Nordic Journal of Psychiatry
ISSN: 0803-9488 (Print) 1502-4725 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsc20
The relationship between childhood sexual/ physical abuse and sexual dysfunction in patients with social anxiety disorder Atilla Tekin, Ceren Meriç, Ezgi Sağbilge, Jülide Kenar, Sinan Yayla, Ömer Akil Özer & Oğuz Karamustafalioğlu To cite this article: Atilla Tekin, Ceren Meriç, Ezgi Sağbilge, Jülide Kenar, Sinan Yayla, Ömer Akil Özer & Oğuz Karamustafalioğlu (2015): The relationship between childhood sexual/ physical abuse and sexual dysfunction in patients with social anxiety disorder, Nordic Journal of Psychiatry To link to this article: http://dx.doi.org/10.3109/08039488.2015.1053097
Published online: 25 Jun 2015.
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Date: 05 November 2015, At: 13:33
The relationship between childhood sexual/ physical abuse and sexual dysfunction in patients with social anxiety disorder
Downloaded by [University of Birmingham] at 13:33 05 November 2015
ATILLA TEKIN, CEREN MERIÇ, EZGI SAĞBILGE, JÜLIDE KENAR, SINAN YAYLA, ÖMER AKIL ÖZER, OĞUZ KARAMUSTAFALIOĞLU
Tekin A, Meriç C, Sağbilge E, Kenar J, Yayla S, Özer ÖA, Karamustafalioğlu O. The relationship between childhood sexual/physical abuse and sexual dysfunction in patients with social anxiety disorder. Nord J Psychiatry 2015;Early online:1–5. Background: Childhood traumatic events are known as developmental factors for various psychiatric disorders. Objective: The aim of this study was to investigate the effects of childhood sexual and physical abuse (CSA/CPA), and co-morbid depression on sexual functions in patients with social anxiety disorder (SAD). Method: Data obtained from 113 SAD patients was analysed. Childhood traumatic experiences were evaluated using the Childhood Trauma Questionnaire, and the Arizona Sexual Experience Scale was used for the evaluation of the sexual functions. The data from interviews performed with SCID-I were used for determination of Axis I diagnosis. The Beck Anxiety Scale, Beck Depression Scale and Liebowitz Social Anxiety Scale were administered to each patient. Results: History of childhood physical abuse (CPA) was present in 45.1% of the SAD patients, and 14.2% had a history of childhood sexual abuse (CSA). Depression co-diagnosis was present in 30.1% of SAD patients and 36.3% had sexual dysfunction. History of CSA and depression co-diagnosis were determined as two strong predictors in SAD patients (odds ratio (OR) for CSA, 7.83; 95% CI, 1.97–31.11; p 0.003 and OR for depression, 3.66; 95% CI, 1.47–9.13; p 0.005). Conclusions: CSA and depression should be considered and questioned as an important factor for SAD patients who suffer from sexual dysfunction. • Childhood trauma, Depression, Sexual dysfunction, Social anxiety disorder Atilla Tekin, Cizre State Hospital, 73200, Cizre, Şırnak, Turkey, E-mail: md.atillatekin@gmail. com; Accepted 16 May 2015.
I
t has been shown that childhood traumatic experiences are related to certain psychiatric disorders. In particular, past studies show that individuals who were abused emotionally and physically in childhood experience much more psychopathology as adults than the general population (1, 2). Certain studies have also shown that the rates of physical and sexual abuse are higher among patients who are diagnosed with social anxiety disorder than in the general population (3–5). In certain studies it has been demonstrated that patients with social anxiety disorder experience sexual dysfunction more frequently. Studies investigating the relationship between anxiety disorders and sexual function have demonstrated that sexual function disorders, especially those related to sexual arousal, are more frequent (6, 7). On the other hand certain publications have reported that adulthood orgasm and sexual function disorders such as dyspareunia are related to childhood traumas (8–10).
© 2015 Informa Healthcare
Although there are studies that investigate the relationship between childhood trauma and social anxiety disorder (SAD), studies that show how traumatic experiences affect sexual functions are very rare. The main aim of this study was to investigate the effects of childhood traumatic experiences on sexual functions in patients with social anxiety disorder.
Materials and method The sampling of the study was constituted by analysis of the data of the patients who had been followed-up with the diagnosis of social anxiety disorder and who had presented to the Anxiety Disorders Outpatient Clinic of Psychiatry Department of Şişli Hamidiye Etfal Research and Training Hospital. The Anxiety Disorders Outpatient Clinic is a specialized part of the Psychiatry Department of Şişli Hamidiye Etfal Research and Training Hospital.
DOI: 10.3109/08039488.2015.1053097
A TEKIN ET AL.
Downloaded by [University of Birmingham] at 13:33 05 November 2015
Patients who were diagnosed with anxiety disorders by using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) were followed up by trained psychiatrists in this outpatient clinic. The data of 113 patients who had been followed up after their diagnosis of social anxiety disorder was analysed. Patients aged 18–60 who were at least primary school graduates were included in the study. Patients who had a history of severe internal or neurological disease, diagnosed with psychotic disorders such as bipolar disorder or schizophrenia, those who abused alcohol or other substances, or who had been codiagnosed with other anxiety disorders, were excluded from the study. The research protocol was approved by the local ethics committee.
Clinical evaluation The socio-demographic data of each patient was recorded and analysed. Their childhood traumatic experiences were evaluated using the Childhood Trauma Questionnaire, while the Arizona Sexual Experiences Scale was used for evaluation of their sexual functions. The data obtained from the SCID-I interviews was used for determination of the Axis I diagnoses.
CHILDHOOD TRAUMA QUESTIONNAIRE This questionnaire comprises nine questions about physical abuse, negligence, sexual abuse, suicide and self-harm behaviours (11). The respondents were asked whether or not they had sexual contact with a family member before the age of 18 or with a stranger 5 or more years older than themselves. Childhood physical abuse is defined as physical violence administered by someone 5 or more years older or a family member 2 or more years older than the victim before the age of 16. The respondents were asked to grade the physical abuse as “once or more than once”, “at least five times”, “several times” or “very severe and frequently”. Similarly, sexual abuse and incest were graded as “once”, “more than once”, “frequently”, or “very often” (12).
ARIZONA SEXUAL EXPERIENCES SCALE The Arizona Sexual Experiences Scale (ASEX) is a five-item self-declarative scale that evaluates sexual drive, arousal, vaginal lubrication/penile erection, orgasm and satisfaction. ASEX evaluates each sexual function on a range of Likert type 1 (no dysfunction) to 6 (complete dysfunction). The probable total score ranges from 5 to 30, and the rate of sexual function disorder increases with higher scores. It was shown that a total ASEX score of 19, an item scoring 5 or three items scoring 4, were associated with sexual function disorder (13).
2
THE STRUCTURED CLINICAL INTERVIEW FOR DSM-IV AXIS I DISORDERS The SCID-I is the clinical interview structured for DSM-IV Axis I disorders by First et al. (14). Validity and reliability studies of SCID-I for Turkey have been performed by Çorapçıoğlu (15).
Statistics The statistical analysis of the study was performed using the SPSS 16.0 software package. Definitive statistical methods (average, standard deviation) were used for the evaluation of the data. The chi-squared test was used for group differences and categorical variables, and the Mann-Whitney U-test was used for variables that did not show normal distribution. The relationship between sexual dysfunction and history of CSA, and depression codiagnosis were evaluated by using multivariate logistic regression analysis. The significance level was accepted as p 0.05 for all tests.
Findings A total of 113 SAD patients analysed who fulfilled the inclusion criteria, were included in the study; 51.3% of the patients were male and 48.7% were female. The mean age of the patients was 27.70 9.41. The sociodemographic characteristics of the patients are shown in Table 1. History of childhood physical abuse (CPA) was present in 45.1% of the SAD patients, and 14.2% had a history of childhood sexual abuse (CSA). Depression co-diagnosis was present in 30.1% of SAD patients and 36.3% had sexual dysfunction.
Table 1. Sociodemographic characteristics of SAD patients.
Gender Education status
Marital status Occupation
Depression co-diagnosis Childhood physical abuse Childhood sexual abuse Sexual dysfunction Number of patients
Variable
N
%
Male Female Primary school Secondary school High school University Married Single Working Not working Student Yes No Yes No Yes No Yes No
58 55 33 20 42 18 40 73 46 49 18 34 79 51 62 16 97 41 72 113
51.3 48.7 29.2 17.7 37.2 15.9 38.1 61.9 40.7 43.4 15.9 30.1 69.9 45.1 54.9 14.2 85.8 36.3 63.7
NORD J PSYCHIATRY·EARLY ONLINE·2015
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DISORDER
Table 2. Comparison of SAD patients who had and did not have sexual dysfunction. Sexual dysfunction () Sexual dysfunction () N 41 N 72
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Gender
Male Female Age 18–40 years 41–60 years Education status Primary school Secondary school High school University Marital status Married Single Occupation Working Not-working Student Childhood sexual abuse Yes No Childhood physical abuse Yes No Co-morbid depression Yes No
17 24 36 5 12 6 15 8 19 22 15 20 6 13 28 23 18 21 20
c²
41 31 63 9 21 14 27 10 24 48 31 29 12 3 69 28 44 13 59
p
2.506
0.113
0.002
0.962
0.866
0.834
1.875
0.171
0.772
0.680
16.302 3.124 13.659
0.001∗ 0.077 0.001
Bold characters represent statistically significant values p 0.05. *Fisher’s exact test.
History of CSA and depression co-diagnosis was significantly higher in SAD patients who had sexual dysfunction than in patients who did not have it (p 0.001 and p 0.001). Statistically, no significant difference was found between SAD patients who had, and who did not have sexual dysfunction with a history of CPA (p 0.077) (Table 2). Beck-D, ASEX-total, and ASEX-subscale scores were significantly higher in SAD patients who had sexual dysfunction than in patients who did not have it (respectively, p 0.015, p 0.001, p 0.001). However, no statistically significant difference was found between SAD patients who had and who did not have sexual dysfunction in the Beck-A, Liebowitz-Fear, and Avoidance scores (Table 3).
In our evaluation, which used multivariate logistic regression analysis, history of CSA and depression codiagnosis were determined as two important predictors for the existence of sexual dysfunction in SAD patients (OR for CSA 7.83, 95% CI 1.97–31.11, p 0.003, and OR for depression 3.66, 95% CI 1.47–9.13, p 0.005) (Table 4).
Discussion Recent studies have shown that there is a relationship between anxiety disorders and childhood traumatic experiences. One of the important findings of our study is that there is an important rate of the history of childhood physical or sexual abuse among SAD patients.
Table 3. Comparison of the scale scores of SAD patients who had and did not have sexual dysfunction.
BECK: Depression BECK: Anxiety Liebowitz: Fear Liebowitz: Avoidance ASEX: Drive ASEX: Arousal ASEX: Lubrication/penile erection ASEX: Orgasm ASEX: Orgasm satisfaction ASEX: Total
Sexual dysfunction () N 41
Sexual dysfunction () N 72
Z
p
23.98 8.64 23.87 11.04 57.09 14.95 57.36 15.26 3.54 1.31 3.49 1.12 4.03 1.04 3.88 0.95 4.34 0.82 19.27 2.38
19.25 9.35 22.85 9.18 59.17 14.29 57.26 14.64 2.53 0.80 2.56 0.69 2.74 0.86 3.01 0.75 3.28 0.68 14.09 2.12
2.432 0.317 0.744 0.161 4.343 4.482 5.787 4.556 6.066 8.056
0.015 0.751 0.457 0.872 0.001 0.001 0.001 0.001 0.001 0.001
Bold characters represent statistically significant values p 0.05. Z, Mann-Whitney U test. NORD J PSYCHIATRY·EARLY ONLINE·2015
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A TEKIN ET AL.
Table 4. Predictors of sexual dysfunction for SAD patients. OR CSA Depression
7.83 3.66
95% CI (lower–upper) 1.97–31.11 1.47–9.13
p 0.003 0.005
Downloaded by [University of Birmingham] at 13:33 05 November 2015
OR, odds ratio; 95% CI, 95% confidence interval.
In their study investigating the relationship between anxiety disorders and childhood traumas, Mancini et al. discovered that 44.9% of SAD patients had a history of physical abuse and 23.4% had a history of sexual abuse (16). In a study conducted by Simon et al. they were able to demonstrate that 70% of SAD patients had at least one type of childhood trauma (17). Simon et al. reported the rate of sexual abuse among the SAD patients as 17% and the rate of physical abuse as 30%. In another recent study Bruce et al. reported that 34.6% of SAD patients had been physically abused, 35.9% had been physically neglected and 68.4% had been sexually abused as forms of childhood trauma (18). In our study, the rate of childhood physical abuse was determined to be similar to the data in the literature. In our study, however, the rate of sexual abuse among the SAD patients was lower than that determined in other studies. The reason for this difference may be due to socio-cultural differences, such as the individuals experiencing difficulty talking about their sexually traumatic experiences. In this cultural aspect, it can be inferred that individuals tend to hide their sexual abuse experience more frequently. It has been shown that childhood traumatic experiences might cause psychiatric disorders as a result of certain neurobiological effects. Studies have shown that traumatic experiences in early life impair hypothalamic–pituitary–adrenal (HPA) axis activity and cause psychiatric disorders such as affective and anxiety disorders by damaging neuroanatomical areas such as the hippocampus and amygdala (19–21). Epidemiological studies have shown that other psychiatric disorders frequently co-exist with SAD (22, 23). Depression, as one of these psychiatric disorders, frequently accompanies SAD. Gökalp et al. have found that the rate of co-diagnosed depression in patients with SAD was 6.9% (24). In another study conducted by Mohammadi et al., the frequencies of life-time major and minor depression were determined as 15% and 2.4% in SAD patients, respectively (25). According to the data collected in our study, the rate of co-diagnosed depression in SAD patients was found to be higher than the rates reported in the literature. There are publications in the literature reporting the existence of a relationship between childhood traumatic experiences and adulthood sexual function disorders (10, 26). In a study conducted by Najman et al. it was
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determined that the loss of sexual functions was more common among individuals with a history of childhood sexual abuse (27). In another study, Harlow et al. revealed the presence of a strong relationship between adulthood vulvodynia and physical and sexual abuse during childhood (28). In a recent study, Swaby et al. reported that individuals with a history of sexual abuse often developed sexual disorders, especially disorders related to arousal and orgasm (9). According to the results of our study, history of CSA was found significantly more frequently in patients who had sexual dysfunction than in the patients who did not have it. In addition, the existence of history of CSA in SAD patients was shown to be a strong predictor of sexual dysfunction. It is known that sexual functions are affected by psychiatric disorders, especially depression and anxiety disorders (29, 30). Casper et al. reported that 72% of unipolar and 77% of bipolar depression patients usually experienced symptoms such as loss of sexual drive and decreased sexual satisfaction (31). In another publication, it was stated that around 70% of depressed patients had sexual function disorder (32). According to the results of our study, one third of SAD patients who had sexual dysfunction also had a co-diagnosis of depression. In addition, like the existence of history of CSA, the existence of a depression co-diagnosis was shown to be a strong predictor for sexual dysfunction. The primary limitation of our study is the inability to eliminate or prevent patients from taking their routine psychotropic medications, such as anti-depressants. Nearly all of the patients diagnosed with SAD were taking antidepressants, which have sexual side effects such as decreased sexual desire, erectil dysfunction and anorgasmia. Also, evaluation of sexual function with the ASEX alone is another limitation of our study. Lastly it should be mentioned that our study has a general limitation regarding the participants’ recall of their experiences.
Conclusion Childhood traumatic experiences and co-diagnosis of depression can cause sexual function disorders in SAD patients. Therefore, the co-diagnosis of depression should be investigated and childhood trauma should be questioned in SAD patients with sexual function disorders. Disclosure of interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support.
NORD J PSYCHIATRY·EARLY ONLINE·2015
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18. Bruce LC, Heimberg RG, Blanco C, Schneier FR, Liebowitz MR. Childhood maltreatment and social anxiety disorder: Implications for symptom severity and response to pharmacotherapy. Depress Anxiety 2012;29:132–9. 19. De Carvalho Tofoli SMC, Baes CW, Martins CMS, Juruena M. Early life stress, HPA axis, and depression. Psychol Neurosci 2011;4:229–34. 20. Carr CP, Martins CMS, Stingel AM, Lemgruber VB, Juruena MF. The role of early life stress in adult psychiatric disorders: A systematic review according to childhood trauma subtypes. J Nerv Ment Dis 2013;201:1007–20. 21. Von Werne Baes C, De Carvalho Tofoli SM, Martins CMS, Juruena MF.Assessment of the hypothalamic–pituitary–adrenal axis activity: Glucocorticoid receptor and mineralocorticoid receptor function in depression with early life stress – A systematic review. Acta Neuropsychiatr 2012;24 :4–15. 22. Schneier FR, Johnson J, Hornig CD, Liebowitz MR, Weissman MM. Social phobia: Comorbidity and morbidity in an epidemiological sample. Arch Gen Psychiatry1992;49:282–8. 23. Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H, ESEMeD⁄MHEDEA 2000 investigators. 12-month comorbidity patterns and associated factors in Europe: Results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand 2004;109:28–37. 24. Gökalp PG, Tükel R, Solmaz D, Demir T, Kiziltan E, Demir D, et al. Clinical features and co-morbidity of social phobics in Turkey. Eur Psychiatry 2001;16:115–21. 25. Mohammadi MR, Ghanizadeh A, Mohammadi M, Mesgarpour B. Prevalence of social phobia and its comorbidity with psychiatric disorders in Iran. Depress Anxiety 2006;23:405–11. 26. Fleming J, Mullen PE, Sibthorpe B, Bammer G. The long-term impact of childhood sexual abuse in Australian women. Child Abuse Negl 1999;23:145–59. 27. Najman JM, Dunne MP, Purdie DM, Boyle FM, Coxeter PD. Sexual abuse in childhood and sexual dysfunction in adulthood: An Australian population-based study. Arch Sex Behav 2005;34: 517–26. 28. Harlow BL, Stewart EG. Adult-onset vulvodynia in relation to childhood violence victimization. Am J Epidemiol 2005;161: 871–80. 29. Labatte LA, Lare SB. Sexual dysfunction in male psycyiatric outpatients: Validity of the Massachusetts General Hospital Sexual Functioning Questionnaire. Psychother Psychosom 2001;70: 221–5. 30. Baldwin DS. Depression and sexual dysfunction. Br Med Bull 2001;57:81–99. 31. Casper RC, Redmond E, Katz MM, Schaffer CB, Davis JM, Koslow SH. Somatic symptoms in primary affective disorders: Presence and relationship to the classification of depression. Arch Gen Psychiatry 1985;42:1098–104. 32. Gitlin MJ. Effects of depression and antidepressants on sexual functioning. Bull Menninger Clin 1995;59:232–48. Atilla Tekin, Cizre State Hospital, Şırnak, Turkey. Ceren Meriç, Şişli Hamidiye Etfal Teaching and Research Hospital, İstanbul, Turkey. Ezgi Sağbilge, Şişli Hamidiye Etfal Teaching and Research Hospital, İstanbul, Turkey. Jülide Kenar, Şişli Hamidiye Etfal Teaching and Research Hospital, İstanbul, Turkey. Sinan Yayla, Çorlu State Hospital, Tekirdağ, Turkey. Ömer Akil Özer, Şişli Hamidiye Etfal Teaching and Research Hospital, İstanbul, Turkey. Oğuz Karamustafalıoğlu, Şişli Hamidiye Etfal Teaching and Research Hospital, İstanbul, Turkey.
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ISSN: 0803-9488 (Print) 1502-4725 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsc20
The relationship between childhood sexual/ physical abuse and sexual dysfunction in patients with social anxiety disorder Atilla Tekin, Ceren Meriç, Ezgi Sağbilge, Jülide Kenar, Sinan Yayla, Ömer Akil Özer & Oğuz Karamustafalioğlu To cite this article: Atilla Tekin, Ceren Meriç, Ezgi Sağbilge, Jülide Kenar, Sinan Yayla, Ömer Akil Özer & Oğuz Karamustafalioğlu (2015): The relationship between childhood sexual/ physical abuse and sexual dysfunction in patients with social anxiety disorder, Nordic Journal of Psychiatry To link to this article: http://dx.doi.org/10.3109/08039488.2015.1053097
Published online: 25 Jun 2015.
Submit your article to this journal
Article views: 28
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipsc20 Download by: [University of Birmingham]
Date: 05 November 2015, At: 13:33
The relationship between childhood sexual/ physical abuse and sexual dysfunction in patients with social anxiety disorder
Downloaded by [University of Birmingham] at 13:33 05 November 2015
ATILLA TEKIN, CEREN MERIÇ, EZGI SAĞBILGE, JÜLIDE KENAR, SINAN YAYLA, ÖMER AKIL ÖZER, OĞUZ KARAMUSTAFALIOĞLU
Tekin A, Meriç C, Sağbilge E, Kenar J, Yayla S, Özer ÖA, Karamustafalioğlu O. The relationship between childhood sexual/physical abuse and sexual dysfunction in patients with social anxiety disorder. Nord J Psychiatry 2015;Early online:1–5. Background: Childhood traumatic events are known as developmental factors for various psychiatric disorders. Objective: The aim of this study was to investigate the effects of childhood sexual and physical abuse (CSA/CPA), and co-morbid depression on sexual functions in patients with social anxiety disorder (SAD). Method: Data obtained from 113 SAD patients was analysed. Childhood traumatic experiences were evaluated using the Childhood Trauma Questionnaire, and the Arizona Sexual Experience Scale was used for the evaluation of the sexual functions. The data from interviews performed with SCID-I were used for determination of Axis I diagnosis. The Beck Anxiety Scale, Beck Depression Scale and Liebowitz Social Anxiety Scale were administered to each patient. Results: History of childhood physical abuse (CPA) was present in 45.1% of the SAD patients, and 14.2% had a history of childhood sexual abuse (CSA). Depression co-diagnosis was present in 30.1% of SAD patients and 36.3% had sexual dysfunction. History of CSA and depression co-diagnosis were determined as two strong predictors in SAD patients (odds ratio (OR) for CSA, 7.83; 95% CI, 1.97–31.11; p 0.003 and OR for depression, 3.66; 95% CI, 1.47–9.13; p 0.005). Conclusions: CSA and depression should be considered and questioned as an important factor for SAD patients who suffer from sexual dysfunction. • Childhood trauma, Depression, Sexual dysfunction, Social anxiety disorder Atilla Tekin, Cizre State Hospital, 73200, Cizre, Şırnak, Turkey, E-mail: md.atillatekin@gmail. com; Accepted 16 May 2015.
I
t has been shown that childhood traumatic experiences are related to certain psychiatric disorders. In particular, past studies show that individuals who were abused emotionally and physically in childhood experience much more psychopathology as adults than the general population (1, 2). Certain studies have also shown that the rates of physical and sexual abuse are higher among patients who are diagnosed with social anxiety disorder than in the general population (3–5). In certain studies it has been demonstrated that patients with social anxiety disorder experience sexual dysfunction more frequently. Studies investigating the relationship between anxiety disorders and sexual function have demonstrated that sexual function disorders, especially those related to sexual arousal, are more frequent (6, 7). On the other hand certain publications have reported that adulthood orgasm and sexual function disorders such as dyspareunia are related to childhood traumas (8–10).
© 2015 Informa Healthcare
Although there are studies that investigate the relationship between childhood trauma and social anxiety disorder (SAD), studies that show how traumatic experiences affect sexual functions are very rare. The main aim of this study was to investigate the effects of childhood traumatic experiences on sexual functions in patients with social anxiety disorder.
Materials and method The sampling of the study was constituted by analysis of the data of the patients who had been followed-up with the diagnosis of social anxiety disorder and who had presented to the Anxiety Disorders Outpatient Clinic of Psychiatry Department of Şişli Hamidiye Etfal Research and Training Hospital. The Anxiety Disorders Outpatient Clinic is a specialized part of the Psychiatry Department of Şişli Hamidiye Etfal Research and Training Hospital.
DOI: 10.3109/08039488.2015.1053097
A TEKIN ET AL.
Downloaded by [University of Birmingham] at 13:33 05 November 2015
Patients who were diagnosed with anxiety disorders by using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) were followed up by trained psychiatrists in this outpatient clinic. The data of 113 patients who had been followed up after their diagnosis of social anxiety disorder was analysed. Patients aged 18–60 who were at least primary school graduates were included in the study. Patients who had a history of severe internal or neurological disease, diagnosed with psychotic disorders such as bipolar disorder or schizophrenia, those who abused alcohol or other substances, or who had been codiagnosed with other anxiety disorders, were excluded from the study. The research protocol was approved by the local ethics committee.
Clinical evaluation The socio-demographic data of each patient was recorded and analysed. Their childhood traumatic experiences were evaluated using the Childhood Trauma Questionnaire, while the Arizona Sexual Experiences Scale was used for evaluation of their sexual functions. The data obtained from the SCID-I interviews was used for determination of the Axis I diagnoses.
CHILDHOOD TRAUMA QUESTIONNAIRE This questionnaire comprises nine questions about physical abuse, negligence, sexual abuse, suicide and self-harm behaviours (11). The respondents were asked whether or not they had sexual contact with a family member before the age of 18 or with a stranger 5 or more years older than themselves. Childhood physical abuse is defined as physical violence administered by someone 5 or more years older or a family member 2 or more years older than the victim before the age of 16. The respondents were asked to grade the physical abuse as “once or more than once”, “at least five times”, “several times” or “very severe and frequently”. Similarly, sexual abuse and incest were graded as “once”, “more than once”, “frequently”, or “very often” (12).
ARIZONA SEXUAL EXPERIENCES SCALE The Arizona Sexual Experiences Scale (ASEX) is a five-item self-declarative scale that evaluates sexual drive, arousal, vaginal lubrication/penile erection, orgasm and satisfaction. ASEX evaluates each sexual function on a range of Likert type 1 (no dysfunction) to 6 (complete dysfunction). The probable total score ranges from 5 to 30, and the rate of sexual function disorder increases with higher scores. It was shown that a total ASEX score of 19, an item scoring 5 or three items scoring 4, were associated with sexual function disorder (13).
2
THE STRUCTURED CLINICAL INTERVIEW FOR DSM-IV AXIS I DISORDERS The SCID-I is the clinical interview structured for DSM-IV Axis I disorders by First et al. (14). Validity and reliability studies of SCID-I for Turkey have been performed by Çorapçıoğlu (15).
Statistics The statistical analysis of the study was performed using the SPSS 16.0 software package. Definitive statistical methods (average, standard deviation) were used for the evaluation of the data. The chi-squared test was used for group differences and categorical variables, and the Mann-Whitney U-test was used for variables that did not show normal distribution. The relationship between sexual dysfunction and history of CSA, and depression codiagnosis were evaluated by using multivariate logistic regression analysis. The significance level was accepted as p 0.05 for all tests.
Findings A total of 113 SAD patients analysed who fulfilled the inclusion criteria, were included in the study; 51.3% of the patients were male and 48.7% were female. The mean age of the patients was 27.70 9.41. The sociodemographic characteristics of the patients are shown in Table 1. History of childhood physical abuse (CPA) was present in 45.1% of the SAD patients, and 14.2% had a history of childhood sexual abuse (CSA). Depression co-diagnosis was present in 30.1% of SAD patients and 36.3% had sexual dysfunction.
Table 1. Sociodemographic characteristics of SAD patients.
Gender Education status
Marital status Occupation
Depression co-diagnosis Childhood physical abuse Childhood sexual abuse Sexual dysfunction Number of patients
Variable
N
%
Male Female Primary school Secondary school High school University Married Single Working Not working Student Yes No Yes No Yes No Yes No
58 55 33 20 42 18 40 73 46 49 18 34 79 51 62 16 97 41 72 113
51.3 48.7 29.2 17.7 37.2 15.9 38.1 61.9 40.7 43.4 15.9 30.1 69.9 45.1 54.9 14.2 85.8 36.3 63.7
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Table 2. Comparison of SAD patients who had and did not have sexual dysfunction. Sexual dysfunction () Sexual dysfunction () N 41 N 72
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Gender
Male Female Age 18–40 years 41–60 years Education status Primary school Secondary school High school University Marital status Married Single Occupation Working Not-working Student Childhood sexual abuse Yes No Childhood physical abuse Yes No Co-morbid depression Yes No
17 24 36 5 12 6 15 8 19 22 15 20 6 13 28 23 18 21 20
c²
41 31 63 9 21 14 27 10 24 48 31 29 12 3 69 28 44 13 59
p
2.506
0.113
0.002
0.962
0.866
0.834
1.875
0.171
0.772
0.680
16.302 3.124 13.659
0.001∗ 0.077 0.001
Bold characters represent statistically significant values p 0.05. *Fisher’s exact test.
History of CSA and depression co-diagnosis was significantly higher in SAD patients who had sexual dysfunction than in patients who did not have it (p 0.001 and p 0.001). Statistically, no significant difference was found between SAD patients who had, and who did not have sexual dysfunction with a history of CPA (p 0.077) (Table 2). Beck-D, ASEX-total, and ASEX-subscale scores were significantly higher in SAD patients who had sexual dysfunction than in patients who did not have it (respectively, p 0.015, p 0.001, p 0.001). However, no statistically significant difference was found between SAD patients who had and who did not have sexual dysfunction in the Beck-A, Liebowitz-Fear, and Avoidance scores (Table 3).
In our evaluation, which used multivariate logistic regression analysis, history of CSA and depression codiagnosis were determined as two important predictors for the existence of sexual dysfunction in SAD patients (OR for CSA 7.83, 95% CI 1.97–31.11, p 0.003, and OR for depression 3.66, 95% CI 1.47–9.13, p 0.005) (Table 4).
Discussion Recent studies have shown that there is a relationship between anxiety disorders and childhood traumatic experiences. One of the important findings of our study is that there is an important rate of the history of childhood physical or sexual abuse among SAD patients.
Table 3. Comparison of the scale scores of SAD patients who had and did not have sexual dysfunction.
BECK: Depression BECK: Anxiety Liebowitz: Fear Liebowitz: Avoidance ASEX: Drive ASEX: Arousal ASEX: Lubrication/penile erection ASEX: Orgasm ASEX: Orgasm satisfaction ASEX: Total
Sexual dysfunction () N 41
Sexual dysfunction () N 72
Z
p
23.98 8.64 23.87 11.04 57.09 14.95 57.36 15.26 3.54 1.31 3.49 1.12 4.03 1.04 3.88 0.95 4.34 0.82 19.27 2.38
19.25 9.35 22.85 9.18 59.17 14.29 57.26 14.64 2.53 0.80 2.56 0.69 2.74 0.86 3.01 0.75 3.28 0.68 14.09 2.12
2.432 0.317 0.744 0.161 4.343 4.482 5.787 4.556 6.066 8.056
0.015 0.751 0.457 0.872 0.001 0.001 0.001 0.001 0.001 0.001
Bold characters represent statistically significant values p 0.05. Z, Mann-Whitney U test. NORD J PSYCHIATRY·EARLY ONLINE·2015
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Table 4. Predictors of sexual dysfunction for SAD patients. OR CSA Depression
7.83 3.66
95% CI (lower–upper) 1.97–31.11 1.47–9.13
p 0.003 0.005
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OR, odds ratio; 95% CI, 95% confidence interval.
In their study investigating the relationship between anxiety disorders and childhood traumas, Mancini et al. discovered that 44.9% of SAD patients had a history of physical abuse and 23.4% had a history of sexual abuse (16). In a study conducted by Simon et al. they were able to demonstrate that 70% of SAD patients had at least one type of childhood trauma (17). Simon et al. reported the rate of sexual abuse among the SAD patients as 17% and the rate of physical abuse as 30%. In another recent study Bruce et al. reported that 34.6% of SAD patients had been physically abused, 35.9% had been physically neglected and 68.4% had been sexually abused as forms of childhood trauma (18). In our study, the rate of childhood physical abuse was determined to be similar to the data in the literature. In our study, however, the rate of sexual abuse among the SAD patients was lower than that determined in other studies. The reason for this difference may be due to socio-cultural differences, such as the individuals experiencing difficulty talking about their sexually traumatic experiences. In this cultural aspect, it can be inferred that individuals tend to hide their sexual abuse experience more frequently. It has been shown that childhood traumatic experiences might cause psychiatric disorders as a result of certain neurobiological effects. Studies have shown that traumatic experiences in early life impair hypothalamic–pituitary–adrenal (HPA) axis activity and cause psychiatric disorders such as affective and anxiety disorders by damaging neuroanatomical areas such as the hippocampus and amygdala (19–21). Epidemiological studies have shown that other psychiatric disorders frequently co-exist with SAD (22, 23). Depression, as one of these psychiatric disorders, frequently accompanies SAD. Gökalp et al. have found that the rate of co-diagnosed depression in patients with SAD was 6.9% (24). In another study conducted by Mohammadi et al., the frequencies of life-time major and minor depression were determined as 15% and 2.4% in SAD patients, respectively (25). According to the data collected in our study, the rate of co-diagnosed depression in SAD patients was found to be higher than the rates reported in the literature. There are publications in the literature reporting the existence of a relationship between childhood traumatic experiences and adulthood sexual function disorders (10, 26). In a study conducted by Najman et al. it was
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determined that the loss of sexual functions was more common among individuals with a history of childhood sexual abuse (27). In another study, Harlow et al. revealed the presence of a strong relationship between adulthood vulvodynia and physical and sexual abuse during childhood (28). In a recent study, Swaby et al. reported that individuals with a history of sexual abuse often developed sexual disorders, especially disorders related to arousal and orgasm (9). According to the results of our study, history of CSA was found significantly more frequently in patients who had sexual dysfunction than in the patients who did not have it. In addition, the existence of history of CSA in SAD patients was shown to be a strong predictor of sexual dysfunction. It is known that sexual functions are affected by psychiatric disorders, especially depression and anxiety disorders (29, 30). Casper et al. reported that 72% of unipolar and 77% of bipolar depression patients usually experienced symptoms such as loss of sexual drive and decreased sexual satisfaction (31). In another publication, it was stated that around 70% of depressed patients had sexual function disorder (32). According to the results of our study, one third of SAD patients who had sexual dysfunction also had a co-diagnosis of depression. In addition, like the existence of history of CSA, the existence of a depression co-diagnosis was shown to be a strong predictor for sexual dysfunction. The primary limitation of our study is the inability to eliminate or prevent patients from taking their routine psychotropic medications, such as anti-depressants. Nearly all of the patients diagnosed with SAD were taking antidepressants, which have sexual side effects such as decreased sexual desire, erectil dysfunction and anorgasmia. Also, evaluation of sexual function with the ASEX alone is another limitation of our study. Lastly it should be mentioned that our study has a general limitation regarding the participants’ recall of their experiences.
Conclusion Childhood traumatic experiences and co-diagnosis of depression can cause sexual function disorders in SAD patients. Therefore, the co-diagnosis of depression should be investigated and childhood trauma should be questioned in SAD patients with sexual function disorders. Disclosure of interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support.
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