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Abuse-related conditions

The negative impact of child abuse on adult mental health has been documented for over 150 years, and, over the last thirty years, in particular, numerous research studies have documented the link between child abuse and mental illness in later life. At present, there is no single diagnosis or condition that describes the psychological effects of child abuse. When in contact with mental health services, many adult survivors of child abuse find themselves diagnosed with multiple psychological conditions, many of which have considerable overlap.

The psychological impact of abuse on a child depends on a range of factors, including: the type of abuse, the severity of abuse, the relationship of the child to the abuser/s, the child's family environment and their relationship with their parents or other caregivers, and whether the child has previous experiences of abuse, or a history of support, care and love. These factors can soften, or exacerbate, the impact of abuse on a child's psychological wellbeing, and the likelihood that they will develop mental illness later in life.

Below is a list of a range of psychological conditions that are associated with child abuse. Please read on to find out more about them.

Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) is a psychological condition that develops after a person has been harmed or exposed to danger, and they have been unable to protect themselves. PTSD is particularly likely to develop when a person experiences fear, helplessness and powerless, which are all common features of child abuse.

PTSD has three main symptoms:

  • Hyperarousal is similar to the jumpy feeling that drinking too much coffee causes. We might experience it as anxiety, agitation or irritability. It is commonly known as the state of ‘fight or flight’.
  • Intrusions occur when traumatic experiences dating from a person’s past, break through into their consciousness and are experienced as though they are occurring in the present. They are called "flashbacks".
  • Avoidance is an attempt to defend oneself against danger by limiting contact with the world. This can involve withdrawing from others or narrowing the range of thoughts and feelings a person allows him/herself to acknowledge. Avoidance can take the form of repression (locking the memory of a traumatic event away), denial (failing to acknowledge that an event which occurred, actually happened), dissociation (altered perception) or amnesia (memory loss). Survivors subconsciously use any or all of these techniques to survive the trauma of their abuse.

Other indicators of PTSD may include:

  • Panic attacks
  • Uncontrollable crying
  • Uncontrollable rages
  • Eating disorders
  • Suicidal feelings
  • Self mutilation
  • Somatic pain
  • Terror
  • Addictions (alcohol, drugs, sex)
  • Overreaction to minor stress
  • Sleep disorders
  • Sense of defilement or stigma
  • Nightmares
  • State of fight or flight
  • Extreme mood swings
  • High risk behaviours
  • Shame, guilt and blame

Panic attacks

Anxiety is a feeling of apprehension associated with symptoms of tension. It is different to fear as fear is a response to perceived present danger. When fear occurs inappropriately anxiety can escalate and a panic attack can occur. People who have experienced childhood abuse are more likely to experience frequent or generalised anxiety or panic attacks than those who haven’t.

Panic attacks occur when an individual experiences a sudden period of intense fear or discomfort, in which four or more of the following symptoms rapidly develop:

  • palpitations/ pounding heart or racing heart
  • sweating
  • trembling
  • feeling of choking or trouble breathing
  • chest pain or discomfort
  • nausea or abdominal distress
  • feeling dizzy or faint
  • feelings of unreality or of being detached from oneself
  • fear of losing control or going crazy
  • fear of dying
  • numbness or tingling
  • chills or hot flushes

Depression

Depression is common. People who are depressed can feel discouraged about the future, dissatisfied with life (maybe even wishing they were dead) or isolated from others. They might lack the energy to get things done or to even get out of bed, be unable to concentrate or to eat or sleep normally. Feeling depressed is often a response to past and current losses. To feel bad as a reaction to a tragedy (such as a significant loss) is to be expected. Major depressive disorder, however, occurs when signs of depression (including lethargy, worthlessness, or loss of interest in family, friends and activities) last two weeks or more for no apparent reason. Symptoms include:

  • Depressed mood
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Markedly diminished interest in all or almost all activities
  • Significant weight loss when not dieting or weight gain, or decrease or increase in appetite
  • Insomnia or hypersomnia
  • Diminished pleasure from usual activities
  • Lethargy
  • Feelings of hopelessness
  • Lack of motivation
  • Diminished ability to think or concentrate, or indecisiveness
  • Recurrent thoughts of death, suicidal ideation or attempts
  • Psychomotor agitation (observable restlessness) or retardation

Dissociation

Dissociation refers to disruptions of aspects of consciousness, identity, memory, and physical actions (`In essence, aspects of psychobiological functioning that should be associated, coordinated, and/or linked are not’; Spiegel et al, 2011:826). Dissociation presents as separation/disconnection from immediate experience and occurs beyond conscious awareness and control.

It also varies in type and intensity. Dissociation can range from healthy and benign to problematic and pathological and it often goes undetected as it manifests in subtle ways. Whereas dissociation was once widely misunderstood `[t]oday the mental health field is paying more and more attention to dissociation and dissociative experiences’ (Howell, 2005: vii) There is also growing recognition that `the dissociative concept of multiple self-states’ applies to us all and is `enormously helpful in understanding both normal experience and pathological conditions’ (Chu, 2011:46).

A pioneer of dissociative studies, Frank Putnam asserts that `[w]e are all multiple to some degree’, and that it is `how well we can keep it together, how harmoniously we can bridge, coordinate and…integrate the different parts of ourselves that determines how functional we are’ (Putnam, 2016: 121). `Everyday’ switches between different states of being are so common as to be taken for granted (`like breathing’; Putnam, ibid). But when dissociation is related to trauma – i.e. an experience so overwhelms a person that their central nervous system cannot assimilate it, the impacts can be severe.

When a person dissociates as a response to trauma, different aspects of their functioning become disconnected from one another in rigid ways which can become disabling and chronic. Trauma-related dissociation can also be reactivated (“triggered”) even when there is no obvious current threat (and is removed from the time of the original trauma) When this happens, dissociation can be viewed as `a healthy defence gone wrong’ (Steinberg & Schnall, 2003). It means that the person cannot move flexibly between their different self-states and this negatively impacts their quality of life. If overwhelming stress occurs in early childhood it can generate severe dissociative divisions of personality which may result in the condition known as Dissociative Identity Disorder (DID).

Dissociative Identity Disorder (D.I.D.)

Dissociative Identity Disorder (DID) is defined in the mental health compendium, DSM-5 as an identity disruption indicated by the presence of two or more distinct personality states (experienced as possession in some cultures), discontinuity in sense of self and agency, and variations in affect, behaviour, consciousness, memory, perception, cognition, or sensory-motor functioning (American Psychiatric Association, 2013). DID is a complex post-traumatic developmental disorder; i.e. a survival mechanism for unbearable trauma (usually before the age of 6). It affects approximately 1% of the general population.

DID has neurobiological underpinnings and a robust research base which attests to the existence of dissociation (`neuroimaging studies provide concrete, theoretically consistent evidence that dissociation exists’, showing that `dissociation is accompanied by altered activation of brain structures… involved in regulating awareness of bodily states, arousal, and emotions’; Brand, 2012: 395). The disorder of DID is not the sensationalised representation that is often portrayed in the media and in film. Rather it develops as a result of protective attempts to preserve continuity at the cost of coherence (having a unified self) when a vulnerable developing brain is flooded with input that it cannot process. The person develops a number of internal `on-call’ self-states (parts of self) (Bromberg, 2001:200) in which `[t]he dissociation must be preserved….to prevent the return of unbearably traumatic self-experience’ (Bromberg, ibid:180).

People with DID can be amnesic (experience partial or total memory loss), ‘lose time’ (have blocks of time for which they have no memory), appear moody, and have gaps in their knowledge they are unable to explain. When people, particularly as adults shift between self-states, in rapid and dramatic ways, it can appear strange and even bizarre. That’s because by the time a person becomes an adult a long time has often passed since they experienced the extreme circumstances which caused them to form non-integrated self-states. It’s possible to explain such shifts when we understand the origin of this disorder i.e. a person’s need to dissociate `unbearably traumatic’ early life experience: `Scepticism about numbers of self-states is a potential intellectualization and deflection of the sad reality…an intolerance of the reality of severe abuse’ (Chefetz, 2015:116)

It can take an average of 6-12 years for people with DID to be accurately diagnosed within the mental health system. Many people who have DID are misdiagnosed with schizophrenia. The extensiveness of the impacts of early life trauma mean that people with DID also have other mental health challenges, often at the same time (e.g. PTSD, major depression, anxiety, eating disorder, substance abuse, engagement in risky behaviours such as self-harm and multiple suicide attempts) which attract multiple diagnoses. Hence there is an urgent need for health professionals to understand more about DID.

Evidence-based treatment for DID has been established to benefit clients, to help them stabilise, and to enhance their quality of life (Brand et al, 2016). Increased integration of self-states (`parts’) and `co-consciousness’ (increased internal communication between them) is possible: `That even those whose sense of self has been most brutally shattered can learn to reunite the broken parts of themselves, and thereby heal, is a lesson that gives hope and wisdom to us all’ (Steinberg & Schnall, ibid:128).

For a contemporary review of the myths and media portrayals around Dissociative Identity Disorder see: www.teachtrauma.com/controversial-topics-trauma/myths-media-portrayals-dissociative-identity-disorder/

Bipolar disorder

This condition occurs less commonly than major depression. A person suffering from bipolar disorder will tend to alternate between the hopelessness and lethargy of depression and the hyperactive, wildly optimistic and impulsive phase of mania. The onset of bipolar disorder is usually in the twenties, although it sometimes starts in adolescence. Treatment for bipolar disease, which may include medication, psychotherapy and lifestyle changes, tends to be effective. Maintenance treatment between episodes may greatly reduce or even prevent further episodes.

Schizophrenia

Schizophrenia refers to a group of severe disorders in which a person loses touch with reality, experiencing grossly irrational ideas or distorted perceptions. It is a potentially serious mental illness which affects almost one person in 100. The first onset is usually in adolescence or early adulthood but the disorder can develop later. The onset may be rapid, developing over weeks, or slow in which case it develops over months or years. Some people only experience one or more brief episodes and recover fully while others have to deal with schizophrenia throughout their lives. The management of schizophrenia has improved a lot in recent years. Medication, psychotherapy, social and family support are all helpful and contribute to returning the person to work, education and personal life. Symptoms of schizophrenia include:

  • Disorganised thinking – fragmented or bizarre and distorted by false beliefs called delusions. Thought and speech may be jumbled and difficult to follow, with conversation jumping from one subject to another without any obvious logic.
  • Delusions can include ideas of persecution (paranoia) or ideas of grandeur.
  • Disturbed perceptions including hallucinations: perceiving things that aren’t there – often auditory i.e. hearing voices although hallucinations can involve any of the five senses.
  • Inappropriate emotional responses and actions
  • Withdrawal from other people
  • Loss of drive, initiative and motivation
  • Lack of insight into own behaviour and thinking, and denial of the illness

Eating disorders

The principle feature of eating disorders is a preoccupation with control over eating, body weight and food. Conversely, `out of control’ eating can likewise become a form of disorder. Both overeating and extreme restriction of food intake can be seriously injurious to health.

Overeating and `binge’ eating can lead to obesity and the many health implications that stem from it.

In relation to extreme restriction of food intake, anorexia nervosa includes features such as self-induced weight loss (through starvation, purging and exercise) and an intense fear of becoming fat.

Bulimia nervosa features repeated bouts of uncontrolled over-eating (bingeing), intense fear of gaining weight, engaging in excessive exercise to prevent weight gain, self-induced vomiting and the use of laxatives and fluid tablets.

Treatment for eating disorders includes nutritional management, cognitive-behavioural therapy around beliefs and distorted body image, psychotherapies and in some instances medication.

Personality disorders

Personality disorders are long-lasting, maladaptive patterns of behaviour that impair social functioning. They are thought to originate in childhood and then continue into adult years.

Types include (this list is not exhaustive):

  • Paranoid personality disorder: a pervasive distrust and suspicion of others
  • Antisocial personality disorder: a pervasive pattern of disregard for and violation of the rights of others
  • Borderline personality disorder: a pervasive pattern of instability of interpersonal relationships, self-image, affects, and control over impulses. A website - the Borderline Mother explains this disorder in more detail.
  • Narcissistic personality disorder: a pervasive pattern of grandiosity, need for admiration, and lack of empathy
  • Obsessive-compulsive personality disorder: a pervasive preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness and efficiency.

Treating people with personality disorders is often difficult as those with a personality disorder often do have little or no insight into the fact that their difficulties are a result of the way they relate to others.