Child sexual abuse,disclosure and PTSD: A systematic and critical review

BackgroundChild sexual abuse (CSA) is a prevalent exposure with potentially serious, negative health consequences, including post-traumatic stress disorder (PTSD) and its symptomatology.ObjectiveTo conduct a systematic and critical review in order to investigate the relationship between CSA disclosure patterns and PTSD.Participants and settingStudies included clinical, college and community-based samples of adults’ and children’s experiences of CSA.MethodsWe conducted systematic searches in five databases (Medline, Embase, PyscINFO, CINAHL, ERIC, Sociological Abstracts) from database inception to October 17, 2017 using index terms and keywords for CSA, disclosure, and PTSD. We included any English-language, primary studies involving children or adults with experiences of CSA that used quantitative research designs to explore the relationship between disclosure and PTSD. We used systematic critical review methodology in order to investigate the relationship between disclosure and PTSD symptoms and disorders. We also investigated factors that explained the relationship between disclosure and PTSD, such as individual, exposure or environmental factors.ResultsTwenty-two articles reporting 20 studies were included in this review. Studies assessing the relationship between CSA and PTSD tended to account for personal (e.g., gender) and CSA exposure variables (e.g., severity of CSA) only. While authors generally used validated measures to assess for PTSD symptoms and disorders, they tended to use author-generated or unvalidated measures to assess for disclosure process variables.ConclusionThe relationship between factors that affect disclosure, and responses to disclosure, are not well theorized in quantitative literature. Study findings suggest important avenues for future research, such as the need to assess disclosure longitudinally.     

Posttraumatic Stress Disorder and Substance Use Disorders in College Students

ABSTRACT

Research indicates that many college students report posttraumatic stress disorder (PTSD) or substance use disorder (SUD), yet there has been scant attention paid to the co-occurrence of these disorders in college students. This review examines the co-occurrence of PTSD and SUD in college students. Recommendations for counseling centers are provided regarding the assessment of this population, an overview of treatment issues, and three areas of clinical importance when working with this population: risk behaviors, interpersonal violence, and social isolation. Future directions for research are also suggested.     

Treating child abuse-related posttraumatic stress and comorbid substance abuse in adolescents

OBJECTIVE: Child abuse is a risk factor for developing Posttraumatic Stress Disorder (PTSD) and subsequent Substance Use Disorder (SUD). The purpose of this review is to summarize current knowledge about effective treatments for adolescent abuse-related PTSD, SUD, and the co-occurrence of these conditions.METHOD: The literature on empirical treatment studies for these conditions in adolescence was reviewed, summarized, and synthesized.RESULTS: Randomized controlled studies of abuse-related PTSD and SUD in adolescents have supported the efficacy of cognitive behaviorally-based individual and family treatment components. Components overlap considerably in empirically supported treatments for each disorder. An integrated treatment approach is described for use in adolescents with abuse-related PTSD and SUD, with recommendations for optimizing services for this population and for future research.CONCLUSIONS: The available evidence on effective treatments suggests that integrated PTSD- and SUD-focused cognitive-behavioral and family treatment for adolescents with comorbid abuse-related PTSD and SUD may optimize outcomes for this population.     

Development of anxiety disorders in a traumatized pediatric population: a preliminary longitudinal evaluation

OBJECTIVE: The current study was conducted to determine if post-traumatic stress disorder (PTSD) symptomatology predicted later development of non-PTSD anxiety disorders in children and adolescents victimized by interpersonal trauma. METHODS: Thirty-four children with a history of interpersonal trauma and no initial diagnosis of anxiety disorder participated in the study. Children were assessed at time one (T1) and then 12-18 months later at time two (T2). At T1, the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA) and the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL) were used to evaluate children's PTSD symptoms and comorbid non-PTSD anxiety disorder diagnosis. At T2, the CAPS-CA and the K-SADS-PL were repeated. RESULTS: The diagnosis of PTSD and PTSD symptoms in children exposed to interpersonal trauma at T1, particularly the symptoms associated with avoidance and constricted emotional expression (criteria C) as well as physiological hyperarousal (criteria D), predicted the development of other anxiety disorders at T2. CONCLUSION: Traumatized children with initial PTSD symptomatology may be at risk of later development of other anxiety disorders.     

Comorbidity of PTSD in anxiety and depressive disorders: Prevalence and shared risk factors

The present study aims to assess comorbidity of posttraumatic stress disorder (PTSD) in anxiety and depressive disorders and to determine whether childhood trauma types and other putative independent risk factors for comorbid PTSD are unique to PTSD or shared with anxiety and depressive disorders. The sample of 2402 adults aged 18–65 included healthy controls, persons with a prior history of affective disorders, and persons with a current affective disorder. These individuals were assessed at baseline (T0) and 2 (T2) and 4 years (T4) later. At each wave, DSM-IV-TR based anxiety and depressive disorder, neuroticism, extraversion, and symptom severity were assessed. Childhood trauma was measured at T0 with an interview and at T4 with a questionnaire, and PTSD was measured with a standardized interview at T4. Prevalence of 5-year recency PTSD among anxiety and depressive disorders was 9.2%, and comorbidity, in particular with major depression, was high (84.4%). Comorbidity was associated with female gender, all types of childhood trauma, neuroticism, (low) extraversion, and symptom severity. Multivariable significant risk factors (i.e., female gender and child sexual and physical abuse) were shared among anxiety and depressive disorders. Our results support a shared vulnerability model for comorbidity of anxiety and depressive disorders with PTSD. Routine assessment of PTSD in patients with anxiety and depressive disorders seems warranted.     

Posttraumatic stress avoidance symptoms as mediators in the development of alcohol use disorders after exposure to childhood sexual abuse in a Swiss community sample

This study examined the role of posttraumatic stress disorder (PTSD) symptoms of re-experience, avoidance, and hyperarousal in the relationship between different types of trauma and alcohol use disorders (AUD). We used data from 731 trauma-exposed individuals who participated in the first wave of the PsyCoLaus-study. Trauma characteristics were assessed relatively to the occurrence of lifetime PTSD symptoms and AUD. The results suggest that lifetime and childhood sexual abuse as well as overall childhood trauma were directly linked to AUD and PTSD symptoms, in particular to avoidance symptoms. From single symptom clusters PTSD avoidance was found to specifically mediate the trauma-AUD pathway. Both childhood and sexual trauma strongly contribute to the comorbidity of PTSD and AUD and avoidance-type symptoms appear to play a central role in maintaining this association. Hence, the alleviation of avoidance symptoms might be an important target for therapeutic intervention among victims of sexual abuse before specific addiction treatment is initiated.     

Predicting school violence: A comparison of violent and nonviolent male students on attitudes toward violence,exposure level to violence,and PTSD symptomatology

This preliminary study examined the relationship of use of violence to exposure to violence, attitudes toward violence, and posttraumatic stress disorder (PTSD) symptomatology in 45 adolescent male perpetrators of school violence and 45 nonviolent control participants from inner‐city schools. Participants completed the Exposure to Violence Questionnaire, Attitudes Towards Violence Scale, Checklist of Children's Distress Symptoms, and Use of Violence Scale. The perpetrator and control groups differed in use of violence, exposure to violence, and PTSD symptomatology. Use of violence demonstrated a unique relationship with attitudes toward violence, PTSD, and exposure to violence for the perpetrator sample, with the relationship between exposure to and use of violence remaining significant after controlling for attitudes and PTSD. © 2006 Wiley Periodicals, Inc. Psychol Schs 43: 591–598, 2006.     

Multiple Forms of Stress in Cambodian Adolescent Refugees

A sample of 170 Cambodian youth and 80 of their mothers were interviewed regarding DSM-III-R diagnoses of Post Traumatic Stress Disorder (PTSD) and depressive disorders, and the stress of war trauma, resettlement, and recent life events. A consistent relation between earlier war trauma, resettlement stress, and symptoms of PTSD was found. In contrast, the strongest relation with depressive symptoms was found for recent stressful events. Despite the long interval of time since the occurrence of the war trauma, these youth and their parents reported these experiences in a highly consistent fashion. PTSD and depression in refugee youth appear to be different conditions following different pathways during adolescent development.     

The relative influence of childhood sexual abuse and other family background risk factors on adult adversities in female outpatients treated for anxiety disorders and depression

OBJECTIVE: This study from Norway examines the relative influence of child sexual abuse (CSA) and family background risk factors (FBRF) on the risk for current mental disorders and the quality of current intimate relationships in women with CSA treated for anxiety disorders and/or depression. Women with these disorders frequently seek treatment, and the place of CSA in therapy is still under debate. METHOD: 112 women, who were treated with outpatient psychotherapy by female therapists for anxiety disorders and/or depression were included. CSA had been admitted at the start of treatment start in 56 women, while no CSA was admitted among the 56 women of the comparison group. Systematic and detailed retrospective information about childhood as well as data on current functioning and current mental disorders were collected by questionnaires and structured interviews done by an independent female psychiatrist. RESULTS: The women of the CSA group reported significantly more FBRF than the comparisons. CSA increased the risk for posttraumatic stress disorder (PTSD), non-suicidal self-inflicted harm, and rape after 16 years. Major depression, dysthymia, and their comorbidity were not associated with CSA. The five indicators of quality of current intimate relationship were not associated with CSA. CONCLUSIONS: Women with CSA who have been treated for anxiety disorders and/or depression, also frequently have been exposed to FBRF. Increased risk for PTSD, self-inflicted harm before therapy, and rape after 16 years of age was influenced by CSA, while mood disorders and the quality of current attachment are not associated with CSA, but with FBRF or other factors not examined in this study.     

Empirically supported psychotherapy interventions for internalizing disorders

The present article provides an overview of the best‐developed interventions for child and adolescent internalizing disorders characterized by anxiety and depression. The review emphasizes interventions that fall into established efficacy categories, but also addresses briefly several other promising treatment procedures. Research on the treatment of child and adolescent depression has not yielded interventions with clearly established efficacy, although there are a number of treatment approaches that may be characterized as possibly efficacious. The treatment of child and adolescent anxiety disorders, on the other hand, includes a number of interventions with good empirical support. While the field is clearly advancing, there remain important deficits and limitations with regard to the evidence base for interventions addressing child internalizing disorders. © 2006 Wiley Periodicals, Inc. Psychol Schs 43: 439–449, 2006.     

Structure and prevalence of PTSD symptomology in children who have experienced a severe tornado

Children served by school psychologists are frequently impacted by natural disasters. In the United States, tornadoes are a particular threat but have been studied very little. The current investigation developed a scale for assessing posttraumatic stress disorder (PTSD) in children in Kindergarten to Grade 6 impacted by a severe tornado. Six factors were found: Avoidance, Re‐experiencing, Interpersonal Alienation, Interference with Daily Functioning, Physical Symptoms/Anxiety, and Foreshortened Future. Prevalence rates for PTSD symptomology ranged from 34 to 44% for factor scores and 41% for meeting all three Diagnostic and Statistical Manual of Mental Disorder, fourth edition‐text revision (DSM‐IV‐TR; American Psychiatric Association, 2000) criteria; 40% indicated no symptoms. Children's fear during the tornado and damage to their school were related to many factor scores. © 2006 Wiley Periodicals, Inc. Psychol Schs 43: 283–295, 2006.     

Childhood trauma,PTSD, and psychosis: Findings from a highly traumatized,minority sample

Trauma, especially early life trauma, is a risk factor for the development of both posttraumatic stress disorder and psychosis. The goal of the present study was to determine specific associations between exposure to childhood abuse, PTSD symptoms, and current psychotic disorder. Subjects were recruited from a public, urban hospital (N = 328, >90% African American). Psychotic disorders were measured using the MINI International Neuropsychiatric Interview, PTSD was measured using the Clinician Administered PTSD Scale, child abuse was measured with the Childhood Trauma Questionnaire, and lifetime trauma exposure was measured with the Traumatic Events Inventory. Logistic regression analyses showed that both child abuse and current PTSD were statistically significant predictors of psychotic disorder beyond the effects of lifetime trauma load. When PTSD symptom clusters were examined, avoidance and numbing symptoms showed unique association with psychotic disorder independent of demographic variables and trauma exposure. Using bootstrapping techniques, we found a full indirect effect of PTSD on the association between child abuse and, suggesting a particularly important role of PTSD symptoms in relation to psychotic disorder in the presence of early life trauma. Because this is a cross-sectional study, continued research is needed to determine causality of such models. Identifying co-occurring psychosis and PTSD, particularly in populations with high levels of trauma exposure, is critical and will likely aid in more successful treatment interventions.     

Child maltreatment prevalence and mental disorders outcomes among American Indian women in primary care

OBJECTIVE: To examine (1) the prevalence, types, and severity of child abuse and neglect (CAN) and (2) the relationship between CAN and lifetime psychiatric disorders among American Indian women using primary care services. METHODS: A cross-sectional study was conducted among 234 American Indian women, age 18-45 who presented for outpatient ambulatory services at a community-based Indian Health Service Hospital in Albuquerque, New Mexico. Dependent measures included mood, substance abuse, and anxiety disorders as well as posttraumatic stress disorder (PTSD) as measured by the Composite International Diagnostic Interview. CAN was assessed using the Childhood Trauma Questionnaire. RESULTS: Approximately three-quarters of respondents (76.5%; 95% CI = 70.4, 81.7) reported some type of childhood abuse or neglect; over 40% reported exposure to severe maltreatment. Severity of child maltreatment was associated in a dose response manner with lifetime diagnosis of mental disorders. After adjusting for social and demographic correlates, severe child maltreatment was strongly associated with lifetime PTSD (prevalence ratio [PR] 3.9; 95% CI = 1.9, 8.0); and was moderately associated with lifetime substance use disorders (PR = 2.3; 95% CI = 1.6, 3.3); mood disorders (PR = 2.1; 95% CI 1.4, 3.2); and with two or more disorders (PR = 2.3; 95% CI = 1.6, 3.4). CONCLUSION: CAN was common in our sample of American Indian women in primary care and was positively associated with lifetime psychiatric disorders outcomes. Screening for CAN and psychiatric disorders would enhance the treatment of patients seeking primary care services. Primary prevention of child maltreatment might reduce the high prevalence of mental disorders among American Indian women.     

Recognition of facial emotions among maltreated children with high rates of post-traumatic stress disorder

OBJECTIVE: The purpose of this study is to examine processing of facial emotions in a sample of maltreated children showing high rates of post-traumatic stress disorder (PTSD). Maltreatment during childhood has been associated independently with both atypical processing of emotion and the development of PTSD. However, research has provided little evidence indicating how high rates of PTSD might relate to maltreated children's processing of emotions. METHOD: Participants' reaction time and labeling of emotions were measured using a morphed facial emotion identification task. Participants included a diverse sample of maltreated children with and without PTSD and controls ranging in age from 8 to 15 years. Maltreated children had been removed from their homes and placed in state custody following experiences of maltreatment. Diagnoses of PTSD and other disorders were determined through combination of parent, child, and teacher reports. RESULTS: Maltreated children displayed faster reaction times than controls when labeling emotional facial expressions, and this result was most pronounced for fearful faces. Relative to children who were not maltreated, maltreated children both with and without PTSD showed enhanced response times when identifying fearful faces. There was no group difference in labeling of emotions when identifying different facial emotions. CONCLUSIONS: Maltreated children show heightened ability to identify fearful faces, evidenced by faster reaction times relative to controls. This association between maltreatment and atypical processing of emotion is independent of PTSD diagnosis.     

An investigation of trauma-centered inpatient treatment for adult survivors of abuse

OBJECTIVE: The purpose of this study was to examine a comprehensive inpatient treatment program designed for adult survivors of childhood abuse with posttraumatic stress disorder (PTSD). METHOD: One hundred and thirty-two formerly abused individuals completed clinician-administered and self-administered measures of PTSD symptomatology at admission and discharge. All participants experienced a range of physical, sexual, and/or emotional abuse as children prior to the age of 17. Approximately one-third of these individuals also completed measures at 3-months postdischarge and 1-year postdischarge. Data were collected using a clinician-administered PTSD measure and self-administered PTSD measure at admission and discharge. On admission, all participants met criteria for a diagnosis of PTSD. RESULTS: Analyses revealed that the program was effective in reducing symptoms from admission to discharge. Additionally, treatment gains were maintained at 1-year postdischarge. CONCLUSION: The findings of this investigation suggest that the current intensive inpatient group treatment program appears to reduce PTSD symptoms effectively for a sample of adult survivors of abuse.     

Mediational significance of PTSD in the relationship of sexual trauma and eating disorders

OBJECTIVE: To examine the mediational significance of posttraumatic stress disorder (PTSD) and the development of eating disorder symptomatology following sexually traumatic experiences. METHOD: Seventy-one victims of sexual trauma and 25 control subjects completed interviews and questionnaires assessing eating disorder psychopathology and posttraumatic stress disorder symptomatology. Mediational analyses were conducted examining the relationships among trauma, posttraumatic stress, and eating disorder symptoms. Mediational significance was assessed by the drop in the overall correlation between trauma and eating disorder symptoms when PTSD symptoms were included in the regression model. RESULTS: There is a significant association between a history of trauma and eating disorder symptoms. Also, there was a significant association between a history of trauma and posttraumatic stress disorder symptoms. Importantly, the relationship between trauma and eating disorder symptoms was significantly reduced when posttraumatic stress disorder symptoms were included in the regression analyses, indicating mediational significance of the posttraumatic stress construct. These findings were most pronounced for the physiological arousal and avoidance components of posttraumatic stress disorder. DISCUSSION: The present findings support the idea that individuals who develop eating disorders after sexual trauma are likely to have experienced posttraumatic stress disorder symptomatology. These findings have significant implications for causal models of eating disorder onset in trauma victims. Furthermore, clinical interventions for traumatized eating disordered individuals may benefit from a focus on posttraumatic stress symptomatology.     

Stressful Life Events Experienced by Academically High-Achieving Females Before the Onset of Disordered Eating

Research on gifted and high-achieving students has shown that they experience some sources of stress that are different from those experienced by general students. This qualitative case study investigated the types of stressful life events experienced by academically high-achieving females before the onset of disordered eating in adolescence. Fourteen academically high-achieving females who had recovered from disordered eating were interviewed and completed a written survey. The results revealed that these high-achieving females reported stressful events in five areas before the onset of disordered eating symptoms. All participants reported stress related to academic issues, yet academic stress is rarely mentioned in the literature on stress and eating disorders. These findings have implications for both prevention and treatment of eating disorders among academically high-achieving females.     

Child multi-type maltreatment and associated depression and PTSD symptoms: the role of social support and stress

OBJECTIVE: This retrospective, cross-sectional study explored the hypothesis that multiple forms of child abuse and neglect (child multi-type maltreatment; CMM) would be associated with women's lower social support and higher stress in adulthood, and that this, in turn, would amplify their vulnerability to symptoms of depression and posttraumatic stress disorder (PTSD). METHOD: Participants were 100 women recruited from an inner-city gynecological treatment center for low-income women. Data were analyzed via structural equation modeling (SEM) with Lisrel 8.0. RESULTS: CMM was directly predictive of decreased social support and increased stress in adulthood. CMM was also directly predictive of PTSD symptoms, but not depression symptoms in adulthood. Social support partially mediated the relationship between CMM and adult PTSD symptoms, and stress fully mediated the relationship between CMM and adult symptoms of depression. CONCLUSIONS: Findings support both direct and mediational effects of social resources on adult depression and PTSD symptoms in women with histories of CMM, suggesting that resources are key factors in psychological adjustment of CMM victims.     

PTSD and marital satisfaction in military service members: Examining the simultaneous roles of childhood sexual abuse and combat exposure

Childhood sexual abuse (CSA) is relatively common and is associated with a multitude of negative outcomes in adulthood, including posttraumatic stress disorder (PTSD) and lower marital satisfaction. However, CSA has been understudied in military samples. The purpose of the present study was to examine the relative contributions of CSA and combat exposure to PTSD and marital satisfaction. Two hundred eighteen National Guard/Reserve veterans who deployed overseas between 2001 and 2008 completed self-report measures of CSA, marital satisfaction, combat exposure, and PTSD symptom severity. Data were analyzed using linear regression and path analysis to evaluate a comprehensive model including all variables. CSA accounted for unique variance in PTSD symptom severity independent of combat exposure. CSA also had a negative direct association with marital satisfaction, independent of combat exposure and PTSD symptom severity. In contrast, combat exposure had only a negative indirect association with marital satisfaction via PTSD when all variables were examined simultaneously. CSA accounted for unique variance in both PTSD symptom severity and marital satisfaction in this sample of combat veterans. Clinically, results suggest that assessment and treatment of CSA is indicated for military veterans suffering from PTSD. Further, treatment of CSA may improve marital satisfaction, which may positively affect psychological functioning in the veteran.     

Posttraumatic stress mediates the relationship between childhood victimization and current mental health burden in newly incarcerated adults

The purpose of this study was to evaluate the interrelationship among childhood abuse and traumatic loss, posttraumatic stress symptoms (PTSS), and Axis I psychiatric disorders other than PTSD among newly incarcerated adults, and to test a proposed model in which the severity of PTSS mediates the relationship between childhood abuse/loss and adult psychiatric disorders. Four hundred sixty-five male and female inmates participated in a structured clinical research interview. Four types of interpersonal potentially traumatic experiences (physical abuse, sexual abuse, emotional abuse, and traumatic loss) were assessed for occurrence prior to the age of 18 years old. Current psychiatric disorders and PTSS were also assessed by structured interview. Negative binomial regression was used to evaluate the association between the cumulative number of types of childhood abuse/loss experienced and number of current Axis I disorders, and to test the mediation model. Approximately half of the sample (51%) experienced 1 or more types of childhood abuse/loss, and 30% of the sample had at least one psychiatric disorder other than PTSD. For both men and women, childhood physical abuse and childhood sexual abuse were independently associated with psychiatric morbidity, and an increasing number of types of childhood trauma experienced was associated with an increase in the number of current Axis I diagnoses. However, these associations were no longer statistically significant when severity of PTSS was added to the model, providing support for the proposed mediation model. Implications for secondary prevention services for at-risk inmates are discussed.