حالت طرحواره و آزار و اذیت دوران کودکی در اختلالات شخصیت مرزی و ضد اجتماعی

Abstract Complex personality disorders (PDs) have been hypothesized to be characterized by alternating states of thinking, feeling and behavior, the so-called schema modes (Young, Klosko, & Weishaar (2003). Schema therapy: A practioner's guide. New York: Guilford). The present study tested the applicability of this model to borderline personality disorders (BPD) and antisocial personality disorders (APD), and related it to a presumed common etiological factor, childhood trauma. Sixteen patients with BPD, 16 patients with APD and 16 nonpatient controls (all 50% of both sexes) completed a Schema Mode Questionnaire assessing cognitions, feelings and behaviors characteristic of six schema modes. Participants were interviewed to retrace abusive sexual, physical and emotional events before the age of 18. BPD as well as APD participants were characterized by four maladaptive modes (Detached Protector, Punitive Parent, Abandoned/Abused Child and Angry Child). APD displayed most characteristics of the Bully/Attack mode, though not significantly different from BPD. The Healthy Adult mode was of low presence in BPD and of high presence in APD and the nonpatients. Frequency and severity of the three kinds of abuse were equally high in both PD groups, and significantly higher than in nonpatients.

Introduction Recent insights have lead to the view that complex personality disorder (PD) are not characterized by one set of pathogenic schemas, but by different sets that can be activated in alternation. Young for instance, has proposed schema modes as relatively independent organized patterns of thinking, feeling and behaving that underlie the different states of severe PD patients (Young, Klosko, & Weishaar, 2003). In Young's view borderline personality disorder (BPD) and antisocial personality disorder (APD) patients are characterized by various pathogenic schema modes. They are assumed to suddenly flip from one mode into an-other, especially in reaction to environmental changes caused by important events. Young hypothesized that four modes are central to BPD: the Detached Protector, the Angry and Impulsive Child, the Abandoned Child (in following with the second author in order to emphasize the central role of abuse, this mode will be further referred to as the Abandoned and Abused Child (Arntz & Bögels, 2000)) and the Punitive Parent. There also is a Healthy Adult mode, however due to extreme psychopathology of these patients it is assumed to be of low presence. Young's schema-mode model is the basis of his schema therapy for severe PD, an increasingly popular therapeutic approach of which the effectivity is high (Giesen-Bloo et al., 2005; Nordahl & Nysæter, 2005). When patients find themselves in the Abandoned and Abused Child mode, they feel the enormous pain and fear of abandonment caused by their abusive history which expresses itself in depressive, fearful, desperate, and inferiority feelings. This mode can be evoked by (perceptions of) (threatening) abandonment and abuse. Sometimes the patient becomes rebellious against the (supposed) injustice (s)he had experienced; this elicits the state of the Angry and Impulsive Child in which all bottled up aggressive feelings discharge so that anger, manipulation and greed are acted out. The evocation of these two child-modes usually leads to activation of self-punishing moral rules, mostly the direct internalizations of the punishing behavior of one of the caregivers, accounting for the symbolic mode name of the Punishing Parent. In this mode, the patient is afraid (s)he did something wrong, sees him/herself as evil and worthless because of feelings and desires that are (threatened to be) activated. As a consequence of this self-directed anger and hate develops and the patient will punish him/herself in one or another way. Most of the time however, the patient finds him/herself in the Detached Protector mode, where (s)he does not have to feel the emotions and pain caused by the three other modes. The patient does not feel emotions, is unaware of any problems and is seemingly compliant (Arntz & Bögels, 2000; Arntz & Kuipers, 1998; Young et al., 2003). As to APD, Young states that beside the Healthy Adult mode and the four modes described above, there is a fifth pathological mode present in antisocials called the Bully and Attack mode. In this mode, the antisocial hurts other people to overcompensate or to cope with mistrust, abuse, deprivation and defectiveness (Young, 2002; Young et al., 2003). A study by Arntz, Klokman, and Sieswerda (2005) investigated whether the four maladaptive schema modes are specific for BPD patients and whether BPD-relevant stress specifically increases one of the modes, the Detached Protector mode. The results indicated that BPD patients were indeed characterized by the modes. The stress induction induced negative emotions in all groups, but the BPD group was unique in that the Detached Protector increased significantly more than in cluster-C PD patients and nonpatient controls (all women). The hypothesized similarity in schema modes of BPD and APD has not been studied yet. Nevertheless, at least two sets of empirical findings suggest that the overlap in schema modes may be considerable. First, it has been noted that there is a large overlap in symptomatic expression of the two PDs. Several DSM-IV diagnostic criteria of BPD and APD are quite similar, such as affect instability, inappropriate, intense and poorly controlled expression of anger and impulsivity that is potentially self-damaging (Blais & Norman, 1997; Holdwick, Hilsenroth, Casttebuty, & Blais, 1998). Furthermore, epidemiological figures point to high percentages of overlap; between 10 and 47% of BPD patients also meet the criteria for APD and about 70% display antisocial behavior (Paris, 1997; Widiger, Frances, & Trull, 1987; Zanarini & Gunderson, 1997). Averaged over studies approximately 70% of the APD patients meet BPD criteria (Widiger & Corbitt, 1997). Furthermore, while the prevalence in the community of both BPD and APD is about 1–2%, the sex distribution for APD is 80% male and for BPD 80% female. This would seem to make them ‘mirror image’ disorders. The gender difference could account to a large degree for the differences between BPD and APD; the differences in behavior being aggressiveness in APD and victimization in BPD could be a reflection of gender differences between men who more frequently display externalizing behavior and women who show more internalizing behavior. It has even been suggested that the two actually concern one underlying disorder, which expresses itself in BPD with women and in APD with men (Hudziak et al., 1996; Widiger & Corbitt, 1997; Paris, 1997). Second, there also seems to be a large overlap in etiological factors. Numerous studies over the past decade have pointed out the frequent occurrence of childhood trauma in patients with BPD. Between 1987 and 1992, eleven studies confirmed this high incidence of childhood trauma in borderline patients (Sabo, 1997). There are also studies reporting a positive relation between childhood abuse and APD (Burgess, Hartman, & McCormack, 1987; Dodge, Pettit, Bates, & Valente, 1995; Dutton & Hart, 1992; Horwitz, Widom, McLaughlin, & White, 2001; Marchall & Cooke, 1999; Pollock et al., 1990; Wallen, 1992). The DSM-IV states that childhood abuse or neglect increases the probability of a conduct disorder evolving in APD (APA, 1995). Burgess et al. (1987) have suggested a link between sexual abuse in childhood and later externalizing social deviant behavior. Dutton and Hart (1992) decided from file research of 604 male prisoners that men who were abused in childhood are three times more at risk of displaying violent behavior compared to nonabused men. Despite the fact that these data suggest a central role of childhood abuse in both BPD and APD, there are—to our knowledge—only two studies that directly compared the prevalence and severity of abuse between both groups. Zanarini and Gunderson (1997) found in both groups substantial figures of childhood neglect and abuse, although verbal abuse and emotional withdrawal were reported by a significantly higher percentage of the BPD group compared to the APD group. A study by Herman, Perry, and van der Kolk (1989) found that BPD patients gave significantly higher reports of physical, sexual and witnessing violence traumas than patients with borderline traits and persons with no borderline diagnoses. No association was found for APD and trauma. However, this study did not concern a systematic comparison between both groups, instead BPD patients were compared with a group of persons with borderline traits and with a mixed nonborderline control group with schizotypal PD (N=6N=6), APD (N=6N=6) and bipolar II affective disorder (N=11N=11) (Herman et al., 1989). The aims of the present study were twofold. Firstly, to assess and compare the presence of the hypothesized schema modes in borderlines, antisocials and nonpatient controls. Secondly, the direct comparison of childhood abuse history in the three groups. In this study, gender was equally divided within both groups so that the probability to detect disorder-specific results is increased. This is of particular interest since gender plays an important role in the prevalence of abuse and the coping behavior of abused persons; girls are at two to three times greater risk for sexual victimization and women more often internalize the anger accompanying abuse, while men more often show an externalizing coping style (Carmen, Rieker, and Mills, 1984).

3. Results 3.1. Schema modes in BPD and APD patients The reliability of the Schema Mode Questionnaire was analysed. Five of the 102 items did not contribute to the internal consistencies of the subscales they were hypothesized to belong to. After elimination of these items, Chronbach's alpha coefficients showed excellent internal consistencies (see Table 1). Table 1. Internal consistencies of the schema mode subscales as assessed with the Schema Mode Questionnaire Mode Internal consistency Detached Protector 0.93 Angry Child 0.87 Abandoned and Abused Child 0.94 Punishing Parent 0.91 Bully and Attack 0.87 Healthy Adult 0.88 Note. Internal reliabilities estimated by Chronbach's alpha coefficient. Table options Fig. 1 depicts the mean scores of the groups on the six schema modes. Group differences were tested by means of MANOVA and Bonferroni corrected pair-wise comparisons. A multivariate test indicates a highly significant group effect, FHot(12,78)=18.07FHot(12,78)=18.07, p<0.001p<0.001. Univariate tests revealed significant group effects on all subscales, F (2, 45)>5.59, p<.007. The groups’ means and standard deviations and contrasts between groups are presented in Table 2. Schema mode ratings by the three groups. DP—Detached Protector; AnCh—Angry ... Fig. 1. Schema mode ratings by the three groups. DP—Detached Protector; AnCh—Angry Child; AACh—Abandoned and Abused Child; PP—Punishing; HA—Healthy Adult; BA—Bully and Attack. Figure options Table 2. Mean, standard deviation and contrasts between groups of the modes Contrastij mi sdi mj sdj t P Detached Protector BPD–APD 55.39 14.38 29.01 15.11 5.94 <0.001 BPD–NPCo 55.39 14.38 5.42 5.76 11.24 <0.001 APD–NPCo 29.01 15.11 5.42 5.76 5.31 <0.001 Angry Child BPD–APD 49.80 10.24 27.54 14.26 5.65 <0.001 BPD–NPCo 49.80 10.24 13.67 8.02 9.17 <0.001 APD–NPCo 27.54 14.26 13.67 8.02 3.52 <0.001 Abandoned and Abused Child BPD–APD 62.18 13.16 25.99 12.73 9.07 <0.001 BPD–NPCo 62.18 13.16 9.77 6.84 13.13 <0.001 APD–NPCo 25.99 12.73 9.77 6.84 4.07 <0.001 Punishing Parent BPD–APD 48.58 16.08 13.06 11.88 5.88 <0.001 BPD–NPCo 48.58 16.08 9.16 7.16 9.09 <0.001 APD–NPCo 13.06 11.88 9.16 7.16 3.21 <0.001 Healthy Adult BPD–APD 46.37 13.10 74.26 12.83 6.48 <0.001 BPD–NPCo 46.37 13.10 81.38 10.41 8.13 <0.001 APD–NPCo 74.26 12.83 81.38 10.41 1.65 0.27 Attack and Bully BPD–APD 24.83 16.76 32.77 17.05 1.54 0.32 BPD–NPCo 24.83 16.76 15.54 8.18 1.80 0.21 APD–NPCo 32.77 17.05 15.54 8.18 3.34 0.007 Table options The BPD group scored significantly higher on the four BPD-related schema modes, and significantly lower on the Healthy Adult mode than the APD and the control group. Although borderlines tended to score higher on the Bully and Attack mode than the nonpatients, this difference did not reach significance. In turn, antisocials also scored significantly higher on the four BPD-related schema modes than the control group. However, antisocials had lower scores on these modes than borderlines did. The Bully and Attack mode was significantly higher present in the APD group than in the normal control group, but the two PD groups did not differ significantly in that mode. APD patients scored significantly higher than the BPD group on the Healthy Adult mode. In fact, the presence of this mode did not differ significantly between the APD and control group. The influence of gender on the mean scores of the modes was also analysed. A multivariate test revealed a gender effect, FHot(6,37)=2.79FHot(6,37)=2.79, p=0.024p=0.024. Univariate tests indicated that only the Bully and Attack mode was significantly stronger in men than in women, F(5,42)=4.48F(5,42)=4.48, p=0.04p=0.04. None of the modes showed a significant interaction between group and gender, F(5,42)>0.12F(5,42)>0.12, p>0.21. To summarize, the modes of the Detached Protector, the Angry Child, the Abandoned and Abused Child and the Punitive parent are indeed, as hypothesized, characteristic of BPD patients and also, but in lower degree, of APD patients. The Bully and Attack mode appeared specific for the APD group, but the difference between APD and BPD failed to reach significance. The Healthy Adult mode was of low presence in the borderlines, while the antisocials reported this mode equally high as the nonpatients. 3.2. Childhood abuse Fig. 2 demonstrates the mean composite scores of severity of sexual, physical and emotional abuse before the age of 18. A multivariate test indicated a highly significant group effect, FHot(6,84)=2.31FHot(6,84)=2.31, p<0.001p<0.001. Univariate tests also revealed significant group effects on all subscales, F(2,45)>17.02F(2,45)>17.02, p <0.001. The groups with borderline and APD reported significantly higher rates of the three kinds of abuse than the nonpatient group (see Table 3). Means of Childhood Abuse scores per group parent. Fig. 2. Means of Childhood Abuse scores per group parent. Figure options Table 3. Mean, standard deviation and contrasts between the groups of Childhood Abuse Contrastij mi sdi mj sdj t p Sexual abuse BPD–APD 14.69 9.90 10.19 9.75 1.59 0.29 BPD–NPCo 14.69 9.90 0.69 1.96 4.93 <0.001 APD–NPCo 10.19 9.75 0.69 1.96 3.35 0.007 Physical abuse BPD–APD 27.25 17.64 34.00 17.95 1.27 0.45 BPD–NPCo 27.25 17.64 4.50 6.34 4.29 <0.001 APD–NPCo 34.00 17.95 4.50 6.34 5.57 <0.001 Emotional abuse BPD–APD 44.50 12.86 43.56 14.73 0.22 0.98 BPD–NPCo 44.50 12.86 5.00 6.74 9.36 <0.001 APD–NPCo 43.56 14.73 5.00 6.74 9.13 <0.001 Table options Although BPD had higher sexual abuse scores than APD, whereas APD had higher physical abuse scores than BPD, these differences did not reach significance. Standardized zz total scores of abuse were also not significantly higher amongst borderlines than amongst antisocials, which indicates that the prevalence and severity of abuse did not differ between the two groups. Abuse data were analyzed more in detail concerning duration of the abuse, the number of perpetrators and abuse actions and the age-level at time of abuse. Inspection of these data showed borderlines experienced a higher number of sexual abuse actions compared to antisocials (means for BPD: 3; APD: 1.50). Furthermore, borderlines who were physically abused experienced this at an earlier age compared to physically abused antisocials (BPD: 84.6% before the age of 12; APD: 50% before the age of 12), while sexually abused antisocials experienced this earlier than sexually abused borderlines (APD: 81.8% before the age of 12; BPD: 46.2% before the age of 12). The data showed no difference between borderlines and antisocials concerning the duration and number of perpetrators of sexual, emotional and physical abuse. Neither did the amount of emotional and physical abuse actions and the age-level at time of emotional abuse differ between BPD and APD. The influence of gender on the mean scores of the subscales of abuse was also analysed. A multivariate test demonstrated a significant gender effect, FHot(3,40)=3.67FHot(3,40)=3.67, p=0.02p=0.02. Univariate tests show that women had significantly higher sexual abuse score than men, F(5,42)=4.57F(5,42)=4.57, p=0.038p=0.038. Although men were more often physically abused than women, this difference failed to reach significance. Multivariate interaction between group and gender was not significant, FHot(6,78)=1.75FHot(6,78)=1.75, p=0.12p=0.12, as were the univariate tests. It can be concluded that borderlines and antisocials reported substantially more sexually, physically and emotionally abuse than the nonpatient group. Prevalence and severity of abuse did not differ between borderlines and antisocials. Women reported significantly more sexual abuse than men.