Different Childhood Adversities Are Associated with Different Symptom Patterns in Adulthood
Authors: Carlo Faravelli, Giovanni Castellini, Giulia Fioravanti, Carolina Lo Sauro, Francesco Pietrini, Lorenzo Lelli, Francesco Rotella, Valdo Ricca
Journal: Psychotherapy and Psychosomatics (2014)

A history of childhood adversities has been associated with the pathogenesis of several psychiatric conditions: major depressive disorder, panic disorder, post-traumatic stress disorder, generalized anxiety disorder, schizophrenia, eating disorders, alcohol/substance dependence, personality disorders [1]. It has therefore been suggested that childhood traumata might be a non-specific risk factor for psychopathology [2].This is in contrast to most psychological models, that postulated a certain specificity between the kind of childhood trauma, the attachment style and adult psychopathology [e.g. [3]].Few studies have dealt with this issue on empirical grounds. It has been reported that patients with a history of maltreatment exhibit greater severity, higher comorbidity, greater risk for suicide and poorer treatment response compared with non-maltreated patients with the same diagnoses [4].Emotional neglect during childhood was reported to be associated with depression, dysthymia and social phobia and with the anhedonic symptoms of depression, whereas sexual abuse in the past was associated with anxious arousal and general distress [5,6].As these findings are scant and not fully consistent, we decided to study the effects of early traumata on adult psychopathology, exploring the hypothesis that different adversities might be associated with different symptom patterns.Operational diagnoses, with their high rate of comorbidity and lack of specificity, might not be an adequate way to explore this topic. It is conceivable that different types of early adversities might produce symptom patterns that range transdiagnostically. Since to our knowledge no study has systematically explored this hypothesis, we assessed the relationship between early adversities (loss, neglect and abuse) and symptoms in a representative sample of psychiatric patients according to a transnosographic perspective.During the period November to December 2010 it was possible to contact and interview 409 consecutive patients admitted, within 1 week of the interview, to all the psychiatric in- and outpatient facilities of Tuscany. A group of 200 people randomly drawn from the general population living in the same catchment area and matched with the psychiatric cases for age, gender and education made up the controls.The adversities of childhood/adolescence were studied by the Childhood Experience of Care and Abuse Questionnaire (CECA-Q [7]) and by an interview for early trauma widely used in the past [8]. For the purpose of this study early adversities were evaluated as follows: (a) presence of a loss event whenever a death or separation (for 1 year or more) from parents was reported; (b) presence of sexual abuse or physical abuse when the CECA-Q or the interview showed the occurrence of physical and/or sexual abuse; (c) the presence of neglect was based on the CECA-Q scores in the scales 'Mother's Neglect' and 'Father's Neglect' using the proposed cut-off [7].DSM-IV diagnoses were made using the Structured Clinical Interview for DSM-IV Axis I Disorders [9]. The symptoms were assessed independently of the diagnoses: the items of several well-known rating scales, combined in a single fully validated instrument [8], were used.Compared with controls, patients as a whole showed an excess of all early life events (below statistical significance only in the case of loss; p value used <0.05). When the patients were divided according to their DSM-IV diagnoses (only diagnoses with at least 30 cases were considered), almost all the main diagnostic groups showed a significantly higher rate of abuse and neglect compared with the control group. An excess of loss events was generally reported, but the significance level was attained only by non-affective psychosis, bipolar disorder and obsessive-compulsive disorder. When the diagnostic categories were compared with each other, no significant difference was found.The psychiatric symptoms of the patients who reported the occurrence of no adversity during childhood/early adolescence were compared with those of the cases who reported loss, neglect, sexual abuse or physical abuse. Of the 54 symptoms shown by at least 10% of cases, 17 bore significant associations with early adversities. Six maintained the significance (p < 0.001) after Bonferroni correction.Compared with patients with no early adversity, the patients reporting neglect were characterized by an excess of early awakening [odds ratio, OR (95% confidence interval, 95% CI) = 1.86 (1.06-3.30)], hyporexia [OR (95% CI) = 2.05 (1.13-3.70)], eating restrictions [OR (95% CI) = 2.87 (1.16-7.06)], suicidal ideation/attempts [OR (95% CI) = 1.83 (1.03-3.53)], decreased sexual desire [OR (95% CI) = 2.09 (1.17-3.74)] and sexual activity [OR (95% CI) = 1.91 (1.08-3.38)], mood-congruent delusions [OR (95% CI) = 2.61 (1.04-6.50)], and a previous history of hyperthymia [OR (95% CI) = 1.87 (1.03-3.38)].Sexual abuse was associated with night terror [OR (95% CI) = 2.46 (1.03-5.69)], recurrent nightmares [OR (95% CI) = 1.99 (1.02-3.91)], intrusive memories [OR (95% CI) = 2.96 (1.05-8.34)] and flashbacks of the event [OR (95% CI) = 3.4 (1.16-9.92)], aggressive impulses [OR (95% CI) = 2.96 (1.51-5.82)], hyporexia [OR (95% CI) = 1.99 (1.02-3.91)], binge eating [OR (95% CI) = 2.18 (1.07-4.42)], eating restrictions [OR (95% CI) = 3 (1.02-8)], suicidal ideation/attempts [OR (95% CI) = 2.04 (1.21-4.76)], decreased sexual desire [OR (95% CI) = 2.43 (1.22-4.83)], mood-congruent delusions [OR (95% CI) = 3.41 (1.03-8.96)], and a past history of substance abuse [OR (95% CI) = 3.02 (1.39-6.82)].Physical abuse bore significant associations with eating restrictions [OR (95% CI) = 3.09 (1.27-7.51)], recurrent nightmares [OR (95% CI) = 3.19 (1.11-9.14)], intrusive memories [OR (95% CI) = 2.63 (1.01-6.84)], decreased sexual desire [OR (95% CI) = 1.9 (1.07-3.67)] and a past history of substance abuse [OR (95% CI) = 2.25 (1.05-4.8)].Loss of parents was associated with a significantly increased risk of having weight loss [OR (95% CI) = 2.54 (1.37-4.59)] and grandiose thoughts [OR (95% CI) = 3.38 (1.54-7.42)].As the symptoms had some level of reciprocal association and the early life events also were not independent of each other, we adopted the stepwise forward conditional method of regression for controlling the multicollinearity. The adjusted ORs confirmed that each type of early adversity was associated with a specific symptom pattern (table 1).A huge number of previous studies already reported that early adversities differentiate psychiatric patients and controls, but failed to distinguish among specific DSM-IV diagnoses [1,2]. The well-known heterogeneity of DSM diagnoses and the high level of comorbidity can account for this. For this reason we chose the 'functional' approach proposed by Van Praag [10] and indeed in the present study early adversities seem to influence differentially specific symptom profiles rather than diagnoses.Retrospective recall may obviously bias the assessment of early adversities. However, the excess of even those early adversities that are reliably retrieved, such as death of parents, renders plausible that also the more subjective accounts retain a sufficient amount of credibility.The present study is one of the first yielding empirical evidence supporting the common psychotherapeutic position that different early adversities are associated with different adult clinical states. While these associations do not warrant a causal link, they suggest that the topic merits being studied from different perspectives rather than by adopting a purely nosological approach.