Childhood Trauma and Hallucinations in Bipolar Affective Disorder

BRITISH JOURNAL OF PSYCHIATRY (2003), 182, 543^547 PRELIMINARY REPORT

Childhood trauma and hallucinations in bipolar verified by a team of four trained graduate research assistants who inspected case notes affective disorder: preliminary investigation and interviewed the patients before therapy and at follow-up points using the Structured Clinical Interview for DSM–IV PAUL HAMMERSLEY, ANTON DIAS, GILLIAN TODD, KIM BOWEN-JONES, (SCID; First et aletal, 1996). Inclusion criteria BERNADETTE REILLYand RICHARD P. BENTALL 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 Background Strong evidence exists Research has shown high levels of child- mood-incongruent psychotic phenomena for an association between childhood hood sexual abuse and other early traumas was reported for 33 of the sample. in patients with serious mental illness Recruitment by centre was as follows: trauma, particularlychildhoodparticularly childhood sexual (Goodman(Goodman et aletal, 1997; Mueser et aletal,, Manchester 22, Liverpool 25, Glasgow 25 abuse, and hallucinationshallucinationsin in schizophrenia. 1998). There is evidence of a specific and Cambridge 24. Individuals with sub- Hallucinations are also well-documented association between childhood sexual stance misuse as a primary diagnosis or evi- symptomssymptomsinpeople in people with bipolar affective abuse and positive symptoms, particularly dence of organic illness were excluded from disorder.disorder. hallucinations, in patient samples (Ross etet the study, as were individuals displaying alal, 1994; Read & Argyle, 1999), com- rapid-cycling bipolar disorder or severe co- Aims Toinvestigate the relationship munity samples (Ross & Joshi, 1992) and morbid borderline personality disorder. As between childhood sexual abuse and also in surveys of schizotypal traits in the research assistants were employed for ordinary people (Startup, 1999). the purposes of the clinical trial, they were otherchildhoodtraumasandhallucinations Goodwin & Jamison (1990) reviewed masked to the hypothesised relationship in people with bipolar affective disorder. 20 studies conducted between 1922 and between trauma and hallucinations. 1989 investigating the prevalence of hallu- The sample comprised 32 men and 64 MethodMethod A sample of 96 participants cinations in bipolar disorder and calculated women. The minimum age was 22 years was drawn fromthe Medical Research a weighted mean average of 18%. To date, and the maximum 70 years (mean 40.5, Council multi-centre trial of cognitive ^ no study has attempted a systematic s.d.s.d.¼10.4). Mean age at illness onset, behaviouraltherapy for bipolar affective analysis of the relationship between child- recorded by the research assistants on the hood sexual abuse or other childhood basis of case-note and interview data, was disorder.The trial therapists recorded trauma and hallucinations in people with known for 95 participants, and found to spontaneous reports of childhood sexual bipolar disorder. In this study we investi- be 24.4 years (s.d.¼7.8). Eighty-one partici- abuse made during the course oftherapy. gated this relationship in a sample of pants had been hospitalised at some point Symptom data were collected by trained patients recruited to a multi-centre, in their illness, and their mean age of research assistants maskedtomasked to the randomised, controlled trial of cognitive– first hospitalisation was 29.4 years behavioural therapy. (s.d.(s.d.¼9.4).9.4). hypothesis.hypothesis.

ResultsResults A significant association was METHOD MeasuresMeasures found betweenthosebetween those reporting general Participants were seen by the trial thera- trauma ((trauma nn¼38) and auditory Participants pists for approximately 24 one-hour hallucinations. A highly significant A total of 255 persons meeting DSM–IV sessions over a 6-month period. Direct association was found betweenthosebetween those (American Psychiatric Association, 1994) references to childhood sexual abuse or criteria for bipolar affective disorder were other traumas made by participants during reportingchildhood sexual abuse (nn¼15)15) recruited to a randomised, controlled trial assessment or at other points in therapy and auditory hallucinations. of cognitive–behavioural therapy for bi- were collected by the therapists, who com- polar disorder. From this group 126 were pleted an eight-item questionnaire for each Conclusions The relationship between randomised to receive therapy, which was patient. The questionnaire listed eight cate- childhood sexual abuse and hallucinations conducted by five qualified therapists gories of trauma: sexual abuse; physical in bipolardisorderbipolar disorder warrants further supervised by internationally recognised abuse; physical abuse with a weapon; wit- investigation. experts (Professor Jan Scott and Dr Peter ness to the killing or serious injury of Kinderman). Four of the therapists agreed another (including parasuicide); having a Declaration of interest None.None. to complete questionnaires recording spon- close friend or relative who was murdered taneous reports of trauma by their patients. or killed (including suicide); experiencing Data were obtained for all 96 patients a significant accident; experiencing a treated by the four participating therapists. natural or human-made disaster; any other Initial diagnostic assignment was made trauma. These categories were based on the by referring consultant psychiatrists and categorisation by Mueser et aletal (1998) of(1998)of

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traumas commonly experienced by those Ta b l e 1 Type of trauma spontaneously reported 9 had experienced other (tactile, somatic with serious mental illness, which were in by patients with bipolar disorder (nn¼96) to theirtheir96) or olfactory) hallucinations. The numbers turn derived from the Trauma History therapiststherapists of participants divulging particular types Questionnaire (Green, 1996). For each ca- of trauma, classified according to the tegory, the therapists were asked to record Trauma History Questionnaire categories, TraumaTrauma nn %% detailed descriptions of the traumatic event are given in Table 1. Fifteen of the 96 where possible. Any traumatraumaAny 3839.6 participants disclosed some kind of child- A report of any trauma including child- Childhood sexual abuse 15 15.815.8 hood sexual abuse to their therapists. No hood sexual abuse was only classified as Assault 1919.8 significant difference between the sexually occurring in childhood if it occurred before traumatised and non-traumatised groups Assault with a weapon 33.13 3.1 the patient’s 16th birthday. The behaviour- was observed for the mean age at illness Witness to the death or injury 13 13.513.5 al descriptions of childhood sexual abuse onset (traumatised group 22.2 years, non- of anotherofanother were categorised according to the criteria traumatised group 24.8 years; tt¼1.14,1.14, used in the Child Maltreatment History Murder of close friend or family 22.12 2.1 two-tailedtwo-tailed PP¼0.26, d.f.0.26,d.f.¼93), or age at first Self-Report (CMHSR; Badgley et aletal,, membermember hospitalisation(traumatised group 28.1 1984), an assessment tool used in a large- Serious accident 44.24 4.2 years,years,non-traumatisednon-traumatised group 29.6; scale Canadian study of childhood sexual Unspecified/other 88.38 8.3 tt¼0.54, two-tailed PP¼0.59, d.f.0.59,d.f.¼79). As79).As abuse in the general population. Sexual both the trauma reports and the SCID abuse is rated in the CMHSR according to yielded categorical data, associations four distinct categories: between trauma and hallucinations were However, to determine whether any find- analysed using the chi-squared statistic. (a)(a)childchild exposed to on more than one ings were specific to hallucinations, parallel Contingency tables showing the occasion;occasion; analyses were calculated using SCID data relationships between different kinds of on patients’ delusions and hallucinations (b)(b)childchild threatened with sexual contact; hallucination report and reports of child- in the non-auditory modalities. (c)(c)childchild touched sexually; hood sexual abuse are shown in Table 2. A significant association was found be- (d)(d)sexualsexual assault (attempted or actual). RESULTSRESULTS tween reports of any trauma and the pre- In our sample no participants reported sence or absence ofauditory hallucinations threatened sexual contact only, and in no Forty-five participants (nearly half of the ((ww22¼7.61,7.61, PP550.01,0.01, d.f.d.f.¼1). The observed case did the recorded onset of illness pre- sample) had experienced hallucinations associations between reports of abuse and date the reported abuse. In order to ensure during their lifetime: 30 had experienced history of anyhallucinations (ww22¼6.83,6.83, that the trauma descriptions were cate- auditory hallucinations, 11 had heard PP550.005, d.f.d.f.0.005, ¼1),1),history of auditory hal- gorised correctly, a psychiatric social voices commenting on their actions, 25 lucinations (ww22¼14.66,14.66, PP550.001, d.f.0.001,d.f.¼1),1), worker with extensive experience in the had experienced visual hallucinations, and and history of voices commenting assessment of trauma and abuse (A.D.) reclassified the detailed descriptions. Inter- rater reliability, indicating consensus for allocation into designated categories, was Ta b l e 2 Contingency table showing associations between lifetime history of different types of hallucination 34/36 for recordedrecorded reports of general and reports of childhood sexual abuse in the sample of patients with bipolar disorder (nn¼96) trauma and15/15 for reports of childhood sexual abuse. Data for lifetime history of experience Hallucinations Total of psychotic symptoms were collected by Absent Present the four trained and supervised research assistants at the trial baseline assessment, nn (%)(%) nn (%) using the lifetime version of the SCID. This provided evidence for the presence or Any hallucinations absence of hallucinations in six distinct Childhood sexual abuse reported 3 (20.0)12 (80.0)15 categories. Only participants scoring 3 Childhood sexual abuse not reported48 (59.3)33 (40.7)81 (threshold or true hallucinations) on the Total 51 (53.1)45 (46.9) 9696 baseline SCID were categorised as having Auditory hallucinations a history of hallucinations; this was to ensure that transient stress-related dissocia- Childhood sexual abuse reported 4 (26.7)11 (73.3)15 tive symptoms or quasi-psychotic experi- Childhood sexual abuse not reported62 (76.5)19 (23.5) 8181 ences of the type that may be present in Total 66 (68.8)30 (31.3) 9696 borderline personality disorder were not Voices commenting classified as hallucinations. To minimise Childhood sexual abuse reported 9 (60)9(60) 6(40)156 (40) 15 the risk of type-I statistical errors, and in Childhood sexual abuse not reported76 (93.8) 5 (6.2)5(6.2)81 accordance with our hypotheses, our Total 85 (88.5)11 (11.5)96 main analyses focused on hallucinations.

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((ww22¼14.28,14.28, PP550.002, d.f.0.002,d.f.¼1) were even and later trauma such as exposure to with a control sample of people with major more significant. However, no significant military combat (Butler et aletal, 1996).,1996). depressive disorder, the lack of appropriate associationassociationwaswas found between trauma In a community survey, Ross & Joshi control data in our study makes it imposs- and reports of delusions, or trauma and (1992) reported that 46% of those who ible for us to verify this finding. As the reports of visual or tactile hallucinations. reported three or more Schneiderian majority of the participants did not report The relationship between mood-incongru- symptoms had experienced childhood phy- childhood sexual abuse, there is certainly ent psychotic symptoms and childhood sical or sexual abuse, compared with 8% nothing in our findings to imply that bi- sexual abuse was not significant. Seven with no such symptoms. In surveys of polar affective disorder is in some direct patients were diagnosed as having border- schizotypal traits in the normal population way caused by trauma, or that patients line personality disorder. However, the it has also been found that reports of with this disorder are more traumatised observed associations between childhood unusual experiences correlate with a re- than other groups. Interestingly, of the 15 sexual abuse and hallucinations all ported history of childhood sexual abuse patients who reported childhood sexual remained when these patients were (Bryer(Bryer et aletal, 1987; Startup, 1999) or abuse, only three reported that the excluded from the analyses. childhood maltreatment (Berenbaum, perpetrator was a blood relative. 1999).1999). However, the findings are consistent Given this apparent association be- with other studies which suggest that child- tween hallucinatory experiences and childhood sexual abuse and other early traumas DISCUSSION hood sexual abuse in people with increase the risk that individuals will ex- schizophrenia, it is obviously important to perience positive symptoms, and especially Previous studies of CSA establish whether the same relationship hallucinations. In our study the association and psychosis exists between hallucinations and child- between childhood sexual abuse and hallu- Many studies have found that high levels of hood sexual abuse in other clinical groups. cinations could not be attributed to border- early trauma are reported by adult psychi- line personality disorder, or to the presence atric patients. In a review of 13 studies con- Findings of this study of mood-incongruent psychotic symptoms. sidered to be methodologically adequate at In all the recorded cases of abuse in the Over a quarter of the participants in our the time, Goodman et aletal (1997) found that sample, the abuse preceded the onset of ill- study reported visual hallucinations, a pro- women undergoing treatment for psychosis ness, including the experience of auditory portion that is higher than in most pre- consistently reported much higher levels of hallucinations. This observation is import- viously reported studies of people with abuse than did controls. In a study of their ant because it makes it unlikely that the bipolar disorder (Goodwin & Jamison, own conducted later (Mueser et aletal, 1998),1998) abuse was imagined, or that the experience 1990). However, in one of the largest these researchers estimated that 52% of of trauma was in some way a consequence studies of this kind (Black & Nazrallah, 153 severely ill women patients they of illness (which would be the case, for ex- 1989), the observed prevalence rate for surveyed had experienced sexual abuse ample, if people experiencing hypomanic or visual hallucinations was 27%, which is during childhood, and nearly 64% had manic symptoms placed themselves in almost identical to our own figure. In con- suffered sexual abuse in later life. These situations where there was a high risk of trast to most previous studies, the figures figures indicate that many women with sexual assault). arrived at in our investigation were based psychosis have experienced multiple epi- The most plausible interpretation of the on lifetime experiences rather than on sodes of abuse. Goodman et aletal (1999) also(1999)also present findings is, therefore, that child- current symptoms. reported that, in a further sample of 50 hood sexual abuse has an impact on the Only 15 (16%) of our patients reported patients with serious mental illness (64% later symptom profile of patients with bi- a history of childhood sexual abuse to their schizophrenia), three-quarters of the polar affective disorder, increasing their therapists. This finding is comparable with women and nearly half of the men had vulnerability to experiencing auditory those obtained from population samples. experienced childhood sexual abuse. hallucinations. For example, Salter (1988) summarised 14 Similar findings were reported in a more North American studies investigating child- recent survey of first-episode patients hood sexual abuse in the general popu- (Neria(Neria et aletal, 2002). In the same study, it Possible mechanisms linking early lation, and reported prevalence rates was reported that only 5% of reports of trauma to hallucinations ranging from 11% to 38% for women. early trauma could be attributed to The processes by which trauma leads to Despite this modest prevalence of aberrant behaviour of the patient (for hallucinations in people with severe mental reported abuse in our sample, strong asso- example, placing themselves in high-risk illness are not understood. However, ciations were observed between reported situations).situations). psychological studies have suggested that childhood sexual abuse and a history of Experience of early trauma has been hallucinations result from the misattribu- hallucinations, especially auditory ones. specifically associated with Schneiderian tion of mental events to an alien or external symptoms (Ross et aletal, 1994; Ellason & source, and that this is most likely to occur Ross, 1997) or hallucinations (Reid & Does childhood trauma cause when experiencing mental events that are Argyle, 1999). Other studies have reported bipolar disorder? automatic and low in cognitive effort that psychotic symptoms, especially halluci- Although Hyun et aletal (2000) reported that a (Bentall, 2000). As intrusive memories of nations, are frequently experienced by childhood history of sexual abuse was sig- trauma are typically mental events of survivors of early trauma such as sexual nificantly more frequent in a sample of this kind, they may be particularly likely abuse (Heins et aletal, 1990; Ensink, 1993) patients with bipolar disorder compared to be experienced as hallucinations by

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individuals whose source-monitoring abil- ities are compromised by severe mental ill- CLINICAL IMPLICATIONS ness. Negative automatic thoughts of the kind experienced during periods of low && Patients with a history of hallucinations may have experienced trauma during self-esteem would also be likely to be ex- childhood. perienced as alien under these circum- stances. Both types of cognitive events are && Childhood sexual abuse may play a role in the aetiology of positive symptoms. especially likely to be experienced during && Patients with bipolar disorder with positive symptoms should be routinely asked stressful periods, especially after an adult survivor of abuse has been further trauma- about any traumatic experiences in childhood. tised by additional negative experiences. LIMITATIONS HonigHonig et aletal (1998) found that many people troubled by hallucinations reported that && Trauma data were collected only from participants’ spontaneous self-report to their hallucinations began following a therapists; and could not be verified from other sources. retraumatising experience. && Lifetime histories of hallucinations were not validated by case note data.

Limitations && Possible causal mechanisms linking trauma to later hallucinations were not Childhood sexual abuse was only recorded investigated. when spontaneously reported to the thera- pist in this study. It is possible that the magnitude of the association between childhood sexual abuse and hallucinations in bipolar disorder has been underestimated PAUL HAMMERSLEY,MSc, RMN, Department of Psychology,University of Manchester; ANTON DIAS, by our method. Conservative criteria were DipSocialWork, South Staffs Mentally Disordered OffendersTeam, St George’s Hospital, Stafford; GILLIAN used to decide whether patients had experi- TODD,BA, Barton House Clinic, Addenbrookes Hospital,Cambridge; KIM BOWEN-JONES, DClinPsychol, Trengweth Mental Health Unit, Redruth; BERNADETTE REILLY,RMN, Department of Psychological Medicine, enced such abuse; for example, two Gartnavel Royal Hospital,Glasgow;Hospital, Glasgow; RICHARD P.BENTALL, PhD,FBPsS,PhD, FBPsS, Department of Psychology,University patients with a history of hallucinations of Manchester,Manchester,Manchester,UK Manchester,UK were not classified as victims of childhood sexual abuse because apparent behavioural CorrespCorrespondence:ondence:Paul Paul Hammersley,Department of Psychology,University of Manchester,Oxford Road, descriptions of abuse obtained by the thera- Manchester M13 9PL,UK. E-mail: Paul@@hammersley7616.freeserve.co.uk pists were considered ambiguous. Conver- (First received 12 March 2002, final revision 24 September 2002, accepted 3 January 2003) sely, it may be possible that the magnitude of the association between childhood sexual abuse and hallucinations has been over- estimated, in that we were not able to verify self-reports of abuse with other sources affective disorder. The findings also suggest REFERENCES such as medical or legal documents, and that clinicians should be sensitive to the had to take these self-reports at face value. possibility that early adverse experience American Psychiatric Association(19 (1994) 94) Diagnostic and Statistical Manual of Mental Disorders (4th edn)edn)(4th may be an issue that needs to be ad- Lifetime histories of hallucinations (DSM^IV).Washington, DC: APA. were not validated against case-note data. dressed in the treatment and management Badgley, R. F., Allard, H. 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