Keinänes Et Al (2012) - Factors For Understanding of Personality Disorder

Psychoanalytic Psychotherapy,
Vol. 26, No. 1, March 2012, 6591
A systematic review of the evidence-based psychosocial risk

factors for understanding of borderline personality disorder
Matti T. Keinanena,b*, Jeffrey G. Johnsonc,d, Elizabeth S. Richardsd and
Elizabeth A. Courtneyd
Downloaded by [Matti T. Keinnen] at 13:44 23 February 2012
Finnish Student Health Service, Kirkkotie; bTurku University, Turku, Finland; cColumbia
University, New York, USA; dNew York State Psychiatric Institute,
New York, USA
Borderline personality disorder (BPD) is a serious personality disorder
characterized by affective instability, impulsivity and interpersonal
disturbance. Currently, intensive research is being conducted concerning
the aetiology of BPD, including research on neurobiological, temperamental,
psychosocial and cultural risk factors. This study focuses on psychosocial
risk factors while other risk factors are taken into account in the discussion of
the development of BPD. To our knowledge, no systematic review of the
evidence-based medicine literature concerning this theme has been made
thus far. However, understanding psychosocial risk factors of BPD is
important in order to develop psychotherapeutic treatment models and
methods. We provide a systematic review of the literature focusing on
psychosocial risk factors for BPD. Utilizing this knowledge, we discuss how
these data may be used when studying the development of borderline
personality disorder and the treatment of borderline personality disorder.
Keywords: borderline personality disorder; psychosocial risk factors;
evidence-based medicine; psychotherapy; aetiology
Introduction
BPD is a serious personality disorder characterized by affective instability,
impulsivity and interpersonal disturbance. Currently, intensive research is being
conducted concerning the aetiology of BPD, including research on neurobiological, temperamental, psychosocial and cultural risk factors. This study strictly
focuses on the psychosocial risk factors although other risk factors are taken into
account when discussing the development and the psychodynamic treatment of
borderline personality disorder.
To the best of our knowledge, no systematic review of the evidence-based
medicine (EBM) literature concerning this theme has been made thus far.
However, understanding the psychosocial risk factors of BPD is important in
order to develop psychotherapeutic treatment models and methods (Fonagy,
2010; Fonagy & Bateman, 2008). These evidence-based models would provide
*Corresponding author. Email: matti.keinanen@pp.fimnet.fi

ISSN 0266-8734 print/ISSN 1474-9734 online
q 2012 The Association for Psychoanalytic Psychotherapy in the NHS
http://dx.doi.org/10.1080/02668734.2011.652659
http://www.tandfonline.com
66
M.T. Keinanen et al.
the basis to develop need-adapted treatment methods for BPD. These needadapted treatment methods should then meet specific evidence-based
psychosocial risk factors throughout the whole treatment process, and especially
in the psychotherapeutic process. In this paper we provide a systematic review of
the literature focusing on the psychosocial risk factors for BPD. It is hoped that
this systematic review will be helpful in further understanding BPD and for
further developing psychotherapeutic treatment methods for BPD.
Method
A systematic literature review of recent empirical well-documented cohort and
controlled clinical studies was conducted to identify vulnerability factors that have
been found to be associated with BPD. Psychosocial vulnerability factors were
identified that meet the international evidence-based medicine (EBM) criteria.
According to the international EBM-criteria, papers included in the systematic
review must be well documented cohort or case and control group studies that use
the international ICD-10 or DSM-IV diagnostics, well documented standard patient
interview methods (such as SCID-II) and reliable statistical evaluations (GRADE
Working Group, 2004; Sackett, et al., 2001; Atkins, et al., 2004). To determine
validity, the methods of each study were assessed according to the four primary
criteria for risk factor studies described by the Evidence-Based Medicine Working
Group (Levine, et al., 1994): (1) comparison groups that were similar with respect to
important determinants of outcome, other than the one of interest; (2) measurement
of exposures and outcomes in the same way; (3) a sufficiently long follow-up (i.e.
one year); and (4) a sufficiently complete follow-up (i.e. including 80% of inception
cohort). Each study was scored with respect to meeting () or not meeting (2) each
of these criteria.
The systematic literature search paradigm
The systematic literature searches of psychosocial risk factors for borderline
personality disorder were conducted as a part of a process to make the Practice
Guidelines for the Treatment of Borderline Personality Disorder in Finland. These
original searches were made by a separate data searching information technology
professional of the Duodecim Association of Physicians in Finland; the Duodecim
Association is the official organization which makes the practice guidelines for the
treatment of different diseases in Finland. After completing the literature searches,
all material concerning psychosocial risk factors for BPD was carefully reviewed.
When processing the tables of this paper, the authors of this text carefully reviewed
the psychosocial risk factors again to see if they met EBM-criteria.
The selection of papers
The papers were selected from two computer databases: Medline and PsychInfo.
Search terms were used to systematically search all risk factor studies that met the
Psychoanalytic Psychotherapy
67
international evidence-based medicine (EBM) criteria. For Medline the keywords

borderline personality disorders and risk factors were used to identify the
studies, for PsychInfo, the keywords borderline personality disorder and risk
factors were used to identify the studies. From these searches the literature was
systematically reviewed, only well-documented case and control group or cohort
studies were selected to identify psychosocial vulnerability factors that have been
found to be associated with BPD.
The categorizing of psychosocial risk factors
After reviewing these works, psychosocial vulnerability factors were searched,
identified and categorized from these studies in order to find the factors that
would meet the international EBM-criteria: fulfilling of EBM-criteria means that
there are at least two well-documented case-control based studies from different
patient cohorts giving congruent statistical evidence of the existence of the risk
factor. The systematic review was done by the entire Duodecim group of
researchers, the results were also analysed by the whole Duodecim group and
finally these categories were documented and accepted to fulfill EBM-criteria.
From the basis of this research, the Duodecim group unanimously agreed
upon the five described primary psychosocial risk factors associated with BPD. In
other words, the process for choosing these five risk factors proceeded so that the
team in consensus accepted as an EBM-validated risk factor of best evidence only
such risk factors which were shown to be present in at least two welldocumented case-control based studies from different patient cohorts giving
congruent statistical evidence of the existence of the risk factor as a common
denominator to both of these two studies (see the charts in the Results). All of
these categories are described and listed in the Results.
Results
The five primary psychosocial risk factors associated with BPD
Altogether 51 papers were retrieved from the search and all of these papers are
included in the tables in order to evaluate the risk factors which meet the EBMcriteria of best evidence. Five vulnerability factors were identified and classified
according to the EBM-criteria that clearly meet the EBM-criteria of best evidence:
1. BPD patients often report a history of severe or multi-factorial childhood
traumas and sexual abuse (see BPD Risk Factor Chart 1: Childhood
Trauma/Abuse).
2. BPD is often associated with a history of problematic parenting during
childhood (see BPD Risk Factor Chart 2: Unfavorable Parenting).
3. BPD patients frequently show evidence of hostile object relations (see BPD
Risk Factor Chart 3).
4. BPD patients tend to have insecure attachment relationships (see BPD Risk
Factor Chart 4).
Adult PD patients
(n 524)
Inpatients (n 82)
Controls (n 85)
NA 21 studies
Bradley
(2005)
Fonagy et al.
(1996)
Fossati et al.
(1999)
Herman et al.
(1989)
Johnson et al.
(1999a)
Johnson et al.
(2001)
Subjects with multiple Axis II diagnoses took The

Childhood Trauma Questionnaire (CTQ).
Outpatients (n 182)
Bierer et al.
(2003)
Community sample of
youths
and mothers (n 639)
BPD subjects (n 21)

Subjects with BPD traits
(n 11) Non-BPD subjects with related diagnoses (n 23)
Community mothers
(n 793)
Retrospective interview (203 questions) about

various risk factors for BPD.
Patients (n 66)
Controls (n 109)
Bandelow
et al. (2005)
Longitudinal study, psychiatric and psychosocial

interviews were administered at various points in
time.
Longitudinal study, psychiatric and psychosocial
interviews were administered at various points in
time.
Psychologists and psychiatrists described PD

patients; the contribution of various risk factors
was assessed.
Non-psychotic inpatients and controls were
assessed using the Adult Attachment Interview.
A meta-analysis of the correlation between BPD
and childhood sexual abuse.
Subjects were interviewed about childhood
trauma and abuse.
Method/Study design
Sample size
Author
(Year)
BPD Risk Factor Chart 1: Childhood trauma/abuse
Children who experienced verbal abuse from

their mothers were much more likely to
develop PDs.
People who experienced child abuse and
neglect were much more likely to develop
PDs.
Significantly higher proportion of BDP

patients reported childhood trauma than
control group.
In males emotional abuse was a significant
risk factor for BPD, other types of childhood
trauma were not significant.
Sexual abuse was a significant predictor of
BPD, and was partially mediated by family
environment.
BPD was correlated with trauma and a lack
of resolution of the trauma.
Childhood sexual abuse was not found to be
significantly tied to BPD diagnosis.
Significantly more BPD subjects had
histories of physical abuse, sexual abuse, and
witnessing serious domestic
violence.
Findings
68
Paris et al.
(1994a)
Paris et al.
(1994b)
Paris et al.
(1993)
Minzenberg
et al. (2006a)
Liotti &
Pasquini
(2000)
Lobbestael
et al. (2005)
Laporte &
Guttman
(1996)
BPD subjects with active

diagnosis (n 26) Female
BPD subjects with previous
diagnosis (n 13)
Female BPD subjects
(n 78)
Female Non-BPD subjects
(n 72)
Male BPD outpatients
(n 61)
Male non-BPD outpatients
(n 60)
BPD patients (n 16)

APD
patients (n 16) Controls
(n 16)
BPD Outpatients (n 40)
Female BPD patients

(n 366)
Female other PD patients
(n 385)
BPD patients (n 66)
Controls (n 146)
Risk factors for BPD were assessed using

a developmental interview and the Parental
Bonding Index.
BPD participants were evaluated for adult

attachment and attachment associations with
childhood maltreatment and current symptoms.
Participants who currently met BPD criteria were
compared with participants who had met
diagnostic criteria in the past but no longer did.
Risk factors were assessed with a developmental
interview and the Parental Bonding Index,
Risk factors for BPD were assessed using
a developmental interview and the Parental
Bonding Index.
A correlation between significant traumatic

events and BPD was found.
Using the Infancy Trauma Interview BPD patients

and non-BPD patients in a multicentric hospital
setting were assessed.
BPD, APD and non-patient controls were assessed
using the schema mode questionnaire
(continued)
Childhood Sexual Abuse was a significant

risk factor for BPD.
Childhood Sexual Abuse was a significant

risk factor for BPD.
Adult attachment issues in BPD patients

were strongly correlated with childhood
maltreatment.
Currently diagnosed BPD subjects reported
higher rates of childhood sexual abuse.
BPD and APD patients had equal and

significantly higher rates of childhood abuse
than controls.
BPD patients experienced more abuse than

other PD patients.
Psychiatric records of discharged patients with PD

diagnoses were examined for childhood trauma.
69
Clinical diagnoses and self-report surveys.
Data from a multisite study of four PD groups was

examined.
Inpatients were assessed for childhood trauma
by diagnosis-blinded interviewers using semistructured research interviews.
Dissociative Experiences Scale was administered
and patients were evaluated with
semi-structured interviews to determine risk
factors for dissociative experiences.
Semi-structured interviews were used to assess
childhood biparental abuse and neglect.
Inpatients (n 99)
Non-clinical participants
(n 65)
18-year-old participants
(n 421)
NA
BPD inpatients (n 358)

PD inpatients (n 109)
BPD patients (n 290)

Axis II patients (n 72)

Axis II controls (n 109)
Sansone et al.
(2005)
Trull (2000a)
Trull
(2000b)
Yen et al.
(2002)
Zanarini et al.
(1997)
Zanarini et al.
(2000a)
Zanarini et al.
(2000b)
Zanarini et al.
(2002)
Two semi-structured interviews were used to

determine the severity of childhood sexual abuse.
Both BPD and non-BPD participants were

assessed for the relationship between borderline
features and multiple predictors such as childhood
abuse and parental mental illness.
Self-report and interview- based assessments of
various risk factors and features of BPD.
Method/Study design
Sample size
Author
(Year)
Chart 1 continued
BPD patients were significantly more likely

to have experienced emotional, and physical
abuse.
The more severe the childhood sexual abuse
the more severe the BPD symptoms.
Sexual abuse by a caretaker during childhood

was a significant risk factor for dissociative
experiences.
BPD participants had higher rates of trauma

exposure, especially childhood sexual
trauma.
to report abuse.
Childhood abuse was correlated with BPD.
Parental mental illness and lifetime axis I

disorder were predictors for BPD.
BPD patients reported higher rates of

childhood trauma.
Findings
70

Twice, 2.5 years apart, mother-child interaction,
father-child interaction, maternal personality, and
adolescent BPD diagnoses were measured.
Psychologists and psychiatrists described PD
patients; the contribution of various risk factors
was assessed.
Compared ratings of family problems by BPD
patients with the ratings by parents of BPD
patients, and against standard ratings from
normative families.
Psychological and psychosocial assessments were
made of families at various points in time in a
longitudinal study.
Patients (n 66) Controls

(n 109)
Adolescents (n 776)
Adult PD patients
(n 524)
BPD patients (n 21)
Community families
(n 593)
Community Youths and

Mothers (n 738)
BPD patients (n 16)

APD patients (n 16)
Controls (n 16)
Bandelow
et al. (2005)
Bezirganian
et al. (1993)
Bradley
(2005)
Gunderson
& Lyoo
(1997)
Johnson et al.
(2006)
Johnson et al.
(2000)
Lobbestael
et al. (2005)
Psychological and psychosocial assessments were

made of families at various points in time in a
longitudinal study.
BPD, APD and non-patient controls were assessed
using the schema mode questionnaire.
Method/Study design
Sample size
Author
(Year)
BPD Risk Factor Chart 2: Unfavourable parenting
(continued)
BPD patients were characterized by the

following modes: detached protector, angry
child, abandoned and abused child, and
punitive parent.
BPD patients perceived family relationships

and environment as more negative, BPD
patients parents reported more normative
family environments.
Ten types of parenting behaviour were
associated with elevated PD risk. Low
parental affection and aversive parental
behaviour, were associated with BPD.
Childhood neglect was associated with
elevated risk for PDs.
Significantly higher proportion of BPD

patients reported unfavourable parenting
styles than the control group.
Only the combination of maternal inconsistency and maternal over-involvement
predicted BPD.
Family environment and parental psychopathology predicted BPD.
Findings
71
Both BPD and non-BPD participants were

assessed for the relationship between borderline
features and multiple predictors such as childhood
abuse and parental mental illness.
Self-report and interview-based assessments of
various risk factors and features of BPD.
Dissociative Experiences Scale was administered
and patients were evaluated with semi-structured
interviews to determine risk factors for dissociative experiences.
Semi-structured interviews were used to assess
childhood biparental abuse and neglect.
Non-clinical participants
(n 65)
18-year-old participants
(n 421)

Axis II patients (n 72)

Axis II controls (n 109)
Trull (2000a)
Trull
(2000b)
Zanarini et al.
(2000a)
Zanarini et al.
(2000b)
Patients from different groups were compared to

see how their perceptions of parental bonding
differed.
Method/Study design
BPD/schizotypal patients
(n 54) Other PD
patients (n 165) NonPD patients (n 52)
Sample size
Torgersen &
Alnaes
(1992)
Author
(Year)
Chart 2 continued
Parental disinhibitory disorder, parental

mood disorder, childhood abuse, negative
affectivity, and disinhibition were found to
play a role in manifestation of BPD.
Inconsistent treatment by a caretaker and
witnessing sexual violence as a child were
significant predictors for disssociative
experiences.
to have experienced emotional biparental
failure in their childhood.
Parental mental illness and lifetime axis I

disorder were predictors for BPD.
BPD patients reported more negative overinvolvement by parents than other groups.
Findings
72
Methodology
Baseline-diagnosed with Dutch version of the
SCID-II. Personality Disorder Beliefs Questionnaire (PDBQ) Childhood Trauma Questionnaire
(CTQ) One week laterrated emotional state
after watching an emotional video.
WAS (world assumptions), PDBQ-BPD, childhood trauma interview, BPD checklist
Holtzman Inkblot Technique (Assess primary

process thinking, primitive defensive operations,
and object relations).
Schema Mode Questionnaire (assess cognitions,
feelings, and behaviours).Interview for traumatic
events.
Sample
BPD patients (n 16)

Cluster-C PD patients
(n 12)
Normal controls (n 15)
All female sample
BPD patients (n 15),

Cluster- C PD (n 14),
Axis-I DX (n 19),
non-patients (n 21)
Hospitalized BPD patients

(n 30) and Hospitalized
Neurotic patients (n 30)
BPD patients (n 16)

APD
patients (n 16) Nonpatient
controls (n 16)
Author Year
Arntz et al.
(1999)
Giesen-Bloo
& Arntz
(2005)
Leichsenring
(1991)
Lobbestael
et al. (2005)
BPD Risk Factor Chart 3: Object relations.
(continued)
BPD group scores higher on four maladaptive modes: detached protector, punitive
parent, abandoned/abused child, and angry
child compared to APD and non-patient
group. BPD and APD experienced abuse
significantly more than control group.
Supported Kernbergs hypothesis of the

connection between primary process thinking and primitive denial, projective identification and malevolent object relations.
BPD patients view the world as malevolent

and dangerous, compared to other groups.
BPD patients reported seeing the world and
other people as significantly less benevolent.
-BPD patients reported significantly more
trauma compared to other patients.
BPD patients reported high belief scores on

each of the 6 PDBQ subscales: BPD
assumptions were very stable, the induction
of negative emotions by the film did not
increase belief scores. There was high
stability in belief scores for BPD patients.
Findings
73
Differences in source memory performance

among BPD subjects were related to
interpersonal functioning. Relationship
between impaired source memory and
interpersonal antagonism.
Groups differed with respect to early
relationships. BPD adults way of representing early childhood relations was related to
present styles of interpersonal functioning.
BPD adults had reports of lower maternal
care and reported higher levels of maternal
overprotection compared to dysthymic
patients.
The BPD group did not distort their
interpersonal perceptions more than the MD
patients. However, findings did support
object relations theory with BPD patients
seeing themselves as hostile, labile, and
unstable compared to MD patients.
Buss-Durkee Hostility Inventory, BDI, Source

Memory Task.
Single interview with the following measures

administered: Adult Attachment Interview (AAI),
Parental Bonding Instrument (PBI) (in regard to
both parents) and the Beck Depression Inventory
(BDI).
Perceived Criticism Scale, Structural Analysis of

Social Behavior, Camberwell Family Interview
(administered to relatives).
BPD outpatients (n 41)

Healthy controls (n 26)
Adult Female Patients

(BPD M 35, 2 mths,
Dys M 32, 3 mths)
Borderline (n 12) Dysthymic (n 12)
Depressed inpatients with

BPD (n 55) Depressed
inpatients who met criteria
for Major Depressive
Episode (MDE) (n 22)
Minzenberg
et al.(2000b)
Patrick et al.
(1994)
Stern et al.
(1997)
Findings
Methodology
Sample
Author Year
Chart 3 continued
74
18- year old non-clinical

young adults screened for
having BPD features
(n 421) by screening
with the Personality
Assessment inventoryBorderline
Features Scale (PAI-BOR)
B group (n 197)
B- group (n 224)
14 18 year olds from

inpatient adolescent unit
BPD (n 33) Psychiatric
comparison group
(n 21) Normal subjects
(n 31)
Trull (2001a)
Westen et al.
(1990)
Findings supported an aetiological model

such that parental disinhibitory disorder,
parental mood disorder, childhood abuse,
negative affectivity, and disinhibition played
important roles in the expression of borderline symptomatology. Disinhibition and
negative affectivity are core personality traits
in the aetiology of BPD features.
Borderline adolescents differed from both

comparison groups by having more malevolent object relations. Borderline adolescents
had a lower level of capacity for emotional
investment in people, relationships, and
moral values. They also had less accurate,
complex, and logical attributions in understanding causality in relations with others.
Borderlines demonstrated more grossly
pathological responses, a tendency to think
egocentrically and a blurring of boundaries
of object representations. Their object
relations can also be complex and distorted.
A 5-hour interview with self-report measures and

structured interviews. Measures included the PAIBOR, MMPI-Borderline Personality Disorder
Scale, Revised Diagnostic Interview for Borderlines, Structured Interview for DSM-IV personality, NEO-PI-R to assess personality traits that
make up the 5-factor model of personality, the
Family History Research Diagnostic Criteria,
and the Familial Experiences Interview.
Four dimensions of object relations measures by
the Thematic Apperception Test (TAT) complexity of representations of people- affecttone of relationship paradigms- capacity for
emotional investment in relationships and moral
standards- understanding social causality.
75
BPD subjects were significantly more likely

to report insecure attachment, and unresolved trauma or loss.

The Adult Attachment Interview was administered to determine mental representations and
attachment. One-way ANOVAs were used to
assess the data.
Patients (n 60) Controls

(n 109)
Non-clinical subjects
(n 40) BPD subjects
(n 40)
Non-psychotic patients
(n 82) Controls
(n 85)
Bandelow
et al. (2005)
Barone
(2003)
Fonagy et al.
(1996)
Adult Attachment Interview was

administered.
Significantly higher proportion of BDP

patients reported childhood separation from
parents.
Review of 13 empirical studies which studied

attachment styles in people with BPD.
Not applicable
Agrawal
et al. (2004)
BPD participants were more likely to have

unresolved issues regarding childhood
trauma and also to have attachment
issues.
All studies reported a correlation between

insecure attachment styles and BPD.
Significant differences were found between

attachment styles in BPD patients and OCDP
patients. Particularly, BPD participants were
more likely to have experienced loss of
availability of a caregiver.
The Reciprocal Attachment Questionnaire was

used to compare attachment styles in BPD
participants and OCDP participants.
BPD participants (n 50)

OCDP participants
(n 40)
Aaronson
et al. (2006)
Findings
Method/Study design
Sample size
Author
(Year)
BPD Risk Factor Chart 4: Insecure attachment/loss.
76
Psychiatric records of discharged patients with PD

diagnoses were examined for childhood trauma.
Using the Questionnaire on Loss Events BPD
patients and non-BPD patients in a multicentric
hospital setting were assessed to see if the primary
caregiver had suffered a significant loss in the
patients early life.
Participants completed questionnaires measuring
APD and BPD features,
temperament, mood, and attachment
experiences.

Other PD patients
(n 385)
BPD patients (n 66)

Controls (n 146)
Adults (n 156)
Liotti & Pasquini (2000)
Meyer et al.
(2005)
Structural Clinical Interview for DSM-IV Axis II

Personality Disorders, Attachment Style Questionnaire, Barratt Impulsiveness Scale-11 and the
Aggression Questionnaire were administered to
determine the relationship among BPD, adult
attachment patterns, and impulsivity and
aggression.
Laporte &
Guttman
(1996)
Fossati et al.
(2005)
Temperament and Character Inventory,

Parental Bonding Instrument, and
Attachment Style Questionnaire were
administered.
BPD patients (n 44)

Non-BPD cluster BPD
patients (n 98) Cluster
A and C PD patients
(n 39) Non-PD patients
(n 70) Non-clinical
patients (n 206)
BPD Outpatients
(n 466)
Fossati et al.
(2001)
(continued)
BPD was more associated with insecure

attachment to parents than APD.
There was a significant correlation between

loss events experienced by the primary
caregiver and BPD diagnoses in patients.
Other studies have shown a correlation
between losses in the life of the primary
caregiver and attachment issues.
More BPD patients experienced childhood

loss than other PD patients.
Adult attachment patterns acted as indirect

risk factors for BPD because of their
association aggressive and impulsive
personality traits.
Findings did not support the role

of attachment issues in development
of BPD.
77
Used self-report measures to evaluate

attachment associations with childhood
maltreatment.
Risk factors for BPD were assessed using a

developmental interview and the Parental Bonding Index
Patients were assessed to determine childhood
separation difficulties and early onset of
symptoms.
BPD Outpatients (n 40)
18-year old participants

(n 393)
Male BPD outpatients

(n 61) Male non-BPD
outpatients (n 60)
BPD Patients (n 290)

Other PD Patients
(n 72)
Women with history of

childhood sexual abuse
(n 40)
Minzenberg
et al. (2000a)
Nickell et al.
(2002)
Paris et al.
(1994a or b)
Reich &
Zanarini
(2001)
Stalker &
Davies
(1994)
Adult attachment interview, global

assessment scale, and the structural
clinical interview for diagnosis on
DSM-III-R were administered.
Participants were assessed for relationships

between parental bonding and attachment constructs. Hierarchical regression analyses were run.
Method/Study design
Sample size
Author
(Year)
Chart 4 continued
A relationship between attachment issues

and borderline personality disorder was
suggested.
BPD patients reported more separation

difficulties and earlier onset of symptoms
(before age 18 years).
Separation and loss during childhood were

significant predictors of BPD.
BPD is characterized by adult attachment

issues which strongly relate to childhood
maltreatment, current problems, and clinical
symptoms.
An association was found between the
presence of borderline traits and attachment
scores and parental bonding.
Findings
78
79
5. BPD patients often have a limited symbolization-reflectiveness capacity

(see BPD Risk Factor Chart 5).
In the following the two most pertinent EBM-papers for descriptively
documenting each of these five risk factors of best evidence found in the
Duodecim team are presented; thus, these two well-documented studies from
different patient cohorts create the central evidence regarding each of these five
categories of EBM-psychosocial risk factors for BPD. There are also several
other EBM-papers in each of these five categories, which support overall results,
as is shown in the charts.
A history of severe or multi-factorial childhood traumas and sexual abuse
In recent years there have been a number of investigations examining severe or
multi-factorial childhood traumas and sexual abuse as the psychosocial risk
factors associated with BPD: several empirical studies suggest that individuals
who have been abused or neglected are at an increased risk for the development
of borderline personality disorder (see BPD Risk Factor Chart 1: Childhood
Trauma/Abuse). In the following, the two pertinent EBM-papers from these
studies for documenting the existence of this EBM-risk factor are presented.
In a retrospective study (Bandelow et al., 2005) outpatients with BPD
(n 66) were compared to healthy controls (n 109) regarding childhood
traumas. In the group of patients with BPD, significantly more childhood traumas
were reported, such as separation traumas from the mother because of prolonged
hospital treatment, the divorce of the parents, psychic disorders of the parents,
and abuse committed by both parents. In a logistic regression model of possible
aetiological factors, the following factors showed a significant influence: familial
neurotic spectrum disorders; childhood sexual abuse; separation from parents;
and unfavourable parenting styles. The data support the hypothesis that the
aetiology of BPD is multi-factorial and that familial psychiatric disorders and
sexual abuse are contributing factors.
In a well-documented paper (Zanarini et al., 1997) it was clarified that
patients with BPD report more childhood traumas in comparison to other
personality disorders. BPD patients (n 358) were compared to patients with
other personality disorders (n 109). It was found that in the group of patients
with BPD significantly more abuse was reported, all kinds of neglect, emotional
abuse of a parent, verbal abuse, physical abuse, emotional withdrawal of a parent,
inconsistent treatment of the caretaker, denial of the childs feelings, caretakers
placing the patient in the parental role and caretakers failure to protect the child.
A history of problematic parenting during childhood
The home environment is generally considered to be one of the most important
sources of socialization for most children (Johnson, Cohen, Chen, Kasen, &
Borderline pattern of self-other differentiation was characterized by a poor differentiation between self and others and the
perception of others is differentiated. (Selfidentity is not fully achieved).
Grid technique - used to explore subjects

representations of themselves and their family
members.
Schizophrenic inpatients
(n 19), Borderline inpatients (n 17), Normal
controls (n 18)
Non-psychotic inpatients
(n 82), Case-matched
controls (n 85)
de Bonis
et al. (1995)
Fonagy et al.
(1996)
Adult Attachment Interview (AAI), ReflectiveSelf Function (RSF).
Reflective function was a predictor of

attachment status. Poor affect mentalization
was associated with an increased chance of
Axis I and Axis-II diagnoses.
Examined verbatim transcripts from the AAI,

Reflective Function scale, Affect mentalization
(The GEVA).
n 73. Both clinical and

non-clinical participants
from six different samples.
Bouchard
et al. (2008)
Psychiatric patients were more likely to be

identified as being precoccupied and
unresolved with a previous loss or abuse.
Axis II BPD was related to experience of
severe trauma and lack of resolution in
regards to the trauma. BPD patients also
scored lower on scale measuring awareness
of mental states. 47% of BPD patients were
fearfully preoccupied with relationships.
BPD subjects had an overall lower affect

compared to both other groups. BPD subjects
also demonstrated a stronger tendency to
view others negatively compared to other
groups.
Exposure to film clips with emotional themes such

as: abandonment, abuse, and rejection. Reactions
to films were measures as well as to traits of film
personalities.
BPD (n 16), Cluster C

PD (n 12), Normal
Controls (n 15)
Arntz &
Veen (2001)
Findings
Methodology
Sample
Author
(Year)
BPD Risk Factor Chart 5: Symbolization-reflectiveness capacity
80
Undergraduates at a
Midwestern US University (n 1418) M 566,
F 810
Leible &
Snell (2004)
Levy et al.
(2006)
Selected from inpatient

(n 25) and outpatient
(n 5) settings, Male
(n 19), Female (n 11)
Neurotic Personality
Organization (NPO)
(n 10) Borderline Personality Organization
(BPO)(n 10) Psychotic
Personality Organization
(PPO)(n 10)
Patients diagnosed with
BPD (N 90; M 6,
F 84)
Jeanneau &
Armelius
(1993)
(continued)
After 12 months, more patients in the TFP

condition were classified as having a secure
attachment. Patients in the TFP condition
also showed significant increases in narrative
coherence and reflective functioning. None
of the conditions showed changes in
resolution of loss or trauma.
Individuals who scored higher on the PDQ
measure of borderline personality disorder
symptomatology reported less emotional
clarity and less emotional regulation.
Individuals who scored higher on the
measure of borderline personality disorder
also scored lower on two other forms of
emotional intelligence: private emotional
preoccupation and public emotional monitoring.
Randomized treatment: Transference-focused

psychotherapy (TFP), psychodynamic supportive
therapy (SPT), dialectical behavior therapy (DBT)
Measures: Adult Attachment Interview, Reflective Function Coding Scale.
Personality Diagnostic Questionnaire (PDQ),

Trait Meta-Mood Scale, Multidimensional
Emotional Awareness Questionnaire.
There was a significant correlation between

personality organization and linguistic variables. Future tense of the verbs was typical
BPO language. Common borderline words
include one/you and references to they, there,
and them. BPO-patients demonstrated a
vacillating identity and were less likely to
self-identify.
Structural interview (a psychodynamic interview

aimed at finding information about the organization of personality) was administered and
transcribed. 2500 words and groups of words
spoken by the patients were used in a textanalysis.
81
Attention network test (ANT)
Diagnosed BPD (n 39),

unselected controls
(n 70), and temperament matched controls
(n 22)
Posner et al.
(2002)
Specific abnormality in BPD patients in their

attention network in terms of their ability
with conflict resolution and cognitive control
compared to both other groups.
The patients with BPD had weaker source

memory in their interpersonal dysfunction
compared to controls in association with
resentment, irritability, negativism, and
suspiciousness.
The verbal source memory test, Buss-Durkee

Hostility Inventory, Beck Depression Inventory.
Findings
Methodology
Outpatients with BPD

(n 41) were compared
to healthy controls
(n 26)
Sample
Minzenberg
et al. (2000b)
Author
(Year)
Chart 5 continued
82
83
Brook, 2006). Because parents typically play a crucial role in the early
socialization of the child, the socialization deficits that are evident among
individuals with personality disorders may result from problems with parents,
including problematic parenting. Thus, several empirical studies propose that
there is an association between unfavourable parenting and the development of
personality disorders (see BPD Risk Factor Chart 2: Unfavourable Parenting). In
the following, the two pertinent EBM papers from these studies for documenting
the existence of this EBM-risk factor are presented.
In a prospective cohort design study, the associations between personality
disorders and types of parental child-rearing behaviour were investigated
(Johnson et al., 2006). With reliable interview and estimation methods of
personality disorders (regarding psychopathology, personality, psychopathology
in parents and parental child-rearing behaviour), 593 families were interviewed.
Statistical analysis showed that ten problematic rearing styles were significantly
associated with adulthood personality disorder (PD), even after the influence of
childhood behavioural and emotional problems and lifetime psychiatric disorders
was taken into account. Risk for offspring PD increased steadily as a function of
the number of problematic parenting behaviours that were evident. Aversive
parental behaviour and low parental affection were associated with offspring
BPD in adulthood, after the influence of childhood behavioural and emotional
problems and lifetime psychiatric disorders were taken into account. The results
indicate that certain types of parental child-rearing behaviour are associated with
the development of BPD in adulthood. This research is thus far the only published
prospective study in this research area.
In a controlled interview study (Zanarini, et al., 2000a), patients with BPD
(n 358) were compared to patients with other PDs (n 109) as a control group
regarding the bi-parental failure in the childhood experiences of BPD patients.
Patients with BPD reported significantly more abuse from both parents: childhood
verbal abuse, emotional abuse and physical abuse, but not sexual abuse. Patients
with BPD also reported significantly more often than the controls that both their
parents denied their right for their own thoughts and feelings, they did not protect
their children, they physically neglected their children and treated the children
inconsistently.
Evidence of hostile object relations
Pathological object relations is a core aspect of borderline psychopathology.
Thus, disorders in interpersonal perceptions among patients with BPD are a
typical feature of BPD (see BPD Risk Factor Chart 3). In the following the two
pertinent EBM-papers from these studies for documenting the existence of this
EBM-risk factor are presented.
In a controlled clinical trial, interpersonal perceptions were studied in patients
with BPD (n 55) and depressed patients (n 22) (Stern, Herron, Primavera, &
Kakuma, 1997). Perceptions of patients, relatives, and interviewers were
84
compared. Patients with BPD perceived themselves as being more hostile in their
earlier relationships, compared to depressive patients, and more criticizing and
rejecting, compared to depressive patients. By the same measure patients with
BPD perceived themselves as being more hostile in their present relationships,
when compared to depressive patients who escape from identifying and reacting
to a critical attitude of their relatives.
Complex personality disorders have been hypothesized to be characterized
by alternating states of thinking, feeling, and behaviour, the so-called schema modes
(Lobbestael, Arntz, & Sieswerda, 2005). The research has tested the applicability of
this model to BPD and antisocial personality disorders (APD), and related it to a
presumed common aetiological factorchildhood trauma. Participants were
interviewed to retrace abusive sexual, physical and emotional events before the age
of 18 years. BPD as well as APD participants were characterized by maladaptive
modes. APD displayed the most characteristics of the Bully (Punitive
Parent)/Attack (Angry Child) mode, although not significantly more so than
BPD. The Healthy Adult mode was of low presence in BPD and of high presence in
the non-patients. Frequency and severity of the three kinds of abuse were equally
high in both PD groups, and significantly higher than in non-patients.
Insecure attachment relationships
Attachment theory postulates that the quality of early relationships with primary
caregivers plays an important role in the development of an individuals
personality; thus, insecure attachments in early childhood may be associated with
the impairment of personality development. Because insecure attachments of BPD
are so manifest, so central to the problems that they present to the treatment, and so
central to the theories of the pathogenesis of BPD, the empirical evidence of
attachment disorders in BPD has considerable clinical and theoretical significance
(see BPD Risk Factor Chart 4). In the following the two pertinent EBM-papers from
these studies for documenting the existence of this EBM-risk factor are presented.
In the systematic review, 13 published empirical research papers which
consider attachment patterns in BPD in adulthood are analysed (Agrawal,
Gunderson, Holmes, & Lyons-Ruth, 2004). Every study concludes that there is a
strong association between BPD and insecure attachment. The types of attachment
found to be most characteristic of BPD subjects are insecure unresolved,
preoccupied, and fearful. Because of the many different methods utilized to
measure attachment style, it was decided that the best way to present and organize
the results was in the systematic chart mode. The results showed that in the control
groups secure attachment was significantly more frequent than in the groups of
BPD patients. Insecure attachment styles are not specific only to BPD patients.
In the controlled study (Minzenberg, Poole, & Vinogradov, 2006a), BPD was
characterized along two fundamental dimensions of adult social attachment and
attachment associations with childhood maltreatment and current symptoms.
BPD outpatients (n 40) were compared to a healthy control group (n 40). In
85
the group of BPD patients, there were significantly more impaired attachment
relationships; there was more attachment-anxiety and attachment-avoidance
compared to controls. Attachment-anxiety was associated with childhood
maltreatment, especially to sexual abuse, attachment-avoidance was associated
with childhood abuse and childhood neglect.
Limited symbolization-reflectiveness capacity

Symbolization-reflectiveness capacity means the ability to mentalize; to label, to
identify and to express feelings and thoughts in ones mind (Fonagy, 2010;
Fonagy & Bateman, 2008). Although the ability to symbolize and to reflect is
generally described as being uniform, several works pinpoint problems in these
psychological functions in borderline psychopathology: these studies propose
that individuals with borderline psychopathology have limited ability to
symbolize and reflect (see BPD Risk Factor Chart 5).
In this study (Fonagy et al., 1996), patterns of attachment and reflective
capacity found in individuals with BPD were clarified with non-psychotic
inpatients (n 82) compared to controls (n 85). In the group of patients with
BPD (n 36), only three were classified as belonging to the group having a secure
attachment capacity, 27 were assigned to the group of insecure preoccupied pattern
of attachment and six to the group of insecure dismissive pattern of attachment.
In the group of patients with BPD the disorder of the attachment pattern was
associated with unresolved childhood trauma compared to controls. Reflection
capacity was measured using the standardized reflective self-function (RSF)-scale
estimated from the AAI-interviews. BPD patients had significantly lower RSF than
controls. The lack of RSF as such is not yet an independent risk factor to BPD, but it
is such with the combination of the presence of childhood abuse.
Source memory, and its association to hostility in interpersonal relationships
and to suspiciousness, was investigated in a controlled clinical trial (Minzenberg
et al., 2006b). Source memory means the context and origin of the remembered
events (Johnson et al., 1993). The outpatients with BPD (n 41) were compared
to healthy controls (n 26). The patients with BPD had weaker source memory in
their interpersonal dysfunction compared to controls in association with
resentment, irritability, negativism, and suspiciousness. In contrast, generic item
recognition memory function was unrelated to hostility measures including
suspiciousness. The weakness of the source memory, when hostile feelings are
predominant, contributes to the impairment of reflective capacity in BPD patients
(Minzenberg et al., 2006b).
Discussion
Other researchers have already undertaken reviews of risk factors of BPD before,
and thus our findings as such are established knowledge in our field. However,
our contribution is an important addition to the existing literature reviews,
86
because it rests on the systematic methodology which we have adopted. So the

key goal of the paper is to describe the systematic literature as accurately as
possible for the mapping of evidence-based risk factors for BPD.
Although there are of course other ways to classify and categorize the material,
the procedure illustrated in this paper was chosen to best fit EBM-principles. On
the other hand, whether there are five risk factors that meet the EBM-criteria, or
whether further work on the literature review would reveal that the number might
be more or less than five is not the most crucial factor for studying the development
of BPD and the planning of the evidence-based, especially psychotherapeutic
treatment for BPD. Rather, it is more important that the EBM-criteria based
evaluation of the papers support our conclusion that the five risk factors discussed
are indeed some of the central risk factors for BPD, which are relevant, when the
development of BPD is studied and the psychotherapeutic treatment for BPD is
planned. Thus, if the classified five psychosocial risk factors are clearly and
properly identified, it is useful information, because it may be helpful for planning
the evidence-based psychotherapeutic treatment approaches for BPD.
It is important to be flexible in our understanding of these risk factors; the five
identified risk factors are not independent of each other, in that some overlap with or
include each other, e.g. bad parenting may include abuse; or one factor is caused by
or influenced by another factore.g. hostile object relations are due to childhood
trauma, or a lack of capacity for symbolization/reflectiveness is a result of an
experience of insecure attachment. So it should not be concluded that the five risk
factors identified here are the only key risk factors or are necessarily more crucial
than other risk factors which may be identified by further systematic EBM-research.
As described, in this study only psychosocial risk factors are delineated, because
it would have been out of the scope of one paper to touch comprehensively all risk
factors of BPD. However, one may hope that this systematic literature review paper
could make a useful contribution by identifying some specific psychosocial risk
factors that need to be studied in more detail in order to develop a model for
understanding BPD and for the appropriate psychotherapeutic treatment of BPD.
It is clear that childhood maltreatment is the most widely validated
psychosocial risk factor, and that some types of childhood maltreatment have
been more closely linked with BPD, because they have been more intensively
studied (Bandelow et al., 2005; Johnson et al., 2006; Zanarini et al., 1997;
Zanarini et al., 2000a & b). It is also important to make it clear that childhood
maltreatment is a summary category that includes at least seven subcategories of
abuse/neglect (emotional abuse: including verbal abuse, physical abuse, sexual
abuse, physical neglect, emotional neglect, cognitive neglect and supervision
neglect meaning the lack of supervision). It is acknowledged in this regard the
limitations of this paper: the seven subtypes are not yet examined separately, and
this work should to be done in future research when developing a model for
understanding BPD and when developing appropriate psychotherapeutic
treatment approaches of BPD.
87
The individual psychological development of personality in childhood is also

significantly influenced by unfavourable parenting and by hostile object relations
as is clearly shown in BPD risk factor charts 2 and 3. These two factors
significantly inhibit the adoption of the individual secure attachment capacity and
on that basis the development of the capacity for symbolizationreflectiveness,
which two last-mentioned individual psychic factors would create the coherent
core of the functioning stable personality structure. Thus, the development of the
individual secure attachment capacity and on that basis the development of the
capacity for symbolizationreflectiveness is central in childhood so that a child
would be able to adopt the coherent stable personality structure.
In conclusion, the purpose of this work has been to summarize and analyse the
existing literature on the topic while leaving room for future research to further
clarify the identified five EBM-risk factors and delve more deeply into the other
risk factors. If we find specific psychosocial risk factors of BPD, we may then
focus the psychotherapeutic process exactly to these risk factors and therefore
treat the patients according to their specific psychic developmental needs.
Acknowledgements
We would like to thank the whole Finnish group of physicians who made the Practice
Guidelines for the Treatment of Borderline Personality Disorder, for their collaboration.
The systematic literature review was originally made as a part of this process.
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Psychoanalytic Psychotherapy,

Vol. 26, No. 1, March 2012, 6591

A systematic review of the evidence-based psychosocial risk

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*Corresponding author. Email: matti.keinanen@pp.fimnet.fi

M.T. Keinanen et al.

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international evidence-based medicine (EBM) criteria. For Medline the keywords

Subjects with multiple Axis II diagnoses took The

BPD subjects (n 21)

Retrospective interview (203 questions) about

Longitudinal study, psychiatric and psychosocial

Psychologists and psychiatrists described PD

BPD Risk Factor Chart 1: Childhood trauma/abuse

Children who experienced verbal abuse from

Significantly higher proportion of BDP

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BPD subjects with active

BPD patients (n 16)

Female BPD patients

Risk factors for BPD were assessed using

BPD participants were evaluated for adult

A correlation between significant traumatic

Using the Infancy Trauma Interview BPD patients

Childhood Sexual Abuse was a significant

Childhood Sexual Abuse was a significant

Adult attachment issues in BPD patients

BPD and APD patients had equal and

BPD patients experienced more abuse than

Psychiatric records of discharged patients with PD

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Clinical diagnoses and self-report surveys.

Data from a multisite study of four PD groups was

BPD inpatients (n 358)

BPD patients (n 290)

BPD inpatients (n 358)

BPD inpatients (n 290)

Two semi-structured interviews were used to

Both BPD and non-BPD participants were

BPD patients were significantly more likely

Sexual abuse by a caretaker during childhood

BPD participants had higher rates of trauma

Childhood abuse was correlated with BPD.

Parental mental illness and lifetime axis I

BPD patients reported higher rates of

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Retrospective interview (203 questions) about

Patients (n 66) Controls

BPD patients (n 21)

Community Youths and

BPD patients (n 16)

Psychological and psychosocial assessments were

BPD Risk Factor Chart 2: Unfavourable parenting

BPD patients were characterized by the

BPD patients perceived family relationships

Significantly higher proportion of BPD

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Both BPD and non-BPD participants were

BPD patients (n 290)

BPD inpatients (n 358)

Patients from different groups were compared to

Parental disinhibitory disorder, parental