Abstract
Heterotypic continuity, whereby individuals transition from one disorder to another, is common; however, longitudinal studies examining transdiagnostic predictors of heterotypic continuity are lacking. The current study examined whether trauma exposure during childhood (maltreatment) and adulthood (interpersonal and non-interpersonal trauma) is associated with heterotypic continuity in a national sample. Men and women (N=34,653) who participated in Waves 1 (2001-2002) and 2 (2004-2005) of the National Survey of Alcohol and Related Conditions (NESARC) completed face-to-face interviews about trauma exposure and psychopathology. Risk ratios and population attributable risk proportions (PARPs) quantified the effects of childhood maltreatment and interpersonal and non-interpersonal trauma exposure between Waves 1 and 2 on risk for incident disorders and transitions between specific types of disorders. Twenty percent of respondents reported a Wave 2 incident disorder. Those with any Wave 1 disorder were at increased risk of incident mood (RR range=1.2-2.1) and anxiety (RR=1.5-2.7) disorders at Wave 2. Child maltreatment and interpersonal trauma exposure since Wave 1 were associated with roughly 50% of the risk for disorder transitions (RR range=1.2-2.7); non-interpersonal trauma was associated with 30% of the risk for disorder transitions (RR range=1.0-1.7). Findings suggest that new onset disorders were common in U.S. adults and trauma exposure explained a large proportion of disorder incidence as well as progression from one disorder to another. Universal prevention efforts that begin early in life, rather than those targeted at specific disorders, would be fruitful for reducing the burden of population mental health and preventing a cascade of mental disorders over the life course.
Keywords: Trauma, child maltreatment, disorder transitions, heterotypic continuity
Background
Psychiatric disorders are highly comorbid, with 80% of individuals with a lifetime disorder meeting criteria for at least one additional disorder (1). Comorbidity is associated strongly with disorder severity, with much of the population burden of lifetime psychiatric disorders concentrated among individuals who meet criteria for multiple disorders (1, 2). Identifying predictors of comorbidity and transitions across different disorders has important clinical and public health implications, as early identification and treatment of psychopathology can potentially prevent a cascade of psychiatric problems throughout the life course.
Comorbidity can refer to meeting criteria for more than one disorder at the same time (i.e., concurrent comorbidity) or multiple psychiatric disorders over time, reflecting temporal relationships among different forms of psychopathology (i.e., successive comorbidity) (3). This more common type of comorbidity, whereby individuals transition from one disorder to another disorder at a later time, also has been termed heterotypic continuity (4, 5).
There is consistent evidence for heterotypic continuity. For example, in the Great Smoky Mountain Study, 9-13 year old children with a prior psychiatric disorder were three times more likely to develop a new disorder compared to those without a prior diagnosis (6). In this sample, adolescent oppositional defiant disorder, generalized anxiety disorder (GAD), and depression predicted multiple disorder onsets in young adulthood (5). Finally, data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a two-wave nationally representative study of US adults, provided evidence for heterotypic continuity, such that having a disorder at Wave 1 predicted the onset of multiple Wave 2 disorders, even after controlling for homotypic continuity (i.e., disorder at one point predicts the same disorder at a later point) (4). Despite evidence for high rates of heterotypic continuity, few studies have examined whether specific types of transitions are more common than others, particularly in adulthood, or identified predictors of particular heterotypic continuity patterns. Consequently, efforts to tailor early interventions to those with psychiatric disorders who are at highest risk for transitioning to new disorders and developing a complicated comorbidity profile have been stymied. The few population representative adult studies that have examined specific transitions focus on a small number of disorders. For example, in a longitudinal birth cohort of individuals from Dunedin, New Zealand, GAD and depression were sequentially related such that each disorder increased the likelihood of later onset of the other disorder (7). However, these findings have not been extended to samples from other geographic locations, nor have other disorders been considered.
Clinical recognition of high rates of concurrent comorbidity and heterotypic continuity has led to the development of conceptual frameworks to identify environmental, cognitive, affective, and neurobiological processes that are shared across disorders and underlie the transitions from one type of psychopathology to another (8-11). Trauma exposure including child maltreatment (12, 13) and interpersonal violence (e.g., rape) (14, 15) has been shown to play a meaningful role in the etiology of most common psychiatric disorders (15-17). Prevailing theories suggest that violence engenders neurobiological changes and problems with cognitive and emotional regulation that increase susceptibility to psychopathology [e.g., (18)]. Unknown, however, is whether the timing (childhood vs. adult) or type (interpersonal vs. non-interpersonal) of trauma exposure predicts transitions among psychiatric disorders, and we are aware of no studies that have examined trauma exposure as a transdiagnostic predictor of disorder transitions in a population-based sample. Better understanding predictors of disorder transitions can provide preliminary evidence of a clinical profile that suggests heightened risk for heterotypic continuity and increased need for early intervention.
The present study extends prior work on heterotypic continuity by quantifying the risk for particular types of transitions over time (e.g., mood to anxiety) as well as associations between trauma exposure and these transitions in a population-representative sample (the NESARC). First, we estimate Wave 2 disorder incidence (i.e., novel disorder onsets) separately for individuals with and without a Wave 1 lifetime psychiatric disorder. Second, we quantify the likelihood of transitioning to a particular type of disorder (i.e., mood, anxiety, substance) based on the presence of prior disorders. Third, we determine whether trauma exposure is associated with incident disorders and disorder transitions. Finally, because anxiety, mood, and substance use disorders vary in median age of onset (2) and prevalence estimates and comorbidity patterns differ by sex (19), we evaluate whether associations vary as a function of age and all analyses are stratified by sex.
Methods
Sample and Procedures
Participants were 34,653 men and women from Waves 1 (2001-2002) and 2 (2004-2005) of the NESARC, a face-to-face survey of non-institutionalized adults living in households and group quarters (20, 21). The Wave 2 re-interview response rate among eligible Wave 1 participants was 86.7%, yielding a cumulative response rate of 70.2% (21). Young adults, Blacks, and Hispanics were oversampled and data were weighted in accordance with the 2000 census demographics (21). The study received full ethical review and approval (21).
Measures
The Alcohol Use Disorder and Associated Disabilities Interview, Schedule IV (AUDADIS-IV) assessed the lifetime presence of mood (Mania, Dysthymia, Major Depression), anxiety (Social Phobia, Generalized Anxiety Disorder, Panic Disorder, Specific Phobia), and substance use [alcohol, nicotine, marijuana, and other drugs (sedative, tranquilizer, opioid, amphetamine, hallucinogen, cocaine, inhalant, and heroin) disorders at each wave. Similar to other structured interviews, two-to-three month test-retest reliability for these diagnoses range from fair (Kappa=0.42, panic disorder) to excellent (Kappa=0.84, alcohol dependence) (22, 23). Convergent and discriminant validity of the AUDADIS-IV has been demonstrated in numerous studies (22, 24, 25).
The AUDADIS-IV also assessed childhood maltreatment and interpersonal and non-interpersonal trauma exposure at Wave 2. As detailed elsewhere (26), eighteen questions adapted from the Adverse Childhood Experiences study (27) that were originally part of the Conflict Tactics Scale (28) and the Childhood Trauma Questionnaire (29) assessed child maltreatment prior to age eighteen. Response options ranged from 1=never to 5=very often and were summed with higher scores reflecting more severe abuse; based on preliminary analyses and consistent with epidemiologic studies using binary variables to reflect maltreatment (12, 13, 30, 31), those above the 75th percentile were considered maltreated. Ten yes/no items assessed interpersonal trauma (combat, sexual assault, physical assault by romantic partner, physical assault by someone else, stalking, kidnapped/held hostage, mugged, injured in terrorist attack, witnessing injury/killing/dead bodies, civilian in war), and two yes/no items assessed non-interpersonal trauma (life-threatening accident, natural disaster) since the last interview. Respondents were coded 1 if they endorsed that type of trauma since the last interview or 0 if they did not report exposure. A dichotomous variable reflecting any exposure to interpersonal or non-interpersonal trauma prior to Wave 1 also was coded for sensitivity analyses.
Statistical Analysis
Analyses were completed in five steps using SAS 9.3. First, the prevalence of incident mood, anxiety, and substance use disorders was estimated separately for individuals with and without a lifetime disorder other than the focal disorder. Second, transitions between disorder types from Wave 1 to Wave 2 were estimated using risk ratios based on predicted marginals in a logistic regression examining incident disorder onset at Wave 2 by disorder type at Wave 1. Third, risk ratios between three types of trauma exposure (child maltreatment; interpersonal and non-interpersonal trauma between Waves 1 and 2) and incident disorder onsets at Wave 2 were estimated among those with and without a Wave 1 lifetime disorder. To further quantify the effect of each trauma type on risk for a Wave 2 incident disorder, Population Attributable Risk Proportions (PARPs) were computed using the following formula: (Ie-Iu)/Ie, where Ie is incidence in the exposed group and Iu is incidence in the unexposed group (32). The resulting PARP reflects the proportion of risk for Wave 2 incident disorders associated with each trauma type. Fourth, risk ratios and corresponding PARPs between trauma types and disorder transitions from Wave 1 to Wave 2 were examined. Fifth, the probability of transitioning from a Wave 1 to Wave 2 disorder by age (young adulthood:18-30; middle adulthood:31-50; older adulthood:51-70) and type of Wave 1 diagnosis was examined. All analyses were stratified by sex, and accounted for sampling weight, clustering, and stratification.
Results
Trauma Exposure Descriptives
More than one-quarter (25.89%) of the sample had a score of 33 (75th percentile) or higher on the child maltreatment measure, 7.21% reported interpersonal trauma, and 4.92% reported non-interpersonal trauma since the last interview.
Incident Disorder Prevalence
Table 1 displays the weighted prevalence of incident psychiatric disorder onsets at Wave 2 among individuals with and without a Wave 1 lifetime disorder, separately by sex. Chi-square tests for differences in incidence based on Wave 1 disorder presence also are presented. A similar proportion of those with (20%) and without (23%) a Wave 1 lifetime disorder met criteria for a Wave 2 incident disorder. A similar proportion of women with (25%) and without (24%) a Wave 1 disorder developed a Wave 2 disorder; however, a smaller proportion of men with (16%) with versus without (22%) a Wave 1 disorder developed a Wave 2 disorder.
Table 1. Wave 2 Incident Disorders Among Those With and Without a Wave 1 Prior Lifetime Disorder (Weighted*).
| Among those with: | Men, among those with: | Women, among those with: | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Onset of: | Prior Psychiatric Disorder Other than Focal Disorder (n=16,713) | No Prior Psychiatric Dx (n=17,940) | Chi Square, p-value | Prior Psychiatric Disorder Other than Focal Disorder (n=7987) | No Prior Psychiatric dx (n=6,577) | Chi Square, p-value | Prior Psychiatric Disorder Other than Focal Disorder (n=8,726) | No Prior Psychiatric Disorder (n =11,363) | Chi Square, p-value |
| Any Psychiatric Disorder | 3483 (19.99%) | 4141 (22.67%) | 24.50, <0.01 | 1286 (15.88%) | 1436 (21.93%) | 55.96, <0.01 | 2197 (24.71%) | 2705 (23.21%) | 3.95, 0.05 |
| Any Mood Disorder | 924 (5.47%) | 1286 (6.78%) | 16.90, <0.01 | 412 (5.34%) | 312 (4.48%) | 3.80, 0.06 | 512 (5.62%) | 974 (8.47%) | 40.99, <0.01 |
| Mania | 647 (3.71%) | 381 (2.06%) | 53.36, <0.01 | 253 (3.29%) | 134 (2.03%) | 14.84, <0.01 | 394 (4.19%) | 247 (2.09%) | 45.52, <0.01 |
| Dysthymia/ Depression | 1506 (8.53%) | 1078 (5.67%) | 71.43. <0.01 | 530 (6.61%) | 233 (3.3%) | 57.03, <0.01 | 976 (10.74%) | 845 (7.42%) | 42.55, <0.01 |
| Any Anxiety Disorder | 2608 (14.71%) | 2174 (11.29%) | 59.72, <0.01 | 910 (11.01%) | 500 (7.27%) | 43.37, <0.01 | 1698 (18.96%) | 1674 (14.26%) | 49.32, <0.01 |
| Social Phobia | 493 (2.78%) | 234 (1.15%) | 81.54, <0.01 | 194 (2.32%) | 70 (0.95%) | 30.56, <0.01 | 299 (3.31%) | 164 (1.31%) | 56.84, <0.01 |
| Panic | 545 (2.99%) | 292 (1.66%) | 43.91, <0.01 | 150 (2.01%) | 62 (1.01%) | 16.80, <0.01 | 395 (4.13%) | 230 (2.14%) | 38.58, <0.01 |
| Specific Phobia | 1186 (6.71%) | 894 (4.63%) | 45.82, <0.01 | 378 (4.59%) | 203 (3.1%) | 15.35, <0.01 | 808 (9.14%) | 691 (5.76%) | 49.88, <0.01 |
| Generalized Anxiety | 842 (4.81%) | 395 (2.2%) | 106.91, <0.01 | 248 (3.11%) | 80 (1.02%) | 55..50, <0.01 | 594 (6.77%) | 315 (3.06%) | 81.01, <0.01 |
| Any Substance Use Disorder | 397 (2.37%) | 1819 (10.77%) | 610.83, <0.01 | 125 (1.57%) | 956 (15.06%) | 487.98, <0.01 | 272 (3.29%) | 863 (7.6%) | 116.53, <0.01 |
| Alcohol Use Disorder | 454 (2.82%) | 912 (5.37%) | 93.36, <0.01 | 218 (2.81%) | 570 (8.7%) | 151.90, <0.01 | 236 (2.83%) | 342 (2.91%) | 0.07, 0.79 |
| Marijuana Use Disorder | 461 (3.08%) | 108 (0.75%) | 143.78, <0.01 | 312 (4.05%) | 81 (1.39%) | 64.03, <0.01 | 149 (1.96%) | 27 (0.27%) | 67.63, <0.01 |
| Nicotine Dependence | 866 (5.44%) | 995 (5.87%) | 1.89, 0.18 | 493 (6.25%) | 452 (7.16%) | 3.23, 0.08 | 373 (4.5%) | 543 (4.91%) | 1.13, 0.29 |
| Other Drug Use Disorder | 169 (1.09%) | 102 (0.62%) | 12.98, <0.01 | 83 (1.09%) | 43 (0.67%) | 4.51, 0.04 | 86 (1.09%) | 59 (0.58%) | 8.36, <0.01 |
Sampling, stratification, and cluster weights were applied.
Incident anxiety disorder onsets were most common, and were higher among those with (15%) versus without (11%) a Wave 1 disorder. Incident substance use disorders were the next most common and were more likely among those without (11%) versus with (2%) a Wave 1 disorder. Incident mood disorders were least common and were more common among those without (7%) versus with (5.5%) a Wave 1 disorder. Although prevalence varied, men and women displayed similar patterns of disorder type onset.
Disorder Transitions
Table 2 presents risk ratios for Wave 2 incident disorder onset by type of Wave 1 lifetime disorder. Any Wave 1 disorder was associated with elevated risk for Wave 2 incident mood and anxiety disorders. Incident substance use disorder risk was only elevated among women with a prior mood disorder (RR=1.2). Incident anxiety disorder risk was more than twice as high among men and women with a mood disorder than those without (RR=2.2 and 2.2, respectively), and incident mood disorder risk was elevated among men and women with a prior anxiety (RR=3.1 and 1.6, respectively) or substance disorder (RR=1.5 and 1.4, respectively).
Table 2. Risk Ratios (95% CI) for New Psychiatric Disorder Onset at Wave 2 by Type of Disorder at Wave 1 (Weighted*).
| Full Sample | |||
|---|---|---|---|
| W1 Lifetime Disorder | Incident Mood Disorder (n = = 27,571) | Incident Anxiety Disorder (n = 30,698) | Incident Substance Use Disorder (n = 21,946) |
| Mood | - | 2.74 (2.54, 2.96) | 0.97 (0.84, 1.12) |
| Anxiety | 2.11 (1.80, 2.49) | - | 0.99 (0.81, 1.19) |
| Substance | 1.24 (1.12, 1.38) | 1.47 (1.36, 1.58) | - |
| Men | |||
| Mood | - | 2.21 (1.92, 2.54) | 0.89 (0.70, 1.15) |
| Anxiety | 3.05 (2.33, 3.98) | - | 0.99 (0.72, 1.38) |
| Substance | 1.54 (1.28, 1.84) | 1.60 (1.41, 1.82) | - |
| Women | |||
| Mood | - | 2.17 (2.01, 2.35) | 1.23 (1.03, 1.47) |
| Anxiety | 1.58 (1.30, 1.94) | - | 1.18 (0.94, 1.50) |
| Substance | 1.36 (1.19, 1.56) | 1.69 (1.56, 1.83) | - |
Note: We also examined concurrent co-morbid disorders at Wave 1 but results were similar to those presented here and we elected to remove so as not to be redundant.
Sampling, stratification, and cluster weights were applied.
Trauma exposure and Incident Psychiatric Disordersi
Table 3 presents risk ratios and PARPS for incident disorder onsets associated with each form of trauma exposure separately for those with and without a prior disorder. Nearly all types of trauma exposure were associated with elevated risk for all incident disorder types except Wave 2 incident substance use disorders among those with a prior psychiatric disorder. Among those with a prior psychiatric disorder, child maltreatment was associated with the greatest risk for mood (RR=2.2) and anxiety (RR=2.1) disorders while interpersonal trauma since Wave 1 was associated with the greatest risk for substance use disorders (RR=2.0). Comparatively, estimates for non-interpersonal trauma since Wave 1 were smaller (RR range=1.0-1.5) and inconsistently associated with incident disorders when examined by sex. Controlling for any pre-wave 1 trauma exposure resulted in slightly attenuated, but similar patterns of associations with
Table 3. Risk Ratios (95% CI) and Population Attributable Risk Proportion (PARPs) for Wave 2 Incident Disorders Among Those With and Without Prior Psychiatric Disorder Overall and Stratified by Sex (Weighted*).
| No Prior Psychiatric Disorder | W1 Psychiatric Disorder | |||||
|---|---|---|---|---|---|---|
| Risk Ratios (CIs) | W2 Mood | W2 Anxiety | W2 Substance | W2 Mood | W2 Anxiety | W2 Substance |
| N= | 1172 | 1952 | 1740 | 880 | 2508 | 384 |
| Child Maltreatment | 2.18 (1.88, 2.54) | 2.1 (1.87, 2.35) | 1.55 (1.36, 1.76) | 1.6 (1.35, 1.9) | 1.62 (1.47, 1.78) | 1.27 (0.98, 1.65) |
| Interpersonal Violence | 1.75 (1.40, 2.18) | 1.85 (1.57, 2.18) | 1.96 (1.66, 2.32) | 1.69 (1.34, 2.14) | 1.51 (1.32, 1.72) | 1.09 (0.76, 1.57) |
| Non-interpersonal Violence | 1.39 (1.04, 1.85) | 1.26 (1.00, 1.6) | 1.52 (1.22, 1.88) | 1.27 (0.93, 1.74) | 1.33 (1.11, 1.59) | 1.21 (0.69, 2.10) |
| Men | ||||||
| N = | 28 7 | 45 8 | 91 2 | 38 8 | 87 4 | 12 0 |
| Child Maltreatment | 2.48 (1.85, 3.34) | 2.42 (1.91, 3.05) | 1.53 (1.28, 1.83) | 1.64 (1.27, 2.13) | 1.73 (1.47, 2.02) | 0.87 (0.52, 1.44) |
| Interpersonal Violence | 1.63 (1.08, 2.47) | 1.6 (1.15, 2.24) | 1.69 (1.35, 2.11) | 1.82 (1.32, 2.53) | 1.66 (1.34, 2.06) | 1.00 (0.51, 1.94) |
| Non- interpersonal Violence | 1.16 (0.67, 2) | 1.4 (0.89, 2.19) | 1.43 (1.08, 1.88) | 1.36 (0.91, 2.02) | 1.5 (1.15, 1.96) | 1.60 (0.71, 3.59) |
| Women | ||||||
| N = | 88 5 | 14 94 | 82 8 | 49 2 | 16 34 | 26 4 |
| Child Maltreatment | 2.05 (1.73, 2.43) | 1.97 (1.73, 2.24) | 1.59 (1.32, 1.92) | 1.58 (1.27, 1.97) | 1.48 (1.32, 1.65) | 1.45 (1.06, 1.97) |
| Interpersonal Violence | 1.91 (1.48, 2.46) | 2.09 (1.74, 2.5) | 2.26 (1.75, 2.92) | 1.53 (1.11, 2.13) | 1.44 (1.23, 1.69) | 1.19 (0.78, 1.82) |
| Non- interpersonal Violence | 1.56 (1.12, 2.17) | 1.28 (0.98, 1.66) | 1.48 (1.03, 2.13) | 1.11 (0.65, 1.91) | 1.32 (1.06, 1.65) | 1.06 (0.5, 2.22) |
| PARPs | ||||||
| Child Maltreatment | 0.4 7 | 0.4 7 | 0.3 2 | 0.2 8 | 0.3 2 | 0.1 7 |
| Interpersonal Violence | 0.48 | 0.52 | 0.63 | 0.43 | 0.40 | 0.20 |
| Non- interpersonal Violence | 0.34 | 0.24 | 0.4 | 0.22 | 0.29 | 0.21 |
| Men | ||||||
| Child Maltreatment | 0.5 1 | 0.5 1 | 0.3 2 | 0.2 9 | 0.3 5 | -0. 10 |
| Interpersonal Violence | 0.44 | 0.43 | 0.57 | 0.47 | 0.45 | 0.13 |
| Non- interpersonal Violence | 0.23 | 0.35 | 0.41 | 0.28 | 0.38 | 0.40 |
| Women | ||||||
| Child Maltreatment | 0.4 6 | 0.4 6 | 0.3 4 | 0.2 7 | 0.2 7 | 0.2 2 |
| Interpersonal Violence | 0.56 | 0.62 | 0.68 | 0.39 | 0.40 | 0.28 |
| Non-interpersional Violence | 0.41 | 0.22 | 0.33 | 0.12 | 0.30 | 0.11 |
Sampling, stratification, and cluster weights were applied.
PARPs indicate that trauma exposure accounted for a substantial proportion of the risk for Wave 2 incident disorders; this effect was more pronounced among individuals without (range=22%-68%) versus with (range=11%-47%) a Wave 1 disorder. For instance, interpersonal trauma was associated with roughly half of the risk for incident mood and anxiety disorders among those without a Wave 1 disorder, but less than 20% of the risk for incident substance use disorders among those with a Wave 1 disorder. To ensure that incident disorders associated with trauma exposure since Wave 1 could not be better accounted for by pre-Wave 1 trauma exposure or the development of PTSD at Wave 2, supplemental analyses controlling for pre-Wave 1 trauma exposure and excluding those with Wave 2 PTSD also were conducted. With few exceptions, patterns of associations were similar to the primary analyses (see Supplemental Tables 3a and 3b).
Trauma Exposure and Disorder Transitions
Table 4 presents risk ratios and PARPs for disorder transitions from Wave 1 to Wave 2 by trauma exposure type. All trauma types were associated with all disorder transitions with few exceptions: no trauma types were associated with the anxiety to substance use disorders transition; interpersonal and non-interpersonal trauma were not associated with the mood to substance use disorder transition; and non-interpersonal trauma was not associated with the anxiety to mood transition. Among men, all trauma types were associated with transitioning from mood or substance use to anxiety disorder, but none were associated with transitioning to a substance use disorder. Among women, child maltreatment and interpersonal trauma were associated with nearly all disorder transitions; however, non-interpersonal trauma was only associated with transitioning from mood to anxiety disorder.
Table 4. Risk Ratios (95% CI) and Population Attributable Risk Proportions (PARPs) for Transdiagnostic Predictors of Disorder Type Transitions from Wave 1 to Wave 2 (Weighted*).
| Risk Ratio (CI) | W1 Mood to W2 Anxiety | W1 Anxiety to W2 Mood | W1 Mood to W2 Substance | W1 Substance to W2 Mood | W1 Anxiety to W2 Substance | W1 Substance to W2 Anxiety |
|---|---|---|---|---|---|---|
| Full sample | ||||||
| N= | 13 59 | 22 0 | 30 1 | 78 2 | 16 3 | 19 25 |
| Child Maltreatment | 2.7 (2.36, 3.09) | 2.18 (1.52, 3.13) | 2.01 (1.50, 2.69) | 1.99 (1.54, 2.57) | 1.2 (0.66, 2.18) | 1.74 (1.48, 2.04) |
| Interpersonal Violence | 2.38 (1.99, 2.85) | 2.46 (1.52, 3.99) | 1.46 (0.98, 2.16) | 1.43 (1.03, 1.99) | 1.16 (0.43, 3.16) | 1.39 (1.13, 1.71) |
| Non-interpersonal Violence | 1.68 (1.31, 2.17) | 1.52 (0.80, 2.90) | 1.32 (0.73, 2.40) | 1.57 (1.21, 2.04) | 0.98 (0.47, 2.05) | 1.52 (1.29, 1.78) |
| Men | ||||||
| N = | 33 4 | 7 7 | 9 0 | 36 8 | 5 0 | 78 9 |
| Child Maltreatment | 2.84 (2.17, 3.73) | 1.73 (0.94, 3.2) | 1.19 (0.67, 2.09) | 2.17 (1.66, 2.84) | 1.42 (0.65, 3.12) | 2.13 (1.8, 2.53) |
| Interpersonal Violence | 3.21 (2.31, 4.47) | 2.49 (1.22, 5.08) | 1.21 (0.59, 2.51) | 1.83 (1.27, 2.63) | 1.22 (0.40, 3.71) | 1.71 (1.34, 2.18) |
| Non- interpersonal Violence | 2.14 (1.36, 3.39) | 2.5 (1.16, 5.39) | 1.44 (0.59, 3.51) | 1.38 (0.91, 2.08) | 2.34 (0.64, 8.55) | 1.51 (1.14, 2.01) |
| Women | ||||||
| N = | 10 25 | 14 3 | 21 1 | 41 4 | 11 3 | 11 36 |
| Child Maltreatment | 2.58 (2.22, 3.01) | 2.59 (1.65, 4.06) | 2.53 (1.79, 3.57) | 2.42 (1.9, 3.08) | 2.51 (1.53, 4.12) | 2.38 (2.07, 2.75) |
| Interpersonal Violence | 2.18 (1.77, 2.68) | 2.46 (1.27, 4.75) | 1.69 (1.06, 2.69) | 2.15 (1.51, 3.07) | 1.24 (0.63, 2.47) | 1.80 (1.46, 2.21) |
| Non- interpersonal Violence | 1.63 (1.22, 2.19) | 0.54 (0.15, 1.95) | 1.35 (0.61, 3.00) | 1.39 (0.80, 2.43) | 0.54 (0.15, 1.96) | 1.31 (0.98, 1.76) |
| PARPs | ||||||
| Child Maltreatment | 0.5 0 | 0.4 2 | 0.3 9 | 0.4 3 | 0.4 1 | 0.4 6 |
| Interpersonal Violence | 0.61 | 0.58 | 0.43 | 0.55 | 0.25 | 0.50 |
| Non- interpersonal Violence | 0.43 | 0.32 | 0.30 | 0.33 | 0.16 | 0.33 |
| Men | ||||||
| Child Maltreatment | 0.5 1 | 0. 3 | 0.1 6 | 0.4 2 | 0.2 1 | 0.4 4 |
| Interpersonal Violence | 0.69 | 0.58 | 0.34 | 0.49 | 0.23 | 0.47 |
| Non- interpersonal Violence | 0.56 | 0.58 | 0.39 | 0.32 | 0.56 | 0.39 |
| Women | ||||||
| Child Maltreatment | 0.4 9 | 0.4 8 | 0.4 6 | 0.4 5 | 0.4 7 | 0.4 7 |
| Interpersonal Violence | 0.6 | 0.59 | 0.51 | 0.59 | 0.32 | 0.54 |
| Non-interpersonal Violence | 0.4 | -0.89 | 0.27 | 0.30 | -0.81 | 0.26 |
Sampling, stratification, and cluster weights were applied.
PARPs suggest that child maltreatment, interpersonal trauma, and non-interpersonal trauma were associated with 39-50%, 25-61%, and 16-43% of the risk for transitioning to a new disorder, respectively. Supplemental analyses controlling for pre-Wave 1 trauma exposure and excluding those with Wave 2 PTSD revealed a similar pattern of associations between trauma exposure and disorder transitions as the primary analyses with few exceptions (see Supplemental Tables 4a and 4b).
Probability of Transitioning from a Wave 1 to Wave 2 Disorder by Life-Course Stage
Table 5 presents risk ratios for disorder transitions as a function of life-course stage. Those aged 18-30 were more likely than those aged 51-70 to transition from a mood disorder to an anxiety or substance use disorder. Those aged 18-50 were more likely than those aged 51-70 to transition from a substance use disorder to a mood or anxiety disorder. Patterns were similar across men and women with one exception: men, but not women, aged 31-50 were more likely than those aged 51-70 to transition from mood to anxiety disorder.
Table 5. Risk Ratios and 95% Confidence Intervals Reflecting the Probability of Transitioning to New Disorder Type by Age and Stratified by Sex (Weighted*).
| N = | W1 Mood to W2 Anxiety | N = | W1 Anxiety to W2 Mood | N = | W1 Mood to W2 Substance | N = | W1 Substance to W2 Mood | N = | W1 Anxiety to W2 Substance | N = | W1 Substance to W2 Anxiety | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Full Sample | ||||||||||||
| N = | 1359 | 220 | 301 | 782 | 163 | 1925 | ||||||
| 18-30 | 396 | 1.45 (1.21, 1.73) | 64 | 1.27 (0.81, 1.99) | 125 | 1.97 (1.39, 2.79) | 125 | 1.82 (1.41, 2.35) | 49 | 1.39 (0.83, 2.33) | 497 | 1.44 (1.24, 1.67) |
| 31-50 | 660 | 1.12 (0.95, 1.33) | 99 | 1.18 (0.78, 1.78) | 107 | 0.70 (0.48, 1.01) | 107 | 1.62 (1.29, 2.04) | 76 | 1.14 (0.70, 1.86) | 1007 | 1.31 (1.15, 1.5) |
| 51-70 | 303 | 1.00 (1.00, 1.00) | 57 | 1.00 (1.00, 1.00) | 69 | 1.00 (1.00, 1.00) | 69 | 1.00 (1.00, 1.00) | 38 | 1.00 (1.00, 1.00) | 421 | 1.00 (1.00, 1.00) |
| Male | ||||||||||||
| N = | 334 | 77 | 90 | 368 | 50 | 789 | ||||||
| 18-30 | 98 | 2.21 (1.52, 3.21) | 22 | 1.72 (0.76, 3.89) | 42 | 2.27 (1.16, 4.42) | 109 | 2.00 (1.39, 2.88) | 14 | 1.28 (0.46, 3.55) | 185 | 1.32 (1.05, 1.67) |
| 31-50 | 172 | 1.71 (1.21, 2.43) | 39 | 1.82 (0.87, 3.78) | 30 | 0.67 (0.33, 1.37) | 188 | 1.59 (1.14, 2.22) | 26 | 1.37 (0.53, 3.51) | 407 | 1.24 (1.02, 1.51) |
| 51-70 | 64 | 1.00 (1.00, 1.00) | 16 | 1.00 (1.00, 1.00) | 18 | 1.00 (1.00, 1.00) | 71 | 1.00 (1.00, 1.00) | 10 | 1.00 (1.00, 1.00) | 197 | 1.00 (1.00, 1.00) |
| Female | ||||||||||||
| N = | 1025 | 143 | 211 | 414 | 113 | 1136 | ||||||
| 18-30 | 298 | 1.23 (1.01, 1.51) | 42 | 1.03 (0.61, 1.75) | 83 | 1.8 (1.21, 2.68) | 107 | 1.62 (1.15, 2.28) | 35 | 1.42 (0.79, 2.55) | 312 | 1.53 (1.26, 1.86) |
| 31-50 | 488 | 0.96 (0.8, 1.15) | 60 | 0.86 (0.52, 1.42) | 77 | 0.7 (0.46, 1.07) | 232 | 1.66 (1.22, 2.26) | 50 | 1.02 (0.57, 1.8) | 600 | 1.37 (1.14, 1.63) |
| 51-70 | 239 | 1.00 (1.00, 1.00) | 41 | 1.00 (1.00, 1.00) | 51 | 1.00 (1.00, 1.00) | 75 | 1.00 (1.00, 1.00) | 28 | 1.00 (1.00, 1.00) | 224 | 1.00 (1.00, 1.00) |
Sampling, stratification, and cluster weights were applied.
Discussion
This investigation extended research suggesting that heterotypic continuity is common by examining specific disorder transitions and predictors of these transitions in a large, nationally representative sample. Although the burden of psychiatric disorders is thought to be concentrated among a small subset of the population (19), findings indicated that incident psychiatric disorders were common in adulthood and cut across disorder categories. Individuals with a Wave 1 disorder had elevated risk of transitioning to a Wave 2 anxiety or mood disorder but not a substance use disorder. These findings were somewhat unexpected in light of longitudinal studies suggesting that anxiety disorders frequently emerge in childhood and early adolescence and precede the onset of mood and substance use disorders in late adolescence and early adulthood (33-35). However, findings cohere with data showing that adolescents with mood and behavior disorders are at increased risk for anxiety disorders in adulthood (36). Mood disorder symptoms (e.g., anhedonia) and substance use may promote immediate avoidance, which in turn may increase risk for anxiety disorders over time. Results suggest that public health efforts aimed at primary prevention of all disorder types in adulthood and secondary prevention of anxiety disorders in particular may be important for improving population mental health.
Consistent with transdiagnostic models emphasizing the role of child maltreatment (12, 13) and interpersonal trauma exposure (14) in predicting psychopathology, trauma exposure was associated with a substantial proportion of incident disorders and transitions, which highlights the critical role of trauma exposure in shaping risk for psychopathology throughout the life course. Although shared correlates of both trauma exposure and mental disorders (e.g., genetic factors) could account for some variance in the observed associations, previous studies have provided evidence for specific mechanisms through which trauma may influence mental health. Specifically, trauma exposure has been linked with HPA axis dysregulation (37) and emotion dysregulation (38), which could increase risk for incident disorders and transitions between disorders. Trauma appears to be an important correlate of a cascade of psychiatric disorders, although future studies should incorporate other correlates of trauma and utilize genetically-informative designs to understand genetic influences in these pathways. Public health campaigns aimed at de-stigmatizing treatment seeking (39) and encouraging trauma exposed individuals to seek help in response to early warning signs before a psychiatric disorder emerges may mitigate the complex and often chronic negative effects that accompany comorbidity.
Some sex differences warrant mention. First, heterotypic continuity was more common among women, which may reflect women's increased risk for anxiety disorders (40). Second, men had a greater risk for transitioning from anxiety to a mood disorder while risk for transitioning from mood to substance use disorder was only significant for women. Relative to women, men may be less likely to seek treatment for anxiety due to stigma (41) and may isolate when feeling anxious, which may increase anhedonia and mood symptoms. For both sexes, substance use disorder onset more often occurred in the absence of prior psychopathology; however, women may have been more likely to self-medicate their mood symptoms with substances in a way that increased risk for disorder. Women who experienced child maltreatment or interpersonal trauma since Wave 1 had more than two times the risk of transitioning to nearly all disorders. In contrast, the effects of trauma exposure for men were circumscribed primarily to transitions between mood or substance use to anxiety disorders and anxiety to mood disorders. Findings may reflect women's increased vulnerability to experience trauma such as child maltreatment and rape and/or develop psychopathology following such exposure (42).
Limitations of the current study should be noted. First, although several lifetime disorders were examined, the NESARC does not assess every possible psychiatric disorder at both waves (e.g., PTSD is only assessed at Wave 2). Therefore, the current study likely represents an underestimate of incident psychiatric disorders and transitions between disorders. Second, transdiagnostic predictors including child maltreatment and both interpersonal and non-interpersonal trauma exposure were only assessed at Wave 2. Ideally, these events would have been assessed at both waves. Additionally, because trauma exposure and Wave 2 disorders were both assessed since Wave 1, the temporal sequencing of variables during that period cannot be established. Third, the average age of participants was 45, which is beyond the onset risk period for most disorders. Findings that younger individuals were more likely to transition to a new disorder suggest future studies could focus on this high-risk period. Fourth, although the overall sample was large, some cell sizes for disorder transitions by age group were small.
Despite these limitations, the current study illustrated in a nationally representative US sample that incident disorders in adulthood were common, and those with a mood, substance, or anxiety disorder had increased risk of transitioning to an incident mood or anxiety disorder. Trauma exposure during childhood and adulthood was significantly associated with transitioning from one disorder type to another. Encouraging trauma-exposed individuals to seek help to effectively regulate emotions and cope with distress prior to disorder onset and de-stigmatizing mental health treatment once a disorder has emerged may prevent a cascade of deleterious psychiatric disorders over the life course.
Supplementary Material
Acknowledgments
This research was funded by National Institutes of Health grants K01AA021511 (Keyes), LODA036213 (Walsh), T32DA031099 (PI: Hasin), and K01MH092526 (McLaughlin).
Footnotes
We also conducted sensitivity analyses for the transdiagnostic predictors that only included participants whose first violence exposure did not occur between wave 1 and 2 of the NESARC; a relatively small number of participants were removed from each analysis and results were largely similar thus we chose to report results for the larger sample. These sensitivity analyses are available upon request, however.
Disclosures: The authors have no conflicts of interest to report.
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