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Sexual and physical abuse during childhood and adulthood as ...

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In light of recent studies indicating a relationship between child abuse and the positive symptoms of schizophrenia, this study investigated the hypotheses that childhood sexual and physical abuse are related to hallucinations, delusions, and thought disorder in adults, and that those relationships are greater in those who have suffered abuse during adulthood as well as childhood. In 200 community mental-health-centre clients, the clinically evaluated symptomatology of the 92 clients who seéles documented sexual or physical abuse at some point in their lives was compared with that of the 108 for whom no abuse was documented. In the 60 patients for whom child abuse was documented, hallucinations (including all six subtypes), but not delusions, thought disorder or negative symptoms, were signié cantly more common than in the non- abused group. Adult sexual assault was related to hallucinations, delusions, and thought disorder. In linear regression analysis, a combination of child abuse and adult abuse predicted hallucinations, delusions, and thought disorder. However, child abuse wasa signiécant predict or of auditory and tactilehallucinations, even in the absence of adult abuse. Possible psychological and neurobiological pathways from abuse to symptoms are discussed, along with research and clinical implications
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1
Psychology and Psychotherapy: Theory, Research and Practice (2003), 76, 1–22
© 2003 The British Psychological Society
www.bps.org.uk
Sexual and physical abuse during childhood and
adulthood as predictors of hallucinations,
delusions and thought disorder
John Read1*, Kirsty Agar1, Nick Argyle2 and Volkmar Aderhold3
1Psychology Department, University of Auckland, New Zealand
2Department of Psychiatry, University of Auckland, New Zealand
3Department of Psychiatry and Psychotherapy, University of Hamburg, Germany
In light of recent studies indicating a relationship between child abuse and the positive
symptoms of schizophrenia, this study investigated the hypotheses that childhood
sexual and physical abuse are related to hallucinations, delusions, and thought disorder
in adults, and that those relationships are greater in those who have suffered abuse
during adulthood as well as childhood. In 200 community mental-health-centre clients,
the clinically evaluated symptomatology of the 92 clients whose les documented
sexual or physical abuse at some point in their lives was compared with that of the 108
for whom no abuse was documented. In the 60 patients for whom child abuse was
documented, hallucinations (including all six subtypes), but not delusions, thought
disorder or negative symptoms, were signi cantly more common than in the non-
abused group. Adult sexual assault was related to hallucinations, delusions, and thought
disorder. In linear regression analysis, a combination of child abuse and adult abuse
predicted hallucinations, delusions, and thought disorder. However, child abuse was a
signi cant predictor of auditory and tactile hallucinations, even in the absence of adult
abuse. Possible psychological and neurobiological pathways from abuse to symptoms
are discussed, along with research and clinical implications.
Investigating whether child abuse (CA) is related to mental-health problems in adulthood
is important theoretically, but also has crucial clinical implications in terms of the
accuracy of formulations and the comprehensiveness of treatment planning. The range
of adult disorders for which studies seem to indicate that CAor neglect mayhave a causal
role includes: depression, anxiety disorders, post-traumatic stress disorder (PTSD),
eating disorders, substance abuse, sexual dysfunction, personality disorders, and dis-
sociative disorders (Beitchman et al., 1992; Boney-McCoy & Finkelhor, 1996; Kendler
* Requests for reprints should be addressed to Dr John Read, Director, Clinical Psychology, The University of Auckland, Private
Bag 92019, Auckland, New Zealand (e-mail: j.read@auckland.ac.nz).

2
John Read et al.
et al., 2000). Studies consistently report a strong relationship between CA and
suicidality (Santa Mina & Gallop, 1998). A recent study of adult outpatients found
child sexual abuse to be a more powerful predictor of suicidality than a current
diagnosis of depression (Read, Agar, Barker-Collo, Davies, & Moskowitz, 2001). The
relationship between CA and adult psychopathology remains after controlling for
mediating variables such as poverty, marital violence, and parental substance abuse or
psychiatric history (Boney-McCoy & Finkelhor, 1996; Fleming, Mullen, Sibthorpe, &
Banner, 1999; Kendler et al., 2000; Pettigrew & Burcham, 1997). The more severe the
abuse, the greater is the probability of psychiatric disorder in adulthood (Fleming et al.,
1999; Mullen, Martin, Anderson, Romans, & Herbison, 1993).
Nevertheless, it is still sometimes assumed that CA is less related, or even
unrelated, to the most severe psychiatric disturbance, including symptoms indicative
of psychosis in general and schizophrenia in particular. The literature reviewed below,
however, suggests that CA may be just as powerfully related to the most severe
symptomatology, including hallucinations and delusions, as it is to less severe
symptomatology.
Child abuse among psychiatric inpatients
Compared with other psychiatric patients, those who experienced childhood physical
abuse (CPA) or childhood sexual abuse (CSA) not only are more likelyto attempt suicide,
but also have earlier rst admissions and longer and more frequent hospitalizations,
spend more time in seclusion, receive more psychotropic medication and exhibit higher
global symptom severity, (Beitchman et al., 1992; Briere, Woo, McRae, Foltz, &Sitzman,
1997; Bryer, Nelson, Miller, & Krol, 1987; Goff, Brotman, Kindlon, Waites, & Amico,
1991; Pettigrew & Burcham, 1997; Read, 1998; Read, Agar et al., 2001; Sansonnet-
Hayden, Haley, Marriage, & Fine, 1987).
A study of girls in a child and adolescent psychiatric inpatient unit found that 73%
had suffered either CSAor CPA(Ito et al., 1993). In 13 studies of ‘seriously mentally ill’
women the percentage that had experienced CSA or CPA ranged from 45% to 92%
(Goodman, Rosenberg, Mueser, & Drake, 1997). A review of 15 studies totalling 817
women inpatients, calculated that 64%reported CPAor CSA(CSA50%, CPA44 %) (Read,
1997). Studies of female inpatients, or predominantly psychotic outpatients, nd incest
rates of 22%–46% (Beck & van der Kolk, 1987; Cole, 1988; Muenzenmaier, Meyer,
Struening, & Ferber, 1993; Rose, Peabody, & Stratigeas, 1991). After controlling for
factors related to disruption and disadvantage in childhood, women who suffered CSA
involving intercourse are 12 times more likely than non-abused females to have had a
psychiatric admission (Mullen et al., 1993).
Male inpatients report similar CPArates. Their CSArate ranges from 22%to 39%and
is at least double that of men in general ( Jacobson & Herald, 1990; Palmer et al., 1994;
Rose et al., 1991; Sansonnet-Hayden et al., 1987; Wurr & Partridge, 1996).
Child abuse and schizophrenia
Research measures
CSA and CPA are consistently related to scales indicative of psychosis in general and
schizophrenia in particular. In the general population, CSA is related to schizotypy,
including perceptual aberrations (Startup, 1999). High perceptual aberration scores,
which are predictive of clinical psychoses, are 10 times more common in adults who

Child abuse and psychosis
3
were maltreated as children (Berenbaum, 1999). Among women inpatients the
‘Psychoticism’ scale of the Symptom Checklist-90-R (SCL-90-R; Derogatis, 1977) corre-
lates with abuse history more strongly than any other clinical scale on the SCL-R-90
(Bryer et al., 1987). ‘Psychoticism’ also discriminates more powerfully between men
who have and have not suffered CA(Swett, Surrey, &Cohen, 1990), and correlates more
strongly with the number of abuse perpetrators (Ellason & Ross, 1997), than any other
SCL-90-R scale. Both the SCL-90-R Psychoticism scale and the Schizophrenia scale of the
Minnesota Multiphasic Personality Inventory (Hathaway &McKinley, 1943) differentiate
incest victims and non-abused women (Lundberg-Love et al., 1992). Chronically
mentally ill women who were abused score higher on the Beliefs and Feelings Scale,
measuring psychotic symptoms (Muenzenmaier et al., 1993).
Clinical diagnoses
Among child psychiatric inpatients, 77%of those who suffered CSA, but only 10%of
those who had not, were diagnosed psychotic (Livingston 1987). In a mixed-gender
sample of inpatients and outpatients with a schizophrenia diagnosis, 45%had suffered
either CSAor CPA(Ross, Anderson, &Clark, 1994). Among women inpatients diagnosed
schizophrenic, 60%had suffered CSA (Friedman & Harrison, 1984). Among chronically
hospitalized psychotic women, 46%had suffered incest (Beck & van der Kolk, 1987). In
a sample of ‘ seriously mentally ill’’ patients (64%diagnosed as schizophrenic), 76%of
the women and 48%of the men had suffered CSA (Goodman et al., 1999). Among 426
rst admissions for psychosis in the USA, the prevalence of lifetime trauma exposure
was 63%for men (24%child abuse) and 77%for women (44%child abuse) (Neria,
Bromet, Sievers, Lavelle, & Fochtman, 2002). Even a chart review (which under-
estimates abuse rates; see Discussion) found that 52% of female, and 28% of male,
patients diagnosed with schizophrenia in a British ‘special hospital’ had suffered
‘parental violence against patient’ (Heads, Taylor, & Leese, 1997). Of 5,362 children,
those whose mothers had poor parenting skills when they were 4 were signi cantly
more likely to be diagnosed schizophrenic as adults ( Jones, Rodgers, Murray, &
Marmont, 1994). Of 524 child guidance clinic attenders, 35% of those who later
became ‘schizophrenic’ had been removed from home because of neglect—twice as
many as any other diagnostic group (Robins, 1966).
Parental hostility precedes, and is predictive of, schizophrenia (Rodnick, Goldstein,
Lewis, & Doane, 1984). In families where both parents expressed high criticism toward
their child, 91%of disturbed but non-psychotic adolescents were diagnosed (within
5 years) as schizophrenic. In families in which both parents were rated low on criticism,
only 10% of similarly disturbed but non-psychotic adolescents were diagnosed
schizophrenic (Norton, 1982).
Among women at a psychiatric emergency room, 53%of those who had suffered
CSA had ‘nonmanic psychotic disorders’ (e.g. schizophrenia, psychosis not otherwise
speci ed) compared with 25%of those not exposed to CSA; with corresponding CPA
rates of 49% and 33%. After controlling for ‘the potential effects of demographic
variables, most of which also predict victimization and/or psychiatric outcome’, CSA
was related to non-manic psychosis ( p = .005) and depression ( p = .035) but not manic
or anxiety disorders (Briere et al., 1997, p. 99).
Child abuse and speci c symptoms
Mapping the relationship between speci c types of CA and speci c types of psychotic
or schizophrenic symptomatology is in its infancy. Such an approach is consistent with

4
John Read et al.
the recent trend towards exploring the aetiology of, and treatments for, discrete
cognitions and experiences considered indicative of schizophrenia rather than
continuing to employ the heterogeneous construct of ‘schizophrenia’ itself (Bentall,
in press; Bentall & Kaney, 1996; Chadwick, Birchwood, & Trower, 1996; Morrison,
2002; Read, Mosher, & Bentall, in press). Thus far, it appears that hallucinations
(particularly certain kinds of auditory hallucinations) may be more strongly related to
CA (particularly CSA in general, and incest in particular) than are delusions or
thought disorder.
Hallucinations
In a community survey, 46%of those with three or more Schneiderian symptoms of
schizophrenia had experienced CPA or CSA, compared with 8%of those with no such
symptoms (Ross & Joshi, 1992). In an inpatient sample, 77%of those reporting CSAor
CPA had one or more of the ‘characteristic symptoms’ of schizophrenia listed in the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric
Association, 1994, p. 285): hallucinations (50%), delusions (45%), or thought disorder
(27%) (Read & Argyle, 1999).
Famularo et al. (1992) found that hallucinations were more likely in maltreated
children than in a control group. Among adolescent inpatients, those that had suffered
CSA were more likely to hallucinate (Sansonnet-Hayden et al., 1987). Among patients
diagnosed schizophrenic, those subjected to CSAor CPAhad a mean of 6.3 Schneiderian
symptoms, compared with 3.3 in the non-abused patients (p < .001). CAwas related to
six Schneiderian symptoms, with the strongest relationship being voices commenting,
and another being visual hallucinations (Ross et al., 1994).
Ellenson (1985) identi ed, in 40 women, a ‘post incest syndrome’, including
hallucinations, which was ‘exclusively associated with a history of childhood incest’
(p. 526). This was replicated in 10 other incest cases (Heins, Gray, & Tennant, 1990). In
an inpatient study (Read & Argyle, 1999) all female incest survivors experienced
hallucinations and were signi cantly more likely to do so than those subjected to
extra-familial CSA. Those subjected to CPA were equally likely to hallucinate (53%) as
those subjected to CSA(58%). Among those who had suffered both CSA and CPA, 71%
experienced hallucinations. In a study of bipolar affective disorder, patients who had
suffered CSA were twice as likely as other patients to experience some form of
hallucination, three times more likely to have auditory hallucinations and six times
more likely to hear voices commenting. However, no relationship was found with visual
or tactile hallucinations (Hammersley et al., in press).
Delusions
Sansonnet-Hayden et al. (1987) found that in adolescent inpatients, those subjected to
CSA were not more likely to have delusions. Hammersley et al. (in press) found no
relationship between CSA and delusions among bipolar affective disorder patients.
However, more paranoid ideation has been found among female inpatients who had
suffered CSAor CPAthan those who had not (Bryer et al., 1987). Paranoid ideation was
also one of the symptom types related to CA among schizophrenic patients in the Ross
et al. (1994) study, along with ideas of reference, thought insertion, and reading others’
minds. High rates of sexual delusions have been found in incest survivors (Beck & van
der Kolk, 1987) but not those exposed to CSA in general or CPA (Goff et al., 1991).

Child abuse and psychosis
5
Thought disorder
The literature on CA and thought disorder is small. Goff et al. (1991) found no
difference. Another inpatient sample found that for those who had suffered CSA,
delusions and thought disorder were equally common (both 35%), but among those
who had suffered CPA, 50%experienced delusions, but only 17%had a thought disorder
(Read & Argyle, 1999).
Symptom content
Famularo et al. (1992) found that in severely maltreated 5–10-year-olds, ‘the content of
the reported visual and/or auditory hallucinations or illusions tended to be strongly
reminiscent of concrete details of episodes of traumatic victimization’ (p. 866). In an
adult inpatient study, the content of 54%of the schizophrenic symptoms of abused
patients was clearly related to CA. For example, the voice commanding that a patient kill
herself was the voice of the parent who had abused her as a child (Read &Argyle, 1999).
Abuse during adulthood
None of these studies relating CA to the symptoms of schizophrenia address adulthood
sexual assault (ASA) or adulthood physical assault (APA). Yet, in studies of female
psychiatric inpatients, the prevalence of ASAranges from 22%to 38%, and of APAfrom
42%to 64%(Goodman et al., 1997). In a study of chronically mentally ill outpatients, the
rates for women were APA—90%and ASA—79%, and for men APA—71%and ASA—
19% (Goodman et al., 1999). Adulthood abuse should therefore be included when
studying the relationship between CA and schizophrenic symptoms. Any such relation-
ships might be partly explicable in terms of adult abuse. Where both child and adult
abuse are related to a symptom, this may be because CAis a risk factor for being abused
as an adult (Briere et al., 1997; Muenzenmaier et al., 1993). Furthermore, many of the
studies reviewed above do not analyse CSA and CPA separately, address a limited
number of symptom types (most exclude negative symptoms of schizophrenia), have
studied women only, or have used samples of 100 or fewer.
Aim of the study
Therefore, the aim of the current study was to analyse, using a mixed-gender sample of
200, the individual relationships of four abuse types (ASA, CSA, APA, ASA) to four
DSM-IV ‘characteristic symptoms’ of schizophrenia (hallucinations, delusions, thought
disorder, and negative symptoms), and to the subtypes of the three positive symptoms.
Method
Participants
The participants were 114 women and 86 men treated consecutively at an urban,
publicly funded, New Zealand Community Mental Health Centre (CMHC). The mean
treatment length was 151 days (range 7–272). The mean age was 36.6 years (range
18–69). One hundred and forty-four were of European descent, 21 Maori, 12 Paci c
Islanders, and 19 classi ed as ‘other’, and in four cases ethnicity was not noted. The
most common diagnoses were depression (85), schizophrenia (28), substance abuse
(20), bipolar disorder (15), personality disorder (10), anxiety disorder (9), adjustment
disorder (7), PTSD(7), psychotic episode (5), schizoaffective disorder (5), and psychotic

6
John Read et al.
disorder—not otherwise speci ed (4). To the best of our knowledge, these demo-
graphic and clinical characteristics are not atypical for New Zealand CMHCs.
Measures
All data were collected through a review of medical records. (In New Zealand ‘audits’ of
medical records for research or administrative purposes require permission from
management but not individual clients.) The 200 les, spanning a 7-month period of
intakes, were read in their entirety (by a registered clinical psychologist with 20 years’
clinical experience—JR and a postgraduate clinical psychology student—KA). Informa-
tion was obtained regarding clinical diagnoses, details of type, subtype and content of
the ‘characteristic symptoms’ of schizophrenia listed in DSM-IV, and documentation of
any sexual or physical abuse. Because the study was a chart review, operational
de nitions were based on what clinicians recorded as ‘abuse’, ‘assault’, or ‘rape’. The
age for childhood abuse was 16 years or younger.
In 25 cases there was evidence that abuse may have occurred, but no clear
conclusion had been reached. These were independently rated by two researchers
(KA and JR) as to whether they were ‘highly probable’; with the criterion being a
subjective estimation of 95%certainty that abuse had occurred. Only the six cases in
which both raters independently judged a case to be highly probable were included for
analysis. An example of a case included as CSA is: ‘ . . . has made serious accusations
about being the victim of sexual abuse . . . needs to be given as much support as
possible’ and elsewhere in notes by different clinician ‘ . . . was living in a situation
where apparently a whole group of boys lived with an older gentleman whose
relationship with them was questionable’. An example of a case included as CPA was:
‘Depressed alcoholic father. Describes a background of violence and physical abuse as a
child’. Examples of the 19 excluded cases are: ‘raised from a babe in an abusive situation
by an aunt’, and ‘abusive father’.
Analyses
For data in discrete categories, analysis utilized the Pearson chi-square. Independent
samples t tests (two-tailed) were used to analyse differences involving continuous
variables. Stepwise linear regression, with p < .05 indicating signi cance, was used to
determine the degree to which CA alone, adult abuse alone, and child and adult abuse
together, predicted the various symptoms. Because of the large number of chi-squares
and t tests used in determining the individual relationships between types of abuse and
symptom types and subtypes, the p-level required for indicating signi cance was
decreased, for these tests, from the traditional p < .05 level to p < .02, in order to
reduce the probability of type one (false positive) errors.
Results
Abuse prevalence and characteristics
Ninety-two charts (46%) documented at least one form of abuse. Sixty (30%) had been
abused in childhood, 50 (25%) as adults, and 18 (9%) in both childhood and as adults.
The percentages for the 86 men were: CSA—13%(incest 9%), CPA—16%, ASA—6%,
APA—12%; and for the 114 women: CSA—25%(incest 15%), CPA—18%, ASA—9%,
APA—25%.

Child abuse and psychosis
7
For 25 of the 40 (62.5%) that had suffered CSA, the abuse was incestuous, for 6 (15%)
the abuse was extra-familial, and for 9 (22.5%) the perpetrator was unidenti ed. For the
25 incest cases, the most common perpetrators were father (40%) and older brother
(20%). Among the 23 incest cases where the gender of the perpetrator was clear, 21
(91%) were male.
Of the six possible pairs from the four abuse types, two pairs were signi cantly
correlated: CSA and CPA, X2(1) = 11.48, p < .005, and CSA and ASA, X2(1) = 7.21,
p < .01. Analysis therefore includes these two combinations of abuse (‘CSA+ CPA’,
N = 14; ‘CSA+ ASA’, N = 7).
Number of DSM-IV ‘characteristic symptoms’ of schizophrenia
The DSM-IV requires two of
ve ‘characteristic symptoms’ for a diagnosis of
schizophrenia, or schizophreniform and schizoaffective disorders (American Psychia-
tric Association, 1994, p. 285). Forty-eight charts (24%) noted two or more of:
hallucinations, delusions, thought disorder, or negative symptoms (no les noted
the fth: grossly disorganized or catatonic behaviour). Table 1 shows that having
two or more symptoms was more common in those subjected to CSA (37.5%),
X2(1) = 5.82, p < .02, ASA (60%), X2(1) = 12.58, p < .001, or CSA+ ASA (71%),
X2(1) = 10.82, p < .005, than in the non-abused group (19%). The mean number
of ‘characteristic symptoms’ found in those subjected to both CSA and ASA was far
greater (M = 2.43, SD = 1.40) than the mean of the non-abused group (M = 0.69,
SD = 1.14), t(113) = 3.87, p < .0005.
Hallucinations
Fifty-seven (28.5%) charts documented one or more types of hallucinations. The
presence of hallucinations was signi cantly related to a diagnosis of schizophrenia,
X2(1) = 29.44, p < .001. Hallucinations were signi cantly related to CSA, CPA, and ASA,
but not to APA. They were most common in those subjected to both forms of
CA (CSA+ CPA) (71%), X 2(1) = 18.71, p < .0005, or to both forms of sexual abuse
(CSA+ ASA) (86%), X2(1) = 16.96, p < .0005.
Table 2 shows that auditory hallucinations were present for 52%of the CSApatients
but only 18%of those for whom no abuse was documented, X2(1) = 18.03, p < .0005.
They were also signi cantly more common among ASAand CPApatients, but not in the
APA group.
Voices commenting were signi cantly related to all four abuse types. In the ASA
group, 47%heard voices commenting, compared with 5%of the non-abused patients,
X2(1) = 26.43, p < .0005.
Command hallucinations to harm or kill oneself were signi cantly related to all four
abuse types. Although only 2%of the non-abused group had command hallucinations,
this was the case for 29% of both the CSA+ CPA, X 2(1) = 18.92, p < .001 and
CSA+ ASA, X2(1) = 13.98, p < .001.
Visual hallucinations, too, were signi cantly related to all four abuse types and were
also found in 29%of the CSA+ CPA, X2(1) = 12.58, p < .001, and CSA+ ASA groups,
X2(1) = 8.22, p < .005, compared with only 4%of the non-abused patients.
Olfactory hallucinations were not signi cantly related to abuse in adulthood.
However, 10%of the CSA patients, X 2(1) = 7.36, p < .01, and 21%of the CSA+ CPA
patients, X2(1) = 16.43, p < .001, experienced olfactory hallucinations, compared with
just 1%of the non-abused group.

8
John Read et al.
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