Author ORCID Identifier

Date of Award


Degree Type


Degree Name

Master of Public Health (MPH)


Public Health

First Advisor

Dr. Shanta R. Dube

Second Advisor

Dr. William W. Thompson


INTRODUCTION: Adverse childhood experiences (ACEs) are traumatic events including abuse, neglect, and related stressors that occur before the age of 18. These exposures affect 61 % of adults in the general population. Studies have documented that ACEs contribute to mental illness; however, less is known about its contribution specifically to borderline personality disorder (BPD) and co-morbid substance use disorder (SUD).

AIM: The purpose of this study was to examine the association between each category of 10 ACEs and the total number (ACE score) with borderline personality disorder alone, borderline personality disorder with comorbid substance use disorder, and lifetime substance use disorder alone.

METHODS: We used cross-sectional limited-use data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III). Data were collected between April 2012 to June 2013 and included 36,309 adults in the United States. We assessed 10 different types of ACEs that occurred before age 18 years. Exposure categories included: physical, emotional, and sexual abuse; physical and emotional neglect; growing up in a household with substance abuse; criminal activity; mental illness; parental divorce or separation; and violence against maternal figure. The outcome measures were Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnosis of borderline personality disorder alone, borderline personality disorder with comorbid substance use disorder and substance use disorder alone. The NESARC dataset was adjusted for nonresponse and oversampling. Poststratification analyses were used to weight data to represent the United States general population. We extracted weighted prevalence estimates of ACEs for the overall NESARC population, BPD overall and BPD with comorbid SUD. To estimate the association between ACEs and BPD alone, comorbid SUD, and SUD alone we used multiple logistic regression models to calculate adjusted odds ratios and 95% CI’s. Analyses were completed using SAS 9.4.

RESULTS: Weighted prevalence estimates of each ACE among adults with BPD (n= 4301) are as follows: sexual abuse (28.1%); physical abuse (40.0%), emotional abuse (55.9%), emotional neglect (21.7%), physical neglect (21.4%), violence against maternal figure (27.6%), household substance use (45.5%), mental illness (17.6%), incarceration (19.3%), and parental separation or divorce (44.1%). Each category of ACE predicted BPD and BPD with comorbid SUD. Emotional abuse in childhood had the strongest association to BPD (aOR = 3.00 [2.59, 3.48]), while childhood sexual abuse had the strongest association to BPD with comorbid SUD (aOR=4.45 [4.03, 4.91]). Additionally, adults who experienced 4 or more ACEs had 4.72 greater odds of being diagnosed with BPD alone, and 10.02 odds of being diagnosed with BPD with comorbid SUD.

CONCLUSION: Exposure to ACEs contributes to the risk of BPD, and BPD with comorbid SUD. Special emphasis on recognizing the occurrence of childhood trauma among persons with BPD and BPD comorbid SUD is paramount in reducing the likelihood of poor health outcomes. Current treatments for BPD and BPD with SUD include psychotherapies such as DBT, but more research is needed to establish the efficacy of these therapies in treating comorbid BPD with SUD.


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