Depression Research and Treatment
Volume 2015 (2015), Article ID 650804, 11 pages
http://dx.doi.org/10.1155/2015/650804

Research Article

Childhood Trauma and Its Relation to Chronic Depression in Adulthood

Alexa Negele,¹ Johannes Kaufhold,¹ Lisa Kallenbach,¹ and Marianne Leuzinger-Bohleber1,2

¹Sigmund-Freud-Institute, 60323 Frankfurt, Germany
²University of Kassel, Psychoanalytical Psychology, 34127 Kassel, Germany

Received 24 June 2015; Revised 25 October 2015; Accepted 29 October 2015

Academic Editor: Janusz K. Rybakowski

Copyright © 2015 Alexa Negele et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

There is a large consensus indicating that childhood trauma is significantly involved in the development of depression. The aim of this study was to examine the prevalence of retrospectively recalled childhood trauma in chronically depressed patients and to investigate a more specific relationship between trauma type and depression. We further asked for the influence of multiple experiences of childhood trauma on the vulnerability to a chronic course of depression in adulthood. 349 chronically depressed patients of the German LAC Depression Study completed the Childhood Trauma Questionnaire, a self-report measure of traumatic experiences in childhood. 75.6% of the chronically depressed patients reported clinically significant histories of childhood trauma. 37% of the chronically depressed patients reported multiple childhood traumatization. Experiences of multiple trauma also led to significantly more severe depressive symptoms. Stepwise multiple regression analysis suggested that childhood emotional abuse and sexual abuse were significantly associated with a higher symptom severity in chronically depressed adults. Yet, expanding the regression model for multiple exposures showed that multiplicity was the only remaining significant predictor for symptom severity in chronically depressed patients. Clinical implications suggest a precise assessment of childhood trauma in chronically depressed patients with a focus on emotional abuse, sexual abuse, and multiple exposures to childhood trauma. This trial is registered with registration number ISRCTN91956346.

1. Introduction

Among the leading causes of the global burden of disease depression currently ranks third place worldwide and first place in middle- and high-income countries [1, p. 43]. Wittchen et al. [2] even reported depression to be “by far the most burdensome disorder of all diseases in the EU” (p. 669). It is predicted that by 2020 depression will have jumped to second place [3]. Depression has a high risk of recidivism: 50% after the first, 70% after the second, and 90% after the third episode [4]; 50% of patients relapse after any form of short-term psychotherapy [5]. 20 to 30% of patients with major depression do not respond to antidepressant medication and one-third of those who initially responded relapse within a year [6]. Depressed patients form a heterogeneous group showing quite different pathogeneses. Traumatic experiences in childhood can be found in most multifactor models on etiopathogenesis as a psychosocial aspect of depression (e.g., [7–10]). Epigenetic studies further substantiate the finding that a genetic vulnerability will only lead to depression if the individual experienced simultaneous early traumatization. Caspi et al. [11] showed that early separation trauma triggers the 5-HTTLPR allele in turn regulating relevant neurotransmitters hence evoking depression. Childhood trauma may be one decisive source of heterogeneity that may also depend on trauma type [10].

Trauma can be understood as a “relational” term, a concept that connects an outer occurrence with its specific consequences for an inner psychic reality [12, 13]. Referring to Cooper [14] psychic trauma is any psychological event that abruptly overwhelms the capacity to “provide a minimal sense of safety and integrative intactness, resulting in overwhelming anxiety or helplessness, or the threat of it, and producing an enduring change in the psychic organization” (p. 44). With single trauma versus multiple trauma the accumulation of traumatic experiences can be differentiated. In multiple trauma different traumatic events or situations can either simultaneously, sequentially [15], complexly [16, 17], or cumulatively [18] be effective and thereby manifold their impacts [12, 19–21]. Terr [22] differentiated between type I and type II trauma. Type I trauma conceptualized as “one sudden blow” (p. 13) following from an “unanticipated single event” (p. 14). Type II trauma refers to “longstanding or repeated exposure to extreme external events” (p. 15).

Clinical and survey studies show in general a significantly higher prevalence of childhood trauma in mental disorders (e.g., [12, 23, 24]) emphasizing a nonspecificity of traumatic experiences as risk factors for the vulnerability to different forms of psychopathology. Nonetheless, the relationship of childhood trauma and an increased risk of depression in adulthood has been confirmed in several cross-sectional (e.g., [25, 26]) and longitudinal (e.g., [27, 28]) studies. Most studies rely on either community based surveys (e.g., [26, 27, 29–31]) or psychiatric outpatient samples with heterogeneous (e.g., [24, 32]) or homogeneous (e.g., [33]) psychopathology and also ask for a possible relative specificity of trauma types and diagnoses.

For example, several studies (e.g., [10, 34, 35]) documented the association of sexual abuse in childhood and depression in adulthood. Molnar et al. [26] showed that among men and women suffering from sexual abuse the risk of developing a depression was 1.8 times higher. Others [34] even discuss four times higher risk. Fergusson and Mullen [34] reported in their community survey that 60% of the women with exposure to childhood sexual abuse fulfilled the criteria of a chronic major depression. Furthermore, empirical findings showed that emotional abuse (e.g., [23, 30–32]) and emotional neglect (e.g., [10, 27, 31, 33]) increase the vulnerability to develop a major depression in adulthood. The more chronic the abuse, the higher the lifetime prevalence [27]. Subic-Wrana et al. [24] analyzed the specific relationship of trauma types and frequencies of diagnoses in a general clinical sample and found an association of emotional abuse with depression and personality disorders (see also [36]) and an association of physical abuse with somatoform disorders. However, sexual abuse was associated with adjustment and posttraumatic stress disorders [24]. Accordingly, Fernando et al. [37] reported in a study on the impact of childhood trauma on emotion regulation in borderline personality disorders and major depression significantly higher scores on emotional abuse and emotional neglect in depressed patients, yet borderline patients reported significantly more emotional abuse than did depressed patients. Bernet and Stein [38] assessed 47 adults with major depression and 41 healthy controls who were given the CTQ. Patients with major depression reported significantly more severe emotional abuse, emotional neglect, and physical abuse in childhood. Also Gibb et al. [32] found in a psychiatric outpatient study that childhood emotional abuse was related to major depression, posttraumatic stress disorder, and social phobia, whereas physical and sexual abuse were related to anxiety disorders. Etain et al. [39] confirmed this same preferential association of emotional abuse for a group of bipolar patients. And Spinhoven et al. [33] found emotional neglect as the predictor of depressive disorders, dysthymia, and social phobia.

Another central finding was the relationship between the number of different types of childhood maltreatment and the risk for mental or medical disorders (e.g., [27, 28, 30, 31, 39, 40]). Multiple traumatic experiences are also assumed to have a substantial impact on the persistence or chronicity of severe depressive symptoms (e.g., [41]). For example, Wiersma et al. [42] reported a dose-response relationship between frequencies of childhood trauma and chronicity of depression and identified childhood trauma as an independent determinant of chronicity of depression. Tanskanen et al. [28] confirmed in a large two-year follow-up community sample that life-threatening accidents, victimization by violent crime, domestic violence, and childhood sexual abuse were significantly higher among “persistent depressives” (p. 461); multiple traumatic experiences substantially increased this likelihood. Widom et al. [27] showed in their prospective longitudinal study on abused and neglected children that children who experienced multiple forms of abuse or neglect were at elevated risk for the development of a later depression. Experiences of multiple childhood trauma also correlate with severity of trauma (e.g., [43]). Khan et al. [31] confirmed this graded dose-response relationship for multiplicity of trauma and depression.

Few studies explicitly compared chronically and nonchronically depressed patients with respect to childhood trauma: Wiersma et al. [42] found besides the longer illness duration significantly more severe symptoms of depression measured by the Inventory of Depressive Symptomatology-Self-Report (IDS-SR) in chronically depressed patients against nonchronically depressed patients signaling thresholds from moderate to severe symptoms and from moderate to mild symptoms, contrastingly. Klein et al. [44] showed in a ten-year follow-up study on the course of chronic and nonchronic depression that patients with dysthymia showed slower rates of improvement over time and higher symptom levels at 10-year assessments. Further, dysthymic patients met symptom criteria for depressive disorder over a period of 60% of the follow-up, compared to 21% for patients with nonchronic depressive disorders. Hence, authors suggested chronic depression to be “more severe condition when considered from a longitudinal perspective” (p. 878).

Moreover, chronicity in contrast to nonchronicity of depression was significantly associated with emotional neglect, psychological abuse, physical abuse, and sexual abuse [42] (the ladder also more frequently in chronic compared with nonchronic outpatients [45]). Spinhoven et al. [33] reported dysthymia to show even higher significant associations with the childhood adversities emotional neglect and sexual abuse than did depression (p. 109). Riso et al. [46] elaborated in their review that the development of chronic depression compared to nonchronic forms may involve increased levels of childhood adversity. Amongst others, longer duration and higher symptom severity were each associated with multiple forms of childhood adversity in especially chronic depression [47]. A history of childhood abuse also predicted a lower probability of remission [47].

Reported studies not only were based on distinct samples but also relied on a variety of measures and different diagnostic procedures. Though several studies used the Childhood Trauma Questionnaire (CTQ) (e.g., [24, 32, 37, 38, 42, 45]), others applied childhood trauma questions (e.g., [28, 40]), scales [31], childhood trauma lists (e.g., [26]), and childhood trauma interviews (e.g., [33, 40]), or abused or neglected children were drawn from records of criminal courts (e.g., [27]). Some studies administered diagnostic interviews yielding DSM-III/IV diagnoses (e.g., [26, 31–33, 45]), and others relied on medical diagnoses (e.g., [24]) or applied symptom inventories (e.g., [27, 28, 37, 42]).

The aims of this study were to examine extent and types of retrospectively reported childhood abuse and neglect in adult patients suffering from acute chronic forms of depression operationalized as either diagnosis of dysthymia or double depression lasting for at least 24 months or longer or a major depressive episode currently lasting for at least 12 months or longer. The CTQ was used to assess patients’ type and level of childhood abuses and/or neglect. We predicted that a substantially high number of the chronically depressed patients would report suffering from childhood trauma. We further assumed a substantially high number of patients reporting experiences of severe and of multiple trauma in childhood. We predicted that depressed patients with multiple trauma reports differed from patients with fewer trauma reports in symptom severity assessed by the Beck Depression Inventory (BDI-2) referring to reportedly higher symptom severity in chronically depressed patients (e.g., [42, 44, 47]). Secondly, we investigated the association between trauma types and symptom severity in chronically depressed patients and asked for the specificity of trauma types or multiplicity.

2. Methods

2.1. Participants

Chronically depressed patients (according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, DSM-IV [48]) were recruited within the German LAC Depression Study between 2007 and 2013. LAC is an abbreviation for long-term treatment of chronically depressed patients in German. The study examines the outcomes of psychotherapeutic long-term treatments and compares psychoanalytic with cognitive-behavioral therapies. The multicentre study combines a naturalistic and randomized-controlled trial design. Patients between 21 and 60 years of age were included. Patients had to currently meet a DSM-IV [48] diagnosis of either a major depressive episode already lasting for at least 12 months or longer or a dysthymia lasting for at least 24 months or longer at study intake, respectively. Hence, chronicity was operationalized as a function of time within diagnoses. In addition, patients had to meet a BDI-2 score of above 17 and a Quick Inventory of Depressive Symptoms (QIDS-C, clinician version) score of above 9. Exclusion criteria included ongoing or previous psychotic symptoms, substance dependence, dementia or decrements in cognitive functioning, a borderline, schizotypal, schizoid, paranoid, or antisocial personality disorder, a severe acute or chronic somatic disease, and acute suicidal intentions. The Ethics Review Commission of the Federal Chamber of Psychotherapy of the State of Hessen, Germany, approved the study protocol. The study was registered with ISRCTN91956346. Written informed consent was obtained from all participants after they had been provided with a full description of the study. The study design is published in detail elsewhere [49–51].

2.2. Measures

Diagnoses were made by independent, trained, and supervised interviewers using the German version of the Structured Clinical Interview for DSM-IV (SCID I and SCID II) [52]. Chronicity was operationalized as a function of time: Major depressive episodes had to last for at least 12 months already at study intake (which extends the diagnostic minimum requirement of two weeks). Diagnoses of dysthymia or double depression indicate depressive symptoms of at least 24 months or longer at study intake. BDI-2 [53] and the QIDS-C [54] were used to assess symptom severity. The global severity index of the Symptom-Checklist (SCL-90-R) [55] indicated self-reported global distress.

Childhood trauma was examined using the German short version of the CTQ, a 28-item, clinically and nonclinically well-validated self-report measure developed by Bernstein et al. [56–58] (for the German version see [59–61]). Only within the scale sexual abuse the perpetrator remains indefinite. The other scales capture traumatic experiences within family. Thus, the CTQ pictures traumatic experiences within primary relations actually expected to offer protection and holding (see also [24]). The retrospective self-report of childhood memories yields five subscales of neglect and abuses on a five-point Likert-scale ranging from 1 “never true” to 5 “very often true”: emotional neglect and physical neglect, emotional abuse, physical abuse, and sexual abuse. Each subscale consists of five items (for subscale details see [57, p. 2]). Higher scores signal a higher extent of traumatic experience. Emotional neglect refers to the lack of holding and support as well as the deficient provision of emotional needs such as love and belonging (item example: “When I was growing up my family was a course of strength and support”). Emotional abuse refers to an atmosphere of hatred, threat, demeaning, and humiliation and pictures verbal abuses on a child’s sense of worth or wellbeing (item example: “When I was growing up someone in my family hated me”). Physical neglect refers to the lack of basic physical needs such as food and shelter and a sense of safeness (item example: “When I was growing up I did not have enough to eat.”) Physical abuse refers to physical assaults resulting in injury or risk (item example: “When I was growing up I got hit so hard by someone in my family that I had to go see a doctor or go to the hospital.”) Sexual abuse corresponds to any sexual contact including coercion between a child and an adult (item example: “When I was growing up, someone tried to touch me in a sexual way or tried to make me touch them”). Walker et al. [62] externally validated the measure by an experienced clinical interviewer who was blind to CTQ scores and determined whether reports of trauma histories represented clinically significant abuses or neglect. Following this clinical focus, the authors calculated cutoff scores using thresholds in order to specifically examine clinically relevant traumatic experiences. In the present study these cutoff scores were used to classify patients according to types of reported childhood neglect or abuses (see also [24, 63]). Cutoff scores according to Walker et al. [62] for each subscale (along with the ranges of scores for low, moderate, and severe trauma by Bernstein et al. [56]) were for sexual abuse ≥8 (low: 6-7; moderate: 8–12; severe: 13–25), physical abuse ≥8 (low: 8-9; moderate: 10–12; severe: 13–25), emotional abuse ≥10 (low: 9–12; moderate 13–15; severe 16–25), physical neglect ≥10 (low: 8-9; moderate 10–12; severe 13–25), and emotional neglect ≥15 (low 10–14; moderate 15–17; severe: 18–25). In order to examine the impact of multiple experiences of trauma we further considered the number of scales achieving these cutoff scores for each patient.

2.3. Data Analysis

Homogeneity between patient and missing data was analyzed using chi-square and Mann-Whitney tests. For further analyses missing data were excluded. The sample was first split into a group of traumatized chronically depressed patients who achieved cutoff scores according to Walker et al. [62] in the CTQ subscales, respectively, and a group of nontraumatized but still chronically depressed patients. For frequencies group differences were calculated using χ ². Spearman correlations were used to estimate correlations between trauma subtypes. Secondly, the sample was divided into four trauma groups using an index counting the number of traumatic experiences reported: a subthreshold trauma group not reporting clinically relevant traumatic experiences, a single trauma group, reporting trauma on one scale, a double trauma group reporting trauma on two scales, and a multiple trauma group reporting trauma on three to five scales according to the above described cutoff scores, respectively. Group differences for multiplicity were tested pertaining to depression symptom severity (BDI-2) using one-way analyses of variance. Stepwise multiple regression analyses were conducted using the BDI-2 as the dependent variable and the five CTQ subscales, gender (Model 1), and multiplicity (Model 2) as independent variables. All statistical tests were two-tailed and for multiple comparisons a Bonferroni correction was applied. All computations were calculated with SPSS 22.

3. Results

The intention to treat sample of the LAC Depression Study included a total of 402 patients. 349 patients completed the CTQ. Missing data arose from incomplete questionnaires or patient study withdrawals. Statistical controls of homogeneity between patient and missing data using Mann-Whitney tests were not significant for age at study intake (), BDI-2 (), QIDS-C (), and GSI/SCL-90 () and were not significant using chi-square tests for gender (), diagnosis (), marital status (), education (), and number of previous outpatient treatments () giving no indication for dropout distortions. The characteristics of the CTQ samples are detailed in Table 1. Age at study intake was on average 40.40 (SD 10.58) years. The female-male ratio corresponded to clinically depressed populations (male: ; female: ). The distribution of diagnoses is shown in Table 1. 34.7% of the patients were depressed for 24 months. The BDI-2 mean score of 32.28 and the QIDS-C at least mean score of 14.41 show severe to moderate depressive symptoms. The sample features a mean score of 1.29 (SD = 0.55) in the general severity index (GSI) of the SCL-90 indicating a fairly high psychic distress in patients. The chronicity of depression of the sample is further underlined by the high rate of 71.4% of patients who had been treated previously to study intake. 43.6% underwent more than one previous treatment.

Table 1: Demographic and clinical characteristics of the sample ().

Mean
SD

Age
40.40
10.58

CTQ total score
57.10
18.41

BDI-2
32.28
8.17

QIDS-C
14.41
3.16

SCL-90 (GSI)
1.29
0.55

N
%

Gender

    Female
236
67.6

    Male
113
32.4

Nationality

    German
307
88

    Other than German
42
22

Education

    9 years
27
7.7

    10 years
84
24.1

    12 years
228
65.3

    Other
7
2.1

Marital status

    Single
199
57.0

    Married
87
25.0

    Separated/divorced
59
17.1

    Widowed
1
0.3

    Other
3
0.9

Diagnosis

    Major depressive episode
228
65.3

    Double depression
81
23.2

    Dysthymia
40
11.5

Number of previous outpatient treatments

    None
91
26.1

    One
97
27.8

    Two and three
112
32.1

    Four and more
40
11.5

    Missing
9
2.6

The CTQ total score reached an average of 57.10 (SD = 18.41). In total, 75.6% of our chronically depressed patients reported clinically relevant histories of traumatic experiences in childhood on at least one scale (Table 2). 60.7% of the sample reported traumatic experiences of emotional abuse, 51.9% reported emotional neglect, and 25.2% reported sexual abuse in childhood. Means within CTQ subscale groups indicate trauma severity on thresholds from moderate to severe [56] indicating clinically relevant traumatization in childhood [62]. Gender differences were found: significantly more women reported a history of emotional abuse (χ ² = 7.44, ) and of sexual abuse (χ ² = 10.83, ). The total number of patients achieving thresholds in at least one subscale also showed significant gender differences (χ ² = 3.97, ).

Table 2: Frequencies, means, and standard deviations of depressed patients achieving cutoff scores in CTQ subscales ().

CTQ scales

%
Male
%
Women
%
Mean
SD

Total number1
264
75.6
78
69.0
186
78.8
63.50
16.49

Emotional abuse
212
60.7
57
50.4
155
65.7
15.47
4.23

Emotional neglect
181
51.9
57
50.4
124
52.5
18.86
2.86

Physical neglect
111
31.8
30
26.5
81
34.3
12.01
2.23

Physical abuse
94
26.9
27
23.9
67
28.4
11.32
3.80

Sexual abuse
88
25.2
16
14.2
72
30.5
12.20
4.49

Achieving cutoff score in at least one scale.

Spearman correlations between the types of childhood trauma were fairly moderate in magnitude. The highest correlations were found between emotional abuse and emotional neglect (0.64, ). Others were lower. Subscale correlations are presented in Table 3.

Table 3: Spearman correlations among the five CTQ subscales ().

Emotional neglect
Physical neglect
Physical abuse
Sexual abuse
BDI-2

Emotional abuse
.64
.48
.51
.55
.22

Emotional neglect

.63
.40
.36
.16

Physical neglect

.40
.38
.15

Physical abuse

.45
.17

Sexual abuse

.21

.

In order to calculate dose-response relationships we further differentiated four trauma groups; hence an index was used counting the number of scales per patient that achieved cutoff scores for clinically relevant reports of traumatic experiences according to Walker et al. [62]: subthreshold trauma, single trauma, double trauma, and multiple trauma. The multiple trauma group refers to trauma reports on three to five scales. Group distribution is shown in Table 4. 37% of our patients reported multiple trauma and 18.1% double trauma. A tendency towards significant gender differences was found (χ ² = 7.47, ) within trauma groups. Most frequently the combination of emotional abuse and emotional neglect was reported (, 14.0%) followed by emotional abuse alone (, 12.5%). 28 (10.6%) patients achieved thresholds on all five CTQ subscales. This was followed by 9.8% () achieving cutoffs for the combination of emotional abuse, emotional neglect, and physical neglect.

Table 4: Four trauma groups: subthreshold, single, double, and multiple trauma.

Trauma groups

%
Male
%
Female
%

Subthreshold trauma
85
24.4
35
41.2
50
58.8

Single trauma
72
20.6
25
34.7
47
65.3

Double trauma
63
18.1
22
34.9
41
65.1

Multiple trauma
129
37.0
31
24.0
98
76.0

Total
349
100
113
32.4
236
67.6

Table 5 shows the BDI-2 descriptive scores within the four trauma groups, respectively. The mean score increases from the single to the multiple trauma group. Interestingly, patients in the subthreshold trauma group show similar values as patients in the double trauma group. In the analysis of variance with age and gender as covariates (Table 6) we found a highly significant effect of the trauma group. Though the Levene test indicates a violation of the assumption of homogeneity of variance, results can be retained as to the large sample and the validation of this highly significant result through an additionally conducted Kruskal-Wallis test. For post hoc analyses we used the Games Howell test robust against violations of homogeneity of variance. The multiple trauma group differs significantly with higher values from the three other trauma groups.

Table 5: Descriptive scores  for BDI-2 and trauma groups.

Measures
Subthreshold trauma ()
Single trauma ()
Double trauma ()
Multiple trauma ()

M
SD
M
SD
M
SD
M
SD

BDI-2
31.29
8.14
29.51
6.31
31.43
7.69
34.88
8.67

Table 6: Analysis of variance (ANOVA) according to trauma group conducted for BDI-2 and age and gender as covariates¹.

Factors
df

Gender
1
1.62
.205

Age
1
0.33
.569

Trauma group
3
7.18
.000

   = .013 
   = .000 
   = .029

Levene -test = .032, additional Kruskal-Wallis -test: chi² = 21.00, .

²Post hoc test: Games Howell.

First, a stepwise multiple regression analysis (Model 1) was performed between the BDI-2 mean score indicating symptom severity as the dependent variable and emotional, physical, and sexual abuse and emotional and physical neglect scores from the CTQ as the predictor variables (Table 7). Due to significant gender differences within the CTQ subscales, emotional abuse and sexual abuse, we included gender in the model. Results included the subscales emotional abuse and sexual abuse as explanatory variables significantly increasing the risk of symptom severity in chronically depressed patients (, , , and ). After emotional abuse and sexual abuse were considered in step two, the remaining abuses and neglect as well as gender failed to contribute significantly to depression symptom severity in chronically depressed patients.

Table 7: Results of stepwise regression analysis for depression symptom severity (BDI-2), trauma subtypes, and gender () (Model 1).

Variables

SE

Step  1

Emotional abuse
.335
.080
.219
4.184

Physical abuse
.082

.072

Sexual abuse
.135

.124

Emotional neglect
.038

.030

Physical neglect
.059

.052

Gender
.065

.066

.219

.048

Adj.
.045

Step  2

Emotional abuse
.244
.089
.159
2.744

Sexual abuse
.294
.126
.135
2.332

Physical abuse
.049

.042

Emotional neglect
.045

.036

Physical neglect
.037

.033

Gender
.053

.066

.251

.063

Adj.
.057

Mean BDI-2
32.28

.

.

Second, a stepwise multiple regression analysis (Model 2) additionally included multiplicity operationalized as achieving cutoff scores according to Walker et al. [62] on at least three to maximum five CTQ subscales (Table 8). Results included multiplicity as remaining explanatory variable significantly increasing the risk of symptom severity in chronically depressed patients (, , , and ). The types of abuses and neglect as well as gender failed to contribute significantly to symptom severity in chronically depressed patients.

Table 8: Results of stepwise regression analysis for depression symptom severity (BDI-2), trauma subtypes, gender, and multiplicity () (Model 2).

Variables

SE

Step  1

Multiplicity
1.378
.293
.245
4.698

Emotional abuse
.107

.085

Physical abuse
.051

.421

Sexual abuse
.114

.103

Emotional neglect
.025

.020

Physical neglect
.011

.009

Gender
.064

.066

.245

.060

Adj.
.057

Mean BDI-2
32.28

.

4. Discussion

This study investigated prevalence, extent, and associations of childhood trauma exposure in a specific chronically depressed adult sample diagnosed according to DSM-IV criteria. We relied on the CTQ as an internationally widely used, reliable, and valid instrument. Chronicity was assessed through DSM diagnoses and validated by the substantial number of patients undergoing up to four treatments before study intake. This allowed comparisons between traumatized chronically depressed patients with a clinically significant history of childhood trauma and chronically depressed patients without such a history providing strength as to the possibility of differentially investigating trauma within chronically depressed patients.

Overall, the prevalence of childhood trauma was remarkably high with a magnitude of 75.6%. Moreover, CTQ subscale means indicated childhood trauma on the thresholds from moderate to severe exposure [56–58]. We additionally applied higher thresholds for the specific examination of clinically relevant childhood trauma [62]. Specific contributions of certain types of childhood trauma to the vulnerability of different forms of psychopathology were repeatedly reported. Our results show that emotional abuse was reported most frequently with 61%. Additionally, 25% of the patients reported childhood sexual abuse. Contrastingly, 15% emotional abuse and 12.6% sexual abuse were found in a representative German survey study on the prevalence of childhood trauma [64]. These findings show chronically depressed patients to be highly burdened by childhood adversities and supports reports of greater childhood adversity in chronic forms of depression compared to nonchronic forms [46]. For example, dysthymic patients were reported to have significantly poorer early parental relationships and to receive less care than patients with episodic depression [65]. Also, duration of depression was reported to be uniquely predicted by maternal abuse, maternal indifference, and paternal overcontrol [47].

In our study, women reported significantly more frequent childhood trauma in general and emotional abuse and sexual abuse in particular. McGrath et al. [66] pointed to the higher risk of victimization in women and estimated childhood abuse in women at 21.7 to 37%. Lampe’s [67] review on childhood trauma confirmed that women suffered more frequently from sexual abuse than men. Scher et al. [63] showed that women were nearly twice as likely to report emotional abuse and four times as likely to report sexual abuse. Furthermore, our results showed that when referring to associations of trauma types and trauma groups with symptom severity, gender did not contribute significantly. Arnow et al. [68] examined the moderating role of gender on the association between childhood abuse, neglect, and depression, yet they found no gender differences. However, they also identified significantly more depressed women than men reporting histories of emotional abuse and sexual abuse, which they interpreted as stemming from higher rates of victimization among women (p. 179). The lack of evidence for gender differences in the relationship of childhood adversity and depression was also substantiated by other studies reporting that among those with a history of childhood sexual abuse [35] with physical [69] or emotional abuse [69, 70] men and women were equally at risk for depression.

Mainly, our results suggest a substantial influence of multiple childhood trauma on a severe and chronic course of depression in adulthood. 37% of our patients reported a history of multiple childhood trauma, that is, trauma reports on at least three to maximum five CTQ scales. Additionally, 18.1% achieved thresholds on at least two subscales. Also in line with other studies [27, 28, 40, 42], the patients reporting multiple childhood trauma showed greater symptom severity suggesting a dose-response relationship between the number of childhood maltreatments and symptomatology. This suggests that cooccurrences of childhood trauma and its possible effects being synergistic or additive [12, 71] due to cumulative, sequential, simultaneous, and/or complex [16, 17] impacts may be specifically relevant in chronically depressed patients. This “cumulative effect of chronic exposure to multiple adversities” (p. 95) [72] was in general stressed as the largest burden of diseases within the ACE study.

Moreover, results indicated that significant associations between the trauma types, emotional abuse and sexual abuse, and symptom severity (Model 1) in chronically depressed patients were not maintained when taking multiplicity (Model 2) into account. Though both regression models only accounted for a poor amount of variance (4–6%), results replicated empirical findings (see, e.g., a meta-analysis on nonsexual maltreatment [43] reporting robust evidence for the relationship of emotional abuse and depression or a systematic review on the evidence of the relationship between childhood sexual abuse and mental disorders reporting odds ratios of 1.1 (p. 1886) for depression [73]). Yet, these studies did not take multiplicity of childhood trauma exposures into account. Multiplicity was also related to severity [30, 43, 74] which we supported referring to our figures of CTQ subscale distributions and mean values.

Fischer and Riedesser [12] stress childhood sexual abuse as a serious relational trauma and conceptualized childhood sexual abuse itself as multiple trauma (p. 303). Wetzel [75], for example, found that 64.3% of sexually abused participants were at the same time physically abused. Molnar et al. [26] examined the relation between childhood sexual abuse and later psychopathology and reported significantly higher percentages of women and men with lifetime dysthymia (15.7% and 12.5%) and depression (39.3% and 30.3%) among those reporting childhood sexual abuse. Briere and Elliott [76] linked experiences of childhood sexual abuse to disruptions in the development of a sense of self, causing difficulties in relating to others. Unfortunately the CTQ subscale for sexual abuse lacks information on perpetrators and the victims’ relations to them making conclusions on familial versus nonfamilial sexual abuse impossible.

With emotional abuse depression is again associated with trauma as a “relational” term. This type captures a narcissistic dimension of hatred, threat, demeaning, and humiliation and pictures verbal abuses on a child’s sense of worth or wellbeing also embodying experiences of repeated losses in primary relations. Emotionally abused children may also attribute more negatively than nonabused children which may lead to the development of a general negative attribution style [77–80]. For example, Gibb and Abela [81] investigated the potential of emotional abuse to change children’s inferential styles in a sample of 140 children of parents with a depression history. They found that emotional abuse was significantly related to changes in children’s inferential styles regarding consequences and self-characteristics.

Beyond multiplicity, Khan et al. [31] argued for specific sensitive exposure periods exerting maximal impact on risk for major depression (see p. 23). The authors caution that the linear increase associated with exposure to the number of different types of maltreatment may be a statistical byproduct of the fact that exposure to more types of abuse increases the chance of experiencing a critical form of maltreatment at a critical age. Their results showed that being rejected at the age of 14 was a crucial risk for depression: females were particularly sensitive to peer emotional abuse and males to parental nonverbal emotional abuse at the age of 14, respectively. Unfortunately, the CTQ neither allows an investigation of critical developmental periods (p. 23) nor asks for peer abuse. Rather, the CTQ captures an atmosphere of primary relations and trauma comprised of a loss of sense of self-worth, wellbeing, or self-efficacy (e.g., [8, 9, 82, 83]). This allows linkages to psychoanalytical conceptions of inner objects through processes of identification and introjection (e.g., [9, 82]) or to attachment theory (e.g., [84–86]) that might explain the strong connection of multiple trauma exposure to symptom severity in chronically depressed patients. It marks the disruption of one’s capacity to ascribe meaning to trauma, the loss of a basic sense of trust, and an enduring shock of one’s understanding of the outer and the inner world [13, 14, 83]. Fonagy et al. [87] showed that rates of insecure attachment in dysthymia were significantly higher than in major depression.

Strengths of this study include a large sample of patients solely diagnosed with chronic forms of depression using structured diagnostic interviews and the use of a well-validated instrument of childhood abuse. However, this study design also has several limitations: the retrospective assessment of childhood abuse and neglect may be subject to recall biases. Yet, adults’ recall on trauma is reported to be relatively reliable [88, 89]. Along with good criterion-related validity with therapist’s ratings of abuse [58], we also applied thresholds specifically developed to investigate clinically significant histories of childhood trauma [62]. Nevertheless, the measure captures specific types of trauma in contrast, for example, to early loss of parents, natural catastrophes, physical or mental disease in childhood or of parents, and peer abuses. Future research would especially benefit from focusing on a longitudinal aspect that allows a direct examination of trauma exposure and its relation to chronic depression and therapy outcomes.

Our findings suggest implications for clinical practice. Clinicians should precisely look for the presence of childhood trauma in chronically depressed patients being aware of its possible prognostic implications. In particular multiple traumatic experiences, emotional abuse, and sexual abuse may lead to a more chronic and severe course of depression. Nonetheless, a group of likewise severely depressed patients reporting histories of childhood trauma subthreshold as conceptualized within this study remained. This underlines that childhood trauma may only be one central pathway leading to chronic depression in adulthood (e.g., [8, 9, 12, 13, 19–21, 89, 90]). Depression summarizes a group of highly complex mental disorders that have to be diagnosed precisely and treated cautiously in consideration of its origins. For example, patients with a history of childhood trauma showed a poorer medication response than those without such a history and were significantly more likely to remit with psychotherapy than pharmacotherapy [47].

5. Conclusion

Consistent with previous studies showing an association of childhood trauma and depression, in our study a high number of chronically depressed patients experienced not only childhood trauma, but also multiple trauma. The magnitude in frequency of traumatized depressives and of multiply traumatized depressed patients remarkably stresses the impact of trauma within chronic courses of depressive disorders and the necessity to intensively and critically integrate this trauma aspect in treatments. Particularly multiple childhood trauma might be specifically related to chronic courses of depression.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

Acknowledgments

The LAC Depression Study is funded by the DGPT (Deutsche Gesellschaft für Psychoanalyse, Psychotherapie, Psychosomatik und Tiefenpsychologie e.V.), the Heidehof Foundation, and the International Advisory Board of the IPA (International Association of Psychoanalysis). The authors thank the project heads of the study, Professor Dr. Marianne Leuzinger-Bohleber, Professor Dr. Manfred Beutel, Professor Dr. Martin Hautzinger, Professor Dr. Wolfram Keller, and Gerhard Fiedler and the head of the Statistics Centre, Professor Dr. Bernhard Rüger. They also wish to thank for coordination of the study Dr. Ulrich Bahrke, Margerete Schoett, Nina Görlach, Mareike Ernst, and others.

References

World Health Organization, The Global Burden of Disease: 2004 Update, World Health Organization (WHO), Geneva, Switzerland, 2008, http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf.

H. U. Wittchen, F. Jacobi, J. Rehm et al., “The size and burden of mental disorders and other disorders of the brain in Europe 2010,” European Neuropsychopharmacology, vol. 21, no. 9, pp. 655–679, 2011.

World Health Organization, Mental Health. A Call for Action by World Health Ministers. Ministerial Round Tables 2001, Geneva, Switzerland, WHO,http://www.who.int/mental_health/advocacy/en/Call_for_Action_MoH_Intro.pdf

J. R. Vittengl, L. A. Clark, T. W. Dunn, and R. B. Jarrett, “Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects,” Journal of Consulting and Clinical Psychology, vol. 75, no. 3, pp. 475–488, 2007.

S. J. Blatt and D. C. Zuroff, “Empirical evaluation of the assupmtion in identifying evidenc-based treatments for seriously disturbed young adults: a reply to Bein,” Psychotherapy Research, vol. 8, pp. 42–53, 2004.

M. Hautzinger, Akute Depression, Hogrefe, Göttingen, Germany, 2010.

G. Schulte-Körne and A. K. Allgaier, “Genetik depressiver Störungen,” Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie, vol. 36, pp. 27–43, 2008.

H. Bleichmar, “Verschiedene Pfade, die in die Depression führen. Implikationen für spezifische und gezielte Interventionen,” in Chronische Depression. Verstehen Behandeln Erforschen, M. Leuzinger-Bohleber, U. Bahrke, and A. Negele, Eds., pp. 82–98, Vandenhoeck & Ruprecht, Göttingen, Germany, 2013.

W. Bohleber, “Neue Ergebnisse der Depressionsforschung. Erklärungsansätze—Therapiemodelle-Behandlungstechnik,” Psyche—Zeitschrift für Psychoanalyse und ihre Anwendungen, vol. 64, pp. 771–781, 2010.

J. Hill, “Developmental perspectives on adult depression,” Psychoanalytic Psychotherapy, vol. 23, no. 3, pp. 200–212, 2009.

A. Caspi, K. Sugden, T. E. Moffitt et al., “Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene,” Science, vol. 301, no. 5631, pp. 386–389, 2003.

G. Fischer and P. Riedesser, Lehrbuch der Psychotraumatologie, Ernst Reinhardt, Munich, Germany, 2009.

W. Bohleber, Destructiveness, Intersubjectivity and Trauma: The Identity Crisis of Modern Psychoanalysis, Karnac Books, London, UK, 2010.

A. Cooper, “Toward a limited definition of psychic trauma,” in The Reconstruction of Trauma, A. Rothstein, Ed., pp. 41–56, International Universities Press, Madison, Wis, USA, 1986.

H. Keilson, Sequentielle Traumatisierung bei Kindern, Enke, Stuttgart, Germany, 1979.

J. L. Herman, “Complex PTSD: a syndrome in survivors of prolonged and repeated trauma,” Journal of Traumatic Stress, vol. 5, no. 3, pp. 377–391, 1992.

B. A. van der Kolk, “Developmental trauma disorder,” Psychiatric Annals, vol. 35, no. 5, pp. 401–408, 2005.

M. M. R. Khan, “The concept of cumulative trauma,” in The Privacy of the Self, M. M. R. Khan, Ed., pp. 42–58, Hogarth, London, UK, 1974.

M. Leuzinger-Bohleber, “Changes in dreams—from a psychoanalysis with a traumatised, chronic depressed patient,” in The Significance of Dreams: Bridging Clinical and Extraclinical Research in Psychoanalysis, P. Fonagy, H. Kächele, M. Leuzinger-Bohleber, and D. Taylor, Eds., pp. 49–85, Karnac Books, London, UK, 2012.

M. Leuzinger-Bohleber, “Chronische Depression und Trauma. Konzeptuelle Überlegungen zu ersten klinischen Ergebnissen der LAC-Depressionsstudie,” in Chronische Depression. Verstehen—Behandeln—Erforschen, M. Leuzinger-Bohleber, U. Bahrke, and A. Negele, Eds., pp. 56–81, Vandenhoeck & Ruprecht, Göttingen, Germany, 2013.

M. Leuzinger-Bohleber, “Working with severely traumatized, chronically depressed analysands,” The International Journal of Psychoanalysis, vol. 96, no. 3, pp. 611–636, 2015.

L. C. Terr, “Childhood traumas: an outline and overview,” The American Journal of Psychiatry, vol. 148, no. 1, pp. 10–20, 1991.

V. Moskvina, A. Farmer, V. Swainson et al., “Interrelationship of childhood trauma, neuroticism, and depressive phenotype,” Depression and Anxiety, vol. 24, no. 3, pp. 163–168, 2007.

C. Subic-Wrana, R. Tschan, M. Michal, R. Zwerenz, M. Beutel, and J. Wiltink, “Childhood trauma and its relation to diagnoses and psychic complaints in patients of an psychosomatic university ambulance,” Psychotherapie Psychosomatik Medizinische Psychologie, vol. 61, no. 2, pp. 54–61, 2011.

R. C. Kessler, “The effects of stressful life events on depression,” Annual Review of Psychology, vol. 48, pp. 191–214, 1997.

B. E. Molnar, S. L. Buka, and R. C. Kessler, “Child sexual abuse and subsequent psychopathology: results from the national comorbidity survey,” The American Journal of Public Health, vol. 91, no. 5, pp. 753–760, 2001.

C. S. Widom, K. DuMont, and S. J. Czaja, “A prospective investigation of major depressive disorder and comorbidity in abused and neglected children grown up,” Archives of General Psychiatry, vol. 64, no. 1, pp. 49–56, 2007.

A. Tanskanen, J. Hintikka, K. Honkalampi, K. Haatainen, H. Koivumaa-Honkanen, and H. Viinamäki, “Impact of multiple traumatic experiences on the persistence of depressive symptoms—a population-based study,” Nordic Journal of Psychiatry, vol. 58, no. 6, pp. 459–464, 2004.

J. Hill, R. Davis, M. Byatt, E. Burnside, L. Rollinson, and S. Fear, “Childhood sexual abuse and affective symptoms in women: a general population study,” Psychological Medicine, vol. 30, no. 6, pp. 1283–1291, 2000.

D. P. Chapman, C. L. Whitfield, V. J. Felitti, S. R. Dube, V. J. Edwards, and R. F. Anda, “Adverse childhood experiences and the risk of depressive disorders in adulthood,” Journal of Affective Disorders, vol. 82, no. 2, pp. 217–225, 2004.

A. Khan, H. C. McCormack, E. A. Bolger et al., “Childhood maltreatment, depression, and suicidal ideation: critical importance of parental and peer emotional abuse during developmental sensitive periods in males and females,” Frontiers in Psychiatry, vol. 6, no. 42, pp. 1–28, 2015.

B. E. Gibb, I. Chelminski, and M. Zimmerman, “Childhood emotional, physical, and sexual abuse, and diagnoses of depressive and anxiety disorders in adult psychiatric outpatients,” Depression and Anxiety, vol. 24, no. 4, pp. 256–263, 2007.

P. Spinhoven, B. M. Elzinga, J. G. F. M. Hovens et al., “The specificity of childhood adversities and negative life events across the life span to anxiety and depressive disorders,” Journal of Affective Disorders, vol. 126, no. 1-2, pp. 103–112, 2010.

D. M. Fergusson and P. E. Mullen, Childhood Sexual Abuse: An Evidence-Based Perspective, SAGE Publications, London, UK, 1999.

E. C. Nelson, A. C. Heath, P. A. F. Madden et al., “Association between self-reported childhood sexual abuse and adverse psychosocial outcomes: results from a twin study,” Archives of General Psychiatry, vol. 59, no. 2, pp. 139–145, 2002.

A. R. Tyrka, M. C. Wyche, M. M. Kelly, L. H. Price, and L. L. Carpenter, “Childhood maltreatment and adult personality disorder symptoms: influence of maltreatment type,” Psychiatry Research, vol. 165, no. 3, pp. 281–287, 2009.

S. C. Fernando, T. Beblo, N. Schlosser et al., “The impact of self-reported childhood trauma on emotion regulation in borderline personality disorder and major depression,” Journal of Trauma & Dissociation, vol. 15, no. 4, pp. 384–401, 2014.

C. Z. Bernet and M. B. Stein, “Relationship of childhood maltreatment to the onset and course of major depression in adulthood,” Depression and Anxiety, vol. 9, no. 4, pp. 169–174, 1999.

B. Etain, F. Mathieu, C. Henry et al., “Preferential association between childhood emotional abuse and bipolar disorder,” Journal of Traumatic Stress, vol. 23, no. 3, pp. 376–383, 2010.

S. R. Dube, V. J. Felitti, M. Dong, W. H. Giles, and R. F. Anda, “The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900,” Preventive Medicine, vol. 37, no. 3, pp. 268–277, 2003.

A. Bifulco, P. M. Moran, R. Baines, A. Bunn, and K. Stanford, “Exploring psychological abuse in childhood: II. Association with other abuse and adult clinical depression,” Bulletin of the Menninger Clinic, vol. 66, no. 3, pp. 241–258, 2002.

J. E. Wiersma, J. G. F. M. Hovens, P. Van Oppen et al., “The importance of childhood trauma and childhood life events for chronicity of depression in adults,” Journal of Clinical Psychiatry, vol. 70, no. 7, pp. 983–989, 2009.

R. E. Norman, M. Byambaa, R. De, A. Butchart, J. Scott, and T. Vos, “The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis,” PLoS Medicine, vol. 9, no. 11, Article ID e1001349, 2012.

D. N. Klein, S. A. Shankman, and S. Rose, “Ten-year prospective follow-up study of the naturalistic course of dysthymic disorder and double depression,” The American Journal of Psychiatry, vol. 163, no. 5, pp. 872–880, 2006.

J. P. Klein, A. Roniger, U. Schweiger, C. Späth, and J. Brodbeck, “The association of childhood trauma and personality disorders with chronic depression: a cross-sectional study in depressed outpatients,” The Journal of Clinical Psychiatry, vol. 76, no. 6, pp. e794–e801, 2015.

L. P. Riso, R. K. Miyatake, and M. E. Thase, “The search for determinants of chronic depression: a review of six factors,” Journal of Affective Disorders, vol. 70, no. 2, pp. 103–115, 2002.

D. N. Klein, B. A. Arnow, J. L. Barkin et al., “Early adversity in chronic depression: clinical correlates and response to pharmacotherapy,” Depression and Anxiety, vol. 26, no. 8, pp. 701–710, 2009.

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, APA, Washington, DC, USA, 4th edition, 1994.

M. E. Beutel, M. Leuzinger-Bohleber, B. Rüger et al., “Psychoanalytic and cognitive-behavior therapy of chronic depression: study protocol for a randomized controlled trial,” Trials, vol. 13, article 117, 2012.

M. Leuzinger-Bohleber, U. Bahrke, M. Beutel et al., “Psychoanalytische und kognitiv-verhaltenstherapeutische Langzeittherapien bei chronischer Depression: Die LAC-Depressionsstudie,” Psyche—Zeitschrift für Psychoanalyse und ihre Anwendungen, vol. 64, pp. 782–832, 2010.

U. Bahrke, M. Beutel, G. Fiedler et al., “Psychoanalytische und kognitiv-verhaltenstherapeutische Langzeittherapien bei chronischer Depression (LAC),” in Chronische Depression. Verstehen—Behandeln—Erforschen, M. Leuzinger-Bohleber, U. Bahrke, and A. Negele, Eds., pp. 217–239, Vandenhoeck & Ruprecht, Göttingen, Germany, 2013.

H. U. Wittchen, U. Wunderlich, S. Gruschwitz, and M. Zaudig, Strukturiertes Klinisches Interview (SKID), Hogrefe, Göttingen, Germany, 1997.

M. Hautzinger, F. Keller, and C. Kühner, Beck-Depressions-Inventar (BDI-II), Harcourt Test Service, Frankfurt am Main, Germany, 2006.

A. J. Rush, M. H. Trivedi, H. M. Ibrahim et al., “The 16-item Quick Inventory of Depressive Symptomatology (QIDS). Clinical rating (QIDS-C) and self report (QIDS-SR). A psychometric evaluation in patients with chronic major depression,” Biological Psychiatry, vol. 54, no. 5, pp. 573–583, 2003.

G. H. Franke, Revised Symptom Checklist of Derogatis (SCL-90-R), Hogrefe, Göttingen, Germany, 2002.

D. P. Bernstein, L. Fink, L. Handelsman et al., “Initial reliability and validity of a new retrospective measure of child abuse and neglect,” The American Journal of Psychiatry, vol. 151, no. 8, pp. 1132–1136, 1994.

D. P. Bernstein and L. Fink, Childhood Trauma Questionnaire: A Retrospective Self-Report-Manual, The Psychological Corporation Harcourt Brace and Company, San Antonio, Tex, USA, 1998.

D. P. Bernstein, J. A. Stein, M. D. Newcomb et al., “Development and validation of a brief screening version of the childhood trauma questionnaire,” Child Abuse & Neglect, vol. 27, no. 2, pp. 169–190, 2003.

G. Klinitzke, M. Romppel, W. Häuser, E. Brähler, and H. Glaesmer, “Die deutsche Version des Childhood Trauma Questionnaire (CTQ)-psychometrische Eigenschaften in einer bevölkerungsrepräsentativen Stichprobe,” Psychotherapie Psychosomatik Psychologische Medizin, vol. 62, pp. 47–51, 2011.

K. Bader, C. Hänny, V. Schäfer, A. Neuckel, and C. Kuhl, “Childhood Trauma Questionnaire—Psychometrische Eigenschaften einer deutschsprachigen Version,” Zeitschrift für Klinische Psychologie und Psychotherapie, vol. 38, pp. 223–230, 2009.

K. Wingenfeld, C. Spitzer, C. Mensebach et al., “Die deutsche Version der Childhood Trauma Questionnaire (CTQ): Erste Befunde zu den psychometrischen Kennwerten,” Psychotherapie, Psychosomatik, Medizinische Psychologie, vol. 60, no. 11, pp. 442–450, 2010.

E. A. Walker, J. Unutzer, C. Rutter et al., “Costs of health care use by women HMO members with a history of childhood abuse and neglect,” Archives of General Psychiatry, vol. 56, no. 7, pp. 609–613, 1999.

C. D. Scher, D. R. Forde, J. R. McQuaid, and M. B. Stein, “Prevalence and demographic correlates of childhood maltreatment in an adult community sample,” Child Abuse and Neglect, vol. 28, no. 2, pp. 167–180, 2004.

W. Häuser, G. Schmutzer, E. Brähler, and H. Glaesmer, “Misshandlungen in Kindheit und Jugend. Ergebnisse einer Umfrage in einer repräsentativen Stichprobe der Deutschen Bevölkerung,” Deutsches Ärzteblatt, vol. 108, pp. 287–294, 2011.

H. Lizardi, D. N. Klein, P. C. Ouimette, L. P. Riso, R. L. Anderson, and S. K. Donaldson, “Reports of the childhood home environment in early-onset dysthymia and episodic major depression,” Journal of Abnormal Psychology, vol. 104, no. 1, pp. 132–139, 1995.

E. McGrath, G. P. Keita, B. R. Stickland, and N. F. Russo, Frauen und Depression: Risikofaktoren und Behandlungsfragen, Meckinger, Bergheim, Germany, 1993.

A. Lampe, “Die Prävalenz von sexuellem Missbrauch, körperlicher Gewalt und emotionaler Vernachlässigung in der Kindheit in Europa,” Zeitschrift für Psychosomatische Medizin und Psychotherapie, vol. 48, pp. 370–380, 2002.

B. A. Arnow, C. M. Blasey, E. M. Hunkeler, J. Lee, and C. Hayward, “Does gender moderate the relationship between childhood maltreatment and adult depression?” Child Maltreatment, vol. 16, no. 3, pp. 175–183, 2011.

S. Pimlott-Kubiak and L. M. Cortina, “Gender, victimization, and outcomes: reconceptualizing risk,” Journal of Consulting and Clinical Psychology, vol. 71, no. 3, pp. 528–539, 2003.

H. Z. Reinherz, A. D. Paradis, R. M. Giaconia, C. K. Stashwick, and G. Fitzmaurice, “Childhood and adolescent predictors of major depression in the transition to adulthood,” The American Journal of Psychiatry, vol. 160, no. 12, pp. 2141–2147, 2003.

M. H. Teicher, J. A. Samson, A. Polcari, and C. E. McGreenery, “Sticks, stones, and hurtful words: relative effects of various forms of childhood maltreatment,” American Journal of Psychiatry, vol. 163, no. 6, pp. 993–1000, 2006.

R. F. Anda, A. Butchart, V. J. Felitti, and D. W. Brown, “Building a framework for global surveillance of the public health implications of adverse childhood experiences,” American Journal of Preventive Medicine, vol. 39, no. 1, pp. 93–98, 2010.

G. Andrews, J. Corry, T. Slade, G. Issakidis, and H. Swanton, “Child sexual abuse,” in Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributale to Selected Major Risk Factors, M. Ezzati, A. D. Lopez, A. Rodgers, and C. J. L. Murray, Eds., pp. 1851–1940, World Health Organization, Geneva, Switzerland, 2003.

J. G. F. M. Hovens, J. E. Wiersma, E. J. Giltay et al., “Childhood life events and childhood trauma in adult patients with depressive, anxiety and comorbid disorders vs. controls,” Acta Psychiatrica Scandinavica, vol. 122, no. 1, pp. 66–74, 2010.

P. Wetzel, Gewalterfahrungen in der Kindheit. Sexueller Missbrauch, körperliche Misshandlung und deren langfristige Konsequenzen, Nomos, Baden-Baden, Germany, 1998.

J. N. Briere and D. M. Elliott, “Immediate and long-term impacts of child sexual abuse,” The Future of Children, vol. 4, no. 2, pp. 54–69, 1994.

A. T. Beck, Cognitive Therapy and the Emotional Disorders, International Universities Press, New York, NY, USA, 1976.

L. Y. Abramson, G. I. Metalsky, and L. B. Alloy, “Hopelessness depression. A theory-based subtype of depression,” Psychological Review, vol. 96, no. 2, pp. 358–372, 1989.

M. Hautzinger, “Verhaltenstheoretische Ansätze bei chronischer Depression,” in Chronische Depression. Verstehen—Behandeln—Erforschen, M. Leuzinger-Bohleber, U. Bahrke, and A. Negele, Eds., pp. 33–55, Vandenhoeck & Ruprecht, Göttingen, Germany, 2013.

B. E. Gibb and L. B. Alloy, “A prospective test of the hopelessness theory of depression in children,” Journal of Clinical Child and Adolescent Psychology, vol. 35, no. 2, pp. 264–274, 2006.

B. E. Gibb and J. R. Z. Abela, “Emotional abuse, verbal victimization, and the development of children's negative inferential styles and depressive symptoms,” Cognitive Therapy and Research, vol. 32, no. 2, pp. 161–176, 2008.

H. B. Bleichmar, “Some subtypes of depression and their implications for psychoanalytic treatment,” International Journal of Psycho-Analysis, vol. 77, no. 5, pp. 935–961, 1996.

J. Küchenhoff, “Verlust des Selbst, Verlust des Anderen—die doppelte Zerstörung von Nähe und Ferne im Trauma,” Psyche—Zeitschrift für Psychoanalyse und Ihre Anwendungen, vol. 58, pp. 811–835, 2004.

J. Bowlby, Attachment and Loss: Vol. 1. Loss, Basic Books, New York, NY, USA, 1969.

J. Bowlby, Attachment and Loss: Volume 2. Separation: Anxiety and Anger, Basic Books, New York, NY, USA, 1973.

J. Bowlby, Attachment and Loss: Vol 3. Loss: Sadness and Depression, Basic Books, New York, NY, USA, 1980.

P. Fonagy, T. Leigh, M. Steele et al., “The relation of attachment status, psychiatric classification, and response to psychotherapy,” Journal of Consulting and Clinical Psychology, vol. 64, no. 1, pp. 22–31, 1996.

I. H. Meyer, K. Muenzenmaier, J. Cancienne, and E. Struening, “Reliability and validity of a measure of sexual and physical abuse histories among women with serious mental illness,” Child Abuse & Neglect, vol. 20, no. 3, pp. 213–219, 1996.

C. R. Brewin, B. Andrews, and I. H. Gotlib, “Psychopathology and early experience: a reappraisal of retrospective reports,” Psychological Bulletin, vol. 113, no. 1, pp. 82–98, 1993.

M. Leuzinger-Bohleber, “Psychoanalyse. Ein Anwendungsfeld bei chronischer Depression,” Psychotherapie im Dialog, vol. 14, pp. 26–29, 2013.