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Revista de Trabajo Social ISSN 2244-808X
Vol. 12 No2 202-213pp. Copyright © 2022
Julio-diciembre
ARTÍCULO DE INVESTIGACIÓN
El maltrato en la infancia como condición previa para el desarrollo del
trastorno límite de la personalidad en la adolescencia
DOI:10.5281/zenodo.7114636
Anatoly Alekhin *, Elena Isagulova **
Resumen
Según un estudio de la Universidad de Manchester, las personas con trastorno límite de
la personalidad son 13 veces más propensas a informar de traumas en la infancia que
las personas sin ningún problema de salud mental. El presente estudio pretende revelar
el estado actual de la problemática del abuso físico, mental y emocional en la infancia
como posible factor de desarrollo de la sintomatología límite en la adolescencia, así como
examinar las tasas de abuso físico, sexual y emocional durante la infancia entre los
adolescentes con sintomatología de personalidad límite en una población clínica no
psiquiátrica. Los estudios sobre la influencia de los traumas infantiles en la salud mental
demuestran que se asocian con mucha más frecuencia al trastorno límite de la
personalidad que a los trastornos del estado de ánimo, las psicosis y otros trastornos de
la personalidad. Una de las formas de experiencia adversa más comúnmente reportada
por las personas con trastorno límite de la personalidad es la negligencia física, seguida
por el abuso emocional, el abuso físico, el abuso sexual y, por último, la negligencia
emocional, aunque varios estudios han encontrado el patrón opuesto. Los hallazgos
muestran que las experiencias traumáticas en la infancia pueden ser un predictor de la
formación de los síntomas del trastorno límite de la personalidad a una edad posterior.
Además, cabe destacar que el abuso y la negligencia emocional en la infancia son los
que más influyen en el desarrollo del trastorno límite de la personalidad en la
adolescencia.
Palabras clave: trastorno límite de la personalidad, trauma infantil, abuso físico, abuso
sexual, abuso emocional.
Abstract
Abuse in childhood as a precondition for the development of borderline
personality disorder in adolescence
According to a study of Manchester University, people with borderline personality
disorder are 13 times more likely to report childhood trauma than people without any
mental health problems. The present study aims to reveal the current state of the
problem of physical, mental, and emotional abuse in childhood as a possible factor in
the development of borderline symptomatology in adolescence, as well as to examine
the rates of physical, sexual, and emotional abuse during childhood among adolescents
with borderline personality symptomatology in a non-psychiatric clinical population. As
demonstrated by the conducted analysis, traumatic experiences at the early stage of
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development increase the probability of the development of the disorder at the next
stages. Studies on the influence of childhood trauma on mental health demonstrate that
it is much more often associated with borderline personality disorder than with mood
disorders, psychoses, and other personality disorders. A widespread form of adverse
experience most commonly reported by people with borderline personality disorder is
physical neglect, followed by emotional abuse, physical abuse, sexual abuse, and, lastly,
emotional neglect, although several studies have found the opposite pattern. The
findings show that traumatic experiences in childhood may be a predictor of the
formation of borderline personality disorder symptoms at a later age. Additionally, it
should be noted that emotional abuse and neglect in childhood have the most significant
impact on the development of borderline personality disorder in adolescence.
Keywords: borderline personality disorder, childhood trauma, physical abuse, sexual
abuse, emotional abuse.
Recibido: 15/08/2022 Aceptado: 12/09/2022
* Doctor en Medicina, Profesor, jefe del Departamento de Clínica Psicología, Instituto de Psicología, Universidad
Herzen, San Petersburgo, Rusia. E-mail: termez59@mail.ru
** PhD (c), Psicólogo clínico, psicoterapeuta psicoanalítico, PhD (c), jefe del Centro Clínico del Instituto Italiano
de Micropsicoanálisis en Moscú, Moscú, Rusia. E-mail: 9477877@gmail.com
1.- Introduction
Personality disorders are defined as “the way of thinking, feeling, and behaving, that
deviates markedly from the expectations of the individual’s culture, is pervasive and
inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads
to suffering or impairment”. It has been reported that worldwide, personality disorders
have a prevalence of 3 to 10% in the population and much higher among people with
other mental disorders, and are therefore considered a global mental health priority.
The goal of the present study is to disclose the present state of the problem of
physical, mental, and emotional abuse in childhood as a possible factor in the
development of borderline symptomatology in adolescence.
2. Methods
The study involves the analysis of publications (research reports, articles) concerning
the association of physical, sexual, and emotional abuse in childhood and the
development of BPD in adolescence published in the last 5 years. The study includes
publications from the MEDLINE, PubMed, Google Scholar, CyberLeninka, and
eLIBRARY.RU databases.
3. Results
Borderline personality disorder (BPD) is one of the most prevalent personality
disorders seen in the general population. The word borderline means “on the edge”. The
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term was initially adopted because the disorder was originally considered “borderline”
between neurosis and psychosis. Now, it is known to be a clearly distinct disorder. BPD
can be thought of as a state of hyperemotionality and hypersensitivity, which occurs
approximately in 1-3% of the general population, 10% of outpatients, 20% of inpatients,
and 9-27% of patients in emergency departments. BPD is three to four times more
common in women in a variety of clinical settings, although in the community, the
distribution of prevalence by gender remains almost identical (Rosenstein et al., 2018).
BPD is characterized by a pronounced overarching pattern of emotional dysregulation,
impulsive behavior, personality disorder, and interpersonal conflicts. Research assessing
the quality of attachment in borderline subjects, points to the predominance of insecure
and disorganized attachment, which strongly correlate with chaotic and inconsistent
relations. Moreover, BPD can be partly considered a severe attachment disorder of the
disorganized type. Borderline personality symptoms tend to peak in intensity and
frequency in young adulthood, when most people are diagnosed, and then decrease in
severity with age. Many people with BPD have at some point in their life suffered from a
comorbidly related mental illness, for example, depressive disorders, bipolar disorder,
anxiety disorder, post-traumatic stress disorder, eating disorders, and addiction to
alcohol or drugs.
Even though BPD is well established as a diagnostic entity, the etiopathogenesis of
this disorder is still not quite clear and remains under active investigation. Researchers
have proposed various etiological hypotheses, including genetic, neurobiological, and
developmental factors. The most recognized among the various etiopathological theories
is the theory proposed by M. Linen, which suggests that BPD may result from a
combination of biological and psychosocial factors.
C.H. Hughes et al. (2005) proposed integration with the etiopathogenetic model of
BPD, emphasizing the role that lack of social closeness or responsiveness on the part of
appropriate caregivers plays in the development of BPD symptoms, which, in turn,
impairs the individual’s emotion regulation. Difficulties in affect regulation have also
been suggested as key mediators in the relationship between childhood trauma and BPD.
The role of childhood trauma in the etiology of BPD has been the subject of research
for over 30 years. The word “trauma” is used these days in the context of various
situations where it is easy to lose its actual psychological-diagnostic meaning. The
definition of a traumatic event refers to the very fact of the occurrence of a particular
event in a person’s life rather than their reaction to that situation.
The definition of trauma presented in the literature on mental disorders reads that it
refers to the immediate and personal experience of an event involving death or serious
injury, or the threat of death or serious injury, or other threat to the physical integrity
of that person; witnessing the death, injury or threat to the physical integrity of another
person, or reporting a sudden or violent death or serious injury or threatened death, or
serious injury to a family member or other loved one. It also involves the person’s
reaction to the event, which is manifested by intense fear, feelings of helplessness or
terror (in the case of a child, it must involve disorganized behavior or agitation).
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In modern psychotherapy and psychiatry, experts increasingly cite early experiences
of developmental trauma among the etiologies of mental disorders. The DSM classifies
as potentially traumatic events the following: war, physical and sexual assault,
kidnapping, terrorism, torture, disasters, serious car accidents and life-threatening
illness, witnessing someone die or being seriously injured after an accident, war, or
disaster. In addition, the DSM-V classification considers a traumatic event to be a threat
to mental integrity. The DSM-V does not mention any kind of traumatic event as a
diagnostic criterion for BPD despite the inextricable link between BPD and trauma.
BPD is described as having “serious consequences in interpersonal relationships”.
Interpersonal relationships are essentially children’s relationships with their caregivers,
those who care for them and raise them. Children are dependent on parents and other
reliable caregivers to provide a safe, loving, and supportive environment. When this is
not the case, the long-term effects can be devastating. In a borderline structuring
problem, when attachment remains unreliable or even disorganized, aggressive action
will be codependent on the experience of dependence on the object. An aggressive act
becomes symptomatic, an impulsive response to anxiety, turning into a source of direct
instinctive gratification. There is a nonspecific weakness of the ego linked to the inability
to cope with aggression, intolerance to the frustration caused by anxiety and insufficient
development of sublimation skills. In addition, there is an inability of the subject to
regulate and neutralize their own aggression. Because of the failure of symbolization, an
attempt is made to eliminate the intrapsychic conflict of thoughts through acting it out,
which is a consequence of primitive anxiety of abandonment. The risk of early distortions
or even deficits and/or abuse, which is common in family dynamics, makes the study of
family relationships in cases of BPD a subject not only of clinical research but also of
public health.
According to the World Health Organization (WHO), more than 1 billion children
between the ages of 2 and 17 are physically, sexually, and emotionally abused each
year. Retrospective studies show that about 25-35% of women and 10-20% of men
confirm that they were victims of childhood sexual abuse, and about 10-20% of men
and women’s descriptions of these experiences meet the criteria for physical abuse
(Zarrati et al., 2019).
Studies around the world provide ample evidence of multiple intrafamilial
pathological experiences in childhood, such as histories of physical, emotional, sexual
abuse, and neglect, commonly reported by patients with BPD. The consequences of child
abuse are nothing short of traumatic, as abused children often struggle with the
consequences long into adulthood.
Exposure to trauma is a common experience for children and adolescents, and the
prevalence of post-traumatic stress disorder (PTSD) in this population is underestimated.
Although most of them demonstrate potential for recovery, giving the child the ability to
overcome these experiences, a certain portion of this population will, nevertheless,
present very diverse reactions, ranging from minimal impairment in the child’s life to
patterns of severe clinical symptoms that heavily interfere with the psychoaffective
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development of their personality. Meanwhile, the long-term consequences of early
childhood trauma are tricky to estimate and are contingent on a wide range of variables.
Among these are the nature, duration, number of instances, and frequency of recurrence
of the trauma, its intensity, and the subject’s age, pre-existing medical condition, and
personality. To this list also belong collateral events, such as illnesses, accidents, or
losses that precede or follow the trauma(s) (Godbout et al., 2019).
BPD and complex post-traumatic stress disorder have a number of common
characteristics and symptoms, such as impaired emotional regulation and altered self-
image. The thoughts, feelings, and behaviors observed in BPD often result from
childhood trauma. These childhood traumas can also put a person at risk for developing
PTSD. In fact, people with BPD and PTSD report prior trauma experiences more often
compared to people with PTSD alone. Yet there is a key difference: complex PTSD clearly
defines a person’s state as a response to trauma – old or recent, long-term or short-
term – while BPD does not. Nevertheless, many people meet the diagnostic criteria for
both disorders simultaneously. Despite this, the role trauma plays in the onset of BPD
was and remains a topic of heated debates between psychiatrists and psychologists.
An analysis of data from 42 international studies involving more than 5,000 people
finds that 71.1% of people with personality disorders report experiencing at least one
trauma in childhood. In the latter, in a series of meta-analyses of the impact of childhood
trauma on adult mental health, it is demonstrated that these traumas are much more
often associated with BPD than with mood disorders, psychoses, and other personality
disorders (Winter et al., 2017).
A large number of empirical studies, both cross-sectional and longitudinal, have
shown that 30% to 90% of patients diagnosed with BPD report a history of child abuse.
Specifically, 40-86% of subjects with BPD report childhood sexual abuse. In addition,
10-73% report physical abuse by parents or adult caregivers, and 17-25% report
neglect. Three-quarters of patients with BPD report emotional abuse and 70% report
emotional detachment during childhood. People with BPD are also significantly more
likely to have witnessed domestic violence (54%) than people with other personality
disorders (20.5%) (Porter et al., 2019). This association has been noted in a variety of
samples, including inpatient psychiatric patients and outpatients, substance users, and
adolescents. At the same time, other authors suggest that a history of trauma is neither
necessary nor sufficient for the development of BPD, and studies have been unable to
empirically demonstrate strong direct causal associations between these variables.
P. Bozzatello et al. review studies published on PubMed over the past 20 years to
assess whether different types of childhood trauma serve as a risk factor and form the
clinical picture of BPD. It is found that compared to subjects with other personality
disorders, patients with BPD are more likely to have been abused in childhood (Bozzatello
et al., 2021).
Following a search of five electronic databases, M. Girard has selected 22 articles
examining the relationship between child maltreatment (e.g., physical, sexual, and
emotional abuse; physical and emotional neglect) and BPD (i.e., the diagnosis, severity,
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assessment of related personality traits). Overall, the results partially support the
hypothesis that early maltreatment is a risk factor for BPD. Evidence for a perceived link
between child maltreatment and BPD is more common when using a symptom scale
compared to a categorical diagnosis (Girard, 2020).
An article entitled “Childhood Adversity and Borderline Personality Disorder: A Meta‐
Analysis” was published in the journal Acta Psychiatrica Scandinavia. F. Varese, along
with his colleagues, found patients with BPD to be 13.91 times more likely to experience
childhood abuse trauma compared to people with no mental health problems. When
compared with epidemiological and prospective cohort studies, the odds drop tenfold.
According to the revised calculations, people with BPD are found to be 3.15 times more
likely to report childhood trauma than people with other psychiatric disorders.
M. Solmi et al. review combined data from five meta-analyses on personality disorder
risk factors. The results show that of 56 associations between 26 potential environmental
factors and the antisocial, dependent, and borderline personality disorders, despite
62.5% of the associations being nominally significant, only 8.92% of the associations
meet Class II evidence for BPD, including emotional abuse, emotional neglect, physical
abuse, sexual abuse, and physical neglect in childhood. All other significant associations
are classified as weak (Class IV evidence) (Solmi et al., 2021).
Experiencing such events early on in development often results in substantial and
persistent dysfunction, mental impairment, and personality development disorders.
The meta-analysis conducted by N. Cattane et al. presents proof of the role of
changes in the hypothalamic-pituitary-adrenal (HPA) axis, in neurotransmission, in the
endogenous opioid system, and in neuroplasticity in childhood trauma vulnerability to
developing BPD; the authors also confirm the presence of morphological changes in
several brain regions in patients with BPD, particularly in those involved in the stress
response. This is presumably due to the fact that memory consolidation occurs during
the first night of sleep after trauma. Conversely, an adequate capacity for resistance,
that is, the ability to adapt to an adverse situation, is shown to be a crucial protective
factor against trauma-related disorders. In response to childhood stressors, there occurs
a cascade of neuromorphological and epigenetic changes that may have a strong link
with the development of BPD (Cattane et al., 2017). Many researchers point to one of
the consequences of trauma – the inability to modulate emotions, which, in turn, is one
of the typical indicators of BPD.
For about 60% of patients with BPD, childhood sexual abuse appears to be an
important etiological factor. A systematic review by L.F. de Aquino Ferreira et al. focuses
on sexual abuse as a predictor of the diagnosis, clinical picture, and prognosis of BPD.
Overall, sexual violence is found to play an important role in BPD, especially in women.
The rate of adult sexual violence is significantly higher in patients with BPD compared to
other personality disorders. A history of sexual abuse predicts a more severe clinical
picture and a worse prognosis.
The strongest evidence is suicidality, followed by self-harm, post-traumatic stress
disorder, dissociation, and the chronic form of BPD. Years of sexual abuse can have a
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detrimental effect on the child’s achievement of age-appropriate developmental goals,
reduce their self-esteem, interfere with the development of a sense of identity, and
impair the ability to establish and build interpersonal relationships and achieve their
goals (De Aquino Ferreira et al., 2018). However, maltreatment tends to seem
embedded in an atmosphere of general chaos and neglect on the part of both parents.
For other patients, other forms of maltreatment combined with various forms of neglect
probably play a more important etiological role.
Physical abuse has been widely researched as a predisposing condition for the
development of BPD. Abuse and inherited susceptibility essentially play a synergistic role
in the development of borderline personality traits. Physically abused children develop
more BPD symptoms by age 12 than their nonabused peers, and they are particularly
vulnerable if they have relatives with psychiatric disorders. Abuse and inherited
susceptibility appear to play a synergistic role in the development of borderline
personality traits. Not only family medical history, but also children’s temperament
characteristics may contribute to BPD symptoms if they were physically abused: children
with low temperament and relatedness who were physically abused exhibit earlier onset
and higher severity of BPD symptoms.
The relationship between maltreatment and temperament is complex and debated:
maltreatment can contribute to BPD in patients with biological susceptibility (specific
temperament traits). However, it is also possible that premature and repeated
maltreatment in the family influences at least some of the temperament traits associated
with BPD. The timing of temperament traits assessment poses a limitation, as it is
difficult to distinguish temperament traits in the personalities of adult patients. The
effects of physical trauma extend to many areas of personality, such as affective
dysregulation, identity dissemination, disturbed relationships, and self-harm. Children
who were physically abused score higher on each parameter compared to a control group
of children who were not abused. Moreover, they have higher overall borderline trait
scores and are more likely to be identified as high risk for BPD (Bozzatello et al., 2021).
A link is discovered between neglect and the early development of BPD. In the
context of child care, neglect is a type of abuse characterized by “failure to properly care
for a child, resulting in physical or emotional harm”. The concept of neglect includes
physical neglect, which refers to the failure to adequately meet children’s physical needs,
and emotional neglect, which is expressed by caregivers’ emotional disconnect from
children’s requests for attention and care. The most important findings suggest that:
adolescents with BPD and concomitant depression have had significantly higher levels of
neglect than healthy control subjects; physical neglect is associated with the onset of
the signs of BPD at an earlier age; the combination of specific temperament traits and
physical/emotional neglect may precipitate the onset of BPD and the symptoms of
antisocial personality disorder; neglect by both parents is reported more frequently by
adolescents with BPD compared with other clinical groups (Solmi et al., 2021).
Attachment to the primary caregiver, the controlling figure, serves as the basis of
security for the child in exploring the environment. The accessibility of the adult, the
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quality of assistance provided, and the appropriateness and adjustment of responses to
the child's cues contribute to the emergence of a progressive sense of security and self-
confidence in the child, as they see their needs being met. The longer the period spent
without stable and adequate attachment, the more limited the opportunities to catch up.
The effects of specific types of neglect (e.g., childhood neglect and maternal
detachment) have been studied. Neglect of child supervision, including failure to set
limits, monitor inappropriate behavior, and know the whereabouts of the child and their
friends, is associated with a higher risk of Cluster B personality disorders in adolescence
and early adulthood. Maternal detachment in infancy, a kind of neglect in which the
mother creates a physical and verbal distance from her child, is found to be a reliable
predictor of both BPD symptoms and self-harm or suicidality in adolescence (Godbout et
al., 2019).
Studies confirm that among the variety of childhood maltreatment, only emotional
abuse acts as a unique predictor of the features of BPD (Rosenstein et al., 2018).
G.D. Xie et al. (2021) also find that resilience and self-worth mediate all three types
of childhood maltreatment (emotional abuse, physical abuse, and sexual abuse) when
these types are considered separately; however, when all three types of childhood
maltreatment are entered into the model simultaneously, neither the indirect nor the
direct effects of physical abuse or sexual abuse are significant, only the relationship
between emotional abuse and BPD characteristics is partially mediated by resilience and
self-worth. Nevertheless, the risk of developing BPD in an emotionally abused child may
be higher only when one or more risk personality traits are already present: rejection
sensitivity, the tendency to frequently expect and experience interpersonal rejection,
and negative affectivity, the tendency to experience large amounts of strong negative
emotions. However, there is a limited body of research explaining how rejection
sensitivity and negative affectivity are related to childhood emotional abuse and the
subsequent development of BPD (Winter et al., 2017).
The parent’s lack of affective accessibility and unpredictable responses to the child’s
needs have serious consequences for the development of the child’s ability to manage
emotions and the maturation of their defense mechanisms.
Studies reveal that children with higher rejection sensitivity are significantly more
likely to develop BPD traits after emotional abuse. With high rejection sensitivity,
children often misinterpret ambiguous social situations as rejecting when the actual
rejection is very mild or non-existent; they often perceive social situations as more
emotionally upsetting than their peers. To protect themselves from rejection, children
with high rejection sensitivity often develop two coping mechanisms over time:
avoidance and excessive attachment. Both coping mechanisms are common among the
behavioral symptoms of patients with BPD, and they are often both present in the same
person.
Higher negative affectivity is characterized by a tendency to be easily disturbed by
emotionally triggering events and to experience greater negative emotions from these
triggers. Compared to rejection sensitivity, which causes children to subjectively
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experience only rejection as more intense, negative affectivity reinforces all of their
negative emotions. Consequently, emotionally distressing experiences can cause much
greater trauma in children with higher negative affectivity than in those with lower
negative affectivity, and this trauma often interferes with their emotional and social
development. Not only has the high prevalence of exposure to childhood trauma in
people with psychotic disorders been proven, but also that such events have a very
significant impact on the course of the illness and the chances of recovery (Kim et al.,
2018).
The results of the study by N. Godbout et al. provide further evidence that a history
of childhood abuse may be directly related to symptoms commonly associated with BPD,
such as anger, stress-reducing behavior, suicidality, dysfunctional sexual behavior, and
self-esteem disorders, and also indirectly related through its effects on insecure
attachment. These findings have important implications for psychological treatment,
including the possibility that trauma and attachment-focused interventions, such as
phased cognitive behavioral therapy for complex trauma, teach affective and
interpersonal skills. Regulation and emotionally oriented therapy for complex trauma,
along with dialectical behavioral therapy known to be effective, may be helpful in treating
BPD. These findings also suggest that men and women may experience parental
maltreatment differently, resulting in gender differences in attachment patterns and
psychosocial symptoms (Godbout et al., 2019). Such findings emphasize the possible
importance of developing and offering gender-specific interventions for men and women
with BPD.
4. Conclusion
Understanding the impact of negative life stressors in early life on adulthood requires
serious attention to early diagnosis and intervention. The multifactorial model suggests
that the development of BPD is largely the end product of childhood trauma, such as
emotional abuse, physical abuse, and sexual abuse. In addition, researchers have found
that childhood maltreatment is an important predictor of BPD in adolescence and
adulthood.
Individuals who experienced childhood maltreatment tend to score higher on BPD
traits than those who did not. However, examining the effect of a particular subtype of
childhood maltreatment on BPD traits without considering the overlap of childhood
maltreatment subtypes does not provide accurate results because most maltreated
children have experienced multiple forms of maltreatment that exhibit high rates of
concurrent acts of abuse or neglect. Therefore, more research is needed to assess the
exact relationship between childhood maltreatment and BPD, and if maltreatment is a
cause, what types of child maltreatment are most closely associated with the
development of BPD.
Additional research is needed on patients with BPD that have or have not had
traumatic experiences in childhood, as well as on the changes that occur in response to
trauma. A detailed study of the influence of the nature and severity of trauma in children
of different age groups can give a better understanding of how to modulate treatment
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based on individual needs. Research also shows that post-trauma patients diagnosed
with BPD tend to report chaotic early environments that may also include sexual,
physical, emotional, or verbal abuse and chronic neglect, and that more severe and
extensive child maltreatment tends to be associated with higher levels of BPD
symptomatology. However, more research is needed to specifically identify the individual
and cumulative effects of different types of child maltreatment and their characteristics,
including the relative contribution of caregiver maltreatment on BPD.
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