- Open Access
Dissociation, trauma, and borderline personality disorder
Borderline Personality Disorder and Emotion Dysregulation volume 9, Article number: 14 (2022)
Dissociation is a complex phenomenon, which occurs in various clinical conditions, including dissociative disorders, (complex) post-traumatic stress disorder (CPTSD, PTSD), and borderline personality disorder (BPD). Traumatic stress is considered an important risk factor, while the etiology of dissociation is still debated. Next to traumatic experiences, temperamental and neurobiological vulnerabilities seem to contribute to the development of dissociation. Stress-related dissociation is a prevalent symptom of BPD, which may interfere with psychosocial functioning and treatment outcome. More research in the field is strongly needed to improve the understanding and management of this complex phenomenon. This article collection brings together research on dissociation and trauma, with a special focus on BPD or sub-clinical expressions of BPD. In this editorial, recent conceptualizations of dissociation and relevant previous research are introduced in order to provide a framework for this novel research.
Dissociation is a complex trans-diagnostic phenomenon, which comprises a wide range of symptoms [1, 2]. It is broadly defined as a discontinuity or disruption of usually integrated functions, such as consciousness, perception, attention, memory, and identity [1, 3]. Psychological symptoms include subjective detachment from the own person (depersonalization) or the environment (derealization), which may be perceived as unreal, blurry, movie-like, or lacking significance. Memory disruptions can range from a diminished ability to access normally amenable information to dissociative amnesia . Somatoform symptoms include altered pain perception (analgesia) and a loss of voluntary motor control . Dissociative experiences exist on a continuum and also occur in non-clinical populations . In clinical settings, dissociation is a core symptom of various disorders, including dissociative disorders (e.g., dissociative identity disorder, DID), (complex) post-traumatic stress disorder (CPTSD, PTSD), and borderline personality disorder (BPD) . Dissociative symptoms may further occur in schizophrenia , major depressive disorder , bipolar disorder  and obsessive-compulsive disorder . The differentiation between dissociative and psychotic symptoms can be challenging [10,11,12]. Many patients who experience pathological dissociation report a long history of hospitalizations and misdiagnoses, before finding adequate treatment [13, 14]. Therefore, it remains of upmost importance to further improve the understanding and management of pathological dissociation [15, 16].
Etiological models of dissociation
The etiology of dissociation is still strongly debated. Most models propose a complex interplay of multiple factors, including genetic neurobiological vulnerabilities, temperamental dispositions, and environmental factors [1, 3]. Currently, two main perspectives exist: trauma models and socio-cognitive models.
Trauma models consider psychological trauma a crucial risk factor in the development of dissociation [17,18,19,20,21]. It has been proposed that dissociation may serve as an (evolutionary-based) defense mechanism to cope with unbearable, overwhelming experiences during a potentially traumatizing event [4, 22, 23]. This initially adaptive response may become maladaptive if generalized to other stressful situations. Dissociation can hinder the integration of emotions, thoughts, and sensations . Salient characteristics of a stressful event may be stored (compartmentalized) as fragmented memories, which can later recur as intrusive flashbacks . Dissociation can also interfere with emotional learning and hinder the acquisition of new information in stressful contexts, e.g., during exposure therapy [25,26,27]. Numerous studies have provided empirical evidence for a link between dissociation and psycho-trauma, including severe childhood maltreatment [18, 19, 28,29,30,31,32,33,34]. A recent meta-analysis found strong associations between dissociation and emotional, sexual, and physical abuse by caregivers. Earlier age of onset, longer duration of abuse, and parental abuse predicted more severe dissociation .
Other researchers point out that trauma is neither a necessary nor sufficient factor for the development of dissociation and question the direct causal link between the two. Socio-cognitive models emphasize the role of cognitive predispositions (e.g., fantasy-proneness, suggestibility, hyper-associativity) social factors (e.g., media influences, questioning techniques) [34, 35] and sleep disturbances . These variables may contribute to the way individuals, who are prone to dissociation, perceive stressful events and express emotional experiences and inconsistencies in identity .
Up to now, the etiology of dissociation remains elusive and different views co-exist.
Potential neurobiological mechanisms of dissociation
A growing number of studies have investigated potential neurobiological underpinnings of dissociation, which are not yet fully understood. A recent systematic review of 205 neuroimaging studies suggests that enhanced task-related activity of the inferior frontal gyrus and medial prefrontal cortex may be linked to dissociation . Largely in line with this, another systematic review concluded that functional alterations in frontal regions are most consistently observed in individuals with dissociative symptoms . This may point to an increased recruitment of brain regions implicated in arousal modulation [21, 40]. Further evidence for this idea stems from studies that used script-driven imagery to induce acute dissociative symptoms and study their impact on information processing. Patients with acute dissociation after script-driven imagery showed increased activity in the inferior frontal gyrus during an inhibitory task [25, 26].
With respect to brain structure, decreased volumes in the hippocampus, basal ganglia, and thalamus were most consistently correlated to dissociative symptoms . However, findings are quite diverse and replication studies are strongly needed .
With regards to psychophysiological research, findings are mixed . Some studies suggest that dissociation may be accompanied by changes in heart rate (variability), skin conductance response (SCR), and fear-potentiated startle responses [21, 40]. Individuals with acute dissociation showed reduced startle response [41,42,43], diminished SCR [42, 44] and a decline in heart rate . However, contradictory findings have also been reported [38, 46].
Dissociation in Borderline Personality Disorder (BPD)
The effects of dissociation on psychosocial functioning may depend on the larger psychopathological context, e.g., emotional dysregulation and identity problems [47, 48]. In BPD, stress-related dissociation is a core symptom, closely linked to other features of the disorder [1, 49]. Up to 80% of patients with BPD report transient dissociative symptoms, such as derealization, depersonalization, numbing, and analgesia [1, 50]. The severity of dissociation is correlated to the severity of traumatic experiences [23, 28, 29]. While trauma is an important risk factor for the etiology of BPD in individuals with genetic, temperamental neurobiological vulnerabilities [51,52,53,54,55], non-trauma related pathways are also involved [56, 57]. Dissociation in BPD is closely linked to emotion dysregulation, disturbed identity, and relationship problems.
Emotion dysregulation includes a tendency to experience intense overwhelming emotions. The strength, frequency and intensity of emotional distress was found to increase and decrease along with dissociative symptoms . Dissociation may exaggerate difficulties identifying emotions . During emotional distress, patients with BPD show impulsive decision making  and often use maladaptive strategies to regulate their emotions, e.g., non-suicidal self-injury (NSSI) [61, 62]. Terminating states of dissociation can be a strong motive for NSSI [63, 64]. A recent study suggests that dissociation is linked to pain hyposensitivity in patients with acute BPD, but not in those who show remission .
A novel line of research further suggests that dissociation is linked to reduced body ownership, i.e., the certainty that body parts belong to oneself . In a recent study, female patients with BPD reported significantly lower levels of body awareness and significantly higher levels of body dissociation compared to healthy women. Significant positive correlations between body dissociation, traumatic childhood experiences, and emotion regulation were found .
Identity disturbances are another core domain of BPD. Individuals with the disorder experience rapid changes in self-image and perceived their identity as incoherent, inconsistent, vague, or fragmented [68,69,70]. They also report chronic feelings of emptiness . Sense of self strongly depends on current self-esteem, which is highly unstable under daily life condition [69, 72]. Identity disturbances in BPD show considerable overlap with dissociative symptoms and may be hard to distinguish .
Interpersonal disturbances in BPD involve profound mistrust, rejection hypersensitivity, and strong ambivalence between a need for closeness and a need for autonomy [74,75,76,77]. It is crucial to improve the understanding of dissociation in this context. In intimate relationships, dissociation may reduce assertiveness and lead to a subjective detachment from violent behaviour [78, 79]. There is preliminary evidence that dissociation contributes to sexual revictimization after child sexual abuse, when BPD symptoms and emotion regulation are taken into account . However, much more prospective research is needed to understand how dissociation interferes with interpersonal functioning in BPD. For instance, future studies may investigate how dissociation interferes with intimacy, trust, and the processing of both positive and negative experiences in close relationships.
Methodological challenges and outstanding research questions
Research on dissociation is rapidly increasing, which has considerably improved its understanding. At the same time, the use of different conceptualizations and methodologies hinders the integration and comparison of these findings.
Acute dissociative states should be differentiated from dissociation proneness, i.e., the general tendency to experience dissociation [5, 81]. For both concepts, various validated measures exist, such as the Dissociative Experience Scale (DES, trait dissociation)  Dissociation Stress Scale (DSS, state dissociation  or the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) ). Script-driven imagery may be used to induce acute states of stress [45, 65] and dissociation [25, 26, 85]. In this paradigm, a personal narrative of an autobiographical situation is created. While listening to the script, participants are asked to recall the autobiographical situation as vividly as possible. When combined with other measures (e.g., behavioral, neuropsychological, psychophysiological, neuroimaging outcomes), direct effects of acute dissociation can be studied. These effects may differ from alterations associated with trait dissociation. Sample characteristics (e.g., comorbidities, trauma histories, medication status) may further hinder a straight-forward comparison of results. There is overlap of BPD with complex presentations of PTSD, following repeated interpersonal trauma [86, 87]. A recent study suggests that traumatized women who reported more dissociative symptoms showed more symptoms of both complex PTSD and BPD, as compared to distinct symptom profiles of CPTSD, PTSD, or BPD . More research is needed to investigate how these symptom profiles can be distinguished .
Possible clinical implications
Dissociation can have an impact on treatment, which was most consistently shown for BPD. For PTSD without BPD this may not be the case, according to meta-analytical evidence . In BPD, dissociative symptoms predicted poor response to psychodynamic therapy [91, 92]. More severe dissociation further predicted negative treatment outcome of Dialectical Behaviour Therapy (DBT) in two independent studies [93, 94]. A multilevel meta-analysis of different psychotherapies for BPD suggests that changes in dissociative symptomatology may be harder to achieve, as compared to symptoms of affective instability and overall BPD severity .
At the same time, there is evidence that dissociative symptoms can be successfully targeted during treatment. For instance, an adapted version of DBT for patients with BPD and PTSD, which involves constant monitoring and management of dissociation, resulted in better treatment outcomes, compared to standard DBT, standard Cognitive Processing Therapy, and control treatment [15, 96,97,98,99]. Evidence-based treatments for BPD, such as DBT, Mentalization-Based Treatment (MBT), Schema-Focused Therapy (SFT), and Transference-Focused Psychotherapy (TFP) target emotion dysregulation and identity problems. Thereby, they may either directly or indirectly improve dissociation [100, 101]. In a prospective follow-up study over 20 years, a decrease of depersonalization and derealization symptoms was strongly associated with overall BPD recovery status .
Overall, the understanding of dissociation and its link to trauma and BPD is steadily increasing. Since dissociation comprises various symptoms and occurs in different psychopathological contexts, a careful assessment of symptoms may help to further deepen this knowledge. In BPD, dissociation is closely linked to other symptoms, such as emotion dysregulation, disrupted identity, and interpersonal disturbances. This may interfere with affective-cognitive functioning (e.g., interference inhibition), body perception, and treatment. Neurobiological findings are still diverse but hint towards increased activity in frontal regions (e.g., inferior frontal gyrus) and temporal areas during dissociative states. Differences in the definition and assessment of dissociation as well as sample characteristics (e.g., comorbidities, trauma history) hinder a straightforward interpretation and comparison of results. Given this complexity, more research, including longitudinal designs with multiple measures, is strongly needed.
Availability of data and materials
American Psychiatric Association. Diagnostic and statistical manual of mental disorders : DSM-5. 5th ed. Arlington: American Psychiatric Association Press; 2013.
Lyssenko L, Schmahl C, Bockhacker L, Vonderlin R, Bohus M, Kleindienst N. Dissociation in psychiatric disorders: a Meta-analysis of studies using the dissociative experiences scale. Am J Psychiatry. 2018;175(1):37–46.
Spiegel D, Loewenstein RJ, Lewis-Fernández R, Sar V, Simeon D, Vermetten E, et al. Dissociative disorders in DSM-5. Depress Anxiety. 2011;28(12):E17–45.
Spiegel D, Cardeña E. Disintegrated experience: the dissociative disorders revisited. J Abnorm Psychol. 1991;100(3):366–78.
Waller N, Putnam FW, Carlson EB. Types of dissociation and dissociative types: a taxometric analysis of dissociative experiences. Psychol Methods. 1996;1(3):300–21.
Holowka DW, King S, Saheb D, Pukall M, Brunet A. Childhood abuse and dissociative symptoms in adult schizophrenia. Schizophr Res. 2003;60(1):87–90.
Parlar M, Densmore M, Hall GB, Frewen PA, Lanius RA, McKinnon MC. Relation between patterns of intrinsic network connectivity, cognitive functioning, and symptom presentation in trauma-exposed patients with major depressive disorder. Brain Behav. 2017;7(5):e00664.
Tuineag M, Therman S, Lindgren M, Rouanet M, Nahon S, Bertrand L, et al. Dissociative symptoms as measured by the Cambridge depersonalization scale in patients with a bipolar disorder. J Affect Disord. 2020;263:187–92.
Rufer M, Held D, Cremer J, Fricke S, Moritz S, Peter H, et al. Dissociation as a predictor of cognitive behavior therapy outcome in patients with obsessive-compulsive disorder. Psychother Psychosom. 2006;75(1):40–6.
Laddis A, Dell PF. Dissociation and psychosis in dissociative identity disorder and schizophrenia. J Trauma Dissociation. 2012;13(4):397–413.
Ross CA. Voices: are they dissociative or psychotic? J Nerv Ment Dis. 2020;208(9):658–62.
Schiavone FL, McKinnon MC, Lanius RA. Psychotic-like symptoms and the temporal lobe in trauma-related disorders: diagnosis, treatment, and assessment of potential malingering. Chronic Stress. 2018;2:247054701879704.
Reinders AATS, Marquand AF, Schlumpf YR, Chalavi S, Vissia EM, Nijenhuis ERS, et al. Aiding the diagnosis of dissociative identity disorder: pattern recognition study of brain biomarkers. Br J Psychiatry. 2019;215(3):536–44.
Brand BL, Lanius R, Vermetten E, Loewenstein RJ, Spiegel D. Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5. J Trauma Dissociation. 2012;13(1):9–31.
Bohus M, Kleindienst N, Hahn C, Müller-Engelmann M, Ludäscher P, Steil R, et al. Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in Complex presentations of PTSD in women survivors of childhood abuse: a randomized clinical trial. JAMA Psychiatry. 2020;77(12):1235–45.
Foote B, Van Orden K. Adapting dialectical behavior therapy for the treatment of dissociative identity disorder. Am J Psychother. 2016;70(4):343–64.
Frewen PA, Lanius RA. Trauma-related altered states of consciousness: exploring the 4-D model. J Trauma Dissociation. 2014;15(4):436–56.
Reinders AATS, Veltman DJ. Dissociative identity disorder: out of the shadows at last? Br J Psychiatry. 2021;219(2):413–4.
Dalenberg CJ, Brand BL, Gleaves DH, Dorahy MJ, Loewenstein RJ, Cardeña E, et al. Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychol Bull. 2012;138(3):550–88.
Carlson EB, Dalenberg C, McDade-Montez E. Dissociation in posttraumatic stress disorder part I: definitions and review of research. Psychol Trauma Theory Res Pract Policy. 2012;4(5):479–89.
Lanius RA, Vermetten E, Loewenstein RJ, Brand B, Schmahl C, Bremner JD, et al. Emotion modulation in PTSD: clinical and neurobiological evidence for a dissociative Subtype. Am J Psychiatry. 2010;167(6):640–7.
Schauer M, Elbert T. Dissociation following traumatic stress: etiology and treatment. Z Für Psychol J Psychol. 2010;218(2):109–27.
Vermetten E, Spiegel D. Trauma and dissociation: implications for borderline personality disorder. Curr Psychiatry Rep. 2014;16(2):434.
Lanius RA. Trauma-related dissociation and altered states of consciousness: a call for clinical, treatment, and neuroscience research. Eur J Psychotraumatol. 2015;6(1):27905.
Krause-Utz A, Winter D, Schriner F, Chiu C-D, Lis S, Spinhoven P, et al. Reduced amygdala reactivity and impaired working memory during dissociation in borderline personality disorder. Eur Arch Psychiatry Clin Neurosci. 2018;268(4):401–15.
Winter D, Krause-Utz A, Lis S, Chiu C-D, Lanius RA, Schriner F, et al. Dissociation in borderline personality disorder: disturbed cognitive and emotional inhibition and its neural correlates. Psychiatry Res Neuroimaging. 2015;233(3):339–51.
Paret C, Hoesterey S, Kleindienst N, Schmahl C. Associations of emotional arousal, dissociation and symptom severity with operant conditioning in borderline personality disorder. Psychiatry Res. 2016;244:194–201.
Vonderlin R, Kleindienst N, Alpers GW, Bohus M, Lyssenko L, Schmahl C. Dissociation in victims of childhood abuse or neglect: a meta-analytic review. Psychol Med. 2018;48(15):2467–76.
Tschoeke S, Bichescu-Burian D, Steinert T, Flammer E. History of Childhood Trauma and Association With Borderline and Dissociative Features. J Nerv Ment Dis. 2020; Publish Ahead of Print. Available from: https://journals.lww.com/10.1097/NMD.0000000000001270 [cited 2020 Nov 30].
Dorahy MJ, Brand BL, Şar V, Krüger C, Stavropoulos P, Martínez-Taboas A, et al. Dissociative identity disorder: an empirical overview. Aust N Z J Psychiatry. 2014;48(5):402–17.
Loewenstein RJ. Dissociation debates: everything you know is wrong. Dialogues Clin Neurosci. 2018;20(3):229–42. https://doi.org/10.31887/DCNS.2018.20.3/rloewenstein.
Lynn SJ, Lilienfeld SO, Merckelbach H, Giesbrecht T, McNally RJ, Loftus EF, et al. The trauma model of dissociation: inconvenient truths and stubborn fictions. Comment on Dalenberg et al. (2012). Psychol Bull. 2014;140(3):896–910.
Dalenberg CJ, Brand BL, Loewenstein RJ, Gleaves DH, Dorahy MJ, Cardeña E, et al. Reality versus fantasy: reply to Lynn et al. (2014). Psychol Bull. 2014;140(3):911–20.
Lynn SJ, Maxwell R, Merckelbach H, Lilienfeld SO, van Kloet D. H der, Miskovic V. Dissociation and its disorders: competing models, future directions, and a way forward. Clin Psychol Rev. 2019;73:101755.
Huntjens RJC, Janssen GPJ, Merckelbach H, Lynn SJ. The link between dissociative tendencies and hyperassociativity. J Behav Ther Exp Psychiatry. 2021;73:101665.
van Heugten−van der Kloet D, Huntjens R, Giesbrecht T, Merckelbach H. Self-reported sleep disturbances in patients with dissociative identity disorder and post-traumatic stress disorder and how they relate to cognitive failures and fantasy proneness. Front Psychiatry. 2014;5 Available from: http://journal.frontiersin.org/article/10.3389/fpsyt.2014.00019/abstract [cited 21 Nov 2020].
Giesbrecht T, Lynn SJ, Lilienfeld SO, Merckelbach H. Cognitive processes in dissociation: an analysis of core theoretical assumptions. Psychol Bull. 2008;134(5):617–47.
Roydeva MI, Reinders AATS. Biomarkers of pathological dissociation: a systematic review. Neurosci Biobehav Rev. 2021;123:120–202. https://doi.org/10.1016/j.neubiorev.2020.11.019.
Lotfinia S, Soorgi Z, Mertens Y, Daniels J. Structural and functional brain alterations in psychiatric patients with dissociative experiences: a systematic review of magnetic resonance imaging studies. J Psychiatr Res. 2020;128:5–15.
Lanius RA, Brand B, Vermetten E, Frewen PA, Spiegel D. The dissociative subtype of posttraumatic stress disorder: rationale, clinical and neurobiological evidence, and implications: dissociative subtype of PTSD. Depress Anxiety. 2012;29(8):701–8.
Ebner-Priemer UW, Badeck S, Beckmann C, Wagner A, Feige B, Weiss I, et al. Affective dysregulation and dissociative experience in female patients with borderline personality disorder: a startle response study. J Psychiatr Res. 2005;39(1):85–92.
Barnow S, Limberg A, Stopsack M, Spitzer C, Grabe HJ, Freyberger HJ, et al. Dissociation and emotion regulation in borderline personality disorder. Psychol Med. 2012;42(4):783–94.
Koenig J, Brunner R, Parzer P, Resch F, Kaess M. The physiological orienting response in female adolescents with borderline personality disorder. Prog Neuro-Psychopharmacol Biol Psychiatry. 2018;86:287–93.
Ebner-Priemer UW, Mauchnik J, Kleindienst N, Schmahl C, Peper M, Rosenthal MZ, et al. Emotional learning during dissociative states in borderline personality disorder. J Psychiatry Neurosci. 2009;34(3):214–22.
Bichescu-Burian D, Steyer J, Steinert T, Grieb B, Tschöke S. Trauma-related dissociation: psychological features and psychophysiological responses to script-driven imagery in borderline personality disorder. Psychophysiology. 2017;54(3):452–61.
Schmitz M, Müller LE, Seitz KI, Schulz A, Steinmann S, Herpertz SC, et al. Heartbeat evoked potentials in patients with post-traumatic stress disorder: an unaltered neurobiological regulation system? Eur J Psychotraumatol. 2021;12(1):1987686.
Scalabrini A, Cavicchioli M, Fossati A, Maffei C. The extent of dissociation in borderline personality disorder: a meta-analytic review. J Trauma Dissociation. 2017;18(4):522–43. https://doi.org/10.1080/15299732.2016.1240738.
Krause-Utz A, Frost R, Chatzaki E, Winter D, Schmahl C, Elzinga BM. Dissociation in borderline personality disorder: recent experimental, neurobiological studies, and implications for future research and treatment. Curr Psychiatry Rep. 2021;23(6):37.
Bohus M, Stoffers-Winterling J, Sharp C, Krause-Utz A, Schmahl C, Lieb K. Borderline personality disorder. Lancet. 2021;398(10310):1528–40. https://doi.org/10.1016/S0140-6736(21)00476-1.
Bohus M, Stoffers-Winterling J, Sharp C, Krause-Utz A, Schmahl C, Lieb K. Borderline personality disorder. Lancet Lond Engl. 2021;398(10310):1528–40.
Porter C, Palmier-Claus J, Branitsky A, Mansell W, Warwick H, Varese F. Childhood adversity and borderline personality disorder: a meta-analysis. Acta Psychiatr Scand. 2020;141(1):6–20.
Mainali P, Rai T, Rutkofsky IH. From child abuse to developing borderline personality disorder into adulthood: exploring the Neuromorphological and epigenetic pathway. Cureus. 2020; Available from: https://www.cureus.com/articles/30035-from-child-abuse-to-developing-borderline-personality-disorder-into-adulthood-exploring-the-neuromorphological-and-epigenetic-pathway [cited 18 Jan 2022].
Luyten P, Campbell C, Fonagy P. Borderline personality disorder, complex trauma, and problems with self and identity: a social-communicative approach. J Pers. 2020;88(1):88–105.
Belsky DW, Caspi A, Arseneault L, Bleidorn W, Fonagy P, Goodman M, et al. Etiological features of borderline personality related characteristics in a birth cohort of 12-year-old children. Dev Psychopathol. 2012;24(1):251–65.
Bozzatello P, Rocca P, Baldassarri L, Bosia M, Bellino S. The role of trauma in early onset borderline personality disorder: a biopsychosocial perspective. Front Psychiatry. 2021;12:721361.
Kleindienst N, Vonderlin R, Bohus M, Lis S. Childhood adversity and borderline personality disorder. Analyses complementing the meta-analysis by Porter et al. (2020). Acta Psychiatr Scand. 2021;143(2):183–4. https://doi.org/10.1111/acps.13256.
Borroni S, Masci E, Franzoni C, Somma A, Fossati A. The co-occurrence of trauma related disorder and borderline personality disorder: AQ study on a clinical sample of patients seeking psychotherapy treatment. Psychiatry Res. 2021;295:113587.
Stiglmayr CE, Ebner-Priemer UW, Bretz J, Behm R, Mohse M, Lammers C-H, et al. Dissociative symptoms are positively related to stress in borderline personality disorder. Acta Psychiatr Scand. 2007;0(0):071120005752001-???
New AS, Rot M, Ripoll LH, Perez-Rodriguez MM, Lazarus S, Zipursky E, et al. Empathy and alexithymia in borderline personality disorder: clinical and laboratory measures. J Personal Disord. 2012;26(5):660–75.
Krause-Utz A, Cackowski S, Daffner S, Sobanski E, Plichta MM, Bohus M, et al. Delay discounting and response disinhibition under acute experimental stress in women with borderline personality disorder and adult attention deficit hyperactivity disorder. Psychol Med. 2016;46(15):3137–49.
Gunderson JG, Herpertz SC, Skodol AE, Torgersen S, Zanarini MC. Borderline personality disorder. Nat Rev Dis Primer. 2018;4(1):18029.
Santangelo P, Reinhard I, Mussgay L, Steil R, Sawitzki G, Klein C, et al. Specificity of affective instability in patients with borderline personality disorder compared to posttraumatic stress disorder, bulimia nervosa, and healthy controls. J Abnorm Psychol. 2014;123(1):258–72.
Sommer JL, Blaney C, Mota N, Bilevicius E, Beatie B, Kilborn K, et al. Dissociation as a Transdiagnostic Indicator of self-injurious behavior and suicide attempts: a focus on posttraumatic stress disorder and borderline personality disorder. J Trauma Stress. 2021;34(6):1149–58.
Kleindienst N, Bohus M, Ludäscher P, Limberger MF, Kuenkele K, Ebner-Priemer UW, et al. Motives for nonsuicidal self-injury among women with borderline personality disorder. J Nerv Ment Dis. 2008;196(3):230–6.
Chung BY, Hensel S, Schmidinger I, Bekrater-Bodmann R, Flor H. Dissociation proneness and pain hyposensitivity in current and remitted borderline personality disorder. Eur J Pain Lond Engl. 2020;24(7):1257–68.
Löffler A, Kleindienst N, Cackowski S, Schmidinger I, Bekrater-Bodmann R. Reductions in whole-body ownership in borderline personality disorder – a phenomenological manifestation of dissociation. J Trauma Dissociation. 2020;21(2):264–77.
Schmitz M, Bertsch K, Löffler A, Steinmann S, Herpertz SC, Bekrater-Bodmann R. Body connection mediates the relationship between traumatic childhood experiences and impaired emotion regulation in borderline personality disorder. Borderline Personal Disord Emot Dysregul. 2021;8(1):17.
Wilkinson-Ryan T. Identity disturbance in borderline personality disorder: an empirical investigation. Am J Psychiatry. 2000;157(4):528–41.
Winter D, Steeb L, Herbert C, Sedikides C, Schmahl C, Bohus M, et al. Lower self-positivity and its association with self-esteem in women with borderline personality disorder. Behav Res Ther. 2018;109:84–93.
Winter D, Koplin K, Lis S. Can’t stand the look in the mirror? Self-awareness avoidance in borderline personality disorder. Borderline Personal Disord Emot Dysregul. 2015;2(1):13.
Miller CE, Townsend ML, Grenyer BFS. Understanding chronic feelings of emptiness in borderline personality disorder: a qualitative study. Borderline Personal Disord Emot Dysregul. 2021;8(1):24.
Santangelo PS, Reinhard I, Koudela-Hamila S, Bohus M, Holtmann J, Eid M, et al. The temporal interplay of self-esteem instability and affective instability in borderline personality disorder patients’ everyday lives. J Abnorm Psychol. 2017;126(8):1057–65.
Campbell SM, Zimmer-Gembeck M, Duffy A. At the junction of clinical and developmental science: associations of borderline identity disturbance symptoms with identity formation processes in adolescence. J Pers Disord. 2021;35(Suppl B):8–28. https://doi.org/10.1521/pedi_2020_34_484.
Liebke L, Koppe G, Bungert M, Thome J, Hauschild S, Defiebre N, et al. Difficulties with being socially accepted: an experimental study in borderline personality disorder. J Abnorm Psychol. 2018;127(7):670–82.
Thome J, Liebke L, Bungert M, Schmahl C, Domes G, Bohus M, et al. Confidence in facial emotion recognition in borderline personality disorder. Personal Disord Theory Res Treat. 2016;7(2):159–68.
Seidl E, Padberg F, Bauriedl-Schmidt C, Albert A, Daltrozzo T, Hall J, et al. Response to ostracism in patients with chronic depression, episodic depression and borderline personality disorder a study using Cyberball. J Affect Disord. 2020;260:254–62.
King-Casas B, Sharp C, Lomax-Bream L, Lohrenz T, Fonagy P, Montague PR. The rupture and repair of cooperation in borderline personality disorder. Science. 2008;321(5890):806–10.
Webermann AR, Brand BL. Mental illness and violent behavior: the role of dissociation. Borderline Personal Disord Emot Dysregul. 2017;4(1):2.
Webermann AR, Murphy CM. Childhood trauma and dissociative intimate partner violence. Violence Women. 2019;25(2):148–66.
Krause-Utz A, Dierick T, Josef T, Chatzaki E, Willem A, Hoogenboom J, et al. Linking experiences of child sexual abuse to adult sexual intimate partner violence: the role of borderline personality features, maladaptive cognitive emotion regulation, and dissociation. Borderline Personal Disord Emot Dysregul. 2021;8(1):10.
Holmes E, Brown R, Mansell W, Fearon R, Hunter E, Frasquilho F, et al. Are there two qualitatively distinct forms of dissociation? A review and some clinical implications. Clin Psychol Rev. 2005;25(1):1–23.
Bernstein EM, Putnam FW. Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis. 1986;174(12):727–35.
Stiglmayr C, Schmahl C, Bremner JD, Bohus M, Ebner-Priemer U. Development and psychometric characteristics of the DSS-4 as a short instrument to assess dissociative experience during neuropsychological experiments. Psychopathology. 2009;42(6):370–4.
Steinberg M, Hall P. The SCID-D diagnostic interview and treatment planning in dissociative disorders. Bull Menn Clin. 1997;61(1):108–20.
Ludäscher P. Pain sensitivity and neural processing during dissociative states in patients with borderline personality disorder with and without comorbid posttraumatic stress disorder: a pilot study. J Psychiatry Neurosci. 2010;35(3):177–84.
Ford JD, Courtois CA. Complex PTSD and borderline personality disorder. Borderline Personal Disord Emot Dysregul. 2021;8(1):16. Published 2021 May 6. https://doi.org/10.1186/s40479-021-00155-9.
Maercker A. Development of the new CPTSD diagnosis for ICD-11. Borderline Personal Disord Emot Dysregul. 2021;8(1):7.
Cyr G, Godbout N, Cloitre M, Bélanger C. Distinguishing among symptoms of posttraumatic stress disorder, complex posttraumatic stress disorder, and borderline personality disorder in a community sample of women. J Trauma Stress. 2022;35(1):186–96. https://doi.org/10.1002/jts.22719.
Ford J D, Courtois C A. Complex PTSD and Borderline Personality Disorder. BPDED. accepted for publication.
Hoeboer CM, De Kleine RA, Molendijk ML, Schoorl M, Oprel DAC, Mouthaan J, et al. Impact of dissociation on the effectiveness of psychotherapy for post-traumatic stress disorder: meta-analysis. BJPsych Open. 2020;6(3):e53.
Spitzer C, Barnow S, Freyberger HJ, Joergen GH. Dissociation predicts symptom-related treatment outcome in short-term inpatient psychotherapy. Aust N Z J Psychiatry. 2007;41(8):682–7.
Wilfer T, Armbrust M, Aalderink T, Spitzer C. Einfluss dissoziativer Phänomene auf das Behandlungsergebnis stationärer Psychotherapie von Patienten mit einer Borderline-Persönlichkeitsstörung. Z Für Psychosom Med Psychother. 2021;67(4):435–50.
Kleindienst N, Limberger MF, Ebner-Priemer UW, Keibel-Mauchnik J, Dyer A, Berger M, et al. Dissociation predicts poor response to Dialectial behavioral therapy in female patients with borderline personality disorder. J Personal Disord. 2011;25(4):432–47.
Kleindienst N, Priebe K, Görg N, Dyer A, Steil R, Lyssenko L, et al. State dissociation moderates response to dialectical behavior therapy for posttraumatic stress disorder in women with and without borderline personality disorder. Eur J Psychotraumatol. 2016;7(1):30375.
Rameckers SA, Verhoef REJ, Grasman RPPP, Cox WR, van Emmerik AAP, Engelmoer IM, et al. Effectiveness of psychological treatments for borderline personality disorder and predictors of treatment outcomes: a multivariate multilevel Meta-analysis of data from all design types. J Clin Med. 2021;10(23):5622.
Bohus M, Dyer AS, Priebe K, Krüger A, Kleindienst N, Schmahl C, et al. Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: a randomised controlled trial. Psychother Psychosom. 2013;82(4):221–33.
Harned MS, Korslund KE, Linehan MM. A pilot randomized controlled trial of dialectical behavior therapy with and without the dialectical behavior therapy prolonged exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behav Res Ther. 2014;55:7–17.
Harned MS, Wilks CR, Schmidt SC, Coyle TN. Improving functional outcomes in women with borderline personality disorder and PTSD by changing PTSD severity and post-traumatic cognitions. Behav Res Ther. 2018;103:53–61.
Kleindienst N, Steil R, Priebe K, Müller-Engelmann M, Biermann M, Fydrich T, et al. Treating adults with a dual diagnosis of borderline personality disorder and posttraumatic stress disorder related to childhood abuse: results from a randomized clinical trial. J Consult Clin Psychol. 2021;89(11):925–36.
Storebo OJ, Stoffers-Winterling JM, Vollm BA, Kongerslev MT, Mattivi JT, Jorgensen MS, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2020;2020(5):CD012955.
Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P. Efficacy of psychotherapies for borderline personality disorder: a systematic review and Meta-analysis. JAMA Psychiatry. 2017;74(4):319–28.
Shah R, Temes CM, Frankenburg FR, Fitzmaurice GM, Zanarini MC. Levels of depersonalization and Derealization reported by recovered and non-recovered borderline patients over 20 years of prospective follow-up. J Trauma Dissociation. 2020;21(3):337–48.
Ethics approval and consent to participate
Consent for publication
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Krause-Utz, A. Dissociation, trauma, and borderline personality disorder. bord personal disord emot dysregul 9, 14 (2022). https://doi.org/10.1186/s40479-022-00184-y
- Borderline personality disorder
- Post-traumatic stress disorder