Magazine article Clinical Psychiatry News

APA Urged to Focus on Exposure to Violence

Magazine article Clinical Psychiatry News

APA Urged to Focus on Exposure to Violence

Article excerpt

NEW YORK -- Traumatic stress in youth is the single most important contributor to later psychiatric morbidity and mortality, and the American Psychiatric Association should make violence and its sequelae a major organizational priority, according to a new report.

The report of the APA Task Force on the Biopsychosocial Consequences of Childhood Violence, which is being submitted by the association's Joint Reference Committee for approval, also concluded that the prevention of trauma and violence is potentially the single most effective strategy for the prevention of mental illness.

Much of the epidemiologic data on exposure to violence during childhood has emerged from the Adverse Childhood Experiences (ACE) study, which is a collaboration of the Centers for Disease Control and Prevention and the Kaiser-Permanente Medical Care Program in San Diego. This ongoing study, which is investigating the impact of adverse childhood experiences on adult health, includes approximately 175,000 members of the Kaiser health plan, co-principal investigator Vincent J. Felitti said at the American Psychiatric Association's Institute on Psychiatric Services.

The ACE study has identified several specific categories of adverse childhood experiences that are associated with numerous health risk factors later in life, and has found these experiences to be far more common than was previously appreciated. (See box at right.)

The subjects in the study are predominantly white and well educated. "In no way can this group be considered an aberrant population," said Dr. Felitti, who is an internist with Kaiser-Permanente and clinical professor of medicine, University of California, San Diego.

Nonetheless, more than half reported having experienced at least one of these early life adverse events (ACE score one) and one-quarter reported having two or more, according to Dr. Felitti. Serious physical and emotional abuse was reported by one in nine people, and sexual abuse was reported by 28% of women and 16% of men. "This is hard to believe unless you routinely ask people--in which case it becomes blatantly obvious," he said.

Then the ACE researchers looked at the impact of these events on health risk factors in adulthood. Smoking and self-acknowledged alcohol abuse strongly correlated with childhood exposure to violence, as did intravenous drug use. For males who had an ACE score of six or higher, there was a 46-fold increase in likelihood of intravenous drug use. An ACE score of six or higher also was associated with a 30- to 51-fold increase in the likelihood of attempted suicide in later life, he said.

The report also highlights the fact that traumatic stress is not only linked to psychological disorders such as depression and posttraumatic stress disorder (PTSD), but is also a major etiologic factor in medical morbidity and mortality. For example, regular smoking before age 14 not only correlated with early life exposure to violence, but also with later development of chronic obstructive pulmonary disease. "This was an important conceptual shift, the conversion of life experience into biomedical disease," Dr. Felitti said. And this conversion extended to ischemic heart disease, cancer, fractures, and liver disease.

Nonetheless, although exposure to violence heightens the risk for the development of PTSD, other stress-related disorders, and medical morbidity, it is not necessarily predictive of psychopathology. Another task force member, Dr. …

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