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Disorders of Extreme Stress (DESNOS) Symptoms Are Associated With Type and Severity of Interpersonal Trauma Exposure in a Sample of Healthy Young Women

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Childhood abuse and other developmentally adverse interpersonal traumas may put young adults at risk not only for posttraumatic stress disorder (PTSD) but also for impairment in affective, cognitive, biological, and relational self-regulation ("disorders of extreme stress not otherwise specified"; DESNOS). Structured clinical interviews with 345 sophomore college women, most of whom (84%) had experienced at least one traumatic event, indicated that the DESNOS syndrome was rare (1% prevalence), but DESNOS symptoms were reported by a majority of respondents. Controlling for PTSD and other anxiety or affective disorders, DESNOS symptom severity was associated with a history of single-incident interpersonal trauma and with more severe interpersonal trauma in a dose-response manner. Noninterpersonal trauma was associated with elevated prevalence of PTSD and dissociation but not with DESNOS severity. Study findings indicate that persistent posttraumatic problems with self-regulation warrant attention, even in relatively healthy young adult populations.
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Disorders of Extreme Stress
(DESNOS) Symptoms Are
Associated With Type and
Severity of Interpersonal
Trauma Exposure in a Sample
of Healthy Young Women
Julian D. Ford
University of Connecticut School of Medicine
Patricia Stockton
Stacey Kaltman
Bonnie L. Green
Georgetown University Medical Center
Childhood abuse and other developmentally adverse interpersonal traumas may
put young adults at risk not only for posttraumatic stress disorder (PTSD) but
also for impairment in affective, cognitive, biological, and relational self-
regulation (“disorders of extreme stress not otherwise specified”; DESNOS).
Structured clinical interviews with 345 sophomore college women, most of
whom (84%) had experienced at least one traumatic event, indicated that the
DESNOS syndrome was rare (1% prevalence), but DESNOS symptoms were
reported by a majority of respondents. Controlling for PTSD and other anxiety
or affective disorders, DESNOS symptom severity was associated with a history
of single-incident interpersonal trauma and with more severe interpersonal trauma
in a dose-response manner. Noninterpersonal trauma was associated with ele-
vated prevalence of PTSD and dissociation but not with DESNOS severity.
Study findings indicate that persistent posttraumatic problems with self-regulation
warrant attention, even in relatively healthy young adult populations.
Keywords: childhood interpersonal trauma; self-regulation; young adults
Exposure to traumatic events is prevalent and often has a profound and last-
ing impact. More than half of the general population report experiencing
Journal of Interpersonal
Violence
Volume 21 Number 11
November 2006 1399-1416
© 2006 Sage Publications
10.1177/0886260506292992
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1399
Authors’ Note: This research was supported in part by National Institute of Mental Health
Grants RO1 MH50332 (Bonnie L. Green, PI) and K23 MH01889-01A (Julian D. Ford, PI).
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trauma at some point in their life (Kessler, Sonnega, Bromet, Hughes, &
Nelson, 1995). Between 10% and 25% of people exposed to psychological
trauma develop posttraumatic stress disorder (PTSD), which can be debili-
tating (Breslau, Davis, & Andreski, 1995; Kessler et al., 1995). When trauma
occurs at critical ages or developmental transitions (Cicchetti & Rogosch,
2001) and involves abuse in the form of “betrayal” by caregivers (Freyd,
1994) or violation of self (Herman, 1992) or core values (e.g., war atroci-
ties; Michultka, Blanchard, & Kalous, 1998), the risk of PTSD in adulthood
is high. Interpersonal violence or violation in childhood is associated with
particularly high (i.e., 50%-75%) risk of PTSD in adolescence or adulthood
(Kessler et al., 1995).
Moreover, interpersonal trauma in childhood is associated with chronic
problems in adulthood with biological and affective self-regulation (DeBellis,
2001; Manly, Kim, Rogosch, & Cicchetti, 2001) that place survivors at risk
for chronic medical illness (e.g., cardiovascular, metabolic, immunologic,
obesity; Schnurr & Green, 2004). Infants and young children exposed to
interpersonal trauma are at risk for regulatory, attachment, anxiety, and
affective disorders in infancy and childhood (Scheeringa & Zeanah, 2001).
Adolescents who were exposed to interpersonal trauma in childhood are at
risk for internalizing (Mazza & Reynolds, 1999), externalizing (Ford,
2002), and substance use (Gordon, 2002) disorders. Adult survivors of child
abuse and family violence are at risk not only for PTSD (Duncan, Saunders,
Kilpatrick, Hanson, & Resnick, 1996) but also for heightened anxiety
(McCauley et al., 1997; Stein et al., 1996), depression and suicidality (Dube
et al., 2001; Duncan et al., 1996; Felitti et al., 1998; McCauley et al., 1997),
addiction (Duncan et al., 1996; Felitti et al., 1998; Gordon, 2002; McCauley
et al., 1997), personality disorders (Zlotnick, Mattia, & Zimmerman, 2001),
mental illness (Leverich et al., 2002; Lysaker, Meyer, Evans, Clements, &
Marks, 2001), and sexual disorders (Felitti et al., 1998). Adult survivors of
child abuse also are at risk for revictimization (Follette, Polusny, Bechtle,
& Naugle, 1996; Whitfield, Anda, Dube, & Felitti, 2003).
These complex posttraumatic impairments have been described as “disor-
ders of extreme stress not otherwise specified” (DESNOS) (Herman, 1992;
Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997; van der Kolk et al.,
1996). DESNOS has been assessed by structured interview (Pelcovitz et al.,
1997) in midlife and older adult community samples (Roth et al., 1997; van
der Kolk et al., 1996), in inpatient (Ford, 1999; Ford & Kidd, 1998) and
outpatient mental health (Roth et al., 1997; van der Kolk et al., 1996) and
substance abuse (Ford & Frisman, 2002) samples, and among homeless
adults (Ford & Frisman, 2002). DESNOS involves persistent alterations in
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seven aspects of self-regulation and psychosocial functioning following
exposure to traumatic stress: (a) affect and impulse regulation (i.e., persis-
tent distress, risky behavior or self-harm), (b) biological self-regulation (i.e.,
somatization—pain or physical symptoms or impairments that cannot be
fully medically explained), (c) attention or consciousness (i.e., dissociation),
(d) perception of perpetrator or perpetrators (e.g., idealization, preoccupa-
tion with revenge), (e) self-perception (e.g., self as damaged or ineffective,
profound shame or guilt), (f) relationships (e.g., inability to trust, revictim-
ization, avoidance of sexuality), and (g) systems of meaning or sustaining
beliefs (e.g., hopelessness, loss of faith).
DESNOS symptoms thus differ from PTSD’s symptoms of unwanted
memories (intrusive reexperiencing), excess arousal (hyperarousal and hyper-
vigilance), and conscious and automatic attempts to cope with these memories
and the excess arousal (avoidance and emotional numbing; American Psy-
chiatric Association, 1994). PTSD is an anxiety disorder, but DESNOS
involves a broader set of self-regulatory impairment that takes the form of
profound and enduring problems with overwhelming emotional distress,
periods of severe dissociation, loss of a basic sense of trust in relationships
and meaning in life, and chronic health problems that cannot be explained
by medical causes. This view of DESNOS as posttraumatic self-dysregulation
is consistent with findings which have been replicated with civilian clinical
samples (Roth et al., 1997; van der Kolk et al., 1996) and military clini-
cal samples (Ford, 1999) that DESNOS is most likely to occur following
(a) trauma in early childhood when many self capacities are formed or mal-
formed and (b) interpersonal violence or violation rather than noninterper-
sonal traumas such as serious accidents, disasters, or illnesses.
However, DESNOS has not been assessed among healthy young adults,
despite evidence that this relatively protected and resilient population may
be adversely affected by trauma exposure in childhood or adolescence (Green
et al., 2000; Krupnick et al., 2004; Lauterbach & Vrana, 2001; Scarpa et al.,
2002). Prior analyses with the present data set (Krupnick et al., 2004)
showed that exposure to interpersonal trauma in adolescence increased
young adults’ risk of Axis I diagnoses (including PTSD) and borderline
personality disorder (BPD) symptoms. BPD shares several features with
DESNOS, and the two syndromes were highly comorbid in a clinical sam-
ple of women (McLean & Gallop, 2003). Early childhood trauma exposure
was not examined in our prior studies, although it has been found to be pre-
dictive of both BPD and DESNOS (McLean & Gallop, 2003). Therefore,
the present study was designed to extend the research literature on DESNOS
and interpersonal trauma by examining the separate relationships of early
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childhood and adolescent interpersonal trauma on the risk of DESNOS in
healthy youth women. The rationale for restricting the sample to young adults
(who were not currently experiencing trauma) was that this enabled us to
examine the impact of childhood and adolescent trauma exposure in adult-
hood without the potential confound of exposure to trauma in adulthood.
Because studies have shown that repeated exposure to traumatic stressors is
associated with cumulative increases in the risk and severity of posttrau-
matic problems (Follette et al., 1996; Green et al., 2000; McCauley et al.,
1997; Whitfield et al., 2003), we also examined the association of DESNOS
with cumulative trauma exposure in two ways: (a) multiple incidents of
traumatic exposure (vs. a single trauma incident) and (b) multiple perpetra-
tors of interpersonal violence or violation (vs. one perpetrator).
We expected that clinically significant DESNOS would be rare in this
population but that the core features of DESNOS would occur with sufficient
frequency to determine if they were distinct from PTSD and other psychi-
atric disorders in their relationship to different types of past trauma expo-
sure. Based on the evidence summarized above, that DESNOS are the sequelae
of cumulative interpersonal trauma exposure in early childhood, we tested
the following primary hypothesis:
Hypothesis 1: The likelihood of meeting criteria for each DESNOS feature will
increase as the severity of trauma exposure increases successively from (a) no
past trauma, to (b) single-incident noninterpersonal trauma, to (c) single-incident
interpersonal trauma, to (d) ongoing (i.e., abuse) or multiple interpersonal trau-
mas by one perpetrator, and finally to (e) abuse by more than one perpetrator or
abuse plus one or more incidents of interpersonal trauma by another perpetrator.
Based on conflicting evidence that DESNOS may be either a complex
and severe form of PTSD (van der Kolk et al., 1996) or a syndrome distinct
from (although often comorbid with) PTSD and other anxiety and affective
disorders (Ford, 1999), we also tested the following hypothesis:
Hypothesis 2: DESNOS will be related to severity of trauma exposure independent
of the effects of (a) PTSD and (b) affective or other anxiety disorders.
Method
Sample and Procedure
As described in Green et al. (2000, 2001) and Krupnick et al. (2004), par-
ticipants were college women recruited via mailings sent to all sophomore
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women who were 24 years old or younger and were taking at least 9 credit
hours per semester at six colleges and universities in the Washington, D.C.,
area. The mailings were sent during four consecutive semesters during 2
successive years and included a detailed description of the study, an assur-
ance of confidentiality, and a packet of self-report questionnaires along
with a self-addressed, postage-paid envelope. A separate consent form was
provided for participants to indicate if they were interested in participating
in the next phase of the study. In total, 10,722 questionnaires were mailed
and 2,568 were returned (response rate = 24%). Of those returned, 65%
gave permission to be contacted for the next phase of the study if they met
study criteria. Approximately 700 women were interviewed by telephone to
screen for specific and mutually exclusive traumatic event exposure histo-
ries. From this second screening, 363 women were interviewed in person.
Women signed a separate consent form for the 2.5- to 3-hour interview and
were paid $25 for their time.
Interviewers were 6 women graduate clinical psychology students and 2
bachelor’s-level female research assistants. Interviewers were trained to
reliably conduct the Structured Clinical Interview for DSM-IV (SCID) and
the Structured Interview for Disorders of Extreme Stress (SIDES) for
DESNOS with training tapes, observation of skilled interviewers, practice
with feedback, and supervision with careful review of each interview.
Based on listwise deletion, 18 respondents were not included in the final
data sample because of missing data on one or more of the measures.
Excluded respondents did not differ from the 345 for whom analyses will
be reported on any demographic or study variables. Five participant sub-
groups were defined to reflect trauma severity based on a structured trauma
history interview (see below). Only events or experiences that met criteria
of the fourth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) for PTSD Criterion A were used to define participant
subgroups. Abuse was defined as sexual or physical assault occurring at
least five times by the same perpetrator within any 12-month period. For
children, age 11 years old or younger sexual assault had to be by an indi-
vidual at least 5 years older. At age 12 or older, unless the perpetrator was
a family member, sexual assault had to involve physical force or physical
threat (including a weapon) against the respondent’s will or while she was
helpless. Physical assault had to involve intentional harm by another person
that caused demonstrable injury, threat with a potentially lethal weapon, or
infliction of extreme pain (e.g., exposure to extremes of heat or cold).
Fights between peers younger than 12 and fights or assaults by siblings
were excluded.
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A no trauma (NT) subgroup (n= 56) included participants who reported
no past traumatic events on the screening questionnaire or in the subsequent
interview. A single-incident noninterpersonal (SNI) subgroup (n= 33) included
participants who reported one accidental injury or bereavement trauma (loss
of a family member or very close friend by homicide, suicide, or accident)
in childhood or adolescence and no other trauma events. A single-incident
interpersonal trauma (SIT) subgroup included participants (n= 76) who
reported a single incident of physical or sexual assault. An ongoing or mul-
tiple interpersonal trauma (OMIT) subgroup (n= 104) included participants
who reported past physical or sexual abuse, or multiple assaults, with only
one perpetrator. A cumulative abuse trauma (CAT) subgroup (n= 76) included
participants reporting past physical and/or sexual abuse by more than one
perpetrator (11%) or abuse by one perpetrator and at least one other incident
of interpersonal trauma by a different perpetrator (89%).
Measures
Stressful Life Events Screening Questionnaire (SLESQ). The 13-item
SLESQ (Goodman, Corcoran, Turner, Yuan, & Green, 1998) screens for
past Criterion A1 stressor events—“actual or threatened death or serious
injury, or a threat to the physical integrity of self or others” (American
Psychiatric Association, 1994, p. 427)—plus one item for traumatic loss.
SLESQ items do not assess Criterion A2 (reactions to exposure). The retest
correlation for number of events reported by a sample of 140 male and
female college students when the SLESQ was readministered 2 weeks after
a first testing was .89, and individual item kappa coefficients for retest reli-
ability ranged from .31 to 1.00 (Mdn = .73). Criterion validity was sup-
ported by a .77 correlation between the total number of events identified on
the SLESQ and in a face-to-face interview covering the same events, with
item kappas ranging from .26 to .90 (Mdn = .64).
SIDES. The SIDES (Pelcovitz et al., 1997) structured interview assesses
the presence of 48 symptoms by asking if the participant had experienced
the symptom “since the event or for as long as you can remember.” A total
score, seven subscale scores, and a dichotomous classification score (pre-
sent vs. absent) can be calculated using rules described by Pelcovitz et al.
(1997). The SIDES subscales correspond to the seven DESNOS features
described above. In this study, respondents in the NT and SNI groups had
no perpetrator, so the fourth SIDES subscale (Altered Perceptions of
Perpetrators) was not utilized. Pelcovitz et al. reported evidence of adequate
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interrater reliability and internal consistency for the SIDES total score and
subscale scores in community and clinical samples.
SCID-NP. Lifetime anxiety (including PTSD) and affective disorders
were assessed using the SCID (First, Spitzer, Gibbon, & Williams, 1996),
a structured interview that follows diagnostic criteria defined by the DSM-
IV of the American Psychiatric Association (1994). Reliability for diagno-
sis ratings was conducted on a sample of 52 interviews from this study in
which one interviewer conducted the interview and a second observed and
rated. Kappas for the reliability of the ratings for lifetime disorders were .81
for acute stress disorder, 1.00 for PTSD, .92 for major depressive disorder,
.78 for alcohol abuse, .79 for alcohol dependence, and .48 to 1.00 for all
other diagnoses.
Data Analyses
First, summary statistics, bivariate correlations of the SIDES subscales,
and comparisons of the prevalence of DESNOS subscales for respondents
with or without a history of PTSD were calculated. To test Hypothesis 1,
cross-tabulations and chi-square analyses were conducted to test the relative
likelihood of meeting criteria for PTSD and each DESNOS feature across all
five trauma subgroups. As a further test of Hypothesis 1, a series of logistic
regression analyses were conducted comparing pairs of trauma subgroups
on the relative likelihood of meeting criteria for PTSD and each DESNOS
feature. To test Hypothesis 2, we conducted a general linear model analysis
of variance (ANOVA) and subsequent analyses of covariance (ANCOVA) to
determine if different types of trauma exposure were associated with level of
DESNOS symptoms after controlling for the effects of lifetime diagnosis of
(a) PTSD and (b) any affective or other anxiety disorder.
Results
As expected, full DESNOS was rare (3 cases; <1% prevalence). Affect
dysregulation was the least commonly endorsed SIDES feature (Table 1).
Somatization, altered self-perceptions, and dissociation also were endorsed by
fewer than half the respondents. Alterations in relationships and sustaining
beliefs each was endorsed by about half the sample. The SIDES features were
moderately intercorrelated (Table 1), sharing up to 17% variance (r2). Affect
dysregulation and somatization were particularly distinct, sharing between 1%
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and 10% variance with each other subscale. Thus, although interrelated, the
DESNOS features were relatively independent of one another in this sample.
One in 9 (n= 38, 11%) respondents met criteria for lifetime (i.e., current
or past) PTSD diagnosis, comparable to prevalence figures reported for
women in community samples (Breslau et al., 1995; Kessler et al., 1995;
Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). The fact that this rel-
atively normative prevalence level was observed despite oversampling of
respondents with a trauma history may reflect the protective influence of
education on PTSD risk (Ullmann & Brecklin, 2002). The relatively low
proportion of the sample with retraumatization and chronicity most likely
reflects the sampling strategy, which was designed to oversample respon-
dents with a single trauma episode. More than one third (n= 125) of the
sample met criteria for lifetime affective (i.e., major depression, dysthymic
disorder) or other anxiety (i.e., panic, agoraphobia, social phobia, obsessive-
compulsive disorder, generalized anxiety disorder) disorders.
Although the low prevalence of full DESNOS does not permit us to
examine the convergence or divergence of full DESNOS and PTSD, bivari-
ate correlations showed that a history of PTSD was most strongly related to
altered self-perceptions and significantly, but less strongly, related to each
other DESNOS feature (Table 1). Cross-tabulations were done to compare
respondents for whom lifetime PTSD and each DESNOS subscale were
present or absent (Table 2). Concordance was particularly strong for the
least prevalent DESNOS features, affect dysregulation, somatization, and
altered self-perceptions. At least 80% of respondents showed a correspon-
dence between lifetime PTSD and each of these three DESNOS features.
The more prevalent DESNOS features frequently were discordant with
(i.e., occurred in the absence of) PTSD: dissociation (32% discordance) and
altered relationships and systems of meaning (42%-43% discordance).
Thus, although there is a great deal of overlap between PTSD and each
DESNOS feature, DESNOS features often occurred separately from PTSD
and may constitute distinct subclinical posttraumatic sequelae (Ford, 1999).
Cross-tabulations comparing the five trauma subgroups resulted in sta-
tistically significant differences in the likelihood of lifetime PTSD and each
DESNOS feature: χ2(df = 4) = 12.1-56.4, p <.015. As shown in Table 3, the
prevalence of lifetime PTSD was between 9% and 10% for the SNI, SIT,
and OMIT groups but 20% for the CAT group. In logistic regression analy-
ses testing the likelihood of PTSD, the NT, SNI, SIT, and OMIT groups did
not differ, but CAT participants were significantly more likely than OMIT
participants to meet PTSD diagnostic criteria (odds ratio, OR = 3.23, 95%
confidence interval, CI = 1.35-7.70), χ2(df = 2) = 6.9, p <.01.
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Table 1
Prevalence and Bivariate Correlations of DESNOS Subscales
Variable Prevalence (%) I II III V VI VII
I. SIDES affect dysregulation 8
II. SIDES somatization 17 .27***
III. SIDES dissociation 36 .19*** .28***
V. SIDES altered self-perception 25 .22*** .33*** .38***
VI. SIDES altered relationships 50 .10 .27*** .30*** .41***
VII. SIDES altered sustaining beliefs 47 .19*** .19*** .35*** .33*** .23***
Lifetime PTSD 11 .21*** .24*** .28*** .38*** .22*** .21***
Note: N= 334 for all variables (listwise deletion of missing data). SIDES = Structured Interview for Disorders of Extreme Stress; PTSD = posttrau-
matic stress disorder.
***p<.001, two-tailed.
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Affect dysregulation and somatization were the least frequently reported
DESNOS features overall (Table 3), showing a pattern of relationships to
the trauma groups similar to that of PTSD: no occurrences in the NT group,
low levels for the SNI, SIT, and OMIT groups (except that somatization
was reported by more than 20% of the OMIT group), and higher levels of
occurrence in the CAT group. Altered self-perceptions were also uncom-
mon but were most frequently reported by participants with an abuse
history (i.e., either OMIT or CAT). Dissociation, altered relationships, and
altered sustaining beliefs were relatively rare (but not absent) in the NT
group, more common in the SNI and SIT groups, and most often reported
by both the OMIT and CAT groups.
Logistic regression analyses comparing pairs of trauma groups sequen-
tially showed that the SNI group was more likely than the NT group to report
dissociation (OR = 4.00, 95% CI = 1.23-13.03), χ2(df = 1) = 5.3, p <.05. The
SNI and SIT groups did not differ significantly on any DESNOS feature.
The OMIT group was more likely than the SIT group to report dissociation
(OR = 1.98, 95% CI = 1.05-3.83), χ2(df = 1) = 4.5, p <.05, altered relation-
ships (OR = 2.08, 95% CI = 1.16-3.97), χ2(df = 1) = 6.1, p <.01, and altered
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Table 2
Co-Occurrence of Lifetime PTSD and Each DESNOS Feature
Lifetime Lifetime
DESNOS Subscale PTSD Absent PTSD Present
I. SIDES affect dysregulation Absent (%) 83 8
Present (%) 63
II. SIDES somatization Absent (%) 77 6
Present (%) 12 5
III. SIDES dissociation Absent (%) 60 3
Present (%) 29 8
V. SIDES altered self-perception Absent (%) 72 3
Present (%) 17 8
VI. SIDES altered relationships Absent (%) 48 2
Present (%) 41 9
VII. SIDES altered sustaining beliefs Absent (%) 50 3
Present (%) 39 8
SIDES symptom count M5.4 14.9
SD 5.7 7.7
Note: N= 345 for all variables based on listwise deletion of missing data. DESNOS = disor-
ders of extreme stress not otherwise specified; PTSD = posttraumatic stress disorder; SIDES =
Structured Interview for Disorders of Extreme Stress. Percentages in bold represent a dis-
crepancy between PTSD and the DESNOS feature.
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Table 3
Posttraumatic Stress Sequelae of Different Types of Trauma Exposure
V. Altered VII. Altered
I. Affect II. III. Self- VI. Altered Sustaining DESNOS
Lifetime PTSD Dysregulation % Somatization % Dissociation % Perception % Relations % Beliefs % Features% MSD
All respondents 11 8 17 36 25 50 47 7.2 5.4
No traumaa0 0 0 9 4 14 24 1.2 1.8
Single-incident noninterpersonal 9 3 12 30 9 27 42 3.4 3.4
traumab
Single-incident interpersonal 10 6 11 31 21 42 35 5.2 5.1
traumac
Ongoing/multiple interpersonal 10 9 21 47 33 65 54 8.2 7.3
traumad
Cumulative abuse traumac20 16 30 48 36 72 70 10.6 7.0
Note: DESNOS = disorders of extreme stress not otherwise specified; PTSD = posttraumatic stress disorder.
a. n= 56.
b. n= 33.
c. n= 76.
d. n= 104.
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sustaining beliefs (OR = 2.10, 95% CI = 1.19-4.02), χ2(df = 1) = 6.4, p <.01.
The CAT group was more likely than the OMIT group to report altered sus-
taining beliefs (OR = 1.92, 95% CI = 1.03-3.57), χ2(df = 1) = 4.3, p <.05.
The ANOVA comparing the five trauma groups on overall DESNOS
symptoms yielded a significant finding, F(4, 340) = 26.2, p<.001. Post hoc
Tukey honestly significant difference tests (p<.05) showed that the CAT
and OMIT groups did not differ from each other (Table 3) but had higher
levels of DESNOS symptoms than the SIT, SNI, and NT groups. In addition,
the SIT group’s mean level of DESNOS symptoms was greater than that for
the NT group. The SIT and SNI groups were comparable, as were the SNI
and NT groups. The ANCOVA comparing the five trauma groups on the
number of DESNOS symptoms while controlling for the presence of a life-
time PTSD or other Axis I psychiatric disorder also produced a significant
finding, F(4, 338) = 12.0, p<.001. The adjusted mean numbers of DESNOS
symptoms still were comparable and significantly higher for CAT (8.7) and
OMIT (7.8) than for SIT (5.6), SNI (4.3), and NT (3.1). SIT participants had
significantly more DESNOS symptoms than NT participants, whereas the
SNI group was comparable to both the SIT and NT participants.
Discussion
Our results suggest that well-educated young women who experienced
trauma in childhood or adolescence—particularly as abuse or by multiple
perpetrators—may suffer from complex forms of posttraumatic biopsy-
chosocial dysregulation that are independent of either PTSD or other Axis I
psychiatric disorders. Independent of the effects of PTSD and other Axis I
psychiatric disorders, even a single incident of interpersonal trauma was suf-
ficient to be associated with elevated levels of DESNOS symptoms (com-
pared to no trauma), but a single incident of noninterpersonal trauma was
not. The finding that few respondents met all DESNOS criteria suggests that
posttraumatic dysregulation is not pervasive or debilitating for most of these
young, educated, and relatively resource-rich women even if they were sub-
jected to abuse or other interpersonal trauma earlier in their lives. However,
subclinical problems with self-regulation were common among these
women if they had experienced abuse or multiple perpetrator interpersonal
violence and more common if they had experienced even a single interper-
sonal assault than if they had no history of trauma.
Subclinical problems with self-regulation have been shown to occur and
cause impairment among young adults who have been exposed to childhood
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abuse (Miltenburg & Singer, 1999), especially following abuse by multiple
perpetrators (Cole-Detke & Kobak, 1998) or abuse combined with other
interpersonal trauma. There also is evidence that subthreshold PTSD is asso-
ciated with significant psychosocial (Stein, Walker, Hazen, & Forde, 1997)
and physical health (Schnurr & Green, 2004) impairment and that subclini-
cal psychiatric symptomatology is associated with both current impairment
and risk of future psychiatric morbidity (Katzelnick et al., 2001; Pearson
et al., 1999). Therefore, research is needed to determine if the DESNOS
symptomatology reported by many of the respondents is sufficient to cause
either current impairment or place them at risk of future clinically sig-
nificant problems. Prospective longitudinal follow-up studies also are
needed to determine if and for whom these self-regulatory problems persist
and if chronicity of DESNOS into and through adulthood is associated with
increasing psychosocial impairment—and if predictors of resilience and
recovery can be identified (Binder, McNiel, & Goldstone, 1996).
Our results suggest that interpersonal violence or violation (abuse) or
multiple interpersonal traumas each are more strongly associated with prob-
lems in self-regulation than either a single episode of noninterpersonal or
interpersonal trauma. This finding replicates results of prior studies of
DESNOS with other populations (Ford, 1999; Ford & Kidd, 1998; van der
Kolk et al., 1996) and is consistent with evidence that child abuse is asso-
ciated with serious biopsychosocial dysregulation (Cicchetti & Rogosch,
2001; DeBellis, 2001; Heim & Nemeroff, 2001; Kaufman, Plotsky, Nemeroff,
& Charney, 2000; Perry & Pollard, 1998). Our findings extend this research
literature by suggesting that this dysregulation may be present early in adult-
hood even among women who have sufficient resources and coping skills
(Binder et al., 1996) to be able to achieve ongoing college attendance.
The impact of persistent or repeated childhood or adolescent abuse is indi-
cated by the finding that the CAT subgroup reported the most DESNOS symp-
toms overall (although not significantly different from the OMIT group because
of substantial within-group variances). The CAT subgroup also was most likely
to have altered sustaining beliefs, had the highest prevalence of lifetime PTSD,
and was associated with high levels of the least common DESNOS features
(i.e., affect dysregulation, somatization). Thus, even among relatively resilient,
advantaged, and otherwise low-risk individuals, ongoing childhood interper-
sonal violence or violation appears to be associated with severe and persistent
forms of self-regulatory impairment (Cole-Detke & Kobak, 1998; DeBellis,
2001; Perry & Pollard, 1998; Scheeringa & Zeanah, 2001; Schore, 2001).
Although dissociation and PTSD were most common for women who
had experienced cumulative abuse, single-incident noninterpersonal or
Ford et al. / DESNOS Symptoms and Interpersonal Trauma 1411
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interpersonal traumas also were associated with an increased risk of both dis-
sociation and PTSD compared to no history of trauma. Thus, even a single
incident of accidental, illness-related, bereavement, or assault trauma may be
associated with PTSD and impairment in the regulation of consciousness.
However, single-incident trauma was associated with higher overall
DESNOS levels only if the trauma was interpersonal. Single-incident inter-
personal trauma was associated with higher likelihood of reporting several
specific DESNOS features (i.e., affect dysregulation, altered self-perceptions
and relationships), compared with noninterpersonal trauma or no trauma.
Interpersonal assault is prevalent in childhood and adolescence and is asso-
ciated with PTSD, depression, and substance abuse (Duncan et al., 1996).
Our findings add the possibility that interpersonal assault, even when it occurs
as a single incident, may be associated with lasting stress-related dysregula-
tion. This finding underscores the importance of developing and broadly
implementing effective violence prevention and social competence programs
for children and adolescents.
Generally, the DESNOS symptoms were not reported by respondents
with no trauma history, except for 1 in 4 who reported alterations in sus-
taining beliefs and about 1 in 10 who endorsed dissociation and altered
relationships. The substantial jump in the likelihood of reporting all of the
DESNOS features, especially dissociation, when even a single incident of
trauma had occurred and the still greater increase in prevalence when abuse
or multiple interpersonal trauma had occurred suggest that trauma (and not
just more routine stressors or developmental challenges) may cause other-
wise healthy and productive young women to suffer potentially problematic
self-regulatory difficulties. This finding replicates and extends prior results
from this data set that single-incident noninterpersonal trauma is associated
with functional impairment (Green et al., 2001).
Several limitations suggest caution in interpreting the findings. Trauma
history was assessed retrospectively and without external confirmation.
However, the presence and specific type of trauma was independently
determined by an intensive interview after first being identified with a com-
prehensive screening questionnaire (the SLESQ) that has shown good evi-
dence of reliability and validity with this (Green et al., 2000) and similar
(Goodman et al., 1998) populations. We did not examine the exact timing
of trauma in childhood or adolescence. Given evidence that the timing of
trauma in infancy (Scheeringa & Zeanah, 2001) and throughout childhood
and adolescence (Thornberry, Ireland, & Smith, 2001) may affect critical
outcomes, future studies should examine the effects of trauma’s timing and
the interpersonal and cumulative effects tested in this study.
1412 Journal of Interpersonal Violence
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The self-report interview measure used to assess DESNOS, the SIDES, has
shown evidence of reliability, but the criterion and construct validity of the
SIDES subscales are uncertain. Our finding that the SIDES subscales were
interrelated but largely distinct provides additional support for their validity
and for the syndromal coherence of DESNOS (Ford, 1999; Roth et al., 1997).
Findings from this socioeconomically advantaged sample of young
women cannot of course be generalized to men or to older or more disad-
vantaged populations. However, the study shows that DESNOS may be pre-
sent and be of concern even in a relatively healthy population and in the
populations in which trauma and psychopathology are more typically inves-
tigated (e.g., Follette et al., 1996; Ford, 1999; McGloin & Widom, 2001;
Stein et al., 1996; van der Kolk et al., 1996; Zlotnick et al., 2001).
Replication of the findings concerning DESNOS and trauma exposure is
warranted with other apparently psychologically healthy individuals for whom
stress reactivity may lead to impaired functioning (e.g., medically compro-
mised individuals; Schnurr & Green, 2004).
In conclusion, it appears that interpersonal trauma—and particularly
childhood and adolescent abuse—place even relatively advantaged and well-
functioning young women at risk for not only PTSD but also for stress-related
impairment in biopsychosocial self-regulation. The hierarchical dose-
response pattern of the relationship among no trauma, single-incident trau-
mas, and abuse with DESNOS severity was independent of other sequelae
of trauma, including PTSD (Cloitre, Scarvalone, & Difede, 1997) or affec-
tive or other anxiety disorders (Stein et al., 1996; Zlotnick et al., 2001).
Therefore, careful health care screening and interventions designed specif-
ically to address the adverse impact of interpersonal trauma in any form and
abuse in particular, and posttraumatic self-dysregulation (e.g., Cloitre, Koenen,
Cohen, & Han, 2002), are important not only with clinical populations but
also as approaches to secondary prevention with relatively low-risk groups
of apparently healthy and high-achieving youths or young adults.
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Julian D. Ford, PhD, is an associate professor in the Department of Psychiatry at the University
of Connecticut School of Medicine. His research interests include the etiology and effects on
physical and mental health and treatment outcome of complex posttraumatic stress disorder.
Patricia Stockton, PhD, is a health services researcher who has conducted studies of the
prevalence and treatment of mental disorders in community-based populations in both the
United Kingdom and the United States. As research assistant professor in the Division of
Psychosocial Research, Department of Psychiatry, Georgetown University Medical Center,
her recent work has focused on studies of traumatic stress in nonclinical populations and the
management of depression by community-based psychiatrists.
Stacey Kaltman is an assistant professor in the Department of Psychiatry, Georgetown
University School of Medicine. She is a licensed clinical psychologist and trauma researcher.
Currently, she is the co-PI of an National Institute of Mental Health-funded grant addressing
the development and evaluation of a novel posttraumatic stress disorder intervention for low-
income battered women.
Bonnie L. Green, PhD, is professor of psychiatry and director of research in the Department
of Psychiatry at Georgetown University Medical School in Washington, DC. Her recent focus
is the mental health needs of poor women with trauma histories who obtain health care in
primary care settings serving low-income patients.
1416 Journal of Interpersonal Violence
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... 5 In addition, individuals with ≥ 4 ACEs are 12 times more likely to attempt suicide than are individuals with zero ACEs. 1 Experiencing sustained, developmentally adverse events as a child puts survivors at risk as adults for both posttraumatic stress disorder (PTSD) and impairments in biological, affective, cognitive, and intra/interpersonal domains that PTSD diagnostic criteria do not fully address. 7 ese sequelae are known collectively as disorders of extreme stress not otherwise specified (DESNOS) and are related to: 1) emotions and impulses, 2) attention and consciousness, 3) self-perception, 4) relationships with others, 5) somatization, and 6) systems of meaning. 8 Although not all individuals with a history of ACEs experience complex trauma sequelae, many do. 1 e current standard of care is to treat individual conditions in isolated subspecialties (eg, cardiac conditions in cardiology, digestive issues in gastroenterology, anxiety and depression in mental health) without screening for and addressing complex trauma. ...
... We did not limit participants to those identified with PTSD because not all complex trauma survivors needing treatment meet diagnostic criteria. 7 After receiving a referral, a CTCP therapist contacted the member by phone to provide an overview of the pilot, discuss the risks and benefits of participation, answer questions, extend an invitation to participate, and complete the informed consent process. Individuals interested in participating were scheduled to meet individually with a CTCP therapist to discuss their complex trauma-related treatment needs and goals and to complete baseline symptom inventories. ...
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... Shame may be an especially important concept to better understand mental health outcomes following an experience of sexual violence. Evidence suggests that individuals exposed to interpersonal violence (e.g., sexual abuse, assault) reported greater shame compared to those exposed to non-interpersonal trauma (Ford et al., 2006). Relatedly, La Bash and Papa (2014) found that interpersonal trauma was indirectly related to PTSD symptoms via shame, but that shame was not an explanatory variable in the relation between other traumatic events (e.g., illness, natural disasters) and PTSD symptoms. ...
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... P r e p r i n t n o t p e e r r e v i e w e d At the start of this study, a validated diagnostic instrument adhering to the ICD-11 criteria for Complex PTSD was not available. Therefore, presence of Complex PTSD was assessed using the Structured Interview for Disorders of Extreme Stress (SIDES; Scorbodia, Ford, Lin, & Frisman, 2008), more specifically the 38-item version developed by Ford et al. (2006). This was the best available instrument to assess Complex PTSD severity at that time. ...
... Early stressors, particularly those that are traumatic, interpersonal, and chronic, are associated with greater rates of depression, anxiety, posttraumatic stress disorder (PTSD), suicidal behaviours, and substance use disorders (e.g. Carrion, Weems, Ray, & Reiss, 2002;Ford, Stockton, Kaltman, & Green, 2006;Widom, DuMont, & Czaja, 2007). Given the range of adverse life outcomes, exposure to ACEs is considered a transdiagnostic risk factor for various forms of psychopathology later in life (De Bellis & Zisk, 2014). ...
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Background It is unclear whether people with post-traumatic stress disorder (PTSD) and symptoms of complex PTSD due to childhood abuse need a treatment approach different from approaches in the PTSD treatment guidelines. Aims To determine whether a phase-based approach is more effective than an immediate trauma-focused approach in people with childhood-trauma related PTSD (Netherlands Trial Registry no.: NTR5991). Method Adults with PTSD following childhood abuse were randomly assigned to either a phase-based treatment condition (8 sessions of Skills Training in Affect and Interpersonal Regulation (STAIR), followed by 16 sessions of eye-movement desensitisation and reprocessing (EMDR) therapy; n = 57) or an immediately trauma-focused treatment condition (16 sessions of EMDR therapy; n = 64). Participants were assessed for symptoms of PTSD and complex PTSD, and other forms of psychopathology before, during and after treatment and at 3- and 6-month follow-ups. Results Data were analysed with linear mixed models. No significant differences between the two treatments on any variable at post-treatment or follow-up were found. Post-treatment, 68.8% no longer met PTSD diagnostic criteria. Self-reported PTSD symptoms significantly decreased for both STAIR–EMDR therapy ( d = 0.93) and EMDR therapy ( d = 1.54) from pre- to post-treatment assessment, without significant difference between the two conditions. No differences in drop-out rates between the conditions were found (STAIR–EMDR 22.8% v. EMDR 17.2%). No study-related adverse events occurred. Conclusions This study provides compelling support for the use of EMDR therapy alone for the treatment of PTSD due to childhood abuse as opposed to needing any preparatory intervention.
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Chapter
There is now ample evidence from the preclinical and clinical fields that early life trauma has both dramatic and long-lasting effects on neurobiological systems and functions that are involved in different forms of psychopathology as well as on health in general. To date, a comprehensive review of the recent research on the effects of early and later life trauma is lacking. This book fills an obvious gap in academic and clinical literature by providing reviews which summarize and synthesize these findings. Topics considered and discussed include the possible biological and neuropsychological effects of trauma at different epochs and their effect on health. This book will be essential reading for psychiatrists, clinical psychologists, mental health professionals, social workers, pediatricians and specialists in child development.
Article
The mental health difficulties of trauma survivors during the COVID-19 pandemic have been under-reported. This study explored the moderating role of trauma history and trauma type (interpersonal and non-interpersonal) in the association between COVID-19-related stressors and depression, anxiety, and stress. A sample of n = 321 participants ages 19 to 71 (M = 36.63, SD = 10.36) was recruited from across the United States through MTurk. Participants reported the number of COVID-19-related stressors, trauma history and psychological symptoms. Hierarchical multiple regression analyses, controlling for age, race, ethnicity, gender, education, and income levels, were used to determine (a) whether COVID-19-related stressors are associated with adverse mental health outcomes; (b) whether trauma history and (c) trauma type moderated this association. Results revealed significant interactions; for those with a trauma history, exposure to COVID-19-related stressors was associated with higher levels of depression (β = .21, p < .05) and anxiety (β = .19, p < .05). For those with a history of interpersonal trauma specifically, COVID-19-related stressors were associated with depression (β = .16, p < .05) more so than for those without a trauma history. These findings highlight the vulnerability of trauma survivors to the unprecedented COVID-19-related stress.
Chapter
This chapter reviews current research and internationally published guidance for conducting interviews with adult sexual assault victims and identifies key best practices to improve the interview process. Among the issues identified by practitioners, researchers, and victims, two of the overriding themes are victim empowerment and a climate of belief. Although police services internationally have special units, enhanced training for sexual assault investigations, and established multi-disciplinary efforts to make victims more comfortable with the process, attrition figures for sexual assault crimes remain high. This chapter will address the following questions: (1) What do victims need? (2) What challenges do investigators face? Answers include the need for a victim-centred and trauma-informed process, good interviewing practices, and having the appropriate mindset. To this end, training should address both attitudes and behavior, with incremental skill development. Recording interviews for evidentiary purposes is discussed as an alternative to written statements. The chapter concludes with suggestions for further research.
Article
This paper describes the clinical and research evidence for the importance of the relational context of posttraumatic stress disorder in young children. We review 17 studies that simultaneously assessed parental and child functioning following trauma. In many studies, despite limitations, an association between undesirable parental/family variables and maladaptive child outcomes has been consistently found. We present a model of the parental/family variables as moderators and vicarious traumatic agents for symptoms in young children. Also, a Compound Model is proposed, with three distinctive patterns of the parent—child relationship that impact on posttraumatic symptomatology in young children. Implications for clinical practice and research directions are discussed.
Article
Data regarding the development of a structured interview measuring alterations that may accompany extreme stress are presented. A list of 27 criteria often seen in response to extreme trauma and not addressed by DSM-IV criteria for posttraumatic stress disorder (PTSD) were generated based on a systematic review of the literature and a survey of 50 experts. A structured interview for disorders of extreme stress (SIDES) measuring the presence of these criteria was administered to 520 subjects as part of the DSM-IV PTSD field trials. Inter-rater reliability as measured by Kappa coefficients for lifetime Disorders of Extreme Stress was .81. Internal consistency using coefficient alpha ranged from .53 to .96. Results indicate that the SIDES is a useful tool for investigation of response to extremes stress.
Article
This article reviews attachment theory and research with high-risk maltreated samples. Evidence linking maltreatment to disorganized behavior in the Strange Situation and Adult Attachment Interview is presented. In addition, we review research linking disorganized attachment status in infants and adults to subsequent interpersonal difficulties. Together, research and theory suggest that the experience of abuse leaves victims vulnerable to lapses in organized behavior. These lapses may include violent or frightening experiences that disrupt close interpersonal relationships. Although individuals with disorganized attachment status are capable of organized behavior in most interpersonal contexts, situations involving high levels of interpersonal stress may increase vulnerability to lapses in self-regula- tion.
Article
Context Suicide is a leading cause of death in the United States, but identifying persons at risk is difficult. Thus, the US surgeon general has made suicide prevention a national priority. An expanding body of research suggests that childhood trauma and adverse experiences can lead to a variety of negative health outcomes, including attempted suicide among adolescents and adults.Objective To examine the relationship between the risk of suicide attempts and adverse childhood experiences and the number of such experiences (adverse childhood experiences [ACE] score).Design, Setting, and Participants A retrospective cohort study of 17 337 adult health maintenance organization members (54% female; mean [SD] age, 57 [15.3] years) who attended a primary care clinic in San Diego, Calif, within a 3-year period (1995-1997) and completed a survey about childhood abuse and household dysfunction, suicide attempts (including age at first attempt), and multiple other health-related issues.Main Outcome Measure Self-reported suicide attempts, compared by number of adverse childhood experiences, including emotional, physical, and sexual abuse; household substance abuse, mental illness, and incarceration; and parental domestic violence, separation, or divorce.Results The lifetime prevalence of having at least 1 suicide attempt was 3.8%. Adverse childhood experiences in any category increased the risk of attempted suicide 2- to 5-fold. The ACE score had a strong, graded relationship to attempted suicide during childhood/adolescence and adulthood (P<.001). Compared with persons with no such experiences (prevalence of attempted suicide, 1.1%), the adjusted odds ratio of ever attempting suicide among persons with 7 or more experiences (35.2%) was 31.1 (95% confidence interval, 20.6-47.1). Adjustment for illicit drug use, depressed affect, and self-reported alcoholism reduced the strength of the relationship between the ACE score and suicide attempts, suggesting partial mediation of the adverse childhood experience–suicide attempt relationship by these factors. The population-attributable risk fractions for 1 or more experiences were 67%, 64%, and 80% for lifetime, adult, and childhood/adolescent suicide attempts, respectively.Conclusions A powerful graded relationship exists between adverse childhood experiences and risk of attempted suicide throughout the life span. Alcoholism, depressed affect, and illicit drug use, which are strongly associated with such experiences, appear to partially mediate this relationship. Because estimates of the attributable risk fraction caused by these experiences were large, prevention of these experiences and the treatment of persons affected by them may lead to progress in suicide prevention.
Article
Background: Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated lifetime prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode.Methods: Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey.Results: The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years.Conclusions: Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
Article
Information about the relationship of experiencing abuse or witnessing domestic violence in childhood to the risk of intimate partner violence (IPV) in adulthood is scant. The relationship of childhood physical or sexual abuse or growing up with a battered mother to the risk of being a victim of IPV for women or a perpetrator for men was studied among 8,629 participants in the Adverse Childhood Experiences Study conducted in a large HMO. Each of the three violent childhood experiences increased the risk of victimization or perpetration of IPV approximately two-fold. A statistically significant graded relationship was found between the number of violent experiences and the risk of IPV. Among persons who had all three forms of violent childhood experiences, the risk of victimization and perpetration was increased 3.5-fold for women and 3.8-fold for men. These data suggest that as part of risk assessment for IPV in adults, screening for a history of childhood abuse or exposure to domestic violence is needed.
Article
This study validates a survey for community violence exposure, provides details of exposure in young adults, and determines psychological effects. 518 university students completed the Survey of Exposure to Community Violence (SECV) and questionnaires regarding trauma and socioemotional outcomes. Participants were divided into high, moderate, or low witnessing and victimization groups. Results showed SECV validity, with violent trauma more frequently reported in moderate/high victimization groups. 93.2% of respondents reported witnessing and 76.4% being victimized by violence. The most frequent events involved being hit, threatened, or seeing a gun/knife used as a weapon. The most frequent perpetrators were non-family members, except for domestic violence. The most frequent location was near home, although school was noted for peer victimization. High-exposure groups reported greater depression, aggression, interpersonal problems, and post-traumatic stress disorder symptoms. This replicates and extends previous findings on the prevalence of violence exposure and its negative effects in today's young adults.