Mariette Chartier

Separate and cumulative effects of adverse childhood experiences in predicting adult health and health care utilization

OBJECTIVES Objectives of this population-based study were: (1) to examine the relative contribution of childhood abuse and other adverse childhood experiences to poor adult health and increased health care utilization and (2) to examine the cumulative effects of adverse childhood experiences on adult health and health care utilization. METHODS Data from the Ontario Health Survey, a representative population sample (n=9,953) of respondents aged 15 years and older, were analyzed using logistic regression. Adverse childhood experiences examined were childhood physical and sexual abuse, parental marital conflict, poor parent-child relationship, low parental education and parental psychopathology. RESULTS Most (72%) respondents reported at least one adverse childhood experience and a considerable proportion of respondents (37%) reported two or more of these experiences. In examining the bivariate models, childhood physical and sexual abuse had a stronger influence than other types of adverse childhood experiences. With the addition of other adverse childhood experiences in the model, the odds ratios for childhood abuse were attenuated but remained statistically significant for most health outcomes. This suggests that childhood abuse may have a unique adverse influence on the development of poor adult health. When an aggregate variable was created to explore the cumulative effects of adverse childhood experience, the odds were increased, with each additional experience, for reporting multiple health problems [odds ratio (OR): 1.22], poor self-rated health (OR: 1.18), pain (OR: 1.24), disability (OR: 1.24), general practitioner use (OR: 1.12), emergency room use (OR: 1.29) and health professional use (OR: 1.19). CONCLUSIONS This study suggests that childhood abuse and other adverse childhood experiences are overlapping risk factors for long-term adult health problems and that the accumulation of these adverse experiences increases the risk of poor adult health. PRACTICE IMPLICATIONS This study highlights the importance of the many adverse childhood experiences influencing long-term health. In practice, childhood abuse is often difficult to identify as families tend to keep it hidden and reported cases represent only a small percentage of the actual cases. Assessments and interventions which focus on improving socio-economic status, strengthening marital and parent-child relationships, and supporting parents with mental health issues are less threatening for families than assessing their experiences with abuse and neglect and are more likely to be effective in identifying and supporting at-risk families.

Health Risk Behaviors and Mental Health Problems as Mediators of the Relationship Between Childhood Abuse and Adult Health

OBJECTIVES We examined the relationship between childhood abuse and adult health risk behaviors, and we explored whether adult health risk behaviors or mental health problems mediated the relationship between childhood abuse and adult health problems and health care utilization. METHODS We used logistic regression to analyze data from the Mental Health Supplement of the Ontario Health Survey, a representative population sample (N = 8116) of respondents aged 15 to 64 years. RESULTS We found relationships between childhood sexual abuse and smoking (odds ratio [OR] = 1.52; 95% confidence interval [CI] = 1.16, 1.99), alcohol problems (OR = 2.44; 95% CI = 1.74, 3.44), obesity (OR = 1.61; 95% CI = 1.14, 2.27), having more than 1 sexual partner in the previous year (OR = 2.34; 95% CI = 1.44, 3.80), and mental health problems (OR = 2.26; 95% CI = 1.78. 2.87). We also found relationships between these factors (with the exception of obesity) and childhood physical abuse. Mediation analysis suggested that health risk behaviors and particularly mental health problems are partial mediators of the relationship between childhood abuse and adult health. CONCLUSIONS Public health approaches that aim to decrease child abuse by supporting positive parent-child relationships, reducing the development of health risk behaviors, and addressing childrens mental health are likely to improve long-term population health.

Social phobia and potential childhood risk factors in a community sample

BACKGROUND This study examined the relationship between potential childhood risk factors and social phobia in an epidemiological sample. Identifying risk factors such as childhood adversities can often uncover important clues as to the aetiology of a disorder. This information also enables health care providers to predict which individuals are most likely to develop the disorder. METHODS Data came from the Mental Health Supplement to the Ontario Health Survey of a survey of 8116 Canadian respondents, aged 15-64. Social phobia was diagnosed using the Composite International Diagnostic Interview (CIDI). Childhood risk factors were assessed by a series of standardized questions. RESULTS A positive relationship was observed between social phobia and lack of close relationship with an adult, not being first born (in males only), marital conflict in the family of origin, parental history of mental disorder, moving more than three times as a child, juvenile justice and child welfare involvement, running away from home, childhood physical and sexual abuse, failing a grade, requirement of special education before age 9 and dropping out of high school. Many of these variables remained significant after controlling for phobias, major depressive disorder and alcohol abuse. The data also suggest that some childhood risk factors may interact with gender to influence the development of social phobia. CONCLUSIONS Although an association was detected between social phobia and childhood risk factors, naturalistic prospective studies are needed to clarify the aetiological importance of these and other potential risk factors for the disorder.

Considering comorbidity in social phobia.

Considering comorbidity in social phobia contributes to our understanding of causal pathways and improved classifications for psychiatric disorders. Comorbidity also has important clinical implications. While a number of studies have investigated comorbidity in social phobia, only one other study has used the Composite International Diagnostic Interview (CIDI) and considered comorbidity in subtypes of social phobia. This study evaluated lifetime social phobia comorbidity with other common mental disorders as well as comorbidity in subtypes of social phobia. We also considered whether social fears, reported by respondents with social phobia, had an earlier or later age of onset than other disorders. Data came from the Mental Health Supplement to the Ontario Health Survey, a survey of 8,116 Canadian respondents, ages 15–64. Psychiatric diagnoses were determined using the CIDI. This instrument is considered more sensitive than earlier instruments for diagnosing social phobia. Fifty-two percent of respondents with lifetime social phobia reported at least one other lifetime mental disorder and 27% reported three or more lifetime mental disorders. Social phobia, in this sample, is strongly comorbid with anxiety and affective disorders, and moderately comorbid with substance abuse disorders. When two social phobia subgroups were considered, the largest odds ratios were found among the not-exclusively-speaking social phobia group. This subgroup would include most of the respondents with a generalized form of social phobia. Age of onset of social fears, in respondents with social phobia, preceded age of onset of the comorbid disorder in 32% of cases with comorbid anxiety disorder, 71% of cases with comorbid affective disorder and 80% of cases with comorbid substance dependence/abuse disorder. Comorbidity and relative age of onset among respondents with social phobia in this study are generally consistent with previous epidemiologic studies. Clinicians should be vigilant for comorbidity in social phobia and should select treatments that target the full range of comorbid disorders. Early intervention or prevention of social fears or social phobia has the potential to reduce the risk of comorbid disorders.

Lifetime patterns of social phobia: a retrospective study of the course of social phobia in a nonclinical population.

This study describes the natural course of social phobia as recalled by a sample of nonclinical subjects and explores, using qualitative research methods, perceived risk factors and factors that may cause changes in its course. Thirty‐nine respondents with a lifetime diagnosis of social phobia were interviewed using a semistructured interview schedule based on DSM‐IV criteria. Four main lifetime patterns emerged: a slight worsening of social phobic symptoms over time, no change, slight improvement and complete remission. Thirty‐eight percent of the sample was in remission at the time of interview. The mean age of onset was 12.8 ± 4.1 years. The average duration of illness was 29.0 ± 12.7 years. Factors perceived by respondents to precipitate social phobia, using content analysis, were family and school environment, onset of adolescence, low self‐esteem, temperament and poverty. Factors perceived to improve symptoms were building self‐esteem, exposure, determination, maturity and counseling. Factors perceived to worsen symptoms were avoidance, exposure to negative attention and comorbid disorders. Depression and Anxiety 7:113–121, 1998.

Familial aggregation of anxiety‐related quantitative traits in generalized social phobia: Clues to understanding “disorder” heritability?

Social phobia, particularly the generalized form, is strongly familial. Given the probable continuity from extremes of normative personality (e.g., shyness) to social phobia to personality disorder (e.g., avoidant personality disorder), it is unlikely that social phobia itself, at the level of an Axis I disorder, is transmitted. Rather, it seems more parsimonious, and in keeping with current notions about the structure and heritability of mental disorders, that one or more temperamental risk factors for social phobia is transmitted. The goal of this study was to explore this possibility by examining relevant quantitative traits in a family study of generalized social phobia (GSP). First-degree (n = 103) relatives of patients with DSM-IV GSP and 65 first-degree relatives of not socially phobic comparison subjects (NC) completed a panel of self-report questionnaires that included measures of trait anxiety, social anxiety, and personality. Regression analysis was used to examine associations between group membership (i.e., whether that family member was a first-degree relative of a GSP proband) and these measures. First-degree relatives of GSP probands scored significantly higher than first-degree relatives of not socially phobic probands on measures of trait anxiety and social anxiety and on the Harm Avoidance subscale of the TPQ. One large factor, accounting for 84% of the variance, was strongly associated with being a first-degree relative of a GSP proband. Quantitative traits elevated in probands with generalized social phobia are also elevated in their first-degree relatives. Future family and genetic studies of social phobia should consider the possibility that one or more traits (or some aggregation thereof) may better approximate the phenotype of interest. More extensive efforts at phenotype refinement should be undertaken before such studies proceed.

Genetic linkage to the serotonin transporter protein and 5HT2A receptor genes excluded in generalized social phobia

Social phobia, particularly the generalized form, is strongly familial and frequently comorbid with major depression, panic disorder, and obsessive-compulsive disorder. It has also recently been shown to be responsive to selective serotonin reuptake inhibitors. We conducted a study to determine if generalized social phobia is genetically linked to either of two candidate genes: the serotonin transporter protein (5HTT) gene, or the 5HT2A receptor (5HT2AR) gene. Rates of social phobia (using several phenotype definitions) were ascertained and blood samples obtained from consenting first-degree family members of generalized social phobic probands. 5HT2AR and 5HTT genotyping was performed using the polymerase chain reaction (PCR). Linkage was tested using LINKAGE and GENEHUNTER software. No evidence of linkage was found; power analysis indicated that failure to find linkage was unlikely due to inadequate statistical power. These findings reasonably exclude linkage between generalized social phobia and the 5HTT or 5HT2AR genes in these samples, although modifier effects cannot be ruled out. Other 5HT receptor subtypes or indirect modulatory effects of 5HT on other neurotransmitter systems may be involved.

Illicit drug use and anxiety disorders: Findings from two community surveys ☆

The focus of this investigation was the relationship between anxiety disorders and lifetime use of amphetamines, cocaine, hallucinogens and heroin in two contemporaneous samples. Data from two independent community surveys conducted in the US (N=5877) and Ontario (N=8116) were used to assess whether a lifetime anxiety disorder diagnosis (social phobia, panic disorder, agoraphobia, specific phobia, and generalized anxiety disorder) was significantly associated with lifetime use of amphetamines, hallucinogens, cocaine, and heroin. Posttraumatic stress disorder was assessed only in the US survey. After controlling for sociodemographics, a significant association between any anxiety disorder diagnosis and lifetime stimulant use, cocaine use, and hallucinogen use was found in both surveys (OR approximately 1.5-3.0). Any anxiety disorder diagnosis was significantly associated with lifetime heroin use in the US survey (OR approximately 3.0). Clinicians and researchers need to be aware of the relationship between anxiety disorders and illicit drug use.

Autonomic responsivity in generalized social phobia.

To determine whether patients with generalized social phobia exhibit evidence of abnormal autonomic nervous system (ANS) functioning, 15 non-depressed, medication-free subjects with DSM-IV social phobia (generalized type) and 15 healthy control subjects participated in a series of autonomic function tests. Generalized social phobics exhibited increased blood pressure responsivity to Valsalva and exaggerated vagal withdrawal in response to isometric exercise, but normal cardiovascular responsivity to all other tasks. Plasma norepinephrine and epinephrine levels were also normal. Studies with larger sample sizes and the use of specific neuropharmacologic probes seem warranted to further delineate a role for autonomic dysfunction in the pathophysiology of this disorder.

Deficits in perceived social support associated with generalized social phobia.

Social phobia is a common anxiety disorder associated with significant impairment in social and occupational functioning. To date, few studies have examined the relationship between social phobia and perceived social support, a construct with important relationships to physical and mental health. The present study examined data from 2 widely used measures of perceived social support administered to 132 individuals with DSM‐IV generalized social phobia. These data were compared with those obtained from a healthy control group and from several clinical and non‐clinical samples reported in the literature. Persons with generalized social phobia scored significantly lower on both measures of social support compared with all other groups. It is suggested that deficits in perceived social support associated with generalized social phobia may play a role in the development of co‐morbid problems and should be explicitly targeted by treatments for social phobia. Low correlations between perceived social support and social anxiety measures suggest that perceived support should be specifically evaluated in this population.