Recent research: six studies on the long-term effects of abuse & deprivation

Here are half a dozen studies on the long-term effects of various forms of abuse & deprivation.  Paras et al systematically reviewed the association between a history of sexual abuse and a lifetime diagnosis of a somatic disorder.  They found significant links with functional gastrointestinal disorders, nonspecific chronic pain, psychogenic seizures, and chronic pelvic pain.  When analysis was restricted to studies where sexual abuse was defined as rape, they also found an association with fibromyalgia.  Abstracts and links, for this research paper and the further papers described, can be found lower down this page.   

There are then two papers on child abuse and subsequent health problems.  Teicher and colleagues looked at the length of time between childhood sexual abuse (CSA) and subsequent emergence of depression (the most common adult outcome of such abuse).  They found that 62% of their sample (aged 18-22 years) had developed depression - on average about 11½ after the onset of abuse.  There was a surge of new depression cases in early puberty.  Average time of onset of PTSD was about 8 years after abuse onset.  The authors concluded "Exposure to CSA appears to sensitize women to the development of depression and to shift age at onset to early adolescence. Findings from this formative study suggest that clinicians should not interpret the absence of symptoms at the time of CSA as a sign of resilience. Continued monitoring of victims of CSA as they pass through puberty is recommended."  Springer looked at childhood physical abuse and subsequent midlife physical health.  He found that the abuse was associated with increases in adult psychological disorder and poorer health behaviours (e.g. increased smoking), and that these changes were then linked with poorer midlife physical health.

Zeanah et al, in a prospective study, explored differences in psychiatric outcome for children raised in institutions, foster families, or families of origin.  As might have been predicted, those raised in institutions had the worst outcomes, followed by those raised in foster families, followed by those raised in families of origin.  There were differences according to gender, and too according to whether one considered internalizing or externalizing disorders.  

Finally there are two papers on bereavement.  Brent et al looked at "The Incidence and Course of Depression in Bereaved Youth 21 Months After the Loss of a Parent to Suicide, Accident, or Sudden Natural Death."  They concluded "Youth who lose a parent, especially through suicide, are vulnerable to depression and alcohol or substance abuse during the second year after the loss. Depression risk in the second year is mediated by the increased incidence of depression within the first 9 months. The most propitious time to prevent or attenuate depressive episodes in bereaved youth may be shortly after the parent's death. Interventions that target complicated grief and blaming of others may also improve outcomes in symptomatic youth with parental bereavement."  In a linked free full text editorial, Shear wrote " ... studies of adults as well as children indicate that most bereaved people experience a painful period of acute grief and go on to make a good adjustment and to restore their ability to attain joy and satisfaction in their ongoing lives. A clinically significant minority do not enjoy this positive outcome and instead experience psychiatric sequelae, the most common of which are major depression, PTSD, alcohol or substance abuse, and complicated grief. Each of these conditions needs to be recognized as early as possible and treated appropriately to prevent the development of enduring disruptive illness."  

Paras, M. L., M. H. Murad, et al. (2009). "Sexual Abuse and Lifetime Diagnosis of Somatic Disorders: A Systematic Review and Meta-analysis." JAMA 302(5): 550-561.  [Abstract/Full Text] 
Context Many patients presenting for general medical care have a history of sexual abuse. The literature suggests an association between a history of sexual abuse and somatic sequelae. Objective To systematically assess the association between sexual abuse and a lifetime diagnosis of somatic disorders. Data Sources and Extraction A systematic literature search of electronic databases from January 1980 to December 2008. Pairs of reviewers extracted descriptive, quality, and outcome data from included studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled across studies by using the random-effects model. The I2 statistic was used to assess heterogeneity. Study Selection Eligible studies were longitudinal (case-control and cohort) and reported somatic outcomes in persons with and without history of sexual abuse. Results The search identified 23 eligible studies describing 4640 subjects. There was a significant association between a history of sexual abuse and lifetime diagnosis of functional gastrointestinal disorders (OR, 2.43; 95% CI, 1.36-4.31; I2 = 82%; 5 studies), nonspecific chronic pain (OR, 2.20; 95% CI, 1.54-3.15; 1 study), psychogenic seizures (OR, 2.96; 95% CI, 1.12-4.69, I2 = 0%; 3 studies), and chronic pelvic pain (OR, 2.73; 95% CI, 1.73-4.30, I2 = 40%; 10 studies). There was no statistically significant association between sexual abuse and a lifetime diagnosis of fibromyalgia (OR, 1.61; 95% CI, 0.85-3.07, I2 = 0%; 4 studies), obesity (OR, 1.47; 95% CI, 0.88-2.46; I2 = 71%; 2 studies), or headache (OR, 1.49; 95% CI, 0.96-2.31; 1 study). We found no studies that assessed syncope. When analysis was restricted to studies in which sexual abuse was defined as rape, significant associations were observed between rape and a lifetime diagnosis of fibromyalgia (OR, 3.35; 95% CI, 1.51-7.46), chronic pelvic pain (OR, 3.27; 95% CI, 1.02-10.53), and functional gastrointestinal disorders (OR, 4.01; 95% CI, 1.88-8.57). Conclusion Evidence suggests a history of sexual abuse is associated with lifetime diagnosis of multiple somatic disorders.

Teicher, M. H., J. A. Samson, et al. (2009). "Length of time between onset of childhood sexual abuse and emergence of depression in a young adult sample: a retrospective clinical report." J Clin Psychiatry 70(5): 684-91.  [PubMed] 
OBJECTIVE: Depression is the most common adult outcome of exposure to childhood sexual abuse (CSA). In this study, we retrospectively assessed the length of time from initial abuse exposure to onset of a major depressive episode. METHOD: A community-based survey of childhood experiences in 564 young adults aged 18 to 22 years, conducted between 1997 and 2001, identified 29 right-handed female subjects with CSA but no other exposure to trauma. Subjects were interviewed for lifetime history and age at onset of Axis I disorders using the Structured Clinical Interview for DSM-IV Axis I Disorders. RESULTS: Sixty-two percent (N = 18) of the sexual abuse sample met full lifetime criteria for major depressive disorder. Episodes of depression emerged a mean +/- SD of 9.2 +/- 3.6 years after onset of exposure to sexual abuse. Mean survival time from onset of abuse to onset of depression for the entire sample was 11.47 years (95% CI = 9.80 to 13.13 years). There was a surge in new cases between 12 and 15 years of age. Mean +/- SD time to onset of posttraumatic stress disorder was 8.0 +/- 3.9 years. CONCLUSIONS: Exposure to CSA appears to sensitize women to the development of depression and to shift age at onset to early adolescence. Findings from this formative study suggest that clinicians should not interpret the absence of symptoms at the time of CSA as a sign of resilience. Continued monitoring of victims of CSA as they pass through puberty is recommended. Reasons for the time lag between CSA and depression are proposed along with potential strategies for early intervention.

Springer, K. W. (2009). "Childhood physical abuse and midlife physical health: Testing a multi-pathway life course model." Social Science & Medicine 69(1): 138-146.  [Abstract/Full Text]
Although prior research has established that childhood abuse adversely affects midlife physical health, it is unclear how abuse continues to harm health decades after the abuse has ended. In this project, I assess four life course pathways (health behaviors, cognition, mental health, and social relation) that plausibly link childhood physical abuse to three midlife physical health outcomes (bronchitis diagnosis, ulcer diagnosis, and general physical health). These three outcomes are etiologically distinct, leading to unique testable hypotheses. Multivariate models controlling for childhood background and early adversity were estimated using data from over 3000 respondents in the Wisconsin Longitudinal Study, USA. The results indicate that midlife social relations and cognition do not function as pathways for any outcome. However, smoking is a crucial pathway connecting childhood abuse with bronchitis; mental health is important for ulcers; and BMI, smoking, and mental health are paramount for general physical health. These findings suggest that abuse survivors' coping mechanisms can lead to an array of midlife health problems. Furthermore, the results validate the use of etiologically distinct outcomes for understanding plausible causal pathways when using cross-sectional data.

Zeanah, C. H., H. L. Egger, et al. (2009). "Institutional Rearing and Psychiatric Disorders in Romanian Preschool Children." Am J Psychiatry 166(7): 777-785. [Abstract/Full Text] 
OBJECTIVE: There is increasing interest in the relations between adverse early experiences and subsequent psychiatric disorders. Institutional rearing is considered an adverse caregiving environment, but few studies have systematically examined its effects. This study aimed to determine whether removing young children from institutional care and placing them with foster families would reduce psychiatric morbidity at 54 months of age. METHOD: Young children living in institutions in Bucharest were enrolled when they were between 6 and 30 months of age. Following baseline assessment, 136 children were randomly assigned to care as usual (continued institutional care) or to removal and placement in foster care that was created as part of the study. Psychiatric disorders, symptoms, and comorbidity were examined by structured psychiatric interviews of caregivers of 52 children receiving care as usual and 59 children in foster care when the children were 54 months of age. Both groups were compared to 59 typically developing, never-institutionalized Romanian children recruited from pediatric clinics in Bucharest. Foster care was created and supported by social workers in Bucharest who received regular consultation from U.S. clinicians. RESULTS: Children with any history of institutional rearing had more psychiatric disorders than children without such a history (53.2% versus 22.0%). Children removed from institutions and placed in foster families were less likely to have internalizing disorders than children who continued with care as usual (22.0% versus 44.2%). Boys were more symptomatic than girls regardless of their caregiving environment and, unlike girls, had no reduction in total psychiatric symptoms following foster placement. CONCLUSIONS: Institutional rearing was associated with substantial psychiatric morbidity. Removing young children from institutions and placing them in families significantly reduced internalizing disorders, although girls were significantly more responsive to this intervention than boys.

Brent, D., N. Melhem, et al. (2009). "The Incidence and Course of Depression in Bereaved Youth 21 Months After the Loss of a Parent to Suicide, Accident, or Sudden Natural Death." Am J Psychiatry 166(7): 786-794.  [Abstract/Full Text]  
OBJECTIVE: This study examined effects of bereavement 21 months after a parent's death, particularly death by suicide. METHOD: The participants were 176 offspring, ages 7-25, of parents who died by suicide, accident, or sudden natural death. They were assessed 9 and 21 months after the death, along with 168 nonbereaved subjects. RESULTS: Major depression and alcohol or substance abuse 21 months after the parent's death were more common among bereaved youth than among comparison subjects. Offspring with parental suicide or accidental death had higher rates of depression than comparison subjects; those with parental suicide had higher rates of alcohol or substance abuse. Youth with parental suicide had a higher incidence of depression than those bereaved by sudden natural death. Bereavement and a past history of depression increased depression risk in the 9 months following the death, which increased depression risk between 9 and 21 months. Losing a mother, blaming others, low self-esteem, negative coping, and complicated grief were associated with depression in the second year. CONCLUSIONS: Youth who lose a parent, especially through suicide, are vulnerable to depression and alcohol or substance abuse during the second year after the loss. Depression risk in the second year is mediated by the increased incidence of depression within the first 9 months. The most propitious time to prevent or attenuate depressive episodes in bereaved youth may be shortly after the parent's death. Interventions that target complicated grief and blaming of others may also improve outcomes in symptomatic youth with parental bereavement.

Shear, M. K. (2009). "Grief and Depression: Treatment Decisions for Bereaved Children and Adults." Am J Psychiatry 166(7): 746-748.  [Free Full Text]  
This excellent free full text editorial comments:  It is common knowledge, and probably instinctively understood, that loss of a close attachment ushers in a period of acute grief characterized by intense emotional distress, intrusive thoughts, and withdrawal from ongoing life. Within the framework of these commonalities, no two people grieve in the same way or for the same period of time. Many people experience intense uncontrollable emotions as foreign and the difficulty connecting with others or being interested in usual activities as disconcerting. Consequently, bereaved people may worry about whether their experience is normal. Clinicians do not always know the answer. Psychiatrists often struggle with whether, when, and how to treat bereaved people. There is a critical need for research that can help answer these questions ... In summary, studies of adults as well as children indicate that most bereaved people experience a painful period of acute grief and go on to make a good adjustment and to restore their ability to attain joy and satisfaction in their ongoing lives. A clinically significant minority do not enjoy this positive outcome and instead experience psychiatric sequelae, the most common of which are major depression, PTSD, alcohol or substance abuse, and complicated grief. Each of these conditions needs to be recognized as early as possible and treated appropriately to prevent the development of enduring disruptive illness.