Traumatic events in Childhood and Adulthood in a Diverse-Ancestry sample and their role in Bipolar Disorder

Abstract

We examined the presence of adverse events in both childhood and adulthood and the prevalence of PTSD in individuals with Bipolar Disorder (BD). There were 191 adults diagnosed with BD Type I and 924 controls, of predominantly African Ancestry (AA). All were administered the GPC-Screening Tool and the BD group the DIPAD. In addition Childhood adversities were measured using the ACE (from 0–10), about traumatic events before age 18 and lifetime adversities were measured with 15 questions adapted from the Study of Addiction: Genetics and Environment (A-SAGE (from 0 to 15) for all cases and controls. Probable PTSD (pPTSD) was measured with 4 questions on the GPC screener. Sum scores were calculated for the ACE and A-SAGE by tallying positive responses. Odd Ratios (OR) were used to measure the association between BD and Controls exposure to adversity. BD was associated with a significantly higher mean ACE score and A-SAGE score compared to controls. There was a significantly higher prevalence of pPTSD in the BD (54.5%) versus Controls (6.6%) as well. Greater OR’s were seen in the BD compared to Controls for each ACE question (p<0.05). Results were similar for A-SAGE. Limitations include possible recall bias, and missing data.

1. Introduction

Literature over the last few decades has suggested that the susceptibility of Bipolar Disorder (BD) is most likely due to a complex interaction between genetic and environmental risk factors (Etain et al., 2008; McGuffin et al., 2003). Previous research has demonstrated a strong correlation between life stressors and the risk of developing and sustaining episodes in BD (Gershon et al., 2013). A meta-analysis of forty-two studies informed that individuals with BD report having more stressful life events than healthy individuals and to physically ill individuals (Lex et al., 2017). Moreover, the severity of the negative events have been found to predict worse illness course, slower recovery and higher rate of relapse (Etain et al., 2008; Gershon et al., 2013).

Among all different types of adversities, childhood adverse events are significantly more common among these patients than in the general population, with emotional abuse most strongly correlated (Palmier-Claus et al., 2016). Estimates of childhood adverse events have varied from 25–75% of BD individuals, and over one third have experienced more than one form of adversity (Dualibe and Osório, 2017; Garno et al., 2005; Leverich et al., 2002). These early stressors, either individually or in combination, have also led to greater disease-related morbidity and mortality, most notably earlier onset and longer duration of illnesses, greater number of inpatient hospitalizations, more lifetime suicidal ideation, suicide, and co-morbid substance use disorders (Brown et al., 2007; Carballo et al., 2008; Garno et al., 2005; Leverich et al., 2002; Marchand et al., 2005; McIntyre et al., 2008; Park et al., 2020; Quidé et al., 2020; Romero et al., 2009; Rowe et al., 2023; Young and Juruena, 2021).

Considering the correlation between adverse events and BD, not surprisingly, evidence has also suggested that BD and Post-traumatic Stress Disorder (PTSD) often co-occur, thus worsening the disease course and complicating the treatment. While PTSD was found in 8% of the general population, up to 40% BD patients were found to have PTSD (Cerimele et al., 2017; Hernandez et al., 2013; Otto et al., 2004; Rowe et al., 2023). While there is ample literature on early life stressors and BD, the impact of adverse events over the lifetime of individuals with BD is less studied. Research to date has looked more broadly at negative life events and chronic stressors, as opposed to specific types of traumas from both childhood and adulthood. Moreover, research on patients with BD has an overall theme of co-occurring anxiety disorders and only recently has there been a specific focus on co-occurring PTSD and BD.

Current studies on childhood trauma in bipolar disorder primarily focus on individuals of European Ancestry (EA) (Etain et al., 2017; Van Bergen et al., 2019) or do not stratify findings by race/ethnicity (Upthegrove et al., 2015). AA with BD also tend to have a greater number of inpatient hospitalizations and more suicide attempts than EA (Kupfer et al., 2005). The role of childhood trauma in this population could provide valuable information that could aid clinicians in improving functional outcomes.

This study examines the number of adverse events, from both childhood and adulthood, and prevalence of PTSD in a sample of individuals with BD, as compared to controls matched by age, and sex. The majority of our sample population consists of AA, and we plan to compare our data to what has been reported in cases and controls of EA in the literature.

2. Methods

2.1. Participants

Participants are a part of the larger ongoing Genomic Psychiatry Cohort (GPC) research study (Pato et al., 2013). The participants of GPC research consist of individuals diagnosed with schizophrenia (SZ), schizoaffective (SA) and bipolar disorder (BD), and control participants with no personal or family psychiatric history, in first- or second-degree relatives, of BD or SZ. This analysis included 191 cases, diagnosed with BD I and 924 controls all over age 18 y/o. All participants received the ACE and the A-SAGE in addition to the GPC screening tool, a self-report measure that is validated by the interviewer. The screener consisted of 32 questions and asks general yes/no questions about psychiatric history for psychosis, mania, depression, panic disorder, PTSD, OCD and substance use history. DIPAD, a semi-structured clinical interview, was also conducted for participants with BD to assess their clinical symptoms. Participants were recruited in hospital waiting rooms, outpatient clinics, health fairs, community outreach activities and online advertising. All the procedures were reviewed and approved by the relevant IRB and all participants signed informed consent.

2.2. Measures

Childhood adverse events were evaluated using ACE questionnaire, a 10-item, well-validated self-report survey (Dube et al., 2004; Felitti et al., 1998). It asked negative experiences prior to the age of 18, including physical and emotional abuse, physical and emotional neglect, and family dysfunctions. What distinguishes the ACE questionnaire from other measures is that all participants were asked to only recall their pre-adult (age <18) exposure to select adverse events, which contrasts with other tools that look at these events throughout respondents’ lifetime. By consolidating all respondent ages as a pre-adult group, ACE removes age as a confounding factor since all participants in this study are over age 18 so all have lived thru the ACE period. However in the A-SAGE, the likelihood of adverse events occurring is logically higher as people live more years, so this can be present a bias for the A-SAGE. In addition, the test-retest reliability of the ACE also indicates that there is consistency of participants’ responses despite time lapse between the childhood events and the research survey (Dube et al., 2004).

Lifetime adverse events were evaluated with 15 questions adapted from Study of Addiction: Genetics and Environment (SAGE). For consistency with the ACE questionnaire and limited exposure in this sample to military trauma, these questions were removed from this analysis. Even with these changes, the modified Adversity SAGE (A-SAGE) includes some different types of adverse events from the ACE. Only questions 4 and 5 in A-SAGE are related to sexual trauma, which were included in the ACE. The A-SAGE also asks at what age the adverse events first happened and the total number of times the event happened up to the day of the interview. Thus, it can provide a quantitative measure of lifetime severity, though it does add some bias related to the varied age of adult subjects at the time of interview. For these complementing strengths both instruments were used.

Probable PTSD:

The GPC screening tool consisted of 32 items and 4 of them are used in this study since they are related to the symptoms and diagnosis with PTSD. Subjects were identified as “probable PTSD” if they answered “yes” to all four questions. The 4 questions are:

32.Have you ever experienced a traumatic event in which you felt that your life might be in danger? (Examples: serious car or other accident, natural disaster [like earthquakes or hurricanes], being physically attacked or threatened with a knife or gun, being sexually assaulted or raped, experienced combat or been in a war zone, or observed sudden violent death [homicide or suicide].)”

32a.Sometimes images or strong memories of traumatic events keep coming back in flashbacks, thoughts that you can’t get rid of, or repeated nightmares. Has that Ever happened to you?

32b.Did you make a special effort to avoid thinking or talking about what happened or deliberately stayed away from things or people that reminded you of the terrible experience?

32c.After this experience did you have trouble sleeping, have difficulty concentrating, were unusually irritable, have outbursts of anger, felt overly watchful or on guard, or been very jumpy or easily startled?

2.3. Data Analysis

The data were analyzed with SPSS for Windows (version 24, SPSS Inc., Chicago, IL, USA) and are provided as percentages, means, medians, and standard deviation (SD). Sum scores were created for the ACE and A-SAGE questionnaires by totaling the number of positive responses to each question type. ACE scoring ranges from 0–10 and A-SAGE scoring ranges from 0–15. Odd Ratios (OR) were used to measure the association between the exposure on the ACE and the presence of BD.

3. Results

3.1. The prevalence and impact of adverse life events (Table 1)

Table 1.

Childhood and Adult Prevalence of Adverse Experiences among those with BD and Controls

	BD N=191	Controls N=924	Significance
Age (mean, SD)	44.5 (12.17)	48.8 (16.38)	p<0.05
Female Sex (ref. Males)	105 (55%)	546 (59.1%)	P=0.294
Race
AA	110 (57.6%)	686 (74.2%)
EA	32 (16.8%)	64 (6.9%)
All Other or Mixed Races	49 (25.7%)	174 (18.8%)
Probable PTSD*
Yes (yes to all 4 screener items)	104 (54.5%)	61 (6.6%)	p<0.05
Sum Score ACE Mean (SD)	4.15 (2.871)	1.11 (1.722)	p<0.05
Sum Score A-SAGE, mean (SD)	3.97 (2.853)	1.75 (1.994)	P<0.05

^**Significance based on Independent Samples t-test for continuous variables and chi-square tests for categorical variables

The total sample size was 1,115 individuals. Approximately 17% were BD cases and 83% were control subjects. The study took place in an underserved neighborhood in Brooklyn, New York, and participants consisted of 71% African ancestry (AA), 8.6% European ancestry (EA) and all other races or mixed races totaling 20%.

The ACE (Adverse Childhood Experiences) average sum score (from 0 to 10) was compared among the two groups. The average sum score for the BD group was significantly higher (M=4.15) than the Control group (M=1.11). This indicates that participants in BD group have experienced more types of traumatic events growing up compared to control group. The A-SAGE average sum score, over one’s lifetime, (from 0 to 15) was also compared among the two groups. The average score for the BD group was also significantly higher (M= 3.97) than the Control group (M=1.75).

It should also be noted that there is a notably high percentage of BD group with probable PTSD (54.5%) compared to control group (6.6%). This shows that probable PTSD diagnosis is associated with BD diagnosis, as well as higher ACE score and A-SAGE score.

3.2. The childhood adverse experience profile of BD and control group with the ACE (Figure 1 and Table 2)

Figure 1.

ACE Questionnaire Responses by Diagnosis

Table 2.

ACE Questionnaire: Individuals that Positively Endorsed ACE Questions

	BD N= 191 (%)	Control N=924 (%)	Odds Ratio (95% CI)
ACE Q1 - Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? Or Act in a way that made you afraid that you might be physically hurt? YES	104 (54.5%)	114 (12.3%)	8.49 (6.01, 12.00)*
ACE Q2 - Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? Or Ever hit you so hard that you had marks or were injured? Yes	97 (50.8%)	94 (10.2%)	9.11 (6.39, 12.99)*
ACE Q3 - Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? Or Attempt or actually have oral, anal, or vaginal intercourse with you? Yes	71 (37.2%)	75 (8.1%)	6.70 (4.60, 9.76)*
ACE Q4 - Did you often or very often feel that … No one in your family loved you or thought you were important or special? Or Your family didn’t look out for each other, feel close to each other, or support each other? Yes	92 (48.2%)	95 (10.3%)	8.11 (5.69, 11.56)*
ACE Q5 - Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?Or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes	45 (23.6%)	32 (3.5%)	8.59 (5.29, 13.97)*
ACE Q6 - Were your parents ever separated or divorced? Yes	114 (59.7%)	310 (33.5%)	2.93 (2.13, 4.04)*
ACE Q7 - Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? Yes	53 (27.7%)	48 (5.2%)	7.01 (4.56, 10.77)*
ACE Q8 - Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? Yes	88 (46.1%)	118 (12.8%)	5.84 (4.14, 8.23)*
ACE Q9 - Was a household member depressed or mentally ill, or did a household member attempt suicide? Yes	72 (37.7%)	36 (3.9%)	14.92 (9.58, 23.25)*
ACE Q10 - Did a household member go to prison? Yes	57 (29.8%)	100 0.8%)	3.51 (2.41, 5.09)*

^*OR: p<0.05

For each item on the ACE, a greater OR was seen in the BD group compared to the control group, indicating that there is a higher ratio of BD participants experiencing childhood trauma for every single traumatic event listed under ACE (Table 2).

The difference between BD and control group is quite noteworthy, since it can be seen that the percentage of ACE events in BD group range from 23.6% to 59.7% while all of the ACE items in control groups are each around 10%, with parental separation being the only exception (Figure 1).

Parental separation is the most common childhood adversity reported in both BD (57.9%) and control group (33.5%). For participants with BD, emotional and physical abuse and neglect are also common and are indicated by a high prevalence in BD: swear/insult/put down/humiliate (54.4%), push/grab/slap/throw (50.8%) and not feeling loved or important (48.2%), living with anyone who uses substance (46.1%) (Figure 1).

All OR were elevated in the BD subjects. For instance, those with BD compared to controls were 15 times more likely to have a household member mentally ill or depressed than control subjects. BD cases were also 9 times more likely to experience physical abuse and 8 times more likely to experience emotional abuse, emotional neglect, and physical neglect. (Table 2)

3.3. The lifetime traumatic experience profile of BD and control group with the A-SAGE (Table 3)

Table 3.

A-SAGE

	BD (N= 191) % (N)	Control (N=924) % (N)	Odds Ratio (95% CI)*
(A05) Have you ever been shot?	6.8% (13)	3.1% (29)	2.25 (1.15, 4.42)*
Mean age (yrs)	22.5	23
Missing # Age	0	3% (1)
Mean Freq	1.85	2.22
Missing # Freq	0	6.7% (2)
(A06) Have you ever been stabbed?	20% (39)	7% (66)	3.34 (2.17, 5.14)*
Mean age (yrs)	22.6	22.6
Missing # Age	0	3% (2)
Mean Freq	1.68	1.17
Missing # Freq	2.6% (1)	4.5% (3)
(A07) Have you ever been mugged or threatened with a weapon, or experienced a break-in or robbery?	49% (93)	21% (190)	3.67 (2.65, 5.08)*
Mean age (yrs)	26.1	24.5
Missing # Age	3.2% (3)	5.3% (10)
Mean Freq	1.93	1.66
Missing # Freq	7.5% (7)	11.1% (21)
(A08) Have you ever been raped or sexually assaulted by a relative?	26% (49)	6% (59)	5.06 (3.33, 7.69)*
Mean age (yrs)	9.66	10.5
Missing # Age	4.1% (2)	5.1% (3)
Mean Freq	4.07	1.97
Missing # Freq	44.9% (22)	35.6% (21)
(A09) Have you ever been raped or sexually assaulted by someone not related to you?	38% (73)	8% (73)	7.21 (4.95, 10.52)*
Mean age (yrs)	16	16.7
Missing # Age	2.7% (2)	6.8% (5)
Mean Freq	3.59	2.05
Missing # Freq	20.5% (15)	23.3% (17)
(A10) Have you ever been in a natural disaster like a fire, flood, earthquake, tornado, mudslide or hurricane?	27% (51)	16% (147)	1.93 (1.34, 2.78)*
Mean age (yrs)	19.4	24.1
Missing # Age	5.9% (3)	2% (3)
Mean Freq	1.41	1.57
Missing # Freq	9.8% (5)	8.8% (13)
(A11) Have you ever learned you had been exposed to radiation, dioxin, or any other dangerous materials?	2.1% (4)	2% (16)	1.21 (0.40, 3.67)
Mean age (yrs)	36	36.9
Missing # Age	50% (2)	12.5% (2)
Mean Freq	1.5	4.7
Missing # Freq	50% (2)	37.5% (6)
(A12) Have you ever experienced an unexpected, sudden death of a close friend or relative?	66% (126)	44% (405)	2.48 (1.79, 3.44)*
Mean age (yrs)	23.5	28.9
Missing # Age	4.8% (6)	4.4% (18)
Mean Freq	2.75	2.03
Missing # Freq	15.1% (19)	10.4% (42)
(A13) Have you ever been held captive, tortured, or kidnapped?	16% (30)	2% (18)	9.38 (5.11, 17.23)*
Mean age (yrs)	23.5	23.9
Missing # Age	3.3% (1)	0
Mean Freq	1.62	1.44
Missing # Freq	13.3% (4)	0
(A14) Have you ever been diagnosed with a life threatening illness?	16% (31)	9% (81)	2.02 (1.29, 3.15)*
Mean age (yrs)	35.4	41.3
Missing # Age	6.5% (2)	1.2% (1)
Mean Freq	2.2	1.19
Missing # Freq	19.4% (6)	11.1% (9)
(A15) Have you ever been in a serious accident?	27% (51)	15% (135)	2.13 (1.47, 3.08)*
Mean age (yrs)	24.6	27.9
Missing # Age	5.9% (3)	4.4% (6)
Mean Freq	1.36	1.14
Missing # Freq	11.8% (6)	6.7% (9)
(A16) Have you ever seen someone being seriously injured or killed?	34% (64)	16% (148)	2.64 (1.87, 3.74)*
Mean age (yrs)	20.3	22.4
Missing # Age	6.3% (4)	8.9% (13)
Mean Freq	3.33	2.05
Missing # Freq	15.6% (10)	12.8% (19)
(A17) Have you ever unexpectedly discovered a dead body?	15% (28)	7% (64)	2.31 (1.44, 3.71)*
Mean age (yrs)	24.3	27.9
Missing # Age	10.7% (3)	6.3% (4)
Mean Freq	1.63	1.49
Missing # Freq	14.3% (4)	10.9% (7)
(A18) Have you ever learned that any of these terrible things had happened to a close friend or relative when you were not there?	30% (58)	14% (125)	2.79 (1.94, 4.00)*
Mean age (yrs)	25.5	27.7
Missing # Age	20.7% (12)	12% (15)
Mean Freq	2.17	2.02
Missing # Freq	37.9% (22)	35.2% (44)
(A19) Have you ever had any other experiences that were terrible, frightening, or horrible?	18% (36)	5% (48)	4.24 (2.66, 6.75)*

^*OR: p<0.05 for all questions except for question PTSD A11

Data analysis was not done for the age of first occurrence and frequency of each occurrence, because there were large amounts of individuals who did not respond to these two questions.

As with the ACE questionnaire, responses to the A-SAGE in the BD group were compared to those in the control group. There was a higher odds of each traumatic event in the BD group compared to controls, except for question 11, which asked about radiation exposure and was very rare in both groups equally (Table 3).

Patients with BD were 9 times more likely to have been held captive, tortured, or kidnapped than controls (Table 3). However, it is important to note that positive responses to A-SAGE Q9 was only 2% (N=18) for control and 16% (N=30) for BD. BD patients were also 7 times more likely to have been sexually assaulted by an individual who was not related to them as compared to Controls (Table 3).

The most common traumatic events experienced were unexpected death of close friend/relative (BD = 66%, control = 44%) and mugged, threatened with weapon, robbery (BD = 49%, control = 21%).

4. Discussion

In concordance with current literature, our research found that individuals with BD bipolar were significantly more likely than controls to have both childhood and adulthood adverse events (Bergink et al., 2016; Daruy-Filho et al., 2011; Gershon et al., 2013; Palmier-Claus et al., 2016). Compared to the control group, BD group was observed to have experienced not just more types of adverse events but to have a higher probability of PTSD diagnosis. Greater OR was seen in BD group compared to control group for each ACE question and each A-SAGE question, with the exception of radiation exposure.

When looking at ACE, our study found that parental psychopathology has the highest odds ratio (Table 2). The increased risk of BD in offspring of parents with mental illness could be multifaceted. Parents’ psychopathology (ACE Q9) could impair their ability to provide ample emotional and physical support to their offspring (Bergink et al., 2016; Singh et al., 2007). Families with parents with mental illnesses, especially mood disorders, can have less cohesion, less organization and more conflict when compared to control families (Chang et al., 2001). Alternatively, the strong correlation between parental psychopathology and BD can also supports the genetic component of BD. Bergink et al. (2016) conducted a large cohort study that included over 980,000 people from Denmark on the impact of childhood adverse life events, especially parental psychopathology, in BD. They found that parental psychopathology has a strong independent effect on developing BD later in life, even when all other adversities were absent. Even though our research cannot fully quantify the influence of genetics vs environmental factors in the progression of BD, recognizing and acknowledging parental psychopathology as one of the most influential adversities from childhood that can impact the progression of BD can give directions to future research.

Apart from parental mental health, it can be noted in ACE that physical abuse, emotional abuse, physical neglect, and emotional neglect are adverse events from childhood that have relatively high OR (Table 2 and figure 1). In comparison, adversities or traumatic experience related to dysfunctional household, including parental divorce or separation, living with substance user, household member going to prison, though still have OR more than 1, but not as great. Moreover, Carbone et al. (2019) conducted a two-step cluster analysis with participants with BD and SZ. Similar to ACE, the Childhood Experience of Care and Abuse scale (CECA), which also looks at physical abuse and neglect, emotional abuse and neglect, sexual abuse and familial dysfunction, was administered to evaluate adverse childhood experiences. Carbone et al. (2019) found that childhood traumatic experiences of abuse and neglect are correlated with higher presence and severity of clinical symptoms, such as more psychotic features and longer duration of illness. A meta-analysis also concluded that the effect of emotional abuse has a particularly high association with BD (OR=4.04 CI 3.12–5.22) among all types of childhood adversity measured (Palmier-Claus et al., 2016). In this way, certain childhood traumatic experience can help us identify individuals with higher risk of developing BD and more complex and severe clinical features.

Perhaps most striking amongst the results of the A-SAGE are the largest OR for item A09, rape and sexual assault by not related person (OR=7.21), and item A13, being held captive, tortured or kidnapped (OR=9.38) (Table 3). While these questions may have been interpreted variably by the study subjects, they are different from other questions in the A-SAGE and the ACE in that they likely refer to circumstances that are both dangerous and unfamiliar. One possible explanation for the high OR for these questions may be the frequently replicated finding of trait impulsivity in patients with BD in both euthymic and manic states compared to controls (Peluso et al., 2007; Rote et al., 2018; Strakowski et al., 2010; Swann et al., 2003). Moeller et al. (2001) pointed out that the embodiments of impulsivity in psychiatric disorders include a lack of consideration for consequences of behaviors and reactions to stimuli before fully processing of information. Individuals with BD may therefore have a higher likelihood than those without BD of findings themselves in more dangerous and unfamiliar situations where they might be attacked or otherwise traumatized by a stranger. However, it should be noted that different measures of impulsivity have been used in the literature and have yielded inconsistent outcomes (Moeller et al., 2001). Reddy (2014) measured self-reported impulsiveness with the Barratt Impulsiveness Scale (BIS) and compared it to the results from the Balloon Analogue Risk Task (BART), a computerized game with predicative validity of real-world risk-taking behaviors. Reddy pointed out that individuals with BD may perform similarly to controls on BART, a more objective measure, even though they may score significantly higher on BIS, a self-reported measure (Reddy et al., 2014). As a result, future research may consider the joint use of self-reported and objective measures to explore the multiple facets of impulsivity in BD.

When comparing the OR of sexual abuse, physical neglect, emotional neglect, parental loss, or physical abuse in BD groups versus controls in both ACE and A-SAGE, our cases had a greater OR of experiencing these events than what has been reported in other studies and meta-analyses (Palmier-Claus et al., 2016; Upthegrove et al., 2015). After examining 19 papers, Palmier-Claus reported that childhood emotional abuse was found to have a strong effect in BD with an OR of 4.04, (OR=4.04, 95% CI 3.12–5.22) (Palmier-Claus et al., 2016). Our data show that the responses to question 4 in ACE, the question related to emotional abuse, has a much higher OR (8.11, 95% CI 5.69–11.56). Similarly, when maltreatment – including physical abuse, sexual abuse, or rape – was examined in BD population in a group of participants consisting of 3% AA and 74% EA, it was found that BD population has an OR=2.53 (95%1.68–3.82) (Grandin et al., 2007). In our ACE, question 2, corresponding to physical abuse, has an OR of 9.11; question 3, corresponding to sexual abuse, has an OR of 6.70 and Question A08 and A09 in A-SAGE, corresponding to rape, have OR of 5.06 and 7.21, respectively. This is likely because the majority of our participants were recruited from an underserved neighborhood in Brooklyn and the majority of our participants are of African Ancestry (AA). Studies have consistently shown that AA experience more violent crime in their lives than other racial or ethnic groups (Ullman, 2021). AA have an exceedingly high rate of trauma exposure (≥65%) compared to EA, including physical assault, sexual assault, and various forms of intimate partner violence (Alim et al., 2006). In fact, AA adults overall report around twice as many adverse childhood experiences as white adults as per the ACE questionnaire (Sheats et al., 2018). However, the gap between the experiences of AA and EAadults aged 18–34 is widest for outcomes with the greatest immediate risk to physical health, such as aggravated assault and physical fights leading to injuries (Sheats et al., 2018). These data may together explain the divergence in OR when it comes to the more violent crimes. However, since the majority of both our cases and controls in this study were of AA, we cannot compare our results from the ACE and A-SAGE with an EA population in this same community but only make reference from the existing literature. This emphasizes the importance of this work in characterizing the AA experience since previous work is largely focuses on European ancestry and this work highlights the difference in a Bipolar versus control sample who are predominantly of AA.

5. Limitations

There are several limitations in the current study. First, as mentioned, our sample was collected as part of an ongoing African Ancestry collection in Brooklyn, NY. The ACE and A-SAGE collection was one of convenience so, generalizability is limited. As a result, even though we have a majority (57.6% BD of 191) and 74.2% controls of 924) of participants being AA, the conclusion about the impact of AA descent on developing PTSD as well as ACE and A-SAGE scores cannot be conclusive because of sample size between cases and controls. However,this is an important first step in addressing the dearth of data on African Ancestry in case and control samples.

Second, it should be noted that there was a large amount of missing data reported from the A-SAGE, related to first age and frequencies of adverse events, this limits our conclusions from the A-SAGE. Because of the amount of missing data, the results on age and frequencies may be skewed and thus are not analyzed. This missing data could be a consequence of participants’ inability or unwillingness, to recall or answer. Even though research has shown that adversity reported by patients with mental illnesses are surprisingly reliable (Brown et al., 2007; Carbone et al., 2019), retrospective study have yielded recall bias due to memory deficiencies (Gorin and Stone, 2001). Self-reported questionnaires may also be related to participants’ subjective interpretation and result in either overestimation or underestimation of the adverse events that occurred (Koenders et al., 2014; Powers et al., 2016). As a result, compared to A-SAGE, ACE appears to be a more powerful tool, since it has a simple Yes/No answer, without further details except for a clear age cutoff, before 18yo. Future studies utilizing A-SAGE will need more diligence in completion of missing self-reported items for a more robust and informative data set.

Despite limitations, our research has shown an increased prevalence of lifetime adverse events and PTSD in populations diagnosed with BD. We identified adverse events with higher OR for individuals with BD, which suggests certain adverse events are more impactful on progression of BD. Clinicians working with BD patients should be aware of the high prevalence of lifetime adversity of patients and comorbidity of PTSD. The exploration of past traumatic experience can allow clinicians to gain a better clinical picture of the patients’ conditions, and even help them to decide whether a trauma-informed treatment module could be beneficial.

Highlights:

• Individuals with BD reported having experienced more childhood and lifetime adverse events.

• Individuals with BD had a higher prevalence of pPTSD

• Among all the ACE questions, parental psychopathology has the highest OR.

• Physical abuse, emotional abuse and emotional neglect also had relatively high OR.