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Impact of childhood adversities on specific symptom dimensions in first-episode psychosis

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Background: The relationship between childhood adversity (CA) and psychotic disorder is well documented. As the adequacy of the current categorical diagnosis of psychosis is being increasingly questioned, we explored independent associations between different types of CA and specific psychotic symptom dimensions in a well-characterized sample of first-episode psychosis (FEP) patients. Method: This study involved 236 FEP cases aged 18-65 years who presented for the first time to psychiatric services in South London, UK. Psychopathology was assessed with the Positive and Negative Syndrome Scale and confirmatory factor analysis was used to evaluate the statistical fit of the Wallwork/Fortgang five-factor model of psychosis. CA prior to 17 years of age (physical abuse, sexual abuse, parental separation, parental death, and being taken into care) was retrospectively assessed using the Childhood Experience of Care and Abuse Questionnaire. Results: Childhood sexual abuse [β = 0.96, 95% confidence interval (CI) 0.40-1.52], childhood physical abuse (β = 0.48, 95% CI 0.03-0.93) and parental separation (β = 0.60, 95% CI 0.10-1.11) showed significant associations with the positive dimension; while being taken into care was associated with the excited dimension (β = 0.36, 95% CI 0.08-0.65), independent of the other types of CA. No significant associations were found between parental death and any of the symptom dimensions. Conclusions: A degree of specificity was found in the relationships between different types of CA and psychosis symptom dimensions in adulthood, suggesting that distinct pathways may be involved in the CA-psychosis association. These potentially different routes to developing psychosis merit further empirical and theoretical exploration.
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Impact of childhood adversities on specic symptom
dimensions in rst-episode psychosis
O. Ajnakina
1
, A. Trotta
1
, E. Oakley-Hannibal
1
, M. Di Forti
2,3
, S. A. Stilo
1
, A. Kolliakou
4
,
P. Gardner-Sood
1
, F. Gaughran
1,3
, A. S. David
1,3
, P. Dazzan
1,3
, C. Pariante
3,4
, V. Mondelli
3,4
,
C. Morgan
3,5
, E. Vassos
2
, R. M. Murray
1,3
and H. L. Fisher
2
*
1
Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
2
MRC Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
3
National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust
and Kings College London, London, UK
4
Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
5
Centre for Epidemiology and Public Health, Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience,
Kings College London, London, UK
Background. The relationship between childhood adversity (CA) and psychotic disorder is well documented. As the ad-
equacy of the current categorical diagnosis of psychosis is being increasingly questioned, we explored independent asso-
ciations between different types of CA and specic psychotic symptom dimensions in a well-characterized sample of
rst-episode psychosis (FEP) patients.
Method. This study involved 236 FEP cases aged 1865 years who presented for the rst time to psychiatric services in
South London, UK. Psychopathology was assessed with the Positive and Negative Syndrome Scale and conrmatory
factor analysis was used to evaluate the statistical t of the Wallwork/Fortgang ve-factor model of psychosis. CA
prior to 17 years of age (physical abuse, sexual abuse, parental separation, parental death, and being taken into care)
was retrospectively assessed using the Childhood Experience of Care and Abuse Questionnaire.
Results. Childhood sexual abuse [β = 0.96, 95% condence interval (CI) 0.401.52], childhood physical abuse (β = 0.48,
95% CI 0.030.93) and parental separation (β = 0.60, 95% CI 0.101.11) showed signicant associations with the positive
dimension; while being taken into care was associated with the excited dimension (β = 0.36, 95% CI 0.080.65), independ-
ent of the other types of CA. No signicant associations were found between parental death and any of the symptom
dimensions.
Conclusions. A degree of specicity was found in the relationships between different types of CA and psychosis symp-
tom dimensions in adulthood, suggesting that distinct pathways may be involved in the CApsychosis association. These
potentially different routes to developing psychosis merit further empirical and theoretical exploration.
Received 13 May 2015; Revised 14 August 2015; Accepted 25 August 2015
Key words: Child abuse, dimensions, factor analysis, rst-episode psychosis, maltreatment.
Introduction
The prevalence of adverse childhood events, such as
childhood sexual abuse (CSA) or childhood physical
abuse (CPA), in the general public is surprisingly
high with estimates of up to a quarter of all children
affected in high-income countries (Gilbert et al. 2009;
Radford et al. 2013). CSA and CPA are often consid-
ered the most toxic forms of childhood adversity
(CA); however, in recent years, death of a signicant
other, separation from a parent gure and placement
in institutional care during early childhood have also
been recognized as having detrimental consequences
for mental health (Read et al. 2005; Morgan et al.
2007; Read & Bentall, 2012). Some have attempted to
claim that, assuming causality, one-third of new
cases of psychotic disorders may be attributable to
CA (Dvir et al. 2013).
Despite this intriguing research, pathogenic mechan-
isms that link CA to psychotic disorders are not well
understood (Bentall et al. 2014). This may be due to
existing studies predominantly utilizing the traditional
diagnostic categories of psychosis, the adequacy of
which has increasingly been questioned (Costello,
1992; van Os et al. 1999; Cuthbert, 2014). Instead it
has been postulated that the phenomenology of
* Address for correspondence: H. L. Fisher, MRC Social, Genetic &
Developmental Psychiatry Centre, Institute of Psychiatry, Psychology
& Neuroscience, Kings College London, 16 De Crespigny Park,
London SE5 8AF, UK.
(Email: helen.2.sher@kcl.ac.uk)
Psychological Medicine, Page 1 of 10. © Cambridge University Press 2015
doi:10.1017/S0033291715001816
ORIGINAL ARTICLE
psychosis may be better conceptualized by symptom
dimensions (Kay & Sevy, 1990; van Os et al. 1996,
1999). The importance of symptom proles (van Os
et al. 1999; Dikeos et al. 2006) and their superiority
over diagnostic categories at predicting clinical course
and outcome of psychosis has been demonstrated (van
Os et al. 1996; Demjaha et al. 2009). In terms of research
into the associations between CA and psychosis, appli-
cation of symptom dimensions may increase the statis-
tical power to detect associations over categories
especially where the categories may lack validity.
However, research conducted in rst-episode psych-
osis (FEP) cases where symptomatology is not affected
by differences in clinical practice, hospitalization and
treatment choices is still lacking (Emsley et al. 2003;
Demjaha et al. 2009). Existing research has most fre-
quently identied multidimensional models with ve
factors (Bell et al. 1994; Lindenmayer et al. 1994;
White et al. 1997; Lançon et al. 1998; Emsley et al.
2003). Based on previous work, Wallwork et al. (2012)
derived a consensus ve-factor model of psychosis
that comprised positive (e.g. delusions, hallucinatory
behaviour), negative (e.g. blunted affect, emotional
withdrawal), disorganized/concrete (e.g. conceptual
disorganization, difculty in abstract thinking), excited
(e.g. excitement, hostility) and depressed (e.g. depres-
sion, guilt feelings) dimensions. This Wallwork/
Fortgang ve-factor model has been shown to be the
most robust Positive and Negative Syndrome Scale
(PANSS) factorial solution for exploring symptom
proles in FEP patients (Langeveld et al. 2013) and
thus is the factorial model we chose to utilize in the
current study.
In the present study we conducted conrmatory fac-
tor analyses (CFAs) of the Wallwork/Fortgang
ve-factor model (Wallwork et al. 2012) using data
from a relatively large and well-characterized sample
of patients presenting to psychiatric services for the
rst time with psychosis. We then aimed to examine
independent associations between different types of
CA (physical abuse, sexual abuse, parental separation,
parental death, and being taken into care) and each of
these specic psychotic symptom dimensions.
Previously an association of childhood trauma with
psychotic disorder has been demonstrated in this sam-
ple (Trotta et al. 2015). Given previous research that has
explored associations between CA and individual
symptoms of psychosis and schizotypy, we hypothe-
sized that all forms of CA would be associated with
the positive dimension (Read et al. 2003; Janssen et al.
2004; Whiteld et al. 2005; Schürhoff et al. 2009;
Bentall et al. 2012; Stilo et al. 2013; Velikonja et al.
2015). As there is a consistent body of literature linking
CSA with depression (e.g. Bifulco et al. 1991; Kendler &
Aggen, 2014; Sitko et al. 2014), we also hypothesized
that this type of CA would be associated with the
depressed symptom dimension.
Method
Sample
Participants were recruited as part of the Biomedical
Research Centre Genetics and Psychosis (GAP) study,
a large casecontrol study conducted in South
London, UK. The study included patients aged 1865
years who presented to psychiatric wards in the
South London and Maudsley National Health Service
(NHS) Foundation Mental Health Trust between
January 2006 and October 2010 with a rst episode
of psychosis [International Classication of Diseases
(ICD-10) codes F20F29 and F30F33] (World Health
Organization, 1992). Exclusion criteria were: (1) evi-
dence of psychotic symptoms precipitated by an
organic cause; (2) transient psychotic symptoms result-
ing from acute intoxication as dened by ICD-10; (3)
head injury causing clinically signicant loss of con-
sciousness; (4) under the age of 18 or over 65 years;
and (5) learning disability (intelligence quotient < 70).
The original GAP sample comprised 339 FEP patients;
of these, symptom data were available for 236 patients
(69.6% of the original GAP sample). Therefore, the data
we present here are based on these 236 patients for
whom we had complete symptom data.
Ethics
The GAP study was granted ethical approval by the
South London and Maudsley and Institute of
Psychiatry Local Research Ethics Committee (reference
number: 05/Q0706/158). All cases gave informed writ-
ten consent after reading a detailed information
sheet. 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.
Assessments
Sociodemographic characteristics
The Medical Research Council Socio-demographic
Schedule modied version was utilized to collect
data on sociodemographic characteristics (Mallett
et al. 2002). Ethnicity was self-ascribed using the 16 cat-
egories employed by the 2001 UK Census (http://www.
ons.gov.uk/ons/guide-method/census/census-2001/index.
html). Due to small numbers in some ethnic categories,
we combined them into three broad ethnic groups:
white (all white groups); black (all black groups); and
other (encompassing Asian, mixedethnicityandother
2 O. Ajnakina et al.
ethnicities). Lifetime history of alcohol use prior to the
onset of psychosis was collated using the Alcohol Use
Disorders Identication Test (Babor et al. 1992)and
was split into ever used alcohol (1) v. never used alcohol
(0). Lifetime use of cannabis and other illegal substances
prior to the onset of psychosis was assessed with the
Cannabis Experience Questionnaire modied version
(Di Forti et al. 2009). Patients were divided into those
whoreportedeverhavingusedcannabis(1)andthose
who reported never having used it (0). Similarly, use of
any other illegal substances was coded as ever used (1)
v. never used (0). The Family Interview for Genetic
Studies (https://www.nimhgenetics.org/interviews/gs)
andclinicalrecordswereusedtoobtaininformation
about patients family history of mental health problems.
A family history of psychosis variable was derived fol-
lowing consensus diagnoses based on the available infor-
mation and referred to the presence (1) or absence (0) of a
currentorpastpsychoticdisorderinatleastone
rst-degree relative.
Clinical presentation
Duration of untreated psychosis (DUP) was deter-
mined from the assessment interview and mental
health records and dened as the difference between
the date of the appearance of the rst positive psy-
chotic symptom [hallucination, delusion or thought
disorder rated as 4 or higher on the PANSS (Kay
et al. 1987) as per Singh et al. 2005] and date of rst
contact with mental health services for psychosis
(Morgan et al. 2006). Diagnoses were made from inter-
views and mental health records utilizing the
Operational Criteria Checklists (McGufn et al. 1991).
In the present study, diagnoses were grouped using
ICD-10 codes into schizophrenia-spectrum (F20F29),
affective psychoses (F30.2, F31.2, F31.5, F32.3 or
F33.3) and other psychoses (F10, F53).
CA
CA was assessed using the Childhood Experience of
Care and Abuse Questionnaire (CECA.Q; Bifulco
et al. 2005), which was read out to participants during
a face-to-face interview. The CECA.Q is a self-report
instrument developed to retrospectively assess CA
that occurred before 17 years of age. In this study,
the focus was on ve forms of CA that have been pro-
posed to play an important role in the aetiology of
psychosis: (i) physical abuse inicted by either one or
both parent gures; (ii) sexual abuse perpetrated by
an individual at least 5 years older than the victim;
(iii) separation from either or both parent gures for
a period of at least 6 months; (iv) death of either or
both parent gures; and (v) being taken into care by
the authorities. Full details of this measure are
provided elsewhere (Bifulco et al. 2005; Fisher et al.
2010). Briey, the CPA and CSA sections begin with
screening questions where the positive responses are
followed up with more detailed questions. In order
to establish the severity of CPA experienced, the four
follow-up questions are designed to elicit more
detailed information on the frequency of attacks, sever-
ity of the injuries sustained and whether the perpetra-
tor was out of control. For CSA, the seven additional
probes inquire about degree of sexual contact, relation-
ship to perpetrator, and frequency of occurrence. The
items for each type of abuse are summed separately
to obtain a total CPA score and a total CSA score.
Full scoring guidance and a copy of the measure are
available (www.cecainterview.com). To ensure that
the CECA.Q scores reected a reasonable level of
severity in the analysis, the total scores for the
CPA and CSA subscales were dichotomized using
the most conservative published cut-points (Bifulco
et al. 2005). This measure has been shown to have
good psychometric properties in patients with psychosis
(Fisher et al. 2011).
Psychotic symptoms
The PANSS (Kay et al. 1987) was completed in
face-to-face interviews with the patients to assess
psychotic symptoms over the week preceding the as-
sessment. The 30 items are each rated on a seven-point
scale (1 = absent, 7 = extreme) and grouped into three
subscales: positive symptoms (seven items), negative
symptoms (seven items) and general psychopathology
(16 items).
Analysis
All analyses were conducted in STATA release 12
(STATACorp LP, USA). CFA was conducted to evalu-
ate the statistical t (Stefanovics et al. 2014) of the
Wallwork/Fortgang ve-factor model of psychosis
(Wallwork et al. 2012) in this sample of patients with
FEP. This model comprises positive (i.e. P1, P3, P5,
G9), negative (i.e. N1, N2, N3, N4, N6 and G7), disor-
ganized/concrete (i.e. P2, N5, G11), excited (i.e. P4, P7,
G8 and G14) and depressed (i.e. G2, G3 and G6) fac-
tors. The factors identied by the Wallwork/Fortgang
ve-factor model were entered as latent variables in
the CFA and the PANSS items were entered as
observed variables. The goodness-of-t index statistics
were used to determine the adequacy of t of the
model. These included the comparative t index
(CFI; values greater than 0.90 indicate good model
t), the root mean square error of approximation
(RMSEA; values less than 0.06 indicate good model
t) and the standardized root mean square residual
(SRMR; values less than 0.08 indicate good model t)
Childhood adversities and specic symptom dimensions in psychosis 3
(Stefanovics et al. 2014). To assess the improvement in
the t of the model, correlated measurement errors
were introduced into the model based on signicantly
correlated residuals indicated by modication indices
(Liemburg et al. 2013).
Following CFA, factor scores for each of the ve
symptom dimensions were calculated for each patient
using STATAs predict post-estimation command.
The distributions of the obtained symptom dimensions
were examined and found to be normally distributed
(see online Supplementary Figs S1S5), thus meeting
criteria for linear regression analysis. Linear regression
was utilized to examine associations between each
type of CA and the continuous symptom dimension
scores. This set of analyses was controlled for age at
rst contact with mental health services for psychosis,
gender, ethnicity, lifetime use of alcohol, cannabis or
other illegal substances prior to psychosis onset, and
family history of psychosis. To explore whether the
relationships were independent of the effects of other
forms of CA, the identied signicant associations
were re-examined additionally controlling for the
other types of CA.
Results
Sample characteristics
Of the patients recruited to the GAP study (n = 339), the
PANSS was completed for 236 patients (69.6%). This
subsample with PANSS ratings did not differ signi-
cantly from the full GAP sample in terms of gender
(χ
2
= 0.41, p = 0.52), ethnicity (χ
2
= 3.29, p = 0.19) and
DUP (in days) (t = 0.37, p = 0.99); however, those
patients without the PANSS tended to be older (t =
1.97, p = 0.05) (online Supplementary Table S1).
Data on demographic characteristics, clinical presen-
tation and prevalence of CA for our sample are pre-
sented in Table 1. The mean age at rst contact was
29 (SD = 9.1) years and the majority of the sample
were men (64.8%). Around one-third (35.2%) was of
white and 40.2% of black ethnicity. Just over two-thirds
of the cases were diagnosed with schizophrenia-
spectrum disorders (68.8%) and a quarter with affect-
ive psychoses (26.8%). The most common type of CA
reported was separation from one or both parent
gures (34.9%), followed by CPA (27.2%). Being placed
into care by the authorities before 17 years of age was
the least prevalent adversity (9.6%).
CFA
CFA was conducted in the current sample with the
Wallwork/Fortgang ve-factor model of PANSS
items. The means and standard deviations of the actual
PANSS scores are presented in online Supplementary
Table S2. When the correlated residuals (i.e. measure-
ment errors) were not introduced into the model the
results of the CFA indicated a poor model t: CFI =
0.767, RMSEA = 0.101 [95% condence interval (CI)
0.0920.111] and SRMR = 0.111. However, once signi-
cantly correlated residuals were incorporated into the
model, the CFA produced an excellent t of the
model [CFI = 0.959, RMSEA = 0.052 (95% CI 0.037
0.067) and SRMR = 0.071]. Scores for all ve symptom
dimensions appeared to be normally distributed (on-
line Supplementary Figs S1S5).
Average symptom dimension scores by type of CA
The mean symptom dimension scores for each of the
ve types of CA are illustrated in Fig. 1. Those patients
who reported parental separation, relative to those
who did not experience this type of CA, had a higher
mean score for the positive dimension. Similarly,
those patients who reported CSA and those who
Table 1. Demographic and clinical characteristics of the sample and
distribution of type of childhood adversity
Characteristics n (%)
Mean age at rst contact, years (
S.D.) 28.7 (9.1)
Gender
Female 83 (35.2)
Male 153 (64.8)
Ethnicity
White: all groups 83 (35.2)
Black: all groups 95 (40.2)
Other 58 (24.6)
Diagnosis
Schizophrenia spectrum 154 (68.8)
Affective psychosis 60 (26.8)
Other psychotic disorders 10 (4.5)
Death of one or both parents
No 208 (89.7)
Yes 24 (10.3)
Separation from one or both parents
No 151 (65.1)
Yes 81 (34.9)
Physical abuse by either or both parents
No 169 (72.8)
Yes 63 (27.2)
Sexual abuse
No 207 (87.7)
Yes 29 (12.3)
Taken into care
No 178 (90.4)
Yes 19 (9.6)
Data are given as number (percentage) unless otherwise
indicated.
S.D., Standard deviation.
4 O. Ajnakina et al.
reported CPA had higher mean scores for the positive
symptom dimension as well as lower mean scores for
the negative symptom dimension compared with
patients who did not report these forms of CA. Apart
from the depressed dimension, the severity of the
other four symptom dimensions was more pro-
nounced among those who were placed in institutional
care before the age of 17 years compared with those
who were not. This was particularly the case for the
positive and disorganized/concrete dimensions.
Among those who had one or both parents die before
they turned 17 years, the mean score for the disorga-
nized/concrete dimension was slightly higher than
for those patients who did not experience parental loss.
Associations between CA and symptom dimensions
Unstandardized βs from regression analyses of the
associations between each type of CA and symptom
dimension scores are shown in Table 2. There was a
signicant association between CSA and the positive
dimension, indicating that those individuals who
experienced this form of CA scored on average 0.90
higher on the positive dimension than those who did
not report CSA. Similarly, there was a signicant but
substantially weaker association of CSA with the
excited dimension (β = 0.22). Although neither of the
95% CIs for these associations contained the point esti-
mate of the other association, there was some overlap
between the CIs indicating that CSA could not be
said to be independently associated with both the posi-
tive and excited dimension. Reported exposure to CPA
was associated with signicant increases in average
scores on the positive, disorganized/concrete and
excited symptom dimensions compared with those
who did not report this form of CA. However, the
CIs for these associations overlapped and contained
the point estimates, thus suggesting that CPA was
not independently associated with these three symp-
toms dimensions. Those who were taken into care
showed an average increase of 0.49 on the disorga-
nized/concrete and 0.40 on the excited dimensions
Fig. 1. Mean psychosis symptom dimension scores for each type of childhood adversity among rst-episode psychosis
patients. The continuous symptom dimension scores were derived using the predict post-estimation command in Stata
following a conrmatory factor analysis of the Wallwork/Fortgang ve-factor model (Wallwork et al. 2012) of the items from
the Positive and Negative Syndrome Scale (Kay et al. 1987). The ve dimensions capture positive, negative, disorganized/
concrete (disorgan/conc), excited, and depressed symptom items at rst presentation to psychiatric services. Childhood
adversities reported by patients as occurring prior to 17 years of age have been dichotomized into yes (present) v. no
(absent) according to published guidelines (Bifulco et al. 2005).
Childhood adversities and specic symptom dimensions in psychosis 5
compared with those patients who did not report this
form of CA. Again there was no evidence of independ-
ent associations with these two symptom dimensions.
Additionally, experience of parental separation was
associated with a signicant increase of 0.51 in the
average score on the positive dimension.
To explore whether these signicant associations
were truly independent of the effects of other forms
of CA, each signicant relationship was reanalysed
additionally controlling for the remaining types of
CA. The relationship between parental separation
and the positive symptom dimension remained signi-
cant (β = 0.60, 95% CI 0.101.11). Although the magni-
tude of the relationship between CPA and the positive
dimension weakened it remained signicant (β = 0.48,
95% CI 0.030.93). The association of CSA with the
positive dimension was also robust to adjustment for
other types of CA and remained signicant (β = 0.96,
95% CI 0.040.64). Finally, the association between
being taken into care and the excited dimension
retained signicance (β = 0.36, 95% CI 0.080.65). All
other associations were attenuated and failed to reach
the conventional 0.05 level of statistical signicance.
Discussion
In the present study of FEP patients we have identied
independent and robust associations between three
forms of CA (CSA, CPA and parental separation)
and the positive psychosis symptom dimension from
the Wallwork/Fortgang ve-factor consensus model
of psychosis. Additionally, placement in institutional
care before the age of 17 years was signicantly asso-
ciated with the excited dimension, independent of
the other forms of adversity. However, no signicant
associations were found between parental death and
any of the symptom dimensions.
Methodological considerations
A major strength of the current study is that it is the
rst study to have examined the relationships between
several speci c forms of CA and symptom dimensions
in a sample of FEP patients. The ve-factor model of
psychosis symptoms employed in the present study
was selected for being a consensus model derived
from existing studies (Wallwork et al. 2012) that has
been shown to be optimal for use in FEP samples
(Langeveld et al. 2013). This will probably facilitate
the comparability of our results with those obtained
in future studies. The symptom dimensions were
founded on the PANSS which has previously been
shown to be resilient to the effects of age, severity of
symptoms, chronicity of illness (White
et al. 1997)
and short-term medication withdrawal (Lindenmayer
Table 2. Associations between types of childhood adversity and the Wallwork/Fortgang continuous ve-factor psychosis symptom dimension scores
a
Type of childhood adversity
Negative Positive Excited Depressed Disorganized/concrete
β (S.E.) 95% CI β (S.E.) 95% CI β (S.E.) 95% CI β (S.E.) 95% CI β (S.E.) 95% CI
Death of one or both parents 0.17 (0.23) 0.29 to 0.63 0.17 (0.34) 0.83 to 0.49 0.01 (0.13) 0.27 to 0.25 0.07 (0.15) 0.22 to 0.36 0.19 (0.23) 0.26 to 0.64
Separation from one or both
parents
0.20 (0.16) 0.52 to 0.11 0.51 (0.23)* 0.06 to 0.96 0.04 (0.09) 0.14 to 0.21 0.12 (0.10) 0.31 to 0.08 0.25 (0.15) 0.06 to 0.55
Physical abuse by either or
both parents
0.03 (0.16) 0.29 to 0.35 0.62 (0.23)*** 0.18 to 1.07 0.20 (0.09)* 0.02 to 0.37 0.02 (0.10) 0.21 to 0.18 0.39 (0.15)** 0.09 to 0.69
Sexual abuse 0.17 (0.21) 0.57 to 0.24 0.90 (0.28)*** 0.34 to 1.46 0.22 (0.11)* 0.003 to 0.45 0.07 (0.13) 0.18 to 0.32 0.17 (0.20) 0.22 to 0.56
Taken into care 0.16 (0.26) 0.35 to 0.66 0.48 (0.36) 0.24 to 1.20 0.40 (0.14)*** 0.13 to 0.67 0.10 (0.16) 0.21 to 0.42 0.49 (0.24)* 0.01 to 0.97
β, Unstandardized linear regression coefcient;
S.E., standard error; CI, condence interval.
a
The analyses are controlled for age at the time of rst contact with mental health services for psychosis, gender, ethnicity, lifetime use of substances (alcohol, cannabis and other
illegal substances) prior to onset of psychosis, and family history of psychosis.
* p < 0.05, ** p < 0.01, *** p < 0.001.
6 O. Ajnakina et al.
et al. 1994). Moreover, the sample utilized in the
present study was a well-characterized sample of
recent-onset patients presenting for the rst time with
psychosis and thus the ndings are not confounded
by chronicity of illness or prolonged medication use.
Additionally, the regression analyses were controlled
for important confounding factors, such as substance
use and proxy genetic risk (Sideli et al. 2012) in add-
ition to age at rst contact with mental health services
for psychosis, gender and ethnicity. Therefore, we can
be more certain that the identied relationships are in-
dependent of the effects of these potentially confound-
ing factors.
However, several methodological issues should be
considered when interpreting the results of this
study. Retrospective accounts of CA were utilized
which could be biased due to forgetting over time
and the reality distortions experienced by many
patients with psychosis (Garety et al. 2001; Lysaker
et al. 2005; Bendall et al. 2008; Vassos et al. 2008).
However, reports of CA obtained retrospectively
from individuals with psychotic disorders have been
shown to be stable over time and unaffected by sever-
ity of psychotic or affective symptoms (Fisher et al.
2011). Second, as we did not have PANSS scores for
the whole sample it is possible that this may have
led to results being affected by selection bias.
However, the comparison analyses between the full
GAP sample and the subsample with PANSS ratings
did not uncover any indication of potential biases. It
is also noteworthy that the PANSS covered only 1
week of symptoms prior to the interview and thus
may not be able to provide the best indicator of the
overall clinical prole of these patients. Finally, the
number of statistical tests carried out was signicantly
sentential; thus we cannot condently rule out the pos-
sibility that some of the associations might have been
due to type I errors.
CA and symptom dimensions
Previously, a 3-fold-increase in odds of psychosis in
those who had reported a history of death of a parent
during childhood has been reported (Stilo et al. 2013).
In the present study, though, this type of CA was not
associated with specic symptom dimensions.
However, the association of CSA with the positive di-
mension was noticeably strong. Population-based
studies have demonstrated that CSA is strongly related
to delusions (Janssen et al. 2004) and hallucinations
(Sitko et al. 2014), though this nding is not consistent
across all studies (Read et al. 2005). Similarly, there was
a robust signicant association between parental separ-
ation and the positive symptom dimension. The patho-
genic mechanism underlying these relationships could
be explained in terms of attachment theory (Levy,
2013). Accordingly, CSA and prolonged separation
from parents may be considered as a profound failure
to provide the security required for the development of
a secure attachment, triggering intense fears and pro-
found anxieties (Smith et al. 2012
). These in turn have
been linked to emotional over-reactivity to stressful ex-
ternal stimuli (Collip et al. 2008), leading to impaired
rational cognition (Garety et al. 2001) and increased
paranoid thoughts (Sitko et al. 2014; Wickham et al.
2015). Additionally, parental separation during the
early years of childhood is also tied to other important
adverse experiences, such as family conict, nancial
burden and neglect (Rutter, 2006), which may be risk
factors increasing vulnerability to positive symptoms
of psychosis. Furthermore, a signicant relationship be-
tween CPA and the positive dimension of psychosis
may indicate that a constant anticipation of threat or vio-
lence may lead to the onset of delusions, unusual
thought processes and hallucinations (Bentall et al. 2008).
In our study we found a signicant association be-
tween being taken into care and the excited symptom
dimension. This is consistent with previous research
indicating associations between childhood maltreat-
ment and the onset of symptoms related to this dimen-
sion (Gilman et al. 2015) and bipolar disorder (Fisher &
Hosang, 2010). Although we did not nd independent
associations between other forms of adversity and the
excited dimension in this study, it is possible that being
taken into care represents the more severe end of the
spectrum of physical and sexual abuse and/or is cap-
turing extreme experiences of neglect. Indeed CSA
and CPA were initially associated with the excited di-
mension but these relationships were attenuated
when controlling for being taken into care (and the
other adversities) indicating some overlap between
them. Behavioural traits such as hostility, lack of im-
pulse control and uncooperativeness, that comprised
the excited dimension, may have developed due to
these institutionalized children being brought up in a
less structured environment. Indeed, around
two-thirds of youths in one local British child welfare
authority met criteria for conduct disorder (McCann
et al. 1996). These behavioural problems could also
have been the outcome of an abusive or neglectful fam-
ily environment (Jaffee et al. 2004; Sarchiapone et al.
2009). Either way, previous research has shown that
maltreatment that comes to the attention of social ser-
vices (which is likely to result in being taken into care)
is associated with antisocial and impulsive behaviour
(Cohen et al. 2001), that may have been captured by
the excited dimension in this study. It will be import-
ant to explore in other samples whether a similar asso-
ciation is evident in order to rule out the possibility
that our nding was a statistical artefact.
Childhood adversities and specic symptom dimensions in psychosis 7
Conclusion
It has been demonstr ated that physical abuse, sexual
abuse, parental separation and being taken into care be-
fore 17 years of age exhibited associations with particu-
lar symptom dimensions of psychosis in adulthood
independent of important confounding factors and the
other types of adversity investigated. These ndings
add further weight to the suggestion that there may be
distinct pathways from specic forms of CA to particular
types of psychotic symptoms (Bentall et al. 2014)and
these warrant further investiga tion. In terms of clinical
implications, our ndings reiterate the need for a history
of CA to be taken during routine psychiatric assessments
of individuals presenting with psychosis in order to fa-
cilitate meaningful and comprehensive treatment plans
(Read & Bentall, 2012). Eventually, these ndings
might also feed into interventions targeting high-risk
children. Howev er, it remains to be determined whether
the present ndings can be replicated in other FEP sam-
ples when controlling for all potential confounders.
Supplementary material
For supplementary material accompanying this paper
visit http://dx.doi.org/10.1017/S0033291715001816
Acknowledgements
This study was funded by the UK National Institute of
Health Research (NIHR) Biomedical Research Centre
for Mental Health, South London and Maudsley
NHS Foundation Trust; The Institute of Psychiatry,
Psychology & Neuroscience at Kings College
London; The Psychiatry Research Trust; and the
Maudsley Charitable research fund. H.L.F. is sup-
ported by a Fellows Award from the MQ:
Transforming Mental Health charity (grant number:
MQ14F40). The patients included in the present
study were recruited in collaboration with the GAP
and PUMP study teams and the South London and
Maudsley NHS Foundation Trust. We would like to
thank all of the patients who gave up their time to
take part in this study and all of the staff and students
who worked tirelessly to collect the data. This paper
summarizes independent research funded by the
NIHR under its IMPACT Programme (grant reference
number RP-PG-0606-1049). The views expressed are
those of the author(s) and not necessarily those of the
NHS, the NIHR or the Department of Health.
Declaration of Interest
R.M.M. has received honoraria from Janssen,
Astra-Zeneca, Lilly, BMS, and is an editor of this
journal (Psychological Medicine). A.S.D. has received
honoraria from Janssen and Roche Pharmaceuticals.
F.G. has received honoraria for advisory work and lec-
tures from Roche, BMS, Lundbeck, and Sunovion and
has a family member with professional links to Lilly
and GSK.
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... The exposure to CA could be associated with more severe psychotic symptoms [11], nevertheless the association between CA and psychotic symptoms among FEP patients received little attention. Some studies showed that FEP patients with early abuse or childhood neglect had more severe psychotic symptoms than FEP patients without CA [5,9,12,13], by contrast other studies showed conflict sfindings [5,9,13,14]. ...
... affective vs non-affective psychosis), site treatment, drug abuse, symptoms severity, childhood adversities co-occurrence. interpretative bias [11,12,37,38]; (2) symptoms were assessed after clinical stabilization had occurred, thus our findings are not biased by the illness acute phase; (3) HPA axis activity was assessed using salivary cortisol, which is a reliable ad non-invasive procedure [39,[40][41][42][43][44][45]. This study has some limitations: (1) it was only possible to evaluate salivary cortisol for some of the patients included in the full study, thus reducing the power of the sample; (2) recall bias may influence the reliability of the retrospective assessment of CAs, although good reliability of retrospective CA evaluation was shown [46,47]; (3) although some findings [25] suggested that cortisol secretion could be related with the length and severity of CA, this issue is not fully investigated in the present study; (4) the sample heterogeneity in terms of diagnosis may lead to interpretative bias; (5) the cross-sectional design of the present study not consent to draw causal inferences in the relationship between CA and psychotic symptoms severity, therefore future longitudinal studies are needed; (6) the level of general functioning of the patients included in the present study was not estimated. ...
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Background: Although it has been proposed that childhood adversities (CAs) may affect the hypothal- amic-pituitary-adrenal (HPA) axis activity and psychotic symptoms severity, these associations have not been fully confirmed in first-episode psychosis (FEP). This study explored the association between CA, cortisol and psychotic symptoms in FEP patients. Methods: 81 FEP patients were enrolled. CAs were evaluated by the Childhood Experience of Care and Abuse Questionnaire and a semi-structured interview. Psychotic symptoms were evaluated by the Positive and Negative Syndrome Scale. Cortisol level was collected using saliva samples. ANCOVA and partial correlation analyses were run. Results: FEP patients with childhood abuse reported severe positive symptoms than those without CA. FEP patients with at least one CA had higher levels of cortisol awaking, cortisol at 12 a.m., and cortisol at 8 p.m. Morning cortisol levels were negatively correlated with the severity of negative symptoms and positively correlated with the severity of general psychopathology. Evening cortisol lev- els were positively correlated with severity of general psychopathology. Conclusion: FEP patients with CAs, compared with those without CA, might report more severe positive symptoms and higher cortisol, even though these findings as prone to bias due to the small sample size, and should be seen in the larger perspective of conflicting evidence in the field.
... We did not find differences in symptoms (PANSS factors) between groups. A previous study by Ajnakina et al., 51 in a sample of 236 patients with first episode of psychosis, reported an association between positive symptoms and child sexual abuse, physical abuse, and parental separation. They also found more symptoms of excited dimension in people that were being taken into care in childhood. ...
... In previous studies, social cognition has been shown to be a trait marker 57 that is present in early stages 58 and independent of the course of the illness. 59,60 In line with other studies 25,51,61 we included people with psychotic disorders (DSM-IV TR psychotic codes 295-298). ...
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... In addition, retrospective reports of PTEs could be biased due to forgetting over time and reality distortion experienced by many patients with psychosis [58,59]. Moreover, we did not consider cultural variations in perceptions of trauma (e.g., [60] and whether participants perceived their experiences as traumatic. ...
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Childhood trauma is an important predictor of psychotic disorders, with special emphasis on physical and sexual abuse. It influences the clinical picture and course of psychotic disorders. This study was conducted in the Department of Psychiatry of the University Clinical Hospital Mostar. The sample consisted of 135 participants, aged 18 to 65 years. The screening instrument to examine cognitive status was the short version of MMSE-2. Patients’ background information was collected using a sociodemographic questionnaire constructed for this study. To determine childhood trauma, the Child Abuse Experience Inventory was used to examine physical, sexual, and emotional abuse, neglect and domestic violence. The positive and negative syndrome scale scale was used to evaluate the clinical profile of psychoticism, the SSI questionnaire was used to evaluate the severity of suicidality, and the functionality of the participants was evaluated using the WHODAS 2.0. Results indicate that a significant number of participants with psychotic disorders experienced childhood trauma, an important determinant of their illness. Participants who had witnessed abuse had more severe clinical presentations (earlier onset and longer duration of illness) and more pronounced psychotic symptomatology and a lower degree of functionality. Decreased functionality is associated with witnessing abuse and physical abuse. During the civil war, a significant percentage of the participants were in childhood and adolescent development (26.7%) and exposed to frequent emotional abuse and domestic violence. As 1 traumatic event in childhood makes a person more susceptible to more traumatic experiences during life. Childhood trauma is a serious and pervasive problem that has a significant impact on the development, course, and severity of the clinical presentation of psychotic disorders. Accordingly, it is necessary to provide continuous education to mental health workers, primarily psychiatrists, regarding childhood trauma so that treatment may be approached more systematically and a plan of therapeutic interventions may be more adequately designed, which would necessarily include psychosocial support in addition to pharmacotherapy.
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Background Childhood maltreatment continues to pose a great challenge to psychiatry. Although there is growing evidence demonstrating that childhood maltreatment is an important risk factor for depressive disorders, it remains to be elucidated which specific symptoms occur after exposure to different kinds of childhood maltreatment, and whether certain pathways may account for these associations. Participants and settings A total of 203 adult patients (18–53 years old) with MDD, diagnosed by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, were recruited from the outpatient clinic of Beijing Anding Hospital, Capital Medical University. Methods Childhood maltreatment, depressive symptoms, functional impairment, and quality of life were evaluated by the Childhood Trauma Questionnaire - Short Form (CTQ-SF), 17-item Hamilton Depression Rating Scale (HAMD-17), Sheehan Disability Scale (SDS), and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF). Undirected network analysis was used to explore the most relevant connections between them. Bayesian network analysis was used to estimate a directed acyclic graph (DAG) while investigating the most likely direction of the putative causal association. Results In network analysis, the strongest edges were a positive correlation between emotional abuse and suicidal behavior as well as a negative association between emotional neglect and age of onset. In DAG analysis, emotional abuse emerged as the most pivotal network node, triggering both suicidal behaviors and depression symptoms. Conclusions Emotional abuse appears to be an extremely harmful form of childhood maltreatment in the clinical presentation of depression. This study has promise in informing the clinical intervention of depression.
Article
Previous research has demonstrated significant associations between adverse childhood experiences (ACEs) and risks of psychosis. Further research has examined underlying mechanisms to understand the relationship between these variables. This review aimed to explore the associations between various ACEs and the development of different psychotic symptoms in adulthood. The Cochrane Library, Cinahl, PsychINFO, Medline, Embase, and Web of Science were searched from January 1980 to November 2021 to ensure a systematic review of relevant literature. Poverty, fostering, adoption, childhood emotional and physical neglect, and childhood physical (CPA), sexual (CSA), and emotional abuse (CEA) significantly correlated with delusions. Significant relationships were found between hallucinations and CSA and CPA. Paranoia correlated with violent adversities including CPA, assault, and witnessing killing. Limited associations were identified for thought disorder and negative symptoms. The findings of this review indicate that there may be a degree of specificity between various ACEs and psychotic symptoms, but these findings are subject to some limitations. The findings also demonstrate the importance of inquiring about and addressing ACE in clinical practice to develop formulations and treatment plans for individuals with psychosis.
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Background The association between childhood adversity and psychosis in adulthood is well established. However, genetic factors might confound or moderate this association. Aims Using a catchment-based case–control sample, we explored the main effects of, and interplay between, childhood adversity and family psychiatric history on the onset of psychosis. Method Childhood adversity (parental separation and death, physical and sexual abuse) was assessed retrospectively in 224 individuals with a first presentation of psychosis and 256 community controls from South London, UK. Occurrence of psychotic and affective disorders in first-degree relatives was ascertained with the Family Interview for Genetic Studies (FIGS). Results Parental history of psychosis did not confound the association between childhood adversity and psychotic disorder. There was no evidence that childhood adversity and familial liability combined synergistically to increase odds of psychosis beyond the effect of each individually. Conclusions Our results do not support the hypothesis that family psychiatric history amplifies the effect of childhood adversity on odds of psychosis
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Background: A growing body of research has investigated associations between insecure attachment styles and psychosis. However, despite good theoretical and epidemiological reasons for hypothesising that insecure attachment may be specifically implicated in paranoid delusions, few studies have considered the role it plays in specific symptoms. Method: We examined the relationship between attachment style, paranoid beliefs and hallucinatory experiences in a sample of 176 people with a diagnosis of schizophrenia spectrum disorders and 113 healthy controls. We also investigated the possible role of negative self-esteem in mediating this association. Results: Insecure attachment predicted paranoia but not hallucinations after co-morbidity between the symptoms was controlled for. Negative self-esteem partially mediated the association between attachment anxiety and clinical paranoia, and fully mediated the relationship between attachment avoidance and clinical paranoia. Conclusions: It may be fruitful to explore attachment representations in psychological treatments for paranoid patients. If future research confirms the importance of disrupted attachment as a risk factor for persecutory delusions, consideration might be given to how to protect vulnerable young people, for example those raised in children's homes.
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Purpose Although there is considerable evidence that adversities in childhood such as social deprivation, sexual abuse, separation from parents, neglect and exposure to deviant parental communication are associated with psychosis in later life, most studies have considered broad diagnoses as outcomes. In this review we consider evidence for pathways between specific types of adversity and specific symptoms of psychosis. Methods We present theoretical arguments for expecting some degree of specificity (although by no means perfect specificity) between different kinds of adversity and different symptoms of psychosis. We review studies that have investigated social–environmental risk factors for thought disorder, auditory–verbal hallucinations and paranoid delusions, and consider how these risk factors may impact on specific psychological and biological mechanisms. Results Communication deviance in parents has been implicated in the development of thought disorder in offspring, childhood sexual abuse has been particularly implicated in auditory–verbal hallucinations, and attachment-disrupting events (e.g. neglect, being brought up in an institution) may have particular potency for the development of paranoid symptoms. Current research on psychological mechanisms underlying these symptoms suggests a number of symptom-specific mechanisms that may explain these associations. Conclusions Few studies have considered symptoms, underlying mechanisms and different kinds of adversity at the same time. Future research along these lines will have the potential to elucidate the mechanisms that lead to severe mental illness, and may have considerable clinical implications.
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In treated cohorts, individuals with bipolar disorder are more likely to report childhood adversities and recent stressors than individuals without bipolar disorder; similarly, in registry-based studies, childhood adversities are more common among individuals who later become hospitalized for bipolar disorder. Because these types of studies rely on treatment-seeking samples or hospital diagnoses, they leave unresolved the question of whether or not social experiences are involved in the etiology of bipolar disorder. We investigated the role of childhood adversities and adulthood stressors in liability for bipolar disorder using data from the National Epidemiologic Survey on Alcohol and Related Conditions (n=33 375). We analyzed risk for initial-onset and recurrent DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) manic episodes during the study's 3-year follow-up period. Childhood physical abuse and sexual maltreatment were associated with significantly higher risks of both first-onset mania (odds ratio (OR) for abuse: 2.23; 95% confidence interval (CI)=1.71, 2.91; OR for maltreatment: 2.10; CI=1.55, 2.83) and recurrent mania (OR for abuse: 1.55; CI=1.00, 2.40; OR for maltreatment: 1.60; CI=1.00, 2.55). In addition, past-year stressors in the domains of interpersonal instability and financial hardship were associated with a significantly higher risk of incident and recurrent mania. Exposure to childhood adversity potentiated the effects of recent stressors on adult mania. Our findings demonstrate a role of social experiences in the initial onset of bipolar disorder, as well as in its prospective course, and are consistent with etiologic models of bipolar disorder that implicate deficits in developmentally established stress-response pathways.Molecular Psychiatry advance online publication, 22 April 2014; doi:10.1038/mp.2014.36.
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The Positive and Negative Syndrome Scale (PANSS) is widely used as a method for the assessment of symptoms of schizophrenia but the most complete model of how symptoms are structured has not been determined. Using the methods of confirmatory factor analysis with a large sample of 1233 of schizophrenic subjects this study examined the goodness of fit of 20 previously proposed models. None of these proposed models met criteria for adequate fit to the empirical data. The sample was then stratified and half of the data was used to calibrate a new model. The model was validated in the second half of the data. The new pentagonal model uses 25 of the 30 items of the PANSS in 5 factors: positive, negative, dysphoric mood, activation, and and autistic preoccupation. Patients who varied widely in age, severity, and chronicity of illness did not differ in their overall symptom structure. The results of this study also implicated some problems in the validity of the PANSS as currently configured when used to assess symptoms of schizophrenia.
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• An operational criteria checklist for psychotic illness and computer programs designed to be used in conjunction with it constitute the OPCRIT system. This provides a simple and reliable method of applying multiple operational diagnostic criteria in studies of psychotic illness. The development of the OPCRIT system and an assessment of reliability are described. Diagnostic agreement between three raters is excellent. Item-by-item agreement, although less good, still achieves reasonable reliability despite the problem of low base rates for some items.
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Background: Schizotypy is a complex concept, commonly defined as a genetic vulnerability to schizophrenia that falls on a continuum between healthy variation and severe mental illness. There is a growing body of evidence supporting an association between childhood trauma and increased psychotic experiences and disorders. However, the evidence as to whether there is a similar association with schizotypy has yet to be systematically synthesized and assessed. Method: We conducted a systematic search of published articles on the association between childhood trauma and schizotypy in four major databases. The search covered articles from 1806 to 1 March 2013 and resulted in 17,003 articles in total. Twenty-five original research studies met the eligibility criteria and were included in this review. Results: All 25 studies supported the association between at least one type of trauma and schizotypy, with odds ratios (ORs) ranging between 2.01 and 4.15. There was evidence supporting the association for all types of trauma, with no differential effects. However, there was some variability in the quality of the studies, with most using cross-sectional designs. Individuals who reported adverse experiences in childhood scored significantly higher on positive and negative/disorganized schizotypy compared to those who did not report such experiences. Conclusions: All forms of childhood trauma and other stressful events (e.g. bullying) were found to be associated with schizotypy, with especially strong associations with positive schizotypy. However, because of the methodological limitations of several studies and a lack of further exploration of different possible mechanistic pathways underlying this association, more research is required.