Association between childhood trauma and dissociation among patients with borderline personality disorder

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Stuart Watson, Consultant Psychiatrist (Correspondence); Helen Fairchild, Trainee Clinical Psychologist

School of Neurology, Neurobiology and Psychiatry, University of Newcastle, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, England, UK. Email: [email protected]

Roy Chilton, Assistant Psychologist; Peter Whewell, Consultant Psychotherapist

Borderline Treatment Service, The Regional Department of Psychotherapy, Newcastle, England, UK

Received 23 February 2005; accepted 23 March 2005.

Association between childhood trauma and

dissociation among patients with borderline

personality disorder

Stuart Watson, Roy Chilton, Helen Fairchild, Peter Whewell

Objective: To examine the relationship between childhood trauma and dissociative

experience in adulthood in patients with borderline personality disorder.

Method: Dissociative experiences scale scores and subscale scores for the Childhood

Trauma Questionnaire were correlated in 139 patients. Patients were dichotomized into high or low dissociators using the Median Dissociative Experiences Scale score as the cut-off.

Results: Childhood Trauma Questionnaire Subscale scores for emotional and physical

abuse and emotional neglect but not sexual abuse correlated significantly with Dissociative Experiences Scale scores. High dissociators reported significantly greater levels of emotional abuse, physical abuse, emotional neglect and physical neglect but not sexual abuse than low dissociators.

Conclusion: Patients with borderline personality disorder therefore demonstrated levels

of dissociation that increased with levels of childhood trauma, supporting the hypothesis that traumatic childhood experiences engender dissociative symptoms later in life. Emotional abuse and neglect may be at least as important as physical and sexual abuse in the development of dissociative symptoms.

Key words: adult development, borderline personality disorder, dissociative disorder,

psychoanalysis and psychodynamic therapy, stress.

Australian and New Zealand Journal of Psychiatry 2006; 40:478–481

Dissociation describes a state of apparent disruption in the normally integrated functions of consciousness, including perception, memory and identity. Borderline personality disorder (BPD) is characterized by core fea-tures of identity confusion and unstable relationships and is commonly associated with high rates of childhood

trauma and dissociation [1]. Some authors have argued that dissociation is an intrinsic component of BPD [1]. This is supported by the inclusion of dissociative symp-toms as a diagnostic feature of BPD in DSM-IV. How-ever, an alternative hypothesis holds that dissociative symptoms are coincident with BPD, develop as a defence against significant childhood trauma and persist into adulthood. We therefore examined the association between dissociation and childhood trauma in adults with BPD and investigated the relationship between specific types of trauma and dissociation.

Method

The sample comprised 139 subjects (34 male, 105 female, mean age = 32.6 years, SD = 9.6) referred to the borderline treatment team

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S. WATSON, R. CHILTON, H. FAIRCHILD, P. WHEWELL 479

ser-vice by health-care professionals in primary and secondary care. A DSM-IV diagnosis of BPD was made based on scores on valid and reliable [2–6] self-report questionnaires – either the Personality Diag-nostic Questionnaire [4] or the Screen Test for Comorbid Personality Disorder [6] and confirmed by a trained psychotherapist during a three-session assessment. There were no exclusion criteria. All patients also completed the Dissociative Experience Scale (DES) [7] and the Childhood Trauma Questionnaire (CTQ) [8]. The DES con-tains a number of statements such as ‘Some people have the experi-ence of finding themselves in a place and having no idea how they got there’ and asks the respondent to circle the percentage of the time this happens to him/her. The CTQ, a 28-item self-report inven-tory, provides a brief, reliable history with five subscales: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. It contains a number of statements, such as ‘When I was growing up I didn’t have enough to eat’ and the respondent is asked to answer on a 5-point Likert scale from ‘never true’ to ‘very often true’.

Data did not fulfil the assumptions of normality and were therefore analysed non-parametrically. The median DES score was used to

cat-egorize subjects as high dissociators (n = 73) or low dissociators

(n = 66). The scores of CTQ subscale were compared between high and

low dissociators using Mann–Whitney U-tests (two-tailed).

Relation-ships between scores on the CTQ subscales and DES scores were examined using Spearman’s rank order correlations. All statistical anal-yses were performed using SPSS version 10.0 (SPSS Inc., Chicago, IL, USA). Twenty-three subjects returned incomplete CTQ scales. Within each questionnaire, scores for all completed subscales were included in the analysis.

Results

The median DES score in the group was 21.0 (95% CI = 17–25;

mean = 24.09%). Over 70% of subjects demonstrated levels of

emo-tional abuse and emoemo-tional neglect at a moderate to severe/severe to extreme level based on the normative data for CTQ scores. A significant relationship was found between CTQ subscales and DES scores for emotional abuse, physical abuse and emotional neglect, but not for sexual abuse or physical neglect. Severity of childhood abuse was significantly greater among high compared with low dissociators for emotional abuse, physical abuse, emotional neglect and physical neglect but not for sexual abuse (Table 1).

Discussion

Mean levels of dissociation are similar to those previ-ously recorded in borderline patients [9]. Overall levels of dissociation increased with levels of childhood trauma, providing support for a putative causal relation-ship between traumatic experiences in childhood events and dissociative experiences in BPD. Such a relationship was further substantiated by our findings of significantly greater reported incidence of physical and emotional

T

able

1.

Summary table of CTQ corr

elation and dif

fer

ence values among high and low dissociator

s Classification of c hildhood trauma † CTQ _score ‡ Correlation of CTQ subscale

scores with DES

CTQ score ‡ for high dissociator s CTQ score ‡ for lo w dissociator s ‡ Diff erence in CTQ subscale

scores between high and lo

w dissociator s. None–minimal/ low–moderate Moderate–se vere/ se vere–e xtreme rp U , z, p § Median diff erence ‡ Emotional ab use 29% (38/132) 71% (94/132) 17 (12–21) 0.33 < 0.0005 19 (14–23) 15 (10–19) 1669, -2.32, < 0.0005 4 (2–6) Ph ysical ab use 61% (81/132) 39% (51/132) 8 (5–13) 0.19 0.029 10 (5–16) 7 (5–10) 1615, -2.59, 0.009 2 (0–4) Se xual ab use 57% (72/126) 43% (54/126) 6 (5–17) 0.13 0.135 7 (5–23) 5 (5–15) 1696, − 1.48, 0.140 0 (0–2) Emotional neglect 29% (38/132) 71% (94/132) 17 (13–21) 0.17 0.046 19 (15–21) 16 (12–20) 1669, -2.32, 0.020 2 (0–4) Ph ysical neglect 57% (75/131) 43% (56/131) 9 (6–13) 0.14 0.110 10 (6–15) 8 (6–10) 1707, -2.03, 0.043 1 (0–3) † Based on nor mativ e data; ‡ Median v

alues with 95% CI in parentheses;

§ Mann–Whitne y U -test. CTQ, Childhood T rauma Questionnaire; DES , Dissociativ e Exper ience Scale .

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abuse and physical and emotional neglect among high compared with low dissociators.

The biological mechanism for the effects of sustained childhood trauma on dissociation is complex and likely to involve multiple factors. It seems likely that childhood trauma causes complex changes in neuroanatomy, neu-roendocrinology and neurotransmitter sensitivity which persist into adult life. For instance, sustained childhood stress causes increased activity of the hypothalamic-pituitary-adrenal (HPA) axis which persists into adult-hood [10]. Dissociation putatively reduces anxiety and the attendant HPA axis response. This thesis is supported by the negative correlation between cortisol and dissoci-ation seen in military personnel during interrogdissoci-ation stress [11]. Adaptive changes secondary to the persistent, maladaptive use of this defence may explain the low cortisol levels and enhanced sensitivity of negative feed-back mechanisms within the HPA axis in conditions associated with dissociation or trauma such as deperson-alization disorder and post-traumatic stress disorder [12]. The amygdala is exquisitely sensitive to HPA axis per-turbations [13]. Sustained childhood trauma may result in a hard-wired tendency to aggression and poor impulse regulation because such trauma may cause structural changes in the amygdala. It is possible only to speculate about the neural substrate underlying dissociation; how-ever, overactivity in amygdala-orbitofrontal cortex cir-cuitry represents a likely candidate and is worthy of further research.

While Freud’s early papers focus on high-impact phys-ical or sexual childhood trauma, recent psychoanalytic literature has highlighted the impact of perceived or real chronic emotional abuse and neglect on the developing personality leading to failures of ‘mentalization’ [14]. A child may dissociate as a developmental necessity to hold the self from potential breakdown and fragmentation in response to high anxiety or hyper-arousal caused not only by intrusive trauma, but also by the failure of the parents to provide an emotionally containing environ-ment for the child. Repeated emotional trauma then has a cumulative effect and the tendency to dissociate under stress may become facilitated and habitual [15].

In our study, the strongest relationship with dissocia-tion was found for emodissocia-tional abuse. This replicates pre-vious findings in patients with schizophrenia [16] and depersonalization disorder [17], corroborates a report that emotional abuse is a better predictor of subsequent dissociation than physical or sexual abuse among male forensic patients [18] and supports a previous study which suggested that maternal neglect may mediate the dissociative effects of physical and sexual abuse [19]. In this study, we did not demonstrate an association between childhood sexual abuse and dissociation. This

may be because such abuse is usually a relatively low time frequency event when compared with a more cumu-lative, sustained effect of chronic emotional or physical abuse or emotional neglect [20].

Unfortunately, in the present study it was not possible to control for the presence of comorbid psychiatric diag-noses, nor abusive experiences during adulthood that may also have impacted on dissociation. In this respect, we note that dissociation is also observed in some patients with post-traumatic stress disorder [21], and the proportion of patients with this diagnosis in our study is not known.

Diagnosis was made on the basis of self-report ques-tionnaires and a three-session diagnostic interview. Both interview and self-report diagnostic measures have poor convergent and divergent validity. This may reflect the conceptualization of personality disorders rather than the instruments per se [22]. The analysis relies on retro-spective reports in adulthood of major adverse experi-ences in childhood. A recent review of data collection in this way suggests that false negatives are seen at a sub-stantial rate, but false positive reports are probably rare [23]; other data suggest that the CTQ is a valid measure of abuse and neglect with good test–retest reliability [24].

We have demonstrated a relationship between child-hood trauma (particularly emotional abuse) and dissocia-tive symptoms in BPD. A similar relationship has been reported in other psychiatric conditions [16]. We suggest that rather than being an intrinsic component of BPD, dissociation and BPD may share childhood trauma as an aetiological factor. This could be further addressed in future studies designed to examine the subtleties of the expected complex interaction between the development of dissociative symptoms and borderline personality organization. The presence of a control group would also help to clarify the relationship between early abuse and dissociation and the extent to which the latter is intrinsic to BPD. Cross-sectional studies should integrate neu-roendocrine and imaging data with rigorous psycho-dynamic assessment to more fully understand the aetiological relationships in dissociation. Prospective studies would also help to establish causality, but would require a considered design to avoid ethical and method-ological constraints.

Acknowledgements

We are grateful to the patients, therapists and administrative staff of the Borderline Treatment Service. Ravi Lingham commented on an earlier draft of the paper.

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S. WATSON, R. CHILTON, H. FAIRCHILD, P. WHEWELL 481

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