Psychiatric With
Morbidity
Childhood
Histories
George
Objective:
patients
R. Brown,
To extend over
1,040
tertiary-care military III-R diagnosis, and childhood
abuse
f emale
II diagnoses, tims
than
also
borderline patients.
physical
frequent histories associated
especially,
for
sexual
sexual
than
ofchildhood
abuse
The
947
abuse
determination
abuse
patients
admitted
were
in adult to a
and abuse history, DSMThe prevalence of reported
(with
or without
physical
and 3 % for combined
disorder,
abuse
and than
nonabused
were
These diagnosis
of patients’
more
alcohol
abuse),
abuse.
in nonabused
inpatients
frequent
abuse
were
more
patients.
and
of combined abuse. Combined abuse with a family history of psychiatric Conclusions: aggressive
in psychiatric
and physical
interviewed, Results:
abuse),
ofdrug
or combined
M.D.
Abuse
More
Alcohol use disorders were more common in sexually abused or nonabused patients.
personality Histories
in abused
holism in male relatives. tion to family dynamics, and,
9%
or without
Anderson,
sexual
Method:
patients reported abuse. or combined abuse than
reporting with were
effects
childhood
admissions.
and Physical
Bradley
on long-term
explored
overall:
(with
particularly
more
patients in men
18%
abuse
in nonabused
patients
and
medical center. Each patient was other characteristics were recorded.
than male ofphysical
victims
consecutive
was
I 0% for physical
M.D.,
the authors
Inpatients
of Sexual
the knowledge
to a large sample,
inpatients
in Adult
was
in abuse
vic-
common
in
Suicidality
noted
in
was
79%
of
in women and physical illness, most commonly
findings emphasize the need and treatment ofalcoholism abuse
in Axis
histories,
for greater attenwithin the family,
if repeated
even
the
abuse alco-
questioning
is
necessary.
J
(Am
M
ental
health
aware abuse
Psychiatry
professionals
in the
histories
abuse
media
and
tic violence.
settings largely
However,
requesting
rape, in the
and
physical treatment
awareness literature
is on
on increased
battering, last
more
and
(1-3). This descriptive sequelae
to incest,
becoming
of sexual
of patients
its potential
attention
148:55-61)
are
of the possibility
in a variety of clinical based on a burgeoning, child
1991;
decade,
views necessarily
ment
in this paper are those of the those of the U.S. Air Force
reported
histories
these
studies,
most
few
studies
inpatients
authors and do or the Depart-
The
authors
for data
diagnostic
Center
thank
Sandra
management; interviews;
for literature
support;
Dinwoodie,
Steve
the library
Sharon
Paolucci, staff
of Wilford
and Cliff Butzin,
analyses.
AmJPsychiatry
148:1,January
M.D.,
1991
Ph.D.,
Foss,
and
Jan
for assisting Hall
Medical
for statistical
reported or physical
that
they had abuse before
been ad-
mission. Carmen et al. (5, 6) investigated the abuse experiences of 188 psychiatric inpatients using retrospective chart review techniques, and they found that 43%
of Defense.
Hooper with
expressed represent
sexual
domes-
Received Jan. 23, 1990; revision received July 16, 1990; accepted Aug. 2, 1990. From the Department of Psychiatry, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Tex. Address reprint requests to Dr. Brown, 1 1 163 Mesquite Flat, Helotes, TX 78023.
The
57%
inpatients, of either
and
have examined the childhood abuse histories of general adult psychiatric inpatients. Jacobson and Richardson (4) conducted one of the few studies with a contemporaneous interview design. Of their 100 psy-
not
chiatric victims
male
have
patients
of abuse.
With
the
of
adult
examinations
focused only
on the
(7-10),
childhood
a limitation
of
exception psychiatric
abuse that
of fe-
is unfor-
tunate given the growing recognition that males are sexually abused far more frequently than was once believed (11). Several studies have examined specialized psychiatnc inpatient samples, e.g., male alcoholic patients in a Veterans Administration hospital (12, 13) and opiate addicts in the inner city (14). Studies of the long-term effects of childhood sexual abuse on adult outpatients have
been
In spite
reviewed
(1, 15). of descriptive
elsewhere
of the plethora
papers
regard-
ing the putative long-term effects of childhood sexual and physical abuse on adult psychological functioning, the study of such sequelae is in its infancy. Few studies
have
involved
valid
comparison
large
samples,
groups,
and
making
many their
did results
not
use
impos-
55
CHILDHOOD
ABUSE
sible to interpret. To compared DSM-III-R sample of abused and atric inpatients.
Methodological cians
our knowledge, no studies have psychiatric diagnoses in a large nonabused general adult psychi-
problems
recognize
that
notwithstanding,
abused
individuals
clini-
seeking
treat-
ment may display characteristic symptoms that need to be addressed in any successful psychotherapeutic intervention.
For
example,
many
exhibit
chronic
self-
destructive behavior, poor self-esteem, anxiety, feelings of isolation, sexual maladjustment, and interpersonal dysfunction (15, 16). Other investigators (4, 5, 8) have called for routine inquiry into patients’ histonies of physical and sexual abuse to address how wide-
spread
these
gaps
clinical
in empirical
Our report
findings
are
to fill the
large
study answers the call for routine inquiry. We on what we believe to be the largest group of
consecutively
admitted,
be
interviewed
routinely
adult
psychiatric
for
childhood
self-reported
histories
corresponding same treatment
agnoses
and
studies addressed
larger
of abuse
were
data for nonabused unit. Associations
previous 18). We
a history
patient
inpatients
to
histories
of
admissions). DSMand alcohol use patdata, length of stay, of adult inpatients
physical and sexual abuse (1,019 III-R psychiatric diagnoses, drug terns, suicidality, family history and demographic characteristics
with
and
knowledge.
compared
to
from specific
the di-
suggested
in
inpatients between
of abuse
have
been
of small groups of inpatients these associations but used
(3, 17, a much
stay
in
patients
Wilford Hall Medical Center is the U.S. Air Force’s largest tertiary-care medical center. Active-duty and military services
Patients
identical queried
30-bed during
members and their
from all dependents
consecutively
admitted
branches of are entitled
to one
psychiatric wards were one or more interviews
the to
of two
each routinely regarding his-
tory of physical and sexual abuse, and these data were entered into a prospectively maintained data base along with demographic variables, admission and dis-
charge diagnoses, past medications, treatment
and family outcome,
psychiatric histories, and disposition (19).
This study used no retrospective chart review logged 1,040 consecutive admissions between 1987,
and
and
Oct.
were
1, 1989;
excluded
21 records
from
(2%)
analyses,
were
yielding
data. We Sept. 1, incom-
1,019
records on 947 different patients. A low rate of readmission is characteristic of this medical center: 63 patients were admitted twice during this 25-month pe-
nod, eight patients were admitted patient was admitted four times.
56
was
13
days,
and
no
patient
stayed
to
admissions
66%
(1,019).
of the admitted
patients
were
active duty at the time of 34% were civilians (N346); mitted during basic military
evaluation (N=673), 18% (N188) were training at Lackland
Force
Base.
latter
highly
specific
ting, duplicate of the armed
Over
Because
the
subpopulation,
group
even
represents
in the
a
military
analyses were performed. services were represented.
half of the subjects
on and adAir
All
set-
branches
were men (59%, N=601). white (N=734), 14% were Hispanic (N=85), and 6%
Seventy-two black (N=
percent were 141), 8% were were Asian (N=59). The was 30 years (median=25
average
age
years,
of the
sample
rangel7-90)
proportions of married and single (45%, N459); 7% were divorced were widowed (N31).
patients
The
were and
(N71),
equal 3%
The majority of the patients were employed, attending college, and/or receiving retirement benefits. A minority were considered to have low socioeconomic standing, and less than 1% were classified as homeless and mentally ill. Procedure
Hall
was evaluated psychiatrists
Center
Medical
by at least on the faculty
psychiatry
one of two of the Wil-
residency
training
program. The interrater diagnostic differences for primary axis I diagnoses were found to be negligible (less than 5%) for 40 paired, blind assessments of the same inpatients. Each patient was also interviewed by one or
Sample
plete
refer
In our sample,
Each patient Board-certified
sample.
METHOD
care.
unit
than
95 days. Because patients frequently responded differently to abuse questions at different admissions, multiple admissions were treated as separate patients; unless otherwise specified, all numbers and percentages involving
ford
retired armed
this
longer
three times, and one The mean length of
more
psychiatric
residents.
interviewers at any used for analysis.
The definition as
follows
: any
time
of sexual
All information during
the
abuse
self-reported
used
sexual
revealed
hospital
to
stay
was
in this study
was
contact-ranging
from fondling to sexual intercourse-experienced by a patient on or before age 18 and initiated by someone S or more years senior or by a family member at least 2 years senior. This definition includes exploitative sexual contact with minor children between 16 and 18 years of age and incestuous contact between siblings of different developmental ages (16, 20). Furthermore, it encompasses the U.S. National Center on Child Abuse and Neglect’s definition of child sexual abuse (any act perpetrated on a child by a significantly older person with the intent to stimulate the child sexually and to satisfy the aggressor’s sexual impulses) (21). Physical abuse was defined as any self-reported assault on or before age 18 that was perpetrated by an assailant S or more years senior or an assault by a family member at least 2 years senior that was not interpreted by the patient as an intrafamilial fight, e.g.,
Am
J
Psychiatry
148:1,
January
1991
GEORGE
sibling rivalry. was verbal or physical contact. mitted by the case. Histories of by
means
of
Fights between peers were excluded, as psychological abuse in the absence of A suspected history of abuse not adpatient was not recorded as an abuse and
sensitive,
category
physical
broad
abuse
questions,
(physical,
sexual,
or
times
such
as,”Be-
This relationship had been sexually
with
Of the 947 patients interviewed, 166 (18%) reported histories of abuse. Sexual abuse (with or without physical abuse) was reported by 86 patients (9%), physical abuse (with or without sexual abuse) was reported by 94 patients (10%), and combined abuse was reported by 28 patients (3%). Physical abuse alone was reported by 70 patients (7%), 41 (59%) of whom were male. Sexual abuse alone was reported by 68 patients (7%), 20 (29%) of whom were male. More women than men reported sexual abuse (71 versus 25; 248.8, dfl, p