- Email: [email protected]
Lung disease and internalizing disorders
Journal of Psychosomatic Research 55 (2003) 215 – 219
Lung disease and internalizing disorders Is childhood abuse a shared etiologic factor? Renee D. Goodwin*, Marianne Z. Wamboldt, Daniel S. Pine Columbia University, New York, NY, USA National Jewish Medical and Research Center, Denver, CO, USA National Institute of Mental Health (NIMH), Bethesda, MD, USA Received 19 September 2001; accepted 18 April 2002
Abstract Objective: To investigate the role of childhood abuse in the relationship between panic attack, depression and lung disease among adults in the population. Methods: Data were drawn from the National Comorbidity Survey (n = 5877), a representative sample of adults age 15 – 54 in the United States. Multiple logistic regression analyses were used to determine the association between childhood abuse and lung disease, and to determine whether childhood abuse is an independent predictor of the co-occurrence of lung disease, panic attack and depression. Results: Childhood abuse was associated with significantly increased odds of panic attacks (OR = 2.2 (1.5, 3.1)) and
depression (OR = 1.6 (1.1, 2.3)). Childhood abuse increased likelihood of lung disease (OR = 1.5 (1.1, 2.2)). Childhood abuse independently predicted the co-occurrence of lung disease, panic attack and depression (OR = 10.7 (2.2, 51.5)). Conclusion: These data are preliminary, but if replicated, suggest that childhood abuse may be associated with increased risk of lung disease during adulthood, and further may reflect a shared vulnerability for the co-occurrence of lung disease, panic attack and depression in the community. Future studies are needed to further explore the mechanism of this association. D 2003 Elsevier Inc. All rights reserved.
Keywords: Lung disease; Respiratory illness; Epidemiology; Anxiety; Childhood abuse
Introduction Recent data suggest that lung disease (e.g., asthma, chronic obstructive pulmonary disease) and internalizing disorders co-occur more often than would be expected by chance [1 – 5]. The mechanism of this association is unknown. It is possible that lung disease such as asthma, which is characterized by sudden constriction of airways, may lead to the development of specific anxiety symptoms (e.g., panic attacks) [6– 8]. Since panic attacks and asthma attacks may share overlapping physiological features and fear of respiratory difficulties, symptoms of each may interact reciprocally to influence progression of both diseases [9,10]. It is also conceivable that anxiety and depression lead to the onset of lung disease. Major depression is
* Corresponding author. 1051 Riverside Dr., Unit 43, New York, NY 10032, USA. Tel.: +1-212-305-6706; fax: +1-212-305-9413. E-mail address: [email protected] (R.D. Goodwin). 0022-3999/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0022-3999(02)00497-X
associated with altered immune functioning, which may increase susceptibility to asthma, bronchitis and other inflammatory diseases [11]. Moreover, previous data from twin studies suggest the possibility of a shared diathesis to both internalizing disorders (i.e., depressive and anxiety disorders) and specific forms of lung disease (i.e., asthma) [12]. These two potential pathways present lung disease, panic attack and depression as discrete phenomena. One alternative hypothesis is that a third factor, possibly a shared vulnerability, for panic attack and lung disease, or depression and lung disease, underlies an association between lung disease and internalizing disorders. Childhood abuse has been hypothesized as a marker of vulnerability for both physical and mental disorders [13,14]. Epidemiologic data support a connection between child abuse and increased risk of panic attack and major depression in the community [15,16]. Clinical and preclinical data also suggest that trauma, such as child abuse, may weaken immune system responses, thereby increasing vulnerability to the development of physical
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illnesses [17,18]. Data from psychiatric and medical patient populations show evidence of an association between trauma and increased risk of physical illness in clinical settings [17 – 20]. To date, however, no study has examined the relationship between child abuse and the co-occurrence of physical illness and mental disorders. Moreover, these associations have not been examined in an epidemiologic sample, which is needed in order to determine associations in the absence of selection into treatment bias. In an effort to begin to address this gap, we examine three main questions. First, is childhood abuse associated with increased odds of lung disease among adults in the general population? Second, is childhood abuse an independent correlate of the co-occurrence of lung disease and internalizing disorders among adults in the population? Third, is the relationship between childhood abuse and lung disease specific? We hypothesized that childhood abuse would be associated with increased odds of lung disease in adulthood. We also predicted that childhood abuse would be an independent correlate of the co-occurrence of lung disease and internalizing disorders among adults in the general population.
Methods Sample The National Comorbidity Survey is based on a national probability sample (n = 5877) of individuals age 15 –54 in the noninstitutionalized population [21]. Fieldwork was carried out between September 1990 and February 1992. There was an 82.4% response rate. The data were weighted for differential probabilities of selection and nonresponse. A weight was also used to adjust the sample to approximate the cross-classification of the population distribution on a range of sociodemographic characteristics. Weighting and a full description of study methodology are described in detail elsewhere [21].
illness or ingestion of any type of drug or medication. A checklist of physical illnesses within the past 12 months included ‘‘chronic stomach or gall bladder trouble,’’ ‘‘heart attack or other serious heart trouble’’ and ‘‘high blood pressure or hypertension.’’ Lung disease was quantified with an affirmative response to having ‘‘severe asthma, chronic bronchitis or tuberculosis.’’ Written informed consent was obtained from each participant after the survey had been fully explained. Childhood abuse History of childhood abuse was defined by affirmative response to a yes or no question inquiring whether an individual had been physically abused as a child. Analytic strategy First, F-based tests for independence were used to determine difference in demographic characteristics and mental disorders among seven mutually exclusive groups: (1) controls: individuals without lung disease, panic or depression; (2) panic attack only: those who have panic attacks but not lung disease or depression; (3) lung disease only: those who have lung disease and have never had panic attacks or depression; (4) depression only: depression without lung disease or panic attack; (5) lung disease and depression; (6) lung disease and panic attack; (7) all three. Second, multiple logistic regression analyses were used to establish the relationship between child abuse and the risk of panic attack, depression and alcohol/substance use disorder. Next, the same method was used to determine the relationship between child abuse and lung disease. Additional logistic regression analyses were used to determine whether the relationship between child abuse and hypertension, heart attack and gall bladder disease in order to determine whether the relationship between lung disease and child abuse was specific to lung disease, as opposed to other
Diagnostic assessment Psychiatric diagnoses were generated from a modified version of the World Health Organization (WHO) Composite International Diagnostic Interview [22,23], a structured interview designed for use by trained interviewers who are not clinicians. WHO field trials [24] and National Comorbidity Survey clinical reappraisal studies [25,26] documented acceptable reliability and validity of all the diagnoses. Psychiatric disorders examined here include major depressive disorder and panic attacks (past 12-month prevalence). Panic attack was defined as endorsing the gate question for having a panic attack in the past 12 months, at least 4 out of 13 panic symptoms, and these symptoms not being associated with medical
Table 1 Relationship between childhood abuse and likelihood of mental disorders among adults in the community Major depression
Panic attacks
Alcohol dependence
Odds ratio (95% CI) Child abuse Unadjusted Adjusteda Adjustedb a
3.3* (2.4, 4.4) 3.2* (2.4, 4.2) 2.2* (1.5, 3.3)
2.8* (2.6, 5.5) 3.3* (2.3, 4.7) 2.2* (1.3, 3.7)
1.7* (1.3, 2.1) 1.8* (1.3, 2.5) 1.2 (0.8, 1.9)
Adjusted for age, gender, race, marital status, education and income. Adjusted for age, gender, race, marital status, education, income, specific phobia, social phobia, generalized anxiety disorder, agoraphobia, alcohol dependence, substance dependence and dysthymia (12-month prevalence). * P < .05. b
R.D. Goodwin et al. / Journal of Psychosomatic Research 55 (2003) 215–219 Table 2 Relationship between childhood abuse and physical illnesses among adults in the community Lung disease
Hypertension Heart attack
217
compared with those without lung disease, depression and panic attack.
Gall bladder disease
Relationship between child abuse and internalizing disorders
OR (95% CI) Child abuse Unadjusted 2.7* (1.8, 4.1) 1.3 (0.8, 2.0) 0.7 (0.2, 2.3) 1.3 (0.3, 5.7) Adjusteda 2.6* (1.7, 4.1) 1.4 (0.9, 2.1) 0.8 (0.2, 2.8) 7.3 (0.3, 6.1) Adjustedb 2.0* (1.3, 3.2) 1.1 (0.8, 1.7) 0.4 (0.1, 1.8) 0.7 (0.1, 4.2)
Child abuse was associated with significantly increased odds of panic attack, after controlling for age, gender, race, marital status and education (see Table 1). Child abuse was also associated with a significantly increased likelihood of risk of major depression, but did not show a statistically significant association with alcohol/substance use disorder or generalized anxiety disorder.
a
Adjusted for age, gender, race, marital status, education and income. Adjusted for age, gender, race, marital status, education, income, specific phobia, social phobia, generalized anxiety disorder, agoraphobia, alcohol dependence, substance dependence and dysthymia (12-month prevalence). * P < .05. b
Relationship between child abuse and lung disease
medical disorders. Fourth, multiple logistic regression analyses were used to determine the relationship between child abuse and co-occurring lung disease and panic attack, lung disease and depression, and the co-occurrence of all three. Statistical analyses were performed using STATA for windows statistical software package [27].
Child abuse was associated with a significantly increased odds of lung disease, controlling for differences in demographic characteristics, comorbid panic attack, major depression and alcohol/substance use disorder (see Table 2). In contrast, child abuse was not associated with a significantly increased likelihood of hypertension, heart attack or gall bladder disease.
Results
Relationship between child abuse, internalizing disorders and respiratory disease
Characteristics of the six groups Results of multiple logistic regression analyses revealed that child abuse is associated with an almost fivefold increase in odds of the co-occurrence of lung disease and panic, in the absence of depression (see Table 3). Child abuse was also associated with an approximately fivefold increase in the likelihood of co-occurrence of panic attack, depression and lung disease, controlling for demographic differences. This effect was specific for lung disease in that child abuse was not associated with significantly increased odds of the co-occurrence of hypertension, heart attack, or gall bladder disease and panic and depression (data not shown). Child abuse was not associated with a statistically significant increase in the co-occurrence of lung disease and depression, in the absence of panic attack.
Respiratory disease, without panic attack or depression, was reported by 5.4% of the sample, panic attack without depression or lung disease occurred among 7.5% of the sample, 6.7% had major depression without lung disease or panic attack, 1.3% had lung disease with panic attack without depression, 1.4% had lung disease with depression without panic attack, and 1.1% had lung disease with panic attack and depression. Those with lung disease with or without panic attack and depression were more likely to be female, less likely to be married and more likely to be divorced or separated (data not shown). Those with lung disease, depression and panic attack were younger, more likely to be female and less likely to be married
Table 3 Relationship between childhood abuse, lung disease, panic attack and depression Lung disease (no panic attack or depression)
Lung disease and panic attack (no depression)
Lung disease and depression (no panic)
Lung disease, panic attack, and depression
Odds ratio (95% CI) Child abuse Unadjusted Adjusteda Adjustedb a
2.2* (1.2, 3.9) 2.2* (1.2, 4.1) 2.1* (1.1, 3.9)
15.4* (6.5, 36.7) 14.4* (6.9, 30.0) 7.8* (3.3, 18.6)
3.9* (1.6, 9.8) 3.6* (1.4, 9.1) 2.0 (0.7, 5.5)
10.4* (4.3, 25.0) 10.0* (4.1, 23.1) 4.8* (1.2, 19.4)
Adjusted for age, gender, race, marital status, education and income. Adjusted for age, gender, race, marital status, education, income, specific phobia, social phobia, generalized anxiety disorder, agoraphobia, alcohol dependence, substance dependence and dysthymia (12-month prevalence). * P < .05. b
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Discussion Consistent with our hypotheses, these data suggest that childhood abuse is associated with a significant and specific increased likelihood of lung disease among adults in the community. Child abuse also predicted the co-occurrence of lung disease and panic attack, and of the co-occurrence of panic attack, depression and lung disease. Comparisons of the observed associations between childhood abuse and lung disease, relative to the relationship between childhood abuse and other physical illnesses, suggest specificity of this relationship. The mechanism of the observed association between childhood abuse and lung disease remains unclear. There is some evidence that traumatic experiences at an early age are associated with stress that may be reflected by higher levels of circulating cortisol [28,29]. Higher levels of cortisol increase Type-II or allergic immune responses, rather than leading to Type I or cell-mediated responses. Increased Type II immune responses may be associated with higher rates of atopy, which may place these individuals at higher risk for lung disease [30,31]. The onset of lung disease during a time when physical, cognitive and psychological development is ongoing may influence biological, psychological and cognitive processes as they are still developing [32]. The impact of these factors on development, which much research has shown to be associated with significant impairment on school achievement, social and psychological development may increase risk of internalizing disorders through cognitive or social pathways as well, potentially having a profound impact on development and later functioning [33,34]. It is thought that the link between respiratory function and panic attack would make this association, with the overlap in somatic symptoms, demonstrate potential etiologic links. It is possible that abused children may also be neglected. For instance, if a child with mild asthma is not given appropriate treatment, there is evidence that lung disease processes will progress into a more serious, and prolonged, illness [35]. Alternatively, or in conjunction with this, the respiratory abnormalities observed in some individuals with panic attack and other early-onset anxiety symptoms and disorders may interact with asthma-related physical differences to increase the severity or progression of one or both of these conditions [8]. For instance, it might be that the overlap in panic attack symptoms and asthma attack symptoms interact to increase risk of progression of panic attacks to panic disorder, agoraphobia, depression and other psychopathology. Considering the elevated physical risks associated with lung disease (e.g., reality-based concerns about physical morbidity and even mortality, depending on severity), it is not inconceivable that the co-occurrence of both lung problems and panic attack could facilitate this progression. The observed relationships between childhood abuse, lung disease and the likelihood of panic attack and
depression could also be due to other environmental associations. Children who have been physically abused may not have learned good self-soothing skills [36]. Thus, for example, those with lung disease and panic attack may be more likely to have dire cognitions, e.g., ‘‘I will die, or this is very dangerous,’’ compared with those with lung disease without anxiety. Given the previously observed association between negative and catastrophic cognitions associated with panic attacks in other samples [37], this may at least partially explain the association between increased panic attack and lung disease among individuals with both of these conditions. It is also conceivable that these relationships are influenced by other factors (e.g., low socioeconomic status, parental psychopathology) known to be associated with child abuse. Still, the association observed here persists even after adjusting for income and education, which are proxies for socioeconomic status. One considerable limitation of our investigation is the exclusive reliance on self-report data for the diagnosis of lung disease. Also, the use of this combined group variable for lung disease, which was the only available measure of lung disease in this dataset, prevents an analysis of associations between lung disease and specific mental disorders related to child abuse or severity of lung disease. This also prevents an examination of specific lung diseases and their relation to internalizing disorders. While selfreport data on physical illnesses is commonly used in epidemiologic studies, the lack of data on objectively measured physical health status does not allow us to exclude the possibility that self-report of lung disease, rather than lung disease itself, is associated with child abuse and internalizing disorders. Lack of data from biological measures (e.g., respiratory function tests) to corroborate presence and severity of physical disease is a serious shortcoming of the study, and these sorts of data are needed for a replication study. These data are also limited by the lack of information on age of onset of lung disease and of internalizing disorders, which would be of interest in examining the temporal relationship between onset of panic attack and asthma onset. Finally, the use of a single item question, without indication of severity, for child abuse limits the extent to which more complex models can be examined. The use of a large, nationally representative sample of adults is a strength of this study. Future studies that investigate the relationship between child abuse, lung disease, and internalizing disorders in a prospective, longitudinal epidemiologic sample and include objective measures of physical symptoms (e.g., respiratory function tests) may provide more definitive answers about the mechanism of this association. Genetic linkage studies that examine the association between panic attack and lung disease may also be useful in providing clues to the potential underlying inherited contribution to both lung disease and panic attack, as there is already evidence of this association in depression and asthma [12]. Better understanding of these
R.D. Goodwin et al. / Journal of Psychosomatic Research 55 (2003) 215–219
pathways and the potential for bidirectional causation of lung disease, panic attack and depression, as well as the role of child abuse in these risks, may help to inform public health prevention efforts. Further work is needed to determine the mechanism of these associations.
References [1] Carr RE. Panic disorder and asthma. J Asthma 1999;36:143 – 52. [2] Carr RE, Lehrer PM, Hochron SM. Predictors of panic-fear in asthma. Health Psychol 1995;14:421 – 6. [3] Vila G, Nollet-Clemencon C, de Blic J, Mouren-Simeoni MC, Scheinmann P. Prevalence of DSM IV anxiety and affective disorders in a pediatric population of asthmatic children and adolescents. J Affect Disord 2000;58:223. [4] Koltek M, Wilkes TC, Atkinson M. The prevalence of posttraumatic stress disorder in an adolescent inpatient unit. Can J Psychiatry 1998; 43:64 – 8. [5] Cluley S, Cochrane GM. Psychological disorder in asthma is associated with poor control and poor adherence to inhaled steroids. Respir Med 2001;95:37 – 9. [6] Klein DF. False suffocation alarms, spontaneous panics, and related conditions. An integrative hypothesis. Arch Gen Psychiatry 1993;50: 306 – 17. [7] Pine DS, Weese-Mayer DE, Silvestri JM, Davies M, Whitaker A, Klein DF. Anxiety and congenital central hypoventilation syndrome. Am J Psychiatry 1994;151:864 – 70. [8] Pine DS, Klein RG, Coplan JD, Papp LA, Hoven CW, Martinez J, Kovalenko P, Mandell DJ, Moreau D, Klein DF, Gorman JM. Differential carbon dioxide sensitivity in childhood anxiety disorders and nonill comparison group. Arch Gen Psychiatry 2000;57:960 – 7. [9] Janson S, Reed ML. Patients’ perceptions of asthma control and impact on attitudes and self-management. J Asthma 2000;37:625 – 40. [10] Centanni S, Di Marco F, Castagna F, Boveri B, Casanova F, Piazzini A. Psychological issues in the treatment of asthmatic patients. Respir Med 2000;94:742 – 9. [11] Anderson JL. The immune system and major depression. Adv Neuroimmunol 1996;6:119 – 29. [12] Wamboldt MZ, Hewitt JK, Schmitz S, Wamboldt FS, Rasanen M, Koskenvuo M, Romanov K, Varjonen J, Kaprio J. Familial association between allergic disorders and depression in adult Finnish twins. Am J Med Genet 2000;96:146 – 53. [13] Walker EA, Keegan D, Gardner G, Sullivan M, Bernstein D, Katon WJ. Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II. Sexual, physical, and emotional abuse and neglect. Psychosom Med 1997;59:572 – 7. [14] Ruppel RA, Kochanek PM, Adelson PD, Rose ME, Wisniewski SR, Bell MJ, Clark RS, Marion DW, Graham SH. Excitatory amino acid concentrations in ventricular cerebrospinal fluid after severe traumatic brain injury in infants and children: the role of child abuse. J Pediatr 2001;138:18 – 25. [15] Young EA, Abelson JL, Curtis GC, Nesse RM. Childhood adversity and vulnerability to mood and anxiety disorders. Depress Anxiety 1997;5:66 – 72. [16] Chaffin M, Kelleher K, Hollenberg J. Onset of physical abuse and neglect: psychiatric, substance abuse, and social risk factors from prospective community data. Child Abuse Negl 1996;20:191 – 203. [17] Pollack MH, Otto MW, Rosenbaum JF, Sachs GS. Personality disorders in patients with panic disorder: association with childhood anxiety disorders, early trauma, comorbidity, and chronicity. Compr Psychiatry 1992;33:78.
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[18] Boisset-Pioro MH, Esdaile JM, Fitzcharles MA. Sexual and physical abuse in women with fibromyalgia syndrome. Arthritis Rheum 1995; 38:235 – 41. [19] Goldberg RT, Pachas WN, Keith D. Relationship between traumatic events in childhood and chronic pain. Disabil Rehabil 1999; 21:23 – 30. [20] Alexander RW, Bradley LA, Alarcon GS, Triana-Alexander M, Aaron LA, Alberts KR, Martin MY, Stewart KE. Sexual and physical abuse in women with fibromyalgia: association with outpatient health care utilization and pain medication usage. Arthritis Care Res 1998;11: 102 – 15. [21] Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman HU, Wittchen HU, Kendler KS. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51:8 – 19. [22] Wittchen H-U, Kessler RC, Zhao S, Abelson J. Reliability and clinical validity of UM-CIDI DSM-III-R generalized anxiety disorder. J Psychiatr Res 1995;29:95 – 110. [23] Wittchen H-U. Reliability and validity studies of the WHO Composite International Diagnostic Interview (CIDI): a critical review. J Psychiatr Res 1994;28:57 – 84. [24] World Health Organization: Composite International Diagnostic Interview (CIDI), version 1.0. Geneva: WHO, 1990. [25] Wittchen H-U, Zhao S, Abelson JM, Abelson JL, Kessler RC. Reliability and procedural validity of UM-CIDI DSM-III-R phobic disorders. Psychol Med 1996;25:1169 – 77. [26] Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am J Psychiatry 1994; 151:979 – 86. [27] StataCorp. Stata Statistical Software: Release 6.0. College Station (TX): Stata Corporation, 2001. [28] Heim C, Newport DJ, Miller AH, Nemeroff CB. Long-term neuroendocrine effects of childhood maltreatment. JAMA 2000;284:2321. [29] Kaufman J, Plotsky PM, Nemeroff CB, Charney DS. Effects of early adverse experiences on brain structure and function: clinical implications. Biol Psychiatry 2000;48:778 – 90. [30] Ramirez F, Fowell DJ, Puklavec M, Simmonds S, Mason D. Glucocorticoids promote a Th2 cytokine response by CD4+ T cells in vitro. J Immunol 1996;156:2406 – 12. [31] Magnan A, Mely L, Prato S, Vervloet D, Romagne F, Camilla C, Necker A, Casano B, Montero-Jullian F, Fert V, Malissen B, Bongrand P. Relationships between natural T cells, atopy, IgE levels, and IL-4 production. Allergy 2000;55:286 – 90. [32] Bender BG, Annett RD, Ikle D, DuHamel TR, Rand C, Strunk RC. Relationship between disease and psychological adaptation in children in the Childhood Asthma Management Program and their families. CAMP Research Group. Arch Pediatr Adolesc Med 2000;154: 706 – 13. [33] Rubin DH, Leventhal JM, Erenberg FG, Kurzon M. Absence from school in children with chronic asthma. Am J Asthma Allergy Pediatr 1990;3:166 – 72. [34] Gutstadt LB, Gillette JW, Mrazek DA, Fukuhara JT, LaBrecque JF, Strunk RC. Determinants of school performance in children with chronic asthma. Am J Dis Child 1989;143:471 – 5. [35] Walsh-Kelly CM, Kim MK, Hennes HM. Chest radiography in the initial episode of bronchospasm in children: can clinical variables predict pathologic findings? Ann Emerg Med 1996;28:391 – 5. [36] Kagan J. The form of early development. Continuity and discontinuity in emergent competences. Arch Gen Psychiatry 1979;36:1047 – 54. [37] Chambless DL, Beck AT, Gracely EJ, Grisham JR. Relationship of cognitions to fear of somatic symptoms: a test of the cognitive theory of panic. Depress Anxiety 2000;11:1 – 9.
Lung disease and internalizing disorders Is childhood abuse a shared etiologic factor? Renee D. Goodwin*, Marianne Z. Wamboldt, Daniel S. Pine Columbia University, New York, NY, USA National Jewish Medical and Research Center, Denver, CO, USA National Institute of Mental Health (NIMH), Bethesda, MD, USA Received 19 September 2001; accepted 18 April 2002
Abstract Objective: To investigate the role of childhood abuse in the relationship between panic attack, depression and lung disease among adults in the population. Methods: Data were drawn from the National Comorbidity Survey (n = 5877), a representative sample of adults age 15 – 54 in the United States. Multiple logistic regression analyses were used to determine the association between childhood abuse and lung disease, and to determine whether childhood abuse is an independent predictor of the co-occurrence of lung disease, panic attack and depression. Results: Childhood abuse was associated with significantly increased odds of panic attacks (OR = 2.2 (1.5, 3.1)) and
depression (OR = 1.6 (1.1, 2.3)). Childhood abuse increased likelihood of lung disease (OR = 1.5 (1.1, 2.2)). Childhood abuse independently predicted the co-occurrence of lung disease, panic attack and depression (OR = 10.7 (2.2, 51.5)). Conclusion: These data are preliminary, but if replicated, suggest that childhood abuse may be associated with increased risk of lung disease during adulthood, and further may reflect a shared vulnerability for the co-occurrence of lung disease, panic attack and depression in the community. Future studies are needed to further explore the mechanism of this association. D 2003 Elsevier Inc. All rights reserved.
Keywords: Lung disease; Respiratory illness; Epidemiology; Anxiety; Childhood abuse
Introduction Recent data suggest that lung disease (e.g., asthma, chronic obstructive pulmonary disease) and internalizing disorders co-occur more often than would be expected by chance [1 – 5]. The mechanism of this association is unknown. It is possible that lung disease such as asthma, which is characterized by sudden constriction of airways, may lead to the development of specific anxiety symptoms (e.g., panic attacks) [6– 8]. Since panic attacks and asthma attacks may share overlapping physiological features and fear of respiratory difficulties, symptoms of each may interact reciprocally to influence progression of both diseases [9,10]. It is also conceivable that anxiety and depression lead to the onset of lung disease. Major depression is
* Corresponding author. 1051 Riverside Dr., Unit 43, New York, NY 10032, USA. Tel.: +1-212-305-6706; fax: +1-212-305-9413. E-mail address: [email protected] (R.D. Goodwin). 0022-3999/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0022-3999(02)00497-X
associated with altered immune functioning, which may increase susceptibility to asthma, bronchitis and other inflammatory diseases [11]. Moreover, previous data from twin studies suggest the possibility of a shared diathesis to both internalizing disorders (i.e., depressive and anxiety disorders) and specific forms of lung disease (i.e., asthma) [12]. These two potential pathways present lung disease, panic attack and depression as discrete phenomena. One alternative hypothesis is that a third factor, possibly a shared vulnerability, for panic attack and lung disease, or depression and lung disease, underlies an association between lung disease and internalizing disorders. Childhood abuse has been hypothesized as a marker of vulnerability for both physical and mental disorders [13,14]. Epidemiologic data support a connection between child abuse and increased risk of panic attack and major depression in the community [15,16]. Clinical and preclinical data also suggest that trauma, such as child abuse, may weaken immune system responses, thereby increasing vulnerability to the development of physical
216
R.D. Goodwin et al. / Journal of Psychosomatic Research 55 (2003) 215–219
illnesses [17,18]. Data from psychiatric and medical patient populations show evidence of an association between trauma and increased risk of physical illness in clinical settings [17 – 20]. To date, however, no study has examined the relationship between child abuse and the co-occurrence of physical illness and mental disorders. Moreover, these associations have not been examined in an epidemiologic sample, which is needed in order to determine associations in the absence of selection into treatment bias. In an effort to begin to address this gap, we examine three main questions. First, is childhood abuse associated with increased odds of lung disease among adults in the general population? Second, is childhood abuse an independent correlate of the co-occurrence of lung disease and internalizing disorders among adults in the population? Third, is the relationship between childhood abuse and lung disease specific? We hypothesized that childhood abuse would be associated with increased odds of lung disease in adulthood. We also predicted that childhood abuse would be an independent correlate of the co-occurrence of lung disease and internalizing disorders among adults in the general population.
Methods Sample The National Comorbidity Survey is based on a national probability sample (n = 5877) of individuals age 15 –54 in the noninstitutionalized population [21]. Fieldwork was carried out between September 1990 and February 1992. There was an 82.4% response rate. The data were weighted for differential probabilities of selection and nonresponse. A weight was also used to adjust the sample to approximate the cross-classification of the population distribution on a range of sociodemographic characteristics. Weighting and a full description of study methodology are described in detail elsewhere [21].
illness or ingestion of any type of drug or medication. A checklist of physical illnesses within the past 12 months included ‘‘chronic stomach or gall bladder trouble,’’ ‘‘heart attack or other serious heart trouble’’ and ‘‘high blood pressure or hypertension.’’ Lung disease was quantified with an affirmative response to having ‘‘severe asthma, chronic bronchitis or tuberculosis.’’ Written informed consent was obtained from each participant after the survey had been fully explained. Childhood abuse History of childhood abuse was defined by affirmative response to a yes or no question inquiring whether an individual had been physically abused as a child. Analytic strategy First, F-based tests for independence were used to determine difference in demographic characteristics and mental disorders among seven mutually exclusive groups: (1) controls: individuals without lung disease, panic or depression; (2) panic attack only: those who have panic attacks but not lung disease or depression; (3) lung disease only: those who have lung disease and have never had panic attacks or depression; (4) depression only: depression without lung disease or panic attack; (5) lung disease and depression; (6) lung disease and panic attack; (7) all three. Second, multiple logistic regression analyses were used to establish the relationship between child abuse and the risk of panic attack, depression and alcohol/substance use disorder. Next, the same method was used to determine the relationship between child abuse and lung disease. Additional logistic regression analyses were used to determine whether the relationship between child abuse and hypertension, heart attack and gall bladder disease in order to determine whether the relationship between lung disease and child abuse was specific to lung disease, as opposed to other
Diagnostic assessment Psychiatric diagnoses were generated from a modified version of the World Health Organization (WHO) Composite International Diagnostic Interview [22,23], a structured interview designed for use by trained interviewers who are not clinicians. WHO field trials [24] and National Comorbidity Survey clinical reappraisal studies [25,26] documented acceptable reliability and validity of all the diagnoses. Psychiatric disorders examined here include major depressive disorder and panic attacks (past 12-month prevalence). Panic attack was defined as endorsing the gate question for having a panic attack in the past 12 months, at least 4 out of 13 panic symptoms, and these symptoms not being associated with medical
Table 1 Relationship between childhood abuse and likelihood of mental disorders among adults in the community Major depression
Panic attacks
Alcohol dependence
Odds ratio (95% CI) Child abuse Unadjusted Adjusteda Adjustedb a
3.3* (2.4, 4.4) 3.2* (2.4, 4.2) 2.2* (1.5, 3.3)
2.8* (2.6, 5.5) 3.3* (2.3, 4.7) 2.2* (1.3, 3.7)
1.7* (1.3, 2.1) 1.8* (1.3, 2.5) 1.2 (0.8, 1.9)
Adjusted for age, gender, race, marital status, education and income. Adjusted for age, gender, race, marital status, education, income, specific phobia, social phobia, generalized anxiety disorder, agoraphobia, alcohol dependence, substance dependence and dysthymia (12-month prevalence). * P < .05. b
R.D. Goodwin et al. / Journal of Psychosomatic Research 55 (2003) 215–219 Table 2 Relationship between childhood abuse and physical illnesses among adults in the community Lung disease
Hypertension Heart attack
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compared with those without lung disease, depression and panic attack.
Gall bladder disease
Relationship between child abuse and internalizing disorders
OR (95% CI) Child abuse Unadjusted 2.7* (1.8, 4.1) 1.3 (0.8, 2.0) 0.7 (0.2, 2.3) 1.3 (0.3, 5.7) Adjusteda 2.6* (1.7, 4.1) 1.4 (0.9, 2.1) 0.8 (0.2, 2.8) 7.3 (0.3, 6.1) Adjustedb 2.0* (1.3, 3.2) 1.1 (0.8, 1.7) 0.4 (0.1, 1.8) 0.7 (0.1, 4.2)
Child abuse was associated with significantly increased odds of panic attack, after controlling for age, gender, race, marital status and education (see Table 1). Child abuse was also associated with a significantly increased likelihood of risk of major depression, but did not show a statistically significant association with alcohol/substance use disorder or generalized anxiety disorder.
a
Adjusted for age, gender, race, marital status, education and income. Adjusted for age, gender, race, marital status, education, income, specific phobia, social phobia, generalized anxiety disorder, agoraphobia, alcohol dependence, substance dependence and dysthymia (12-month prevalence). * P < .05. b
Relationship between child abuse and lung disease
medical disorders. Fourth, multiple logistic regression analyses were used to determine the relationship between child abuse and co-occurring lung disease and panic attack, lung disease and depression, and the co-occurrence of all three. Statistical analyses were performed using STATA for windows statistical software package [27].
Child abuse was associated with a significantly increased odds of lung disease, controlling for differences in demographic characteristics, comorbid panic attack, major depression and alcohol/substance use disorder (see Table 2). In contrast, child abuse was not associated with a significantly increased likelihood of hypertension, heart attack or gall bladder disease.
Results
Relationship between child abuse, internalizing disorders and respiratory disease
Characteristics of the six groups Results of multiple logistic regression analyses revealed that child abuse is associated with an almost fivefold increase in odds of the co-occurrence of lung disease and panic, in the absence of depression (see Table 3). Child abuse was also associated with an approximately fivefold increase in the likelihood of co-occurrence of panic attack, depression and lung disease, controlling for demographic differences. This effect was specific for lung disease in that child abuse was not associated with significantly increased odds of the co-occurrence of hypertension, heart attack, or gall bladder disease and panic and depression (data not shown). Child abuse was not associated with a statistically significant increase in the co-occurrence of lung disease and depression, in the absence of panic attack.
Respiratory disease, without panic attack or depression, was reported by 5.4% of the sample, panic attack without depression or lung disease occurred among 7.5% of the sample, 6.7% had major depression without lung disease or panic attack, 1.3% had lung disease with panic attack without depression, 1.4% had lung disease with depression without panic attack, and 1.1% had lung disease with panic attack and depression. Those with lung disease with or without panic attack and depression were more likely to be female, less likely to be married and more likely to be divorced or separated (data not shown). Those with lung disease, depression and panic attack were younger, more likely to be female and less likely to be married
Table 3 Relationship between childhood abuse, lung disease, panic attack and depression Lung disease (no panic attack or depression)
Lung disease and panic attack (no depression)
Lung disease and depression (no panic)
Lung disease, panic attack, and depression
Odds ratio (95% CI) Child abuse Unadjusted Adjusteda Adjustedb a
2.2* (1.2, 3.9) 2.2* (1.2, 4.1) 2.1* (1.1, 3.9)
15.4* (6.5, 36.7) 14.4* (6.9, 30.0) 7.8* (3.3, 18.6)
3.9* (1.6, 9.8) 3.6* (1.4, 9.1) 2.0 (0.7, 5.5)
10.4* (4.3, 25.0) 10.0* (4.1, 23.1) 4.8* (1.2, 19.4)
Adjusted for age, gender, race, marital status, education and income. Adjusted for age, gender, race, marital status, education, income, specific phobia, social phobia, generalized anxiety disorder, agoraphobia, alcohol dependence, substance dependence and dysthymia (12-month prevalence). * P < .05. b
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R.D. Goodwin et al. / Journal of Psychosomatic Research 55 (2003) 215–219
Discussion Consistent with our hypotheses, these data suggest that childhood abuse is associated with a significant and specific increased likelihood of lung disease among adults in the community. Child abuse also predicted the co-occurrence of lung disease and panic attack, and of the co-occurrence of panic attack, depression and lung disease. Comparisons of the observed associations between childhood abuse and lung disease, relative to the relationship between childhood abuse and other physical illnesses, suggest specificity of this relationship. The mechanism of the observed association between childhood abuse and lung disease remains unclear. There is some evidence that traumatic experiences at an early age are associated with stress that may be reflected by higher levels of circulating cortisol [28,29]. Higher levels of cortisol increase Type-II or allergic immune responses, rather than leading to Type I or cell-mediated responses. Increased Type II immune responses may be associated with higher rates of atopy, which may place these individuals at higher risk for lung disease [30,31]. The onset of lung disease during a time when physical, cognitive and psychological development is ongoing may influence biological, psychological and cognitive processes as they are still developing [32]. The impact of these factors on development, which much research has shown to be associated with significant impairment on school achievement, social and psychological development may increase risk of internalizing disorders through cognitive or social pathways as well, potentially having a profound impact on development and later functioning [33,34]. It is thought that the link between respiratory function and panic attack would make this association, with the overlap in somatic symptoms, demonstrate potential etiologic links. It is possible that abused children may also be neglected. For instance, if a child with mild asthma is not given appropriate treatment, there is evidence that lung disease processes will progress into a more serious, and prolonged, illness [35]. Alternatively, or in conjunction with this, the respiratory abnormalities observed in some individuals with panic attack and other early-onset anxiety symptoms and disorders may interact with asthma-related physical differences to increase the severity or progression of one or both of these conditions [8]. For instance, it might be that the overlap in panic attack symptoms and asthma attack symptoms interact to increase risk of progression of panic attacks to panic disorder, agoraphobia, depression and other psychopathology. Considering the elevated physical risks associated with lung disease (e.g., reality-based concerns about physical morbidity and even mortality, depending on severity), it is not inconceivable that the co-occurrence of both lung problems and panic attack could facilitate this progression. The observed relationships between childhood abuse, lung disease and the likelihood of panic attack and
depression could also be due to other environmental associations. Children who have been physically abused may not have learned good self-soothing skills [36]. Thus, for example, those with lung disease and panic attack may be more likely to have dire cognitions, e.g., ‘‘I will die, or this is very dangerous,’’ compared with those with lung disease without anxiety. Given the previously observed association between negative and catastrophic cognitions associated with panic attacks in other samples [37], this may at least partially explain the association between increased panic attack and lung disease among individuals with both of these conditions. It is also conceivable that these relationships are influenced by other factors (e.g., low socioeconomic status, parental psychopathology) known to be associated with child abuse. Still, the association observed here persists even after adjusting for income and education, which are proxies for socioeconomic status. One considerable limitation of our investigation is the exclusive reliance on self-report data for the diagnosis of lung disease. Also, the use of this combined group variable for lung disease, which was the only available measure of lung disease in this dataset, prevents an analysis of associations between lung disease and specific mental disorders related to child abuse or severity of lung disease. This also prevents an examination of specific lung diseases and their relation to internalizing disorders. While selfreport data on physical illnesses is commonly used in epidemiologic studies, the lack of data on objectively measured physical health status does not allow us to exclude the possibility that self-report of lung disease, rather than lung disease itself, is associated with child abuse and internalizing disorders. Lack of data from biological measures (e.g., respiratory function tests) to corroborate presence and severity of physical disease is a serious shortcoming of the study, and these sorts of data are needed for a replication study. These data are also limited by the lack of information on age of onset of lung disease and of internalizing disorders, which would be of interest in examining the temporal relationship between onset of panic attack and asthma onset. Finally, the use of a single item question, without indication of severity, for child abuse limits the extent to which more complex models can be examined. The use of a large, nationally representative sample of adults is a strength of this study. Future studies that investigate the relationship between child abuse, lung disease, and internalizing disorders in a prospective, longitudinal epidemiologic sample and include objective measures of physical symptoms (e.g., respiratory function tests) may provide more definitive answers about the mechanism of this association. Genetic linkage studies that examine the association between panic attack and lung disease may also be useful in providing clues to the potential underlying inherited contribution to both lung disease and panic attack, as there is already evidence of this association in depression and asthma [12]. Better understanding of these
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pathways and the potential for bidirectional causation of lung disease, panic attack and depression, as well as the role of child abuse in these risks, may help to inform public health prevention efforts. Further work is needed to determine the mechanism of these associations.
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