The Consequences of Trauma in Early Life For Adult Mental Health Alison Lowit, Linda Treliving, Ian...

The Consequences of Trauma in Early Life For Adult Mental Health

Alison Lowit, Linda Treliving, Ian Reid

Aberdeen UniversityNHS Grampian

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Background

• Research over the past twenty years has shown that Early Trauma (Childhood Physical, Sexual and Emotional Abuse) is relatively common in our culture.

• Reported prevalence rates range 6-62% for women 3-31% for Men.

• Early Trauma has been linked to many physical health problems, such as:

• Obesity (Williamson et al. 2002)

• Gastrointestinal problems (Drossman et al. 1995)

• Generalized pain (Kendal-Tackett 2001)

Background

• Children who have experienced Early Trauma often grow up to experience psychological difficulties

• Research indicates that prevalence rates for Early Trauma amongst psychiatric patients are significantly higher than the general population.

• Associated psychological symptoms include:

Depression (Wexler et al 1997) Post Traumatic Stress Disorder (Kaplan et al. 2000) Eating disorders (Tobin & Griffin 1996)

Self mutilation (Lipschitz et al. 1999) Suicidality (Brodsky et al. 2001)

Background

Early Trauma and Personality Disorder.

There is a high association between early trauma and personality Disorders (Laporte & Guttman 1996), the correlation is most frequently found in patients with Borderline Personality Disorder. (Grilo et al. 1999)

Both early trauma and personality disorder tend to be underreported and under diagnosed (Herman et al.1999).

The Scottish Executive is trying to address the therapeutic needs of these two neglected groups and recommend that more research is needed to improve care, treatment and prognosis.

Evidence suggests that:

• early trauma has a physical effect on the development of the brain (Vythilingam et al. 2002, Hiem & Nemeroff 2002)

• the experience of early trauma affects the way adult patients respond to treatment for various mental health disorders (Kaplan et al. 2000, Gladstone et al 2004)

There are serious consequences for mental health patients with an unrecognised history of early trauma; both in terms of their prescribed treatment regimes and their long-term prognosis.

Literature reviewIndicated that studies investigating the consequences of early trauma are of a very mixed quality. For example:

• standardised scales have not been used• frequency and duration of abuse is often ignored • one type of abuse is often studied in isolation • some studies only investigate one psychiatric diagnosis• small sample sizes• to date very little work has been done on any European population

Primary Research Aims.

• To determine an accurate estimate of the rate of childhood sexual, physical and emotional abuse (early trauma) amongst clients in contact with Mental Health Services in Aberdeen.

• To determine the range of psychological distress likely to be associated with early trauma in this population.

Secondary Research Aims

• To estimate the prevalence of personality disorder amongst clients in Aberdeen and correlate this with early trauma.

• To determine the rate of recording by health care professionals in Aberdeen of early trauma as a possible factor in adult mental illness.

Study designInclusion Criteria:

• Aged over 18

• A client of the Mental Health Services in Aberdeen.

• Able to understand English

• Able to give informed consent to participate.

• Willing to participate following a description of the study.

Study design

Exclusion Criteria:

• Patients unwilling to participate, who do

not give their consent

• Patients who are deemed unable to give informed consent by the consultant in charge of their care.

Study design

Method: A consecutive recruitment/assessment cross-sectional study to estimate the prevalence of early trauma.

Study participants: clients in contact with

the Mental Health Services, Aberdeen

Recruitment: via consultant psychiatrists

Study design

Instruments: three validated questionnaires:

• The Childhood Trauma Questionnaire

(CTQ)

• The Symptom Checklist 90 Revised

(SCL-90-R)

• The Personality Disorder Questionnaire

(PDQ-4)

Method

• Originally we planned to use the 3 questionnaires as self-reporting instruments.

• Feedback from initial participants indicated that they did not want to complete the 3 questionnaires themselves.

• A structured interview format was adopted as this was the method preferred by the initial participants.

Method

• Participants were interviewed at the Royal Cornhill Hospital.

• Participant’s case notes were reviewed immediately after the interview.

• All data was tabulated onto a computer on the same day as the interview.

Questionnaires

The Symptom Checklist 90 Revised

(SCL90R) designed to measure current psychological distress.

The Childhood Trauma Questionnaire(CTQ) designed to screen for histories of abuse and neglect.

The Personality Disorder Questionnaire (PDQ-4) designed to screen for Personality disorders

SCL90-R A 90-item checklist designed to measure

psychological distress

It measures the following primary symptom dimensions:

SomatizationObsessive-compulsiveInterpersonal sensitivityDepressionAnxietyHostilityPhobic anxiety Paranoid ideationPsychoticism

SCL-90-R measures the following global indices:Global severity index: combines

information concerning the number of symptoms reported with the intensity of perceived distress – bestsingle indicator of current level of distress

Positive symptom distress index: reflects the average level of distress reported for the symptoms that were endorsed – measure of symptom intensity

Positive symptom total: the symptoms endorsed (regardless of level of distress) - a measure of symptom breadth

The Childhood Trauma QuestionnaireThe CTQ screens for 5 types of maltreatment:

• Emotional Abuse

• Physical Abuse

• Sexual Abuse

• Emotional Neglect

• Physical Neglect

The Childhood Trauma Questionnaire

Participants respond to a series of questions about childhood events, by endorsing one of the following options:

• Never True = 1• Rarely True = 2• Sometimes True =3• Often True = 4• Very Often True = 5

Classification of CTQ Scale Total Scores

Scale none tominimal

low to moderate

moderate to severe

Severe to extreme

Emotional Abuse

5-8 9-12 13-15 =>16

Physical Abuse 5-7 8-9 10-12 =>13

Sexual Abuse 5 6-7 8-12 =>13

Emotional Neglect

5-9 10-14 15-17 =>18

Physical Neglect 5-7 8-9 10-12 =>13

Classification of CTQ Scale Total Scores

In this study participants are considered to have suffered

childhood trauma if they have scored the following for a

category: (shaded area of table)

• Emotional Abuse 13 and above

• Physical Abuse 10 and above

• Sexual Abuse 8 and above

• Emotional Neglect 15 and above

• Physical Neglect 10 and above

PDQ-4PDQ-4 is designed to assess 12 personality

disorders.

• Paranoid• Schizoid• Schizotypal• Histrionic• Narcissistic• Borderline• Antisocial• Avoidant• Dependent• Obsessive Compulsive• Negativistic• Depressed

PDQ-4

PDQ-4 is a series of 99 true/false questions

Each question describes a behavioral pattern that is consistent with a symptom of a personality disorder.

Patients are asked• to think about how they have tended to feel,

think, and act over the past several years.

• whether each description is "generally true“ or "generally false" of them.

If the patient indicates a sufficient number

questions that are related to a specific personality disorder are True for them, an additional series of questions are asked in the Clinical Significance Scale section of the test.

Borderline PD T

6 I’ll go to extremes to prevent those who I love from ever leaving me.

19 I either love someone or hate them, with nothing in between

32 I often wonder who I really am.

45 I have tried to hurt or kill myself.

58 I am a very moody person.

69 I feel my life is dull and meaningless.

78 I have difficulty controlling my anger or temper.

93 When stressed and things happen, I get paranoid or just black out.

98 I have done things on impulse that could have gotten me into trouble. Need two of:Spending more money than I have.Having sex with people I hardly know.Drinking two much.Taking drugs.Eating binges.Reckless driving.

Threshold score: Score must be equal to, or above 5

Clinical Significance Questions Clinical Sig. Response

√

A) Read checked items; Are any of these items not really true for you?

No change

B) How long have these items been part of your personality?

> 5 years

D) In what areas have these items created difficulties for you: home/work/relationships, or other areas of your life?

At least one.

C) Have these items been part of your personality only when depressed, anxious, using alcohol/drugs or physically ill or, there most of the time regardless of your mood, level of anxiety, use of alcohol/drugs or general state of health?

Not linked to other issues.

E) Are you bother about yourself because of these behaviours?

Yes

A+B+C+(D or E) = clinically significant

PDQ-4

The total PDQ-4 score is an index of overall personality disturbance.

• Controls generally score 20 or less.

• Patients in therapy generally score between 20-30.

• A total score of 30 or more indicates a substantial likelihood that the patient has significant personality disturbance.

PDQ-4

Participants included in the PD group

• scoring positively for a specific PD• total score of 30 or above

Participants not included in PD group

• scoring positively for a specific PD• total score of less than 30

Results

• Interviewed 136 inpatients

Male(ET) N=48

Male (N- ET)N=26

Female

(ET)N=42

Female

(N-ET)N=20

Age

Mean (SD) 43 (11) 45 (11) 42 (9) 42 (15)

Education:

School (≥16) 38 18 23 13

Highers/College 9 4 10 5

University/PG 1 4 9 2

Marital Status

Single 25 13 12 9

Married 9 6 14 5

Divorced/Sep 14 7 11 3

Widow 0 0 5 3

Demographics

Early Trauma

90 of the 136 Psychiatric Inpatients have experienced moderate/severe early trauma.(66%)

48/74 Males (64%)

42/62 Females (67%)

60 of the 90 participants who have experience early trauma have this recorded in their psychiatric medical records. (66%)

PDQ4

95 of the 136 participants have significant personality disturbance.(70%) 58/74 Males (78%) 37/62 Females (60%)

20 of the 95 participants who have significant personality disturbance have a recorded diagnosis of PD. (21%)

Personality Disorder and Early Trauma

70 of the 95 participants with significant personality disturbance have experienced moderate/severe early trauma. (74%)

43/58 Males (74%)

27/37 Females (73%)

Personality Disorder and Early Trauma

PD Yes PD No TotalET Yes 70 20 90

ET No 25 21 46Total 95 41 136

Chi-square Test: 6.86 p=0.009

Category(1st Diagnosis)

Total inpatients

Abused (%)

Not Abused(%)

Depression 29 19 (65) 10 (35)

Bipolar 26 17 (65) 9 (35)

Personality Disorder

15 14 (93) 1 (7)

Substance misuse 13 9 (69) 4 (31)

Anxiety 8 5 (63) 3 (37)

Schizophrenia 37 23 (62) 14 (38)

No Diagnosis 2 2 (100) -

1st Psychotic episode (3) Eating Disorder(2) DSH(1)

6 1 (17) 5 (83)

Total 136 90 (66) 46 (34)

Diagnosis and association to early trauma

Category(1st Diagnosis)

Total inpatients

PD No PD

Depression 29 22 (76) 7 (24)

Bipolar 26 14 (54) 12 (46)

Personality Disorder 15 15 (100) 0

Substance misuse 13 13 (100) 0

Anxiety 8 3 (38) 5 (62)

Schizophrenia 37 24 (65) 13 (35)

No Diagnosis 2 1 (50) 1 (50)

1st Psychotic episode(3)Eating disorder(2) DSH(1)

6 3 (50) 3 (50)

Total 136 95 (70) 41 (30)

Diagnosis and presence of significant personality disturbance

Determining the range of psychological

distress associated with early trauma in the

inpatient population.

• Comparisons were made between the ET

and Non-ET groups.

• Comparisons were made within same sex

and between genders.

Gender comparisons

• Few studies have investigated gender differences in the long term effects of ET.

• Those that have suggest that there are more similarities than differences between men and women survivors of ET.

• However, epidemiologically, men and women in the overall population report different symptoms and severity of symptoms.

• Those gender differences are confounding factors that may distort the interpretation of the results.

• In order to get a true picture of the long term effects of ET on male and female populations we need to take into account the gender differences in the general population when analysing the results.

Gender comparisonsTo take into account the inherent symptom differences between males and females in the general population,

we used a standard normalised T score (Derogatis 1994)

– The SCL-90-R unadjusted scores are the respondents actual results upon completion of the questionnaire.

– The SCL-90-R adjusted scores are the unadjusted scores transformed by converting to a normalised T score using a non-patient normative sample.

Psychological Symptom Comparisons.

Six analysis were performed:

• ET females compared to ET males – unadjusted

• ET females compared to ET males – adjusted

• N-ET females compared to N-ET males – unadjusted

• N-ET females compared to N-ET males – adjusted

• ET females compared to N-ET females – unadjusted

• ET males compared to N-ET males – unadjusted(ET = Early Trauma; N-ET = No Early Trauma)

0

0.5

1

1.5

2

2.5

3

som o-c ips dep anx hos phanx parid psy gsi psdi

females ET (n=42) males ET (n=48)

Unadjusted Scores

50

55

60

65

70

75

80


females ET (n=42) males ET (n=48)

Adjusted Scores

**

****

** **

** ***

**

*p<0.05, **p<0.01

Males & Females with Early Trauma Summary

• Unadjusted score comparisons – no significant differences emerge

• Adjusted score comparisons – significant differences become apparent.

Males & Females with Early Trauma Summary

• Males scored significantly higher for:Somatization, Obsessive-compulsive, Interpersonal sensitivity, Depression, Anxiety, Phobic anxiety, Paranoid ideation, Psychoticism, Global severity Index and Positive symptom Total.

• ET males had higher symptom scores relative to males in the SCL-90-R non-patient standardised sample than did ET females relative to their standardised sample.

0

0.5

1

1.5

2

2.5

3


females N-ET (n=20) males N-ET (n=26)

*

*

**

Unadjusted Scores

*p<0.05, **p<0.01

**

50

55

60

65

70

75

80


females N-ET (n=20) males N-ET (n=26)

Adjusted Scores

*

*p<0.05

N-ET Males & Females

• Unadjusted score comparisons – female scores were significantly higher for:

Somatization, Interpersonal sensitivity, Depression, Global severity index and Positive symptom distress index.

• Adjusted score comparisons – These Significant differences disappear when scores are adjusted to account for inherent gender differences.

Female Inpatients ET & N-ET

• No Significant differences between the groups.

• We suspect no significant differences emerged because the study was conducted amongst a highly distressed female population who had already reached the symptom ceiling capable of being detected by the SCL-90-R, and further elevated symptoms would not be picked up by this symptom checklist instrument.

Male Inpatients ET & N-ET• ET males scored significantly higher than N-ET

males for all symptom dimension and global indices.• This is evidence that ET has a profound effect on

males, and even amongst the generally distressed inpatient male population there is a highly significant elevation of symptoms for males who have experienced ET.

• This also indicates the value of standardising scores (for example using T-scores) when undertaking gender comparisons.

10

12

14

16

18

20

22

24

emotional abuse physical abuse sexual abuse emotional neglect physical neglect

depression bipolar disorder personality disorders

substance misuse schizophrenic disorders anxiety disordersMean score

Diagnosis and nature of trauma

10

12

14

16

18

20

22

24

emotional abuse(N=15)

physical abuse (N=6)

sexual abuse (N= 6)

emotional neglect(N=13)

physical neglect (N= 9)

depression (19/29)Mean score

Depression

10

12

14

16

18

20

22

24

emotional abuse (N= 15)

physical abuse(N=11)

sexual abuse (N= 5)

emotional neglect(N=10)


bipolar disorder (17/26)Mean score

Bipolar disorder

10

12

14

16

18

20

22

24


physical abuse (N= 11)

sexual abuse (N= 5)

emotional neglect(N= 11)

physical neglect(N=7)

personality disorders (14/15)Mean score

Personality Disorder

10

12

14

16

18

20

22

24


physical abuse (N= 5)

sexual abuse (N= 5)

emotional neglect(N= 5)


substance misuse (9/13)Mean score

Substance misuse

10

12

14

16

18

20

22

24



sexual abuse (N=17)

emotional neglect (N= 11)


schizophrenic disorders (23/37)Mean score

Schizophrenic disorders

10

12

14

16

18

20

22

24



sexual abuse (N= 3)

emotional neglect (N= 5)

physical neglect (N=3)

anxiety disorders (5/8)Mean score

Anxiety disorders

Conclusions

• There are very high rates of early trauma amongst mental health inpatients in Aberdeen.

• A high percentage of inpatients have significant personality disturbance.

• Early trauma is associated with significant personality disturbance (p<0.01) within this patient population.

Conclusions

• Male inpatients with early trauma report higher symptom levels than female inpatients with early trauma when gender differences in the reporting of symptoms are taken into account.

• Female inpatients regardless of presence or absence of early trauma report similar symptom levels.

• Males with early trauma reported significantly higher symptom levels for all symptoms measured by the SCL-90-R than males without early trauma.

Clinical Implications• A diagnosis of personality disorder is known to

complicate treatment regimes. However, this complication could have its origins in an unrecognised history of early trauma.

• It is likely there is an under recognition of comorbid diagnoses involving personality disorder.

• If a patient presents with symptoms of personality disorder it is crucial to check for a history of early trauma – a treatment regime may be more effective if it also tackles problems directly attributable to early trauma.

Thank you

0

0.5

1

1.5

2

2.5

3


females ET females N-ET

Unadjusted Scores

0

0.5

1

1.5

2

2.5

3


males ET males N-ET

**

** **

0

0.5

1

1.5

2

2.5

3


males ET males N-ET

**

0

0.5

1

1.5

2

2.5

3


males ET males N-ET

****

****

**

*

**

*

*p<0.05, **p<0.01

Table 1 Inpatients ET M&F unadjusted scores

T-Test unadjusted scores

Variable FemalesET

MalesET

(n=42) (n=48)

Scale Mean SD Mean SD T

Somatization 1.22 0.84 1.47 0.84 -1.39

Obsessive-Compulsive 1.96 0.90 2.11 0.91 -0.77

Interpersonal Sensitivity a 1.71 0.81 1.90 0.98 -1.02

Depression a 2.30 1.07 2.36 1.06 -0.28

Anxiety a 1.90 0.98 2.11 0.91 -1.06

Hostility 0.97 0.96 1.18 0.97 -1.03

Phobic Anxiety a 1.65 1.24 1.83 1.18 -0.69

Paranoid Ideation a 1.48 0.95 1.68 1.00 -0.96

Psychoticism 1.29 1.02 1.50 0.89 -1.04

Global Severity Index 1.70 0.75 1.86 0.76 -0.99

Positive Symptom DI 2.67 0.65 2.70 0.72 -0.23

Positive Symptom Total 55.57 19.06 60.56 15.57 -1.37

Table 2 Inpatients ET adjusted M&F

T-Test adjusted scores

Variable MalesET

FemalesET

(n=48) (n=42)


Somatization 70.25 10.30 61.71 11.91 3.65**

Obsessive-Compulsive 74.96 9.35 69.62 9.02 2.75**

Interpersonal Sensitivity a 74.56 8.94 69.45 9.26 2.66**

Depression a 76.73 7.81 70.83 9.81 3.28**

Anxiety a 77.96 5.99 70.12 10.82 4.17**

Hostility 63.98 12.23 58.88 12.48 1.95

Phobic Anxiety a 74.23 9.56 67.93 12.15 2.71**

Paranoid Ideation a 69.60 9.82 65.52 10.94 1.86

Psychoticism 74.42 7.30 69.12 11.85 2.51*

Global Severity Index 78.02 5.34 71.36 10.45 3.73**

Positive Symptom DI 73.46 8.21 72.14 8.57 0.74

Positive Symptom Total 72.19 5.97 66.17 8.97 3.78**

*p<0.05, **p<0.01

Table 3 Inpatients N-ET M&F unadjusted scores

FemalesN-ET

MalesN-ET

(n=20) (n=26)


Somatization 1.36 1.06 0.80 0.63 2.20*

Obsessive-Compulsive 2.10 1.21 1.45 1.05 1.93

Interpersonal Sensitivity 1.87 1.18 1.12 0.99 2.33*

Depression 2.49 1.23 1.57 1.25 2.48*

Anxiety 2.01 1.18 1.42 1.11 1.73

Hostility a 1.08 1.11 0.58 0.56 1.82

Phobic Anxiety 1.63 1.22 1.20 1.06 1.30

Paranoid Ideation 1.28 1.25 1.19 0.93 0.28

Psychoticism 1.22 1.03 0.95 0.97 0.88

Global Severity Index 1.77 1.00 1.19 0.83 2.15*

Positive Symptom Distress Index 2.94 0.66 2.29 0.69 3.33**

Positive Symptom Total 51.70 24.96 41.88 24.03 1.35

*p<0.05, **p<0.01

Table 4 Inpatients N-ET M&F adjusted scores

FemalesN-ET

MalesN-ET

(n=20) (n=26)


Somatization 62.95 12.68 61.00 10.83 0.56

Obsessive-Compulsive 68.45 15.09 66.35 15.37 0.46

Interpersonal Sensitivity 69.20 12.75 64.50 14.31 1.58

Depression 72.45 10.59 68.65 14.84 1.01

Anxiety 70.20 11.86 69.35 14.90 0.21

Hostility 60.05 13.24 55.73 10.86 1.22

Phobic Anxiety 68.05 11.37 68.92 12.60 -0.24

Paranoid Ideation 60.60 15.96 63.15 13.08 -0.20

Psychoticism 67.75 13.91 64.73 14.84 0.70

Global Severity Index 71.15 10.94 68.46 14.47 0.69

Positive Symptom Distress Index 75.20 8.31 68.12 11.17 2.37*

Positive Symptom Total 64.80 11.03 62.81 13.61 0.53

T-Test

Variable FemalesET

FemalesN-ET

(n=42) (n=20)


Somatization 1.22 0.84 1.39 1.06 -0.69

Obsessive-Compulsive 1.96 0.90 2.10 1.21 -0.49

Interpersonal Sensitivity a 1.71 0.81 1.87 1.18 -0.55

Depression a 2.30 1.07 2.49 1.23 -0.65

Anxiety a 1.90 0.98 2.01 1.18 -0.36

Hostility 0.97 0.96 1.08 1.11 -0.39

Phobic Anxiety a 1.65 1.24 1.63 1.22 0.06

Paranoid Ideation a 1.48 0.95 1.28 1.25 0.69

Psychoticism 1.29 1.02 1.22 1.03 0.25

Global Severity Index 1.70 0.75 1.77 1.00 -0.31

Positive Symptom DI 2.67 0.65 2.94 0.66 -.3.20

Positive Symptom Total 55.57 19.06 51.70 24.96 -1.56

Table 5 Female Inpatients ET/N-ET

Table 6 Male Inpatients ET/N-ET

T-Test

Variable MalesET

MalesN-ET

(n=48) (n=26)


Somatization 1.47 0.84 0.80 0.63 3.81**

Obsessive-Compulsive 2.11 0.91 1.45 1.05 2.82**

Interpersonal Sensitivity a 1.90 0.98 1.12 0.99 3.27**

Depression a 2.36 1.06 1.58 1.25 2.83**

Anxiety a 2.11 0.91 1.42 1.11 2.90**

Hostility 1.18 0.97 0.58 0.56 3.30**

Phobic Anxiety a 1.83 1.18 1.20 1.06 2.28*

Paranoid Ideation a 1.68 1.00 1.19 0.93 2.03*

Psychoticism 1.50 0.89 0.95 0.97 2.42*

Global Severity Index 1.86 0.76 1.19 0.83 3.49**

Positive Symptom DI 2.70 0.72 2.29 0.69 2.42*

Positive Symptom Total 60.56 15.57 41.88 24.03 3.58**

*p<0.05, **p<0.01

The Consequences of Trauma in Early Life For Adult Mental Health Alison Lowit, Linda Treliving, Ian...

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