Study guide with articlesummaries for Psychological and Neurobiological Consequences of Child Abuse at Leiden University

Summaries with articles with Psychological and Neurobiological Consequences of Child Abuse

Summaries with articles with Psychological and Neurobiological Consequences of Child Abuse

  • Summaries with 25 prescribed articles for Psychological and Neurobiological Consequences of Child Abuse 2022-2023
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Table of content

  • Child maltreatment and risk for psychopathology in childhood and adulthood
  • Paradise Lost: The Neurobiological and Clinical Consequences of Child Abuse and Neglect
  • AMaltreatment in childhood substantially increases the risk of adult depression and anxiety in prospective cohort studies: Systematic review, meta-analysis, and proportional attributable fractions
  • A tangled start: The link between childhood maltreatment, psychopathology, and relationships in adulthood
  • Parents’ experiences of childhood abuse and neglect are differentially associated with behavioral and autonomic responses to their offspring
  • Childhood maltreatment, latent vulnerability, and the shift to preventative psychiatry - the contribution of functional brain imaging
  • Effects of early life stress on cocaine self-administration in post-pubertal male and female rhesus macaques
  • Emotion Modulation in PTSD: Clinical and Neurobiological Evidence for a Dissociative Subtype
  • Childhood Trauma in Adult Depressive and Anxiety Disorders: An Integrated Review on Psychological and Biological Mechanisms in the NESDA Cohort
  • Pass it on? The neural responses to rejection in the context of a family study on maltreatment
  • Genetic sensitivity to the environment: the case of the serotonin transporter gene and its implications for studying complex diseases and traits
  • Self-reported impulsivity in women with borderline personality disorder: the role of childhood maltreatment severity and emotion regulation difficulties
  • Childhood Maltreatment, Borderline Personality Features, and Coping as Predictors of Intimate Partner Violence
  • Using Principles of Behavioral Epigenetics to Advance Research on Early-Life Stress
  • Non-suicidal Self-Injury in Adolescence
  • Resilience to adult psychopathology following childhood maltreatment: Evidence from a community sample
  • Neurobiological Markers of Resilience to Depression Following Childhood Maltreatment: The Role of Neural Circuits Supporting the Cognitive Control of Emotion
  • The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis
  • Psychoneuroimmunology of early-life stress: the hidden wounds of childhood trauma?
  • The relationship between childhood psychosocial stressor level and telomere length: a meta-analysis
  • Sexual problems and post-traumatic stress disorder following sexual trauma: A meta-analytic review
  • The Sexual Well-Being of Women Who Have Experienced Sexual Abuse During Childhood
  • Effect of Prolonged Exposure, intensified Prolonged Exposure and STAIR+Prolonged Exposure in patients with PTSD related to childhood abuse: a randomized controlled trial
  • Treatment efficacy and effectiveness in adults with major depressive disorder and childhood trauma history: a systematic review and meta-analysis
  • Imagery rescripting and eye movement desensitisation and reprocessing for treatment of adults with childhood trauma-related post-traumatic stress disorder: IREM study design by

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Article summary of Child maltreatment and risk for psychopathology in childhood and adulthood by Jaffee - Chapter

Article summary of Child maltreatment and risk for psychopathology in childhood and adulthood by Jaffee - Chapter

What is this article about?

In 2014, around 3.9 million children were under investigation for allegations of abuse or neglect. In this paper, the focus is on the relationship between childhood maltreatment and mental health in childhood and adulthood, and on biological and psychosocial factors that mediate and moderate the relationship.

Maltreatment includes neglect and emotional, sexual, and physical abuse. Neglect refers to not providing children with the necessary clothes, hygiene, foods, and safety. Physical abuse is defined as harm by a caregiver or by someone who has responsibility for the child. It refers to physical injury on purpose.

Based on statistics it seems that children under three are more often victimized compared to older children. Also, children under one year were victimized most often. Boys and girls are equally victims, but there is a difference between African-American children and White and Hispanic children, with African-American children being abused more than White and Hispanic children.

Some predictors of maltreatment include family poverty, young motherhood, parental history of antisocial behavior, and a perpetrator’s history of maltreatment.

How is maltreatment measured?

When adults are studied, childhood maltreatment is measured by retrospective self-report. However, these retrospective self-reports are often biased, for example by the current mental state and they are subject to omission. For instance, some adults were asked during two interviews about whether they had experienced maltreatment as children. 51% of the adults with documented records of sexual abuse did not report their abuse in these interviews. Also, 21% of the adults without documented records stated to be sexually abused, which would mean that their sexual abuse was not detected, or that they made it up. Also, the experiences that people have in adulthood also bias retrospective records. For instance, 75% of adults who had a lifetime diagnosis of drug abuse reported that they had been victims of abuse or neglect in childhood. However, only 35% of the victims of abuse or neglect are diagnosed with drug abuse. Also, drug abuse in adulthood is the same for those with and without a history of childhood abuse. Thus, experiencing childhood maltreatment is not a good predictor for drug abuse in adulthood.

Thus, there are some issues with retrospective self-report. Therefore, the authors describe studies in which maltreatment was measured in childhood and in which these children were followed into adulthood.

What is the relationship between maltreatment and the risk for psychopathology?

In the following sections, studies will be described that have looked into whether experiencing childhood maltreatment puts individuals at risk for psychopathology in adulthood. All these studies involve a prospective research design in which maltreatment predated the onset of psychopathology; a demographically matched control sample or statistical adjustments for variables that could confound the association between maltreatment and risk for psychopathology; and psychometrically valid measures of psychopathology, including diagnostic measures. Information about maltreatment came from Child Protective Services. Official records are probably lower than the true prevalence of maltreatment, so studies that combine official records with informant reports probably provide the most valid information.

Maltreatment and the risk on externalizing and internalizing psychopathology

It seems that children who experience maltreatment are at higher risk for experiencing externalizing problems in their childhood and adolescence, such as attention deficit/hyperactivity disorder (ADHD), conduct disorder (CD), oppositional defiant disorder (ODD), delinquency, and antisocial behavior. The risk on externalizing problems in adulthood is also present. Some victims show higher rates of antisocial personality disorder, crime, and criminal arrests. Findings with regard to drug use are mixed. Experiencing maltreatment also increases the risk on internalizing problems in childhood, such as major depressive disorder, anxiety disorders, posttraumatic stress disorder (PTSD), and internalizing symptoms. This risk extends into adulthood. In adulthood, they experience more often major depressive disorder, depressive symptoms, and anxiety disorders.

Childhood maltreatment and mental disorders are predictive of PTSD in adulthood, through two ways. First, children who have been maltreated have a higher risk on mental disorders in childhood and adolescence, and a history of mental health problems increases the risk that an adult develops PTSD after experiencing a trauma. Second, maltreatment sensitizes the neurobiological response to subsequent trauma, again increasing the risk that an adult who experiences trauma will develop PTSD.

Maltreatment and the risk on personality pisorders, psychotic pymptoms, and suicide

Children who experience maltreatment are at higher risk for borderline personality disorder in adulthood. They are also at higher risk for suicide in adolescence and adulthood, and they more often engage in self-injury. One study also demonstrated that child victims experience psychotic symptoms in early adolescence. Lastly, one study found that victims of maltreatment were also at higher risk for psychotic disorder, schizoaffective disorder, and schizophrenia.

What is the causal status of effects?

It is difficult to determine causality. For example, if we find that child victims of maltreatment develop mental disorders in childhood or adulthood. This could be explained by that maltreatment causes mental disorders, or that there is a (non)genetic factor that is associated with maltreatment and with mental disorders. One way to test this would be by looking at adopted kids: when they are maltreated, do they also develop mental disorders? This would rule out a genetic factor. However, fortunately, adoption parents are screened and maltreatment is low in adopted children.

The most feasible currently is to compare maltreated children to sociodemographically similar, non-maltreated youth. These studies have shown that maltreated children significantly show more depressive symptoms and suicidal thoughts, substance use problems, and criminal behaviors in young adulthood compared to non-maltreated children.

How does intergenerational transmission of maltreatment take place?

According to the ‘cycle of violence hypothesis’, adults who experience maltreatment in their childhood are at higher risk for maltreating their own children. This hypothesis seems to be supported. However, it could also be a reflect detection bias: among parents who reported engaging in abuse or neglect, 31% of those were investigated by Child Protective Services, because they were themselves maltreated in childhood.

However, there are two important remarks. First, a cycle of violence is not inevitable: it can be broken through. The majority of adults with a history of maltreatment do not maltreat their own children. Second, the hypothesis is based on the bias of the Child Protective Services to investigate and substantiate cases of abuse or neglect, when they know that the parent had a history of maltreatment.

What are mediators of maltreatment effects?

There are certain ways in which maltreatment increases the risk for psychopathology, called mediators. There are three mediators that have been studied: hypervigilance to threat, deficits in emotion recognition, and insensitivity to reward.

Hypervigilance to threat

This mediator has to do with attention bias. Attention bias refers to the tendency to focus on threats, even mild threats. Because of their experience with anger and other negative emotions in their families, children become sensitized to attend to threatening stimuli. This could lead to more anxiety. This is often measured by showing children pairs of faces, with a neutral and an angry face. The results have shown that children and adults who have experienced maltreatment, exhibit biased attention towards angry faces, but not to sad or happy faces. These children and adults also show higher levels of anxiety. This is also true for children who experienced harsh forms of parenting; they also showed this attention bias. This biased attention involves limbic and prefrontal activity. Maltreated children show heightened amygdala reactivity to threat cues compared to nonmaltreated children. However, these responses can also be modulated. When the respondents are told that they should try to decrease their emotional response to negative stimuli, they show greater activation in prefrontal regions.

Maltreated children also show different social information processing styles. For example, they are more likely to attribute hostile intent to others when their behavior is ambiguous. This may lead them to also act more aggressively. For example, in an online game, they acted more aggressively towards an online ‘partner’.

Thus, maltreated children are more attentive to anger cues, find it difficult to disengage attention from anger cues, they identify ambiguous cues as threatening, and they recognize anger faster compared to nonmaltreated children. However, some studies found the opposite. This could probably be explained by the fact that samples vary in terms of their maltreatment exposure: the specific form of maltreatment. It could also be that high rates of PTSD in the samples disturbed the results. PTSD involves hypervigilance toward threatening stimuli and avoidance of threat. Therefore, in these samples, one may find an attentional bias away from threat.

Deficits in emotion recognition

When children and adults are less skilled in recognizing emotions, this may lead to social rejection. Differences in children’s recognition abilities are partly the result of parents’ efforts to model and explain emotions, called emotion socialization. This may differ between abuse and non-abusive family environments. For example, mothers who are physically abusive produce less prototypical facial expressions of anger and vocal expressions of anger, fear, and happiness compared to non-abusive mothers.  They also engage less in coaching, validation and they more often invalidate their children’s emotions. Also, parents who were at high risk for child physical abuse are less accurate in emotion recognition.

From studies it has been shown that children who have been maltreated are also less skilled in recognizing facial expressions of emotions. For instance, in one study, children were presented with stories in which children are experiencing a certain emotion. Then, they have to pick between three photos the photo that matches the story the best. Maltreated children do not do well on this task. One study found that the specific form of emotion recognition deficit matches the type of maltreatment experienced. For example, neglected children are less able to differentiate facial expressions of emotion. Physically abused children show a bias to recognize angry emotions. Maltreated children also experience difficulties in matching emotional outcomes with common elicitors. Healthy, nonmaltreated children are often able to predict which kinds of situations will elicit positive versus negative emotions, but maltreated children are less able to do this. Instead, they report that positive, equivocal, and negative events are all possible elicitors of anger or fear in a task. In this task, emotional outcomes (happy, sad, angry) were presented to children, and then they were asked how likely it was that a positive, negative, or equivocal event might have elicited that emotion.

Maltreated children are poor at emotion recognition and understanding compared to nonmaltreated children. The magnitude of this effect is also bigger for emotion recognition compared to emotion understanding. The effects are the largest in early childhood.

Thus, maltreated children experience difficulties in emotion recognition. This may affect their ability to respond appropriately when others express emotions. They also find it difficult to determine which situations elicit positive and negative emotions: this may affect their ability to predict what reactions they will get from their environment when they perform a certain behavior.

Reward responsiveness

It seems that maltreated children are less sensitive to cues for reward. This puts them at higher risk for depression, and particularly anhedonic symptoms. In a task in which participants were presented with reward, loss, and no-incentives, children who had been maltreated rated rewards as less positive compared to control participants. They show less ventral striatum activation. Other research focused on the anterior cingulate cortex (ACC). It seems that children and adults who have experienced maltreatment are less responsive to reward compared to nonmaltreated individuals. They do not discriminate between cues for high risk/high reward and low risk/low reward in terms of reaction times. They also rate cues for reward less positively compared to control participants. They also show different neural activation. This may explain why they are at increased risk for depression: they have a reduced responsivity to reward and they experience deficits in learning from positive experiences.

What are moderators of child maltreatment?

Moderators of maltreatment are defined as factors that make the effects of maltreatment on the risk of psychopathology, greater or lower. Studies have shown that the effect of maltreatment on risk for psychopathology is similar across demographic groups. However, the effects of maltreatment on risk for psychopathology differ as a function of genotype, and other individual and environmental factors.

Genetic moderators of maltreatment effects

MAOA x maltreatment. The MAOA gene regulates the metabolism of dopamine, serotonin, and norepinephrine. Interest in this gene increased when studies showed that a mutation in this gene was associated with violent behavior among males in Dutch families. Caspi (2002) showed that men in the Dunedin Longitudinal Study birth cohort, who had experienced childhood maltreatment, had elevated levels of childhood conduct and adult antisocial behavior problems, if they carried the low activity variant of the MAOA gene. In contrast, men who had the high activity variant were not at this elevated risk for antisocial behaviors.

5-HTTLPR x maltreatment. 5-HTT plays an important role in the regulation of serotonin uptake. Dysregulated 5-HT is associated with both depression and aggression. The Dunedin Longitudinal Study showed that individuals who had the short form of this gene and who had experienced childhood maltreatment were at elevated risk for depression and depressive symptomatology in adulthood. Individuals who carry the 5-HTTLPR S allele also have a more pronounced physiological response to stress than L allele carriers. Coping is also associated with the 5-HTTLPR genotype. Adults who carried the S allele reported that they were less able to cope with situations that evoked strong feelings of sadness or fear than individuals who were homozygous for the L allele.

What are psychosocial moderators of maltreatment?

Studies have shown that children who do not experience a lot of negative effects of maltreatment (thus, children who are resilient to maltreatment), often have high ego control, high self-esteem, high self-reliance, and they attribute their successes to themselves. These are thus protective factors. However, when children are exposed to more stressors next to maltreatment, these protective factors may disappear. Social support is also a protective factor. It buffers, protects, children and adults from the adverse effects of experiencing maltreatment during childhood. Social support can refer to different domains, such as material support, emotional support, and the satisfaction of relationships with parents, friends, intimate partners, and other relatives.

However, individuals who have experienced maltreatment often have lower levels of social support, and also less stable social support. This may be an explanation for why children and adults with such a history of maltreatment have higher rates of psychopathology. But, when they do have social support, this buffers them against psychopathology. Then, they have the same levels of psychopathology as compared to nonmaltreated children and adults. For example, women who have experienced childhood maltreatment or rape show lower PTSD symptoms when they have high social support. However, for women who did not experience these traumas, social support was not related to PTSD symptoms.

Thus, children and adults with histories of maltreatment have less social support compared to children and adults without such a history. But, the evidence is a bit mixed in whether social support has a buffering effect or whether it has a direct protective effect (which means that having social support is beneficial, regardless of whether someone has been maltreated or not).

What are the conclusions?

Maltreatment has serious negative consequences and thus is an important public health problem. There needs to be more research conducted in a prospective way and with the use of longitudinal data. This can help to better understand the course of resilience and dysfunctions over time, and can help to determine what the effects of maltreatment are on mental and physical health. Thus, there needs to be a mix of research strategies. There needs to be an integrative and multilevel perspective to determine on the pathways from genes to brain to behavior. There also needs to be more research that can help to evaluate treatment efficacy for maltreated children, and to improve access to services and the quality of services. More research is also needed to know why some children respond better to treatment compared to others.

Summary points

  • Children under the age of 3 have the highest risk on being maltreated;
  • Having a childhood history of maltreatment increases the chance that an individual will also engage in abuse and neglect as an adult, however most of the children who have experienced maltreatment do not themselves engage in abuse or neglect;
  • Having experienced maltreatment increases the risk for mental health problems, such as depression, anxiety, substance abuse, antisocial behavior, psychotic symptoms, and personality disorders;
  • Maltreatment also increases the risk on psychopathology, because of increased threat sensitivity, decreased responsivity to reward, and because it produces deficits in emotion recognition and understanding;
  • Even though maltreatment increases the risk on being mental health problems, this is not inevitable. Having social support can buffer against the adverse effects of being maltreated. Also, some people have genes that make them less susceptible to maltreatment.
Article summary of Paradise Lost: The Neurobiological and Clinical Consequences of Child Abuse and Neglect by Nemeroff - Chapter

Article summary of Paradise Lost: The Neurobiological and Clinical Consequences of Child Abuse and Neglect by Nemeroff - Chapter


In the last few years, evidence has been found to demonstrate that child maltreatment is associated with the risk of developing major psychological disorders in adulthood. These disorders include: depression, bipolar disorder, post-traumatic stress disorder (PTSD), substance -and alcohol abuse. Another consequence of child abuse is getting medical illnesses, such as: asthma, diabetes and cardiovascular disease. For children that experienced abuse in their childhood, the course of a mental disorder is more severe. Therefore, the biological substrates of the diathesis of psychiatric and medical morbidity were studied. In the current review, these studies were summarized. The focus is on the biological alterations and brain alterations associated with mental -and physical disease caused by childhood maltreatment.

What are the psychological effects of child maltreatment?

Sexual, emotional -and physical abuse can lead to a significant increase in mood -and anxiety disorders, but also substance -and alcohol abuse and some medical disorders. According to a recent study 78.3% of children referred to the department of health and services suffered from neglect, which is the failure of a parent or caretaker to comply with the responsibility for providing shelter, safety, medical care, supervision and well-being. It is important to consider he majority of neglect is unreported, and that sexual abuse is most reported happening at a very young age.

The researchers of this study measured adverse childhood experiences (ACE) and found that 64% of participants experienced at least one ACE. The risk of developing a medical -or mental illness is significant for persons with more than three experiences of childhood abuse. Moreover, children with experiences of neglect and abuse were more likely to develop comorbid disorders. When exposed to sexual abuse, the risk for the development of the disorders: depression, PTSD, eating disorders, sleep disorders and suicide effects was bigger. Bullying is not included as a form of child abuse by most studies. However, the untoward effects of verbal aggression between the age of 18-22 were the same as those when witnessing non-familial sexual abuse or domestic violence. Bully victims showed larger rates of panic disorder, agoraphobia in women -and suicidality in men.

Another finding is that early life stress (ELS) is a major risk factor in the risk for suicide of which sexual -and physical abuse had the most effect. In general, childhood trauma is associated with both suicidal ideation and depressive symptoms. The effects of ELS on vulnerability to other disorders has not been studied as often. It was found that ELS increases the risk for bipolar disorder and substance abuse. Patients with bipolar disorder combined with childhood adversities show higher rates in suicide attempts compared to patients without ELS. There is considerable evidence that ELS and childhood trauma can cause a more severe course of depression.

What are the neurobiological consequences of child maltreatment?

The biological consequences of ELS change the role of hypothalamic pituitary-adrenal (HPA) and extra-hypothalamic corticotropin-releasing factor (CRF) in handling effects of stress. These circuits mediate endocrine behaviour, immune and autonomic effects of stress. Maternal deprivation causes deprivation of neural activity in the response to CRF. Furthermore, there is an effect of repeated stress during the first postnatal week which influences the dendritic development in the cingulate -and prelimbic cortex. Lastly, it is repeatedly demonstrated that ELS has both neuroendocrine and neurotransmitter effects in non-human primates. Maternally deprived subjects display greater regional glucose metabolism in sensory -and emotional processing areas (thalamus, inferotemporal cortex) in response to moderate stress.

The role of the HPA axis in the regulation of stress is potentially affected by early life trauma. Both increased and decreased HPA axis activity can be the consequence of child maltreatment. For example, in depression, hyperactivity of the HPA axis was reported for people that experienced ELS. They also showed increased ACTH and cortisol responses in the Trier Social Stress Test (TSST). However, the findings are discordant and currently an active avenue of investigation. The effects of child abuse and neglect on HPA axis activity are impacted by the following factors:

  1. The nature of ELS, this can be sexual, physical, emotional or neglect. Also, the number of episodes, chronicity and the age of first abuse/neglect is important.

  2. The presence of psychosocial support.

  3. The existence of traumatic events during childhood.

  4. Whether there is a family history in psychiatric disorders.

  5. Genetic and epigenetic factors.

Besides changes in the HPA-axis, evidence was found that oxytocin plays a critical role in mediating social affiliation, attachment, intimacy, trust and maternal behaviour. This neural system is also affected by ELS. Furthermore, the hormones progesterone, oestrogen and testosterone are affected by ELS.

What are the risks of child maltreatment in developing a medical disorder?

There are several medical disorders that can be caused by ELS. These include: chronic lung disease, cancer, heart disease, skeletal fractures, liver disease and autoimmune disorders. Sexual abuse was found to be associated with in increased risk for functional gastrointestinal (GI) disorders, psychogenic seizures and chronic pain. Also, rape was associated with an increased risk for fibromyalgia. Evidence has been found that the occurrence of many medical disorders is increased in people exposed to ELS. There are effects of child maltreatment on biomarkers of inflammation. Maltreated children exhibit a significant increase in C-reactive protein (CRP). This effect was independent of other life stressors. Prenatal adversity is also associated with higher levels of CRP. It is suggested such inflammation may contribute to the poor outcome in breast cancer patients with depression.

What are genetic and epigenetic consequences of child maltreatment?

Inflammation can reduce telomere length, which is associated with increased morbidity and mortality of age-related diseases. Telomeres are DNA-protein complexes that protect the genome from damages. Several studies have been done to assess the connection between childhood abuse and telomere shortening. It turns out greater adverse childhood experience cause reduced telomere length. In depressed participants, telomerase activity increased. In healthy volunteers there was no change in telomere length or telomerase activity during the experiment. Disorders including PTSD, major depression, schizophrenia and bipolar disorder are complex illnesses that are virtue to an environmental and genetic contributions. Child maltreatment accounts for a great environmental risk factor and it turns out that several candidate gene polymorphisms are modifiers for the development of PTSD and depression in victims of child abuse. The number of ELS events is associated with depressive symptom severity. Findings of genetic and epigenetic consequences of child abuse pave the way for the development of new anxiolytic and antidepressant agents.

The emerge of epigenetics in physiology and pathophysiology is considered a major advance in biomedical science. Epigenetics are the alterations in gene expression that is not a consequence of DNA-change, but of DNA methylation or acetylation, post-transitional histone modifications and non-coding RNA’s. There is evidence that early life experiences alter DNA expressions. A molecular model has emerged on how maternal care changes gene expressions by effecting DNA methylation.

What does brain imaging research conclude on the consequences of child maltreatment?

The long-lasting effects of child abuse can be researched using functional brain imaging. Different forms of childhood maltreatment produce distinct effects on brain areas, just like the heterogeneity of an individual’s past experiences. Polymorphisms of candidate genes are impactful on some provocative studies using fMRI. The responsiveness of the amygdala to fearful stimuli is one thing that can be shaped by childhood maltreatment. These MRI studies can be divided into two types:

  1. The testing of specific hypothesis that are related to the effects of specific types of abuse and neglect on the brain.

  2. The testing of effects of child abuse on grey and white matter volumes and their connectivity to different regions of the brain.

Besides the amygdala, the hippocampus is affected by child maltreatment and plays a significant role in the development of several mental illnesses. In patients with PTSD or major depression, the hippocampus has a reduced volume. The amygdala plays a critical role in mood-and anxiety related illnesses. Amygdala volume and its response to stressors have repeatedly been studied in non-human primates. It turns out, an increased amygdala volume can be the result of abuse and neglect. This can cause increased anxiety and depression. Finally, grey -and white matter volumes are affected by ELS. A reduction in grey matter in the prefrontal cortex, hippocampus and orbitofrontal cortex was found in subjects with ELS. Furthermore, childhood maltreatment was found to be associated with changes in the cortical network.

What are the implications for treatment?

There is also an effect of child maltreatment on treatment response of both mental and physical illnesses. The available evidence suggest that childhood maltreatment causes a poorer response to psychotherapy and pharmacotherapy in patients suffering from depression. Also, childhood sexual abuse was a negative predictor of response to cognitive behavioural therapy. In another study it was found that ELS predicts a poor response to antidepressants and people need a longer time for remission. Childhood abuse can not predict antidepressant response though. However, having a neglectful parent did predict a poorer antidepressant response. This evidence suggests that individuals with a history of child abuse have a fundamentally different biological endophenotype that cause corresponding differences in treatment.

What are suggestions for further research?

In the current review, evidence has been stated to support the claim that child abuse has devastating effects on the course -and risk for inflammation, mood -and anxiety disorders, depression and PTSD. Furthermore, child maltreatment has a negative effect on treatment of these disorders. However, some critical questions remain:

  • How does the timing of adverse childhood experiences affect their impact?

  • Which biological mechanisms are involved in the response to neglect and child abuse into vulnerability to disease?

  • What interactions in gene-environment can mediate the effects of child maltreatment?

  • How can treatment methods benefit from research on the effects of child maltreatment?

  • Should there be therapeutic interventions directly after the recognition of child abuse to prevent the development of psychiatric syndromes?

  • Are the biological effects caused by ELS reversible?

  • What prevention programs for parental abuse and neglect should be implemented?

  • What biological mechanisms are involved in mediation of the risk for obesity, cardiovascular disease and diabetes in patients that experienced childhood maltreatment?

Article summary of Maltreatment in childhood substantially increases the risk of adult depression and anxiety in prospective cohort studies: Systematic review, meta-analysis, and proportional attributable fractions by Li et al. - Chapter

Article summary of Maltreatment in childhood substantially increases the risk of adult depression and anxiety in prospective cohort studies: Systematic review, meta-analysis, and proportional attributable fractions by Li et al. - Chapter


There is a strong relationship between childhood maltreatment and the development of depression and anxiety disorders. There are several neurobiological mechanisms that contribute to the emerge of psychopathology.

  • Stress

  • Structural brain differences

  • Functional brain differences

  • Genetics and epigenetics and vulnerability

What is wrong with previous research on the relationship between child abuse and psychiatric disorders?

If there is childhood abuse, this also impacts the development of affective processing abilities, adaptation in school, self-system processes, relationships with peers and attachment relationships. The biggest causes of morbidity because of psychiatric disorders are depression and anxiety. Children coming from abusive environments and families are significantly more prone to develop depressive -and anxiety symptoms. The direct relationship between child maltreatment and psychiatric disorders has been proven repeatedly, however the measurement of maltreatment is susceptible to bias and false memory. This is because most studies review cross-sectional -or use recall to assess maltreatment.

The reason for this is that a large part of people that have been interviewed in their adult life do not report child abuse or maltreatment. Mental health is related to filtering out harmful -and negative memories. The mind will represent them in a non-threatening manner. Therefore, people with good functioning forget negativity in their past and people that function poorly exaggerate negativity. Thus, current mental health influences reporting of negative childhood experiences. Also, cross-sectional studies fail to establish the temporal relationship between the outcomes of risk factors.

There is too little research on the potential prospective impact of maltreatment reduction on psychiatric disorders. People attribution factors (PAFs) can be used to point out the reduction of a disease in a population. It shows what would occur if the risk factor exposure decreases to an ideal exposure level. It could potentially help judging priorities on health action.

What method is used in the current study?

This study is a systematic review and meta-analysis, of English articles published in the last 25 years. Electronic databases and grey literature were searched for studies with criteria for depression or anxiety together with a non-recall measurement of childhood maltreatment. A systematic meta-study is done to analyse the results and the reviewed articles were grouped for five analysis:

  1. Maltreatment and depression (anything).
  2. Maltreatment and anxiety (anything).

  3. Physical abuse and depression -or anxiety.

  4. Sexual abuse and depression -or anxiety.

  5. Neglect and depression -or anxiety.

The constructs: study quality, heterogeneity and publication bias were reviewed as well. The initial screening of titles and abstracts resulted in 199 remaining papers. Finally, eighty-eight articles were found matching the criteria. Potential preventive impact was measured using population attributable fractions (PAFs).

What were the results of this study?

The odds ratio (OR) was calculated between maltreatment in general and depression (OR = 2.03). This indicates that individuals with any type of child maltreatment have 2.03 times more chance get depression than others. For the relation between any type of maltreatment the outcome was: OR = 2.70. Also, the OR was calculated between specific types of maltreatment and depression or anxiety disorders. These include physical abuse, sexual abuse and neglect. The relationship between physical abuse and depression or anxiety was OR = 2.00 meaning children that were abused in childhood are two times more likely to develop depression -or anxiety than children without maltreatment. For sexual abuse the chance was 2.66 times higher and for neglect this chance was 1.75 times.

After this initial analysis the PAFs were calculated to show potential depression and anxiety cased that could be prevented if child abuse would be reduced worldwide. The PAFs suggest that about fifty percent of depression and anxiety cases are caused by self-reported childhood maltreatment. A reduction in maltreatment of ten to fifteen percent could prevent millions of depressions -and anxiety cases worldwide.

What did the researchers conclude?

There are significant relationships between the various types of maltreatment (i.e. neglect, physical and sexual abuse) and psychiatric disorders later in life. Childhood maltreatment should be viewed as a risk factor for depression and anxiety disorders. All types of child maltreatment are associated with developing psychological disorders. This study is the first in estimating the projected decrease of mental disorders by reducing child abuse worldwide. The conclusion is that there is evidence for childhood maltreatment as increasing the risk for depression and anxiety. Furthermore, it reinforces the need for more policies and programs to prevent the occurrence.

What are the limitations of measures of child maltreatment?

There are strengths and limitations to both self-reported and informant measures of child abuse. The disadvantage of self-report is that it relies on retrospective memory, which is often flawed. Informant reports are often displaying the most severe cases of maltreatment, such as neglect or emotional abuse. Self-report measures work better for cases of sexual abuse, which might be invisible to informants. Also, informant studies have the drawback that they can underestimate abuse because they are based on short-period reports by a professional of child protective service. When chronicity is not considered, childhood maltreatment can be overestimated. When measurements are taken on a one-time basis, maltreatment can be underestimated.

What is the advantage of using PAFs?

PAFs provide a quantitative measure of impact on the prevalence of depression and anxiety that could be accomplished by the reduction of child maltreatment. A decreasing amount of child abuse can prevent cases of mental illness and should be a target for mental health promotion. Child abuse is both a threat for a child’s development as lifetime perspectives. Early childhood experience sets the trajectory for future risk behaviours. Interventions and services should be improved to enhance the populations’ overall mental health.

What are the strengths of the current study?

The pooled findings from longitudinal and cohort studies that have externally documented cases of child abuse are a strength of this study. The use of these studies decreases the issue of recall bias, false memories and effort after meaning. The reviewed studies are quite recent, and the quality was controlled for. Furthermore, the use of PAF estimates show the decrease of depression and anxiety by reducing child maltreatment.

What are the limitations of the current study?

Limitations are that there is only a small number of reviewed articles. Unfortunately, not more studies met the requirements for the inclusion criteria. The studies that are reviewed are not representative for the world’s population. These studies only review the USA, Australia and New Zealand. Studies from developing countries were not included. The PAF measures might have been influenced by the inconsistent measures between global prevalence of maltreatment and the connection between maltreatment and depression -and anxiety. The third limitation is that heterogeneity was high in some of the analysis. This indicates substantial variation in the connection between child abuse and mental health in the outcomes. Therefore, these measures should be standardized. Potential moderators in child abuse should be identified. Finally, only cases without recall bias are included in this study meaning that the reported cases are more severe.

Article summary of A tangled start: The link between childhood maltreatment, psychopathology, and relationships in adulthood by Shahab et al. - Chapter

Article summary of A tangled start: The link between childhood maltreatment, psychopathology, and relationships in adulthood by Shahab et al. - Chapter


Childhood maltreatment is an important public health concern impacting both the individual and the relation with others. Four categories of childhood maltreatment are distinguished: physical abuse, sexual abuse, psychological/emotional abuse, and neglect.

Adults with a history of childhood maltreatment are more likely to experience interpersonal relationship difficulties such as distrust, feeling distant from others, and developing insecure attachments style which influence relationship quality. Childhood maltreatment has also been linked to several mental health problems including depression, anxiety, and alcohol dependence severity.

Seeing as some, but not all, people who experience childhood maltreatment have difficulties in adult intimate relationships highlights the complexity of the association between maltreatment and interpersonal relationships in adulthood and indicates that other variables moderate/mediate this association. A potential mediator is adult attachment style. Studies have found that the relationship is mediated partially by avoidant and anxious-ambivalent attachment styles in adulthood. Moreover, negative emotions are more frequent in adults with both anxious and avoidant attachment styles than in securely attached adults, and these negative emotions may lead to additional problems in relationships. Several studies suggest that mental health problems may also mediate the relationship between childhood maltreatment and the quality of intimate relationships.

Altogether, research suggests that symptoms of depression, anxiety, alcohol abuse, and insecure attachment in adulthood may play a role in the diminished quality of intimate relationships in adulthood among individuals with a history of childhood maltreatment.

In order to better understand the association between childhood maltreatment, insecure attachment styles, and the quality of intimate relationships in adulthood, this study aimed to investigate the link between childhood maltreatment, insecure attachment patterns, and the quality of intimate relationships, and to what extent depression, anxiety, and alcohol dependence severity and insecure attachment styles mediate the association between childhood maltreatment and the quality of intimate relationships. This will be done by using the Netherlands Study of Depression and Anxiety (NESDA), a longitudinal epidemiological study designed to investigate the course and consequences of depressive and anxiety disorders.



The NESDA is an on-going longitudinal cohort study in depression and anxiety. Including 2981 respondents between the ages of 18-65. Participants underwent an assessment consisting of demographics, a standardized psychiatric interview, a structured interview on childhood maltreatment, and assessment of personality characteristics. Post baseline respondents were invited for five follow up waves (FU1, FU2, FU4, FU6, and FU9). For the present study, a total of 2035 respondents who had a current or previous relationship were selected after the 9-year follow-up.


  • Childhood maltreatment was assessed using the Childhood Trauma Questionnaire (CTQ), a validated, 28-item self-report questionnaire that assesses emotional and physical neglect, psychological, physical, and sexual abuse. It contains five subscales: three assessing abuse (emotional, physical, and sexual, each of 5 items) and two assessing neglect (emotional and physical, each of 5 items).
  • Psychological distress was assessed using the 30-item Inventory of Depressive Symptomatology self-report (IDS-SR). It uses a four-point Likert scale (i.e., feeling sad) and a 7-day timeframe for assessing symptom severity.
  • Anxiety severity was assessed using the Beck Anxiety Inventory (BAI), which is a self-report instrument consisting of 21 items. Respondents are asked to indicate how much they had been bothered by each mentioned symptom over the past week using a four-point scale.
  • Alcohol dependence symptom severity was assessed using the 10-item Alcohol Use Disorder Identification Test (AUDIT), a self-report questionnaire. Respondents rate how often they have consumed alcohol in the past year, how much they consumed on average, and how often they experienced negative consequences of alcohol use.
  • Insecure attachment styles were measured with the Experiences of Close Relationship Scale – Short Version (ECR-S). It consists of 12 items that are designed to assess individual differences with respect to avoidance and anxiety attachment styles.
  • The Revised Dyadic Adjustment Scale (R-DAS) is a self-report questionnaire that assess partner relationships in three categories: consensus, satisfaction, and cohesion.


  • Model 1 (crude): showed a positive association between childhood maltreatment and anxious attachment as well as avoidant attachment.
  • Model 2 (including demographics): showed a significant positive association for anxious attachment and avoidance attachment.
  • Model 3 (including partner status and mean duration of relationship): showed a significant positive association for anxious attachment and avoidance attachment.
  • Childhood maltreatment was also negatively associated with the quality of intimate relationships in model 1.

The overall model showed an acceptable fit and suggested full mediation of the association of childhood maltreatment with quality of intimate relationships by depression severity and anxious attachment and avoidant attachment. Anxiety and alcohol dependence severity were not significant mediators.

Discussion & Conclusion

This study found an association between childhood maltreatment and the quality of intimate relationships in adulthood and gained a better understanding on how maltreatment and psychopathology are associated with relationship quality in adulthood. Individuals reporting more childhood maltreatment also manifest more insecure attachment patterns and their intimate relationships in adulthood are generally of lower quality. Findings also indicate that there may be two typical pathways:

  1. The strongest pathway links childhood maltreatment to increased depression severity, anxious attachment, and lower quality of intimate relationships.
  2. The second pathway links childhood maltreatment to depression severity and avoidant attachment. which is quite strongly associated with lower quality of intimate relationships.

In this sample, alcohol dependence severity was only associated with anxious but not avoidant attachment. While childhood maltreatment has been identified as an important risk factor for excessive alcohol use and alcohol use problems in some studies, not all studies found these associations. Furthermore, attachment styles may play a role in the quality of intimate relationships, the reverse may also be the case: a solid and loving relationship may also play a role on attachment styles and longer lasting relationships may yield a stronger sense of secure attachment.

Based on the richness of the NESDA study, with a large sample including healthy participants and individuals with psychological issues, adds clinically relevant insights to the literature. these findings can have clinical implications, by informing parents, teachers, general practitioners, and the general public about the possible destructive impact of childhood maltreatment on mental wellbeing and intimate relations, may lead to better recognition and earlier detection.

In conclusion, the study suggests that

  1. Intimate relationships are generally of lower quality in individuals with a history of childhood maltreatment
  2. Depression and insecure attachment styles fully mediate the relationship between childhood maltreatment and the quality of intimate relationships in adulthood

Future studies may consider looking more closely at respondents with severe alcohol use in order to better understand the impact it may have on relationships in adulthood. Future long-term longitudinal studies that focus on different types of childhood maltreatment are imperative to the literature to further elucidate the impact effects of different types of childhood maltreatment on adult attachment styles and quality of relationship.

Article summary of Parents’ experiences of childhood abuse and neglect are differentially associated with behavioral and autonomic responses to their offspring by Buisman et al. - Chapter

Article summary of Parents’ experiences of childhood abuse and neglect are differentially associated with behavioral and autonomic responses to their offspring by Buisman et al. - Chapter


Childhood maltreatment experiences are associated with a range of negative consequences like emotional and behavioural dysregulation in childhood and subsequent adverse mental health outcomes in adulthood. They have also been shown to compromise adults’ interpersonal functioning including their parenting behaviour. But little is known about what happens in terms of physiological responses and regulation when parents with a history of childhood maltreatment interact with their offspring. In an effort to expand the knowledge regarding childhood maltreatment and subsequent parenting behaviour, the present research examines how parents’ childhood experiences of neglect are associated with their physiological reactivity and parenting behaviour – specifically warmth, negativity, and emotional support, during a parent-offspring conflict interaction task.

Theoretical Perspectives

Multiple perspectives may be useful to explain the association between childhood maltreatment and later maladaptive parenting behaviour.

  1. Developmental psychopathology suggests that early childhood trauma impacts the quality of caregiving behaviours through stress or trauma-related symptoms that undermine caregiving capacities. Childhood maltreatment has been associated with heightened attentional and affective responses to fearful and angry faces, deficits in emotion recognition, and reduced responsiveness to reward in children and adults.
  2. Attachment theory posits that children develop “internal working models” (i.e., mental representations) of the self and others through repeated interactions with their primary caregiver(s), from which they then interpret and experience other relationships, including relationships with their own offspring.
  3. Social learning theory holds that behaviour is learned in large part through observation, imitation, and reinforcement. It postulates that violence is learned through role models provided by the family directly or indirectly, is reinforced in childhood, and continues in adulthood as a coping response to stress or as a method of conflict resolution.
  4. Allostatic load theory suggests that the autonomic nervous system (ANS) attempts to maintain stability through change during stressful conditions in order to maximize survival, a process called allostasis. When the system is exposed to repeated or chronic stress, including maltreatment, physiological responses may become dysregulated, a process referred to as allostatic load.

Empirical Research

Various empirical studies have investigated the association between childhood maltreatment and later parenting. Studies using self-report measures of parenting behaviour showed that child maltreatment is associated with maladaptive parenting outcomes including lower perceived parenting competence, more parenting stress, more role reversal, decreased responsivity, more harsh physical discipline, and more abusive and neglectful parenting behaviours. As opposed to self-reports of parenting, observational measures of parenting are considered to be less influenced by bias and have been shown to be stronger and more consistent predictors of offspring outcomes.

Vaillancourt et al. (2017) identified fourteen studies on the association between maternal experiences of physical and sexual abuse and observed parent-infant interactions. Generally, it was shown that childhood abuse experiences were, directly or indirectly, associated with maternal interactive behaviour, including hostile, intrusive, and inconsistent behaviour toward infants. It was revealed that mothers’ history of maltreatment was associated with less sensitive, more hostile, and more self-focused behaviour. Majority of studies didn’t include any fathers, whereas fathers’ involvement in childcare has continuously increased in the past decades. Most studies investigated the impact of physical abuse, leaving open whether the effects hold true for other types of maltreatment like emotional or physical neglect. The current study examines the impact of childhood abuse and neglect in maternal and paternal interactions with offspring spanning a wide age range.

Continuity in parent-offspring interactions

Research also points to continuity in parent-offspring relationships. For example, social learning theory and attachment theory assume that interaction patterns learned and enacted during childhood and adolescence will continue to manifest themselves in young adults’ relationships. Parent-offspring relationships during childhood are predictive of parent-offspring relationships during adolescence and adulthood. Conversely, more conflict with parents during adolescence is associated with conflict with parents during young adulthood. To a certain extent, parental interactions with their underage offspring therefore show continuity in their interactions with their adolescent and adult offspring.

Child maltreatment history and autonomic reactivity

Studies including ANS activity measures may provide insight into the mechanisms underlying the effects of childhood maltreatment experiences on parenting behaviour. Studies focusing on this association and ANS reactivity to psychosocial stressors reveal physiological hyper-reactivity in response to stressors following childhood maltreatment, but hypo-reactivity has also been found. More insight into what happens when parents with a history of childhood maltreatment interact with their offspring can help researchers and practitioners to understand how maladaptive parenting behaviours are transmitted from one generation to the next.



The current sample was part of a larger sample form the 3G parenting study, a family study on the intergenerational transmission of parenting styles, stress, and emotion regulation. The final sample consisted of 395 participants from 63 families with two to four generations and an average of 6.27 family members per family. Eventually this sample reduced to 229 participants. Nuclear families were invited for a lab visit at the Leiden University medical Center, which involved questionnaires, computer tasks, family interaction tasks, and collection of saliva and hair samples, and during specific tasks, skin conductance and heart rate were measured.


  • Childhood maltreatment was measured using subscales of the Conflict Tactics Scales: Parent-child (CTSPC) and the Childhood Trauma Questionnaire (CTQ).
  • Parental behaviour was measured ruing a parent-offspring conflict interaction task (revealed differences task). The patterns of interaction between parents and offspring were investigated and coded with the Supportive Behaviour Task Coding Manual, version 1.1.
  • Autonomic (re)activity was measured by recording electrocardiogram (ECG) and impedance cardiogram (ICG) signals using an ambulatory monitoring system before and after the conflict task.
  • Physical exercise/condition and smoking were taken into consideration as this may influence heart rate.
  • Analyses was done by computing Pearson correlations between maltreatment, parental interactive behaviour, and autonomic (re)activity. Subsequently a structural model was computed to estimate the associations between experienced maltreatment, parental interactive behaviour, and autonomic reactivity during the interaction task. Age, gender, and SES were included as covariates.

Discussion & Conclusion

This study is the first to investigate the role of childhood abuse and neglect in parents’ autonomic and behavioural responses during a conflict interaction task. Findings showed that experiences of childhood neglect were uniquely associated with autonomic hyper-activity responses, whereas experiences of childhood abuse were uniquely associated with behavioural responses while discussing conflict. Thus, there may be unique consequences of the two types of maltreatment.

The present study suggests that behavioural and physiological systems respond differentially to childhood abuse and neglect. When discussing conflict with their offspring, parents who experienced higher levels of childhood abuse responded more strongly on a behavioural level but not on an autonomic level, whereas the opposite pattern was observed for parents who experienced more childhood neglect. Both response patterns, however, may indicate maladaptive emotion regulation and responding that may contribute to the transmission of dysfunctional caregiving. Results support previous suggestions that individuals with maltreatment experienced could benefit from interventions aimed at physiological and behavioural-based stress regulation.

Though different types of maltreatment often co-occur, findings of this study suggest that they do represent different experiences, highlighting the need to measure different types of maltreatment and to compare their separate influences. This will promote effective targeting of intervention and preventive efforts and understanding of the developmental pathways form unique experiences to adaptive parenthood.

Article summary of Childhood maltreatment, latent vulnerability, and the shift to preventative psychiatry - the contribution of functional brain imaging by McCrory et al. - Chapter

Article summary of Childhood maltreatment, latent vulnerability, and the shift to preventative psychiatry - the contribution of functional brain imaging by McCrory et al. - Chapter

What is this article about?

Experiencing childhood maltreatment, for example physical, sexual, emotional abuse and neglect is a predictor of poor mental health across the life span. It increases the risk on psychiatry disorders in childhood and in adulthood. However, there is a lack of understanding in how maltreatment alters the neurocognitive systems and how it leads to mental health problems. Thus, clinicians are not so well equipped to identify or help children who are at most risk of developing mental health problems. This gap in the literature resulted from different factors. First, research in the field of child mental health has mainly focused on finding a medical model that explains psychiatric disorders. However, this is not good, because this research is underpinned by the assumption that individuals who have the same diagnosis are comparable. This is incorrect: individuals with the same disorder, differ from each other. For example, in individuals who have experienced maltreatment and have a psychiatric disorder, differ from people without such a history. Psychiatric disorders in this group often develop earlier, and often the symptomatology is more severe. There is also a higher risk on comorbidity, and a disorder in this group is more likely to be persistent and recurrent. Often standard treatment also do not work as well for this group.  Thus, individuals who have experienced childhood maltreatment within a diagnostic category have specific ecophenotypes.

Another reason for why there is such a big gap in the literature, is that it is difficult to measure and define maltreatment. Children who experience maltreatment often experience more than one form of abuse or neglect. There are also individual differences in severity, frequency, and the age of onset. Therefore, research has neglected this research domain.

However, there is now a shift. Because of neuroimaging research, alternations in neurocognitive systems following maltreatment can be measured. This is done using functional magnetic resonance imaging (Fmri). Research groups are also increasing into the topic of maltreatment. These groups started to systematically study neurocognitive mechanisms which are associated with maltreatment.

What is the theory of latent vulnerability?

The theory of latent vulnerability is a theory about the link between childhood maltreatment and the associated risk on psychiatric disorders across the life span. This theory states that because of maltreatment, there are measurable changes in neurobiological systems. These changes are often adaptive within the early maladaptive context; so they help to adapt to the environment. However, these changes which can be functional for the maladaptive environment, may be ineffective for other, normative contexts. This may increase the vulnerability of the individual for future stressors. These adaptations or changes can occur in different levels. For example, young adults who have experienced childhood maltreatment showed altered patterns of epigenetic modulation in genes which are implicated in different physical and psychiatric disorders. For example, maltreatment subtypes have unique methylation patterns. For example, physical abuse leads to changes in stress regulation, fear response, heart rate regulation. Physical neglect leads to changes in lipoprotein metabolism, polyamine metabolism, and regulation of cholesterol efflux.

The indicators of latent vulnerability are characterized by three key features, namely:

  1. The indicators are not directly symptoms of a future disorder. Instead, the indicators refer to cognitive processes or representations and associated patterns of neural activation that are implicated in the existence of a disorder. For example, decreased reward sensitivity may make someone more vulnerable to depression. However, being reward insensitive is not a symptom of depression.
  2. The indicators are best to be indexed at a systems level. This means that latent vulnerability refers to a complex phenotype which can be seen as ‘maladaptive calibration’ in higher order systems which are important for socioemotional and cognitive functioning. It would be more reasonable to hypothesize that a limited but different set of candidate neurocognitive systems are altered in a way that increases or reduces the risk on psychopathology after having experienced maltreatment. This would be better, because there is heterogeneity of maladaptive outcomes of maltreatment experiences.
  3. The indicators should be present before the existence of a psychiatric disorder, and they should help to predict future risk. Even if we know that latent vulnerability is present, this does not tell us anything about the timing of the onset. For example, the vulnerability could be present for months or years, but disorders may only come into play when there is stress. Thus, the emergence or existence of a psychiatric disorder can be seen as an interaction between latent vulnerability and stressor exposure.

How is functional magnetic resonance imaging used in the study of childhood maltreatment?

Functional studies can help us to understand psychological mechanisms better. The evidence gathered with functional studies have shown differences in four neurocognitive systems, namely threat processing, reward processing, emotion regulation, and executive control.

Threat processing

For humans to survive, it is necessary for them to detect threat and respond to aversive and potentially dangerous stimuli. Therefore, we have neurobiological and cognitive systems which are prioritized for this detection of threat. The neural system associated with this often operates outside awareness, so consciously. The amygdala seems to play a critical role in detecting salient stimuli, and particularly dangerous stimuli. The amygdala works together with the thalamus, the pulvinar nucleus, and the superior colliculus.

Thus, threat processing is important for survival. Therefore we can expect that when there are alterations in this system, that this may lead someone to develop maladaptive behaviors. This is visible in anxiety disorders, which are associated with both vigilance (even in dangerous environments), and avoidance (when threat is present, and when someone should not avoid, but instead allocate attention to the threat). Inappropriate hypervigilance costs resources, which should be used for other important functions. Studies have shown that being hyperresponsive to threat predicts future symptomatology or psychopathology. For example, higher amygdala activity before stress exposure can predict later psychiatric symptoms.

Studies of threat processing in children and adolescents with a history of maltreatment have shown that experiencing maltreatment is associated with long-term impairments in their threat-processing and fear-processing systems. These changes are visible as early as 15 months. Changes include preferential attention to threatening information, heightened neural response to negative stimuli, and enhanced perceptual ability for cues that are associated with danger, such as angry faces. Animals also show changes as a result of early adverse experiences (such as reduced maternal care).

Functional brain studies have shown that children who have experienced maltreatment show greater activation in subcortical regions such as the amygdala and hippocampus during threat processing. Other researchers have demonstrated higher amygdala response to threatening facial cues in children who are exposed to early institutional neglect. Other research has demonstrated the role of the anterior insula. In children who had been exposed to maltreatment, amygdala activity and anterior insula activity was heightened. Thus, it seems that altered threat reactivity is a candidate neurocognitive system which is altered after maltreatment.

Reward processing

Humans have to be able to process rewards. This helps us to successfully adapt to our environment, because if we anticipate rewards, we are motivated and show goal-directed behavior. Therefore, humans always seek out natural rewards and also learn which neutral stimuli predict rewards. This happens in a conscious as well as an unconscious manner. Reward processing consists of three components: liking, wanting, and learning. Each of these components reflect different psychological processes.

Alterations in reward processing are visible during different pathological disorders, such as depression, substance abuse, and anxiety. It has been shown that disrupted striatal response during reward anticipation predicts anhedonia. Also, reduced activation in the ventral striatum predicts clinical depression and anhedonia two years later. Alterations in this reward network are also associated with vulnerability.

Studies on Romanian adoptees have shown that these adoptees have disrupted neural responses during the anticipation of monetary rewards.

There have also been three studies that have looked into reward processing in individuals who have experienced maltreatment. This showed that emotional neglect was associated with disrupted striatal response during reward processing. This lowered activity is also associated with more depressive symptoms. Another study found that maltreatment experience was associated with reduced activation to reward cues in the striatum, and in other regions such as the orbitofrontal cortex and insula. Another study conducted on older adolescents who had experienced physical and/or sexual abuse found an increased BOLD response when viewing positive social stimuli compared to neutral social stimuli. Maltreatment seems to predict depressive symptoms only for youth who have lower reward reactivity both neurally and behaviourally. Thus, maltreatment predicts more depressive symptoms only for adolescents who have low activation of the left putamen in response to positive images. Having greater reactivity to rewards is a protective factor against depression for adolescents who have experienced maltreatment.

Emotion regulation

Emotions are difficult to define and therefore, emotion regulation is too. However, most researchers agree on that emotions are innate, and that they are adaptive. They help us to appraise our environment and prepare us for action. Emotions are seen as a complex neurophysiological phenomenon which help to evaluate our environment as well as change our motivational state and behaviour. Emotion regulation is defined as the ability to produce changes in emotions. Thus, it is used to change the valence of it (good or bad), and its intensity or duration. It is a dynamic and multifaceted process, and it can take place without conscious awareness.

Neuroimaging studies have shown interconnected circuits which are involved in emotion regulation. Especially subcortical or limbic regions are involved in the evaluation of threat, reward, and internal physiological states have been shown to be interconnected with frontal regions such as the anterior cingulate cortex (ACC). These regions are important for integrating information from different sensory modalities, and they are implicated in processes of successful emotion regulation. This involves assessing one’s own and others’ mental states, monitoring conflicting information, inhibiting and selecting behavioural responses and attributing context-dependent value to stimuli.

When people experience difficulties in emotion regulation, this is often associated with psychiatric disorders, such as anxiety, depression, conduct disorder, and substance abuse disorder. Also, alterations in emotion processing serve as a predictor for future psychiatric conditions and difficulties in social functioning. Studies in maltreated children show that differences in emotion regulation predict future psychopathology. For example, maltreatment experience has been shown to be associated with high emotion lability/negativity at the age of 7. This leads to poor emotion regulation, and this in turn predicts internalizing symptoms later. Thus, poor emotion regulation is involved in the development of internalizing problems, such as anxiety.

There have been multiple studies that have looked into the brain circuits that are involved in emotion regulation in children and adolescents with a history of maltreatment. These studies have shown that there is atypical focal brain activity in regulatory brain regions such as the ventral ACC (vACC) and the IPFC. Also, there are alterations in the connections between frontal and subcortical brain regions, such as the amygdala-vACC circuit. Studies into the functional connectivity between the amygdala and frontal regions have shown that there are differences in younger children’s functional coupling between the amygdala and mPFC when they viewed emotional faces. Another study has shown that, in a group of normative developing adolescents, that there is more negative functional connectivity between amygdala activity and the rostral ACC. This is associated with more verbal abuse and depressive symptoms. Another study found that a group of trauma-exposed children did not show a typical pattern of negative connectivity between the amygdala and the vACC. They differed from their peers.

Other studies have looked into brain activity in children with a history of maltreatment. Differences between this group and nonmaltreated children were mostly found in brain regions such as the ventral and dorsal ACC and the IPFC. Other studies found an overall increase activity in the dorsolateral PFC and also in the dorsal and ventral ACC.

Executive control

Executive control refers to planning, flexible thinking, and anticipating outcomes. This is really important, because this helps to accomplish day-to-day activities as well as long-term goals. There are three functions of executive control: updating, inhibiting, and task shifting. Updating refers to working memory, and is defined as manipulating and maintaining information in an active state (sustaining attention), and to disregard distracting inputs (attention control).

Inhibitory control is defined as the ability to constrain automatic or dominant behavioural and cognitive responses which are counterproductive. Shifting refers to the ability to switch between different mental tasks, mental states, and concepts. All three functions interact and are necessary for effective decision-making and adaptive behaviours such as self-regulation, and the ability to monitor performance and detect errors.

When people have disrupted executive control, this is associated with lower emotion regulation skills, more rumination, and reduced social skills. In turn, these are all predictors of psychopathology.

There have been two studies conducted using fMRI to find neural correlates of executive control in children and adolescents who have been exposed to maltreatment or institutionalization. These studies have shown that there is increased activity during error monitoring and inhibition in regions such as the medial and frontal motor regions. This may increase the risk on future psychopathology.

What are implications for future research?

There are five suggestions from these authors to enhance the validity of future studies, namely

  1. Ensure effective matching. In studies that compare nonmaltreated children and adolescents to a control group, it is important to make sure that these groups are matched on age, IQ, sex, and SES;
  2. All maltreatment domains should be characterized. Studies should be clear about which kinds of maltreatment their participants have experienced.
  3. Do not conflate adversity in the normal range with maltreatment exposure. When a sample includes mostly typically developing children, then these findings can tell us about development as a result of normal adversity. But, they do not tell us a lot about actual maltreatment.
  4. Take particular care in measuring emotional abuse using self-report instruments. When possible, researchers should try to use prospective and objective measures of maltreatment, such as institutional records.
  5. Longitudinal designs. Longitudinal studies are necessary to determine whether alterations in neurocognitive functioning lead to future psychiatric disorders.
Article summary of Effects of early life stress on cocaine self-administration in post-pubertal male and female rhesus macaques by Wakeford et al. - Chapter

Article summary of Effects of early life stress on cocaine self-administration in post-pubertal male and female rhesus macaques by Wakeford et al. - Chapter


Cocaine use disorder (CUD) is a major public health concern in the USA. CUD is defined as a chronic relapsing disorder where users continue to seek out and use cocaine despite harmful consequences. Despite these risks, it’s not clear why only a fraction of users transition from initial use to dependence. Researchers have spent a lot of effort trying to identify genetic and environmental variables that confer specific vulnerabilities to the reinforcing effects of cocaine.

Adolescence has been described as a vulnerable period, as this is typically the time at which drug use is initiated. Preclinical studies indicate that adolescent rodents also show heightened vulnerability to the reinforcing effects of cocaine compared with adults. Superimposed on this vulnerability to cocaine use is the fact that the occurrence of adverse events early in life, or early life stress (ELS), represents one of the most predictive risk factors for the emergence of CUD in adolescence. ELS includes:

  • Childhood maltreatment
  • Early adverse experiences taking the form of physical/sexual abuse, neglect, or emotional maltreatment

These experiences have long-lasting psychological and neurobiological consequences to the victim, including heightened vulnerability to the development of mood and anxiety disorders.

Sex has also emerged as a critical variable determining vulnerabilities to drug abuse. Specifically, women progress form recreational drug use to drug dependence faster at a younger age, display a propensity to relapse more readily, and consume more cocaine following a relapse in comparison with men.

The goal of the present set of experiments was to examine if ELS was associated with increased sensitivity to the reinforcing effects of cocaine in post-pubertal (late adolescent to young adulthood) male and female rhesus macaques. This study adds important information to the existing literature by examining cocaine self-administration in post-pubertal monkeys that have had no previous experience with operant tasks or drugs of abuse.


Sample and Procedure

Total sample of 14 rhesus monkeys (8 male, 6 female). Infants were randomly assigned at birth to be fostered to multiparous mothers with either a history of nurturing maternal care (control) or histories of infant maltreatment (maltreated) according to published protocols in an effort to control for heritable/biological factors that may confound the effects of ELS. Around age 4-5 the animals were transferred to the main station for the cocaine self-administration studies. The animals were fitted with primate collars, chair-trained to sit comfortably in chairs specifically designed for nonhuman primates and implanted with intravenous (I.V.) catheters at around 5-6 years of age.

Focal observations of maternal care and infant behaviour were performed at the field station following birth and cross-fostering over the first 3 months of life to verify and quantify early maternal caregiving experienced by infants and its impact on socioemotional behavioural development. Observations were collected by experienced coders form observation towers.

Drug used was cocaine hydrochloride dissolved in 0.9% sterile saline and administered I.V.


  • ELS: rates of abuse and rejection were computed by averaging the frequency of abusive and rejection events towards the infant by the mother. Frequencies of screams and tantrums were computed into overall rates by averaging the frequency of screams or tantrums over all observations. Anxiety was also computed as an overall composite score and averaged across all observations.
  • Cocaine self-administration: days to acquire self-administration were operationalized as the number of days required before meeting stability criteria under terminal performance conditions. Two-way ANOVAs were used to examine performance at each stage of acquisition, and the max dose of cocaine.

Discussion & Conclusion

The goal of the study was to examine if ELS influenced sensitivity to the reinforcing effects of cocaine in post-pubertal animals. During infancy, maltreated animals displayed significantly greater rates of abuse and rejection, as well as behavioural distress measured by rates of screams, compared with control animals. The major findings of this initial set of self-administration experiments were that control males required more days to acquire terminal performance criteria compared to females. They also required more total days to acquire cocaine self-administration compared with other experimental groups. Together, these data suggest that ELS in the form of infant maltreatment results in a phenotype that includes heightened emotional reactivity and faster acquisition of cocaine self-administration in drug-naïve post-pubertal males.

This is the first study to examine infant maltreatment as a form of specific ELS that may induce a unique vulnerability to the reinforcing effects of cocaine in post-pubertal nonhuman primates. The most translationally relevant models of psychosocial stress include the occurrence of chronic and unpredictable stressors, given that these two aspects of stress are frequently responsible for sustained changes in behaviour as a result of maladaptive change sin hormonal and physiological systems regulating the stress-response system.

Much work has characterized the role of stress in drug abuse, with a key finding being that stress exacerbates the reinforcing effectiveness of many drugs of abuse. The results of the control monkeys are consistent with other preclinical findings showing that females are more sensitive to the reinforcing effects of cocaine compared with males. Data would suggest that males without a history of ELS demonstrate a resiliency towards the initial reinforcing effects of cocaine compared to maltreated males.

Sex was explicitly examined as a biological variable in these experiments, given the extensive literature demonstrating that women have a higher susceptibility to several aspects of psychostimulant abuse. In the experiments described, post-pubertal females regardless of early life care required fewer days than males to demonstrate stability under terminal performance conditions, suggesting that females may show an initial sensitivity to the reinforcing effects of cocaine as evidenced by a quicker progression through terminal performance criteria when compared to males.

While results from this study suggest a relationship between the occurrence of ELS and sensitivity to the reinforcing effects of cocaine in post-pubertal males and females, there are some limitations to the study. The sample size is relatively small. However, this is the first published study assessing ELS-induced vulnerability to the reinforcing effects of cocaine using post-pubertal, drug-naïve nonhuman primates and adds to the existing literature investigating the effects of ethologically valid models of social stress as a risk factor for the development of substance use disorders in adolescence.

Article summary of Emotion Modulation in PTSD: Clinical and Neurobiological Evidence for a Dissociative Subtype by Lanius et al. - Chapter

Article summary of Emotion Modulation in PTSD: Clinical and Neurobiological Evidence for a Dissociative Subtype by Lanius et al. - Chapter


In this article, the authors want to demonstrate that there is a dissociative subtype of the post-traumatic stress disorder (PTSD). They mention the specific neurobiological characteristics of this subtype, which distinguishes it from non-dissociative post-traumatic stress disorder. Dissociation is common in PTSD and it means experiencing disruption and fragmentation in areas such as consciousness, memory, identity and perception of self and the environment. There are many definitions of dissociation, but the authors choose to see it as "detachment" from the overwhelming emotional content during and after a trauma. Things such as chronic psychological, sexual and physical trauma are related to dissociation.

In addition to chronic trauma, acute trauma can also lead to dissociative experiences. This is called peritraumatic dissociation. There are a number of studies that have demonstrated this: individuals who experience acute trauma sometimes experience peritraumatic dissociative changes such as changes in time awareness, perception, attention, and awareness of pain in others. Depersonalization also occurs in many individuals who (have) experienced acute trauma. When individuals are in a dissociative or depersonalizing state, they store information related to the trauma differently in their memory. This leads to that they have less access to this information when they are in a 'normal' (not stressed) state. This can lead to 'compartmentalization' of the trauma and to cognitive fragmentation or emotional distance from the experience. The consequence of this is that these individuals are unable to process the cognitive and affective effects of the trauma effectively.

Acute dissociative responses to psychological trauma predicts the development of chronic PTSD. Individuals who show an acute dissociative response to psychological trauma also exhibit these dissociative responses when they are confronted with stimuli (things) that remind them of the trauma and even during minor stressors in daily life.

The authors of this article focus on the neurobiological and clinical characteristics of chronic dissociation in patients with PTSD. They also want to demonstrate that there is a specific, dissociative subtype in PTSD that differs from non-dissociative PTSD. The dissociative subtype of PTSD is characterized by overmodulation of affect. The non-dissociative subtype of PTSD is characterized by re-experiences (flashbacks) and hyperarousal (extreme physical arousal). Recognizing this difference has important implications for the treatment of individuals with PTSD.

Incomplete versus excessive cortico limbic inhibition: a model about the emotional under- and overmodulation in PTSD

Neurobiological studies

According to Bremner, there are two subtypes of responses to trauma: dissociation and hyperarousal. Neuroimaging studies have shown that there are also two different, specific neural pathways. However, these paths are not completely different, meaning that individuals with PTSD can exhibit both responses (simultaneously or in different time periods). However, patients with PTSD who have experienced long-term trauma (child abuse, war trauma) are more likely to exhibit dissociative symptoms compared to patients who have experienced acute trauma. The neural pathways have been investigated using functional MRI (fMRI) and imagination. During these studies, patients must write a story about their trauma. This story is then read to them later, while they are under an MRI scanner. The results of these studies show that the psychobiological responses of patients with chronic PTSD differ. For example, 70% of the patients reported to relive their trauma and showed an increased heart rate. The remaining 30%, on the other hand, showed a dissociative response. They also showed no increase in heart rate! Based on brain scans, researchers have concluded that there are opposite patterns of brain activity for emotion regulation and arousal modulation. These patterns of activation happen in the medial prefrontal cortex, the cortex cingularis anterior and the limbic system.

Emotional under-modulation: the failure of cortico limbic inhibition

Patients with non-dissociative PTSD exhibit extremely low activation in the medial anterior areas of the brain. These are areas that have to do with arousal modulation and emotion regulation. The specific areas are: the ventromedial prefrontal cortex and the rostral cingularis anterior cortex. In addition, these patients also experience increased activity in the limbic system while observing things that remind them of the trauma and seeing anxious faces. This increased activity is mainly in the amygdala. This is a brain area that has to do with fear. Patients with this form of activation are called "emotional under-modulators" (while seeing things that remind them of their trauma).

Emotional over-modulation: extreme cortico limbic inhibition

Patients with a dissociative form of PTSD, on the other hand, exhibit extremely high activation in the brain regions that have to do with arousal modulation and emotion regulation. These are mainly the dorsal anterior cingulate cortex and the medial prefrontal cortex. These patients are called "emotional overmodulators".

These two forms of modulation are part of the cortico limbic model.

Felmingham and his colleagues are also in favor of the cortico limbic model. They have used fMRI to determine the effect of dissociation for the processing of anxiety. They used two groups: one group that scores high on dissociation and one group that scores low on dissociation. They then compared the brain activity between these two groups during the conscious processing of fear and during unconscious processing of fear. Their study showed that dissociation does indeed occur in extreme arousal in patients with PTSD. This is due to hyper inhibition of limbic regions and is most common during the conscious processing of threats.

Studies in neurobiology have also shown that dissociation is probably the result of hyper inhibition of the limbic system and the amygdala. In addition, a reduced effect of the amygdala can also be observed in patients with borderline personality disorder.

Clinical studies

Patients with PTSD can therefore show both under and overmodulation of affect. Some patients may also exhibit these two responses simultaneously or alternately. However, it has been shown that patients with PTSD who have experienced long-term chronic trauma have more frequent dissociative symptoms compared to patients who have experienced acute trauma.

According to Terr, there are two types of traumatic experiences. Type 1 trauma is about a single traumatic experience. During Type 1 trauma, patients often experience complete and vivid memories. Type 2 trauma is long-term trauma. With this type of trauma, patients often experience symptoms such as dissociation, denial and paralysis.

Treatment and examination

The best treatments against PTSD are exposure therapies. Exposure therapies are therapies in which patients are exposed to trauma-related stimuli. However, before these therapies can be effective, patients must be able to connect with the trauma-related information. The purpose of exposure therapy is to reduce avoidance symptoms, improve affect management and facilitate cognitive restructuring of trauma-related memories. This would lead to a reduction in flashbacks and hyperarousal and ultimately to the elimination of the disorder.

A recent study has shown that dissociation in patients has a negative relationship with outcome in therapy. This means that the higher the patient scores on dissociation, the worse the patient will do in therapy. Therefore, according to the authors, it is important to determine the level of dissociation in a patient. Subsequently, interventions must be offered that reduce this dissociation. If this does not happen, then therapies can lead to people experiencing more symptoms!


So there are two subtypes of PTSD: one based on flashbacks and hyperarousal, and one based on dissociation. These two forms of reactions are two extremes of emotion regulation. This means that they are deviant forms of emotion regulation. The first form of PTSD is also called 'undermodulation' and the second form is called 'overmodulation'. Each of these two has its own specific path in the brain and correlations with the central nervous system. This also serves as proof for that there is indeed a distinction.

Experiencing flashbacks and hyperarousal is associated with a reduced activation in the medial prefrontal brain areas. There is also excessive limbic activity. This fits with the first type of PTSD: undermodulation.

The second type of PTSD, the dissociative subtype, is associated with increased activity in the medial prefrontal brain regions. This leads to inhibition in the limbic system, which ultimately leads to overmodulation.

Article summary of Childhood Trauma in Adult Depressive and Anxiety Disorders: An Integrated Review on Psychological and Biological Mechanisms in the NESDA Cohort by Kuzminskaite et al. - Chapter

Article summary of Childhood Trauma in Adult Depressive and Anxiety Disorders: An Integrated Review on Psychological and Biological Mechanisms in the NESDA Cohort by Kuzminskaite et al. - Chapter


Childhood trauma (CT) is one of the most robust and significant risk factors for depressive and anxiety disorders. CT is commonly defined as “all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power”. CT is operationalized as emotional (or psychological) abuse, physical abuse, and neglect (emotional or physical) before the age of 18 years.

CT has severe and long-lasting effects on both mental and somatic health across the lifespan. About one-third of all adult-onset psychiatric disorders are related to CT, with lifelong effects on morbidity and mortality. It increases the risk of negative life events, suicidality, sleep problems, and cognitive problems.

Biological research findings suggest that severe stress in early life elevates cortisol levels that over-activate glucocorticoid receptor (GR). The consequence of this glucocorticoid overproduction during early life is the abnormal development of the stress systems. Though this response may be adaptive in the short term, it comes at the cost of long-term maladaptation: a reduced capacity to respond to stress adequately and dynamically across the lifespan.

This review aims to summarize and integrate CT findings from a large longitudinal adult sample – The Netherlands Study of Depression and Anxiety (NESDA), in relation to psychopathology and discuss different psychological and biological mechanisms that may underlie the long-lasting impact of CT.

The Netherlands Study of Depression and Anxiety (NESDA)

NESDA is an ongoing longitudinal cohort study examining the course and consequences of depressive and anxiety disorders. Its sample includes Dutch-fluent adults between 18 and 65 years old with a current or remitted depressive and/or anxiety disorder. Within NESDA, CT was examined in 37 articles focused on psychopathology and potential psychological biological mechanisms underlying CT. Exposure to CT in NESDA was assessed twice: at the baseline using the structured Childhood Trauma Interview (CTI), and at a 4-year follow using the self-reported Childhood Trauma Questionnaire-Short Form (CTQ-SF). Both assess different types of CT: emotional neglect, emotional abuse, physical abuse, sexual abuse, and/or physical neglect before the age of 16, thus, while growing up.

Epidemiological Findings of CT Within NESDA

Prevalence rates of CT within NESDA (n=2970), exposure of at least once as assessed by the CTI:

  • Emotional neglect (28.9%) and emotional abuse (24.8%) were most common
  • Sexual (18.5%) and physical abuse (13.8%)
  • Approximately half of participants (48.6%) experienced at least one type of CT

Many previous studies that reported a relationship between CT and depressive or anxiety disorders in adulthood have focused on lifetime psychopathology and the more obvious forms of maltreatment like physical and sexual abuse. Within NESDA, the emphasis was on multiple types of CT and the specificity of associations with psychopathology.

It was demonstrated that exposure to any type of CT was associated with a higher risk of current anxiety and depressive disorders in increasing strength from current anxiety to current depressive to current comorbid this order. All types of CT were also consistently and strongly associated with the presence of current anxiety and depressive disorders in adulthood.

Exposure to CT as a predictor of the 2-year course of depressive and anxiety disorders was studied in a follow-up sample of 1209 NESDA participants with a baseline diagnosis of depressive and/or anxiety disorder. Results confirmed that a reported history of CT was associated with a poor outcome, characterized by more comorbidity and chronicity.

Additionally, authors explored the differential impact of different types of CT on the onset or recurrence of anxiety, depressive, and comorbid disorders in a sub-sample of 1167 NESDA participants without current baseline depressive and/or anxiety disorder followed over a 2-year time period. It was found that a history of CT significantly predicted the first onset and recurrence of depressive and comorbid disorders, but only slightly increased the risk for anxiety disorders. Among the types, emotional neglect was the main independent predictor of first onset and recurrence of any depressive or comorbid disorder at 2-year follow-up, suggesting that the relationship between CT and psychopathology is predominantly driven by emotional neglect.

Exposure to CT may alter basic cognitive assumptions about the self and others, that over time become ingrained in an individual’s personality. The five-factor model (FFM), in which individual personality differences are grouped to the five major dimensions of neuroticism, extraversion, openness, agreeableness, and conscientiousness, presently constitutes one of the dominant models comprehensively examining personality functioning. The development of the less adaptive personality characteristics has been proposed as a potential underlying mechanism explaining the link between CT and subsequent psychopathology. The severity of CT corresponded with more maladaptive personality characteristics and cognitive reactivity styles, including higher levels of neuroticism, openness, hopelessness, rumination, and external locus of control and lower levels of extraversion, agreeableness, and conscientiousness.

Alterations in the activity of the major stress systems, namely, the hypothalamic-pituitary-adrenal (HPA)-axis, the immune-inflammatory system, and the autonomic nervous system (ANS), are at the center of the biological psychiatry research seeking to explain the enduring impact of CT. stressful life events can dysregulate the functioning of stress systems by chronically stimulating the release of cortisol, the secretion of pro-inflammatory cytokines, and the alteration of sympathetic and parasympathetic nervous system activity. These stress systems are also firmly connected by regulating each other’s functioning.

CT not only affects the brain but also extends itself to poor health behaviours and the functioning of our entire body. A recent meta-analysis showed significant associations between multiple exposures to CT and poor adult lifestyle behaviours like physical inactivity, obesity, smoking, sexual risk-taking, heavy alcohol, and illicit drug use. Within NESDA, the authors found that individuals with severe CT had significantly higher rates of smoking and body mass index (BMI) than healthy controls without CT.

Observational research shows that exposure to adverse childhood events leads to dramatically different life-course trajectories, including a two-times higher risk for premature mortality but also increased onset of various somatic conditions. CT consequently seems to be more generally linked to an increased risk for age related health conditions. This suggests that CT can generally accelerate the aging process.

Although CT is a major risk factor for depression and anxiety, considerable heterogeneity exists in outcomes after exposure to CT. Many theories posit that the impact of CT may depend on individual characteristics. But these characteristics are generally hard to identify due to methodological heterogeneity and lack of replicated findings.

Discussion & Conclusion

This review summarized and integrated the potential mechanisms through which CT exerts its adverse effects using finding from the large longitudinal adult NESDA cohort. NESDA results indicated that CT has a negative impact on the onset and the course of affective disorders, both for depression and/or anxiety disorders and their comorbidity. These findings are in line with a large body of literature showing that CT negatively impact mental health across the lifespan and is, therefore, one of the most prominent public health risks for poor mental outcomes. Findings also suggested existing interindividual differences, with some individuals exposed to CT being at significant risk for psychopathology or further biological CT-related alterations.

It’s important to determine the mechanisms by which CT exerts its adverse outcomes to better understand who is at risk and ultimately develop personalized (preventative) interventions. Findings demonstrated the complexity of an organism, suggesting that the impact of CT on poor mental health outcomes is probably a result of a complex interaction of genes, brain processes, environment, and psychological factors. We have to be careful with causal inferences, as its currently unknown how different system interact due to a lack of theoretic underpinnings and comprehensive longitudinal projects integrating psychological, environmental, and biological factors in the same samples in the context of CT.

To advance our knowledge, there are currently several unmet needs in psychiatric research concerning CT and affective disorders:

  • Lack of comprehensive longitudinal projects investigating how multiple systems interact to result in affective disorders
  • How these different interactions sustain and proliferate symptomatology

It is essential to elucidate the time path between CT, its underlying mechanisms, and psychopathology, as well as investigate how genes and environment are both involved in adverse CT outcomes.

The current review also has limitations as it focuses on CT findings within one cohort, and replications of integrative approaches related to CT are essential. But this is also a strength as findings are comparable since the assessment of CT and other methodology were homogenous.

Overall, this review has shown that CT impacts the functioning of the brain, mind, and body. All these aspects most likely work together and contribute to a higher vulnerability for affective disorders across the lifespan. An integration of mechanistic explanations at different psychological, biological, and environmental levels is essential to better understand the life-long adverse effects of CT in the context of affective disorders.

Article summary of Pass it on? The neural responses to rejection in the context of a family study on maltreatment by Berg et al. - Chapter

Article summary of Pass it on? The neural responses to rejection in the context of a family study on maltreatment by Berg et al. - Chapter


Child physical and emotional abuse and neglect are associated with increased risk for long-lasting behavioural, physical, and mental problems. Among the adverse consequences is the increased risk for maltreated individuals to maltreat their own children. to better identify risk factors for perpetrating abuse and neglect, it is crucial to examine factors that might play a role in the transmission of maltreatment. This multigenerational family study investigates the impact of experienced and perpetrated abuse and neglect on neural reactivity to social exclusion in 144 family members (90 parents and 54 offspring).

A core aspect of child abuse and neglect is parental rejection of needs for attention and nurturance, which can occur through parental aggression and hostility or via parental neglect and indifference. Chronic exposure to rejection during childhood is linked to emotional, cognitive, behavioural, and social deficits, like decreased self-esteem and hypersensitivity to signs of threat and rejection. Rejection sensitivity is associated with increased feelings of aggression and aggressive behaviour. Being rejected by your parents can enhance sensitivity for social rejection in many situations, including next-generation parent-child interactions.

Many studies show that the network of brain areas associated with social rejection and exclusion includes the insula, anterior cingulate cortex (ACC) and medial prefrontal cortex (mPFC). Altered neural responses to social exclusion have been observed in maltreated individuals. A history of maltreatment appears to affect neural networks that are also implicated in parenting behaviour. These networks enable parents to respond to infant pain and emotions, understand non-verbal signals, and infer intentions through empathy and mentalizing.

In sum this study examines the impact of experienced and perpetrated abuse and neglect on neural reactivity to social exclusion by strangers and family members using a multi-informant, multigenerational family design.

Materials & Methods


The sample was part of a larger sample from the 3G parenting study, a three-generation family study on the intergenerational transmission of parenting styles, stress, and emotion regulations. Ultimately 144 participants from two generations (parents and their offspring) of 54 families were included.


Informed consent was obtained after describing the study to the participants. If eligible, participants did an fMRI session, performing three tasks in the scanner.


  • Childhood maltreatment: adapted versions of the Conflict Tactics Scales (CTS) were administered in combination with the emotional neglect scale from the Childhood Trauma Questionnaire (CTQ-SF) to measure experienced childhood abuse and neglect by mother and/or father.
  • Cyberball task: a commonly used paradigm to study the neural correlates of social exclusion. For his study an adapted version of the task was used where participants played two rounds of this with virtual ball-tossing game with two other players.
  • Mood and need satisfaction: right before the cyberball game and right after each round of the game, participants completed four items from a mood questionnaire which measured feeling sad, happy, angry, and insecure. After each round additional items from the Need Threat Scale were completed to measure levels of need satisfaction, which measured belonging, control, self-esteem, and meaningful existence.
  • Covariates: questionnaires were used to assess demographic information (age, gender, handedness, and household social economic status (SES)).

Results & conclusion

It was found that exclusion by strangers was especially associated with increased activity in the left insula while exclusion by a family member was mainly associated with higher activation in the ACC. Furthermore, altered neural activity to social exclusion by strangers in the insula, ACC, and dmPFC was associated with experienced maltreatment but not with parents’ own maltreating behaviour, indicating different neural correlates of experienced and perpetrated maltreatment. More specifically, hypersensitivity to social rejection in maltreated individuals was mainly driven by experienced neglect. Furthermore, exploratory analyses showed that abusive parents exhibited lower activation in the pre- and post-central gyrus during exclusion by strangers, possibly reflecting lower levels of perspective taking and empathic abilities. This study underscores the importance to distinguish between effects of abuse and neglect and suggests that the impact of experiencing rejection and maltreatment by your own parents goes beyond the family context.

What are the Strengths & limitations of this study?

This is the first multigenerational family study where differential neural effects of (experienced and perpetrated) abuse and neglect are examined, and the role of neural reactivity to social exclusion by strangers versus family is investigated. Research about the neural correlates of childhood maltreatment and maltreating parenting behaviour in particular is scarce, and our family study design enabled the investigation of intergenerational transmission of maltreatment directly. Another strength is that parent (both fathers and mothers) and child reports of maltreatment were combined to minimize the influence of individual reporter bias. Moreover, this study allowed to differentiate between a general sensitivity for exclusion versus rejection sensitivity in the family context.

A limitation is the use of retrospective reports to measure maltreatment, which can be subject to recall bias. However, parent and child reports in maltreatment scores were combined. Moreover, in this paradigm names of family members were used. For future research, pictures of own offspring and parents might be used, although this would decrease standardization of the task. Further, the sample to examine the effects of perpetrated maltreatment was smaller than the sample to assess effects of experienced maltreatment since only part of the sample were parents.

Article summary of Genetic sensitivity to the environment: the case of the serotonin transporter gene and its implications for studying complex diseases and traits by Caspi et al. - Chapter

Article summary of Genetic sensitivity to the environment: the case of the serotonin transporter gene and its implications for studying complex diseases and traits by Caspi et al. - Chapter

The concept of serotonin transport genes and the consequences for research into complex illnesses and traits

Despite the same exposure to equal risk factors in environments, the effects of stressors varies greatly between individuals. This finding can be explained by individual differences in genetic vulnerability. In this article, the variation in serotonin (also called 5-HT) systems is examined and the contribution of these systems to stress sensitivity is evaluated. Specific attention is paid to the serotonin receptor (also known as the 5HTT receptor). This receptor ensures the reuptake of serotonin that is released into the synaptic cleft.


Studies show that the reuptake of serotonin by the 5HTT receptor is an important predictor for the amount of depressive symptoms that someone experiences. SSRIs (selective serotonin reuptake inhibitor), antidepressants, work by reducing the effect of the 5-HTT receptor. When the effect of this receptor is inhibited, this leads to more serotonin in the synaptic cleft, which leads to a reduction in depressive symptoms. 

In the promoter region of the 5-HTT gene there is a polymorphism which is also called 5-HTTLPR (serotonin transporter promoter polymorphism). A polymorphism is a variation in the same gene. This means that individuals differ in which variation of the gene they possess. This polymorphism concerns the length of the 5-HTT gene. Studies have shown that the short variant of the 5-HTTLPR gene leads to that individuals more susceptible to anxiety and depression in response to stress compared to people who possess the longer gene. This creates a relationship between the short variant of the 5-HTTLPR gene and the development of neuroticism. An increased anxiety response to stress is due to increased amygdala reactivity. Increased amygdala activity occurs in people with this short gene. The amygdala regulates physiological and behavioral responses so that an individual can effectively respond to the environment during social challenges. The extent to which the amygdala is sensitive to environmental threats predicts individual differences in sensitivity to environmental stressors.

Evidence for the 5-HT stress sensitivity hypothesis

Studies show that variation in length of the 5-HTTLPR gene alters the stress response of an organism. The authors of this article made use of observational research to study depressive outcomes.

Observational research in humans

Most observational research with humans into the variation in length of the 5-HTTLPR gene and the interaction of this gene with the environment focused on depression. These studies showed that people with a short variant of this gene who had experienced child abuse or other stressors were more anxious and had more negative thoughts compared to people who possess the long variant of the gene. Children with a short variant of the 5-HTTLPR gene who had a non-supporting mother had lower self-regulation skills. Lower self-regulation skills predict having a psychiatric disorder in adulthood. The underlying mechanism for this is that 5-HT is a genetic basis for personality traits such as negative affect and neuroticism. Negative affect in turn is a predictor for the development of psychopathology in adulthood.

Human primate studies

Rhesus monkeys have a similar variant of the 5-HTTLPR compared to humans, which means that results from studies on gene-environment interactions with these animals are generalizable to humans. Studies looked at the short version of the 5-HTTLPR and its influences on the experience of stress in early life. The monkeys were separated from their mother at a young age and showed increased fear responses and also increased responses from the HPA axis. These responses persist throughout life in the form of higher ACTH responses to stressors released upon activation of the HPA axis. These consequences are associated with depression in humans.

Recommendations for research into gene-environment interaction

Research into gene-environment interaction is a useful tool for discovering genes

It is suspected that genes can reduce the effects of the environment on an organism. Genes that may play a role in this are genes that are involved in physiological responses to psychological stress (regulated by the HPA axis). A gene that has potential involvement in a trait or a disease is called a candidate gene. One can discover new genetic traits through studies into risk factors in the environment. By looking at effects of genotype on gene expression, polymorphisms in positively responsive genes on the environment can be studied to explain why some people develop an illness and others don't.

Public understanding of gene science

An important contribution from research into gene-environment interaction is the elucidation of erroneous genetic assumptions. In the twentieth century, as a result of findings about heredity, it was implied that non-genetic factors did not play a role in mental health and behavior. It was also thought that one's future behavior could be predicted by looking at one's genes. The latest findings about the interaction between genes and the environment provide more realistic public beliefs about the causes of behavior in which some genetic effects depend on the choices that people make during their lives.

Article summary of Self-reported impulsivity in women with borderline personality disorder: the role of childhood maltreatment severity and emotion regulation difficulties by Krause-Utz et al. - Chapter

Article summary of Self-reported impulsivity in women with borderline personality disorder: the role of childhood maltreatment severity and emotion regulation difficulties by Krause-Utz et al. - Chapter


Borderline personality disorder (BDP) is a serious mental disorder. This disorder is characterized by a pattern of instability in affect, cognition (self-image), interpersonal relationships and impulsive behavior. Also, impulsivity and emotion dysregulation are main features of borderline personality disorder. Impulsivity in this disorder has many negative outcomes and is linked to risky behavior, suicidal behavior and to difficulties in establishing and maintaining stable relationships. Impulsivity in borderline personality disorder has to do with things such as substance abuse, spending sprees, gambling, reckless driving, risky sexual behavior, sudden relationship break-ups (which also includes dropping out of treatment) and non-suicidal self-injury or self-harm. 

The impulsive behaviors described often occur during emotional stress. So, impulsivity in borderline personality disorder is regarded as a consequence of malfunctioning emotion regulation mechanisms or as a "facet of emotional dysregulation".

Severe childhood maltreatment such as emotional, physical and sexual abuse and neglect serves as a risk factor for the development of borderline personality disorder. In contemporary views, as a result of an interplay between genetic, neurobiological dispositions (increased affective sensitivity and reactivity) and stressful or traumatic life experiences, individuals with the disorder are hindered in the acquisition of functional and adaptive emotional coping mechanisms. This results in a pervasive form of emotion dysregulation, which is believed to be the core of the disorder. 

Linehan's biosocial theory focuses on the role of an invalidating environment (which is an abusive, neglectful or unstable environment) in the development of emotion dysregulation and impulsivity. According to this theory, difficulties in emotion regulation are the consequence of childhood adversities. This emotion dysregulation leads to the use of impulsive coping strategies. So, impulsivity is regarded as a response to stress. There is a lot of evidence that shows that is in line with this.

However, a remaining research question is whether the effect of childhood maltreatment on impulsivity is mediated by emotion dysregulation. Since it is known that emotion dysregulation and impulsivity are also core features of other disorders, such as ADHD and substance use disorder, the question is whether the mediation is specific to borderline personality disorder.

Severe childhood maltreatment can have a big impact on the development of self-control capacities. This includes the regulation of impulses and emotions. As children grow older, emotion regulation becomes more and more important in psychosocial development. To develop a healthy emotion regulation ability, early caregivers' interactions are very important. Children who are exposed to early negative life events, show an increased risk for developing mood and anxiety disorders. This is probably due to changes in neurobiological systems which are involved in the regulation of stress and emotions. An example of such a change is an increased stress responsiveness. Such changes can have very negative consequences across many life domains, because the ability to inhibit strong emotions is crucial to maintain goal-directed behavior and self-control. 

As mentioned earlier, emotion dysregulation and impulsivity are also core features of other mental disorders, which often co-occur with borderline personality disorder. Examples are ADHD and substance use disorder. These disorders are also associated with higher rates of childhood trauma. This means that individuals with ADHD or substance use disorder, have experienced childhood trauma more compared to people without these disorders. Emotion dysregulation serves as a mediator for the relationship between childhood trauma severity and substance abuse related impulsivity. So, childhood trauma leads to impulsivity, because (this is what a mediator tells) it leads to emotion dysregulation. Also, non-acceptance of emotions and being unable to label emotions is related to impulse control problems among problem drinkers and to higher substance use rates. However, even though there is a high comorbidity (they occur together) between borderline personality disorder and these disorders, the studies have not controlled for the presence of borderline personality disorder, which may have lead to confound results.

So, childhood maltreatment is linked to difficulties in emotion regulation and impulsivity. This puts individuals at a higher risk for developing different psychopathologies (disorders). However, it is not clear whether the effect of childhood maltreatment severity is mediated by emotion dysregulation and if this is specific for borderline personality disorder as compared to other clinical samples (such as ADHD). Answering this question might help to understand impulsivity in borderline personality disorder. This current study used self-reports to examine the role of emotion dysregulation in the relationship between childhood maltreatment and impulsivity in women with borderline personality disorder compared to healthy controls and clinical controls without borderline personality disorder. 


Impulsivity is a complex construct. In this study, the authors used the UPPS Impulsive Behaviour model by Whiteside and Lynam. This model conceptualizes impulsive behavior in four ways: a lack of premeditation (which involves difficulties considering the consequences of an action and making accurate plans or precautions); increased sensation seeking (the tendency to pursue exciting activities, openness to try new potentially dangerous experiences); a lack of perseverance (maintaining task-related attention and goal-directed behaviour in demanding situations) and urgency (the tendency to act without forethought during emotional stress).

This study studied whether: higher childhood maltreatment severity predicts higher impulsivity; whether difficulties in emotion regulation statistically mediate the relationship between childhood maltreatment and impulsivity and whether this mediating relationship is particularly strong in patients with borderline personality disorder, as compared to clinical controls. The authors hypothesized that across all participants, childhood maltreatment positively predicts emotion regulation difficulties and impulsivity. They also expected that this mediating relationship would be stronger in borderline personality disorder patients compared to other groups.


Mental disorders

The Structured Clinical Interview for DSM-IV I disorders (SCID-1) was used to determine DSM-IV major mental disorders. This is a semi-structured clinical interview.

Substance abuse 

Substance abuse was measured by looking at symptoms within 12 months, such as tolerance effects; withdrawal symptoms; taking up more drugs than attempted; failure to reduce or stop taking drugs; spending more than two hours on obtaining, using or recovering from drugs; social, financial, legal, health and/or mental problems.

Borderline personality disorder assessment

To assess borderline personality disorder, the International Personality Disorder Examination (IPDE) is a semi-structured clinical interview based on the International Classification of Diseases (ICD 10) and the DSM-III-R classification systems.

Primary measures

Childhood Trauma

To assess childhood maltreatment severity, the authors used the Childhood Maltreatment Questionnaire (CTQ). This is a self-report scale with five subscales which measure emotional, sexual, and physical abuse and emotional and physical neglect.


To measure impulsivity, the authors made use of the UPPS scale. This measures different facets of impulsivity, which are based on the Five Factor Model of Personality. This scale contains 45 items which are related to four subscales: Urgency ("I have trouble resisting my cravings)", (Lack of) premeditation ("I don't like to start a project until I know exactly how to proceed), (Lack of) perseverance ("I generally like to see things through to the end); and Sensation Seeking ("I generally seek new and exciting experiences and sensations").

Emotion regulation

To assess difficulties in emotion regulation, the authors made use of the Difficulties In Emotion Regulation Scale (DERS). It contains 35 items. The DERS assesses emotion regulation as: being aware of current emotional experiences ("When I am upset, I believe that my feelings are valid and important"); understanding these experiences ("I can make sense of my emotions"); being able to accept and reflect on these emotions and ("When I am upset, I feel guilty for feeling that way"); having a clear idea about how to effectively regulate and mature regulation strategies ("When I am upset, I have difficulty getting work done).


This study looked at the effect of childhood maltreatment severity on impulsivity and at whether difficulties in emotion regulation served as a mediator for this relationship in borderline personality disorder compared to healthy controls and clinical controls. The results showed that higher childhood maltreatment and in particular emotional maltreatment, does predict more difficulties in emotion regulation and impulsivity across all groups. There was also a significant interaction effect of childhood maltreatment and group in the prediction of impulsivity. This means: the effect of childhood maltreatment severity on impulsivity was stronger for individuals with borderline personality disorder compared to individuals with ADHD. The authors also found a significant mediation effect which depended on the group. For example, in the group with borderline personality disorder, when controlled for difficulties in emotion regulation, the effect of childhood maltreatment on impulsivity was not significant anymore. 

The findings with regards to a positive relationship between childhood maltreatment severity, difficulties in emotion regulation and impulsivity are in line with the hypothesis of the authors. So, childhood maltreatment can have big negative consequences on the development of healthy emotion regulation strategies and self-control. To elaborate, it can lead to: an inability to tolerate intense negative emotions, an inability in considering the results of one's actions and an inability to focus on goal-directed behaviour when being in a negative emotional state. 

Emotional maltreatment was the only significant predictor for regulation difficulties as well as for impulsivity. This form of maltreatment therefore has a big impact. Examples of this kind of maltreatment include humiliating or demeaning behavior toward the child, psychological inability of caretakers and a failure to meet children's basic emotional and psychological needs. These kinds of behaviours often arise as a result of the parent's own unresolved childhood adversities. 

Emotional maltreatment is also linked to changes in emotional processing, including increased affect intensity and decreased distress tolerance. It is also the strongest predictor of emotion regulation difficulties later in life. When controlling for other types of abuse, emotional maltreatment was the strongest predictor for malfunctioning emotion regulation strategies and borderline personality disorder symptom severity. 

Borderline personality disorder patients reported the highest rate of traumatic exposure (particularly sexual traumas including childhood sexual abuse and being physically attacked), compared to other three groups of personality disorders (schizotypal, avoidant and obsessive-compulsive). The effect of childhood maltreatment was also more pronounced in borderline personality disorder compared to control groups. Having experienced trauma is not necessary for the etiology of borderline personality disorder, but trauma does aggravate symptoms of the disorder. This is in line with Linehan's biosocial theory. 

Limitations of this study

The authors of this article made use of a patient group and excluded comorbid patients. This is a strength of the study, but also a downfall, because it leads to a lower sample size. This sample size may lead to a lower power to detect effects. 

The authors also only included women. So, future research should include male participants. 

The self-reports that the authors used may be susceptible to bias, such as social desirability, limited awareness and insight, different subjective interpretations of measured concepts, and 'coloring' of reports by current mood. Also, childhood maltreatment was assessed in a retrospective and subjective manner, which may also involve recall biases. This is important, because individuals with borderline personality disorder may experience traumatic experiences more vividly and they show a tendency to report more negative childhood adversities.  

Previous findings also showed that self-reports and behavioral and psychophysiological measures of emotion regulation and impulsivity in borderline personality, are not correlated. Therefore, future research should make use of experimental tasks of emotion regulation, impulsivity and emotional distress.

Article summary of Childhood Maltreatment, Borderline Personality Features, and Coping as Predictors of Intimate Partner Violence by Krause-Utz et al. - Chapter

Article summary of Childhood Maltreatment, Borderline Personality Features, and Coping as Predictors of Intimate Partner Violence by Krause-Utz et al. - Chapter


Violent or coercive acts committed by one partner against the other, either in an existing or past relationship, is called intimate partner violence (IPV). Intimate partner violence is globally regarded as a serious physical and mental health concern. In the United States, around 15 to 35% of women and 20 to 25% of men, have experienced one or more forms of psychological, physical and sexual intimate partner violence. The consequences of intimate partner violence can persist over a lifetime. Sometimes this kind of violence is even deadly. For example, intimate partner violence is the main way in which people get murdered. It is also a risk factor for suicidal attempts and it can lead to other outcomes such as an increased risk for depression, anxiety disorders, posttraumatic stress disorder (PTSD), substance abuse and personality disorders. These conditions are not only an outcome, they can also serve as a risk factor for intimate partner violence.

Because of the negative consequences, high prevalence and complexity of intimate partner violence, it is important to determine risk factors and contributing factors. 

Previous studies have shown that childhood maltreatment, such as abuse and neglect, increase the risk for perpetrating and/or being a victim of violence in close and intimate relationships in adulthood. However, the studies that have looked at this intergenerational transmission, have only reported low to moderate effect sizes. This means that growing up in an abusive environment is not the whole story. Therefore, identifying risk factors for experiencing intimate partner violence, can help in the prevention and treatment of it. The authors of this article suggest that features of borderline personality disorder (BPD) and maladaptive coping may be important in this relationship.

The features of borderline personality disorder such as affective instability, disturbed sense of self, unstable identity, interpersonal disturbances and self-harming impulsivity, are often seen as the consequence of maltreatment during childhood. These features are also positively related to intimate partner violence. 

Even though the symptoms of borderline personality disorder often decrease over time, interpersonal problems and difficulties in establishing meaningful relationships, persist. Often interpersonal stressors such as real or perceived social rejection and abandonment are triggers of emotional distress in people with borderline personality disorder. For instance, increased emotional distress due to rejection sensitivity, separation concerns, fear of abandonment and intolerance of being alone, may lead to impulsive aggression in individuals with borderline personality disorder.

The current study

However, it is not clear if a combination of borderline personality features and childhood trauma lead to intimate partner violence. Multiple studies have reported a link between borderline personality disorder and intimate partner violence, but in most of these studies, the focus was on intimate partner violence perpetration. So, it was only looked at whether having borderline personality features and having experienced childhood trauma leads to higher perpetration of violence. However, there are two forms of intimate partner violence: perpetration and victimization. The authors of this article suggest that these forms may co-occur, but that the underlying mechanisms may not be the same. For instance, maladaptive coping during stress may be one of the underlying mechanisms, especially in individuals with borderline personality disorder. These individuals often lack effective coping strategies and problem-solving skills.

It is also not clear whether gender plays a significant role in this relationship. For instance, men are thought to perpetrate forms of intimate partner violence which may lead to physical injury, more often than women. In borderline personality disorder, intense anger and impulsive aggression are more prominent in men. Another study found that borderline personality features are related to both intimate partner violence perpetration and victimization in men. However, in women, borderline personality features are only related to victimization. 

So, previous research has revealed that there are relations between all of these factors. However, there has not been differentiated between perpetration and victimization in both genders. Therefore, the authors look at this. 

The current study looked at; whether borderline personality features mediate the relationship between childhood maltreatment and ipv perpetration and victimization; whether coping mediated this indirect effect and whether gender has a significant effect in this model. The authors also looked at whether anxious attachment affected the results, because previous studies suggested that attachment may be a confounder. The authors also looked at the direct effects of childhood maltreatment on intimate partner violence and at the indirect effects through borderline personality disorder and coping in female as well as male participants. They controlled for age and attachment style. The hypothesis was that childhood maltreatment would positively predict intimate partner violence and that borderline personality features would mediate this relationship. They also expected that the mediating effects of borderline personality disorder would be mediated by coping.

Materials and Methods

This study was conducted in the Netherlands, at the Leiden University. The participants were recruited through online platforms for victims of childhood maltreatment. 

The severity of childhood maltreatment was assessed using the Childhood Trauma Questionnaire. This is a self-report which assesses emotional, sexual and physical abuse and also emotional and physical neglect. Each of these scales consists of five items.

The borderline personality features were assessed using the Personality Assessment Inventory-Borderline Features Scale. This is a self-report which was derived from the Personality Assessment Inventory. It contains 24 items and contains four subscales: affective instability, identity diffusion, self-harm and negative relationships. Affective instability involves intense and unstable emotions. An example of an item measuring this subscale, is: "My mood gets quite intense and it can change shift suddenly". Identity diffusion refers to having an unstable self-image and sense of self. An example of an item measuring identity diffusion is: "My attitude about myself changes a lot". Self-harm refers to potentially self-damaging impulsivity. An example of an item which measures this, is: "I am too impulsive for my own good and I sometimes do things so impulsively that I get into trouble. When I am upset, I typically do things to hurt myself". Negative relationships refer to experiencing interpersonal disturbances, such as experiencing extreme fear of abandonment. An example of an item which measures this, is: "I worry a lot about other people leaving me. I can not handle separation from those close to me very well".

Intimate partner violence was assessed by means of the Conflict Tactics Scale-Revised. This is a questionnaire which contains 78 items. It contains pairs of questions, which refer to the self (perpetration) as well as to the partner (victimization). There are five subscales: Negotiation, Psychological Aggression, Physical Assault, Sexual Coercion and Injury. 

Coping was assessed using the Cognitive Emotion Regulation Strategies Inventory. It contains 18 items and measures cognitive emotion regulation strategies after one has experienced a negative life event.

Lastly, participants completed the Revised Adult Attachment Scale. This measures three dimensions: close, dependent and anxious. This scale measures the attachment styles of the participants.


This study wanted to investigate the effect of childhood maltreatment severity on intimate partner violence perpetration and victimization. It also looked at the indirect effects, through borderline personality features and maladaptive coping. The study found a significant indirect effect through borderline personality features. So, having borderline personality features served as a mediator for childhood maltreatment and intimate partner violence. There were no indirect effects through coping. Gender also did not seem to have any significant effect.

Having experienced childhood maltreatment, especially emotional and physical maltreatment, may serve as a risk factor for perpetrating and re-experiencing violence in adult relationships. The authors also found strong significant relationships between all forms of childhood maltreatment and borderline personality features. In the current study, borderline personality features played a significant role in the relationship between the severity of childhood maltreatment and borderline personality features. To elaborate, the presence of borderline personality features seems to be an important risk factor for intimate partner violence.

Borderline personality features are related to higher rates of violence perpetration in marriages and more teen dating violence. The authors' findings suggest that individuals with borderline personality features may be at a higher risk for perpetrating and experiencing intimate partner violence. Borderline personality features may also be an important psychological factor which underlies the relationship between growing up in an abusive environment and experiencing intimate violence in adult intimate relationships. 

The specific borderline personality features were affective instability and interpersonal disturbances alone and in interaction with identity disturbance and self-harming, are risk factors for intimate partner violence perpetration. For victimization, interpersonal disturbances together with unstable self-image, were a significant factor for victimization. So, these results suggest that there are different psychological mechanisms. For example, adults who have experienced childhood maltreatment, may have come to learn that violence is normal for close relationships. Therefore, they may respond with helplessness when they are confronted with violence in intimate adult relationships. 

The authors controlled for anxious attachment and found the same results. This means that anxious attachment does not account for the observed findings.

In contrast with the hypothesis, coping was not identified as a significant psychological factor in the relationship between childhood maltreatment, borderline personality disorder and intimate partner violence. There was also no significant predictive effect for perpetration. This is in contrast with previous research, which has reported that coping with stress plays an important role in violence. In other words, previous research showed that individuals with a history of childhood abuse may have learned that violence is an acceptable strategy for coping with conflicts in close relationships. 

Also, previous research showed that aggressive and impulsive behavior in individuals with borderline personality features, are primarily present under emotional distress and may have to do with a lack of adaptive coping strategies. The authors explain that these inconsistencies may have to do with that in the present study, coping was measured using the CERQ. This focuses on cognitive coping strategies and might not look at difficulties in emotion regulation. Cognitive coping and emotion regulation are related, but it might be the case that other behaviors, such as problematic alcohol use, may be mediators of the relationship between borderline personality features and intimate partner violence. The authors suggest that impulsivity may play an important role.

Gender did not have a significant effect on intimate partner violence perpetration or victimization. However, previous research suggested that women and men are both equally likely to perpetrate and to be a victim of intimate partner violence. For example, some studies reported higher rates of intimate partner violence perpetration in women than in men. Females were also thought to experience a wider range of poor mental health outcomes. In line with these results, the authors of this article found that women report higher rates of psychological aggression and physical assault toward their partners. Male participants reported more sexual coercion. Reciprocal violence is the most prevalent form of intimate partner violence. In previous research, men with borderline personality disorder, showed more impulsive aggression, while women with borderline personality disorder, were more often victims of intimate partner violence. However, in the present study, gender did not play a significant role in this relationship.

There are a few limitations of the current study. First, because this study was a cross-sectional correlational design, no causal conclusions can be drawn. So, it is not clear if borderline personality features predate or follow intimate partner violence. Second, childhood maltreatment and other variables were assessed retrospectively and subjectively, so it could be that the participants' responses were biased. Also, individuals with higher levels of borderline personality features may be more likely to remember and report more severe childhood abuse, suffer more from traumatic experience and have more vivid negative memories. Also, half of the sample did not complete the survey, which might have led to selection bias.

Article summary of Using Principles of Behavioral Epigenetics to Advance Research on Early-Life Stress by Conradt - Chapter

Article summary of Using Principles of Behavioral Epigenetics to Advance Research on Early-Life Stress by Conradt - Chapter

What is this article about?

It is known that in the United States, at least 16 million children under the age of 6 experience stress early in their lives. This stress ranges from abuse to neighbourhood violence. Especially children living in poverty experience a lot of stress. This stress starts in utero, when their mothers experience a lot of stress. They often have lower birth weight, and they experience more neighbourhood and family violence. Also, they are less likely to be cared for by a nurturing adult, and their caregivers often have psychopathological disorders.

Being exposed to such adversities in childhood predicts one third of adult-onset psychiatric disorders, such as depression and posttraumatic stress disorder (PTSD). However, knowing this does not tell us anything about how this happens. Also, why do some children that experience the same stressors seem unaffected by it?

Early childhood is a sensitive period for the effects of stress on development. So, stress experienced in early lifehood can have a big impact on later development. However, the effect of this stress differs between children. Some children are affected to a great extent, while others do not seem to have any problems. The answer as to how this is possible may stem from epigenetics.

Epigenetics has not been used often in research in developmental science. However, it may yield interesting insights. For example, epigenetic processes may be one way in which early life stress leads to biological changes, which alters how children respond physiologically and behaviorally to stress. Also, epigenetics may also help to identify which children are vulnerable to early life stress.

What is epigenetics?

The DNA of an organism does normally not change without an unusual environmental event (such as radiation). Twins have the same DNA, but why do they look and often behave differently? This may be due to epigenetics. Epigenetics are modifications to DNA, that do not alter the sequence of DNA itself. Thus, the DNA is the same, but there are small differences. Epigenetic processes can be the result of histone modifications, genomic imprinting, and DNA methylation. DNA methylation is the best well-studied form of epigenetics. To explain, DNA exists of four nucleotides: cytosine, guanine, adenine, and thymine. The expression of genes occur in a region of the gene called the ‘promotor’,  in which there are many cytosine and guanine nucleotides. They are often clustered in the promotor region, and these clusters are called CpG islands. When a methyl molecule is added to a cytosine molecule, DNA methylation occurs. This blocks transcription, and thus activity of the gene is turned off.

DNA methylation does not directly lead to changes in behavior. Often, it has no result at all. It only results in behavioral changes when the methylation occurs close to a transcription factor binding site. This transcription factor induces gene expression.

For developmental researchers, this is important information, because this suggests that there should be specific CpG sites selected which are close to transcription factors.

Van Ijzendoorn and colleagues defined child development as “experiences being sculpted in the organism’s DNA through methylation.” Thus, when children grow up in stressful conditions, because of DNA methylation, they may suffer from psychological and physical diseases.

How can epigenetics explain how early-life stress becomes biologically embedded?

Researchers state that when an association is found between a stressor and a physiological marker, this indicates that an experience has been biologically embedded.

For example, one study with rodents showed that maternal licking, grooming, and arched-back nursing led to lower levels of DNA methylation in Exon 17 of the promotor region of glucocorticoid receptor gene NR3C1. In turn, this leads to greater expression of glucocorticoid receptors, and more efficiency of the hypothalamic-pituitary-adrenal (HPA) axis. This HPA axis regulates the amount of cortisol in our bloodstream, the stress hormone. Compared to rodents who did not receive this maternal care, the group who did get the maternal care appeared less stressed and anxious, explored more, and showed lower levels of cortisol. Researchers tried to translate these findings to humans, but this showed to be difficult, because it’s easier to examine the brains of rats. In humans, one can mostly use peripheral tissues.

However, Oberlander succeeded in showing a similar finding in humans. He found that three-months-old of mothers who had depression showed greater cord blood methylation of Exon 1F in the promotor region NR3C1. Also they showed greater cortisol reactivity. Another study showed that DNA methylation in other sites of Exon 1F also leads to more cortisol reactivity in response to a social stressor for infants of 5 months old. In turn, this leads to less optimal self-regulation in behavior.

When children experience abuse early in life, this also leads to DNA methylation. For example, in 11 to 14 year olds, greater methylation was found as a result of physical abuse.

Gunnar and Loman stated that maternal sensitivity is the analogue of the licking and grooming in rats. This can help to regulate and buffer children’s responses to stress. The authors of this article tested this hypothesis. They examined whether maternal sensitivity, maternal depression, or both are related to DNA methylation of Exon 1F of the NR3C1 promotor. They found that maternal sensitivity and maternal depression predict DNA methylation. Also, infants of mothers who were depressive and less sensitive showed greater methylation. This is different compared to mothers who had depression, but who were sensitive to their infants.

How can epigenetic processes be used to identify who is most susceptible to the effects of early-life stress?

There have been four studies conducted that have looked into epigenetic processes as moderators of early-life stress on behavioral outcomes. The results showed that prenatal depression was related to less self-regulation, more lethargy, and more hypotonia (low tone), but only if the infants had high levels of methylation of a specific CpG site of NR3C1. Another study showed that a variant of the serotonin transporter gene predicted more unresolved loss or trauma in adulthood, but only for those individuals who had lower levels of DNA methylation in their serotonin transporter. Thus, it could be the case that prenatal exposure to maternal depression has an impact on their infant’s behavior, through epigenetic processes.

What are some challenges in the field of epigenetics and what are potential solutions?

The field of epigenetics is not an old field. Thus, there are several challenges, namely:

  • There is an overreliance on candidate genes. Most often, the NR3C1 gene is examined. However, more genes should be examined.
  • There is a need for studies of normative developmental trajectories. There is not much known about how DNA methylation develops normatively. Researchers should try to identify this.
  • Tissue type. All the studies that have been published in epigenetics have used peripheral tissue. However, this is problematic, because it may not be the same as neural tissue.
  • Independent replication. Independent replication is important, because some epigenetic studies have reported false positives (Type I errors), and some have reported false negatives (Type II errors).
  • Measuring phenotype. There is a need for finding associated epigenetic processes with a phenotype of interest (such as temperament, stress reactivity). If this is not found, it is difficult to measure the associations between epigenetic processes and these traits.
  • Assumptions of causality. Causality can not be determined without intervention research. Therefore, there should be intervention work conducted.

What are the conclusions?

Exposure to early life stress leads to a lot of negative consequences, ranging from diabetes to depression. Therefore, it is important to know how to decrease these consequences. One such way can come from epigenetics.

Article summary of Non-suicidal Self-Injury in Adolescence by Brown & Plener - Chapter

Article summary of Non-suicidal Self-Injury in Adolescence by Brown & Plener - Chapter

What is NSSI?

Non-suicidal self-injury (NSSI) refers to intentional self-injury to the body without a suicidal intend. It is not socially sanctioned, and does not include accidental and indirect self-injurious behaviors such as disturbed eating or drug abuse, or tattooing, piercing, or religious rituals. The most common forms of NSSI are cutting, scratching, hitting, banging, carving, and scraping. It is most prevalent in mid-adolescence, and thus it is an important point of concern for people who work with adolescents.


In 2002, the prevalence of self-mutilation was around 14%. Other studies have found a prevalence of 17-18% for at least one form of NSSI. The rates of adolescents who meet the criteria for DSM-5 are around 1.5 to 6.7%.

NSSI can occur within psychiatric disorders, but also in individuals without a psychiatric disorder. Around 15-16 years NSSI peaks, and declines in late adolescence. Even though in late adolescence there is a decline, adolescents who engage in this behavior are at higher risk to develop dysfunctional emotion regulation strategies, even after they quit the behavior.

One study has shown that adolescents with NSSI behavior more often engage in substance abuse. It is also a risk factor for suicide attempts and suicides.

Etiology and Risk Factors

There are certain risk factors for the development of NSSI.

Demographic Factors

Adolescence is a vulnerable phase for developing NSSI. This is a result of increased impulsivity and emotional reactivity, which result from brain developmental processes. Females are also at higher risk for developing NSSI. They are also more likely to cut themselves compared to males, and males are more likely to hit against a wall. Higher IQ is also associated with a higher risk of engaging in NSSI.

Social Factors

Dysfunctional relationships and bullying are risk factors for developing NSSI. Being bullied poses a greater risk compared to being maltreated. The initial engagement in NSSI may be the result of social contagion (friends do it, so you do it, or the media shows it, and you try it). However, maintaining NSSI is not predicted by thus. Having a non-heterosexual orientation also increases the risk on NSSI.

Media Influence

There are a lot of internet searches on NSSI. There are also YouTube videos with a lot of views about it. However, it is not clear whether this is beneficial or harmful.

Adverse Childhood Events

Experiencing adverse childhood events like neglect, abuse or deprivation also increase the risk for engaging in NSSI. However, there are differentiated findings. For example, in one study only emotional abuse was a significant predictor. In another study, only indirect childhood maltreatment (witnessing domestic violence) was related to NSSI. Parental critique or parental apathy has repeatedly been shown to be a risk factor.

Neurobiological Factors

Studies have shown that there is an altered pattern of HPA axis regulation in NSSI. Individuals with NSSI also show higher cortisol awakening responses. There were also differences found in the activity of the medial prefrontal cortex (mPFC) and the ventrolateral prefrontal cortex (vlPFC) during social exclusion.

Thus, adolescent’s age, gender, social or medial contact with NSSI, bullying, and averse childhood experiences are risk factors for the development of NSSI.

What are the functions of NSSI?

The four-factor model describes what functions NSSI can have. There are intrapersonal and interpersonal processes. One function can be to diminish negative feelings or thoughts (anger, tension). This is called automatic negative reinforcement. Automatic positive reinforcement refers to experiencing positive feelings or thoughts after engaging in NSSI. Social positive reinforcement refers to getting attention from others, and negative social reinforcement refers to escaping unpleasant social interactions.

Automatic negative reinforcement has been found to be the most common function of NSSI. Experiencing physical pain leads to a decrease In negative effect.

What are therapies for NSSI in adolescence?

Surgical Treatments

Sometimes when wounds are deep, surgical treatment is necessary. Then, a good cooperation between all parties involved is necessary. Also, professionals should not show any negative emotions toward NSSI or the patient.


Dialectical behavioral therapy for adolescents (DBT-A) and mentalization-based treatment for adolescents (MBT-A) have shown to be effective therapies for NSSI in adolescence.

Treatment with Psychatric Medication

There is not a lot of research conducted on using psychiatric medication for the treatment of NSSI in adolescents.

NSSI as Independent Diagnosis

Currently, NSSI is only a symptom of borderline personality disorder (BPD). However, it has been suggested to be an independent disorder. There needs to be more research conducted before this can be established. If this would happen, this could lead to better communication, research, prevention, and intervention.

What is the conclusion?

NSSI is an important problem in adolescence. Even when adolescents quit, they have greater risks on long-term mental health problems. Bullying and negative social interactions are important risk factors, and childhood sexual abuse and physical abuse are less predictive. There are neurobiological alterations in the HPA-axis and the endogenous opioid system, and in the processing of emotional stimuli. There need to be more studies to validate the effectiveness of treatments such as DBT-A and MBT-A. There is also much research needed on the etiology and treatment of NSSI in adolescence. There is also an ongoing debate about whether it should be an independent disorder in the DSM-5.

Article summary of Resilience to adult psychopathology following childhood maltreatment: Evidence from a community sample by Collishaw et al. - Chapter

Article summary of Resilience to adult psychopathology following childhood maltreatment: Evidence from a community sample by Collishaw et al. - Chapter


Child abuse is a serious and common risk affecting the long-term mental health of individuals. A growing body of evidence indicates that the mental health of a substantial minority of abused individuals appears relatively unaffected. Gaining a fuller understanding of the factors and processes involved in positive adaptation is important for many reasons:

  • Theoretically, models of resilience have the potential to enhance the understanding of the mechanisms by which abuse affects psychosocial development.
  • Clinically, some protective factors may be amenable to external manipulation and could present a potential focus for future treatments and interventions.

This study uses longitudinal data from a general population sample studied first in adolescence and again at mid-life to examine correlates and outcomes of child abuse, the extent of resilience for adult psychopathology, and the factors that best predict such resilience.

The implications for children’s psychological development and long-term mental health have been well documented. Consequences include cognitive delays and lowered IQ, neurobiological abnormalities, dysfunctional behaviours like conduct problems, aggression, and substance abuse, and an increased risk of adolescent and adult psychiatric disorders including depression, suicide, anxiety disorder, PTSD, and somatization disorders.

Current evidence also makes clear, however, that not all abused children go on to experience mental health problems later in life. Researchers have realized that understanding positive adaptation in the face of adversity is important, but there has been a debate on how to best define and study the concept of resilience. It’s agreed that a working definition should consider two points:

  1. The experience to which individuals have been exposed should present a sufficient “risk” to which individuals can be considered to have shown “resilience”.
  2. Markers of resilience should encompass a variety of domains and be evident across an extended time period.

This study defines resilience by identifying individuals who (1) had experienced repeated, ongoing or severe sexual and/or physical abuse, and (2) who reported no psychiatric disorders or suicidality over a 30-year adult follow-up period.

The first aim of this paper was to examine adolescent and adult psychopathology in individuals who reported being abused in childhood and to establish the extent of resilience in this group. The second aim was to identify factors that distinguished resilient and non-resilient individuals with experiences of abuse.


Data are drawn form a follow-up of the Isle of Wight study, an epidemiological sample assessed in adolescence and at midlife. Ratings of psychiatric disorder, peer relationships and family functioning were made in adolescence; adult assessment included a lifetime psychiatric history, personality, and social functioning assessments, and retrospective reports of childhood sexual and physical abuse.


  • Psychopathology: psychiatric disorder was assessed through interviews with parents and children through reports form teachers. Interviews assessed the frequency, severity, and duration of specific behaviours and symptoms over the past year.
  • Peer relationships: accounts by adolescents and parents were used to rate the adequacy of peer relationships over the past year on a 3-point scale (normal, moderate abnormality, marked abnormality).
  • Family functioning and demographics: interviews with parents provided information on parental separation and divorce, parental discord, family size, repeated long-term separations from parents, family social class, and housing tenure.
  • Childhood abuse: childhood abuse was defined using retrospective reports collected during the adult interviews with the intensively studied sample. The sexual and physical abuse modules were based on the Childhood Experience of Care and Abusive Interview (CECA).
  • Adult psychopathology: adult psychopathology was assessed using the Schedule for Affective Disorders and Schizophrenia-Lifetime version (SADS-L), revised as appropriate to cover DSM-IV diagnostic criteria.
  • Parental care: study members completed mother and father versions of the shortened seven-item Parental Bonding Instrument (PBI), to measure their perceptions of the parenting they experienced as children.
  • The Adult Personality Functioning Assessment (APFA): the APFA is an investigator-based interview designed to assess patterns of specific and general social dysfunction. It covers six domains of functioning: work, marriage/cohabitation, friendships, non-specific social contacts, day-to-day coping, and negotiations.
  • Relationship history: informants’ descriptions of their first long-term relationship were used to rate how supportive their first partner was (both emotionally and practically).
  • Personality: a 48-item Eysenck Personality Questionnaire (EPQ-R) was administered, focusing on the Neuroticism sub-scale.
  • Crime: study members completed a questionnaire about involvement in illegal activities since age 18.
  • Self-rated health: individuals rated their current health on a five-point scale (poor, fail, good, very good, excellent).
  • “Quality of relationships” index (adolescent/adult composite): a summary scale of positive relationships across the life span was derived by counting across the following indicators: either parent rated as very caring; adolescent peer relationships rated as normal; adult relationships rated as positive; first adult partner rated as supportive; stable relationship history.


10% of individuals reported repeated or sever physical or sexual abuse in childhood. Prospective measures revealed increased rates of adolescent psychiatric disorders in this group. Rates of adult psychopathology were also high. A substantial minority of abused individuals reported on mental health problems in adult life. Resilience of this kind was related to perceived parental care, adolescent peer relationships, the quality of adult love relationships, and personality style.

Discussion & conclusion

This study provided further evidence that child abuse is relatively common, and that it constitutes a serious risk for adult psychopathology. Risks for adult recurrent depression, suicidal behaviour, PTSD, and substance abuse were elevated several-fold among abused individuals, even controlling for prospective indicators of other types of adolescent family adversity. However, not all individuals with abusive experiences showed such difficulties. A large portion reported no psychiatric problems over the 30-year follow-up period. Further tests also showed positive adaptation in other domains such as health, inter-personal relationships of non-criminality in this non-disordered group, supporting the view that these individuals can be described as “resilient” in the face of abuse.

Findings also highlighted two domains of particular relevance for understanding the risk of psychopathology in the context of abuse:

  1. Variations in the characteristics and severity of abuse were strongly related to better or worse outcomes in adulthood.
  2. Prospective and retrospective assessment of individuals’ relationships with parents, friends, and partners were potent predictors of adult resilience.

This design did not allow to test for the direction of these effects. It’s possible that psychiatric problems will undermine individuals’ relationship competence, just as chronic problems in interpersonal relationships may elevate the risk of future mental illness. These findings suggest that understanding the processes whereby relationship competencies are developed and maintained constitutes an important goal for future research on resilience in individuals exposed to abusive experiences and may be a core target for clinical interventions.

Article summary of Neurobiological Markers of Resilience to Depression Following Childhood Maltreatment: The Role of Neural Circuits Supporting the Cognitive Control of Emotion by Rodman et al. - Chapter

Article summary of Neurobiological Markers of Resilience to Depression Following Childhood Maltreatment: The Role of Neural Circuits Supporting the Cognitive Control of Emotion by Rodman et al. - Chapter


Childhood adversity, which robustly predicts psychopathology, refers to negative experiences that deviate from the expectable environment, requiring meaningful adaptation by an average child. These experiences can reflect either threat, defined as relating to harmful experiences, or deprivation, the absence of expected environmental inputs, like caregiver support and cognitive stimulation. This paper focuses on adversity in the form of threat and maltreatment as it has strong ties to depression and anxiety.

Resilience involves processes that buffer children from risk for negative consequences. Identifying mechanisms of resilience may reveal targets for preventative interventions designed to protect children following adversity. This study advances a neurobiological model of resilience, focusing on neural circuits underlying the cognitive control of emotion. The authors posit that a child’s ability to recruit the frontoparietal control network to modulate amygdala reactivity to negative emotional cues buffers risk for internalizing symptoms following exposure to adversity.

Definitions and Concepts


Various definitions have been proposed by developmental and clinical psychologists. Some have conceived of resilience as a fixed trait or set of traits that are immutable and may be present within an individual whether or not they have experienced adversity. This paper utilizes the definition that resilience reflects an absence of negative outcomes despite exposure to adversity.

Cognitive reappraisal

Cognitive reappraisal involves thinking about a stimulus in a way that changes the meaning to modify one’s emotional response. It has been shown to modulate emotional responses in experimental settings, real-world settings, and clinical intervention studies, where training to enhance reappraisal is associated with reductions in symptoms of depression and anxiety in children and adults.

Cognitive reappraisal neural circuitry in depression and anxiety

Behaviourally, children and adults with depression and anxiety report similar reductions in negative emotion following reappraisal as those without psychopathology. But those with depression and anxiety appear to use less-efficient reappraisal strategies. Disruptions in neural activation in frontoparietal and limbic regions involved in cognitive reappraisal have also been associated with depression and anxiety. But findings vary across age and diagnosis.

Cognitive control circuitry as a mechanism of resilience following childhood adversity

The ability to effectively recruit frontoparietal circuitry in support of effortful emotion regulation strategies could be a critical compensatory mechanism that may help to buffer against the heightened emotional and neurobiological reactivity commonly observed following childhood adversity. Prior work consistently demonstrates that children exposed to diversity exhibit elevated emotional responses to negative stimuli assessed at multiple levels of analysis, including subjective report, autonomic nervous system response, and amygdala reactivity.

Methods & Materials

The hypotheses were examined in a longitudinal sample of 151 participants 8 to 17 years of age and without history of childhood maltreatment. They completed an emotion regulation task while undergoing functional magnetic resonance imaging, which assessed neural activation during passive viewing and effortful attempts to regulate emotional responses to negative stimuli using cognitive reappraisal. Participants reported on their tendency to engage in reappraisal in their daily lives. Symptoms of depression and anxiety were assessed at the time of assessment and in a follow-up assessment two years later. Gender, age, race/ethnicity, and socioeconomic status were controlled for.

Results & Discussion

Among maltreated youths, those who were better able to recruit prefrontal control regions and modulate amygdala reactivity during reappraisal exhibited lower risk for depression over time. By contrast, no association was observed between neural functioning during reappraisal and depression among youths without a history of maltreatment.

The ability to modulate negative emotion using cognitive control strategies may represent a resiliency marker, which protects against depression in children who have experienced adversity, for which this report found evidence of such a relationship. Specifically, greater capacity to modulate amygdala activation using cognitive reappraisal predicts decreasing levels of depressive symptoms across a 2-year follow-up period. Preliminary findings support the proposed model of resilience, which underscores a specific neurobiological marker involved in the cognitive control of emotional as a potential protective factor buffering children who have experienced adversity from negative outcomes later in life.

Examining a youth sample is advantageous, as insights about mechanisms of resilience can be leveraged to inform early interventions. Additionally, studies examining resilience to psychopathology in adults who experienced childhood adversity often reflect an accumulation of environmental stressors over the life course and suffer from recall biases that are mitigated somewhat when studying resilience in closer temporal proximity to the initial adversity.

Resilience involves many dynamic and interacting factors that modulate risk in the face of adversity, including cultural, familial, and genetic factors. The current study leverages advances in developmental cognitive neuroscience to examine brain function supporting specific cognitive processes as a mechanistic path to resilience. This analysis on a neuropsychological level is advantageous as it can be used to identify malleable targets for preventing the onset or progression of internalizing disorders.


Exposure to child adversity is a potent risk factor for depression and anxiety. The authors argue that the ability to recruit frontoparietal control networks to modulate amygdala reactivity to negative cues may be a protective factor that buffers children from developing internalizing problems following exposure to adversity. Findings are consistent with this possibility, demonstrating that children who are more able to modulate amygdala reactivity and recruit prefrontal regions of the frontoparietal network during cognitive reappraisal are less likely to exhibit symptoms of depression following exposure to maltreatment – pointing to a potential neurobiological mechanism of resilience. Greater efforts to identify resilience factors at the neural and behavioural levels can provide mechanistic translational targets for interventions aimed at preventing or treating psychopathology among children who have experienced adversity.

Article summary of The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis by Hughes et al. - Chapter

Article summary of The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis by Hughes et al. - Chapter


Studies are increasingly identifying the importance of early life experiences to people’s health throughout the life course. Individuals who have adverse childhood experiences (ACEs) tend to have more physical and mental health problems as adults that those who do not have ACEs and ultimately greater premature mortality. ACEs include harms that affect children directly or indirectly through their living environments. Individuals who have ACEs can be more susceptible to disease development through both differences in physiological development and adoption and persistence of health-damaging behaviours.

In this study, the authors present findings from a systematic review and meta-analysis of studies measuring associations between multiple ACEs and health outcomes. The primary outcomes of interest were pooled measures of relations between multiple ACEs and health outcomes. The analyses were restricted to exposure to at least four types of adversity during childhood, with individuals reporting no ACEs as the comparator.


The search strategy of this review focused on six categories of health outcomes: substance use, sexual health, mental health, weight and physical exercise, violence, and physical health status and conditions. Studies were excluded based on high-risk or clinical populations because of often few individuals with low ACE exposure in such populations. Included studies met the following criteria: cross-sectional, case control, or cohort study, using a cumulative measure of at least four ACEs spanning both direct and indirect types, focused predominantly of adults aged at least 18 years, a sample size of at least 100, and reported odds ratios (ORs, comparable statistics, or data to enable their calculation for a health outcome. Included articles were independently assessed for quality by two reviewers using criteria based on the standard principles of quality assessment. Studies received a point for each quality criterion that they met, for a maximum score of 7.


Of 11621 references identified by the search, 37 included studies provided risk estimates for 23 outcomes, with a total of 253719 participants. Individuals with at least four ACEs were at increased risk of all health outcomes compared with individuals with no ACEs. Associations were:

  • Weak or modest for physical inactivity, overweight or obesity, and diabetes (ORS of less than two)
  • Moderate for smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease (ORs of two or three)
  • Strong for sexual risk taking, mental ill health, and problematic alcohol use (ORs of more than three to six)
  • Strongest for problematic drug use and interpersonal and self-directed violence (ORs of more than seven)

Discussion & Conclusion

This study is the first to synthesize evidence for the effect of multiple ACEs and measure the relative magnitude of associations with many of the lifestyle behaviours and health conditions that challenge public health globally. For all outcomes examined, pooled ORs indicated increased risk among individuals with at least four ACEs compared with those reporting none. The results suggest that to have multiple ACEs is a major risk factor for many health conditions. The outcomes most strongly associated with multiple ACEs represent ACE risks for the next generation. To sustain improvements in public health requires a shift in focus to include prevention of ACEs, resilience building, and ACE-informed service provision. The

Sustained prevention gains might require a shift in focus to include the early drivers of poor health. Policies that capture the environmental and societal causes of adversity in childhood offer new opportunities to address ACEs rather than just their consequences. Specifically, through the UN 2030 Agenda for Sustainable Development, countries have committed to action to meet 17 global Sustainable Development Goals (SDGs) by 2030. Though several SDGs address violence directly, many others support focus on broad ACEs and their risk factors (e.g., goal 3 (good health and wellbeing), goal 4 (quality education), and goal 10 (reduced inequalities)). The SDGs also place major focus on early childhood development as a means of securing lifelong health and provide strong political endorsement and a multisectoral framework for this approach.

Along with the outcomes covered in this analysis, studies are now identifying associations between multiple ACEs and broad harms to life prospects, including education, employment, and poverty. Strengthening understanding of the combined effect of ACEs across multiagency priorities should catalyze multidisciplinary prevention focused on early intervention. Collaborative, trauma-informed services can address the various adversities affecting individuals and families across the life course, providing integrated services to support individuals and reduce the likelihood that their own children in turn will be affected by ACEs.

This systematic review and meta-analysis identify the pervasive effects that childhood adversity can have on health across the life course, with exposure to multiple ACEs affecting all the health outcomes examined, including some of the leading causes of the global burden of disease. Outcomes showing the strongest relations with multiple ACEs (violence, mental illness, and problematic substance abuse) can represent ACEs for the next generation (exposure to parental domestic violence, mental illness, and substance use) and thus are indicative of the intergenerational effects that can lock families into cycles of adversity, deprivation, and ill health. Although research into ACEs is far from complete, a compelling case exists for increased international focus on prevention of ACEs, and implementation of policies that support a sustainable life-course approach to health.

Article summary of Psychoneuroimmunology of early-life stress: the hidden wounds of childhood trauma? by Danese & Lewis - Chapter

Article summary of Psychoneuroimmunology of early-life stress: the hidden wounds of childhood trauma? by Danese & Lewis - Chapter

What are the objectives of this study?

The immune system and the brain are both not fully formed at birth. They carry on growing in reaction to their postnatal environment. Through experiences in the early periods of development, the brain and the immune system develop progressively. They expand their repository in adaptation to stimuli specific to one’s unique environment. The plasticity of brain development is best studied looking at basic brain functions, they are recognized to be predictors of one’s immune functions. In the current study, the relationship between early life stress and the development of the immune system with regards to the development of psychopathology is discussed.

What is the relationship between childhood trauma and inflammation?

Many studies have investigated the association between immune functioning and early life stress in rodents and non-human primates. They found that stress reactivity of the offspring depended on child care of the mother. Reduced maternal caregiving in rats leads to an increased stress reactivity. When looking at measures of immune functioning, unstimulated pro-inflammatory cytokines in the plasma, expression levels of pro-inflammatory genes in the brain and intestinal microflora were examined. They concluded the existence of links between early life stress and immunity.

In humans it was found that cumulative exposure to childhood trauma was related to significant elevation of inflammation twenty years later. Changes in the biomarkers for inflammation could not be explained by potential confounders such as birthweight or low IQ. Also, mediators like poor adult health or acute infections could not fully explain the effects. Thus, evidence was found for the influence of childhood maltreatment and other stressors in this period on elevated inflammation levels. Childhood maltreatment also predicts a bigger reactivity to psychosocial challenges. For example, adults with a history of maltreatment showed higher inflammation levels in the context of depression, caregiving stress and daily stressors in comparison to healthy control participants.  The conclusion was that the interaction between the immune system and the brain makes it possible for stressors caused by childhood maltreatment to affect the development of the immune system. This can affect the brain and its long-term functioning.  

What is the relationship between inflammation and psychopathology?

Inflammation is seen as a primary determinant in the functioning and development of the brain. Evidence was found for the effectiveness of anti-inflammatory medication in treatment of affective disorders such as depression. Also, Hart (1988) found that experimental administration of pro-inflammatory cytokines generated a response similar to depression. Also, depressed patients showed systemic activation of the immune system and a small increase in levels of inflammation biomarkers.  With regards to bipolar disorder, evidence was found for a small increase in pro-inflammatory cytokines. Inflammation might be a latent vulnerability factor both influencing the onset -and progression of bipolar disorder. In schizophrenia, the influence of inflammatory abnormalities has long been discussed. In 2015, Mondelli et al. found hat increased baseline levels of inflammation predict poor treatment outcomes in first-episode psychosis patients. In PTSD inflammation is a pre-existing vulnerability and correlates to subjective distress, maladaptive coping and disease severity.

Therefore, the researchers propose that early-life stress can provide an innovative framework to understand and treat psychopathology related to childhood trauma and early-life stress as a predictor of later inflammation. The key points derived from research on the relationship between inflammation and psychiatric disorders are:

  1. Elevated inflammation levels are observed in several groups of patients. It was found that there are overlapping trans-diagnostic patterns of the relationship between childhood trauma and clinical outcomes of inflammation.
  2. Several meta-analyses concluded that not all patients suffering from psychological disorders have elevated inflammation. Thus, it is important to identify what correlates there are to increased inflammation in psychiatric patients and aim interventions accordingly.
  3. Inflammation is not related to just some cases of psychiatric disorders, it is a key marker displaying vulnerability.

What is the link between childhood trauma and psychopathology?

Studies discussed in the current review suggest that childhood trauma is related to the later activation of the immune system. This can affect the vulnerability for later psychopathology. Further support for the mediating role comes from the examination of analogy, synergy, specificity and reversibility.  One example of synergy is that both inflammation and childhood trauma are likely to be on the same pathways that influence the brain and its behaviour. Carpenter et al. (2010) found that participants with a history of childhood trauma have bigger inflammatory responses to experimental psychosocial stressors.

What did the researchers conclude?

The effect of childhood trauma should be remediated before the onset of clinical symptoms, including potentiation of adaptive immunity and anti-inflammatory interventions. Comparable methods may be used to alleviate the adverse reaction to treatment that is described in patients suffering from childhood trauma.


  • Through experiences in the early periods of development, the brain and the immune system develop progressively. They expand their repository in adaptation to stimuli specific to one’s unique environment. The plasticity of brain development is best studied looking at basic brain functions, they are recognized to be predictors of one’s immune functions.
  • Studies discussed in the current review suggest that childhood trauma is related to the later activation of the immune system. This can affect the vulnerability for later psychopathology.
  • The effect of childhood trauma should be remediated before the onset of clinical symptoms, including potentiation of adaptive immunity and anti-inflammatory interventions.

Study note:

  • You should know that inflammatory markers are not always responsible for the onset -and course of psychopathology but are in most cases. You should be able to explain the role of inflammatory biomarkers on psychopathology and the relationship to childhood trauma.
  • What mediators could be responsible for the high risk of psychopathology in children with a history of childhood trauma? This is explained in the last section of the article.
The relationship between childhood psychosocial stressor level and telomere length: a meta-analysis - Hanssen & Schutte - 2017 - Article

The relationship between childhood psychosocial stressor level and telomere length: a meta-analysis - Hanssen & Schutte - 2017 - Article

What are the objectives of this study?

Maltreatment or neglect experienced during childhood are predictors of negative (mental) health outcomes across the life course. These negative childhood experiences are linked to the development of depression, substance abuse, post-traumatic stress disorder and bipolar disorder. Besides mental illness, child abuse is also linked to several physiological disorders including metabolic disorders and gastrointestinal disorder. These negative childhood experiences, or stressors may also have epigenetic effects and influence the functioning of the immune system and biomarkers. In previous studies high levels of experience of stressors during childhood are related to physiological, cellular and immune stress responses.  

Later health developments as a result of childhood maltreatment might be associated with telomere length. Telomere length is considered an important health biomarker. They are nucleoprotein complexes that preserve genetic information, but also regulate cellular activity and prevent end-to-end fusion. Also, they can lengthen and shorten over time. These changes in telomere length are associated with cardiovascular disease and obesity. In this study the relationship between childhood psychological stressors and telomerase length is examined. Also, moderating effects are studied, because evidence for the influence of maltreatment on telomere length is done using various variables. The main aim of the study is to determine the overall effect sizes of the relationship between childhood psychological stressors and telomere length.

What method was used?

Various web libraries of scientific articles were searched reporting on psychological stressors and telomere length. They found 2,122 potentially relevant studies of which 27 samples met the inclusion criteria. A meta-analysis is done over 27 samples and 16,238 participants.

What were the results of the meta-analysis?

The researchers found a significant relationship (0.08) between an elevated level of childhood stressors and a shorter telomerase length. The mean age across studies was 42.

Moderator analysis showed the trend in the direction of effect size. Effect sizes tend to be larger when there are shorter times between the stressor and measurement of telomerase. Also, studies that used a categorical method for assessing the stressor level of a child showed higher effect sizes. Studies comparing groups, so being abused or not, showed higher associations between telomere length and childhood stressor. In comparison to studies using the level of stress as a continuous variable, these studies showed lower effect sizes. Also, studies completed with qPCR reported higher effect sizes than studies using the Southern blot method.

No significant moderation was fount between the assay of leukocytes or buccal cells. There was also no moderation of the assessment of child stressor, this could be either memory-based recall or archival records, it did not make a difference. No significant moderator effect was found when controlled for age and sex either.

What was the conclusion of the study?

A significant, but small relationship between telomere length and childhood stressors was found, regardless if stressor level was measured based on recall or objective documentation. Stressors experienced during childhood can have a long-term effect on telomere length at a mean of 42 years of age.  Therefore, perceived stress and negative emotions are associated to telomere length. The results also provide a mediational explanation for the relationship between experiencing psychosocial stressors during childhood and poor mental -or physiological outcomes across the life span. For example, early trauma affects inflammation, which is associated with telomere length.

Negative psychological states, such as depression, anxiety and perceived stress are predicted by negative childhood experiences. These negative childhood experiences -or stressors can predict shorter telomeres which is the reason for increased anxiety levels and stress. Also, telomere functioning is dynamic, so when time passes after exposure to a stressor shorter telomere could recover. Therefore, it was predicted that time would moderate effect size. However, according to findings, childhood stressors were still significantly related to shorter telomeres much later. Childhood stressors probably have more impact on the telomere length, because it happens during a critical period of the development of biological systems.

Another finding was that in the comparison of extreme groups, a significantly greater effect size was found. This effect size was bigger than the comparison between groups reporting various levels of stressors. For example, when looking at the relationship between telomerase length and anxiety level, extreme groups showed much higher effect sized. This could mean that only extreme experiences cause long-term effects on telomere length.

What are the recommendations for further research?

The results obtained from the moderator studies can be considered a suggestion. This is because the moderator analysis only used 27 samples. The analysis thus had little statistical power to identify significant differences. Also, there were no randomly assigned participants or studies -and every examined study used a different research method. Therefore, the outcome of the influence of moderators could be varied when conservative one-tail tests controlling for alpha inflation are done. Therefore, future research should focus on the influence of childhood psychosocial stressors and discuss the role of characteristics of both the stressors and caused distress. This way, important predictors of resilience and vulnerability to the effects of childhood stressors can be discovered.


  • Besides mental illness, child abuse is also linked to several physiological disorders including metabolic disorders and gastrointestinal disorder. These negative childhood experiences, or stressors may also have epigenetic effects and influence the functioning of the immune system and biomarkers. In previous studies high levels of experience of stressors during childhood are related to physiological, cellular and immune stress responses.  
  • A significant, but small relationship between telomere length and childhood stressors was found, regardless if stressor level was measured based on recall or objective documentation. Stressors experienced during childhood can have a long-term effect on telomere length at a mean of 42 years of age.  

Study note:

  • In this study they look at the relationship between childhood stressors and telomerase. What is the importance of finding moderating effects on this relationship and what does this mean for the association between negative childhood experiences and (mental) health issues across the life span?
  • Make sure you can explain the moderating influences on effect size found by this study. What are the outcomes of the meta-analysis and what does this mean for past -and future research
Article summary of Sexual problems and post-traumatic stress disorder following sexual trauma: A meta-analytic review by O'Driscoll et al. - Chapter

Article summary of Sexual problems and post-traumatic stress disorder following sexual trauma: A meta-analytic review by O'Driscoll et al. - Chapter


Sexual dysfunction refers to a series of problems associated with a reduced ability to respond sexually or to experience sexual pleasure. Areas of malfunction include: arousal, pain, orgasm, and satisfaction. There is scarce research into sexual problems in the context of post-traumatic stress disorder (PTSD), although almost 45% of the people who have been raped, experience PTSD after 3 months. The DSM-5 does not refer to sexual problems that may be present within the PTSD diagnostic criteria. The article looked at the potential relevance of sexual problems with regard to any diagnostic criteria for PTSD: 

  • Criterion A: A certain exposure to a traumatic event. According to the article, traumatic events related to sexual violence or abuse can often be linked to the development of PTSD.

  • Criterion B: Covers intrusive experiences (memories, dreams or flashbacks) as a result of experienced trauma. Sexual contact can also lead to such experiences.

  • Criterion C: High avoidance regarding the traumatic event. Traumatic experiences with regard to sex can lead to an association between sexual contact and anxiety. For example, a traumatized person can show behaviors such as reduced sexual contact and experiencing emotions such as guilt, shame, emotional and disgust. Someone can also block feelings of love and closeness.

  • Criterion D: Negative changes in cognition or mood. Many cognitions about sex can change after a sexual trauma (for example: "Sex is harmful and disgusting"), which can be accompanied by difficult emotions such as guilt and shame. Negative thoughts and feelings about sex can hinder positive sexual experiences and have an impact on sexual desire.

  • Criterion E: There is a clear change in excitement and reactivity. Experienced anxiety and threat can affect healthy sexual functioning.

Since sexual problems are not part of the standard PTSD treatment, they are not identified. Treatment of sexual problems normally takes place after successful PTSD treatment, while it would be possible to combine these two treatments.

Integrating psychological treatment of PTSD and sexual problems

Sexual problems and their treatment are heterogeneous. However, four common elements of psychological treatment could be integrated into the article for comorbid PTSD and sexual problems:

  • Psycho-education: can help people to understand biological systems involved in PTSD and sexual response, to normalize emotions, to motivate someone to go to therapy and to have open conversations about sex

  • Relaxation: learning to relax in PTSD can help to reduce the activity in the amygdala and therefore the anxiety

  • Sensory sensation: this involves concentrating on the sensory sensation of touch, alone or with a partner, through which intimacy is slowly reintegrated.

  • Exposure: in this phase, someone is exposed to his or her fear, which leads to a reduction in the experience of symptoms related to anxiety

Purpose research

The purpose of this meta-analysis was to quantify the influence of psychological interventions on sexual problems in people with PTSD as a result of sexual trauma.


Studies were excluded from the meta-analysis if they were not published in English and / or if the study was not fully available. Studies were included based on the following criteria:

  • Adults

  • The diagnosis of PTSD in relation to sexual trauma

  • RCT (psychological treatments for sexual abuse)

  • Outcome measures of sexual problems


There were five studies that fit the included criteria. Out of these five, four studies had available data. The average age was 37.8 and all participants were women (N = 799). Two studies examined adult sexual trauma, child sexual trauma and a combination of both. Two studies were three-armed RCTs: active treatment, active comparison treatment and an inactive control. The other two studies were two-armed: active treatment and active comparison treatment.

Types of meta-analysis

There were two types of meta-analysis that were performed:

  • Between-groups analysis: Psychological treatment compared which compared both active and inactive controls had no effect on sexual problems. Psychological treatment which compared both active and inactive controls also showed no effect on dysfunctional sexual behavior.

  • Within-groups analysis: All four studies were included in the within-group analysis for sexual problems. A moderate effect size was found for psychological treatment, before and after treatment, on the subscale of sexual problems. Three studies were included in the within-groups analysis for dysfunctional sexual behavior. In this analysis there was a small effect size of psychological treatment on dysfunctional sexual behavior.


Study comparisons

The meta-analysis found no improvement in sexual problems and dysfunctional sexual behavior in a large range of psychological treatments. This was also somewhat expected since the interventions focused merely on PTSD symptoms. It was emphasized that sexual problems cannot improve as a result of improving PTSD symptoms, but that immediate intervention is required in the case of sexual problems. The treatments often took place in groups. This may be an explanation for the fact that sexual problems were not addressed by the treatment, since it was found to be difficult and uncomfortable to share these sexual problems. Another explanation may be that PTSD treatments are aimed at sexual traumatic memory and to facilitate emotional processing. However, this can indirectly neglect fear-based avoidance. For example, the frequency of flashbacks may have been reduced, but feelings of guilt, shame, or disgust may still prevent sexual contact. 

Changes in pre and post treatment

A small to moderate effect of improvement was found on both the subscale sexual problems and psychological treatment. However, this effect cannot be attributed to an effect of the treatment. Given the lack of data to draw conclusions, more research is needed into the changes that are observed in pre-post analysis.

Limitations of this study

This study is limited by the lack of studies that have measured sexual problems as a result of psychological treatment for PTSD of sexual trauma. The meta-analysis also only contains subscales of measurements of broader trauma symptoms and a limited recording of sexual problems. More thorough measures can lead to a more convincing effect of psychological treatments for sexual problems. Another limitation of the study is that the data that was included in the assessment consists mainly of women participants, without comparable data for men. Men who are assaulted report more sexual problems than women and experience less improvement in sexual dysfunction than women. Although all participants in the samples have experienced sexual trauma, it is not possible to say whether PTSD is specifically caused by the sexual trauma. This is especially true when someone has experienced multiple forms of trauma. The risk of bias is relatively low between studies, however, some studies had heterogeneous samples that reduce the quality of the results in this meta-analysis.


There are people with PTSD after sexual trauma in who sexual problems are not identified or treated immediately. This can hinder the progression of therapy for PTSD and / or be related to other psychosocial problems. The results of this study suggest that it is false to assume that sexual problems will improve directly when symptoms of PTSD improve. 

Article summary of The Sexual Well-Being of Women Who Have Experienced Sexual Abuse During Childhood by Lemieux & Byers - Chapter

Article summary of The Sexual Well-Being of Women Who Have Experienced Sexual Abuse During Childhood by Lemieux & Byers - Chapter


Sexual abuse during childhood is associated with a variety of negative short- and long-term effects such as depression, anxiety, anger, poor self-esteem, drug abuse, eating disorders and experiencing sexual abuse again. However, there have been relatively little studies conducted into the sexual well-being of women who have been abused during childhood. Some women may not experience sexual problems after sexual abuse. However, they may still experience a decrease in positive aspects of their sexual functioning (for example lower sexual satisfaction, sexual rewards, or a negative sexual self-image).

Explanations of long-term effects of sexual abuse during childhood

The conditioning model

The consequences of sexual abuse can be explained with the use of the conditioning model. In this model, it is thought that the coupling (the association) of negative cognitive, emotional and physical responses to sexual abuse are conditioned (so, they are associated together in the mind). So, over time, these negative responses can be triggered by a wide range of stimuli and lead to a series of behaviors aimed at avoiding painful thoughts, feelings, and memories of the sexual abuse.

Traumagenic dynamics model

This model is mainly used to understand how sexual abuse can contribute to later sexual problems. In this model, traumatic sexualization is defined as: "a process in which the sexuality of a child, which contains both sexual feelings and sexual attitudes, is shaped in an inappropriate developmental area and in an interpersonal dysfunctional manner as a result of sexual abuse". More serious sexual abuse will lead to greater traumatic sexualization and will have a greater impact on later sexual functioning.

Sexual abuse during childhood and the sexual well-being of women

Studies have shown that women who used to be sexually abused during their childhood have unhealthy or inappropriate sexual practices, have less sex and experience more sexual problems and dysfunctions compared to women who have not been sexually abused during their childhood. In this study, the association between sexual abuse during childhood and a series of positive and negative aspects of women's sexual functioning was studied. Three types of cognitive and emotional sexual assessments were used for this.

  • Various sexual stimuli of women (erotophobia-erotophilia)

  • Assessment of sexual self-image

  • Assessment of sexual experiences

Erotophobia erotophilia

Childhood sexual abuse leads to greater erotophobia, more negative sexual self-schemas and lower sexual self-esteem. This can cause some women to avoid sex because of negative associations. People with erotophobia often have negative emotional responses and evaluations on a variety of sexual simili and behaviors. These individuals show less erotic behavior, have fewer heterosexual experiences, are less likely to acquire and use contraception and have a more negative attitude towards their sexuality compared to people with eterotophilia.

Assessment of sexual self-image and sexual self-esteem

Sexual self-image is defined as 'cognitive representations (or thoughts) about the sexual aspects of the self'. People with a negative sexual self-schemas tend to view themselves as sexually conservative, inhibited and insecure. A sexual self-image consists of five different dimensions: experiences, evaluation, attractiveness, control, moral judgment and adaptability. In previous research, sexually abused women had a lower sexual self-image on the dimensions of moral judgment and control.

Sexual self-esteem is defined as a woman's emotional responses to her subjective assessment of her sexual thoughts, feelings, and behaviors.

Assessment of sexual experiences

Some studies have shown that lower sexual satisfaction occurs in women who have been sexually abused during their childhood. Higher yields and lower costs in the sexual relationship are associated with greater sexual satisfaction. Little research has been conducted into whether women with a history of sexual abuse experience lower sexual rewards and higher sexual costs.


The relationship between sexual abuse in childhood and the various aspects of women's sexual well-being has been investigated in this study. First, it was predicted that women who experienced sexual abuse where an attempt was made to penetrate sexually would function worse sexually compared to women who experienced sexual abuse, but were only sexually fondled. Second, it was predicted that non-abused women would function better sexually. Finally, it was predicted that the cognitive and emotional sexual assessments of women would mediate the relationship between sexual abuse and sexual functioning.   


The sample eventually consisted of 224 participants who were obtained through psychology classes at the University of Canada. The participants were between the ages of 17 and 48 and were almost all born in Canada. The average age of the participants when they first started dating was 14.6. On average they were 16.5 years old when they had sex for the first time and had an average number of sex partners of 4.8. The participants received extra credits for their participation in the study. The researchers used a broad range of instruments to capture all the different aspects of sexual well-being in women who were abused during childhood.


Ultimately, the sample was divided into three groups: 'no experience with sexual abuse', 'sexually touched' and 'sexual abuse with penetration'.   

A sexual victim, again

Women who were sexually abused with penetration were significantly more likely to fall victim to sexual abuse again in their adult age compared to women from the other two groups. 

Experiences of sexual violence and the sexual functioning of women

Women who were sexually abused with penetration are significantly more likely to have superficial sex and report a higher value of sexual costs than the other two groups. Also, the group with "sexually touched women" and "sexual abuse with penetration" were more often engaged in unprotected sex. Finally, women from the "sexual abuse with penetration" group deliberately abstained from sexual activities more often and they reported fewer sexual rewards compared to the "no sexual abuse experience" group.

Sexual abuse and the cognitive and emotional sexual assessments of women

Women who were sexually abused with penetration had significantly lower sexual self-esteem than the other two groups. Contrary to expectations, the group of women who were sexually abused with penetration, were more often erotophilic and had a more positive sexual self-schema compared to the two other groups.

The role of childhood abuse in the sexual functioning of women

Women who experienced emotional abuse had a greater risk on experiencing sexual abuse and voluntarily renounced sexual activities. They also reported more sexual problems, lower sexual rewards, higher sexual costs, lower sexual self-esteem and less sexual satisfaction. Women who were physically abused were more likely to engage in superficial sex, unprotected sex, and reported lower sexual confidence.

The mediating role of cognitive and emotional assessments of women

The sexual self-esteem of women who were sexually abused was significantly associated with superficial sex, sexual withdrawal and a higher level of perceived sexual costs.


As predicted, the women from the group who were sexually abused with penetration had lower sexual confidence than the other two groups. It has also been found that women who have experienced sexual abuse are less comfortable with their sexual behavior and see themselves as less physically and sexually attractive compared to women who had not been sexually abused experience. However, contrary to the researchers' hypothesis, women who were sexually abused are more erotophilic and report having more positive sexual self-schedules. 

Limitations research

First, the women who had not yet had sexual intercourse were removed from the sample due to a large amount of missing data. Although they were younger, less experienced and were not yet married / cohabiting, that does not mean that their chance of experiencing sexual abuse is less. Second, the majority in the sample were heterosexual students. Thirdly, the women were asked whether they had ever had an STD or had accidentally become pregnant to determine if they were engaged in unprotected sexual activities. This could provide a distorted picture, since there may be other reasons for, for example, getting pregnant unintentionally (for example, the tearing of a condom). Finally, there are women who have experienced multiple types of child abuse in their youth, but these types are not distinguished. However, certain combinations of abuse may have more specific outcomes with regards to sexual functioning. 

Article summary of Effect of Prolonged Exposure, intensified Prolonged Exposure and STAIR+Prolonged Exposure in patients with PTSD related to childhood abuse: a randomized controlled trial by Oprel et al. - Chapter

Article summary of Effect of Prolonged Exposure, intensified Prolonged Exposure and STAIR+Prolonged Exposure in patients with PTSD related to childhood abuse: a randomized controlled trial by Oprel et al. - Chapter

What is the relationship between childhood abuse and PTSD?

Childhood physical and sexual abuse are important risk factors for the development of post-traumatic stress disorder (PTSD). Both childhood abuse and childhood abuse-related PTSD (CA-PTSD) are associated with sever psychiatric symptoms and negative long-term outcomes, emphasizing the need for effective treatment. There’s a limited number of studies assessing trauma-focused treatment among those with CA-PTSD, and it is therefore uncertain how effective trauma-focused treatment is in this group of patients.

Patients with CA-PTSD more often experience emotional regulation difficulties and interpersonal problems than patients with non-CA-PTSD. Additionally, co-morbid diagnoses are more common in these patients – particularly depression, substance abuse, and personality disorders.

A recent meta-analysis indicated that patents with PTSD related to childhood trauma don’t benefit optimally from treatment. Compared with patients with PTSD related to trauma in adulthood, they improve less on PTSD symptoms, emotion regulation and interpersonal functioning.

What is the aim of this study?

The aim of this study was to investigate whether the effectiveness and the dropout rates of trauma-focused treatment for TPSD can be improved in patients with CA-PTSD. Prolonged Exposure (PE), an established treatment of PTSD was compared with two adaptations of PE:

  • The first was an intensified version of PE (iPE). It was expected that offering several sessions per week would lead to faster improvement and lower drop-out rates.
  • The second adaptation was a phase-based treatment in which PE is preceded by Skills Training in Affective and Interpersonal Regulation (STAIR). This treatment is based on the notion that emotion regulation and interpersonal problems interfere not only with daily life functioning but also the processing of trauma memories and that improvement in these capacities during the STAIR phase facilitates the effectiveness of PE.

The following hypotheses were tested:

  1. iPE and STAIR+PE lead to more clinician-rated and self-reported PTSD symptom reduction than PE from baseline to follow-up.
  2. iPE leads to faster improvement, that is, it leads to more clinician-rated and self-reported PTSD symptom reduction than PE and STAIR-PE from baseline to the first assessment.
  3. STAIR+PE leads to more improvement in emotion regulation, interpersonal problems, and self-esteem than PE and iPE from baseline to follow-up.
  4. iPE and STAIR+PE result in lower drop-out rates from treatment than PE.

What method was used?

In this randomized-controlled trial, the authors compared the effectiveness of PE, iPE and STAIR+PE. Participants were recruited in two outpatient mental health services specializing in the treatment of trauma-related disorders located in the Hague and Rotterdam, the Netherlands. Inclusion criteria were:

  1. ages 18-65
  2. a PTSD diagnosis according to DSM-5 classification
  3. traumata related to childhood sexual and/or physical abuse that occurred before 18 years of age, committed by a primary caretaker or an authority figure as index event
  4. sufficient fluency in Dutch to complete the treatment and research protocols

Exclusion criteria were:

  1. involvement in a compensation case or legal procedures concerning admission or stay in the Netherlands
  2. pregnancy given the limited available information about safety
  3. severe non-suicidal self-injury (NSSI) which required hospitalization during the past 3 months
  4. severe suicidal behaviour: a suicide attempt during the past 3 months or acute suicidal ideations with serious intent to die with a specific plan for suicide and preparatory acts
  5. severe disorder in the use of alcohol or drugs in the last 3 months
  6. cognitive impairment
  7. changes in psychotropic medication in the 2 months prior to inclusion
  8. engagement in any current psychological treatment

PE was delivered in 16 weekly face-to-face sessions of 90 minutes. PE is a form of cognitive behavioural therapy involving psychoeducation about PTSD, imaginal exposure (repeatedly recounting the most disturbing traumatic memories) and exposure in vivo (repeatedly approaching trauma-related stimuli.

iPE was delivered in 14 face-to-face sessions of 90 minutes which started with 3 sessions per week for 3 weeks followed by 2 sessions after one and 2 months.

STAIR+PE was delivered in 8 weekly face-to-face sessions of 60 minutes for STAIR and 8 weekly face-to-face sessions of 90 minutes for PE. STAIR+PE comprised skill training and prolonged exposure.

What were the results?

149 patients were randomly assigned to PE (48), iPE (51) or STAIR+PE (50). All treatments resulted in large improvements in clinician assessed and self-reported PTSD symptoms from baseline to 1-year follow-up, with no significant differences among treatments. iPE led to faster initial symptom reduction than PE for self-report PTSD symptoms but not clinician-assessed symptoms and faster initial symptom reduction than STAIR+PE for self-reported and clinician-assessed symptoms. STAIR+PE did not result in significantly more improvement from baseline to 1-year follow-up on the secondary outcome emotion regulation, interpersonal problems and self-esteem compared to PE and iPE. Dropout rates did not differ significantly between conditions.

What conclusions were made?

The three variants of Pe were each effective treatments of PTSD in patients with CA-PTSD.

  • The hypothesis that iPE and STAIR+PE result in larger PTSD symptom reductions compared to PE from baseline to 1-year follow-up was not supported. There were no significant differences between PE and iPE/STAIR+PE at post-treatment or at 1-year follow-up. It was found that STAIR+PE led to more improvement than PE in the post-treatment to follow-up phase on interviewer-assessed but not self-reported PTSD symptoms.
  • The hypothesis that iPE would lead to faster symptom improvement than PE and STAIR+PE was partly supported. Compared with PE, iPE led to faster improvement on self-reported but not interviewer-assessed PTSD symptom severity. iPE led to faster improvement than STAIR+PE on both self-reported and interview-based assessments.
  • The hypothesis that STAIR+PE leads to more improvement in emotion regulation, interpersonal problems and self-concept compared to PE and iPE was not supported. There were no significant differences between STAIR+PE and PE/iPE post-treatment or at 1-year follow-up. STAIR+PE showed more improvement in emotion regulation and interpersonal problems post-treatment to 1-year follow-up compared to PE, but not compared to iPE.
  • The final hypothesis that iPE (27% dropout) and STAIR+PE (18% dropout) would lead to lower dropout rates than PE (29%) was not supported. PE led to significantly more early completers (23% early completers) compared to iPE (2% early completers) and STAIR+PE (4% early completers), but this may be related to the relatively large amount of exposure sessions in PE (16 sessions) compared to iPE (14 sessions) and STAIR+PE (8 sessions).

The results of this study demonstrate that PE, iPE, and STAIR+PE are effective treatments for CA-PTSD. intensifying treatment may speed up recovery but does not lead to an overall better outcome. Moreover, all treatments led to improvements in emotion regulation, interpersonal problems, and self-esteem from baseline to follow-up.

To conclude, iPE and STAIR+PE did not improve the overall outcome of PE. All treatments were effective for patients with CA-PTSD.

Article summary of Treatment efficacy and effectiveness in adults with major depressive disorder and childhood trauma history: a systematic review and meta-analysis by Kuzminskaite et al. - Chapter

Article summary of Treatment efficacy and effectiveness in adults with major depressive disorder and childhood trauma history: a systematic review and meta-analysis by Kuzminskaite et al. - Chapter

What is the aim of this study?

Childhood trauma, operationalized as emotional or physical neglect, or emotional, physical, or sexual abuse before the age of 18 years, is a common and major risk factor for the development and more severe course of depression in adulthood. A high prevalence of childhood trauma (about 46%) in adults with depression has been found, with even higher rates in patients with chronic depression.

Being a common and potent risk factor for depression, childhood trauma presents an opportunity to provide insights into personalized treatment planning, essential to reduce personal and societal burden. Meta-analytic findings of studies found that adults and adolescents with depression and childhood trauma were around 1-5 times more likely not to respond or remit after pharmacotherapy, psychotherapy, or combination treatment than adults and adolescents with depression but no childhood trauma. However, evidence on poorer treatment outcomes in patients with childhood trauma has not been definitive, with meta-analytic findings showing large between-study heterogeneity. Some primary studies showed that childhood trauma history predicted greater symptom improvement following solution-focused or psychodynamic psychotherapies compared to the absence of childhood trauma in adults with mood or anxiety disorders.

Further findings on treatment type suggest that psychotherapy (CBASP) alone or in combination with pharmacotherapy could be more beneficial than pharmacotherapy alone for individuals with chronic depression and childhood trauma but not for individuals without childhood trauma. But evidence hasn’t been consistent, with meta-analytic findings showing no significant differences between psychotherapy and pharmacotherapy treatment approaches when comparing patients with depression with and without childhood trauma.

The current meta-analysis aimed to examine whether adults with major depressive disorder, including chronic depression, and self-reported childhood trauma have more severe depressive symptoms before treatment, have less favourable baseline-to-post-treatment outcomes with active treatments, and are less likely to benefit from active treatments relative to a control condition. The authors also examined the influence of childhood trauma on dropout rates, the relative contribution of childhood trauma types to treatment outcomes, and the impact of potential effect modifiers such as treatment type or study quality.

What method was used?

The authors conducted a comprehensive meta-analysis, for which the protocol was registered at PROSPERO. A study-selection approach was used to identify journal articles in English on childhood trauma and adult depression treatment outcome, searching three bibliographical databases (PubMed, PsycINFO, and Embase) from Nov 21, 2013 (the search date of the latest meta-analysis) to March 16, 2022, and full-text screening studies in three sources of randomized clinical trials (RCTs): a database on psychological treatment, a network meta-analysis of pharmacological depression treatment, and a large-scale systematic review of clinical trials. Both RCTs and open trials comparing the efficacy or effectiveness of evidence-based interventions for acute treatment of adult depression for patients with and without childhood trauma were considered for inclusion. Two independent researchers extracted study characteristics. Group data for effect-size calculations were requested from study authors. The primary outcome was depression severity change from baseline to the end of the acute treatment phase, expressed as standardized effect size. Meta-analyses were done using random-effects models.

What were the results?

A total of 10,505 publications were examined overall, 61 studies met the inclusion criteria; 54 unique studies remained after removal of duplicates, of which 29 (54%) had authors who agreed to contribute their data and were included in the meta-analysis. This contributed to a maximum of 6830 participants (age range 18-85). More than half (4268 (62%) of 6830) of patients with major depressive disorder reported a history of childhood trauma. Despite having more severe depression at baseline, patients with childhood trauma benefitted from active treatment similarly to patients without childhood trauma history, with no significant difference in active treatment effects between individuals with and without childhood trauma, and similar dropout rates.

Findings did not significantly differ by childhood trauma type, study design, depression diagnosis, assessment method of childhood trauma, study quality, year, or treatment type or length, but differed by country. For example, North American studies showed larger treatment effects for patients with childhood trauma. Most studies had a moderate to high risk of bias, but the sensitivity analysis in low-bias studies yielded similar findings to when all studies were included.

What conclusions were made?

The current meta-analysis comprehensively examined the effect of childhood trauma on the efficacy and effectiveness of pharmacotherapy and psychotherapy for adult depression using data from 29 interventional studies and 6830 patients with major depressive disorder, including chronic depression. 62% of adults with depression in the intervention studies examined report a history of childhood trauma, suggesting that the prevalence of childhood trauma was slightly higher than in a previous meta-analysis (46%). Higher childhood trauma rates in the meta-analysis could be explained by a large number of studies focused on individuals with chronic or treatment-resistant depression, because childhood trauma rates are high (about 75%) in such groups.

The results suggested that childhood trauma did not significantly affect the efficacy of depression treatment, contrast with previous meta-analytic findings that observed poorer treatment response in individuals with depression and childhood trauma. These inconsistencies could be explained by differences in treatment outcome definition and publication and selection bias.

Contrary to previous studies, we found evidence that the symptoms of patients with major depressive disorder and childhood trauma significantly improve after pharmacological and psychotherapeutic treatments, notwithstanding their higher severity of depressive symptoms. Evidence based psychotherapy and pharmacotherapy should be offered to patients with major depressive disorder regardless of childhood trauma status.

Article summary of Imagery rescripting and eye movement desensitisation and reprocessing for treatment of adults with childhood trauma-related post-traumatic stress disorder: IREM study design by Boterhoven de Haan et al. - Chapter

Article summary of Imagery rescripting and eye movement desensitisation and reprocessing for treatment of adults with childhood trauma-related post-traumatic stress disorder: IREM study design by Boterhoven de Haan et al. - Chapter

What is EMDR and ImRs?

Trauma-focused cognitive behaviour therapy (Tf-CBT) and eye movement desensitization and reprocessing (EMDR) have been identified as the most efficacious post-traumatic stress disorder (PTSD) treatments. Compared to other treatment modalities like pharmacotherapy, and to non-trauma-focused approaches, EMDR and Tf-CBT interventions have been identified as more effective at reducing PTSD symptom severity. The research on treatments for adults with childhood trauma-related PTSD (Ch-PTSD) has suggested that this population is difficult to treat due to the additional symptom complexity that can develop as a consequence of early trauma experiences.

Three main approaches for treatment of Ch-PTSD were outlined by Ehring and colleagues. One approach suggests that the aim of treatment should be on improving functioning through skill building, rather than focusing on trauma reprocessing. Secondly, there is the phase-based approach which incorporates skill building with trauma reprocessing techniques like prolonged exposure. The third approach uses trauma-focused treatments without any modifications to protocol. Treatments are categorized as trauma focused when they specifically target processing of trauma memories and their meaning.

There is much debate regarding the appropriateness of trauma-focused interventions, and some have argued that treatments which primarily focus on trauma reprocessing, are inappropriate for the Ch-PTSD population. Other trauma-focused treatments like EMDR and Imagery Respricting (ImRs) have been proposed for Ch-PTSD. EMDR and ImRs share similarities with prolonged exposure techniques by activating imagery, emotions and cognitions related to the trauma memory and providing corrective information.

EMDR asks individuals to recall their trauma experience in their mind while tracking the back-and-forth movement of the therapist’s finger. The dual attention focus facilitates reconsolidation of the original trauma memory so that it is less vivid and less distressing.

ImRs involves the individual imagining a different ending to a trauma experience. Individuals are encouraged to recall a memory in the first person, present tense as their child self. The memory is then rescripted, by imagining a different course of events, which helps to satisfy the needs of the person.

What is the aim of this study?

This article describes the study design of IREM, an international, multi-center randomized clinical trial (RCT) whose primary objectives are to compare the effectiveness of EMDR and ImRs in the treatment of Ch-PTSD and to test whether different mechanisms of change are involved. Various additional sub-studies will be performed which include investigating the participant and therapists’ perspectives of treatment, assessing the effects of treatment integrity, prediction of drop out and changes in how trauma memories are stored following treatment.

What method was used?

IREM is an international multicenter randomized controlled trial involving seven sites across Australia, Germany, and the Netherlands. We aim to recruit 142 participants who were randomly assigned to treatment conditions. Assessments were conducted before treatment until 1-year follow-up. assessments before and after the waitlist assessed change in time only.

The primary outcome measure was change in PTSD symptom severity from pre-treatment to 8-weeks post-treatment. Secondary outcome measures include change in severity of depression, anger, trauma-related cognitions, guilt, shame, dissociation, and quality of life. Underlying mechanisms of treatment will be assessed on changes in vividness, valence, and encapsulated belief of a worst trauma memory. Additional sub-studies will include qualitative investigation of treatment experiences from the participant and therapists’ perspective, change in memory and the impact of treatment fidelity on outcome measures.

Taking into account all the data collected, a mixed regression model was used to analyze the data. This identified any fixed or random effects resulting from the treatment and changes over time. A mixed logistic regression analysis was used for diagnostic outcomes. A mixed gamma regression was used for skewed distributions. Poisson or negative binomial regression as used for analyzing medication use and other count data. Analysis included an intent-to-treat sample.

The mechanism test was done by advance medication tests, using multiple assessments of dependent variables (CAPS-5, IES-R) and variables representing indices that should predict change in symptoms (imagery interview-based ratings of vividness, valence, and encapsulated beliefs of the primary trauma memory).  Secondary investigations were performed as additional sub-studies to explore and further the authors’ understanding of the effectiveness of EMDR and ImRs in the treatment of Ch-PTSD.

What conclusions were made and discussed?

This study described the study design of IREM, an international multicenter RCT comparing the effectiveness of EMDR and ImRs for treatment of Ch-PTSD. this RCT and the additional sub-studies broadened the understanding of the effectiveness of these approaches in Ch-PTSD treatment and help furthering our understanding of their underlying mechanisms of change.

The evidence from this RCT will contribute to clinical decisions on whether to use trauma-focused approaches for the sequela associated with Ch-PTSD. while the primary aims of this study were to compare EMDR and ImRs treatments on PTSD symptom severity and to clarify whether or not different mechanisms of change are involved, secondary outcome measures will assess some disturbances associated with Ch-PTSD such as guilt, shame, anger, and dissociation. EMDR and ImRs might more directly target change through cognitive and experiential mechanisms, thus having a greater impact on a wider range of symptoms than just PTSD.

This study contributes to the growing evidence for the efficacy of trauma-focused treatment for Ch-PTSD. the documented lack of implementation of trauma-focused approaches has highlighted the need to explore treatments, which will be accepted to both participants and therapists. A large issue for treating Ch-PTSD is the perception that individuals won’t be able to tolerate treatment. However, it is unclear if the reluctance to engage in trauma-focused treatment is a shared view as it is suggested that avoidance of the therapist is a much greater barrier. This RCT will be able to contribute to our knowledge of participants’ capacity to engage in treatment. The exploration into therapist and participants’ perspective will help to identify barriers and issues with the implementation of treatment.

Taken together, findings from this RCT will make a significant contribution towards developing best practice for treating PTSD caused by childhood experiences. Both EMDR and ImRs hold promise as being efficacious treatments for Ch-PTSD and the sequela of symptoms associated with this disorder.

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