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Journal of Trauma & Dissociation

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Dissociation in Borderline Personality Disorder: A Detailed Look

Marilyn I. Korzekwa MD FRCPC , Paul F. Dell PhD , Paul S. Links MD FRCPC , Lehana Thabane PhD
a c d e a b

& Philip Fougere HBA

Department of Psychiatry and Behavioural Neurosciences , McMaster University , Hamilton, Ontario, Canada
b c

Trauma Recovery Center , Norfolk, Virginia, USA

The Arthur Rotenberg Chair in Suicide Studies , St. Michael's Hospital , Toronto, Ontario, Canada
d

Department of Clinical Epidemiology and Biostatistics , McMaster University , Hamilton, Ontario, Canada
e

Biostatistics Unit , Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare , Hamilton, Ontario, Canada Published online: 06 Jul 2009.

To cite this article: Marilyn I. Korzekwa MD FRCPC , Paul F. Dell PhD , Paul S. Links MD FRCPC , Lehana Thabane PhD & Philip Fougere HBA (2009) Dissociation in Borderline Personality Disorder: A Detailed Look, Journal of Trauma & Dissociation, 10:3, 346-367, DOI: 10.1080/15299730902956838 To link to this article: http://dx.doi.org/10.1080/15299730902956838

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Journal of Trauma & Dissociation, 10:346367, 2009 Copyright Taylor & Francis Group, LLC ISSN: 1529-9732 print/1529-9740 online DOI: 10.1080/15299730902956838

1529-9740 1529-9732 WJTD Journal of Trauma & Dissociation, Dissociation Vol. 10, No. 3, May 2009: pp. 139

Dissociation in Borderline Personality Disorder: A Detailed Look

MARILYN I. KORZEKWA, MD, FRCPC

Dissociation M. I. Korzekwa in Borderline et al. Personality Disorder

Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada

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PAUL F. DELL, PhD

Trauma Recovery Center, Norfolk, Virginia, USA

PAUL S. LINKS, MD, FRCPC

The Arthur Rotenberg Chair in Suicide Studies, St. Michaels Hospital, Toronto, Ontario, Canada

LEHANA THABANE, PhD

Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; and Biostatistics Unit, Father Sean OSullivan Research Centre, St. Josephs Healthcare, Hamilton, Ontario, Canada

PHILIP FOUGERE, HBA

Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada

The objective of the present study was to assess in detail the whole spectrum of normal and pathological dissociative experiences and dissociative disorder (DD) diagnoses in borderline personality disorder (BPD) as diagnosed with the Revised Diagnostic Interview for Borderlines. Dissociation was measured comprehensively in 21 BPD outpatients using the Structured Clinical Interview for
Received 25 April 2008; accepted 20 October 2008. This study was partially funded by the Department of Psychiatry and Behavioural Neurosciences at McMaster University. An earlier version of this study was presented at the 23rd Annual Conference of the International Society for the Study of Trauma and Dissociation, November 2006, Los Angeles, CA. The authors would like to thank all the clinicians at St. Josephs Hospital Outpatients and Shelley Jordan, PhD, C Psych, at the School of Psychology, University of Ottawa. The authors report no financial or other relationship relevant to the subject of this article. Address correspondence to Marilyn I. Korzekwa, MD, FRCPC, 3rd Floor Fontbonne Building, St. Josephs Hospital, 50 Charlton Avenue East, Hamilton, Ontario, L8E 4A6 Canada. E-mail: mkorzek@mcmaster.ca 346

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DSMIV Dissociative DisordersRevised, the Multidimensional Inventory of Dissociation (MID), the Dissociative Experiences Scale pathological taxon analysis, and the Somatoform Dissociation Questionnaire. The frequencies of DDs in this BPD sample were as follows: 24% no DD, 29% mild DD (dissociative amnesia and depersonalization disorder), 24% DD Not Otherwise Specified (DDNOS), and 24% dissociative identity disorder. With regard to the dissociative experiences endorsed, almost all patients reported identity confusion, unexplained mood changes, and depersonalization. Even those BPD patients with mild DD reported derealization, depersonalization, and dissociative amnesia. BPD patients with DDNOS reported frequent depersonalization, frequent amnesia, and notable experiences of identity alteration. BPD patients with dissociative identity disorder endorsed severe dissociative symptoms in all categories. Analysis of the MID pathological dissociation items revealed that 32% of the items were endorsed at a clinically significant level of frequency by more than 50% of our BPD patients. In conclusion, the frequencies of Diagnostic and Statistical Manual of Mental Disorders (4th ed.) DDs in these patients with BPD were surprisingly high. Likewise, the average BPD patient endorsed a wide variety of recurrent pathological dissociative symptoms. KEYWORDS borderline personality disorder, dissociation, dissociative disorders

INTRODUCTION
Pathological dissociation has been described in articles on borderline personality almost since the diagnostic term was coined. Peculiar ego states . . . have been variously categorized as depersonalization, dissociation and derealization . . . as responses to anxiety, depression and rage (Gunderson & Singer, 1975, p. 5). In 1994, transient, stress-related . . . severe dissociative symptoms was added to the diagnostic criteria for borderline personality disorder (BPD) in the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSMIV]; American Psychiatric Association, 1994). Research has consistently demonstrated that levels of dissociation are significantly higher in BPD than in normal controls, persons with other personality disorders, and general psychiatric patients (e.g., Herman, Perry, & Van der Kolk, 1989; Ross, 2007; Simeon, Nelson, Elias, Greenberg, & Hollander, 2003; Zanarini, Ruser, Frankenburg, Hennen, & Gunderson, 2000). Dissociation is related to BPD in two different ways. First, some persons with a severe dissociative disorder (DD) have comorbid BPD. DD cases

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with comorbid BPD have increased morbidity and poorer functioning than DD cases without comorbid BPD (Dell, 1998; Horevitz & Braun, 1984). Dissociative identity disorder (DID) can be diagnosed in 10% to 27% of the BPD population (Conklin & Westen, 2005; Laddis & Dell, 2002; Ross, 2007; Sar, Akyuz, Kugu, Ozturk, & Ertem-Vehid, 2006; Sar et al., 2003). Conversely, BPD is diagnosed in 30% to 70% of the DID population (Boon & Draijer, 1993; Dell, 1998; Ellason, Ross, & Fuchs, 1996; Horevitz & Braun, 1984; Ross et al., 1990; Sar et al., 2003). Second, some of the persons with a primary diagnosis of BPD have one or more dissociative symptoms (but not a comorbid severe DD diagnosis). This group continues to be poorly understood in the literature. The development of pathological dissociation has been consistently linked to trauma, most strongly childhood sexual abuse (CSA; Allen, Fultz, Huntoon, & Brethour, 2002), co-occurring CSA and childhood physical abuse (Draijer & Langeland, 1999), and early and severe abuse (Carlson et al., 2001; Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997). In BPD, the rates of CSA and multiple forms of childhood abuse are higher than in other personality disorders and psychiatric control groups (Herman et al., 1989; Laporte & Guttman, 2001; Links, Steiner, Offord, & Eppel, 1988; Paris, Zweig-Frank, & Guzder, 1994). Most studies have found that in BPD, dissociation is significantly related to childhood abuse (Ross-Gower, Waller, Tyson, & Elliott, 1998; Shearer, 1994; Van Den Bosch, Verheul, Langeland, & Van Den Brink, 2003). In some BPD patients, however, dissociation appears to be mediated by other factors such as neglect, inconsistent treatment by a caregiver, fearful attachment, severe maternal dysfunction, witnessing of violence, sexual assault as an adult, or substance abuse (Shearer, 1994; Simeon et al., 2003; Van Den Bosch et al., 2003; Zanarini et al., 2000).

Measuring Dissociation in BPD

The literature on dissociation in BPD is fraught with methodological problems. First, most of the above studies failed to exclude serious DDs such as DD Not Otherwise Specified (DDNOS) and DID. Failure to control for the presence of comorbid DDs in a study of dissociation in BPD is a serious methodological inadequacy (Sar & Ross, 2006). Second, most of the studies failed to exclude substance abuse. This is important because Van Den Bosch et al. (2003) found no association between trauma and dissociation in their addicted BPD patients. Third, most of the studies on dissociation in BPD did not use a comprehensive measure of dissociation; instead they used screening tests such as the Dissociative Experiences Scale (DES; E. M. Bernstein & Putnam, 1986). The DES contains several items that tap normal dissociative experiences (N. G. Waller & Ross, 1997), it does not assess the entire domain of pathological dissociation (Dell, 2006b), and it does not diagnose DDs.

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Only a few studies have used a comprehensive measure of dissociation to study dissociation in BPD. In our view, a list of the most rigorous dissociation instruments would include at least the DES-Taxon scale (DES-T), the Somatoform Dissociation Questionnaire (SDQ-20), the Structured Clinical Interview for DSMIV Dissociative Disorders (SCID-D), and the Dissociative Disorders Interview Schedule (DDIS). The DES-T (N. G. Waller, Putnam, & Carlson, 1996) consists of eight items from the DES that describe dissociative amnesia (DA), depersonalization, derealization, and identity alteration or confusion. The DES-T differentiated patients with severe DDs from controls in two studies (Allen et al., 2002; N. G. Waller & Ross, 1997) but not in a third study (Modestin & Erni, 2004). It has been suggested that high DES scores in BPD may be a mixture of nonpathological and pathological dissociation (Goodman et al., 2003). Somatoform dissociation involves lack of integration of the somatoform components of experience; examples include anesthesia, paralysis, unexplained pain, and uncontrolled movements. Scores on the SDQ-20 (Nijenhuis, Spinhoven, van Dyck, van der Hart, & Vanderlinden, 1996) correlate highly with psychological dissociation (Nijenhuis et al., 1996; G. Waller et al., 2000), CSA, and childhood physical abuse (Nijenhuis, Spinhoven, van Dyck, van der Hart, & Vanderlinden, 1998; G. Waller et al., 2000). BPD patients have higher somatoform dissociation scores than do normal persons (Stiglmayr, Shapiro, Stieglitz, Limberger, & Bohus, 2001). The gold-standard measure for diagnosing DDs is the Structured Clinical Interview for DSMIV Dissociative DisordersRevised (SCID-D-R; Steinberg, 1994). The SCID-D-R assesses the presence and severity of five symptoms (amnesia, depersonalization, derealization, identity confusion, and identity alteration) and yields DSMIV DD diagnoses (Steinberg, Rounsaville, & Cicchetti, 1990). In a SCID-D-R study of 80 randomly selected university students with BPD, 12.5% had DA, 7.5% depersonalization disorder (DPD), 32.5% DDNOS type 1, 10% other DDNOS, and 10% DID (Sar et al., 2006). In another study, Sar et al. (2003) screened psychiatric outpatients with the DES, the SDQ-20, and DSMIIIR BPD criteria and followed up high scorers with a SCID-D interview. Of 25 BPD patients, 4% were diagnosed with comorbid DA, 36% DDNOS, and 24% DID. An interesting table listed the dissociative symptoms in BPD, but not as a function of comorbid DDs. The DDIS (Ross, 1997) is a structured interview that makes BPD and DD diagnoses; it also inquires about a variety of related symptoms. In a recent study that used the DDIS and the SCID-D, Ross (2007) reported that 93 BPD inpatients had a prevalence of 59% DDs and 18% DID. In addition, the prevalence of DA, DDNOS, DID, any DD, and SCID-D symptoms of depersonalization, derealization, identity confusion, and alteration was significantly greater in the BPD inpatients than in a control group of nonborderline inpatients (Ross, 2007).

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The Multidimensional Inventory of Dissociation (MID; Dell, 2006a) is a new self-report instrument that diagnoses DDs and measures the entire spectrum of pathological dissociation (Dell, 2006b). The MID was explicitly designed for clinical research and for assessing patients who present with a mixture of dissociative, posttraumatic, and borderline symptoms. In a study of 30 BPD patients diagnosed by structured interview (Laddis & Dell, 2002), the MID diagnosed 27% DID, 43% DDNOS, and 30% no DD. BPDDID patients did not differ significantly from a comparison group of patients with DID only. Almost all BPDDDNOS patients endorsed flashbacks, internal struggle, and self-puzzlement. This BPDDDNOS group was sorted into two clusters. Cluster 1 (30% of total) had primarily angry self-states; these patients endorsed memory problems, but they reported little frank amnesia. Cluster 2 (13% of the total) had DID-like self-states; they reported extensive amnesia and frequent voices (especially child and persecutory voices). BPD patients without a comorbid DD had less intense posttraumatic stress disorder (PTSD) symptoms. In summary, DES research has shown that (a) BPD patients, as a group, manifest significantly more dissociation than most psychiatric patients; (b) most BPD patients endorse dissociating more often than normal persons, but some do not; and (c) dissociation in BPD patients is often, but not always, associated with trauma. Newer, more comprehensive dissociation instruments are demonstrating the high comorbidity of DDs with BPD. These findings, in turn, raise several questions: Which dissociative symptoms (both pathological and nonpathological) occur in BPD? How common are pathological dissociative symptoms in BPD? How should BPD patients with pathological dissociative symptoms best be characterized (in terms of DDs)? The objective of the current study was to comprehensively assess the dissociative symptoms and DDs that occur in a well-diagnosed sample of adult outpatients with BPD.

METHODS Procedure
This was a three-phase study approved by the hospital research ethics board. Separate informed consent was obtained for each phase. In Phase 1, the entire population of an adult outpatient clinic was screened for BPD using the self-report Structured Clinical Interview for DSMIV Axis II Disorders (SCID-II) criteria for BPD. In Phase 2, patients who met the self-report DSMIV criteria for BPD were invited to be assessed with the Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989). The interviewers were trained by a local expert who had been trained by the authors of the instrument. Patients who scored positive for BPD (a DIB-R

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score of 8 or greater) were invited to participate in the third phase of the study. In Phase 3, exclusion factors included illiteracy; active substance abuse; or a history of definite psychosis, psychotic mania, or organic diagnoses. The participants (a) completed the computer self-report version of the Structured Clinical Interview for DSMIV Axis I Disorders (SCID-I); (b) underwent a brief interview to confirm the findings of the SCID-I and to confirm the absence of exclusion criteria; (c) completed the DES, SDQ-20, MID, and SCID-II self-report at home; and (d) were administered the SCID-D-R by an experienced interviewer (the first author), who established interrater reliability with 10 videotape ratings with an expert (Dr. S. Jordan) trained by Dr. Steinberg. The SCID-D-R interviewer was blind to the MID diagnosis, and the MID rater was blind to the SCID-D-R diagnosis.

Measures
SCID-I (First, Gibbon, Williams, Spitzer, & MHS Staff, 2001) and SCID-II (First, Spitzer, Gibbon, & Williams, 1995). SCID-I and -II are widely used instruments with good reliability and internal consistency (Maffei et al., 1997; Williams et al., 1992). The computer self-report SCID-I is deliberately over-inclusive; the false positives were clarified with a short interview. These instruments were used to confirm exclusion criteria and describe comorbidity. DIB-R. The DIB-R is one of the most extensively used instruments for diagnosing BPD. The DIB-R inquires about the DSMIV criteria, but the scoring rules emphasize four sections thought to be of critical clinical importance in diagnosing BPD (i.e., affect, cognition, impulse action patterns, and interpersonal relationships). A cutoff score of 8 has a sensitivity of 82%, a specificity of 80%, a positive predictive power of 74%, and a negative predictive power of 87% for differentiating BPD from other personality disorders (Zanarini et al., 1989). DES. The DES measures 28 dissociative experiences on a Likert scale of 1 to 100. It has good to excellent testretest reliability; internal consistency (Cronbachs a = .93); convergent validity with other dissociation instruments (combined effect size Cohens d = 1.82); and predictive validity for DID (d = 1.05), PTSD (d = 0.75), and abuse (d = 0.52; van IJzendoorn & Schuengel, 1996). DES scores of 30 or greater should be followed up with a structured clinical interview (Carlson & Putnam, 1993). The probability of pathological taxon membership (N. G. Waller et al., 1996) was calculated using the statistical package available on the Web site of the International Society for the Study of Trauma and Dissociation (n.d.). The DES-T (mean) can also be approximated by averaging the eight pathological items. A DES-T (mean) cutoff score of 35 has 57% sensitivity, 100% specificity, and 100% positive predictive value for DES-T probability level 0.9 (N. G. Waller & Ross, 1997).

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SDQ-20. The SDQ-20 is a 20-item self-report scale that measures somatoform dissociation on a 5-point Likert scale, generating scores from 20 to 100. The SDQ-20 has high construct validity; it differentiates patients with DDs from normal persons and other clinical samples (Nijenhuis et al., 1996, 1998; Sar, Kundakci, Kiziltan, Bakim & Bozkurt, 2000). The SDQ-20 has an alpha coefficient of .95 (Nijenhuis et al., 1996). SCID-D-R. The SCID-D-R is a semistructured interview for diagnosing DDs that asks 200 questions to evaluate five main dissociative symptoms. Each symptom is rated on a 4-point scale. Ratings of severe are generally awarded if a pathognomonic symptom is present for a prolonged period, occurs frequently, produces impairment in social or occupational functioning, or produces dysphoria. The SCID-D-R must be administered by a clinician who is experienced in DDs. The SCID-D-R has good to excellent reliability and discriminant validity for DDs (Steinberg et al., 1990) and has been useful in discriminating PTSD (Bremner, Steinberg, Southwick, Johnson, & Charney, 1993), schizophrenia, and feigning (Welburn et al., 2003). MID. The MID is a comprehensive 218-item self-report instrument. The MID surveys all known manifestations of pathological dissociation and provides a DSMIV diagnosis (Dell, 2006a). It contains 168 dissociation items that are sorted into 23 dissociation scales; it also contains 50 validity items that are sorted into 5 validity scales (defensiveness, rare and bizarre symptoms, emotional suffering, attention seeking, and factitiousness). Each of the 18 items on the MIDs BPD Index significantly distinguished between 100 interview-diagnosed BPD patients and 51 DID patients (Laddis & Dell, 2003). The MIDs Excel-based scoring program recognizes four diagnoses: no DD, DD deferred, DDNOS, and DID. The MIDs diagnostic algorithm for DID requires the presence of at least 4 of 6 general dissociative symptoms, at least 6 of 11 dissociative intrusions into executive functioning or sense of self, and at least 2 of 6 manifestations of amnesia (Dell, 2006b). The MID has excellent internal, temporal, convergent, discriminant, and construct validities. MID scores correlate strongly with trauma history. The MID discriminates DID patients from normal persons, persons with DDNOS, and mixed psychiatric patients. The alpha coefficient for the diagnostic scales is .99 and for the validity scales is .78 to .92. Factor analysis of the 168 dissociation items yielded a single, second-order factor: pathological dissociation (Dell & Lawson, in press). The MID correlates strongly with other dissociation measures: DES (r = .90), SDQ-20 (r = .75), SCID-D-R (r = .78; Dell, 2006a; Somer & Dell, 2005). Childhood trauma questionnaire (CTQ; D. P. Bernstein & Fink, 1998). The CTQ is a widely used, brief 28-item self-report questionnaire that retrospectively assesses childhood abuse experiences on a 5-point Likert scale. A five-factor model (emotional neglect, emotional abuse, physical neglect, physical abuse, and sexual abuse) has been replicated and normative community data published (Scher, Stein, Asmundson, McCreary, & Forde, 2001).

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The CTQ has demonstrated high convergent validity with clinician-rated interviews of abuse, excellent testretest reliabilities over 2 to 6 months, and excellent internal consistency coefficients ranging from 0.66 to 0.92 across a range of samples (D. P. Bernstein & Fink, 1998; D. P. Bernstein et al., 1994).

Statistical Analysis
This was a pilot study. Descriptive statistics are reported by count (percent) for categorical variables and mean (standard deviation) for continuous variables. Convergent validity among the six dissociation instruments was determined using the Spearmans coefficient test because the data distribution was nonnormal. Because this involved 10 analyses, the criterion for significance was adjusted to alpha = .005 using the Bonferroni method for multiple analyses. We also assessed agreement between raters using Cohens kappa statistic (k). We judged agreement as moderate if 0.41 k 0.6, substantial if 0.61 k 0.8, and near perfect if k 0.81. All analyses were performed using SPSS version 9 (Chicago, IL).

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RESULTS Demographics
In Phase 1, 306 general outpatients were invited to be screened, 239 completed the screening, and 173 were positive for DSMIV BPD. In Phase 2, 131 completed the DIB-R interview, and 54 were positive for BPD. We found a fairly high rate of BPD (22.6%, 54/239; 95% confidence interval = 17.3%27.9%) because our hospital outpatient clinic serves the downtown core of a city of 500,000, all of our population is insured and has access to health care, and many of our referrals come from the psychiatric emergency or inpatient services. Phase 1 and 2 results are detailed in Korzekwa, Dell, Links, Thabane, and Webb (2008). A total of 21 participants completed Phase 3. The remaining 33 did not enter or complete Phase 3 for the following reasons: 9 did not consent, 6 were excluded because they were the first authors psychotherapy patients, 9 were excluded due to psychosis or current substance abuse, and 9 dropped out. The mean (SD) age was 38 (8) years, 76% were female, and 57% had never been married. They averaged (SD) 12.8 (2.3) years of schooling and DIB-R scores of 8.9 (0.7). Median (minimummaximum) number of lifetime hospitalizations was 1.0 (030). The following were the highest occupational levels: 14% professional or managerial; 38% technical, clerical, or skilled labor; 19% unskilled labor; 5% student; and 24% none. BPD patients who did not enter or complete Phase 3 were compared to the participants who did complete the study; they did not differ significantly on any of the above variables.

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Comorbid Diagnoses
SCID-I and -II diagnoses of our sample are presented in Table 1 . The greatest Axis I comorbidity for this BPD sample was PTSD (86%), followed by major depressive disorder, panic disorder with agoraphobia, and social phobia. The high rate of comorbid anxiety and mood disorders is consistent with the literature (Swartz, Blazer, George, & Winfield, 1990; Zanarini et al., 1998a). Our rate of PTSD is higher than that reported by the above authors (34%56%) but is consistent with the overall higher level of psychopathology in our clinic. The pattern of Axis II comorbidity we found is consistent with the BPD literature (Zanarini et al., 1998b), although our rates are somewhat higher, given that our instrument was a self-report measure. The highest rates were found for depressive, paranoid, avoidant, schizoid, and passive-aggressive personality disorders. The mean (SD) number of personality disorders per participant was 6.7 (2.2). Comorbid histrionic personality disorder was endorsed by only one participant (no DD). The SCID-D-R DD diagnoses are also listed in Table 1. Of note are the findings that no DD was found in 23.8% of the sample, and DID was diagnosed in 23.8%. Our sample was comparable to literature that reported a similar rate for DID (Sar et al., 2003, 2006).

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Mean Dissociation Scores

The mean (SD) scores on the dissociation scales were as follows: SCID-D-R = 14.7 (4.7), MID = 25.4 (18.1), DES = 26.9 (19.9), DES-T [mean] = 19.6 (22.1), and SDQ-20 = 28.0 (6.8). The mean MID score in this study is in the mild to moderate DD range and is comparable to that of Laddis and Dell (2002). The mean DES score in our study is slightly higher than the mean of 23.7 that the authors calculated from 20 BPD studies in the literature that provided DES data, but it is consistent with psychiatric groups with high levels of PTSD (Carlson & Putnam, 1993). For example, Heffernan and Cloitre (2000) found a DES mean score of 30.1 in a group of BPD outpatients with comorbid PTSD. Also, four participants clearly over-endorsed on the DES. The average DES-T (mean) score was in the mild to moderate DD range: 33% (7/21) of the sample had greater than a 0.6 probability of being in the pathological dissociation taxon (Goodman et al., 2003), and 19% (4/21) had a 0.9 probability (N. G. Waller et al., 1996). The sensitivity and specificity for severe DD (DDNOS or DID) at the 0.6 level were 50% (5/10) and 81.8% (9/11) and at the 0.9 level were 30.0% (3/10) and 90.9% (10/11), respectively. The mean (SD) SDQ-20 score was 28.0 (6.8), which is indicative of mild somatoform dissociation.

CTQ Results
The CTQ results are shown in Table 2, displayed by DD diagnosis. In general, scores for no DD and mild DD patients are around the 90th and 95th

Dissociation in Borderline Personality Disorder TABLE 1 Phase 3 Diagnoses (n = 21) Diagnosis SCID-I Diagnoses Mood disorders Major depressive disorder (lt) Major depressive disorder current Dysthymic disorder Bipolar II (lt) Bipolar I (lt) Mood disordermedica1 Anxiety disorders Posttraumatic stress disorder Panic disorder with agoraphobia (lt) Social phobia Generalized anxiety disorder Obsessive compulsive disorder Specific phobia Agoraphobia (lt) Panic disorder without agoraphobia (lt) Substance disorders Dependence (lt) Substance abuse (lt) Alcohol dependence (lt) Alcohol abuse(lt) Somatoform and eating disorders Anorexia nervosa (lt) Hypochondriasis Bulimia (lt) Somatization SCID-D-R Diagnoses None Dissociative amnesia Depersonalization disorder Dissociative disorder NOS Type 1A Dissociative identity disorder SCID-II Self-Report Diagnoses Borderline Paranoid Depressive Avoidant Schizoid Passive aggressive Obsessive compulsive Narcissistic Antisocial (criteria C only) Schizotypal Dependent Histrionic n (%)

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15 13 5 3 1 1 18 14 12 11 9 4 1 1 6 4 4 1

(71.4) (61.9) (23.8) (14.3) (4.8) (4.8) (85.7) (66.7) (57.1) (52.4) (42.9) (19.0) (4.8) (4.8) (28.6) (19.0) (19.0) (4.8)

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2 (9.5) 1 (4.8) 1 (4.8) 0 5 2 4 5 5 21 17 17 15 14 13 12 9 9 6 7 1 (23.8) (9.6) (19.0) (23.8) (23.8) (100.0) (81.0) (81.0) (71.4) (66.7) (61.9) (57.1) (42.9) (42.9) (28.6) (33.3) (4.8)

Notes: All diagnoses are current unless labeled lifetime (lt). SCID-I = Structured Clinical Interview for DSMIV Axis I Disorders; SCID-D-R = Structured Clinical Interview for DSMIV Dissociative DisordersRevised; NOS = not otherwise specified; SCID-II = Structured Clinical Interview for DSMIV Axis II Disorders.

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TABLE 2 Mean (SD) CTQ Scores by Dissociative Disorder SCID-D-R diagnosis None DA/DPD DDNOS DID Physical neglect 7.8 8.2 12.2 12.2 (2.6) (2.8) (7.4) (7.1) Emotional neglect 12.8 14.8 17.8 21.0 (5.3) (5.2) (5.2) (4.7) Physical abuse 9.2 11.8 13.8 13.4 (1.8) (5.2) (7.6) (8.6) Emotional abuse 13.6 17.0 16.2 20.6 (5.6) (7.1) (5.9) (3.0) Sexual abuse 9.0 8.3 14.2 21.2 (8.9) (3.8) (7.9) (5.5) Total CTQ 52.4 60.2 74.2 88.4 (20.3) (21.7) (23.2) (21.1)

Notes: CTQ = Childhood Trauma Questionnaire; SCID-D-R = Structured Clinical Interview for DSMIV Dissociative DisordersRevised; DA/DPD = dissociative amnesia/depersonalization disorder; DDNOS = dissociative disorder not otherwise specified; DID = dissociative identity disorder.

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percentiles, respectively, for the general population (Scher et al., 2001). Four participants in the no DD and three in the mild DD group denied experiencing CSA, whereas none of the DDNOS or DID participants did so. The more severe the DD, the higher the CTQ score. However, because of the small sample size, the correlation with DD diagnosis severity was significant only for sexual abuse (analysis of variance; F = 4.115, p = .023). Emotional neglect (2.506, p = .094) and total CTQ (2.757, p = .074) showed trends toward significance.

Detailed Description of Symptoms

Table 3 provides a detailed description of 21 BPD cases and their SCID-D-R diagnoses. Elevated scores on the MID validity scales are indicated, as is the probability of membership (0.6 or 0.9) in the dissociative taxon. BPD cases with no DD had mean DES-T scores that fell well below the cutoff score (13) for pathological dissociation. Validity scales were significantly elevated for 3/5 participants. The MID also diagnosed 3/5 with no DD. In the mild DD category, the SCID-D-R diagnosed one case of DA, whose selfreport scores were just above normal. Another case met criteria for both DA and DPD, but the DA was more disabling, so the case was classified as DA. The four DPD cases had an extremely wide range of scores. The MID diagnosed 3/4 with DID. Two of these had high BPD indices; had significantly elevated validity scales, including both attention seeking and emotional suffering; and were classified as DES-T taxon members (0.6 probability level). Of the DDNOS cases, all five met criteria for DSMIV type 1A, Clinical presentations similar to DID that fail to meet full criteria for this disorder. Example includes presentations in which a) there are not two or more distinct personality states (DSMIV, 1994, p. 490). Cases number 12 and 13 were diagnosed as probable because of uncertainty about the separateness of their dissociated behavior. These were also diagnosed as DD diagnosis deferred by the MID. Of the definite DDNOS cases, the MID diagnosed 2/3 with DID. The DES-T classified 3/5 DDNOS cases as taxon members (0.6 probability). The scores in the DID patients were very high,

Dissociation in Borderline Personality Disorder TABLE 3 Individual Case Studies No. SCID-D-R diagnosis SCID-D-R 5 7 7 9 11 7.8 13 15 13 13 15 16 14.2 14.0 15 15 18 19 20 17.4 18 20 20 20 20 19.6 MID 13.5b 2.6c 8.8c 8.6c 9.8b 8.7 12.3b 10.6c 28.3d 49.9d 15.5b 46.2d 27.1 16.7 9.6b 22.7b 15.3b 30.1d 40.5d 23.6 45.1d 24.3b 26.8d 55.9d 64.0d 43.2 DES 17.5 6.9 10.0 9.6 14.6 11.7 17.5 16.1 19.6 36.4 15.0 52.1 26.1 17.1 8.2 33.6 16.1 48.6 28.6 27.4 32.1 18.2 19.3 59.3 84.6 42.7 DES-T (M) 6.3 1.3 5.0 3.8 6.3 4.5 7.5 15.0 8.8 21.3e 11.3 62.5f 21.1 10.6 3.8 16.3e 6.3 36.3f 15.0e 15.5 16.3 12.5 12.5 65.0f 78.8f 37.0 Validity scalesa Att Def Att, Def Att, Em

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BPD index 29 3 11 22 9 5 7 5 67 1 25

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No DD 1 None 2 None 3 None 4 None 5 None Means 15 Mild DD 6 DA 7 DA 8 DPD 9 DPD 10 DPD 11 DPD Means 611 Means 6, 7, 8, 10 DDNOS 12 DDNOS 13 DDNOS 14 DDNOS 15 DDNOS 16 DDNOS Means 1216 DID 17 DID 18 DID 19 DID 20 DID 21 DID Means 1721

Def Def Att, Em, Fac, Rare Att, Em

Def Em Att, Def Em Em Rare Att, Em

10 0 7 10 12 13 3 2 12 32

Notes: Numbers in bold are values discrepant for their SCID-D-R diagnostic category. SCID-D-R = Structured Clinical Interview for DSMIV Dissociative DisordersRevised; MID = Multidimensional Inventory of Dissociation; DES = Dissociative Experiences Scale; DES-T = DES-Taxon scale; BPD = borderline personality disorder; DD = dissociative disorder; Att = attention seeking; Def = defensiveness; Em = emotional suffering; DA = dissociative amnesia; DPD = depersonalization disorder; Fac = factitious behavior; Rare = rare symptoms; DDNOS = DD not otherwise specified; DID = dissociative identity disorder. a Validity scales: = subclinically elevated; = significantly elevated. bDiagnosed as DD deferred on MID. cDiagnosed as no DD on MID. dDiagnosed as DID on MID. eProbability of taxon membership = 0.660.8. fProbability of taxon membership = 0.91.0.

as expected. One case, with significantly elevated BPD index, attention seeking, and emotional suffering scales, had extremely high scores. The MID also diagnosed 4/5 with DID; the other case was short one criterion. Both the DES-T mean and probability missed 3/5 cases of DID. The most frequent SCID-D-R dissociative symptoms (see Table 4 ) and the clinically significant (frequency at or above the cutoff for DID) MID dissociation scales (see Table 5 ) showed that BPD patients without a DD still

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TABLE 4 Frequency of SCID-D-R Symptoms in Borderline Personality Disorder No DD DA/DPD DDNOS DID Total (n = 5) (n = 6) (n = 5) (n = 5) (n = 21) SCID-D-R symptom Identity Confusion Struggle inside about who you really are Confused as to who you are Struggle going on inside of you Depersonalization Detachment from behavior Feeling not in control of emotions Watching self from outside the body Simultaneous participating and observing Feeling not in control of behavior Feelings of estrangement Part or whole body feels unreal Feeling not in control of speech Part or whole body disappears Altered perception of body Part of body disconnected from the rest Change in size of arms or legs Associated features of DID Mood changes without any reason Flashbacks Internal voices Changes in talent or capacities Amnesia Memory gaps Difficulty remembering daily activities Finding self in places Blocks of time missing Inability to recall personal information Identity Alteration Acting like a child Told by others seem like different person Acting as a different person Finding things without remembering Referred to by different names Feeling of being possessed Derealization Surroundings or people unreal/unfamiliar Surroundings or people fade away Friends, family, home strange or foreign Puzzled about what is real and unreal Not recognizing friends, family or home n 3 2 3 0 3 1 1 1 0 0 0 1 1 0 0 5 2 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 n 4 4 2 6 4 4 2 2 2 1 2 0 0 0 1 2 4 0 0 1 2 2 3 1 2 0 0 0 0 0 2 1 1 2 1 n 4 5 4 4 2 4 4 5 3 3 2 3 3 2 1 4 3 2 0 4 4 4 2 1 2 1 2 0 0 1 2 1 1 0 0 n 5 5 5 4 5 4 5 3 4 3 4 1 1 1 0 4 5 3 4 4 4 4 4 3 4 5 4 2 1 0 2 3 3 3 3 n 16 16 14 14 14 13 12 11 9 7 8 5 5 3 2 15 14 5 4 10 10 10 9 5 8 7 7 2 1 1 6 5 5 5 4 % 76 76 67 67 67 62 57 52 43 33 38 24 24 14 10 71 67 24 19 48 48 48 43 24 38 33 33 10 5 5 29 24 24 24 19

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Notes: SCID-D-R = Structured Clinical Interview for DSMIV Dissociative DisordersRevised; DD = dissociative disorder; DA/DPD = dissociative amnesia/depersonalization disorder; DDNOS = DD not otherwise specified; DID = dissociative identity disorder.

Dissociation in Borderline Personality Disorder TABLE 5 Frequency of MID Dissociation Scales Endorsed at a Clinically Significant Level No DD (n = 5) MID diagnostic scale General Dissociative Symptoms Memory problems Depersonalization Derealization Posttraumatic flashbacks Somatoform symptoms Trance Dissociative Intrusions Child voices Voices/internal struggle Persecutory voices Speech insertion Thought insertion/withdrawal Made intrusive emotions Made intrusive impulses Made intrusive actions Temporary loss of knowledge Self-alteration Self-puzzlement Amnesia Time loss Coming to Fugues Being told of actions Finding objects Evidence of actions n DA/DPD (n = 6) n DDNOS (n = 5) n DID (n = 5) n

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Total (n = 21) n %

2 0 1 2 0 0 0 0 0 0 1 3 0 0 0 0 4 0 0 0 0 0 0

5 4 4 5 4 3 4 3 2 3 3 3 3 3 4 3 5 3 4 1 3 2 2

4 3 2 5 0 4 4 2 3 2 3 4 2 2 3 2 4 2 2 1 4 0 0

4 3 4 5 3 4 5 5 5 4 5 5 3 5 4 5 5 5 4 3 3 3 4

15 10 11 17 7 11 13 10 10 9 12 15 8 10 11 10 18 10 10 5 10 5 6

71.4 47.6 52.4 81.0 33.3 52.4 61.9 47.6 47.6 42.9 57.1 71.4 38.1 47.6 52.4 47.6 85.7 47.6 47.6 23.8 47.6 23.8 28.6

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Notes: MID = Multidimensional Inventory of Dissociation; DD = dissociative disorder; DA/DPD = dissociative amnesia/depersonalization disorder; DDNOS = DD not otherwise specified; DID = dissociative identity disorder.

reported significant levels of depersonalization (not in control of emotions and behavior), identity confusion, unexplained mood changes, and flashbacks. In addition to these symptoms, BPD patients with DA or DPD also reported internal voices, additional manifestations of depersonalization (including detachment from behavior and watching self from outside the body), some derealization, some Schneiderian first-rank symptoms, and amnesia. In DDNOS, multiple types of depersonalization were often present, and amnesia and identity alteration became significant. The DID group endorsed severe levels of all forms of dissociation. The symptoms of pathological dissociation (i.e., depersonalization, derealization, amnesia, and identity alteration) on both the MID and the SCID-D-R appear to constitute a spectrum of severity within BPD. This is also seen clearly in Table 6, which displays the mean severity of SCID-D-R symptoms by dissociative diagnosis.

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TABLE 6 Mean Severity of SCID-D-R Symptoms in 21 Borderline Personality Disorder Patients as a Function of Comorbid Dissociative Diagnosis Symptom Amnesia Depersonalization Derealization Identity Confusion Identity Alteration No DD (n = 5) 1.2 1.8 1.0 2.6 1.2 DA/DPD (n = 6) 2.8 3.8 2.3 3.3 1.8 DDNOS (n = 5) 3.8 3.8 2.6 4.0 3.2 DID (n = 5) 4.0 4.0 3.8 3.8 4.0 Total sample (n = 21) 2.9 3.4 2.4 3.4 2.5

Notes: SCID-D-R severity scores range from 1 to 4: 1 = absent, 2 = mild, 3 = moderate, 4 = severe. SCID-D-R = Structured Clinical Interview for DSMIV Dissociative DisordersRevised; DD = dissociative disorder; DA/DPD = dissociative amnesia/depersonalization disorder; DDNOS = DD not otherwise specified; DID = dissociative identity disorder.

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Dissociative Symptoms of the Average BPD Patient in This Sample

We defined the dissociative symptoms of the average BPD patient by identifying the MID dissociation items (53/168) that were endorsed at a clinically significant level by 50% or more of our BPD patients. Consistent with Table 5, the 53 items comprised almost all of the items in four scales: memory problems, posttraumatic flashbacks, made intrusive emotions, and selfpuzzlement. Memory problems included participants having amnesia for recent and remote events, having large memory gaps, and being bothered by how much they have forgotten. Posttraumatic flashbacks included vivid recall in all senses, nightmares, difficulty functioning, and wanting to self-injure or die in response. Made intrusive emotions included rapid mood changes and strong emotions that seemed to come out of nowhere. Self-puzzlement involved participants being confused about their actions, emotions, and identity. The 53 items comprised one third to one half of the items in four other scales: derealization, trance, voices/internal struggle, and thought insertion. Specifically, and most important, participants were concerned by (a) how frequently they tranced out, (b) the fact that other people noticed their being gone, (c) feeling the presence of an angry part that tried to control them, (d) hearing an internal voice that told them to shut up, (e) internal voices that argued or conversed with one another, and (f) thoughts coming into their minds that they could not stop. The 53 items comprised one or two items on seven other scales: made intrusive impulses, made intrusive actions, temporary loss of well-rehearsed knowledge, self-alteration, time loss, coming to, and being told of disremembered recent actions. Especially noteworthy items included people telling you that you sometimes act so differently that you seem like another person, blank spells or memory blackouts, coming to in the middle of a conversation and having no idea what was discussed, and when you are angry, doing or saying things that you dont remember.

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Spearman Correlations Among the Dissociation Instruments

SCID-D-R scores correlated substantially with mean MID scores (Spearmans rho [r] = 0.71), with mean DES-T scores (r = 0.67), with DES-T probability scores (r = 0.68), and with mean DES scores (r = 0.62; all ps < .05). The correlation with SDQ-20 scores was not significant. Mean MID scores correlated nearly perfectly with mean DES scores (r = 0.95) and mean DES-T scores (r = 0.90) and substantially with DES-T probability scores (r = 0.79) and SDQ-20 scores (r = 0.60; all ps < .005). Interrater reliability on the SCID-D-R interview, as measured by Cohens kappa, was 0.62 (p = .001). The weighted analysis (intraclass coefficient) was 0.71 (p = .03), and consideration of raters probable comments resulted in an intraclass coefficient of 0.85 (p = .004). This is substantial interrater agreement, especially for this difficult group of patients.

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DISCUSSION
This study used the semistructured SCID-D-R interview as the gold standard to assess dissociative symptoms in a cross-sectional sample of DIB-R BPD outpatients. Methodologically, the first step in understanding dissociation in BPD patients was to examine the details of each case (see Table 3). BPD patients with no DD had low scores on all dissociation scales; their dissociation scores were consistent with those obtained by the normal population. BPD patients in the mild DD category had significant, but not pervasive, symptoms of dissociation. The SCID-D-R diagnosed these BPD patients as having either DA or DPD. Although three of these SCID-D-R DPD patients received an initial MID diagnosis of DID, this diagnosis was invalidated in two cases by extreme scores on the MID validity scales (see Table 3). BPD patients with DDNOS endorsed significant and pervasive symptoms of dissociation. As expected, their dissociation scores straddled the cutoff for DID. On the MID, they endorsed the I have parts scale but not the I have DID scale. BPD patients with DID obtained high dissociation scores. The MID diagnosed 4/5 with DID. These cases all endorsed I have parts and I have DID. The second method of examining dissociation in BPD was to look in detail at the symptoms endorsed on the SCID-D-R (see Table 4) and the MID (see Table 5). Most participants endorsed mood changes for no reason, flashbacks, identity confusion, and some depersonalization. One can justifiably argue that these symptoms belong to the zone of symptomatic overlap between BPD and DDs. Mood changes and flashbacks are included in the SCID-D-R as associated features of DID, not as dissociative symptoms per se. Mood swings, of course, are listed as Criterion 6 of BPD in the DSMIV. Participants in this study gave vivid accounts of how their mood changed

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rapidly, without any reason (Question 134, SCID-D-R). Follow-up questioning revealed suspicion of dissociated ego states causing this phenomenon in only two participants. Taken by itself, mood changes without any reason obviously lacks specificity for dissociation; it is diagnostically relevant to the DDs only when it is part of a larger pattern of dissociative symptoms. The dissociation-relevant concept of identity confusion clearly overlaps with the DSMIV Criterion 3 for BPD, identity disturbance: markedly and persistently unstable self-image or sense of self. On the SCID-D-R (see Table 6), identity confusion was rated as severe in 71% of our participants who described a frequent, intense battle between ego states or a profound lack of identity. It is interesting that a MID study found that DID patients had significantly higher identity confusion scores than a sample of well-diagnosed BPD patients (Laddis & Dell, 2003). Depersonalization is one of the transient, stress-related severe dissociative symptoms to which Criterion 9 refers. In the mild DD group, the frequency of frankly pathological dissociative symptoms on the SCID-D-R and MID is surprising. Our BPD patients with DDNOS reported frequent depersonalization, frequent amnesia, and notable experiences of identity alteration. The symptom of internal voices accords with a recent report of chronic auditory hallucinosis in about 30% of a non-DID BPD sample; these BPD patients conversed with internal voices that they experienced as ego-alien (Yee, Korner, McSwiggan, Meares, & Stevenson, 2005). BPD patients with DID endorsed severe dissociative symptoms in all categories. In all, 53 of 168 MID items were endorsed at a clinically significant level by more than half of the participants in this study. Those items comprise a wide variety of disturbing dissociative symptoms: amnesia, derealization, flashbacks, trance states, and a plethora of dissociative intrusions into conscious experience (i.e., intruding thoughts, emotions, impulses, actions, and voices). Especially concerning is the toxic nature of the angry voices and angry ego states, the Schneiderian voices, and the desire to self-harm triggered by flashbacks. The fact that more than half of our BPD patients endorsed these symptoms at a level consistent with DID supports Rosss (2007) claim that the DSMIV does not adequately address the frequent, severe dissociative comorbidity in BPD. We postulate that there are three dissociative subgroups among persons diagnosed with BPD. The first subgroup, comprising about one quarter to one third of BPD patients, has minimal dissociative symptoms, and if symptoms do occur, they are brief and mild. These participants have minimal abuse histories compared to the others. The second subgroup, comprising about one third to one half of BPD patients, probably has a disorganized attachment status and a more significant abuse history (Classen, Pain, Field, & Woods, 2006; Holmes, 2003). The third subgroup is the most severe. This subgroup includes the definite DDNOS type 1 and DID cases, comprising about 30% to 40% of clinical samples of BPD; they have the most disturbed

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attachment and abuse histories. As Chu (1998) has noted, patients with both a severe DD and BPD are severely ill and a tremendous burden to the health care system. Of the self-report measures, the MID unquestionably provided the most useful information about the dissociative symptoms of BPD patients. Its comprehensive set of dissociation scales provided valuable information over and above that obtained using the other questionnaires. The validity scales were invaluable in assessing whether participants over-endorsed or denied symptoms. Even in this difficult population, the MID had acceptable agreement with the time-intensive SCID-D-R interview for sorting BPD patients into the categories of no DD, mild to moderate DD, or severe DD. This study has several limitations. First, the generalizability of our findings to general psychiatric outpatients is limited by our samples higher rate of PTSD, which is probably due to (a) the higher severity of illness in our clinic, (b) the sample selection process (patients already in treatment), and (c) the rigorous DIB-R selection process (selecting more severe BPD). Second, interrater reliability between DIB-R interviewers was not formally established, although all interviewers agreed with the expert on the total DIB-R score on two interviews. Third, the computer over-endorsed SCID-I diagnoses, although the interview with the researcher confirmed the presence and severity of each diagnosis. Similarly, the self-report SCID-II was likely over-endorsed by some and under-endorsed by others. Fourth, most of the instruments used were self-report. In this population, attention seeking, factitious behavior, and emotional suffering can be confounding issues, as evidenced by the MID validity scales and the discrepancies between the dissociation interview and the self-report scales. Finally, because our sample size was fairly small and a significant number of potential participants did not consent, estimates of the prevalence of DDs in BPD cannot be made with confidence.

CONCLUSIONS
This study replicated the findings of previous studies: Approximately half of BPD patients meet criteria for DA, DPD, or DDNOS, and about 24% of BPD patients meet criteria for DID (Laddis & Dell, 2002; Sar et al., 2003). The pathological dissociative symptoms of our BPD patients seemed to constitute a spectrum of severity (that paralleled the severity of their comorbid DD). Even BPD patients who did not have a DD reported a surprising number of dissociative symptoms, but to a milder degree. The average BPD patient endorsed a wide variety of deeply disturbing dissociative symptoms that were anything but transient and stress related. Hopefully, future research will clarify the clinical and diagnostic meaning of these dissociative symptoms in patients with BPD.

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