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Anomalous self-experience and childhood trauma in first-episode schizophrenia
Available online at Anomalous self-experience and childhood trauma in Elisabeth Hauga,⁎, Merete Øiea,b, Ole A. Andreassen c, Unni Bratlien a, Barnaby Nelson d, Monica Aas c, Paul Møller e, Ingrid Melle c aDivision of Mental Health, Innlandet Hospital Trust, Ottestad, Norway bDepartment of Psychology, University of Oslo, Oslo, Norway cNORMENT, KG Jebsen Centre for Psychosis Research, Institute of Clinical Medicine, Division of Mental Health and Addiction, University of Oslo, and Oslo University Hospital, Oslo, Norway dOrygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia eDepartment of Mental Health Research and Development, Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Drammen, Norway Background: Anomalous self-experiences (ASEs) are viewed as core features of schizophrenia. Childhood trauma (CT) has been postulatedas a risk factor for developing schizophrenia.
Aim: The aim of this study is to investigate the relationships between CT, depression and ASEs in schizophrenia.
Method: ASEs were assessed in 55 patients in the early treated phases of schizophrenia using the Examination of Anomalous Self-Experience (EASE) instrument. Data on CT were collected using the Childhood Trauma Questionnaire, short form (CTQ-SF). This consistsof 5 subscales: physical abuse, sexual abuse, emotional abuse, emotional neglect, and physical neglect. Assessment of depression was basedon the Calgary Depression Scale for Schizophrenia (CDSS).
Results: We found significant associations between EASE total score and CTQ total score and between EASE total score and emotionalneglect subscore in women, but not men. We also found significant associations between CDSS total score and CTQ total score and betweenCDSS total score and emotional abuse, emotional neglect, and physical neglect subscores in women, but not men. In men we did not find anysignificant associations between EASE total score, CDSS total score and any CTQ scores.
Conclusion: CT was significantly associated with higher levels of ASEs in women in the early treated phases of schizophrenia, but not inmen. This again associated with an increase in depressive symptoms.
2014 Elsevier Inc. All rights reserved.
CT also has a more long-lasting effect on the HPA axis, withsubsequent stress-sensitivity, compared to trauma in adulthood Studies show that childhood trauma (CT) is associated with or recent stressful events . In addition to changes in the a wide range of psychiatric disorders and has also been stress- and immune systems, CT has also been found to be related to subclinical psychopathology in otherwise healthy associated with sensitization of the mesolimbic dopamine adults CT has a profound impact on development; an system and concomitant changes in brain structures such as the impact that goes far beyond the increased risks for post- hippocampus and the amygdala , with clear indications traumatic stress-disorders and related symptomatologies.
of gene × environment interactions Studies also demonstrate that CT often is followed by identity CT has repeatedly been postulated as a risk factor for problems, affect dysregulation, and relational disturbances developing psychotic disorders including schizophrenia, with a recent meta-analysis which includedprospective case-control studies showing a modest butstatistically significant odds-ratio . Another meta- ⁎ Corresponding author at: Innlandet Hospital Trust, Division of Mental analysis which included retrospective studies also found a Health, Department for Psychosis and Rehabilitation, 2840 Reinsvoll, greater prevalence of CT among patients with a psychotic Norway. Tel.: +47 95781487; fax: +47 61147785.
E-mail address: (E. Haug).
disorder than in the general population Trauma and 0010-440X/ 2014 Elsevier Inc. All rights reserved.
E. Haug et al. / Comprehensive Psychiatry 56 (2015) 35–41 bullying are also found to be more prevalent in persons with biological disturbances , vulnerabilities and risk psychotic experiences than in healthy controls and are factors . CT appears to have a pervasive effect on related to increased levels of depression and anxiety and a psychopathology, but as far as we know there is no research poorer sense of self in this group, in addition to more investigating the relationships between CT and ASEs in perceptual disturbances The presence of CT has also schizophrenia. This relationship is however of interest since been associated with specific clinical characteristics after CT, particularly in the form of emotional maltreatment, has onset of psychosis, including increased cognitive impair- been linked to the phenomenon of depersonalization in the ments, social dysfunction and dissociative symptoms otherwise healthy persons , while severe depersonaliza- Most studies indicate that CT is more frequently tion can involve many experiences that resemble ASEs present in women than in men, with suggestions that the The main purpose of the current study was to explore the impact of CT on later psychopathology is stronger in women possible relationships between CT and ASEs in the early and with one study finding the association between CT treated phases of schizophrenia. Our main hypothesis was and psychosis to only be present in women .
that CT is related to high levels of ASEs in schizophrenia.
Profoundly altered basic self-experience in the form of characteristic non-psychotic disturbances of the basic senseof self is recognized as a core feature of schizophrenia .
Anomalous self-experiences (ASEs; i.e. disturbances of 2. Material and methods basic self-awareness or sense of self) aggregate in schizo- 2.1. Design and sample phrenia spectrum disorders , are present also in theprodromal stages and might be predictive of The current study is part of the Norwegian Thematically conversion to psychosis in individuals at ultra high risk Organized Psychosis (TOP) Study . The study involved The phenomenological concept of the self refers to all treatment facilities in two neighboring Norwegian here-and-now experiences associated with implicit aware- counties (Hedmark and Oppland) with a county-wide ness, and in this context differs from self-concepts based on population of 375,000 people. Inclusion criteria were age developmental theories including psychoanalytic—or self- between 18 to 65 years, and being consecutive in- or psychological notions of the self. The phenomenological outpatient referred to first adequate treatment for a DSM-IV concept of the self has three hierarchical but interconnected diagnosis of schizophrenia spectrum psychosis (schizophre- levels: the narrative self, the reflective self and the pre- nia, schizophreniform disorder and schizoaffective disorder) reflective self . The narrative self refers to explicit in 2008 and 2009. Exclusion criteria were the presence of experiences and recollections of the person as having brain injury, neurodegenerative disorder, or intellectual specific characteristics such as personality, habits, style, disability. Patients with concurrent substance use disorders and a personal history. The reflective self is a relatively were included, but had to demonstrate at least 1 month explicit, cognitive awareness of the self as an invariant and without substance use, or clear signs that the psychotic persisting subject of experience and action; the presence of a disorder had started before the onset of significant substance relatively stable "I" over time. The pre-reflective self is the use (i.e. did not meet the criteria for substance induced most basic level of self-awareness and refers to the first- person quality of a person's experiences, i.e. the tacit A total of 55 patients early in their treatment course awareness that this is "my" experience. This level of completed the full protocol including the Examination of selfhood is fully implicit in—and inseparable from—the Anomalous Self-Experience (EASE) interview measur- experience itself. ASEs are subjective experiences that ing ASEs. Coming to first adequate treatment was defined as include certain and subtle forms of depersonalization, not having previously received adequate antipsychotic anomalous experiences of cognition and stream of con- medication (adequate doses for 12 weeks, or until sciousness, self-alienation, pervasive difficulties in grasping remission), or any treatment at all. Some of the patients familiar and taken-for-granted meanings, unusual bodily had not even initiated their first treatment at the time of feelings, permeability or complete loss of the self-world inclusion. To enhance statistical power, we also included 11 boundary, in addition to existential reorientation These patients consecutively enrolled in a closely related ongoing are fundamental distortions of the first-person perspective, study of young psychosis patients born in 1985/86. They met including deficiencies in the sense of being a coherent the same inclusion and exclusion criteria except for the strict subject or a self-coinciding center of action, thought and definition of first treatment. They were, however, in an early experience Phenomenology is focused on experiential phase of their treatment course, with an even shorter phenomena and not on the search for underlying mecha- duration of untreated psychosis (DUP) than the strict first nisms or etiology. ASEs are from this perspective core treatment patients.
features of schizophrenia, and thus carry the same complex All participants gave written, informed consent to etiology as the disease itself. Recent research has however participate. The study was approved by the Regional addressed the pathogenic role of ASEs in schizophrenia , Committee for Medical Research Ethics and the Norwegian and the relationship between ASEs and underlying neuro- Data Inspectorate.
E. Haug et al. / Comprehensive Psychiatry 56 (2015) 35–41 2.2. Clinical assessments the level of lifetime occurrence of ASEs. Each EASEinterview lasted 30–90 minutes. EH was trained by one of Diagnoses were ascertained by two experienced psychia- the authors of the EASE (PM), and conducted all the trists using the Structural Clinical Interview for the Diagnostic interviews. The inter-rater reliability (IRR) for the EASE and Statistical Manual of Mental Disorders, fourth edition items was found to be very good .
(SCID-IV) . Symptom severity and function were assessedusing standard psychiatric measures including the Structured 2.5. Statistical analysis Clinical Interview for the Positive and Negative SyndromeScale (SCI-PANSS) Duration of untreated psychosis All analyses were performed with the statistical package (DUP) was measured as time from onset of psychosis (first SPSS, version 18.0. Mean and standard deviations are week with a score of four or more on one of the of the PANSS reported for continuous variables and percentages for subscale items: delusions, hallucinatory behavior, grandiosity, categorical variables. We examined bivariate associations suspiciousness/persecution or unusual thought content).
(nonparametric correlations) between the 5 subscales of Assessment of depression was based on the Calgary CTQ and EASE total score in addition to symptoms as Depression Scale for Schizophrenia (CDSS) . Both raters measured by PANSS subscales and CDSS. A two-way completed the TOP study group's training and reliability analysis of variance was conducted to explore the impact of program with SCID training based on and supervised by the CT and gender on levels of ASEs. In the analyses of CTQ UCLA training program For DSM-IV diagnostics, mean subscales, we controlled for multiple comparisons using overall kappa for the standard diagnosis of training videos for Bonferroni adjustments i.e. with a p-value of 0.01 as the the study as a whole was 0.77, and mean overall kappa for a level of statistical significance. Multiple regression analysis randomly drawn subset of study patients was also 0.77 (95% was used to control for CDSS total score as a covariate.
CI 0.60–0.94). Intra class coefficients (ICC 1.1) for the otherscales were: PANSS positive subscale 0.82 (95% CI 0.66– 0.94), PANSS negative subscale 0.76 (95% CI 0.58–0.93),PANSS general subscale 0.73 (95% CI 0.54–0.90), and GAF-F presents the sociodemographic and clinical 0.85 (95% CI 0.76–0.92).
features of the sample, including the mean scores of theCTQ. The mean EASE total score is in accordance with other 2.3. Assessment of childhood trauma studies on ASEs, and significantly higher than in other Data on CT were collected using the Norwegian version mental disorders . There were no significant gender of the Childhood Trauma Questionnaire, short form (CTQ- differences in the number of patients reporting childhood SF) . This is a 28-item self-report inventory, developed trauma. This was also the case for physical abuse, sexual and validated based on the original 70-item version , that abuse, emotional abuse, emotional neglect, and physical provides a relatively short screening of maltreatment neglect subscale scores ).
experiences before the age of 18. It comprises 28 items, For the whole sample taken together we did not find any yielding scores on 5 subscales of trauma: physical abuse, significant associations between EASE total score and CTQ sexual abuse, emotional abuse, emotional neglect, and total score, or between EASE total score and CTQ subscores.
physical neglect. For estimates of frequencies of childhood We found a significant association between current depres- trauma we used the moderate to severe predefined cutoff sion (CDSS total score) and CTQ total score. In addition, we suggested by Bernstein of ≥10 for physical abuse, ≥8 found significant associations between CDSS score and for sexual abuse, ≥13 for emotional abuse, ≥15 for EASE total score (not in table; r = .319, p = .018) and emotional neglect, and ≥10 for physical neglect.
2.4. Assessment of anomalous self-experiences Demographic and clinical characteristics.
Number of patients ASEs were assessed using the EASE manual comprising five domains: (1) Cognition and stream of Male gender, n (%) consciousness. (2) Self-awareness and presence. (3) Bodily Age years, mean (SD) experiences. (4) Demarcation/transitivism. (5) Existential DUP weeks, median (range) reorientation. This represents a wide variety of anomalous self-experiences condensed into 57 main items and scored on a 5-point Likert scale (0–4), in which 0 = absent; 1 = questionably present; 2 = definitely present, mild; 3 = definitely present, moderate; 4 = definitely present, severe.
For the purpose of the analyses, the resulting scores were dichotomized into 0 (absent or questionably present) and 1 Emotional neglect (definitely present, all severity levels). The EASE measures E. Haug et al. / Comprehensive Psychiatry 56 (2015) 35–41 lower levels of current depression in men compared to Childhood trauma report (CTQ subscales).
women. Mean CDSS score was 7.1 (SD 4.0) in men and 11.1 (SD 7.0) in women (p = 0.033) (not in table). In men we did not find any significant associations between EASE total score and CTQ based scores, nor between CDSS total score and any CTQ scores 4.1. General discussion Our main finding was that childhood trauma (CTQ total score) was significantly associated with high levels of anomalous self-experiences (ASEs/EASE total score) in the early treated phases of schizophrenia in women, but not in men. This seemed to be specifically driven by the level of a Mann Whitney U test.
emotional neglect; as shown by significant associations b Moderate to severe cutoff scores: ≥10 for physical abuse, ≥8 for between ASEs and this subscale, but not other subtypes of sexual abuse, ≥13 for emotional abuse, ≥15 for emotional neglect, and ≥10 childhood trauma. The level of ASEs as indicated by the for physical neglect).
EASE total score was the same as in previous studies of Fisher's exact test.
schizophrenia populations ; comparable to levelsreported in ultra high risk populations and significantlyhigher than in healthy controls or non-schizophrenia between CDSS score and sexual abuse, emotional abuse, spectrum disorders .
emotional neglect subscores ). A two-way analysis Our findings are consistent with previous studies that of variance indicated a trend-level effect of emotional show a stronger association between CT and clinical neglect on EASE total score (p = 0.04), with an additional manifestations of psychiatric disorders in women significant interaction effect between gender and emotional Although most studies indicate that women report a higher neglect on EASE total score ().
prevalence of childhood trauma than men, there were no In follow-up analyses investigating genders separately, such gender differences in the current study. The lack of we found highly statistically significant associations between associations between ASEs and emotional neglect in men EASE total score and CTQ total score and between EASE could thus not simply be due to less statistical power in the total score and emotional neglect subscore in women (). We also found statistically significant associations We also found a statistically significant association between CDSS total score and CTQ total score and between between CT and current depression in women, in line with CDSS total score and emotional abuse, emotional neglect, several studies demonstrating a firm link between CT and the and physical neglect subscores in women (). When risk of depression and with studies suggesting that CDSS total score was introduced as a covariate, the emotional maltreatments may have particular effects on the significant association between EASE total score and CTQ development of negative self-image and depression In scores was no longer apparent. There were significantly particular, emotional neglect in childhood has been Table 3Correlation (Spearman's rho) between childhood trauma (CTQ scores) and anomalous self-experiences, and between childhood trauma and depression.
Emotional neglect (EASE total score) Depression (CDSS total score) ⁎ Correlation is significant at the 0.01 level (2-tailed).
E. Haug et al. / Comprehensive Psychiatry 56 (2015) 35–41 4.2. Strengths and limitations of the study We included patients in the early phase of the treated course of the disorder, thereby minimizing potential confoundingeffects such as selection of non-responders and chronicity thatmight impact on the assessment of ASEs and CT. TheNorwegian mental health care offers public mental health careto all individuals with mental illness within a given catchmentarea. Because of the absence of private mental health care inNorway, the sample is not biased for socioeconomic class. Thestudy population is representative because we included allconsecutive in- or outpatients referred to treatment for apsychotic disorder in two neighboring Norwegian counties in adefined time period.
4.2.2. Limitations Fig. 1. Interaction between gender and emotional neglect on EASE total The correlational nature of this study gives no firm score.ANOVA, interaction between gender and emotional neglect: Df = 1,f = 4.91, p = 0.03.
conclusions about the direction of associations, or about "No emotional neglect," n = 29; "emotional neglect," n = 25; men, n = 28; women, n = 26.
causality. CT ratings are made from retrospective self-reports, and childhood adversities might be both conse-quences and triggers of distorted self-experiences. Highlevels of ASEs and high levels of CT reported could also be a associated with hippocampal and striatal alterations in adults result of recall bias among patients with high levels of . Sex differences in stress-reactivity, including in the depression. However, the retrospective examination of CT in development of the stress-sensitive cortico-striatal-limbic patients with psychosis has been found to be a valid and regions could partly explain why CT contributes reliable source when collecting data in previous studies .
differently to risk for depression in women and men in linewith previous indications that women might be more susceptible to the negative effects of stress and toearly trauma in general. The presence of ASEs is today Childhood trauma was significantly associated with most often viewed as a stage in the development of higher levels of ASEs (EASE total score) in women in the schizophrenia . The results of this study could early treated phases of schizophrenia. This seemed to be indicate that CT adds to this particular development.
specifically driven by emotional abuse, emotional neglect There are several possible explanations of the link between and physical neglect. Our data support including emotional CT, ASEs and depression. It is well-known that CT is a risk abuse, emotional neglect and physical neglect in addition to factor for the development of depression. If CT also increases the more frequently investigated sexual abuse and physical the risk of ASEs in susceptible individuals, the link between abuse when investigating associations between CT and pre- ASE and depression could either be a statistical artifact or psychotic and psychotic features.
indicate that the presence of ASEs further increases the risk ofdepression. A model where depression mediates the effect ofCT on ASEs in the strict definition of the term is, however, Role of funding source unlikely, since ASEs and CT are thought to be relatively stableover time, while depression fluctuates. We can however not Funding for this study was provided by Innlandet completely rule out that depressive individuals could be biased Hospital Trust (grant number 150229). The funding source towards reporting both more CTs and more ASEs. Empirical had no further role in study design; in the collection, analysis studies documenting the stability of ASEs over time are thus and interpretation of data; in the writing of the report; and in required. Finally, as we know that ASEs are present before the the decision to submit the paper for publication.
onset of psychosis and thus could potentially be presentalready in childhood and adolescence , they could interactwith difficulties in eliciting or receiving emotional support, which in turn could increase the risk of depression. Analternative explanation could be that females have a more EH, IM, PM, MØ and BN planned the current study, and complex response to trauma involving more ASE-like OAA contributed to the study design. EH and UB depersonalization and dissociation like phenomena contributed to data collection. EH conducted the statistical . However, the lack of gender differences in relevant analyses and also wrote the first draft of the manuscript. EH, EASE subscales does not support this hypothesis at present.
IM and MA contributed to the analyses. All authors E. Haug et al. / Comprehensive Psychiatry 56 (2015) 35–41 participated in critical revision of manuscript drafts and approved the final version.
Author disclosure All authors declare no conflict of interest.
The authors thank the patients for participating in the study. We also thank Innlandet Hospital Trust for making convenient and necessary arrangements for the work on this article. BN was supported by an NHMRC Career Develop- ment Fellowship (#1027532).
E. Haug et al. / Comprehensive Psychiatry 56 (2015) 35–41
Symptom control in the last days of life Owner Anne Garry Contributions from Specialist Palliative Care teams in York and Scarborough Jane Crewe, Lynn Ridley and Diabetes team Version 3 Date of issue December 2014 Review date December 2017 Principles of symptom management in last days of life These principles are applicable to the care of patients who may be dying from any cause Recognise that death is approaching Studies have found that dying patients will manifest some or all of the following: