Department of Psychology, University of Manchester
South Staffs Mentally Disordered Offenders Team, St George's Hospital, Stafford
Barton House Clinic, Addenbrookes Hospital, Cambridge
Trengweth Mental Health Unit, Redruth
Department of Psychological Medicine, Gartnavel Royal Hospital, Glasgow
Department of Psychology, University of Manchester, Manchester, UK
Correspondence: Paul Hammersley, Department of Psychology, University of Manchester, Oxford Road, Manchester M13 9PL, UK. E-mail: Paul{at}hammersley7616.freeserve.co.uk
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To investigate the relationship between childhood sexual abuse and other childhood traumas and hallucinations in people with bipolar affective disorder.
Method A sample of 96 participants was drawn from the Medical Research Council multi-centre trial of cognitivebehavioural therapy for bipolar affective disorder. The trial therapists recorded spontaneous reports of childhood sexual abuse made during the course of therapy. Symptom data were collected by trained research assistants masked to the hypothesis.
Results A significant association was found between those reporting general trauma (n=38) and auditory hallucinations. A highly significant association was found between those reporting childhood sexual abuse (n=15) and auditory hallucinations.
Conclusions The relationship between childhood sexual abuse and hallucinations in bipolar disorder warrants further investigation.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Goodwin & Jamison (1990) reviewed 20 studies conducted between 1922 and 1989 investigating the prevalence of hallucinations in bipolar disorder and calculated a weighted mean average of 18%. To date, no study has attempted a systematic analysis of the relationship between childhood sexual abuse or other childhood trauma and hallucinations in people with bipolar disorder. In this study we investigated this relationship in a sample of patients recruited to a multi-centre, randomised, controlled trial of cognitivebehavioural therapy.
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Initial diagnostic assignment was made by referring consultant psychiatrists and verified by a team of four trained graduate research assistants who inspected case notes and interviewed the patients before therapy and at follow-up points using the Structured Clinical Interview for DSMIV (SCID; First et al, 1996). Inclusion criteria were doubly ratified diagnosis of bipolar disorder in individuals aged 16 years or older drawn from four geographically distinct areas of the UK. No patient reported mood-incongruent psychotic symptoms at referral. Evidence of a lifetime history of mood-incongruent psychotic phenomena was reported for 33 of the sample.
Recruitment by centre was as follows: Manchester 22, Liverpool 25, Glasgow 25 and Cambridge 24. Individuals with substance misuse as a primary diagnosis or evidence of organic illness were excluded from the study, as were individuals displaying rapid-cycling bipolar disorder or severe comorbid borderline personality disorder. As the research assistants were employed for the purposes of the clinical trial, they were masked to the hypothesised relationship between trauma and hallucinations.
The sample comprised 32 men and 64 women. The minimum age was 22 years and the maximum 70 years (mean 40.5, s.d.=10.4). Mean age at illness onset, recorded by the research assistants on the basis of case-note and interview data, was known for 95 participants, and found to be 24.4 years (s.d.=7.8). Eighty-one participants had been hospitalised at some point in their illness, and their mean age of first hospitalisation was 29.4 years (s.d.=9.4).
Measures
Participants were seen by the trial therapists for approximately 24
one-hour sessions over a 6-month period. Direct references to childhood sexual
abuse or other traumas made by participants during assessment or at other
points in therapy were collected by the therapists, who completed an
eight-item questionnaire for each patient. The questionnaire listed eight
categories of trauma: sexual abuse; physical abuse; physical abuse with a
weapon; witness to the killing or serious injury of another (including
parasuicide); having a close friend or relative who was murdered or killed
(including suicide); experiencing a significant accident; experiencing a
natural or human-made disaster; any other trauma. These categories were based
on the categorisation by Mueser et al
(1998) of traumas commonly
experienced by those with serious mental illness, which were in turn derived
from the Trauma History Questionnaire
(Green, 1996). For each
category, the therapists were asked to record detailed descriptions of the
traumatic event where possible.
A report of any trauma including childhood sexual abuse was only classified as occurring in childhood if it occurred before the patient's 16th birthday. The behavioural descriptions of childhood sexual abuse were categorised according to the criteria used in the Child Maltreatment History Self-Report (CMHSR; Badgley et al, 1984), an assessment tool used in a large-scale Canadian study of childhood sexual abuse in the general population. Sexual abuse is rated in the CMHSR according to four distinct categories:
In our sample no participants reported threatened sexual contact only, and in no case did the recorded onset of illness predate the reported abuse. In order to ensure that the trauma descriptions were categorised correctly, a psychiatric social worker with extensive experience in the assessment of trauma and abuse (A.D.) reclassified the detailed descriptions. Interrater reliability, indicating consensus for allocation into designated categories, was 34/36 for recorded reports of general trauma and 15/15 for reports of childhood sexual abuse.
Data for lifetime history of experience of psychotic symptoms were collected by the four trained and supervised research assistants at the trial baseline assessment, using the lifetime version of the SCID. This provided evidence for the presence or absence of hallucinations in six distinct categories. Only participants scoring 3 (threshold or true hallucinations) on the baseline SCID were categorised as having a history of hallucinations; this was to ensure that transient stress-related dissociative symptoms or quasi-psychotic experiences of the type that may be present in borderline personality disorder were not classified as hallucinations. To minimise the risk of type-I statistical errors, and in accordance with our hypotheses, our main analyses focused on hallucinations. However, to determine whether any findings were specific to hallucinations, parallel analyses were calculated using SCID data on patients' delusions and hallucinations in the non-auditory modalities.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
Contingency tables showing the relationships between different kinds of
hallucination report and reports of childhood sexual abuse are shown in
Table 2. A significant
association was found between reports of any trauma and the presence or
absence of auditory hallucinations (2=7.61,
P<0.01, d.f.=1). The observed associations between reports of
abuse and history of any hallucinations (
2=6.83,
P<0.005, d.f.=1), history of auditory hallucinations
(
2=14.66, P<0.001, d.f.=1), and history of voices
commenting (
2=14.28, P<0.002, d.f.=1) were even
more significant. However, no significant association was found between trauma
and reports of delusions, or trauma and reports of visual or tactile
hallucinations. The relationship between mood-incongruent psychotic symptoms
and childhood sexual abuse was not significant. Seven patients were diagnosed
as having borderline personality disorder. However, the observed associations
between childhood sexual abuse and hallucinations all remained when these
patients were excluded from the analyses.
|
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Experience of early trauma has been specifically associated with Schneiderian symptoms (Ross et al, 1994; Ellason & Ross, 1997) or hallucinations (Reid & Argyle, 1999). Other studies have reported that psychotic symptoms, especially hallucinations, are frequently experienced by survivors of early trauma such as sexual abuse (Heins et al, 1990; Ensink, 1993) and later trauma such as exposure to military combat (Butler et al, 1996).
In a community survey, Ross & Joshi (1992) reported that 46% of those who reported three or more Schneiderian symptoms had experienced childhood physical or sexual abuse, compared with 8% with no such symptoms. In surveys of schizotypal traits in the normal population it has also been found that reports of unusual experiences correlate with a reported history of childhood sexual abuse (Bryer et al, 1987; Startup, 1999) or childhood maltreatment (Berenbaum, 1999).
Given this apparent association between hallucinatory experiences and childhood sexual abuse in people with schizophrenia, it is obviously important to establish whether the same relationship exists between hallucinations and childhood sexual abuse in other clinical groups.
Findings of this study
Over a quarter of the participants in our study reported visual
hallucinations, a proportion that is higher than in most previously reported
studies of people with bipolar disorder
(Goodwin & Jamison, 1990). However, in one of the largest studies of this kind (Black & Nazrallah,
1989), the observed prevalence rate for visual hallucinations was 27%, which
is almost identical to our own figure. In contrast to most previous studies,
the figures arrived at in our investigation were based on lifetime experiences
rather than on current symptoms.
Only 15 (16%) of our patients reported a history of childhood sexual abuse to their therapists. This finding is comparable with those obtained from population samples. For example, Salter (1988) summarised 14 North American studies investigating childhood sexual abuse in the general population, and reported prevalence rates ranging from 11% to 38% for women. Despite this modest prevalence of reported abuse in our sample, strong associations were observed between reported childhood sexual abuse and a history of hallucinations, especially auditory ones.
Does childhood trauma cause bipolar disorder?
Although Hyun et al
(2000) reported that a
childhood history of sexual abuse was significantly more frequent in a sample
of patients with bipolar disorder compared with a control sample of people
with major depressive disorder, the lack of appropriate control data in our
study makes it impossible for us to verify this finding. As the majority of
the participants did not report childhood sexual abuse, there is certainly
nothing in our findings to imply that bipolar affective disorder is in some
direct way caused by trauma, or that patients with this disorder are more
traumatised than other groups. Interestingly, of the 15 patients who reported
childhood sexual abuse, only three reported that the perpetrator was a blood
relative.
However, the findings are consistent with other studies which suggest that childhood sexual abuse and other early traumas increase the risk that individuals will experience positive symptoms, and especially hallucinations. In our study the association between childhood sexual abuse and hallucinations could not be attributed to borderline personality disorder, or to the presence of mood-incongruent psychotic symptoms. In all the recorded cases of abuse in the sample, the abuse preceded the onset of illness, including the experience of auditory hallucinations. This observation is important because it makes it unlikely that the abuse was imagined, or that the experience of trauma was in some way a consequence of illness (which would be the case, for example, if people experiencing hypomanic or manic symptoms placed themselves in situations where there was a high risk of sexual assault).
The most plausible interpretation of the present findings is, therefore, that childhood sexual abuse has an impact on the later symptom profile of patients with bipolar affective disorder, increasing their vulnerability to experiencing auditory hallucinations.
Possible mechanisms linking early trauma to hallucinations
The processes by which trauma leads to hallucinations in people with severe
mental illness are not understood. However, psychological studies have
suggested that hallucinations result from the misattribution of mental events
to an alien or external source, and that this is most likely to occur when
experiencing mental events that are automatic and low in cognitive effort
(Bentall, 2000). As intrusive
memories of trauma are typically mental events of this kind, they may be
particularly likely to be experienced as hallucinations by individuals whose
source-monitoring abilities are compromised by severe mental illness. Negative
automatic thoughts of the kind experienced during periods of low self-esteem
would also be likely to be experienced as alien under these circumstances.
Both types of cognitive events are especially likely to be experienced during
stressful periods, especially after an adult survivor of abuse has been
further traumatised by additional negative experiences. Honig et al
(1998) found that many people
troubled by hallucinations reported that their hallucinations began following
a retraumatising experience.
Limitations
Childhood sexual abuse was only recorded when spontaneously reported to the
therapist in this study. It is possible that the magnitude of the association
between childhood sexual abuse and hallucinations in bipolar disorder has been
underestimated by our method. Conservative criteria were used to decide
whether patients had experienced such abuse; for example, two patients with a
history of hallucinations were not classified as victims of childhood sexual
abuse because apparent behavioural descriptions of abuse obtained by the
therapists were considered ambiguous. Conversely, it may be possible that the
magnitude of the association between childhood sexual abuse and hallucinations
has been overestimated, in that we were not able to verify self-reports of
abuse with other sources such as medical or legal documents, and had to take
these self-reports at face value.
Lifetime histories of hallucinations were not validated against case-note data. However, case notes probably provide a highly inaccurate record of these kinds of experiences, which will be sometimes underrecorded, or sometimes falsely recorded on the basis of ambiguous evidence (for example, patients talking to themselves). Rosenhan (1973) long ago noted that normal behaviour is sometimes misinterpreted by ward staff in this way. A further weakness of the study was that we were unable to analyse in which mood state hallucinations occurred, or whether auditory hallucinations in particular occurred in the depressive or manic phase of the illness. None the less, our findings suggest that some common mechanisms might be responsible for the hallucinations experienced by people with schizophrenia and those experienced by people with bipiolar affective disorder. The findings also suggest that clinicians should be sensitive to the possibility that early adverse experience may be an issue that needs to be addressed in the treatment and management of hallucinating patients with bipolar disorder.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Badgley, R. F., Allard, H. A., McCormick, N., et al (1984) Sexual Offences Against Children. Catalogue no. J2-50/1984E. Ottowa: Department of Supply and Services.
Bentall, R. P. (2000) Hallucinatory experiences. In Varieties of Anomalous Experience: Examining the Scientific Evidence (eds E. Cardena, S. J. Lynn & S. Krippner), pp. 85120. Washington, DC: American Psychological Association.
Berenbaum, H. (1999) Peculiarity and childhood maltreatment. Psychiatry, 62, 2135.[Medline]
Black, D.W. & Nasrallah, A. (1989) Hallucinations and delusions in 1715 patients with unipolar and bipolar affective disorders. Psychopathology, 22, 2834.[Medline]
Bryer, J., Nelson, B., Miller, J., et al (1987) Childhood sexual and physical abuse as a factor in psychiatric illness. American Journal of Psychiatry, 44, 14261430.
Butler, R.W., Mueser, K. T., Sprock, J., et al (1996) Positive symptoms of psychosis in posttraumatic stress disorder. Biological Psychiatry, 39, 839844.[CrossRef][Medline]
Ellason, J. & Ross, C. (1997) Childhood trauma and psychiatric symptoms. Psychological Reports, 80, 447450.[Medline]
Ensink, E. (1993) Trauma: A study of child abuse and hallucinations. In Accepting Voices (eds M. Romme & S. Escher), pp. 165171. London: Mind.
First, M. B., Spitzer, R. L., Gibbon, M., et al (1996) Structured Clinical Interview for DSMIV (SCID). New York: Biometric Research.
Goodman, L. A., Rosenberg, S. D., Mueser, K., et al (1997) Physical and sexual assault history in women with serious mental illness: prevalence, correlates, treatment, and future research directions. Schizophrenia Bulletin, 23, 685696.[Medline]
Goodman, L. A., Thompson, K., Weinfurt, K., et al (1999) Reliability of reports of violent victimisation and posttraumatic stress disorder among men and women with serious mental illness. Journal of Traumatic Stress, 12, 587599.[CrossRef][Medline]
Goodwin, D.W. & Jamison, K. R. (1990) Manic Depressive Illness. New York: Oxford University Press.
Green, B. L. (1996) Trauma History Questionnaire. In Measurement of Stress and Self-Report Trauma (ed. H. H. Slamm). Lutherville, MD: Sidran Press.
Heins, T., Gray, A. & Tennant, M. (1990) Persisting hallucinations following childhood sexual abuse. Australian and New Zealand Journal of Psychiatry, 24, 561565.[Medline]
Honig, A., Romme, M. A. J., Ensink, B.J., et al (1998) Auditory hallucinations: a comparison between patients and nonpatients. Journal of Nervous and Mental Disease, 186, 646651.[CrossRef][Medline]
Hyun, M., Friedman, S. D. & Dunner, D. L. (2000) Relationship of childhood physical and sexual abuse to adult bipolar disorder. Bipolar Disorders, 2, 131135.[CrossRef][Medline]
Mueser, K.T., Goodman, L. B., Trumbetta, S. L., et al (1998) Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 66, 493499.[CrossRef][Medline]
Neria, Y., Bromet, E. J., Sievers, S., et al (2002) Trauma exposure and posttraumatic stress disorder in psychosis: findings from a first admission cohort. Journal of Consulting and Clinical Psychology, 70, 245251.
Read, J. & Argyle, N. (1999)
Hallucinations, delusions, and thought disorder among adult psychiatric
patients with a history of child abuse. Psychiatric
Services, 50,
14671472.
Rosenhan, D. L. (1973) On being sane in insane places. Science, 179, 250258.[Medline]
Ross, C. A., Anderson, G. & Clark, P. (1994) Childhood abuse and positive symptoms of schizophrenia. Hospital and Community Psychiatry, 45, 489491.[Medline]
Ross, S. M. & Joshi, S. (1992) Schneiderian symptoms and childhood trauma in the general population. Comprehensive Psychiatry, 45, 489491.
Salter, A. (1988) Treating Child Sex Offenders and Their Victims. London: Sage.
Startup, M. (1999) Schizotypy, dissociative experiences and childhood abuse: Relationships among self report measures. British Journal of Clinical Psychology, 38, 333344.[CrossRef][Medline]
Received for publication March 12, 2002. Revision received September 24, 2002. Accepted for publication January 3, 2003.
Related articles in BJP: