International Journal of Psychiatry in Clinical Practice, 2009; 13(1): 2530

ORIGINAL ARTICLE

Childhood traumatic events and dissociation in university students

YUNUS EMRE AYDIN1, ABDURRAHMAN ALTINDAG2 & MUSTAFA OZKAN1 1

Department of Psychiatry, Dicle University Faculty of Medicine, Diyarbakir, Turkey, and 2Department of Psychiatry, Gaziantep University Faculty of Medicine, Gaziantep, Turkey

Abstract Objective. The purpose of this study was to determine the frequency of childhood traumatic events, to investigate its relationship with dissociation and other psychiatric symptoms and to examine the potential effect of family functioning on dissociative symptoms and general psychopathology in a Turkish university student sample. Methods. All participant completed Brief Physical and Sexual Abuse Questionnaire, Symptom Checklist-90-Revised (SCL-90-R), Dissociative Experiences Scale (DES) and Family Assessment Device (FAD). Results. The most frequent childhood trauma type was separation from caretaker (46.1%). Witnessing violence (33.1%), harsh punishment (21.2%) and substance abuse in family (10.5%) followed. Sexual abuse of incest type was seen in 6.3%. Students who reported childhood traumatic events had higher DES and SCL-90-R scores compared to those who did not. There were fair relationships between SCL-90-R and FAD scores. Conclusion. A history of childhood traumatic events may be related to increased level of dissociation and general psychopathology in university students. Other pathogenic family factors also may contribute to the development of psychiatric symptoms.

Key Words: Childhood trauma, dissociation, family functioning, sexual abuse

Introduction DSM-IV-TR defines dissociation as a disruption of normally integrated function of consciousness, memory, identity or perception of environment or the body. Traumatic experiences and dissociative symptoms seem to be intrinsically related. There are two main theories about this relationship. One theory proposes that some people have the capacity to dissociate and will use this capacity to ward off the impact of horrible experiences [1]. In this view, dissociation is a coping mechanism with negative side effects, because non-integrated traumatic experiences  that is, aversive sensorimotor and highly affectively charged experiences tend to intrude consciousness. In another theory [2], dissociation arises because severe stress can interfere with normal integrative mental processes, notably when the individual’s integrative capacity is limited because of factors such as immaturity of the brain and prior stress exposure. In line with these theories, higher levels of dissociation are reported in groups of traumatized

individuals compared to non-traumatized control groups [3]. Chronicity and severity of trauma were also found to predict the level of dissociation in abused children [4]. Furthermore, an association between traumatization and dissociation is supported by moderate correlations between a measure of traumatization and dissociation in groups of traumatized individuals [5]. Foote et al. [6] reported that compared to the patients without a dissociative disorder diagnosis, patients with a dissociative disorder were significantly more likely to report childhood physical abuse (71 vs. 27%) and childhood sexual abuse (74 vs. 29%). Family functioning may play an important role in the development of psychiatric disorders. Brown et al. [7] indicated that many people with somatization disorder are exposed to an early environment that is emotionally cold, harsh, and characterized by frequent criticism, insults, rejection, and physical punishment. This environment also appears to be linked to the development of dissociative disorders.

Correspondence: Dr. Abdurrahman Altindag, Gaziantep Universitesi Tip Fakultesi, Psikiyatri AD, 27310 Gaziantep, Turkey. Tel: 90 342 3606060 (76375). Fax: 90 342 3608272. E-mail: [email protected]

(Received 14 May 2008; accepted 7 July 2008) ISSN 1365-1501 print/ISSN 1471-1788 online # 2009 Informa UK Ltd. DOI: 10.1080/13651500802331540

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Many studies on psychological trauma, to date, conducted in developed Western societies. However, developing countries much more exposed to traumatic events. Besides abusive traumatic experiences, non-abusive traumas like wars, natural disasters, severe poverty, lower educational level, epidemic diseases, immigration, political and religious terrorism, and social violence are very common in developing countries, including Turkey [8]. The purpose of this study was to determine the frequency of childhood traumatic events, to investigate its relationship with dissociation and other psychiatric symptoms and to examine the potential effect of family functioning on dissociative symptoms and general psychopathology in a Turkish university student sample.

Methods Participants and procedure The study group consisted of the first-year students of Dicle University in Diyarbakir, the second largest city of South-eastern Turkey. Students mostly come from low-middle class urban families. Instructions were read orally and students were assured that participation would be anonymous and voluntary. Subjects gave consent by their completion of these measures. All subjects were informed in advance that the study was concerned about particular types of life experiences. It had been requested from participants that they should not give any knowledge of self-identity, such as name, student number or any other sign. The students were surveyed in their classrooms. As part of the study, the participants were asked to fill out some questionnaires. Five hundred and thirty-five students, 15 of whom refused to participate, were approached for the study (response rate 97%). Thirty-five students were excluded from the study because they had answered the questionnaires incompletely. The final group consisted of 485 students: 265 (54.6%) male and 220 (45.4%) female. Their age range was from 17 to 32 years (mean 20.6, SD 1.8).

for the presence (score 1) or absence (score 0) of a history of traumatic events before age 16 in seven categories: (1) traumatic separation from the primary caregiver for more than 1 month, (2) substance-abusing family member in the home, (3) experience of harsh punishment (hitting with object), (4) physical injury to patient or sibling resulting from harsh punishment, (5) witnessing physical violence between caregivers, (6) forced sexual contact with an older child or adult (nonrelative), and (7) forced sexual contact with a relative (maximum score 7).

Symptom Checklist-90-Revised (SCL-90-R). The SCL-90-R [10] is a 90-item, self-report inventory designed to assess the current level of symptoms experienced by an individual. Participants indicate the extent to which they were bothered by a particular symptom during the preceding week, such as ‘‘feeling that most people cannot be trusted’’ or ‘‘feeling lonely’’, on a five-point scale ranging from ‘‘not at all’’ to ‘‘extremely’’. There are three global indices of distress (the Global Severity Index, Positive Symptom Distress Index, and Positive Symptom Total) and nine primary symptom subscales (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism).

Dissociative Experiences Scale (DES). The DES [11] is a 28-item self-report scale that asks the respondent to indicate the frequency of various dissociative experiences, such as derealization, depersonalization, and psychogenic amnesia on 100-mm visual analogue scales (VAS). A sample item is ‘‘Some people have the experience of looking in a mirror and not recognizing themselves. Mark the line to show what percentage of the time this happens to you.’’ The anchors of the 100-mm VAS are 0 (never) and 100 (always). The DES exhibits high internal consistency and testretest correlations ranging from 0.74 to 0.84.

Measures Basic sociodemographic characteristics of the participants (age, sex, economic status, etc.) were investigated using a semi-structured, open-ended questionnaire.

Brief Physical and Sexual Abuse Questionnaire. A semistructured interview, the Brief Physical and Sexual Abuse Questionnaire [9], was used to assess

Family Assessment Device (FAD). The FAD [12] is a 60-item self-report questionnaire that assesses multiple aspects of family functioning. Similar to other screening measures, the FAD allows for a rating of level of health or pathology but is not diagnostic in nature. Factor analysis has confirmed the presence of six subscales: Roles (the established patterns of behavior to support and sustain family functions), Communication (the way the family exchanges

Childhood traumas and dissociation information with each other), Problem Solving (the family’s effectiveness in resolving problems), Affective Responsiveness (the ability of family members to utilize appropriate affect over a range of situations), Affective Involvement (the extent to which family members express interest in and value each other’s activities), and Behavioral Control (the way the family expresses and maintains acceptable standards of behavior). The General Functioning scale provides a global rating of overall family functioning. Scale and subscale scores range from 1 to 4, with higher scores representing less healthy functioning. Normative studies have established cutoff scores for unhealthy or distressed family functioning for each scale, ranging from 1.9 to 2.2. Statistical analyses The Statistical Package for Social Sciences (SPSS 11.5, SPSS Inc, Chicago, IL) was used for all statistical analyses. A series of logistic regression analyses were performed to determine if any of the childhood traumatic events predicted dissociation among university students. All identified childhood traumatic events by using Brief Physical and Sexual Abuse Questionnaire were included in the regression analysis. Bivariate analyses were conducted by chi square statistics for categorical variables and twotailed t-tests for continuous data. Pearson’s correlations conducted to examine the relationship between SCL-90-R and FAD scores. The two-tailed significance level was set at 0.05. Results The most frequent childhood trauma type was separation from caretaker (Table I). Witnessing violence 33.1% (n 161), harsh punishment 21.2% (n 103) and substance abuse in family 10.5% (n 51) followed. Sexual abuse of incest type was seen in 6.3% (n 31). There was not any gender difference in the frequency of incest. 26.5%

(n 129) of the participants reported just one type of trauma, whereas 23.2% (n 113) reported two types, 14.4% (n 70) three types, 7.2% (n 35) four types, 3.5% (n 17) five types, 1.2% (n 6) six types and 0.8% (n 4) all of seven types of trauma. A total of 77.1% (n 374) of the participants reported childhood traumatic events. Stepwise logistic regression identified four childhood traumatic events as predictors of dissociation among university students: separation from caretaker, physical injury to patient or sibling from harsh punishment, sexual contact with unrelated adult and sexual contact with a relative (Table I). Comparison of SCL-90-R subscale scores between students who have and do not have childhood traumatic events is shown in Table II. Students who reported childhood traumatic events had higher scores on all SCL-90-R subscales (PB0.05 for all) than those who did not. Pearson’s correlations revealed fair relationships between SCL-90-R and FAD scores (Table III). Discussion The results of the present study confirm previous research regarding the prevalence of childhood traumatic events as well as the association of childhood traumatic events with increased level of dissociation [13]. In the present study, 77.1% of the participants reported a history of childhood traumatic events. Furthermore, history of childhood traumatic events was found to be associated with all subscales of the SCL-90-R reflecting the findings of previous studies, which report an association between childhood traumatic events and psychological symptoms [14]. Dissociative disordered people report a high incidence of sexual, physical and emotional abuse in childhood [15]. Nonclinical samples also have demonstrated an association between dissociative tendencies and the incidence of such childhood trauma as a loss in the family, intrafamilial or

Table I. Childhood traumatic events as predictors of dissociation among university students (n485).

Wald’s test (df) Separation from caretaker Substance abuse in family Harsh punishment Physical injury to patient or sibling from harsh punishment Witnessing violence Sexual contact with unrelated adult Sexual contact with a relative *PB0.05.

4.99 0.02 2.86 4.52

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P

Unadjusted odds ratios (95% confidence interval)

(1) (1) (1) (1)

0.02* 0.65 0.09 0.03*

1.63 1.33 1.54 2.00

(1.072.48) (0.712.51) (0.962.48) (1.083.67)

2.96 (1) 8.79 (1) 12.39 (1)

0.08 0.003* 0.004*

1.36 (0.882.09) 3.36 (1.806.29) 4.00 (1.908.41)

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Table II. Childhood traumatic events and SCL-90-R scores. Childhood traumatic events

SCL-90-R Somatization Obsessive-compulsion Interpersonal sensitivity Depression Anxiety Anger-hostility Phobic anxiety Paranoid ideation Psychoticism GSI

Present (n374) Mean9SD

Absent (n111) Mean9SD

t

df

P

1.1790.67 1.5390.68 1.3890.73 1.3890.74 1.1990.74 1.1890.78 0.8390.64 1.3390.70 1.0090.60 1.2690.59

0.8190.53 1.1990.62 1.1190.75 1.0490.70 0.8390.64 0.8090.57 0.6590.63 0.9590.63 0.6690.56 0.9390.53

4.69 4.31 3.19 3.94 4.24 4.36 2.34 4.49 4.79 4.68

440 445 448 448 449 449 449 450 449 425

B0.001 B0.001 B0.01 B0.001 B0.001 B0.001 B0.05 B0.001 B0.001 B0.001

GSI, Global Severity Index.

extrafamilial sexual abuse, and intrafamilial physical abuse [16]. Rodriguez-Srednicki [17] compared female college students reporting a history of childhood sexual abuse and not reporting a history of childhood sexual abuse on indices of dissociation and self-destructive behaviors. The childhood sexual abuse group had significantly higher mean scores on the indices of dissociation and self-destructive behavior. If a dissociative coping style tends to be engendered by childhood trauma, what specific psychological effects of these traumas prompt the use of dissociation and become the object of dissociative processes? Several recent studies suggest that unresolved emotions associated with the original trauma are pivotal in this context. Dissociative tendencies in adulthood are found to be predicted by a proneness to experiences of grief, shame and guilt, anger, depression and anxiety [18]. These data might be interpreted to indicate that traumatized children eventually tend to dissociate knowledge of their traumatic experiences from the feelings that these experiences evoked, and at the same time these unresolved affects leave the children prone to ex-

perience the same affects in other everyday situations [19]. Gregory-Bills and Rhodeback [20] reported that psychopathology is much more evident in women who have experienced intrafamilial sexual abuse than those who have experienced extrafamilial sexual abuse. We demonstrated that sexual abuse of incest type is seems to be most related to dissociation in our university student sample. Collin-Vezina and Hebert [21] indicated that whether childhood sexual abuse is intrafamilial or extrafamilial, it can be considered severe enough to generate symptoms of dissociation. In the present study, subjects who reported childhood traumatic events had significantly higher scores on all subscales of the SCL-90-R. This is in concordance with the results of Bryer et al. [22], discussed previously, that indicated that CSA may be an etiological factor that contributes to psychiatric morbidity. In similar, Sun et al. [14] reported that students who experienced childhood sexual abuses got higher scores than the students who did not have such experience in the nine basic symptom factors of SCL-90 and higher than normal model of

Table III. Pearson’s correlations between SCL-90-R and FAD scores.

SCL-90-R

Mean

SD

Roles

Communication

Somatization Obsessive-compulsion Interpersonal sensitivity Depression Anxiety Anger-hostility Phobic anxiety Paranoid ideation Psychoticism GSI

1.10 1.46 1.33 1.31 1.12 1.10 0.80 1.25 0.93 1.19

0.66 0.67 0.73 0.74 0.73 0.76 0.65 0.70 0.61 0.59

0.16** 0.23** 0.23** 0.25** 0.24** 0.29** 0.22** 0.21** 0.32** 0.25**

0.11* 0.25** 0.27** 0.26** 0.30** 0.25** 0.20** 0.23** 0.34** 0.28**

FAD, Family Assessment Device; GSI, Global Severity Index. *PB0.05; **PB0.01.

Problem Affective Affective solving responsiveness involvement 0.16** 0.21** 0.21** 0.27** 0.28** 0.24** 0.12* 0.21** 0.23** 0.24**

0.09 0.21** 0.21** 0.22** 0.20** 0.20** 0.11* 0.15** 0.25** 0.23**

0.08 0.14** 0.18** 0.21** 0.14** 0.15** 0.16** 0.14** 0.25** 0.17**

Behavioral General control functioning 0.07 0.13** 0.06 0.12* 0.12* 0.09 0.12* 0.10* 0.18** 0.08

0.21 0.29** 0.32** 0.37** 0.33** 0.31** 0.26** 0.25** 0.36** 0.34**

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Childhood traumas and dissociation national young group. They suggested that personal experience of childhood sexual abuses may be one of the important factors influencing the victims’ results of SCL-90 test. Peleikis et al. [23] reported that six of the nine SCL-90-R mean subscale scores were significantly higher in women with childhood sexual abuse than controls, the exceptions were the three dimensions concerning anxiety: anxiety, phobic anxiety, and obsessive-compulsive. Ozkan and Altindag [24] reported a link between the experience of sexual abuse in childhood and adolescence and the development of panic disorder and borderline personality disorder in adults. Gladstone et al. [25] examined relationships of several childhood and personality variables with deliberate self-harm in adulthood and recent interpersonal violence. They found that the home environment for those with a history of childhood sexual abuse was rated as more emotionally and physically abusive and as having more parental conflict. Subjects’ ratings of maternal indifference suggested that women with childhood sexual abuse held particularly strong perceptions of deprivation in maternal care. Peleikis et al. [23] reported that women of the childhood sexual abuse group had significantly more other family background risk factors than women without childhood sexual abuse. Our findings on the relationship between family functioning and general psychopathology were consistent with these reports. Finally, a note of caution is necessary due to some methodological limitations of our study. First, the value of retrospective histories of trauma is questionable, given the possibilities of underreporting, overreporting or ‘‘false memory’’. Second, one needs to be cautious in generalizing results from a study of traumatization in a student sample to the general population. Third, we used dichotomous codes for physical or sexual abuse (i.e. present versus absent), without reporting information about frequency, severity, or duration. This approach prevents analyses that can assess the relationship between trauma magnitude and subsequent psychopathology. Taken together, these findings suggest that a history of childhood traumatic events may be related to increased level of dissociation and general psychopathology in university students. Other pathogenic family factors also may contribute to the development of psychiatric symptoms. The prevalence of childhood traumas is similar to those reported from studies conducted in Western societies. Further studies exploring the relationship of childhood traumas and psychiatric problems in nonWestern cultures are required.

Key points . Childhood traumatic events are related to increased level of dissociation and general psychopathology in university students . The most frequent childhood trauma type was separation from caretaker . The prevalence of childhood traumas in the present Turkish university student population is similar to those reported from studies conducted in Western societies Statement of interest There is no conflict of interest.

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Childhood traumatic events and dissociation in university students.

Objective. The purpose of this study was to determine the frequency of childhood traumatic events, to investigate its relationship with dissociation a...
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