Neurological changes in brain structures among individuals with a history of childhood sexual abuse: A review

Abstract

Objective:

To gain an understanding of associated psychological phenomena among child sexual abuse (CSA) survivors, this article reviewed existing literature focused on neurological changes in brain structure and associated psychological problems among individuals who experienced CSA.

Methodology:

A review of literature examining physiological irregularities in brain structures and subsequent psychological problems of individuals with a history of CSA was conducted.

Results:

Results revealed a history of CSA was associated with irregularities in the: prefontal cortex, corpus callosum visual cortex, insular cortex, anterior cingulate gyrus, and temporal lobe. These irregularities contribute to various cognitive deficits, internalizing and externalizing behavioral problems, and psychological and physical health outcomes later in life. The age of CSA onset was associated with different neurological changes in brain structures.

Conclusion:

Mental and behavioral health problems associated with CSA may persist into adulthood and cause lifelong impairments including anxiety, depression, substance abuse, dissociative disorders, and sexual dysfunction. A lack of research depicting the effects of CSA on neurological outcomes emphasizes the need to examine the biological and subsequent psychological effects of CSA. Early intervention is imperative for CSA survivors. Limitations of current research findings are discussed and the direction of future research, focusing on the consideration of neurological implications of CSA prior to development of targeted interventions.

Full text

Neuroscience
and
Biobehavioral
Reviews
57
(2015)
63–69
Contents
lists
available
at
ScienceDirect
Neuroscience
and
Biobehavioral
Reviews
jou
rn
al
h
om
epage:
www.elsevier.com/locate/neubiorev
Review
Neurological
changes
in
brain
structure
and
functions
among
individuals
with
a
history
of
childhood
sexual
abuse:
A
review
Lyzette
Blancoa,c,∗,
Liesl
A.
Nydeggerb,c,
Giselle
Camarillob,c,
Dennis
R.
Trinidadd,c,
Emily
Schramme,c,
Susan
L.
Amesa,c
aSchool
of
Community
and
Global
Health,
Claremont
Graduate
University,
Claremont,
CA,
United
States
bCenter
for
Aids
Intervention
Research,
Department
of
Psychiatry
and
Behavioral
Medicine,
Medical
College
of
Wisconsin,
United
States
cUniversity
of
California,
Davis,
CA,
United
States
dDepartment
of
Family
Medicine
and
Public
Health,
University
of
California,
San
Diego,
CA,
United
States
eFred
Finch
Youth
Center,
Oakland,
CA,
United
States
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
18
August
2014
Received
in
revised
form
19
July
2015
Accepted
27
July
2015
Available
online
5
August
2015
Keywords:
Childhood
sexual
abuse
Subcortical
Cortical
Human
behavior
a
b
s
t
r
a
c
t
Objective:
Review
literature
focused
on
neurological
associations
in
brain
structure
among
individuals
with
a
history
of
childhood
sexual
abuse
(CSA).
Methodology:
A
review
of
literature
examining
physiological
irregularities
in
brain
structures
of
individ-
uals
with
a
history
of
CSA
was
conducted.
Results:
Results
revealed
that
a
history
of
CSA
was
associated
with
irregularities
in
the
cortical
and
subcortical
regions
of
the
brain.
These
irregularities
have
been
recognized
to
contribute
to
various
cog-
nitive,
behavioral,
and
psychological
health
outcomes
later
in
life.
Age
of
CSA
onset
was
associated
with
differential
neurological
brain
structures.
Conclusion:
Mental
and
behavioral
health
problems
such
as
anxiety,
depression,
substance
abuse,
dis-
sociative
disorders,
and
sexual
dysfunction
are
associated
with
CSA
and
may
persist
into
adulthood.
Research
depicting
the
associations
of
CSA
on
neurological
outcomes
emphasizes
the
need
to
exam-
ine
the
biological
and
subsequent
psychological
outcomes
associated
with
CSA.
Early
intervention
is
imperative
for
CSA
survivors.
©
2015
Elsevier
Ltd.
All
rights
reserved.
Contents
1.
Introduction
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1.1.
Cortical
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1.1.1.
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1.1.2.
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1.2.
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1.2.1.
Limbic
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axis
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1.2.2.
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1.2.3.
Hippocampus
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1.2.4.
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1.3.
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2.
Discussion
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68
References
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∗Corresponding
author
at:
School
of
Community
and
Global
Health,
Claremont
Graduate
University,
675
W.
Foothill
Blvd.,
Suite
310,
Claremont,
CA
91711,
United
States.
E-mail
address:
lyzette.blanco@cgu.edu
(L.
Blanco).
1.
Introduction
While
research
has
demonstrated
the
brain’s
resiliency
to
many
factors,
particular
stressors
have
been
linked
to
modifying
its
devel-
opment.
Various
factors
such
as
malnutrition
(Uauy
and
Dangour,
http://dx.doi.org/10.1016/j.neubiorev.2015.07.013
0149-7634/©
2015
Elsevier
Ltd.
All
rights
reserved.

64
L.
Blanco
et
al.
/
Neuroscience
and
Biobehavioral
Reviews
57
(2015)
63–69
2006;
Prado
and
Dewey,
2014),
maternal
stress
(King
and
Laplante,
2005;
Talge
et
al.,
2007),
violence
(Fonzo
et
al.,
2010;
Perry
et
al.,
1995),
and
other
stress-inducing
experiences
during
childhood
development
can
negatively
impact
and
alter
neuroplasticity
and
structural
composition
of
the
brain
(Teicher
et
al.,
2004).
A
history
childhood
sexual
abuse
(CSA)
has
been
associated
with
a
host
of
adverse
health
issues,
including
but
not
limited
to
cognitive
impair-
ments
(Bohn
and
Holz,
1996;
De
Bellis
et
al.,
2011;
Leserman,
2005;
Moeller
et
al.,
1993;
Murray
et
al.,
2014).
CSA
is
defined
as
coercive
or
unwanted
sexual
acts
occur-
ring
between
a
child
and
a
perpetrator
(Wyatt,
1985;
Wyatt
and
Newcomb,
1990;
Wyatt
and
Peters,
1986;
Zwickl
and
Merriman,
2011).
Rates
of
CSA
are
surprisingly
high
with
33%
of
women
(Finkelhor,
1994;
Wyatt
et
al.,
2004)
and
16%
of
men
(Finkelhor,
1994)
reporting
a
history
of
CSA.
Recent
finding
suggest
approx-
imately
20–26%
(The
National
Center
for
Victims
of
Crime,
2012)
of
young
girls
experience
CSA
(Finkelhor
et
al.,
2014).
Prevalence
rates
of
sexual
abuse
often
differ
due
to
non-disclosure
by
survivors
(Sciolla
et
al.,
2011).
Reluctance
to
discuss
abuse
may
occur
due
to
a
fear
of
repercussions
from
the
abuser,
victim
blaming,
self-blame,
and
fear
of
re-living
the
experience
(Bohn
and
Holz,
1996;
Sciolla
et
al.,
2011).
Innovative
research
has
investigated
the
neurological
and
neurocognitive
differences
associated
with
women
who
have
expe-
rienced
CSA
compared
to
those
who
have
not
(De
Bellis
et
al.,
2011;
Minzenberg
et
al.,
2008).
Neuro-analytical
techniques
sup-
port
the
finding
that
differences
in
brain
structure
and
plasticity
is
associated
with
a
significant
number
of
women
who
experienced
early
CSA.
Such
areas
include,
but
are
not
limited
to,
sections
of
cerebral
cortex,
prefrontal
cortex,
hippocampus,
amygdala,
cor-
pus
callosum,
cerebellum,
limbic
system
as
well
as
the
endocrinal
Hypothalamic-Pituitary-Adrenal
axis
(HPA;
De
Bellis
et
al.,
1999;
Hart
and
Rubia,
2012;
Heim
et
al.,
2008;
Shin
et
al.,
1999;
Teicher
et
al.,
2003).
This
review
includes
neurologic
structural
and
func-
tional
associations
with
CSA
(see
Table
1)
and
addresses
cognitive
deficits
of
CSA
survivors.
1.1.
Cortical
regions
1.1.1.
Cerebral
cortex
The
cerebral
cortex
is
responsible
for
higher
cognitive
functions
such
as
language
and
information
processing.
It
is
composed
of
four
lobes:
(a)
the
frontal
lobe
which
is
associated
with
reasoning,
higher
level
cognition,
language
expression,
and
motor
movements;
(b)
the
parietal
lobe,
which
includes
the
somatosensory
cortex,
and
is
involved
with
processing
sensory
information;
(c)
the
temporal
lobe,
which
includes
the
hippocampus
and
is
tied
with
memory
and
serves
as
an
auditory
interpreting
center;
and
finally,
(d)
the
occip-
ital
lobe,
which
is
involved
with
interpretation
of
visual
stimuli
(Sherwood,
2012,
p.
144).
The
lobes
divide
into
structures
that
have
shed
light
on
neuronal
differences
associated
with
experiencing
CSA.
1.1.1.1.
Frontal
lobe.
The
prefrontal
cortex,
a
major
part
of
the
frontal
lobe,
is
involved
in
understanding
emotions,
planning
com-
plex
cognitive
behaviors,
and
expressing
social
and
personality
characteristics
(Dubin,
2001).
The
orbitofrontal
cortex
of
the
pre-
frontal
cortex
is
responsible
for
sensory
integration,
automatic
reactions,
learning,
prediction,
and
decision-making
for
emo-
tional
and
reward-related
behaviors
(Kringelbach,
2005).
Bremner
and
colleagues
(1999)
observed
increased
cerebral
blood
flow
in
the
orbitofrontal
cortex
among
CSA
survivors
with
and
without
post-traumatic
stress
disorder
(PTSD).
Using
positron
emission
tomography
(PET)
imaging,
Bremner
and
colleagues
(1999)
pre-
sented
neutral
and
personalized
accounts
of
abuse
to
previously
abused
women
with
and
without
a
diagnosis
of
PTSD.
Survivors
with
PTSD
who
were
read
CSA
scripts
experienced
decreased
blood
flow
in
the
medial
and
dorsolateral
prefrontal
cortex
(Bremner
et
al.,
1999).
As
blood
flow
in
an
area
of
the
brain
is
linearly
cor-
related
with
activity
(Lee
et
al.,
2005),
decreased
blood
flow
may
disrupt
optimal
functioning
of
a
structure.
A
decrease
in
blood
flow
within
this
neural
region
could
lead
to
difficulty
in
execut-
ing
frontal
lobe
processes
such
as
complex
decision-making
tasks
(Dubin,
2001).
Bremner
and
colleagues
(1999)
suggest
that
impair-
ment
within
the
medial
prefrontal
cortex
may
lead
to
decreased
ability
to
minimize
or
eliminate
fear
responses
and
pathological
emotions
among
individuals
diagnosed
with
PTSD.
Furthermore,
decreased
blood
flow
in
the
bilateral
anterior
front
regions
and
left
inferior
frontal
gyrus
(Shin
et
al.,
1999)
may
lead
to
difficulty
in
the
structures’
functions
such
as
decision-making,
weigh-
ing
alternatives,
and
interpreting
emotional
meanings
(Wilson,
2003).
1.1.1.2.
Temporal
lobe.
The
temporal
lobe
processes
auditory,
olfactory,
and
taste
information.
It
provides
information
about
the
form
of
objects
that
make
up
visual
images
and
decodes
images
of
the
human
face
(Dubin,
2001).
Using
PET,
Shin
and
colleagues
(1999)
examined
differences
in
activation
of
the
anterior
limbic
and
para-limbic
regions
of
the
brain
when
presented
with
per-
sonalized
traumatic
and
neutral
scripts
among
women
with
and
without
PTSD.
Shin
and
colleagues
(1999)
observed
regional
dif-
ferences
in
the
women
across
three
conditions:
a
neutral
event,
a
neutral
event
with
teeth
clenched,
and
a
traumatic
event.
After
hearing
scripts
of
CSA
experiences,
CSA
survivors
with
and
without
PTSD
showed
increased
cerebral
blood
flow
and
increased
activ-
ity
in
the
anterior
temporal
poles,
although
increases
were
greater
among
those
with
PTSD
(Shin
et
al.,
1999).
The
differences
may
indicate
that
CSA
survivors,
especially
those
with
PTSD,
experience
heightened
perceptions
of
their
surroundings.
In
this
study,
Shin
et
al.
(1999)
also
observed
increased
activity
in
the
anterior
cingu-
late
gyrus,
a
structure
implicated
in
various
functions
of
the
frontal
lobe
and
limbic
system.
Increased
cerebral
blood
flow
in
this
region
may
indicate
that
experiencing
CSA
is
associated
with
sensitivity
to
emotions
involving
situations
that
evoke
sadness,
anxiety,
and
phobias
(Dubin,
2001).
1.1.1.3.
Occipital
lobe.
The
visual
cortex
of
the
occipital
lobe
receives
and
processes
visual
information
(Dubin,
2001;
Wilson,
2003).
Gray
matter,
a
major
component
of
the
central
nervous
system,
is
comprised
of
primarily
neuronal
cell
bodies
that
work
together
to
relay
motor
or
sensory
stimuli
to
interneurons
and
eventually
elicit
an
appropriate
response
to
the
stimuli
(Sherwood,
2012,
p.
143).
The
visual
cortex
is
composed
of
gray
matter
and
pro-
cesses
visual
stimuli,
thus
suggesting
people
with
less
gray
matter
volume
may
be
less
capable
of
optimally
processing
and
com-
prehending
visual
stimuli.
Significant
differences
in
gray
matter
volume
for
female
CSA
survivors
and
non-survivors
were
observed
in
a
structural
magnetic
resonance
imaging
(MRI)
study
(Tomoda
et
al.,
2009).
In
this
study,
CSA
survivors
were
found
to
have
18.1%
less
gray
matter
volume
in
the
left
visual
cortex
and
12.6%
less
volume
in
the
right
visual
cortex
compared
to
women
without
a
history
of
abuse.
Further,
changes
in
gray
matter
volume
in
the
left
and
right
visual
cortex
were
associated
with
the
duration
of
CSA
occurring
before
the
age
of
12
(Tomoda
et
al.,
2009).
Tomoda
and
colleagues
(2009)
suggest
that
the
duration
of
abuse
occurring
prior
to
12
years
of
age
may
have
a
greater
impact
on
the
development
of
brain
structure
and
concomitant
function.
This
study
was
focused
solely
on
women
with
a
history
of
CSA
versus
CSA
and
other
forms
of
abuse,
therefore,
findings
provide
support
only
for
neurological
differences
associated
with
CSA.

L.
Blanco
et
al.
/
Neuroscience
and
Biobehavioral
Reviews
57
(2015)
63–69
65
Table
1
Summaries
of
studies
focusing
on
neurology
and
CSA.
Authors
Participants
Scan/task
Correlated
measures
Findings
Application
for
prevention
Andersen
et
al.
(2008)
•
26
female
CSA
survivors
(mean
age
=
20.0,
range
18–22)
•
17
female
healthy
controls
(mean
age
=
19.4,
range
18–22)
MRI
•
ADHD
•
Bipolar
disorder
•
Bulimia
nervosa
•
Cannabis
use
•
Depersonalization
disorder
•
Depressive
disorder
•
Generalized
anxiety
disorder
•
MDD
•
PTSD
•
OCD
•
Separation
anxiety
disorder
•
Social
phobia
•
List
recall
•
Hippocampal
volume
reduced
among
CSA
ages
3–5
and
11–13
•
Corpus
callosum
reduced
among
CSA
ages
9–10
•
Reduction
in
gray
matter
in
PFC
among
CSA
ages
14–16
•
No
difference
in
amygdala
volume
•
Depression
associated
with
CSA
ages
3–5
•
PTSD
associated
with
CSA
ages
9–10
•
Predict
problems
depending
on
age
of
CSA
•
Provide
early
treatment
Anderson
et
al.
(2002)
•
8
CSA
survivors
(1
male,
7
female;
ages
18–22)
•
16
healthy
controls
(6
male,
10
female;
ages
18–22)
fMRI
•
LSCL-33
•
DES
•
Depression
•
Anxiety
•
Somatization
•
Anger-hostility
•
Substance
use
•
Alcohol
use
•
Repeated
CSA
associated
with:
depression,
anxiety,
somatization,
anger-hostility,
higher
LSCL-33
scores,
higher
DES
scores
•
Increased
T2-RT
in
cerebellar
vermis
(decreased
blood
flow)
among
CSA
survivors
•
Decreased
T2-RT
associated
with
increased
LSCL-33
•
Cerebellar
vermis
may
help
control
irritability
•
Increased
risk
for
substance
use
(early
prevention)
Bremner
et
al.
(1999)
•
10
female
CSA
survivors
with
PTSD
(mean
age
=
35.0)
•
12
female
CSA
survivors
without
PTSD
(mean
age
=
32.0)
PET:
2
neutral
scripts
(form
image),
2
personalized
CSA
scenario
scripts
(form
image)
•
PTSD
•
Dissociative
States
Scale
•
Distress
Scale
•
Among
CSA
survivors
with
PTSD,
CSA
scripts
increased
blood
flow
in
posterior
cingulate
and
anterolateral
prefrontal
cortex
•
Among
CSA
survivors
with
PTSD,
SCA
scripts
decreased
blood
flow
in:
medial
prefrontal
cortex,
parietal
cortex,
right
hippocampus,
visual
association
cortex,
inferior
temporal
gyrus,
dorsolateral
prefrontal
cortex
•
Among
all
CSA
survivors,
CSA
scripts
increased
activation
in:
cerebellum,
thalamus,
uncus,
left
inferior
frontal
gyrus,
temporal
pole
•
No
activation
in
amygdala
•
Neural
correlate
of
the
strength
of
remembrance
in
PTSD
group
Bremner
et
al.
(2003)
•
10
female
CSA
survivors
with
PTSD
•
12
female
CSA
survivors
without
PTSD
•
11
female
healthy
controls
•
MRI
•
PET
•
CSA
survivors
with
PTSD
exhibited
failure
of
hippocampal
activation
and
16%
smaller
hippocampal
volume
than
CSA
survivors
without
PTSD
•
CSA
survivors
with
PTSD
had
19%
smaller
hippocampal
volume
compared
to
controls
Heim
et
al.
(2008)
•
12
female
healthy
controls
•
13
female
survivors
of
CSA
or
CPA
with
MDD
•
14
female
survivors
of
CSA
or
CPA
without
MDD
•
10
females
with
MDD
but
no
history
of
CSA
or
CPA
•
Psychosocial
laboratory
stressor
•
ACTH
levels
•
Heart
rate
•
CSA
survivors
had
higher
ACTH
secretion
and
heart
rate
than
controls
•
CSA
survivors
with
MDD
had
6
times
the
ACTH
than
controls
Shin
et
al.
(1999)
•
8
female
CSA
survivors
with
PTSD
(mean
CSA
onset
age
=
8.3)
•
8
female
CSA
survivors
without
PTSD
(mean
CSA
onset
age
=
8.9)
•
PET:
neutral
scenario
script
(form
image),
neutral
scenario
script
(told
to
clench
teeth),
traumatic
scenario
•
Both
neutral
conditions
were
combined
for
analyses
due
to
no
differences
•
Blood
pressure
Emotional
state
imagery
•
All
conditions
revealed
increased
CBF
in
orbitofrontal
cortex
and
anterior
poles
•
Participants
with
PTSD
showed
greater
increases
CBF
flow
in
orbitofrontal
cortex
and
anterior
poles
•
CSA
survivors
without
PTSD
had
greater
activation
in
insular
cortex
and
anterior
cingulate
gyrus
•
CSA
survivors
with
PTSD
had
decreased
CBF
in
bilateral
anterior
frontal
regions
and
left
inferior
frontal
gyrus

66
L.
Blanco
et
al.
/
Neuroscience
and
Biobehavioral
Reviews
57
(2015)
63–69
Table
1
(Continued)
Authors
Participants
Scan/task
Correlated
measures
Findings
Application
for
prevention
Stein
et
al.
(1997)
•
21
female
CSA
survivors
(mean
age
=
32.0)
•
21
female
healthy
controls
(mean
age
=
30.2)
•
MRI
•
PTSD
•
DES
•
Beck
Depression
Inventory
•
WAIS-R
•
CSA
survivors
had
smaller
left-side
hippocampal
volumes
•
No
difference
in
right-side
hippocampal
volumes
•
Depression
not
correlated
with
hippocampal
volume
•
No
relationship
between
hippocampal
volume
and
age
of
CSA
onset
or
duration
•
DES
and
PTSD
associated
with
left
hippocampal
volume
•
Reduced
hippocampal
volume
may
be
the
consequence
of
CSA
or
CSA
predisposes
survivors
to
developing
psychiatric
disorders
Teicher
et
al.
(1997)
•
26
sexual
abuse
survivors
without
CPA
•
41
sexual
abuse/CPA
survivors
•
77
CPA
survivors
•
109
health
controls
•
LSCL-33
•
CSA
survivors
scored
66%
higher
on
LCSL-33
than
controls
•
No
difference
between
sexually
abused
participants
(abuse
after
18
years)
and
controls
•
CSA/CPA
survivors
scored
147%
higher
on
LSCL-33
than
controls
Teicher
et
al.,
(2004)
•
28
abuse/neglected
children
(13
boys,
15
girls;
mean
age
=
12.9)
•
Of
28
abused,
9
CSA
survivors
(3
boys,
6
girls)
•
115
healthy
controls
(70
boys,
45
girls;
mean
age
=
11.9)
•
MRI
•
PTSD
•
Corpus
callosum
no
smaller
when
controlled
for
neglect
•
CSA
associated
with
17%
reduction
in
anterior
midbody
•
Girls:
CSA
associated
with
reductions
in:
rostral
body,
anterior
midbody,
isthmus,
corpus
callosum
•
Corpus
callosum
growth
in
females
may
have
later
period
of
vulnerability/sensitivity
Tomoda
et
al.
(2009)
•
23
female
CSA
survivors
(mean
age
=
20.2,
range
18–22)
•
14
female
healthy
controls
(mean
age
=
19.0,
range
18–22)
•
MRI
•
Visual
memory
•
Anxiety
•
Depression
•
Somatization
•
Anger/hostility
•
Suicidal
ideation
•
CSA
survivors
had
less
gray
matter
volume
in
left
fusiform,
left
middle
occipital
lobe,
right
lingual
gyri
•
CSA
survivors
had
18.1%
less
gray
matter
volume
on
left
visual
cortex
•
CSA
survivors
had
12.6%
less
gray
matter
volume
on
right
visual
cortex
•
Duration
of
CSA
prior
to
age
12
associated
with
reduction
of
gray
matter
of
right
and
left
visual
cortices
Vythilingam
et
al.
(2002)
•
21
female
CSA
survivors
with
MDD
(mean
age
=
33.0)
•
11
females
with
MDD
(no
CSA;
mean
age
=
34.0)
•
14
female
healthy
controls
(mean
age
=
27.0)
•
MRI
•
Alcohol
abuse
•
CSA
survivors
with
MDD
had
18%
smaller
mean
left
hippocampal
volume
than
those
with
MDD
only
•
CSA
survivors
with
MDD
had
15%
smaller
mean
left
hippocampal
volume
than
health
controls
•
No
difference
between
all
3
groups
in
right
hippocampus
•
Smaller
left
hippocampal
volume
could
be
risk
factor
for
developing
psychiatric
disorders
after
exposure
to
overwhelming
stress
Note.
CSA:
childhood
sexual
abuse;
CPA:
childhood
physical
abuse;
MRI:
magnetic
resonance
imaging;
fMRI:
functional
magnetic
resonance
imaging;
PET:
positron
emission
tomography;
PFC:
prefrontal
cortex;
LSCL-33:
Limbic
System
Checklist
33;
ACTH:
adrenocorticotropin
hormone;
CBF:
cerebral
blood
flow;
ADHD:
attention
deficit
hyper-
activity
disorder;
MDD:
major
depressive
disorder;
PTSD:
posttraumatic
stress
disorder;
OCD:
obsessive
compulsive
disorder;
DES:
Dissociative
Experience
Scale;
WAIS-R:
Wechsler
Adult
Intelligence
Scale—Revised.
1.1.2.
Corpus
callosum
The
corpus
callosum
connects
neurons
in
the
left
and
right
cere-
bral
hemispheres
(Wilson,
2003).
Some
studies
have
attributed
reductions
in
corpus
callosum
size
to
factors
such
as
CSA
(e.g.,
De
Bellis
et
al.,
1999;
Teicher
et
al.,
1997;
Andersen
and
Teicher,
2008).
With
the
use
of
structural
MRI,
Teicher
and
colleagues
(1997)
examined
the
association
between
child
maltreatment
and
reduced
corpus
callosum
area
in
a
sample
of
young
girls
admitted
for
psy-
chiatric
evaluations.
The
study
found
CSA
to
be
associated
with
a
17%
reduction
in
one
region
of
the
corpus
callosum
when
compared
to
healthy
control
subjects;
however,
the
reduction
was
associated
among
girls
but
not
boys
(Teicher
et
al.,
2004).
The
difference
found
in
this
study
in
the
structure
of
the
corpus
callosum
may
be
due,
in
part,
to
general
gender
differences
in
the
corpus
callosum.
The
cor-
pus
callosum
has
been
found
to
be
thicker
in
women
than
men,
allowing
for
more
intercommunication
between
the
two
halves
of
the
brain
(Dubin,
2001).
Therefore,
the
reductions
observed
in
girls
and
not
boys
may
be
due
to
the
already
larger
size
of
the
cor-
pus
callosum
in
women;
thereby
reductions
among
boys
may
not
appear
to
be
significant.
In
another
structural
imaging
study,
Ander-
sen
and
colleagues
(2008)
observed
reduced
volume
in
the
corpus
callosum
in
female
survivors
of
CSA
that
occurred
between
the
ages
of
9
and
10
when
compared
to
healthy
controls,
and
the
duration
of
CSA
between
the
ages
of
14
and
16
was
associated
with
reduced
gray
matter
volume
in
the
prefrontal
cortex
(Andersen
et
al.,
2008).
1.2.
Subcortical
regions
1.2.1.
Limbic
system
and
Hypothalamic-Pituitary-Adrenal
axis
As
the
body
encounters
stressful
situations,
it
relies
on
the
limbic
system
and
HPA
axis
to
respond
with
the
appropri-
ate
release
of
hormones.
The
limbic
system
consists
of
several
structures
relevant
to
this
review,
including
the
hypothalamus,
thalamus,
amygdala,
and
hippocampus.
While
the
hypothalamus

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Neuroscience
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57
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67
regulates
homeostasis
within
the
body,
the
thalamus,
amygdala,
and
hippocampus
process
sensory,
fear,
and
memory
information,
respectively
(Sherwood,
2012).
Major
neuronal
maturation
including
neuronal
proliferation
and
dendritic
and
axonal
branching
occur
until
about
the
age
of
10
(Sowell
et
al.,
2003).
Research
has
identified
the
association
with
CSA
and
the
victims’
age
on
the
Limbic
System
Checklist
33
(LSCL-33),
a
self-report
assessment
of
various
behavioral,
sensory,
somatic
and
memory
symptoms.
Compared
to
non-abused
individ-
uals,
those
with
a
history
of
CSA
before
18
years
of
age
scored
66%
higher
on
the
LSCL-33
test
and
limbic
dysfunction
(Teicher
et
al.,
1997).
Neurotransmitters
regulate
the
hormone
corticotropin-
releasing-factor
(CRF)
from
the
hypothalamus
which
then
facilitates
the
secretion
of
adrenocorticotropin
hormone
(ACTH)
from
the
pituitary.
ACTH
travels
through
the
blood
stream
and
sig-
nals
the
adrenal
gland
to
release
cortisol
and
other
glucocorticoid
hormones,
which
regulates
stress
in
a
negative
feedback
manner
(Meyer
and
Quenzer,
2005).
An
inability
to
regulate
cortisol
levels
has
been
shown
to
correlate
with
depression,
obstruction
of
neurons,
and
loss
of
response
and
inhibition
of
the
HPA
axis.
This
may
result
in
higher
levels
of
cortisol
in
the
system
and
a
decline
in
one’s
ability
to
manage
stressors
(Meyer
and
Quenzer,
2005).
Anderson
et
al.
(2002)
examined
physical,
psychological
and
cognitive
(depression,
anxiety,
somatic,
sensory,
automa-
tons,
mnemonic)
differences
among
CSA
survivors
and
healthy
controls
and
found
CSA
survivors
had
higher
scores
on
assess-
ments
of
depression,
anxiety,
dissociative
experience,
and
the
LSCL-33.
A
stress
test
conducted
on
women
with
and
without
a
history
of
CSA
and
diagnosis
of
MDD
found
that
women
with
a
history
of
trauma
with
or
without
a
MDD
diagnoses
had
higher
levels
of
cortisol
and
HPA
axis
activity
due
to
probable
hyper-secretion
of
CRF.
Additionally,
the
women
with
a
history
of
physical
or
sex-
ual
abuse
and
a
current
diagnosis
of
MDD
showed
ACTH
levels
6
times
greater
than
controls
(no
history
of
trauma
or
MDD
diag-
nosis)
during
stress
responses
(Heim
et
al.,
2000).
The
increased
levels
of
hormones
and
HPA
axis
activity
strengthen
the
association
between
a
history
of
abuse
and
irregular
neuroendocrine
function,
which,
in
turn,
may
impact
and
exacerbate
adult
psychological
con-
ditions
in
patients.
Research
has
shown
a
linear
correlation
between
limbic
system
dysfunction
and
various
types
of
physical
and
sexual
abuse.
For
example,
Teicher
et
al.
(1997)
divided
participants
into
four
groups,
(1)
adults
with
a
history
of
no
abuse
(control
group),
(2)
physi-
cal
abuse
only,
(3)
CSA
only,
and
(4)
adults
with
histories
of
both
physical
abuse
and
CSA,
and
assessed
group
differences
on
the
LSCL-
33.
They
found
that
adults
who
experienced
CSA
only
scored
49%
higher
on
the
scale
than
the
control
group,
while
CSA
and
physical
abuse
survivors
scored
113%
higher
than
the
average
control
group
score
(Teicher
et
al.,
1997).
These
results
imply
that
CSA
may
be
strongly
associated
with
limbic
system
dysfunction,
which
could,
in
turn,
be
associated
with
higher
levels
of
physical
and
psychiatric
distress.
1.2.2.
Amygdala
The
amygdala
is
a
brain
region
known
to
process
fear
when
one
experiences
negative
emotions
and
is
involved
in
the
learn-
ing
of
consequences
(Dubin,
2001;
Wilson,
2003).
On
average,
the
amygdala
obtains
its
full
adult
size
by
the
age
of
4,
indicating
an
early
sensitivity
period
(Andersen
and
Teicher,
2008).
Interestingly,
several
studies
have
found
no
change
in
amygdala
volume
among
CSA
survivors
(Andersen
et
al.,
2008;
Bremner
et
al.,
1997)
with
or
without
PTSD
(Bremner
et
al.,
1997),
suggestive
that
CSA
is
not
associated
with
amygdala
volume.
1.2.3.
Hippocampus
The
hippocampus,
responsible
for
memory
and
interpreting
auditory
information
(Wilson,
2003),
reaches
85%
of
its
volume
by
age
4
(Andersen
and
Teicher,
2008).
A
study
examining
differ-
ences
in
hippocampal
volume
among
adult
CSA
survivors
found
the
hippocampus
to
be
smaller
(Andersen
and
Teicher,
2008;
Jonsson,
2009),
specifically
among
survivors
who
experienced
CSA
between
ages
3–5
and
11–13
(Andersen
et
al.,
2008).
In
contrast,
another
study
found
no
relationship
between
hippocampal
volume
and
age
of
onset
of
abuse
(Stein
et
al.,
1997).
Observed
structural
deficits
in
the
hippocampus
may
be
suggestive
that
experiencing
CSA
is
asso-
ciated
with
some
memory
problems
(Dubin,
2001),
although
more
research
is
needed
due
to
inconsistent
study
findings.
With
the
use
of
structural
MRI,
Stein
and
colleagues
(1997)
examined
differences
in
hippocampal
volume
among
women
with
severe
experiences
of
CSA
and
women
of
similar
backgrounds
but
without
a
history
of
CSA.
CSA
survivors
had
5%
smaller
left-
side
hippocampal
volume
than
the
non-CSA
women;
however,
no
statistically
significant
difference
in
hippocampal
volume
was
observed
on
the
right
side.
Additionally,
the
study
found
that
depression
was
not
correlated
with
hippocampal
volume
although
it
was
associated
with
dissociative
symptoms
and
PTSD
(Stein
et
al.,
1997).
CSA
survivors
with
a
diagnosed
major
depressive
disor-
der
(MDD)
had
18%
smaller
mean
left
hippocampal
volume
than
those
with
MDD
and
no
history
of
abuse,
and
15%
smaller
mean
volume
than
healthy
controls
(Vythilingam
et
al.,
2002).
Smaller
left-side
hippocampal
volume
may
indicate
that
survivors
experi-
ence
stronger
emotional
responses
relative
to
those
who
have
not
experienced
CSA
(Matsuoka
et
al.,
2007).
The
right-side
hippocampus
is
thought
to
involve
learning
and
memory
for
non-verbal
memory
(Gleißner
et
al.,
1998).
While
Stein
and
colleagues
(1997)
found
no
significant
right-side
volume
dif-
ference
between
CSA
survivors
and
non-CSA
survivors,
Bremner
and
colleagues
(1999,
2003)
observed
decreased
blood
flow
in
the
right
hippocampus
among
CSA
survivors
with
PTSD
who
listened
to
scripts
describing
the
CSA
they
had
experienced.
Reduced
regional
blood
flow
may
indicate
that
the
function
of
the
right
hippocam-
pus
is
altered
and
perhaps
weakened
relative
to
individuals
with
normal
blood
flow.
1.2.4.
Cerebellum
The
cerebellum
is
involved
in
coordinating
and
controlling
movement
(Dubin,
2001;
Wilson,
2003)
and
motor
components
linked
to
thinking,
learning,
and
remembering
(Dubin,
2001).
In
a
functional
MRI
study
examining
neural
activation
among
CSA
survivors
compared
to
healthy
controls,
Bremner
and
colleagues
(1999)
found
that
listening
to
scripts
of
CSA
experiences
increased
neural
activity
in
the
cerebellum
among
CSA
survivors
(with
and
without
PTSD).
Further
research
noted
similar
findings.
Interest-
ingly,
Anderson
and
colleagues
(2002)
also
found
that
CSA
survivors
compared
to
healthy
controls
had
decreased
blood
flow
in
the
cerebellar
vermis
as
shown
by
reductions
of
neural
activity
dur-
ing
functional
imaging.
Deficits
in
this
region
have
been
implicated
in
affect
and
movement
disorders.
Although
causality
cannot
be
determined,
this
research
suggests
that
abuse
incurred
early
in
development
may
possibly
result
in
functional
deficits
in
this
brain
region.
1.2.5.
Insular
cortex
Increased
activity
in
the
insular
cortex
is
believed
to
correlate
with
anticipation
of
fear
(Wilson,
2003).
In
a
PET
study
in
which
survivors
of
CSA
listened
to
scripts
describing
CSA
experiences,
Shin
and
colleagues
(1999)
observed
increased
activation
in
the
insular
cortex
among
those
CSA
survivors
without
PTSD
diagnoses
but
not
among
those
with
PTSD.

68
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/
Neuroscience
and
Biobehavioral
Reviews
57
(2015)
63–69
1.3.
Cognitive,
behavioral,
and
psychological
responses
Experiencing
CSA
does
not
produce
a
distinct
identifiable
syn-
drome
but
rather
yields
a
variety
of
symptomatic
and
pathological
behaviors
(Ross
and
O’Carroll,
2004).
Negative
outcomes
stemming
from
CSA
can
affect
cognitive,
behavioral,
and
psychological
health
(Bailey
and
McCloskey,
2005).
Previous
research
has
documented
deficits
in
attention,
abstract
reasoning,
executive
functioning,
and
increased
impulsivity
among
CSA
survivors
(Beers
and
De
Bellis,
2002).
More
recent
work
has
also
documented
intellectual
impairment,
verbal
deficiencies,
and
poor
academic
performance
experienced
by
CSA
survivors
(De
Bellis
et
al.,
2011).
Individuals
who
have
experienced
CSA
often
engage
in
mul-
tiple
coping
strategies
to
minimize
or
avoid
aversive
emotions
brought
forth
by
abuse
(Write
et
al.,
2007;
Zwickl
and
Merriman,
2011).
Ross
and
O’Carroll
(2004)
discuss
that
maladaptive
cop-
ing
strategies
include
a
variety
of
symptomatic
and
pathological
behaviors
including
substance
use,
dissociative
behaviors,
suicidal
or
self-injurious
behavior,
aggression,
over
and
under
sexual-
ized
behaviors,
and
poor
self-esteem.
These
maladaptive
coping
responses
to
abuse
may
persist
into
adulthood
and
cause
lifelong
impairments
including
anxiety
(Arreola
et
al.,
2009;
Mimiaga
et
al.,
2009),
depression
(Arreola
et
al.,
2009;
Mimiaga
et
al.,
2009),
aca-
demic
and
occupational
difficulties
(Cohen
et
al.,
2000;
Gilbert
et
al.,
1997),
unhealthy
partner
relationships
(Cohen
et
al.,
2000;
Gilbert
et
al.,
1997),
and
sexual
dysfunction
(Black
and
DeBlassie,
1993;
Grumet,
1985;
Loeb
et
al.,
2000;
Najman
et
al.,
2005;
Watkins
and
Bentovim,
1992).
2.
Discussion
Research
on
CSA
is
of
vital
importance
since
it
is
conservatively
estimated
that
one-third
to
one-half
of
all
women
will
experi-
ence
some
type
of
abuse
in
their
lifetime
(Bohn
and
Holz,
1996).
Recent
research
has
found
that
15–30%
of
girls
experience
CSA
and
approximately
one-third
experience
penetrative
abuse
(Gilbert
et
al.,
2009).
The
present
review
provides
findings
with
respect
to
structural
and
functional
neurological
differences
among
CSA
survivors.
Studies
have
identified
reduced
hippocampal
volumes
among
CSA
survivors
(Stein
et
al.,
1997;
Vythilingam
et
al.,
2002).
Ander-
sen
and
colleagues
(2008)
report
hippocampal
volume
reductions
associated
with
experiencing
CSA
between
the
ages
3–5
and
11–13.
Although,
Stein
and
colleagues
(1997)
reported
no
association
between
age
of
CSA
and
hippocampal
reduction,
a
difference
was
observed
in
left
hippocampal
volume
among
CSA
survivors
and
controls.
Further
research
is
needed
to
examine
the
impact
of
struc-
tural
and
functional
neurological
outcomes
based
on
age
of
CSA
exposure.
It
is
unclear
whether
this
reduction
is
a
consequence
of
CSA
or
some
individuals
have
this
reduction
beforehand,
which
pre-
disposes
them
to
developing
psychiatric
disorders
following
CSA
(Stein
et
al.,
1997;
Vythilingam
et
al.,
2002).
Researchers
have
made
great
strides
in
treating
PTSD
(Foa
and
Kozak,
1986;
Foa
et
al.,
2005)
and
PTSD
with
CSA
(Cloitre
et
al.,
2002,
2010).
Encouragingly,
a
study
has
shown
that
psychotherapy
can
increase
the
hippocampal
size
following
CSA
(Jonsson,
2009).
Research
evaluating
associations
between
CSA
and
neurologi-
cal
outcomes
is
needed
to
further
understand
the
nature
of
these
relationships.
In
conjunction
with
current
work
examined,
future
research
should
consider
examining
structural
brain
differences
across
gender
and
developmental
stages:
adolescents,
young
adult-
hood,
and
older
adults.
While
many
studies
identified
neurological
and
cognitive
abnormalities
among
CSA
survivors,
effects
of
these
abnormalities
on
behaviors
needs
to
be
further
investigated.
It
is
important
to
understand
effects
of
structural
and
functional
dysfunction
associated
with
CSA
in
order
to
determine
the
best
course
of
action
and
protocol
used
to
help
minimize
negative
out-
comes.
While
one
study
found
that
psychotherapy
could
impact
hippocampal
size
(Jonsson,
2009),
future
research
is
needed
to
investigate
whether
psychotherapy
or
other
intervention
methods
can
improve
neurological
differences
that
may
affect
CSA
survivors’
function
ability.
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