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Comprehensive Psychiatry 54 (2013) 123 – 127 www.elsevier.com/locate/comppsych
High prevalence of childhood trauma in patients with schizophrenia spectrum and affective disorder Sara Larsson a , Ole A. Andreassen a, b , Monica Aas b , Jan I. Røssberg a, b , Erlend Mork c , Nils E. Steen a , Elizabeth A. Barrett a , Trine V. Lagerberg b , Dawn Peleikis a , Ingrid Agartz b, d , Ingrid Melle a, b , Steinar Lorentzen a, b,⁎ a
Department of Research and Development, Clinic of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway b Institute of Clinical Medicine, Medical Faculty, University of Oslo, Norway c National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, Medical Faculty, University of Oslo, Norway d Diakonhjemmet Hospital, Oslo, Norway
Abstract Objective: Childhood trauma (CT) is a major risk factor for various psychiatric disorders. We wanted to determine the prevalence of CT in a catchment area–based sample of schizophrenia spectrum and affective disorder (including bipolar disorder and depressive episodes with psychotic features) and to explore potential differences in types of CT between the diagnostic groups. Method: Three hundred five patients were recruited consecutively from psychiatric units at 3 major hospitals in Oslo, Norway, diagnosed with Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Traumatic childhood events were assessed with Childhood Trauma Questionnaire. Results: Eighty-two percent of the patients had experienced one or more CT events, the most frequent subtype of trauma being emotional neglect. The schizophrenia spectrum group reported significantly more physical abuse and physical neglect than the affective group. Conclusion: A high prevalence of CT in patients with severe mental disorder was detected. This reminds us of the importance of exploring this issue when we treat such patients. The mechanisms behind these differences are unclear. Further research is needed to study potential associations between CT and the clinical picture of the disorder. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Childhood trauma (CT) has been postulated as an important risk factor for psychiatric disorders [1,2], and it has been associated with poorer physical and mental health and increased substance abuse in the general population [3]. The role of CT in schizophrenia spectrum and affective disorders, including bipolar patients and patients with major Significant outcomes: High prevalence of childhood trauma in patients with severe mental disorder, especially emotional neglect; more physical neglect and abuse in schizophrenia spectrum disorder. Limitations: Retrospective reporting of abuse. Differences in mood symptoms during assessment may contribute to report bias; lack of a healthy control group. ⁎ Corresponding author. Clinic for Mental Health and Addiction, Oslo University Hospital, University of Oslo, Institute of Clinical Medicine, 0372 Oslo, Norway. Tel.: +47 90029788; fax: +47 22923530. E-mail address:
[email protected] (S. Lorentzen). 0010-440X/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2012.06.009
depressive disorder with psychotic features, is still unclear. Prevalence estimates of CT range from 25% to 70% in bipolar disorder [4-7], with similar estimates in schizophrenia [8]. However, some of these studies did not use structured CT questionnaires, and there are no conclusive data about the prevalence of CT in schizophrenia compared with bipolar disorder [9,10], apart from 1 study showing higher prevalence of CT in schizophrenia spectrum compared with patients with affective psychosis [11]. The potential role of CT in the development of psychosis is debated. A recent review concluded that childhood abuse is a causal factor for psychosis and schizophrenia [12]. This is contested by Morgan and Fisher [13] who, in their review, infer that current data do not support a causal connection because of methodological problems. Psychotic disorders are highly heritable [14], and CT is most likely interacting with genetic factors in the development of psychiatric disorders [15,16]. Schizophrenia and
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bipolar disorder have been suggested to be part of a psychosis continuum [17]. It has been proposed that there is a common genetic susceptibility in psychotic disorders [18-20] and that environmental factors may influence the development into affective or nonaffective psychosis [21]. We suggest that CT could be such an environmental factor. There are some indications that specific types of abuse are related to particular diagnoses, such as emotional abuse (EA) to major depressive and bipolar disorders and physical abuse (PA) to antisocial personality disorder [22-24]. Further evidence supports that specific types of CT are associated with specific disease characteristics in psychotic disorders, such as affective symptoms [25-28]. Sexual abuse (SA), EA, and PA seem to be disease modifiers in bipolar disorder in a similar way as in major depressive disorder [24,25,28-30], which indicates that CT could impact affect regulation. Thus, it could be hypothesized that there is a higher prevalence of CT in affective vs schizophrenia spectrum disorders or that there are different types of CT associated with these 2 types of psychosis. To our knowledge, no studies have yet investigated if specific types of CT are differently associated with affective compared with schizophrenia spectrum disorders. The assessment of trauma in childhood may be done by different methods, and there are several challenges in this line of research: First, the bipolar and the schizophrenia samples tend to be small. Second, differences in the assessment methods of CT (structured interview vs selfreport measure) may create problems in comparisons between studies [24,31]. Furthermore, some studies present total CT scores, whereas others have focused on subgroups of abuse, mainly SA or PA [24,32]. 1.1. The aims of the study The aims of the study were to (1) determine prevalence and types of childhood maltreatment in patients with schizophrenia spectrum or affective disorder from a Norwegian catchment based organization and (2) investigate differences between the schizophrenia spectrum and the affective group regarding (a) prevalence and (b) types of CT. 2. Method 2.1. Subjects Between 2007 and 2010, 305 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)– diagnosed patients were included in the study. All participants were recruited consecutively from psychiatric units (outpatient and inpatient) in 3 major hospitals in Oslo, Norway, as part of the larger Thematically Organized Psychosis Research study. Among these, 194 had a diagnosis of schizophrenia spectrum disorder (111, schizophrenia; 13, schizophreniform disorder; and 28, schizoaffective disorder), and 42 were classified as other psychoses (delusional disorder, brief psychotic disorder, or psychosis not otherwise
specified [NOS]). Moreover, 111 had a diagnosis of affective disorders (67, bipolar I disorder; 20, bipolar II disorder; 10, bipolar disorder NOS; and 14, major depressive disorder with psychotic features). All patients were aged 17 to 61 years (mean, 30.5 years; SD, 11 years), and 46% were women. Twenty-seven percent were married or living with a partner, and 27% worked or studied half time or more. Exclusion criteria were a history of severe head trauma, mental retardation, neurologic disorder, or lack of knowledge of a Scandinavian language. The study was approved by the Regional Committee for Medical Research Ethics and the Norwegian Data Inspectorate. All participants gave written, informed consent. 2.2. Clinical assessment Clinical assessment was carried out by trained psychiatrists and clinical psychologists. Diagnosis was based on the Structured Clinical Interview for DSM-IV (SCID) Axis I disorders. Diagnostic reliability was found satisfactory [33], with overall agreement for DSM-IV diagnostic categories of 82% and the overall κ 0.77 (95% confidence interval, 0.600.94). Current positive and negative symptoms were rated using the Positive and Negative Symptom Scale (PANSS) [34]. Interrater reliability was acceptable with intraclass correlation coefficients [35] for PANSS subscales ranging from 0.71 to 0.73. Participants were defined as currently psychotic if they scored 4 or higher on any one of the following PANSS items: P1, P3, P5, P6, and G9. History of psychosis was based on information retrieved from the SCID interview; the bipolar participants were considered to have a history of psychosis if they had any previous SCID-verified psychotic episodes. Duration of psychosis (years since first contact with mental health services due to a primary symptom, ie, psychotic symptoms for schizophrenia group or psychotic or affective symptoms for schizoaffective and bipolar groups), number of affective and psychotic episodes, hospitalization, and suicide attempts was determined through clinical interview and medical records. A Norwegian version of the standardized Childhood Trauma Questionnaire (CTQ) [36] had been rated for 305 patients. Table 1 summarizes demographic characteristics and distribution of diagnosis of the sample, categorized by affective (bipolar patients or major depressive with psychotic features) or nonaffective psychosis (schizophrenia spectrum group). The nonaffective group (schizophrenia spectrum group) had significantly lower global assessment of functioning (GAF), both on symptom (t = −8.94, P b .001) and on function scale (t = −5.47, P b .001). They also had fewer years of education (t = −4.05, P b .001) than the affective group, and patients in the schizophrenia spectrum group was also significantly younger (t = −2.98, P = .003). Traumatic events in childhood were rated using a Norwegian version of the CTQ [37]. This is a self-report questionnaire with 28-items, yielding scores on 5 subscales of trauma: emotional abuse (EA), physical abuse (PA), sexual
S. Larsson et al. / Comprehensive Psychiatry 54 (2013) 123–127 Table 1 Demographic and clinical characteristics Total sample, Schizophrenia Affective N = 305 spectrum disorder, disorder, n = 111 n = 194 Age (y), mean ± SD Sex, female, n (%) Married/cohabitant, n (%) Lifetime psychosis, n (%) Years of education, mean ± SD Age at onset, mean ± SD GAF S, mean ± SD GAF F, mean ± SD Diagnosis, n (%) Schizophrenia Schizophreniform Schizoaffective Bipolar I disorder Bipolar II disorder Bipolar disorder NOS Major depressive disorder Other psychosis
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Moroever, the most extreme (5 subtypes of trauma) was reported more often in the nonaffective compared with the affective group. No effect of age or sex was found. 3.2. Types of CT
30.5 ± 10.89 140 (46) 82 (27) 266 (87) 13.1 ± 3.18
29.0 ± 9.93 81 (58) 47 (24) 195 (100) 12.6 ± 2.97
33.0 ± 12.02 ⁎ 58 (42) 35 (32) 73 (66) ⁎⁎ 14.1 ± 3.32 ⁎⁎
The most frequent subtype of trauma was EN reported by 65% of the participants. Next was EA (60%), followed by PN (40%), SA (32%), and PA (25%). The ranking of the subtypes was the same in the schizophrenia spectrum and affective groups.
19.9 ± 8.73 44.8 ± 12.89 44.2 ± 11.74
19.5 ± 8.38 40.4 ± 11.04 41.7 ± 10.49
20.7 ± 9.28 52.6 ± 12.23 ⁎⁎ 49.1 ± 12.30 ⁎⁎
3.3. Association between type of CT in patients with schizophrenia spectrum and affective disorders
111 (36) 13 (4) 28 (9) 67 (22) 20 (6) 10 (3) 14 (5)
Patients with schizophrenia spectrum disorders had more frequently experienced PA (χ 2 = 4.723, df = 1, P = .030) and PN (χ 2 = 5.843, df = 1, P = .016) compared with the affective group (see Table 2 and the Fig.). 4. Discussion
42 (14)
S indicates symptom; F, function. ⁎ P b .05. ⁎⁎ P b .001.
abuse (SA), physical neglect (PN), and emotional neglect (EN) [37,38]. Each subscale was measured by rating 5 items on a 5-point Likert scale, from 1 (never true) through 5 (very often true). In addition, 4 cutoff scores were provided for each scale: none to low; low to moderate; moderate to severe; and severe to extreme exposure. We used the low to moderate cutoff scores to dichotomize each subscale and to classify subjects as having/not having a history of CT in that category [39]. In this study, the overall internal consistency was 0.86, and for the subscales, EA, 0.86; PA, 0.82; SA, 0.91; EN, 0.88; and PN, 0.65. 2.3. Statistical analyses All analyses were conducted with the PASW statistics 17 (SPSS Inc, Chicago, IL). Dichotomous variables were analyzed with χ 2 test. Group mean differences between continuous variables were analyzed by independent samples t test. An α level of P b .05 (2 way) was used throughout the study. 3. Results 3.1. Prevalence of CT The number of trauma subgroups reported by the participants is presented in Table 2 and in the Fig. Two hundred fifty persons (82%) of the study group had experienced at least 1 type of trauma. Two or more types of trauma were reported by 186 (61%) of the whole sample: of these 49 (16%) had experienced 2 types; 58 (19%), 3 types; 52 (17%), 4 types; and 27 (9%), all 5 types of abuse.
The main finding of the present study was that a high proportion (82%) of patients with a schizophrenia spectrum or affective disorder (including bipolar and major depression with psychotic features) had experienced trauma in childhood. The most frequent trauma was EN (65%), followed by EA (60%), PN (40%), SA (32%), and PA (25%). Although the schizophrenia spectrum group showed a higher prevalence of CT compared with the affective group (85% and 77%, respectively) both on total score and all subscales, only the differences in scores on PA and PN were statistically significant. The present findings of CT are somewhat higher than previous prevalence estimate of 28% to 70% in bipolar disorder [9,10]. However, these studies only assessed SA and PA in childhood. Our results are similar to previous findings in studies of patients with schizophrenia [8,11,13], studies that sometimes include neglect. The lack of statistically significant differences in overall CT prevalence between the schizophrenia spectrum and affective groups replicates the results of several previous studies that did not use standardized instruments for assessing CT [6,9,10]. This suggests that CT plays a role as predisposing factor in both schizophrenia spectrum and the affective disorder. A statistically significant higher number of physical trauma, both neglect and abuse, among patients with a schizophrenia spectrum diagnosis has not been investigated and reported earlier. The findings support the notion that different types of trauma may be associated with different types of psychotic disorders. This could be in line with the hypothesis of how genetic and environmental factors interact in the development of psychosis put forward by Murray et al [21]. Other studies have reported that SA leads to more of both affective and psychotic symptoms, and EA, to problems in affective regulation, whereas PA leads to more psychotic symptoms [25,26,28,40-42].
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Table 2 Trauma type in schizophrenia spectrum and affective disorders
Total sample, n (%) Schizophrenia spectrum, n (%) Affective disorder, n (%)
n
CTQ total
EA
PA
SA
EN
PN
305 194 111
250 (82) 165 (85) 85 (77)
182 (60) 123 (63) 59 (53)
77 (25) 57 (29)⁎ 20 (18)
99 (32) 69 (35) 30 (27)
199 (65) 130 (67) 68 (62)
124 (40) 89 (46)⁎ 35 (32)
Number (percentage) of scores above cutoff for CT. ⁎ P ≤ .05.
It is noteworthy that EN is the most frequently experienced trauma subtype in this study, whereas SA and PA are most commonly reported in the literature. An explanation could be that the main interest has been paid to SA and PA in the past compared with EA and neglect. In particular, it is not common to assess both abuse and neglect as we have done in the present study using CTQ. This indicates that the use of CTQ as assessment may give a more complete picture of what adversities these patients might have had. In addition to a higher prevalence of PA and PN, the schizophrenia spectrum group also showed significantly worse functioning and higher levels of symptoms, as indicated by lower scores on the GAF function and the GAF symptom scales. Based on this, we would like to do a further study of the relationship between CT prevalence and the associations with symptom severity and other clinical correlates in patients with schizophrenia spectrum and affective (bipolar patients and major depression with psychotic features) disorder. The difference in prevalence of trauma between the nonaffective and affective groups may be related to the presence of psychotic episodes. To test this, we divided the group of patients with a bipolar disorder into 2 groups based on reports of psychotic episodes: n = 73 (66%) reported psychotic features; no significant differences
in trauma were detected between psychotic and nonpsychotic bipolar patients. We have tried to address some issues that have been problematic in previous studies: the assessment of trauma in childhood has often been done by different methods (structured interview vs self-report measure), which may create problems in comparisons between studies [24,41]. Furthermore, some studies present total CT scores, whereas others have focused on subgroups of abuse, mainly SA or PA [24,42]. A final point is that the bipolar and the schizophrenia samples tend to be small. All this emphasize the importance of using standardized and common methods for CT assessments in future studies. Some limitations to our study should be mentioned. Although the CTQ is a well-validated instrument, one apparent problem with data in all studies on CT in adult populations is the retrospective reporting of the abuse history. Secondly, we did not take current mood symptoms when the patients were assessed into consideration. This may also have led to recall biases as patients may under- or overreport traumatic events [24] depending on present mood. Third, we did not include a healthy control group and cannot, therefore, compare CT prevalence in a clinical and a nonclinical population within our catchment area. However, in previous studies, the rate for child maltreatment in the general population has been estimated to be around 11% for SA and 24% for PA in a large (N = 2869) UK sample [43], with even lower scores reported in a smaller (N = 160) sample in Norway [44]. A prevalence of CT as high as 82% supports the findings of other recent studies that indicates higher rates of CT in patients with severe mental disorders compared with the general population [13]. Nevertheless, our study would have benefitted strongly from having a healthy control group from the same geographical area. Clinicians should be alert of childhood abuse in severely mentally ill, as the consequences may contribute to the clinical picture and may require special attention and measures to be taken into treatment. More research is needed to improve our knowledge of the relationship between CT, genetic predisposition, and the clinical picture in patients with severe mental disorders. Acknowledgment
Fig. Prevalence (percentage) of CT (total score and subtypes) in schizophrenia spectrum disorder and affective disorder.
The authors thank the patients who took part in the study and the Thematically Organized Psychosis study researchers who contributed to the data collection. This study was
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