Childhood Emotional and Physical Trauma and Unresolved
Segregated Systems and their association with Borderline
Personality Disorder: A pilot study
Name: Joëlle Berendsen Student number: 10197982 Supervisor: Carlijn Wibbelink Date: 17-09-2017
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ABSTRACT
Current pilot study explored individual differences in BPD by looking at two of its
proclaimed precursors: childhood trauma and attachment. The sample size included a total of 15 participants, of whom 75% were female. Through a new measure, the Adult Attachment Projective Picture System, unresolved segregated systems were investigated. These are deactivated systems found in people with unresolved attachment, and they contain painful attachment-related memories. The study first showed that increasing trauma severity is associated with increasing BPD severity (p < .001). A trend was found in the association between unresolved segregated systems and BPD severity (p = .061). Explorative analyses showed a positive association between denial and BPD severity, suggesting the need for further research into the precise role of denial in BPD. Limitations of the study and
recommendations for future research are discussed. Gaining more insight into the individual differences in BPD could assist in choosing and developing the best treatment for each BPD patient and current study seems to encourage the idea of trauma processing in treatment.
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Introduction
Borderline Personality Disorder (BPD) is characterized by multiple symptoms, such as unstable emotion regulation, interpersonal relationships and self-representation, problems with impulse control, and suicidality (American Psychiatric Association, 2013; Leichsenring, Kruse, New, & Leweke, 2011; Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004). Looking at the symptom of suicidality, the mortality rate in BPD is significant, up to 10% (Paris & Zweig-Frank, 2001). In addition, a lifetime history of self-harm is seen in 47.6%-51.7% of BPD patients (Chapman, Specht, & Cellucci, 2005; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006) and a lifetime history of suicide attempts in 72.6% of BPD patients
(Soloff, Lis, Kelly, Cornelius, & Ulrich, 1994).BPD has a prevalence rate of 1% to 2.5% in the general population (Van Genderen, & Arntz, 2010; Trimbos instituut, 2016) and around 7.8% in adolescents ranging from the ages 11-21 (Lieb et al., 2004). BPD is a relatively heterogeneous disorder (Clarkin, Hull, & Hurt, 1993; Sanislow, et al., 2002). Patients need to meet five out of nine diagnostic criteria which means that two patients can have almost completely different manifestations of the disorder. In addition, there is also a lot of room for an increasing amount of symptoms (e.g., eight out of nine criteria; American Psychiatric Association, 2013), from which BPD patients can experience a lot of distress (Bateman & Fonagy, 1999). BPD patients place a high demand on mental health care, since they make extensive use of utilities (Bender, et al., 2001; Trull, Sher, Minks-Brown, Durbin, & Burr, 2000; Van Asselt, Dirksen, Arntz, & Severens, 2007). Fully understanding the individual differences could help decide which type of treatment is most beneficial for the patient in question (Fonagy & Luyten, 2016) and could possibly also provide pinpoints for treatment in the early stages of BPD, so that the high costs of treatment could be brought down. In
addition, being able to choose the most beneficial treatment for each individual instead of them going through multiple treatments without significant improvement, promotes their well-being.
In 1993, Linehan proposed a biosocial theory to explain the development of BPD. An extension on this theory was later created by Crowell, Beauchaine, and Linehan (2009). This biosocial theory proposes a model to explain the developmental pathways to BPD by
combining biological vulnerabilities and an emotionally invalidating environment. They discuss different factors in the environment, the two main factors being insecure attachment to caregivers and childhood trauma due to maltreatment. The model explains how these factors pave the way to BPD development in adolescence and onwards into adulthood,
4 namely by creating an emotionally invalidating environment which makes it difficult for a child to develop important capabilities like emotion regulation. A key characteristic of an invalidating environment is inconsistency in tolerance of the expression of and
communication about emotions by the caregivers. This results in emotion dysregulation in the child, because the child has not learned to properly recognize, understand, and modulate emotions, and this is an important feature of BPD (American Psychiatric Association, 2013; Clarkin, et al., 1993). If emotional maltreatment, inflicted by the child’s caregivers, occurs in an unsafe home environment, it is expected that it becomes hard for a secure attachment relationship to develop between the child and its caregiver. Riggs and Kaminski (2010) show that emotional maltreatment is a predictor for insecure attachment. Current research will build forward on these two precursors of BPD development: childhood trauma and insecure attachment.
Childhood Trauma
The first focus of the current study will lie on childhood trauma. This being an
important factor in BPD has been concluded in multiple studies (Herman, Perry, & Van Der Kolk, 1989; Larrivée, 2013). Childhood trauma, namely emotional abuse, emotional neglect, physical abuse, physical neglect, and sexual abuse, is seen in 70%-92% of BPD patients (Battle et al., 2004; Herman et al., 1989; Zanarini, Gunderson, Marino, Schwartz, & Frankenburg, 1989; Zanarini, Williams, Lewis, & Reich, 1997) and might have a causal relationship with BPD (Ball & Links, 2009). When looking at the consequences of
experiencing childhood trauma, a lot of resemblance can be found with symptoms of BPD, such as suicidality, substance abuse, low self-esteem, maladaptive sexual behaviour, depression, aggression against self or others, and emotion dysregulation (Ehring & Quack, 2010; Mullen, Martin, Anderson, Romans, & Herbison, 1996; Norman, Byambaa, De, Butchart, Scott, & Vos, 2012; Van Der Kolk, 1987; Widom, & White, 1997). Arntz (1994) described a cognitive hypothesis which includes an explanation for dichotomous, or black-and-white, thinking due to childhood trauma in BPD patients. This is a way of thinking in which people show a sudden change in evaluation of themselves and others around them, namely by idealization and devaluation. Dichotomous thinking is often seen in BPD patients (American Psychiatric Association, 2013). According to the cognitive hypothesis,
experiencing trauma in childhood could cause the development of cognitive capabilities to stagnate which would leave them underdeveloped. Therefore, as an adult, the BPD patient usually still thinks in a more childish, black-and-white manner (Arntz, 1994).
5 Taking childhood trauma into account as a contributor to BPD manifestation in
adulthood, current study will first focus on the association between the severity of childhood traumas a BPD patient has experienced and the severity of BPD. Looking at BPD severity could be important to get insight into which individual differences are associated with an increasing severity of manifestation. Zanarini and colleagues (2002) found that increasing severity of childhood trauma was associated with increasing BPD symptom severity in BPD inpatients. However, the main focus of this study was sexual abuse. Messina and Grella (2006) investigated the influence of accumulated childhood traumatic experiences, such as sexual abuse, physical abuse and neglect, and emotional abuse and neglect, on mental health. Even though the sample consisted only of incarcerated women, it gave more insight into the consequences of an increasing amount of traumatic experiences. The study showed that if the number of traumatic experiences increases, the number of women that needed mental health treatment or psychiatric medication increased as well. In addition, it showed that the number of women that were suicidal or experienced traumatic distress or substance abuse increased as the number of traumatic experiences increased. Another study that investigated the effect of accumulative childhood traumas on BPD specifically, found that as the number of traumas increased, so did the number of BPD traits measured by the Borderline Personality Disorder Scale (Herman et al., 1989). Physical abuse, sexual abuse, and witnessing serious domestic violence as forms of childhood trauma were taken into account. Concluding from these studies, increasing severity or an increasing number of childhood traumas could have an accumulative effect on BPD severity through number of symptoms or symptom severity.
Secondly, apart from the total severity of childhood trauma, current study will focus on the severity of different types of trauma. There is still a lack in knowledge about the effects of different types of trauma on BPD. In many studies, emotional abuse and emotional neglect are not taken into account, even though they might play an important factor in BPD
development. Crowell, Beauchaine, and Linehan (2009) proposed in their biosocial theory, that emotional trauma could potentially create an emotionally invalidating environment and insecure attachment, which in turn could lead to the development of BPD. In addition, it has been discussed in research that emotional maltreatment might be the most damaging type of trauma compared to physical and sexual maltreatment (Kaplan, Pelcovitz, & Labruna, 1999; Riggs, 2010). Neglect should also be taken into account as a form of trauma when studying childhood trauma and BPD, because it seems to have a big impact on someone’s
psychological development, especially in the development of BPD (Battle et al., 2004). Other studies that have taken multiple types of trauma into consideration, have found evidence that
6 BPD patients most commonly report emotional abuse and emotional neglect compared to the other types of trauma, e.g., physical abuse, and more than patients with other personality disorders (Kaplan et al., 1999; Rogosch & Cicchetti, 2005; Zanarini et al., 1997). The possible individual differences that could result from different types of trauma have hardly been studied in BPD patients. However, following Crowell, Beauchaine, and Linehan’s (2009) biosocial theory, it seems likely that children who grow up in an emotionally traumatizing environment will have an even bigger disadvantage at developing proper
mentalization and emotion-regulation than children in a physically traumatizing environment. This is suspected since the development of these capabilities is possibly less promoted by caregivers who cause emotional trauma for their children, for example by maternal withdrawal, which has been shown to be a factor in emotional neglect (Spertus, Yehuda,
Wong, Halligan, & Seremetis, 2003). The lack of mentalization and emotion-regulation capabilities is related to the development of BPD (Gratz, Tull, Baruch, Bornovalova, & Lejuez, 2008; see Fonagy & Luyten, 2016, for an overview of studies that implicate the influence of childhood maltreatment on mentalization). The second focus of this study will therefore lie on the different effects of emotional trauma (i.e., emotional abuse and emotional neglect) and physical trauma (i.e., physical abuse, physical neglect, and sexual abuse) on BPD severity. It is expected that emotional trauma will be associated with a higher severity of BPD than physical trauma. However, as Fonagy and Luyten (2016) showed, many BPD patients report both physical and emotional trauma. Therefore the co-occurrence of these two types of trauma will also be taken into account in the current study and it is expected that this will be associated with the highest severity of BPD.
Attachment
Besides childhood trauma, studies have also shown a clear association between attachment and BPD in adolescence and adulthood. In 1982, Bowlby founded the attachment theory, which describes the nature of the relationship between a child and its mother. During this relationship, a child develops certain interaction patterns. These patterns then become internalised and are called ‘internal working models’ (IWMs; Bowlby, 1988). When the attachment system is activated in situations where someone is in interaction with others, the IWMs are activated as well. They are used to anticipate and understand the other person’s behaviour and from there plan one’s own behaviour in that specific situation (Bretherton, 1990). Ainsworth (1978) further built on this theory by studying the variations in interactions between a child and its mother. She found specific secure and insecure interaction patterns
7 which she called ‘attachment classifications’. When a child is insecurely attached to its
caregivers, the IWMs tend to be dysfunctional or underdeveloped (Bretherton, 1990), which can cause problems in other attachment-related interactions. In adulthood, the attachment classifications are labelled secure-autonomous, dismissive, preoccupied, and unresolved attachment, the last three being insecure attachments (Levy, Ellison, Scott, & Bernecker, 2011; Van IJzendoorn, 1995). Adults that are securely-autonomous attached tend to be open minded towards the world and can talk about attachment-related experiences in a coherent and consistent way. Dismissive adults are usually very positive about their parents, but as they talk more about their childhood, contradictory statements start to occur. This means that more negative memories about their parents start to arise. This is due to them trying to distance themselves from attachment-related experiences (Van IJzendoorn, 1995).
Preoccupied adults show negative preoccupation with their caregivers and are not able to tell a coherent story about attachment-related experiences. Finally, unresolved attachment means that a person has experienced trauma such as abuse and loss and has not yet been able to resolve these experiences (Levy et al., 2011; Van IJzendoorn, 1995). Lyons-Ruth and Jacobvitz (2008) showed that disruptions in maternal communication, such as maternal withdrawal, are associated with unresolved attachment and this type of attachment is in turn associated with the development of BPD (Carlson, Egeland, & Sroufe, 2009; Juen, Arnold, Meissner, Nolte, & Buchheim, 2013; Van Genderen & Arntz, 2010). Levy and his colleagues (2011) compared different studies and found that the attachment of 32%-62% of BPD
patients was classified as unresolved regarding experiences of loss or trauma. In addition, Fonagy and colleagues (1996) found this percentage to be 89% in a sample of BPD patients.
In addition to the four classifications of adult attachment, Bowlby also introduced the concept of segregated systems (Bowlby, 1980) as an underlying factor to unresolved attachment (George & Solomon, 1996). He explains that a person who has an unresolved attachment classification has two principal systems. One of these systems governs daily life and the other is a, sometimes unconscious, segregated system. This second system contains the painful attachment-related memories from a person’s past. The segregated system is usually deactivated, because it benefits the person to not experience what lies inside. The person will then make sure that all sensory input that can activate the system is avoided. However, if the system does get activated, the behaviour that flows from it tends to be ill-organized and dysfunctional, creating problematic situations and interpersonal interactions. It results in the flooding of emotions related to the overwhelming experiences that the person had originally blocked from consciousness (Juen et al., 2013). Since unresolved attachment is
8 seen so often in BPD patients, segregated systems are too. The segregated systems can be ‘resolved’ or ‘unresolved’. Them being resolved means that the person has found a way to functionally cope with the segregated material that is activated by attachment-related stimuli. When unresolved, the ill-organized and dysfunctional behaviour occurs and this means that the attachment remains dysregulated (Juen et al., 2013).
Since the proportion of BPD patients being classified with unresolved attachment seems to be so significant, current study will focus on unresolved segregated systems in relation to BPD severity. It is suspected that more unresolved segregated systems are
associated with higher BPD severity. Gaining more insight in the impact of these unresolved segregated systems broadens our knowledge of individual differences in BPD patients and could therefore help determine the treatment which best fits each BPD patient.
Current study
The current study will try to answer three questions: (1) is the severity of childhood trauma experiences associated with BPD severity?; (2) can a different association be found between emotional trauma and BPD severity and physical trauma and BPD severity?; (3) is the number of unresolved segregated systems associated with BPD severity? In the first research question it is hypothesized that as the severity of childhood trauma experiences increases, BPD severity increases with it. The second research question comes with two hypotheses: (2a) emotional trauma is associated with a higher severity than physical trauma; (2b) having experienced both emotional and physical trauma will be associated with a higher BPD severity than emotional trauma. For the last research question it is hypothesized that as the number of unresolved segregated systems increases, so does BPD severity.
Method Participants
The study sample included a total of 15 participants who performed the Borderline Personality Disorder Severity Index IV (BPDSI-IV) and the Jeugd Trauma Vragenlijst (JTV). Of these 15 participants, 11 also performed the Adult Attachment Projective Picture System (AAP) and can therefore be used in analyses for the research question concerning unresolved segregated systems. Ages of the participants ranged from 21-47 (M = 31.2, SD = 9.24), most of the subjects were women (75%) and every participant has previously been diagnosed with BPD. Participants were recruited at the Viersprong Institute for Studies on Personality
9 Disorders, Duivendrecht. Participation was on voluntary basis, which means that participants did not receive compensation.
Inclusion and exclusion criteria were based on the larger research that this study is part of. This means that participants were recruited on the basis of these criteria, but not all are relevant to the current study. The first exclusion criteria were based on a few additional diagnoses, specifically a psychotic disorder (except when they have had short reactive psychotic episodes), bipolar I disorder (except when in full remission), antisocial personality disorder in the case that they displayed physical violence towards others in the past two years, and severe addiction for which clinical detoxification is necessary. Furthermore, participants with an IQ lower than 80 and no fixed home address have been excluded. Finally, exclusion from the study took place if participants had received Schema Therapy or Mentalization-Based Treatment in the previous year, or if their travel time to the location where they would receive treatment was longer than 45 minutes (unless they live in the same city). All
participants have been diagnosed with BPD, had Dutch literacy, and were able, and willing, to take part in (group) treatment for at least two years.
Procedure
Patients have been approached by their therapist to participate in the study. After they decided to participate, they signed an informed consent, agreeing to the terms of the study and to having read all the information. This way they also gave consent that their results are stored anonymously and used for research.
Screening has then been performed by a trained research assistant, working on location, with use of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) Axis I (SCID-I) and Structured Clinical Interview for DSM-IV Axis II (SCID-II), which determined which participants could be included in the study. With use of the BPDSI-IV the severity of each participant’s BPD manifestation was measured. The participant has also filled out the JTV to establish if they have experienced trauma in childhood and if so, which type of trauma. The AAP has been performed by the researcher of the current study after being trained to perform this particular interview. All interviews have been transcribed by the same researcher and the scoring of this interview has been done by the researcher from the larger project, who has received extensive training for this scoring process. The results of this test show how many (unresolved) segregated systems are present in each participant.
10 Data collection has lasted approximately 12 months, and analyses have been
conducted using IBM SPSS Statistics.
Materials
Severity of BPD symptoms. The BPDSI-IV is a semi-structured interview used to assess
the frequency and severity of BPD symptoms. The instrument contains 70 items, measuring the nine BPD dimensions as defined by the DSM-IV: (1) relationships, (2) impulsivity, (3) affective instability, (4) anger-control, (5) parasuicidal behavior, (6) identity disturbance, (7) feelings of emptiness, (8) fear of abandonment, and (9) dissociation and paranoid ideation (Arntz et al., 2003). It is the only instrument that uses multiple items per BPD criterion, based on the DSM-IV. Responses for all scales, except the identity disturbance scale, are coded on a 11-point scale ranging from never to daily. On the identity disturbance scale responses are coded on a 5-point scale ranging from absent to dominant and are then multiplied by 2.5. An increasing total score on the nine dimensions means a higher severity of BPD, with a cut-off score of 15 (Arntz et al., 2003). Research shows that the BPDSI-IV is a reliable and valid instrument and can therefore be used in clinical practice and research (Giesen-Bloo, Wachters, Schouten, & Arntz, 2010). Interrater reliability was found to be high for the BPDSI-IV with subscale scores ranging from 0.98-1.00 and individual item scores ranging from 0.75-1.00. Internal consistencies were high in a BPD group (α = 0.85). Looking at validity, the discriminant and concurrent and construct validity (rcorrected = 0.30) were found
to be sufficient (Giesen-Bloo et al., 2010). It can therefore be expected that scores on the BPDSI-IV by BPD patients are significantly higher than scores by non-BPD patients. In the current research, reliability of the BPDSI-IV has been found to be α = .98, which is extremely high. The BPDSI-IV is therefore a reliable instrument to use in the current study.
Childhood trauma. To measure maltreatment histories the JTV is used. The JTV is the
Dutch version of the Childhood Trauma Questionnaire (Arntz & Wessel, 1996; Bernstein & Fink, 1998). This 28-items questionnaire assesses childhood trauma on five factors: sexual abuse, physical abuse, emotional abuse, physical neglect, and emotional neglect. The
instrument also includes a validity scale, that measures denial, which consists of three items. Scores on these three questions are not to be taken into account when calculating the total score. Responses are measured on a 5-point Likert scale ranging from never true to very often
true. The denial scale is not scored in this continuous way, but instead very often true is
scored as 1 and any lower answer is scored as 0. Scores on this subscale therefore range from 0 to 3 (Bernstein & Fink, 1998). Thombs et al. (2009) found evidence of reliability and
11 validity for the Dutch version of the CTQ. Cronbach’s alpha for reliability was .91 for
physical abuse, .89 for emotional abuse, .95 for sexual abuse, .63 for physical neglect, and .91 for emotional neglect. Cronbach’s alpha for the entire measure was found to be .91 for the English version of the CTQ (Scher, Stein, Asmundson, McCreary, & Forde, 2001). Cronbach’s alpha in the current study was found to be .90, which makes the instrument reliable for use.
Segregated systems. The AAP interview is used to measure adult attachment
classifications and defensive exclusion. The instrument contains eight pictures (George & West, 2012). The first picture is a neutral, warm-up picture, followed by seven attachment-related scenes (four dyadic pictures and three monadic pictures). These attachment-attachment-related pictures activate the attachment system and in that way show someone’s internal working models. The interviewee will be asked to tell a story about each of the pictures in which they will have to tell what is going on in the picture, what led up to the scene, what the characters are thinking or feeling, and what will happen next. These narratives will then be transcribed and scored so that an attachment classification (i.e., secure, dismissive, preoccupied, or unresolved) can be concluded. In addition, the AAP looks at different forms of defensive exclusion, called segregated systems. Defensive exclusion is measured by the AAP on two forms of response content. The first one is dysregulation, which can be expressed during the telling of a story as (a) fear and failed protection, (b) helplessness, (c) emptiness, and (d) spectral, dysregulated thinking and obtrusions. The second form is constricted
immobilization, in which the participant shuts down while telling a story about a picture
(George & West, 2012). When comparing the AAP and AAI ratings, interrater reliability is found to be very high (κ = 0.86) and convergence between the two is 94% (Ravitz, Maunder, Hunter, Sthankiya, & Lancee, 2010). George and West (2001) investigated interrater
reliability between the different classification groups, which was found to be high (κ = 0.79). These results regarding the reliability and validity of the AAP show that this instrument can be used in the current study.
Data Analyses
Before conducting the data analyses to investigate the research questions, total scores on all measures were calculated per subscale and for the total measures. Preliminary analyses were then performed to check if assumptions for the analyses were met. The residuals of the outliers have been checked to see if they substantially influenced the results, which had been the case if they exceeded a value of 3 (STAT 501, 2017) and then they were to be removed.
12 In addition, a factor analysis has been performed to check if six subscales were found in the JTV data. Previous studies (Lundgren, Gerdner, & Lundqvist, 2002; Wright et al., 2001) found structural ambiguity in the CTQ (English version of the JTV) subscales, which means that items for certain subscales loaded on different factors in analysis, making the factor unstable. A study looking at female participants struggling with addiction found structural ambiguity for the physical neglect subscale of the CTQ (Lundgren, Gerdner, & Lundqvist, 2002). Another study found this same problem, but for the physical abuse subscale (Wright et al., 2001). In the current study, only factors with an eigenvalue larger than 1 were included (Field, 2013).
For the first research question a multiple hierarchical regression was used. This investigated if an increasing severity of childhood traumas on the JTV is associated with a higher BPD severity score on the BPDSI-IV, while controlling for the denial subscale of the JTV. The severity of childhood trauma was analyzed as a continuous variable. It was
expected that as the scores on the JTV increase, so would the scores on the BPDSI-IV. The JTV validity scale ‘denial’ has been considered as a possible covariate in this analysis, based on found correlations between denial and BPDSI-IV subscales in the current sample. Not much research has been conducted to study the effect of denial in childhood trauma, although questions have been raised about the effect of this factor (Briere, 1992; Hardt & Rutter, 2004). Therefore, in this study the possible role of denial was investigated in an explorative manner by adding it to the analysis of the first research question.
The second research question concerned the different associations between severity of physical trauma and emotional trauma and BPD severity, for which a hierarchical regression was supposed to be conducted. It was expected that higher scores on the emotional trauma dimension would have been associated with higher BPDSI-IV scores compared to the scores on the physical trauma dimension. Secondly, the group of participants who report both emotional and physical trauma were expected to be associated with the highest BPDSI-IV scores. Due to results from the factor analysis, described in the results paragraph below, analysis for this research question turned out to be impossible.
The third research question investigated the association between the number of stories with unresolved segregated systems and BPD severity. Current study looked at the number of stories, since the pictures used in the AAP are based on attachment-related events, which were derived from attachment theories (Juen et al., 2013). Therefore, these stories are specific attachment representations. A simple linear regression was used to investigate this research
13 question. It was expected that as the number of stories with unresolved segregated systems increases, so would the BPDSI-IV scores.
Results
First, descriptive statistics on all measures are presented in Table 1. All participants exceeded the cut-off score of 15 on the BPDSI-IV. In the study of Juen and colleagues (2013) a mean number of stories with unresolved segregated systems of around 1.8 was found. The mean number found in the current study was much lower (Table 1). A first interesting finding in the data was that every participant had reported having experienced childhood trauma.
Table 1.
Descriptive Statistics for Key Study Variables
Variables M SD Emotional Abuse 14.00 7.21 Emotional Neglect 12.80 5.73 Physical Abuse 11.53 4.50 Physical Neglect 8.93 4.28 Sexual Abuse 9.40 7.58 Denial 0.60 1.12 JTV Total 56.67 20.98 BPDSI-IV Total 30.33 17.62 Number of stories with unresolved SS 0.91 0.70
Note. BPDSI-IV = Borderline Personality Disorder Severity Index, Fourth Version; JTV = Jeugd Trauma Vragenlijst; SS = Segregated systems.
Secondly, preliminary analyses were conducted to investigate violation of the
assumptions. The analyses detected several outliers of more than three standard deviations of the mean score when inspecting the distribution of the scores. However, inspecting
standardized residuals revealed no values that exceeded 3, indicating the outliers had no negative effect on the reliability of the results. Therefore, it has been decided to include these values in the analyses.
14 In addition, in preliminary analyses, a factor analysis was conducted to check if the JTV measured six subscales in the current sample. It was found that there were only four significantly loaded factors (see Table 2). The scree plot (see Graph 1) shows a point of inflexion at the third component, which would mean that only the first two components are to be included. As can be seen in Table 2, the first four factors are included since they exceed an eigenvalue of 1. All factor loadings higher than .3 or lower than -.3 (Field, 2013) can be found in Appendix A. The first, most significantly loaded factor included JTV items from the three abuse scales (i.e., physical abuse, emotional abuse, and sexual abuse), but cross-loading can be seen with other factors, especially for sexual abuse. Most items of physical neglect also loaded on factor 1, though one item loaded on factor 2 and one item did not load on any of the four factors. The denial items showed most structural ambiguity as items loaded on multiple factors. Lastly, emotional neglect seemed to load strongest on factor 3, making it seem to be the most reliable factor. For current analyses this suggests that no distinction can be made between emotional trauma and physical trauma, since emotional abuse, physical abuse and sexual abuse all loaded on the same factor. The neglect subscales (i.e., physical neglect and emotional neglect) did not load on the same factor and physical neglect loaded partially on the same factor as the three abuse scales. Conclusion drawn from analyses using the four found factors would not provide reliable results and as a consequence, analyses for the second research question cannot be run.
Table 2.
Eigenvalues, Explained Variance and Rotation Sums of Squared Loadings Based on a
Principal Components Analysis with Oblique Rotation for the Jeugd Trauma Vragenlijst (N = 15).
Factor Eigenvalue % of Variance Rotation Sums of
Squared Loadings 1 17.06 60.9 16.0 2 5.04 18.0 6.9 3 1.83 6.5 6.4 4 1.16 4.2 3.4 Graph 1.
15
Scree Plot of Eigenvalues for Components Based on a Principal Components analysis with Oblique Rotation for the Jeugd Trauma Vragenlijst (N = 15).
A correlation matrix was derived from the data (see Appendix B) to investigate correlations between all total scales and subscales from the JTV, BPDSI-IV and AAP. The denial scale of the JTV was significantly, positively correlated with multiple BPDSI-IV subscales. This means that as participants scored high on the denial subscale, they also scored higher on multiple BPDSI-IV subscales. Therefore, it was decided to control for the denial subscale scores by including it in analysis used for hypothesis testing for the first research question.
This first research question investigated the association between reported trauma severity on the JTV and BPDSI-IV scores, using a multiple hierarchical regression analysis that controlled for reported denial. The denial subscale score was entered in step 1, explaining 48% of the variance in BPDSI-IV scores. After including the JTV total score at step 2, the total variance explained by the model as a whole was 83%, F(2,12) = 28.98, p < .001. This model that includes both measures explained an additional 35% of the variance in BPDSI-IV scores, F change = 24.11, p < .001. Participants who reported higher trauma severity, also reported higher BPDSI-IV scores, with b = .55, SE = .11, t(14) = 4.91, 95% CI[0.31, 0.84], p < .001.
Since analyses for the second research question could not be run, due to the before described results from the factor analysis, the third research question was investigated next. For this research question, regarding the association between number of stories with
-2 0 2 4 6 8 10 12 14 16 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 E ig enva lue Number of component
Scree Plot
16 unresolved segregated systems and BPDSI-IV scores, a simple linear regression was used. The association was just shy of significant, F(1, 9) = 4.60, p = .061. An effect size of f = .29 was found for analysis in the current sample, which is considered to be a small size (Field, 2013). Total explained variance for this model was 34%. Despite the small sample size, a trend is found in this association, which indicates the possibility that participants with a higher number of stories with unresolved segregated systems, score higher on the BPDSI-IV.
Discussion
Current study was a pilot study conducted to get more insight into individual
differences in BPD, focussing on childhood trauma and unresolved segregated systems. The association between childhood trauma, unresolved segregated systems and BPD severity was investigated. A first interesting finding in this study was that every participant (100%) reported having experienced trauma (e.g., emotional abuse, emotional neglect, physical abuse, physical neglect, and/or sexual abuse). Previous research showed that 70%-92% of BPD patients reported trauma (Battle et al., 2004; Herman et al., 1989; Zanarini, Gunderson, Marino, Schwartz, & Frankenburg, 1989; Zanarini, Williams, Lewis, & Reich, 1997), which means that rates in the current study were even higher. A possible explanation for this could be a higher mean BPD severity in the current sample and patients with more severe BPD reporting their traumatic experiences as more severe compared to patients with less severe BPD (Zanarini et al., 2002). The first research question focussed on the association between total reported childhood trauma severity and severity of BPD. It was found that a higher severity of childhood trauma was associated with higher BPD severity. This was in
concordance with the study conducted by Zanarini and colleagues (2002). This might suggest that trauma processing therapy could be very beneficial to reduce BPD symptom severity and accompanying distress for the BPD patient. This could in turn increase their well-being, participation in society and reduce their demands on health care.
However, when looking further into trauma it was found that the current sample did not seem to differentiate between the five trauma types. The participants in the current sample seemed to report physical abuse, emotional abuse, and sexual abuse as one construct, instead of different types. Physical neglect also seemed to partially be considered as this same construct. Emotional neglect was the only trauma type that could be specifically
distinguished from the other trauma types Therefore, no analyses could be run for the second research question which was focussed on the different association between emotional and physical trauma and BPD severity. The finding of structural ambiguity in the current sample
17 is in line with the results from the studies of Lundgren and colleagues (2002) and Wright and colleagues (2001). However, in those studies, structural ambiguity was found only for either physical abuse or physical neglect. In the current sample, cross-loadings were found for items of all trauma subscales, making it impossible to differentiate between the trauma types. It has been argued by Villano and colleagues (2004) that different types of trauma tend to occur simultaneously, which could possibly make it difficult for participants to differentiate between trauma types. In the current sample, 100% of participants reported having experienced trauma, and when looking at independent items it can be seen they reported multiple types of traumatic experiences. In future research, an interview to measure childhood trauma could possibly be used to reduce problems with distinguishing between trauma types, or give more insight into the concurrence of childhood trauma in BPD patients.
The final research question investigated the association between unresolved
segregated systems and BPD severity, where it was hypothesized that BPD severity would increase as the number of unresolved segregated systems increased. The results showed a positive trend in the association between the number of unresolved segregated systems and BPD severity. This was expected since unresolved segregated systems underlie the
unresolved attachment classification (Bowlby, 1980) and this classification seems very common in BPD patients (Fonagy et al., 1996). The study conducted by Juen and colleagues (2013) found that BPD patients present a lot of stories with unresolved segregated systems when compared to other disorders. Since the AAP is a relatively new measure, no previous research has been conducted to investigate the association between unresolved segregated systems and BPD severity. Current pilot study was the first of its kind and the trend shown in the results is promising for an association between unresolved segregated systems and BPD severity. This seems to call for more extensive research on the matter. Gaining more insight in the association between (unresolved) segregated systems and BPD severity could provide more information about individual differences. Having this information could be used to choose the most beneficial treatment for every BPD patient, since it could possibly point towards treatment focussing on limited reparenting or on trauma processing.
Lastly, the denial scale was added to the current analyses in an explorative manner. An association was found between denial and BPD severity, which indicates that as someone is more in denial, BPD severity increases. Questions have been raised in previous research (Briere, 1992; Hardt & Rutter, 2004) about the role this specific JTV subscale plays in analyses. Results in the current study indicate a possible association between denial and BPD severity, where denial seems to play a damaging role, since it is associated with a higher
18 severity of BPD symptoms. If a patient scores high on the denial scale, this could determine if treatment will improve their well-being, because it could possibly mean that there’s more lying in the unconsciousness of the patients mind (e.g. trauma). More research is necessary to examine the specific role of denial in BPD manifestation and the influence of denial on treatment outcome.
The current study had a few limitations, mainly the small sample size. The aimed sample size was 26 participants to detect a large effect size (ƒ = .40) with the necessary power of .80. Unfortunately, due to unforeseen delays in data collection, this sample size could not be reached. The first two research questions, focussing on childhood trauma and BPD severity, have been investigated with a sample size of 15 participants. The last research question, investigating the association between unresolved segregated systems and BPD severity, was performed with only 11 participants. As a consequence, the results of the current study cannot be generalized. However, findings for the first research question are in line with previous research. Results for the third research question are promising and indicate a need for more extensive studying of unresolved segregated systems.
A second limitation of the current study is focussed around the use of the JTV. Results of the current study showed no distinction between different types of trauma on the JTV measure. This could be due to the measure being based on self-reported traumatic memories. As mentioned earlier, a possible explanation for this could be that different types of trauma tend to occur simultaneously, which would make it difficult for participants to differentiate between different types of trauma. In addition, Grover and colleagues (2007) argued in their study on the association between childhood abuse and personality disorder symptoms, that a retrospective measure, such as the JTV, is susceptible to subjectivity of the participants. Therefore, the results are dependent on the interpretation of the participants on the abuse and neglect. In retrospect, they could therefore recall the trauma as more severe or as it being both, for example, emotionally traumatizing and physically traumatizing. A possible solution for this problem is a trauma measure where an interviewer scores the participants traumatic memories instead of it being a self-report questionnaire, such as the Childhood Trauma Interview (Fink, Bernstein, Handelsman, Foote, & Lovejoy, 1995).
Finally, the cross-sectional design of this study has been used to detect correlations. A recommendation for future research would be a longitudinal design with a larger sample size to investigate possible causal relationships between childhood trauma, unresolved segregated systems, and BPD severity.
19 To conclude, more severe childhood trauma seems to be associated with higher BPD severity. This conclusion emphasizes the importance of trauma processing in BPD treatment. It could also indicate that early detection of childhood traumatic experiences and treating them early on, could prevent an increasing severity of BPD symptoms. Further research investigating the causal relationship between trauma and BPD severity is necessary to draw more specific conclusions. Unfortunately, the associations of different types of trauma and BPD severity could not have been investigated since the current sample did not differentiate between trauma types. In addition, more knowledge about unresolved segregated systems in relation to BPD severity has been acquired, although more research is necessary to draw more specific and generalizable conclusions.
References
Agrawal, H. R., Gunderson, J., Holmes, B. M., & Lyons-Ruth, K. (2004). Attachment studies with borderline patients: A review. Harvard review of psychiatry, 12(2), 94-104. doi: 10.1080/10673220490447218
Ainsworth, M. D. S. (1978). Patterns of attachment: A psychological study of the strange
situation. Hillsdale, NJ; Lawrence Erlbaum Associates, NY.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (DSM-5®). American Psychiatric Pub.
Arntz, A. (1994). Treatment of Borderline Personality Disorder: A challenge for cognitive-behavioural therapy. Behaviour Research and Therapy, 32(4), 419-430. doi:
10.1016/0005-7967(94)90005-1
Arntz, A., van den Hoorn, M., Cornelis, J., Verheul, R., van den Bosch, W. M., & de Bie, A. J. (2003). Reliability and validity of the borderline personality disorder severity
index. Journal of personality disorders, 17(1), 45-59. doi: 10.1521/pedi.17.1.45.24053 Arntz, A., & Wessel, I. (1996). Jeugd trauma vragenlijst [Dutch version of the childhood
trauma questionnaire]. The Netherlands.
Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2009). The first 10,000 Adult Attachment Interviews: Distributions of adult attachment representations in clinical and non-clinical groups. Attachment & human development, 11(3), 223-263. doi:
10.1080/14616730902814762
Ball, J. S., & Links, P. S. (2009). Borderline personality disorder and childhood trauma: evidence for a causal association. Current psychiatry reports, 11(1), 63-68. doi: 10.1007/s11920-009-0010-4
20 Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of
borderline personality disorder: a randomized controlled trial. American journal of
Psychiatry, 156(10), 1563-1569. doi: 10.1176/ajp.156.10.1563
Battle, C. L., Shea, M. T., Johnson, D. M., Zlotnick, C., Zanarini, M. C., Sanislow, C. A., Skodol, A. E., Gunderson, J. G., Grilo, C. M., McGlashan, T. H., & Morey, L. C. (2004). Childhood maltreatment associated with adult personality disorders: findings from the Collaborative Longitudinal Personality Disorders Study. Journal of
personality Disorders, 18(2), 193-211. doi: 10.1521/pedi.18.2.193.32777
Bender, D. S., Dolan, R. T., Skodol, A. E., Sanislow, C. A., Dyck, I. R., McGlashan, T. H., Shea, M. T., Zanarini, M. C., Oldham, J. M., & Gunderson, J. G. (2001). Treatment utilization by patients with personality disorders. American Journal of
psychiatry, 158(2), 295-302. doi: 10.1176/appi.ajp.158.2.295
Bernstein, D., & Fink, L. (1998). Childhood Trauma Questionnaire: A retrospective
self-report. Manual. San Antonio, TX: The Psychological Corporation.
Bowlby, J. (1980). Loss: Sadness and depression (Vol. 3). Basic Books.
Bowlby, J. (1988). A secure base: parent-child attachment and healthy human development. Basic Books.
Bretherton, I. (1990). Communication patterns, internal working models, and the intergenerational transmission of attachment relationships. Infant mental health
Journal, 11(3), 237-252.
Briere, J. (1992). Methodological issues in the study of sexual abuse effects. Journal of
consulting and clinical psychology, 60(2), 196.
Briere, J., Kaltman, S., & Green, B. L. (2008). Accumulated childhood trauma and symptom complexity. Journal of traumatic stress, 21(2), 223-226. doi: 10.1002/jts.20317
Burns, E. E., Jackson, J. L., & Harding, H. G. (2010). Child maltreatment, emotion regulation, and posttraumatic stress: The impact of emotional abuse. Journal of
Aggression, Maltreatment & Trauma, 19(8), 801-819. doi:
10.1080/10926771.2010.522947
Carlson, E. A., Egeland, B., & Sroufe, L. A. (2009). A prospective investigation of the development of borderline personality symptoms. Development and
psychopathology, 21(04), 1311-1334. doi: 10.1017/S0954579409990174
Chapman, A. L., Specht, M. W., & Cellucci, T. (2005). Borderline personality disorder and deliberate self-harm: does experiential avoidance play a role?. Suicide and
21 Clarkin, J. F., Hull, J. W., & Hurt, S. W. (1993). Factor structure of borderline personality
disorder criteria. Journal of Personality Disorders, 7(2), 137-143.
Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality: Elaborating and extending linehan’s theory.
Psychological bulletin, 135(3), 495-510. doi: 10.1037/a0015616
Ehring, T., & Quack, D. (2010). Emotion regulation difficulties in trauma survivors: The role of trauma type and PTSD symptom severity. Behavior therapy, 41(4), 587-598. doi: 10.1016/j.beth.2010.04.004
Field, A. (2013). Discovering statistics using IBM SPSS statistics. Sage.
Fink, L. A., Bernstein, D., Handelsman, L., Foote, J., & Lovejoy, M. (1995). Initial reliability and validity of the Childhood Trauma Interview: A new multidimensional measure of childhood interpersonal trauma. American Journal of Psychiatry, 152(9), 1329-1335. First, M. B., Gibbon, M., Spitzer, R. L., Benjamin, L. S., & Williams, J. B. (1997). Structured
clinical interview for DSM-IV axis II personality disorders: SCID-II. American
Psychiatric Pub.
Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G., Target, M., & Gerber, A. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of consulting and clinical psychology, 64(1), 22-31. Fonagy, P., & Luyten, P. (2016). A multilevel perspective on the development of borderline
personality disorder. Developmental psychopathology. 727-792.
George, C., & Solomon, J. (1996). Representational models of associations: Links between caregiving and attachment. Infant Mental Health Journal, 17(3), 198-216. doi: 10.1002/(SICI)1097-0355(199623)17:3<198::AID-IMHJ2>3.0.CO;2-L
George, C., & West, M. L. (2001). The development and preliminary validation of a new measure of adult attachment: The Adult Attachment Projective. Attachment & human
development, 3(1), 30-61. doi: 10.1080/14616730010024771
George, C., & West, M. L. (2012). The Adult Attachment Projective Picture System:
attachment theory and assessment in adults. Guilford Press.
Giesen-Bloo, J. H., Wachters, L. M., Schouten, E., & Arntz, A. (2010). The borderline personality disorder severity index-IV: psychometric evaluation and dimensional structure. Personality and Individual Differences, 49(2), 136-141. doi: 10.1016 Gratz, K. L., Tull, M. T., Baruch, D. E., Bornovalova, M. A., & Lejuez, C. W. (2008).
Factors associated with co-occurring borderline personality disorder among inner-city substance users: The roles of childhood maltreatment, negative affect
22 intensity/reactivity, and emotion dysregulation. Comprehensive psychiatry, 49(6), 603-615. doi: 10.1016/j.comppsych.2008.04.005
Grover, K. E., Carpenter, L. L., Price, L. H., Gagne, G. G., Mello, A. F., Mello, M. F., & Tyrka, A. R. (2007). The relationship between childhood abuse and adult personality disorder symptoms. Journal of personality disorders, 21(4), 442-447. doi:
10.1521/pedi.2007.21.4.442
Herman, J. L., Perry, C., & Van der Kolk, B. A. (1989). Childhood trauma in borderline personality disorder. The American journal of psychiatry, 146(4), 490-495. doi: 10.1176/ajp.146.4.490
Hilderson, K. M. I., Germans, S., Rijnders, C. T., van Heck, G. L., & Hodiamont, P. P. G. (2011). Is de SCID-II persoonlijkheidsvragenlijst bruikbaar als
screeningsinstrument?. Psychopraktijk, 3(2), 32-36. doi: 10.1007/s13170-011-0027-3 Juen, F., Arnold, L., Meissner, D., Nolte, T., & Buchheim, A. (2013). Attachment
Disorganization in Different Clinical Groups: What Underpins Unresolved Attachment? Psihologija, 46 (2), 127-141. doi: 10.2298/PSI1302127J
Kaplan, S. J., Pelcovitz, D., & Labruna, V. (1999). Child and adolescent abuse and neglect research: A review of the past 10 years. Part I: Physical and emotional abuse and neglect. Journal of the American Academy of Child & Adolescent Psychiatry, 38(10), 1214-1222. doi: 10.1097/00004583-199910000-00009
Kernberg, P. F., Weiner, A. S., & Bardenstein, K. K. (2000). Personality Disorders in Children and Adolescents. New York: Basic Books.
Larrivée, M. P. (2013). Borderline personality disorder in adolescents: the He-who-must-not-be-named of psychiatry. Dialogues in clinical neuroscience, 15(2), 171-179.
Leichsenring, F., Leibing, E., Kruse, J., New, A. S., & Leweke, F. (2011). Borderline personality disorder. The Lancet, 377(9759), 74-84. doi:
10.1016/S0140-6736(10)61422-5
Levy, K. N., Ellison, W. D., Scott, L. N., & Bernecker, S. L. (2011). Attachment style. Journal of clinical psychology, 67(2), 193-203. doi: 10.1002/jclp.20756
Lewinsohn, P. M., Rohde, P., Seeley, J. R., & Klein, D. N. (1997). Axis II psychopathology as a function of Axis I disorders in childhood and adolescence. Journal of the American
Academy of Child & Adolescent Psychiatry, 36(12), 1752-1759. doi:
23 Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, M. (2004). Borderline
personality disorder. The Lancet, 364(9432), 453-461. doi: 10.1016/S0140-6736(04)16770-6
Lobbestael, J., Leurgans, M., & Arntz, A. (2011). Inter‐rater reliability of the Structured Clinical Interview for DSM‐IV Axis I disorders (SCID I) and Axis II disorders (SCID II). Clinical psychology & psychotherapy, 18(1), 75-79. doi: 10.1002/cpp.693
Lundgren, K., Gerdner, A., & Lundqvist, L. O. (2002). Childhood abuse and neglect in severely dependent female addicts: Homogeneity and reliability of a Swedish version of the childhood trauma questionnaire. International Journal of Social Welfare, 11(3), 219-227. doi: 10.1111/1468-2397.00219
Lyons-Ruth, K., Bureau, J. F., Holmes, B., Easterbrooks, A., & Brooks, N. H. (2013). Borderline symptoms and suicidality/self-injury in late adolescence: prospectively observed association correlates in infancy and childhood. Psychiatry Research, 206(2), 273-281. doi: 10.1016/j.psychres.2012.09.030
Lyons-Ruth, K., & Jacobvitz, D. (2008). Attachment disorganization: Genetic factors, parenting contexts, and developmental transformation from infancy to adulthood.
Handbook of Attachment, 666-697.
Maffei, C., Fossati, A., Agostoni, I., Barraco, A., Bagnato, M., Namia, C., Novella, L., & Petrachi, M. (1997). Interrater reliability and internal consistency of the structured clinical interview for DSM-IV axis II personality disorders (SCID-II), version
2.0. Journal of personality disorders, 11(3), 279-284. doi: 10.1521/pedi.1997.11.3.279 Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A
move to the level of representation. Monographs of the society for research in child
development, 66-104. doi: 10.2307/3333827
Messina, N., & Grella, C. (2006). Childhood trauma and women's health outcomes in a California prison population. American journal of public health, 96(10), 1842-1848. doi: 10.2105/AJPH.2005.082016
Miller, A. L., Muehlenkamp, J. J., & Jacobson, C. M. (2008). Fact or fiction: Diagnosing borderline personality disorder in adolescents. Clinical psychology review, 28(6), 969-981. doi: 10.1016/j.cpr.2008.02.004
Mullen, P. E., Martin, J. L., Anderson, J. C., Romans, S. E., & Herbison, G. P. (1996). The long-term impact of the physical, emotional, and sexual abuse of children: A
community study. Child abuse & neglect, 20(1), 7-21. doi: 10.1016/0145-2134(95)00112-3
24 Nock, M. K., Joiner, T. E., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006).
Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry research, 144(1), 65-72. doi:
10.1016/j.psychres.2006.05.010
Norman, R. E., Byambaa, M., De, R., Butchart, A., Scott, J., & Vos, T. (2012). The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med, 9(11), 1-31. doi: 10.1371/journal.pmed.1001349 Paris, J., & Zweig-Frank, H. (2001). A 27-year follow-up of patients with borderline
personality disorder. Comprehensive psychiatry, 42(6), 482-487. doi: Paris, J., & Zweig-Frank, H. (2001). A 27-year follow-up of patients with borderline personality disorder. Comprehensive psychiatry, 42(6), 482-487. doi: 10.1053/comp.2001.26271 Ravitz, P., Maunder, R., Hunter, J., Sthankiya, B., & Lancee, W. (2010). Adult attachment measures: A 25-year review. Journal of psychosomatic research, 69(4), 419-432. doi: 10.1016/j.jpsychores.2009.08.006
Riggs, S. A. (2010). Childhood emotional abuse and the attachment system across the life cycle: What theory and research tell us. Journal of Aggression, Maltreatment &
Trauma, 19(1), 5-51. doi: 10.1080/10926770903475968
Riggs, S. A., & Kaminski, P. (2010). Childhood emotional abuse, adult attachment, and depression as predictors of relational adjustment and psychological aggression. Journal
of aggression, maltreatment & trauma, 19(1), 75-104. doi:
10.1080/10926770903475976
Rogosch, F. A., & Cicchetti, D. (2005). Child maltreatment, attention networks, and potential precursors to borderline personality disorder. Development and
Psychopathology, 17(04), 1071-1089. doi: 10.1017/S0954579405050509
Sanislow, C. A., Grilo, C. M., Morey, L. C., Bender, D. S., Skodol, A. E., Gunderson, J. G., Shea, M. T., Stout, R. L., Zanarini, M. C., & McGlashan, T. H. (2002). Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: findings from the collaborative longitudinal personality disorders study. American Journal of
Psychiatry, 159(2), 284-290. doi: 10.1176/appi.ajp.159.2.284
Scher, C. D., Stein, M. B., Asmundson, G. J., McCreary, D. R., & Forde, D. R. (2001). The childhood trauma questionnaire in a community sample: psychometric properties and normative data. Journal of traumatic stress, 14(4), 843-857. doi:
25 Soloff, P. H., Lis, J. A., Kelly, T., Cornelius, J., & Ulrich, R. (1994). Risk factors for suicidal
behavior in borderline personality disorder. American Journal of Psychiatry, 151(9), 1316-1323. doi: 10.1176/ajp.151.9.1316
Spertus, I. L., Yehuda, R., Wong, C. M., Halligan, S., & Seremetis, S. V. (2003). Childhood emotional abuse and neglect as predictors of psychological and physical symptoms in women presenting to a primary care practice. Child abuse & neglect, 27(11), 1247-1258. doi: 10.1016/j.chiabu.2003.05.001
Spitzer, R. L., First, M. B., Gibbon, M., & Williams, J. B. (1990). Structured clinical
interview for DSM-III-R. American Psychiatric Press.
STAT 501 (2017). https://onlinecourses.science.psu.edu/stat501/node/339. The Pennsylvania State University.
Thombs, B. D., Bernstein, D. P., Lobbestael, J., & Arntz, A. (2009). A validation study of the Dutch Childhood Trauma Questionnaire-Short Form: factor structure, reliability, and known-groups validity. Child abuse & neglect, 33(8), 518-523.
Trimbos Instituut (2016): https://www.trimbos.nl/actueel/nieuws/bericht/?bericht=2086
Trull, T. J., Sher, K. J., Minks-Brown, C., Durbin, J., & Burr, R. (2000). Borderline personality disorder and substance use disorders: A review and integration. Clinical
psychology review, 20(2), 235-253. doi: 10.1016/S0272-7358(99)00028-8
Van Asselt, A. D. I., Dirksen, C. D., Arntz, A., & Severens, J. L. (2007). The cost of borderline personality disorder: societal cost of illness in BPD-patients. European
Psychiatry, 22(6), 354-361. doi: 10.1016/j.eurpsy.2007.04.001
Van Der Kolk, B. A. (1987). The psychological consequences of overwhelming life experiences. Psychological trauma, 1-30.
Van Genderen, H., & Arntz, A. (2010). Schematherapie bij Borderline
Persoonlijkheidsstoornis. Uitgeverij Nieuwezijds.
Van IJzendoorn, M. H. (1995). Adult attachment representations, parental responsiveness, and infant attachment: A meta-analysis on the predictive validity of the Adult Attachment Interview. Psychological bulletin, 117(3), 387-403. doi: 10.1037/0033-2909.117.3.387
Villano, C. L., Cleland, C., Rosenblum, A., Fong, C., Nuttbrock, L., Marthol, M., & Wallace, J. (2004). Psychometric utility of the Childhood Trauma Questionnaire with female street-based sex workers. Journal of trauma & dissociation, 5(3), 33-41. doi: 10.1300/J229v05n03_03
26 Waters, E., Merrick, S., Treboux, D., Crowell, J., & Albersheim, L. (2000). Attachment
security in infancy and early adulthood: A twenty‐year longitudinal study. Child
development, 71(3), 684-689.
Widom, C. S., & White, H. R. (1997). Problem behaviours in abused and neglected children grown up: prevalence and co‐occurrence of substance abuse, crime and
violence. Criminal behaviour and mental health, 7(4), 287-310. doi: 10.1002/cbm.191 Wright, K. D., Asmundson, G. J., McCreary, D. R., Scher, C., Hami, S., & Stein, M. B.
(2001). Factorial validity of the Childhood Trauma Questionnaire in men and women. Depression and anxiety, 13(4), 179-183. doi: 10.1002/da.1034
Zanarini, M. C., Gunderson, J. G., Marino, M. F., Schwartz, E. O., & Frankenburg, F. R. (1989). Childhood experiences of borderline patients. Comprehensive psychiatry, 30(1), 18-25. doi: 10.1016/0010-440X(89)90114-4
Zanarini, M. C., Williams, A. A., Lewis, R. E., & Reich, R. B. (1997). Reported pathological childhood experiences associated with the development of borderline personality disorder. The American journal of psychiatry, 154(8), 1101-1106. doi:
10.1176/ajp.154.8.1101
Zanarini, M. C., Yong, L., Frankenburg, F. R., Hennen, J., Reich, D. B., Marino, M. F., & Vujanovic, A. A. (2002). Severity of reported childhood sexual abuse and its
relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients. The Journal of nervous and mental disease, 190(6), 381-387.
27 Appendix A
Factor Loadings of Principal Components Analysis with Oblique Rotation for the 28 Items of the Jeugd Trauma Vragenlijst (N = 15)
1 2 3 4
Physical Abuse
Ben ik door iemand uit mijn gezin zo hard geslagen dat ik naar een dokter of naar het ziekenhuis moest
.961 -.412
Ben ik zo hard geslagen door mensen in mijn gezin dat ik er blauwe plekken of littekens aan overhield
.948 -.420
Ben ik gestraft met een riem, een plank, een touw, of een ander hard voorwerp
.974 -.407
Geloof ik lichamelijk mishandeld te zijn geweest .930 -.462 .545
Ben ik zou hard geslagen dat het opgemerkt werd door iemand zoals een leraar, een van de buren, of een dokter
.930 -.456 -.587
Physical Neglect
Moest ik vieze kleren dragen .974 -.407
Had ik niet voldoende te eten .972 -.340
Was er iemand die me naar de dokter bracht als dat nodig was
-.696
Waren mijn ouders te dronken of stoned (onder invloed van drugs) om voor het gezin te zorgen
.961 -.386
Wist ik dat er iemand was om voor me te zorgen en me te beschermen
.902
Sexual Abuse
Dreigde iemand me pijn te doen of leugens over me te vertellen als ik niet iets seksueels met ze deed
.930 -.456 .587
Ben ik door iemand gemolesteerd .894 -.322 .598
Probeerde iemand mij op een seksuele manier te betasten, of mij ertoe te brengen hem of haar te betasten
.910 -.310 .602
Wilde iemand mij seksuele dingen laten doen of naar seksuele dingen laten kijken
.905 -.601
Geloof ik seksueel misbruikt te zijn geweest .905 .601
28 Had ik het gevoel dat mijn ouders wensten dat ik nooit
geboren was
.797
Zeiden mensen in mijn gezin kwetsende of beledigende dingen tegen me
.762 -.574
Noemden mensen in mijn gezin mij dingen als “dom”, “lui” of “lelijk”
.738 -.547
Had ik het gevoel dat iemand in mijn gezin me haatte .667 -.719
Geloof ik emotioneel mishandeld te zijn .676 -.703
Emotional Neglect
Was er iemand in mijn gezin die me het gevoel gaf dat ik belangrijk en bijzonder was
-.314 .872 -.337
Kwamen mijn gezinsleden voor elkaar op -.626 .506 .467 -.588
Had ik het gevoel dat er van me gehouden werd .904 -.378 -.526
Voelden de leden van mijn gezin zich met elkaar verbonden
-.315 .671 -.764 -.532
Was mijn gezin een bron van kracht en ondersteuning -.421 .750 -.689 -.303
Denial
Had ik de perfecte jeugd -.594 .609 .816
Groeide ik op in het best denkbare gezin -.457 .650 .715
29 Appendix B
Correlation Matrix for Key Study Variables
* Correlation is significant at the 0.05 level (2-tailed). ** Correlation is significant at the 0.01 level (2-tailed). Variables Emotional abuse Emotional neglect Physical abuse Physical neglect Sexual abuse Denial BPDSI-IV Total Score Abandon-ment Subscale Relation-ships Subscale Emotional Abuse 1 Emotional Neglect .593 1 Physical Abuse .724 ** -.541 * 1 Physical Neglect .761 ** -.355 .906 ** 1 Sexual Abuse .716 ** -.465 .945 ** .945 ** 1 Denial .389 .680 ** .696 ** .544 * .676 * 1 BPDSI-IV Total Score .724 ** -.394 .847 ** .883 ** .915 ** -.600 * 1 Abandonme nt Subscale .284 -.559 * .590 * .644 ** .663 ** .490 * .747 ** 1 Relationship s Subscale .755 ** -.256 .802 ** .916 ** .922 ** .581* .936 ** .670 ** 1 Identity Subscale .578 * -.062 .549 * .657 ** .703 ** .344 -.824 ** .586 * .837 ** Impulsivity Subscale .708 ** -.373 .849 ** .924 ** .935 ** .659 ** .910 ** .633 * .895 ** Parasuicidali ty Subscale .679 ** -.572 * .957 ** .897 ** .949 ** .789 ** .929 ** .658 ** .843 ** Affect Subscale .374 -.123 .277 .361 .360 .481 .656 ** .580 * .550 * Anger Subscale .291 -.377 .478 .273 .276 .400 .393 .198 .140 Emptiness Subscale .711 ** -.177 .677 ** .792 ** .829 ** .534* .872 ** .516 * .898 ** Dissociation Subscale .754 ** -.427 .937 ** .910 ** .964 ** .687 ** .953 ** .691 ** .899 ** Unresolved Segregated Systems .246 .138 .681* -.242 -.059 .043 -.551 -.640* -.280
30 Variable Identity Subscale Impulsivity Subscale Parasuicidality Subscale Affect Subscale Anger Subscale Emptiness Subscale Dissociation Subscale Unresolved Segregated Systems Emotional abuse .578 * .708 ** .679 ** .374 .291 .711 ** .754 ** X Emotional neglect -.062 -.373 -.572 * -.123 -.377 -.177 -.427 X Physical abuse .549 * .849 ** .957 ** .277 .478 .677 ** .937 ** X Physical neglect .657 ** .924 ** .897 ** .361 .273 .792 ** .910 ** X Sexual abuse .703 ** .935 ** .949 ** .360 .276 .829 ** .964 ** X Denial .344 .659 ** .789 ** .481 .400 .534 * .687 ** X BPDSI-IV total score .824 ** .910 ** .929 ** .656 ** .393 .872 ** .953 ** X Abandonment subscale .586 * .633 * .658 ** .580 * .198 .516 * .691 ** X Relationships subscale .837 ** .895 ** .843 ** .550 * .140 .898 ** .899 ** X Identity subscale 1 .693 ** .652 ** .592 * .130 .730 ** .759 ** -.463 Impulsivity subscale 1 .915 ** .387 .304 .825 ** .919 ** -.366 Parasuicidality subscale 1 .437 .486 .754 ** .964 ** -.398 Affect subscale 1 .113 .554 * .481 -.497 Anger subscale 1 .140 .392 -.263 Emptiness subscale 1 .784 ** -.167 Dissociation subscale 1 -.365 Unresolved Segregated Systems 1
* Correlation is significant at the 0.05 level (2-tailed). ** Correlation is significant at the 0.01 level (2-tailed).
