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Psychiatry Research
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a r t i c l e i n f o a b s t r a c t
Article history: Dissociation, though understood as a response to trauma, lacks a proven etiology. The assumption of a dose–
Received 29 April 2010 response relationship between trauma, dissociation and Schneiderian symptoms led to the proposal of a
Received in revised form 5 January 2011 dissociative subtype of schizophrenia characterized by severe child maltreatment, dissociation and psychosis.
Accepted 10 January 2011
Child maltreatment and dissociation are common features of neurotic disorders as well, and the link between
trauma, dissociation, and hallucinations is not specific for schizophrenia. This study compares childhood
Keywords:
Childhood trauma
abuse and neglect, posttraumatic distress and adult dissociation in patients with psychotic vs. non-psychotic
Dissociation disorder. Thirty-five participants with non-psychotic disorder and twenty-five with schizophrenia were
PTSD analyzed using the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of
Psychotic disorder Negative Symptoms (SANS), the Montgomery–Åsberg Depression Rating Scale (MADRS), the Posttraumatic
Non-psychotic disorder Stress Diagnostic Scale PDS (PDS), the Childhood Trauma Questionnaire (CTO) and the Arbeitsgemeinschaft
Methodik und Dokumentation in der Psychiatrie (AMDP)-module on dissociation. Trauma and clinical
syndromes were compared by means of T-testing and logistic regression between 1) the diagnoses and
2) groups with and without post-traumatic stress disorder (PTSD), marked dissociation and psychotic symptoms.
While non-psychotic disorder was related to abuse, schizophrenia showed an association with neglect. Childhood
trauma predicted posttraumatic symptomatology and negative symptoms. Childhood abuse and neglect may
effectuate different outcomes in neurotic and psychotic disorder. The underlying mechanisms, including
dissociation, dovetail with cognitive, emotional and behavioural changes involved in depression, posttraumatic
distress and chronic schizophrenia symptoms rather than being directly linked to trauma.
© 2011 Elsevier Ireland Ltd. All rights reserved.
0165-1781/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2011.01.008
122 M. Vogel et al. / Psychiatry Research 189 (2011) 121–127
1993; Molina-Serrano et al., 2008), obsessive compulsive disorder (2004a) contends that trauma, especially early and chronic childhood
(Fontenelle et al., 2007), anxiety disorders (Michal et al., 2005), trauma and dissociation, is the most important contributing factor to
substance abuse disorder (Evren and Evren, 2006), somatisation mental illness. Consequently, Ross (2004) proposes a dissociative
disorder (Brown et al., 2005), borderline personality disorder subtype of schizophrenia and contends that non-dissociative schizo-
(Merckelbach et al., 2005), and also severe mental illness, such as phrenia, dissociative subtype of schizophrenia, schizo-dissociative
schizophrenia (Ross and Keyes, 2004b; Vogel et al., 2009a). Therefore, disorder, and dissociative identity disorder constitute a psychopath-
the high prevalence of dissociative disorders, found to be 25–30% in ological spectrum. Since this hypothesis is based on comorbidity,
in- and outpatient psychiatric populations, does not come as a sur- elevated trauma rates and concurrent dissociative symptoms, the
prise (Saxe et al., 1993; Foote et al., 2006). question arises as to what extent patients that dissociate in the
Similarly, adverse childhood experiences are common not only schizophrenia spectrum differ from maltreated dissociators outside
among individuals suffering from post-traumatic stress disorder this diagnostic range. Notably, an intriguing difference between these
(PTSD) (Mulder et al., 1998) and dissociative disorder (Tutkun et al., clinical populations pertains to their reaction to PTSD, which seems to
1998) but also among those with mood disorder (Johnstone et al., induce psychotic symptoms in non-schizophrenic populations, but
2009), substance use disorder (Tucci et al., 2010), anxiety (Hovens et not to accentuate psychotic symptoms in those with schizophrenia
al., 2010; Simon et al., 2009), somatoform disorder (Spitzer et al., (Hamner et al., 2000; Vogel et al., 2009a).
2008) and schizophrenia (Vogel et al., 2009b). More specifically, The present study aims at the investigation of the differences in the
childhood neglect has been associated with depression (Harkness and experience of dissociation, psychotic features and posttraumatic
Monroe, 1997; Bernet and Stein, 1999), substance abuse disorder stress symptoms as potential responses to trauma between psychotic
(Singer et al., 2004; Evren and Evren, 2006), obsessive–compulsive vs. non-psychotic disorders. Both these clinical domains are known to
disorder (Lochner et al., 2004), eating disorder (Grilo and Masheb, exhibit high degrees of dissociation, childhood trauma and PTSD, but
2001; Mitchell and Mazzeo, 2005), anxiety in obsessive–compulsive differ substantially in the expression of symptoms, raising the
disorder (Matthews et al., 2008), depression (Moskvina et al., 2007) question whether different histories of childhood trauma may
and schizophrenia (Vogel et al., 2009a; Sar et al., 2010). account for their respective clinical appearances in adulthood. In
Incidence of childhood abuse has been correlated to depression addition, the present study is concerned with the association of
(Brown et al., 2005; Hovens et al., 2009; Tucci et al., 2010), anxiety trauma and dissociation with different psychopathological syn-
disorder (Simon et al., 2009), somatisation disorder (Spitzer et al., dromes, in particular negative symptoms of schizophrenia, as they
2008) and severe mental illness, i.e. bipolar disorder (McIntyre et al., may lend support to claims of a complex causation of dissociation as a
2008) and schizophrenia (Ross and Keyes, 2004). Moreover, there are result of cognitive alterations, which are a hallmark of these negative
associations of childhood sexual abuse with multiple personality symptoms.
disorder (Ross and Ness, 2010) and of childhood emotional abuse
with depersonalization disorder (Simeon et al., 2001, 2008), which 2. Methods
(Ross and Keyes, 2004; Jessop et al., 2008; van der Hart et al., 2006).
2.2. Instruments
Not only does this pose the question of differential diagnosis and
comorbidity, but it may also be accounted for by shared risk factors, Symptoms were assessed in interviews using the Scale for the Assessment of
fuzzy boundaries between the overlapping diagnoses or a mutual Positive Symptoms (SAPS; Andreasen, 1984), the Scale for the Assessment of Negative
effect on the respective vulnerability. Accordingly, Sar and Öztürk Symptoms (SANS; Andreasen, 1983), the Montgomery–Åsberg Depression Rating Scale
(MADRS; Montgomery and Åsberg, 1979), the German version (Ehlers et al., 1996) of
(2008) propose a duality (interaction) model to explain the complex the Posttraumatic Stress Diagnostic Scale (PDS) (Foa et al., 1997) and the
co-existence of two qualitatively distinct but interactive, concurrent Arbeitsgemeinschaft Methodik und Dokumentation in der Psychiatrie (AMDP) module
or subsequent psychopathologies as a possibility. Contrarily, Ross “dissociation”, hereafter referred to as AMDP-Dis (Freyberger and Moller, 2004) by
M. Vogel et al. / Psychiatry Research 189 (2011) 121–127 123
thoroughly trained raters. The PDS is assigned good to very good internal consistence and high and low on SANS, respectively. It should be noted that PTSD was treated
(Cronbach's alpha = 0.92) and retest reliability (kappa = 0.74). Convergent validity at both as a category (for the purpose of investigating its impact on the variables of
comparison with the corresponding SCID section is moderate (Cohen's Kappa = 0.59). interest) and dimensionally (based on the assumption that the number of PTSD
The SAPS has 30 items while its companion, SANS, has 20. Each item is scored on a six- symptoms would indicate severity of posttraumatic distress independently from the
point Likert-type scale; the interrater-reliabilities are 0.84 and 0.60, respectively. The fulfilment of all formal requirements on which the diagnosis is based by definition). For
AMDP scale for dissociation and conversion is a 30 item rating scale (english translation the purpose of this study, participants were asked to respond to the full scope of the
in Vogel et al., 2009b) with good psychometric properties: its high correlation with the Post-Traumatic Distress Scale (PDS) questionnaire. In this respect, the authors deviated
German version of the dissociative experiences scale (r = 0.8; FDS) suggests strong from the standard diagnostic procedure, which would have, in some cases, stopped the
concordant validity (Spitzer et al., 2004), and the interrater-reliability of the AMDP interview based on the non-fulfilment of certain PTSD criteria. The rationale behind
system is judged to be high, in general (Bobon et al., 1985). The score for each item is utilizing the full scope of the PDS scale was to obtain the most comprehensive and
either 0 (not at all) or one (mild) or two (moderate) or three (severe). The present multi-dimensional evaluation of post-traumatic distress and ensure that no single
study made use of the 15 items pertaining to psychological dissociation, only. symptom was overlooked. In order to ensure a consistent and objective rating of each
The 28 item version of the Childhood Trauma Questionnaire (CTQ) was used for the participant, the PDS was observer-rated as opposed to self-rated. The dimensional
self-report of child maltreatment (Bernstein et al., 2003). It is a brief, reliable and valid measures of PTSD symptoms are referred to as PTSD-Dim, and the categorical measures
screening device for histories of childhood trauma including emotional, sexual and shall hereafter be referred to as the secondary category. Additionally, the sample was
physical abuse (CEA, CSA, and CPA), as well emotional and physical neglect (CEN, and divided in terms of those with and without a history of childhood abuse and neglect on
CPN) with good reliability and validity (Bernstein and Fink, 1998). For the intended the CTQ. Any score above low trauma rendered the participant positive for childhood
analyses, the group as a whole was split according to the means of AMDP-Dis, SAPS and trauma. This procedure was adopted from Dorahy et al. (2009b).
SANS measures into groups scoring high and low on dissociation, high and low on SAPS,
2.3. Statistical analyses
Step 3, so far as they were not defining the dependent variable. For disorder. Likewise, child abuse and MADRS seem to synergistically
example, SAPS scores were omitted in the prediction of high scores on increase the risk of dissociation. Interestingly, a key difference is
SAPS, AMDP-Dis scores omitted in the prediction of high dissociation, evident among participants in the primary categories, namely that
and nPTE/PTSD-Dim scores omitted in the prediction of PTSD. Block 3 the elevated severity of childhood neglect in patients with schizo-
also contained the primary diagnostic category as a covariate. phrenia stands in sharp contrast to the relative elevation of child-
As shown in Table 4, gender and SANS were significant predictors hood abuse in the non-schizophrenia group. This result corroborates
of the diagnostic category but lost significance when AMDP-Dis was previous findings (Vogel et al., 2009a; Sar et al., 2010), which
entered as covariate. CEA and AMDP-Dis predicted PTSD. Only MADRS establish a relationship between CPN and high dissociation in
predicted high dissociation significantly, but CPA increased the odds schizophrenia. However, rather than linking neglect to dissociation,
ratio (OR) of belonging to the high dissociatiors' group to a similar the present study yields evidence for a link between negative
extent (17% vs. 16%) as MADRS. By choice of forward stepwise symptoms and childhood trauma, which is more relevant for chronic
methods, further variables were excluded from the model due to lack psychosis given the specificity of negative syndromes for schizo-
of significance. Scoring highly on SAPS was better predicted by SANS phrenia (Schennach-Wolff et al., 2009; Wobrock et al., 2009).
than by AMDP-Dis. Negative symptoms were predicted by SAPS, Negative symptoms tend to be associated with higher levels of
AMDP-Dis and the presence of any childhood trauma. physical neglect, lower levels of abuse and the presence of any
childhood trauma. Notwithstanding the small sample size, regres-
4. Discussion sion analysis suggests the presence of childhood trauma and
dissociation to be protective against negative symptoms in those
The purpose of the present study was to explore differences in the patients with neurotic disorder, but the presence of any childhood
association of childhood trauma, PTSD and dissociation with psychotic trauma was positively correlated with negative symptoms in
and non-psychotic disorder. As reported in previous studies (Vogel patients with schizophrenia. Given the contrast between high levels
et al., 2009b), severe CPN has been associated with schizophrenia. of abuse in the non-psychotic category and high levels of neglect in
Although childhood trauma among participants in the present study the schizophrenia category, a factual increase in the odds of negative
was predominantly low and did not differ markedly between the symptoms may originate in neglect but be disguised by opposite
categories, the results have interesting implications. Firstly, all forms effects of different childhood trauma domains in the distinct diag-
of childhood abuse showed significant associations with PTSD and nostic categories. Research has found an impact of dissociation on
dissociation. Secondly, at the symptom level, a link between positive and, to a lesser extent, on negative symptoms of schizo-
dissociation and positive symptoms apparently holds in one direction, phrenia (Ross and Keyes, 2004; Vogel et al., 2009a). Negative
with dissociation predicting high scores on SAPS, but high scores on symptoms of schizophrenia, however, have been disregarded within
SAPS not necessarily predicting high dissociation. Thirdly, PTSD and the heuristic models of the interplay between psychosis and dis-
high dissociation showed similar associative patterns with each of sociation, probably due to the lack of an apparent overlap between
their respective defining variables (PTSD-Dim, nPTE and AMDP-Dis) these negative symptoms and dissociative syndromes. Hence, the
and also with MADRS scores. Lastly, positive symptoms, as measured results of the present study may point to an innovative new path of
by SAPS, were more closely related to dissociation than to PTSD and research: instead of causing dissociation, childhood abuse and
were not specific to schizophrenia. Surprisingly, negative symptoms neglect may engender disruptions of cognitive, emotional, motiva-
of schizophrenia were not only linked to their counterpart with tional, and social functioning which map onto the construct of
schizophrenia and to dissociation but also to the presence of child- negative symptoms. This is a cogent assertion, given that repeated
hood trauma. and long-lasting experiences of neglect could intuitively be dis-
couraging to relational engagement.
4.1. Childhood adversities and adult susceptibility to symptoms of
posttraumatic distress and schizophrenia 4.2. Negative symptoms may function as a cognitive and emotional defence
The prediction of PTSD by dissociation holds obvious implications Dorahy et al. (2009a) observed interpersonal disconnectedness
for the concept of PTSD, which perhaps unjustly excludes dissoci- and childhood neglect were linked to complex PTSD, a chronic
ation within its definition. Moreover, the stepwise results suggest posttraumatic condition characterized by somatisation, impaired
that CEA and dissociation could increase an individual's propensity affect regulation, altered consciousness, self-perceptions and systems
to encounter posttraumatic distress, meaning that child abuse, of meanings, as well as distorted relations to others (Herman, 1992).
dissociation and trauma appear to co-participate in the mediation of Negative symptoms in schizophrenia could be as effective a mecha-
PTSD, without categorical specificity for either psychotic or neurotic nism for the elusion of adverse cognitive and emotional stimulation as
avoidance is in the fields of anxiety and posttraumatic distress. This
interesting, albeit tentative, proposal is empirically supported by an
Table 2 association of amnesia with negative symptoms and of CPN with
Distribution of PTSD and groups classified according to low and high expression of the dissociation in patients with schizophrenia (Vogel et al., 2009a,b). A
defining characteristic among the diagnostic categories. putative overlap of negative symptoms and PTSD dimensions might
N (%/%females) Schizophrenia Neurotic disorder χ2 p
also lend an explanation to the finding that a concurrent diagnosis of
PTSD and schizophrenia is not associated with a dramatic increase in
No CHT 21 (84.0/28.6) 33 (94.3/72.7) 1.71 0.2
schizophrenia symptoms (Vogel et al., 2009a), as PTSD may simply
CHT 4 (16.0/25.0) 2 (5.7/50.0)
No PTSD 15 (60.0/33.3) 19 (54.3/78.9) 0.19 0.79 amalgamate with schizophrenic syndromes in terms of functional and
PTSD 10 (40.0/20.0) 16 (45.7/62.5) phenomenological similarities. Moreover, linking negative syndromes
Low dissociation 14 (56.0/35.7) 16 (45.7/56.3) 0.62 0.6 to dissociation is in-line with claims of a significant contribution of
High dissociation 11 (44.0/18.2) 19 (54.3/84.2)
cognitive failures to the etiology of dissociation (Giesbrecht et al.,
Low SAPS 8 (32.0/37.5) 30 (85.7; 73.3) 18.12 b0.01
High SAPS 17 (68.0/23.5) 5 (14.3/60.6) 2008). Whether an individual's diagnosis is neurotic or psychotic
Low SANS 3 (12.0/33.3) 32 (8.6/71.9) 40.26 b0.01 disorder, vulnerability to posttraumatic distress and adult dissociation
High SANS 22 (88.0/27.3) 3 (91.4/100.0) may originate in childhood experiences of abuse and neglect and be
CHT: childhood trauma; SAPS: Scale for the Assessment of Positive Symptoms; SANS: mediated by adult trauma and cognitive alterations in later life. By
Scale for the Assessment of Negative Symptoms. contrast, Schneiderian symptoms may be less relevant in this context,
M. Vogel et al. / Psychiatry Research 189 (2011) 121–127 125
Table 3
t-testing statistics.
Mean (S.D.) CEA CPA CSA CEN CPN CTQ-total SAPS SANS MADRS AMDP-Dis PTSD-Dim nPTE
Psychotic (n = 25) 8.88 7.20 6.17 16.17 12.46 38.36 51.48 65.00 25.72 13.52 10.48 1.84
4.10a 3.35b 3.23a 5.56c 3.36d 16.93 25.95 19.96 9.28 7.84 11.66 1.46
Neurotic (n = 35) 10.23 7.54 5.89a 17.20 11.63 39.00 19.80 24.29 26.14 15.46 13.34 1.65
5.30a 3.89a 2.84 5.86c 1.63c 868 12.17 9.12 8.89 6.59 13.85 1.51
t − 1.05 − 0.36 0.35 − 0.68 1.12 − 0.17 5.67 9.49 − 0.18 − 1.04 − 0.84 0.47
p 0.3 0.72 0.73 0.5 0.27 0.86 b0.01 b0.01 0.9 0.3 0.4 0.64
No CHT (n = 54) 9.07 7.13 5.72 16.78 11.61 35.83 32.15 39.28 25.59 14.53 11.33 1.61
4.31a 3.66b 2.36a 5.79c 2.11c 9.03 24.68 24.42 9.11 7.18 12.87 1.47
CHT (n = 6) 16.20 9.83 9.00 16.80 15.80 64.83 40.67 61.50 29.33 15.67 19.50 2.83
6.06d 2.79c 6.52c 5.31c 3.27d 10.83 25.11 22.39 7.47 7.34 12.34 1.17
t − 3.42 − 1.75 − 1.11 − 0.01 − 4.05 − 7.33 − 0.80 − 2.13 − 0.97 − 0.37 − 1.45 − 1.96
p b0.01 0.09 0.33 0.99 b 0.01 b 0.01 0.43 0.04 0.34 0.72 0.14 0.06
No PTSD (n = 34) 7.82 6.21 5.18 17.91 11.68 34.06 28.65 40.58 23.65 11.94 3.47 1.00
3.57b 2.74b 0.52b 5.25d 2.42c 9.94 24.81 26.27 9.24 6.76 7.37 1.18
PTSD (n = 26) 12.20 8.9 7.12 15.24 12.36 44.85 38.69 42.77 29.00 18.19 23.50 2.69
5.28a 4.13a 4.33a 6.06c 2.58c 13.37 23.69 3.68 7.78 6.07 9.37 1.29
t − 3.59 − 2.94 − 2.23 1.81 − 1.04 − 3.59 − 1.58 − 0.33 −2.38 − 3.71 − 8.98 −5.29
p b0.01 b 0.01 0.04 0.08 0.3 b 0.01 0.12 0.74 0.02 b0.01 b 0.01 b 0.01
LD (n = 30) 6.47 8.34 5.41 17.69 11.90 36.90 24.60 36.83 21.03 8.80 8.10 1.47
2.80b 3.70a 1.09b 5.43d 2.50c 13.68 19.35 24.04 7.73 4.69 10.61 1.33
HD (n = 30) 8.33 10.97 6.57 15.90 12.03 40.57 41.40 45.00 30.90 20.50 16.20 2.00
4.18b 5.51c 3.99a 5.93c 2.53c 11.48 26.75 26.13 7.33 3.30 13.96 1.60
t − 2.03 − 2.15 − 1.53 1.21 − .209 − 1.13 − 2.79 − 1.26 − 5.07 −11.18 − 2.53 − 1.40
p 0.05 0.04 0.14 0.23 0.84 0.27 0.01 0.21 b 0.01 b0.01 0.01 0.12
LP (n = 38) 7.63 10.12 5.70 16.59 11.46 39.12 17.21 28.39 23.95 12.95 10.16 1.68
3.75b 5.23c 2.67a 5.67c 1.85c 11.96 9.24 16.34 9.04 6.63 12.28 1.56
HP (n = 22) 7.00 8.95 6.50 17.09 12.82 38.09 60.27 62.55 29.45 17.59 15.59 1.82
3.52b 4.16a 3.45a 5.90c 3.17d 14.05 18.04 23.34 7.88 7.17 13.64 1.37
t 0.64 0.88 − 1.00 −0.32 − 1.83 0.30 − 10.43 −6.06 − 2.38 − 2.54 − 1.59 − 0.34
p 0.52 0.38 0.32 0.75 0.08 0.77 b0.01 b0.01 0.02 0.01 0.12 0.74
LN (n = 35) 7.40 10.06 5.46 17.43 11.49 37.91 20.54 23.26 25.94 14.97 11.83 1.60
3.77b 4.72c 1.07a 5.44c 1.72c 8.12 11.81 7.07 8.70 6.62 13.65 1.44
HN (n = 25) 7.50b 9.30 6.87 15.48 12.65 39.96 52.54 68.21 26.83 14.79 13.00 1.96
3.59 5.11a 4.51a 5.95c 3.30d 17.64 25.89 15.76 8.75 7.51 12.27 1.57
t − 0.10 0.57 −1.48 1.29 − 1.56 − 0.53 − 5.67 − 13.10 − 0.39 0.10 − 0.91 −0.34
p 0.92 0.57 0.15 0.20 0.13 0.60 b0.01 b0.01 0.70 0.92 0.37 0.74
Footnotes denote corresponding levels of severity according to CTQ-classifications; CEA: childhood emotional abuse; CPA: childhood physical abuse; CSA: childhood sexual abuse;
CEN: childhood emotional neglect; CPN: childhood physical neglect; CTQ-total: total CTQ-score; SAPS: scale for the assessment of positive symptoms; SANS: scale for the assessment
of negative symptoms; MADRS: Montgomery–Asberg depression rating scale; AMDP-Dis: AMDP-dissociation; PTSD-Dim: PTSD symptoms; nPTE: number of potentially traumatic
events. CHT: childhood trauma; LD: low dissociation, HD: high dissociation, LP: low scores on SAPS; HP: high scores on SAPS; LN: low scores on SANS; HN: high scores on SANS.
a
Low.
b
None.
c
Moderate.
d
Severe.
inasmuch as they are more closely linked to negative symptoms than as a whole, enabling a trauma-related phenomenology of both,
to trauma and dissociation. partial similarities and distinctive features to become apparent by
direct comparison. Thus, we see a lack of specific interactions
4.3. Synergism of current syndromes and distal causes to shape a between a) the diagnostic categories, b) dissociation, c) psychotic
phenomenology of similarities? features, and d) PTSD. Both categories exhibit psychotic features and
dissociation in coping with trauma. Furthermore, high dissociators
One can infer from the present results that inter-syndromal inter- very likely involve a high degree of psychotic features as well,
actions and dose–response relationships between trauma, posttraumatic suggesting an essential link between dissociation and Schneiderian
distress, dissociation and psychotic symptoms cross the borders of symptoms, regardless of whether or not the clinical diagnosis is
schizophrenic, depressive and neurotic disease in the studied sample. schizophrenia. However, in this study, pronounced Schneiderian
Dissociation holds a central role within this interplay as it functions as a symptoms are limited to conditions which accumulate negative and
mediator of posttraumatic distress and, to a lesser degree, also of not dissociative symptoms. Hence, severe psychosis does not appear
psychotic symptomatology but is itself engendered by current symp- to be a result of dissociation, particularly since dissociation is
toms of depression and – more distally – by childhood abuse. equally present in non-psychotic and psychotic disorders. The
Contrary to previous findings, this study does not confirm the present study is not consistent with a linear dose–response
close relationship between childhood trauma and adult dissociation, relationship between childhood trauma and psychotic or dissocia-
which many authors have described for both psychotic (Ross, tive symptoms. Rather, it points to an interaction between avoidant
2004a; Vogel et al., 2009b; Sar et al., 2010) and non-psychotic behaviour, cognitive impeding, emotional numbing, and dissocia-
disorder (Tutkun et al., 1998; Gershuny and Thayer, 1999). Apart tion, that is mediated by the recurrence of trauma and which is
from the heterogeneity of symptoms among individuals with shown to originate in childhood neglect if the clinical appearance is
schizophrenia on one hand, and among patients with neurotic and characterized by negative symptoms and in childhood abuse if the
affective disorder on the other, this inconsistency may also be clinical appearance is characterized by a lack of negative symptoms.
substantiated by the design of the present study in which the The present study clearly warrants replication as the results may
distinct categories were merged and underwent regression analyses encourage researchers to not preclude negative symptoms from their
126 M. Vogel et al. / Psychiatry Research 189 (2011) 121–127
Table 4
Logistic regression statistics (d.f. = 1).
Schizophrenia (χ2 = 11.38; d.f. = 1; p b 0.01; Nagelkerke R2 = 0.23) Gender − 2.52 1.24 4.14 0.04 0.08 0.07/0.9
SANS 0.17 0.05 11.28 0.001 1.18 1.1/1.3
Gender − 7.43 5.47 1.85 0.17 0.01 0.01/26.87
SANS 0.65 0.4 2.57 0.11 1.91 0.87/4.21
AMDP-Dis − 1.18 0.78 2.28 0.13 0.3 0.07/1.42
PTSD (χ2 = 26.75; d.f. = 3; p b 0.01; Nagelkerke R2 = 0.50) CEA 0.17 0.08 5.08 0.02 1.19 1.02/ 1.37
CSA 0.44 0.37 1.29 0.26 1.53 0.73/ 3.19
AMDP-Dis 0.15 0.06 5.76 0.02 1.16 1.03/1.32
Dissociation (χ2 = 23.16; d.f. = 3; p b 0.01; Nagelkerke R2 = 0.43) CPA 0.15 0.10 2.23 0.14 1.16 0.95/1.42
MADRS 0.16 0.04 12.87 b0.01 1.17 1.08/1.28
SAPS (χ2 = 39.61; d.f. = 3; p b 0.01; Nagelkerke R2 = 0.66) Gender − 0.93 0.73 1.60 0.21 0.40 0.09/1.67
SANS 0.07 0.017 15.46 b0.01 1.07 1.03/1.10
Gender − 1.07 0.82 1.71 0.19 0.34 0.07/1.71
SANS 0.092 0.03 11.00 b0.01 1.10 1.04/1.16
AMDP-Dis 0.21 0.08 6.01 0.01 1.23 1.04/1.45
SANS (χ2 = 43.42; d.f. = 4; p b 0.01; Nagelkerke R2 = 0.7) Gender −0.095 0.78 1.48 0.22 0.39 0.08/1.78
Any CHT − 2.83 1.42 3.96 0.05 0.06 0.04/1.0
SAPS 0.08 0.02 11.91 b0.01 1.08 1.04/1.14
Gender − 0.76 0.86 0.79 0.37 0.47 0.09/2.5
Any CHT − 3.33 1.62 4.24 0.04 0.04 0.01/0.85
AMDP-dis − 0.19 0.08 5.76 0.02 0.83 0.71/0.97
SAPS 0.12 0.04 12.08 b0.01 1.13 1.05/1.21
CHT: childhood trauma; CEA: childhood emotional abuse; CPA: childhood physical abuse; CSA: childhood sexual abuse; SAPS: Scale for the Assessment of Positive Symptoms; SANS:
Scale for the Assessment of Negative Symptoms; MADRS: Montgomery–Åsberg Depression Rating Scale; AMDP-Dis: AMDP-dissociation.
endeavours to explore the complex relationships between trauma and quences: findings from a treatment-receiving Northern Irish sample. Journal of
Affective Disorder 112, 71–80.
dysfunctional outcomes. Despite the strength of its interview-based Dorahy, M.J., Shannon, C., Seagar, L., Corr, R., Stewart, K., Donncha, H., Mulholland, C.,
assessment of symptoms and the advantage of its case–control design, Middleton, W., 2009b. Auditory hallucinations in dissociative identity disorder and
the present study holds two potential shortcomings. The first is the schizophrenia with and without a childhood maltreatment history. The Journal of
Nervous and Mental Disease 197, 892–898.
unbalanced distribution of genders and the poor matching of socio- Ehlers, A., Steil, R., Winter, H., Foa, E.B., 1996. Deutsche Übersetzung der Posttraumatic
demographic characteristics in the psychotic vs. non-psychotic Distress Scale (PDS). Warneford Hospital, Dept. of Psychiatry, Oxford.
groups. Although, given the similarities of the variables of interest Ellason, J.W., Ross, C.A., 1997. Two-year-follow-up of inpatients with dissociative
identity disorder. The American Journal of Psychiatry 154, 832–839.
in this study, one could also argue that the process of coping with
Evren, C., Evren, B., 2006. The relationship of suicide attempt history with
childhood trauma and PTSD is not influenced by sociodemographic childhood abuse and neglect, alexithymia and temperament and character
factors. The second potential shortcoming is that the generalizibility dimensions of personality in substance dependents. Nordic Journal of
Psychiatry 60, 263–269.
of the results is somewhat limited by the small sample size of
Foa, E.B., Cashman, L., Jaycox, L., Perry, K., 1997. The validation of a self-report measure
heterogenous individuals and by the small sizes of the distinct of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale. Psychological
subgroups within the sample. Nevertheless, the results of this study Assessment 9, 445–451.
reinforce the notion that childhood development plays a critical role Fontenelle, F.L., Domingues, A.M., Souza, W.F., Mendlowicz, M.V., de Menezes, G.B.,
Figueira, I.L., Versiani, M., 2007. History of trauma and dissociative symptoms
in the prediction of neurotic as well as severe mental illness in later among patients with obsessive–compulsive disorder and social anxiety disorder.
phases of life. Psychiatry Quarterly 78, 241–250.
Foote, B., Smolin, Y., Kaplan, M., Legatt, M.E., Lipschitz, D., 2006. Prevalence of
dissociative disorders in psychiatric outpatients. The American Journal of
References Psychiatry 163, 623–629.
Freyberger, H.J., Moller, H.J., 2004. Die AMDP-Module. Hogrefe Verlag, Goettingen.
American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Gershuny, B.S., Thayer, J.F., 1999. Relations among psychological trauma, dissociative
Disorders—DSM-IV-TR (4th edition, Text Revision). American Psychiatric Associ- phenomena, and trauma-related distress: a review and integration. Clinical
ation, Washington, DC. Psychology Review 19, 631–657.
Andreasen, N.C., 1983. Scale for the Assessment of Negative Symptoms (SANS). Giesbrecht, T., Lynn, S.J., Lilienfeld, S.O., Merckelbach, H., 2008. Cognitive processes in
University of Iowa, Iowa City. dissociation: an analysis of core theoretical assumptions. Psychological Bulletin
Andreasen, N.C., 1984. Scale for the Assessment of Positive Symptoms (SAPS). 134, 617–647.
University of Iowa, Iowa City. Grilo, C.M., Masheb, R.M., 2001. Childhood psychological, physical, and sexual
Atchison, M., McFarlane, A.C., 1994. A review of dissociation and dissociative disorders. maltreatment in outpatients with binge eating disorder: frequency and associa-
The Australian and New Zealand Journal of Psychiatry 28, 591–599. tions with gender, obesity, and eating-related psychopathology. Obesity Research
Bernet, C.Z., Stein, M.B., 1999. Relationship of childhood maltreatment to the onset and 9, 320–325.
course of major depression in adulthood. Depression and Anxiety 9, 169–174. Hacking, I., 1995. Rewriting the Soul: Multiple Personality and the Sciences. Princeton
Bernstein, D.P., Fink, L., 1998. Childhood Trauma Questionnaire: A Retrospective Self- University Press, Princeton, NJ.
Report Manual. The Psychological Corporation, San Antonio. Hamner, M.B., Frueh, B.C., Ulmer, H.G., Huber, M.G., Twomey, T.J., Tyson, C., Arana, G.W.,
Bernstein, D.P., Stein, J.A., Newcomb, M.D., Walker, E., Pogge, D., Ahluvalia, T., Stokes, J., 2000. Psychotic features in chronic posttraumatic stress disorder and schizophre-
Handelsman, L., Medrano, M., Desmond, D., Zule, W., 2003. Development and nia: comparative severity. The Journal of Nervous and Mental Disease 188,
validation of a brief screening version of the childhood trauma questionnaire. Child 217–221.
Abuse & Neglect 27, 169–190. Harkness, K.L., Monroe, S.M., 1997. Childhood adversity and endogenous versus non-
Bobon, D., von Frenckell, R., Troisfontaines, B., Mormont, C., Peilet, J., 1985. Construction endogenous distinction in women with major depression. The American Journal of
et validation preliminaire d'une echelle d'anxiete extraite de I'AMOP francophone, Psychiatry 159, 387–393.
I'AMOP-AT. L'Encéphale 11, 107–111. Herman, J.L., 1992. Complex PTSD: a syndrome in survivors of prolonged and repeated
Bremner, J.D., 2010. Cognitive processes in dissociation: comment on Giesbrecht et al. trauma. Journal of Traumatic Stress 5, 377–391.
(2008). Psychological Bulletin 136, 1–11. Holmes, E.A., Brewin, C.R., Hennessy, R.G., 2004. Trauma films, information processing,
Brown, R.J., Schrag, A., Trimble, M.R., 2005. Dissociation, childhood interpersonal and intrusive memory development. Journal of Experimental Psychology 3–22
trauma, and family functioning in patients with somatisation disorder. The General.
American Journal of Psychiatry 162, 899–905. Honig, A., Romme, M.H., Ensink, B.J., Escher, S.D., Pennings, M.H., de Vries, M.N., 1998.
Dorahy, M.J., Corry, M., Shannon, M., Macsherry, A., Hamilton, G., McRobert, G., Elder, R., Auditory hallucinations: a comparison between patients and non-patients. The
Hanna, D., 2009a. Complex PTSD, interpersonal trauma and relational conse- Journal of Nervous and Mental Disease 10, 646–651.
M. Vogel et al. / Psychiatry Research 189 (2011) 121–127 127
Hovens, J.G., Wiersma, J.E., Giltay, E.J., van Oppen, P., Spinhoven, P., Penninx, B.W., Sar, V., Taycan, O., Bolat, N., Ozmen, M., Duran, A., Oztürk, E., Ertem-Vehid, H., 2010.
Zitman, F.G., 2010. Childhood life events and childhood trauma in adult patients Childhood trauma and dissociation in schizophrenia. Psychopathology 43, 33–40.
with depressive, anxiety and comorbid disorders vs. controls. Acta Psychiatrica Saxe, G.N., van der Kolk, B.A., Berkowitz, R., Chinman, G., Hall, K., Lieberg, G., Schwartz,
Scandinavica 122, 66–74. J., 1993. Dissociative disorders in psychiatric inpatients. The American Journal of
Jessop, M., Scott, J., Nurcombe, B., 2008. Hallucinations in adolescent in patients with Psychiatry 150, 1037–1042.
post-traumatic stress disorder and schizophrenia: similarities and differences. Schennach-Wolff, R., Jäger, M., Seemüller, F., Obermeier, M., Messer, T., Laux, G., Pfeiffer,
Australasian Psychiatry 16, 268–272. H., Naber, D., Schmidt, L.G., Gaebel, W., Huff, W., Heuser, I., Maier, W., Lemke, M.R.,
Johnstone, J.M., Luty, S.E., Carter, J.D., Mulder, R.T., Frampton, C.M., Joyce, P.R., 2009. Rüther, E., Buchkremer, G., Gastpar, M., Möller, H.J., Riedel, M., 2009. Defining and
Childhood neglect and abuse as predictors of antidepressant response in adult predicting functional outcome in schizophrenia and schizophrenia spectrum
depression. Depression and Anxiety 26, 711–717. disorders. Schizophrenia Research 113, 210–217.
Jureidini, J., 2003. Does dissociation offer a useful explanation for psychopathology? Simeon, D., Guralnik, O., Schmeidler, J., Sirof, B., Knutelska, M., 2001. The role of
Psychopathology 37, 259–265. childhood interpersonal trauma in depersonalization disorder. The American
Lochner, C., Seedat, S., Hemmings, S.M., Kinnear, C.J., Corfield, V.A., Niehaus, D.J., Journal of Psychiatry 158, 1027–1033.
Moolman-Smook, J.C., Stein, D.J., 2004. Dissociative experiences in obsessive– Simeon, D., Smith, R.J., Knutelska, M., Smith, L.M., 2008. Somatoform dissociation in
compulsive disorder and trichotillomania: clinical and genetic findings. Compre- depersonalization disorder. Journal of Trauma & Dissociation 9, 335–348.
hensive Psychiatry 45, 384–391. Simon, N.M., Herlands, N.N., Marks, E.H., Mancini, C., Letamendi, A., Li, Z., Pollack, M.H.,
Matthews, C.A., Kaur, N., Stein, M.B., 2008. Childhood trauma and obsessive– Van Ameringen, M., Stein, M.B., 2009. Childhood maltreatment linked to greater
compulsive symptoms. Depression and Anxiety 25, 742–751. symptom severity and poorer quality of life and function in social anxiety disorder.
McIntyre, R.S., Soczynska, J.K., Mancini, D., Lam, C., Woldeyohannes, H.O., Moon, S., Depression and Anxiety 26, 1027–1032.
Konarski, J.Z., Kennedy, S.H., 2008. The relationship between abuse and suicidality Singer, L.T., Linares, T.J., Nitri, S., Henry, R., Minnes, S., 2004. Psychosocial profiles of
in adult bipolar disorder. Violence and Victims 23, 361–372. older adolescent MDMA users. Drug and Alcohol Dependence 74, 245–252.
Merckelbach, H., à Compo, J., Hardy, S., Giesbrecht, T., 2005. Dissociation and fantasy Spitzer, C., Barnow, S., Gau, K., Freyberger, H.J., Grabe, H.J., 2008. Childhood
proneness in psychiatric patients: a preliminary study. Comprehensive Psychiatry maltreatment in patients with somatisation disorder. The Australian and New
16, 181–185. Zealand Journal of Psychiatry 42, 335–341.
Michal, M., Kaufhold, J., Grabhorn, R., Krakow, K., Overbeck, G., Heidenreich, T., 2005. Spitzer, C., Wrede, K.H., Freyberger, H.J., 2004. The “AMDP scale for dissociation and
Depersonalization and social anxiety. The Journal of Nervous and Mental Disease conversion (AMDP-DK)”: development of an observer-rated scale and first
193, 629–632. psychometric properties. Fortschritte der Neurologie-Psychiatrie 72, 404–410.
Mitchell, K.S., Mazzeo, S.E., 2005. Mediators of the association between abuse and Tucci, A.M., Kerr-Correa, F., Souza-Formigoni, M.L., 2010. Childhood trauma in
disordered eating in undergraduate men. Eating Behaviours 6, 318–327. substance use disorder and depression: an analysis by gender among a Brazilian
Molina-Serrano, A., Linotte, S., Amat, M., Souery, D., Barretto, M., 2008. Dissociation in major clinical sample. Child Abuse & Neglect 34, 95–104.
depressive disorder: a pilot study. Journal of Trauma and Dissociation 9, 411–421. Tutkun, H., Sar, V., Yargic, L.I., Özpulat, T., Kiziltan, E., Yanik, M., 1998. Frequency of
Montgomery, S.A., Asberg, M., 1979. New depression scale designed to be sensitive to dissociative disorders among psychiatric inpatients in a Turkish university clinic.
change. The British Journal of Psychiatry 134, 382–389. The American Journal of Psychiatry 155, 800–805.
Moskvina, V., Farmer, A., Swainson, V., O'Leary, J., Gunasinghe, C., Owen, M., Craddock, Van der Hart, O., Nijenhuis, E.R., Steele, K., 2006. The Haunted Self: Structural
N., McGuffin, P., Korszun, A., 2007. Interrelationship of childhood trauma, Dissociation and the Treatment of Chronic Dissociation. Norton, London (NY).
neuroticism, and depressive phenotype. Depression and Anxiety 24, 163–168. Van IJzendorn, M.H., Schuengel, C., 1996. The measurement of dissociation in normal
Mulder, R.T., Beautrais, A.L., Joyce, P.R., 1998. Relationship between dissociation, and clinical populations: meta-analytic validation of the Dissociative Experience
childhood sexual abuse and mental illness in a general population sample. The Scale (DES). Clinical Psychology Review 16, 365–382.
American Journal of Psychiatry 155, 806–811. Vogel, M., Schatz, D., Spitzer, C., Kuwert, P., Moeller, B., Freyberger, H.J., Grabe, H.J.,
Ross, C.A., 2004a. Schizophrenia. Innovations in Diagnosis and Treatment. Haworth 2009a. A more proximal impact of dissociation than of trauma and posttraumatic
Press, Birmingham, NY. stress disorder on Schneiderian symptoms in patients diagnosed with schizophre-
Ross, C.A., Keyes, B., 2004. Dissociation and schizophrenia. Journal of Trauma & nia. Comprehensive Psychiatry 50, 128–139.
Dissociation 5, 69–83. Vogel, M., Spitzer, C., Kuwert, P., Moeller, B., Freyberger, H.J., Grabe, H.J., 2009b.
Ross, C.A., Ness, L., 2010. Symptom patterns in dissociative identity disorder patients Association of childhood neglect with adult dissociation in inpatients with
and the general population. Journal of Trauma & Dissociation 2010 (11), 458–468. schizophrenia. Psychopathology 42, 124–130.
Sar, V., Öztürk, E., 2008. Psychotic symptoms in complex dissociative disorders. In: Moskowitz, Wobrock, T., Köhler, J., Klein, P., Falkai, P., 2009. Achieving symptomatic remission in
A., Schäfer, I., Dorahy, M.J. (Eds.), Psychosis, Trauma and Dissociation: Emerging out-patients with schizophrenia—a naturalistic study with quetiapine. Acta
Perspectives on Severe Psychopathology. Wiley & Sons Ltd, London, pp. 165–175. Psychiatrica Scandinavica 120 (2), 120–128.