OBJECTIVE: This study examined whether women with a history of early-onset sexual abuse or those with late-onset sexual abuse were more likely to meet diagnostic criteria for both borderline personality disorder and complex posttraumatic stress disorder (PTSD). METHOD: The Revised Diagnostic Interview for Borderlines and the Trauma Assessment Package were administered to 65 women from three outpatient clinics in a metropolitan area. Thirty-eight subjects met criteria for early-onset abuse, while 27 subjects met criteria for late-onset abuse. RESULTS: The diagnoses of both borderline personality disorder and complex PTSD were significantly higher in women reporting early-onset abuse than in those with late-onset abuse. The trauma variables sexual abuse and paternal incest were significant predictors of both diagnoses. CONCLUSIONS: In contrast to those with comorbid diagnoses, some women with a history of childhood sexual abuse may be extricated from the diagnosis of borderline personality disorder and subsumed under that of complex PTSD.
The empirical literature points to the association of severe childhood trauma with both borderline personality disorder and posttraumatic stress disorder (PTSD) and has highlighted the overlapping nature of both disorders (1). In adhering to the DSM, clinicians have been placed in the contradictory position of having to affirm that individuals manifesting characteristic symptoms of both borderline personality disorder and PTSD have two separate illnesses. This approach condemns individuals to potentially numerous diagnostic categories and has contributed to cross purposes in treatment (1, 2).
An attempt to collapse the conceptual space between the DSM-IV axis I and II diagnoses of PTSD and borderline personality disorder, respectively, is represented by the elaboration of the disorder of extreme stress or complex PTSD (1, 3–5) as a new nosological entity. Complex PTSD is currently described with the associated features and disorders of PTSD in association with an interpersonal stressor (e.g., childhood sexual and/or physical abuse) and integrates the disorders of affect regulation, dissociation, somatization, and altered perceptions of the self and others (5). The construct of complex PTSD may be a useful addition to the DSM nomenclature (1, 3–5).
The high rates of childhood sexual abuse in subjects with both borderline personality disorder and complex PTSD (3, 4, 6) led to the current empirical evaluation of a group of women with such histories.
The goal of this study was to determine in a subset of women who met diagnostic criteria for both borderline personality disorder and complex PTSD if early-onset (i.e., ≤12 years of age) versus late-onset (i.e., ≥13 years of age) sexual abuse (3) was the primary predictor of a diagnosis of borderline personality disorderd.
A diagnosis of borderline personality disorder was determined through administration of the Revised Diagnostic Interview for Borderlines (7), while a diagnosis of current and/or lifetime complex PTSD was assessed by use of the Structured Interview for Disorders of Extreme Stress (5). Psychometric properties are reported in the Trauma Center Assessment Package (8).
The Traumatic Antecedents Questionnaire, included in the Trauma Center Assessment Package (8), assessed lifetime experiences in 10 domains (e.g., neglect, physical trauma, sexual trauma) at four developmental periods (i.e., ≤6, 7–12, 13–18, and ≥19 years of age). A study reported in the Trauma Center Assessment Package found Traumatic Antecedents Questionnaire scores to be significantly related to symptoms of PTSD and symptoms of complex PTSD.
The women with early-onset sexual abuse and those with late-onset sexual abuse were compared by using Pearson’s chi-square tests with continuity adjustment for categorical data (e.g., intrafamilial sexual abuse [yes/no] and borderline personality disorder/complex PTSD [yes/no]). Logistic regression was used to determine predictors of diagnostic outcomes.
Logistic regression analysis showed that intrafamilial (paternal) sexual abuse and sexual abuse were significant predictors of meeting the criteria for both borderline personality disorder and complex PTSD (Wald’s χ2=5.11, df=7, p<0.05 [beta=2.08, p=0.02], and Wald’s χ2=4.18, df=7, p<0.05 [beta=0.36, p=0.04], respectively). Intrafamilial (paternal) sexual abuse increased the odds of meeting the criteria for both diagnoses by 26%, while sexual abuse increased the odds of meeting the criteria for both borderline personality disorder and complex PTSD by 25%.
Multicollinearity was addressed by removing the predictor variable for intrafamilial (paternal) sexual abuse from the equation in a repeated regression. The new analysis echoed the first and found sexual abuse to be the most significant predictor (Wald’s χ2=4.18, df=7, p<0.05 [beta=0.36, p=0.04]) of the diagnoses of both borderline personality disorder and complex PTSD.
Using two-way and three-way contingency table analyses, respectively, we examined the predictor variable for intrafamilial sexual abuse, as opposed to the variable for extrafamilial abuse, and the variable for chronicity (i.e., 10 or more incidents of sexual abuse), as opposed to the variable for acute (i.e., more than one and fewer than 10 incidents of sexual abuse) or the variable for a single acute of sexual abuse in regard to the diagnoses of both borderline personality disorder and complex PTSD. Both predictor variables were shown to be statistically significant (Pearson’s χ2=18.31, df=1, p<0.0001, two-tailed; Cramer’s V=0.53; p<0.0001) (single acute versus chronic sexual abuse, respectively: Pearson’s χ2=21.16, df=2, p<0.0001; Cramer’s V=0.57, p<0.0001; Holm’s sequential Bonferroni: χ2=19.23, df=1, p<0.0001a, Fisher’s exact test=a, two-tailed; Cramer’s V=0.58, p<0.0001).
Consideration of disorders of extreme stress (complex PTSD) as a nosological classification in DSM for a subset of borderline patients broadens our way of thinking about diagnoses and allows more room to consider the hierarchy of problems that the initial trauma sets into motion. A shared understanding of the survivor’s characteristic disturbances of relationship directs clinicians in using the various tools needed to help reduce the suffering so often observed in this population (1, 4).
Two limitations of this study—namely, the use of an all-female group and the use of a convenience group—indicate that our findings may not be generalizable to women with a history of sexual abuse. In regard to the first point, a substantial proportion of those diagnosed with borderline personality disorder are women (1).
This study highlights the need for replication in order to clarify diagnostic dilemmas and the integrity of disorders of extreme stress or complex PTSD in contrast to comorbid diagnoses. Furthermore, the significance of future empirical, methodically rigorous, correlational, and multivariate research in illuminating the ways in which childhood sexual abuse may contribute to adult psychopathology is underscored.
Presented in part at Harvey Stancer Research Day, University of Toronto, Department of Psychiatry, Toronto, June 21, 2001. Received Jan. 30, 2002; revision received June 18, 2002; accepted July 25, 2002. From the Faculty of Nursing and the Women’s Mental Health & Addiction Research Program, Center for Addiction & Mental Health, Department of Psychiatry, Clarke Division, University of Toronto. Address reprint requests to Dr. McLean, Women’s Mental Health & Addiction Research Program, Center for Addiction & Mental Health, Department of Psychiatry, Clarke Division, University of Toronto, 250 College St., Rm. 610B, Toronto, Ont., M5T 1R8 Canada; email@example.com (e-mail). The authors thank Anne Alonso, Ph.D., Kjell E. Rudestam, Ph.D., and Charles. E. Elliott, Ph.D., of the Fielding Graduate Institute, Santa Barbara, Calif.; Nira Kolers, Ph.D., the Coach House Clinic, Toronto; and Noreen Stuckless, Ph.D., Sunnybrook and Women’s Health Sciences Center, Women’s College Campus, Toronto, for their expertise.
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