BRIERE, JOHN PH.D1; WOO, ROSE PH.D.1; MCRAE, BONNIE M.S.W.2; FOLTZ, JAMES M.S.W.2; SITZMAN, ROBERT PH.D.2
Studies on the impacts of violence often overlook the moderating role of social or demographic variables and the confounding effects of different victimization experiences on the same individual. In the present study, 93 adult women presenting to an urban psychiatric emergency room were interviewed regarding their lifetime victimization history, and their charts were examined for relevant demographic and psychiatric variables. Self-reported childhood sexual and physical abuse were common in this sample (53% and 42%, respectively). Adult physical assaults outside of a relationship were described by 29% of patients, 37% reported adult sexual assaults or rapes, and 42% stated that they had experienced one or more physical assaults within an adult relationship. Childhood and adult victimization experiences were intercorrelated and were associated with certain sociodemographic variables. Logistic regression analyses indicated that both child abuse and adult assaults were uniquely associated with psychiatric difficulties, even after controlling for relevant background variables. Childhood sexual abuse was the most powerful predictor of later psychiatric symptoms and disorders.
Recent research indicates that interpersonal victimization experiences can serve as significant risk factors for the development of later psychological symptoms and disorders. For example, the long-term sequelae of childhood sexual abuse appear to include anxiety, depression, and posttraumatic stress (Briere & Runtz, 1987; Lindberg & Distad, 1985; Peters, 1988); suicidality (Briere & Runtz, 1986; Briere & Zaidi, 1989); substance abuse (Rohsenow, et al., 1988; Swett et al., 1991); and personality disorders (Briere & Zaidi, 1989; Herman, et al., 1989). Studies on the long-term effects of childhood physical abuse report symptoms similar to those documented for sexual abuse (McCord, 1983; Pollock, et al., 1990; Widom, 1989). Research on adult victimization suggests that rape, physical assault, and spousal battering have substantial psychological sequelae as well (Astin, et al., 1993; Becker, et al., 1986; Frank & Stewart, 1984; Houskamp & Foy, 1991; Kilpatrick, et al., 1979).
Although this literature documents the wide variety of difficulties potentially associated with interpersonal violence, methodological difficulties inherent in most victimization research limit the conclusions that can be made from such data (Briere, 1992). These include: (a) failure to control for demographics and other background variables that might increase the likelihood of both victimization and psychological symptoms; (b) the co-occurrence of various types of victimization (e.g., childhood sexual and physical abuse or adult rape and physical assault), such that symptoms thought to be due to a given (monitored) assault type might actually be due to the impacts of another (concomitant but unmonitored) form of assault; and (c) the assumption that a given symptom or dysfunctional behavior is the result of victimization when, in fact, it may be a risk factor for it (e.g., although being assaulted may motivate greater subsequent alcohol consumption, those consuming greater amounts of alcohol are also more vulnerable to being assaulted). Finally, because several studies report an increased likelihood of assaults in adulthood among those who were sexually abused as children (e.g., Briere & Runtz, 1987; Fromuth, 1986), the relationship between a given adult victimization experience and a given symptom or behavior may be due to the childhood abuse experience underlying both.
The purpose of the current study, conducted in an urban psychiatric emergency room, was to clarify potential connections between psychological or psychosocial difficulties, previous victimization experiences, and relevant demographic factors. Based on clinical experience and the extant literature, we hypothesized that (a) both childhood and adult victimization experiences would be relatively common, (b) childhood victimization history would predict later victimization as an adult, (c) childhood sexual and physical abuse would each correlate with symptoms and dysfunctional behaviors even after controlling for demographics, and (d) adult victimization experiences would be associated with clinical outcome variables even after demographics and childhood victimization experiences were taken into account.
The charts of 100 female patients evaluated in the psychiatric emergency room of a major urban medical center were examined. Patients were queried about any history of physical and sexual victimization as a child and as an adult as part of their regular initial interview. Childhood sexual abuse was operationally defined as any sexual contact ranging from fondling to intercourse occurring before 17 years of age and initiated by someone 5 or more years older than the patient. Physical abuse was defined as intentional physical acts by a parent or caretaker before the patient was 17 years of age that caused, at minimum, bruises or bleeding. Finally, patients were asked whether they had ever been raped or physically assaulted, in or outside of a relationship as adults. Women who had difficulty understanding the interviewer, who were sufficiently distraught that the interviewer chose to skip the victimization questions, who responded in an incoherent or grossly psychotic fashion, or whose medical records were missing or incomplete were excluded from the study. The presence or absence of an abuse or adult victimization history was not a selection factor.
Of the first 100 women who completed the full interview, 93 intact records were obtained. These were coded for demographic data, various chart variables (e.g., reference to suicidal and homicidal ideation, psychiatric diagnosis), and the specific victimization variables of interest to this study: history of childhood physical and sexual abuse, adult rape or attempted rape, having been battered in a sexual relationship, and having been physically assaulted outside of a sexual relationship. Any victimization or outcome variable found to occur in less than 10% of cases was eliminated from further consideration, because its crosstabulation with any other variable would result in an insufficient cell size for meaningful statistical analysis. For ease of presentation and analysis, DSM-III-R diagnoses that exceeded 10% of cases were clustered into four groups: depressive disorders (e.g., major depression, dysthymic disorder), anxiety disorders (e.g., generalized anxiety disorder, adjustment disorders), nonmanic psychotic disorders (e.g., schizophrenia, psychosis NOS), and manic disorders.
Hierarchical step-wise logistic regression analyses (Hosmer & Lemeshow, 1989) were conducted to predict the presence or absence of the clinical variables in this study. Variables were entered in the following order: At Step 1 demographic characteristics (age, income, race, and marital status) were allowed to compete for entry as control variables, with a minimal [chi]2-to-enter of p <.05; at Step 2 childhood sexual abuse and childhood physical abuse were entered if they met the [chi]2-to-enter criterion after controlling for (Step 1) significant demographic variables; at Step 3 the chronologically later events of adult rape or attempted rape, adult victimization through battering in a sexual relationship, and adult physical assault outside of a sexual relationship competed for entry, controlling for (Step 1 and Step 2) significant demographics, and childhood abuse experiences.
The mean age (± SD) of the women in this sample was 35.2 ± 10.0 years, and the modal ethnic status was Hispanic (43.2%), followed by Black (33.0%), Caucasian (19.3%), and Asian (4.5%). Half of this sample was never married, 36.4% were divorced or separated, 10.2% were married or cohabiting, and 3.4% were widowed. The average monthly income was $337.1 ± $324.0.
As presented in Table 1, 53% of women in this study reported childhood events satisfying criteria for sexual abuse, and 42% reported experiences definable as physical abuse. Also relatively common were reports of attempted or completed rape in adulthood, battery in an adult sexual relationship, and/or having been physically assaulted as an adult outside of a sexual relationship.
| TABLE 1 Victimization and Clinical Variables Occurring in at least 10% of Patients |
Frequent outcome variables in this sample were nonmanic psychotic disorders, depressive and anxiety disorders, substance abuse, an arrest history, homicidal ideation, and suicidality. Regarding the latter, for example, almost half of patients had chart references to suicidal ideations, and nearly half had made at least one suicide attempt in the past. No specific Axis II diagnosis was assigned in 10% or more of cases, and thus personality disorders were not considered in the present study.3
Childhood sexual and physical abuse were significantly associated in the current sample ([chi]2 = 4.65, df = 1, p <.031), with 25.8% of patients reporting both forms of maltreatment. Sexual abuse was related to later adult experiences of attempted or completed rape ([chi]2 = 8.10, df = 1, p <.002) and physical assault outside of a sexual relationship ([chi]2 = 7.36, df = 1, p <.007) but not battering within a sexual relationship. Childhood physical abuse, on the other hand, was not associated with any form of adult victimization. Attempted or completed rape was related to physical assault outside of a sexual relationship ([chi]2 = 14.87, df = 1, p <.001) and battering within a sexual relationship ([chi]2 = 6.28, df = 1, p <.012). Of the entire sample, only 16 women (17%) reported neither child abuse nor adult assault experiences.
Two demographic variables were associated with interpersonal victimization experiences. Women reporting childhood sexual abuse were younger than those not reporting sexual abuse (mean = 32.8 years ± 8.6, versus mean = 38.0 years ± 10.7; t = 2.59, df = 91, p <.011) and were more likely to be Black ([chi]2 = 12.32, df = 3, p <.006).
A variety of outcome variables were associated with demographics and self-reported childhood and/or adult victimization experiences (see Tables 2 and 3 for frequencies of outcome variables as a function of child abuse and adult victimization, respectively). These findings, reflected by significant logistic regression results as Steps 1 through 3 (see Table 4), are presented below. Two outcome variables were not related to any predictor variables: problems with alcohol and manic disorders.
| TABLE 2 Percentage of Patients with References to Evaluation Variables as a Function of their Self-reported Child Abuse |
| TABLE 3 Percentage of Patients with References to Evaluation Variables as a Function of Their Self-reported Adult Victimization History |
| TABLE 4 Logistic Regression of Demographic and Victimization Variables on Clinical and Related Variables |
The Step 1 logistic regression results indicated that all demographic variables but income were associated with one or more outcome variables (see Table 4). Single women reported a greater incidence than other women of engaging in violence against others (27.3% versus 6.1%) and had a greater likelihood of being admitted to a psychiatric hospital in the past (70.5% versus 44.9%). Black women were more likely than other women to report engaging in violence (34.5% versus 7.8%), to have suicidal and homicidal ideations (65.5% versus 39.1%, and 34.5% versus 15.6%, respectively), and to have a depressive disorder (55.2% versus 23.4%). Finally, those women with suicidal ideations were younger (mean = 33.1 ± 11.4 years) than those with no reference to suicidal ideations (mean = 37.1 ± 8.1 years).
After significant demographics were controlled, self-reports of childhood sexual abuse were related to later arrests, drug addiction, violence against others, homicidal and suicidal ideation, suicide attempts, depressive disorders, nonmanic psychotic disorders, and previous psychiatric hospitalizations (see Table 4, Step 2). Childhood physical abuse reports were related to three outcome variables: suicidal and homicidal ideations and suicide attempts.
After significant demographics as well as child abuse history were controlled, logistic analyses revealed a relationship between adult rape and previous psychiatric hospitalizations (see Table 4, Step 3). Three clinical variables were associated with patients' reports of having been battered within a sexual relationship: drug addiction, depressive disorders, and anxiety disorders. Physical assaults by those who were not sexual partners were associated with arrests, drug addiction, nonmanic psychotic disorders, homicidal ideations, and suicide attempts.
The current results suggest that women presenting to emergency settings with acute psychological distress or dysfunction are especially likely to have a history of one or more types of interpersonal victimization. In fact, over four-fifths of women in this acute clinical sample identified some form of childhood abuse or adult assault experience in their lives. Similar rates of interpersonal victimization have been reported in other studies of acute psychiatric patients (e.g., Briere & Zaidi, 1989; Bryer, et al., 1987). These data may reflect, in part, the prevalence of violence against women and children in North American culture and the greater risk of violence found in socially and economically stressed inner city environments. Further, to the extent that interpersonal victimization produces lasting psychological effects, acute psychiatric populations would be more likely than others to overrepresent those exposed to such experiences.
Victimization history was correlated with age, race, and martial status in the present study. Although income was not a significant mediator, other research indicates that this variable is associated reliably with mental health status (Gibbs, 1980). It is possible that the very low average income of patients in the current study, as well as the potentially confounding impacts of welfare and psychiatric disability funding, reduced the extent to which financial status could covary meaningfully with psychiatric difficulties. The correlation of other demographic variables with victimization and psychiatric outcome variables, however, validates the concern that social and demographic issues may confound the relationship between victimization history and social or psychiatric problems, thereby requiring the use of statistical control procedures such as hierarchical logistic regression analysis.
As reported by other researchers (e.g., Briere & Runtz, 1987; McCord, 1983), there was a significant overlap between physical and sexual child abuse histories in the present study as well as between childhood sexual abuse and later sexual and physical assault in adulthood. This revictimization effect highlights the presence of multiple trauma histories in some psychiatric patients as well as the likelihood that childhood sexual abuse is a risk factor for later assaults in adulthood.
Even after controlling for significant demographic variance and associations between other forms of abuse and clinical variables, childhood maltreatment predicted a variety of adult psychiatric or social problems. Reports of sexual abuse, in particular, were related to a number of clinical outcomes, ranging from drug addiction and violence against others to depression, nonmanic psychosis, and suicidality. Childhood physical abuse and adult physical and sexual assault were also each associated with later difficulties, although to a lesser extent than sexual abuse.
The numerous sequelae of childhood sexual abuse reported in this study are in relative agreement with other studies of clinical, university student, and general population samples (Neumann, et al., 1996). Because the current data assessed these relationships after controlling for the potential effects of demographic variables, most of which also predict victimization and/or psychiatric outcome variables, their continued significance becomes especially meaningful. The specific reason for the greater symptomatology and behavioral disturbance associated with sexual-as opposed to physical-abuse in this study is unclear, although some writers have stressed the uniquely intrusive and stigmatizing aspects of sexual abuse, per se (e.g., Courtois, 1988). It is also possible that childhood sexual abuse serves as a partial proxy for other coexisting pathogenic family dynamics or events, such that the unique and epiphenominal aspects of sexual abuse combine to produce especially profound effects (Briere & Elliott, 1993).
A newer finding is the association between reports of childhood sexual abuse and chart references to a nonmanic psychotic disorder, although this has been reported previously (Ross, Anderson, & Clark, 1994; van der Kolk, 1987). The meaning of this finding is unclear given the retrospective nature of this study. It is possible that, as might be predicted by a diathesis-stress model, childhood sexual abuse produces a greater vulnerability to the effects of preexisting neural or biochemical dynamics associated with the development of psychotic symptoms. From this perspective, an inherited predisposition toward psychosis might be exacerbated or triggered by the stress and developmental disturbance associated with childhood sexual abuse. It is also possible that the dissociative and intrusive symptoms of child abuse related trauma may mimic psychotic symptoms in some individuals, thereby leading to a misdiagnosis of psychotic disorder (Briere, in press). Alternatively, psychotic individuals may be more likely than others to confabulate or otherwise report nonexistent child abuse experiences. It should be noted, however, that manic patients-often thought to have more sexual delusions or preoccupations than other psychotic individuals-were no more likely than nonpsychotic patients to report childhood or adult sexual victimization in the present study. Further, patients with a nonmanic psychosis were no more likely than other patients to report childhood physical abuse or adult sexual or physical assault.
Although most of the child abuse findings reported in this study are relatively unambiguous in terms of chronology, the relationship between adult victimization and psychiatric or social variables is less straightforward. Specifically, drug addiction and behavior likely to result in arrests may be antecedent to physical or sexual assault rather than be inherently a consequence of such phenomena. For example, women addicted to drugs or involved in other illegal activities may be more likely than other women to interact with violent or predatory individuals, thereby increasing the likelihood that they would be a target of aggression. Similarly, women may be especially vulnerable to assault when under the influence of psychoactive substances or when suffering from the cognitive and emotional impairment associated with a psychotic disorder. Causality is likely to occur in the opposite direction as well, however, in instances when an assault victim becomes clinically depressed, anxious, or suicidal or attempts to numb her posttraumatic distress with drugs. Finally, one might posit reciprocating relationships between certain variables based on the current results: Substance abuse, for example, may arise in part from childhood sexual abuse and may, in turn, increase the likelihood of adult physical or sexual assault-both types of victimization thereafter potentially leading to further substance abuse, revictimization, and/or various types of psychological symptomatology.
Although this study has ecological validity by virtue of its conduct in a major urban psychiatric emergency room, its interpretability is constrained by several methodological limitations. These include the retrospective nature of the study, in that patients were asked to report instances of victimization that occurred in childhood or earlier adulthood. Such data may be biased by time-related memory distortions, the effects of current symptoms on recall of prior events, and demand characteristics potentially associated with the psychiatric evaluation process (Briere, 1992). Further, psychiatric diagnoses assigned to patients in this study were those arising from the normal emergency room evaluation process as opposed to being generated by a structured diagnostic interview schedule such as the SCID (Spitzer, Williams, & Gibbon, 1987).
Finally, the center in which this study was performed is one of the largest and most active urban emergency settings in North America, and thus the severity of presenting problems and background histories of violence may not be entirely generalizable to some other psychiatric emergency room populations.
The present study suggests that various forms of interpersonal victimization are quite common in acute mental health populations and that such maltreatment is associated with a variety of negative mental health outcomes. This relationship is complex, with significant comorbidity between and across childhood and adult assault history, and with multiple relationships found between victimization, sociodemographic, and mental health variables. Even when these various relationships were controlled for, however, victimization history (especially childhood sexal abuse) emerged as unique predictors of later dysfunction and mental disorder.
The overlap between childhood and adult victimization in the present study highlights the importance of avoiding research methodologies that are limited to a single abuse or assault variable. Further, it appears that social or demographic variables may moderate, if not confound, the relationship between victimization and subsequent distress or disorder. Finally, the chronology of victimization and psychiatric outcome may be less than straightforward, in that the presumed traumatic causes of some forms of symptomatology or maladaptive behavior may, instead, ultimately turn out to be at least partially effects. These various issues highlight the importance of multivariate research designs that intrinsically control for-if not delineate-the role of relevant variables in victimization-symptom relationships.
Clinical implications of this study reside primarily in the high rate of self-reported interpersonal victimization found in this cohort and the various forms of distress and dysfunction associated with such maltreatment. The former suggests that clinicians include questions about childhood and adult victimization experiences in their evaluations of mental health patients, whereas the latter should alert clinicians to the potential victimization-related aspects of what otherwise might be considered solely intrapsychic or biochemical phenomena. Most generally, the current data suggest that the presentation of (at minimum) psychiatric emergency room patients should be considered in the context of demographic, social, and victimization history variables.
Axis II diagnoses are rarely assigned during the psychiatric emergency interviews at this center. [Context Link]
Astin MC, Lawrence KJ, Foy DW (1993) Posttraumatic stress disorder among battered women: Risk and resiliency factors. Violence Vict 8:17-28. [Context Link]
Becker JV, Skinner LJ, Abel GG, Cichon J (1986) Level of post-assault sexual functioning in rape and incest victims. Arch Sexual Behav 15:37-49. [Context Link]
Briere J (in press). Psychological Assessment of Adult Posttraumatic States. Washington, DC: American Psychological Association. Author. [Context Link]
Briere J (1992a) Methodological issues in the study of sexual abuse effects. J Consult Clin Psychol 60:196-203.
Briere J, Elliott DM (1993) Sexual abuse, family environment, and psychological symptoms: On the validity of statistical control. J Consult Clin Psychol 61:284-288. [Context Link]
Briere J, Runtz MR (1986) Suicidal thoughts and behaviors in former sexual abuse victims. Can J Behavioral Sci 18:413-423. [Context Link]
Briere J, Runtz MR (1987) Post-sexual abuse trauma: Data and implications for clinical practice. J Interpersonal Violence 2:367-379. [Context Link]
Briere J, Zaidi LY (1989) Sexual abuse histories and sequelae in female psychiatric emergency room patients. Am J Psychiatry 146:1602-1606. Bibliographic Links [Context Link]
Bryer JB, Nelson BA, Miller JB, Krol PA (1987) Childhood sexual and physical abuse as factors in adult psychiatric illness. Am J Psychiatry 144:1426-1430. Bibliographic Links [Context Link]
Courtois CA (1988) Healing the Incest Wound: Adult Survivors in Therapy. New York: W.W. Norton. [Context Link]
Frank E, Stewart BD (1984) Depressive symptoms in rape victims: A revisit. J Affect Disord 7:77-85. Bibliographic Links [Context Link]
Fromuth ME (1986) The relationship of childhood sexual abuse with later psychological and sexual adjustment in a sample of college women. Child Abuse Negl 10:5-16. Bibliographic Links [Context Link]
Gibbs MS (1980) Social class, mental disorder, and the implications for community psychology. In M.S. Gibbs, J.R. Lachenmeyer, and J. Sigal (Eds), Community psychology: theoretical and community approaches. New York: Gardner. [Context Link]
Herman JL, Perry C, van der Kolk BA (1989) Childhood trauma in borderline personality disorder. Am J Psychiatry 146:490-494. Bibliographic Links [Context Link]
Hosmer DW, Lemeshow S (1989) Applied logistic regression. New York: John Wiley & Son. [Context Link]
Houskamp BM, Foy DW (1991) The assessment of posttraumatic stress disorder in battered women. J Interpersonal Violence 6:367-375. [Context Link]
Kilpatrick DG, Veronen LJ, Best CL (1984) Factors predicting psychological distress among rape victims. In C.R. Figley (Ed), Trauma and its wake: The study and treatment of post-traumatic stress disorder. New York: Brunner/Mazel.
Kilpatrick DG, Veronen LJ, Resick PA (1979) The aftermath of rape: Recent empirical findings. Am J Orthopsychiatry 49:658-669. Bibliographic Links [Context Link]
Lindberg FH, Distad LJ (1985) Post-traumatic stress disorders in women who experienced childhood incest. Child Abuse Negl 9:329-334. Bibliographic Links [Context Link]
McCord J (1983) A forty year perspective on effects of child abuse and englect. Child Abuse Negl 7:265-270. Bibliographic Links [Context Link]
Neumann DA, Houskamp BM, Pollock VE, Briere J (1996) The long-term sequelae of childhood sexual abuse in women: A meta-analytic review. Child Maltreatment 1:6-16. Bibliographic Links [Context Link]
Peters SD (1988) Child sexual abuse and later psychological problems. In G.E. Wyatt and G. Powell (Eds), Lasting effects of child sexual abuse. Newbury Park, CA: Sage. [Context Link]
Pollock VE, Briere J, Schneider L, Knop J, Mednick SA, Goodwin DW (1990) Childhood antecedents of antisocial behavior: Parental alcoholism and physical abusiveness. Am J Psychiatry 147:1290-1293. [Context Link]
Rohsenow DJ, Corbett R, Devine D (1988). Molested as children: A hidden contribution to substance abuse? J Subst Abuse 5:13-18. [Context Link]
Ross CA, Anderson G, and Clark P (1994) Childhood abuse and the positive symptoms of schizophrenia. Hosp Community Psychiatry 45:489-491. Bibliographic Links [Context Link]
Spitzer RL, Williams JBW, Gibbon M (1987) Structured clinical interview for DSM-III-R (SCID). New York: New York State Psychiatric Institute, Biometrics Research. [Context Link]
Swett C, Cohen C, Surrey J, Compaine A, et al. (1991) High rates of alcohol use and history of physical and sexual abuse among women outpatients. Am J Drug Alcohol Abuse 17:49-60. Bibliographic Links [Context Link]
van der Kolk BA (1987) The psychological consequences of over-whelming life experiences. In B.A. van der Kolk, Psychological trauma. Washington DC: American Psychiatric Press, 1987. Author. [Context Link]
Wisdom CS (1989) The cycle of violence. Science 244:160-166. [Context Link]
