Childhood
Sexual and Physical Abuse in Adult With Borderline Personality Disorder
Susan Naomi
N. Ogata, Ph.D., Kenneth R. Silk, M.D., Sonya Goodrich, Ph.D., E. Lohr, Ph.D., Drew Westen, Ph.D., and Elizabeth M. Hill, Ph.D.
Experiences ofabuse and neglect were assessed in 24 adults diagnosed as having borderline personality disorder according to the Diagnostic Interview for Borderline Patients and in 1 8 depressed control subjects without borderline disorder. Significantly more of the borderline patients than depressed patients reported childhood sexual abuse, abuse by more than one person, and both sexual and physical abuse. There were no between-group differences for rates of neglect or physical abuse without sexual abuse. A stepwise logistic regression revealed that derealization, diagnostic group, and chronic dysphoria were the best predictors of childhood sexual abuse in this group of patients. (Am J Psychiatry 1990; 147:1008-1013)
T
his study explores childhood abuse in adult patients with borderline personality disorder. Experiences in early childhood are viewed as important in contributing to borderline pathology (1-4). Stone (2) and Zananini et al. (3) cited a high prevalence of childhood abuse histories in borderline patients. Herman and van der Kolk (1) noted that the symptoms of traumatically
abused
individuals
are
similar
to
those
of
patients with borderline personality disorder. Surveys of childhood abuse reveal that the rates of a history of sexual and physical abuse may be as high as 57% in inpatients and 33% in nonclinical populations (1, 5-8). Caution is advised in interpreting these estimates, however, because methods of study and definitions of abuse differ across studies. Demographic profiles indicate that abuse occurs across economic, religious, and racial backgrounds (5, 9, 10). Although both sexes are probably at equal risk for physical
Presented
in part
Psychiatric
at the
Association,
141st
annual
Montreal,
4, 1989; revision received Jan. From the Personality Disorders sion, Department of Psychiatry, University of Michigan, Silk, UH-9C-9150 Box
Ann 0120,
May
meeting 7-12,
of the American
1988.
Received
April
24, 1990; accepted March 1, 1990. Program and the Biometrics Diviand the Department of Psychology, Arbor. 1500
Address reprint requests to Dr. East Medical Center Drive, Ann
Arbor, MI 48109-0120. The
Joel
authors
Nigg,
Copyright
1008
thank
Tom
TenHave,
Mark
P. Becker,
A.C.S.W. © 1990
Patients
American
Psychiatric
Association.
Ph.D.,
and
abuse, risks for sexual abuse are estimated to be approximately one in three for females and one in ten for males (1 1, 12). Victims of physical abuse are usually preschoolers or adolescents, but sexual abuse usually begins before puberty (7, 10). Sexual abuse generally ends in mid-adolescence because the child tells someone about it, runs away, refuses to continue, or gets pregnant (13). Most abuse, both physical and sexual, is perpetrated by male relatives of the victims (7, 9). The initial effects of sexual abuse include fear, anxiety, depression, guilt, anger, hostility, and inappropniate sexual behaviors (6, 10, 14-17). Long-term sequelae
include
impulsivity,
self-blame,
suicidal
be-
havior, anxiety, feelings of isolation, poor self-esteem, substance abuse, sexual problems, and lack of trust in interpersonal relationships (5, 6, 8, 15). Victims of sexual abuse may direct their negative feelings against themselves, resulting in depression and self-destructive acts such as cutting, burning, and suicide attempts (12, 18). Similar symptoms are often seen in borderline patients (DSM-III-R). Studies have found that female patients who had been sexually or physically victimized as children were more likely to be given a borderline diagnosis than those who had not been so victimized (16, 19). Herman et al. (20), Stone (2), and Zanarini et al. (3) found that many borderline outpatients and inpatients had a history of abuse during childhood. Westen et al. (21) found physical and/or sexual abuse documented in more than 50% of the charts of 27 inpatient adolescents with borderline personality disorder. Although sexual and physical abuse are not likely to be solely responsible for borderline pathology, they may be highly influential etiological factors. In this study we will explore two questions related to abuse: 1) Have borderline patients experienced a greater incidence of physical, sexual, or both physical and sexual abuse during childhood than depressed patients and, if so, in what ways? 2) Are particular bonderline symptoms, as measured by the Diagnostic Interview for Borderline Patients (DIB) (22), more likely to predict past occurrence of sexual abuse? We hypothesized
that
1) more
borderline
than
nonborderhine
patients would report sexual abuse histories, 2) sexual abuse would predict the borderline diagnosis, and 3) predictors of sexual abuse would be found among DIB
Am
]
Psychiatry
147:8, August
1990
OGATA,
to impulsivity, dissociative experiences, interpersonal relationships because these symptoms are reported as adult sequelae of sexual abuse (5, 6, 8, 12, 15, 18). We used depressed patients who did not have borderline personality disorder as comparison subjects because the possible overlap between depression and borderline disorder (23) renders this a more stringent test of the hypotheses. items
and
relating disordered
METHOD Subjects were male and female inpatients between the ages of 18 and 60 at a university medical center. Patients who satisfied at least two DSM-III criteria for borderline personality disorder or schizotypal personahity disorder or three DSM-III criteria for major depressive episode were considered as potential subjects. Eighty-seven percent of the eligible subjects agreed to participate. All provided informed consent. All patients were drug free, and all were given the DIB (22) by a research team member (K.R.S., N.E.L., or D.W.). Data on interrater reliability (kappa=0.8O) among our group have been published elsewhere (24); reliability has been maintained through periodic retraining. Patients who obtained a DIB score of 7 or more were included in the borderline group. This cutoff score has been shown by Frances et al. (25) to provide optimal balance between sensitivity and specificity. Subjects scoring S or less on the DIB were considered potential control subjects. We decided in advance to exclude subjects scoring 6 on the DIB to minimize group overlap (25). Patients qualified for the depressed control group if, in addition to the DIB score of S or less, they met Research Diagnostic Criteria (RDC) (26) for probable or definite major depressive disorder on independent evaluation. RDC diagnoses were made by senior supervisors after contact with the patient and the patient’s primary therapist (K.R.S. or N.E.L.). Senior supervisors were blind to the actual DIB score but were familiar with the patient’s clinical presentation and history. Senior supervisors achieved an average interrater reliability on the RDC diagnosis of depression of 0.92 (weighted kappa) (27); pairwise reliability was 0.88-094. Exclusion criteria included organic disordens, chronic psychosis, age over 60, non-native-English-speaking, and IQ less than 70. The patients were interviewed regarding recollections of a variety of childhood and family events by researchers blind to DIB and RDC results (S.N.O. and S.G.). The interview, the Familial Experiences Interview, was developed by one of us (S.N.O.) in collaboration with the research team. Items included physical and sexual abuse; physical neglect; loss by death, divorce, or prolonged separation ; school performance difficulties; frequent moves; long periods of parental unemployment; and other events. Abuse categories included sexual abuse by mother, father, sibling, other relatives, or a nonrelated person as well as physical
Am
]
Psychiatry
I47:8, August
1990
SILK, GOODRICH,
ET AL.
abuse by a caretaker and physical neglect. Sexual abuse was defined as any sexual act that included exposure to genitals with no physical contact, fondling or caressing of genitals, or penetration. Physical abuse was defined as punishment by a caretaker that produced physical marks, bruises, breaks in the skin, or an injury that warranted medical treatment regardless of whether treatment was obtained. Physical neglect included negligence by a caretaker to provide physical needs of clothing, nutrition, shelter, or proper hygiene. The interview is available on request. Each abuse event was assessed for reported frequency, severity, duration, perceived emotional impact on the patient, age of occurrence, and type of perpetraton. Intennater reliabilities (weighted kappas) for interview items ranged from 0.47 to 1.0. The weighted kappas for all items indicating occurrence of an event ranged from 0.75 to LO. Weighted kappas below 0.75 were for impact, age, and severity items. Only six of 150 items had reliability of less than 0.70; none of those items was used in our analyses. Patients cooperated with the interview and appeared invested in providing reliable information. Table 1 shows the demographic characteristics of the two groups of patients. Most of the patients in both groups were Caucasian and female. They had comparable family characteristics with regard to family size and birth order.
RESULTS
Table 2 shows that borderline patients reported significantly higher rates of childhood sexual abuse than depressed patients. More of the borderline patients were abused by siblings, other relatives, and nonrelatives than by fathers. Physical neglect was relatively infrequent in both groups; physical abuse was relatively frequent. All patients who reported sexual abuse described at least fondling alone or in combination with penetration. Seven (41%) of the 17 sexually abused borderline patients reported penetration; nine (53%) described being abused by different people some time during their childhood. All nine of these patients reported abuse by both a family member and a nonrelative. When physical abuse is also considered, 11 (65%) of the 17 sexually abused borderline patients described multiple abuse. In contrast, none of the four depressed patients who reported sexual abuse reported being abused by more than one person, and only three (17%) of the 18 patients recalled both sexual and physical abuse. Only women reported combined sexual abuse by a family member and physical abuse. Seven borderline patients did not report sexual abuse; four of these were men. The one man who reported sexual abuse described the abuser as a nonrehative. Nine of the 17 borderline patients who reported having experienced sexual abuse and two of the seven borderline patients
1009
CHILDHOOD
ABUSE IN BORDERLINE
DISORDER
TABLE 1. Characteristics of 24 Patients With Borderline Personality Disorder and 18 Depressed Patients Without Borderline Personality Disorder
Characteristic
Borderline
Depressed
Patients
Patients
Sex Men S 21
Number
Percent Women
S
28
Number
19
13
Percent
79
72
30.0 9.0
42.0 10.6
Age
(yeats)”
Mean SD
TABLE 2. Type of Childhood Abuse and Perpetrator Abuse of Borderline and Depressed Patients
Type of Abuse Perpetrator”
“Percents
Race Caucasian Number
some 20 83
Percent
patients
88
bBorderline
Hispanic
ual
Percent Black Number
Percent Native
1
0
4
0
American
Number
0
1
Percent
0
6
Marital status’ Single Number Percent
IS 63
3 17
3 13
10 56
Number
6
Percent
25
S 28
Married
Separated
Number
%
N
%
17
7
71 21 4 29
4 1 0 0
22 6 0 0
6 12 10 4
25 50 42 17
0 3 6 1
0 17 33 6
parent
patients both
abused
add sexual
by more had
up to more and
than
physical
higher
patients
100% abuse
because and
some
one person.
significantly
depressed
than
rates
(x2=7.88,
df=1,
of childhood
sex-
p=O.OOS).
who did not report sexual abuse met RDC criteria for major depressive disorder. Most of the borderline patients who experienced sexual abuse reported it before age 12. The patients’ mean±SD age when sexual abuse started was 7.4±2.0 .
years
Number Percent
than
patients than
N
1 6
3 13
Number
Patients (N=18)
1
suffered
were
abuse
Depressed
Patients (N=24)
S
for borderline patients
16
Borderline
and
Sexual abuseb Father Mother Sibling Relative other or sibling Nonrelative Physical abuse Physical neglect
of Sexual
.
when
sexual
abuse
was
perpetrated
by
fathers,
8.0±2.3 when perpetrated by siblings, 9.6±3.7 when perpetrated by relatives other than parents and siblings, and 9.8±4.3 when perpetrated by nonnelatives. A stepwise logistic regression was performed with diagnosis as the dependent variable in order to test the
or divorced
of siblings
Mean SD Birth order Youngest Number
4.0
3.6
1.7
1.3
7
Percent Middle
6 33
29
9
Number Percent
6
38
33
8 33
6 33
14.1
16.6
hypothesis that sexual abuse could predict the diagnosis of borderline personality disorder. Six variables were forced to be tested in the model until the residual variation was not significant. The predictor variables were any sexual abuse, physical abuse, physical neglect, sexual abuse perpetrated by nuclear family members (father, mother, siblings), sexual abuse penpetrated by other relatives, and sexual abuse perpetrated by nonrelatives. The regression was run first for all patients and then only for female patients because only one man reported sexual abuse. A sufficiently good fit
Oldest Number Percent Hamilton score’
Rating
Scale
for
Depression
Mean SD
5.7
Socioeconomic Mean
36.2 13.7
SD aThe
difference
(t=9.04, df=40, bThe difference
(x211.2, cl7item
6.7
status’
df=2, version.
between
the two
p
Sexual and Physical Abuse in Adult With Borderline Personality Disorder
Susan Naomi
N. Ogata, Ph.D., Kenneth R. Silk, M.D., Sonya Goodrich, Ph.D., E. Lohr, Ph.D., Drew Westen, Ph.D., and Elizabeth M. Hill, Ph.D.
Experiences ofabuse and neglect were assessed in 24 adults diagnosed as having borderline personality disorder according to the Diagnostic Interview for Borderline Patients and in 1 8 depressed control subjects without borderline disorder. Significantly more of the borderline patients than depressed patients reported childhood sexual abuse, abuse by more than one person, and both sexual and physical abuse. There were no between-group differences for rates of neglect or physical abuse without sexual abuse. A stepwise logistic regression revealed that derealization, diagnostic group, and chronic dysphoria were the best predictors of childhood sexual abuse in this group of patients. (Am J Psychiatry 1990; 147:1008-1013)
T
his study explores childhood abuse in adult patients with borderline personality disorder. Experiences in early childhood are viewed as important in contributing to borderline pathology (1-4). Stone (2) and Zananini et al. (3) cited a high prevalence of childhood abuse histories in borderline patients. Herman and van der Kolk (1) noted that the symptoms of traumatically
abused
individuals
are
similar
to
those
of
patients with borderline personality disorder. Surveys of childhood abuse reveal that the rates of a history of sexual and physical abuse may be as high as 57% in inpatients and 33% in nonclinical populations (1, 5-8). Caution is advised in interpreting these estimates, however, because methods of study and definitions of abuse differ across studies. Demographic profiles indicate that abuse occurs across economic, religious, and racial backgrounds (5, 9, 10). Although both sexes are probably at equal risk for physical
Presented
in part
Psychiatric
at the
Association,
141st
annual
Montreal,
4, 1989; revision received Jan. From the Personality Disorders sion, Department of Psychiatry, University of Michigan, Silk, UH-9C-9150 Box
Ann 0120,
May
meeting 7-12,
of the American
1988.
Received
April
24, 1990; accepted March 1, 1990. Program and the Biometrics Diviand the Department of Psychology, Arbor. 1500
Address reprint requests to Dr. East Medical Center Drive, Ann
Arbor, MI 48109-0120. The
Joel
authors
Nigg,
Copyright
1008
thank
Tom
TenHave,
Mark
P. Becker,
A.C.S.W. © 1990
Patients
American
Psychiatric
Association.
Ph.D.,
and
abuse, risks for sexual abuse are estimated to be approximately one in three for females and one in ten for males (1 1, 12). Victims of physical abuse are usually preschoolers or adolescents, but sexual abuse usually begins before puberty (7, 10). Sexual abuse generally ends in mid-adolescence because the child tells someone about it, runs away, refuses to continue, or gets pregnant (13). Most abuse, both physical and sexual, is perpetrated by male relatives of the victims (7, 9). The initial effects of sexual abuse include fear, anxiety, depression, guilt, anger, hostility, and inappropniate sexual behaviors (6, 10, 14-17). Long-term sequelae
include
impulsivity,
self-blame,
suicidal
be-
havior, anxiety, feelings of isolation, poor self-esteem, substance abuse, sexual problems, and lack of trust in interpersonal relationships (5, 6, 8, 15). Victims of sexual abuse may direct their negative feelings against themselves, resulting in depression and self-destructive acts such as cutting, burning, and suicide attempts (12, 18). Similar symptoms are often seen in borderline patients (DSM-III-R). Studies have found that female patients who had been sexually or physically victimized as children were more likely to be given a borderline diagnosis than those who had not been so victimized (16, 19). Herman et al. (20), Stone (2), and Zanarini et al. (3) found that many borderline outpatients and inpatients had a history of abuse during childhood. Westen et al. (21) found physical and/or sexual abuse documented in more than 50% of the charts of 27 inpatient adolescents with borderline personality disorder. Although sexual and physical abuse are not likely to be solely responsible for borderline pathology, they may be highly influential etiological factors. In this study we will explore two questions related to abuse: 1) Have borderline patients experienced a greater incidence of physical, sexual, or both physical and sexual abuse during childhood than depressed patients and, if so, in what ways? 2) Are particular bonderline symptoms, as measured by the Diagnostic Interview for Borderline Patients (DIB) (22), more likely to predict past occurrence of sexual abuse? We hypothesized
that
1) more
borderline
than
nonborderhine
patients would report sexual abuse histories, 2) sexual abuse would predict the borderline diagnosis, and 3) predictors of sexual abuse would be found among DIB
Am
]
Psychiatry
147:8, August
1990
OGATA,
to impulsivity, dissociative experiences, interpersonal relationships because these symptoms are reported as adult sequelae of sexual abuse (5, 6, 8, 12, 15, 18). We used depressed patients who did not have borderline personality disorder as comparison subjects because the possible overlap between depression and borderline disorder (23) renders this a more stringent test of the hypotheses. items
and
relating disordered
METHOD Subjects were male and female inpatients between the ages of 18 and 60 at a university medical center. Patients who satisfied at least two DSM-III criteria for borderline personality disorder or schizotypal personahity disorder or three DSM-III criteria for major depressive episode were considered as potential subjects. Eighty-seven percent of the eligible subjects agreed to participate. All provided informed consent. All patients were drug free, and all were given the DIB (22) by a research team member (K.R.S., N.E.L., or D.W.). Data on interrater reliability (kappa=0.8O) among our group have been published elsewhere (24); reliability has been maintained through periodic retraining. Patients who obtained a DIB score of 7 or more were included in the borderline group. This cutoff score has been shown by Frances et al. (25) to provide optimal balance between sensitivity and specificity. Subjects scoring S or less on the DIB were considered potential control subjects. We decided in advance to exclude subjects scoring 6 on the DIB to minimize group overlap (25). Patients qualified for the depressed control group if, in addition to the DIB score of S or less, they met Research Diagnostic Criteria (RDC) (26) for probable or definite major depressive disorder on independent evaluation. RDC diagnoses were made by senior supervisors after contact with the patient and the patient’s primary therapist (K.R.S. or N.E.L.). Senior supervisors were blind to the actual DIB score but were familiar with the patient’s clinical presentation and history. Senior supervisors achieved an average interrater reliability on the RDC diagnosis of depression of 0.92 (weighted kappa) (27); pairwise reliability was 0.88-094. Exclusion criteria included organic disordens, chronic psychosis, age over 60, non-native-English-speaking, and IQ less than 70. The patients were interviewed regarding recollections of a variety of childhood and family events by researchers blind to DIB and RDC results (S.N.O. and S.G.). The interview, the Familial Experiences Interview, was developed by one of us (S.N.O.) in collaboration with the research team. Items included physical and sexual abuse; physical neglect; loss by death, divorce, or prolonged separation ; school performance difficulties; frequent moves; long periods of parental unemployment; and other events. Abuse categories included sexual abuse by mother, father, sibling, other relatives, or a nonrelated person as well as physical
Am
]
Psychiatry
I47:8, August
1990
SILK, GOODRICH,
ET AL.
abuse by a caretaker and physical neglect. Sexual abuse was defined as any sexual act that included exposure to genitals with no physical contact, fondling or caressing of genitals, or penetration. Physical abuse was defined as punishment by a caretaker that produced physical marks, bruises, breaks in the skin, or an injury that warranted medical treatment regardless of whether treatment was obtained. Physical neglect included negligence by a caretaker to provide physical needs of clothing, nutrition, shelter, or proper hygiene. The interview is available on request. Each abuse event was assessed for reported frequency, severity, duration, perceived emotional impact on the patient, age of occurrence, and type of perpetraton. Intennater reliabilities (weighted kappas) for interview items ranged from 0.47 to 1.0. The weighted kappas for all items indicating occurrence of an event ranged from 0.75 to LO. Weighted kappas below 0.75 were for impact, age, and severity items. Only six of 150 items had reliability of less than 0.70; none of those items was used in our analyses. Patients cooperated with the interview and appeared invested in providing reliable information. Table 1 shows the demographic characteristics of the two groups of patients. Most of the patients in both groups were Caucasian and female. They had comparable family characteristics with regard to family size and birth order.
RESULTS
Table 2 shows that borderline patients reported significantly higher rates of childhood sexual abuse than depressed patients. More of the borderline patients were abused by siblings, other relatives, and nonrelatives than by fathers. Physical neglect was relatively infrequent in both groups; physical abuse was relatively frequent. All patients who reported sexual abuse described at least fondling alone or in combination with penetration. Seven (41%) of the 17 sexually abused borderline patients reported penetration; nine (53%) described being abused by different people some time during their childhood. All nine of these patients reported abuse by both a family member and a nonrelative. When physical abuse is also considered, 11 (65%) of the 17 sexually abused borderline patients described multiple abuse. In contrast, none of the four depressed patients who reported sexual abuse reported being abused by more than one person, and only three (17%) of the 18 patients recalled both sexual and physical abuse. Only women reported combined sexual abuse by a family member and physical abuse. Seven borderline patients did not report sexual abuse; four of these were men. The one man who reported sexual abuse described the abuser as a nonrehative. Nine of the 17 borderline patients who reported having experienced sexual abuse and two of the seven borderline patients
1009
CHILDHOOD
ABUSE IN BORDERLINE
DISORDER
TABLE 1. Characteristics of 24 Patients With Borderline Personality Disorder and 18 Depressed Patients Without Borderline Personality Disorder
Characteristic
Borderline
Depressed
Patients
Patients
Sex Men S 21
Number
Percent Women
S
28
Number
19
13
Percent
79
72
30.0 9.0
42.0 10.6
Age
(yeats)”
Mean SD
TABLE 2. Type of Childhood Abuse and Perpetrator Abuse of Borderline and Depressed Patients
Type of Abuse Perpetrator”
“Percents
Race Caucasian Number
some 20 83
Percent
patients
88
bBorderline
Hispanic
ual
Percent Black Number
Percent Native
1
0
4
0
American
Number
0
1
Percent
0
6
Marital status’ Single Number Percent
IS 63
3 17
3 13
10 56
Number
6
Percent
25
S 28
Married
Separated
Number
%
N
%
17
7
71 21 4 29
4 1 0 0
22 6 0 0
6 12 10 4
25 50 42 17
0 3 6 1
0 17 33 6
parent
patients both
abused
add sexual
by more had
up to more and
than
physical
higher
patients
100% abuse
because and
some
one person.
significantly
depressed
than
rates
(x2=7.88,
df=1,
of childhood
sex-
p=O.OOS).
who did not report sexual abuse met RDC criteria for major depressive disorder. Most of the borderline patients who experienced sexual abuse reported it before age 12. The patients’ mean±SD age when sexual abuse started was 7.4±2.0 .
years
Number Percent
than
patients than
N
1 6
3 13
Number
Patients (N=18)
1
suffered
were
abuse
Depressed
Patients (N=24)
S
for borderline patients
16
Borderline
and
Sexual abuseb Father Mother Sibling Relative other or sibling Nonrelative Physical abuse Physical neglect
of Sexual
.
when
sexual
abuse
was
perpetrated
by
fathers,
8.0±2.3 when perpetrated by siblings, 9.6±3.7 when perpetrated by relatives other than parents and siblings, and 9.8±4.3 when perpetrated by nonnelatives. A stepwise logistic regression was performed with diagnosis as the dependent variable in order to test the
or divorced
of siblings
Mean SD Birth order Youngest Number
4.0
3.6
1.7
1.3
7
Percent Middle
6 33
29
9
Number Percent
6
38
33
8 33
6 33
14.1
16.6
hypothesis that sexual abuse could predict the diagnosis of borderline personality disorder. Six variables were forced to be tested in the model until the residual variation was not significant. The predictor variables were any sexual abuse, physical abuse, physical neglect, sexual abuse perpetrated by nuclear family members (father, mother, siblings), sexual abuse penpetrated by other relatives, and sexual abuse perpetrated by nonrelatives. The regression was run first for all patients and then only for female patients because only one man reported sexual abuse. A sufficiently good fit
Oldest Number Percent Hamilton score’
Rating
Scale
for
Depression
Mean SD
5.7
Socioeconomic Mean
36.2 13.7
SD aThe
difference
(t=9.04, df=40, bThe difference
(x211.2, cl7item
6.7
status’
df=2, version.
between
the two
p
