اثرات و عوارض مصرف دوران کودکی بر پیچیدگی علائم در نمونه های بالینی: اثرات واسطه ای مشکلات تنظیم احساسات

The purpose of the present study was to first examine whether childhood abuse predicts symptom complexity, as indicated by the number of clinically elevated scales on the MMPI-2 in an adult clinical sample. Secondly, we investigated whether emotion regulation difficulties mediated the relationship between childhood abuse and symptom complexity. A total of 162 adult outpatients not presenting with psychotic symptoms completed the Korean Childhood Trauma Questionnaire (K-CTQ), Life Events Checklist (LEC), Difficulties in Emotion Regulation Scale (DERS), and Korean Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Partial correlation analysis results indicated that after controlling for the presence of adulthood trauma, childhood abuse was associated with more symptom complexity, or more clinically elevated scales on the MMPI-2. Furthermore, structural equation modeling results showed that emotion regulation difficulties partially mediated the relationship between childhood abuse and symptom complexity. These findings indicate that individuals who had experienced childhood abuse evidence simultaneous presentation of diverse clinical symptoms.

It has been widely recognized that childhood abuse serves as a significant risk factor for maladjustment and psychopathology in adulthood (Briere and Rickards, 2007 and Cicchetti et al., 1995). Studies focusing on community and clinical samples consistently report a significant correlation among childhood emotional, physical, and sexual abuse and impairment in diverse functional domains, as well as indices of psychopathology such as posttraumatic stress, depression, substance abuse, and suicidal ideation in adulthood (Briere and Runtz, 1988, Fergusson et al., 2008, Min et al., 2007, Rowan et al., 1994 and Schaaf and McCanne, 1998). Interpersonal trauma such as childhood abuse is associated with symptom sequelae which are different from typical posttraumatic stress disorder (PTSD), and thus, such a clinical presentation has been posited to be a unique variation of PTSD. Herman (1992) and Pelcovitz and colleagues (1997) had proposed an independent diagnosis of Complex PTSD or Disorders of Extreme Stress Not Otherwise Specified (DESNOS) manifested as alterations in six areas of functioning such as regulation of affect and impulses, attention and consciousness, self-perception, somatization, relations with others, and systems of meaning. Such propositions attempted to explain the consequences of cumulative childhood trauma as a unique pathological entity. If Complex PTSD or DESNOS focused on the psychopathological presentation as an independent specific diagnostic entity, the concept of symptom complexity can be construed as a more comprehensive construct encompassing more diverse symptoms that are presented simultaneously. Indeed, several researchers have focused on the complexity in symptomatology as a unique negative consequence of childhood trauma. Symptom complexity has been defined as more different kinds of symptoms that occur simultaneously, or multisymptom clinical presentations ( Briere, Kaltman, & Green, 2008). Thus, symptom complexity refers to a complex symptom presentation that includes not only difficulties related to mood or social withdrawal, reflecting disturbances predominantly in affective and interpersonal domains, but also symptoms such as destructive behavior and anger ( Cloitre et al., 2009). In this vein, symptom complexity does not reflect the severity of clinical symptomatology per se but presentation of multiple symptoms across diverse domains of psychopathology. For instance, greater number of cumulative childhood trauma was positively associated with clinical levels of symptomatology in 10 different symptom subdomains such as anxiety arousal, depression, sensitivity, and re-experiencing on the Trauma Symptom Inventory (Briere et al., 2008). This finding suggests that childhood trauma is related to symptom complexity in adulthood. Cloitre and colleagues (2009) examined whether more types of childhood trauma experienced (e.g., sexual abuse, physical abuse, neglect, emotional abuse, separation from mother) is associated with symptom complexity in a sample of women seeking treatment for abuse. Symptom complexity in this study was assessed through the number of clinically elevated levels of symptomatology in six symptom types across three domains such as symptoms of posttraumatic stress, emotion dysregulation, and problems in interpersonal relationship. Interest in symptom complexity shares the context of Complex PTSD or DESNOS in that repeated trauma that persists from the early phase of development leads to complex symptomatology secondary to not only disruption in self-concept or trust but also impairment in basic emotion regulation capacity. Emotion regulation has been defined in diverse ways, but in general, it has been regarded as both an internal and external process wherein an individual monitors, evaluates, corrects and modulates emotional responses, in particular emotional responses characterized by intense and transient nature for the purpose of attaining a goal (Thompson, 1994). Extant studies have consistently demonstrated that difficulties in emotion regulation is associated with diverse psychological problems such as depression, anxiety, and posttraumatic stress symptoms (Eftekhari et al., 2009, McLaughlin et al., 2011 and Price et al., 2006). It has been demonstrated that higher-order cortical structures, particularly the prefrontal cortex and its subunits, mediate attempts to regulate emotions, structures implicated in studies examining fear and anxiety (Quirk & Beer, 2006). In the case of trauma-related stress response, overwhelming anxiety or intense negative affective experience not only triggers PTSD symptoms such as anxiety-arousal response but also general emotion regulation difficulties such as reactivity and arousal regulation problems (Ford, Wasser, & Connor, 2011). In other words, trauma disturbs the anxiety-arousal response system and in this vein, the re-experiencing and hyperarousal responses characteristic of PTSD may also be considered as a form of emotion regulation difficulty that is associated with diverse psychological problems and general functional impairment (Tull, Barrett, McMillan, & Roemer, 2007). In particular, abuse experience in childhood when emotion regulation skills have not been adequately acquired or developed may magnify changes in reactivity and ultimately interfere with children's achievement of adequate self-soothing and other emotion regulation strategies (Cloitre et al., 2005, Kim and Cicchetti, 2009 and Maughan and Cicchetti, 2002). This notion has been suggested as one reason why there exists a greater likelihood of survivors of childhood trauma to manifest more complex clinical symptomatology in adulthood in addition to the characteristic emotion regulation difficulties. Recent studies have looked more particularly into the role of emotion regulation as both a direct negative consequence of childhood abuse and also as a mediator in the relationship between childhood abuse and subsequent psychological problems. Abused children evidenced more externalizing problems such as aggressive behavior as well as more internalizing problems such as depression and anxiety and such results were mediated by impairments in emotion regulation (Schwartz and Proctor, 2000 and Shields and Cicchetti, 2001). Such impairment in emotion regulation also mediated the relationship between cumulative trauma and behavior problems (Choi and Oh, 2014). Childhood interpersonal trauma significantly predicted emotion regulation difficulties and such difficulties mediated the relationship between childhood interpersonal trauma and interpersonal functioning and many adjustment-related problems (Briere and Rickards, 2007 and Cloitre et al., 2005). In summary, extant research suggests the childhood trauma such as abuse results in significant negative consequences and that impairment in emotion regulation is both a negative consequence and an important mechanism connecting the experience of childhood trauma with subsequent difficulties. Furthermore, one of the unique features of such negative consequence of childhood trauma is the manifestation of symptom complexity. However, extant research has mostly focused on complex PTSD as reflective of symptom complexity. This precludes the possibility that symptom presentation related to childhood abuse can be simultaneously manifested across diverse symptom domains in the actual clinical setting. As such, using a tool such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), which can measure not only symptoms of affective or relational dysfunction but more comprehensive psychiatric symptoms and personality-related issues, may assist in evaluating symptom complexity. The MMPI-2 holds the advantage as a well standardized and validated tool that is applicable to diverse clinical samples and capable of assessing diverse clinical symptoms. One study utilized the MMPI to examine the characteristics of Complex PTSD (Reinhard, Wolf, & Cozolino, 2010). Inpatients diagnosed with anxiety and mood disorders who reported a history of abuse exhibited significant differences on Scale 8 (Schizophrenia) and a subscale assessing neurological dysfunction compared to inpatients without a history of abuse. This was discussed to be reflective of cognitive disturbance and somatization tendency that is central to Complex PTSD (Reinhard et al., 2010). As such, the purpose of the present study was to first examine whether childhood abuse is related to symptom complexity, as indicated by the number of simultaneously elevated clinical scales on the MMPI-2. We also examined the mediating role of emotion regulation in the relationship between childhood abuse and symptom complexity. Previous research typically examined individuals who had been exposed to specific trauma or focused on particular clinical samples. Participants exhibiting more diverse clinical symptomatology were included in the present study.