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.

Preface

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.

Introduction

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.

Method

Sample

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.

Measures

• 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.

Introduction

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.

Method

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.

Measures

• 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.

Introduction

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.

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.

Preface

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.

Introduction

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.

Discussion

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.

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.

Epidemiology

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.

Psychotherapy

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.

Introduction

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

Resilience

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.

Conclusion

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.

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.

Summary:

• 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.

Preface

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.

Method

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

Results

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.

Discussion

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.

Conclusion

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. 

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.

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.