The Link Between Maltreatment in Childhood and The Development of Borderline Personality Disorder by Jaime Burns

Borderline Personality Disorder, also known as BPD, is estimated to be present in 1.6%, or approximately four million people in the United States population alone [Chapman, 2021.], yet the disorder continues to lack sufficient scientific and psychiatric research. Out of the disorders’ many complex aspects, perhaps one of the most important in my eyes, is what impact the nature of ones’ upbringing and early development has on one's' potential development of Borderline Personality Disorder later in life (in which adolescence is marked as a significant period for symptoms to become apparent). Maladaptive parenting, sexual abuse and one developing in an overall adverse family environment has been, and continues to be, implicated in psychiatry as some significant environmental factors that evidently, may precede a personality disorder diagnosis later in life. Trials show many borderline-diagnosed individuals recall some forms of childhood maltreatment, including but not limited to sexual abuse, low warmth from parents, and harsh punishments in their development, at much higher rates than those of the healthy individuals against which they were compared to. [Steele, 2019] This report will evaluate and challenge these scientific and psychiatric findings relating to sexual abuse and maladaptive parenting (specifically low warmth from parent and harsh punishments) as possible mediating factors preceding ones’ diagnosis of Borderline Personality Disorder later in life. 

Borderline Personality Disorder, also known as BPD, in abstract, is recognised for the abnormal, fixed patterns of thinking it causes, significantly, ones’ intense fear of real or imagined abandonment, which as a direct result may lead to recurrently unstable interpersonal relationships. Emotional disregulation is also a significantly-recognised symptom in those diagnosed with the disorder. Many patients have been recorded to display frequent, wild, and intense emotional reactions, often disproportionate to the preceding event. The Diagnostic and Statistical Manual of Mental Disorders (DSM) identifies 5 of 9 of the following criterias are required to be met for ones’ diagnosis of borderline personality disorder: chronic feelings of emptiness, unstable emotional reactions to day-to-day events (this may include periods of sadness, anger, numbness, etc, all of which are generally severe in intensity, lasting anywhere from a few minutes to days), frantic efforts to avoid real or imagined abandonment, persistently unstable sense of self and self-image, impulsive behaviour (eg. hypersexuality, substance abuse, overspending), difficulty in controlling anger, which may be extremely intense and frequent, significant patterns in unstable and at times, intense interpersonal relationships, recurring suicidal ideation, self-harming behaviours and/or attempts at one’s life, and symptoms of dissociation. It is also important to recognise ‘splitting’, which is not listed as an actual symptom of the disorder, but is instead a subconscious coping mechanism commonly used by Borderline individuals, especially in periods of stress or intense emotion. Splitting is typically periodic, and causes one to view all aspects of their life, including people, in extreme absolutes- ‘black and white’, or ‘good and bad’: there is no inbetween. While used as a coping mechanism, splitting significantly affects one's emotional responses and reactions, and can be exhausting to both the borderline individual and those around them: unstable relationships remain one of the most commonly-reported symptoms in patients.

Borderline Personality Disorder, evidently, has many factors that precede a diagnosis later in life: there is an increased likelihood of offspring inheriting the disorder from a parent with the disorder, some studies showing over 50% inheritability [Amad, A., Ramoz, N., Thomas, P., Jardri, R., & Gorwood, P. (2014)]. From my own view, it could be important to take into account that parents with Borderline Personality Disorder can actually produce children with the disorder not through genetic predisposition, but instead through maltreatment in the childs’ development, and statistics on this could be skewed: genetics may be assumed as the sole preceding factor for a childs’ diagnosis, if negative early environmental factors are not discussed, are disregarded, or unknown. Nevertheless, environmental factors, particularly in childhood, continue to be heavily implemented in psychiatry as a factor in the development of Borderline Personality Disorder. This report specifically discusses the following environmental factors: low warmth from parents, harsh punishments, and sexual abuse. ‘Low warmth’ may refer to using shame, hostility or ridicule against a child when in times of high psychological stress, eg. during temper tantrums, when unable to sleep, when sick or injured. The child, instead of being provided care, support, and healthy ways to cope with the situation, is instead having their emotions invalidated and disregarded; they are essentially being told to hide them away. This is just one form of malaptative parenting that may lead to emotional dysregulation. According to US psychologist Marsha Linehan’s 1993 (updated in 2009) biosocial theory of Borderline Personality Disorder, emotional dysregulation is a core symptom of the disorder. Linehan theorises the disorder stems almost entirely from emotional dysregulation, which emerges from ‘transactions between individuals with biological vulnerabilities and specific environmental influences.’ [Linehan, M. M. (2009)]’. However, here I believe it necessary to note that emotional dysregulation is merely one symptom of the disorder: it should be recognised that while yes, a child can very well develop emotional dysregulation due to maladaptive parenting, the disorder in it’s entirety hasn’t necessarily developed. 

Harsh punishment from parents is a significant environmental factor implemented as a mediating factor in the development of Borderline Personality Disorder. According to M. A Straus’ 1998 Parent-Child Conflict Tactics Scale, a scale created and used to identify maltreatment between parent and child, parent disciplinary practises can be divided into five categories. The first category is classified as ‘non-violent’ which may include removing privileges, or explaining why something is wrong.Non-violent disciplinary action is deemed to be positive and healthy for a childs’ development. The second category is classified as ‘psychologically aggressive’, which may include yelling or name-calling, and the third category being ‘physically violent’, which includes physical abuse: hitting, slapping, or beating a child (this includes the widely-used practice of spanking). The fourth category is neglect, defined here as: The fifth category, which we will discuss further in detail later in the report, is reserved for sexual abuse, which the scale defines as “unwanted sexual touch” and “forced sexual contact”. In this report, I will refer to actions under categories ‘psychologically aggressive’ and ‘physical assault’ as harsh punishment; these may include verbal acts by the parent which ‘cause psychological pain or fear on the part of the child [M. Straus, 1998], such as yelling, swearing, using threatening words, etc, as well as physically-harmful behaviours, which range from low in severity (spanking) to high severity (punching, kicking, slapping, etc). Any form of these behaviours performed against a child may be detrimental to their development: growing evidence in psychiatry supports the fact there is a significant link between a range of the above actions and the development of Borderline Personality Disorder later in life. A trial led by S. D Stepp, conducted to explore ‘bidirectional effects of parenting on the development of BPD symptoms in adolescence’ [Stepp, S. D., Whalen, D. J., Scott, L. N., Zalewski, M., Loeber, R., & Hipwell, A. E. (2014).], specifically examined the impact of child-reported harsh punishment practices in 2,451 adolescent girls (aged 14-17) diagnosed with Borderline Personality Disorder. The trial was concluded to have found a ‘moderate’ association between symptoms of Borderline Personality Disorder and parental behaviour that included the use of harsh punishment and low warmth. I find it important to mention that this trial referred to the Conflict Tactics Scale to identify which actions can be classified as harsh punishment. For one question in the trial, girls were asked to report on how often they experienced harsh punishment from their parents in the past year, referring specifically to the actions of shouting, yelling, screaming (psychologically aggressive behaviour) as well as spanking (moderately severe physical assault). The Stepp trial was concluded to have found evidence relating the girls’ elevations in their BPD symptoms within one year to elevations in the use of harsh punishment and low warmth from parents in the same time period, therefore suggesting a relationship between these forms of maltreatment and the development of Borderline Personality Disorder later in life. An important acknowledgement that should be made is that this trial only supports specific forms of maltreatment, low warmth and harsh punishment, and therefore should not be used as evidence to justify any other forms of maltreatment as a mediating factor of Borderline Personality Disorder: other actions were not explored and therefore cannot refer to Stepp’s report as evidence. Another acknowledgement, or rather a personal problem I have with these statistics is that the trial was merely child-reported: ones’ recorded experiences with their parents are simply taken for word; there is no way to determine if the victims are telling the truth. In a disorder where negative or unstable relationships with family, including parents, are incredibly prevalent, it is important to acknowledge that the childs’ responses may be inaccurate or exaggerated, possibly to paint their parents in a bad light, and therefore could result in inaccurate data and false conclusions. Furthermore, the Stepp trial took data solely from adolescent girls (aged 14-17) - the evidence taken does not necessarily reflect other age groups, nor males with Borderline Personality Disorder. These acknowledgements made, I do think this trials’ evidence is useful and rectifies my belief that there is a moderate link between the maltreatment practises of harsh punishment and low warmth in childhood and the development of Borderline Personality Disorder later in life. 

Another form of maltreatment in childhood that has been identitfied in psychiatry as a possible mediating factor in ones’ development of Borderline Disorder is sexual abuse. The implication that sexual abuse and borderline personality disorder are linked makes me curious, as I personally wouldn’t say I know enough information about the subject, and the link between the two is not as obviously clear to me, at least compared to the other two factors (low warmth, harsh punishment) included in this report. To my surprise, the studies I researched had contradicting conclusions. A 2013 cohort study conducted by Marina A. Bornovalova studied the link between seuxal, emotional, and physical abuse in childhood and Borderline Personality Disorder traits at age 24. ‘Sexual abuse’ in this specific trial refers to two questions participants were asked: if they ‘had sexual contact with anyone five or more years older than him/her before age 13, and whether anyone (friend, relative, etc) ever used pressure, force, or physical threats to make the participant engage in some sort of unwanted sexual contact.’ [Bornovalova, M. A. (2013).], sexual abuse in this trial was specifically defined to include any form of sexual exploitation under the age of 18. To my surprise, the trial’s results actually show more evidence linking genetic deposition as a more significant mediating factor compared to the various forms of child abuse the trial explored (emotional child abuse, physical child abuse, and sexual child abuse). The trial concluded, “Genetic factors accounted for most of the association between BPD and CA.” [Bornovalova, M. A. (2013).] Furthermore, I learned these results were consistent with another clinical trial, Distel et al. (2011), which also concluded that genetics are a more significant mediating factor in the development of Borderline Personality Disorder rather than exposure to traumatic events. It’s important for me to note here that these trials did not specifically focus on sexual abuse as a possible mediating factor, but a range of traumatic life events, including but not limited to: divorce, violent assault and sexual assault. However, the results were intriguing, and give me the idea in my mind that possibly exposure to early traumatic events (which I deem to include sexual abuse, harsh punishment, and low wamrth) in childhood, could overlap with genetics as mediating factors in ones’ development of Borderline Personality Disorder. The conclusions of these two clinical trials contrast to other publications I researched. A 2018 systematic review published by Dr. Lucas Fortaleza de Aquino Ferreira, “Borderline personality disorder and sexual abuse: A systematic review”, which reviewed 40 papers based on the link between sexual abuse and borderline personality disorder, attributed sexual abuse to play a major role in the development of the BPD patients studied- particularly women. Moreso, Ferreria established that BPD patients with a history of sexual abuse presented more severe symptoms of the disorder, such as self-harm and dissociation, as well as PTSD (post-traumatic-stress disorder). [de Aquino Ferreira, L. F. (2018)]. Another finding of research I looked into was a study investigating reported pathological childhood experiences associated with the development of Borderline Personality Disorder, conducted in 1997 and led by M C Zanarini. ‘Pathological experiences’ included emotional abuse, physical abuse, sexual abuse, and neglect: while sexual abuse by a male noncaretaker (along with emotional denial by a male caretaker, inconsistent treatment by a female caretaker, and being a female) were concluded to be predictors of a diagnosis with Borderline Personalty Disorder, the trial concluded that experiencing sexual abuse in childhood was “neither necessary nor sufficient for the development of borderline personality disorder”. [Zanarini, M. C. (1997)] With all of my research findings combined, I find the link between sexual abuse and the development of BPD weak and unresearched, although diagnosed patients may have a history of sexual abuse in childhood, many also experienced other forms of abuse such as physical and emotional abuse; to me, there is simply not enough strong, clear and defined research for me to to say I believe sexual abuse is a predictor of a Borderline Personality Disorder diagnosis: I think it would be more harmful to do so.

From my research into these clinical trials, systematic reviews, and other psychiatric findings, I have come to the personal conclusion that there is a moderate link between the maltreatment practises of harsh punishment and low warmth and the development of Borderline Personality Disorder, and a weak-moderate link between sexual abuse in childhood and the development of Borderline Personality Disorder. I’m also further interested in investigating the possibility that these mediating factors, and ones’ genetic predisposition, could overlap with one another into ones’ development of the disorder. I do wish more research is undertaken to more clearly establish this. I believe psychiatrists should aim to establish a more clear understanding of the parenting practises- deemed harmful or not- in Borderline patients, to continue to strengthen presently ‘moderate’ links between harsh punishment, low warmth and sexual abuse in childhood and the development of BPD later in life. Not only that, but psychiatrists could also implement the practise of delving into patients’ genetic predispositions to the disorder, by acknowledging not only the parents mental health history, but that of grandparents and siblings. Coinciding with the patients’ early childhood circumstances, i.e identifying forms of possible maltreatment that have occurred, these practises will be helpful in that it helps psychiatrists be able to draw a firmer, more-defined conclusion on the link between maltreatment in childhood and the development of Borderline Personality Disorder, a link I personally consider to be moderate.