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Adverse childhood events and psychosis in bipolar affective disorder

  • Rachel Upthegrove (a1), Christine Chard (a2), Lisa Jones (a2), Katherine Gordon-Smith (a3), Liz Forty (a4), Ian Jones (a4) and Nick Craddock (a4)...



There has been increasing interest in the association between childhood trauma and psychosis. Proposals for potential mechanisms involved include affective dysregulation and cognitive appraisals of threat.


To establish if, within bipolar disorder, childhood events show a significant association with psychosis, and in particular with symptoms driven by dysregulation of mood or with a persecutory content.


Data on lifetime-ever presence of psychotic symptoms were determined by detailed structured interview with case-note review (n = 2019). Childhood events were recorded using a self-report questionnaire and case-note information.


There was no relationship between childhood events, or childhood abuse, and psychosis per se. Childhood events were not associated with an increased risk of persecutory or other delusions. Significant associations were found between childhood abuse and auditory hallucinations, strongest between sexual abuse and mood congruent or abusive voices. These relationships remain significant even after controlling for lifetime-ever cannabis misuse.


Within affective disorder, the relationship between childhood events and psychosis appears to be relatively symptom-specific. It is possible that the pathways leading to psychotic symptoms differ, with delusions and non-hallucinatory symptoms being influenced less by childhood or early environmental experience.

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Corresponding author

Rachel Upthegrove, Senior Clinical Lecturer, School of Clinical and Experimental Medicine, University of Birmingham, The Barberry, National Centre for Mental Health, 25 Vincent Drive, Birmingham B15 2FG, UK. Email:


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Adverse childhood events and psychosis in bipolar affective disorder

  • Rachel Upthegrove (a1), Christine Chard (a2), Lisa Jones (a2), Katherine Gordon-Smith (a3), Liz Forty (a4), Ian Jones (a4) and Nick Craddock (a4)...
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Hearing Voices: are we getting the message?

Golam M. Khandaker, Clinical Lecturer, Department of Psychiatry, University of Cambridge
Claire R.M. Dibben, Consultant Psychiatrist, Norfolk and Suffolk NHS Foundation Trust
Peter B. Jones, Professor, Department of Psychiatry, University of Cambridge
26 March 2015

In a large study of adults with bipolar disorder Upthegrove and colleagues report associations between childhood sexual abuse and lifetime occurrence of mood congruent auditory and visual hallucinations; however, no associations are seen for delusions or diagnoses of psychotic disorders (1). The findings are similar to a recent study of psychotic symptoms in borderline personality disorder (BPD) that shows high lifetime prevalence of auditory and other hallucinations (with predominantly negative contents) but not delusions (2). Together these studies provide important clues regarding mechanisms of specific psychopathology. They also raise a wider question regarding the relationships between psychotic and common mental symptoms such as mood and anxiety.

Using interviews with the present state examination, the BPD study found that 80% of 30 patients (collected from a specialist personality disorder service) had experienced psychotic symptoms at some point during their life time. Auditory hallucinations were reported by 50% while visual hallucinations were present in about a third of the sample. Although the form of auditory hallucinations was similar to that in schizophrenia the content was predominantly negative and critical even when they occurred outside an affective episode. Contents of visual and olfactory hallucinations were also mainly negative and unpleasant. Delusions, however, when present, indicated previously undiagnosed psychotic disorder. Although the study did not examine maltreatment specifically such history is common in BPD. Thus mood dysregulation, which is an important feature of both BPD and bipolar disorder, might explain the emergence of negative, self-critical auditory/visual/other hallucinations in victims of childhood maltreatment.

The findings along with other research indicate psychotic symptoms are common and can occur in the context of non-psychotic disorders. A recent phenomenological study found that auditory hallucinations are present in a diverse sample of people with various diagnoses and clinical histories, where they are associated with fear, anxiety, depression, and stress as well as positive or neutral emotions (3). In young people auditory hallucinations have been reported to occur alongside mild to moderate depression and anxiety, where they are a marker of severity, e.g. multiple psychiatric comorbidity or suicidality (4). Similarly, a recent study found that depression, anxiety and psychotic symptoms measure a single, common underlying factor in the population, with psychotic items measuring the more severe end of this continuum (5). Together these findings suggest that similar to depression and anxiety, psychotic symptoms particularly auditory hallucinations are common mental symptoms. Therefore, psychotic phenomena should be routinely included in epidemiological assessments of psychiatric morbidity. Diagnostic classification systems should acknowledge the presence of psychotic symptoms in non-psychotic disorders to reflect evidence, which will also allay worries among patients and many clinicians who tend to associate hallucinations exclusively with psychosis.


1.Upthegrove R, Chard C, Jones L, Gordon-Smith K, Forty L, Jones I, et al. Adverse childhood events and psychosis in bipolar affective disorder. The British journal of psychiatry : the journal of mental science. 2015; 206(3): 191-7.

2.Pearse LJ, Dibben C, Ziauddeen H, Denman C, McKenna PJ. A study of psychotic symptoms in borderline personality disorder. The Journal of nervous and mental disease. 2014; 202(5): 368-71.

3.Woods A, Jones N, Alderson-Day B, Callard F, Fernyhough C. Experiences of hearing voices: analysis of a novel phenomenological survey. The Lancet Psychiatry.

4.Kelleher I, Keeley H, Corcoran P, Lynch F, Fitzpatrick C, Devlin N, et al. Clinicopathological significance of psychotic experiences in non-psychotic young people: evidence from four population-based studies. The British journal of psychiatry : the journal of mental science. 2012; 201(1): 26-32.

5.Stochl J, Khandaker GM, Lewis G, Perez J, Goodyer IM, Zammit S, et al. Mood, anxiety and psychotic phenomena measure a common psychopathological factor. Psychological medicine. 2014: 1-11.
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