The roles of peritraumatic dissociation, child physical abuse, and child sexual abuse in the development of posttraumatic stress disorder and adult victimization
Introduction
The possible long-term consequences of childhood sexual abuse and childhood physical abuse have been well documented (e.g., Beitchman et al., 1992; Browne & Finkelhor, 1986; Malinosky-Rummell & Hansen, 1993). Children who endure either sexual abuse or physical abuse appear to be at risk of developing a number of adult problems, including depression, low-self-esteem, posttraumatic stress disorder (PTSD; Roesler & McKenzie, 1994) and adult victimization (Messman & Long, 1996). Research on childhood trauma has also suggested that children who experience a combination of both sexual and physical abuse may be at higher risk of developing adult psychological problems than children who experience only one form of childhood abuse (Briere & Runtz, 1990; Schaaf & McCanne, 1998).
Schaaf and McCanne (1998) examined the relationship between different types of childhood abuse (sexual, physical, and combined sexual and physical) and the development of posttraumatic stress disorder (PTSD) and adult victimization in a sample of college women. Schaaf and McCanne found that women who experienced combined sexual and physical abuse as children were at greater risk of developing PTSD than women who had not been abused. Women who experienced either childhood sexual abuse or childhood physical abuse were at a greater risk of developing PTSD than women who had not been abused; however, these women were at a lower risk of developing PTSD as an adult than women with combined childhood abuse experiences. Schaaf and McCanne's results also showed that both the child physical abuse group and the combined childhood abuse group experienced higher levels of adult physical and/or sexual victimization than women who had not experienced any child abuse. A number of other studies have reported results similar to those of Schaaf and McCanne (e.g., Hanson et al., 2001; Wind & Silvern, 1992; Windle, Windle, Scheidt, & Miller, 1995).
There exist a number of possible mechanisms and pathways by which multiple forms of abuse can lead to poorer adult outcomes. First, multiple victimization may be partially due to a more general vulnerability to victimization (Mandoki & Burkhardt, 1989). Second, further victimization may maintain or exacerbate the impact of an initial trauma (Proulx, Koverola, Fedorowicz, & Kral, 1995). Third, dual abuse could be interpreted as a distinctive type of abuse associated with unique features, such as a lack of familial social support (Wind & Silvern, 1992). Rodriguez, Vande Kemp, and Foy (1998) suggested that to establish dual abuse as an independent antecedent to the development of poorer adult outcomes, researchers should compare rates of adult problems between groups with dual abuse and groups experiencing only sexual abuse, only physical abuse, and no abuse. Fourth, multiply victimized women may represent individuals who have not yet learned to cope successfully with their initial victimization (Mandoki & Burkhardt, 1989). Proulx et al. (1995) established that coping strategies appear to be powerful predictors of distress and suggested that coping styles could carry over from one incident of victimization to another. Proulx et al. also found that individuals with multiple victimization may be more prone than individuals with single abuse experiences to use escapist coping strategies, which can be associated with increased emotional distress.
One possible coping mechanism by which childhood physical and/or sexual abuse could lead to both PTSD and adult victimization is dissociation. Dissociation is a structured compartmentalization of mental processes (such as thoughts, feelings, or memories) that are normally integrated (Spiegel & Cardena, 1991). Dissociative experiences are common and normal occurrences during childhood (Putnam, 1993), and children are more likely than adults to use dissociation as a defense mechanism. Dissociation has been associated with sequelae of abuse (Browne & Finkelhor, 1986). Several studies have shown that higher levels of dissociation experienced after childhood sexual abuse (e.g., Briere & Runtz, 1988; Chu & Dill, 1990) or childhood physical abuse (e.g., Sanders, McRoberts, & Tollefson, 1989; Swett & Halpert, 1993) are associated with poorer adult outcomes.
When faced with physical or sexual abuse, a child may try to maximize his or her ability to function and make sense out of the world by utilizing dissociation (Siegel, 1996). Classen, Koopman, and Spiegel (1993) have suggested that a child may use dissociative strategies to feel relief and protection from the abuse experience. The child may not be able to control the traumatic event, but may be able to control his or her perception of the event.
Shalev (1993) has suggested that the initial dissociative reactions utilized by the victims of child abuse may lead to the development of a more chronic state of PTSD. Unlike normal, non-stressful events, traumatic situations may cause a significant amount of strain on cognitive processing. The individual may not be able to assimilate the cognitive and emotional information associated with the trauma (Greenberg, 1995; Resick & Schnicke, 1993). Dissociation, utilized by the individual because of the amount of panic and physiological arousal caused by the trauma, may prevent the individual from emotionally processing the external cues associated with the trauma (Shalev, 1997). Thus, dissociation may lead to the development of pathological fear structures and symptoms of PTSD (Foa & Kozak, 1986; Lang, 1979).
Dissociation may also lead to increased risk of adult victimization in survivors of child sexual and physical abuse. Becker-Lausen, Sanders, and Chinsky (1995) assessed female and male undergraduate students and proposed that dissociation would mediate the relationship between any type of child abuse and adult victimization. Their results indicated that child abuse (both sexual and physical) was significantly associated with adult victimization and that dissociation was a significant mediator of this relationship. Becker-Lausen et al. suggested that individuals who experience a dissociation of their perception in response to child maltreatment do so in an attempt to survive the pain of the abuse experience. However, the dissociative reaction may lead abuse victims to learn to dismiss clues that would otherwise warn them to be wary of more dangerous situations. Becker-Lausen et al.'s interpretation is supported by Cloitre, Scarvalone, and Difede (1997), who suggested that dissociation may decrease awareness of environmental cues in an individual who was abused in childhood, causing confusion and distraction that may lead to increased vulnerability.
One type of dissociation that has received a significant amount of attention in recent years is peritraumatic dissociation, or dissociation that occurs during or immediately following a traumatic event (Marmar et al., 1994). Peritraumatic dissociation has been found to be positively associated with PTSD in Vietnam veterans (Tichenor, Marmar, Weiss, Metzler, & Ronfeldt, 1996), motor vehicle accident victims (Ehlers, Mayou, & Bryant, 1998; Ursano et al., 1999), natural disaster survivors (Marmar, Weiss, & Metzler, 1997), civilian trauma victims (Shalev, Peri, Canetti, & Schreiber, 1996), victims of violent assault (Birmes et al., 2001), rape victims (Griffen, Resick, & Mechanic, 1997; Zoellner, Alvarez-Conrad, & Foa, 2002), and college students who have experienced trauma (Bernat, Ronfeldt, Calhoun, & Arias, 1998). The results of the current research on peritraumatic dissociation call into question the commonly held belief that dissociative reactions that occur during or immediately after a traumatic event usually resolve themselves quickly (Putnam, 1999).
Only one study to date has investigated the relationships between peritraumatic dissociation, child abuse, and PTSD. Johnson, Pike, and Chard (2001) examined the relationship between various childhood sexual abuse-related variables (e.g., presence of injury, age of onset, etc.) and peritraumatic dissociation. Johnson et al. found that the presence of penile penetration, the presence of injury during child sexual abuse, and believing that you or someone else would be killed were associated with a higher degree of peritraumatic dissociation. Johnson et al. also found that peritraumatic dissociation was a significant predictor of PTSD symptoms.
To date, no published study has examined the extent to which peritraumatic dissociation may occur after childhood physical abuse. Although Johnson et al. (2001) found that peritraumatic dissociation experienced after childhood sexual abuse was associated with greater self-reported PTSD symptoms, they did not examine the influence that childhood physical abuse may have on the development of adult psychopathology. Previous research has shown that experiencing multiple forms of abuse (sexual and physical) may lead to more serious adult outcomes (e.g., Schaaf & McCanne, 1998; Wind & Silvern, 1992). The present study sought to examine the contributions of single and multiple forms of abuse and peritraumatic dissociation on the development of PTSD.
The current research also attempted to determine the role that peritraumatic dissociation may play in adult revictimization. Past research has determined that abuse in childhood increases the risk of adult victimization (e.g., Gidycz, Coble, Latham, & Layman, 1993; Messman-Moore, Long, & Siegfried, 2000). Therefore, a second goal of the present study was to investigate the role of childhood physical abuse, childhood sexual abuse, and peritraumatic dissociation experienced after childhood abuse on adult victimization.
Section snippets
Participants
Participants for this study were obtained from a sample of female undergraduate college students enrolled in an introductory psychology class at a Midwestern university. Seven hundred and forty-six introductory psychology students completed an initial screening from which participants for the current experiment were selected.
Inclusion requirements for the child physical abuse (PA) group were based on the CPEQ, an adapted form of Milner, Robertson, and Roger's (1990) Childhood History
Description of the child abuse groups
The final sample consisted of 151 female college students between the ages of 18 and 21 who had experienced physical and/or sexual abuse before the age of 15 and 316 females who had experienced no abuse before the age of 15. Mean ages of the groups were as follows: 19.8 years (SD = 5.5) for the CA group, 19.1 years (SD = 2.5) for the SA group, 18.8 years (SD = 1.9) for the PA group, and 19.2 years (SD = 4.1) for the NA group. The four abuse groups did not differ significantly from one another in age, F
Discussion
Peritraumatic dissociation that occurs during or immediately following a childhood abuse experience appeared to be strongly and consistently related to the presence of PTSD symptoms in adulthood (see Table 1). Childhood sexual abuse, whether experienced by itself or in combination with childhood physical abuse, also appeared to be significantly associated with reported symptoms of adult PTSD. Analyses of covariance indicated that these relationships between abuse history, peritraumatic
References (59)
- et al.
A review of the long-term effects of child sexual abuse
Child Abuse & Neglect
(1992) - et al.
Symptomatology associated with childhood sexual victimization in a nonclinical adult sample
Child Abuse & Neglect
(1988) - et al.
Differential symptomatology associated with three types of child abuse histories
Child Abuse & Neglect
(1990) The relationship of childhood sexual abuse with later psychological and sexual adjustment in a sample of college women
Child Abuse & Neglect
(1986)- et al.
Factors predicting PTSD, depression, and dissociative severity in female treatment-seeking childhood sexual abuse survivors
Child Abuse & Neglect
(2001) - et al.
Child sexual abuse and its relationship to revictimization in adult women: A review
Clinical Psychology Review
(1996) Dissociative disorders in children: Behavioral profiles and problems
Child Abuse & Neglect
(1993)- et al.
Relationship of childhood sexual, physical, and combined sexual and physical abuse to adult victimization and posttraumatic stress disorder
Child Abuse & Neglect
(1998) Cognition, memory, and dissociation
Child and Adolescent Psychiatric Clinics of North America
(1996)- et al.
History of physical and/or sexual abuse and current suicidality in college women
Child Abuse & Neglect
(2000)
Diagnostic and statistical manual of mental disorders
Diagnostic and statistical manual of mental disorders
The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations
Journal of Personality & Social Psychology
Mediation of abusive childhood experiences: Depression, dissociation, and negative life outcomes
American Journal of Orthopsychiatry
Prevalence of traumatic events and peritraumatic predictors of posttraumatic stress symptoms in a nonclinical sample of college students
Journal of Traumatic Stress
Development, reliability, and validity of a dissociation scale
The Journal of Nervous and Mental Disease
Peritraumatic dissociation and posttraumatic stress disorder in victims of violent assault
Journal of Nervous & Mental Disease
Impact of child sexual abuse: A review of the research
Psychological Bulletin
Physical violence between young adults and their parents: Associations with a history of child maltreatment
Journal of Family Violence
Dissociative symptoms in relation to childhood physical and sexual abuse
American Journal of Psychiatry
Trauma and dissociation
Bulletin of the Menninger Clinic
Posttraumatic stress disorder: Self- and interpersonal dysfunction among sexually retraumatized women
Journal of Traumatic Stress
Validation of a self-report measure of posttraumatic stress disorder in college-age women
Journal of Traumatic Stress
SCL-90-R: Administration, scoring, and procedures manual II
Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents
Journal of Abnormal Psychology
History of abuse during infancy
Analise Psicologica
Sexually victimized children
Structured clinical interview for the DSM-IV Axis-I Disorders
Emotional processing of fear: Exposure to corrective information
Psychological Bulletin
Cited by (97)
The role of emotion dysregulation and alexithymia in the link between types of child abuse and neglect and psychopathology: A moderated mediation model
2021, European Journal of Trauma and DissociationDispositional optimism mediates relations between childhood maltreatment and PTSD symptom severity among trauma-exposed adults
2021, Child Abuse and NeglectCitation Excerpt :This revictimization relationship suggests that it is especially important to investigate childhood maltreatment in relation to the development and degree of severity of adult-onset PTSD not only due to the wide prevalence of childhood maltreatment, but also because cumulative trauma is associated with increased PTSD symptom severity (Briere, Agee, & Dietrich, 2016; Cloitre et al., 2009; Ogle, Rubin, & Siegler, 2014). Specifically, different forms of childhood trauma, whether isolated or combined, are also associated with adult revictimization and subsequent PTSD symptom severity (Clemmons, Walsh, DiLillo, & Messman-Moore, 2007; Desir & Karatekin, 2020; Hetzel & McCanne, 2005; Schaaf & McCanne, 1998; Walker, Freud, Ellis, Fraine, & Wilson, 2019). Despite the implications of these findings which recommend early intervention to mitigate these associations, mechanisms by which childhood maltreatment increase the risk of developing PTSD after stressors in adulthood remain unclear.
Child maltreatment and mental health problems in 30-year-old adults: A birth cohort study
2020, Journal of Psychiatric ResearchCitation Excerpt :The specific association between PTSD and sexual abuse was also apparent at the 21-year follow-up and highlights that while less common than depression or anxiety, the diagnosis is a relatively specific outcome of this form of maltreatment (Kisely et al., 2018; Mills et al., 2016). Although this association is widely reported, findings are again almost completely based on cross-sectional self-report studies (Hetzel and Mccanne, 2005), and not on longitudinal follow-up of prospective agency-notified maltreatment. There are several limitations to the study.