Environment and schizophrenia: environmental factors in schizophrenia: childhood trauma--a critical review

The relationship between childhood trauma history and the psychotic subtype of major depression

OBJECTIVE

Increasing evidence exists linking childhood trauma and primary psychotic disorders, but there is little research on patients with primary affective disorders with psychotic features.

METHOD

The sample consisted of adult out-patients diagnosed with major depressive disorder (MDD) at clinic intake using a structured clinical interview. Patients with MDD with (n = 32) vs. without psychotic features (n = 591) were compared as to their rates of different types of childhood trauma.

RESULTS

Psychotic MDD patients were significantly more likely to report histories of physical (OR = 2.81) or sexual abuse (OR = 2.75) compared with non-psychotic MDD patients. These relationships remained after controlling for baseline differences. Within the subsample with comorbid post-traumatic stress disorder, patients with psychotic MDD were significantly more likely to report childhood physical abuse (OR = 3.20).

CONCLUSION

Results support and extend previous research by demonstrating that the relationship between childhood trauma and psychosis is found across diagnostic groups.

Psychotic symptoms with sexual content in the "ultra high risk" for psychosis population: frequency and association with sexual trauma

Individuals at "ultra high risk" (UHR) for psychosis have been found to experience high rates of sexual trauma. An aetiological role for sexual trauma has been proposed for psychotic disorders and may influence psychotic symptom content. We aimed to investigate the relationship between previous sexual trauma and reported psychotic-like experiences, in particular psychotic symptoms with a sexual content in a UHR sample. We investigated the prevalence of "attenuated" or "subthreshold" psychotic symptoms with a sexual content in a consecutive series of patients recruited to a specialist UHR clinic. Patient's experience of general and sexual trauma was rated separately using a trauma questionnaire based on the list of events qualifying as traumas under DSM IV. The sample consisted of 92 patients, 14 (15.2%) had experienced an attenuated psychotic symptom with sexual content. The most common symptom was overvalued ideas/delusions of being watched in the shower/toilet or undressing. A considerable proportion of the sample (36.2%) had experienced sexual trauma (sexually molested or raped). Presence of attenuated psychotic symptoms with sexual content was related to history of previous sexual trauma (OR 7.17, P<0.01). This relationship remained significant when other traumatic experiences, PTSD diagnosis, age and sex were adjusted for. Further research into this relationship with regard to outcome and treatment is warranted.

The social determinants of psychosis in migrant and ethnic minority populations: a public health tragedy

High rates of schizophrenia and other psychoses have been repeatedly found in migrant populations. However, the development of public health responses has been hindered by unfounded claims that the high rates are an artefact of misdiagnosis. Recent research implicating exposure to social adversity across the life course as the key explanation for these high rates has the potential to inform initiatives to tackle this major public health problem.

Experience of trauma and conversion to psychosis in an ultra-high-risk (prodromal) group

OBJECTIVE

We aimed to replicate a recent finding of high prevalence of trauma history in patients at 'ultra-high risk' (UHR) of psychotic disorder and to investigate whether trauma predicts conversion to psychosis in this population.

METHOD

A consecutive sample of UHR patients was assessed. History of trauma was accessed with the General Trauma Questionnaire. Cox regression models were used to explore relationship between conversion to psychosis and trauma.

RESULTS

Of 92 UHR patients nearly 70% had experienced a traumatic event and 21.7% developed psychosis during follow-up (mean 615 days). Patients who had experienced a sexual trauma (36%) were significantly more likely to convert to first-episode psychosis (OR 2.96) after controlling for meeting multiple UHR intake groups.

CONCLUSION

UHR patients have a high prevalence of history of trauma. Previous sexual trauma may be a predictor of onset of psychotic disorder in this population.

Etiological and clinical features of childhood psychotic symptoms: results from a birth cohort

CONTEXT

It has been reported that childhood psychotic symptoms are common in the general population and may signal neurodevelopmental processes that lead to schizophrenia. However, it is not clear whether these symptoms are associated with the same extensive risk factors established for adult schizophrenia.

OBJECTIVE

To examine the construct validity of children's self-reported psychotic symptoms by testing whether these symptoms share the risk factors and clinical features of adult schizophrenia.

DESIGN

Prospective, longitudinal cohort study of a nationally representative birth cohort in Great Britain.

PARTICIPANTS

A total of 2232 twelve-year-old children followed up since age 5 years (retention, 96%). Main Outcome Measure Children's self-reported hallucinations and delusions.

RESULTS

Children's psychotic symptoms are familial and heritable and are associated with social risk factors (eg, urbanicity); cognitive impairments at age 5; home-rearing risk factors (eg, maternal expressed emotion); behavioral, emotional, and educational problems at age 5; and comorbid conditions, including self-harm.

CONCLUSIONS

The results provide a comprehensive picture of the construct validity of children's self-reported psychotic symptoms. For researchers, the findings indicate that children who have psychotic symptoms can be recruited for neuroscience research to determine the pathogenesis of schizophrenia. For clinicians, the findings indicate that psychotic symptoms in childhood are often a marker of an impaired developmental process and should be actively assessed.

Staging perspectives in neurodevelopmental aspects of neuropsychiatry: agents, phases and ages at expression

Neurodevelopmental risk factors have assumed a critical role in prevailing notions concerning the etiopathogenesis of neuropsychiatric disorders. Staging, diagnostic elements at which phase of disease is determined, provides a means of conceptualizing the degree and extent of factors affecting brain development trajectories, but is concurrently specified through the particular interactions of genes and environment unique to each individual case. For present purposes, staging perspectives in neurodevelopmental aspects of the disease processes are considered from conditions giving rise to neurodevelopmental staging in affective states, adolescence, dopamine disease states, and autism spectrum disorders. Three major aspects influencing the eventual course of individual developmental trajectories appear to possess an essential determinant influence upon outcome: (i) the type of agent that interferes with brain development, whether chemical, immune system activating or absent (anoxia/hypoxia), (ii) the phase of brain development at which the agent exerts disruption, whether prenatal, postnatal, or adolescent, and (iii) the age of expression of structural and functional abnormalities. Clinical staging may be assumed at any or each developmental phase. The present perspective offers both a challenge to bring further order to diagnosis, intervention, and prognosis and a statement regarding the extreme complexities and interwoven intricacies of epigenetic factors, biomarkers, and neurobehavioral entities that aggravate currents notions of the neuropsychiatric disorders.

Neurocognitive function in schizophrenia with comorbid posttraumatic stress disorder

Individuals with schizophrenia are at a greater risk for experiencing trauma and developing posttraumatic stress disorder (PTSD) than the general population. Despite an increased incidence of neurocognitive dysfunction in both schizophrenia and PTSD, there are few studies that have examined the potential compounding effects of these diagnoses when they co-occur. The current study examined this issue by administering comprehensive diagnostic, symptom, and neurocognitive evaluations to four groups including normal controls (C), as well as individuals with PTSD (PTSD), schizophrenia (SZ), or both schizophrenia and PTSD (SZP). Results indicated that when compared to the SZ group, the SZP group exhibited higher rates of positive symptoms, general psychopathology, and PTSD symptoms, as well as lower rates of negative symptoms. Regarding neurocognitive test performance, both schizophrenia groups performed significantly worse than the C and PTSD groups across all neurocognitive domains. However, differences were not significant between the SZP and SZ groups, although a differential pattern of performance between the groups was indicated. Results of this study do not support the idea that the presence of comorbid PTSD in SZ results in a substantial increase in cognitive impairment.

The epidemiology of schizophrenia: replacing dogma with knowledge

Major advances have been made in our understanding of the epidemiology of schizophrenia. We now know that the disorder is more common and severe in young men, and that the incidence varies geographically and temporally. Risk factors have been elucidated; biological risks include a family history of the disorder, advanced paternal age, obstetric complications, and abuse of drugs such as stimulants and cannabis. In addition, recent research has also identified social risk factors such as being born and brought up in a city, migration, and certain types of childhood adversity such as physical abuse and bullying, as well as social isolation and adverse events in adult life. Current research is focussing on the significance of minor psychotic symptoms in the general population, gene-environmental interaction, and how risk factors impact on pathogenesis; perhaps all risk factors ultimately impact on striatal dopamine as the final common pathway.

Hallucinations in nonpsychotic disorders: toward a differential diagnosis of "hearing voices"

While auditory hallucinations (AH) are prototypic psychotic symptoms whose clinical presence is often equated with a psychotic disorder, they are commonly found among those without mental illness as well as those with nonpsychotic disorders not typically associated with hallucinations in DSM-IV. This incongruity presents a significant challenge for clinical work and efforts to revise the next iteration of the DSM. Auditory hallucinations found among "normal" people suggest that either AH are not as pathologic as they are typically taken to be, or that less-than-hallucinatory experiences are routinely mischaracterized as AH. Such hallucinations in the context of conversion disorder, trauma, sensory deprivation, and certain cultural settings strengthen an association between AH and psychopathology but suggest limited diagnostic specificity and relevance. It may be useful to think of AH like coughs-common experiences that are often, but not always, symptoms of pathology associated with a larger illness. Although these issues have been known for many years, they are rarely discussed in American psychiatry and need to be addressed in future research and clinical work.

Trauma and posttraumatic stress disorder (PTSD) in patients with schizophrenia or schizoaffective disorder

Trauma and posttraumatic stress disorder (PTSD) have high prevalence among individuals with severe mental illness, such as schizophrenia or schizoaffective disorder. This study examined whether trauma and PTSD are under-detected in this population, and whether the cognitive theory of PTSD is applicable to these individuals. Traumatic experiences, PTSD symptoms and negative posttraumatic cognitions were directly measured with questionnaires, and compared to information obtained via chart-review. Results showed clear evidence of under-report of trauma and under-diagnosis of PTSD in patients' charts. Furthermore, negative posttraumatic cognitions were positively related to PTSD symptom severity, supporting the cognitive model of PTSD. These findings underscore the importance of assessing trauma history as well as PTSD in the routine evaluation of patients with schizophrenia or schizoaffective disorder in outpatient clinical settings. Furthermore, the finding of negative posttraumatic cognitions suggests that the cognitive model of PTSD may be applicable to patients with schizophrenia or schizoaffective disorder.

Mentalization-based psychodynamic psychotherapy for psychosis

This article discusses and illustrates the use of mentalization-based psychodynamic psychotherapy for disturbances of awareness of the self and others in patients with psychotic-spectrum disorders. The literature on impairments of mental processes involved in self-awareness and awareness of others occurring in psychotic illnesses and the relationship between childhood trauma and the emergence of psychotic symptoms is reviewed. A case illustrates how mentalization-based treatment can facilitate treatment engagement and be used to manage enactments in the psychotherapy with a patient with a psychotic disorder. Mentalization-based psychotherapy may offer a useful adjunct to antipsychotic medication and psychosocial evidence-based treatments in the care of individuals in the early phase of psychotic disorders.

Childhood abuse and psychosis; a critical review of the literature

Childhood trauma has long been recognised as a potential cause for a range of affective mental health problems arising in adulthood. Only in recent years has the association between childhood abuse and psychosis begun to be investigated. This paper provides a critical review of the literature addressing the relationship between childhood abuse and psychosis. Implications for practitioners are discussed, including practice, policy, treatment and child protection issues. A significant proportion of people develop psychosis in adulthood following all types of childhood abuse, including people diagnosed with schizophrenia, major depressive disorders, dissociative identity disorder and post-traumatic stress disorder. Evidence suggests the possibility of a causal relationship between childhood abuse and psychosis in adulthood. Mental health nurses are ideally placed to offer help, care and support to those individuals who experience psychosis by acknowledging and listening to their life events, including experiences of childhood abuse.

The association of child abuse and neglect with adult disability in schizophrenia and the prominent role of physical neglect

OBJECTIVE

To assess long-lasting effects of childhood trauma on the functional outcome of adult patients diagnosed with schizophrenia.

METHOD

Ninety-nine stable patients with schizophrenia followed in an outpatient program at a public university hospital in Porto Alegre, southern Brazil, were investigated for childhood traumatic experiences by the Childhood Trauma Questionnaire (CTQ) and for functional impairment by the World Health Organization Disability Assessment Schedule (WHO/DAS). The schizophrenia diagnosis was assessed by ICD-10 and DSM-IV criteria according to the Operational Criteria Checklist for Psychotic Illness (OPCRIT).

RESULTS

Childhood trauma in general was associated with increased disability in adulthood, reflected by impaired Overall Behavior (p=.023) and Global Evaluation (p=.032). Analysis of specific traumatic domains revealed that increased childhood physical neglect was associated with functional impairment in Overall Behavior (p<.000), Social Role Performance (p=.037) and Global Evaluation (p=.014). Higher emotional abuse was associated with impaired Overall Behavior (p=.026), and higher emotional neglect with poor Global Evaluation (p=.047). Additionally, earlier onset of illness was associated with lower level of functioning evidenced by impairment in Overall Behavior (p=.042). Linear regression using WHO/DAS sections (Overall Behavior, Social Role Performance and Global Evaluation) as dependent variables and CTQ subscales indicated that only physical neglect had an effect on adult functionality.

CONCLUSIONS

Childhood trauma was associated with functional and social impairment in adult patients with schizophrenia. Specific types of abuse and neglect, such as physical neglect and emotional abuse and neglect, influenced disability, and the most robust association was physical neglect. Studies involving more patients, with normal controls and additional measurements of biological liability, should be conducted to confirm this association and to increase the understanding of gene-environment relationship in schizophrenia and pathways to disability.

PRACTICE IMPLICATIONS

Further investigation is warranted to clarify the association between childhood trauma and disability in schizophrenia, as well as to develop standardized instruments for the assessment of trauma and earlier detection of risk along with education of patients and families about adequate care, in an effort to reduce the incidence of disability in schizophrenia.

The antecedents of schizophrenia: a review of birth cohort studies

BACKGROUND

Birth cohort (BC) studies demonstrate that individuals who develop schizophrenia differ from the general population on a range of developmental indices. The aims of this article were to summarize key findings from BC studies in order to identify areas of convergence and to outline areas requiring further research.

METHOD

We define BC studies as studies based on general population BCs where data are collected prospectively from birth or childhood and which identify schizophrenia or related disorders as an outcome. To identify such studies, we searched various electronic databases using the search parameters (schizo* OR psych*) AND (birth cohort). We also checked the references of relevant articles and previous reviews.

RESULTS

We identified 11 BCs from 7 countries that have examined schizophrenia as an outcome in adulthood. There is relatively consistent evidence that, as a group, children who later develop schizophrenia have behavioral disturbances and psychopathology, intellectual and language deficits, and early motor delays. Evidence with respect to alterations in language, educational performance, and physical growth has also been identified in some studies. BC studies have also contributed evidence about a wide range of putative risk factors for schizophrenia.

CONCLUSIONS

BC studies have provided important, convergent insights into how the developmental trajectory of individuals who develop schizophrenia differs from their peers. The combination of new paradigms and larger cohorts, with the tools of modern epidemiology and biomedical science, is advancing our understanding of the developmental pathways to schizophrenia.

Gender differences in the association between childhood abuse and psychosis

BACKGROUND

Studies demonstrating an association between childhood trauma and psychosis in adulthood have not systematically explored gender differences.

AIMS

To investigate gender differences in the prevalence of childhood sexual and physical abuse among people with psychosis in comparison with healthy controls.

METHOD

The Childhood Experiences of Care and Abuse Questionnaire was completed to elicit experiences of sexual and physical abuse during childhood in first-episode psychosis cases and population-based controls.

RESULTS

Among women, those in the cases group were twice as likely to report either physical or sexual abuse compared with controls following adjustment for all confounders. In particular, the effect of physical abuse in women was stronger and more robust than that for sexual abuse. A similar trend was found for psychotic-like experiences in the female control group. No association was found in men.

CONCLUSIONS

Reports of severe childhood physical or sexual abuse were associated with psychosis in women but not in men.

Copy number variation showers in schizophrenia: an emerging hypothesis

Genetic discoveries on Schizophrenia remain challenging. Traditional approaches have provided clues, but no genes. Novel theories that must account for extensive heterogeneity, including high discordance of monozygotic (MZD) twins, are needed. To this end, the extensive repeats of the human genome may provide the predisposition for DNA replication errors operational at every cell cycle during meiosis and mitosis. These errors will shower the genome with replication errors including copy number variations. Depending on the timing and the genes involved, this will contribute to the mutational load and disease. The evidence for such a mechanism in schizophrenia is emerging.

Cannabis use and age of diagnosis of schizophrenia

BACKGROUND AND OBJECTIVES

Observational studies have reported earlier onset of psychosis in schizophrenic patients with a history of cannabis use. Earlier age of onset of schizophrenia has been associated with a poorer outcome. We aimed to examine whether cannabis use determined an earlier onset of schizophrenia in a sample of first episode patients, in an area with one of Europe's highest rates of cannabis use.

METHODS

116 subjects with first episode psychosis and subsequent diagnosis of schizophrenia (after a 12-month follow-up) were included Age at first antipsychotic treatment (A1T) was used as proxy for age of psychosis onset, and acted as dependent variable for the statistical analysis. Cannabis use was evaluated retrospectively, and divided into three groups according to peak frequency (never, sporadic/frequent, daily).

RESULTS

46 (39.7%) subjects had never used cannabis, 23 (19.9%) had done so sporadically/frequently, and 47 (40.5%) daily. A1T differed between the three groups (mean, in years and [SD]: 27.0 [4.94]; 25.7 [4.44] and 24.5 [4.36]; p=0.033) and diminished as cannabis use increased (linear tendency; p=0.009). Post-hoc analysis showed that cannabis use (irrespective of frequency) was significantly associated with decrease in A1T (p=0.033), as shown by the first contrast [1 -1/2 -1/2]. Post-hoc contrast showed that cannabis users had a significantly lower age of onset of psychosis (mean decrease, in years: 1.93; CI (confidence interval) 95%: 0.17-3.70; p=0.033).

CONCLUSIONS

Cannabis use was significantly associated with a decrease in age of onset of schizophrenia. Age of onset of the disease correlated with frequency of cannabis use.

Psychiatric comorbidities and schizophrenia

Psychiatric comorbidities are common among patients with schizophrenia. Substance abuse comorbidity predominates. Anxiety and depressive symptoms are also very common throughout the course of illness, with an estimated prevalence of 15% for panic disorder, 29% for posttraumatic stress disorder, and 23% for obsessive-compulsive disorder. It is estimated that comorbid depression occurs in 50% of patients, and perhaps (conservatively) 47% of patients also have a lifetime diagnosis of comorbid substance abuse. This article chronicles these associations, examining whether these comorbidities are "more than chance" and might represent (distinct) phenotypes of schizophrenia. Among the anxiety disorders, the evidence at present is most abundant for an association with obsessive-compulsive disorder. Additional studies in newly diagnosed antipsychotic-naive patients and their first-degree relatives and searches for genetic and environmental risk factors are needed to replicate preliminary findings and further investigate these associations.

Childhood trauma and prodromal symptoms among individuals at clinical high risk for psychosis

INTRODUCTION

Numerous studies point to an association between childhood trauma and the later development of psychotic illness. However, little is known about the prevalence of childhood trauma and its relationship to attenuated positive and other symptoms in individuals at heightened clinical risk for psychosis.

METHOD

Thirty clinical high-risk patients (83% male, 43% Caucasian, and with a mean age of 19) were ascertained from the New York metropolitan area and evaluated for prodromal and affective symptoms, and queried regarding experiences of childhood trauma and abuse.

RESULTS

Ninety-seven percent endorsed at least one general trauma experience, 83% reported physical abuse, 67% emotional abuse, and 27% sexual abuse. As hypothesized, total trauma exposure was positively associated with severity of attenuated positive symptoms (in particular grandiosity), an effect primarily accounted for by ethnic minority participants, who reported greater exposure to trauma. Trauma exposure was related to affective symptoms only in the Caucasian subgroup.

CONCLUSIONS

Childhood trauma was commonly self-reported, especially among clinical high-risk patients from ethnic minorities, for whom trauma was related to positive symptoms. Future areas of research include an evaluation of potential mechanisms for this relationship, including neuroendocrine and subcortical dopaminergic function.

Are psychotic experiences among detained juvenile offenders explained by trauma and substance use?

OBJECTIVE

High rates of psychotic experiences among detained adolescents have been reported. However, the significance of psychotic experiences in detained juveniles is still poorly understood. The current study, therefore, (1) examines whether psychotic experiences could be explained by substance use and/or traumatic experiences, and (2) investigates this objective without taking into account the frequently occurring paranoia-related symptoms that may not be psychosis-related in detained minors.

METHOD

Data were derived from 231 detained adolescents. By means of the Diagnostic Interview Schedule for Children, psychotic experiences, life-threatening events and substance use were assessed while the Child Traumatic Questionnaire was used for a history of abuse and neglect.

RESULTS

In univariate logistic regression analyses, having psychotic experiences was positively associated with substance-related (e.g. past year intense marihuana use) and trauma-related (e.g. emotional abuse) variables. However, without taken paranoia-related experiences into account, different associations between psychotic experiences and substance-related and/or trauma-related variables were found. After building best fitting models, logistic regression analyses demonstrated a preponderance of trauma-related over substance-related variables in predicting the number of psychotic experiences (i.e. 0, 1-2, >2).

CONCLUSION

These findings suggest that psychotic experiences in detained adolescents may be explained by trauma and substance use. In addition, paranoia-related experiences seemed to be particularly associated with emotional abuse.

Burden and consequences of child maltreatment in high-income countries

Child maltreatment remains a major public-health and social-welfare problem in high-income countries. Every year, about 4-16% of children are physically abused and one in ten is neglected or psychologically abused. During childhood, between 5% and 10% of girls and up to 5% of boys are exposed to penetrative sexual abuse, and up to three times this number are exposed to any type of sexual abuse. However, official rates for substantiated child maltreatment indicate less than a tenth of this burden. Exposure to multiple types and repeated episodes of maltreatment is associated with increased risks of severe maltreatment and psychological consequences. Child maltreatment substantially contributes to child mortality and morbidity and has longlasting effects on mental health, drug and alcohol misuse (especially in girls), risky sexual behaviour, obesity, and criminal behaviour, which persist into adulthood. Neglect is at least as damaging as physical or sexual abuse in the long term but has received the least scientific and public attention. The high burden and serious and long-term consequences of child maltreatment warrant increased investment in preventive and therapeutic strategies from early childhood.

Early adverse experiences in schizophrenia and unipolar depression

To study the prevalence of early adversities in schizophrenia and unipolar depression, 2 groups of consecutive adult-onset inpatients with DSM-IV diagnoses of schizophrenia (n = 173) and unipolar depression (n = 305) were compared with an unscreened control group of volunteers from the general population (n = 310), with respect to their association with 4 types of childhood abuse and with early parental adversities (discord, separation, death, psychiatric caseness). Compared with general population, most types of early adversities (except sexual abuse and parental death) were significantly associated with both clinical groups. Compared with depression, all early adversities with the same 2 exceptions were significantly associated with schizophrenia; both frequency of abuse and number of types of abuse increased the risk of schizophrenia in a dose-response pattern, suggesting causality. These findings stress the role of social developmental factors in the etiology of schizophrenia.

The changing role of mother of the mentally ill: from schizophrenogenic mother to multigenerational caregiver

Psychiatry's understanding of the contribution of mothers to mental illness has markedly changed over the last 60 years, evolving from a view that mothers were to blame for everything, passing through a subsequent period when mothers were seen less as instigators of illness and more as provocateurs, inducing relapse through the expression of criticism and hostility. Currently, mothers are mainly viewed as "burdened caregivers." Because psychiatric patients no longer live in asylums and no longer are prescribed first generation antipsychotics that used to render them effectively sterile, more and more women with schizophrenia are bearing children-children that their mothers, more often than not, raise. This paper is about caregiving by grandmothers, especially as this pertains to daughters with schizophrenia and especially as it impacts on the grandmother's health and well-being. The role of the grandmother is characterized by divided loyalties, by the toll of caregiving, but also, unquestionably, by the rewards that come with raising children. The experience of grandmothers makes them potent allies in the battle against mental illness in their children and the children of their children. Expanding on their existing role as caregivers, mothers of the mentally ill are evolving into auxiliary therapists.

A view from Riggs: treatment resistance and patient authority-IX. Integrative psychodynamic treatment of psychotic disorders

Psychotic spectrum disorders present treatment challenges for patients, families, and clinicians. This article addresses the history of the dualism in the field between biological and psychological approaches to mental disorders, and surveys the contemporary literature about the etiology and treatment of psychotic spectrum disorders. An integrative approach to treatment derived from work at Austen Riggs with previously treatment refractory patients with psychotic spectrum disorders is described that combines individual psycho- dynamic psychotherapy, psychopharmacology, family systems approaches, and intensive psychosocial engagement. Helping patients develop their own authority to join the treatment, use relationships for learning, and understand the meaning of their symptoms is central to the treatment at Austen Riggs. An extended case vignette of a patient diagnosed with a schizoaffective disorder is presented illustrating this integrative psychodynamic treatment approach.

Symptomatic remission in a multiracial urban population of older adults with schizophrenia

OBJECTIVE

Symptomatic remission has been reported in younger patients with schizophrenia. This study aims to determine the prevalence of symptomatic remission in older adults with schizophrenia.

METHODS

The Schizophrenia Group consisted of 198 persons aged 55+ years living in the community who developed schizophrenia before age 45 years. Our definition of remission was adapted from the criteria of the Remission in Schizophrenia Working Group. To attain remission, persons had to have scores of <3 on eight domains of the Positive and Negative Symptom Scale and no hospitalizations within the previous year. Using George's Social Antecedent Model, we examined the association of remission with 18 predictor variables.

RESULTS

Forty-nine percent of the sample met the criteria for symptomatic remission. In logistic regression analysis, four variables--fewer total network contacts, greater proportion of intimates, fewer lifetime traumatic events, and higher Dementia Rating Scale scores--were significantly associated with remission.

CONCLUSIONS

Remission rates were consistent with those reported in younger samples. Our findings suggest that symptomatic remission is an attainable goal and that treatments focused on those variables associated with remission may augment outcomes in older persons with schizophrenia.

Cumulative social disadvantage, ethnicity and first-episode psychosis: a case-control study

BACKGROUND

Numerous studies have reported high rates of psychosis in the Black Caribbean population in the UK. Recent speculation about the reasons for these high rates has focused on social factors. However, there have been few empirical studies. We sought to compare the prevalence of specific indicators of social disadvantage and isolation, and variations by ethnicity, in subjects with a first episode of psychosis and a series of healthy controls.

METHOD

All cases with a first episode of psychosis who made contact with psychiatric services in defined catchment areas in London and Nottingham, UK and a series of community controls were recruited over a 3-year period. Data relating to clinical and social variables were collected from cases and controls.

RESULTS

On all indicators, cases were more socially disadvantaged and isolated than controls, after controlling for potential confounders. These associations held when the sample was restricted to those with an affective diagnosis and to those with a short prodrome and short duration of untreated psychosis. There was a clear linear relationship between concentrated disadvantage and odds of psychosis. Similar patterns were evident in the two main ethnic groups, White British and Black Caribbean. However, indicators of social disadvantage and isolation were more common in Black Caribbean subjects than White British subjects.

CONCLUSIONS

We found strong associations between indicators of disadvantage and psychosis. If these variables index exposure to factors that increase risk of psychosis, their greater prevalence in the Black Caribbean population may contribute to the reported high rates of psychosis in this population.

Beyond genetics: childhood affective trauma in bipolar disorder

OBJECTIVES

Despite the demonstrated high heritability of bipolar disorder, few susceptibility genes have been identified and linkage and/or association studies have produced conflicting results. This search for susceptibility genes is hampered by several methodological limitations, and environmental risk factors for the disease (requiring incorporation into analyses) remain misunderstood. Among them, childhood trauma is probably the most promising environmental factor for further investigation. The objectives are to review the arguments in favor of an association between childhood trauma and bipolar disorder and to discuss the interpretations of such an observation.

METHODS

We computed a literature search using PubMed to identify relevant publications concerning childhood trauma and bipolar disorder. We also present some personal data in this field.

RESULTS

Growing evidence suggests that incidences of childhood trauma are frequent and severe in bipolar disorder, probably affect the clinical expression of the disease in terms of suicidal behavior and age at onset, and also have an insidious influence on the affective functioning of patients between episodes. The relationships between childhood trauma and bipolar disorder suggest several interpretations, mainly a causal link, a neurodevelopmental consequence, or the intergenerational transmission of traumatic experiences. The neurobiological consequences of childhood trauma on a maturing brain remain unclear, although such stressors may alter the organization of brain development, leading to inadequate affective regulation.

CONCLUSIONS

Childhood trauma is associated with bipolar disorder and its clinical expression and may interact with genetic susceptibility factors. Although not completely understood, the relationships between childhood trauma and bipolar disorder require further attention. Several suggestions for further exploration of this environmental factor and of its interaction with susceptibility genes are proposed.

Environmental studies of schizophrenia through the prism of epigenetics

Traditionally, etiological research of schizophrenia has been focused on elucidating predisposing genes and environmental risk factors. While numerous putative environmental hazards have been suggested, inconsistencies and methodological limitations of epidemiological studies have made it difficult to identify even a single exogenous cause of schizophrenia. Furthermore, there is increasing evidence that environmental risk factors may not play as much of a significant role in schizophrenia as previously suspected. In this article, we argue that molecular epigenetic studies can overcome the complexities of traditional epidemiological studies and may become a productive line of research in understanding the nongenetic mechanisms of schizophrenia.

Which environments for G x E? A user perspective on the roles of trauma and structural discrimination in the onset and course of schizophrenia

Now that schizophrenia researchers may be moving from unilateral molecular genetic approaches to models including so-called gene-environment interactions, the question rises which environments may be considered for such research and how a user perspective may inform the field. It is argued that trauma and stigma, or perhaps better structural discrimination, represent 2 important environmental factors that deserve more attention. Experiential evidence, collected by users, suggests that trauma in childhood and/or adulthood, before, during, and after the onset of schizophrenia, as well as stigma/structural discrimination, may play important roles in the onset and course of the disorder. A certain reluctance on the part of the professional schizophrenia research community to take these variables as serious as, eg, interesting but inconclusive etiological signals from prenatal hypoxia, prenatal folate deficiency, and prenatal toxoplasmosis is suggested. This article outlines the concepts of trauma and stigma and their negative consequences for the onset and course of schizophrenia. The importance of research into these factors and their possible relevance for gene-environment interactions is discussed. While gene-environment interaction research using these variables is indicated and may possibly prove productive, it is argued that such efforts may not be useful if no subsequent attempt is made to translate the results to the level of interventions, codeveloped by users, eg, in the area of coping with the vicious circle of environmental adversity that users can become exposed to.

Associations between childhood trauma, bullying and psychotic symptoms among a school-based adolescent sample

BACKGROUND

Children and adolescents who report psychotic symptoms appear to be at increased risk for psychotic disorders in adulthood - a putative ;symptomatic' high-risk group. However, little research has investigated whether those in this high-risk population have increased rates of exposure to traumatic events in childhood, as seen in patients who have a psychotic illness.

AIMS

To examine whether adolescents with psychotic symptoms have an increased rate of traumatic experiences.

METHOD

Psychiatric interviews were carried out with 211 adolescents aged between 12 and 15 years and their parents as part of a population-based study. The interview enquired about a number of early traumatic events including physical and sexual abuse, exposure to domestic violence and bullying.

RESULTS

Fourteen adolescents (6.6% of those interviewed) reported experiencing at least one psychotic symptom. Adolescents who reported psychotic symptoms were significantly more likely to have been physically abused in childhood, to have been exposed to domestic violence and to be identified as a bully/victim (that is, both a perpetrator and victim of bullying) than those who did not report such symptoms. These findings were not confounded by comorbid psychiatric illness or family history of psychiatric history.

CONCLUSIONS

Our findings suggest that childhood trauma may increase the risk of psychotic experiences. The characteristics of bully/victims deserve further study.

Sex differences in the cortisol response to awakening in recent onset psychosis

A dysregulation of the hypothalamus-pituitary-adrenal (HPA) axis has been suggested as a factor in the etiology and exacerbation of psychosis, but has not been reported consistently. Sex differences are apparent in many aspects of psychotic disorders and may explain some of the equivocation associated with the regulation of the HPA axis in the illness. The present study compared the cortisol response to awakening (CRA) in 27 patients (16 men and 11 women) with recent onset of psychosis (within the past 2 years) and 40 age and gender matched controls. Within the patient group, we also assessed the relationship between the CRA and positive and negative symptoms of psychosis, anxiety and depression. The CRA in patients was not significantly different from controls. However, within the patient group, we observed a significant sex difference, with a blunted cortisol response to awakening in men but not in women (F=7.26; p<0.002). This difference could not be explained by differences between male and female patients in awakening time, medication, or diagnosis of schizophrenia vs. affective psychosis. Cortisol levels were not related to symptom measures. Our findings demonstrate a dysregulation of the HPA axis in male patients with recent onset of psychosis. This sex specificity might be related to and explain in part the unfavorable course of the illness observed in men.

Can antistigma campaigns be improved? A test of the impact of biogenetic vs psychosocial causal explanations on implicit and explicit attitudes to schizophrenia

Antistigma campaigns have been promoting a medical view of schizophrenia. Given the growing body of research finding negative associations between biogenetic (BG) causal attributions and stigmatizing attitudes, this approach must be reappraised. The present study investigates the impact of different psychoeducational interventions on the etiology of schizophrenia (BG and psychosocial [PS], vs a neutral condition) and on stigmatizing attitudes in medical (n = 60) and psychology students (n = 61). Information was presented via information brochures and a video presentation. Attitudes were assessed before and after the interventions on an explicit level using the stereotype questionnaire and the Social Distance Scale as well as on an implicit level, using the Implicit Association Test. Both educational interventions produced a significant decrease in several stereotype components, which was not the case in the neutral condition. The BG intervention decreased the attribution of blame in both groups. It also decreased the stereotype unpredictability/incompetence and social distance in the medical students but increased the negative outlook on prognosis in the psychology students. The PS intervention reduced the widespread stereotype of dangerousness as well as social distance in the group of medical students. While further research into antistigma interventions is necessary, the proposal for antistigma campaigns is to take a multidimensional and balanced approach, which is adapted to target groups and provides additional facts that challenge the myths maintaining stigma.

Associations between ethnicity and self-reported hallucinations in a population sample of young adults in The Netherlands

BACKGROUND

Psychotic disorders are more common in people from ethnic minorities. If psychosis exists as a continuous phenotype, ethnic disparities in psychotic disorder will be accompanied by similar ethnic disparities in the rate of psychotic symptoms. This study examined ethnic disparities in self-reported hallucinations in a population sample of young adults. MethodA cross-sectional population survey (n=2258) was carried out in the south-west Netherlands. Seven ethnic groups were delineated: Dutch natives, Turks, Moroccans, Surinamese/Antilleans, Indonesians, other non-Western immigrants (mostly from Africa or Asia) and Western immigrants (mostly from Western Europe). Self-reported auditory and visual hallucinations were assessed with the Adult Self-Report (ASR). Indicators of social adversity included social difficulties and a significant drop in financial resources.

RESULTS

Compared to Dutch natives, Turkish females [odds ratio (OR) 13.48, 95% confidence interval (CI) 5.97-30.42], Moroccan males (OR 8.36, 95% CI 3.29-21.22), Surinamese/Antilleans (OR 2.19, 95% CI 1.05-4.58), Indonesians (OR 4.15, 95% CI 1.69-10.19) and other non-Western immigrants (OR 3.57, 95% CI 1.62-7.85) were more likely to report hallucinations, whereas Western immigrants, Turkish males and Moroccan females did not differ from their Dutch counterparts. When adjusting for social adversity, the ORs for self-reported hallucinations among the non-Western immigrant groups showed considerable reductions of 28% to 52%.

CONCLUSIONS

In a general population sample, several non-Western immigrant groups reported hallucinations more often than Dutch natives, which is consistent with the higher incidence of psychotic disorders in most of these groups. The associations between ethnicity and hallucinations diminished after adjustment for social adversity, which supports the view that adverse social experiences contribute to the higher rate of psychosis among migrants.

Dissociative identity disorder and schizophrenia: differential diagnosis and theoretical issues

Schizophrenia and dissociative identity disorder (DID) are typically thought of as unrelated syndromes--a genetically based psychotic disorder versus a trauma-based dissociative disorder--and are categorized as such by the DSM-IV. However, substantial data exist to document the elevated occurrence of psychotic symptoms in DID; awareness of these features is necessary to prevent diagnostic confusion. Recent research has also pointed out that schizophrenia and DID overlap not only in psychotic symptoms but also in terms of traumatic antecedents, leading to a number of suggestions for revision of our clinical, theoretical, and nosologic understanding of the relationship between these two disorders.

Childhood trauma and psychotic disorders: a systematic, critical review of the evidence

There is controversy over whether childhood trauma (CT) is a causal factor in the development of psychosis. This review aims to identify and critically analyze the association between CT and psychotic disorders. Studies investigating CT and psychotic disorder were identified by searches of electronic databases and manual searches of references lists, and 46 studies were identified. Forty studies had no control group, only psychiatric control groups, or unmatched, nonpopulation control groups and thus had methodologies that were inadequate to determine the relationship between CT and psychosis. Six studies used appropriate control groups. Three studies found an association between CT and psychosis, 2 found potentially real associations that failed to reach statistical significance, and 1 found no association, tentatively suggesting a relationship between CT and psychotic disorders. Several methodological problems were found in the studies in the review, including the highest quality studies, which limit the strength of the conclusions that can be drawn from them. These were lack of statistical power, lack of attention to moderating or mediating variables, the way in which CT was measured, and the use of cross-sectional research designs. These problems, some of which may be unavoidable in CT research, suggest the need for new and innovative methodologies in the investigation of CT and psychosis. Directions for further research are explored.

Prevention inherent in services for women with schizophrenia

OBJECTIVE

Effective care to women with serious mental illness provides an opportunity for prevention of mental health problems in their offspring. The objective of this study is to outline the preventive possibilities of a service targeted to women with schizophrenia.

METHOD

An analysis of recently published literature on women suffering from schizophrenia, focusing on intervention.

RESULTS

Genetic counselling, prenatal care, prevention of obstetrical complications, substance abuse reduction, appropriate antipsychotic treatment, parenting support, safety issues, quality of life, ethics, cultural competence, and advocacy are components of a comprehensive service to women with schizophrenia.

CONCLUSIONS

These components improve maternal health and, by also ensuring fetal and neonatal health, are potentially preventive against schizophrenia in the second generation.

A theory of social integration as quality of life

OBJECTIVE

Quality of life, once a priority in caring for people with severe mental illness, has since been eclipsed by other concerns. This article returns attention to quality of life by offering a theory of social integration (as quality of life) for persons disabled by severe mental illness.

METHODS

Data collection for this qualitative study consisted of 78 individual, unstructured interviews with 56 adults who have been psychiatrically disabled. Field observations and interviews with staff and service users were carried out during eight ethnographic visits to service sites working to promote social integration. Data were analyzed with an inductive strategy based on grounded theory methodology and framed theoretically by the capabilities approach to human development. Goals were to identify personal capacities needed for integration, characterize occasions for capacity development in mental health care, and develop a working theory.

RESULTS

Six personal capacities were identified: responsibility, accountability, imagination, empathy, judgment, and advocacy. Occasions were characterized in terms of their defining mechanisms: contradiction, reinterpretation, rehearsal, raising expectations, and confrontation. A working theory was constructed to characterize the process of capacity development for social integration through exposure to increasingly challenging occasions for growth in the context of mental health care.

CONCLUSIONS

Capacities for social integration can be effectively developed as part of the everyday routines of mental health care. Eventually, the process shifts from development to the exercise of capacities and to participation as full citizens in the social world beyond treatment.

Does the concept of "sensitization" provide a plausible mechanism for the putative link between the environment and schizophrenia?

Previous evidence reviewed in Schizophrenia Bulletin suggests the importance of a range of different environmental factors in the development of psychotic illness. It is unlikely, however, that the diversity of environmental influences associated with schizophrenia can be linked to as many different underlying mechanisms. There is evidence that environmental exposures may induce, in interaction with (epi)genetic factors, psychological or physiological alterations that can be traced to a final common pathway of cognitive biases and/or altered dopamine neurotransmission, broadly referred to as "sensitization," facilitating the onset and persistence of psychotic symptoms. At the population level, the behavioral phenotype for sensitization may be examined by quantifying, in populations exposed to environmental risk factors associated with stress or dopamine-agonist drugs, (1) the increased rate of persistence (indicating lasting sensitization) of normally transient developmental expressions of subclinical psychotic experiences and (2) the subsequent increased rate of transition to clinical psychotic disorder.

A theory of social integration as quality of life

OBJECTIVE

Quality of life, once a priority in caring for people with severe mental illness, has since been eclipsed by other concerns. This article returns attention to quality of life by offering a theory of social integration (as quality of life) for persons disabled by severe mental illness.

METHODS

Data collection for this qualitative study consisted of 78 individual, unstructured interviews with 56 adults who have been psychiatrically disabled. Field observations and interviews with staff and service users were carried out during eight ethnographic visits to service sites working to promote social integration. Data were analyzed with an inductive strategy based on grounded theory methodology and framed theoretically by the capabilities approach to human development. Goals were to identify personal capacities needed for integration, characterize occasions for capacity development in mental health care, and develop a working theory.

RESULTS

Six personal capacities were identified: responsibility, accountability, imagination, empathy, judgment, and advocacy. Occasions were characterized in terms of their defining mechanisms: contradiction, reinterpretation, rehearsal, raising expectations, and confrontation. A working theory was constructed to characterize the process of capacity development for social integration through exposure to increasingly challenging occasions for growth in the context of mental health care.

CONCLUSIONS

Capacities for social integration can be effectively developed as part of the everyday routines of mental health care. Eventually, the process shifts from development to the exercise of capacities and to participation as full citizens in the social world beyond treatment.

New directions in the conceptualization of psychotic disorders

PURPOSE OF REVIEW

Recent studies raise controversies about the nature of psychotic illnesses, and the role of life experiences and drug abuse as causative agents in the onset of psychoses.

RECENT FINDINGS

Evidence from studies across many geographic locales and cultures finds increased risk of psychoses in first- and second-generation immigrant populations. Trauma incurred in war and civil unrest, trauma of child abuse, and the experience of being bullied in childhood are correlated with increased rates of psychoses in the populations at risk. The risk of onset of psychoses is increased by maternal and infant starvation, and by substance misuse (marijuana, khat) in late childhood and adolescence. These studies question the validity of a categorical distinction between the schizophrenic and affective illnesses.

SUMMARY

A variety of extrinsic factors, such as in-utero and infant malnutrition, substance abuse, and traumatic experiences, appear to be significant risk factors for the development of schizophrenia-like and psychotic affective disorders. These findings raise the issue of whether the present classification of the psychoses is in urgent need of reconceptualization.

Families and schizophrenia: the view from advocacy

Historically, families of persons who have schizophrenia often were blamed for the development of the condition and subsequently might have been excluded from care. Now these notions, which never had much systematic empiric support, have been abandoned. Family involvement often is critical to the recovery process and must be engaged actively whenever possible. This article calls for the inclusion of patients who have schizophrenia and their families in a redesigned model of care that is explicitly collaborative in its orientation and routinely includes evidence-based treatments that are informed by a vision of recovery.

A classification of sociomedical health indicators: perspectives for health administrators and health planners

The conceptualization and operationalization of measures of health status are considered. Health indicators are conceived as a subset of social indicators, and therefore, as any social indicator, they are viewed as derivative from social issues. The interrelationships of different frames of reference for defining and measuring health that have accompained three distinct health problem patterns in the United States are viewed from a developmental perspective. Mortality and morbidity rates, the traditional health indicators, by themselves no longer serve to assess health status in developed nations. Their deficiencies as indicators serve as background for a classification schema for sociomedical health status indicators that relates health definition frames of reference, measures of health status, and health problems. The role of a group of health indicators-sociomedical heath indicators-in the current formulation of health status measures is assessed.