Is there a specific relationship between childhood sexual and physical abuse and repeated suicidal behavior?

Abstract

Objective:

Studies show that childhood sexual and physical abuse predict repeated suicide attempts and self-mutilation. Little is known about the importance of sexual and physical abuse when compared to other severe childhood adversities with respect to chronic suicidal behavior.

Method:

Seventy-four subjects, 65% of whom were women, consecutively admitted to a general hospital after having made a suicide attempt, were interviewed as part of the intake interview about prior suicide attempts and self-mutilation and received DSM-IV diagnoses. Sexual abuse, physical abuse, neglect, antipathy from parents, loss of parents, and severe discord in the family before the age of 18, were covered by the Childhood Experience of Care and Abuse (CECA) interview schedule.

Results:

The prevalence of severe sexual abuse was 35%, severe physical abuse 18%, neglect 27%, antipathy 34%, loss of caregiver 37% and exposure to family violence 31%. Physical and sexual abuse were independently associated with repeated suicide attempts when controlling for the effects of the other childhood adverse factors. No other childhood adversity was related to chronic suicidal behavior. The odds ratio of exposure to sexual or physical abuse was highest among those who both repeated suicide attempts and self-mutilated.

Conclusion:

Physical and sexual abuse are significantly and independently associated with repeated suicidal behavior.

Résumé

Objectif:

Des études montrent que des mauvais traitements physiques et sexuels subis dans l’enfance peuvent permettre de prédire des tentatives répétées de suicide et d’auto-mutilation. On connait peu de choses sur l’importance des mauvais traitements physiques et sexuels en comparaison avec l’influence d’autres malheurs subis dans l’enfance sur le comportement suicidaire chronique.

Méthode:

74 sujets dont 65% de femmes admises dans un hopital général à la suite de tentative de suicide, ont été interrogés dans le cadre d’un entretien d’admission au sujet de tentatives de suicide antérieures et d’auto-mutilation. Elles ont reçu un diagnostic DSM-IV. On a abordé, à l’aide du protocole d’entretien Childhood Experience of Care and Abuse (CECA), les thèmes: abus sexuels, mauvais traitements physiques, négligence, antipathie des parents, perte des parents ainsi que la mésentente grave vécue dans la famille avant l’âge de 18 ans.

Résultats:

La prévalence observée a été de 35% pour les mauvais traitements sexuels graves, 18% pour les sévices physiques graves, 27% pour la négligence, 34% pour l’antipathie, 37% pour la perte de quelqu’un qui donnait des soins, et 31% pour être témoin de la violence familiale. Les mauvais traitements physiques et sexuels étaient associés indépendamment avec les tentatives de suicide répétées si l’on contrôlait les effets des autres facteurs défavorables subis durant l’enfance. Il n’est pas apparu d’autres facteurs défavorables en relation avec un comportement suicidaire chronique. La relation avec le fait d’avoir été exposé à des sévices sexuels ou physiques était plus élevée chez ceux qui avaient présenté de façon répétitive à la fois des tentatives de suicide et de l’automutilation.

Conclusion:

Les sévices physiques et sexuels sont associés avec les comportements suicidaires répétés de façon significative et indépendante.

Resumen

Objetivo:

Los estudios demuestran que el abuso sexual y físico contra los niños predice los intentos de suicidio y la auto-mutilación. Se conoce poco acerca de la importancia del abuso sexual y físico cuando es comparado con otras adversidades infantiles severas en r elación a la conducta suicida.

Método:

Setenta y cuatro sujetos, de los cuales el 65% eran mujeres, admitidas en secuencia en el hospital general después de un intento de suicidio, fueron entrevistadas como parte de los datos iniciales acerca de intentos de suicidio y auto-mutilación anteriores y recibieron diagnósticos del DSM-IV. El “Childhood Experience of Care and Abuse (CECA) se aplicó para evaluar abuso sexual, abuso físico, negligencia, antipatía de los padres, pérdida de los padres, y desarmonía severa en la familia antes de los 18 años.

Resultados:

La prevalencia del abuso sexual severo fue 35%, abuso físico severo 18%, negligencia 27%, antipatía 34%, y pérdida del cuidador primario 37%, y exposición a violencia familiar 31%. El abuso físico y sexual fueron asociados independientemente con intentos repetidos de suicidio al controlar los efectos de los demás factores infantiles adversos. Ninguna otra adversidad estuvo relacionada a la conducta suicida crónica. El riesgo de exposición al abuso sexual o físico era mayor entre los que repetían los intentos de suicidio y las auto-mutilaciones.

Conclusión:

El abuso físico y sexual están significativamente e independientemente asociados con la conducta suicida repetitiva.

Introduction

Past research has demonstrated apparent links between childhood abuse, especially sexual abuse, and suicidal behavior (suicide attempts or deliberate self-harm) in adult life, as recently documented in a review of Andrews, Corry, Slade, Issakidis, and Swanston (2002). This association has been demonstrated in community samples of adults and adolescents (Bensley, Van Eenwyk, Spieker, & Schoder, 1999; Davidsen, Huges, George, & Blazer, 1996; Silverman, Reinherz, & Giaconia, 1996). The relationship has also been documented among undergraduate students (Peters & Range, 1995) and homeless and runaway street youth (Molnar, Shade, Kral, Booth, & Watters, 1998). Several studies have in particular shown this relationship in females, both in community samples (Bagley & Ramsay, 1986; Romans et al., 1995) and in undergraduates (Bryant & Range, 1995; Stepakoff, 1998). With regard to clinical research, the association has been demonstrated in primary care settings (Briere & Runtz, 1986; Gould et al., 1994), in psychiatric adult patients (Brown & Anderson, 1991; Kaplan, Asnis, Lipschitz, & Chorney, 1995), in patients with personality disorders (Brodsky, Malone, Ellis, Dulit, & Mann, 1997; van der Kolk, Perry, & Herman, 1991), in patients with major depression (Brodsky et al., 2003) and in adolescent inpatients (de Wilde, Kienhorst, Diekstra, & Wolters, 1992; Lipschitz et al., 1999; Shaunesey, Cohen, Plummer, & Berman, 1993). Coll and co-workers show that woman admitted to hospital because of deliberate self-poisoning also are more likely to have been abused than matched non-abused hospital admissions (Coll, Law, Tobias, Hawton, & Tomas, 2001).

In particular, some studies of random community samples show a strong relationship between childhood sexual abuse and repeated suicide attempts or more chronic self-destructive behavior (Boudewyn & Liem, 1995; Brown, Cohen, Johnson, & Smailes, 1999; Martin, 1996). In patients diagnosed with borderline personality disorder it is also shown that childhood sexual abuse in particular increases the risk of chronic self-destructive acts (repeated suicide attempts and self-mutilation) (Brodsky et al., 1997, van der Kolk et al., 1991).

To date, relatively few studies have examined the relationship between childhood abuse and suicidal acts within the group of suicide attempters. However, the findings so far suggest an association between sexual abuse and repeated suicide attempts. A study by van Egmond and co-workers suggests that female suicide attempters with a history of sexual abuse were disproportionately vulnerable to repetition (van Egmond, Garnefski, Jonker, & Kerkhof, 1993). Similarly Law and co-workers showed that childhood abuse contributed to an increase in the number of self-poisoning episodes and other deliberate self-harm episodes in women who had been admitted to hospital after having taken an overdose (Law, Coll, Tobias, & Hawton, 1998). Another study of patients admitted to psychiatric hospital after attempting suicide found that significantly more repeaters than first-evers had experienced an unhappy childhood (Krarup, Nielsen, Rask, & Petersen, 1991). However, this study did not specifically record physical or sexual abuse. In a prospective comparison of repeaters and non-repeaters, Hjelmeland found that a history of sexual abuse predicted repetition in both men and women (Hjelmeland, 1996). In a recent study of suicide attempters Stanley et al. distinguish between suicide attempters with and without a history of self-mutilation (Stanley, Gameroff, Michalsen, & Mann, 2001). Self-mutilation in their study is characterized by habitual self-harm with the intention of providing emotional relief by inflicting pain. Their findings suggest that suicide attempters who self-mutilate represent a unique population within the group of suicide attempters, having higher levels of mental problems and being more likely to have a history of childhood abuse than suicide attempters who do not self-mutilate.

To sum up, several studies highlight a relationship between childhood sexual abuse and chronic self-destructive acts (either repeated suicide attempts or self-mutilation). However, childhood sexual abuse often coincides with physical or psychological abuse (Coll, Law, Tobias, & Hawton, 1998). Furthermore, abusive experiences typically occur in complex contexts where other childhood adversities prevail such as lack of care, family disruption and violence (Bifulco & Moran, 1998; Dong, Anda, Dube, Giles, & Felitti, 2003; Finkelhor & Berliner, 1995; McGee, Wolfe, Yuen, Wilson, & Carnochan, 1995). Most studies addressing the relationship between childhood maltreatment and suicidal behavior in adult life examine one type of abuse or a combination of a limited number of types of abuse (physical, sexual or psychological abuse) (Lipschitz et al., 1999; Wiederman, Sansone, & Sansone, 1998). Moreover, in a review of the methodological problems encountered in child maltreatment research, Kinard (1994) notes that researchers and clinicians have problems in classifying multiple problems. Children tend to be classified by one type of maltreatment, which may not reflect all forms of maltreatment experienced by the child. However, a study of Dube and co-workers addressing multiple adverse childhood experiences show that adverse experience in any category increase the risk of attempted suicide. Furthermore, the number of such experiences strongly increases the risk of suicide attempts (Dube et al., 2001). Little is known about the importance of various severe childhood adversities with respect to chronic suicidal behavior.

Thus, the research so far does not allow for inferences regarding the importance of sexual abuse with respect to chronic self-destructive behavior when other adverse experiences in childhood such as physical abuse, neglect, family violence and disruption, are taken into consideration.

Another limitation of most studies is that they rely on retrospective self-report questionnaires of childhood experiences and thus have no way to substantiate the actual occurrence of the event. Reliance on self-reports also raises the question of mood or response bias that may falsely affect the results. In the present study the Childhood Experience of Care and Abuse (CECA) interview schedule (Bifulco, Brown, & Harris, 1994) was used in order to reduce the risk of bias of reporting style or emotional response. To our knowledge this instrument is unique in its emphasis of investigator-based measurement in a semi-structured format where the investigator rather than the respondent decides whether the experiences reported meet criteria for inclusion.

The main purpose of the present study is to:

• Assess the prevalence of a wide range of severe childhood adverse experiences in a group of suicide attempters consecutively admitted to a general hospital by using the CECA interview schedule.

• Investigate if there is a specific relationship between childhood sexual abuse and repeated suicide attempts and self-mutilation when adjusting for other severe childhood adverse experiences.