Symptom overreporting obscures the dose-response relationship between trauma severity and symptoms

We investigated whether symptom overreporting affects the dose-response relationship between self-reported abuse severity and psychiatric symptoms in two samples. The first sample (N=599) consisted of adults who had previously reported to a public commission that they had been witnesses to or victims of childhood sexual abuse by Roman Catholic Church representatives. The second sample (N=1756) consisted of general population respondents who indicated that they had been victims of non-familial childhood sexual abuse. Using a web-based data collection procedure, both samples completed the Brief Symptom Inventory (BSI-18), items addressing abuse severity, and items flagging symptom overreporting. Adjusting for overreporting reduced the proportion of participants with clinically raised BSI-18 scores from 60% to 47% in sample 1 and from 26% to 22% in sample 2. Also, in both samples, normal range reporting participants exhibited the typical dose-response relationship between trauma severity and BSI-18 scores, whereas this pattern was largely non-significant in overreporting participants. Our findings show that symptom overreporting has a psychometric impact that may obscure relationships between clinically relevant variables and should therefore preferably be monitored in surveys.

Early traumatized inpatients high in psychoform and somatoform dissociation: characteristics and treatment response

This study examined the clinical relevance of differences in psychoform and somatoform dissociative symptoms in 55 early traumatized inpatients. The high psychoform and somatoform dissociative group (n = 18), somatoform dissociative group (n = 22), and nondissociative group (n = 15) did not differ on abuse severity, depressive symptoms, interpersonal problems, Axis I or II comorbidity, or deterioration rates. Compared to the other 2 groups, the highly dissociative group was characterized by younger age, living alone, higher levels of posttraumatic and general distress, more frequent reports of suicidality, self-mutilation, eating problems, and less favorable treatment response. The results highlight the clinical relevance of using dissociation measures for identifying subgroups of patients with severe psychopathology who may be more treatment resistant.

Impact of dissociation and interpersonal functioning on inpatient treatment for early sexually abused adults

BACKGROUND

Little is known about the possible predictors of treatment outcome in early chronically sexually abused adults. The current study aimed to investigate what impact initial levels of dissociation and pre-treatment negative change in interpersonal functioning have on treatment response after 3 months of first-phase trauma inpatient treatment as well as after a period of 1 year the patients returned to their usual lives.

METHODS

The sample comprised 48 inpatients with childhood sexual abuse histories and mixed trauma-related disorders who were examined at discharge and prospectively followed up for a period of 1 year under naturalistic conditions. Outcome variables were general psychiatric symptoms and interpersonal problems as measured with the Symptom Check List-Revised (SCL-R) and the Inventory of Interpersonal Problems (IIP) Circumplex.

RESULTS

The central findings were that pathological dissociation and deterioration in interpersonal functioning prior to admittance predicted general psychiatric symptom levels and interpersonal problems at the end of treatment and at 1-year follow-up. Pathological dissociation, involving memory and identity problems, alone predicted negative outcome at the end of treatment. The findings at 1-year follow-up indicate that it is not pathological dissociation in isolation that affects outcomes, but rather the interaction between dissociation and change in interpersonal functioning prior to treatment.

CONCLUSION

These findings indicate the need of addressing dissociation and interpersonal problems in treatment planning and favor an integrated treatment approach for complex trauma patients. Future research should investigate whether and how this leads to better outcome, including long-term maintenance of gains after the end of treatment.

A validation study of the Four-Dimensional Symptom Questionnaire (4DSQ) in insurance medicine

OBJECTIVE

This study aimed to evaluate the criterion validity and the diagnostic accuracy of the Four-Dimensional Symptom Questionnaire (4DSQ) regarding the identification of depressive and anxiety disorders in an insurance medicine setting.

PARTICIPANTS

Our sample consisted of 230 individuals who applied for a work disability benefit due to mental health problems.

METHODS

Depressive and anxiety disorders were assessed using the 4DSQ and the Composite International Diagnostic Interview (CIDI). Internal consistency was determined by calculating Cronbach's alpha values. Criterion validity was evaluated by regression techniques. A Receiver Operating Characteristic (ROC) analysis was performed to evaluate diagnostic accuracy.

RESULTS

Of the 230 participants 109 (47.4%) had a current DSM-IV depressive disorder and 146 (63.5%) an anxiety disorder. The 4DSQ scales showed an excellent internal consistency. The depression scale of the 4DSQ had specific sensitivity for major depressive disorder. The anxiety scale was also sensitive for the anxiety disorders. The area under the ROC curve (AUC) indicated good diagnostic accuracy of the 4DSQ for assessing depressive and/or anxiety disorders: AUC-value 0.81 for both depression and anxiety.

CONCLUSIONS

Although the 4DSQ shows good criterion validity and diagnostic accuracy with respect to depressive and anxiety disorders in applicants for a work disability benefit due to mental health problems, the feasibility of the 4DSQ as a screening measure for depressive and anxiety disorders is limited due to the high prevalence of depressive and anxiety disorders.

Complex Posttraumatic Stress Disorders in Patients with Substance Abuse

The author will review the published data on complex posttraumatic stress disorder (Complex PTSD) in patients with substance abuse. Especially after interpersonal traumatization in childhood PTSD symptoms may be complicated by personality changes suchs as disturbed affect regulation, memory, self-image and relational problems. This syndrome has been labelled "PTSD with associated features" in DSM-IV-TR and is known by clinicians as "complex PTSD" or "Disorders of Extreme Stress NOS". The recognition of the range of interrelated problems associated with a history of early severe interpersonal trauma is an important development with much relevance for the field of substance abuse. Despite the evidence that a majority of women who are seeking treatment for addictions have been exposed to early and multiple traumatic experiences, standard treatment programs do not typically assess or target these associated impairments, which greatly complicates the prognosis. In practice, integrating interventions that specifically target the associated features are often recommended for these patients. Suggestions will be given for furture research.

Psychobiology of posttraumatic stress disorder in pediatric injury patients: A review of the literature

Research suggests that about a quarter to a third of children with traffic-related injuries develop posttraumatic stress disorder (PTSD). Early symptoms of PTSD have been found to predict poor mental and physical outcome in studies of medically injured children. However, these symptoms are rarely recognized by physicians who provide emergency care for these children. In addition, there is insufficient knowledge about predictors of posttraumatic stress symptoms in this specific pediatric population. Early identification of those children at particular risk is needed to target preventive interventions appropriately. After some introducing remarks on the classification and the nature of posttraumatic stress reactions, current research findings on psychological and biological correlates of PTSD in pediatric injury patients are presented. The particular focus in this paper is on the neurobiological mechanisms that influence psychological responses to extreme stress and the development of PTSD. Continued study of the psychobiology of trauma and PTSD in pediatric injury patients, both in terms of neurobiology and treatment is needed.

Dissociative symptoms in alcohol-dependent patients: associations with childhood trauma and substance abuse characteristics

OBJECTIVE

Inconsistent findings have been reported concerning the level of dissociative symptoms and their relationship with childhood trauma in alcohol-dependent patients. The present study aimed to further examine the level of dissociation and the trauma-dissociation relationship in a sample of alcohol-dependent patients, taking potential mediating factors into account.

METHOD

A sample of 100 consecutively admitted inpatients with alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition were administered the Dissociative Experiences Scale, the Childhood Trauma Questionnaire, the International Diagnostic Checklist for posttraumatic stress disorder, the European Addiction Severity Index, and an additional questionnaire assessing the age at onset of different symptoms of alcohol dependence.

RESULTS

Substantial rates of childhood trauma were found. However, the mean Dissociative Experiences Scale score was low (9.0). Dissociative symptoms were significantly related to childhood emotional abuse; however, other forms of childhood trauma and posttraumatic stress disorder status were not. Younger age at onset of alcohol dependence was related to both childhood trauma and a higher level of dissociative symptoms. In a hierarchical linear regression model, emotional abuse was found to contribute to dissociation independent of potential chronic residual effects resulting from early onset of alcohol abuse as well as its chronicity or severity.

CONCLUSION

The findings support the idea that (clinically significant) dissociation is relatively uncommon in alcohol-dependent patients. Yet, when it occurs, dissociation is associated with childhood emotional abuse independent of chronic alcohol abuse. In addition, patients with an earlier onset of alcohol dependence could be more similar to patients with other substance-related disorders with regard to levels of dissociation.

Gender differences in posttraumatic stress disorder

One of the most consistent findings in the epidemiology of posttraumatic stress disorder (PTSD) is the higher risk of this disorder in women. Explanations reviewed within a psychobiological model of PTSD suggest that women's higher PTSD risk may be due to the type of trauma they experience, their younger age at the time of trauma exposure, their stronger perceptions of threat and loss of control, higher levels of peri-traumatic dissociation, insufficient social support resources, and greater use of alcohol to manage trauma-related symptoms like intrusive memories and dissociation, as well as gender-specific acute psychobiological reactions to trauma. This review demonstrates the need for additional research of the gender differences in posttraumatic stress. Recommendations are made for clinical practice.

The psychobiology of PTSD: coping with trauma

Posttraumatic stress disorder (PTSD) is one of the few psychiatric conditions where a specific psychosocial stressor is explicitly tied to etiology. Although a majority of people experience a traumatic event in their life, most of them will not develop PTSD or other mental health problems such as depressive or anxiety disorders. Emotional and neurobiological responses to psychosocial stressors show striking individual variation. In this paper cognitive appraisal and coping factors are explored as potential sources of individual differences in the neuroendocrinological stress response, and subsequently in mental health outcome. Continued study of the psychobiology of trauma and PTSD will enhance our understanding of adaptation to psychosocial stressors and support efforts to treat associated psychological and biological sequelae.

Effects of appraisal and coping on the neuroendocrine response to extreme stress

Although many people are exposed to extreme stress, only some of them develop psychobiological disturbances that can lead to posttraumatic stress disorder (PTSD) or other posttrauma psychopathology. This paper examines the effects of different types of appraisal and coping to find clues to how individuals differ in their neuroendocrine responses to extreme stress. It proposes a conceptual model for components of the adult response to stressors. Threat appraisal and defensive coping may play crucial roles in determining the neuroendocrine response to trauma with potential mental health consequences, particularly PTSD.

Psychiatric Comorbidity in Treatment-Seeking Alcoholics: The Role of Childhood Trauma and Perceived Parental Dysfunction

BACKGROUND

This study among treatment-seeking alcoholics examined the relationship between childhood abuse (sexual abuse only [CSA], physical abuse only [CPA], or dual abuse [CDA]) and the presence of comorbid affective disorders, anxiety disorders, and suicide attempts, controlling for the potential confounding effects of other childhood adversities (early parental loss, witnessing domestic violence, parental alcoholism, and/or dysfunction) and adult assault histories.

METHOD

We assessed 155 (33 females, 122 males) treatment-seeking alcoholics using the European Addiction Severity Index, the Structured Trauma Interview, and the Composite International Diagnostic Interview.

RESULTS

The severity of childhood abuse was associated with posttraumatic stress disorder (PTSD) and suicide attempts in females and with PTSD, social phobia, agoraphobia, and dysthymia in males. Among men, multiple logistic regression models showed that CPA and CDA were not independently associated with any of the examined comorbid disorders or with suicide attempts. However, CSA independently predicted comorbid social phobia, agoraphobia, and PTSD. For the presence of comorbid affective disorders (mainly major depression) and suicide attempts, maternal dysfunctioning was particularly important. CSA also independently contributed to the number of comorbid diagnoses. For females, small sample size precluded the use of multivariate analyses.

CONCLUSION

Childhood abuse is an important factor in understanding clinical impairment in treated alcoholics, especially regarding comorbid phobic anxiety disorders, PTSD, and suicidality. These findings underline the importance of routine assessment of childhood trauma and possible trauma-related disorders in individuals presenting to alcohol treatment services. More studies with bigger samples sizes of female alcohol-dependent patients are needed.

Trauma, dissociation, and posttraumatic stress disorder in female borderline patients with and without substance abuse problems

OBJECTIVE

To examine the associations of childhood traumatic experiences and childhood neglect with dissociative experiences and posttraumatic stress disorder (PTSD) in a population of female borderline personality disorder (BPD) patients with and without substance abuse.

METHOD

The sample included 64 female patients with BPD. Childhood traumatic experiences and childhood neglect were measured using the Structured Trauma Interview, dissociative experiences with the Dissociative Experiences Scale, and PTSD with the Structured Clinical Interview for DSM-IV.

RESULTS

In general, dissociation scores were higher among those with a history of childhood trauma and neglect, in particular among those who reported both sexual and physical abuse before age 16, more than one perpetrator and severe maternal dysfunction. The prevalence of PTSD was clearly associated with the severity of childhood sexual abuse (CSA) in terms of the occurrence of penetration during CSA, intrafamilial CSA, a duration of CSA longer than 1 year and more than one perpetrator. Comorbid substance abuse problems modified the observed associations such that the associations mentioned above were also present or even more pronounced among those without substance abuse, whereas no associations were found in those with substance abuse.

CONCLUSIONS

The results suggest a moderately strong association between childhood trauma and neglect with dissociation and PTSD. However, trauma-dissociation and trauma-PTSD links were only observed among BPD patients without addictive problems. The findings are largely consistent with the literature. Potential explanations for the lack of a trauma-dissociation and trauma-PTSD link in the addicted subgroup are discussed.

Assessment of lifetime physical and sexual abuse in treated alcoholics. Validity of the Addiction Severity Index

We examined the validity of the Addiction Severity Index (ASI) regarding the identification of lifetime physical and sexual abuse histories using the Structured Trauma Interview (STI) as external criterion in alcohol-dependent patients (n=144). Compared to the STI, the ASI showed a lower incidence of lifetime physical abuse reports (51% vs. 24%) and lifetime sexual abuse reports (29% vs. 17%). Lower incidence of abuse reports was stronger in males compared to females, which could be largely explained by ASI perpetrator restrictions (i.e. exclusion of several extrafamilial perpetrators). Controlling for these restrictions, acceptable sensitivity for both sexual and physical abuse as well as good specificity was found. Data indicated no response bias on the ASI in terms of social desirability or abuse severity. Sensitivity of the ASI method can probably be improved by including an opening preface to the subsequent abuse questions, including questions inquiring about abuse histories that have neutral wording instead of using the word "abuse," and inclusion of all possible perpetrators.

Trauma and dissociation in treatment-seeking alcoholics: towards a resolution of inconsistent findings

There is consistent empirical evidence for a trauma-dissociation relation in general population samples and in psychiatric patients. However, contradictory findings have been reported on this relation among substance abusers. The present study attempts to resolve these inconsistencies by testing a series of hypotheses related to problems regarding the measurement of childhood abuse, the measurement of psychological dissociation, and the potential existence of substance abuse as a form of chemical dissociation. Alcoholic patients (N = 155) were administered the Dissociative Experiences Scale (DES), the Structured Trauma Interview (STI), the European Addiction Severity Index (EuropASI), and the Posttraumatic Stress Disorder (PTSD) section of the Composite International Diagnostic Interview (CIDI). The DES showed good psychometric properties. Substantial rates of traumatization and PTSD were observed, as well as a significant trauma-PTSD relation. However, the mean DES score was low (11.4) and dissociation was not related to trauma (childhood or lifetime) or to PTSD. Years of lifetime regular medicine use, however, was significantly correlated with the severity of dissociative symptoms and PTSD, particularly in males. Overall, these findings suggest that absence of a trauma-dissociation relation in alcoholics may not be due to measurement problems of childhood abuse and/or dissociation. Rather, a trauma-dissociation link may not exist, particularly in male alcoholics, because these individuals may abuse substances to achieve dissociative-like states. Additional research is needed to further evaluate the utility of the DES in alcoholic samples and to examine the notion of chemical dissociation.

Sensitivity of the Addiction Severity Index physical and sexual assault items: preliminary findings on gender differences

OBJECTIVE

Evaluation of the Addiction Severity Index (ASI) as a screen for identifying sexual and physical assault histories.

METHOD

The sensitivity and specificity of the ASI assault items were examined in 146 alcoholic patients with the assault questions of the Composite International Diagnostic Interview posttraumatic stress module as external criterion.

RESULTS

The sensitivity of the ASI items was lower than their specificity for both physical (sensitivity = 0.35, specificity = 0.83) and sexual abuse (sensitivity = 0.69, specificity = 0.94). These findings indicate an underestimation of such abuse histories in male patients due to screening for a narrow range of possible perpetrators.

CONCLUSION

The ASI method as a screen for sexual and physical assault histories could be improved, considering that men clearly outnumber women in persons applying for alcohol treatment.

Childhood trauma and perceived parental dysfunction in the etiology of dissociative symptoms in psychiatric inpatients

OBJECTIVE

Research on the etiology of dissociation in adults has focused primarily on childhood sexual abuse. The role of co-occurring childhood stressors and of more chronic adverse conditions such as neglect is less clear. This study examined the level of dissociation in relation to childhood trauma (sexual/physical abuse, witnessing interparental violence), early separation from a parent, and perceived parental dysfunction.

METHOD

One hundred sixty inpatients consecutively admitted to a general psychiatric hospital were administered the Dissociative Experiences Scale and the Structured Trauma Interview.

RESULTS

The mean Dissociative Experiences Scale score was 17.4; 18.0% of the patients scored beyond 30. Early separation was reported by 26.4% of the patients; 30.1% had witnessed interparental violence; 23.6% reported physical abuse; 34.6% reported sexual abuse; 11.7% reported rape before age 16; and 42.1% reported sexual and/or physical abuse. The level of dissociation was primarily related to reported overwhelming childhood experiences (sexual and physical abuse). When sexual abuse was severe (involving penetration, several perpetrators, lasting more than 1 year), dissociative symptoms were even more prominent. Highest dissociation levels were found in patients reporting cumulative sexual trauma (intrafamilial and extrafamilial) or both sexual and physical abuse. In particular, maternal dysfunction was related to the level of dissociation. With control for gender and age, stepwise multiple regression analysis indicated that the severity of dissociative symptoms was best predicted by reported sexual abuse, physical abuse, and maternal dysfunction.

CONCLUSIONS

These findings indicate that dissociation, although trauma-related, is neglect-related as well. This implies the importance of object relations and attachment in the diagnosis and treatment of patients with dissociative disorders.

Child sexual and physical abuse and alcoholism: a review

OBJECTIVE

To examine possible relations between child sexual or physical abuse and adult alcoholism.

METHOD

Studies reviewed included prospective studies, retrospective studies on the prevalence of child sexual or physical abuse in alcoholics and nonalcoholics, and retrospective studies in mental health clients and in population samples comparing the prevalence of alcohol use disorders in abused and nonabused subjects.

RESULTS

Prospective studies do not indicate a significant association between child sexual or physical abuse and alcoholism. In contrast, studies among alcoholic women do suggest a relationship. Also, a significantly higher prevalence of alcohol problems in abused women than in nonabused women is found in population samples. The results of studies among mental health clients are inconclusive. In addition, several methodological limitations should be taken into consideration when evaluating results of the available studies.

CONCLUSIONS

Current evidence is insufficient to draw conclusions about relationships between child sexual or physical abuse and alcoholism among men. Among females, however, there is a higher likelihood of alcohol problems if they were sexually or physically abused as children.