Distress Related to Childhood Experiences of Abuse, Loss. 19/7/2017


Childhood adversity (ie, experiences of loss and/or abuse) is significantly associated with later onset of personality disorder (PD) and higher levels of psychiatric distress, according to a new study published in Personality and Mental Health.

Antonella Cirasola and colleagues from the Anna Freud Centre and University College, London, United Kingdom, explored the relationship between childhood adversities, unresolved states of mind, PD diagnosis, and psychiatric distress in 245 adults (aged 18 to 53 years; mean age, 32 years). Most participants (68.6%) were women.

The researchers divided participants into 2 groups: those with at least 1 clinical PD (n=124), and nonpsychiatric control patients without a PD diagnosis (n=121). Participants were required to be free of symptoms of schizophrenia or evidence of organic brain disorder. Participants in both groups were matched on the basis of age and sex.

The researchers used the Cassel Baseline Questionnaire, based on a structured interview that uses operationalized definitions to elicit experience of loss, sexual abuse, and physical abuse as 3 separate variables. Early loss was defined as "significant periods of separation from a primary caregiver or important relative during the first 10 years of life" because of factors such as death, hospitalization, adoption, or divorce.

The experience of sexual abuse was based on subjects' self-report of "sexual interference by an adult or forced sexual assault before the age of 14" years. Presence of physical abuse was based on reports of maltreatment by caregivers (eg, physical assaults or extreme verbal abuse). 

Adversities were rated on a 5-point scale, ranging from 0 (absent) to 4 (very severe). The researchers "dichotomized the trauma variables into presence or absence of adversity by recoding absent and mild into absent and moderate, severe, and very severe into present."

The presence or absence of the 10 Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition (DSM-IV), Axis II PDs were determined on the basis of the Structured Clinical Interview for DSM-IV-II. Researchers also used the Symptoms Checklist-90-R to measure subjective severity of general psychiatric distress, and the Adult Attachment Interview as a measure to rate adult attachment.

Within the overall unresolved attachment category, the researchers distinguished between unresolved for abuse and unresolved for loss.

More than half of the PD group (50.6%) met criteria for at least 1 PD. The most-represented PDs were borderline (27.8%), avoidant (27.3%), and paranoid (20.4%). The average number of PD diagnoses of each patient was 3.97 (SD, 2.33; median, 3.50). 

In the overall sample, 85 (34.7%) participants reported experiences of early loss, 62 (25.3%) of physical abuse, and 68 (27.7%) of sexual abuse. The researchers used a 4-way-Adult Attachment Interview classification to assess adult attachment and found that 82 (33.5%) participants were classified as secure, 52 (21.2%) as dismissing, 31 (12.7%) as preoccupied, and 80 (32.7%) as unresolved/disorganized (U/d).

As the researches had hypothesized, the 2 samples were "significantly different in early adversities and psychiatric severity variables." The PD sample reported a significantly higher frequency of sexual abuse, physical abuse, and loss, as compared with the non-PD sample. There was also a significant difference in self-reported severity of psychiatric symptoms, based on the General Severity Index.

The researchers found significant differences in attachment status between the 2 samples in the secure and U/d categories. Only 12 (14.6%) were coded as secure in the PD sample compared with 70 (85.4%) in the non-PD sample, and 69 (86.3%) were coded as U/d in the PD sample compared with only 11 (13.8%) in the control sample.

Those who were unresolved for abuse and unresolved for loss (PD, n=43 [34.7%] vs non-PD, n=9 [17.3%]; PD n=34 [27%] vs non-PD, n=2 [1.7%], respectively) were also significantly different in the 2 groups. In contrast, there were no significant differences in the 2 groups in the dismissing and preoccupied categories of organized insecure attachment. Moreover, 90.2% (n = 55) of participants within the U/d subgroup had a history of childhood adversity (loss or/and abuse), and 61.1% (n = 55) of participants who reported experience of trauma were coded as U/d.

In particular, 61.1% (n=23) of those who had reported experiences of early loss were coded as U/d for loss, whereas 87.0% of participants with a history of abuse were rated as U/d for abuse.

The researchers conducted correlational analyses for the whole study sample and found that current diagnosis of PD was significantly associated with experiences of loss (P <0.0001), sexual abuse (P <0.0001), and physical abuse (P <0.0001). Self-reported severity of psychiatric symptoms (as measured by the General Severity Index) and average number of PD diagnoses were also found to be significantly associated with experiences of loss, sexual abuse, and physical abuse.

"This study examined the relationships between childhood adversity, U/d attachment and a diagnosis of PD in later life," the researchers wrote.

"In line with previous findings, it was confirmed that childhood experiences of loss and/or abuse were significantly associated with later onset of PD and higher level of psychiatric distress," they said.

They contrasted the insecure/disorganized categories of attachment to the U/d category, which showed a significant association with childhood adversity, PD diagnoses, and severity variables. This indicates "a lack of resolution of these experiences may be an important factor in shaping the developmental pathway in the direction of long-term negative effects that continue into adulthood."

The researchers acknowledged several limitations to the study. One is that they used cross-sectional data without any manipulation or variables, so "no solid conclusions can be drawn about causality, prediction or time of onset of PD." Moreover, "current levels of distress may have an influence on the sharpness of recall of past experiences."

Nevertheless, they pointed to strengths, including the "adequate power of the study sample that included matched clinical and non-clinical participants."

The concluded that the study findings may have "important clinical implications suggesting possible refinements of the targets for intervention."