Relationship between childhood trauma, parental bonding, and defensive styles and psychiatric symptoms in adult life

Abstract Introduction A relationship between different types of childhood trauma, parental care, and defensive styles and development of psychiatric symptoms in adulthood is proposed in this study. Understanding the nature of this association is essential to assist psychotherapists who treat patients with a history of past trauma. This study aims to examine the associations between childhood trauma, parental bonding, and defensive styles and current symptoms in adult patients who sought care at an analytical psychotherapy clinic. Methods The sample comprised 197 patients from an analytically oriented psychotherapy clinic. Participants responded to four self-report instruments that assessed, respectively, presence and frequency of several types of early trauma, type of parental attachment, styles of defenses, and current symptoms encompassing a wide variety of psychopathological syndromes. Results Only 5% of patients reported not having experienced any traumatic experience in childhood. Several traumas such as emotional and physical abuse, emotional neglect, and physical neglect showed positive and significant associations with several dimensions of current symptoms, and also with parental bonding and defensive styles. When analyzed together with the other variables, defensive styles explained the level of psychological suffering caused by the symptoms. Conclusions This study offers additional support for understanding the associations between childhood trauma, parental bonding styles, and defense styles and the psychiatric symptoms of patients in analytically oriented psychotherapy.


Introduction
According to the World Health Organization, 1 child maltreatment includes various forms of neglect and abuse that cause potential damage to health, development, and the child's dignity. According to Bins et al.,2 there are four types of child abuse: physical abuse (use of physical force with the aim of hurting), sexual abuse (sexually stimulate, to obtain sexual satisfaction), emotional abuse (defined as using words and actions that shame, censor, humiliate, and permanently pressure the child), and neglect (depriving the child of something it needs, when this is essential to its healthy development). A single meta-analysis found to date has estimated that more than three quarters of children on the planet have had some moderate or severe experience of physical, sexual, and/or emotional abuse during 2015, affecting almost 1.5 billion children aged between two and 17. 3 In Brazil, according to the Ministry of Human Rights, 4  From a psychoanalytic perspective, psychic trauma means a "violent shock" capable of breaking the protective barriers of the ego, leading to lasting disturbances in the individual's mind. 5 If treated inappropriately, the severity and frequency of these traumatic experiences in childhood can predispose to manifestation of several psychiatric symptoms, especially anxiety, depression, and psychosis, 6-8 as well as contributing to changes in the architecture and function of the brain in adulthood. 9,10 Garland 11 points out that the possibility of the individual recovering is associated with the quality of their relationships and primary care. This care is crucial for the structure of their psychic apparatus and for acquisition of important skills such as emotional regulation, reflexive function, and the ability to mentalize. 12 Failures in primary relationships and exposure of individuals to childhood adversities can alter the course of normal development, leading to precarious psychic resources. This results in impairment of the symbolic capacity to represent traumatic experiences, leading the individual to become more susceptible to psychological suffering. It is therefore understood that a sufficiently healthy relationship between the child and their parental figures acts as a protective factor against development of psychiatric symptoms. 13,14 Research has shown associations between childhood trauma, parental bonding, and psychiatric symptoms in adulthood. Catalan et al. 15 investigated the relationships between different types of parental care, childhood trauma, and psychotic symptoms in adulthood in patients with borderline personality disorder, patients with a first psychotic episode, and healthy controls.
They found positive associations between psychotic symptoms and the existence of childhood trauma in all groups. In addition, "affectionless control" was directly associated with the existence of trauma. From this same perspective, Marshall et al. 16 explored these relationships and found that maternal "affectionless control" was significantly associated with depressive symptoms in adults.
In favor of protecting the ego in the presence of symptoms, in The neuro-psychoses of defense, 17 Freud describes how defense mechanisms are unconscious psychological processes that aim to protect the individual from the internal perception of painful affective states.
These mechanisms are characterized as a psychic phenomenon that appears in early childhood and are mainly influenced by attachment style. [18][19][20] As stated by Gabbard,21 immature defenses allow individuals to maintain an illusion of emotional control when they experience a situation of helplessness.
According to Colovic et al., 22 anxiety and depression can be distinguished using certain defense mechanisms.
Immature defenses were significantly more associated with depressed patients than with anxious ones. Their results did not confirm a significant difference in use of neurotic defenses between patients with anxiety and depressive disorders.
The social and occupational impacts of these adverse conditions reinforce the importance of considering the issue as a public health problem at all levels of prevention, especially in programs that promote learning of positive parenting and care skills. 1,23,24 This study aims to examine the associations between child trauma, parental bonding, defensive styles, and current symptoms in adult patients who sought care at an analytical psychotherapy clinic. It is essential to study this relationship because child abuse is still being reported as a widespread problem worldwide and it has devastating impacts on mental health.

Design
The present study has a quantitative, crosssectional design. 25

Brief Symptom Inventory (BSI)
The BSI is an abbreviation of the SCL-90 (Symptom Checklist -90), an instrument widely used in several countries to assess symptoms of mental disorders and psychological distress. 31 The Some cases were included in which the participants did not return the instruments at the 5th session but who, having spontaneously expressed their intention to bring them to the next session (the 6th session), did so. The remaining cases were excluded and treated as losses from the sample.

Data analysis procedure
Data analysis was performed using SPSS 18 In addition, multicollinearity between covariates was also tested. The level of significance (p) adopted in all analyses was 0.05.

Ethical procedures
The  Table 1.

Descriptive analysis for the variables in study
In this study, descriptive analyses were performed of the results of the following instruments: CTQ, PBI, DSQ-40, and BSI, as shown in Table 2.
The  Table 3.

Study of correlations between variables
Possible associations between childhood trauma, parental bonding, defensive styles, as well as the current symptoms of patients, were tested using Spearman's correlation coefficients.

Childhood trauma and symptomatology
This analysis was performed previously in an earlier study with the same sample of patients by Waikamp & Serralta. 7

Parental bonding and symptomatology
As shown in Table 4, it can be observed that

Hierarchical multiple linear regression
As shown in Table 6, when referring to parental bonding, the subset that indicated maternal and paternal affectionless control had higher symptoms scores than those who reported optimal parenting by their fathers and mothers. As for the traumas reported, abuse and emotional neglect were the adverse experiences that most explained the symptoms observed in the patients.
However, when all variables are included in the model, the mature and immature defense styles were sufficient to explain more than 50% (r 2 = 0.575) of the variance in general psychopathology severity, reinforcing the hypothesis that defenses, except for neurotic defenses, explain the level of perceived psychological suffering caused by these patients' current symptoms.   Obsessive-compulsive symptoms were most prevalent in the sample, followed by depressive symptoms. These symptoms are predominantly related to a neurotic personality structure or organization, confirming the profile of patients who sought care at the clinic where this study was conducted. 7,35 The powerful associations between abuse and emotional neglect and more serious symptoms such as paranoid ideation, interpersonal sensitivity, depression and psychoticism were notable, corroborating findings in the literature on the association between early trauma and psychotic symptoms 6,15,36 and also with personality disorders. 15,21 According to Siegel & Kohut,37 when studying severe symptoms, the individual is exempt from internalized object relations and there is a predisposition to emergence of psychotic symptoms.
These symptoms would then be the individual's attempt to recover contact with the lost objects. The typical symptoms of patients with severe personality disorders result from activation of the insecure attachment system that is also derived from adverse childhood experiences. 38 Anxiety in adulthood was also directly associated with occurrence of traumatic experiences in childhood, particularly abuse and emotional neglect. 39 As expected, the most prevalent care style in the sample was paternal and maternal affectionless control, which is characterized by high parental control

Predictors of symptomatology
Individuals who experienced unstable relationships with their caregivers needed to defend themselves from painful affective states derived from this failure of emotional restraint. 49 These feelings not contained in the dyad are intensified by the child's emotional responses, reinforcing their destructive potential.
These experiences end up being internalized, impacting healthy development, which may disintegrate the ego. Therefore, there is a need to exclude these emotional states, as a way of protecting the ego from these pathogenic emotions. Early adversities lead to a negative perception of oneself and the other, leaving the individual unable to cope adaptively with their conflicts.
Thus, there is a predominance of immature defenses for dealing with the perceived suffering derived from these early experiences.
In contrast, when children establish safe and supportive bonds with their caregivers, the caregivers can assist in regulation and containment of negative feelings, minimizing their effects. 12

Conclusion
This study offers additional support for understanding the relationships between childhood trauma, experiences of bonding with parents in childhood, and defensive styles and the symptomatology of adult patients in analytically oriented psychotherapy. This is a correlational, inferential, and explanatory study and uses a hierarchical model that was based not only on the data, but also on theoretical hypotheses with a psychodynamic basis. In general, the results obtained suggest that there are associations between the variables, reinforcing the clinical character of the processes that involve early traumas and their long-term repercussions. The results obtained are in accordance with these assumptions and with empirical data from international studies that have examined these associations. It is important to highlight that the present study was carried out with a naturalistic sample, which explains its heterogeneity in terms of symptoms.
Another important limitation of the study is related to the data collection procedures of the larger project from which this study is derived, in that instruments were applied during the fifth session in an uncontrolled environment. Moreover, this study used self-report measures, which can contribute to response bias due to the participants' mental health status.