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Intrusive Traumatic Recollections and Comorbid Posttraumatic Stress Disorder in Depressed Patients

From the Department of Psychiatry (I.V.E.C., B.E.V., B.P.R.G.), Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.

Address reprint requests to: Ingrid V. E. Carlier, Department of Psychiatry, Academical Medical Centre, University of Amsterdam, Tafelbergweg 25, 1105 BC Amsterdam, The Netherlands.

	ABSTRACT

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OBJECTIVE: Recent studies have found evidence of the presence and role of intrusive traumatic memories in depressed patients. In this study, we attempted to replicate these findings, examining the full range of early and later traumatic events, as well as comorbid posttraumatic stress disorder, in male and female depressed patients.

METHODS: Sixty-nine outpatients meeting criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, for major depressive episode were recruited from the outpatient department of an academic hospital.

RESULTS: Seventy-five percent of the depressed patients were found to have had one or more early and/or more recent traumatic experiences. The symptom category of reexperiencing was diagnosed in 48% of these trauma-exposed respondents. Comorbid posttraumatic stress disorder was diagnosed in 13% of the total sample.

CONCLUSIONS: The findings show that depressed patients are highly likely to have experienced traumatic events and intrusive traumatic recollections. Future research should focus on the direction of any causal relationship between trauma, reexperiencing, posttraumatic stress disorder, and depression.

Key Words: intrusion • comorbidity • posttraumatic stress disorder • depression • trauma.

Abbreviations: DSM-IV = Diagnostic and Statistical Manual of MentalDisorders, fourth edition; PTSD = posttraumatic stressdisorder; SCID = Structured Clinical Interview for DSM-III-R; SI-PTSD = Structured Interview for PTSD.

	INTRODUCTION

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Research has demonstrated that depressed people are significantly more likely than their nondepressed counterparts to have experienced traumatic events. Predominantly these are early traumas (1, 2). There is an alarmingly high prevalence of early abuse (3). That such adverse experiences can have persistent harmful effects is also well known (4–7). Boudewyn and Liem (8) have shown that early sexual abuse can result in serious self-destructive behavior in the form of suicidality or self-mutilation. The high rate of traumatization in depressed patients implies at least two important lines of research: 1) intrusive memories in depressed patients and the role of intrusions in the course of depression and 2) the relationship of PTSD to depressive illness.

Intrusive recollections are extremely common in the immediate aftermath of traumatic events and are considered to be necessary aspects of emotional processing. If such intrusions persist over a longer period, however, they may give rise to long-term psychiatric disturbances, particularly PTSD (9). The persistence and maintenance of intrusive traumatic recollections is therefore a crucial focus for research. Although DSM-IV classifies intrusive memories as a characteristic of PTSD and acute stress disorder, it does not explicitly associate them with other mental disorders (10). However, several studies have demonstrated that intrusive memories, whether of life events or childhood traumatic experiences, are almost invariably found in patients with major depression (11–14). Kuyken and Brewin (11) interviewed depressed patients about their experiences of childhood physical and sexual abuse and found that most patients with such backgrounds had had spontaneous intrusive memories of abuse within the past week, with an average intensity of intrusive memories equivalent to that of patients diagnosed with PTSD. It thus seems that intrusive memories are a more common aspect of psychopathology than was previously believed (14).

The comorbidity of PTSD as a diagnosis secondary to depression has scarcely been studied. Conversely, depression as a diagnosis secondary to PTSD has been investigated more extensively. Concurrent psychiatric diagnoses, particularly major depression, can be made in the majority of patients with PTSD (15–17). Even if major depression is not diagnosed, depressive signs and symptoms are a common, and perhaps underestimated, feature of PTSD (18).

This study covers the full spectrum of early and more recent traumatic experiences that satisfy the stressor A criterion for a diagnosis of PTSD (10) in a sample of both male and female depressed patients. It also focuses on intrusive recollections and comorbid PTSD in depressed patients.

	METHODS

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Respondents
Twenty-four male (35%) and forty-five female (65%) outpatients meeting DSM-IV criteria for major depressive episode were randomly selected from the outpatient department of the academic hospital in Amsterdam. Patients showing any evidence of psychosis or organic brain disease were excluded.

The mean age of our sample was 45.4 years (SD = 12.9 years, range = 21–81 years); for the men, it was 47.2 years (SD = 11.7 years, range = 29–70 years), and for the women, 44.5 years (SD = 13.6 years, range = 21–81 years). Forty-one patients (60%) were married or cohabiting, and 28 (40%) were single.

At the time of the interview, 55 depressed patients (80%) were classified as having chronic or recurrent depression (either multiple episodes of depression or a single episode lasting >2 years), and 14 patients (20%) were classified as having acute depression (a single depressive episode of <2 years). As for comorbidity, 52% of the sample qualified for an additional diagnosis, mostly for panic disorder and substance abuse.

Measures and Procedure
The initial clinical assessment of each patient, performed in the outpatient department, included a clinical history, a mental status examination, and a physical examination. Information about current and lifetime diagnostic status was obtained by practicing, trained psychiatrists using the SCID (19). This also provided an indication of the severity of depression, expressed as 1) the intensity of depression (mild to severe) and 2) lifetime number of depressive episodes. Although no formal reliability data were collected in this study, the SCID has been shown to have good interrater reliability (7, 20).

Next, patients were administered a semistructured interview inquiring about any traumatic experiences they had had (List of Traumatic Events, adapted version; see also Table 1) (21, 22). Patients were asked whether they had experienced such events at any time in the past and at any time in the 12 months preceding their current depressive episode. An additional question about the perceived adverse effects of each specific event was rated on a five-point scale (1 = "no effects"; 5 = "very strong effects"). The events listed in Table 1 satisfy the stressor A(1) criterion for a diagnosis of PTSD: "The person directly experienced an event or events that involved actual or threatened death or serious injury, or other threat to one’s physical integrity ... or [that of] another person" (10).

Finally, demographic variables were obtained from medical records and patient interviews. These included age, gender, race, educational attainment, and current employment status. All subjects gave written informed consent after a full explanation of the procedure. Patient confidentiality was maintained. The study was approved by the Medical Ethics Committee of the Amsterdam Academic Medical Center.

	RESULTS

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Prevalence of Traumatic Experiences
Fifty-two (75%) of the respondents in our sample (N = 69) had experienced one or more psychological traumas. More specifically, 46 respondents (67%) had experienced two or more traumatic events (compared with only 8% with one trauma), and 19 respondents (41%) had been abused and/or assaulted in their youth. Most of these respondents (12 of 19) were women who had also faced violence later in life (eg, rape or partner violence). Table 1 gives a comprehensive overview of the specific traumatic events experienced within the sample.

As Table 1 shows, traumatic experiences were very prevalent in our sample of depressed patients: A total of 131 traumatic events were reported, with an average of 1.9 traumas per person and a maximum of 9 events per individual. Some types of events had occurred more than 10 times. The five most frequent types were 1) assault (25%), 2) serious threat of bodily harm (22%), 3) incest (17%), 4) death of partner in an accident (17%), and 5) war (13%). The average perceived negative impact of the traumatic events was 3.4, which is between "fairly strong" and "strong" on a five-point scale of negative effects.

Taken over the entire sample, the events occurred, on average, 20.9 years ago. For a clearer picture of the time elapsed since the traumas, we distinguished the traumas into three categories: recent (up to 1 year ago), medium range (1–10 years ago), and long range (>10 years ago). For seven events, the year could not be ascertained. Only two events came under the recent category: "failed resuscitation" (N = 1) and "seeing a suicide victim" (N = 1). In the medium-range category, there were 31 events, the most common of them being "involvement in disaster with no injury to self" (N = 6), which concerned witnessing of the so-called Bÿlmermeer plane crash of October 1992 in The Netherlands (25). The long-term category included 91 events, most frequently war (N = 13), serious threat of harm (N = 11), assault (N = 14), and incest (N = 12).

Of the entire sample, 32% had been exposed to a traumatic event before age 16, 28% after age 16, and 15% both before and after age 16. The variables gender and age were significantly associated with traumatization: 92% of the men and 67% of the women had experienced one or more psychological traumas (² = 5.3, df = 1, p < .05); the higher the age, the more likely a patient was to be exposed to a traumatic event (² = 12.7, df = 4, p < .05).

No significant differences were found between trauma-exposed and nonexposed respondents in the intensity of depression (² = 0.16, df = 3, p > .05) or number of depressive episodes (² = 4.46, df = 4, p > .05).

Prevalence of Reexperiencing
Table 2 summarizes for each reexperiencing symptom how many respondents reported it and how many years it persisted. In total, the symptom category of reexperiencing was diagnosed for 48% of the trauma-exposed respondents. What is especially striking is symptom B4, intense psychological distress at exposure to reminders of the trauma. This was more common than any other reexperiencing symptom, occurring in 35% of the trauma-exposed subjects; it also lasted the longest, 13.1 years (not shown).

Multiple regression analysis was performed, using the age at which the trauma occurred as the independent variable (before or after age 16) and the specific reexperiencing symptoms as dependent variables. No significant correlations were found.

Correlation Between Reexperiencing and Severity of Depression
Only one significant connection was found between a specific reexperiencing symptom and the severity of depression. Persons with symptom B3 (acting/feeling as if trauma were recurring) suffered a greater number of depressive episodes (² = 9.6, df = 3, p < .05). No significant associations appeared between the total reexperiencing category and either intensity of depression (² = 3.9, df = 3, p > .05) or number of depressive episodes (² = 2.3, df = 3, p > .05).

Avoidance, Hyperarousal, and Comorbid PTSD
Table 3 shows that the symptom category of avoidance could be identified in 12 patients (23% of the trauma-exposed subsample). The most prevalent symptoms in this cluster were avoidance of thoughts and feelings (35% of trauma-exposed group) and loss of interest (25%).

Finally, nine patients (17% of the trauma-exposed group) qualified for the full PTSD diagnosis. Five events can be pinpointed as possible causes of the PTSD. The respondents with PTSD had experienced serious threat of harm (2%), assault (6%), incest (1%), loss of partner in an accident (3%), and loss of partner through a criminal act (1%). One final result is that no significant differences were found between those with and without PTSD in the intensity of depression (² = 0.62, df = 3, p > .05) or number of depressive episodes (² = 1.2, df = 5, p > .05).

	DISCUSSION

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The preliminary data from this study show that 75% of the depressed patients had been through one or more psychologically traumatic experiences in the distant or more recent past. This is a relatively high figure, especially considering that we screened for severe and clear-cut trauma cases meeting the stressor A criterion for PTSD (10). On the other hand, the rate of trauma among the depressed subjects in our study is not much higher than it is in the general population (26–31). Other studies have found that traumas are more prevalent among mental patients (32, 33). Research has also shown that men experience substantially more traumas than women, as was the case in our study. We observed an increase in the number of traumas as respondents grew older, as did Hubbard et al. (34).

The literature shows that, as a rule, about 50% of psychiatric inpatients and outpatients report having suffered sexual, mental, or physical abuse at some time in their lives (3, 33). Our study even found such a rate for the more limited group of events that directly or indirectly involved violence. Incest was reported by 17% of our respondents, and 25% had been physically assaulted, 7% had been raped, 3% had been abducted, and 1% had been tortured. For clinical practice, it therefore seems advisable to record not only the traumatic event that triggered PTSD but also the full range of events that may have been traumatic (17). The present study shows that it is not sufficient to record only one factor, such as a history of incest. That could even be inadvertently selective.

The reexperiencing symptom category (PTSD-B, DSM-IV) was diagnosed in 48% of those who were exposed to a traumatic event in our sample. Although this rate is lower than that found in Kuyken and Brewin’s 1994 study (11), in which 86% of the depressed respondents reported intense reexperiencing, a later study by Brewin et al. (13) found reexperiencing in 43% of depressed patients, a rate closer to ours. The discrepancy may be attributable to the fact that Kuyken and Brewin recruited both inpatient and outpatient depressed respondents and exclusively those with histories of early abuse. Our present study targeted only outpatients, both those with early and those with recent traumas. In further contrast to our study, Kuyken and Brewin did not use a structured diagnostic interview to record reexperiencing, and they restricted their study to female patients, which may have been a source of bias (11). The literature shows that women are more likely than men to suffer sexual and physical abuse.

We diagnosed comorbid PTSD (DSM-IV) in 17% of our sample of trauma-exposed depressed patients and 13% of the total sample. As we have pointed out, this combination has received little research attention. One exception was the study by Kroll et al. (35), who found a rate of comorbid PTSD of 14%. As may be expected, the rate of PTSD has been found to be higher in the psychiatric population than in the general population, in which there is a 8% to 9% lifetime prevalence (see Refs. 26). A higher prevalence of chronic PTSD has also been found among women (although that was not confirmed in our study). Important inferences for clinical practice can be drawn from recent findings that patients suffering from combinations of PTSD with depression or dysthymia are more likely to report suicidal thoughts and behaviors than patients diagnosed with only one of these disorders (36, 37).

Our findings partially bear out the link we hypothesized between the severity of reexperiencing and the severity of depression. People exhibiting the reexperiencing symptom B3 (acting/feeling as if the event were recurring) were more prone to depressive episodes. Kuyken and Brewin (11) were the first to demonstrate a connection between the severity of depression and intrusive memories of trauma, a finding replicated by Brewin et al. (13). These outcomes were interpreted as tentative support for Teasdale’s (38) differential activation hypothesis, which proposed that individuals, when depressed, preferentially access episodes stored in long-term memory that were also characterized by a depressive mood. Teasdale argued explicitly that such episodes need only have some depressive content and need not be contextually similar to current sources of adversity. Once accessed, the memories are said to enter consciousness and continuously reactivate the depressive schemas, thus prolonging the course of depression. At present, it is not clear whether this hypothesis can be applied to PTSD-type intrusions or whether these phenomena are qualitatively different from the process of activating memories with depressive content.

The limitations of the present study should be noted. Our findings are retrospective in nature, and one should be aware of the potential role of selective reporting and the possible effect of the patients’ current mental state on reporting trauma. There is a possible effect of trauma risk, a proneness to exposure to repeated traumatic events. Our sample, which was rather small, consisted of depressed patients who were in psychiatric treatment at the time of the study, and, as such, they may have represented the most symptomatic group. The absence of a control group of depressed individuals not seeking help or one containing patients with another clinical condition or healthy individuals possibly limits our ability to generalize the findings.

Because it is recognized that PTSD and depression more or less overlap in symptoms such as concentration and memory impairment, sleep problems, loss of interest, and irritability (39–41), we cannot rule out the possibility that our results were influenced by this symptom overlap.

We should make one final point concerning the scientific status of memories of childhood traumatic events. There is a good deal of agreement that traumas are sometimes forgotten (42). What remains disputed is whether traumatic events, especially repeated traumas, can be forgotten and then later recalled with reliable accuracy (43). Although we cannot say for sure whether the recollections of the childhood traumatic events in this study were accurate, that certainly seems possible in light of such empirical findings as those of Williams (44). She provides evidence that some adults who claim to have recovered memories of sexual abuse are indeed recalling actual events that occurred in childhood.

Future research should focus on the direction of any causal relationships between traumatic events, reexperiencing, PTSD, and depression (45). Longitudinal research is the only way to clarify this further. More study is also needed on the interaction between life events and traumatic experiences. Last but not least, research is needed on the effects of treatment on trauma-exposed depressed individuals with PTSD. For depressed patients with a history of sexual abuse, Brand et al. (16) have suggested a combined program of medication and psychotherapy. Should intrusive trauma-related memories indeed prove to be a major predictor of the course of depression, episodes could possibly be shortened by treatments specifically aimed at resolving memories, such as imaginal exposure and cognitive restructuring (46, 47).

	ACKNOWLEDGMENTS

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Special thanks to M. Repko for assistance in data collection for this study.

Received for publication February 22, 1999.

Revision received July 15, 1999.

	REFERENCES

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