Psychiatry Research 177 (2010) 150–155

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Psychiatry Research
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

Examining the unique relationships between anxiety disorders and childhood

physical and sexual abuse in the National Comorbidity Survey-Replication
Jesse R. Cougle ⁎, Kiara R. Timpano, Natalie Sachs-Ericsson, Meghan E. Keough, Christina J. Riccardi
Department of Psychology, Florida State University, Tallahassee, FL, United States

a r t i c l e i n f o a b s t r a c t

Article history: Research has accumulated over the past several years demonstrating a relationship between childhood abuse
Received 17 November 2008 and anxiety disorders. Extant studies have generally suffered from a number of methodological limitations,
Received in revised form 4 March 2009 including low sample sizes and without controlling for psychiatric comorbidity and parental anxiety. In
Accepted 10 March 2009
addition, research has neglected to examine whether the relationships between anxiety disorders and
childhood abuse are unique to physical abuse as opposed to sexual abuse and vice versa. The current study
Keywords:
Comorbidity
sought to examine the unique relationships between anxiety disorders and childhood physical and sexual
Parental anxiety abuse using data from the National Comorbidity Survey-Replication. Participants (n = 4141) completed
Epidemiology structured interviews from which data on childhood abuse history, lifetime psychiatric history, parental
Childhood abuse anxiety, and demographics were obtained. After controlling for depression, other anxiety disorders, and
Trauma demographic variables, unique relationships were found between childhood sexual abuse and social anxiety
Anxiety disorders disorder (SAD), panic disorder (PD), generalized anxiety disorder (GAD), and posttraumatic stress disorder
(PTSD); in contrast, physical abuse was only associated with PTSD and specific phobia (SP). Further, among
women, analyses revealed that physical abuse was uniquely associated with PTSD and SP, while sexual abuse
was associated with SAD, PD, and PTSD. Among men, both sexual and physical abuse were uniquely
associated with SAD and PTSD. Findings provide further evidence of the severe consequences of childhood
abuse and help inform etiological accounts of anxiety disorders.
© 2009 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Despite considerable advances in elucidating the phenomenology of
anxiety syndromes, the development of concise models of pathogenesis
and the identification of definitive risk factors has remained relatively
elusive. Family and twin studies have found only moderate estimates of
heritability for anxiety disorders (Hettema et al., 2001), which points
to the important role that possible gene–environment interactions
and discrete environmental factors (e.g., Caspi et al., 2003; Murphy
et al., 2003) may play in the liability for anxiety psychopathology. Given
this literature, researchers have increasingly argued that certain
adverse life events may be more substantive to etiological explanations.
Among these events, childhood abuse has been given much research
attention.
There are a number of potential mechanisms by which childhood
abuse could contribute to different anxiety disorders. Such experi-
ences may play a role in the development of beliefs that are linked
with the onset and/or maintenance of anxiety disorders. For example,
individuals who have experienced child abuse may develop the beliefs
⁎ Corresponding author. Department of Psychology, Florida State University, P.O. Box
3064301, Tallahassee, FL 32306, United States. Tel.: +1 850 645 8729; fax: +1 850 644
7739.
E-mail address: cougle@psy.fsu.edu (J.R. Cougle).
that the world is a dangerous place and that they have little control
over what happens to them, both of which are important to anxiety
disorders (Barlow, 2002). Similarly, childhood abuse may sensitize
victims to the effects of subsequent traumatic exposure (Breslau et al.,
1999), by leading to the development of beliefs about the effect or
meaning of fear reactions. One such cognitive vulnerability is anxiety
sensitivity, which has been found to increase in response to stress
(Schmidt et al., 2000) and which is linked to several anxiety disorders
(Taylor et al., 1992).
Certain biological mechanisms may also act as pathways towards
increasing risk of anxiety disorders among people with childhood
abuse histories. Nemeroff (2004) hypothesized that early life-stress
leads to neuronal changes in the hypothalamic–pituitary–adrenal axis
and the induction of persistently-elevated neuronal releases of
corticotropin releasing factor. The net effect is an increased respon-
siveness to stress. Several investigations have shown that this
increased responsiveness renders individuals more susceptible to
psychopathology in adulthood (Heim and Nemeroff, 2001).
In an effort to address the complex relationship between childhood
adversity and adult psychopathology, a number of studies have
examined childhood abuse histories among patients with anxiety
disorders. David et al. (1995) found rates of childhood abuse that were
much higher (63%) among those diagnosed with panic disorder,
agoraphobia, and/or social phobia compared to a nonclinical group

0165-1781/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2009.03.008
 J.R. Cougle et al. / Psychiatry Research 177 (2010) 150–155
with no psychopathology (24%). They also found abuse history to be
most pronounced among patients with social phobia. Other investiga-
tors compared childhood abuse histories among a clinical sample of
patients with panic disorder, social phobia, or obsessive compulsive
disorder to a matched community group (Stein et al., 1996). Their data
revealed higher rates of child abuse histories among men and women
with anxiety disorders compared to the non-clinical comparison group.
In addition, women with panic disorder reported higher rates of sexual
abuse than women with other anxiety disorders. Rates of sexual abuse
among men were too small for meaningful analyses. In an epidemio-
logical investigation, Sachs-Ericsson et al. (2006) found rates of anxiety
symptoms to be greater in men and women with a history of childhood
abuse (sexual or physical) compared to those without an abuse history.
However they failed to compare rates of specific anxiety disorders in
relation to abuse.
More recently, researchers investigated childhood abuse histories
among treatment-seeking patients with panic disorder, social anxiety
disorder, and generalized anxiety disorder (Safren et al., 2002). They
found that patients with panic disorder had higher rates of childhood
abuse (physical or sexual) than those with social anxiety disorder. Those
individuals with generalized anxiety disorder had similar rates of abuse
to those with either panic or social anxiety disorder. These findings
remained significant when controlling for depression comorbidity.
Although investigations on childhood abuse and anxiety have
consistently found a relationship between early life stress and adult
psychopathology, they have also suffered from a number of methodo-
logical limitations. The first of these relates to weaknesses in general-
izability. Researchers often used treatment-seeking patients from a
narrow demographic and excluded patients with (rather than con-
trolled for) posttraumatic stress disorder (PTSD). Exclusion of patients
with a history of PTSD may have resulted in a sample that was more
likely to possess certain resilient characteristics than people who meet
for non-PTSD anxiety disorders. In addition, these studies included low
sample sizes, thus limiting the types of comparisons available. This is
especially significant given the lower prevalence of childhood sexual
abuse among men. In addition, physical and sexual abuse frequently co-
occur (e.g., Sachs-Ericsson et al., 2005), and low sample size prevents the
examination of whether associations between childhood abuse and
anxiety disorders are due to physical versus sexual abuse. Some anxiety
disorders, such as specific phobia and agoraphobia were also not
considered in published studies. Another consideration is that most of
these studies have not attempted to assess for parental psychopathol-
ogy. Given the overlap between anxiety and abusive behavior (De Bellis
et al., 2001) and the fact that parents of anxious children have much
higher rates of anxiety disorders (Turner et al., 1987), this would be an
important control to include, as it would help exclude heritable risk
factors and parental modeling of anxious behavior as explanations for
increased risk. Lastly, researchers have often neglected to control for
additional variables such as history of divorce or parental loss or
abandonment that may be important to explaining the relationship
between anxiety disorders and abuse history.
The current study sought to examine history of childhood physical
and sexual abuse in a large national sample. Multivariate analyses were
conducted to assess the unique relationships between lifetime anxiety
disorders and childhood physical and sexual abuse when controlling for
comorbidity, parental anxiety, childhood history of divorce or loss of
parent, and important demographic characteristics. Further, given that
childhood abuse is associated with depression (Weiss et al., 1999) and
depression is a condition commonly comorbid with anxiety disorders
(Brown et al., 2001), we examined these relationships when also
controlling for lifetime depression history. Since we were furthermore
interested in the unique relationships between anxiety disorders and
physical and sexual abuse, we sought to test whether associations
between anxiety disorders and physical abuse would remain significant
when controlling for sexual abuse and whether relationships with
sexual abuse would remain significant when controlling for physical
151
abuse. Lastly, given the differential relationships that have been found
between childhood abuse and psychopathology among men and
women (MacMillan et al., 2001; Verona and Sachs-Ericsson, 2005), we
conducted separate analyses by gender.
2. Methods
2.1. Sample
The NCS-R respondents are a representative sample of English-speaking adults
from the continental United States. Interviews of the respondents were conducted in-
person at their place of residence between February 2001 and April 2003. Kessler et al.
(2004) have provided a detailed description of the methodology, weighting and
sampling procedures used in the NCS-R.
Part I of the interview, which contained a section covering each of the core mental health
disorders, was completed by all respondents (n=9282). Sections on disorders of secondary
importance as well as risk factors, consequences, services and other correlates of mental
health disorders were included in Part II. In order to reduce the burden on participants, Part II
was completed only by those who met criteria for a lifetime core diagnosis as well as a
probability subsample of those who did not meet criteria. The current investigation was based
on data from both Part I and II from which we obtained a subsample of individuals (n=4141)
who completed questions regarding childhood physical and sexual abuse. The sample was
56% female with an average age of 49.9 (S.D.=16.4). The racial and ethnic representation of
the study participants were 73.2% Caucasian, 12.6% African-American, 10.7% Hispanic, and
3.5% from other ethnicities. The average years of education were 12.9 (S.D.=2.5).
2.2. Procedure
The NCS-R sampling was based on the 2000 US Census, from which a stratified,
multistage probability sample was created. Procedures used for this national survey have
been described extensively elsewhere (Kessler et al., 2004).
2.3. Measures
2.3.1. Demographic
An extensive demographic section was included in the interview to assess gender,
age, education, income, ethnicity/race, martial status as well as other demographic
variables.
2.3.2. Respondent diagnostic assessment
Lifetime history of psychiatric diagnoses for each respondent was determined using
the World Mental Health Survey Initiative version of the World Health Organization
Composite International Diagnostic Interview (WMH-CIDI). This is a structured diagnostic
interview from which DSM-IV Axis I (American Psychiatric Association, 2000) diagnoses
are derived including anxiety and mood disorder diagnoses. The CIDI has been determined
to have good validity and reliability (First et al., 2002).
2.3.3. Parental panic attacks
Items assessing parental history of probable panic attacks and GAD symptoms (see
below) were based on Family History Research Diagnostic Criteria (Andreasen et al., 1977),
which has been shown to have good sensitivity. To determine whether either of the
respondent's parents (e.g., mother or father) likely experienced a panic attack while the
respondent was a child, two questions were asked of the respondent. They were first asked
if either parent complained of having an anxiety attack in which all of a sudden they felt
frightened, anxious or panicky. If that had occurred, they were queried as to whether the
parent also mentioned the attack being accompanied by a pounding heart, shortness of
breath, feeling ill or the fear of death. If the respondent answered in the affirmative to both
of these questions for either caregiver, then they were coded as having a parent with a
probable history of panic attacks.
2.3.4. Parental generalized anxiety disorder symptoms
To determine whether either of the respondent's parents likely experienced
symptoms of GAD while the respondent was a child, several questions were asked of
the respondent. They were first asked if either parent experienced a month or more of
being constantly nervous, edgy or anxious. They were also asked if the nervousness was
accompanied by physiological symptoms (restlessness, irritability, fatigue or trouble
sleeping) and whether the nervousness had a significant impact on the caregiver's life. If
the respondent answered in the affirmative to these three questions for either parent, then
they were coded as having a parent with a probable history of GAD symptoms.
2.3.5. Childhood history of abuse
Respondent's history of childhood physical and sexual abuse was also assessed
during the interview. Previous studies have indicated that respondents are often
embarrassed and/or uncomfortable discussing a history of sexual or physical assault
(Kessler et al., 1999). Therefore, pilot studies were conducted prior to the construction
of this interview in an effort to decrease respondents' discomfort and in turn increase
the validity and reliability of reported abuse (see Kessler et al., 1999). The strategies
employed based on the pilot studies have been reported in detail by Sachs-Ericsson
et al. (2005). Two questions regarding sexual assault and one regarding physical assault
152 J.R. Cougle et al. / Psychiatry Research 177 (2010) 150–155

Table 1
Prevalence rates of childhood abuse across the anxiety disorders with univariate comparisons.

Physical abuse n % OR (95% CI) Sexual abuse n % OR (95% CI) Physical or sexual abuse n % OR (95% CI)
Women (530/2312) 22.9% – (375/2313) 16.2% – (739/2313) 31.9% –
Men (440/1828) 24.1% – (78/1828) 4.3% – (483/1828) 26.4% –
Total sample (970/4140) 23.4% – (453/4141) 10.9% – (1222/4141) 29.5% –
Total sample without any anxiety disorder (580/2970) 19.5% – (212/2969) 7.1% – (720/2969) 24.3% –
Agoraphobia without panic (43/99) 43.4% 2.56 (1.72–3.83)⁎⁎ (29/99) 29.3% 3.51 (2.26–5.47)⁎⁎ (52/99) 52.5% 2.70 (1.92–3.80)⁎⁎
Social anxiety disorder (168/471) 35.7% 1.98 (1.65–2.37)⁎⁎ (112/470) 23.8% 3.08 (2.48–3.82)⁎⁎ (216/470) 46.0% 2.26 (1.83–2.79)⁎⁎
Panic disorder ± agoraphobia (103/251) 41.0% 2.42 (1.80–3.24)⁎⁎ (74/251) 29.5% 3.86 (2.89–5.17)⁎⁎ (130/252) 51.6% 2.73 (2.05–3.63)⁎⁎
Generalized anxiety disorder (140/350) 40.0% 2.39 (1.98–2.88)⁎⁎ (90/350) 25.7% 3.28 (2.60–4.14)⁎⁎ (172/350) 49.1% 2.53 (2.11–3.03)⁎⁎
Posttraumatic stress disorder (137/299) 45.8% 3.06 (2.42–3.87)⁎⁎ (104/298) 34.9% 5.41 (4.34–6.75)⁎⁎ (176/299) 58.9% 3.83 (2.94–5.00)⁎⁎
Specific phobia (187/525) 35.6% 2.00 (1.69–2.37)⁎⁎ (100/526) 19.0% 2.17 (1.73–2.72)⁎⁎ (228/525) 43.4% 2.03 (1.73–2.38)⁎⁎

⁎⁎ P < 0.01; OR: Odds Ratio.

were included in the posttraumatic stress disorder (PTSD) section. Two questions
regarding mild and severe physical assault was included in the section on general
childhood experiences.
2.3.6. Sexual abuse
In this investigation, respondents were included as having a history of childhood
sexual abuse if they indicated they had been raped or molested prior to the age of 15.
2.3.7. Physical abuse
The physical assault question from the PTSD section inquired as to whether
they had ever been badly beaten up by their parents or those who raised them
when they were a child (Yes/No). Respondents reporting ‘yes’ were classified as
having been physically abused. Further, the first question from the childhood
experiences section asked how often as a child they were pushed, grabbed, shoved,
slapped, hit or had something thrown at them by their parents or those who raised
them. Respondents who reported they had “Often” or “Sometimes” had those
experiences as a child were identified as having been physically abused. The second
question asked if they had ever been badly abused as a child by their parent
including being beaten up, stabbed, choked, burned or scalded, or threatened with
a knife or gun. Those participants who indicated that they had ever been badly
abused as a child were included as having a history childhood physical abuse.
Sachs-Ericsson et al. (2007) reported good sensitivity and specificity among the
PTSD items on physical abuse and the subsequent physical abuse items in the
subsequent childhood history section.
2.3.8. Parental divorce or loss
The interview also inquired as to whether the respondent's parents had divorced or
one of their parents had died or abandoned the family before the age of 15. If the
respondent indicated they had any such an experience, they were coded as having
experienced parental divorce or loss which was controlled for in the analyses because it
has previously been shown to be correlated with childhood abuse and psychopathology
(Sachs-Ericsson et al., 2006).
3. Results
Analyses were conducted using Statistical Analysis Software (SAS)
version 9.1 and employed the appropriate NCS-R statistical weights to
ensure that the sample was representative of the general US
population. Table 1 presents the prevalence rates of childhood abuse
in the entire sample and across the anxiety disorders. Overall, 44.5%
(201/452) of the sample reporting a history of sexual abuse also
reported a history physical abuse, and 20.7% (201/970) of those
reporting a history of physical abuse also reported sexual abuse.
Univariate logistic regression analyses found each of the anxiety
disorders to be associated with history of childhood physical or sexual
abuse.
In order to control for a number of anxiety and childhood abuse
related correlates, multivariate logistic regression analyses were con-
ducted to further explore the relationship between childhood abuse and
anxiety disorders (see Table 2). Anxiety disorders were entered into
each model simultaneously. The first set of analyses controlled for
gender, age, ethnicity, marital status, childhood parental divorce/loss,
parental anxiety, and income. Since we also wished to examine whether
the relationships between anxiety disorders and abuse history could be
accounted for by comorbid depression, the second set of analyses
included the first set of covariates as well as lifetime depression history.
In addition, given the overlap between physical and sexual abuse, we
conducted a third set of analyses with the same covariates and the
addition of either physical or sexual abuse depending on which abuse
type was the dependent variable. Results from these analyses indicate
that history of childhood physical or sexual abuse was associated with
increased risk for lifetime social anxiety disorder (SAD), panic disorder

Table 2
Multivariate logistic regression analyses of child abuse experiences and lifetime anxiety disorder histories.

Physical abuse Sexual abuse

AOR-1a (95% CI) AOR-2b (95% CI) AOR-3c (95% CI) AOR-1a (95% CI) AOR-2b (95% CI) AOR-3d (95% CI)
Parental panic attacks 1.84 (1.31–2.58)⁎⁎ 1.77 (1.26–2.48)⁎⁎ 1.76 (1.23–2.53)⁎⁎ 1.25 (0.76–2.03) 1.20 (0.73–1.96) 1.09 (0.66–1.81)
Parental generalized anxiety disorder 3.22 (2.39–4.34)⁎⁎ 3.13 (2.31–4.24)⁎⁎ 3.05 (2.28–4.09)⁎⁎ 1.59 (1.02–2.50)⁎ 1.53 (0.97–2.42) 1.22 (0.77–1.96)
symptoms
Agoraphobia without panic disorder 0.74 (0.47–1.15) 0.73 (0.47–1.14) 0.77 (0.49–1.21) 0.67 (0.40–1.15) 0.67 (0.40–1.12) 0.69 (0.40–1.18)
Social anxiety disorder 1.25 (1.02–1.53)⁎ 1.17 (0.96–1.43) 1.10 (0.91–1.34) 1.85 (1.44–2.39)⁎⁎ 1.71 (1.33–2.20)⁎⁎ 1.70 (1.33–2.19)⁎⁎
Panic disorder ± agoraphobia 1.46 (1.08–1.98)⁎ 1.41 (1.05–1.91)⁎ 1.29 (0.96–1.75) 2.10 (1.46–3.03)⁎⁎ 2.00 (1.42–2.84)⁎⁎ 1.91 (1.36–2.70)⁎⁎
Generalized anxiety disorder 1.51 (1.20–1.89)⁎⁎ 1.31 (1.03–1.66)⁎ 1.26 (1.00–1.60) 1.62 (1.28–2.05)⁎⁎ 1.34 (1.06–1.69)⁎ 1.28 (1.03–1.60)⁎
Posttraumatic stress disorder 2.06 (1.59–2.66)⁎⁎ 1.91 (1.49–2.45)⁎⁎ 1.68 (1.31–2.16)⁎⁎ 2.83 (2.19–3.65)⁎⁎ 2.58 (2.00–3.32)⁎⁎ 2.38 (1.85–3.06)⁎⁎
Specific phobia 1.35 (1.13–1.63)⁎⁎ 1.31 (1.10–1.56)⁎⁎ 1.33 (1.12–1.59)⁎⁎ 0.95 (0.72–1.26) 0.91 (0.68–1.21) 0.85 (0.63–1.15)
Likelihood ratio test χ2(16) = 265.68, χ2(17) = 281.20, χ2(18) = 334.13, χ2(16) = 404.53, χ2(17) = 422.10, χ2(18) = 473.23,
P < 0.0001 P < 0.0001 P < 0.0001 P < 0.0001 P < 0.0001 P < 0.0001
No anxiety disorder – – – – –
1 anxiety disorder 1.44 (1.18–1.75)⁎⁎ 1.32 (1.07–1.62)⁎⁎ 1.26 (1.03–1.54)⁎ 1.85 (1.31–2.62)⁎⁎ 1.63 (1.13–2.36)⁎⁎ 1.57 (1.10–2.25)⁎
2 anxiety disorders 2.00 (1.59–2.52)⁎⁎ 1.70 (1.33–2.17)⁎⁎ 1.55 (1.22–1.97)⁎⁎ 2.97 (2.10–4.21)⁎⁎ 2.39 (1.76–3.26)⁎⁎ 2.23 (1.64–3.02)⁎⁎
3 or more anxiety disorders 2.77 (2.06–3.73)⁎⁎ 2.18 (1.64–2.91)⁎⁎ 1.92 (1.44–2.56)⁎⁎ 3.59 (2.73–4.71)⁎⁎ 2.58 (2.00–3.33)⁎⁎ 2.28 (1.79–2.91)⁎⁎

⁎P < 0.05; ⁎⁎ P < 0.01.

a
Adjusted Odds Ratios (AOR-1) were adjusted for each variable listed above plus age, ethnicity, marital status, childhood divorce/loss of parent, and income.
b
Adjusted Odds Ratios (AOR-2) included the variables used for AOR-1 plus depression.
c
Adjusted Odds Ratios (AOR-3) included the variables used for AOR-2 plus sexual abuse.
d
Adjusted Odds Ratios (AOR-3) included the variables used for AOR-2 plus physical abuse.
 J.R. Cougle et al. / Psychiatry Research 177 (2010) 150–155 153

Table 3
Multivariate logistic regression analyses of child abuse experiences and lifetime anxiety disorder histories among women.

Physical abuse Sexual abuse

AOR-1a (95% CI) AOR-2b (95% CI) AOR-3c (95% CI) AOR-1a (95% CI) AOR-2b (95% CI) AOR-3d (95% CI)
Parental panic attacks 1.85 (1.26–2.71)⁎⁎ 1.81 (1.23–2.65)⁎⁎ 1.88 (1.26–2.80)⁎⁎ 0.91 (0.57–1.47) 0.90 (0.55–1.47) 0.80 (0.49–1.33)
Parental generalized anxiety disorder 3.59 (2.47–5.21)⁎⁎ 3.51 (2.41–5.10)⁎⁎ 3.35 (2.34–4.79)⁎⁎ 1.78 (1.03–3.07)⁎ 1.72 (0.99–3.01) 1.34 (0.77–2.36)
symptoms
Agoraphobia without panic disorder 0.84 (0.50–1.40) 0.82 (0.48–1.40) 0.88 (0.51–1.52) 0.67 (0.38–1.17) 0.66 (0.38–1.15) 0.67 (0.37–1.19)
Social anxiety disorder 1.09 (0.82–1.44) 1.01 (0.77–1.32) 0.93 (0.72–1.22) 1.74 (1.29–2.34)⁎⁎ 1.62 (1.20–2.20)⁎⁎ 1.65 (1.23–2.22)⁎⁎
Panic disorder ± agoraphobia 1.57 (1.09–2.25)⁎ 1.49 (1.04–2.14)⁎ 1.34 (0.94–1.91) 2.12 (1.44–3.11)⁎⁎ 2.02 (1.41–2.91)⁎⁎ 1.93 (1.34–2.76)⁎⁎
Generalized anxiety disorder 1.63 (1.22–2.18)⁎⁎ 1.35 (1.03–1.78)⁎ 1.32 (1.00–1.73) 1.47 (1.13–1.92)⁎⁎ 1.23 (0.91–1.65) 1.17 (0.88–1.56)
Posttraumatic stress disorder 1.88 (1.41–2.50)⁎⁎ 1.70 (1.27–2.29)⁎⁎ 1.46 (1.09–1.96)⁎ 2.83 (2.20–3.65)⁎⁎ 2.59 (2.02–3.34)⁎⁎ 2.41 (1.88–3.08)⁎⁎
Specific phobia 1.40 (1.09–1.80)⁎⁎ 1.33 (1.04–1.70)⁎ 1.38 (1.08–1.77)⁎ 0.90 (0.69–1.18) 0.85 (0.64–1.13) 0.80 (0.60–1.06)
Likelihood ratio test χ2(15) = 198.86, χ2(16) = 216.45, χ2(17) = 262.28, χ2(15) = 198.80, χ2(16) = 212.67, χ2(17) = 258.21,
P < 0.0001 P < 0.0001 P < 0.0001 P < 0.0001 P < 0.0001 P < 0.0001

⁎P < 0.05; ⁎⁎ P < 0.01.

a
Adjusted Odds Ratios (AOR-1) were adjusted for each variable listed above plus age, ethnicity, marital status, childhood divorce/loss of parent, and income.
b
Adjusted Odds Ratios (AOR-2) included the variables used for AOR-1 plus depression.
c
Adjusted Odds Ratios (AOR-3) included the variables used for AOR-2 plus sexual abuse.
d
Adjusted Odds Ratios (AOR-3) included the variables used for AOR-2 plus physical abuse.

(PD), generalized anxiety disorder (GAD), and PTSD. Physical abuse but
not sexual abuse also conveyed a risk for specific phobia (SP). With the
exception of the association between physical abuse and SAD, most of
these results remained significant when also controlling for depression.
However, once sexual abuse was covaried, only SP and PTSD were
significantly associated with physical abuse, while SAD, GAD, PD, and
PTSD were uniquely associated with sexual abuse after controlling for
physical abuse. Additionally, the results indicate that a greater number of
anxiety disorders is associated with greater likelihood of childhood
abuse history.
Following a data-analytic strategy outlined by Cohen et al. (2002),
analyses relying on beta coefficients and pooled standard errors were
conducted to examine whether those anxiety disorders significantly
associated with childhood abuse differed in the strength of their
associations with childhood abuse history. These analyses used data
from the previous multivariate logistic analyses that also controlled for
lifetime depression and either sexual or physical abuse history
(depending on the dependent variable used in analyses). Individuals
with PTSD were not significantly more likely to have a history of
childhood physical abuse than those with SP. For sexual abuse, PTSD was
a stronger predictor than GAD, though it was similar to PD and SAD in
the strength of its association with abuse history.
When multivariate regression analyses were separated by gender,
a different picture emerged for women (see Table 3) as opposed to
men (see Table 4). For women, each anxiety disorder was associated
with physical abuse with the exception of SAD and agoraphobia.
Further, each anxiety disorder except SP and agoraphobia was
associated with sexual abuse. These findings remained significant
when also controlling for depression, with the exception of the
relationship between sexual abuse and GAD. However, after control-
ling for sexual abuse, only PTSD and SP were associated with physical
abuse, while PTSD, PD, and SAD were uniquely associated with sexual
abuse when controlling for physical abuse. For men, both SAD and
PTSD were associated with physical and sexual abuse. However, after
controlling for depression and sexual or physical abuse history, SAD
was found to be uniquely associated with physical and sexual abuse,
while PTSD was only associated with physical abuse. It should be
noted that the sexual abuse analysis was likely limited by low power
(only 78 total cases of reported sexual abuse).
4. Discussion
Using a large-scale nationally representative sample, we found
elevated rates of self-reported childhood sexual and physical abuse
among individuals with a lifetime history of PD, GAD, SP, SAD, and
PTSD. Moreover, these associations generally remained significant
when controlling for comorbid conditions. However, once the
associations with physical abuse were examined when controlling
for sexual abuse and vice versa, a different picture emerged. Only PTSD
and SP were uniquely associated with physical abuse, while PTSD,
SAD, GAD, and PD were each associated with sexual abuse history. The
data also indicated that individuals with multiple anxiety disorders
were significantly more likely to have childhood abuse history than
those with one or no anxiety disorder. Whereas, agoraphobia without
panic disorder was not uniquely associated with childhood abuse, this
may be a statistical artifact due to the low base rate of this condition.

Table 4
Multivariate logistic regression analyses of child abuse experiences and lifetime anxiety disorder histories among men.

Physical abuse Sexual abuse

AOR-1a (95% CI) AOR-2b (95% CI) AOR-3c (95% CI) AOR-1a (95% CI) AOR-2b (95% CI) AOR-3d (95% CI)
Parental panic attacks 1.83 (0.95–3.51) 1.77 (0.94–3.35) 1.68 (0.87–3.22) 3.52 (1.13–10.98)⁎ 3.15 (0.96–10.31) 2.96 (0.87–9.99)
Parental generalized anxiety disorder 2.64 (1.66–4.19)⁎⁎ 2.58 (1.64–4.07)⁎⁎ 2.61 (1.77–4.09)⁎⁎ 0.92 (0.36–2.32) 0.88 (0.36–2.18) 0.77 (0.32–1.88)
symptoms
Agoraphobia without panic disorder 0.58 (0.25–1.35) 0.59 (0.26–1.34) 0.61 (0.26–1.41) 0.57 (0.11–2.96) 0.60 (0.12–3.06) 0.66 (0.13–3.38)
Social anxiety disorder 1.52 (1.12–2.07)⁎⁎ 1.47 (1.09–1.99)⁎ 1.42 (1.04–1.94)⁎ 2.51 (1.40–4.51)⁎⁎ 2.26 (1.31–3.91)⁎⁎ 2.12 (1.21–3.69)⁎⁎
Panic disorder ± agoraphobia 1.30 (0.73–2.32) 1.28 (0.72–2.26) 1.23 (0.70–2.17) 2.04 (0.87–4.77) 1.94 (0.81–4.67) 1.85 (0.78–4.42)
Generalized anxiety disorder 1.35 (0.90–2.03) 1.28 (0.78–2.08) 1.23 (0.78–1.94) 2.42 (0.97–6.02) 2.05 (0.85–4.91) 1.99 (0.87–4.56)
Posttraumatic stress disorder 2.52 (1.37–4.61)⁎⁎ 2.43 (1.33–4.46)⁎⁎ 2.33(1.27–4.26)⁎⁎ 2.69 (1.02–7.10)⁎ 2.39 (0.89–6.41) 2.20 (0.80–6.01)
Specific phobia 1.29 (0.89–1.88) 1.28 (0.88–1.85) 1.27 (0.87–1.85) 1.26 (0.51–3.10) 1.21 (0.49–2.99) 1.14 (0.44–2.93)
Likelihood ratio test χ2(15) = 88.04, χ2(16) = 88.92, χ2(17) = 95.10, χ2(15) = 61.46, χ2(16) = 64.16, χ2(17) = 69.81,
P < 0.0001 P < 0.0001 P < 0.0001 P < 0.0001 P < 0.0001 P < 0.0001

⁎P < 0.05; ⁎⁎ P < 0.01.

a
Adjusted Odds Ratios (AOR-1) were adjusted for each variable listed above plus age, ethnicity, marital status, childhood divorce/loss of parent, and income.
b
Adjusted Odds Ratios (AOR-2) included the variables used for AOR-1 plus depression.
c
Adjusted Odds Ratios (AOR-3) included the variables used for AOR-2 plus sexual abuse.
d
Adjusted Odds Ratios (AOR-3) included the variables used for AOR-2 plus physical abuse.
154 J.R. Cougle et al. / Psychiatry Research 177 (2010) 150–155
Additional analyses revealed that lifetime SP was similar to PTSD in
the strength of its association with childhood physical abuse, while
PTSD was stronger than GAD but similar to PD and SAD diagnoses in
its association with sexual abuse.
Analyses stratified by gender revealed important differences.
Among women, childhood sexual abuse was uniquely related to
PTSD, SAD, and PD, yet physical abuse was only related to SP and PTSD.
Further, among men, SAD was uniquely associated with sexual and
physical abuse, while PTSD was only associated with physical abuse. It
is worth noting that analyses of sexual abuse among men were limited
by low power. Only 4.3% (n = 78) of men reported a history of
childhood sexual abuse, and odds ratios suggest a trend towards
higher rates among men with PD or GAD.
The associations between childhood abuse and PTSD were
expected, since trauma history is a requirement for PTSD diagnosis.
However, the specificity of the association between SAD and child-
hood abuse among men and the broader associations between abuse
and SAD, PD, and SP among women are new and interesting findings
worth additional discussion. Childhood abuse may increase risk of
anxiety disorders through the general mechanisms discussed pre-
viously, but it may also be the case that unique mechanisms work to
increase risk for specific disorders. For SAD, it is likely that physical or
sexual abuse contributes to feelings of shame, perceptions of
incompetence and inadequacy, and negative self-views that are
characteristic of the disorder (Sachs-Ericsson et al., 2006). In contrast,
the associations between sexual abuse and PD among women may be
explained via the heightened anxiety sensitivity that may be produced
through such severe events and that is so integral to this disorder
(Taylor et al., 1992). We are unaware of previous research demon-
strating a unique relationship between physical abuse and SP and
given the heterogeneity of this disorder can devise no theoretical
explanations for its association with physical but not sexual abuse.
The fact that abuse history was associated with more anxiety
disorders among women than men is consistent with the trauma
literature, which has found that women have a greater risk of developing
PTSD following interpersonal violence (Breslau and Anthony, 2007).
There are a variety of explanations for these gender differences (Craske,
2003). Biological mechanisms provide some evidence that gender
differences may exist in the effects of gene and environment interac-
tions. For example, analogue research with rhesus macaques has
demonstrated that females are more susceptible to stressors if they
have a specific polymorphism of the serotonin transporter gene
promoter (Barr et al., 2004).
Depression was a particularly important covariate to include in our
analyses. Prior research suggests that a non-specific genetic vulner-
ability exists for both anxiety and depression (Kendler et al., 1995;
Kendler et al., 2007). Further, research has found that childhood
adversity is strongly associated with anxiety and depression comor-
bidity, yet is only weakly associated with the occurrence of either
disorder alone (Levitan et al., 2003). The fact that the relationships
between anxiety disorders and childhood abuse were generally
unaffected when controlling for depression testifies to the strength
and uniqueness of the associations between these variables.
The present study improved upon existing research in a number of
ways. The sample used in our analyses was large, nationally representa-
tive, and was not limited to treatment-seeking clinical samples with
more uniform diagnostic profiles. We furthermore were able to control
for a range of psychiatric comorbidities in our analyses. Similarly,
respondents' reports of parental anxiety were covaried, an important
methodological consideration that helps exclude other potential causes
of psychopathology. Others have argued that parental pathology leads to
increase risk of childhood abuse (Medley and Sachs-Ericsson, 2009), and
indeed, our analyses found especially strong relationships between
parental anxiety and physical abuse (see Table 2). The large sample size
allowed us to examine which anxiety disorders were uniquely
associated with physical abuse when controlling for sexual abuse and
vice versa. Another benefit of the large sample size was that it allowed us
to conduct meaningful analyses stratified by gender, which revealed
important gender differences in the relationships between anxiety
disorders and childhood abuse. Finally, we considered anxiety disorders
such as SP that had not previously been examined in different studies on
this topic.
A number of limitations of this study should be noted. First, the use
of cross-surveys and retrospective reports of abuse suffer from
problems associated with recall bias. It may be that those with greater
pathology are more likely to recall abuse experiences. Second, the
NCS-R relied on respondent reports of parental anxiety rather than
diagnostic interviews with parents. Third, a coding error resulted in
the absence of diagnostic information related to obsessive–compul-
sive disorder in this survey, so this anxiety disorder was not included
in our analyses. Fourth, as already mentioned, analyses of sexual abuse
among men suffered from low power.
To summarize, the findings of the present study provide further
evidence for the role of childhood physical and sexual abuse in
increasing risk for a range of anxiety disorders. Additionally, these
analyses suggest childhood sexual abuse is more consequential than
physical abuse in increasing risk of anxiety disorders overall, and SAD
and PTSD appear to be the anxiety disorders most uniquely associated
with both childhood physical and sexual abuse among men. The fact
that childhood abuse was associated with increased risk of a number
of anxiety disorders among women is consistent with a dimensional
view of anxiety disorders and suggests that women presenting with
multiple anxiety disorders might benefit from treatments that target
specific underlying factors (e.g., high anxiety sensitivity) common to
the anxiety disorders. Further research is needed exploring the exact
mechanisms responsible for these identified associations. Such
research will likely be very beneficial towards informing etiological
accounts of these disorders.
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