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Social Psychiatry and Psychiatric Epidemiology

, Volume 42, Issue 11, pp 865–873 | Cite as

Childhood trauma history and dissociative experiences among Turkish men diagnosed with antisocial personality disorder

  • Umit B. Semiz
  • Cengiz Basoglu
  • Servet Ebrinc
  • Mesut Cetin
ORIGINAL PAPER

Abstract

Objective

This study investigated the association between antisocial personality disorder (APD), childhood trauma history, and dissociative symptoms in a sample of Turkish recruits.

Methods

A total of 579 male patients diagnosed with APD were examined in a military hospital setting. An age and gender matched control group of 599 normal persons with no known medical or psychiatric disorder were also chosen among military personnel. The subjects were evaluated with an assessment battery using a semi-structured interview for socio-demographic characteristics, APD section of SCID-II, an adapted version of the Structured Trauma Interview, and Dissociative Experiences Scale.

Results

Childhood sexual abuse, physical abuse, neglect, and early separation from parents were significantly more common among antisocial subjects than among controls. APD group reported significantly more dissociative symptoms and 50.4% of them reported pathological level of dissociation. Overwhelming childhood experiences of all four types were significant predictor of the APD diagnosis. Analyses also showed that childhood traumatic events and comorbid psychopathological features relevant to antisocial personality were significantly associated with pathological level of dissociation.

Conclusion

These results revealed the importance of inquiring about patient’s history of childhood traumatization and dissociative experiences when diagnosed with APD.

Keywords

antisocial personality disorder childhood trauma abuse dissociation 

Introduction

Antisocial personality disorder (APD) is a condition characterized by a pervasive pattern of poor social conformity, deceitfulness, impulsivity, criminality, and lack of remorse [1]. It has major public health implications in terms of its association with drug abuse, early unnatural death, violent crime, unemployment, homelessness, and family violence [53]. Epidemiological surveys have shown that APD is a common disorder, with a prevalence rate between 2 and 4% among community samples [42, 63], rising up to 80% among male prisoners [32]. APD is primarily a problem among younger persons because the prevalence rates of APD diminish with increasing age [63]. Research [65] indicates that men are two to eight times more likely to have APD than women. Antisocial persons who join the armed forces often have unsatisfactory experiences because of their inability to accept military authority and discipline [30, 64]. They are more likely than others to be absent without leave, court-martialed, or dishonorably discharged [7].

A number of environmental risk factors for APD have been elucidated [10] and there is growing evidence for substantial interaction of these factors in the etiology of the APD. These individuals’ pasts are often characterized by dysfunctional family structures, parental neglect and abuse, emotional deprivation, inconsistent disciplinary techniques, antisocial values, violent home life, and adverse neighborhoods [50]. It has proven that traumatic childhood experiences lead to or correlate with various forms of antisocial characteristics, such as conduct disorder [40], social maladjustment [51], substance abuse [41], aggressiveness [2], antisocial behavior [14, 49], delinquency, criminality, and violence behavior [82], low levels of empathy [51], depression [6, 24, 56], and suicidal ideation and suicide attempts [15]. Research using a prospective cohort design have shown that, by comparison with controls, abused and neglected children are more likely to be arrested [82], and are more likely to meet criteria for APD [49]. Abuse and poor parental care and associated trauma in childhood and adolescence have been found to be risk factors for APD in adult life [5, 14, 29, 36]. DSM-III-R also notes that child abuse is one of the predisposing factors of APD. Little is known about possible mechanisms underlying these associations. However, with so many antisocial individuals sharing similar backgrounds it is easy to conclude that early childhood trauma and adverse life experiences may play a role in the creation of APD.

Dissociation is primarily a response to overwhelming experiences, especially in childhood [73, 79]. Putnam [59] has suggested that aggressive, risk-taking behavior often occurs in the context of dissociative experiences, when individuals feel out of control and compelled to do something against their wills. Childhood trauma could be a precursor for dissociative tendencies, since higher dissociation levels have been found in victims reporting childhood abuse [66]. Research on the etiology of dissociation in adults has focused primarily on the impact of sexual abuse [58] and often involves female patients. However, the role of physical abuse [55] in the etiology of dissociation is also strongly emphasized and is sometimes found to be even more important than sexual abuse. Therefore, implication not only of childhood sexual abuse but also of other traumatic childhood experiences, including physical abuse, neglect, and early separation especially in male subjects needs to be investigated.

Until recently, there had been very few attempts to investigate how common dissociative experiences were in people with APD. The few studies conducted with formalized measures in violent and criminal populations [71, 72, 80] suggested that dissociative experiences were surprisingly common. The levels of pathological dissociation in these studies ranged from 9.5 to 49.0% [54]. Nevertheless, little research to date has empirically tested the association between childhood trauma and dissociative experiences in adults diagnosed with APD.

The primary focus of this article was to examine whether individuals diagnosed with APD as young adults were more likely to be exposed to traumatic experiences as children than individuals in a normal comparison group. Specifically, we proposed that patients with APD were more likely to have experienced childhood victimization of sexual abuse, physical abuse, neglect, and/or early separation than healthy control subjects. The second aim was to investigate the association between severity of dissociative symptoms and presence of childhood traumatic events and comorbid psychopathological features relevant to antisocial personality structure. Since childhood victims of trauma have shown greater levels of dissociative experiences, we also tested whether overwhelming childhood experiences have a predictive value in the level of adult dissociative symptoms among antisocial individuals.

Methods

Sample

We conducted a cross-sectional study of APD in recruits who were consecutively admitted to the outpatient psychiatric unit of a military, tertiary-care training hospital located in Istanbul, the greatest city of Turkey. Subjects were either referred for mental status examination because of their maladaptive and criminal behavior (stealing, fighting, injuring others, disobedience to superiors and disregard for rules) or consulted the psychiatrist at their own request with complaints of self-mutilation, suicidal tendencies or chronic conflict with their surroundings. All male citizens without an evident physical or mental illness are obliged to complete their military service in Turkey. Army service is required after 20 years of age and lasts for 15 months. Soldiers are not paid for military service. Criminal behavior of soldiers falls within the jurisdiction of a separate military court, and the request for a psychiatric opinion is common practice. Many of these antisocial subjects not adapt to the military profession should be discharged after psychiatric evaluation.

The study group included 579 male recruits who endorsed at least three of 15 conduct disorder criteria prior to age 15 and at least three of seven APD criteria since age 18. Data were collected and evaluated anonymously. After the study was described, subjects who agreed to participate signed a consent form indicating their willingness to participate.

According to chart review and unstructured clinical interview, they had no history or current symptoms of schizophrenia, schizoaffective disorder, bipolar I disorder, posttraumatic stress disorder, or an organic condition that could cause psychiatric symptoms. Subjects less than 18 years, those who suffered from severe cognitive impairments and severe physical illness were also excluded. However, patients with a current or past history of alcohol and substance abuse and impulse control disorder were not excluded from the study because it is frequently associated with APD. None of the participants in the sample had a history of combat exposure.

An age and gender matched healthy control group of 599 persons were chosen among the military personnel who were admitted for routine medical screening to other departments of the same hospital. They were not prescribed any psychotropic medication, nor did they have any history of psychiatric disorder or suicide attempt. The controls were interviewed with the same diagnostic instruments. After providing a complete description of the study, written informed consent was obtained from control subject as well.

Instruments

The subjects were evaluated with an assessment battery, administered by clinically experienced and trained psychiatrists. APD diagnosis was made using the Turkish version of the Structured Clinical Interview for DSM-III-R Personality Disorders [SCID-II; 74]. The section for APD was administered in this study. The Turkish version of this section has an inter-rater reliability of 0.95 (kappa) [16]. Additionally, reports from records and information by the soldier’s personal counselor were also included in the diagnostic process.

To gather information about the details of socio-demographic characteristics, a semi-structured interview was administered to all subjects.

An adapted version of the Structured Trauma Interview developed by Draijer [18] was used to investigate subjects’ childhood trauma history. It addresses childhood experiences proven to be risk factors for adult psychopathology (early separation from parents, parental dysfunction, parental physical aggression, and sexual abuse before age 16). Although the Structured Trauma Interview has been used in several studies [20], no data on its validity have been published yet. In the present study, inter-rater reliability of this interview (kappa) for the four childhood trauma types were 0.92 for physical abuse, 0.86 for sexual abuse, 0.88 for neglect, and 0.94 for early separation. The definitions and questions for each childhood trauma used in this interview form were as follows:

“Physical abuse” was defined as severe parental aggression, including recurrent and chronic forms of physical violence by parental figures that could have hurt the child physically. Questions asked to investigate whether the patients met the criteria for physical abuse were, “Sometimes parents hit their children as a disciplinary measure or because they lose their temper. If your parents wanted to punish you, what did they do? How often do you remember that your parents hit you? If you try to remember the occasions they hit you, which made the biggest impression on you?” Instances of culturally accepted physical punishment, such as gently twisting ears, pinching, or shaking were not rated as abusive.

“Sexual abuse” was defined as any pressure to engage in or any forced sexual contact before age 16, originally ranging from fondling to penetration. To assess whether participants met the criteria for sexual abuse, the following questions were asked: “Nowadays, it is clear that many people have had negative sexual experiences in their childhood. Do you know if something like this has happened to you?” If the answer was positive, the interviewer inquired about perpetrators, sexual activities, force or pressure, frequency, age at onset, and how upsetting these experiences were at the time.

“Neglect” was defined as parental dysfunction or unavailability resulting from recurrent illness, nervousness, depression, alcohol misuse, and use of sedatives. The patients in the present study were asked the following questions with regard to their father and mother, respectively: “Was your (step/adoptive) father/mother often ill? Was she nervous, tense? Was she depressed? Did she use a lot of alcohol? Did she use sedatives, as far as you know?” Answers were coded in a yes or no format. A total score for each parental figure was based on these questions.

“Early separation” was defined as the loss of, or separation from, a natural parent or caretaker by death, divorce, illness, foster care, or other reasons before age 12 during a period of at least 6 months.

Dissociative symptoms were assessed by using the Turkish version [86] of the Dissociative Experiences Scale [DES; 4]. It is a 28-item self-report scale that requires the individual to indicate on a scale ranging from 0 to 100 to what extent presented statements of dissociative experiences apply to them. The statements include experiences such as having done something without knowing when and how or finding oneself at a place without being able to recollect how one got there. Total scores are calculated by averaging the scores of the 28 items which refer to amnesia, depersonalization, derealization, absorption, and identity alteration. Typically, a score of 30 or higher is considered suggestive of severe or pathological dissociation. The DES was not designed to diagnose dissociative disorders per se and is generally used as a screening instrument. It has been used in hundreds of studies and is generally considered to have good reliability and clinical validity [11, 28]. The Turkish version of this widely used screening instrument has a reliability and validity as high as its original form [86].

Data Analyses

Clinical data were expressed as percentages or mean values ± standard deviation. Differences between groups with respect to the clinical variables were tested for significance with chi-square analyses and two-tailed t test when appropriate. Logistic regression was a suitable statistical technique for examining the effects of a predictor variable on a dichotomous-dependent variable (e.g., APD diagnosis or pathological level of dissociation). Statistical significance was set at 0.05. All analyses were carried out using the SPSS for Windows 10.0 program.

Results

Socio-demographic and clinical features of both APD and control group are presented in Table 1. There was no significant difference between groups in terms of age. APD group had lower educational (t = 8.1, P < 0.001) and socioeconomic (χ= 506.3, P < 0.001) level and higher rates of parental psychiatric illness (χ= 110.4, P < 0.001) than the control group. APD subjects suffered significantly grater rates of childhood physical abuse (χ= 88.4, P < 0.001), sexual abuse (χ= 39.5, P < 0.001), neglect (χ= 32.3, P < 0.001), and early separation (χ= 52.8, P < 0.001) as compared to controls. 60.8% of the APD group versus 37.4% of the control group had at least one type of traumatization (χ= 64.5, P < 0.001). With regard to the dissociative symptoms, APD subjects reported significantly higher DES scores than did the control group (32.6 ± 22.0 and 9.1 ± 5.7, respectively; t = 24.8, P < 0.001). As expected, subjects with APD had significantly higher rates of clinical features relevant to antisocial personality structure, including alcohol abuse (N = 209, 36.1%), substance abuse (N = 189, 32.6%), self-mutilating behavior (N = 334, 57.7%), suicide attempt (N = 76, 13.1%), violent crime (N = 183, 31.6%), sexual assault (N = 48, 8.3%), and a co-diagnosis of impulse control disorder (N = 201, 34.7%).
Table 1

Demographic Status and Clinical Characteristics of APD and Control Subjects

Sample characteristics

APD (N = 579)

Control (N = 599)

Analysis (χ2 or t)

P value

Age (Years ± SD)

22.0 ± 3.1

22.2 ± 3.9

1.1

0.25

Education (Years ± SD)

7.7 ± 3.3

9.4 ± 3.5

8.1

<0.001

Socioeconomic status

Low

374 (64.6%)

17 (2.8%)

506.3

<0.001

Moderate/high

205 (35.4%)

582 (97.2%)

 

Parental history of psychiatric disorder

193 (33.3%)

51 (8.5%)

110.4

<0.001

Childhood traumatic events

Childhood physical abuse

177 (30.5%)

53 (8.8%)

88.4

<0.001

Childhood sexual abuse

64 (11.1%)

12 (2%)

39.5

<0.001

Childhood neglect

140 (24.2%)

69 (11.5%)

32.3

<0.001

Early separation

229 (39.6%)

121 (20.2%)

52.8

<0.001

Any childhood traumatic event

352 (60.8%)

224 (37.4%)

64.5

<0.001

Dissociative Experiences Scale (Mean ± SD)

32.6 ± 22.0

9.1 ± 5.7

24.8

<0.001

Alcohol abuse

209 (36.1%)

51 (8.5%)

130.2

<0.001

Substance abuse

189 (32.6%)

0 (0%)

 

<0.001a

Self-mutilating behavior

334 (57.7%)

0 (0%)

 

<0.001a

Suicide attempt

76 (13.1%)

0 (0%)

 

<0.001a

Violent crime

183 (31.6%)

0 (0%)

 

<0.001a

Sexual assault

48 (8.3%)

0 (0%)

 

<0.001a

Impulse control disorder co-diagnosis

201 (34.7%)

0 (0%)

 

<0.001a

aFisher’s exact test

To explore whether childhood traumatization is predictive of APD diagnosis regardless of demographic characteristics and parental history of psychiatric disorder, logistic regression equation was estimated (Table 2). Dependent variable was group (that is, antisocial subjects versus healthy control subjects) while independent variables involved education, socioeconomic status, parental history of psychiatric disorder, and childhood traumatic experiences including physical abuse, sexual abuse, neglect, and early separation. The results of this logistic regression analysis indicate that childhood physical abuse, sexual abuse, neglect, and early separation altogether were significant predictors of the APD even when schooling, socioeconomic status, and parental psychiatric history were controlled for. Based on this analysis, which provides a more conservative test of the relationship between childhood trauma and adult APD, we generally revealed that the variables of childhood trauma significantly (χ= 705,73, df  = 7, P < 0.001) predict the APD (84.6% correct).
Table 2

Logistic Regression Predicting Antisocial Personality Disorder Diagnosis

Independent Variables

β coefficient

SE

Wald

95.0% C.I. for β coefficient

P value

Education

0.95

0.02

4.01

0.91–0.99

0.045

Socioeconomic status

.019

0.27

213.03

0.01–0.03

<0.001

Parental history of psychiatric disorder

3.83

0.23

35.11

2.45–5.97

<0.001

Early separation

1.99

0.19

12.93

1.37–2.90

<0.001

Childhood neglect

1.91

0.23

7.85

1.21–2.99

0.005

Childhood physical abuse

2.71

0.23

18.76

1.72–4.25

<0.001

Childhood sexual abuse

3.22

0.41

8.02

1.43–7.25

0.005

A total of 292 (50.4%) APD subjects reported pathological level of dissociation (that is, they scored 30 or higher on the DES). To test the association between level of dissociative symptoms and presence of childhood victimization and other comorbid psychopathological features relevant to antisocial personality structure, we assessed the rates of these clinical entities in 579 APD subjects with and without pathological level of dissociation. Our results indicated that the APD subjects with pathological level of dissociation constituted a clinically more severely ill group than those without pathological level of dissociation. With respect to the early trauma history, APD subjects with pathological level of dissociation suffered significantly more childhood physical abuse (χ = 41.6, P < 0.001), childhood neglect (χ = 6.8, P = 0.009), and early separation (χ = 32.4, P < 0.001) as well as any traumatic event (χ = 30.6, P < 0.001) than those with non-pathological dissociation levels. Furthermore, they had significantly greater rates of alcohol (χ = 21.2, P < 0.001) and substance abuse (χ = 35.6, P < 0.001), self-mutilating behavior (χ = 46.5, P < 0.001), suicide attempt (χ = 11.3, P = 0.001), violent crime (χ = 17.9, P < 0.001), and impulse control disorder co-diagnosis (χ = 21.6, P < 0.001). However, the two groups did not differ with respect to the history of childhood sexual abuse and any reported act of sexual assault (Table 3).
Table 3

Childhood Traumatic Events and Psychopathological Features in 579 APD Subjects with and without Pathological Level of Dissociation

Childhood traumatic events and psychopathological features

APD subjects with pathological level of dissociation

APD subjects without pathological dissociation

Analysis (χ2)

P value

Childhood physical abuse (N = 177)

125 (70.6%)

52 (29.4%)

41.6

<0.001

Childhood sexual abuse (N = 64)

39 (60.9%)

25 (39.1%)

3.2

0.075

Childhood neglect (N = 140)

84 (60%)

56 (40%)

6.8

0.009

Early separation (N = 229)

149 (64.1%)

80 (34.9%)

32.4

<0.001

Any childhood traumatic event (N = 352)

210 (59.7%)

142 (40.3%)

30.6

<0.001

Alcohol abuse (N = 209)

132 (63.2%)

77 (36.8%)

21.2

<0.001

Substance abuse (N = 189)

129 (68.3%)

60 (31.7%)

35.6

<0.001

Self-mutilating behavior (N = 334)

209 (62.6%)

125 (37.4%)

46.5

<0.001

Suicide attempt (N = 76)

52 (68.4%)

24 (31.6%)

11.3

0.001

Violent crime (N = 183)

116 (63.4%)

67 (36.6%)

17.9

<0.001

Sexual assault (N = 48)

28 (58.3%)

20 (41.7%)

1.7

0.19

Impulse control disorder co-diagnosis (N = 201)

128 (63.7%)

73 (36.3%)

21.6

<0.001

Since the presence of childhood trauma has previously been shown to be a relevant factor for high levels of dissociative experiences as well [20], we performed an additional logistic regression analysis which tested the predictive role of childhood victimization for pathological levels of dissociative symptoms in APD group (Table 4). Results of this analysis revealed that childhood physical abuse and early separation significantly predicted pathological levels of dissociation (67.0% correct; χ= 75.95, df  = 7, P < 0.001). No such effects were found for childhood sexual abuse (P = 0.69) or neglect (P = 0.53).
Table 4

Logistic Regression Predicting Pathological Level of Dissociation in APD Subjects

Independent Variables

β coefficient

SE

Wald

95.0% C.I. for β coefficient

P value

Education

0.92

0.03

8.02

0.87–0.97

0.005

Socioeconomic status

0.88

0.19

0.38

0.60–1.29

0.535

Parental history of psychiatric disorder

1.56

0.19

5.03

1.06–2.29

0.025

Early separation

1.86

0.19

10.56

1.28–2.71

0.001

Childhood neglect

1.15

0.21

0.44

0.75–1.76

0.505

Childhood physical abuse

2.65

0.21

20.65

1.74–4.04

<0.001

Childhood sexual abuse

0.90

0.30

0.12

0.49–1.63

0.731

Discussion

The first aim of this study was to find out whether childhood victimization is a typical feature of APD. For this purpose, we compared individuals with APD to healthy comparison subjects with respect to childhood physical abuse, sexual abuse, neglect, and early separation. Similar to prior reports, it was shown that the patients with APD reported significantly higher rates of childhood psychotraumatic events of all four types than did the controls. In several studies [34, 37, 62, 67, 70, 75, 83, 84], significant association was observed between development of APD and exposure to childhood physical and sexual abuse and/or neglect. It is not surprising, because many of these individuals grew up with neglectful and sometimes violent antisocial parents [65]. Haapasalo and Pokela [33] suggested that a trauma model is the most interesting theoretical approach in explaining the mechanism between childhood victimization and antisocial behavior. That 60.8% of our APD subjects had at least one type of childhood traumatization was consistent with many previous reports [21, 25, 81], which were predominantly conducted with prison populations and found an early childhood victimization rate between 40 and 68% among their samples. In a recent study [5] evaluated self-rated indices of sustained childhood abuse and neglect in an outpatient sample of well-characterized personality disorder subjects, childhood sexual and physical abuse were highlighted as predictors of both paranoid and antisocial personality disorders. We also revealed that childhood trauma was a significant predictor of the APD diagnosis, even when controls for a number of demographic and clinical characteristics were introduced. Our results thus contribute to the previous knowledge of the outcomes of childhood trauma and provide strong empirical support for childhood traumatization as an antecedent of APD in a different sample. Due to high rates of childhood abuse found in different settings of APD samples, we assume that childhood victimization of trauma will be a common precursor to APD. Although early childhood trauma is certainly not the only path to later APD, it appears to play a key role in the cycle of antisocial behavior [81].

Further psychosocial risk factor for antisocial behavior includes early separation from parents. Prolonged separation from the mother had been suggested to cause antisocial behavior in the child [9]. Loeber [48] found that the critical link was not the maternal bond, but the child’s need to bond with any significant adult. It has been theorized that depriving a young child of a significant emotional bond could damage his competence to form intimate and trusting relationships later in life, thereby failing to develop the appropriate emotional attachments to adult figures [7]. Lacking appropriate role models, the child learns to use aggression to solve disputes, and fails to develop empathy and concern for other individuals. Martens [51] suggested that traumatic experiences of a child might be linked to disorganized patterns of attachment, which cause aggressive, controlling, and conduct disordered behaviors contributing to the development of antisocial personality. It was shown that teenage boys who had experienced attachment difficulties early in life were three times more likely to commit violent crimes [45].

The present study’s findings on level and contributing effect of education and socioeconomic status in the APD agree with those of other studies which also report a low level of schooling and low socioeconomic status among individuals with aggressive and antisocial behavior [17, 43, 47]. The influence of the parents’ psychiatric history on developing child should also be taken into consideration to understand the relationship between childhood trauma and APD. Some abusive parents have been characterized as having general behavioral problems and psychological dysfunction [26, 85]. Previous research [3, 61] suggested that exposure to combat trauma might also play a role in the etiology of adult antisocial behavior in veteran populations. However, our study group consisted of only soldiers who had never experienced combat conditions.

The second aim of the study was to reveal whether the severity of dissociative symptoms was associated with the presence of each type of childhood trauma and comorbid psychopathological features relevant to antisocial personality structure. Results of this study suggested that the APD subjects with higher dissociation levels evidenced a more severe clinical profile in terms of several clinical features. Actually, pathological dissociation levels in APD subjects were significantly associated with higher rates of childhood traumatic experiences. APD subjects with pathological level of dissociation also suffered a significantly greater rate of alcohol and substance abuse, self-mutilation, suicide attempt, violent crime, and impulse control disorder co-diagnosis. Due to the possible increase in morbidity, mortality, criminality, and adverse behaviors, it is advisable that clinicians screen all patients with APD for high dissociation levels.

We also demonstrated a predictive role of childhood trauma (particularly physical abuse and early separation) for the severity of dissociative symptoms in APD subjects, half of whom reported pathological levels of dissociation. The evidence for a relationship between childhood traumatization and symptom severity on the DES found in the present study is similar to previous findings of greater trauma reports of patients with borderline personality disorder, a cluster B personality disorder [87]. Although dissociative phenomenon is accepted as an intrinsic component [88] and diagnostic feature [1] of borderline personality disorder, the importance of dissociation has not adequately emphasized among antisocial individuals. Researchers published several studies assessing the prevalence of dissociation in persons with criminal and violent behavior [13, 23, 27, 80]. Increased dissociation is reported with increased aggression and violence in a wide range of populations, including psychiatric inpatients [60] and outpatients [39], military veterans [68], college students [57], young mothers abused as children [22], and sexual [8], domestic violence [71], and homicide offenders [78]. A recent review [54] concluded that about one quarter of inmates report pathological levels of dissociative experiences. Amnesia for violent crime was frequent and reported in almost one-third of homicides [31, 44, 78].

In the present study, the strongest predictive relationship with pathological dissociation was found for physical abuse and, to a lesser degree, for early separation. Contrary to our expectation, childhood sexual abuse or neglect did not contribute to the level of dissociation. This result corroborates previous studies [13, 52, 55, 77], which revealed a significant association between dissociation and a history of physical abuse and failed to find this association with a history of sexual abuse among different samples. Why we did not demonstrate an association between childhood sexual abuse and dissociation, may be due to the fact that physical abuse is specifically more prevalent than sexual abuse in APD population. Supporting this, research data suggest that there may be differential associations between types of adverse childhood experiences and personality disorder diagnoses. In a longitudinal study of a community sample, Johnson et al. [38] found that documented childhood sexual abuse was associated with borderline personality disorder symptoms while documented physical abuse was associated with antisocial and depressive personality disorder symptoms. Contribution of early separation to higher levels of adult dissociation is a novel result in antisocial individuals. A similar relationship was reported in patients with dissociative disorders, which found that early separation from parents was significantly more often than in control patients with other axis I diagnoses but was as often in patients with cluster B personality disorders [19].

As a general rule, the higher the DES score, the more likely it is that the person has a dissociative disorder. However, it should not be overlooked that the DES is not a diagnostic instrument but a screening instrument. High scores on the DES do not prove that a person has a dissociative disorder; they only suggest that clinical assessment for dissociation is warranted. In a sample of 1,051 clinical subjects, only 17% of those scoring above 30 on the DES actually were reported to be diagnosed as dissociative identity disorder [11]. Although the current study’s aim is not to detect the rate of dissociative disorders among APD patients, the reported rate of 50.4% of APD group who scored beyond 30 on the DES in this study should be viewed critically, because individuals scoring higher than 30 on the DES are accepted as having dissociative experiences in pathological degree. Some authors [12, 76] have argued that the overwhelming superiority of women diagnosed with dissociative disorders could partly be due to males with dissociative disorders being funneled into the criminal justice system and their diagnoses missed. As the reason why multiple personality disorder is recognized so infrequently in the offender population, Lewis and Bard [46] suggest that so many of its characteristics are similar to the symptoms associated with APD. For example, amnesia for behaviors is dismissed as lying, fugue states appear to be attempts to evade justice; finding things in one’s possession looks like stealing; self-mutilation and suicide attempts seem manipulative; and the use of different names at different times and in different circumstances is interpreted as the conscious use of aliases in order to evade the law.

It must also be noted that a potential confound to the high dissociation levels found in this study may be the effects of restrictive nature of compulsory military service. It is possible, that living in restricting and stressful conditions due to military rules and discipline may exacerbate or possibly even induce dissociative symptoms. Supporting this, we recently revealed a positive correlation between severity of dissociative symptoms and length of service among soldiers [69]. Also, violent offenders given a community sentence have been found to be less violent and thus possibly less dissociative than those who are incarcerated [72].

Conclusions

Our results corroborate previous findings suggesting that traumatic childhood experiences are important components in the etiology of APD. Childhood trauma appears to contribute directly to APD diagnosis. It may be hypothesized that dissociative symptoms in APD patients develop as a defense against significant childhood trauma and persist into adulthood. The charm, glibness, lack of affect, and manipulation of others seen in antisocial individuals may mask consequences of past childhood trauma and dissociative symptoms. Understanding that the origins of some behavioral symptoms among antisocials may be the result of the trauma and subsequent dissociation could be critical to the diagnosis and treatment of behavioral disturbances in this group. The prevention of childhood trauma is a particularly important target for several reasons, because there is a strong association between childhood trauma and the development of APD in adult life. Different pathways from psychological trauma into APD should be examined in order to provide more insight that is required for the construction of more adequate treatment programs for antisocial patients with severe traumatic experiences.

Limitations

With respect to the study’s limitations, a clinical comparison group was not studied yet, therefore it remains unclear whether these findings are specific for APD. Unfortunately, in the present study it was also not possible to control for the presence of comorbid Axis II and some Axis I diagnoses, nor abusive experiences during adulthood that might have impact on dissociation. It is possible that some of our findings can be attributed to the presence of a diagnosis different from APD. The use of retrospective reporting of childhood traumatic events should also be noted as a limitation to our study, although a recent review of data collection in this way suggests that false negatives are seen at a substantial rate, but false positive reports are probably rare [35]. Our findings, of course, require replication in order to determine the strength and stability of the present results. Additional studies also investigating other comorbid diagnoses are needed to fully understand the predictive role of childhood traumatic events in developing of APD and dissociative symptoms in different settings.

References

  1. 1.
    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edn. APA, Washington, DCGoogle Scholar
  2. 2.
    Barnow S, Lucht M, Freyberger HJ (2001) Influence of punishment, emotional rejection, child abuse, and broken home on aggression in adolescence: an examination of aggressive adolescents in Germany. Psychopathology 34:167–173PubMedCrossRefGoogle Scholar
  3. 3.
    Barrett DH, Resnick HS, Foy DW, Dansky BS, Flanders WD, Stroup NE (1996) Combat exposure and adult psychosocial adjustment among U.S. Army veterans serving in Vietnam, 1965–1971. J Abnorm Psychol 105:575–581PubMedCrossRefGoogle Scholar
  4. 4.
    Bernstein EM, Putnam FW (1986) Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis 174:727–735PubMedCrossRefGoogle Scholar
  5. 5.
    Bierer LM, Yehuda R, Schmeidler J, Mitropoulou V, New AS, Silverman JM, Siever LJ (2003) Abuse and neglect in childhood: relationship to personality disorder diagnoses. CNS Spectr 8:737–754PubMedGoogle Scholar
  6. 6.
    Bifulco A, Brown GW, Adler Z (1991) Early sexual abuse and clinical depression in adult life. Br J Psychiatry 159:115–122PubMedGoogle Scholar
  7. 7.
    Black DW (2001) Antisocial Personality Disorder: The Forgotten patients of Psychiatry. Primary Psychiatry 8:30–81Google Scholar
  8. 8.
    Bourget D, Bradford JM (1995) Sex offenders who claim amnesia for their alleged offense. Bull Am Acad Psychiatry Law 23:299–307PubMedGoogle Scholar
  9. 9.
    Bowlby J (1946) Forty-Four Juvenile Thieves: Their Character and Home Life. Tindall and Cox, Baillere, UKGoogle Scholar
  10. 10.
    Cadoret R, O’Gorman T, Troughton E, Heywood E (1985) Alcoholism and antisocial personality: interrelationships, genetic, and environmental factors. Arch Gen Psychiatry 42:161–167PubMedGoogle Scholar
  11. 11.
    Carlson EB, Putnam FW, Ross CA, Torem M, Coons P, Dill DL, Loewenstein RJ, Braun BG (1993) Validity of the Dissociative Experiences Scale in screening for multiple personality disorder: a multicenter study. Am J Psychiatry 150:1030–1036PubMedGoogle Scholar
  12. 12.
    Carlson EB, Putnam FW (1993) An update on the Dissociative Experiences Scale. Dissociation 6:16–27Google Scholar
  13. 13.
    Carrion VG, Steiner H (2000) Trauma and dissociation in delinquent adolescents. J Am Acad Child Adolesc Psychiatry 39:353–359PubMedCrossRefGoogle Scholar
  14. 14.
    Chamberlain P, Moore KJ (2002) Chaos and trauma in the lives of adolescent females with antisocial behavior and delinquency. In: Geffner R, Greenwald R (eds) Trauma and juvenile delinquency: Theory, research, and interventions. The Haworth Press, Binghamton, NY, pp 79–108Google Scholar
  15. 15.
    Christoffersen M, Poulsen H, Nielsen A (2003) Attempted suicide among young people: risk factors in a prospective register based study of Danish people born in 1966. Acta Psychiatr Scand 108:350–358PubMedCrossRefGoogle Scholar
  16. 16.
    Coskunol H, Bagdiken I, Sorias S, Saygili R (1994) The reliability and validity of the SCID-II Turkish Version. Turkish J Psychology 9:26–29Google Scholar
  17. 17.
    Criss MM, Shaw DS (2005) Sibling Relationships as Contexts for Delinquency Training in Low-Income Families. J Fam Psychol 19:592–600PubMedCrossRefGoogle Scholar
  18. 18.
    Draijer N (1989) Structured Trauma Interview. Vrije Universiteit, Department of Psychiatry, AmsterdamGoogle Scholar
  19. 19.
    Draijer N, Boon S (1993) Trauma, dissociation and dissociative disorders. In: Boon S, Draijer N (eds), Multiple Personality in the Netherlands: A Study on Reliability and Validity of the Diagnosis. Swets & Zeitlinger, Amsterdam, pp 177–194Google Scholar
  20. 20.
    Draijer N, Langeland W (1999) Childhood trauma and perceived parental dysfunction in the etiology of dissociative symptoms in psychiatric inpatients. Am J Psychiatry 156:379–385PubMedGoogle Scholar
  21. 21.
    Dutton DG, Hart SD (1994) Evidence for long-term, specific effects of childhood abuse and neglect on criminal behavior in men. Int J Offender Ther Comp Criminol 36:129–137CrossRefGoogle Scholar
  22. 22.
    Egeland B, Susman-Stillman A (1996) Dissociation as a mediator of child abuse across generations. Child Abuse Negl 11:1123–1132CrossRefGoogle Scholar
  23. 23.
    Ellason JW, Ross CA (1999) Childhood trauma and dissociation in male sex offenders. Sex Addict Compulsivity 6:105–110CrossRefGoogle Scholar
  24. 24.
    Fergusson DM, Horwood J, Lynskey MT (1996) Childhood sexual abuse and psychiatric disorder in young adulthood: II. Psychiatric outcomes of childhood sexual abuse. J Am Acad Child Adolesc Psychiatry 34:1365–1374Google Scholar
  25. 25.
    Fondacaro KM, Holt JC, Powell TA (1999) Psychological impact of childhood sexual abuse on male inmates: The importance of perception. Child Abuse Negl 23:361–369PubMedCrossRefGoogle Scholar
  26. 26.
    Frick PJ, Lahey BB, Loeber R, Stouthamer-Loeber M, Green S, Hart E, Christ MAG, Hansen K (1992) Familiar risk factors to oppositional deviant disorder and conduct disorder: Parental psychopathology and maternal parenting. J Consult Clin Psychol 60:49–55PubMedCrossRefGoogle Scholar
  27. 27.
    Friedrich WN, Gerber PN, Koplin B, Davis M, Giese J, Mykelbust C, Franckowiak D (2001) Multimodal assessment of dissociation in adolescents: Inpatients and juvenile sex offenders. Sex Abuse 13:167–177PubMedCrossRefGoogle Scholar
  28. 28.
    Frischholz EJ, Braun BG, Sachs GR, Hopkins L, Shaeffer DM, Lewis J, Leavitt F, Pasquotto JN, Schwartz DR (1990) The Dissociative Experiences Scale: further replication and validation. Dissociation 3:151–153Google Scholar
  29. 29.
    Gibson LE, Holt JC, Fondacaro KM, Tang TS, Powell TA, Turbitt EL (1999) An examination of antecedent traumas and psychiatric comorbidity among male inmates with PTSD. J Trauma Stress 12:473–484PubMedCrossRefGoogle Scholar
  30. 30.
    Goodwin D, Guze S (1989) Psychiatric diagnosis, 4th edn. Oxford University Press, New YorkGoogle Scholar
  31. 31.
    Gudjonsson GH, Hannesdottir K, Petursson H (1999) The relationship between amnesia and crime: The role of personality. Pers Individ Differ 26:505–510CrossRefGoogle Scholar
  32. 32.
    Guze S (1976) Criminality and Psychiatric Disorders, Oxford University Press, New YorkGoogle Scholar
  33. 33.
    Haapasalo J, Pokela E (1999) Child rearing and child abuse: Antecedents of criminality. Aggression Viol Behav 4:107–127CrossRefGoogle Scholar
  34. 34.
    Haapasalo J, Kankkonen M (1997) Self-reported childhood abuse among sex and violent offenders. Arch Sex Behav 26:421–432PubMedCrossRefGoogle Scholar
  35. 35.
    Hardt J, Rutter M (2004) Validity of adult retrospective reports of adverse childhood experiences: review of the evidence. J Child Psychol Psychiatry 45:260–273PubMedCrossRefGoogle Scholar
  36. 36.
    Horwitz AV, Widom CS, McLaughlin J, White HR (2001) The impact of childhood abuse and neglect on adult mental health: A prospective study. J Health Soc Behav 42:184–202PubMedCrossRefGoogle Scholar
  37. 37.
    Johnson DM, Sheahan TC, Chard KM (2003) Personality disorders, coping strategies, and posttraumatic stress disorder in women with histories of childhood sexual abuse. J Child Sex Abus 12:19–39PubMedCrossRefGoogle Scholar
  38. 38.
    Johnson JG, Cohen P, Brown J, Smailes EM, Bernstein DP (1999) Childhood maltreatment increases risk for personality disorders during early adulthood. Arch Gen Psychiatry 56:600–606PubMedCrossRefGoogle Scholar
  39. 39.
    Kaplan ML, Erensaft M, Sanderson WC, Wetzler S, Foote B, Asnis GM (1998) Dissociative symptomatology and aggressive behavior. Compr Psychiatry 39:271–276PubMedCrossRefGoogle Scholar
  40. 40.
    Kelso J, Stewart MA (1983) Factors which predict the persistence of aggressive conduct disorder. J Child Psychol Psychiatry 24:77–86Google Scholar
  41. 41.
    Kendler K, Bulik S, Silberg J, Hettema J, Myers J, Prescott C (2000) Childhood sexual abuse and adult psychiatric and substance use disorders in women. Arch Gen Psychiatry 57:953–959PubMedCrossRefGoogle Scholar
  42. 42.
    Kessler RC, McGonagle KA, Zhao S (1994) Lifetime and twelve month prevalence of DSM-III-R psychiatric disorders in the United States–Results from the National Comorbidity Survey. Arch Gen Psychiatry 51:8–19PubMedGoogle Scholar
  43. 43.
    Kilgore K, Snyder J, Lentz C (2000) The contribution of parental discipline, parental monitoring, and school risk to early onset conduct problems in African American boys and girls. Dev Psychol 36:835–845PubMedCrossRefGoogle Scholar
  44. 44.
    Kopelman MD (1987) Crime and amnesia: A review. Behav Sci Law 5:323–342CrossRefGoogle Scholar
  45. 45.
    Levy TM, Orlans M (1999) Kids who kill: Attachment disorder, antisocial personality and violence. Forensic Examiner 8:19–24Google Scholar
  46. 46.
    Lewis DO, Bard JS (1991) Multiple personality and forensic issues. Psychiatr Clin North Am 14:741–756PubMedGoogle Scholar
  47. 47.
    Linver MR, Brooks-Gunn J, Kohen DE (2002) Family processes as pathways from income to young children’s development. Dev Psychol 38:719–734PubMedCrossRefGoogle Scholar
  48. 48.
    Loeber R (1990) Development and risk factors of juvenile antisocial behavior in delinquency. Clin Psychol Rev 10:1–41CrossRefGoogle Scholar
  49. 49.
    Luntz BK, Widom CS (1994) Antisocial personality disorder in abused and neglected children grown up. Am J Psychiatry 151:670–674PubMedGoogle Scholar
  50. 50.
    Martens WJ (2000) Antisocial and psychopathic personality disorders: causes, course and remission. Int J Offender Ther Comp Criminol 44:406–430CrossRefGoogle Scholar
  51. 51.
    Martens WJ (2005) Multidimensional model of trauma and correlated antisocial personality disorder. J Loss Trauma 10:115–129CrossRefGoogle Scholar
  52. 52.
    Martinez-Taboas A, Canino G, Wang MQ, Garcia P, Bravo M (2006) Prevalence and victimization correlates of pathological dissociation in a community sample of youths. J Trauma Stress 19:439–448PubMedCrossRefGoogle Scholar
  53. 53.
    Moran P (1999) The epidemiology of antisocial personality disorder. Soc Psychiatry Psychiatr Epidemiol 34:231–242PubMedCrossRefGoogle Scholar
  54. 54.
    Moskowitz A (2004) Dissociation and violence: a review of the literature. Trauma Violence Abuse 5:21–46PubMedCrossRefGoogle Scholar
  55. 55.
    Mulder RT, Beautrais AL, Joyce PR, Fergusson DM (1998) Relationship between dissociation, childhood sexual abuse, childhood physical abuse, and mental illness in a general population sample. Am J Psychiatry 155:806–811PubMedGoogle Scholar
  56. 56.
    Mullen PE, Martin JL, Anderson JC, Romans SE, Herbison GP (1993) Childhood sexual abuse and mental health in adult life. Br J Psychiatry 163:721–732PubMedGoogle Scholar
  57. 57.
    Narang DS, Contreras JM (2000) Dissociation as a mediator between child abuse history and adult abuse potential. Child Abuse Negl 24:653–665PubMedCrossRefGoogle Scholar
  58. 58.
    Nash MR, Hulsey TL, Sexton MC, Harralson TL, Lambert W (1993) Long-term sequelae of childhood sexual abuse: perceived family environment, psychopathology, and dissociation. J Consult Clin Psychol 61:276–283PubMedCrossRefGoogle Scholar
  59. 59.
    Putnam FW (1997) Dissociation in children and adolescents, The Guilford Press, New YorkGoogle Scholar
  60. 60.
    Quimby LG, Putnam FW (1991) Dissociative symptoms and aggression in a state mental hospital. Dissociation 4:21–24Google Scholar
  61. 61.
    Resnick HS, Foy DW, Donahoe CP, Miller EN (1989) Antisocial behavior and post-traumatic stress disorder in Vietnam veterans. J Clin Psychol 45:860–866PubMedCrossRefGoogle Scholar
  62. 62.
    Rivera B, Widom CS (1990) Childhood victimization and violent offending. Violence Vict 5:19–35PubMedGoogle Scholar
  63. 63.
    Robins L, Helzer JE, Weissman MM, Orvaschel H, Gruenberg E, Burke JD Jr, Regier DA (1984) Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 41:949–958PubMedGoogle Scholar
  64. 64.
    Robins L (1966) Deviant children grown up. Williams & Wilkins, BaltimoreGoogle Scholar
  65. 65.
    Robins LN (1987) The epidemiology of antisocial personality disorder. In: Michels RO, Cavenar JO (eds) Psychiatry, vol 73. JB Lippincott, PhiladelphiaGoogle Scholar
  66. 66.
    Roelofs K, Keijsers GP, Hoogduin KA, Naring GW, Moene FC (2002) Childhood abuse in patients with conversion disorder. Am J Psychiatry 159:1908–1913PubMedCrossRefGoogle Scholar
  67. 67.
    Rundell JR, Ursano RJ, Holloway HC, Silberman EK (1989) Psychiatric responses to trauma. Hosp Community Psychiatry 40:68–74PubMedGoogle Scholar
  68. 68.
    Schapiro JA, Glynn SM, Foy DW, Yavorsky C (2002) Participation in war-zone atrocities and trait dissociation amongVietnam veterans with combat-related posttraumatic stress disorder. J Trauma Dissociation 3:107–114CrossRefGoogle Scholar
  69. 69.
    Semiz UB, Ebrinc S, Cetin M, Cobanoglu N, Baykiz AF (2000) Exploring dissociative experiences among individuals in mandatory conditions. Program Book of the 9th Annual Meeting of Anatolian Psychiatry Congress, Alemdar Ofset, Istanbul, pp 576–584Google Scholar
  70. 70.
    Shahar G, Wisher A, Chinman M, Sells D, Kloos B, Tebes JK, Davidson L, Shahar G (2004) Trauma and adaptation in severe mental illness: The role of self-reported abuse and exposure to community violence. J Trauma Dissociation 5:29–47CrossRefGoogle Scholar
  71. 71.
    Simoneti S, Scott EC, Murphy CM (2000) Dissociative experiences in partner-assaultive men. J Interpers Violence 15:1262–1283CrossRefGoogle Scholar
  72. 72.
    Snow MS, Beckman D, Brack G (1996) Results of the Dissociative Experiences Scale in a jail population. Dissociation 9:98–103Google Scholar
  73. 73.
    Spiegel D, Cardena E (1991) Disintegrated experience: the dissociative disorders revisited. J Abnorm Psychol 100:366–378PubMedCrossRefGoogle Scholar
  74. 74.
    Spitzer RL, Williams JW, Gibbon M (1987) Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Biometrics Research, New YorkGoogle Scholar
  75. 75.
    Stein A, Lewis DO (1992) Discovering physical abuse: insights from a follow-up study of delinquents. Child Abuse Negl 16:523–531PubMedCrossRefGoogle Scholar
  76. 76.
    Steinberg M (1995) Handbook for the assessment of dissociation: a clinical guide, American Psychiatric Press, Washington, DCGoogle Scholar
  77. 77.
    Swett C, Halpert M (1993) Reported history of physical and sexual abuse in relation to dissociation and other symptomatology in women psychiatric inpatients. J Interpers Violence 8:545–555CrossRefGoogle Scholar
  78. 78.
    Taylor PJ, Kopelman MD (1984) Amnesia for criminal offences. Psychol Med 14:581–588PubMedCrossRefGoogle Scholar
  79. 79.
    van der Kolk BA, van der Hart O (1989) Pierre Janet and the breakdown of adaptation in psychological trauma. Am J Psychiatry 146:1530–1540PubMedGoogle Scholar
  80. 80.
    Walker A (2002) Dissociation in incarcerated juvenile male offenders—a pilot study in Australia. Psychiatry Psychology Law 9:56–61Google Scholar
  81. 81.
    Weeks R, Widom CS (1998) Self-reports of early childhood victimization among incarcerated adult male felons. J Interpers Violence 13:346–361CrossRefGoogle Scholar
  82. 82.
    Widom CS (1989) Child abuse, neglect, and adult behavior: research design and findings on criminality, violence, and child abuse. Am J Orthopsychiatry 59:355–367PubMedCrossRefGoogle Scholar
  83. 83.
    Widom CS (1989) The cycle of violence. Science 244:160–166PubMedCrossRefGoogle Scholar
  84. 84.
    Widom CS (1991) Avoidance of criminality in abused and neglected children. Psychiatry 54:162–174PubMedGoogle Scholar
  85. 85.
    Wolfe DA (1985) Child-abusive parents: an empirical review and analysis. Psychol Bull 97:462–482PubMedCrossRefGoogle Scholar
  86. 86.
    Yargic LI, Tutkun H, Sar V (1995) The reliability and validity of the Turkish version of the Dissociative Experiences Scale. Dissociation 8:10–13Google Scholar
  87. 87.
    Zanarini MC, Ruser TF, Frankenburg FR, Hennen J, Gunderson JG (2000) Risk factors associated with the dissociative experiences of borderline patients. J Nerv Ment Dis 188:26–30PubMedCrossRefGoogle Scholar
  88. 88.
    Zweig-Frank H, Paris J, Guzder J (1994) Psychological risk factors for dissociation and self-mutilation in female patients with borderline personality disorder. Can J Psychiatry 39:259–264PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Umit B. Semiz
    • 1
    • 2
  • Cengiz Basoglu
    • 1
  • Servet Ebrinc
    • 1
  • Mesut Cetin
    • 1
  1. 1.Dept. of PsychiatryGATA Haydarpasa Training HospitalIstanbulTurkey
  2. 2.GATA Haydarpasa Egitim HastanesiIstanbulTurkey

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