Access to this full-text is provided by Taylor & Francis.
Content available from Psychology Research and Behavior Management
This content is subject to copyright. Terms and conditions apply.
ORIGINAL RESEARCH
Structural Equation Modeling of Childhood
Trauma and Self-Stigma in Adult Inpatients with
Borderline Personality Disorder
Marie Ociskova
1,2
, Jan Prasko
1–4
, Krystof Kantor
1,5
, Jakub Vanek
1
, Vlastimil Nesnidal
1
,
Kamila Belohradova
1
1
Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic;
2
Jessenia Inc. Rehabilitation Hospital
Beroun, Akeso Holding, MINDWALK, S.r.o, Beroun, Czech Republic;
3
Department of Psychological Sciences, Faculty of Social Sciences and Health
Care, Constantine the Philosopher University in Nitra, Nitra, Slovak Republic;
4
Department of Psychotherapy, Institute for Postgraduate Training in
Health Care, Prague, Czech Republic;
5
Department of Child Psychiatry, University Hospital in Motol, Prague, Czech Republic
Correspondence: Jan Prasko, Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, Hnevotinska 3, Olomouc,
779 00, Czech Republic, Email praskojan@seznam.cz
Purpose: Child abuse and trauma are signicant risk factors in the etiology of borderline personality disorder (BPD). Apart from
affecting the risk of developing BPD, adverse childhood experiences seem to increase its symptoms and related disability. Self-stigma
presents another common issue with equally prominent consequences for mental health. Despite being theoretically linked, the
connections among childhood trauma, self-stigma, and mental health have not been explored in patients with BPD. This study
aimed to provide rst insights into this understudied topic.
Patients and Methods: This cross-sectional study included 283 inpatients diagnosed with BPD participating in a residential
transdiagnostic psychotherapeutic program. The patients completed several measurements – the Internalized Stigma of Mental
Illness Scale, the Childhood Trauma Questionnaire – Short Form, the Clinical Global Impression – Severity, the Beck Depression
Inventory-II, the Beck Anxiety Inventory, the Dissociative Experiences Scale, the Sheehan Disability Scale, and a demographic
questionnaire. The data was statistically analyzed using IBM SPSS and AMOS 26 programs, and bivariate correlation tests and
structural equation modeling explored the hypotheses.
Results: Retrospectively reported childhood trauma positively correlated with current self-stigma. Both childhood trauma and self-
stigma were also positively related to several indicators of general psychopathology and disability. The signicance of these
connections was subsequently conrmed by structural equation modeling, where self-stigma acted as a partial mediator of childhood
trauma, general psychopathology, and disability.
Conclusion: Self-stigma signicantly mediates the relationship between childhood trauma and selected mental health symptoms
among adult patients diagnosed with BPD. Longitudinal studies are necessary to explore the causality of the ndings. Therapeutic and
societal efforts to tackle childhood trauma or self-stigma might benet from reecting its broader psychosocial context.
Keywords: borderline personality disorder, self-stigma, childhood trauma, depression, anxiety, disability
Introduction
Borderline personality disorder (BPD) is a common mental disorder that presents with impulsivity and pervasive
instability in interpersonal relationships, affect, and self-concept. Other symptoms include anger management issues
and short depressive or psychotic episodes. Abandonment anxiety is common, as are self-harm and suicidality.
1
The prevalence of BPD in the general population is estimated at around 1% and rises to 12% in outpatient psychiatric
settings and 22% in inpatient psychiatric care.
2
The consequences of BPD may be severe. Individuals with BPD
experience functional impairment and reduced quality of life.
3,4
Although many patients’ symptoms remit over time,
5
up to 40% do not experience sufcient recovery within twenty years of follow-up.
6
Moreover, remitted patients still tend
to struggle with psychosocial functioning.
7,8
Psychology Research and Behavior Management 2024:17 3761–3777 3761
© 2024 Ociskova et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.
php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the
work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For
permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
Psychology Research and Behavior Management Dovepress
Open Access Full Text Article
Received: 4 May 2024
Accepted: 14 October 2024
Published: 30 October 2024
The etiology of BPD is multifactorial and intertwined.
9,10
Genetic factors account for approximately 40% of BPD
variation and interact with environmental factors, increasing the risk of BPD.
9,11
Major environmental risks are childhood
trauma and abuse. Individuals with BPD are more likely to report childhood adversity than non-clinical controls and
other psychiatric patient groups.
12
According to Ball and Links,
13
between 74% and 93% of individuals with BPD
experience at least one type of abuse or a signicant loss in their childhood. A recent study by Schulze et al found that
these experiences are usually moderate or severe.
14
The most common type is emotional neglect (62%), followed by
physical abuse (48.3%), sexual abuse (45.8%), emotional abuse (28.4%), and physical neglect (14.5%).
14
Although
individuals with BPD are generally highly interpersonally sensitive, those with BPD and a history of childhood
maltreatment are even more sensitive and prone to feeling interpersonally threatened.
15,16
Apart from that, childhood
trauma relates to more severe symptoms of dissociation,
17
anxiety,
18
depression,
19
and disability.
20
While dealing with BPD can be challenging by itself,
20,21
many of these patients also struggle with stigma.
Borderline personality disorder is one of the most stigmatized mental disorders.
22,23
The general population may
misperceive BPD symptoms as purposefully disruptive or deliberately annoying, which can lead to increased social
distance.
22–25
Since patients diagnosed with BPD are sensitive to rejection, they might perceive the consequences of
the stigma as particularly hurtful.
24
Furthermore, they tend to react to perceived rejection by harsh self-criticism and
self-insults.
25–28
Negative social attitudes, such as the stigma, thus might harmfully shape a person’s relations towards
themselves.
Self-stigma is another side of the BPD stigma. The term denotes a process in which an individual with a stigmatized
characteristic becomes aware of prejudices about their condition, agrees with them, and applies them to themselves.
29
Self-stigma is prominent among patients with a diagnosis of BPD.
30,31
Individuals with diagnosed BPD often state that
the knowledge of the diagnosis diminished their self-image and self-esteem and led to feeling helpless and burdensome.
32
They also tend to judge their mental health issues with self-labeling such as: “I am worthless”, “I’m dysfunctional”, or “I
am evil”
25,31,33
. Furthermore, they frequently engage in self-invalidation, which is thought to result from an emotionally
invalidating childhood environment.
34
Self-stigma presents one of three types of self-invalidation observed in BPD,
along with harsh self-criticism and self-doubt.
25
Compared to other patients, individuals with BPD might stigmatize themselves more intensely than individuals with
anxiety disorders, attention decit-hyperactivity disorder, or bipolar disorder.
30,31,35
Despite that, correlates of self-stigma
in BPD have been less explored than in other mental disorders, and the knowledge base is sparse. Still, it seems that self-
stigma in BPD positively correlates with more severe symptomatology, a higher number of psychiatric inpatient care, and
the absence of a romantic relationship.
30,35
Self-stigma has been connected with low self-esteem, depressed mood, anxiety, dissociation, and loss of motiva-
tion in other patient groups.
22,36,37
It also relates to more severe psychiatric symptoms, impaired social and occupa-
tional functioning, reduced income, and poor adherence to psychiatric treatment.
36,38
Furthermore, self-stigma
positively correlates with an increased risk of suicide attempts and death by suicide.
39
Thus, self-stigma might
severely impact patients’ mental health and healthcare costs due to more signicant disability and less favorable
prognosis.
38
Although both childhood trauma and self-stigma are prominent issues in BPD, their relations have not been studied in
these patients. Still, there is some data about self-stigma and childhood adversities in patients with other psychiatric
diagnoses. A recent study by Hofmann et al explored the topic in a mixed sample of individuals with unipolar depression
or bipolar disorder.
40
The results showed that childhood trauma seems to be a signicant predictor of self-stigma. Similar
ndings were published by Kolek et al,
41
who researched various factors inuencing treatment resistance in patients with
panic disorder, and by Holubova et al, who collected data from individuals with neurotic spectrum disorders.
36
Lee et al
reported comparable ndings in patients diagnosed with schizophrenia, highlighting the connection with emotional abuse
and adding signicant relations with physical abuse and bullying.
42
Stolzenburg et al then explored the connection
between childhood trauma and self-stigma among individuals with alcohol use disorder.
43
Interestingly, depressive
symptoms and a level of agreement with negative stereotypes fully mediated the relationship between childhood trauma
and harm caused by self-stigma.
https://doi.org/10.2147/PRBM.S476768
DovePress
Psychology Research and Behavior Management 2024:17
3762
Ociskova et al Dovepress
Powered by TCPDF (www.tcpdf.org)
Aim of the Study
The study aimed to explore the relationship between self-stigma and retrospectively evaluated childhood trauma in patients
with BPD. Since individuals with BPD and a history of childhood adversities were reported to be more interpersonally
sensitive than patients without this history, we expected the childhood trauma to connect with more severe self-stigma.
Furthermore, we expected both to positively relate to psychopathology and disability, as has been shown in BPD and other
patient groups, and for self-stigma to mediate the connection between childhood trauma and these symptoms. An exploration
of these connections would contribute to understanding factors shaping childhood trauma and self-stigma in BPD and provide
insights for the treatment and future developments of anti-stigma campaigns in this populace.
We formulated the following hypotheses:
H1: Childhood trauma (CTQ) positively correlates with self-stigma (ISMI).
H2: Childhood trauma (CTQ) / H3: Self-stigma (ISMI) positively correlates with current severity of:
a) Anxiety (BAI)
b) Depressive symptoms (BDI-II)
c) Dissociation (DES)
d) Overall severity of psychopathology (CGI)
e) Disability (SDS)
H4: Self-stigma (ISMI) signicantly mediates the relationship between childhood trauma (CTQ) and:
a) Psychopathology (Dependent variables in H2 and H3)
b) Disability (SDS)
Material and Methods
Study Design and Sample
This cross-sectional study took place between February 2015 and August 2022 in a transdiagnostic psychotherapeutic
ward of the Department of Psychiatry, Olomouc, the Czech Republic. The target population was individuals with BPD
who sought intensive inpatient treatment. Upon admittance, all patients underwent a thorough diagnostic process with an
attending psychiatrist who conrmed the primary diagnosis and potential comorbidities according to ICD-10.
44
A senior
psychiatrist and head of the department then independently reviewed and conrmed the diagnoses.
Patients meeting the following criteria were offered participation in the study. Inclusion criteria were adult age (18+)
and BPD diagnosis according to ICD-10 research criteria.
44
Exclusion criteria were organic mental disorder, current
substance use disorder, psychotic disorder, bipolar disorder, current moderate or severe depressive episode, intellectual
disability, acute suicidality, and severe somatic illness (such as oncological disease or sclerosis multiplex). Figure 1
describes the enrollment process.
Ethics Approval and Consent to Participate
The study was conducted according to the principles of the Helsinki Declaration and approved by the Ethical Committee of the
Faculty of Medicine, Palacky University in Olomouc (No. MZ13-FNOL-Grant 152/12). A researcher explained the study,
including its aims, methodology, and all aspects of the potential participation, and provided written information and an informed
consent form. All agreeing patients then signed the informed consent form and subsequently completed measurements.
Measurements
Internalized Stigma of Mental Illness Scale
This ISMI scale consists of 29 items measuring ve facets of self-stigma: alienation, stereotype endorsement, perceived
discrimination, social withdrawal, and stigma resistance.
45
Participants denote their agreement with each statement on
Psychology Research and Behavior Management 2024:17 https://doi.org/10.2147/PRBM.S476768
DovePress
3763
Dovepress Ociskova et al
Powered by TCPDF (www.tcpdf.org)
a four-point scale, ranging from 1 (Strongly disagree) to 4 points (Strongly agree). Examples of items are: “People with
mental illness cannot live a good, rewarding life” or “I am disappointed in myself for having a mental illness”
45
. These
general statements may be tailored to the specic population by switching the term “mental illness” for more relevant,
such as “borderline personality disorder”
45
. Total scores range from 29 to 116; the subscales’ scores are variable, as they
contain differing numbers of items. The total scores between 49 and 78 points suggest average self-stigma compared to
results of a heterogeneous patient group.
46
The average item score may be interpreted as follows – minimal self-stigma:
1.0–2.0; mild self-stigma: 2.0–2.5; moderate self-stigma: 2.5–3.0; severe self-stigma: 3.0–4.0.
47
The scale is reliable
(Cronbach’s alpha = 0.91), stable in time (r = 0.90), and valid, as seen by the original study and Czech adaptation.
45,46
Subscale norms are sten-based and reported in detail by Ociskova et al.
46
The Cronbach’s alpha was 0.88 in this study.
Childhood Trauma Questionnaire – Short Form
CTQ-SF is a retrospective questionnaire that measures the severity of selected childhood adversities: physical abuse and
neglect, emotional abuse and neglect, and sexual abuse.
48
It has 28 items, of which three evaluate validity and are not
calculated in the total score. Individuals choose from a ve-point scale based on how true that particular experience was
in their case. For example, the rst item states, “I did not have enough to eat”. Participants chose if that was never true (1
point), rarely true, sometimes true, often true, or very often true (5 points). The total score ranges from 25 to 125 points;
each subscale has 5 to 25 points.
48,49
Bernstein and Fink created the following cut-off scores to distinguish moderate to
severe adversity – emotional abuse: ≥ 13, physical abuse: ≥ 10, sexual abuse: ≥ 8, emotional neglect: ≥ 15, and physical
neglect: ≥ 10.
48
Psychometric analyses found the questionnaire to be mostly reliable (Cronbach’s alphas = 0.68-0.95),
adequately internally structured, and valid.
50
As for the internal consistency, Cronbach’s alpha was 0.86 in this study.
Clinical Global Impression – Severity
CGI-S evaluates the overall severity of the mental health issues.
51
It is rated on one seven-point scale with anchors
ranging from 1 (Normal, not at all ill) to 7 (Among the most severely ill patients). The clinician version (CV) asks:
“Considering your total clinical experience with this particular population, how mentally ill is the patient at this time?”
while the patient version (PV) contains a question, ”To what degree do you currently consider yourself ill?”.
51,52
Both
measures were used in this study. Two heads of the department completed the clinician version in this study (the rst
Figure 1 Flowchart of the enrollment.
https://doi.org/10.2147/PRBM.S476768
DovePress
Psychology Research and Behavior Management 2024:17
3764
Ociskova et al Dovepress
Powered by TCPDF (www.tcpdf.org)
from 2015 to 2017, the second from 2018 to 2022). Both of them were professors of psychiatry with extensive experience
in clinical practice and research in the eld. As for the psychometric properties, this one-item scale proved stable in time
(r = 0.72-0.82) and valid when compared to other rating scales.
53
Beck Depression Inventory-II
BDI-II is a 21-item inventory that measures the severity of common symptoms of major depression.
54
Participants
choose one of four levels of severity for each symptom based on their perceived state during the last two weeks. For
example, the item evaluating sadness has the following options: I do not feel sad (0 points), I feel sad much of the time,
I am sad all the time, and I am so sad or unhappy that I cannot stand it (3 points). The total score ranges from 0 to 63,
with higher scores interpreted as more severe depressive symptoms.
54
The total score falls into one of the severity
categories – minimal symptoms: 0–13; mild: 14–19; moderate: 20–28; or severe: 29–63.
54
A total score of 17 has been
used to detect clinically signicant depressive symptoms.
55
The inventory has excellent internal reliability (Cronbach’s
alpha = 0.90) and stability over time (r = 0.77-0.83) and proved good convergent and discriminatory validity when
compared with other measures.
54,55
The Cronbach’s alpha was also 0.90 in this study.
Beck Anxiety Inventory
BAI is a 21-item inventory focusing on common symptoms of anxiety.
56
Compared to BDI-II, the evaluated period is one
week. Patients score on a four-point scale based on how much the symptoms have bothered them. Examples of the symptoms
are Numbness or tingling, Fear of losing control, or Inability to relax. The anchors are: Not at all (0 points), Mildly, but it did
not bother me much, Moderately – it was not pleasant at times, and Severely – it bothered me a lot (3 points). The total score is
0 to 63 points, with higher scores meaning more severe anxiety.
56
A score of 17 distinguishes patient and non-clinical
samples.
57
The total score has several severity categories: Minimal: 0–7, Mild: 8–15, Moderate: 16–25, and Severe: 26–63.
58
Similar to BDI-II, this inventory has excellent internal consistency (Cronbach’s alpha = 0.92) and temporal stability (r = 0.75-
0.90), as well as adequate convergent validity.
56,57
The Cronbach’s alpha was also 0.92 in this study.
Dissociative Experiences Scale
DES has 28 items that measure common dissociative symptoms, specically dissociative amnesia, absorption, depersonaliza-
tion, and derealization.
59
An individual marks a spot on a 10-cm line according to how often they experience each symptom:
0% means “never”, while 100% represents “always”. For example, a participant considers an item. Some people nd they
have no memory of important events (for example, a wedding or graduation). The total score ranges between 0 and 100 points,
based on the average time spent in dissociative states.
59
Twenty points have been suggested as a cut-off score for a more in-
depth clinical exploration. The general population usually scores between 8 and 12 points, while patients with BPD tend to
score around 28 points.
60
DES has excellent internal consistency (Cronbach’s alpha = 0.88-0.92), good temporal stability
(r = 0.81-0.84), and convergent validity.
61,62
The Cronbach’s alpha was 0.94 in this study.
Sheehan Disability Scale
SDS consists of three scales that evaluate disability in work/school, social life/leisure activities, and family life/home
responsibilities.
63
For example, a participant answers a question to what degree “the symptoms have disrupted your
social life/leisure activities” on a scale ranging from 0 (not at all) to 10 (extremely). The Work/School subscale can be
incomplete if the individual “has not worked or studied at all during the past week for reasons unrelated to the disorder”.
Scores 1–3 show a mild impairment, 4–6 a moderate impairment, and 7–9 a marked impairment in that area.
63
SDS has
good internal consistency (Cronbach’s alpha = 0.83-0.89), structure, and adequate convergent and discriminatory
validity.
64–66
The Cronbach’s alpha was 0.73 in this study.
Demographic Questionnaire and Clinical Documentation
This questionnaire asked for demographic data – age, sex, education, employment status, and relationship status. Clinical
documentation provided information on the onset and duration of BPD, familial psychiatric history, the number of
hospitalizations, and the currently used medication.
Psychology Research and Behavior Management 2024:17 https://doi.org/10.2147/PRBM.S476768
DovePress
3765
Dovepress Ociskova et al
Powered by TCPDF (www.tcpdf.org)
Statistics
Statistical software G*Power 3.1
67
was used to estimate a sample size with the studies of Holubova et al and Stolzenburg et al
as reference points.
36,43
Results showed that at least 88 patients were required to detect a moderate effect size in a two-tailed
correlation with α = 0.05 and power 0.80. The sample size for the structural equation modeling was estimated with Soper’s
calculator and set at a minimum of 204 individuals to detect a moderate effect size with the same power and probability level.
68
IBM SPSS and AMOS 26 programs analyzed the data. Descriptive statistics was applied to demographic and clinical
data to obtain frequencies and percentages of categorical variables and numerical variable means and standard deviations.
Missing data were analyzed using Little’s MCAR test, and variables with less than 10% missing values were handled
with multiple imputations, as Bennett recommended.
69
Little’s MCAR test was negative, showing the pattern of data missing completely at random (χ
2
= 594.9, df =
598, sig.: 0.53). BAI, BDI-II, and DES did not have any missing values. Multiple imputations were performed on
variables with less than 10% missing values and used for subsequent analyses: ISMI and its CGIs and SDS Family
and Social life subscales. The CTQ subscales were missing values from 15.9 to 17.3% due to temporal
mismanagement of questionnaires by the hospital personnel. The SDS Work/School subscale was often left
incomplete by patients for an unknown reason (27.2%). These missing values were not imputed to avoid a bias
in imputing larger portions of data.
69
The implications of the missing data are considered in the Discussion.
The Shapiro–Wilk test then analyzed the data distribution and found non-normal distribution in most variables (W = 0.573-
0.975, p ≤ 0.05) except for BDI-II (W = 0.985, p = 0.13) and the ISMI total score (W = 0.994, p = 0.80), its Perceived
discrimination (W = 0.982, p = 0.07), Social withdrawal (W = 0.987, p = 0.20), and Stigma resistance (W = 0.982, p = 0.06)
subscales.
Spearman’s and Pearson’s bivariate correlations explored the majority of the hypotheses. We used the total scores of
the measurements to test all of them. Subscale analyses were explorative, as their connections varied in other studies. The
Holm-Bonferroni method was used to correct the multiple comparisons.
70
This correction is more powerful than the
traditional Bonferroni method and has been successfully applied in health care.
71,72
Based on the current literature, we also made several assumptions regarding the inter-relations among child-
hood trauma, self-stigma, psychopathology, and disability. We hypothesized that childhood trauma would increase
the proneness towards self-stigma and the severity of psychopathology and disability in adults with BPD. Since
self-stigma has been related to early adverse experiences, mental health struggles, and functional impairment, we
expected that self-stigma could be a mediator of these connections. The latent factors of psychopathology and
disability were correlated because of the bidirectional nature of their connection. When creating the model, we
made two adjustments. We did not include the work disability due to many missing values in the respective
subscale. Further, we included the patient version of CGI instead of the clinician version because it provided
a subjective perception of the patient, and other measurements were also self-reported (Figure 2).
The data were checked for multicollinearity, and none of the Variance Ination Factor values were larger than the
recommended 5 (according to Kim
73
), as their range was 1.12–1.73. Mardia’s test in AMOS showed that the data met the
multivariate normality (the critical ratio was 1.72) when applying ± 1.96 as the recommended cut-off value.
74
The structural equation modeling was performed by applying the maximum likelihood estimation, and mediations were
analyzed with 5000 bootstrapped iterations. Based on a recommendation of Hooper et al, the following t indices and their
interpretations were used: χ
2
(> 0.05), χ
2
/df (< 3), Standardised Root Mean Square Residual (sRMR: < 0.08), Comparative Fit
Index (CFI: > 0.95), Root Mean Square Error of Approximation (RMSEA: < 0.07), and Parsimony-Adjusted Measures Index
(PNFI > 0.50).
75
The effect sizes of mediations were calculated as the indirect effect divided by the total effect and interpreted
according to Cohen’s guidelines along with other effect sizes.
76–78
The level of statistical signicance was set at p < 0.05.
Results
Sample and Data Description
The sample consisted of 283 inpatients with BPD with an average age of 29.0 ± 9.7 years. See Table 1 for their demographic
and Table 2 for clinical characteristics. The average BPD onset was reported at 18.8 years. Common comorbidities were
https://doi.org/10.2147/PRBM.S476768
DovePress
Psychology Research and Behavior Management 2024:17
3766
Ociskova et al Dovepress
Powered by TCPDF (www.tcpdf.org)
anxiety disorders (38.5% of the sample), obsessive-compulsive disorder (11.3%), and unipolar depression (3.5%). The
participants were admitted with medication prescribed by their outpatient psychiatrist. The most commonly prescribed
medication was antidepressants (80.9% of the sample), followed by antipsychotics (29.3%), anxiolytics (22.6%), or anti-
epileptics (20.1%) (Table 2). Forty-two individuals (14.8%) were medication-free. The severity of psychopathology was
moderate in most parameters except anxiety and depressive symptoms. Self-stigma was mild to moderate. Emotional abuse
and neglect were the most prominent types of childhood trauma (Table 3).
Figure 2 Standardized path estimates of the hypothesized model.
Note: * p<0.05; ** p<0.01; *** p <0.001.
Table 1 Demographic Characteristics of the Sample
Characteristics n Percentage
Sex
Male 46 16.3
Female 237 83.7
Age groups
18–25 146 51.5
26–35 65 23.0
36–45 50 17.7
46–56 22 7.8
Education
Primary 47 16.6
Vocational training 50 17.7
Secondary 148 52.3
Tertiary 36 12.7
N/A 2 0.7
Employment
Student 79 27.9
(Self-)Employed 121 42.8
Unemployed 53 18.7
Disability rent 30 10.6
Marital Status
Single 218 77.0
Married 37 13.1
Divorced 27 9.5
Widowed 1 0.4
Being in a Romantic Relationship
Yes 126 44.5
Psychology Research and Behavior Management 2024:17 https://doi.org/10.2147/PRBM.S476768
DovePress
3767
Dovepress Ociskova et al
Powered by TCPDF (www.tcpdf.org)
Bivariate Correlation Between Childhood Trauma, and Self-Stigma
Self-stigma positively correlated with reported childhood trauma. This was mainly due to a signicant correlation
between social withdrawal (the ISMI subscale) and childhood trauma (Table 4). All signicant connections were small
in size. None of the specic childhood adversities remained statistically signicant after the correction, though the
emotional abuse was near the cut-off signicance value.
Table 2 Clinical Characteristics of the Sample
Characteristics n Percentage
Psychiatric Family History
None 91 32.2
Different Disorder 101 35.7
Same Disorder 85 30.0
Not Disclosed 6 2.1
Comorbid Anxiety Disorder (ICD-10)
At least one anxiety disorder 109 38.5
Agoraphobia 15 5.3
Social Phobia 43 15.2
Panic Disorder 38 13.4
Generalized Anxiety Disorder 21 7.4
Mixed Anxiety Depressive Disorder 11 3.9
Comorbid Obsessive-Compulsive Disorder (ICD-10)
Comorbidity Present 32 11.3
Predominantly obsessional thoughts or ruminations 3 1.1
Predominantly compulsive acts 2 0.7
Mixed obsessional thoughts and acts 26 9.1
Other obsessive-compulsive disorders 1 0.4
Comorbid Depressive Disorder (ICD-10)
Comorbidity Present 10 3.5
Mild Depressive Episode 5 1.7
Mild Recurrent Depressive Episode 4 1.4
Other Depressive Episode 1 0.4
Characteristics Mean ± Standard
Deviation
Percentage
BPD Onset 18.8 ± 9.1
BPD Duration 9.9 ± 8.6
Psychiatric Hospitalizations 2.8 ± 2.9
Antidepressant Index
Patients using the medication (n) 229 80.9
Dosage in mg of paroxetine equivalent 43.5 ± 27.4
Antipsychotic Index
Patients using the medication (n) 83 29.3
Dosage in mg of risperidone equivalent 1.8 ± 2.3
Anxiolytic Index
Patients using the medication (n) 64 22.6
Dosage in mg of diazepam equivalent 13.8 ± 10.7
Antiepileptic Index
Patients using the medication (n) 57 20.1
Dosage in mg of lamotrigine equivalent 224.1 ± 148.5
https://doi.org/10.2147/PRBM.S476768
DovePress
Psychology Research and Behavior Management 2024:17
3768
Ociskova et al Dovepress
Powered by TCPDF (www.tcpdf.org)
Bivariate Correlation Between Childhood Trauma, Psychopathology, and Disability
We subsequently explored the correlations between reported childhood trauma, psychopathology, and disability.
Childhood trauma positively connected with the severity of depressive, anxiety, and dissociation symptoms but not
with the overall severity of psychopathology measured by CGI. Most signicant correlation coefcients were small in
size (Table 5). As for the subscales, neither the connection with work or social life disability was statistically signicant,
though the latter did not pass the corrected p-value only by a small margin. Emotional and sexual abuse were the only
specic adversities that were signicantly connected with psychopathology.
Table 3 Measures and Their Mean Scores
Measurement Mean ± Standard
Deviation
Category
Clinical Global Impression
Clinician Version 4.3 ± 0.8 Moderately ill
Patient Version 4.3 ± 1.4 Moderately ill
Beck Depression Inventory-II 33.1 ± 11.8 Severe
Beck Anxiety Inventory 24.9 ± 12.7 Severe
Dissociative Experiences Scale 23.2 ± 16.8 Increased
Sheehan Disability Scale
Work/School 6.6 ± 2.5 Moderate
Family Life/Home Responsibilities 6.2 ± 2.4 Moderate
Social Life/Leisure Activities 6.2 ± 2.3 Moderate
Internalized Stigma of Mental Illness Scale
Total Score 70.5 ± 12.5 Mild
Alienation 16.5 ± 3.5 Moderate
Stereotype Endorsement 14.3 ± 3.6 Mild
Perceived Discrimination 11.3 ± 3.2 Mild
Social Withdrawal 14.8 ± 3.7 Moderate
Stigma Resistance 13.5 ± 2.5 Moderate
Childhood Trauma Questionnaire-Short Form
Total Score 54.7 ± 16.5 N/A
Emotional Abuse 14.2 ± 5.4 Moderate
Physical Abuse 8.0 ± 4.4 Low
Sexual Abuse 7.4 ± 4.8 Low
Physical Neglect 8.9 ± 3.9 Low
Emotional Neglect 16.3 ± 4.7 Moderate
Table 4 Bivariate Correlation Matrix Between Childhood Trauma, and Self-Stigma
Factors Self-stigma
(Total score)
Alienation Stereotype
endorsement
Perceived
discrimination
Social
withdrawal
Stigma
resistance
Childhood trauma (Total score) 0.23 * 0.21 0.14 0.21 0.22 * 0.06
Emotional abuse 0.21 0.18 0.13 0.19 0.20 0.10
Physical abuse 0.07 0.07 0.07 0.05 0.05 0.02
Sexual abuse 0.12 0.10 0.05 0.19 0.13 −0.10
Physical neglect 0.17 0.12 0.12 0.13 0.14 0.06
Emotional neglect 0.16 0.18 0.11 0.11 0.13 0.13
Notes: All coefcients are Spearman’s rho. Values with an asterisk remained statistically signicant after applying the Holm-Bonferroni method.
Psychology Research and Behavior Management 2024:17 https://doi.org/10.2147/PRBM.S476768
DovePress
3769
Dovepress Ociskova et al
Powered by TCPDF (www.tcpdf.org)
Bivariate Correlation Between Self-Stigma, Psychopathology, and Disability
Self-stigma positively correlated with all mental health symptoms and two types of disability, and these correlation
coefcients remained signicant after applying the Holm-Bonferroni method (Table 6). Connections between self-stigma,
psychopathology, and disability ranged widely from small to large effect sizes. Stigma resistance was the only ISMI
subscale that did not signicantly correlate with any variable.
Model
The nal model explored hypothesized interconnections among all variables, with childhood trauma being an independent
variable, measures of psychopathology and disability being dependent variables, and self-stigma acting as a mediator. The
model met the criteria of most t indices except for the chi-square: χ
2
= 26.59, df = 16, p = 0.046; χ
2
/df = 1.66; sRMR = 0.04;
CFI = 0.98; RMSEA = 0.05; and PNFI = 0.55. Figure 2 contains the path estimates. All paths were statistically signicant.
Childhood trauma positively predicted self-stigma and psychopathology, represented by the overall severity, anxiety,
depression, dissociation, and disability, dened by functional impairment in the family and social life. Self-stigma also
predicted the severity of mental health symptoms and functional impairment. The R
2
effect sizes ranged from small (for
a prediction of self-stigma and disability) to moderate (for a prediction of psychopathology) (Figure 2).
A subsequent mediation analysis showed a signicant direct effect of childhood trauma on the psychopathology
(standardized direct effect: SDE = 0.169, SE = 0.057, p = 0.003) and the disability (SDE = 0.173, SE = 0.066, p = 0.011).
The self-stigma was a partial mediator of both connections – between the childhood trauma and the psychopathology
(standardized indirect effect: SIDE = 0.199, SE = 0.036, p < 0.001; the effect size = 0.54) and between the childhood
trauma and the disability (SIDE = 0.141, SE = 0.031, p < 0.001; the effect size = 0.45).
Table 5 Bivariate Correlation Matrix Between Childhood Trauma, Psychopathology, and Disability
Factors Childhood
trauma
(Total score)
Emotional
abuse
Physical
abuse
Sexual
abuse
Physical
neglect
Emotional
neglect
Overall severity of psychopathology rated by a clinician 0.06 0.08 0.04 0.10 0.06 −0.03
Overall severity of psychopathology rated by a patient 0.15 0.17 0.10 0.13 0.07 0.07
Depression 0.26* 0.27* 0.06 0.22* 0.04 0.19
Anxiety 0.31* 0.30* 0.13 0.29* 0.17 0.15
Dissociation 0.25* 0.24* 0.05 0.27* 0.13 0.13
Work disability 0.08 0.09 0.001 0.05 0.05 0.07
Family life disability 0.25* 0.22 0.06 0.18 0.19 0.19
Social life disability 0.22 0.19 0.07 0.16 0.18 0.19
Notes: All coefcients are Spearman’s rho. Values with an asterisk remained statistically signicant after applying the Holm-Bonferroni method.
Table 6 Bivariate Correlation Matrix Between Self-Stigma, Psychopathology, and Disability
Factors Self-stigma
(Total score)
Alienation Stereotype
endorsement
Perceived
discrimination
Social
withdrawal
Stigma
resistance
Overall severity of psychopathology rated by a clinician 0.04 −0.002 −0.01 0.06 0.08 0.06
Overall severity of psychopathology rated by a patient 0.30* 0.27* 0.24* 0.19 0.26* 0.12
Depression 0.51* 0.42* 0.35* 0.38* 0.45* 0.14
Anxiety 0.44* 0.40* 0.34* 0.35* 0.41* 0.08
Dissociation 0.27* 0.21* 0.22* 0.30* 0.32* −0.07
Work disability 0.19 0.13 0.14 0.13 0.14 0.15
Family life disability 0.40* 0.26* 0.30* 0.28* 0.41* 0.16
Social life disability 0.30* 0.25* 0.28* 0.22* 0.25* 0.11
Notes: All coefcients are Spearman’s rho except the coefcients between the depression score (BDI-II) and self-stigma (ISMI Total score) along with perceived
discrimination, social withdrawal, and stigma resistance (the ISMI subscales), which are Pearson’s r. Values with an asterisk remained statistically signicant after applying
the Holm-Bonferroni method.
https://doi.org/10.2147/PRBM.S476768
DovePress
Psychology Research and Behavior Management 2024:17
3770
Ociskova et al Dovepress
Powered by TCPDF (www.tcpdf.org)
Discussion
Individuals diagnosed with BPD struggle with the symptoms of their condition and related stigma.
20,21
Despite being one
of the most stigmatized groups, little is known about the predictors and consequences of the BPD stigma.
22,23
This study
aimed to explore the connections between childhood trauma, self-stigma, general symptomatology, and disability in
adults with BPD.
A total of 283 patients diagnosed with BPD underwent 6-week hospitalization in a psychotherapeutic department.
They were primarily young adults who had been suffering from BPD for approximately ten years. Their symptoms and
disability were moderately to largely severe on average. In contrast, their overall self-stigma was mild, as were most
types of childhood trauma except for emotional abuse and neglect.
These characteristics might be somewhat surprising, given that individuals with BPD seem to suffer from more
intense self-stigma than some other patient groups.
30,31
However, self-stigma was equally low in the study of Grambal
et al (the ISMI total score was 71.2 ± 14.7 versus 70.5 ± 12.5 points in this study).
30
More frequent comorbidity with
major depression, bipolar disorder, or substance use disorders and a different self-stigma measure might then explain
different results of Rüsch et al
31
. This suggests that while patients diagnosed with BPD might struggle with more
prominent self-stigma than their counterparts in some studies, they do not have to experience severe self-stigma
necessarily. It also calls for careful examination of variables that might inuence self-stigma in highly comorbid
populations, such as individuals with BPD, and to avoid equating results of comparisons with severity indicators.
79
The average reported childhood trauma was also low to moderate in this study. Adverse childhood experiences are
common among individuals diagnosed with BPD, and their severity might be variable.
9,10,12
While Schulze et al found
that childhood trauma is usually moderate or severe in this populace, it might not always be the case.
14
For example,
a recent Wu et al study reported an average CTQ score of 48.5, which is considerably lower than ours (54.7 + 16.5
points).
80
Interestingly, the average CTQ score was 50.8 + 12.5 in Schulze et al study
14
. The heterogeneous conclusions
(mild to moderate or moderate to severe childhood trauma) might come from applying different cut-off scores for
interpretation.
Several hypotheses explored the topic of childhood trauma and self-stigma among individuals with BPD. The rst
hypothesis focused on the connection between the self-stigma and childhood trauma. The results showed that retro-
spectively reported childhood trauma and self-stigma positively correlated with each other. Similar ndings have been
reported by researchers studying other patient groups.
36,40–43
This might suggest that it presents a transdiagnostic issue.
Childhood trauma has already been connected with numerous somatic and mental health issues, including heightened
threat-related social processing that might generally increase the risk of self-stigma.
81,82
However, the causality of this connection remains unclear. Childhood trauma has been found to increase interpersonal
sensitivity among individuals with BPD,
15
including sensitivity towards potential social threats.
16
Since BPD symptoms
might trigger negative social responses,
22,23
increased interpersonal sensitivity caused by childhood trauma might further
exacerbate distress when experiencing rejection and trigger harsh self-criticism along with self-stigma.
25–28,32
This line of interpretation reects ongoing discussion about the centrality of trauma in the development of BPD. The
eleventh revision of the International Classication of Diseases introduced complex posttraumatic stress disorder
(cPTSD) as a new stress-related diagnosis with symptoms overlapping with BPD.
83
The new classication describes
cPTSD as a disorder that may develop after chronic or repetitive traumatic events. Common examples include childhood
sexual or physical abuse. cPTSD consists of diagnostic criteria of posttraumatic stress disorder (such as hyperarousal or
intrusive memories of the trauma) and three other clusters of symptoms: affect dysregulation, negative self-concept, and
interpersonal difculties. The symptoms need to impair daily functioning signicantly.
83,84
This new diagnosis overlaps with BPD. Both disorders share symptoms of emotion dysregulation, difculties in self-
concept, and interpersonal struggles.
85
From this point of view, self-stigma presents one facet of a chronically negative
attitude toward oneself that has been reported in cPTSD as a result of childhood trauma.
81,85
BPD is a multifactorial
disorder with a common history of adverse childhood experiences, but these are not necessary for the diagnosis.
9,10
Childhood trauma may shape the self-concept of individuals diagnosed with BPD who experienced early adverse events,
but non-traumatized individuals may also suffer from unstable and negative self-concepts.
81
Since self-stigma may be
Psychology Research and Behavior Management 2024:17 https://doi.org/10.2147/PRBM.S476768
DovePress
3771
Dovepress Ociskova et al
Powered by TCPDF (www.tcpdf.org)
a form of self-invalidation,
25
its social predispositions might include occasionally invaliding and hurtful but not
necessarily traumatic events. Non-traumatic variants of childhood social environment that contribute to BPD develop-
ment or its severity have been understudied and remain a topic for future research.
Despite the former research linking early traumatic experiences with later mental struggles, the causal direction of
the connection between childhood trauma and self-stigma is not as straightforward. Many studies employed
a retrospective and cross-sectional design,
30,36,40–43
including ours. This prevents us from making denite conclusions.
A recent study reported poor agreement between retrospective and prospective observations of childhood
maltreatment.
86
This was especially concerning retrospective questionnaires that showed only a slight agreement
with prospective measures. There are many sources of the differences, ranging from imperfect measurements to
memory bias and adult attachment.
86,87
It is important to consider that retrospectively accessed memories do not
represent perfect presentations of actual events.
This raises the question of how much the current emotional state inuences memory access and interpretation.
Emotional suppression might hinder access to long-term memories,
88
while accessing emotionally-laden memories can
be enhanced by emotional re-activation.
89
Retrospectively evaluated emotional abuse and neglect showed the weakest
agreements with prospective measures in the study of Baldwin et al,
86
which makes the potential inferring processes all
the more important. It is noteworthy that retrospective emotional abuse has been connected with BPD symptoms.
14
In
light of the cognitive research, it is unclear to what extent this connection shows the impact of traumatic childhood on
borderline symptoms and to what extent it might show the effects of current distressing symptoms on memory. Mood-
congruent memory is a transdiagnostic issue that challenges the retrospective research.
90
Being mindful of these limitations, we explored the remaining hypotheses. The second hypothesis focused on the
relationship between childhood trauma, symptomatology, and functional impairment. As expected, the traumatic experi-
ences showed small to moderate connections with the symptoms of depression, anxiety, and dissociation. These ndings
are comparable to reports by Krause-Utz,
17
Cattane et al,
18
and Martin-Gagnon et al,
19
who studied the topic in
individuals with a BPD diagnosis or BPD traits. Neither the patient- nor the clinician-rated CGI signicantly correlated
with childhood trauma. Clinical Global Impression contains only one item and thus might be too short to identify
signicant connections. It is unclear what factors and with what weight inuence general measurements such as CGI.
More specic measures, such as CGI-BPD, might offer clearer interpretations.
91
Similarly, Cotter et al stated that childhood trauma positively correlated with functional impairment in a sample that
also included patients with BPD.
20
They reported signicant connections with social and occupational functioning. The
missing values in the Work disability subscale of SDS might explain the differing results in our study. The connection
with social functioning was non-signicant in our results. Different characteristics of the samples might explain this.
Zanarini et al found childhood sexual abuse to be a signicant predictor of functioning.
92
The patients in our study
reported low average scores of childhood sexual abuse. A sample with more severe traumatic experiences could show
more considerable impairment that could be traced to their childhood adversities.
We then explored the connections between the self-stigma, disability, and selected psychiatric symptoms. The
correlation between patient-rated CGI and self-stigma was moderate, comparable to the ndings of Grambal et al
30
in
a similar patient group and Holubova et al
36
with Ociskova et al
37
in other diagnostic groups. However, the clinician-
rated severity of the disorder did not signicantly correlate with self-stigma. The patients seem to evaluate the overall
severity differently than the physicians. This was already highlighted by Forkmann et al, who administered the CGI
scales to patients with major depression, their treating therapists, and the therapeutic team.
93
The authors found low
congruence among the measurements, indicating the need to include self-report and clinician-report measures in the
research. The results of the current study might suggest that the patients also consider the stigma when evaluating their
mental struggles, while their psychiatrists might focus on other aspects of psychopathology.
The self-stigma then positively correlated with the severity of depression, anxiety, and dissociation, all of which are
connections that have been reported by other papers focusing on the same or different patient groups.
22,36–38,41
As
Sheehan et al
22
hypothesized, these common symptoms might be exacerbated by what Scheel et al described as an
existential shame, a profound feeling of inadequacy that permeates the whole being.
94
Shame has been identied as
a core experiential feature of the stigma.
95
Since patients with BPD are prone to feeling intense existential shame,
94
https://doi.org/10.2147/PRBM.S476768
DovePress
Psychology Research and Behavior Management 2024:17
3772
Ociskova et al Dovepress
Powered by TCPDF (www.tcpdf.org)
future research might benet from incorporating this topic into its design. Furthermore, the self-stigma moderately
correlated with functional impairment in the family and social life. The results are comparable to the ndings of other
patient groups, highlighting again the transdiagnostic nature of self-stigma.
36,38
Interestingly, the self-stigma did not
signicantly correlate with work disability. A large percentage of missing values is a likely cause.
96
The nal hypothesis aimed to explore whether self-stigma acts as a mediator in the connections between childhood
trauma and psychopathology on one side and disability on the other side. All paths in the model were signicant.
Childhood trauma and self-stigma explained only a small variance of disability scores, indicating that more prominent
factors may play a role. Robust predictors include baseline severity of borderline symptoms, a history of sexual abuse
(which was low in this sample), and contextual factors such as housing or nancial status.
97,98
Childhood trauma and
self-stigma then explained a moderate variance of an aggregated symptomatology score, reecting the well-established
connections of these factors with mental health struggles.
38,99
Both latent factors, psychopathology and disability, are
largely correlated. While they are partially independent and should be evaluated separately,
100
one can predict the other
and vice versa.
101
The hypothesized model showed good tness in most parameters except for the chi-square, which is sensitive to
a sample size.
102
Childhood trauma explained only a small variance of psychopathology and disability scores in this
sample. Similarly, Stolzenburg et al reported that childhood trauma was a small to moderate predictor of self-stigma,
including its last step – the harm.
43
This step refers to the consequences of applying negative social stereotypes on
oneself, resulting in diminished self-respect and self-esteem.
29
Stolzenburg et al found that the agreement with negative
stereotypes and depressive symptoms fully mediated the relationship between childhood trauma and harm.
43
Our analysis
identied self-stigma as a partial mediator of the connection between childhood trauma and psychopathology, explaining
54% of the total effect. The second mediation between childhood trauma and disability was similarly large, as it
explained 45% of the total effect. While Stolzenburg et al focused on the harm caused by self-stigma as the dependent
variable, we opted for a more general look at psychopathology and disability.
43
Limitations
Our study has several limitations that need to be mentioned. The most signicant limitation is the cross-sectional design,
which prevents making conclusions of causality. Since the sample consisted of inpatients with BPD, the representative-
ness of the results was also limited. The severity of their symptoms was marked but primarily not severe. The average
severity of their childhood trauma and self-stigma was also mild to moderate. While we expect that the described
connections might extend to individuals with more severe symptoms and self-stigma, we cannot verify that without
studying these patients. A study design with mostly self-report measures is another limitation. The missing data in CTQ
and SDS–Work subscales could have also decreased the validity of several results. Finally, we focused on general
symptomatology (depressive symptoms, anxiety, dissociation, and global severity of the mental disorder) rather than on
the specic borderline symptoms that would also be useful to explore in this population. Self-report instruments, such as
Borderline Symptom List 23 (already adapted to Czech by Radimecka et al),
103
or some of the established rating scales
could have provided valuable insights.
Future Research and Clinical Implications
Future studies could benet from focusing on potential mediators or moderators of the connection between childhood
trauma and self-stigma – increased interpersonal sensitivity, shame-proneness, or early maladaptive schemas. The impact
of the work disability and the specic borderline symptoms also need to be explored. Apart from that, it would be
interesting to nd whether tackling childhood trauma in treatment automatically decreases self-stigma. If childhood
trauma shapes the tendency towards self-stigma, psychoeducation might not sufce as the common strategy to bring
relief and may instead require experiential therapeutic approaches.
104,105
Future research could explore their potential.
The ndings have several clinical implications. Self-stigma might present an important topic in psychotherapy and
general psychiatric management, as it signicantly connects with various symptoms of mental disorders and retro-
spectively reported childhood trauma among individuals with BPD. Resolving childhood trauma might require paying
attention to self-stigma that can connect childhood experiences with current suffering. Since self-stigma might be
Psychology Research and Behavior Management 2024:17 https://doi.org/10.2147/PRBM.S476768
DovePress
3773
Dovepress Ociskova et al
Powered by TCPDF (www.tcpdf.org)
partially explained by early maladaptive schemas,
106
it is important to explore patients’ attitudes to their mental struggles
and their connection with their childhood experiences. A case conceptualization might benet from exploring self-stigma
and its impact on an individual. Furthermore, Common psychotherapeutic methods, such as imagery rescripting or
chairwork,
107,108
could then be applied to enhance the processing of both self-stigma and childhood trauma and bring
a sense of relief and closure to patients.
Conclusion
This study aimed to explore the connections between childhood trauma, self-stigma, general symptomatology, and
disability in 283 adults diagnosed with BPD. The results showed that self-stigma was a partial mediator of childhood
trauma, acting as an independent variable, and mental health symptoms and disability as dependent variables. Since the
study employed a cross-sectional design, the ndings are preliminary, and their causality remains unclear. Future studies
would benet from a longitudinal design to explore causal trajectories. These initial ndings suggest that therapeutic and
societal efforts to tackle childhood trauma and self-stigma might benet from reecting its broader psychosocial context.
Disclosure
The authors report no conict of interest in this work.
References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th Ed). Arlington, VA: American Psychiatric
Publishing; 2013.
2. Ellison WD, Rosenstein LK, Morgan TA, Zimmerman M. Community and clinical epidemiology of borderline personality disorder. Psychiatr
Clin North Am. 2018;41(4):561–573. doi:10.1016/j.psc.2018.07.008
3. Javaras KN, Zanarini MC, Hudson JI, Greeneld SF, Gunderson JG. Functional outcomes in community-based adults with borderline
personality disorder. J Psychiatr Res. 2017;89:105–114. doi:10.1016/j.jpsychires.2017.01.010
4. Ten Have M, Verheul R, Kaasenbrood A, et al. Prevalence rates of borderline personality disorder symptoms: a study based on the Netherlands
Mental Health Survey and Incidence Study-2. BMC Psych. 2016;16:249. doi:10.1186/s12888-016-0939-x
5. Biskin RS. The lifetime course of borderline personality disorder. Can J Psychiatry. 2015;60(7):303–308. doi:10.1177/070674371506000702
6. Zanarini MC, Temes CM, Frankenburg FR, Reich DB, Fitzmaurice GM. Description and prediction of time-to-attainment of excellent recovery
for borderline patients followed prospectively for 20 years. Psychiatry Res. 2018;262:40–45. doi:10.1016/j.psychres.2018.01.034
7. Alvarez-Tomás I, Soler J, Bados A, et al. Long-Term Course of Borderline Personality Disorder: a Prospective 10-Year Follow-Up Study.
J Pers Disord. 2017;31(5):590–605. doi:10.1521/pedi_2016_30_269
8. Videler AC, Hutsebaut J, Schulkens JEM, Sobczak S, van Alphen SPJ. A Life Span Perspective on Borderline Personality Disorder. Curr
Psychiatry Rep. 2019;21(7):51. doi:10.1007/s11920-019-1040-1
9. Arranz MJ, Gallego-Fabrega C, Martín-Blanco A, et al. A genome-wide methylation study reveals X chromosome and childhood trauma
methylation alterations associated with borderline personality disorder. Transl Psychiatry. 2021;11(1):5. doi:10.1038/s41398-020-01139-z
10. Wilson N, Robb E, Gajwani R, Minnis H. Nature and nurture? A review of the literature on childhood maltreatment and genetic factors in the
pathogenesis of borderline personality disorder. J Psychiatr Res. 2021;137:131–146. doi:10.1016/j.jpsychires.2020.12.025
11. Amad A, Ramoz N, Thomas P, Jardri R, Gorwood P. Genetics of borderline personality disorder: systematic review and proposal of an
integrative model. Neurosci Biobehav Rev. 2014;40:6–19. doi:10.1016/j.neubiorev.2014.01.003
12. Porter C, Palmier-Claus J, Branitsky A, Mansell W, Warwick H, Varese F. Childhood adversity and borderline personality disorder: a
meta-analysis. Acta Psychiatr Scand. 2020;141(1):6–20. doi:10.1111/acps.13118
13. Ball JS, Links PS. Borderline personality disorder and childhood trauma: evidence for a causal relationship. Curr Psychiatry Rep.
2009;11:63–68. doi:10.1007/s11920-009-0010-4
14. Schulze A, Cloos L, Zdravkovic M, Lis S, Krause-Utz A. On the interplay of borderline personality features, childhood trauma severity,
attachment types, and social support. Border Personal Disord Emot Dysr. 2022;9(1):35. doi:10.1186/s40479-022-00206-9
15. Bungert M, Liebke L, Thome J, Haeussler K, Bohus M, Lis S. Rejection sensitivity and symptom severity in patients with borderline
personality disorder: effects of childhood maltreatment and self-esteem. Borderline Personal Disord Emot Dysregul. 2015;2:4. doi:10.1186/
s40479-015-0025-x
16. Seitz KI, Leitenstorfer J, Krauch M, et al. An eye-tracking study of interpersonal threat sensitivity and adverse childhood experiences in
borderline personality disorder. Borderline Pers Disord Emot Dysregul. 2021;8(1):2. doi:10.1186/s40479-020-00141-7
17. Krause-Utz A. Dissociation, trauma, and borderline personality disorder. Borderline Personal Disord Emot Dysregul. 2022;9(1):14.
doi:10.1186/s40479-022-00184-y
18. Cattane N, Rossi R, Lanfredi M, Cattaneo A. Borderline personality disorder and childhood trauma: exploring the affected biological systems
and mechanisms. BMC Psych. 2017;17(1):221. doi:10.1186/s12888-017-1383-2
19. Martin-Gagnon G, Normandin L, Fonagy P, Ensink K. Adolescent mentalizing and childhood emotional abuse: implications for depression,
anxiety, and borderline personality disorder features. Front Psychol. 2023;14:1237735. doi:10.3389/fpsyg.2023.1237735
20. Cotter J, Kaess M, Yung AR. Childhood trauma and functional disability in psychosis, bipolar disorder and borderline personality disorder:
a review of the literature. Ir J Psychol Med. 2015;32(1):21–30. doi:10.1017/ipm.2014.74
https://doi.org/10.2147/PRBM.S476768
DovePress
Psychology Research and Behavior Management 2024:17
3774
Ociskova et al Dovepress
Powered by TCPDF (www.tcpdf.org)
21. IsHak WW, Elbau I, Ismail A, et al. Quality of life in borderline personality disorder. Harv Rev Psychiatry. 2013;21(3):138–150. doi:10.1097/
HRP.0b013e3182937116
22. Sheehan L, Nieweglowski K, Corrigan P. The stigma of personality disorders. Curr Psychiatry Rep. 2016;18:11. doi:10.1007/s11920-015-0654-
1
23. Ring D, Lawn S. Stigma perpetuation at the interface of mental health care: a review to compare patient and clinician perspectives of stigma and
borderline personality disorder. J Ment Health. 2019;1–21. doi:10.1080/09638237.2019.1581337
24. Aviram RB, Brodsky BS, Stanley B. Borderline personality disorder, stigma, and treatment implications. Harv Rev Psychiatry. 2006;14
(5):249–256. doi:10.1080/10673220600975121
25. Koivisto M, Melartin T, Lindeman S. Self-invalidation in borderline personality disorder: a content analysis of patients’ verbalizations.
Psychother Res. 2022;32(7):922–935. doi:10.1080/10503307.2022.2025627
26. Fitzpatrick S, Liebman RE, Monson CM. The borderline interpersonal-affective systems (BIAS) model: extending understanding of the
interpersonal context of borderline personality disorder. Clin Psychol Rev. 2021;84:101983. doi:10.1016/j.cpr.2021.101983
27. Sorgi-Wilson KM, McCloskey MS. Emotion regulation strategies among individuals with borderline personality disorder relative to other
groups: a review. Clin Psychol Psychother. 2022;29(5):1655–1678. doi:10.1002/cpp.2738
28. Sato M, Fonagy P, Luyten P. Rejection sensitivity and borderline personality disorder features: the mediating roles of attachment anxiety, need
to belong, and self-criticism. J Pers Disord. 2020;34(2):273–288. doi:10.1521/pedi_2019_33_397
29. Corrigan PW, Rao D. On the self-stigma of mental illness: stages, disclosure, and strategies for change. Can J Psychiat. 2012;57(8):464–469.
doi:10.1177/070674371205700804
30. Grambal A, Prasko J, Kamaradova D, et al. Self-stigma in borderline personality disorder - cross-sectional comparison with schizophrenia
spectrum disorder, major depressive disorder, and anxiety disorders. Neuropsychiatr Dis Treat. 2016;12:2439–2448. doi:10.2147/NDT.S114671
31. Rüsch N, Holzer A, Hermann C, et al. Self-stigma in women with borderline personality disorder and women with social phobia. J Nerv Ment
Dis. 2006;194:766–773. doi:10.1097/01.nmd.0000239898.48701.dc
32. Stiles C, Batchelor R, Gumley A, Gajwani R. Experiences of stigma and discrimination in borderline personality disorder: a systematic review
and qualitative meta-synthesis. J Pers Disord. 2023;37(2):177–194. doi:10.1521/pedi.2023.37.2.177
33. Gad MA, Pucker HE, Hein KE, et al. Facets of identity disturbance reported by patients with borderline personality disorder and
personality-disordered comparison subjects over 20 years of prospective follow-up. Psychiatry Res. 2019;271:76–82. doi:10.1016/j.
psychres.2018.11.020
34. Musser N, Zalewski M, Stepp S, Lewis J. A systematic review of negative parenting practices predicting borderline personality disorder: are we
measuring biosocial theory’s ‘invalidating environment’? Clin Psychol Rev. 2018;65:1–16. doi:10.1016/j.cpr.2018.06.003
35. Quenneville AF, Badoud D, Nicastro R, et al. Internalized stigmatization in borderline personality disorder and attention decit hyperactivity
disorder in comparison to bipolar disorder. J Affect Disord. 2020;262:317–322. doi:10.1016/j.jad.2019.10.053
36. Holubova M, Prasko J, Vanek J, et al. Self-stigma, severity of psychopatology, dissociation, parental style and comorbid personality disorder in
patient with neurotic spectrum disorders Part 1: relationships between self-stigma and clinical, psychosocial and demographics. Neuro
Endocrinol Lett. 2021;42(2):99–112.
37. Ociskova M, Prasko J, Kamaradova D, Grambal A, Sigmundova Z. Individual correlates of self-stigma in patients with anxiety disorders with
and without comorbidities. Neuropsychiatr Dis Treat. 2015;11:1767–1779. doi:10.2147/NDT.S87737
38. Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and
meta-analysis. Soc Sci Med. 2010;71:2150–2161. doi:10.1016/j.socscimed.2010.09.030
39. Latalova K, Prasko J, Kamaradova D, et al. Self-stigma and suicidality in patients with neurotic spectrum disorder – a cross sectional study.
Neuro Endocrinol Lett. 2014;35:474–480.
40. Hofmann M, Jermann F, Baggio S, et al. Childhood trauma and mood disorders. Psychiatr Res Comm. 2023;3:100129. doi:10.1016/j.
psycom.2023.100129
41. Kolek A, Prasko J, Vanek J, et al. Severity of panic disorder, adverse events in childhood, dissociation, self-stigma and comorbid personality
disorders Part 1: relationships between clinical, psychosocial and demographic factors in pharmacoresistant panic disorder patients. Neuro
Endocrinol Lett. 2019;40(5):233–246.
42. Lee H-S, Jeong Y, Yoo T, et al. Associations of childhood trauma with psychopathology and clinical characteristics in patients with
schizophrenia. Korean J Schizophr Res. 2017;20:37–43. doi:10.16946/kjsr.2017.20.2.37
43. Stolzenburg S, Tessmer C, Corrigan PW, et al. Childhood trauma and self-stigma of alcohol dependence: applying the progressive model of
self-stigma. Stig Health. 2018;3(4):417–423. doi:10.1037/sah0000112
44. World Health Organization. The ICD-10 Classication of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines.
Geneva: Author; 1992.
45. Ritsher JB, Otilingam PG, Grajales M. Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Res.
2003;121(1):31–49. doi:10.1016/j.psychres.2003.08.008
46. Ociskova M, Prasko J, Kamaradova D, et al. Self-stigma in psychiatric patients – standardisation of the ISMI scale. Neuro Endocrinol Lett.
2014;35(7):624–632.
47. Lysaker PH, Roe D, Yanos PT. Toward understanding the insight paradox: internalized stigma moderates the association between insight and
social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders. Schizophr Bull. 2007;33(1):192–199.
doi:10.1093/schbul/sbl016
48. Bernstein DP, Fink L Childhood Trauma Questionnaire: a Retrospective Self-Report Manual. San Antonio, TX: Harcourt Brace & Company;
1998.
49. Scher CD, Stein MB, Asmundson GJ, McCreary DR, Forde DR. The childhood trauma questionnaire in a community sample: psychometric
properties and normative data. J Trauma Stress. 2001;14(4):843–857. doi:10.1023/A:1013058625719
50. Cruz D. Childhood Trauma Questionnaire-Short Form: evaluation of factor structure and measurement invariance. J Child Adolesc Trauma.
2023;16(4):1099–1108. doi:10.1007/s40653-023-00556-8
51. Guy W. Clinical Global Impressions (CGI) Scale, Modied. In: Rush JA: Task Force for the Handbook of Psychiatric Measures (Eds.).
Handbook of Psychiatric Measures. 1st ed. Washington, DC: American Psychiatric Association; 2000.
Psychology Research and Behavior Management 2024:17 https://doi.org/10.2147/PRBM.S476768
DovePress
3775
Dovepress Ociskova et al
Powered by TCPDF (www.tcpdf.org)
52. Rush AJ, First MB, Blacker D. Handbook of Psychiatric Measures. Washington, DC: American Psychiatric Publishing; 2008.
53. Zaider TI, Heimberg RG, Fresco DM, Schneier FR, Liebowitz MR. Evaluation of the Clinical Global Impression scale among individuals with
social anxiety disorder. Psychol Med. 2003;33(4):611–622. doi:10.1017/S0033291703007414
54. Beck AT, Steer RA, Ball R, Ranieri W. Comparison of Beck Depression Inventories-IA and II in psychiatric outpatients. J Pers Assess. 1996;67
(3):588–597. doi:10.1207/s15327752jpa6703_13
55. Ociskova M, Prasko J, Kupka M, et al. Psychometric evaluation of the Czech Beck Depression Inventory-II in a sample of depressed patients
and healthy controls. Neuro Endocrinol Lett. 2017;38(2):98–106.
56. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psych. 1988;56
(6):893–897. doi:10.1037/0022-006X.56.6.893
57. Kamaradova D, Prasko J, Latalova K, et al. Psychometric properties of the Czech version of the Beck Anxiety Inventory – comparison between
diagnostic groups. Neuro Endocrinol Lett. 2015;36(7):706–712.
58. Julian LJ. Measures of anxiety: state-Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression
Scale-Anxiety (Hads-A). Arthritis Care Res. 2011;11(0 11):S467–72.
59. Bernstein E, Putnam F. Development, reliability and validity of a dissociation scale. J Nerv Ment Dis. 1986;174:727–735. doi:10.1097/
00005053-198612000-00004
60. Lyssenko L, Schmahl C, Bockhacker L, Vonderlin R, Bohus M, Kleindienst N. Dissociation in psychiatric disorders: a meta-analysis of studies
using the Dissociative Experiences Scale. Am J Psychiatry. 2018;175(1):37–46. doi:10.1176/appi.ajp.2017.17010025
61. Carlson EB, Putnam FW. An update on the Dissociative Experience Scale: an update on the Dissociative. Dissociation. 1993;6:16–27.
62. Ptacek R, Bob P, Paclt I. Skala disociativnich zkusenosti – ceska verze [Dissociative Experiences Scale – a Czech Version]. Cesk Psychol.
2006;50(3):262–272.
63. Sheehan DV, Harnett-Sheehan K, Raj BA. The measurement of disability. Int Clin Psychopharmacol. 1996;11(3):89–95. doi:10.1097/
00004850-199606003-00015
64. Arbuckle R, Frye MA, Brecher M, et al. The psychometric validation of the Sheehan Disability Scale (SDS) in patients with bipolar disorder.
Psychiatry Res. 2009;165(1–2):163–174. doi:10.1016/j.psychres.2007.11.018
65. Luciano JV, Bertsch J, Salvador-Carulla L, et al. Factor structure, internal consistency and construct validity of the Sheehan Disability Scale in
a Spanish primary care sample. J Eval Clin Pract. 2010;16(5):895–901. doi:10.1111/j.1365-2753.2009.01211.x
66. Sheehan KH, Sheehan DV. Assessing treatment effects in clinical trials with the discan metric of the Sheehan Disability Scale. Int Clin
Psychopharmacol. 2008;23(2):70–83. doi:10.1097/YIC.0b013e3282f2b4d6
67. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a exible statistical power analysis program for the social, behavioral, and biomedical
sciences. Behav Res Methods. 2007;39(2):175–191. doi:10.3758/BF03193146
68. Soper DS A-priori sample size calculator for structural equation models. Accessed at May 2, 2024. Available. from https://www.danielsoper.
com/statcalc.
69. Bennett DA. How can I deal with missing data in my study? Aust N Z J Public Health. 2001;25(5):464–469. doi:10.1111/j.1467-842X.2001.
tb00294.x
70. Holm S. A simple sequential rejective multiple test procedure. Scand J Statist. 1979;6:65–70.
71. Giacalone M, Agata Z, Cozzucoli PC, Alibrandi A. Bonferroni-Holm and permutation tests to compare health data: methodological and
applicative issues. BMC Med Res Methodol. 2018;18(1):81. doi:10.1186/s12874-018-0540-8
72. Ludbrook J. Multiple comparison procedures updated. Clin Exp Pharmacol Physiol. 1998;25(12):1032–1037. doi:10.1111/j.1440-1681.1998.
tb02179.x
73. Kim JH. Multicollinearity and misleading statistical results. Korean J Anesthesiol. 2019;72(6):558–569. doi:10.4097/kja.19087
74. Ghasemi A, Zahediasl S. Normality tests for statistical analysis: a guide for non-statisticians. Int J Endocrinol Metab. 2012;10(2):486–489.
doi:10.5812/ijem.3505
75. Hooper D, Coughlan J, Mullen MR. Structural equation modelling: guidelines for determining model t. EJBRM. 2008;6:53–60.
76. MacKinnon DP, Cheong J, Pirlott AG, et al. APA Handbook of Research Methods in Psychology, Vol 2: Research Designs: Quantitative,
Qualitative, Neuropsychological, and Biological 313–331:Washington, DC, US: American Psychological Association;2012
77. Cohen J. Statistical Power Analysis for the Behavioral Sciences (2nd Ed). Hillsdale: Lawrence Erlbaum Associates; 1988.
78. Preacher KJ, Kelley K. Effect size measures for mediation models: quantitative strategies for communicating indirect effects. Psychol Methods.
2011;16(2):93–115. doi:10.1037/a0022658
79. Shen CC, Hu LY, Hu YH. Comorbidity study of borderline personality disorder: applying association rule mining to the Taiwan national health
insurance research database. BMC Med Inform Decis Mak. 2017;17(1):8. doi:10.1186/s12911-016-0405-1
80. Wu Y, Zheng Y, Wang J, Zhang T. Specic type of childhood trauma and borderline personality disorder in Chinese patients. Front Psychiatry.
2022;13:936739. doi:10.3389/fpsyt.2022.936739
81. Banaj N, Pellicano C. Childhood trauma and stigma. In: Childhood Trauma in Mental Disorders. Cham: Springer; 2020:413–430.
82. McLaughlin KA, Colich NL, Rodman AM, Weissman DG. Mechanisms linking childhood trauma exposure and psychopathology:
a transdiagnostic model of risk and resilience. BMC Med. 2020;18(1):96. doi:10.1186/s12916-020-01561-6
83. World Health Organization. International Classication of Diseases, Eleventh Revision (ICD-11). Geneva: Author.
84. Ford JD, Courtois CA. Complex PTSD and borderline personality disorder. Borderline Personal Disord Emot Dysregul. 2021;8(1):16.
doi:10.1186/s40479-021-00155-9
85. Powers A, Petri JM, Sleep C, et al. complex PTSD, and borderline personality disorder using exploratory structural equation modeling in a
trauma-exposed urban sample. J Anxiety Disord. 2022;88:102558. doi:10.1016/j.janxdis.2022.102558
86. Baldwin JR, Reuben A, Newbury JB, Danese A. Agreement between prospective and retrospective measures of childhood maltreatment:
a systematic review and meta-analysis. JAMA Psych. 2019;76(6):584–593. doi:10.1001/jamapsychiatry.2019.0097
87. Lau-Zhu A, Williams F, Steel C. Attachment patterns and autobiographical episodic memory functioning: a systemic review of adult studies to
advance clinical psychological science. Clin Psychol Rev. 2023;101:102254. doi:10.1016/j.cpr.2023.102254
88. Katsumi Y, Dolcos S. Suppress to feel and remember less: neural correlates of explicit and implicit emotional suppression on perception and
memory. Neuropsychologia. 2020;145:106683. doi:10.1016/j.neuropsychologia.2018.02.010
https://doi.org/10.2147/PRBM.S476768
DovePress
Psychology Research and Behavior Management 2024:17
3776
Ociskova et al Dovepress
Powered by TCPDF (www.tcpdf.org)
89. Erk S, von Kalckreuth A, Walter H. Neural long-term effects of emotion regulation on episodic memory processes. Neuropsychologia. 2010;48
(4):989–996. doi:10.1016/j.neuropsychologia.2009.11.022
90. Faul L, LaBar KS. Mood-congruent memory revisited. Psychol Rev. 2023;130(6):1421–1456. doi:10.1037/rev0000394
91. Perez V, Barrachina J, Soler J, et al. The clinical global impression scale for borderline personality disorder patients (CGI-BPD): a scale sensible
to detect changes. Actas Esp Psiquiatr. 2007;35(4):229–235.
92. Zanarini MC, Yong L, Frankenburg FR, et al. Severity of reported childhood sexual abuse and its relationship to severity of borderline
psychopathology and psychosocial impairment among borderline inpatients. J Nerv Ment Dis. 2002;190(6):381–387. doi:10.1097/00005053-
200206000-00006
93. Forkmann T, Scherer A, Boecker M, Pawelzik M, Jostes R, Gauggel S. The Clinical Global Impression Scale and the inuence of patient or
staff perspective on outcome. BMC Psych. 2011;11:83. doi:10.1186/1471-244X-11-83
94. Scheel CN, Bender C, Tuschen-Cafer B, et al. Do patients with different mental disorders show specic aspects of shame? Psychiatry Res.
2014;220(1–2):490–495. doi:10.1016/j.psychres.2014.07.062
95. Dolezal L. Shame anxiety, stigma and clinical encounters. J Eval Clin Pract. 2022;28(5):854–860. doi:10.1111/jep.13744
96. Kang H. The prevention and handling of the missing data. Korean J Anesthesiol. 2013;64(5):402–406. doi:10.4097/kjae.2013.64.5.402
97. Gunderson JG, Daversa MT, Grilo CM, et al. Predictors of 2-year outcome for patients with borderline personality disorder. Am J Psychiatry.
2006;163(5):822–826. doi:10.1176/ajp.2006.163.5.822
98. Volkert J, Ilagan GS, Iliakis EA, Ren B, Schröder-Pfeifer P, Choi-Kain LW. What predicts psychosocial functioning in borderline personality
disorder? Investigating the association with reective functioning. Psychol Psychother. doi:10.1111/papt.12516
99. Copeland WE, Shanahan L, Hinesley J, et al. Association of childhood trauma exposure with adult psychiatric disorders and functional
outcomes. JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493
100. Zimmerman M, Morgan TA, Stanton K. The severity of psychiatric disorders. World Psychiatry. 2018;17(3):258–275. doi:10.1002/wps.20569
101. Brown LA, Krull JL, Roy-Byrne P, et al. An examination of the bidirectional relationship between functioning and symptom levels in patients
with anxiety disorders in the CALM study. Psychol Med. 2015;45(3):647–661. doi:10.1017/S0033291714002062
102. Bergh D. Chi-Squared Test of Fit and Sample Size-A Comparison between a Random Sample Approach and a Chi-Square Value Adjustment
Method. J Appl Measu. 2015;16(2):204–217.
103. Radimecka M, Jerabkova P, Latalova A, Linhartova P. Psychometricke vlastnosti ceske verze Borderline Symptom List 23 (BSL-23)
[Psychometric properties of the Czech version of Borderline Symptom List 23 (BSL-23)]. Psychoterapie. 2022;16(1):85–101.
104. Mills H, Mulnger N, Raeder S, Rüsch N, Clements H, Scior K. Self-help interventions to reduce self-stigma in people with mental health
problems: a systematic literature review. Psychiatry Res. 2020;284:112702. doi:10.1016/j.psychres.2019.112702
105. Yanos PT, Lucksted A, Drapalski AL, Roe D, Lysaker P. Interventions targeting mental health self-stigma: a review and comparison. Psychiatr
Rehabil J. 2015;38(2):171–178. doi:10.1037/prj0000100
106. Pyszkowska A, Stojek MM. Early maladaptive schemas and self-stigma in people with physical disabilities: the role of self-compassion and
psychological exibility. Int J Environ Res Public Health. 2022;19(17):10854. doi:10.3390/ijerph191710854
107. Kip A, Schoppe L, Arntz A, Morina N. Efcacy of imagery rescripting in treating mental disorders associated with aversive memories - An
updated meta-analysis. J Anxiety Disord. 2023;99:102772. doi:10.1016/j.janxdis.2023.102772
108. Pascual-Leone A, Baher T. Chairwork in individual psychotherapy: meta-analyses of intervention effects. Psychotherapy. 2023;60(3):370–382.
doi:10.1037/pst0000490
Psychology Research and Behavior Management Dovepress
Publish your work in this journal
Psychology Research and Behavior Management is an international, peer-reviewed, open access journal focusing on the science of psychology and
its application in behavior management to develop improved outcomes in the clinical, educational, sports and business arenas. Specic topics
covered in the journal include: Neuroscience, memory and decision making; Behavior modication and management; Clinical applications; Business
and sports performance management; Social and developmental studies; Animal studies. The manuscript management system is completely online
and includes a very quick and fair peer-review system, which is all easy to use. Visit http://www.dovepress.com/testimonials.php to read real quotes
from published authors.
Submit your manuscript here: https://www.dovepress.com/psychology-research-and-behavior-management-journal
Psychology Research and Behavior Management 2024:17 DovePress
3777
Dovepress Ociskova et al
Powered by TCPDF (www.tcpdf.org)
Content uploaded by Marie Ociskova
Author content
All content in this area was uploaded by Marie Ociskova on Oct 30, 2024
Content may be subject to copyright.
