Childhood adversities in relation to psychiatric disorders
Christian Pietrek a, Thomas Elberta, Roland Weierstall a, Oliver MiilIer
b,Brigitte Rockstroh a.*
• Department of Psychology. University of Konstanz. 78457 Konstanz. Germany
b Center for Psychiatry Reichenau. 78479 Reichenau. Gelmany
Keywords:
Childhood adversities Emotional neglect Sexual abuse Depression BPD
Substantial evidence documented that adverse childhood experiences exert deleterious effects on mental health. It is less clear. to what extent specific maltreatment during specific developmental periods vary between disorders rather than raising vulnerability for any suffering. The present comparison of characteristics of childhood adversity (type and frequency of adversity. developmental period) between Major Depressive Disorder (MDD). Borderline Personality Disorder (BPD). schizo- phrenia. and psychiatrically healthy subjects examined how effects of adverse childhood experiences vary between disorders. Patients generally reported more adversities than healthy subjects. Irrespective of diagnosis. emotional maltreatment was substantial in all patients. BPD was characterized by marked increase of adversities across age relative to MDD and schizophrenia. Fifty-six percent of BPD. 40% MDD and 18% of schizophrenia sample experienced significant degree of early adversities. Stress pattern (type and time) varied between diagnoses. but not for patients with significant early adversities.
Regression analyses confirmed early experiences as predictor of BPD. but not MDD and schizophrenia.
Prepubescent experiences predicted affective and traumatic symptoms in BPD. and moderated the association with symptoms in MDD. Results indicate a dose-effect with differential impact of adverse childhood experiences in BPD. MDD. and schizophrenia. while early maltreatment beyond a certain degree affects mental health independent of diagnosis.
1. Introduction
A relationship between adverse childhood experiences (ACE) and psychiatric disorder has been frequently emphasized. referring to prevalence, risk, course, and severity of disorder (e.g. Chapman et aI., 2004; Dube et al.. 2003; McEwen, 2003; Rutter and Maughan.
1997; Teicher et aI., 2002). Association has been described for different diagnoses including Major Depressive Disorder (MDD, e.g.
Kessler, 1997; Heim et al.. 1997,2004; Teicher et aI., 2006, 2009;
Widom et aI., 2007), Borderline Personality Disorder (BPD, e.g.
Crawford et al.. 2009; Allen, 2008; Liotti et aI., 2000; van del' Kolk et aI., 1994), anxiety disorders (e.g., Kessler et al.. 1997) or schizophrenia spectrum disorders (overview Varese et aI., 2012;
see also Read and Bentall. 2010; Read et aI., 2005; Rosenberg et al..
2007; Bebbington et aI.. 2004, 2011; Betensky et aI., 2009;
Matheson et aI., 2012; Sideli et al.. 2012). Efforts to understand the impact of adverse experience on disorder targeted develop- mental periods and type of experience. Maltreatment at different age during childhood affects development of different brain regions.
suggesting sensitive periods of brain (Andersen, 2003; Andersen
* Correspondence to: Department of Psychology. P.O. Box 023. University of Konstanz. 0-78457 Konstanz. Germany.
Tel.: +497531884625; fax: +497531882891.
E-mail address:Brigitte.rockstroh@uni-konstanz.de (B. Rockstroh).
and Teicher, 2008, 2009; Andersen et aI., 2008) and neuroendocrine systems development (Weiss et al.. 1999; Paus et al.. 2008;
Kaufman and Charney, 2001; Heim et al.. 1997; Wingenfeld et aI..
2010). Effects on risk. onset. severity or chronicity of disorder were reported for different adversities including trauma. interpersonal trauma. parental loss/neglect or verbal aggression (e.g. Kessler et al..
1997; Rubino et aI., 2009; Teicher et aI.. 2004, 2006; De Marco.
2000; Widom et aI., 2007; Angst et a!., 2011; Crawford et aI., 2009) or physical abuse (5ugaya et aI.. 2012).
Comparison of diagnostic groups and type of maltreatment show more or less specific associations: focusing on the study of one diagnostic group suggested specific impact, e.g. of early sexual abuse and BPD (e.g. Wingenfeld et al.. 2010) or punish- ment and psychosis (Fisher et al.. 2010). while comparison of types of adversities and diagnostic groups suggest less specificity (Kessler et aI., 1997; Rubino et aI., 2009; Matheson et al.. 2012;
Anda et al.. 2002; McLaughlin et aI., 2010a,b). This may vary with the 'dose' or intensity of experience with different adversities increasing the risk or predicting the onset of severe disorders when accumulating (Rubino et aI., 2009; 5ugaya et aI., 2012;
Mueser et aI.. 2002), It may also vary with the definition of severe disorder: while increasing amount of various adversities increase the risk in different disorders (Kessler et al.. 1997; Read and Bental!, 2010). no dose effect was found for first-presentation psychosis patients (Fisher et a!.. 2010; Sideli et a!.. 2012).
Zuerst ersch. in : Psychiatry Research ; 206 (2013), 1. - S. 103-110 DOI : 10.1016/j.psychres.2012.11.003
Konstanzer Online-Publikations-System (KOPS)
URN: http://nbn-resolving.de/urn:nbn:de:bsz:352-226236
2
Comparing different aspects of childhood experiences like type and developmental period across diagnoses may offer additional inforJ1lation regarding severity of illness and current symptoms.
For adolescent depression as example, Andersen and Teicher (2009) (see also Teicher et al.. 2009) show that stress exposure during windows of vulnerability at some stages in brain matura- tion affects further developments that increase susceptibility for depression in adolescents. This may serve as model of stress exposure contribution to disorder-specific developments.
Tile present study screened types of adverse childhood experi- ences for different developmental periods from early age to adolescence in inpatient samples with primary International Classification of Disorders (ICD)-l 0 diagnoses of Major Depressive Disorder (MDD), Borderline Personality Disorder (BPD) or schizo- phrenia, and in healthy comparison subjects. Major goals were to evaluate whether the pattern of different types of adverse experiences at different age periods varied between diagnostic groups and how such patterns contributed to current psycho- pathology as reflected by symptom severity. In addition, the impact of 'dose' of early adversities on this pattern was examined.
Many studies addressing the impact of childhood adversities have focused on sexual abuse in (healthy) women (e.g. Teicher et aI., 2009) or in female patients with Borderline Personality Disorder (e.g. Wingenfeld et aI., 2010), others examined effects of life events (Brown et aI., 1994; Bifulco et aI., 1998) or childhood adversities (Heim et aI., 2004) in female MDD patients. Gender- specific types of experiences have been assumed (see also Catani et aI., 2009). and a gender-specific stress-sensitivity has been concluded from higher overall responses to pharmacological challenge of the stress-system-though unrelated to specific stressors (DeSantis et al.. 2011). Results on gender-specific inter- action of childhood adversities and psychopathology are incon- sistent: whereas Schilling et a!. (2007) did not find significant gender differences in effects of different childhood adversities on depression and drug abuse. Keyes et al. (2012) report gender differences in the impact of different childhood adversities on the liability for externalizing (higher liability associated with physical abuse in men) and internalizing (higher liability associated with physical abuse in women)-but no impact on specific disorders and no gender-specific impact of neglect. Wainwright and Surtees (2002) show gender-specific effects of trauma or physical abuse on risk of first onset of depression. but not prevalence per se.
Although gender-specific pattern of adverse experiences and its interaction with disorder was not the major goal of the present study. the potential role of gender was considered in the analyses.
2. Methods 2.1. Sample
Data were collected from a total 160 inpatients of the local Center for Psychiatry. Diagnosed by the respective responsible psychiatrist or psychologist following criteria of International Classification of Disorders-l0 (ICD. 10th
Table 1a
Demographic data of patients and healthy controls.
Variable Healthy controls Patients Group
(n=85) (n=160) difference
Age (M ± S.D.) 38.3 ± 14.1 36.7
±
13.8 n.s.Gender-malel 32/53 67/93 n.s.
female
Years of education 11.7
±
1.5 10.3±
1.5 F{ 1.243)=51.04***'" p <0.01.
Revision. WHO). 41 patients received the primary diagnosis of BOI-derline Person- ality Disorder (BPD). 86 patients were diagnosed with Major Depressive Disorder (MOD) 33 patients with schizophrenia. Patients were included in the study if they met ICD-l0 diagnoses ofBPD (F60.31), MOD (1'31-33) or schizophrenia (F20-F25).
if they were in a sufficiently remitted state to allow data collection including the interview on childhood adversities. As the clientele of the center mainly includes long-term patients. most were on psychoactive medication. With the aim to evaluate a larger data set. data of two samples screened with the identical instruments and recruited according to identical rules were Collapsed: a first sample including 75 patients (34 MOD. 33 schizophrenia patients. and eight BPD) and 30 healthy subjects had been screened for prepubescent stress load (Weber et al.. 2008). For those 75 patients data were presently re-analyzed for detailed information about time periods and types of stress. With the aim to enlarge the sample size additional 52 MDD and 33 BPD patients were recruited from the same wards and drawn from the same population of patients admitted to the local Center for Psychiatry were screened together with another 55 healthy subjects using the same screening instrument. The respective two samples did not differ with respect to demographic (age. years of schooling) variables.
Healthy subjects (HC, healthy comparison subjects) were recruited from the community by flyers and screened with the MINI interview (Gemlan version by Ackenheil et al.. 1999) to rule out current or life-time mental disorders; further exclusion criteria were the use of psychoactive medication and neurological disorder in the past. While the patient group did not differ from HC in age and gender, HC had more years of school education than patients (see Table la). The diagnostic groups differed from each other in age and gender. but not in education (Table la).
2.2. Procedures
The study protocol was approved by the ethics committee of the University of Konstanz. Participants were informed about the goal of the study and procedures.
and signed written informed consent. Amount and severity of childhood adver- sities were screened using the standardized interview following Bremner's Early Trauma Interview (ETI. Bremner et aI., 2007; German version by Heim. 2000; see also Wingenfeld et al.. 2011 for psychometric characteristics). The interview assesses the occurrence in the four domains. general trauma. emotional abuse/
neglect. physical abuse/neglect. and sexual abuse. Any reported experience within each domain is considered as a single event. For each reported event the age when it started and the age when it terminated are specified, and the event frequency within each domain and year is encoded on a seven-point Likert-scale ranging from 'never within this year' to 'several times a day'. These ratings per year were summed up for time windows that have been proposed to be differentially affected by stress according to Andersen et al. (2008): pre-school (3-5 years).
prepubescent (9-10 years). pubertal (11-13 years) and adolescent (14-16). In the present analysis. the period from 6 to 8 years was added with the aim to characterize the full profile of adverse experiences across childhood from 3 to 16 years. Since the age periods were of different length, the mean score/year was determined as measure of time of adverse experiences. For evaluation of the type of experience. scores were summed up across age periods for each domain.
Symptom severity was determined in all participants at the time of the stress interview. Symptom measures (see Table 1 b for group means) included self- ratings of depressive symptoms (Beck Depression Inventory. BDI-II, Hautzinger et aI., 2006). negative affect during the preceding week (Positive and Negative Affect Scale. PANAS Watson et al.. 1988). and (in the second sample only) borderline symptoms using the borderline symptom list (BSL-23; Bohus et al..
2009; Wolf et aI., 2009). Symptoms associated with posttraumatic stress disorder (PTSD), hyperarousal, intrusions. and avoidance, were assessed using the Post- traumatc Stress Scale interview (PSSI) that covers the DSM IV criteria (PDS. Foa, 1995; Foa and Tolin. 2000). Symptom severity was assessed irrespective of whether criteria of PTSD diagnosis were met. Comorbid PTSD diagnosis deter- mined from the PSSI. and comorbidity of BPD and MOD diagnoses served as additional measures of severity of psychopathology. Borderline symptoms were available only for the second patient sample (see Table Ib).
BPD MDD Schizophrenia Diagnostic group
(n=41) (n=86) (n=33) differences
26.4
±
6.8 42.3 ± 12.1 33.0± 9.2 F(2,lS7)= 33.99*' All post-hoc comparisons"*4/37 41/45 22/11 zf3)=27.6**
10.0
±
1.2 10.3±
1.6 10.6±
1.6 Diagnostic groups: n.s.SYll1ptom measures in patients and healthy controls.
Variable (M ± S.D.) SDI-depression posthoc comparisons Negative affect PANAS PQsthoc comparisons
PTSD symptoms (avoidance, intrusion, hyperactivity) posthoc comparisons
Borderline Symptom List BSL-23
Posthoc comparisons
• p <0.05 . .. p <0.01.
20
15
10
5
0 age3-5
20
15
10
5
0 age3-5
age6-8 age9-10
age6-8 age9-10
HC N=82 4.0±4.0
< Patient groups"
N=85 19.5 ± 4.7
< Patient groups*'"
N=85 0.5 ± 1.6
< Patient groups**
N=37 4.2 ± 3.7
< Patient groups"
agell-13 age14-16
MOD
a8el1-13 age14-16 40 30
20
10Q BPD N=38 29.2 ± 13.0
>MDD'
> Schiz>/;*
N=40 37.3 ± 12.1
>MDD**
> Schiz**
N=40 18.9± 14.5
>MDD**
> Schiz**
N=21 43.9±24
>MDD""
20
15
10
5
0
ageS-S a8e6-8
MDD Schizophrenia Group differences
N=83 N=33 F(3,232)=96.1""
25.4 ± 11.0 15.3 ± 9.5
> Schiz"''''
N=86 n=33 F(3,240)=53.6"*
30.1 ± 8.0 25.9 ± 7.5
> SchizW$
N=81 N=30 F(3,232)=34.7*"
9.5 ± 12.8 3.0±6.0
> Schiz'
N=46 No data F(2,101 )=26.1"*
25.0 ± 20.1
sez
a8e9-10 agel1-B age14-16
Fig. 1. Distinct profiles of adverse childhood experiences for the three diagnostic groups MDD (top left), BDP (bottom left), schizophrenia (top right). Experience scores relative to those of healthy controls (z-transformed) are plotted for the five age periods (abscissa) and for the four domains (color coded: emotional neglect/abuse: blue, physical punishment/abuse: red, sexual abuse: magenta, general trauma: green).
2.3. Data analyses
Differences in adverse childhood experiences (score) between patients and healthY controls, and between diagnostic groups were evaluated in repeated- measures analyses of variance (ANOVA) with the between-subjects factor Group (comparing patients and HC) in one ANOVA, and the between-subjects factor Diagnostic group (comparing patients with primary lCD-Diagnoses of BPD, MDD, or schizophrenia) in another ANOVA. The latter comparison used z-transformed scores, that is, experience scores in patients relative to He.
An omnibus ANOVA compared the five age periods and the four adversity domains as two within-subject factors, Time and Type. Main effects and interactions were then scrutinized in follow-up ANOVAs including each factor separately. More- over, effect sizes were determined using Hedge's g. A main effect of time was further
evaluated for the slope of the z-scores across age periods s= -2"z3-5" -"26- 8"+"z11-13"+2"z-14-16") between diagnostic groups. The impact of degree of early adversities on the pattern of experiences between diagnostic groups was explored by repeating analyses for those patients who reported experiencing a Significant degree of early adversity. The latter was defined as mean score/year during the age period 3-8 years exceeding the mean of controls by more than one standard deviation. This criterion was met by 23 (of 41) BPD, 35 (of 86) MDD and six (of 33) schizophrenia patients.
Additional ANOVAs comparing patients with and without comorbid PTSD diagnosis and with and without comorbid BPD and MDD probed an influence of adverse childhood experiences on comorbidity as index of severity of disorder.
Post-hoc one-factor ANOVA or t-tests decomposed significant main effects of interactions. All analyses were repeated with Gender as additional factor.
4 C Pietrek et al. / Psychiatry Research I (1111) III-III
Table 2
Best fitting models predicting diagnosis from time (left) and type (right) of adverse experience
I
ACE score 3-5 yrs ~.1 1"
===~==I.?~~epO.R'",.18"ACE soore 14-10 yrs
r"""'--
c:.IA:.:C:.:E:.:S::;CO:.:.fe::;.3::;.-.:..16::;.Y;.:.f::;.S
_...JI~
MOO. R'" .05'ACE score 9-13 yes MDO
EmotiOnal neg!eCtiabuse Sexual abuse
BPO. Rt= .22"
PTSO. R'= AO"
Note; ACE: lid""",· cilifdlldM expel'irlrc,'; diagllose.~ mitred 11S duml!liJ wrill/.its;
R'= ildjusted R'; '; p< .05, "; p< .01, I: p< .1
Contributions of adverse childhood experiences (time and type) to diagnoses and to symptom severity were examined by multiple linear regression analyses. In separate regression analyses, the dependent variables primary lCD-diagnosis (MOD. BPD. or schizophrenia). comorbid PTSD. and symptoms (BDI-depression.
PANAS-negative affect. PTSD-symptoms. Borderline symptom score) were regressed on the scores for age period and type of experience. For symptom measures, the primaty!CD diagnosis (entered as dummy variable) and all possible two-way interactions were added. High collinearity (ViF > 10) of stress scores at age 9-10 and 11-13 years suggested to collapse the two age ranges. (The number of patient per diagnostic group with significant degree of early adversity seemed too small for regression analyses.)
3. Results
3.1. Disorder-specific patterns of adverse childhood experiences
Patients as a group reported significantly higher load of adverse experiences than healthy subjects across all age periods (main effect Group,
F(l,243)=55.15, p<O.OOl).Main effects Time
(F(4,972)=46.11, p<O.OOl)
and Type
(F(3,729)=90.11, p<O.OOl)confirmed an increase of experiences with age and a dominance of emotional neglect/abuse in all participants. Interactions Group x Time
(F(4,972)= 10.89,
p<O.OOl)and GroupxType (F(3,729)=29.lO, p
< 0.001)suggested closer inspection of the pattern of experiences in the patient samples. An interaction Diagnostic group x Time x Type
(F(24.1824)=3.59, P <:
0.01)indicated specific profiles, which are characterized in Fig. 1 by time and type of adverse experiences for the three diagnostic groups (see mean scores in Supplementary Table lc).
This profile was described step by step in separate ANOVAs. The comparison of diagnostic groups, as illustrated in Fig. 2a, showed that BPD patients had experienced more adversities across childhood than MDD patients and schizophrenia patients. This is verified for z- transformed average stress scores in the ANOVA including patients only by a main
effec~Diagnostic groups,
F(2,157)=18.34, P
< 0.001;see Fig. 2b for effect sizes. In all diagnostic groups the amount of adverse experiences increased across age peIiods (Time,
F(4,12)=5.82, p<O.OOl).Significant linear and quadratic trends (F( 1,241) = 96.42 and
46.01,p <
0.001)indicated a pronounced increase before pUberty. Comparison of regression slope between diagnostic groups
(F(3,241)=7.94, p
< 0.01)verified that the increase of adverse experiences across time was larger in BPD and MOD (who
a
10
b
2 1.8 '6l 1.8
_f/) Q) 1.4
-§'
1.2;s.
Q) 1
.l/i
0.8~
Q) 0.60.4 0.2 0
.... ¥ ... *
9-10 11·13 14-16
mean/year for five age periods between 3-16 years
g-3·5 g-6-8 g .. 9-10 g-11-13 9·14-16 effect sizes per age period
-··BPD -<>-MDD ... SCHIZ
"""HC
IIIBPO
DIVIJO
[JSCH
Fig. 2. (a) Stress score (ordinate: mean/year ± S.D.) averaged across types of adverse childhood experiences separately for the five time periods pre-school (age 3-5). primary school (age 6-8). prepubescent (age 9-10), pubertal (age 11- 13) and adolescent (age 14-16) and separately for patients with primary ICD- diagnosis of MOD (black diamonds). patients with primary lCD-diagnosis of Borderline Personality Disorder (filled circles). patients with schizophrenia (filled triangles) and healthy controls (open circles). (b) Stress scores for the five age periods expressed as effect sizes (Hedge's g) for the three patient samples Borderline Personality Disorder (dark gray bars). MOD (hatched bars). and schizophrenia (checkered bars).
a
300
25O
2
~200§15O fJl
£:100
ii
50
b
2 1.8
en
1.6(Jl
~ 1.4
"5l
1.2~
.m
(J> 0.8~ 0.6
~
0.40.2 0
errotiol1al physical
neglect punishrmnt
emotional physical neglect punishment
sexual abuse
sexual abuse
general traurm
general trauma
lIIIBPD OHC OMJD OSCH
lIIaf{)
DMJD DSCH
Fig. 3. (a) Stress scores (ordinate) summed up for each type of adverse experience, emotional neglect, physical punishment, sexual abuse, and general trauma, separately for patients with primary lCD-diagnosis of MOD (black diamonds), patients with primary lCD-diagnosis of Borderline Personality Disorder (filled circles), patients with schizophrenia (filled triangles) and healthy controls (open circles). (b) Stress score for type of experience expressed as effect sizes (Hedge's g) for the three patient samples Borderline Personality Disorder (dark gray bars), MOD (hatched bars), and schizophrenia (checkered bars).
Table 3
did not differ from each other) than in schizophrenia patients and He (who did not differ from each other). Although differences between diagnostic groups were evident in all age periods an interaction Diagnostic group x Time
(F(8,628)=4.07, p < 0,01) suggest prominentearly-life adversities in BPD relative to the other patient groups.
Within the patient subsample with high degree of adversities, the amount of adversities across age periods did not differ, 23 (56%) BPD, 35 (40%) MDD and six (18%) schizophrenia patients had experienced a significant degree of adversities between three and eight years. Within this sample, the amount of adversities across age periods did not differ significantly between diagnoses (comparison of three groups,
F(2,52)=1.23,
P> 0.1, comparison of BPD and MDD only
F(l,56)=2.72, p=O.l).Still, the regression slope indicates a steeper increase of adverse experiences across time in BPD than in MDD
(F(l,56)=7.38, P < 0.01) and schizo- phrenia patients
(F(2,61)=3.93, p < 0.05).
The comparison of different types of adversities showed marked experiences of emotional neglect/abuse relative to other types of adversities (Fig. 3a; Type,
F(3,6)=14.49. P < 0.001). Experiences differed between diagnostic groups (effect sizes in Fig, 3b; Diagnostic group
xType, F(6,471)= 11.84, P < 0.01) in that sexual abuse was particularly pronounced in patients with BPD (post-hoc t-test comparison with all other groups
p < 0.01). while BPD and MDDreported more physical punishment and general traumata than schizophrenia patients
(p< 0.01). The dominance of emotional neglect/abuse was confirmed for the patient sample with significant early adversities (Type, F(3,6)= 54.44, p
<0.001). Although BPD with significant degree of early adversities experienced more sexual abuse than MDD
(F(2,60)=9.17, p <0.001), the interaction Diagnos- tic group
xType did not reach significance.
3.2.
Impact of adverse childhood experiences on diagnosis.
co morbidity. and symptoms
Multiple regression analyses examined the impact of adverse childhood experiences on diagnoses. Regressing diagnoses on time and type of adverse experiences showed that early (3-5
Best fitting models predicting symptoms from time
(left)
and type (right) of adverse experience: = : ! l ::ii:'
t=~~======;~~ ,===, === 21" Depression (801)
Schizophrenia . . 1'1"", .55"
F
MOO xACE9·13 yrs====:;i.~ I
i
MOOI,
t~: ~~3:::
):::.:::======
.2 •• N;gatiV~~ffect!
SchIzophrenia!
.1~ R ;.40I
MOO x emolionalneg!ectjNelf; ACE; a(/llel'SC childfrood expcriclICI'; ,liaglillSi's fllierea "sdumlllY mriaNes;
R1~ lid/lISted IF; '; 1'< .05, ": 1'< .01, t: p< .1
6
years) and adolescent (14-16 years), or sexual and emotional abuse added explained variance to BPO diagnosis, whereas explained variance was low for MOO and non-significant for schizophrenia diagnosis (Table 2).
In addition to primary diagnoses comorbid diagnoses were evaluated as indication of more severe disorder. Comorbid BPO and MOO was diagnosed in fourteen patients, eight of whom had experienced a significant degree of early adversities. An associa- tion of adversity and comorbity was suggested by a particularly high amount of childhood adversities in patients with comorbid PBO and MOO relative to patients with MOO only (S5), BPO only (2S) or schizophrenia (33). An explorative comparison of diag- nostic subgroups points at group difference with
F(4,240)=24.92,p
<0.001. Adverse childhood experiences also varied with the
likelihood of comorbid PTSO diagnosis across diagnostic groups:
an ANOVA comparing patients with (63.4% or 26 BPO, 33.7% or 29 MOO, 6.1% or two schizophrenia patients) and without comorbid PTSO diagnosis (15 BPO, 57 MOO, 31 schizophrenia patients) verified more severe childhood adversities in patients with comorbid than without comorbid PTSO in all age periods (z-scores,
F(l,243)=103.4, P < 0.001). Although most pronounced in MDD (t(S4)=4.0, P < 0.01), the difference was confirmed for each diagnostic group (BPO,
t(39)=-2.3, P
<0.05; schizophrenia,
t(31)=-2.0, p<0.05).Similarly, 15 BPO, 20 MOO, one schizo- phrenia patient with significant degree of early adversity and comorbid PTSO reported overall more severe childhood adver- sities than those with significant degree of early adversity but without comorbid PTSO
(F(l,61)=5.40, P
<0.05). Sexual abuse was most frequently reported in patients with significant degree of early adversity and comorbid PTSO
(F(3,lS3)=2.63, p=0.05).Multiple regression analysis complemented this result (see Table 2): adversity scores around puberty (9-13 years), or emo- tional neglect and sexual abuse explained comorbid PTSO in addition to MOO or BPO diagnoses, adverse experiences at an earlier developmental stage moderated the association between diagnosis and comorbid PTSO.
Stepwise multiple regression analyses specified the contribu- tions of diagnoses and adverse childhood experiences to current symptom scores. As evident from Table 3, affective symptoms (BDJ-depression, PANAS-negative affect) were predicted best by primary diagnoses, with (prepubescent) time and sexual abuse adding explained variance or (prepubescent experiences, emo- tional neglect) moderating the relationship between disorder and symptom expression. Only BPO diagnosis added variance to the prediction of PTSO-symptoms together with experience load between 6 and 13 years, and (sexual, physical) abuse.
3.3. Gender-specific effects
The present sample reflected the known higher prevalence of female BPO and male schizophrenia inpatients (see Table 1 a). When Gender was introduced as factor in the ANOVA of disorder-specific experience patterns, no interactions with diagnosis or developmen- tal period were found, whereas female patients reported generally more adverse experiences than male patients
(F(l,3)=4.35,p
<0.05), and the expected higher prevalence of sexual abuse in
women was reflected by an interaction Gender x Type
(F(3,9)==3.23,p < 0.05) irrespective of diagnosis. Additional ANO- VAs comparing male and female MOO patients (as diagnostic group with more balanced gender distribution), and male and female healthy subjects did not confirm main effects of gender or interac- tion for time or type of adversities (main effects or interactions
F <1). Moreover, including gender as independent variable in the multiple regression analyses did not change the overall pattern of explained variance.
4. Discussion
The present comparison of adverse childhood experiences between three diagnostic groups and across developmental periods and types of experience suggest different patterns of exposure to stressors associated with diagnosis. A significant impact of sexual abuse and traumata in the history of BPO or an effect of prepubes- cent stress load on course and severity of depression confirmed previous findings when diagnostic groups had been studied sepa- rately (e.g. Trull, 2001a,b; Heim et aI., 2004). Schizophrenia patients reported less severe adverse childhood experiences than suggested by earlier reports (e.g. Read et aI., 2005; Rosenberg et aI., 2007).
Celtainly, the exposure to stressors during childhood is higher in schizophrenia patients when compared to healthy subjects (Betensky et aI., 2009; McCabe et aI., 2012), but not necessarily higher than for other disorders (Rubino et aI., 2009). It might be argued that under-reporting of stressors may be part of the symptoms of schizophrenia patients. However, the profile of experi- ences showed characteristics of adversity similar, though less frequent, to those of the other patient groups. Finally. the present sample included only chronic inpatients whereas other reports may have included larger patient samples covering a larger range of age, course, and psychotic syndromes.
Studies screening different types of adversities in different groups indicate a dose-effect, in that a higher degree of exposure to early adversities predicts a higher symptom score across diag- noses (Kessler et aI., 1997; Rubino et aI., 2009). Such a dose-effect was also obtained in the present study: for patients with significant degree of early adverse experiences the association between type of adversity and severity of disorder (indexed by primary diagnosis, comorbidity, and symptom severity) was the same across diagnoses.
The percentage of patients per diagnostic group who had experi- enced a significant degree of early adversities was in the range of rates reported in the literature (e.g. Chapman et aI., 2004; Zanarini et aI., 1997). Still, BPO and MOO differed with respect to adversities across age (with BPO experiencing more adversities than MOO particularly around pUberty) and with respect to experience of sexual abuse (more in BPO than in MOO). Thus, comparison of adversity profiles for a larger sample of patients and for a subsample of those patients who had experienced a significant degree of early adversities suggest the impact of the 'dose' of maltreatment, but also additional disorder-specific effects of childhood experiences. The present comparison further strengthens the impact of interpersonal stress (emotional neglect/abuse, family chaos, early separation or mentally
illparents) across diagnoses in addition to sexual abuse and traumata (Allen, 200S; Teicher et aI., 2004; Kessler et al.. 1997).
This directs attention to the frequent occurrence and impact of emotional neglect, humiliation and other interpersonal maltreat- ment on the manifestation of disorder.
Childhood and early adolescence offer particular risks for mal- treatment effects as periods of marked brain maturation and development (Paus et aI., 200S; Teicher et aI., 2002). From gray matter changes of cortical and subcortical brain regions across age Andersen and Teicher (200S) conclude specific windows of vulner- ability for the influence of adverse experience and suggest a stress- incubation cortico-limbic developmental cascade that may increase the risk and susceptibility for (adolescent) depression (see also Kaufman and Charney. 2001). The association between adverse experiences, particularly before puberty, and severity of disorder is in agreement with this model. Further contributions including genetic influence (Pally. 2002; Goodman et aI., 2004; Bradley et a!..
200S), parental psychopathology (Kessler et aI., 1997). and person-
ality factors Trull (2001 b) are assumed to modify the complex
interaction. Many reports emphasized 'early life stress' as influential
for the development and course of mental disorders. The present
results verified an impact of pre-school adverse experiences
(if defined as 'early') only for BPD and highly intense experiences such as sexual abuse. This may point to a less clear distinction in the m3turational periods before and after school onset. or. alternatively.
be explained by memory bias favoring better recollection of experi- ences at school age than before. The latter has been considered a source of inaccuracy and unreliability in all retrospective assess- ments (Kessler et al.. 1997). Assessment through interview with standardized questions and check-lists of items instead of free recall have been carefully designed to reduce memory bias. and this procedure shows good psychometric properties (e.g. Bremner et
al..2007; Wingenfeld et a!.. 2011).
Present results are in line with an impact of early life stress. if time and type of experience are considered conjointly: sexual abuse. a most severe adverse experience. was frequent early in life particularly in BPD. The time around puberty has been considered' as another 'vulnerable' developmental period during which adverse experiences exert particular effects (Giedd et al..
2008; De Bellis et al.. 1999; Heim et al.. 2004). Present results suggest adverse experiences during this period to be influential for current symptom severity. The impact of prepubescent stress on course and severity of depression (Heim et aI.. 1997. 2004) may be manifest in the present impact as moderator of the relationship of disorder and symptom severity.
Considering different experience profiles between diagnostic groups in both. the entire sample and the subgroup of patients experiencing a significant degree of early adversities showed an impact of adverse childhood experiences on the development of BPD compared to MDD and an impact of diagnosis and pre- pubescent adversities on symptom severity. Future studies (including large samples and additional information e.g. from genetics) need to clarifY the interaction of both factors in the course and expression of disorder.
Small sample sizes and retrospective assessment pose major limitations on the evaluation of childhood adversities and mental disorder. introducing inaccuracy and variability (Kessler et a!.. 1997).
Present results are based on a limited sample of chronic. treated inpatients. which reflects psychiatric reality, but lacks the power of epidemiological studies with large representative samples. However.
present results may add to results obtained from those surveys, and accumulation of results contributes to the strengthening of conclusions.
Retrospective assessment is supposed to induce inaccuracy through memory bias. This is particularly assumed for psychiatric patients. for whom memory bias may vary with symptoms. More- over, the recall of traumatic experiences may be avoided particularly in patients with PTSD symptoms. Using standardized interviews with lists of possible experiences and structured sequence of assessment when, how often, how long the particular event was experienced aimed to reduce the memory bias. Sufficient psycho- metric properties have been demonstrated for the instruments used in the present study (Bremner et a!.. 2007; Foa and Tolin, 2000;
Powers et aI., 2012; Hyman et aI., 2005). Accurate retrieval of the time/age of experience may deteriorate with increasing time delay, and therefore bias memories of early life experiences. Structured' interviews were used to compensate to some extent. as was averaging across time (following Teicher's suggestion of develop- mental peIiods). Still, the smaller number of events reported at age 3-5 may have resulted from both fewer experiences at that age and retIieval problems.
The present results are based on two samples that were assessed with identical methods in similar patient groups one year apart.
However, reported adversities did not differ between the two subsarnples, which supports the reliability of interview-based data.
In conclusion, consideration of the diagnosis-specific profile of time and type of adverse childhood experiences and the distinct impact of profile aspects on prediction of diagnoses and current
symptoms add to the discussion of the role of stress in the complex pattern of etiological factors in mental disorders.
Acknowledgment
Research was supported by The Deutsche Forschungs- gemeinschaft (German Research Foundation. FOR 751). The assis- tance of Sabine Scheermesser, Johanna Fiess, Amra Covic, Jonas Pregitzer in data collection is greatly acknowledged.
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