.30 201.03 +/- 70.87 215.12 +/- 63.23 0.07
Self-perception 35.65 +/- 17.83 34.42 +/- 18.50 37.64 +/- 16.57 0.12
Affect regulation 32.59 +/- 10.45 31.68 +/- 10.98 34.09 +/- 9.39 0.04
Auto aggression 28.69 +/- 13.07 27.77 +/- 13.47 30.17 +/- 12.32 0.11
Dysphoria 32.65 +/- 5.94 32.58 +/- 6.24 32.77 +/- 5.44 0.78
Isolation 23.57 +/- 10.51 23.36 +/- 10.59 23.90 +/- 10.40 0.65
Intrusions 13.86 +/- 8.19 12.49 +/- 8.11 16.05 +/- 7.86 0.001
Hostility 10.15 +/- 5.22 10.04 +/- 5.35 10.32 +/- 5.03 0.64
Number of BPD criteria 6.63 +/- 1.24 6.55 +/- 2.02 6.76 +/- 1.19 0.90
BPD dimensional score 14.49 +/- 1.97 14.39 +/- 1.26 14.66 +/- 1.88 0.21
Table 1 Demographic characteristics of BPD patients with and without PTSD
Total PTSD absent PTSD present P
Age (M ± SD) 28.6 ± 7.9 28.8 ± 7.9 28.1 ± 7.9 0.46
Schooling 0.08
No schooling 5 1.5 3 1.5 2 1.5
9 years of schooling 73 21.4 42 20.6 31 22.6
10 years of schooling 150 44.0 80 39.2 70 51.1
1213 years of schooling 113 33.1 79 38.7 34 24.8
Education 0.13
Apprenticeship, University 205 61.0 128 64.3 77 56.2
No degree 131 39.0 71 35.7 60 43.8
Employment status 0.48
Employed 86 25.2 54 26.6 32 23.2
Unemployed 255 74.8 149 73.4 106 76.8
Marital status 0.41
Single, divorced/widowed 273 82.2 164 83.7 109 80.1
Married 59 17.8 32 16.3 27 19.9
Valid numbers and percentages (i.e., not including missing data) are presented
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BPD patients without PTSD. CSA significantly affected
the link between PTSD and the history of suicide
attempts in BPD patients, as this link became non-
significant after controlling for CSA (p= 0.23).
As the (lifetime) history of at least one suicide attempt
might be related to lifetime PTSD rather than to current
PTSD, analyses were also carried out for lifetime PTSD.
Hereby, the results were fully confirmed. In contrast to
the results on the occurrence of at least one suicide
attempt, the frequency of previous suicide attempts
was not significantly related to the diagnosis of PTSD
(p= 0.90). Concerning the history of self-mutilation, the
relation with PTSD diagnosis showed a trend (p=0.09).
98.4% of BPD patients with PTSD self-mutilated com-
pared to 92.7% of BPD patients without PTSD. There
was no significant effect of CSA on self-mutilation and
the connection stayed non-significant after controlling
for CSA (p= 0.10). As further shown in Table 3, two of
the seven BSL subscales showed a significant relation
with PTSD diagnosis: intrusions (p0.01) and affect
regulation (p= 0.01).
This study adds to a growing body of evidence about
patients with BPD and co-occurring PTSD. According to
our results, PTSD is significantly related to dissociation
(DES) and a history of suicide attempts in BPD patients.
A trend was found for the impact of PTSD on the symp-
tom severity (BSL) and the history of self-mutilation in
patients with BPD.
Our finding that patients with co-occurring current
PTSD scored significantly higher on the DES than
patients without a co-occurring diagnosis, is in line with
the findings from Heffernan and Cloitre, who also re-
ported higher scores on the DES in the group of BPD
patients with co-occurring PTSD [9]. However, this asso-
ciation became non-significant in our study after con-
trolling for CSA, suggesting that the effect of PTSD on
dissociation in BPD patients may be associated with the
history of sexual abuse in childhood [38, 39]. Our
finding that significantly more BPD patients with PTSD
reported having attempted suicide than patients without
PTSD diagnosis is consistent with the results of several
previous studies [4, 8]. When controlling for CSA, the
connection between PTSD and the history of suicide
attempts disappeared, suggesting that CSA and not
PTSD, is influencing suicidality rates in BPD patients.
Similar previous results have been reported stating that
severity of CSA is associated with higher rates of suicide
attempts [19, 20]. For example, Ferraz and colleagues
revealed that in BPD patients, the presence, number and
severity of previous suicide attempts are significantly
predicted by CSA [40]. In recent studies [8, 13] it has
been assumed that CSA could be associated with the
effects of PTSD in BPD patients and even account for
BPD [18]. Interestingly, BPD patients with and with-
out PTSD did not differ in terms of the frequency of
suicide attempts. However, our findings indicate that
the frequency of suicide attempts was significantly re-
lated to CSA.
While self-mutilation tended to be higher in BPD pa-
tients with co-occurring PTSD, this trend was not statis-
tically significant, despite the relatively large number of
patients included in our study. This is not fully consist-
ent with previous studies, which revealed that BPD pa-
tients with co-occurring PTSD had a higher frequency
of intentional self-injury, typically being triggered by
flashbacks, nightmares or thoughts about sexual abuse
or rape [13, 14]. The slight differences between our find-
ing and previous results might relate to the very high
prevalence of self-mutilation in our study (>90% in both
subsamples of BPD patients with and without PTSD),
which might have caused a ceiling effect. Self-mutilation
was unrelated to CSA in our sample.
With respect to the impact of PTSD on BPD severity,
our study provided preliminary evidence that some
specific aspects (rather than overall severity) might be
impacted by co-occurring PTSD. With respect to overall
severity, we only found a non-significant trend towards
Table 3 Indirect effects related to CSA
Total effect of PTSD Indirect component related to CSA Direct component after controlling for CSA
Regression coefficients,
SEs and P-values
Regression coefficients,
SEs and P-values
Regression coefficients,
SEs and P-values
DES 5.40 ± 2.32 (p= 0.02) 4.16 ± 1.38 (p0.01)* 1.24 ± 2.51 (p= 0.62)
Suicide attempts/self-mutilation
History of suicide attempts** 0.83 ± 0.31 (p0.01)* 0.51 ± 0.19 (p0.01)* 0.40 ± 0.33 (p= 0.23)
Affect regulation 3.53 ± 1.40 (p= 0.01) 1.11 ± 0.63 (p= 0.08) 2.42 ± 1.54 (p= 0.12)
Intrusions 3.25 ± 1.04 (p0.01) 1.25 ± 0.56 (p= 0.02) 2.00 ± 1.16 (p= 0.09)
Remains statistically significant after Bonferroni-correction
Remains statistically significant when considering lifetime PTSD (p0.01)*
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2016) 3:7 Page 5 of 7
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higher total scores in the BSL. We found no evidence for
higher scores with respect to the number of BPD criteria
and the dimensional IPDE score in the subgroup of
patients with co-occurring PTSD. This is in line with
previous reports that PTSD does not necessarily affect the
extent of BPD psychopathology [11, 13, 18]. With respect
to the facets of psychopathology (BSL), we did, however,
detect higher scores in the subscales intrusionand
affect regulationin BPD patients with co-occurring
PTSD. This indicates that patients with both diagnoses re-
port more intrusions and elevated problems in affect regu-
lation than BPD patients without a co-occurring PTSD
diagnosis. Overall, these results are in line with the find-
ings by Harned and colleagues, who did not find an effect
for PTSD on the number of BPD criteria and the dimen-
sional score, but on emotion regulation [13]. However,
these results do not support the outcomes of other stud-
ies, which indicated that co-occurring PTSD has a nega-
tive effect on general BPD symptomatology [8, 10, 14].
Our study has both strengths and limitations. A strength
of our study is the relatively large sample of well diag-
nosed participants. All patients underwent standardized
diagnostics including structured interviews for BPD
(IPDE) and Axis-I disorders (SCID-I), which were con-
ducted by experienced diagnosticians. With respect to the
limitations, we would like to emphasize that our sample
only included treatment-seeking female BPD patients re-
cruited at specialized university settings. Hence, general-
izations beyond the population investigated in this study
should be made with caution. Furthermore, as most of
our dependent variables were based on retrospective self-
reports, there is a possibility of bias. One significant
limitation concerns the assessment of the presence and
frequency of previous suicide attempts and the history of
self-mutilation in this study. As we did not use a well-
established and validated measure, the validity of our
results on suicide attempts and self-mutilation might be
constrained. Future studies investigating this topic should
make use of measures such as the Columbia-Suicide
Severity Rating Scale (C-SSRS), which have been devel-
oped to consistently define and classify these behaviours
and show good psychometric properties [41]. Further-
more, as we conducted an observational study, the possi-
bility of making any causal conclusions regarding the
impact of PTSD and CSA in BPD patients is precluded.
Finally, multiple testing poses the question regarding
the inflation of alpha-error. To address this issue, a
Bonferroni-correction was applied. We found that dis-
sociation and a history of at least one suicide attempt
would still hold after correction for multiple testing.
Despite these limitations, the results of our study should
be considered in further research, as well as in clinical
practice. From an etiological perspective, it is interesting
that both dissociation and a history of at least one sui-
cide attempt were related to CSA rather than to PTSD.
From a clinical perspective, our data highlights the need
to address these aspects in the treatment of BPD pa-
tients with co-occurring PTSD or a history of CSA, as
suicide attempts are highly prevalent within this popula-
tion of patients and as dissociation has been shown to
detrimentally affect the success of treatment in both
BPD [13, 14] and PTSD patients [3].
The mentioned percentages refer to 93 of the 142
patients with PTSD. For the remaining 49 patients infor-
mation regarding the type of trauma (from SCID-I) was
either missing or not entirely conclusive retrospectively.
BPD, borderline personality disorder; BSL, borderline symptoms list- 95;
CSA, childhood sexual abuse; C-SSRS, Columbia-Suicide Severity Rating Scale;
CTQ, childhood trauma-questionnaire; DES, dissociative experiences scale;
GAF, global assessment of functioning scale; IPDE, International Personality
Disorder Examination; PTSD, posttraumatic stress disorder; SCID-I, structural
clinical interview for DSM-IV; SPSS, statistical package for the social sciences
We thank all participants for their collaboration in this study. We also thank
Melanie Harned for previous research in this field and the inspiration for our
The study has been funded by the Borderline Personality Disorder Research
Foundation, New York.
Availability of data and materials
The dataset supporting the conclusions of this article is available on request
to Nikolaus Kleindienst (
NK drafted the manuscript, conducted the analysis and led the interpretation
of the data. SC made substantial contributions to the manuscript conceptualising
and revision. TN assisted to in the manuscript drafting. All authors approved the
final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
The investigation was conducted in accordance with GCP guidelines and the
declaration of Helsinki and was approved by the Ethics committee of the
Medical Faculty of Heidelberg University. The procedure of the study was
explained in detail and a written informed consent was signed by all
Author details
Department of Psychosomatic Medicine and Psychotherapy, Central
Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University,
Mannheim, Germany.
Institute of Psychiatric and Psychosomatic
Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim,
Heidelberg University, Mannheim, Germany.
Received: 17 December 2015 Accepted: 12 July 2016
Cackowski et al. Borderline Personality Disorder and Emotion Dysregulation (2016) 3:7 Page 6 of 7
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... Epidemiological studies indicate that about one in three individuals with a diagnosis of borderline personality disorder (BPD) also meets the diagnostic criteria for posttraumatic stress disorder (PTSD; Pagura et al., 2010). Among patients who seek treatment for BPD, the percentage of those with co-occurring PTSD is even higher, exceeding 50% in several clinical samples (Cackowski et al., 2016;Harned et al., 2008;Harned, Rizvi, et al., 2010;McGlashan et al., 2000;Sack et al., 2013;Zanarini et al., 1998). A dual diagnosis of BPD + PTSD is particularly prevalent in survivors of childhood abuse (CA), which is here defined as having been subjected to sexual or physical abuse before the age of 18 (Scheiderer et al., 2016). ...
... At a minimum, they require therapy that addresses the symptoms of both disorders. Furthermore, they may exhibit very high levels of problematic clinical features, including emotion dysregulation, self-harming behaviors, interpersonal difficulties, and dissociation (Cackowski et al., 2016;Harned, Rizvi, et al., 2010;Heffernan & Cloitre, 2000;Krause-Utz, 2021;Marshall-Berenz et al., 2011), and are at a high risk for suicide attempts (Yen et al., 2021). However, there is a lack of treatment programs that proved efficacious for both aspects of the dual diagnosis within a randomized controlled trial (RCT). ...
Objective: About half of individuals seeking treatment for borderline personality disorder (BPD) present with co-occurring posttraumatic stress disorder (PTSD). However, therapies that have been proven efficacious for simultaneously treating the full spectrum of core symptoms in patients with a dual diagnosis of BPD + PTSD are lacking. Method: This is a subgroup analysis from a randomized controlled trial (registration number DRKS00005578) which compared the efficacy of two treatment programs, dialectical behavior therapy for PTSD (DBT-PTSD) versus cognitive processing therapy (CPT). Specifically, the present analysis was carried out in 93 women with a dual diagnosis of BPD + PTSD (Diagnostic and Statistical Manual for Mental Disorders; DSM-5). Outcome evaluations included the Clinician-Administered PTSD Scale, the Borderline Symptom List, and validated scales assessing dissociation, depression, and global functioning. The primary analysis was based on the intent-to-treat population, using mixed models. Results: Both PTSD and BPD symptoms significantly decreased in both treatment groups. For PTSD symptoms, pre-post effect sizes were d = 1.20, 95% confidence interval (CI): [0.80-1.58] in the DBT-PTSD group and d = 0.90, 95% CI: [0.57-1.22] in the CPT group; for BPD symptoms, they were d = 1.17, 95% CI: [0.77-1.55], and d = 0.50, 95% CI: [0.20-0.79], respectively. Between-group comparisons significantly favored DBT-PTSD for improvement in symptoms of PTSD, BPD, and dissociation. Between-group differences regarding depression and global functioning were not significant. Conclusion: Both DBT-PTSD and CPT emerged as promising treatment options for simultaneously addressing the full spectrum of core symptoms in patients diagnosed with BPD + PTSD. Differential efficacy was in favor of DBT-PTSD as participants randomized to the DBT-PTSD arm improved more with respect to both their BPD and PTSD symptoms. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Emotion dysregulation, identity disturbances (including dissociation), and risky self-harming behaviour are core features of BPD [43], which were found to be more pronounced in individuals who experienced CSA [45]. As previously mentioned, these factors are also thought to increase the risk for sexual-revictimization. ...
Full-text available
Background Child sexual abuse (CSA) has been linked to a higher risk of sexual re-victimization, including sexual intimate partner violence (IPV). The aim of this study was to investigate whether borderline personality disorder (BPD) features, dissociation, and maladaptive cognitive emotion regulation mediate the link between self-reported CSA severity and sexual IPV. Specifically, we were interested in the unique effect of each mediator variable, when accounting for the effect of the other variables. Methods Data was assessed in a cross-sectional anonymous online survey, posted on platforms for people affected by domestic violence, and research platforms of Leiden University. Overall, n = 633 participants completed the survey (including n = 100 participants with CSA and n = 345 reporting at least one incidence of sexual IPV). Multivariate regression analyses and path-analytical modelling were performed for hypothesis testing. Results Adult sexual IPV was predicted by more severe CSA, more severe BPD features, higher dissociation, and more maladaptive emotion regulation. Each mediator variable showed a significant effect in the separate mediation models. In the overall model, only dissociation and maladaptive emotion regulation, but not BPD features, mediated the association between CSA and sexual IPV. Conclusions Findings add to the existing literature, suggesting that CSA severity, BPD features, dissociation, and maladaptive emotion regulation are important risk factors for sexual IPV. Given the cross-sectional correlational design of our study, prospective studies are needed to corroborate our findings regarding potential psychological mechanisms underlying sexual re-victimization. Ultimately, this can help developing interventions aimed at breaking the cycle of abuse.
... These changes gradually reduce the level of performance and the ability of family members, destruct of emotional system and communication structures of family, affect the relationships among members, emergence of financial and economic problems, reduce social interactions of the family, change in roles, reduce life expectancy, and emerge the symptoms such as anger, feeling guilty and grief. 8 Overall, psychological burden of care, while reducing the quality of life of caregivers, can jeopardize their physical and mental health, ultimately leading to poor care, leaving the treatment or violent behavior with patients; these problems can exacerbate the patients' disorder. 9 These caregivers show a high level of mental and physical distress compared to the normal population. ...
Full-text available
Background: Having a patient with borderline personality disorder (BPD) in the family is a complicated and stressful experience. The caregivers' experiences and the problems they have in care of patient with BPD have remained unknown. The aim of this research was to explore the experiences of the caregivers while living with BPD patients in Iran. Methods: This interpretive phenomenological research was performed on 10 caregivers of patients with BPD at Ibn-sina Hospital in Mashhad, Iran, in 2019. Purposeful sampling was used for sampling. Data were collected through semi-structured interviews and saturated after 16 interviews. The analysis of data was concurrently carried out using the method proposed by Diekelman (1989). The MAXQDA software (Ver.10) was used for data organization. Results: The participants in this study were aged 25 to 55 years. After data analysis, three themes ("life in hell", "chain to the feet", and "black shadow of stigma") and six sub-themes ("disrupted from the life", "self-discrepancy", "care bottlenecks", "in the fence of restriction", "society dagger" and "resort to secrecy") emerged. Conclusion: The results of this study showed that the caregivers of patients with BPD during the period of care were faced with a variety of problems. It is suggested that health policy-makers should pay more attention to the problems related to the mental health of caregivers.
... These results are consistent with the findings that PTSD may intensify symptoms of BPD, resulting in emotion dysregulation (e.g. Cackowski, Neubauer, & Kleindienst, 2016), or overlap with BPD symptoms (Cloitre et al., 2014). Hence, BPD symptoms may decrease when PTSD symptoms decline, and skill training to address the BPD symptoms beforehand may not be necessary. ...
Full-text available
Background: It is generally recommended to exercise caution in applying trauma-focused treatment to individuals with posttraumatic stress disorder (PTSD) and comorbid borderline personality disorder (BPD). Objective: To investigate the effects of a brief, intensive, direct trauma-focused treatment programme for individuals with PTSD on BPD symptom severity. Methods: Individuals (n = 72) with severe PTSD (87.5% had one or more comorbidities; 52.8% fulfilled the criteria for the dissociative subtype of PTSD) due to multiple traumas (e.g. 90.3% sexual abuse) participated in an intensive eight-day trauma-focused treatment programme consisting of eye movement desensitization and reprocessing (EMDR) and prolonged exposure (PE) therapy, physical activity, and psychoeducation. Treatment did not include any form of stabilization (e.g. emotion regulation training) prior to trauma-focused therapy. Assessments took place at pre- and post-treatment (Borderline Symptom List, BSL-23; PTSD symptom severity, Clinician Administered PTSD Scale for DSM-5, CAPS-5), and across the eight treatment days (PTSD Checklist, PCL-5). Results: Treatment resulted in significant decreases of BPD symptoms (Cohen’s d = 0.70). Of the 35 patients with a positive screen for BPD at pre-treatment, 32.7% lost their positive screen at post-treatment. No adverse events nor dropouts occurred during the study time frame, and none of the patients experienced symptom deterioration in response to treatment. Conclusion: The results suggest that an intensive trauma-focused treatment is a feasible and safe treatment for PTSD patients with clinically elevated symptoms of BPD, and that BPD symptoms decrease along with the PTSD symptoms.
... Because trauma-specific interventions are not described in more detail in the standard DBT, we supplemented trauma-specific cognitive [55] and exposure-based techniques as described by Ehlers [55], and Foa et al. [56]. However, we had to consider, that within this group of patients, in-sensu exposure as described/applied in PE often goes with intense dissociative features, which hamper emotional learning [57][58][59][60] and therefore have negative impact on treatment outcome [61]. Accordingly, we modified the standard PE procedure [56] by adding anti-dissociative skills (skills-assisted exposure). ...
Full-text available
Background Posttraumatic stress disorder (PTSD) after childhood abuse (CA) is often related to severe co-occurring psychopathology, such as symptoms of borderline personality disorder (BPD). The ICD-11 has included Complex PTSD as a new diagnosis, which is defined by PTSD symptoms plus disturbances in emotion regulation, self-concept, and interpersonal relationships. Unfortunately, the empirical database on psychosocial treatments for survivors of CA is quite limited. Furthermore, the few existing studies often have either excluded subjects with self-harm behaviour and suicidal ideation — which is common behaviour in subjects suffering from Complex PTSD. Thus, researchers are still trying to identify efficacious treatment programmes for this group of patients. We have designed DBT-PTSD to meet the specific needs of patients with Complex PTSD. The treatment programme is based on the rules and principles of dialectical behavioural therapy (DBT), and adds interventions derived from cognitive behavioural therapy, acceptance and commitment therapy and compassion-focused therapy. DBT-PTSD can be provided as a comprehensive residential programme or as an outpatient programme. The effects of the residential programme were evaluated in a randomised controlled trial. Data revealed significant reduction of posttraumatic symptoms, with large between-group effect sizes when compared to a treatment-as-usual wait list condition (Cohen’s d = 1.5). The first aim of this project on hand is to evaluate the efficacy of the outpatient DBT-PTSD programme. The second aim is to identify the major therapeutic variables mediating treatment efficacy. The third aim is to study neural mechanisms and treatment sensitivity of two frequent sequelae of PTSD after CA: intrusions and dissociation. Methods To address these questions, we include female patients who experienced CA and who fulfil DSM-5 criteria for PTSD plus borderline features, including criteria for severe emotion dysregulation. The study is funded by the German Federal Ministry of Education and Research, and started in 2014. Participants are randomised to outpatient psychotherapy with either DBT-PTSD or Cognitive Processing Therapy. Formal power analysis revealed a minimum of 180 patients to be recruited. The primary outcome is the change on the Clinician-Administered PTSD Scale for DSM-5. Discussion The expected results will be a major step forward in establishing empirically supported psychological treatments for survivors of CA suffering from Complex PTSD. Trial registration German Clinical Trials Register: registration number DRKS00005578, date of registration 19 December 2013.
Comorbid borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) is a severe and complicated clinical presentation characterized by especially high rates of suicide, healthcare utilization, and psychosocial impairment. Although guidelines exist for treating each of these disorders alone, there remains limited guidance on the optimal treatment in cases where BPD and PTSD co-occur. Therefore, this systematic review synthesizes the existing research on the treatment of BPD-PTSD with the aim of optimizing treatment for this population. First, the prevalence and clinical severity of comorbid BPD-PTSD is reviewed. Next, we describe the results of our systematic review, which identified 21 articles that examined treatment outcomes in the context of BPD-PTSD or subclinical BPD-PTSD. Based on our results, we describe existing psychotherapeutic approaches, including BPD-specific treatments, trauma-focused and non-trauma-focused treatments for PTSD, and stage-based treatments for BPD-PTSD. We also summarize BPD-PTSD treatment outcomes, including whether each disorder interferes with treatment and recovery of the other. Results related to treatment safety and concerns regarding conducting trauma-focused treatment for BPD-PTSD are addressed. We end by highlighting important gaps in the literature and provide recommendations for further research.
Symptomatic disorders often co-occur with borderline personality disorder (BPD). This study's purpose was to compare the rates of comorbidity reported by adult and adolescent inpatients with BPD, including complex comorbidity (i.e., a combination of disorders of affect and impulsivity). One hundred four adolescents (aged 13–17) and 290 adults (aged 18–35) with BPD were interviewed using an age-appropriate semistructured interview for the assessment of symptomatic disorders. Lifetime rates of mood disorders and ADHD were quite similar for the two study groups. However, rates of anxiety disorders, including PTSD, substance use disorders, eating disorders, and complex comorbidity were significantly higher among adults than adolescents. Taken together, the results of this study suggest that broadly defined disorders of both affect and impulsivity are more common among adults than adolescents with BPD. They also suggest that a pattern of complex comorbidity is even more distinguishing for these two groups of borderline patients.
Full-text available
Background Emotion dysregulation is a core feature of borderline personality disorder (BPD), which often co-occurs with posttraumatic stress disorder (PTSD). Difficulties in emotion regulation (ER) have been linked to lower high-frequency heart rate variability (HF-HRV), a measure of autonomous nervous system functioning. However, previous research on vagally-mediated heart rate in BPD revealed heterogeneous findings and the effects of comorbid PTSD and dissociation on HF-HRV are not yet completely understood. This study aim to investigate HF-HRV during resting-state and an ER task in female BPD patients with comorbid PTSD (BPD + PTSD), patients without this comorbidity (BPD), and healthy controls (HC). Methods 57 BPD patients (BPD: n = 37, BPD + PTSD: n = 20) and 27 HC performed an ER task with neutral, positive, and negative images. Participants were instructed to either attend these pictures or to down-regulate their upcoming emotions using cognitive reappraisal. Subjective arousal and wellbeing, self-reported dissociation, and electrocardiogram data were assessed. Results Independent of ER instruction and picture valence, both patient groups (BPD and BPD + PTSD) reported higher subjective arousal and lower wellbeing; patients with BPD + PTSD further exhibited significantly lower HF-HRV compared with the other groups. Higher self-reported state dissociation predicted higher HF-HRV during down-regulating v. attending negative pictures in BPD + PTSD. Conclusions Findings suggest increased emotional reactivity to negative, positive, and neutral pictures, but do not provide evidence for deficits in instructed ER in BPD. Reduced HF-HRV appears to be particularly linked to comorbid PTSD, while dissociation may underlie attempts to increase ER and HF-HRV in BPD patients with this comorbidity.
Emotional intelligence as a part of social cognition has, to our knowledge, never been investigated in patients with Posttraumatic Stress Disorder (PTSD), though the disorder is characterized by aspects of emotional dysfunctioning. PTSD often occurs with Borderline Personality Disorder (BPD) as a common comorbidity. Studies about social cognition and emotional intelligence in patients with BPD propose aberrant social cognition, but produced inconsistent results regarding emotional intelligence. The present study aims to assess emotional intelligence in patients with PTSD without comorbid BPD, PTSD with comorbid BPD, and BPD patients without comorbid PTSD, as well as in healthy controls. 71 patients with PTSD (41 patients with PTSD without comorbid BPD, 30 patients with PTSD with comorbid BPD), 56 patients with BPD without PTSD, and 63 healthy controls filled in the Test of Emotional Intelligence (TEMINT). Patients with PTSD without comorbid BPD showed impairments in emotional intelligence compared to patients with BPD without PTSD, and compared to healthy controls. These impairments were not restricted to specific emotions. Patients with BPD did not differ significantly from healthy controls. This study provides evidence for an impaired emotional intelligence in PTSD without comorbid BPD compared to BPD and healthy controls, affecting a wide range of emotions.
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In this article, we attempt to distinguish between the properties of moderator and mediator variables at a number of levels. First, we seek to make theorists and researchers aware of the importance of not using the terms moderator and mediator interchangeably by carefully elaborating, both conceptually and strategically, the many ways in which moderators and mediators differ. We then go beyond this largely pedagogical function and delineate the conceptual and strategic implications of making use of such distinctions with regard to a wide range of phenomena, including control and stress, attitudes, and personality traits. We also provide a specific compendium of analytic procedures appropriate for making the most effective use of the moderator and mediator distinction, both separately and in terms of a broader causal system that includes both moderators and mediators. (46 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Full-text available
Background: Traditionally, the presence of post-traumatic stress disorder (PTSD) in subjects diagnosed with borderline personality disorder (BPD) has been the object of scant empirical research. The clarification of issues related to the different areas of study for this comorbidity is not only significant from a theoretical point of view but also relevant for clinical practice. The aim of this review is to describe the main theoretical findings and research conclusions about the comorbidity between PTSD and BPD. Methods: A literature review was carried out via PubMed and PsycINFO for the period between 1990 and September 2013. The descriptors used were 'post-traumatic stress disorder', 'borderline personality disorder', 'PTSD', 'complex PTSD' and 'BPD'. Results: Epidemiological studies show that the risk of PTSD among BPD subjects is not regularly higher than in subjects with other personality disorders. Furthermore, there is no conclusive evidence about the main aetiopathogenic mechanism of this comorbidity, either of one disorder being a risk factor for the other one or of common underlying variables. Concerning comparative studies, several studies with PTSD-BPD subjects have found a higher severity of psychopathology and psychosocial impairment than in BPD subjects. With regard to nosological status, the main focus of controversy is the validation of 'complex PTSD', a clinical entity which may comprise a subgroup of PTSD-BPD subjects. With regard to treatment, there are preliminary evidences for the efficient treatment of psychopathology in both PTSD and BPD. Conclusions: These findings are remarkable for furthering the understanding of the link between PTSD and BPD and their implications for treatment. The results of this review are discussed, including methodological constraints that hinder external validity and consistency of referred findings.
Full-text available
Objective: Few data are available on interpersonal trauma as a risk factor for borderline personality disorder (BPD) and its psychiatric comorbidity in ethnic minority primary care populations. This study aimed to examine the relation between trauma exposure and BPD in low-income, predominantly Hispanic primary care patients. Method: Logistic regression was used to analyze data from structured clinical interviews and self-report measures (n = 474). BPD was assessed with the McLean screening scale. Trauma exposure was assessed with the Life Events Checklist (LEC); posttraumatic stress disorder (PTSD) was assessed with the Lifetime Composite International Diagnostic Interview, other psychiatric disorders with the SCID-I, and functional impairment with items from the Sheehan Disability Scale and Social Adjustment Scale Self-Report (SAS-SR). Results: Of the 57 (14%) patients screening positive for BPD, 83% reported a history of interpersonally traumatic events such as sexual and physical assault or abuse. While interpersonal trauma experienced during adulthood was as strongly associated with BPD as interpersonal trauma experienced during childhood, noninterpersonal trauma was associated with BPD only if it had occurred during childhood. The majority (91%) of patients screening positive for BPD met criteria for at least one current DSM-IV Axis I diagnosis and exhibited significant levels of functional impairment. Conclusion: Increased awareness of BPD in minority patients attending primary care clinics, high rates of exposure to interpersonal trauma, and elevated risk for psychiatric comorbidity in this population may enhance physicians' understanding, treatment, and referral of BPD patients.
Objective: The primary purpose of this report was to investigate whether characteristics of subjects with borderline personality disorder observed at baseline can predict variations in outcome at the 2-year follow-up. Method: Hypothesized predictor variables were selected from prior studies. The patients (N=160) were recruited from the four clinical sites of the Collaborative Longitudinal Personality Disorders Study. Patients were assessed at baseline and at 6, 12, and 24 months with the Structured Clinical Interview for DSM-IV Axis I Disorders; the Diagnostic Interview for DSM-IV Personality Disorders, a modified version of that instrument; the Longitudinal Interval Follow-Up Evaluation; and the Childhood Experiences Questionnaire-Revised. Univariate Pearson's correlation coefficients were calculated on the primary predictor variables, and with two forward stepwise regression models, outcome was assessed with global functioning and number of borderline personality disorder criteria. Results: The authors' most significant results confirm prior findings that more severe baseline psychopathology (i.e., higher levels of borderline personality disorder criteria and functional disability) and a history of childhood trauma predict a poor outcome. A new finding suggests that the quality of current relationships of patients with borderline personality disorder have prognostic significance. Conclusions: Clinicians can estimate 2-year prognosis for patients with borderline personality disorder by evaluating level of severity of psychopathology, childhood trauma, and current relationships.
Objective: The purpose of this study was to determine the most clinically relevant baseline predictors of time to remission for patients with borderline personality disorder. Method: A total of 290 inpatients meeting criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R for borderline personality disorder were assessed during their index admission with a series of semistructured interviews and self-report measures. Diagnostic status was reassessed at five contiguous 2-year time periods. Discrete survival analytic methods, which controlled for baseline severity of borderline psychopathology and time, were used to estimate hazard ratios. Results: Eighty-eight percent of the patients with borderline personality disorder studied achieved remission. In terms of time to remission, 39.3% of the 242 patients who experienced a remission of their disorder first remitted by their 2-year follow-up, an additional 22.3% first remitted by their 4-year follow-up, an additional 21.9% by their 6-year follow-up, an additional 12.8% by their 8-year follow-up, and another 3.7% by their 10-year follow-up. Sixteen variables were found to be significant bivariate predictors of earlier time to remission. Seven of these remained significant in multivariate analyses: younger age, absence of childhood sexual abuse, no family history of substance use disorder, good vocational record, absence of an anxious cluster personality disorder, low neuroticism, and high agreeableness. Conclusions: The results of this study suggest that prediction of time to remission from borderline personality disorder is multifactorial in nature, involving factors that are routinely assessed in clinical practice and factors, particularly aspects of temperament, that are not.
Background: Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated lifetime prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode.Methods: Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey.Results: The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years.Conclusions: Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
Impulsivity is a multidimensional construct and has been previously associated with suicidal behaviour in borderline personality disorder (BPD). This study examined the associations between suicidal behaviour and impulsivity-related personality traits, as well as history of childhood sexual abuse, in 76 patients diagnosed with BPD using both the Structured Interview for Diagnostic and Statistical Manual of Mental Disorders III (DSM-III) Axis-II diagnoses and the self-personality questionnaire. Impulsivity-related traits were measured using the Barratt Impulsiveness Scale-11 (BIS-11), the Buss-Durkee Hostility Inventory (BDHI) and the Temperament and Character Inventory-Revised (TCI-R). We found that hostility and childhood sexual abuse, but not impulsivity or other temperament traits, significantly predicted the presence, number and severity of previous suicide attempts. Hostility traits and childhood sexual abuse showed an impact on suicide attempts in BPD. Our results support previous findings indicating that high levels of hostility and having suffered sexual abuse during childhood lead to an increased risk for suicidal behaviour in BPD.