Dissociative Symptoms and the Quality of Structural Integration in Borderline Personality Disorder Shirey Sole D.Clin.Psy. Thesis (Volume 1), 2014 University College London Declaration I, Shirey Sole, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Signature: Date: 2 Overview This thesis explores the etiology and characteristics of dissociation and structural integration in borderline personality disorder (BPD). This dissertation is a part of a joint project co-led with Daniel Ghossain (2014). Part 1, the literature review, evaluates the efficacy of psychological interventions in treating dissociation and the impact of dissociation on therapy outcome. 20 randomized control trials and observational studies were reviewed. Psychological interventions were not superior to treatment as usual. Outcome of dissociation was moderated by dissociation at baseline and application of narrative based therapeutic techniques. Standard interventions for BPD show promising results for effectively targeting dissociation. However, further research is required. Part 2, the empirical paper, assesses the relevance of structural integration in understanding BPD. The etiology of dissociative experiences in BPD was of particular interest. As expected the results show that BPD patients present with distinct personality structure compared to healthy controls. History of adverse early experiences and level of psychopathology were associated with the quality of structural integration. The impact of childhood trauma on dissociation was partially mediated by structural integration, suggesting of a complex developmental trajectory of this symptom of BPD. Part 3, presents a critical appraisal of the process of undertaking this research. It reviews methodological and theoretical issues in the diagnosis of BPD, study of dissociation, and structural integration that were encountered while writing this thesis. This section also reflects on the challenges of the study and the learning points that can inform future research. 3 Table of Contents Acknowledgements ........................................................................................................ 10 Part 1: Literature Review ............................................................................................. 11 Are Psychological Interventions for BPD Effective in Reducing Dissociative Symptoms? Abstract ........................................................................................................................... 12 1. Introduction ................................................................................................... 13 1.1. Dissociation in BPD ........................................................................... 14 1.2. Psychological interventions ................................................................ 15 1.3. Aims and objectives ........................................................................... 16 2. Methods ......................................................................................................... 23 2.1. Search strategy ................................................................................... 23 2.2. Search terms ....................................................................................... 23 2.3. Study selection ................................................................................... 24 2.4. Method of appraising studies ............................................................. 25 2.5. Synthesis ............................................................................................. 25 3. Results ........................................................................................................... 28 3.1. Overall study quality .......................................................................... 29 3.2. Efficacy Studies .................................................................................. 31 3.3. Prospective Studies ............................................................................. 39 3.4. Moderators of improvement in dissociation ....................................... 49 3.5. Dissociation as a moderator of therapy outcome ............................... 50 4. Discussion ..................................................................................................... 51 4.1. Summary of findings .......................................................................... 51 4 4.2. Comparison to findings from previous reviews ................................. 52 4.3. Implication for clinical work .............................................................. 53 4.4. Implication for future research ........................................................... 55 4.5. Quality of the evidence ....................................................................... 56 4.6. Conclusions ........................................................................................ 58 Part 2: Empirical Paper ................................................................................................ 73 Dissociative Symptoms and the Quality of Structural Integration in Borderline Personality Disorder Abstract ........................................................................................................................... 74 4. Introduction ................................................................................................... 75 4.1. Personality structure ........................................................................... 76 4.2. Dissociation as a symptom of poor structural integration .................. 80 4.3. Childhood trauma ............................................................................... 82 4.4. Aims of the current study ................................................................... 84 5. Methods ......................................................................................................... 85 5.1. Design ................................................................................................. 85 5.2. Ethical approval and joint working .................................................... 85 5.3. Participants and setting ....................................................................... 85 5.4. Recruitment ........................................................................................ 86 5.5. Assessment procedure ........................................................................ 87 5.6. Measures ............................................................................................. 88 5.7. Statistical analysis .............................................................................. 93 6. Results ........................................................................................................... 97 6.1. Sample characteristics ........................................................................ 97 5 6.2. Comparison of groups and questionnaire versions ........................... 101 6.3. Structural integration and psychological distress ............................. 104 6.4. Childhood trauma in BPD sample compared to HCs ....................... 112 6.5. Is childhood trauma related to psychological distress in adulthood?113 6.6. Does structural integration mediate the influence of childhood trauma on dissociation in adulthood? .......................................................................... 118 7. Discussion ................................................................................................... 120 4.1. Psychopathology and personality structure ...................................... 120 4.2. The indirect effect of maltreatment on dissociation ......................... 122 4.3. Implications for practice and research .............................................. 124 4.4. Limitations ........................................................................................ 126 4.5. Conclusions ...................................................................................... 128 Part 3: Critical Appraisal 1. Introduction ................................................................................................. 148 2. Context of the research ............................................................................... 148 3. Theoretical and methodological issues ....................................................... 150 1.1. Heterogeneity of BPD diagnosis ...................................................... 150 1.2. Assessment of personality structure ................................................. 152 1.3. Current knowledge on dissociation in BPD ..................................... 155 6 4. Challenges ................................................................................................... 157 5. Conclusions ................................................................................................. 160 Self report questionnaires completed over two sessions: ......................................... 180 Computer based behavioral tasks: ............................................................................. 181 Interview based measures: .......................................................................................... 183 5. Questionnaire on Self-description ............................................................... 191 OPD-SQ ........................................................................................................................ 191 6. Self-description