Original Article
Objective
:
This study was conducted to examine any differences between two groups of adult substance abuse disorder (SAD) patients: those with and without a childhood history of maltreatment.
Methods
: The interview survey subjects were 216 adult SAD patients admitted to three detoxification units. Their reports of childhood maltreatment history as presented to the nurse and physician, and on the Childhood Trauma Questionnaire (CTQ) were investigated. The CTQ was used to divide the patients into the maltreatment positive group (MPG, n=103) and the maltreatment negative group (MNG, n=80). Both groups were compared on demographics, history of substance abuse, and psychiatric and family histories.
Results
: The report rates of childhood abuse to the nurse and physician, and on the CTQ were 29%, 42%, and 78%, respectively, indicating an increase of nearly three-fold for the detailed, self-report, CTQ inventory. The concordance (agreement) rate of the three reports of sexual abuse (92%) was higher than that of physical and emotional abuse (47% and 54%, respectively). Female SAD patients reported more childhood sexual (36% vs. 10%) and emotional (48% vs. 28%) abuse than male SAD patients did. Compared to MNG, MPG had more female patients, higher alcohol (50% vs. 36%) and lower heroin (47% vs. 63%) use as the main substance abused, earlier onset of substance abuse problems (14.1 years old vs. 16.2 years old), and increased history of psychiatric diagnosis and treatment (59% vs. 25%).
Conclusion
: The SAD patients seemed to be heterogeneous, and the SAD patients could be divided according to their history of childhood maltreatment.
Correspondence: Jaehak Yu, M.D., Department of Psychiatry, Konkuk University Hospital, 4-12 Hwayang-dong, Gwangjin-gu, Seoul 143-72, Korea
Tel: +82-2-2030-7566, Fax: +82-2-2030-7399, E-mails: drjaehakyu@kuh.ac.kr, drjaehakyu@yahoo.co.kr
Much research attention has focused on the term 'dual diagnosis', which is used to refer to the simultaneous occurrence of substance abuse disorders (SADs) and psychiatric disorders in the same patient. According to Parran, the incidence of psychiatric diagnoses among substance abusers ranges between 25% and 75%1 which is too broad for clinical indication and suggests the need for study.
Brady et al. postulated five possible relationships between psychiatric disorders and SADs: (1) substance abuse and psychiatric disorders may co-occur by coincidence, (2) substance abuse may cause psychiatric conditions or increase the severity of previous psychiatric symptoms, (3) psychiatric disorders may cause or increase the severity of SAD, (4) both disorders may be caused by a third condition, and (5) substance abuse and withdrawal may produce symptoms that mimic a psychiatric disorder.2 Among these five possible relationships, many investigators have studied the third hypothesis, i.e., that psychiatric disorders may cause or increase the severity of SADs.
It has been suggested that SAD patients are understood to use alcohol and drugs to alleviate their psychiatric symptoms, such as depression and anxiety, rather than to use alcohol and drugs to relax or get pleasure. This 'self-medication theory'3 of substance abuse stems from studies in both psychoanalytic and psychiatric fields. From developmental and social points of view, psychiatric symptoms can be understood as resulting from early environmental defects including psychic traumas such as a history of being sexually, physically, and/or emotionally abused and neglected.
Many authors have investigated the incidence of a history of childhood abuse and neglect in the SAD population.4,5,6,7,8,9,10,11,12,13 The incidence is highly variable according to many factors, including the types of abuse investigated, how the history of abuse was gathered, and when the abuse history was taken. Additionally, the study results have varied with such characteristics as patient gender, substance abuse type, and inpatient versus outpatient setting. The incidences of a history of sexual and physical abuse in SAD patients ranged between 4% and 90% and between 15.2% and 73%, respectively. For overall abuse history, the incidence varied from 27% to 90%. The incidence of emotional abuse history has not been investigated.
There are many theories about the relationship between SAD and a history of childhood abuse. While many authors have reported a direct relationship10,14-35 others found no specific direct relationship between the two.7,36,37,38 Generally speaking, most authors have agreed that a history of childhood abuse has an indirect effect on a later SAD.4,15,36,39,40,41,42 It is also recognized by most investigators that SAD patients who have a history of childhood abuse have a more severe psychopathology than patients without an abuse history.12,25,36,43,44,45 Studies have also indicated that SAD patients who have a history of childhood abuse have an earlier onset of SADs than abuse-free patients.46,47 While some authors found a relationship between a specific abuse history such as sexual, physical, and emotional abuse, and a specific psychopathology such as depression, aggression, antisocial personality disorder, and borderline personality disorder,48,49,50 others did not.8,39,51 Other authors have found that female addiction patients tended to report more sexual and/or physical abuse than male addiction patients do.52,53,54,55 The findings concerning the relationship between parental substance addiction and a childhood abuse history were inconsistent.32,56,57
In summary, a history of childhood maltreatment seems to be one of the important causative factors in inducing psychiatric symptoms in adolescence and adulthood including SADs.
The aim of the study
The discrepancies in the aforementioned studies regarding any direct relationship between a history of maltreatment in childhood and a later incidence of SAD, and the variability of reports rates of a history of maltreatment in childhood among SAD patients point to several methodological problems of these studies. Specifically, Arellano pointed to the lack of proper control groups, the variability of their definition and measurement of abuse, and the lack of prospective studies as being problematic in studying the relationship between childhood abuse and a later SAD.58
Another explanation for the variability of these studies is the variety seen in the demographic characteristics of SAD patients. Clinically, we know the substance abuse population is comprised of various groups. Also recognized is the presence of SAD patients who do not show any psychiatric symptoms, such as depression and/or anxiety. Therefore, we may assume that one useful sub-groupings of SAD population may be based on the criterion of having a history of childhood abuse and/or neglect.
This study aimed to determine whether there are any differences between the groups with and without a history of childhood maltreatment (abuse and neglect) among the SAD patients.
In addition, the incidence of sexual, physical, and emotional abuse reported to a nurse and physician, and on the Childhood Trauma Questionnaire (CTQ, see procedure in the Method section) was investigated to elucidate any factors which could influence the rate of reporting an abuse history by SAD patients. Also, the concordance or agreement rates of the reports to the nurse and physician, and on the CTQ were investigated to expose any difficulties in reporting one type of abuse versus another type.
Method
Subjects
Every fourth patient who was voluntarily admitted to three detoxification units in Cleveland (Rosary Hall, Stella Maris, and Veterans Administration detoxification Unit) from February 2001 to January 2002 was selected for the study. All of the resulting 216 patients were over the age of 18 at the time of data collection and met the criteria for substance dependence as defined in DSM-IV-TM.59 Patients with moderate to severe psychiatric symptoms, such as active psychotic symptoms and current suicidal ideation and with serious medical problems were excluded. Informed consent was not obtained because all the procedures were done as a part of the initial evaluation for all admitted patients.
Procedures
On initial admission the patients were interviewed by the detoxification unit nurse. The nurse's initial evaluation included their history of substance abuse and their history of childhood sexual, physical, and emotional abuse. The typical question that was asked regarding childhood abuse history was "Have you ever been abused sexually, physically, or emotionally as a child?" These questions were part of the standard nursing intake form.
On the next day following admission, the addiction medicine physician, who was trained in psychiatry, interviewed the patient. The substance abuse history and childhood history of sexual, physical, and emotional abuse were again investigated as a part of the initial doctor's evaluation. This time, however, three questions were asked regarding the history of child-hood abuse: "Do you believe that you were sexually abused as a child?" "Do you believe that you were physically abused as a child?" and "Do you believe that you were emotionally abused as a child?" to expand on the single question asked by the nurse on the previous day.
The past psychiatric history of the patient and any family history of substance abuse and psychiatric disorder were also investigated. Other demographic data were also collected.
As the last part of the doctor's initial evaluation, the subjects were asked to complete the CTQ.60 This is a 28-item, self-report inventory that provides a brief, reliable, and valid screening for histories of abuse and neglect. The CTQ inquires about five types of maltreatment- sexual, physical, and emotional abuse, and physical and emotional neglect-with five items being assigned to each type of maltreatment. The sexual abuse items include the question "I believe that I was sexually abused." The physical abuse items include the question "I believe.Childhood maltreatment history and substance abuse disorder 84 that I was physically abused." The emotional abuse items include the question "I believe that I was emotionally abused." The CTQ also includes a three-item minimization/denial scale for detecting false-negative trauma reports. Individuals responded to a series of statements on the CTQ about childhood events, which are endorsed on a 5-point, Likert-type scale according to their frequency. The response options are never true, rarely true, sometimes true, often true, and very often true. Item scores are then summed up to produce scale scores that quantify the severity of maltreatment in each of the five areas. Even though the CTQ is a self-report inventory, in this study, the patients were asked by the investigator, in order to improve the validity of their history of childhood abuse and neglect.
When the patients were examined for their history of substance abuse and for the onset age of their substances abused they were asked how old they were when they started to use substance (s) "regularly." We investigated their onset age of substance abuse according to their reports to the nurse, physician, and social worker through the medical records. In the case of a discrepancy among their reports, we accepted the patient's report to the physician. In calculating the multiplicity of SAD, we ignored nicotine use disorder because most of the patients had nicotine dependence diagnoses.
Statistically, we used paired t-test to compare between the groups. SPSS was used for all data analyses.
Results
We first examined the difference in the report rates of abuse history to the nurse and physician, and on the CTQ (Table 1). The report rate of any kind of childhood abuse history was 29%, 42%, and 78% respectively. The report rate of childhood sexual abuse history was 12%, 11%, and 17% respectively. The report rates of childhood physical and emotional abuse history were 17% and 22% to the nurse, increased to 28% and 39% to the physician, and increased again to 68% and 62% on the CTQ, respectively.
Second, we investigated the concordance rate of patients' reports of sexual, physical, and emotional abuse history to the nurse and physician, and on the CTQ (Table 2). As expected, the concordance rates of sexual abuse reports were highest among three different kinds of abuse. The concordance rate among the three sexual abuse reports was 92%, in contrast with the concordance rates of physical and emotional abuse of 47% and 54%, respectively.
To increase the study validity we discarded 26 of the 216 patients who scored 3 out of 3 on the minimization/denial scale of the CTQ. This was done to discard those patients who showed extreme denial and minimization in reporting their childhood abuse and neglect histories through the CTQ. Of the 190 remaining patients, 148 were male and 42 were female.
Third, we examined the difference of reported abuse and neglect according to gender. Table 3 shows the percentages of maltreatment reports according to the CTQ for male and female SAD patients. In preparing the data for this table, we used the criteria recommended by Bernstein to assign moderate and severe classifications in the five different maltreatments.60 In all five maltreatment categories, the female SAD patients reported higher percentages of abuse and/or neglect than their male counterparts. The report rate of sexual abuse according to the CTQ was significantly higher for female SAD patients (36%) than for their male counterparts (10%) (p=0.02). The emotional abuse report rate was also higher for the female patients (48% vs. 28%), but the difference was not statistically significant at the alpha=0.05 level.
Finally, we divided the patients into two groups according to the CTQ results. We accepted the idea of those authors8,39,51 that suggested that there was no difference between abuse and neglect, and among sexual, physical, and emotional abuse, in inducing childhood trauma and resulting in a later SAD. Therefore, the following criteria were used for the two groups. One group was comprised of patients who had a positive history of childhood maltreatment (abuse and neglect) (maltreatment positive group, MPG). These patients meet the recommended criteria of Bernstein for moderate and severe classification of any of five different types of maltreatment: sexual, physical, and emotional abuse, and physical and emotional neglect of the CTQ. In other words, the MPG inclusion criteria was any patient whose combined score, within a possible range of 5 to 25, of any of the five different types of maltreatment was more than 8, 10, 12, 10, and 15 for sexual abuse, physical abuse, emotional abuse, physical neglect, and emotional neglect, respectively. The other group was comprised of those patients who had a negative history of child-hood maltreatment (maltreatment negative group, MNG). These patients met the recommended criteria of none or minimal classifications for all five different types of maltreatment. In other words, the MNG inclusion criteria was any patient whose total combined score of the whole CTQ, within a possible range of 25 to 125, was less than 36.
To more accurately divide these two groups, we discarded the 7 patients who had a total combined score on the whole CTQ (possible range of 25 to 125) of more than 36, who met the criteria of the 'low' classification, but who did not meet the 'moderate' and 'severe' classification for the five different types of maltreatment. The 183 remaining subjects comprised 103 MPG and 80 MNG patients.
The results of the comparison between the MPG and MNG subgroups are shown in Table 4. Among the demographic data, the ages of MPG and MNG were 43.6 and 43.7 years old, respectively. MPG had significantly more women than MNG did (28% vs. 16%, p=0.049). MPG had more white patients and MNG had more African-American patients. MPG had fewer married patients (11% vs. 19%), fewer single patients (37% vs. 41%), but more divorced patients (38% vs. 26%) than MNG. These findings of differences of the marital status between the two groups, however, were not statistically significant at the alpha =0.05 level. The educational levels of both groups were not different.
In the history of substance abuse, heroin abuse as the main substance was significantly higher in MNG than in MPG (63% vs. 47%, p =0.01), while alcohol abuse as the main substance was significantly higher in MPG than in MNG (50% vs. 36%, p =0.01). A history of multiple substance abuse was higher in MPG than in MNG (74% vs. 64%), but the difference was not statistically significant. The age at the onset of substance abuse problems was 14.1 and 16.2 years old (p =0.008) when we included nicotine as a substance but 15.9 years old and 19.2 years old (p =0.002) when we exclude nicotine as a substance, for MPG and MNG. The earlier onsets of substance abuse problems for MPG than for MNG in both conditions (including and excluding nicotine) were statistically significant. The age of onset of the current substance abused was earlier for MPG than for MNG (19.5 years old vs. 21.3 years old), but this difference was not statistically significant.
In the comparison of the psychiatric and family histories of both groups, the history of a psychiatric diagnosis and treatment was significantly higher for MPG than for MNG (59% vs. 25%, p<0.0001). The family history of substance abuse was higher for MPG than for MNG (55% vs. 44%) but the difference was not statistically significant. MPG had a higher family history of psychiatric illness than MNG (18% vs. 6%) but the difference was not statistically significant at alpha =0.05 level.
Discussion
The incidence of reported history of abuse in SAD patients
The incidence of a reported history of sexual, physical, and emotional abuse in the substance abuse population varies according to many factors, as described in the introduction. The incidence of reported abuse history was higher when patients used the questionnaire or inventory, and when the questions were repeated rather than a self report with the simple question of "Have you ever been abused sexually, physically or emotionally abused?" Cohen & Densen-Gerber used an 8-page questionnaire and reported an extremely high abuse and neglect history of 84% among SAD patients.5 Miller et al. used multiple questions of a specific nature rather than a single, more generalized question in investigating the sexual and physical abuse history. They showed a sexual abuse history of 66- 70% and a physical abuse history of 71-73% among female alcoholic patients.10 Rohsenow et al. observed that when the question about abuse was asked more routinely, the incidences of sexual abuse history among adolescent patients increased from 0% to 42% in male and from 0% to 90% in female patients.11 In their study of adult patients, the incidences of sexual abuse history increased from 4% to 18% in males, and from 20% to 77% in females. Martin et al. showed that many women who replied negatively to a general screening question on child sexual abuse went on to report abuse in response to a detailed descriptive question,61 even though their study subjects were not substance abusers.
Our study also showed that repeated interviews and questions regarding abuse history, which were done in the interview with the physician after the initial interview with the nurse, increased in the report rates of physical and emotional abuse. We also noted that the report rates of sexual, physical, and emotional abuse based on CTQ increased dramatically compared to those based on simple interview questions. The incidence of any kind of abuse history increased 2.7 fold from the initial report to the nurse (29%), through the report to the physician (42%), to the CTQ assessment (78%). The above results indicated that repeated questions possibly and questions using the questionnaire are more effective in eliciting a history of childhood abuse from the patients.
Rohsenow et al. have shown gender differences in the report rate of sexual abuse.11 In their study, 4% to 18% of male adult patients reported sexual abuse compared to 20% to 77% of female adult patients while 42% of male and 90% of female adolescent patients reported sexual abuse. Toray et al. found the biggest gender difference (female >male) in physical and sexual abuse when they compared male and female adolescent SAD patients.54 Windle et al. reported that 12% of their male and 49% of their female patients reported sexual abuse.13 Their study also showed more physical abuse for female than male patients (33% vs. 24%). Wallen found 9.4% and 32.6% of her male and female patients, respectively, had a history of childhood sexual abuse.55 Other authors52,53 also found that female substance abusers showed a higher incidence of sexual and/or physical abuse than did the male substance abusers did. These reports confirm that females report more sexual and/or physical abuse history than males.
Our study also showed more reports of and/or actual incidence of sexual, physical, and emotional abuse in female patients, with MPG having more women than MNG. This was further evidence of a higher rate of reported history of abuse for female than for male SAD patients. However, we do not know the higher report of abuse actually translates into a higher rate of actual abuse in female patients.
The characteristics in reporting the history of sexual, physical, and emotional abuse
The highest possible incidences of sexual, physical and emotional abuse history among our SAD patients were 17%, 68%, and 62%, respectively. The report rate of sexual abuse history was much lower than that of physical and emotional abuse. However, we do not know whether this translates into a lower incidence of actual sexual abuse than physical and emotional abuse.
Reporting childhood trauma and especially a sexual abuse history would be difficult for anyone. One study, which interviewed 129 women 17 years after they had reported sexual assault and had been examined at the emergency room, found that 38% of these sexually abused women did not even remember their sexual abuse history at all.62 In the discussion of this interesting finding, several authors62,63,64,65,66 mentioned the possibility of underestimating the sexual abuse history with suggested reasons including the normal forgetting process, psychodynamic repression process, the decision of the patient not to report the sexual trauma, an early age of sexual trauma, and the influence of less emphasis being placed on sexual abuse 20 years ago. However, Loftus also raised the possibility of overestimating the sexual abuse history due to memory distortion and creation about sexual abuse.63 She postulated that the recovered memory of sexual abuse is possibly literally true, or metaphorically true, or may be based on fantasy or dream material.
We also found a lower changeability of a reported sexual abuse history than that of a reported physical and emotional abuse history. As we have seen, the concordance rates of sexual abuse histories reported to the nurse and physician, and on the CTQ were higher than the physical and emotional abuse history reports.
The lower changeability of sexual abuse reports could be explained in two ways. First, compared to physical and emotional abuse, sexual abuse is simple to define. Second, if we assume that the actual incidences of sexual, physical, and emotional abuse are similar, as was demonstrated in previous studies,4,5,6,7,8,9,10,11,12,13 and if we consider our own finding of a lower incidence of reported sexual abuse history compared to physical and emotional abuse history, then the patients who had actual sexual abuse could be thought of as being more resistant to reporting, as compared to those who had actual physical and emotional abuse.
In addition, we found the concordance rate of physical abuse history reported to the physician and on the CTQ was lower than the other rates and further that the physical and emotional abuse report rates were dramatically increased when we applied the CTQ. These factors resulted in lower concordance rates for physical and emotional abuse reports, as compared to sexual abuse reports. This may mean that patients did not consider that they had been physically and/or emotionally abused, even though they had actually been abused in their childhood, which contrasts to the case of sexual abuse.
However, we have no direct evidence for our contention that sexual abuse is more difficult to report than physical and emotional abuse. Nor can we say that sexual abuse induces more severe psychic trauma than physical and emotional abuse do.
Division of the SAD patients into Maltreatment Positive Group (MPG) and Maltreatment Negative Group (MNG)
There are different ways to study the relationship between early childhood maltreatment history and resultant later SADs. Miller & Downs presented the pros and cons of prospective and retrospective study methods in investigating child abuse and neglect histories.30 They stated that a prospective study is based on the data of reported and confirmed maltreatment cases whereas a retrospective study can provide the best data available on unreported and untreated maltreatment cases. It is true that most maltreatment cases are not reported. Straus & Gelles estimated that 70% to 95% of childhood physical abuse is not reported.67 Therefore, in the study of maltreatment histories, a retrospective study could have the advantage of greater coverage of the abused and neglected population.
In retrospective studies, there are basically two ways of studying the relationship between early childhood abuse and neglect history and the later SAD, either comparing the abuse history of SAD cases with those of a control group or dividing the SAD patients into groups with positive or negative histories of childhood maltreatment. Then it is possible to examine the differences between these two groups. The limitation of the former study design is the difficulty in finding an adequate control group for SAD patients. Therefore, the comparison between maltreatment positive and negative groups among SAD patients is thought to be the best way to study the relationship between a childhood maltreatment history and the resultant substance abuse problem.
Only a few studies4,8,12,39,46 have examined differences of abuse history between positive and negative groups among SAD patients. Schaefer et al. showed in their study with 100 male adult alcoholic patients that the mean age of the abused group was 5 years younger than that of the non-abused group.12 It is possible that the younger age group reported more abuse history, and this was true in the study by Rohsenow et al.11 They showed that adolescent SAD patients reported more sexual abuse history than adult SAD patients did. However, our study showed no difference between the mean age of MPG and MNG.
The difference in the gender ratio in MPG and MNG, previously mentioned in the discussion above, suggests that females have more childhood abuse history than males.
Surprisingly, no study has investigated the marital status of the abuse positive and abuse negative groups. Our study showed a lower marital status and higher divorce status in MPG than in MNG, although the differences were not statistically significant at alpha = 0.05 level.
Schaefer et al. also showed in their study that 64% of non-abused patients attended or completed college, as compared to 53% of abused patients.12 Our study, however, showed no difference in educational years between the two groups.
In Browne et al.'s study,46 those patients with a history of sexual abuse in the past had a significantly younger mean age of first opiate use (16.7 years vs. 19.1 years). Cavaiola & Schiff showed that the abused patients had earlier onset of drug abuse, but not alcohol abuse, as compared to non-abused chemically dependent patients.4 Also, Harrison et al.'s sexual abuse victims reported earlier onset of alcohol and drug abuse compared to non-victims.8 Our study showed the same result for an earlier onset of abused substances in MPG than in MNG, regardless of the onset of nicotine use.
Harrison et al.8 showed that the frequency of alcohol, marijuana, and cocaine abuse did not differ significantly among sexual abuse victims and non-victims. However, sexual abuse victims were significantly more likely to use stimulants, sedatives, and hallucinogens. Our study showed more alcohol use in MPG and more heroin use in MNG as the main substance abused. These findings were statistically significant and we considered them to be very important. It was thought that patients with an abuse history had used alcohol because it is more available than any other substances at an earlier age. On the other hand, patients without an abuse history had used heroin as a "recreational" drug at a later age. There was a greater tendency to use multiple substances in.Childhood maltreatment history and substance abuse disorder 90 MPG than in MNG, but the difference was not significant statistically.
Many studies have investigated the relationship between an early childhood abuse and neglect history, and later psychiatric diagnoses such as depressive disorder, anxiety disorder and bipolar disorder, as was mentioned earlier. Our study showed more psychiatric diagnoses and treatment history in MPG than in MNG, in agreement with the results of previous studies. This finding suggests the hypothesis that a childhood history of abuse and neglect can induce later psychiatric problems.
The difference between MPG and MNG in family history was one of our main interests. If these two groups are different in family history, then their division might be partially biologically determined. Therefore, any difference between MPG and MNG in the "biological" family history of SADs and psychiatric disorders could give support to this hypothesis for sub-grouping of the two groups among SAD patients. In our study results, more MPG family members than MNG tended to be substance abusers and tended to have psychiatric disorders. However, these differences were not statistically significant. Therefore, these results of family history did not give strong support to the hypothesis of dividing the SAD patients into MPG and MNG.
Our study confirmed the viability of sub-grouping among SAD patients according to the history of childhood maltreatment. They were significantly distinguished in sex ratio (more females in MPG than in MNG), marital status (lower marital status in MPG than in MNG), choice of substance abused (more alcohol use in MPG and more heroine use in MNG), onset age of substance use problems (earlier substance use problems in MPG than in MNG), and history of psychiatric diagnoses (more previous psychiatric diagnoses and treatment history in MPG than in MNG).
Summary of the positive findings
To summarize the positive findings of this study first, of 216 adult SAD patients who were admitted for detoxification, 29%, 42%, and 78% reported a childhood maltreatment history to the nurse on the day of admission, to the physician on the day following admission, and on the CTQ, respectively. With repeated interview (i.e. with the physician), and interview with the CTQ, the report rates from the patients about childhood maltreatment history increased dramatically, with rates escalating almost three-fold for any kind of abuse, and four-fold for physical abuse.
Second, the concordance (agreement) rates of the patients' reports to nurse/ physician/ CTQ about sexual, physical, and emotional abuse were 92%, 47%, and 54%, respectively. In reporting the childhood abuse history to the nurse and physician, and on the CTQ, the sexual abuse history exhibited greater regularity than the physical and emotional abuse histories.
Third, female patients reported more childhood sexual abuse (36% vs. 10%) and more emotional abuse (48% vs. 28%) than male patients did. However, there were no significant differences in the rates of reporting physical abuse, physical neglect, and emotional neglect.
Fourth, compared to MNG, MPG had more females, more alcohol (50% vs. 36%) and less heroin (47% vs. 63%) use as their choice of substance abused, an earlier onset age of substance use problems (14.1 years old vs. 16.2 years old), and more history of psychiatric diagnosis and treatment (59% vs. 25%). Therefore, the two groups were considered to be distinguishable.
Conclusions
In conclusion, the study aim of dividing SAD patients according to the presence or absence of a history of childhood maltreatment was well supported by the results suggesting that the origins of the current substance abuse problems may be different between substance abusers with and without a childhood history of maltreatment. If a substance abuse problem is thought to be an expression of psychopathology, we suspect that the history of being maltreated in childhood is one of the core causative factors of the later resultant psychopathology. However, our SAD patients were heterogeneous. Some of the SAD patients could be explained by the hypothesis which postulates that they used substances to reduce their psychopathology which had resulted from childhood abuse and neglect.
Reflecting on the findings of this study, we made the following recommendations to the doctors, including the addiction specialists, psychiatrists, and primary care physicians, who take care of SAD patients.
First, in eliciting a childhood abuse and neglect history in SAD patients, repeated questions, especially with a questionnaire such as CTQ, rather than using a simple question such as "Has the patient ever been abused sexually, physically, and emotionally as a child?", are important. This technique elicits more of a history of abuse and neglect from the patients.
Second, the differences found in this study between the patients with and without a history of childhood maltreatment suggest that any evidence for a childhood maltreatment history in an SAD patient mandates further investigation into any possible psychopathology which has resulted from that previous maltreatment history. On this basis, we can also recommend different types of treatment for SAD patients with a maltreatment history.
As far as we know, this is the first study to divide SAD patients according to their history of childhood maltreatment. The other strong point of this study is that the childhood history of maltreatment was assessed by a face-to-face interview with the patients. Nevertheless we were unable to verify whether or not a history of childhood maltreatment translates into an actual occurrence. Irrespective a current report of a maltreatment history may be more clinically relevant than the actual abuse occurrence in the past. Further study on the importance of the childhood maltreatment history, including verifying the reports of childhood abuse through interviews with family members, will expose the relationship between childhood maltreatment and SAD.
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