Department of Clinical Psychology, Long Island University, Brooklyn, New York
Bipolar Disorders Research Program, Department of Psychiatry Research, The Zucker Hillside Hospital, Glen Oaks, New York
Department of Clinical Psychology, Long Island University, Brooklyn, New York, USA
Correspondence: Dr Joseph F. Goldberg, The Zucker Hillside Hospital, 75-79 263rd Street, Glen Oaks, New York 11004, USA. Tel: 718 470 4134; fax: 718 343 1659; e-mail: Jgoldber{at}lij.edu
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To evaluate the prevalence and subtypes of childhood abuse reported by adult patients with bipolar disorder and relationship to clinical outcome.
Method Prevalence rates of childhood abuse were retrospectively assessed and examined relative to illness complexity in a sample of 100 patients at an academic specialty centre for the treatment of bipolar disorder.
Results Histories of severe childhood abuse were identified in about half of the sample and were associated with early age at illness onset. Abuse subcategories were strongly inter-related. Severe emotional abuse was significantly associated with lifetime substance misuse comorbidity and past-year rapid cycling. Logistic regression indicated a significant association between lifetime suicide attempts and severe childhood sexual abuse. Multiple forms of abuse showed a graded increase in risk for both suicide attempts and rapid cycling.
Conclusions Severe childhood trauma appears to have occurred in about half of patients with bipolar disorder, and may lead to more complex psychopathological manifestations.
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INTRODUCTION |
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METHOD |
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Study procedures
After giving written informed consent, all participants underwent SCID-IV
assessments. The presence of childhood abuse was rated using the Childhood
Trauma Questionnaire (CTQ), a 28-item self-report measure developed by
Bernstein et al
(1994). Individual component
measures of childhood sexual abuse, physical abuse, physical neglect,
emotional abuse and emotional neglect have been derived from this instrument,
further subdivided along a continuum of severity ranging from
none through mild and moderate to
severe. Categorical distinctions between the presence or absence
of severe forms of childhood abuse were conservatively used for
dichotomous analyses.
Clinical status at the time of study entry was evaluated by one of the authors (J.L.G.) using standardised symptom severity indices, including the 17-item Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960) and the Young Mania Rating Scale (YMRS; Young et al, 1978). Ratings on the HRSD and YMRS were made for the week preceding the assessment, in order to provide an estimate of current affective symptoms. Past-year rapid cycling and lifetime substance misuse or dependence were rated from the SCID-IV. Lifetime suicide attempts were assessed by one of the authors (J.L.G.) using a semi-structured interview developed by our group and used previously (Michaelis et al, 2003). The study protocol was approved by the institutional review boards of both the New York Presbyterian Hospital and Long Island University.
Statistical analyses
Statistical analyses were conducted using the Statistical Package for the
Social Sciences, SPSS PC (version 11.5). Numbers are expressed as means and
standard deviations. Group mean differences between continuous variables were
analysed by t-tests; dichotomous variables were analysed by
chi-squared tests. Logistic regression analyses were used to assess the
strength of association between one or more continuous interval variables and
a dichotomous dependent variable, from which odds ratios, 95% confidence
intervals and Wald 2 statistics were generated. In order to
correct for multiple comparisons, a Bonferroni-corrected
level of
P<0.005 (0.05/10) was used for the ten independent variables
examined in Table 1. Otherwise,
an
level of 0.05 was used throughout. All statistical tests were
two-tailed.
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RESULTS |
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Total HRSD and YMRS scores were independently assessed relative to a three-point minimisation/denial sub-scale of the CTQ, in order to estimate the extent to which participants might minimise or deny trauma histories relative to current affective symptoms. Modest but significant negative correlations were observed, suggesting that the denial or minimisation of trauma history items was negatively associated with levels of current depression (measured by HRSD scores; r=-0.259, P=0.011) or mania symptoms (measured by YMRS scores; r=-0.208, P=0.041).
No significant relationship was found between gender and overall severe
childhood abuse histories, or abuse subtypes: emotional abuse
(2=2.347, d.f.=1, P=0.126), emotional neglect
(
2=0.990, d.f.=1, P=0.320), physical abuse
(
2=0.003, d.f.=1, P=0.995), physical neglect
(
2=1.611, d.f.=1, P=0.204) or sexual abuse
(
2=0.624, d.f.=1, P=0.430).
Because type I and type II bipolar disorder may differ with regard to
symptom intensity (Vieta et al,
1997), we separately compared prevalence rates of severe childhood
abuse subtypes between these two diagnostic groups. No significant difference
was observed in any domains (childhood emotional abuse,
2=0.018, d.f.=1, P=0.894; emotional neglect,
2=0.026, d.f.=1, P=0.872; physical abuse,
2=0.026, d.f.=1, P=0.872; physical neglect,
2=0.011, d.f.=1, P=0.916; sexual abuse,
2=0.716, d.f.=1, P=0.397) or in the mean total number
of abuse subtypes for each of the two groups (t=0.466, d.f.=97,
P=0.642). About half of the study group had experienced severe
childhood abuse in at least one domain, most frequently emotional abuse.
Within (non-mutually exclusive) subcategories of severe abuse, 37% reported
emotional abuse, 24% physical abuse, 24% emotional neglect, 21% sexual abuse
and 12% physical neglect. Two or more distinct forms of severe abuse were
identified in 36 of the 99 participants (36%): of these, 16 had experienced
two forms of severe abuse, an additional 10 three forms of severe abuse, 6
four forms of abuse and 4 all five forms of severe abuse. All the forms of
abuse were significantly interrelated, with the strongest associations
emerging between emotional abuse and physical abuse (r=0.74,
P<0.001) and between emotional abuse and neglect
(r=0.737, P<0.001).
Table 2 presents individual
odds ratios with corresponding 95% confidence intervals for each of the five
abuse components relative to lifetime comorbid substance misuse or dependence,
past-year rapid cycling and lifetime suicide attempts. These analyses
indicated significant associations between comorbid substance misuse or
dependence and severe emotional abuse or emotional neglect; past-year rapid
cycling and severe emotional abuse, physical abuse or emotional neglect; and a
lifetime suicide attempt with severe childhood emotional abuse or childhood
sexual abuse. In light of previous research suggesting that suicide risk might
be influenced by both sexual and physical abuse, we conducted an additional
logistic regression analysis taking the presence or absence of lifetime
suicide attempts as the dependent variable. A significant association was
found with childhood sexual abuse (OR=3.327, 95% CI 1.027-10.412; Wald
2=4.020, d.f.=1, P=0.045), but not with physical
abuse (OR=1.163, 95% CI 0.340-3.975; Wald
2=0.058, d.f.=1,
P=0.810), physical neglect (OR=0.573, 95% CI 0.102-3.216; Wald
2=0.401, d.f.=1, P=0.527), emotional abuse (OR=2.074
95% CI 0.626-6.876; Wald
2=1.424, d.f.=1, P=0.233) or
emotional neglect (OR=1.121, 95% CI 0.305-4.126; Wald
2=0.030,
d.f.=1, P=0.864).
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Multiple forms of childhood abuse
To test the hypothesis that multiple forms of childhood abuse would be
progressively associated with more complex forms of adult bipolar disorder, we
undertook three separate logistic regression analyses to examine the number of
forms of abuse (the independent variable) relative to the presence or absence
of a lifetime suicide attempt; rapid cycling; and comorbid substance misuse or
dependence (each as a respective dependent variable). Significant
relationships were seen between an increasing number of childhood abuse forms
and the presence of a lifetime suicide attempt (OR=1.466, 95% CI 1.095-1.964;
Wald 2=6.615, d.f.=1, P=0.010) and rapid cycling
(OR=1.476, 95% CI 1.073-2.030; Wald
2=5.730, d.f.=1,
P=0.017). A marginally significant association was observed between
the number of forms of abuse and the presence of comorbid substance misuse or
dependence (OR=1.325, 95% CI 1.000-1.758; Wald
2=3.809,
d.f.=1, P=0.051).
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DISCUSSION |
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The observed prevalence of severe childhood abuse in about half of our adult patients with bipolar disorder is consistent with the 49% prevalence rate described within the Stanley Foundation Bipolar Network (Leverich et al, 2002). These rates are only slightly higher than those previously reported from semi-structured interviews of patients with major depression (Brodsky et al, 2001) or community samples (McHolm et al, 2003), although lower rates (e.g. 20-30%) have been reported among general medical out-patients (Dube et al, 2001; Edwards et al, 2003). Also consistent with our findings are reports suggesting that multiple forms of childhood maltreatment often co-occur (Cicchetti & Rizley, 1981) and may contribute additively or synergistically to more extensive psychopathology and suicidality seen in adulthood (Dube et al, 2001; Read et al, 2001; Edwards et al, 2003).
Several factors could account for the high rates of childhood abuse among people with bipolar disorder. One issue involves intrinsic, developmental or familial factors that are especially deleterious for bipolar disorder, such as negative expressed emotion (Miklowitz et al, 1988). Factors that probably underlie the origins of childhood abuse are undoubtedly complex, although environments with high levels of expressed emotion could theoretically contribute to the potential for aggressive behaviours and verbal or emotional hostility. This may be an especially important consideration when prodromal features of severe psychopathological disorder become manifest in childhood, potentially evoking greater family distress (Boye et al, 2001). In addition, given the complex traits linked with the genetics of bipolar disorder (Faraone & Tsuang, 2003), it is also possible that aspects of parental psychopathology could represent a potential moderating factor in the expressivity of trait aggression in probands or parent-proband constellations.
Our study recruited people with bipolar disorder seeking treatment from an academic specialty centre, in contrast to those in the general population not seeking treatment, or those seen in more community-based treatment centres. In addition, earlier studies have suggested that patients more typically underreport abuse histories during clinical interviews as compared with self-report surveys (Dill et al, 1991). The validity and reliability with which adult patients with bipolar disorder report histories of childhood abuse may also vary, given the known links between bipolar disorder and poor insight (Ghaemi et al, 2000).
The relationship between affective symptoms and recall of childhood trauma also warrants discussion. Given recent concerns about the potential for patients to report factually inaccurate repressed memories of sexual abuse recovered during psychotherapy (Boakes, 1995; Royal College of Psychiatrists, 1997), caution is warranted in interpreting the validity of self-reported trauma. On the other hand, Goodman et al (1999) observed good reliability in the longitudinal assessment of trauma histories among psychiatrically ill women.
In our study significant or near-significant associations were observed between current affective symptoms and self-reported childhood abuse. It is possible that the presence of current affective symptoms could influence the recall of adverse childhood experiences, as might be further suggested from the lack of denial or minimisation associated with either manic or depressive symptom severity. Indeed, the limitation posed by current depressive symptoms influencing retrospective recall has been noted previously in the trauma literature, in light of the high prevalence of persistent depressive symptoms among trauma survivors (Bernet & Stein, 1999). Moreover, attempts to obtain corroboration of retrospectively recalled childhood trauma histories in adult populations pose obvious impracticalities. This limitation of the current findings pertains to most (if not all) existing studies of bipolar disorder patient populations.
Although most other studies have subsumed physical, sexual and other forms of childhood abuse under one rubric, our study points to differences across abuse subtypes relative to illness complexity and course in bipolar disorder. The observed connection between suicidality and sexual (but not emotional or physical) abuse is consistent with prior observations in patients with this disorder (Leverich et al, 2003). In addition, Brown et al (1999) found in a non-clinical sample of young adults that childhood sexual abuse conferred more than 8 times greater risk of repeated suicide attempts, whereas childhood neglect apparently had no moderating role. Physical abuse has previously been identified in connection with suicidal behaviour among psychiatric patients (Silverman et al, 1996), although existing studies have not systematically controlled for the potential overriding effects of sexual abuse relative to suicidal behaviour.
In our study the lack of an observed relationship between sexual, emotional or physical abuse and gender was surprising and contrary to previous findings in broad community-based samples (Levitan et al, 1998; MacMillan et al, 2001; Edwards et al, 2003) or clinical populations (Gladstone et al, 1999). Data from the Stanley Foundation Bipolar Network similarly indicate no significant gender difference with regard to childhood physical abuse, although women were more likely than men to report childhood sexual abuse. Many - if not most - existing studies of childhood abuse in general focus on female samples, although a smaller body of research suggests that sexual and other forms of abuse may be more prevalent than many clinicians realise among male psychiatric outpatients (Swett et al, 1990). Further studies are needed to clarify potential gender differences across childhood abuse subtypes in patients with bipolar disorder relative to other diagnostic groups.
The generalisability of our findings is limited to adult patients seen in an academic specialty centre for the treatment of bipolar illness; all the participants were evaluated in a dedicated research clinic, where diagnoses were established by standardised interviews conducted by trained and reliable raters. Although the diagnostic reliability of bipolar disorder (particularly bipolar II disorder) has been demonstrated when interviews are conducted by experienced clinicians (Simpson et al, 2002), the same has not yet been demonstrated in general community samples, and remains a source of debate. Hence, replication of our findings in community-based treatment centres would help to establish the representativeness of the study results to the broader community of adults identified as having bipolar disorder.
The study data have a number of both clinical and theoretical implications. First, in light of the strikingly high prevalence of childhood abuse in our sample, coupled with its potential moderating role in suicide risk, it would seem prudent for clinicians to routinely evaluate histories of childhood trauma in patients with bipolar disorder. This point is underscored by similar observations by Read et al (2001). In particular, because multiple forms of abuse during childhood appear to heighten the risk of suicide attempts in a graded fashion, consideration of the nature and extent of abuse may bear directly on gauging the risk of suicide attempts in patients with bipolar disorder, consonant with findings reported elsewhere (Dube et al, 2001; Edwards et al, 2003). The findings also suggest that the nature and extent of childhood abuse among men with this disorder may be higher and more comparable to that seen in women than has previously been identified. From a theoretical as well as a clinical standpoint, the nature, extent and magnitude of childhood abuse - particularly sexual and emotional abuse - have been hypothesised to contribute to cycle acceleration and illness complexity through mechanisms related to behavioural sensitisation (Leverich et al, 2002). Although our findings are consistent with that model, additional preclinical evidence is required, to address this process more directly. Further investigations using prospective longitudinal designs are needed to affirm and extend these initial observations.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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---|
Bernstein, D. P., Fink, L., Handelsman, L., et al
(1994) Initial reliability and validity of a new
retrospective measure of child abuse and neglect. American Journal
of Psychiatry, 151, 1132
-1136.
Boakes, J. (1995) False memory syndrome.
Lancet, 346, 1048
-1049.
Boye, B., Bentsen, H., Ulstein, I., et al
(2001) Relatives' distress and patients' symptoms and
behaviours: a prospective study of patients with schizophrenia and their
relatives. Acta Psychiatrica Scandinavica,
104, 42-50.
Brodsky, B. S., Oquendo, M., Ellis, S. P., et al
(2001) The relationship of childhood abuse to impulsivity and
suicidal behavior in adults with major depression. American Journal
of Psychiatry, 158, 1871
-1877.
Brown, G. R. & Anderson, B. (1991)
Psychiatric morbidity in adult inpatients with childhood histories of sexual
and physical abuse. American Journal of Psychiatry,
148, 55-61.
Brown, J., Cohen, P., Johnson, J. G., et al
(1999) Childhood abuse and neglect: specificity of effects on
adolescent and young adult depression and suicidality. Journal of
the American Academy of Child and Adolescent Psychiatry,
38, 1490
-1496.
Bryer, J. B., Nelson, B. A., Miller, J. B., et al
(1987) Childhood sexual and physical abuse as factors in
adult psychiatric illness. American Journal of
Psychiatry, 144, 1426
-1430.
Cicchetti, D. & Rizley, R. (1981)
Developmental perspectives on the etiology, intergenerational transmission and
sequelae of child maltreatment. New Directions in Child
Development, 11, 31
-55.
Dill, D. L., Chu, J. A., Grob, M. C., et al
(1991) The reliability of abuse history reports: a comparison
of two inquiry formats. Comprehensive Psychiatry,
32, 166
-169.
Dube, S. R., Anda, R. F., Felitti, V. J., et al
(2001) Childhood abuse, household dysfunction, and the risk
of attempted suicide throughout the life span: findings from the adverse
childhood experiences study. JAMA
286, 3089
-3096.
Edwards, V. J., Holden, G. W., Felitti, V. J., et al
(2003) Relationship between multiple forms of childhood
maltreatment and adult mental health in community respondents: results from
the adverse childhood experiences study. American Journal of
Psychiatry, 160, 1453
-1460.
Faraone, S. V. & Tsuang, M. T. (2003)
Heterogeneity and the genetics of bipolar disorder. American
Journal of Medical Genetics, 123C, 1
-9.
First, M. B., Spitzer, R. L., Gibbon, M., et al
(1995) Structured Clinical Interview for the
DSM-IV Axis I - Patient Edition (SCID-IP, Version 2.0). New York:
Biometrics Research Department, New York State Psychiatric
Institute.
Ghaemi, S. N., Boiman, E. & Goodwin, F. K.
(2000) Insight and outcome in bipolar, unipolar, and anxiety
disorders. Comprehensive Psychiatry,
41, 167
-171.
Gladstone, G., Parker, G., Wilhelm, K., et al
(1999) Characteristics of depressed patients who report
childhood sexual abuse. American Journal of
Psychiatry, 156, 431
-437.
Goodman, L. A., Thompson, K. M., Weinfurt, K., et al
(1999) Reliability of reports of violent victimization and
posttraumatic stress disorder among men and women with serious mental illness.
Journal of Traumatic Stress,
12, 587
-599.
Hamilton, M. (1960) A rating scale for
depression. Journal of Neurology, Neurosurgery and
Psychiatry, 23, 56
-61.
Hammersley, P., Dias, A. & Todd, G., et al
(2003) Childhood trauma and hallucinations in bipolar
affective disorder: preliminary investigation. British Journal of
Psychiatry, 182, 543
-547.
Heim, C. & Nemeroff, C. B. (2001) The role
of childhood trauma in the neurobiology of mood and anxiety disorders:
preclinical and clinical studies. Biological
Psychiatry, 49, 1023
-1039.
Leverich, G. S., McElroy, S. L., Suppes, T., et al
(2002) Early physical and sexual abuse associated with an
adverse course of bipolar illness. Biological
Psychiatry 51, 288
-297.
Leverich, G. S., Altshuler, L. L., Frye, M. A., et al
(2003) Factors associated with suicide attempts in 648
patients with bipolar disorder in the Stanley Foundation Bipolar Network.
Journal of Clinical Psychiatry,
64, 506
-515.
Levitan, R. D., Parikh, S. V., Lesage, A. D., et al
(1998) Major depression in individuals with a history of
childhood physical or sexual abuse: relationship to neurovegetative features,
mania, and gender. American Journal of Psychiatry,
155, 1746
-1752.
MacMillan, H. L., Fleming, J. E., Streiner, D. L., et
al (2001) Childhood abuse and lifetime psychopathology
in a community sample. American Journal of Psychiatry,
158, 1878
-1883.
McHolm, A. E., MacMillan, H. L. & Jamieson, E.
(2003) The relationship between childhood physical abuse and
suicidality among depressed women: results from a community sample.
American Journal of Psychiatry,
160, 933
-938.
Michaelis, B. H., Goldberg, J. F., Singer, T. M., et al
(2003) Characteristics of first suicide attempts in single
versus multiple suicide attempters with bipolar disorder.
Comprehensive Psychiatry,
44, 15-20.
Miklowitz, D. J., Goldstein, M. J., Nuechterlein, K. H., et
al (1988) Family factors and the course of bipolar
affective disorder. Archives of General Psychiatry,
45, 225
-231.
Read, J., Agar, K., Barker-Collo, S., et al
(2001) Assessing suicidality in adults: integrating childhood
trauma as a major risk factor. Professional Psychology: Research
and Practice, 32, 367
-372.
Royal College of Psychiatrists (1997) Reported
recovered memories of child sexual abuse. Recommendations for good practice
and implications for training, continuing professional development and
research. Psychiatric Bulletin,
21, 663
-665.
Santa Mina, E. E. & Gallop, R. M. (1998)
Childhood sexual and physical abuse and adult self-harm and suicidal
behaviour: a literature review. Canadian Journal of
Psychiatry, 43, 793
-800.
Silverman, A. B., Reinherz, H. Z. & Giaconia, R. M.
(1996) The long term sequelae of child and adolescent abuse:
a longitudinal community study. Child Abuse and
Neglect, 20, 709
-723.
Simpson, S. G., McMahon, F. J., McInnis, M. G., et al
(2002) Diagnostic reliability of bipolar II disorder.
Archives of General Psychiatry,
59, 736
-740.
Swett, C. Surrey, J. & Cohen, C. (1990)
Sexual and physical abuse histories and psychiatric symptoms among male
psychiatric outpatients. American Journal of
Psychiatry, 147, 632
-636.
Trull, T. J. (2001) Structural relations
between borderline personality disorder features and putative etiological
correlates. Journal of Abnormal Psychology,
110, 471
-481.
Vieta, E., Gastro, C., Otero, A., et al
(1997) Differential features between bipolar I and bipolar II
disorder. Comprehensive Psychiatry,
38, 98-101.
Young, R. C., Biggs, J. T., Ziegler, V. E., et al
(1978) A rating scale for mania: reliability, validity and
sensitivity. British Journal of Psychiatry,
133, 429
-435.
Received for publication January 14, 2004.
Revision received August 11, 2004.
Accepted for publication August 11, 2004.
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