case study on emotional abuse

Emotional abuse case study: ‘If I had stayed longer, I probably would have ended up dead’

Bullying and control can be difficult to pinpoint – it may take time for a victim of emotional abuse to realise what is happening.

Emotional abuse is so much worse than physical abuse. A bruise heals. The inside takes longer. Photograph: Thinkstock

The beginning I used to be a girl about town. I was working in accounts, bought my first home at 22 and had my little sports car. I had my life planned out.

If he had punched me in the face on our first date, I wouldn’t have gone back. I couldn’t see what was really happening.

I got pregnant shortly after we started going out, and I was diagnosed with breast cancer the same year. I was 24. He left when all that happened, so I had my daughter by myself. I moved to Dublin for cancer treatment.

I bumped into him when I came back to Limerick. I think I was vulnerable because of my illness. I went from being confident to thinking I was going to die.

We got married less than nine months after that. The abuse started from there. It was all emotional or psychological. And it was the worst. I can’t even explain it.

Little signs

There were little signs of jealousy at first, but I thought: Isn’t that lovely? He’s mad about me. But really, it was about control.

It started with things like my clothes. At first he’d say, “I don’t know about those shoes.” It progressed to, “Everyone’s looking at you, and you can’t go out like that.” Eventually, it was, “You look like a slut.”

As soon as we got married, my house wasn’t right because it was mine. So I had to sell it and buy another property with the money I made. He had debts, and I paid them off. I bought another home, and everything about that was wrong as well. It was all my money, and it’s all gone now.

Our daughter would finish school, and he knew how long it took me to drive home. I’d have to be at home to answer the phone when he rang.

He cut me off from my friends. He encouraged me to work from home and then to stop working completely. Sometimes he rang me 30 times a day.

When he came home from work, I’d have his shirts ironed, but he wanted the only one left in the laundry basket. It was always the wrong shirt, the wrong food.

The last straws

I can only assume that he was jealous of our daughter because she took my attention away from him. He wanted to know why she had to go everywhere with us. She was three.

Then I wasn’t able to go to the doctor because he said the cancer was all in my head. He said all I wanted was for the doctor to see me naked. I didn’t have a check-up for many years, and my health deteriorated.

I finally went to the doctor and found out I had to have my ovaries removed. I had the surgery, and afterwards my husband said I did it to spite him.

I was in and out of hospital during that time. He never came to see me and wouldn’t look after our daughter. My parents, who were in their 70s, looked after her.

Getting out

We were together for seven years. I got married at 26, and I’m 35 now. If I had stayed longer, I probably would have ended up dead. He spoke about killing me often enough.

Towards the end, he started threatening to kill me in front of our daughter. When we got home from school, she would cross her fingers that he wouldn’t be at home. “Can we run away, Mammy?” she used to ask me every night.

One day he went ballistic, and we ran outside and drove to my parents’ house. He tried to block me and then ram my parents’ house with the jeep. I rang the police. The police told me to stay with my parents for a few days. They left the perpetrator in the house.

I actually thought it would be easier to stay with him.

I was dealing with one good garda who told me not to back down. He was the best thing that ever happened to me.

Gardaí told me to contact a domestic violence refuge. I said: “Are you crazy? I’m not one of those people. I’m not poor.”

But when I went there, I realised I totally am one of those people. I’ve met doctors and judges hiding from their abusers at the refuge. Abuse is straight across the board.

I got a barring order to remove him from the home, and I’m back in my house now. There is help out there. You can get through it, and your kids will thank you.

A lot of people think they should stay for their kids, but my daughter is a different person now. She’s a happy child. She’s in the top 2 per cent in the country in standardised testing. She’s the most mannerly and well-adjusted kid.

I left three years ago, and I still go to a support group to get him out of my head. He told me I was worthless so [many times that] I believed it.

I had a lovely childhood. We weren’t poor by any means. I was the most confident person you could ever meet, and I just vanished. I’m trying to find myself again now.

Emotional abuse is so much worse than physical abuse. A bruise heals. The inside takes longer.

This story is from a member of United & Strong, a group of domestic violence survivors advocating to strengthen the rights of victims of domestic abuse. For more information, see United & Strong on Facebook and @strong_united on Twitter.

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• Research article
• Open access
• Published: 17 March 2021

The invisible scars of emotional abuse: a common and highly harmful form of childhood maltreatment

• Camila Monteiro Fabricio Gama 1 ,
• Liana Catarina Lima Portugal 1 ,
• Raquel Menezes Gonçalves 1 ,
• Sérgio de Souza Junior 1 ,
• Liliane Maria Pereira Vilete 2 ,
• Mauro Vitor Mendlowicz 2 , 3 ,
• Ivan Figueira 2 ,
• Eliane Volchan 4 ,
• Isabel Antunes David 1 ,
• Leticia de Oliveira 1 &
• Mirtes Garcia Pereira 1  

BMC Psychiatry volume  21 , Article number:  156 ( 2021 ) Cite this article

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Childhood maltreatment (CM) is unfortunately widespread globally and has been linked with an increased risk of a variety of psychiatric disorders in adults, including posttraumatic stress disorder (PTSD). These associations are well established in the literature for some maltreatment forms, such as sexual and physical abuse. However, the effects of emotional maltreatment are much less explored, even though this type figures among the most common forms of childhood maltreatment. Thus, the present study aims to investigate the impact of each type of childhood maltreatment, both individually and conjointly, on revictimization and PTSD symptom severity using a nonclinical college student sample.

Five hundred and two graduate and undergraduate students participated in the study by completing questionnaires assessing lifetime traumatic experiences in general, maltreatment during childhood and PTSD symptoms. Bivariate and multivariate negative binomial regressions were applied to examine the associations among childhood maltreatment, revictimization, and PTSD symptom severity.

Our results showed that using bivariate models, all types of CM were significantly associated with revictimization and PTSD symptom severity. Multivariate models showed that emotional abuse was the type of maltreatment associated with the highest incidence rates of revictimization and PTSD symptom severity.

Conclusions

These data provide additional evidence of the harmful effects of childhood maltreatment and its long-term consequences for individuals’ mental health. Notably, the findings highlight the importance of studying the impacts of emotional abuse, which seems to be a highly prevalent, understudied, and chronic form of maltreatment that is as toxic as other maltreatment forms.

Peer Review reports

Stressful experiences in childhood, especially those involving childhood maltreatment, began to be studied in the late 1970s and early 1980s [ 1 ]. Childhood maltreatment consists of abusive or neglectful acts perpetrated by parents or caregivers having the potential to “harm or threaten a child” [ 2 ]. Five subtypes of childhood maltreatment are commonly recognized: physical abuse, emotional abuse, sexual abuse, physical neglect and emotional neglect. In terms of prevalence, a worldwide meta-analysis estimated rates of 12.7% for sexual abuse, 16.3% for physical neglect, 18.4% for emotional neglect, 22.6% for physical abuse, and 36.3% for emotional abuse [ 3 ]. These data indicate that childhood maltreatment is globally widespread, affecting the lives of millions of children. Exposure to childhood maltreatment has been associated with a variety of psychiatric disorders in adults, such as depression and anxiety disorders [ 4 ], bipolar disorder [ 5 , 6 ], eating disorders [ 7 ], personality disorders [ 8 ] and trauma-related disorders, such as posttraumatic stress disorder (PTSD) [ 9 ].

Associations between childhood maltreatment and posttraumatic stress disorder

As a severe mental disorder that involves exposure to real or threatening death events, serious injury, or sexual violence, PTSD profoundly impairs cognitive and behavioural functioning. The main symptoms are reexperiencing, avoidance, negative mood and cognitions, and hyperarousal [ 10 ]. Trauma exposure is highly prevalent: epidemiological surveys suggest that approximately 70% of their samples reported lifetime exposure to at least one traumatic event [ 11 , 12 ]. However, the prevalence of PTSD among the general population is less than 10% [ 13 , 14 ]. Studies that explore the factors that might be related to an increased vulnerability to PTSD are crucial [ 15 ], and childhood maltreatment seems to be an important risk factor for PTSD development [ 16 , 17 , 18 , 19 , 20 , 21 ] and severity [ 9 , 22 , 23 , 24 , 25 , 26 ].

The link between childhood physical and sexual abuse and PTSD is well established in the literature [ 24 , 27 , 28 , 29 , 30 , 31 ], especially when investigated individually. However, studies exploring the impact of all childhood maltreatment types conjointly on PTSD symptomatology are sparse. Furthermore, childhood emotional maltreatment is much less explored as a potential vulnerability factor, not only to PTSD but also to psychiatric disorders in general (see [ 32 ] for a review). As mentioned before, it is important to highlight that emotional maltreatment not only figures among the most common forms of childhood maltreatment [ 3 , 9 , 23 ] but is also significantly associated with depressive symptoms [ 33 , 34 , 35 , 36 ], substance use disorders [ 37 ] and suicide risk [ 38 , 39 ]. Nevertheless, emotional maltreatment rarely prompts specific actions for child protection. Thus, it is urgent to expand knowledge about the consequences of childhood emotional maltreatment, individually or conjointly with all other maltreatment types, on mental health. Particularly its role as a factor for PTSD vulnerability, considering the high prevalence of lifetime trauma exposure in the population [ 12 ] and the abundant evidence that other forms of maltreatment are a risk factor for this disorder.

Associations between childhood maltreatment and Revictimization

Early caregiver-child relationships establish a critical foundation for lifelong learning and can have permanent sequelae. The lack of security in a maltreatment environment increases the risk for further trauma exposure [ 40 , 41 ]. In fact, many studies have highlighted that childhood maltreatment is predictive of revictimization, which refers to the exposure of individuals who were victimized during childhood to subsequent traumatic events [ 42 ]. For instance, in a sample of substantiated childhood maltreatment victims, sexual and physical abuse experiences predicted revictimization [ 42 , 43 ]. Similar results were found for male psychiatric inpatients [ 44 ] and in a community sample [ 45 ] for physical and sexual abuse. Emotional and sexual abuse during childhood predicted adult rape in college women [ 46 ]. Recently, a study suggested that all types of abuse and neglect, except for emotional neglect that was not investigated, were significantly associated with higher levels of revictimization in a sample of adolescent girls involved with the child welfare system [ 47 ]. Important differences in the characteristics of the samples used to probe the association between childhood maltreatment and revictimization, such as gender, age at investigation, and education level, make it more difficult to generalize the results to other populations. Dias et al. [ 23 ] was the only study that investigated the impact of all maltreatment types conjointly and found evidence that emotional abuse is significantly associated with revictimization and PTSD symptoms in a convenience sample from a European high-income country. Geographic and economic factors seem to play an important role in worldwide estimates of childhood maltreatment [ 48 ]. Thus, it is necessary to expand knowledge about how different forms of childhood maltreatment are related to revictimization and PTSD severity in other cultural contexts. Here, we explored the impact of all childhood maltreatment types on PTSD severity and revictimization in a nonclinical and relatively healthy sample from a South American middle-income country and exposed to a wide variety of forms of childhood maltreatment. According to Viola et al. [ 48 ], among all continents, South America has the highest rates of childhood maltreatment severity. Studies carried out with non-clinical samples present many advantages given that they reduce the biases of more severe cases, higher prevalence of psychiatric disorders, medication, and higher levels of functional impairment. For the purpose of this article, we consider a broader definition of revictimization, referring to individuals who were victimized during childhood and exposed to any subsequent type of traumatic event occurring during adolescence or adult life, not only a specific adverse experience.

In summary, the present study aims to investigate the impact of each type of childhood maltreatment, both individually and conjointly, on the severity of PTSD symptoms using a nonclinical Brazilian college student sample. Additionally, we explored the association of childhood maltreatment and revictimization. We hypothesize that those who experienced childhood maltreatment are more prone to experience other traumatic events and their harmful consequences and present higher levels of PTSD symptoms when facing another trauma later in life. We also hypothesize that all childhood maltreatment types, including emotional maltreatment, will impact mental health, predicting revictimization and PTSD symptoms for another trauma. Exploring the impact of emotional maltreatment is particularly relevant considering its high prevalence and the fact that it is the least visible form of maltreatment experienced by a child.

Participants

A sample of five hundred and two volunteers (mean age 21.2; SD = 4.01) participated in the survey. All participants were graduate or undergraduate students at Federal Fluminense University and at Federal University of Rio de Janeiro, Rio de Janeiro – Brazil. They were recruited through a brief announcement in their classrooms, and all interested students stayed in class and received numbered questionnaires. Then, they were instructed to read the consent terms, which guaranteed anonymity and freedom to end participation. After completing all the questionnaires, participants were instructed to put them into a box, with no individual identification.

The inclusion criterion was being 18 years old or older, and the only exclusion criterion was failing to fill out all the questionnaires. Fifty-nine participants who did not fully complete the questionnaire battery were excluded, leaving an “original sample” of 443 participants. The characteristics of this sample are described in Table  1 . This was the sample used for revictimization analysis.

This study was approved by the Ethics Review Board of the Federal University of Rio de Janeiro, process number CAAE 56431116.5.0000.5263, and all methods were carried out in accordance with relevant guidelines and national regulations. Each participant gave written informed consent prior to participation.

Trauma History Questionnaire (THQ)

Translated and adapted to Portuguese [ 49 ] from the original [ 50 ], the Trauma History Questionnaire (THQ) is a self-report questionnaire that examines exposure to different types of traumatic events, from urban violence crimes to sexual assault and natural disasters. The scale is composed of 23 items divided into three clusters (crime-related events, trauma and disaster in general, and sexual and physical experiences) that investigate potentially traumatic events through yes/no questions and further investigate frequency and approximate age at the time of exposure. The questionnaire also contains an open-ended question that allows participants to specify other extraordinarily stressful situations or events that they have experienced.

In this study, one subitem was added to all the questionnaire items to determine the intensity of the worst event (0 = not stressful at all; 5 = extremely stressful). For all the analyses involving the THQ, we included only the traumatic events that occurred after 12 years of age (i.e., after childhood according to local laws and the NIH definitions cited above) and with an intensity score ≥ 3 (mild to extremely stressful). The test-retest reliability results in a psychometric evaluation study of trauma and PTSD indicated moderate to high coefficients [ 51 ].

Posttraumatic stress disorder checklist for DSM-5 (PCL-5)

Posttraumatic stress symptoms were assessed using the PCL-5, which was developed by the National Center for PTSD in accordance with the DSM-5 [ 10 , 52 ]. Translated and adapted to Portuguese [ 53 ], the PCL-5 is a 20-item self-report questionnaire that measures the four cluster symptoms of PTSD: intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. Each item in the PCL-5 questionnaire is rated on a 5-point Likert scale (from 0= “Not at all” to 4 = “Extremely”). Symptom severity can be calculated by summing the items in each of the four clusters or summing all 20 items. In this case, the severity score ranges from zero to 80 points. For our study, we opted to consider the total score to analyse symptom severity [ 52 ]. Participants were instructed to consider one worst event previously reported in the THQ, as they indicated how each item of the PCL-5 bothered them in the last month.

The psychometric properties of the PCL-5 have been assessed in different cultural contexts and samples, presenting satisfactory to high internal consistency, very good to high test-retest reliability and strong convergent and discriminant validity [ 54 , 55 , 56 , 57 ].

Childhood Trauma Questionnaire - Short Form (CTQ-SF)

Childhood maltreatment (CM) was quantitatively assessed with the 28-item Childhood Trauma Questionnaire (CTQ) [ 58 , 59 ] that was translated and adapted to Portuguese [ 60 ]. It measures childhood exposure to physical, emotional and sexual abuse and physical and emotional neglect. The instrument has five items exploring each of these five subtypes of CM, yielding 25 items for analysis and three more items to investigate minimization and denial. Participants respond to each item on a scale from 1 (“Never”) to 5 (“Always”), which indicates the frequency with which they had these experiences. Responses are converted into a maltreatment severity subtype: “None to Minimal”, “Low to Moderate”, “Moderate to Severe” or “Severe to Extreme” [ 58 ].

We used the Bernstein and Fink [ 58 ] cut-off points for “Low to Moderate” severity to classify the presence of CM (physical abuse≥8; sexual abuse ≥6; emotional abuse ≥9; physical neglect ≥8; emotional neglect ≥10) [ 58 ]. Thus, the presence of maltreatment was considered if a participant had a CTQ score equal to or higher than the low to moderate cut-off point for each maltreatment type.

• Revictimization

We considered revictimization as any subsequent type of traumatic event occurring during adolescence or adult life in victims of childhood maltreatment. Revictimization was measured by summing the quantity of types of traumatic events reported in the THQ with an intensity greater than or equal to 3 that occurred after the age of 12 years. Thus, events that met these criteria were summed and provided a final revictimization score for each volunteer.

It is important to mention that we assessed childhood maltreatment using the CTQ scale and that participants were instructed to answer the questionnaire based only on their childhood experiences (not including adolescence or adult life). Childhood is locally defined as the period before the age of 12 years (Brazil, Law 8069 - Child and Adolescence Statute) [ 61 , 62 ]. Additionally, questionnaires investigating childhood versus later periods of life were presented in different parts in the questionnaire booklet (see Fig.  1 and procedures subsection). The instruction to consider only events that occurred during childhood was reinforced in the beginning of the second part (Childhood maltreatment part). When measuring revictimization, we considered only traumas occurring above the age of 12 years in the THQ. This procedure was important to avoid an overlap between events considered childhood maltreatment and those included in revictimization scores.

Diagram describing the specific order of the scales in the questionnaire battery. The basic sociodemographic questionnaire was the first presented, succeeded by two parts. Part one was composed of the Trauma History Questionnaire (THQ) [ 49 , 50 ] and Posttraumatic Stress Disorder Checklist 5 (PCL-5) [ 52 , 53 ], and part two contained the Childhood Trauma Questionnaire (CTQ) [ 58 , 59 , 60 ]. At the end of the THQ, participants had to indicate the event that they considered the most traumatic in their life and answer the PCL-5 based on this event

To investigate the association between childhood maltreatment and revictimization, we used the original sample of 443 participants.

Childhood maltreatment and PTSD severity

Additional exclusion criteria were applied to investigate the effects of different forms of childhood maltreatment on the prediction of PTSD severity for a subsequent trauma (that occurred during adolescence or adulthood). Participants were excluded if they did not report an index traumatic event in one of the Trauma History Questionnaire clusters (see the Measures section below) or if the index traumatic event reported occurred before 12 years of age ( n  = 181). The rationale was to include only participants with an index trauma that met PTSD criterion A and that occurred after 12 years of age. This age cut-off was set to guarantee that the PTSD symptoms were related to the index for trauma that occurred after childhood, following local definitions of the age range for childhood [ 61 , 62 ].

Thus, the final sample for the analysis that examined the influence of childhood maltreatment on PTSD severity (“PTSD symptoms sample”) to a subsequent trauma comprised 262 volunteers. Note that this additional exclusion was applied exclusively to the PTSD symptom severity analysis.

The questionnaires were distributed in classrooms, and volunteers took approximately 1 h and 20 min to complete them. Each questionnaire was composed of a self-report basic sociodemographic survey collecting data on sex, age, religion, educational level, family income and previous and current diagnosed disorders, followed by three self-report scales. As shown in Fig. 1 , the scales were grouped into two parts. In the first part, participants were instructed to complete the questionnaires in accordance with their lifetime experiences. Volunteers completed the (I) THQ and (II) PCL-5. At the end of the THQ, participants were asked to indicate the event that they considered the most traumatic in their life. Participants answered the PCL-5 based on the traumatic event identified as the worst in the THQ. In the second part, participants were instructed to fill out the questionnaire according to their childhood experiences and completed the (III) Childhood Trauma Questionnaire - Short Form (CTQ-SF). They were asked to report responses on as many experiences as they could remember.

Statistical analysis

First, we calculated the average age of the participants and the proportions for sex, absence of any type of childhood maltreatment, presence of at least one type of childhood maltreatment and presence of each type of childhood maltreatment. We considered maltreatment as present if the participant had a CTQ score equal to or higher than the “low to moderate” cut-off point, according to Bernstein and Fink’s [ 58 ] cut-off points, for each maltreatment type. The average quantity of traumatic events according to the THQ self-reports was also computed.

Normality tests were carried out to investigate the distribution profile of the dependent variables. The Shapiro–Wilk test indicated that the number of types of traumatic events and the PCL-5 scores did not follow a normal distribution (quantity of traumatic events: W = 0.97; p  < 0.000; PCL-5: W = 0.92; p  < 0.000).

Negative binomial models were used to address the problem of overdispersed count data. The exponentiated regression coefficients provide the incidence ratio, which is interpreted as an increase or decrease in the dependent variable in terms of percentage for each unit change of the independent variable. We performed bivariate and multivariate negative binomial regressions to examine the influence of childhood maltreatment with respect to two outcomes: revictimization (measured as the quantity of types of traumatic events after childhood, i.e., 12 years old, with an intensity score ≥ 3 reported in the THQ) and PTSD severity for a subsequent trauma (PCL-5 score based on the worst traumatic event reported in one of the THQ clusters and that occurred after childhood, i.e., 12 years old). Age, gender and socioeconomic status were included as potential confounders in the multivariate models.

The independent variable of interest was the presence of childhood maltreatment reported in the CTQ, and the dependent variables were the number of types of traumatic events after 12 years old reported in the THQ and the PCL-5 score for the worst traumatic event. In the modelling processes for the two outcomes, we followed the same strategy. First, we performed bivariate analysis to examine the influence of each form of childhood maltreatment on the prediction of revictimization or PTSD severity later in life. The forms with p -values less than 0.20 and with confidence intervals that did not present a null value (i.e., CI did not include 1.0) were selected for inclusion in the multivariate model. Those with p-values less than 0.10 and with confidence intervals that did not present a null value were retained in the model.

All statistical analyses were performed using the Stata 12.0 package, and statistical significance was established at p  < 0.05.

Childhood maltreatment and revictimization

Original sample characteristics.

Information on participants’ age, sex, childhood maltreatment exposure, and quantity of types of traumatic events is provided in Table 1 . As shown, the original sample ( N  = 443) was mainly female (79%), and 74% reported the presence of at least one type of childhood maltreatment. Emotional abuse and emotional neglect presented the highest frequencies of exposure. The mean number of types of traumatic events that occurred after 12 years of age was 5.6 (SE = 0.1). Furthermore, Fig.  2 and Table  2 depicts the percentage of volunteers from the original sample who reported a single type of childhood maltreatment as well as the overlap between the maltreatment types. Overall, the co-occurrence of different types of maltreatment was common. For emotional abuse, we observed a slightly higher percentage of participants who reported a single type of maltreatment.

Venn diagram illustrating the percentage of single types and the overlap of types of childhood maltreatment in the original sample ( n  = 443). This diagram was partially constructed using an online tool available at ( http://bioinformatics.psb.ugent.be/cgi-bin/liste/Venn/calculate_venn.htpl )

For mean CTQ total scores and subscales scores see supplemental material Table S1 .

Frequency of traumatic events occurring during adolescence/adulthood in the original sample

The percentage of volunteers who reported an intensity of three or higher for at least one question in each of the THQ clusters is presented in Table  3 . Note that the same volunteer can report an intensity of three or higher for questions in more than one cluster.

The highest rate of exposure was found for the “Trauma and disaster in general” cluster, with almost 90% of the sample reporting at least one event in this cluster, followed by 65.2% of the sample reporting at least one event in the “Crime-related events” cluster and 32.3% in the “Sexual and physical experiences” cluster.

Only traumas reported as occurring at ≥12 years old were included. The percentage was calculated by dividing the number of volunteers who reported an intensity of 3 or higher for at least one item in each cluster by the number of volunteers in the original sample.

Predicting revictimization

We used the original sample to investigate the influence of different forms of childhood maltreatment on the prediction of revictimization (number of types of traumatic events after childhood reported in the THQ). We performed five bivariate negative binomial regressions to investigate whether each type of childhood maltreatment was associated with revictimization (number of types of traumatic events occurring after childhood). As shown in Table  4 (bivariate model), all types of childhood maltreatment caused an increase in the incidence of revictimization. Note that emotional abuse had the highest impact in this sample, causing a 52% increase in the incidence rate of revictimization for participants who were exposed to this maltreatment compared to those who were not exposed. In other words, participants exposed to emotional abuse during childhood had on average 52% more types of traumatic events (with an intensity rating of 3 or higher) that occurred after 12 years of age.

When all the maltreatment forms were included in the same model but without controlling for confounders, only sexual and emotional abuse significantly predicted the risk for revictimization (Table 4 – raw multivariate model). When gender, age and socioeconomic status were included as potential confounders, sexual ( p  < 0.041, 95% CI [1.01–1.30]) and emotional abuse ( p  < 0.000, 95% CI [1.23–1.59]) remained statistically significant (Table 4 - adjusted multivariate model). Emotional abuse showed the highest impact in this sample, causing a 40% increase in the average number of types of subsequent (after 12 years old) traumatic events.

Childhood maltreatment and PTSD symptom severity

Characteristics of the ptsd symptom sample.

The association between the occurrence of childhood maltreatment and PTSD symptom severity for a subsequent trauma was investigated in a subsample of participants, the PTSD symptom sample. For this analysis, only the participants who answered the PCL-5 based on a traumatic event reported in one of the THQ clusters that occurred after childhood (after 12 years old) were included (262 volunteers). Table  5 shows the characteristics of this sample in terms of age, sex, childhood maltreatment exposure, and mean PTSD score. Note that for this subsample, emotional abuse and emotional neglect also presented the highest frequencies of occurrence among the maltreatment types. The frequency of lifetime traumatic events considered the most traumatic and used to answer the PCL-5 is shown in Table  6 .

Predicting PTSD symptom severity

To investigate the association between each type of childhood maltreatment and PTSD symptom severity for a subsequent trauma, we ran five bivariate negative binomial regressions. As shown in Table  7 (bivariate model), all types of childhood maltreatment significantly predicted PTSD severity for a subsequent trauma. These results show that all forms of childhood maltreatment caused an increase in the average PCL-5 scores for another trauma occurring in adolescence/adulthood. Note that emotional abuse had the highest impact, being associated with an increase of 94% in the incidence rate of PTSD symptoms.

When all the childhood maltreatment forms were entered in the same model, emotional and sexual abuse remained significant predictors of PTSD severity for a subsequent trauma (that occurred after childhood), causing increments of 76 and 56%, respectively, in the incidence rate of PTSD symptoms (Table 7 – raw multivariate model). Physical neglect was associated with a more moderate effect. When control variables (age, gender and socioeconomic status) were included in the model, emotional abuse and sexual abuse remained significant, and emotional abuse still showed the highest impact in this sample, causing a 77% increase in the average posttraumatic stress symptoms (Table 7 – adjusted multivariate model).

For completeness, the results of the bivariate and multivariate models for revictimization and PTSD symptom prediction, but considering CTQ scores as continuous variables, are presented in the supplemental material (Tables S2 and S3 respectively).

This study aimed to investigate whether the presence of childhood maltreatment, especially emotional abuse maltreatment, could predict revictimization and PTSD severity symptoms for a subsequent traumatic event in adolescence and young adulthood. Our main results demonstrate that each maltreatment subtype, when individually analysed in bivariate regressions, was significantly associated with revictimization and with PTSD symptom severity. Moreover, when all the forms of maltreatment were investigated together in a multivariate regression model, emotional and sexual abuse remained significant predictors of revictimization and PTSD severity symptoms. Importantly, emotional abuse was associated with the largest increases in the number of types of subsequent traumatic events and the highest incident rates of PTSD symptoms, highlighting the long-term consequences of emotional maltreatment in a nonclinical sample of Brazilian college students.

In addition, 74% of our sample was exposed to at least one form of childhood maltreatment, and 50.3% of students reported being exposed to two or more types of childhood maltreatment. In fact, among all continents, South America, and specifically Brazil, has been reported to have the highest rates of estimated childhood maltreatment [ 48 ]. Additionally, in our sample, emotional maltreatment was the most common form of maltreatment, with prevalence rates of 59 and 42% for emotional abuse and emotional neglect, respectively. These results are in line with a meta-analysis of worldwide prevalence that showed that emotional abuse is a universal problem [ 3 ] and with a previous study by Grassi-Oliveira and Stein [ 9 ] that also showed that emotional abuse was the most prevalent childhood maltreatment type in a low-income Brazilian sample.

In line with the literature, our data revealed that childhood maltreatment is associated with revictimization. Individuals who were victimized during their childhood reported a higher number of types of traumatic events that occurred later during adolescence/adulthood. The association of childhood maltreatment and revictimization was present for each subtype of maltreatment when analysed individually, but only emotional and sexual abuse remained significant predictors for revictimization when all subtypes were included in the same regression model. Consistent with our findings, other studies also reported that particular types of childhood maltreatment are associated with subsequent revictimization [ 42 , 43 , 44 , 45 , 46 , 47 ]. However, the majority of the studies focused primarily on childhood physical and sexual abuse, including substantiated cases, and/or did not investigate all five types of childhood maltreatment reported here. One exception is the study by Dias et al. [ 23 ], which also explored all forms of maltreatment and found that individuals who experienced emotional or physical abuse had higher risks for revictimization than those who did not.

Remarkably, in our sample, emotional abuse was the maltreatment subtype that showed the highest impact, causing an increase of 40% in the average number of types of subsequent traumatic events reported by individuals. In fact, if CTQ scores for each maltreatment are considered a continuous independent variable in the multivariate model for revictimization prediction, instead of a categorical presence/absence variable, emotional abuse is the only significant predictor of revictimization after controlling for potential confounders (see supplemental material ). One possible explanation of why adverse situations related to childhood maltreatment lead to revictimization is that experiencing these events impairs the cognitive processing of emotional situations and compromises the acquisition of emotional-regulation capacities and interpersonal skills [ 63 ]. In fact, it was demonstrated that trauma exposure during childhood impairs neural processing of salient emotional stimuli and is associated with a failure to differentiate between nonthreat and threat-related stimuli [ 64 ]. Interestingly, Burns and colleagues [ 65 ] showed that emotional abuse was strongly related to emotional regulation difficulties, suggesting that emotion regulation skills might be more likely to be negatively impacted by emotional abuse than by other forms of maltreatment due to the former’s more chronic nature.

In addition to diminished risk detection skills, childhood maltreatment may lead to long-term dysregulation of the functioning of biological stress responses and hamper the implementation of typical defensive responses at imminent risk of victimization [ 66 ]. Arguments of dysfunction in the brain’s normal fear/defence circuit and impaired defensive engagement due to cumulative traumatization were also proposed by Lang and McTeague [ 67 ]. In their study, PTSD patients who had experienced recurrent traumatic exposure were among the least reactive to emotional stimuli and often reported a history of repeated childhood maltreatment exposure. It is important to mention that revictimization involves many other aspects in addition to the individual difficulties mentioned above. Interpersonal and sociocultural factors certainly contribute to an increased risk of experiencing other traumatic events. For example, cultural patterns and belief systems (ex. rigid gender roles) tend to create an environment that puts the victim in an unprotected situation, which in turn facilitates revictimization. In addition, family of origin functioning, characteristics of the initial maltreatment (ex. frequency, age of onset), community (ex. lack of family support), lack of resources, lack of security in a maltreatment environment and practices that normalize victim blaming were also identified as risk factors for further trauma exposure [ 40 , 41 , 68 , 69 ].

Additionally, experiencing adverse situations during childhood has been consistently identified as a potential risk factor for mental health problems, including PTSD. Indeed, our results showed that all maltreatment subtypes, when individually analysed in bivariate regression models, were significantly associated with an increase in PTSD symptoms. This finding is consistent with several previous studies reporting that childhood maltreatment is associated with increased PTSD symptoms [ 9 , 22 , 23 , 24 , 25 , 26 ]. Moreover, we showed that when all the forms of maltreatment were investigated together in a multivariate regression model, emotional and sexual abuse remained significant predictors of PTSD severity symptoms. There is abundant evidence confirming the negative consequences of sexual abuse during childhood [ 28 , 32 , 70 , 71 ], but much less attention is given to emotional abuse. Remarkably, emotional abuse was the form of maltreatment that caused the highest increase in the incidence rate of PTSD symptoms in our sample. In the same vein, it was also reported that emotional abuse had the largest effect on the prediction of PTSD severity [ 23 ] and psychological symptoms [ 72 ] in a Portuguese community sample.

One of the most important symptoms of PTSD is the re-experiencing of the traumatic event, which has been linked to an inability to downregulate negative emotions [ 73 ], an overreaction to and a failure to recover from unpleasant events [ 74 , 75 , 76 , 77 ]. Accordingly, increased brain reactivity to negative stimuli [ 78 ] and difficulty with emotion regulation [ 79 ] were related to posttraumatic stress symptom severity in trauma-exposed undergraduate students. One of the pathways by which childhood maltreatment might lead to increased risk for PTSD is that childhood maltreatment could cause impairments in the ability to understand and regulate emotions, and emotional abuse in particular emerged as the strongest predictor of emotion dysregulation [ 65 ]. As emphasized by this study, emotional abuse usually occurs more frequently than other forms of maltreatment, and this might overwhelm an individual’s capacity to effectively regulate emotions, as he or she is chronically exposed to situations involving negative affect [ 65 ]. Taken together, these findings support the urgent need to identify and treat individuals who suffer emotional maltreatment due to its high probability of being associated with poor mental health in adulthood.

Limitations

This study presents some limitations. As a cross-sectional study, the retrospective design may have led to recall bias. Individuals were asked to report PTSD symptoms based on their worst trauma, and only individuals who reported an index trauma that occurred after childhood were included in the analysis. However, considering the youthfulness of the participants, it is conceivable that the posttraumatic symptomatology reported is based on both childhood and adult traumas and not solely on adult trauma. It is also important to keep in mind that the co-occurrence of different types of childhood maltreatment might have influenced our results. Furthermore, the sample was predominantly female, which might have inflated our results, as recent studies have shown that the prevalence of emotional abuse is higher for women than for men [ 34 , 80 , 81 ]. All sources of data were obtained using the same method, self-report questionnaires, which could lead to common method variance. Strategies such as creating a psychological separation among measurements, protecting the anonymity of the respondents, and minimizing evaluation apprehension were carefully implemented in our procedures to minimize this problem [ 82 ]. The external validity of the findings is limited due to the homogeneity of the present sample, and the results might not be generalizable to clinical populations. Nevertheless, this study can provide important insights into how harmful untimely experiences can be in a traumatized young student sample. In addition, the homogeneity of this sample may suggest that similar results could be found for samples with similar characteristics.

In sum, this study provides additional knowledge on the harmful effects of childhood maltreatment and its long-term consequences for individuals’ mental health. Particularly, it highlights the importance of studying the consequences of emotional abuse, which seems to be a universal and chronic form of maltreatment that has a strong impact across the lifespan and that may be more harmful than other types of maltreatment. Emotional abuse needs to be studied further, and research on it has lagged behind that on other forms of childhood maltreatment. One key aspect of emotional abuse research is its lack of consideration in the diagnosis of PTSD. Considering that the concept of trauma encompasses different traumatic experiences not previously considered traumas but that are also harmful, future reformulations of the definition of traumatic events could contemplate emotional abuse.

In addition, the focus on emotional abuse might encourage the development of prevention and treatment strategies. By understanding how implicit memories of emotional abuse episodes impact future emotional regulation capacity, we might prevent the harmful effects of this type of abuse on intergenerational attachment styles, which can lead to societal problems such as parental violence, marital violence, and mental health disorders. Accordingly, the improvement of intervention strategies for memory reconsolidation and reprocessing of those events could have an immense impact on society.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to local ethics committee restrictions but are available from the corresponding author on reasonable request.

Abbreviations

Confidence Interval

• Childhood maltreatment

Childhood Trauma Questionnaire - Short Form

Incidence Rate Ratio

Sample number

Posttraumatic Stress Disorder Checklist for DSM-5

Posttraumatic Stress Disorder

Standard error

Trauma History Questionnaire

Shapiro-Wilk Test

Fromuth ME. The relationship of childhood sexual abuse with later psychological and sexual adjustment in a sample of college women. Child Abuse Negl. 1986;10(1):5–15.

Article   CAS   PubMed   Google Scholar  

Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet. 2009;373(9657):68–81.

Article   PubMed   Google Scholar  

Stoltenborgh M, Bakermans-Kranenburg MJ, Alink LRA, van IJzendoorn MH. The prevalence of child maltreatment across the globe: review of a series of meta-analyses: prevalence of child maltreatment across the globe. Child Abuse Rev. 2015;24(1):37–50.

Article   Google Scholar  

Gallo EAG, Munhoz TN, Loret de Mola C, Murray J. Gender differences in the effects of childhood maltreatment on adult depression and anxiety: A systematic review and meta-analysis. Child Abuse Negl. 2018;79:107–14.

Daruy-Filho L, Brietzke E, Lafer B, Grassi-Oliveira R. Childhood maltreatment and clinical outcomes of bipolar disorder: childhood maltreatment and bipolar disorder. Acta Psychiatr Scand. 2011;124(6):427–34.

Agnew-Blais J, Danese A. Childhood maltreatment and unfavourable clinical outcomes in bipolar disorder: a systematic review and meta-analysis. Lancet Psychiatry. 2016;3(4):342–9.

Molendijk ML, Hoek HW, Brewerton TD, Elzinga BM. Childhood maltreatment and eating disorder pathology: a systematic review and dose-response meta-analysis. Psychol Med. 2017;47(8):1402–16.

Lobbestael J, Arntz A, Bernstein DP. Disentangling the relationship between different types of childhood maltreatment and personality disorders. J Personal Disord. 2010;24(3):285–95.

Grassi-Oliveira R, Stein LM. Childhood maltreatment associated with PTSD and emotional distress in low-income adults: the burden of neglect. Child Abuse Negl. 2008;32(12):1089–94.

American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

Book   Google Scholar  

Benjet C, Bromet E, Karam EG, Kessler RC, McLaughlin KA, Ruscio AM, et al. The epidemiology of traumatic event exposure worldwide: results from the world mental health survey consortium. Psychol Med. 2016;46(2):327–43.

Kessler RC, Aguilar-Gaxiola S, Alonso J, Benjet C, Bromet EJ, Cardoso G, et al. Trauma and PTSD in the WHO World Mental Health Surveys. Eur J Psychotraumatol. 2017;8(sup5):1353383. Available from: https://doi.org/10.1080/20008198.2017.1353383 .

Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593.

Pietrzak RH, Goldstein RB, Southwick SM, Grant BF. Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: results from wave 2 of the National Epidemiologic Survey on alcohol and related conditions. J Anxiety Disord. 2011;25(3):456–65.

Yehuda R. Advances in understanding neuroendocrine alterations in PTSD and their therapeutic implications. Ann N Y Acad Sci. 2006;1071(1):137–66.

Yehuda R, Halligan SL, Grossman R. Childhood trauma and risk for PTSD: Relationship to intergenerational effects of trauma, parental PTSD, and cortisol excretion. Dev Psychopathol. 2001;13(3):733–53.

Pratchett LC, Yehuda R. Foundations of posttraumatic stress disorder: does early life trauma lead to adult posttraumatic stress disorder? Dev Psychopathol. 2011;23(2):477–91.

Lopez-Castroman J, Jaussent I, Beziat S, Guillaume S, Baca-Garcia E, Olié E, et al. Posttraumatic stress disorder following childhood abuse increases the severity of suicide attempts. J Affect Disord. 2015;170:7–14.

Glaesmer H, Kuwert P, Braehler E, Kaiser M. Childhood maltreatment in children born of occupation after WWII in Germany and its association with mental disorders. Int Psychogeriatr. 2017;29(7):1147–56.

Paquette G, Tourigny M, Baril K, Joly J, Séguin M. Mauvais traitements subis dans l’enfance et problèmes de santé mentale à l’âge adulte : une étude nationale conduite auprès des Québécoises. Sante mentale au Quebec. 2017;42(1):43–63. https://doi.org/10.7202/1040243ar .

Ozen S, Dalbudak E, Topcu M. The relationship of posttraumatic stress disorder with childhood traumas, personality characteristics, depression and anxiety symptoms in patients with diagnosis of mixed anxiety-depression disorder. Psychiatr Danub. 2018;30(3):340–7.

Nöthling J, Suliman S, Martin L, Simmons C, Seedat S. Differences in abuse, neglect, and exposure to community violence in adolescents with and without PTSD and depression. J Interpers Violence. 2016;34(21–22):4357–83.

PubMed   Google Scholar  

Dias A, Sales L, Mooren T, Mota-Cardoso R, Kleber R. Child maltreatment, revictimization and post-traumatic stress disorder among adults in a community sample. Int J Clin Health Psychol. 2017;17(2):97–106.

Article   PubMed   PubMed Central   Google Scholar  

Messman-Moore TL, Bhuptani PH. A review of the long-term impact of child maltreatment on posttraumatic stress disorder and its comorbidities: an emotion Dysregulation perspective. Clin Psychol Sci Pract. 2017;24(2):154–69.

Price M, Connor JP, Allen HC. The moderating effect of childhood maltreatment on the relations among PTSD symptoms, positive urgency, and negative urgency: moderation of PTSD and positive urgency. J Trauma Stress. 2017;30(4):432–7.

Lueger-Schuster B, Knefel M, Glück TM, Jagsch R, Kantor V, Weindl D. Child abuse and neglect in institutional settings, cumulative lifetime traumatization, and psychopathological long-term correlates in adult survivors: the Vienna institutional abuse study. Child Abuse Negl. 2018;76:488–501.

Widom CS. Posttraumatic stress disorder in abused and neglected children grown up. Am J Psychiatry. 1999;156(8):1223–9.

MacMillan HL, Fleming JE, Streiner DL, Lin E, Boyle MH, Jamieson E, et al. Childhood abuse and lifetime psychopathology in a community sample. AJP. 2001;158(11):1878–83.

Article   CAS   Google Scholar  

Tyler KA. Social and emotional outcomes of childhood sexual abuse. Aggress Violent Behav. 2002;7(6):567–89.

Libby AM, Orton HD, Novins DK, Beals J, Manson SM. Childhood physical and sexual abuse and subsequent depressive and anxiety disorders for two American Indian tribes. Psychol Med. 2005;35(3):329–40.

Cougle JR, Timpano KR, Sachs-Ericsson N, Keough ME, Riccardi CJ. Examining the unique relationships between anxiety disorders and childhood physical and sexual abuse in the National Comorbidity Survey-Replication. Psychiatry Res. 2010;177(1–2):150–5.

Carr CP, Martins CMS, Stingel AM, Lemgruber VB, Juruena MF. The role of early life stress in adult psychiatric disorders: a systematic review according to childhood trauma subtypes. J Nerv Ment Dis. 2013;201(12):1007–20.

Martins CMS, Von Werne BC, de Carvalho Tofoli SM, Juruena MF. Emotional Abuse in Childhood Is a Differential Factor for the Development of Depression in Adults. J Nerv Ment Dis. 2014;202(11):774–82.

Gallo EAG, De Mola CL, Wehrmeister F, Gonçalves H, Kieling C, Murray J. Childhood maltreatment preceding depressive disorder at age 18 years: a prospective Brazilian birth cohort study. J Affect Disord. 2017;217:218–24.

Novelo M, von Gunten A, Gomes Jardim GB, Spanemberg L, Argimon II de L, Nogueira EL. Effects of childhood multiple maltreatment experiences on depression of socioeconomic disadvantaged elderly in Brazil. Child Abuse Negl. 2018;79:350–7.

Christ C, de Waal MM, Dekker JJM, van Kuijk I, van Schaik DJF, Kikkert MJ, et al. Linking childhood emotional abuse and depressive symptoms: The role of emotion dysregulation and interpersonal problems. PLoS One. 2019;14(2):e0211882 Seedat S, editor.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Tucci AM, Kerr-Corrêa F, Souza-Formigoni MLO. Childhood trauma in substance use disorder and depression: an analysis by gender among a Brazilian clinical sample. Child Abuse Negl. 2010;34(2):95–104.

Barbosa LP, Quevedo L, da Silva GDG, Jansen K, Pinheiro RT, Branco J, et al. Childhood trauma and suicide risk in a sample of young individuals aged 14-35 years in southern Brazil. Child Abuse Negl. 2014;38(7):1191–6.

de Araújo RMF, Lara DR. More than words: the association of childhood emotional abuse and suicidal behavior. Eur Psychiatry. 2016;37:14–21.

Crawford E, Wright MO. The impact of childhood psychological maltreatment on interpersonal schemas and subsequent experiences of relationship aggression. J Emot Abus. 2007;7(2):93–116.

Atmaca S, Gençöz T. Exploring revictimization process among Turkish women: the role of early maladaptive schemas on the link between child abuse and partner violence. Child Abuse Negl. 2016;52:85–93.

Widom CS, Czaja SJ, Dutton MA. Childhood victimization and lifetime revictimization. Child Abuse Negl. 2008;32(8):785–96.

Widom CS, Czaja S, Dutton MA. Child abuse and neglect and intimate partner violence victimization and perpetration: a prospective investigation. Child Abuse Negl. 2014;38(4):650–63.

Cloitre M, Tardiff K, Marzuk PM, Leon AC, Portera L. Consequences of childhood abuse among male psychiatric inpatients: dual roles as victims and perpetrators. J Trauma Stress. 2001;14(1):47–61.

Desai S, Arias I, Thompson MP, Basile KC. Childhood victimization and subsequent adult revictimization assessed in a nationally representative sample of women and men. Violence Vict. 2002;17(6):639–53.

Messman-Moore TL, Walsh KL, DiLillo D. Emotion dysregulation and risky sexual behavior in revictimization. Child Abuse Negl. 2010;34(12):967–76.

Auslander W, Tlapek SM, Threlfall J, Edmond T, Dunn J. Mental health pathways linking childhood maltreatment to interpersonal Revictimization during adolescence for girls in the child welfare system. J Interpers Violence. 2018;33(7):1169–91.

Viola TW, Salum GA, Kluwe-Schiavon B, Sanvicente-Vieira B, Levandowski ML, Grassi-Oliveira R. The influence of geographical and economic factors in estimates of childhood abuse and neglect using the childhood trauma questionnaire: a worldwide meta-regression analysis. Child Abuse Negl. 2016;51:1–11.

Fiszman A, Cabizuca M, Lanfredi C, Figueira I. The cross-cultural adaptation to Portuguese of the trauma history questionnaire to identify traumatic experiences. Braz J Psychiatry. 2005;27(1):63–6.

Green BL. Trauma history questionnaire. In: Stamm BH, editor. Measurement of stress, trauma, and adaptation. Lutherville: Sidran; 1996.

Google Scholar  

Mueser KT, Rosenberg SD, Fox L, Salyers MP, Ford JD, Carty P. Psychometric evaluation of trauma and posttraumatic stress disorder assessments in persons with severe mental illness. Psychol Assess. 2001;13(1):110–7.

Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP. The PTSD Checklist for DSM-5 (PCL-5). In: National Center for PTSD. 2013. Available from: http://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp [Accessed 21 March 2019].

de Lima EP, Vasconcelos AG, Berger W, Kristensen CH, do Nascimento E, Figueira I, et al. Cross-cultural adaptation of the posttraumatic stress disorder checklist 5 (PCL-5) and life events checklist 5 (LEC-5) for the Brazilian context. Trends Psychiatry Psychother. 2016;38(4):207–15.

Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The posttraumatic stress disorder checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489–98.

Ashbaugh AR, Houle-Johnson S, Herbert C, El-Hage W, Brunet A. Psychometric Validation of the English and French Versions of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). PLoS One. 2016;11(10):e0161645. Available from: https://doi.org/10.1371/journal.pone.0161645 .

Sveen J, Bondjers K, Willebrand M. Psychometric properties of the PTSD Checklist for DSM-5: a pilot study. Eur J Psychotraumatol. 2016;7. Available from: https://wwwncbinlmnihgov/pmc/articles/PMC4838990/ Accessed 13 Jul 2019 [cited 2020 Jun 30].

Krüger-Gottschalk A, Knaevelsrud C, Rau H, Dyer A, Schäfer I, Schellong J, et al. The German version of the posttraumatic stress disorder checklist for DSM-5 (PCL-5): psychometric properties and diagnostic utility. BMC Psychiatry. 2017;17(1):379.

Bernstein D, Fink L. Manual for the childhood trauma questionnaire – a retrospective self-report. New York: Pearson; 1998.

Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, et al. Development and validation of a brief screening version of the childhood trauma questionnaire. Child Abuse Negl. 2003;27(2):169–90.

Grassi-Oliveira R, Stein LM, Pezzi JC. Tradução e validação de conteúdo da versão em português do Childhood Trauma Questionnaire. Rev Saude Publica. 2006;40(2):249–55.

Brazil. Child And Adolescence Statute (Estatuto da Criança e do Adolescente), no. 8.069. In: Diário Oficial da República Federativa do Brasil. 1990. Available from: http://www.planalto.gov.br/ccivil_03/leis/l8069.htm [Accessed 15th Feb 2020].

Eisenstein E. Adolescência: definiçoes, conceitos e critérios. AdolescSaude. 2005;2(2):6–7.

CAS   Google Scholar  

Dvir Y, Ford JD, Hill M, Frazier JA. Childhood maltreatment, emotional Dysregulation, and psychiatric comorbidities. Harv Rev Psychiatry. 2014;22(3):149–61.

Chu AT, Lieberman AF. Clinical implications of traumatic stress from birth to age five. Annu Rev Clin Psychol. 2010;6(1):469–94.

Burns EE, Jackson JL, Harding HG. Child maltreatment, emotion regulation, and posttraumatic stress: the impact of emotional abuse. J Aggress Maltreat Trauma. 2010;19(8):801–19.

Noll JG, Grych JH. Read-react-respond: an integrative model for understanding sexual revictimization. Psychol Violence. 2011;1(3):202–15.

Lang PJ, McTeague LM. Discrete and recurrent traumatization in PTSD: fear vs. anxious misery. J Clin Psychol Med Settings. 2011;18(2):207–9.

Grauerholz L. An ecological approach to understanding sexual Revictimization: linking personal, interpersonal, and sociocultural factors and processes. Child Maltreat. 2000;5(1):5–17.

Scoglio AAJ, Kraus SW, Saczynski J, Jooma S, Molnar BE. Systematic review of risk and protective factors for Revictimization after child sexual abuse. Trauma Violence Abuse. 2021 Jan;22(1):41–53.

Häuser W, Kosseva M, Üceyler N, Klose P, Sommer C. Emotional, physical, and sexual abuse in fibromyalgia syndrome: a systematic review with meta-analysis. Arthritis Care Res. 2011;63(6):808–20.

Adams J, Mrug S, Knight DC. Characteristics of child physical and sexual abuse as predictors of psychopathology. Child Abuse Negl. 2018;86:167–77.

Dias A, Sales L, Hessen DJ, Kleber RJ. Child maltreatment and psychological symptoms in a Portuguese adult community sample: the harmful effects of emotional abuse. Eur Child Adolesc Psychiatry. 2015;24(7):767–78.

Lobo I, de Oliveira L, David IA, Pereira MG, Volchan E, Rocha-Rego V, et al. The neurobiology of posttraumatic stress disorder: dysfunction in the prefrontal-amygdala circuit? Psychol Neurosci. 2011;4(2):191–203.

Foa EB, Feske U, Murdock TB, Kozak MJ, McCarthy PR. Processing of threat-related information in rape victims. J Abnorm Psychol. 1991;100(2):156–62.

Orr SP, Metzger LJ, Lasko NB, Macklin ML, Peri T, Pitman RK. De novo conditioning in trauma-exposed individuals with and without posttraumatic stress disorder. J Abnorm Psychol. 2000;109(2):290–8.

Shin LM, Wright CI, Cannistraro PA, Wedig MM, McMullin K, Martis B, et al. A functional magnetic resonance imaging study of amygdala and medial prefrontal cortex responses to overtly presented fearful faces in posttraumatic stress disorder. Arch Gen Psychiatry. 2005;62(3):273–81.

Wessa M, Flor H. Failure of extinction of fear responses in posttraumatic stress disorder: evidence from second-order conditioning. Am J Psychiatry. 2007;164(11):1684–92.

Lobo I, David IA, Figueira I, Campagnoli RR, Volchan E, Pereira MG, et al. Brain reactivity to unpleasant stimuli is associated with severity of posttraumatic stress symptoms. Biol Psychol. 2014;103:233–41.

Tull M, Barrett H, McMillan E, Roemer L. A Preliminary Investigation of the Relationship Between Emotion Regulation Difficulties and Posttraumatic Stress Symptoms. Behav Ther. 2007;38:303–13.

Soares ALG, Hammerton G, Howe LD, Rich-Edwards J, Halligan S, Fraser A. Sex differences in the association between childhood maltreatment and cardiovascular disease in the UK biobank. Heart. 2020;106(17):1310–6.

Salokangas RKR, Patterson P, Hietala J, Heinimaa M, From T, Ilonen T, et al. Childhood adversity predicts persistence of suicidal thoughts differently in females and males at clinical high-risk patients of psychosis. Results of the EPOS project. Early Interv Psychiatry. 2019;13(4):935–42.

Tehseen S, Ramayah T, Sajilan S. Testing and controlling for common method variance: a review of available methods. J Manage Sci. 2017;4:142–68.

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Acknowledgements

We thank Dr. Coutinho for his valuable help with the statistical analysis and description. This work was supported in part by federal and state Brazilian research agencies (CAPES 001, CAPES/PRINT, CNPq and FAPERJ).

This work (data collection, analysis and writing) was supported in part by federal and state Brazilian research agencies (CNPq and FAPERJ).

Scholarships were awarded by the federal Brazilian research agency CAPES 614 001, CAPES/PRINT.

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Additional file 1: table s1..

Mean CTQ total scores and subscales scores (original sample). Table S2. The Impact of Childhood Maltreatment on Revictimization: Bivariate and Multivariate Negative Binomial Regression Model (using CTQ scores) . Table S3. Predicting PTSD Symptoms: Bivariate and Multivariate Negative Binomial Regression for the Prediction of PTSD Severity (using CTQ scores).

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Gama, C.M.F., Portugal, L.C.L., Gonçalves, R.M. et al. The invisible scars of emotional abuse: a common and highly harmful form of childhood maltreatment. BMC Psychiatry 21 , 156 (2021). https://doi.org/10.1186/s12888-021-03134-0

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Research suggests that childhood psychological maltreatment (i.e., emotional abuse and emotional neglect) is associated with mental health problems that persist into adulthood, for example anxiety, depression, post-traumatic stress disorder (PTSD), suicidal ideation, and aggression; however, a systematic review and meta-analysis of the existing literature would help clarify the magnitude and moderators of these associations, and the extent to which they may be affected by publication bias, as well as the methodological strengths and weakness of studies in this area.

The reporting of this protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) Statement. Searches will be carried out via several databases, including Web of Science, Medline, PubMed, PsycINFO, Applied Social Science Index and Abstract, ERIC and EMBASE. Empirical peer-reviewed research articles that fit pre-specified eligibility criteria will be included in the review. Studies will be eligible if they include participants age 18 or over at time of mental health assessment, include information on childhood psychological maltreatment (emotional abuse and/or neglect) perpetrated by a primary caregiver or adult in the same household, and provide quantitative information on the association between these factors. Studies using prospective and retrospective designs and written in either English or Chinese will be eligible. Two independent reviewers will screen and assess studies for inclusion in the review as well as extract the data, with consensus reached through discussion in cases of discrepancy. A third reviewer will be consulted to resolve any discrepancies that remain. The relevant Newcastle–Ottawa scales will be used for assessing the quality of studies. If a sufficient number of comparable studies are retrieved, a meta-analysis will be conducted using a random effects model. Study-level moderators (i.e., year of publication, quality of the study and study geographical location) will be examined in the meta-analyses.

This systematic review will provide an understanding of the long-term effects of childhood psychological maltreatment on adult mental health, which adds to previous reviews focusing primarily on the effects of physical and sexual abuse. The results of the review will help inform clinical practice in approaches to treating those with a history of psychological maltreatment in childhood. The gaps and weaknesses in the evidence identified will also inform recommendations for future research.

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Childhood abuse is significantly associated with adverse emotional, cognitive, behavioural and social outcomes for children [ 16 , 19 , 22 ], with difficulties frequently continuing into adulthood [ 7 ]. According to the World Health Organization (WHO) (2020), childhood abuse refers to all forms of abuse (e.g. physical, sexual, emotional, psychological and neglect) that result in potential or actual harm to a child’s physical or psychological health.

Childhood emotional abuse is the type of abuse least well-studied [ 1 ]. There has been one systematic review on the association between childhood emotional abuse and neglect in school-aged children [ 19 ],however, there has been no systematic review or meta-analysis on the long-term mental health effects of childhood psychological maltreatment on adults.

There are different definitions of psychological maltreatment, for example, Vega Castelo (2012) stated that psychological maltreatment refers to affective and cognitive aspects of child maltreatment. For the purpose of this review, psychological maltreatment is defined as including two specific concepts: childhood emotional abuse and childhood emotional neglect. Forms of psychological maltreatment may include rejecting, isolating, neglecting, exploiting, and terrorizing [ 12 ]. Emotional abuse in childhood refers to continual deliberate mistreatment of a child, which may include deliberately trying to scare, humiliate, ignore, and isolate the child. Emotional abuse is often a part of other forms of abuse,however, it can also happen on its own [ 4 ]. In contrast to emotional abuse, emotional neglect may be unintentional, and caregivers are sometimes unaware that they are emotionally neglecting their child. Emotional neglect in childhood refers to caregivers’ failure to recognize, understand or provide what a child really needs, and may sometimes refer to lack of attention to a child [ 4 ]. The primary distinction between childhood emotional neglect and childhood emotional abuse is that the former reflects indifferent parenting while the latter reflects hostile parenting [ 17 ].

This review will focus on psychological maltreatment perpetrated by primary caregivers or another adult in household specifically. This focus is motivated by the fact that in the traditional family model, primary caregivers and cohabiting adults are often the most important figures for a child. This is also reflected in commonly used measures of maltreatment. For example, in measures such as the Childhood Traumatic Questionnaire [ 5 ], Adverse Childhood Experience, etc., the items ask whether primary caregivers or adults living in the same household committed maltreatment. The focus on psychological maltreatment is motivated by the fact that it is currently the least-well studied form of abuse in terms of its effects on adult mental health. Part of the reason may be the challenges inherent in measuring psychological maltreatment. Compared with physical and sexual abuse, the assessment and identification of psychological maltreatment can be more difficult [ 2 ], since there is no physical evidence of its occurrence. However, the negative outcomes of it may manifest in numerous ways such as impaired emotional, cognitive, or social development, including outcomes such as depression [ 13 ], helplessness (Black, SlepAM, & Heyman, 2001), aggression (Diza, Simantov, & Rickert, 2002), emotional dysregulation (Burns, Jacksons, & Harding, 2010) delinquency, substance abuse, PTSD, anxiety, and low self-esteem (Kilpatrict, Saunders, & Smith, 2003).

Rationale for the current review

There are numerous systematic reviews on the associations between physical or sexual abuse and adult mental health [ 3 , 15 ],however—to the best of the authors’ knowledge—to date, no research has been carried out to synthesize current evidence on the relationships between childhood psychological maltreatment by primary caregivers (or adults living in the same household) and adult mental health. A systematic review on this topic can provide an understanding of the consistency and strength of the link between early childhood maltreatment and adult mental health outcomes at both the clinical and sub-clinical level. A systematic review and meta-analysis can help provide a more precise estimate of the association than has been provided by primary studies to date. It will also allow us to examine the factors that moderate the magnitude of this association, and to evaluate whether the field is affected by publication bias. Further, it will provide a characterization of the quality of empirical studies in this field and identify gaps in the literature.

The primary review questions will be:

What are the long-term effects of childhood psychological maltreatment on adult mental health?

What are the unique effects of childhood psychological maltreatment by caregivers on adult mental health after adjusting for other forms of abuse?

How do study-level moderators such as year of publication, quality of study and location of study affect these associations?

The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) recommendations have been used to guide the reporting in this systematic review protocol and will be used to guide the reporting of the review itself [ 21 ]. This systematic review protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD42020197833.

Search strategy

To search the existing literature on childhood psychological maltreatment, the following keywords will be used: ‘child abuse’, ‘childhood psychological maltreatment’, ‘childhood emotional abuse’, ‘child neglect’, ‘childhood emotional neglect’, ‘psychological aggression’, ‘psychological violence’, ‘psychological domestic violence’ and ‘childhood psychological victimisation’. The Boolean operator ‘OR’ will be used to combine the search terms and with specific syntax be adapted to the different databases.

To capture the concept of mental health, these key search terms will be used: ‘mental health’, ‘generalised anxiety disorder’, ‘depression’, ‘major depression disorder’, ‘PTSD’, ‘personality disorder’, ‘eating disorder’, ‘bipolar disorder’, ‘schizophrenia’, ‘panic disorder’, ‘psychosis’, ‘social anxiety disorder’, ‘suicide ideation’, ‘suicide attempt’, ‘non-suicidal self-injury’ and ‘substance abuse’. The Boolean operator ‘OR’ will be used to combine these search terms, adapted to the syntax of different databases.

The Boolean operator (‘AND’) will be used to combine keywords from psychological maltreatment and mental health. In addition, the maltreatment terms will be combined with child* and the mental health terms with adult* using the AND operator in order to link the concepts to the relevant developmental stages.

Several databases will be used searching for relevant papers: Web of Science, Medline, PubMed, PsycINFO, Applied Social Science Index and Abstract, ERIC and EMBASE. For grey literature, several databases will be used: WHO database, PhD thesis/dissertation databases, and Open Grey.

For literature written in Chinese, ZhiWang which is a well-known database in China, and covers various journals written in Chinese, will be used for searching the literature.

Inclusion criteria

Participants aged over 18 at assessment of the mental health problems.

Measurement of abuse: studies that measured childhood psychological maltreatment using retrospective self-report, questionnaires, interviews, or police or social work records will be included.

Measurement of mental health: studies that measured mental health problems (standard diagnoses as listed in the DSM-V or ICD-10 or using mental health scores based on validated measures) using self-report, questionnaires or clinical interviews will be included.

Types of maltreatment: studies that only assessed childhood psychological maltreatment, childhood emotional neglect, childhood emotional abuse, or studies that assessed both childhood emotional abuse and childhood emotional neglect and other types of abuse (e.g., physical, or sexual) will be included. The abuse must have been committed by the primary caregivers, or the adult living in the same household.

Comparison: adults who experienced only childhood psychological maltreatment versus adults who experienced different forms of abuse during childhood, with or without psychological maltreatment versus adults who experienced no abuse during childhood will be compared.

Ascertainment of exposure to childhood psychological maltreatment by primary caregivers (or adults living in the same household): Studies using either retrospective or prospective data will be included.

Studies that reported odds ratio or other effect size: If the studies do not report the relevant effect size, they will be eligible for inclusion only if they provide the raw information such that the effect size could be calculated. When the raw information not available in the text, authors will contact the authors to request such data.

Additional inclusion criteria include:

Articles written in either English or Chinese will be included reflecting the language capabilities of the team.

Exclusion criteria

Any book chapters, case studies, letter, opinions, and editorials that do not present new data will be excluded.

Qualitative investigations will be excluded.

Studies that do not provide an analysis of childhood psychological maltreatment will be excluded.

Studies that focus on psychological maltreatment perpetrated by non-parental others or where data for primary caregivers or another adult in household cannot be disaggregated from data on abuse perpetrated by others will not be included.

Studies where different types of abuse are combined and not separately reported so that it is not possible to obtain an effect for childhood psychological maltreatment will be excluded.

Studies where the outcome is physical rather than mental illness will be excluded.

Review papers (narrative reviews, systematic reviews, and meta-analyses) will be excluded.

Study selection

The bibliographic software program Zotero will be used to manage and store relevant studies. Duplicate studies will be removed via this software. Two independent reviewers will scrutinise the electronic searches for eligibility and inclusion of studies into the systematic review based on their title and abstract. Full texts of potentially relevant papers will be retrieved and reviewed independently by two reviewers. A final determination of whether an article meets inclusion criteria will be made on examination of the full article, the reason for each excluded study will be documented. A third reviewer will be consulted to resolve any discrepancies that cannot be resolved through discussion between the original reviewers. Figure  1 presents the flow diagram to be adopted in the systematic review for study selection [ 20 ].

PRISMA flow diagram

Methodological appraisal of study

Classification of risk of bias as recommended by the Newcastle–Ottawa Quality Assessment Scale will be used to assess the quality of selected case–control for retrospective study or cohort studies for longitudinal studies [ 25 ]. Main domains of this assessment are selection (adequateness of case definition, representativeness of the cases, selection of controls and definition of controls), comparability (comparability of cases and controls based on the design or analysis) and exposure (ascertainment of exposure, same method of ascertainment for cases and control and non-response rate). A study can be awarded a maximum of four stars for selection, two stars for comparability and three stars for exposure. More stars represent lower risk of bias. Two reviewers will independently assess the studies for methodological quality with discrepancies being resolved through discussion and a third reviewer will be consulted where consensus cannot be reached through discussion.

Data extraction

Study findings will be extracted using a structured database. It will include pertinent information such as author name and date of publication, sample size, sample population, study geographical location, sample population demographic, study setting, study methodology, types of abuse, measurement of childhood psychological maltreatment, duration of abuse, measurement of various mental health outcomes, perpetrator of the maltreatment, age at exposure to maltreatment, the relation between childhood psychological maltreatment and mental health outcomes (as an odds ratio or risk ratio), and covariates adjusted for. When available, both adjusted and unadjusted statistics will be extracted. Two reviewers will independently conduct the data extraction with consensus reached through discussion in case of discrepancies. Where consensus is not reached through discussion, a third reviewer will be consulted. If any new categories are identified during the course of the review, they will be added, and the extraction database will be modified as needed. If there are any missing data or relevant information, authors will be contacted to supply the information. To detect the unique effects of childhood psychological maltreatment by caregivers on adult mental health after adjusting for other forms of abuse, researchers will extract the statistical information of the studies exploring the associations between childhood psychological maltreatment and adult mental health when adjusting for other types of abuse.

Data analysis

A narrative synthesis of the findings from the included studies will be presented. The narrative synthesis will focus on socio-demographic characteristics of the samples (duration of abuse, who the maltreatment was inflicted by, age at exposure to maltreatment), characteristic of the studies (study setting, sample size, study design), methodology (questionnaire, self-report, experimental design, clinical interview, police or social work records), types of mental health issues, effect size and odd/risk ratios.

A meta-analysis will be conducted if there are enough studies with information related to both childhood psychological maltreatment and mental health. Results will be summarized using a forest plot. Results from different study designs will not be pooled together (e.g., studies that assessed only childhood psychological maltreatment and studies that assessed different types of abuse) to prevent a misleading summary of the study effect; rather, they will be analysed separately. If possible, meta-analyses of both adjusted and unadjusted effects will be conducted and results compared. A random effects model will be utilized for the meta-analysis as it is likely that studies will not be homogeneous. Studies are expected to represent fairly substantial differences in method (i.e. types of participants, measurements) and are thus not anticipated to reflect a single underlying effect size. The ‘Metafor’ package for R statistical software will be used for meta-analysis [ 24 ].

The GRADE criteria will be used to assess the quality of the evidence provided by the observational studies in relation to the outcome (Higgins & Green, 2011). The quality of the evidence will be rated as very low, low, moderate, and high; and factors that may decrease the quality are risk of bias, imprecision, inconsistency and indirectness (Higgins & Green, 2011).

Assessment of heterogeneity and moderator analysis

Study heterogeneity will be assessed by examining the characteristics of studies and similarities between childhood psychological maltreatment and mental health outcomes. Statistical heterogeneity will be assessed by calculating Q and I 2 . Where there are sufficient numbers of studies in the meta-analysis, study-level moderators will be tested. These may include study quality (based on the quality assessment described above), study geographical location, year of publication, and sample size. Moderator analysis will be using the ‘Metafor’ package.

Assessment of reporting bias

In case of an appropriate number of studies ( n  ≥ 10), publication bias will be assessed using a funnel plot for each outcome by plotting the effect size against study size (Higgins & Green, 2011). An Egger test [ 11 ] and the trim and fill method [ 10 ] will be used to statistically test for publication bias and its potential impact.

This protocol outlines the plan for a systematic review and, if applicable, a meta-analysis on the effects of childhood emotional abuse and childhood emotional neglect (collectively ‘psychological maltreatment’) perpetrated by primary caregivers or adults living in the same household in childhood on adult mental health outcomes. There is currently no systematic review and meta-analysis focusing specifically on the long-term effects of childhood psychological maltreatment on adult mental health outcomes, therefore, the review will help fill this important gap. The findings from this review could help illuminate the long-term impact of psychological maltreatment, in combination with and net of other forms of abuse. This can help inform prevention and intervention strategies to help target resources and minimise the impact of psychological maltreatment. It will also potentially provide insights into whether the impact of psychological maltreatment varies across contexts; which mental health outcomes it is most strongly related to; and whether its impact has changed over time. This review will also explore where the major gaps are in current evidence in other to make recommendations for future research. Finally, it will help provide an assessment of the quality of the work on the field and identify areas for improvement in future research to strengthen the evidence in the field.

Availability of data and materials

Not applicable.

Abbreviations

The Diagnostic and Statistical Manual of Mental Disorders (5th edition)

International Classification of Diseases, tenth revision

Preferred Reporting Items for Systematic Review and Meta-Analysis

Post-traumatic stress disorder

World Health Organization

Afroz S, Tiwari PSN. Psychological abuse: Impact on children. Ind J Health Wellbeing. 2015;6(5).

Aiosa-Karpas CJ, Karpas R, Pelcovitz D, Kaplan S. Gender identification and sex role attribution in sexually abused adolescent females. J Am Acad Child Adolesc Psychiatry. 1991;30(2):266–71.

Article   CAS   Google Scholar  

Angelakis I, Austin J, Gooding P. Childhood maltreatment and suicide attempts in prisoners: A systematic meta-analytic review. Psychol Med. 2020;50(1):1–10.

Article   Google Scholar  

Baker A, Festinger T. Emotional abuse and emotional neglect subscales of the CTQ: Associations with each other, other measures of psychological maltreatment, and demographic variables. Child Youth Serv Rev. 2011;33(11):2297–302.

Bernstein DP, Fink L, Handelsman L, Foote J. Childhood trauma questionnaire. Assessment of family violence: A handbook for researchers and practitioners. 1998.

Black DA, Smith SlepAM, Heyman RE. Risk factors for psychological abuse. Aggression Violent Behavior. 2001;6:189–201.

Bor W, Collerson M, Cupit SC, McDermott B, Stallman HM, Walmsley KE. New directions in treatment of child physical abuse and neglect in Australia: MST-CAN a case study. Adv Mental Health. 2010;9:148–61.

Burns EE, Jackson JL, Harding HG. Child maltreatment, emotion regulation, and posttraumatic stress: The impact of emotional abuse. Journal of Aggression, Maltreatment & Trauma. 2010;19:801–19. https://doi.org/10.1080/10926771.2010.522947 .

Diaz A, Simantov E, Rickert VI. Effect of abuse on health: results of a national survey. Arch Pediatr Adolesc Med. 2002;156(8):811–7.

Duval S. The Trim and Fill Method. In Publication Bias in Meta-Analysis: Prevention, Assessment and Adjustments. Wiley; 2006. p. 127–44.

Egger M, Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34.

Garbarino J, Guttman E, Seeley JW. The psychologically battered child. San Francisco, CA: Jossey-Bass; 1986.

Google Scholar  

Gibb BE, Alloy LB, Abrahamson LY, Rose DT, Whitehouse WG, Donovan P, Tierney S. History of child maltreatment, negative cognitive styles and episodes of depression in adulthood. Cogn Ther Res. 2001;25:426–46. https://doi.org/10.1023/A:1005586519986 .

Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1. 0 [updated March 2011]. The Cochrane Collaboration: 2011. Available from www.cochrane-handbook.org . Accessed 29 Aug 2011.

Hovdestad W, Campeau A, Potter D, Tonmyr L. A systematic review of childhood maltreatment assessments in population-representative surveys since 1990. PloS One. 2015;10(5).

Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, Dunne MP. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. The Lancet Public Health. 2017;2(8):e356–66.

Iwaniec D. The emotionally abused and neglect child: Identification, assessment, and intervention. New York: John Wiley and Sons; 1995.

Kilpatrick DG, Saunders BE, Smith DW. Youth victimization: Prevalence and implications. Research in brief. Washington, DC: US Department of Justice, Office of Justice Programs; 2003.

Maguire W, Naughton C, Tempest M, . . . Kemp. A systematic review of the emotional, behavioural and cognitive features exhibited by school‐aged children experiencing neglect or emotional abuse. Child Care Health Develop. 2015;41(5):641–53.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9.

Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Stewart LA. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1.

Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med. 2012;9(11):e1001349.

Vega Castelo ADL. Outcomes of psychological maltreatment in children. 2013.

Viechtbauer W. Conducting meta-analyses in R with the metafor package. J Stat Softw. 2010;36(3):1–48.

Wells G, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P. NewCastle–Ottawa quality assessment scale—case control studies. 2012–06–15]. 2017. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp .

World Health Organization. Child Maltreatment. 2020. Retrieved from https://www.who.int/news-room/fact-sheets/detail/child-maltreatment .

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Acknowledgements

FM received support from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme [Grant Agreement Number 852787] and the UK Research and Innovation Global Challenges Research Fund [ES/S008101/1].

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Zhuoni Xiao, Mina Murat Baldwin & Aja Louise Murray

School of Social and Political Science, University of Edinburgh, Edinburgh, UK

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Clinical Psychology Department, University of Edinburgh, Edinburgh, UK

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ZX is the guarantor of this review and has conceived the original research idea, has developed the selection criteria and search strategy, and will analyse the data. ZX and MMB will screen and extract the data from studies and will assess the risk of bias of each study. ALM will resolve any disagreements, make the final judgement, and will provide the guidance for interpreting the analysis. ALM, IO and FM guided the draft of the protocol, verified the selection criteria and search strategy, and contributed the revision of the protocol. ALM, IO and FM will also supervise the review process and will provide feedback if needed. All authors have read and approved the final manuscript of the review protocol.

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Correspondence to Zhuoni Xiao .

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Xiao, Z., Baldwin, M.M., Meinck, F. et al. The impact of childhood psychological maltreatment on mental health outcomes in adulthood: a protocol for a systematic review and meta-analysis. Syst Rev 10 , 224 (2021). https://doi.org/10.1186/s13643-021-01777-4

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DOI : https://doi.org/10.1186/s13643-021-01777-4

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How Emotional Abuse in Childhood Changes the Brain

Ann-Louise T. Lockhart, PsyD, ABPP, is a board-certified pediatric psychologist, parent coach, author, speaker, and owner of A New Day Pediatric Psychology, PLLC.

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Childhood emotional abuse and neglect can result in permanent changes to the developing human brain. These changes in brain structure appear to be significant enough to potentially cause psychological and emotional problems in adulthood, such as psychological disorders and substance misuse.

Around 14% of Americans report experiencing emotional abuse or neglect during their childhood. Emotional abuse can include:

• Insulting , name-calling, or swearing at a child
• Threatening to physically harm the child
• Terrorizing or otherwise making the child feel afraid

Emotional neglect involves failing to meet a child's emotional needs. This can include failing to:

• Believe in the child
• Create a close-knit family
• Make the child feel special or important
• Provide support
• Want the child to be successful

If you are a victim of child abuse or know someone who might be, call or text the Childhelp National Child Abuse Hotline at 1-800-422-4453 to speak with a professional crisis counselor.

For more mental health resources, see our National Helpline Database .

How Abuse Alters Brain Structure

As children grow, their brains undergo periods of rapid development . Negative experiences can disrupt those developmental periods, leading to changes in the brain later on.

Research supports this idea and suggests that the timing and duration of childhood abuse can impact the way it affects those children later in life. Abuse that occurs early in childhood for a prolonged period of time, for example, can lead to particularly negative outcomes.

Dr. Martin Teicher and his colleagues at McLean Hospital, Harvard Medical School, and Northeastern University studied the relationship between abuse and brain structure by using magnetic resonance imaging (MRI) technology to identify measured changes in brain structure among young adults who had experienced childhood abuse or neglect.

They found clear differences in nine brain regions between those who had experienced childhood trauma and those who had not. The most obvious changes were in the brain regions that help balance emotions and impulses, as well as self-aware thinking. The study's results indicate that people who have been through childhood abuse or neglect do have an increased risk of developing mental health issues later on.

Childhood maltreatment has also been shown to increase the risk of anxiety disorders , bipolar disorder , major depression , personality disorders , post-traumatic stress disorder (PTSD) , and psychosis . The experience may also translate into a higher risk of substance misuse as a result of changes in their brain associated with impulse control and decision-making.

Effects on Brain Structure

Childhood abuse and neglect can have several negative effects on how the brain develops. Some of these are:

• Decreased size of the corpus callosum, which integrates cortical functioning—motor, sensory, and cognitive performances—between the hemispheres
• Decreased size of the hippocampus , which is important in learning and memory
• Dysfunction at different levels of the hypothalamic-pituitary-adrenal (HPA) axis, which is involved in the stress response
• Less volume in the prefrontal cortex, which affects behavior, emotional balance, and perception
• Overactivity in the amygdala , which is responsible for processing emotions and determining reactions to potentially stressful or dangerous situations
• Reduced volume of the cerebellum , which can affect motor skills and coordination

Press Play for Advice On Healing Childhood Wounds

This episode of The Verywell Mind Podcast , featuring award-winning actress Chrissy Metz, shares how to heal childhood trauma, safeguard your mental health, and how to get comfortable when faced with difficult emotions. Click below to listen now.

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Effects on Behavior, Emotions, and Social Function

Because childhood abuse, neglect, and trauma change brain structure and chemical function, maltreatment can also affect the way children behave, regulate emotions, and function socially. These potential effects include:

• Being constantly on alert and unable to relax, no matter the situation
• Feeling fearful most or all of the time
• Finding social situations more challenging
• Learning deficits
• Not hitting developmental milestones in a timely fashion
• A tendency to develop a mental health condition
• A weakened ability to process positive feedback

These effects can continue to cause issues in adulthood if they're not addressed. Adults who experienced maltreatment during childhood may have trouble with interpersonal relationships—or they may avoid them altogether.

These outcomes could be related to attachment theory , or the idea that our early relationships with caregivers influence the way we relate to people later on in life. Emotional abuse and neglect don't allow for a secure attachment to form between a child and caregiver, which causes distress for the child and influences the way they see themselves and others.

Adults who went through childhood emotional abuse or neglect may also experience:

• Emotional dysregulation
• Feelings of hopelessness
• Low self-esteem
• Negative automatic thoughts
• Problems coping with stressors

How childhood abuse or neglect affects children later in life depends on a variety of factors:

• How often the abuse occurred
• How long the abuse lasted
• The kind and severity of the abuse
• The age of the child during the abuse
• Who the abuser was
• Whether or not the child had a dependable, loving adult in their life
• If there were any interventions in the abuse
• Other individual factors

Through treatment, it is possible to address the effects of childhood emotional abuse and neglect. Treatment in these cases is highly individual since maltreatment can take many forms and each person's response to it may differ.

Any form of treatment would likely include therapy and, depending on whether or not any other mental health conditions are present, may include medication as well. Brain plasticity is at its peak during early childhood, meaning early intervention is the best way to recover from changes in the brain caused by stress and trauma. Although the adult brain continues to have plasticity, it requires more effort and time to re-establish healthy neural connections. Some effective forms of therapy for children and adults are:

• Attachment and Biobehavioral Catchup (ABC): Partnering with parents and teaching them to re-interpret their children's behavior and respond to them sensitively. Creating a safe and positive interaction between the parent and the child fosters a secure attachment and healthy brain development. This results in children who can learn to self-regulate their own emotions and behaviors.
• Exposure therapy : Exposure therapy involves interacting with something that typically provokes fear while slowly learning to remain calm. This form of therapy may improve neural connections between several regions in the brain.
• Family therapy : Family therapy is a psychological treatment intended to improve relationships within the entire family and create a better, more supportive home environment. This type of treatment may improve HPA axis functioning and lead to a healthier stress response. 
• Mindfulness-based approaches : Mindfulness-based therapy focuses on helping people develop a sense of awareness of their thoughts and feelings so they can understand them and better regulate them. These approaches may help improve resiliency against stress by benefiting several brain regions and improving neural connections.
• Play therapy: Play therapy can help a child process and express emotions in a safe environment. Using toys, games, and crafts can help a child get comfortable and may use play to act out or express their emotions and learn to regulate their behavior while adopting healthier coping mechanisms.
• Trauma-focused cognitive behavioral therapy (TF-CBT) : TF-CBT focuses on helping people learn new coping skills, restructure negative or unhelpful thoughts, regulate their moods, and overcome trauma by crafting a trauma narrative. This form of therapy may help reduce overactivity in the amygdala.

A Word From Verywell

Emotional abuse and neglect are linked with structural and functional changes in the brain of a child that can affect their well-being for years to come. Depending on the severity and duration of the abuse, and other factors, a neglected or abused child may develop cognitive impairments, behavioral problems, and emotional dysregulation, as well as challenges in developing healthy social relationships.

Early intervention and support can help reverse some of the damage that happened in the young developing brain. Without intervention, the child is at higher risk for developing mental health problems, personality disorders, and substance abuse in the future.

It is also important to increase education and awareness for new parents to help them understand their child’s needs and how to respond appropriately and sensitively. Some parents have endured abuse themselves and may need additional support from parenting coaches and psychotherapy, to stop the cycle of intergenerational abuse.

Can You Get PTSD From Emotional Abuse?

• Emotional Abuse and PTSD

Emotional Abuse and C-PTSD

Signs of emotional abuse.

• PTSD Symptoms

Effects of Emotional Abuse

• How to Heal
• Next in PTSD Guide How PTSD Is Diagnosed

Emotional abuse may lead to PTSD or another stress disorder known as C-PTSD (complex post traumatic stress disorder). The two stress disorders have several overlapping symptoms. But C-PTSD often causes more extensive issues with emotional regulation, interpersonal relationships, and negative self-thoughts.

Unlike PTSD, which is typically caused by a single traumatic event, C-PTSD usually involves chronic trauma that lasts for months or years. As a result, some people with C-PTSD may need long-term therapy to recover from emotional abuse.

This article explains how you can develop C-PTSD or PTSD from emotional abuse. Learn more about emotional abuse, its effects, and the signs you may be experiencing it.

How Is Emotional Abuse Related to PTSD?

Abusers can use many non-violent tactics to assert their power over someone. These emotionally abusive behaviors are meant to terrorize and control another person and keep them in the abusive relationship .

Living in this constant state of stress or experiencing extremely frightening events, such as being threatened, can lead to symptoms from the trauma.

The DSM-5 (Diagnostic Manual for Mental Disorders 5th revision), a handbook used by healthcare professionals to diagnose mental health disorders, does not recognize C-PTSD as a formal diagnosis, but it does recognize PTSD as one.

On the other hand, the ICD-11 (International Classification of Diseases 11th Revision), which is published by the World Health Organization, recognizes C-PTSD as a "sibling disorder" to PTSD that has three additional groups of symptoms:

• Problems in affect regulation, such as irritability or feeling emotionally numb
• Beliefs about oneself as defeated or worthless, along with feelings of shame, guilt, or failure related to the traumatic event
• Difficulties sustaining interpersonal relationships

Because the concept of C-PTSD is relatively new, healthcare providers typically make a diagnosis of PTSD instead of C-PTSD. Still, understanding C-PTSD helps providers more accurately define a person's experience and form an appropriate treatment plan.

Emotional abuse is defined as any non-physical behavior that is designed to control, subdue, punish, or isolate another person through the use of humiliation or fear.

Emotional abuse includes—but is not limited to—the following tactics:

• Erosion of self-esteem: Abusers may insult your appearance, dismiss your thoughts, feelings, or passions as silly or unimportant, attempt to humiliate you in public, belittle you, call you mean names, or accuse you of being things you are not.
• Control: Abusers may follow or spy on you, gaslight you by trying to convince you the abuse never happened, control your access to finances, force you to quit your job, or stonewall you by refusing to communicate.
• Instilling fear: Abusers may have frequent outbursts or behave unpredictably. They may destroy your property, drive recklessly with you in the vehicle, outright threaten you or your loved ones, or tell you stories of how they could physically abuse you.
• Blame-shifting: Abusers may try to convince you that the abuse wouldn't happen if you were different in some way. They may blame you for their problems, deny the abuse, or throw made-up accusations your way, such as cheating or lying, when you try to raise an issue.
• Dehumanization: Abusers may try to make you feel unimportant. They may deny you support, withhold affection, degrade you, ignore your physical or emotional boundaries, or constantly interrupt you.
• Isolation: Abusers may try to come in between you and your family and friends. They may prevent you from socializing, character assassinate you, or attempt to turn you against your family members (or your family members against you).

How Trauma Impacts the Brain

During a traumatic event, the body produces large amounts of stress hormones which affect the amygdala , hippocampus, and prefrontal cortex. These areas of the brain are responsible for feelings and actions related to fear, clear thinking, decision-making, and memory. These functions and abilities have been found to be decreased in a person who has experienced trauma.

PTSD From Emotional Abuse Symptoms

A person who is diagnosed with PTSD will experience symptoms that persist for months or even years after the traumatic event.

There are four categories of PTSD symptoms, which can vary in severity:

• Intrusive thoughts: Someone with PTSD may experience distressing dreams or flashbacks of a traumatic event over and over again. They may feel as though it is impossible for them to escape their trauma.
• Avoidance: Someone with PTSD may avoid anything that reminds them of the trauma, such as people, places, activities, or situations. They may try to avoid remembering, thinking, or talking about their feelings or what happened.
• Cognition and mood changes: Someone with PTSD may be unable to recall important aspects of the traumatic event. They may have distorted thoughts or feelings about themselves or others, or blame themselves for what happened. They may have persistent feelings of fear, horror, anger, guilt, and shame, or feel uninterested in activities they once enjoyed. They may feel detached from others, or become unable to experience positive emotions.
• Heightened reactivity: Someone with PTSD may become easily irritable, have angry outbursts, or behave recklessly. They may become easily startled, overly suspicious of their surroundings, or have problems concentrating or sleeping .

Research shows that people who experience emotional abuse often experience more severe depression, anxiety, stress, and emotional dysfunction compared to people who have experienced only physical abuse, only sexual abuse, or combined physical and sexual abuse.

Emotional abuse can have short and long-term effects on a person's mental and physical health as well as their ability to have healthy relationships down the line.

Verywell / Danie Drankwalter

Mental Health

Emotional abuse can impact your mental health. Repeatedly experiencing emotional abuse can wear down your sense of self, self-worth, and confidence. You may find yourself feeling constantly afraid, ashamed, guilty, unwanted, powerless, and hopeless. You may feel like you're unable to feel positive feelings. Emotional abuse can even lead to depression and anxiety .

Physical Health

Emotional abuse puts the body in a constant state of stress, which can lead to physical health problems, including changes to the brain. Studies have also shown that children who experience psychological abuse are at higher risk for long-term and future health problems, including diabetes , lung disease, malnutrition , vision problems, heart attack , arthritis , back problems, and high blood pressure .

Interpersonal Relationships

When you have been in an emotionally abusive relationship, the abuser has probably made you feel isolated, unwanted, and alone. These experiences affect how you see yourself and others, even when the abusive relationship ends.

Many people who have experienced abuse feel distrustful of others and cannot form stable relationships. They may end up in another abusive relationship because the dysfunctional relationship dynamic has been normalized.

How to Heal from C-PTSD

Individuals with PTSD should work with a mental health professional experienced with PTSD, such as a therapist or psychiatrist.

Treatment for PTSD includes medications, psychotherapy, or both. Some people with PTSD may also be affected by ongoing trauma, depression, panic disorder, or substance abuse , which will also need to be addressed by a team of health professionals.

Treatment options for PTSD and C-PTSD include:

• Medications: The most common medications for treating PTSD are SSRI antidepressants , which can often help decrease certain PTSD symptoms. Other medications may be recommended for symptoms such as sleeping problems or nightmares .
• Psychotherapy: Also known as talk therapy , psychotherapy helps a person with PTSD learn about symptoms, identify triggers, and help develop skills and strategies to manage symptoms. Psychotherapy may also target symptoms directly or help a person manage social, family, or job-related problems.
• Cognitive behavioral therapy (CBT): Two types of CBT used for PTSD are prolonged exposure (PE) therapy and cognitive processing (CP) therapy . PE helps a person face negative feelings associated with trauma through gradual exposure to their emotional triggers. CP helps a person make sense of and reframe their bad memories and negative thoughts.
• Eye movement desensitization and reprocessing (EDMR): This therapy combines PE therapy with a series of rapid, rhythmic eye movements that help you to reprocess traumatic memories and weaken your response to them.

Emotional abuse is a type of trauma that can lead to significant consequences. PTSD is a psychiatric disorder that affects your thoughts, memory, emotions, and thinking. It can have you in a constant state of fear and alertness, which causes your body to produce large amounts of stress hormones.

Emotional abuse affects your physical and mental health, as well as your ability to form healthy relationships, even when you leave the abusive relationship. If you've been diagnosed with PTSD, a mental health professional and appropriate medication can help you process your trauma and manage symptoms.

Giourou E, Skokou M, Andrew S, Alexopoulou K, Gourzis P, Jelastopulu E. Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? . World J Psychiatry . 2018 Mar;8(1):12-19. doi:10.5498/wjp.v8.i1.12

Maercker A. Development of the new CPTSD diagnosis for ICD-11 . Bord Personal Disord Emot Dysregul. 2021 Mar;8(1):1-4. doi:10.1186/s40479-021-00148-8

Karakurt G, Silver K. Emotional abuse in intimate relationships: The role of gender and age . Violence Vict . 2013 Dec;28(5):804-821. doi:10.1891/0886-6708.vv-d-12-00041

Roeckner A, Oliver K, Lebois L, Rooij S, Stevens J. Neural contributors to trauma resilience: A review of longitudinal neuroimaging studies . Transl Psychiatry . 2021 Oct;11(1):508. doi:10.1038/s41398-021-01633-y

American Psychiatric Association. What is posttraumatic stress disorder? .

Dye H. Is emotional abuse as harmful as physical and/or sexual abuse? . J Child Adolesc Trauma . 2020 Dec;13(4):399-407. doi:10.1007/s40653-019-00292-y

U.S. Department of Health and Human Services. Emotional and verbal abuse .

Children's Bureau. Long-term consequences of child abuse and neglect .

Huh HJ, Kim SY, Yu JJ, Chae JH. Childhood trauma and adult interpersonal relationship problems in patients with depression and anxiety disorders .  Ann Gen Psychiatry . 2014;13:26. doi:10.1186/s12991-014-0026-y

National Institute of Mental Health. How is PTSD treated? .

Schrader C, Ross A. A review of PTSD and current treatment strategies . Mo Med . 2021 Dec;118(6):546-551.

By Rebecca Valdez, MS, RDN Valdez is a registered dietitian nutritionist, health writer, and nutrition consultant. She received her MS degree in nutrition from Columbia University.

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Emotional abuse and neglect: time to focus on prevention and mental health consequences

Veena kumari.

Division of Psychology, Department of Life Sciences, Brunel University London; and Centre for Cognitive Neuroscience, College of Health, Medicine and Life Sciences, Brunel University London, UK

Associated Data

For supplementary material accompanying this paper visit https://doi.org/10.1192/bjp.2020.154.

Emotional abuse and emotional neglect are among the most prevalent of childhood maltreatment types and associated with a range of poor mental health outcomes. We need to move beyond correlational research and shift our focus to sophisticated multimodal studies to fully understand the psychobiological mechanisms underlying these associations and to intervention studies.

Childhood maltreatment is commonly described as physical, sexual or emotional abuse and physical or emotional neglect by a parent, caregiver or other adult, with all kinds of abuse resulting from acts of commission, and neglect from acts of omission. There has been relatively less societal and research attention on emotional abuse and emotional neglect, compared with physical and sexual abuse and physical neglect. This might be explained, at least in part, by their less visible immediate impact (i.e. no physical injury or outward signs of abuse) and considerable regional and cultural variations in the definition of what constitutes emotional abuse or (emotional) neglect. Certain facets of emotional abuse, such as constant swearing, yelling, criticism or humiliation of a child, are easily noticeable, but others, such as unrealistic expectations or unreasonable demands on the child, or unfair treatment because of certain characteristics (e.g. physical disability, or appearance), are not always recognised. In some cases, these less apparent facets of emotional abuse may arise out of the childhood or lived experience of parents, caregivers, teachers and others, but nonetheless still cause (unintended) harm to the child. Emotional neglect, defined usually as a failure to attend to the child's emotional needs (e.g. never showing emotion while interacting with the child), can also be difficult to spot and quantify, as many parents or caregivers find it hard to provide a safe and loving environment for their children when facing relationship difficulties, mental health problems or addiction issues. In some settings, emotional abuse/neglect may also echo culturally accepted practices, for example the girl child neglect phenomenon seen in certain Asian communities, whereby girls receive less care and fewer resources than boys in the same family. Elimination of childhood maltreatment, if (at all) possible, is going to require efforts from many sections of society, including the government. Until these efforts completely succeed, psychiatry, psychology and neuroscience disciplines must continue to act to fully understand the psychobiological processes that explain mental health problems emerging in association with emotional abuse/neglect, alone or simultaneously with other kinds of maltreatment, and to develop and test suitable interventions to correct them.

The scale of the problem

Despite difficulties in recognising and measuring emotional abuse, meta-analyses of the global prevalence of maltreatment convincingly reveal that childhood emotional abuse is self-reported by a much larger proportion of the adult population (about 36%) compared with physical (about 18%) or sexual abuse (8–18%), or physical neglect (about 16%). 1 , 2 Interestingly, studies reliant on informants of abuse have documented a much lower prevalence of emotional abuse than those using self-reports. Childhood emotional neglect, which is likely to be underreported in some settings, is still reported by about 18% of the adult population. 2 Children from any background can experience emotional abuse/neglect, although the prevalence rates may be higher in certain groups. For example, lesbian, gay, bisexual or transgender (LGBTQ+) youth may be more prone to experiencing emotional abuse, and possibly all types of abuse, because of societal ignorance or non-acceptance. Children from disadvantaged sectors of society, such as child workers or children displaced owing to war and other crises, may be subject to both inter- and intra-familial abuse and neglect as they spend time away from their families. At present, there are limited data on this topic from specific subgroups or low-resource countries.

Unpacking mental health consequences

Children who suffer maltreatment of any kind are known to experience poorer physical and mental health as adults, regardless of culture and geographical variations. Many people who suffered emotional abuse as children show feelings of hopelessness, poor self-esteem, reduced sense of social support, poor satisfaction with life, neurobiological changes in stress response systems, and structural and functional brain deficits; they are also at a heightened risk of developing psychiatric disorders. Problems such as depression, anxiety, eating disorders, suicidal symptomatology, psychosis, personality disorder and substance misuse often emerge in childhood and last through adulthood to old age. Importantly, a growing body of literature from both high- and low-income countries indicates that emotional abuse might have the most wide-ranging negative mental health impact of all childhood maltreatment types. 3 At present, there are few data addressing mental health consequences of emotional versus physical neglect. Nonetheless, both emotional abuse and emotional neglect seem to be a transdiagnostic risk factor for psychiatric disorders, especially anxiety and depression, perhaps mediated by dysfunctional (emotional) processing of self- and other-related information, accompanied with altered use or reduced availability of neural resources.

Further to simple association studies, there is now a pressing need for further research to fully examine the mental health consequences of emotional abuse and neglect at both ‘what’ and ‘how’ levels (i.e. what are the behavioural and brain changes following emotional abuse/neglect and how do they contribute to specific mental health outcomes?). A clear understanding of the psychobiological mechanisms that mediate between childhood emotional abuse and neglect and later vulnerability to specific mental disorders is critical for reducing such vulnerability and identifying targets for developing novel interventions. Although there have been some studies of neurophysiological correlates of childhood maltreatment (e.g. event-related brain potentials to facial expressions of anger or fear in maltreated versus non-maltreated children, or adults with and without a history of childhood maltreatment), they typically have not distinguished between different types of abuse and neglect. They have neither specifically focused on emotional abuse/neglect, which can be present with or without physical and sexual abuse and physical neglect, nor examined the observed neurophysiological changes in relation to the risk for particular disorders (e.g. depression versus psychosis). There is also a need for longitudinal studies examining the long-term impact of specific abuse and neglect, along with associated psychobiological changes, on prevalence of psychiatric disorders that usually emerge later in life. Lastly, future studies must proactively enquire about the protective factors that might promote resilience in the face of childhood emotional abuse/neglect.

Reversing adverse mental health effects

With a paucity of studies empirically addressing the mechanisms underlying the association between emotional abuse/neglect and mental disorders, there are few clearly defined targets for reversing, or preventing the risks for, mental health problems in emotionally maltreated youth. However, it is already known that adults who suffered childhood maltreatment in general show a worse-than-usual response to standard pharmacological approaches to ameliorate their mental health problems, such as depressive symptoms, and respond relatively better to psychological interventions. This, taken together with evidence (e.g. 3 ) of the extensive and undesirable mental health impact of emotional abuse and neglect, encourages the development and use of psychological interventions, especially those targeting aberrant emotional processes, to reverse or even prevent (if applied in time) adverse mental health outcomes for maltreated children.

Encouragingly, there are early indications that psychological interventions aimed at correcting aberrant attentional processes or interpretational biases may be applied to improve mental health outcomes in maltreated youth. 4 However, much of the research in this area has been correlational. The research focus and funding priorities now need to be expanded to include intervention studies 5 and facilitate studies that would yield valuable information for identifying specific treatment targets (e.g. certain information processing or memory biases, unhelpful coping styles) for developing novel interventions and refining existing ones.

Reducing harm through prevention strategies

To minimise the short- and long-term harm associated with emotional abuse and neglect, child and adolescent psychiatrists, clinical psychologists and other professionals who routinely work with young people need to actively look for their signs and intervene to educate and safeguard where indicated. It is also important for these disciplines to interact with law makers and enforcement bodies to ensure that emotional abuse and (emotional) neglect, in the absence of visible signs, are appropriately acknowledged in governmental policies, and that no historically underserved populations (e.g. girls in certain societies) are ignored. Armed with empirical evidence, mental health professionals should also be encouraged and empowered to actively contribute to grass root campaigns to raise public awareness about the signs and consequences of these extremely harmful forms of childhood maltreatment.

Conclusions

Given the high prevalence rates and well-documented harmful mental health consequences of emotional abuse and neglect across countries and cultures, it is essential that we not only learn to recognise their signs but focus our efforts on clearly understanding the underlying mechanisms and on developing suitable interventions to minimise and prevent the risk of associated poor mental health outcomes. At present, the research on possible interventions for reversing the mental health problems associated with this kind of childhood maltreatment is in its infancy but shows promise. In parallel, we must also work towards raising public awareness about the signs and the mental health impact of emotional abuse and neglect and ensure that they are appropriately acknowledged in global child protection laws and policies.

V.K. reports a grant from Medical Research Council, UK (grant number: MR/N006194/1), for some of the research discussed in this editorial.

Declaration of interest

Supplementary material.

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Emotional Abuse

Reviewed by Psychology Today Staff

Emotional abuse is a pattern of behavior in which the perpetrator insults, humiliates, and generally instills fear in an individual in order to control them. The individual's reality may become distorted as they internalize the abuse as their own failings.

• What Is Emotional Abuse?
• Healing from Abuse

An isolated occurrence doesn’t necessarily qualify as emotional abuse, but a pattern of behavior that creates fear and control does. Such mistreatment can occur in a range of interpersonal contexts, including a parental relationship, a romantic relationship , or a professional relationship.

People who suffer emotional abuse can experience short-term difficulties such as confusion, fear, difficulty concentrating, and low confidence , as well as nightmares, aches, and a racing heart. Long-term repercussions may include anxiety , insomnia , and social withdrawal.

Emotional abuse centers around control, manipulation, isolation, and demeaning or threatening behavior. Signs of abuse include:

• Monitoring and controlling a person’s behavior, such as who they spend time with or how they spend money. 

• Threatening a person’s safety, property, or loved ones

• Isolating a person from family, friends, and acquaintances

• Demeaning, shaming , or humiliating a person

• Extreme jealousy , accusations, and paranoia

• Delivering constant criticism

• Regular ridicule or teasing

• Making acceptance or care conditional on a person’s choices

• Refusing to allow a person to spend time alone

• Thwarting a person’s professional or personal goals

• Instilling self-doubt and worthlessness 

• Gaslighting : making a person question their competence and even their basic perceptual experiences.

Sometimes emotional abuse doesn’t involve overt threats or vigilant monitoring. More subtle signals that emotional abuse may be occurring in an important relationship include regularly judging a person’s perspective without trying to understand it, relying on blame rather than improvement, regarding the other person as inferior, frequent sarcasm, and telling the other person how to feel in an attempt to be “helpful.”

Perpetrators of emotional abuse consistently criticize, shame , and humiliate in order to gain control and power in a relationship. They may yell at their victim, call them names, or level baseless accusations against them. They may act jealous and possessive, monitoring the person’s whereabouts and communication by checking their phone.

An emotional abuser may gaslight their victim into believing that their unhappiness is their own fault. And they often seek to isolate their victim from friends and family, to prevent the person from getting a reality check or broader perspective.

Abusers are often skilled manipulators, so those suffering emotional abuse often don’t recognize the harmful patterns. Those tactics may lead the victim to believe that they are to blame for the problems in the relationship. These patterns occur consistently and often relent only when the victim understands the partner’s manipulative behavior and threatens to leave or ends the relationship.

Gaslighting constitutes a form of emotional abuse. By manipulating the victim to doubt his or her own sense of reality—continually saying things like, “That’s not how it happened,” or “You’re crazy,”—the gaslighter asserts control over the relationship, leading the victim to rely on the perpetrator for a sense of reality. Gaslighting can instill confusion, self-doubt, anxiety, and depression .

Abusers deny their harmful patterns of behavior and blame their victims. They tend to be possessive, hypersensitive, and have a strong need for control, which motivates them to wield power in the relationship. Abusive tendencies may stem from deep insecurities or a mental health condition such as a Cluster B disorder like antisocial personality disorder or narcissistic personality disorder.

Emotional abuse and physical abuse sometimes co-occur, but not always. Emotional abuse, however, often precedes physical violence, which only begins after a perpetrator's emotional assault tactics fail to control a person’s behavior.

Psychological abuse can sometimes be as damaging, or even more damaging, than physical violence. While physical abuse is occasional and cyclical, emotional abuse is constant. Violence tends to be perceived as the offender’s failing, whereas victims are more likely to internalize emotional abuse as their own personal failings.

Research suggests that over 50 percent of adults may experience emotional abuse in their lifetime, although the concept is difficult to reliably measure. Emotional abuse is designated as an adverse childhood experience , one experienced by 11 percent of children, according to the Centers for Disease Control and Prevention.

Leaving an abusive relationship is challenging but completely possible. Victims must come to recognize that reasoning with an abuser is not effective and that the individual will probably never change. To begin to heal, experts advise those leaving an emotionally abusive relationship seek support from one’s social circle and often a therapist.

Victims of emotional abuse are often worn down so that they cannot see the harmful dynamics clearly. They come to believe that the relationship challenges are their own fault. They may spend time ruminating and bargaining, considering how they can adapt their behavior or avoid confrontation. Victims may struggle with problems of self-esteem , as well as anxiety and depression.

Childhood verbal abuse can include constant criticism, put-downs, and rejection. Parents may stop the child from expressing anger or sadness, thereby stifling their range of emotions. The brain also inflates the prominence of negative experiences compared to positive experiences, which renders parental abuse deeply ingrained. (It also makes it nearly impossible for an affectionate parent to counter the effects of an abusive parent.) Childhood abuse can lead to emotional pain, anxiety, depression, self-criticism, low self-esteem, and difficulty forming stable and trusting relationships. But therapy can help individuals process parental abuse and abandon the maladaptive coping mechanisms they developed in childhood.

Survivors of emotional abuse or domestic violence often remain tethered to the relationship longer than outsiders can understand. But there are many reasons why leaving is so difficult. Constant accusations and harassment can wear down the victim and lead to distorted thoughts such as believing that she or he “deserves it” or that emotional abuse isn’t “real abuse.” Fear, damaged self-worth, concern for children or the family, financial constraints, and other factors can also lead victims to stay in abusive relationships .

Most victims of abusive or violent relationships eventually leave. It often takes several attempts, but a few common themes emerge from womens’ experience finally ending the relationship. One step is confronting reality, by acknowledging that the circumstances will not change, becoming educated about emotional abuse, and realizing the abuse is not the victim’s fault, which allows them to recover a sense of self-worth. Another step is accepting help from family, friends, or a therapist, who can see the situation clearly and provide resources and support. Another factor is the desire to protect the children from witnessing abuse or being abused themselves. The last factor for some is reaching a breaking point, where fear simply becomes overwhelming. 

Although turbulent childhoods can produce substantial challenges, research suggests they can also yield great strengths. People raised in a stressful household—whether due to poverty, abuse, neglect, or other circumstances—may have enhanced cognitive flexibility, showcasing the ability to adapt, take risks, and tolerate ambiguity.

Therapy can help survivors move forward by processing the experience, rebuilding self-esteem, and addressing symptoms such as anxiety or insomnia. In the context of a new relationship, survivors can continue healing from emotional abuse by acknowledging the past abuse with their partner, resolving to prioritize oneself over any potential abuse in the future, and then responding to triggers of past pain with self-compassion.

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