Journal of Child Sexual Abuse, 23:918–934, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1053-8712 print/1547-0679 online DOI: 10.1080/10538712.2014.964440

Impact of Traumatic Events on Posttraumatic Stress Disorder among Danish Survivors of Sexual Abuse in Childhood ASK ELKLIT University of Southern Denmark, Odense, Denmark, and University of Ulster, Coleraine, United Kingdom

DORTE M. CHRISTIANSEN, SABINA PALIC, SIDSEL KARSBERG, and SARA BEK ERIKSEN University of Southern Denmark, Odense, Denmark

Childhood sexual abuse can be extremely traumatic and lead to lifelong symptomatology. The present study examined the impact of several demographic, abuse, and psychosocial variables on posttraumatic stress disorder severity among a consecutive sample of treatment-seeking, adult child sexual abuse survivors ( N = 480). The child sexual abuse sample was characterized by severe trauma exposure, insecure attachment, and significant traumatization, with an estimated 77% suffering from posttraumatic stress disorder, more than twice the level of the comparison group. Regression analyses revealed risk factors associated with the development of posttraumatic stress disorder in which the strongest predictors being additional traumas, negative affectivity, and somatization. The findings add to existing research confirming the stressful nature of child sexual abuse and the variables that contribute to the development and severity of posttraumatic stress disorder. KEYWORDS child sexual abuse, posttraumatic stress disorder, general distress, risk factors Studies have reported varying rates of adolescent and childhood sexual abuse (CSA), with reports ranging from 4% to 50% (Paolucci, Genuis, & Violato, 2001). Variations in rates of prevalence are related to the definition of Received 22 March 2014; revised 6 May 2014; accepted 8 May 2014. Address correspondence to Ask Elklit, National Research Centre of Psychotraumatology, Department of Psychology, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark. E-mail: [email protected] 918

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CSA, the populations studied, and the measures used. Scandinavian studies of CSA have mostly focused on adolescents. In a Danish youth probability sample (aged 13 to 15 years), 2.6% of girls and 0.5% of boys reported having been sexually abused in childhood (Elklit, 2002). A Swedish study using a slightly older sample found that 7.1% of females and 2.3% of males had experienced sexual abuse and that 3.1% and 1.2% of females and males, respectively, had been subjected to sexual abuse involving intercourse (Edgardh & Ormstad, 2000). High rates of posttraumatic stress disorder (PTSD) have been reported in adult CSA survivors. In a meta-analysis of 37 studies, Paolucci and colleagues (2001) found that 37% to 43% of CSA survivors suffered from PTSD and that clinical and help-seeking samples generally showed higher degrees of traumatization compared to other samples. CSA has not only been associated with PTSD in adulthood but also with a range of other mental health problems like depression (Maniglio, 2010), anxiety (Maniglio, 2013), somatization, and dissociation (Neumann, Houskamp, Pollock, & Briere, 1996). However, gender, socioeconomic status, type of abuse, age of onset, relationship to perpetrator, and number of abuse incidents have failed to significantly account for the variance in PTSD severity and general distress across studies (Paolucci et al., 2001; Whiffen & MacIntosh, 2005). A number of sociopsychological factors appear to be more promising in accounting for variance in the degree of traumatization and general distress following CSA.

ATTACHMENT A review of the interpersonal and family functioning of female CSA survivors indicates that they experience problems with attachment (Rumstein-McKean & Hynsley, 2001). In line with this, a number of studies (Alexander, 1993; Whiffen, Judd, and Aube, 1999) have found that female CSA survivors in convenience samples show evidence of insecure attachment. Gold (2000) proposed that the long-term psychological effects of CSA not only derive from the abuse itself but also from dysfunctional family environments. Studies show that survivors of CSA often have experienced high levels of parental neglect and rejection (Gold, 2000) and greater family dysfunction (Alexander & Schaeffer, 1994) than adults without CSA history. Gold (2000) states that these dysfunctional family patterns render the CSA victims vulnerable to maltreatment as a result of unassertiveness and unmet attachment needs.

COGNITIONS Cognitions about self-worth and the individual’s thoughts about the benevolence and meaningfulness of the world make up another group of potential

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mediators of CSA and its psychological sequalae. According to the theories of Janoff-Bulman (1992) and McCann and Pearlman (1990), shattered assumptions and disturbed schemas are likely outcomes of profound early adverse experiences. A study by Wenniger and Ehlers (1998) examined American and German convenience samples and provides some evidence to suggest that a relationship exists between dysfunctional cognitions and posttraumatic symptoms among CSA survivors. These results have been confirmed by a more recent study that examined a clinical sample of CSA survivors (Owens & Chard, 2001). In relation to this, Cukor and McGinn (2006) investigated the mediating role of cognitive schema on depression and anxiety in a clinical group of CSA survivors. The abused women in the study were significantly more depressed and reported more maladaptive cognitions than the control group.

SOCIAL SUPPORT A recent study by Stevens and colleagues (2013) found that childhood maltreatment survivors, including CSA victims, reported low satisfaction with current social support and that this lack of social support, among other variables, accounted for 63% of the variance in the symptoms of PTSD in the sample. Schumm, Briggs-Phillips, and Hobfoll (2006) also studied the association between perceived social support and PTSD among women who had been victims of CSA and found that negative perceptions of current social support increased the women’s levels of PTSD symptomatology. Associations between psychological maladjustment and types of social support are complex, and the research is far from conclusive. Furthermore, the effects of retrospective social support (i.e., at the time of victimization) have not yet been evaluated alongside present social support, which is also a well-known contributor to present adjustment. It is therefore meaningful to investigate which type of social support (past or present) exerts the strongest influence on adult adjustment. Finally, according to the review by Rumstein-McKean and Hunsley (2001), there is a scarcity of CSA survivor studies that apply appropriate control–comparison groups. A study by Rodriguez, Ryan, Rowan, and Foy (1996) that examined help-seeking women demonstrated substantial differences in prevalence rates of PTSD among CSA survivors and women who sought treatment for relationship problems. The aim of the present study was to examine PTSD and general distress in a sample of women and men seeking help at a support center for CSA survivors. The study consisted of two parts. In the first part we examined the prevalence of PTSD and general distress in a sample of treatment-seeking, adult CSA survivors and compared the results to those of a sample of women seeking counseling because of

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a recent traumatic experience. We expected that PTSD and general distress would be more prevalent among people in the CSA sample than among women in the comparison sample. Thus, the goal of this part of the study was to further illuminate the level of trauma reactions among CSA survivors compared to other trauma populations. In the second part we examined possible risk factors associated with PTSD and general distress specific to CSA survivors. We hypothesized that an insecure attachment style, dysfunctional cognitions, and poor social support would be related to higher levels of PTSD and general distress among CSA survivors and that these psychological variables would be more important than both demographic and abuse related variables as predictors of CSA symptomatology.

METHOD Participants Women and men eligible for the study were all consecutive outpatients (N = 480) at four treatment centers in Denmark that exist for sexually abused individuals in childhood. The recruitment rate was 100% (N = 480). Most of the participants were women (85%), and almost all of the participants (91%) had experienced CSA before the age of 15 committed by a person at least 5 years older. The mean age of the sample was 36.4 years (SD = 10.8; range 15 to 70 years), and all participants were Caucasian. Fifty-one percent were married or cohabiting. The average length of education was 13.3 years (SD = 3.3; range 7 to 24 years). Almost two thirds of the participants (59%) had children. The comparison group consisted of 213 help-seeking clients (66% women) from an intervention study (Elklit, 2000). The clients were recruited from a sample of clients who had been referred to the psychologists’ crisis service in the Danish national emergency corps (“Falck”). Twenty-two percent came via a private insurance arrangement and the others via the insurance arrangements of their workplaces. Like the CSA group, the clients in the comparison group received outpatient psychological treatment. These clients received crisis intervention via their health insurance after recent (< 1 month) exposure to a traumatic event, such as the death of a colleague or a physical assault. The participating clients were 16–77 years old, with a mean age of 37.8 years (SD = 12.3; range = 16−77 years). Sixty-six percent were married or cohabiting. The average length of education was 13.1 years (SD = 3.2; range = 7−27). Sixty-eight percent (n = 139) had children.

Procedure All participants were informed that they would be asked to fill out a number of questionnaires during their next session based on which the therapy

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would be planned. The present study is based on information from the questionnaires. All of the survivors received individual therapy. The comparison group was introduced to the study during the first session, and questionnaires were filled out after the first session.

Measures The CSA group was asked questions about their abuse history, such as onset, duration, relationship to the perpetrator, types of sexual acts they were exposed to, legal consequences for perpetrator, and age of abuse disclosure. Descriptions of sexual victimization that did not fit into the respective items of the questionnaire regarding types of sexual abuse were registered in the “other types of sexual assaults” item. Participants were also asked questions about exposure to 11 other traumatic events, modeled after the National Comorbidity Survey (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). The participants were also asked if they had experienced any serious life events during the year prior to the present study. The comparison group was also asked about previous trauma exposure and received the Harvard Trauma Questionnaire and the Trauma Symptom Checklist. The Harvard Trauma Questionnaire Part IV (HTQ; Mollica et al., 1992) was applied for estimating the occurrence of PTSD at the time of the present study. It consists of 30 items, 16 of which correspond to PTSD symptoms in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Participants who fell just one avoidance or arousal symptom short of a full diagnosis were considered to have subclinical PTSD. Mollica and colleagues (1992) found good reliability and criterion validity for the HTQ. The HTQ Part IV has been validated and used extensively in Denmark (Bach, 2003). The Trauma Symptom Checklist (TSC) was originally created by Briere and Runtz (1989) as a measure of traumatic impact following CSA. The present study employed a revised 23-item version of the TSC with two factors: negative affectivity and somatization. The revised version of the TSC has good psychometric properties as well as good factor and criteria validity (Krog & Duel, 2003). The total score has shown to be a valid measure of general psychological distress after a traumatic event (Krog & Duel, 2003) and was thus employed in the present study. The Revised Adult Attachment Scale (RAAS; Collins & Read 1990; Collins, 1996) is based on attachment theory (Bowlby, 1988). The scale consists of 18 items relating to how respondents act and feel in relationships with others. Items are scored on a 5-point Likert scale ranging from 1 (is not true for me) to 5 (is very true for me). The scale contains 3 subscales (closeness, dependency, and anxiety). Scores can be used to categorize respondents into 4 groups of attachment: secure, anxious-ambivalent, avoidant, and fearful. The reliability and validity of the scale is good (Collins & Read, 1990).

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The World Assumption Scale (WAS; Janoff-Bulman, 1989) is a 32-item checklist of assumptions. Respondents are asked to indicate on a 6-point Likert Scale, ranging from 1 (strongly disagree) to 6 (strongly agree) the degree to which they consider a certain statement appropriate. Research suggests that the scale discriminates well on degrees of traumatization and that it performs uniformly across cultures (Elklit, Shevlin, Solomon, & Dekel, 2007). The Crisis Support Scale (CSS; Joseph, Andrews, Williams, & Yule, 1992) is used to measure experience of perceived social support after a traumatic event. The scale comprises the following 7 items: emotional support, practical support, contact with people in a similar situation, the ability to express oneself, the experience of being let down, and general satisfaction with social support. Items are rated on a 7-point Likert Scale, ranging from 1 (never) to 7 (always). The CSS has been used in several disaster studies, and it has a good internal consistency as well as good discriminatory power. Elklit, Pedersen, and Jind (2001) analyzed 4,213 CSS questionnaires from 11 studies, and the results confirmed the psychometric reliability and validity of the CSS.

RESULTS A one-way ANOVA analysis showed no significant differences in age or in years of education between the CSA and the comparison group. There were significantly more women in the CSA group compared to the comparison group (χ 2 (1,537) = 33.89; p < .0005). The two groups also differed in marital status as the comparison group more often was married or cohabitated than the CSA group (χ 2 (1,675,) = 10.33; p < .001). However, the CSA sample had significantly more children (χ 2 (6,499) = 20.98; p < .002) compared to the non-CSA sample. The mean age for the onset of CSA was 6.7 years (SD 4.8; range 0–17 years). The mean duration of CSA was 7 years (SD 6.6; median 6 years; range 0–46 years). The mean age for disclosure of CSA was 22.0 years (SD 11.2; median 19 years; range 0–53 years). In almost a third of the cases (30%), the perpetrator was the father. In the remaining cases, the perpetrator was the stepfather (15%), another adult relative (28%), another adult (32%), a sibling (16%), or the mother (4%). In 64 cases (14%) several perpetrators were involved. Only 17% of the victims had reported the abuse to the police, and only 10% of the perpetrators were convicted. The number and type of CSA acts are shown in Table 1. Participants had experienced an average of 6.1 (SD = 4.40) different abusive acts, indicating that CSA is generally not restricted to one unique episode, rather it comprises of a series of various sexual behaviors. Seventy-two percent of the CSA survivors compared to 55% of the comparison women had experienced a major life event during the year prior to

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TABLE 1 Acts of Childhood Sexual Abuse (N = 447) Sexually Abusive Acts Sexually addressed or spoken of Questioned about own sexuality Teased about sexual development Had to listen to other’s sexual experiences Proposals or threats about taking part in sexual acts Kiss or fondling in a sexual way Had to watch someone presenting their genitals Had to watch adult intercourse or pornographic material Had to present own genitals to someone else Was touched in a sexual way My genitals were touched in a sexual way Had to touch or fondle the genitals of someone else Had to masturbate while someone was watching Reciprocal masturbation Attempted intercourse Oral intercourse Anal intercourse Genital intercourse Other types of sexual assaults

N

%

210 119 161 156 160 277 269 105 197 345 302 238 38 49 156 125 72 109 77

47 27 36 35 36 62 60 24 44 77 68 54 9 11 35 28 16 25 17

start of therapy. An analysis revealed that the CSA group (M = 4.08; SD = 2.52) had experienced almost three times as many traumas as the comparison group (M = 1.56; SD = 1.49) and that this difference was significant (F = 183.7; p = .000). In addition, the total number of traumatic events reported in the CSA sample was high (Table 2). Traumatic exposure was less in the comparison group (all χ 2 s ≥ 14.94; all ps ≤ .0005). Furthermore, only 4% of the comparison group had experienced CSA. Fifty-seven percent of them reported having lost someone close. This number was significantly higher than in the CSA group (χ 2 (2,677) = 7.90; p = .02), which is likely due to the fact that many of the clients in the comparison group sought psychological counseling because of a recent loss. The means, standard deviations, ranges, and internal consistency values for all scales of the CSA sample are shown in Table 3. Using the four-category attachment model (Bartholomew, 1990), the distribution of CSA survivors was: secure attachment style = 14.4%, preoccupied style = 15.4%, dismissive style = 12.9%, and fearful style = 48%. Thus, 85% of the CSA sample belonged to an insecure attachment style. Due to median placement, it was not possible to classify 10.7%. It was estimated that 77% of the CSA survivors met the three core criteria for a PTSD diagnosis. In the comparison group, 31% met the three core criteria for a PTSD diagnosis, Significantly more survivors in the CSA sample than in the comparison group suffered from PTSD (χ 2 (1,610) = 118.33; p = .001).

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TABLE 2 Percentage of Respondents in the CSA and the Comparison Group that Have Previously Been Exposed to 12 Potentially Traumatic Events

Event Rape CSA Physical assault Shock because someone close was traumatized Threatened with a weapon Serious accident Fire Witnessed someone else being killed or injured Childhood physical abuse Childhood neglect Lost someone close Other traumatic event

CSA group (N = 464)

Comparison group (N = 213)

29% 85% 35% 27% 17% 22% 11% 17% 33% 61% 46% 22%

1% 4% 13% 13% 6% 28% 9% 6% 5% 7% 57% 8%

TABLE 3 Descriptive Statistics for the CSA Survivors Sample Test

Variable

Range

Mean

SD

α

HTQ

Intrusion Avoidance Arousal Total Negative affect Somatization Total Close-dependency Anxiety Self-worth Luck Benevolence of the world Self-control Control Randomness Total score at the time of CSA Total score at present

4–16 9–67 5–20 42–124 15–49 11–40 30–89 14–59 6–36 7–30 4–24 8–42 4–24 7–40 4–24 1–32 10–46

10.54 19.60 15.52 89.44 31.65 23.71 55.37 32.90 20.66 24.81 2.66 28.36 16.03 19.42 13.49 11.54 30.40

2.81 4.80 2.94 17.90 7.33 6.04 12.17 8.17 5.80 4.98 4.90 6.83 3.87 6.23 4.03 5.99 8.17

.75 .67 .65 .90 .84 .80 .88 .76 .67 .69 .70 .82 .71 .74 .54 .79 .64

TSC-23 RAAS WAS

CSS

Associations between Various Variables and Traumatization in the CSA Sample No significant relationships were found between total HTQ scores and most of the demographic variables (age, educational level, marital status, number of children, and length of present romantic relationship) except number of years of education, which negatively correlated with PTSD symptomatology (r = –.17; p = .001). Correlation analyses between the CSA exposure variables and PTSD intensity scores revealed significant positive relationships between 12 variables of sexual acts (r values ranging from .11–.17, p values

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ranging from .05–.01) as well as the number of total CSA acts (r = .21; p < .005) and PTSD intensity. The identity of the perpetrator was significantly associated with PTSD severity, when the perpetrator was the father (F = 5.16; p = .02) or another adult outside the family (F = 4.19; p = .05), and a significant correlation between number of perpetrators and PTSD symptomatology was also found (r = .10; p = .001). Age of CSA onset was not associated with PTSD; however, in contrast to the duration of CSA (r = .14; p = .05) and time of termination (r = .12; p = .06). There was also a significant relationship between the number of recent life events (r = .18; p = .001) and PTSD symptomatology. Furthermore, the number of previous traumatic events correlated significantly and positively with PTSD intensity (r = .30; p = .001).

Initial Regression Analyses Predicting PTSD Level and Symptom Severity Variables associated with the degree of PTSD were examined using a number of regression models, which tested the influence of abuse characteristics, abuse acts, lifetime trauma, recent life events, and the specific psychosocial variables that were the focus in this study on the dependent variable. Because of the very high prevalence of PTSD, total HTQ scores were used in the regression analyses in order to preserve more information when identifying variables related to PTSD symptomatology. The use of continuous symptom measures reduced the risk of underestimating the impact of exposure compared to categorical diagnostic measures (Ozer, Best, Lipsey, & Weiss, 2003). Due to shortage of space, none of these initial analyses are presented in this article; however, the variables that showed some association with PTSD symptomatology are presented next. Based on a series of initial regression analyses, years of education, duration of the sexual abuse, the total number of sexual acts experienced, and the total amount of lifetime trauma were the only demographic and stressor variables included in final analyses together with four psychosocial variables: Attachment, previous and present social support, and cognitions were entered into a regression analysis with the total HTQ scores as the dependent variable.

Final Regression Analyses Predicting PTSD Level and Symptom Severity All of the variables that proved to be significant in the previous analyses were entered into a hierarchical regression model with total HTQ as the dependent variable (Table 4). The order in which the independent variables were

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TABLE 4 Hierarchical Multiple Regression Analyses for the CSA Sample with HTQ Total Score as the Dependent Variable Step 1 2

3

4

5

6

Variable

β

p

R 2

F

Years of education Years of education Duration of CSA Total number of CSA acts Years of education Duration of CSA Total number of CSA acts Total number of traumas Years of education Duration of CSA Total number of CSA acts Total number of traumas Anxious attachment Close/dependent attachment Years of education Duration of CSA Total number of CSA acts Total number of traumas Anxious attachment Dependent/close attachment Self-worth Present social support Years of education Duration of CSA Total number of CSA acts Total number of traumas Anxious attachment Dependent/close attachment Self-worth Present social support Negative affectivity Somatisation

−.20 −.22 .23 .09 −.21 .18 .06 .29 −.09 .14 .06 .22 .24 −.20 −.02 .12 .10 .22 .18 −.10 −.37 −.01 −.02 .01 .04 .17 −.01 −.04 −.03 −.04 .53 .26

.000 .01 .01 .30 .01 .05 .46 .001 .26 .09 .43 .005 .005 .02 .81 .12 .19 .005 .02 .22 .000 .90 .77 .81 .43 .002 .93 .61 .25 .45 .000 .000

.03 .10

5.68∗ 5.83∗∗∗

.17

7.78∗∗∗∗∗

.27

9.09∗∗∗∗∗

.37

10.85∗∗∗∗∗

.69

30.87∗∗∗∗∗

Note: All VIF values in the model were < 10, and all tolerances were > .1, indicating that the model had no problems with collinearity. Furthermore, there were no problems with outliers, and all scores were close enough to a normal distribution to not cause any problems for the regression analysis. ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .005. ∗∗∗∗ p < .001. ∗∗∗∗∗ p < .0005.

entered into the model reflects the time aspect of the traumatization process. Before introducing coexisting symptomatology, the model predicted 37% of the HTQ total scores. The last step included the coexisting symptomatology that proved to be significant in the earlier regression analysis. Thus, in the analysis predicting PTSD severity, we controlled for negative affectivity and somatization. In the final step of the regression analysis, total number of traumas, negative affectivity, and somatization were all significant and accounted for 69% of the variance in symptoms of posttraumatic stress.

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DISCUSSION The high prevalence of PTSD in our CSA group (77% full and 16% subclinical PTSD) is consistent with findings from other treatment studies that have compared PTSD symptoms among adult CSA survivors with matched control groups (Albach & Everaerd, 1992; Rodriguez et al., 1996; Saunders, 1991). O’Neill and Gupta (1991), Rodriguez and colleagues (1996), and Rowan, Foy, Rodriguez, and Ryan (1994) reported current PTSD prevalence between 69% and 72% among help-seeking CSA survivors. Combining the DSM-III-R criteria for full and partial PTSD, Rodriguez and colleagues (1996) found that 86% of their primarily female treatment-seeking sample suffered significant posttraumatic symptoms. Similarly, the present study found that only 7% of the treatment-seeking female victims of CSA did not suffer from at least subclinical levels of PTSD. Thus, results from numerous studies support the importance of CSA as an etiological agent for chronic PTSD. However, CSA was not the only adversity in life that the survivors were subjected to in the current study. Indeed, a better way of characterizing this group would be a repeatedly traumatized group with a high incidence of exposure to various forms of interpersonal violence. The issue can be raised as to whether CSA contributes to increased vulnerability for subsequent trauma or whether only CSA combined with subsequent trauma leads to symptoms and treatment seeking. CSA has been recognized as a major risk factor for later sexual revictimization in several studies (Arata, 2002; Briere & Elliot, 2003; Chu, 2011; Lau & Kristensen, 2009). Rodriguez and colleagues (1996) advocate that help-seeking populations should be assessed for exposure to different types of trauma in childhood and later adulthood. In the present study, the total number of traumas experienced by the survivor showed to be one of the strongest predictors of the variance in PTSD together with negative affectivity and somatization. This variable explained 69% of the variance in PTSD. This could suggest an accumulated effect of traumas with the survivors being increasingly vulnerable to mental health problems after each traumatic event, which is in line with earlier research (Brewin, Andrews, & Valentine, 2000; Briere, Kaltman, & Green, 2008). The present study examined the effect of potential risk factors on chronic PTSD following CSA by testing a number of hypotheses. As expected, the effects of specific demographic factors and abuse characteristics on PTSD were quite modest. However, the survivor’s level of education did in some respect seem to act as a buffer against the development of PTSD, although this effect was leveled out by the attachment variables in the following steps of the regression analysis. This was also the case with the duration of the CSA, which proved to be a significant factor in predicting PTSD symptomatology before the entering of attachment into the model. Together, educational level and duration of CSA accounted for 10% of the variance in PTSD, controlling for other variables. The total number of CSA acts experienced by the

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survivor did not hold any significance over the development of PTSD symptomatology. The modest influence of the demographic and abuse-related variables is consistent with findings from previous studies (e.g., Briere & Runtz, 1989; Rodriguez et al., 1996; Wenninger & Ehlers, 1998). The passage of time and the growing impact of other variables on maintaining symptoms could be part of the explanation for the modest effect of these factors. Consistent with our hypothesis, the sociopsychological variables proved to be more important correlates of PTSD than both demographic and abuse-related variables. As expected, only a few of the CSA survivors were characterized by a secure attachment style. A recent Danish study of PTSD and attachment styles among 328 adult students, which used the same scale as the present study, showed that 67% had a secure attachment style compared to only 14% in the present sample (O’Connor & Elklit, 2008). Nine percent of the adult students had a preoccupied attachment style compared to 14% in the present study, and 10% had a dismissive attachment style compared to 15% in the CSA sample. Only 7% of the adult student sample had a fearful attachment style compared to 48% in the present study. Thus, the difference between the CSA sample and a nonclinical sample is striking. Despite sample differences, this suggests that insecure attachment is more prevalent in CSA samples than in the general population. The association between attachment and degree of traumatization in the initial analyses was expected. In the regression analyses, the two basic dimensions of the Revised Adult Attachment Scale (RAAS) were preferred to the four categorical styles to more fully exploit the information available from continuous measures. In the present study, both anxious attachment and lack of close/dependent attachment contributed to PTSD intensity, predicting 37% of the variance in PTSD symptomatology before the final step of the analysis. The combination of a low level of close and dependent attachment and a high level of anxious attachment resulted in the fearful pattern of the attachment model proposed by Bartholomew (1990). Roche, Runtz, and Hunter (1999) found evidence to suggest that fearful attachment was the pattern that best reflected the difference between CSA survivors and nonabused female undergraduates, and they also demonstrated that attachment style mediated the association between CSA and later psychological adjustment. In accordance with the latter finding, the present study demonstrated that attachment is of central importance in predicting posttraumatic symptoms. However, the two types of attachment became both insignificant in the final step of the regression analysis when negative affectivity and somatization were controlled. Consistent with theory on CSA survivors (McCann & Pearlman, 1990; Herman, 1992), as well as empirical studies on dysfunctional beliefs in CSA survivors (Owens & Chard, 2001; Wenniger & Ehlers, 1998), we found that low self-worth was significantly related to increased levels of PTSD. However, this effect became insignificant when negative affectivity and

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somatization were entered into the regression analysis. According to McCann, Sakheim, and Abrahamson (1988), negative schemas operate as self-fulfilling prophecies influencing low expectations of self and others and, subsequently, maladaptive behavior. As this study was of a correlational nature, we cannot be sure as to whether low self-worth acts as a risk factor for symptoms of PTSD or whether high levels of posttraumatic distress leads to a poor self-image. The social support at the time of the study was not significantly related to PTSD symptomatology when entered into the model with another strong predictor, namely self-worth. This is in line with previous findings indicating that social support is generally not a strong predictor of PTSD in traumaexposed adults, only the absence of support is (Brewin et al., 2000). Finally, negative affectivity and somatization proved to be the strongest predictors of PTSD, with these variables explaining 69% of the variance in symptomatology together with the prevalence of lifetime trauma. Negative affectivity was two times stronger as a predictor than the two other variables. The preoccupation with negative cognitions has also been reported as predictors of PTSD in other studies studying trauma reactions in adults (Dörfel, Rabe, & Karl, 2008; Hyland, Shevlin, Adamson, & Boduszek, 2013). However, the positive side about this finding is that it is possible to alter these cognitions into more adaptive processes through various psychotherapeutic treatments and hereby maybe prevent the development of PTSD in some individuals. There are several limitations related to the current study. The use of selfreport, and often retrospective, data may limit the validity of the measures, and the cross-sectional nature of the data denotes that great caution should be exercised when interpreting the causality of the associations between variables. Furthermore, a treatment-seeking, female-dominated sample may not be representative of CSA survivors in general. Therefore, results can only be generalized to clinical settings and should be interpreted with caution. The strengths of the study are the consecutive sample selection, the relatively large sample size, the 100% response rate, the early stage assessment, the use of validated measures, and the application of a treatment-seeking comparison group in the first part of this study. As expected, the prevalence of PTSD was higher among the CSA survivors than in the non-CSA group. Furthermore, the CSA sample reported exposure to more potentially traumatic events other than CSA, particularly events of a more interpersonal nature, such as rape and nonsexual assault. The vast majority of CSA survivors were insecurely attached, with a fearful attachment style being the most common. Hence, the preliminary findings of the present study confirm the highly stressful nature of CSA and contribute to the literature by identifying a number of central cognitive and emotional psychological variables, which help explain a considerable amount of the variation in PTSD severity.

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AUTHOR NOTES Ask Elklit, PhD, is a professor of clinical psychology and founder of the National Research Centre of Psychotraumatology at the Department of

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Psychology, University of Southern Denmark. His research interests focus broadly on the field of psychological trauma, crisis intervention, and crisis management in Denmark and internationally. Dorte M. Christiansen is a PhD student at the National Research Centre of Psychotraumatology, University of Southern Denmark. Her PhD project addresses gender differences in relation to psychological trauma, and she is the industrious author or co-author of many trauma-related articles. Sabina Palic, PhD, works as a postdoc at the National Research Centre of Psychotraumatology, University of Southern Denmark, where her research interests primarily focus on complex PTSD in relation to immigrants. She recently defended her PhD thesis addressing complex PTSD in Bosnian immigrants in Denmark in affiliation with the National Research Centre of Psychotraumatology. Sidsel Karsberg is a PhD student at the National Research Centre of Psychotraumatology, University of Southern Denmark. Her PhD project addresses dating violence among young people in Denmark, and she has done epidemiological studies of trauma in Kenya and in Greenland. Sara Bek Eriksen works as a research assistant at the National Research Centre of Psychotraumatology at the Department of Psychology, University of Southern Denmark. Her research area addresses psychological trauma in preschool children, and she is currently involved in the validation of screening tools in relation to psychological trauma in this age group.

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