CHICAGO – Childhood trauma and family dysfunction were associated with multiple DSM diagnoses on a structured interview in a nationally representative adult sample.
A history of childhood sexual abuse alone significantly increased the likelihood for 18 of 26 DSM-IV lifetime diagnoses in males (mean odds ratio, 3.3) and for 23 of 26 diagnoses in females (mean OR, 3.0), Dr. Frank Putnam reported at the annual meeting of the International Society for Traumatic Stress Studies.
The National Comorbidity Survey-Replication involving 5,692 households inquired about adverse childhood antecedents occurring before age 18 years, including sexual abuse, physical abuse, parental depression, parental substance abuse, being a crime victim, loss of a parent, and exposure to domestic violence. For each participant, a cumulative risk score was calculated by adding the number of adverse childhood antecedents that happened “most of the time” or “all of the time.”
As cumulative risk scores increased from 0 to 4 or more, the mean number of DSM Axis I diagnoses per individual increased in a stepwise fashion, said Dr. Putnam, director of the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center. Individuals with a risk score of 4 or more averaged more than six lifetime DSM diagnoses, compared with less than two diagnoses for those with a risk score of 1. (See box.)
“We set public policy in this country on whether to use hormone replacement therapy in postmenopausal women based on an odds ratio of 1.23, and look at these ratios,” he said. “These are enormous effects.”
The effects were not only large but crossed multiple DSM categories, indicating increased clinical complexity in participants exposed to a high level of childhood trauma or family dysfunction.
More than half of the 252 high-risk respondents had diagnoses that crossed three or more DSM categories.
The pattern of diagnoses also differed for males and females, with posttraumatic stress disorder (PTSD) being diagnosed in 20% or more of females starting at a risk score of 2. In males, PTSD was not a common diagnosis, even with a risk score of 4 or more, Dr. Putnam reported at the meeting, cosponsored by Boston University.
For male survivors of childhood sexual abuse, the most common diagnoses were dysthymia (OR, 5.4); PTSD (OR, 4.3); attention-deficit/hyperactivity disorder (OR, 3.8); agoraphobia (OR, 3.6); and panic disorder (OR, 3.6). In female survivors, the most common diagnoses were bipolar disorder type I (OR, 6.6); drug abuse (OR, 5.2); PTSD (OR, 4.8); alcohol dependence (OR, 4.7); and oppositional-defiant disorder (OR, 4.1).
The survey included face-to-face structured diagnostic interviews conducted in 2001–2003 with a representative sample of the U.S. population, based on census indicators of age, gender, race, education, marital status, and region.
The findings highlight the need for a new developmental trauma disorder diagnosis to help focus care and for early identification of children who have suffered abuse or neglect, Dr. Putnam said in an interview. Dr. Putnam noted that the findings also replicate the results of the seminal Adverse Childhood Events (ACE) study, which identified a strong graded relationship between the breadth of childhood abuse and family dysfunction and multiple health risk factors later in life (Am. J. Prev. Med. 1998;14:245–58).
The current study was sponsored by the Ohio Can Do 4 Kids project. Dr. Putnam disclosed that he has no commercial relationships.
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