Further Evidence for the Significance of a Childhood Abuse History in Psychiatric Inpatients Geoffrey M. Margo and Elvera M. McLees The high prevalence of histories of childhood sexual and physical abuse in inpatient psychiatric populations is documented. In the present study, 38 female inpatients on a psychiatric unit in a teaching hospital were administered an abuse questionnaire and standard measures of psychological distress. Seventy-six percent of the women reported some history of abuse before the age of 16. As predicted, women who reported a childhood history of physical or sexual abuse scored significantly higher on measures of symptomatology and psychopathology as compared with women who did not report an abuse history. Findings confirm the reports of previous researchers, providing further evidence of the generalizability of these observations. Copyright 0 199 1 by W.B. Saunders Company
T
HERE IS a growing awareness of the high frequency of childhood physical and sexual abuse in the histories of adult psychiatric patients. Although most work in this area investigated outpatient populations, there are several studies indicating that a significant proportion of psychiatric inpatients have such abuse histories. Based on current evidence, the incidence of a history of childhood sexual abuse, with and without accompanying physical abuse, ranges from 20% to 51% in psychiatric inpatient populations.‘-5 Both individual interviews or selfreport questionnaire methods present higher figures than do chart reviews, indicating that patients do not spontaneously offer such information to their therapists, or if it is offered, it is not reliably documented. Differences in prevalence may arise from differing definitions of abuse, ranging from more detailed (i.e., “contacts or interactions between an adult and child when the child is being used for the sexual stimulation of the perpetrator or another person”4) to more global (i.e., “any form of serious sexual or physical abuse”“) descriptions. Despite the differences in methodological approach, these studies indicate a relatively high incidence of childhood abuse in the histories of the psychiatric patients studied. It is essential to confirm whether these findings are widespread or are specific to the published studies. The percentages of hospitalized patients reporting an abuse history is significantly higher than the current estimates of childhood sexual abuse within the general population, with approximately 30% of adult women reporting such histories.6 It is equally important to tease apart what effects, if any, such abusive histories have on the current mental health status of these patients. Current studies, although varied in their attempts to get at these effects, are also consistent in their findings. That is, in general, women with abusive histories tend to have more serious psychiatric problems than women without abusive histories. This is
From the Department of Psychiatry and Behavioral Sciences, SUNY-Health Science Center, Syracuse, NY. Address reprint requests to Geoffrey M. Margo, M.D., Ph.D., Department of Psychiatry and Behavioral Sciences, SUNY-Health Science Center, 750 EAdams St, Syracuse, Ny13210. Copyright 0 1991 by W.B. Saunders Company OOIO-440X/91/3204-0001$03.00~0 362
Comprehensive
Psychiatry,
Vol. 32, No. 4 (July/August),
1991: pp 362-366
CHILDHOOD
ABUSE IN PSYCHIATRIC
INPATIENTS
363
evidenced by their being assigned more serious diagnoses, such as borderline personality disorder, expressing more suicidality, having a family history significant for alcohol abuse and psychiatric problems, and admitting to higher levels of distress as measured by such instruments as the Symptom Checklist-revised (SCL-90-R) and the Beck Depression Inventory.‘.” This study provides validation of the above findings by offering additional information derived from a sample of adult women hospitalized on a university hospital inpatient psychiatric service. It also raises the important problem of differentiating the long-term effects of physical from sexual abuse in childhood. Indeed, the data presented here suggest that such differentiation will be extremely difficult. METHOD This study was conducted on a 23-bed psychiatric unit in a university hospital. All patients were admitted voluntarily. Thirty-eight consecutively admitted female inpatients who were between the ages of 18 and 45, had at least an 11th grade education (to reduce the likelihood of misunderstanding the research questionnaires), and who had no concurrent major medical illnesses, were included in the study. Patients not included in the study were those who did not meet the selection criteria based on age or education, as well as those with current alcohol or drug abuse problems, as acute withdrawal reactions might have an uncontrolled impact on our measures of psychopathology. There were also a small number of patients (nine) who, because of their current psychiatric state, were not able to give informed consent to participate in this study. Patients were approached individually by the primary investigator and asked to participate in the study. After giving informed consent, the primary investigator gathered historical and diagnostic information through interview and chart review, including the patient’s and her family of origin’s drug and alcohol history, the history of psychiatric illness in her family, and the history of the patient’s psychiatric treatment (e.g., age at initial entry into the mental health system and number of previous hospitalizations). Standard measures of psychopathology and symptomatology (Beck Depression Inventory, SCL-90-R, and the Body Symptom Questionnaire’) were administered by a research assistant in a different session. Patients were also given self-report questionnaires to gather data about sexual and physical abuse before the age of 16. Definitions of physical and sexual abuse were the same as those used by Bryer et al.’ Sexual abuse was defined as being “pressured into doing something more sexually than you wanted to do (sexually means being pressured against your will into forced contact with the sexual parts of your body or his/her body).” Physical abuse was defined as being *‘hit really hard, kicked, punched, stabbed or thrown down.” Abused and nonabused women were compared on the measures of psychopathology and the historical variables using t tests and chi-square tests, as appropriate. Differences among patients reporting no abuse, sexual abuse, physical abuse, and both forms of abuse were also examined, using analysis of variance (ANOVA) followed by post hoc comparisons using the Tukey test.
RESULTS Thirty-eight women were interviewed and completed the questionnaires. The mean age of the sample was 27.2 + 6.3 years. There were no differences in age between the abused and nonabused patients. All women in the sample were white. Of the total sample, 57.9% were single and 28.9% were married. One patient was separated and four were divorced. There was no significant difference in marital status between the abused and nonabused groups. Over three quarters of the patients were from social classes IV and V as defined by Hollingshead.R There was no difference between abused and nonabused women on this dimension. Of the 38 women, nine reported no abuse (23%) seven reported physical abuse (18%) four reported sexual abuse (10%) and 18 reported sexual and physical abuse (47%). Therefore, a total of 29 women (76%) reported abuse of some kind
364
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before the age of 16. In most cases in which patients endorsed a history of abuse, their therapists were already aware of the fact. In a few cases, participation in the study stimulated the patients to discuss their abuse history in therapy and this was reflected in subsequent progress notes in their charts. Women with a history of childhood abuse entered the mental health system at a younger age than those without such a history (18.4 years of age v 24.9 years, t = 2.69, P < .Ol). The abused women reported a significantly higher occurrence of mental illness in their mothers compared with the nonabused women (32.1% v O%, x2 = 3.80, df = 1, P < .05). No significant differences were found on axis I disorders between the abused and nonabused women, as well as among the abused groups. Depression was the most frequent diagnosis in both groups (abused, 58%; nonabused, 44%). There was one patient diagnosed as schizophrenic in each group. There were severa patients with anxiety disorders and eating disorders. The frequency of diagnoses of axis II disorders was significantly different between the abused and nonabused groups. Abused women had a greater likelihood of receiving an axis II diagnosis (48% v ll%, x2 = 3.97, df = 1, P < .0.5), the majority receiving a diagnosis of borderline personality disorder (38% of the abused group). A significantly higher proportion of abused women reported a history of substance abuse (64.3% v 22.2%, x2 = 4.852, df = 1, P < .05). There were significantly higher depression scores for the abused patients. This was confirmed both on the Beck Depression Inventory (30.4 + 12.2 v 19.4 ? 10.5; t = 2.32, P < .05) and by the depression score on the SCL-90-R (53.7 * 7.8 v 46.2 -+ 9.5, t = 2.37, P < .05). Scores obtained on the SCL-90-R show that patients with sexual abuse and physical abuse or combined abuse admit to significantly more symptomatology than the nonabused women as evidenced by the scores for somatization, interpersonal sensitivity, depression, anxiety, the global severity index, the positive symptom distress index, and the positive symptom total. The means + SD for the significant SCL-90-R findings are shown in Table 1. ANOVA and post hoc comparisons showed no significant differences among the three abused groups. The higher frequency of somatic complaints was also confirmed on the Body Table 1.
Means k SD for SCL-90-R Factors That Showed Significant Differences Between Nonabused and Abused Women on t Test
SCL-90-R Somatization” Interpersonal sensitivityt Depressiont Anxiety” Hostilityt Global severity index* Positive symptom distress indext Positive symptom totalt *P < .Ol. tP < .05.
Not Abused (N = 9) Mean 2 SD 44.1 46.2 46.2 43.8 45.8 44.5 43.7 46.7
f 4.2 f 8.2 f 9.5 k 9.8 f 6.1 f 8.2 2 7.5 I? 8.3
Abused (N = 28) Mean 2 SD 51.7 53.2 53.7 53.6 51.8 52.9 52.3 52.9
+ 8.6 + 8.6 ?z 7.8 +- 8.4 2 7.3 ” 7.3 2 7.5 2 7.1
CHILDHOOD
ABUSE IN PSYCHIATRIC
INPATIENTS
365
Symptom Questionnaire. The total weighted score on this test for the abused group was 97.7 + 31.99 versus 70.2 2 31.0 for the nonabused women (t = 2.27, P < .05). ANOVA and post hoc comparisons once again showed that the abused groups were not significantly different among themselves on this measure of somatization. DISCUSSION
This study provides additional confirmation of the high incidence of a history of sexual and physical abuse in a population of psychiatric inpatients. If anything, our figures may somewhat underestimate the problem given our exclusion criteria. For example, by excluding those with less than 11th grade education, those with significant current physical illness, and those with current drug and alcohol problems, we may well have reduced the true number of patients with this type of background. Future research should address this issue. Criticisms are often raised about the validity of self-report of abuse histories. Herman and Schatzow’ provide empirical support for the validity of abused patients’ self-report. They found, that when corroborating evidence is sought, the majority of women are able to obtain confirmation of abuse. Our overall percentages of abuse are similar to the figures reported by Bryer et al.’ Due to this similarity and due to the fact that our patients revealed their abuse histories to their therapists, we believe that our abuse figures are accurate. The findings of elevated scores for the abused groups on the measures of symptomatology and psychopathology compared with the nonabused patients in both studies are similar. The evidence therefore points to more severe symptomatology and psychopathology in women with a history of abuse compared with those who do not have this history. This is most striking for symptoms of somatization, anxiety, hostility, and depression. This latter finding is all the more important given that almost all of our patients in both groups were admitted with a primary diagnosis of depression. The abused women were also different in that they have a higher rate of alcohol abuse histories and have entered the mental health system at an earlier age. They also had a greater likelihood of having an axis II diagnosis, especially borderline personality disorder. These findings also replicate and confirm the findings of other researchers.‘.5 Although one cannot assume a direct causal relationship between childhood abuse and adult psychopathology, the evidence continues to be strong and to suggest such a relationship. Future research that controls for other variables of possible influence, such as early parent-child relationships and family environment, is crucial in this field. Our data also show that abused women, during childhood, had mothers who received treatment for psychiatric illness. This finding supports Finkelhor’s”‘,” studies of sexual abuse, which identified the absence (either emotionally or physically) of mothers from homes as a risk factor for childhood sexual abuse. An important finding in this study, which once again parallels the findings of Bryer et al.,’ is the inability to distinguish between women with a sexual abuse history from those with a physical abuse history. On the measures of psychopathology used, both groups look similar. In fact, the physically abused women scored higher (not to a significant degree) than the sexually abused women on a number of measures (Beck Depression Inventory, the Body Symptom Questionnaire-total
366
MARGO AND McLEES
weighted score, SCL-90-R-depression, anxiety, global severity, and positive symptoms of distress scores). It is also noteworthy that, in both studies, the number of women reporting both physical and sexual abuse is weighty (23% to 47%). A crucial area for further study would be to attempt to dissect out the contributions of various types of abuse to the long-term outcome in these women. Judging from our preliminary data, it may well be that such a dissection will be extremely difficult. Perhaps all severe forms of abuse, including emotional deprivation, may lead to a similar end point. On the other hand, there may be various outcomes, such as difficulties with intimacy, that are more striking in women with sexual abuse histories as compared with other forms of abuse. Future research hopes to further delineate and clarify these concerns. REFERENCES 1. Beck J, van der Kolk B: Reports of childhood incest and current behavior of chronically hospitalized psychotic women. Am J Psychiatry 144:1474-1476,1987 2. Bryer JB, Nelson BA, Miller JB, et al: Childhood physical and sexual abuse as factors in adult psychiatric illness. Am J Psychiatry 144:1426-1430, 1987 3. Carmen EH, Rieker PP, Mills T: Victims of violence and psychiatric illness. Am J Psychiatry 141:378-383, 1984 4. Craine L, Henson C, Colliver J, et al: Prevalence of a history of sexual abuse among female psychiatric patients in a state hospital system. Hosp Community Psychiatry 39:300-304, 1988 5. Goodwin J, Attias R, McCarty T, et al: Reporting by adult psychiatric patients of childhood sexual abuse. Am J Psychiatry 145:1183, 1988 (letter) 6. Russell D: The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of children. Child Abuse Neglect 12:.51-59,1988 7. Reihman J, Fisher S, Greenberg R: Dimensionality of the body symptom questionnaire. Percept Mot Skills 55:739-744, 1982 8. Hollingshead A: Two Factor Index of Social Position. New Haven, CT, Yale Station, 1965 9. Herman JL, Schatzow E: Recovery and verification of memories of childhood sexual trauma. Psychoanal Psycho1 4:1-14, 1987 10. Finkelhor D: Sexually Victimized Children. New York, NY, Free Press, 1979 11. Finkelhor D: Child Sexual Abuse: New Theory and Research. New York, NY, Free Press, 1984
T
HERE IS a growing awareness of the high frequency of childhood physical and sexual abuse in the histories of adult psychiatric patients. Although most work in this area investigated outpatient populations, there are several studies indicating that a significant proportion of psychiatric inpatients have such abuse histories. Based on current evidence, the incidence of a history of childhood sexual abuse, with and without accompanying physical abuse, ranges from 20% to 51% in psychiatric inpatient populations.‘-5 Both individual interviews or selfreport questionnaire methods present higher figures than do chart reviews, indicating that patients do not spontaneously offer such information to their therapists, or if it is offered, it is not reliably documented. Differences in prevalence may arise from differing definitions of abuse, ranging from more detailed (i.e., “contacts or interactions between an adult and child when the child is being used for the sexual stimulation of the perpetrator or another person”4) to more global (i.e., “any form of serious sexual or physical abuse”“) descriptions. Despite the differences in methodological approach, these studies indicate a relatively high incidence of childhood abuse in the histories of the psychiatric patients studied. It is essential to confirm whether these findings are widespread or are specific to the published studies. The percentages of hospitalized patients reporting an abuse history is significantly higher than the current estimates of childhood sexual abuse within the general population, with approximately 30% of adult women reporting such histories.6 It is equally important to tease apart what effects, if any, such abusive histories have on the current mental health status of these patients. Current studies, although varied in their attempts to get at these effects, are also consistent in their findings. That is, in general, women with abusive histories tend to have more serious psychiatric problems than women without abusive histories. This is
From the Department of Psychiatry and Behavioral Sciences, SUNY-Health Science Center, Syracuse, NY. Address reprint requests to Geoffrey M. Margo, M.D., Ph.D., Department of Psychiatry and Behavioral Sciences, SUNY-Health Science Center, 750 EAdams St, Syracuse, Ny13210. Copyright 0 1991 by W.B. Saunders Company OOIO-440X/91/3204-0001$03.00~0 362
Comprehensive
Psychiatry,
Vol. 32, No. 4 (July/August),
1991: pp 362-366
CHILDHOOD
ABUSE IN PSYCHIATRIC
INPATIENTS
363
evidenced by their being assigned more serious diagnoses, such as borderline personality disorder, expressing more suicidality, having a family history significant for alcohol abuse and psychiatric problems, and admitting to higher levels of distress as measured by such instruments as the Symptom Checklist-revised (SCL-90-R) and the Beck Depression Inventory.‘.” This study provides validation of the above findings by offering additional information derived from a sample of adult women hospitalized on a university hospital inpatient psychiatric service. It also raises the important problem of differentiating the long-term effects of physical from sexual abuse in childhood. Indeed, the data presented here suggest that such differentiation will be extremely difficult. METHOD This study was conducted on a 23-bed psychiatric unit in a university hospital. All patients were admitted voluntarily. Thirty-eight consecutively admitted female inpatients who were between the ages of 18 and 45, had at least an 11th grade education (to reduce the likelihood of misunderstanding the research questionnaires), and who had no concurrent major medical illnesses, were included in the study. Patients not included in the study were those who did not meet the selection criteria based on age or education, as well as those with current alcohol or drug abuse problems, as acute withdrawal reactions might have an uncontrolled impact on our measures of psychopathology. There were also a small number of patients (nine) who, because of their current psychiatric state, were not able to give informed consent to participate in this study. Patients were approached individually by the primary investigator and asked to participate in the study. After giving informed consent, the primary investigator gathered historical and diagnostic information through interview and chart review, including the patient’s and her family of origin’s drug and alcohol history, the history of psychiatric illness in her family, and the history of the patient’s psychiatric treatment (e.g., age at initial entry into the mental health system and number of previous hospitalizations). Standard measures of psychopathology and symptomatology (Beck Depression Inventory, SCL-90-R, and the Body Symptom Questionnaire’) were administered by a research assistant in a different session. Patients were also given self-report questionnaires to gather data about sexual and physical abuse before the age of 16. Definitions of physical and sexual abuse were the same as those used by Bryer et al.’ Sexual abuse was defined as being “pressured into doing something more sexually than you wanted to do (sexually means being pressured against your will into forced contact with the sexual parts of your body or his/her body).” Physical abuse was defined as being *‘hit really hard, kicked, punched, stabbed or thrown down.” Abused and nonabused women were compared on the measures of psychopathology and the historical variables using t tests and chi-square tests, as appropriate. Differences among patients reporting no abuse, sexual abuse, physical abuse, and both forms of abuse were also examined, using analysis of variance (ANOVA) followed by post hoc comparisons using the Tukey test.
RESULTS Thirty-eight women were interviewed and completed the questionnaires. The mean age of the sample was 27.2 + 6.3 years. There were no differences in age between the abused and nonabused patients. All women in the sample were white. Of the total sample, 57.9% were single and 28.9% were married. One patient was separated and four were divorced. There was no significant difference in marital status between the abused and nonabused groups. Over three quarters of the patients were from social classes IV and V as defined by Hollingshead.R There was no difference between abused and nonabused women on this dimension. Of the 38 women, nine reported no abuse (23%) seven reported physical abuse (18%) four reported sexual abuse (10%) and 18 reported sexual and physical abuse (47%). Therefore, a total of 29 women (76%) reported abuse of some kind
364
MARGO AND McLEES
before the age of 16. In most cases in which patients endorsed a history of abuse, their therapists were already aware of the fact. In a few cases, participation in the study stimulated the patients to discuss their abuse history in therapy and this was reflected in subsequent progress notes in their charts. Women with a history of childhood abuse entered the mental health system at a younger age than those without such a history (18.4 years of age v 24.9 years, t = 2.69, P < .Ol). The abused women reported a significantly higher occurrence of mental illness in their mothers compared with the nonabused women (32.1% v O%, x2 = 3.80, df = 1, P < .05). No significant differences were found on axis I disorders between the abused and nonabused women, as well as among the abused groups. Depression was the most frequent diagnosis in both groups (abused, 58%; nonabused, 44%). There was one patient diagnosed as schizophrenic in each group. There were severa patients with anxiety disorders and eating disorders. The frequency of diagnoses of axis II disorders was significantly different between the abused and nonabused groups. Abused women had a greater likelihood of receiving an axis II diagnosis (48% v ll%, x2 = 3.97, df = 1, P < .0.5), the majority receiving a diagnosis of borderline personality disorder (38% of the abused group). A significantly higher proportion of abused women reported a history of substance abuse (64.3% v 22.2%, x2 = 4.852, df = 1, P < .05). There were significantly higher depression scores for the abused patients. This was confirmed both on the Beck Depression Inventory (30.4 + 12.2 v 19.4 ? 10.5; t = 2.32, P < .05) and by the depression score on the SCL-90-R (53.7 * 7.8 v 46.2 -+ 9.5, t = 2.37, P < .05). Scores obtained on the SCL-90-R show that patients with sexual abuse and physical abuse or combined abuse admit to significantly more symptomatology than the nonabused women as evidenced by the scores for somatization, interpersonal sensitivity, depression, anxiety, the global severity index, the positive symptom distress index, and the positive symptom total. The means + SD for the significant SCL-90-R findings are shown in Table 1. ANOVA and post hoc comparisons showed no significant differences among the three abused groups. The higher frequency of somatic complaints was also confirmed on the Body Table 1.
Means k SD for SCL-90-R Factors That Showed Significant Differences Between Nonabused and Abused Women on t Test
SCL-90-R Somatization” Interpersonal sensitivityt Depressiont Anxiety” Hostilityt Global severity index* Positive symptom distress indext Positive symptom totalt *P < .Ol. tP < .05.
Not Abused (N = 9) Mean 2 SD 44.1 46.2 46.2 43.8 45.8 44.5 43.7 46.7
f 4.2 f 8.2 f 9.5 k 9.8 f 6.1 f 8.2 2 7.5 I? 8.3
Abused (N = 28) Mean 2 SD 51.7 53.2 53.7 53.6 51.8 52.9 52.3 52.9
+ 8.6 + 8.6 ?z 7.8 +- 8.4 2 7.3 ” 7.3 2 7.5 2 7.1
CHILDHOOD
ABUSE IN PSYCHIATRIC
INPATIENTS
365
Symptom Questionnaire. The total weighted score on this test for the abused group was 97.7 + 31.99 versus 70.2 2 31.0 for the nonabused women (t = 2.27, P < .05). ANOVA and post hoc comparisons once again showed that the abused groups were not significantly different among themselves on this measure of somatization. DISCUSSION
This study provides additional confirmation of the high incidence of a history of sexual and physical abuse in a population of psychiatric inpatients. If anything, our figures may somewhat underestimate the problem given our exclusion criteria. For example, by excluding those with less than 11th grade education, those with significant current physical illness, and those with current drug and alcohol problems, we may well have reduced the true number of patients with this type of background. Future research should address this issue. Criticisms are often raised about the validity of self-report of abuse histories. Herman and Schatzow’ provide empirical support for the validity of abused patients’ self-report. They found, that when corroborating evidence is sought, the majority of women are able to obtain confirmation of abuse. Our overall percentages of abuse are similar to the figures reported by Bryer et al.’ Due to this similarity and due to the fact that our patients revealed their abuse histories to their therapists, we believe that our abuse figures are accurate. The findings of elevated scores for the abused groups on the measures of symptomatology and psychopathology compared with the nonabused patients in both studies are similar. The evidence therefore points to more severe symptomatology and psychopathology in women with a history of abuse compared with those who do not have this history. This is most striking for symptoms of somatization, anxiety, hostility, and depression. This latter finding is all the more important given that almost all of our patients in both groups were admitted with a primary diagnosis of depression. The abused women were also different in that they have a higher rate of alcohol abuse histories and have entered the mental health system at an earlier age. They also had a greater likelihood of having an axis II diagnosis, especially borderline personality disorder. These findings also replicate and confirm the findings of other researchers.‘.5 Although one cannot assume a direct causal relationship between childhood abuse and adult psychopathology, the evidence continues to be strong and to suggest such a relationship. Future research that controls for other variables of possible influence, such as early parent-child relationships and family environment, is crucial in this field. Our data also show that abused women, during childhood, had mothers who received treatment for psychiatric illness. This finding supports Finkelhor’s”‘,” studies of sexual abuse, which identified the absence (either emotionally or physically) of mothers from homes as a risk factor for childhood sexual abuse. An important finding in this study, which once again parallels the findings of Bryer et al.,’ is the inability to distinguish between women with a sexual abuse history from those with a physical abuse history. On the measures of psychopathology used, both groups look similar. In fact, the physically abused women scored higher (not to a significant degree) than the sexually abused women on a number of measures (Beck Depression Inventory, the Body Symptom Questionnaire-total
366
MARGO AND McLEES
weighted score, SCL-90-R-depression, anxiety, global severity, and positive symptoms of distress scores). It is also noteworthy that, in both studies, the number of women reporting both physical and sexual abuse is weighty (23% to 47%). A crucial area for further study would be to attempt to dissect out the contributions of various types of abuse to the long-term outcome in these women. Judging from our preliminary data, it may well be that such a dissection will be extremely difficult. Perhaps all severe forms of abuse, including emotional deprivation, may lead to a similar end point. On the other hand, there may be various outcomes, such as difficulties with intimacy, that are more striking in women with sexual abuse histories as compared with other forms of abuse. Future research hopes to further delineate and clarify these concerns. REFERENCES 1. Beck J, van der Kolk B: Reports of childhood incest and current behavior of chronically hospitalized psychotic women. Am J Psychiatry 144:1474-1476,1987 2. Bryer JB, Nelson BA, Miller JB, et al: Childhood physical and sexual abuse as factors in adult psychiatric illness. Am J Psychiatry 144:1426-1430, 1987 3. Carmen EH, Rieker PP, Mills T: Victims of violence and psychiatric illness. Am J Psychiatry 141:378-383, 1984 4. Craine L, Henson C, Colliver J, et al: Prevalence of a history of sexual abuse among female psychiatric patients in a state hospital system. Hosp Community Psychiatry 39:300-304, 1988 5. Goodwin J, Attias R, McCarty T, et al: Reporting by adult psychiatric patients of childhood sexual abuse. Am J Psychiatry 145:1183, 1988 (letter) 6. Russell D: The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of children. Child Abuse Neglect 12:.51-59,1988 7. Reihman J, Fisher S, Greenberg R: Dimensionality of the body symptom questionnaire. Percept Mot Skills 55:739-744, 1982 8. Hollingshead A: Two Factor Index of Social Position. New Haven, CT, Yale Station, 1965 9. Herman JL, Schatzow E: Recovery and verification of memories of childhood sexual trauma. Psychoanal Psycho1 4:1-14, 1987 10. Finkelhor D: Sexually Victimized Children. New York, NY, Free Press, 1979 11. Finkelhor D: Child Sexual Abuse: New Theory and Research. New York, NY, Free Press, 1984
