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Emotional Abuse in Childhood Is a Differential Factor  for the Development of Depression in Adults
Camila Maria Severi Martins, MPhil,* Cristiane Von Werne Baes, MD, MPhil,*Sandra Marcia de Carvalho Tofoli, MPhil,* and Mario Francisco Juruena, MD, PhD*
† 
Abstract:
 We evaluate the association between subtypes of early life stress(ELS; sexual abuse, physical abuse, emotional abuse, physical neglect, and emo-tional neglect) and psychiatric disorders in adults. The sample was composed of 81 adult psychiatric patients treated at the Day Hospital Unit in Brazil. The pa-tients were assessed using the Mini International Neuropsychiatric Interview ac-cording to diagnostic criteria of the
 Diagnostic and Statistical Manual of Mental  Disorders,FourthEdition
.ThepresenceofELSwasconfirmedbytheChildhoodTrauma Questionnaire, which investigates abuse and neglect subtypes. The pa-tients were also evaluated for the severity of psychiatric symptoms throughself-reportquestionnaires.Atotalof71.6%ofthepatientsexperiencedsometypeof severe ELS compared with 28.4% of the patients without ELS. Of these,55.5% reported having experienced emotional abuse; 48.1%, physical neglect;45.7%, emotional neglect; 39.5%, physical abuse; and 27.2%, sexual abuse.Our data showed that, among the ELS subtypes, emotional abuse was positivelyassociatedwithpsychopathologyinadults,particularlywithmooddisorders(
 p
<
0.05).Thepatientswithahistoryofemotionalabusehadhigherseverityscoresinall symptoms, such as depression, hopelessness, suicidal ideation, anxiety, andimpulsivity. These data demonstrate the impact of ELS, especially in cases of emotional abuse, as a trigger for psychiatric disorders and indicate that the sever-ityofELSisassociatedwithseverityofpsychiatricsymptoms.Therefore,further studies are needed to assess the importance of emotional abuse as a risk factor of severe psychopathology in adults.
Key Words:
 Early life stress, emotional abuse, psychiatric disorders,depression, psychiatric symptoms(
 J Nerv Ment Dis
 2014;202: 774
 – 
782)
C
urrentliteraturehasdemonstratedsignificantassociationsbetweentraumatic events occurring in childhood and adolescence, called
early life stress
 (ELS), with unfavorable outcomes for the individual'shealth (Butchart, 2006; Bernstein et al., 2003). The effects of ELS nega-tivelyinfluencechilddevelopment,affectingallspheresofanindividual'slife: behavioral, emotional, social, cognitive, and physical (Mclaughlinet al., 2010).In Brazil, from 1980 to 2000, a total of 2 million people died asa result of situations of violence. From 1999 to 2007, a total of 159,754children were victims of domestic violence. Moreover, situations of  physical abuse are the primary cause of death in the age group from 5to 19 years old and the second leading cause among children from 1to 4 years old (Pires and Miyazaki, 2005). These data show some of the reality facts, with only sparse records of individual services that do not reveal the true extent of the problem (Carvalho et al., 2010;Ferreira and Azambuja, 2011).Concerning global statistics, in 1997, the World Health Organi-zation (WHO) revealed that, considering all countries, 1 in every5000children die per yearasa result of physical abuse. Anothersurveyconducted in 1999 showed that 20% of women and 5% to 10% of men were sexually abused in childhood. Worldwide, the prevalenceof different forms of sexual abuse among children and adolescentsreaches 73 million (7%) among boys and 150 million (14%) amonggirls (Hatzenberger et al., 2012). Prevalence of physical abuse rangesfrom 4% to 16%, whereas prevalence of neglect or emotional abusereaches 10% in high-income countries (Norman et al., 2012).Furthermore, in 2011, the National Child Abuse and Neglect Data System of the Children's Bureau, a service protecting Americanchildren and adolescents, conducted a research to identify the profileof children who were victims of abuse. According to statistical data,most of the children were white, and more than 25% were 2 years oldor younger. Four fifths of the victims were maltreated by a parent,17.6 % were physically abused, and 9.1% were sexually abused (
Child  Maltreatment Reports
).Children and adolescents exposed to ELS experience seriousconsequences in their biopsychosocial constitution. The literatureshows that, during early childhood and adolescence, important brainstructures are being formed, so the negative consequences of traumaticeventsarelastingandcanremainduringthelifeofthechildren(Teicher,2002; Valente, 2011). These children and adolescents may experienceshort- to long-term losses, including damage to health in general (frac-tures, lacerations, brain injuries) and mental health problems (anxiety;depression; social isolation; suicidal ideation andsuicideattempts; sub-stance abuse; conduct disorder; delinquency; and more specifically,symptoms of posttraumatic stress disorder, such as numbness, chronicanxiety,helplessness,lowself-esteem,andsleepand/or nutritiondistur- bances) at the entrance to adulthood (Koss et al., 2003; Saffioti, 1997;Williams, 2002). Other consequences of ELS are related to cognitivedevelopmental delay, intellectual deficit and school failure, as well asviolence and crime in adolescence (Heim and Nemeroff, 2001;Mclaughlin et al., 2010; Neigh et al., 2009; Vitolo et al., 2005).Many epidemiological studies have documented significant as-sociations between ELS and psychiatric disorders in adulthood(Collishawet al., 2007; Edwards et al., 2003; Kessler et al., 1997; Mul-lenetal.,1996).Inadditiontothis,researchtodayshowsthatmorethan30% of the adult psychiatric disorders are directly associated with theoccurrence of ELS, revealing that such experiences have a cumulativeimpact on mental health. Furthermore, these studies demonstrate that ELS may adversely affect a child's development, triggering severe anddisablingpsychiatricdisordersinadulthood,suchasdepression(Benjeet al., 2010; Gibb et al., 2003; Mclaughlin et al., 2010).The psychological consequences may acutely affect a child
smental health for entry into adulthood (Aded et al., 2006; Brewerton,2007). Mello et al. (2009) emphasize that children who have beenthrough ELS situations have a moderately increased risk for developingdepression in adolescence and adulthood. Approximately a quarter of abused children fill the criteria for depression when they reach the endof the second decade of age, representing, then, a substantial publichealthproblem.Nannietal.(2012)alsofoundthatexposuretoELSdou- bles the risk for depression recurrence. In this sense, researchers point 
*Stress and Affective Disorders Programme, Department of Neurosciences and Be-haviour UniversityofSaoPaulo,Brazil; and
CentreforAffective Disorders,Psy-chological Medicine, King's College London, United Kingdom.Send reprint requests to Mario Francisco Juruena, MD, PhD, Saude Mental (MentalHealth), University of Sao Paulo, Av. Tenente Catao Roxo,2650 Ribeirão Preto, Sao Paulo, Brazil, CEP: 14051-140.E-mail: juruena@fmrp.usp.br.Copyright © 2014 by Lippincott Williams & WilkinsISSN: 0022-3018/14/20211
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0774DOI: 10.1097/NMD.0000000000000202
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 The Journal of Nervous and Mental Diseas
 
 Volume 202, Number 11, November 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 
out that approximately 60% of cases of depressive episodes are pre-ceded by the occurrence of stressors, especially of psychosocial origin,so the influence of genetic factors in the development of depressioncould be due to an increased sensitivity to stressful events (Baes et al.,2014; Mello et al., 2009).In the same direction, occurrence and severity of ELS increasethree times the risk for developing depression in adulthood, accordingto a study presented by Wise et al. (2001). Similar data were found inarecentsystematicreviewconductedbyMartinsetal.(2011),revealingthattheseverityofELSisassociatedwiththeseverityofdepressionandalso that ELS subtypes are important risk factors of depression inadults. Gibb et al. (2003) have also shown an association betweenELS subtypes, specifically emotional abuse, and increased depressionsymptoms in adulthood. Other studies suggest an increase in suicidalideationinadulthoodindepressedpatientswithELS(BriereandRuntz,1988; Mullen et al., 1996; Tunnard et al., 2014). Surveys also show theassociation between emotional abuse and physical abuse with schizo- phrenia in adulthood (Holowka et al., 2003; Rubino et al., 2009),whereas the presence of abuse increases the risk for psychosis(Bebbington et al., 2004; Conus et al., 2010; Tunnard et al., 2014).Regarding negligence, studies have shown an association withdifferent psychopathologies, such as the following: physical and emo-tional neglect are associated with psychotic disorders (Heins et al.,2011, Uçok and Bikmaz, 2007), physical neglect is associated with personality disorders (Laporte et al., 2011), and emotional neglect isassociated with depressive and anxiety disorders (Hovens et al.,2010). In this same direction, Carr et al. (2013) published a recent re-view and found that different subtypes of ELS are associated with sev-eral psychiatric disorders; that is, physical abuse, sexual abuse, andunspecifiedneglectareassociatedwithmooddisordersandanxietydis-orders, and emotional abuse is associated with personality disordersand schizophrenia.In addition, researchers have identified important considerationsregarding the association between ELS subtypes and therapeutic re-sponse of depressive patients. Douglas and Porter (2012) demonstratedthat the severity of ELS subtypes is significantly correlated with the re-duction of the worst clinical status, suggesting that ELS subtypes aredetrimental to the successful treatment of severe depression. Kaplanand Klinetob (2000) found that emotional abuse and parental overpro-tection are associated with a negative response to antidepressants in pa-tientswithmoderate-to-severedepression.Althoughscientificevidencesuggests the existence of association between ELS and psychiatric dis-orders, more research is needed to confirm it. Thus, the present studyaimed to replicate and extend these findings, evaluating the association between occurrence and severity of ELS and psychiatric disorders inadult patients.
METHODSStudy Design
Thisisa cross-sectional studyfromaquantitativeandqualitativeevaluation of the life history and psychiatric diagnosis of patientstreatedat theDayHospitalUnitof GeneralClinical Hospital.Thestudywas approved by the Research Ethics Committee of General ClinicalHospital, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo.
Participants
The sample was composed of 81 adult psychiatric patients,treatedattheDayHospitalUnitofGeneralClinicalHospital.Theinclu-sion criteria for this study were as follows: having a psychiatric diagno-sis confirmed according to the
 Diagnostic and Statistical Manual of   Mental Disorders, Fourth Edition
 (
 DSM-I
; American Psychiatric As-sociation [APA], 1994), being followed up at the Day Hospital Unit of the General Clinical Hospital, and aged from 18 to 65 years. We ex-cluded patients with mental disorders caused by a general medical con-dition or resulting from direct physiological effect of a substance,substance abuse, or substance dependence. Patients with mental retar-dation, cognitive deficits, as well as neurological progressive and de-generative diseases and in an acute psychotic episode that couldimpair the comprehension of the assessment instruments adopted inthe study were also excluded. Patients were clinically assessed by twosenior psychiatrists (M. F. J., C. V. W. B.) and excluded if they met any exclusion criteria. After complete study description to the subjects,their comprehension, and agreement, signed written informed consent was obtained.The sample was divided into two groups based on positive his-tory of ELS according to the Childhood Trauma Questionnaire (CTQ;Bernstein et al., 1994). The first group included those with ELS (withELS), and the second included those without ELS (without ELS). Weincluded in the group of patients with ELS thosewith moderate and se-vere scores in at least one of the five ELS subtypes according tothe CTQ.
Instruments and Procedure
Theparticipantswereinformedthatthepurposeofthestudywasto investigate the association between ELS and psychiatric disorders inadult life. Later, signed written informed conent was obtained from all patients, and the questionnaires included in this study were applied.
Demographic and Clinical Data Measures
Clinical and sociodemographic characteristics, such as age, gen-der, ethnicity, religious practice, family history of psychiatric disorder,and suicide attempt, were obtained through administration of asociodemographic questionnaire developed by the researchers.
Psychiatric Diagnosis Measures
The assessment of psychiatric diagnosis was conducted usingthe Mini International Neuropsychiatric Interview (MINI; Sheehanet al., 1998), the version in Portuguese translated and adapted byAmorim (2000). The MINI is a brief structured interview designed toassess criteria for most psychiatric disorders classified in the
 DSM-IV 
and the ICD-10. There is aversion called MINI PLUS, intended for as-sessment of main psychiatric diagnoses throughout life, in clinical andresearch psychiatry, and systematically explores all the criteria for in-clusion, exclusion, and chronology (onset and duration of the disorder,number of episodes; Amorim, 2000). All subjects were interviewed bytwoseniorpsychiatrists(M.F.J.,C.V.W.B.)trainedandcertifiedtousethe standardized interviews. The interviewers had long-standing expe-rience in administration of the standardized interviews.The evaluation of personality disorders was performed throughthe Structured Clinical Interview for 
 DSM-IV 
 Axis II Disorders(SCID-II; Spitzer et al., 1990). The SCID-II is a self-assessmensemistructured interview, based on axis II criteria of 
 DSM-IV-TR
, for assessingpersonalitydisorders (APA,1989).TheversioninPortuguesewas translated and adapted by Del-Ben et al. (2001).
ELS Measures
ELS was assessed using the CTQ (Bernstein et al., 1994). TheCTQisaretrospectiveself-reportquestionnairethatinvestigateshistoryofabuse(sexual,emotional,physical)andneglect(emotional,physical)during childhood and can be applied to adolescents (from 12 years old)and adults, in which the responder assigns values of frequency in 28graduate assertive issues related to situations arising in childhood.The items are rated on a Likert scale ranging from 1 (never) to 5 (veryoften), and the scores range from 5 to 25 for each type of ELS. The in-strument also contains a subscale of minimization/denial to identify
The Journal of Nervous and Mental Disease 
 
 Volume 202, Number 11, November 2014
 Emotional Abuse and Depression
© 2014 Lippincott Williams & Wilkins
 775
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 
individuals responding in a socially desirable manner. A cut point for  presence or absence of ELS was defined when one of these experi-ences, before the age of 18 years, reached at least a degree of moderateor severe to extreme. This classification is proposed by major authorsintheareaofchildhoodtrauma(Bernsteinetal.,1997,1994,2003;Car- penter et al., 2007). The version in Portuguese was translated andadapted by Grassi-Oliveira et al. (2006).
Severity of Psychiatric Symptoms
To assess severityof psychiatricsymptoms, weusedinstrumentscommonly applied in the mental health research area.
Depression
To assess severityofdepressive symptoms, the BeckDepressionInventory (BDI) was applied (Beck et al., 1961), a self-report question-nairewith21items,inwhichascoreoflessthan9pointsindicatesnoor minimal depression; 10 to 18 points, mild-to-moderate depression; 19to29points,moderate-to-severedepression;andgreaterthan30 points,severe depression. The version in Portuguese was validated, translated,and adapted by Cunha (2001).
Anxiety
Toassessseverityofanxietysymptoms,theBeckAnxietyInven-tory (BAI) was applied (Beck et al., 1988), a self-report questionnairewith 21 items, with an emphasis on physical symptoms. The versionin Portuguese was validated, translated, and adapted by Cunha (2001).
Anxiety-Depression
We also used the Hospital Anxiety and Depression Scale(HADS; Zigmond and Snaith, 1983), a self-report questionnaire con-taining 14 items. The version in Portuguesewas translated and adapted by Botega et al. (1995).
Hopelessness
To assess severity of hopelessness symptoms, the Beck Hope-lessnessScale(BHS)wasapplied(Becketal.,1974),aself-reportques-tionnairewith 20true-false statements developed to assess the extent of  positiveandnegativebeliefsaboutthefuture.TheversioninPortuguesewas translated and adapted by Cunha (2001).
Suicide Ideation
To assess severityof suicide ideation, the Beck Scale for SuicideIdeation (BSI) was applied (Beck et al., 1979), a self-report question-nairewith 21 items, assessing the intensityof the patient 
s specific atti-tudes, behaviors, and plans to commit suicide. Each item consists of three options graded according to the intensity of the suicidality andrated on a 3-point scale ranging from 0 to 2 points. The version in Por-tuguese was translated and adapted by Cunha (2001).
Impulsivity
Toassessseverityof impulsivity,theBarrattImpulsivenessScale(BIS-11) was applied (Patton et al., 1995), a self-report questionnairewith 30 items. The literature suggests that a total score of 72 or greater should be used to classify an individual as highly impulsive. The totalscores of the BIS-11 situated between 52 and 71 points should be con-sidered within normal limits for impulsivity. Scores lower than 52 points are generally representative of individuals who are very con-trolled or who have not responded to the questionnaire honestly(Stanford et al., 2009). The version in Portuguese was translated andadapted by Diemen et al. (2007).
Statistical Procedures
The comparison of parametric data between the two groups(with ELS and without ELS) was performed using the Student 
s
 
-tests, when they presented normal distribution. We used the Mann-Whitney
s
 U 
 test for datawithout normal distribution. For nonparamet-ric data analysis, as demographic and clinical characteristics, we ap- plied the chi-square test. We also calculated the association betweenELS and psychiatric diagnoses with the chi-square test, usingBonferroni
s correction when necessary. Correlations between ELSand psychometric measures were examined using Pearson
s correla-tion. All analyses were conducted using the Statistical Package for the Social Sciences, SPSS for Windows, release 15.0. Significancevalue was considered when
 p
<
0.05.
RESULTS
Amongthe81patientsassessed,weobservedapredominanceof women (
n
 = 59, 72.8%), Caucasians (
n
 = 57, 70.4%), and people whohadcompletedhighschool(
n
=29,35.8%).Thepatients
meanagewas37.62 (SD
1.21) years, with a minimum of 19 years and a maximumof 65 years. Most (
n
 = 41, 50.6%) were married, and a significant por-tion (
n
 = 42, 51.9%) were living with spouses/partners. Furthermore,86.5% of the patients reported religious practice and 77.0% had a fam-ily history of mental disorder.In the assessed sample, 71.6% (
n
 = 58) of the patients had sometype of severe ELS, compared with 28.4% (
n
 = 23) who had no historyofELS,according tothe CTQ. Among 71.6% ofthe patientswith ELS,55.5% reported experiencing emotional abuse; 48.1%, physical ne-glect; 45.7%, emotional neglect; 39.5%, physical abuse; and 27.2%,sexual abuse. We found that the emotional abuse subtype was the most  prevalentinELSsubtypes,accordingtothescale.Furthermore,mostof the sample (60.4%) reported experiencing three to five ELS categories.However,wefoundthatthepatientswithELSdidnotdifferfromthe patients without ELS on demographic and clinical characteristics.Furthermore,amongpatients
sociodemographicandclinicalcharacter-istics, suicide attempt wasthe only variablewe foundthat showeda sta-tistically significant difference (
 p
 = 0.02) between the groups. Inaddition, among 81 subjects evaluated in the psychiatric sample, ap- proximately 60% of the patients with ELS had a diagnosis of personal-ity disorder, whereas inthegroupwithout ELS, 40%had a diagnosis o personalitydisorder,resultinginastatisticallysignificantdifferencebe-tween the groups (
 p
 = 0.032).Table 1 describes sociodemographic and clinical characteristicsof the psychiatric patients according to ELS.In the total sample, the distribution of psychiatric disorders wasas follows: more than 70% had a diagnosis of mood disorders, prevail-ing depressive disorders (
n
 = 44, 54.3%), followed by bipolar disorder (
n
 = 17, 21.0%). The other diagnoses assessed were anxiety disorders(
n
 = 10, 12.3%), schizophrenia and other psychotic disorders (
n
 = 5,6.2%), eating disorders (
n
 = 3, 3.7%), dissociative disorders (
n
 = 1,1.2%), as well as impulse control disorders not elsewhere classified(
n
 = 1, 1.2%). We did not include patients with diagnoses of substanceuse disorder in the sample because the Day Hospital Unit does not ad-mit patients with this diagnosis.We conducted the analysis of association between ELS and all psychiatric disorders. However, according to data presented in Table2,therewasnosignificantdifferencebetweenthegroupswithandwith-out ELS(
χ
2
= 8.44,
df  
 =6.0,
 p
= 0.188)inrelationtothedistributionof  psychiatric diagnoses.In addition, we performed a second statistical analysis, compar-ing ELS subtypes with psychiatric disorders. Thus, significant associa-tion was found only between the emotional abuse subtype and psychiatric diagnoses. Table 3 shows the results of the association be-tween psychiatric disorders and emotional abuse.
 Martins et al.
 The Journal of Nervous and Mental Diseas
 
 Volume 202, Number 11, November 2014
776
 © 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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