Motivation and emotion/Book/2018/Childhood trauma and emotion

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Childhood trauma and emotion:
What are the emotional consequences of childhood trauma?

Overview[edit]

Figure 1. Childhood trauma has significant emotional consequences on children

Childhood trauma is an unfortunate reality in our society, one that has significant negative effects on those who are exposed to it. Children all around the world are faced with trauma. Whether it be physical or emotional, trauma greatly effects a child’s emotional development, often continuing into adulthood. The specific emotional consequences of childhood trauma on an individual are extensive. Trauma has the potential to effect large aspects of a person’s life, for their entire lifetime.

This chapter describes childhood trauma, including the different types of trauma. Neurobiological issues that arise from childhood trauma are addressed, and the emotional consequences are investigated in line with theory and research.

Some readers might find the content of this chapter emotionally distressing. This chapter intends to provide current information on the topic of childhood trauma. It is not a medically or psychologically approved document, and does not cover every single aspect of childhood trauma. If you seek help for any of the issues raised here, contact a professional.


Focus questions
  • What is childhood trauma?
  • How does attachment theory relate to childhood trauma?
  • What are the emotional consequences of childhood trauma?
  • What is the importance of emotional dysregulation in relation to childhood trauma?

What is childhood trauma?[edit]

The National Institute of Mental Health (USA) defines childhood trauma as;

“The experience of an event by a child that is emotionally painful or distressful, which often results in lasting mental and physical effects.” ("NIMH - Helping Children and Adolescents Cope with Violence and Disasters: What Parents Can Do", 2018)

Childhood trauma refers to negative, intense events that threaten or cause harm to a child’s emotional and/or physical well-being. Trauma in early childhood can be especially harmful. A child’s brain is growing and developing rapidly during these early formative years, so the stressful effects of trauma have especially deleterious effects on development. Additionally, young children are very dependent on the caregivers for care, nurture and protection, making young children especially vulnerable to trauma. When trauma occurs early, it can significantly affect a child’s emotional development.

Types of childhood trauma[edit]

The Adverse Childhood Experiences Study (Felliti and Anda, 1998) classifies childhood trauma in ten categories:

  • Abuse of child: emotional, physical, sexual abuse
  • Trauma in child's household environment: substance abuse, parental separation and/or divorce, mentally ill or suicidal household member, violence to mother, imprisoned household member
  • Neglect of child: abandonment, child's basic physical and/or emotional needs unmet

What is emotion?[edit]

As defined by the Collins English dictionary;

“An emotion is a feeling such as happiness, love, fear, anger, or hatred, which can be caused by the situation that you are in or the people you are with.”

However, from a psychological perspective, it is much harder to describe and much more complex. In psychology, emotion is often defined as a complex state of feeling that results in physical and psychological changes that influence thought and behaviour. Emotionality is associated with a range of psychological phenomena, including temperament, personality, mood, and motivation. Human emotion is often described to involve physiological arousal, expressive behaviours, and conscious experience ("Overview of the 6 Major Theories of Emotion", 2018).

Attachment theory[edit]

Recent studies on abuse have proposed that trauma and related traumatic experiences have important implications for parent-child relationships, and may disrupt normal attachment behavior in children (Prather & Golden, 2009). Research studies focusing on repetitive child abuse and neglect have argued that a history of trauma can interfere with secure attachment and disrupt healthy development in children.

Attachment theory concerns the importance of attachment in regards to personal development. Specifically, it claims that the ability for an individual to form an emotional and physical attachment to another person gives a sense of stability and security necessary to take risks, branch out, and grow and develop (Prather & Golden, 2009). The security of an early child-parent bond is reflected in the child’s interpersonal relationships across the life span. Children who grow up in supportive, healthy environments with caring parents are likely to form secure attachments, whereas children reared in abusive or neglectful homes are unlikely to form a secure attachment style, which has implications for their interpersonal relationships and emotional functioning throughout the life span (Prather & Golden, 2009).

Figure 2. Children who grow up in warm, caring, safe environments are much more likely to develop a secure attachment.

Attachment and trauma has been investigated in foster and adoptive children. Research on foster children and problematic attachment has consistently found that long-term child abuse leads to a complex array of emotional deficiencies and behavioral symptoms that reflect the traumatic effects of maltreatment on children, and create strain on attachment with their adoptive parents. Researchers investigating maltreated children have repeatedly found that neglected or abused children in foster and adoptive populations develop different emotional and behavioral reactions to regain lost or secure relationships, and are frequently reported to have disorganised attachments and a need to control their environment (Prather & Golden, 2009).

When children are not adequately cared for during their early years of dependency and vulnerability and their safety and survival needs are compromised, they fail to learn the cluster of behaviors referred to as “attachment”, and learn an entirely different set of behaviors and emotional responses in their interactions with adults. Such children often learn to avoid their adult caregivers and fend for themselves and approach strangers to obtain what they need (Prather & Golden, 2009). Loved and well-cared for children, on the other hand, learn to trust, believe, and rely on their adult caregivers. They want to be in the presence of their adult caregivers and they want to please them (Prather & Golden, 2009).

Attachment may play a critical role in the link between childhood trauma and alexithymia, and other emotional regulation deficits, such that abusive and neglectful home environments might foster insecure attachment patterns with caregivers. These patterns may provide youth with limited opportunities for modeling and reinforcement of appropriate coping strategies and emotional expressivity, thereby increasing their risk for psychological distress and internalising problems (Brown et al., 2016).


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Quiz Time!

A 'secure' attachment occurs when...

A child grows up in an abusive, neglectful environment
A child grows up in a supportive, healthy environment
A child grows up on a farm

Emotional consequences of childhood trauma[edit]

The emotional consequences of childhood trauma are devastating and long lasting. Children who experience some form of trauma in their early lives tend to experience the consequences throughout their entire lives (Mandavia et. al., 2016). The emotional consequences of childhood trauma are numerous and complex, however the core of these consequences come back to emotional dysregulation. Emotional dysregulation refers to the inability of an individual to appropriately regulate their emotions. Children exposed to early adversity may not process and regulate emotions in the same way as others; leading to suppressed or intensified emotional expression. Emotional dysregulation effects many aspects of a person’s life, and itself has numerous consequences, including substance abuse, self-injurious behaviours, alexithymia, relationship problems, mood disorders including depression and anxiety, and eating disorders.

Emotional regulation deficits[edit]

Figure 3. People with emotion regulation deficits often struggle with experiencing emotions appropriately.

Emotional regulation deficits are thought to be strongly connected to childhood trauma, with a large body of research supporting this hypothesis (van Schie et al., 2017). Emotional development occurs throughout infancy and childhood, and extensive research has shown that exposure to childhood trauma is a strong risk factor for emotional dysregulation in adulthood (Mandavia et al., 2016). Literature on emotional development suggests that the reactions of parents to their children’s emotional expressions have an important effect on their children’s coping with emotions, regulating emotions, and realising and expressing them in the future (Zlotnick et al., 2001). So when the home environment is harmful or unsupportive, as is often seen in cases of childhood trauma, children are less likely to be exposed to appropriate emotional labeling, expression, and regulation behaviors often modeled by primary caregivers. In a supportive, positive home environment, parental responsiveness and encouragement of emotional expression is associated with positive emotional and social developmental status for children. However, for children growing up in an invalidating environment where appropriate emotional expression is ignored, rejected, or punished, emotion regulation problems occur (Mandavia et al., 2016). 

Alexithymia[edit]

Alexithymia, defined as having "no words for feelings", is characterised as a deficit in emotional intelligence (Paivio & McCulloch, 2004). The salient features of alexithymia include difficulty identifying and describing subjective feelings; difficulty distinguishing between feelings and the bodily sensations of emotional arousal; constricted imaginal capacities, and an externally oriented thinking (Taylor, 2000). Individuals with high degrees of alexithymia are limited in their ability to reflect on and regulate their emotions, are unable to accurately identify their own subjective feelings, and also struggle to verbally communicate emotional distress to other people, thereby failing to enlist others for aid or comfort. In turn, the lack of emotion-sharing may contribute to the difficulty in identifying emotions (Taylor, 2000).

The deficits underlying alexithymia have been attributed, at least in part, to problems associated with emotional affect development during early childhood (Taylor, 2000).  Researchers have posited that in abusive and neglectful homes, children are exposed to negative, invalidating environments. In these environments, children may learn that emotional expression is unacceptable or condemned and attempts at interactions or emotional expressivity are ignored or invalidated. In an effort to adapt, children may suppress, deny, or distance themselves from their own emotional needs. These coping mechanisms, although adaptive in emotionally unsafe environments, may result in poor emotional awareness when employed over time (Brown et al., 2018). This deficiency in one’s ability to manage their own emotions and affect leads to the development of alexithymia (Brown et al., 2018).

Furthermore, trauma itself is also considered to be an etiological factor contributing to alexithymia. Alexithymia is seen as a defense or adaptation to trauma, more or less associated with dissociation. In this view, alexithymia is conceived as dealing with the emotional overflow created by childhood trauma, specifically emotionally based trauma (Zlotnick et al., 2001). Because of the overwhelming nature of a traumatic event, a rapid regression of emotional affect occurs. Impairment in the ability to control and experience emotional affect, and to make emotions useful as “signals” for perceptions about the self and its surroundings, results in alexithymia. Thus, individuals suffering from alexithymia struggle to convey their emotions to others, furthering the detrimental nature of alexithymia (Zlotnick et al., 2001).


Case study

Joshua was emotionally abused by his father as a child, constantly receiving verbal abuse in the form of insults and hard words. Joshua now struggles to express his emotions appropriately, as he doesn't perceive his emotions as most people do. Joshua is shunned by his co-workers, never invited to lunch or after-work drinks. He never understood the reasons for this but is aware of feeling lonely. He comes across as flat, uninterested, and when he speaks it is always in a monotone. He doesn't feel like he has anything to talk about or say. He doesn't like seeing other people and feels uncomfortable around them. Joshua also isn't very good at telling people how he feels. He tends to keep his thoughts and feelings to himself, never communicating with other or asking for help when distressed. He knows there is something wrong with him, with the way he experiences and perceives emotions.

Substance abuse[edit]

Childhood trauma has been linked to substance abuse in numerous studies. Research has shown that individuals abused and neglected as children were approximately 1.5 times more likely to report illicit drug use in the past year compared to healthy, non-abused, non-neglected controls (Ekinci & Kandemir, 2014). Many epidemiological studies have shown that individuals with substance abuse problems frequently suffer from co-occuring mental health problems (Ekinci & Kandemir, 2014). A study conducted by Kandel et al. (1999) identified co-occurring affect disorders in 32% of people with substance abuse disorders. Childhood trauma is a known risk factor for psychiatric disorders. Previous research has established that depression and anxiety levels tend to increase the severity levels of substance abuse and may result in less successful rehabilitation outcomes (Ekinci & Kandemir, 2014). So, childhood trauma leads to mental health issues, which in turn increases the risk of substance abuse.

Figure 4. Abused and neglected children are 1.5 times more likely to suffer from substance abuse.

The self-medication hypothesis of addictive disorders posits that substance use occurs in response to self-regulation vulnerabilities (Mandavia et al., 2016). Individuals may experience negative emotions, but might not possess the appropriate resources to help manage those emotions, and so consequently turn to substances to temporarily relieve the undesirable feeling of negative emotional states (Mandavia et al., 2016). Researchers suggest that exposure to traumatic events can elicit negative emotions that persist over time, are difficult to manage, and potentially lead to self-medication with substances. Particularly among individuals who do not have adequate emotion regulation strategies to tolerate strong negative emotions, substance use may become a maladaptive coping mechanism used repeatedly when these emotions arise (Mandavia et al., 2016).

Additionally, emotional dysregulation is also highly implicated in substance abuse in childhood trauma affected individuals (Mandavia et al., 2016) Emotional dysregulation is thought to be a vulnerability factor for the development of substance use problems, in that emotional dysregulation as a result of childhood abuse increases the likelihood of substance use problems as an adult. Various studies have shown associations between child abuse and emotional dysregulation, with some evidence that emotional abuse in particular may have a strong association. A study by Mandavia et al. (2016) found emotional dysregulation may play an important role in understanding the relationship between child abuse and later substance use.

Self-injurious behaviours[edit]

Self-injurious behaviours, or self-mutilation, is characterised by repetitive non-fatal actions that are intended to destroy or change body tissue without an intention of committing suicide. Cutting or scratching arms or other body parts, burning the arms and other body parts with cigarettes or other means, tearing out hair, or hitting the head, fist, or other body parts violently on firm ground, are all regarded as self-mutilation (Zlotnick et al., 2001). Considerable literature supports the link between childhood trauma and self-injurious behaviour. For example, Weilderman et al. (1999) found that all forms of childhood maltreatment, except physical neglect, were related to an increased likelihood of bodily self-harm.

There is a link between deficits in emotion regulation and self-injurious behaviour. The most widely accepted explanation for non-lethal self-injury is that self-mutilation is a response to unmanageable emotional pain and distress. It is suggested that individuals who engage in self-injurious behaviours are not able to express what they want and need, and so turn to self-mutilation to alter unmanageable emotional pain and distress into more manageable physical pain (Paivio & McCulloch, 2004).

The literature on self-injurious behaviours and emotion regulation deficits suggests a chain of associations between childhood trauma, impaired capacities for emotion regulation, and self-injurious behaviours (Paivio & McCulloch, 2004). Experiences of abuse and neglect generate painful feelings and distress. At the same time, absence of parental support and emotional coaching limits emotional development, particularly, the capacity to attend to, identify, and communicate emotional experience. During times of stress, and in the absence of healthy coping strategies, survivors of childhood trauma are at risk for coping with emotional distress through impulsive self-destructive action, including superficial self-injurious behaviours (Paivio & McCulloch, 2004).

Relationship problems[edit]

There is a high prevalence of relational and sexual problems among adult women exposed to childhood trauma. The most commonly reported sexual and relationship problems for women with a history of childhood trauma include inhibited sexual desire, lower levels of sexual satisfaction, difficulties becoming sexually aroused or reaching orgasm, difficulties developing emotional intimacy with a partner, and interpersonal aggression.

Previous studies suggest that people who suffer from some form of childhood trauma are more likely to experience distress in their relationships as adults than are people who do not suffer such abuse as children. For example, a survey by Paradis and Boucher (2010) found that those who reported emotional, physical, or sexual abuse and emotional or physical neglect by their caregivers as children were more likely to report significant problems in their couple relationships (e.g., emotional distance, difficulty asserting them- selves and their needs) as adults.

Emotional regulation is thought to be an important contributing factor to the relationship problems seen in childhood trauma victims. It is thought that difficulty regulating the intense and sometimes-intrusive emotional states related to past abuse plays an important role in the diminished relationship quality that adult survivors of abuse tend to report. Additionally, adults who experience abuse or neglect as children tend to display biased perceptions of others as harsh or demanding and to have an elevated need for comfort and reassurance, depending on the type of abuse that they endured as children (Rellini et al., 2012). It is plausible that this kind of mistrust of other people and a heightened need for comfort might hinder the establishment of strong emotional ties to significant others.

Additionally, low emotional clarity is seen to be negatively associated with sexual satisfaction, as well as affection and intimacy satisfaction, suggesting that clarity of emotional responses is an important aspect of sexual and relational satisfaction (Rellini et al., 2012). Assumedly[grammar?], understanding one’s emotions is an essential aspect of communication which, in turn, is essential for sexual and relationship satisfaction. Thus, clarity of emotions becomes important for both sexual and relationship satisfaction. Individuals exposed to childhood trauma experience a disturbance in their emotional regulation, which effects this emotional clarity and thus sexual and relationship satisfaction (Rellini et al., 2012).

Depression and anxiety[edit]

Figure 5. Depression is an unfortunate but common consequence of childhood trauma.

Epidemiological studies have provided strong evidence that childhood trauma is associated with dramatic increases in the risk to develop depression, anxiety disorders, or both (Heim et al., 2008). Childhood trauma contributes to the persistent sensitisation of central nervous system (CNS) circuits due to early life stress. As these circuits are integrally involved in the regulation of stress and emotion, they may represent the underlying biological causes of an increased vulnerability to subsequent stress, as well as to the development of depression and anxiety (Heim & Nemeroff, 2001). Numerous studies provide evidence to suggest that early life stress is a major risk factor for the development and persistence of mental disorders. Early life stress causes long-lived hyperactivity of corticotrophin-releasing factor (CRF) systems and other neurotransmitter systems, resulting in enhanced endocrine, autonomic, and behavioral stress responsiveness. With repeated exposure to life stress, this vulnerability may result in symptoms of depression and anxiety disorders, as well as in other physiologic abnormalities frequently observed in adult survivors of abuse (Heim & Nemeroff, 2001).

An ever-increasing body of literature indicates that child maltreatment places individuals at increased risk for subsequent internalising problems, including depression, anxiety, and loneliness. Specifically, there is evidence suggesting that all five child maltreatment types (i.e., physical abuse, physical neglect, sexual abuse, emotional abuse, and emotional neglect) are associated with elevated depressive and anxiety symptoms in adulthood (Heim & Nemeroff, 2001). A community-based study found that women with a history of childhood sexual or physical abuse, but not adulthood rape or physical assault, exhibited more symptoms of depression and anxiety and had more frequently attempted suicide than women without a history of childhood abuse (Heim & Nemeroff, 2001).

It is suggested that adverse experiences during development may result in a vulnerability to the effects of stress later in life, predisposing childhood trauma survivors to develop a wide array mental and physical disorders including depression and anxiety (Heim & Nemeroff, 2001).

Eating disorders[edit]

Research has found childhood abuse and trauma to be powerful antecedents to eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating (Kong & Bernstein, 2009). Several studies have demonstrated that a significant proportion of individuals with eating disorders report a history of childhood abuse. Rodriguez et al. (2005) found that 45% of the patients with eating disorders had a history of sexual abuse or other forms of childhood abuse or trauma.

Childhood trauma contributes to the development of emotion regulation difficulties which is thought to predispose an individual to develop eating disorders such as anorexia (Racine & Wildes, 2014). Different types of childhood trauma appear to result in different aspects of eating psychopathology. Emotional abuse is seen to be a predictor of impulse regulation. This suggests survivors of childhood emotional abuse might turn to self-destructive and self-harming behaviours, such as purging and vomiting, for relief from tension and distress and to regulate their internal emotional states, as they do not possess the ability to appropriately regulate their emotions (Kong & Bernstein, 2009). Additionally, a study by Kong and Bernstein (2009) found childhood physical neglect to be a predictor for the drive for thinness, bulimia and body dissatisfaction. Previous research has also pointed towards bulimic symptoms, including weight problems, to be related to physical abuse and physical neglect

Sexual abuse has the most research in relation to eating disorders (Wonderlich et al., 1997). Childhood sexual abuse is found to be a predictor for impulse regulation and perfectionism. A study of 10–15-year-old girls found that sexual abuse status significantly predicts impulsivity, and that impulsivity provides the strongest mediation between a history of childhood sexual abuse and purging and/or restricting diet behaviour (Wonderlich et al., 1997).

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Quiz time!

Which of the following does not have links to emotional dysregulation?

Self-injurious behaviours
Relationship problems
Eating disorders
None of the above

Conclusion[edit]

Childhood trauma has significant, terrible, long-lasting effects on an individual. Childhood trauma has serious consequences on a child's emotional development, such that it affects the individuals for their entire life. Childhood trauma causes emotional regulation deficits, which causes further complications in various aspects of one's life. Children exposed to trauma are more likely to suffer from alexithymia, substance abuse, self-injurious behaviours, depression and anxiety, and eating disorders. Overall, childhood trauma is an awful reality, and one that doesn't leave it's victims unscathed, with the emotional consequences being devestanding[spelling?] and far-reaching.

See also[edit]

References[edit]

Brown, S., Fite, P., Stone, K., & Bortolato, M. (2016). Accounting for the associations between child maltreatment and internalizing problems: The role of alexithymia. Child Abuse & Neglect, 52, 20-28. https://doi.org/10.1016/j.chiabu.2015.12.008

Brown, S., Fite, P., Stone, K., Richey, A., & Bortolato, M. (2018). Associations between emotional abuse and neglect and dimensions of alexithymia: The moderating role of sex. Psychological Trauma: Theory, Research, Practice, And Policy, 10, 300-308. https://doi.org/10.1037/tra0000279

Definition of childhood trauma, which includes abuse. (2018). Retrieved from https://www.blueknot.org.au/Resources/Information/Understanding-abuse-and-trauma/What-is-childhood-trauma

Ekinci, S., & Kandemir, H. (2014). Childhood trauma in the lives of substance-dependent patients: The relationship between depression, anxiety and self-esteem. Nordic Journal Of Psychiatry,69, 249-253. https://doi.org/10.3109/08039488.2014.981856

Heim, C., & Nemeroff, C. (2001). The role of childhood trauma in the neurobiology of mood and anxiety disorders: Preclinical and clinical studies. Biological Psychiatry, 49, 1023-1039. https://doi.org/10.1016/s0006-3223(01)01157-x

Heim, C., Newport, D., Mletzko, T., Miller, A., & Nemeroff, C. (2008). The link between childhood trauma and depression: Insights from HPA axis studies in humans. Psychoneuroendocrinology, 33, 693-710. https://doi.org/10.1016/j.psyneuen.2008.03.008

Kandel, D., Johnson, J., Bird, H., Weissman, M., Goodman, S., & Lahey, B. et al. (1999). Psychiatric comorbidity among adolescents with substance use disorders: Findings from the MECA study. Journal Of The American Academy Of Child & Adolescent Psychiatry, 38, 693-699. https://doi.org/10.1097/00004583-199906000-00016

Kong, S., & Bernstein, K. (2009). Childhood trauma as a predictor of eating psychopathology and its mediating variables in patients with eating disorders. Journal Of Clinical Nursing, 18, 1897-1907. https://doi.org/10.1111/j.1365-2702.2008.02740.x

Mandavia, A., Robinson, G., Bradley, B., Ressler, K., & Powers, A. (2016). Exposure to childhood abuse and later substance use: Indirect effects of emotion dysregulation and exposure to Trauma. Journal Of Traumatic Stress, 29, 422-429. https://doi.org/10.1002/jts.22131

NIMH » Helping Children and Adolescents Cope with Violence and Disasters: What Parents Can Do. (2018). Retrieved from https://www.nimh.nih.gov/health/publications/helping-children-and-adolescents-cope-with-violence-and-disasters-parents/index.shtml

Overview of the 6 Major Theories of Emotion. (2018). Retrieved from https://www.verywellmind.com/theories-of-emotion-2795717

Paivio, S., & McCulloch, C. (2004). Alexithymia as a mediator between childhood trauma and self-injurious behaviours. Child Abuse & Neglect, 28, 339-354. https://doi.org/10.1016/j.chiabu.2003.11.018

Paradis, A., & Boucher, S. (2010). Child maltreatment history and interpersonal problems in adult couple relationships. Journal Of Aggression, Maltreatment & Trauma, 19, 138-158. https://doi.org/10.1080/10926770903539433

Prather, W., & Golden, J. (2009). A behavioral perspective of childhood trauma and attachment issues: Toward alternative treatment approaches for children with a history of abuse. International Journal Of Behavioral Consultation And Therapy, 5, 56-74. https://doi.org/10.1037/h0100872

Racine, S., & Wildes, J. (2014). Emotion dysregulation and anorexia nervosa: An exploration of the role of childhood abuse. International Journal Of Eating Disorders, 48, 55-58. https://doi.org/10.1002/eat.22364

Rellini, A., Vujanovic, A., Gilbert, M., & Zvolensky, M. (2012). Childhood maltreatment and difficulties in emotion regulation: Associations with sexual and relationship satisfaction among young adult women. Journal Of Sex Research, 49, 434-442. https://doi.org/10.1080/00224499.2011.565430

Rodríguez, M., Pérez, V., & García, Y. (2005). Impact of traumatic experiences and violent acts upon response to treatment of a sample of Colombian women with eating disorders. International Journal Of Eating Disorders, 37, 299-306. https://doi.org/10.1002/eat.20091

Taylor, G. (2000). Recent developments in Alexithymia theory and research. The Canadian Journal Of Psychiatry, 45, 134-142. https://doi.org/10.1177/070674370004500203

van Schie, C., van Harmelen, A., Hauber, K., Boon, A., Crone, E., & Elzinga, B. (2017). The neural correlates of childhood maltreatment and the ability to understand mental states of others. European Journal Of Psychotraumatology, 8, 1272788. https://doi.org/10.1080/20008198.2016.1272788

Wonderlich, S., Brewerton, T., Jocic, Z., Dansky, B., & Abbott, D. (1997). Relationship of childhood sexual abuse and eating disorders. Journal Of The American Academy Of Child & Adolescent Psychiatry, 36, 1107-1115. https://doi.org/10.1097/00004583-199708000-00018

Zlotnick, C., Mattia, J., & Zimmerman, M. (2001). The relationship between posttraumatic stress disorder, childhood trauma and alexithymia in an outpatient sample. Journal Of Traumatic Stress, 14, 177-188. https://doi.org/10.1023/a:1007899918410

External links[edit]