Psychosocial Traumatic Environments: A Clinical Case of Childhood Abuse
Round 1
Reviewer 1 Report
Dear authours,
It has been a pleasure for me to read your paper. As a clinical psychologist myself, I find case reports very enriching and worthy. Please, find below some suggestions and questions that I hope can help you improve your work's quality.
Congratulations on your paper.
- lines 35-45, I don’t see the relevance of explaining physical development of the brain in this case report
- can you distinguish between boys and girls?
- is there any data on children sexual abuse?
- line 69: you mean girls when you say "children giving birth"?
- line 70: explain further the nature of these marriages: are they concerted? are children forced to get married? to an adult?
- I don’t think you should give statistic data within the Introduction (line 105)
- given that your patient is 60 years old, it would be good if in the Introduction section you give some information about the living of adults who have suffered trauma and not focusing only in what happens to children
- line 146: "your" medical treatment?
- who was the abuser?
- line 160: moody mood swings? please, check
- line 167: bank account
- Is Maria working now?
- I find necessary to make clear the consent given by Maria for this paper to be published.
- since later you talk about personality disorders, I think you should make an introduction to them here, as you have done with bipolar disorder and also, talk about adult life and how it can prevent or promote mental disorders
- can you give more information on how was the diagnosis carried out? some of the questions used in the interview? the measures used (if used?
- which kind of behaviors does Maria show currently?
- if it is already stated the relation between abuse, trauma, and bipolar disorder, what does this paper add?
- why you don’t diagnose of dependent personality or bpd? can you explain further?
- line 296: you state that the diagnosis is due to her childhood, maybe we are not having into account their adult life and I am sure it has contributed to her current condition
- in the abstract genogram is mentioned, where is it within the text? I think this would be a very interesting used tool to talk about
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I don't have anything to say about the English.
Author Response
Dear Reviewer,
Initially, we would like to thank you for your thorough analysis of our manuscript. Certainly, it served to improve the quality of the text and the content reported. The answers are in the attached document.
Best regards,
The authors
Author Response File: 
Author Response.pdf
Reviewer 2 Report
This was a very interesting paper-- thank you for the opportunity to review and provide feedback. I'll forewarn you that I'm not very familiar with case studies, so please feel free to ignore any recommendations that you know don't fit with case study methodology, reporting of findings, etc.
Introduction
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Overall: Many references about the impacts of abuse and trauma are 15+ years old. Recommend doing another quick literature search to include more recent relevant references.
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Overall: The bulk of the discussion in the intro about the impact of abuse and trauma focuses on abuse and trauma very broadly, or focuses on things like parental mental health problems or emotional abuse/neglect. Recommend starting with general info about abuse/neglect/trauma, but making sure to focus on the impacts of child sexual abuse, which is the form of abuse experienced by the subject. If the other topics discussed are relevant to the patient, recommend making this clearer at the outset.
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Pg.1 lines 25-27: Recommend revising definition of child abuse– the part about “under one's care, custody, or supervision” may not sufficiently capture all child abuse, particularly child sexual abuse. I would recommend using the second definition the authors provide on lines 29-31 (two definitions aren’t needed anyway)
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Pg.1, line 32: Recommend changing “their” to “a child’s” for the sake of clarity
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Pg.2, Table 1: Recommend completing “Abandonment of incapable” and defining the acronym “RV”
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Pg. 2, line 69: Recommend changing “gave birth to live-born babies” to simply “gave birth.”
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Pg.3, line 79: Recommend changing “regular emotions” to “emotional regulation”
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Pg. 3, lines 78-80: Recommend clarifying. Does this mean the abuse causes issues with emotional regulation that render children unable to respond appropriately to abuse? Or to future situations requiring emotional regulation?
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Pg.3, lines 84-85: Recommend changing “Insufficient social skills repertoire is” to “Insufficient social skills are”
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Pg.3, lines 87-95: Recommend removing this paragraph as it’s about the impact of living with a parent with a psychiatric disorder (or make a clearer connection between the relevance of this paragraph and the case under study)
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Pg.4, lines 122-124: “In this sense, we found that a limited number of quantitative studies investigated the consequences and long-term impacts on the lives of individuals who did not have access to public policies, forms of protection or social support, after the identification of child abuse.” Recommend clarifying this. Flowing from the last paragraph, it’s unclear which population(s) you’re referring to. Clarify what is meant by “access to public policies”-- access in terms of knowledge? And which policies? Does this refer to available resources? Options for legal recourse? And “after the identification of child abuse” this referring to the child or the parents– does this mean parents who just discovered their child was abused? If it’s referring to the person experiencing abuse, “identified” the abuse is confusing.
Patient overview
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Pg.4, line 145: Change “his” to “her”
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Pg.4, lines 145-146: Recommend editing “Therefore, she did not wean off the medication, cutting his intake at random. Thus, compromising your medical treatment” to the following: “Therefore, she did not wean off the medication, cutting her intake at random and compromising her medical treatment.”
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Pg.5, line 160: Recommend changing “moody mood swings” to “mood swings”
Methods
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Overall: Recommend providing more detail about the methods used in the case study (see one specific recommendation below, re: pg.5, lines 201-202).
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Pg.5, lines 196-197: Recommend editing “...as its results can be influenced by multifactorial factors and, consequently, be altered over the years” as follows: “...as its results can be influenced by multiple factors and shift over the years”
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Pg.5, lines 201-202: Recommend providing brief descriptions of each of these forms of data collection: “The following meetings were dedicated to data collection through a semi-structured anamnesis interview, behavioral observation, genogram creation, and active listening.”
Results
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No results section– maybe this is common in case studies? That is not a form of research I’m very familiar with. It seems like it would be helpful to present the specific information and insights gained from the various forms of data collection.
Discussion and conclusions
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Overall: The discussion section lacks direction/cohesion. It contains a significant amount of information that seems like it would fit better in the introduction. The discussion can and should touch on things brought up in the introduction, in terms of how relevant concepts, theories, etc. were demonstrated in the patient’s life/case study. But the first several paragraphs of the discussion define bipolar disorder, discuss personality disorders, discuss the impacts of violence on personality, emphasizes the need to distinguish between borderline personality disorder and dependent personality disorder, etc.– which all read like Introduction material. The actual patient/subject of the article isn’t even mentioned until the 9th paragraph of the discussion. Recommend revising this section to focus on the findings from the case study, relating them back as appropriate to concepts and topics introduced in the Introduction section.
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Overall: Similarly, it’s confusing how many conclusions are being drawn about things the patient reported, but these things weren’t described in the results (as there was no results section). Is this typical for a case study?
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Pg.7, lines 287-294: Again, I’ll provide the disclaimer that I don’t perform case studies, and I’m not familiar with the methods or ways of reporting and discussing the findings, but this section read to me like general recommendations that you might see from a research study with a larger sample. That may be appropriate for the discussion section of a case study, but it stood out as strange to me as a reader just because it wouldn’t typically be advised in other types of research to offer generalized recommendations off of a sample size of 1, so I would’ve thought the discussion would be focused mostly on the patient.
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Pg.7, lines 312-314: Recommend providing more detail here: “It is important to recognize the limitations of the study, both in terms of sample size and available information, which may be addressed in future research.”
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Pg.7, lines 314-316: “Given the global prevalence of this issue, along with the relatively sparse academic literature on the subject, further study is needed to expand our understanding.” This is unclear. Does the author mean prevalence of child sexual abuse? Abuse and trauma more generally? Another, more specific issue raised (e.g., bipolar disorder among people who have experienced trauma?) Recommend clarifying, and if the issue being described is child sexual abuse or abuse/trauma, it isn’t accurate to say there is sparse academic literature on the subject.
N/A
Author Response
Dear Reviewer,
Initially, we would like to thank you for your thorough analysis of our manuscript. Certainly, it served to improve the quality of the text and the content reported. The answers are in the attached document.
Best regards,
The authors
Author Response File: Author Response.pdf
Reviewer 3 Report
Thank you for submitting this case review. I sympathise with a perceived lack of literature on adult outcomes for child abuse. This literature does exist, perhaps dominated by the global North (UK, USA, Canada, with notable contributions from Australia from the Royal Commission into Institutional Responses to Child Sexual Abuse). There is a significant body of work from a psychological perspective also.
The case presented is interesting but not notably unique. Perhaps the most significant distinguishing factor is Maria's academic success in her accumulation of degrees. Maria is not unique amongst survivors for this but it is something that is not often allowed for in literature (the successes of survivors). Maria has some real strengths and resilience alongside her struggles.
The difference between BPD and DPD is interesting and a meaningful contribution.
Given that Maria suffered multiple adverse childhood experiences and forms of abuse, why is the sexual abuse significant above the others? Especially as Maria appears to remember little of this and it is unclear where in the forms of abuse this occurred, for how long, and by whom?
The literature review can be tightened to be more focused. Given that a range of forms of childhood abuse are discussed, why is sexual assault the most significant? I am also not sure about the benefit of either table.
I think there is merit in this case study. I would just have a rethink about what makes it unique. If it is not unique, why is it significant enough for publication? How will it aid researchers and clinicians?
There is some need of a proof read for errors.
Significantly, line243 reads "It is not worthy" when I think it should read it is "note" worthy.
Line 145 the gender rads as his and should be hers?
Self-mutilation is a very loaded and potentially offensive term that could be corrected to self-harm.
Author Response
Dear Reviewer,
Initially, we would like to thank you for your thorough analysis of our manuscript. Certainly, it served to improve the quality of the text and the content reported. The answers are in the attached document.
Best regards,
The authors
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
Dear authors,
Thank you for your responses to the comments provided. Since the strenght of your work is to be qualitative, I encourage you to re-write the abstract so this is clear to the reader. I find no coherence between what you expect reading the abstract and what you find within the text. In addition, I would recommend to make it more clear in the Introduction.
Your #11 response (within the response letter) is clear and is key to understand your study. I suggest you add this paragraph with no many changes to the Method section as I still find it incomplete.
I do not agree with your statement (response 13). Childhood trauma is the baseline for developing psychological problems and can be the main cause but what the person lives, does, and experiences during adulthood (especially in mood disorders, such as BD) does matter. I suggest you present childhood trauma as the origin for the disorder diagnosed but not as the only cause.
Thank you for your interesting work. It is necessary for both science and clinicians to publish good qualitative studies. I encourage you to publish further in this line.
Author Response
Dear Reviewer,
Once again, we would like to thank you for your re-analysis of our manuscript. The answers are in the attached document.
Best regards,
The authors
Author Response File: Author Response.pdf
Reviewer 3 Report
Thank you for taking the time to review and resubmit this case study.
I still think there is a body of qualitative literature that is being missed in the paper but don't find this at all prohibitive to publication.
Congratulations.
Author Response
Dear Reviewer,
Once again, we would like to thank you for your re-analysis of our manuscript. The answers are in the attached document.
Best regards,
The authors
Author Response File: Author Response.pdf
