Prevalence estimates are available from the reported cases of emotional abuse, but such numbers are gross underestimates of its true prevalence. Hamarman and coauthors5 reviewed all the cases of emotional abuse reported by the National Center for Child Abuse and Neglect for 1998 in 43 states. They found a mean reported number of 11.7 per 10,000 children, vastly varying among states as a function of differences in caregiver culpability statutes.
In reexamining National Incidence Study of Child Abuse and Neglect NIS- 2 data (2814 children), Jones and McCurdy8 found that emotional maltreatment, broadly defined as emotional abuse and neglect, was present in 13.7% of the sample. Similarly, Vissing and colleagues9 surveyed 3346 parents of children under the age of 17 in the Second National Family Violence Survey. Setting conservative frequency criteria, they estimated that 26.7% and 11.3% reported at least 10 and 25 verbal abuse incidents per year, respectively.
The general psychological and psychiatric impact of emotional maltreatment has been studied in both nonclinical and clinical samples and has yielded compelling evidence that emotional abuse and neglect can have farreaching consequences, as great as or greater than thoese other types of abuse, and that these can include internalizing disorders, externalizing disorders, general psychiatric morbidity and impairment, low self-esteem, and suicidality.5
Vissing and colleagues9 eloquently demonstrated some of the interactions between different types of abuse and the challenge of teasing them out from a large sample of 3346 American parents surveyed for verbal and physical aggression. They found that the relationship between parental physical abuse and child delinquency was minimal unless the parents were also verbally abusive. They also found that there was no significant relationship between parental physical aggression and child interpersonal problems when the overlap with verbal aggression was controlled for. In other words, the psychological damage associated with physical abuse occurs at least in part because of the verbal abuse that typically accompanies it.
Mullen and coinvestigators10 studied a community sample of 497 women who reported an 11.5% rate of emotional abuse, similar for both maternal and paternal abuse. The association of emotional abuse to numerous negative adult outcomes (eg, adolescent pregnancy, sexual problems, low selfesteem, overall psychiatric diagnoses, eating disorders, depression, suicide attempts, and psychiatric hospitalization) was almost as strong as that for sexual abuse and stronger than that for physical abuse.
Ferguson and Dacey11 compared women health care providers with and without a history of psychological abuse (in the absence of physical or sexual abuse) and found that emotional abuse significantly predicted greater anxiety, depression, and dissociation. Similarly, in a sample of about 200 women presenting to a primary care practice, emotional abuse and neglect predicted psychological and physical symptoms, even when controlling for physical and sexual abuse and for lifetime trauma exposure.12RELATIONSHIP TO PSYCHIATRIC DISORDERS
Despite the relatively sparse research literature compared with that for other types of childhood maltreatment, emotional maltreatment has been shown to be associated with a wide range of Axis I and II psychiatric disorders. Some of the more relevant studies are noted here (although this is by no means intended as an exhaustive review of the literature).Personality disorders
In a sample of 168 outpatients who were depressed, emotional neglect predicted personality dysfunction.13 In addition, emotional abuse was found to be a risk factor for increasing personality disorder symptomatology in the outpatients. Another study compared a sample of 20 participants with borderline personality disorder (BPD) with 24 healthy controls.14 The researchers found that dissociative symptoms within the borderline group were associated only with emotional neglect and not other types of childhood trauma. Emotional neglect accounted for 23% of the total variance in dissociation scores.
Compared with patients without BPD, those with BPD remember both parents as significantly less caring and more controlling.15 In a sample of 116 outpatients with binge-eating disorder, of all the childhood traumas, emotional abuse was the one associated with greater likelihood of personality disorders.16 In a community-based longitudinal prospective study, it was found that childhood emotional neglect was associated with more avoidant and cluster A personality disorder symptoms in adolescence and adulthood.17
Similarly, in a large sample of 339 adults with alcohol(Drug information on alcohol) or drug dependence, emotional abuse emerged as a broad risk factor for personality disorders in clusters A, B, and C, while emotional neglect was more specifically related to schizoid personality traits.18 In a sample of 174 adults with various personality disorders, emotional abuse was the only trauma variable significantly associated with affective instability.19Mood disorders
A study of adults with major depression compared with healthy controls reported significantly greater emotional abuse and neglect, as well as physical abuse, in participants with depression.20 In a sample of 228 outpatients with major depression, greater depression severity at baseline was associated with childhood emotional abuse.21
There is growing body of research providing evidence for the long-standing clinical wisdom that trauma history is associated with more treatment-refractory depressions. Kaplan and Klinetob22 reported that compared with a small sample of adult outpatients with treatment-responsive depression, those with treatment-refractory depression reported histories of greater emotional abuse.Eating disorders
In one study, 80 women with bulimia nervosa were compared with a control group (there was no difference in sexual abuse history). The researchers found the most robust difference between the 2 groups was in psychological maltreatment, despite the fact that the women with bulimia nervosa had greater physical abuse histories than the controls.23
In a sample of 145 outpatients with binge-eating disorder, emotional abuse was significantly associated with greater body dissatisfaction, higher depression levels, and lower self-esteem in both genders.24 Similarly, in a non clinical sample of 236 women, emotional abuse was the only form of childhood trauma that predicted unhealthy adult eating attitudes.25Dissociative disorders
Although extreme childhood trauma is often encountered in the more severe dissociative disorders, such as dissociative identity disorder, emotional maltreatment appears to play a more prominent role at the less severe end of the dissociative spectrum. In a sample of about 50 patients with depersonalization disorder, severity of emotional abuse was found to predict depersonalization symptoms specifically, whereas severity of emotional combined with sexual abuse was predictive of overall dissociative symptoms.26 Similarly, in a sample of about 200 adolescent inpatients, it was found that emotional neglect was the strongest pathogenic risk factor for dissociative symptoms.27Somatoform and psychosomatic disorders
Van Houdenhove and colleagues28 found that patients with chronic fatigue syndrome and fibromyalgia had significantly higher emotional neglect and abuse scores than participants with medical disease and healthy controls. Similarly, in a group of patients with somatization disorder, of all childhood interpersonal traumas, chronic emotional abuse was the best predictor of unexplained medical symptoms.29Schizophrenia
In adults with schizophrenia, dissociative symptoms have been found to be associated with a history of emotional abuse as well as physical abuse.30 Similarly, emotional abuse was found to be associated with substance use in patients with schizophrenia.31 Emotional abuse and neglect, along with other childhood traumas, represent a risk factor for suicide attempts in patients with schizophrenia.32BIOLOGIC FINDINGS
The neurobiologic correlates and sequelae of emotional maltreatment have received very little attention. Nevertheless, studies suggest that emotional maltreatment can be associated with long-standing neurobiologic perturbations in adulthood.
In a study of individuals who were dependent on cocaine but abstaining, it was found that greater childhood emotional neglect was associated with lower cerebrospinal fluid levels of the serotonin metabolite 5-hydroxyindole acetic acid and the dopamine(Drug information on dopamine) metabolite homovanillic acid.33 Similarly, in patients with cocaine dependence who were abstaining, emotional neglect was independently associated with decreased urinary free cortisol output.34 On the other hand, Yehuda and colleagues35 found that adult offspring of Holocaust survivors reported significantly higher emotional abuse than controls, and that this abuse was significantly associated with 24-hour mean urinary cortisol.CONCLUSIONS
In conclusion, both researchers and clinicians run an important risk of faulty or incomplete models and interpretations when focusing primarily on physical and sexual abuse as the traumas of childhood. Clinicians must always be mindful that in patients presenting with or eventually revealing physical or sexual maltreatment, the emotional milieu in which those incidents occurred and that existed outside that maltreatment is paramount for a rich and full appreciation of patients' pathology as well as resilience.
Future psychiatric research will hopefully pay more attention to emotional abuse and neglect and their often profound impacts in their own right. It is likely that over the next decade, the growing attachment literature as well as animal models of maternal neglect will provide an important inroad to neurobiologic research on the impact of major emotional neglect on human development and psychopathologic outcomes.
Dr Simeon is associate professor of psychiatry at Mount Sinai School of Medicine, in New York, where she is director of the Depersonalization and Dissociation Research Program and codirector of the Compulsive and Impulsive Disorders Research Program. She is the author of many journal articles and books; her latest offering, Feeling Unreal: Depersonalization and the Loss of Self, is geared for professional and general audiences and is available from Oxford University Press. She reports no conflicts of interest regarding the topic of this article.