Childhood maltreatment, anxiety disorders and outcome in borderline personality disorder
Introduction
Borderline Personality Disorder (BPD) is a fairly common psychiatric disorder. About 2% of the general population is diagnosed with BPD. In clinical populations, BPD is the most common personality disorder, with a prevalence of 10% of psychiatric outpatients and 20% of psychiatric inpatients (Korzekwa et al., 2008; Leichsenring et al., 2011; Skodol et al., 2002a; Tomko et al., 2014). BPD is a serious mental disorder associated with severe behavioural and emotional dysregulation, severe functional impairment, a high rate of comorbid mental disorders, a high rate of suicide, and substantial costs to society (Leichsenring et al., 2011; Lieb, 2004; Oldham, 2006; Skodol, 2002; Winsper, 2016).
The literature indicates a high rate of comorbid mental disorders in BPD, with increased odds of major depressive disorders, anxiety disorders, post-traumatic stress disorders, substance use disorders and eating disorders (Skodol et al., 2002b; Winsper, 2016; Zimmerman and Mattia, 1999). Anxiety disorders are estimated to be three times more frequent in BPD than in the general population (Silverman et al., 2012), with an estimated lifetime prevalence of 48% for panic disorder, 12% for agoraphobia, 46% for social phobia, 32% for simple phobia, 14% for generalized anxiety disorder (GAD), 16% for obsessive-compulsive disorder (OCD) and 56% for post-traumatic stress disorder (PTSD) (Harned and Valenstein, 2013; Zanarini et al., 1998).
Longitudinal studies show that the prevalence of anxiety disorders in BPD declines with time. Remission is frequent, but recurrence is also common, which suggests that anxiety disorders often follow an intermittent course in subjects with BPD (Silverman et al., 2012; Zanarini et al., 2014). Ansell et al. (2011), over the course of a seven-year study, suggested that individuals with BPD are at higher risk of new onset anxiety disorder episodes, specifically panic disorder and GAD, and have an increased risk for OCD relapse (Ansell et al., 2011). The course of BPD has been shown to influence anxiety disorders, with an improvement of BPD symptoms associated with remission of GAD and PTSD, and a worsening of BPD predicting a relapse of social phobia (Keuroghlian et al., 2015). Moreover, numerous studies have revealed that anxiety disorders negatively impact BPD, with lower remission and a higher risk of suicidal and self-damaging behaviours (Harned and Valenstein, 2013; Nepon et al., 2010),
Severity of anxiety also seems to be higher in BPD. In their study, Zanarini and al. found that BPD sufferers reported twice as many severe anxiety symptoms than the comparison group. They identified two predictors for severe anxiety: non-sexual childhood abuse and neuroticism traits (Zanarini et al., 2014). Gibb and colleagues have also demonstrated a high association between social phobia and PTSD and childhood emotional abuse (Gibb et al., 2007).
Anxiety disorders and childhood maltreatment are both named as factors influencing symptomatology and prognosis in BPD. Literature about the relation between these two factors is also beginning to see the day. Negative experiences in childhood are conducive to vulnerability to psychopathology and many studies have shown an association between childhood maltreatment and mental health illness in adulthood, such as depression, anxiety disorders and PTSD (Gibb et al., 2007; Stein et al., 1996). In BPD particularly, many studies have focused on the association between the disorder and childhood maltreatment (Battle et al., 2004; Herman et al., 1989; Johnson et al., 2001, 1999; Nickel et al., 2004; Weaver and Clum, 1993; Winsper et al., 2016; Ibrahim et al., 2018; Widom et al., 2009) and show that all types of maltreatment (sexual, physical and emotional abuse) increase the risk of BPD and its severity, including suicidal behaviours (Ibrahim et al., 2018; Kuo et al., 2015; Lobbestael et al., 2010). In the general population as well as in clinical populations, both childhood maltreatment and anxiety disorders have been associated with suicide ideation and attempts (Bentley et al., 2016). Pavlova and al. studied childhood maltreatment, anxiety disorders and severity of the disorder in bipolar disorder, finding a positive correlation between these factors (Pavlova et al., 2018). Personality disorders, childhood maltreatment and suicide have also been studied in panic disorder by Ozkan and al. These studies show increased severity of panic disorder and suicide attempts when comorbid personality disorder was present. Sexual abuse was associated with BPD and early onset panic disorder (Ozkan and Altindag, 2005).
Despite these observations, only a few studies have investigated anxiety disorders and their link with childhood maltreatment and severity of disorder in patients suffering from BPD (Nepon et al., 2010; Perroud et al., 2007). The aim of our study was therefore to examine the relationship between childhood maltreatment, comorbid anxiety disorders and severity of BPD, including, among other severity indexes, history of suicide attempts. To our knowledge, this is the first study evaluating the association between these factors in BPD. We hypothesized that exposure to maltreatment in childhood would be associated with increased comorbid anxiety disorders among patients with BPD and a higher severity of the disorder.
Section snippets
Sample
Three hundred and eighty-eight participants were recruited within a specialized unit providing healthcare to outpatients suffering from BPD at the Geneva University Hospital (HUG). The BPD diagnosis was established both by an anamnestic interview conducted by a psychiatrist and by a trained psychologist using the Structured Interview for Axis II Disorder-BPD part (SCID-II) (Maffei et al., 1997). Subjects meeting at least five criteria from DSM-IV-TR (Association, 2000) for BPD were enrolled
Sample characteristics
Clinical and demographic characteristics of the sample are described in Table 1. Only 74 participants (19.1%) were free of any anxiety disorder, 97 (25.0%) suffered from only one comorbid anxiety disorder, and a striking 55.9% had two or more anxiety disorders.
Social phobia was the most common anxiety disorder (42.01%), followed by panic disorder (39.1%) and PTSD (33%). GAD (28%), agoraphobia (15.2%) and OCD (14.4%) were less frequent.
Abbreviations: CTQ = Childhood Trauma Questionnaire;
Discussion
Firstly, we found that anxiety disorders were quite prevalent in BPD, with more than half of participants diagnosed with two or more comorbid anxiety disorders. The most common anxious comorbidity was social phobia (42%), followed by panic disorder (39%), PTSD (33%), GAD (28%), agoraphobia (15%) and OCD (14%). These results are supported by the literature, which not only shows that anxiety disorders are common comorbidities in BPD, but also that panic disorder, social phobia, simple phobia and
Declaration of Competing Interest
None.
Acknowledgments
The study was supported by the Swiss National Center of Competence in Research (NCCR): “Synapsy: the Synaptic Basis of Mental Diseases” [grant number: 51NF40-185897].
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These two authors contributed equally to the work