Borderline personality disorder is a personality disorder characterized by a passive pattern of instability of interpersonal relationships, self-image and affects and marked impulsivity by early adulthood and present in a variety of contexts and is estimated to be about 2% of general population. 1.5% of that population are females and 0.5% are males (Sutartz et al., 1990). Theories of the etiology of BPD suggest that a combination of: a) A genetic history of impulsivity and substance abuse b) An early childhood characterized by a troubled relationship with the child's primary attachment figure and c) Later childhood experiences that include sexual abuse (Zittel & Westen, 1998). About 75% of those diagnosed as having borderline personality disorder have a history of sexual abuse (Duilt et at., 1990). Some authors suggested that sexual abuse is the main etiological factor in the development of borderline personality disorder (Zanarini et at., 1997). Childhood sexual abuse is frequently described by survivors as a violation of body boundaries and trust that can affect the survivors relationships with herself, her body and others.
When a child is abused, she feels out of control and disempowered, she is invalidated. Thus her relationship to her sense of self and her sense of who she is damaged (Schachter et at., 1999). Studies indicate that guilt, self-blame, low self-esteem perceptions of helplessness and chronic danger and hyper vigilance to danger are common feelings of powerlessness may be manifested as passivity or conversely as controlling behavior.
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Long-term sequel includes depression, anxiety, anger, fear, dissociation and numbing of feelings. Actions frequently used by survivors to cope with or avoid distress or pain include substance abuse and addiction, self-mutilation, suicide attempts and eating disorders (Schachter et at., 1999). Characteristics that make an experience more or less serious include the identity of the perpetrator, the severity of the sexual acts; duration and frequency of the abuse and whether force was used (Finkelhor, 1987). Abuse by parent figures ranges from 16% in non clinical samples to as high as 62% in clinical sample (Brelinerd Elliot, 1996). Percentage of subjects reporting penetration ranges from 4-25% in non clinical sample to 43-48% in clinical samples (Kendall-Tackett et al., 1993). Not surprisingly, use of force has been shown to increase the severity of reaction to sexual abuse (Elwell & Ephross, 1987). Sex with a parent predicted chronic feelings of hopelessness and worthlessness in the entire borderline personality disorder cohort and intolerance of being alone ongoing sexual abuse predicted parasuicide regression in therapy and some of the symptoms that are well-known facets of interpersonal functioning among patients with borderline personality disorder (Qunderson, 1984).
Also, childhood sexual abuse and early stressors result in both acute and chronic changes in the activity and regulation of the hypothalamic-pituitary-adrenal axis (HPA), chiefly in the form of hypersecretion of CRH and ACTH with accompanying adrenal and pituitary hypertrophy chronic elevation of cortisol, in turn ultimately decrease level of serotonin in the brain (Zittel & Westen, 1998), because glucocorticoids stimulate serotonin breakdown (Maes, Meltzerlty, 1995), decreased serotonin has been correlated with hostility, impulsivity and self-directed aggression in
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patients with BPD (Zittel & Westen, 1998). Unlike working with some personalities, such as antisocials or schizotypals, borderline disturbances are much more amenable to personality change and reorganization psychodynamic psychotherapy for BPD takes many verities, although two approaches with differing principles tend to dominate one is the approach of Kernberg which focus on confronting aggression and manipulation; the other, a self-psychological approach, was derived from Kohut's work by Alder, Bute and otfiers they take a more gentle approach, using empathic attunement with borderline patients torty to help them internalize soothing functions that they never developed in childhood. Dialectical behavior therapy was developed especially for individuals with complex problems associated with BPD as a problem with emotional regulation, which is believed to result from a combination of biological irregularities, dysfunctional environments and interactions between these overtime pharmacotherapy can be useful in treating depressive symptoms, anger and some of the cognitive disturbance in borderline patients but it is rarely appropriate as a treatment by itself, anticonvulsantsm naltrexone and risperidone have been used for treatment.
In this study, forty borderline personality disorder patients who visited the psychiatric outpatient clinic of Benha University Hospital were divided into 2 groups according to exposure to childhood sexual abuse (abused and non-abused). All participants include in the study were subjected to: a) Structured clinical interview for DSM-III-R personality disorders (SCID-II) b) Sexual abuse questionnaire c) Present state examination-10 (PSE-10)
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d) The defense style questionnaire-40 (DSQ-40) e) Determination of the level of platelet serotonin We found that female : male ratio of borderline disorder is 4:1, about 60% of our patients reported a childhood history of sexual abuse with higher percentage of women who were abused than men with mean age of abuse for both sexes about 10.6 years old? 12.5 has been abused by a member of nuclear family, 33.3% had been abused by a member of extended family, 54.2% had been abused by a stranger, 33.3% had been abused by multiple abusers. Penetration occurred in 33.3% of cases, while touching genitals occurred in 54.2%, trial of penetration occurred in 12.5%, 71% of sexually abused BPD patients are single 12.5% divorced and only 16.5% are married. Compared with 50% of non-sexually abused BPD patients are single 6.2% divorced and 31.4% are married so, marital status shown a highly significant difference between abused and non-abused participants. The mean of participants of abused BPD patients was lower than that of non-abused BPD patients.
In relation to Comorbidities, anxiety disorders were present in 80% of BPD (83.1% of abused and 75% of non-abused). Generalized anxiety disorder was higher among the abused BPD than the non-abused BPD. This can be explained by that, early abuse would modify a child's assumptions about self and world. Mood disorders are present in 80% borderline patients depression was significantly higher among sexually abused than non-abused borderline patients which could be explained by that childhood sexual abuse is an important early stressor that may predispose individuals to adult-onset depression by means of dysregulation of the hypothalamic-ptuitary-
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adrenal axis. Somatoform disorders presented in 25% of borderline patients with higher presentation in sexually abused patients, dissociative disorders were present in 75% of BPD patients. Substance abuse was present in 25% of BPD with higher presentation in abused patients than non-abused patients which may be due to causal relationship between childhood sexual abuse and the development impulsive behavior such as substance abuse. 67.5% of borderline personality disorder patients attempted suicide, with higher presentation in sexually abused than non-abused. 83.3% of abused borderline patient attempted suicide of whom 35% attempted suicide more than 4 times compared to 43.7% of non-abused borderline patients of whom no one attempted suicide more than 4 times which arise from a background of impulsive aggression which may represent a primary behavioral dyscontrol in this disorder, also platelet serotonin level is lower in borderline patients who attempts suicide 100% of BPD patients experienced penetration attempted suicide and 100% of BPD patients who were abused by their parents attempted suicide which could be explained by that sex with a parent predicted feelings of hoplessness and worthlessness.
Self-mutilation present in 72.5% of BPD, with higher presentation in sexually abused than non-sexually abused. Self -mutilation present in 100% of abused by 1st degree relative compared to 85.7% of abused by others, 100% of abused with penetration compared to 81% of abused without penetration, 77% of abused less than 1 month to 100% of abused more than 1 year, which indicate strong relationship between the severity of childhood sexual abuse and self-destructive symptoms of BPD.
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Significant psychological impairment is affecting sexually abused borderline patients which could be explained by that sexual abuse damages one's attachments at an early age. Sexually abused BPD patients use more immature defense mechanisms than non-abused do and the most immature defense styles used by abused BPD were projection, autistic fantasy, displacement, passive-aggression and somatization. The strongest link with severity of childhood sexual abuse was found for projection especially those abused by a member of 1st degree relatives. The content of platelet serotonin was higher in borderline disorder patients than healthy controls platelet 5-HT was lower in sexually abused than non-abused sexually borderline personality patients.
This can be explained by the fact that childhood sexual abuse and early stressors acute and chronic changes in the activity and regulation of hypothalamic-pituitary-adrenal axis, elevation of cortisol decrease level of serotonin. |
