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. Author manuscript; available in PMC: 2015 Apr 10.
Published in final edited form as: Child Abuse Negl. 2010 Apr 18;34(6):465–470. doi: 10.1016/j.chiabu.2009.10.007

Traumatic stress symptoms and breast cancer: The role of childhood abuse☆

Rachel E Goldsmith a, Lina Jandorf a,*, Heiddis Valdimarsdottir b,c, Kandace L Amend a, Brett G Stoudt a, Christine Rini a, Dawn Hershman d, Alfred Neugut d, James J Reilly e, Paul I Tartter f, Sheldon M Feldman g, Christine B Ambrosone a,h, Dana H Bovbjerg a
PMCID: PMC4392906  NIHMSID: NIHMS677376  PMID: 20400179

Abstract

Objective

The present study investigated relations between reported childhood abuse and recent traumatic stress symptoms in women newly diagnosed with breast cancer (n = 330).

Methods

As part of a larger ongoing study, patients from eight public and private hospitals were referred by their physicians and completed the Childhood Trauma Questionnaire (CTQ), and the Impact of Events Scale-breast cancer (IES), which measured breast cancer-related intrusive and avoidant symptoms.

Results

Emotional abuse, physical abuse, and sexual abuse were correlated with intrusive symptoms. Cancer-related avoidant symptoms approached significance in their relation to emotional and sexual abuse. Multivariate analysis, controlling for age and time since diagnosis, revealed that childhood emotional abuse was an independent predictor of breast cancer-related intrusive symptoms, but that childhood physical abuse and sexual abuse were not significant predictors.

Conclusions

Childhood emotional, physical, and sexual abuse were associated with breast cancer-related intrusive symptoms. Emotional abuse uniquely predicted intrusive symptoms after controlling for other predictors. Results suggest that a cancer diagnosis may trigger cognitive and emotional responses that relate to patients’ prior trauma experiences.

Practice implications

Physicians and psychologists treating women with breast cancer should be aware that a history of childhood abuse may exacerbate patients’ cancer-related intrusive symptoms. Interventions for women affected by both childhood abuse and breast cancer may be most effective when they address both stressors and associated emotional responses. Findings highlight the importance of additional research to explore links between prior trauma and distress following a cancer diagnosis stress.

Keywords: Child abuse, Emotional abuse, Breast cancer, Intrusive symptoms, Traumatic stress

Introduction

Breast cancer is the most commonly diagnosed cancer and the second-leading cause of cancer deaths among women in the United States (Ries et al., 2007). In addition to substantial physical challenges, many women with breast cancer experience depression, anxiety, and posttraumatic intrusive and avoidant symptoms (e.g., Koopman et al., 2002). Prospective studies indicate that breast cancer-related intrusive symptoms at the time of diagnosis are predictive of long-term distress, including anxiety and depression (e.g., Epping-Jordan et al., 1999). It is less clear, however, if childhood abuse increases vulnerability to current cancer-related traumatic stress symptoms. The present study seeks to address this issue.

Psychosocial variables such as a younger age at diagnosis, lower income, and a more recent breast cancer diagnosis are associated with higher levels of traumatic stress symptoms, including intrusive and avoidant symptoms (e.g., Koopman et al., 2002). Intrusive symptoms include unwanted cancer-related thoughts, images, emotions, and dreams, whereas avoidant symptoms constitute attempts to avoid cancer-related thoughts, feelings, or reminders. A small body of research indicates that women with prior trauma experiences report more severe breast cancer-related traumatic stress symptoms. Breast cancer-related intrusive and avoidant symptoms have been associated with the number of past traumas (Andrykowski, Cordova, McGrath, Sloan, & Kenady, 2000), having parents who survived the Holocaust (Baider et al., 2000; Baider, Goldsweig, Ever Hadani, & Peretz, 2006), and with lifetime exposure to past traumas and current stressors (Green et al., 2000). Only one study (Salmon et al., 2006) examined the specific relation between breast cancer-related traumatic stress symptoms and childhood abuse. Salmon et al. assessed abuse using five self-report questions culled from published surveys, and reported that sexual and emotional abuse were related to levels of general mental distress, whereas physical and emotional abuse were associated with traumatic stress symptoms.

A history of childhood abuse is generally quite prevalent among health care populations. One study of 292 adults in a primary care setting found that 44% reported childhood abuse (Gould et al., 1994). Felitti et al. (1998) reported prevalence rates of 11.1% for emotional abuse, 10.8% for physical abuse, and 22.0% for sexual abuse among 9508 patients in a large HMO, as well as a dose–response relationship between the number of childhood traumas and the likelihood of adult cancer diagnoses. An extensive literature, including prospective studies, demonstrates strong associations between childhood abuse and adult physical and mental health difficulties (e.g., Horwitz, Widom, McLaughlin, & White, 2001; Kendall-Tackett, 2002; Silverman, Reinherz, & Giaconia, 1996). Emotional abuse may comprise a basis for all forms of abuse and neglect (e.g., Hart & Brassard, 1987; Schore, 2001), and recent empirical evidence indicates that emotional abuse is related to psychological difficulties to a greater extent than are other abuse subtypes (e.g., Gibb, Chelminski, & Zimmerman, 2007; Spertus, Yehuda, Wong, Halligan, & Seremetis, 2003; Teicher, Samson, Polcari, & McGreenery, 2006).

Researchers have proposed several possible mechanisms for the dysregulations in affect, cognitions, and neurobiological systems observed in survivors of childhood abuse and other trauma (e.g., Bremner, 2003; Brewin & Holmes, 2003; Briere, 2002). For instance, Briere (2002) proposes that conditioned emotional responses occur in response to abuse-related stimuli, are inculcated during repeated abuse, and may generalize to subsequent stressors. Brewin and Holmes (2003) describe three recent theoretical approaches to posttraumatic responses that emphasize components such as encoding, appraisal, beliefs, and cognitive styles. Emotional processing theory (Foa & Rothbaum, 1998), dual representation theory (Brewin, Dalgleish, & Joseph, 1996), and Ehlers and Clark (2000) cognitive theory provide accounts of psychological processes that are each consistent with a wide scope of empirical data, but differ with respect to the pathways proposed. Other contributions accentuate psychobiological responses to trauma, including sympathetic nervous system hyperreactivity and abnormalities in neurotransmitter and neuroendricine activity (e.g., Friedman & McEwan, 2004). Bremner (2003) hypothesizes that long-term alterations in brain regions and neurochemical systems may contribute to enduring posttraumatic symptoms in childhood abuse survivors. Although the specific mechanisms through which childhood trauma relates to adult psychological difficulties have yet to be established, research indicates that a history of childhood abuse is associated with increased posttraumatic stress symptoms and maladaptive coping in response to subsequent stressors (Bremner, Southwick, Johnson, Yehuda, & Charney, 1993; Leitenberg, Gibson, & Novy, 2004). These models and data suggest that childhood abuse would be positively associated with levels of traumatic stress symptoms following a cancer diagnosis.

The current study explored the relations among childhood abuse and cancer-related intrusive and avoidant symptoms in newly diagnosed breast cancer patients using validated measures with strong psychometric properties. The study examined the hypothesis that childhood abuse, particularly emotional abuse, would be associated with these patients’ levels of cancer-related intrusive and avoidant symptoms.

Method

Participants

Participants for the present study were 350 women who were recruited as part of a larger, ongoing molecular epidemiologic case–control study on reproductive, hormonal, and behavioral factors in women with breast cancer. Two hundred women (61%) were African American, and 130 (39%) were White/European American. Forty-nine women (15%) reported 11 or fewer years of education, 73 (22%) reported having received a high school diploma, and 208 (63%) reported additional education. Ninety-seven women (32%) reported an income of below $20,000 per year; 82 women (27%) reported earning between $20,000 and $49,999 per year; and 128 women (41%) reported an income of over $50,000 per year. Eighty-four women (25%) reported that they were currently receiving medical treatment, whereas 203 women (62%) indicated that they were not. Participants had undergone a range of medical treatments, including chemotherapy (n = 119; 36%), radiation (n = 100; 30%), a combination of radiation and chemotherapy (n = 50; 15%), surgery (n = 25; 8%), or other treatment (n = 36; 11%). Forty-three women (13%) did not provide their treatment status, and 147 women (45%) did not supply information regarding the type of medical treatment they had received.

Study participants were recruited from public and private hospitals in the New York metropolitan area. Inclusion criteria for the larger study included female sex, a breast cancer diagnosis within the previous 9 months, no history of previous cancers (excluding non-melanoma skin cancer), a Black/African American or White/European American racial background, and English proficiency. The present sample included all patients with complete data for age, race, income, and education (n = 330).

Materials

An in-person interview was used to collect data on self-reported age, race, income, education, date of cancer diagnosis, and current medical treatment (e.g., chemotherapy, radiation, or medications). Participants also completed the two self-report measures described below.

The Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979) was used to measure traumatic stress symptoms related to breast cancer over the previous 2 weeks. The IES is the most commonly used instrument for assessing traumatic stress symptoms among cancer patients (Gurevich, Devins, & Rodin, 2002), and has well-established content, construct, convergent, and clinical validities. The scale uses a 4-point Likert scale (0 = not at all; 1 = rarely; 3 = sometimes; 5 = often) and contains two subscales: a 7-item scale of intrusive thoughts, feelings, images and nightmares, and an 8-item scale of cognitive and behavioral avoidance of stimuli related to a stressor (in this case, breast cancer). Items were presented to participants visually as a categorical scale with both verbal descriptions and numeric responses. Item scores are totaled and averaged for each subscale. Distributions for the IES had acceptable levels of skewness and kurtosis (±1.0). In the present sample, α = .86 for intrusive symptoms and .83 for avoidant symptoms.

The Child Trauma Questionnaire (Bernstein et al., 2003) was used to assess childhood abuse. The 28-item CTQ contains emotional, physical, and sexual abuse subscales, and has established validity and consistency (Bernstein et al., 2003). Scores are continuous and represent the amount of childhood abuse experiences that participants report. Respondents indicated the extent of their experiences before puberty for each item using a Likert scale (1 = never; 5 = very often), which are then summed for each subscale. Participants’ questionnaires included both verbal descriptions and numeric responses for the measure’s Likert scale. For this sample, = .84 for emotional abuse, .77 for physical abuse, and .88 for sexual abuse.

Procedure

Women who met eligibility criteria were identified at eight hospitals in the New York metropolitan region and in eastern New Jersey. After physician consent, patients were invited to participate. All participants signed informed consent and HIPAA forms and received $25.00. After a detailed interview, participants completed self-report measures without assistance and in privacy. The project was approved by the Institutional Review Boards of the Mount Sinai School of Medicine, the New Jersey Department of Health, and each participating hospital.

Data analysis

For individuals with missing data on the CTQ or any other continuous variable, a state of the art procedure for missing data was used (PROC MI and PROC MIANALYZE in SAS) with the recommended 5 cycles of imputation (Schafer & Graham, 2002). This procedure imputed data for 3 CTQ sexual abuse items that were missing from 213 women due to a clerical printing error. For these data, multiple imputation was especially appropriate because the probability of missing data was unrelated to their values or to other variables (Allison, 2002). Descriptive statistics and Pearson correlations were then generated. Simultaneous multiple regression models (PROC REG in SAS) were run to examine unique relationships between CTQ and IES scores, after controlling for age and time since diagnosis. To confirm the results, the models were rerun using only data from women with no missing data (n = 119).

Results

Descriptive statistics and intercorrelations for the study variables are presented in Table 1. Table 1 presents a correlation matrix for variables correlated with childhood abuse measures and with intrusive and avoidant symptoms. Emotional abuse was associated with intrusive symptoms (r = .23, p < .001). Physical abuse was correlated with intrusive symptoms at the level of r = .13 (p < .05), and sexual abuse was correlated with intrusive symptoms at the level of r = .12 (p < .05). Emotional abuse was related to avoidant symptoms at the level of r = .10 (p = .06). The relation between sexual abuse and avoidant symptoms also approached significance (r = .10, p = .07); however, the relation between physical abuse and avoidant symptoms did not (r = .07, p = .23). Age was significantly negatively related to intrusive symptoms (r = −.21, p = .001). The correlation between the number of days since diagnosis and intrusive symptoms approached significance (r = −.11, p = .06). Results indicated that race and income were associated with avoidant symptoms, with African American women and women with lower incomes reporting higher levels of avoidant symptoms (r = −.16, p < .05 for both correlations).

Table 1.

Means, standard deviations, and intercorrelations for variables related to IES scores (n = 330).

Variable Mean SD 1 2 3 4 5 6 7 8
1. Age 50.68 9.86
2. Days since diagnosis 211.22 137.30 .02
3. Race (see note) – – .11* .08 –
4. Income (see note) – – .01 .10 .55***
5. Emotional abuse 7.85 4.04 .00 .03 .15** .00
6. Physical abuse 6.65 2.94 −.04 .00 −.13* −.09 .58***
7. Sexual abuse 6.34 3.16 −.11* .02 −.05 −.07 .44*** .50***
8. IES intrusion 1.78 1.27 −.21** −.11 −.08 −.10 .23*** .13* .12*
9. IES avoidance 1.88 1.23 −.09 −.08 −.16** −.16** .10 .07 .10 .60***
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Note: Race was coded as 0 = Black/African/African American and 1 = European American/White. Correlations that used race were explored using point biserial correlations. Annual income before taxes for the last year was measured with an ordinal scale where 1 = less than $15,000; 2 = $15,000–19,999; 3 = $20,000–24,999; 4 = $25,000–34,999; 5 = $35,000–49,000; 6 = $50,000–69,000; 7 = $70,000–89,999; 8 = $90,000 or more. Education and current treatment were not related (p < .10) to IES scores.

*

p < .05.

**

p < .01.

***

p < .001.

To determine if childhood abuse was significantly related to intrusive symptoms after controlling for the potentially confounding variables of age and time since diagnosis, a simultaneous multiple regression analyses was conducted. Because no abuse subscales were related to avoidant symptoms at levels of p < .05, a model was constructed to predict intrusive symptoms only (Table 2). The model indicated that intrusive symptoms were independently negatively related to age and days since diagnosis, and positively related to emotional abuse. When the model was rerun using only participants with complete data, emotional abuse remained a significant predictor of intrusive symptoms [t(118) = 4.04, p = < .0001].

Table 2.

Summary of simultaneous multivariate regression model for variables predicting IES intrusive symptoms (n = 330).

Variable Adjusted R2 F df p b t p
Model: Predicting IES intrusion .10 8.04 329 <.0001
Age .007 −3.94 <.0001
Days since diagnosis .0005 −2.08 .04
Emotional abuse .02 3.85 .002
Physical abuse .02 −.46 .65
Sexual abuse .02 .11 .87
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Discussion

In this study, childhood abuse was associated with breast cancer-related intrusive symptoms among women with recently diagnosed breast cancer. Although all three abuse subtypes were related to intrusive symptoms, emotional abuse uniquely predicted intrusive symptoms after controlling for other predictors. These data constitute the first report of an association between any type of childhood abuse assessed with a validated measure and breast cancer-related intrusive symptoms. These findings are congruent with previous research (e.g., Gibb et al., 2007; Spertus et al., 2003) that identifies emotional abuse as especially predictive of adult emotional difficulties. These data may reflect the continuing cognitive and emotional schemas, hypervigilance, dysregulated stress responses, and altered neurological systems observed in survivors of childhood abuse (Bremner, 2003; Briere, 2002; De Bellis, 2001; Schore, 2001). A cancer diagnosis may trigger negative cognitions and emotions that are consistent with patients’ prior trauma experiences.

As in previous studies (e.g., Green et al., 2000; Koopman et al., 2002), younger women with breast cancer reported more severe psychological symptoms. Psychological symptoms were not related to patients’ current treatment status or type of treatment received, a result consistent with other data (e.g., Green et al., 2000). IES scores for this sample were comparable to other reports of women recently diagnosed with breast cancer (e.g., Epping-Jordan et al., 1999). CTQ subscale scores were somewhat lower than reports of abuse among substance abusing or psychiatric participants (Bernstein et al., 2003), and similar to other samples (e.g., Thombs et al., 2007). The finding that avoidant symptoms were related to intrusive symptoms, but not to childhood abuse, is somewhat surprising given previous reports of associations between childhood abuse and avoidant symptoms (e.g., Stovall-McClough & Cloitre, 2006; Yoshihama & Horrocks, 2002). The present results are, however, consistent with conceptualizations and research that regard avoidant symptoms as attempts to defend oneself against intrusive symptoms, rather than as resulting directly from trauma (McFarlane, 1992). Avoidant symptoms appear to predict and perpetuate subsequent intrusive symptoms in cancer and other medical populations (Lawrence, Fauerbach, & Munster, 1996; Manne, Glassman, & Du Hamel, 2000). The results demonstrate relations among race, income, abuse subtype, and avoidant symptoms that merit further investigation in future studies.

The clinical implications of this study include the potential to screen and provide services to newly diagnosed cancer patients with a history of childhood abuse. Just as physicians assess preexisting conditions, psychologists should consider prior vulnerabilities that may exacerbate current stressors. While many breast cancer patients have low levels of distress and may not need psychological interventions, those who report higher levels of childhood abuse have more severe psychological symptoms. Treating this population may prove beneficial, as trauma-focused interventions appear to be more effective than other treatments for survivors of trauma (e.g., Bisson et al., 2007), and because health care costs are greater for survivors of abuse, even after controlling for chronic diseases (e.g., Walker et al., 1999). The findings also underscore the need for further efforts in child abuse prevention and in training health care professionals regarding the profound, life-long effects of childhood abuse (see Courtois, 2002).

The study had several limitations. The project was cross-sectional, and only included patients with European and African backgrounds. Other limitations included some missing data, particularly on the sexual abuse subscale, and the unavailability of data regarding the type and stage of breast cancer. Several of the correlations reported were quite small, and should be interpreted with caution. The overall variance in IES intrusive symptoms was relatively small. While emotional abuse was a significant predictor of IES intrusive symptoms in the multivariate analysis, age and days since diagnosis also made significant contributions. The study used retrospective self-report data to gather information about abuse experiences, a method with both advantages and disadvantages (Kendall-Tackett & Becker-Blease, 2004). Studies indicate that survivors’ perceptions of childhood abuse differ from those of researchers, who are more likely to view behaviors as abusive (e.g., Knutson & Selner, 1994; Silvern, Waelde, Baughan, Karyl, & Kaersvang, 2000). Retrospective data may contain false negative reports (e.g., Fergusson, Horwood, & Woodward, 2000), whereas false positive reports are rare (e.g., Hardt & Rutter, 2004). Although retrospective data may include multiple sources of error, adults appear “generally accurate” (Brewin, Andrews, & Gotlib, 1993, p. 87) regarding factual childhood details. The study did not assess adolescent or adult trauma, which may contribute to patients’ psychological symptoms.

This report forms a basis for future work examining psychological symptoms in survivors of childhood abuse and breast cancer. Research on stress and breast cancer has concentrated on current circumstances and recent life events (Delahanty & Baum, 2001). Future research should address the limitations of the present study, investigate additional ways childhood abuse relates to coping with breast cancer and other diseases, and explore facets of emotional processing such as emotion regulation that may mediate relations between childhood abuse and current traumatic stress symptoms. Finally, interventions with women impacted by both abuse and cancer may provide information regarding effective support for this population.

Acknowledgments

We gratefully acknowledge the contribution of all the investigators who have been involved in the Women’s Circle of Health Study (WCHS) Research Consortium and all the women who participated in the research.

Footnotes

☆

This research was supported in part by grant DAMD17-01-1-0334 from the Department of Defense and by grants CA81137 and CA100598 from the National Cancer Institute.

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