Karen was sexually abused by her father at the age of five. She developed a severe separation anxiety reaction whenever her mother tried to leave. As an adult, Karen developed a dissociative disorder due to the same abuse. This is an example of how the same factor, in this case abuse, can be __________.

A. both a sufficient and a necessary cause
B. both a reinforcing contributory cause and a punishing contributory cause
C. both a primary and a secondary process
D. both a proximal and a distal causal factor

Answer: D