The effects of childhood abuse on self-reported psychotic symptoms in severe mental illness: Mediating effects of posttraumatic stress symptoms
Introduction
Childhood abuse has been widely accepted as a significant risk factor for psychological problems. In particular, persistent and repeated experience of abuse particularly when it is interpersonal in nature, has been found to exert a more negative effect on mental health compared to non-interpersonal trauma or single episode trauma (Pietrek et al., 2013). Childhood abuse has been linked as a risk factor to a number of psychiatric disorders in adulthood including depression (Widom et al., 2007, Nanni et al., 2011), substance use (Banducci et al., 2014), and posttraumatic stress disorder (MacMillan et al., 2001, Stevens et al., 2013, Weiss et al., 2013). Until recently, most of the studies examining the link between childhood abuse and adulthood outcomes focused primarily on nonpsychotic disorders (Maniglio, 2011, Nanni et al., 2011).
There is growing interest in the effects of childhood abuse in severe mental illness (SMI) which is believed to have a greater biogenetic basis. The risk for developing SMI increases up to 33% following childhood abuse (Kessler et al., 2010) and this significant role of childhood abuse remains even after controlling for the presence of psychiatric illness in the parent (Husted et al., 2010). A meta-analysis of 10 prospective studies indicates that exposure to childhood abuse significantly increases the risk for the development of psychosis (Varese et al., 2012). In addition, patients diagnosed with depression with co-occurring psychosis report significantly more physical and sexual abuse (Gaudiano and Zimmerman, 2010).
Childhood abuse has been suggested as a predictor of psychosis later in life that often occur in a dose-response manner, suggesting that psychosis worsens as the severity of abuse increases (Janssen et al., 2004, Schenkel et al., 2005). Studies have found that childhood abuse was related to more severe symptoms, greater aggressive tendencies, earlier onset, more frequent recurrence, and lower functional status in severe mental illness such as schizophrenia spectrum disorders, bipolar disorder, and psychotic major depression (Goldberg and Garno, 2005, Larsson et al., 2013b). In particular, experience of abuse was associated with more significant positive symptoms, a primary focus of clinical interest in determining severity of psychosis (DeRosse et al., 2014). Childhood abuse is also related to more significant hallucinatory symptoms in both schizophrenia and bipolar disorder (Janssen et al., 2004). However, a majority of these studies utilized a relatively small sample and focused primarily on individuals with a specific psychiatric diagnosis, leading to the difficulty generalizing the results to wider diagnostic groups presenting with psychosis.
In a large-scale national survey of all diagnostic groups exhibiting symptoms of psychosis in Australia, Shah et al. (2014) found that those who had experienced childhood abuse manifested significantly more clinical symptoms such as hallucination, suicidal ideation, anxiety, premorbid personality disorder, and substance abuse. Interestingly, when demographic variables, premorbid functioning level, and problems in physical health were examined together in multiple logistic regression analyses, the effects of childhood abuse were significant only in accounting for self-reported symptoms of thought disorder. This suggests that in addition to more overt signs of psychosis such as hallucination, more covert signs of disturbed cognitive and thought processes may also be implicated. Although more research is needed to conclude whether childhood abuse is associated with a wide spectrum of psychotic symptoms in a diverse sample representing different psychotic disorders, subjectively experienced psychotic symptoms may also be clinically relevant following childhood abuse.
Furthermore, only a limited number of studies examined the mechanism that potentially mediates the relationship between childhood abuse and psychosis. For example, Lardinois et al. (2011) reported that childhood trauma increases sensitivity to stress and that the interaction between childhood trauma and daily stress affects the intensity of negative emotions and symptoms of psychotic patients. Childhood abuse is widely believed to be a type of childhood trauma and as such PTSD has often been mentioned when discussing the frequent report of childhood abuse in psychotic patients. Experience of childhood abuse in patients with SMI ranges from 11% to 66% and comorbidity with PTSD is also high at 14–53% (Kessler et al., 2005; Grubaugh et al., 2011). In addition, quality of life in patients with SMI with co-existing PTSD is significantly lower than those without PTSD and greater substance use and other psychosocial dysfunction and severity of symptoms are also reported (Ford et al., 2007). Indeed, posttraumatic stress symptoms often occur with psychosis (Romme and Escher, 2006). Such findings suggest that traumatic experiences may play a role in the development of psychosis. One explanation may be that traumatic experiences lead to co-existing PTSD symptoms and psychosis in adulthood (Muenzenmaier et al., 2005).
In spite of the growing interest in the effects of childhood abuse and PTSD in patients with SMI, the specific role of posttraumatic stress symptoms in the relationship between childhood abuse and psychosis has not been found. Mueser et al. (2002) proposed a theoretical model wherein PTSD directly and indirectly mediates the course from childhood abuse to SMI. Childhood abuse was associated with greater PTSD symptoms while PTSD symptoms and symptoms of dissociation predicted the presence of positive symptoms. As a type of PTSD symptoms, dissociative response has also been examined in relation to the association between childhood abuse and SMI. For instance, patients with schizophrenia who experienced childhood abuse manifested more dissociative symptoms, and more dissociative symptoms positively correlated with more significant positive and negative symptoms (Holowka et al., 2003).
Most of the current research report a significant effect of childhood abuse and PTSD on psychosis using correlational or regression analyses. Such analyses make it difficult to delineate the potential mediating effects of PTSD symptoms. Secondly, majority of studies targeted only patients diagnosed with schizophrenia. Thus, the aim of the present study was to examine the mediating role of posttraumatic stress symptoms in the relationship between childhood abuse and degree of psychosis in a sample of patients with SMI using structural equation modeling. Based on the findings of prior studies that found that while posttraumatic stress symptoms predicted psychosis in nonpsychotic patients more significantly compared to patients diagnosed with schizophrenia, and that when other risk factors were controlled for, the effects of childhood abuse was significant only in affecting self-reported symptoms of thought disorder in individuals with psychosis (Vogel et al., 2009), we chose to focus on self-reported symptoms of psychosis. Furthermore, as a recent meta-analysis found that childhood abuse is related to psychosis regardless of the type of psychotic disorder (Varese et al., 2012), we sought to investigate this finding by including a wide range of psychiatric conditions that may exhibit symptoms of psychosis such as schizophrenia spectrum disorders, bipolar disorders, major depressive disorder with psychosis in our structural equation modeling to examine the mediational model.
Section snippets
Participants and procedure
A total of 126 adult psychiatric inpatients (female=70; male=56) at a university hospital with symptoms of psychosis and who received a severe mental illness (SMI) diagnosis participated in the present study. Upon admission to the inpatient ward, patients underwent routine comprehensive psychological evaluation within one week of their admission. Those individuals who provided informed consent to participate in the present study completed the Korean Childhood Trauma Questionnaire (Yu et al.,
Sample characteristics
Diagnostic grouping was as follows: 60 participants diagnosed with schizophrenia (47.6%), 32 diagnosed with bipolar disorder with psychotic features (25.4%), 12 with major depressive disorder with psychotic features (9.5%), 9 diagnosed with schizoaffective disorder (7.1%), and 13 participants diagnosed with delusional disorder, schizophreniform disorder, and psychotic disorder not otherwise specified (10.3%). The mean age of the sample was 36.14 years (SD=13.79). Of the participants, 51
Discussion
The mediating effect of posttraumatic symptoms in the relationship between childhood abuse and psychotic symptoms was tested using structural equation modeling in a sample of inpatients with psychosis. Whereas extant research typically focused on particular diagnostic groups and the effects of childhood abuse on clinician-rated symptoms of psychosis such as hallucinations or delusions, we included a more diverse spectrum of diagnoses within the severe mental illness spectrum thought to be
Funding information
No funding source existed in the present research.
Competing interests
The authors declare that they have no competing interests.
Contributors
J.Y. Choi and S.H. Park carried out the conception, design, analysis and writing of the manuscript. Y. M. Choi, B. Kim, D. W. Lee, and M. S. Gim participated in its design and helped to draft the manuscript. All authors read and approved the final manuscript.
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