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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 39  |  Issue : 1  |  Page : 1-4

Dissociative phenomenon among sexually abused egyptian female participants with substance dependence


1 Department of Psychiatry, Faculty of Medicine, Cairo University, Beni Suef, Egypt
2 Department of Psychiatry, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt

Date of Submission30-May-2017
Date of Acceptance12-Jun-2017
Date of Web Publication29-Jan-2018

Correspondence Address:
Walaa Fakher
Lecturer of Psychiatry, Kasr Al Ainy Hospital, Psychiatry and Addiction Hospital, Cairo University, Cairo, 11562
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejpsy.ejpsy_21_17

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  Abstract 


Objective The purpose of this article is to study dissociative symptoms in female addicts exposed to sexual abuse in their childhood.
Participants and methods This study included 44 Egyptian females who were recruited from a private psychiatric hospital and from a halfway center receiving treatment for substance abuse. Overall, 22 cases were sexually abused during their childhood (before age of 18 years), whereas 22 controls were not exposed to sexual abuse. Addiction severity index was used to assess history of addiction, age of starting smoking, and age of starting substance abuse. Addiction severity index was used to measure emotional abuse and physical abuse. Sexual abuse questionnaire was used to measure sexual abuse. Questionnaire of experience of dissociation was used to measure dissociative phenomena.
Results There was a statistically significant difference regarding the age of starting smoking (P=0.03) and age of starting substance abuse (P=0.04). Moreover, there was a highly statistically significant difference between both groups regarding questionnaire of experience of dissociation scores (P=0.00).
Conclusion Female participants with substance dependence who are sexually abused showed more pathological dissociative symptoms than those who were not. Female participants who are sexually abused during their childhood are more prone to start smoking and substance abuse at younger age than their peers. Physical abuse was higher in sexually abused female participants than those who were not.

Keywords: dissociation, females, sexual abuse, substance dependence


How to cite this article:
Abolmagd S, Adel A, Salah H, Gohar SM, Victor T, Fakher W. Dissociative phenomenon among sexually abused egyptian female participants with substance dependence. Egypt J Psychiatr 2018;39:1-4

How to cite this URL:
Abolmagd S, Adel A, Salah H, Gohar SM, Victor T, Fakher W. Dissociative phenomenon among sexually abused egyptian female participants with substance dependence. Egypt J Psychiatr [serial online] 2018 [cited 2018 Feb 17];39:1-4. Available from: http://new.ejpsy.eg.net/text.asp?2018/39/1/1/224003




  Introduction Top


Many clients engaged in substance abuse treatment programs have histories of child abuse or neglect that might affect their chances of recovery. There is accumulating research and clinical evidence that physical, sexual, emotional abuse, and neglect during childhood increase a person’s risk of developing substance abuse disorders [US Department of Health and Human Services _DHHS), 199}].

In a community sample study, it was found that the lifetime prevalence rate of substance abuse disorders was 14–31% among women who had been sexually abused and 3–12% among women who had not been abused. However, in clinical samples, the rate of lifetime substance abuse diagnoses among sexually abused women ranged from 21 to 57% compared with a range of 2 to 27 % for women without such histories. Another representative study of young adults found that 43.5% of the women who had been sexually abused as children met diagnostic criteria for an alcohol abuse disorder, whereas the criteria were met by only 8% of those who had not been sexually abused (Silverman et al., 1996; Simpson et al., 1994).

Dissociation is defined as a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment and may be sudden or gradual, transient, or chronic (Vedat Sar, 2011). High rates of dissociative symptoms were thought to be a potential mediator of the course and outcome of psychiatric disorders. However, evidence on dissociative phenomenon in patients with substance use disorders remains conflicting (Schäfer et al., 2007). Yet, Lee et al. (2008) reported that individuals who are sexually abused are more prone to abuse substances such as alcohol and illicit drugs than those who are not. Therefore, childhood sexual abuse is supposed to be a contributing factor in the etiology and maintenance of addictive behavior among substance abusers.

The lifetime prevalence of dissociative disorders was 17.2% among inpatients admitted to a dependency treatment unit of a large state mental hospital in Istanbul, Turkey. These rates were 9% for patients with alcohol dependency only and 26% for patients with chemical dependency. Moreover, it was shown by a multicenter study in Germany that dissociative disorder is higher among participants with chemical dependency than those with alcohol dependency (Sar, 2011).

Many researchers believe that dissociation is a common and readily available defense against childhood trauma, as children dissociate more easily than adults (Turkus, 1998). Moreover, what is notable is that both substance use and withdrawal may be confused with dissociation, and substance-related cognitive impairment may be related to difficulty in reporting dissociative and other psychiatric symptoms (Langeland et al., 2002).


  Participants and methods Top


The study was a cross-sectional case–control study with consecutive sampling. This study included 44 Egyptian female addicts, with age range from 18 to 40 years old. They had no withdrawal symptoms, cognitive impairment, or comorbid psychiatric and medical diseases. They were recruited from the addiction unit of a private psychiatric hospital and from a halfway rehabilitation center. They were classified into two groups: the case group, which included 22 females who were sexually abused during their childhood, and the control group, which included 22 females who were not exposed to sexual abuse during their childhood. After signing an informed written consent form, all females were examined through a structured clinical interview based on diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders-IV for diagnosis of substance use disorders and to exclude other chronic psychiatric disorders. Thereafter, they were interviewed through the addiction severity index to assess severity of addiction problems. Then, the sexual abuse questionnaire was introduced to patients to evaluate the history of sexual abuse. Finally, patients completed the questionnaire of experience of dissociation (QED) to assess the pathological dissociation.

Instruments

The structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-IV axis I disorders Arabic version {Hatata et al., 2004}

Structured Clinical Interview for DSM-IV axis I disorders is a semistructured interview for making the major Diagnostic and Statistical Manual of Mental Disorders-IV Axis I diagnoses. The Structured Clinical Interview for DSM-IV axis I disorders is broken down into separate modules corresponding to categories of diagnoses. Most sections started with an entry question that would allow the interviewer to skip the associated questions if not met. For all diagnoses, symptoms are coded as present, subthreshold, or absent.

Addiction severity index {Qasem et al., 2003}

It was developed by McLellan in 1980 and has been used in clinical and research settings for assessment of severity of addiction. The addiction severity index is a semistructured interview questionnaire designed to provide a multidimensional assessment of problems presented by patients with substance use disorders to guide initial treatment planning and to allow monitoring of patient progress over time. It is designed for use in inpatient and outpatient alcohol and drug abuse treatment settings. It is composed of seven subscales, which measure the severity of medical, occupational, alcohol and drug use, legal, family or social, and psychiatric problems. Subjective ratings of the participant are made on a 0–4 scale. For each functional area, the interviewer also makes severity ratings (0–9) that reflect the degree to which the interviewer believes the patient needs additional treatment. It is a reliable and valid instrument.

Sexual abuse questionnaire {Leserman et al., 1996}

This questionnaire was proposed by Leserman et al. in 1996 based on the work of many researchers working in the field of child sexual abuse. The items of the questionnaire were adapted from National Population Survey of Canada. The questionnaire was employed to categorize patients into abused and nonabused groups. Individuals are considered to be sexually abused if they answered yes to any of the questions. Sexual abuse according to the questionnaire is defined as any of three types of sexual experiences: those involving attempts those involving forced sexual touching with hands, mouth, or objects; and lastly, those in which vaginal or anal intercourse (rape) occurred.

QED was used to assess pathological dissociation. It was developed by Riley in 1988 and consists of 26 true–false items that were drawn from the clinical literature dealing with dissociative and multiple personality disorders ([Table 1]).
Table 1 Description of the sample

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  Results Top


There was a statistically significant difference regarding the age of starting smoking, age of starting substance abuse, and the results of QED between the case and control groups.

In the case group, the mean age of starting smoking is 15.59±3.38 years. In the control group, the mean age is 16.75±3.09 years. There was a statistically significant difference regarding the age of starting smoking (P<0.05), which suggests that the case group started smoking at a younger age than the control group.

In the case group, the mean age of starting substance abuse is 16.23±3.35 years. In the control group, the mean age is 18.5±4.27 years. There was a statistically significant difference regarding the age of starting substance abuse (P<0.05), which suggests that the case group started substance abuse at a younger age than the control group.

Results of questionnaire of experience of dissociation

In the case group, the mean score was 14.09±5.59. In the control group, the mean score was 9.25±3.84. There was a statistically significant difference regarding the results of QED (P=0.00), which suggests that pathological dissociation was more frequent in the case group than in the control group, which have a score of normal dissociation.


  Discussion Top


Thus far, the literature shows few studies that include an assessment of all three domains (substance use disorders, sexual abuse, and dissociation). In this study, we are aiming at assessment of dissociative phenomenon among substance-dependent females who experienced sexual abuse during childhood.

In victims of trauma, substance abuse itself can be seen as a method of dissociating for those who cannot do it successfully through other means. For this reason, it is common for survivors of child abuse to self-medicate with substances, thus beginning a process that often leads to substance abuse and dependence (Young, 1995).

Regarding the age of starting smoking (P=0.03) and the age of starting substance abuse (P=0.04), those who are sexually abused start smoking at a younger age than those who are not. The mean age for starting smoking among those who are sexually abused was 15.59±3.38 years, whereas for those who are not sexually abused, the mean age for starting smoking was 16.75±3.09. Moreover, those who were sexually abused started using substances at a younger age than those who were not sexually abused (the mean age being 16.23±3.35 and 18.5±4.27 years, respectively), and this is consistent with the study that reported that women who are sexually abused during childhood are greatly at risk for drug abuse as adults (Kendler et al., 2000).

Earlier studies on addicted women and trauma showed that 74% of the addicted women reported sexual abuse, 52% had been physically abused, and 72% had been emotionally abused. It was found that addicted women have been abused sexually, physically, and emotionally more frequently and for longer periods of time than their nonaddicted counterparts. The addicted women also showed more incidents of incest and rape (Covington and Kohen, 1984). Others reported that nearly 90% of women with alcohol dependency were sexually abused as children or experienced severe violence from their parents (Switzer et al., 1999).

Regarding dissociative symptoms, there were significant pathological dissociative symptoms (P=0.00) reported in female addicts who were exposed to sexual abuse during childhood than female addicts who are not. It was shown that individuals who are sexually abused during childhood are prone to dissociative disorders. However, it is unclear whether people who have substance abuse disorder and childhood abuse histories engage in more dissociative behaviors than those without childhood abuse histories (Polusny and Follette, 1995).

Findings in this research are consistent with the findings of a study that showed that age at first traumatic experience plays a major role in activating dissociative reactions such as dissociative defense mechanisms and pathological alcohol consumption which may be considered a dissociative response of individuals with difficulties in identifying, expressing, and regulating emotions (Craparo et al., 2014). Another study reported that dissociation is relatively uncommon in alcohol-dependent patients; however, when it occurs, dissociation is associated with childhood emotional abuse independent of chronic alcohol abuse. On the contrary, patients with an earlier onset of alcohol dependence could be more similar to patients with other substance-related disorders with regard to levels of dissociation (Schäfer et al., 2007). Another study on females with substance abuse suggests that those who were abused as children use a wider variety of dissociative behaviors than other women (Jarvis et al., 1998). The number of female addicts receiving treatment in hospitals is still low compared with male addicts. Female addicts may prefer to be treated at home; moreover, there are cultural issues of how they are looked upon by the society. A larger sample size would allow for a more detailed analysis by substance type than we were able to achieve in this research. In summary, there are rich areas to be explored in both the research and clinical domains to better understand dissociation in relation to sexual abuse and substance use disorders.[17]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Covington S, Kohen J (1984). Women, alcohol, and sexuality. Adv Alcohol Subst Abuse 4: 41–56.  Back to cited text no. 1
    
2.
Craparo G, Ardino V, Gori A, Caretti V (2014). The relationships between early trauma, dissociation, and alexithymia in alcohol addiction. Psychiatry Investig 11: 330–335.  Back to cited text no. 2
    
3.
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4.
Jarvis TJ, Copeland J, Walton L (1998). Exploring the nature of the relationship between child sexual abuse and substance use among women. Addiction 93:865–875.  Back to cited text no. 4
    
5.
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6.
Langeland W, Draijer N, van den Brink W (2002). Trauma and dissociation in treatment-seeking alcoholics: towards a resolution of inconsistent findings. Compr Psychiatry 43:195–203.  Back to cited text no. 6
    
7.
Lee S, Lyvers M, Edwards M (2008). Childhood sexual abuse and substance abuse in relation to depression and coping. J Subst Use 13:349–360.  Back to cited text no. 7
    
8.
Polusny MA, Follette VM (1995). Long-term correlates of child sexual abuse: theory and review of the empirical literature. Appl Prev Psychol 4:143–166.  Back to cited text no. 8
    
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Schäfer I, Reininghaus U, Langeland W, Voss A, Zieger N, Haasen C, Karow A (2007). Dissociative symptoms in alcohol-dependent patients: associations with childhood trauma and substance abuse characteristics. Compr Psychiatry 48:539–545.  Back to cited text no. 10
    
11.
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Simpson TL, Westerberg V, Little LM, Trujillo M (1994). Screening for childhood physical and sexual abuse among outpatient substance abusers. J Subst Abuse Treat 11:347–358.  Back to cited text no. 12
    
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Switzer GE, Dew MA, Thompson K, Goycoolea JM, Derricott T, Mullins SD (1999). Posttraumatic stress disorder and service utilization among urban mental health center clients. J Trauma Stress 12:25–39.  Back to cited text no. 13
    
14.
Turkus JA (1998). The spectrum of dissociative disorders: an overview of diagnosis and treatment. Available at: https://www.healthyplace.com/abuse/wermany/spectrum-of-dissociative-disorders-an-overview-of-diagnosis-and-treatment/. [Last accessed 2017 Oct].  Back to cited text no. 14
    
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US Department of Health and Human Services (DHHS) (1999). Blending perspectives and building common ground: a report to congress on substance abuse and child protection. Washington, DC: US Government Printing Office.  Back to cited text no. 15
    
16.
Sar V (2011). Epidemiology of dissociative disorders: an overview. Epidemiol Res Int 2011. doi: 10.1155/2011/404538  Back to cited text no. 16
    
17.
Young EB (1995). The role of incest issues in relapse and recovery. In: Washton AM, editor. Psychotherapy and substance abuse: a practitioner’s handbook. New York, NY: Guilford Press.  Back to cited text no. 17
    



 
 
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