Relation between psychotic symptoms, parental care and childhood trauma in severe mental disorders

Author’s Accepted Manuscript Relation between psychotic symptoms, parental care and childhood trauma in severe mental disorders Ana Catalan, Virxina Angosto, Aida Díaz, Cristina Valverde, Maider Gonzalez de Artaza, Eva Sesma, Claudio Maruottolo, Iñaki Galletero, Sonia Bustamante, Amaia Bilbao, Jim van Os, Miguel Angel Gonzalez-Torres

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S0165-1781(16)31544-X http://dx.doi.org/10.1016/j.psychres.2017.02.017 PSY10308

To appear in: Psychiatry Research Received date: 9 September 2016 Revised date: 15 December 2016 Accepted date: 5 February 2017 Cite this article as: Ana Catalan, Virxina Angosto, Aida Díaz, Cristina Valverde, Maider Gonzalez de Artaza, Eva Sesma, Claudio Maruottolo, Iñaki Galletero, Sonia Bustamante, Amaia Bilbao, Jim van Os and Miguel Angel GonzalezTorres, Relation between psychotic symptoms, parental care and childhood trauma in severe mental disorders, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2017.02.017 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Relation between psychotic symptoms, parental care and childhood trauma in severe mental disorders Ana Catalana,b*, Virxina Angostob, Aida Díazb, Cristina Valverdeb, Maider Gonzalez de Artazab, Eva Sesmab, Claudio Maruottoloc, Iñaki Galletero c, Sonia Bustamantea,b, Amaia Bilbaod, Jim van Ose,f, Miguel Angel Gonzalez-Torresa,b.

a

Department of Neuroscience, University of the Basque Country, Basque Country, Spain

b

c

Department of Psychiatry, Basurto University Hospital, Bilbao, Spain

Avances Médicos S.A. Santurtzi, Vizcaya, Spain

d

Research Unit, Basurto University Hospital, Red de Investigación en Servicios de Salud en

Enfermedades Crónicas (REDISSEC), Bilbao, Vizcaya, Spain e

Department of Psychiatry and Psychology, South Limburg Mental Health Research and Teaching

Network, EURON, Maastricht University Medical Centre, Maastricht, The Netherlands f

King’s College London, King’s Health Partners, Department of Psychosis Studies, Institute of

Psychiatry, London, United Kingdom

*

Corresponding author: Ana Catalan. Tel: +34944006137. fax: +34944006180 ,

[email protected]

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Abstract: A relation between different types of parental care, trauma in childhood and psychotic symptoms in adulthood has been proposed. The nature of this association is not clear and if it is more related to psychotic disorders per se or to a cluster of symptoms such as positive psychotic symptoms remains undefined. We have analysed the presence of childhood trauma using the CTQ scale and types of parental care using the PBI scale in three groups of subjects: borderline personality disorder patients (n=36), first psychotic episode patients (n=61) and healthy controls (n=173). Positive psychotic symptomatology was assessed with the CAPE scale. General linear models were used to study the relation between positive psychotic symptomatology and variables of interest. BPD patients had the highest rate of any kind of trauma, followed by FEP patients. We found a positive relationship between psychotic symptomatology and the existence of trauma in childhood in all groups. Moreover, an affectionless control rearing style was directly associated with the existence of trauma. Furthermore, subjects with trauma presented less probability of having an optimal parenting style in childhood. The relation between psychotic symptoms and trauma remained statistically significant after adjusting for other variables including parental rearing style. There seems to be a link between trauma in childhood and psychotic symptomatology across different populations independently of psychiatric diagnosis. Taking into account that there is an association between trauma and psychosis and that trauma is a modifiable factor, clinicians should pay special attention to these facts.

Key words: childhood trauma, psychosis, parenting rearing style, and severe mental disorder

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1. Introduction: Recent literature has established a link between the development of trauma in childhood and psychosis (Bebbington, 2009; Bebbington et al., 2004; Bebbington et al., 2011; Janssen et al., 2004; Read et al., 2005). Some authors have stated that most of the risk is conferred by the severest form of childhood sexual abuse and less severe abuse was not solely associated with psychosis, although it most certainly may be with other psychiatric disorders (Bebbington et al., 2011).

Until now, the majority of reviews (Bendall et al., 2008; Read et al., 2008; Read and Gumley, 2008; Read et al., 2005) have reported strong links between emotional, physical and sexual abuse in childhood and psychosis, as well as childhood neglect. Some studies concluded that literature has now established that the relationship is causal; however, others called for further research. Some studies have even found that after checking for other factors (including family history of psychosis or cannabis use), adverse events in childhood were significantly related to psychosis (Varese et al., 2012). For example, a prospective study from the Netherlands that checked for a history of hallucinations or delusions in first-degree relatives found that people who had been abused as children were nine times more likely to experience pathologylevel psychosis (Janssen et al., 2004) than non-abused people. This link between psychosis and trauma has also been described in first episode psychosis (FEP) (Spauwen et al., 2006; Ucok and Bikmaz, 2007) and in borderline personality disorder patients (BPD) (Kingdon et al., 2010).

A study conducted at the Reina Sofia Centre in 2011, described an abuse rate of 4.54% in males and 3.94% in females aged between 8 and 17 years in Spain (Sanmartin, 2011). These figures are very low when compared to other countries. For example, one UK survey found a prevalence of childhood sexual abuse of 11% in young adults (May-Chahal and Cawson, 2005), and estimates from elsewhere in the world have generally been in the same range (Dinwiddie et al., 2000; Friedman et al., 2002; Pereda et al., 2009). In general terms, women are more likely to suffer sexual abuse than men, while males are more frequently victims of physical abuse (Alvarez et al., 2011). In patients with psychiatric disorders, the rate of any kind of abuse is high. A review of 20 studies covering exclusively psychotic samples reported that 28% of men and 42% of women had been sexually abused and that 50% of both sexes had been either sexually or physically abused as children (Morgan and Fisher, 2007).

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In the case of patients with BPD, symptoms associated with psychosis have often been described, such as auditory hallucinations and paranoia (Zanarini et al., 2004). We know that childhood trauma is very common in subjects with BPD. Between 30% and 90% of these patients have reported some kind of traumatic event in childhood (Battle et al., 2004; Bornovalova et al., 2013; Lobbestael et al., 2010; Zanarini, 2000). In fact, childhood trauma is considered the main environmental factor associated to BPD development (Spataro et al., 2004; Widom et al., 2009). In the case of BPD patients with psychotic comorbidity, in just one study up to 44% reported severe sexual abuse. Furthermore, there were some major similarities between schizophrenia and BPD patients in terms of their experience of voices (Kingdon et al., 2010).

On the other hand, there is a possible association between parental rearing styles and the onset of psychotic disorder (Parker et al., 1982; Willinger et al., 2002). Parental bonding is a complex two-way process in which the child becomes emotionally attached to its caregivers. The parent–child bond will be broadly influenced by characteristics of the child (e.g. individual differences in attachment behaviour), characteristics of the parent or care-taking system (e.g. psychological and cultural influences) and by characteristics of the reciprocal, dynamic and evolving relationship between the child and the parent (Parker et al., 1979). In the Finnish prospective adoption studies, it was shown that parental rearing styles interacted with genetic liability to increase the risk of schizophrenia-related outcomes, but that genetic liability itself was not associated with rearing style (Wahlberg et al., 1997). In a more recent study, lower baseline care was strongly associated with developing psychosis. However, when history of trauma was included in the adjusted equation, the excess risk associated with low care was greatly reduced, and no longer statistically significant, at the expense of a strong and significant remaining main effect of trauma. The results suggest that the association between a subject’s representation of parental rearing and psychosis may be an indicator of the effect of earlier exposure to childhood trauma (Janssen et al., 2005).

The purpose of this study is twofold. Firstly, to study the rate of childhood trauma and parental rearing styles in three groups of subjects: borderline personality patients (BPD), first episode psychosis patients (FEP), and healthy controls (HC); and, secondly, to determine the interaction between childhood trauma, parental rearing style and positive psychotic symptomatology.

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2. Material and Methods: 2.1. Ethical statement: The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The local ethics committee (Ethics Committee of Clinical Research of Basurto University Hospital) approved the study design and the patients provided written informed consent.

2.2. Sample: The recruitment procedures for this study were described previously (Catalan et al., 2015). Controls were recruited from the general population in the same catchment area of the patients through public announcements. They were similar in age and sex to the patients, and did not have first – degree family members with a psychotic disorder. Inclusion criteria were the following (for the three groups): age between 18 and 60 years, adequate ability to speak and understand the Spanish language, IQ >70; for FEP patients: treatment with antipsychotic medication < 1 year. The psychotic episode fulfilled DSM-IV-TR criteria for affective or non-affective psychotic disorder; for BPD patients: meeting DSM-IV-TR criteria for BPD in the absence of current psychotic disorder comorbidity (two of the patients had previous history of psychotic symptoms). Exclusion criteria for three groups were (a) current or past comorbid diagnosis of any neurological disorder which could prevent neuropsychological task performance, (b) history of severe head injury, (c) currently suffering severe medical conditions, (d) any current drug dependence and (e) unwillingness to participate.

For FEP, the Operational Criteria Checklist for Psychosis (Williams et al., 1996) was completed, based on clinical instruments and relevant data in the medical history, and used to establish the diagnosis of the patients using the associated OPCRIT computer programme (Craddock et al., 1996).

Socio-demographic and clinical variables collected in the sample have been detailed previously (Catalan et al., 2015).

2.3. Psychotic dimension: 5

The Community Assessment of Psychic Experiences (CAPE) (Ros-Morente et al., 2011; Stefanis et al., 2002) consists of 42 items that tap into the psychotic phenotype. This scale was used to determine positive, negative and depressive symptoms along a frequency scale (1=never to 4=nearly always) and a distress scale (1=not distressed to 4=very distressed). The mean CAPE positive, negative, and depressive score was the mean of the positive, negative, and depressive symptom frequency scale, respectively.

2.4. Childhood trauma: The Childhood Trauma Questionnaire (CTQ-SF) validated to Spanish (Hernández et al., 2013) was used to establish the rate of trauma retrospectively in three groups. This 25-item version was derived from the original 70-item CTQ (Bernstein et al., 1998). This questionnaire assesses five aspects of abuse history: physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect. Each item uses a 5-point scale to identify the frequency or severity of the experience. Scores for each type of trauma can be calculated separately. The CTQ does not discriminate between current and past experiences of abuse. It can be given to both clinical and non-clinical respondents.

Cut-off scores for ‘moderate to severe’ exposure were used to classify the occurrence (presence or absence) of a specific trauma in the three groups (emotional abuse >=13; physical abuse >=10; sexual abuse >=8; emotional neglect >=15; physical neglect >=10). Scores above this cut-off score correspond with rating most traumatic experiences of that specific trauma as ‘often true’ (Daalman et al., 2012). The short form of the CTQ demonstrated good criterion related validity in a subsample of adolescents and appeared to be viable across diverse populations (Bernstein et al., 2003).

In order to improve statistical power we created three variables of trauma: ctq1 being the existence of emotional abuse or negligence; ctq2 the existence of any kind of physical or sexual abuse; and ctq3 the existence of any kind of abuse.

2.5. Parental rearing styles: A Parental Bonding Instrument (PBI) (Parker et al., 1979) was used to establish parental rearing styles. This self-report questionnaire has 25 items that are scored on a 4-point Likert-type scale ranging from very unlikely to very likely. The Spanish PBI showed good internal consistency for the four subscales,

6

with Cronbach’s α ranging from 0.82 to 0.88 (Ballús Creus, 1991; Gomez-Beneyto et al., 1993). This is a self-reporting questionnaire in which subjects were asked to rate their parents on a variety of attitudes and behaviours related to two dimensions (care and overprotection), referring to the period of their first 17 years of life. There is one scale for each of the parents, one for the mother and another one for the father. We chose parental bonding categories as shown in figure 1. Higher scores indicate less care and more overprotection. Figure 1 PBI Categories

*for mothers, a care score of 27 and a protection score of 13.5 *for fathers, a care scoreof 24 and a protection score of 12.5

2.6. Statistical analysis: The description of the variables was carried out using frequency tables, means and standard deviations (SD), or median and interquartile range (IQR). The socio-demographic and clinical variables were compared between the three groups. The Chi-square or Fisher’s exact tests were used for the comparison of categorical variables, and the non-parametric Kruskal-Wallis test for the continuous variables. The association between trauma in childhood and parenting rearing styles was studied by the Chi-square or Fisher’s exact test. To examine the association between each parenting rearing style with positive psychotic symptoms (CAPE) the general linear model was used, considering the CAPE Positive as the dependent variable, and the parenting rearing style as the independent one. We also considered other adjusting variables, such as age, sex, cannabis abuse, IQ, socio-demographic level and group of each subject. Similarly, general linear models were also used to study the association between trauma in childhood with CAPE Positive. In this case, besides the previous adjusting variables, the parenting rearing styles were also considered.

A result was considered statistically significant at p<0.05. Statistical analyses were carried out with statistical software STATA version 12 (StataCorp, 2011) and SAS for Windows, version 9.2 (SAS Institute, 2010).

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3. Results: Socio-demographic and clinical variables are detailed in table 1. Table 1. Socio-demographic and clinical variables Variable Age Mean (SD)*** Median (IQR)* Gender, n (%)* Male Female Partnership status, n (%)** Single Married/stable partnership Divorced/separated Widowed Housing, n (%)* With original family With own family Alone Employment status, n (%)*** Full-time employment Unemployed Student Retired Other IQ, mean (SD)*** CAPE positive CAPE negative CAPE depressive

Group FEP patients (n= 61) 36.1 (12.5) 36.1 (12.5) 35 (23 – 44)

BPD patients (n= 36) 37.5 (10.7) 37.5 (10.7) 36 (29 – 42)

Controls (n= 173) 31.9 (11.6) 31.9 (11.6) 28 (22 – 41)

36 (59%) 25 (41%)

11 (30.6%) 25 (69.4%)

94 (54.3%) 79 (45.7%)

34 (55.7%) 20 (32.8%) 6 (9.8%) 1 (1.6%)

20 (55.6%) 10 (27.8%) 6 (16.7%) 0

98 (56.7%) 72 (41.6%) 3 (1.7%) 0

32 (52.5%) 20 (32.8%) 9 (14.7%)

16 (44.4%) 12 (33.3%) 8 (22.2%)

81 (46.8%) 81 (46.8%) 11 (6.4%)

27 (44.3%) 28 (45.9%) 3 (4.9%) 3 (4.9%) 0 93.4 (16.2) Mean (SD) 10.5 (6.9) 10.8 (5.4) 12.3 (5.8)

5 (13.9%) 24 (66.7%) 1 (2.8%) 0 6 (16.7%) 90.8 (14.8) Mean (SD) 11.7 (8.1) 14.6 (7.9) 12.3 (5.8)

91 (52.9%) 32 (18.6%) 44 (25.6%) 2 (1.2%) 3 (1.7%) 109.2 (14.6) Mean (SD) 4.2 (2.9) 6.7 (4.1) 4.9 (2.7)

*

p<0.05 p<0.001 *** p<0.0001 **

CTQ rates of abuse and neglect were quite high in the three groups. BPD patients had more frequently suffered any of five types of trauma (p<0.001). The most dramatic differences were in relation with sexual abuse (36% of BPD patients vs 8% of FEP patients and 2% of HC). BPD patients reported 36% emotional abuse, 31% emotional neglect, 31% physical abuse and 28% physical neglect. Although to a lesser degree, FEP patients also demonstrated to have suffered higher emotional abuse (15% vs 2% in HC, p=0.001), emotional neglect (13% vs 4% in HC, p= 0.013), physical abuse (8% vs 1% in HC, p=0.03), physical neglect (18% vs 5% in HC, p=0.001) and sexual abuse (p=0.014) than controls.

Regarding parenting rearing styles, an affectionless control parenting style was the most frequent parental rearing style in the BPD group, (51.4% vs 48.3% in FEP and 28.9% in HC in reference to mothers, p= 0.003; 52.9% vs 38.6% in FEP and 28.9% in HC in reference to fathers, p= 0.02) which at the same time had the lowest rate of optimal parenting style (8.6% vs 16.7% in FEP and 28.9% in HC in reference to mothers, p= 0.013; 8.8% vs 26.3% in FEP and 30.2% in HC in reference to fathers, p= 0.036). There was no difference between affectionate constraint and neglectful parenting styles between groups. 8

In table 2 we present data for the relation between trauma and parental rearing styles. In general terms, both maternal and paternal affectionless control conditions were more related with all kinds of trauma than other parental care styles. As expected, optimal care was related with a low probability of trauma. An affection constraint rearing style was also associated with a low probability of suffering emotional abuse or neglect. Table 2. Relation between trauma in childhood and parenting rearing styles Trauma in childhood ctq1 Parenting rearing

No (n=233)

ctq2

Yes

styles

p

No

(n=37)

Maternal affection

ctq3

Yes

p

No

Yes

p

(n=223)

(n=47)

(n=213)

(n=57)

66 (28.6)

2 (5.4)

0.0026

57 (25.7)

11 (23.9)

0.8026

57 (26.9)

11 (19.6)

0.2679

73 (31.6)

24 (64.9)

<0.0001

73 (32.9)

24 (52.2)

0.0132

68 (32.1)

29 (51.8)

0.0063

constraint Maternal affectionless control Maternal optimal

62 (26.8)

1 (2.7)

0.0013

60 (27.0)

3 (6.5)

0.0028

59 (27.8)

4 (7.1)

0.0012

Maternal neglect

30 (13.0)

9 (24.3)

0.0694

31 (13.9)

8 (17.4)

0.5485

28 (13.2)

11 (19.6)

0.2245

Paternal affection

45 (20.1)

1 (2.8)

0.0115

41 (19.0)

5 (11.4)

0.2275

41 (19.9)

5 (9.3)

0.0681

67 (29.9)

22 (61.1)

0.0003

66 (30.6)

23 (52.3)

0.0057

59 (28.6)

30 (55.6)

0.0002

constraint Paternal affectionless control Paternal optimal

66 (29.5)

3 (8.3)

0.0077

63 (29.2)

6 (13.6)

0.0335

62 (30.1)

7 (12.9)

0.0111

Paternal neglect

46 (20.5)

10 (27.8)

0.3265

46 (21.3)

10 (22.7)

0.8333

44 (21.4)

12 (22.2)

0.8908

Data are given as frequency (percentage).

There was a strong relation between the mother´s parenting styles and positive psychotic symptomatology (table 3), the relation was not significant for the father´s rearing styles (table 4). An affectionless control rearing style in mothers was related with positive symptomatology while optimal care was inversely related to this symptomatology. Table 3. Maternal parental care and CAPE positive Variables

Model with MPBIAC

Model with MPBIAC1

Model with MPBIOP

Model with MPBINP

β

p

β

β

p

p

β

p

Sex male

0.17

0.7941

0.13

0.8377

0.16

0.8061

0.18

0.7776

THCa

0.84

0.2702

0.56

0.4572

0.57

0.4583

0.86

0.2614

Group HC

Ref.

FEP

5.56

<0.0001

5.33

<0.0001

5.49

<0.0001

5.54

<0.0001

BPD

6.81

<0.0001

6.54

<0.0001

6.58

<0.0001

6.79

<0.0001

IQ

-0.03

0.2399

-0.02

0.2621

-0.02

0.3538

-0.03

0.2293

Age

-0.01

0.6749

-0.02

0.4197

-0.01

0.6171

-0.01

0.6549

-2

0.0170

-2.09

0.0112

-2.02

0.0146

-2.04

0.0148

0.10

0.8912

–

–

–

–

–

–

High socio-economic level MPBIAC

b

Ref.

Ref.

Ref.

9

–

–

1.85

0.0041

–

–

d

MPBIOP

–

–

–

–

-1.89

0.0093

–

–

MPBINPe

–

–

–

–

–

–

-0.67

0.4349

MPBIAC1c

–

–

Ref.: reference group; aTHC: abuse of cannabis; bMPBIAC: maternal affection constraint; cMPBIAC1: maternal affectionless control; dMPBIOP: maternal optimal; eMPBINP: maternal neglect

Table 4. Paternal parental care and CAPE positive Variables

Model with FPBIAC

Model with FPBIAC1

Model with FPBIOP

Model with FPBINP

β

p

β

β

p

p

β

p

Sex Male

0.34

0.5932

0.24

0.7050

0.28

0.6622

0.28

0.6652

THCa

0.93

0.2172

0.93

0.2211

0.80

0.2965

1.03

0.1786

Group HC

Ref.

FEP

5.53

<0.0001

5.53

<0.0001

5.60

<0.0001

5.48

<0.0001

BPD

6.28

<0.0001

6.11

<0.0001

6.11

<0.0001

6.21

<0.0001

IQ

-0.02

0.2774

-0.02

0.2478

-0.02

0.2863

-0.03

0.2387

Age

0.01

0.8536

-0.003

0.9260

-0.0003

0.9925

0.0003

0.9914

High socio-economic level

-1.89

0.0219

-1.98

0.0167

-1.95

0.0182

-1.95

0.0182

1.11

0.1622

–

–

–

–

–

–

–

–

0.59

0.3604

–

–

–

–

d

FPBIOP

–

–

–

–

-0.92

0.1814

–

–

FPBINPe

–

–

–

–

–

–

-0.68

0.3593

FPBIAC

b

FPBIAC1c

Ref.

Ref.

Ref.

Ref.: reference group; aTHC: abuse of cannabis; bFPBIAC: paternal affection constraint; cFPBIAC1: paternal affectionless control; dFPBIOP: paternal optimal; eFPBINP: paternal neglect

All sorts of trauma (emotional, physical and sexual) were associated with positive psychotic symptomatology after adjusting by age, cannabis abuse, IQ, group of subjects and parental rearing styles (table 5). Table 5. Trauma in childhood and CAPE positive Variables

Model with ctq1

Model with ctq2

Model with ctq3

β

P

β

p

β

p

Sex Male

0.32

0.6142

0.32

0.6134

0.39

0.5409

THCa

0.22

0.7745

0.29

0.6992

0.30

0.6883

Group HC

Ref.

FEP

5.13

<0.0001

5.07

<0.0001

4.92

<0.0001

BPD

5.81

<0.0001

5.55

<0.0001

5.28

<0.0001

IQ

-0.02

0.2952

-0.02

0.3793

-0.02

0.2792

Age

-0.02

0.4424

-0.03

0.2791

-0.03

0.3277

High socio-economic level

-2.13

0.0091

-2.10

0.0098

-2.06

0.0111

MPBIAC1b

1.21

0.0837

1.36

0.0481

1.33

0.0536

MPBIOP

c

Ref.

Ref.

-1.17

0.1325

-1.09

0.1593

-1.04

0.1810

ctq1

1.94

0.0425

–

–

–

–

ctq2

–

–

2.21

0.0130

–

–

ctq3

–

–

–

–

2.32

0.0053

10

Ref.: reference group; aTHC: cannabis abuse; bMPBIAC1: maternal affectionless control; cMPBIOP: maternal optimal

4. Discussion: Our figures of childhood abuse in HC are similar to these described in previous studies from Spain (Sanmartin, 2011). In the case of psychotic patients, we have found a rate of abuse lower than other authors, especially with regard to sexual abuse (8%) (Morgan and Fisher, 2007). More congruent with other studies (Zanarini, 2000) was the rate of abuse reported by BPD patients, almost 40% of this group reported sexual abuse and the percentage of emotional and physical abuse was about 30%.

We also found a relationship between the existence of trauma in childhood and an affectionless control parenting style in mothers and in fathers. Moreover, subjects with a history of trauma showed the lowest rate of optimal parenting style. This was true for any kind of trauma and for both parents. Subjects with a history of emotional trauma reported a less affectionate constraint rearing style (high overprotection and high care), which can be congruent with the fact that these kinds of parents may show an excessive preoccupation for their children, which in fact can become protection against them suffering from emotional distress. In general terms, the affectionless control parenting style was more prevalent in patients than in HC. This style has been associated with harm avoidance personality traits in HC (Otani et al., 2009) and with the development of anxiety. Other studies have found significant connections between lower parental care and psychiatric disorders (Gerra et al., 2004; Heider et al., 2006; Torresani et al., 2000).

We know that in some studies, inadequate parenting styles assessed during childhood also increase the risk of subclinical psychotic experiences (SPE) twenty years later (Galletly et al., 2011). This is congruent with our results. In fact, a maternal affectionless control parenting style was related to positive psychotic symptoms while an optimal parenting style was inversely related to positive psychotic symptoms in all groups. That is, subjects with maternal optimal rearing style had a lower probability of suffering positive psychotic symptoms in adulthood. This did not happen in relation to paternal rearing styles. One possible explanation is that in Spain during 70´s, 80´s and 90,s mainly mothers were in charge of parenting care in Spain, due to socioeconomic and cultural causes. So their influence over children would be more decisive.

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Furthermore, we demonstrated a link between existence of trauma and positive psychotic symptoms in our sample. This relation maintained statistical significance despite other possible confounding factors, such as group, age, IQ, socio-economic level, sex and cannabis abuse. This relation was found with all categories of trauma (emotional, physical and sexual).

We could hypothesize that the fact that the trauma is related to the positive psychotic symptomatology does not necessarily imply that FEP patients should have more traumatic antecedents. It is clear that other factors contribute to the aetiology of the psychosis, such as genetic vulnerability. Positive psychotic symptoms are only a part of the dimension of the psychotic illness, perhaps not even the most important (negative symptoms, cognitive symptoms…). However, suffering from a traumatic event in childhood may be more significant on the aetiology of BPD diagnosis (Bandelow et al., 2005; Belford et al., 2012). Nevertheless, in our study, we found a clear relation between trauma and positive psychotic symptomatology.

In fact, in literature any kind of trauma during childhood is associated with an earlier diagnosis of mental illness, a higher number of suicide attempts and negative outcomes, such as, drug abuse and more severe positive psychotic symptoms (Alvarez et al., 2011; Conus et al., 2010; Kilcommons and Morrison, 2005; Ross et al., 1994). The relation between positive psychotic symptomatology and trauma has been described not only in clinical samples but also in non-clinical samples. Psychosis and its aetiological correlate therefore, may not be confined to diagnostic extremes but emerge instead throughout the general population. Median prevalence of SPE in the general population is about 5% (van Os et al., 2009). Recent studies have shown that exposure to physical or psychological trauma, including bullying and sexual abuse, increases the risk of later SPE (Bak et al., 2005; Lataster et al., 2006). In our sample, controls also showed this relationship was significant.

Some findings (Varese et al., 2012) suggest that if trauma in childhood was entirely removed from the population (with the assumption that the pattern of the other risk factors remained unchanged), and assuming causality, the number of people with psychosis would be reduced by 33%. The association between childhood adversity and psychosis accounted for the occurrence of psychotic symptoms in the general population, as well as for the development of psychotic disorder in prospective studies; the

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association remained significant when studies were included that corrected for possible demographic and clinical confounders which is congruent with our study.

As in our study, literature demonstrates that all types of adversity are related to an increased risk of psychosis, indicating that exposure to adverse experiences in general increases psychosis risk, regardless of the exact nature of the exposure. Besides, one meta-analysis found no evidence that any specific type of trauma is a stronger predictor of psychosis than any other (Schreier et al., 2009).

Several theories have been suggested to explain the relation between trauma and psychosis. First, it is possible that early abuse may block effective social engagement and lead to an isolation that may itself favour the development of psychotic symptoms (White et al., 2000). These cognitive explanations state that traumatic experiences enhance negative or maladaptive schematic models of the self, of others and the world. Another possibility is the traumagenic neurodevelopmental model (TNM), which combines social, psychological and biological factors (Read et al., 2001). This model suggests that prolonged exposure to stressors leads to a chronic heightened glucocorticoid release. This could cause permanent changes in the hypothalamic–pituitary–adrenal axis, which in turn may induce increased striatal dopamine turnover, rendering a person more vulnerable for positive psychotic symptoms. A third possibility is that offered by Garety et al. (2001) (Garety et al., 2001), who define a central role for cognitive disturbances, leading to external appraisal errors. They hypothesized that childhood trauma affects the appraisal of internal experiences as coming from an external agent. Other cognitive models such as the Threat Anticipation Model (Freeman et al., 2002) have proposed that paranoid (persecutory) delusions may be interpreted as threat beliefs which surface as a response to interpersonal trauma (Kilcommons and Morrison, 2005). Attachment theory provides another valuable lens on the relationship, (e.g. insecure attachment may be associated with poorer interpersonal relationships and less integrative recovery styles which predispose individuals to anomalous experiences and perceptions) (Read and Gumley, 2008). One recent article points out the relation between stressors and alterations on presynaptic synthesis and release of dopamine, as the major locus of dopaminergic dysfunction in psychosis (Howes et al., 2016). As the aforementioned theories all describe how psychotic symptoms can arise, it remains unclear whether these are also applicable in non-psychotic individuals who experience subclinical psychotic symptoms. Surely, the mediation of the link between childhood abuse and psychosis is likely to be multifarious and complex.

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There have been specific concerns about the reliability of reports of abuse in people affected by psychosis. However, in recent studies, such disclosures have been shown to be reliable and the credibility of the methodology has been established (Fergusson et al., 2000; Fisher et al., 2011; Goldman and Padayachi, 2000; Goodman et al., 1999; Patton et al., 2001). There is also evidence that the retrospective assessment of childhood trauma tends to underestimate rather than over-report real incidence rates (Hardt and Rutter, 2004).

On the other hand, our sample is quite heterogeneous. Nonetheless, transdiagnostically we have demonstrated a relation between trauma and positive psychotic symptoms and this can be important when taking the importance of for assessing traumatic experiences in childhood into account in all kind of subjects who seek psychiatric help.

Moreover, the CAPE scale is used mainly in the population vulnerable to psychosis in order to assess subclinical psychotic symptoms in non-clinical samples. In any case, this scale has proved itself reliable not only to report psychotic symptoms at subclinical levels, but also in clinical samples (Fonseca-Pedrero et al., 2012; Moritz et al., 2013). In any case, it is true that there is substantial stability in the internal structure of the CAPE positive scale, with the exception of the factors relating to magical thinking or grandiosity. A more valid version of this scale has recently been developed (Capra et al., 2013).

4.1. Conclusions: It is possible that in vulnerable individuals, trauma may exacerbate changes in brain structure and function leading to an increased risk of psychosis with terrible consequences. Trauma in childhood and inadequate parenting styles seem to be related to positive psychotic symptoms. If we bear in mind that trauma and parenting style are modifiable factors, we as clinicians should identify subjects at risk in order to prevent future psychopathology.

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This research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors.

Conflicts of interest: none. Acknowledgements: we would like to thank to our patients for their patience and collaboration and to the staff of the Psychiatry Service at Basurto University Hospital for their collaboration on this project.

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Highlights  An affectionless control parenting style was related to positive psychotic symptoms while an optimal parenting style was inversely related to positive psychotic symptoms in all groups. 

We demonstrated a link between existence of trauma and positive psychotic symptoms in our sample.



All types of adversity are related to an increased risk of psychosis, indicating that exposure to adverse experiences in general increases psychosis risk.

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