Childhood adversity in people with first-episode psychosis

Summary, English
This study concerns childhood adversity in people with non-affective first-episode psychosis (FEP). There is now evidence that childhood adversities increase the risk of psychosis, but the prevalence of childhood adversity in people with non-affective psychosis remains unclear. Previous studies have found different forms of interpersonal childhood adversities to be central for the risk of non affective psychosis. Meanwhile, there is accumulating evidence of a dose-response gradient between childhood adversity and non-affective psychosis. This study sought to assess childhood adversity prevalence in a representative sample of people with non-affective FEP and to examine aspects of their relation to the risk of psychosis and to central social and functional factors. The importance of the form and the amount of childhood adversity, i.e. sexual, physical and emotional abuse and physical and emotional neglect, separation and institutionalization, was explored in relation to the risk of psychosis. In addition to risk factors, factors of resilience may influence the development of non-affective psychosis. Perceived support has been found to decrease the risk for PTSD and to affect the risk conveyed by adversities. Perceived support from peers and adults during childhood was hypothesized to diminish the risk of psychosis and ameliorate the risk caused by childhood adversity. Childhood adversity has furthermore been found to be associated with several functional difficulties in different populations. These relations have been sparsely studied in people with non-affective psychosis, though it is likely that childhood adversity may cause some of the functional decline that the majority experience in both premorbid and psychotic phases. Childhood adversities were hypothesized to be associated with worse premorbid social and academic adjustment trajectories; worse global functioning prior to treatment start; and lower current educational, vocational and living functioning. It was hypothesized to be associated with less family contact. The family is one of the primary sources of support for people with FEP and it is therefore important to know if this relation is affected by previous childhood adversity. Studies indicate that metacognitive abilities are a specific part of functioning that seem especially associated with non-affective psychosis, but few studies have compared metacognition in people with FEP to non-clinical control persons. Positive and negative symptoms constitute the core of non-affective psychosis and it remains unclear how metacognition affects both positive and negative symptomatology. To examine these questions, metacognitive abilities were compared to a non-clinical control group and to positive and negative symptom profiles. The latter was done through identification of symptom profiles based on positive and negative symptom levels. The research questions were examined in a cross-sectional case-control study, which included 101 persons with non-affective FEP and 101 non-clinical control persons matched by gender, age and parental education. The FEP group was included consecutively over a two-year period from April 2011 to April 2013 and the control group from October 2013 to May 2014. The assessment instruments comprised the CTQ, CECA.Q, PANSS, PAS, GAF, Lehman Quality of Life Interview, IPII, MAS-A and the MINI 6.0 for the control group. The childhood adversities thus included sexual, physical and emotional abuse, physical and emotional neglect, separation and institutionalization. Statistical analyses comprised t-tests and Mann-Whitney U-tests, ANOVAs, MANOVAs and logistic regression analyses. Fifty-two percent of the FEP group and seven percent of the control group had experienced three or more adversities. Regarding the importance of the form of childhood adversity, all forms predicted the risk of psychosis. However, when they were corrected for each other, only emotional abuse, physical and emotional neglect, parental separation and institutionalization remained predictors of psychosis. All the odds ratios from the different forms were reduced considerably by the adjustments and all the adversities were correlated with at least two other forms of adversity. Concerning a dose-response relation, we found that the risk of psychosis increased with the number of childhood adversities. Peer and adult support during childhood was less prevalent in the FEP group and peer support continued to reduce the risk of psychosis after adjustment for childhood adversities. Peer but not adult support diminished the risk of psychosis caused by childhood adversities. Regarding current family contact, it was found to be lower for those with more childhood adversities. Childhood adversities were equally common for all the different social and academic premorbid trajectories. Childhood adversities were negatively correlated with global functioning the year prior to treatment start, while they were unrelated to current educational, vocational and living functioning. Metacognitive abilities were lower in the FEP group compared to the control group. In the FEP group, they were lower for the two groups with high negative symptom scores, but not for the one group with high positive symptoms and low negative symptom scores. Thus, metacognition was consistently associated with high negative, but not with positive symptom scores. As numerous studies have found that physical and sexual abuse increase the risk of psychosis, we think that it would be incorrect to conclude that they did not play a role for the risk of psychosis in our FEP sample. Their insignificance was caused by the fact that almost all with sexual or physical abuse had experienced other adversities as well. Thus, this approach falsely diminishes the effects of the assessed childhood adversities. Since numerous different studies have found different adversities to be rendered insignificant and since they have found different adversity profiles, it may be that the form of childhood adversity is not crucial for the risk of psychosis. Instead, it may be that shared aspects of traumatization convey the risk of psychosis, such as HPA-axis dysregulation or psychological mechanisms such as feelings of social defeat and dissociation. The data support that the amount, and implicitly the frequency and severity, of childhood adversity is crucial for the risk of non-affective psychosis. Taken together, it may be that a conceptualization that combines the effects of the different forms of childhood adversity may offer a more correct risk estimate. This may prompt research to explore shared mechanisms and to increase awareness of the likelihood of confounding by other adversities when seeking to examine single adversity forms. The findings of lower levels of perceived support from adults and peers during childhood in the FEP group suggest that they may be important resilience factors. This should be further studied in similar research designs and in prospective cohort studies. The data regarding premorbid trajectories and global functioning propose that adversities only affected them when the psychotic breakdown was imminent or happening. This may only be fully examined in longitudinal studies. Theoretically, metacognition is considered closely linked to childhood adversity, and since this study is the first to explore the association with adequate adversity assessment, replication of this finding is required. Metacognitive abilities were lower in the FEP group, which supports their importance and future investigation. Our findings suggested that the level of negative, but not positive symptoms is affected by metacognition. Previous findings of relations with positive symptoms may have been confounded by negative symptoms, and it is important that future researchers are aware of this. Overall, the high prevalence of childhood adversity and the finding that peer support ameliorated the risk of psychosis conveyed by childhood adversities, suggests that preventive strategies for vulnerable children should be instigated. It furthermore proposes that current interventions should implement thorough childhood adversity assessment and approaches that deal with childhood adversity. This is supported by the finding of an association between more childhood adversities and less current family contact, as family relations may be improved by interventions that deal with childhood adversity. Additionally, individuals with past adversity exposure may require more assistance in attaining and maintaining social support. The high prevalence of childhood adversity and poor metacognitive abilities supports the importance of providing psychotherapy for people with non-affective psychosis, as both the consequences of childhood adversity and metacognitive abilities are responsive to such intervention. Additionally, the strong association between metacognition and negative symptoms may suggest that improvements of metacognition can reduce the level of negative symptoms, which is one of the greatest challenges of current psychosis interventions. Future research should explore this hypothesis.