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The incidence and influence of early traumatic life events in patients with panic disorder: A comparison with other psychiatric outpatients
Anxiety Disorders 16 (2002) 259±272
The incidence and in¯uence of early traumatic life events in patients with panic disorder: A comparison with other psychiatric outpatients$ Steven Friedman*, Lisa Smith, Dov Fogel, Cheryl Paradis, Ramaswamy Viswanathan, Robert Ackerman, Brian Trappler Department of Psychiatry, Box 1203, State University of New York Health Science Center at Brooklyn, 450 Clarkson Avenue, Brooklyn, NY 11203, USA Received 4 June 2000; accepted 1 May 2001
Abstract Early traumatic life events, including childhood physical and sexual abuse, has been associated with increased risk for panic disorder in adulthood. We examined the incidence and in¯uence of early traumatic life events in outpatients with panic disorder (n 101), compared to outpatients with other anxiety disorders (n 58), major depression (n 19), or chronic schizophrenia (n 22). Data were obtained by means of Structured Clinical Interviews and self-report questionnaires. The incidence of childhood physical abuse ranged from 16 to 40% and for childhood sexual abuse from 13 to 43% with no signi®cant differences among the four diagnostic groups. Across all outpatient groups a history of childhood physical or sexual abuse was positively correlated to clinical severity. Patients with panic disorder who reported childhood physical abuse were more likely to be diagnosed with comorbid depression, to have more comorbid Axis I disorders, to score higher on symptom checklists as well as reporting a greater history of suicide attempts in the past year (5% vs. 0%); or lifetime (36% vs. 15%). Similar ®ndings were noted, but not as robustly, for patients with panic disorder who reported childhood sexual abuse. There is a high rate of adverse early childhood events across diagnostic groups in psychiatric outpatients and these events are likely to in¯uence the severity of the disorder but are $ An earlier version of this paper was presented at the 30th Annual Meeting of the Association for the Advancement of Behavior Therapy, November 1996, New York. * Corresponding author. E-mail address: [email protected] (S. Friedman).
0887-6185/02/$ ± see front matter # 2002 Published by Elsevier Science Inc. PII: S 0 8 8 7 - 6 1 8 5 ( 0 2 ) 0 0 0 9 7 - X
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unlikely to be a unique risk factor for any one type of disorder. # 2002 Published by Elsevier Science Inc. Keywords: Panic disorder; Childhood sexual abuse; Physical abuse
A number of studies have suggested that psychiatric morbidity in adulthood is associated with a variety of developmental traumas such as sexual and physical abuse. In particular, childhood abuse has been found to be a possible risk factor for anxiety disorders such as panic disorder (PD), in both epidemiological (Brown & Harris, 1993a; Brown, Harris, & Eales, 1993b; Burnam et al., 1988; Kessler, Davis, & Kendler, 1997) and clinical studies (Brier, Charney, & Heninger, 1986; Faravelli, Webb, Ambonetti, Fonnesu, & Sessarego, 1985; Mancini, Van Ameringen, & Macmillan, 1995; Raskin et al., 1989; Stein et al., 1996). In addition, a history of developmental traumas, such as early losses and separations, childhood illnesses, and chaotic family environments have also been implicated as possible factors affecting the course and treatment response of patients with PD (Alnaes & Torgersen, 1988; Brier et al., 1986; David, Giron, & Mellman, 1995; Fierman et al., 1993; Gerlsma, Emmelkamp, & Arrindell, 1990; Laraia, Stuart, Frye, Lydiard, & Ballenger, 1994; Mancini et al., 1995; Noyes et al., 1993; Servant & Parquet, 1994; Wade, Monroe, & Michelson, 1993). The purpose of the present study was to examine the incidence and possible in¯uence of early traumatic life events in patients with PD. Previous studies have been hampered by a number of methodological limitations; among them are insuf®cient psychiatric comparison groups or the lack of standardized questions regarding traumatic events. The present study bene®ted from the use of standardized structured interviews, selfreport questionnaires, and use of comparison groups which covered a wide range of outpatient diagnostic groups. Studies that have looked at the frequency of childhood sexual and physical abuse in patients with panic disorder have found rates ranging from 13 to 54% (Mancini et al., 1995; Stein et al., 1996). Similarly the range reported for childhood sexual or physical abuse is quite high in patients with other anxiety disorders such as generalized anxiety disorder (GAD) with a reported incidence of childhood sexual abuse range from 7 to 35%, and for physical abuse 5±45% (Mancini et al., 1995; Stein et al., 1996). At the same time studies have found that the rate of childhood sexual or physical abuse is elevated for affective disorders (35% for sexual or physical abuse) and schizophrenia (sexual abuse as high as 60% and physical abuse 44±60%) (Bryer, Nelson, Miller, & Krol, 1987; DavresBornoz, Lemperiere, Degiovanni, & Gaillard, 1995; Friedman & Harrison, 1984; Giese, Thomas, Dubovsky, & Hilty, 1998; Jacobson & Herald, 1990; Jacobson & Richardson, 1987; Mullen, Martin, Anderson, Romans, & Herbison, 1993; Read, 1997; Sansomnet-Hayden, Haley, Marriage, & Fine, 1987; Surrey, Swett, Michaels, & Levin, 1990; Swett, Surrey, & Cohen, 1990). In psychiatric inpatient settings, reviews of the literature have found that incidence of childhood physical and/or sexual abuse in patients, of mixed
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diagnostic groups, ranges from 51 to 64% for women and from 24 to 39% for males (Jacobson & Richardson, 1987; Sansomnet-Hayden et al., 1987). In comparison, the range for severe childhood physical abuse in several community samples is 8±10% (Burnam et al., 1988), though one study (Straus & Gelles, 1986) reported a 62% rate for physical abuse. Childhood sexual abuse rates in community samples are also reported to be lower than that of psychiatric patients with a range for men from 1 to 16% and for women from 15 to 27%. In summary, a consistent ®nding in the literature appears to be that childhood physical or sexual abuse is more common in clinical populations than in non-clinical groups. Within anxiety disorders several studies have found that occurrence of sexual and physical abuse was not associated with any particular anxiety disorder (Mancini et al., 1995). However, subjects with an anxiety disorder who reported childhood abuse scored signi®cantly higher on measures of trait and state anxiety (Mancini et al., 1995), exhibited increased social fears and avoidance (Stein et al., 1996), higher depressive symptoms (Mancini et al., 1995), were more likely to be diagnosed with post-traumatic stress disorder (PTSD) (Fierman et al., 1993), were more likely to be diagnosed with Axis II disorders (Moisan & Engels, 1995), reported a greater number of previous episodes of major depression, and were less likely to remit from these depressive episodes (Zlotnick, Warshaw, Shea, & Keller, 1997). Incidence of other kinds of developmental trauma, when compared to normal subjects, has been reported to be greatly elevated in patients with panic disorder. Developmental trauma has been de®ned as either childhood separations from early caretakers, ``grossly disturbed childhood environments'' (Raskin et al., 1989), parental alcohol abuse, parental divorce (Moisan & Engels, 1995), and major losses or separations before age 15 (David et al., 1995; Faravelli et al., 1985; Servant & Parquet, 1994). This relationship of the role of childhood adversity in anxiety disorders is illustrated in a study by Brown and Harris (1993a), in which they administered a survey to an inner city population consisting of 404 working class and single mothers. They found that subjects diagnosed with PD, when compared to community members without psychiatric disorders, were 8.7 times more likely to report a history of any childhood adversity (de®ned as either physical abuse, sexual abuse, or parental indifference). Subjects diagnosed with agoraphobia, Social Phobia or GAD were 3.7 times more likely to report a history of any childhood adversity than the control groups. The above studies suggest that developmental traumas (such as early separations or losses), childhood sexual and physical abuse, and life stressors (such as chronic poverty and chaotic family environments) may be associated with the later development of anxiety disorders, and in particular PD. However, given the lack of appropriate comparison groups, such as patients from different psychiatric diagnostic categories (i.e., non-anxiety related disorders), these traumatic events may actually be markers for severity of psychopathology and/or comorbidity rather than a risk factor for any particular anxiety disorder. For example, Van der
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Molen, Van der Hout, Van Dieren, & Griez (1989) found that although a higher incidence of childhood separations and separation anxiety was reported by patients with PD, this ®nding did not appear to be uniquely related to the diagnosis of PD. Rather, their data suggested that such a history was associated with severity of psychopathology, since their comparison groups of ``mixed neurotics'' showed similar prevalence rates and treatment outcome. Another example of how childhood sexual abuse may be a risk factor for a variety of psychiatric conditions is a study by Fergusson, Horwood, and Lynskey (1996), who followed a birth cohort of over 1000 children. At age 18, they obtained retrospective reports of childhood sexual abuse prior to age 16 and concurrently measured psychiatric symptoms. Individuals who reported childhood sexual abuse were diagnosed with higher rates of major depression, anxiety disorders, conduct disorders, substance use disorders, and suicidal behavior. Those reporting more severe sexual abuse, such as attempted or completed intercourse, had higher rates of these disorders. These results persisted even when adjusted for prospectively measured possibly confounding childhood family and related factors. Increased risk ranged from 3.0 to 8.7 with the highest risk demonstrated for conduct disorder and lowest for anxiety disorders. We, therefore, decided to study four groups of patients (panic disorder, ``other anxiety disorder,'' depression and schizophrenia), who presented to an inner-city outpatient psychiatric clinic. Through use of structured diagnostic and assessment interviews we obtained data on the incidence of a host of early life traumas, including self-report of childhood physical and sexual abuse. At the same time, we assessed a variety of symptoms and their intensity. In particular, for patients with PD we were interested in examining the association of early negative life events on severity of the anxiety disorder as measured by psychometric and clinical ratings. 1. Method 1.1. Subjects Four groups of subjects were recruited through a general psychiatry outpatient clinic. One hundred and one consecutive patients with a principal diagnosis of PD (with or without agoraphobia) and 59 consecutive patients with other anxiety disorders (GAD, 11, obsessive compulsive disorder (OCD), 16, Social Phobia, 12, PTSD, 6, and Speci®c Phobia, 14) were evaluated. For comparison purposes, we randomly recruited 22 patients with chronic schizophrenia (attending a clozaril clinic) and 19 patients with recurrent major depressive disorder. Patients with organic brain disease, or who were actively (past 6 months) abusing alcohol/ drugs, or who were seen as a current active suicidal risk were excluded. All patients who were approached agreed to participate. None of the patients were involved in a controlled treatment trial.
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1.2. Procedure Anxiety disorder patients had been diagnosed through the use of the Anxiety Disorders Interview Schedule-R (DiNardo & Barlow, 1988), a structured interview designed to assess differentially the anxiety disorders as well as the major affective disorders and substance/alcohol abuse, and includes a brief screen to rule out psychotic disorder. All interviewers were at the Ph.D. or M.D. level and had been trained to a reliability criteria by senior clinicians before doing solo interviews. All protocols were reviewed, and only those cases in which both the interviewer and reviewer agreed on a principal diagnosis were used. As an additional reliability check, 10% of the anxiety disorder patients' charts were randomly reviewed by a third reviewer. There was perfect agreement for the principal diagnosis and .85 agreement on the secondary comorbid diagnosis. The diagnosis assigned by the initial interviewer was utilized in the analysis. Schizophrenia and major depressive disorder (recurrent) patients were recruited from a psychopharmacology clinic and were in stable treatment for at least 1 year. These patients, whose principal diagnosis was assigned by the attending psychiatrist, were re-interviewed (by a 4th year medical student) with the Structured Clinical Interview (SCID; Spitzer, Williams, Gibbon, & First, 1990) to con®rm the attending psychiatrist's diagnosis and to rule out a comorbid anxiety disorder. The medical student was not blind to the psychiatrist's diagnosis. Diagnoses with the SCID agreed in all but seven of the schizophrenic patients, with the psychiatrist's diagnosis. These seven cases were eliminated from the analysis. We utilized patients who were stabilized in treatment for the following reasons. One, we were more likely to have a reliable diagnosis. Two, our Institutional Review Board (IRB) was concerned that patients with schizophrenia and recurrent depression would not be able to provide informed consent. The IRB suggested that we use stabilized patients. In addition, we believed that the self-report data would be more reliable if their clinical status was stabilized. All patients provided informed consent, and this study was approved by our IRB. All patients completed a Life History Questionnaire (LHQ). For all patients with an anxiety disorder this was done at intake (between 1993 and 1995). For the major depressive group and schizophrenic group, an assessor (4th year medical student) brie¯y interviewed subjects to collect all demographic and clinical materials as well as life history variables, using the same questionnaire that was utilized when data was collected from the anxiety disorder patients. All patients also completed the Beck Depression Inventory (BDI, Beck & Steer, 1993), the Fear Questionnaire (FQ, Marks & Mathews, 1979), and our LHQ. The BDI (Beck & Steer, 1993) was used to measure depressive symptoms on a scale from 0 to 63. This scale consisting of 21 items categorizes patients within a 5-level range of severity of depression. The FQ (Marks & Mathews, 1979) is designed to measure the degree to which a patient avoids a variety of situations in the subscale areas of agoraphobia, Social
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Phobia, blood or illness phobia, and dysphoria on a 0±8 scale. Each subscale score ranges from 0 to 40 with higher scores indicating greater distress. The LHQ asked subjects to report the context of the occurrence and their age at the time of occurrence for the following possible events: death of and/or separation from either mother and/or father, parents' separation or divorce, substance abuse in either parent or siblings, childhood sexual or physical abuse (de®ned as unwanted sexual touches or physically hurt to the point of receiving or should have received medical attention), other traumatic events (i.e., history of separations, de®ned as 3 months absence of a signi®cant care-taker), age of onset of current psychiatric illness, previous psychiatric treatment or hospitalizations, presence of school phobia and/or separation anxiety (de®ned by the patient's recall of persistent fear and/or absences from attending school for more than 1 month, age 4±16), parental psychiatric histories, and patients' description of the early family environment. The records were examined by an assessor not involved in the initial interview or diagnosis. All patients with an anxiety disorder were also asked to complete the Agoraphobic Cognitions Questionnaire (ACQ), the Body Sensations Questionnaire (BSQ, Chambless, Caputo, Bright, & Gallagher, 1984), and the Mobility Inventory for Agoraphobia (MI) (Chambless, Caputo, Jasin, Gracely, & Williams, 1985). The ACQ (Chambless et al., 1984) measures the degree to which a patient is afraid of various thoughts while experiencing anxiety. On a ®ve-point scale, subjects rate how frequently, from ``never'' to ``always'' they experience 14 possible maladaptive thoughts when anxious. Scores are averaged and range from 1 to 5 with higher scores indicating more fear. The BSQ (Chambless et al., 1984) is a 17-item scale tapping the subject's fear of autonomic arousal when anxious. The items are rated on a ®ve-point scale, ranging from ``not frightened or worried'' to ``extremely frightened'' by the sensation. Scores are averaged and range from 1 to 5 with higher scores indicating more fear. The MI (Chambless et al., 1985) lists 26 situations that patients with agoraphobia typically avoid. Situations are rated on a ®ve-point scale, ranging from no avoidance to complete avoidance. Two separate subscales measure avoidance when the patient is alone and avoidance when the patient is accompanied by another. Scores are averaged and range from 1 to 5 with higher scores indicating more avoidance. 2. Results Our patient sample was ethnically diverse (49% White, 25% African±American, 16% Caribbean American, and 10% Hispanic), with 70% of the entire sample female and 30% male. Twenty-three percent of the total sample were married or cohabitating in a stable relationship. The mean age was 39 13:0 with an average length of illness being 12:2 12:8 years. There were no signi®cant
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Table 1 Positive history of early traumatic or negative life events among 101 panic disordered, 59 anxious, 19 depressed, and 22 schizophrenic patients Variable
Panic (%)
Anxiety (%)
Depressed (%)
Schizophrenic (%)
w2 (df 3)
Physical abuse Sexual abuse Maternal separation Paternal separation Parental divorce Family con¯ict Childhood illness Separation/school anxiety Parental anxiety Maternal substance abuse Paternal substance abuse
36 22 27 40 31 42 26 39 39 15 31
16 13 18 33 27 45 32 40 33 0 11
40 43 38 38 61 33 40 27 0 7 31
32 32 55 43 29 15 19 36 5 5 32
ns ns 10.78** ns 7.70* ns ns ns 15.57*** 8.87* ns
*
P < :05. P < :01. *** P < :001. **
differences across our four patient groups for marital status, age, or length of illness. There was a signi®cant difference among the diagnostic groups by gender (w2 38:0, df 3, P < :001), with 84% of PD, 46% of other anxiety, 94% of depressed and 42% of schizophrenic patients being female. Table 1 summarizes incidence of a variety of early traumatic (before age 16) or negative life events for our four patient groups. As seen in Table 1, there were no signi®cant differences on the incidence of self-reported childhood physical (range 16±40%) or sexual abuse (13±43%). There was a signi®cant gender difference on the report of childhood sexual abuse with 27% of females versus none of our male patients reporting a history of sexual abuse (w2 4:4, df 1, P < :04). Neither were there signi®cant differences on the self-report of paternal separation, ``family con¯ict'' (range 15±45%), childhood illness (range 19±40%), early childhood separation/school anxiety (range 27±40%), or paternal substance abuse (range 11±32%). There were signi®cant differences on reports of maternal separation (w2 10:78, df 3, P < :01) with the schizophrenic group (55%) having a greater incidence than the PD (27%) or anxious group (18%). Similarly, there was a signi®cant difference for the report of parental divorce (61% in depressed group vs. 27% in the anxious group, w2 7:70, df 3, P < :05). Not surprisingly, patients with panic disorder recalled signi®cantly higher anxiety symptoms in either one of their parents (39%) than depressed (0%) or schizophrenic subjects (5%) (w2 15:57, df 3, P < :001). Patients with PD reported a higher incidence of maternal substance abuse (15%) than the anxious group (0%) (w2 8:87, df 3, P < :05). We examined correlations for the entire sample, rather than differentiating between diagnostic groups, for the relationship between childhood physical and
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Table 2 Correlations between childhood physical and sexual abuse and severity measures Current depressiona
BDIb
FQc
ACQd
r
P
r
P
r
P
r
P
r
P
Total sample Physical abuse Sexual abuse
.27 .33
.001 .001
.22 .26
.006 .002
.18 .12
.03 ns
± ±
± ±
± ±
± ±
Panic sample Physical abuse Sexual abuse
.25 .35
.02 .002
.17 .12
ns ns
.13 .02
ns ns
.18 .06
Panic frequency
ns ns
.29 .02
.01 ns
a
Diagnosed primary or comorbid major depression or dysthymia. Beck Depression Inventory. c Fear Questionnaire. d Agoraphobic Cognitions Questionnaire. b
sexual abuse and four measures of clinical severity. As seen in Table 2, a history of childhood physical abuse was signi®cantly correlated with current depression (diagnosed as either primary or comorbid major depression or dysthymia) (r :27, P < :001) with a higher BDI score (r :22, P < :006), and a higher score on the FQ (r :18, P < :03). Similarly, for subjects with a history of childhood sexual abuse there was a signi®cant positive correlation with a current diagnosis of depression (r :33, P < :001), and a higher BDI score (r :26, P < :002). We focused on some speci®c relationships between clinical and psychometric measures in patients with PD. In particular, we examined the association for childhood physical or sexual abuse in PD patients with current depression, score on the BDI, ACQ, FQ, and panic frequency. As seen in the table for a history of childhood abuse there was a signi®cant positive correlation for current depression (comorbid major depression or dysthymia, r :25, P < :02) and panic frequency (r :29, P < :01). For patients with PD and a history of childhood sexual abuse, only current depression was correlated signi®cantly (r :35, P < :002). Table 3 presents the data on the relationship between childhood physical or sexual abuse to a variety of clinical and psychometric measures for patients with PD. As can be seen in Table 3 subjects with PD who reported childhood physical abuse had higher scores on the BDI (M 24:7 11:7 vs. M 19:2 11:3, t 2:8, P < :006), higher Social Phobia score (M 16:5 10:3 vs. M 12:9 8:9, t 2:2, P < :03), higher total phobia score (M 48:8 23:8 vs. M 39:6 23:9, t 2:2, P < :03), higher scores on the ACQ (M 2:7 :9 vs. M 2:2 :8, t 3:1, P < :003) and on the BSI (M 3:0 1:0 vs. M 2:5 :9, t 3:1, P < :002). They were also more likely to have a greater number of comorbid diagnoses (M 1:2 1:0 vs. M :7 :9, t 2:7, P < :008), including a greater likelihood of having a current comorbid (major depression or dysthymia) depression (57% vs. 32%, w2 5:1, df 1, P < :02). Finally,
Table 3 Relationship of childhood physical and sexual abuse to clinical and psychometric measures for panic disorder patients Variables
Physical abuse
No physical abuse
M
S.D.
M
S.D.
24.7
11.7
19.2
11.3
2.8
FQ Agoraphobia Blood/illness Social Total Dysphoria
17.8 14.5 16.5 48.8 22.7
12.4 8.4 10.3 23.8 10.3
13.6 12.9 12.9 39.6 20.1
12.1 8.9 8.9 23.9 10.2
MIc Alone Accompanied
3.1 2.4
1.2 .9
2.7 2.2
1.2 1.1
ACQd
2.7
.9
2.2
3.0 11.0 1.2 25.4
1.0 19.3 1.0 11.3
2.5 6.3 .7 27.0
BDI
a
t
P-value
Sexual abuse
No sexual abuse
t
P-value
M
S.D.
M
S.D.
.006
26.8
10.4
19.6
11.7
3.1
.002
± ± 2.2 2.2 ±
ns ns .03 .03 ns
17.2 14.7 14.7 47.7 21.7
12.6 8.7 8.7 23.7 9.2
14.6 12.9 12.9 41.0 20.7
12.1 8.7 8.7 23.8 10.3
± ± ± ± ±
ns ns ns ns ns
± ±
± ns ns
± 3.2 2.6
± 1.3 1.0
± 2.8 2.2
± 1.2 1.0
± ± ±
ns ns ns
.8
3.1
.003
2.4
.8
2.3
.8
±
ns
.9 11.1 .9 13.3
3.1 ± 2.7 ±
.002 ns .008 ns
2.8 5.4 1.2 27.0
1.0 12.6 1.2 13.2
2.6 7.5 .8 26.0
.9 12.9 .9 12.8
± ± 2.1 ±
ns ns .04 ns
P-value
(%)
(%)
.03 .005 .02
3 42 75
1 15 33
b
BSI Panic frequency #Comorbid diagnosed Age of onset
Suicide attempt Past year Lifetime
f
Current depression
(%)
(%)
5 36 57
0 15 32
w2 4.9 7.8 5.1
w2
P-value ± 10.6 8.9
ns .001 .003
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e
a
Beck Depression Inventory. Fear Questionnaire. c Mobility Inventory. d Agoraphobic Cognitions Questionnaire. e Body Sensations Inventory. f Diagnosed primary or comorbid major depression or dysthymia. b
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subjects with a history of childhood physical abuse were more likely to report a suicide attempt in the past year (5% vs. 0%, w2 4:9, df 1, P < :03) or to report at least one suicide attempt in their lifetime (36% vs. 15%, w2 7:8, df 1 P < :005). Patients with PD who reported childhood sexual abuse were more likely to have higher scores on the BDI (M 26:8 10:4 vs. M 19:6 11:7, t 3:1, P < :002) and a greater number of comorbid diagnoses (M 1:2 1:2 vs. M :8 :9, t 2:1, P < :04). They were also more likely to be diagnosed with a comorbid depression (75% vs. 33%, w2 9:5, df 1, P < :002) and to report at least one suicide attempt in their lifetime (42% vs. 15%, w2 10:6, df 1, P < :001). Overall, both childhood physical and sexual abuse were associated with greater clinical severity. This association was stronger for a history of childhood physical abuse than sexual abuse. 3. Discussion The purpose of the present study was to examine the incidence and in¯uence of early traumatic life events in patients with PD. Our ®ndings overall, suggest that when one compares patients with PD to other psychiatric outpatients there are few signi®cant differences in the incidence of early childhood adverse events. Across our four groups the incidence of childhood physical abuse ranged from 16 to 40%, and for sexual abuse from 13 to 43%. Previous studies (Brier et al., 1986; Brown & Harris, 1993a; Brown et al., 1993b; David et al., 1995; Faravelli et al., 1985; Mancini et al., 1995; Raskin et al., 1989; Servant & Parquet, 1994; Stein et al., 1996), which have suggested that the high prevalence of these and other adverse childhood events predispose to the development of panic disorder, are limited because they rarely include a wide range of diagnostic outpatient groups. Although patients with PD in our study, in contrast to patients with other anxiety disorders, did report a somewhat higher incidence of maternal separation and maternal substance abuse, these differences were not signi®cant. The few signi®cant differences we found were that depressed patients and/or patients with schizophrenia had a higher incidence of adverse events than our PD patients. For example, the highest rate of maternal separation was reported by our schizophrenic subjects. Our rate of a 36% incidence of childhood physical abuse for patients with PD and 16% rate for patients with other anxiety disorder compares to a 23% rate (Stein et al., 1996) and a 45% rate (Mancini et al., 1995) found in two previous studies that used a mixed sample of anxiety disorder patients (primarily PD, OCD, Social Phobia, or GAD). Stein et al. (1996) reported for childhood sexual abuse a 60% rate for female PD patients and an overall 39.6% rate in their total anxiety disorder sample. Mancini et al. (1995) found an overall 23.4% incidence rate of childhood sexual abuse. We found a 22% rate for patients with PD and a 13% rate for other anxiety disorder. In our sample, there were no signi®cant differences
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between men (29%) and women (38%) on physical abuse. There was however, a signi®cant difference between self-report of childhood sexual abuse with 27% of women reporting a history of abuse versus none of our male subjects. The variability in patients report of either sexual or physical abuse in the literature can easily be due to variations in methodology as well as how these questions were assessed. A number of recent studies (Collings, 1995; Fergusson et al., 1996; Hutchings & Dutton, 1997; Mullen et al., 1993) suggest that the risk of psychiatric disorder increases with increasing severity of childhood sexual abuse, suggesting that exposure to childhood sexual abuse acts as a risk factor that increases vulnerability to psychiatric disorder but it appears that childhood sexual abuse is not speci®c to panic disorder or to any one type psychiatric disorder. While for our entire sample, we had only limited clinical measures of severity, such as the diagnosis of current depression, score on the BDI, and score on the ACQ, a childhood history of physical abuse was signi®cantly correlated with each of these measures. A history of childhood sexual abuse was signi®cantly correlated to two of these measures. As several previous studies have suggested (Gladstone, Parker, Wilhelm, Mitchell, & Austin, 1999) childhood physical abuse may be an even more signi®cant clinical risk factor for the development of psychiatric disorder than sexual abuse. For patients with PD, we were able to examine the relationship of childhood physical and sexual abuse on a host of clinical and psychometric measures of severity. We found that patients with PD who reported childhood physical abuse, on 9 of 16 possible clinical measures of severity, had a more severe clinical picture. Patients with PD who were physically abused were more likely to be diagnosed with a current depression, to suffer with more comorbid Axis I diagnosis, to report higher scores on the total FQ and Social Phobia subscale of the FQ, BDI, ACQ, and BSI. In addition, they were more likely to report a history of suicide attempts in the past year (5% vs. 0%) or lifetime (36% vs. 15%). Similar ®ndings, though not as robust, were found for those patients with PD who reported a childhood history of sexual abuse. There are a number of important limitations to our study and ®ndings. In questioning subjects regarding a childhood history of traumatic events our ®ndings are possibly affected by recall bias, with more depressed subjects more likely to recall negative life events (Jorm & Henderson, 1992). We also did not include measures of Axis II, and we had only very limited measures of clinical severity. Our subjects were recruited from a clinical population somewhat differently. A helpful additional comparison group would have been to include subjects without any Axis I disorder. Finally, by eliminating patients who currently were actively suicidal/homicidal or abusing substances we are probably presenting a conservative estimate of the prevalence of these adverse early life events. In summary, we found a high rate of adverse early childhood events in all four outpatient groups. Childhood physical and sexual abuse appears to be common in
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psychiatric outpatients and is likely to in¯uence the severity of the disorder but only prospective longitudinal studies can untangle cause and effect. Prospective follow up is also necessary to study how these events in¯uence treatment adherence, outcome, and long-term maintenance. However, these events do not appear to be a unique risk factor for any one type of disorder (i.e., PD). Further clinical research is clearly warranted to examine these important issues. Acknowledgments This study was supported in part by the Department of Psychiatry Practice Plan. References Alnaes, R., & Torgersen, S. (1988). Major depression, anxiety disorders and mixed conditions: childhood and precipitating events. Acta Psychiatry Scandivanian, 78, 632±638. Beck, A. T., & Steer, R. A. (1993). Beck depression inventory. San Antonio, Tx, Psychological Corp. Brier, A., Charney, D. S., & Heninger, G. R. (1986). Agoraphobia with panic attacks: development, diagnostic stability and course of illness. Archives of General Psychiatry, 43, 1029±1036. Brown, G. W., & Harris, T. O. (1993a). Aetiology of anxiety and depressive disorders in an inner-city population. 1. Early adversity. Psychological Medicine, 23, 143±154. Brown, G. W., Harris, T. O., & Eales, M. J. (1993b). Aetiology of anxiety and depressive disorders in an inner-city population. 2. Comorbidity and adversity. Psychological Medicine, 23, 155±165. Bryer, J. B., Nelson, B. A., Miller, J. B., & Krol, P. A. (1987). Childhood sexual and physical abuse as factors in adult psychiatric illness. American Journal of Psychiatry, 144, 1426±1430. Burnam, M. A., Stein, J. A., Golding, J. M., Siegel, J. M., Sorenson, S. B., Forsythe, A. B., & Telles, C. A. (1988). Sexual assault and mental disorders in a community population. Journal of Consulting and Clinical Psychology, 56, 843±850. Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). The assessment of fear of fear in agoraphobics the body sensations questionnaire and the agoraphobic cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090±1097. Chambless, D. L., Caputo, G. C., Jasin, S. E., Gracely, E. J., & Williams, C. (1985). The mobility inventory for agoraphobia. Behavior Research and Therapy, 23, 35±44. Collings, S. J. (1995). The long-term effects of contact and noncontact forms of child sexual abuse in a sample of university men. Child Abuse and Neglect, 19, 1±6. David, D., Giron, A., & Mellman, T. A. (1995). Panic-phobic patients and developmental trauma. Journal of Clinical Psychiatry, 56, 113±117. Davres-Bornoz, J. M., Lemperiere, T., Degiovanni, A., & Gaillard, P. (1995). Sexual victimization in women with schizophrenia and bipolar disorder. Social Psychiatry and Psychiatric Epidemiology, 30, 78±84. DiNardo, P. A., & Barlow, D. H. (1988). Anxiety disorders interview schedule-revised (ADIS-R). Albany: State University of New York, Phobia and Anxiety Disorders Clinic. Faravelli, C., Webb, T., Ambonetti, A., Fonnesu, F., & Sessarego, A. (1985). Prevalence of early traumatic life events in 31 agoraphobic patients with panic attacks. American Journal of Psychiatry, 142, 1493±1494. Fergusson, D. M., Horwood, L. J., & Lynskey, M. T. (1996). Childhood sexual abuse and psychiatric disorder in young adulthood. II. Psychiatric outcomes of childhood sexual abuse. Journal of American Academy of Child Adolescence Psychiatry, 34, 1365±1374.
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Fierman, E. J., Hunt, M. F., Pratt, L. A., Warshaw, M. G., Yonkers, K. A., Peterson, L. G., EpsteinKaye, T. M., & Norton, H. S. (1993). Trauma and posttraumatic stress disorder in subjects with anxiety disorders. American Journal of Psychiatry, 150, 1872±1874. Friedman, S., & Harrison, G. (1984). Sexual histories, attitudes, and behavior of schizophrenic and ``normal'' women. Archives of General Psychiatry, 13, 555±567. Gerlsma, C., Emmelkamp, P. M. G., & Arrindell, W. A. (1990). Anxiety, depression, and perception of early parenting: a meta-analysis. Clinical Psychology Review, 10, 251±277. Giese, A. A., Thomas, M. R., Dubovsky, S. L., & Hilty, S. (1998). The impact of a history of childhood abuse on hospital outcome of affective episodes. Psychiatry Services, 49, 77±81. Gladstone, G., Parker, G., Wilhelm, K., Mitchell, P., & Austin, M. P. (1999). Characteristics of depressed patients who report childhood sexual abuse. American Journal of Psychiatry, 156, 431± 437. Hutchings, P. S., & Dutton, M. A. (1997). Symptom severity and diagnoses related to sexual assault history. Journal of Anxiety Disorders, 2, 607±618. Jacobson, A., & Herald, C. (1990). The relevance of childhood sexual abuse to adult psychiatric inpatient care. Hospital Community Psychiatry, 4, 154±158. Jacobson, A., & Richardson, B. (1987). Assault experiences of 100 psychiatric inpatients: evidence of the need for routine inquiry. American Journal of Psychiatry, 144, 908±913. Jorm, A. F., & Henderson, A. S. (1992). Memory bias in depression: implications for risk factor studies relying on self-reports of exposure. International Journal of Methods in Psychiatric Research, 2, 312±338. Kessler, R. C., Davis, C. G., & Kendler, K. S. (1997). Childhood adversity and adult psychiatric disorder in the US national comorbidity survey. Psychological Medicine, 27, 1101±1119. Laraia, M. T., Stuart, G. W., Frye, L. H., Lydiard, R. B., & Ballenger, J. C. (1994). Childhood environment of women having panic disorder with agoraphobia. Journal of Anxiety Disorders, 8, 1±17. Mancini, C., Van Ameringen, M., & Macmillan, H. (1995). Relationship of childhood sexual and physical abuse to anxiety disorders. Journal of Nervous Mental Disease, 183, 309±314. Marks, I. M., & Mathews, A. M. (1979). Brief standard self-rating scales for phobic patients. Behavior Research and Therapy, 17, 263±267. Moisan, D., & Engels, M. L. (1995). Childhood trauma and personality disorder in 43 women with panic disorder. Psychological Reports, 76, 1133±1134. Mullen, P. E., Martin, J. L., Anderson, J. C., Romans, S. E., & Herbison, G. P. (1993). Childhood sexual abuse and mental health in adult life. British Journal of Psychiatry, 163, 721±732. Noyes, R., Jr., Clancy, J., Woodman, C., Holt, C. S., Suelzer, M., Christiansen, J., & Anderson, D. J. (1993). Environmental factors related to the outcome of panic disorder: a seven-year follow-up study. Journal of Nervous Mental Disease, 181, 529±538. Raskin, M., Nurnberg, G., Prince, R., Fine, J., Levine, P. E., & Siegel, O. (1989). Abuse of the child and anxiety in the adult. NYS Journal of Medicine, 89, 138±140. Read, J. (1997). Child abuse and psychosis: a literature review and implications for professional practice. Professional Psychology Research and Practice, 28, 448±456. Sansomnet-Hayden, H., Haley, G., Marriage, G. K., & Fine, S. (1987). Sexual abuse and psychopathology in hospitalized adolescents. Journal of American Academy and Child Adolescence Psychiatry, 26, 735±757. Servant, D., & Parquet, P. J. (1994). Early life events and panic disorder: course of illness and comorbidity. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 18, 373±379. Spitzer, R. L., Williams, J. B. W., Gibbon, M., & First, M. B. (1990). Structured clinical interview for DSM-III-R (SCID). American Psychiatric Press, Inc. Stein, M. B., Walker, J. R., Anderson, G., Hazen, A. L., Ross, C. A., Eldridge, G., & Forde, D. R. (1996). Childhood physical and sexual abuse in patients with anxiety disorders and in a community sample. American Journal of Psychiatry, 153, 275±277. Straus, M. A., & Gelles, R. J. (1986). Social change and change in family violence for 1975±1985 as revealed by two national surveys. Journal of Marriage and Family, 48, 465±479.
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Surrey, J., Swett, C., Jr., Michaels, A., & Levin, S. (1990). Reported history of physical and sexual abuse and severity of symptomatology in women psychiatric outpatients. American Journal of Orthopsychiatry, 60, 412±417. Swett, C., Jr., Surrey, J., & Cohen, C. (1990). Sexual and physical abuse histories and psychiatric symptoms among male psychiatric outpatients. American Journal of Psychiatry, 147, 632±636. Van der Molen, G. M., Van der Hout, M. A., Van Dieren, A. C., & Griez, E. (1989). Childhood separation anxiety and adult-onset panic disorders. Journal of Anxiety Disorders, 3, 97±106. Wade, S. L., Monroe, S. M., & Michelson, L. K. (1993). Chronic life stress and treatment outcome in agoraphobia with panic attacks. American Journal of Psychiatry, 150, 1491±1495. Zlotnick, C., Warshaw, M., Shea, M. T., & Keller, M. B. (1997). Trauma and chronic depression among patients with anxiety disorders. Journal of Consulting Clinical Psychology, 65, 333±336.
The incidence and in¯uence of early traumatic life events in patients with panic disorder: A comparison with other psychiatric outpatients$ Steven Friedman*, Lisa Smith, Dov Fogel, Cheryl Paradis, Ramaswamy Viswanathan, Robert Ackerman, Brian Trappler Department of Psychiatry, Box 1203, State University of New York Health Science Center at Brooklyn, 450 Clarkson Avenue, Brooklyn, NY 11203, USA Received 4 June 2000; accepted 1 May 2001
Abstract Early traumatic life events, including childhood physical and sexual abuse, has been associated with increased risk for panic disorder in adulthood. We examined the incidence and in¯uence of early traumatic life events in outpatients with panic disorder (n 101), compared to outpatients with other anxiety disorders (n 58), major depression (n 19), or chronic schizophrenia (n 22). Data were obtained by means of Structured Clinical Interviews and self-report questionnaires. The incidence of childhood physical abuse ranged from 16 to 40% and for childhood sexual abuse from 13 to 43% with no signi®cant differences among the four diagnostic groups. Across all outpatient groups a history of childhood physical or sexual abuse was positively correlated to clinical severity. Patients with panic disorder who reported childhood physical abuse were more likely to be diagnosed with comorbid depression, to have more comorbid Axis I disorders, to score higher on symptom checklists as well as reporting a greater history of suicide attempts in the past year (5% vs. 0%); or lifetime (36% vs. 15%). Similar ®ndings were noted, but not as robustly, for patients with panic disorder who reported childhood sexual abuse. There is a high rate of adverse early childhood events across diagnostic groups in psychiatric outpatients and these events are likely to in¯uence the severity of the disorder but are $ An earlier version of this paper was presented at the 30th Annual Meeting of the Association for the Advancement of Behavior Therapy, November 1996, New York. * Corresponding author. E-mail address: [email protected] (S. Friedman).
0887-6185/02/$ ± see front matter # 2002 Published by Elsevier Science Inc. PII: S 0 8 8 7 - 6 1 8 5 ( 0 2 ) 0 0 0 9 7 - X
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unlikely to be a unique risk factor for any one type of disorder. # 2002 Published by Elsevier Science Inc. Keywords: Panic disorder; Childhood sexual abuse; Physical abuse
A number of studies have suggested that psychiatric morbidity in adulthood is associated with a variety of developmental traumas such as sexual and physical abuse. In particular, childhood abuse has been found to be a possible risk factor for anxiety disorders such as panic disorder (PD), in both epidemiological (Brown & Harris, 1993a; Brown, Harris, & Eales, 1993b; Burnam et al., 1988; Kessler, Davis, & Kendler, 1997) and clinical studies (Brier, Charney, & Heninger, 1986; Faravelli, Webb, Ambonetti, Fonnesu, & Sessarego, 1985; Mancini, Van Ameringen, & Macmillan, 1995; Raskin et al., 1989; Stein et al., 1996). In addition, a history of developmental traumas, such as early losses and separations, childhood illnesses, and chaotic family environments have also been implicated as possible factors affecting the course and treatment response of patients with PD (Alnaes & Torgersen, 1988; Brier et al., 1986; David, Giron, & Mellman, 1995; Fierman et al., 1993; Gerlsma, Emmelkamp, & Arrindell, 1990; Laraia, Stuart, Frye, Lydiard, & Ballenger, 1994; Mancini et al., 1995; Noyes et al., 1993; Servant & Parquet, 1994; Wade, Monroe, & Michelson, 1993). The purpose of the present study was to examine the incidence and possible in¯uence of early traumatic life events in patients with PD. Previous studies have been hampered by a number of methodological limitations; among them are insuf®cient psychiatric comparison groups or the lack of standardized questions regarding traumatic events. The present study bene®ted from the use of standardized structured interviews, selfreport questionnaires, and use of comparison groups which covered a wide range of outpatient diagnostic groups. Studies that have looked at the frequency of childhood sexual and physical abuse in patients with panic disorder have found rates ranging from 13 to 54% (Mancini et al., 1995; Stein et al., 1996). Similarly the range reported for childhood sexual or physical abuse is quite high in patients with other anxiety disorders such as generalized anxiety disorder (GAD) with a reported incidence of childhood sexual abuse range from 7 to 35%, and for physical abuse 5±45% (Mancini et al., 1995; Stein et al., 1996). At the same time studies have found that the rate of childhood sexual or physical abuse is elevated for affective disorders (35% for sexual or physical abuse) and schizophrenia (sexual abuse as high as 60% and physical abuse 44±60%) (Bryer, Nelson, Miller, & Krol, 1987; DavresBornoz, Lemperiere, Degiovanni, & Gaillard, 1995; Friedman & Harrison, 1984; Giese, Thomas, Dubovsky, & Hilty, 1998; Jacobson & Herald, 1990; Jacobson & Richardson, 1987; Mullen, Martin, Anderson, Romans, & Herbison, 1993; Read, 1997; Sansomnet-Hayden, Haley, Marriage, & Fine, 1987; Surrey, Swett, Michaels, & Levin, 1990; Swett, Surrey, & Cohen, 1990). In psychiatric inpatient settings, reviews of the literature have found that incidence of childhood physical and/or sexual abuse in patients, of mixed
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diagnostic groups, ranges from 51 to 64% for women and from 24 to 39% for males (Jacobson & Richardson, 1987; Sansomnet-Hayden et al., 1987). In comparison, the range for severe childhood physical abuse in several community samples is 8±10% (Burnam et al., 1988), though one study (Straus & Gelles, 1986) reported a 62% rate for physical abuse. Childhood sexual abuse rates in community samples are also reported to be lower than that of psychiatric patients with a range for men from 1 to 16% and for women from 15 to 27%. In summary, a consistent ®nding in the literature appears to be that childhood physical or sexual abuse is more common in clinical populations than in non-clinical groups. Within anxiety disorders several studies have found that occurrence of sexual and physical abuse was not associated with any particular anxiety disorder (Mancini et al., 1995). However, subjects with an anxiety disorder who reported childhood abuse scored signi®cantly higher on measures of trait and state anxiety (Mancini et al., 1995), exhibited increased social fears and avoidance (Stein et al., 1996), higher depressive symptoms (Mancini et al., 1995), were more likely to be diagnosed with post-traumatic stress disorder (PTSD) (Fierman et al., 1993), were more likely to be diagnosed with Axis II disorders (Moisan & Engels, 1995), reported a greater number of previous episodes of major depression, and were less likely to remit from these depressive episodes (Zlotnick, Warshaw, Shea, & Keller, 1997). Incidence of other kinds of developmental trauma, when compared to normal subjects, has been reported to be greatly elevated in patients with panic disorder. Developmental trauma has been de®ned as either childhood separations from early caretakers, ``grossly disturbed childhood environments'' (Raskin et al., 1989), parental alcohol abuse, parental divorce (Moisan & Engels, 1995), and major losses or separations before age 15 (David et al., 1995; Faravelli et al., 1985; Servant & Parquet, 1994). This relationship of the role of childhood adversity in anxiety disorders is illustrated in a study by Brown and Harris (1993a), in which they administered a survey to an inner city population consisting of 404 working class and single mothers. They found that subjects diagnosed with PD, when compared to community members without psychiatric disorders, were 8.7 times more likely to report a history of any childhood adversity (de®ned as either physical abuse, sexual abuse, or parental indifference). Subjects diagnosed with agoraphobia, Social Phobia or GAD were 3.7 times more likely to report a history of any childhood adversity than the control groups. The above studies suggest that developmental traumas (such as early separations or losses), childhood sexual and physical abuse, and life stressors (such as chronic poverty and chaotic family environments) may be associated with the later development of anxiety disorders, and in particular PD. However, given the lack of appropriate comparison groups, such as patients from different psychiatric diagnostic categories (i.e., non-anxiety related disorders), these traumatic events may actually be markers for severity of psychopathology and/or comorbidity rather than a risk factor for any particular anxiety disorder. For example, Van der
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Molen, Van der Hout, Van Dieren, & Griez (1989) found that although a higher incidence of childhood separations and separation anxiety was reported by patients with PD, this ®nding did not appear to be uniquely related to the diagnosis of PD. Rather, their data suggested that such a history was associated with severity of psychopathology, since their comparison groups of ``mixed neurotics'' showed similar prevalence rates and treatment outcome. Another example of how childhood sexual abuse may be a risk factor for a variety of psychiatric conditions is a study by Fergusson, Horwood, and Lynskey (1996), who followed a birth cohort of over 1000 children. At age 18, they obtained retrospective reports of childhood sexual abuse prior to age 16 and concurrently measured psychiatric symptoms. Individuals who reported childhood sexual abuse were diagnosed with higher rates of major depression, anxiety disorders, conduct disorders, substance use disorders, and suicidal behavior. Those reporting more severe sexual abuse, such as attempted or completed intercourse, had higher rates of these disorders. These results persisted even when adjusted for prospectively measured possibly confounding childhood family and related factors. Increased risk ranged from 3.0 to 8.7 with the highest risk demonstrated for conduct disorder and lowest for anxiety disorders. We, therefore, decided to study four groups of patients (panic disorder, ``other anxiety disorder,'' depression and schizophrenia), who presented to an inner-city outpatient psychiatric clinic. Through use of structured diagnostic and assessment interviews we obtained data on the incidence of a host of early life traumas, including self-report of childhood physical and sexual abuse. At the same time, we assessed a variety of symptoms and their intensity. In particular, for patients with PD we were interested in examining the association of early negative life events on severity of the anxiety disorder as measured by psychometric and clinical ratings. 1. Method 1.1. Subjects Four groups of subjects were recruited through a general psychiatry outpatient clinic. One hundred and one consecutive patients with a principal diagnosis of PD (with or without agoraphobia) and 59 consecutive patients with other anxiety disorders (GAD, 11, obsessive compulsive disorder (OCD), 16, Social Phobia, 12, PTSD, 6, and Speci®c Phobia, 14) were evaluated. For comparison purposes, we randomly recruited 22 patients with chronic schizophrenia (attending a clozaril clinic) and 19 patients with recurrent major depressive disorder. Patients with organic brain disease, or who were actively (past 6 months) abusing alcohol/ drugs, or who were seen as a current active suicidal risk were excluded. All patients who were approached agreed to participate. None of the patients were involved in a controlled treatment trial.
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1.2. Procedure Anxiety disorder patients had been diagnosed through the use of the Anxiety Disorders Interview Schedule-R (DiNardo & Barlow, 1988), a structured interview designed to assess differentially the anxiety disorders as well as the major affective disorders and substance/alcohol abuse, and includes a brief screen to rule out psychotic disorder. All interviewers were at the Ph.D. or M.D. level and had been trained to a reliability criteria by senior clinicians before doing solo interviews. All protocols were reviewed, and only those cases in which both the interviewer and reviewer agreed on a principal diagnosis were used. As an additional reliability check, 10% of the anxiety disorder patients' charts were randomly reviewed by a third reviewer. There was perfect agreement for the principal diagnosis and .85 agreement on the secondary comorbid diagnosis. The diagnosis assigned by the initial interviewer was utilized in the analysis. Schizophrenia and major depressive disorder (recurrent) patients were recruited from a psychopharmacology clinic and were in stable treatment for at least 1 year. These patients, whose principal diagnosis was assigned by the attending psychiatrist, were re-interviewed (by a 4th year medical student) with the Structured Clinical Interview (SCID; Spitzer, Williams, Gibbon, & First, 1990) to con®rm the attending psychiatrist's diagnosis and to rule out a comorbid anxiety disorder. The medical student was not blind to the psychiatrist's diagnosis. Diagnoses with the SCID agreed in all but seven of the schizophrenic patients, with the psychiatrist's diagnosis. These seven cases were eliminated from the analysis. We utilized patients who were stabilized in treatment for the following reasons. One, we were more likely to have a reliable diagnosis. Two, our Institutional Review Board (IRB) was concerned that patients with schizophrenia and recurrent depression would not be able to provide informed consent. The IRB suggested that we use stabilized patients. In addition, we believed that the self-report data would be more reliable if their clinical status was stabilized. All patients provided informed consent, and this study was approved by our IRB. All patients completed a Life History Questionnaire (LHQ). For all patients with an anxiety disorder this was done at intake (between 1993 and 1995). For the major depressive group and schizophrenic group, an assessor (4th year medical student) brie¯y interviewed subjects to collect all demographic and clinical materials as well as life history variables, using the same questionnaire that was utilized when data was collected from the anxiety disorder patients. All patients also completed the Beck Depression Inventory (BDI, Beck & Steer, 1993), the Fear Questionnaire (FQ, Marks & Mathews, 1979), and our LHQ. The BDI (Beck & Steer, 1993) was used to measure depressive symptoms on a scale from 0 to 63. This scale consisting of 21 items categorizes patients within a 5-level range of severity of depression. The FQ (Marks & Mathews, 1979) is designed to measure the degree to which a patient avoids a variety of situations in the subscale areas of agoraphobia, Social
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Phobia, blood or illness phobia, and dysphoria on a 0±8 scale. Each subscale score ranges from 0 to 40 with higher scores indicating greater distress. The LHQ asked subjects to report the context of the occurrence and their age at the time of occurrence for the following possible events: death of and/or separation from either mother and/or father, parents' separation or divorce, substance abuse in either parent or siblings, childhood sexual or physical abuse (de®ned as unwanted sexual touches or physically hurt to the point of receiving or should have received medical attention), other traumatic events (i.e., history of separations, de®ned as 3 months absence of a signi®cant care-taker), age of onset of current psychiatric illness, previous psychiatric treatment or hospitalizations, presence of school phobia and/or separation anxiety (de®ned by the patient's recall of persistent fear and/or absences from attending school for more than 1 month, age 4±16), parental psychiatric histories, and patients' description of the early family environment. The records were examined by an assessor not involved in the initial interview or diagnosis. All patients with an anxiety disorder were also asked to complete the Agoraphobic Cognitions Questionnaire (ACQ), the Body Sensations Questionnaire (BSQ, Chambless, Caputo, Bright, & Gallagher, 1984), and the Mobility Inventory for Agoraphobia (MI) (Chambless, Caputo, Jasin, Gracely, & Williams, 1985). The ACQ (Chambless et al., 1984) measures the degree to which a patient is afraid of various thoughts while experiencing anxiety. On a ®ve-point scale, subjects rate how frequently, from ``never'' to ``always'' they experience 14 possible maladaptive thoughts when anxious. Scores are averaged and range from 1 to 5 with higher scores indicating more fear. The BSQ (Chambless et al., 1984) is a 17-item scale tapping the subject's fear of autonomic arousal when anxious. The items are rated on a ®ve-point scale, ranging from ``not frightened or worried'' to ``extremely frightened'' by the sensation. Scores are averaged and range from 1 to 5 with higher scores indicating more fear. The MI (Chambless et al., 1985) lists 26 situations that patients with agoraphobia typically avoid. Situations are rated on a ®ve-point scale, ranging from no avoidance to complete avoidance. Two separate subscales measure avoidance when the patient is alone and avoidance when the patient is accompanied by another. Scores are averaged and range from 1 to 5 with higher scores indicating more avoidance. 2. Results Our patient sample was ethnically diverse (49% White, 25% African±American, 16% Caribbean American, and 10% Hispanic), with 70% of the entire sample female and 30% male. Twenty-three percent of the total sample were married or cohabitating in a stable relationship. The mean age was 39 13:0 with an average length of illness being 12:2 12:8 years. There were no signi®cant
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Table 1 Positive history of early traumatic or negative life events among 101 panic disordered, 59 anxious, 19 depressed, and 22 schizophrenic patients Variable
Panic (%)
Anxiety (%)
Depressed (%)
Schizophrenic (%)
w2 (df 3)
Physical abuse Sexual abuse Maternal separation Paternal separation Parental divorce Family con¯ict Childhood illness Separation/school anxiety Parental anxiety Maternal substance abuse Paternal substance abuse
36 22 27 40 31 42 26 39 39 15 31
16 13 18 33 27 45 32 40 33 0 11
40 43 38 38 61 33 40 27 0 7 31
32 32 55 43 29 15 19 36 5 5 32
ns ns 10.78** ns 7.70* ns ns ns 15.57*** 8.87* ns
*
P < :05. P < :01. *** P < :001. **
differences across our four patient groups for marital status, age, or length of illness. There was a signi®cant difference among the diagnostic groups by gender (w2 38:0, df 3, P < :001), with 84% of PD, 46% of other anxiety, 94% of depressed and 42% of schizophrenic patients being female. Table 1 summarizes incidence of a variety of early traumatic (before age 16) or negative life events for our four patient groups. As seen in Table 1, there were no signi®cant differences on the incidence of self-reported childhood physical (range 16±40%) or sexual abuse (13±43%). There was a signi®cant gender difference on the report of childhood sexual abuse with 27% of females versus none of our male patients reporting a history of sexual abuse (w2 4:4, df 1, P < :04). Neither were there signi®cant differences on the self-report of paternal separation, ``family con¯ict'' (range 15±45%), childhood illness (range 19±40%), early childhood separation/school anxiety (range 27±40%), or paternal substance abuse (range 11±32%). There were signi®cant differences on reports of maternal separation (w2 10:78, df 3, P < :01) with the schizophrenic group (55%) having a greater incidence than the PD (27%) or anxious group (18%). Similarly, there was a signi®cant difference for the report of parental divorce (61% in depressed group vs. 27% in the anxious group, w2 7:70, df 3, P < :05). Not surprisingly, patients with panic disorder recalled signi®cantly higher anxiety symptoms in either one of their parents (39%) than depressed (0%) or schizophrenic subjects (5%) (w2 15:57, df 3, P < :001). Patients with PD reported a higher incidence of maternal substance abuse (15%) than the anxious group (0%) (w2 8:87, df 3, P < :05). We examined correlations for the entire sample, rather than differentiating between diagnostic groups, for the relationship between childhood physical and
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Table 2 Correlations between childhood physical and sexual abuse and severity measures Current depressiona
BDIb
FQc
ACQd
r
P
r
P
r
P
r
P
r
P
Total sample Physical abuse Sexual abuse
.27 .33
.001 .001
.22 .26
.006 .002
.18 .12
.03 ns
± ±
± ±
± ±
± ±
Panic sample Physical abuse Sexual abuse
.25 .35
.02 .002
.17 .12
ns ns
.13 .02
ns ns
.18 .06
Panic frequency
ns ns
.29 .02
.01 ns
a
Diagnosed primary or comorbid major depression or dysthymia. Beck Depression Inventory. c Fear Questionnaire. d Agoraphobic Cognitions Questionnaire. b
sexual abuse and four measures of clinical severity. As seen in Table 2, a history of childhood physical abuse was signi®cantly correlated with current depression (diagnosed as either primary or comorbid major depression or dysthymia) (r :27, P < :001) with a higher BDI score (r :22, P < :006), and a higher score on the FQ (r :18, P < :03). Similarly, for subjects with a history of childhood sexual abuse there was a signi®cant positive correlation with a current diagnosis of depression (r :33, P < :001), and a higher BDI score (r :26, P < :002). We focused on some speci®c relationships between clinical and psychometric measures in patients with PD. In particular, we examined the association for childhood physical or sexual abuse in PD patients with current depression, score on the BDI, ACQ, FQ, and panic frequency. As seen in the table for a history of childhood abuse there was a signi®cant positive correlation for current depression (comorbid major depression or dysthymia, r :25, P < :02) and panic frequency (r :29, P < :01). For patients with PD and a history of childhood sexual abuse, only current depression was correlated signi®cantly (r :35, P < :002). Table 3 presents the data on the relationship between childhood physical or sexual abuse to a variety of clinical and psychometric measures for patients with PD. As can be seen in Table 3 subjects with PD who reported childhood physical abuse had higher scores on the BDI (M 24:7 11:7 vs. M 19:2 11:3, t 2:8, P < :006), higher Social Phobia score (M 16:5 10:3 vs. M 12:9 8:9, t 2:2, P < :03), higher total phobia score (M 48:8 23:8 vs. M 39:6 23:9, t 2:2, P < :03), higher scores on the ACQ (M 2:7 :9 vs. M 2:2 :8, t 3:1, P < :003) and on the BSI (M 3:0 1:0 vs. M 2:5 :9, t 3:1, P < :002). They were also more likely to have a greater number of comorbid diagnoses (M 1:2 1:0 vs. M :7 :9, t 2:7, P < :008), including a greater likelihood of having a current comorbid (major depression or dysthymia) depression (57% vs. 32%, w2 5:1, df 1, P < :02). Finally,
Table 3 Relationship of childhood physical and sexual abuse to clinical and psychometric measures for panic disorder patients Variables
Physical abuse
No physical abuse
M
S.D.
M
S.D.
24.7
11.7
19.2
11.3
2.8
FQ Agoraphobia Blood/illness Social Total Dysphoria
17.8 14.5 16.5 48.8 22.7
12.4 8.4 10.3 23.8 10.3
13.6 12.9 12.9 39.6 20.1
12.1 8.9 8.9 23.9 10.2
MIc Alone Accompanied
3.1 2.4
1.2 .9
2.7 2.2
1.2 1.1
ACQd
2.7
.9
2.2
3.0 11.0 1.2 25.4
1.0 19.3 1.0 11.3
2.5 6.3 .7 27.0
BDI
a
t
P-value
Sexual abuse
No sexual abuse
t
P-value
M
S.D.
M
S.D.
.006
26.8
10.4
19.6
11.7
3.1
.002
± ± 2.2 2.2 ±
ns ns .03 .03 ns
17.2 14.7 14.7 47.7 21.7
12.6 8.7 8.7 23.7 9.2
14.6 12.9 12.9 41.0 20.7
12.1 8.7 8.7 23.8 10.3
± ± ± ± ±
ns ns ns ns ns
± ±
± ns ns
± 3.2 2.6
± 1.3 1.0
± 2.8 2.2
± 1.2 1.0
± ± ±
ns ns ns
.8
3.1
.003
2.4
.8
2.3
.8
±
ns
.9 11.1 .9 13.3
3.1 ± 2.7 ±
.002 ns .008 ns
2.8 5.4 1.2 27.0
1.0 12.6 1.2 13.2
2.6 7.5 .8 26.0
.9 12.9 .9 12.8
± ± 2.1 ±
ns ns .04 ns
P-value
(%)
(%)
.03 .005 .02
3 42 75
1 15 33
b
BSI Panic frequency #Comorbid diagnosed Age of onset
Suicide attempt Past year Lifetime
f
Current depression
(%)
(%)
5 36 57
0 15 32
w2 4.9 7.8 5.1
w2
P-value ± 10.6 8.9
ns .001 .003
S. Friedman et al. / Anxiety Disorders 16 (2002) 259±272
e
a
Beck Depression Inventory. Fear Questionnaire. c Mobility Inventory. d Agoraphobic Cognitions Questionnaire. e Body Sensations Inventory. f Diagnosed primary or comorbid major depression or dysthymia. b
267
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S. Friedman et al. / Anxiety Disorders 16 (2002) 259±272
subjects with a history of childhood physical abuse were more likely to report a suicide attempt in the past year (5% vs. 0%, w2 4:9, df 1, P < :03) or to report at least one suicide attempt in their lifetime (36% vs. 15%, w2 7:8, df 1 P < :005). Patients with PD who reported childhood sexual abuse were more likely to have higher scores on the BDI (M 26:8 10:4 vs. M 19:6 11:7, t 3:1, P < :002) and a greater number of comorbid diagnoses (M 1:2 1:2 vs. M :8 :9, t 2:1, P < :04). They were also more likely to be diagnosed with a comorbid depression (75% vs. 33%, w2 9:5, df 1, P < :002) and to report at least one suicide attempt in their lifetime (42% vs. 15%, w2 10:6, df 1, P < :001). Overall, both childhood physical and sexual abuse were associated with greater clinical severity. This association was stronger for a history of childhood physical abuse than sexual abuse. 3. Discussion The purpose of the present study was to examine the incidence and in¯uence of early traumatic life events in patients with PD. Our ®ndings overall, suggest that when one compares patients with PD to other psychiatric outpatients there are few signi®cant differences in the incidence of early childhood adverse events. Across our four groups the incidence of childhood physical abuse ranged from 16 to 40%, and for sexual abuse from 13 to 43%. Previous studies (Brier et al., 1986; Brown & Harris, 1993a; Brown et al., 1993b; David et al., 1995; Faravelli et al., 1985; Mancini et al., 1995; Raskin et al., 1989; Servant & Parquet, 1994; Stein et al., 1996), which have suggested that the high prevalence of these and other adverse childhood events predispose to the development of panic disorder, are limited because they rarely include a wide range of diagnostic outpatient groups. Although patients with PD in our study, in contrast to patients with other anxiety disorders, did report a somewhat higher incidence of maternal separation and maternal substance abuse, these differences were not signi®cant. The few signi®cant differences we found were that depressed patients and/or patients with schizophrenia had a higher incidence of adverse events than our PD patients. For example, the highest rate of maternal separation was reported by our schizophrenic subjects. Our rate of a 36% incidence of childhood physical abuse for patients with PD and 16% rate for patients with other anxiety disorder compares to a 23% rate (Stein et al., 1996) and a 45% rate (Mancini et al., 1995) found in two previous studies that used a mixed sample of anxiety disorder patients (primarily PD, OCD, Social Phobia, or GAD). Stein et al. (1996) reported for childhood sexual abuse a 60% rate for female PD patients and an overall 39.6% rate in their total anxiety disorder sample. Mancini et al. (1995) found an overall 23.4% incidence rate of childhood sexual abuse. We found a 22% rate for patients with PD and a 13% rate for other anxiety disorder. In our sample, there were no signi®cant differences
S. Friedman et al. / Anxiety Disorders 16 (2002) 259±272
269
between men (29%) and women (38%) on physical abuse. There was however, a signi®cant difference between self-report of childhood sexual abuse with 27% of women reporting a history of abuse versus none of our male subjects. The variability in patients report of either sexual or physical abuse in the literature can easily be due to variations in methodology as well as how these questions were assessed. A number of recent studies (Collings, 1995; Fergusson et al., 1996; Hutchings & Dutton, 1997; Mullen et al., 1993) suggest that the risk of psychiatric disorder increases with increasing severity of childhood sexual abuse, suggesting that exposure to childhood sexual abuse acts as a risk factor that increases vulnerability to psychiatric disorder but it appears that childhood sexual abuse is not speci®c to panic disorder or to any one type psychiatric disorder. While for our entire sample, we had only limited clinical measures of severity, such as the diagnosis of current depression, score on the BDI, and score on the ACQ, a childhood history of physical abuse was signi®cantly correlated with each of these measures. A history of childhood sexual abuse was signi®cantly correlated to two of these measures. As several previous studies have suggested (Gladstone, Parker, Wilhelm, Mitchell, & Austin, 1999) childhood physical abuse may be an even more signi®cant clinical risk factor for the development of psychiatric disorder than sexual abuse. For patients with PD, we were able to examine the relationship of childhood physical and sexual abuse on a host of clinical and psychometric measures of severity. We found that patients with PD who reported childhood physical abuse, on 9 of 16 possible clinical measures of severity, had a more severe clinical picture. Patients with PD who were physically abused were more likely to be diagnosed with a current depression, to suffer with more comorbid Axis I diagnosis, to report higher scores on the total FQ and Social Phobia subscale of the FQ, BDI, ACQ, and BSI. In addition, they were more likely to report a history of suicide attempts in the past year (5% vs. 0%) or lifetime (36% vs. 15%). Similar ®ndings, though not as robust, were found for those patients with PD who reported a childhood history of sexual abuse. There are a number of important limitations to our study and ®ndings. In questioning subjects regarding a childhood history of traumatic events our ®ndings are possibly affected by recall bias, with more depressed subjects more likely to recall negative life events (Jorm & Henderson, 1992). We also did not include measures of Axis II, and we had only very limited measures of clinical severity. Our subjects were recruited from a clinical population somewhat differently. A helpful additional comparison group would have been to include subjects without any Axis I disorder. Finally, by eliminating patients who currently were actively suicidal/homicidal or abusing substances we are probably presenting a conservative estimate of the prevalence of these adverse early life events. In summary, we found a high rate of adverse early childhood events in all four outpatient groups. Childhood physical and sexual abuse appears to be common in
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psychiatric outpatients and is likely to in¯uence the severity of the disorder but only prospective longitudinal studies can untangle cause and effect. Prospective follow up is also necessary to study how these events in¯uence treatment adherence, outcome, and long-term maintenance. However, these events do not appear to be a unique risk factor for any one type of disorder (i.e., PD). Further clinical research is clearly warranted to examine these important issues. Acknowledgments This study was supported in part by the Department of Psychiatry Practice Plan. References Alnaes, R., & Torgersen, S. (1988). Major depression, anxiety disorders and mixed conditions: childhood and precipitating events. Acta Psychiatry Scandivanian, 78, 632±638. Beck, A. T., & Steer, R. A. (1993). Beck depression inventory. San Antonio, Tx, Psychological Corp. Brier, A., Charney, D. S., & Heninger, G. R. (1986). Agoraphobia with panic attacks: development, diagnostic stability and course of illness. Archives of General Psychiatry, 43, 1029±1036. Brown, G. W., & Harris, T. O. (1993a). Aetiology of anxiety and depressive disorders in an inner-city population. 1. Early adversity. Psychological Medicine, 23, 143±154. Brown, G. W., Harris, T. O., & Eales, M. J. (1993b). Aetiology of anxiety and depressive disorders in an inner-city population. 2. Comorbidity and adversity. Psychological Medicine, 23, 155±165. Bryer, J. B., Nelson, B. A., Miller, J. B., & Krol, P. A. (1987). Childhood sexual and physical abuse as factors in adult psychiatric illness. American Journal of Psychiatry, 144, 1426±1430. Burnam, M. A., Stein, J. A., Golding, J. M., Siegel, J. M., Sorenson, S. B., Forsythe, A. B., & Telles, C. A. (1988). Sexual assault and mental disorders in a community population. Journal of Consulting and Clinical Psychology, 56, 843±850. Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). The assessment of fear of fear in agoraphobics the body sensations questionnaire and the agoraphobic cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090±1097. Chambless, D. L., Caputo, G. C., Jasin, S. E., Gracely, E. J., & Williams, C. (1985). The mobility inventory for agoraphobia. Behavior Research and Therapy, 23, 35±44. Collings, S. J. (1995). The long-term effects of contact and noncontact forms of child sexual abuse in a sample of university men. Child Abuse and Neglect, 19, 1±6. David, D., Giron, A., & Mellman, T. A. (1995). Panic-phobic patients and developmental trauma. Journal of Clinical Psychiatry, 56, 113±117. Davres-Bornoz, J. M., Lemperiere, T., Degiovanni, A., & Gaillard, P. (1995). Sexual victimization in women with schizophrenia and bipolar disorder. Social Psychiatry and Psychiatric Epidemiology, 30, 78±84. DiNardo, P. A., & Barlow, D. H. (1988). Anxiety disorders interview schedule-revised (ADIS-R). Albany: State University of New York, Phobia and Anxiety Disorders Clinic. Faravelli, C., Webb, T., Ambonetti, A., Fonnesu, F., & Sessarego, A. (1985). Prevalence of early traumatic life events in 31 agoraphobic patients with panic attacks. American Journal of Psychiatry, 142, 1493±1494. Fergusson, D. M., Horwood, L. J., & Lynskey, M. T. (1996). Childhood sexual abuse and psychiatric disorder in young adulthood. II. Psychiatric outcomes of childhood sexual abuse. Journal of American Academy of Child Adolescence Psychiatry, 34, 1365±1374.
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