Role of Child Abuse in Psychosis is there Such a Thing as Primary Prevention of Schizophrenia?

Editorial

The repercussions in adults of traumatic experiences during childhood have been studied in psychiatric diseases as varied as posttraumatic stress, addictions, affective disorders, and antisocial and borderline personality disorders. Childhood adversity explains 28.9% of non psychotic psychiatric disease in countries with very different socioeconomic profiles [1]. Although the relationship between trauma and psychosis had been largely ignored, over the past decade the study of childhood adversity and psychosis has begun to receive the clinical attention it deserves. Studies based on representative population samples of the relationship between trauma and psychosis did not really come to light until 2004. A review published in 2005 included 51 studies (published from 1987 to 2004) in clinical populations, and with limited sample sizes, that related childhood trauma to psychosis. The authors reported very high rates of childhood sexual abuse (48% in women and 28% in men) and physical maltreatment (48% and 50%, respectively) in populations affected with serious mental disorders [2].

Since 2004,retrospective3 and prospective [4,5] studies have been carried out in broad populations drawn from national health service records, in which close relationships were observed between childhood trauma and psychosis, both subsyndromic psychotic symptoms and clinical psychosis.

In a sample of 102 patient’s diagnosed with schizophrenia, bipolar disorder, or schizoaffective disorder in Spain, our group found that 47.7% of the patients had experienced some type of abuse or neglect during childhood. These individuals had more hospital admissions, more suicide attempts, and earlier onset of mental disease [6] than the remaining participants.

Given the vague diagnostic boundaries for schizophrenia, researchers have attempted to assess the relationship between different traumatic events and psychotic experiences. Childhood sexual abuse has been associated with clinical hallucinations, and institutionalization during childhood with delusional thinking. Physical abuse was associated with both types of psychotic experiences. Both the intensity and the presence of more than one type of traumatic experiences were related to symptom severity [7].

Finally, we would cite a Meta analysis that observed a significant relationship between childhood trauma and psychosis, with a mean odds ratio of 2.8. The authors concluded that childhood trauma was related both to the presence of psychotic symptoms in the general population and to the development of psychotic disorders. All types of interpersonal trauma experienced during childhood were related to psychosis, with the key factors being polytraumatization and the child’s age at the time of exposure to trauma [8].

We would emphasize the concept of “polytraumatization”, defined as having a history of more than one type of interpersonal trauma during childhood, including sexual abuse, physical abuse and/or neglect, and psychological abuse and/or neglect. Polytraumatization has been associated with the appearance of psychotic symptoms, in a dose-response relationship [9]. In this sense, a study by our team showed that the experience of more than 4 types of trauma during childhood resulted in a 10 times greater risk of schizophrenia [10].

It seems that the total effect of a greater number of types of traumas on adult psychopathology, and psychosis as well, is greater than the simple “sum of the parts”, understood as the effects of each distinct type of abuse suffered. Individuals who have experienced polytraumatization also present the most severe traumas and come from families that were the most dysfunctional overall, with a higher rate of parental unemployment, poverty, alcoholism, or mental illness [11].

Although the past decade has seen the emergence of literature on childhood trauma and psychosis, much work is needed to shed light on the mediating factors between these two entities. Even so, families on the margins of society seem to have a greater propensity toward childhood polytraumatization and psychosis. This brings us to consider the possibility of primary prevention of schizophrenia by investing in at-risk children with health care policies that will also have economic and social impact.

References

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