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Adulthood revictimization: looking beyond childhood trauma

Childhood trauma is a risk factor for a range of psychiatric disorders and other adverse outcomes including impaired social functioning, poor physical health, self-injurious behaviour and addiction (1). This has important clinical implications and has led to further examination of the relationship between the type and severity of childhood trauma and the course of disorders in adulthood becoming a recent focus of psychiatric research (2, 3). While it is accepted that childhood trauma may play a role in the development and onset of psychiatric disorders, its relationship to long-term psychopathology remains unclear. A largely overlooked factor is the impact of ongoing revictimization in adulthood. The toxic effect of childhood trauma is likely to be worsened by sustained and repeated abuse. However, trauma is often treated in the literature as an isolated event, despite well-established evidence that sufferers of abuse in childhood are at an elevated risk of revictimization in later life. This is particularly true for physical and sexual abuse (4), forms of trauma that are widely considered to be the most damaging. A dose–response relationship has also been reported, with exposure to multiple forms of childhood trauma associated with an elevated risk of developing a psychiatric disorder. However, an important consideration should be that these factors also increase the risk of adulthood revictimization (4). Mental health problems themselves are also risk factors for victimization and may further perpetuate ongoing abuse. A mechanism by which childhood trauma may be associated with the severity of symptomatology in adulthood is through its impact on early psychiatric symptoms interacting with ongoing revictimization. For example, sexual abuse in childhood may cause feelings of anxiety and guilt, leading to substance abuse as a form of self-medication. The individual may then become vulnerable to further abuse which, in turn, leads to more severe psychopathology. Sustained symptoms and ongoing trauma may form a reciprocal loop, collectively driving a more severe clinical course of illness and failure to achieve symptomatic remission. This could also plausibly lead to many of the other adverse outcomes associated with childhood trauma such as poor social functioning and addiction (1). While this theory is only speculative, it is consistent with recent network approaches to mental disorders (2), which suggest symptoms may arise directly as a result of other symptoms, as well as from their interaction with other psychological, biological and sociological factors. Many studies report a sustained detrimental effect of childhood trauma on symptoms and functioning long into adulthood without consideration of recent or ongoing revictimization. There is evidence suggesting that reductions in exposure to traumatic experiences may be associated with decreased psychiatric symptom severity. For example, Kelleher and colleagues reported that cessation of physical abuse and bullying among a large cohort of school children was associated with a significant reduction in psychotic symptoms (5). While this was not conducted in a clinical group, these results are useful and suggest that the impact of trauma in childhood may not always be enduring. Factors such as personal resilience, social support and clinical intervention may buffer the relationship, while ongoing revictimization may sustain and even exacerbate psychopathology and disability. These in turn may lead to individual differences in long-term illness course. In summary, evaluation of childhood trauma is clinically useful for identifying those people at elevated risk of adverse long-term physical and mental health outcomes. It should also trigger assessment of revictimization. Further research is needed to establish the relationship between adulthood revictimization and illness course among those with psychiatric disorders. Prevention of revictimization and management of it and its effects could potentially improve clinical outcomes.