European Journal of Trauma & Dissociation 2 (2018) 91–99

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Research Paper

Affect dysregulation, adult attachment problems, and dissociation

mediate the relationship between childhood trauma and borderline
personality disorder symptoms in adulthood
Annemiek van Dijke a,b,*, Juliette A.B. Hopman c, Julian D. Ford d
a
Department of Clinical Psychology, VU University Amsterdam, Netherlands
b
Parnassia-PsyQ, Amsterdam area, Netherlands
c
Yulius academy/Yulius/COLK centre for psychosomatics Yulius, Greater Rotterdam Area, Netherlands
d
Department of Psychiatry, University of Connecticut Health Center, Farmington, CT, USA

A R T I C L E I N F O A B S T R A C T

Article history: Introduction. – Both borderline personality disorder (BPD) and childhood trauma have been shown to be
Received 30 May 2017 associated with affect dysregulation, dissociation, and fear-based attachment schemas. However, the
Received in revised form 21 November 2017 inter-relationships of these clinical phenomena have not been studied in unison.
Accepted 28 November 2017
Objective. – To study the interrelations between childhood psychological trauma and adult BPD
mediated by dissociation, attachment schemas, and affect dysregulation in unison while differentiating
Keywords: for inhibitory- and excitatory regulation symptoms.
Childhood trauma
Method. – Adult chronic psychiatric patients with BPD, BPD with comorbid somatoform disorder, and
Dissociation
Borderline personality disorder
two psychiatric control groups with SoD-only, or chronic anxiety or affective disorders com-pleted
Attachment schemas structured interviews and self reports. Affect dysregulation, fear-based attachment schemas and
Affect dysregulation dissociation were tested simultaneously -in their separate inhibitory- and excitatory form- as potential
Alexithymia mediators in the relationship between childhood psychological trauma and BPD symptoms in adulthood.
Next, two alternative models partitioning childhood trauma into more specific features as source
(primary-caretaker or not), or type i.e. emotional-, physical-, or sexual abuse, while differentiating for
developmental epochs, were compared to the original model. Analyses were re-run for participants who
report more severe symptoms that meet criteria for a BPD diagnosis.
Results. – Structured equation modeling with bootstrap 95% confidence intervals revealed that
hallmark features of BPD – affect dysregulation involving extreme emotional intensity and lability
(under-regulation), fragmentation of consciousness (positive psychoform dissociation; e.g., flashbacks),
and core attachment fears of closeness and abandonment – partially account for the relationship
between overall childhood trauma and BPD-symptom severity. The unifying theme for these mediators
is excitatory dysregulation. Alternative models distinguishing types and nature of trauma did not fit the
data. However, adults who report more severe symptoms that meet criteria for a BPD diagnosis were
likely to have experienced sexual trauma in early childhood or adolescence, and to have an intense fear of
abandonment, with the path from early childhood sexual trauma to BPD symptoms as strongest direct
relationship.
Conclusion. – Relationships between overall childhood trauma and BPD symptoms in adulthood
through three mediators i.e., affect dysregulation, fear-based attachment schemas and dissociation were
found, over alternative models distinguishing types of perpetrator, nature of trauma, and developmental
epoch. These findings contribute to and replicate a substantial research base that highlights sexual
trauma in early childhood and severe attachment insecurity (and disorganization) as contributors to
adult BPD. Prospective studies are needed to elucidate the complex relationships between childhood
trauma and BPD.
C 2017 Published by Elsevier Masson SAS.

* Corresponding author. VU University, Fac of Psychology and Educational Studies Van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands.
E-mail address: a.vandijke@psyQ.nl (A. van Dijke).

https://doi.org/10.1016/j.ejtd.2017.11.002
2468-7499/ C 2017 Published by Elsevier Masson SAS.
92 A. van Dijke et al. / European Journal of Trauma & Dissociation 2 (2018) 91–99

Childhood trauma has been shown to be associated with
borderline personality disorder (BPD; Ford & Courtois, 2014), with
sexual, physical, and emotional maltreatment identified in 90% or
more of adults diagnosed with BPD (Alvarez et al., 2011; Van Dijke
et al., 2011; Verdurmen et al., 2007). Childhood trauma also has
been found to be related to several features of BPD, including affect
dysregulation, dissociation, and fear-based or disorganized attach-
ment schemas (D’Andrea, Ford, Stolbach, Spinazzola, & van der
Kolk, 2012). The present study was conducted to simultaneously
test affect dysregulation, dissociation, and fear-based attachment
schemas as potential mediators in the relationship between
childhood psychological trauma and BPD symptoms in adulthood.
1. Dysfunctional affect regulation
mediate the relationship of childhood trauma by primary caretaker
with BPD (Van Dijke, 2012) and of childhood maltreatment with
chronic negative affect in BPD (Gratz, Tull, Baruch, Bornovalova, &
Lejuez, 2008). Latency/pre-adolescent children with BPD symp-
toms were found to have chronic problems with negative affect
and impulsivity/disinhibition that were partially mediated by
emotion-regulation deficits (Gratz et al., 2009). Further, pre/early
adolescent children with histories of emotional abuse were at risk
for developing BPD symptoms only if they also had problems with
under-regulated affect and impulsivity (Gratz, Latzman, Tull,
Reynolds, & Lejuez, 2011). In a community sample of adolescents,
distress intolerance, deficits in adaptive affect regulation, and
impulsivity were independently associated with BPD symptoms
(Fossati, Gratz, Maffei, & Borroni, 2013).

Affect dysregulation can take two forms that may occur
separately or in unison (Van Dijke et al., 2010a; Fig. 1). Under-
regulation involves difficulties in modulating and recovering from
intense negative affect (e.g., rage, despair, impulsivity). Over-
regulation involves, numbing, suppression, or dissociation of
positive and negative affect (Van Dijke et al., 2013). Both over-
and under-regulation of affect have been shown to be associated
with BPD symptom severity (Carvalho Fernando et al., 2014; Van
Dijke et al., 2010a), and under-regulation of affect has been shown
to be associated with BPD diagnosis (Van Dijke et al., 2011) and to
2. Dysfunctional dissociative regulation
Transient but severe dissociative symptoms are another feature
of BPD that have been associated with a history of severe childhood
trauma (Ross, Ferrell, & Schroeder, 2014). Severe dissociative
symptoms, including but not limited to first rank Schneiderian
symptoms also are reported by a large (i.e., 40–50%) sub-group of
individuals with BPD (Korzekwa, Dell, Links, Thabane, & Fougere,
2009; Vermetten & Spiegel, 2014), almost always in combination
with affect dysregulation (Van Dijke et al., 2010b). The combined

Fig. 1. Dysfunctional regulation operating in vicious cycles. Note: A: affect and emotion dysregulation; S: somatic/bodily symptoms; C: cognitive symptoms; I: relational
impairment; R: reflective difficulties; ED: executive dysfunction; B: behavioral action tendencies; PF: psychophysiological symptoms. Van Dijke (2008) described
dysfunctional regulation as operating in vicious cycles that approach the long-term sequelae of trauma-by-primary-caretaker from a developmental perspective.
Dysfunctional regulation may presents in patients in three qualitatively different forms: Inhibitory-, Excitatory-, and combined Inhibitory & Excitatory (IE)-regulation.
Symptoms include disturbances in self-regulation across several domains of functioning including affective, cognitive, somatic, relational, reflective, executive, behavioral,
and psycho-physiological functioning. Activation of dysfunctional regulation seems to follow trauma-by-primary-caretaker associated negatively biased cognitive-emotional
information processing. However, when potentially neutral situations are processed and evaluated as threatening or potentially harmful, dysfunctional regulation is
activated false positively. Inhibitory regulation when activated based upon biased (negative avoidant) cognitive-emotional information processing encompasses, among
others, overregulation of affect, negative psychoform and somatoform dissociation, fear of closeness in adult relationships, inhibited mentalization, narrowed executive
functioning, immobilizing action tendencies, and dominance of the sympathetic system. Consequently, this results in interpersonal misunderstanding and disappointments,
which in turn condition and uphold the insecure attachment representation/working models turning into inhibitory regulation vicious circle. Excitatory regulation when
activated based upon biased (negative-anxious) cognitive-emotional information processing encompasses e.g., under regulation of affect, positive psychoform and
somatoform dissociation, fear of abandonment in adult relationships, pseudo mentalization, overly executive functioning, mobilizing action tendencies, and dominance of the
dorsal vagal system. Consequently, this results in interpersonal misunderstanding and disappointments, which in turn conditions and upholds the insecure attachment
representation/working models turning into an excitatory regulation vicious circle. Combined Inhibitory & Excitatory (IE)-regulation encompasses both inhibitory and
excitatory domains and symptoms that can present alternating or in combinations in patients. It should be noted that dysfunctionally regulated persons, when confronted
with internal or external adverse events, risk to never meet the sense of personal efficacy, resilience, and optimism.
 A. van Dijke et al. / European Journal of Trauma & Dissociation 2 (2018) 91–99
dissociative-dysregulated presentation takes three forms: a
primarily excitatory subtype characterized by under-regulated
affect and positive somatoform and psychoform dissociative
symptoms (e.g., muscle cramps and flashbacks, respectively
intrusions) consistent with severe PTSD (Ford, 1999); an inhibitory
sub-type characterized by over-regulated affective experiencing
and negative somatoform and psychoform dissociative symptoms
(e.g., extreme physical weakness and loss of emotional awareness,
respectively) consistent with alexithymia and dissociative dis-
orders including the dissociative PTSD sub-type (Lanius, Brand,
Vermetten, Frewen, & Spiegel, 2012; e.g., derealization, deperson-
alization); or a combined or alternating excitatory/under-regulat-
ed- and inhibitory/over-regulated presentation consistent with
self-harm and suicidality (Ford & Gomez, 2015), extreme affective
and personality lability (Ford & Courtois, 2014), and the disorga-
nized sub-type of primary caregiver attachment relationships
(Lyons-Ruth, Dutra, Schuder, & Bianchi, 2006).
3. Impaired adult relational regulation
Adult relational impairment such as severe conflict and lability
in adult relationships also is a cardinal feature of BPD (Ford &
Courtois, 2014). Underlying these relational problems in BPD are
schemas of self and others that have been shown to involve shame
(Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2010) and fear of
social rejection and fear of abandonment (Dixon-Gordon, Gratz,
Breets, & Tull, 2013). Both BPD and somatoform disorders have
been shown to be associated with a form of adult attachment
disturbance that also is associated with over-regulation of
emotion: the fear of closeness (Van Dijke & Ford, 2015). In that
sample of adults with BPD or somatoform disorders, under-
regulation of emotion was moderately related to adult fear of
abandonment but weakly related to adult fear of closeness. (Van
Dijke & Ford, 2015). Consistent with these findings, relational
distrust and aggression in BPD have been linked to a tendency to
view primary relationships as rejecting or abandoning (Lazarus,
Cheavens, Festa, & Rosenthal, 2014) or insufficiently protective or
even harmful (Lyons-Ruth, Choi-Khan, Pechtel, Bertha, & Gunder-
son, 2011). These adult fear-based attachment schemas in BPD also
have been described as resulting from childhood primary caregiver
neglect, abuse, invalidation, or impairment (Agrawal, Gunderson,
Holmes, & Lyons-Ruth, 2004; Van Dijke, Hopman, & Ford, 2018;
Zanarini, Yonge, & Frankenburg, 2002).
4. Aim and study hypotheses
Although some studies have addressed the interrelations
between childhood trauma, affect dysregulation, dissociation
and adult attachment schemas, these variables have never been
studied in unison in BPD. Also, this study aims at differentiating
affect dysregulation, dissociation, and adult attachment schemas
in their inhibitory and excitatory forms. In research as well as in
treatment protocols more attention is paid to excitatory symp-
toms. However, inhibitory self and affect regulation can be just as
dysfunctional for social-cognitive-emotional functioning. There-
fore, affect dysregulation, dissociation, and adult fear-based
attachment schemas in unison were hypothesized to be interre-
lated and to jointly mediate the relationship between childhood
trauma and adult BPD symptom severity. As an extension of the
current research literature on developmental paths, both inhibi-
tory and excitatory forms of the putative mediators were assessed
(Fig. 1), as well as differentiating several forms and epochs of
childhood trauma (Teicher & Samson, 2013). To increase the
generalizability of the results, the study was done with a mixed
chronic psychiatric sample including patients diagnosed with BPD
93
with or without a disorder associated with inhibitory forms of
dysregulation (Somatoform Disorders, SoD), and a psychiatric
control sample with no Axis II disorder by chronic anxiety or
affective disorders. Analyses were run for BPD-symptoms for all
participants and re-run separately for participants who reported
sufficiently severe symptoms to meet criteria for a BPD diagnosis.
5. Method
5.1. Procedure and participants
Adult psychiatric patients participated in this multi-center
psychotherapy project (Van Dijke et al., 2010a, 2010b, 2012), with
a protocol approved by the Dutch medical ethics committee for
mental health research (METiGG). In line with the Declaration of
Helsinki, all participants provided written informed consent to
participate after the procedure had been fully explained.
Clinical interviews were conducted by trained interviewers
supervised by the first author, during an initial diagnostic and
evaluation phase following the inpatient psychiatric admission.
Exclusion criteria were assessed, including: history of potential
brain damage (e.g., head injury, electroshock therapy), psychotro-
pic medications that may impair executive function (e.g., anti-
psychotics, neuroleptics, lithium), severe mental illness (i.e.,
bipolar disorder, schizophrenia, other psychotic disorders), eating
disorder with severe underweight, imminent suicidality, and
developmental disorders (i.e., autism spectrum or attention-deficit
hyperactivity disorders). All participants had chronic psychosocial
impairment sufficient to require multiple previous episodes of
inpatient and outpatient psychiatric care.
Participants: Patient characteristics included in the overal
sample (n = 449 sample), M [SD] = 34.7 [10.1] years with range 17–
63 years; 69% female; 62% no primary partner and were diagnosed
with BPD (n = 120), BPD with comorbid somataform disorder
(BPD + SoD, n = 129), or two psychiatric control groups with SoD
only (n = 159) or chronic anxiety or affective disorders (AAD,
n = 64). A sub-group ofparticipants reported sufficiently severe
symptoms to meet criteria for a BPD diagnosis (BPD only = 47%,
BPD + SoD = 53%; n = 244 sample; M [SD] = 31.8 [9.14] years with
range [17-58]; 72% female; 64% no primary partner). No significant
differences other than BPD symptom severity were found for the
subsample versus the full sample. Therefore, re-running SEM
analyses separately with the BPD-diagnosed sub-group is war-
ranted.
Age and gender were significantly related to the study variables
(i.e., age with BPD symptoms, r = .27, fear of abandonment,
r = .28, fear of closeness, r = .11, negative psychoform disso-
ciations, r = .16, and positive psychoform dissociations,
P < 001 to .026); gender with BPD symptoms, r = .10, fear of
closeness, r = .18, positive psychoform dissociations, r = .12, and
positive somatoform dissociations, r = 10, P < 001 to .032), and
were used as covariates in subsequent analyses. Relationship
status was unrelated to study variables and therefore was not used
as a covariate.
5.2. Measures
Borderline personality disorder symptoms were assessed using
the Borderline Personality Disorder Severity Index (BPDSI; Weaver
& Clum, 1993; Dutch version IV, Arntz, 1999). The BPDSI is a semi-
structured interview assessing BPD’s nine features (abandonment,
relationships, self-image, impulsivity, parasuicide, emotion, emp-
tiness, anger, and dissociation and paranoia). Each section contains
items asking about incidents in which a symptom occurred, e.g.,
‘‘Did you, during the last three months, ever become desperate
94 A. van Dijke et al. / European Journal of Trauma & Dissociation 2 (2018) 91–99
when you thought that someone you cared for was going to leave
you?’’ Interviewers score items on a 10-point scale for frequency of
occurrence in the last three months. An average score was
calculated for each section and a total score was the sum of all
section scores (Cronbach’s alphas in this study for the subscales
ranging from .70 to .93; and for the total score .96). The BPDSI has
been shown to have good validity and reliability (Arntz et al.,
2003). For re-running the SEM analyses and to meeting BPD
diagnoses criteria, a severity cut-off score of 20 on the BPDSI-total
score was applied.
Affective and anxiety disorders were assessed using the
Composite International Diagnostic Interview (CIDI; World Health
Organization, 1997; Dutch version: Ter Smitten, Smeets, & Van den
Brink, 1998; administered by AvD) to verify the DSM-IV diagnostic
criteria of SoD and for all cases reliability of diagnosis was
evaluated with clinical coworkers (psychiatrist/clinical psycholo-
gists) to come to a consensus diagnosis of SoD. The CIDI is a
structured clinical interview. Next, SoD diagnosis was confirmed
(and somatic illness ruled out) by independent review by a
specialist in internal medicine. Three groups of SoD patients were
included; patients with somatoform disorder, undifferentiated
somatoform disorder, and patients with a combined conversion
disorder and pain disorder (not body dysmorphic disorder or
hypochondria).
Trauma was measured using the Traumatic Experiences
Checklist (TEC; Dutch version, Nijenhuis, Van der Hart, & Kruger,
2002), a retrospective self-report questionnaire concerning ad-
verse experiences and potential traumatic events. Reports of
potential traumatic events were confirmed interviewing close
relatives in a sub-sample of n = 354 participants, with 100%
agreement. Total trauma score was calculated by the sum of all
scores. Three specific childhood developmental epochs were
considered in the present study (age 0–6 years, age 7–12 years,
and age 13–18 years) and the presence of three types (emotional,
physical, and sexual) of potentially traumatic childhood events
was identified. Whether childhood trauma was perpetrated by a
primary caregiver (TPC) or by another adult or older youth (other
childhood interpersonal trauma, OCIT) also was reported (Van
Dijke et al., 2013). Scores were calculated by summation of positive
items. The TEC has been shown to have good reliability and validity
among psychiatric outpatients (Nijenhuis et al., 2002).
The mediators were assessed in their separate inhibitory- and
excitatory forms:
 dysfunctional affect regulation involves under-regulation and
over-regulation (Van Dijke et al., 2010a; Van Dijke et al., 2010b).
Under-regulation, was assessed with the Dutch self-report
version of the Structured Interview for Disorders of Extreme
Stress Not Otherwise Specified, Revised dysregulated affect sub-
scale, which is internally consistent (Cronbach’s alpha = .75) and
has shown evidence of convergent and discriminant validity
(Van Dijke et al., 2010b) and construct validity (Van Dijke et al.,
2011, 2012) with the current study sample. The sub-scale’s three
items assess: often getting ‘‘quite upset over daily matters’’,
being ‘‘unable to get over the upset for hours or not being able to
stop thinking about it’’, and having to ‘‘stop everything to calm
down and it took all your energy’’ or ‘‘getting drunk, using drugs
or harming yourself’’ to cope with distress;
over-regulation of affect/cognitive alexithymia was assessed
with the Bermond Vorst Alexithymia Questionnaire (BVAQ), a
Dutch forty-item questionnaire with good psychometric quali-
ties (Vorst & Bermond, 2001) for two sub-scales: cognitive
(inhibited verbalizing, identifying, and analyzing emotions) and
emotive (inhibited emotional expressivity and fantasizing) over-
regulation of emotion. The cognitive sub-scale was used to
assess over-regulation to enable comparisons with previous
studies (Waller & Scheidt, 2004, 2006), based on its strong
correlation with the Toronto Alexithymia Scale (TAS-20; Bagby,
Parker, & Taylor, 1994; r = .80) and internal consistency
reliability in the present sample (Cronbach’s alpha = .88);
 dysfunctional dissociatieve regulation involves positive and
negative psychoform and somatoform features (Van Dijke et al.,
2010b). Psychoform dissociation was assessed with the Disso-
ciative Experiences Scale (DES; Bernstein & Putnam, 1986;
Dutch version, Ensink & Van Otterloo, 1989) for negative (e.g.,
amnesia) and positive (e.g., intrusions) psychoform features, and
the Somatoform Dissociation Questionnaire (SDQ-20; Dutch
version, Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Van der
Linden, 1996) for negative (e.g., anesthesia, paralysis) and
positive (e.g., pain, cramps; Nijenhuis, 2004; Van der Hart, Van
Dijke, Van Son, & Steele, 2000; Van der Hart et al., 2006)
somatoform features. The 28-item DES is internally consistent
(Cronbach’s alpha = .95), temporally reliable, and extensively
validated (Ensink & Van Otterloo, 1989; Frischholz et al., 1990)
for positive (items 7, 14, 15, 18, 22, 23, 27) and negative (items 3,
4, 5, 6, 8, 10, 11, 12, 13, 16, 17, 25, 26) psychoform features (Van
Dijke et al., 2010b). The 20-item SDQ-20 is internally consistent
(Cronbach’s alpha = .96) and has demonstrated evidence of
construct validity (Nijenhuis et al., 1996) for positive (items 2, 4,
6, 7, 9, 10, 17) and negative (items 3, 5, 8, 11, 12, 13, 15, 16, 18,
19, 20) somatoform features (Van Dijke et al., 2010b);
 impaired adult relational regulation involves the fear of
abandonment and fear of closeness (Van Dijke, 2012) and was
assessed using the Dutch version of the validated 30-item
Relationship Style Questionnaire (RSQ; Griffin and Batholomew,
1994; Van Dijke, 2002). Dimensional scores (Fortuna & Roisman,
2008) were calculated for fear of abandonment (attachment-
related anxiety; Cronbach’s alpha = .74) and fear of closeness
(attachment-related avoidance; Cronbach’s alpha = .72). The
RSQ has demonstrated good reliability and convergent validity
(Bartholomew & Horowitz, 1991). We recoded the Likert scale,
such that the values ranged from 0 to 4 instead of 1 to 5. To
examine empirically the best approach for operationalizing self-
reported adult relational impairment is the RSQ, an omnibus
measure was used containing all items from several commonly
used adult attachment style assessments (Roisman et al., 2007).
5.3. Data analysis
Using Mplus, version 6.12 (Muthén & Muthén, 1998), mediation
analyses were conducted on continuous scores with path analysis
and the indirect effects were tested with bootstrap 95%-confidence
intervals with the bootstrap sample set to 5,000 estimates. Indirect
effects were considered insignificant when zero appeared in the
confidence interval. When conducting the mediation analyses, a
statistical approach was used as proposed by Muthén and Muthén
(1998) and Preacher and Hayes (2004), following two steps. First, a
model was specified in which BPD symptom severity were
predicted directly by reports of potential traumatic events only
(model 1a). Second, to test for mediation through adult attachment
anxiety/avoidance, affect regulation, and dissociation, candidate
mediators that correlated with reports of childhood trauma and
BPD symptoms were added to model 1 (model 2a). Two alternative
models were specified to explore whether two sub-sets of
childhood trauma by a primary caregiver (models 1b and 2b) or
the type of childhood trauma (models 1c and 2c) served as better
predictors of BPD symptoms than overall childhood trauma
severity. As these models included different predictors from the
first model, they were considered non-nested. Lower Aikake
information criterion (AIC) and Bayesian information criterion
(BIC) values were interpreted as identifying the model with best fit
 A. van Dijke et al. / European Journal of Trauma & Dissociation 2 (2018) 91–99 95

to the data (Burnham & Andersen, 2004). To determine whether
these findings would hold true specifically with patients with BPD
diagnoses, the models were re-tested including only participants
who report more severe symptoms that meet criteria for a BPD
diagnosis (n = 244), leading to model 3 (direct association) and
model 4 (mediation).
6. Results
6.1. Descriptive statistics and bivariate correlations
Table 1 shows that BPD symptoms were positively related to
severity of childhood trauma, as well as to affect dysregulation,
attachment anxiety/avoidance, and dissociation symptoms. Child-
hood trauma severity was positively related to all types of
dissociation, to attachment anxiety/avoidance, and to under-
regulation (but not over-regulation) of affect.
6.2. Mediation analyses
Results depicted in Fig. 2.
Fig. 2a shows that in model 1a, controlling for gender and age, a
direct path between childhood trauma severity and BPD symptoms
was statistically significant (b = .39; AIC = 10,061.3;
BIC = 10,090.1; the direct path is displayed in Fig. 2a between
parentheses). When indirect paths through affect dysregulation,
attachment anxiety/avoidance, and dissociation symptoms were
added to produce model 2a and statistically insignificant paths
(P > .10) were removed, the direct path between childhood trauma
and BPD symptoms reduced in magnitude, but remained statisti-
cally significant (b = .19). There were four significant indirect
paths, involving: positive psychoform dissociation (b = .06),
under-regulation (b = .04), attachment anxiety (b = .07), and
attachment avoidance (b = .03). Model 2a showed adequate model
fits (CFI = 1.00, RMSEA = .03, 90% CI [< .001, .07], SRMR = .02). The
final model (AIC = 16,490.9; BIC = 16,622.3) is depicted in Fig. 2a.
Depicted in Fig. 3 in model d1, the final model was re-run
including only participants meeting or scoring above the severity
cut-off score on the BPDSI for BPD diagnosis (model 3a; n = 244).
The direct relationship between childhood trauma and BPD
symptoms was significant (b = .31; AIC = 5,230.4; BIC = 5,254.8),
and remained so when potential mediators were added, although
with a reduce magnitude of association (model 4a; b = .27). One
indirect mediation path was identified, involving attachment
anxiety (b = .05; AIC = 5,718.8; BIC = 5,760.8).
6.3. Alternative models
Fig. 2b First alternative model distinguishing between child-
hood trauma by a primary caregiver (TPC) and other childhood
interpersonal trauma (OCIT). On a bivariate basis (Table 1), OCIT
was positively associated with under-regulation of affect, attach-
ment anxiety/avoidance, and all features of dissociation, but not to
over-regulation of affect. Results of the first alternative path model
(Fig. 2b) shows a direct path between OCIT and BPD symptoms
(model 1b; b = .29) which was reduced but still significant when
mediators were added (model 2b; b = .15). Three indirect paths
emerged between OCIT and BPD symptoms, involving: positive
psychoform dissociation (b = .06), under-regulation of affect
(b = .05), and attachment anxiety (b = .06). On a bivariate basis,
TPC was positively related to higher levels of attachment anxiety/
avoidance, and all features of dissociation, but not to affect
dysregulation. The direct path between trauma caused by a
primary caregiver and BPD symptoms also was significant (model
1b; b = .14). When adding the potential mediators to the model,
this path became insignificant (model 2b; b = .06), and was fully
mediated by attachment avoidance (b = .04).
This first alternative model showed adequate fit (CFI = .98,
RMSEA = .06, 90% CI [.03, .08], SRMR = .04), but resulted in a poorer
fit with the data (i.e., larger AIC and BIC) than the first (overall
childhood trauma) model (AIC = 17,779.1; BIC = 17,926.9). There-
fore, although the model distinguishing TPC versus OCIT was
empirically viable, it was rejected in favor of the original model
linking overall childhood trauma severity and adult BPD (in
Fig. 2a).
As depicted in Fig. 3 in model d2, when the first alternative
path model was re-run only including BPD-diagnosed partici-
pants (model 3b), the direct path between OCIT and BPD
symptoms remained significant (b = .30). However, the path
between TPC and BPD symptoms was no longer significant
(b = .03). Therefore, the alternative model distinguishing TPC
and OCIT was determined to be untenable for the sub-group of
BPD-diagnosed participants.
Fig. 2c Second alternative model distinguishing forms (sexual,
physical, or emotional) of childhood trauma nested within
developmental epochs (early childhood, middle childhood, ado-
lescent) as paths to BPD symptoms. In bivariate analyses, sexual
trauma and emotional trauma generally were positively related to
affect under-regulation (but not over-regulation), attachment
anxiety/avoidance, and positive and negative psychoform (but
not psychoform) dissociation. Physical trauma generally was
positively related to both types of affect dysregulation, attachment
anxiety/avoidance, and psychoform (but not somatoform) dissoci-
ation only in the adolescent developmental epoch.
Fig. 2c displays direct and indirect associations between
childhood trauma types at different developmental epochs and
BPD severity. A path between adolescent sexual trauma and BP
severity was significant (b = .11), but became insignificant when
mediators were added (b = .06), although no indirect path to BPD
symptoms was significant. The direct path between emotional
trauma in adolescence and BPD severity also was significant

Table 1
Descriptive statistics and pearson correlations coefficients of symptoms of borderline personality disorder, trauma events, and problems in attachment, affect regulation and
dissociation (n = 449).

M SD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

15. Affect over-regulation 75.49 18.20 .17 .03 .06 .02 .05 .09 .09 .03 .01 .03 .09 .12 .15 .11
16. Fear of abandonment 1.89 .75 .46 .25 .17 .25 .04 .08 .14 .18 .23 .27 .17 .19 .21 .28 -.02
17. Fear of closeness 2.34 .82 .33 .17 .27 .11 .21 .20 .17 .20 .21 .22 .22 .26 .25 .15 .45 .08
18. Pos psych of dissociation* 11.05 5.50 .51 .23 .16 .22 .07 .12 .16 .11 .16 .19 .08 .06 .11 .45 .15 .22 .25
19. Neg psych of dissociationa 12.59 6.84 .46 .20 .14 .20 .04 .09 .12 .09 .13 .14 .08 .06 .10 .42 .14 .19 .22 .82
20. Pos somat of dissociationa 2.94 .39 .21 .14 .10 .14 .02 .07 .19 -.04 .02 .05 .04 .02 .09 .23 .10 .10 .05 .38 .42
21. Neg somat of dissociationa 3.87 .68 .24 .15 .09 .16 .03 .06 .17 .01 .01 .06 .03 .03 .06 .31 .08 .14 .08 .42 .51 .60

Note: P < .05, significant correlations are presented in bold; BPD: borderline personality disorder; pos: positive; neg: negative; psychof: psychoform; somatof: somatoform;
TPC: trauma by primary caregiver; OCIT: other childhood interpersonal trauma.
a
Scores are square rooted.
96 A. van Dijke et al. / European Journal of Trauma & Dissociation 2 (2018) 91–99

Fig. 2. Results of SEM analyses for the full sample. Results of the final model (a) with regard to the relationship between childhood trauma and borderline personality disorder
(BPD) symptoms mediated by problems in attachment, affect dysregulation, and dissociation with path coefficients represented as standardized regression weights. The two
alternative models are also depicted; the first alternative model with regard to the relationship between cause of trauma, i.e., trauma by primary caregiver (TPC) and other
childhood interpersonal trauma (OCIT), and BPD symptoms (b), and the second alternative model regarding the relationship between nature of trauma, i.e., sexual trauma
(ST), emotional trauma (ET) and physical trauma (PT), and BPD symptoms (c), both mediated by problems in attachment, affect dysregulation, and dissociation with path
coefficients represented as standardized regression weights. The direct relationships between the predictors and BPD symptoms without accounting for the mediating
variables result in a standardized regression coefficient depicted between parentheses. Insignificant direct relationships (P > .05) are depicted in italic. Models d depict
results for BPDdiagnoses participants only.

(b = .21) and became insignificant when adding the mediating
variables (b = .08). Four indirect paths were identified, via:
 positive psychoform dissociation (b = .05);
 under-regulation of affect (b = .04), (3) attachment anxiety
(b = .07), and;
 attachment avoidance (b = .02).
The direct path between physical trauma in early childhood and
BPD symptoms was also significant (b = .12), but became
insignificant after adding mediators (b = .08). One indirect path
was identified involving attachment avoidance (b = .03). This
second alternative model, depicted in Fig. 2c, showed adequate
model fit (CFI = 1.00, RMSEA = .02, 90% CI [< .001, .05], SRMR = .03;
AIC = 20,676.5; BIC = 20,853.1), but was rejected due to poorer fit
to the data (i.e., larger AIC and BIC) than the first model based on
overall childhood trauma severity.
As depicted in Fig. 3 in model d3, when these analyses were re-
run including only participants diagnosed with BPD (model 3c) the
association between emotional trauma in childhood and BPD
 A. van Dijke et al. / European Journal of Trauma & Dissociation 2 (2018) 91–99 97

Fig. 3. Results of SEM analyses with participants who report more severe symptoms that meet criteria for a borderline personality disorder (BPD) diagnosis. Results of the final
model (a) with regard to the relationship between childhood trauma and participants who report more severe symptoms that meet criteria for a borderline personality
disorder (BPD) diagnosis mediated by problems in attachment, affect dysregulation, and dissociation with path coefficients represented as standardized regression weights.
The two alternative models are also depicted; the first alternative model with regard to the relationship between cause of trauma, i.e., trauma by primary caregiver (TPC) and
other childhood interpersonal trauma (OCIT), and BPD symptoms (b), and the second alternative model regarding the relationship between nature of trauma, i.e., sexual
trauma (ST), emotional trauma (ET) and physical trauma (PT) for developmental epochs (0–6 y; 7–12 y; 13–18 y), and BPD symptoms (c), both mediated by problems in
attachment, affect dysregulation, and dissociation with path coefficients represented as standardized regression weights. The direct relationships between the predictors and
more severe symptoms that meet criteria for a borderline personality disorder (BPD) diagnosis without accounting for the mediating variables result in a standardized
regression coefficient depicted between parentheses. Insignificant direct relationships (P > .05) are depicted in italic. Models d depict results for BPD-diagnoses participants
only.

symptoms was statistically insignificant at all developmental
epochs (ps ranging from .06 to .08). The direct path between
physical trauma in early childhood and BPD symptoms was also no
longer significant (b = .10). However, compared to the results with
the full sample, additional direct paths were found between
childhood trauma and BPD symptoms: sexual trauma in early
childhood (b = .16) and in adolescence (b = .15) were directly
related to BPD symptom severity. The path between sexual trauma
during early childhood and BPD symptom severity remained
significant after adding potential mediating variables (model 4c;
b = .19) and no indirect paths were significant. The path between
sexual trauma during adolescence and BPD symptom severity
became insignificant when mediators were added (b = .13), but no
statistically significant indirect paths were identified.
This last model (AIC = 5,404.5; BIC = 5,443.0) proved to be a
more adequate fit to the data for the sub-sample of BPD-diagnosed
participants than the original model with paths between overall
childhood trauma and BPD severity.
7. Discussion
This study aimed at assessing the relations between trauma
(when differentiating several forms of trauma and several
developmental epochs; Teicher & Samson, 2013) and BPD
symptom severity with affect dysregulation, dissociation, and
adult fear-based attachment schemas in unison and in their
inhibitory and excitatory forms (Van Dijke, 2012) as putative
mediators.
Study results indicate that, as hypothesized, adult affect
dysregulation, dissociation, and problems with attachment par-
tially mediate the relationship between childhood trauma and BPD
symptom severity. However, only a sub-set of types of affect
dysregulation (i.e., under-regulation) and dissociation (i.e., posi-
tive symptoms of psychoform dissociation) consistently mediated
the relationship of childhood trauma with adult BPD symptom
severity. Additionally, both forms of fear-based attachment
schemas were relatively consistent mediators between overall
childhood trauma severity and adult BPD severity. Thus, results
support the hypothesis that hallmark features of BPD—affect
dysregulation involving extreme emotional intensity and lability
(under-regulation), fragmentation of consciousness (positive
psychoform dissociation; e.g., flashbacks), and core attachment
fears of closeness and abandonment—partially account for the
relationship between overall childhood trauma and BPD symptom
severity. The unifying theme for these mediators (with the possible
exception of fear of closeness) is excitatory self-regulation (Van
Dijke, 2008; Van Dijke et al., 2010a, 2010b; 2012), suggesting that
childhood trauma may lead (or increase vulnerability) to BPD
symptoms via several types of excitatory self-dysregulation
(D’Andrea et al., 2012) that involve overwhelming distress related
to primal relational needs for a balance between security and
autonomy (Ford & Courtois, 2014). The inclusion of fear of
closeness in the mediator set suggests that inhibitory self-
dysregulation also may play a role in linking childhood trauma
to adult BPD severity (Zannarini et al., 2002; Van Dijke, & Ford,
2015; Van Dijke et al., 2010b).
In addition, childhood interpersonal trauma that did not involve
primary caregivers, and particularly emotional abuse in adoles-
cence, was strongly associated with adult BPD symptom severity.
As with overall childhood trauma severity, here too the excitatory
forms of self-dysregulation (i.e., under-regulation of affect, positive
psychoform dissociation, and attachment fears) were partial
statistical mediators of this relationship. These findings are
consistent with the growing research literature on the severe
detrimental effects of emotional abuse on biological (Teicher &
Samson, 2013) and psychosocial (Spinazzola et al., 2014)
development. Excitatory dysregulation of affect, consciousness,
and relational schemas have consistently been identified empiri-
cally as facets of BPD, and the findings provide further support for a
link between emotional abuse in adolescence as a focal form of
98 A. van Dijke et al. / European Journal of Trauma & Dissociation 2 (2018) 91–99
interpersonal trauma in childhood linked to BPD via several
pathways of excitatory self-dysregulation.
Both trauma by primary caregiver (TPC) and physical trauma in
early childhood, as well as adolescent (but not earlier childhood)
sexual trauma, were associated with BPD symptom severity.
However, these relationships were less robust and were, respec-
tively, fully mediated by fear of closeness (for TPC and early
childhood physical trauma) or not accounted for by mediator
variables (for sexual trauma). Thus, while these forms of betrayal
trauma (Freyd, 1994) contribute to BPD symptoms, they appear to
do so independently of under-regulation of affect and dissociation.
Consistent with a betrayal trauma formulation, fear of closeness,
an inhibitory form of self-dysregulation (Van Dijke, 2008; Van
Dijke et al., 2010a, 2010b; 2012) may link trauma by a primary
caregiver (Van Dijke et al., 2011; 2015) and physical abuse in early
childhood to BPD symptoms. Other psychosocial processes not
examined in the current study (e.g., shame, moral injury) may
require consideration as links between adolescent sexual trauma
and adult BPD symptoms (Ford & Courtois, 2014).
However, when analyses were re-run for patients who report
more severe symptoms that meet criteria for a BPD diagnosis the
results differed in some important respects from the findings just
discussed based on the full sample. Considering overall childhood
trauma severity, a much simpler model with only one mediator
was identified as a link to adult BPD symptoms: fear of
abandonment. It was not empirically possible to distinguish
different paths to adult BPD symptom severity from trauma by
primary caregiver versus other childhood interpersonal traumas.
On the other hand, a link between sexual trauma in either early
childhood or adolescence and adult BPD symptoms was found.
Somewhat paradoxically, none of the potential mediators could
account for the robust direct link between early childhood sexual
trauma and adult BPD symptoms, while the mediators in total—but
no single mediator alone—accounted for the entire direct
relationship between adolescent sexual trauma and BPD symptom
severity. The findings suggest that adults who report more severe
symptoms that meet criteria for BPD diagnosis are likely to have an
intense fear of abandonment related to early childhood trauma, or
to have experienced sexual trauma in early childhood or
adolescence. These findings suggest that alternative pathways
may lead from childhood or adolescent interpersonal trauma to
severe BPD symptoms, and contribute to and replicate a
substantial research base that highlights sexual trauma in those
two developmental epochs and severe attachment insecurity (and
disorganization) as contributors to adult BPD (Ford & Courtois,
2014).
This study has methodological limitations that can inform
future research. First, all study measures were obtained on a cross-
sectional retrospective basis, and therefore the identified associa-
tions cannot be used to make causal or predictive inferences
without replication by prospective studies. The association
amongst study variables thus may reflect the influence of BPD
symptoms on the recollection and reporting of childhood traumas,
as well as on problems in attachment, affect dysregulation, and
dissociation, rather than actual mediating mechanisms (Ford &
Courtois, 2014). Second, the reliance on participant self-report may
have yielded biased results compared to data based on other
informants (e.g., current family members, past adult caregivers
such as school teachers). Third, the predictor variables also were
moderately to highly inter-correlated, and thus the variables
identified as best contributing to each path model may have been
chosen over other related variables based upon relatively small
differences in their actual contribution to the model. Fourth, the
sample, although large and including patients with and without
BPD diagnoses—which increases the generalizability of findings—
was composed of only chronic and treatment-refractory psychiat-
ric inpatients (including a large sample with primary somatoform
disorders, and none with psychotic or other serious mental
illnesses), and thus was not representative of the larger population
of adult severe mental illness inpatients. Replication across varied
psychiatric samples with a multiple wave prospective assessment
design beginning in childhood or adolescence and multiple
informants will be necessary to establish definitive portrayal of
the complex pathways linking childhood trauma and borderline
personality disorder.
With regard to clinical implications of the present study, the
results warrant carefully differentiating childhood trauma features
and self-regulation strategies during intake or assessment for
treatment planning and understanding of the complex therapeutic
relationships with patients with BPD symptoms. Patients reporting
early physical abuse by primary caretaker who manifest inhibitory
forms of self-dysregulation such as fear of closeness may focus on
overcoming denial of intimacy in relationships and safely
exploring emotional experiencing, and may benefit from treatment
designed to enable them to experience healthy past and current
relationships as safe and nurturing (Van Dijke, 2008). Patients who
experienced adolescent emotional or sexual trauma and present
with BPD symptoms may benefit from treatment designed to
enable them to reduce excitatory self-dysregulation by developing
or strengthening their abilities to regulate affect, consciousness,
and attachment schemas (Ford & Courtois, 2014). Finally, patients
diagnosed with BPD who have particularly severe and acute
symptoms may benefit from treatment designed to enable them to
work through fears of abandonment and betrayal, specifically in
relationship to past childhood interpersonal trauma.
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