The Relationship between Childhood Trauma and Medically Self-Sabotaging Behaviors among Psychiatric Inpatients

Abstract

This study was designed to explore the relationship between five forms of childhood trauma and medically self-sabotaging behaviors (i.e., the intentional induction, exaggeration, and/or exacerbation of medical symptoms).
Using a cross-sectional sample of convenience, 120 psychiatric inpatients were surveyed about childhood sexual, physical, and emotional abuses, the witnessing of violence, and physical neglect, as well as 19 medically self-sabotaging behaviors (i.e., intentional behaviors that represent attempts to sabotage medical care).
As expected, in this sample there were high prevalence rates of trauma (62.5% emotional abuse, 58.3% witnessing of violence, 46.7% physical abuse, 37.5% sexual abuse, 28.3% physical neglect). Simple correlations demonstrated statistically significant relationships between sexual abuse and physical neglect and medically self-sabotaging behaviors. Using multiple regression analysis, only physical neglect remained a unique predictor of medically self-sabotaging behaviors.
These findings indicate that among psychiatric inpatients there appears to be a relationship between physical neglect in childhood and the generation of medically self-sabotaging behaviors in adulthood. Perhaps physical neglect in childhood contributes to the generation of somatic behaviors in adulthood for the purpose of eliciting caring responses from others.

Full text

INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 38(4) 469-479, 2008
THE RELATIONSHIP BETWEEN CHILDHOOD
TRAUMA AND MEDICALLY SELF-SABOTAGING
BEHAVIORS AMONG PSYCHIATRIC INPATIENTS
RANDY A. SANSONE, M.D.
Wright State University, Dayton, Ohio and
Kettering Medical Center, Ohio
MICHAEL W. WIEDERMAN, PH.D.
Columbia College, South Carolina
JAMIE S. MCLEAN, M.D.
Wright State University, Dayton, Ohio
ABSTRACT
Objective: This study was designed to explore the relationship between
five forms of childhood trauma and medically self-sabotaging behaviors
(i.e., the intentional induction, exaggeration, and/or exacerbation of medical
symptoms). Method: Using a cross-sectional sample of convenience, 120
psychiatric inpatients were surveyed about childhood sexual, physical, and
emotional abuses, the witnessing of violence, and physical neglect, as well
as 19 medically self-sabotaging behaviors (i.e., intentional behaviors that
represent attempts to sabotage medical care). Results: As expected, in this
sample there were high prevalence rates of trauma (62.5% emotional abuse,
58.3% witnessing of violence, 46.7% physical abuse, 37.5% sexual abuse,
28.3% physical neglect). Simple correlations demonstrated statistically
significant relationships between sexual abuse and physical neglect and
medically self-sabotaging behaviors. Using multiple regression analysis,
only physical neglect remained a unique predictor of medically self-sabo-
taging behaviors. Conclusions: These findings indicate that among psychi-
atric inpatients there appears to be a relationship between physical neglect
in childhood and the generation of medically self-sabotaging behaviors
in adulthood. Perhaps physical neglect in childhood contributes to the
469
Ó2009, Baywood Publishing Co., Inc.
doi: 10.2190/PM.38.4.f
http://baywood.com

generation of somatic behaviors in adulthood for the purpose of eliciting
caring responses from others.
(Int’l. J. Psychiatry in Medicine 2008;38:469-479)
Key Words: childhood trauma, physical neglect, medical self-sabotage
INTRODUCTION
In the empirical literature, childhood trauma appears to have recurrent correla-
tions with the emergence of multiple somatic symptoms in adulthood [1-5]. Not
surprisingly, the majority of studies have explored the relationship between
childhood sexual abuse and somatic effects in adulthood. For example, Walker
and colleagues [6] compared women with and without chronic pelvic pain; among
those with symptoms, there was a higher rate of childhood sexual abuse as well
as a significantly higher number of general somatic symptoms. In a small study
of psychiatric inpatients, Sansone and colleagues [7] found that participants
with histories of sexual abuse reported significantly higher levels of somatic
preoccupation. McLean and colleagues [8] compared women with childhood
sexual abuse to community controls, and found significantly higher rates of
somatization in the former cohort. Finally, Spitzer and colleagues [9] compared
patients with somatization disorder to those with depression; sexual abuse statis-
tically emerged as the only significant predictor of somatization disorder.
In addition to the relationship between childhood sexual abuse and multiple
somatic symptoms in adulthood, other forms of childhood maltreatment have
been explored in this regard. For example, compared with medical controls,
Brown, Schrag, and Trimble [10] found among patients with somatization
disorder a significantly higher prevalence of childhood emotional and physical
abuses. In addition, Spertus and colleagues [11] examined over 200 women in
a primary care setting and confirmed a relationship between emotional abuse
and neglect and the number of reported somatic symptoms.
Collectively, these preceding data strongly suggest that in various types of
populations (clinical/non-clinical, primary care/psychiatric, women/men), there
is an association between specific types of childhood trauma (i.e., sexual, physical,
emotional abuses) and multiple somatic symptoms in adulthood. This does not
necessarily imply direct causality, but rather that childhood trauma may be
one of several contributory factors to the development of somatic preoccupation
in adulthood.
Given the preceding associations between childhood trauma and somatic
symptoms in adulthood, it was hypothesized that there might be associa-
tions between various types of childhood trauma and medically self-sabotaging
behaviors (i.e., the intentional induction, exaggeration, and/or exacerbation of
470 / SANSONE, WIEDERMAN AND MCLEAN

medical symptoms) in adulthood. To expand on this concept, medically self-
sabotaging behaviors consist of patient behaviors that function to create
fictitious somatic symptoms, intentionally induce bona fide medical illness,
and/or exaggerate or exacerbate existing illness—that is, all behaviors that
intentionally sabotage effective medical care. Like the phenomena of somat-
ization disorder and somatic preoccupation that were described in the preceding
studies, medically self-sabotaging behaviors also result in the generation of
somatic symptoms. Like factitious disorder, physical symptoms are intentionally
generated—however, the functional nature of the symptoms is not necessarily
limited to the strict purpose of developing or maintaining a sick role. For
example, some of these behaviors and their functional purposes may be more
transient and fleeting in nature, rather than consolidated into an ongoing
role. Therefore, it is likely that factitious disorders are a subset of this broader
category of behaviors.
In addition to examining the relationships, if any, between various forms
of childhood trauma and medically self-sabotaging behaviors in adulthood, a
second focus of this study was to explore the possible role of borderline per-
sonality in mediating these relationships. In a previous report based on this data
set [12], it was found that scores on a commonly used measure of borderline
personality (i.e., the borderline personality scale of the Personality Diagnostic
Questionnaire-4 [13]) were related to higher scores on the measure of medically
self-sabotaging behaviors. Therefore, if any statistical relationships between
childhood trauma and medically self-sabotaging behaviors emerged, the plan
for further analyses was to examine the possible influence of borderline per-
sonality disorder.
METHOD
Participants
Participants were 47 male and 73 female psychiatric inpatients who were
being treated in an urban community hospital located in a mid-sized mid-western
city. All participants were under the care of one attending psychiatrist and 18 years
of age or older. Exclusion criteria were cognitive (e.g., psychosis, dementia),
medical, or intellectual impairment that would preclude the successful completion
of a survey. Of the 145 individuals approached, 120 agreed to participate, for a
response rate of 82.8%.
Respondents (N= 120) ranged in age from 18 to 74 years (Mean = 38.69,
SD = 11.74). With regard to race/ethnicity, 81.5% were White, 15.1% African
American, 2 Native American, 1 Asian, and 1 “Other.” As for the highest
level of completed education, 12.7% had not graduated high school, 35.6%
had completed high school, 35.6% some college coursework but not a degree,
9.3% college, and 6.8% graduate school.
CHILDHOOD TRAUMA AND PSYCHIATRIC INPATIENTS / 471

Procedure
A single investigator (JM) approached and recruited all participants during a
weekly visit to the psychiatric inpatient unit (i.e., a sample of convenience).
Following an explanation of the project, each participant was asked to complete
a 5-page research booklet that took approximately 15 minutes. The research
booklet contained:
a. a demographic query (e.g., age, sex, marital status, level of completed
education);
b. a brief author-developed (RAS) childhood trauma questionnaire; and
c. an author-developed (RAS) measure to assess medically self-sabotaging
behaviors.
Childhood Trauma
With regard to the assessment of childhood trauma, participants were asked if,
“Prior to the age of 12, did you ever experience...”:
a. “sexual abuse (i.e., any sexual activity against your will)”;
b. “physical abuse (i.e., any physical insult against you that would be con-
sidered inappropriate by either yourself or others and that left visible signs
of damage on your body either temporarily or permanently or caused pain
that persisted beyond the ‘punishment’)”;
c. “emotional abuse (i.e., verbal and nonverbal behaviors by another individual
that were purposefully intended to hurt and control you, not kid or tease
you)”;
d. “physical neglect (i.e., not having your basic life needs met)”; and
e. “witnessing violence (i.e., the first-hand observation of violence that did
not directly involve you).”
Response options were simply “yes” or “no.” This brief inquiry about childhood
trauma was elected in an effort to accommodate a busy inpatient treatment setting.
Medically Self-Sabotaging Behaviors
Medically self-sabotaging behaviors were assessed with the Medical Sabotage
Survey, a 19-item measure that was used in a previous study [14]. Items in
the survey are preceded by the statement, “Have you ever, intentionally or on
purpose, . . .” and include, “not taken a prescribed medication to hurt yourself;
exposed yourself to an infected person with the hopes of getting infected,
yourself; damaged yourself, on purpose, and sought medical treatment; not gone
for medical treatment, despite knowing that you need it, to purposefully hurt
yourself; created additional symptoms to attract the attention of a healthcare
provider,” and, “exaggerated physical symptoms to attract the attention of a
healthcare provider.” Individual items are seemingly face valid.
472 / SANSONE, WIEDERMAN AND MCLEAN

Participants were not paid for their participation in this project. Because
of the survey methodology, written consent was not indicated; rather, com-
pletion of the survey was assumed to be implied consent. This project was
approved by the Institutional Review Boards of both the community hospital
and the university.
RESULTS
Of the 120 respondents, 77.5% reported at least one childhood trauma. Specif-
ically, 75 (62.5%) indicated having experienced emotional abuse, 70 (58.3%)
indicated having witnessed violence, 56 (46.7%) indicated having experienced
physical abuse, 45 (37.5%) indicated having experienced sexual abuse, and 35
(28.3%) indicated having experienced physical neglect. As for total number
of different forms of childhood trauma experienced, 14.2% of respondents indi-
cated having experienced just one form of trauma, 15.0% indicated having
experienced two forms, 19.2% indicated having experienced three forms,
13.3% indicated having experienced four forms, and 15.8% indicated having
experienced all five forms of childhood trauma.
The mean scores on the measure of medically self-sabotaging behaviors as a
function of having experienced each form of childhood trauma are presented in
Table 1. Compared to those who did not experience abuse, respondents who
indicated sexual abuse reported a greater number of medically self-sabotaging
behaviors, as did respondents who indicated having experienced physical neglect.
The total number of different forms of childhood trauma experienced was not
statistically significantly related to scores on the measure of medically
self-sabotaging behaviors (r= .15, p< .12).
CHILDHOOD TRAUMA AND PSYCHIATRIC INPATIENTS / 473
Table 1. Mean Scores on the Measure of Medical Self-Sabotage
Behaviors as a Function of Having Experienced Each
Form of Childhood Trauma
Experienced Did not experience
Childhood trauma M(SD)M(SD)t(df)p<
Witnessed violence
Emotional abuse
Physical neglect
Physical abuse
Sexual abuse
2.81
2.57
4.06
2.71
3.53
(3.36)
(3.27)
5.32)
(3.61)
(4.41)
2.30
2.64
2.00
2.50
2.04
(4.14)
(4.37)
(2.59)
(3.81)
(3.10)
–0.75
0.10
–2.85
–0.32
–2.17
.48
.92
.01
.76
.05
Note: df = 1,118; pvalues are two-tailed.

Because childhood sexual abuse and physical neglect have been shown to be
correlated with borderline personality symptoms, could the observed relation-
ship between childhood sexual abuse and physical neglect and medically self-
sabotaging behaviors be due to borderline personality symptomatology? In other
words, perhaps these childhood abuses are related to medically self-sabotaging
behaviors simply because these forms of abuse are indicators of subsequent
borderline personality symptomatology, which in turn is predictive of medically
self-sabotaging behaviors. To test this possibility, a multiple regression analysis
was performed in which childhood sexual abuse, childhood physical neglect, and
scores on the measure of borderline personality symptomatology were simul-
taneously entered to predict scores on the measure of medically self-sabotaging
behaviors. The overall equation was statistically significant: Multiple R= .36,
F(3,115) = 5.85, p< .001. Importantly, sexual abuse (standardized coefficient =
.07, t= 0.72, p< .48) was no longer uniquely related to medically self-sabotaging
behaviors, whereas both physical neglect (standardized coefficient = .19, t= 2.04,
p< .05) and borderline personality symptomatology scores were (standardized
coefficient = .25, t= 2.80, p< .01).
To further investigate the relationship between childhood physical neglect
and subsequent medically self-sabotaging behaviors, possible relationships were
examined at the level of individual items on the latter measure. The results for
those six items that exhibited statistically significant (p< .05) relationships to
childhood physical neglect are presented in Table 2.
DISCUSSION
In this sample of psychiatric inpatients, findings indicate:
1. high rates of childhood trauma;
2. correlations between two types of childhood trauma (i.e., sexual abuse and
physical neglect) and medically self-sabotaging behaviors; and
3. using multiple regression analysis, that physical neglect and borderline
personality are uniquely predictive of medically self-sabotaging behaviors.
Trauma Profile
In this sample of 120 psychiatric inpatients, the prevalence of trauma was
expectedly high. As a comparison, using the identical measure for the assessment
of childhood trauma in an internal medicine outpatient population (N= 113),
the following percentages were determined: 46.0% emotional abuse, 41.6% the
witnessing of violence, 31.0% physical abuse; 21.2% sexual abuse; and 14.2%
physical neglect. Note that the prevalence rates for the five types of childhood
trauma are consistently higher in the present study sample, which is not surprising.
Simply put, higher levels of childhood trauma would be more likely to result in
psychiatric symptomatology, which would be more likely to be associated with a
474 / SANSONE, WIEDERMAN AND MCLEAN

psychiatric hospitalization—the setting for this study. However, the rates of
childhood trauma in the internal medicine setting are noteworthy, suggesting
the possibility of other contributory factors to psychopathology among the
present sample such as genetic predisposition, life stressors, lack of family/social
support, etc.
Childhood Abuses and Medically
Self-Sabotaging Behaviors
It was also found that both sexual abuse and physical neglect in childhood
demonstrated significant correlations with medically self-sabotaging behaviors.
That childhood sexual abuse contributes to the generation of medically self-
sabotaging behaviors echoes, to some degree, the literature reviewed in the
Introduction. However, the finding that physical neglect is a contributory factor
to medically self-sabotaging behaviors is a novel finding.
CHILDHOOD TRAUMA AND PSYCHIATRIC INPATIENTS / 475
Table 2. Percentages of Respondents Who Indicated Specific
Forms of Medically Self-Sabotaging Behavior as a Function of History
of Childhood Physical Neglect
Childhood
physical neglect
Have you ever, intentionally or on purpose...
Yes
(n= 35)
No
(n= 85) c2p<
Not taken a prescribed medication to hurt
yourself?
Exposed yourself to an infected person with
the hopes of getting infected yourself?
Not followed directions from a healthcare
provider to intentionally prolong an illness?
Tampered with medical equipment to cause
false readings?
Prevented wounds from healing?
Come into contact with something that you
are allergic to, to purposefully hurt yourself?
38.2%
14.3%
25.7%
11.4%
28.6%
8.6%
17.4%
3.5%
7.1%
2.4%
7.1%
1.2%
5.43
4.61
7.89
4.30
9.93
4.21
.05
.05
.01
.05
.01
.05
Note:df =1;pvalues are two-tailed.

In this study, both physical neglect and borderline personality evidenced
unique contributions to medically self-sabotaging behaviors. This finding seems
to partially confirm a previous concern—that childhood trauma heightens the
risk for borderline personality and, in turn, borderline personality contributes
to the generation of medically self-sabotaging behaviors. At the same time,
physical neglect remained a unique predictor, indicating a specific association
with medically self-sabotaging behaviors. To summarize, it appears that child-
hood physical neglect is an independent as well as mediated influence on the
development of medically self-sabotaging behaviors. Whether in these two
scenarios there is a different intent on the behalf of the individual is unknown,
but it is certainly worth exploring (i.e., do the physically neglected with versus
without borderline personality harbor different motives in their generation of
medically self-sabotaging behaviors?).
In examining the individual items on the Medical Sabotage Survey that
evidenced correlations with childhood physical neglect, each is clearly related to
the sabotage of one’s medical care (i.e., there appears to be little latitude for the
misinterpretation of these particular items). The most frequently acknowledged
behavior is related to medication noncompliance. It is important to emphasize
that medication noncompliance is related to a number of rationales including
cost, side effects, and the perception of illness. However, the endorsement of
this particular item was specific to “intentional” noncompliance for the pur-
pose of “hurting yourself.” The remaining items in Table 2 echo this focus on
“intentional hurt.”
The Role of Borderline Personality
In the context of borderline personality, physical neglect maintained a sig-
nificant association with medically self-sabotaging behaviors. This suggests
that within the dysfunctional family context of borderline personality, it may
not be possible for the child to have his/her essential needs addressed. Through
the development and maintenance of medically self-sabotaging behaviors,
borderline individuals may be able to successfully elicit caring responses from
unsuspecting others through the use of negative behaviors (in this case, somatic
symptoms rather than psychological symptoms such as self-cutting or
overdosing). While the healthcare provider may function as the primary source
of solicitation, such behaviors may also elicit caring responses from friends and
acquaintances.
In addition, given that borderline personality emerged in the multiple regression
equation as a unique predictor, one could readily posit that medically self-
sabotaging behaviors uniquely compliment the psychodynamics of this disorder.
Explicitly, borderline personality disorder is characterized by ongoing self-harm
behavior. Because medically self-sabotaging behaviors are likely to impede effec-
tive medical care, they may be functioning as self-injury equivalents. Therefore,
476 / SANSONE, WIEDERMAN AND MCLEAN

medically self-sabotaging behaviors may represent the borderline individual’s
characteristic behavioral pattern of self-destructive acting out (i.e., damaging
oneself, for example, by not taking prescribed medications).
Clinical Application of Findings
What do these findings tell us? They suggest that clinicians in primary care
settings need to be acutely attuned to the potential meaning of recurrent, illogical,
uncommon, and unusual medical symptoms. These types of symptom presen-
tations may be related to childhood trauma, which in turn may be linked with
borderline personality disorder. When these atypical types of symptoms are
present, the clinician may elect to undertake a conservative treatment approach
[15] and determine a means to facilitate a referral to mental health services.
Oftentimes, an emphasis on the need for stress management can be a useful
means of redirecting patients to mental healthcare. However, the treatment in
mental health settings of somatic patients with borderline personality disorder
has undergone limited study and there is little if any empirical data regarding
effective approaches, potential patient compliance with treatment, the effects of
psychotropic medications, or long-term outcomes.
Study Limitations
This study has a number of potential limitations. First, while the sample is
reasonable in size, it is somewhat small. Second, all measures in this study
were self-report in nature and subject to the inherent limitations of such
measures. Third, the measure used in this study for the assessment of childhood
trauma is not a standardized or validated one, but rather, one of expediency.
Fourth, there may have been selection bias in the recruitment of participants
(e.g., the determination of intellectual capacity was very informal and based
upon the recruiter’s initial encounter with the patient; there is no data regarding
those individuals who declined to participate, so it is unknown whether these
individuals differed in any meaningful way from the participant group).
CONCLUSIONS
This appears to be the first study to investigate relationships between various
forms of childhood trauma and medically self-sabotaging behaviors. In this study,
while two childhood traumas demonstrated statistically significant correlations
with medically self-sabotaging behaviors, only one (i.e., physical neglect) evid-
enced a continued relationship when analyzed with multiple regression analysis
that included the addition of borderline personality scores. In addition, borderline
personality scores predicted for medically self-sabotaging behaviors. The relation-
ship between physical neglect and medically self-sabotaging behaviors warrants
CHILDHOOD TRAUMA AND PSYCHIATRIC INPATIENTS / 477

further investigation, particularly with regard to which aspects of physical neglect
might account for these findings.
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Direct reprint requests to:
Randy A. Sansone, M.D.
Sycamore Primary Care Center
2115 Leiter Road
Miamisburg, OH 45342
e-mail: Randy.sansone@khnetwork.org
CHILDHOOD TRAUMA AND PSYCHIATRIC INPATIENTS / 479