Individual Differences in Psychophysiological Reactivity in Adults with Childhood Abuse

Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 9, 7 76 () Individual Differences in Psychophysiological Reactivity in Adults with Childhood Abuse Christian G. Schmahl, Bernet M. Elzinga * and J. Douglas Bremner Department of Psychiatry and Psychotherapy, University of Freiburg Medical School, Germany University of Leiden, Department of Clinical and Health Psychology, The Netherlands Departments of Psychiatry and Behavioral Sciences and Radiology, and Center for Positron Emission Tomography, Emory University School of Medicine, Atlanta, GA, and Atlanta VAMC, Decatur, GA Little is known about the neurobiological correlates of stressrelated disorders. In particular almost nothing is known about biological correlates of specific personality disorders that have been linked to stress. We measured heart rate and blood pressure reactivity in response to personalized traumatic s together with subjective psychological ratings in four women with a history of childhood abuse with no disorder, Posttraumatic Stress Disorder, Borderline Personality Disorder, and Histrionic Personality Disorder. Psychophysiology as well as subjective ratings differed markedly between the four women, with elevated reactions found in PTSD and histrionic personality, and extreme decline in physiological reactivity associated with a dissociative response in the borderline patient. It is concluded that reactivity to traumatic reminders can be correlated with the existence of different stress-related diagnoses. Personality characteristics seem to have an influence on psychophysiological reactivity in patients with stress-related psychiatric disorders. Copyright John Wiley & Sons, Ltd. INTRODUCTION Childhood sexual and physical abuse play an important role in the development of psychiatric disorders. Although the experience of childhood trauma does not necessarily lead to longterm psychological problems, a significant proportion of individuals continues to experience * Correspondence to: BernetM. Elzinga, University of Leiden, Department of Clinical and Health Psychology, PO Box 9555 RB Leiden, The Netherlands. Tel: (C) 7 57 75, Fax: (C) 7 57 678. E-mail: elzinga@fsw.leidenuniv.nl These authors contributed equally to this work. trauma-related symptoms long after the abuse occurred. Large individual differences have been observed in the effects of abuse in childhood, resulting in a range of interrelated psychopathological conditions, such as posttraumatic stress disorder (PTSD), depression, dissociative disorders, alcohol or substance abuse, and personality disorders (Beitchman et al. 99; Brown & Anderson, 99; Johnson, Cohen, Brown, Smailes, & Bernstein, 999). It remains unclear which specific factors predispose a person to develop a particular axis I or axis II disorder. Both physiological factors (e.g. genetics) and psychological characteristics, such as the appraisal of the event, perceived control, social support, and self-esteem Copyright John Wiley & Sons, Ltd. Published online 8 May in Wiley InterScience (www.interscience.wiley.com). DOI:./cpp.5

7 C. G. Schmahl, B. M. Elzinga and J. D. Bremner may contribute to the development of specific posttraumatic conditions. A model of trauma-spectrum disorders has been proposed to explain the overlap between these different conditions (Bremner, 999). According to that model traumatic stress can cause brain damage and lead to the development of a range of psychiatric disorders, including depression, PTSD, dissociative disorders and personality disorders such as Borderline Personality Disorder (BPD). Trauma may result in long-term changes in stress-responsive neurobiological systems, such as the locus coeruleus/noradrenergic system and the hypothalamic pituitary adrenal axis system (Bremner, Southwick, & Charney, 999). Differences and similarities between trauma-spectrum disorders are related to varying effects of stress on these systems. Stress-responsive neurohormonal systems that can be easily studied include the catecholamine and cortisol systems. One method to assess measures related to catecholamine function is to measure heart rate and blood pressure response to a stressful challenge, a paradigm referred to as psychophysiological reactivity. Psychophysiological reactivity to trauma cues in patients with PTSD has been widely investigated (Blanchard & Buckley, 999). Despite some variations, most studies have found larger psychophysiological responses to trauma-related cues in patients with PTSD compared to control subjects. In comparison to PTSD, much less is known about psychophysiology of other stress-related disorders, such as BPD or dissociative disorders, and other personality disorders. It is apparent that early stress has a long-term effect on the development of personality, and can lead to a range of personality disorders. Inversely, personality characteristics may also affect the way a stressful event is perceived and processed. So far, the relationship between specific personality disorders and stress-induced psychophysiological reactivity has not been evaluated. The first study of physiological correlates of emotional reactivity in BPD was conducted by Herpertz and coworkers (999). She examined female patients with BPD and 7 normal control subjects. Participants were shown a set of standardized (i.e. not personalized) photographic slides with pleasant, neutral, or unpleasant emotional valence. In addition to self-reports, physiological reactions to the slides were measured by heart rate, skin conductance, and startle response. Contrary to expectations, the borderline patients did not produce higher levels of startle amplitude than control subjects and while viewing unpleasant slides they showed a startle potentiation effect that was largely similar to that of the comparison group. Furthermore, neither skin conductance nor heart rate responses differed between patients and controls. The histrionic personality disorder, and the accompanying feature of exaggerated expression of emotion, is also of interest when looking at the relation between personality characteristics and psychophysiological reactivity to trauma cues. To date, no studies have appeared on the relation between stress and histrionic personality, however. To illustrate how factors other than PTSDsymptomatology can affect reactivity to traumatic reminders, we present psychophysiological and subjective responses to personalized stressful s in four women with childhood abuse. We report data of a patient with Histrionic and Narcissistic Personality Disorder, and a patient with Borderline Personality Disorder, and compare them with a patient with severe PTSD and a woman with a history of childhood abuse without any related psychiatric disorder. METHOD Participants The women all took part in a larger study investigating autonomic responses to reminders of stressful life events. We included women over the age of 8 years with a history of childhood sexual and/or physical abuse. Exclusion criteria were a lifetime history of psychotic disorders, organic mental disease, a history of head injury, and use of benzodiazepines. We present the four cases with a brief deion of traumatic experience, lifetime and current diagnoses. Measures Axis I diagnoses were assessed by a trained psychiatrist and psychologist (C.G.S and B.M.E.) using the Structured Clinical Interview for DSM-IV axis I disorders (SCID; Spitzer, Williams, & Gibbon, 995). Axis II diagnoses were assessed using the Diagnostic Interview for Personality Disorders (DIPD, Zanarini, Frankenburg, Sickel, & Yong, 996). Current PTSD was further assessed by the Clinician- Administered PTSD Scale for DSM-IV, Current and Lifetime Version (CAPS, Blake et al., 997). History of traumatic childhood events was assessed using the Early trauma inventory self-report-version Copyright John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 9, 7 76 ()

Individual Differences in Psychophysiological Reactivity 7 (ETI). The ETI is an interview that assesses physical, emotional, and sexual abuse. For each item of the ETI, frequency of trauma, perpetrator of the trauma by developmental stage, onset and termination of trauma, and impact on the individual are assessed (see Bremner, Vermetten, & Mazure, for psychometric properties). Procedure After informed consent was obtained, participants listened to personalized s of (sexual or physical) abuse situations and situations of abandonment in childhood for min. Heart rate and blood pressure were assessed before and after the reading of the s. After each, subjective ratings were collected, including a PTSD symptom scale (Southwick et al., 99), a Clinician-Administered Dissociative States Scale (Bremner et al., 998), a Subjective Units of Distress Scale, and a visual analogue scale for the assessment of nervousness and anxiety..5.5.5 5 5 Ratings for Case (PTSD) PTSD symptoms Psychophysiology for Case (PTSD) CASE REPORTS Case The first participant was a typical patient with PTSD. This 9-year-old Hispanic woman with a history of sexual and physical abuse, starting at age 6 years, had had an ongoing pattern of traumatic experiences during her life. People close to her, including her parents, had repeatedly abandoned her. Her feelings of self-worth mostly depended on taking care of others. She fulfilled lifetime diagnoses of PTSD, social phobia, and major depressive disorder. During the time of the study she fulfilled criteria for PTSD, but not for any axis II disorder. Her CAPS score was 8, her ETI score 6. While she listened to the traumatic, she showed a large increase in blood pressure and heart rate (see Figure ). She reported having flashbacks, out-of-body-experiences, she felt emotionally numb and had difficulties concentrating. Also during the abandonment she reacted markedly in terms of psychophysiology and subjective ratings. During the whole procedure she displayed strong affective reactions of sadness and anger. Case The second participant was a -year-old abused Hispanic woman who had recovered from PTSD and was currently healthy. At the age of 5 Figure. Subjective ratings (top) and psychophysiological changes (bottom) for case. Rating scales from to ( D notatall,d worst ever) years she had been abused multiple times by two family members. One incident, in which one of the perpetrators took her with him in his car and raped her, was particularly traumatic for her. Following these events, she had fulfilled axis I major depressive disorder, and PTSD. She had tried to commit suicide and frequented unsafe places at night. During the time of study, however, she did not fulfil any DSM-IV diagnosis. Her CAPS score at the time of study was. Her total ETI score was 5. She did not fulfil criteria for any personality disorder. During the traumatic as well as during the abandonment there was no change of heart rate and blood pressure (see Figure ). Although she was emotionally affected by listening to the s, in contrast to the other three patients she did not display an intense emotional reaction. Case This was a 6-year-old Caucasian female with BPD aswellasptsdandahistoryofbothphysical and sexual abuse in childhood. She fulfilled axis I lifetime diagnoses for major depressive disorder, Copyright John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 9, 7 76 ()

7 C. G. Schmahl, B. M. Elzinga and J. D. Bremner Ratings for Case (Abuse control) Ratings for Case (BPD).5.5.5 PTSD SYMPTOMS.5 PTSD SYMPTOMS.5.5 Psychophysiology for Case (Abuse control) Psychophysiology for Case (BPD) 8 6 6 8 Figure. Subjective ratings (top) and psychophysiological changes (bottom) for case. Rating scales from to ( D not at all, D worst ever) 8 6 6 8 Figure. Subjective ratings (top) and psychophysiological changes (bottom) for case. Rating scales from to ( D notatall,d worst ever) PTSD, panic disorder with agoraphobia, alcohol dependence, and cocaine dependence. At the time of the study she fulfilled axis I diagnoses for PTSD and panic disorder with agoraphobia. Her total CAPS score was 7, her total ETI score was. On axis II she fulfilled criteria for BPD as well as avoidant personality disorder. She had a history of suicide attempts, self-injurious behaviour, and severe emotional instability. When the trauma was read to this patient, she displayed an intense emotional reaction, and a moderate increase in heart rate. While listening to the abandonment she dissociated. She had the impression that things were moving in slow motion, that things seemed to be unreal to her, and that she was watching the situation as an observer. She felt disconnected from her own body and the sense of her own body felt changed. During this period her heart rate fell by 7 bpm and her diastolic blood pressure by mmhg (see Figure ). After termination of the imagination period the dissociative state lasted for a few more minutes after which the psychophysiological measurements went back to baseline. Case This person was a -year-old Caucasian woman with Histrionic as well as Narcissistic Personality Disorder. Her traumatic experience consisted of an unwanted sexual experience when she was 5 years old. At the age of 7 years, she was sexually harassed by a male adult. During the diagnostic interview she cried frequently. She complained about feeling lonely and not being understood and she showed more than usual interest in the private life of the interviewer. During the diagnostic interview she revealed that she might have special abilities in understanding people, and that she performs better at work than other people. In the past, she fulfilled a past major depressive disorder, and dysthymia. Her CAPS score was, her ETI score 65. During the time of the study she fulfilled no axis I disorder, but she did fulfil axis II criteria for Histrionic and Narcissistic Personality Disorder. While she imagined the traumatic, the patient s heart rate and blood pressure increased largely. Both values returned to baseline quickly. During that period the patient showed a strong emotional reaction with loud crying, tremor, and rapid movements of her body. Right after starting Copyright John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 9, 7 76 ()

Individual Differences in Psychophysiological Reactivity 75.5.5.5 5 5 5 5 Ratings for Case (Histrionic PD) Psychophysiology for Case (Histrionic PD) PTSD SYMPTOMS Figure. Subjective ratings (top) and psychophysiological changes (bottom) for case. Rating scales from to ( D not at all, D worst ever) listening to the abandonment her heart rate increased again markedly for about min (see Figure ). Although she remained in an intense emotional state, her psychophysiological parameters returned to baseline rapidly. DISCUSSION The cases we present here were chosen to illustrate different behavioural and psychophysiological responses to stressful reminders in patients with trauma-related disorders including PTSD and personality disorders, such as Borderline and Histrionic Personality Disorder. All subjects had a history of childhood sexual or physical abuse. However, the four women revealed different reactivity to stressful s in terms of psychophysiological parameters and subjective ratings. These differences in reactivity to personalized stress-related s might be related to the clinical diagnosis. A PTSD patient (case ) with severe symptoms as indicated by a high CAPS score, was profoundly affected by the s and displayed strong psychophysiological reactivity. Her reaction was similar to those of other PTSD patients reported elsewhere (Blanchard & Buckley 999). In contrast to that, a woman with a history of severe abuse but no current trauma-related disorder (case ) did not show any strong emotional and psychophysiological reactions and was not overwhelmed emotionally by the procedure. Even though she had had a diagnosis of PTSD in the past, her reaction to stressful s revealed that the trauma memory had no strong emotional impact on her any longer. A patient (case ) with BPD and comorbid PTSD with a high CAPS score, initially showed a similar pattern to the patient with PTSD, but entered a severe dissociative state while listening to the describing an abandonment situation. During that time, her heart rate and blood pressure decreased significantly. A histrionic and narcissistic woman (case ) had a relatively low CAPS score. In contrast, her physiological reactions were as marked as those found in the PTSD patient, which was paralleled by high scores of the subjective ratings during the challenge. These four cases illustrate large individual differences in reaction to traumatic reminders. Although all four women had a history of physical and/or sexual abuse, their psychophysiological reactivity to traumatic reminders was not uniform. PTSD patients are generally characterized by a marked autonomic arousal following traumatic reminders. In contrast, dissociative symptoms, as observed in our BPD patient, seem to be related to a suppression of autonomic responses. Interestingly, subjects with high peri-traumatic dissociation also show a suppression of autonomic physiological responses within weeks after the trauma (Griffin, Resick, & Mechanic, 997). Dissociative reactions, which can occur both in PTSD and in BPD patients, may be one of the factors contributing to the divergent findings in physiological reactivity among PTSD patients to exposure to trauma cues (see Blanchard & Buckley, 999). The observed differences in psychophysiological reactivity could be partly explained by the idea of traumatic experiences leading to the development of various trauma-related psychiatric disorders, including certain personality disorders, Copyright John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 9, 7 76 ()

76 C. G. Schmahl, B. M. Elzinga and J. D. Bremner each with its own psychophysiological underpinnings. On the other hand, personality characteristics (e.g. histrionic features) might also affect the processing of traumatic experiences, thereby influencing emotional and psychophysiological reactions to traumatic reminders. So far, these factors have practically been left unnoticed. Since traumatized patients contribute largely to inpatient and outpatient clinical populations and individual trauma-related psychopathology can vary largely, a differentiated analysis of the psychological and physiological sequelae of traumatic stress appears to be justified. In addition, more research concerning the role of personality in the development and maintenance of trauma-related disorders seems to be necessary. REFERENCES Beitchman, J.H., Zucker, K.J., Hood, J.E., dacosta, G.A., Akman, D., & Cassavia, E. (99). A review of the longterm effects of child sexual abuse.. Child Abuse and Neglect, 6, 8. Blake, D.D., Weathers, F.W., Nagy, L.M., Kaloupek, D.G., Charney, D.S., & Keane, T.M. (997). Clinician- Administered PTSD Scale for DSM-IV, current and lifetime version. West Haven, CT: National Center for Posttraumatic Stress Disorder, Boston. Blanchard, E.B., & Buckley, T.C. (999). Psychophysiological assessment of Posttraumatic Stress Disorder. In P.A. Saigh, & J.D. Bremner (Eds), Posttraumatic stress disorder: a comprehensive text (pp. 8 66). Boston: Allyn and Bacon. Bremner, J.D. (999). Acute and chronic responses to stress: Where do we go from here? (Editorial). American Journal of Psychiatry, 56, 9 5. Bremner, J.D., Krystal, J.H., Putnam, F., Southwick, S.M., Marmar, C., Charney, D.S., & Mazure, C.M. (998). Measurement of dissociative states with the Clinician Administered Dissociative States Scale (CADSS). Journal of Traumatic Stress,, 5 6. Bremner, J.D., Southwick, S.M., & Charney, D.S. (999). The neurobiology of posttraumatic stress disorder: An integration of animal and human research. In P.A. Saigh, & J.D. Bremner (Eds), Posttraumatic stress disorder: a comprehensive text (pp. ). Boston: Allyn and Bacon. Bremner, J.D., Vermetten, E., & Mazure, C.M. (). Development and preliminary psychometric properties of an instrument for the measurement of childhood trauma: The early trauma inventory. Depression and Anxiety,,. Brown, G.R., & Anderson, B. (99). Psychiatric morbidity in adult inpatients with histories of sexual and physical abuse. American Journal of Psychiatry, 8, 55 6. Griffin, M.G., Resick, P.A., & Mechanic, M.B. (997). Objective assessment of peritraumatic dissociation: psychophysiological indicators. American Journal of Psychiatry, 5, 8 88. Johnson, J.G., Cohen, P., Brown, J., Smailes, E.M., & Bernstein, D.P. (999). Childhood maltreatment increases risk for personality disorders during early childhood. Archives of General Psychiatry, 56, 6 66. Herpertz, S.C., Kunert, H.J., Schwenger, U.B., & Sass, H. (999). Affective responsiveness in borderline personality disorder: A psychophysiological approach. American Journal of Psychiatry, 56, 55 556. Southwick, S.M., Krystal, J.H., Morgan, C.A., Johnson, D., Nagy, L.M., Nicolaou, A., Heninger, G.R., & Charney, D.S. (99). Abnormal noradrenergic function in posttraumatic stress disorder. Archives of General Psychiatry, 5, 66 7. Spitzer, R.L., Williams, J.B.W., & Gibbon, M. (995). Structured Clinical Interview for DSM-IV (SCID). New York: New York State Psychiatric Institute, Biometrics Research. Zanarini, M.C., Frankenburg, F.R., Sickel, A.E., & Yong, L. (996). The diagnostic interview for DSM-IV personality disorders. Belmont,MA:McLeanHospital, Laboratory for the Study of Adult Development. Copyright John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 9, 7 76 ()