This article was downloaded by: [University of Leeds]

On: 11 March 2015, At: 23:38

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954
Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,
UK

The Journal of Psychology:

Interdisciplinary and Applied
Publication details, including instructions for authors
and subscription information:
http://www.tandfonline.com/loi/vjrl20

Relationship of Childhood
Sexual Abuse to Borderline
Personality Disorder,
Posttraumatic Stress Disorder,
and Multiple Personality
Disorder
a
John B. Murray
a
Department of Psychology , St. John's University ,
USA
Published online: 02 Jul 2010.

To cite this article: John B. Murray (1993) Relationship of Childhood Sexual Abuse to
Borderline Personality Disorder, Posttraumatic Stress Disorder, and Multiple Personality
Disorder, The Journal of Psychology: Interdisciplinary and Applied, 127:6, 657-676,
DOI: 10.1080/00223980.1993.9914905

To link to this article: http://dx.doi.org/10.1080/00223980.1993.9914905

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the
information (the “Content”) contained in the publications on our platform.
However, Taylor & Francis, our agents, and our licensors make no
representations or warranties whatsoever as to the accuracy, completeness,
or suitability for any purpose of the Content. Any opinions and views
expressed in this publication are the opinions and views of the authors, and
are not the views of or endorsed by Taylor & Francis. The accuracy of the
Content should not be relied upon and should be independently verified with
primary sources of information. Taylor and Francis shall not be liable for any
 losses, actions, claims, proceedings, demands, costs, expenses, damages,
and other liabilities whatsoever or howsoever caused arising directly or
indirectly in connection with, in relation to or arising out of the use of the
Content.

This article may be used for research, teaching, and private study purposes.
Any substantial or systematic reproduction, redistribution, reselling, loan,
sub-licensing, systematic supply, or distribution in any form to anyone is
expressly forbidden. Terms & Conditions of access and use can be found at
http://www.tandfonline.com/page/terms-and-conditions
Downloaded by [University of Leeds] at 23:38 11 March 2015
 The Journal of Psychology, 127(6),657-676

Relationship of Childhood Sexual Abuse to

Borderline Personality Disorder,
Posttraumatic Stress Disorder, and Multiple
Personality Disorder
Downloaded by [University of Leeds] at 23:38 11 March 2015

JOHN B. MURRAY
Department of Psychology
St. John’s University

ABSTRACT. In this article, I have reviewed recent research into the relationship between
childhood sexual abuse and borderline personality disorder, posttraumatic stress disorder,
and multiple personality disorder. Evidence that such a relationship exists appears con-
vincing.

A LARGE BODY OF NEW RESEARCH has shown that sexual abuse of children
is a social pattern of major importance (Bagley & King, 1990; Cozolino, 1989;
DeJong, Hervada, & Emmett, 1983; Paris & Zweig-Frank, 1992; Putnam, 1991;
Young, Sachs, Braun, & Watkins 1991). As the literature has grown, its orienta-
tion has focused more on the victims, and evidence suggests that the conse-
quences of childhood sexual abuse may be severe and long lasting (Alexander &
Lupfer, 1987; Alter-Reid, Gibbs, Lachenmeyer, Sigal, & Massoth, 1986; Brernner,
Southwick, Johnson, Yehuda, & Charney, 1993; Bryer, Nicholson, Miller, & Krol,
1987; Burnam et al. 1988; Figley, 1985; Gelinas, 1983; Harter, Alexander, & Nie-
meyer, 1988; Herman, 1986; Jackson, Calhoun, Amick, Maddever, & Habif,
1990; Johnson & Kenkel, 1991; Kendall-Tackett, Williams, & Finkelhor, 1993;
Kinzl & Bieble, 1992; Pribor & Dinwiddie, 1992; Russell, 1986; Shearer, Peters,
Quaytman, & Ogden, 1990; Summit & Kryso, 1978; Terr, 1991).
Researchers have shown that in some instances borderline personality disor-
der (BPD), multiple personality disorder (MPD), and posttraumatic stress disor-
der (PTSD) in adulthood may be traced to childhood sexual abuse (Brown &

Address correspondence to John B. Murray, Department of Psychology. St. John’s Univer-

sity, 81-50 Utopia Parkway, Jamaica, NY 11439.

657
 Anderson. I99 I ; Goldman. D' Angelo, DeMaso, & Mezzacappa. 1992; Herman,
Russell. & Trocki. 1986; Putnam. 1991; Ross, et al. 1990; Ross. Norton, & Woz-
ney, 1989: Schafer, 1986; Westen, Ludolph. Misle. Ruffins, & Block, 1990;
Wolfe. Gentile. & Wolfe, 1989). The relationships between these three psychiatric
states and childhood sexual abuse are the focus of this review.
The incidence of child sexual abuse is difficult to estimate, partly because of
differences in its definition and the varied factors that can contribute to its impact
including the age of the victim, the relationship to perpetrators, and family char-
acteristics (Alexander & Lupfer, 1987; Bentovim. Boston, & Van Elburg, 1987;
Brickman & Briere. 1984; Brown & Anderson, 1991; Browning & Boatman,
1977; Byrne & Valdiserri, 1982; Donaldson & Gardner, 1985; Finkelhor & Hota-
ling, 1984: Green, 1984; Harter et al., 1988; Hunter, Kilstrom, & Loda, 1985:
Downloaded by [University of Leeds] at 23:38 11 March 2015

Pribor & Dinwiddie, 1992; Russell, 1983, 1986; Shearer et al., 1990: Storr. 1979;
Straus. 1979; Wolfe, 1985; Wyatt, 1985: Wyatt & Peters, 1986).Reports of child-
hood sexual experiences based on clinical or court case populations may tend to
overestimate the scope of the problem (Sedney & Brooks, 1984). And victims
often have been unaware of the possible relationship between their presenting
symptoms and sexual abuse. Even when they sought psychotherapy, they rarely
disclosed the abuse (Brickman & Briere, 1984; Bryer et al., 1987; Carmen,
Rieker. & Mills, 1984; Gelinas. 1983; Rosenfeld, 1979; Vander Mey, 1988).
A survey of incestuous abuse in childhood in a nonclinical group of 152
women in San Francisco and 53 female outpatients in short-term therapy in Bos-
ton indicated that. although the majority of the women had been upset by the
experience, almost one half said they had recovered well, and about one quarter
were unaware of any long-term effects (Herman et al.. 1986). From a review of
recent empirical studies of the impact of sexual abuse on children, it appeared that
no specific syndrome followed from sexual abuse. that within 12 to I8 months of
the abuse two thirds of the children studied showed signs of recovery, and that
about one half of the children had no symptoms (Kendall-Tackett et al., 1993).
Identified patterns of typical victim behavior are similar across different kinds of
disaster (Bagley & King. 1990). The potential of error in retrospective reports of
childhood experiences has to be considered in interpreting reports of sexual child
abuse (Brewin, Andrews, & Gotlib, 1993; Green, 1986). Children under 7 years
old may have difficulty distinguishing fantasies and reality. but they rarely fanta-
size or fabricate sexual encounters (DeJong, 1985; Nurcombe, 1986).
Women are the victims of childhood sexual abuse in a ratio of 10:1 over men,
who have not received as much study as needed (Brown & Anderson, 1991; Jason,
Williams, Burton. & Rochat. 1982; Ross. I99 I ). Children from families of a lower
socioeconomic level predominated among 566 children brought to a sexual as-
sault crisis center, and in 14.9% of the children, evidence of trauma was present
(DeJong et al. 1983). However. sexual abuse occurs at all socioeconomic levels
(Alexander & Lupfer, 1987). and childhood sexual abuse is predominantly intra-
familial (Brown & Anderson. 1991; Herman, 1986).The majority of perpetrators
 Murray 659

are men, most often natural fathers or stepfathers of victims (Carmen et al., 1984;
Hunter et al., 1985; Husain & Chapel, 1983; Margolin, 1992; Russell, 1983). The
relationship of the child to perpetrator is a critical factor because abuse by a rela-
tive or caretaker is more harmful to the child than extrafamilial abuse (Paris &
Zweig-Frank, 1992).
The closer the sexual act is to intercourse the more serious the consequences
at early ages. Effects can be lessened if the incidents are disclosed and if reaction
is appropriate and action is taken to prevent recurrence. The support that victims
receive is an important variable that is rarely included in reports of victims’ expe-
riences (Alexander & Lupfer, 1987).
The deleterious effects of childhood sexual abuse on development have been
associated with symptomatology that includes elements of numerous psychiatric
Downloaded by [University of Leeds] at 23:38 11 March 2015

diagnostic categories (Chu & Dill 1990; Craine, Henson, Colliver, & MacLean,
1988; Pribor & Dinwiddie, 1992). The profile of female survivors may include
sexual dysfunction, vulnerability to further sexual abuse, promiscuity, homosexu-
ality, distrust of others, and substance abuse (Alexander & Lupfer, 1987; Alter-
Reid et al., 1986; Beitchman, Zucker, Hood, DaCosta, & Akman, 1991; Brown &
Anderson, 1991; Gelinas, 1983; Jackson et al., 1990; Jennings & Armsworth,
1992; Ogata et al., 1990; Simons & Whitbeck, 1991).
The first-born child, especially a girl, is most at risk of sexual abuse (Ben-
tovim et al. 1987). She is often forced into substitute roles that contribute to confu-
sion about her own sexual role development (Browning & Boatman, 1977). Incest
very often includes the element of violating the young girl’s will (Stone, 1981).
Chronic victimization of this kind cannot help but have a debilitating impact on
the psychic development of the victim. The effects usually include impaired rela-
tions with and mistrust of men, inordinate preoccupation with sexual themes, and
impulsivity in the area of sex. Victims may develop severely self-depreciating
attitudes, as though they had been instigators rather than victims (Briere &
Runtz, 1986).
The dynamics of the sexual abuse of boys and girls have little in common
(Vander Mey, 1988). The abuse experiences of boys are poorly understood as
are the possible psychiatric consequences (Brown & Anderson, 1991). Boys are
sexually abused at a younger age and more often by nonfamily members than are
girls. Male victims frequently suffer silently, often victimizing themselves, and
when they come for help, they more often present their problems in a masked way
(Hunter et al., 1985).
Appropriate sexual development may be derailed by early childhood sexual
abuse (Alter-Reid et al. 1986; Bagley & King, 1990). Sexual abuse can over-
whelm children’s desperate efforts to cope, and they may flee inward when flight
from the external situation seems impossible (Kluft, 1987a). The disruption of
relationships with primary caretakers appears to be an important factor in the
development of psychiatric disorders (Herman, Perry, & van der Kolk, 1989).
When 372 female survivors of sexual assault who came to a university clinic were
 compared with 99 women who had no history of sexual assault, 58% of the survi-
vors experienced sexual dysfunction as opposed to 17% of the control group
women (Becker, Skinner, Abel, & Cichon, 1986).
In a report by Simons and Whitbeck (1991), early childhood sexual abuse
also seemed to be a frequent part of the background of young women who
ran away from home and into prostitution. Oppenheimer, Howells, Palmer, and
Chaloner’s ( 1985) study of 78 consecutive female patients in an eating disorder
clinic, two thirds of whom had been victims of childhood sexual abuse. indi-
cated that their eating disorders were linked to feelings of inferiority or disgust
about their own femininity and sexuality, feelings that became entangled with
concern about their body size and shape. Root (1991) and Shearer et al. (1990)
Downloaded by [University of Leeds] at 23:38 11 March 2015

also suggested that eating disorders might be related to a history of childhood

sexual abuse.
The short-term effects of childhood sexual abuse may include difficulty in
coping with anger and aggression, low self-esteem, emotional coldness. impaired
social and sexual relationships, and lack of trust (Browne & Finkelhor, 1986;
Carnien et al.. 1984). Self-destructive behavior including biting, cutting, burning,
and suicide attempts have been observed (Briere & Runtz, 1986; Green, 1978;
Shearer et al., 1990). The literature on self-injurious behavior often mentions the
presence of a history of childhood sexual abuse (van der Kolk, Perry, & Her-
man. 1991).
Regressive behavior. higher levels of sexualized behavior, and masturbation
in socially stressful situations were reported in a study of 17 sexually abused
children ( 2 to 6 years old) who were referred to a child clinic and compared with
two control groups. children of the same age. and a group who were not neglected
(White, Halpin, Strom, & Santilli. 1988). Of 1,037 children evaluated in a univer-
sity child clinic, 28 young children. mostly White girls who had received little
support from close relatives and were sexually abused over a long period by their
fathers and more than one male relative. were most likely to be emotionally dis-
turbed (Adams-Tucker, 1982).
However, most o f the short-term effects of child sexual abuse are symptoms
that are general characteristic of clinical symptoms in children (Beitchman et al.,
1991). although depression and suicidal thoughts or behavior appeared to be more
likely in such victims than in either normal or psychiatric nonabused control
groups of children (Shapiro. Leifer, Martone, & Kassem, 1990). The prevalence
of niarital breakdown and psychopathology among parents of sexually abused
children also makes it difficult to identify the specific impact of the abuse.
Retrospective investigations of psychiatric in- and outpatients’ childhood ex-
periences have been one approach to evaluating the impact of childhood sexual
abuse on adult psychiatric illness (Alexander & Lupfer. 1987; Beck & van der
Kolk. 1987: Craine et al., 1988; Herman et al., 1986; Jacobson, 1989; Johnson &
Kenkel. 1991: Kinzl & Bieble, 1992). Studies done in mental hospitals have
shown that adults suffering from multiple personality disorder, borderline person-
 Murray 661

ality disorder, or PTSD, very often had been sexually abused in their childhood
(Herman, 1986; Lindberg & Distad, 1985; Terr, 1991).
Sixty-six female psychiatric inpatients consecutively admitted to a private
psychiatric hospital had a high ratio of childhood sexual and physical abuse, pat-
terns that correlated with the severity of adult psychiatric illness (Bryer et al.,
1987). Most of the perpetrators of the abuse were family members. Patients’ re-
sponses to a questionnaire indicated that 72% had had a history of childhood
sexual abuse and that abuse was more common among the adults who developed
major mental illness than had been suspected.
Brown and Anderson ( 1 990) interviewed 947 psychiatric inpatients consecu-
tively admitted to a military medical center. The authors questioned all the pa-
tients about their abuse history, and their DSM-111-R diagnoses were recorded.
Downloaded by [University of Leeds] at 23:38 11 March 2015

Sexual abuse was reported by 9% of the sample and by significantly more women
than men. In the abused patients, borderline personality disorder accounted for
48% of the DSM-111-R diagnoses.
Investigations of long-term effects of childhood sexual abuse have been done
in nonclinical populations. Sedney and Brooks (1984) asked 301 college women
for a history of their “sexual experiences involving other people while they were
growing up.” The authors preferred this broad definition of childhood sexual
abuse to avoid a priori decisions of what types of sexual experiences are problems.
Participants were students in both Catholic colleges and public tax-supported col-
leges, and from lower and middle class backgrounds to avoid differences traceable
to socioeconomic or religious differences. Fifty-one (16%) of the college women
reported childhood sexual experiences. Adults who had been victims were sig-
nificantly more likely to have symptoms of depression and anxiety than college
women who had not been abused.
In Sedney and Brooks’s (1984) study, those whose childhood sexual experi-
ences were with family members were at greater risk for disturbance than women
whose experiences were extrafamilial. Three quarters of the sexual experiences
had occurred before they were 12 years old. Younger children are more home-
bound, and not surprisingly, 72% of their sexual experiences were with family
members, whereas only 36% of the sexual experiences that occurred after 12 years
of age involved family members.
College women who experienced childhood sexual abuse, compared with
their peers and with 5 1 women in a control group, were more likely to have psy-
chiatric problems, and negative consequences were more evident when their sex-
ual experiences involved family members rather than when the experiences were
extrafamilial. Fifteen of 18 symptoms, symptoms of anxiety and depression as
well as thoughts of hurting themselves, were more likely in those who had experi-
enced early childhood sexual abuse. Survey data offer only correlational relation-
ships and do not establish cause-effect, but reports suggest that childhood sex-
ual experiences frequently are associated with symptoms of disturbances later in
life.
 Another investigation using a nonclinical population of college women be-
gan with 29 women who had been sexually abused by family members and a
control group of 56 women who had no such history (Harter et al., 1988). The
college women responded to a scale of family adaptability and cohesion and a
standardized interview measuring their social adjustment. They also rated them-
selves, men in general, women in general, and 10 figures in 10 standardized inter-
personal constructs. From their data and that reported by Alexander and Lupfer
( 1987). it appeared that those who were victims of sexual abuse before they were
I8 years old were likely to perceive themselves as socially isolated, as possessing
poorer social adjustment, and as members of less cohesive and adaptable families.
Downloaded by [University of Leeds] at 23:38 11 March 2015

When the results of direct interviews in the homes of those who had experi-
enced sexual assault were compared with the responses of those with no such
history, sexual assault predicted later development of major depressive disorders,
anxiety disorders, and substance abuse (Burnam et al., 1988). Their sample was
large, 3.132 adults. Also, those who had been assaulted as children in comparison
with those assaulted in adulthood were more likely to report subsequent develop-
ment of a mental disorder.
Because samples in childhood sexual abuse studies often are small and
drawn from treatment populations. one must be cautious in drawing conclusions
from their findings. But studies using larger numbers of nonclinical populations
have tended to confirm findings based on smaller groups of patients, and both
suggest that child sexual abuse may have lasting consequences. Among the varied
possible consequences in adulthood, considerable research has been directed
toward borderline personality disorder, multiple personality disorder, and to a
lesser extent, posttraumatic stress disorder.

Borderline Personality Disorder

Borderline personality disorder (BPD) was officially recognized as a diagnosis in

the DSM-I11 (American Psychiatric Association, 1980) and since then the cate-
gory has been used so widely that 20% of psychiatric patients receive this diagno-
sis. Some etiological theories propose that BPD is a disorder of developmental
trauma and arrest that arises out of disturbed relationships between children and
parents, including both sexual ad physical parental abuse (Horevitz & Braun,
1984; Petti & Vela. 1990; Stone, 1981). Recent investigations of the long-term
consequences of child sexual abuse have shown a clear connection in female pa-
tients between a history of sexual abuse and BPD (Herman, 1986; Westen et al.,
1990).
Adult patients with histories of childhood sexual abuse often present symp-
toms of impulsivity, self-destructive behavior, substance abuse, identity distur-
bance, and depression, symptoms that appear in the DSM-111-R (American Psy-
chiatric Association, 1987) criteria for BPD (Westen et al.. 1990). Many BPD
 Murray 663

patients report childhood histories of sexual abuse (Herman et al., 1989; Paris &
Zweig-Frank, 1992; Perry, Herman, van der Kolk, & Hoke, 1990; Shearer et al.,
1990). Browne and Finkelhor’s (1986) review of empirical results found a wide
range of difficulties associated with child sexual abuse, and the psychogenic fac-
tors can create a borderline psychopathology (Stone, 1981). Girls are more likely
than boys to be victims, and women more often than men have been assigned the
borderline diagnosis (Herman et al., 1989).
A large number of studies have reported a high frequency of childhood sex-
ual abuse among those with a BPD diagnosis (Ogata et al., 1990; Shearer et al.,
1990). In a Canadian study, 88 inpatients diagnosed as BPD, when compared with
42 inpatients matched in socioeconomic class and education level, were signifi-
cantly more likely to have been victims of sexual abuse by caretakers (Links,
Downloaded by [University of Leeds] at 23:38 11 March 2015

Steiner, Offord, & Eppel, 1988). BPD was the most common diagnosis in 66
female psychiatric inpatients who had been sexually abused as children (Bryer et
al., 1987). The victims continued to experience long-standing negative conse-
quences of their childhood experiences, and the seventy of adult psychiatric
symptoms correlated with the childhood sexual and physical abuse.
In the Goldman et al. (1992) study, 44 children, outpatients diagnosed as
BPD at a pediatric hospital clinic, were significantly more likely to have experi-
enced physical and combined physicaYsexual abuse than 100 children in a control
group with a wide range of diagnoses other than BPD. These findings with chil-
dren corresponded to the results of studies of adult BPD patients who have had a
history of childhood sexual abuse. The prevalence of sexual abuse in these chil-
dren (38%) was smaller than the rates (between 60% and 80%) in adults. Most of
the children in this study were boys, a pattern that differs from the usual largely
female samples in most studies of BPD adults.
As one facet of a longitudinal study, 21 patients diagnosed as BPD were
compared with 11 schizotypal personality disorder patients and 23 bipolar I1 de-
pression patients (Herman et al., 1989). Their results showed a strong association
between the BPD diagnosis and a history of abuse in childhood. Responses to a
semistructured interview consisting of 100 items indicated that significantly more
BPD patients had histories of childhood trauma, and two thirds of the BPD pa-
tients had experienced childhood sexual abuse. BPD patients suffered from expe-
riences of sexual abuse more commonly than patients with other psychiatric disor-
ders, and their traumatic experiences began earlier in childhood and were repeated
over a longer time period.
The victims of childhood sexual abuse commonly did not perceive a direct
connection between their current symptoms and their childhood abuse. BPD ad-
aptation to the childhood traumatic experience of sexual abuse may be less ex-
treme than that of multiple personality disorder, and anxiety and panic disorders
might represent adaptation to more circumscribed events. The same group of 21
BPD patients had rates of childhood sexual abuse (68%) significantly greater than
rates of 23 patients who were not BPD (Perry et al., 1990).
 Twenty-four BPD patients. 19 women and 5 men. reported significantly
higher rates of childhood sexual abuse than the I8 in a control group of depressed
patients. 13 women and 5 men (Ogata et al., 1990). All the subjects were in-
patients in a university medical center, and all had been interviewed regarding
recollections of a variety of childhood and family events by team members
who were blind to their diagnosis. In most cases the sexual abuse experienced
by the BPD patients. often together with physical abuse, had occurred before
age I?.
Stepwise regression performed with diagnosis as the dependent variable in-
dicated that sexual abuse was the best predictor of BPD diagnosis for all the pa-
tients and for female patients taken alone. When only female patients were in-
Downloaded by [University of Leeds] at 23:38 11 March 2015

cluded, stepwise regression with sexual abuse as the dependent variable pointed
to a diagnosis of BPD as the strongest significant predictor of childhood sexual
abuse. Because the number of patients was small and all were inpatients, general-
izations must be limited, but other studies’ findings have yielded similar results.
Their results suggested that a history of sexual abuse is frequently associated
with BPD.
In another investigation at a university medical center, female patients were
divided almost equally between 27 BPD and 23 control patients (Westen et al.
1990). Review of their records showed that 80% of the BPD group had been
sexually abused and most of the abuse had been documented. Most of the sexual
abuse had occurred in the latency years when ego structuring and character devel-
opment occur and begin to solidify. Sexual abuse seemed likely to disturb im-
portant psychological developmental processes, self-esteem, relationships with
others, trust, and capacity to regulate feelings. Their results suggested that a his-
tory of sexual abuse is frequently associated with BPD. Brown and Anderson’s
(19911) investigation of the long-term effects of childhood sexual abuse in 947
inpatients at a military medical center showed that BPD was more frequent in
abuse victims than in nonabused patients.
The Shearer et al. ( 1990) investigation of suicidal behavior in 40 female BPD
inpatients found that 40% of them had a history of childhood sexual abuse. Etiol-
ogy cannot be inferred from a correlational approach but the trend in the literature
in this area surely points to a need for reexamination of the relationship between
childhood sexual abuse and BPD. Childhood sexual abuse often occurs in the
context of other family problems, including parental alcoholism, depressive disor-
ders, and family fragmentation. Hence, victims of childhood sexual abuse may
also be weighed down with other conditions, such as multiple developmental
trauma, that may compound the impact of victimization. Sexual abuse may, how-
ever, be a contributor in a subgroup of BPD subjects.
While the cause of BPD is not agreed upon, a 60% to 80% prevalence of
childhood abuse, particularly sexual abuse, i n adults with BPD has emerged from
data drawn from both inpatient and outpatient psychiatric settings (Goldman et
al., 1992). Some of the symptoms of BPD may reflect a history of severe and
 Murray 665

repetitive trauma and some of the trauma of abuse may contribute to the border-
line patients’ difficulties in handling emotion.
However, patients who meet the criteria of BPD are heterogeneous, and no
one factor is recognized as the cause of BPD (Paris & Zweig-Frank, 1992). Also,
childhood sexual abuse may be associated with many pathogenic development
factors such as the type of sexual act, the duration, frequency, age at onset, and
type of family environment (Goldman et al., 1992; Jackson et al., 1990; Paris &
Zweig-Frank, 1992).
BPD sufferers generally do not perceive a direct connection between their
current symptoms and the abusive experience in childhood so that inclusion of an
inquiry and assessment of sexual abuse experiences would be recommended in
treating BPD patients (Brown & Anderson, 1991; Herman et al., 1989). Focusing
Downloaded by [University of Leeds] at 23:38 11 March 2015

on the relation between childhood sexual abuse and their symptoms might help
BPD patients organize their experiences. Etiological theories are needed that ex-
plain the interaction of important risk factors, especially the significantly greater
rate of histories of sexual abuse among BPD patients than among their peers.
Symptoms of one third of 19 children who received a BPD diagnosis also fit
the criteria for PTSD (Famularo, Kinscherff, & Fenton, 1991). Underlying psy-
chodynamic properties suggest relationships between BPD and MPD, and the
parallels between BPD and PTSD may help link child sexual abuse and subse-
quent development of BPD (Goldman et al., 1992; Gunderson, & Sabo 1993;
Herman et al. 1989; Horevitz & Braun, 1984).

Posttraumatic Stress Disorder

PTSD like BPD became an official diagnosis in the DSM-111 (1980). PTSD is a
clinical manifestation of problems associated with trauma induced during catas-
trophe and represented by posttraumatic stress reaction (Figley, 1985). A precise
definition of what causes PTSD is impossible, and symptom profiles may change
during the course of the disorder (Scurfield, 1985). PTSD has most often been
studied in soldiers, but many other types of natural and civilian catastrophes,
criminal assault, rape, and accidents may precipitate it (Kinzie, Sack, Angell,
Manson, & Rath, 1986; Solkoff, Gray, & Keill, 1986). The DSM-111-R (1987)
expanded the definition of the concept of stressors of PTSD, rearranged the symp-
toms in all the clusters, increased the range of items in both the re-experience and
avoidant cluster symptoms, and revised criteria to include items representing
PTSD in children.
Recently, PTSD has also been linked with childhood sexual abuse (Craine et
al., 1988). The recognized symptoms of PTSD are very similar to symptoms iden-
tified as clinical predictors of childhood sexual abuse (Bagley & King, 1990).
Symptoms of 25 of 26 women, patients in a treatment program, who had experi-
enced incest as children, met the DSM-111 criteria for PTSD (Donaldson & Gard-
ner, 1985). Watson, Kucala, Manifold, and Vassar (1989) studied male Vietnam
 veterans. 63 of whom were PTSD inpatients in a Veterans Administration hospi-
tal. Results of a structured interview with the PTSD veterans were compared with
interview responses of two control groups, one psychiatric and the second normal.
Retrospective self-ratings of their childhood stress behavior met I3 of 15 elements
of DSM-I11 ( 1980) PTSD criteria. Their data supported the theory that emotional
problems caused by childhood trauma might persist for years, even in those with
normal pretrauniatic adjustment. The relationship between childhood sexual
abuse and combat-related PTSD had not been investigated until the study of
Bremner et al. (1993).
The most distinctive signs of PTSD are re-experiencing symptoms such as
intrusive memories, avoidance of stimuli connected with the event, a numbing of
Downloaded by [University of Leeds] at 23:38 11 March 2015

general responsiveness that may involve loss of ability to have loving feelings,
heightened bodily arousal. recurrent nightmares, or flashbacks (Murray, 1992).
PTSD involves impaired functioning following exposure to an event that is out-
side the range of usual human experiences and that would be disturbing to nearly
everyone (DSM-111-R, 1987).The diagnosis is not made unless the disturbance is
endured for at least I month. Sometimes the symptoms do not begin until 6
months or more after the trauma. PTSD is classified as an anxiety disorder in
DSM-111-R. but it differs from other anxiety disorders in that it involves a stress-
related disorder that follows a traumatic experience.
Clinical descriptions of 53 adult short-term outpatients in therapy who had
a history of childhood sexual abuse, compared with 152 women who responded
to a survey. were consistent with PTSD formulation (Herman et al., 1986). In a
sample of 105 female psychiatric patients who were sexually abused as children
or adolescents and drawn randomly from 9 of 1 1 state hospitals. 66% met the
criteria for PTSD (Craine et al. 1988). None had received that diagnosis. A history
of sexual abuse may be a significant factor contributing to psychopathology severe
enough to require hospitalization. In comparisons of patients. 70% of the sexually
abused as opposed to 5 1% of the nonabused group came from families with his-
tories of psychiatric illness. Patients' experience of this unstable family environ-
ment along with childhood sexual abuse may have contributed to their hospitaliza-
tion and PTSD diagnosis.
The reactions of 7 I sexually abused children who were referred by a child
protection agency were likened to PTSD (Wolfe et al., 1989). An extensive battery
of tests was administered to the children in their homes, and other tests were given
orally in the university clinic. Their mothers' ratings of the children met the PTSD
criteria. All the perpetrators of the abuse were men and 83% of these were family
members or lived in the same house as the children. Individual and contextual
factors, such as the age of the child and severity of the sexual abuse. seemed to
mediate its impact.
In Lindberg and Distad's ( 1985) report. I7 women sexually abused in child-
hood had entered therapy with a variety of presenting complaints that fitted
closely DSM-111 (1980) criteria for PTSD. All the women regarded these events
 Murray 661

as the most damaging of their lives. None was aware of the relationship between
their symptoms and the childhood sexual experience. Long-term psychological
effects are difficult to relate to causes.
Brewer et al. (1993) compared the rates of childhood abuse in 38 Vietnam
combat veterans seeking treatment for PTSD with 28 Vietnam combat veterans
who sought treatment for medical disorders not related to FTSD. Those with
PTSD had higher rates of childhood sexual abuse than the comparison group.
Veterans with FTSD also had significantly higher rates of traumatic experiences
before joining the military. The association between child sexual abuse and FTSD
persisted after the level of combat exposure i n the two groups was controlled.
However, 74% of patients with PTSD in this study did not report a history of
childhood abuse on the 5 1-item self-report questionnaire that assessed a broad
Downloaded by [University of Leeds] at 23:38 11 March 2015

range of traumatic events including childhood physical and sexual abuse.

Persistent eating disorders may disguise posttraumatic responses to sexual
abuse and may become a general response to negative internal states. Root (1991)
judged that eating problems, including anorexia nervosa and bulimia, may be
traceable to sexual assault in childhood. Studies of patients with addictions to
food showed that as many as 75% have experienced childhood sexual abuse.
However, Pope and Hudson's (1992) review of controlled and uncontrolled retro-
spective studies of the prevalence of childhood sexual abuse among bulimic
groups indicated that current evidence does not support the hypothesis that child-
hood sexual abuse is a risk factor for the development of bulimia nervosa.
Childhood trauma is a pathogenic factor in some adult psychiatric disorders.
Children who have been sexually abused often report re-experiencing in night-
mares their fright at the time of sexual abuse (Gelinas, 1983). Adults sometimes
relive their painful childhood sexual experiences during therapy, simulating the
characteristics of PTSD. Victims tend to seek psychotherapy for PTSD without
disclosing their history of childhood sexual abuse history, or they may disguise
their presentations.

Multiple Personality Disorder

Some 6,000 cases of multiple personality disorder (MPD) have appeared since
1980, and by the middle of 1980 the relationship between MPD and child abuse
was clearly recognized (Greaves, 1980; Putnam, 1984, 1991; Ross, 1989; Ross et
al., 1989). Most large scale studies drawing cases from many sources confirmed
the high incidence of child abuse in MPD patients (Kluft, 1987a). More than 90%
of those diagnosed as MPD have been victims of physical and/or sexual abuse in
childhood (Ross, 1991).
The DSM-I11 (1980) defined MPD in such a way that the diagnosis could
be applied in situations where a person experienced disorganization of self and
attributed discrepant experiences to the operation of separate individuals residing
in the self. Most recent MPD victims have had three or more personalities (Coons,
 1980; Ross & Norton. 1989; Schafer. 1986). Pierre Janet's view of multiple per-
sonality as an autohypnotic phenomenon is a leading theory or model o f MPD
(Bliss, 1986: Putnam. I99 I: Putnam, Curoff, Silberman, Barbari, & Post. 1986).
Morton Prince elaborated on Janet's views, and Breuer described an autohypnotic
model of dissociative psychopathology.
Research in ego psychology. especially study of the etiology of the border-
line disorders, has thrown light on the origins of multiple personality disorders
(Greaves, 1980).Many clinicians believe that MPD is a psychological adaptation
to traumatic experiences in early childhood. and the connection between multiple
personality disorder and childhood sexual experiences, especially very severe
abuse. has been documented in increasingly sophisticated inkestigations
Downloaded by [University of Leeds] at 23:38 11 March 2015

(Coons, & Milstein, 1986; Kluft, 1987a; Putnam, 1991 ; Ross, Anderson,
Fleisher, & Norton, 1991: Stem. 1984).
Several studies have linked childhood sexual abuse with the development of
dissociative symptoms (Gelinas, 1983). The majority of 98 female psychiatric
inpatients, who had experienced physical and/or sexual abuse, also reported
higher levels of dissociative symptoms than those not abused (Chu & Dill, 1990).
Some children who are sexually abused may learn to dissociate parts of them-
selves and develop alternative personalities that may be a means of psychologi-
cally escaping from their emotional pain (Greaves, 1980; Spiegel, 1984). Alter-
nate personalities may enable sexually abused children (superficially) to function
sexually (Coons & Milstein. 1986).
Sometimes imaginary playmates, a normal childhood phenomenon, and
dolls or puppets are drawn into the creation of secondary personalities (Bliss,
1984, 1986; Coons, 1980). These secondary personalities may also enable chil-
dren 10 act out impulses that would be unacceptable to the primary personality. A
few children who suffer extreme childhood sexual abuse over longer periods may
become unable to maintain an integrated personality (Schafer, 1986). Children
with more active and creative imaginations may be more prone to construct alter-
nate personalities as a defense against the sexual abuse. If the traumatic experi-
ences of sexual abuse occur early enough during the period of ego and identity
formation, BPD may develop, whereas MPD may develop if the traumatic epi-
sodes occurred relatively late in the period of ego formation (Greaves. 1980).
Coons and Milstein (1986) found a 75% incidence of sexual abuse in 20
MPD patients, significantly more than in 20 psychiatric patients i n a control
group. Coons, Bowman. and Milstein ( 1988) studied 50 consecutive MPD pa-
tients using a psychiatric interview, a neurological exam, EEG. MMPI, intelli-
gence test, and several psychiatric rating scales. Clinical history frequently
showed childhood trauma, particularly sexual abuse. Childhood trauma was
strongly associated with MPD that began in childhood as a defensive response to
overwhelming trauma.
Putnam et al. (1986) conducted one of the first large-scale investigations of
MPD patients in which they reported the results of a standardized questionnaire
 Murray 669

of 366 items sent to 400 clinicians across North America who were treating a
MPD patient. As part of the questionnaire, evidence for a link between childhood
history of trauma and development of MPD symptoms was sought. One hundred
cases of MPD were selected from the cases of 92 clinicians including almost
equal numbers of psychiatrists and psychologists and a few with masters’ degrees
in social work; most of the clinicians were men. All but three of the 100 cases
had a history of significant childhood trauma, and sexual abuse occurred in 83%
of the cases of childhood trauma.
Ross et al. (1990) gathered information on 102 cases of MPD from four
centers, two in Canada and two in the United States. All the patients were inter-
viewed using the same instrument and data that was sent to a coordinating center
Downloaded by [University of Leeds] at 23:38 11 March 2015

that provided a clinical profile of MPD. A history of childhood physical andor

sexual abuse was present in 95.1% of the cases. The profile of MPD that emerged
fit the findings of other studies and provided a strong case for consistency in the
features of MPD. Childhood sexual abuse ranged from 68% to 90% for patients
with MPD.
In an earlier investigation of MPD, through a questionnaire sent to members
of the Canadian Psychiatric Association members, Ross et al. (1989) had found
that 79.2% of 236 patients with the MPD diagnosis had experienced extensive
sexual abuse as children. Most were women, 87.7% of 236 cases. The Ross et al.
(1989) findings were similar to those reported by F’utnam et al. (1986) based on
100 cases using a different questionnaire. MPD was linked to a higher rate of
childhood trauma than any other psychiatric disorder.
There are many variations of MPD. Women have been more likely to develop
it, and women are more likely to be the victims of childhood sexual abuse (Ross &
Norton, 1989). Some who receive the diagnosis show behavior associated with
schizophrenia, such as hearing voices or having visual hallucinations (Kluft,
1987b). The dominant personality of those suffering from MPD may report hear-
ing voices. Some symptoms of MPD overlap with those of BPD (Clay, Burstin, &
Carpenter, 1984; Horevitz & Braun, 1984). The posttraumatic nature of MPD also
has been noted in the research (Ross, 1989; Spiegel, 1984). Further research will
be needed to decide whether child sexual abuse is a cause of or one of the contrib-
utors to formation of MPD (Greaves, 1980).

Discussion
Although the literature on childhood sexual abuse has proliferated, investigation
of its lasting consequences is in the beginning stages. Methodological problems
are almost inevitable, given the different definitions of sexual abuse, the small
numbers and treatment populations investigated, the frequent use of retrospective
and correlational approaches that preclude cause-effect conclusions, and the lim-
ited statistical analysis of results.
 However, despite the limitations of these investigations, clinicians have re-
ported that abused subjects seeking treatment display consistent characteristic
symptoms similar to those described in various studies and that these findings
need to be addressed. Investigations have shown that victims of childhood sexual
abuse exhibit symptoms that include poor self-esteem, anxiety, feelings of isola-
tion, interpersonal dysfunction, in some cases self-destructive behavior, and sub-
stance abuse. These symptoms fit the criteria for many psychiatric disorders, and
the literature tends to support the higher prevalence of many psychiatric disorders
in those who have a history of childhood sexual abuse. The rate of childhood
sexual abuse history is very high in MPD, and high in BPD and in PTSD patients.
An alternative explanation for the association between childhood sexual
Downloaded by [University of Leeds] at 23:38 11 March 2015

abuse and psychiatric disorders may lie in family background. Using this ap-
proach, the sexual abuse could be viewed as a prevalent marker for a severely
dysfunctional family environment, which plays the major role in the origin of
interpersonal problems leading to development of psychiatric problems. Child-
hood sexual abuse often occurs in the context of other family problems including
parental alcoholism, depression, physical handicaps, or death of a parent. Child
abuse victims in some nonclinical studies recalled their family life as chaotic,
fragmented, less cohesive, and less adaptable.
Fathers and stepfathers most often were the perpetrators of sexual abuse. The
impact of mothers who remained passive and failed to protect or support the chil-
dren has not been studied. Mothers’ lack of support, as described in victims’ re-
ports. was often disastrous and contributed strongly to their feelings of help-
lessness and isolation.
Victims may acquire characteristic methods of coping with stressful experi-
ence that may increase their vulnerability to subsequent sexual abuse and sexual
maladjustment. In some reports, feelings of isolation and helplessness drove the
women to run away from home and into prostitution. Evidence for the develop-
ment of MPD from the youthful dissociative strategies for coping with and surviv-
ing childhood sexual abuse has been investigated in studies with large numbers
and sophisticated statistical design.
Many studies indicated that victims were not identified as such while they
were patients in psychiatric facilities or at mental health agencies. The victims
often did not voluntarily reveal their sexual abuse history and in some instances
did not see the connection between their current psychiatric problems and their
history of abuse. Some studies have recommended inclusion of routine ques-
tioning about sexual abuse at the beginning of psychotherapeutic intervention and
again later when the psychotherapeutic alliance has been established. Particularly,
evidence of physical abuse can be a reason for inquiring about sexual abuse be-
cause they so frequently occur together, although the motivation for each may
be differel’.
Sexual abuse in childhood has been linked to adult psychiatric problems in
many investigations. Whether childhood sexual abuse is a cause of or contributor
 Murray 671

to BPD, PTSD, or MPD, and whether different abusive experiences in childhood

contribute to different psychiatric problems in adulthood remain for future re-
search to determine.

REFERENCES

Adams-Tucker, C. (1982). Proximate effects of sexual abuse in childhood. Arnerican Juitr-

nal of Psychiatv, 139, 1252-1 259.
Alexander. P. C., & Lupfer. S . L. (1987). Family characteristics and long-term conse-
quences associated with sexual abuse. Archiivs of"Se.rual Beha\inr, 16. 235-241.
Alter-Reid, K., Gibbs, M. S.. Lachenmeyer. J. R.. Sigal. J.. & Massoth, N. A. ( 1986). Sex-
ual abuse of children: A review of the empirical findings. Clinical Psychology Review,
Downloaded by [University of Leeds] at 23:38 11 March 2015

6, 249-266.
American Psychiatric Association ( 1980). Diagnostic and S t a t i s t i c d Manual of Mental
Disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association ( 1987). Diagrtosric and Statisticul Manual of Mental
Disorder (3rd ed. revised). Washington, DC: Author.
Bagley. C., & King, K. ( 1990). Child sevuul abuse: The search for healing New York:
TavistocklRoutIedge.
Beck. J. C., & van der Kolk, B. (1987). Reports of childhood incest and current behavior
of chronically hospitalized psychotic women. Atnericcin Journal of Psychiatre 144,
1474-1476.
Becker, J. V., Skinner, L. J., Abel. G. C.. & Cichon. J. ( 1986). Level of postassault sexual
functioning in rape and incest victims. Archirips ufSexual Behavior, 15, 37-49.
Beitchman. J. H.. Zucker, K . J.. Hood, J. E.. DaCosta, G. A,, & Akman, D. (1991). A re-
view of the short-term effects of child sexual abuse. Child Abuse arid Neglect, 15,
537-5156,
Bentovim, A,, Boston. P.. & Van Elburg, A. (1987). Child sexual abuse-children and fami-
lies referred to a treatment project and the effects of intervention. British Medicul Juur-
nal. 295. 1453-1457.
Bliss, E. L. (1984). A symptom profile of patients with multiple personalities, including
MMPI results. Journal ofNenws and Mental Disease. 172. 197-202.
Bliss, E. L. ( 1986).Midriple persunality, allied disorders, arid hypnosis. New York: Oxford
University Press.
Bremner, J. D.. Southwick, s. M., Johnson. D. R.. Yehuda. R.. & Charney. D. S. (1993).
Childhood physical abuse and combat-related posttraumatic stress disorder in Vietnam
veterans. American Journal oJ'Psychiatn, 150, 235-239.
Brewin. C. R.. Andrews. B., & Gotlib. I. H. ( 1993). Psychopathology and early experience:
A reappraisal of retrospective reports. Psy/iological Bulletin. 113. 82-98.
Brickman, J., & Briere. J. (1984). Incidence of rape and sexual assault in an urban Cana-
dian population. Internationcil Journal uf Wimenk Studies, 7. 195-201.
Briere. J., & Runtz. M. ( 1985). Suicidal thoughts and behaviours in former sexual abuse
victims. Canadian Joicrnal of Behaiioral Science. 20, 4 13-423.
Brown, G . R.. & Anderson, B. (1991). Psychiatric morbidity in adult inpatients with child-
hood histories of sexual and physical abuse. American Journal of Psyhiatn, 148.
55-61.
Browne, A.. & Finkelhor, D. ( 1986). Impact of child sexual abuse: A review of research.
Psychological Bulletin. 99. 66-77.
Browning, D. H.. & Boatman, B. (1977). Incest: Children at risk. Americun Journal u/
Psvchiatn, 134. 6%72.
 612 The Journal of Psychologv

Bryer. J. B., Nicholson. B. A.. Miller, J. B., & Krol, P. A. (1987). Childhood sexual and
physical abuse as factors in adult psychiatric illness. American Journal of Psychiatry.
144, 1426-1430.
Bumam, M. A., Stein, J. A., Golding, J. M., Siegel, J. M., Sorenson, S. B., Forsythe,
A. B., & Telles, C. A. (1988). Sexual assault and mental disorders in a community popu-
lation. Journal of Consulting and Clinical Psychology, 56, 843-850.
Byme. J. P., & Valdisem, E. V. (1982). Victims of childhood sexual abuse: A follow-
up study of a noncompliant population. Hospital and Community Psychiatry, 33, 938-
940.
Carmen, E. (H), Rieker, P. P., & Mills, T. (1984). Victims of violence and psychiatric ill-
ness. American Journal of Psychiatv, 141, 378-383.
Chu, J. A.. & Dill, D. L. (1990). Dissociative symptoms in relation to childhood physical
and sexual abuse. American Journal of Psychiatry, 147, 887-892.
Clary, W. E, Burstin, K. J., & Carpenter, J. S. (1984). Multiple personality and borderline
Downloaded by [University of Leeds] at 23:38 11 March 2015

personality disorder. Psychiatric Clinics of North America. 7, 89-99.

Coons, P. M. (1980).Multiple personality: Diagnostic considerations. Journal of Clinical
Psychiatry, 41 (10). 330-336.
Coons, P. M., Bowman, E. S., & Milstein, V. (1988). Multiple personality disorder: A
clinical investigation of 50 cases. Journal of Nervous and Mental Disease. 176, 5 19-
527.
Coons, P. M., & Milstein, V. (1986). Psychosexual disturbances in multiple personal-
ity: Characteristics,etiology, and treatment. Journal of Clinical Psychiatty 47 (3),106-
110.
Cozolino, L. J. (1989). The ritual abuse of children: Implications for clinical practice and
research. Journal of Sex Research, 26, 131-1 38.
Craine, L. S., Henson, C. E., Colliver, J. A., & MacLean, D. G. ( 1 988). Prevalence of a
history of sexual abuse among female psychiatric patients in a state hospital system.
Hospital and Comnzunity Psychiatry 39, 300-304.
DeJong, A. R. ( 1 985). The medical evaluation of sexual abuse in children. Hospital and
Community Psychiatr?;,36, 509-5 12.
DeJong, A. R., Hervada, A. R.. & Emmett, G . A. (1983). Epidemiologic variations in
childhood sexual abuse. Child Abuse and Neglect, 7, 155-162.
Donaldson, M. A., & Gardner, R., Jr. (1985). Diagnosis and treatment of traumatic stress
among women after childhood incest. In C. R. Figley (Ed.). Trauma and its wake: The
study and treatment of post-traumatic stress disorder (pp. 356-377). New York:
BrunnerMazel.
Famularo, R., Kinscherff, R., & Fenton, T. (1991). Posttraumatic stress disorder among
children clinically diagnosed as borderline personality disorder. Journal of Nervous and
Mental Disease, 179. 428-43 I .
Figley, C. R. (Ed.). ( 1985). Truuma and its wake: The study and treatment of post-traumatic
stress disorder. New York: BrunnerNazel.
Finkelhor. D., & Hotaling, G. T. (1984). Sexual abuse in the national study of child abuse
and neglect: An appraisal. Child Abuse and Neglect. 8, 22-33.
Gelinas, D. J. (1983). The persisting effects of incest. Psychiatry, 46. 312-317.
Goldman, S . J., D’Angelo, E. J., DeMaso, D. R.. & Mezzacappa, E. (1992). Physical and
sexual abuse histories among children with borderline personality disorder. American
Journal of Psychiatq. 149, 1723-1 726.
Greaves, G. 9. (1980). Multiple personality: 165 years after Mary Reynolds. Journal of
Nervous and Mental Disease. 168, 577-596.
Green, A. H. ( 1978). Self-destructive behavior in battered children. American Journal of
Psyhiatty, 135, 579-582.
 Murray 673

Green, A. H. (1984). Child abuse by siblings. Child Abuse and NegIect, 8, 3 I 1-3 17.
Green, A. H. (1986). True and false allegations of sexual abuse in child custody disputes.
Journal of American Academy of Child Psychiatry, 25. 449-456.
Gunderson, J. G., & Sabo, A. N. (1993). The phenomenological and conceptual interface
between borderline personality disorder and PTSD. American Journal of Psychiarry,
150, 19-27.
Haner, S., Alexander, P. C., & Niemeyer, R. A. (1988). Long-term effects of incestuous
child abuse in college women: Social adjustment, social cognition, and family character-
istics. Journal of Consulting and Clinical Psychology, 56, 5-8.
Herman, J., Russell, D., & Trocki, K. (1986). Long-term effects of incestuous abuse in
childhood. American Journal of Psychiatry, 143, 1293-1296.
Herman, J. L. (1986). Histories of violence in an outpatient population: An exploratory
study. American Journai of Orthopsychiatp, 56, 137-141.
Herman, J. L..Perry, J. C., & van der Kolk, B. A. (1989). Childhood trauma in borderline
Downloaded by [University of Leeds] at 23:38 11 March 2015

personality disorder. American Journal of Psychiatv, 146, 490-495.

Horevitz, R. P., & Braun, B. G. (1984). Are multiple personalities borderline? Psychiarric
Clinics of North America, 7. 69-87.
Hunter, R. S . , Kilstrom, N., & Loda, E (1985). Sexually abused children: Identifying
masked presentations in a medical setting. Child Abuse and Neglect, 9, 17-25.
Husain, A., & Chapel, J. L. (1983). History of incest in girls admitted to a psychiatric
hospital. American Journal of Psychiatry, 140, 591-593.
Jackson, J. L., Calhoun, K. S., Amick, A. E., Maddever. H. H.. & Habif, V. L. (1990).
Young adult women who report childhood intrafamilial sexual abuse: Subsequent adjust-
ment. Archives of Sexual Behavior; 19, 21 1-221,
Jacobson, A. (1989). Physical and sexual assault histories among psychiatric outpatients.
American Journal of Psychiatry, 146. 755-758.
Jason, J., Williams, S. L., Burton, A., & Rochat, R. (1982). Epidemiologic differences
between sexual and physical child abuse. Journal of American Medical Association,
247, 3344-3348.
Jennings, A. G., & Armsworth, M. W. (1992). Ego development in women with histories
of sexual abuse. Child Abuse and Neglect, 16, 553-567.
Johnson, B. K., & Kenkel, M. B. (1991). Stress, coping, and adjustment in female adoles-
cent incest victims. Child Abuse and Neglect, 15, 293-305.
Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse
on children: A review and synthesis of recent empirical studies. Psychological Bulletin,
113, 164-180.
Kinzie, J. D., Sach, W. H., Angel], R. H., Manson, S., & Rath, B. (1986). The psychiatric
effects of massive trauma in Cambodian children: 1. The children. Journal ofAmerican
Academy of Child Psychiatry, 25. 370-376.
Kinzl, J., & Bieble, W. (1992). Long-term effects of incest: Life events triggering mental
disorders in female patients with sexual abuse in childhood. Child Abuse and Neglect.
16. 567-573.
Kluft, R. P. (1987a). An update on multiple personality disorder. Hospital and Community
Psychiatry, 38, 363-373.
Kluft. R. P. (1987b). First rank symptoms as a diagnostic clue to multiple personality disor-
der. American Journal of Psychiatry, 144, 293-298.
Lindberg, F. H., & Distad, L. J. (1985). Post-traumatic stress disorders in women who ex-
perienced childhood incest. Child Abuse and Neglect, 9, 329-334.
Links, P. S., Steiner, M., Offord, D. R., & Eppel, A. (1988). Characteristics of border-
line personality disorder: A Canadian study. Canadian Journal of Psychiatry, 33, 336-
340.
 Margolin, L. ( 1992). Sexual abuse by grandparents. Child Abuse trtid Neglect, 16. 735-
742.
Murray, J. B. ( 1997). Posttraumatic stress disorder: A review. Genetic. Social,mid General
Psyhology Monographs. 118. 3 15-338.
Nurcombe, B. ( 1986).The child as witness: Competency and credibility. Jounial cfAnieri-
can Acaderrrx of Child P.Tychiatn, 25, 373-480.
Ogata, S. N., Silk, K. R., Goodrich, S.. Lohr, N. E.. Westen. D., & Hill, E. M. (1990).
Childhood sexual and physical abuse in adult patients with borderline personality disor-
der. American Journal of Psychiatp, 147, 1008-1 0 I 3.
Oppenheimer, R.. Howells. K.. Palmer. R. L.. & Chaloner, D. A. (1985). Adverse sexual
experience in childhood and clinical eating disorders: A preliminary description. Jour-
nal of' Psychiutric Research. 19. 357-36 1.
Paris, J.. & Zweig-Frank. H. (1992). A critical review of the role of childhood sexual
abuse in the etiology of borderline personality disorder. Cunudian Joicrticil qfPsychiaty,
Downloaded by [University of Leeds] at 23:38 11 March 2015

37, 125-128.
P e w , J. C.. Herman, J. L.. van der Kolk. B., & Hoke, L. A. (1990). Psychotherapy
and psychological trauma in borderline personality disorder. Psychiatric Anriuls. 20,
33-43.
Petti, T. A,, & Vela, R. M. ( 1990).Borderline disorders of childhood: An overview. Journal
r?fAniericcin Acadmiy of Child unci Adolescent Psvchiatn, 39. 327-337.
Pope. H. G., Jr.. & Hudson. J. I. (1992). Is childhood sexual abuse a risk factor for bulimia
nervosa? American Joirrnul of P s y c h i a t ~149. 455-463.
Pribor, E. F., & Dinwiddie. S. H. (1992). Psychiatric correlates of incest in childhood.
Americon Journal of Psychiutp, 149. 52-56.
Putnam, F. W. ( 1984).The psychophysiologic investigation of multiple personality disor-
ders: A review. Psychiatrii, Clinics ofNorth Aniericu. 7, 3 1-39.
Putnam, F. W. ( 1991). Recent research on multiple personality disorder. Psychiatric Clinics
of .Vorth Americu, I 4 489-502.
Putnam. F. W., Curoff. J. J., Silberman, E. K.. Barbari, L.. & Post, R. M. ( 1986). The clini-
cal phenomenology of multiple personality disorder: Review of 100 recent cases. Joirr-
nal of Clinirul Psychiatn, 47. 285-293.
Root. M. P. ( 199 I ). Persistent. disordered eating as a gender-specific. post-traumatic stress
response to sexual assault. P.sychothrrups, ZX. 96-102.
Rosenfeld, A. A. ( 1979). Incidence of a history of incest among 18 female psychiatric
patients. Aniericari Joitrnul OJ'Psyhiatty 136. 791-793.
Ross. C. A. ( 1989). Mitlfiple personality clisorcler: Diugriosis, clinicalfe~rtures,and treut-
ment. New York: Wiley.
Ross, C. A. (1991). Epidemiology of multiple personality disorder and dissociation. Psy-
chiatric C1inic.s of North Atiierica. 14, 503-5 17.
Ross, C. A.. Anderson. G., Fleisher, W. P.. & Norton. G. R. ( 1991). The frequency ofmulti-
ple personality disorder among psychiatric inpatients. Anierican Jourtial of Psychiaty,
148, 17 17-1 720.
Ross, C. A., Miller. S. D.. Reagor, P.. Bjornson. L., Fraser. G. A,. & Anderson, G. (1990).
Structured interview data on 102 cases of multiple personality disorder from four cen-
ters. Atnericcin Joiirtirrl of'P.~ychicitn,147>596-60 I .
Ross, C. A,. & Norton. G. R. (1989).Differences between men and women with multiple
personality disorder. Hospital and Coninrunit?.Ps.vchiatp. 40, 186-1 88.
Ross, C. A,, Norton, G. R., & Wozney. K. (1989). Multiple personality disorder: An analy-
sis of 236 cases. Canadian Journal of Psychiarn, 34, 4 13-4 18.
Russell. D. E. H. ( 1983). The incidence and prevalence of intrafamilial and extrafamilial
sexual abuse of female children. Child Ahitse arid Neglect. 7, 133-146.
 Murray 675

Russell, D. E. H. (1986). The secret trauma: Incest in the lives of girls and women. New
York: Basic Books.
Schafer, D. W. (1986). Recognizing multiple personality patients. American Journal of
Psychotherapy, 40, 500-505.
Scurfield, R. M. (1985). Post-traumatic stress assessment and treatment: Overview and
formulations. In C. R. Figley (Ed.), Trauma and its wake: The study and treatment of
post-traumatic stress disorder (pp. 2 19-256). New York: Brunnerhlazel.
Sedney, M. A., & Brooks, B. (1984). Factors associated with a history of childhood sexual
experience in a nonclinical female population. Journal of American Academy of Child
Psychiatry, 23, 2 15-2 18.
Shapiro, J. P., Lifer, M., Martone, M. W., & Kassem, L. (1990). Multimethod assess-
ment of depression in sexually abused girls. Journal of Personhlify Assessment, 55.
234-248.
Shearer, S. L., Peters, C. P., Quaytman, M. S., & Ogden, R. L. (1990). Frequency and cor-
Downloaded by [University of Leeds] at 23:38 11 March 2015

relates of childhood sexual and physical abuse histories in adult female borderline inpa-
tients. American Journal of Psychiatry, 147, 214-216.
Simons, R. L., & Whitbeck, L. B. (1991). Sexual abuse as a precursor to prostitution and
victimization among adolescent and adult homeless women. Journal of Family Issue,
12, 361-379.
Solkoff, N., Gray, P.,& Keill, S. (1986). Which Vietnam veterans develop posttraumatic
stress disorders? Journal of Clinical Psychology, 42, 687-698.
Spiegel, D. (1984). Multiple personality as a post-traumatic stress disorder. Psychiatric
Clinics of North America, 7. 101-1 10.
Stem, C. R. (1984). The etiology of multiple personalities. Psychiatric Clinics of North
America, 7, 149-1 59.
Stone, M. H. (1981). Borderline syndromes: A consideration of subtypes and an overview,
directions for research. Psychiatric Clinics of North America, 4, 3-24.
Storr, R. H., Jr. (1979). Child abuse. American Psychologist, 34, 872-878.
Straus, M. (1979).Family patterns and child abuse in a nationally representative American
sample. Child Abuse and Neglect, 3, 213-225.
Summit, R., & Kryso, J. (1978). Sexual abuse of children: A clinical spectrum. American
Journal of Orthopsychiatry, 48, 237-25 1.
Terr, L. C. ( 1991). Childhood traumas: An outline and overview. American Journal o f f s y -
chiatry, 148, 10-20.
van der Kolk, B. A., Perry, J. C., & Herman, J. L. (1991). Childhood origins of self-
destructive behavior. American Journal of Psychiatry, 148, 1665-1671.
Vander Mey, B. J. (1988). The sexual victimization of male children: A review of previous
research. Child Abuse and Neglect, 12, 61-72.
Watson, C. G., Kucala, T., Manifold, V., & Vassar, P. (1989). Childhood stress disorder
behaviors in veterans who do and do not develop posttraumatic stress disorder. Journal
of Nervous and Mental Disease, I77, 92-95.
Westen, D., Ludolph, P., Misle, B., Ruffins. S., & Block, J. (1990). Physical and sexual
abuse in adolescent girls with borderline personality disorder. American Journal of Or-
thopsychiatry, 60, 55-66.
White, S., Halpin, B. M., Strom, G. A., & Santilli, G. (1988). Behavioral comparisons of
young sexually abused, neglected, and nonreferred children. Journal of Clinical Child
Psychology, 17, 53-6 I .
Wolfe, D. A. (1985). Child-abusive parents: An empirical review and analysis. Psychologi-
cal Bulletin, 97, 462-482.
Wolfe, V. V., Gentile, C., & Wolfe, D. A. (1989). The impact of sexual abuse on children:
A PTSD formulation. Behavior Therapy, 20, 215-229.
 Wyatt, G. E. ( 1985). The sexual abuse of Afro-American and White American women in
childhood. Child Ahrise irritl Neglect. 9, 507-5 19.
Wyatt, G. E.. & Peters. S. D. ( 1986). Methodological considerations in research on the
prevalence of child sexual abuse. Child Ahuse iuzd Neg/ec/, 10, 241-25 I .
Young,W. C.. Sachs. R. G.. Braun. B. G., & Watkins. R. T. (1991). Patients reporting ritual
abuse in childhood: A clinical syndrome: Report of 37 cases. Chi/dAhit.se uncl Neglect.
1.5. 181-189.

Receii*edApril 13, 1993

Downloaded by [University of Leeds] at 23:38 11 March 2015