The mediating role of post-traumatic stress disorder symptoms in the relationship between childhood adversities and depressive symptoms in two samples

Trauma-related mental health problems among mothers in Taiwan and their relationship with children's emotional and behavioral problems

ABSTRACTBackground: Trauma can give rise to mental health problems and emotional and interpersonal difficulties, which in turn can perpetuate the cycle of trauma and adversity for future generations. However, little is known about the prevalence and potential effects of trauma and trauma-related mental health problems among parents.Objective: The primary goal of this study was to examine childhood and adulthood trauma and trauma-related symptoms among mothers of children aged between 6 and 18. We also conducted exploratory analyses of their potential relationship with children's emotional and behavioural problems.Method: A total of 817 mothers living with a child aged between 6 and 18 in Taiwan completed standardized self-report assessments of trauma exposure, trauma-related symptoms, and children's emotional and behavioural problems. A subsample (n = 256) also provided follow-up data after six months.Results: Most surveyed mothers reported at least one childhood traumatic event (74.79%) and one adulthood traumatic event (78.70%); 4.4% met the ICD-11 criteria for PTSD, and 12.1% for complex PTSD; 11.4% reported clinically significant dissociative symptoms. Mothers' complex PTSD and dissociative symptoms were cross-sectionally correlated with children's emotional and behavioural problem (rs = .186 to .239, p < .001). After controlling for possible confounding variables and baseline scores, mothers' childhood non-betrayal trauma reported at baseline was found to be a predictor of children's emotional and behavioural problems reported at follow up.Conclusion: This study is the first to provide data regarding childhood and adulthood trauma and trauma-related disorders, including ICD-11 complex PTSD, among mothers in the community. It calls for more studies to understand the potential effects of intergenerational trauma.

The bidirectional relationship between depression and dissociation: A longitudinal investigation

Depression is a major public health concern. Recent studies suggest that dissociative symptoms are associated with depressive symptoms, and the concept of "dissociative depression" has been proposed. Yet, only cross-sectional evidence is available in the literature. This study examined the bidirectional relationship between dissociative and depressive symptoms through the use of screening tools in a sample of Chinese young adults (N = 340) over four months. Baseline dissociative symptoms predicted depressive symptoms at follow-up (β = .262, p < .001), but not the other way around (β = .065, p = .121). Among different dissociative symptom clusters, identity dissociation was the only significant predictor of subsequent depressive symptoms (β = .177, p < .001). Furthermore, identity dissociation symptoms partially mediated the relationship between childhood trauma and subsequent depressive symptoms. This preliminary study is the first to test the bidirectional relationship between dissociative and depressive symptoms. The results highlight the importance of taking dissociative symptoms into account when preventing and treating depressive symptoms, especially among childhood trauma survivors.

Trauma, Emotional Regulation, and Coping Styles in Individuals with and without Probable Dissociative Disorders in Hong Kong

Previous studies showed that dissociation and dissociative disorders (DDs) are prevalent and are associated with considerable individual and social consequences. There are ongoing debates regarding whether dissociation is a response to betrayal trauma across cultures and whether dissociation can be explained by maladaptive coping. Additionally, little is known about the clinical features of individuals with DDs in the Chinese context. This study aimed to investigate the relationship between trauma, emotional regulation, coping, and dissociation. We analyzed baseline data from a randomized controlled trial (N = 101). Participants with dissociative symptoms in Hong Kong completed self-report assessments. Structured interviews were also conducted subsequently. Participants with probable DDs reported more traumatic events (p = .009 to .017) and exhibited significantly higher levels of dysfunctional coping (p < .001) compared to those who reported dissociative symptoms but did not have a DD. Dissociative symptoms were more strongly associated with betrayal trauma than with non-betrayal trauma. Among different emotion regulation and coping strategies, dysfunctional coping was the only significant factor associated with dissociative symptoms (β = .309, p = .003). Dysfunctional coping was a statistically significant mediator that may explain the relationship between betrayal trauma and dissociative symptoms. Although other mediation paths are also possible and further longitudinal studies are required, our findings highlight the strong link between dysfunctional coping and dissociative symptoms and suggest that coping skills training should be incorporated into interventions for betrayal trauma survivors with dissociative symptoms. Additionally, this study provides evidence for the cross-cultural validity of the betrayal trauma theory. Further studies, however, are required.

The different role of adversity before and after birth in adolescent depression

BACKGROUND

Early adversity is strongly linked to adolescent depression, but there is limited research on the impact of indirect exposure to adversity before birth and the distinct role of adversity before and after birth.

METHODS

A total of 1911 Chinese adolescents (48.8 % males; ages 11 to 19, Mean = 13.96) reported early adversities before and after birth, depression, negative self-cognition and perceived school climate. Structural equation model was used to test the association between early adversity before/after birth and adolescent depression, with negative self-cognition serving as a mediator and school climate as a moderator.

RESULTS

Adversity before birth was related to adolescent depression through the full mediating role of negative self-cognition. Furthermore, it was more associated with negative self-cognition in schools with a more favorable climate. Adversity after birth was related to adolescent depression through the partial mediating role of negative self-cognition, and school climate played a nonsignificant moderating role in the mediating path.

LIMITATIONS

Early adversity was measured through adolescent reports, possibly generating recall bias. The cross-sectional design should be taken into consideration when drawing conclusions about causality.

CONCLUSIONS

Adversities before and after birth are associated with adolescent depression in distinct ways. The more association between adversity before birth and negative self-cognition in a favorable school climate supports the "healthy context paradox." Interventions that target depression should focus on promoting a positive school climate and helping adolescents who have experienced early adversity bolster positive self-cognition.

Reliability and Mental Health Correlates of a Single-Item Measure of Self-Rated Mental Health (SRMH) in the Chinese Context

The use of single-item measures of self-rated mental health (SRMH) has been increasingly valued in epidemiologic research. However, little is known about the reliability and mental health correlates of SRMH in Chinese populations. This study examined the reliability and mental health correlates of SRMH in three Chinese samples. We analyzed data collected from two convenience samples of Chinese adults from Hong Kong and/or Taiwan (Sample 1: N = 205; Sample 2: N = 377), and a random sample of Taiwan psychiatric inpatients (Sample 3: N = 100). Our results showed that the single-item measure of SRMH had moderate to good test-retest reliability (intraclass correlation [ICC] = 0.75) in Sample 1 and acceptable reliability between the self-report and interviewer-administered versions (ICC = 0.58) in Sample 3. It had a high positive correlation with self-esteem and a moderately high negative correlation with depression. It also had a consistently negative correlation with borderline personality disorder symptoms and post-traumatic stress disorder symptoms. The SRMH score was also associated with psychiatric service usage. These findings contribute to the body of knowledge regarding the use of a single-item measure of SRMH to assess overall self-perceived mental health in Chinese communities.

A Preliminary Longitudinal Analysis of Symptom Management, Post-traumatic Stress, and Depressive Symptoms in Chinese Adults with Dissociative Symptoms

People with dissociative symptoms are generally poly-symptomatic and require high levels of healthcare resources. Post-traumatic stress disorder (PTSD) and depressive symptoms are two major disabling comorbid symptoms in people with dissociative symptoms. While the sense of control over symptoms may be associated with PTSD and dissociative symptoms, the interplay among these factors over time remains unexplored. This study examined the predictors of PTSD and depressive symptoms in people with dissociative symptoms. Longitudinal data from 61 participants with dissociative symptoms were analyzed. Participants completed self-report measures of dissociative, depressive, and PTSD symptoms and the sense of control over symptoms two times (T1 & T2) with an interval of over one month. PTSD and depressive symptoms were not transient or time-specific, but they persisted over time in our sample. Hierarchical multiple regression analyses revealed that, after controlling for age, treatment usage and baseline symptom severity, T1 symptom management scores (β = -.264, p = .006) negatively predicted T2 PTSD symptoms, while T1 PTSD symptoms (β = .268, p = .017) positively predicted T2 depressive symptoms. T1 depressive symptoms (β = -.087, p = .339) did not predict T2 PTSD symptoms. The findings highlight the importance of improving symptom management skills and treating comorbid PTSD symptoms when working with people with dissociative symptoms.

Substance abuse among mothers in Taiwan: Investigating its prevalence and testing the trauma model

Substance abuse is a serious problem in our society. In particular, household or parental substance abuse could lead to adverse childhood experiences for the affected children. However, little is known about the prevalence of substance abuse among parents, especially in Asian societies. Moreover, although the trauma model of addiction has significant implications for the prevention and treatment of substance abuse, most evidence comes from Western samples. To address these knowledge gaps, we examined the prevalence of substance abuse in a sample of mothers in Taiwan and tested the trauma model of substance abuse. A total of 867 Taiwanese mothers completed standardized self-report assessments in 2023. The screening results indicated that the 12-month prevalence of drug abuse and alcohol abuse was 12.3% and 7.3%, respectively; 15.5% had either or both drug and alcohol abuse. Most types of trauma exposure were associated with drug abuse severity, while interpersonal stress and dissociative symptoms were associated with alcohol abuse severity, even after controlling for a variety of demographic and health variables as well as general psychopathology (i.e., depressive symptoms). The relatively high prevalence of substance abuse among Taiwanese mothers in our sample is concerning, particularly when compared to the rates reported in other Asian samples. We also provide preliminary cross-cultural evidence supporting the self-medication theory and the trauma model of substance abuse in the Asian context. We discuss the potential importance of addressing trauma and stress to prevent substance abuse and call for follow-up studies.

Childhood experiences and dissociation among high school students in China: Theoretical reexamination and clinical implications

BACKGROUND

Dissociation remains a controversial topic in terms of its prevalence, cross-cultural validity, and relationship with childhood trauma and adversities.

AIMS

This study investigated the prevalence of dissociative symptoms and probable dissociative disorders among Chinese high school students and tested the trauma model of dissociation.

METHODS

A total of N = 1,720 high school students completed standardized measures of positive and adverse childhood experiences (PCEs and ACEs), dissociation, depression, and anxiety.

RESULTS

The prevalence rates of dissociative symptoms and (probable) DSM-5 dissociative disorders (DDs) were 11.2% and 6.9%, respectively. Dissociation was a reliable construct (ICC = .682 to .752, p < .001) and was moderately correlated with general psychopathology (r = .424 with depressive symptoms, r = .423 with anxiety symptoms). Participants with a probable DD reported more ACEs, fewer PCEs, and more mental health symptoms than those without a probable DD. ACEs were significantly associated with dissociative symptoms (β = .107, p < .001) even after controlling for age, depressive, and anxiety symptoms. PCEs moderated the relationship between ACEs and dissociative symptoms.

CONCLUSIONS

This is the first report of the prevalence of dissociative symptoms and probable DSM-5 DDs among nonclinical children. We provide cross-cultural evidence that dissociation is a reliable and valid clinical phenomenon associated with psychopathology in children across cultures. The findings partly support the trauma model of dissociation. This study contributes to the limited literature on dissociation in children. It also offers empirical data to facilitate the ongoing controversy about (childhood) trauma and dissociation. Our findings imply that dissociation is cross-culturally associated with childhood adversities, but trauma is not the only, sufficient cause. Theoretical and clinical implications are discussed.

Dissociative symptoms among community health service users in Hong Kong: a longitudinal study of clinical course and consequences

Background: Previous studies have demonstrated the high prevalence of dissociative symptoms and their association with considerable healthcare costs. However, there is a lack of studies that describe whether dissociative symptoms persist and lead to other clinical outcomes over time in the community.Objectives: This study investigated the persistence, predictors, and consequences of dissociative symptoms in the community.Methods: We analyzed longitudinal data in a sample of community health service users in Hong Kong (N = 173).Results: A relatively high proportion (63.6%) of participants with baseline dissociative symptoms continued to exhibit dissociative symptoms after approximately 9 months. Baseline non-betrayal trauma predicted subsequent dissociative symptoms (β = .141, p = .024). Participants with baseline dissociative symptoms were more likely to have received subsequent emergency mental health services (9.1% vs 0.7%, p = .005). Baseline dissociative symptoms significantly predicted subsequent post-traumatic symptoms (β = .165 to .191, p < .05) and difficulty in social and occupational participation (β = -.152 to -.182, p < .05) even after controlling for baseline scores, trauma exposure, and use of professional support. The predictive role of dissociative symptoms on subsequent disturbances in self-organization symptoms and social participation difficulty remained significant after applying the Bonferroni correction.Conclusions: This is one of the very few studies showing that dissociative symptoms are persistent to a certain degree and could predict other symptoms and subsequent impairments even in community settings. Factors that affect the trajectory of dissociative symptoms should be further investigated. Regular screening for dissociative symptoms is recommended. Considering its prevalence, persistence, and clinical and social consequences, dissociation should be given greater public health attention.

Persistence and clinical consequences of post-traumatic and dissociative symptoms in people with depressive symptoms: a one-year follow-up study

BACKGROUND

Recent studies found that post-traumatic and dissociative symptoms are common in people with depressive symptoms. Although a trauma-related subtype of depression has been proposed, little is known about the persistence and clinical consequences of these symptoms.

OBJECTIVE

This one-year follow-up study investigated the persistence and clinical consequences of post-traumatic and dissociative symptoms in people with depressive symptoms.

METHODS

We analyzed longitudinal data from an international sample of people self-reporting depressive emotions (N = 152) (mean Patient Health Questionnaire-9 score = 17.27; SD = 6.31).

RESULTS

More than half (58.4%) of participants with baseline post-traumatic stress disorder (PTSD) still met the criteria for PTSD after one year. Participants with dissociative symptoms at baseline were significantly more likely to report lifetime psychiatric hospitalization (31.2% vs 14.7%), past-year use of psychiatric hospitalization (10.4% vs 0%) and emergency services (16.9% vs 4%) than those without dissociative symptoms. All post-traumatic and dissociative symptom clusters were cross-sectionally (r = .286 to .528, p < .001) and longitudinally (r = .181 to .462, p < .001) correlated with depressive symptoms. A sense of current threat (β = .146, p < .05) and negative self-concept (β = .173, p < .05) at baseline significantly predicted depressive symptoms after one year.

CONCLUSIONS

These findings contribute to the increasing body of knowledge regarding the PTSD/dissociation-depression comorbidity. Given their persistence and clinical consequences, we recommend that post-traumatic and dissociative symptoms be regularly screened for in clinical settings. The existence of a possible trauma-related subtype of depression should receive more attention in both research and clinical practice.

Correlation between childhood trauma experience and depressive symptoms among young adults: The potential mediating role of loneliness

BACKGROUND

It is widely recognized that childhood trauma poses a significant risk of developing depressive symptoms. However, the underlying mediation mechanism between childhood trauma and depressive symptoms requires further exploration.

OBJECTIVE

This study focuses on exploring whether loneliness may act as a potential mediator between childhood trauma and depressive symptoms.

PARTICIPANTS AND SETTING

We analyzed a large sample of college students (N = 7293). Participants completed online questionnaires in the WeChat group.

METHODS

Childhood trauma, depressive symptoms, and loneliness were evaluated using the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Patient Health Questionnaire-9 (PHQ-9), and the University of California Los Angeles Loneliness Scale (UCLA-LS) respectively. The linear regression method was applied to explore the mediating role.

RESULTS

Gender, relationship with family, and left-behind experience are all substantial depressive symptoms risk factors. Childhood trauma was shown to be highly related to depressive symptoms, and this relationship was potentially mediated by loneliness.

CONCLUSIONS

Our research indicates that treating loneliness in those who have undergone childhood trauma may help prevent or treat depressive symptoms. Therefore, loneliness should be taken into consideration while treating and preventing depressive symptoms.

Borderline personality disorder features and their relationship with trauma and dissociation in a sample of community health service users

BACKGROUND

Previous studies have indicated that borderline personality disorder (BPD) is closely associated with trauma and dissociation. Nevertheless, BPD is a heterogeneous condition, and not all people with BPD have severe dissociation. This study examined whether the relationship of BPD features with trauma and dissociation would remain significant after controlling for some general non-specific mental health distress. We also made the first attempt to explore which specific BPD features would be particularly associated with dissociation.

METHODS

We analyzed survey data from a sample of community health service users in Hong Kong (N = 376). Hierarchical multiple regression and data-driven network analysis were used.

RESULTS

The lifetime prevalence of DSM-5 BPD was 16.0% in our sample. Of participants who met criteria for BPD, 43.3% scored above cutoff on the dissociation measures, thus possibly having clinically significant dissociative symptoms. BPD features were associated with adulthood trauma and psychoform dissociation even after controlling for age, depression and self-esteem. Network analysis showed that some BPD features - including impulsivity, identity disturbance and suicidal/self-mutilation behaviors - were particularly associated with dissociation; other BPD features such as interpersonal-related problems had relatively weak to no connection with dissociation.

CONCLUSIONS

Our results suggested that some particular BPD features might be dissociative in nature, although further longitudinal research is required. We argue that a trauma-informed perspective should be employed when working with clients presenting with BPD features despite these features being commonly stigmatized. Further research on the intervention needs of the people with BPD who suffer from high levels of dissociation is required.

Advances in stress and depression research

PURPOSE OF REVIEW

Stress plays a central role in the onset and course of depression. However, only a subset of people who encounter stressful life events go on to experience a depressive episode. The current review highlights recent advances in understanding when, why, and for whom the stress-depression link occurs, and we identify avenues for future research.

RECENT FINDINGS

In the last 18 months, researchers have taken a more nuanced perspective on the biopsychosocial mechanisms critical to the stress-depression link. For example, examination of specific facets of emotion regulation, including emotion regulation flexibility and interpersonal emotion regulation, has been critical to understanding its role in depression. Similarly, refined investigations of social support allowed researchers to identify distinct - and occasionally opposite - outcomes depending on the context or manner in which the support was provided. Researchers also documented that the stress-depression link was enhanced by dysregulation of several stress-sensitive biological systems, such as the immune system, microbiome, endocrine system, and neuroanatomical substrates.

SUMMARY

Recent studies highlight the importance of adopting a nuanced understanding of mechanisms and moderators that explain the stress-depression link. We also encourage continued engagement in collaborative, open science that uses multiple methods to study the full breadth of human diversity.

Prevalence and sociocultural correlates of post-traumatic stress disorder and complex PTSD among Chinese community health service users in Hong Kong

OBJECTIVES

Complex post-traumatic stress disorder (CPTSD) is a newly recognized trauma disorder in ICD-11. Little is known about the prevalence and correlates of CPTSD in primary care settings. Its cultural aspects also remained minimally explored. This study investigated the prevalence and sociocultural correlates of PTSD and complex PTSD among Chinese community health service users in Hong Kong.

METHODS

This study investigated ICD-11 PTSD and CPTSD in a sample of adults (N = 376) who had recently received services from Registered Chinese Medicine Practitioners in Hong Kong. Traditional Chinese medicine service is part of primary care services in Chinese societies. Participants completed self-report measures of CPTSD, trauma exposure, perceived family support, perceived caregiver's Chinese traditionality/modernity, participation (social activities and occupational productivity), depression and pain.

RESULTS

The past-month prevalence of ICD-11 PTSD and CPTSD was 5.6% and 18.4%, respectively, in our sample. Chi-square tests and one-way ANOVAs revealed that participants with CPTSD were younger and reported more trauma, lower family support, lower levels of social participation and productivity, more depressive symptoms and pain, and more social welfare and mental health service usages than those without PTSD. We found that perceived caregiver's Chinese modernity (e.g. egalitarianism) was negatively correlated with CPTSD symptoms. Apart from age, non-betrayal trauma had the strongest association with classical PTSD symptoms, while betrayal trauma and perceived family support had the strongest association with disturbances in self-organization symptoms.

CONCLUSION

This study provides the first data regarding the prevalence and correlates of ICD-11 PTSD and CPTSD among community health service users in Hong Kong. PTSD and CPTSD are common but often unrecognized mental health problems which are associated with more impairments and more service needs.

Interpersonal stress mediates the relationship between childhood trauma and depressive symptoms: Findings from two culturally different samples

OBJECTIVE

Childhood trauma is associated with adulthood depressive symptoms, but very few studies explored potential social and interpersonal mediators behind this association. This study made the first attempt to test the potential mediating effects of interpersonal stress in the associations between childhood betrayal and non-betrayal trauma and depressive symptoms.

METHOD

We analyzed data in a sample of English-speaking adults from diverse backgrounds (from 19 different countries, mainly from Western countries) (N = 468). We then replicated and compared the results with those in another convenience sample of Chinese-speaking younger adults with different cultural backgrounds and mental health status (N = 205).

RESULTS

The results in both samples indicated that (1) childhood betrayal trauma had a stronger relationship with depressive symptoms than childhood non-betrayal trauma and that (2) interpersonal stress was a significant mediator in the relationship between childhood betrayal trauma and depressive symptoms, even when childhood non-betrayal trauma was included as a covariate. The indirect effect of childhood non-betrayal trauma on depressive symptoms through interpersonal stress was not consistent in two samples.

CONCLUSIONS

Our findings point to the importance of taking social and interpersonal contexts into account when investigating, preventing and managing depression in trauma-exposed populations. Early social interventions such as family interventions, interpersonal skills training and building social resources may have the potential to change the trajectory of the development of mental health problems in trauma survivors.

Trauma and dissociation among inpatients diagnosed with schizophrenia spectrum disorders in Taiwan

Background: The overlapping symptoms of schizophrenia and dissociation have been increasingly recognized. This paper explains why it is reasonable to expect that there would be a substantial subgroup of patients diagnosed with schizophrenia spectrum disorders (SSDs) who suffer from pathological dissociation. Objective: As little is known about the prevalence of dissociative disorders and symptoms among patients with SSDs, we investigated the prevalence of dissociative disorders and symptoms among patients with SSDs. Method: We used both self-report measures and structured interviews to examine dissociative disorders and symptoms in a randomly recruited sample of inpatients with a clinical diagnosis of SSDs in Taiwan (N = 100). Results: Over 60% of participants exhibited pathological dissociation, and 54% had a dissociative disorder according to structured interview data; three participants met the DSM-5 diagnostic criteria for dissociative identity disorder. The concurrent validity of pathological dissociation in this sample was similar to that of depression among patients with schizophrenia reported in the literature. Participants with a dissociative disorder were more likely to report high-betrayal traumas and meet DSM-5 criteria for post-traumatic stress disorder; they also reported more psychotic symptoms than those without a dissociative disorder. Conclusions: This was one of very few studies that used structured interviews to examine pathological dissociation in patients with SSDs. The results indicate that pathological dissociation in SSDs is not uncommon. Clinical assessment should include measures of dissociation to facilitate early identification.