Does Childhood Trauma Cause Personality Disorders in Adults?
Joel Paris, MD1
Objective: To examine the relationship between trauma in childhood and personality disorders in adulthood.
Method: A review of the literature was conducted.
Results: The reported associations between trauma and personality pathology are illuminated by the following research findings: 1) personality is heritable; 2) only a minority of patients with severe personality disorders report childhood trauma; and 3) children are generally resilient, and traumatic experiences do not consistently lead to psychopathology.
Conclusions: The role of trauma in the personality disorders is best understood in the context of gene–environment interactions.
(Can J Psychiatry 1998;43:148–153)
Key Words: personality disorders, childhood trauma
A large body of empirical research on personality disorders shows that patients with these diagnoses report an unusually high number of traumatic events during their childhood (1,2). Some writers have drawn on these data to conclude that borderline personality disorder (BPD) is a chronic form of posttraumatic stress disorder (3).
The defect with this reasoning is that its data base is correlational. As we all know, but often forget, correlation does not prove causation. The relationships between risk factors and outcomes can often be explained by “latent variables.” For example, although alcoholism is correlated with lung cancer, many people who drink too much also smoke too much (4). In the case of personality disorders, the latent variables can include factors ranging from genetic vulnerabilities to coexisting environmental risks.
Associations between trauma and personality disorders also suffer from a “base rate problem;” that is, the high frequency of childhood trauma in the general population (5). In other words, studies using clinical samples fail to take into account the large number of traumatized children who grow up to be well-functioning adults.
We must be very cautious before concluding that life events have a truly etiological role in mental disorders. Over 30 years ago, Hill argued that to prove any environmental factor causes disease, it must meet the following criteria: strength, consistency, specificity, temporality, biological gradient, and theoretical coherence (6). Regier and Burke have suggested similarly strict criteria: the risk factor must precede the development of pathology and be consistently, strongly, and specifically associated with that disorder (7). Finally, Kraemer and others suggest that risk factors can only be considered causal when they are measured prior to and not after the development of mental disorders (8). None of these criteria is usually met in practice.
The relationships between risk factors and mental disorders are very complex. Even when an environmental event is related to pathology, most exposed individuals will not become ill. Moreover, there are many pathways to the same outcome, and different individuals with the same disorder will have been exposed to different risks. Finally, each risk is only one of many factors implicated in any disorder. Research findings show that a single risk rarely causes illness, and the cumulative effects of multiple risks are needed to cross thresholds between diatheses and disorders (9,10).
Personality Traits and Personality Disorders
Personality pathology is best understood as derived from amplifications of normal traits (2). Individual variations in personality are ubiquitous and usually fall within a normal range. Traits only become pathological when exaggerated to dysfunctional levels.
Trait differences depend strongly on temperament, although they are also shaped by social learning (10). Personality traits, whether defined broadly or narrowly, are strongly heritable, and a genetic component accounts for approximately 40% of the variance in most traits (11–14). Moreover, behavioural genetic research shows that the 60% of the variance which is environmental is largely “unshared” (14). This means that, contrary to popular opinion, personality is not formed by rearing practices in the family but by a multitude of other experiences, which are unique to the individual and derive from experiences outside the family.
Personality is stable over time (15). This stability, which is rooted in temperament, helps to explain the early onset and long-term chronicity of personality disorders. Although there is little continuity between temperament and adult psychopathology in normal populations, extreme or abnormal temperaments are associated with an increased risk for adult mental disorders (16–18). These temperamental abnormalities may be associated with differences in neurotransmitter activity (19).
Personality disorders are much less heritable than traits (20,21). Nonetheless, 1 recent twin study found that genetic factors account for half the variance in borderline and avoidant personality disorders (22). No biological markers have yet been found to account for the mechanisms behind this vulnerability (2). The biological factors in personality probably do not determine whether individuals become disordered, but they set limits on the category of disorder that can develop (2).
The Long-Term Effects of Childhood Trauma
The Principle of Primacy
The assumption that psychopathology is shaped by events during childhood can be termed the primacy of early experience (23). Primacy has been taken for granted by generations of theorists and clinicians. The principle supports certain concepts: 1) early learning must have a stronger impact than later learning; 2) children are more vulnerable than adults; and 3) the more severe the psychopathology, the earlier in life is its origin.
Despite its ubiquity, there is little empirical evidence to support primacy. Early childhood may be no more important than later childhood in personality formation, nor is there good evidence showing that traumatic events in childhood, by themselves, lead to disorders in adulthood (23–25). Rather, the literature shows that negative childhood events are one of many risk factors for psychopathology in adulthood; whether such events go on to produce long-term consequences depends on interactions with other risks and protective factors in development (5,26).
The Long-Term Effects of Negative Experiences
The following general principles can be drawn from research in developmental psychopathology (24): 1) The impact of life experiences is different for different people; 2) children exposed to negative experiences demonstrate resilience; 3) only the cumulative effects of multiple risks overcome resilience; 4) individuals vary in their sensitivity to their environment; and 5) this sensitivity depends on their personality traits.
Resilience is the capacity to emerge intact from negative life experiences. Research on children at risk shows that resilience is the rule, not the exception. In general, only about 25% of children exposed to severe trauma develop demonstrable psychopathology as adults (27).
These findings are not sufficiently well known among clinicians. Practitioners, who only see individuals presenting for treatment, tend to overestimate the impact of traumatic experiences. Community studies, which take into account the frequency of negative experiences in the general population and the circumstances under which experiences lead to long-term consequences, paint a very different picture.
Community Studies of Childhood Trauma
A large number of studies have examined the long-term impact of childhood sexual abuse and childhood physical abuse (28,29). Abuse in childhood does increase the risk for developing psychological symptoms in adulthood. Only one-fifth of adults with histories of childhood sexual or physical abuse, however, develops demonstrable psychopathology. Although some symptoms are statistically more likely to appear in these populations, there is no such thing as a “clinical profile” of an abuse victim.
The long-term sequelae of childhood sexual abuse depend, to some extent, on their severity (28,29). For example, sexual abuse by a family member, most particularly father–daughter incest, causes more sequelae than molestation by nonfamily members. The nature of the sexual act is also important, with penetration being one of the more more traumatic acts. Other parameters associated with long-term consequences include higher frequency, longer duration, and the use of force.
Fortunately, most incidents of child abuse in community populations are of low severity. Moreover, even when severity is taken into account, effects are difficult to predict, with high-risk types of child abuse having only a statistical relationship to outcome.
The sequelae of child abuse depend on covarying psychological risks and the presence or absence of protective factors. Community studies show that many of the sequelae of abuse can be accounted for by dysfunction and neglect in families (30). This is why pedophiles selectively approach children who seem lonely or vulnerable (31). The long-term effects of child abuse also depend on cognitive schemata. When abused children feel stigmatized, self-esteem decreases and the outcome is worse (32). Moreoever, support from the social network makes children much less likely to be negatively affected (33).
The sequelae of physical abuse follow a similar pattern. The often-quoted clinical wisdom that being beaten in childhood leads to violent behaviour in adulthood is a good example of the failure to consider base rates. Although prospectively followed children exposed to violence are statistically more likely to grow up into violent adults, the vast majority never become violent (34).
The sequelae of parental separation during childhood offer another instructive example of the balance between risk and resilience. Long-term outcome is determined not by family breakdown itself, but by the personality traits of the affected child and the quality of family life before the separation, the availability of the noncustodial parent after the separation, decreases in financial resources, changes of domicile, continued conflict between the parents, and depression in the custodial parent (35,36).
Traumatic experiences have their most severe effects on individuals who are already predisposed to psychopathology. This principle has been demonstrated by research on adults with posttraumatic stress disorder. While the short-term effects of trauma are largely mediated by the nature of the event, long-term effects are determined by factors that are intrinsic to the individual (37). Moreover, only about 25% of adults who are exposed to severe trauma develop long-term sequelae (23). In spite of speculations that children are more vulnerable to trauma, the same conclusions apply at all developmental stages (28,29,38,39).
The Problems of Retrospective Methodology
Most of the research on the psychological risk factors for the personality disorders has applied retrospective designs to cross-sectional samples. In other words, most of the data are drawn from interviews of adult patients about their memories of childhood experiences.
Unfortunately, retrospective methods can never establish causality. To study etiology, we need a prospective methodology. We might, for example, gather a cohort of children at risk and follow them into adulthood in order to predict which individuals will develop mental disorders. Such studies are expensive and have therefore been rare. Moreover, none of the studies using this longitudinal method have used personality disorder as an outcome variable (26).
Without corroborating data, one cannot know whether memories of childhood are accurate. Memories tend to be distorted in the light of problems later in life. When life is not going well, there is a strong temptation to blame the past (4). Moreover, it is well known that memories of past events are seriously inaccurate (40).
Recently, the idea that trauma causes repression and that lost memories can be accessed in psychotherapy has attracted the interest of many clinicians (3,41). These ideas, however, are contradicted by a large body of scientific evidence (42–44). Moreover, therapists run the danger of eliciting false memories of trauma in suggestible patients, with hypnosis being particularly problematic in this regard (42,43). Inaccurate memories may be particularly common among patients with personality disorders, who tend to distort recent interactions, both with significant others and with therapists (45).
Obtaining independent validation of patient histories is difficult. The most common method involves interviews with family members (46). The problem is that while siblings may give concordant reports about some aspects of childhood experiences, such as deaths and illnesses, they often disagree about the quality of their upbringing (47). The most likely explanation of this observation is that family life is experienced very differently by children with different personality traits (48).
Although child abuse is more common than we once believed, care must be taken to obtain independent verification of these events (49). Unfortunately, much of this literature, whether using sibling concordance or prospective follow-up of children known to be abused, has suffered from methodological flaws, which makes it impossible to conclude that trauma causes repression (50–52). The safest course for both clinicians and researchers is to accept as valid only those accounts that have never been forgotten by patients (45).
Trauma and Borderline Personality Disorder
With these caveats in mind, let us examine what the literature says about the association between trauma and BPD. First, cross-sectional retrospective studies have found that patients with BPD report an unusually high number of traumatic experiences during childhood, most particularly sexual and physical abuse, and this association has even been found in a nonclinical sample of volunteers with BPD (53–64). Second, in community samples of women who report having been abused as children, the symptoms characteristic of BPD, particularly suicide attempts and problems with intimate relationships, are significantly more prevalent (27). Although this evidence has been taken to support a posttraumatic theory of the etiology of borderline personality, this conclusion is unjustified because of problems in the interpretation of the empirical findings (54,65–67).
Strength of Association
In a recent metaanalysis of all studies of trauma in people with BPD, Fossati and others found that the pooled effect size of this association is 0.27 (only a fair level of strength) (68).
Specificity of Association
There is a large overlap between the frequency of trauma in BPD and other forms of personality disorder, and traumatic histories are also seen in a wide range of other mental disorders (2,61,62).
Role of Parameters
The range of reports of trauma in patients with personality disorders resembles the spectrum of experiences found in community studies, with the vast majority involving single incidents. In patients with BPD, only 25% report severe abuse, with about one-third reporting no abuse at all (61,62).
Interaction With Other Risks
Childhood trauma usually occurs in the context of significant family dysfunction, and most BPD patients describe family dysfunction, including high levels of parental psychopathology, emotional neglect, and family breakdown (1). Child abuse may play a greater role in cases experiencing severe trauma.
The Lack of a Relationship Between Trauma and Symptoms
There are no “markers” for childhood trauma. The idea that dissociation and self-mutilation have this significance is not supported by empirical evidence (1,54). These symptoms are more related to having a BPD diagnosis than to having a traumatic history (69–72). Similar findings emerge with defence styles, or levels of hostility, which are traits related to BPD, rather than to particular childhood experiences (73).
In summary, trauma is neither a necessary nor sufficient condition for the development of personality disorders. The symptoms of personality disorders reflect underlying traits, not specific experiences.
Trauma and Gene–Environment Interactions
The role of trauma in the personality disorders can best be understood in the context of gene–environment interactions. Several lines of evidence support this conclusion.
First, behavioural genetic research demonstrates that temperament determines exposure to negative events (73–76). The parents of BPD patients frequently have impulsive spectrum disorders or depressive spectrum disorders (77). Thus histories of trauma, separation, loss, or abnormal parenting in patients must partly reflect personality traits shared between parents and children. Moreover, impulsive or depressed parents are more likely to inflict trauma on their children or initiate a family breakdown (8). In addition, children with difficult temperaments are more likely to receive poor parenting (78). Finally, children with impulsive dispositions are more difficult to calm down and need more limit-setting and structure from their parents. These predispositions make many of the negative events in childhood reported by adults with personality disorders much more likely to occur.
Second, the quality of life experiences is itself a function of personality. Genetic factors affect the likelihood that negative events will occur, as well as the number and type of these negative events (73,74). The range of life experiences with a heritable component is astonishing: marital problems, divorce, friendships, social supports, problems at work, drug use, socioeconomic status, and education. These findings show that we cannot understand the impact of trauma without factoring in the role of personality traits. Finally, genes influence individual differences in susceptibility to environmental stressors (74). The minority of cases, which exhibit a strong predisposition to psychopathology, are most likely to be affected by trauma. The majority, which exhibit constitutional resilience against trauma, are less affected.
In summary, the relationship between childhood trauma and personality disorders can be best understood in the context of gene–environment interactions, which corresponds to the diathesis–stress theory of psychopathology (2,79). Biological factors, as reflected in trait profiles, determine vulnerability. Psychological and social factors function as precipitants for psychopathology. Thus the psychological risk factors for personality disorders do not depend only on traumatic experiences, but on temperament and the cumulative effects of multiple stressful events.
Childhood trauma does not necessarily lead to adult personality disorders. Negative events are contributing factors to pathology, but not unique causes. The majority of children exposed to trauma are resilient. Children who are most resilient have adaptive personality traits, which increase the likelihood that they will form secure attachments and persist in their goals (27). They are also more likely to have had positive life experiences, which buffer the effects of stressful events (24). Some may even demonstrate “steeling,” defined as increased adaptation as a result of negative experiences (5). These findings are in accord with the role of the “unshared environment” in adult personality and psychopathology (74).
Taking into account the effects of genes does not mean downplaying the effects of childhood trauma. Rather, we need to develop methods to identify children who are particularly vulnerable to environmental insults (80). We need to explain the mechanisms that determine differences between children who are resilient and those who are not.
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Objectif : Examiner la relation entre les traumatismes de l’enfance et les troubles de la personnalité à l’âge adulte.
Méthode : On a réalisé un examen de la littérature.
Résultats : Les associations signalées entre les traumatismes et une pathologie de la personnalité s’expliquent par les résultats de recherche suivants : 1) la personnalité peut être héritée; 2) seule une minorité de patients atteints de troubles de la personnalité fait état de traumatismes de l’enfance; et 3) en général, les enfants sont résistants et les expériences traumatiques n’entraînent pas forcément la psychopathologie.
Conclusions : Le rôle joué par les traumatismes dans les troubles de la personnalité est plus facile à comprendre dans le contexte des interactions entre l’environnement et les gènes.
1Professor of Psychiatry, McGill University, The Sir Mortimer B Davis Jewish General Hospital, Institute of Community and Family Psychiatry, Montreal, Quebec.
Address for correspondence: Dr J Paris, The Sir Mortimer B Davis Jewish General Hospital, Institute of Community and Family Psychiatry, 4333 Chemin de la Côte Ste-Catherine, Montreal, QC H3T 1E4
Can J Psychiatry, Vol 43, March 1998