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Reported childhood trauma, attempted suicide and self-mutilative behavior among women in the general population
European Psychiatry 20 (2005) 268–273 http://france.elsevier.com/direct/EURPSY/
Original article
Reported childhood trauma, attempted suicide and self-mutilative behavior among women in the general population Gamze Akyuz a, Vedat Sar b, Nesim Kugu a, Orhan Dog˘an a,* a b
Department of Psychiatry, Medical Faculty, Cumhuriyet University, Sivas 58140, Turkey Department of Psychiatry, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey Received 17 May 2004; accepted 14 January 2005 Available online 27 April 2005
Abstract This study attempted to determine the prevalence of childhood trauma among women in the general population as assessed in a representative sample from a city in central Turkey. The Dissociative Experiences Scale (DES) was administered to 628 women in 500 homes. They were also asked for childhood abuse and/or neglect. DES was administered to 251 probands. Mean age of the probands was 34.8 ± 11.5 years (range 18–65). Sixteen women (2.5%) reported sexual abuse, 56 women (8.9%) physical abuse, and 56 women (8.9%) emotional abuse in childhood. The most frequently reported childhood trauma was neglect (n = 213, 33.9%). The prevalence of suicide attempts was 4.5% (n = 28). Fourteen probands (2.2%) reported self-mutilative behavior. © 2005 Elsevier SAS. All rights reserved. Keywords: Abuse; Childhood trauma; Neglect; Suicide attempt; Self-mutilation; Dissociative Experiences Scale
1. Introduction Mental health professionals are becoming more aware of the possibility of sexual and physical abuse in the histories of patients requesting treatment in a variety of clinical settings [3]. Clinical and non-clinical studies related to child maltreatment and its effects on psychopathology demonstrated that childhood abuse and neglect is highly correlated with suicidal and self-mutilative behavior in children, adolescents and adults [8,26]. Deliberate self-harm typically starts in adolescence and involves numerous episodes and a variety of methods, including cutting, burning, slapping, bunging, picking and bone breaking [12,14]. Many patients report feeling of numb and ‘dead’ prior to harming themselves [2,18]. They often claim not to experience pain during self-injury and report a sense of relief afterward [18,22]. Episodes of self-mutilation often follow feeling of disappointment or abandonment [17,32]. In the first controlled study, Green (1978) found that 41% of his sample of physically abused children exhibited signifi* Corresponding author. Cumhuriyet Üniversitesi Hastanesi, Psikiyatri Anabilim Dal1, 58140 Sivas, Turkey; Tel./fax: +90 346 219 1574; fax: +90 346 219 1284. E-mail address: [email protected] (O. Dog˘an). 0924-9338/$ - see front matter © 2005 Elsevier SAS. All rights reserved. doi:10.1016/j.eurpsy.2005.01.002
cantly much more self-destructive behaviors (such as head banging, self-biting, self-burning, and self-cutting) when compared to normal children [19]. Ferguson et al. [15] suggest that between 16.5% and 19.5% of suicide attempts of young adults may be exposure to childhood sexual abuse. While the symptomatic effects of sexual abuse one well studied [20,24], the possible mediators of the complex relationship between childhood abuse and psychopathology are currently a focus [24]. Several empiric literatures document significant association between overwhelming traumatic experiences and pathological levels of dissociation. Dissociation has been described as a disruption of normally integrated function of consciousness, memory, identity or perception of environment or the body [1]. Putnam has suggested that aggressive, risk-taking behavior often occurs in the context of dissociative experiences, when individuals feel out of control and compelled to do something against they wills [23]. In a recent study Kisiel and Lyons [21] determined that dissociation might be critical mediator of selfdestructive behavior in abused adolescents. The purpose of the present study is to determine the frequency of childhood abuse and neglect, to investigate its relationship with attempted suicide, self-mutilation and dissociation and to examine the potential impact of dissociation on
G. Akyuz et al. / European Psychiatry 20 (2005) 268–273
self-destructive behaviors of adult females in a non-western culture.
2. Materials and methods 2.1. Subjects This study was conducted in Sivas city, a town with a population of 221,500 according to the census data of 1990. The rural areas of the province, which include 546,000 people, were not included in the study. One hundred and twenty thousand people in the city were between 18 and 65 years of age. Approximately 40% of the population is under 18 years of age, and 4% is above 65. Our target population was 60,000 women. 2.2. Instruments 2.2.1. Dissociative experiences scale (DES) The DES is a self-report scale consisting of 28 items and quantifying dissociative experiences. Bernstein and Putnam [4] developed The DES and it has adequate test–retest reliability, good split-half reliability and good clinical validity. The Turkish Version of the DES was also shown as a reliable and valid measure in a previous study [35]. 2.2.2. Childhood abuse and neglect questionnaire (CANQ) We used the CANQ designed and formerly used in various studies [33]. This questionnaire consists of questions about childhood physical, sexual and emotional abuse, and neglect. After each question, information regarding the identity and age of the perpetrator, and the age of the subject during abuse was requested. For physical and sexual abuse, the respondent indicated on a four-point scale how frequent some particular events or situations occurred during his or her childhood and adolescence. Childhood physical abuse is defined as physical violence against a person under 16 years old, by someone at least 5 years older or by a family member at least 2 years older than the victim. Close confinement, such as being locked in a closet is also included. The victim perceives it severe, but should not consider this maltreatment as sibling rivalry. Quarrels between friends that do not include any physical contact are not accepted as physical abuse. Childhood sexual abuse is defined as involvement of a person younger than 16 years old in any kind of sexual activities, such as genital fondling, an adult exhibiting his or her genitalia to a child, forcing the child to exhibit himself or herself to the adult or the child to have sexual intercourse with someone at least 5 years older or with a family member (incest) at least 2 years older than the victim. All questions about physical and sexual abuse were based on Brown and Anderson’s [7] descriptions. Emotional abuse involves the use of excessive verbal threats, ridiculous and personally demeaning comments,
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derogatory statements and threats against the young person to the extent that a child’s emotional and mental well-being will be jeopardized. Neglect refers to acts of omission in which the child is not properly cared for physically (nutrition, safety, education, medical care etc.) or emotionally (failure to bond, lack of affection, love, support, nurturing or concern). Questions about emotional abuse and neglect were based on the descriptions of Walker et al. [34]. 2.2.3. Suicide attempt and self-mutilation A self-report questionnaire developed by authors investigates frequency, duration and types of self-mutilative behaviors and suicide attempts over the life course. For the present study’s purposes, self-mutilation was defined as deliberate harm to one’s body without a conscious intent to die [13], and included such behaviors as cutting, slashing, burning, pulling hair or banging and hitting of some body areas. Suicide attempt was defined as any behavior that is intended to end the life of a child or an adolescent and included such behaviors as overdose ingestion, hanging, cutting of the arms or neck, jumping from a height, stabbing himself or herself, drowning or self shooting. 3. Procedure 3.1. Subjects The procedure was a two stage stratified random sampling. A sample set of households’ representative for a team of sociologists had defined the Sivas City, previously [10]. We used this sample set. All neighborhoods in the city were included in the sample. There were 34,831 households in 600 neighborhoods of the city. Sample sizes of 500 households were chosen (Table 1). The number of households drawn from each neighborhood was determined in proportion to the population of the neighborhood. The households in each neighborhood were selected randomly by using the records of the electricity company. A random sample of 100 alternative addresses was drawn up to replace those households where nobody was present. All neighborhoods had been classified according to the socioeconomic status in a nine level system [10]. These nine levels were grouped as upper, middle and low, respectively. Distance to the center of the city, the characteristics of the buildings and the income of the families concerned were taken as the main criteria of socioeconomic level. Consequently, in our sample, 36 (5.7%) households were from upper socioeconomic level, 468 (74.5%) households middle, and 123 (19.6%) low. Table 1 The population of the Sivas City Province Sivas City (including city) Sivas City 18–65 years of age Women (age: 18–65) Households (city)
767,500 221,500 120,000 60,000 34,831
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The households were visited without previous notification. Respondents had to be women in the range between 18 and 65 years of age. In each selected household, the number of female residents between the age ranges was determined and we tried to reach all of them in maximal two visits in the same day. Subjects who could not be contacted as they were away from home during both visits were replaced. Informed consent to participate in the study was obtained by all respondents.
cation at all (they were illiterate), 47.1% (n = 296) had primary school graduate, 24.2% (n = 152) had secondary or high school education, 5.3% (n = 33) had university graduate. There was no statistically significant relation between education levels and all types of abuse (P > 0.05). 78.3% (n = 492) were married, 13.1% (n = 82) single, and 8.6% (n = 54) divorced or widowed. 88.5% (n = 556) of the subjects were housewives, 7.5% (n = 47) were employed, 3.0% (n = 19) were student and 1.0% (n = 6) was retired (Table 3).
3.2. Interviewing
4.2. DES scores
One of us (G.A.) who are a female psychiatrist and assistant professor in the local university clinic administered the interviews to all probands. The interviewer had extensive experience about the administration of the assessment instruments and had participated in a previous epidemiological study on dissociative disorders in Sivas. The study was completed in 4 months. The interviews were conducted in homes privately.
As the rate of illiteracy was high, we were able to administer the DES only to 40.0% (n = 251) of the probands the mean DES score of the entire sample was 11.8 ± 10.2 (range: 0–55.7), the median score was 9.3 (we only administered the DES as self-report because there are differences between DES scores of self-report and verbal). There was no correlation between age and the DES score (r = 0.08, n = 251, P > 0.05). However, there was a negative correlation between education and DES score (r = –0.16, n = 251, P < 0.01). Marital status did not exert any influence (F = 0.21, P > 0.05). Forty (15.9%) of the probands had a DES score 20 or higher. Sixteen (6.4%) of the probands had a score above 30.7 (2.8%) probands had DES score above 40 (Table 4). The mean DES score of 11.8, it this study is similar to the result reported by Ross et al. [25] as 10.8 previously.
4. Results 4.1. Sample The sample consisted of 628 women in 500 households (Table 2). None of the subjects refused to participate in the study. Forty-nine households were replaced as nobody was found there on either visit. 19 subjects could not be contacted as they were away from home during both visits; they were replaced. Age distributions in decades had significant difference (v2 = 15.28, df = 3, P < 0.01) compared with the distribution of women in the general population of Sivas City according to the census data [24] (Table 2). In our sample, subjects in the age range 25–54 are slightly over represented. It is not known whether the change in the demography of the city after the census in 1990 has played a role in this difference. The mean age for the entire sample was (34.8 ± 11.5). The median age for the entire sample was 33.0 years. Concerning the education of the respondents 21.8% (n = 137) had no eduTable 2 Ages of the respondents in the present study in Sivas and 1990 census data
Age (years) 18–19 20–24 25–34 35–44 45–54 55–64 65
Present study women (n = 628) n % 33 5.2 100 15.8 208 32.8 155 24.7 83 13.2 47 7.6 3 0.5
1990 Census women (n = 59220) n % 5250 8.9 10,183 17.2 17,384 29.4 12,203 20.6 7602 12.8 5919 10.0 679 1.1
v2 = 15.28, df = 3, P < 0.01. Subjects in the age range 25–54 are slightly over represented in the sample.
4.3. The prevalence of childhood abuse and neglect The most frequent trauma type was neglect (Table 5). Emotional 21.5% (n = 135), physical 24.5% (n = 154), and sexual 2.5% (n = 16) abuse followed. Sexual abuse of incest type was seen in 0.8% (n = 5) of the probands. In sexually abused group, the age at onset of abuse fell into one of three ranges: 0–6 years (6.7%, n = 1), 7–11 years (6%, n = 6), or 12 years and above (8%, n = 53.3). There was not any gender difference in the frequency of incest. 20.5% (n = 172) of the probands reported just one type of abuse, whereas 8.7% (n = 73) reported two types, 3.8% (n = 32) three types and 1.3% (n = 11) all of four types of trauma. Table 3 Demographic characteristics of the sample Households Probands Age Mean Range Married Illiterate or no education Only primary school graduated Occupation Housewife (n = 556) Employed (n = 47) Student (n = 19) Retired (n = 6)
500 628 34.8 18–65 78.3% 21.8% 47.1% 88.5% 7.5% 3% 1%
G. Akyuz et al. / European Psychiatry 20 (2005) 268–273 Table 4 Correlations with age, education, and distribution of DES scores DES scores >20 >30 >40 General mean = 11.8 ± 10.2 Median = 9.3 Range = 0–55.7 Correlation with Age Education
N 251 251
n (251) 40 16 7
% 15.9 6.4 2.8
r –0.08 –0.16
P n.s. <0.01
Table 5 Frequency of childhood abuse and neglect in 628 women before 16 years of age Childhood trauma Neglect Emotional Physical Education Nutrition Medical care Security Physical Sexual (including incest) Incest Emotional Any of them
n 213 135 154 132 22 22 19 65 16 5 68 238
% 33.9 21.5 24.5 21.0 3.5 3.5 3.0 10.4 2.5 0.8 10.8 37.9
The frequency of sexual abuse ranged from either one occasion (61.5%, n = 8) or rarely more than once (30.8%, n = 4) to weekly (0%, n = 0) and monthly (7.7%, n = 1). Majority of the perpetrators (53.3%, n = 8) were related to victims (33.3%, n = 5) of them were immediate family members or 20.0% (n = 3) were extended family members); whereas 20.0% (n = 3) of them were unrelated but known and 26.7% (n = 4) were strangers to the victim. 4.4. The prevalence of self-mutilative and suicidal behavior Self-mutilative behavior was found in 2.2% (n = 14) of the study group. Most frequent types of self-mutilative behaviors were banging of head, hitting of fist and other body parts to the wall and floor (1.8%, n = 11). The rate of cutting some body areas was found 0.6% (n = 4). The rate of pulling hair was 1.3% (n = 8), of inflicting cigarette burns was 0% (n = 0), and of other types were 0.2% (n = 1). Number of the probands who reported an attempted suicide at least once was 28 (4.5%). The most common type of suicide attempt was overdose (3.2%, n = 20), followed by other types such as cutting (0.8%, n = 5), jumping (0.2%, n = 1), hanging (0.2%, n = 1), and others (0.2%, n = 1), respectively. The prevalence of suicide attempts and self-mutilative behaviors are shown in Table 6. Probands who have suicide attempt reported more frequent physical abuse (35.7% versus 7.6%, Fisher’s exact test, P < 0.001), emotional abuse (35.7% versus 7.6%, Fisher’s
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exact test, P < 0.001), sexual abuse (21.4% versus 0.1%, Fisher’s exact test, P < 0.001), and neglect (78.5% versus 31.8%, Fisher’s exact test, P < 0.001). Self-mutilative subjects reported more frequent physical abuse (21.4% versus 8.1%, Fisher’s exact test, P < 0.001), emotional abuse (25% versus 7.9%, Fisher’s exact test, P < 0.001), sexual abuse (47.8% versus 2.1%, Fisher’s exact test, P < 0.005) and neglect (17.8% versus 33.2%, Fisher’s exact test, P < 0.02) in comparison with the remaining group. The frequency of at least one type of trauma was higher in probands who had suicide attempt (10.5%) than who did not (0%) (Fisher’s exact test, P < 0.001) and was higher in probands who had selfmutilation (4.2%) than who did not (1.0%) (Fisher’s exact test, P < 0.002) (Table 7). Probands who reported childhood traumas had higher DES scores compared to those who did not, except for physical abuse. A linear regression analysis shows that physical neglect and sexual abuse are two significant childhood trauma types, which predict higher DES scores (Table 8). Regression analysis among the types of abuse, DES scores, suicide attempts, and self-mutilation was applied. According to regression analysis, there were statistically significant relations between suicide attempts and all types of abuse (P < 0.001), also among self-mutilation with physical and emotional abuse, and incest (P < 0.05) as probable risk factors.
5. Discussion This study addressed the magnitude of risk of selfmutilative behavior and suicide attempt associated with child abuse, neglect and dissociation among women in an eastern cultural population. It is noteworthy that the evaluated community is representative for a population living in almost semirural conditions rather than from that of a metropolis of a highly industrialized area. We had no refusal by the participants (an attitude expected in semi-rural parts of Turkey where traditional attitudes for Table 6 Frequency of suicide attempt and self-mutilation Suicide attempts Types of suicide attempts Overdose Cutting Jumping Hanging Other Self-mutilation Types of self-mutilation Banging, head, hitting fist or other body areas Cutting body areas Pulling hair Burning Other
n (628) 28
% 4.5
20 5 1 1 1 14
3.2 0.8 0.2 0.2 0.2 2.2
11 4 8 0 1
1.8 0.6 1.3 0 0.2
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Table 7 Relationship of abuse and neglect with suicide attempt and self-mutilation
Physical abuse Emotional abuse Neglect Sexual abuse At least one type of trauma
Probands a n (28) % 10 35.7 10 35.7 22 78.5 6 21.4
Probands b n (600) 46 46 191 9
% 7.6 7.6 31.8 0.1
25
213
35.5
89.2
Probands d n (614) % 50 8.1 49 7.9 204 33.2 13 2.1
P*
<0.000 <0.000 <0.000 <0.000
Probands c n (14) % 6 21.7 7 25 5 17.8 12 42.8
<0.000
10
228
<0.002
P*
71.4
37.1
<0.000 <0.000 <0.02 <0.005
* Fisher’s exact test. a Who have suicide attempt. b Who do not have suicide attempt. c Who have self-mutilation. d Who do not have self-mutilation. Table 8 DES scores and childhood trauma Childhood abuse Emotional Physical Sexual Physical neglect Emotional neglect Any of them
n 27 18 9 5 49 93
DES scores Present Mean ± S.D. 18.8 ± 13.5 13.8 ± 8.6 21.3 ± 17.6 15.4 ± 11.0 14.5 ± 11.9 14.7 ± 11.8
home visitors still prevail). All participants could be interviewed face to face by an interviewer with complete psychiatric training. This made our results more concrete. In this present study the mean DES score is 11.8. This result is similar to result reported by Ross et al. [25] as 10.8 previously. In this present study physical neglect and sexual abuse are two significant childhood trauma types predict higher DES scores, previous studies stated that both physical and sexual abuse in childhood are significant childhood traumas predict higher DES scores [9]. Childhood sexual abuse was reported only by 2.5% of the probands. Reported childhood sexual abuse rates for women have ranged from 8% to 32% retrospective in general population [5]. Possible reasons for such variability include differences in abuse definitions, methods and samples collected and maybe cultural differences among studies. Our rates are lower than some other general population studies. We do not know if social inhibitions or dissociative amnesia for childhood prevented some subjects giving affirmative answer to the question on sexual abuse. Indeed, if disclosed, sexual abuse can be stigmatizing for a woman living in a limited social sphere and under conditions where conservative/ traditional attitudes prevail. Traditionally, sexuality is seen, as a matter of honor and it is quite possible for the woman to be blamed for the abuse. Furthermore, for a woman who depends on her family socially and financially, it is not possible to endanger her relationship by disclosing the abuse, especially if the perpetrator is a relative. However, such factors seem to be valid for abuse in adulthood but not usually for childhood abuse in which instance the victim is considered innocent. Also we visited houses without previous noti-
DES scores Absent Mean ± S.D. 11.3 ± 9.7 11.6 ± 10.3 11.4 ± 9.7 10.9 ± 9.8 11.1 ± 9.7 10.1 ± 8.8
t (df = 249) 2.05 0.86 2.90 2.81 2.09 3.40
P <0.05 n.s. <0.05 <0.005 <0.05 <0.01
fication so underreported of childhood sexual abuse may in a small part be explained in the terms of ‘lack of preparation’ on their part. However, 33.9% of the probands reported neglect. Twentyone percent of the probands said that their education was stopped early; a major component of childhood neglect in this group. It is a known condition in rural districts in Turkey, most families prefer those sons and girls are not allowed to pursue their education. They usually have to comply at an early age (usually before 18) to an arranged marriage. Recently, a new regulation has been enforced, according to which the obligatory education has been increased to 8 years from 5 years. The predominance of neglect may be a cultural feature originating from the traditional/conservative/religious life style and socio-economic structure in rural/semiurban districts in Turkey, characteristically having restrictive influences on women’s life beginning even in childhood, i.e. early and arranged marriage, preference of sons, and early curtailing of education of girls [28,30]. Poverty is also a cause of childhood neglect in many families. The importance of childhood neglect in dissociative disorders has been reported in Turkey, previously [27–29]. We do not know whether the social control by extended family structure and close relationships around the family might prevent childhood abuse and create rather protective conditions in provinces like Sivas, which can no more be valid in large cities in highly industrialized parts of Turkey (e.g. Istanbul). Several retrospective studies have shown that a history of abuse is associated with increased risk for suicide attempts [11,31], but other studies have not [6,16]. In this present study
G. Akyuz et al. / European Psychiatry 20 (2005) 268–273
probands who reported at least one type of abuse and neglect the rate of suicide attempt was increased 15-fold, and the rate of self-mutilation increased 39-fold. The clinicians should give a special attention childhood abuse and neglect in patients with self-mutilative behavior and suicide attempts. Most of the studies investigating the frequency of childhood abuse and neglect have been done in patients and in western countries. This present study supplies of information about this topic in non-western cultures and in general population.
6. Limitations of the study There are some limitations of this study. First, this study includes only female probands; second, the value of the retrospective histories of trauma is questionable, and the third, the generalizability of the findings to other populations may be limited because of the cultural differences.
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Original article
Reported childhood trauma, attempted suicide and self-mutilative behavior among women in the general population Gamze Akyuz a, Vedat Sar b, Nesim Kugu a, Orhan Dog˘an a,* a b
Department of Psychiatry, Medical Faculty, Cumhuriyet University, Sivas 58140, Turkey Department of Psychiatry, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey Received 17 May 2004; accepted 14 January 2005 Available online 27 April 2005
Abstract This study attempted to determine the prevalence of childhood trauma among women in the general population as assessed in a representative sample from a city in central Turkey. The Dissociative Experiences Scale (DES) was administered to 628 women in 500 homes. They were also asked for childhood abuse and/or neglect. DES was administered to 251 probands. Mean age of the probands was 34.8 ± 11.5 years (range 18–65). Sixteen women (2.5%) reported sexual abuse, 56 women (8.9%) physical abuse, and 56 women (8.9%) emotional abuse in childhood. The most frequently reported childhood trauma was neglect (n = 213, 33.9%). The prevalence of suicide attempts was 4.5% (n = 28). Fourteen probands (2.2%) reported self-mutilative behavior. © 2005 Elsevier SAS. All rights reserved. Keywords: Abuse; Childhood trauma; Neglect; Suicide attempt; Self-mutilation; Dissociative Experiences Scale
1. Introduction Mental health professionals are becoming more aware of the possibility of sexual and physical abuse in the histories of patients requesting treatment in a variety of clinical settings [3]. Clinical and non-clinical studies related to child maltreatment and its effects on psychopathology demonstrated that childhood abuse and neglect is highly correlated with suicidal and self-mutilative behavior in children, adolescents and adults [8,26]. Deliberate self-harm typically starts in adolescence and involves numerous episodes and a variety of methods, including cutting, burning, slapping, bunging, picking and bone breaking [12,14]. Many patients report feeling of numb and ‘dead’ prior to harming themselves [2,18]. They often claim not to experience pain during self-injury and report a sense of relief afterward [18,22]. Episodes of self-mutilation often follow feeling of disappointment or abandonment [17,32]. In the first controlled study, Green (1978) found that 41% of his sample of physically abused children exhibited signifi* Corresponding author. Cumhuriyet Üniversitesi Hastanesi, Psikiyatri Anabilim Dal1, 58140 Sivas, Turkey; Tel./fax: +90 346 219 1574; fax: +90 346 219 1284. E-mail address: [email protected] (O. Dog˘an). 0924-9338/$ - see front matter © 2005 Elsevier SAS. All rights reserved. doi:10.1016/j.eurpsy.2005.01.002
cantly much more self-destructive behaviors (such as head banging, self-biting, self-burning, and self-cutting) when compared to normal children [19]. Ferguson et al. [15] suggest that between 16.5% and 19.5% of suicide attempts of young adults may be exposure to childhood sexual abuse. While the symptomatic effects of sexual abuse one well studied [20,24], the possible mediators of the complex relationship between childhood abuse and psychopathology are currently a focus [24]. Several empiric literatures document significant association between overwhelming traumatic experiences and pathological levels of dissociation. Dissociation has been described as a disruption of normally integrated function of consciousness, memory, identity or perception of environment or the body [1]. Putnam has suggested that aggressive, risk-taking behavior often occurs in the context of dissociative experiences, when individuals feel out of control and compelled to do something against they wills [23]. In a recent study Kisiel and Lyons [21] determined that dissociation might be critical mediator of selfdestructive behavior in abused adolescents. The purpose of the present study is to determine the frequency of childhood abuse and neglect, to investigate its relationship with attempted suicide, self-mutilation and dissociation and to examine the potential impact of dissociation on
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self-destructive behaviors of adult females in a non-western culture.
2. Materials and methods 2.1. Subjects This study was conducted in Sivas city, a town with a population of 221,500 according to the census data of 1990. The rural areas of the province, which include 546,000 people, were not included in the study. One hundred and twenty thousand people in the city were between 18 and 65 years of age. Approximately 40% of the population is under 18 years of age, and 4% is above 65. Our target population was 60,000 women. 2.2. Instruments 2.2.1. Dissociative experiences scale (DES) The DES is a self-report scale consisting of 28 items and quantifying dissociative experiences. Bernstein and Putnam [4] developed The DES and it has adequate test–retest reliability, good split-half reliability and good clinical validity. The Turkish Version of the DES was also shown as a reliable and valid measure in a previous study [35]. 2.2.2. Childhood abuse and neglect questionnaire (CANQ) We used the CANQ designed and formerly used in various studies [33]. This questionnaire consists of questions about childhood physical, sexual and emotional abuse, and neglect. After each question, information regarding the identity and age of the perpetrator, and the age of the subject during abuse was requested. For physical and sexual abuse, the respondent indicated on a four-point scale how frequent some particular events or situations occurred during his or her childhood and adolescence. Childhood physical abuse is defined as physical violence against a person under 16 years old, by someone at least 5 years older or by a family member at least 2 years older than the victim. Close confinement, such as being locked in a closet is also included. The victim perceives it severe, but should not consider this maltreatment as sibling rivalry. Quarrels between friends that do not include any physical contact are not accepted as physical abuse. Childhood sexual abuse is defined as involvement of a person younger than 16 years old in any kind of sexual activities, such as genital fondling, an adult exhibiting his or her genitalia to a child, forcing the child to exhibit himself or herself to the adult or the child to have sexual intercourse with someone at least 5 years older or with a family member (incest) at least 2 years older than the victim. All questions about physical and sexual abuse were based on Brown and Anderson’s [7] descriptions. Emotional abuse involves the use of excessive verbal threats, ridiculous and personally demeaning comments,
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derogatory statements and threats against the young person to the extent that a child’s emotional and mental well-being will be jeopardized. Neglect refers to acts of omission in which the child is not properly cared for physically (nutrition, safety, education, medical care etc.) or emotionally (failure to bond, lack of affection, love, support, nurturing or concern). Questions about emotional abuse and neglect were based on the descriptions of Walker et al. [34]. 2.2.3. Suicide attempt and self-mutilation A self-report questionnaire developed by authors investigates frequency, duration and types of self-mutilative behaviors and suicide attempts over the life course. For the present study’s purposes, self-mutilation was defined as deliberate harm to one’s body without a conscious intent to die [13], and included such behaviors as cutting, slashing, burning, pulling hair or banging and hitting of some body areas. Suicide attempt was defined as any behavior that is intended to end the life of a child or an adolescent and included such behaviors as overdose ingestion, hanging, cutting of the arms or neck, jumping from a height, stabbing himself or herself, drowning or self shooting. 3. Procedure 3.1. Subjects The procedure was a two stage stratified random sampling. A sample set of households’ representative for a team of sociologists had defined the Sivas City, previously [10]. We used this sample set. All neighborhoods in the city were included in the sample. There were 34,831 households in 600 neighborhoods of the city. Sample sizes of 500 households were chosen (Table 1). The number of households drawn from each neighborhood was determined in proportion to the population of the neighborhood. The households in each neighborhood were selected randomly by using the records of the electricity company. A random sample of 100 alternative addresses was drawn up to replace those households where nobody was present. All neighborhoods had been classified according to the socioeconomic status in a nine level system [10]. These nine levels were grouped as upper, middle and low, respectively. Distance to the center of the city, the characteristics of the buildings and the income of the families concerned were taken as the main criteria of socioeconomic level. Consequently, in our sample, 36 (5.7%) households were from upper socioeconomic level, 468 (74.5%) households middle, and 123 (19.6%) low. Table 1 The population of the Sivas City Province Sivas City (including city) Sivas City 18–65 years of age Women (age: 18–65) Households (city)
767,500 221,500 120,000 60,000 34,831
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The households were visited without previous notification. Respondents had to be women in the range between 18 and 65 years of age. In each selected household, the number of female residents between the age ranges was determined and we tried to reach all of them in maximal two visits in the same day. Subjects who could not be contacted as they were away from home during both visits were replaced. Informed consent to participate in the study was obtained by all respondents.
cation at all (they were illiterate), 47.1% (n = 296) had primary school graduate, 24.2% (n = 152) had secondary or high school education, 5.3% (n = 33) had university graduate. There was no statistically significant relation between education levels and all types of abuse (P > 0.05). 78.3% (n = 492) were married, 13.1% (n = 82) single, and 8.6% (n = 54) divorced or widowed. 88.5% (n = 556) of the subjects were housewives, 7.5% (n = 47) were employed, 3.0% (n = 19) were student and 1.0% (n = 6) was retired (Table 3).
3.2. Interviewing
4.2. DES scores
One of us (G.A.) who are a female psychiatrist and assistant professor in the local university clinic administered the interviews to all probands. The interviewer had extensive experience about the administration of the assessment instruments and had participated in a previous epidemiological study on dissociative disorders in Sivas. The study was completed in 4 months. The interviews were conducted in homes privately.
As the rate of illiteracy was high, we were able to administer the DES only to 40.0% (n = 251) of the probands the mean DES score of the entire sample was 11.8 ± 10.2 (range: 0–55.7), the median score was 9.3 (we only administered the DES as self-report because there are differences between DES scores of self-report and verbal). There was no correlation between age and the DES score (r = 0.08, n = 251, P > 0.05). However, there was a negative correlation between education and DES score (r = –0.16, n = 251, P < 0.01). Marital status did not exert any influence (F = 0.21, P > 0.05). Forty (15.9%) of the probands had a DES score 20 or higher. Sixteen (6.4%) of the probands had a score above 30.7 (2.8%) probands had DES score above 40 (Table 4). The mean DES score of 11.8, it this study is similar to the result reported by Ross et al. [25] as 10.8 previously.
4. Results 4.1. Sample The sample consisted of 628 women in 500 households (Table 2). None of the subjects refused to participate in the study. Forty-nine households were replaced as nobody was found there on either visit. 19 subjects could not be contacted as they were away from home during both visits; they were replaced. Age distributions in decades had significant difference (v2 = 15.28, df = 3, P < 0.01) compared with the distribution of women in the general population of Sivas City according to the census data [24] (Table 2). In our sample, subjects in the age range 25–54 are slightly over represented. It is not known whether the change in the demography of the city after the census in 1990 has played a role in this difference. The mean age for the entire sample was (34.8 ± 11.5). The median age for the entire sample was 33.0 years. Concerning the education of the respondents 21.8% (n = 137) had no eduTable 2 Ages of the respondents in the present study in Sivas and 1990 census data
Age (years) 18–19 20–24 25–34 35–44 45–54 55–64 65
Present study women (n = 628) n % 33 5.2 100 15.8 208 32.8 155 24.7 83 13.2 47 7.6 3 0.5
1990 Census women (n = 59220) n % 5250 8.9 10,183 17.2 17,384 29.4 12,203 20.6 7602 12.8 5919 10.0 679 1.1
v2 = 15.28, df = 3, P < 0.01. Subjects in the age range 25–54 are slightly over represented in the sample.
4.3. The prevalence of childhood abuse and neglect The most frequent trauma type was neglect (Table 5). Emotional 21.5% (n = 135), physical 24.5% (n = 154), and sexual 2.5% (n = 16) abuse followed. Sexual abuse of incest type was seen in 0.8% (n = 5) of the probands. In sexually abused group, the age at onset of abuse fell into one of three ranges: 0–6 years (6.7%, n = 1), 7–11 years (6%, n = 6), or 12 years and above (8%, n = 53.3). There was not any gender difference in the frequency of incest. 20.5% (n = 172) of the probands reported just one type of abuse, whereas 8.7% (n = 73) reported two types, 3.8% (n = 32) three types and 1.3% (n = 11) all of four types of trauma. Table 3 Demographic characteristics of the sample Households Probands Age Mean Range Married Illiterate or no education Only primary school graduated Occupation Housewife (n = 556) Employed (n = 47) Student (n = 19) Retired (n = 6)
500 628 34.8 18–65 78.3% 21.8% 47.1% 88.5% 7.5% 3% 1%
G. Akyuz et al. / European Psychiatry 20 (2005) 268–273 Table 4 Correlations with age, education, and distribution of DES scores DES scores >20 >30 >40 General mean = 11.8 ± 10.2 Median = 9.3 Range = 0–55.7 Correlation with Age Education
N 251 251
n (251) 40 16 7
% 15.9 6.4 2.8
r –0.08 –0.16
P n.s. <0.01
Table 5 Frequency of childhood abuse and neglect in 628 women before 16 years of age Childhood trauma Neglect Emotional Physical Education Nutrition Medical care Security Physical Sexual (including incest) Incest Emotional Any of them
n 213 135 154 132 22 22 19 65 16 5 68 238
% 33.9 21.5 24.5 21.0 3.5 3.5 3.0 10.4 2.5 0.8 10.8 37.9
The frequency of sexual abuse ranged from either one occasion (61.5%, n = 8) or rarely more than once (30.8%, n = 4) to weekly (0%, n = 0) and monthly (7.7%, n = 1). Majority of the perpetrators (53.3%, n = 8) were related to victims (33.3%, n = 5) of them were immediate family members or 20.0% (n = 3) were extended family members); whereas 20.0% (n = 3) of them were unrelated but known and 26.7% (n = 4) were strangers to the victim. 4.4. The prevalence of self-mutilative and suicidal behavior Self-mutilative behavior was found in 2.2% (n = 14) of the study group. Most frequent types of self-mutilative behaviors were banging of head, hitting of fist and other body parts to the wall and floor (1.8%, n = 11). The rate of cutting some body areas was found 0.6% (n = 4). The rate of pulling hair was 1.3% (n = 8), of inflicting cigarette burns was 0% (n = 0), and of other types were 0.2% (n = 1). Number of the probands who reported an attempted suicide at least once was 28 (4.5%). The most common type of suicide attempt was overdose (3.2%, n = 20), followed by other types such as cutting (0.8%, n = 5), jumping (0.2%, n = 1), hanging (0.2%, n = 1), and others (0.2%, n = 1), respectively. The prevalence of suicide attempts and self-mutilative behaviors are shown in Table 6. Probands who have suicide attempt reported more frequent physical abuse (35.7% versus 7.6%, Fisher’s exact test, P < 0.001), emotional abuse (35.7% versus 7.6%, Fisher’s
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exact test, P < 0.001), sexual abuse (21.4% versus 0.1%, Fisher’s exact test, P < 0.001), and neglect (78.5% versus 31.8%, Fisher’s exact test, P < 0.001). Self-mutilative subjects reported more frequent physical abuse (21.4% versus 8.1%, Fisher’s exact test, P < 0.001), emotional abuse (25% versus 7.9%, Fisher’s exact test, P < 0.001), sexual abuse (47.8% versus 2.1%, Fisher’s exact test, P < 0.005) and neglect (17.8% versus 33.2%, Fisher’s exact test, P < 0.02) in comparison with the remaining group. The frequency of at least one type of trauma was higher in probands who had suicide attempt (10.5%) than who did not (0%) (Fisher’s exact test, P < 0.001) and was higher in probands who had selfmutilation (4.2%) than who did not (1.0%) (Fisher’s exact test, P < 0.002) (Table 7). Probands who reported childhood traumas had higher DES scores compared to those who did not, except for physical abuse. A linear regression analysis shows that physical neglect and sexual abuse are two significant childhood trauma types, which predict higher DES scores (Table 8). Regression analysis among the types of abuse, DES scores, suicide attempts, and self-mutilation was applied. According to regression analysis, there were statistically significant relations between suicide attempts and all types of abuse (P < 0.001), also among self-mutilation with physical and emotional abuse, and incest (P < 0.05) as probable risk factors.
5. Discussion This study addressed the magnitude of risk of selfmutilative behavior and suicide attempt associated with child abuse, neglect and dissociation among women in an eastern cultural population. It is noteworthy that the evaluated community is representative for a population living in almost semirural conditions rather than from that of a metropolis of a highly industrialized area. We had no refusal by the participants (an attitude expected in semi-rural parts of Turkey where traditional attitudes for Table 6 Frequency of suicide attempt and self-mutilation Suicide attempts Types of suicide attempts Overdose Cutting Jumping Hanging Other Self-mutilation Types of self-mutilation Banging, head, hitting fist or other body areas Cutting body areas Pulling hair Burning Other
n (628) 28
% 4.5
20 5 1 1 1 14
3.2 0.8 0.2 0.2 0.2 2.2
11 4 8 0 1
1.8 0.6 1.3 0 0.2
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Table 7 Relationship of abuse and neglect with suicide attempt and self-mutilation
Physical abuse Emotional abuse Neglect Sexual abuse At least one type of trauma
Probands a n (28) % 10 35.7 10 35.7 22 78.5 6 21.4
Probands b n (600) 46 46 191 9
% 7.6 7.6 31.8 0.1
25
213
35.5
89.2
Probands d n (614) % 50 8.1 49 7.9 204 33.2 13 2.1
P*
<0.000 <0.000 <0.000 <0.000
Probands c n (14) % 6 21.7 7 25 5 17.8 12 42.8
<0.000
10
228
<0.002
P*
71.4
37.1
<0.000 <0.000 <0.02 <0.005
* Fisher’s exact test. a Who have suicide attempt. b Who do not have suicide attempt. c Who have self-mutilation. d Who do not have self-mutilation. Table 8 DES scores and childhood trauma Childhood abuse Emotional Physical Sexual Physical neglect Emotional neglect Any of them
n 27 18 9 5 49 93
DES scores Present Mean ± S.D. 18.8 ± 13.5 13.8 ± 8.6 21.3 ± 17.6 15.4 ± 11.0 14.5 ± 11.9 14.7 ± 11.8
home visitors still prevail). All participants could be interviewed face to face by an interviewer with complete psychiatric training. This made our results more concrete. In this present study the mean DES score is 11.8. This result is similar to result reported by Ross et al. [25] as 10.8 previously. In this present study physical neglect and sexual abuse are two significant childhood trauma types predict higher DES scores, previous studies stated that both physical and sexual abuse in childhood are significant childhood traumas predict higher DES scores [9]. Childhood sexual abuse was reported only by 2.5% of the probands. Reported childhood sexual abuse rates for women have ranged from 8% to 32% retrospective in general population [5]. Possible reasons for such variability include differences in abuse definitions, methods and samples collected and maybe cultural differences among studies. Our rates are lower than some other general population studies. We do not know if social inhibitions or dissociative amnesia for childhood prevented some subjects giving affirmative answer to the question on sexual abuse. Indeed, if disclosed, sexual abuse can be stigmatizing for a woman living in a limited social sphere and under conditions where conservative/ traditional attitudes prevail. Traditionally, sexuality is seen, as a matter of honor and it is quite possible for the woman to be blamed for the abuse. Furthermore, for a woman who depends on her family socially and financially, it is not possible to endanger her relationship by disclosing the abuse, especially if the perpetrator is a relative. However, such factors seem to be valid for abuse in adulthood but not usually for childhood abuse in which instance the victim is considered innocent. Also we visited houses without previous noti-
DES scores Absent Mean ± S.D. 11.3 ± 9.7 11.6 ± 10.3 11.4 ± 9.7 10.9 ± 9.8 11.1 ± 9.7 10.1 ± 8.8
t (df = 249) 2.05 0.86 2.90 2.81 2.09 3.40
P <0.05 n.s. <0.05 <0.005 <0.05 <0.01
fication so underreported of childhood sexual abuse may in a small part be explained in the terms of ‘lack of preparation’ on their part. However, 33.9% of the probands reported neglect. Twentyone percent of the probands said that their education was stopped early; a major component of childhood neglect in this group. It is a known condition in rural districts in Turkey, most families prefer those sons and girls are not allowed to pursue their education. They usually have to comply at an early age (usually before 18) to an arranged marriage. Recently, a new regulation has been enforced, according to which the obligatory education has been increased to 8 years from 5 years. The predominance of neglect may be a cultural feature originating from the traditional/conservative/religious life style and socio-economic structure in rural/semiurban districts in Turkey, characteristically having restrictive influences on women’s life beginning even in childhood, i.e. early and arranged marriage, preference of sons, and early curtailing of education of girls [28,30]. Poverty is also a cause of childhood neglect in many families. The importance of childhood neglect in dissociative disorders has been reported in Turkey, previously [27–29]. We do not know whether the social control by extended family structure and close relationships around the family might prevent childhood abuse and create rather protective conditions in provinces like Sivas, which can no more be valid in large cities in highly industrialized parts of Turkey (e.g. Istanbul). Several retrospective studies have shown that a history of abuse is associated with increased risk for suicide attempts [11,31], but other studies have not [6,16]. In this present study
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probands who reported at least one type of abuse and neglect the rate of suicide attempt was increased 15-fold, and the rate of self-mutilation increased 39-fold. The clinicians should give a special attention childhood abuse and neglect in patients with self-mutilative behavior and suicide attempts. Most of the studies investigating the frequency of childhood abuse and neglect have been done in patients and in western countries. This present study supplies of information about this topic in non-western cultures and in general population.
6. Limitations of the study There are some limitations of this study. First, this study includes only female probands; second, the value of the retrospective histories of trauma is questionable, and the third, the generalizability of the findings to other populations may be limited because of the cultural differences.
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