Curr Psychiatry Rep (2014) 16:434
DOI 10.1007/s11920-013-0434-8
PERSONALITY DISORDERS (C SCHMAHL, SECTION EDITOR)
Trauma and Dissociation: Implications for Borderline
Personality Disorder
Eric Vermetten & David Spiegel
Published online: 21 January 2014
# Springer Science+Business Media New York 2014
Abstract Psychological trauma can have devastating conse-
quences on emotion regulatory capacities and lead to disso-
ciative processes that provide subjective detachment from
overwhelming emotional experience during and in the after-
math of trauma. Dissociation is a complex phenomenon that
comprises a host of symptoms and factors, including deper-
sonalization, derealization, time distortion, dissociative flash-
backs, and alterations in the perception of the self. Dissocia-
tion occurs in up to two thirds of patients with borderline
personality disorder (BPD). The neurobiology of traumatic
dissociation has demonstrated a heterogeneity in posttraumat-
ic stress symptoms that, over time, can result in different types
of dysregulated emotional states. This review links the con-
cepts of trauma and dissociation to BPD by illustrating differ-
ent forms of emotional dysregulation and their clinical rele-
vance to patients with BPD.
Keywords Dissociation . Trauma . Borderline personality
disorder . BPD . Posttraumatic stress disorder . PTSD .
Emotion regulation
This article is part of the Topical Collection on Personality Disorders
E. Vermetten
Department Psychiatry, Leiden University Medical Center, Utrecht,
The Netherlands
E. Vermetten
Arq Psychotrauma Expert Group, Diemen, The Netherlands
D. Spiegel
Department Psychiatry and Behavioral Sciences, Stanford University
School of Medicine, Stanford, USA
E. Vermetten (*)
Department Psychiatry, Leiden University Medical Center Utrecht,
Einthovenweg 20, 2333 ZC, Leiden, The Netherlands
e-mail: e.vermetten@lumc.nl
Introduction
A vast but still emerging literature concerns the fact that
childhood trauma and disruptions in attachment are not only
common in the histories of patients with dissociative [1•] and
complex posttraumatic stress disorders (PTSD) [2] but also
among those with borderline personality disorder (BPD) [3•,
4–8, 9•, 10]. There is also growing evidence that a trauma
history should be taken into account in planning treatment for
BPD, which has not always been standard clinical practice.
More specifically, BPD patients with trauma histories often
meet criteria for both PTSD as well as dissociative disorders,
which puts an emphasis on careful assessment [11], treatment
planning [12] as well as detailed assessment of responses to
treatment [13•]. Some authors have expressed an interest in
including BPD in the list of ‘trauma spectrum disorders’ [14,
15].
Driven by new developments in biological research and the
current diagnostic criteria of trauma-related disorders and in
particular BPD, new opportunities for a reappraisal of the
contribution of early life trauma have arisen. Critical has been
a lack of acknowledgement of psychological trauma as an
important factor in the psychopathology of BPD. Also, the
DSM-IV-TR criteria for BPD do not adequately describe
trauma-related dissociative symptomatology in the disorder.
Transient, stress-related paranoid ideation or severe dissocia-
tive symptoms were listed in DSM IV as only one of nine
criteria, which include a pervasive pattern of instability of
interpersonal relationships, self-image, and affects and
marked impulsivity characterize BPD [16]. This is quite dis-
proportional to the prevalence of trauma and dissociation in
the disorder. A further description of dissociative symptoms or
discussion of psychological trauma exposure in the diagnostic
criteria for BPD is missing. In DSM5 this situation is not
much different for BPD, even though quite a few changes
have been made to the diagnosis of BPD as well as to
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Dissociative Disorders [17, 18•, 19••, 20]. In the latest revi-
sion, BPD is described as involving impairment in personality
functioning, as part of identity disturbance, and (only) one
reference to dissociation is made to ‘dissociative states under
stress’. The concept of ‘trauma spectrum disorders’ in
which BPD would be given a place next to PTSD, and
dissociative disorders was proposed by some, but not
adopted in the DSM-5. The initial DSM-5 metastructure
proposal did include a chapter labeled Posttraumatic and
Dissociative Disorders but was not pursued in the final
edition. However, the Dissociative Disorders were placed
next to the Trauma and Stressor-Related Disorders to
indicate relationships between the two.
Impact of Childhood Trauma on Mental Health and BPD
In general, systematic reviews of the impact of child-
hood sexual trauma on physical and mental health have
shown varied results but all point in the same direction,
namely that early life trauma has a profound and long-
lasting impact on a wide variety of general and mental
health. This can be seen in the impressive series of
adverse childhood experiences (ACE) studies started in
1998 by Felitti et al., [21] as well as in a series of other
systematic reviews [22, 23]. Some explanation of vari-
ance in the effect sizes of the various studies can be
partially accounted for by sample source and size:
smaller studies with positive findings are more likely
to be published than smaller studies with null or nega-
tive findings [22]. In terms of risk factors for anxiety
disorders the evidence is particularly strong; a system-
atic review of 171 studies showed a significant although
general and nonspecific, risk factor for anxiety disor-
ders, especially posttraumatic stress disorder, regardless
of gender of the victim and severity of abuse among
those with a childhood trauma history [24].
The relationship between BPD and childhood trauma is
documented in numerous studies. More than 25 years ago
Judith Herman reported in a landmark study on high rates of
trauma exposure for BPD patients: 71 % had been physically
abused, 67 % sexually abused, and 62 % had witnessed
domestic violence. Histories of early childhood trauma (under
age six) were only present in BPD patients versus other
personality disorder patients [25]. Other estimates of the inci-
dence of trauma in BPD typically are reported to exceed 70 %
and are significantly greater than the incidence of trauma in
comparison groups with other mental disorders (e.g., [26]. In
the 1990s studies emerged demonstrating that childhood his-
tories of emotional, physical, and sexual abuse were common-
ly reported by patients with BPD. A general conclusion from
these studies was that a relationship between childhood trau-
ma and BPD was quite convincing [27–32], particularly if the
Curr Psychiatry Rep (2014) 16:434
relationship was considered as part of a multifactorial etiolog-
ic model [33]. It must be noted however, that nearly all these
studies relied on self-report.
A decade later, studies emerged in the domain of so-called
complex PTSD (labeled Disorders of Extreme Stress Not
Otherwise Specified, DESNOS) that described a similar clin-
ical phenotype to BPD suggesting that exposure to multiple
traumas, especially in childhood, might be related to a type of
PTSD that is associated with a wide range of non-typical
PTSD difficulties (e.g., impulsivity, rage, depression, self-
harm, somatization, and interpersonal problems) that included
dissociation as well as pathological changes in personal iden-
tity [2, 34].
Yet, while most existing research lead to a conclusion that a
relationship existed between BPD and childhood sexual abuse
(CSA), it was also clear that not everyone who had been
sexually abused as a child would develop BPD [35, 36]. Some
believed that the relationship had been overrepresented in
literature and that other moderating variables were more sig-
nificant in the development of the disorder [35]. A meta-
analysis of 21 studies performed between 1980 and 1995 to
examine the effect size between BPD and childhood sexual
abuse resulted only a moderate effect size (r=.279) between
CSA and BPD. Yet, it should be noted that many sexually
abused girls appear to be able to maintain adequate social
competence while still suffering from high levels of internal-
izing and clinical symptomatology [37].
Traumatic Stress and Dissociative Symptomatology
During or in the immediate aftermath of acute trauma, such as
a violent physical or sexual abuse, victims can report feeling
dazed, unaware of physical injury, or can experience the
trauma as if they were in a dream. Many rape victims report
floating above their body, feeling sorry for the person being
assaulted below them. One rape victim reported: ‘I heard
someone screaming and discovered it was me.’ Sexually or
physically abused children often report seeking comfort from
imaginary playmates or imagined protectors, or by imagining
themselves absorbed in the pattern of the wallpaper [38, 39].
Some continue to feel detached and disintegrated for weeks,
months or years after trauma. This could lead to a kind of
‘somatic estrangement’ with changes in bodily perceptions:
feeling as if one’s entire body or a part of one’s body does not
belong to oneself. This typical dissociative symptomatology
can include affect compartmentalization, disrupted memory
encoding, and time distortion and fugue [40–42]. The disrup-
tion of a consistent stream of memory and associated personal
identity has been thought of as serving a protective function, at
least in response to acute stress. However, over time, these
defences may start to interfere with necessary cognitive and
affective processing of traumatic experiences, and as a result,
Curr Psychiatry Rep (2014) 16:434
lead to failure of integration of episodic and autobiographical
memory [42, 43•]. The dissociative spectrum is complex:
depersonalization and derealization can be seen as belonging
to self-monitoring and identity. Other domains and symptoms
that coincide are: (a) emotion (withdrawal/detachment), (b)
memory (amnesia, shifts in memory encoding), (c) sensory
perception (altered time, visual or contextual perception, pro-
prioception, analgesia, changes in olfaction, taste) and (d)
cognition (constricted attention, neglect, confusion, altered
associated capacities). Dissociative symptoms are further
characterized by: (a) unbidden and unpleasant intrusions into
awareness and behavior, with an accompanying loss of conti-
nuity in subjective experience: i.e., ‘positive’ dissociative
symptoms; and/or (b) an inability to access information or
control mental functions that are normally amenable to such
access or control: i.e., ‘negative’ dissociative symptoms [44].
The more severe forms of dissociation include stupor,
derealization, or depersonalization. Dissociative responses
can accompany a multitude of psychiatric disorders, in-
cluding PTSD, acute stress disorder (ASD), dissociative
disorders, panic disorder, mood disorders, and psychoses.
Based recent research [45••, 46••, 47••, 48••, 49••] a
dissociative subtype has been included in the DSM-5
definition of PTSD [50]. It involves all the intrusion,
avoidance, dysphoria, and hyperarousal symptoms plus
depersonalization and/or derealization. Moreover, disso-
ciative responses have been reported to occur in several
neurological conditions such as epilepsy, migraine head-
aches, cerebral vascular disease, cerebral neoplasms, and
posttraumatic brain damage [51–54].
Traumatic dissociation has a longstanding history in both
fields of psychiatry and neurology [55–57]. Not unlike what
has been the situation for BPD, the psychiatric approach to the
dissociative disorders for long time failed to acknowledge any
relationship to psychological trauma [58••]. Before DSM III,
dissociation was grouped with the old remnant of hysteria,
conversion disorder, and was called ‘dissociative hysteria’.
Due to this the Dissociative Disorders had difficulty shaking
the suspicion that they were not true disorders, or that they
were a disguise for secondary gain, malingering, or criminal-
ity. The study of dissociative disorders for long time was
distanced from mainstream research. In addition, there were
the so called ‘memory wars’ in the 1990s of the last century
that complicated the situation as well. It was also proposed
that dissociation makes individuals prone to fantasy, thereby
engendering confabulated memories of trauma [59]. However,
the available research evidence contradicts this theory [58••].
There is ample evidence now of the impact of trauma on
dissociative symptoms, and that dissociation remains related
to trauma history, even when fantasy proneness is controlled.
Little support was found for the hypothesis that the dissocia-
tion–trauma relationship is due to fantasy proneness or con-
fabulated memories of trauma.
Page 3 of 10, 434
Co-occurrence or Trauma Subtypes?
Given the fact that early trauma is not always associated with
the etiology of BPD and is also associated with many other
mental disorders, it may not seem justified to categorize BPD
as a trauma spectrum disorder. At the same time it is important
to emphasize recognition of the role of early trauma in the
assessment of mental health problems, and therefore also for
BPD, even if it probably is neither a necessary nor a sufficient
condition [36, 60]. Some authors proposed to extend the
diagnosis of BPD to complex PTSD to characterize a subset
of BPD patients with trauma-related disorders [2, 3•, 10,
61–63], in which factors such as duration of the trauma
exposure, the developmental phase during which it occurred,
genetic vulnerabilities, and other biological variables, in ad-
dition to specifics of the traumatic antecedent, as taken into
account. Complex PTSD is defined by disturbances of affect
regulation, dissociative symptoms and somatization, disturbed
self-perception, disturbance of sexuality and relationship for-
mation, and changes in personal beliefs and values. The need
for and benefits of the introduction of an additional complex
PTSD diagnosis is controversial, in particular because of
insufficient construct validity, and potentially high overlap
with other psychiatric diagnoses [64]. Its usefulness as a
clinical entity is fiercely debated in literature, and it must be
clear that not all authors believe BPD is the same as complex
PTSD [62, 63, 65].
Relatively few studies have rigorously assessed for both
BPD and the Dissociative Disorders. A high endorsement of
dissociative symptoms in BPD patients was reported by
Korzekwa et al. [66], calling this a zone of symptomatic
overlap. With regard to the dissociative experiences endorsed,
most patients reported identity confusion, unexplained mood
changes, and depersonalization. BPD patients with mild dis-
sociative disorders reported derealization, depersonalization,
and dissociative amnesia. BPD patients with DSM-IV Disso-
ciative Disorder Not Otherwise Specified (DDNOS) reported
frequent depersonalization, frequent amnesia, and notable
experiences of identity alteration. BPD patients with comorbid
Dissociative Identity Disorder (DID) endorsed severe disso-
ciative symptoms in all categories. The authors postulate that
three dissociative subgroups can be identified among persons
diagnosed with BPD. The first subgroup, about one quarter to
one third of BPD patients, have minimal dissociative symp-
toms, and if symptoms do occur, they are brief and mild.
These patients 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 [67,
68]. The third subgroup appears as the most severe. This
group includes DDNOS and DID cases, comprising about
30 % to 40 % of clinical samples of BPD; they also have the
most disturbed attachment and serious abuse histories.
434, Page 4 of 10
Recognizing subgroups, or subtypes to BPD are increasingly
represented in other recent studies [69–72].
Emotional Modulation as Key Concept in PTSD
If dissociation is viewed as a conditioned form of emotional
regulation, if follows that that this can become automatized in
situations of chronicity. Moreover, it can also become habitual
in response even to minor stressors that require some form of
regulating of emotional information. This response process
can be well described as ‘modulatory response process’ [48••,
73]. Traumatic reminders are the good examples in that these
can evoke strong emotional responses. The typical response to
traumatic reminders is the flashback response, in which the
person becomes hyperaroused with a concomitant increase in
heart rate and an intense feeling of reliving the experience as
though it were occurring in the present. This calls for a
regulatory system that is capable of managing (read: contain-
ing) these typically unregulated and involuntary emotional
responses. Recently it has become better understood that there
are different response types in individuals with chronic PTSD.
These are associated with distinct neural correlates in response
to recalling traumatic memories [44, 71, 74–77].
PTSD patients with histories of early, repeated or
prolonged trauma, such as occurs in situations of childhood
maltreatment or after prolonged combat trauma, these habitual
responses can turn to differently regulated processes, and
different manifestations of modulation of emotional re-
sponses. What is seen here is a predominantly dissociative
response [49••] with no concomitant increase in psychophys-
iology, yet with feelings of depersonalization and derealiza-
tion, can be labeled as emotional over-modulation. There is
accumulating evidence that in chronic early trauma dissocia-
tion can be habituated (read overmodulated) to an involuntary
emotion modulation strategy that can emerge in response to
major and sometimes also even minor stressors.
The concept of emotional under-modulation has been pro-
posed to emphasize the failure of inhibition of conditioned
fear circuitry [48••]. While approximately 70 % of patients
with PTSD report this experiencing of the traumatic event in
response to traumatic script-driven imagery concomitant with
psychophysiological hyperarousal [78••, 79•], it has recently
been shown that a minority report symptoms of derealization,
depersonalization, numbing and a feeling of emotional de-
tachment while evidencing no significant increase in heart rate
[75].
A closer look learns that two pathways to this emotion
dysregulation can be identified: 1) the first pathway describes
emotion dysregulation as an outcome of fear conditioning
through stress sensitization and kindling; 2) the second path-
way views emotion dysregulation as a distal vulnerability
factor and hypothesizes a further exacerbation of fear and
Curr Psychiatry Rep (2014) 16:434
other emotion regulatory problems, including the develop-
ment of PTSD after exposure to one or several traumatic
event(s) later in life [80••]. Investigations of PTSD to date
have focused predominantly on cross sectional studies, which
are not able to directly address the causal relationships just
described. However, the pathways described above pave a
road map for subsequent longitudinal studies that examine
this crucial causal relationship in order to elucidate the neuro-
nal underpinnings of PTSD in a prospective manner [80••].
The model of emotional modulation has further been val-
idated by modulation of startle reflex and electrodermal re-
sponses [81] as well as converging neuroimaging data from a
study that compared brain activation patterns during the pro-
cessing of consciously and non-consciously perceived fear
stimuli [82]. PTSD patients with high state-dissociation scores
showed enhanced activation in the ventromedial prefrontal
cortex (PFC) during conscious fear processing as compared
to those with low state-dissociation scores. Interestingly, dur-
ing processing of non-conscious fear, high dissociative symp-
tomatology at the time of the scan in PTSD was associated
with increased activation in the bilateral amygdala, insula and
left thalamus as compared to those with low state-dissociation.
This further supported the theory that dissociation can be seen
as a regulatory emotional strategy that plays a role in coping
with extreme arousal in PTSD, but also illustrated that this
strategy appears to function only during conscious processing
of threat.
A Dissociative Subtype of PTSD
In 1992, Judith Herman had proposed a construct, Complex
PTSD (labeled Disorders of Extreme Stress Not Otherwise
Specified, DESNOS) which defined a non-PTSD posttrau-
matic syndrome in which dissociative symptoms were a prom-
inent feature. Although DESNOS was not included in the
DSM-IV, clinicians and investigators continue to observe
dissociative symptoms such as depersonalization and dereal-
ization among a significant minority of patients. Based on this
as well as new research evaluating the relationship between
posttraumatic stress disorder (PTSD) and dissociation has
accumulated, leading to the implementation of dissociative
subtype of PTSD in DSM5. This subtype is defined primarily
by symptoms of derealization (i.e., feeling as if the world is
not real) and depersonalization (i.e., feeling detached from
oneself, or as though one were not real) [50].
The addition of a dissociative subtype of PTSD in the new
DSM-5 was based on three lines of evidence. First, as
reviewed in here neurobiological studies suggested that de-
personalization and derealization responses in PTSD were
distinct from the anxiety based re-experiencing/hyperarousal
reactivity. The distinct neurocircuitry pattern that distin-
guished individuals with PTSD from those with PTSD plus
Curr Psychiatry Rep (2014) 16:434
dissociative symptoms also contributed to this subtype [48••].
As discussed, typically individuals who re-experienced their
traumatic memory and showed concomitant psychophysio-
logical hyperarousal exhibited reduced activation in the me-
dial prefrontal- and the rostral anterior cingulate cortex and
had increased amygdala reactivity to traumatic reminders.
Their reliving responses therefore were thought to be mediat-
ed by failure of prefrontal inhibition or top-down control of
limbic regions (emotional undermodulation); whereas indi-
viduals with PTSD plus dissociative symptoms demonstrated
a reversal of this pattern with increased prefrontal activity
associated with diminished amygdala activity (emotional
overmodulation) [49••, 83••]. Second, studies using latent
class, taxometric, epidemiological, and confirmatory factor
analyses conducted on PTSD symptom endorsements collect-
ed from veteran and civilian PTSD samples indicated that a
subgroup of individuals (roughly 15-30 %) suffering from
PTSD reported symptoms of depersonalization and derealiza-
tion [45••, 46••, 84••]. Individuals with the dissociative sub-
type were more likely to be male, have experienced repeated
traumatization and early adverse experiences, have comorbid
psychiatric disorders, and evidenced greater suicidality and
functional impairment [47••]. The subtype was also replicated
cross-culturally. The third line of evidence suggested that
symptoms of depersonalization and derealization in PTSD
are relevant to treatment decisions in PTSD individuals with
PTSD who exhibited symptoms of depersonalization and
derealization tended to respond better to treatments that in-
cluded cognitive restructuring and skills training in affective
and interpersonal regulation in addition to exposure-based
therapies [85••, 86••]. It was felt that recognizing a dissocia-
tive subtype of PTSD carries the potential to improve the
assessment and treatment outcome of patients with PTSD.
The new criteria for PTSD in DSM-5 have also moved
beyond the conceptualization of PTSD as predominantly a
fear response and include dysregulation of a variety of emo-
tional states, including fear, anger, guilt, and shame in addition
to dissociation and numbing [87–89]. The term ‘emotion
dysregulation’ could start to be used to collectively refer to
disturbances in a variety of emotional responses. A model that
describes the relationship between fear circuitry and emotion-
al modulation in PTSD had thus far been lacking.
Overlapping Emotion Modulation Strategies in PTSD
and BPD?
As reviewed in the landmark work of Marsha Linehan on
BPD, emotion dysregulation is considered to be a core symp-
tom in patients with BPD [81, 90–92]. Several authors also
highlighted affective instability in the disorder [93, 94] that
can be seen as a downstream component of the emotional
dysregulation. Emotion dysregulation has been characterized
Page 5 of 10, 434
by highly sensitized responding to emotional stimuli as well as
delayed habituation to such events. Only recently have studies
begun to explicitly examine emotion dysregulation in BPD
patients. Yet, the empirical psychophysiological and neurobi-
ological evidence for this model in BPD has thus far been
scarce. The majority of these studies exclusively focused on
the patients' self-report of emotional experience [95]. New
studies indicate that, especially in BPD patients, dissociative
symptoms are frequently present and may influence psycho-
physiological reactions to emotional stimuli [72, 81, 96] as
well as neural processing of painful stimuli in response to
personalized scripts [71]. The novel perspective that recently
is being proposed here is to look at emotional dysregulation
represented as derealization, depersonalization and dissocia-
tive amnesia; all considered dissociative symptoms [66]. Up
until recently in many studies dissociative symptoms had not
been considered to be part of the emotional spectrum of
response types in BPD.
There are recent studies that investigated the moderating
impact of dissociation on baseline startle response in BPD [81,
97]. In these habituation studies, the authors found overall
increased startle reactivity in BPD patients relative to controls,
but these group differences were modulated by participants'
dissociative experiences at the beginning of the experiment.
Patients experiencing no dissociative symptoms showed larg-
er overall startle response magnitude compared with patients
with high dissociative experiences. Furthermore, experimental
studies found reduced pain sensitivity in patients with BPD
under stress conditions [98, 99] and revealed a significant
correlation between self-reported pain insensitivity and disso-
ciative features [100] found no differences in emotional reac-
tivity during an imagery task in electrodermal activity con-
trolling for dissociation. In this study dissociation was used
only as a covariate and no mediation analyses were conducted.
These are the first studies to suggest that individual differences
in dissociation among BPD individuals may help to explain
the apparent discrepancies in the patterns of findings across
psychophysiological studies.
A recent meta-analysis of neural correlates subserving
negative emotionality in BPD further supported the emotion
modulation dichotomy. It showed that compared with healthy
control subjects, BPD patients demonstrated greater activation
within the insula and posterior cingulate cortex. Conversely,
they showed less activation than control subjects in a network
of regions that extended from the amygdala to the subgenual
anterior cingulated cortex (ACC) and dorsolateral PFC [101].
So, when thinking of negative emotions as carrying elements
of dissociation it is important to realize that these are
subserved by an abnormal reciprocal relationship between
limbic structures (representing the degree of dissociation or
subjectively experienced negative emotion) and anterior brain
regions that support the modulation or regulation of emotion
[48••, 101].
434, Page 6 of 10
Clinical Implications
It is clear that for all victims of recent childhood trauma, early
intervention as well as careful monitoring over time for poten-
tial negative outcomes that may present during adulthood must
be a priority to decrease the risk of psychiatric disorders. All
children who have been sexually abused recently should be
assessed for the presence of psychological problems. With the
current state of knowledge, it is highly appropriate to target
available treatment resources at symptomatic children, because
sexually abused children who have symptoms (e.g., symptoms
of PTSD or behavioral problems) are likely to perceive benefit
from psychotherapy [102, 103]. Yet, it must be noted that
services for abused children must have a long-term orientation,
because these children may experience enduring problems,
such as attachment problems, or BPD, or the later onset of
other forms of mental illness.
For all adults with psychiatric disorders as well as with
medical problems which are psychological in origin, a review
of child sexual experiences should be a routine part of the
clinical history. There is strong evidence, for example, that
depressed individuals with trauma histories respond better to
psychotherapy, while those with depression but without a
trauma history respond better to antidepressant medication
[104]. Given that a certain number of individuals who seek
psychiatric treatment have a history of child sexual abuse, this
places a clear responsibility on mental health services in the
first instance to enquire about early abuse within admission
procedures.
A few years after Herman’s landmark study in 1993
Gunderson and Chu, in a paper on treatment implications of
past trauma in BPD, stated that ‘when early trauma is in the
form of childhood abuse, clinicians could be better able to
understand the difficulties these patients experience in rela-
tional skills, affect tolerance, behavioral control, self-identity,
and self-worth’. They stated that ‘clinicians should be able to
facilitate a strong therapeutic alliance through acknowledge-
ment of the patient's victimization and empathy with the
effects of early trauma on the patient's life‘ [105]. They
considered it essential that the therapist reframe the patient's
experience as a consequence of childhood trauma, especially
when making traditional interventions like interpretation and
confrontation. They also emphasized the role of trauma in the
development of BPD and suggested the need for modification
of models of individual, family, and group psychotherapies to
allow more productive and successful treatment. Many other
authors have followed since.
As has been reviewed earlier in this paper, dissocia-
tion occurs in up to two thirds of people with BPD. It
is important to note that while dissociative responses
during and immediately after psychological trauma are
common and often adaptive, persistent dissociation that
is lasting weeks, months or even years may prevent the
Curr Psychiatry Rep (2014) 16:434
necessary working through of traumatic memories and
emotions. Individuals with dissociative symptoms often
feel strangely in control of events at the time of the
trauma, in an attempt to regulate their emotions in an
ability to cope with the situation, but experience intru-
sive thoughts, flashbacks, nightmares, numbing, amnesia
and hyperarousal as a kind of retraumatization. These
symptoms seem to sensitize rather than produce habitu-
ation to traumatic experiences, producing and perpetuat-
ing acute stress disorder (ASD), PTSD, and dissociative
disorders.
The development of dialectical behavior therapy has been
based on the biosocial theory that views BPD as a dysfunction
of emotion regulation system [106]. As has been reviewed
here there is new research that the emotion regulating system
can have dissociative qualities, characterized by derealization
and depresonalization, and that both are seen in patients with
complex manifestations of PTSD. Distinguishing the dimen-
sions of emotional modulation (over-modulation versus
under-modulation) may also help to clarify differences in
dissociation and affect dysregulation between and within
BPD. Specific interventions addressing over-modulation in
BPD, or under-modulation in PTSD, should be added to
disorder-specific evidence-based treatments. There are several
treatments for BPD, yet these may differentially address the
under- and over-modulation of affect depending on the re-
sponse type, e.g., mentalization can be seen as a therapeutic
spin off of the acknowledgement of early trauma in the devel-
opment of BPD [107–109]. Critical in these approaches is that
the process that is started needs to be contingent on an optimal
level of arousal that sustains prefrontal functioning [110],
warranting development and recruitment of cortical structures
needed to regulate emotional involvement and affective states.
Successful therapy needs to engage the mental processes that
make psychotherapy yield lasting change.
Conclusions
Trauma can trigger dissociative responses, in part because
traumatic stress is a sudden discontinuity of experience,
substituting threat for safety, fear, pain and uncertainty for
constancy of the external and internal environment. Traumatic
dissociation can be considered a unique descriptor for a set of
categorically related phenomena in patients exposed to ex-
treme traumatizing events. It relates to a breakdown of usually
integrative functions. As the studies in this paper indicate,
major advances have been made in our understanding of
traumatic dissociation. Several lines of evidence have been
put forward to understand this as a form of emotional modu-
lation response. This perspective can serve to bridge response
types that we formerly reserved for distinct disorders. We also
now have more systematic measures of the dissociative
Curr Psychiatry Rep (2014) 16:434
phenotype, and a better understanding of the neural subsys-
tems involved in dissociative symptoms and emotion modu-
lation responses. The recognition that trauma is widespread in
patients with BPD, the perspective of a co-occurrence with
dissociative symptoms and a supportive neurobiology of emo-
tional modulation is a result of cross fertilization of related
fields in psychiatry, psychology, neurobiology, and psycho-
physiology. This has already opened new research for a dis-
order that had long been considered unsuited for this perspec-
tive. Our patients will benefit.
Compliance with Ethics Guidelines
Conflict of Interest Eric Vermetten and David Spiegel declare that they
have no conflict of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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