First published in Mad in America 23rd July 2024
Childhood trauma (CT) plays a significant role in the development and recovery from psychosis. A new study published in Schizophrenia Research reveals that individuals with a history of childhood trauma face a slower and more arduous recovery from first-episode psychosis (FEP). The study’s findings underscore the critical need for addressing childhood trauma in the treatment of psychosis.
This research, led by Kristin Fjelnseth Wold of Oslo University Hospital, underscores the importance of pre-psychosis functioning and timely intervention in improving recovery outcomes.
Forty-five percent of the participants reported experiencing childhood trauma, with emotional abuse and neglect being the most common. These individuals were found to have a higher likelihood of early treatment resistance, highlighting the need for trauma-informed approaches in psychosis care.
The current research aimed to investigate how CT affects recovery from FEP. The authors also wanted to explore how the duration of untreated psychosis (DUP) and PA (a measure of pre-FEP functioning) could affect the relationship between CT and recovery.
To achieve this goal, the authors used data collected as part of the ongoing TOP (Thematically Organized Psychosis Research) study, a research project on psychosis by the Norwegian Centre for Mental Disorders Research. The TOP study recruited participants from psychiatric units around Oslo between the ages of 18 to 65. All data was collected between 2003 and 2019.
To qualify for the TOP study, participants had to have a DSM-IV diagnosis of schizophrenia, schizophreniform disorder, schizoaffective disorder, or psychotic disorder NOS. Participants were excluded if they had a history of severe brain injury, an IQ below 70, or if they could not speak a Scandinavian language. To be eligible for the current study, participants had to have completed a CT assessment and have one year of follow-up data available. In total, 141 people participated in the current research.
Clinical assessment and diagnosis were determined through structured clinical interviews performed by clinical psychologists, medical doctors, and psychiatrists familiar with the TOP study. The authors obtained participant education, occupation, marital status, illness history, and treatment data using interviews, medical records, blood samples, and survey questionnaires. Psychosis symptoms were measured initially and at the one-year follow-up using the Positive and Negative Syndrome Scale (PANSS).
CT was evaluated using a Norwegian version of the Childhood Trauma Questionnaire-Short Form (CTQ-SF), a self-report survey that measures five dimensions of CT: emotional abuse, emotional neglect, physical abuse, physical neglect, and sexual abuse. DUP was calculated from the initial onset of psychosis until the start of treatment. PA was measured using the Premorbid Adjustment Scale (PAS), a survey that measures social and academic functioning. Recovery was evaluated using the Global Functioning Scale (GFS), a measure of a person’s ability to live independently, meet basic needs, hold employment, and maintain social relationships.
59% of participants were male. The mean age when recruited into the study was 26.6. 51% of participants had a diagnosis of schizophrenia. The median DUP was 30 weeks. At the one-year follow-up, 44% of participants were resistant to early treatment, 31% were in early recovery, and 25% were in partial early recovery.
The researchers report:
“Forty-five percent of the participants in the current FEP sample reported experiences of CT, with emotional abuse, emotional neglect, and physical neglect as the most prevalent subtypes. CT was more prevalent in the early treatment resistance group, indicating that CT may contribute to early treatment resistance. We also identified a potential mediating effect of DUP and PA (premorbid adjustment) on the relationship between CT and outcome at one-year follow-up.”
45% of participants reported moderate to severe CT. 12% reported physical abuse, 10% sexual abuse, 26% emotional abuse, 29% emotional neglect, and 24% physical neglect. CTQ scores for participants in the treatment-resistant group were higher than those in the early recovery group. 55% of participants from the treatment-resistant group reported moderate to severe CT compared to 34% of the early recovery group. In the present study, CT alone equated to 4.59 times increased chance of being in a more severe group at a one-year follow-up.
Both DUP and PA had mediating effects on the relationship between CT and recovery. Higher premorbid functioning showed a partial mediation of the CT-treatment-resistant relationship, meaning that CT was not as big a factor in recovery for participants who were high functioning before experiencing psychosis. DUP showed a complete mediation of the CT-treatment-resistant relationship, meaning that shorter durations of untreated psychosis completely erased the link between CT and treatment resistance.
The authors acknowledge several limitations to the current work. The self-report nature of the CT survey could bias data due to participants’ recall bias and misremembering. The small sample size limits generalizability. The present study was conducted entirely in Norway with a population that spoke Scandinavian languages. This could vastly limit generalizability to other populations.
The authors conclude:
“Identifying modifiable mediators could inform tertiary prevention- and promote early treatment strategies. Our finding also underlines the need for trauma assessment in FEP to avoid diagnostic unclarity that may increase treatment delays and the need to incorporate adapted trauma treatments into FEP treatment when relevant.”
Past research has linked psychosis symptoms to childhood trauma, particularly in treatment-resistant cases. Shorter durations of untreated psychosis have also led to better outcomes, according to some studies. However, new research has questioned this relationship, arguing that:
“Long-DUP patients are ahead of short-DUP patients in illness progression at given study timepoint, causing spurious differences between groups even though they are on the same trajectory.“
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Wold, K. F. et. al. (2024). Childhood trauma and treatment resistance in first-episode psychosis: Investigating the role of premorbid adjustment and duration of untreated psychosis. Schizophrenia Research 270 441-450. (Link)