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Dissociation in Borderline PersonalityDisorder: A Detailed LookMarilyn I. Korzekwa MD FRCPC a , Paul F. Dell PhD b , Paul S. Links MDFRCPC c , Lehana Thabane PhD d e & Philip Fougere HBA aa Department of Psychiatry and Behavioural Neurosciences ,McMaster University , Hamilton, Ontario, Canadab Trauma Recovery Center , Norfolk, Virginia, USAc The Arthur Rotenberg Chair in Suicide Studies , St. Michael'sHospital , Toronto, Ontario, Canadad Department of Clinical Epidemiology and Biostatistics , McMasterUniversity , Hamilton, Ontario, Canadae Biostatistics Unit , Father Sean O'Sullivan Research Centre, St.Joseph's Healthcare , Hamilton, Ontario, CanadaPublished online: 06 Jul 2009.

To cite this article: Marilyn I. Korzekwa MD FRCPC , Paul F. Dell PhD , Paul S. Links MD FRCPC , LehanaThabane PhD & Philip Fougere HBA (2009) Dissociation in Borderline Personality Disorder: A DetailedLook, Journal of Trauma & Dissociation, 10:3, 346-367, DOI: 10.1080/15299730902956838

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Journal of Trauma & Dissociation, 10:346–367, 2009 Copyright © Taylor & Francis Group, LLC ISSN: 1529-9732 print/1529-9740 onlineDOI: 10.1080/15299730902956838

WJTD1529-97321529-9740Journal of Trauma & Dissociation, Vol. 10, No. 3, May 2009: pp. 1–39Journal of Trauma & Dissociation

Dissociation in Borderline Personality Disorder: A Detailed Look

Dissociation in Borderline Personality DisorderM. I. Korzekwa et al.

MARILYN I. KORZEKWA, MD, FRCPCDepartment of Psychiatry and Behavioural Neurosciences, McMaster University,

Hamilton, Ontario, Canada

PAUL F. DELL, PhDTrauma Recovery Center, Norfolk, Virginia, USA

PAUL S. LINKS, MD, FRCPCThe Arthur Rotenberg Chair in Suicide Studies, St. Michael’s Hospital,

Toronto, Ontario, Canada

LEHANA THABANE, PhDDepartment of Clinical Epidemiology and Biostatistics, McMaster University,

Hamilton, Ontario, Canada; and Biostatistics Unit, Father Sean O’Sullivan Research Centre, St. Joseph’s Healthcare, Hamilton, Ontario, Canada

PHILIP FOUGERE, HBADepartment of Psychiatry and Behavioural Neurosciences, McMaster University,

Hamilton, Ontario, Canada

The objective of the present study was to assess in detail the wholespectrum of normal and pathological dissociative experiences anddissociative disorder (DD) diagnoses in borderline personalitydisorder (BPD) as diagnosed with the Revised Diagnostic Interviewfor Borderlines. Dissociation was measured comprehensively in21 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. Joseph’s 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. Joseph’s Hospital, 50 Charlton Avenue East, Hamilton, Ontario, L8E 4A6 Canada.E-mail: [email protected]

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Dissociation in Borderline Personality Disorder 347

DSM–IV Dissociative Disorders–Revised, the MultidimensionalInventory of Dissociation (MID), the Dissociative Experiences Scalepathological taxon analysis, and the Somatoform DissociationQuestionnaire. The frequencies of DDs in this BPD sample were asfollows: 24% no DD, 29% mild DD (dissociative amnesia and dep-ersonalization disorder), 24% DD Not Otherwise Specified(DDNOS), and 24% dissociative identity disorder. With regard tothe dissociative experiences endorsed, almost all patients reportedidentity confusion, unexplained mood changes, and depersonaliza-tion. Even those BPD patients with mild DD reported derealization,depersonalization, and dissociative amnesia. BPD patients withDDNOS reported frequent depersonalization, frequent amnesia,and notable experiences of identity alteration. BPD patients withdissociative identity disorder endorsed severe dissociative symptomsin all categories. Analysis of the MID pathological dissociationitems revealed that 32% of the items were endorsed at a clinicallysignificant level of frequency by more than 50% of our BPDpatients. In conclusion, the frequencies of Diagnostic and StatisticalManual of Mental Disorders (4th ed.) DDs in these patients withBPD were surprisingly high. Likewise, the “average” BPD patientendorsed a wide variety of recurrent pathological dissociativesymptoms.

KEYWORDS borderline personality disorder, dissociation, disso-ciative disorders

INTRODUCTION

Pathological dissociation has been described in articles on “borderlinepersonality” almost since the diagnostic term was coined. “Peculiar egostates . . . have been variously categorized as depersonalization, dissocia-tion 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 bor-derline personality disorder (BPD) in the Diagnostic and Statistical Manualof Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association,1994). Research has consistently demonstrated that levels of dissociation aresignificantly higher in BPD than in normal controls, persons with other per-sonality disorders, and general psychiatric patients (e.g., Herman, Perry, & Vander 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 personswith a severe dissociative disorder (DD) have comorbid BPD. DD cases

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348 M. I. Korzekwa et al.

with comorbid BPD have increased morbidity and poorer functioning thanDD cases without comorbid BPD (Dell, 1998; Horevitz & Braun, 1984). Dis-sociative identity disorder (DID) can be diagnosed in 10% to 27% of theBPD 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; Rosset al., 1990; Sar et al., 2003). Second, some of the persons with a primarydiagnosis of BPD have one or more dissociative symptoms (but not acomorbid severe DD diagnosis). This group continues to be poorly under-stood in the literature.

The development of pathological dissociation has been consistentlylinked to trauma, most strongly childhood sexual abuse (CSA; Allen, Fultz,Huntoon, & Brethour, 2002), co-occurring CSA and childhood physicalabuse (Draijer & Langeland, 1999), and early and severe abuse (Carlson et al.,2001; Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997). In BPD, therates of CSA and multiple forms of childhood abuse are higher than in otherpersonality 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 significantlyrelated 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 mediatedby other factors such as neglect, inconsistent treatment by a caregiver, fearfulattachment, severe maternal dysfunction, witnessing of violence, sexualassault 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 prob-lems. First, most of the above studies failed to exclude serious DDs such asDD Not Otherwise Specified (DDNOS) and DID. Failure to control for thepresence of comorbid DDs in a study of dissociation in BPD is a seriousmethodological inadequacy (Sar & Ross, 2006). Second, most of the studiesfailed to exclude substance abuse. This is important because Van Den Boschet al. (2003) found no association between trauma and dissociation in theiraddicted BPD patients. Third, most of the studies on dissociation in BPD didnot use a comprehensive measure of dissociation; instead they used screen-ing tests such as the Dissociative Experiences Scale (DES; E. M. Bernstein &Putnam, 1986). The DES contains several items that tap normal dissociativeexperiences (N. G. Waller & Ross, 1997), it does not assess the entire domainof pathological dissociation (Dell, 2006b), and it does not diagnose DDs.

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Only a few studies have used a comprehensive measure of dissociationto study dissociation in BPD. In our view, a list of the most rigorous dissoci-ation instruments would include at least the DES-Taxon scale (DES-T), theSomatoform Dissociation Questionnaire (SDQ-20), the Structured ClinicalInterview for DSM–IV Dissociative Disorders (SCID-D), and the DissociativeDisorders Interview Schedule (DDIS). The DES-T (N. G. Waller, Putnam, &Carlson, 1996) consists of eight items from the DES that describe dissociativeamnesia (DA), depersonalization, derealization, and identity alteration orconfusion. The DES-T differentiated patients with severe DDs from controlsin two studies (Allen et al., 2002; N. G. Waller & Ross, 1997) but not in athird study (Modestin & Erni, 2004). It has been suggested that high DESscores in BPD may be a mixture of nonpathological and pathological disso-ciation (Goodman et al., 2003).

Somatoform dissociation involves lack of integration of the somatoformcomponents of experience; examples include anesthesia, paralysis, unex-plained pain, and uncontrolled movements. Scores on the SDQ-20 (Nijenhuis,Spinhoven, van Dyck, van der Hart, & Vanderlinden, 1996) correlate highlywith 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 havehigher somatoform dissociation scores than do normal persons (Stiglmayr,Shapiro, Stieglitz, Limberger, & Bohus, 2001).

The gold-standard measure for diagnosing DDs is the Structured ClinicalInterview for DSM–IV Dissociative Disorders–Revised (SCID-D-R; Steinberg,1994). The SCID-D-R assesses the presence and severity of five symptoms(amnesia, depersonalization, derealization, identity confusion, and identityalteration) and yields DSM–IV DD diagnoses (Steinberg, Rounsaville, &Cicchetti, 1990). In a SCID-D-R study of 80 randomly selected universitystudents 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 outpatientswith the DES, the SDQ-20, and DSM–III–R BPD criteria and followed uphigh scorers with a SCID-D interview. Of 25 BPD patients, 4% were diag-nosed with comorbid DA, 36% DDNOS, and 24% DID. An interestingtable listed the dissociative symptoms in BPD, but not as a function ofcomorbid DDs.

The DDIS (Ross, 1997) is a structured interview that makes BPD andDD diagnoses; it also inquires about a variety of related symptoms. In arecent study that used the DDIS and the SCID-D, Ross (2007) reported that93 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 ofdepersonalization, derealization, identity confusion, and alteration wassignificantly greater in the BPD inpatients than in a control group of non-borderline inpatients (Ross, 2007).

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The Multidimensional Inventory of Dissociation (MID; Dell, 2006a) is anew self-report instrument that diagnoses DDs and measures the entirespectrum of pathological dissociation (Dell, 2006b). The MID was explicitlydesigned for clinical research and for assessing patients who present with amixture of dissociative, posttraumatic, and borderline symptoms. In a studyof 30 BPD patients diagnosed by structured interview (Laddis & Dell, 2002),the MID diagnosed 27% DID, 43% DDNOS, and 30% no DD. BPD–DIDpatients did not differ significantly from a comparison group of patientswith DID only. Almost all BPD–DDNOS patients endorsed flashbacks, inter-nal struggle, and self-puzzlement. This BPD–DDNOS group was sorted intotwo clusters. Cluster 1 (30% of total) had primarily angry self-states; thesepatients endorsed memory problems, but they reported little frank amnesia.Cluster 2 (13% of the total) had DID-like self-states; they reported extensiveamnesia and frequent voices (especially child and persecutory voices). BPDpatients 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 per-sons, but some do not; and (c) dissociation in BPD patients is often, but notalways, associated with trauma. Newer, more comprehensive dissociationinstruments 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 arepathological dissociative symptoms in BPD? How should BPD patients withpathological dissociative symptoms best be characterized (in terms of DDs)?

The objective of the current study was to comprehensively assess thedissociative symptoms and DDs that occur in a well-diagnosed sample ofadult outpatients with BPD.

METHODS

Procedure

This was a three-phase study approved by the hospital research ethicsboard. Separate informed consent was obtained for each phase. In Phase 1,the entire population of an adult outpatient clinic was screened for BPDusing the self-report Structured Clinical Interview for DSM–IV Axis II Disorders(SCID-II) criteria for BPD.

In Phase 2, patients who met the self-report DSM–IV criteria for BPDwere invited to be assessed with the Revised Diagnostic Interview forBorderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989).The interviewers were trained by a local expert who had been trained bythe 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 thestudy.

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 Struc-tured Clinical Interview for DSM–IV Axis I Disorders (SCID-I); (b) underwenta brief interview to confirm the findings of the SCID-I and to confirm theabsence of exclusion criteria; (c) completed the DES, SDQ-20, MID, andSCID-II self-report at home; and (d) were administered the SCID-D-R by anexperienced interviewer (the first author), who established interrater reli-ability with 10 videotape ratings with an expert (Dr. S. Jordan) trained byDr. 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 deliberatelyover-inclusive; the false positives were clarified with a short interview.These instruments were used to confirm exclusion criteria and describecomorbidity.

DIB-R. The DIB-R is one of the most extensively used instruments fordiagnosing BPD. The DIB-R inquires about the DSM–IV criteria, but thescoring rules emphasize four sections thought to be of critical clinical impor-tance in diagnosing BPD (i.e., affect, cognition, impulse action patterns, andinterpersonal relationships). A cutoff score of 8 has a sensitivity of 82%, aspecificity of 80%, a positive predictive power of 74%, and a negativepredictive power of 87% for differentiating BPD from other personalitydisorders (Zanarini et al., 1989).

DES. The DES measures 28 dissociative experiences on a Likert scaleof 1 to 100. It has good to excellent test–retest reliability; internal consis-tency (Cronbach’s a = .93); convergent validity with other dissociationinstruments (combined effect size Cohen’s d = 1.82); and predictive validityfor 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 astructured clinical interview (Carlson & Putnam, 1993). The probability ofpathological taxon membership (N. G. Waller et al., 1996) was calculated usingthe statistical package available on the Web site of the International Society forthe Study of Trauma and Dissociation (n.d.). The DES-T (mean) can also beapproximated by averaging the eight pathological items. A DES-T (mean)cutoff score of 35 has 57% sensitivity, 100% specificity, and 100% positive pre-dictive 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 measuressomatoform dissociation on a 5-point Likert scale, generating scores from 20to 100. The SDQ-20 has high construct validity; it differentiates patients withDDs from normal persons and other clinical samples (Nijenhuis et al., 1996,1998; Sar, Kundakci, Kiziltan, Bakim & Bozkurt, 2000). The SDQ-20 has analpha coefficient of .95 (Nijenhuis et al., 1996).

SCID-D-R. The SCID-D-R is a semistructured interview for diagnosingDDs that asks 200 questions to evaluate five main dissociative symptoms.Each symptom is rated on a 4-point scale. Ratings of severe are generallyawarded 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 clinicianwho is experienced in DDs. The SCID-D-R has good to excellent reliabilityand discriminant validity for DDs (Steinberg et al., 1990) and has been use-ful 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. TheMID surveys all known manifestations of pathological dissociation and pro-vides a DSM–IV diagnosis (Dell, 2006a). It contains 168 dissociation itemsthat are sorted into 23 dissociation scales; it also contains 50 validity itemsthat are sorted into 5 validity scales (defensiveness, rare and bizarre symptoms,emotional suffering, attention seeking, and factitiousness). Each of the18 items on the MID’s BPD Index significantly distinguished between 100interview-diagnosed BPD patients and 51 DID patients (Laddis & Dell,2003). The MID’s Excel-based scoring program recognizes four diagnoses:no DD, DD deferred, DDNOS, and DID. The MID’s diagnostic algorithm forDID requires the presence of at least 4 of 6 general dissociative symptoms,at least 6 of 11 dissociative intrusions into executive functioning or sense ofself, 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 withDDNOS, and mixed psychiatric patients. The alpha coefficient for the diag-nostic scales is .99 and for the validity scales is .78 to .92. Factor analysis ofthe 168 dissociation items yielded a single, second-order factor: pathologicaldissociation (Dell & Lawson, in press). The MID correlates strongly withother 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 retro-spectively 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 com-munity data published (Scher, Stein, Asmundson, McCreary, & Forde, 2001).

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The CTQ has demonstrated high convergent validity with clinician-ratedinterviews of abuse, excellent test–retest reliabilities over 2 to 6 months, andexcellent internal consistency coefficients ranging from 0.66 to 0.92 across arange 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 continuousvariables. Convergent validity among the six dissociation instruments wasdetermined using the Spearman’s coefficient test because the data distributionwas nonnormal. Because this involved 10 analyses, the criterion for signifi-cance was adjusted to alpha = .005 using the Bonferroni method for multipleanalyses. We also assessed agreement between raters using Cohen’s kappastatistic (k). We judged agreement as moderate if 0.41 ≤ k ≤ 0.6, substantialif 0.61 ≤ k ≤ 0.8, and near perfect if k ≥ 0.81. All analyses were performedusing SPSS version 9 (Chicago, IL).

RESULTS

Demographics

In Phase 1, 306 general outpatients were invited to be screened, 239 com-pleted the screening, and 173 were positive for DSM–IV BPD. In Phase 2,131 completed the DIB-R interview, and 54 were positive for BPD. Wefound a fairly high rate of BPD (22.6%, 54/239; 95% confidence interval =17.3%–27.9%) because our hospital outpatient clinic serves the downtowncore of a city of 500,000, all of our population is insured and has access tohealth care, and many of our referrals come from the psychiatric emergencyor 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 notenter or complete Phase 3 for the following reasons: 9 did not consent, 6were excluded because they were the first author’s psychotherapy patients,9 were excluded due to psychosis or current substance abuse, and 9dropped out. The mean (SD) age was 38 (8) years, 76% were female, and57% had never been married. They averaged (SD) 12.8 (2.3) years of school-ing and DIB-R scores of 8.9 (0.7). Median (minimum–maximum) number oflifetime hospitalizations was 1.0 (0–30). The following were the highestoccupational levels: 14% professional or managerial; 38% technical, clerical,or skilled labor; 19% unskilled labor; 5% student; and 24% none. BPDpatients who did not enter or complete Phase 3 were compared to the par-ticipants who did complete the study; they did not differ significantly onany of the above variables.

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Comorbid Diagnoses

SCID-I and -II diagnoses of our sample are presented in Table 1 . The greatestAxis I comorbidity for this BPD sample was PTSD (86%), followed by majordepressive disorder, panic disorder with agoraphobia, and social phobia. Thehigh rate of comorbid anxiety and mood disorders is consistent with the liter-ature (Swartz, Blazer, George, & Winfield, 1990; Zanarini et al., 1998a). Ourrate of PTSD is higher than that reported by the above authors (34%–56%) butis consistent with the overall higher level of psychopathology in our clinic.

The pattern of Axis II comorbidity we found is consistent with the BPDliterature (Zanarini et al., 1998b), although our rates are somewhat higher,given that our instrument was a self-report measure. The highest rates werefound for depressive, paranoid, avoidant, schizoid, and passive-aggressivepersonality disorders. The mean (SD) number of personality disorders perparticipant was 6.7 (2.2). Comorbid histrionic personality disorder wasendorsed by only one participant (no DD). The SCID-D-R DD diagnoses arealso 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 comparableto literature that reported a similar rate for DID (Sar et al., 2003, 2006).

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 tomoderate 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 thatthe authors calculated from 20 BPD studies in the literature that provided DESdata, but it is consistent with psychiatric groups with high levels of PTSD(Carlson & Putnam, 1993). For example, Heffernan and Cloitre (2000) found aDES 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 sam-ple had greater than a 0.6 probability of being in the pathological dissociationtaxon (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 orDID) at the 0.6 level were 50% (5/10) and 81.8% (9/11) and at the 0.9 levelwere 30.0% (3/10) and 90.9% (10/11), respectively. The mean (SD) SDQ-20score 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

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TABLE 1 Phase 3 Diagnoses (n = 21)

Diagnosis n (%)

SCID-I DiagnosesMood disorders

Major depressive disorder (lt) 15 (71.4)Major depressive disorder current 13 (61.9)Dysthymic disorder 5 (23.8)Bipolar II (lt) 3 (14.3)Bipolar I (lt) 1 (4.8)Mood disorder—medica1 1 (4.8)

Anxiety disordersPosttraumatic stress disorder 18 (85.7)Panic disorder with agoraphobia (lt) 14 (66.7)Social phobia 12 (57.1)Generalized anxiety disorder 11 (52.4)Obsessive compulsive disorder 9 (42.9)Specific phobia 4 (19.0)Agoraphobia (lt) 1 (4.8)Panic disorder without agoraphobia (lt) 1 (4.8)

Substance disordersDependence (lt) 6 (28.6)Substance abuse (lt) 4 (19.0)Alcohol dependence (lt) 4 (19.0)Alcohol abuse(lt) 1 (4.8)

Somatoform and eating disordersAnorexia nervosa (lt) 2 (9.5)Hypochondriasis 1 (4.8)Bulimia (lt) 1 (4.8)Somatization 0

SCID-D-R DiagnosesNone 5 (23.8)Dissociative amnesia 2 (9.6)Depersonalization disorder 4 (19.0)Dissociative disorder NOS Type 1A 5 (23.8)Dissociative identity disorder 5 (23.8)

SCID-II Self-Report DiagnosesBorderline 21 (100.0)Paranoid 17 (81.0)Depressive 17 (81.0)Avoidant 15 (71.4)Schizoid 14 (66.7)Passive aggressive 13 (61.9)Obsessive compulsive 12 (57.1)Narcissistic 9 (42.9)Antisocial (criteria C only) 9 (42.9)Schizotypal 6 (28.6)Dependent 7 (33.3)Histrionic 1 (4.8)

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

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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 deniedexperiencing CSA, whereas none of the DDNOS or DID participants did so.The more severe the DD, the higher the CTQ score. However, because ofthe small sample size, the correlation with DD diagnosis severity was signif-icant only for sexual abuse (analysis of variance; F = 4.115, p = .023). Emo-tional neglect (2.506, p = .094) and total CTQ (2.757, p = .074) showedtrends toward significance.

Detailed Description of Symptoms

Table 3 provides a detailed description of 21 BPD cases and their SCID-D-Rdiagnoses. Elevated scores on the MID validity scales are indicated, as is theprobability of membership (≥0.6 or ≥0.9) in the dissociative taxon. BPDcases with no DD had mean DES-T scores that fell well below the cutoffscore (13) for pathological dissociation. Validity scales were significantlyelevated for 3/5 participants. The MID also diagnosed 3/5 with no DD. Inthe mild DD category, the SCID-D-R diagnosed one case of DA, whose self-report scores were just above “normal.” Another case met criteria for bothDA and DPD, but the DA was more disabling, so the case was classified asDA. The four DPD cases had an extremely wide range of scores. The MIDdiagnosed 3/4 with DID. Two of these had high BPD indices; had signifi-cantly elevated validity scales, including both attention seeking and emo-tional suffering; and were classified as DES-T taxon members (≥0.6probability level). Of the DDNOS cases, all five met criteria for DSM–IV type1A, “Clinical presentations similar to DID that fail to meet full criteria forthis disorder. Example includes presentations in which a) there are not twoor more distinct personality states” (DSM–IV, 1994, p. 490). Cases number12 and 13 were diagnosed as probable because of uncertainty about theseparateness of their dissociated behavior. These were also diagnosed asDD diagnosis deferred by the MID. Of the definite DDNOS cases, the MIDdiagnosed 2/3 with DID. The DES-T classified 3/5 DDNOS cases as taxonmembers (≥0.6 probability). The scores in the DID patients were very high,

TABLE 2 Mean (SD) CTQ Scores by Dissociative Disorder

SCID-D-R diagnosis

Physical neglect

Emotional neglect

Physical abuse

Emotional abuse

Sexual abuse

Total CTQ

None 7.8 (2.6) 12.8 (5.3) 9.2 (1.8) 13.6 (5.6) 9.0 (8.9) 52.4 (20.3)DA/DPD 8.2 (2.8) 14.8 (5.2) 11.8 (5.2) 17.0 (7.1) 8.3 (3.8) 60.2 (21.7)DDNOS 12.2 (7.4) 17.8 (5.2) 13.8 (7.6) 16.2 (5.9) 14.2 (7.9) 74.2 (23.2)DID 12.2 (7.1) 21.0 (4.7) 13.4 (8.6) 20.6 (3.0) 21.2 (5.5) 88.4 (21.1)

Notes: CTQ = Childhood Trauma Questionnaire; SCID-D-R = Structured Clinical Interview for DSM–IVDissociative Disorders–Revised; DA/DPD = dissociative amnesia/depersonalization disorder; DDNOS =dissociative disorder not otherwise specified; DID = dissociative identity disorder.

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as expected. One case, with significantly elevated BPD index, attentionseeking, and emotional suffering scales, had extremely high scores. TheMID 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 ) andthe clinically significant (frequency at or above the cutoff for DID) MID dis-sociation scales (see Table 5 ) showed that BPD patients without a DD still

TABLE 3 Individual Case Studies

No.SCID-D-Rdiagnosis SCID-D-R MID DES

DES-T(M) Validity scalesa

BPD index

No DD1 None 5 13.5b 17.5 6.3 ↑↑ Att 29 ↑2 None 7 2.6c 6.9 1.3 ↑↑ Def 33 None 7 8.8c 10.0 5.0 ↑ Att, Def 114 None 9 8.6c 9.6 3.8 ↑↑ Att, Em 225 None 11 9.8b 14.6 6.3 9Means 1–5 7.8 8.7 11.7 4.5

Mild DD6 DA 13 12.3b 17.5 7.5 ↑ Def 57 DA 15 10.6c 16.1 15.0 ↑ Def 78 DPD 13 28.3d 19.6 8.8 59 DPD 13 49.9d 36.4 21.3e ↑↑ Att, Em, Fac, Rare 67 ↑↑10 DPD 15 15.5b 15.0 11.3 111 DPD 16 46.2d 52.1 62.5f ↑↑ Att, Em 25 ↑Means 6–11 14.2 27.1 26.1 21.1Means 6, 7, 8, 10 14.0 16.7 17.1 10.6

DDNOS12 DDNOS 15 9.6b 8.2 3.8 ↑ Def 1013 DDNOS 15 22.7b 33.6 16.3e ↑ Em 014 DDNOS 18 15.3b 16.1 6.3 ↑ Att, Def 715 DDNOS 19 30.1d 48.6 36.3f 1016 DDNOS 20 40.5d 28.6 15.0e ↑↑ Em 12Means 12–16 17.4 23.6 27.4 15.5

DID17 DID 18 45.1d 32.1 16.3 ↑↑ Em 1318 DID 20 24.3b 18.2 12.5 319 DID 20 26.8d 19.3 12.5 220 DID 20 55.9d 59.3 65.0f ↑↑ Rare 1221 DID 20 64.0d 84.6 78.8f ↑↑ Att, Em 32 ↑↑Means 17–21 19.6 43.2 42.7 37.0

Notes: Numbers in bold are values discrepant for their SCID-D-R diagnostic category. SCID-D-R = Struc-tured Clinical Interview for DSM–IV Dissociative Disorders–Revised; MID = Multidimensional Inventoryof Dissociation; DES = Dissociative Experiences Scale; DES-T = DES-Taxon scale; BPD = borderlinepersonality disorder; DD = dissociative disorder; Att = attention seeking; Def = defensiveness; Em = emotionalsuffering; DA = dissociative amnesia; DPD = depersonalization disorder; Fac = factitious behavior; Rare =rare symptoms; DDNOS = DD not otherwise specified; DID = dissociative identity disorder.aValidity scales: ↑ = subclinically elevated; ↑↑ = significantly elevated. bDiagnosed as DD deferred onMID. cDiagnosed as no DD on MID. dDiagnosed as DID on MID. eProbability of taxon membership =0.66–0.8. fProbability of taxon membership = 0.9–1.0.

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TABLE 4 Frequency of SCID-D-R Symptoms in Borderline Personality Disorder

SCID-D-R symptom

No DD(n = 5)

DA/DPD(n = 6)

DDNOS(n = 5)

DID(n = 5)

Total (n = 21)

n n n n n %

Identity ConfusionStruggle inside about who you really are 3 4 4 5 16 76Confused as to who you are 2 4 5 5 16 76Struggle going on inside of you 3 2 4 5 14 67

DepersonalizationDetachment from behavior 0 6 4 4 14 67Feeling not in control of emotions 3 4 2 5 14 67Watching self from outside the body 1 4 4 4 13 62Simultaneous participating and observing 1 2 4 5 12 57Feeling not in control of behavior 1 2 5 3 11 52Feelings of estrangement 0 2 3 4 9 43Part or whole body feels unreal 0 1 3 3 7 33Feeling not in control of speech 0 2 2 4 8 38Part or whole body disappears 1 0 3 1 5 24Altered perception of body 1 0 3 1 5 24Part of body disconnected from the rest 0 0 2 1 3 14Change in size of arms or legs 0 1 1 0 2 10

Associated features of DIDMood changes without any reason 5 2 4 4 15 71Flashbacks 2 4 3 5 14 67Internal voices 0 0 2 3 5 24Changes in talent or capacities 0 0 0 4 4 19

AmnesiaMemory gaps 1 1 4 4 10 48Difficulty remembering daily activities 0 2 4 4 10 48Finding self in places 0 2 4 4 10 48Blocks of time missing 0 3 2 4 9 43Inability to recall personal information 0 1 1 3 5 24

Identity AlterationActing like a child 0 2 2 4 8 38Told by others seem like different person 1 0 1 5 7 33Acting as a different person 1 0 2 4 7 33Finding things without remembering 0 0 0 2 2 10Referred to by different names 0 0 0 1 1 5Feeling of being possessed 0 0 1 0 1 5

DerealizationSurroundings or people unreal/unfamiliar 0 2 2 2 6 29Surroundings or people fade away 0 1 1 3 5 24Friends, family, home strange or foreign 0 1 1 3 5 24Puzzled about what is real and unreal 0 2 0 3 5 24Not recognizing friends, family or home 0 1 0 3 4 19

Notes: SCID-D-R = Structured Clinical Interview for DSM–IV Dissociative Disorders–Revised; DD =dissociative disorder; DA/DPD = dissociative amnesia/depersonalization disorder; DDNOS = DD nototherwise specified; DID = dissociative identity disorder.

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reported significant levels of depersonalization (not in control of emotionsand behavior), identity confusion, unexplained mood changes, and flash-backs. In addition to these symptoms, BPD patients with DA or DPD alsoreported internal voices, additional manifestations of depersonalization(including detachment from behavior and watching self from outside thebody), some derealization, some Schneiderian first-rank symptoms, andamnesia. In DDNOS, multiple types of depersonalization were often present,and amnesia and identity alteration became significant. The DID groupendorsed severe levels of all forms of dissociation. The symptoms of patho-logical dissociation (i.e., depersonalization, derealization, amnesia, and iden-tity alteration) on both the MID and the SCID-D-R appear to constitute aspectrum of severity within BPD. This is also seen clearly in Table 6, whichdisplays the mean severity of SCID-D-R symptoms by dissociative diagnosis.

TABLE 5 Frequency of MID Dissociation Scales Endorsed at a Clinically Significant Level

MID diagnostic scale

No DD (n = 5)

DA/DPD (n = 6)

DDNOS (n = 5)

DID (n = 5)

Total (n = 21)

n n n n n %

General DissociativeSymptomsMemory problems 2 5 4 4 15 71.4Depersonalization 0 4 3 3 10 47.6Derealization 1 4 2 4 11 52.4Posttraumatic flashbacks 2 5 5 5 17 81.0Somatoform symptoms 0 4 0 3 7 33.3Trance 0 3 4 4 11 52.4

Dissociative IntrusionsChild voices 0 4 4 5 13 61.9Voices/internal struggle 0 3 2 5 10 47.6Persecutory voices 0 2 3 5 10 47.6Speech insertion 0 3 2 4 9 42.9Thought insertion/withdrawal 1 3 3 5 12 57.1“Made” intrusive emotions 3 3 4 5 15 71.4“Made” intrusive impulses 0 3 2 3 8 38.1“Made” intrusive actions 0 3 2 5 10 47.6Temporary loss of knowledge 0 4 3 4 11 52.4Self-alteration 0 3 2 5 10 47.6Self-puzzlement 4 5 4 5 18 85.7

AmnesiaTime loss 0 3 2 5 10 47.6“Coming to” 0 4 2 4 10 47.6Fugues 0 1 1 3 5 23.8Being told of actions 0 3 4 3 10 47.6Finding objects 0 2 0 3 5 23.8Evidence of actions 0 2 0 4 6 28.6

Notes: MID = Multidimensional Inventory of Dissociation; DD = dissociative disorder; DA/DPD = disso-ciative amnesia/depersonalization disorder; DDNOS = DD not otherwise specified; DID = dissociativeidentity 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 identi-fying the MID dissociation items (53/168) that were endorsed at a clinicallysignificant level by 50% or more of our BPD patients. Consistent with Table5, the 53 items comprised almost all of the items in four scales: memoryproblems, posttraumatic flashbacks, “made” intrusive emotions, and self-puzzlement. Memory problems included participants having amnesia forrecent and remote events, having large memory gaps, and being bothered byhow much they have forgotten. Posttraumatic flashbacks included vivid recallin all senses, nightmares, difficulty functioning, and wanting to self-injure ordie in response. “Made” intrusive emotions included rapid mood changesand strong emotions that seemed to come out of nowhere. Self-puzzlementinvolved participants being confused about their actions, emotions, andidentity. The 53 items comprised one third to one half of the items in fourother scales: derealization, trance, voices/internal struggle, and thoughtinsertion. Specifically, and most important, participants were concerned by(a) how frequently they “tranced out,” (b) the fact that other people noticedtheir “being gone,” (c) feeling the presence of an angry part that tried to con-trol them, (d) hearing an internal voice that told them to “shut up,” (e) internalvoices that argued or conversed with one another, and (f) thoughts cominginto their minds that they could not stop. The 53 items comprised one ortwo items on seven other scales: “made” intrusive impulses, “made” intrusiveactions, temporary loss of well-rehearsed knowledge, self-alteration, timeloss, “coming to,” and being told of disremembered recent actions. Especiallynoteworthy items included “people telling you that you sometimes act sodifferently that you seem like another person,” blank spells or memoryblackouts, “coming to” in the middle of a conversation and having no ideawhat was discussed, and “when you are angry, doing or saying things thatyou don’t remember.”

TABLE 6 Mean Severity of SCID-D-R Symptoms in 21 Borderline Personality DisorderPatients as a Function of Comorbid Dissociative Diagnosis

SymptomNo DD (n = 5)

DA/DPD (n = 6)

DDNOS (n = 5)

DID (n = 5)

Total sample(n = 21)

Amnesia 1.2 2.8 3.8 4.0 2.9Depersonalization 1.8 3.8 3.8 4.0 3.4Derealization 1.0 2.3 2.6 3.8 2.4Identity Confusion 2.6 3.3 4.0 3.8 3.4Identity Alteration 1.2 1.8 3.2 4.0 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 DSM–IV Dissociative Disorders–Revised; DD = dissociativedisorder; DA/DPD = dissociative amnesia/depersonalization disorder; DDNOS = DD not otherwisespecified; DID = dissociative identity disorder.

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Spearman Correlations Among the Dissociation Instruments

SCID-D-R scores correlated substantially with mean MID scores (Spearman’srho [r] = 0.71), with mean DES-T scores (r = 0.67), with DES-T probabilityscores (r = 0.68), and with mean DES scores (r = 0.62; all ps < .05). The cor-relation with SDQ-20 scores was not significant. Mean MID scores corre-lated nearly perfectly with mean DES scores (r = 0.95) and mean DES-Tscores (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 Cohen’skappa, was 0.62 (p = .001). The weighted analysis (intraclass coefficient) was0.71 (p = .03), and consideration of raters’ “probable” comments resulted inan intraclass coefficient of 0.85 (p = .004). This is substantial interrateragreement, especially for this difficult group of patients.

DISCUSSION

This study used the semistructured SCID-D-R interview as the gold standardto assess dissociative symptoms in a cross-sectional sample of DIB-R BPDoutpatients. Methodologically, the first step in understanding dissociation inBPD patients was to examine the details of each case (see Table 3). BPDpatients with no DD had low scores on all dissociation scales; their dissoci-ation 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 ashaving either DA or DPD. Although three of these SCID-D-R DPD patientsreceived an initial MID diagnosis of DID, this diagnosis was invalidated intwo cases by extreme scores on the MID validity scales (see Table 3). BPDpatients with DDNOS endorsed significant and pervasive symptoms of dis-sociation. As expected, their dissociation scores straddled the cutoff forDID. On the MID, they endorsed the “I have parts” scale but not the “I haveDID” scale. BPD patients with DID obtained high dissociation scores. TheMID 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 indetail at the symptoms endorsed on the SCID-D-R (see Table 4) and theMID (see Table 5). Most participants endorsed mood changes for no reason,flashbacks, identity confusion, and some depersonalization. One can justifiablyargue that these symptoms belong to the “zone of symptomatic overlap”between BPD and DDs. Mood changes and flashbacks are included in theSCID-D-R as associated features of DID, not as dissociative symptoms perse. Mood swings, of course, are listed as Criterion 6 of BPD in the DSM–IV.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 questioningrevealed suspicion of dissociated ego states causing this phenomenon inonly two participants. Taken by itself, “mood changes without any reason”obviously lacks specificity for dissociation; it is diagnostically relevant to theDDs only when it is part of a larger pattern of dissociative symptoms. Thedissociation-relevant concept of “identity confusion” clearly overlaps withthe DSM–IV Criterion 3 for BPD, “identity disturbance: markedly and persis-tently 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 whodescribed a frequent, intense battle between ego states or a profound lackof identity. It is interesting that a MID study found that DID patients had sig-nificantly higher identity confusion scores than a sample of well-diagnosedBPD 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 dissocia-tive symptoms on the SCID-D-R and MID is surprising. Our BPD patientswith DDNOS reported frequent depersonalization, frequent amnesia, andnotable experiences of identity alteration. The symptom of internal voicesaccords with a recent report of chronic auditory hallucinosis in about 30%of a non-DID BPD sample; these BPD patients conversed with internalvoices that they experienced as ego-alien (Yee, Korner, McSwiggan, Meares,& Stevenson, 2005). BPD patients with DID endorsed severe dissociativesymptoms in all categories.

In all, 53 of 168 MID items were endorsed at a clinically significantlevel by more than half of the participants in this study. Those items comprisea wide variety of disturbing dissociative symptoms: amnesia, derealization,flashbacks, trance states, and a plethora of dissociative intrusions into con-scious experience (i.e., intruding thoughts, emotions, impulses, actions, andvoices). Especially concerning is the toxic nature of the angry voices andangry ego states, the Schneiderian voices, and the desire to self-harm trig-gered by flashbacks. The fact that more than half of our BPD patientsendorsed these symptoms at a level consistent with DID supports Ross’s(2007) claim that the DSM–IV does not adequately address the frequent,severe dissociative comorbidity in BPD.

We postulate that there are three dissociative subgroups among personsdiagnosed with BPD. The first subgroup, comprising about one quarter toone third of BPD patients, has minimal dissociative symptoms, and if symptomsdo occur, they are brief and mild. These participants have “minimal” abusehistories compared to the others. The second subgroup, comprising aboutone third to one half of BPD patients, probably has a disorganized attach-ment status and a more significant abuse history (Classen, Pain, Field, &Woods, 2006; Holmes, 2003). The third subgroup is the most severe. Thissubgroup includes the definite DDNOS type 1 and DID cases, comprisingabout 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 botha severe DD and BPD are severely ill and a tremendous burden to thehealth care system.

Of the self-report measures, the MID unquestionably provided the mostuseful information about the dissociative symptoms of BPD patients. Itscomprehensive set of dissociation scales provided valuable information overand above that obtained using the other questionnaires. The validity scaleswere invaluable in assessing whether participants over-endorsed or deniedsymptoms. Even in this difficult population, the MID had acceptable agree-ment with the time-intensive SCID-D-R interview for sorting BPD patientsinto the categories of no DD, mild to moderate DD, or severe DD.

This study has several limitations. First, the generalizability of our findingsto general psychiatric outpatients is limited by our sample’s higher rate ofPTSD, which is probably due to (a) the higher severity of illness in ourclinic, (b) the sample selection process (patients already in treatment), and(c) the rigorous DIB-R selection process (selecting more severe BPD). Sec-ond, interrater reliability between DIB-R interviewers was not formallyestablished, although all interviewers agreed with the “expert” on the totalDIB-R score on two interviews. Third, the computer over-endorsed SCID-Idiagnoses, although the interview with the researcher confirmed the pres-ence and severity of each diagnosis. Similarly, the self-report SCID-II waslikely over-endorsed by some and under-endorsed by others. Fourth, mostof the instruments used were self-report. In this population, attention seeking,factitious behavior, and emotional suffering can be confounding issues, asevidenced by the MID validity scales and the discrepancies between the dis-sociation interview and the self-report scales. Finally, because our samplesize was fairly small and a significant number of potential participants didnot consent, estimates of the prevalence of DDs in BPD cannot be madewith confidence.

CONCLUSIONS

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

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