Personality disorders in child sexual abuse victims

Review Noemí Pereda1 David Gallardo-Pujol1 Rosa Jiménez Padilla1 Personality disorders in child sexual abuse victims 1 Universitat de Barcelona The main aim of the present study is to offer an updated review of the international studies published on personality disorders in child sexual abuse victims. The different papers were classified according to the most frequently found topics regarding this issue, with special focus on antisocial personality disorder and borderline personality disorder. The studies reviewed provide inconclusive results, which demonstrate the need for longitudinal studies that could test the directionality of the relationship between child sexual abuse, personality traits, and personality disorders. The concept of resilience is emphasized in order to explain the interindividual differences that are found in victims of the same traumatic event. Key words: Sexual abuse, personality, disorder, development, victimology, trauma. Actas Esp Psiquiatr 2011;39(2):131-9 Trastornos de personalidad en víctimas de abuso sexual infantil Este trabajo tiene como objetivo ofrecer una revisión actualizada de los estudios publicados a nivel internacional sobre trastornos de la personalidad en víctimas de abuso sexual en la infancia. Se clasificaron los distintos trabajos en función de los trastornos más frecuentemente encontrados en los estudios llevados a cabo en este ámbito, especialmente trastorno antisocial y trastorno límite de la personalidad. Los trabajos revisados muestran resultados poco concluyentes que muestran la necesidad de un mayor número de estudios longitudinales que permitan observar la dirección de la relación entre abuso sexual infantil, rasgos de personalidad y trastornos de la personalidad. Se subraya la importancia del concepto de Correspondence: Departament de Personalitat, Avaluació i Tractament Psicològics Facultat de Psicologia Universitat de Barcelona Pg. Vall d’Hebron, 171 08035 Barcelona (Spain) Tel. 933125113 Fax. 934021362 E-mail: [email protected] 55 resiliencia para explicar las diferencias interindividuales encontradas en víctimas de un mismo acontecimiento traumático. Palabras clave: Abuso sexual, personalidad, trastorno, desarrollo, victimología, trauma. INTRODUCTION Over the course of the history of psychology and psychiatry, there has been much speculation on the influence of the potentially traumatic experiences occurring in childhood on the development of the personality and its psychopathology.1, 2 Currently, the different works carried out within this setting have demonstrated that both biological and environmental factors and their interaction intervene in the development of the personality.3 This has only recently been taken into account in the empirical studies.4, 5 In fact, that which has been manifested by studies on the genetic bases of personality and psychopathology is the importance of the unshared setting and the special influence this has on development.6 In recent years, the study of development of the personality has been driven, among other factors, by genetic advances,7 showing that personality is formed by a combination between specific genes and the life events experienced by the individual.8 There are varied studies that have observed the stability of the personality traits during the life cycle and how temperament, present from childhood,9 affects the development of the adult personality.10 The genotype, however, will be expressed in one way or another based on the environmental experiences of the individual. 4 Especially standing out among these environmental factors is that now called life events, child sexual abuse being one of the most relevant both because of its clinical as well as social implications. The experience of sexual abuse in childhood is Actas Esp Psiquiatr 2011;39(2):131-9 131 Noemí Pereda, et al. Personality disorders in child sexual abuse victims an important risk factor for the development of a large diversity of psychopathological disorders in the adult age.11 However, the studies performed up to now have not made it possible to confirm the existence of a causal relationship between this experience and the presence of psychopathology.12 As far as we know, very few studies have empirically and specifically studied how child sexual abuse affects personality development. One of the most important ones is that of Tong et al.13 In this study, the authors presented a longitudinal follow-up of approximately 3 years on boys and girls who have been sexual abuse victims. They found that at the end of this period, 3 out of every 4 minors had less confidence in adults than before their traumatic experience, 30% had fewer friends, 20% were more aggressive, 24% had greater sexual awareness, 28% had behavioral problems, 17% had repeated a school year, and even another 17% had experienced worsening of their academic performance at school. The authors concluded that child sexual abuse could have implications in the capacity of the victims to relate with others, both in the friendship relationships that they could establish with adults as well as the way they related with their peers. Thus, some authors have observed worst general mental health in victims of child sexual abuse,14 with greater presence of psychiatric symptoms and disorders in the adult age,15-18 establishing a four-times greater likelihood of developing personality disorders in these victims than in the general population.19 Different studies have demonstrated how the history of traumatic events in childhood, among them sexual abuse experience, seems to increase the risk of antisocial disorder,20 borderline and antisocial personality disorder,21 borderline and personality dependent disorder,22 obsessive-compulsive disorder,23 or psychopathological personality traits such as paranoid, borderline, histrionic, narcissistic, or dependent,24, 25 among others. Recently, Putnam,26 in his review of the studies published during the last decade on the psychological consequences of child sexual abuse, stressed the great variety of psychiatric conditions that have been consistently associated with the abuse experience, such as depressive disorders, borderline personality disorder, somatization disorder, substance use disorders, posttraumatic stress disorder, dissociative disorder and bulimia nervosa. The seminal article of Johnson et al.19 concluded that different types of maltreatment entailed the development of different personality disorders, stressing the risk of borderline disorder in victims of sexual abuse and antisocial and dependent disorder in those of physical abuse and neglect. 132 That is why it is important to take into account the influence of the so-called mediating or moderator variables between the experience of sexual abuse in the development of this symptom.27, 28 The presence or absence of certain variables related with both the objective characteristics of the abusive experience and the psychosocial and individual variables of the victim per se and of the aggressor may help to facilitate or minimize the possible psychological effects related with this situation.29, 30 For example, Johnson, Sheahan and Chard31 analyzed the possible interaction between the presence of posttraumatic stress disorder, the use of avoidant coping strategies and the diagnosis of personality disorders, principally avoidant, dependent, antisocial and borderline disorder in child sexual abuse victims. The authors observed that the child sexual abuse victims who employed avoidant strategies to cope with their problems, but not those who used problem approach strategies, had a greater risk of developing the posttraumatic stress disorder as well as personality disorders. The relationship between posttraumatic stress disorder and personality disorders in sexual abuse victims has also been observed in other studies. McLean and Gallop32 verified that women who were victims of sexual abuse who participated in his study were diagnosed with both posttraumatic stress disorder and borderline personality disorder. They concluded that perhaps a single disorder model should be made on the axis I (posttraumatic stress disorder) regardless of the state, and axis II (borderline personality) regardless of the trait. Other studies, such as that of Bernstein, Stein and Handelsman,33 have concluded that, as opposed to that which occurs in other types of childhood maltreatment, sexual abuse does not correlate with any specific personality disorder, but rather, to a certain degree, it does so with all of them. Their results, however, seem to be mediated by the fact that the participants were men and gender could have acted as a moderating factor. Other subsequent studies have not been able to consistently replicate this association.34 Along this line, other works, such as the recent one of Lobbestael et al.,36 have studied the relationship between different types of childhood maltreatment and personality disorders using structural equation models, controlling the comorbidity between them. Thus, following the findings of Bernstein et al.,33 they found that childhood sexual abuse predicts personality disorders in the three clusters (specifically paranoid, schizoid, borderline and avoidant disorder) while other types of maltreatment, such as for example physical maltreatment, only affects the antisocial personality disorder. The present work has aimed to review the different studies published internationally on the relationship existing between the experience of sexual abuse in childhood and Actas Esp Psiquiatr 2011;39(2):131-9 56 Noemí Pereda, et al. Personality disorders in child sexual abuse victims the development of personality disorders in the adult age. A classification is presented based on the three personality disorder groups. This classification allows the professional to know those disorders that have been repeatedly linked to sexual abuse from the scientific setting. METHOD Table 1 Personality disorders in childhood sexual abuse victims: Cluster A Symptoms Studies Paranoid disorder 34, 36, 41-44 Schizoid disorder 36, 42-44 Schizotypal disorder 19, 37-40, 42-44 Selection of studies For this work, those studies in English or Spanish that focused on personality disorders in childhood sexual abuse victims were selected by means of a search in the principal databases, including Psycinfo, Medline, Science Citation Index and Social Sciences Citation Index of the Science Web. In order to cover most of the articles published in this area, two more strategies were adopted (a) searching the bibliographic references of the most relevant articles on the subject and (b) making a manual search in the three reference journals within this subject (Child Abuse & Neglect, Journal of Child Sexual Abuse and Journal of Personality Disorders). however, also related serious sexual abuse (greater frequency and chronicity, use of violence, more intrusive behaviors) with schizotypal symptoms.40 Regarding paranoid personality disorder, a recent work34 with a community sample found an increase in paranoid symptoms in subjects who did not have any disorder on the DSM-IV-TR axis.35 On the other hand, in a sample of outpatients, together with emotional abuse, sexual abuse predicted the appearance of paranoid personality disorder.36, 41 In order to facilitate the understanding of the results presented, the different studies that have focused on the analysis of personality disorders in childhood sexual abuse victims have been grouped based on the personality clusters of the DSM-IV-TR.35 Other studies have also reported more personality disorder symptoms of group A in childhood sexual abuse victims,42-44 although nonspecifically, that is, without differentiating childhood sexual abuse from other forms of childhood maltreatment regarding their effects. However, it was found that there was greater severity of abuse (for example, in cases in which there had been penetration), the greater severity in the psychopathological symptoms. Group A Group B Group A is characterized by covering those disorders that consider that the subject has an odd or eccentric personality. Paranoid disorder, schizoid disorder and personality schizotypal disorder are included.35 (Table 1) Group or cluster B of personality disorders covers antisocial, borderline, histrionic or narcissistic disorders.35 Precisely, this has been one of the personality disorder groups that has received the most attention,45 both in the professional as well as investigational practice, due to its clinical and social importance. In the clinical aspect, for example, borderline disorder is the most prevalent personality disorder among those persons seen in the state public mental health network.46 Specifically, one out of every four persons seen in these centers has been diagnosed of borderline personality disorder, followed by histrionic disorder. The severe consequences that lack of treatment may have in the life of those affected by this disorder can also be stressed.47 In relationship to the social consequences of antisocial personality disorder, these have led the WHO to consider the violence and their manifestations as one of the most urgent public health problems on the planet.48 Thus, it is not surprising that these disorders have received the most attention in the literature (Table 2). RESULTS There are few existing works that have examined the relationship between the presence of childhood sexual abuse and personality disorders of group A.36 Among them, those that have examined the relationship between schizotypal symptoms and childhood sexual abuse in community samples are the most frequent. These works have found that the fact of having suffered childhood maltreatment elevates the likelihood of having a schizotypal personality disorder in adulthood.19, 37, 38 These same results have been replicated in a more recent work.39 However, when this work considered the simultaneous effects of the different forms of maltreatment, the only one that maintained a significant association with the schizotypal disorder was emotional abuse. Other works carried out with clinical samples, 57 Actas Esp Psiquiatr 2011;39(2):131-9 133 Noemí Pereda, et al. Personality disorders in child sexual abuse victims Antisocial personality disorder Table 2 In general, antisocial behavior can be defined as a general pattern of disregard for and violation of the rights of others, that begins in childhood or the beginning of adolescence and continues in adulthood.35 Some victims have grown up with the belief that the use of aggressiveness is the best way to achieve what they want. As several authors have stated (see the reviews of Widom49 or Maxfield & Widom50), having been a victim in childhood seems to favor that the subject as an adult victimizes others, this phenomenon being known as the intergenerational transmission of violence. According to the evidence, experiences of abuses in childhood seem to increase the risk of being an abuser by 30% in the adult age. In fact, in samples belonging to the general population,19, 51 an association between having suffered sexual abuse in childhood and antisocial behaviors in adulthood has been observed, especially when we take the interactions with the gender of the subject into account. Haller and Miles52 determined that, in the case of childhood sexual abuse, almost twice the number of women developed personality disorders than in other cases of abuse. For these investigators, the development of an antisocial behavior may be a way of self-protection, as a means of being able to be independent from others and to avoid intimate relationships, understood as signs of weakness. Personality disorders in childhood sexual abuse victims: Cluster B Symptoms Studies Antisocial disorder 19-21, 41, 49-54, 56-58 Borderline disorder 19, 21, 29, 34, 36, 41, 44, 47, 51, 60-73, 80-84 Histrionic disorder 24, 25 Narcissistic disorder 24, 25 of abuses and the subsequent appearance of violent behavior. This work has been replicated on several occasions, the work of Haberstick et al.56 standing out. In a subsequent meta-analysis study, Kim-Cohen et al.57 concluded that the MAOA gene explained part of the variability in the development of antisocial behaviors after the maltreatment experience. It seems that an event such as sexual abuse in childhood causes hyperactivity in the hypothalamicpituitary-adrenal axis and in the autonomous system which, together with the low activity of the MAOA-LPR allele, may cause a tendency in the individual to develop a personality disorder such as the antisocial personality disorder.58 Borderline personality disorder On their part, Semiz, Başoğlu, Ebrinç and Cetin53 studied the association between antisocial personality disorder and the history of traumatic events in childhood, finding that adults diagnosed of antisocial personality disorder have a high prevalence of victimization in childhood, among them sexual abuse. Along this same line, the work of Bierer et al.41 also stands out. In their work, a specific connection is revealed between childhood sexual abuse and physical abuse in the diagnosis of antisocial disorder in a sample of outpatients. One of the disorders frequently related with the experience of childhood sexual abuse is the borderline personality disorder, defined as a general pattern of instability in interpersonal relationships, self-image and affectivity, and elevated impulsiveness, that can be reflected in the existence of substance abuse, eating disorders characterized by bingings and promiscuous sexual behaviors, among others35 and that are observed with relative frequency in sexual abuse victims (for a review, see ref. 59).59 One of the most important publications regarding the relationship between abuse in childhood, including sexual abuse as a subgroup, and its possible relationship with antisocial behavior, is the investigation of Caspi et al.54 The authors found that part of the individuals who had been victims of childhood abuse incurred in manifestly anti-social behavior in adulthood. The most surprising result was that when the genotype of this group was analyzed, the individuals having a certain version of the MAOA gene (cerebral enzyme involved in response to adverse situations and linked to violent behavior55) were those who had a much more violent behavior than the abuse victims who were carriers of another version of the same gene. That is, the genotype acted as a modulator factor between the experience Different studies have confirmed this relationship in the general population,31, 51, 60-63 and in clinical36, 41, 64-69 or penitentiary samples.70 As in other personality disorders, borderline disorder is not associated with any specific form of childhood maltreatment,71 although childhood sexual abuse is a very strong predictive factor of the borderline symptoms. Other works have confirmed this association.34, 44 134 In turn, it has been stated that women diagnosed of borderline personality disorder suffer sexual abuse in childhood more frequently as well as more serious sexual abuses than the undiagnosed women.72, 73 For Meza-Rodríguez,74 the experience of childhood sexual abuse can activate the hypothalamic-pituitary-adrenal system which, related with Actas Esp Psiquiatr 2011;39(2):131-9 58 Noemí Pereda, et al. Table 3 Personality disorders in child sexual abuse victims Personality disorders in childhood sexual abuse victims: Cluster C Symptoms Studies Avoidant disorder 31, 34, 36, 44, 51, 71 Dependant disorder 19, 22, 24-25, 34, 44, 71 Obsessive-compulsive disorder 23, 44, 51, 71 hyperactivation of the serotoninergic system, may lead to the manifestation of impulsive behaviors. Furthermore, Rüsch et al.75 demonstrated a relationship between the experience of sexual abuse and thinner corpus callosum in women with borderline personality disorder. However, other studies have not found this relationship between neurobiological dysfunctions and childhood sexual abuse in patients with borderline personality disorder.76 Different variables seem to affect the development of the disorder, such as if the victim reveals the abuse and undergoes psychological treatment77 or the presence of low self-esteem.78 Along this same line, a study conducted by Gladstone et al.79 considers childhood sexual abuse as an important risk factor for the development of borderline personality disorder. This, in turn, is related with a greater risk of depression, the diagnosis of borderline disorder acting as mediator between the status of sexual abuse and depression. Recently, other authors47, 80 have demonstrated a strong relationship between the experience of sexual abuse, development of borderline personality disorder and suicidal ideation and behavior. However, some authors,29, 81-83 standing out among them the meta-analysis study conducted by Fossati, Madeddu and Maffei,84 have undervalued the supposed relationship existing between the experience of childhood sexual abuse and the development of borderline personality disorder. They consider that childhood sexual abuse is not a necessary or sufficient requirement for the development of this disorder, there being other childhood experiences and multiple variables involved, mainly the severity of the abuse experienced, that require the development of multifactorial etiological models. Group C Group C disorders are characterized by a high incidence of symptoms related with anxiety and social withdrawal. Thus, the avoidant disorder is characterized by a general pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation whose onset is at the 59 beginning of the adult age.35 On its part, dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fear of separation.35 The last one of the disorders of this group, obsessive-compulsive personality disorder, is characterized by pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, at the expense of flexibility, spontaneity and efficiency35 (Table 3). Empirical research linking sexual abuse with development has not been found as frequently for the group C disorders, probably because its prevalence is not as high as that of the group B disorders. Standing out a the works published on this is that by Johnson et al.31 A strong relationship was found in this study between avoidant coping strategies, sexual abuse in childhood and personality disorders. Another important work is that of Lobbestael et al.,36 that verified the association between childhood sexual abuse and avoidant personality disorder, controlling the comorbidity with the rest of the disorders. Another study that concluded the existence of a relationship between sexual abuse and dependent personality disorder was that carried out by Strickland.22 That study investigated a group of women serving a sentence in prison. The author reached the conclusion that sexually delinquent women, who had suffered abuses in childhood, lacked skills for negotiation in social context in addition to a dependent personality type that led them to become involved in dysfunctional relationships, and not knowing how to negotiate their sexual relationships. Other previously mentioned works also studied this association between childhood sexual abuse and group C personality disorder. These include those of Johnson et al.,19 MacMillan et al.,51 Wonderlich et al.,71 Grover et al.34 or Tyrka et al..44 These works found a positive association in most of the cases between childhood abuse and the symptoms related with this group. Significant differences between the abused group and non-abused group in relationship to the obsessive-compulsive symptoms were not found in only one of the studies.23 DISCUSSION AND CONCLUSIONS The studies reviewed in this work show the interindividual variability in the development of personality disorders in child sexual abuse victims. Although specific associations between childhood sexual abuse and some personality disorders were detected in less recent bibliography, a more up-dated review indicates that the effects of childhood sexual abuse seem to be non-specific. If we add up both factors, interindividual variability and the nonspecificity of Actas Esp Psiquiatr 2011;39(2):131-9 135 Noemí Pereda, et al. Personality disorders in child sexual abuse victims sexual abuse per se, we inevitably reach the study of the resilience which, as has recently been defended, should be analyzed from a wide psychobiological perspective85 that includes both psychosocial variables of the individuals and their neurobiological responses to stress.54, 86-88 Undoubtedly, understanding the associations and interactions produced between childhood traumatic experiences and the psychobiological variables of the individual per se during the development of personality would make it possible to carry out more effective treatments.89 These could be performed either by primary and secondary prevention environmental interventions or by personalized interventions within the tertiary prevention setting when exposure to the childhood sexual abuse cannot be avoided. In the words of Lazarus90 “Trauma can never be adequately defined as an external event. To be traumatized depends on the specifics of the connection between the event and the person who is responding to it – in other words, on the person-environment relationship.” In this sense, the relationship between the positive experiences during childhood and the capacity of resilience and recovery from a personality disorder has been empirically stated, specifically that of avoidant disorder and schizotypal disorder.91 Knowing and promoting positive interpersonal relation experiences can help, based on the results, favor resilience in sexual abuse victims. These posttraumatic interventions should take into account the differences of the individuals in relationship to their personality structure, coping strategies, feelings of guilt, support and supportive networks, or even on another level, their genetic endowment for a more effective pharmacogenomic intervention, if necessary. In general, it seems that childhood sexual abuse and the relationship with personality disorders is related with loss of confidence, security, stability, self-efficacy and regulation of affect,44 variables present in most of the victims and very related with paranoid personality, borderline personality, antisocial personality and group C disorders. The studies published on sexual abuse, however, do not make it possible to establish the existence of a syndrome that defines and covers the emotional, cognitive and social problems related with this experience, establishing consequences that affect all the areas of the life of the victim and even the total absence of symptoms and some of them.92 Therefore, it is difficult to establish causal relationships that make it possible to describe the direction of the relation between the experience of sexual abuse in childhood and the development of personality disorders in adulthood. On the other hand, variables linked to the methodology of the works reviewed, such as that most of the results come from retrospective studies, the lack of control of possible mediator variables in many of the studies and the use of mainly female gender samples, limit the establishment of clear conclusions regarding the development of psychopathology in childhood 136 sexual abuse victims. In fact, the differences in the prevalence by gender and some of the disorders presented hinder the obtaining of solid conclusions in this regards. Another one of the important limitations is that most of the works have not specifically studied the effects of childhood sexual abuse but rather have done so within the general framework of maltreatment. Even though there are some tools to evaluate the different forms of abuse, among which the Juvenile Victimization Questionnaire de Finkelhor, Hamby, Ormord, & Turner,93 or the Childhood Trauma Questionnaire,94 stand out and that some works have considered the overlapping of different types of maltreatment, it is very difficult to separate the effects of childhood sexual abuse from other typologies of violence or from other types of factors related with the dysfunctional family environment,43 or simply with the passage of time.95 It should be stressed that victims of a single maltreatment are very uncommon, the most common being the combination of several.96, 97 This is one of the causes that has also made it difficult to establish typologies of consensus and to determine specific sequels caused by one type or another of maltreatment. 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