Impact of Childhood Abuse on Adult Psychopathology: a Case Report

Post-traumatic stress disorder (P7 SD), borderline personality disorder (BPD) and multiple personality disorder (MPD), although categorized separately in DSM-II1-R under anxiety disorder, personality disorder, and dissociative disorder, respectively, have each been shown to be associated with early childhood abuse. Many authors have noted the importance of determining the relative impact of childhood trauma on the etiology of psychiatric illness, both from diagnostic and treatment perspectives. In this article, we will present the case of a multiply traumatized woman who satisfies criteria for all three disorders, providing support for the hypothesis that these three diag noses may be viewed as separate phenotypic expressions of a common origin: childhood trauma. A hierarchical model ofadaptation to childhood abuse is proposed to order the clinical data. Evidence is growing that childhood incest and abuse are i mplicated in the etiology of a number of adult psychopathological conditions, particularly multiple personality disorder (renamed dissociative identity disorder in DSMIV), borderline personality disorder, sornatoform disorder, substance abuse, and depression (Kluft, 1990). These appear to be variants on, or longstanding consequences of, what is known in adulthood as post-traumatic stress disorder, though these syndromes are not identical. The substantive question facing the field now is which factors within the domains of the victim's personality, social environment, and traumatic experience, are critical to the formation of adult disorders, and how do they interact to determine the specific form of symptomatic expression. Potentially important factors include 1) age at onset of abuse, 2) severity, 3) duration, 4) relationship to perpetrator, 5) child's constitutional resiliency, and 6) stability of and support from the family environment (Schetky, 1990) . This article will contribute to this effort through the examination of one case report of a woman multiply traumatized who developed several distinct disorders as an adult. In the discussion, we will propose a framework for understanding the complex relationships among the etiological factors in her case. CHILDHOOD ABUSE AND PSYCHOPATHOLOGY Dissociation is widely recognized as an extreme defensive response to overwhelming psychological trauma. Hence it is not surprising that individuals with a history of childhood abuse report higher levels of dissociative symptoms than those who were not abused (Chu & Dill, 1990). Multiple personality disorder is associated with very high rates of childhood trauma (Coons, Bowman, & Milstein, 1988; Putnam, Guroff, Silberman, Barban, & Post, 1986; Ross, Norton, & Wozney, 1989; Schultz, Braun, & Kluft, 1989). Kluft (1987) reported a 90% rate of childhood physical and/or sexual abuse in subjects with multiple personality disorder, while Putnam et al. (1986) reported a 97% rate. Ross et al. (1990) , in a series of multiple personality disorder cases diagnosed by structured interviews, found childhood physical and/or sexual abuse history in 95% of the cases; 50% of the subjects endorsed both physical and sexual abuse before age five, as well as abuse lasting for more than 10 years. Ross (1991), in a prevalence study of childhood abuse in various diagnostic categories, identified childhood trauma as a major factor for the development of multiple personality disorder. Rates of multiple personality disorder and dissociation were significantly higher in abused (10.5%) than non-abused (.2%) individuals. Borderline personality disorder is also strongly associated with a history of childhood abuse (Bryer, Nelson, Miller, & Krol, 1987; Byrne, Velamoor, & Cernovsky, 1990; Herman, Perry, & van der Kolk, 1989; Ludolph et al., 1990; Ogata, Silk, Goodrich, Lohr, & Westen, 1990; Ross, 1991; Stone, 1981; Westen, Ludolph, Misle, Ruffins, & Block, 1990; Zanarini, Gunderson, Marino, Schwartz, & Frankenburg,