The Consequences of Trauma in Early Life

1
The Consequences of Trauma in Early Life
For Adult Mental Health Alison Lowit, Linda
Treliving, Ian Reid Aberdeen University NHS
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)

3

• 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)

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• 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 under
• reported 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.

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• 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.

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• Literature review
• Indicated 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

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• 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.

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• 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.

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• Study design
• Inclusion 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.
•  

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• 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.

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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

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• 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)

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• 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.

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• Method
• Participants were interviewed at the Royal
  Cornhill Hospital.
• Participants case notes were reviewed
  immediately after the interview.
• All data was tabulated onto a computer on the
  same day as the interview.

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• 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

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• SCL90-R
• A 90-item checklist designed to measure
  psychological distress
• It measures the following primary symptom
  dimensions
• Somatization
• Obsessive-compulsive
• Interpersonal sensitivity
• Depression
• Anxiety
• Hostility
• Phobic anxiety
• Paranoid ideation
• Psychoticism

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• 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 best
• single 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

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• The Childhood Trauma Questionnaire

• The CTQ screens for 5 types of maltreatment
• Emotional Abuse
• Physical Abuse
• Sexual Abuse
• Emotional Neglect
• Physical Neglect

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• 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

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• Classification of CTQ Scale Total Scores

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• 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

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• PDQ-4
• PDQ-4 is designed to assess 12 personality
  disorders.
• Paranoid
• Schizoid
• Schizotypal
• Histrionic
• Narcissistic
• Borderline
• Antisocial
• Avoidant
• Dependent
• Obsessive Compulsive
• Negativistic
• Depressed

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• 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.

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• 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.

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• 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

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• Results
• Interviewed 136 inpatients

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Demographics
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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)
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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)
33
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)
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• Personality Disorder and Early Trauma
•   
•   

Chi-square Test 6.86 p0.009
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Diagnosis and association to early trauma
36
Diagnosis and presence of significant personality
disturbance
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• 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.

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• 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.

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• Gender comparisons
• To 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.

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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)

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Unadjusted Scores
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Adjusted Scores









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Males Females with Early Trauma Summary

• Unadjusted score comparisons no significant
  differences emerge
• Adjusted score comparisons significant
  differences become apparent.

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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.

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Unadjusted Scores





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Adjusted Scores

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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.

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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.

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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.

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Diagnosis and nature of trauma
Mean score
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Depression
Mean score
52
Bipolar disorder
Mean score
53
Personality Disorder
Mean score
54
Substance misuse
Mean score
55
Schizophrenic disorders
Mean score
56
Anxiety disorders
Mean score
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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 (plt0.01) within this
  patient population.

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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.

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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.

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• Thank you

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Unadjusted Scores
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Table 1 Inpatients ET MF unadjusted scores
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Table 2 Inpatients ET adjusted MF
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Table 3 Inpatients N-ET MF unadjusted scores
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Table 4 Inpatients N-ET MF adjusted scores
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Table 5 Female Inpatients ET/N-ET
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Table 6 Male Inpatients ET/N-ET
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