Journal of Psychosomatic Research 77 (2014) 97–103
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Journal of Psychosomatic Research
The impact of childhood trauma on depression: Does resilience matter? Population-based results from the Study of Health in Pomerania Andrea Schulz a,⁎,1, Mathias Becker b,1, Sandra Van der Auwera a, Sven Barnow c, Katja Appel a, Jessie Mahler d, Carsten Oliver Schmidt e, Ulrich John f, Harald J. Freyberger b, Hans J. Grabe a a
Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany Department of Psychiatry, University Medicine Greifswald, HELIOS-Hanseklinikum Stralsund, Stralsund, Germany Department of Clinical Psychology and Psychotherapy, University of Heidelberg, Heidelberg, Germany d Institute for Medical Psychology, University Medicine Greifswald, Greifswald, Germany e Institute for Community Medicine, University of Greifswald, Greifswald, Germany f Institute of Social Medicine and Prevention, University Medicine Greifswald, Greifswald, Germany b c
a r t i c l e
i n f o
Article history: Received 31 December 2013 Received in revised form 12 June 2014 Accepted 16 June 2014 Keywords: Child abuse Childhood maltreatment Childhood Trauma Questionnaire Depression Resilience
a b s t r a c t Objective: Data suggests that traumatic experiences at early age contribute to the onset of major depressive disorder (MDD) in later life. This study aims at investigating the influence of dispositional resilience on this relationship. Methods: Two thousand and forty-six subjects aged 29–89 (SD = 13.9) from a community based sample who were free of MDD during the last 12 months prior to data collection were diagnosed for Lifetime diagnosis of MDD by the Munich-Composite International Diagnostic Interview (M-CIDI) according to DSM-IV criteria. Childhood maltreatment (CM) and resilience were assessed with the Childhood Trauma Questionnaire (CTQ) and the Resilience-Scale (RS-25). Results: Both CM (OR = 1.03, 95% CI [1.02, 1.04], P b .000) and resilience (OR = 0.98, 95% CI [0.98, 0.99], P b .000) were associated with MDD later in life. The detrimental effects of low resilience on MDD were not only especially prominent in subjects with a history of CM (OR = 3.18, 95% CI [1.84, 5.50], P b .000), but also effective in subjects without CM (OR = 2.62, 95% CI [1.41, 4.88], P = .002). Conclusions: The findings support the clinical assumption that resilient subjects may be partly protected against the detrimental long-term effects of child abuse and neglect. © 2014 Elsevier Inc. All rights reserved.
Introduction Depressive disorders are a major mental health problem and widely recognized as most prevalent cause of morbidity, disability and impaired quality of life [1]. In particular intense early stress and traumatic experiences like childhood maltreatment (CM) were consistently associated with adult psychopathology, especially with major depression (MDD) [2–5]. In this regard CM not only increases the risk of life-time MDD [6–11], but it also aggravates its course [12,13] in terms of a ⁎ Corresponding author at: Department of Psychiatry and Psychotherapy, University Medicine of Greifswald, Ellernholzstraße 1-2, D-17475 Greifswald, Germany. Tel.: +49 3834 86 22 166; fax: +49 3834 86 6889. E-mail addresses: [email protected] (A. Schulz), [email protected] (M. Becker), [email protected] (S. Van der Auwera), [email protected] (S. Barnow), [email protected] (K. Appel), [email protected] (J. Mahler), [email protected] (C.O. Schmidt), [email protected] (U. John), [email protected] (H.J. Freyberger), [email protected] (H.J. Grabe). 1 Contributed equally.
http://dx.doi.org/10.1016/j.jpsychores.2014.06.008 0022-3999/© 2014 Elsevier Inc. All rights reserved.
dose–response relationship as numerous studies have indicated [9,10, 14–16]. Maerker et al. [17] found a higher probability of developing MDD compared to Posttraumatic Stress Disorder if a trauma occurred in early developmental stages rather than in adolescence which they explained by premature neurobiological mechanisms of memory and emotion regulation. This is in line with studies that linked intense early stress to greater sensitivity of the hypothalamic-pituitaryadrenal axis in adulthood, which in turn was associated with greater vulnerability to MD [8]. Besides the impact of early trauma on neurobiology and neurochemistry, psychological and cognitive dimensions are also affected by early traumatization. According to the attachment theory by Bowlby [18], a secure attachment to primary caregivers promotes successful emotional development and is a protective factor against psychopathology [19]. For this reason traumatic and violent experiences, especially caused by caregivers, are highly detrimental to a child's system of beliefs, expectations, emotions, and behaviors about the self and others [20] and may result in the development of learned helplessness an external locus of control [7],
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inappropriate coping styles [21] and therefore in higher vulnerability to stress and stress disorders. Resilience as a protective factor Although a great deal of research investigating the immediate and delayed pathogenic effects of CM has been conducted, only a small body of literature has focused on adaptive outcomes in the aftermath of CM [22–24]. Yet it seems that besides trauma-related factors like frequency and intrusiveness, individual biological and psychological factors modify the risk for long-term consequences of CM [5]. As research has consistently shown a considerable number of CM victims show little or no psychological long-term damage [22,25]. Over the years the vague term “resilience” was established to describe this phenomenon. As there is no definition of “resilience” generally agreed on, one can assign the attempted definitions to (at least) two main streams (cf. [26]). First: the end of a complex adaptation process to adversity (cf. [27]) and second: the dispositional ability to access and use resources in the face of traumatic events [28,29]. An integrated conceptualization of the term “resilience” was provided by Wagnild et al. [29,30]. They defined resilience as a “dynamic personality trait that comprises the individual's ability to react resiliently in the aftermath of adversity”. Hereby they acknowledged the existence of certain inherent resources which are however fluid and alterable rather than determined and inflexible. To our knowledge, there is only one other cross-sectional study that assessed the moderating effects of dispositional resilience on depressive symptoms following childhood trauma. Wingo et al. [22] found an effect of resilience on depression severity after CM, but no interaction between CM and resilience in depression in a predominantly African American sample. In our study, we first aimed to determine relations between childhood maltreatment, resilience, and depression in later life in a representative population based sample using a standardized and broadly validated self-report instrument for childhood maltreatment and a diagnostic interview for major depressive disorder according to DSM-IV. Secondly, we analyzed the putative moderating effect of resilience on the association of childhood maltreatment and depression. We assumed that a considerable number of study participants with a history of childhood maltreatment adapted well and developed resilience that counteracted the risk of depression in later life. Methods
Table 1 Sociodemographic and clinical characteristics of SHIP-LEGEND participants.
Total sample School educationa
Marital statusa
Childhood trauma positiveb Childhood trauma subtypes Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect
b10 years =10 years N10 years Married/living with partner Single/living separated/ divorced/widowed
None Positiveb None Positiveb None Positiveb None Positiveb None Positiveb
Major depressive disorderc
Age Resilienced e
Quartile I Quartile II Quartile III Quartile IV a b c d e
n
%
2046 611 1014 416 1661 380
100 29.9 49.7 20.4 81.4 18.6
1167
57.0
1807 226 1860 178 1896 138 1266 760 1255 778 262
88.9 11.0 91.3 8.7 93.2 6.7 62.5 37.1 61.7 38.0 12.8
Median
Range
56.0 148 127 143 153 166
29–89 25–175 25–140 130–154 144–166 155–175
School education, marital status: 0.6% missing. Categorical, combined CTQ severity categories: mild/moderate/severe (=positive). Diagnosis lifetime by M-CIDI. Resilience-Scale 25 (RS-25) by Wagnild & Young [29]. Age (10 year increments) and sex specific quartiles of the RS score.
the beginning of the interview [35]. The criterion for exclusion based on the VLMT was less than four recalled words at the first trial. We further excluded 131 subjects with a diagnosis of MDD in the previous 12 months to the LEGEND interview to reduce any cognitive bias in the response of the questionnaires that can be ascribed to current major depressive symptoms. Furthermore, subjects with missing data for lifetime diagnosis of MDD (n = 5) or CM (n = 84) were excluded (overlap exists), resulting in a final study population of 2046 participants. All participants had given written informed consent. SHIP and LEGEND were approved by the local Institutional Review Board and conformed to the principles of the Declaration of Helsinki. A sample description is provided in Table 1.
Sample and sample recruitment Instruments Data from the Study of Health in Pomerania (SHIP) were used [31]. SHIP is a population-based cohort study conducted in West Pomerania [32–34] which comprises a net sample of 6267 eligible adults, out of which 4308 Caucasian subjects participated in the baseline of SHIP (SHIP-0) 1997–2001. Between 2007 and 2010, the “Life-Events and Gene-Environment Interaction in Depression” (LEGEND) study comprised a profound psychometric assessment of the SHIP-0 participants. Until then, 639 participations from SHIP-0 were either deceased (n = 383) or refused further participation on SHIP (n = 256). In total, 3669 subjects of the baseline sample were invited to LEGEND, 92 of these deceased during study conduction and 1011 refused participation in LEGEND. 132 subjects did not respond to repeated efforts of contact (at least three written invitations, 10 telephone calls and five home visits). Thirty-four subjects agreed to participate, but did not show up on several arranged dates or were not able to arrange an appointment. Among the 2400 subjects who participated in LEGEND, 134 were excluded from the analyses because of unreliable information or inconsistencies in the interview according to a judgment of the interviewer or supervisor that included the performance on a verbal memory test (VLMT) at
Childhood maltreatment Recognizing a lack of a comprehensive standard definition of childhood maltreatment, the WHO Consultation on Child Abuse Prevention drafted a comprehensive definition in 1999: “Child abuse or maltreatment constitutes all forms of physical and/ or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power.” We applied the German version of the 28-item Childhood Trauma Questionnaire (CTQ) whose items reflect common definitions of child abuse and neglect as found in the childhood trauma literature [36]. “Emotional abuse (EA) refers to verbal assaults on a child's sense of worth or well-being, or any humiliating, demeaning, or threatening behavior directed toward a child by an older person. Physical abuse (PA) refers to bodily assaults on a child by an older person that pose the
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risk of, or result in, injury. Sexual abuse (SA) refers to sexual contact or conduct between a child and older person; explicit coercion is a frequent but not essential feature of that experiences. Emotional neglect (EN) refers to the failure of caretakers to provide a child's basic psychological and emotional needs, such as love, encouragement, belonging, and support. Physical neglect (PN) refers to the failure of caregivers to provide a child's basic physical needs, including food, shelter, safety and supervision, and health.” [36]. Each item is scored on a five-point Likert scale from “never true” (=1) to “very often true” (=5). Dependent on the scale sum score, participants can be grouped into the severity categories “none”, “mild”, “moderate”, and “severe”. In accordance with the American CTQ-manual [36], we classified subjects having experienced at least mild forms of maltreatment as being traumatized (scale sum score ≥ 9 for emotional abuse, ≥ 8 for physical abuse, ≥ 6 for sexual abuse, ≥10 for emotional neglect, ≥8 for physical neglect). To the best of our knowledge, there are no German cut-offs available so far. All studies that handle with these CTQ severity categories, including translation and validation studies [37,38], used the defined cut-offs for severity categories from the original study [39]. Depression The diagnosis of lifetime MDD according to DSM-IV criteria was determined using the standardized and computerized Munich-Composite International Diagnostic Interview (M-CIDI). Test–retest reliability analysis of the diagnosis of MDD revealed kappas between .62 and .77 [40]. The interview was used by clinically experienced interviewers (psychologists) in a face-to-face situation. Multiple studies regarding clinical validity and reliability of the M-CIDI yielded excellent results for the inter-rater reliability and confirmed a high clinical validity [41,42]. The diagnosis of lifetime MDD was used as dichotomous outcome measure in all analyses. Resilience To assess resilience, we used the German translation (RS-25) [43] of the resilience scale [30]. Participants have to rate 25 statements about their personal view on a 7-point Likert-Scale. While the original US-American version of the RS-25 is comprised of two scales, Schumacher et al. [43] postulated a one-dimensional factor structure for the German translation. The RS-25 yielded good results for reliability (Cronbach's alpha = 0.94) and confirmed significant construct validity [43]. The questionnaire was developed from a qualitative study among successfully adjusted elderly woman, using the transactional model of stress [44] as an organizing framework. Although the instrument had been used for almost two decades, an elaborate theoretical framework was devised only recently [30]. Briefly, every person has the potential to react resiliently in the aftermath of adversity. The degree of adaptation is dependent on the so called Resilience Core. It is composed of the five components: [1] a purposeful life, [2] perseverance, [3] equanimity, [4] self-reliance and [5] the awareness of being on your own in a lot of situations in life (Existential aloneness). According to Wagnild's theory, researchers are able to assess the strength of the Resilience Core by applying the RS-25. Overall scores range from 25 to 175 with higher scores implying a higher degree of resilience. Wagnild [30] provided cut-off values for assessing the actual degree of resilience. Six ranks from a very low to a very high degree of resilience have been proposed. As there are no such standard values for the German translation of the scale [43], we divided our subjects into 4 groups by sex- and age specific quartiles of the resilience score. Statistical analyses Given our special interest in the potential influence of resilience on the development of MDD in later life depending on childhood maltreatment, we first examined resilience (sum score and quartiles) as a predictor on MDD lifetime in a binary logistic regression analysis stratified by history of CM. We furthermore used binary logistic regression
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models with lifetime MDD as outcome to assess the main effects of both predictors (CM and resilience as continuous variable) and their putative interaction on depression. We examined the potential influence of CM in general and specifically of all subtypes of CM (CTQ subscale scores on EA, PA, SA, EN and PN). For all models we derived odds ratios (ORs) with 95% confidence intervals (95% CI) adjusted for gender and age. Males were the reference group in all regression analyses. To receive a more detailed view on the relationship between CM and different gradations of resilience and the putative effect modification on the association of CM and MDD, we categorized and dummy-coded our continuous variables age (10-year increments), resilience (quartiles), and CM (0 = no CM, 1 = at least one mild form of CM) and rerun the described regression models. Additionally, we repeated our analysis with dichotomous, dummycoded predictors: resilience (median split; 0 = low degree of resilience, b148 points; 1 = high degree of resilience, ≥148 points) and CM (0 = no CM, 1 = at least one mild form of CM). To quantify the magnitude of an additive interaction effect, the relative excess risk due to interaction (RERI) [59–61] was calculated (descriptions and results presented in supplement). To avoid a direct (state-) impact of current depressive symptoms on the rating of the RS-25, we excluded subjects meeting the criteria of MDD during the last 12 months. Results Main characteristics of the study population (n = 2046) are given in Table 1. Excluding subjects with a diagnosis of MDD within the last 12 months, 12.8% of remaining participants suffered at least from one episode of MDD. The RS-25 score had a median of 148 (range 25–175). More than half of the study sample (57.0%) reported at least one form of childhood traumatization on a mild, moderate or severe level. Emotional and physical neglect were more prevalent than incidences of abuse. Effects of resilience and MDD depending on history of CM Subjects with and without a history of CM differed significantly in their degree of resilience considered as a continuous variable. Divided in quartiles by resilience, we found that even subjects with CM expressed high levels of resilience although the proportions were lower than in subjects without CM (e.g. 20.4% vs. 29.5% in quartile IV). The association between resilience and MDD was significant. Considered in quartiles, subjects with low resilience scores (quartile I and II) had a significantly higher chance for MDD in respect of subjects with higher levels of resilience (quartile IV) (Table 2). Effects of RES and CM on MDD Resilience and all forms of childhood maltreatment showed significant associations with MDD lifetime. Whereas CM and all subtypes of abuse and neglect were positively associated with MDD lifetime, resilience was negatively associated, i.e. higher degrees of resilience were associated with lower rates of MDD lifetime. However the analysis on continuous variables revealed no significant interaction between CM or its subtypes and resilience on MDD lifetime (results not shown) (Table 3). For a more detailed view on the relationship between CM and lifetime MDD by gradations of resilience, we plotted the proportion for the presence and absence of MDD according to quartiles of resilience. In line with theory, the proportion of cases of MDD decreases as resilience increases (irrespective of CM): 17.5% in resilience quartile I, 12.6% in quartile II, 11.8% in quartile III and 8.5% in quartile IV. Considering the factor CM on this relationship, the proportion of MDD cases between subjects with and without CM did not differ in resilience quartiles I (OR 1.05, 95% CI [0.71, 1.57], P = .90) and IV (OR 1.32, 95% CI [0.74, 2.36], P = .42). Though, in resilience quartiles II and III, the proportion of MDD cases was higher in subjects with a history of CM (quartile II: OR 2.42, 95% CI [1.41, 4.18], p = 0.001; quartile III (OR 1.68, 95% CI [0.87, 2.33], p = 0.168). Based on these descriptive analyses, we analyzed the putative effect modification by resilience on the association of CM and MDD and consider the characteristic categories discretely on their own (Fig. 1). Effect modification between CM and MDD by resilience Table 4 depicts the association to MDD as a function of the presence or absence of risk factor (CM) and different degrees of resilience (quartiles). Within the subjects without CM only low degrees of resilience (quartile I) were significantly associated with greater chance of MDD. Within the subjects with a history of CM, only high resilient subjects (quartile IV) showed no association toward MDD in later life. In contrast, in quartiles I–III, higher resilience was associated with lower rates of lifetime MDD in subjects with CM.
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Table 2 Characteristics of resilience and its association to lifetime major depressive disorder between groups with and without a history of childhood maltreatment (n = 2046). Childhood maltreatmenta n = 1167
Resilience (continuous) Resilienced
Quartile I Quartile II Quartile III Quartile IV
No childhood maltreatmentb n = 879
M (SD)
n (%)
M (SD)
n (%)
144.8 (18.2) 123.9 (14.3) 143.4 (4.6) 154.3 (4.9) 167.1 (5.3)
355 (30.4) 312 (26.7) 262 (22.5) 238 (20.4)
148.8 (16.4) 124.5 (13.3) 142.3 (4.3) 153.7 (4.8) 165.6 (5.4)
172 (19.6) 210 (23.9) 238 (27.1) 259 (29.5)
Pc b.001⁎⁎⁎
Binary logistic regression for MDD lifetime adjusted for age and sex OR Resilience (continuous) Resilienced
Quartile I Quartile II Quartile III
0.99⁎⁎ 1.98⁎ 1.90⁎ 1.47
95% CI
OR
95% CI
[0.98, 0.99] [1.18, 3.31] [1.12, 3.22] [0.84, 2.58]
0.98⁎⁎ 2.56⁎⁎
[0.97, 0.99] [1.38, 4.76] [0.51, 2.12] [0.74, 2.65]
1.04 1.40
OR = odds ratio; 95% CI = 95% confidence interval. a At least one form of childhood trauma, on a mild, moderate or severe level referring to CTQ. b No form of childhood trauma referring to CTQ. c 2-Tailed t-tests. d Quartile IV (highest resilience scores) as reference. ⁎ P ≤ .05. ⁎⁎ P ≤ .01. ⁎⁎⁎ P ≤ .001.
Discussion Based on a general population sample of 2046 subjects, we found that childhood maltreatment contributed significant to MDD in later life while resilience significantly mitigated it. Moreover, we revealed that the detrimental effects of low resilience were not only especially prominent in subjects with a history of CM, but also effective in subjects without CM. Concerning this effect modification of resilience on the association of CM and MDD, our analysis implied that the combined effect of the two risk exposures childhood maltreatment and low resilience (quartile II) exceeded the effect of each considered separately, but not through all defined groups. It appeared that subjects with CM in general were more effected by MDD in adulthood than persons without CM (15.1% MDD cases in subjects with CM vs. 6.8% MDD cases in subjects without CM), but with descending levels of resilience these detrimental effects of CM on MDD are particularly apparent (Table 4). Furthermore, in subjects with the lowest levels of resilience (quartile I) the lack of resilience blurred the putative additional detrimental effect of CM on MDD, as the proportions of MDD in the lowest quartile of resilience (quartile I) are comparable between subjects with CM and without
Table 3 Binary logistic regression analyses of the impact of childhood maltreatment (CTQ sum score and subscale scores) and dispositional resilience (RS-25 sum score) on lifetime major depressive disorder. MDD lifetime Model Ia
OR
95% CI
Resilience CTQ sum score Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect
0.98⁎⁎⁎ 1.03⁎⁎⁎ 1.13⁎⁎⁎ 1.14⁎⁎⁎ 1.09⁎, ⁎⁎ 1.05⁎ 1.06⁎
[0.98, 0.99] [1.02, 1.04] [1.08, 1.19] [1.08, 1.21] [1.09, 1.16] [1.02, 1.08] [1.01, 1.11]
OR = odds ratio; 95% CI = 95% confidence interval. a Continuous predictors (CTQ sum score, CTQ scale scores for EA, PA, SA, EN, and PN), adjusted for sex and age, reference category sex: male. ⁎ P ≤ .05. ⁎⁎ P ≤ .01. ⁎⁎⁎ P ≤ .001.
CM (17.7% vs. 16.9%). Comparable results were found in subjects with the highest levels of resilience (quartile IV), where we revealed low MDD rates for subjects with and without CM as well (9.7% vs. 7.3%). In line with other studies, a considerable number of subjects developed and maintain resilience despite their early traumatic experiences in childhood. The results fit to the concept of resilience as a dynamic personality trait by Wagnild et al. that comprises the individual's ability to react resiliently in the aftermath of adversity [29,30,45]. Inherent to this position, resilience results from the interplay between individual and environmental characteristics and precedes resistance to stressors [45]. Our results correspond to previous work on moderating effects of resilience on depression in traumatized subjects. Wingo et al. [22] found that resilience as a trait moderated depression severity in predominantly African Americans (N = 792). Further studies on the role of resilience on psychiatric symptoms referred to samples of college students and patients [21,46] or defined resilience as the end of a complex adaptation process measured by external criteria such as absence of psychiatric disorders. These studies consistently found resilient outcomes (good psychological adjustment and social functioning, less psychopathology) in subjects with trauma exposure and examined associated and determining factors. Data identified resilience promoting factors like purpose in life, coping styles, personality style, quality of adult love relationships and perceived parental care. On the contrary, Wagnild et al. [29] define resilience as a dynamic personality trait that influences the individual's ability to react resiliently in the aftermath of adversity. They concluded that the degree of adaptation is dependent on the Resilience Core that incorporates five factors: a purposeful life, perseverance, equanimity, self-reliance and the awareness of being on your own in a lot of situations in life. Hereby they acknowledged the existence of certain inherent resources which are however fluid and alterable rather than determined and inflexible. This definition would probably provide an ‘umbrella’ definition for several study results mentioned above. Arguable is whether the resilience scale could be an adequate substitute to all constructs accounting to resilience so far. Future studies with longitudinal assessments of resilience, resilient outcomes and promoting factors are needed to decide whether resilience is dispositional ability to access and use resources in the face of traumatic events [28,29] or the result of a complex adaptation process. Research of gene by environment interaction has started to shed light on this
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Fig. 1. Diffentiated by degree of resilience (quartile I [left upper row] to quartile IV [right lower row]) and history of childhood maltreatment (CM [positive] = combined CTQ severity categories: mild/moderate/severe vs. no history of CM according to the CTQ), numbers of subjects with (dark grey bar) and without (light gray bar) a lifetime major depression are presented. Percentages of subjects with lifetime major depression within the groups of presence or absence of CM are added.
complex interplay [47–52]. Thus, it is probable that human behavior is influenced not only by personality traits or current states, but also by personality states and current states. Our results indicate that strengthening resilience could be a useful therapeutic goal especially in subjects with CM. The Resilience Core has been conceived as an alterable parameter, which could be amenable to external manipulation through specific conducts and processes like seeking social support, taking care of oneself, engaging in life and balancing recreation, rest and responsibilities [30]. Especially children and adolescent growing up in high-risk families should get the opportunity to “take the necessary steps to build up their resilience and go forward boldly and live resiliently” [30] (p. 17). Possible starting-points might be the provision of trainings that build up stress coping skills, health behavior and a balanced life style in a functional social network [53]. Our findings support the relevance of identifying subjects lacking resilience as a significant personal resource. Strengths of our study include the use of a large community sample and reliable and well-established instruments (CTQ, BDI-II, RS-25). Limitations include recall bias and the debate on the psychometric construct of resilience. Our retrospective cross-sectional data exclude causal interpretation. Nevertheless, the events inferred on in the instruments were related to different periods in life: the CTQ aimed to
experiences during childhood and youth, whereas the mean onset of MDD life-time diagnosis was specified at 37.3 years (SD 13.0). Thus, a chronological order is inherent to our cross-sectional data regarding trauma and MDD diagnoses but not resilience. Autobiographical memory is at least partly reconstructive and affected by cognitive mechanisms like misattribution, suggestibility, and biases due to subjective logic [54]. With respect to traumatic events such as CM, the possibility of conscious motives, e.g. concealment because of shame and unconscious motives, e.g. repression, dissociation, ordinary forgetting, and false memory, was comprehensively discussed in research [54,55]. On the other hand, previous studies revealed that adults' recall of particular childhood experiences like childhood maltreatment is relatively accurate and retrospective reports of CM are generally credible and stable over time [56]. Additionally, DiLillo et al. [57] demonstrated, disclosure of CM was not influenced by the mode of retrospective assessments, but participants feel more comfortable and less distressed by questionnaires or computer assessment compared to face to face interview. Although retrospective data is valuable in several ways (practicability) and also may have advantages over prospective data (fewer missing cases, unreported more severe abuse [58]), prospective studies are needed to identify the causal interplay between trauma load, resilience and mental disorders.
Table 4 Binary logistic regression analyses of the effect modification between dispositional resilience (RS-25) and childhood maltreatment on lifetime major depressive disorder (n = 2046). Modela b
c
Childhood maltreatment
Resilience
No No No No Yes Yes Yes Yes
Quartile IV Quartile III Quartile II Quartile I Quartile IV Quartile III Quartile II Quartile I
Participants n = 2046 With MDD
Without MDD
19 23 15 29 23 36 54 63
240 215 195 143 215 226 258 292
OR = odds ratio; 95% CI = 95% confidence interval. a Adjusted for sex and age, reference category: male, reference category: 80–89 years. b Presence of at least one mild form of PA, EA, SA, PN, EN. c Categorized by sex- and age-specific quartiles. ⁎ P b .05. ⁎⁎ P b .01. ⁎⁎⁎ P b .001.
OR
95% CI
REF 1.43 1.04 2.62⁎⁎ 1.61 2.37⁎⁎ 3.05⁎⁎⁎ 3.18⁎⁎⁎
[0.76, 2.72] [0.51, 2.10] [1.41, 4.88] [0.84, 3.05] [1.31, 4.28] [1.74, 5.33] [1.84, 5.50]
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Conflict of interest In representation of all mentioned authors, I state that we have full access to all study data, that we are responsible for all contents, and that we had authority over manuscript preparation and the decision to submit the manuscript for publication. All authors have approved of the submission of the manuscript to the journal and the results are original and have not been published or submitted elsewhere. Furthermore I would like to certify that all authors have no competing interests. Acknowledgments This work was supported by the German Research Foundation (GR 1912/5-1) and the Federal Ministry of Education and Research in Germany (01ZZ9603, 01ZZ0103, and 01ZZ0403), the Ministry of Cultural Affairs and the Social Ministry of the Federal State of Mecklenburg-West Pomerania and by the Greifswald Approach to Individualized Medicine (GANI_MED) network funded by the Federal Ministry of Education and Research in Germany (grant 03IS2061A). SHIP is part of the Community Medicine Research Net of the Ernst-MoritzArndt-University of Greifswald, Germany. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.jpsychores.2014.06.008. References [1] Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095–105. [2] Kendler KS, Gardner CO, Prescott CA. Toward a comprehensive developmental model for major depression in woman. Am J Psychiatry 2002;159:1133–45. [3] Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol 2000;68:748–66. [4] Kessler RC, McLaughlin KA, Green JG, Gruber MJ, Sampson NA, Zaslavsky AM, et al. Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys. Br J Psychiatry 2010;197:378–85. [5] Collishaw S, Pickles A, Messer J, Rutter M, Shearer C, Maughan B. Resilience to adult psychopathology following childhood maltreatment: evidence from a community sample. Child Abuse Negl 2007;31:211–29. [6] Wainwright NW, Surtees PG. Childhood adversity, gender and depression over the life-course. J Affect Disord 2002;72:33–44. [7] Hovens J, Wiersma J, Giltay EJ, van Oppen P, Spinhoven P, Penninx BP, et al. Childhood life events and childhood trauma in adult patients with depressive, anxiety and comorbid disorders vs controls. Acta Psychiatr Scand 2010;122:66–74. [8] Heim C, Nemeroff CB. The role of childhood trauma in the neurobiology of mood and anxiety disorders: preclinical and clinical studies. Biol Psychiatry 2001;49:1023–39. [9] Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord 2004;82:217–25. [10] MacMillan HL, Fleming JE, Streiner DL, Lin E, Boyle MH, Jamieson E, et al. Childhood abuse and lifetime psychopathology in a community sample. Am J Psychiatry 2001;158:1878–83. [11] Korkeila K, Korkeila J, Vahtera J, Kivimäki M, Kivelä SL, Sillanmäki L, et al. Childhood adversities, adult risk factors and depressiveness: a population study. Soc Psychiatry Psychiatr Epidemiol 2005;40:700–6. [12] Brown GW, Moran P. Clinical and psychosocial origins of chronic depressive episodes, 1: a community survey. Br J Psychiatry 1994;165:447–52. [13] Wiersma J, Hovens J, van Oppen P, Giltay EJ, van Schaik DJF, Beekman ATF, et al. The importance of childhood trauma and childhood life events for chronicity of depression in adults [CME]. J Clin Psychiatry 2009;70:983–9. [14] van der Vegt EJ, Tieman W, van der Ende J, Ferdinand RF, Verhulst FC, Tiemeier H. Impact of early childhood adversities on adult psychiatric disorders: a study of international adoptees. Soc Psychiatry Psychiatr Epidemiol 2009;44:724–31. [15] Edwards VJ, Holden GW, Felitti VJ, Anda RF. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study. Am J Psychiatry 2003;160: 1453–60. [16] Fergusson DM, Boden JM, Horwood LJ. Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child Abuse Negl 2008;32:607–19. [17] Maercker A, Michael T, Fehm L, Becker ES, Margraf J. Age of traumatisation as a predictor of post-traumatic stress disorder or major depression in young women. Br J Psychiatry 2004;184:482–7. [18] Bowlby J. Attachment and loss: volume 1: attachment. London: The Hogarth Press and the Institute of Psycho-Analysis; 1969.
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Contents lists available at ScienceDirect
Journal of Psychosomatic Research
The impact of childhood trauma on depression: Does resilience matter? Population-based results from the Study of Health in Pomerania Andrea Schulz a,⁎,1, Mathias Becker b,1, Sandra Van der Auwera a, Sven Barnow c, Katja Appel a, Jessie Mahler d, Carsten Oliver Schmidt e, Ulrich John f, Harald J. Freyberger b, Hans J. Grabe a a
Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany Department of Psychiatry, University Medicine Greifswald, HELIOS-Hanseklinikum Stralsund, Stralsund, Germany Department of Clinical Psychology and Psychotherapy, University of Heidelberg, Heidelberg, Germany d Institute for Medical Psychology, University Medicine Greifswald, Greifswald, Germany e Institute for Community Medicine, University of Greifswald, Greifswald, Germany f Institute of Social Medicine and Prevention, University Medicine Greifswald, Greifswald, Germany b c
a r t i c l e
i n f o
Article history: Received 31 December 2013 Received in revised form 12 June 2014 Accepted 16 June 2014 Keywords: Child abuse Childhood maltreatment Childhood Trauma Questionnaire Depression Resilience
a b s t r a c t Objective: Data suggests that traumatic experiences at early age contribute to the onset of major depressive disorder (MDD) in later life. This study aims at investigating the influence of dispositional resilience on this relationship. Methods: Two thousand and forty-six subjects aged 29–89 (SD = 13.9) from a community based sample who were free of MDD during the last 12 months prior to data collection were diagnosed for Lifetime diagnosis of MDD by the Munich-Composite International Diagnostic Interview (M-CIDI) according to DSM-IV criteria. Childhood maltreatment (CM) and resilience were assessed with the Childhood Trauma Questionnaire (CTQ) and the Resilience-Scale (RS-25). Results: Both CM (OR = 1.03, 95% CI [1.02, 1.04], P b .000) and resilience (OR = 0.98, 95% CI [0.98, 0.99], P b .000) were associated with MDD later in life. The detrimental effects of low resilience on MDD were not only especially prominent in subjects with a history of CM (OR = 3.18, 95% CI [1.84, 5.50], P b .000), but also effective in subjects without CM (OR = 2.62, 95% CI [1.41, 4.88], P = .002). Conclusions: The findings support the clinical assumption that resilient subjects may be partly protected against the detrimental long-term effects of child abuse and neglect. © 2014 Elsevier Inc. All rights reserved.
Introduction Depressive disorders are a major mental health problem and widely recognized as most prevalent cause of morbidity, disability and impaired quality of life [1]. In particular intense early stress and traumatic experiences like childhood maltreatment (CM) were consistently associated with adult psychopathology, especially with major depression (MDD) [2–5]. In this regard CM not only increases the risk of life-time MDD [6–11], but it also aggravates its course [12,13] in terms of a ⁎ Corresponding author at: Department of Psychiatry and Psychotherapy, University Medicine of Greifswald, Ellernholzstraße 1-2, D-17475 Greifswald, Germany. Tel.: +49 3834 86 22 166; fax: +49 3834 86 6889. E-mail addresses: [email protected] (A. Schulz), [email protected] (M. Becker), [email protected] (S. Van der Auwera), [email protected] (S. Barnow), [email protected] (K. Appel), [email protected] (J. Mahler), [email protected] (C.O. Schmidt), [email protected] (U. John), [email protected] (H.J. Freyberger), [email protected] (H.J. Grabe). 1 Contributed equally.
http://dx.doi.org/10.1016/j.jpsychores.2014.06.008 0022-3999/© 2014 Elsevier Inc. All rights reserved.
dose–response relationship as numerous studies have indicated [9,10, 14–16]. Maerker et al. [17] found a higher probability of developing MDD compared to Posttraumatic Stress Disorder if a trauma occurred in early developmental stages rather than in adolescence which they explained by premature neurobiological mechanisms of memory and emotion regulation. This is in line with studies that linked intense early stress to greater sensitivity of the hypothalamic-pituitaryadrenal axis in adulthood, which in turn was associated with greater vulnerability to MD [8]. Besides the impact of early trauma on neurobiology and neurochemistry, psychological and cognitive dimensions are also affected by early traumatization. According to the attachment theory by Bowlby [18], a secure attachment to primary caregivers promotes successful emotional development and is a protective factor against psychopathology [19]. For this reason traumatic and violent experiences, especially caused by caregivers, are highly detrimental to a child's system of beliefs, expectations, emotions, and behaviors about the self and others [20] and may result in the development of learned helplessness an external locus of control [7],
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inappropriate coping styles [21] and therefore in higher vulnerability to stress and stress disorders. Resilience as a protective factor Although a great deal of research investigating the immediate and delayed pathogenic effects of CM has been conducted, only a small body of literature has focused on adaptive outcomes in the aftermath of CM [22–24]. Yet it seems that besides trauma-related factors like frequency and intrusiveness, individual biological and psychological factors modify the risk for long-term consequences of CM [5]. As research has consistently shown a considerable number of CM victims show little or no psychological long-term damage [22,25]. Over the years the vague term “resilience” was established to describe this phenomenon. As there is no definition of “resilience” generally agreed on, one can assign the attempted definitions to (at least) two main streams (cf. [26]). First: the end of a complex adaptation process to adversity (cf. [27]) and second: the dispositional ability to access and use resources in the face of traumatic events [28,29]. An integrated conceptualization of the term “resilience” was provided by Wagnild et al. [29,30]. They defined resilience as a “dynamic personality trait that comprises the individual's ability to react resiliently in the aftermath of adversity”. Hereby they acknowledged the existence of certain inherent resources which are however fluid and alterable rather than determined and inflexible. To our knowledge, there is only one other cross-sectional study that assessed the moderating effects of dispositional resilience on depressive symptoms following childhood trauma. Wingo et al. [22] found an effect of resilience on depression severity after CM, but no interaction between CM and resilience in depression in a predominantly African American sample. In our study, we first aimed to determine relations between childhood maltreatment, resilience, and depression in later life in a representative population based sample using a standardized and broadly validated self-report instrument for childhood maltreatment and a diagnostic interview for major depressive disorder according to DSM-IV. Secondly, we analyzed the putative moderating effect of resilience on the association of childhood maltreatment and depression. We assumed that a considerable number of study participants with a history of childhood maltreatment adapted well and developed resilience that counteracted the risk of depression in later life. Methods
Table 1 Sociodemographic and clinical characteristics of SHIP-LEGEND participants.
Total sample School educationa
Marital statusa
Childhood trauma positiveb Childhood trauma subtypes Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect
b10 years =10 years N10 years Married/living with partner Single/living separated/ divorced/widowed
None Positiveb None Positiveb None Positiveb None Positiveb None Positiveb
Major depressive disorderc
Age Resilienced e
Quartile I Quartile II Quartile III Quartile IV a b c d e
n
%
2046 611 1014 416 1661 380
100 29.9 49.7 20.4 81.4 18.6
1167
57.0
1807 226 1860 178 1896 138 1266 760 1255 778 262
88.9 11.0 91.3 8.7 93.2 6.7 62.5 37.1 61.7 38.0 12.8
Median
Range
56.0 148 127 143 153 166
29–89 25–175 25–140 130–154 144–166 155–175
School education, marital status: 0.6% missing. Categorical, combined CTQ severity categories: mild/moderate/severe (=positive). Diagnosis lifetime by M-CIDI. Resilience-Scale 25 (RS-25) by Wagnild & Young [29]. Age (10 year increments) and sex specific quartiles of the RS score.
the beginning of the interview [35]. The criterion for exclusion based on the VLMT was less than four recalled words at the first trial. We further excluded 131 subjects with a diagnosis of MDD in the previous 12 months to the LEGEND interview to reduce any cognitive bias in the response of the questionnaires that can be ascribed to current major depressive symptoms. Furthermore, subjects with missing data for lifetime diagnosis of MDD (n = 5) or CM (n = 84) were excluded (overlap exists), resulting in a final study population of 2046 participants. All participants had given written informed consent. SHIP and LEGEND were approved by the local Institutional Review Board and conformed to the principles of the Declaration of Helsinki. A sample description is provided in Table 1.
Sample and sample recruitment Instruments Data from the Study of Health in Pomerania (SHIP) were used [31]. SHIP is a population-based cohort study conducted in West Pomerania [32–34] which comprises a net sample of 6267 eligible adults, out of which 4308 Caucasian subjects participated in the baseline of SHIP (SHIP-0) 1997–2001. Between 2007 and 2010, the “Life-Events and Gene-Environment Interaction in Depression” (LEGEND) study comprised a profound psychometric assessment of the SHIP-0 participants. Until then, 639 participations from SHIP-0 were either deceased (n = 383) or refused further participation on SHIP (n = 256). In total, 3669 subjects of the baseline sample were invited to LEGEND, 92 of these deceased during study conduction and 1011 refused participation in LEGEND. 132 subjects did not respond to repeated efforts of contact (at least three written invitations, 10 telephone calls and five home visits). Thirty-four subjects agreed to participate, but did not show up on several arranged dates or were not able to arrange an appointment. Among the 2400 subjects who participated in LEGEND, 134 were excluded from the analyses because of unreliable information or inconsistencies in the interview according to a judgment of the interviewer or supervisor that included the performance on a verbal memory test (VLMT) at
Childhood maltreatment Recognizing a lack of a comprehensive standard definition of childhood maltreatment, the WHO Consultation on Child Abuse Prevention drafted a comprehensive definition in 1999: “Child abuse or maltreatment constitutes all forms of physical and/ or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power.” We applied the German version of the 28-item Childhood Trauma Questionnaire (CTQ) whose items reflect common definitions of child abuse and neglect as found in the childhood trauma literature [36]. “Emotional abuse (EA) refers to verbal assaults on a child's sense of worth or well-being, or any humiliating, demeaning, or threatening behavior directed toward a child by an older person. Physical abuse (PA) refers to bodily assaults on a child by an older person that pose the
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risk of, or result in, injury. Sexual abuse (SA) refers to sexual contact or conduct between a child and older person; explicit coercion is a frequent but not essential feature of that experiences. Emotional neglect (EN) refers to the failure of caretakers to provide a child's basic psychological and emotional needs, such as love, encouragement, belonging, and support. Physical neglect (PN) refers to the failure of caregivers to provide a child's basic physical needs, including food, shelter, safety and supervision, and health.” [36]. Each item is scored on a five-point Likert scale from “never true” (=1) to “very often true” (=5). Dependent on the scale sum score, participants can be grouped into the severity categories “none”, “mild”, “moderate”, and “severe”. In accordance with the American CTQ-manual [36], we classified subjects having experienced at least mild forms of maltreatment as being traumatized (scale sum score ≥ 9 for emotional abuse, ≥ 8 for physical abuse, ≥ 6 for sexual abuse, ≥10 for emotional neglect, ≥8 for physical neglect). To the best of our knowledge, there are no German cut-offs available so far. All studies that handle with these CTQ severity categories, including translation and validation studies [37,38], used the defined cut-offs for severity categories from the original study [39]. Depression The diagnosis of lifetime MDD according to DSM-IV criteria was determined using the standardized and computerized Munich-Composite International Diagnostic Interview (M-CIDI). Test–retest reliability analysis of the diagnosis of MDD revealed kappas between .62 and .77 [40]. The interview was used by clinically experienced interviewers (psychologists) in a face-to-face situation. Multiple studies regarding clinical validity and reliability of the M-CIDI yielded excellent results for the inter-rater reliability and confirmed a high clinical validity [41,42]. The diagnosis of lifetime MDD was used as dichotomous outcome measure in all analyses. Resilience To assess resilience, we used the German translation (RS-25) [43] of the resilience scale [30]. Participants have to rate 25 statements about their personal view on a 7-point Likert-Scale. While the original US-American version of the RS-25 is comprised of two scales, Schumacher et al. [43] postulated a one-dimensional factor structure for the German translation. The RS-25 yielded good results for reliability (Cronbach's alpha = 0.94) and confirmed significant construct validity [43]. The questionnaire was developed from a qualitative study among successfully adjusted elderly woman, using the transactional model of stress [44] as an organizing framework. Although the instrument had been used for almost two decades, an elaborate theoretical framework was devised only recently [30]. Briefly, every person has the potential to react resiliently in the aftermath of adversity. The degree of adaptation is dependent on the so called Resilience Core. It is composed of the five components: [1] a purposeful life, [2] perseverance, [3] equanimity, [4] self-reliance and [5] the awareness of being on your own in a lot of situations in life (Existential aloneness). According to Wagnild's theory, researchers are able to assess the strength of the Resilience Core by applying the RS-25. Overall scores range from 25 to 175 with higher scores implying a higher degree of resilience. Wagnild [30] provided cut-off values for assessing the actual degree of resilience. Six ranks from a very low to a very high degree of resilience have been proposed. As there are no such standard values for the German translation of the scale [43], we divided our subjects into 4 groups by sex- and age specific quartiles of the resilience score. Statistical analyses Given our special interest in the potential influence of resilience on the development of MDD in later life depending on childhood maltreatment, we first examined resilience (sum score and quartiles) as a predictor on MDD lifetime in a binary logistic regression analysis stratified by history of CM. We furthermore used binary logistic regression
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models with lifetime MDD as outcome to assess the main effects of both predictors (CM and resilience as continuous variable) and their putative interaction on depression. We examined the potential influence of CM in general and specifically of all subtypes of CM (CTQ subscale scores on EA, PA, SA, EN and PN). For all models we derived odds ratios (ORs) with 95% confidence intervals (95% CI) adjusted for gender and age. Males were the reference group in all regression analyses. To receive a more detailed view on the relationship between CM and different gradations of resilience and the putative effect modification on the association of CM and MDD, we categorized and dummy-coded our continuous variables age (10-year increments), resilience (quartiles), and CM (0 = no CM, 1 = at least one mild form of CM) and rerun the described regression models. Additionally, we repeated our analysis with dichotomous, dummycoded predictors: resilience (median split; 0 = low degree of resilience, b148 points; 1 = high degree of resilience, ≥148 points) and CM (0 = no CM, 1 = at least one mild form of CM). To quantify the magnitude of an additive interaction effect, the relative excess risk due to interaction (RERI) [59–61] was calculated (descriptions and results presented in supplement). To avoid a direct (state-) impact of current depressive symptoms on the rating of the RS-25, we excluded subjects meeting the criteria of MDD during the last 12 months. Results Main characteristics of the study population (n = 2046) are given in Table 1. Excluding subjects with a diagnosis of MDD within the last 12 months, 12.8% of remaining participants suffered at least from one episode of MDD. The RS-25 score had a median of 148 (range 25–175). More than half of the study sample (57.0%) reported at least one form of childhood traumatization on a mild, moderate or severe level. Emotional and physical neglect were more prevalent than incidences of abuse. Effects of resilience and MDD depending on history of CM Subjects with and without a history of CM differed significantly in their degree of resilience considered as a continuous variable. Divided in quartiles by resilience, we found that even subjects with CM expressed high levels of resilience although the proportions were lower than in subjects without CM (e.g. 20.4% vs. 29.5% in quartile IV). The association between resilience and MDD was significant. Considered in quartiles, subjects with low resilience scores (quartile I and II) had a significantly higher chance for MDD in respect of subjects with higher levels of resilience (quartile IV) (Table 2). Effects of RES and CM on MDD Resilience and all forms of childhood maltreatment showed significant associations with MDD lifetime. Whereas CM and all subtypes of abuse and neglect were positively associated with MDD lifetime, resilience was negatively associated, i.e. higher degrees of resilience were associated with lower rates of MDD lifetime. However the analysis on continuous variables revealed no significant interaction between CM or its subtypes and resilience on MDD lifetime (results not shown) (Table 3). For a more detailed view on the relationship between CM and lifetime MDD by gradations of resilience, we plotted the proportion for the presence and absence of MDD according to quartiles of resilience. In line with theory, the proportion of cases of MDD decreases as resilience increases (irrespective of CM): 17.5% in resilience quartile I, 12.6% in quartile II, 11.8% in quartile III and 8.5% in quartile IV. Considering the factor CM on this relationship, the proportion of MDD cases between subjects with and without CM did not differ in resilience quartiles I (OR 1.05, 95% CI [0.71, 1.57], P = .90) and IV (OR 1.32, 95% CI [0.74, 2.36], P = .42). Though, in resilience quartiles II and III, the proportion of MDD cases was higher in subjects with a history of CM (quartile II: OR 2.42, 95% CI [1.41, 4.18], p = 0.001; quartile III (OR 1.68, 95% CI [0.87, 2.33], p = 0.168). Based on these descriptive analyses, we analyzed the putative effect modification by resilience on the association of CM and MDD and consider the characteristic categories discretely on their own (Fig. 1). Effect modification between CM and MDD by resilience Table 4 depicts the association to MDD as a function of the presence or absence of risk factor (CM) and different degrees of resilience (quartiles). Within the subjects without CM only low degrees of resilience (quartile I) were significantly associated with greater chance of MDD. Within the subjects with a history of CM, only high resilient subjects (quartile IV) showed no association toward MDD in later life. In contrast, in quartiles I–III, higher resilience was associated with lower rates of lifetime MDD in subjects with CM.
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Table 2 Characteristics of resilience and its association to lifetime major depressive disorder between groups with and without a history of childhood maltreatment (n = 2046). Childhood maltreatmenta n = 1167
Resilience (continuous) Resilienced
Quartile I Quartile II Quartile III Quartile IV
No childhood maltreatmentb n = 879
M (SD)
n (%)
M (SD)
n (%)
144.8 (18.2) 123.9 (14.3) 143.4 (4.6) 154.3 (4.9) 167.1 (5.3)
355 (30.4) 312 (26.7) 262 (22.5) 238 (20.4)
148.8 (16.4) 124.5 (13.3) 142.3 (4.3) 153.7 (4.8) 165.6 (5.4)
172 (19.6) 210 (23.9) 238 (27.1) 259 (29.5)
Pc b.001⁎⁎⁎
Binary logistic regression for MDD lifetime adjusted for age and sex OR Resilience (continuous) Resilienced
Quartile I Quartile II Quartile III
0.99⁎⁎ 1.98⁎ 1.90⁎ 1.47
95% CI
OR
95% CI
[0.98, 0.99] [1.18, 3.31] [1.12, 3.22] [0.84, 2.58]
0.98⁎⁎ 2.56⁎⁎
[0.97, 0.99] [1.38, 4.76] [0.51, 2.12] [0.74, 2.65]
1.04 1.40
OR = odds ratio; 95% CI = 95% confidence interval. a At least one form of childhood trauma, on a mild, moderate or severe level referring to CTQ. b No form of childhood trauma referring to CTQ. c 2-Tailed t-tests. d Quartile IV (highest resilience scores) as reference. ⁎ P ≤ .05. ⁎⁎ P ≤ .01. ⁎⁎⁎ P ≤ .001.
Discussion Based on a general population sample of 2046 subjects, we found that childhood maltreatment contributed significant to MDD in later life while resilience significantly mitigated it. Moreover, we revealed that the detrimental effects of low resilience were not only especially prominent in subjects with a history of CM, but also effective in subjects without CM. Concerning this effect modification of resilience on the association of CM and MDD, our analysis implied that the combined effect of the two risk exposures childhood maltreatment and low resilience (quartile II) exceeded the effect of each considered separately, but not through all defined groups. It appeared that subjects with CM in general were more effected by MDD in adulthood than persons without CM (15.1% MDD cases in subjects with CM vs. 6.8% MDD cases in subjects without CM), but with descending levels of resilience these detrimental effects of CM on MDD are particularly apparent (Table 4). Furthermore, in subjects with the lowest levels of resilience (quartile I) the lack of resilience blurred the putative additional detrimental effect of CM on MDD, as the proportions of MDD in the lowest quartile of resilience (quartile I) are comparable between subjects with CM and without
Table 3 Binary logistic regression analyses of the impact of childhood maltreatment (CTQ sum score and subscale scores) and dispositional resilience (RS-25 sum score) on lifetime major depressive disorder. MDD lifetime Model Ia
OR
95% CI
Resilience CTQ sum score Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect
0.98⁎⁎⁎ 1.03⁎⁎⁎ 1.13⁎⁎⁎ 1.14⁎⁎⁎ 1.09⁎, ⁎⁎ 1.05⁎ 1.06⁎
[0.98, 0.99] [1.02, 1.04] [1.08, 1.19] [1.08, 1.21] [1.09, 1.16] [1.02, 1.08] [1.01, 1.11]
OR = odds ratio; 95% CI = 95% confidence interval. a Continuous predictors (CTQ sum score, CTQ scale scores for EA, PA, SA, EN, and PN), adjusted for sex and age, reference category sex: male. ⁎ P ≤ .05. ⁎⁎ P ≤ .01. ⁎⁎⁎ P ≤ .001.
CM (17.7% vs. 16.9%). Comparable results were found in subjects with the highest levels of resilience (quartile IV), where we revealed low MDD rates for subjects with and without CM as well (9.7% vs. 7.3%). In line with other studies, a considerable number of subjects developed and maintain resilience despite their early traumatic experiences in childhood. The results fit to the concept of resilience as a dynamic personality trait by Wagnild et al. that comprises the individual's ability to react resiliently in the aftermath of adversity [29,30,45]. Inherent to this position, resilience results from the interplay between individual and environmental characteristics and precedes resistance to stressors [45]. Our results correspond to previous work on moderating effects of resilience on depression in traumatized subjects. Wingo et al. [22] found that resilience as a trait moderated depression severity in predominantly African Americans (N = 792). Further studies on the role of resilience on psychiatric symptoms referred to samples of college students and patients [21,46] or defined resilience as the end of a complex adaptation process measured by external criteria such as absence of psychiatric disorders. These studies consistently found resilient outcomes (good psychological adjustment and social functioning, less psychopathology) in subjects with trauma exposure and examined associated and determining factors. Data identified resilience promoting factors like purpose in life, coping styles, personality style, quality of adult love relationships and perceived parental care. On the contrary, Wagnild et al. [29] define resilience as a dynamic personality trait that influences the individual's ability to react resiliently in the aftermath of adversity. They concluded that the degree of adaptation is dependent on the Resilience Core that incorporates five factors: a purposeful life, perseverance, equanimity, self-reliance and the awareness of being on your own in a lot of situations in life. Hereby they acknowledged the existence of certain inherent resources which are however fluid and alterable rather than determined and inflexible. This definition would probably provide an ‘umbrella’ definition for several study results mentioned above. Arguable is whether the resilience scale could be an adequate substitute to all constructs accounting to resilience so far. Future studies with longitudinal assessments of resilience, resilient outcomes and promoting factors are needed to decide whether resilience is dispositional ability to access and use resources in the face of traumatic events [28,29] or the result of a complex adaptation process. Research of gene by environment interaction has started to shed light on this
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Fig. 1. Diffentiated by degree of resilience (quartile I [left upper row] to quartile IV [right lower row]) and history of childhood maltreatment (CM [positive] = combined CTQ severity categories: mild/moderate/severe vs. no history of CM according to the CTQ), numbers of subjects with (dark grey bar) and without (light gray bar) a lifetime major depression are presented. Percentages of subjects with lifetime major depression within the groups of presence or absence of CM are added.
complex interplay [47–52]. Thus, it is probable that human behavior is influenced not only by personality traits or current states, but also by personality states and current states. Our results indicate that strengthening resilience could be a useful therapeutic goal especially in subjects with CM. The Resilience Core has been conceived as an alterable parameter, which could be amenable to external manipulation through specific conducts and processes like seeking social support, taking care of oneself, engaging in life and balancing recreation, rest and responsibilities [30]. Especially children and adolescent growing up in high-risk families should get the opportunity to “take the necessary steps to build up their resilience and go forward boldly and live resiliently” [30] (p. 17). Possible starting-points might be the provision of trainings that build up stress coping skills, health behavior and a balanced life style in a functional social network [53]. Our findings support the relevance of identifying subjects lacking resilience as a significant personal resource. Strengths of our study include the use of a large community sample and reliable and well-established instruments (CTQ, BDI-II, RS-25). Limitations include recall bias and the debate on the psychometric construct of resilience. Our retrospective cross-sectional data exclude causal interpretation. Nevertheless, the events inferred on in the instruments were related to different periods in life: the CTQ aimed to
experiences during childhood and youth, whereas the mean onset of MDD life-time diagnosis was specified at 37.3 years (SD 13.0). Thus, a chronological order is inherent to our cross-sectional data regarding trauma and MDD diagnoses but not resilience. Autobiographical memory is at least partly reconstructive and affected by cognitive mechanisms like misattribution, suggestibility, and biases due to subjective logic [54]. With respect to traumatic events such as CM, the possibility of conscious motives, e.g. concealment because of shame and unconscious motives, e.g. repression, dissociation, ordinary forgetting, and false memory, was comprehensively discussed in research [54,55]. On the other hand, previous studies revealed that adults' recall of particular childhood experiences like childhood maltreatment is relatively accurate and retrospective reports of CM are generally credible and stable over time [56]. Additionally, DiLillo et al. [57] demonstrated, disclosure of CM was not influenced by the mode of retrospective assessments, but participants feel more comfortable and less distressed by questionnaires or computer assessment compared to face to face interview. Although retrospective data is valuable in several ways (practicability) and also may have advantages over prospective data (fewer missing cases, unreported more severe abuse [58]), prospective studies are needed to identify the causal interplay between trauma load, resilience and mental disorders.
Table 4 Binary logistic regression analyses of the effect modification between dispositional resilience (RS-25) and childhood maltreatment on lifetime major depressive disorder (n = 2046). Modela b
c
Childhood maltreatment
Resilience
No No No No Yes Yes Yes Yes
Quartile IV Quartile III Quartile II Quartile I Quartile IV Quartile III Quartile II Quartile I
Participants n = 2046 With MDD
Without MDD
19 23 15 29 23 36 54 63
240 215 195 143 215 226 258 292
OR = odds ratio; 95% CI = 95% confidence interval. a Adjusted for sex and age, reference category: male, reference category: 80–89 years. b Presence of at least one mild form of PA, EA, SA, PN, EN. c Categorized by sex- and age-specific quartiles. ⁎ P b .05. ⁎⁎ P b .01. ⁎⁎⁎ P b .001.
OR
95% CI
REF 1.43 1.04 2.62⁎⁎ 1.61 2.37⁎⁎ 3.05⁎⁎⁎ 3.18⁎⁎⁎
[0.76, 2.72] [0.51, 2.10] [1.41, 4.88] [0.84, 3.05] [1.31, 4.28] [1.74, 5.33] [1.84, 5.50]
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Conflict of interest In representation of all mentioned authors, I state that we have full access to all study data, that we are responsible for all contents, and that we had authority over manuscript preparation and the decision to submit the manuscript for publication. All authors have approved of the submission of the manuscript to the journal and the results are original and have not been published or submitted elsewhere. Furthermore I would like to certify that all authors have no competing interests. Acknowledgments This work was supported by the German Research Foundation (GR 1912/5-1) and the Federal Ministry of Education and Research in Germany (01ZZ9603, 01ZZ0103, and 01ZZ0403), the Ministry of Cultural Affairs and the Social Ministry of the Federal State of Mecklenburg-West Pomerania and by the Greifswald Approach to Individualized Medicine (GANI_MED) network funded by the Federal Ministry of Education and Research in Germany (grant 03IS2061A). SHIP is part of the Community Medicine Research Net of the Ernst-MoritzArndt-University of Greifswald, Germany. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.jpsychores.2014.06.008. References [1] Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095–105. [2] Kendler KS, Gardner CO, Prescott CA. Toward a comprehensive developmental model for major depression in woman. Am J Psychiatry 2002;159:1133–45. [3] Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol 2000;68:748–66. [4] Kessler RC, McLaughlin KA, Green JG, Gruber MJ, Sampson NA, Zaslavsky AM, et al. Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys. Br J Psychiatry 2010;197:378–85. [5] Collishaw S, Pickles A, Messer J, Rutter M, Shearer C, Maughan B. Resilience to adult psychopathology following childhood maltreatment: evidence from a community sample. Child Abuse Negl 2007;31:211–29. [6] Wainwright NW, Surtees PG. Childhood adversity, gender and depression over the life-course. J Affect Disord 2002;72:33–44. [7] Hovens J, Wiersma J, Giltay EJ, van Oppen P, Spinhoven P, Penninx BP, et al. Childhood life events and childhood trauma in adult patients with depressive, anxiety and comorbid disorders vs controls. Acta Psychiatr Scand 2010;122:66–74. [8] Heim C, Nemeroff CB. The role of childhood trauma in the neurobiology of mood and anxiety disorders: preclinical and clinical studies. Biol Psychiatry 2001;49:1023–39. [9] Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord 2004;82:217–25. [10] MacMillan HL, Fleming JE, Streiner DL, Lin E, Boyle MH, Jamieson E, et al. Childhood abuse and lifetime psychopathology in a community sample. Am J Psychiatry 2001;158:1878–83. [11] Korkeila K, Korkeila J, Vahtera J, Kivimäki M, Kivelä SL, Sillanmäki L, et al. Childhood adversities, adult risk factors and depressiveness: a population study. Soc Psychiatry Psychiatr Epidemiol 2005;40:700–6. [12] Brown GW, Moran P. Clinical and psychosocial origins of chronic depressive episodes, 1: a community survey. Br J Psychiatry 1994;165:447–52. [13] Wiersma J, Hovens J, van Oppen P, Giltay EJ, van Schaik DJF, Beekman ATF, et al. The importance of childhood trauma and childhood life events for chronicity of depression in adults [CME]. J Clin Psychiatry 2009;70:983–9. [14] van der Vegt EJ, Tieman W, van der Ende J, Ferdinand RF, Verhulst FC, Tiemeier H. Impact of early childhood adversities on adult psychiatric disorders: a study of international adoptees. Soc Psychiatry Psychiatr Epidemiol 2009;44:724–31. [15] Edwards VJ, Holden GW, Felitti VJ, Anda RF. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study. Am J Psychiatry 2003;160: 1453–60. [16] Fergusson DM, Boden JM, Horwood LJ. Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child Abuse Negl 2008;32:607–19. [17] Maercker A, Michael T, Fehm L, Becker ES, Margraf J. Age of traumatisation as a predictor of post-traumatic stress disorder or major depression in young women. Br J Psychiatry 2004;184:482–7. [18] Bowlby J. Attachment and loss: volume 1: attachment. London: The Hogarth Press and the Institute of Psycho-Analysis; 1969.
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