Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2015 Oct 1.
Published in final edited form as: Addict Behav. 2014 Jun 2;39(10):1522–1527. doi: 10.1016/j.addbeh.2014.05.023

The Relationship between Child Abuse and Negative Outcomes among Substance Users: Psychopathology, Health, and Comorbidities

Anne N Banducci 1,*, Elana Hoffman 1, CW Lejuez 1, Karestan C Koenen 2
PMCID: PMC4134319  NIHMSID: NIHMS609557  PMID: 24976457

Abstract

Background

Adults with substance use disorders (SUDs) report higher rates of child abuse than adults without SUDs. Prior work suggests this abuse is associated with higher rates of psychosis, posttraumatic stress disorder, physical health problems, alcohol dependence, and cannabis dependence among substance users. Little is known about other problems associated with child abuse experienced by substance users. We hypothesized among adults with SUDs, child abuse would be associated with elevated rates of all Diagnostic and Statistical Manual (DSM-IV-TR) psychiatric disorders, substance dependencies, and comorbidities assessed.

Method

We assessed 280 inpatients in substance use treatment with the Structured Clinical Interview for the DSM-IV-TR, the Diagnostic Instrument for Personality Disorders, and Childhood Trauma Questionnaire (CTQ). We used chi-square and regression analyses to establish whether rates of psychiatric disorders, substance dependencies, and comorbidities differed as a function of child abuse.

Results

Consistent with our hypotheses, higher scores on the CTQ were associated with elevated rates of psychiatric disorders (mood disorders, anxiety disorders, psychotic symptoms, and personality disorders) and substance dependencies (alcohol dependence and cocaine dependence). Moreover, higher rates of all comorbidity patterns (e.g. comorbid alcohol dependence and anxiety) were observed among individuals who reported experiencing child abuse. Across all substance dependencies examined, individuals who had been abused had significantly higher rates of all psychiatric disorders assessed.

Conclusions

Individuals with substance use disorders who have been abused have particularly elevated rates of psychiatric and substance use disorders as a function of their abuse experiences. These findings have important treatment implications for individuals in residential substance use treatment settings.

Keywords: child abuse, substance use, psychopathology, comorbidities

1. INTRODUCTION

Child abuse and trauma are important public health problems associated with increased rates of psychiatric disorders, substance use disorders, and physical health problems among survivors (Green et al., 2010; Huang et al., 2011; Kessler, Davis, & Kendler, 1997; McLaughlin et al., 2010; Scott et al., 2011). It has been estimated that 30% of psychiatric disorders diagnosed in adults can be directly linked to these childhood experiences (Afifi, Enns, Cox, Asmundson, Stein, & Sareen, 2008; Green et al., 2010), with abuse accounting for an increased persistence of mood, anxiety, and substance use disorders across the lifespan (McLaughlin, Green, Grueber, Sampson, Zaslavsky, & Kessler, 2010). Based on a rich body of literature, child abuse appears to represent a particularly potent risk factor for psychopathology in adulthood.

Substance users as a group report particularly elevated rates of child abuse (Hefferman et al., 2000; Kendler et al., 2000; Rosenhow et al., 1988) and abuse has been shown to be robustly associated with increased odds of being diagnosed with DSM-IV-TR substance use disorders (Afifi, Henriksen, Asmundson, & Sareen, 2012). This abuse is associated with earlier substance use initiation, greater functional impairments, and increased odds of substance dependencies (Nomura, Herd, & Pilowsy, 2012). Further, individuals with substance use disorders who experienced child abuse have higher rates of posttraumatic stress disorder, psychosis, alcohol dependence, and cannabis dependence (Wu, Schairer, Dellor, & Grella, 2010). These results suggest child abuse not only increases the likelihood individuals will use substances, but also that these individuals will be dually diagnosed with comorbid psychopathology. Although prior work demonstrates increased rates of some psychiatric disorders among substance users who have experienced child abuse, the full range of DSM-IV-TR psychiatric and substance use disorders have not previously been examined as a function of child abuse in this population. Moreover, although individuals in the general population who have been abused are more likely to have comorbidities (e.g. multiple psychiatric and/or substance use disorders; Scott, Smith, & Ellis, 2010), rates of these comorbidities have not been previously examined among substance users as a function of abuse. An exploration of these relationships would enhance our understanding of the high rates of psychiatric disorders observed among substance users (e.g. Chen et al., 2011) and would be relevant to developing treatments addressing comorbid psychiatric and substance use disorders.

The current study aims to examine the relationships between child abuse, psychiatric disorders, substance dependencies, comorbidities, and health problems among individuals in residential substance use treatment. We hypothesized more severe child abuse would be associated with elevated rates of a variety of psychiatric disorders and substance dependencies in adult substance users (Brems et al., 2004), with the expectation that more severe abuse would be associated with higher rates of these disorders (Edwards et al., 2003). Further, we hypothesized substance users who had been abused would have a greater odds of being dually diagnosed with comorbidities (e.g. both alcohol dependence and major depressive disorder) and with health problems.

2. MATERIAL AND METHODS

2.1. Participants

As a part of a larger study, we recruited 280 participants (M age = 43.3; S.D. = 9.79; 69.7% male; 88.4% African American) from a residential substance use treatment center in inner city Washington D.C. As a part of the treatment center requirements, participants were required to evidence a negative urine drug screen; those with positive urine screens entered a detoxification program before admittance. Typical inpatient treatment lasted between 30 and 180 days, depending on participants’ treatment funding sources. During treatment, participants were only permitted to leave the center for scheduled appointments (e.g. appointments with psychiatrists, primary care physicians). Participants were involved in a variety of programs from 8am to 9pm daily, based on Alcoholics Anonymous and Narcotic Anonymous techniques, as well as on strategies focusing on the development of relapse prevention skills.

All participants were administered a standardized diagnostic assessment by our staff (graduate students and advanced post-baccalaureate research assistants) as a part of the treatment center’s intake process. After completing this assessment, participants were given the option to become involved with our research study; informed consent was obtained after the study was explained (< 5% refused to participate). The University of Maryland Institutional Review Board approved the study protocol. All paper-based assessments completed by participants were coded with a subject number so that the identities of participants were kept confidential.

2.2. Assessments

2.2.1. Childhood abuse

Childhood abuse was assessed using the Childhood Trauma Questionnaire-Short Form (CTQ-SF; Bernstein et al., 2003), which is a validated self-report retrospective questionnaire (Thombs et al., 2007). The CTQ-SF has satisfactory specificity and good sensitivity in comparison to reports from child welfare agencies (Bernstein et al., 1997), as well as convergent and discriminant validity with other trauma measures (Bernstein et al., 1994). The sexual, physical, and emotional abuse subscales were administered (Bernstein & Fink, 1998); the internal consistency was good to excellent (.88, .86, .96, respectively). We examined the CTQ total score continuously and based on established cutoffs (Bernstein & Fink, 1998).

2.2.2. Diagnostic assessments

The Structured Clinical Interview for the DSM-IV-TR was used to diagnose current and lifetime Axis I and II disorders (First, Spitzer, Gibbon, & Williams, 2010), including major depressive disorder, dysthymia, bipolar I disorder, substance-induced mood disorder, panic disorder, social phobia, specific phobia, obsessive compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, antisocial personality disorder (ASPD), and substance dependencies (alcohol, cannabis, opioid, hallucinogen/PCP, stimulant, crack/cocaine, and polydrug). We also assessed for the presence or absence of psychotic symptoms using a screener included in the SCID. Borderline personality disorder (BPD) was assessed using the Diagnostic Instrument for Personality Disorders, because it is a more precise measure of BPD than the SCID-IV (Zanarini et al., 1987).

2.2.3. Composite scores

We created several composite scores based on the number of current and lifetime DSM-IV-TR disorders endorsed; higher composite scores indicated a greater number of DSM-IV-TR Axis I and II disorders endorsed within the composite (range: 0 – 13 disorders). Separate composite scores were created for the number of substance use disorders (range: 0–12), mood disorders (range: 0–4), and anxiety disorders (range: 0–4) endorsed. Additionally, a composite score was computed to indicate the total number of DSM-IV-TR Axis I and II psychiatric disorders endorsed (Psychiatric disorder composite; range: 0–13; substance use disorders were not included in this composite), as well as the total number of psychiatric and substance use disorders (All disorder composite; range: 0–17). These four composite scores were examined within analyses continuously (number of disorders endorsed) and dichotomously (to indicate the presence or absence of a given disorder within a particular category).

2.2.4. Health and symptom-level assessments

Additional measures were included to better understand the range of problems experienced by individuals within residential drug treatment programs. Basic questions about demographic characteristics and health behaviors were assessed verbally during the intake assessment. The Hamilton Rating Scale for Depression (HAM-D; Hamilton, 1960) was used as an additional symptom-level measure of psychopathology.

2.3. Analytic Strategy

Prior to data entry, the completed questionnaires and SCID interview sheets were checked for completeness or obvious errors. Data were double entered into SPSS (versions 14–20 over the course of the study) so potential inconsistencies or inaccuracies could be easily detected. There were occasional missing data points due to non-responses such as: “don’t know” or “refused” as participants could choose to not answer questions asked during the intake assessment. For example rates of missing data for psychiatric and substance use disorder diagnoses ranged from 0 – 2.1%. We did not implement any imputation procedure for these missing data, and only report results based on participants with valid and complete responses for the relevant questions (thus the N’s vary across analyses).

2.3.1. Analyses for diagnoses as a function of abuse

Hierarchical linear regression was used to determine the relationship between the number of DSM-IV-TR psychiatric disorders and substance dependencies endorsed in our composite scores (i.e., all disorders, psychiatric disorders, anxiety disorders, mood disorders, substance use disorders composites) and CTQ total scores. Logistic regression was used to determine whether the presence of all individual disorders (e.g., major depressive disorder) and problematic behaviors assessed were associated with CTQ total scores. All analyses included gender, race/ethnicity, income, and education as covariates in the first step of the regression model. All betas presented are standardized regression coefficients.

2.3.2 Analyses of comorbid psychiatric and substance use disorders as a function of abuse

To determine whether rates of comorbid psychiatric and substance use disorders varied as a function of abuse experiences, we conducted two separate sets of analyses. For all chi square analyses described below, composite scores were recoded as 0 (does not have any disorders within the category) and 1 (has at least one disorder within the category). Psychotic symptoms, ASPD, and BPD, were coded as 0 (does not have the disorder) and 1 (has the disorder).

2.3.2.1. Basic comorbid psychiatric and substance use disorders analyses

For the first set of comorbidity analyses, chi-square analyses were conducted to examine whether the presence of comorbid psychiatric and substance use disorders varied as a function of abuse experienced by comparing persons with a specific substance use disorder (e.g. alcohol dependence) and a) any psychiatric disorder, b) any anxiety disorder, c) any mood disorder, d) psychotic symptoms, e) BPD, and f) ASPD. These analyses indicate whether the presence of comorbid psychiatric and substance use diagnoses differed within our sample as a function of abuse.

2.3.2.2. Conditional comorbid psychiatric and substance use disorder analyses

We conducted a second set of chi-square analyses of comorbid psychiatric and substance use disorders to better understand which types of substance dependences and psychiatric disorders were most likely to co-occur, without base rates of substance use disorders biasing our results. With these conditional analyses, we examined the presence of each category of comorbid psychiatric disorder (e.g. mood disorders, and anxiety disorders) as described above, given dependence across a specific substance type. This indicated the likelihood a participant would have a particular psychiatric disorder within a specific category, given the participant had a particular type of substance dependence.

3. RESULTS

3.1. Demographics

Within our sample, 43.6% of participants experienced childhood abuse, based on established CTQ cutoff scores (Bernstein & Fink, 1998). Women were significantly more likely to report abuse than men (53.5% of women versus 40.2% of men, χ2 = 3.83, p = .035). For substance dependencies, 44.8% of the sample reported ever having alcohol dependence, 28.4% ever having cannabis dependence, 68.4% ever having cocaine dependence, 29.9% ever having opioid dependence, and 18.4% ever having PCP/hallucinogen dependence. For psychiatric disorders, 68.8% reported ever having any of the psychiatric disorders we assessed, with 32.0% ever having an anxiety disorder, 47.4% ever having a mood disorder, 12.6% ever having psychotic symptoms, 24.0% having borderline personality disorder (BPD), and 25.3% having antisocial personality disorder (ASPD).

3.2. Psychiatric and Substance Use Disorders as a Function of Abuse Severity

Separate regression models were tested to determine the association between trauma severity and rates of psychiatric and substance use disorders. The model examining the relationship between the CTQ total score, covariates, and the psychiatric disorders composite was significant, with higher CTQ scores associated with a greater number of psychiatric disorders (Table 1). Similar findings were observed for the substance use disorders composite, mood disorder composite, and anxiety disorder composite; higher CTQ scores were associated with a greater number of current and past disorders within all of these composites (Table 1). Further, higher CTQ scores were associated with an increased likelihood of having psychotic symptoms, BPD, and ASPD (Table 1).

Table 1.

Association between Childhood Trauma Severity and Psychiatric Disorders, Substance Use Disorders, and Health Outcomes

β t p OR 95% CI
All Disorders Composite1 .098 6.46 <.001
Psychiatric Disorders Composite .354 6.18 <.001
Mood Disorders Composite .271 4.64 <.001
 Major Depressive Disorder (MDD)2 .004 1.03 [1.01, 1.05]
 Dysthymia .765 1.01 [0.95, 1.07]
 Substance-Induced MDD .310 .984 [0.95, 1.04]
 Bipolar I/II Disorder .002 1.04 [1.01, 1.07]
Anxiety Disorders Composite .253 4.26 <.001
 Social Phobia .011 1.04 [1.01, 1.07]
 Specific Phobia .080 1.03 [1.00, 1.05]
 Generalized Anxiety Disorder .018 1.03 [1.01, 1.06]
 Obsessive Compulsive Disorder .669 1.01 [0.96, 1.06]
 Posttraumatic Stress Disorder .015 1.03 [1.01, 1.05]
 Panic Disorder .084 1.04 [0.99, 1.10]
Psychotic Symptoms .003 1.04 [1.01, 1.06]
Borderline Personality Disorder <.001 1.05 [1.03, 1.07]
Antisocial Personality Disorder <.001 1.04 [1.02, 1.06]
Substance Use Disorders Composite .268 4.49 <.001
 Alcohol Dependence <.001 1.05 [1.02, 1.07]
 Cannabis Dependence .063 1.02 [1.00, 1.04]
 Cocaine Dependence .004 1.04 [1.01, 1.06]
 Opioid Dependence .190 0.99 [0.96, 1.00]
 PCP/Hallucinogen Dependence .749 1.00 [0.98, 1.03]
 Stimulant Dependence .373 1.03 [0.97, 1.08]
Mental and Physical Health Outcomes
 Has a serious medical condition .007 1.03 [1.01, 1.05]
 Has received treatment for a psychological problem <.001 1.05 [1.03, 1.08]
 Is court-mandated to attend substance use treatment <.001 0.96 [0.94, 0.98]
 Is currently taking psychiatric medication <.001 1.06 [1.03, 1.08]
 Has previously attended 12 step groups .038 1.02 [1.00, 1.05]
 Is currently married .010 .951 [0.92, 0.99]
 HAM-D score .224 2.37 .020
Open in a new tab
1

Linear regression was used for the composite scores to assess whether participants had a greater number of disorders within the composite score, as a function of trauma severity.

2

Logistic regression was used to assess whether participants had a particular diagnosis or particular outcomes, as a function of trauma severity.

To better understand these patterns, we further probed the data using logistic regression to determine whether abuse severity was associated with a greater likelihood of ever being diagnosed with all individual disorders assessed (see Table 1). There were a number of disorders that were more frequently endorsed by participants who had higher CTQ scores (Table 1). Higher CTQ scores were associated with an increased likelihood of being diagnosed with major depressive disorder, bipolar disorder, social phobia, generalized anxiety disorder, and posttraumatic stress disorder. For substance dependencies, higher CTQ scores were associated with an increased likelihood of being diagnosed with alcohol and cocaine dependence; cannabis approached significance (Table 1).

3.3. Health and Symptom-Level Outcomes as a Function of Abuse

Abuse severity was associated with a number of health and symptom level outcomes. Previously receiving treatment for psychiatric and substance use disorders, taking psychiatric medications, attending 12-step groups, having a serious medical condition, not being married, and having an elevated HAM-D score were all associated with being abused as a child (Table 1).

3.4. Comorbidities as a Function of Abuse

3.4.1. Overall comorbidity rates as a function of abuse

When examining rates of comorbidities as a function of whether participants had been abused, there generally were elevated rates of comorbidities among participants who had been abused (Table 2). Particularly elevated rates of comorbidities, as a function of abuse, were observed for comorbid alcohol dependence and all psychiatric disorders examined, as well as comorbid cocaine dependence and all psychiatric disorders examined (excluding antisocial personality disorder and psychotic symptoms; Table 2). Individuals who had been abused also had significantly elevated rates of comorbid cannabis dependence and psychiatric disorders, specifically ASPD (Table 2). However, there were not significant differences in rates of comorbidities as a function of abuse experiences for participants with comorbid opioid dependence and psychiatric disorders (Table 2).

Table 2.

Comorbidity of Psychiatric and Substance Use Disorders as a Function of Abuse

Comorbid Psychiatric and Substance Use Disorders Total N ≤ 280 Abused N ≤ 122 Not Abused N ≤ 158 p-value1 Odds Ratio [95% CI]
Alcohol Dependence and Any Psychiatric Disorder (%) 36.1 59.2 18.5 <.001 3.42 [1.97, 5.87]
 Alcohol Dependence and Any Anxiety Disorder 19.9 35.8 7.6 <.001 3.48 [2.03, 5.98]
 Alcohol Dependence and Any Mood Disorder 29.2 49.2 14.0 <.001 3.65 [2.22, 6.00]
 Alcohol Dependence and Psychotic Symptoms 8.1 16.8 1.3 .004 2.98 [1.35, 6.56]
 Alcohol Dependence and BPD 17.4 34.2 4.5 <.001 4.08 [2.26, 7.39]
 Alcohol Dependence and ASPD 16.2 29.2 6.4 <.001 2.60 [1.50, 4.53]
Cocaine Dependence and Any Psychiatric Disorder 51.3 70.5 36.3 <.001 3.29 [1.93, 5.60]
 Cocaine Dependence and Any Anxiety Disorder 24.0 39.3 12.1 .014 2.01 [1.11, 3.65]
 Cocaine Dependence and Any Mood Disorder 38.7 57.4 24.2 <.001 3.10 [1.80, 5.35]
 Cocaine Dependence and Psychotic Symptoms 9.5 18.3 2.6 .083 2.07 [0.82, 5.24]
 Cocaine Dependence and BPD 20.9 36.9 8.3 <.001 3.29 [1.59, 6.81]
 Cocaine Dependence and ASPD 19.0 27.9 12.1 .213 1.34 [0.73, 2.43]
Opioid Dependence and Any Psychiatric Disorder 17.0 20.7 14.2 .455 0.93 [0.53, 1.63]
 Opioid Dependence and Any Anxiety Disorder 7.6 11.6 4.5 .389 0.87 [0.49, 1.58]
 Opioid Dependence and Any Mood Disorder 13.0 16.5 10.3 .436 1.08 [0.64, 1.85]
 Opioid Dependence and Psychotic Symptoms 3.7 8.4 0 .333 1.29 [0.58, 2.88]
 Opioid Dependence and BPD 5.5 8.3 3.2 .260 0.76 [0.40, 1.46]
 Opioid Dependence and ASPD 8.7 12.4 5.8 .072 1.63 [0.90, 2.93]
Cannabis Dependence and Any Psychiatric Disorder 23.5 32.5 16.6 .008 2.08 [1.17, 3.72]
 Cannabis Dependence and Any Anxiety Disorder 11.2 17.5 6.4 .077 1.55 [0.90, 2.66]
 Cannabis Dependence and Any Mood Disorder 15.5 24.2 8.9 .301 1.19 [0.71, 1.98]
 Cannabis Dependence and Psychotic Symptoms 4.0 7.6 1.3 .375 1.22 [0.56, 2.67]
 Cannabis Dependence and BPD 7.2 13.3 2.6 .488 0.94 [0.52, 1.72]
 Cannabis Dependence and ASPD 11.6 16.7 7.6 .003 2.29 [1.31, 4.02]
Open in a new tab
1

p values are based on chi-square tests

3.4.2. Conditional comorbidities as a function of abuse

As fewer participants in our sample endorsed cannabis dependence and opioid dependence, we were particularly interested in further probing comorbidity rates by looking at conditional rates. Here we examined rates of comorbidities among participants who endorsed particular substance dependencies. Across all substances examined, participants who experienced child abuse were significantly more likely to have psychiatric disorders (Table 3). More specifically, across all substances examined, they were significantly more likely to have each specific disorder class assessed (excluding antisocial personality disorder among individuals with cannabis dependence). Among participants with alcohol dependence, those who had been abused were 9.97 times more likely to have a comorbid psychiatric disorder as compared to those who had not been abused. Similarly, among those with cannabis dependence, cocaine dependence, and opioid dependence individuals were 4.5 times, 5.35 times, and 4.77 times more likely to be diagnosed with psychiatric disorders, respectively (Table 3). Thus, when examining comorbidities within specific substance dependence categorizations, individuals who had been abused were significantly more likely to have comorbid psychiatric disorders.

Table 3.

Conditional Comorbidities as a Function of Abuse

Substance Dependence Comorbidity Total (%) By Abuse p-value 1 OR [C.I.]
Abused (%) Not Abused (%)
Any psychiatric disorder 80.0 93.4 59.2 <.001 9.79 [3.36, 28.58]
Any mood disorder 64.8 77.6 44.9 <.001 4.26 [1.95, 9.29]
Alcohol Dependence Any anxiety disorder 44.0 56.6 24.5 <.001 4.02 [1.82, 8.88]
 # Abused= 76 Psychotic symptoms 17.7 26.7 4.1 .001 8.55 [1.90, 38.48]
 # Not Abused= 49 BPD 38.4 53.9 14.3 <.001 7.03 [2.81, 17.61]
ASPD 36.0 46.1 20.4 .003 3.33 [1.45, 7.62]
Any psychiatric disorder 76.5 88.6 63.4 .006 4.5 [1.46, 13.89]
Any mood disorder 50.6 65.9 34.1 .003 3.73 [1.52, 9.15]
Cannabis Dependence Any anxiety disorder 36.5 47.7 24.4 .022 2.83 [1.12, 7.15]
 # Abused= 44 Psychotic symptoms 13.3 20.9 5.0 .032 5.03 [1.02, 24.92]
 # Not Abused= 41 BPD 23.5 36.4 9.8 .004 5.29 [1.59, 17.56]
ASPD 37.6 45.5 29.3 .094 2.01 [0.82, 4.94]
Any psychiatric disorder 74.1 88.7 59.4 <.001 5.35 [2.53, 11.30]
Any mood disorder 56.0 72.2 39.6 <.001 3.96 [2.16, 7.24]
Cocaine Dependence Any anxiety disorder 34.7 49.5 19.8 <.001 3.97 [2.09, 7.53]
 # Abused= 97 Psychotic symptoms 13.8 23.2 4.3 <.001 6.78 [2.24, 20.56]
 # Not Abused= 96 BPD 30.2 46.4 13.7 <.001 4.46 [2.69, 11.08]
ASPD 27.5 35.1 19.8 .013 2.19 [1.14, 4.20]
Any psychiatric disorder 64.4 83.3 51.2 .004 4.77 [1.54, 14.79]
Any mood disorder 49.3 66.7 37.2 .012 3.38 [1.27, 8.98]
Opioid Dependence Any anxiety disorder 28.8 46.7 16.3 .005 4.50 [1.53, 13.27]
 # Abused= 30 Psychotic symptoms 13.9 33.3 0.0 <.001 1.50 [1.17, 1.93]
 # Not Abused= 43 BPD 20.8 33.3 11.9 .028 3.70 [1.11, 12.33]
ASPD 32.9 50.0 20.9 .010 3.78 [1.46, 10.54]
Open in a new tab
1

p values are based on chi-square tests

4. DISCUSSION

The results of the current study demonstrate a strong relationship between child abuse and adult psychopathology among individuals in residential substance use treatment. These findings are in line with and expand upon prior work demonstrating that child abuse was a predictor of posttraumatic stress disorder, psychosis, alcohol, and cannabis dependence among adults in residential drug treatment programs (e.g. Wu et al., 2010). Further, they follow patterns of findings within non-substance using samples, which demonstrate that child abuse is associated with elevated rates of delusions and hallucinations in adults with schizophrenia (Schenkel et al., 2005) and with severity of depression (Bifulco et al., 2002). Our work replicates and extends these findings by assessing the full range of psychiatric and substance use disorders in individuals in residential treatment. These findings suggest the importance of assessing for abuse experiences within substance using populations in order to better understand psychiatric symptoms that might be present.

An important extension of prior work is our findings regarding rates and patterns of comorbidities within our sample of substance users. When examining the entire sample, individuals who had experienced child abuse had elevated rates of comorbid alcohol/cocaine dependence and psychiatric disorders. These elevated rates of comorbidities are consistent with the findings of Scott and colleagues (2010) who demonstrated that individuals who experienced child abuse were more likely to be diagnosed with more than one psychiatric disorder. Our work extends these finding to a particularly at-risk sample, namely substance users in residential treatment. Moreover, we probed rates of specific DSM-IV-TR psychiatric and substance use disorder comorbidities, which have not previously been examined as a function of abuse status. These analyses allowed us to better understand patterns of comorbidities as a function of abuse experiences among substance users.

Perhaps even more interesting are the patterns of conditional comorbidities, as these findings better represent patterns of comorbidities among substances for which fewer participants met dependence. Conditional comorbidity rates, as compared to rates of overall comorbidities, may be less biased to regional differences in substance use patterns. Results demonstrated that participants who were dependent on alcohol, cocaine, cannabis, or opioids were 4.5 to 9.79 times more likely to have psychiatric disorders if they had been abused as children. Moreover, across the types of specific psychiatric disorders examined, they were significantly more likely to have these comorbidities if they had been abused. This dramatic pattern of findings suggests abuse experiences need to be taken into account when attempting to understand any pattern of comorbidities within this type of sample. As individuals with comorbid substance use and psychiatric disorders are unlikely to be screened for psychiatric disorders (Substance Abuse and Mental Health Service Administration, 2009) or receive treatment for these disorders (Watkins et. al., 2004; Weaver et al., 2001), it is particularly important to understand the types of factors that might distinguish individuals most in need of additional treatment services.

These results should be considered within the context of four limitations. First, ratings of child abuse were limited to self-report, which could result in reporting bias. However, as individuals generally underreport abuse experiences (Widom & Morris, 1997; Widom & Shepard, 1996) we did not believe that such-reporting bias would influence our pattern of findings. Second, we cannot assume our findings generalize to all residential substance use treatment populations, as some of the findings may have been due to region-specific patterns of substance use. Third, since this study was somewhat exploratory in nature, multiple statistical analyses were conducted, necessitating replications of these findings to ensure their accuracy. Finally, although we were careful to ensure the accuracy of the psychiatric and substance use disorder diagnoses, it would have been better to have audiotaped assessments for review or to have conducted multiple interviews with a subset of participants to establish reliability. It is necessary to replicate this pattern of findings among substance users in additional settings.

Despite these limitations, this work has important clinical implications. Due to elevated rates of child abuse among substance users, (Hefferman et al., 2000; Kendler et al., 2000), it is critical to incorporate interventions for trauma into existing substance use treatments. Existing evidence-based treatments targeting substance use behaviors include contingency management, cognitive-behavioral therapy, motivational interviewing, and structured family therapies (Knapp, Soares, Farrel, & Lima, 2008; Dutra, Stathopoulous, Basden, Leyro, Powers, & Otto, 2008; Kleber, Weiss, Anton, George, Greenfield, Kosten, et al, 2007). Given existing implementation challenges for these approaches in substance use treatment centers (Brown, Stout, & Mueller, 1999), the implementation of evidence-based treatments for comorbidities and trauma poses a particularly difficult challenge. Unfortunately, the current lack of attention to comorbidities leads to particularly poor outcomes among these individuals (Brown, Stout, & Mueller, 1999), making integrated treatment a priority in these settings.

5. CONCLUSIONS

Both abuse severity and presence of child abuse experiences are associated with a number of problems among substance users in residential treatment. In particular, child abuse is associated with elevated rates of substance dependencies, psychiatric disorders, and rates of comorbidities. Many of these challenges are currently not addressed within substance use treatment settings, making them an important target. Additionally, screening for and providing forums for a discussion of these abuse experiences is critical for substance users, as almost half of individuals within our sample experienced child abuse and associated difficulties.

Highlights.

  • DSM-IV disorders were examined as a function of child abuse in substance users

  • Substance users who had been abused had a greater number of DSM-IV disorders

  • They also had increased rates of comorbidities as a function of abuse

Acknowledgments

Role of Funding Sources

Funding for this study was provided by grants from the National Institute of Drug Abuse Grant 5 F31 DA035033-02 (primary investigator, Anne N. Banducci) and R01 DA19405 (primary investigator, C.W. Lejuez). NIDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Footnotes

Contributors

Anne N. Banducci took the lead on developing the conceptualization for the paper, conducting the data analyses, writing the first draft of the paper, and editing the final manuscript. Elana Hoffman and Karestan C. Koenen contributed to writing and editing the manuscript. C.W. Lejuez contributed to the study design, oversaw the study implementation, and was involved with all stages of manuscript preparation. All authors have contributed to and have approved of the final manuscript.

Conflict of Interest

We have no conflicts of interest to report.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

  1. Afifi TO, Enns MW, Cox BJ, Asmundson GJ, Stein MB, Sareen J. Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. American Journal of Public Health. 2008;98:946–952. doi: 10.2105/AJPH.2007.120253. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Afifi TO, Henriksen CA, Asmundson GG, Sareen J. Childhood maltreatment and substance use disorders among men and women in a nationally representative sample. Canadian Journal Of Psychiatry. 2012;57:677–686. doi: 10.1177/070674371205701105. [DOI] [PubMed] [Google Scholar]
  3. Bernstein DP, Ahluvalia T, Pogge D, Handelsman L. Validity of the Childhood Trauma Questionnaire in an adolescent psychiatric population. Journal of the American Academy Of Child & Adolescent Psychiatry. 1997;36:340–348. doi: 10.1097/00004583-199703000-00012. [DOI] [PubMed] [Google Scholar]
  4. Bernstein DP, Fink L. Psychological Corporation. San Antonio, TX: Harcourt, Brace, & Company; 1998. Childhood Trauma Questionnaire manual: A retrospective self-report. [Google Scholar]
  5. Bernstein DP, Fink L, Handelsman L, Foote J, Lovejoy M, Wenzelk K, Ruggiero J. Initial reliability and validity of a new retrospective measure of child abuse and neglect. American Journal of Psychiatry. 1994;151:1132–1136. doi: 10.1176/ajp.151.8.1132. [DOI] [PubMed] [Google Scholar]
  6. Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, Zule W. Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse & Neglect. 2003;27:169–190. doi: 10.1016/j.bbr.2011.03.031. [DOI] [PubMed] [Google Scholar]
  7. Bifulco A, Moran PM, Baines R, Bunn A, Stanford K. Exploring psychological abuse in childhood: II. Association with other abuse and adult clinical depression. Bulletin of the Menninger Clinic. 2002;66:241–258. doi: 10.1521/bumc.66.3.241.23366. [DOI] [PubMed] [Google Scholar]
  8. Brems C, Johnson ME, Neal D, Freemon M. Childhood abuse history and substance use among men and women receiving detoxification services. American Journal of Drug and Alcohol Abuse. 2004;30:799–821. doi: 10.1081/ADA-200037546. [DOI] [PubMed] [Google Scholar]
  9. Brown PJ, Stout RL, Mueller T. Substance use disorder and posttraumatic stress disorder comorbidity: addiction and psychiatric treatment rates. Psychology of Addictive Behaviors. 1999;13:115–122. doi: 10.1037/0893-164X.13.2.115. [DOI] [Google Scholar]
  10. Chen KW, Banducci AN, Guller L, Macatee RJ, Lavelle A, Daughters SB, Lejuez CW. An examination of psychiatric comorbidities as a function of gender and substance type within an inpatient substance use treatment program. Drug and Alcohol Dependence. 2011;118:92–99. doi: 10.1016/j.drugalcdep.2011.03.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Dutra L, Stathopoulou G, Basden SL, Leyro TM, Powers MB, Otto MW. A meta analytic review of psychosocial interventions for substance use disorders. American Journal of Psychiatry. 2008;165:179–87. doi: 10.1176/appi.ajp.2007.06111851. [DOI] [PubMed] [Google Scholar]
  12. Edwards VJ, Holden GW, Felitti VJ, Anda RF. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: Results from the Adverse Childhood Experiences study. American Journal of Psychiatry. 2003;160:1453–1460. doi: 10.1176/appi.ajp.160.8.1453. [DOI] [PubMed] [Google Scholar]
  13. First MB, Spitzer RL, Gibbon M, Williams JBW. Patient Edition With Psychotic Screen (SCID-I/P W/PSY SCREEN) New York: Biometrics Research, New York State Psychiatric Institute; 2010. Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version. [Google Scholar]
  14. Green JG, McLaughlin KA, Berglund PA, Gruber MJ, Sampson NA, Zaslavsky AM, Kessler RC. Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: associations with first onset of DSM-IV disorders. Archives of General Psychiatry. 2010;67:113–123. doi: 10.1001/archgenpsychiatry.2009.186. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Hamilton M. A rating scale for depression. Journal of neurology, neurosurgery, and psychiatry. 1960;23:56–61. doi: 10.1136/jnnp.23.1.56. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Hefferman K, Cloitre M, Tardiff K, Marzuk PM, Portera L, Leon AC. Childhood trauma as a correlate of lifetime opiate use in psychiatric patients. Addictive Behaviors. 2000;25:797–803. doi: 10.1016/S0306-4603(00)00066-6. [DOI] [PubMed] [Google Scholar]
  17. Huang S, Trapido E, Fleming L, Arheart K, Crandall L, French M, Prado G. The long-term effects of childhood maltreatment experiences on subsequent illicit drug use and drug-related problems in young adulthood. Addictive behaviors. 2011;36:95–102. doi: 10.1016/j.addbeh.2010.09.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Kendler KS, Bulik CM, Silberg J, Hettema JM, Myers J, Prescott CA. Childhood sexual abuse and adult psychiatric and substance use disorders in women: an epidemiological and cotwin control analysis. Archives of General Psychiatry. 2000;57:953. doi: 10.1001/archpsyc.57.10.953. [DOI] [PubMed] [Google Scholar]
  19. Kessler RC, Crum RM, Warner LA, Nelson CB. Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Archives of general psychiatry. 1997;54:313–321. doi: 10.1001/archpsyc.1997.01830160031005. [DOI] [PubMed] [Google Scholar]
  20. Kleber HD, Weiss RD, Anton RF, George TP, Greenfield SF, Kosten TR, et al. Work group on substance use disorders: American Psychiatric Association Steering Committee on Practice Guidelines: treatment of patients with substance use disorders, second edition. American Journal of Psychiatry. 2007;164:5–123. [PubMed] [Google Scholar]
  21. Knapp WP, Soares BG, Farrel M, Lima MS. Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders. Cochrane Database of Systematic Reviews. 2008;3:1–93. doi: 10.1002/14651858.CD003023.pub2. [DOI] [PubMed] [Google Scholar]
  22. McLaughlin KA, Green JG, Gruber MJ, Sampson NA, Zaslavsky AM, Kessler RC. Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication II: associations with persistence of DSM-IV disorders. Archives of general psychiatry. 2010;67:124–132. doi: 10.1001/archgenpsychiatry.2009.187. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Nomura Y, Hurd YL, Pilowsky DJ. Life-time risk for substance use among offspring of abusive family environment from the community. Substance Use & Misuse. 2012;47(12):1281–1292. doi: 10.3109/10826084.2012.695420. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Rohsenow DJ, Corbett R, Devine D. Molested as children: A hidden contribution to substance abuse? Journal of Substance Abuse Treatment. 1988;5:13–18. doi: 10.1016/0740-5472(88)90032-3. [DOI] [PubMed] [Google Scholar]
  25. Schenkel LS, Spaulding WD, DiLillo D, Silverstein SM. Histories of childhood maltreatment in schizophrenia: relationships with premorbid functioning, symptomatology, and cognitive deficits. Schizophrenia Research. 2005;76:273–286. doi: 10.1016/j.schres.2005.03.003. [DOI] [PubMed] [Google Scholar]
  26. Scott KM, Smith DR, Ellis PM. Prospectively ascertained child maltreatment and its association with DSM-IV mental disorders in young adults. Archives of general psychiatry. 2010;67:712–719. doi: 10.1001/archgenpsychiatry.2010.71. [DOI] [PubMed] [Google Scholar]
  27. Thombs BD, Lewis C, Bernstein DP, Medrano MA, Hatch JP. An evaluation of the measurement equivalence of the Childhood Trauma Questionnaire—Short Form across gender and race in a sample of drug-abusing adults. Journal of Psychosomatic Research. 2007;63:391–398. doi: 10.1016/j.jpsychores.2007.04.010. [DOI] [PubMed] [Google Scholar]
  28. Watkins KE, Hunter SB, Wenzel SL, Tu W, Paddock SM, Griffin A, Ebener P. Prevalence and characteristics of clients with co-occurring disorders in outpatient substance abuse treatment. American journal of drug and alcohol abuse. 2004;30:749–764. doi: 10.1081/ADA-200037538. [DOI] [PubMed] [Google Scholar]
  29. Weaver T, Rutter D, Madden P, Ward J, Stimson G, Renton A. Results of a screening survey for co-morbid substance misuse amongst patients in treatment for psychotic disorders: prevalence and service needs in an inner London borough. Social Psychiatry and Psychiatric Epidemiology. 2001;36:399–406. doi: 10.1007/s001270170030. [DOI] [PubMed] [Google Scholar]
  30. Widom C, Morris S. Accuracy of adult recollections of childhood victimization, Part 2: Childhood sexual abuse. Psychological Assessment. 1997;9:34–46. doi: 10.1037/1040-3590.9.1.34. [DOI] [Google Scholar]
  31. Widom C, Shepard RL. Accuracy of adult recollections of childhood victimization: Part 1. Childhood physical abuse. Psychological Assessment. 1996;8:412–421. doi: 10.1037/1040-3590.8.4.412. [DOI] [Google Scholar]
  32. Wu NS, Schairer LC, Dellor E, Grella C. Childhood trauma and health outcomes in adults with comorbid substance abuse and mental health disorders. Addictive Behaviors. 2010;35:68–71. doi: 10.1016/j.addbeh.2009.09.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Zanarini MC, Frankenburg FR, Chauncey DL, Gunderson JG. The Diagnostic Interview for Personality Disorders: interrater and test-retest reliability. Comprehensive Psychiatry. 1987;28:467–480. doi: 10.1016/0010-440X(87)90012-5. [DOI] [PubMed] [Google Scholar]

RESOURCES