سوء استفاده از کودکان و بی توجهی بررسی ارتباط بین سوءاستفاده احساسی در دوران کودکی و خصیصه¬های اختلال شخصیت مرزی: نقش مشکلات در تنظیم احساسات

Childhood abuse has been consistently linked with borderline personality disorder (BPD) and recent studies suggest that some forms of childhood abuse might be uniquely related to both BPD and BPD features. In addition, difficulties with emotion regulation have been found to be associated with childhood abuse, BPD, as well as BPD features. The present study examined (1) whether frequency of childhood emotional abuse is uniquely associated with BPD feature severity when controlling for other forms of childhood abuse and (2) whether difficulties with emotion regulation accounts for the relationship between childhood emotional abuse and BPD feature severity. A sample of undergraduates (n = 243) completed the Childhood Trauma Questionnaire – Short Form, Difficulties in Emotion Regulation Scale, and Borderline Symptom List-23. Multiple regression analyses and Structural Equation Modeling were conducted. Results indicated that frequency of childhood emotional abuse (and not sexual or physical abuse) was uniquely associated with BPD feature severity. In addition, while there was no direct path between childhood emotional abuse, childhood physical abuse, or childhood sexual abuse and BPD features, there was an indirect relationship between childhood emotional abuse and BPD features through difficulties with emotion regulation. These findings suggest that, of the different forms of childhood abuse, emotional abuse specifically, may have a developmental role in BPD pathology. Prevention and treatment of BPD pathology might benefit from the provision of emotion regulation strategies.

Borderline personality disorder (BPD) is a severe and debilitating disorder that represents 20–40% of psychiatric inpatient admissions (Geller, 1986, Grant et al., 2008 and Lieb et al., 2004). Approximately 84% of individuals with BPD engage in suicidal behavior (Soloff, Lynch, & Kelly, 2002), and 8% die by suicide (Pompili, Girardi, Ruberto, & Tatarelli, 2005). BPD is not only problematic in clinical populations, but also in the general population, where BPD features exist along a continuum (Trull, 2001). Higher BPD features in the general population are associated with significant negative outcomes such as academic dysfunction, meeting lifetime criteria for a mood disorder, relationship dysfunction, and alcohol use problems (e.g., Stepp et al., 2005; Trull, 2001). Thus, BPD features pose a significant problem not only for those with BPD diagnoses, but among individuals in the general population as well. Indeed, examination of key factors associated with the development of BPD features serves significant clinical utility, as it would provide important implications for both prevention and intervention efforts. Several developmental models suggest that BPD pathology (i.e., BPD or BPD-features) is shaped by a combination of biological and environmental mechanisms, the latter of which includes social and attachment-related disturbances. Perhaps one of the most prominent models of BPD pathology is Linehan's (1993) biosocial model, which proposes that BPD is the result of a transaction between an individual's biological predisposition to difficulties with emotion regulation and an invalidating social rearing environment, or one that communicates that “the individual's private experiences and emotional expressions are not […] valid responses to events” (Linehan, 1993, p. 50). Other models similarly emphasize the critical role of the individual's social rearing environment in the development of BPD. Zanarini and Frankenburg (1997) have proposed a multifactorial model, the first of which consists of a traumatic home environment. These traumas include a variety of factors, ranging from prolonged early parental separation to emotional and sexual abuse. Recently, Hughes, Crowell, Uyeji, and Coan (2012) proposed a developmental model nested within the social baseline theory (Coan, 2008), which suggests that the development of BPD might be due to a child's lack of social proximity to or responsiveness from relevant caregivers, which subsequently disrupts the individual's ability to effectively regulate their emotions. Thus, a common theme across various developmental models of BPD is an emphasis on a disrupted social rearing environment that is likely characterized by different forms of childhood abuse. Consistent with this model, there is a robust body of literature indicating an association between BPD pathology and a history of childhood abuse. Up to 91% of individuals with BPD diagnoses report experiencing some form of childhood abuse (Zanarini et al., 1997), including elevated levels of childhood sexual, emotional, and physical abuse (Davidson et al., 2010, Spatz Widom et al., 2009 and Zanarini et al., 2002). In addition, individuals with BPD diagnoses report abuse by more than one person and multiple forms of abuse compared to clinical and nonclinical samples (Bierer et al., 2003, Brown and Anderson, 1991, Herman et al., 1989, Hernandez et al., 2012, Ogata et al., 1990 and Pietrek et al., 2013). Further, females with BPD experience higher levels of emotional and physical abuse than their non-BPD sisters, suggesting that the severity of abuse within the family environment may be associated with the disorder (Laporte, Paris, Guttman, Russell, & Correa, 2012). Different forms of abuse rarely occur in isolation (Bierer et al., 2003, Briere and Elliott, 2003 and Pérez-Fuentes et al., 2013). Notably, childhood sexual abuse is unlikely to occur in the absence of emotional abuse (Bagley, 1991 and Sørbø et al., 2013) and childhood emotional abuse is the most likely to occur independent of other forms of abuse (Moeller, Bachmann, & Moeller, 1993). Accordingly, though sexual, physical, and emotional abuse are consistently associated with BPD, a smaller body of literature has examined whether a specific subtype of abuse might uniquely account for the disorder. Briere and Elliott (2003) found that childhood emotional abuse—and not physical or sexual abuse, or any form of neglect—predicted a BPD diagnosis among male participants. Similarly, in a sample of inner city substance users in which childhood abuse and neglect were examined as risk factors for BPD diagnoses, Bornovalova, Gratz, Delany-Brumsey, Paulson, and Lejuez (2006) reported that only emotional abuse was predictive of BPD diagnostic status. Emotional abuse is also relevant to BPD features more broadly; different facets of emotional abuse (i.e., degradation and ignoring), but not physical abuse, uniquely predict BPD features (Allen, 2008). Similarly, emotional abuse and neglect, compared to other forms of abuse and neglect, are most strongly associated with dissociative symptoms among individuals with BPD diagnoses (Watson, Chilton, Fairchild, & Whewell, 2006). Thus, extant evidence provide support for the disruption of the child's social rearing environment specified across several models, and further suggest that emotional abuse, specifically, may be a core facet of the social environment. This is theoretically concordant with Linehan (1993) and Hughes et al. (2012) theories, which propose the invalidating environment and lack of responsiveness, respectively, as hallmarks of the social rearing environment. Linehan's model, specifically, notes that an invalidating environment is characterized by a response to the individual's internal or private experiences (i.e., emotions). Thus, both theory and recent research have indicated emotional abuse as a potential “core” feature of the one's social environment that leads to the development of BPD pathology. Given the established association between childhood abuse and BPD pathology, recent studies have aimed to delineate the specific mechanisms accounting for this relationship. Consistent with theories proposed by Linehan (1993) and Hughes et al. (2012), a handful of studies have identified difficulties with emotion regulation as an explanatory link between childhood abuse and BPD pathology. Difficulties with emotion regulation is a multi-faceted construct, and has been proposed to constitute a lack of awareness and acceptance of emotions, as well as failures to have access to and/or engage in emotion regulation strategies (Gratz & Roemer, 2004). Developmental theories identify the ability to regulate emotions as a major developmental milestone of childhood (see Cole et al., 1994, Southam-Gerow and Kendall, 2002 and Thompson, 1994), its acquisition of which is heavily reliant on parental guidance and support (e.g., Feng et al., 2008 and Kopp, 1989). Given that individuals constituting the child's rearing environment (i.e., family members and others close to the family) are often perpetrators of childhood abuse, the development of these skills is likely disrupted among victims of childhood abuse. Consequently, rather than acquiring the skills necessary to tolerate and modify their emotions, these individuals experience increased emotional arousal, and have difficulties tolerating emotional distress and developing emotional awareness and understanding (Linehan, 1993 and Thompson and Calkins, 1996). Studies suggest that children with a history of childhood abuse are more likely to have difficulties with emotion regulation compared to children without (Shields and Cicchetti, 1998, Shipman et al., 2005 and Shipman et al., 2000). Childhood abuse is also correlated with higher levels of emotional nonacceptance (Gratz, Bornovalova, Delany-Brumsey, Nick, & Lejuez, 2007) and lower levels of emotional understanding (Shipman et al., 2000). Moreover, recent evidence suggests that emotional abuse uniquely predicts difficulties with emotion regulation when sexual abuse is controlled for Burns, Jackson, and Harding (2010) and a composite of emotional abuse and neglect predict difficulties with emotion regulation after controlling for physical abuse, sexual abuse, and physical neglect (Bradbury & Shaffer, 2012). Thus, while data suggest a relation between childhood abuse and difficulties with emotion regulation, emerging evidence suggests that this relationship might be largely accounted for by emotional abuse specifically. Similarly, a robust body of research also indicates a link between difficulties with emotion regulation and BPD pathology. Individuals with BPD diagnoses report having general difficulties with emotion regulation (Kuo & Linehan, 2009), are less willing to endure distress in the pursuit of goal-directed behavior (Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006), and have higher emotional avoidance (Bijttebier & Vertommen, 1999) than non-clinical controls. Further, higher BPD features are associated with lower emotional awareness (Leible & Snell, 2004) and elevated fear of emotions (Yen, Zlotnick, & Costello, 2002). Recent neuroimaging findings also corroborate these data, suggesting that, relative to non-clinical controls, individuals with BPD diagnoses have deficits in their ability to implement specific emotion regulation strategies such as cognitive reappraisal (Koenigsberg et al., 2009 and Lang et al., 2012). Only one study has evaluated whether difficulties with emotion regulation is a potential mechanism explaining the link between childhood abuse and BPD features. Among a sample of 450 psychiatric inpatients, van Dijke, Ford, van Son, Frank, and van (2013) reported a positive correlation between the presence of a traumatizing event by a primary caregiver (TPC) and severity of BPD features. Moreover, when testing for the indirect effect of both over and underregulation of affect, results indicated that underregulation (and not overregulation) partially mediated the relationship between TPC and BPD feature severity. While this study provides greater clarity into the relationship between childhood abuse, emotion dysregulation, and BPD features, what remains unknown is whether there are unique and specific relations between different subtypes of childhood abuse, emotion dysregulation, and BPD features. Thus, the current study aims to delineate the specificity of these relations by examining (1) whether childhood emotional abuse is uniquely associated with BPD feature severity when other forms of abuse are controlled for, and (2) whether difficulties with emotion regulation is a factor specifically associated with childhood emotional abuse (and not other forms of abuse), that links its relationship with BPD feature severity. In order to build directly upon extant literature which has predominantly examined the relationship between childhood abuse (versus neglect) and BPD pathology, only subtypes of childhood abuse (i.e., sexual abuse, physical abuse, and emotional abuse) were examined. Consistent with the literature to date, we hypothesized that, when controlling other forms of abuse, frequency of childhood emotional abuse would be uniquely associated with severity of BPD features. Moreover, we also hypothesized that the relationship between childhood emotional abuse and BPD feature severity would be explained by difficulties with emotion regulation.

See Table 1 for means, standard deviations, and ranges for all variables and Table 2 for correlations among all variables in the analyses. Gender (Pearson's r = .09, p = .18), age (Pearson's r = −.11, p = .12), and level of education (Pearson's r = .01, p = .85) were not significantly associated with BPD severity and therefore, were not entered as covariates in the primary analyses. Table 1. Descriptive statistics for variables included in primary analyses. Variable Mean (SE) Range Childhood emotional abuse 9.00 (.28) 4.00–25.00 Childhood sexual abuse 5.97 (.20) 3.00–25.00 Childhood physical abuse 6.70 (.19) 3.00–25.00 Non-acceptance of negative emotions 12.83 (.36) 6.00–30.00 Lack of emotional awareness 15.25 (.33) 5.00–30.00 Lack of emotional clarity 11.47 (.26) 3.00–25.00 Difficulties engaging in goal-directed behaviors when distressed 15.77 (.31) 5.00–25.00 Difficulties controlling impulsive behaviors when experiencing negative emotions 12.45 (.35) 6.00–30.00 Limited access to emotion regulation strategies perceived as effective 17.75 (.46) 7.00–40.00 BPD severity .70 (.04) 0–3.04 Note. Childhood abuse subtypes reflect summed totals from the emotional, sexual, and physical abuse subscales of the Childhood Trauma Questionnaire – Short Form (CTQ-SF). Difficulties with emotion regulation subscales reflect summed totals from each subscale of the Difficulties with Emotion Regulation Scale (DERS). BPD severity reflects the mean score on the Borderline Symptom List-23 item (BSL-23). Table options Table 2. Pearson correlations between BPD severity, childhood abuse subtypes, and difficulties with emotion regulation subscales. 1 2 3 4 5 6 7 8 9 10 1. BPD severity – 2. Childhood emotional abuse .42** – 3. Childhood sexual abuse .11 .28** – 4. Childhood physical abuse .13* .55** .23** – 5. Nonacceptance of negative emotions .60** .36** .10 .11 – 6. Lack of emotional awareness .12 .09 .06 .15* .08 – 7. Lack of emotional clarity .46** .20** .11 .11 .42** .53** – 8. Difficulties engaging in goal-directed behaviors when distressed .49** .24** .06 .04 .47** .08 .39** – 9. Difficulties controlling impulsive behaviors when experiencing negative emotions .67** .46** .20** .24** .62** .18** .47** .52** – 10. Limited access to emotion regulation strategies perceived as effective .69** .41** .15* .18** .73** .17** .51** .66** .73** – Note. BPD, borderline personality disorder. * p < .05. ** p < .01. *** p < .00. Table options We applied cut-off scores that have been previously used in the literature in order to examine the presence/absence of each abuse subtype (Bernstein & Fink, 1998): sexual abuse ≥6, physical abuse ≥8, and emotional abuse ≥9. Among the sample, 11.8% (n = 4) of males and 20% (n = 42) of females endorsed the presence of sexual abuse, 26.5% (n = 9) of males and 23.6% (n = 49) of females endorsed the presence of physical abuse, and 38.2% (n = 13) of males and 42.3% (n = 88) of females endorsed the presence of emotional abuse. Although BSL cut-offs do not exist, Bohus et al. (2009) reported a mean score of 2.05 (SD = .90) in a clinically diagnosed BPD sample. Though the mean score of our study suggests that this group was not similar to that of Bohus and colleagues (M = .70, SD = .68), participants’ BSL scores (0–3.04) suggest that the sample included individuals ranging in BPD feature severity.