Murray1993 PDF
Murray1993 PDF
Murray1993 PDF
Relationship of Childhood
Sexual Abuse to Borderline
Personality Disorder,
Posttraumatic Stress Disorder,
and Multiple Personality
Disorder
a
John B. Murray
a
Department of Psychology , St. John's University ,
USA
Published online: 02 Jul 2010.
To cite this article: John B. Murray (1993) Relationship of Childhood Sexual Abuse to
Borderline Personality Disorder, Posttraumatic Stress Disorder, and Multiple Personality
Disorder, The Journal of Psychology: Interdisciplinary and Applied, 127:6, 657-676,
DOI: 10.1080/00223980.1993.9914905
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The Journal of Psychology, 127(6),657-676
JOHN B. MURRAY
Department of Psychology
St. John’s University
ABSTRACT. In this article, I have reviewed recent research into the relationship between
childhood sexual abuse and borderline personality disorder, posttraumatic stress disorder,
and multiple personality disorder. Evidence that such a relationship exists appears con-
vincing.
A LARGE BODY OF NEW RESEARCH has shown that sexual abuse of children
is a social pattern of major importance (Bagley & King, 1990; Cozolino, 1989;
DeJong, Hervada, & Emmett, 1983; Paris & Zweig-Frank, 1992; Putnam, 1991;
Young, Sachs, Braun, & Watkins 1991). As the literature has grown, its orienta-
tion has focused more on the victims, and evidence suggests that the conse-
quences of childhood sexual abuse may be severe and long lasting (Alexander &
Lupfer, 1987; Alter-Reid, Gibbs, Lachenmeyer, Sigal, & Massoth, 1986; Brernner,
Southwick, Johnson, Yehuda, & Charney, 1993; Bryer, Nicholson, Miller, & Krol,
1987; Burnam et al. 1988; Figley, 1985; Gelinas, 1983; Harter, Alexander, & Nie-
meyer, 1988; Herman, 1986; Jackson, Calhoun, Amick, Maddever, & Habif,
1990; Johnson & Kenkel, 1991; Kendall-Tackett, Williams, & Finkelhor, 1993;
Kinzl & Bieble, 1992; Pribor & Dinwiddie, 1992; Russell, 1986; Shearer, Peters,
Quaytman, & Ogden, 1990; Summit & Kryso, 1978; Terr, 1991).
Researchers have shown that in some instances borderline personality disor-
der (BPD), multiple personality disorder (MPD), and posttraumatic stress disor-
der (PTSD) in adulthood may be traced to childhood sexual abuse (Brown &
657
Anderson. I99 I ; Goldman. D' Angelo, DeMaso, & Mezzacappa. 1992; Herman,
Russell. & Trocki. 1986; Putnam. 1991; Ross, et al. 1990; Ross. Norton, & Woz-
ney, 1989: Schafer, 1986; Westen, Ludolph. Misle. Ruffins, & Block, 1990;
Wolfe. Gentile. & Wolfe, 1989). The relationships between these three psychiatric
states and childhood sexual abuse are the focus of this review.
The incidence of child sexual abuse is difficult to estimate, partly because of
differences in its definition and the varied factors that can contribute to its impact
including the age of the victim, the relationship to perpetrators, and family char-
acteristics (Alexander & Lupfer, 1987; Bentovim. Boston, & Van Elburg, 1987;
Brickman & Briere. 1984; Brown & Anderson, 1991; Browning & Boatman,
1977; Byrne & Valdiserri, 1982; Donaldson & Gardner, 1985; Finkelhor & Hota-
ling, 1984: Green, 1984; Harter et al., 1988; Hunter, Kilstrom, & Loda, 1985:
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Pribor & Dinwiddie, 1992; Russell, 1983, 1986; Shearer et al., 1990: Storr. 1979;
Straus. 1979; Wolfe, 1985; Wyatt, 1985: Wyatt & Peters, 1986).Reports of child-
hood sexual experiences based on clinical or court case populations may tend to
overestimate the scope of the problem (Sedney & Brooks, 1984). And victims
often have been unaware of the possible relationship between their presenting
symptoms and sexual abuse. Even when they sought psychotherapy, they rarely
disclosed the abuse (Brickman & Briere, 1984; Bryer et al., 1987; Carmen,
Rieker. & Mills, 1984; Gelinas. 1983; Rosenfeld, 1979; Vander Mey, 1988).
A survey of incestuous abuse in childhood in a nonclinical group of 152
women in San Francisco and 53 female outpatients in short-term therapy in Bos-
ton indicated that. although the majority of the women had been upset by the
experience, almost one half said they had recovered well, and about one quarter
were unaware of any long-term effects (Herman et al.. 1986). From a review of
recent empirical studies of the impact of sexual abuse on children, it appeared that
no specific syndrome followed from sexual abuse. that within 12 to I8 months of
the abuse two thirds of the children studied showed signs of recovery, and that
about one half of the children had no symptoms (Kendall-Tackett et al., 1993).
Identified patterns of typical victim behavior are similar across different kinds of
disaster (Bagley & King. 1990). The potential of error in retrospective reports of
childhood experiences has to be considered in interpreting reports of sexual child
abuse (Brewin, Andrews, & Gotlib, 1993; Green, 1986). Children under 7 years
old may have difficulty distinguishing fantasies and reality. but they rarely fanta-
size or fabricate sexual encounters (DeJong, 1985; Nurcombe, 1986).
Women are the victims of childhood sexual abuse in a ratio of 10:1 over men,
who have not received as much study as needed (Brown & Anderson, 1991; Jason,
Williams, Burton. & Rochat. 1982; Ross. I99 I ). Children from families of a lower
socioeconomic level predominated among 566 children brought to a sexual as-
sault crisis center, and in 14.9% of the children, evidence of trauma was present
(DeJong et al. 1983). However. sexual abuse occurs at all socioeconomic levels
(Alexander & Lupfer, 1987). and childhood sexual abuse is predominantly intra-
familial (Brown & Anderson. 1991; Herman, 1986).The majority of perpetrators
Murray 659
are men, most often natural fathers or stepfathers of victims (Carmen et al., 1984;
Hunter et al., 1985; Husain & Chapel, 1983; Margolin, 1992; Russell, 1983). The
relationship of the child to perpetrator is a critical factor because abuse by a rela-
tive or caretaker is more harmful to the child than extrafamilial abuse (Paris &
Zweig-Frank, 1992).
The closer the sexual act is to intercourse the more serious the consequences
at early ages. Effects can be lessened if the incidents are disclosed and if reaction
is appropriate and action is taken to prevent recurrence. The support that victims
receive is an important variable that is rarely included in reports of victims’ expe-
riences (Alexander & Lupfer, 1987).
The deleterious effects of childhood sexual abuse on development have been
associated with symptomatology that includes elements of numerous psychiatric
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diagnostic categories (Chu & Dill 1990; Craine, Henson, Colliver, & MacLean,
1988; Pribor & Dinwiddie, 1992). The profile of female survivors may include
sexual dysfunction, vulnerability to further sexual abuse, promiscuity, homosexu-
ality, distrust of others, and substance abuse (Alexander & Lupfer, 1987; Alter-
Reid et al., 1986; Beitchman, Zucker, Hood, DaCosta, & Akman, 1991; Brown &
Anderson, 1991; Gelinas, 1983; Jackson et al., 1990; Jennings & Armsworth,
1992; Ogata et al., 1990; Simons & Whitbeck, 1991).
The first-born child, especially a girl, is most at risk of sexual abuse (Ben-
tovim et al. 1987). She is often forced into substitute roles that contribute to confu-
sion about her own sexual role development (Browning & Boatman, 1977). Incest
very often includes the element of violating the young girl’s will (Stone, 1981).
Chronic victimization of this kind cannot help but have a debilitating impact on
the psychic development of the victim. The effects usually include impaired rela-
tions with and mistrust of men, inordinate preoccupation with sexual themes, and
impulsivity in the area of sex. Victims may develop severely self-depreciating
attitudes, as though they had been instigators rather than victims (Briere &
Runtz, 1986).
The dynamics of the sexual abuse of boys and girls have little in common
(Vander Mey, 1988). The abuse experiences of boys are poorly understood as
are the possible psychiatric consequences (Brown & Anderson, 1991). Boys are
sexually abused at a younger age and more often by nonfamily members than are
girls. Male victims frequently suffer silently, often victimizing themselves, and
when they come for help, they more often present their problems in a masked way
(Hunter et al., 1985).
Appropriate sexual development may be derailed by early childhood sexual
abuse (Alter-Reid et al. 1986; Bagley & King, 1990). Sexual abuse can over-
whelm children’s desperate efforts to cope, and they may flee inward when flight
from the external situation seems impossible (Kluft, 1987a). The disruption of
relationships with primary caretakers appears to be an important factor in the
development of psychiatric disorders (Herman, Perry, & van der Kolk, 1989).
When 372 female survivors of sexual assault who came to a university clinic were
compared with 99 women who had no history of sexual assault, 58% of the survi-
vors experienced sexual dysfunction as opposed to 17% of the control group
women (Becker, Skinner, Abel, & Cichon, 1986).
In a report by Simons and Whitbeck (1991), early childhood sexual abuse
also seemed to be a frequent part of the background of young women who
ran away from home and into prostitution. Oppenheimer, Howells, Palmer, and
Chaloner’s ( 1985) study of 78 consecutive female patients in an eating disorder
clinic, two thirds of whom had been victims of childhood sexual abuse. indi-
cated that their eating disorders were linked to feelings of inferiority or disgust
about their own femininity and sexuality, feelings that became entangled with
concern about their body size and shape. Root (1991) and Shearer et al. (1990)
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ality disorder, or PTSD, very often had been sexually abused in their childhood
(Herman, 1986; Lindberg & Distad, 1985; Terr, 1991).
Sixty-six female psychiatric inpatients consecutively admitted to a private
psychiatric hospital had a high ratio of childhood sexual and physical abuse, pat-
terns that correlated with the severity of adult psychiatric illness (Bryer et al.,
1987). Most of the perpetrators of the abuse were family members. Patients’ re-
sponses to a questionnaire indicated that 72% had had a history of childhood
sexual abuse and that abuse was more common among the adults who developed
major mental illness than had been suspected.
Brown and Anderson ( 1 990) interviewed 947 psychiatric inpatients consecu-
tively admitted to a military medical center. The authors questioned all the pa-
tients about their abuse history, and their DSM-111-R diagnoses were recorded.
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Sexual abuse was reported by 9% of the sample and by significantly more women
than men. In the abused patients, borderline personality disorder accounted for
48% of the DSM-111-R diagnoses.
Investigations of long-term effects of childhood sexual abuse have been done
in nonclinical populations. Sedney and Brooks (1984) asked 301 college women
for a history of their “sexual experiences involving other people while they were
growing up.” The authors preferred this broad definition of childhood sexual
abuse to avoid a priori decisions of what types of sexual experiences are problems.
Participants were students in both Catholic colleges and public tax-supported col-
leges, and from lower and middle class backgrounds to avoid differences traceable
to socioeconomic or religious differences. Fifty-one (16%) of the college women
reported childhood sexual experiences. Adults who had been victims were sig-
nificantly more likely to have symptoms of depression and anxiety than college
women who had not been abused.
In Sedney and Brooks’s (1984) study, those whose childhood sexual experi-
ences were with family members were at greater risk for disturbance than women
whose experiences were extrafamilial. Three quarters of the sexual experiences
had occurred before they were 12 years old. Younger children are more home-
bound, and not surprisingly, 72% of their sexual experiences were with family
members, whereas only 36% of the sexual experiences that occurred after 12 years
of age involved family members.
College women who experienced childhood sexual abuse, compared with
their peers and with 5 1 women in a control group, were more likely to have psy-
chiatric problems, and negative consequences were more evident when their sex-
ual experiences involved family members rather than when the experiences were
extrafamilial. Fifteen of 18 symptoms, symptoms of anxiety and depression as
well as thoughts of hurting themselves, were more likely in those who had experi-
enced early childhood sexual abuse. Survey data offer only correlational relation-
ships and do not establish cause-effect, but reports suggest that childhood sex-
ual experiences frequently are associated with symptoms of disturbances later in
life.
Another investigation using a nonclinical population of college women be-
gan with 29 women who had been sexually abused by family members and a
control group of 56 women who had no such history (Harter et al., 1988). The
college women responded to a scale of family adaptability and cohesion and a
standardized interview measuring their social adjustment. They also rated them-
selves, men in general, women in general, and 10 figures in 10 standardized inter-
personal constructs. From their data and that reported by Alexander and Lupfer
( 1987). it appeared that those who were victims of sexual abuse before they were
I8 years old were likely to perceive themselves as socially isolated, as possessing
poorer social adjustment, and as members of less cohesive and adaptable families.
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When the results of direct interviews in the homes of those who had experi-
enced sexual assault were compared with the responses of those with no such
history, sexual assault predicted later development of major depressive disorders,
anxiety disorders, and substance abuse (Burnam et al., 1988). Their sample was
large, 3.132 adults. Also, those who had been assaulted as children in comparison
with those assaulted in adulthood were more likely to report subsequent develop-
ment of a mental disorder.
Because samples in childhood sexual abuse studies often are small and
drawn from treatment populations. one must be cautious in drawing conclusions
from their findings. But studies using larger numbers of nonclinical populations
have tended to confirm findings based on smaller groups of patients, and both
suggest that child sexual abuse may have lasting consequences. Among the varied
possible consequences in adulthood, considerable research has been directed
toward borderline personality disorder, multiple personality disorder, and to a
lesser extent, posttraumatic stress disorder.
patients report childhood histories of sexual abuse (Herman et al., 1989; Paris &
Zweig-Frank, 1992; Perry, Herman, van der Kolk, & Hoke, 1990; Shearer et al.,
1990). Browne and Finkelhor’s (1986) review of empirical results found a wide
range of difficulties associated with child sexual abuse, and the psychogenic fac-
tors can create a borderline psychopathology (Stone, 1981). Girls are more likely
than boys to be victims, and women more often than men have been assigned the
borderline diagnosis (Herman et al., 1989).
A large number of studies have reported a high frequency of childhood sex-
ual abuse among those with a BPD diagnosis (Ogata et al., 1990; Shearer et al.,
1990). In a Canadian study, 88 inpatients diagnosed as BPD, when compared with
42 inpatients matched in socioeconomic class and education level, were signifi-
cantly more likely to have been victims of sexual abuse by caretakers (Links,
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Steiner, Offord, & Eppel, 1988). BPD was the most common diagnosis in 66
female psychiatric inpatients who had been sexually abused as children (Bryer et
al., 1987). The victims continued to experience long-standing negative conse-
quences of their childhood experiences, and the seventy of adult psychiatric
symptoms correlated with the childhood sexual and physical abuse.
In the Goldman et al. (1992) study, 44 children, outpatients diagnosed as
BPD at a pediatric hospital clinic, were significantly more likely to have experi-
enced physical and combined physicaYsexual abuse than 100 children in a control
group with a wide range of diagnoses other than BPD. These findings with chil-
dren corresponded to the results of studies of adult BPD patients who have had a
history of childhood sexual abuse. The prevalence of sexual abuse in these chil-
dren (38%) was smaller than the rates (between 60% and 80%) in adults. Most of
the children in this study were boys, a pattern that differs from the usual largely
female samples in most studies of BPD adults.
As one facet of a longitudinal study, 21 patients diagnosed as BPD were
compared with 11 schizotypal personality disorder patients and 23 bipolar I1 de-
pression patients (Herman et al., 1989). Their results showed a strong association
between the BPD diagnosis and a history of abuse in childhood. Responses to a
semistructured interview consisting of 100 items indicated that significantly more
BPD patients had histories of childhood trauma, and two thirds of the BPD pa-
tients had experienced childhood sexual abuse. BPD patients suffered from expe-
riences of sexual abuse more commonly than patients with other psychiatric disor-
ders, and their traumatic experiences began earlier in childhood and were repeated
over a longer time period.
The victims of childhood sexual abuse commonly did not perceive a direct
connection between their current symptoms and their childhood abuse. BPD ad-
aptation to the childhood traumatic experience of sexual abuse may be less ex-
treme than that of multiple personality disorder, and anxiety and panic disorders
might represent adaptation to more circumscribed events. The same group of 21
BPD patients had rates of childhood sexual abuse (68%) significantly greater than
rates of 23 patients who were not BPD (Perry et al., 1990).
Twenty-four BPD patients. 19 women and 5 men. reported significantly
higher rates of childhood sexual abuse than the I8 in a control group of depressed
patients. 13 women and 5 men (Ogata et al., 1990). All the subjects were in-
patients in a university medical center, and all had been interviewed regarding
recollections of a variety of childhood and family events by team members
who were blind to their diagnosis. In most cases the sexual abuse experienced
by the BPD patients. often together with physical abuse, had occurred before
age I?.
Stepwise regression performed with diagnosis as the dependent variable in-
dicated that sexual abuse was the best predictor of BPD diagnosis for all the pa-
tients and for female patients taken alone. When only female patients were in-
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cluded, stepwise regression with sexual abuse as the dependent variable pointed
to a diagnosis of BPD as the strongest significant predictor of childhood sexual
abuse. Because the number of patients was small and all were inpatients, general-
izations must be limited, but other studies’ findings have yielded similar results.
Their results suggested that a history of sexual abuse is frequently associated
with BPD.
In another investigation at a university medical center, female patients were
divided almost equally between 27 BPD and 23 control patients (Westen et al.
1990). Review of their records showed that 80% of the BPD group had been
sexually abused and most of the abuse had been documented. Most of the sexual
abuse had occurred in the latency years when ego structuring and character devel-
opment occur and begin to solidify. Sexual abuse seemed likely to disturb im-
portant psychological developmental processes, self-esteem, relationships with
others, trust, and capacity to regulate feelings. Their results suggested that a his-
tory of sexual abuse is frequently associated with BPD. Brown and Anderson’s
(19911) investigation of the long-term effects of childhood sexual abuse in 947
inpatients at a military medical center showed that BPD was more frequent in
abuse victims than in nonabused patients.
The Shearer et al. ( 1990) investigation of suicidal behavior in 40 female BPD
inpatients found that 40% of them had a history of childhood sexual abuse. Etiol-
ogy cannot be inferred from a correlational approach but the trend in the literature
in this area surely points to a need for reexamination of the relationship between
childhood sexual abuse and BPD. Childhood sexual abuse often occurs in the
context of other family problems, including parental alcoholism, depressive disor-
ders, and family fragmentation. Hence, victims of childhood sexual abuse may
also be weighed down with other conditions, such as multiple developmental
trauma, that may compound the impact of victimization. Sexual abuse may, how-
ever, be a contributor in a subgroup of BPD subjects.
While the cause of BPD is not agreed upon, a 60% to 80% prevalence of
childhood abuse, particularly sexual abuse, i n adults with BPD has emerged from
data drawn from both inpatient and outpatient psychiatric settings (Goldman et
al., 1992). Some of the symptoms of BPD may reflect a history of severe and
Murray 665
repetitive trauma and some of the trauma of abuse may contribute to the border-
line patients’ difficulties in handling emotion.
However, patients who meet the criteria of BPD are heterogeneous, and no
one factor is recognized as the cause of BPD (Paris & Zweig-Frank, 1992). Also,
childhood sexual abuse may be associated with many pathogenic development
factors such as the type of sexual act, the duration, frequency, age at onset, and
type of family environment (Goldman et al., 1992; Jackson et al., 1990; Paris &
Zweig-Frank, 1992).
BPD sufferers generally do not perceive a direct connection between their
current symptoms and the abusive experience in childhood so that inclusion of an
inquiry and assessment of sexual abuse experiences would be recommended in
treating BPD patients (Brown & Anderson, 1991; Herman et al., 1989). Focusing
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on the relation between childhood sexual abuse and their symptoms might help
BPD patients organize their experiences. Etiological theories are needed that ex-
plain the interaction of important risk factors, especially the significantly greater
rate of histories of sexual abuse among BPD patients than among their peers.
Symptoms of one third of 19 children who received a BPD diagnosis also fit
the criteria for PTSD (Famularo, Kinscherff, & Fenton, 1991). Underlying psy-
chodynamic properties suggest relationships between BPD and MPD, and the
parallels between BPD and PTSD may help link child sexual abuse and subse-
quent development of BPD (Goldman et al., 1992; Gunderson, & Sabo 1993;
Herman et al. 1989; Horevitz & Braun, 1984).
general responsiveness that may involve loss of ability to have loving feelings,
heightened bodily arousal. recurrent nightmares, or flashbacks (Murray, 1992).
PTSD involves impaired functioning following exposure to an event that is out-
side the range of usual human experiences and that would be disturbing to nearly
everyone (DSM-111-R, 1987).The diagnosis is not made unless the disturbance is
endured for at least I month. Sometimes the symptoms do not begin until 6
months or more after the trauma. PTSD is classified as an anxiety disorder in
DSM-111-R. but it differs from other anxiety disorders in that it involves a stress-
related disorder that follows a traumatic experience.
Clinical descriptions of 53 adult short-term outpatients in therapy who had
a history of childhood sexual abuse, compared with 152 women who responded
to a survey. were consistent with PTSD formulation (Herman et al., 1986). In a
sample of 105 female psychiatric patients who were sexually abused as children
or adolescents and drawn randomly from 9 of 1 1 state hospitals. 66% met the
criteria for PTSD (Craine et al. 1988). None had received that diagnosis. A history
of sexual abuse may be a significant factor contributing to psychopathology severe
enough to require hospitalization. In comparisons of patients. 70% of the sexually
abused as opposed to 5 1% of the nonabused group came from families with his-
tories of psychiatric illness. Patients' experience of this unstable family environ-
ment along with childhood sexual abuse may have contributed to their hospitaliza-
tion and PTSD diagnosis.
The reactions of 7 I sexually abused children who were referred by a child
protection agency were likened to PTSD (Wolfe et al., 1989). An extensive battery
of tests was administered to the children in their homes, and other tests were given
orally in the university clinic. Their mothers' ratings of the children met the PTSD
criteria. All the perpetrators of the abuse were men and 83% of these were family
members or lived in the same house as the children. Individual and contextual
factors, such as the age of the child and severity of the sexual abuse. seemed to
mediate its impact.
In Lindberg and Distad's ( 1985) report. I7 women sexually abused in child-
hood had entered therapy with a variety of presenting complaints that fitted
closely DSM-111 (1980) criteria for PTSD. All the women regarded these events
Murray 661
as the most damaging of their lives. None was aware of the relationship between
their symptoms and the childhood sexual experience. Long-term psychological
effects are difficult to relate to causes.
Brewer et al. (1993) compared the rates of childhood abuse in 38 Vietnam
combat veterans seeking treatment for PTSD with 28 Vietnam combat veterans
who sought treatment for medical disorders not related to FTSD. Those with
PTSD had higher rates of childhood sexual abuse than the comparison group.
Veterans with FTSD also had significantly higher rates of traumatic experiences
before joining the military. The association between child sexual abuse and FTSD
persisted after the level of combat exposure i n the two groups was controlled.
However, 74% of patients with PTSD in this study did not report a history of
childhood abuse on the 5 1-item self-report questionnaire that assessed a broad
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(Coons, & Milstein, 1986; Kluft, 1987a; Putnam, 1991 ; Ross, Anderson,
Fleisher, & Norton, 1991: Stem. 1984).
Several studies have linked childhood sexual abuse with the development of
dissociative symptoms (Gelinas, 1983). The majority of 98 female psychiatric
inpatients, who had experienced physical and/or sexual abuse, also reported
higher levels of dissociative symptoms than those not abused (Chu & Dill, 1990).
Some children who are sexually abused may learn to dissociate parts of them-
selves and develop alternative personalities that may be a means of psychologi-
cally escaping from their emotional pain (Greaves, 1980; Spiegel, 1984). Alter-
nate personalities may enable sexually abused children (superficially) to function
sexually (Coons & Milstein. 1986).
Sometimes imaginary playmates, a normal childhood phenomenon, and
dolls or puppets are drawn into the creation of secondary personalities (Bliss,
1984, 1986; Coons, 1980). These secondary personalities may also enable chil-
dren 10 act out impulses that would be unacceptable to the primary personality. A
few children who suffer extreme childhood sexual abuse over longer periods may
become unable to maintain an integrated personality (Schafer, 1986). Children
with more active and creative imaginations may be more prone to construct alter-
nate personalities as a defense against the sexual abuse. If the traumatic experi-
ences of sexual abuse occur early enough during the period of ego and identity
formation, BPD may develop, whereas MPD may develop if the traumatic epi-
sodes occurred relatively late in the period of ego formation (Greaves. 1980).
Coons and Milstein (1986) found a 75% incidence of sexual abuse in 20
MPD patients, significantly more than in 20 psychiatric patients i n a control
group. Coons, Bowman. and Milstein ( 1988) studied 50 consecutive MPD pa-
tients using a psychiatric interview, a neurological exam, EEG. MMPI, intelli-
gence test, and several psychiatric rating scales. Clinical history frequently
showed childhood trauma, particularly sexual abuse. Childhood trauma was
strongly associated with MPD that began in childhood as a defensive response to
overwhelming trauma.
Putnam et al. (1986) conducted one of the first large-scale investigations of
MPD patients in which they reported the results of a standardized questionnaire
Murray 669
of 366 items sent to 400 clinicians across North America who were treating a
MPD patient. As part of the questionnaire, evidence for a link between childhood
history of trauma and development of MPD symptoms was sought. One hundred
cases of MPD were selected from the cases of 92 clinicians including almost
equal numbers of psychiatrists and psychologists and a few with masters’ degrees
in social work; most of the clinicians were men. All but three of the 100 cases
had a history of significant childhood trauma, and sexual abuse occurred in 83%
of the cases of childhood trauma.
Ross et al. (1990) gathered information on 102 cases of MPD from four
centers, two in Canada and two in the United States. All the patients were inter-
viewed using the same instrument and data that was sent to a coordinating center
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Discussion
Although the literature on childhood sexual abuse has proliferated, investigation
of its lasting consequences is in the beginning stages. Methodological problems
are almost inevitable, given the different definitions of sexual abuse, the small
numbers and treatment populations investigated, the frequent use of retrospective
and correlational approaches that preclude cause-effect conclusions, and the lim-
ited statistical analysis of results.
However, despite the limitations of these investigations, clinicians have re-
ported that abused subjects seeking treatment display consistent characteristic
symptoms similar to those described in various studies and that these findings
need to be addressed. Investigations have shown that victims of childhood sexual
abuse exhibit symptoms that include poor self-esteem, anxiety, feelings of isola-
tion, interpersonal dysfunction, in some cases self-destructive behavior, and sub-
stance abuse. These symptoms fit the criteria for many psychiatric disorders, and
the literature tends to support the higher prevalence of many psychiatric disorders
in those who have a history of childhood sexual abuse. The rate of childhood
sexual abuse history is very high in MPD, and high in BPD and in PTSD patients.
An alternative explanation for the association between childhood sexual
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abuse and psychiatric disorders may lie in family background. Using this ap-
proach, the sexual abuse could be viewed as a prevalent marker for a severely
dysfunctional family environment, which plays the major role in the origin of
interpersonal problems leading to development of psychiatric problems. Child-
hood sexual abuse often occurs in the context of other family problems including
parental alcoholism, depression, physical handicaps, or death of a parent. Child
abuse victims in some nonclinical studies recalled their family life as chaotic,
fragmented, less cohesive, and less adaptable.
Fathers and stepfathers most often were the perpetrators of sexual abuse. The
impact of mothers who remained passive and failed to protect or support the chil-
dren has not been studied. Mothers’ lack of support, as described in victims’ re-
ports. was often disastrous and contributed strongly to their feelings of help-
lessness and isolation.
Victims may acquire characteristic methods of coping with stressful experi-
ence that may increase their vulnerability to subsequent sexual abuse and sexual
maladjustment. In some reports, feelings of isolation and helplessness drove the
women to run away from home and into prostitution. Evidence for the develop-
ment of MPD from the youthful dissociative strategies for coping with and surviv-
ing childhood sexual abuse has been investigated in studies with large numbers
and sophisticated statistical design.
Many studies indicated that victims were not identified as such while they
were patients in psychiatric facilities or at mental health agencies. The victims
often did not voluntarily reveal their sexual abuse history and in some instances
did not see the connection between their current psychiatric problems and their
history of abuse. Some studies have recommended inclusion of routine ques-
tioning about sexual abuse at the beginning of psychotherapeutic intervention and
again later when the psychotherapeutic alliance has been established. Particularly,
evidence of physical abuse can be a reason for inquiring about sexual abuse be-
cause they so frequently occur together, although the motivation for each may
be differel’.
Sexual abuse in childhood has been linked to adult psychiatric problems in
many investigations. Whether childhood sexual abuse is a cause of or contributor
Murray 671
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