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The Axis-I Dissociative Disorder
Comorbidity
of Borderline Personality Disorder
Among Psychiatric Outpatients
Vedat Sar, MD
Turgut Kundakci, MD
Emre Kiziltan, MD
Ilhan L. Yargic, MD
Hamdi Tutkun, MD
Bahadir Bakim, MD
Oya Bozkurt, MD
Tuba Özpulat, MD
Vehbi Keser, MD
Özay Özdemir, MD
Vedat Sar is Professor of Psychiatry, and Director, Clinical Psychotherapy Unit and
Dissociative Disorders Program, Department of Psychiatry, Istanbul University Istanbul
Medical Faculty, Istanbul, Turkey. He is also in private practice in Istanbul.
Turgut Kundakci is Psychiatrist, Istanbul University Student Health Center, Istanbul,
Turkey.
Emre Kiziltan is Psychiatrist, Division of Health Services, Municipality of Metropoli-
tan Istanbul, Istanbul, Turkey.
Ilhan L. Yargic is Associate Professor of Psychiatry, Istanbul University Istanbul
Medical Faculty, Department of Psychiatry, Istanbul, Turkey.
Hamdi Tutkun is Associate Professor of Psychiatry and Chair, Department of Psychia-
try, Gaziantep University, Gaziantep, Turkey.
Bahadir Bakim is Psychiatrist, Istinye District General Hospital, Istanbul, Turkey.
Oya Bozkurt is Psychiatrist in private practice, Istanbul, Turkey.
Tuba Özpulat is Psychiatrist, Bayrampasa District General Hospital, Istanbul, Turkey.
Vehbi Keser and Özay Özdemir are Psychiatrists in private practice, Istanbul, Turkey.
All authors were affiliated with the Department of Psychiatry of Istanbul University
when the study was conducted.
Address correspondence to: Prof. Dr. Vedat Sar, Istanbul Tip Fakültesi Psikiyatri
Klinigi, 34390 Capa Istanbul, Turkey (E-mail: vsar@istanbul.edu.tr).
An earlier version of this study was presented at the 16th Annual Meeting of the Inter-
national Society for the Study of Dissociation, November 12, 1999, and at the 15th An-
nual Meeting of the International Society for Traumatic Stress Studies, November 16,
1999, Miami.
Journal of Trauma & Dissociation, Vol. 4(1) 2003
http://www.haworthpressinc.com/store/product.asp?sku=J229
Ó2003 by The Haworth Press, Inc. All rights reserved. 119
ABSTRACT. The aim of this study was to determine the frequency of
dissociative disorders among psychiatric outpatients with borderline per-
sonality disorder (BPD). In order to ascertain the extent of the overlap be-
tween two diagnostic groups, the overall prevalence of both disorders were
evaluated. Two hundred and forty (240) consecutive patients who pre-
sented to a university outpatient psychiatry unit were screened using the
self-report questionnaire version of the BPD section of Structured Clinical
Interview for DSM-III-R Personality Disorders (SCID-II), the Dissociative
Experiences Scale (DES) and the Somatoform Dissociation Questionnaire
(SDQ). One hundred and twenty-nine (129) participants who had a score
above the cut-off point on at least one of these instruments were evaluated
using the interview version of the BPD section of the SCID-II, the
Dissociative Disorders Interview Schedule (DDIS), and the PTSD module
of the Structured Clinical Interview for DSM-III-R (SCID-I). All partici-
pants who were diagnosed as having BPD or a dissociative disorder were
evaluated then with the Structured Clinical Interview for DSM-IV
Dissociative Disorders (SCID-D). Twenty-five (25; 10.4%) participants
had BPD and 33 participants (13.8%) had dissociative disorder in the final
evaluation. Sixteen participants (64.0%) with BPD had the Axis I diagnosis
of a dissociative disorder; all six participants (2.5%) with dissociative iden-
tity disorder were among them. The findings demonstrate that a significant
part of psychiatric outpatients who fit the criteria of BPD have a DSM-IV
dissociative disorder on Axis I. The presence of dissociative symptoms as a
part of BPD should not lead to overlooking the possibility of a co-occurring
dissociative disorder. [Article copies available for a fee from The Haworth
Document Delivery Service: 1-800-HAWORTH. E-mail address: <getinfo@
haworthpressinc.com> Website: <http://www.HaworthPress.com> Ó2003 by
The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Borderline personality disorder, dissociative disorder,
comorbidity, DSM-IV, prevalence, outpatients
The borderline syndrome was formally classified as an Axis II person-
ality disorder in DSM-III (American Psychiatric Association, 1980) after
a period of debate about its relationship with affective disorders and
schizophrenia (Akiskal, 1981; McGlashan, 1983). Several studies have
demonstrated that patients with borderline personality disorder (BPD) of-
ten meet DSM criteria for a number of common Axis I disorders, such as
major depression, substance abuse, anxiety disorders, and somatization
disorder (Andrulonis & Vogel, 1984; Koenigsberg, Kaplan, Gilmore, &
Cooper, 1985; Fyer, Frances, Sullivan, Hurt, & Clarkin, 1988; Dulit, Fyer,
120 JOURNAL OF TRAUMA & DISSOCIATION
Haas, Sullivan, & Frances, 1990; Hudziak et al., 1996; Zanarini et al.,
1998). There are also studies reporting high frequency of dissociative
symptoms among patients with BPD (Shearer, 1994; Brodsky, Cloitre, &
Dulit, 1995; Zanarini, Ruser, Frankenburg, & Hennen, 2000).
Research concerning paranoid ideation, depersonalization and dereal-
ization among patients with BPD (e.g., Zanarini, Gunderson, Franken-
burg, & Chauncey, 1990) led to the introduction of the ninth diagnostic
criterion of BPD in DSM-IV (American Psychiatric Association). This
criterion covers transient, stress-related and severe dissociative symptoms
as a feature of BPD. However, the limited information about the charac-
teristics of these dissociative symptoms and the inclusion of psychotic
features such as paranoid ideation at the same item has made this criterion
rather imprecise. Consequently, this phenomenological overlap regarding
DSM-IV criteria has made the differentiation of dissociative disorders
from BPD difficult. However, as the growing experiences on the treatment
of dissociative disorders increasingly demonstrate the possibility of a
more favorable outcome than that of a severe personality disorder (Sar,
Öztürk, & Kundakci, 2002), the recognition of the presence of a major
dissociative disorder as an Axis I diagnosis is a clinically relevant task.
The present study attempted to determine the frequency and character-
istics of DSM-IV dissociative disorders among psychiatric outpatients
with BPD. We gathered data from a series of consecutively admitted pa-
tients in order to determine the extent of the overlap between two catego-
ries in a non-biased clinical sample. This study also provided the overall
prevalence rates of dissociative disorder and BPD among newly admitted
psychiatric outpatients in a university clinic.
METHOD
Participants
All patients admitted to psychiatric outpatient unit of the Istanbul Med-
ical Faculty Hospital for the first time over a three-and-a-half-month pe-
riod (March 15, 1998, to June 30, 1998) were considered for participation
in the study. Emergency admissions were not included. The patients who
agreed to participate provided written informed consent after the study
procedures had been fully explained. All patients were approached for the
study if their treating physician felt that they could give informed consent
and there were no other clinical contraindications to their participation.
Sar et al. 121
Three hundred and two (302) consecutive patients presented during the
study period. Two hundred and forty (240; 79.5%) completed the ques-
tionnaires. Sixty-two (62) patients were excluded for the following rea-
sons: illiteracy (N= 30), mental retardation (N= 7), too severe
psychopathology to be included (N= 13), refusal to participate (N= 4),
poor physical condition due to organic illness (N= 2), deficient language
(N= 1), and other (N= 5). Patients who did not participate were signifi-
cantly older (mean = 43.6, SD = 17.7) than those (mean = 30.0, SD = 11.0)
than those who participated (t= 7.53, df = 300, p< .001). Women made up
67.9% (N= 163) of those who completed the questionnaires and 71.0% (N
= 44) of those who did not complete them; this difference was not signifi-
cant (c2= 0.21, df =1,p> 0.05).
The study group consisted of 163 women and 77 men. The average age
of the participants was 30.0 (range: 16-75, SD = 11.0). There was no sig-
nificant difference in age (t= 0.26, df = 238, p> 0.05) between women
(mean = 30.2, SD = 10.9) and men (mean = 29.8, SD = 11.4). Eleven (11)
patients (4.6%) were below 18 years of age.
Instruments
Structured Clinical Interview for DSM-IV Dissociative Disorders. The
SCID-D is a semi-structured interview developed by Steinberg (1994). It
is used to make DSM-IV diagnoses for all dissociative disorders. The
SCID-D scores differ dissociative patients from control subjects signifi-
cantly, and there is high interrater reliability (kappa = 0.92) on dissoci-
ative disorder diagnoses (Steinberg, Rounsaville, & Cicchetti, 1990). The
Turkish version of the SCID-D (Sar, Tutkun, Yargic, Kundakci, &
Kiziltan, 1996) was investigated on 40 patients with a dissociative disor-
der and 40 controls and yielded an 100% agreement in the presence and
absence of a dissociative disorder (Kundakci, Sar, Kiziltan, Yargic, &
Tutkun, 1998). Interrater reliability of the interview was evaluated by four
psychiatrists using ten videotaped interviews with patients with either
dissociative disorder or other psychiatric disorders. The sole discrepancy
between raters was on the type of the dissociative disorder in one patient
who was assessed as having either dissociative identity disorder or
dissociative disorder not otherwise specified (DDNOS).
Dissociative Disorders Interview Schedule. The DDIS is a structured
interview used to make DSM-IV diagnoses of somatization disorder, ma-
jor depressive episode, and all dissociative disorders (Ross et al., 1989). It
also inquires about childhood abuse and neglect. The schedule has an
122 JOURNAL OF TRAUMA & DISSOCIATION
overall interrater reliability of 0.68 (kappa), a sensitivity of 0.90, and a
specificity of 1.00 for the diagnosis of dissociative identity disorder. A
study with the Turkish version (Yargic, Sar, Tutkun, & Alyanak, 1998)
also yielded good sensitivity (95%), and specificity (98%).
Structured Clinical Interview for DSM-III-R Personality Disorders.
The SCID-II is a semi-structured interview developed by Spitzer, Wil-
liams, Gibbon, & First (1990). It serves as a diagnostic instrument for
Axis II personality disorders. In a sample of outpatients with anxiety dis-
orders, the kappa coefficients for the interview were between 0.61-0.81
(Renneberg, Chambless, Dowdall, Fauerbach, & Gracely, 1994). A
self-report initial evaluation questionnaire version of this instrument is
available and was used for the screening at the first stage of the study. The
Turkish version of the SCID-II has an interrater reliability of 0.95 (kappa)
for BPD (Coskunol, Bagdiken, Sorias, & Saygili, 1994).
PTSD-Module of Structured Clinical Interview for DSM-III-R. The
SCID-PTSD (Spitzer, Williams, & Gibbon, 1987) basically uses the DSM
criteria for PTSD. It has a sensitivity of 0.69 and specificity of 1.00 for the
diagnosis of PTSD with an overall agreement of 0.76 (kappa) between rat-
ers (Saigh et al., 1998).
Dissociative Experiences Scale-II. The DES-II is a self-report instru-
ment that evaluates the severity of dissociative psychopathology
(Bernstein & Putnam, 1986; Carlson & Putnam, 1993). The Turkish ver-
sion has a test-retest reliability of 0.77 (Sar et al., 1997). It distinguishes
patients with dissociative identity disorder from those with other psychiat-
ric disorders with a sensitivity of 0.85 and specificity of 0.77 (Yargic,
Tutkun, & Sar, 1995; Sar et al., 1997; Yargic et al., 1998).
Somatoform Dissociation Questionnaire. The SDQ is a 20 item self-re-
port instrument developed by Nijenhuis, Spinhoven, Van Dyck, Van der
Hart, & Vanderlinden (1996). It screens somatoform dissociative symp-
toms with possible scores ranging from 20 to 100. An SDQ score of 35 or
above screened Turkish patients with dissociative disorder with a speci-
ficity of 0.88 and sensitivity of 0.97 (Sar, Kundakci, Kiziltan, Bakim, &
Bozkurt, 2000).
History Form for Childhood Abuse and Neglect. This self-report his-
tory form for childhood abuse and neglect is consisted of five items
(Yargic et al.,1998) based on definitions of Walker, Bonner, and Kauf-
mann (1988). Each item includes questions on details of the reported trau-
matic event including the age of the victim and perpetrator, and severity of
the experience.
Sar et al. 123
Procedure
The study consisted of three phases. In the first phase, the DES, the
SDQ, the self-report questionnaire version of the SCID-II BPD section,
and the History Form for Childhood Abuse and Neglect were adminis-
tered to all participants by three psychiatry residents (T.Ö., Ö.Ö., and
V.K.). All participants who affirmatively endorsed either at least five cri-
teria of BPD, and/or who had a DES score greater or equal to 25, and/or
who had a SDQ score greater or equal to 35 were asked to participate in a
structured interview. The DDIS, the BPD Section of the SCID-II, and the
SCID-PTSD were administered to these participants. All structured inter-
views were conducted by two senior psychiatry residents (B.B., and O.B.)
who have extensive experience using these instruments. All participants
who were diagnosed as having BPD according to the SCID-II and/or a
dissociative disorder according to the DDIS were considered for a sepa-
rate interview with the SCID-D.
The evaluation at the third step aimed the confirmation of dissociative
disorder diagnosis and provided detailed information about dissociative
symptoms. The clinicians in the third phase (V.S., T.K., and E.K.) are all
psychiatrists with extensive research and treatment experience on
dissociative disorders.
RESULTS
Of the original 240 participants, 145 (60.4%) endorsed five or more of
the eight DSM-III-R BPD criteria. Sixty-seven participants (67; 27.9%)
had a DES score 25 or higher and 65 participants (27.1%) had an SDQ
score 35 or higher. Upon combining participants who met inclusion crite-
ria on the three widely overlapping measures, a total of 153 participants
(63.7%; 106 women and 47 men) were invited to the structured evalua-
tion.
One hundred twenty-nine (129) participants (85.4% of the invited
group) came to the interview. In contrast of the results obtained by the
self-report questionnaire, only 25 (10.4%) participants (23 women and 2
men) had a DSM-III-R BPD in the structured diagnostic interview. With
the additional 19 participants who had dissociative disorder on the DDIS,
a total of 44 participants (37 women and 7 men) were eligible for the final
stage.
According to the SCID-D interview, 33 participants (13.8%) had a def-
inite dissociative disorder (27 women and 6 men). Six of them (2.5%) had
124 JOURNAL OF TRAUMA & DISSOCIATION
dissociative identity disorder, 23 (9.6%) had DDNOS, and four (1.7%)
had dissociative amnesia. In the final analysis, 42 participants (17.5%)
had either dissociative disorder (N= 17) or BPD (N= 9) or both (N= 16).
The co-occurrence of both disorders was 38.1% in 42 participants.
Table 1 shows some clinical features of the participants with dissoci-
ative disorder and/or BPD. The group with both dissociative disorder and
BPD (dual diagnosis group) had the highest frequencies in comorbid diag-
noses of somatization disorder and PTSD. Five of the six PTSD cases (all
women) were among participants with dual diagnosis. The dual diagnosis
group had also the highest frequencies in suicide attempt, childhood imag-
inary companionship, and all types of childhood abuse and neglect (Table
2). This group also had the highest scores on the DES, and the SDQ (Table
3) suggesting that they had the most severe form of dissociative
psychopathology. Participants with dissociative disorder and/or BPD (N=
42) as a whole reported childhood traumata more frequently than the re-
maining participants in our study (Table 4).
All PTSD participants in the dual diagnosis group reported childhood
sexual abuse. PTSD was related to rape in three of them. One of the partic-
ipants witnessed a murder and her brother being injured with a knife. The
other participant had two traumatic events: experiencing a traffic accident
and being stabbed by her husband. Three participants had dissociative
Sar et al. 125
TABLE 1. Comorbid Diagnoses in Participants with Borderline Personality Disor-
der (BPD) and/or Dissociative Disorder
Dissociative
disorder only
BPD only Both
diagnoses
Fisher
exact test
(df =2)p
(N= 17) (N=9) (N= 16)
N% N% N%
SCID-D diagnosis (DSM-IV)
Dissociative amnesia 3 17.6 - - 1 6.3 < 0.01*
Dissociative disorder NOS 14 82.4 - - 9 56.3
Dissociative identity disorder 0 0.0 - - 6 37.5
DDIS section diagnoses (DSM-IV)
Major depression (lifetime) 14 82.4 9 100.0 15 93.8 n.s.
Major depression (current) 13 77.5 9 100.0 15 93.8 n.s.
Somatization disorder 8 47.1 5 55.6 11 68.8 n.s.
Substance abuse (alcohol) 0 0.0 0 0.0 1 6.3 n.s.
SCID-PTSD diagnosis (DSM-III-R)
PTSD 1 5.9 0 0.0 5 31.3 n.s.
* The dissociative identity disorder row contributes 79% of this c2
identity disorder. The sole participant with PTSD in the “dissociative dis-
order only” group reported torture.
Results from participants with BPD (N= 25) were analyzed as a sepa-
rate group. Participants’ mean age was 24.6 years (SD = 5.6). They had an
average DES score of 44.4 (SD = 22.6) and an average SDQ score of 46.5
(SD = 16.1). Eighteen (72.0%) had a DES score above 30.0 (mean = 44.4
SD = 22.6) and an SDQ score above 35.0. Sixteen (16; 64.0%) of the par-
126 JOURNAL OF TRAUMA & DISSOCIATION
TABLE 2. Gender Distribution and Mental Health History of Participants with Bor-
derline Personality Disorder (BPD) and/or Dissociative Disorders
Dissociative
disorder only
BPD only Both diagnoses Fisher
exact test
(df =2)p
(N= 17) (N=9) (N= 16)
N% N% N%
Gender (female) 12 70.6 8 88.9 15 93.8 n.s.
Suicide attempt 5 29.4 3 33.3 14 62.5 < 0.002
Self-mutilation 11 64.7 4 44.4 12 75.0 n.s.
Somnambulism 4 23.6 2 22.2 3 18.9 n.s.
Trance states 12 70.6 5 55.6 13 81.3 n.s.
Childhood imaginary
companionship
2 11.8 0 0.0 7 44.1 < 0.05
Neglect* 10 58.8 7 77.8 15 93.8 n.s.
Physical abuse* 6 35.3 4 44.4 11 68.8 n.s.
Emotional abuse* 7 41.2 5 55.6 10 62.5 n.s.
Sexual abuse* 4 23.5 2 22.2 9 56.3 n.s.
At least one type
of childhood trauma*
12 70.6 8 88.9 15 93.8 n.s.
* Combined data from self-report questionnaire and structured interview
TABLE 3. Dissociation Scores in Participants with Borderline Personality Disor-
der (BPD) and/or Dissociative Disorder
Measures of
dissociation
BPD only Dissociative
disorder only
Both diagnoses Variance analysis
(N=9) (N= 17) (N= 16)
mean SD mean SD mean SD F(df = 39,2) p
SDQ total score 36.4 10.6 41.9 15.2 52.2 16.1 3.79 < 0.05
DES total score 31.8 17.6 24.0 38.8 51.5 22.4 2.61 n.s.
Age 25.3 5.2 24.5 7.3 24.1 5.9 0.10 n.s.
ticipants with BPD had a dissociative disorder diagnosis; all six cases of
dissociative identity disorder (all female) were among them. Additionally,
nine cases of DDNOS (eight of them female), and one case of dissociative
amnesia were among the BPD group. Sixteen (16; 64.0%) participants
with BPD had somatization disorder.
Table 5 shows the frequency of dissociative symptoms observed
among participants with BPD as assessed with the SCID-D. Besides de-
personalization, dissociative amnesia and associated symptoms of dis-
sociative identity disorder were the most frequently observed features.
Identity alteration, mood changes without any reason, ongoing internal di-
alogues, episodes of acting like as a child, and memory gaps were among
the most prevalent symptoms.
The agreement rates between the DDIS and the SCID were of particular
interest. 44 participants were evaluated both with the DDIS and SCID-D.
The rate of agreement on the presence or absence of any dissociative dis-
order was 79.5% between the two instruments. This rate dropped to 59.1%
when the type of dissociative disorder was considered. For two partici-
pants, the DDIS diagnoses of depersonalization disorder (a 23-year-old
woman with somatization disorder, major depression,and emotional
abuse history without PTSD, with a DES score of 19.6, and an SDQ score
of 61.0) and DDNOS (a 25-year-old man with social phobia, and emo-
tional and physical abuse and neglect history without PTSD, a DES score
Sar et al. 127
TABLE 4. Childhood Trauma Reports of 240 Psychiatric Outpatients on a
Self-Rating Questionnaire
Dissociative disorder and/or
borderline personality disorder
Yes
(N= 42)
No
(N= 198)
c2(df =1) p
N%N%
Gender (women) 35 83.3 128 64.6 5.55 < 0.05
Childhood trauma
Sexual abuse 14 33.3 25 12.6 11.14 < 0.001
Emotional abuse 16 38.1 41 20.7 5.88 < 0.05
Emotional neglect 26 61.9 85 42.9 4.54 < 0.05
Physical neglect 18 42.9 55 28.7 3.40 n.s.
Neglect (overall) 27 64.3 95 48.0 11.56 < 0.001
Physical abuse 17 40.5 54 27.3 2.97 n.s.
Any of them 32 76.2 111 56.1 16.28 < 0.001
128 JOURNAL OF TRAUMA & DISSOCIATION
TABLE 5. Frequency of Dissociative Symptoms in Borderline Personality Disor-
der (N= 25)
SCID-D items N%
Depersonalization 20 80.0
Detachment from behavior 13 52.0
Feelings of estrangement 11 44.0
Sensation of not being in complete control of one's
behavior 11 44.0
speech 10 40.0
emotions 9 36.0
One’s self or body unreal 7 28.0
Passive influence of body as a puppet 6 24.0
Altered perception of body 6 24.0
Feelings as two different people participating and observing 6 24.0
Watching himself from a point outside the body 4 16.0
Change in size of arms or legs 4 16.0
Amnesia 19 76.0
Difficulty of remembering daily activities 15 60.0
Memory gaps 13 52.0
Blocks of time missing 13 52.0
Inability to recall personal information 7 28.0
Blank spells 6 24.0
Fugue 1 4.0
Associated features of DID 19 76.0
Mood changes without any reason 16 64.0
Ongoing internal dialogues 15 60.0
Changes in talent or capacities 10 40.0
Flashbacks 6 24.0
Identity alteration 16 64.0
Acting like a child 12 48.0
Told by others acting as a different person 10 40.0
Acting as a different person 9 36.0
Use of different names 9 36.0
Referred by others with different names 7 28.0
Finding things without remembering 7 28.0
Feelings of possession 4 16.0
Derealization 13 52.0
Surroundings or people unreal or unfamiliar 11 44.0
Friends, family or home strange or foreign 8 32.0
Surroundings or people vague 6 24.0
Not recognizing friends or family, home 4 16.0
Identity confusion 13 52.0
Ongoing internal struggle 11 44.0
Confusion over identity 11 44.0
of 21.4, and an SDQ score of 30.0) were not confirmed by the SCID-D in-
terview. As they also did not have BPD, they were not included in the final
analysis. Three participants who had a dissociative disorder diagnosis on
the DDIS (two depersonalization disorder and one DDNOS) but not on the
SCID-D, and four participants who had a dissociative disorder on the
SCID-D (three DDNOS and one dissociative amnesia) but did not have a
dissociative disorder diagnosis on the DDIS were included in the final
analysis as they had BPD.
DISCUSSION
It was possible to recruit 79.5% of all consecutively admitted new out-
patients. A considerable proportion of the psychiatric participants
(17.5%) had either BPD or a dissociative disorder or both. The prevalence
of BPD was 10.4%. The frequency of DSM-IV dissociative disorders
(13.8%) was similar to the rate (11.8%) obtained in a previous study
among psychiatric outpatients in Turkey (Sar, Tutkun, Alyanak, Bakim,
& Baral, 2000). Although, according to the DSM-III-R criteria, we did not
use dissociative symptoms in making the diagnosis of BPD, two-thirds
(64.0%) of the participants with BPD had an Axis I dissociative disorder.
As this study did not include inpatients who are expected to demonstrate a
larger overlap between BPD and dissociative disorder (Tutkun et al.,
1998; Sar et al., 2000), this rate seems to be the minimum. The use of
DSM-IV criteria for BPD would raise this rate even further. The ninth di-
agnostic criterion of BPD in the DSM-IV states that “during periods of ex-
treme stress, transient paranoid ideation or dissociative symptoms may
occur, but these are generally of insufficient severity or duration to war-
rant an additional diagnosis” (American Psychiatric Association, 1994, p.
651). However, in a considerable group of the participants with BPD in
this study, the dissociative phenomena were not simply stress-related or
transient, but were symptoms of a dissociative disorder that warranted a
separate diagnosis. Moreover, besides depersonalization, the clusters of
dissociative amnesia and associated symptoms of dissociative identity
disorder were also among the most frequently observed dissociative
symptoms in BPD participants. Consequently, the dissociative
psychopathology seen among these participants extends beyond the limits
of the ninth criterion.
Several measures supported this high comorbidity rate. The DES
(mean = 44.4) and the SDQ (mean = 46.5) scores of the participants with
BPD were comparable to the average scores reported for dissociative dis-
Sar et al. 129
orders in Turkey (Yargic et al., 1995, 1998; Sar et al., 1997; Sar et al.,
2000). Seventy-two percent (72%) of them had a DES score above the
cut-off point for dissociative disorders (Sar et al., 1997; Yargic et al.,
1998; Carlson & Putnam, 1993). The distribution of the SCID-D items
among participants with BPD covered the whole range of dissociative
phenomena. Similar to the findings of a previous study (Hudziak et al.,
1996), a high proportion of these participants had comorbid somatization
disorder which is known to be highly correlated with dissociation (Saxe et
al., 1994). It is of particular interest that a considerable proportion (55.6%)
of the participants with BPD only also had comorbid somatization disor-
der implying a further subtle overlap between BPD and dissociative
psychopathology.
Participants who had both BPD and dissociative disorder diagnoses
seem to have more severe clinical conditions, as they had the highest fre-
quencies of reported childhood trauma, concurrent diagnoses, self-de-
structive behavior including self-mutilation and suicide attempts, and the
highest DES and SDQ scores. All participants with the diagnosis of
dissociative identity disorder, i.e., the most severe and chronic form of
dissociative disorder, were included in the dual diagnosis group. Indeed,
several studies demonstrated that a large proportion of participants with
dissociative identity disorder concurrently fit the criteria of BPD (Ellason,
Ross, & Fuchs, 1996; Kiziltan, Sar, Kundakci, Yargic, & Tutkun, 1998;
Yargic et al., 1998; Sar, Yargic, & Tutkun, 1996; Fink, 1991). Dissocia-
tion in response to childhood traumata (Chu, Frey, Ganzel, & Matthews,
1999) may be at the core of the pathogenic process that results in
symptomatology embodied in the diagnoses of both BPD and dissociative
disorder.
High rates of childhood abuse and/or neglect have been reported as
central to both BPD (Herman, Perry, & van der Kolk, 1989; Ogata et al.,
1990; Shearer, Peters, Quaytman, & Ogden, 1990; Stone, 1990; Goldman,
D’Angelo, DeMaso, & Mezzacappa, 1992; Zanarini et al., 1997) and
dissociative disorders (Chu & Dill, 1990; Yargic, Tutkun, & Sar, 1994;
Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997; Lewis, Yeager,
Swica, Pincus, & Lewis, 1997; Nijenhuis, Spinhoven, van Dyck, van der
Hart, & Vanderlinden, 1998; Chu et al., 1999). Indeed, the participants in
the final stage of our study, i.e., participants with either dissociative disor-
der and/or BPD, reported childhood trauma more frequently than the rest
of the study group. Although many other factors (e.g., temperament and
other forms of biological vulnerability) may also play a role, childhood
trauma has almost certain etiological significance in the development of
this spectrum of disorders.
130 JOURNAL OF TRAUMA & DISSOCIATION
The high psychiatric comorbidity observed among traumatized sub-
jects has led some investigators to subsume these phenomena in a new di-
agnostic category of complex PTSD (Herman, 1992; Van der Kolk, 1996)
which has not as yet become part of any official classification system.
Symptoms of affect dysregulation, impulse control, alterations in self-per-
ception, impairment in interpersonal relationships and occupational func-
tioning, dissociative symptoms, self-destructive behavior, dyscontrol of
anger, and substance abuse are core features of this syndrome. Although
this concept provides a solution to the comorbidity problem, it does not re-
fer to any underlying basic psychopathological mechanism, e.g., dissocia-
tion.
McLean (2001) reported that current (i.e., past month) symptoms of
dissociation were significantly higher in women reporting early onset (#
12 years of age) of sexual abuse as opposed to late onset abuse. The diag-
noses of both BPD and complex PTSD were higher in women reporting
early onset of sexual abuse as opposed to late onset. The small size of the
BPD and/or dissociative disorder group in our study does not allow any
meaningful analysis in this regard.
Most of the participants with BPD and/or dissociative disorder in our
study were women. In an epidemiological study in Turkey (Akyüz,
Dogan, Sar, Yargic, & Tutkun, 1999), although there was no difference in
average DES score between genders, two times more women than men
were included among high scorers. Thus, the overrepresentation of female
participants in our study does not seem to be a selection bias. These results
suggest that women are either traumatized more frequently or more
readily develop pathological dissociation as a response to trauma.
There was considerable agreement (79.5%) between the DDIS and the
SCID-D about the presence or absence of dissociative disorder. The
semi-structured characteristics of the SCID-D make clinical judgement
possible. The fully structured DDIS, on the other hand, is free of clinical
judgement. The most frequent cause of false positive diagnosis on the
DDIS seems to be the presence of another psychiatric disorder (usually an
anxiety disorder or an affective disorder) that contains dissociative symp-
toms (usually depersonalization) as well. The possibility of clinical judge-
ment makes a false positive diagnosis on the SCID-D rather improbable.
We believe that the simultaneous use of both instruments and independ-
ently used self-rating scales increased the diagnostic accuracy in this
study.
Sar et al. 131
CONCLUSION
A significant part of psychiatric outpatients who fit the DSM-III-R cri-
teria of BPD have a DSM-IV dissociative disorder on Axis I. Thus, an
Axis II diagnosis of BPD should not prevent clinicians from diagnosing a
co-occurring dissociative disorder. The ninth criterion of BPD in the
DSM-IV often does not sufficiently account for complex dissociation.
The extensive phenomenological and etiological relationship between
two disorders warrants further study.
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RECEIVED: 03/04/02
REVISED: 04/17/02
ACCEPTED: 04/17/02
Sar et al. 135
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