Introduction
Trauma is a broad term that encompasses exposure to a range of adverse experiences including neglect, and physical, emotional and sexual abuse. Experiencing trauma has been recognized as a risk factor for a range of psychiatric disorders (Widom et al. Reference Widom, DuMont and Czaja2007; Chen et al. Reference Chen, Murad, Paras, Colbenson, Sattler, Goranson, Elamin, Seime, Shinozaki, Prokop and Zirakzadeh2010). Childhood trauma in particular, has been identified as a potentially causal factor in the development of borderline personality disorder (Ball & Links, Reference Ball and Links2009) and has been linked to psychotic-like experiences in adolescence (Kelleher et al. Reference Kelleher, Harley, Lynch, Arseneault, Fitzpatrick and Cannon2008, Reference Kelleher, Keeley, Corcoran, Ramsay, Wasserman, Carli, Sarchiapone, Hoven, Wasserman and Cannon2013), and the development of full-threshold psychosis later in life (Varese et al. Reference Varese, Smeets, Drukker, Lieverse, Lataster, Viechtbauer, Read, van Os and Bentall2012; Thompson et al. Reference Thompson, Nelson, Yuen, Lin, Amminger, McGorry, Wood and Yung2014). Childhood trauma may also be a driver of functional problems across the lifespan (Zielinski, Reference Zielinski2009; Bücker et al. Reference Bücker, Kapczinski, Post, Ceresér, Szobot, Yatham, Kapczinski and Kauer-Sant’Anna2012). To our knowledge, there are no reviews that have examined the relationship between childhood trauma and functional impairment in psychiatric disorders. A large proportion of patients across different phases of psychosis (Bonoldi et al. Reference Bonoldi, Simeone, Rocchetti, Codjoe, Rossi, Gambi, Balottin, Caverzasi, Politi and Fusar-Poli2013; Larsson et al. Reference Larsson, Andreassen, Aas, Røssberg, Mork, Steen, Barrett, Lagerberg, Peleikis, Agartz, Melle and Lorentzen2013a), bipolar disorder (Lu et al. Reference Lu, Mueser, Rosenberg and Jankowski2008; Conus et al. Reference Conus, Cotton, Schimmelmann, Berk, Daglas, McGorry and Lambert2010) and borderline personality disorder (Zanarini et al. Reference Zanarini, Yong, Frankenburg, Hennen, Reich, Marino and Vujanovic2002; Afifi et al. Reference Afifi, Mather, Boman, Fleisher, Enns, Macmillan and Sareen2011) report exposure to traumatic events during childhood. As childhood trauma is common and a potentially important determinant of psychosocial functioning across these different psychiatric illnesses, we will examine this issue cross-diagnostically. We will also discuss possible mechanisms that underlie this association and the implications for clinical work.
Childhood trauma and functional impairment
The impact of childhood trauma on functioning and psychiatric symptoms is typically assessed by dichotomizing patients into those who report having experienced or not experienced traumatic childhood events and analysing whether differences exist between the two groups. However, definitions of traumatic experiences vary. For the purposes of this review, childhood maltreatment includes sexual, physical or emotional abuse as well as childhood neglect. Childhood trauma extends this, including additional factors such as bullying and witnessing domestic violence. Childhood adversity is an even broader term that also encompasses issues such as parental separation and divorce, parental mental health problems and poverty. Similarly, functioning across studies has been evaluated using a variety of methods, including questionnaires and scales that examine the frequency of, quality of and subjective satisfaction with social, occupational and academic activity, as well as ‘real-world’ outcomes such as occupational performance and hospitalization rates. In this review, we will focus our attention predominantly on childhood trauma (including maltreatment) and its association with a broad range of measures of functional disability.
Psychotic disorders
Patients with a first episode of psychosis and those with established schizophrenia who had experienced childhood trauma exhibited worse premorbid social and academic functioning compared with those without a history of childhood trauma (Schenkel et al. Reference Schenkel, Spaulding, DiLillo and Silverstein2005; Stain et al. Reference Stain, Brønnick, Hegelstad, Joa, Johannessen, Langeveld, Mawn and Larsen2014). Childhood trauma has also been associated with functional deficits in adulthood in patients with schizophrenia (Lysaker et al. Reference Lysaker, Meyer, Evans, Clements and Marks2001a; Spence et al. Reference Spence, Mulholland, Lynch, McHugh, Dempster and Shannon2006; Gil et al. Reference Gil, Gama, de Jesus, Lobato, Zimmer and Belmonte-de-Abreu2009; Choi et al. Reference Choi, Davidson and Spaulding2011). Moreover, functioning seemed to decline in patients with schizophrenia and a history of trauma, whereas patients without a history of childhood trauma exhibited improvement in functioning (Davidson et al. Reference Davidson, Shannon, Mulholland and Campbell2009). These previous studies have largely examined functioning using structured questionnaire or scale measures, however, others have also examined the relationship between childhood trauma and ‘real-world’ outcomes. Childhood trauma has been associated with significantly lower age at first hospitalization and greater total number of hospitalizations among patients with schizophrenia (Schenkel et al. Reference Schenkel, Spaulding, DiLillo and Silverstein2005; Rosenberg et al. Reference Rosenberg, Lu, Mueser, Jankowski and Cournos2007). Patients with a schizophrenia-spectrum diagnosis and a history of childhood sexual trauma also display impaired vocational functioning, working significantly fewer hours and exhibiting poorer occupational performance compared with those patients that had not experienced sexual trauma (Lysaker et al. Reference Lysaker, Nees, Lancaster and Davis2004, Reference Lysaker, Beattie, Strasburger and Davis2005).
Moreover, poor functioning is likely to be entrenched prior to the manifestation of full-threshold psychotic symptoms (Cotter et al. Reference Cotter, Drake, Bucci, Firth, Edge and Yung2014). Criteria have been developed to identify individuals vulnerable to developing a psychotic disorder (Yung et al. Reference Yung, McGorry, McFarlane, Jackson, Patton and Rakkar1996, Reference Yung, Phillips, McGorry, McFarlane, Francey, Harrigan, Patton and Jackson1998; Miller et al. Reference Miller, McGlashan, Rosen, Somjee, Markovich, Stein and Woods2002; Yung et al. Reference Yung, Yuen, McGorry, Phillips, Kelly, Dell'Olio, Francey, Cosgrave, Killackey, Stanford, Godfrey and Buckby2005). These have been referred to as the prodromal, ultra-high risk (UHR), clinical high-risk and at-risk mental state criteria (Fusar-Poli et al. Reference Fusar-Poli, Borgwardt, Bechdolf, Addington, Riecher-Rössler, Schultze-Lutter, Keshavan, Wood, Ruhrmann, Seidman, Valmaggia, Cannon, Velthorst, De Haan, Cornblatt, Bonoldi, Birchwood, McGlashan, Carpenter, McGorry, Klosterkötter, McGuire and Yung2013). This patient group is characterized by the presence of subthreshold psychotic symptoms and/or genetic vulnerability and deterioration in functioning. In a cross-sectional study, bullying was correlated with poor social and role functioning in a UHR cohort, but emotional neglect and physical, psychological and sexual abuse were not (Addington et al. Reference Addington, Stowkowy, Cadenhead, Cornblatt, McGlashan, Perkins, Seidman, Tsuang, Walker, Woods and Cannon2013). However, our recent longitudinal analysis of a large UHR sample identified that Childhood Trauma Questionnaire (CTQ) total scores were the strongest predictors of poor long-term functional outcome (Yung et al. personal communication). This was true both for those patients who did and did not go on to develop a full-threshold psychotic disorder. In multivariate analyses, childhood trauma remained the only significant independent predictor and explained variance over and above clinical symptoms, patient demographics and functioning at baseline.
Bipolar disorder
Amongst patients presenting with a first episode of psychotic mania, those with a history of sexual or physical abuse had poorer premorbid functioning, assessed using both the Global Assessment of Functioning (GAF) and Premorbid Adjustment Scale (Conus et al. Reference Conus, Cotton, Schimmelmann, Berk, Daglas, McGorry and Lambert2010). This was despite no significant symptomatic differences between the two groups at presentation. Significantly worse global functioning in adulthood was also identified in young adult patients with bipolar disorder who had experienced childhood trauma compared with those who had not (Bücker et al. Reference Bücker, Kozicky, Torres, Kauer-Sant’anna, Silveira, Bond, Lam and Yatham2013). In addition, GAF scores and CTQ total scores were inversely correlated, indicating that greater childhood trauma was associated with greater functional impairment. Using a split-version of the GAF that incorporated separate measures for functioning and symptoms, Larsson et al. (Reference Larsson, Aas, Klungsøyr, Agartz, Mork, Steen, Barrett, Lagerberg, Røssberg, Melle, Andreassen and Lorentzen2013b) also reported that total CTQ score and factor scores for emotional abuse/neglect and physical abuse were significantly associated with functioning scores in adulthood. Childhood maltreatment has also been associated with a younger age at illness onset (Bücker et al. Reference Bücker, Kozicky, Torres, Kauer-Sant’anna, Silveira, Bond, Lam and Yatham2013) and more severe illness course in bipolar disorder (Etain et al. Reference Etain, Aas, Andreassen, Lorentzen, Dieset, Gard, Kahn, Bellivier, Leboyer, Melle and Henry2013; Larsson et al. Reference Larsson, Aas, Klungsøyr, Agartz, Mork, Steen, Barrett, Lagerberg, Røssberg, Melle, Andreassen and Lorentzen2013b).
Borderline personality disorder
There is a lack of literature examining the association between childhood trauma and poor functioning in borderline personality disorder, possibly because childhood maltreatment is so common in this patient group (Afifi et al. Reference Afifi, Mather, Boman, Fleisher, Enns, Macmillan and Sareen2011). This could result in low variance of traumatic experiences and consequently a publication bias due to non-significant results. However, childhood abuse has been correlated with poor functional outcome (Gunderson et al. Reference Gunderson, Daversa, Grilo, McGlashan, Zanarini, Shea, Skodol, Yen, Sanislow, Bender, Dyck, Morey and Stout2006) and childhood sexual abuse has been reported as a significant independent predictor of poor psychosocial functioning, after controlling for age, gender and race amongst patients with borderline personality disorder (Zanarini et al. Reference Zanarini, Yong, Frankenburg, Hennen, Reich, Marino and Vujanovic2002).
Possible mechanisms
Mechanisms that underlie the association between childhood trauma and functional disability remain complex and poorly understood. Both the causes and consequences of childhood trauma may contribute to poor functioning.
Consequences of childhood trauma
Clinical symptoms
Childhood trauma has been associated with more severe depressive and anxiety symptoms (Lysaker et al. Reference Lysaker, Beattie, Strasburger and Davis2005; Schenkel et al. Reference Schenkel, Spaulding, DiLillo and Silverstein2005; Spence et al. Reference Spence, Mulholland, Lynch, McHugh, Dempster and Shannon2006; Kingdon et al. Reference Kingdon, Ashcroft, Bhandari, Gleeson, Warikoo, Symons, Taylor, Lucas, Mahendra, Ghosh, Mason, Badrakalimuthu, Hepworth, Read and Mehta2010; Addington et al. Reference Addington, Stowkowy, Cadenhead, Cornblatt, McGlashan, Perkins, Seidman, Tsuang, Walker, Woods and Cannon2013), among adults with psychosis and borderline personality disorder. Links between childhood maltreatment and the development of substance use problems in adulthood (Gilbert et al. Reference Gilbert, Widom, Browne, Fergusson, Webb and Janson2009; Schwandt et al. Reference Schwandt, Heilig, Hommer, George and Ramchandani2013) also appear to extend to patients with schizophrenia and bipolar disorder (Rosenberg et al. Reference Rosenberg, Lu, Mueser, Jankowski and Cournos2007; Lu et al. Reference Lu, Mueser, Rosenberg and Jankowski2008). Childhood trauma is also associated with more severe positive symptoms in people with psychotic disorders (Hammersley et al. Reference Hammersley, Dias, Todd, Bowen-Jones, Reilly and Bentall2003; Lysaker et al. Reference Lysaker, Beattie, Strasburger and Davis2005; Schenkel et al. Reference Schenkel, Spaulding, DiLillo and Silverstein2005; Berg et al. Reference Berg, Aas, Larsson, Nerhus, Hauff, Andreassen and Melle2014) and overall symptom severity in borderline personality disorder (Zanarini et al. Reference Zanarini, Yong, Frankenburg, Hennen, Reich, Marino and Vujanovic2002). It may be that the presence of high levels of positive symptoms and significant anxiety, depressive and substance use comorbidity contributes to functional disability in patients with psychosis and borderline personality disorder.
In addition, childhood trauma is associated with lower self-esteem (Fowke et al. Reference Fowke, Ross and Ashcroft2012), and elevated behavioural hostility (Lysaker et al. Reference Lysaker, Wright, Clements and Plascak-Hallberg2002) dissociative symptoms (Sar et al. Reference Sar, Taycan, Bolat, Ozmen, Duran, Oztürk and Ertem-Vehid2010; Schäfer et al. Reference Schäfer, Fisher, Aderhold, Huber, Hoffmann-Langer, Golks, Karow, Ross, Read and Harfst2012; Braehler et al. Reference Braehler, Valiquette, Holowka, Malla, Joober, Ciampi, Pawliuk and King2013) and suicide risk (Etain et al. Reference Etain, Aas, Andreassen, Lorentzen, Dieset, Gard, Kahn, Bellivier, Leboyer, Melle and Henry2013; Ferraz et al. Reference Ferraz, Portella, Vállez, Gutiérrez, Martín-Blanco, Martín-Santos and Subirà2013; Links et al. Reference Links, Kolla, Guimond and McMain2013) compared with those patients without exposure to trauma. These factors may also be driving poor functioning.
Attachment
Secure parental attachments are important throughout childhood and adolescence for normal healthy development and are protective against adverse mental health outcomes (Moretti & Peled, Reference Moretti and Peled2004). Both attachment-anxiety and attachment-avoidance were significantly higher in those patients with borderline personality disorder and a history of childhood trauma, which in turn correlated with more severe clinical symptoms and interpersonal problems in adulthood (Minzenberg et al. Reference Minzenberg, Poole and Vinogradov2006). There is also evidence that childhood trauma is associated with higher rates of insecure attachment in adulthood among patients with psychosis (Tait et al. Reference Tait, Birchwood and Trower2004; Berry et al. Reference Berry, Barrowclough and Wearden2009). Compared with patients with secure attachments, insecure attachment has been associated with worse psychiatric symptoms (Gumley et al. Reference Gumley, Taylor, Schwannauer and MacBeth2014) and social cognitive performance (Pos et al. Reference Pos, Bartels-Velthuis, Simons, Korver-Nieberg, Meijer and de Haan2014). It has also been associated with poorer engagement with clinical services and more interpersonal problems (Gumley et al. Reference Gumley, Taylor, Schwannauer and MacBeth2014), including poorer treatment adherence and greater likelihood of disengagement from mental health services (Tait et al. Reference Tait, Birchwood and Trower2004; MacBeth et al. Reference MacBeth, Gumley, Schwannauer and Fisher2011). These may all be important factors that contribute to the association between childhood trauma and poor functioning in these patient groups.
Revictimization
Revictimization is also an important issue to consider when examining the impact of childhood trauma on adult functioning. Experiencing trauma in childhood is a well-established risk factor for revictimization in later life (Classen et al. Reference Classen, Palesh and Aggarwal2005). Many studies ask patients to retrospectively self-report childhood physical and sexual abuse; however, such issues may be ongoing and continue to have detrimental physical and psychological consequences, which impact on functioning. Among patients with borderline personality disorder, rates of adult experiences of abuse are remarkably high and predict failure to achieve symptomatic remission (Zanarini et al. Reference Zanarini, Frankenburg, Reich, Hennen and Silk2005). Stain et al. (Reference Stain, Brønnick, Hegelstad, Joa, Johannessen, Langeveld, Mawn and Larsen2014) also reported that 45% of first-episode psychosis patients who had experienced childhood trauma also experienced adulthood trauma. This suggests that the damaging effects of trauma on functioning may be initiated in childhood and maintained into adulthood in a large proportion of patients.
Brain development
Childhood trauma can have a number of detrimental effects on the developing brain (Read et al. Reference Read, Perry, Moskowitz and Connolly2001; Neigh et al. Reference Neigh, Gillespie and Nemeroff2009; Tyrka et al. Reference Tyrka, Burgers, Philip, Price and Carpenter2013). Volumetric reductions in the amygdala (Soloff et al. Reference Soloff, Nutche, Goradia and Diwadkar2008; Aas et al. Reference Aas, Navari, Gibbs, Mondelli, Fisher, Morgan, Morgan, MacCabe, Reichenberg, Zanelli, Fearon, Jones, Murray, Pariante and Dazzan2012a; Hoy et al. Reference Hoy, Barrett, Shannon, Campbell, Watson, Rushe, Shevlin, Bai, Cooper and Mulholland2012), hippocampus (Hoy et al. Reference Hoy, Barrett, Shannon, Campbell, Watson, Rushe, Shevlin, Bai, Cooper and Mulholland2012), ventrolateral prefrontal cortex (Morandotti et al. Reference Morandotti, Dima, Jogia, Frangou, Sala, Vidovich, Lazzaretti, Gambini, Marraffini, d’Allio, Barale, Zappoli, Caverzasi and Brambilla2013) and in total grey matter (Sheffield et al. Reference Sheffield, Williams, Woodward and Heckers2013) have been reported among patients with psychotic disorders and borderline personality disorder with a history of childhood trauma compared with those without such a history. Structural brain changes as a result of childhood maltreatment have been associated with the severity of substance use relapse (Van Dam et al. Reference Van Dam, Rando, Potenza, Tuit and Sinha2014), which may represent a significant problem given the high rates of such disorders reported among psychosis and borderline personality disorder cohorts (Regier et al. Reference Regier, Farmer, Rae, Locke, Keith, Judd and Goodwin1990; Trull et al. Reference Trull, Sher, Minks-Brown, Durbin and Burr2000). There is also evidence that childhood trauma may increase stress sensitivity among patients with psychosis, potentially through alterations in functioning of the hypothalamic–pituitary–adrenal axis, the body’s neurobiological stress response system (Neigh et al. Reference Neigh, Gillespie and Nemeroff2009; Lardinois et al. Reference Lardinois, Lataster, Mengelers, Van Os and Myin-Germeys2011). Decreases in brain-derived neurotrophic factor and increases in peripheral markers of inflammation (Mondelli et al. Reference Mondelli, Cattaneo, Belvederi Murri, Di Forti, Handley, Hepgul, Miorelli, Navari, Papadopoulos, Aitchison, Morgan, Murray, Dazzan and Pariante2011) have also been associated with childhood trauma in these patient groups.
Neurocognitive and social cognitive impairment
Given the aforementioned structural and neurochemical abnormalities, it is perhaps unsurprising that childhood trauma has also been associated with a range of neurocognitive deficits (Aas et al. Reference Aas, Dazzan, Mondelli, Melle, Murray and Pariante2014), particularly relating to impaired memory functioning (Lysaker et al. Reference Lysaker, Meyer, Evans and Marks2001b; Shannon et al. Reference Shannon, Douse, McCusker, Feeney, Barrett and Mulholland2011; Aas et al. Reference Aas, Steen, Agartz, Aminoff, Lorentzen, Sundet, Andreassen and Melle2012b; Bücker et al. Reference Bücker, Kozicky, Torres, Kauer-Sant’anna, Silveira, Bond, Lam and Yatham2013; Campbell et al. Reference Campbell, Barrett, Shannon, Hoy, Rushe, Cooper and Mulholland2013). Neurocognitive impairment contributes to poor functional outcome across the psychosis spectrum (Martinez-Aran et al. Reference Martinez-Aran, Vieta, Torrent, Sanchez-Moreno, Goikolea, Salamero, Malhi, Gonzalez-Pinto, Daban, Alvarez-Grandi, Fountoulakis, Kaprinis, Tabares-Seisdedos and Ayuso-Mateos2007; Shamsi et al. Reference Shamsi, Lau, Lencz, Burdick, DeRosse, Brenner, Lindenmayer and Malhotra2011; Cotter et al. Reference Cotter, Drake, Bucci, Firth, Edge and Yung2014), suggesting this likely plays an important role in the relationship between childhood trauma and impaired functioning.
Social cognition involves the ability to infer the mental states of others and is also amongst the strongest predictors of poor functional outcome in schizophrenia (Fett et al. Reference Fett, Viechtbauer, Dominguez, Penn, van Os and Krabbendam2011; Horan et al. Reference Horan, Green, DeGroot, Fiske, Hellemann, Kee, Kern, Lee, Sergi, Subotnik, Sugar, Ventura and Nuechterlein2012). There is increasing evidence from both clinical and non-clinical samples that adverse childhood experiences are associated with deficits in social cognitive processes such as emotion perception and theory of mind (Barahal et al. Reference Barahal, Waterman and Martin1981; Cicchetti et al. Reference Cicchetti, Rogosch, Maughan, Toth and Bruce2003; Pears & Fisher, Reference Pears and Fisher2005; Koizumi & Takagishi, Reference Koizumi and Takagishi2014). Social cognitive deficits are a core impairment of borderline personality disorder and are thought to be worsened by childhood maltreatment (Roepke et al. Reference Roepke, Vater, Preißler, Heekeren and Dziobek2013). Among 143 patients with a schizophrenia-spectrum diagnosis or bipolar disorder, social functioning was best amongst those patients who performed well on a social inference and theory of mind task and exhibited a lower external locus of control, regardless of history of childhood physical abuse (Choi et al. Reference Choi, Davidson and Spaulding2011). This suggests social cognition could potentially moderate the impact of childhood abuse on adult functioning.
Risk factors for child abuse and poor functioning
There are also common factors that increase the risk for both childhood trauma and poor functional outcome. Young age of becoming a parent, mental health problems, drug and alcohol abuse, unemployment, low income, marital discord and parental history of being abused are all well-established parental risk factors for childhood abuse and neglect (Spencer, Reference Spencer2002; Carter & Myers, Reference Carter and Myers2007; Smith et al. Reference Smith, Johnson, Pears, Fisher and DeGarmo2007; Gilbert et al. Reference Gilbert, Widom, Browne, Fergusson, Webb and Janson2009; Mersky et al. Reference Mersky, Berger, Reynolds and Gromoske2009).
Characteristics of the child may also increase the risk both of being abused and experiencing poor functional outcome. While the overwhelming majority of research to date has focused on the causal relationship between childhood maltreatment and the development of psychiatric disorders, there is evidence that this relationship may in fact be bidirectional. It may be that children with behavioural and mental health problems (including problematic temperament or personality) are more likely to be abused or neglected (Jaudes & Mackey-Bilaver, Reference Jaudes and Mackey-Bilaver2008), including those with psychotic experiences (Kelleher et al. Reference Kelleher, Keeley, Corcoran, Ramsay, Wasserman, Carli, Sarchiapone, Hoven, Wasserman and Cannon2013). In line with the neurodevelopmental hypothesis of schizophrenia (Murray & Lewis, Reference Murray and Lewis1987; Weinberger, Reference Weinberger1987) these children may exhibit cognitive impairment and developmental delays (Jones et al. Reference Jones, Rodgers, Murray and Marmot1994; Isohanni et al. Reference Isohanni, Jones, Moilanen, Rantakallio, Veijola, Oja, Koiranen, Jokelainen, Croudace and Järvelin2001; Dickson et al. Reference Dickson, Laurens, Cullen and Hodgins2012) which, in turn, place them at increased risk of neglect or abuse by parents struggling with their potentially difficult or abnormal behaviour. Temperamental factors seem to play an important role in the development of borderline personality disorder (Kaess et al. Reference Kaess, Resch, Parzer, von Ceumern-Lindenstjerna, Henze and Brunner2013) and could also lead to traumatic experiences. A recent genetic study revealed both gene×environment interactions and gene×environment correlations (Distel et al. Reference Distel, Middeldorp, Trull, Derom, Willemsen and Boomsma2011), suggesting the genetic predisposition for borderline personality disorder was linked to a higher risk for childhood trauma. Therefore, it may be that antecedent mental health problems or problematic temperament and personality in the child increase the likelihood of poor functioning, even in the absence of childhood trauma.
Implications for clinical management
To date, there is a large body of evidence for the potential role of childhood trauma in the aetiology of many common mental disorders. However, it is only recently that childhood trauma has gained attention as a potential predictor of treatment outcome. Traumatized individuals often show poorer treatment response (Teicher & Samson, Reference Teicher and Samson2013) with the best evidence so far for major depressive disorders (Nanni et al. Reference Nanni, Uher and Danese2012). Clinicians should be aware that abuse history is likely to affect therapeutic alliance, adherence to treatment and engagement with services.
Borderline personality disorder and post-traumatic stress disorder (PTSD) following childhood abuse frequently co-occur, and often result in complex conditions with severe psychopathology and low remission rates (Zlotnick et al. Reference Zlotnick, Johnson, Yen, Battle, Sanislow, Skodol, Grilo, McGlashan, Gunderson, Bender, Zanarini and Shea2003; Harned et al. Reference Harned, Rizvi and Linehan2010). Likewise, the co-occurrence of PTSD and psychosis is again associated with more severe psychopathology and reduced treatment adherence (Schenkel et al. Reference Schenkel, Spaulding, DiLillo and Silverstein2005; Mueser et al. Reference Mueser, Lu, Rosenberg and Wolfe2010). However, childhood trauma may influence treatment outcome via mechanisms that go over and above the presence of PTSD. For example, childhood trauma confers enhanced susceptibility to interpersonal dysfunction, which itself hinders successful treatment (Pechtel & Pizzagalli, Reference Pechtel and Pizzagalli2011).
Although data are still scarce for both psychotic disorders and personality disorders, the preliminary results along with clinical experience suggest that childhood trauma may influence treatment response to both pharmacological and psychological interventions. Consequently, we propose that there is a need to target childhood trauma in both assessment and treatment of these severe psychiatric conditions.
Assessment
The findings of this review support previous calls for routine clinical inquiry about childhood maltreatment in mental health settings (Janssen et al. Reference Janssen, Krabbendam, Bak, Hanssen, Vollebergh, de Graaf and van Os2004; Schenkel et al. Reference Schenkel, Spaulding, DiLillo and Silverstein2005). Discussion of childhood trauma is often neglected or even actively avoided by clinicians (Read et al. Reference Read, Perry, Moskowitz and Connolly2001); yet this review indicates that this should be an important consideration to identify individuals at increased risk of poor functional outcome. Despite evidence that childhood trauma may be more common among women in these patient groups (Addington et al. Reference Addington, Stowkowy, Cadenhead, Cornblatt, McGlashan, Perkins, Seidman, Tsuang, Walker, Woods and Cannon2013; Bonoldi et al. Reference Bonoldi, Simeone, Rocchetti, Codjoe, Rossi, Gambi, Balottin, Caverzasi, Politi and Fusar-Poli2013; Etain et al. Reference Etain, Aas, Andreassen, Lorentzen, Dieset, Gard, Kahn, Bellivier, Leboyer, Melle and Henry2013), men still report high rates of exposure to adverse childhood experiences and screening should be considered a priority for both sexes. The use of standardized instruments may help to guide clinicians through the assessment of patients’ adverse childhood experiences, and may also help to overcome constraints from both the therapists’ and patients’ side. There are several tools available for the standardized assessment of childhood trauma ranging from brief self-report screening questionnaires to detailed semi-structured interviews (for a review, see Thabrew et al. Reference Thabrew, de Sylva and Romans2012).
Treatment approaches to improve functioning that takes into account trauma history
To date, no clear guidance is available on how to target childhood trauma in the treatment of psychotic disorders or borderline personality disorder, thereby improving outcomes and functioning. Nevertheless, clinical research groups around the world have become increasingly interested in this topic, and several therapeutic approaches are currently being evaluated.
One approach is to target co-occurring PTSD in individuals with psychotic disorders, borderline personality disorder or both. A newly developed modular treatment programme that combines principles of the widely used Dialectical Behaviour Therapy (Linehan, Reference Linehan1993) and trauma-focused interventions has recently been found to be effective in women with borderline personality disorder who had experienced sexual abuse (Bohus et al. Reference Bohus, Dyer, Priebe, Krüger, Kleindienst, Schmahl, Niedtfeld and Steil2013). This intervention was also associated with significantly greater improvements in global functioning compared with a waiting list control. Similarly, a trial testing a cognitive-behavioural intervention targeting PTSD, which may result from experiences of childhood trauma in patients with first-episode psychosis is under way in Australia (Bendall et al. personal communication), and may provide further evidence for improvement in functioning by targeting PTSD in these individuals.
In addition to targeting PTSD as one potential consequence of childhood trauma, there may be a variety of other potential dysfunctions and impairments that are related to childhood trauma and that may be targeted by more specific interventions. For example, strategies of interpersonal learning that may specifically target core interpersonal relationship impairments caused by early and complex trauma have been successfully adopted in treatments of borderline personality disorder (e.g. Mentalization-Based Therapy; Bateman & Fonagy, Reference Bateman and Fonagy2009). Encouraging early evidence from cognitive remediation therapy suggests that this approach is efficacious for improving functioning in patients with psychosis (Wykes et al. Reference Wykes, Huddy, Cellard, McGurk and Czobor2011; Statucka & Walder, Reference Statucka and Walder2013). This could be particularly useful given that neurocognitive and social cognitive deficits appear to be particularly severe amongst those patients with a history of childhood trauma. Efforts to improve coping strategies may also be useful. An alternative approach for further research could be to examine factors that appear to make individuals more resilient to poor functioning, to inform the development of future interventions.
Strengths and limitations
This is a narrative review that covers a broad range of literature examining the association between childhood trauma and functional disability in three major psychiatric disorders. The traditional focus of reviews in this area has been to determine whether childhood trauma plays a key role in the aetiology of psychopathology. However, we sought to widen this perspective to examine its impact on functioning. To the authors’ knowledge, this is the first review to examine this relationship. An additional strength is the inclusion of multiple disorders, which collectively suggest that a history of childhood trauma is associated with more severe clinical symptoms as well as insecure attachment and abnormal brain development cross-diagnostically. We focussed on these three disorders because they often share similar psychotic features (Dunayevich & Keck, Reference Dunayevich and Keck2000; Kingdon et al. Reference Kingdon, Ashcroft, Bhandari, Gleeson, Warikoo, Symons, Taylor, Lucas, Mahendra, Ghosh, Mason, Badrakalimuthu, Hepworth, Read and Mehta2010). Future studies could examine these issues in a wider range of psychiatric conditions, such as depressive and anxiety disorders.
A limitation is that this review adopted a narrative as opposed to systematic approach. However, efforts were made to ensure that it was comprehensive. It is hoped that this provides a broad overview of the current literature to inform and guide future research.
Conclusions
Childhood trauma is associated with functional impairment and a range of biological and psychological abnormalities over and above those typically observed across three major psychiatric disorders. It is an important and understudied area with significant clinical implications. In this review, we have suggested a number of potential mechanisms through which this association may occur. This is likely to be through a multifaceted process in which childhood trauma has detrimental effects on brain development, attachment, psychological well-being, symptoms, neurocognition and social cognition. These factors are all likely to interact and contribute to functional disability. These results remain tentative and require further empirical evidence to draw more definitive conclusions.
