Acta Psychiatr Scand 2013: 127: 455–463 © 2012 John Wiley & Sons A/S.

hn Wiley & Sons A/S. Published by John Wiley & Sons Ltd
All rights reserved ACTA PSYCHIATRICA SCANDINAVICA
DOI: 10.1111/acps.12041

Schizophrenia patients with and without

Post-traumatic Stress Disorder (PTSD) have
different mood symptom levels but same
cognitive functioning
Peleikis DE, Varga M, Sundet K, Lorentzen S, Agartz I, Andreassen D. E. Peleikis1, M. Varga1,
OA. Schizophrenia patients with and without Post-traumatic Stress K. Sundet2, S. Lorentzen1,
Disorder (PTSD) have different mood symptom levels but same I. Agartz1, O. A. Andreassen1,3
cognitive functioning. 1
Department of Mental Health and Addiction, Oslo
University Hospital, 2Institute of Psychology, University
Objective: To investigate differences in cognitive function and level of of Oslo and 3Institute of Clinical Medicine, University of
psychopathology in patients with schizophrenia (SZ) with or without Oslo, Oslo, Norway
psychological traumatization/post-traumatic stress disorder (PTSD).
We hypothesized that traumatized patients with or without PTSD
would have more severe cognitive impairments because of the
neuropathological changes associated with PTSD, and more severe
psychopathology compared with non-traumatized SZ patients.
Method: Seventy-five SZ patients with traumatization and 217 SZ
patients without traumatization were evaluated regarding the symptoms Please also see editorial comment to this paper by K.
and cognitive functioning, using standard symptom scales (PANSS; Mueser in this issue, Acta Psychiatr Scand 2013;127:
CDSS) and a neuropsychological test battery (IQ, verbal memory, 440–441.
attention, working memory, psychomotor speed, and executive
functioning). Key words: Schizophrenia; post-traumatic stress
Results: No significant differences were observed between the groups in disorder; cognitive function
cognitive test performance. The patients in the traumatized group with Dawn E. Peleikis, Department of Psychiatry, Akershus
PTSD showed significantly more current depression than the non- University Hospital, Alna Outpatient Clinic,
traumatized group (P = 0.012). 1478 Lørenskog, Norway.
Conclusion: The findings did not support the hypothesis that the E-mail: dawn.peleikis@vikenfiber.no, dawn.
peleikis@ahus.no
presence of comorbid PTSD/traumatization in SZ is associated with
increased cognitive impairment. The increase in current depression in
SZ with comorbid traumatization suggests that more severe
psychopathology is associated with traumatization. Accepted for publication October 9, 2012

Significant outcomes
• No significant differences were observed between the groups in cognitive test performance.
• Schizophrenia patients with trauma and post-traumatic stress disorder (PTSD) had significantly more
current depression than the non-traumatized group.

Limitations
• Given the nature of the cross-sectional design, causal relationships between traumatization/PTSD,
schizophrenia, and functional measures cannot be drawn.
• Some questionnaires have a low response rate Calgary Depression Scale for Schizophrenia (CDSS).
• Heterogeneity within the trauma group with regard to the type and age when the traumatic event
happened complicates the interpretation of our results.

455
Peleikis et al.
Introduction
Numerous studies have documented high rates of
exposure to traumatic events in patients with
schizophrenia (SZ), which often leads to high rates
of comorbid post-traumatic stress disorder (PTSD)
(1–3). In contrast, not much is known about the
associations between traumatization and the clini-
cal symptoms and cognitive dysfunctions in SZ.
The prevalence of psychological traumatization
(PT), here, defined as in DSM-IV: ‘The person
experienced, witnessed, or was confronted with an
event or events that involved actual or threatened
death or serious injury, or a threat to the physical
integrity of self or others. The person’s response
involved intense fear, helplessness, or horror’. The
prevalence of PT is high in the general population.
American epidemiological studies show a lifetime
prevalence of 40–50%. The National Comorbidity
Survey (NCS) found that violence and sexual
abuse in childhood and adolescence were strongly
associated with mental disorders in adulthood
(4,5).
The prevalence of PT in SZ is still somewhat
uncertain, although the first study to assess preva-
lence of PTSD in this population was written in
the late 1980s (6, 7). Another important study (8)
focusing on people with the first episode of psycho-
sis showed lifetime prevalence of PT and PTSD in
a cohort of 426 patients initially hospitalized for
psychosis. The prevalence of PT was 68.5%, and
the prevalence of PTSD was 14.3% in the full sam-
ple and 26.5% in those with PT. The prevalence of
PTSD in the sample of patients with SZ was 10%.
A weighted average of data from several studies
indicates a 29% prevalence of PTSD in patients
with SZ (9); however, most of these studies
assessed the rates of current PTSD, not lifetime
PTSD.
A substantial body of evidence has documented
that patients with SZ display cognitive deficits,
especially in the domains of attention, working
and verbal memory, and executive function (10–
13). Similarly, research in patients with PTSD has
identified the basic deficits in attention, memory,
and executive function (14,15), with some overlap
with SZ patients in affected brain regions. In par-
ticular, structural and functional abnormalities in
frontal and temporal regions are found in patients
with SZ and in patients with PTSD (16–18).
With regard to PTSD, the hippocampus is a
region of particular interest because noradrenergic
activity during the stress response directly affects
the hypothalamic–pituitary–adrenal (HPA) axis,
disrupting the normal activities of the limbic struc-
tures (16). Magnetic resonance imaging (MRI)
456
studies have documented bilateral, hippocampal
volume reductions in trauma survivors with PTSD
(19,20), although it is not clear whether this is the
result of PTSD or a risk factor existing prior to the
development of PTSD (18). Also frontal lobe
abnormalities are reported in PTSD, including
hypoactivity of the mediolateral and dorsolateral
prefrontal cortex (21,22), consistent with docu-
mented deficits in attention and executive function-
ing in individuals with PTSD (19, 23, 24). Building
on advances in social cognitive and effective neuro-
science, it has been suggested that a core set of
brain regions, including cortical midline structures,
amygdala, insula, posterior parietal cortex, and
temporal poles, is vulnerable to psychological
trauma. Patients with PTSD have exhibited
behavioural and neurobiological impairments
impacting emotional self-awareness, emotional
regulation, social–emotional processing, and self-
referential processing as compared with healthy
controls (25). Studies have also found explicit
memory deficits in PTSD (26–29).The findings
have been reported in various populations such as
college students (30), combat veterans (23, 31, 32),
Holocaust survivors (33), victims of childhood sex-
ual abuse (34), and victims of natural disasters
(35).
A trauma history contributes to increased psy-
chiatric symptoms and poorer functional out-
comes in patients with SZ compared with those
without trauma (36,37). Similarly, a recent study
(38) hypothesize that the cognitive impairment
associated with traumatization/PTSD could fur-
ther affect the cognitive impairment in SZ,
because of a limited cognitive reserve in individ-
uals with SZ to compensate for the HPA stress
response associated with PTSD. The documented
cognitive impairments may be the result of HPA
abnormalities arising from an extreme stressor
or reflect premorbid neurological abnormalities
that predispose an individual to the development
of PTSD.
Aims of the study
The aim of the study was to assess psychologi-
cal traumatization/post-traumatic stress disorder
(PTSD), cognitive function, and level of psychopa-
thology in a sample of patients with schizophrenia
(SZ) using a self-reported history of trauma expo-
sure. We hypothesized that traumatized patients
with or without PTSD would have more severe cog-
nitive impairments because of the neuropathologi-
cal changes associated with PTSD, and more severe
psychopathology compared with non-traumatized
SZ patients.

Material and methods
The study included patients from the ongoing
Thematically Organized Psychosis (TOP) Study
in Norway. The TOP Study is a large collabora-
tive effort including the University of Oslo and
hospitals in the Oslo region, including Oslo Uni-
versity Hospital, Lovisenberg and Diakonhjem-
met Hospital, and two hospitals in neighboring
counties of Oslo. The project is catchment-area-
based, and aims at recruiting all patients within
the relevant diagnostic groups (schizophrenia,
bipolar disorders, and other psychosis). Recruit-
ment started in 2002 and is still ongoing. In addi-
tion to clinical and cognitive studies, specific
subprojects investigate genetic factors and brain
imaging.
The patient sampling was conducted between
January 2002 and September 2010 and consecu-
tively recruited from in- and out-patient psychiat-
ric units in the five catchment areas of Oslo City,
covering inner city as well as suburban areas. The
sample consisted of 292 patients (161 men and 131
women) with a schizophrenia spectrum diagnosis,
in the following named schizophrenia (SZ). This
includes schizophrenia (n = 225), schizophreni-
form disorder (n = 8), and schizoaffective disorder
(n = 59).
Inclusion criteria were age 23–67 years at
intake; a main diagnosis of schizophrenia, includ-
ing schizophreniform disorder and schizoaffective
disorder according to the DSM-IV (39). Exclu-
sion criteria were a history of traumatic brain
injury, organic brain disorders, diagnosis of
mental retardation, primary substance depen-
dence disorder, or poor neuropsychological test
effort. Inadequate test effort among participants
was determined based on the Forced Choice Rec-
ognition subtest from the California Verbal
Learning Test – Second Edition CVLT-II (40).
A cutoff of <15 on this subtest was used. Seven
participants were excluded. To assure valid cog-
nitive test performance and self-rating of depres-
sive symptoms, all participants had to have
Norwegian as their first language or had received
their compulsory schooling in Norway. Patients
with first episode psychosis are not included in
the current sample.
The patients were assessed by the Structured
Clinical Interview for DSM-IV (SCID-I) to con-
firm the diagnosis of SZ or schizoaffective disorder
(41). Lifetime trauma and PTSD were assessed
with a Structured Clinical Interview M.I.N.I., ver-
sion 5.0 to diagnose DSM-IV Axis I disorder for
PTSD (42) This particular method does not require
participants to respond with a yes or no to each
PTSD in Schizophrenia patients
traumatic event from a list, but rather asks partici-
pants to indicate whether they have experienced
any events after reading an extended list of trau-
matic events. Also information from the patients’
hospital medical records was collected by a psychi-
atrist or clinical psychologist.
All interviewers were trained in SCID assess-
ment based on the programme at the University of
California, Los Angeles, and had regularly meet-
ings where diagnostics in severe mental disorders
were discussed with an experienced clinical
researcher in the field.
Ethics and approvals
All participants gave written informed consent.
Responders participated in an altogether 3-h inter-
view divided into three sessions. Participants were
paid 89 USD for participating and were provided
with test results, post-test counseling, and referrals
for follow-up and treatment as needed. The study
was approved by the Regional Committee for
Medical Research Ethics and the Norwegian Data
Inspectorate.
Symptom assessment
The Positive and Negative Syndrome Scale
(PANSS) (43) assessed the severity of general,
positive and negative psychotic symptoms. The
PANSS is a semistructured interview using a
7-point rating scale over 30 items and is a com-
monly used tool in schizophrenia research. Func-
tional level was assessed with the Global
Assessment of Functioning Scale, split version-
function score (GAF-F) (44), with an ICC inter-
rater reliability of 0.81. Calgary Depression Scale
for Schizophrenia (CDSS) (45) was used to mea-
sure the severity of depression and suicidality;
CDSS is a 9-item semistructured interview
designed for use for individuals with a diagnosis
of schizophrenia. The scale assesses the levels of
depressive symptoms independent of positive and
negative symptoms of schizophrenia and any
effects of medication (46). Current depression
was assessed by CDSS total score, with an inter-
nal consistency Cronbach’s coefficient alpha of
0.82.
Neuropsychological assessment
All participants underwent testing with a compre-
hensive neuropsychological test battery, carried
out by trained psychologists. The tests were
selected a priori based on the domain specific cog-
nitive impairments commonly reported to be
457
Peleikis et al.

central to SZ in general (47). As measures of verbal

Results
memory, California Verbal Learning Test (48) and
a Norwegian research version of Logical Memory Description of sample, comparisons between groups and cognitive
from the Wechsler Memory Scale (49) were correlates of trauma exposure
included. Attention was assessed with the Digit
In the sample of 292 patients with a schizophrenia
Span Forwards, and working memory with the
spectrum diagnosis, 217 (74%) patients (124 men
Digit Span Backwards from the Wechsler Adult
and 93 women) had no trauma, and 75 (25%)
Intelligence Scale – Third Edition, WAIS-III (50).
patients (37 men and 37 women) had experienced
Psychomotor speed was measured with the Digit
trauma (Table 1). Of the patients with trauma
Symbol from the WAIS-III. As measures of execu-
exposure, 21 (7%) patients fulfilled the criteria for
tive functioning, tests from the Norwegian version
the diagnosis PTSD, and the type of trauma in
of the Delis–Kaplan Executive Function System
relation to age is further specified in Table 2. There
(51) were administered. From the Letter-Colour
were no significant difference in the living situation
Inhibition test, the ‘Stroop’ condition was used,
between the no trauma, trauma, and PTSD
that is, the third subtest where the subject is
groups. No significant difference was seen in sub-
instructed to name the color of the ink of color
stance use 2 weeks prior to study entry between
words that are written in ink of a different color.
the three SZ groups. The majority of the patients
From the Verbal Fluency test scores, Letter Flu-
with SZ were living on social welfareillness benefit.
ency, Category Fluency (animals and boys’
There were few patients from the sample without
names), and Category Switching (where the subject
any psychiatric hospitalization (Table 1).
is instructed to shift between naming as many
In Global Assessment of Functioning (GAF)
items of fruits and furniture as possible within
score, split version, symptoms and function in all
60 s) were used. Different aspects of executive
three groups were comparable. Respectively, there
functioning are covered when these tests are
were no significant differences between the three
included in the analyses: inhibition of behaviour
groups’ no trauma, trauma, and PTSD groups in
(the ‘Stroop’ task), initiation of behaviour
years of education (Table 1). Neither the total
(Category Fluency), and set shifting (Category
PANSS score nor factor analyses of the PANSS
Switching).
(55,56) using subscales of positive, negative, psy-
Current IQ was assessed with a Norwegian
chopathology, and dysphoric mood did show any
research version (52) of the Wechsler Abbreviated
significant differences between the groups
Scale of Intelligence (WASI) (53). Mean current
(Table 1). There were no significant differences
IQ was 100.3 (range: 59–136; SD = 15.9) in the SZ
when comparing all three groups (no trauma,
group without PT and 97.6 (range: 63–129;
trauma, and PTSD) on all measures (Table 1),
SD = 17.1) in the SZ group with trauma. Premor-
except for CDSS (total) current depression, with
bid IQ was estimated from the NART score (54):
CDSS scores of mean (SD) of 4.0 (4.0) no trauma,
mean premorbid IQ in the SZ group without PT
4.1 (4.2) trauma, and 7.4 (4.3) PTSD, P = 0.012.
was 109.3 (SD = 5.90) and 109.0 (SD = 7.40) in
CDSS was completed by 44% of our sample. We
the SZ group with trauma.
have also investigated the difference in sociodemo-
graphic or clinical variables between the groups
Statistical analysis and found no significant difference between with
(n = 128) and without (n = 164) CDSS (data not
The data were analyzed with PASW for PC
shown). Current suicidal thoughts, plans, and
version 18.0. The chosen outcome instruments
attempts (CDSS-item 8) were rated and showed no
have continuous and categorical scales, and the
significant differences between groups
analyses focused on comparing average scores
(Table 1).Yet, SZ patients with trauma and PTSD
between the groups. When the data were normally
had significantly more current depression (CDSS
distributed with equal variance, analyses were
total) than the other groups (P = 0.012).
based on parametric tests. When comparing
groups, independent sample t-tests and ANOVA
statistics were used for continuous variables, and Cognitive test performance
chi-squared test was applied for categorical vari-
Regarding the cognitive test performance, includ-
ables. However, when there was no normal distri-
ing the premorbid IQ measure, no significant dif-
bution, nonparametric, alternative Mann–Whitney
ferences between the three groups were found.
U-test was used. An alpha level of P < 0.05
Most cognitive measures were within the normal
was used throughout the study, and all tests were
range of performance compared with established
two-sided.

458
 PTSD in Schizophrenia patients

Table 1. Demographical and clinical characteristics of patients with schizophrenia: No trauma, trauma and PTSD groups

All patients N = 292 No trauma n = 218 Trauma n = 54 PTSD n = 21 P

Measure n (%) n (%) n (%) n (%)

Gender: Male 161 (55.1) 124 (57.1) 24 (45.3) 13 (61.9) 0.244†
Employed 216 (74.0) 22 (10.2) 4 (7.4) 1 (5.0) 0.823‡
Living on their own 217 (74.3) 98 (45.2) 23 (42.6) 6 (31.6) 0.238‡
Substance use, current§ 202 (69.2) 13 (6.4) 3 (5.8) 1 (5.3) 0.810‡
CDSS (item 8)¶ 120 (41.1) 16 (26.2) 8 (17.4) 3 (23.1) 0.568‡
Not hospitalized 217 (74.3) 25 (11.5) 5 (9.3) 2 (10.5) 0.547
n (%) M (SD) M (SD) M (SD) P†
Education in years 284 (97.3) 12.8 (2.6) 12.4 (3.1) 12.0 (4.9) 0.373
PANSS total 252 (86.3) 62.7 (17.8) 63.6 (17.9) 64.8 (13.1) 0.850
Positive scale 256 (87.7) 15.1 (6.1) 16.0 (6.3) 14.6 (4.6) 0.559
Negative scale 258 (88.4) 15.8 (6.5) 14.8 (6.9) 17. 9 (6.3) 0.206
Psychopathology** 257 (88.0) 31.6 (8.8) 31.4 (10.7) 32.3 (6.9) 0.925
G.2 (anxiety) 287 (98.2) 3.0 (1.4) 3.0 (1.5) 3.8 (1.8) 0.083
G.6 (depression) 287 (98.2) 2.5 (1.5) 2.6 (1.3) 3.2 (1.6) 0.172
Dysphoric mood†† 285 (97.6) 2.3 (0.9) 2.3 (0.9) 2.6 (0.9) 0.263
CDSS (current depression, total) 128 (43.8) 4.0 (4.0) 4.1 (4.2) 7.4 (4.3) 0.012*
GAF-S 292 (100) 43.2 (11.6) 43.2 (10.8) 43.6 (6.4) 0.987
GAF-F 292 (100) 43.5 (11.1) 41.6 (9.5) 43.1 (6.8) 0.281
Current IQ‡‡ 211 (72.3) 99.5 (16.5) 97.3 (17.5) 94.4 (19.6) 0.377
Premorbid IQ‡‡ 211 (72.3) 101.5 (15.8) 99.2 (17.0) 94.4 (16.8) 0.160

*ANOVA, P < 0.05, PTSD > no trauma, trauma statistically sign. by post hoc test (Tukey’s test). Mean and Standard Deviation (M, SD). Positive and Negative Syndrome Scale
(PANSS). Global Assessment of Functioning (GAF), Symptom-(GAF-S) and Function-(GAF-F) subscale.
†Chi-squared test, two-sided for categorical variables, ANOVA one-way analysis for scaled variables.
‡Fisher’s exact test.
§Use of tablets, alcohol, cannabis, amphetamine, ecstasy, or cocaine during the last 2 weeks before inclusion.
¶The Calgary Depression Scale (CDSS) (item 8): Any current suicidal thoughts, plans, or attempts (score  1).
**The psychopathology mean score from the three-factor model of Kay et al. (43) (Item G1–G16).
††Dysphoric mood factor from five-factor PANSS model of White et al. (56) (Item G1, G2, G3, G4, and G6).
‡‡Intelligence Quotient (IQ) assessed by the Wechsler Abbreviated Scale of Intelligence (WASI).

Table 2. Type of trauma in relation to age between the groups on the current IQ measure,
Trauma (not PTSD) (n = 54) PTSD (n = 21)
consisting of the subtests Vocabulary, Similarities,
Block Design, and Matrix Reasoning of the WASI,
Age where the patients with SZ in no trauma, trauma,
Type of trauma Child* Adult unknown Total Child* Adult Total and PTSD performed equally (P = 0.377).
Violence 3 0 0 3 0 0 0
Child sexual 6 0 0 6 0 0 0
abuse (CSA) Discussion
Neglect 3 0 0 3 1 0 1
CSA+ violence 5 0 0 5 4 0 4
The main finding of the current study was no sig-
Violence + neglect 4 0 0 4 3 0 3 nificant differences in cognitive functioning
CSA+ neglect 8 0 0 8 4 0 4 between schizophrenia (SZ) spectrum disorder
CSA+ neglect 14 0 0 14 8 0 8 patients with trauma, post-traumatic stress disor-
+ violence
Accident 1 1 0 2 0 0 0
der (PTSD), or no trauma, but clear psychopatho-
Trauma, not 6 0 3 9 0 1 1 logical differences. The study of Duke et al., 2010
specified (38), did not find any association between PTSD
*Child of age <16 years.
and cognitive abnormalities already present in
patients with SZ. This result was in line with our
main findings where no significant differences in
norms of healthy controls, except for psychomotor cognitive functioning between SZ patients with
speed or processing speed (Digit Symbol from the trauma, PTSD, or no trauma were seen. However,
WAIS) with performances 1 SD below the mean in some studies have found an association of comor-
all groups. Because no significant differences were bid PTSD with cognitive dysfunction in schizo-
found regarding age, education, and positive and phrenia (14, 57). Fan and colleagues (14) suggest
negative symptoms, there was no need for adjust- that patients with comorbid PTSD (n = 15) suffer
ments in the further analyses (Table 3). As can be more cognitive impairments especially in the
seen in this table, there is no significant difference domains of attention, working memory, and

459
Peleikis et al.

Table 3. Cognitive test performance for Schizophrenia between patients with no regarded as a result of abnormal neurodevelop-
trauma, trauma, and PTSD
ment. Trauma seems more related to mood symp-
Trauma (without toms, which are generally regarded as a state
Neuropsychological No trauma PTSD) PTSD measure. To our knowledge, our study provides
tests Mean (SD) Mean (SD) Mean (SD) P the most extensive evaluation of cognitive function
Verbal memory in the largest traumatized SZ sample to date.
WMS-III LM I 8.26 (2.89) 8. 30 (3.05) 8.24 (3.33) 0.996 As assumed, we found a significantly higher level
CVLT-II 46.72 (11.84) 46.89 (13.34) 46.76 (13.57) 0.997 of depression in the SZ group with PTSD com-
Total A1-5
CVLT-II LDR 0.44 (1.27) 0.52 (1.37) 0.36 (1.35) 0.883
pared with both the no trauma and the trauma
Attention group (Table 1). Our findings of current depres-
Digit span 5.85 (1.06) 5.71 (1.08) 5.33 (1.46) 0.121 sion (CDSS total) were in line with a recent study
forward (38), which shows that trauma and PTSD have
Working
memory
been related to a variety of adverse outcomes in
Digit span 4.15 (1.07) 3.98 (1.10) 4.19 (1.21) 0.611 patients with SZ. Patients with PTSD tend to have
backward more severe psychotic symptoms (58), increased
Psychomotor suicidality (59), and to use more psychiatric ser-
speed
Digit symbol 6.36 (2.14) 6.78 (2.29) 6.76 (2.81) 0.456
vices (60). Our study, however, did not find any
Executive significant differences between the groups concern-
functioning ing psychotic symptoms, suicidality, or the use of
Inhibition 7.38 (3.68) 6.82 (3.93) 7.19 (4.25) 0.688 psychiatric services.
Letter fluency 8.92 (3.94) 8. 23 (4.02) 8.40 (3.44) 0.544
Category 8. 62 (4.15) 8.18 (4.22) 8.05 (3.59) 0.729 A series of studies have been conducted on the
fluency prevalence of PTSD in patients with SZ (7, 37,
Inhibition 7.81 (3.61) 7.43 (3.46) 7.52 (4.08) 0.809 61–64), with some discrepancies in the prevalence
/Switching
estimates. Apparently, 20–29% of psychological
WASI
Vocabulary 47.06 (12.35) 45.55 (12.91 43.81 (16.86) 0.493 traumatization results in the development of PTSD
Similarities 48.92 (11. 32) 47.89 (11.30) 46.65 (12.10) 0.653 (2, 3, 64, 65). In our study, we found a prevalence
Block design 50.33 (10.41) 49.23 (11.73) 46.25 (11.93) 0.275 of trauma in the total SZ group of 25%, of which
Matrix 51.08 (11.63) 48.76 (12.54) 45.57 (12.73) 0.102
reasoning
only 7% had current PTSD. The prevalence of
WASI VIQ 97.39 (16.59) 95.52 (17.13) 94.80 (20.29) 0.707 PTSD in our study was low, but comparable to
WASI PIQ 101.52 (15.82) 98.77 (16.96) 94.40 (16.81) 0.160 Neria and coworkers (8) who found a prevalence
WASI FIQ 99.54 (16.48) 97.30 (17.51) 94.35 (19.64) 0.377 of PTSD in their sample of patients with schizo-
4 subtests
phrenia of approximately 10%.
WMS-III LM I, Wechsler’s Memory Scale-III Logical Memory I; CVLT-II, California There are several limitations in the present
Verbal Learning Task-II; LDR, long delay–free recall. study. Given the nature of the cross-sectional
All neuropsychological values were converted to z (or t) score (mean 10; SD 3), design, causal relationships between traumatiza-
except the CVLT-II Total (number of correct words recollected) and Digit Span For-
ward and Backward (raw scores).
tion/PTSD, SZ, and functional measures cannot
be drawn. Our sample size with the groups con-
taining 292 participants with SZ, 75 traumatized
executive functioning, compared with those who patients, and 21 with a comorbid PTSD may lack
have not developed PTSD. adequate power to detect between-group differ-
Previous studies of cognitive function in SZ ences. Also some questionnaires have a low
patients with traumatization/PTSD have some lim- response rate (CDSS). The reason for CDSS not
itations including a small number of participants being used for the total sample is that CDSS was
with limited evaluation of cognitive abilities and first included in the protocol after the first phase of
reliance of clinical diagnoses of SZ and PTSD. It the TOP recruitment; thus, it is missing in 164
may be speculated whether the cognitive deficits patients. However, there is no selection bias in
associated with traumatization are sufficiently these two subsamples, because there is no reason
severe to be differentiated from those associated to believe that patient characteristics changed over
with SZ development. There is also a large varia- time in Oslo. There were no significant differences
tion in cognitive functioning in SZ, which suggests in clinical or sociodemographic characteristics
that some of the discrepant findings in this field between the CDSS and no CDSS groups (data not
could be due to differences in statistical power. shown).
Due to the correlation design, the current findings A limitation of the method for assessing trauma
cannot be used for causative inferences. However, was that the approach probably led to underre-
it may be speculated that trauma has less effect porting of traumatic events that are common in
on neurocognitive functioning, which is often the general population (66), such as the sudden,

460

unexpected death of a loved one. These are even
more common in people with severe mental illness
(67). This is a significant limitation for the current
study. However, we did obtain self-reports about
witnessing traumatic events, but these were rare.
Another limitation of the current study was the use
of a semistructured clinical interview to assess life-
time trauma exposure. This may have the disad-
vantage of ‘false low’ rate of lifetime trauma
exposure.
Heterogeneity within the trauma group with
regard to the type and also age when the traumatic
event happened complicates the interpretation of
our results. There is some evidence that suggests
that certain types of trauma differentially contrib-
ute to cognitive impairment and that the age at
which the traumatic event took place may influ-
ence the impact of trauma on cognitive function
(29).
The theoretical approach of the vulnerability–
stress model can be used as a starting point for
studying the role of PTSD and post-traumatic
symptoms in SZ.
In a clinical perspective, an individual with
schizophrenia can be considered to have a ‘dual
vulnerability’ with respect to traumas, with both
types of vulnerability leading to the same func-
tional deficits in the patients. These deficits include
cognitive deficits and interpersonal and intraper-
sonal deficits that lead to difficulties in comprehen-
sion of situations and increased tendency to
misinterpret the intentions of others.
Further longitudinal investigations are needed
to delineate the relationship between PTSD com-
orbidity in SZ and the cognitive deficits that poten-
tially could impact the level of distress, subjective
quality of life, and poorer treatment outcomes in
these patients.
Acknowledgements
A special thanks to Mari H. Vårdal for helpful discussions and
advice regarding the statistical analysis concerning this article.
We would also like to thank Alna Outpatient Rehabilitation
Unit for recruiting patients and clinical social worker Irma
Helgesen for her dedication and assistance throughout the
study. The study was supported by South–East Norway Health
Authority (2010-074) and Research Council of Norway
(#167153/V50).
Declaration of interest
None.
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