Differentiating between intrapsychic symptoms and behavioral expressions of borderline personality disorder in relation to childhood emotional maltreatment and emotion dysregulation: an exploratory investigation

ABSTRACT

Background:

Borderline personality disorder (BPD) is a severe mental disorder, characterized by pronounced instability in emotions, self-image, and interpersonal relationships. Experiences of childhood maltreatment are among the risk factors for BPD. While self-damaging and aggressive acts often occur, not every person with the disorder shows markedly dysregulated behaviour. Internalized symptoms, such as shame, loneliness, and self-disgust tend to be more pervasive and persist after clinical remission.

Objective:

Here we investigated associations between BPD symptom severity, childhood maltreatment, and emotion regulation difficulties. We further explored if the Borderline Symptom List (BSL) could potentially be used to differentiate between internalized symptoms (intrapsychic strain) and externalized symptoms (dysregulated behaviours) in future research.

Method:

187 women with at least mild BPD symptoms (65% having a diagnosis of BPD) completed the BSL 23 including its 11-item supplement (BSL-S), the Childhood Trauma Questionnaire (CTQ), and Difficulties in Emotion Regulation Scale (DERS). Participants further underwent a semi-structured clinical interview to assess BPD criteria (International Personality Disorder Examination, IPDE). Multivariate models and regression-based bootstrapping analyses were performed to test direct and indirect effects.

Results:

Childhood trauma severity, especially emotional abuse, positively predicted BPD symptom severity. A significant indirect effect through emotion regulation difficulties was found (k²=.56). When exploring associations with BPD criteria (IPDE), the BSL-23 mean significantly correlated with separation anxiety, identity and mood problems, chronic emptiness, suicidal ideation, and dissociation, while the BSL-S correlated with self-harming impulsive behaviour and anger outbursts.

Conclusions:

Findings complement previous research, highlighting the role of childhood maltreatment and emotion regulation difficulties in BPD. While our findings need to be seen as preliminary and interpreted with caution, they suggest that the BSL may be used to differentiate between internalized symptoms and behavioural expressions of BPD in future research. Such a distinction might help to deepen the understanding of this complex heterogenous disorder.

Highlights

• Severity of borderline personality disorder was related to experiences of childhood maltreatment, mediated by emotion regulation difficulties.

• The Borderline Symptom List might be useful to differentiate between internalizing symptoms and externalizing symptoms associated with borderline personality disorder.

Antecedentes: El trastorno límite de la personalidad (TLP) es un trastorno mental grave, caracterizado por una marcada inestabilidad en las emociones, la autoimagen y las relaciones interpersonales. Las experiencias de maltrato en la infancia se encuentran entre los factores de riesgo del TLP. Aunque a menudo se producen actos autolesivos y agresivos, no todas las personas con el trastorno muestran un comportamiento marcadamente desregulado. Los síntomas internalizantes, como la vergüenza, la soledad y el autodesprecio, tienden a ser más generalizados y persisten tras la remisión clínica.

Objetivo: Investigamos las asociaciones entre la severidad de los síntomas del TLP, el maltrato infantil y las dificultades en la regulación emocional. Además, exploramos si la Lista de Síntomas Límite (BSL por sus siglas en ingles) podría ser potencialmente utilizada para diferenciar entre síntomas internalizantes (tensión intrapsíquica) y síntomas externalizantes (comportamientos desregulados) en futuras investigaciones.

Método: 187 mujeres con al menos síntomas leves de TLP (65% con diagnóstico de TLP) completaron el BSL 23, incluido su suplemento de 11 ítems (BSL-S), el Cuestionario de Trauma Infantil (CTQ) y la Escala de Dificultades en la Regulación de las Emociones (DERS). Además, los participantes se sometieron a una entrevista clínica semiestructurada para evaluar los criterios de TLP (Examen Internacional de Trastornos de la Personalidad, IPDE). Se realizaron modelos multivariantes y análisis bootstrapping basados en regresión para comprobar los efectos directos e indirectos.

Resultados: La gravedad del trauma infantil, especialmente el abuso emocional, predijo positivamente la gravedad de los síntomas del TLP. Se encontró un efecto indirecto significativo a través de las dificultades de la regulación emocional (k² = .56). Al explorar las asociaciones con los criterios de TLP (IPDE), la media del BSL-23 se correlacionó significativamente con la ansiedad por separación, los problemas de identidad y del estado de ánimo, el vacío crónico, la ideación suicida y la disociación, mientras que el BSL-S se correlacionó con la conducta impulsiva autolesiva y los arrebatos de ira.

Conclusiones: Los hallazgos complementan la investigación previa, destacando el papel del maltrato infantil y las dificultades de regulación emocional en el TLP. Aunque nuestros hallazgos deben considerarse preliminares e interpretarse con cautela, sugieren que el BSL puede utilizarse para diferenciar entre los síntomas internalizantes y las expresiones conductuales del TLP en investigaciones futuras. Esta distinción podría ayudar a profundizar en la comprensión de este complejo y heterogéneo trastorno.

背景：边缘性人格障碍（BPD）是一种严重的精神障碍，其特征是情绪、自我形象和人际关系的明显不稳定。 童年期受虐待经历是边缘性人格障碍的风险因素之一。虽然自我伤害和攻击性行为经常发生，但并不是每个患有这种疾病的人都表现出明显的失调行为。羞耻、孤独和自我厌恶等内化症状往往更加普遍，并在临床缓解后持续存在。

目的：在这里，我们考查了 BPD 症状严重程度、童年期虐待和情绪调节困难之间的关联。 我们进一步探讨了边缘症状列表（BSL）是否可以在未来的研究中用于区分内化症状（内心紧张）和外在症状（失调行为）。

方法：187 名至少有轻度 BPD 症状的女性（65% 诊断为 BPD）完成了 BSL 23，包括其 11 条目补充 (BSL-S)、儿童创伤问卷 (CTQ) 和情绪调节困难量表 (DERS）。 参与者进一步接受了半结构化临床访谈，以评估 BPD 标准（国际人格障碍检查，IPDE）。进行多变量模型和基于回归的重新抽样分析来检验直接和间接效应。

结果：童年创伤的严重程度，尤其是情感虐待，可以正向预测 BPD 症状的严重程度。发现情绪调节困难有显著的间接效应（k² = .56）。在探索与 BPD 标准 (IPDE) 的关联时，BSL-23 平均值与分离焦虑、身份和情绪问题、慢性空虚、自杀意念和解离显著相关，而 BSL-S 与自残冲动行为和愤怒爆发相关 。

结论：研究结果补充了之前的研究，强调了童年虐待和情绪调节困难在边缘性人格障碍中的作用。虽然我们的研究结果需要被视为初步的并谨慎解释，表明在未来的研究中，BSL 可用于区分 BPD 的内化症状和行为表达。 这种区别可能有助于加深对这种复杂的异质性疾病的理解。

KEYWORDS:

• Borderline personality disorer
• childhood trauma
• emotion regulation
• trauma
• borderline symptom list

PALABRAS CLAVE:

• Maltrato emocional infantil
• trauma complejo
• trastorno límite de la personalidad

关键词:

• 童年情感虐待
• 复杂性创伤
• 边缘性人格障碍

Acknowledgements

We thank all participants of this study for their crucial contribution. We thank Androniki Nikakis, Behazin Khosravi, and Linnea Ott for their contribution to the pre-processing of the data.

Disclosure statement

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

Data availability

According to European law (GDPR), the sharing of data containing potentially identifying or sensitive information is restricted. Our data involving clinical participants are not freely available in the manuscript, supplemental files, or in a public repository. Data access can be requested on reasonable demand via the corresponding author.

Ethics approval and consent to participate

All subjects have given their written informed consent. The study protocol has been approved by the local Ethical committee of the Mannheim Medical Faculty of Heidelberg University.

Consent for publication

All co-authors gave consent for publication.

Authors’ contributions

RG and AKU designed the study and its rationale, designed the structure of the paper and drafted its first version. CN and AP recruited participants, performed diagnostic interviews and collected self-report data. AR provided theoretical input, performed systematic literature search, and helped with formatting the final manuscript. All authors contributed to the final version of the paper.