Borderline personality disorder and childhood trauma: Evidence for a causal relationship
Abstract
The debate over whether childhood trauma is a causative factor in the development of borderline personality disorder continues in the literature despite decades of research. This review examines this body of literature published from 1995 through 2007 to assess the strength of evidence for such a causal relationship. A unique conceptual approach was used, as we considered the literature in the context of Hill's classic criteria for demonstrating causation. Results of this review suggest that evidence supports the causal relationship, particularly if the relationship is considered as part of a multifactorial etiologic model. Directions for future research and clinical implications are discussed.
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Early rejection experiences proposed to underlie rejection sensitivity may overlap within invalidating environments frequently observed in the childhood of people with Borderline Personality Disorder.
“Furthermore, the early rejection experiences proposed to underlie RS may overlap within the invalidating environments frequently observed in the childhood of people with BPD (Ball & Links, 2009;Crowell, Beauchaine, & Linehan, 2009).”
From The link between rejection sensitivity and borderline personality disorder: A systematic review and meta-analysis (2019) · cites this paper as Ball & Links, 2009
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Social Judgement in Borderline Personality Disorder
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“Measuring childhood trauma was of particular interest due to the strong association between childhood adversity and BPD [2,3].”
BackgroundYung, A. R., Cotter, J., Wood, S. J., McGorry, P. D., Thompson, A. D., Nelson, B., & Lin, A. P. (2015) · Psychological Medicine · doi:10.1017/s003329171500135x · Cited by 57 · see citing works
“…and poor functioning Childhood maltreatment is associated with risk for a range of psychotic and non-psychotic disorders (Janssen et al. 2004; Ball & Links, 2009; Chen et al. 2010; Thompson et al. 2010; Varese et al. 2012) and is associated with poor functioning regardless of diagnosis…”
BackgroundPeng, W., Liu, Z., Liu, Q., Chu, J., Zheng, K., Wang, J., Wei, H., Zhong, M., Ling, Y., & Yi, J. (2021) · Depression and Anxiety · doi:10.1002/da.23082 · Cited by 56 · see citing works
“Childhood trauma has long been considered as an etiologic factor for BPD (Ball & Links, 2009; Herman, Perry, & Van der Kolk, 1989; Ibrahim, Cosgrave, & Woolgar, 2018).”
BackgroundReichborn‐Kjennerud, T., Czajkowski, N. O., Ystrøm, E., Ørstavik, R., Aggen, S. H., Tambs, K., Torgersen, S. O., Neale, M. C., Røysamb, E., Krueger, R. F., et al. (2015) · Psychological Medicine · doi:10.1017/s0033291715001117 · Cited by 57 · see citing works
“Although it is not clear if these associations represent a causal relationship (Ball & Links, 2009; Bornovalova et al. 2013b), it is possible that such childhood experiences have a lasting impact (Ehlert, 2013), and thus reflect the stable proportion of the environmental influences identified in…”
BackgroundDifferentiating the bipolar disorders from borderline personality disorder
Bayes, A. J., McClure, G., Fletcher, K., del Moral, Y. R. R., Hadzi‐Pavlovic, D., Stevenson, J., Manicavasagar, V. L., & Parker, G. B. (2015) · Acta Psychiatrica Scandinavica · doi:10.1111/acps.12509 · Cited by 56 · see citing works
“While (nonsexual) developmental trauma and parental rejection were univariate predictors of BPD status, as identified in other studies (36, 39), their impact was almost invariably removed in the multivariate analyses, suggesting a higher-order role for CSA.”
ResultHow Do Stress Exposure and Stress Regulation Relate to Borderline Personality Disorder?
Bourvis, N., Aouidad, A., Cabelguen, C., Cohen, D., & Xavier, J. (2017) · Frontiers in Psychology · doi:10.3389/fpsyg.2017.02054 · Cited by 48 · see citing works
“When studied within this methodological frame, childhood trauma may be considered a cause of later BPD when included in a multifactor aetiological model that accounts for the lack of specificity and robustness of the statistical association (Ball and Links, 2009).”
BackgroundDevelopment of the Offender Personality Disorder Pathway: A summary of the underpinning evidence
Skett, S., & Lewis, C. (2019) · Probation Journal · doi:10.1177/0264550519832370 · Cited by 52 · see citing works
“…which, in turn, has a long-term impact on how that individual develops, their core understanding of how the world is, their place within it, and their relationships with others (Ball and Links, 2009; Barnow et al., 2010; Glaser et al., 2010; Berenbaum et al., 2008; Van der Kolk et al., 1994).”
BackgroundEisenlohr-Moul, T. A., Schmalenberger, K. M., Owens, S., Peters, J. R., Dawson, D. N., & Girdler, S. S. (2018) · Psychological Medicine · doi:10.1017/s0033291718001253 · Cited by 52 · see citing works
“First, stress exposure and vulnerability are relevant to the etiology of BPD (Lynam and Widiger, 2001; Ball and Links, 2009) and associated with hormone sensitivity (Gollenberg et al.”
BackgroundHernandez, A., Arntz, A., Gaviria, A. M., Labad, A., & Gutiérrez-Zotes, J. A. (2012) · Journal of Personality Disorders · doi:10.1521/pedi.2012.26.5.727 · Cited by 49 · see citing works
McDermid, J., Sareen, J., El-Gabalawy, R. M., Pagura, J., Spiwak, R. P., & Enns, M. W. (2015) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2015.01.004 · Cited by 49 · see citing works
Zhang, T. H., Chow, A., Wang, L. L., Yu, J. H., Dai, Y. F., Lu, X., Good, M.-J. D., Good, B. J., & Xiao, Z. P. (2013) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2013.03.014 · Cited by 44 · see citing works
“Our results are consistent with other studies [58, 59] that have examined the effects of child abuse on borderline PD.”
ResultAloba, O., Opakunle, T., & Ogunrinu, O. (2020) · International Journal of Child Abuse & Neglect · doi:10.1016/j.chiabu.2020.104357 · Cited by 43 · see citing works
Emotions and Memory in Borderline Personality Disorder
Winter, D., Elzinga, B., & Schmahl, C. (2013) · Psychopathology · doi:10.1159/000356360 · Cited by 50 · see citing works
Ehrenthal, J. C., Levy, K. N., Scott, L. N., & Granger, D. A. (2018) · Journal of Personality Disorders · doi:10.1521/pedi.2018.32.supp.93 · Cited by 48 · see citing works
“However, subsequent studies were not able to support this finding as particularly disorder-specific (for a discussion, see Ball & Links, 2009; Ford & Courtois, 2014; Fossati, Madeddu, & Maffei, 1999).”
ResultBack, S. N., Flechsenhar, A., Bertsch, K., & Zettl, M. (2021) · Current Psychiatry Reports · doi:10.1007/s11920-021-01265-5 · Cited by 46 · see citing works
Rosenbach, C., & Renneberg, B. (2014) · Personality and Individual Differences · doi:10.1016/j.paid.2014.05.032 · Cited by 43 · see citing works
Childhood trauma and personality disorder criterion counts: A co-twin control analysis.
Berenz, E. C., Amstadter, A. B., Aggen, S. H., Knudsen, G. P., Reichborn-Kjennerud, T., Gardner, C. O., & Kendler, K. S. (2013) · Journal of Abnormal Psychology · doi:10.1037/a0034238 · Cited by 42 · see citing works
“For example, one review paper on CT in Borderline PD concluded that, “the evidence suggests that childhood trauma should be included in a multifactorial model of BPD” (Ball & Links, 2009).”
BackgroundBeatson, J. A., Broadbear, J. H., Duncan, C., Bourton, D., & Rao, S. (2019) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000001073 · Cited by 42 · see citing works
Dugal, C., Bigras, N., Godbout, N., & Bélanger, C. (2016) · A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice · doi:10.5772/64476 · Cited by 62 · see citing works
“Precisely, between 30 and 90% of individuals diagnosed with borderline personality disorder report having sustained childhood sexual, physical, or psychological abuse [88–90].”
BackgroundCSF 5-HIAA and exposure to and expression of interpersonal violence in suicide attempters
Moberg, T., Nordström, P., Forslund, K., Kristiansson, M., Åsberg, M., & Jokinen, J. (2011) · Journal of Affective Disorders · doi:10.1016/j.jad.2011.01.018 · Cited by 39 · see citing works
Krause-Utz, A., Mertens, L. J., Renn, J. B., Lucke, P., Wöhlke, A. Z., van Schie, C. C., & Mouthaan, J. (2021) · Journal of Interpersonal Violence · doi:10.1177/0886260518817782 · Cited by 37 · see citing works
“…propose that complex interactions between genetic, neurobiological predispositions, and traumatic experiences underlie the development of BPD (Ball & Links, 2009; Battle et al., 2004; Golier et al., 2003; Herman et al., 1989; Pietrek, Elbert, Weierstall, Müller, & Rockstroh, 2013; Yen et…”
BackgroundKrause-Utz, A., Walther, J.-C., Lis, S., Schmahl, C., & Bohus, M. (2019) · Psychological Medicine · doi:10.1017/s0033291718002489 · Cited by 38 · see citing works
“Traumatic stress, including severe childhood maltreatment, is highly prevalent in BPD (Battle et al., 2004; Ball and Links, 2009), 30–80% of patients suffer from comorbid posttraumatic stress disorder (PTSD) (Zanarini et al., 1998; Zimmerman and Mattia, 1999; Grant et al., 2008; Pagura et al.,…”
BackgroundChildhood trauma, midbrain activation and psychotic symptoms in borderline personality disorder
Nicol, K., Pope, M., Romaniuk, L., & Hall, J. (2015) · Translational Psychiatry · doi:10.1038/tp.2015.53 · Cited by 37 · see citing works
Pabst, A., Schauer, M., Bernhardt, K., Ruf‐Leuschner, M., Göder, R., Elbert, T. R., Rosentreager, R., Robjant, K., Aldenhoff, J. B., & Seeck-Hirschner, M. (2014) · KOPS (University of Konstanz) · Cited by 36 · see citing works
Sato, M., Fonagy, P., & Luyten, P. (2019) · Journal of Personality Disorders · doi:10.1521/pedi_2019_33_397 · Cited by 36 · see citing works
Violent offending in borderline personality disorder and attention deficit/hyperactivity disorder
Sebastian, A., Retz, W., Tüscher, O., & Turner, D. (2019) · Neuropharmacology · doi:10.1016/j.neuropharm.2019.03.008 · Cited by 34 · see citing works
Fossati, A., Gratz, K. L., Somma, A., Maffei, C., & Borroni, S. (2016) · Journal of Personality Disorders · doi:10.1521/pedi_2015_29_222 · Cited by 33 · see citing works
Euler, S., Stalujanis, E., Lindenmeyer, H. J., Nicastro, R., Kramer, U., Perroud, N. A., & Weibel, S. (2019) · Journal of Personality Disorders · doi:10.1521/pedi_2019_33_461 · Cited by 34 · see citing works
Sengutta, M., Gawęda, Ł., Moritz, S., & Karow, A. (2018) · European psychiatry · doi:10.1016/j.eurpsy.2018.11.009 · Cited by 26 · see citing works
“Similarly, the development of BPD is strongly related to childhood trauma [37] and it was suggested that childhood trauma could constitute an etiological factor for the development of BPD [25,38].”
BackgroundJohnson, B. N., Lumley, M. A., Cheavens, J. S., & McKernan, L. C. (2020) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2020.110164 · Cited by 32 · see citing works
“Considerable research supports the view that trauma (especially childhood sexual and emotional abuse) plays an important role, along with other biological and psychosocial risk factors, in the development of BPD (27-30).”
BackgroundMazer, A. K., Cleare, A. J., Young, A. H., & Juruena, M. F. (2018) · Behavioural Brain Research · doi:10.1016/j.bbr.2018.04.015 · Cited by 32 · see citing works
“Evidence from the literature demonstrates a positive association between early life stress (ELS) and the development of both BPD and BD [22-25].”
Frías, Á., Palma, C., Farriols, N., Gonzalez, L., & Horta, A. (2016) · Personality and Mental Health · doi:10.1002/pmh.1348 · Cited by 32 · see citing works
Hallucinations et trouble de personnalité borderline : une revue de littérature
Gras, A., Amad, A., Thomas, P., & Jardri, R. (2014) · L Encéphale · doi:10.1016/j.encep.2014.07.002 · Cited by 31 · see citing works
Yang, H., Lei, X., Zhong, M., Zhou, Q., Ling, Y., Jungkunz, M., & Yi, J. (2018) · Frontiers in Psychology · doi:10.3389/fpsyg.2018.00605 · Cited by 30 · see citing works
Reciprocal processes in trauma and coping: Bidirectional effects over a four-year period.
Jenzer, T., Meisel, S. N., Blayney, J. A., Colder, C. R., & Read, J. P. (2019) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0000500 · Cited by 30 · see citing works
“A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript Discussion Trauma can have devastating effects on mental health and functioning (Dulin & Passmore, 2010; Hovens et al., 2010; Ball & Links, 2009).”
BackgroundSimpson, S., Azam, F., Brown, S., Hronis, A., & Brockman, R. N. (2021) · Personality and Mental Health · doi:10.1002/pmh.1533 · Cited by 30 · see citing works
Arens, E. A., Grabe, H.-J., Spitzer, C., & Barnow, S. (2010) · Personality and Mental Health · doi:10.1002/pmh.143 · Cited by 30 · see citing works
Amad, A., Raduà, J., Vaïva, G., Williams, S., & Fovet, T. (2019) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2019.07.018 · Cited by 30 · see citing works
Evren, C., Cinar, O., Evren, B., & Çelik, S. (2012) · Psychiatry Research · doi:10.1016/j.psychres.2012.03.017 · Cited by 29 · see citing works
“Both BPD (Ball and Links, 2009) and SUDs (Evren et al.”
BackgroundGeerling, I., Roberts, R., & Williams, A. S. (2019) · Infant Mental Health Journal · doi:10.1002/imhj.21776 · Cited by 29 · see citing works
Löffler, A., Kleindienst, N., Cackowski, S., Schmidinger, I., & Bekrater‐Bodmann, R. (2019) · Journal of Trauma & Dissociation · doi:10.1080/15299732.2019.1678213 · Cited by 28 · see citing works
“Additionally, we included reports of childhood trauma which has been shown being a causal predictor for the development of BPD psychopathology (Ball & Links, 2009).”
BackgroundSmits, M. L., Luyten, P., Feenstra, D. J., Bales, D. L., Kamphuis, J. H., Dekker, J., Verheul, R., & Busschbach, J. J. V. (2022) · American Journal of Psychotherapy · doi:10.1176/appi.psychotherapy.20210027 · Cited by 31 · see citing works
Ensink, K., Biberdzic, M., Normandin, L., & Clarkin, J. F. (2015) · Journal of Infant Child and Adolescent Psychotherapy · doi:10.1080/15289168.2015.1007715 · Cited by 27 · see citing works
“Abuse, neglect and childhood maltreatment are widely recognized to be important risk factors for the development of BPD in adults (Ball & Links, 2009), young adults (Widom, Czaja, & Paris, 2009), adolescents (Horesh, Ratner, Laor, & Toren, 2008; Horesh, Sever, & Apter, 2003; Venta,…”
BackgroundCyr, G., Godbout, N., Cloître, M., & Bélanger, C. (2021) · Journal of Traumatic Stress · doi:10.1002/jts.22719 · Cited by 26 · see citing works
“In addition, although no research has yet established a causal association between trauma exposure and BPD (Ball & Links, 2009), up to 97% of BPD patients report having experienced childhood trauma (Temes et al., 2017).”
BackgroundInconsistency and social decision making in patients with Borderline Personality Disorder
Preuss, N., Brändle, L. S., Hager, O. M., Haynes, M., Fischbacher, U., & Hasler, G. (2016) · Psychiatry Research · doi:10.1016/j.psychres.2016.06.017 · Cited by 25 · see citing works
Meulemeester, C. D., Lowyck, B., Panagiotopoulou, E., Fotopoulou, A., & Luyten, P. (2020) · Personality Disorders Theory Research and Treatment · doi:10.1037/per0000415 · Cited by 23 · see citing works
“Indeed, individuals with BPD typically show high levels of attachment insecurity (Agrawal, Gunderson, Holmes, & Lyons-Ruth, 2004) and childhood trauma (Ball & Links, 2009), pointing towards disrupted caregiver-infant attunement.”
BackgroundRobin, M., Douniol, M., Pham‐Scottez, A., Gicquel, L., Delvenne, V., Nezelof, S., Speranza, M., Falissard, B., Silva, J., & Corcos, M. (2021) · Journal of Personality Disorders · doi:10.1521/pedi_2021_35_523 · Cited by 26 · see citing works
Out of touch? How trauma shapes the experience of social touch – Neural and endocrine pathways
Stevens, L., Bregulla, M., & Scheele, D. (2024) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2024.105595 · Cited by 24 · see citing works
“…al., 2015; Negele et al., 2015 for reviews; O ’ Donnell et al., 2004), substance abuse disorders (see Brady et al., 2004 for a review; Farley et al., 2004; Min et al., 2007; Triffleman et al., 1995), and borderline personality disorder (see Ball and Links, 2009 for a review; Golier et al., 2003).”
BackgroundBøen, E., Westlye, L. T., Elvsåshagen, T., Hummelen, B., Hol, P. K., Boye, B., Andersson, S., Karterud, S., & Malt, U. F. (2014) · Journal of Psychiatry and Neuroscience · doi:10.1503/jpn.130070 · Cited by 24 · see citing works
“Our findings also suggest that reductions in the DGCA4 and CA2–3 subfield volumes are main contributors to the reductions in total hippocampal volume reported in previous studies of patients with BPD.”
BackgroundInfluentialDadomo, H., Salvato, G., Lapomarda, G., Ciftci, Z., Messina, I., & Grecucci, A. (2022) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2022.773593 · Cited by 24 · see citing works
“These traumatic events have a specific effect on the subject’s behavior and accurately predicts the symptom class observed in the borderline patients such as affective and interpersonal dysfunctionalities, which negatively impact on their relationships (Ball and Links, 2009).”
BackgroundCholesterol and the “Cycle of Violence” in attempted suicide
Asellus, P., Nordström, P., Nordström, A., & Jokinen, J. (2014) · Psychiatry Research · doi:10.1016/j.psychres.2014.01.009 · Cited by 24 · see citing works
“Abused children do present an increased risk of later suicide attempts, suicide, aggressive behaviour and development of personality disorders (Klomek et al., 2009, Ball and Links, 2009, Jokinen et al., 2010).”
Fung, H. W., & Chan, C. (2019) · Social Work in Health Care · doi:10.1080/00981389.2019.1597006 · Cited by 24 · see citing works
“It should be noted that BPD symptoms are highly related to trauma (Ball & Links, 2009; Lewis &Grenyer, 2009), and that currently there are no effective pharmaceutical treatments to target such psychosocial symptoms of BPD (Goodman, Vail, West, New, & Siever, 2007).”
BackgroundThe Social Psychology of Trauma
Muldoon, O. T. (2024) · Cambridge University Press eBooks · doi:10.1017/9781009306997 · Cited by 22 · see citing works
Early maladaptive schemas as common and specific predictors of skin picking subtypes
Pozza, A., Albert, U., & Dèttore, D. (2020) · BMC Psychology · doi:10.1186/s40359-020-0392-y · Cited by 23 · see citing works
Skancke, J. F., Holsen, I., & Schredl, M. (2014) · International journal of dream research · doi:10.11588/ijodr.2014.1.12184 · Cited by 23 · see citing works
The Social-Cognitive Basis of Personality Disorders: Commentary on the Special Issue
Herpertz, S. C. (2013) · Journal of Personality Disorders · doi:10.1521/pedi.2013.27.1.113 · Cited by 22 · see citing works
Alberdi‐Páramo, Í., Sáiz-González, M. D., Díaz‐Marsá, M., & Carrasco‐Perera, J. L. (2019) · Psychiatry Research · doi:10.1016/j.psychres.2019.112730 · Cited by 24 · see citing works
Krause-Utz, A., Dierick, T., Josef, T., Chatzaki, E., Willem, A., Hoogenboom, J., & Elzinga, B. M. (2021) · Borderline Personality Disorder and Emotion Dysregulation · doi:10.1186/s40479-021-00150-0 · Cited by 23 · see citing works
Childhood trauma and borderline personality disorder traits: A discordant twin study.
Skaug, E., Czajkowski, N. O., Waaktaar, T., & Torgersen, S. O. (2022) · Journal of Psychopathology and Clinical Science · doi:10.1037/abn0000755 · Cited by 20 · see citing works
- Authors
- Ball, J. S., & Links, P. S.
- Affiliations
- St. Michael's Hospital (CA)
- Corresponding author
- Ball, Jeffrey S.
- Venue
- Current Psychiatry Reports
- Published
- 2009-01-22
- Volume
- 11
- Issue
- 1
- Pages
- 63-68
- ISSN
- 1523-3812 (ISSN-L)
- 1535-1645
- OpenAlex
- W1994608326
- Cited by
- 320
- References
- 53
- Citations by year
- 2026: 10 · 2025: 18 · 2024: 25 · 2023: 11 · 2022: 26 · 2021: 31 · 2020: 26 · 2019: 33 · 2018: 22 · 2017: 10 · 2016: 20 · 2015: 22 · 2014: 21 · 2013: 17 · 2012: 10
- FWCI
- 1.21
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Current Psychiatry Reports (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- borderline personality disorder, childhood trauma, causal relationship, etiology, multifactorial etiology, quality of evidence
- MeSH terms
- Adult, Borderline Personality Disorder, Brain, Child, Child Abuse, Child Abuse, Sexual, Cross-Sectional Studies, Humans, Interpersonal Relations, Life Change Events, Object Attachment, Risk Factors, Self Concept, Causality
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