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Dissociation is associated with emotional maltreatment in a sample of traumatized women with a history of child abuse a
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Lisa Haferkamp , Anke Bebermeier , Andrea Möllering & Frank Neuner a
Bielefeld University
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Klinik für Psychotherapeutische und Psychosomatische Medizin Bielefeld Accepted author version posted online: 03 Nov 2014.
Click for updates To cite this article: Lisa Haferkamp, Anke Bebermeier, Andrea Möllering & Frank Neuner (2014): Dissociation is associated with emotional maltreatment in a sample of traumatized women with a history of child abuse, Journal of Trauma & Dissociation, DOI: 10.1080/15299732.2014.959149 To link to this article: http://dx.doi.org/10.1080/15299732.2014.959149
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DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
Running Head: DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
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Dissociation is associated with emotional maltreatment in a sample of traumatized women with a history of child abuse
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Bielefeld University Anke Bebermeier and Andrea Möllering
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Klinik für Psychotherapeutische und Psychosomatische Medizin Bielefeld Frank Neuner
Author note
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Bielefeld University
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Lisa Haferkamp (M. Sc.), Department of Psychology, Bielefeld University; Anke Bebermeier (Dipl.-Psych.) and Andrea Möllering (Dr. med.), Klinik für Psychotherapeutische und Psychosomatische Medizin Bielefeld; Frank Neuner (Prof. Dr.), Department of Psychology, Bielefeld University. This research was supported in part by data from the first measuring period of a longitudinal study conducted by the Klinik für Psychotherapeutische und Psychosomatische Medizin of the Evangelisches Krankenhaus, Bielefeld (Germany). Many thanks for the allocation of the data for this study. Correspondence concerning this article should be addressed to Lisa Haferkamp, Department of Psychology, Bielefeld University, Universitätsstr. 25, 33615 Bielefeld.
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Lisa Haferkamp
E-mail: [email protected] Contact information: Dr. med Andrea Möllering: [email protected] Dipl.-Psych. Anke Bebermeier: [email protected]
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Prof. Dr. Frank Neuner: [email protected] Abstract Theories of dissociation emphasize that symptoms of dissociation are correlated with traumatic
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events. While the association of dissociative symptoms and retrospective reports of child abuse with a focus on mainly sexual and physical abuse has been well documented, the investigation of
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dissociation has been neglected to a great extent. The aim of this study was to determine the differential impact of different types of maltreatment on dissociative symptoms in a sample of
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203 female residential patients treated for posttraumatic stress disorder linked to child maltreatment. Moreover, it was examined if the link between dissociation and child maltreatment
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is direct or indirect. Subjects completed questionnaires on child maltreatment, posttraumatic
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stress and dissociative symptoms. While all types of maltreatment were related to dissociative symptoms, emotional abuse was the strongest and direct predictor of dissociation in multivariate hierarchical analyses with the influence of other trauma types being confounded by emotional abuse. This study highlights the importance of emotional types of maltreatment for the genesis of dissociative symptoms in patients with PTSD. KEY WORDS: dissociation; childhood maltreatment; emotional maltreatment; PTSD
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the contribution of emotional or psychological types of maltreatment to the prediction of
Dissociation includes symptoms such as depersonalization, derealization, amnesia, absorption
and changes of identity. Theories relate dissociative symptoms to the pathological processing of traumatic events, the most prominent being child abuse (e.g. Putnam, 1989; Spiegel, 1986; Spiegel & Cardeña, 1990; Resch, Brunner, & Parzer, 1998). These trauma theories assume that
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DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
dissociation operates as a protective mechanism to split off traumatic perceptions from consciousness and to prevent the full confrontation with extremely stressful emotions (Classen, Koopman, & Spiegel, 1993). Other perspectives do not only postulate the connection between
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trauma and dissociation but also provide an evolutionary-based perspective (Nijenhuis, Spinhoven, Vanderlinden, Van Dyck, & Van der Hart, 1998; Nijenhuis, Vanderlinden, &
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responses to threat can become chronic and dissociated and provide a biological explanation as to why dissociative symptoms can arise. This biological stage of a stress response can be
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associated with the trauma memory and can also be subsequently triggered by reminders. Consistent with the trauma hypothesis of dissociation, several studies have shown significant,
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strong and consistent correlations between dissociation and retrospective reports of child abuse
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(e.g. Putnam et al., 1996; Alpert, 1995; Carlson, Dalenberg, & McDade-Montez, 2012) in psychiatric patients (e.g. Waldinger, Swett, Frank, & Miller, 1994; Gast, Rodewald, Nickel, & Emrich, 2001) as well as in the general population (Mulder, Beautrais, Joyce, & Fergusson, 1998). Moreover, recent research found a change in dissociative symptoms associated with change in PTSD which favors the trauma hypothesis (Lynch, Forman, Mendelsohn, & Herman, 2008; Carlson et al., 2012).
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Spinhoven, 1998; Schauer & Elbert, 2010). They underline the possibility that physical defense
The trauma theories assume that events that imply immediate and extreme biological threats combined with limited possibilities for active defense should elicit the most peritraumatic dissociation and consequently lead to the highest level of dissociative symptoms. A prototype of such events is child sexual abuse. Therefore, many studies focused primarily on physical forms
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of maltreatment and found significant correlations between dissociation and both sexual (e.g. Briere & Runtz, 1987; Waldinger et al., 1994; Van Ijzendoorn & Schuengel, 1996; Carlson, Dalenberg, Armstrong, Daniels, Loewenstein, & Roth, 2001) and physical abuse (e.g. Irwin,
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1996; Mulder et al, 1998; Van Ijzendoorn & Schuengel, 1996; Macfie, Cicchetti, & Toth, 2001a, 2001b; Carlson et al., 2001; Dalenberg & Palish, 2004; Holowka, King, Saheb, Pukall, & Brunet,
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chronic and severe dissociation has been shown (e.g. Chu & Dill, 1990; Waldinger et al., 1994; Macfie et al., 2001a), with chronic and severe sexual and physical abuse as well as medical
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traumas like long-lasting, invasive treatments of chronic illnesses in young children causing high levels of dissociative symptoms (e.g. Nijenhuis et al., 1998; Diseth, 2006).
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Other studies did not exclusively focus on physical types of maltreatment and indicated that not
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only these forms of abuse but also psychological types of maltreatment are correlated with dissociation (e.g. Ferguson & Dacey, 1997; Holowka et al., 2002; Simeon, Nelson, Elias, Greenberg, & Hollander, 2003; O’Dougherty Wright, Crawford, & Del Castillo, 2009). For example, Watson, Chilton, Fairchild, and Whewell (2006) not only confirmed the link between child maltreatment and dissociation in a sample of 139 patients with borderline personality disorder: They also found a higher correlation of dissociation with emotional abuse than with sexual and physical abuse. Therefore, Watson et al. (2006) concluded that emotional abuse and
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2002). In addition to this, a cumulative effect of traumatic experiences on the development of
emotional neglect may be as important as both sexual and physical abuse with regard to developing dissociative symptoms. As emotional abuse and neglect involve rejection, humiliation, verbal abuse and non-responsiveness of caretakers but no direct threat to life and limb, this finding challenges the view of previous theories and investigations which emphasized
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the linkage of dissociation to the extreme stress caused by an assumed threat to life. However, other research (e.g. Porges, 2003) supports the position that severe attachment disruption cannot only be perceived as dangerous by small children but also that attachment deprivation can
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endanger life. Hence, a possible threat to life or a perceived threat caused by emotional forms of maltreatment can be possible. On a related note, although the relationship between dissociation
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physical and sexual trauma, emotional abuse is considerably more prevalent than other types of trauma, and has not only received more attention (O’Dougherty Wright et al., 2009) but has also
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shown to have devastating neurobiological effects (Teicher, Glod, Surry, & Swett, 1993; Ito, Teicher, Glod, Harper, Magnus, & Gelbhard, 1993)..
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Besides the already mentioned research, other researchers have questioned the stated direct
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causal link between trauma and dissociation (e.g. Cima, Merckelbach, Hollnack, & Knauer, 2003). Some studies indicate that co-occurring environmental factors like socio-cognitive processes or emotional support may play a mediating role for the onset and maintenance of pathological dissociation (Irwin, 1996, 1999; Nijenhuis et al., 1998; Merckelbach & Muris, 2001) and thus emphasize the possibility of mediating links between trauma and dissociation. The Betrayal Trauma Theory (Freyd, 1996), also allows to doubt a direct link. The theory assumes that staying unaware of abuse is socially useful when the perpetrator is a caregiver
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and emotional forms of maltreatment has been studied much less than its relationship with
(Freyd, 1996). In this context, it has been found that betrayal by caregivers can predict future dissociative symptoms in traumatized individuals (DePrince, 2001). Thus, the relationship to the perpetrator (e.g. physical abuse by a caregiver or a stranger) influences the intensity of the
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symptoms which can be seen as a contradiction of a clear connection between trauma and dissociation. The aim of this study was to determine the relative contribution of different types of
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maltreatment to symptoms of dissociation. Furthermore, we wanted to examine if the relation between trauma and dissociative symptoms is direct or confounded, with a focus on possible
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of n = 203 female resident patients diagnosed with PTSD related to child abuse. We expected this sample to provide a high level and variance of different types of child maltreatment which
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allow a multivariate analysis of the relationship between traumatic events and dissociation. Using the Childhood Trauma Questionnaire (CTQ: Bernstein & Fink, 1998; German version
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CTQ: Driessen, Gast, Hill, & Wulff, 2000), we assessed four types of childhood maltreatment
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(emotional abuse, physical abuse, sexual abuse and emotional neglect) and related them to dissociative symptoms as measured with the Dissociative Experiences Scale (DES: Carlson & Putnam, 1986; German short version: Kurzform des Fragebogens zu Dissoziativen Symptomen FDS-20: Freyberger, Spitzer, & Stieglitz, 2005). We hypothesized that all types of child maltreatment are significantly correlated with dissociation with emotional abuse and neglect being the main significant predictors of dissociation in hierarchical regression analyses as was assumed by previous studies (e.g. Watson et al., 2006; O’Dougherty Wright et al., 2009). In this
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confounder effects of emotional types of maltreatment. For this purpose, we examined a sample
context, we did not only expect emotional forms of maltreatment to explain further variance over and above the effects of physical and sexual abuse, but, based on the findings of e.g. Irwin (1999) und Watson et al. (2006), we also expected emotional forms of maltreatment to play a confounder role between dissociative symptoms and physical forms of maltreatment.
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Method
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Sample Selection and Participants
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The analyses presented here are based on data from an evaluation study of the Klinik für
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Bielefeld, Germany. The psychosomatic clinic focuses on the treatment of complex traumarelated disorders often based on child abuse. The data was collected between January 2009 and
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December 2009 and the Ethics Committee of the Department of Psychology of Bielefeld University approved the research of the current study. After arriving at the clinic, the patients
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were asked to complete a set of questionnaires. They received a standardised information letter and instructions for completing them. The letter included information about the confidential
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treatment of the given data as well as information about the longitudinal study. Moreover and with regard to the study, it was mentioned that the given information and data were used in an anonymized form. The patients had to sign an informed consent form which was handed out with the information letter to show their agreement to the usage of their data for research purposes. All female patients of the clinic were generally considered for this study. Besides the interest of the study to examine more closely the relationship between dissociative symptoms and different
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Psychotherapeutische und Psychosomatische Medizin of the Evangelisches Krankenhaus in
traumatic events, the recent discussion of a dissociative subtype of the PTSD diagnosis due to its frequent appearance and challenging treatment (e.g. Lanius, Brand, Vermetten, Frewen, & Spiegel, 2012) additionally underlines the importance of a further examination of the connection between the two problem areas. Therefore, women included in the analyses had to fulfil the
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DSM-IV criteria of PTSD, determined by the Posttraumatic Stress Diagnostic Scale (PDS: Foa, 1995; German version PDS: Ehlers, Steil, Winter, & Foa, 2000. The resulting sample of n = 203 women ranged in age from 19 to 66 with a mean age of M = 38.26 (SD = 10.01). Clinical
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characteristics are presented in Table 1. Mean sum scores for the maltreatment types measured with the Childhood Trauma Questionnaire (CTQ) were M = 12.10 (SD = 6.26) for physical
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M = 19.21 (SD = 5.16) for emotional neglect. The existence of a type of maltreatment for a single case was determined using empirically derived cut-off scores (Walker, 1999, see Table 1).
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During the analyses for this study, we rather considered a continuous progress of maltreatment instead of taking cut-off scores into account to postulate the existence of the different trauma
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types. We decided to regard maltreatment as a continuous process that ranges from dysfunctional parenting to severe abuse and neglect. The purpose of the CTQ is to cover this variance with a
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continuous scale. This assumption is supported by data from a representative sample of the German population (Iffland, Brähmer, Neuner, Häuser, & Glaesmer, 2013) which indicates a continuous instead of a dichotomous, bipolar distribution of CTQ scores.
Instruments
PTSD. The Posttraumatic Stress Diagnostic Scale (PDS; Ehlers, Steil, Winter, & Foa, 2000)
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abuse, M = 15.57 (SD = 7.53) for sexual abuse, M = 17.91 (SD = 5.80) for emotional abuse and
consists of four parts which scan the DSM-IV criteria A to F as well as quantify the severity of the PTSD symptoms (Foa, Cashman, Jaycox, & Perry, 1997). To establish the diagnosis of PTSD with the PDS, the empirically derived cut-off score of 17 in combination with the DSMIV algorithm (Griffin, Uhlmannsiek, Resick, & Mechanic, 2004) was applied.
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Child Maltreatment. We used the German 34-item-version of the Childhood Trauma Questionnaire (CTQ; Driessen, Gast, Hill, & Wulff, 2000) to assess child maltreatment. It provides scores for the five maltreatment types childhood emotional abuse, physical abuse,
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sexual abuse, emotional neglect and physical neglect as well as a total sum score (Bernstein et al., 1994). Bernstein, Ahluvalia, Pogge, and Handelsman (1997) found both a high internal
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German version of the questionnaire an unsatisfying internal consistency was found for physical neglect (Bader, Hänny, Schäfer, Neuckel, & Kuhl, 2009). Hence, this scale will not be
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considered in the analyses.
Dissociation. The German short version of the Dissociative Experiences Scale (DES), the FDS-
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20 (Freyberger, Spitzer, & Stieglitz, 2005), was used to assess the severity of dissociative
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symptoms in the previous two weeks. In the FDS-20, each symptom is rated using an 11-pointscale ranging from 0 to 100% (Bernstein Carlson & Putnam, 1993). The DES score is the mean score of all items and therefore ranges between 0 and 100 (Bernstein & Putnam, 1986). Validation studies proved a high convergent validity with structured interviews as well as other dissociative experiences questionnaires (Van Ijzendoorn & Schuengel, 1996).
Results
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consistency of the CTQ factors and a convergent and discriminant validity. However, in the
The relationship between dissociative symptoms and the trauma types was estimated using Spearman rank correlations and hierarchical regression analyses. Multicollinearity between the
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different trauma types was checked and could be ruled out in all analyses. An overview of the correlation coefficients between the types of maltreatment is provided (see Table 2). In the first regression model, age, physical abuse and sexual abuse were entered in the first step.
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In the second step, either emotional abuse (model 2) or emotional neglect (model 3) was entered (see Table 3). We decided to present two separate models to examine the individual impact of
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dissociative symptoms and age (b= -.29, SD= .12, β= -.17, t= -2.39, p< .05), physical abuse (b= .57, SD= .22, β= .20, t= 2.54, p< .05) and sexual abuse (b= .60, SD= .19, β= .26, t= 3.21, p< .01)
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was found. When emotional abuse was entered in the second step (model 2), a significant relationship with dissociative symptoms was found for this trauma type (b= .91, SD= .29, β= .30,
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t= 3.15, p< .01) with age (b= -.30, SD= .12, β= -.17, t= -2.52, p< .05) and sexual abuse (b= .40,
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SD= .19, β= .17, t= 2.06, p< .05) remaining significant predictors and physical abuse no longer having a significant relation to dissociative symptoms (b= .13, SD=2 .26, β= .05, t= .48, p> .05). The change in R² (F(1,171)= 9.34, p< .01) was significant. For the third regression model, after entering emotional neglect (b= .34, SD= .29, β= .10, t= 1.17, p> .05) in the second step, physical abuse (b= .47, SD= .25, β= .17, t= 1.89, p> .05) no longer had significant effects while age (b= .31, SD= .18, β= -.18, t= -2.54, p< .05) and sexual abuse (b= .57, SD= .19, β= .25, t= 3.05, p< .01) remained significant predictors of dissociative symptoms. The change in R² (F(1,170)= 1.00,
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either emotional abuse or emotional neglect. In model 1, a significant relationship between
p> .05) was not significant (see Table 3). To evaluate the robustness of the effect of emotional abuse, we also tested a reversed hierarchical regression model with emotional abuse being entered in the first step and physical and sexual
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abuse being entered in the second step. We decided to not enter emotional neglect to have a precise model that matches the one used in the earlier calculations. Our results show that emotional abuse (b= .89, SD= .29, β= .30, t= 3.06, p< .01) remained the strongest and only
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significant predictor of dissociative symptoms when sexual (b= .37, SD= .19, β= .16, t= 1.91, p> .05) and physical abuse (b= .08, SD= .26, β= .03, t= .31, p> .05) were entered. Furthermore, the
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Discussion
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In this study we could show that, among women with PTSD, symptoms of dissociation are
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related to child maltreatment. While the univariate analyses showed that all types of maltreatment are related to dissociation, the hierarchical regression analyses revealed that both
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sexual and physical abuse explain variance of dissociation when only physical types of maltreatment are considered. Physical abuse no longer had a significant effect on dissociation after emotional abuse was entered to the regression model. Moreover, the influence of sexual abuse dropped with emotional abuse becoming the strongest predictor of dissociative symptoms and accounting for additional variance in the model (see Table 3). Further analyses revealed that similar effects could not be found for a reversed stepwise regression model with emotional abuse
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R² change after entering physical forms of abuse was not significant (F(2,171)= 2.08, p> .05).
being entered in the first step and physical forms of abuse being entered in the second step which underlines the robustness of the found effect. Previous assumptions and findings that postulate that sexual and physical abuse have the strongest relationship to dissociative symptoms (e.g. Waldinger et al., 1994; Carlson et al., 2001; Dalenberg & Palesh, 2004) are contradicted by these
results.
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There are several explanations for the relatively strong association between emotional maltreatment and dissociation. Watson and colleagues (2006) have suggested a mediating role of emotional maternal neglect on evolving dissociative symptoms after experiencing sexual abuse.
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Moreover, other studies also stated that emotionally neglectful surroundings at the time of severe violations may be a risk factor for dissociative symptoms in adulthood (e.g. Nijenhuis et al.,
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abuse. Such a mediating effect of emotional neglect is not supported by our findings. An alternative explanation is that repetitive and intense emotional abuse in the form of verbal
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insults, rejections and humiliations may be as threatening and stressful as physical and sexual abuse. Recent concepts of social pain assume that threats to social integrity may trigger the same
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stress response as threats to physical integrity (MacDonald & Leary, 2005). In turn, similar peritraumatic responses including dissociation might be provoked by emotional abuse as a
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survival strategy. The fact that the impact of physical and to some extent even sexual abuse was reduced as soon as emotional abuse was entered to the analysis, argues for a confounder effect of emotional abuse. Possibly, the detrimental effects of maltreatment on the onset of dissociation are mainly based on social rather than physical threats. Moreover, the confounding role of emotional abuse may also lead to the assumption that even the patients in this sample who did not report emotional maltreatment experienced it but are unaware of it, which is consistent with
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1998). However, these results primarily see effects of emotional neglect rather than emotional
the Betrayal Trauma Theory (Freyd, 1996). These results are also consistent with the idea of emotional abuse underlying all forms of childhood maltreatment (e.g. Schore, 2001). The fact that the pathogenetic effect of emotional abuse in comparison to other forms of maltreatment has been underestimated is also shown by recent findings that other symptoms, like social anxiety,
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are also rather predicted by emotional than by other forms of abuse (e.g. Gibb, Chelminski, & Zimmerman, 2007). Nevertheless, some limitations to this study need to be taken into account with regard to the
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results and their interpretation. First of all, it should be considered that the information about
experienced traumata and dissociative symptoms was not based on elaborate interviews with the
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on a retrospective basis. Although the power of the used questionnaires in relation to the quality was demonstrated above, data of retrospective self-report questionnaires needs to be considered
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with caution. These reports give the possibility of a reversed causality. Especially for trauma types like emotional abuse and neglect, that do not contain physical invasions, memories can
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change easily. However, examinations of the validity of retrospective statements show that
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biases exist but that they do not have the power to invalidate retrospective data (Iffland, Sansen, Catani, & Neuner, 2012). Furthermore, it was not possible to control the presence of potential comorbid psychiatric diagnoses or other possibly influential variables such as environmental traumatic factors or the family environment that is associated with emotional abuse. Taking these limitations into consideration, we can still conclude that the traumatic impact of emotional abuse seems to be stronger than previously assumed, even for symptoms of
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patients but was collected with self-report instruments. Moreover, the given data was collected
dissociation that had clearly been linked to the highest levels of stress responses. The results indicate that emotional abuse might be implied in other trauma types and thus seems to confound the relationship between these trauma types and dissociative symptoms. Hence, the abovedescribed distinct findings of a direct or mediated relationship between trauma and dissociation
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(e.g. Cima et al., 2003; Irwin, 1999) may be reconcilable: a direct connection can be found between emotional maltreatment and dissociative symptoms, whilst the relations between other forms of trauma and dissociation can at least partly be explained by emotional abuse. This
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indicates that, for women with PTSD, the emotional components of a trauma rather than any physical components (which are contained in physical and sexual abuse) are mainly correlated
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Spiegel, D., & Cardeña, E. (1990). Dissociative mechanisms in posttraumatic stress disorder. In
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Watson, S., Chilton, R., Fairchild, H., & Whewell, P. (2006). Association between childhood trauma and dissociation among patients with borderline personality disorder. Australian and New
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Zealand Journal of Psychiatry, 40, 478-481.
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DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
n
above cut-off
M
(%) 132
65.02
12.10 (6.26)
Sexual abuse
143
70.44
15.57 (7.53)
Emotional abuse
174
85.71
Emotional neglect
156
an
27
ce pt ed
Two maltreatment types
19
17.91 (5.80)
76.85
19.21 (5.16)
9.90
M
One maltreatment type
us
Physical abuse
14.10
> Two maltreatment types
146
76.10
Dissociative symptoms
201
29.50 (17.38)
PDS total sum score
198
34.05 (7.64)
Note. Percentages of trauma types are based on cut-off scores for maltreatment
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(SD)
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Variable
with ≥ 8 for sexual abuse and physical abuse, ≥ 10 for emotional abuse and ≥ 15 for emotional neglect as provided by Walker et al. (1999).
The mean sum scores for the four maltreatment types were calculated from the
23
t
Table 1 Clinical Characteristics and Rates of Types of Maltreatment (n= 203)
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
answers to the CTQ scales (assuming a continuous progress without considering cut-off scores).
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to the FDS-20. PDS= Posttraumatic Stress Diagnostic Scale.
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The mean sum scores for dissociative symptoms were calculated from the answers
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DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
Table 2 Correlations Between the Measured Types of Maltreatment Sexual
Emotional
Emotional
abuse
abuse
abuse
neglect
.42**
.62**
.56**
.49**
.41**
.42**
Emotional abuse
.62**
.49**
Emotional neglect
.56**
.41**
.67**
.67**
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Sexual abuse
Note. Zero-order rank correlation coefficients (Spearman) for correlations between all measured
ce pt ed
M
an
types of maltreatment. Significant correlation coefficients are indicated. ** p < .01.
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Physical abuse
t
Physical
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Variables
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DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
Table 3 Zero-Order Rank Correlation Coefficients and Standard-ß Coefficients Resulting from Hierarchical Regression Analyses Dissociative symptoms
ß -.17*
Physical abuse
.28**
.21*
Sexual abuse
.32**
.26**
Emotional abuse
.41**
n.e.
Emotional neglect
.35**
ß -.17*
R²
t
ß
R²
-.18*
us
-.06
M
Age
R²
.05
.17
.17*
.25**
.30**
n.e.
n.e.
.10
an
r
Model 3
n.e.
.20
.16
ce pt ed
.15
Note. r = Zero-order rank correlation coefficients (Spearman). n.e.= not entered in regressions analysis.
R²= Adjusted R², with F(3,170)= 11.41, p< .01 for model 1, F(4,169)= 11.48, p< .01 for model 2 and F(4,168)= 9.40, p< .01 for model 3. Significance of R² change tested with F(1,171)= 9.34,
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Variable
Model 2
cr ip
Model 1
p< .01 for model 2 (in comparison with model 1) and F(1,170)= 1.00, p> .05 for model 3 (in comparison with model 1). Significant correlation and regression coefficients are indicated. * p < .05. ** p < .01.
26
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Dissociation is associated with emotional maltreatment in a sample of traumatized women with a history of child abuse a
b
b
a
Lisa Haferkamp , Anke Bebermeier , Andrea Möllering & Frank Neuner a
Bielefeld University
b
Klinik für Psychotherapeutische und Psychosomatische Medizin Bielefeld Accepted author version posted online: 03 Nov 2014.
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DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
Running Head: DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
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Dissociation is associated with emotional maltreatment in a sample of traumatized women with a history of child abuse
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Bielefeld University Anke Bebermeier and Andrea Möllering
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Klinik für Psychotherapeutische und Psychosomatische Medizin Bielefeld Frank Neuner
Author note
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Bielefeld University
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Lisa Haferkamp (M. Sc.), Department of Psychology, Bielefeld University; Anke Bebermeier (Dipl.-Psych.) and Andrea Möllering (Dr. med.), Klinik für Psychotherapeutische und Psychosomatische Medizin Bielefeld; Frank Neuner (Prof. Dr.), Department of Psychology, Bielefeld University. This research was supported in part by data from the first measuring period of a longitudinal study conducted by the Klinik für Psychotherapeutische und Psychosomatische Medizin of the Evangelisches Krankenhaus, Bielefeld (Germany). Many thanks for the allocation of the data for this study. Correspondence concerning this article should be addressed to Lisa Haferkamp, Department of Psychology, Bielefeld University, Universitätsstr. 25, 33615 Bielefeld.
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Lisa Haferkamp
E-mail: [email protected] Contact information: Dr. med Andrea Möllering: [email protected] Dipl.-Psych. Anke Bebermeier: [email protected]
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DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
Prof. Dr. Frank Neuner: [email protected] Abstract Theories of dissociation emphasize that symptoms of dissociation are correlated with traumatic
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events. While the association of dissociative symptoms and retrospective reports of child abuse with a focus on mainly sexual and physical abuse has been well documented, the investigation of
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dissociation has been neglected to a great extent. The aim of this study was to determine the differential impact of different types of maltreatment on dissociative symptoms in a sample of
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203 female residential patients treated for posttraumatic stress disorder linked to child maltreatment. Moreover, it was examined if the link between dissociation and child maltreatment
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is direct or indirect. Subjects completed questionnaires on child maltreatment, posttraumatic
ce pt ed
stress and dissociative symptoms. While all types of maltreatment were related to dissociative symptoms, emotional abuse was the strongest and direct predictor of dissociation in multivariate hierarchical analyses with the influence of other trauma types being confounded by emotional abuse. This study highlights the importance of emotional types of maltreatment for the genesis of dissociative symptoms in patients with PTSD. KEY WORDS: dissociation; childhood maltreatment; emotional maltreatment; PTSD
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the contribution of emotional or psychological types of maltreatment to the prediction of
Dissociation includes symptoms such as depersonalization, derealization, amnesia, absorption
and changes of identity. Theories relate dissociative symptoms to the pathological processing of traumatic events, the most prominent being child abuse (e.g. Putnam, 1989; Spiegel, 1986; Spiegel & Cardeña, 1990; Resch, Brunner, & Parzer, 1998). These trauma theories assume that
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DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
dissociation operates as a protective mechanism to split off traumatic perceptions from consciousness and to prevent the full confrontation with extremely stressful emotions (Classen, Koopman, & Spiegel, 1993). Other perspectives do not only postulate the connection between
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trauma and dissociation but also provide an evolutionary-based perspective (Nijenhuis, Spinhoven, Vanderlinden, Van Dyck, & Van der Hart, 1998; Nijenhuis, Vanderlinden, &
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responses to threat can become chronic and dissociated and provide a biological explanation as to why dissociative symptoms can arise. This biological stage of a stress response can be
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associated with the trauma memory and can also be subsequently triggered by reminders. Consistent with the trauma hypothesis of dissociation, several studies have shown significant,
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strong and consistent correlations between dissociation and retrospective reports of child abuse
ce pt ed
(e.g. Putnam et al., 1996; Alpert, 1995; Carlson, Dalenberg, & McDade-Montez, 2012) in psychiatric patients (e.g. Waldinger, Swett, Frank, & Miller, 1994; Gast, Rodewald, Nickel, & Emrich, 2001) as well as in the general population (Mulder, Beautrais, Joyce, & Fergusson, 1998). Moreover, recent research found a change in dissociative symptoms associated with change in PTSD which favors the trauma hypothesis (Lynch, Forman, Mendelsohn, & Herman, 2008; Carlson et al., 2012).
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Spinhoven, 1998; Schauer & Elbert, 2010). They underline the possibility that physical defense
The trauma theories assume that events that imply immediate and extreme biological threats combined with limited possibilities for active defense should elicit the most peritraumatic dissociation and consequently lead to the highest level of dissociative symptoms. A prototype of such events is child sexual abuse. Therefore, many studies focused primarily on physical forms
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DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
of maltreatment and found significant correlations between dissociation and both sexual (e.g. Briere & Runtz, 1987; Waldinger et al., 1994; Van Ijzendoorn & Schuengel, 1996; Carlson, Dalenberg, Armstrong, Daniels, Loewenstein, & Roth, 2001) and physical abuse (e.g. Irwin,
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1996; Mulder et al, 1998; Van Ijzendoorn & Schuengel, 1996; Macfie, Cicchetti, & Toth, 2001a, 2001b; Carlson et al., 2001; Dalenberg & Palish, 2004; Holowka, King, Saheb, Pukall, & Brunet,
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chronic and severe dissociation has been shown (e.g. Chu & Dill, 1990; Waldinger et al., 1994; Macfie et al., 2001a), with chronic and severe sexual and physical abuse as well as medical
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traumas like long-lasting, invasive treatments of chronic illnesses in young children causing high levels of dissociative symptoms (e.g. Nijenhuis et al., 1998; Diseth, 2006).
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Other studies did not exclusively focus on physical types of maltreatment and indicated that not
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only these forms of abuse but also psychological types of maltreatment are correlated with dissociation (e.g. Ferguson & Dacey, 1997; Holowka et al., 2002; Simeon, Nelson, Elias, Greenberg, & Hollander, 2003; O’Dougherty Wright, Crawford, & Del Castillo, 2009). For example, Watson, Chilton, Fairchild, and Whewell (2006) not only confirmed the link between child maltreatment and dissociation in a sample of 139 patients with borderline personality disorder: They also found a higher correlation of dissociation with emotional abuse than with sexual and physical abuse. Therefore, Watson et al. (2006) concluded that emotional abuse and
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2002). In addition to this, a cumulative effect of traumatic experiences on the development of
emotional neglect may be as important as both sexual and physical abuse with regard to developing dissociative symptoms. As emotional abuse and neglect involve rejection, humiliation, verbal abuse and non-responsiveness of caretakers but no direct threat to life and limb, this finding challenges the view of previous theories and investigations which emphasized
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DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
the linkage of dissociation to the extreme stress caused by an assumed threat to life. However, other research (e.g. Porges, 2003) supports the position that severe attachment disruption cannot only be perceived as dangerous by small children but also that attachment deprivation can
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endanger life. Hence, a possible threat to life or a perceived threat caused by emotional forms of maltreatment can be possible. On a related note, although the relationship between dissociation
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physical and sexual trauma, emotional abuse is considerably more prevalent than other types of trauma, and has not only received more attention (O’Dougherty Wright et al., 2009) but has also
an
shown to have devastating neurobiological effects (Teicher, Glod, Surry, & Swett, 1993; Ito, Teicher, Glod, Harper, Magnus, & Gelbhard, 1993)..
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Besides the already mentioned research, other researchers have questioned the stated direct
ce pt ed
causal link between trauma and dissociation (e.g. Cima, Merckelbach, Hollnack, & Knauer, 2003). Some studies indicate that co-occurring environmental factors like socio-cognitive processes or emotional support may play a mediating role for the onset and maintenance of pathological dissociation (Irwin, 1996, 1999; Nijenhuis et al., 1998; Merckelbach & Muris, 2001) and thus emphasize the possibility of mediating links between trauma and dissociation. The Betrayal Trauma Theory (Freyd, 1996), also allows to doubt a direct link. The theory assumes that staying unaware of abuse is socially useful when the perpetrator is a caregiver
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and emotional forms of maltreatment has been studied much less than its relationship with
(Freyd, 1996). In this context, it has been found that betrayal by caregivers can predict future dissociative symptoms in traumatized individuals (DePrince, 2001). Thus, the relationship to the perpetrator (e.g. physical abuse by a caregiver or a stranger) influences the intensity of the
5
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
symptoms which can be seen as a contradiction of a clear connection between trauma and dissociation. The aim of this study was to determine the relative contribution of different types of
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maltreatment to symptoms of dissociation. Furthermore, we wanted to examine if the relation between trauma and dissociative symptoms is direct or confounded, with a focus on possible
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of n = 203 female resident patients diagnosed with PTSD related to child abuse. We expected this sample to provide a high level and variance of different types of child maltreatment which
an
allow a multivariate analysis of the relationship between traumatic events and dissociation. Using the Childhood Trauma Questionnaire (CTQ: Bernstein & Fink, 1998; German version
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CTQ: Driessen, Gast, Hill, & Wulff, 2000), we assessed four types of childhood maltreatment
ce pt ed
(emotional abuse, physical abuse, sexual abuse and emotional neglect) and related them to dissociative symptoms as measured with the Dissociative Experiences Scale (DES: Carlson & Putnam, 1986; German short version: Kurzform des Fragebogens zu Dissoziativen Symptomen FDS-20: Freyberger, Spitzer, & Stieglitz, 2005). We hypothesized that all types of child maltreatment are significantly correlated with dissociation with emotional abuse and neglect being the main significant predictors of dissociation in hierarchical regression analyses as was assumed by previous studies (e.g. Watson et al., 2006; O’Dougherty Wright et al., 2009). In this
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confounder effects of emotional types of maltreatment. For this purpose, we examined a sample
context, we did not only expect emotional forms of maltreatment to explain further variance over and above the effects of physical and sexual abuse, but, based on the findings of e.g. Irwin (1999) und Watson et al. (2006), we also expected emotional forms of maltreatment to play a confounder role between dissociative symptoms and physical forms of maltreatment.
6
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
Method
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Sample Selection and Participants
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The analyses presented here are based on data from an evaluation study of the Klinik für
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Bielefeld, Germany. The psychosomatic clinic focuses on the treatment of complex traumarelated disorders often based on child abuse. The data was collected between January 2009 and
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December 2009 and the Ethics Committee of the Department of Psychology of Bielefeld University approved the research of the current study. After arriving at the clinic, the patients
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were asked to complete a set of questionnaires. They received a standardised information letter and instructions for completing them. The letter included information about the confidential
ce pt ed
treatment of the given data as well as information about the longitudinal study. Moreover and with regard to the study, it was mentioned that the given information and data were used in an anonymized form. The patients had to sign an informed consent form which was handed out with the information letter to show their agreement to the usage of their data for research purposes. All female patients of the clinic were generally considered for this study. Besides the interest of the study to examine more closely the relationship between dissociative symptoms and different
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Psychotherapeutische und Psychosomatische Medizin of the Evangelisches Krankenhaus in
traumatic events, the recent discussion of a dissociative subtype of the PTSD diagnosis due to its frequent appearance and challenging treatment (e.g. Lanius, Brand, Vermetten, Frewen, & Spiegel, 2012) additionally underlines the importance of a further examination of the connection between the two problem areas. Therefore, women included in the analyses had to fulfil the
7
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
DSM-IV criteria of PTSD, determined by the Posttraumatic Stress Diagnostic Scale (PDS: Foa, 1995; German version PDS: Ehlers, Steil, Winter, & Foa, 2000. The resulting sample of n = 203 women ranged in age from 19 to 66 with a mean age of M = 38.26 (SD = 10.01). Clinical
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characteristics are presented in Table 1. Mean sum scores for the maltreatment types measured with the Childhood Trauma Questionnaire (CTQ) were M = 12.10 (SD = 6.26) for physical
us
M = 19.21 (SD = 5.16) for emotional neglect. The existence of a type of maltreatment for a single case was determined using empirically derived cut-off scores (Walker, 1999, see Table 1).
an
During the analyses for this study, we rather considered a continuous progress of maltreatment instead of taking cut-off scores into account to postulate the existence of the different trauma
M
types. We decided to regard maltreatment as a continuous process that ranges from dysfunctional parenting to severe abuse and neglect. The purpose of the CTQ is to cover this variance with a
ce pt ed
continuous scale. This assumption is supported by data from a representative sample of the German population (Iffland, Brähmer, Neuner, Häuser, & Glaesmer, 2013) which indicates a continuous instead of a dichotomous, bipolar distribution of CTQ scores.
Instruments
PTSD. The Posttraumatic Stress Diagnostic Scale (PDS; Ehlers, Steil, Winter, & Foa, 2000)
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abuse, M = 15.57 (SD = 7.53) for sexual abuse, M = 17.91 (SD = 5.80) for emotional abuse and
consists of four parts which scan the DSM-IV criteria A to F as well as quantify the severity of the PTSD symptoms (Foa, Cashman, Jaycox, & Perry, 1997). To establish the diagnosis of PTSD with the PDS, the empirically derived cut-off score of 17 in combination with the DSMIV algorithm (Griffin, Uhlmannsiek, Resick, & Mechanic, 2004) was applied.
8
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
Child Maltreatment. We used the German 34-item-version of the Childhood Trauma Questionnaire (CTQ; Driessen, Gast, Hill, & Wulff, 2000) to assess child maltreatment. It provides scores for the five maltreatment types childhood emotional abuse, physical abuse,
cr ip
t
sexual abuse, emotional neglect and physical neglect as well as a total sum score (Bernstein et al., 1994). Bernstein, Ahluvalia, Pogge, and Handelsman (1997) found both a high internal
us
German version of the questionnaire an unsatisfying internal consistency was found for physical neglect (Bader, Hänny, Schäfer, Neuckel, & Kuhl, 2009). Hence, this scale will not be
an
considered in the analyses.
Dissociation. The German short version of the Dissociative Experiences Scale (DES), the FDS-
M
20 (Freyberger, Spitzer, & Stieglitz, 2005), was used to assess the severity of dissociative
ce pt ed
symptoms in the previous two weeks. In the FDS-20, each symptom is rated using an 11-pointscale ranging from 0 to 100% (Bernstein Carlson & Putnam, 1993). The DES score is the mean score of all items and therefore ranges between 0 and 100 (Bernstein & Putnam, 1986). Validation studies proved a high convergent validity with structured interviews as well as other dissociative experiences questionnaires (Van Ijzendoorn & Schuengel, 1996).
Results
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consistency of the CTQ factors and a convergent and discriminant validity. However, in the
The relationship between dissociative symptoms and the trauma types was estimated using Spearman rank correlations and hierarchical regression analyses. Multicollinearity between the
9
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
different trauma types was checked and could be ruled out in all analyses. An overview of the correlation coefficients between the types of maltreatment is provided (see Table 2). In the first regression model, age, physical abuse and sexual abuse were entered in the first step.
cr ip
t
In the second step, either emotional abuse (model 2) or emotional neglect (model 3) was entered (see Table 3). We decided to present two separate models to examine the individual impact of
us
dissociative symptoms and age (b= -.29, SD= .12, β= -.17, t= -2.39, p< .05), physical abuse (b= .57, SD= .22, β= .20, t= 2.54, p< .05) and sexual abuse (b= .60, SD= .19, β= .26, t= 3.21, p< .01)
an
was found. When emotional abuse was entered in the second step (model 2), a significant relationship with dissociative symptoms was found for this trauma type (b= .91, SD= .29, β= .30,
M
t= 3.15, p< .01) with age (b= -.30, SD= .12, β= -.17, t= -2.52, p< .05) and sexual abuse (b= .40,
ce pt ed
SD= .19, β= .17, t= 2.06, p< .05) remaining significant predictors and physical abuse no longer having a significant relation to dissociative symptoms (b= .13, SD=2 .26, β= .05, t= .48, p> .05). The change in R² (F(1,171)= 9.34, p< .01) was significant. For the third regression model, after entering emotional neglect (b= .34, SD= .29, β= .10, t= 1.17, p> .05) in the second step, physical abuse (b= .47, SD= .25, β= .17, t= 1.89, p> .05) no longer had significant effects while age (b= .31, SD= .18, β= -.18, t= -2.54, p< .05) and sexual abuse (b= .57, SD= .19, β= .25, t= 3.05, p< .01) remained significant predictors of dissociative symptoms. The change in R² (F(1,170)= 1.00,
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either emotional abuse or emotional neglect. In model 1, a significant relationship between
p> .05) was not significant (see Table 3). To evaluate the robustness of the effect of emotional abuse, we also tested a reversed hierarchical regression model with emotional abuse being entered in the first step and physical and sexual
10
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
abuse being entered in the second step. We decided to not enter emotional neglect to have a precise model that matches the one used in the earlier calculations. Our results show that emotional abuse (b= .89, SD= .29, β= .30, t= 3.06, p< .01) remained the strongest and only
cr ip
t
significant predictor of dissociative symptoms when sexual (b= .37, SD= .19, β= .16, t= 1.91, p> .05) and physical abuse (b= .08, SD= .26, β= .03, t= .31, p> .05) were entered. Furthermore, the
us
Discussion
an
In this study we could show that, among women with PTSD, symptoms of dissociation are
M
related to child maltreatment. While the univariate analyses showed that all types of maltreatment are related to dissociation, the hierarchical regression analyses revealed that both
ce pt ed
sexual and physical abuse explain variance of dissociation when only physical types of maltreatment are considered. Physical abuse no longer had a significant effect on dissociation after emotional abuse was entered to the regression model. Moreover, the influence of sexual abuse dropped with emotional abuse becoming the strongest predictor of dissociative symptoms and accounting for additional variance in the model (see Table 3). Further analyses revealed that similar effects could not be found for a reversed stepwise regression model with emotional abuse
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R² change after entering physical forms of abuse was not significant (F(2,171)= 2.08, p> .05).
being entered in the first step and physical forms of abuse being entered in the second step which underlines the robustness of the found effect. Previous assumptions and findings that postulate that sexual and physical abuse have the strongest relationship to dissociative symptoms (e.g. Waldinger et al., 1994; Carlson et al., 2001; Dalenberg & Palesh, 2004) are contradicted by these
results.
11
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
There are several explanations for the relatively strong association between emotional maltreatment and dissociation. Watson and colleagues (2006) have suggested a mediating role of emotional maternal neglect on evolving dissociative symptoms after experiencing sexual abuse.
cr ip
t
Moreover, other studies also stated that emotionally neglectful surroundings at the time of severe violations may be a risk factor for dissociative symptoms in adulthood (e.g. Nijenhuis et al.,
us
abuse. Such a mediating effect of emotional neglect is not supported by our findings. An alternative explanation is that repetitive and intense emotional abuse in the form of verbal
an
insults, rejections and humiliations may be as threatening and stressful as physical and sexual abuse. Recent concepts of social pain assume that threats to social integrity may trigger the same
M
stress response as threats to physical integrity (MacDonald & Leary, 2005). In turn, similar peritraumatic responses including dissociation might be provoked by emotional abuse as a
ce pt ed
survival strategy. The fact that the impact of physical and to some extent even sexual abuse was reduced as soon as emotional abuse was entered to the analysis, argues for a confounder effect of emotional abuse. Possibly, the detrimental effects of maltreatment on the onset of dissociation are mainly based on social rather than physical threats. Moreover, the confounding role of emotional abuse may also lead to the assumption that even the patients in this sample who did not report emotional maltreatment experienced it but are unaware of it, which is consistent with
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1998). However, these results primarily see effects of emotional neglect rather than emotional
the Betrayal Trauma Theory (Freyd, 1996). These results are also consistent with the idea of emotional abuse underlying all forms of childhood maltreatment (e.g. Schore, 2001). The fact that the pathogenetic effect of emotional abuse in comparison to other forms of maltreatment has been underestimated is also shown by recent findings that other symptoms, like social anxiety,
12
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
are also rather predicted by emotional than by other forms of abuse (e.g. Gibb, Chelminski, & Zimmerman, 2007). Nevertheless, some limitations to this study need to be taken into account with regard to the
cr ip
t
results and their interpretation. First of all, it should be considered that the information about
experienced traumata and dissociative symptoms was not based on elaborate interviews with the
us
on a retrospective basis. Although the power of the used questionnaires in relation to the quality was demonstrated above, data of retrospective self-report questionnaires needs to be considered
an
with caution. These reports give the possibility of a reversed causality. Especially for trauma types like emotional abuse and neglect, that do not contain physical invasions, memories can
M
change easily. However, examinations of the validity of retrospective statements show that
ce pt ed
biases exist but that they do not have the power to invalidate retrospective data (Iffland, Sansen, Catani, & Neuner, 2012). Furthermore, it was not possible to control the presence of potential comorbid psychiatric diagnoses or other possibly influential variables such as environmental traumatic factors or the family environment that is associated with emotional abuse. Taking these limitations into consideration, we can still conclude that the traumatic impact of emotional abuse seems to be stronger than previously assumed, even for symptoms of
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patients but was collected with self-report instruments. Moreover, the given data was collected
dissociation that had clearly been linked to the highest levels of stress responses. The results indicate that emotional abuse might be implied in other trauma types and thus seems to confound the relationship between these trauma types and dissociative symptoms. Hence, the abovedescribed distinct findings of a direct or mediated relationship between trauma and dissociation
13
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
(e.g. Cima et al., 2003; Irwin, 1999) may be reconcilable: a direct connection can be found between emotional maltreatment and dissociative symptoms, whilst the relations between other forms of trauma and dissociation can at least partly be explained by emotional abuse. This
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indicates that, for women with PTSD, the emotional components of a trauma rather than any physical components (which are contained in physical and sexual abuse) are mainly correlated
us
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t
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DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
n
above cut-off
M
(%) 132
65.02
12.10 (6.26)
Sexual abuse
143
70.44
15.57 (7.53)
Emotional abuse
174
85.71
Emotional neglect
156
an
27
ce pt ed
Two maltreatment types
19
17.91 (5.80)
76.85
19.21 (5.16)
9.90
M
One maltreatment type
us
Physical abuse
14.10
> Two maltreatment types
146
76.10
Dissociative symptoms
201
29.50 (17.38)
PDS total sum score
198
34.05 (7.64)
Note. Percentages of trauma types are based on cut-off scores for maltreatment
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(SD)
cr ip
Variable
with ≥ 8 for sexual abuse and physical abuse, ≥ 10 for emotional abuse and ≥ 15 for emotional neglect as provided by Walker et al. (1999).
The mean sum scores for the four maltreatment types were calculated from the
23
t
Table 1 Clinical Characteristics and Rates of Types of Maltreatment (n= 203)
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
answers to the CTQ scales (assuming a continuous progress without considering cut-off scores).
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to the FDS-20. PDS= Posttraumatic Stress Diagnostic Scale.
cr ip
t
The mean sum scores for dissociative symptoms were calculated from the answers
24
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
Table 2 Correlations Between the Measured Types of Maltreatment Sexual
Emotional
Emotional
abuse
abuse
abuse
neglect
.42**
.62**
.56**
.49**
.41**
.42**
Emotional abuse
.62**
.49**
Emotional neglect
.56**
.41**
.67**
.67**
us
Sexual abuse
Note. Zero-order rank correlation coefficients (Spearman) for correlations between all measured
ce pt ed
M
an
types of maltreatment. Significant correlation coefficients are indicated. ** p < .01.
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Physical abuse
t
Physical
cr ip
Variables
25
DISSOCIATION ASSOCIATED WITH EMOTIONAL MALTREATMENT
Table 3 Zero-Order Rank Correlation Coefficients and Standard-ß Coefficients Resulting from Hierarchical Regression Analyses Dissociative symptoms
ß -.17*
Physical abuse
.28**
.21*
Sexual abuse
.32**
.26**
Emotional abuse
.41**
n.e.
Emotional neglect
.35**
ß -.17*
R²
t
ß
R²
-.18*
us
-.06
M
Age
R²
.05
.17
.17*
.25**
.30**
n.e.
n.e.
.10
an
r
Model 3
n.e.
.20
.16
ce pt ed
.15
Note. r = Zero-order rank correlation coefficients (Spearman). n.e.= not entered in regressions analysis.
R²= Adjusted R², with F(3,170)= 11.41, p< .01 for model 1, F(4,169)= 11.48, p< .01 for model 2 and F(4,168)= 9.40, p< .01 for model 3. Significance of R² change tested with F(1,171)= 9.34,
Ac
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Variable
Model 2
cr ip
Model 1
p< .01 for model 2 (in comparison with model 1) and F(1,170)= 1.00, p> .05 for model 3 (in comparison with model 1). Significant correlation and regression coefficients are indicated. * p < .05. ** p < .01.
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