Skip to main content
NCBI home page
European Journal of Psychotraumatology logoLink to European Journal of Psychotraumatology
. 2025 Apr 22;16(1):2491172. doi: 10.1080/20008066.2025.2491172

The impact of types of childhood maltreatment on the severity of PTSD and comorbid personality disorder symptoms

El impacto de los tipos de maltrato infantil en la gravedad de los síntomas del TEPT y del trastorno de personalidad comórbido

Christin Kühner a,b,c,CONTACT, Marleen de Waal a,b, Lisa Steenkamp c, Isabel van Zwol a, Anneke Goudriaan a,b, Kathleen Thomaes b,c
PMCID: PMC12016238  PMID: 40261043

ABSTRACT

Background: Childhood maltreatment is associated with various psychiatric disorders, including post-traumatic stress disorder (PTSD) and personality disorders (PDs). Previous research has suggested that PTSD and PD are highly comorbid. However, the impact of different types of childhood maltreatment on the severity of PTSD and PD symptoms in a clinical population with PTSD/PD symptoms remains unclear.

Objective: We aimed to clarify the role of (a) the overall severity and (b) the severity of subtypes of childhood maltreatment on the severity of (a) PTSD and (b) comorbid PD symptoms.

Methods: Data was collected from participants (N = 197) seeking treatment for PTSD with comorbid PD symptoms at a trauma expertise centre in the Netherlands. We assessed childhood maltreatment using the Childhood Trauma Questionnaire-short form (CTQ-sf), PTSD severity with the Clinician-administered PTSD Scale for DSM-5 (CAPS-5), and PD severity with the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD). Data were analyzed using linear and Poisson regression.

Results: We found that emotional neglect was the most prevalent form of childhood maltreatment (80.7%), followed by emotional abuse (72.6%). Sexual and emotional abuse shared independent associations with the severity of PTSD. The overall maltreatment severity and emotional abuse were significantly associated with the severity of comorbid borderline PD symptoms. Sexual abuse was significantly associated with the severity of comorbid avoidant PD symptoms. None of the childhood maltreatment types were significantly associated with the severity of comorbid obsessive-compulsive PD symptoms.

Conclusions: We demonstrated the relationship between childhood sexual and emotional abuse and PTSD severity in people with PTSD and comorbid PD symptoms. This has important implications since emotional abuse usually does not fulfil the A-criterion required for the diagnosis of PTSD. We recommend routinely assessing emotional abuse in trauma- and PD treatment, and investigating the effectiveness of adapting trauma treatment for emotional abuse.

Trial registration: ClinicalTrials.gov identifier: NCT03833453.

KEYWORDS: Post-traumatic stress disorder (PTSD), borderline personality disorder, cluster C personality disorder, childhood maltreatment, emotional abuse

HIGHLIGHTS

  • Childhood emotional and sexual abuse were independently associated with the severity of post-traumatic stress disorder.

  • Childhood emotional and sexual abuse were associated with the severity of comorbid borderline and avoidant personality disorder symptoms, respectively.

  • Childhood maltreatment types were not significantly associated with comorbid obsessive-compulsive personality disorder symptoms.

1. Introduction

Childhood maltreatment can take the form of sexual, physical, and emotional abuse, and physical and emotional neglect, with most victims experiencing multiple types of maltreatment (Finkelhor et al., 2007). Childhood maltreatment is a common phenomenon, affecting around one in four children (Brown et al., 2024). Experiences of childhood maltreatment have been linked with a plethora of negative consequences, such as post-traumatic stress disorder (PTSD), personality disorders (PD), and substance use disorder (SUD) (de Aquino Ferreira et al., 2018; Lortye et al., 2024; Rameckers et al., 2021). Additionally, the higher the exposure to or severity of childhood maltreatment, the higher the risk of later psychopathology (da Silva et al., 2024; Messman-Moore & Bhuptani, 2017; Nemeroff, 2016). Notably, PTSD symptoms must be related to an experience that meets the A-criterion, defined as experiences of actual or threatened physical or sexual violence, serious illness, or death (American Psychiatric Association., 2013). In terms of childhood maltreatment, only physical and sexual abuse meet the A-criterion (unless the emotional abuse includes threats of violence or death), and both have been associated with the severity of PTSD (Lortye et al., 2024; Nöthling et al., 2019). However, research has also established strong links between emotional abuse and the severity of PTSD (Hoeboer et al., 2021; Lortye et al., 2024; Rameckers et al., 2021). One study has found positive univariate relationships between physical and emotional neglect and the severity of PTSD (Lortye et al., 2024). Another study has found evidence for the association between physical and emotional neglect and the severity of PTSD also when accounting for other types of abuse (Dovran et al., 2016), while others have not (Lortye et al., 2024; Rameckers et al., 2021). This discrepancy may have been caused by the use of adult clinical samples (Lortye et al., 2024; Rameckers et al., 2021) versus a mixed adolescent/adult clinical and prison sample (Dovran et al., 2016). When accounting for other types of childhood maltreatment, studies found only emotional abuse (Rameckers et al., 2021) or emotional abuse and sexual abuse (Lortye et al., 2024) to be independently related with the severity of PTSD. We aimed to clarify the role of different types of childhood maltreatment for the severity of PTSD in a clinical population that has not been studied so far: people with PTSD and comorbid symptoms of PDs.

Meta-analytic evidence suggests that PTSD and PDs are highly comorbid (Friborg et al., 2013). The most researched PD in the context of childhood maltreatment is borderline PD, while cluster C PDs (avoidant -, dependent -, obsessive-compulsive PD) share similar rates of comorbidity with PTSD (de Aquino Ferreira et al., 2018; Friborg et al., 2013; Hailes et al., 2019). Borderline PD is characterised by externalising behaviours, such as affective instability, disturbances in identity, interpersonal difficulties, and harmful behaviour directed at self or others (American Psychiatric Association., 2013). Cluster C PDs are characterised by internalising behaviours, such as experiential avoidance, passivity, control mechanisms, and hypersensitivity to rejection (American Psychiatric Association., 2013; van den End et al., 2024).

Moreover, sexual and physical abuse have been linked with borderline PD in systematic reviews (de Aquino Ferreira et al., 2018; Hailes et al., 2019; Stepp et al., 2016). According to one of the reviews, sexual abuse increased the odds of developing borderline PD by 2.9 (Hailes et al., 2019). Emotional abuse, physical neglect, and emotional neglect have been linked with (symptoms of) borderline PD (Battle et al., 2004; Johnson et al., 2001; Lobbestael et al., 2010; Waxman et al., 2014; Wu et al., 2022). People with comorbid PTSD and borderline PD experienced an earlier age of onset across types of abuse, as well as higher rates of physical and sexual abuse, when compared to people with stand-alone PTSD (Clarke et al., 2008; Heffernan & Cloitre, 2000; Van Den Bosch et al., 2003). Additionally, people with comorbid PTSD and borderline PD, were more likely to have experienced sexual abuse, physical abuse and neglect than people with either disorder alone (Pagura et al., 2010). Moreover, neither sexual or physical abuse nor physical or emotional neglect have been linked with cluster C PDs (Battle et al., 2004; Lobbestael et al., 2010; Waxman et al., 2014). Specifically, physical abuse increased the odds ratio of experiencing avoidant PD symptoms by 1.25, while sexual abuse decreased the odds ratios of experiencing avoidant PD symptoms by 0.91 (Waxman et al., 2014). Emotional abuse has been linked with obsessive-compulsive PD in a community-based sample (Johnson et al., 2001) and all cluster C PDs in a clinical sample (Cohen et al., 2014). However, studies in epidemiological, population-based, and clinical samples have failed to find a relationship between emotional abuse and cluster C PDs (Afifi et al., 2011; Battle et al., 2004; Waxman et al., 2014). Notably, the clinical study that found no association between emotional abuse and cluster C PDs employed a different statistical approach by predicting the presence of emotional abuse based on the presence of the cluster C PDs instead of vice versa (Battle et al., 2004). No study so far has investigated the influence of childhood maltreatment on the severity of comorbid cluster C PD symptoms alongside full-blown PTSD, despite their frequent co-occurrence (Friborg et al., 2013).

In the 11th version of the International Classification of Diseases (ICD-11) put forth by the World Health Organization (WHO), the diagnosis of complex PTSD (CPTSD) was introduced. CPTSD entails meeting the criteria for PTSD and additionally experiencing (1) problems in affect regulation, (2) negative beliefs about oneself, (3) interpersonal difficulties (Cloitre et al., 2019). Moreover, while CPTSD and PTSD share a high comorbidity, they are phenomenologically distinct (Ford & Courtois, 2021). Previous research indicated that adverse childhood experiences, some of which constitute childhood maltreatment, are associated with both, PTSD and CPTSD (Frewen et al., 2019). Another study found that higher severity of childhood maltreatment was associated with CPTSD but not PTSD in trauma-exposed adults (Karatzias et al., 2022). However, the current study was conducted in the Netherlands, where the DSM-5, not the ICD-11, is used for diagnosing mental disorders, which is why we have chosen to focus on PTSD and concurrent symptoms of borderline/cluster C PDs.

Based on the findings described above, we have formulated the following research questions: In patients with PTSD and comorbid symptoms of borderline and/or cluster C PDs, (1) What is the association between types of childhood maltreatment and the severity of PTSD? (2) What is the association between the types of childhood maltreatment and the severity of comorbid borderline PD and cluster C PD symptoms? We expected positive univariate relationships between all types of maltreatment and the severity of PTSD and the severity of comorbid borderline PD symptoms (de Aquino Ferreira et al., 2018; Dovran et al., 2016; Lobbestael et al., 2010; Lortye et al., 2024; Nöthling et al., 2019; Rameckers et al., 2021; Stepp et al., 2016; Waxman et al., 2014; Wu et al., 2022). We expected only sexual and emotional abuse to share independent associations with the severity of PTSD (Lortye et al., 2024; Rameckers et al., 2021). We expected to find a positive association only between emotional abuse and the severity of comorbid symptoms of cluster C PDs (Cohen et al., 2014; Johnson et al., 2001).

2. Methods

2.1. Procedure

Participants were people seeking treatment for PTSD at a trauma-expertise centre in the Netherlands (Sinai centrum) who were included in the Prediction and Outcome Study of PTSD and Personality Disorder (PROSPER) study. In short, participants were randomised to one of two conditions, namely: stand-alone trauma-focused therapy (TFT) or combined trauma-focused and personality disorder treatment. The study design has been described extensively elsewhere (Snoek et al., 2020; van den End et al., 2021). Importantly, after inclusion in the PROSPER study, participants were informed about their allotted treatment condition (a) TFT or (b) TFT combined with PD treatment. For the current study, we used data from the baseline assessment. Considering the baseline data were part of a treatment randomised controlled trial, we opted to control for the allotted treatment condition in all analyses although no treatment had taken place at the time of the baseline assessment. Data for the baseline assessment was collected between May 2018 and September 2022. The inclusion criteria were: (1) age between 18 and 65 years old, (2) meeting diagnostic criteria for PTSD, (3) meeting at least (a) four symptoms of borderline PD, and/or (b) three symptoms of avoidant PD, and/or (c) four symptoms of dependent PD, and/or (d) three symptoms of obsessive-compulsive PD, i.e. one criterion less than required for the diagnosis of each of these PDs according to the DSM-5, (4) sufficient knowledge of Dutch (written and spoken). The exclusion criteria were: (1) current psychosis, (2) severe aggression as indicated by the psychologist conducting the intake at the trauma-expertise centre, (3) primary diagnosis of substance use or eating disorders as measured with the SCID-5-S, (4) primary diagnosis of: paranoid, schizoid, schizotypal, narcissistic, histrionic, or antisocial PD, (5) IQ < 70.

2.2. Childhood trauma questionnaire – short form

The severity of childhood maltreatment was assessed with the Dutch version of the Childhood Trauma Questionnaire – short form (CTQ-sf) (Bernstein et al., 2003). The CTQ-sf consists of 25 items across five subscales: sexual, physical, and emotional abuse, and physical and emotional neglect. Three additional items assess minimization/denial. The five maltreatment scales are answered on a 5-point Likert scale from 1 = never true to 5 = very often true, with higher scores indicating a higher severity of childhood maltreatment. The subscale scores range from 5 to 25. The sum score across all 25 items can be used to calculate the overall severity of childhood maltreatment (range 25–125). The CTQ-sf has been used in research settings and demonstrated good psychometric qualities (Bernstein et al., 2003; Lortye et al., 2024; Rameckers et al., 2021). In the current study, the internal consistency was .91.

2.3. Clinician-administered PTSD scale for DSM 5

The severity of PTSD was assessed with the Dutch version of the Clinician-administered PTSD Scale for DSM-5 (CAPS-5) (Boeschoten et al., 2018; Weathers et al., 2018). The CAPS-5 is a clinical interview that assesses the presence and severity of the four symptom clusters for PTSD (intrusions, avoidance, negative changes in mood and cognition, hyperarousal) across 20 items. Each item is scored on a 5-point Likert scale ranging from 0 = absent to 4 = extreme/incapacitating, resulting in a maximum score of 80, with higher scores indicating a higher severity of PTSD. The CAPS-5 has demonstrated good to excellent psychometric properties in clinical and research settings (Boeschoten et al., 2018; Lortye et al., 2024). In the current study, the internal consistency for the CAPS-5 total score was .79.

2.4. Structured clinical interview for DSM 5 personality disorders

The severity of borderline PD, avoidant PD, dependent PD, and obsessive-compulsive PD symptoms was assessed with the respective modules of the Dutch version of the Structured Clinical Interview for DSM 5 Personality Disorders (SCID-5-PD) (Arntz et al., 2017). Items represent the DSM-5 criteria for the respective PD and are rated on a 3-point scale (0 = criterion absent, 1 = subthreshold, 2 = true/present) by a trained assessor. For diagnosing a PD, only clinically relevant items, i.e. score 2, are counted. We were interested in the number of clinically relevant items for the PD modules under investigation (borderline, avoidant, dependent, obsessive-compulsive). The SCID-5-PD has demonstrated sound psychometric properties, such as good to excellent inter-rater reliability, and is considered the gold standard for the assessment of PDs (Somma et al., 2017; van den End et al., 2024). In the current study, internal consistency for the SCID-5-PD ranged from acceptable to good with .86 for the borderline PD module, .83 for the avoidant PD module, .75 for the dependent PD module, and .67 for the obsessive-compulsive PD module.

3. Analysis

All data analyses were conducted in IBM SPSS version 29. For the descriptive statistics, we inspected only those childhood maltreatment types scored as moderate or severe, i.e. whereby this type of abuse occurred sometimes up until very often (Gerhardt et al., 2022; Lortye et al., 2024; Witt et al., 2017). For all inferential statistics, we used the continuous score of the CTQ – sf (total/subscale). We conducted two-tailed tests with a pre-specified α < .05 for all analyses. All reported R2 are adjusted R2. We verified that our data met all requirements for linear regression (linear relationship, normality of residuals, no outliers, no multicollinearity, homoscedasticity) and Poisson regression (the mean approximately equals the variance, outcome follows a Poisson distribution). For our first research question, we were interested in the univariate effects of (a) overall severity of childhood maltreatment, and (b) severity of the types of childhood maltreatment on the severity of PTSD. We controlled for sex, age, and allotted treatment condition in all analyses. Firstly, we conducted a univariate regression analysis with the overall severity of childhood maltreatment (CTQ total score) as the predictor and the severity of PTSD (CAPS-5 total score) as the outcome. Secondly, we conducted five separate univariate regression analyses with the types of childhood maltreatment (CTQ subscale score) as the predictors and the severity of PTSD (CAPS-5 total score) as the outcome. Predictors that were significant at α < .05 were included in the multiple regression model (last step).

For our second research question, we were interested in the univariate effects of (a) overall severity of childhood maltreatment, and (b) severity of the types of childhood maltreatment on the severity of PD symptoms. The severity of PD symptoms was based on the number of criteria of the SCID-5 that were scored with a 2, making the outcome variable a count-variable. Therefore, we employed Poisson regression with a loglink for the analyses. Before we could conduct the analysis, we checked whether there would be enough cases (n ≥ 100) for the assessment of each PD. The cut-off of n ≥ 100 was based on Simmons et al. (2011), who demonstrated a significant decrease in the chance of finding a false positive when n > 20 per predictor. Given that our main interest concerned the multiple regression model on the influence of the five subtypes of childhood maltreatment, we arrived at 5 × 20 = 100 cases needed per analysis. We found more than n = 100 assessments for borderline PD (n = 191), avoidant PD (n = 170), and obsessive-compulsive PD (n = 159), but not for the dependent PD (n = 85). Therefore, we conducted our analyses on the severity of borderline PD, avoidant PD, and obsessive-compulsive PD symptoms as the respective outcomes. We controlled for sex, age, allotted treatment condition, and severity of the two other PDs under investigation in all analyses. Firstly, we conducted a univariate Poisson regression analysis with the overall severity of childhood maltreatment (CTQ-sf total score) as the predictor and the severity of PD symptoms (number of SCID-5-PD items scored with a 2) as the outcome. Secondly, we conducted five separate univariate Poisson regression analyses with the severity of each type of childhood maltreatment (CTQ-sf subscale score) as the predictor and the severity of PD symptoms as the outcome. Predictors that were significant at α < .05 were included in the multiple regression model.

4. Sample size and power

The current study made use of baseline data of two RCTs and therefore the sample size calculations were based on a between-group design (Snoek et al., 2020; van den End et al., 2021). We have conducted a post-hoc power analysis for the current study based on F2 = .19, N = 197, eight predictors, and α = .05. The post-hoc power analysis indicated a power of 99%.

5. Results

5.1. Participants

Of the N = 254 included participants, n = 52 had missing data on the CTQ-sf and n = 23 had missing data on the CAPS-5. There were significant differences for missingness based on sex (χ2(1) = 15.07, p < .001) with relatively more men missing data. There were no differences between those with complete/missing data based on age, F(1) = 0.64, p = .424. We opted for case-wise deletion in case of missing data on any of these essential measures, resulting in an overall sample size of N = 197 for the analyses. These N = 197 participants were between 19 and 62 years old (M = 38.0, SD = 11.0), and 81.2% (n = 160) were female. Most participants had completed upper secondary education (46.2%), followed by a Bachelor’s degree or an equivalent (25.9%). Most participants did not have children (67%) and lived with a partner (42.6%) or on their own (38.6%). All participants met DSM-5 diagnostic criteria for PTSD based on the CAPS-5 (M = 41.7, SE = 10.7) and n = 159 (80.7%) met full diagnostic criteria for at least one of the PDs under investigation. See Table 1 for an overview of demographic characteristics and Table 2 for an overview of clinical characteristics of the sample.

Table 1.

Demographic characteristics of the N = 197 included participants.

Characteristic M (SD) or N (%)
Age 38.0 (11.0)
Female sex 160 (81.2%)
Educational background  
 Primary education 8 (4.1%)
 Lower secondary education 26 (13.2%)
 Upper secondary education 91 (46.2%)
 Bachelor’s or equivalent 51 (25.9%)
 Master’s or higher 10 (5.1%)
Other 7 (3.6%)
 Employment status  
 Primarily homemaker 15 (7.6%)
 Primarily in education or employed 63 (32.0%)
 Unemployed, no benefits 2 (1.0%)
 Unemployed and receiving disability benefits 48 (24.4%)
 Social benefits 35 (17.8%)
 Other 32 (16.2%)
In a relationship 113 (57.4%)
Living alone 76 (38.6%)
Born in the Netherlands 112 (56.9%)
Born outside of the Netherlands 80 (40.6%)
At least one child 65 (33.0%)
CTQ-sf  
 Total-score 70.4 (20.2)
 Sexual abuse 12.3 (7.0)
 Physical abuse 11.7 (6.3)
 Emotional abuse 16.6 (6.0)
 Physical neglect 11.3 (4.0)
 Emotional neglect 18.6 (4.7)
Open in a new tab

Note: M = mean, SD = standard deviation, CTQ-sf = Childhood Trauma Questionnaire – short form, range 25–125 for the total score and 5–25 for all subscale scores. Not all questionnaire data add up to 100% because of the answer option ‘I cannot/ do not want to disclose this information’. Hereafter we provide the number of data points available per question: age and sex: n = 197, educational background n = 194, employment status: n = 195, relationship, living situation, country of birth, CTQ-sf scores n = 197, at least one child n = 132.

Table 2.

Clinical characteristics of the N = 197 included participants.

Characteristic M (SD) or N (%)
CAPS-5 41.7 (10.7)
One symptom less than required for the diagnosis:  
 Borderline PD 106 (53.8%)
 Avoidant PD 112 (56.9%)
 Dependent PD 8 (8.1%)
 Obsessive-compulsive PD 84 (42.6%)
Full diagnostic criteria  
 Borderline PD 78 (39.6%)
 Avoidant PD 93 (47.0%)
 Dependent PD 4 (2.0%)
 Obsessive-compulsive PD 48 (24.4%)
Open in a new tab

Note: M = mean, SD = standard deviation, CAPS-5 = total score of the Clinician-administered PTSD Scale for DSM-5 (range 0–80), PD = personality disorder. All personality disorders were assessed using the SCID-5-PD.

5.2. Descriptive statistics childhood maltreatment

Emotional neglect was the most prevalent (80.7%), followed by emotional abuse (72.6%), physical neglect (64.5%), sexual abuse (59.4%), and physical abuse (51.3%). The data showed a high degree of poly-victimization: 7.1% reported no childhood maltreatment, 10.7% reported one type, 11.7% reported two types, 16.8% reported three types, 24.9% reported four types, and 28.9% reported five types of childhood maltreatment. In sum, 82.2% of participants reported two or more types of moderate to severe childhood maltreatment. There were several moderate to high correlations between trauma subtypes, the highest between emotional abuse and physical abuse (.55), and between emotional abuse and emotional neglect (.58, see Table 3).

Table 3.

Pearson correlations between subscales of the CTQ-sf (N = 197).

  Sexual abuse Physical abuse Emotional abuse Physical neglect Emotional neglect
Sexual abuse   .33** .17* .15* .14
Physical abuse     .55** .37** .38**
Emotional abuse       .33** .58**
Physical neglect         .43**
Open in a new tab

Note: Significant p-values were denoted as follows: * p < .05, ** p < .01, *** p < .001.

5.3. Effect of childhood maltreatment on PTSD severity

In the univariate regression analyses, the overall severity of childhood maltreatment was significantly associated with the severity of PTSD. The severity of sexual, physical, and emotional abuse and physical and emotional neglect were significantly associated with the severity of PTSD. We proceeded with the multiple regression model that included sexual, physical, and emotional abuse, as well as physical and emotional neglect as predictors, and the severity of PTSD as the outcome (see Table 4 for all models). In this model, only sexual abuse and emotional abuse were significantly associated with the severity of PTSD.

Table 4.

Results of the univariate regression analyses with the severity of PTSD as outcome.

Univariate regression analyses
  β b SE CI95LL-UL t p R2 (%) Zero-order correlation
 Overall severity 0.39 0.21 0.04 0.14–0.28 5.80 <.001*** 15.1 .35
 Sexual abuse 0.31 0.47 0.11 0.26–0.68 4.48 <.001*** 9.6 .29
 Physical abuse 0.27 0.47 0.12 0.23–0.70 3.90 <.001*** 7.5 .23
 Emotional abuse 0.36 0.64 0.12 0.40–0.88 5.24 <.001*** 12.6 .35
 Physical neglect 0.22 0.58 0.20 0.20–0.96 2.97 .003** 4.6 .17
 Emotional neglect 0.21 0.48 0.16 0.16–0.80 2.96 .003** 4.5 .19
Multiple regression analyses
 
 β
 b
 SE
 CI95LL-UL
 t
 p
 R2 (%)
 Partial correlation
 Overall model             15.8  
 Sexual abuse 0.23 0.35 0.11 0.13–0.57 3.18 .002**   .23
 Physical abuse −0.02 −0.03 0.16 −0.35–0.28 −0.19 .847   −.01
 Emotional abuse 0.30 0.55 0.19 0.17–0.92 2.89 .004**   .21
 Physical neglect 0.05 0.14 0.22 −0.29–0.58 0.66 .512   .05
 Emotional neglect −0.04 −0.09 0.20 −0.49–0.31 −0.45 .650   −0.03
Open in a new tab

Note: Analyses were conducted on all N = 197 participants. Overall severity of childhood maltreatment was assessed with the total score of the CTQ-sf (range 25–125). All subtypes of childhood maltreatment were assessed with the respective subscales of the CTQ-sf (range 5–25). Severity of PTSD was assessed with the CAPS-5 (range 0–80). We controlled for sex, age, and allotted treatment condition in all analyses. Significant p-values were denoted as follows: * p < .05, ** p < .01, *** p < .001. β = standardized regression coefficient, b = unstandardised regression coefficient, SE = standard error of the unstandardised regression coefficient, CI95LL – UL = lower limit and upper limit of the 95% confidence interval of the unstandardised regression coefficient.

5.4. Effect of childhood maltreatment on comorbid borderline PD symptoms

The overall severity of childhood maltreatment and emotional abuse were significantly associated with the severity of comorbid borderline PD symptoms (Table 5). We did not proceed with a multiple regression model because we only found one significant univariate (subscale) association.

Table 5.

Results of the univariate analyses with the severity of comorbid borderline PD symptoms as outcome.

Severity of maltreatment b CI95LL-UL p Wald χ2 (df)
Overall severity 0.00 0.00–0.01 .030* 4.70 (1)
Sexual abuse 0.00 −0.01–0.01 .811 0.06 (1)
Physical abuse 0.01 −0.00–0.02 .171 1.87 (1)
Emotional abuse 0.02 0.01–0.04  < .001** 11.14 (1)
Physical neglect 0.01 −0.01–0.03 .166 1.92 (1)
Emotional neglect 0.01 −0.00–0.03 .090 2.88 (1)
Open in a new tab

Note: Analyses were conducted on all N = 197 participants. Overall severity of childhood maltreatment was assessed with the total score of the CTQ-sf (range 25–125). All subtypes of childhood maltreatment were assessed with the respective subscales of the CTQ-sf (range 5–25). Severity of Borderline PD Symptoms was assessed with the SCID-5-PD (range 0–9). We controlled for sex, age, allotted treatment condition, and severity of avoidant – and obsessive-compulsive PD in all analyses. Significant p-values were denoted as follows: * p < .05, ** p < .01, *** p < .001. CI95LL – UL = lower limit and upper limit of the 95% confidence interval, df = degrees of freedom.

5.5. Effect of childhood maltreatment on comorbid avoidant PD symptoms

Only the severity of sexual abuse was significantly associated with the severity of comorbid avoidant PD symptoms. See Table 6 for the results of the univariate analyses.

Table 6.

Results of the univariate analyses with the severity of comorbid avoidant PD symptoms as outcome.

Severity of maltreatment b CI95LL-UL p Wald χ2 (df)
Overall severity 0.00 −0.00–0.01 .757 0.10 (1)
Sexual abuse 0.02 0.01–0.03 .001** 10.41 (1)
Physical abuse −0.01 −0.03–0.00 .090 2.87 (1)
Emotional abuse −0.01 −0.03–0.00 .054 3.72 (1)
Physical neglect 0.02 −0.01–0.04 .160 1.97 (1)
Emotional neglect 0.00 −0.02–0.02 .979 0.00 (1)
Open in a new tab

Note: Analyses were conducted on all N = 197 participants. Overall severity of childhood maltreatment was assessed with the total score of the CTQ-sf (range 25–125). All subtypes of childhood maltreatment were assessed with the respective subscales of the CTQ-sf (range 5–25). Severity of Avoidant PD Symptoms was assessed with the SCID-5-PD (range 0–7). We controlled for sex, age, allotted treatment condition, and severity of borderline – and obsessive-compulsive PD in all analyses. Significant p-values were denoted as follows: * p < .05, ** p < .01, *** p < .001. CI95LL – UL = lower limit and upper limit of the 95% confidence interval, df = degrees of freedom.

5.6. Effect of childhood maltreatment on comorbid obsessive-compulsive PD symptoms

None of the factors investigated were significantly associated with the severity of comorbid obsessive-compulsive PD symptoms (Table 7).

Table 7.

Results of the univariate analyses with the severity of comorbid obsessive-compulsive PD symptoms as outcome

Severity of maltreatment b CI95LL-UL p Wald χ2 (df)
Overall severity −0.00 −0.01–0.00 .492 0.47 (1)
Sexual abuse 0.00 −0.01–0.01 .966 0.00 (1)
Physical abuse −0.00 −0.02–0.02 .999 0.00 (1)
Emotional abuse −0.01 −0.02–0.01 .569 0.33 (1)
Physical neglect −0.02 −0.05–0.00 .079 3.09 (1)
Emotional neglect −0.01 −0.03–0.01 .485 0.49 (1)
Open in a new tab

Note: Analyses were conducted on all N = 197 participants. Overall severity of childhood maltreatment was assessed with the total score of the CTQ-sf (range 25–125). All subtypes of childhood maltreatment were assessed with the respective subscales of the CTQ-sf (range 5–25). Severity of Obsessive-compulsive PD Symptoms was assessed with the SCID-5-PD (range 0–8). We controlled for sex, age, allotted treatment condition, and severity of borderline – and avoidant PD in all analyses. Significant p-values were denoted as follows: * p < .05, ** p < .01, *** p < .001. CI95LL – UL = lower limit and upper limit of the 95% confidence interval, df = degrees of freedom.

6. Discussion

Sexual and emotional abuse were independently associated with the severity of PTSD in the multiple regression model. The overall severity of childhood maltreatment and emotional abuse were associated with the severity of comorbid borderline PD symptoms. Sexual abuse was associated with the severity of comorbid avoidant PD symptoms and none of the childhood maltreatment types were associated with the severity of comorbid obsessive-compulsive PD symptoms.

6.1. Types of childhood maltreatment and PTSD

Our results indicated, that emotional and sexual abuse seem to play a unique and independent role in the development/severity of PTSD, even when accounting for other forms of childhood maltreatment. In line with our results, studies in treatment-seeking adults demonstrated that sexual and emotional abuse were the two optimal predictors for the severity of PTSD (Lortye et al., 2024). Another clinical study demonstrated that emotional abuse was the only predictor for the severity of PTSD (Rameckers et al., 2021). Also, studies in treatment-seeking adolescents have provided evidence that, when accounting for other types of childhood maltreatment, emotional abuse emerges as the only relevant predictor for the severity of PTSD (Hoeboer et al., 2021). In contrast, past research demonstrated that other types of childhood maltreatment (physical abuse, physical and emotional neglect) were also associated with the severity of PTSD (Dovran et al., 2016). However, in that study, the abuse-maltreatment types led to greater odds ratios (3.8–4.9) for PTSD than the neglect types (2.4–3.1). Moreover, other studies that found a relationship between childhood physical abuse and the severity of PTSD (symptoms) were conducted in veteran samples (Fritch et al., 2010) and community-dwelling adults (Nöthling et al., 2019), potentially indicating that these relationships could be sample-specific. In sum, when accounting for all types of childhood maltreatment, emotional and sexual abuse seem to contribute the most to the severity of PTSD in patients with comorbid PD symptoms. Since current therapies are not focused on non-A-criterion trauma, treatments for trauma-related disorders should be adapted and their effectiveness should be studied in the case of emotional abuse.

6.2. Types of childhood maltreatment and borderline PD

Our results indicated that the severity of overall childhood maltreatment and childhood emotional abuse were associated with the severity of comorbid borderline PD symptoms. This was in contrast to our hypothesis since we expected that all types of childhood maltreatment would be associated with severity of comorbid borderline PD symptoms. The evidence for the association between childhood emotional abuse and the severity of borderline PD (symptoms) comes largely from older studies in both clinical and community-based samples (Battle et al., 2004; Johnson et al., 2001). Our results highlight the importance of childhood emotional abuse as a contributing factor to the severity of borderline PD symptoms in a clinical sample. Although a previous systematic review has linked physical abuse with the severity of borderline PD (Stepp et al., 2016), the review also included several studies in clinical samples that failed to find an association between childhood physical abuse and borderline PD (Battle et al., 2004; Thatcher et al., 2005). The evidence for the association between emotional and physical neglect and the severity of borderline PD (symptoms) also comes from community/mixed samples (Lobbestael et al., 2010; Tyrka et al., 2009; Waxman et al., 2014; Wu et al., 2022). The vast majority of research on the relationship between childhood maltreatment and the presence of borderline PD (symptoms) has focused on sexual abuse as indicated by several meta-analyses and systematic reviews (de Aquino Ferreira et al., 2018; Hailes et al., 2019). It could be that childhood sexual abuse is related to the presence of borderline PD but not to an increased severity in symptoms of borderline PD.

6.3. Types of childhood maltreatment and avoidant PD

We expected and failed to find a positive association between emotional abuse and the severity of comorbid avoidant PD symptoms (Afifi et al., 2011; Battle et al., 2004; Cohen et al., 2014; Waxman et al., 2014). Our finding that childhood sexual abuse was associated with greater severity of comorbid avoidant PD symptoms is not in line with previous literature that failed to find this association in both clinical and population-based samples (Battle et al., 2004; Waxman et al., 2014). However, given the scarcity of research on this relationship these results need to be interpreted with caution. Moreover, we have demonstrated the relationship between childhood sexual abuse and the severity of comorbid avoidant PD symptoms in a sample wherein all participants met full diagnostic criteria for PTSD. As mentioned before, sexual abuse fulfils the A-criterion so the inclusion criteria for the current study may have inflated the proportion of people with symptoms of an avoidant PD who experienced childhood sexual abuse. Only two previous studies have investigated and failed to find a relationship between physical abuse, physical neglect, emotional neglect, and the severity of avoidant PD (symptoms) (Lobbestael et al., 2010; Waxman et al., 2014). These findings need to be interpreted with caution, the decade that has passed since they were published, implicating a need for replication within the current diagnostic framework.

6.4. Types of childhood maltreatment and obsessive-compulsive PD

We expected and failed find a positive association between emotional abuse and the severity of comorbid obsessive-compulsive PD symptoms. This expectation was based on studies that have found evidence for the association between emotional abuse and obsessive-compulsive PD in clinical and community-based samples (Cohen et al., 2014; Johnson et al., 2001). At the same time, other studies in epidemiological, population-based, and clinical samples have failed to find a relationship between emotional abuse and cluster C PDs (Afifi et al., 2011; Battle et al., 2004; Waxman et al., 2014). Our finding that neither sexual or physical abuse nor physical or emotional neglect were associated with the severity of comorbid obsessive-compulsive PD (symptoms) is in line with previous research (Battle et al., 2004; Lobbestael et al., 2010; Waxman et al., 2014). The discrepancy of our findings and the previous studies may be related to the different types of samples under investigation as they ranged from epidemiological to community, and clinical samples.

6.5. Strengths and limitations

The current study has several strengths, such as clinical data of patients seeking treatment for PTSD with comorbid borderline and/or cluster C PD symptoms. This population has rarely been studied in previous research, making our findings valuable for understanding the relationships between childhood maltreatment, PTSD and comorbid PD symptoms in a clinical setting. Second, we used the gold-standard clinician-administered assessments for PTSD (CAPS-5) and PD symptoms (SCID-5-PD). Moreover, the study examined the impact of types of childhood maltreatment separately, allowing for a more nuanced understanding of their effects on PTSD and comorbid PD symptoms. Several limitations need to be considered. First, the study used a retrospective self-report questionnaire to measure childhood maltreatment, which may be influenced by recall bias (Coughlin, 1990). In addition, current PTSD symptoms might influence the self-report of types of childhood maltreatment (Hoeboer et al., 2021). Nevertheless, self-reports of patients seem to be a reliable indicator of childhood maltreatment compared to reports via other sources (Winegar & Lipschitz, 1999). Second, given the cross-sectional nature of the study, we cannot draw conclusions about the directionality nor causality of the relationship between childhood maltreatment and PTSD or comorbid PD symptoms. Third, while the SCID-5-PD is the gold-standard instrument for assessing personality disorders, it does not provide a continuous score for the severity of personality disorders. This may be complicated further by our use of a heterogeneous sample, wherein 19.3% did not meet full-diagnostic criteria for any of the PDs under investigation. Fourth, the high rates of comorbidity and poly-victimization in our sample might complicate the isolation of effects from specific maltreatment types on PTSD or comorbid PD symptoms. Our analysis showed that 82.2% of the patients experienced two or more types of childhood maltreatment, indicating a high degree of poly-victimization. No assumptions were violated due to this overlap. The high degree of poly-victimization reflects real-world experiences but could make it challenging to disentangle the unique effects of specific maltreatment types. Additionally, we have used the gold-standard of diagnostic instruments that are based on the DSM-5, not the ICD-11. Therefore, we cannot draw any conclusions about the potential presence of alternative constructs, such as CPTSD, in the current sample. We encourage future studies to investigate the effect of childhood maltreatment on PTSD/CPTSD/PDs to highlight potential overlap and differences, similar to Ford & Courtois, 2021. Another potential limitation of the current study is the focus on borderline PD/cluster C PDs, leaving a knowledge gap regarding cluster A PDs and the other cluster B PDs. We encourage future studies to investigate the relationship between childhood maltreatment and the severity/presence of cluster A PDs.

7. Conclusion

Childhood emotional and sexual abuse were the main contributors to the severity of PTSD. Emotional abuse, which typically does not meet the A-criterion of PTSD, should therefore be routinely assessed during treatment for trauma-related disorders. A potential implication could be the adaptation of treatment for trauma-related disorders to address emotional abuse and the subsequent evaluation of the effectiveness of this approach in future randomised controlled trials. Emotional abuse also predicted the severity of comorbid borderline PD symptoms, further underlining the role of early adverse experiences in the etiology of borderline PD (symptoms). Sexual abuse emerged as a predictor for comorbid avoidant PD symptoms, suggesting that also, some cluster C PDs may be related to early adverse experiences. In sum, research on cluster C PD is, besides inconclusive, extremely limited. Therefore, more research should focus on the predictors of cluster C PDs. Given the importance of emotional abuse and its association with the severity of PTSD and borderline PD, future research should investigate the working mechanisms that link childhood emotional abuse to PTSD and (symptoms of) borderline PD. Potential working mechanisms that link exposure to emotional abuse and adulthood psychopathology are the development of maladaptive schemas that lead to internalising behaviour and misattribution of guilt to the maltreated child as opposed to the perpetrator (Rameckers et al., 2021). Another possibility is that childhood maltreatment may be associated with the development of factors, such as difficulties with emotion regulation, a distorted view of the self- and others, and higher reactivity to future stress, which may function as vulnerabilities for the development of both, PTSD and PD (Gunderson & Sabo, 1993). Additionally, qualitative research with lived experience experts could be helpful in generating hypotheses regarding the potential working mechanisms linking emotional abuse with PTSD/symptoms of PDs.

Acknowledgements

The authors would like to offer their sincere gratitude to Arne van den End, Aishah Snoek, and Inga Aarts for their tireless efforts during data collection and Nick Lommerse for his support in data management and clean-up.

Funding Statement

The work was supported by the Dutch Victim Support Fund (Fonds Slachtofferhulp) under grant 21.12.40 awarded to Marleen de Waal and Kathleen Thomaes, and the Stichting Steunfonds Joodse Geestelijke Gezondheidszorg awarded to Kathleen Thomaes.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethical standards statement

The current study was approved by the Medical Ethical Committee of the Amsterdam University Medical Center, reference number 2017.335.

Participant consent statement

Participants signed a written informed consent form before the data collection started.

Data availability statement

The data that support the findings of this study are available from the corresponding author, CK, upon reasonable request.

References

  1. Afifi, T. O., Mather, A., Boman, J., Fleisher, W., Enns, M. W., MacMillan, H., & Sareen, J. (2011). Childhood adversity and personality disorders: Results from a nationally representative population-based study. Journal of Psychiatric Research, 45(6), 814–822. 10.1016/j.jpsychires.2010.11.008 [DOI] [PubMed] [Google Scholar]
  2. American Psychiatric Association . (2013). Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.). American Psychiatric Publishing, a division of American Psychiatric Association. [Google Scholar]
  3. Arntz, A., Kamphuis, J. H., & Derks, J. (2017). Gestructureerd Klinisch Interview Voor DSM-5 Persoonlijkheidsstoornissen [SCID-5-P: Structured clinical interview for DSM-5 personality disorders]. Boom. [Google Scholar]
  4. Battle, C. L., Shea, M. T., Johnson, D. M., Yen, S., Zlotnick, C., Zanarini, M. C., Sanislow, C. A., Skodol, A. E., Gunderson, J. G., Grilo, C. M., McGlashan, T. H., & Morey, L. C. (2004). Childhood maltreatment associated with adult personality disorders: Findings from the Collaborative Longitudinal Personality Disorders Study. Journal of Personality Disorders, 18(2), 193–211. 10.1521/pedi.18.2.193.32777 [DOI] [PubMed] [Google Scholar]
  5. Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D., Ahluvalia, T., Stokes, J., Handelsman, L., Medrano, M., Desmond, D., & Zule, W. (2003). Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse & Nelgect, 27(2), 169–190. 10.1016/S0145-2134(02)00541-0 [DOI] [PubMed] [Google Scholar]
  6. Boeschoten, M. A., Van der Aa, N., Bakker, A., Ter Heide, F. J. J., Hoofwijk, M. C., Jongedijk, R. A., Van Minnen, A., Elzinga, B. M., & Olff, M. (2018). Development and evaluation of the dutch clinician-administered PTSD scale for DSM-5 (CAPS-5). European Journal of Psychotraumatology, 9(1), 1546085. 10.1080/20008198.2018.1546085 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Brown, C. L., Yilanli, M., & Rabbitt, A. L. (2024). Child physical abuse and neglect. In StatPearls (pp. 1). StatPearls Publishing Copyright © 2024, StatPearls Publishing LLC. [PubMed] [Google Scholar]
  8. Clarke, S. B., Rizvi, S. L., & Resick, P. A. (2008). Borderline personality characteristics and treatment outcome in cognitive-behavioral treatments for PTSD in female rape victims. Behavior Therapy, 39(1), 72–78. 10.1016/j.beth.2007.05.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M. (2019). ICD-11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: A population-based study. Journal of traumatic stress, 32(6), 833–842. 10.1002/jts.22454 [DOI] [PubMed] [Google Scholar]
  10. Cohen, L. J., Tanis, T., Bhattacharjee, R., Nesci, C., Halmi, W., & Galynker, I. (2014). Are there differential relationships between different types of childhood maltreatment and different types of adult personality pathology? Psychiatry Research, 215(1), 192–201. 10.1016/j.psychres.2013.10.036 [DOI] [PubMed] [Google Scholar]
  11. Coughlin, S. S. (1990). Recall bias in epidemiologic studies. Journal of Clinical Epidemiology, 43(1), 87–91. 10.1016/0895-4356(90)90060-3 [DOI] [PubMed] [Google Scholar]
  12. da Silva, H. C., Vilete, L., Coutinho, E. S. F., Luz, M. P., Mendlowicz, M., Portela, C. M., Figueira, I., Ventura, P., Mari, J. J., Quintana, M. I., Ribeiro, W. S., Andreoli, S. B., & Berger, W. (2024). The role of childhood cumulative trauma in the risk of lifetime PTSD: An epidemiological study. Psychiatry Research, 336, 115887. 10.1016/j.psychres.2024.115887 [DOI] [PubMed] [Google Scholar]
  13. de Aquino Ferreira, L. F., Queiroz Pereira, F. H., Neri Benevides, A. M. L., & Aguiar Melo, M. C. (2018). Borderline personality disorder and sexual abuse: A systematic review. Psychiatry Research, 262, 70–77. 10.1016/j.psychres.2018.01.043 [DOI] [PubMed] [Google Scholar]
  14. Dovran, A., Winje, D., Øverland, S., Arefjord, K., Hansen, A., & Waage, L. (2016). Childhood maltreatment and adult mental health. Nordic Journal of Psychiatry, 70(2), 140–145. 10.3109/08039488.2015.1062142 [DOI] [PubMed] [Google Scholar]
  15. Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglected component in child victimization. Child Abuse & Neglect, 31(1), 7–26. Epub 2007 Jan 16. 10.1016/j.chiabu.2006.06.008 [DOI] [PubMed] [Google Scholar]
  16. Ford, J. D., & Courtois, C. A. (2021). Complex PTSD and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 8(1), 16. 10.1186/s40479-021-00155-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Frewen, P., Zhu, J., & Lanius, R. (2019). Lifetime traumatic stressors and adverse childhood experiences uniquely predict concurrent PTSD, complex PTSD, and dissociative subtype of PTSD symptoms whereas recent adult non-traumatic stressors do not: results from an online survey study. European Journal of Psychotraumatology, 10(1), 1606625. 10.1080/20008198.2019.1606625 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Friborg, O., Martinussen, M., Kaiser, S., Overgård, K. T., & Rosenvinge, J. H. (2013). Comorbidity of personality disorders in anxiety disorders: A meta-analysis of 30 years of research. Journal of Affective Disorders, 145(2), 143–155. 10.1016/j.jad.2012.07.004 [DOI] [PubMed] [Google Scholar]
  19. Fritch, A. M., Mishkind, M., Reger, M. A., & Gahm, G. A. (2010). The impact of childhood abuse and combat-related trauma on post deployment adjustment. Journal of Traumatic Stress, 23(2), 248–254. 10.1002/jts.20520 [DOI] [PubMed] [Google Scholar]
  20. Gerhardt, S., Eidenmueller, K., Hoffmann, S., Bekier, N. K., Bach, P., Hermann, D., Koopmann, A., Sommer, W. H., Kiefer, F., & Vollstädt-Klein, S. (2022). A history of childhood maltreatment has substance- and sex-specific effects on craving during treatment for substance use disorders. Frontiers in Psychiatry, 13. 10.3389/fpsyt.2022.866019 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Gunderson, J. G., & Sabo, A. N. (1993). The phenomenological and conceptual interface between borderline personality disorder and PTSD. American Journal of Psychiatry, 150(1), 19–27. 10.1176/ajp.150.1.19 [DOI] [PubMed] [Google Scholar]
  22. Hailes, H. P., Yu, R., Danese, A., & Fazel, S. (2019). Long-term outcomes of childhood sexual abuse: An umbrella review. The Lancet Psychiatry, 6(10), 830–839. 10.1016/s2215-0366(19)30286-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Heffernan, K., & Cloitre, M. (2000). A comparison of posttraumatic stress disorder with and without borderline personality disorder among women with a history of childhood sexual abuse: Etiological and clinical characteristics. The Journal of nervous and mental disease, 188(9), 589–595. 10.1097/00005053-200009000-00005 [DOI] [PubMed] [Google Scholar]
  24. Hoeboer, C., de Roos, C., van Son, G. E., Spinhoven, P., & Elzinga, B. (2021). The effect of parental emotional abuse on the severity and treatment of PTSD symptoms in children and adolescents. Child Abuse & Neglect, 111, 104775. 10.1016/j.chiabu.2020.104775 [DOI] [PubMed] [Google Scholar]
  25. Johnson, J. G., Cohen, P., Smailes, E. M., Skodol, A. E., Brown, J., & Oldham, J. M. (2001). Childhood verbal abuse and risk for personality disorders during adolescence and early adulthood. Comprehensive Psychiatry, 42(1), 16–23. 10.1053/comp.2001.19755 [DOI] [PubMed] [Google Scholar]
  26. Karatzias, T., Shevlin, M., Ford, J. D., Fyvie, C., Grandison, G., Hyland, P., & Cloitre, M. (2022). Childhood trauma, attachment orientation, and complex PTSD (CPTSD) symptoms in a clinical sample: Implications for treatment. Development and Psychopathology, 34(3), 1192–1197. 10.1017/S0954579420001509 [DOI] [PubMed] [Google Scholar]
  27. Lobbestael, J., Arntz, A., & Bernstein, D. P. (2010). Disentangling the relationship between different types of childhood maltreatment and personality disorders. Journal of Personality Disorders, 24(3), 285–295. 10.1521/pedi.2010.24.3.285 [DOI] [PubMed] [Google Scholar]
  28. Lortye, S. A., Will, J. P., Rameckers, S. A., Marquenie, L. A., Goudriaan, A. E., Arntz, A., & de Waal, M. M. (2024). Types of childhood maltreatment as predictors of posttraumatic stress disorder severity and complex posttraumatic stress disorder in patients with substance use disorders. European Journal of Psychotraumatology, 15(1), 2367179. 10.1080/20008066.2024.2367179 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Messman-Moore, T. L., & Bhuptani, P. H. (2017). A review of the long-term impact of child maltreatment on posttraumatic stress disorder and its comorbidities: An emotion dysregulation perspective. Clinical Psychology: Science and Practice, 24(2), 154–169. 10.1111/cpsp.12193 [DOI] [Google Scholar]
  30. Nemeroff, C. B. (2016). Paradise lost: The neurobiological and clinical consequences of child abuse and neglect. Neuron, 89(5), 892–909. 10.1016/j.neuron.2016.01.019 [DOI] [PubMed] [Google Scholar]
  31. Nöthling, J., Suliman, S., Martin, L., Simmons, C., & Seedat, S. (2019). Differences in abuse, neglect, and exposure to community violence in adolescents with and without PTSD and depression. Journal of Interpersonal Violence, 34(21–22), 4357–4383. 10.1177/0886260516674944 [DOI] [PubMed] [Google Scholar]
  32. Pagura, J., Stein, M. B., Bolton, J. M., Cox, B. J., Grant, B., & Sareen, J. (2010). Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population. Journal of Psychiatric Research, 44(16), 1190–1198. 10.1016/j.jpsychires.2010.04.016 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Rameckers, S. A., van Emmerik, A. A. P., Bachrach, N., Lee, C. W., Morina, N., & Arntz, A. (2021). The impact of childhood maltreatment on the severity of childhood-related posttraumatic stress disorder in adults. Child Abuse & Nelgect, 120, 105208. 10.1016/j.chiabu.2021.105208 [DOI] [PubMed] [Google Scholar]
  34. Simmons, J. P., Nelson, L. D., & Simonsohn, U. (2011). False-positive psychology: Undisclosed flexibility in data collection and analysis allows presenting anything as significant. Psychological Science, 22(11), 1359–1366. 10.1177/0956797611417632 [DOI] [PubMed] [Google Scholar]
  35. Snoek, A., Beekman, A. T. F., Dekker, J., Aarts, I., van Grootheest, G., Blankers, M., Vriend, C., van den Heuvel, O., & Thomaes, K. (2020). A randomized controlled trial comparing the clinical efficacy and cost-effectiveness of eye movement desensitization and reprocessing (EMDR) and integrated EMDR-Dialectical Behavioural Therapy (DBT) in the treatment of patients with post-traumatic stress disorder and comorbid (Sub)clinical borderline personality disorder: study design. BMC Psychiatry, 20(1), 396. 10.1186/s12888-020-02713-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Somma, A., Borroni, S., Maffei, C., Besson, E., Garbini, A., Granozio, S., Limuti, B., Perego, G., Pietrobon, A., & Rugi, C. (2017). Inter-rater reliability of the Italian translation of the structured clinical interview for DSM-5 personality disorders (SCID-5-PD): A study on consecutively admitted clinical adult participants. Journal of Psychopathology, 23(3), 105–111. [Google Scholar]
  37. Stepp, S. D., Lazarus, S. A., & Byrd, A. L. (2016). A systematic review of risk factors prospectively associated with borderline personality disorder: Taking stock and moving forward. Personality Disorders: Theory, Research, and Treatment, 7(4), 316–323. 10.1037/per0000186 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Thatcher, D. L., Cornelius, J. R., & Clark, D. B. (2005). Adolescent alcohol use disorders predict adult borderline personality. Addictive Behaviors, 30(9), 1709–1724. 10.1016/j.addbeh.2005.07.008 [DOI] [PubMed] [Google Scholar]
  39. Tyrka, A. R., Wyche, M. C., Kelly, M. M., Price, L. H., & Carpenter, L. L. (2009). Childhood maltreatment and adult personality disorder symptoms: Influence of maltreatment type. Psychiatry Research, 165(3), 281–287. 10.1016/j.psychres.2007.10.017 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Van Den Bosch, L. M., Verheul, R., Langeland, W., & Van Den Brink, W. (2003). Trauma, dissociation, and posttraumatic stress disorder in female borderline patients with and without substance abuse problems. Australian and New Zealand Journal of Psychiatry, 37(5), 549–555. 10.1046/j.1440-1614.2003.01199.x [DOI] [PubMed] [Google Scholar]
  41. van den End, A., Beekman, A. T. F., Dekker, J., Aarts, I., Snoek, A., Blankers, M., Vriend, C., van den Heuvel, O. A., & Thomaes, K. (2024). Trauma-focused and personality disorder treatment for posttraumatic stress disorder and comorbid cluster C personality disorder: A randomized clinical trial. European Journal of Psychotraumatology, 15(1), 2382652. 10.1080/20008066.2024.2382652 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. van den End, A., Dekker, J., Beekman, A. T. F., Aarts, I., Snoek, A., Blankers, M., Vriend, C., van den Heuvel, O. A., & Thomaes, K. (2021). Clinical efficacy and cost-effectiveness of imagery rescripting only compared to imagery rescripting and schema therapy in adult patients with PTSD and comorbid Cluster C personality disorder: Study design of a randomized controlled trial [Study Protocol]. Frontiers in Psychiatry, 12: 633614. 10.3389/fpsyt.2021.633614 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Waxman, R., Fenton, M. C., Skodol, A. E., Grant, B. F., & Hasin, D. (2014). Childhood maltreatment and personality disorders in the USA: Specificity of effects and the impact of gender. Personality and Mental Health, 8(1), 30–41. 10.1002/pmh.1239 [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Weathers, F. W., Bovin, M. J., Lee, D. J., Sloan, D. M., Schnurr, P. P., Kaloupek, D. G., Keane, T. M., & Marx, B. P. (2018). The clinician-administered PTSD scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans. Psychological Assessment, 30(3), 383–395. 10.1037/pas0000486 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Winegar, R. K., & Lipschitz, D. S. (1999). Agreement between hospitalized adolescents’ self-reports of maltreatment and witnessed home violence and clinician reports and medical records. Comprehensive Psychiatry, 40(5), 347–352. 10.1016/S0010-440X(99)90139-6 [DOI] [PubMed] [Google Scholar]
  46. Witt, A., Brown, R. C., Plener, P. L., Brähler, E., & Fegert, J. M. (2017). Child maltreatment in Germany: prevalence rates in the general population. Child and Adolescent Psychiatry and Mental Health, 11(1), 47. 10.1186/s13034-017-0185-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Wu, Y., Zheng, Y., Wang, J., & Zhang, T. (2022). Specific type of childhood trauma and borderline personality disorder in Chinese patients. Frontiers in Psychiatry, 13, 936739. 10.3389/fpsyt.2022.936739 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, CK, upon reasonable request.

Articles from European Journal of Psychotraumatology are provided here courtesy of Taylor & Francis

RESOURCES