Trauma-Related Disorders in Patients with Borderline Personality Disorders
(original: Sack, Martin, et al. 
Traumafolgestörungen bei Patienten mit Borderline-Persönlichkeitsstörung. Der Nervenarzt 84.5 (2013): 608-614.)

Translation completed by Katie Duncan
 
Originals
 
Nervenarzt 2013 • 84:608–614 DOI 10.1007/s00115-012-3489-6 © Springer-Verlag Berlin Heidelberg 2012 June 30, 2012 © Springer-Verlag Berlin Heidelberg 2012
M. Sack1 • U. Sachsse2 • B. Overkamp3 • B. Dulz4
1 Clinic for Psychosomatic Medicine and Psychotherapy, Rechts der Isar Hospital, Technical University Munich 2 Asklepios Fachklinikum Göttingen 3 Department of Psychotraumatology, Emergency Hospital Berlin 4 Asklepios Klinikum Nord, Hamburg

Trauma-Related Disorders in Patients with Borderline Personality Disorders. Results of a Multicenter Study


The borderline personality disorder (BPD) is characterized by symptoms of emotional instability, impulsive behavior, and instable interpersonal relationships [1]. While empirical studies in the past indicated no clear indications of a specific influence of traumatic experiences of the development of the symptomatology of BPD, findings accumulate in the meantime that cover high prevalence rates of traumatic life experiences and resulting symptoms of trauma in BPD [4, 5, 6, 7]. In addition, patients with BPD describe frequent experiences of sexual abuse in childhood than patients with other personality disorders [4, 8]. For this reason, the issue of potential importance of traumatic childhood experiences for the etiology of BPD in the context of a multi factor disease concept is raised.

Because childhood traumas are not specifically associated with the etiology of BPD, but correlates with many principal psychological characteristics, it does not appear justified, that BPD emerges isolated as a trauma-associated disorder. However, it is stressed at the same time that the role of traumatization is of importance for the treatment of BPD, even if this describes probably neither a necessary nor adequate etiology condition.

Due to considerations regarding a therapeutic setting of the agenda that was suggested, the diagnosis of BPD complements via the research diagnosis “complex posttraumatic stress disorder” (complex PTSD), in order to characterize a subcategory of BPD patients with treatment-related trauma-related disorders [16, 17]. A symptom picture is defined as complex PTSD, including the disorders of affect regulation, dissociate symptoms and somatization, disturbed sense of self, disorders of sexuality and interpersonal relationship formation as well as changes of belief and personal moral concepts [18]. The need and the use of implementation of an additional diagnose of complex PTSD is controversial [19, 20], particularly due to the potential of high overlap with other Axis 1 and Axis 2 diagnoses. Essentially a simple comparison of diagnosis criteria of BPD and complex PTSD already shows considerable overlap for example in the areas affect regulation and impulsiveness, disorders of the sense of self as well as dissociative symptoms. For this reason, the question arises whether the two diagnostic constructs can be differentiated from one another at all or rather how frequently both diagnoses exist at the same time.
The portrayed diverging results and assessments give reasons that overlap of trauma-related disorders and BPD are investigated closer. While the prevalence of traumatization and the PTSD in patients with BPD was already examined in a series of studies and can be considered to be well-documented [2, 3, 4, 5, 6, 7, 8], the overlap of the BPD with the diagnostic construct of complex PTSD was not yet investigated with standardized interview diagnostic. So far, the prevalence of dissociative disorders was also estimated in patients with BPD with an exclusion [21] merely through investigatory questionnaires.

Methodology

In the context of a multi center data collection 5 consecutive patients were studied in the treatment of patients with BPD and with complex trauma-related disorders respectively at specialized centers. Criterion for inclusion in the study was backed with the standardized interview (IPDE Module Borderline) circumstances of a BPD appropriate to the diagnosis criteria of the ICD-10 [1]. The investigation of the prevalence of PTSD, complex PTSD, as well as dissociative disorders take place with standardized interviews. To investigate the symptomatology and the prevalence of traumatization of the lifetime questionnaire instruments were used. Examiners were 2 physicians and 4 psychologists each with at least 3 years of diagnostic and clinical psychotherapeutic experience. The procedure of the diagnostic interviews was exercised and standardized through a grader training before the start of the data collection by means of video recording. A consent for the implementation of the study was available by the local appropriate ethics committee at all involved centers. A written consent by all study participants was obtained to participate in the study.

The study was awarded the Hamburg Award on Personality Disorders in 2010.

Instruments

The International Personality Disorder Examination (IPDE) is the official instrument as a structured interview for the diagnosis of personality disorders [22]. In our study the model for the diagnosis of BPD was used. The IPDE allows a careful and comprehensive diagnosis of BPD, because the exact diagnosis criteria are requested by ICD-10 An elaborate manual describes the application, execution, and evaluation.

The model to diagnose PTSD from the Clinical Interview for the DSM-IV (SCID-PTSD) [23] is considered to be the gold standard for compiling the diagnosis of PTSD. The interview asks for 17 symptoms and disorders in a systematic way in correspondence to the diagnose criteria. Additionally, the duration of symptoms and the impairment in everyday life are asked for through the symptomatology. The interviewer also considers statements of family members and behavioral observations in order to form a clinical verdict.

With the Interview of Complex PTSD (I-CPTSD), an adaptation of the Structured Interview for Disorders of Extreme Stress (SIDES) [16], a valid German-language instrument for diagnosing complex PTSD is available. The I-cPTSD comprises of 40 items altogether, by which the symptom criteria of complex PTSD are obtained. All 6 appropriate criterion disorder areas must be developed for the diagnosis analogous to the American research criteria of PTSD: 1. Disorders of the affect regulation, 2. Disorders of the cognition and the consciousness, 3. Disorders of the sense of self, 4. Disorders in the relation with other people, 5. Somatization, 6. Changes of attitude towards life.

The Dissociative Disorders Interview Schedule (DDIS) records primary and secondary symptoms of dissociative disorders [25]. The validated version was used [26]. The interview comprises of 131 items and possess an acceptable inter-rater reliability. The interview allows a clear diagnostic assessment regarding the existence of dissociative amnesia, fugue, depersonalization disorder, and dissociative identity disorder according to the criteria of the DSM-IV. In addition, the diagnosis was assigned complex dissociative disorder [27], if at least 4 distinct symptoms of dissociative fragmentation (tip-of-the-tongue, hearing voices, uncertainty of identity, change of identity) were not only existing on occasion.

The assessment of traumatization is obtained at the span of life made with the German version of the Traumatic Antecedents Questionnaire (TAQ) [28, 29]. The questionnaire covers a total of 11 scales. The potential answers are separate for 4 age ranges (0–6 years, 7–12 years, 13–18 years, and adults) with graded potential answers (not at all, never up to very strong/often) simulated. The characteristic scales neglect, emotional violence, physical violence, and sexual violence were chosen for the evaluation for complex trauma-related disorders.

The Impact of Event Scale (IES-R) [30] is the most frequently used instrument for compiling the symptomatology of trauma-specific ailments and for follow-up examining of PTSD. We utilize the revised 22 items comprehensive version [31]. The IES-R includes the frequency of posttraumatic symptoms in the areas of re-experience of the traumatic event, avoidance behavior, and psychophysiological overexcitation. The respondents rank on a rating scale (0=never to 5=often) how frequent the specified symptoms have occurred to them during the last week. Sub-scale values may be identified from it for the three aforementioned symptom groups as well as an overall dimension for the severity code of the posttraumatic symptomatology. The scales exhibit good internal consistency values and a high correlation to construct-related other items and scales.

The Questionnaire on Dissociative Symptoms (QDS) [32] is the German handling and extension of the Dissociative Experiences Questionnaires (DES) [33]. The instrument is used for dimensional recording of dissociative phenomena. The items are recorded on a scale of 0% (never) to 100% (always). The arithmetic average of all items is assessed as general measure of dissociation, in which a cut-off value of 25 is deemed to be striking. The internal consistency of the QDS is specified by α=0.91. In the existing study, the QDS was shortened to 28 items for economic reasons, according to the item number of the American original version DES. The items were arranged in the original order of the American version so as to facilitate a preferably high measure of comparability with data from international studies.

The Screening for Somatoform Symptoms (SOMS) [34] is a questionnaire that measures existence of physical pain. The content of the 53 items are the 35 physical symptoms of a somatoform disorder as well as somatoform disorders like hypochondria, body dysmorphic disorder, and the somatoform pain disorder according to DSM-III-R. The internal consistency of the SOMS, measured by Cronbach’s α, provides very good values for the global test of 0.73-0.88. The validity of the questionnaire was proven by the content validity, intercorrelation of the scales, and discriminative validity.

The Beck Depression Inventory (BDI) was established by the Schmitt and Maes modified German version [35]. The BDI asks for the frequency of the appearance of 20 symptoms of clinical depression. The measurement properties of the modified BDI were validated in a random sample of 2500 subjects. The internal consistency of the scale amounts to 0.90. The instrument shows a very good reliability of the cumulative value.

The State-Trait Anxiety Inventory (STAI) [36] in the translation by Laux [37] is a frequently used self-assessment questionnaire for detected anxiety intensity (Scale X1) and the general anxiety as a personality trait (Scale X2). The scale was used in the present study for general anxiety (Scale X2), since there is a relatively stable personality trait recorded. The Test-Retest Reliability adds up to κ=0,84 for the scale X2 [36]. The validity of the STAI is supported by high correlations with construct-related scales.

Sample Description

Participants of the study were a total of 104 (76.5%) female and 32 (23.5%) male patients with an average age of 31.5 years (range 18–58). The distribution of the participants at the single study centers yielded as follows:

— Trauma Station of Lower Saxony State Hospital of Göttingen, now called Asklepios Fachklinikum Göttingen, Trauma Station (n=22),
— Hannover Medical School, Clinic for Trauma-Related Disorders (n=20),
— Asklepios Klinikum Nord Hamburg, Day Hospital (n=32),
— Asklepios Klinikum Nord Hamburg, Borderline Station (n=42),
— Lübben State Clinic, Psychiatric Clinic (n=20).

The diagnostic criteria of BPD corresponding to interview diagnosis were satisfied in all patients: Depressive disorders were existent in 47 (34.6%) of patients. 13 (9.6%) of patients were diagnosed with an eating disorder at the same time, there are 8 (6%) patients with an addictive disorder with active drug consumption.

A medication with at least one psychotropic drug was reported by 99 (73%) of all participants, whereupon 24 (18%) had received 4 or more different prescribed drugs and 44 (31%) 3 or more different prescribed drugs at the same time. The taking of neuroleptics (n=63 [46%]), SSRI (“selective serotonin reuptake inhibitors”), or NSRI (“noradrenalin serotonin reuptake inhibitor”), antidepressants (n=48 [35%]), benzodiazepines (n=32 [24%]), and tricyclic antidepressants (n=28 [20%]) was indicated the most frequently used.

Altogether 81 (60%) of patients report, that no fixed partnership exists. Unwed were 102 (75%), married 21 (15%), divorced or widowed 12 (10%) of patients. 10 (7%) patients gave an account of no school leaving certificate or no actual attendance at school, certificate of secondary education 32 (24%), general certificate of secondary education 59 (44%), university-entrance diploma 34 (25%). The reference of a disability pension was indicated by 23 (17%) of patients. A pension request had been placed 14 (10%), benefits obtained after the Victims Compensation Act merely one patient (0.7%). 40 (29%) patients reported to be registered as unemployed.

Summary

Trauma-Related Disorders in Patients with Borderline Personality Disorders. Results of a Multicenter Study.

Summary

Problem. There is controversy with the issue of the diagnostic overlap from personality disorders especially borderline personality disorder (BPD) with trauma-related disorders. Patients and Methodology. In the framework of a multicenter data collection at 5 specialized centers trauma-related disorders were recorded in 136 patients with BPD by interview diagnosis. In addition, traumatic stresses and further symptoms were raised by questionnaires.

Results. There were high diagnostic overlaps of BPD with the posttraumatic stress disorder (79%), with the complex posttraumatic stress disorder (55%), and with severe dissociative disorders with fragmentation symptoms (41%). Including the categories “neglect” and “emotional violence” was an extremely high prevalence of traumatization relating to the lifetime (96%). Sexual violence in childhood and youth was indicated in 48% of all women and 28% of all men, severe physical violence of a total of 65% of all patients.

Conclusion. In patients with severe distinct BPD is a high calculating comorbidity of trauma-related disorders inclusive of dissociative disorders. This connection should be respected with the therapy planning.

Keywords

Borderline personality disorder • Trauma-related disorders • Posttraumatic stress disorder • Dissociative disorders • Diagnostic overlap
    
Tab. 1 Prevalence of trauma-related disorders at the university center
Place of study N Percentage of female study participants PTSD Complex PTSD Complex dissociative disorder
Göttingen Trauma Station 22 22 (100%) 22 (100%) 14 (64%) 12 (55%)
Hanover Trauma Outpatient Department 20 16 (80%) 16 (80%) 11 (55%) 6 (30%)
Hamburg Day-Care Hospital 32 25 (78%) 27 (84%) 16 (50%) 15 (47%)
Hamburg Borderline Station 42 26 (62%) 26 (60%) 22 (52%) 18 (43%)
Lübben Trauma Outpatient Department 20 15 (75%) 18 (90%) 12 (60%) 5 (25%)
Total 136 104 (77%) 108 (79%) 75 (55%) 56 (41%)
PTSD posttraumatic stress disorder

Tab. 2 Comparison of borderline patients without and with present complex PTSD at the same time: Results of the Diagnostic Interview
Disorder BPD patients Group comparison
Without complex PTSD (n=61) With complex PTSD (n=75) Χ2 p
PTSD 43 (70.5%) 65 (86.7%) 5.4 0.032
Depersonalization disorder 40 (65.6%) 62 (82.7%) 5.2 0.029
Amnesia (lifetime) 16 (26.2%) 31 (41.3%) 3.4 n.s.
Fugue 0 (0%) 3 (4%) 2.5 n.s.
Complex dissociative disorder 16 (26.2%) 40 (53.3%) 10.2 0.002
Dissociative identity disorder 2 (3.3%) 9 (12.0%) 3.4 n.s.
BPD borderline personality disorder, n.s. not significant, PTSD posttraumatic stress disorder


                        
Statistical Evaluation

The group comparison dichotomous variables occurred using the χ2-Test. Differences between the groups of interval-scaled variables were tested using variance analysis (ANOVA). All of the results were tested regarding the influence of the variable of gender (covariance analysis, ANCOVA) and reported separately in case of error of result for both genders The statistical calculations were executed with the statistics software SPSS, version 18.0.

Results

Prevalence of Trauma-Related Disorders

A total of 79% of all patients of our sample satisfy recorded diagnosis criteria of existing PTSD by means of the SCID-PTSD one for the survey period. The prevalence of PTSD in the single university center varied between 100% (Trauma Station of Lower Saxony State Hospital of Göttingen) and 60% (Borderline Station, Asklepios Klinik Nord, Hamburg).

With a total of 55% of all study participants, the compiled diagnosis criteria of one of the complex PTSD were fulfilled with the I-cPTSD. The distribution of the frequency of the diagnosis of complex PTSD at the university center was relatively uniform (range 50-60%). With 41% of all patients of our sample was diagnosed a complex dissociative disorder with severe dissociative symptoms in the form of tip-of-the-tongue, hearing voices, uncertainty of identity, change of identity with the DDIS (. Tab. 1.)

Prevalence of Childhood Traumatization

The most frequently used were experiences of neglect (n=119 [87.5%]) and emotional violence for example through humiliation and abuse (n=112 [82.4%]) stated over reported physical experience of violence in 88 (65%) patients. Sexual traumatizations were reported from 43% (n=59) of all patients altogether, whereupon women with 48% (n=50) in comparison to men with 28% (n=9) by trend reported sexual experience of violence more frequently (χ2: 4.0 (0.066).

Among the inclusion of the categories of neglect and emotional violence a total of 130 patients (95.6%) reported about at least a serious traumatic childhood stress.

Comparison of BPD Patients with and without Present Complex PTSD at the Same Time:

Patients with borderline personality disorder and present complex PTSD at the same time satisfied the diagnosis of PTSD significantly more frequently as well. Dissociative disorder prevails with borderline patients with the diagnosis of complex PTSD altogether more frequently. Notably, depersonalization disorder and complex dissociative disorder are found significantly more frequently (. Tab. 2.)

BPD patients with and without complex PTSD do not differ significantly in age. The degree of the specific posttraumatic symptoms (IES-R) and the anxiety symptoms (STAI-X2) was also not significantly different. There are significantly stronger distinct depressive (BDI), dissociative (DES), and somatoform symptoms (SOMS) with patients with complex PTSD, however (. Tab. 3.)

In comparison to the means of questionnaire recorded traumatic stresses (TAQ) there are significantly more frequently data merely for experiences of physical violence in ages of 7 to 12 years and for sexual experience of violence in ages of 7 to 12 in patients with present complex PTSD at the same time. In all of the asked traumatic categories consistently very high prevalence rates of traumatic stresses were also indeed indicated by patients without present complex PTSD at the same time. Tab. 4.)

Tab. 3 Comparison of borderline patients without and with present complex PTSD at the same time: Age and Symptom Questionnaires

BPD without complex PTSD (n=61) BPD with complex PTSD (n=75) Group Comparison (GLM)

Mean (SD) Mean (SD) F (df) p
Age (years) 31.3 (8.8) 31.7 (10.1) 0.05 (135) n.s.
Intrusions (IES-R) 26.3 (6.1) 27.4 (4.0) 1.55 (129) n.s.
Avoidance Behavior (IES-R) 27.0 (5.9) 28.1 (6.1) 1.1 (129) n.s.
Overexcitation (IES-R) 26.1 (4.7) 27.0 (5.1) 0.90 (129) n.s.
IES-R Total Score 79.5 (14.3) 82.5 (11.7) 1.8 (129) n.s.
Anxiety (STAI-X2) 57.3 (8.6) 60.0 (8.5) 3.2 (132) n.s.
Depression (BDI) 55.4 (15.9) 63.4 (14.7) 9.2 (132) 0.003
Dissociative Symptoms (DES) 24.5 (12.4) 31.9 (17.4) 7.7 (132) 0.006
Somatoform Symptoms (SOMS) 17.4 (8.5) 23.1 (9.8) 12.2 (132) <0.001
BPD borderline personality disorder, n.s. not significant, PTSD posttraumatic stress disorder. Questionnaire: BDI Beck Depression Inventory, DES Dissociative Experiences Scales, IES-R Impact of Event Scale, SOMS Screening for Somatoform Symptoms, STAI State-Trait Anxiety Inventory.

Tab. 4 Prevalence of Traumatic Stress in Borderline Patients with and without Present Complex PTSD at the Same Time

BPD patients Statistical comparison (Fischer’s exact test)

Without complex PTSD (n=61) With complex PTSD (n=75) Χ2 p
Neglect (0-6) 19 (31.1%) 29 (38.7%) 0.83 n.s.
Neglect (7-12) 33 (54.1%) 48 (64.0%) 1.4 n.s.
Neglect (13-18) 42 (68.9%) 62 (82.7%) 3.6 n.s.
Neglect (over 18) 44 (72.1%) 55 (73.3%) 0.03 n.s.
Neglect (total) 52 (85.2%) 67 (89.3%) 0.51 n.s.
Emotional Violence (0-6) 28 (45.9%) 47 (62.7%) 3.8 n.s.
Emotional Violence (7-12) 41 (67.2%) 59 (78.7%) 2.3 n.s.
Emotional Violence (13-18) 45 (73.8%) 61 (81.3%) 1.1 n.s.
Emotional Violence (over 18) 38 (62.3%) 51 (68.0%) 0.48 n.s.
Emotional Violence (total) 47 (77.0%) 65 (86.7%) 2.1 n.s.
Physical Violence (0-6) 12 (19.7%) 26 (34.7%) 3.8 n.s.
Physical Violence (7-12) 20 (32.8%) 40 (53.3%) 5.8 0.024
Physical Violence (13-18) 23 (37.7%) 41 (54.7%) 3.9 n.s.
Physical Violence (over 18) 12 (19.7%) 24 (32.0%) 2.6 n.s.
Physical Violence (total) 34 (55.7%) 54 (72.0%) 3.9 n.s.
Sexual Violence (0-6) 7 (11.5%) 15 (20.0%) 1.8 n.s.
Sexual Violence (7-12) 6 (9.8%) 23 (30.7%) 8.7 0.003
Sexual Violence (13-18) 17 (27.9%) 22 (29.3%) 0.04 n.s.
Sexual Violence (over 18) 8 (13.1%) 13 (17.3%) 0.05 n.s.
Sexual Violence (total) 23 (37.7%) 36 (48.0%) 3.9 n.s.
BPD borderline personality disorder, n.s. not significant, PTSD posttraumatic stress disorder

Discussion

The present study examines the prevalence of trauma-related disorders in patients with borderline personality disorder in 5 specialized treatment centers in Germany. The diagnosis occurs by standardized interview diagnosis through expert clinical and trained graders.

With 55% of all study participants, a notably high percentage of patients with BPD satisfied the research criteria of complex PTSD at the same time. The prevalence of more serious dissociative symptoms as defined by a complex dissociative disorder with fragmentation symptoms [27] was also markedly high with 41% of all investigated patients. As previously acknowledged in the repeatedly described [4, 7] research literature, we also found a high comorbidity of BPD with the diagnosis of posttraumatic stress disorder. The diagnosis criteria of PTSD according to DSM-IV were measured in 79% of all examined patients. Our results show for this reason a markedly high overlap of the diagnosis of BPD with a spectrum of disorders, which follow the associated mental traumatizations, ranging from that of the diagnosis PTSD, to complex PTSD, up to complex dissociative disorders.

To clarify the issue, to what extent patients with BPD and complex PTSD of patients with BPD without current complex PTSD at the same time differ, the specifications were compared in symptom questionnaires. Borderline patients with complex PTSD differed from patients without complex PTSD not in degree of symptomatology of current PTSD at the same time or of anxiety symptoms, however, they told about significantly stronger pronounced depressive symptoms, dissociative symptoms, and somatoform life troubles as patients without comorbid complex PTSD.

In the total sample a high prevalence in specifications regarding traumatic strains was found. Under inclusion of neglect and emotional violence 96% of our studied patients with severely distinct BPD reported of at least one traumatic experience in their lifetime. Particularly striking was an extremely high prevalence rate of sexual traumatization with 28% of men and 48% of women in our sample, compared with data for population prevalence in Germany [10, 38]. Statistically significant differences in the prevalence of traumatic events between patients with and without current complex PTSD at the same time are only in physical and sexual experiences of violence in single ages of their lives.
 
Because the diagnostic investigation of the current study in specialized outpatient or residential treatment centers was conducted, the appropriate area of validity of the results in patients with more massively distinct borderline symptomatology is restricted. The prevalence rates possibly yield to traumatization and trauma-related disorders in borderline patients, who reside in nondedicated treatment facilities or in outpatient psychotherapy who are reported on in our study.

It can be said in a nutshell that our studied samples of patients with BPD is characterized not only by a high prevalence of trauma-related disorders, but also by a markedly high stress via traumatic life experiences. A differentiation with the help of complaint symptomatology between patients with and without current complex PTSD at the same time succeeded only gradually. Patients with current complex PTSD were severely burdened by depressive, dissociative, and somatoform symptoms, differed but not significantly regarding the degree of posttraumatic suffering. Indeed, there are dissociative disorders with fragmentation symptoms twice as common with BPS patients who fulfilled the diagnosis criteria of complex PTSD at the same time.

The located distinct overlap in our investigation of the disorder BPD and complex PTSD is an explanation whether both diagnoses could be looked at as different characteristics of a combined basic problem. This proposal makes Miller and Resick [39], who could be discriminated, both with sexually traumatized women as well as with war veterans of two types of posttraumatic stress symptoms in the form of externalizing and internalizing symptoms. Externalizing symptoms are characterized through impulsiveness, substance abuse, and traits of Cluster B personality disorder. Internalizing symptoms correspond to depressive behaviors, self-harm, dissociative symptoms, as well as anxious avoidance behavior and social withdrawal. Thus BPD would be characterized as an externalizing type of a disorder understanding through self and affect regulation, while the suggested diagnosis by Herman [18] corresponds to complex PTSD of the internalizing characteristic of this disorder. The concept of a combined fundamental problem with externalizing and internalizing characteristics coincide well with the clinical observation, that there are hybrid forms between the two extreme poles of the severity of symptoms and that internalizing and externalizing symptomatology can alternate temporally in the same patients. This is typically then observed, when considerable dissociative symptoms are also on hand.

From a synopsis of over 50 articles in the current issue of the guide of Borderline-Störungen [41] suggests that BPD is determined in the literal sense with its problems of identity diffusion, anxiety of loneliness and disturbed capacity for emotional regulation substantially through serious disturbed bonding and relationship experiences culminating in massive traumatizing relationships in childhood. However, the treatment of borderline patients is considerably hindered if they were subjected to sexual violence as children [42], and the long-term prognosis of patients with BPD and comorbid PTSD is similarly charged to those with BPD and addiction [7]. Therefore, the diagnostic status of a trauma-related disorder in patients with BPD represents important information for the differential indication of psychotherapeutic treatment procedures. In addition to a stabilizing, supporting treatment, the ego-functions are available, in the meantime confrontational treatment strategy, that the flexible load capacity of patients with BPD could be adapted and they already have stood the test of time clinically [43, 44, 45, 46, 47].

There are references after that that impede acute dissociative symptoms learning processes and for this reason can affect adverse psychotherapeutic treatment [48]. Thus the adaptation of the treatment earns specific attention, the dissociative symptomatology was frequently present at the same time, particularly then, if for example symptoms of fragmentation exist in the form of amnesia in everyday life or stronger uncertainty of identity [49]. To enable aligned indication status for the individual patient needs, thus the existence of trauma-related disorders should routinely be included also especially in the diagnostics of patients with BPD and dissociative disorders.

Conclusion for Clinical Practice

The results of our study show that a considerable prevalence of complex trauma-related disorders including complex dissociative disorders exists in patients with severely distinct BPD. Trauma-therapeutic treatment concepts should be included in the therapy planning in patients with BPD with appropriate comorbidity [50]. According to evidence, a successful reduction of specific trauma-related disorders (intrusions, anxieties, dissociative symptoms, hyperarousal) is accompanied with an improvement of ability of affect and impulse regulation and has an effect on the core symptomatology of BPD.
  
Contact address

PD Dr. M. Sack
Department of Psychosomatic Medicine and Psychotherapy, Rechts der Isar Hospital, Technische Universität München Langerstr. 3, 81675 Munich m.sack@tum.de
Conflict of Interest. The corresponding author indicates for himself and his coauthors, that no conflicts of interest exist


Literature

1. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders. DSM-IV-TR. APA, Washington
2. Fossati A, Madeddu F, Maffei C (1999) Borderline personality disorder and childhood sexual abuse: a meta-analytic study. J Pers Disord 13:268–280
3. Zlotnick C, Franklin CL, Zimmerman M (2002) Is comorbidity of posttraumatic stress disorder and borderline personality disorder related to greater pathology and impairment? Am J Psychiatry 159:1940–1943
4. Yen S, Shea MT, Battle CL et al (2002) Traumatic exposure and posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders: findings from the collaborative longitudinal personality disorders study. J Nerv Ment Dis 190:510–518
5. Battle C, Shea MT, Johnson DM et al (1998) Childhood maltreatment associated with adult personality disorders: findings from the Collaborative Longitudinal Personality Disorders Study. J Pers Disord 18:193-211
6. Bandelow B, Krause J, Wedekind D et al (2005) Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with borderline personality disorder and healthy controls. Psychiatry Res 134:169–179
7. Zanarini MC, Frankenburg FR, Hennen J et al (2006) Prediction of the 10-year course of borderline personality disorder. Am J Psychiatry 163: 827–832
8. Zanarini MC, Williams AA, Lewis RE et al (1997) Reported pathological childhood experiences associated with the development of borderline personality disorder. Am J Psychiatry 154:1101-1106
9. Gunderson JG, Sabo AN (1993) The phenomenological and conceptual interface between borderline personality disorder and PTSD. Am J Psychiatry 150:19-27
10. Sachsse U, Eßlinger K, Schilling L (1997) From Childhood Trauma to Severe Personality Disorder. Fundamenta Psychiatrica 11:12–20
11. Wöller W (2010) Concept of Therapy for Traumatized Patients with Severe Personality Disorders. Psychotherapeut 55:6–11
12. Golier JA, Yehuda R, Bierer L et al (2003) The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. Am J Psychiatry 160:2018-2024
13. Paris J, Zweig-Frank H (1992) A critical review of the role of childhood sexual abuse in the etiology of borderline personality disorder. Can J Psychiatry 37:125–128
14. Lieb K, Zanarini MC, Schmahl C et al (2004) Borderline personality disorder. Lancet 364:453–461
15. Leichsenring F, Leweke E, Kruse J et al (2011) Borderline personality disorder. Lancet 377:34–44
16. Pelcovitz D, Kolk BA van der, Roth S et al (1997)
Development of a criteria set and a structured interview for disorders of extreme stress (SIDES). J Trauma Stress 10:3–16
17. Sack M (2004) Diagnostic and Clinical Aspects of Complex Posttraumatic Stress Disorder. Nervenarzt 75:451–459
18. Herman JL (1992) Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. J Trauma Stress 5:377-391
19. Schweiger U, Sipos V, Hohagen F (2005) Critical Considerations for the Phrase of “Complex Posttraumatic Stress Disorder”. Nervenarzt 76:344-347
20. Lewis KL, Grenyer BF (2009) Borderline personality or complex posttraumatic stress disorder? An update on the controversy. Harv Rev Psychiatry 17:322–328
21. Korzekwa M, Dell PF, Links PS et al (2009) Dissociation in borderline personality: a detailed look. J Trauma Dissociation 10:346–367
22. Mombour W, Zaudig M, Berger P et al (1996) International Personality Disorder Examination (IPDE). Hogrefe Testzentrale, Göttingen
23. Wittchen H-U, Zaudig M, Fydrich T (1997) SCID – Structured Clinical Interview for DSM-IV. Hogrefe, Göttingen
24. Boroske-Leiner K, Hofmann A, Sack M (2008) Results for Internal and External Validity of Interviews of Complex Posttraumatic Stress Disorder (I-cPTSD). Psychother Psychosom Med Psychol 58:192–199
25. Ross CA, Heber S, Norton RG et al (1989) The dissociative disorder interview schedule: a structured interview. Dissociation 2:169–190
26. Frör K (2000) Validation of the German Translation of Dissociative Disorders Diagnostic Schedule, Unpublished Dissertation
27. Gast U (2002) Complex Dissociative Disorders. Professional Dissertation: Medizinische Hochschule Hannover
28. Herman JL, Kolk B van der (1987) Traumatic antecedents of borderline personality disorder. In: Kolk B van der (Hrsg) Psychological Trauma. Am Psychiatr Press, Washington, S 111–126
29. Hofmann A, Fischer G, Koehn F (1997) Traumatic Antecedents Questionnaire (TAQ) Unpublished German Translation
30. Horowitz MJ, Wilner N, Alvarez W (1979) Impact of Event Scale: a measure of subjective stress. Psychosom Med 41:209–218
31. Maercker A, Schützwohl M (1998) Compilation of Mental Disorders: The Impact of Event Scale-Revised Version. Diagnostica 44:130–141
32. Freyberger HJ, Spitzer C, Stieglitz R-D (1999) Dissociative Experiences Scales (DES). Huber, Bern
33. Bernstein EM, Putnam FW (1986) Development, reliability and validity of a dissociation scale. J Nerv Ment Dis 174:727-735
34. Rief W, Hiller W, Heuser J (1997) SOMS – Screening for Somatoform Symptoms. Huber, Bern
35. Schmitt M, Maes J (2000) Proposal for the Simplification of the Beck Depression Inventory (BDI). Diagnostica 46:38-46
36. Laux L, Glanzmann P, Schaffner P, Spielberger CD (1981) The State-Trait Anxiety Inventor. Theoretical Fundamentals and Manuals Beltz-Test, Weinheim
37. Spielberger CD, Gorsuch RL, Lushene RE (1970) STAI. Manual for the State-Trait-Anxiety-Inventory. Consulting Psychologist Press, Palo Alto
38. Lampe A (2002) Prevalence of Sexual Abuse, Physical Abuse, and Emotional Neglect in Europe. Z Psychosom Med Psychother 48:370–380
39. Miller MW, Resick PA (2007) Internalizing and externalizing subtypes in female sexual assault survivors: implications for the understanding of complex PTSD. Behav Ther 38:58–71
40. Van der Kolk BA, Roth S, Pelcovitz D et al (2005) Disorders of extreme stress: the empirical foundation of a complex adaptation to trauma. J Trauma Stress 18:389-399
41. Buchheim A (2011) Borderline Personality Disorder and Bonding Experiences. In: Dulz B, Herpertz SC, Kernberg OF, Sachsse U (Hrsg) Hadbook of Borderline Personality Disorder. Schattauer, Stuttgart, 158–167
42. Sachsse U (2004) Trauma-Centered Psychotherapy. Schattauer, Stuttgart
43. Sachsse U, Vogel C, Leichsenring F (2006) Results of psychodynamically oriented trauma-focused inpatient treatment for women with complex posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). Bull Menninger Clinic 70:125–144
44. Cloitre M, Stovall-McClough KC, Nooner K et al (2010) Treatment for PTSD related to childhood abuse: a randomized controlled trial. Am J Psychiatry 167:915-924
45. Sack M (2010) Careful Traumatherapy – Resource-Oriented Treatment of Trauma-Related Disorders. Schattauer, Stuttgart
46. Müller S, Sachsse U (2010) Long-Term Course Hospitalized Psychotherapy with Complex Trauma-Related Disorders. Personality Disorders 14:125–152
47. Steil R, Dyer A, Priebe K et al (2011) Dialectical behavior therapy for posttraumatic stress disorder related to childhood sexual abuse: a pilot study of an intensive residential treatment program. J Trauma Stress 24:102-106
48. Mattheß H, Sack M (2010) Proven Strategies in the Treatment of Patients with Dissociative Disorders. Personality Disorders 14:104-116
49. Ebner-Priemer U, Mauchnik J, Kleindienst et al (2009) Emotional learning during dissociative states in borderline personality disorder. J Psychiatry Neurosci 34:214–222
50. Bohus M, Dyer A, Priebe K et al (2010) Dialectical Behavioral Therapy for Posttraumatic Stress Disorders after Sexualized Violence in Childhood and Youth (DBT-PTSD). Psychother Psychosom Med Psychol 61:140-147

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