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Childhood sexual abuse and psychosis: data from a cross-sectional national psychiatric survey in England

  • Paul Bebbington (a1), Sarah Jonas (a1), Elizabeth Kuipers (a2), Michael King (a1), Claudia Cooper (a1), Traolach Brugha (a3), Howard Meltzer (a3), Sally McManus (a4) and Rachel Jenkins (a5)...
Abstract
Background

A number of studies in a range of samples attest a link between childhood sexual abuse and psychosis.

Aims

To use data from a large representative general population sample (Adult Psychiatric Morbidity Survey 2007) to test hypotheses that childhood sexual abuse is linked to psychosis, and that the relationship is consistent with mediation by revictimisation experiences, heavy cannabis use, anxiety and depression.

Method

The prevalence of psychosis was established operationally in a representative cross-sectional survey of the adult household population of England (n = 7353). Using computer-assisted self-interview, a history of various forms of sexual abuse was established, along with the date of first abuse.

Results

Sexual abuse before the age of 16 was strongly associated with psychosis, particularly if it involved non-consensual sexual intercourse (odds ratio (OR) = 10.14, 95% CI 4.8–21.3, population attributable risk fraction 14%). There was evidence of partial mediation by anxiety and depression, but not by heavy cannabis use nor revictimisation in adulthood.

Conclusions

The association between childhood sexual abuse and psychosis was large, and may be causal. These results have important implications for the nature and aetiology of psychosis, for its treatment and for primary prevention.

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Copyright
Corresponding author
Paul Bebbington, Department of Psychiatry & Behavioural Sciences, Royal Free & University College Medical School, Holborn Union Building, Archway Campus, Whittington Hospital, Highgate Hill, London N19 5LW, UK. Email: p.bebbington@ucl.ac.uk
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Declaration of interest

None.

Footnotes
References
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Childhood sexual abuse and psychosis: data from a cross-sectional national psychiatric survey in England

  • Paul Bebbington (a1), Sarah Jonas (a1), Elizabeth Kuipers (a2), Michael King (a1), Claudia Cooper (a1), Traolach Brugha (a3), Howard Meltzer (a3), Sally McManus (a4) and Rachel Jenkins (a5)...
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eLetters

Is Borderline Personality being confused with psychosis

Prabhat Mahapatra, Consultant Psychiatrist
15 July 2011



Bebbington et al. found a large association between childhood sexual abuse and psychosis in later life. In order to identify subjects with a ‘psychosis’, they used a screening test, where they checked if respondents met at least one of the four criteria – being on antipsychotics currently, a psychiatric inpatient stay in last three months, a positive response to question 5a in the Psychosis Screening Questionnaire, or a self reported diagnosis of psychotic disorder or symptoms suggestive of it. They identified 313 screen positive participants, of whom 190 respondents were offered a Phase two interview with SCAN, and 23 were found to have definite psychosis. Of the 313 screen positive participants, 123 were not tested on SCAN, but the authors selected 20 respondents as having probable psychosis, as these respondents met at least two criteria on screening.

The screening questions appear to have a high level of sensitivity, but don’t seem to be very specific. The questions would have identified most patients with schizophrenia, but would result in a high number of false positives, and would end up including patients with conditions like Borderline Personality Disorder, which manifest themselves in the form of transient psychotic symptoms.

The core sample of 23 patients identified by the gold standard SCAN was therefore contaminated by a group of patients who might not have had a psychosis.

Therefore, it would be difficult to conclude that childhood sexual abuse is associated with psychosis in later life, unless the term ‘psychosis’ is considered by the authors to include conditions like Borderline Personality. It is of course well known that Borderline Personality is often associated with a history of childhood sexual abuse.

It would have been interesting for the data to be broken down to show how many of the respondents diagnosed with SCAN had a history of childhood sexual abuse, and this would have given a better indication between the association between psychosis and childhood sexual abuse.

Bebbington P, Jonas S, Kuipers E, Cooper C, Brugha T, Meltzer H et al. Childhood sexual abuse and psychosis: data from a cross-sectional national psychiatric survey in England. Br J Psychiatry 2011; doi:10.1192/bjp.bp.110.083642
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Conflict of interest: None Declared

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Childhood sexual abuse and psychosis

MOHINDER KAPOOR, Specialty Registrar (ST5) Old age psychiatry
15 July 2011

Bebbington et al 1 should be congratulated for presenting useful information in relation to an important and sensitive issue of childhood sexual abuse and its impact on mental health of people suffering the abuse. The authors concluded that sexual abuse before the age of 16 was not only strongly associated with psychosis, particularly if it involved non-consensual sexual intercourse, but may be causal as well.

However, I have few reservations in relation to the identification ofpsychosis in study subjects. 23 out of 43 subjects had “definite psychosis” which was based on gold standard conditions of SCAN,2 a semi-structured interview that provides ICD-10 3 diagnoses of psychotic disorder. The remaining 20, however, were not interviewed with SCAN but were diagnosed because they met at least two (out of four) of the phase-one psychosis screening criteria. The authors referred this to a measure of “probable psychosis” which they used in their analyses.

When we look at these criteria one of them states “an in-patient stayfor a mental or emotional problem in the past 3 months, or admission to a hospital or ward specialising in mental health problems at any time”; and the other, “a self-reported diagnosis of psychotic disorder or symptoms suggestive of it”. One can argue the fact that in-patient stay in a mentalhealth setting could be for other reasons apart from a psychotic illness. Also self-reported diagnosis of psychotic illness is prone to the possibility of misdiagnosis related to the subjectivity of the outcomes used in this study. We don’t know how many out of 20 subjects were diagnosed to be suffering from a psychotic disorder based on these above mentioned criteria. Unless we have more information it raises questions regarding author’s justification in using the category of “probable psychosis” in their data analyses.

Declaration of interest: None

References:

1.Bebbington P et al. Childhood sexual abuse and psychosis: data from a cross-sectional national psychiatric survey in England. Br J Psychiatry 2011; 199: 29-37

2.World Health Organization. SCAN: Schedules for Clinical Assessmentin Neuropsychiatry. WHO, 1992.

3.World Health Organization. The ICD–10 Classification of Mental andBehavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO, 1992.
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Conflict of interest: None Declared

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Re: Childhood psychotic symptoms may explain the link between non-consensual sex and later psychosis

Paul Bebbington, Emeritus Professor of Social and Community Psychiatry
07 July 2011

We thank Dr Daly for his interest in our paper (Bebbington et al., 2011), and for his reminder that conclusions in epidemiological work must always be tentative. He argues that the link between child sexual abuse and adult psychosis may be the result of confounding by psychotic symptomsin childhood or adolescence. He adduces evidence for this from his secondary analysis of data from the 1970 British Birth Cohort sample (Daly2011). Of the female sample, 1.6% indicated that they had been forced to have sex by the age of 16, and this was associated with an elevated risk of visual and auditory hallucinations at age 29 (OR 8.5). However, after controlling for the experience of such quasi-psychotic symptoms before theage of 16, the odds ratio fell to a non-significant 2.4. Daly interprets this as indicating that this relationship exists because children with quasi psychotic symptoms are more at risk of abuse and also at greater risk of developing psychosis as adults.

Nevertheless Dr Daly’s conclusion must equally be tentative. First, the British Birth Cohort sample apparently does not provide temporal discrimination between the occurrence of sexual abuse and the development of quasi psychotic symptoms. Secondly, given that this is so, the diminution of the odds ratio after controlling for quasi psychotic symptoms in adolescence could indicate mediation. In other words the sexual abuse leads to adolescent symptoms which are then associated with adult symptoms. I find this explanation more plausible than the suggestionthat psychotic symptoms themselves have a major effect in increasing vulnerability to abuse. There is some evidence that psychotic symptoms in adolescence are associated with prior abuse (Kelleher et al., 2008).

It would be good to resolve this argument with appropriate data from a cohort study. However, this might not be possible: there are considerable ethical difficulties in contemporaneous enquiry about sexual abuse in child and adolescent epidemiological samples. Current research has provided some indication that the psychological consequences of abuse show similarities to psychological antecedent and maintaining factors in psychosis (Fowler et al. 2006; Smith et al. 2006), and this does add plausibility to the aetiological role of sexual abuse. The particular association of early trauma with psychotic disorders (schizophreniform or bipolar) characterised by hallucinations is also difficult to explain in terms of confounding (Hardy et al. 2005; Hammersley et al., 2003).

The final worry about Dr Daly’s argument is that it may detract attention from therapeutic engagement with the consequences of sexual abuse and other trauma in people with psychosis.

ReferencesBebbington P, Jonas S, Kuipers E, Cooper C, Brugha T, Meltzer H et al. Childhood sexual abuse and psychosis: data from a cross-sectional nationalpsychiatric survey in England. Br J Psychiatry 2011; doi:10.1192/bjp.bp.110.083642. Daly M. Poor childhood mental health may explain linkages between trauma, cannabis use, and later psychotic experiences. Psychol Med 2011; doi:10.1017/S0033291711001024. Fowler D, Freeman D, Smith B, Kuipers E, Bebbington P, Bashforth H, Coker S, Gracie A, Dunn G, Garety P. The Brief Core Schema Scales (BCSS): Psychometric properties and associations with paranoia and grandiosity in non-clinical and psychosis samples. Psychol Med. 2006; 36: 749-759.

Hammersley P, Dias A, Todd G, Bowen-Jones K, Reilly B, Bentall RP. Childhood trauma and hallucinations in bipolar affective disorder: preliminary investigation. Br J Psychiatry, 2003; 182: 543-547.Hardy A, Fowler D, Freeman D, Smith B, Steel C, Evans J, Garety P, KuipersE, Bebbington P, Dunn G. Trauma and hallucinatory experience in psychosis.J Nerv Ment Dis, 2005; 193, 501-507.Kelleher I, Harley M, Lynch F, Arsenault L, Fitzpatrick C, Cannon M. Associations between childhood all manner, bullying and psychotic symptomsamong a school-based adolescent sample. Br J Psychiatry 2008; 193: 378-382.Smith B, Fowler DG, Freeman D, Bebbington P, Bashforth H, Garety P, Dunn G, Kuipers E. Emotion and psychosis: Links between depression, self-esteem, negative schematic beliefs and delusions and hallucinations. Schizophr Res 2006; 86: 181-188.
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Conflict of interest: None Declared

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Childhood psychotic symptoms may explain the link between non-consensual sex and later psychosis

Michael Daly, Lecturer in Health Psychology
23 June 2011

Numerous studies have established a link between trauma early in lifeand psychosis in adulthood (1). In particular, non-consensual sex in childhood appears to robustly predict the occurrence of psychotic symptomslater in life (2). Bebbington et al (3) add to this literature by demonstrating a large potential role of non-consensual sexual intercourse in the development of psychosis in a large representative sample of English adults. However, whilst the authors take several steps to adjust for residual confounding they make no attempt to correct for the presence of psychotic symptoms in childhood. This is a potentially critical error as reverse causation remains a distinct possibility. Children who exhibit psychotic symptoms may be at high risk of sexual victimization due to their poor social skills, paucity of social relationships, and for numerous other reasons. Thus, initial mental health may explain the link between sexual abuse and adult psychosis.

In an analysis of over 3,500 British adults reported elsewhere (4) I showed that non-consensual sex at age 16 or earlier placed females at a substantial risk of auditory and visual hallucinations at age 29 (OR = 8.51 (95% CI = .99 - 73.28)). However, females who experienced hallucinations in childhood were also likely to have been forced to have sex by age 16. When the presence of initial psychotic symptoms was taken into account the link between non-consensual sex in childhood and hallucinations in adulthood was diminished to non-significance (OR = 2.43 (95% CI = .09 - 62.88)). These findings suggest that childhood sexual abuse may not be related to psychosis in adulthood over and above psychotic symptoms in childhood, at least in the domain of visual and auditory hallucinations.

Thus, when patent non-causal explanations have not been tested, vigilance is required prior to inferring that the link between sexual abuse and psychosis may be causal. Although the design utilized by Bebbington et al was cross-sectional it would have been possible to ask participants to retrospectively gauge the age-of-onset of their psychotic symptoms. This would have allowed the researchers to produce a more methodologically robust assessment of the potential causal effect of sexual abuse.

Bebbington et al also identified anxiety and depression as partial mediators of the relation between sexual abuse and psychosis. However, poor initial mental health may have determined both childhood abuse and later experiences of depression, anxiety, and psychosis. It is therefore of utmost importance that those assessing the role of environmental risk factors in predicting psychosis endeavor to assess the presence of psychosis and sub-clinical psychotic symptoms and mental health more generally at baseline. This will allow the contribution of early environmental risk factors to psychosis to be evaluated and will provide arobust evidence base for clear policy-relevant recommendations.

1. Read J, van Os J, Morrison AP, Ross CA. Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavica 2005 ; 112: 330-350.

2. Houston JE, Murphy J, Shevlin M, Adamson G. Cannabis use and psychosis: re-visiting the role of childhood trauma. Psychol Med 2011;doi:10.1017/ S0033291711000559.

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