Childhood Maltreatment, Limbic
Dysfunction, Resilience, and
Psychiatric Symptoms
Majed Ashy1,2, Brian Yu3, Ellen Gutowski4, Anna Samkavitz5,6, and
Kathleen Malley-Morrison5
Abstract
:
Previous research has indicated that childhood maltreatment is
predictive of psychiatric symptoms in adulthood. Among the
potential intervening factors in this relationship are affective
reactions in the victims, neurodevelopmental problems, and
resilience. The purpose of this study was to test, in a nonclinical lowrisk sample, an integrative developmentally based
psychoneurological model of the roles of limbic system dysfunction,
shame and guilt, and resiliency as potential intervening variables
between childhood maltreatment and adult psychiatric symptoms.
Also of interest was whether there were gender-specific pathways
from maltreatment to symptoms. Based on the results of preliminary
analyses, several regressions were conducted separately by gender,
entering the different forms of parental aggression at Step 1,
resilience at Step 2, the resilience by parental aggression interaction
term at Step 3, shame and guilt at Step 4, and limbic dysfunction at
Step 5, as predictors of psychiatric symptoms. Analyses indicated
that both maternal psychological maltreatment and paternal physical
maltreatment were predictive of total psychiatric symptomatology in
adulthood, with shame mediating the relationship in women and guilt
mediating it in men, limbic system symptoms mediating the
relationship in both genders, and trait resilience moderating the
relationship in both genders.
Keywords
child maltreatment, shame, guilt, psychiatric symptoms, limbic
system dysfunction, resilience, psychoneurological model
1Developmental
Bio-Psychiatry Research Program, McLean Hospital
(Harvard Medical School), Belmont, MA, USA
2Adult
and Child Therapy Center (ACT), Jeddah, Saudi Arabia
3Tulane
University, New Orleans, LA, USA
4Boston
College, Chestnut Hill, MA, USA
5Boston
University, MA, USA
6Massachusetts
General Hospital, Boston, MA, USA
Corresponding author(s):
Majed Ashy, 53 South Huntington Ave, Apt B2, Jamaica Plain, MA
02130-4715, USA. Email: majed.ashy@gmail.com
:
There is a substantial literature on the negative effects of childhood
maltreatment, with a considerable emphasis on intergenerational
transmission of violence and the contribution of childhood
experience of violence to later psychopathology. Although this
research supports the propositions that violence breeds violence
and violence breeds illness, it also indicates that not every
maltreated child becomes an abusive or mentally ill adult. Moreover,
much of this research (a) lacks a strong theoretical basis, (b)
provides limited information on the developmental mechanisms
contributing to later pathology in maltreated children, (c) relies on
clinical samples, and (d) fails to consider the extent to which
developmental pathways may differ by gender. The purpose of the
current study was to examine an integrative developmentally based,
psychoneurological model of mechanisms that mediate or moderate
the relationship between childhood maltreatment and psychiatric
symptoms in nonclinical samples of women and men. This
developmental model assumes that shame, guilt, and resilience
share with limbic system dysfunction significant psychoneurological
foundations that help elucidate the understudied pathways from
childhood maltreatment to adult symptomatology.
:
Childhood maltreatment encompasses physical abuse (defined as
nonaccidental bodily injury), emotional or psychological abuse
(defined as persistent opposition to basic emotional needs), sexual
abuse, and neglect (Cicchetti & Toth, 2005). According to the U.S.
Department of Health & Human Services, Administration for Children
and Families, Administration on Children, Youth and Families,
Children’s Bureau (2016), an estimated 702,000 children reported
maltreatment in 2014, a rate of 9.4 per 1,000 children. Seventy-five
percent of these children experienced parental or caretaker neglect,
17.0% experienced physical abuse, 8.3% experienced sexual abuse,
and 6.8% experienced other types of maltreatment, such as
psychological (U.S. Department of Health & Human Services,
Administration for Children and Families, Administration on Children,
Youth and Families, Children’s Bureau, 2016).
Moreover, reports such as these from government agencies often
underestimate the true prevalence of abuse (Cicchetti & Toth, 2005;
Gilbert et al., 2009). A study of self-reported childhood maltreatment
in the Eastern and Southeastern United States found 4 to 6 times
greater prevalence of abuse than reported in Child Protection
Services’ records (Everson et al., 2008). In a sample of 15,197 adults,
the National Research Council Panel of Research on Child Abuse and
Neglect found a prevalence rate of 41.5% who had experienced
supervision neglect, such as being left unsupervised when an adult
should have been at home; 11.8% reporting physical neglect, such as
not being cleaned or attended to medically; 28.4% physical assault;
and 4.5% sexual abuse (Hussey, Chang, & Kotch, 2006).
The relationship between childhood maltreatment and later
psychiatric symptomatology has been investigated in many patient
samples. Compared with the general population, patients with the
following conditions have reported greater prevalence of childhood
abuse: major depression (e.g., Mueller-Pfeiffer et al., 2013; Pietrek,
Elbert, Weierstall, Müller, & Rockstroh, 2013); posttraumatic stress
disorder (PTSD; e.g., Alim et al., 2006; Breslau et al., 2014; Khoury,
Tang, Bradley, Cubells, & Ressler, 2010; McQuaid, Pedrelli, McCahill,
& Stein, 2001; Van Voorhees, Dennis, Calhoun, & Beckham, 2014);
somatization disorder and physical symptoms in adulthood (e.g.,
Felitti et al., 1998; Schulte & Petermann, 2011); and bipolar disorder
(Etain et al., 2010; Hyun, Friedman, & Dunner, 2000; Larsson et al.,
2013). Other research indicates that individuals with a history of
childhood physical or sexual abuse exhibit more symptoms of
anxiety (MacMillan et al., 2001; Teicher, Samson, Polcari, &
McGreenery, 2006), depression (MacMillan et al., 2001; Teicher et
al., 2006), and anger-hostility (Teicher et al., 2006) than individuals
not reporting such abuse.
:
In our review of the literature underlying our proposed
psychoneurological model of the developmental pathways from
childhood maltreatment to psychiatric symptoms, the strands of
evidence that contribute to each of the proposed pathways are
considered. To our knowledge, there is no previous research testing
a model of the maltreatment–symptoms relationship that includes
limbic system dysfunction, shame, guilt, and resilience and the
relationships among them.
Neurological Outcomes of Childhood
Maltreatment
:
Studies of the neurodevelopmental outcomes of childhood
maltreatment have tended to focus on its impact on the limbic
system (Teicher et al., 2003). The major structures of the limbic
system consist of the hippocampus (involved in memory formation
and retrieval), the hypothalamus (which regulates the autonomic
nervous system and thereby the stress response), and the amygdala
(involved in emotion processing and regulation). There is evidence
that childhood maltreatment is associated with later limbic system
dysfunction, particularly limbic system irritability (heightened
electrical activity in limbic structures, overreactivity in limbic
structures in response to stress, increased prevalence of symptoms
suggestive of temporal lobe epilepsy; Teicher, 2000).1
In studies using a self-report measure of symptoms of limbic system
irritability (e.g., somatic and perceptual distortions, brief
hallucinatory events, motor automatisms, and dissociative
symptoms), Teicher, Glod, Surrey, and Swett (1993) found positive
associations between childhood maltreatment and symptoms of
limbic abnormality, and Teicher et al. (2006) found that adults with a
history of childhood emotional or physical abuse reported greater
limbic system irritability than those with no abuse; moreover, adults
with combined childhood emotional and physical abuses reported
higher rates of limbic system symptoms than individuals reporting a
single type of abuse. In an exploratory diffusion tensor imaging study
of young adults, Choi, Jeong, Rohan, Polcari, and Teicher (2009)
found that reports of parental verbal abuse during childhood were
associated with reduced neural integrity in pathways also
characterized by increased limbic system irritability.
There has also been research regarding the possibility that
neurobiological outcomes mediate the relationship between
childhood maltreatment and later vulnerability to traumatic stress
and other psychiatric disorders, particularly as related to aggression
(e.g., Lee & Hoaken, 2007). There is some evidence that repeated
exposure to childhood trauma is associated with kindling, a process
of oversensitizing the limbic system (van der Kolk & Saporta, 1991),
and is implicated in lowering the threshold for psychological
vulnerability to subsequent traumas (van der Kolk, McFarlane, &
Weisaeth, 2006). There is also evidence that limbic system
dysfunction is linked to various consequences of childhood
maltreatment pertaining to emotional expression and cognition
(Grassi-Oliveira, Ashy, & Stein, 2008). For example, limbic system
irritability has been found to be positively correlated with psychiatric
symptoms of anxiety, depression, and anger-hostility (Anderson,
Teicher, Polcari, & Renshaw, 2002).
Affective Responses to Childhood
Maltreatment
:
The immediate outcomes of childhood maltreatment include
heightened feelings of shame, feelings that are associated with
psychiatric symptoms. In one longitudinal study of children from
abusive and nonabusive homes, Stuewig and McCloskey (2005)
found that harsh parenting during childhood was associated with
shame-proneness during adolescence and that, over time, shameproneness was associated with depression. In a study looking at
childhood maltreatment and internalized shame in adults diagnosed
with bipolar disorder, Fowke, Ross, and Ashcroft (2012) found that
significantly more participants in their bipolar disorder sample than in
their nonpsychiatric sample reported childhood physical abuse,
emotional abuse, and neglect; levels of internalized shame were also
significantly higher in the bipolar group. Moreover, in the bipolar
group, there were significant positive correlations between all of the
:
childhood maltreatment scores and internalized shame. There
appears to have been little or no research on the relationship
between childhood maltreatment and guilt, and little or no attention
to the possibility of gender differences in any such relationship.
Kim, Thibodeau, and Jorgensen (2001) have emphasized the
importance of differentiating between shame and guilt, both of which
are considered to involve self-evaluative processes related to
important behavioral standards and having important implications for
“social survival” within particular cultural contexts. They describe
shame as involving an inner-directed negative view of the entire self
and guilt as involving an outward-directed negative view of specific
behaviors in regard to others. In their comprehensive review of
relevant studies, they found that shame was much more strongly
related to depression than guilt. In their discussion of their findings,
they suggest that more research is needed to determine the extent
to which sex moderates associations of shame and guilt with
depressive symptoms. In the current study, a somewhat different
approach was taken, examining the extent to which shame and guilt
mediated the relationship between childhood maltreatment and
symptomatology.
Evidence has started to emerge in support of a developmental,
neurological basis for those two “moral” emotions, guilt and shame.
Neuroimaging studies have identified unique activation patterns for
shame and guilt that differ from neutral emotion conditions (Michl et
al., 2014). Both emotions have been found to be associated with
activation in the temporal lobe; however, shame is associated with
greater activation in the medial and anterior frontal lobe, whereas
guilt is associated with activation in the amygdala and insula.
Studies involving lesions and other forms of damage to the prefrontal
cortex have provided further evidence for a neurological basis for
these emotions. For example, patients with lesions in the medial
prefrontal cortex show diminished emotional experience, including
lowered self-conscious emotions that serve a social function, such
as guilt, shame, and embarrassment (e.g., Philippi & Koenigs, 2014).
In a study conducted by Koenigs and colleagues (2007), patients
with focal bilateral damage to the ventromedial prefrontal cortex
showed severely diminished embarrassment and guilt, while
comparison subjects had intact emotional processing. Moreover,
fronto-temporal dementia, which causes degeneration of the medial
prefrontal cortex, is tied to a decline in self-conscious emotions that
are closely linked to shame and guilt (Lewis, 2010; Michl et al., 2014)
such as embarrassment (Philippi & Koenigs, 2014).
Resilience
:
Not all individuals who experience childhood maltreatment develop
psychiatric symptoms; some of these victims appear to be resilient.
Resilience refers to individual characteristics (e.g., positive selfesteem and self-control) and external/environmental factors (e.g.,
family and educational support) that allow individuals to adapt
successfully to stressful situations (Luthar, Cicchetti, & Becker,
2000). In a study of 132 college students, Campbell-Sills, Cohan,
and Stein (2006) identified trait resilience as a protective factor in
the relationship between childhood emotional neglect and present
psychiatric symptoms. In a study of 70 PTSD patients, Daniels et al.
(2012) found trait resilience to be a significant negative predictor of
PTSD symptoms in patients who had reported severe childhood
trauma. In a sample of adults who had experienced childhood sexual
abuse, Ginzburg et al. (2006) found psychiatric symptoms to be
positively correlated with guilt and shame, and negatively correlated
with traits of resilience.
Research exploring neurobiological contributors to resilience has
indicated the importance of genetic and potential epigenetic
mechanisms in response to stress (Feder, Nestler, & Charney, 2009;
:
Southwick & Charney, 2012). Genetic polymorphisms affect limbic
reactivity and prefrontal-limbic connectivity, influencing responses to
traumatic events (Feder et al., 2009). Brain-imaging studies have
confirmed that the prefrontal region is potentially influential in
reducing activity in the amygdalae (Hariri, Bookheimer, & Mazziotta,
2000). Animal studies have also shown the importance of this region
(Southwick & Charney, 2012). Early experiences coping with stress
increase neuroplasticity in the prefrontal cortex, which buffers
against the negative effects of future uncontrollable stress
(Southwick & Charney, 2012). In addition to prefrontal cortical
functioning and capacity to regulate limbic reactivity to stress,
moderators of resilience include effective regulation of the
hypothalamic-pituitary-adrenal (HPA) axis (which influences
hormone secretion in reaction to stress) and the sympathetic
nervous system (SNS; which influences the body’s “fight or flight”
reaction in response to stress) (Southwick & Charney, 2012).
Russo, Murrough, Han, Charney, and Nestler (2012) have noted that
the “study of human resilience is still a mostly phenomenological
literature that has only begun to characterize biological factors in
resilient individuals that are associated with more successful coping
responses” (p. 1475). Based on their review of the scanty relevant
literature, they report that developmentally, childhood abuse affects
the same regions of the brain shown to contribute to resilience, such
as the limbic system. They also found that neurological and genetic
resilience has a buffering effect against depression. Thus, resilience
may involve psychoneurological processes. The research they
summarize on the impact of stress on the limbic system and related
processes, taken together with Teicher and colleagues’ (2006)
conclusions about the neurological impact of childhood abuse,
suggests that childhood abuse may affect the same regions of the
brain shown to contribute to resilience, and that any relationship
between childhood maltreatment and resilience may have a
neurological basis. Previous literature has incorporated resilience, as
well as shame and guilt, into studies investigating neurological
underpinnings of stress outcomes and psychiatric symptoms;
however, the relationship between shame and guilt and resilience
has been neglected, particularly from a developmental
psychoneurological framework that attends to the issue of potential
gender differences in pathways.
Figure 1 provides our proposed model of the relationships among the
variables of interest in the current study: childhood maltreatment as
a predictor, adult psychiatric symptoms as an outcome, shame and
guilt as affective mediators of the maltreatment–psychiatric
outcomes relationship, limbic system dysfunction as a neurological
mediator of the maltreatment–psychiatric outcomes relationship, and
resilience as a moderator of the maltreatment–psychiatric outcomes
relationship. This conceptual model of psychiatric outcomes was
tested in the current study. Specifically, the present study
investigated a conceptual model of psychiatric outcomes in
nonclinical samples of men and women reporting childhood
psychological or physical maltreatment.
Figure 1. Childhood maltreatment model of psychiatric outcomes.
The investigation was guided by the following hypotheses:
Hypothesis 1: Reports of childhood maltreatment will be negatively
correlated with resilience and positively correlated with limbic
dysfunction, guilt, shame, and psychiatric symptoms.
Hypothesis 2: Limbic dysfunction will be negatively correlated with
resilience and positively correlated with guilt, shame, and psychiatric
symptoms.
:
Hypothesis 3: The relationship between childhood maltreatment
and young adult psychiatric symptoms will be mediated by limbic
dysfunction and guilt and shame, and moderated by resilience. Of
particular interest was the extent to which the patterns of
relationships varied by gender.
Method
The current project was a secondary analysis of an available dataset.
Protocols of the project were reviewed and approved by the
university’s Institutional Review Board. The research was conducted
in compliance with all American Psychological Association guidelines
and state and federal laws. All surveys were collected anonymously,
and all participants included in the dataset had given permission for
their anonymous responses to be analyzed in future studies.
Participants
The sample consisted of 439 participants (239 females, 200 males)
recruited by students in a research methods class from a large,
urban university in the Northeastern United States. Participants
ranged in age from 18 to 69 years, with a mean age of 27 years and a
median age of 21 years. The average participant was a non-Hispanic,
White, unmarried college student whose self-reported
socioeconomic status was middle or upper-middle class.
Measures
Demographic Questionnaire
Information regarding sex, age, ethnicity, marital status,
socioeconomic status, and education level was obtained from the
participants.
:
Conflict Tactics Scales: Parent–Child (CTSPC)
The CTSPC is a 44-item questionnaire that measures the selfreported frequency of conflict tactics (negotiation tactics,
psychological aggression, and physical aggression) employed by the
participant’s parents during the “worst year” of the participant’s
childhood (Straus & Hamby, 1997). For each tactic witnessed or
reported by the participant, participants reported frequencies
ranging from 0 (“never happened”) to 6 (“happened more than 20
times”). These numbers were summed to obtain the overall scores
for each conflict subscale. The CTSPC has shown good construct
and discriminant validity and good reliability, with internal
consistencies ranging from .79 to .95 (Ashy, 2003; Straus & Hamby,
1997).
Resilience Scale (RS)
The RS (Wagnild & Young, 1993) is a self-report questionnaire
dealing with self-acceptance and personal competence (e.g., “I
usually take things in stride”; “I am friends with myself”). Originally
consisting of 25 items, the version employed in this study was a
shortened, 10-item questionnaire derived from a factor analysis
performed by Neill and Dias (2001). Participants respond to each
question on a scale of 1 to 7, with 1 being “strongly disagree,” 4 being
“neutral,” and 7 being “strongly agree.” The RS has demonstrated
good construct validity along with high reliability (Wagnild & Young,
1993). A review of resilience instruments by Ahern, Kiehl, Lou Sole,
and Byers (2006) found the RS to be the most suitable instrument to
study resilience in young adults due to its confirmation in multiple
studies.
Limbic System Function Questionnaire (LSCL-33)
:
The LSCL (Teicher et al., 1993) is a 33-item, self-report scale that
asks participants to rate how frequently they experience various
forms of limbic irritability, consisting of visual disturbances, somatic
disturbances (e.g., numbness), dissociative disturbances,
hallucinatory events (e.g., hearing voices), and automatisms (e.g.,
twitching). The LSCL is a noninvasive method of measuring
temporolimbic functioning and has been correlated with the
Dissociative Experiences Scale and the Hopkins Symptoms Checklist
(Teicher et al., 1993). Participants are asked to describe the lifetime
frequency of limbic system events as occurring “never,” “rarely,”
“sometimes,” or “often.” A score of 0, 1, 2, 3, or 4 is assigned for each
item (0 = never, 4 = often). A total score for all 33 items was
calculated, along with scores for sensory, somatic, behavioral, and
mnemonic disturbances. In prior studies, normal adults have
exhibited total LSCL-33 scores lower than 10, while patients
diagnosed with temporal lobe epilepsy have exhibited total LSCL-33
scores in the range of 23 to 60 (Anderson et al., 2002). The LSCL-33
has shown high test–retest reliability, with r = .92 for the whole scale
and .78 to .86 for subscales (Ashy, 2003; Teicher et al., 1993).
Symptom Questionnaire (SQ)
The SQ (Kellner, 1987) is a 92-item, true/false scale with four
symptom subscales (Depression, Anxiety, Anger, Somatization) and
four well-being subscales (Content, Relaxed, Friendly, Somatic WellBeing). The SQ has been validated in a normal population (Teicher,
Samson, Sheu, Polcari, & McGreenery, 2010). The test–retest
reliability of the subscales in various studies was r = .71 for anxiety, r
= .95 for depression, r = .77 for somatic, and r = .82 for hostility
(Ashy, 2003; Kellner, 1987).
Personal Feelings Questionnaire (PFQ-2)
:
The PFQ (Harder & Zalma, 1990) is a 22-item measure that assesses
expressions of shame and guilt. Response choices range from 1
(“You never experience the feeling”) to 4 (“You almost continuously
feel the feeling”). The PFQ has shown good internal consistency and
construct validity with evidence of convergent and discriminant
validity (Harder & Zalma, 1990).
Data Analysis
The t tests were performed to determine whether differences by
gender were present in any of the main variables under investigation
(childhood maltreatment history, psychiatric symptoms, guilt and
shame assessments, limbic system symptom rating, and resilience
score).
To test Hypotheses 1 and 2, Pearson’s correlations were conducted
separately by gender. Based on the outcomes of the bivariate
Pearson correlations, multiple regressions were conducted to
determine the relative contributions of the predictor factor
(childhood maltreatment), the proposed mediators (guilt, shame, and
limbic system symptoms), and the proposed moderator (resilience)
to psychiatric outcomes. Relationships were analyzed separately for
males and females as a function of type of maltreatment (mother
physical, mother psychological, father physical, and father
psychological).2
Results
Descriptive Statistics
:
Table 1 provides means and standard deviations for all study
variables, separately by gender. Participants reported incidences of
parental psychological and physical aggression comparable with
samples in previous studies (Teicher & Parigger, 2015). Furthermore,
their limbic ratings were comparable with those in previous
nonclinical samples (Teicher et al., 1993), as were their reported
levels of anxiety, depression, somatization, and hostility (Kellner,
1987).
As shown in Table 1, t tests revealed significant gender differences
on several study variables. Specifically, male participants reported a
higher incidence of paternal psychological and physical aggression
than females. By contrast, female participants reported higher levels
of guilt and shame, as well as higher levels of anxiety, depression,
somatization, and total psychiatric symptoms than males.
Correlations Between Different Forms of Parental
Aggression and Predicted Outcomes, Mediators,
and Moderator
To test Hypothesis 1 (that exposure to childhood maltreatment would
be negatively correlated with resilience and positively correlated with
limbic system dysfunction, guilt, shame, and psychiatric symptoms),
several correlations were performed, separately by gender. As can
be seen in Table 2, patterns of correlation varied somewhat by
subject gender, type of aggression, and source of aggression.
Parental aggression and later symptoms
:
In females, both maternal and paternal psychological and physical
aggression were significantly positively correlated with all
psychological symptoms and limbic system dysfunction. In males,
paternal and maternal physical aggression were significantly
positively correlated with somatization but uncorrelated with other
psychiatric symptoms, and there were no significant correlations
between psychological aggression from either parent and any
psychiatric symptom or limbic system dysfunction.
Parental aggression and resilience
In females, paternal and maternal psychological aggression, as well
as paternal physical aggression, were significantly negatively
correlated with resilience, whereas in males, only paternal and
maternal physical aggression showed significant negative
correlations with resilience. In females, paternal and maternal
psychological aggression were significantly positively correlated with
shame, and paternal and maternal psychological aggression, as well
as maternal physical aggression, were significantly positively
correlated with guilt. By contrast, in males, paternal and maternal
physical aggression, as well as maternal psychological aggression,
were significantly positively correlated with shame, but no forms of
parental aggression were significantly correlated with guilt.
Correlates of Limbic System Dysfunction,
Separately by Gender
Findings regarding Hypothesis 2 (that limbic dysfunction would be
negatively correlated with resilience and positively correlated with
guilt, shame, and psychiatric symptoms) can be found in Table 3. As
can be seen, for women, limbic system dysfunction was significantly
negatively correlated with resilience and positively correlated with
shame, guilt, and all psychiatric symptoms. In males, limbic
dysfunction was significantly positively correlated with shame, guilt,
and all psychiatric symptoms but was not associated with resilience.
Regression Analyses
:
The results of regression analyses run to test Hypothesis 3 (that the
relationship between childhood maltreatment and adult psychiatric
symptoms would be mediated by limbic system dysfunction, guilt,
and shame, and moderated by trait resilience) can be seen in Tables
4 to 6. The analyses are separated by type of parental aggression
(mother psychological, mother physical, father psychological, and
father physical) and also by gender. In each analysis, total scores for
psychiatric symptoms were regressed first on one specific form of
parental aggression; resilience scores were added at Step 2; the
resilience by parental aggression interaction term was added at Step
3; guilt and shame were added at Step 4; and limbic system
dysfunction was added at Step 5.
As shown in Step 1 of Tables 4 to 6, each type of parental
maltreatment contributed significantly to psychiatric symptoms in
females; however, in males, only paternal physical aggression
contributed significantly to psychiatric symptoms, with maternal
physical aggression and paternal psychological aggression making
only marginally significant contributions. In both males and females,
trait resilience added significantly to variance in psychiatric
symptoms at Step 2 of each equation. The resilience by parental
aggression interaction term, added at Step 3, did not add
significantly to variance explained in any of the equations. At Step 4,
in females, shame and guilt added significantly to variance in
symptomatology, but the Betas revealed that it was only shame that
added significantly to psychiatric outcomes in all four parental
aggression analyses. In males, it was guilt that added significantly to
variance in psychiatric symptoms in each equation. At the final step,
limbic system symptoms added significantly to prediction of
psychiatric symptoms in both males and females in all four
equations.
Discussion
:
The goal of this developmentally based psychoneurological study
was to examine the relationships among childhood maltreatment,
limbic dysfunction, trait resilience, shame and guilt, and psychiatric
symptoms, and to determine whether those relationships varied by
gender. It was predicted that shame and guilt and limbic dysfunction
would mediate, and resilience would moderate the relationships
between childhood maltreatment and later psychiatric symptoms.
The findings of this investigation indicated that maternal
psychological maltreatment and paternal physical maltreatment were
predictive of total psychiatric symptomatology in adulthood, with
shame contributing to symptomatology in women and guilt in men.
Limbic dysfunction was found to play a significant role in mediating
the relationship between childhood maltreatment and psychiatric
symptoms, whereas trait resilience was found to play a moderating,
protective role in predicting psychiatric symptomatology.
:
In our preliminary analyses, female participants scored higher than
males in anxiety, depression, somatization, guilt, shame, and total
psychiatric symptoms. These findings are consistent with other
studies showing higher scores in females than in males in
somatization (e.g., Ashy, 2003; Teicher et al., 1993), anxiety and
depression (e.g., Altemus, 2006; Piccinelli & Wilkinson, 2000),
shame and guilt (e.g., Else-Quest, Higgins, Allison, & Morton, 2012;
Hoglund & Nicholas, 1995), and a range of internalizing symptoms
(e.g., Kramer, Krueger, & Hicks, 2008). Males reported more paternal
psychological and physical aggression than females, which is
consistent with previous research findings (Ashy, 2003; Ashy &
Malley-Morrison, 2000).
The first hypothesis in our developmentally based
psychoneurological model, that exposure to childhood maltreatment
would be negatively correlated with resilience and positively
correlated with limbic dysfunction, guilt, shame, and psychiatric
symptoms, was partially supported in both males and females. These
correlations are consistent with the results of previous research on
:
childhood maltreatment and resilience in adulthood (e.g., Luthar et
al., 2000), as well as research on childhood maltreatment and limbic
dysfunction in adulthood (e.g., Anderson et al., 2002; Ashy, 2003;
Teicher et al., 2006). The positive association between childhood
maltreatment and guilt and shame is also consistent with research
showing high levels of negative self-perception and neuroticism in
individuals with traumatic experiences (Campbell-Sills et al., 2006;
Kling, Ryff, Love, & Essex, 2003).
From a psychoneurological perspective, a possible basis for the link
between childhood maltreatment and limbic dysfunction can be
found at the biological level, as enhanced activity of stress response
systems may cause the brain to follow alternative developmental
pathways to manage an environment of heightened stressors
(Teicher et al., 2006). Moreover, the negative associations found
between maltreatment and resilience can be considered in light of
the altered environment experienced by maltreated children; what
may constitute resilience in an abnormally stressful environment may
not characterize resilience in the normal environment as measured
by the Reslience Scale (Wagnild & Young, 1993). Furthermore, the
contribution of childhood maltreatment to feelings of guilt and
shame may be explained through limbic dysfunction or through
behavioral and cognitive mechanisms, such as a negative selfconcept and behavioral inhibition, or through internalization of blame
for the experienced abuse.
There were several gender-specific findings related to the first
hypothesis. Exposure to maltreatment was associated with all
psychiatric symptoms in females; however, in males, exposure to
maltreatment was associated only with somatization. One possible
explanation for this finding is that the connection between abuse and
psychiatric symptoms is direct in females but may be indirect in
males through other variables such as alcohol and substance abuse
(Kessler et al., 1994).
:
The second hypothesis, that limbic dysfunction would be negatively
correlated with resilience and positively correlated with guilt, shame,
and psychiatric symptoms, was partially supported, with some
variations observed for males and females. The negative association
between limbic dysfunction and resilience was supported in females
but not in males; this association was not robust, so further study
would be appropriate. Resilience has been shown to be a moderator
of psychiatric symptoms and PTSD in both males and females with
histories of childhood trauma (Campbell-Sills et al., 2006; Daniels et
al., 2012), and the amygdala has been implicated in the ability to
regulate emotions in response to fearful stimuli (Amorapanth,
LeDoux, & Nader, 2000). As the limbic system is involved in
emotional regulation, and resilience is conceptualized as the ability
to regulate emotions, the limbic dysfunctions might be affecting the
core of resilience.
In support of our developmentally based psychoneurological model,
the positive relationships among self-reported limbic dysfunction,
guilt, and shame are consistent with functional magnetic resonance
imaging (fMRI) studies showing activation of the amygdala in
response to hostile stimuli (Aleman & Swart, 2008; Sambataro et al.,
2006). The association between limbic dysfunction and psychiatric
symptoms is consistent with findings from Teicher et al. (2006)
indicating comparatively large effect sizes for anxiety, depression,
and hostility in individuals exposed to childhood traumas compared
with individuals not reporting such exposure.
The third hypothesis, which was the most direct test of our
integrated developmentally based psychoneurological model,
predicted that resilience, guilt, shame, and limbic dysfunction are
intervening variables between childhood maltreatment and adult
psychiatric symptoms; this hypothesis was supported by the results
of the linear regression analyses. In females, maternal and paternal
psychological aggression, shame, limbic system dysfunction, and
:
resilience contributed significantly to the variance in psychiatric
symptoms, with shame as a major predictor of symptoms and a
mediator of the childhood aggression–symptoms relationship. In
males, paternal physical aggression, guilt, limbic system dysfunction,
and resilience contributed significantly to the variance in psychiatric
symptoms, with guilt as a major predictor of symptoms and a
mediator of the maltreatment–symptoms relationship. Based on the
regression analysis, limbic system dysfunction, guilt, and shame can
be seen as risk factors for psychiatric symptoms (with some variation
by gender), while, consistent with previous research (Campbell-Sills
et al., 2006), resilience can be seen as a protective factor.
Of particular interest are the findings concerning shame and guilt,
which provide some support for a partially gender-specific pathway
from childhood maltreatment to psychiatric symptomatology. These
findings make sense in regard to the literature, indicating that
abused females tend to express their distress through internalizing
symptoms and abused males tend to express their distress more
through externalizing symptoms. The findings also have clinical
implications, suggesting that child and adolescent clinicians might
do well to address symptoms of extreme shame or guilt in an effort
to subvert the development of psychiatric symptoms, particularly in
traumatized youth. Moreover, Sable, Danis, Mauzy, and Gallagher
(2006) found that shame and guilt were barriers to the reporting of
sexual assault in college students; shame and guilt may play similar
roles in maltreated children.
The nature of the sample recruited for this study has both negative
and positive implications. On one hand, finding support for
hypotheses derived from our developmentally based
psychoneurological model in a relatively advantaged nonclinical
sample testifies to the power of these relationships in a sample with
access to environmental protective factors that are not typically
available to severely maltreated children (Garmezy, 1991). On the
other hand, inclusion of a higher risk sample would have provided
additional confirmation of the generalizability of the proposed
pathways between various levels of maltreatment and
developmentally based psychoneurological outcomes.
Like most studies, the present study has limitations that point to the
need for future research. For example, our version of the widely used
childhood maltreatment measure included only physical and
psychological maltreatment from parents to child. Other forms of
childhood maltreatment, including neglect, sexual trauma, witnessed
violence between parents, sibling and peer aggressions, and abuses
by authority figures outside the home, are potential areas for future
research. Future tests of the model might consider the extent to
which social class and other demographic variables moderate the
relationships described in our current model and the extent to which
gender differences vary by culture.
:
The risk of recall bias in the use of CTS might be considered another
limitation, and indeed has been identified as a limitation in at least
one critical review of literature analyzing studies of childhood
maltreatment as a predictor of intimate partner violence (GilGonzalez, Vives-Cases, Ruiz, Carrasco-Portino, & Alvarez-Dardet,
2008). However, the CTS has been administered numerous times in
studies all around the world and has gained consistent support for its
validity. Given that the findings of this study are largely consistent
with the predictions of the conceptual model, this suggests that
recall bias is not a unique problem for this study and does not call
the findings of this study into question.
Another limitation of the project was its technical inability to specify
and assess dysfunctions in particular limbic areas or other areas
such as the prefrontal cortex. Childhood emotional maltreatment has
been found to be linked to changes in the medial prefrontal cortex
(mPFC) morphology. In addition, child emotional maltreatment has
been linked to amygdala hyperactivity and increased risk for the
development of psychopathology (van Harmelen et al., 2014). Future
research should use imaging techniques and physiological
instruments to confirm limbic dysfunction through direct
assessments of the brain. Moreover, resilience is a relatively new
area of research, and multilevel analysis may be needed to
understand the complex phenomena that determine individual levels
of resilience and their relevance to various psychiatric disorders.
Despite these limitations, these findings provide a basis for some
optimism regarding the development of individuals who have been
maltreated in childhood. Even if maltreatment has the power to affect
neurological functioning, the development of resilience can help
counter the long-term negative effects of maltreatment. Indeed, the
findings of this study may have implications for health care
professionals. The mediating role of resilience suggests that
treatment of individuals who have experienced childhood traumas
should focus on the psychological resources available to the
individual in addition to his or her vulnerabilities.
Authors’ Note
The authors of this article would like to acknowledge Victoria
Guskiewicz, Kimberly Roemer, and Kyle Shields of Merrimack
College for their contribution in editing the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
:
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Notes
1.
Although language varies somewhat across studies, in this article,
when we refer to limbic system dysfunction, we are focusing on
limbic system irritability.
2.
The issue of multiple comparisons is complex, and there are multiple
perspectives on the issue. The most popular argument is that if a lot
of statistical tests are performed with alpha set at .05, some of them
will be statistically significant by chance alone, so that some sort of
adjustment of alpha, to make it more rigorous, is needed. The most
common adjustment is the Bonferroni correction. However, the
assumptions behind the Bonferroni correction have met with
important challenges. For example, Perneger (1998) has argued that
“adjusting statistical significance for the number of tests that have
been performed on study data—the Bonferroni method—creates
more problems than it solves.”
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Author Biographies
:
Majed Ashy received his BA, MA, and PhD, in psychology from
Boston University and did his post doctorate in Psychiatric research
at McLean Hospital/Harvard Medical School, and a post doctorate at
the Mind, Brain, and Learning Program at the The Graduate School of
Education at Harvard University. His research interests are in the
areas of childhood maltreatment and the brain,
psychoneuroimmunology, cross-cultural psychology, and political
psychology. His publications include chapters in The Encyclopedia of
Psychological Trauma (Wiley & Sons, 2008), International
Perspectives on Family Violence and Abuse (Erlbaum, 2004), and
Stress in Health and Disease (Wiley-V-CH Verlag GmbH & Co. KGaA,
Weinhem, 2006).
Brian Yu received his MA from Boston University School of Public
Health and is a Medical Student at Tulane University.
Ellen Gutowski is a doctoral student in Counseling Psychology at
Boston College. Her research interests include poverty reduction,
community interventions, and the economic empowerment of people
who have experienced marginalization including youth, women, and
trauma survivors. She has previously worked as a lab manager at
Boston University, served in the Peace Corps, and worked clinically
in Boston area counseling settings.
Anna Samkavitz received her bachelor’s degree in psychology from
Boston University. She currently works as a clinical research
coordinator in the Psychiatric & Neurodevelopmental Genetics Unit
at Massachusetts General Hospital.
:
Kathleen Malley-Morrison is a professor emerita of psychology in
the Development Science Program, Boston University. She is lead
author (with Denise A. Hines) of Family Violence in a Cultural
Perspective (Sage, 2004), co-author of Family Violence in the United
States: Defining, Understanding, and Combating Abuse (Sage,
2005), and editor of International Perspectives on Family Violence
and Abuse (Erlbaum, 2004). She also assembled and edited a four
volume series on State Violence and the Right to Peace, the
International Handbook of War, Torture, and Terrorism (with Hines
and McCarthy), and the International Handbook of Peace and
Reconciliation (with Mercurio and Twose). She has a blog,
http://engagingpeace.com, and monthly e-newsletter, Choosing
peace for good.