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Trauma Link to Psychosis Is Strengthened

25 June 2005. Does exposure to psychological trauma in childhood—war, natural disasters, child abuse—cause schizophrenia? A new study that assessed childhood trauma, then prospectively measured the appearance of psychotic symptoms, doesn’t answer that question directly, but it suggests that for at least a subset of schizophrenia symptoms, the answer is yes. The work, from Jim van Os at the University of Maastricht, the Netherlands, with Roselind Lieb and Hans-Ulrich Wittchen at Max Planck Institute, Munich, showed a dose-response relationship between the severity of self-reported childhood trauma and later psychoses in a large group of young Germans. The effect of trauma was enhanced in subjects who measured high on a scale of psychotic proneness at the beginning of the study. The results, appearing in the June issue of the British Journal of Psychiatry, support the idea that childhood trauma can promote psychosis later in life, and in particular may bring out or exacerbate symptoms in a subset of susceptible people.

While psychological trauma is clearly associated with depression and other symptoms of post-traumatic stress disorder, a link to psychosis has been unclear. Many previous studies have surveyed populations with existing mental illness and found a high incidence of a history of childhood physical or sexual abuse. To prospectively look for an association between self-reported traumatic experiences and the risk of psychosis, first author Janneke Spauwen and colleagues interviewed 3,021 subjects between 14 and 24 years old at entry to determine their experience of traumatic events. Showing a list of nine horrors ranging from war experience, abuse, rape, and natural catastrophe to a serious accident, the interviewers elicited histories from the subjects. The presence of psychosis or a proneness to psychosis was assessed with a checklist of psychosocial effects, including scales for hallucinations, delusions, paranoia, and psychoticism. Subjects were reassessed an average of 3.5 years later.

The data, based on follow-up of 2,524 men and women, showed that exposure to any trauma at all increased the risk of psychosis, and the effect was strongest for the most stringent definition of psychosis (three or more psychotic symptoms reported vs. zero, one, or two). The odds ratio (adjusted for confounding factors and psychosis proneness at the beginning of the study) was 1.89 (95 percent confidence interval 1.16-3.08) for exposure to any trauma and the occurrence of at least three psychotic symptoms. Beyond the broad categories of trauma, the study did not measure the type of trauma in great detail, except to distinguish severe trauma—engendering feelings of intense fear, helplessness, or horror—which was more strongly associated with later psychosis. The association was the same whether the trauma occurred before age 13 or later in life.

A dose response effect supported the idea that trauma played a causal role in the psychotic symptoms. The odds ratio for psychosis increased with an increasing number of trauma events. The effect of trauma appeared specific for psychosis, as the researchers found no association between self-reported trauma and the occurrence of bipolar disorder or major depression.

Experiencing traumatic events was significantly more likely to produce psychoses in people who scored in the top quartile on tests of psychosis proneness, compared to those in the lower three quarters. The effect size for trauma in those without psychosis proneness was 1.8 percent, while in those with proneness, it was 7 percent. The difference was statistically significant, and showed a synergistic rather than additive effect of childhood trauma on later psychoses in this susceptible group. Of course, the authors concede, childhood abuse itself could affect psychosis proneness, and they did detect a weak interaction between reported trauma at baseline and signs of psychosis proneness.

The results are entirely consistent with many previous retrospective studies showing high levels of childhood abuse and trauma among schizophrenia patients. By relaxing the outcome criteria from a diagnosis of schizophrenia to the presence of any of a broad category of symptoms, the researchers were able in this study to prospectively and convincingly link trauma to a later psychotic state. A handful of other studies have recently used similar designs and along with this report, the results are starting to show a consistent pattern between trauma and psychosis, particularly hallucinations (reviewed in Read et al., 2005). It remains to be seen, however, if the association between trauma and psychotic symptoms also applies to psychotic disorders, including schizophrenia.

More work will be necessary to sort out the mechanisms by which trauma increases the risk of psychosis, but several likely hypotheses exist. Childhood stress affects early brain development, and changes the sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis. This could contribute to the dopamine abnormalities seen in psychosis. It is also possible that traumatic experiences early in life could directly affect dopamine pathways.

In any case, the study reveals childhood trauma as an often-hidden factor that could explain much of the burden of psychosis that occurs outside of major mental disorders. But what about the psychosis of schizophrenia? As van Os and colleagues have written (Read et al., 2005), the practice of classifying psychotic symptoms as PTSD whenever there is clear evidence of trauma may have led clinicians astray and hindered studies on the possible role of trauma in raising the risk of schizophrenia-like disorders. The current work bolsters the case for taking a symptom-centric view of stress-related mental illnesses, especially in light of the fact that different diagnoses, including post-traumatic stress disorder and schizophrenia, involve common psychotic hallmarks like hallucinations and paranoia.—Pat McCaffrey.

Spauwen J, Krabbendam L, Lieb R, Wittchen HU, van Os J. Impact of psychological trauma on the development of psychotic symptoms: relationship with psychosis proneness. Br J Psychiatry. 2006 Jun;188:527-33. Abstract

Comments on News and Primary Papers
Comment by:  Margaret Almeida
Submitted 28 June 2006 Posted 30 June 2006
  I recommend the Primary Papers

This article supported absolutely what our research clinic is anecdotally experiencing. On more than several occasions we have conducted a Structured Clinical Interview for DSM-IV Axis I disorders (SCID) to find a diagnosis of schizophrenia or schizoaffective disorder. However, in contrast, the clinical chart is describing psychotic symptoms, but the clinical diagnosis is post-traumatic stress disorder alone or perhaps along with borderline personality disorder with depression. All of these cases involved younger clients (18-25 years old), either just beginning mental health services or certainly without a long history of mental health care to reflect on. They also had histories (according to primary care providers) of severe childhood abuse and trauma.

View all comments by Margaret Almeida

Comment by:  Craig Morgan
Submitted 30 July 2006 Posted 31 July 2006
  I recommend the Primary Papers

This is a fascinating study investigating the relationship between psychological trauma and the development of psychotic symptoms using data from the Early Developmental Stages of Psychopathology (EDSP) study conducted in Munich, Germany.

There are a number of interesting findings: 1) Self-reported trauma (any) was associated with experiencing one (OR 1.40; 95 percent CI 1.09, 1.78), two (OR 1.88; 95 percent CI 1.35-2.62) and three or more (OR 2.60; 95 percent CI 1.66-4.09) psychotic symptoms during the follow-up period. While these odds ratios increase linearly with number of psychotic symptoms, when potential confounders, such as urbanicity and psychosis proneness, were controlled for, only the association with three or more psychotic symptoms remained significant (Adj. OR 1.89, 95 percent CI 1.16-3.08); 2) Most specific categories of trauma showed positive associations with psychotic symptoms, particularly at the level of three or more, though only physical threat, natural catastrophe and terrible event to other reached statistical significance (though this may be...  Read more

View all comments by Craig Morgan

Comment by:  Ezra Susser, SRF Advisor
Submitted 9 August 2006 Posted 9 August 2006

I agree with most of the comments already posted by others on the very interesting paper by Spauwen et al on psychological trauma and psychotic symptoms. I'd like to raise just one additional point. This pertains to the specificity for psychotic symptoms. It appears that the study found no relation of these psychological traumas to depression or bipolar disorder, but it isn't clear whether there was any relation to depressive symptoms. It's worth considering this point in the interpretation of the results, because psychological traumas have been related to a number of other conditions in previous studies.

View all comments by Ezra Susser

Comment by:  Maurits Van den NoortPeggy Bosch
Submitted 10 August 2006 Posted 10 August 2006
  I recommend the Primary Papers

We read the paper by Spauwen et al. (2006) with great interest. Their findings suggest a specific relationship between psychological trauma and psychosis. Previous studies already showed that psychological trauma is clearly associated with depression and other symptoms of post-traumatic stress disorder, but the link between childhood trauma and psychosis was controversial. The current finding is very interesting and based on a study with a large data set and a good methodology. However, more research on this topic needs to be done. This research should measure the type of trauma in greater detail since this could give a better understanding of the exact link between trauma and psychosis. Moreover, the focus of future research should be more on the underlying neurological mechanisms by which childhood trauma increases the risk of psychosis. For instance, it would be interesting to conduct neuroimaging studies (Ni Bhriain et al., 2005), that focus on dopamine abnormalities (  Read more

View all comments by Maurits Van den Noort
View all comments by Peggy Bosch

Comment by:  James ScottJohn McGrath (SRF Advisor)
Submitted 10 August 2006 Posted 10 August 2006
  I recommend the Primary Papers

Spauwen and colleagues add further weight to research linking traumatic experiences and psychotic symptoms (Spauwen et al., 2006). There are now a number of studies showing an association between trauma and psychotic symptoms (Bebbington et al., 2004; Janssen et al., 2004; Sareen et al., 2005; Shevlin et al., 2006; Whitfield et al., 2005). There are also a number of large community-representative studies showing that psychotic symptoms are highly prevalent in community populations (Eaton et al., 1991;   Read more

View all comments by James Scott
View all comments by John McGrath

Comment by:  Ella Matthews
Submitted 24 August 2006 Posted 27 August 2006

Spauwen and colleagues find that exposure to psychological trauma may increase the risk of psychotic symptoms in people vulnerable to psychoses. The experiences of war, natural disasters and child abuse cannot be good for anyone. Am I wrong to think that these add up to much more than psychological trauma or that such events would also tend to bring on and exacerbate the symptoms of myriad other conditions such as those relating to the heart, lungs and other bodily organs?

View all comments by Ella Matthews

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