Shame, Guilt and Anger Among a Group of Inner-City Young Women with Borderline Personality Features and Trauma History (A Latent Growth Curve Analysis with Implications for Accessible Care of Low-income Minorities)

Background/Purpose: Borderline Personality Disorder (BPD) is a serious and disabling mental disorder characterized by a pervasive pattern of instability in interpersonal relationships, emotions, and behavior. The core feature of BPD is emotion dysregulation, particularly related to negative emotions such as shame, guilt and anger. In addition, a high prevalence of childhood trauma has been reported among BPD individuals, yet etiological mechanisms remain unclear. Understanding the role of trauma and negative emotions is key to developing targeted, accessible and affordable treatment and services to diverse BPD populations. This study analyzes repeated measures data from a study of BPD symptomatology in an at-risk group of young urban women, hypothesizing that trauma is predictive of higher BPD symptoms and negative emotions as well as steeper changes over time.

Methods: Participants were 166 young women (ages 18–24) with clinically significant BPD symptoms (e.g., aggression and/or self-injurious behavior) recruited from a larger community-based longitudinal study (Pittsburgh Girls Study; PI: Loeber).

Measures: BPD scores were obtained from Semi-structured Interview for DSM-IV Personality. Trauma was measured by Childhood Trauma Questionnaire, Guilt and Shame by Guilt and Shame Proneness scale, and Anger by State Trait Anger Expression Inventory 2, respectively. Guilt/ Shame/Anger and BPD were measured at baseline, 6-month and 12-month; whereas childhood trauma was assessed at baseline only.

Analyses: Using baseline data, multivariate linear models were employed to test the effects of Shame/Guilt/Anger and trauma on BPD features, controlling for age, race/ethnicity and sexual orientation. Two sets of latent growth curve analyses were conducted to investigate the longitudinal changes of Shame/Guilt/Anger in terms of mediating the effect of trauma on BPD features.

Results: 72% of participants self-identified as racial or ethnic minority (70% African American; 2% multi-racial; 4% Hispanic/Latina) and 51% reported receipt of public assistance such as WIC benefits. Participants reported minimal exposure of physical abuse, physical neglect, emotional abuse and emotional neglect, in comparison with moderate level of sexual abuse. Multivariate analyses indicated higher trauma exposure, guilt and anger expression were predictive of higher BPD scores. LGV results showed that (1) elevated baseline trauma was associated with more baseline scores and heightened longitudinal changes of guilt and anger (2) guilt and anger intensify the acceleration of BPD symptoms overtime.

Conclusion and Implications: Our focus on low-income, ethnic minority, young women provides new findings critical to developing more tailored and culturally competent interventions. Existing BPD treatments and trauma modalities require extensive clinical training and are often long-term. Many individuals with BPD need a combination of both, thereby raising the cost of care, time and commitment and, thus, are often not accessible or affordable for low income clients. Our results suggest that the development of a novel shorter-term trauma informed DBT approach targeting skills for negative emotion regulation, which are proven to be linked to both trauma and BPD features, would be fruitful. Finally, for such a treatment to be viewed as acceptable and relevant, it must rest on a scaffolding of cultural competence combined with a clinical stance of cultural humility.