Research paperThe relationship between childhood trauma and the severity of adulthood depression and anxiety symptoms in a clinical sample: The mediating role of cognitive emotion regulation strategies
Introduction
A considerable body of evidence suggests that childhood trauma is associated with the onset, symptom severity, and course of depression and anxiety symptoms (Friis et al., 2002, Gibb et al., 2007, Kendler et al., 1999). Despite the well-established relationship between childhood trauma and adulthood mental health problems, the specific mechanism underlying early life trauma relationship to later psychiatric problems is still unclear.
The ability of emotion regulation is a possible mediator of the relationship between childhood trauma and later depression and anxiety symptoms. Although different researchers have used the term “emotion regulation” in different ways (Gross and Thompson, 2007), emotion regulation can be generally defined as “the ability to respond to the ongoing demands of experience with a range of emotion in a manner that is socially tolerable and sufficiently flexible to permit spontaneous reactions as well as the ability to delay spontaneous reactions as needed” (Cole et al., 1994). Previous studies have suggested that emotion regulation ability is developed in early life within the context of interpersonal emotional exchanges between caregiver and child (Feldman and Greenbaum, 1997). The quality of caregiver–child emotional exchanges is an important factor in adulthood emotion regulation capacity (Cole et al., 2004).
It appears that childhood trauma disturbs development of the ability to regulate emotions in a healthy manner. Childhood trauma, especially repeated interpersonal trauma between caregiver and child, interferes with the acquisition of appropriate emotion regulation skills (Burns et al., 2010, Cicchetti and Rogosch, 2009). Several studies have provided empirical evidence that childhood trauma can cause subsequent problems related to emotion regulation. One study described sexually abused girls who had difficulty understanding and regulating their emotions (Shipman et al., 2000). They also expected less emotional support from others and had more interpersonal problems and more negative emotional states. Neglected children were shown to be less able to understand negative emotion and to have fewer adaptive emotion regulation skills. They expected caregivers to respond negatively to their emotions, and attempted to suppress their emotions (Shipman et al., 2005). These findings show that different types of childhood maltreatment can cause various patterns of deficits or difficulties in understanding and regulating emotions. However, it is still unclear how distinctive types of childhood trauma differentially influence the development of emotion regulation ability.
Emotion dysregulation originating from childhood trauma can contribute to the development, maintenance, and treatment of many psychiatric disorders, including depression and anxiety (Berking and Wupperman, 2012, Gross and Muñoz, 1995, Kring and Werner, 2004). Depressed individuals were found to have difficulty identifying, tolerating, and adaptively regulating their negative emotions with respect to stressful events. (Campbell-Sills et al., 2006, Ehring et al., 2008, Gilbert et al., 2006, Honkalampi et al., 1999) Emotion regulation deficits in anxious individuals can lead to maladaptive coping with fear related stimuli, increasing the possibility of chronic avoidance (Cisler et al., 2010). Several prospective studies have revealed that emotion dysregulation predicts later depression and anxiety symptom severity (Berking and Wupperman, 2012). One study suggested that emotion dysregulation predicted depression severity two years later. Other research showed that positive expectations for the ability to manage negative emotion were associated with reduced depression and anxiety (Kassel et al., 2007, Kraaij et al., 2002).
A few studies have investigated emotion regulation as a mediator between childhood trauma and subsequent mental health problems. One study with a low-income African American sample provided support for emotion regulation as a mediator between childhood trauma and adult depression (Crow et al., 2014). In addition, several other studies in children and adolescents showed the negative influence of childhood trauma on psychological adjustment was mediated by emotion regulation deficits (Choi and Oh, 2014, Kim and Cicchetti, 2010). These findings support the role of emotion dysregulation as a mediator between childhood trauma and adulthood depression/anxiety symptoms. However, most participants in these previous studies were adolescents or adults in a community.
To the best of our knowledge, only one recent study with clinical sample provided evidence for the mediating role of emotion regulation in the relationship between childhood trauma and later depression (Hopfinger et al., 2016). Although the study additionally explored whether specific types of emotion regulation were important for explaining the association between childhood trauma and current depression, they did not consider factors such as comorbid anxiety and possible differential effects of various childhood traumas in depressive disorders.
Thus, this study used structural equation modeling (SEM) to characterize the relationships between cognitive emotion regulation strategies, childhood trauma, adulthood depression, and comorbid anxiety symptoms in a clinical sample diagnosed with depressive disorder. Specifically, cognitive emotion regulation strategy use was examined as a mediator of the relationship between childhood trauma and adult depression and anxiety symptoms. We hypothesized that patients with childhood trauma would use more maladaptive and fewer adaptive cognitive emotion regulation strategies. In addition, we hypothesized that these tendencies would influence current depressive and comorbid anxiety symptoms. Further, we explored whether specific types of childhood trauma had differential effects on current depression/anxiety as mediated by cognitive emotion regulation strategies and if specific strategies were significantly important for the relationship between childhood trauma and later depression/anxiety.
Section snippets
Participants
During the 36-month study period from August 2011 to July 2014, patients who visited the Mood and Anxiety Disorders Unit at Seoul St. Mary's Hospital, The Catholic University of Korea, and who met DSM-IV diagnostic criteria for nonpsychotic depressive disorder as a principal diagnosis were recruited consecutively. Diagnosis was determined by a psychiatrist using semi-structured diagnostic interviews from the Mini-International Neuropsychiatric Interview (M.I.N.I) (Sheehan et al., 1998).
Participant demographics and clinical characteristics
Participant demographics and clinical characteristics are summarized in Table 1. Mean age was 36.94 (±12.29) years, and 54.3% (n=316) of the participants were female. Mean education years were 14.05 (±2.77). 28.8% (n=159) of the participants were unemployed and 57.1% (n=324) of the participants were married or cohabited. Mean BDI score was 24.31 (±12.04), indicating severe depression in the study sample (Beck et al., 1961, Lee et al., 1995). Mean STAI score was 85.82 (±10.94), which is below
Discussion
Prior research has investigated the negative effects of childhood trauma for many psychiatric problems and the relationship between early life trauma and emotion regulation ability. In this clinical study a mediation model was tested in which early life trauma was associated with depression and anxiety symptom severity as mediated by cognitive emotion regulation ability.
Patients reporting greater childhood traumatic experiences had a tendency to use more overall maladaptive cognitive emotion
Limitation
This study has several limitations. First, this was a cross-sectional study which assessed measurements concurrently. To establish causal relationships, future longitudinal studies following children experiencing early life trauma are necessary. Especially, prospective studies which serially assess changes in emotion regulation ability and mental health outcomes would be informative. Second, we could not apply a standardized instrument for evaluating and excluding comorbid personality
Conclusions
Despite its limitations, this study provides clinically useful evidence from a large clinical sample for the mediating role of cognitive emotion regulation between childhood trauma and current depression/anxiety symptoms. Specifically, these findings support a model in which the relationship between overall childhood trauma and adult depressive and anxiety symptoms in clinical populations is mediated by maladaptive cognitive emotion regulation strategies. This suggests that cognitive emotion
Author disclosure
Contributors
All authors designed the study. Hyu Jung Huh managed the literature searches, wrote the first draft of the manuscript under the supervision of Jeong-Ho Chae. Kyung Hee Kim and Hee Kyung Lee participated in the statistical analysis. All authors contributed to and have approved the final manuscript.
Role of funding sources
This research was supported by a grant from the Korea Research Foundation (2014R1A2A1A11050691). The Korea Research Foundation did not play further role in study design; in the collection, analysis, and interpretation of data; in writing of the manuscript; or in the decision to submit the paper for publication.
Acknowledgments
This research was supported by a grant from the Korea Research Foundation (2014R1A2A1A11050691).
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