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

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

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 largely an issue of statistical power); and 3) There was evidence that the association between trauma and psychotic symptoms varied by psychosis proneness. That is, the association between trauma and psychosis was strongest in those with pre-existing vulnerability to psychosis.

There has been recent controversy, at least in the U.K., about the role of trauma in the etiology of psychosis, largely as a consequence of a review paper published by John Read and colleagues which concluded that child abuse is a cause of schizophrenia (Read et al., 2005). Does the study by Spauwen et al. provide support for this conclusion? The findings allow interpretation both ways.

On the one hand, there is a robust association between any traumatic event and subsequent development of three or more psychotic symptoms. There are also indications that this may be a dose-response relationship. Further, this study has a number of methodological advantages over much of what has gone before. The prospective design overcomes many of the concerns regarding potential recall bias and direction of causation, as does the inclusion of a measure of psychosis proneness. The sample was large, and the analyses sophisticated.

On the other hand, it could be countered, the observed association between any trauma and psychotic symptoms was modest (Adj. OR 1.89) and much smaller than that found in other studies (e.g., Janssen et al. (2004) reported an adjusted odds ratio of 7.3 over a 2-year period). The evidence for a dose-response relationship was weak, and when confounders were adjusted for, only the association with the most severe level of psychotic symptoms remained significant. Furthermore, and issues of statistical power notwithstanding, it is important to note that only a small number of specific types of trauma were significantly associated with risk of developing psychotic symptoms, and these did not include sexual abuse. And there remains the ongoing issue of the relationship, if any, between psychotic-like symptoms reported in general population samples and the clinical syndromes of psychosis, particularly schizophrenia.

So, there are reasons to retain a healthy skepticism, particularly in relation to claims that child abuse causes schizophrenia. But equally, the emerging evidence suggests it would be wrong to reject a possible role for psychological trauma out of hand. Studies are becoming more methodologically robust, and that by Spauwen et al. is an example of this. There is, however, clearly a need for much more research. Until this is available, we should remain open-minded.

References:

Janssen I, Krabbendam L, Bak M, Hanssen M, Vollebergh W, de Graaf R, van Os J. Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatr Scand. 2004 Jan;109(1):38-45. Abstract

Read J, van Os J, Morrison AP, Ross CA. Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatr Scand. 2005 Nov;112(5):330-50. Review. Abstract

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

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

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 (McGowan et al., 2004) in patients with traumatic experiences early in life.

References:

McGowan S, Lawrence AD, Sales T, Quested D, Grasby P. Presynaptic dopaminergic dysfunction in schizophrenia: a positron emission tomographic [18F]fluorodopa study. Arch Gen Psychiatry. 2004 Feb;61:134-142. Abstract

Ni Bhriain S, Clare AW, Lawlor BA. Neuroimaging: a new training issue in psychiatry? Psychiat Bull. 2005 May;29:189-192.

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

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

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; Scott et al., 2006; van Os et al., 2000).

Read and colleagues have argued that child abuse may be an etiological factor for schizophrenia in some individuals (Read et al., 2001; Read et al., 2005). In a clinical study of adolescent inpatients who hallucinated, we found using a structured questionnaire and structured clinical interview (K-SADS) that the hallucinations of schizophrenia and those of post-traumatic stress disorder (PTSD) were very similar in form and content (Scott et al., 2006, in press). Thus, clinicians and researchers need to remain mindful of the overlap of psychotic symptoms in these disorders.

A possible explanation for the above is that psychotic symptoms are non-specific experiences. Perhaps they represent a final common pathway to a range of stressors including unemployment, social isolation, migration, substance use and trauma. From a different perspective in relation to trauma, psychotic symptoms may be part of a dissociative process (van der Kolk et al., 1996), and the positive psychotic symptoms in PTSD are phenomenologically difficult to distinguish from those of schizophrenia.

The association between trauma and psychotic symptoms is a fascinating one requiring further objective, open-minded research.

References:

Bebbington PE, Bhugra D, Brugha T, Singleton N, Farrell M, Jenkins R, Lewis G, Meltzer H. Psychosis, victimisation and childhood disadvantage: evidence from the second British National Survey of Psychiatric Morbidity. Br J Psychiatry. 2004 Sep;185:220-6. Abstract

Eaton WW, Romanoski A, Anthony JC, Nestadt G. Screening for psychosis in the general population with a self-report interview. J Nerv Ment Dis. 1991 Nov;179(11):689-93. Abstract

Janssen I, Krabbendam L, Bak M, Hanssen M, Vollebergh W, de Graaf R, van Os J. Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatr Scand. 2004 Jan;109(1):38-45. Abstract

Read J, Perry BD, Moskowitz A, Connolly J. The contribution of early traumatic events to schizophrenia in some patients: a traumagenic neurodevelopmental model. Psychiatry. 2001 Winter;64(4):319-45. Review. Abstract

Read J, van Os J, Morrison AP, Ross CA. Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatr Scand. 2005 Nov;112(5):330-50. Review. Abstract

Sareen J, Cox BJ, Goodwin RD, J G Asmundson G. Co-occurrence of posttraumatic stress disorder with positive psychotic symptoms in a nationally representative sample. J Trauma Stress. 2005 Aug;18(4):313-22. Abstract

Scott J, Chant D, Andrews G, McGrath J. Psychotic-like experiences in the general community: the correlates of CIDI psychosis screen items in an Australian sample. Psychol Med. 2006 Feb;36(2):231-8. Epub 2005 Nov 23. Abstract

Scott J, Nurcombe B, Sheridan J, et al. (2006) Hallucinations in Adolescents with Post-traumatic Stress Disorder and Psychotic Disorder. Australasian Psychiatry, In press.

Shevlin M, Dorahy M, Adamson G. Childhood traumas and hallucinations: An analysis of the National Comorbidity Survey. J Psychiatr Res. 2006 Apr 24; [Epub ahead of print] Abstract

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

van der Kolk BA, Pelcovitz D, Roth S, Mandel FS, McFarlane A, Herman JL. Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma. Am J Psychiatry. 1996 Jul;153(7 Suppl):83-93. Review. Abstract

van Os J, Hanssen M, Bijl RV, Ravelli A. Strauss (1969) revisited: a psychosis continuum in the general population? Schizophr Res. 2000 Sep 29;45(1-2):11-20. Abstract

Whitfield CL, Dube SR, Felitti VJ, Anda RF. Adverse childhood experiences and hallucinations. Child Abuse Negl. 2005 Jul;29(7):797-810. Abstract

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