1. The Consequences of Trauma in Early Life For Adult Mental Health Alison Lowit, Linda Treliving, Ian Reid Aberdeen University NHS Grampian

2. Background Research over the past twenty years has shown that Early Trauma (Childhood Physical, Sexual and Emotional Abuse) is relatively common in our culture. Reported prevalence rates range 6-62% for women 3-31% for Men. Early Trauma has been linked to many physical health problems, such as: Obesity (Williamson et al. 2002) Gastrointestinal problems (Drossman et al. 1995) Generalized pain (Kendal-Tackett 2001)

3. Background Children who have experienced Early Trauma often grow up to experience psychological difficulties Research indicates that prevalence rates for Early Trauma amongst psychiatric patients are significantly higher than the general population. Associated psychological symptoms include: Depression (Wexler et al 1997) Post Traumatic Stress Disorder (Kaplan et al. 2000) Eating disorders (Tobin & Griffin 1996) Self mutilation (Lipschitz et al. 1999) Suicidality (Brodsky et al. 2001)

4. Background Early Trauma and Personality Disorder. There is a high association between early trauma and personality Disorders (Laporte & Guttman 1996), the correlation is most frequently found in patients with Borderline Personality Disorder. (Grilo et al. 1999) Both early trauma and personality disorder tend to be under reported and under diagnosed (Herman et al.1999). The Scottish Executive is trying to address the therapeutic needs of these two neglected groups and recommend that more research is needed to improve care, treatment and prognosis.

5. Evidence suggests that: early trauma has a physical effect on the development of the brain (Vythilingam et al. 2002, Hiem & Nemeroff 2002) the experience of early trauma affects the way adult patients respond to treatment for various mental health disorders (Kaplan et al. 2000, Gladstone et al 2004) There are serious consequences for mental health patients with an unrecognised history of early trauma; both in terms of their prescribed treatment regimes and their long-term prognosis.

6. Literature review Indicated that studies investigating the consequences of early trauma are of a very mixed quality. For example: standardised scales have not been used frequency and duration of abuse is often ignored one type of abuse is often studied in isolation some studies only investigate one psychiatric diagnosis small sample sizes to date very little work has been done on any European population

7. Primary Research Aims. To determine an accurate estimate of the rate of childhood sexual, physical and emotional abuse (early trauma) amongst clients in contact with Mental Health Services in Aberdeen. To determine the range of psychological distress likely to be associated with early trauma in this population.

8. Secondary Research Aims To estimate the prevalence of personality disorder amongst clients in Aberdeen and correlate this with early trauma. To determine the rate of recording by health care professionals in Aberdeen of early trauma as a possible factor in adult mental illness.

9. Study design Inclusion Criteria: Aged over 18 A client of the Mental Health Services in Aberdeen. Able to understand English Able to give informed consent to participate. Willing to participate following a description of the study.

10. Study design Exclusion Criteria: Patients unwilling to participate, who do not give their consent Patients who are deemed unable to give informed consent by the consultant in charge of their care.

11. Study design Method: A consecutive recruitment/assessment cross-sectional study to estimate the prevalence of early trauma. Study participants: clients in contact with the Mental Health Services, Aberdeen Recruitment: via consultant psychiatrists

12. Study design Instruments: three validated questionnaires: The Childhood Trauma Questionnaire (CTQ) The Symptom Checklist 90 Revised (SCL-90-R) The Personality Disorder Questionnaire (PDQ-4 )

13. Method Originally we planned to use the 3 questionnaires as self-reporting instruments. Feedback from initial participants indicated that they did not want to complete the 3 questionnaires themselves. A structured interview format was adopted as this was the method preferred by the initial participants.

14. Method Participants were interviewed at the Royal Cornhill Hospital. Participant’s case notes were reviewed immediately after the interview. All data was tabulated onto a computer on the same day as the interview.

15. Questionnaires The Symptom Checklist 90 Revised (SCL90R) designed to measure current psychological distress. The Childhood Trauma Questionnaire (CTQ) designed to screen for histories of abuse and neglect. The Personality Disorder Questionnaire (PDQ-4) designed to screen for Personality disorders

16. SCL90-R A 90-item checklist designed to measure psychological distress It measures the following primary symptom dimensions: Somatization Obsessive-compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism

17. SCL-90-R measures the following global indices: Global severity index: combines information concerning the number of symptoms reported with the intensity of perceived distress – best single indicator of current level of distress Positive symptom distress index: reflects the average level of distress reported for the symptoms that were endorsed – measure of symptom intensity Positive symptom total: the symptoms endorsed (regardless of level of distress) - a measure of symptom breadth

18. The Childhood Trauma Questionnaire The CTQ screens for 5 types of maltreatment : Emotional Abuse Physical Abuse Sexual Abuse Emotional Neglect Physical Neglect

19. The Childhood Trauma Questionnaire Participants respond to a series of questions about childhood events, by endorsing one of the following options: Never True = 1 Rarely True = 2 Sometimes True =3 Often True = 4 Very Often True = 5

20. Classification of CTQ Scale Total Scores Scalenone to minimal low to moderate moderate to severe Severe to extreme Emotional Abuse5-89-1213-15=>16 Physical Abuse5-78-910-12=>13 Sexual Abuse56-78-12=>13 Emotional Neglect5-910-1415-17=>18 Physical Neglect5-78-910-12=>13

21. Classification of CTQ Scale Total Scores In this study participants are considered to have suffered childhood trauma if they have scored the following for a category: (shaded area of table) Emotional Abuse 13 and above Physical Abuse 10 and above Sexual Abuse 8 and above Emotional Neglect 15 and above Physical Neglect 10 and above

22. PDQ-4 PDQ-4 is designed to assess 12 personality disorders. Paranoid Schizoid Schizotypal Histrionic Narcissistic Borderline Antisocial Avoidant Dependent Obsessive Compulsive Negativistic Depressed

23. PDQ-4  PDQ-4 is a series of 99 true/false questions  Each question describes a behavioral pattern that is consistent with a symptom of a personality disorder.  Patients are asked to think about how they have tended to feel, think, and act over the past several years. whether each description is "generally true“ or "generally false" of them.  If the patient indicates a sufficient number questions that are related to a specific personality disorder are True for them, an additional series of questions are asked in the Clinical Significance Scale section of the test.

25. Borderline PD T 6 I’ll go to extremes to prevent those who I love from ever leaving me. 19 I either love someone or hate them, with nothing in between 32 I often wonder who I really am. 45 I have tried to hurt or kill myself. 58 I am a very moody person. 69 I feel my life is dull and meaningless. 78 I have difficulty controlling my anger or temper. 93 When stressed and things happen, I get paranoid or just black out. 98 I have done things on impulse that could have gotten me into trouble. Need two of:  Spending more money than I have.  Having sex with people I hardly know.  Drinking two much.  Taking drugs.  Eating binges.  Reckless driving. Threshold score: Score must be equal to, or above 5

26. Clinical Significance Questions Clinical Sig. Response √ A) Read checked items; Are any of these items not really true for you? No change B) How long have these items been part of your personality? > 5 years D) In what areas have these items created difficulties for you: home/work/relationships, or other areas of your life? At least one. C) Have these items been part of your personality only when depressed, anxious, using alcohol/drugs or physically ill or, there most of the time regardless of your mood, level of anxiety, use of alcohol/drugs or general state of health? Not linked to other issues. E) Are you bother about yourself because of these behaviours? Yes A+B+C+(D or E) = clinically significant

27. PDQ-4 The total PDQ-4 score is an index of overall personality disturbance. Controls generally score 20 or less. Patients in therapy generally score between 20-30. A total score of 30 or more indicates a substantial likelihood that the patient has significant personality disturbance.

28. PDQ-4 Participants included in the PD group scoring positively for a specific PD total score of 30 or above Participants not included in PD group scoring positively for a specific PD total score of less than 30

29. Results Interviewed 136 inpatients

30. Male (ET) N=48 Male (N- ET) N=26 Female (ET) N=42 Female (N-ET) N=20 Age Mean (SD)43 (11)45 (11)42 (9)42 (15) Education: School (≥16)38182313 Highers/College94105 University/PG1492 Marital Status Single2513129 Married96145 Divorced/Sep147113 Widow0053 Demographics

31. Early Trauma 90 of the 136 Psychiatric Inpatients have experienced moderate/severe early trauma.(66%) 48/74 Males (64%) 42/62 Females (67%) 60 of the 90 participants who have experience early trauma have this recorded in their psychiatric medical records. (66%)

32. PDQ4 95 of the 136 participants have significant personality disturbance.(70%) 58/74 Males (78%) 37/62 Females (60%) 20 of the 95 participants who have significant personality disturbance have a recorded diagnosis of PD. (21%)

33. Personality Disorder and Early Trauma 70 of the 95 participants with significant personality disturbance have experienced moderate/severe early trauma. (74%) 43/58 Males (74%) 27/37 Females (73%)

34. Personality Disorder and Early Trauma PD YesPD NoTotal ET Yes702090 ET No252146 Total9541136 Chi-square Test: 6.86 p=0.009

35. Category (1 st Diagnosis) Total inpatients Abused (%) Not Abused (%) Depression2919 (65)10 (35) Bipolar2617 (65)9 (35) Personality Disorder1514 (93)1 (7) Substance misuse139 (69)4 (31) Anxiety85 (63)3 (37) Schizophrenia3723 (62)14 (38) No Diagnosis22 (100)- 1 st Psychotic episode (3) Eating Disorder(2) DSH(1) 61 (17)5 (83) Total13690 (66)46 (34) Diagnosis and association to early trauma

36. Category (1 st Diagnosis) Total inpatients PDNo PD Depression2922 (76)7 (24) Bipolar2614 (54)12 (46) Personality Disorder1515 (100)0 Substance misuse1313 (100)0 Anxiety83 (38)5 (62) Schizophrenia3724 (65)13 (35) No Diagnosis21 (50) 1 st Psychotic episode(3) Eating disorder(2) DSH(1) 63 (50) Total13695 (70)41 (30) Diagnosis and presence of significant personality disturbance

37. Determining the range of psychological distress associated with early trauma in the inpatient population. Comparisons were made between the ET and Non-ET groups. Comparisons were made within same sex and between genders.

38. Gender comparisons Few studies have investigated gender differences in the long term effects of ET. Those that have suggest that there are more similarities than differences between men and women survivors of ET. However, epidemiologically, men and women in the overall population report different symptoms and severity of symptoms. Those gender differences are confounding factors that may distort the interpretation of the results. In order to get a true picture of the long term effects of ET on male and female populations we need to take into account the gender differences in the general population when analysing the results.

39. Gender comparisons To take into account the inherent symptom differences between males and females in the general population, we used a standard normalised T score (Derogatis 1994) –The SCL-90-R unadjusted scores are the respondents actual results upon completion of the questionnaire. –The SCL-90-R adjusted scores are the unadjusted scores transformed by converting to a normalised T score using a non-patient normative sample.

40. Psychological Symptom Comparisons. Six analysis were performed: ET females compared to ET males – unadjusted ET females compared to ET males – adjusted N-ET females compared to N-ET males – unadjusted N-ET females compared to N-ET males – adjusted ET females compared to N-ET females – unadjusted ET males compared to N-ET males – unadjusted (ET = Early Trauma; N-ET = No Early Trauma)

41. Unadjusted Scores

42. Adjusted Scores ** * *p<0.05, **p<0.01

43. Males & Females with Early Trauma Summary Unadjusted score comparisons – no significant differences emerge Adjusted score comparisons – significant differences become apparent.

44. Males & Females with Early Trauma Summary Males scored significantly higher for: Somatization, Obsessive-compulsive, Interpersonal sensitivity, Depression, Anxiety, Phobic anxiety, Paranoid ideation, Psychoticism, Global severity Index and Positive symptom Total. ET males had higher symptom scores relative to males in the SCL-90-R non-patient standardised sample than did ET females relative to their standardised sample.

45. * * * * Unadjusted Scores *p<0.05, **p<0.01 **

46. Adjusted Scores * *p<0.05

47. N-ET Males & Females Unadjusted score comparisons – female scores were significantly higher for: Somatization, Interpersonal sensitivity, Depression, Global severity index and Positive symptom distress index. Adjusted score comparisons – These Significant differences disappear when scores are adjusted to account for inherent gender differences.

48. Female Inpatients ET & N-ET No Significant differences between the groups. We suspect no significant differences emerged because the study was conducted amongst a highly distressed female population who had already reached the symptom ceiling capable of being detected by the SCL-90-R, and further elevated symptoms would not be picked up by this symptom checklist instrument.

49. Male Inpatients ET & N-ET ET males scored significantly higher than N-ET males for all symptom dimension and global indices. This is evidence that ET has a profound effect on males, and even amongst the generally distressed inpatient male population there is a highly significant elevation of symptoms for males who have experienced ET. This also indicates the value of standardising scores (for example using T-scores) when undertaking gender comparisons.

50. Mean score Diagnosis and nature of trauma

51. Mean score Depression

52. Mean score Bipolar disorder

53. Mean score Personality Disorder

54. Mean score Substance misuse

55. Mean score Schizophrenic disorders

56. Mean score Anxiety disorders

57. Conclusions There are very high rates of early trauma amongst mental health inpatients in Aberdeen. A high percentage of inpatients have significant personality disturbance. Early trauma is associated with significant personality disturbance (p<0.01) within this patient population.

58. Conclusions Male inpatients with early trauma report higher symptom levels than female inpatients with early trauma when gender differences in the reporting of symptoms are taken into account. Female inpatients regardless of presence or absence of early trauma report similar symptom levels. Males with early trauma reported significantly higher symptom levels for all symptoms measured by the SCL- 90-R than males without early trauma.

59. Clinical Implications A diagnosis of personality disorder is known to complicate treatment regimes. However, this complication could have its origins in an unrecognised history of early trauma. It is likely there is an under recognition of comorbid diagnoses involving personality disorder. If a patient presents with symptoms of personality disorder it is crucial to check for a history of early trauma – a treatment regime may be more effective if it also tackles problems directly attributable to early trauma.

60. Thank you

61. Unadjusted Scores

62. ** * * * * *p<0.05, **p<0.01

63. Table 1 Inpatients ET M&F unadjusted scores T-Test unadjusted scores VariableFemales ET Males ET (n=42)(n=48) ScaleMeanSDMeanSDT Somatization1.220.841.470.84-1.39 Obsessive-Compulsive1.960.902.110.91-0.77 Interpersonal Sensitivity a 1.710.811.900.98-1.02 Depression a 2.301.072.361.06-0.28 Anxiety a 1.900.982.110.91-1.06 Hostility0.970.961.180.97-1.03 Phobic Anxiety a 1.651.241.831.18-0.69 Paranoid Ideation a 1.480.951.681.00-0.96 Psychoticism1.291.021.500.89-1.04 Global Severity Index1.700.751.860.76-0.99 Positive Symptom DI 2.670.652.700.72-0.23 Positive Symptom Total55.5719.0660.5615.57-1.37

64. Table 2 Inpatients ET adjusted M&F T-Test adjusted scores VariableMales ET Females ET (n=48)(n=42) ScaleMeanSDMeanSDT Somatization70.2510.3061.7111.913.65** Obsessive-Compulsive74.969.3569.629.022.75** Interpersonal Sensitivity a 74.568.9469.459.262.66** Depression a 76.737.8170.839.813.28** Anxiety a 77.965.9970.1210.824.17** Hostility63.9812.2358.8812.481.95 Phobic Anxiety a 74.239.5667.9312.152.71** Paranoid Ideation a 69.609.8265.5210.941.86 Psychoticism74.427.3069.1211.852.51* Global Severity Index 78.025.34 71.3610.453.73 ** Positive Symptom DI73.468.2172.148.570.74 Positive Symptom Total72.195.9766.178.973.78** *p<0.05, **p<0.01

65. Table 3 Inpatients N-ET M&F unadjusted scores Females N-ET Males N-ET (n=20)(n=26) ScaleMeanSDMeanSDT Somatization1.361.060.800.632.20* Obsessive-Compulsive2.101.211.451.051.93 Interpersonal Sensitivity1.871.181.120.992.33* Depression2.491.231.571.252.48* Anxiety2.011.181.421.111.73 Hostility a 1.081.110.580.561.82 Phobic Anxiety1.631.221.201.061.30 Paranoid Ideation1.281.251.190.930.28 Psychoticism1.221.030.950.970.88 Global Severity Index1.771.001.190.832.15* Positive Symptom Distress Index2.940.662.290.693.33** Positive Symptom Total51.7024.9641.8824.031.35 *p<0.05, **p<0.01

66. Table 4 Inpatients N-ET M&F adjusted scores Females N-ET Males N-ET (n=20)(n=26) ScaleMeanSDMeanSDT Somatization62.9512.6861.0010.830.56 Obsessive-Compulsive68.4515.0966.3515.370.46 Interpersonal Sensitivity69.2012.7564.5014.311.58 Depression72.4510.5968.6514.841.01 Anxiety70.2011.8669.3514.900.21 Hostility60.0513.2455.7310.861.22 Phobic Anxiety68.0511.3768.9212.60-0.24 Paranoid Ideation60.6015.9663.1513.08-0.20 Psychoticism67.7513.9164.7314.840.70 Global Severity Index71.1510.9468.4614.470.69 Positive Symptom Distress Index75.208.3168.1211.172.37* Positive Symptom Total64.8011.0362.8113.610.53

67. T-Test VariableFemales ET Females N-ET (n=42)(n=20) ScaleMeanSDMeanSDT Somatization1.220.841.391.06-0.69 Obsessive-Compulsive1.960.902.101.21-0.49 Interpersonal Sensitivity a 1.710.811.871.18-0.55 Depression a 2.301.072.491.23-0.65 Anxiety a 1.900.982.011.18-0.36 Hostility0.970.961.081.11-0.39 Phobic Anxiety a 1.651.241.631.220.06 Paranoid Ideation a 1.480.951.281.250.69 Psychoticism1.291.021.221.030.25 Global Severity Index1.700.751.771.00-0.31 Positive Symptom DI 2.670.652.940.66-.3.20 Positive Symptom Total 55.5719.0651.70 24.96 -1.56 Table 5 Female Inpatients ET/N-ET

68. Table 6 Male Inpatients ET/N-ET T-Test VariableMales ET Males N-ET (n=48)(n=26) ScaleMeanSDMeanSD T Somatization1.470.840.800.633.81** Obsessive-Compulsive2.110.911.451.052.82** Interpersonal Sensitivity a 1.900.981.120.993.27** Depression a 2.361.061.581.252.83** Anxiety a 2.110.911.421.112.90** Hostility1.180.970.580.563.30** Phobic Anxiety a 1.831.181.201.062.28* Paranoid Ideation a 1.681.001.190.932.03* Psychoticism1.500.890.950.972.42* Global Severity Index1.860.761.190.833.49** Positive Symptom DI2.700.722.290.692.42* Positive Symptom Total60.5615.5741.8824.033.58** *p<0.05, **p<0.01