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Does Childhood Sexual Abuse Cause Borderline Personality Disorder?
... Firstly, retrospective designs are vulnerable to the vagaries of memory (Fiske & Taylor, 1991). Compounding this problem is the tendency of borderline patients to misinterpret or misremember childhood events (Bailey & Shriver, 1999). ...
... Maladaptive experiences during childhood have been consistently linked with borderline personality disorder (BPD) including: abuse and neglect Zanarini, Frankenburg, Hennen, Reich, & Silk, 2006), parent hostility and resentment (Hooley & Hoffman, 1999;Johnson, Cohen, Chen, Kasen, & Brook, 2006) and exposure to domestic violence and parent conflict (Herman, Perry, & van der Kolk, 1989;Weaver & Clum, 1993). Most studies have been retrospective, however, with concomitant methodological issues, such as the tendency of patients with BPD to misinterpret or misreport past experiences with family members (Bailey & Shriver, 1999). Further, domestic conflict and child maltreatment usually occur in family environments characterised by multiple risk factors (Fergusson, Boden & Horwood, 2006), which are difficult to disentangle with retrospective designs. ...
... to combined victimisation (overt and relational) or experienced chronic victimisation (at 8 and 10 years) were at highly increased risk for developing BPD symptoms, indicating a dose-response relationship. We found comparable associations using mother and teacher report; therefore, the observed relationships between victimisation and BPD cannot be attributed solely to self-report bias, i.e. the tendency of individuals with BPD to misinterpret or misreport (Bailey & Shriver, 1999) peer victimisation experiences. ...
... In contrast, however, heightened stress levels could render memory in BPD particularly susceptible for interferences ( Krause-Utz et al., 2012). This would be in line with studies in which BPD patients have been judged by clinicians to be prone to inaccurate perceptions and to memory errors for events ( Bailey & Shriver, 1999;Reid, 2009;Snyder, 1986). To rule out increased susceptibility for false memories in BPD could be important for the treatment of BPD as it gives credit to the (autobiographical) reports of patients. ...
... In addition, up to 75% of BPD patients suffer from dissociative experiences (for a review see Barnow et al., 2010). As mentioned before, these (comorbid) symptoms seem to be associated with increased false memories and could impede the encoding and retrieval of objective events ( Bailey & Shriver, 1999). Hence, we expected that patients diagnosed with BPD show worse visual memory performance and, in particular, a heightened susceptibility for false memories on the DRM paradigm compared to healthy controls. ...
... A final noncausal explanation would be that some individuals possess a trait that increases probability of exposure to CSA and independently their risk for developing psychiatric disorders. 35 Given that twins are likely to share this trait, our cotwin control analyses have power to address this difficult issue. This model predicts that the nonabused member of a pair discordant for CSA (who is likely to have this trait) should also be at high risk for developing future psychopathologic disorders. ...
Women who report childhood sexual abuse (CSA) are at increased risk for developing psychiatric disorders in adulthood. What is the diagnostic specificity and cause of this association?
In a population-based sample of 1411 female adult twins, 3 levels of CSA were assessed by self-report and cotwin report: nongenital, genital, and intercourse. Interviews with twins and parents assessed family background and diagnoses of psychiatric and substance dependence disorders. Odds ratios (ORs) were calculated by logistic regression.
By self-report, 30.4% reported any CSA and 8.4% reported intercourse. Self-reported CSA was positively associated with all disorders, the highest ORs being seen with bulimia and alcohol and other drug dependence. The ORs were modest and often nonsignificant with nongenital CSA and increased with genital CSA and especially intercourse, where most ORs exceeded 3.0. A similar pattern of findings was seen with CSA as reported by the cotwin, although many ORs were smaller. Controlling for family background factors and parental psychopathology produced a small to modest reduction in ORs. In twin pairs discordant for CSA, the exposed twin was at consistently higher risk of illness.
Women with CSA have a substantially increased risk for developing a wide range of psychopathology. Most of this association is due to more severe forms of CSA and cannot be explained by background familial factors. Although other biases cannot be ruled out, these results are consistent with the hypothesis that CSA is causally related to an increased risk for psychiatric and substance abuse disorders.
The American diagnosis manual Diagnostic and Statistical Manual of Mental Disorders, version four,-DSM-(APA-95) operates with nine criteria in relation to borderline personality disorders. BPD is diagnosed when at least five of these criteria are confirmed through psychological/psychiatric tests and examination by a competent person. The nine criteria are as follows: 1. frantic efforts to avoid real or imagined abandonment 2. a pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation 3. identity disturbance: unstable self-identity 4. potentially self-damaging impulsivity 5. recurrent suicidal behaviour 6. affective instability due to a marked reactivity of mood (e.g., intense dysphoria, irritability) 7. chronic feelings of emptiness 8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger) 9. transient, stress-related paranoid ideation or severe dissociative symptoms DSM presupposes theoretical indifference regarding criteria relevance. This means that the system does not operate with a hierarchy of symptoms in which certain symptoms are more important than others in relation to the correct diagnosis. The only thing that one should make sure is that five out of nine specific criteria are met before diagnosing a borderline personality disorder. This might be seen, in any case clinically, as a weakness of the system since it does not give the clinician any instruction about which criteria or symptoms he should pay more attention to. ICD (International Classification of Diseases, now version 10), the category system which has been adopted by WHO, has to a great extend been harmonised with DSM. However it has historically a somewhat different theoretical base that allows a certain selection of symptoms. This implies that in the ICD-system some criteria must be included in order to reach a certain diagnosis. Furthermore ICD divides "Emotional unstable (Borderline) personality disorder" into an "impulsive type" that is primarily characterised by emotional instability and lack of impulse control, and a "Borderline type" that in addition includes the remaining criteria according to DSM IV. The disorder of the character that we call borderline or unstable personality disorder is characterized primarily by a relational incapacity. This includes continuous emotional instability; impulsiveness, inadequate-possibly excessive-aggression and irritation together with diffusion of identity united with a wavering or even rudimentarily established self-image. Marziali and Blum (-90) consider, referring to Clarkin and Hurt (-88), that "borderline disorder is best defined by three criteria: 1) unstable relationship, 2) affect instability, and 3) impulsive behaviour". This is in agreement with what others report as the dysfunctional central domain (for instance Westen-91). Clarkin and Hurt 2 (-88) consider the first 6 criteria of the DSM-system as expressions of interpersonally characterized disorders. In the research about the pathogenesis and aetiology of BPD a traditional dividing line exists between those who maintain that the cause primarily consists of an unsolved central conflict in the development phase Margaret Mahler (-84) calls the rapprochement phase (Kernberg-75, Masterson and Rinsley-75) and between those who think that the borderline person in childhood and youth has experienced an uninterrupted deficit of an environment that could have supported the development of healthy qualities of the mind, for instance stable identity of the ego (Gunderson-84). The deficit theoreticians consider these repeating traumas during a long period of time in childhood and youth as the fundamental cause. As a consequence Gunderson lays greater stress upon the interpersonal factors in the pathogenesis than for instance Kernberg does (Valliant-77, Buie and Adler-82, Gunderson-84, Segal-90). In any case representatives of the different points of view share the acknowledgement that interpersonal disorders are a key element in characterizing the borderline disorder. Possibly Kernberg is quite right in stating that something went wrong in the individuation/separation phase. Yet intuitively it seems more plausible to assume that it is not only separate events during a certain sensitive period in childhood that mainly determine later development (even though these events naturally can have a profound influence on the person's later development), but more likely the total relation pattern (upbringing and model behaviour included) that the parents show during a long period in the development of the child, which primarily forms the personality of the child (Buie and Adler-82, Gunderson-84). Zanarini and Frankenburg summarise it all with the hypothesis that borderline pathology develops "in response to serious, chronic maladaptive behaviours on the part of immature and emotionally incompetent, but not necessarily deliberately malevolent caregivers" (p. 26, Zanarini and Frankenburg-97). This is quite consistent with my own experience with persons that have a borderline disorder or structure. Conclusively it must be mentioned that the literature generally speaking is short of epidemiological data. Gunderson and Zanarini (-87) estimate the occurrence between 2 and 4%. In an outpatient setting Kass and others (-85) and Widiger and Frances (-89) calculate the prevalence to be approximately 11%. Another source (Widiger and Weissman-91) calculates that up to 2% of the normal population as a whole is to be considered as suffering from a borderline disorder, 15% of a mixed psychiatric population, and that half of all the personality disorders are either borderline cases or a comorbid type. Note that these studies do not operate with Kernberg's hypothesis about a borderline personality structure (Kernberg-75) and the epidemiological derivative of this theoretical conception which estimates that up to about 15-20% (Gunderson-84) of a normal population can show this type of personality structure. Widiger and Weissman (-91) estimate that ca 76% of people with a borderline disorder are women. This overrepresentation of women can be considered as being relatively well verified in the international literature. There are few things one can be more certain about in the case of borderline than the fact that it is a female, more than a male, phenomenon. Swartz and others (-90) accordingly state, supported by a comprehensive study of the literature for the purpose of reaching valid prevalence estimates of borderline, that "the only consistent demographic feature associated with borderline 3 personality disorder appears to be female predominance"(p. 258). This is why, for reasons of simplicity, we will in the following indicate the person with the borderline disorder as "she" and the partner as "he". 1 SOME RESEARCH ON COUPLE-RELATIONS Below I will briefly refer to some studies, which try to find out what it is that distinguishes a close personal relationship between two people. This will offer a background for the following discussion that will focus on trends in the borderline pathology, which cause relational problems. In this connection it should be mentioned that the research program we refer to is founded on studies of normal populations-and the results are naturally characterized by that fact. This gives the advantage that the result can form a background or contrast to the relations that will be described below which are characterised by more psychopathological deviations. It is difficult to determine what the definition of a couple, which I concisely reproduced in the introduction, should contain more specifically. Research from different disciplines-social psychology, micro sociology, communication theory, social anthropology and psychotherapy, just to mention some relevant fields-has a tendency to reach somewhat different results. Often one finds, reading the literature on the subject, that studies use the hypothesis, or have proven, that there exist certain essentials, which can be considered as absolutely fundamental to what the research on "personal relationship" (La Folette-96) calls "romantic relationship" (as opposed to friendship, comradeship and more "distant" forms of "personal relationship"). An example of such an essential is found in Sidney Jourard's work. He describes the fact that happy marriages are always characterized by partners who are self-revealing ("self-disclosure") in relation to each other. This implies being transparent to each other, appearing as the persons they really are-the real self-, being able, and being allowed, to do so. One allows oneself to be translucent and has access to look into the other person's psyche (Jourard-71). Now and then discoveries of such basic "facts" are cited in support of building therapy systems, which have their rationale in these facts. For instance Jourards research has become the foundation of a more general approach for a kind of couple therapy that has been described as successful. The results are documented in the journal Family Process (Warning-90). Another example is the finding of Hendrick, Hendrick and Adlers (-88), based on an earlier study of six different "love styles" (Hendrick & Hendrick-86), that the aspect of love or "love style" they call "Eros" (the passionate, erotic and intensively experienced emotional love) is the one which in both men and women has the highest correlation to satisfaction in couple relationships. 2 1 This implies in consequence that it is the man in some relationships who will have borderline traits. It will also be possible that both partners will have these traits, and-this must be underlined-that bps also will occur in situations where the persons have the same sex. (About bps and homosexuality, see among others Zubenko-87, Dulit-93). 2 The words ludus, storge, pragma, mania and agape indicate the other styles. 4 Often the essentiality of (the good) relation is comprehended by looking at the factors that determine basic conflicts or the field of relation problems. This kind of reaching a definition by a negative approach is especially justified in a situation where the scientific material has an empirical character to a high degree. This is the case with research based on cognitive psychology, which has been done by Howard Markman, Scott Stanley and others for a number of years (Markman and others-88, Markman and others-93). In his self-help book Fighting for your marriage (Markman and others-94)-which by the way forms the theoretical background for those who have taken the training for course leader in the life-together program PREP-four areas or conflict models are reported as fundamentally injurious for good couple relationships:-escalation owing to negative responses,-disqualifying the thoughts, feelings and acts of the partner,-an avoiding or withdrawing style of coping with conflicts,-tendencies towards interpreting the other one's statements and actions negatively. Hinde 1981 (referred to in Duck-88) figures out that close personal relationships of the affective kind are determined by a collection of factors that change, but are still present as phenomena during the development of a relation. Below we will refer to these factors and some examples of questions that can be raised against the background of the factors presented.
We conducted an Internet survey of 1,102 men sexually attracted to children concerning their history of adjudicated offenses related to child pornography and sexual contact with children. Most of the men reported no offenses, but their rate of offenses was much higher than that expected for adult-attracted men. Correlates of offending are consistent with a strong role of the cumulative effects of temptation, especially age. Older men, men who had repeatedly worked in jobs with children, men who had repeatedly fallen in love with children, and men who had often struggled not to offend were especially likely to have offended. Attraction to male children, relative attraction to children versus adults, and childhood sexual abuse experiences were also strong predictors of offending. In contrast, permissive attitudes regarding child-adult sex and frequent indulgence in sexual fantasies about children were not significantly related to offending. Our findings represent the first large study of offending among men sexually attracted to children who were not recruited via contact with the legal system. Because of methodological limitations, our findings cannot be definitive. Reassuringly, however, results are generally consistent with those from the most pertinent existing studies, of recidivism among convicted sex offenders.
Introduction. There is renewed interest in modern psychiatry in studying the link between psychopathology and traumatic events during childhood. Methods. The Marshall scale of childhood trauma was applied to173 psychiatric patients at the Curicó Mental Hospital. The traumatic events were correlated with Axis I diagnoses and probable Axis II diagnoses according to DSM-IV. Results. Positive correlations were obtained between substance abuse and childhood events involving alcohol, physical abuse and forced sexual contact (correlations 0.19 p
Physicians and psychologists who treat headache not infrequently encounter patients with borderline personality disorder (BPD). BPD patients frequently suffer from headache, and often pose special problems in treatment. Few guidelines exist for the management of the BPD headache patient.
To provide an overview of current concepts on BPD, including comorbidity, psychopathophysiology, and treatment. To provide an explicit framework for managing borderline behavior in patients with chronic headache.
A literature review combined with clinical observations from the tertiary treatment of intractable headache in outpatient and inpatient settings.
BPD is found in almost 2% of the general population, with increased prevalence in patients with comorbid psychopathology and substance abuse. Severe headaches and migraine appear to be more prevalent in patients with BPD than the general population. A reported history of abuse is common, but must be interpreted with caution. Recent research has found reduced hippocampal volume in women patients with BPD; hypometabolism in the premotor, prefrontal, and anterior cingulate cortex, as well as the thalamic, caudate, and lenticular nuclei; and serotonergic dysfunction. Opioid medications may have an adverse influence on certain clinical features of BPD. Some patients show at least short-term improvement in dissociative behavior when given opioid antagonists. Treatment should combine appropriate pharmacotherapy with ongoing psychotherapy. Early identification of BPD is likely to improve the course of treatment. Treatment often requires explicit contracts, consistent limit-setting, confrontation, and communication between different treating professionals to avoid "splitting." The recognition and management of the doctor's own countertransference is important to successful management. Noncompliant patients may need to be terminated from treatment.
Specific management guidelines and the use of explicit treatment contracts can help sustain patients in treatment, reduce the risk of medication abuse, and minimize distress in the treating professional. Headaches and other symptoms in patients with BPD can be successfully managed over the course of a long-term relationship with clearly defined limits.
This study examined associations between childhood abuse and personality disturbances in 228 drug-dependent women. Thirty-six percent denied abuse, 50% reported emotional, 42% physical, and 42% sexual abuse. Million Clinical Multiarial Inventory (MCMI-III) scores > 74 provided evidence of personality disturbance and scores on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales measuring somatic complaints, depression, anxiety and postraumatic stress disorder (PTSD) served as covariates. Emotional and physical abuse survivors were at increased risk for borderline, masochistic, and avoidant disturbances and decreased risk for narcissistic disturbances. Emotional abuse survivors were also less likely to be sadistic whereas physical abuse survivors were more likely to be paranoid. Sexual abuse survivors were twice as likely be antisocial; however, no association was found with borderline personality. Finally, an increased prevalence of severe personality disturbances was observed among those experiencing multiple types of abuse. Childhood trauma predisposes drug-dependent women to develop troublesome personality characteristics that are independent of drug addiction and other psychological problems associated with childhood trauma.
Through reviewing what is known about the nature, course, and heritability of borderline personality disorder (BPD), we argue for a reconceptualization of this disorder that would lead to its placement on Axis I. Borderline personality disorder is a prevalent and disabling condition, and yet the empirical research into its nature and treatment has not been commensurate with the seriousness of the illness. We not only review empirical evidence about the etiology, phenomenology, and course of the disorder in BPD but we also address fundamental misconceptions about BPD that we believe have contributed to misunderstanding and stigmatization of the disease. Finally, we suggest future directions for research that might permit the identification of core features of this disorder, with a focus on the importance of naturalistic assessments and of assessments through the course of development.
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