Childhood trauma and the risk of violence in adulthood in a population with a psychotic illness

The relationship between patterns of negative life experiences and clinical presentation in a psychiatric sample

BACKGROUND

Attempts have been made to classify the patterns of polytraumatization using a person-centered approach. However, most studies have only focused on maltreatment and interpersonal trauma and have been unable to examine various clinical symptoms.

OBJECTIVES

This study aimed to explore patterns of negative life experiences, including maltreatment, lifetime trauma, and recent stressful life events, and compare diverse dimensions of the clinical manifestations among the subtypes in a clinical sample.

METHOD

We investigated childhood maltreatment, lifetime trauma, and recent stressful events using a self-report method in 1410 psychiatric patients; we classified the patterns of lifelong negative life experiences using latent profile analysis (LPA). We used the rates of psychiatric diagnosis, the Beck Depression Inventory, the Impact of Event Scale-Revised (IES-R-K), and the Multiphasic Minnesota Personality Inventory-2-Restructured Form to compare various symptom dimensions among the derived subtypes.

RESULTS

LPA indicated a four-class solution: mild, recent stress, maltreatment, and multiple adversity group. The multiple adversity group experiencing both lifetime trauma and recent stressful life events, in addition to maltreatment, including sexual abuse, had a high rate of severe mental illness and more symptom dimensions of thought and behavior problems. However, the rates of depressive disorders and emotional/internalizing symptoms were not more than those in the other two groups (recent stress and maltreatment groups) experiencing moderate levels of lifetime trauma. There was no significant difference between the recent stress and maltreatment groups for most symptom dimensions.

CONCLUSIONS

The findings indicate that distinct symptom profiles may be associated with the pattern of negative experiences, suggesting that negative experiences need multidimensional investigation in clinical settings.

Evaluation of the association COMT Val158Met variant and childhood trauma on aggression in Turkish SCZ patients

Childhood trauma is a serious form of stress that makes individuals more vulnerable to developing Schizophrenia (SCZ). Many studies have predicted the association between the catechol-O-methyltransferase (COMT) gene Val158Met variant and aggressive attack. We aimed to investigate the association the COMT variant and childhood trauma on aggression in Turkish SCZ patientsThis study included 89 patients diagnosed with SCZ. Childhood Trauma Questionnaire (CTS) and Overt Aggression Scale (OAS) were used to assess childhood trauma and aggression. COMT Val158Met variant was analyzed by PCR-RFLP method from isolated DNAs.There was no statistically significant difference in comparing the COMT genotype distribution and clinical characteristics including suicide attempts, self-destructive behavior, crime history, substance, alcohol and tobacco use. When we evaluate Spearman's rank correlation coefficients between CTQ and OAS, the correlation between the OAS and CTQ scores of the patients was statistically significant except for the sexual abuse subgroup of the CTQ. In the univariate logistic regression analysis, in which the dichotomized OAS score was accepted as the dependent variable, it was found that age, suicide attempt, substance abuse, and CTQ total score significantly predicted the higher OAS scores. In the multivariate logistic regression analysis, which included the variables that predicted OAS significantly, age, suicide attempt, and total CTQ score were determined as independent variables predicting OAS.Because of the phenotypic complexity in SCZ, it is difficult to draw strong conclusions about COMT and to highlight a definitive relationship. Larger-scale studies are needed to examine the multifactorial inheritance pattern of schizophrenia in different dimensions.

Examining associations, moderators and mediators between childhood maltreatment, social functioning, and social cognition in psychotic disorders: a systematic review and meta-analysis

Childhood maltreatment (CM) has been related to social functioning and social cognition impairment in people with psychotic disorders (PD); however, evidence across different CM subtypes and social domains remains less clear. We conducted a systematic review and meta-analysis to quantify associations between CM, overall and its different subtypes (physical/emotional/sexual abuse, physical/emotional neglect), and domains of social functioning and social cognition in adults with PD. We also examined moderators and mediators of these associations. A PRISMA-compliant systematic search was performed on 24 November 2022 (PROSPERO CRD42020175244). Fifty-three studies (N = 13 635 individuals with PD) were included in qualitative synthesis, of which 51 studies (N = 13 260) with 125 effects sizes were pooled in meta-analyses. We found that CM was negatively associated with global social functioning and interpersonal relations, and positively associated with aggressive behaviour, but unrelated to independent living or occupational functioning. There was no meta-analytic evidence of associations between CM and social cognition. Meta-regression analyses did not identify any consistent moderation pattern. Narrative synthesis identified sex and timing of CM as potential moderators, and depressive symptoms and maladaptive personality traits as possible mediators between CM and social outcomes. Associations were of small magnitude and limited number of studies assessing CM subtypes and social cognition are available. Nevertheless, adults with PD are at risk of social functioning problems after CM exposure, an effect observed across multiple CM subtypes, social domains, diagnoses and illness stages. Maltreated adults with PD may thus benefit from trauma-related and psychosocial interventions targeting social relationships and functioning.

A multinational case-control study comparing forensic and non-forensic patients with schizophrenia spectrum disorders: the EU-VIORMED project

BACKGROUND

The relationship between schizophrenia and violence is complex. The aim of this multicentre case-control study was to examine and compare the characteristics of a group of forensic psychiatric patients with a schizophrenia spectrum disorders and a history of significant interpersonal violence to a group of patients with the same diagnosis but no lifetime history of interpersonal violence.

METHOD

Overall, 398 patients (221 forensic and 177 non-forensic patients) were recruited across five European Countries (Italy, Germany, Poland, Austria and the United Kingdom) and assessed using a multidimensional standardised process.

RESULTS

The most common primary diagnosis in both groups was schizophrenia (76.4%), but forensic patients more often met criteria for a comorbid personality disorder, almost always antisocial personality disorder (49.1 v. 0%). The forensic patients reported lower levels of disability and better social functioning. Forensic patients were more likely to have been exposed to severe violence in childhood. Education was a protective factor against future violence as well as higher levels of disability, lower social functioning and poorer performances in cognitive processing speed tasks, perhaps as proxy markers of the negative syndrome of schizophrenia. Forensic patients were typically already known to services and in treatment at the time of their index offence, but often poorly compliant.

CONCLUSIONS

This study highlights the need for general services to stratify patients under their care for established violence risk factors, to monitor patients for poor compliance and to intervene promptly in order to prevent severe violent incidents in the most clinically vulnerable.

Child abuse and aggressiveness in individuals diagnosed with schizophrenia in Lebanon

OBJECTIVES

To identify individual and clinical risk factors of aggressiveness, including exposure to different forms of childhood trauma, in a sample of Lebanese patients with schizophrenia.

METHODS

A total of 131 patients diagnosed with schizophrenia participated in this cross-sectional study.

RESULTS

Higher physical (Beta = 0.24, p < 0.001) and sexual (Beta = 0.29, p = 0.003) abuse, alcohol drinking (Beta = 1.46, p = 0.008), having a history of head trauma (Beta = 1.10, p = 0.041), and male gender (Beta = -1.59, p = 0.009) were significantly associated with higher mean aggression scores.

PRACTICAL IMPLICATIONS

Our investigation of the factors linked to aggressiveness in patients with schizophrenia complement those of earlier findings, showing that the relationship between interacting individual and environmental risk factors and later aggressiveness is quite complex, and needs further longitudinal and prospective studies.

Childhood trauma, social cognition and schizophrenia: Specific association between physical neglect and cognitive theory of mind in homicide offenders

Schizophrenia is associated with a small, but increased risk of violent behavior, including homicide. Violent individuals with schizophrenia have elevated rates of childhood trauma and substantial social cognitive impairments. The aim of this study was to examine if childhood trauma is related to social cognition in homicide offenders with schizophrenia. We recruited 26 individuals with schizophrenia sentenced to compulsory mental care for homicide/attempted homicide and 28 non-violent schizophrenia controls. They filled out the Childhood Trauma Questionnaire (CTQ), providing scores for physical abuse, sexual abuse, emotional abuse, physical neglect and emotional neglect. Social cognition was assessed with two measures of emotion processing (Emotion in Biological Motion, Pictures of Facial Affect) and two theory of mind (ToM) tests (Hinting Task, Movie for the Assessment of Social Cognition: MASC). Spearman's rho correlation coefficients were computed, and significant results followed up with partial correlation analyses controlling for IQ. Three associations were statistically significant, all in the homicide group; between CTQ physical neglect and cognitive ToM assessed with Hinting Task and with MASC, and between CTQ emotional neglect and Hinting Task. Only the first remained significant after controlling for IQ, indicating a specific association between physical neglect and cognitive ToM in homicide offenders with schizophrenia.

Pathways to aggression and violence in psychosis without longstanding antisocial behavior: A review and proposed psychosocial model for integrative clinical interventions

There is a need for a clearer understanding of the factors associated with increased risk of aggression and violence (AV) among people with psychosis and other severe mental illness (SMI) to guide effective prevention and intervention. The current article (1) reviews the literature regarding psychosocial factors associated with AV among individuals with psychosis and other SMI who do not have longstanding antisocial behaviors, (2) proposes an integrative psychosocial model of AV that can be practically applied, and (3) proposes appropriate evidence-based clinical interventions to reduce AV and facilitate recovery. We propose that increased risk for AV among people with psychosis is driven by anger, which is affected by a range of factors including victimization and situational stressors, social rejection or experiences of discrimination, anxious arousal, and hostile attribution bias related to psychosis. The cumulative effect of these systems is exacerbated by co-occurring substance misuse and increased impulsivity, particularly negative urgency. In consideration of the current psychosocial model and existing evidence-based interventions for AV in individuals with psychosis, we propose that trauma-informed interventions that integrate skills training in emotion regulation, social and interpersonal situations, cognitive restructuring and remediation, and modified prolonged exposure may demonstrate the most promise for this population.

Childhood Trauma in Persons With Schizophrenia and a History of Interpersonal Violence

BACKGROUND

Childhood trauma is a risk factor for psychosis as well for violent behavior and offending later in life. Childhood trauma comprises subdomains of abuse and neglect that may be differently related to later violence among patients with schizophrenia. The aim of this study was to map the subdomains of childhood trauma associated with violent offending in schizophrenia.

METHODS

Information on childhood trauma from predominantly male patients with a DSM-IV diagnosis of schizophrenia and a history of violent offending (interpersonal violence) (SCZ-V, n = 19), schizophrenia patients without a history of violence (SCZ-NV, n = 34), and healthy controls (HC, n = 66) was obtained with the Childhood Trauma Questionnaire (CTQ). Differences between groups in total maltreatment scores and the five subdomains including physical, emotional, and sexual abuse, as well as physical and emotional neglect were analyzed.

RESULTS

SCZ-V had the highest median CTQ scores for all sub-domains. SCZ-V reported significantly higher total CTQ scores than SCZ-NV and HC. SCZ-V had significantly higher scores than HC on all subdomains, and significantly higher than SCZ-NV on physical and emotional neglect. SCZ-NV had higher scores on all domains except sexual abuse compared to HC.

CONCLUSION

SCZ-V patients had higher exposure to childhood trauma than SCZ-NV, and both schizophrenia groups had higher exposure than HC. The results suggest that childhood physical and emotional neglect may be of specific importance to later violence in schizophrenia.

A History of Trauma is Associated with Aggression, Depression, Non-Suicidal Self-Injury Behavior, and Suicide Ideation in First-Episode Psychosis

The association between trauma and psychosis outcomes is well-established, and yet the impact of trauma on comorbid clinical symptoms-such as aggression, non-suicidal self-injury behavior (NSSIB), suicide ideation, and suicide behavior-for those with psychosis is unclear. To effectively treat those with first-episode psychosis (FEP) and a history of trauma, we need to understand the impact of trauma on their whole presentation. FEP participants were recruited from an Early Psychosis Program (N = 187, ages 12-35, 72.2% male). Clinicians gathered history of trauma, aggression, and suicide data, and rated current symptom severity and functioning. Data was coded using clinician rated measures, self-report measures, and retrospective clinical chart review. Regression analyses examined whether trauma was associated with a history of aggression, suicidal ideation, suicide behavior, NSSIB, symptoms, and functioning. Trauma was associated with aggression, aggression severity and type of aggression (aggression towards others). Trauma was also associated with depression severity, suicide ideation, most severe suicide ideation, and NSSIB. Trauma was not associated with suicide behavior, severity of suicide behavior or psychosocial functioning. Integrating trauma treatment into FEP care could reduce rates of depression, aggression, suicide ideation, and NSSIB for those with a history of trauma. To reduce suicide attempt occurrence and improve functioning, more research is needed.

The Relationship Between Childhood Maltreatment and Violence to Others in Individuals With Psychosis: A Systematic Review and Meta-Analysis

BACKGROUND

There is a growing body of literature identifying a relationship between experiences of child abuse and symptoms of psychosis in adults. However, the impact of this relationship on risk of violence has not been systematically explored.

AIMS

This meta-analysis aimed to consider the influence of childhood abuse on the risk of violence among individuals with psychosis.

METHOD

Five bibliographic databases and two gray literature resources were systematically searched to identify quantitative research which measured risk of violence and experiences of childhood maltreatment in individuals with psychosis. Risk of bias for each study was assessed under predefined criteria. Logged odds ratios (OR) were synthesized quantitatively in a meta-analysis.

RESULTS

A total of 6,298 studies were identified, 11 of which were included in the final analysis (N = 2,215), all studies were of a cross-sectional or case-control design. Individuals with psychotic illnesses who reported historical child maltreatment were at approximately twice the risk of perpetrating violence than patients who reported no early abuse, OR = 2.46, 95% confidence interval (CI) = [1.91, 3.16]. There was no statistical heterogeneity between main effects (τ = .00; χ² = 8.87, df = 10, p = .54, I² = 0%).

DISCUSSION

Risk assessments and interventions may benefit from considering the unique contribution of trauma to violence in this population. Future research considering the interaction between childhood experiences and other risk factors for violence in this population, including specific symptoms of psychosis, would inform the current findings. Findings are limited by the lack of longitudinal research in this area, and there was some evidence of publication bias.

Early life stress predicts cortisol response to psychosocial stress in healthy young adults

Repeated exposure to stress during early life has a lifetime impact on physical and psychological functions. Our study investigated the long-term effects of early life stress (ELS; measured retrospectively) on the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system functions under psychosocial stress among healthy adults. Fifty healthy volunteers (33 male, 17 female, mean age 22.6 ± 1.8 years) underwent a standardized psychosocial stress protocol (the Trier Social Stress Test), with the collection of salivary cortisol, heart rates, and positive and negative affect. The results showed increases in cortisol, heart rate, and negative affect after the stress inducement. More importantly, a significant negative correlation was found between the severity of ELS and the increase of cortisol to the stress. The severity of stress in one's early life predicted his/her cortisol reactivity to the stress in adulthood. Neither the heart rate reactivity nor the affective reactivity shows significant association with ELS. The blunted cortisol reactivity reflects the alteration of the HPA axis, which may confer the risk for certain stress-related disorders.

DO POSITIVE PERCEPTIONS OF CORRECTIONAL STAFF MITIGATE INSTITUTIONAL VIOLENCE AMONG YOUTHFUL OFFENDERS?

Juvenile justice facilities can be dangerous places for adolescents and may promote violent behavior among incarcerated youth. With high rates of violence among detained juveniles, youth who do not feel safe may resort to violent behavior to protect themselves. However, this "cycle of violence" may be interrupted if youth can turn to correctional staff for support. Using a 3-wave, longitudinal sample of 373 male incarcerated adolescents, the results indicated that as compared to violence exposure prior to incarceration, exposure to institutional violence more strongly predicts violent behavior. Further, the findings indicated that perceptions of staff serve as a buffer to violence exposure and may interrupt the cycle of violence. Policy implications are discussed.

Aggressive Behavior, Hostility, and Associated Care Needs in Patients With Psychotic Disorders: A 6-Year Follow-Up Study

Background: Hostility and aggressive behavior in patients with psychotic disorders are associated with demographic and clinical risk factors, as well as with childhood adversity and neglect. Care needs are an essential concept in clinical practice; care needs in the domain of safety for others reflect the actual problem the patient has. Hostility, aggressive behavior, and associated care needs, however, are often studied in retrospect. Method: In a sample of 1,119 patients with non-affective psychotic disorders, who were interviewed three times over a period of 6 years, we calculated the incidence of hostility, self-reported maltreatment to others and care needs associated with safety for other people (safety-to-others). Regression analysis was used to analyze the association between these outcomes and risk factors. The population attributable fraction (PAF) was used to calculate the proportion of the outcome that could potentially be prevented if previous expressions of adverse behavior were eliminated. Results: The yearly incidence of hostility was 2.8%, for safety-to-others 0.8% and for maltreatment this was 1.8%. Safety-to-others was associated with previous hostility and vice versa, but, assuming causality, only 18% of the safety-to-others needs was attributable to previous hostility while 26% was attributable to impulsivity. Hostility, maltreatment and safety-to-others were all associated with number of unmet needs, suicidal ideation and male sex. Hostility and maltreatment, but not safety-to-others, were associated with childhood adversity. Neither safety-to-others, maltreatment nor hostility were associated with premorbid adjustment problems. Conclusion: The incidence of hostility, self-reported aggressive behaviors, and associated care needs is low and linked to childhood adversity. Known risk factors for prevalence also apply to incidence and for care needs associated with safety for other people. Clinical symptoms can index aggressive behaviors years later, providing clinicians with some opportunity for preventing future incidents.

A feasibility study on violence prevention in outpatients with schizophrenia

Patients with schizophrenia have an increased risk of violent behavior, and occupy a large percentage of forensic beds. Most patients in forensic psychiatry have already undergone general psychiatric therapy. This predestinates general psychiatrists to identify those patients presenting such a risk, and to try to intervene so that violence can be prevented. Feasibility study of violence prevention using cognitive-behavioral therapy interventions in male patients with schizophrenia on a general psychiatric ward. Of our patients admitted with schizophrenia, 39.1% had committed violent acts against others; the severity of the act was usually low. The percentage of non-participants was high (83.1%). Study subjects were younger, had not been ill for as long, and were less apt to drop out of the ongoing general psychiatric treatment than the non-participants. Study subjects and non-participants did not differ in the violent act's severity. Our therapy manual proved to be sensible and practical. Those of us attempting to prevent schizophrenic patients from committing violence must deal with individuals who are generally hard to reach. We succeeded in achieving a low drop-out rate after having recruited patients who had displayed a substantial propensity to violence against others.

Toward a unified theory of childhood trauma and psychosis: A comprehensive review of epidemiological, clinical, neuropsychological and biological findings

There is a growing body of research focused on the relationship between childhood trauma and the risk of developing psychosis. Numerous studies, including many large-scale population-based studies, controlling for possible mediating variables, provide persuasive evidence of a dose-response association and are indicative of a causal relationship. Existing evidence supports the specificity model, showing differential associations between particular adversities and clinical symptoms, with cumulative adversity causing less favorable clinical and functional outcomes in psychotic patients. To date, several psychological and biological models have been proposed to search for underlying developmental trajectories leading to the onset of psychosis, influencing psychopathological manifestation and negative functional outcomes due to a history of childhood trauma. In this article, we provide a unified review on the relationship between childhood trauma and psychosis by integrating results of epidemiological, clinical, neuropsychological and biological studies. The question whether psychosis with a positive history of childhood trauma should be considered as a new psychotic phenotype, requiring specific therapeutic interventions, warrants further investigation.

The Violent Content in Attenuated Psychotic Symptoms

The relationship between psychosis and violence has typically focused on factors likely to predict who will commit violent acts. One unexplored area is violence in the content of subthreshold positive symptoms. The current aim was to conduct an exploratory analysis of violent content in the attenuated psychotic symptoms (APS) of those at clinical high risk of psychosis (CHR) who met criteria for attenuated psychotic symptom syndrome (APSS). The APS of 442 CHR individuals, determined by the Structured Interview for Prodromal Syndromes, were described in comprehensive vignettes. The content of these symptoms were coded using the Content of Attenuated Positive Symptoms Codebook. Other measures included clinical symptoms, functioning, beliefs and trauma. Individuals with violent content had significantly higher APS, greater negative beliefs about the self and others, and increased bullying. The same findings and higher ratings on anxiety symptoms were present when participants with self-directed violence were compared to participants with no violent content. Individuals reporting violent content differ in their clinical presentation compared to those who do not experience violent content. Adverse life events, like bullying, may impact the presence of violent content in APS symptoms. Future studies should explore violent content in relation to actual behavior.

Childhood adversity and conduct disorder: A developmental pathway to violence in schizophrenia

BACKGROUND

Both childhood adversity and conduct disorder are over-represented among adult patients with schizophrenia and have been proposed as significant factors that may increase the risk of violence. It is not known how childhood adversity and conduct disorder might interact to contribute towards an increased risk of violence in schizophrenia. This study aimed to explore the relationships between childhood adversity, conduct disorder and violence among men with schizophrenia.

METHODS

54 male patients with schizophrenia from a range of inpatient and outpatient mental health services were assessed for exposure to a variety of childhood adversities, conduct disorder before the age of 15 and later violent behaviour in adulthood.

RESULTS

Exposure to domestic violence during childhood was associated with an increased propensity to violence in adulthood. Symptoms of conduct disorder were associated both with cumulative exposure to childhood adversities and with later propensity to violence. The cumulative number of childhood adversities was associated with adult propensity to violence. This association was significantly attenuated by inclusion of conduct disorder in the model.

CONCLUSIONS

This is the first study to demonstrate an association between childhood exposure to domestic violence and later violent behaviour in schizophrenia. Conduct disorder may mediate the association between cumulative childhood adversities and adult propensity to violence, indicating an indirect pathway. These results indicate a complex interplay between childhood adversity, conduct disorder and later violent behaviour in schizophrenia, and suggest that there may be shared aetiological risk factors on a common developmental pathway to violence.

The effects of childhood abuse on self-reported psychotic symptoms in severe mental illness: Mediating effects of posttraumatic stress symptoms

The present study examined the role of posttraumatic stress symptoms in the relationship between childhood abuse and self-reported psychotic symptoms in severe mental illness. A total of 126 patients diagnosed with major psychiatric conditions with comorbid symptoms of psychosis participated in the present study. The representative psychiatric diagnoses included schizophrenia, bipolar disorder with psychotic features, major depressive disorder with psychotic features, schizoaffective disorder, schizophreniform disorder, and delusional disorder. The Korean Child Trauma Questionnaire measured the type and degree of childhood abuse including emotional, physical, and sexual abuse. Korean version of the Impact of Event Scale-Revised assessed posttraumatic stress symptoms, and PSYC subscale of the PSY-5 Factor Scale of the MMPI-2 was used as a measure of self-reported psychotic symptoms. There was a significant relationship between childhood physical, emotional, sexual abuse and psychotic symptoms. Posttraumatic stress symptoms partially mediated the relationship between childhood abuse and psychotic symptoms. This implies that childhood abuse is significantly associated with the experience of chronic posttraumatic stress symptoms, and that such symptoms in turn increases the likelihood of experiencing psychotic symptoms. The results highlight the need for appropriate assessment and intervention concerning childhood abuse and posttraumatic stress symptoms in severe mental illness.