Beyond PTSD: Emotion Regulation and Interpersonal Problems
as Predictors of Functional Impairment in Survivors
of Childhood Abuse
Marylene Cloitre, Regina Miranda, K. Chase StovalI-McCIough, Hyemee Han
NewYork UniversitySchool of Medicine
This study sought to determine the relative contribution of
problems in emotion regulation and interpersonal function-
ing compared to PTSD symptoms in predicting functional
impairment among women with childhood abuse histories.
One hundred sixty-four treatment-seeking women com-
pleted measures of emotion regulation, interpersonal prob-
lems, PTSD symptoms, and social adjustment. Severity of
PTSD symptoms was a significant predictor of functional
impairment. In addition, after controlling for the effects of
PTSD symptomatology, emotion regulation and interper-
sonal problems were both significant predictors and to-
gether made contributions to functional impairment equal
to that of PTSD symptoms. These data indicate that emo-
tion regulation and interpersonal problems play an impor-
tant role in functional impairment among women with a
history of childhood abuse. These factors should be taken
into account in treatment planning to ensure successful re-
habilitation from the long-term effects of chronic childhood
trauma.
SINCE THE INTRODUCTION o f p o s t t r a u m a t i c stress
disorder (PTSD) into the DSM nomenclature in
1980, numerous studies have identified a high de-
gree of associated impairment and reduced success
in larger life-course opportunities such as educa-
tional attainment, childbearing, marriage, and earn-
ings (Kessler, 2000). The factors contributing to
functional impairment have significant implications
for the development of effective treatments for
PTSD. Several treatment studies of mood and anx-
iety disorders have found that functional impair-
This work was supported by NIMH grants R21 MH57883 and
RO1 MH62347-02 to the first author.
Address correspondence to Marylene Cloitre, Ph.D., NYU
Child Study Center, Institute for Trauma and Stress, 215 Lexington
Avenue, 16th Floor, New York, NY, 10016; e-mail: marylene.cloitre@
med.nyu.edu.
B~HAWORTHERAeY36, 119--124, 2005
005-7894/05/0119--012451.00/0
Copyright2005 by Associationfor Advancementof BehaviorTherapy
All rights for reproductionin any form reserved.
ment persists even after disorder-specific symptoms
have been alleviated (Agosti & Stewart, 1998;
Coryell et al., 1993; Rapaport, Endicott, & Clary,
2002; Serretti et al., 1999), suggesting that the
factors contributing to impairment may go beyond
or be different from the symptoms of a disorder.
This may be particularly true for trauma patients
who have experienced chronic childhood sexual or
physical abuse. Data from both the developmental
and adult literature converge to suggest that early
childhood abuse influences basic lifelong patterns
of interpersonal relating and success in mastering
emotion-management skills, both of which are
needed for later role performance. The purpose of
this study was to determine whether and to what
extent emotion regulation and interpersonal prob-
lems contribute to functional impairment, above
and beyond that identified by the symptoms of
PTSD among treatment-seeking women with a his-
tory of childhood abuse.
Unlike PTSD symptom severity, which is similar
across childhood abuse and adult-onset trauma
survivors (e.g., rape, disaster victims), difficulties in
emotion regulation and interpersonal relating are
salient among childhood abuse survivors and distin-
guish them from adult-onset trauma victims (Browne
& Finkelhor, 1986; Cloitre, Scarvalone, & Difede,
1997; Zlotnick, Zakriski, Shea, & Costello, 1996).
Grounded in developmental theory, trauma ex-
perts (e.g., Briere, 2002; Pynoos, Steinberg, Ornitz,
& Goenjian, 1997; van der Kolk, 1996) have hy-
pothesized that one source of these difficulties
relates to the negative effect of trauma on the child-
hood and adolescent developmental tasks of inter-
personal and emotion-regulation skills building and
consolidation.
Empirical studies in the developmental literature
have indicated that childhood abuse disturbs the
acquisition of appropriate emotion regulation and
interpersonal skills (e.g., Cicchetti & White, 1990;
Shields & Cicchetti, 1998). For instance, early mal-
treatment, including both sexual and physical abuse,
is associated with high levels of negativity and
anger in toddlers and lack of self-control in pre-
120 CLOITRE
schoolers (Erickson, Egeland, & Pianta, 1989). Re-
active aggression, difficulty with peers (bullying or
experiencing victimization), and limited social com-
petence is seen in older children and adolescents
with histories of abuse (e.g., Howes & Eldredge,
1985; Shields, Ryan, & Cicchetti, 1994; Shipman,
Zeman, Penza, & Champion, 2000). Similarly,
adults with a history of childhood abuse have noted
problems with modulating feeling states (van der
Kolk, 1996), higher levels of hostility and anxiety
compared to other clinical samples (Zlotnick et al.,
1996), and chronic problems with anger manage-
ment (Briere, 1988; Browne & Finkelhor, 1986).
Compared to women with no history of abuse,
those with childhood abuse histories report en-
dorsing problems with sensitivity to criticism, in-
ability to hear other viewpoints, difficulty in stand-
ing up for oneself, and a tendency to quit jobs and
relationships without negotiation (van der Kolk,
Roth, Pelcovitz, & Mandel. 1993).
In summary, there is sufficient empirical evidence
to suggest that women with a history of childhood
abuse have significant problems in emotion regula-
tion and interpersonal functioning. We propose
that these problems place a substantial burden on
role functioning in day-to-day life. Accordingly, we
wished to examine the contribution of these prob-
lems, as well as those of PTSD symptoms, to func-
tional impairment. The results of this investigation
have implications for treatment development. It has
been proposed that advances in treatment effective-
ness be focused on the larger goal of improving life
functioning (e.g., Shalev, 1997). The evaluation of
problem domains other than disorder-specific symp-
toms will help determine the directions for treat-
ment development as it takes on enhancing func-
tional capacity as a high-priority goal.
Method
SAMPLE
One hundred sixty-four treatment-seeking women
(ages 21 to 65) with a history of childhood sexual
and/or physical abuse were evaluated for participa-
tion in clinical trials of psychotherapy treatment
for abuse-related PTSD. Candidate participants
were excluded from the treatment studies if they
were diagnosed by the Structured Clinical Inter-
view for DSM-IV (SCID; Spitzer, Williams, Gib-
bon, & First, 1994) to have a current dissociative,
bipolar, or substance dependence disorder, an eat-
ing disorder, psychotic symptoms, or acute suicid-
ality requiring hospitalization. Participants ranged
in age from 21 to 64 years (M = 34.1, SD = 9.4).
The sample was primarily single (55 %), Caucasian
(49%), and college-educated (58%), with annual
ET AL.
earnings of $30,000 or less (72%). Participants re-
ceived a complete description of the study and gave
written informed consent.
ASSESSMENT
Individuals completed a battery of assessments that
included both clinical interviews and self-report
measures. History of trauma was assessed using
two clinician-administered instruments, the Child-
hood Maltreatment Interview Schedule (Briere,
1992) and the Sexual Assault and Additional Inter-
personal Violence Schedule (Resick & Schnicke,
1992). Childhood sexual abuse was defined as at
least one episode of sexual contact (fondling, at-
tempted or completed vaginal, oral, or anal inter-
course) by a caretaker or person in authority be-
fore age 18. Participants were classified as having a
history of childhood physical abuse if they had
been punished or treated by a caretaking figure in a
way that left bruises, marks, lacerations, or resulted
in broken bones or medical attention before the
age of 18.
Functional impairment was measured with a
self-report instrument, the Social Adjustment Scale-
Self Report (SAS-SR; Weissman & Bothell, 1976).
Measures of PTSD symptoms, emotion regulation,
and interpersonal problems were derived, respec-
tively, from the following: the Modified PTSD
Symptoms Scale (Falsetti, Resnick, Resick, & Kil-
patrick, 1993), the General Expectancy for Nega-
tive Mood Regulation scale (Cantanzaro & Mearns,
1990), and the Inventory of Interpersonal Prob-
lems (Horowitz, Rosenberg, Baer, Ureno, & Vil-
lasenor, 1988).
The Social Adjustment Scale Self-Report (SAS-SR;
Weissman & Bothwell, 1976) is a 54-item ques-
tionnaire that assesses instrumental and expressive
role performance in seven major areas (work, social
and leisure activities, relationships with extended
family, relationships with spouse or partner, func-
tioning as a parent, functioning in the family unit,
and financial status). It has been shown to have ad-
equate agreement with interview-based measures
of social adjustment (r = .72), to be unrelated to
sociodemographic characteristics, and to be sensi-
tive to change in clinical status. The SAS-SR is
rated on a 5-point Likert scale from 0 (never a
problem) to 4 (always a problem), so that higher
scores indicate greater impairment.
The Modified PTSD Symptom Scale (MPSS; Fal-
setti et al., 1993) is a 34-item self-report instru-
ment that separately assesses the frequency and se-
verity of PTSD symptoms corresponding to the 17
diagnostic criteria for the DSM-IV (modified from
the DSM-III-R). The frequency items are rated on
a 4-point Likert scale ranging from 0 (not at all) to
 FUNCTIONAL IMPAIRMENT
3 (5 times or more per week); the severity items are
rated on a 5-point scale ranging from 0 (not at all)
to 4 (extremely). The total score ranges from 0 to
119. Using DSM-IV criteria for the minimum re-
quired number of symptoms to reach threshold for
the disorder along with the recommended severity
score (see Blake et al., 1990) of 2 (moderately se-
vere), the minimum score on the MPSS-SR to reach
diagnostic status is 18. However, typical scores for
individuals positive for PTSD range between 46
and 71 (Falsetti et al., 1993). The MPSS has good
overall internal consistency in both treatment and
community samples as well as adequate concurrent
validity with the SCID I. In this study, the MPSS
was completed in reference to childhood abuse
trauma; the alpha coefficient for the study sample
was .91.
The General Expectancy for Negative Mood
Regulation (NMR; Cantanzaro & Mearns, 1990)
is a 30-item Likert scale that measures generalized
expectancy that some overt behavior or cognition
will alleviate a negative state or induce a positive
one. Expectations concerning negative feelings in-
clude the ability to change a negative state ("I can
usually find a way to cheer myself up") as well as
tolerate a negative state ("It won't be long before I
can calm myself down"). The N M R has been
shown to have adequate internal consistency (rang-
ing .86 to .92) and good test-retest reliability in fe-
male samples over 4 and 8 weeks (r = .76; r = .78)
(Catanzaro & Mearns, 1990). Internal consistency
for our study sample was .79.
The Inventory of Interpersonal Problems (IIP;
Cantanzaro & Mearns, 1990) is a psychometri-
cally sound 127-item self-report measure that exam-
ines difficulties in six dimensions of interpersonal
functioning: assertiveness, sociability, intimacy, sub-
missiveness, responsibility, and control. Internal
consistency for the subscales ranges from .82 to
.92. In this study sample, the internal consistency
for the subscales ranged from .73 to .93, with an
alpha of .97 for the total score. The IIP has been
used to differentiate adult- versus childhood-onset
PTSD (Cloitre et al., 1997) and is sensitive to the out-
come of treatment among women with childhood
abuse (Cloitre, Koenan, Cohen, & H a n , 2002).
ANALYSES
A multiple hierarchical regression approach was
taken in which sociodemographic and abuse char-
acteristics were entered in the first block to adjust
for their effect on functional impairment (SAS-SR).
In order to examine the role of emotional regula-
tion and interpersonal problems beyond that of
PTSD symptoms in functional impairment, the
PTSD symptoms measure (MPSS) was entered into
IN SURVIVORS OF ABUSE 121
the second block, with emotion regulation prob-
lems (NMR) in the third block, and interpersonal
problems (IIP) entered in the fourth and final block.
Preliminary zero-order correlations were com-
pleted to examine the relationships between socio-
demographic characteristics (age, income, education,
ethnicity, and marital status), abuse characteristics
(severity of sexual abuse, severity of physical abuse,
number of perpetrators, and relationship to perpe-
trator), and functional impairment. Variables that
were at least marginally (p ~ .10) associated with
the outcome variable were included in the first
block of the regression analysis. D u m m y variables
were computed for the sociodemograpic variables,
with the exception of age. Nonsignificant correlates
were excluded from the final regression model.
Results
DESCRIPTIVE DATA
Seventy-four percent of the sample reported a his-
tory of childhood sexual abuse, 52% reported at
least a "moderate" degree of childhood physical
abuse by a primary caretaker, and 29% reported a
history of both physical and sexual abuse. The av-
erage age at which physical and/or sexual abuse
began was 7.3 years and the average age at which it
ended was 12.2 years. The duration of abuse was
an average of 7.7 years (SD = 4.84) for physical
abuse and 4.6 years (SD = 3.49) for sexual abuse.
The global SAS-SR score (M = 2.59, SD = .49)
indicated that the sample had significant functional
impairment, exceeding the SAS-SR score of the
psychiatric sample of acutely depressed females
(M = 2.26, SD = .46) reported by Weissman, Pru-
soft, Thompson, Harding, and Myers (1978). The
level of PTSD symptomatology was severe, with an
average MPSS score for the sample of 69.20 (SD =
20.41). The average score for the N M R was 93.53
(SD = 13.42), which compares poorly to norma-
tive means for adult females, which range from
99.14 (SD = 14.33) to 105.60 (SD = 14.34) (Can-
tanzaro & Mearns, 1990). The average for the IIP
was 1.76 (SD = .58), which indicates greater inter-
personal problems than found among adult psychi-
atric samples (M = 1.48, SD = .56) reported by
Horowitz et al. (1988).
CORRELATIONS
None of the abuse characteristics were significantly
correlated with functional impairment and so were
not entered into the regression. Sociodemographic
variables of age, income, ethnicity, and marital sta-
tus were associated with functional impairment, as
were the PTSD, emotion regulation, and interper-
sonal variables.
122 CLOITRE ET AL.

TABLE I Z e r o - O r d e r Correlations o f Symptom Measures unique variance, calculated by squaring the partial
W i t h Functional Impairment (SAS-SR) correlation, contributed by N M R and IIP (21%),
PTSD was equal to and numerically greater than that
(MPSS) NMR liP contributed by PTSD symptoms ( 15 % ). The model
accounted for approximately 50% of the variance
SAS-SR
in impairment. (See Table 1 for zero-order correla-
r i486"* --.240** 520**
tions of symptom measures with functional impair-
Sig. .000 .002 .000
ment and Table 2 results of regression.)
N 163 164 160
PTSD Discussion
r -.107 .328**
This study revealed that among women with a his-
Sig, .174 .000
N 163 t59
tory of childhood abuse, PTSD symptoms predict
significant psychosocial impairment, indicating that
NMR
the effects of childhood abuse-related PTSD symp-
F --.241"*
toms are long-lasting, detrimental and generalized,
Sig, .002
N 160
affecting multiple domains of daily functioning. In
addition, however, the hierarchical regression anal-
Note. MPSS = Modified PTSD Symptoms Scale; NMR = General Expect- yses revealed that emotion regulation and interper-
ancy for Negative Mood Regulation; SAS-SR = Social Adjustment Scale sonal problems were strong predictors of functional
Self-Report; liP = Inventory of Interpersonal Problems.
** p < .00 I.
impairment beyond the effects of sociodemograph-
ics and severity of PTSD symptoms. Affect regula-
tion and interpersonal problems accounted for an
equal or greater proportion of the variance as
HIERARCHICAL REGRESSION ANALYSES that of PTSD symptoms, suggesting that these
In the initial hierarchical regression of the four characteristics are equally important contributors
blocks, ethnicity and marital status were not signif- to impairment. Explaining a total of 50% of the
icant predictors of impairment and were dropped variance, the model as a whole provides an identifi-
from the model. In the final regression model, age cation of the multiple substantial factors involved
was positively associated with the SAS-SR and in functional impairment among childhood abuse
greater income was associated with lesser impair- survivors.
ment. PTSD was a significant predictor of impair- It has been frequently reported that PTSD symp-
ment. Most importantly, negative mood regulation toms are but one of many concerns to childhood
and interpersonal problems were strong predictors abuse survivors and other chronic PTSD popula-
of functional impairment beyond the effects of de- tions (e.g., veterans), competing with social isolation,
mographics and severity of PTSD symptoms. The parenting difficulties, employment, and financial dif-
ficulties (e.g., Briere, 1988; Shalev, 1997; Zatzick et
al., 1997). The results of this study indicate that
TABLE 2 Hierarchical Hultiple Regression Analysis, W i t h PTSD symptoms do contribute to this impairment
Functional Impairment (SAS-SR) as O u t c o m e among childhood abuse survivors, but, more im-
Partial r,
portantly, suggest the additional and distinct con-
Beta, Final Change in R2 Final tributions of emotion regulation and interpersonal
Step Predictor Model (F value) Model problems.
These results have potential implications for treat-
I Age .22** . t 3** (12.10) .29**
ment development. It has frequently been sug-
Income -.20"* -.26"*
gested that the chronicity of PTSD symptoms pro-
2 PTSD Total .32** .20** (46.32) .39**
3 N M R Total -.13" .04** (10.54) -.17"
duces a decline in affective and interpersonal
4 IIPTotal .36** . I I * * (31.85) .42**
functioning over time, which then has a life of its
own (e.g., Shalev, 1997). In addition, the develop-
Note. Beta represents the proportion increase in standard deviation of the out- mental literature has identified that difficulties in
come variable with every increase of one standard deviation in the pre-
dictor variable. Change in R2 represents the percentage of additional
affect regulation and interpersonal relating are
variance in functional impairment accounted for by predictor variables present early on, in the childhood and adolescent
included in each step, beyond that accounted for by variables included in years, suggesting the presence of basic skills deficits
the previous step. Partial r is the partial correlation of each variable in the among those who have experienced chronic and
complete model with all other variables partialled out, NMR = General
Expectancy for Negative Mood Regulation;SAS SR = SocialAdjustment
sustained childhood trauma. The findings suggest
Scale Self-Report; lip = Inventory of Interpersonal Problems. the potential value of including a rehabilitation
*p < .OS;**p < .01. component in PTSD treatments geared toward the
 FUNCTIONAL IMPAIRMENT
reconstitution or development of skills in manag-
ing feelings and in negotiating relationships with
significant members of the potential social n e t w o r k
(e.g., partner, children, boss, and coworkers).
There are empirically supported treatments emerg-
ing for m u l t i p l y a n d c h r o n i c a l l y t r a u m a t i z e d
populations that incorporate a life skills c o m p o -
nent (Cloitre et al., 2002; Ford & Frisman, 2002;
M c D o n a g h - C o y l e , Ford, & D e m m e n t , 2002) and
measure outcomes relevant to these interventions.
It remains to be seen whether the presence of life
skills training in addition to traditional trauma-
focused interventions (such as imaginal exposure
and cognitive restructuring) will provide greater
improvements in social adjustment than is seen in
PTSD-only focused treatments. It will be necessary
to directly c o m p a r e these different types of treat-
ment and to include a b r o a d e r set of o u t c o m e mea-
sures such as i m p r o v e m e n t in w o r k performance,
i m p r o v e d p a r e n t i n g skills, and r e d u c e d rates of
aggression and repeated victimization.
Generalization of these findings should be made
with caution. Given that our sample consisted of
treatment-seeking w o m e n with histories of child-
h o o d abuse, the results obtained may not generalize
to other trauma populations or to non-treatment-
seeking samples. In addition, this study employed a
cross-sectional rather than a longitudinal design,
with the limitations that implies a b o u t assump-
tions of causal relationships. Furthermore, the in-
struments used in this study were self-report ques-
tionnaires and thus suffer f r o m the limitations of
this m e t h o d of data collection. Future studies might
benefit f r o m the use of objective measures of func-
tional impairment, such as collateral reports.
In summary, this study indicates that functional
impairment in w o m e n with childhood abuse is re-
lated to both symptoms of PTSD and to other be-
havioral and emotional disturbances that exert an
influence independently of diagnostic symptoms.
Functional i m p a i r m e n t and PTSD symptoms were
not equivalent p h e n o m e n a . E x p a n d i n g the core
outcomes for PTSD treatments to diverse measures
implicated in compromised functional capacity m a y
help guide the development and testing of treat-
ments aimed at recovery goals that extend b e y o n d
PTSD symptoms.
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RECEIVED: August 21, 2003
ACCEPTED: March 2, 2004