Toward a Better Understanding of the Relationship between Childhood Trauma and Psychiatric Disorders: Measurement and Impact on Addictive Behaviors.

Craparo, Ardino, Gori and Caretti recently published an interesting brief report in Psychiatry Investigation concerning the role of childhood trauma, dissociation, and alexithymia in alcohol dependence.1 In their exploratory study, Craparo and colleagues found that people suffering from alcohol use disorder were exposed to a greater number of traumatic events in their childhood (sexual, physical and emotional abuse), and showed more dissociative experiences and higher levels of alexithymia, compared to a matched control group. Another interesting finding of the study concerned the negative correlation between the age of the first relational trauma and the severity of dissociative symptoms.

This is consistent with a wealth of existing research emphasizing that adverse childhood experiences can alter the affect regulation circuits (alexithymia) and the possibility of integrating mental, somatic, and relational experiences (dissociation), thus constituting a risk-factor for the development of addictive disorders, including the so-called behavioral addictions such as pathological gambling2 and Internet addiction.3 The study by Craparo and colleagues provides additional evidence in a growing field for the influence exerted by negative childhood environment and relationships in the development of addictive disorders. As the literature indicates, people suffering from addictive disorders may in fact use substances or excessive behaviors as an external regulator and a self medication for their dysregulated feelings and painful states of mind. This then supports a psychopathological model according to which the earlier and more frequent the exposure to abuse for an individual, the higher the likelihood of deviation from normal development. In fact, both theoretical and empirical research states that early and frequent negative experiences in childhood, especially in the context of attachment relationships, can foster the onset of a developmental trauma disorder,4 which entails significant alterations in different domains of psychological functioning, including attachment, biology, affect regulation, dissociation, behavioral control, cognition and self-concept.5

Therefore, research findings are consistent in supporting developmental models for psychiatric disorders, whereby childhood neglect or abuse is an important causal factor, increasingly for a range of disorders. However, it is now necessary for research on the developmentally traumatic roots of addictive behaviors to make a quantum leap, in order to provide more detailed patterns of associations between childhood experiences and addictive behaviors in a search for more specific models. In doing this, a valid, reliable, comprehensive, and detailed assessment of child maltreatment becomes essential for increasing our understanding of the origins of addictive behaviors in addition to other forms of psychopathology. In fact, given potential methodological issues around retrospective mea-surement, accurate recall, and willingness to report sensitive or stigmatizing personal information, the choice of a suitable measure of childhood maltreatment is a critical issue for both research and clinical purposes.

In this sense, the Childhood Experience of Care and Abuse (CECA) interview6 is unique as the first, most comprehensive, well tested measure of child maltreatment, with published reliability and validity (including a sibling corroboration study),7 and it has been used in patient and community samples internationally.8910 The only other similar interview is the Childhood Trauma Interview,11 which has a narrower range, less validational testing and less international use, but which has recently been adapted to follow the CECA in utilizing a wider range of indices for analysis.12 The CECA is considered the gold standard for the retrospective assessment of both trauma and lack of care experienced during childhood, due to its good psychometric properties, its careful, detailed, and behaviorally-based questioning, and wide range of experiences covered. In the 20 years since its initial publication, there are more than 100 studies with this measure that have identified specific patterns of psychopathological development. For example, studies with the CECA show that emotional neglect in childhood is specifically associated with the development of anxiety disorders13 and depressive disorders,14 and that role-reversal15 (i.e., parentification) and physical abuse16 are associated with the development of suicidal and self-injurious behaviors. Another recent study with the CECA showed that witnessing violence in the household is specifically associated with the development of substance use disorder among late adolescents.17 Other analyses point to differentiation of disorder according to parent involved with maternal neglect/abuse relating to internalizing disorders (e.g., anxiety, depression) and paternal neglect/abuse to externalizing disorder (e.g., conduct disorder, substance use disorder, antisocial personality disorder).171819 On the basis of these and other findings, we believe that the use of the CECA measure and using an intensive interview approach can dramatically improve the quality of research data on the relationship between child abuse and addictive behaviors, as well as improving the understanding of the relationship between childhood maltreatment and psychopathology more generally. This is not to underrate the usefulness of self-report screening tools for certain types of study, in particular for screening studies-the CECA.Q,20 a self-report measure based on the CECA interview, has proved robust in showing early experience influencing later disorder, and dose-response effects, but without the range of the interview measure to develop specificity of models, and the safeguards imposed in the rating scheme on accurate reporting.

It has been illuminating in the 20 years since the CECA was first published, to see its initial success in the prediction of depression being widely replicated but for a range of disorders. The measure has proved robust over time and across culture, and using the full range of the CECA measurement potential will allow for ever more specific models of disorder in relation to type of childhood maltreatment, by particular perpetrators and at specific ages. We believe that this kind of retrospective assessment for child maltreatment can make all the difference for developing consistent psychopathological model to inform clinical practice with individuals who have been traumatized in childhood.