Abstract
Aim
Several lines of evidence suggest a possible association between a history of trauma in childhood and later psychosis or psychotic-like-experiences. The purpose of this study was to determine the extent of childhood trauma and bullying in young people at clinical high risk (CHR) of developing psychosis.
Methods
The sample consisted of 360 individuals who were at CHR of developing psychosis and 180 age and gender matched healthy controls. All participants were assessed on past trauma and bullying. The CHR participants were also assessed on a range of psychopathology and functioning.
Results
Individuals at CHR reported significantly more trauma and bullying than healthy controls. Those who had experienced past trauma and bullying were more likely to have increased levels of depression and anxiety and a poorer sense of self.
Conclusions
These results offer preliminary support for an association between a history of trauma and later subthreshold symptoms.
Keywords: clinical high risk, psychosis, trauma, prodrome, risk
INTRODUCTION
Several lines of evidence suggest a possible association between a history of trauma in childhood and later psychosis or psychotic like experiences.1–10 Adolescents who report experiencing psychotic symptoms are six times more likely to have experienced physical abuse, ten times more likely to have witnessed domestic violence, and more likely to be both a victim and perpetrator of bullying.11 Arseneault and colleagues recently reported that after controlling for SES, low IQ, early psychopathology and genetic susceptibility, maltreatment by an adult and bullying by peers were significantly associated with children’s report of psychotic symptoms. 9 Furthermore, a recent longitudinal prospective study showed that early and recent traumas were highly correlated and that they work additively to increase the risk of psychosis. 12 This is supported by results that indicated that total childhood trauma is significantly associated with psychosis in a dose response fashion, and that while rates of reported trauma appear to be highest for individuals with psychosis, the siblings of these patients also evidenced more traumas compared to healthy controls. 13 In addition to this, a preliminary investigation of the impact of appraisals, trauma and psychosis found that interpersonal trauma was associated with more maladaptive appraisals of experiences, creating a more “paranoid” view of the world. 14 Several theories including the stress-vulnerability model, genetic predisposition hypothesis, and attachment theory have attempted to understand these connections. 15 However, despite the interest in this area of research it has been cautioned in the literature that much of the evidence in the area of trauma and psychosis is controversial and that several methodological issues still remain. 2;6;16
Most studies to date investigating trauma have focused on established psychotic disorders or non-clinical samples. Little is known about trauma for those individuals considered to be at clinical high risk (CHR) of developing psychosis. To date, there are two studies that examined the impact of trauma among a sample of CHR individuals. 17–19 The first study reported that in a small sample of 30, 97% had experienced at least one general trauma and that total trauma was positively associated with severity of attenuated positive symptoms. 19 A second study from Melbourne found that approximately 70% of their sample of 92 CHR individuals had experienced at least one type of trauma, and that the rates of conversion to psychosis significantly increased when the type of trauma was sexual abuse. 17
The goal of this study was to first determine the extent of trauma that had been experienced in a large sample of individuals at CHR for psychosis relative to age and gender matched healthy controls, and secondly, to examine the relationship of past trauma to current psychopathology, cannabis use and functioning.
METHODS
Participants
The sample consisted of 360 CHR participants (210 male, 150 female) and 180 healthy controls (100 male, 80 female). All participants were recruited as part of the NIMH funded North American Prodrome Longitudinal Study 2 (NAPLS 2) and were drawn from the participating NAPLS2 sites (Emory University, Harvard University, University of Calgary, University of California Los Angeles, University of California San Diego, University of North Carolina, Yale University, and Zucker Hillside Hospital). The NAPLS 2 project was established to investigate predictors and mechanisms of conversion to psychosis. Details on ascertainment, inclusion and exclusion criteria has been described in detail elsewhere (Addington et al., in press). All CHR participants met the Criteria of Prodromal Syndromes (COPS) using the Structured Interview for Prodromal Symptoms (SIPS).20 Participants were excluded if they met criteria for any current or lifetime axis I psychotic disorder, prior history of treatment with an antipsychotic, IQ< than 70 or past or current history of a clinically significant central nervous system disorder. In addition, control participants were also excluded if they had a first degree relative with a current or past psychotic disorder
Measures
The Structured Interview for Prodromal Symptoms (SIPS) and the Scale for Assessment of Prodromal Symptoms (SOPS) 20 were used to determine criteria for a prodromal syndrome and to determine severity of attenuated positive symptoms. Experience of trauma and abuse was assessed using a Childhood Trauma and Abuse scale, 5 a semi-structured interview in which the interviewer enquires about trauma and abuse before the age of 16. The participant is asked about any emotional, physical, psychological or sexual abuse they may have experienced. In addition participants were also asked if they had experienced either psychological bullying or physical bullying.
Clinical measures included the Calgary Depression Scale for Schizophrenia, 21 the Brief Core Schema Scale, 22;23 the Social Interaction Anxiety Scale (SIAS) & Social Anxiety Scale (SAS), 24 the Perceived Discrimination scale, 25 and the Alcohol and Drug Use Scale. 26 Functioning was assessed with the Global Functioning Scale: Social and Role. 27
Procedures
The study was approved by Institutional Review Boards at all eight sites participating in NAPLS. Participants provided informed consent or assent (parental informed consent for minors). Participants were assigned a clinical rater who conducted semi structured interviews. Raters were experienced research clinicians who demonstrated adequate reliability at routine reliability checks. Gold standard post-training agreement on the determining the prodromal diagnoses was excellent (kappa=0.90).
Statistical Analysis
Chi square tests were used to compare the groups on type of trauma. Mann-Whitney U tests were used for comparison of total traumas. Associations between type of trauma and total trauma to clinical variables were examined using Spearman correlations.
RESULTS
There were no significant differences between the groups on any of the demographic measures assessed. The average age of CHR participants was 18.98 (SD=4.18) and 19.54 (SD=4.78) for controls. The majority of the sample were male (55.2%), unmarried (94.4% for CHR, 95.0% for controls), currently enrolled as students (80.7% for CHR, 82.2% for controls), and Caucasian (55.0% for CHR, 58.9% for controls). Further clinical characteristics describing the CHR participants are provided in table 1.
Table 1.
Clinical Characteristics of CHR Participants
Current Axis 1 Comorbid Diagnoses | n (%) | |
---|---|---|
Mood Disorder | 168 (46.67%) | |
Substance Use Disorder | 34 (9.4%) | |
Anxiety Disorder | 241 (66.9%) | |
Developmental Disorder | 94 (17.9%) | |
Axis 2 Personality Disorder | ||
Avoidant | 36 (10.0%) | |
Borderline | 12 (3.0%) | |
Schizotypal | 62 (17.22%) | |
Self Reported Anxiety/Depression | M (SD) | Ranges |
Calgary Depression Scale for Schizophrenia (CDSS) | 5.98 (4.83) | 0–27 |
Social Interaction Anxiety Scale (SIAS) | 29.90 (16.91) | 0–80 |
Social Anxiety Scale (SAS) | 37.09 (10.40) | 20–80 |
Current Functioning | ||
GAF | 46.72 (10.85) | 0–100 |
Global Functioning: Social Scale | 6.20 (1.65) | 0–10 |
Global Functioning: Role Scale | 5.96 (2.19) | 0–10 |
Overall, CHR participants experienced significantly more types of trauma (z=−8.68, p<0.05) and bullying (z=−4.89, p<0.05) compared to controls. Chi square comparisons for each type of trauma revealed several significant differences. These results are presented in Table 1.
Compared to CHR males, CHR females reported significantly more trauma. There were no differences for bullying. There were no significant differences between male and female control participants on any kind of trauma or bullying. See Table 2.
Table 2.
Differences in Trauma for Clinical High Risk (CHR) Participants and Healthy Controls
Type of Trauma | CHR n (%) | Controls n (%) | χ2 |
---|---|---|---|
Psychological Bullying | 178 (60.5%) | 52 (36.1%) | 23.14*** |
Physical Bullying | 88 (29.8%) | 21 (14.7%) | 11.82*** |
Emotional Neglect | 128 (44.0%) | 11 (7.7%) | 57.50*** |
Physical Abuse | 80 (27.7%) | 9 (6.3%) | 26.47*** |
Psychological Abuse | 118 (40.1%) | 10 (7.0%) | 51.03*** |
Sexual Abuse | 47 (16.3%) | 2 (1.4%) | 23.68*** |
Total Scores (Mann-Whitney) | |||
M (SD) | U | Z | |
| |||
Total Bullying | 0.77 (0.93) | 15632.5 | −4.89*** |
Total Trauma | 1.69 (1.70) | 10594.0 | −8.68*** |
p<0.0001
There were several significant correlations particularly for the CHR group between clinical measures and traumas. Higher levels of anxiety and depression were observed in both groups as well as a negative sense of self and others. For the CHR group in particular trauma and perceived discrimination were highly correlated. Poor social functioning was more likely to be related to bullying rather than other kinds of trauma. After Bonferroni corrections, several significant relationships remained. These results are presented in Table 3.
TABLE 3.
Comparison of Males and Females on Trauma
Type of Trauma | CHR Male n (%) | CHR Female n (%) | χ2 | Control Male n (%) | Control Female n (%) | χ2 |
---|---|---|---|---|---|---|
Psychological Bullying | 101 (34.4%) | 77 (26.2%) | 0.22 | 27 (18.8%) | 25 (17.4%) | 0.22 |
Physical Bullying | 56 (19.0%) | 32 (10.8%) | 2.07 | 14 (9.8%) | 7 (4.9%) | 2.85 |
Emotional Neglect | 58 (19.9%) | 70 (24.1%) | 15.29** | 5 (3.5%) | 6 (4.2%) | 0.07 |
Physical Abuse | 36 (12.5%) | 44 (15.2%) | 7.41* | 5 (3.5%) | 4 (2.8%) | 0.00 |
Psychological Abuse | 56 (19.0%) | 62 (21.1%) | 8.68* | 5 (3.5%) | 5 (3.5%) | 0.00 |
Sexual Abuse | 13 (4.5%) | 34 (11.8%) | 20.88** | 1 (0.7%) | 1 (0.7%) | 0.00 |
p<0.01,
p<0.0001
DISCUSSION
This paper examined the prevalence of past traumatic experiences in a large sample of individuals at CHR of developing psychosis. Relative to controls the CHR group reported having experienced significantly more trauma and bullying. Within the CHR group, females had more often experienced trauma but not bullying, relative to males. Furthermore, those who had experienced trauma were more likely to report anxiety and depression as well as a negative sense of self and others. Those who had experienced bullying generally had poorer functioning. These results fit with previous studies that suggest an association between a history of trauma in childhood and later experience of psychotic-like experiences. Our rates of reported trauma are similar to those reported by the Melbourne group. 17 Furthermore, our CHR sample was twice as likely to report bullying and between four and 10 times more likely to report a range of other traumas. Unlike the small Corcoran study, 19 we did not find a relationship between past experience of trauma and increased attenuated positive symptoms. However, it is not surprising that those who report more trauma also report higher levels of anxiety, depression and sense of self. However, in this cross-sectional report it is unclear whether this increased level of psychopathology is related to trauma, or to other causes such as being at CHR for psychosis. Furthermore, although significant the association is small which may be attributed to the fact the symptoms are current and we do not have details on the recency of the trauma.
The limitations of this study include the brief measure used, the lack of details on how often the trauma occurred, the age of the participant at the time of the trauma and that the raters were not blind to study group. There is as in any study on past trauma the possibility of recall bias. The study is cross-sectional and it is not known at present the role of trauma in conversion. The trauma measure used although brief was relatively non-invasive and had been used in many of the studies cited. The strengths of this study are the sample size and the well-defined sample. Future studies should assess not only the age that the trauma occurred but also the frequency of such trauma overtime. What will be important will be the role of trauma in later conversion to psychosis, and if associated, what is the relationship of trauma to other markers of conversion. These outcomes will be part of the longitudinal component of the NAPLS 2 project. Finally, based on the high reported rates of trauma in this population, it may be important to consider on an individual basis if addressing therapeutically the trauma may be an important aspect of prevention in these already vulnerable young people.
Table 4.
Relationship between Clinical Measures and Trauma for CHR individuals (N=360)
Measure | Psych. Bullying | Physical Bullying | Emotional Neglect | Psych. Abuse | Physical Abuse | Sexual Abuse | Total Bullying | Total Trauma |
---|---|---|---|---|---|---|---|---|
Spearman r | ||||||||
SOPS-P | 0.01 | −0.03 | −0.06 | −0.03 | 0.00 | −0.01 | −0.01 | −0.04 |
SOPS-N | −0.06 | −0.13* | −0.07 | 0.05 | −0.02 | −0.07 | −0.11 | −0.08 |
CDSS | 0.16** | 0.18** | 0.27*** | 0.13** | 0.16** | 0.07 | 0.19** | 0.26*** |
SIAS | 0.19** | 0.10 | 0.21*** | 0.16** | 0.22*** | 0.11 | 0.17** | 0.28*** |
SAS | 0.20** | .017** | 0.27*** | 0.25*** | 0.25*** | 0.21*** | 0.21*** | 0.34*** |
Neg-Self | 0.25*** | 0.21*** | 0.21*** | 0.27*** | 0.24*** | 0.14* | 0.27*** | 0.33*** |
Neg-Others | 0.24*** | 0.19** | 0.17** | 0.13** | 0.13* | 0.13* | 0.27*** | 0.28*** |
Cur. PD | 0.22*** | 0.22*** | 0.19*** | 0.27*** | 0.21*** | 0.25*** | 0.25*** | 0.33*** |
Lifetime PD | 0.25*** | 0.30*** | 0.20*** | 0.27*** | 0.24*** | 0.24*** | 0.32*** | 0.37*** |
GF-Social | 0.02 | −0.12* | −0.05 | −0.09 | −0.07 | 0.08 | −0.05 | −0.07 |
GF: Role | −0.15* | −0.14* | −0.05 | −0.10 | −0.11 | −0.02 | −0.16** | −0.16** |
Cannabis | −0.05 | 0.09 | 0.11 | 0.09 | 0.10 | −0.01 | 0.00 | 0.07 |
p<0.05,
p<0.01,
p<0.0001 → Adjustment: 0.05/24 = 0.002
Psych.= Psychological, SOPS-P = SOPS Total Positive Symptoms, SOPS-N= SOPS Total Negative Symptoms, CDSS = Calgary Depression Scale for Schizophrenia, SIAS = Social Interaction Anxiety Scale, SAS = Social Phobia Scale, Neg-Self = Brief Core Schema Scale Negative Self, Neg-Others = Brief Core Schema Scale Negative Others, Cur. PD = Perceived Discrimination in Past Year, Lifetime PD = Perceived Discrimination in Lifetime, GF: Social = Global Functioning Scale: Social, GF: Role = Global Functioning Scale: Role
Acknowledgments
Role of funding source
This study was supported by the National Institute of Mental Health (grant U01MH081984 to Dr Addington; grants U01 MH081928; P50 MH080272; Commonwealth of Massachusetts SCDMH82101008006 to Dr Seidman; grants R01 MH60720, U01MH082022 and K24 MH76191 to Dr Cadenhead; grant to Dr Cannon; grant U01MH082004-01A1 to Dr Perkins; grant U01MH081988 to Dr Walker; grant U01MH082022 to Dr Woods; and UO1 MH081857-05 grant to Dr Cornblatt.
Acknowledgements to the NAPLS group
J Stowkowy, T Raedler, L McGregor, D Marulanda, L Legere, L Liu, C Marshall, E Falukozi, E Fitton, K Smith, J., A. Addington (University of Calgary). T Alderman, K Shafer, I Domingues, A Hurria, H Mirzakhanian (UCSD). B Walsh, J Saksa, N Santamauro, A Carlson, J Kenney, B Roman (Yale University). K Woodberry, AJ Giuliano, W Stone, JM Rodenhiser, L Tucker, R Serur, G Min, R Szent-Imrey (Beth Israel Deaconess Medical Center/Harvard). C Bearden, P Bachman, J Zinberg, S DeSilva, A Andaya, S Uguryan (UCLA). J Brasfield, H Trotman, (Emory University). A Pelletier, K Lansing, H Mates, J Nieri, B Landaas, K Graham, E Rothman, J Hurta, Y Sierra (University of North Carolina). A Auther, R Carrion, M McLaughlin, R Olsen ( Zucker Hillside Hospital)
Footnotes
The NIMH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Reference List
- 1.Shevlin M, Dorahy M, Adamson G. Childhood traumas and hallucinations: An analysis of the National Comorbidity Survey. J Psychiatr Res. 2006 doi: 10.1016/j.jpsychires.2006.03.004. [DOI] [PubMed] [Google Scholar]
- 2.Read J, van OJ, Morrison AP, Ross CA. Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatr Scand. 2005;112:330–350. doi: 10.1111/j.1600-0447.2005.00634.x. [DOI] [PubMed] [Google Scholar]
- 3.Janssen I, Krabbendam L, Hanssen M, et al. Are apparent associations between parental representations and psychosis risk mediated by early trauma? Acta Psychiatr Scand. 2005;112:372–375. doi: 10.1111/j.1600-0447.2005.00553.x. [DOI] [PubMed] [Google Scholar]
- 4.Spauwen J, Krabbendam L, Lieb R, Wittchen HU, van OJ. Impact of psychological trauma on the development of psychotic symptoms: relationship with psychosis proneness. Br J Psychiatry. 2006;188:527–533. doi: 10.1192/bjp.bp.105.011346. [DOI] [PubMed] [Google Scholar]
- 5.Janssen I, Krabbendam L, Bak M, et al. Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatr Scand. 2004;109:38–45. doi: 10.1046/j.0001-690x.2003.00217.x. [DOI] [PubMed] [Google Scholar]
- 6.Bendall S, Jackson HJ, Hulbert CA, McGorry PD. Childhood Trauma and Psychotic Disorders: a Systematic, Critical Review of the Evidence. Schizophr Bull. 2007 doi: 10.1093/schbul/sbm121. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Gracie A, Freeman D, Green S, et al. The association between traumatic experience, paranoia and hallucinations: a test of the predictions of psychological models. Acta Psychiatr Scand. 2007;116:280–289. doi: 10.1111/j.1600-0447.2007.01011.x. [DOI] [PubMed] [Google Scholar]
- 8.Bebbington P, Bhugra D, Brugha T, Singleton N, Farrel M, Jenkins J, et al. Psychosis, victimization and childhood disadvantage: evidence from the second British National Survey of Psychiatric Morbidity. Br J Psychiatry. 2004;185(3):220–226. doi: 10.1192/bjp.185.3.220. [DOI] [PubMed] [Google Scholar]
- 9.Arseneault L, Cannon M, Fisher HL, Polanczyk G, Moffitt TE, Caspi A. Childhood trauma and children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study. Am J Psychiatry. 2011;168:65–72. doi: 10.1176/appi.ajp.2010.10040567. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Schafer I, Fisher H. Childhood trauma and psychosis -what is the evidence? Dialogues Clin Neurosci. 2011;13(3):360–365. doi: 10.31887/DCNS.2011.13.2/ischaefer. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kelleher I, Harley M, Lynch F, Arseneault L, Fitzpatrick C, Cannon M. Associations between childhood trauma, bullying and psychotic symptoms among a school-based adolescent sample. Br J Psychiatry. 2008;193:378–382. doi: 10.1192/bjp.bp.108.049536. [DOI] [PubMed] [Google Scholar]
- 12.Lataster J, Myin-Germeys I, Lieb R, Wittchen HU, van Os J. Adversity and psychosis: a 10-year prospective study investigating synergism between early and recent adversity in psychosis. Acta psychiatr scand. 2011:1–12. doi: 10.1111/j.1600-0447.2011.01805.x. [DOI] [PubMed] [Google Scholar]
- 13.Heins M, Simons C, Lataster T, Pfeifer S, Versmissen D, Lardinois M, et al. Childhood trauma and psychosis: a case-control and case-sibling comparison across different levels of genetic liability, psychopathology, and type of trauma. Am J Psychiatry. 2011;168(12):1286–1294. doi: 10.1176/appi.ajp.2011.10101531. [DOI] [PubMed] [Google Scholar]
- 14.Lovatt A, Mason O, Brett C, Peters E. Psychotic-like experiences, appraisals, and trauma. J Nerv Ment Dis. 2010;198:813–819. doi: 10.1097/NMD.0b013e3181f97c3d. [DOI] [PubMed] [Google Scholar]
- 15.Read J, Fink PJ, Rudegeair T, Felitti V, Whitfield CL. Child Maltreatment and Psychosis: A return to a genuinely integrated bio-psycho-social model. Clinical Schizophrenia & Related Psychoses. 2008:235–254. [Google Scholar]
- 16.Morgan C, Fisher H. Environmental Factors in Schizophrenia: Childhood Trauma--A Critical Review. Schizophr Bull. 2006 doi: 10.1093/schbul/sbl053. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Bechdolf A, Thompson A, Nelson B, et al. Experience of trauma and conversion to psychosis in an ultra-high-risk (prodromal) group. Acta Psychiatr Scand. 2010 doi: 10.1111/j.1600-0447.2010.01542.x. [DOI] [PubMed] [Google Scholar]
- 18.Thompson A, Nelson B, McNab C, et al. Psychotic symptoms with sexual content in the “ultra high risk” for psychosis population: Frequency and association with sexual trauma. Psychiatry Res. 2010 doi: 10.1016/j.psychres.2010.02.011. [DOI] [PubMed] [Google Scholar]
- 19.Thompson JL, Kelly M, Kimhy D, et al. Childhood trauma and prodromal symptoms among individuals at clinical high risk for psychosis. Schizophr Res. 2009;108:176–181. doi: 10.1016/j.schres.2008.12.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Miller TJ, McGlashan TH, Rosen JL, et al. Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability. Schizophr Bull. 2003;29:703–715. doi: 10.1093/oxfordjournals.schbul.a007040. [DOI] [PubMed] [Google Scholar]
- 21.Addington D, Addington J, Maticka-Tyndale E. Assessing Depression in Schizophrenia: The Calgary Depression Scale. British Journal of Psychiatry. 1993;163:39–44. [PubMed] [Google Scholar]
- 22.Fowler D, Freeman D, Smith B, et al. The Brief Core Schema Scales (BCSS): psychometric properties and associations with paranoia and grandiosity in non-clinical and psychosis samples. Psychol Med. 2006:1–11. doi: 10.1017/S0033291706007355. [DOI] [PubMed] [Google Scholar]
- 23.Addington J, Tran L. Using the brief core schema scales with individuals at clinical high risk of psychosis. Behav Cogn Psychother. 2009;37:227–231. doi: 10.1017/S1352465809005116. [DOI] [PubMed] [Google Scholar]
- 24.Olivares J, Garcia_Lopez LJ, Hidalgo MD. The Social Phobia Scale and the Social Interaction Anxiety Scale: Factor structure and reliability in a Spanish speaking population. Journal of Psycho educational Assessment. 2001;19:69–80. [Google Scholar]
- 25.Janssen I, Hanssen M, Bak M, et al. Discrimination and delusional ideation. Br J Psychiatry. 2003;182:71–76. doi: 10.1192/bjp.182.1.71. [DOI] [PubMed] [Google Scholar]
- 26.Drake RE, Mueser K, McHugo G. Clinical Rating Scales. In: Sederer L, Dickey B, editors. Outcomes assessment in clinical practice. Baltimore: Williams and Wilkins; 1996. pp. 113–116. [Google Scholar]
- 27.Cornblatt B, Neindam T, Auther A, Smith C, Johnson JCT. Validation of two new measures of functional outcome in the schizophrenia prodrome. Schizophrenia Bulletin. 2007 [Google Scholar]