Huh et al.

Annals of General Psychiatry 2014, 13:26

http://www.annals-general-psychiatry.com/content/13/1/26

PRIMARY RESEARCH Open Access

Childhood trauma and adult interpersonal

relationship problems in patients with depression
and anxiety disorders
Hyu Jung Huh1, Sun-Young Kim2, Jeong Jin Yu3 and Jeong-Ho Chae1,2*

Abstract
Introduction: Although a plethora of studies have delineated the relationship between childhood trauma and onset,
symptom severity, and course of depression and anxiety disorders, there has been little evidence that childhood trauma
may lead to interpersonal problems among adult patients with depression and anxiety disorders. Given the lack of prior
research in this area, we aimed to investigate characteristics of interpersonal problems in adult patients who had
suffered various types of abuse and neglect in childhood.
Methods: A total of 325 outpatients diagnosed with depression and anxiety disorders completed questionnaires on
socio-demographic variables, different forms of childhood trauma, and current interpersonal problems. The Childhood
Trauma Questionnaire (CTQ) was used to measure five different forms of childhood trauma (emotional abuse, emotional
neglect, physical abuse, physical neglect, and sexual abuse) and the short form of the Korean-Inventory of Interpersonal
Problems Circumplex Scale (KIIP-SC) was used to assess current interpersonal problems. We dichotomized patients into
two groups (abused and non-abused groups) based on CTQ score and investigated the relationship of five different
types of childhood trauma and interpersonal problems in adult patients with depression and anxiety disorders using
multiple regression analysis.
Result: Different types of childhood abuse and neglect appeared to have a significant influence on distinct symptom
dimensions such as depression, state-trait anxiety, and anxiety sensitivity. In the final regression model, emotional abuse,
emotional neglect, and sexual abuse during childhood were significantly associated with general interpersonal distress
and several specific areas of interpersonal problems in adulthood. No association was found between childhood physical
neglect and current general interpersonal distress.
Conclusion: Childhood emotional trauma has more influence on interpersonal problems in adult patients with
depression and anxiety disorders than childhood physical trauma. A history of childhood physical abuse is related to
dominant interpersonal patterns rather than submissive interpersonal patterns in adulthood. These findings provide
preliminary evidence that childhood trauma might substantially contribute to interpersonal problems in adulthood.
Keywords: Childhood trauma, Interpersonal relationship, Depression, Anxiety

* Correspondence: alberto@catholic.ac.kr
1
Department of Psychiatry, College of Medicine, Seoul St. Mary’s Hospital,
The Catholic University of Korea, 222 Banpodaero, Seocho-Gu, Seoul 137-701,
Republic of Korea
2
Laboratory of Emotion, Catholic Institute of Medical Science and Biolife
Industry, Seoul, Republic of Korea
Full list of author information is available at the end of the article

© 2014 Huh et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
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Background Given the paucity of research, the present study aims to

Many studies over the last 20 years have shown that child- investigate the association between different types of child-
hood trauma is related to the onset, symptom severity, hood trauma and interpersonal problem in adult patient
and course of depression and anxiety disorders [1-3]. Vari- with depression and anxiety disorders. Furthermore, the
ous types of childhood trauma have been demonstrated to present study seeks to clarify the specific interpersonal pat-
be associated with anxiety and depressive symptom sever- tern in different types of childhood trauma and neglect in
ity [4,5]. Although relationship between specific psycho- patients with depression and anxiety disorders.
pathology such as depression and anxiety and different
kinds of childhood traumatic events is still unclear, specific Methods
pathways from childhood trauma to psychopathology have Participant
been proposed in some theory. In cognitive-behavioral ap- During the 12-month study period between August 2012
proach, the type of emotion is influenced by thought and and July 2013, patients who firstly visited Mood and
belief contents activated by various types of childhood ex- Anxiety Disorders Unit at Seoul St. Mary's Hospital, The
perience [6]. For example, depression is considered to be Catholic University of Korea, and met the DSM-IV diag-
characterized by loss and self-deprecation, whereas anxiety nostic criteria for depressive and/or anxiety disorders were
is related with threat and danger [7,8]. Thus, specific types recruited consecutively. Diagnosis was conducted by a
of childhood trauma might cause specific symptoms in an psychiatrist (JHC) using semi-structured diagnostic inter-
individual with specific vulnerabilities [5]. views of the Mini-International Neuropsychiatric Inter-
In spite of a considerable body of literature on the rela- view (M.I.N.I.) [29]. Eligibility criteria included being 18–
tionship between childhood trauma and the various symp- 65 years of age and literate in Korean. Exclusion criteria
toms of depression and anxiety disorders, there were too included a lifetime diagnosis of psychotic disorder, bipolar
few studies which investigated how childhood trauma af- disorder, mental retardation, and any mental disorder due
fects on interpersonal problems in adults. Freud suggests to a general medical condition. We also excluded individ-
that relationship schemas or patterns can be defined as or- uals with significant personality disorders and/or medical
ganized representations of past behaviors and previous problems that would interfere with study participation.
experiences in relationships [9,10]. On the perspective of A total of 351 outpatients who met the inclusion and
cognitive-behavioral theory, various types of maladaptive exclusion criteria consented to participate in this study.
schematic representations of the self, world, and future are Restricting analyses to those who had completed all
activated by matching specific life experience [5]. Specific measures, the final sample included 325 patients. The
types of maladaptive schema might influence specific adult study procedure was approved by the institutional review
attachment style and interpersonal relationships [11]. Al- boards of the ethical committee of the Seoul St. Mary's
though these theories have a deep impact on many differ- Hospital at the Catholic University of Korea. This study
ent types of current psychotherapy, there were few clinical was in compliance with the Helsinki Declaration. Written
studies to support this position. Recently, a few studies have informed consent was obtained from the patient for the
suggested that survivors of childhood trauma may experi- publication of this report and any accompanying images.
ence lower relationship quality, intimacy dysfunction, and
social adjustment difficulties [12,13]. While most research Instruments
has focused on childhood sexual trauma in community Demographics and psychiatric symptoms
samples [14-16], relatively few studies have attempted to During clinical interviews, we asked patients about demo-
clarify the impact of various kinds of trauma such as emo- graphic information such as years of formal education,
tional or physical trauma on interpersonal problems in clin- marital status, and employment status.
ically ill patients [17]. Among the psychiatric symptoms, we assessed the par-
Much evidence suggests that relatively worse pretreat- ticipants' symptoms of depression, anxiety, and anxiety
ment social functioning is associated with earlier age of sensitivity using the Beck Depression Inventory (BDI) [30],
onset, higher levels of depressive symptoms, and lower the State-Trait Anxiety Inventory (STAI) [31], and Anxiety
remission rates after treatment [18-22]. Furthermore, Sensitivity Index-Revised (ASI-R) [32,33]. Korean versions
there is a lot of evidence that childhood trauma is a risk of BDI [34], STAI [35], and ASI-R [36] were all well
factor for more frequent recurrent episode, chronicity of validated.
depression, and suicidality [8,23-27]. Therefore, it is cru-
cial to investigate the relationship between childhood Childhood trauma
traumatic experiences and adult interpersonal and social Childhood abuse and neglect was assessed using the
functioning in order to find one of the mediating factors Childhood Trauma Questionnaire (CTQ) [37], a 28-item
between childhood trauma experiences and treatment out- self-report inventory assessing five types of trauma expe-
come in depression and anxiety disorders [28]. rienced as a child and a teenager: emotional, physical, and
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sexual abuse and emotional and physical neglect. Items behaviors as difficult or done too much on a 5-point scale
are rated on a 5-point frequency scale (1 = never true to (‘not at all’, ‘a little’, ‘moderately’, ‘quite a lot’, ‘a lot’).
5 = very often true) and summed to yield a total score The measure is based on a theoretical circumplex struc-
for each trauma, ranging from 5 to 25, with higher ture of interpersonal behavior and has received consider-
scores indicative of greater severity. The CTQ provides able research support on its structural validity [39-41]. It
three thresholds/cut-score (mild, moderate, and severe) yields global interpersonal distress, two dimensional
for each type of trauma. To minimize false identification of scores of dominance distress and affiliation distress,
trauma, moderate thresholds (>12 for emotional abuse, >9 and octant scores which indicate eight dimensions of
for physical abuse, >7 for sexual abuse, and >14 and >9 for interpersonal problems constituting a circumplex of
emotional and physical neglect, respectively) were used to personality: domineering/controlling (PA), vindictive/
dichotomize all scores (abused vs non-abused or neglected self-centered (BC), cold/distant(DE), socially inhibited
vs non-neglected) for descriptive purposes. We also de- (FG), nonassertive (HI), overly accommodating (JK),
fined emotional trauma (emotional abuse and emotional self-sacrificing (LM), and intrusive/needy (NO) [42].
neglect) and physical trauma (physical abuse and physical Figure 1 describes the circumplex structure of Inventory
neglect) as >21 emotional trauma and >18 physical trauma. of Interpersonal Problems.
Therefore, we used operational definition as non-abused vs To analyze the specific pattern of interpersonal problems
abused or non-neglected vs neglected group according to associated with childhood abuse and neglect, the following
the classification of CTQ scale scores. Korean version of formulas were used to calculate affiliation, dominance, and
CTQ was also validated [38]. length scores [43].
Affiliation ¼ LM þ 0:71ðNO þ JK Þ−0:71ðBC þ FGÞ−DE
Adulthood interpersonal problems
Dominance ¼pPA þ 0:71ðBC þ NOÞ−0:71ðFG ffi þ JK Þ−HI
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
Current interpersonal problems were assessed using the Length ¼ ðAffiliation2 þ Dominance2 Þ
short form of the Korean-Inventory of Interpersonal
Problems Circumplex Scale (KIIP-SC), a 40-item self- The affiliation score represents behavioral dimensions
report inventory assessing eight dimensions of interper- ranging from friendly to hostile, while the dominance
sonal problems. The respondents were asked to indicate score means behavioral patterns ranging from submis-
to what degree he or she experiences a set of 40 different sive to dominant attitudes in interpersonal relationships.

Figure 1 Inventory of Interpersonal problems circumplex subscales (Hardy AO et al, 2011).

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The length score is an indication of how exclusively one emotional neglect (82.9% vs 73.6%, p = 0.048) than those
experiences a specific interpersonal problem and also re- with anxiety disorders, while there were no significant
flects interpersonal rigidity [43,44]. The Korean version differences in physical neglect (80.6% vs 82.3%, p = 0.781)
of Inventory of the Interpersonal Problems Circumplex and sexual abuse in childhood (20.6% vs 15.6%, p = 0.259)
Scale (KIIP-SC) was also validated [45]. between patients with depressive disorder and those with
anxiety disorder. Patients with depressive disorder had sig-
Statistical analysis nificantly higher KIIP-SC scores (69.40 ± 24.02) than those
All statistical analyses were performed using the Statistical with anxiety disorder (60.90 ± 26.79) (p = 0.003).
Package for Social Sciences (SPSS) version 18.0 (SPSS Inc.,
Chicago, USA). To compare demographic and clinical
characteristics of the groups with and without childhood Demographic and clinical characteristics of the groups
trauma, we performed independent t tests for continuous with and without childhood trauma in adult patients with
variable and x2 tests for categorical variables. depression and anxiety disorders
Stepwise multiple regression analysis with backward Table 1 summarizes demographic and clinical characteris-
elimination was used to examine the effect of childhood tics of the groups with and without trauma in patients with
abuse and neglect on interpersonal problems in adult- depression and anxiety disorders. Younger patients re-
hood after controlling for age, educational level, scores ported higher levels of emotional abuse (33.73 ± 12.47 vs
of BDI and ASI-R, and other variables that were signifi- 38.13 ± 13.28, p = 0.011) and physical neglect (36.26 ±
cant in the bivariate analysis. 12.54 vs 40.69 ± 15.30, p = 0.039) than older patients. Pa-
Since we consider the possibility that the more depres- tients without a history of childhood emotional abuse were
sive or anxious patients tend to report greater interper- more likely to have an intact marriage than those with a
sonal problems due to cognitive distortions, we controlled history of childhood emotional abuse (27.1% vs 48.8%, p =
for BDI, ASI-R, and Trait Anxiety Inventory scores as co- 0.002). Lower levels of formal education (4.81 ± 1.38 vs
variates. Separate analyses were conducted for the KIIP-SC 5.19 ± 1.30, p = 0.049) and lower unemployment rates
total score, each eight dimensional subscore, KIIP-SC affili- (51.5% vs 35.1%, p = 0.028) were found among patients
ation, dominance, and length, which served as dependent with a history of childhood physical neglect than those
variables. The experience of childhood trauma and neglect without such a history.
served as an independent variable. BDI scores were significantly higher in patients with a
In addition, we divided patients as non-traumatized history of childhood emotional abuse (28.57 ± 11.60 vs
group, only emotional traumatized group, only physical 22.76 ± 12.06, p < 0.001), emotional neglect (25.57 ±
traumatized group, and both emotional and physical 12.08 vs 18.90 ± 11.16, p < 0.001), physical abuse (27.75 ±
traumatized group to analyze co-occurrence effect of 11.78 vs 21.95 ± 11.92, p < 0.001), and sexual abuse
childhood trauma. ANCOVA (analysis of covariance) (29.07 ± 12.26 vs 22.90 ± 11.87, p < 0.001) than in those
was used to compare four groups, controlling covariate without such a history. Patients with a history of child-
as BDI, ASI, and STAI. All results were considered sig- hood emotional abuse (60.73 ± 11.73 vs 56.43 ± 13.07.
nificant at p = 0.05, two-tailed. p = 0.008), emotional neglect (58.86 ± 12.01 vs 52.45 ±
14.51, p = 0.001), physical abuse (60.25.86 ± 11.42 vs
Results 55.60 ± 13.43, p < 0.001), and sexual abuse (61.33.86 ±
A total of 325 participating patients had the following 12.05 vs 56.05 ± 13.04, p = 0.007) had higher state anx-
principal diagnosis: 174 (53.5%) patients had depressive iety scores than those without such as history. Trait
disorders comprising major depressive disorder (N = 121), anxiety scores were also significantly higher in patients
dysthymic disorder (N = 3), and depressive disorder not with a history of childhood emotional abuse (63.56 ±
otherwise specified (NOS) (N = 50). The remaining 151 10.42 vs 57.49 ± 12.47, p < 0.001), emotional neglect
(46.5%) patients had anxiety disorders comprising panic (60.17 ± 11.83 vs 54.01 ± 12.72, p < 0.001), physical
disorder (N = 40), generalized anxiety disorder (N = 30), abuse (61.69 ± 10.45 vs 57.08 ± 12.88, p < 0.001), and
obsessive compulsive disorder (N = 20), posttraumatic sexual abuse (61.80 ± 10.91 vs 58.17 ± 12.49, p = 0.026)
stress disorder (N = 18), social anxiety disorder (N = 8), than in those without such a history. Similarly, patients
and anxiety disorder NOS (N = 35). Among them, 43 with a history of childhood emotional abuse (98.13 ±
(13.7%) were diagnosed as having both depressive and 34.43 vs 88.77 ± 34.47, p = 0.045), physical abuse
anxiety disorders. The mean (±SD) KIIP-SC score in all (100.13 ± 32.18 vs 86.45 ± 35.55, p < 0.001), physical
patients was 65.07 (±25.78). neglect (92.93 ± 34.67 vs 82.16 ± 33.10, p = 0.029), and
Patients with depressive disorder reported more child- sexual abuse (104.23 ± 33.85 vs 87.98 ± 34.09, p <
hood emotional abuse (30.1% vs 14.4%, p = 0.001) and 0.001) had higher ASI-R scores than those without such
physical abuse (45.1% vs 26.7%, p < 0.001) and childhood a history.
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Huh et al. Annals of General Psychiatry 2014, 13:26
Table 1 Demographic and clinical characteristics of the groups with childhood trauma and without childhood trauma in patients with depression and anxiety
disorders
Emotional abuse Emotional neglect Physical abuse Physical neglect Sexual abuse
Yes (n = 70) No (n = 255) Yes (n = 255) No (n = 70) Yes (n = 115) No (n = 210) Yes (n = 60) No (n = 265) Yes (n = 60) No (n = 265)
Age 33.73 ± 12.47 38.13 ± 13.28 36.67 ± 12.79 38.94 ± 14.34 35.65 ± 12.44 37.78 ± 13.51 36.26 ± 12.54 40.69 ± 15.30 39.92 ± 12.79 36.35 ± 13.22
0.011 0.239 0.155 0.039 0.056
Gender (female) 60.3% 39.7% 54.0% 59.2% 48.3% 57.9% 54.8% 51.6% 55.7% 53.9%
0.351 0.502 0.109 0.674 0.887
Educational years 4.86 ± 1.40 5.19 ± 1.30 5.06 ± 1.34 5.27 ± 1.29 5.18 ± 1.27 5.09 ± 1.34 5.19 ± 1.30 4.81 ± 1.38 4.90 ± 1.27 5.15 ± 1.34
0.080 0.240 0.559 0.049 0.178
Marital status (yes) 27.1% 48.8% 43.7% 46.2% 37.8% 48.0% 42.7% 45.8% 39.0% 44.6%
0.002 0.780 0.082 0.771 0.469
Employment status (yes) 50.0% 48.1% 48.0% 50.0% 54.8% 45.3% 51.5% 35.1% 41.8% 50.4%
0.788 0.785 0.128 0.028 0.299
Depression (BDI) 28.57 ± 11.60 22.76 ± 12.06 25.57 ± 12.08 18.90 ± 11.16 27.75 ± 11.78 21.95 ± 11.92 24.17 ± 12.21 23.50 ± 11.91 29.07 ± 12.26 22.90 ± 11.87
0.000 0.000 0.000 0.692 0.001
State anxiety (SAI) 60.73 ± 11.73 56.43 ± 13.07 58.86 ± 12.01 52.45 ± 14.51 60.25 ± 11.42 55.60 ± 13.43 57.78 ± 12.88 56.74 ± 13.30 61.33 ± 12.05 56.05 ± 13.04
0.008 0.001 0.001 0.336 0.007
Trait anxiety (TAI) 63.56 ± 10.42 57.49 ± 12.47 60.17 ± 11.83 54.01 ± 12.72 61.69 ± 10.45 57.08 ± 12.88 59.41 ± 11.89 56.74 ± 13.30 61.80 ± 10.91 58.17 ± 12.49
0.000 0.000 0.000 0.152 0.026
Anxiety-sensitivity (ASI-R) 98.13 ± 34.43 88.77 ± 34.47 92.38 ± 34.23 85.86 ± 37.20 100.13 ± 32.18 86.13 ± 35.64 92.68 ± 34.79 82.16 ± 33.10 104.23 ± 33.85 87.73 ± 34.18
0.045 0.182 0.000 0.029 0.001

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Effect of childhood abuse and neglect on interpersonal childhood physical neglect and those without such a
problems in adulthood history.
Table 2 shows the associations between different types In addition to general interpersonal distress, patients
of childhood trauma and KIIP-SC total score, two di- who had experienced sexual abuse in childhood were more
mensional scores of dominance distress and affiliation likely to be domineering/controlling (p < 0.001), overly ac-
distress, and octant scores after controlling for BDI, ASI-R, commodating (p = 0.031), self-sacrificing (p = 0.001), and
and Trait Anxiety Inventory scores and other demographic intrusive/needy (p = 0.013) than those without a history of
variables that were significantly related to a history of childhood sexual abuse.
childhood trauma. Affiliation distress scores were not related to any forms
A history of childhood emotional abuse (p = 0.041), of childhood abuse and neglect. However, patients with a
emotional neglect (p = 0.001), and sexual abuse (p = 0.010) history of physical (p = 0.006) or sexual abuse in child-
appeared to be associated with the KIIP-SC total score, hood (p = 0.005) were found to be in a more dominant
which represents general interpersonal problems. No position in interpersonal relationships than those with no
significant associations were found between a history of history of childhood physical abuse.
childhood physical abuse and physical neglect and the
KIIP-SC total score. Comparison of BDI, STAI, ASI-R, and adult interpersonal
Considering the octant scores of the KIIP-SC, patients problems by groups with co-occurrence or without co-
who had experienced childhood emotional abuse were occurrence of childhood emotional and physical trauma
more domineering/controlling (p < 0.001) and intrusive/ Tables 3 and 4 and Figures 2 and 3 summarize comparison
needy (p = 0.022) than those who had not experienced of BDI, STAI, ASI-R, and adult interpersonal problems
such maltreatment. Patients with a childhood history of by groups with co-occurrence or without co-occurrence of
emotional neglect were more likely to be domineering/ childhood emotional and physical trauma. All of the symp-
controlling (p < 0.001), nonassertive (p = 0.029), overly tom severity scores were significantly higher in patients with
accommodating (p = 0.003), self-sacrificing (p = 0.050), both emotional and physical trauma than non-traumatized
and intrusive/needy (p = 0.006) than those with no such group (p = 0.001 for BDI, p = 0.002 for SAI, p < 0.001 for
history. TAI, and p = 0.002 for ASI-R). Co-occurrence effect of emo-
Although no significant difference was found in the tional and physical trauma appeared only in state and trait
KIIP-SC total score between patients with a history of anxiety. State anxiety and trait anxiety scores were signifi-
physical abuse in childhood and those without such a cantly higher in patients with both emotional and physical
history, the former were more likely to be domineer- trauma than patients with only physical trauma (p = 0.002
ing/controlling (p = 0.001) and intrusive/needy (p = for SAI and p < 0.001 for TAI).
0.038) than the latter. There were no significant differ- Significant difference has appeared in KIIP-SC (p < 0.001),
ences in either the KIIP-SC total score or other sub- dominant/controlling (p = 0.001), socially inhibited (p <
scores of KIIP-SC between patients with a history of 0.001), non-assertive (p = 0.004), overly accommodating

Table 2 Effect of childhood abuse and neglect associated on adult interpersonal problems (adjusted by demographics
and psychiatric symptoms)
Emotional abuse Emotional neglect Physical abuse Physical neglect Sexual abuse
β(p value) β(p value) β(p value) β(p value) β(p value)
KIIP-SC 0.108(0.041) 0.178(0.001) 0.061(0.249) 0.033(0.528) 0.133(0.010)
Domineering/controlling (PA) 0.232(0.000) 0.211(0.000) 0.213(0.000) 0.016(0.795) 0.278(0.000)
Vindictive/self-centered (BC) 0.050(0.414) 0.106(0.075) 0.059(0.324) −0.023(0.700) 0.071(0.234)
Cold/distant (DE) 0.053(0.358) 0.071(0.210) 0.034(0.568) −0.039(0.488) 0.002(0.975)
Socially inhibited (FG) 0.080(0.155) 0.102(0.069) 0.024(0.666) 0.058(0.294) 0.076(0.170)
Nonassertive (HI) 0.018(0.747) 0.120(0.029) −0.089(0.105) 0.047(0.386) −0.039(0.474)
Overly accommodating (JK) 0.099(0.071) 0.160(0.003) 0.008(0.882) 0.049(0.366) 0.116(0.031)
Self-sacrificing (LM) 0.082(0.136) 0.107(0.050) 0.023(0.679) 0.053(0.335) 0.181(0.001)
Intrusive/needy (NO) 0.133(0.022) 0.159(0.006) 0.120(0.038) 0.022(0.705) 0.214(0.000)
Affiliation 0.038(0.548) 0.043(0.498) 0.004(0.946) 0.045(0.469) 0.116(0.059)
Dominance 0.084(0.162) −0.014(0.819) 0.164(0.006) −0.067(0.255) 0.166(0.005)
Length −0.055(0.365) 0.078(0.194) 0.012(0.837) 0.027(0.646) −0.073(0.223)
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Table 3 Comparison of BDI, STAI, and ASI-R by groups with co-occurrence or without co-occurrence of childhood
emotional and physical trauma
Emotional Physical Emotional Physical Emotional Physical Emotional Physical p value
trauma trauma trauma trauma trauma trauma trauma trauma
No No No Yes Yes No Yes Yes
n = 32 n = 73 n = 50 n = 170
Depression (BDI) 18.10 (±11.72) 19.49 (±11.93) 24.73 (±11.69) 26.74 (±11.65) 0.000
State anxiety (SAI) 50.58 (±13.05) 53.25 (±15.09) 59.18 (±11.78) 60.00 (±12.83) 0.000
Trait anxiety (TAI) 51.50 (±11.87) 54.49 (±12.91) 60.58 (±12.49) 61.63 (±10.83) 0.000
Anxiety-sensitivity 70.73 (±28.56) 89.16 (±37.66) 90.14 (±35.90) 95.34 (±32.85) 0.004
(ASI-R)

(p < 0.001), and self-sacrificing scores (p = 0.004) between patients, little evidence has been provided whether inter-
patients with history of both emotional and physical personal problems in adulthood originated from child-
trauma and patients with no history of childhood trauma. hood abuse and neglect. Furthermore, most of the studies
Co-occurrence effect was observed in general interper- about the effect of childhood trauma on interpersonal re-
sonal problem and dominant/controlling, non-assertive, lationships in adulthood have been done using community
and overly accommodating interpersonal pattern. KIIP-SC samples. To our best knowledge, there is only one study
total score (p = 0.001), dominant/controlling (p < 0.001), to investigate the characteristics of interpersonal patterns
and overly accommodating subscores (p = 0.004) were in 119 psychiatrically ill adult patients who experienced
higher in patients with both childhood emotional and various types of childhood trauma [17]. In feeling this
physical trauma than patients with only physical trauma. void, the present study examines the relationships between
Non-assertive subscore (p = 0.022) was lower in patients different types of childhood trauma and adult interper-
with both childhood emotional and physical trauma than sonal problems in a relatively large clinical sample. Below,
patients with only emotional trauma. we summarize our findings and discuss their limitations
and implications.
Discussion First of all, from a symptomatic perspective, depressive
Although childhood trauma has been extensively investi- symptoms, state-trait anxiety, and anxiety sensitivity are
gated on symptomatic perspectives in psychiatrically ill related to various types of childhood trauma, although a

Table 4 Comparison of adult interpersonal problems by groups with co-occurrence or without co-occurrence of childhood
emotional and physical trauma (mean ± standard error adjusted by demographics and psychiatric symptoms)
Emotional Physical Emotional Physical Emotional Physical Emotional Physical p value
trauma trauma trauma trauma trauma trauma trauma trauma
No No No Yes Yes No Yes Yes
n = 32 n = 73 n = 50 n = 170
KIIP-SC 50.38 (4.60) 57.86 (2.76) 72.41 (3.24) 68.85 (1.70) 0.000
Domineering/ 3.81 (0.68) 4.14 (0.47) 6.10 (0.55) 6.42 (0.286) 0.000
controlling (PA)
Vindictive/self- 5.24 (0.84) 5.10 (0.57) 7.11 (0.67) 6.51 (0.35) 0.067
centered (BC)
Cold/distant (DE) 6.65 (0.89) 6.84 (0.61) 8.95 (0.71) 8.23 (0.37) 0.059
Socially inhibited (FG) 5.46 (0.86) 8.21 (0.58) 10.34 (0.68) 9.21 (0.36) 0.000
Nonassertive (HI) 7.08 (0.80) 8.66 (0.54) 11.33 (0.64) 9.67 (0.36) 0.000
Overly 6.27 (0.77) 7.46 (0.52) 9.02 (0.61) 9.25 (0.32) 0.001
accommodating (JK)
Self-sacrificing (LM) 8.88 (0.68) 10.20 (0.46) 11.11 (0.54) 11.04 (0.28) 0.022
Intrusive/needy (NO) 7.00 (0.72) 7.27 (0.49) 8.47 (0.57) 8.51 (0.30) 0.074
Affiliation 4.06 (2.10) 4.35 (1.43) 2.19 (1.68) 4.29 (0.88) 0.725
Dominance −2.91 (1.74) −6.84 (1.18) −7.90 (1.39) −5.69 (0.73) 0.120
Length 10.35 (1.43) 13.90 (0.97) 14.00 (1.14) 14.07 (0.60) 0.120
Huh et al. Annals of General Psychiatry 2014, 13:26 Page 8 of 13
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Figure 2 Comparison of BDI, STAI, and ASI-R by groups with co-occurrence or without co-occurrence of childhood emotional and
physical trauma.

specific symptom dimension, especially anxiety sensitiv- anxiety were not significantly associated with childhood
ity, has different relationships with different types of physical neglect. There are at least two possible interpreta-
childhood trauma. tions of this finding. First, each type of childhood trauma
Based on the accumulated evidence, it is reasonable to is associated with a different component (e.g., physical,
assume that childhood trauma is an important risk fac- cognitive, behavioral) of anxiety and depression. Previous
tor for depression and anxiety disorders in adulthood factor analytic studies indicate that Anxiety Sensitivity Index
[3,46,47]. Adding to prior work, our findings show that (ASI) is comprised of three lower-order components
patients with a history of childhood trauma report sig- representing physical, psychological, and social con-
nificantly higher depression and anxiety symptom sever- cerns [32,50,51]. In contrast, the item content of the
ity than those without these experiences. In addition to State-Trait Anxiety Inventory (STAI) primarily refers
the symptom severity of depression and anxiety, child- to cognitive symptoms of anxiety [52].
hood trauma is known to be related with other import- Another possibility is that childhood trauma is differently
ant psychopathology such as dissociation, affecting age associated with specific symptom dimensions of depression
of onset, chronicity, and recurrence of anxiety/depressive and anxiety. A series of factor analyses to evaluate the
disorder. For this reason, several researchers have delin- STAI-T (trait anxiety) found that it is comprised of both
eated new concepts about trauma-related syndrome like an anxiety factor and a depression factor, but not specific
‘dissociative depression’ [48,49]. for anxiety [51,53]. Previous research has found that emo-
Anxiety sensitivity was significantly associated with tional neglect and psychological abuse during childhood
childhood physical neglect but not with childhood emo- have a stronger association with pure depression than
tional neglect, whereas depressive symptom and state-trait pure anxiety, whereas physical trauma during childhood
Huh et al. Annals of General Psychiatry 2014, 13:26 Page 9 of 13
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Figure 3 Comparison of adult interpersonal problems by groups with co-occurrence or without co-occurrence of childhood emotional
and physical trauma (mean ± standard error adjusted by demographics and psychiatric symptoms).

was associated only with anxious arousal [5]. Consist- Another important finding in this study is that childhood
ent with prior research, childhood emotional neglect abuse and neglect, especially emotional abuse, emotional
is significantly related to BDI and STAI scores, but not neglect, and sexual abuse, contributes to interpersonal
to ASI scores. Furthermore, childhood physical abuse problems in adult patients with depression and anxiety
and neglect is significantly associated with anxiety disorders. Patients with a history of emotional abuse,
sensitivity. neglect, or sexual abuse in childhood report more general
Huh et al. Annals of General Psychiatry 2014, 13:26 Page 10 of 13
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interpersonal distress than those without such a history. intrusive/needy interpersonal patterns. Therefore, childhood
Although patients with a history of childhood physical sexual abuse seems to have contrasting interpersonal pat-
abuse do not report higher levels of general interpersonal terns such as dominant and submissive attitude simultan-
distress, they report significantly higher levels of dominant/ eously. There are at least two possible interpretations of this
controlling and intrusive/needy interpersonal patterns than finding.
non-abused patients. However, childhood physical neglect One possibility is that childhood sexual abuse may
is not associated with any areas of interpersonal difficulty. involve both emotional and physical trauma. That is,
Extensive evidence suggests that childhood abuse can childhood sexual trauma is largely associated with ad-
lead to difficulty with intimate relationships later in life verse psychological, behavioral, and social consequences.
and the formation of a secure attachment [12,13,47,54,55]. Another interpretation is that sexually abused victims
Thus, it can be inferred that childhood trauma leads to tend to show some ambivalence about wanting to be close
problems with interpersonal relationships in adult pa- enough to others to obtain help but not wanting to be
tients. However, little has been demonstrated with a hurt [12,14,17]. Thus, our findings may reflect sexually
clinical sample of psychiatrically ill patients about the abused victims' ambivalent feelings toward others and
impact of the childhood trauma on interpersonal func- dominant or submissive attitude in interpersonal relations.
tioning in adulthood. Our study thus represents an im- Fifth, we found that patients who had experienced child-
portant addition to the literature. hood emotional neglect exhibited a wide range of interper-
Although the underlying mechanisms between childhood sonal problems like those with a history of childhood sexual
trauma, specific symptoms, and interpersonal problems are abuse. In addition to domineering/controlling and intrusive/
unclear, biological effect of trauma is the disturbance of the needy interpersonal problems, these patients reported
stress response systems, including the HPA axis and the nonassertive, overly accommodating, and self-sacrificing
CRF system. Increasing stress sensitivity would lower the interpersonal problems. Indeed, there is some evidence to
threshold to provoke depression and anxiety [56]. Regard- suggest that a history of childhood neglect, either physical
ing interpersonal relationship, childhood trauma can or emotional, is related to a lower prevalence of the wish
disrupt the development of attachment to others and for self-assertion [17].
reflective awareness of self and others [25]. It might lead to In a similar vein, previous research has suggested that
difficulty with interpersonal functioning. Furthermore, clin- childhood emotional neglect is closely related to later
ical characteristics such as earlier age of onset, chronicity, anhedonic depression [5]. Therefore, it might be possible
and more recurrent episodes of trauma-related depression that participants reporting childhood emotional neglect
might interrupt the interpersonal relationship because pa- tended to interpret their interpersonal situations nega-
tients with trauma-related depression suffered from illness tively. Future studies would be needed to further elabor-
for a longer period of their life [8,23-26]. ate on the findings of this study.
Third, all types of childhood trauma except physical neg- Finally, no association was found between childhood
lect have a significant influence on dominant/controlling physical neglect and adult interpersonal relationship prob-
and intrusive/needy interpersonal patterns. Items assessing lems. Our finding is inconsistent with previous studies
dominant/controlling and intrusive/needy patterns are re- showing that patients with a history of childhood physical
lated to aggressiveness; thus, these findings implicate that neglect are more likely to seek comfort and to have diffi-
victims of childhood trauma are at risk for abusive or trau- culty in self-assertion [17,61]. Because our results did not
matic relationships in adulthood. In other words, patients consider a dose-response relationship between childhood
who had experienced childhood trauma may attempt to trauma and interpersonal relationships in adulthood, more
resolve the emotional turmoil associated with traumatic research efforts would be required to address the relation-
events by organizing their interpersonal relationships in a ship between childhood physical neglect and later inter-
way that allows some degree of perceived control and at- personal relationships in more detail.
tempt to develop a sense of mastery by being the initiator Sixth, considering co-occurrence of various type of child-
of the potentially traumatic interactions [9,10,57]. It re- hood trauma, trait anxiety and state anxiety tend to be
mains for future research to inquire directly about the link more severe in patients with co-occurrence of emotional
between childhood trauma and later aggression and delin- and physical trauma than patients with only physical
quency [58-60]. trauma. Regarding adult interpersonal problem, general
Fourth, our findings suggest that childhood sexual abuse interpersonal distress and dominant/controlling and overly
is more strongly associated with diverse interpersonal accommodating interpersonal pattern were more frequent
problems in adulthood than other abusive trauma such as in patients with co-occurrence of emotional and physical
emotional and physical trauma. Patients who had experi- trauma than patients reporting only physical trauma. On
enced sexual abuse in childhood suffered from domineer- the other hand, non-assertive interpersonal problem sub-
ing/controlling, overly accommodating, self-sacrificing, and score appeared to be lower in patients with both types of
Huh et al. Annals of General Psychiatry 2014, 13:26 Page 11 of 13
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childhood trauma than patients with only emotional emotional abuse, emotional neglect, and sexual abuse
trauma. A lot of previous research suggested that child- in childhood contributed more to diverse interpersonal
hood physical abuse is related with interpersonal ag- problems in adulthood than did physical abuse and
gression or violent behavior [62,63]. Furthermore, there neglect in childhood. The present study provides pre-
is a possibility that patients with both physical and liminary evidence that childhood trauma has an adverse
emotional trauma inherit genes related with aggressive impact on interpersonal problems in adulthood. More
behavior from their parents [64,65]. Therefore, it might elaborate studies to delineate the relationship between
be possible that patients with both types of trauma have childhood trauma and later interpersonal relationships
more assertive attitude than patients with only emo- would be required in the future.
tional trauma by gene-environment interactions [66].
Several limitations are needed to be considered in the Competing interests
present study. First, although widely used and well vali- This research was supported by a grant from the Korea Research Foundation,
NRF-2012R1A1B3001314 and NRF-2006-2005152. The Korea Research
dated, CTQ and KIIP-SC are self-report measures which Foundation did not play further role in study design; in the collection, analysis,
may not always provide accurate information. Although and interpretation of data; in writing of the manuscript; or in the decision to
depressive and anxiety symptoms were used as control submit the paper for publication. Dr. J-H Chae has received research grant from
the Korea Research Foundation. All other authors declare that they have no
variables in the present study, it is possible that many conflict of interest.
patients might have distorted mental representations on
their interpersonal problems and traumatic memory due Authors' contributions
to depressive or anxiety symptoms. Moreover, recall re- HHJ performed the study by design of the study, analysis of data, and
ports might be biased because of age differences between writing of the papers. SYK contributed to data collection. JJY contributed to
theoretical interpretation and provided significant input on the manuscript.
the childhood trauma and the non-trauma groups. Sec- JHC contributed to design of the study, supervised the data collection, and
ond, because we did not analyze separately anxiety and provided significant input on the manuscript. All authors read and approved
depressive patients, it is possible that distinct patterns of the final manuscript.

interpersonal problems might exist depending on differ- Author details

ent symptom dimensions such as depression and anx- 1
Department of Psychiatry, College of Medicine, Seoul St. Mary’s Hospital,
iety. Further research would need to elaborate on the The Catholic University of Korea, 222 Banpodaero, Seocho-Gu, Seoul 137-701,
Republic of Korea. 2Laboratory of Emotion, Catholic Institute of Medical
distinctive interpersonal patterns between anxiety and Science and Biolife Industry, Seoul, Republic of Korea. 3Faculty of Education,
depressive disorder. Third, although childhood trauma is University of Tasmania, Hobart, Australia.
also known to be related with many other psychiatric
Received: 4 April 2014 Accepted: 2 September 2014
conditions such as dissociative disorders and borderline
personality, we could not consider the possibility of co-
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doi:10.1186/s12991-014-0026-y
Cite this article as: Huh et al.: Childhood trauma and adult interpersonal
relationship problems in patients with depression and anxiety disorders.
Annals of General Psychiatry 2014 13:26.

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