Elsevier

Journal of Affective Disorders

Volume 217, 1 August 2017, Pages 144-152
Journal of Affective Disorders

Research paper
Anxiety among adults with a history of childhood adversity: Psychological resilience moderates the indirect effect of emotion dysregulation

https://doi.org/10.1016/j.jad.2017.03.047Get rights and content

Highlights

  • Childhood adversity was associated with increased symptoms of anxiety in adulthood.

  • Emotion dysregulation mediated the effects of childhood adversity on anxiety.

  • The strength of the mediation model varied according to psychological resilience.

Abstract

Background

Adverse childhood experiences (ACEs) have been widely identified as risk factors for increased symptoms of anxiety across the lifespan. Little is known, however, about the processes by which ACEs set the stage for increased symptoms of anxiety in adulthood. The current study evaluated whether emotion dysregulation and psychological resilience influence the association between ACEs and symptoms of anxiety.

Methods

A sample of adult primary care patients (N=4006) completed self-report measures related to ACEs, symptoms of anxiety, emotion dysregulation, and psychological resilience.

Results

A moderated mediation analysis showed that emotion dysregulation mediated the association between ACEs and anxiety symptoms, and that the strength of this effect varied as a function of psychological resilience. Specifically, the influence of ACEs on emotional dysregulation was stronger among individuals with low levels of psychological resilience than among those with high levels of psychological resilience. These findings remained significant when controlling for a range of sociodemographic variables in the model.

Limitations

Cross-sectional designs preclude inferences about causality and self-report data may be susceptible to reporting biases. Other psychological variables that may be relevant to the current results, such as protective factors in childhood, were not assessed.

Conclusions

These results have implications for the conceptualization of ACEs, emotion dysregulation, and psychological resilience in etiological models of anxiety. They also highlight the relevance of ACEs, emotion dysregulation, and psychological resilience to the detection, treatment, and prevention of anxiety disorders.

Introduction

Anxiety disorders are common in the general population, with 12-month and lifetime rates of 18.1% and 28.8%, respectively (Kessler et al., 2005b, Kessler et al., 2005a). Anxiety disorders are characterized by excessive fear/worry and subsequent avoidance (American Psychiatric Association, 2013) and are often chronic and re-occurring (Moffitt et al., 2007). Elevated symptoms of anxiety represent a significant public health concern, as they are associated with substantial functional impairment (Löwe et al., 2008), high rates of comorbidity (Roy-Byrne et al., 2008), reduced work productivity, and increased health care costs and utilization (Wittchen et al., 2002, Wittchen, 2002). In the United States alone, anxiety disorders are estimated to cost $44 billion dollars per year in indirect and direct costs (Greenberg et al., 1999).

Although the consequences associated with anxiety disorders have received increased recognition in recent years, further research is needed to clarify the etiology of anxiety. Results of twin and family studies suggest that the magnitude of heritable influences on anxiety disorders is relatively moderate (see Hettema et al., 2001 for a review), indicating that psychosocial factors may be especially relevant in the etiology of anxiety disorders. One factor that theorists and researchers have emphasized to be relevant to the development of anxiety disorders throughout the lifespan is childhood exposure to adversity.

Section snippets

Adverse childhood experiences

Adverse childhood experiences (ACEs) are defined as exposure to emotional, physical, and sexual abuse, emotional and physical neglect, and household dysfunction (i.e., household substance abuse, mental illness, and criminal behavior; intraparental violence; parental separation or divorce) prior to the age of 18 years. Approximately two in every three American adults report a history of at least one ACE, and 12% report at least four types of ACEs (Dube et al., 2001). ACEs have consistently been

Participants

Data were collected from a total of 4,0064006 primary care patients aged 18 years and older. Participants were recruited from 11 primary care clinics in the greater Calgary, AB, Canada area, as part of the EmbrACE study. Recruitment took place from October 2014 to July 2015. The EmbrACE study was approved by the University of Calgary's Human Research Ethics Board.

Procedure

Physicians at primary care clinics in Calgary, AB, Canada and surrounding areas were invited to participate in the EmbrACE study. On

Demographic information

All participants were asked to provide information on their age, gender, ethnicity, education, annual household income, marital status, and employment status. All nominal and ordinal variables (i.e. ethnicity, education, income, marital status, employment) were dummy coded.

Adverse childhood experiences (ACEs)

The Adverse Childhood Experiences (ACE) Questionnaire is a 29-item scale adapted from a variety of published questionnaires including the Conflict Tactics Scale (Straus, 1979), The Child Trauma Questionnaire (Bernstein et

Statistical analyses

Results indicated that the data met assumptions related to multicollinearity, linearity, homoscedasticity, and normally distributed errors. Missing values analyses (e.g, Little's MCAR test, t-tests) revealed that missing data were missing at random and thus did not reflect selection bias. Thus, list-wise deletion was utilized to handle all missing data. Finally, one-way ANOVAs were utilized to evaluate differences in responses to self-reported data as a function of survey modality (i.e. online

Results

Table 1 summarizes the descriptive data for the sample. Approximately 68% of the respondents were women. Participants ranged in age from 18 to 92 years (M=44.13 years, SD=16.98). Eighty-three percent of respondents were White, 9.9% were Asian, 1% were Black, .8% were Native American, and 5.2% were of other ethnicities. In general, the sample had relatively high socioeconomic status and was highly educated (e.g., approximately 57% of the sample had obtained post-secondary or graduate degrees).

Discussion

The current study revealed important insights regarding the psychosocial processes that underlie elevated symptoms of anxiety in adulthood. First, results provided support for the hypothesis that increased cumulative ACEs were associated with elevated symptoms of anxiety in adulthood. Further, each type of ACE (emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, and household dysfunction) was significantly associated with increased symptoms of anxiety. Second,

Conclusions

Despite the substantial personal and economic costs associated with anxiety disorders, only a minority of patients are effectively recognized and treated within primary care settings (Kessler et al., 2009; Goorden et al., 2014). Adverse childhood experiences have been repeatedly identified as an antecedent to anxiety disorders and thus appear to be highly relevant to the conceptualization and treatment of anxiety disorders. Prior to the current study, little was known about the mechanisms by

References (71)

  • J.K. Lee et al.

    Investigating cognitive flexibility as a potential mechanism of mindfulness in generalized anxiety disorder

    J. Behav. Ther. Exp. Psychiatry

    (2014)
  • B. Löwe et al.

    Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment

    Gen. Hosp. Psychiatry

    (2008)
  • D.S. Mennin et al.

    Preliminary evidence for an emotion dysregulation model of generalized anxiety disorder

    Behav. Res. Ther.

    (2005)
  • J.A. Min et al.

    Low trait anxiety, high resilience, and their interaction as possible predictors for treatment response in patients with depression

    J. Affect. Disord.

    (2012)
  • J.C. Poole et al.

    Childhood adversity and adult depression: the protective role of psychological resilience

    Child Abus. Negl.

    (2017)
  • P.P. Roy-Byrne et al.

    Anxiety disorders and comorbid medical illness

    Gen. Hosp. Psychiatry

    (2008)
  • P. Spinhoven et al.

    The specificity of childhood adversities and negative life events across the life span to anxiety and depressive disorders

    J. Affect. Disord.

    (2010)
  • G.E. Wyatt

    The sexual abuse of Afro-American and white-American women in childhood

    Child Abus. Negl.

    (1985)
  • T.N. Alim et al.

    Trauma, resilience, and recovery in a high-risk African-American population

    Am. J. Psychiatry

    (2008)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders (DSM-5)

    (2013)
  • M. Ansseau et al.

    Socioeconomic correlates of generalized anxiety disorder and major depression in primary care: the GADIS II study

    Depress. Anxiety

    (2008)
  • P.M. Barrett et al.

    Parent-child interactions with anxious children and with their siblings: an observational study

    Behav. Change

    (2005)
  • G.A. Bonanno

    Resilience in the face of potential trauma

    Curr. Dir. Psychol. Sci.

    (2005)
  • L. Campbell-Sills et al.

    Psychometric analysis and refinement of the Connor–Davidson Resilience Scale (CD-RISC): validation of a 10-item measure of resilience

    J. Trauma. Stress

    (2007)
  • D.S. Charney

    Psychobiological mechanisms of resilience and vulnerability

    Am. J. Psychiatry

    (2004)
  • D. Cicchetti

    Annual review: Resilient functioning in maltreated children–past, present, and future perspectives

    J. Child Psychol. Psychiatry

    (2013)
  • J. Cohen

    Statistical Power Analysis for the Behavioral Sciences

    (1988)
  • T. Colton

    Regression and correlation

    Stat. Med.

    (1974)
  • K.M. Connor et al.

    Development of a new resilience scale: the Connor-Davidson resilience scale (CD-RISC)

    Depress. Anxiety

    (2003)
  • K.M. Connor et al.

    Practical assessment and evaluation of mental health problems following a mass disaster

    J. Clin. Psychiatry

    (2006)
  • Dobson, K.S., Poole, J.C., Pusch, D., Whitsitt, D., McKay, M., Bhosale, A., 2016. Assessing adverse childhood...
  • S.R. Dube et al.

    Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study

    J. Am. Med. Assoc.

    (2001)
  • A. Etkin et al.

    Failure of anterior cingulate activation and connectivity with the amygdala during implicit regulation of emotional processing in generalized anxiety disorder

    Am. J. Psychiatry

    (2010)
  • K.L. Gratz et al.

    Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale

    J. Psychopathol. Behav. Assess.

    (2004)
  • P.E. Greenberg et al.

    The economic burden of anxiety disorders in the 1990s

    J. Clin. Psychiatry

    (1999)
  • Cited by (0)

    View full text