Department of Clinical Psychology and Psychotherapy, University of Zurich
University of Basel, Switzerland
University of Technology, Dresden, Germany
University Nijmegen, The Netherlands
University of Basel, Switzerland
Correspondence: Dr Andreas Maercker, Department of Clinical Psychology and Psychotherapy, Zurichbergstrasse 43, CH-8044 Zurich, Switzerland. E-mail: a.maercker{at}psychologie.unizh.ch
Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To estimate the impact of traumatisation in childhood or adolescence in a community sample.
Method A representative sample of 1966 young women from Dresden aged 1845 years were interviewed for occurrence of traumatic events and the onset of PTSD and major depression. The sample was subdivided into a childhood trauma group (trauma up to age 12 years) and an adolescent trauma group (trauma from age 13 years).
Results A quarter of all participants reported traumatic events meeting the DSM AI criterion. In the childhood group conditional risks for PTSD and major depressive disorder were 17.0% and 23.3%, respectively, compared with risks of 13.3% and 6.5%, respectively, in the adolescent group. In 29% of those with PTSD, major depression was also present.
Conclusions The riskof developing major depressive disorder after traumatisation in childhood is approximately equal to the risk of developing PTSD. After age 13 years, the risk of PTSD is greater than the risk of major depression after traumatisation.
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INTRODUCTION |
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METHOD |
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For the purposes of the current analysis, the sample was further restricted. Participants who failed to supply data concerning the time of the trauma (n=67) or who had an episode of depression before experiencing a trauma (n=31) were withdrawn from the analysis. The final sample for our analysis therefore consisted of 1966 women, and the mean age was 21.8 years (s.d.=1.80).
The majority of the women in the final sample had a stable intimate partner (62.1%); 4.2% were married and 0.5% were separated or divorced. About half (51.8%) were living with their parents at the time of the study, about a third with a partner or spouse (26.2%) and 6.8% with spouse or partner and children. With regard to educational level, 93.2% had completed school education, with 6.7% having had the lowest level of school education (Hauptschule), about a third (30.1%) having had the medium level of schooling (Realschule or Polytechnische Oberschule) and about half (55.5%) having left school with the qualification that allows German students to attend university (Abitur).
Assessment
The data on traumatic events, symptoms and disorder onsets were gathered
retrospectively. Diagnostic assessment was done using the Diagnostisches
Interview bei psychischen Störungen Forschungsversion
(FDIPS; Margraf et al,
1996), a structured interview for diagnosing DSMIV
disorders (American Psychiatric
Association, 1994). The FDIPS is a modified version of the
Anxiety Disorder Interview Schedule for DSMIV Lifetime version
(ADISIVL; DiNardo et
al, 1994), which is widely used for the assessment of anxiety
disorders and shows excellent psychometric properties
(Brown et al, 2001).
The modification consisted of the addition of comprehensive diagnostic modules
for affective and childhood disorders according to DSMIV criteria.
Interviewers were either psychology students in their last year of training in clinical psychology, psychologists or medical doctors. All underwent extensive training totalling approximately 40 h and received biweekly supervision. For control and supervisory purposes, all interviews were audiotaped and randomly selected tapes were assessed by supervisors. Interviews took place either in the participants home or in the university department of psychology. There was no financial reimbursement for participants in the study.
Traumatic events
The DSMIV A1 criterion of trauma was assessed with an open question:
Have you ever experienced a traumatic or life-threatening event?
(Examples of such events are physical assaults, severe injuries, rape,
killing, combat actions, accidents, natural disasters and man-made
catastrophes.) Participants were then asked whether they had witnessed
such an event happening to others. Any number of traumatic events could be
noted, and the respondents age at the time the event occurred was
recorded for each example. The following question was asked specifically for
childhood trauma: Can you remember events of this kind that took place
in your childhood? Again, an unlimited number of events were noted,
together with the dates of their occurrence. The next question addressed
personal experience of intense fear, helplessness, or horror
(the DSMIV A2 criterion of trauma), and in the concluding question
participants were asked to identify one event that was most upsetting
the worst trauma of their lives.
Assessment of PTSD and major depression
The FDIPS structured interview evaluated all DSMIV criteria
for PTSD and major depressive disorder in the order listed in the DSM. For
appropriate PTSD symptoms (e.g. loss of interest, sense of restricted future,
irritability), questions were followed by the prompt, Did this occur
only in the aftermath of the event? The F criterion (clinically
significant distress) was assessed by asking, Did the disturbances
cause any significant distress or handicap in your professional life or other
areas like family life or leisure? All symptoms or criteria were rated
on a nine-point scale from 0 (not present) to 8 (extreme). Only symptom
endorsement values of 48 were counted as symptom presence.
Major depression was assessed according to the DSMIV algorithm asking introductory questions and questions regarding current and past episodes. In the introductory section, the main question was: Has there ever been a phase lasting a minimum of 2 weeks in which you felt depressed, sad, or hopeless or in which you lost interest or pleasure in all your usual activities? This was followed by the childhood-specific question: Was there a phase of 2 weeks in your life before age 18 where you were in a very irritable mood? Participants were subsequently asked to indicate how long such phases lasted. Current and past episodes were assessed by asking single symptom questions relating to the current and the most distressing past episode. Finally, patients were asked to disclose any excluding symptom criteria according to DSMIV (e.g. drug misuse, medication, physiological conditions).
Psychosocial functioning
Psychosocial functioning was assessed by the clinicians rating of
DSM Axis V (Global Assessment of Functioning, GAF;
Endicott et al, 1976)
separately for current and past years of general assessment of functioning
(GAF scale rating range 1100).
Data analysis
Trauma categories
The idiosyncratic terms for traumatic events given by the participants were
noted by the assessors. In a subsequent step they were grouped into nine
categories of traumatic events, according to previously published trauma
category lists (Breslau et al,
1991; Kessler et al,
1995). Raters were given descriptions of the categories as
follows:
Three clinically experienced members of the research group categorised a total of 761 idiosyncratic terms into the above categories. There was agreement across all categories and raters of 77.5%, and dyadic kappa coefficients ranged from 0.88 to 0.94. The category showing least agreement was witnessing trauma (average agreement 55.6%) and the category with the highest agreement was rape (96.8%). In the case of non-agreement, the idiosyncratic term was assigned to the category endorsed by two of the three raters. In cases of total disagreement (22 of 761 trauma terms), all three raters discussed it until a consensus was reached.
Post hoc group divisions
The sample was divided into subgroups according to the age at which an
individuals worst trauma took place or began. Following conventional
distinctions of childhood and adolescence derived from developmental
psychology (Bornstein, 1999)
and previous research (Mullen et
al, 1993), we assigned participants who experienced a
traumatic event at age 12 years or younger to the childhood trauma group,
whereas a traumatic event occurring after age 13 years qualified the
participant for the adolescent trauma group. Finally, we divided the sample
according to DSMIV diagnosis, ending up with a pure PTSD group, a pure
major depression group and a comorbid (mixed) PTSD and major depression
group.
Statistical analyses
Data were analysed using the Statistical Package for Social Sciences,
version 10.x for PC. Statistical tests included analyses of variance,
2 tests and relative risk estimates.
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RESULTS |
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Conditional risks of PTSD and major depressive disorder
Table 1 also shows the
conditional risks of PTSD and major depressive disorder for the total sample.
Rape and serious accident had the highest and
lowest probability of PTSD respectively, with rape having a PTSD
probability of 43.3% and serious accident having a PTSD
probability of 2.5%. The categories rape and Dont
want to talk about it had the highest probability of major depressive
disorder (both 25.0%), followed by molestation, which had a PTSD
probability of 23.8%. Serious accident had the lowest
probability of major depressive disorder (8.5%).
In a comparison of the PTSD and major depressive disorder conditional
probabilities, the only trauma category with a significant probability
difference was witnessing trauma (2(1)=5.33,
P<0.05) with a probability of 3.8% for PTSD and 19.2% for major
depressive disorder. Accordingly, for the comprehensive category any
traumatic event, there was no significant difference between
conditional probability for PTSD (14.9%) and conditional probability for major
depressive disorder (13.4%;
2(1)=0.30, P=0.58).
Overall, the PTSD prevalence rate of the total sample was 3.2%. The prevalence for trauma-related major depression in the total sample was 3.0%; however, if trauma is not taken into consideration, the overall (non-trauma-related) prevalence of major depression in the total sample was 10.3% (n=203).
Age specific risks of PTSD and major depressive disorder
Table 1 also includes
comparisons of the two age groups. In accordance with our prediction, the
probabilities for A1 criterion of any traumatic event differed between the age
groups (2(1)=12.22, P<0.001), with more cases in
the adolescent group than in the child group (288 v. 210). The
conditional probability of PTSD for any traumatic event did not differ between
the age groups (17.0% v. 13.3%;
2(1)=0.14,
P=0.71), with a non-significant relative risk of 1.3. For major
depressive disorder, both the estimated relative risk (3.6; 95% CI
2.096.22) and the conditional probability (23.3% v. 6.5%;
2(1)=12.07, P=0.001) indicated a higher risk of
developing major depression when trauma occurred in childhood. The trauma
category witnessing trauma had a relative risk of 9.7 for
subsequent major depressive disorder, with 36.0% conditional risk for the
younger group and 3.7% for the older group (
2(1)=6.40,
P=0.01). For physical attack the relative risk was 14.0, with
significant differences in conditional probabilities for the different age
groups (childhood trauma 28.6% v. adolescent trauma 2.0%;
2(1)=5.44, P=0.02).
The sample was then divided into three groups: PTSD only (pure PTSD), trauma-related major depressive disorder only (pure major depressive disorder) and a mixed PTSD/trauma-related major depressive disorder group. Table 2 shows the odds ratios of these groups for the two age groups. In accordance with our prediction, the odds ratio for pure major depressive disorder is increased in the childhood trauma group and decreased in the adolescent trauma group. There was no difference in odds ratios between the age groups for pure PTSD.
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The age-dependence hypothesis is further corroborated by the difference between the diagnostic groups of pure PTSD and pure major depressive disorder with regard to the mean age at trauma, with an age for the PTSD group of 13.8 years compared with 9.8 years for the major depressive disorder group and 9.9 years for the mixed group (F(2,103)=8.36, P<0.001).
Finally, analyses of psychosocial functioning (GAF rating) during the current and previous year revealed significant differences between the three groups (Table 2). For current GAF, analysis of variance indicated significant group differences (F(2,100)=6.83, P=0.002). In post hoc analyses, the comorbid group showed the lowest level compared with the PTSD or major depressive disorder groups, whereas the GAF ratings of the pure PTSD and pure major depressive disorder groups did not differ.
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DISCUSSION |
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A complementary explanation of our results could refer to the fact that the length of time elapsing between the reported trauma and the assessment of psychopathological state can also affect the degree of depression. The natural history of response to trauma seems to indicate that the response begins with anxiety symptoms and then possibly mediated by functional impairment and resulting vulnerabilities evolves towards depression (Wittchen et al, 2000). However, we consider this explanation to be of limited value, as it does not explain why the group of respondents traumatised in childhood separate into a pure major depressive disorder group and a comorbid PTSD and major depressive disorder group.
Prevalences of trauma and PTSD
The rates of exposure to traumatic events and prevalences for PTSD can be
seen as meaningful with regard to previous studies
(Kessler et al, 1995;
Breslau et al, 1998;
Perkonigg et al,
2000). Our population-based sample of young women (aged
1824 years) showed a trauma prevalence (DSM A1 criterion) of 25.3% and
a PTSD prevalence rate of 3.4%. Another study in Germany
(Perkonigg et al,
2000) with a sample aged 1424 years found a somewhat lower
trauma prevalence (DSM A1 criterion) of 17.7% and a PTSD prevalence rate of
2.2% for female participants.
In the USA the National Comorbidity Survey, using the somewhat more liberal DSMIIIR algorithm, reported a trauma prevalence of 51.2% and a PTSD prevalence of 10.3% for women aged 1524 years (Kessler et al, 1995). Breslau et al (1991) reported similarly high prevalence rates for PTSD in a sample of mainly middle-aged women in Detroit: trauma prevalence was 40% and PTSD prevalence was 13.8%. Only the study by Cuffe et al (1998) on older adolescents in the USA reported lower prevalence rates, comparable with the range of findings from studies in Germany. The greater differences of the National Comorbidity Survey and Detroit area studies may reflect substantial changes in the definition of PTSD from DSMIIIR to DSMIV, as well as true differences between study populations, such as considerably lower event rates of natural disasters, threat with weapons, and witnessing such events, in the different geographical regions of the studies. Interestingly, our study showed similar conditional risks of developing PTSD for the particular trauma event categories to those reported by Kessler et al (1995), Breslau et al (1991) and Perkonigg et al (2000): for example, for rape the risks were 55%, 49% and 52%, respectively, compared with 52% in the adolescent group in the present study.
Major depression and comorbidity with PTSD
For trauma-related major depression there are fewer published studies
available. In the study by Mullen et al
(1993) on childhood sexual
abuse before age 13 years, only 13% of participants reported a major
depressive disorder; our study shows a prevalence of major depressive disorder
of 40% after rape and 15% after molestation. It could be speculated that these
differences are due to diagnostic algorithms and definitions of events. In
addition, the data of Mullen et al
(1993) suggest that greater
severity, frequency and duration of abuse result in an increased likelihood of
subsequently developing depression. This might lead to the conclusion that our
definition of rape or molestation as trauma may be significantly different
from theirs.
In our sample, we found relatively low comorbidity rates of PTSD and major depression: 29% of the women with PTSD also had major depressive disorder, and 32% of the women with major depressive disorder also had PTSD. This indicates lower comorbidity rates than in other studies (Bleich et al, 1997; Goenjian et al, 2000). In our sample, comorbidity rates may not be as marked because of the young age of the participants. Wittchen et al (2000) provided evidence that comorbid disorders are developed and maintained particularly in extended, untreated, chronic courses, typical of middle-adulthood samples (Deering et al, 1996). Our finding of the lowest levels of psychosocial functioning in the comorbid group may point to the fact that young women suffering from more than one trauma-related disorder may struggle with a larger range of mental health problems and their distal stress consequences (Pynoos et al, 1999).
Limitations
There are various limitations to the present study. First, the sample
consisted entirely of women, and it has been shown that the aftermath of
trauma differs substantially between the genders (e.g.
Springer & Padgett, 2000).
Second, the response rate of the study was less than 40%. The main reason for
this low response rate is probably rooted in the macrocontext of the study,
which was conducted in Dresden, in the eastern part of Germany. Because of
economic and other problems relating to the transformation of the political
system following the demise of communism, many of those living in this part of
the country are unwilling to participate in psychiatric studies
(Maercker & Herrle, 2003).
Specific reasons for non-participation include the scarcity of telephones at
the time of the assessment (mid-1990s), high levels of economic migration to
other parts of Germany, and a general reluctance to allow personal data to be
reported the legacy of years of surveillance by the East German secret
security police. A third limitation was that we assessed trauma
retrospectively from adults; numerous studies have suggested that such data
are subject to recall bias (Maughan &
Rutter, 1997). If the errors introduced in our assessment were
random, this would attenuate the true associations. However, biases that would
exaggerate the true associations are also possible. Fourth, the methodology
differed somewhat from previous epidemiological studies on trauma
consequences. Although we used DSMIV criteria, we used the more
uncommon structured interview version, originally developed for the assessment
of anxiety disorders (ADISIVL). Trauma categories were first
assessed by using the participants idiosyncratic terms and later
classified into categories. There is no information available concerning the
reliability of this method for assessing personal trauma in an epidemiological
study, although the trauma prevalence rates in our study were comparable in
range to those previously published. Fifth, although our study had the
advantage of applying an age limit between childhood and adolescence based on
developmental psychological literature, the inflexible application of this
limit remains largely conventional. In developmental psychology age is
regarded as a carrier variable for various psychodevelopmental processes.
Further research should look for more appropriate markers (e.g. maturation of
emotional or physiological regulation) in childhood and adolescent development
to explain differential effects. Furthermore, since PTSD symptoms decrease
over time and depression normally increases in this age group, the study may
overemphasise depression as an outcome of traumatic stress in the younger age
group. Finally, psychopathological outcomes other than PTSD and major
depressive disorder were not investigated. Other important sequelae of
childhood traumatisation (e.g. alcohol and drug misuse, anxiety disorders,
borderline personality disorder) would be worth following up in a similar
age-stratified study design.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication June 30, 2003. Revision received December 8, 2003. Accepted for publication January 6, 2004.
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