Psychiatry Research 228 (2015) 633640

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Impact of childhood adversities on the short-term course of illness

in psychotic spectrum disorders
Inga Schalinski n, Yolanda Fischer, Brigitte Rockstroh
Department of Psychology, University of Konstanz, Germany

art ic l e i nf o a b s t r a c t

Article history: Accumulating evidence indicates an impact of childhood adversities on the severity and course of mental
Received 15 July 2014 disorders, whereas this impact on psychotic disorders remains to be specied. Effects of childhood
Received in revised form adversities on comorbidity, on symptom severity of the Positive and Negative Syndrome Scale and global
1 February 2015
functioning across four months (upon admission, 1 and 4 months after initial assessment), as well as the
Accepted 5 April 2015
Available online 11 June 2015
course of illness (measured by the remission rate, number of re-hospitalizations and dropout rate) were
evaluated in 62 inpatients with psychotic spectrum disorders. Adverse experiences (of at least 1 type)
Keywords: were reported by 73% of patients. Patients with higher overall level of childhood adversities (n 33)
Childhood adversities exhibited more co-morbid disorders, especially alcohol/substance abuse and dependency, and higher
Psychosis
dropout rates than patients with a lower levels of adverse experiences (n 29), together with higher
Symptom severity
levels of positive symptoms and symptoms of excitement and disorganization. Emotional and physical
Short-term course
Comorbidity neglect were particularly related to symptom severity. Results suggest that psychological stress in
childhood affects the symptom severity and, additionally, a more unfavorable course of disorder in
patients diagnosed with psychoses. This impact calls for its consideration in diagnostic assessment and
psychiatric care.
& 2015 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction relationship between exposure to childhood sexual abuse with

In the complex gene-environment interaction determining men-
tal disorders (Rutter et al., 2006), environmental stress early in life
(including psychological stress and adversities in childhood) is
considered a factor that modies the development of psychopathol-
ogy (Morgan and Fisher, 2007; Read et al., 2008; van Os et al., 2010;
Teicher and Samson, 2013; Schmitt et al., 2014). Supporting evi-
dence has related psychological stress and childhood adversities to
a higher risk for mental disorders, to more severe psychopathology
and to a poorer course of illness (meta-analysis and reviews:
Zanarini et al., 2006; Daruy-Filho et al., 2011; Nanni et al., 2012;
Maniglio, 2013). For instance, patients with major depression and
higher levels of childhood abuse and maltreatment exhibit an
earlier onset of illness (Bernet and Stein, 1999; Widom et al.,
2007), more complex and severe psychopathology including psy-
chotic features (Gaudiano and Zimmerman, 2010), lower remission
rates (Enns and Cox, 2005) or longer time to remission (Miniati
et al., 2010). For patients diagnosed with bipolar disorder, a
n
Correspondence to: University of Konstanz, Department of Psychology, P.O. Box
23/24, 78457 Konstanz, Germany Tel.: 49 7531 883301; fax: 49 7531 885702.
E-mail address: inga.schalinski@uni-konstanz.de (I. Schalinski).
more comorbid alcohol and substance abuse/dependency (e.g.,
Brown et al., 2005; Teicher and Samson, 2013), a younger age at
the onset of disease (Leverich et al., 2002), higher rates of rapid
cycling and suicide attempts (e.g., Garno et al., 2005; Tunnard et al.,
2014), more severe psychotic symptoms (Hammersley et al., 2003)
and lower rates of remission (Neria et al., 2005) have been reported.
For psychotic disorders, evidence validates the genetic
and neurobiological contributions to psychopathology (e.g.
Schizophrenia Psychiatric GWAS Consortium, 2011; Svrakic et al.,
2013; Graux et al., 2014), while the modulating role of childhood
adversities seems less clear. Early-life stress is thought to inuence
neuronal development (Andersen et al., 2008; Murgatroyd et al.,
2009) and neuroendocrine response (Heim et al., 2000) as well as
epigenetic imprinting (Peedicayil 2011; Shonkoff et al., 2012;
Svrakic et al., 2013), thereby interacting in a complex manner
with genetic and epigenetic factors.
A diagnosis of schizophrenia spectrum disorder is related to a
heterogeneous and dynamic symptom prole, and is often associated
with chronic courses. Evidence of the impact of childhood adversities
on the severity and course of psychotic disorder, as aimed for in the
present study, should help to understand the impact of environ-
mental factors in the complex gene-environment interaction, and
should inform prognoses and the adjustment of therapeutic

http://dx.doi.org/10.1016/j.psychres.2015.04.052
0165-1781/& 2015 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
634 I. Schalinski et al. / Psychiatry Research 228 (2015) 633640

strategies to prevent unfavorable, chronic courses. In patients with 2. Methods

psychotic disorders, evidence has linked childhood adversities to
more severe psychopathology: psychotic patients exhibit more com-
plex symptoms, including suicidality (see also Roy, 2005; lvarez
et al., 2011), self-mutilation, higher symptom severity and more co-
morbid disorders in particular, alcohol/substance abuse (Compton
et al., 2009; Conus et al., 2010). Childhood adversities affect the
course of illness, as evident in a younger age of onset (Goff et al.,
1991; Aas et al., 2011; lvarez et al., 2011). Malla et al. (1990) showed
that relapses were associated with proximal life events in schizo-
phrenia. In rst-episode patients, lower treatment compliance was
associated with childhood trauma (Lysaker et al., 2005, for compli-
ance in vocational training, Lecomte et al., 2008; Conus et al., 2010).
Lysaker et al. (2011) reported an impact of childhood sexual abuse on
metacognitive capacity. A history of adversities has been shown to
vary with poorer social functioning and social withdrawal (Schenkel
et al., 2005; Steinert et al., 2006), insecure attachment style (Gumley
et al., 2014), with more severe cognitive impairments and functional
disability (Compton et al., 2009).
2.1. Participants, setting and procedure
Sixty-two patients (n 19 female, age M 32.2 S.D. 10.3 years) with a primary
diagnosis of psychotic spectrum disorder (International Classication of Mental and
Behavioral Disorders Tenth Version (ICD-10): F20- F29, World Health Organization,
1992) were recruited from the inpatient pool at the local Center for Psychiatry (see
Table 1 for demographic data). Patients met criteria of a diagnosis of schizophrenia
F20 (77.4%), 16.1% a diagnosis of schizoaffective disorder, and 4.8% of acute
polymorphic psychotic disorder. Forty-one percent of the sample was admitted
for diagnosis and treatment of psychoses for the rst time, 59% was chronically ill.
Symptom severity and global level of functioning were assessed across a four-
month period starting at admission. Patients received routine care including
maintenance neuroleptic medication, group therapy, physical exercise and adjunct
cognitive behavioral psychotherapy if needed. Data assessment (see below) took
place in the post-acute phase. Prior to assessment, each participant was informed
about the aim and procedure of the study and provided written informed consent.
The responsible psychologist or the psychiatrists in charge veried that the patient
sufciently improved to provide informed consent and participate in data assess-
ment. The study was reviewed and approved by the Institutional Review Board
(Ethics Committee) of the University of Konstanz.

Many of these studies focused on the number of childhood

adversities or on traumatic experiences (such as sexual or physical
abuse) in particular. Indeed, the overall stress load and the exposure
to multiple types of maltreatment affect the severity of various
mental disorders following a dose-response function in patients with
posttraumatic stress disorder, depression and borderline personality
disorder (Neuner et al., 2004; Weber et al., 2008; Pietrek et al., 2013).
With the assessment of different types of childhood adversities and
their effects on measures of severity and course of the disorder in a
sample of patients diagnosed with psychotic spectrum disorders, the
present study sought to clarify the impact of childhood adversities on
the course of psychotic psychopathology. The prole of ten distinct
adversities experienced in childhood and adolescence (up to age 18)
was described in order to examine the importance of dose effect
versus specic effects, and the explained variance by distinct types of
experience. Severity of illness and course were quantied by the
number of current comorbid psychiatric diagnoses, symptomatic
remission, re-hospitalization and dropout rate as well as the short-
term course across a four-month observation period of symptom
severities and global level of functioning.
2.2. Measures and instruments
Childhood adversities were screened by the Maltreatment and Abuse Chron-
ology of Exposure (MACE) scale administered as an interview (Isele et al., 2014;
Teicher and Parigger, 2011). The MACE scale captures the exposure to ten types of
adversity during childhood, up to age 18: parental physical and verbal abuse,
parental non-verbal emotional abuse, familial and non-familial sexual abuse,
witnessed physical violence towards parents, witnessing violence towards siblings,
peer emotional and peer physical violence, emotional and physical neglect). Good
psychometric properties of the MACE scale are documented by test-retest relia-
bility, r 0.91, n 75 at 10 weeks, and correlation coefcients of r 0.75 with the
Childhood Trauma Questionnaire (Wingenfeld et al., 2010) in a German validation
sample (Isele et al., 2014). The MACE MULTI score indicates the number of different
types of childhood adversities that reached the dened severity, ranging from 0 to
10. The MACE SUM score indicates the overall severity of exposure to childhood
adversities, ranging from 0 (no childhood adversities at all) to 100 (reporting
maximal exposure to all types of childhood adversities). Using a median split of
the MACE MULTI score (Mdn 2), patients of the present sample were assigned to a
group with lower level of childhood adversities (0 or 1 types) or higher level of
childhood adversities (2 or more types).
Symptom severity was evaluated three times upon admission as well as one
and four months after the initial assessment using the Positive and Negative
Syndrome Scale (PANSS; Kay et al., 1987). The 30-item expert rating assesses

Table 1
Demographic data, childhood adversities, comorbidity and course of illness for the group with low and high childhood adversities.

Low childhood High childhood Statistics for group

adversities (n 29) adversities (n 33) difference

M/n S.D./% M/n S.D./%

Demographic data
Female sex (n, %) 12 41% 7 21% (1, 62) 2.95 p 0.104
Number of rst admission (n, %) 9 31% 17 52% (1, 62) 2.66 p 0.127
Age (Years, M, S.D.) 32.9 10.1 31.6 10.7 t(60) 0.5 p 0.621
Total number of hospitalizations (M, S.D.) 3.3 2.9 4.6 7.5 t(58)  0.85 p 0.396
Duration of hospitalization (in days, M, S.D.) 123 73 124 73 t(54)  0.04 p 0.968

Adverse childhood experiences

Number of different types of childhood adversities (MACE Multi, M, S.D.) 0.4 0.5 3.8 1.6 t(39.19)  11.64 p o 0.001
Severity of adverse childhood experiences (MACE sum score, M, S.D.) 13.3 6.6 36.5 12.2 t(50.40)  9.48 p o 0.001

Comorbidity
Number of individuals with axis I comorbidities (n, %) 1 3% 16 49% (1, 62) 15.73 p o 0.001
Number of Individuals with abuse or addiction diagnosis (ICD-10: F10- F19; (n, %) 1 3% 12 36% (1, 62) 10.09 p 0.002

Course of illness
Patients with remission (n, %) 11 39%a 6 26%a (1, 51) 0.99 p 0.381
Number of rehospitalisation within the period of observation (n, %) 4 14% 10 30% (1, 62) 2.41 p 0.141
Number of dropouts (n, %) 1 3% 10 30% (1, 62) 7.63 p 0.007

Note. Mean (M), Standard Deviation (S.D.), absolute number of respondents (n), t-tests were used for continuous variables and tests were applied for nominal/binary
variables; international classication of mental and behavioral disorders tenth version (ICD-10) chapter F.
a
The total number and percentage include study completers (n28 patients of the low childhood adversity group and n 23 of the high childhood adversity group).
 I. Schalinski et al. / Psychiatry Research 228 (2015) 633640 635

symptoms of schizophrenia including positive, negative and global psychopathol-

ogy. Based on information reported by the patient, direct observations and
observations made by health care staff or family members, the responsible
psychologist/psychiatrist rated the severity of each item for the past seven days
on a scale of 1 (absent), 2 (minimal), 3 (mild), 4 (moderate), 5 (moderate to severe),
6 (severe), to 7 (extreme). Good inter-rater reliability and a high concurrent validity
are reported for the PANSS (Peralta and Cuesta, 1994).
The present analyses measured symptom severity on ve dimensions, following
the ve-factor structure of the PANSS (including symptoms of positive, negative,
disorganization, excitement and emotional distress; van der Gaag et al., 2006).
In addition, the global level of functioning estimated with the Global Assess-
ment of Functioning (GAF; American Psychiatric Association, 2000) was evaluated
three times across the four-month period to depict the severity of illness.
In addition to symptom severity, the number of comorbid Axis I Diagnoses
served as an index of severity of disorder. Moreover, measures of the course of
illness were symptomatic remission, dened with a maintaining period of three
months using stringent criteria proposed by Andreasen et al. (2005), the rate of
rehospitalization obtained from the medical record documentation, and dropout,
dened as non-compliance for follow-up assessments. While PANSS symptoms and
GAF scores were assessed three times across the four-month period, all other
measures were obtained once, independent of interview and ratings.

2.3. Statistical analysis

Analyses were performed using R version 2.15.1 and SPSS 20.0. The relationship
between childhood adversities and symptom severity (PANSS dimensions as well
as global functioning were evaluated in separate repeated-measure ANOVAs, with
the between-subject factor group (comparing patients with low, i.e. 01 type of
adversity according to MACE MULTI, versus high levels, i.e., 2 or more types of
childhood adversities) and the within-subject factor time (at admission, 1 month
and 4 months follow-up). For the PANSS positive symptom scale, Mauchly's test
indicated that the assumption of sphericity had been violated for the main effect of
trial repetition, (2) 6.79, p 0.034. Degrees of freedom were therefore corrected
using Greenhouse-Geisser estimates of sphericity, 0.88. Group differences of
course measures (remission, relapse and dropout rate) were evaluated using chi-
square -tests.
The independent impact of the ten types of adversities (MACE SUM score) on
the severity of PANSS symptoms was evaluated using random forest regression. The
sum scores per type of childhood adversity were entered into a conditional model
for predicting the symptom levels. A variant of Breiman's approach was
applied and generated 500 conditional trees using three variables randomly
selected at each node (cforest in R package party). R2 was calculated by the
difference of the predicted model and data. Point-biseral correlation with MACE
SUM score and course measures (status of remission, rehospitalization as
well as drop out), partialing out the overall PANSS symptom severity served to
evaluate relationships between adverse experiences and illness factors (severity vs.
course).

3. Results

3.1. Prevalence of childhood adversities

Seventy-three percent of the sample reported at least one type

of childhood adversity. Nineteen percent fullled the criteria for
one type of childhood adversity, and about half of the sample
(53%) reported at least two different types of childhood adver-
sities. The prevalence per type of adversity was (Fig. 1a) peer
physical violence (48%), parental verbal abuse (27%), emotional
neglect (24%) and emotional violence through peers (23%), par-
ental non-verbal emotional abuse (21%), sexual abuse (21%),
parental physical abuse (21%), witnessing violence towards sib-
lings (16%), witnessed physical violence towards parents (13%)
and physical neglect (7%). Peer emotional violence was particularly Fig. 1. (a) Prevalence (in %) of each type of childhood adversity as well as
reported by male (33%), but not by female patients (0%, (1, 62) (b) severity of childhood adversities per type, separately for the group with high
7.99, p 0.003), whereas female patients reported more sexual ( 41) or low ( r 1) types of adverse experiences in childhood. The error bars
abuse (42%) than male patients (13%, (1, 62) 7.39, p 0.015). The represent the standard deviation.
opposite relationship was found for parental physical abuse (39%
male versus 5% female patients, (1, 62) 4.08, p 0.050).
comorbid diagnosis. In contrast, 12 of 33 patients with a high
3.2. Comorbidity level of childhood adversities met criteria for substance abuse
disorders (ICD-10: F10- F19), and 4 patients were diagnosed with
One of the 29 patients reporting a low level of childhood posttraumatic stress disorder, ((1, 62) 15.73, p o0.001, see
adversities fullled the criteria for alcohol dependency as the only Table 1).
636 I. Schalinski et al. / Psychiatry Research 228 (2015) 633640
Fig. 2. Course of symptom severities over time measured with the respective
dimension of the Positive and Negative Syndrome Scale (PANSS) and global level of
functioning. The course is presented separately for the group with high (solid lines)
and low (dashed lines) levels of childhood adversities. The error bars represent the
standard deviation of the mean.
3.3. Course of symptom severity and global functioning
Fig. 2 illustrates symptom severity for the ve PANSS dimensions
across the three assessments. Patients with a high level of childhood
adversities expressed more positive symptoms than patients with a
low level of childhood adversities (F(1, 49) 4.44, p0.040, 2 0.08).
While the severity of positive symptoms decreased over time in both
groups (F(1.77, 86.58) 5.76, p0.006, 2 0.11), the more pronounced
and prevailing decrease in patients with a low level of childhood
adversities shown in Fig. 2 was not conrmed by a signicant
interaction of Group  Time (F(1.77, 86.58) 0.49, p0.590, 2 0.01).
Similarly, disorganized symptoms decreased over time (F(2, 98) 11.54,
po0.001, 2 0.19) without a difference between groups
(F(1, 49) 2.76, p0.103, 2 0.05; Group  Time, F(2, 98) 1.38,
p0.256, 2 0.03). Excitement was more pronounced in patients
with a high compared to a low level of childhood adversities
(F(1, 49) 8.64, p0.005, 2 0.15), without a change over time
(F(2, 98) 2.02, p0.138, 2 0.04; Group  Time, F(2, 98) 0.78,
p0.839, 2 o0.01. Negative symptoms, similar in both groups, did
not change over time (F(2, 98) 2.18, p 0.118, 2 0.04; Group,
F(1, 49) 0.40, p0.529, 2 o0.01; Group  Time, F(2, 98) 0.56, p
0.574, 2 0.01), while emotional distress was similar in both groups
and invariant over time (Group, F(1, 49) 3.29, p 0.076, 2 0.06;
Time, F(2, 98) 2.62, p0.078, 2 0.05; Group  Time, F(2, 98) 0.78,
p 0.948, 2 o0.01). The overall higher symptom expression evident
in patients with a high level of childhood adversities across all ve
dimensions in Fig. 2 was supported by a main effect of Group for the
overall PANSS sum score (F(1, 49) 5.48, p0.023, 2 0.10). In
addition, general symptom improvement across time was veried
(F(2, 98) 8.85, po0.001, 2 0.15). There was no signicant interac-
tion of Group  Time (F(2, 98) 1.11, p0.332, 2 0.02) (Table 2).
Independent of the childhood adversity load, the global func-
tioning (GAF score) increased across the time in the patient sample
(Time, F(2, 94) 10.64, po 0.001, 2 0.19; Group, F(1, 47) 1.69,
p 0.200, 2 0.04; Group  Time, F(2, 94) 0.63, p 0.533,
2 0.01; see Fig. 2).
3.4. Impact of types of childhood adversities
Forest regression explained symptom severity for all ve PANSS
dimensions from the MACE SUM scores (sum scores of the ten
MACE subscales): for positive symptoms overall stress load
accounted for 20% of symptom severity at admission, 14% at one
month and 15% at the four-month follow-up; variations in nega-
tive symptom severity were explained by 11% at admission, 5% at
one month, and 13% at four months after admission; 16% of
disorganization symptoms were explained at admission, 10% at
one month and 20% at four months after admission; for the
severity of emotional distress shared variance was 17% at admis-
sion, and 8% as well as 13% at follow-up assessments; nally, the
MACE SUM of each type of childhood adversity shared 22% of its
variation with symptoms of excitement at rst admission, 14% at
the one-month follow-up and 11% at the four-month follow-up.
Predictive models derived from the analysis indicated the impact
of different types of childhood adversities on symptom severity, in
particular emotional neglect and physical neglect. The analysis
indicated the strongest impact of emotional neglect on all ve
PANSS dimensions at admission. At the one month follow-up,
emotional neglect predicted positive symptoms. At the four month
follow-up, emotional neglect proved important for positive, nega-
tive and disorganized symptoms. In addition, physical neglect
inuenced positive and disorganized symptoms as well as excite-
ment and emotional distress at admission, one and four months
after rst admission (for further specic effects on the PANSS
dimensions compare relative importance in Table 3 with the
highest value being the most important, and the second as the
second most important predictor etc.).
3.5. Course of illness
Symptom remission occurred in 39% of the sample with a low
level and 26% with a high level of childhood adversities
((1, 51) 0.99, p 0.381). Yet, the odd ratio of non-remission was
1.83 times higher in the group with a high level relative to a low
level of adversities. Relapse rate during the four-month period as
measured by the rate of rehospitalization did not differ between
patients with a low level (n 4, 14%) and patients with a high level
(n 10, 30%) of childhood adversities ((1, 62) 2.41, p 0.141).
Ten patients with a high level of childhood adversities dropped
out before the nal assessment (30%), in contrast to one patient in
the group with a low level of childhood adversities (3%;
(1, 62) 7.63, p 0.007). The odd ratio of for dropout was 7.48
times higher in the former compared to the latter group (Table 1).
3.6. Severity of illness versus course of illness
The remission status (1 obtained remission, 0 no remission)
remained unaffected by the severity of childhood adversities when
 I. Schalinski et al. / Psychiatry Research 228 (2015) 633640 637

Table 2
PANSS symptom severity and functioning across a four month observation period of patients with psychotic spectrum disorders reporting low and high levels of childhood
adversities.

PANSS symptom severity Group with low childhood adversities Group with high childhood adversities t-Test

M S.D. M S.D.

Positive symptoms
First assessment 15.31 4.83 17.00 5.86 t(60)  1.23, p 0.224
1 month follow up 12.71 4.46 15.14 5.58 t(54)  1.80, p 0.078
4 month follow up 13.14 5.30 16.43 5.54 t(49)  2.16, p 0.035n
Negative symptoms
First assessment 17.72 7.52 19.21 7.21 t(60)  0.80, p 0.430
1 month follow up 17.00 6.82 17.86 7.57 t(54)  0.45, p 0.658
4 month follow up 17.71 5.84 18.96 5.87 t(49)  0.75, p 0.455
Disorganization
First assessment 22.41 6.48 23.27 5.94 t(60)  0.55, p 0.588
1 month follow up 19.36 4.69 20.82 6.27 t(54)  0.99, p 0.327
4 month follow up 19.43 4.92 23.04 5.47 t(49)  2.48, p 0.017n
Excitement
First assessment 14.31 3.44 16.06 3.33 t(60)  2.03, p 0.047n
1 month follow up 12.93 3.29 15.36 4.63 t(54)  2.26, p 0.028n
4 month follow up 13.39 3.96 16.22 4.48 t(49)  2.39, p 0.021n
Emotional distress
First assessment 17.83 5.11 20.27 4.97 t(60)  1.91, p 0.061
1 month follow up 16.54 4.73 18.46 5.78 t(54)  1.37, p 0.178
4 month follow up 16.68 4.55 18.65 4.44 t(49)  1.56, p 0.126
GAF score
First assessment 48.90 15.45 47.71 14.75 t(60) 0.31, p 0.759
1 month follow up 54.68 13.67 51.30 14.85 t(53) 0.88, p 0.383
4 month follow up 54.59 12.50 48.91 15.22 t(48) 1.45, p 0.154

Note. Mean (M), Standard Deviation (S.D.), PANSS Positive and Negative Syndrome Scale, GAF Global Assessment of Functioning,
n
indicates p o 0.050.

partialling out the overall symptom severity at admission
(prpb  0.10, p 0.489). However, rehospitalization within the
period of observation (1 yes, 0 no) was related to more severe
childhood adversities independent of PANSS sum score at admis-
sion (prpb 0.29, p 0.041). After controlling for the PANSS sum
score at admission, the partial point-biseral correlation remained
signicant between the overall severity of childhood adversities
and the drop-out status (1 drop out, 0 no drop out), prpb 0.34,
p 0.007.
4. Discussion
More detailed knowledge about the inuence of adverse
experiences including their amount and type of adversity on the
severity and course of psychotic psychopathology should help to
specify the role of childhood adversities (as an environmental
factor) in the complex interaction of genetic and environmental
factors that determine psychotic illness. With this purpose, the
present study screened different types of childhood adversities
within one sample of psychotic patients and examined effects on
different measures of severity and course of disorder.
The present results conrmed ndings (e.g., Mueser et al.,
2002) of high childhood stress load in psychotic patients. A
prevalence of 4 70% of at least one type of adversity exceeds the
prevalence reported in healthy populations (e.g., o 50%;
Cuijpers et al., 2011). A more detailed description of types of
stress veried the prominence of peer physical and emotional
violence as well as parental verbal abuse and emotional neglect.
A high amount of adverse experiences varied with indices of the
severity of illness such as comorbid diagnoses, more severe
positive symptoms, disorganization as well as excitement
symptoms prevailing beyond the treatment and follow-up
period, and a high dropout rate. Comparable with a review of
comorbidity in schizophrenia, substance abuse comorbidity
predominated in the present study (Buckley et al., 2009). In
particular, the group with more childhood adversities showed
high rates of alcohol/substance abuse or addiction, correspond-
ing with previous reports (Leverich et al., 2002; Scheller-Gilkey
et al., 2004; Garno et al., 2005; Romero et al., 2009; Conus et al.,
2010). Following Khantzian (1997), comorbidity with alcohol or
substance abuse disorders may indicate that childhood adver-
sities promote a stress-sensitive phenotype that responds to
stress and negative states in adulthood (emotions, daily life
stressors, managing illness) with alcohol/drug abuse as avoid-
ance or self-medication.
Besides the comorbidity effect, a detailed pattern of relation-
ships suggests a multifaceted impact of childhood adversities on
the severity of psychotic psychopathology. Overall symptom
severity as well as positive, disorganization and excitement
symptoms were more prominent in patients with high compared
to patients with low levels of childhood adversities, and the
former group still showed these high symptom levels four months
after the initial assessment. Despite overall symptom improve-
ment, the short-term course suggests an ongoing impact of early-
life stress on symptom severity, thereby adding to previous reports
(e.g., Garno et al., 2005). Thus, present result document a dose-
effect, but also draw attention to specic deleterious effects of
types of childhood adversities.
In addition to the overall amount of adverse childhood experi-
ences, forest regression indicated an independent impact of
specic types of childhood adversities on the severity of symptoms
particularly emotional and physical neglect, sexual abuse and
peer verbal violence. Specic relationships conrm previous
results, for instance, of an impact of sexual abuse on positive
symptoms (e.g., Ross et al., 1994; Read et al., 2003; Whiteld et al.,
2005), or of emotional neglect on psychotic symptoms (Colins
et al., 2009). In contrast to previous results, physical abuse did not
explain symptom levels in the present sample (Shevlin et al., 2007;
Fisher et al., 2010). In addition to the effects of symptom severity, a
638 I. Schalinski et al. / Psychiatry Research 228 (2015) 633640

high amount of childhood adversities contributed to higher drop-

Emotional

R2 0.13
Distress
out rates and higher rates of rehospitalization. We can only

0.26 ( )

0.40 ( )
speculate about the reasons patients may have had for dropping
PANSS dimensions: four months after admission n 51

out of follow-up assessment; for instance, as a consequence of

R2 0.11 symptom exacerbation or other ongoing characteristics related to
childhood adversities, such as an insecure attachment style
Excite-

0.47 ( )
0.15 ( )
ment

associated with mistrusting beliefs about others, including

Note. Variable importance. Non-predictive values are suppressed. Direction of association (+ for positive association and for negative associations). PANSS = Positive and Negative Syndrome Scale.
mental health professionals (Gumley et al., 2014), or maladaptive
avoidance coping style (Tait et al., 2004). Low compliance
Disorganization

and treatment adherence has been associated with childhood

R2 0.20

trauma (Lecomte et al., 2008; Conus et al., 2010; Lysaker et al.,

0.25 ( )
0.24 ( )

1.98 ( )
1.17 ( )
2005).
A plausible mediation of relationship by symptom severity and
Variable importance derived from conditional random forest regression: predicting symptom severities of PANSS dimensions from exposure to each type of maltreatment and abuse.

level of functioning remains to be specied: In the present sample,

Negative
R2 0.13

0.27 ( ) 0.51 ( )
0.04 ( ) 1.77 ( )

childhood adversities varied with lasting symptom severity and

with more dropouts. However, a causal link, whether patients
dropped out from follow-up assessment as a consequence of

1.29 ( )
R2 0.14

0.18 ( )
Positive

symptom exacerbation, or whether both measures of severity of

illness are independently inuenced by childhood adversities,
cannot be concluded.
Not all measures selected to describe the severity and course of
Emotional

R2 0.08
Distress

illness were modied by the amount of adversities experienced

0.21 ( )

early in life. Neither relapse nor symptom remission differed

PANSS dimensions: one month after admission n 56

between patients with high and low overall childhood stress

loads. This may indicate a stronger inuence of disorder-specic
R2 0.14
Excite-

0.05 ( )

0.38 ( )
0.37 ( )

0.16 ( )
ment

pathophysiology (such as the genetic contribution, progressive

gray matter loss, progressive cognitive decline, neuronal pathol-
ogy) on the course of psychopathology, to which environmental
Disorganization

inuences such as childhood adversities add. Still, the relationship

R2 0.10

of a high level of childhood adversities and some indices of a more

0.42 ( )

severe course of illness suggest that factors of pathophysiology

and early-life stress accumulate or interact in their impact on
psychopathology, which cannot be compensated insufciently via
treatment. More work is needed to further unravel the complex
Negative
R2 0.06

interaction of these inuences in the prediction of the course of

psychopathology.
Limitations of the present study have to be noted: The
0.84 ( )

0.07 ( )

0.76 ( )
R2 0.14
Positive

described relationships between childhood adversities and mea-

sures of the severity of illness and its course do not inform causal
links or the nature of the impact. Moreover, if early-life stress
Emotional

R2 0.19

triggers a string of biological and social consequences that dyna-

Distress

0.07 ( )
0.91 ( )

0.11 ( )

mically unfold and interact with factors of illness in a complex

2.1 ( )

manner, long-term manifestations of the impact of childhood

adversities that differ from the short-term manifestations
described in the present study have to be assumed. Though
R2 0.22
Excite-

0.08 ( )

0.60 ( )
1.31 ( )

0.17 ( )
ment

hampered by drop-outs, a longitudinal assessment including

longer follow-up periods is needed for modeling the impact of
PANSS dimensions: at admission N 62

childhood adversities on the course of illness. Finally, the assess-

Disorganization

ment of childhood adversities was retrospective and reliance on

R2 0.16

those reports are discussed for patients with severe mental illness,
0.42 ( )

0.99 ( )
1.61 ( )

and severely handicapped inpatients in particular (Lieberman

et al., 1995; Conus et al., 2010). Although previous studies provided
evidence for sufcient test-retest reliability in patients with severe
Positive Negative
R2 0.20 R2 0.11

1.84 ( ) 0.49 ( )

0.74 ( )

mental illness (Meyer et al., 1996; Goodman et al., 1999), an impact

of state at the time of assessment cannot be ruled out.
Still, present results emphasize the impact of childhood adver-
0.48 ( )

0.84 ( )

sities sufciently to call for its consideration in diagnostic assessment

and treatment. For instance, patients with a dual diagnosis, especially
dependency on alcohol or other substances, could benet from
Parental verbal abuse

programs that integrate childhood experiences. Studies suggest that

Parental non-verbal

Witnessed violence

Witnessed physical
emotional abuse

violence toward
Emotional neglect

toward siblings

patients with adverse childhood experiences benet from additional

SUM score of the

Parental physical

Physical neglect
Peer emotional
MACE subscale

cognitive behavioral therapy (Nemeroff et al., 2003; Bulmash et al.,

Peer physical

Sexual abuse

2009; Lewis et al., 2010). As shown for treatment of chronic

violence

violence

parents
abuse

depression integration of childhood adversities in treatment strate-

Table 3

gies should improve outcomes of schizophrenia patients with high

levels of early life stress (McCullough, 2003).
 I. Schalinski et al. / Psychiatry Research 228 (2015) 633640
Acknowledgments
We thank the patients for their participation, the psychiatrists/
psychologists of the involved wards for their support, and Almut
Carolus and Petia Popova for administrative support in data
acquisition. The University of Konstanz supported the project.
References
Aas, M., Dazzan, P., Fisher, H.L., Morgan, C., Morgan, K., Reichenberg, A., Zanelli, J.,
Fearon, P., Jones, P.B., Murray, R.M., Pariante, C.M., 2011. Childhood trauma and
cognitive function in rst-episode affective and non-affective psychosis. Schi-
zophrenia Research 129, 1219.
lvarez, M.J., Roura, P., Oss, A., Foguet, Q., Sola, J., Arrufat, F.X., 2011. Prevalence and
clinical impact of childhood trauma in patients with severe mental disorders.
The Journal of Nervous and Mental Disease 199, 156161.
American Psychiatric Association, 2000. Diagnostic and Statistical Manual of
Mental Disorders: DSM-IV-TRs. American Psychiatric Pub, Washington, DC.
Andersen, S., Tomada, A., Vincow, E., Valente, E., Polcari, A., Teicher, M., 2008.
Preliminary evidence for sensitive periods in the effect of childhood sexual
abuse on regional brain development. The Journal of neuropsychiatry and
clinical neurosciences 20, 292301.
Andreasen, N.C., Carpenter, W.T., Kane, J.M., Lasser, R.A., Marder, S.R., Weinberger,
D.R., 2005. Remission in schizophrenia: proposed criteria and rationale for
consensus. American Journal of Psychiatry 162, 441449.
Bernet, C.Z., Stein, M.B., 1999. Relationship of childhood maltreatment to the onset
and course of major depression in adulthood. Depression and Anxiety 9,
169174.
Brown, G.R., McBride, L., Bauer, M.S., Williford, W.O., 2005. Impact of childhood
abuse on the course of bipolar disorder: a replication study in US veterans.
Journal of Affective Disorders 89, 5767.
Buckley, P.F., Miller, B.J., Lehrer, D.S., Castle, D.J., 2009. Psychiatric comorbidities and
schizophrenia. Schizophrenia Bulletin 35, 383402.
Bulmash, E., Harkness, K.L., Stewart, J.G., Bagby, R.M., 2009. Personality, stressful life
events, and treatment response in major depression. Journal of Consulting and
Clinical Psychology 77, 10671077.
Colins, O., Vermeiren, R., Vreugdenhil, C., Schuyten, G., Broekaert, E., Krabbendam,
A., 2009. Are psychotic experiences among detained juvenile offenders
explained by trauma and substance use? Drug and Alcohol Dependence 100,
3946.
Compton, M., Kelley, M., Ramsay, C., Pringle, M., Goulding, S., Esterberg, M., Stewart,
T., Walker, E., 2009. Association of pre-onset cannabis, alcohol, and tobacco use
with age at onset of prodrome and age at onset of psychosis in rst-episode
patients. American Journal of Psychiatry 166, 12511257.
Conus, P., Cotton, S., Schimmelmann, B.G., McGorry, P.D., Lambert, M., 2010.
Pretreatment and outcome correlates of sexual and physical trauma in an
epidemiological cohort of rst-episode psychosis patients. Schizophrenia
Bulletin 36, 11051114.
Cuijpers, P., Smit, F., Unger, F., Stikkelbroek, Y., Ten Have, M., de Graaf, R., 2011. The
disease burden of childhood adversities in adults: a population-based study.
Child Abuse Neglect 35, 937945.
Daruy-Filho, L., Brietzke, E., Lafer, B., Grassi-Oliveira, R., 2011. Childhood maltreat-
ment and clinical outcomes of bipolar disorder. Acta Psychiatrica Scandinavica
124, 427434.
Enns, M.W., Cox, B.J., 2005. Psychosocial and clinical predictors of symptom
persistence vs remission in major depressive disorder. Canadian Journal of
Psychiatry 50, 769777.
Fisher, H.L., Jones, P.B., Fearon, P., Craig, T.K., Dazzan, P., Morgan, K., Hutchinson, G.,
Doody, G.A., McGufn, P., Leff, J., Murray, R.M., Morgan, C., 2010. The varying
impact of type, timing and frequency of exposure to childhood adversity on its
association with adult psychotic disorder. Psychological Medicine 40,
19671978.
Garno, J.L., Goldberg, J.F., Ramirez, P.M., Ritzler, B.A., 2005. Impact of childhood
abuse on the clinical course of bipolar disorder. British Journal of Psychiatry
186, 121125.
Gaudiano, B.A., Zimmerman, M., 2010. The relationship between childhood trauma
history and the psychotic subtype of major depression. Acta Psychiatrica
Scandinavica 121, 462470.
Goff, D.C., Brotman, A.W., Kindlon, D., Waites, M., Amico, E., 1991. Self-reports of
childhood abuse in chronically psychotic patients. Psychiatry Research 37,
7380.
Goodman, L.A., Thompson, K.M., Weinfurt, K., Corl, S., Acker, P., Mueser, K.T.,
Rosenberg, S.D., 1999. Reliability of reports of violent victimization and
posttraumatic stress disorder among men and women with serious mental
illness. Journal of Traumatic Stress 12, 587599.
Graux, J., Bidet-Caulet, A., Bonnet-Brilhault, F., Camus, V., Bruneau, N., 2014.
Hallucinations and negative symptoms differentially revealed by frontal and
temporal responses to speech in schizophrenia. Schizophrenia Research 155,
3944.
Gumley, A.I., Schwannauer, M., Macbeth, A., Fisher, R., Clark, S., Rattrie, L., Fraser, G.,
McCabe, R., Davidson, K., Birchwood, M., 2014. Insight, duration of untreated
psychosis and attachment in rst-episode psychosis: prospective study of
639
psychiatric recovery over 12-month follow-up. The British Journal of Psychia-
try, 18.
Hammersley, P., Dias, A., Todd, G., Bowen-Jones, K., Reilly, B., Bentall, R.P., 2003.
Childhood trauma and hallucinations in bipolar affective disorder: preliminary
investigation. British Journal of Psychiatry 182, 543547.
Heim, C., Newport, D.J., Heit, S., Graham, Y.P., Wilcox, M., Bonsall, R., Miller, A.H.,
Nemeroff, C.B., 2000. Pituitary-adrenal and autonomic responses to stress in
women after sexual and physical abuse in childhood. JAMA 284, 592597.
Isele, D., Teicher, M.H., Ruf-Leuschner, M., Elbert, T., Kolassa, I.T., Schury, K., Schauer,
M., 2014. KERFEin Instrument zur umfassenden Ermittlung belastender
Kindheitserfahrungen. Zeitschrift fr Klinische Psychologie und Psychotherapie
43, 121130.
Kay, S.R., Fiszbein, A., Opler, L.A., 1987. The positive and negative syndrome scale
(PANSS) for schizophrenia. Schizophrenia Bulletin 13, 261276.
Khantzian, E.J., 1997. The self-medication hypothesis of substance use disorders: a
reconsideration and recent applications. Harvard Review of Psychiatry 4,
231244.
Lecomte, T., Spidel, A., Leclerc, C., MacEwan, G.W., Greaves, C., Bentall, R.P., 2008.
Predictors and proles of treatment non-adherence and engagement in
services problems in early psychosis. Schizophrenia Research 102, 295302.
Leverich, G.S., McElroy, S.L., Suppes, T., Keck Jr, P.E., Denicoff, K.D., Nolen, W.A.,
Altshuler, L.L., Rush, A.J., Kupka, R., Frye, M.A., Autio, K.A., Post, R.M., 2002. Early
physical and sexual abuse associated with an adverse course of bipolar illness.
Biological Psychiatry 51, 288297.
Lewis, C.C., Simons, A.D., Nguyen, L.J., Murakami, J.L., Reid, M.W., Silva, S.G., March, J.S.,
2010. Impact of childhood trauma on treatment outcome in the treatment for
adolescents with depression study (TADS). Journal of the American Academy of
Child & Adolescent Psychiatry 49, 132140.
Lieberman, J.A., Koreen, A.R., Chakos, M., Sheitman, B., Woerner, M., Alvir, J.M.,
Bilder, R., 1995. Factors inuencing treatment response and outcome of rst-
episode schizophrenia: implications for understanding the pathophysiology of
schizophrenia. The Journal of Clinical Psychiatry 57, 59.
Lysaker, P.H., Beattie, N.L., Strasburger, A.M., Davis, L.W., 2005. Reported history of
child sexual abuse in schizophrenia: associations with heightened symptom
levels and poorer participation over four months in vocational rehabilitation.
The Journal of Nervous and Mental Disease 193, 790795.
Lysaker, P.H., Gumley, A., Brne, M., Vanheule, S., Buck, K.D., Dimaggio, G., 2011.
Decits in the ability to recognize one's own affects and those of others:
associations with neurocognition, symptoms and sexual trauma among persons
with schizophrenia spectrum disorders. Consciousness and cognition 20,
11831192.
Malla, A.K., Cortese, L., Shaw, T.S., Ginsberg, B., 1990. Life events and relapse in
schizophrenia. Social Psychiatry and Psychiatric Epidemiology 25, 221224.
Maniglio, R., 2013. Prevalence of child sexual abuse among adults and youths with
bipolar disorder: A systematic review. Clinical Psychology Review 33, 561573.
McCullough Jr, J.P., 2003. Treatment for chronic depression: cognitive behavioral
analysis system of psychotherapy (CBASP). Journal of Psychotherapy Integration
13, 241263.
Meyer, I.H., Muenzenmaier, K., Cancienne, J., Struening, E., 1996. Reliability and
validity of a measure of sexual and physical abuse histories among women with
serious mental illness. Child Abuse and Neglect 20, 213219.
Miniati, M., Rucci, P., Benvenuti, A., Frank, E., Butteneld, J., Giorgi, G., Cassano, G.B.,
2010. Clinical characteristics and treatment outcome of depression in patients
with and without a history of emotional and physical abuse. Journal of
Psychiatry Research 44, 302309.
Morgan, C., Fisher, H., 2007. Environment and schizophrenia: environmental
factors in schizophrenia: childhood traumaa critical review. Schizophrenia
Bulletin 33, 310.
Mueser, K.T., Rosenberg, S.D., Goodman, L.A., Trumbetta, S.L., 2002. Trauma, PTSD,
and the course of severe mental illness: an interactive model. Schizophrenia
Research 53, 123143.
Murgatroyd, C., Patchev, A.V., Wu, Y., Micale, V., Bockmhl, Y., Fischer, D., Holsboer,
F., Wotjak, C.T., Almeida, O.F., Spengler, D., 2009. Dynamic DNA methylation
programs persistent adverse effects of early-life stress. Nature Neuroscience 12,
15591566.
Nanni, V., Uher, R., Danese, A., 2012. Childhood maltreatment predicts unfavorable
course of illness and treatment outcome in depression: a meta-analysis.
American Journal of Psychiatry 169, 141151.
Nemeroff, C.B., Heim, C.M., Thase, M.E., Klein, D.N., Rush, A.J., Schatzberg, A.F.,
Ninan, P.T., McCullough, J.P., Weiss, P.M., Dunner, D.L., Rothbaum, B.O., Korn-
stein, S., Keitner, G., Keller, M.B., 2003. Differential responses to psychotherapy
versus pharmacotherapy in patients with chronic forms of major depression
and childhood trauma. Proceedings of the National Academy of Sciences 100,
1429314296.
Neria, Y., Bromet, E.J., Carlson, G.A., Naz, B., 2005. Assaultive trauma and illness
course in psychotic bipolar disorder: ndings from the Suffolk county mental
health project. Acta Psychiatrica Scandinavica 111, 380383.
Neuner, F., Schauer, M., Karunakara, U., Klaschik, C., Robert, C., Elbert, T., 2004.
Psychological trauma and evidence for enhanced vulnerability for posttrau-
matic stress disorder through previous trauma among West Nile refugees. BMC
psychiatry 4, 34.
Peedicayil, J., 2011. Epigenetic management of major psychosis. Clinical epigenetics
2, 249256.
Peralta, V., Cuesta, M.J., 1994. Psychometric properties of the positive and negative
syndrome scale (PANSS) in schizophrenia. Psychiatry Research 53, 3140.
640 I. Schalinski et al. / Psychiatry Research 228 (2015) 633640
Pietrek, C., Elbert, T., Weierstall, R., Mller, O., Rockstroh, B., 2013. Childhood
adversities in relation to psychiatric disorders. Psychiatry Research 206,
103110.
Read, J., Agar, K., Argyle, N., Aderhold, V., 2003. Sexual and physical abuse during
childhood and adulthood as predictors of hallucinations, delusions and thought
disorder. Psychology and Psychotherapy: Theory, Research and Practice 76,
122.
Read, J., Fink, P.J., Rudegeair, T., Felitti, V., Whiteld, C.L., 2008. Child maltreatment
and psychosis: a return to a genuinely integrated bio-psycho-social model.
Clinical Schizophrenia & Related Psychoses 2, 235254.
Romero, S., Birmaher, B., Axelson, D., Goldstein, T., Goldstein, B.I., Gill, M.K., Iosif, A.,
Strober, M.A., Hunt, J., Esposito-Smythers, C., Ryan, N.D., Keller, M., 2009.
Prevalence and correlates of physical and sexual abuse in children and
adolescents with bipolar disorder. Journal of Affective Disorders 112, 144150.
Ross, C.A., Anderson, G., Clark, P., 1994. Childhood abuse and the positive symptoms
of schizophrenia. Psychiatry Service 45, 489491.
Roy, A., 2005. Reported childhood trauma and suicide attempts in schizophrenic
patients. Suicide and Life-Threatening Behavior 35, 690693.
Rutter, M., Moftt, T.E., Caspi, A., 2006. Geneenvironment interplay and psycho-
pathology: multiple varieties but real effects. Journal of Child Psychology and
Psychiatry 47, 226261.
Scheller-Gilkey, G., Moynes, K., Cooper, I., Kant, C., Miller, A.H., 2004. Early life stress
and PTSD symptoms in patients with comorbid schizophrenia and substance
abuse. Schizophrenia Research 69, 167174.
Schenkel, L.S., Spaulding, W.D., DiLillo, D., Silverstein, S.M., 2005. Histories of
childhood maltreatment in schizophrenia: relationships with premorbid func-
tioning, symptomatology, and cognitive decits. Schizophrenia Research 76,
273286.
Schizophrenia Psychiatric GWAS Consortium, 2011. Genome-wide association
study identies ve new schizophrenia loci. Nature Genetics 43, 969976.
http://dx.doi.org/10.1038/ng.940.
Schmitt, A., Malchow, B., Hasan, A., Falkai, P., 2014. The impact of environmental
factors in severe psychiatric disorders. Frontiers in Neuroscience, 8.
Shevlin, M., Dorahy, M., Adamson, G., 2007. Childhood traumas and hallucinations:
an analysis of the National Comorbidity Survey. Journal of Psychiatric Research
41, 222228.
Shonkoff, J.P., Garner, A.S., Siegel, B.S., Dobbins, M.I., Earls, M.F., McGuinn, L., Pascoe,
J., Wood, D.L., 2012. The lifelong effects of early childhood adversity and toxic
stress. Pediatrics 129, 232246.
Steinert, T., Schmid, P., Bergbauer, G., 2006. History of trauma in people with
schizophrenia predicts need for seclusion and restraint. Journal of Clinical
Psychiatry 67, 995.
Svrakic, D.M., Zorumski, C.F., Svrakic, N.M., Zwir, I., Cloninger, C.R., 2013. Risk
architecture of schizophrenia: the role of epigenetics. Current opinion in
psychiatry 26, 188195.
Tait, L., Birchwood, M., Trower, P., 2004. Adapting to the challenge of psychosis:
personal resilience and the use of sealing-over (avoidant) coping strategies. The
British Journal of Psychiatry 185, 410415.
Teicher, M.H., Parigger, A., 2011. Modied Adverse Childhood Experience Scale,
version 0.9; inspired by the ACE Scale. In Schauer, M., Neuner, F. Elbert, T., 2011.,
Narrative Exposure Therapy (NET). A Short-Term Intervention for Traumatic
Stress, 2. Au. Cambridge/Gttingen: Huber Publishers & Hogrefe.
Teicher, M.H., Samson, J.A., 2013. Childhood maltreatment and psychopathology: a
case for ecophenotypic variants as clinically and neurobiologically distinct
subtypes. American Journal of Psychiatry 170, 11141133.
Tunnard, C., Rane, L.J., Wooderson, S.C., Markopoulou, K., Poon, L., Fekadu, A.,
Juruena, M., Cleare, A.J., 2014. The impact of childhood adversity on suicidality
and clinical course in treatment-resistant depression. Journal of Affective
Disorders 152, 122130.
van der Gaag, M., Hoffman, T., Remijsen, M., Hijman, R., de Haan, L., van Meijel, B.,
van Harten, P.N., Valmaggia, L., de Hert, M., Cuijpers, A., Wiersma, D., 2006. The
ve-factor model of the positive and negative syndrome scale II: a ten-fold
cross-validation of a revised model. Schizophrenia Research 85, 280287.
van Os, J., Kenis, G., Rutten, B.P., 2010. The environment and schizophrenia. Nature
468, 203212.
Weber, K., Rockstroh, B., Borgelt, J., Awiszus, B., Popov, T., Hoffmann, K., Schonauer,
K., Watzl, H., Prpster, K., 2008. Stress load during childhood affects psycho-
pathology in psychiatric patients. BMC Psychiatry 8, 63.
Widom, C., DuMont, K., Czaja, S.J., 2007. A prospective investigation of major
depressive disorder and comorbidity in abused and neglected children grown
up. Archives of General Psychiatry 64, 4956.
Wingenfeld, K., Spitzer, C., Mensebach, C., Grabe, H.J., Hill, A., Gast, U., Schlosser, N.,
Hpp, H., Beblo, B., Driessen, M., 2010. Die deutsche Version des Childhood
Trauma Questionnaire (CTQ): Erste Befunde zu den psychometrischen Kenn-
werten. Psychotherapie Psychoso- matik Medizinische Psychologie 60,
442450.
Whiteld, C.L., Dube, S.R., Felitti, V.J., Anda, R.F., 2005. Adverse childhood experi-
ences and hallucinations. Child Abuse Neglect 29, 797810.
World Health Organization, 1992. The ICD-10 International Classication of Mental
ond Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines.
WHO, Geneva.
Zanarini, M., Frankenburg, F., Hennen, J., Reich, D., Silk, K., 2006. Prediction of the
10-year course of borderline personality disorder. American Journal of Psy-
chiatry 163, 827832.