Psychiatry Research 251 (2017) 7884

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Relation between psychotic symptoms, parental care and childhood trauma MARK
in severe mental disorders

Ana Catalana,b, , Virxina Angostob, Aida Dazb, Cristina Valverdeb, Maider Gonzalez de Artazab,
Eva Sesmab, Claudio Maruottoloc, Iaki Galleteroc, Sonia Bustamantea,b, Amaia Bilbaod, Jim van
Ose,f, Miguel Angel Gonzalez-Torresa,b
a
Department of Neuroscience, University of the Basque Country, Basque Country, Spain
b
Department of Psychiatry, Basurto University Hospital, Bilbao, Spain
c
Avances Mdicos S.A. Santurtzi, Vizcaya, Spain
d
Research Unit, Basurto University Hospital, Red de Investigacin en Servicios de Salud en Enfermedades Crnicas (REDISSEC), Bilbao, Vizcaya, Spain
e
Department of Psychiatry and Psychology, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht University Medical Centre,
Maastricht, The Netherlands
f
King's College London, King's Health Partners, Department of Psychosis Studies, Institute of Psychiatry, London, United Kingdom

A R T I C L E I N F O A BS T RAC T

Keywords: A relation between dierent types of parental care, trauma in childhood and psychotic symptoms in adulthood
Childhood trauma has been proposed. The nature of this association is not clear and if it is more related to psychotic disorders per
Psychosis se or to a cluster of symptoms such as positive psychotic symptoms remains undened. We have analysed the
Parenting rearing style presence of childhood trauma using the CTQ scale and types of parental care using the PBI scale in three groups
Severe mental disorder
of subjects: borderline personality disorder patients (n=36), rst psychotic episode patients (n=61) and healthy
controls (n=173). Positive psychotic symptomatology was assessed with the CAPE scale. General linear models
were used to study the relation between positive psychotic symptomatology and variables of interest. BPD
patients had the highest rate of any kind of trauma, followed by FEP patients. We found a positive relationship
between psychotic symptomatology and the existence of trauma in childhood in all groups. Moreover, an
aectionless control rearing style was directly associated with the existence of trauma. Furthermore, subjects
with trauma presented less probability of having an optimal parenting style in childhood. The relation between
psychotic symptoms and trauma remained statistically signicant after adjusting for other variables including
parental rearing style. There seems to be a link between trauma in childhood and psychotic symptomatology
across dierent populations independently of psychiatric diagnosis. Taking into account that there is an
association between trauma and psychosis and that trauma is a modiable factor, clinicians should pay special
attention to these facts.

1. Introduction psychosis, as well as childhood neglect. Some studies concluded that

Recent literature has established a link between the development of
trauma in childhood and psychosis (Bebbington, 2009; Bebbington
et al., 2004, 2011; Janssen et al., 2004; Read et al., 2005). Some
authors have stated that most of the risk is conferred by the severest
form of childhood sexual abuse and less severe abuse was not solely
associated with psychosis, although it most certainly may be with other
psychiatric disorders (Bebbington et al., 2011).
Until now, the majority of reviews (Bendall et al., 2008; Read et al.,
2008, 2005; Read and Gumley, 2008) have reported strong links
between emotional, physical and sexual abuse in childhood and
literature has now established that the relationship is causal; however,
others called for further research. Some studies have even found that
after checking for other factors (including family history of psychosis or
cannabis use), adverse events in childhood were signicantly related to
psychosis (Varese et al., 2012). For example, a prospective study from
the Netherlands that checked for a history of hallucinations or
delusions in rst-degree relatives found that people who had been
abused as children were nine times more likely to experience pathol-
ogy-level psychosis (Janssen et al., 2004) than non-abused people. This
link between psychosis and trauma has also been described in rst
episode psychosis (FEP) (Spauwen et al., 2006; Ucok and Bikmaz,

Corresponding author at: Department of Psychiatry, Basurto University Hospital, Bilbao, Spain.
E-mail address: ana.catalanalcantara@osakidetza.eus (A. Catalan).

http://dx.doi.org/10.1016/j.psychres.2017.02.017
Received 9 September 2016; Received in revised form 15 December 2016; Accepted 5 February 2017
Available online 06 February 2017
0165-1781/ 2017 Elsevier B.V. All rights reserved.
A. Catalan et al.
2007) and in borderline personality disorder patients (BPD) (Kingdon
et al., 2010).
A study conducted at the Reina Soa Centre in 2011, described an
abuse rate of 4.54% in males and 3.94% in females aged between 8 and
17 years in Spain (Sanmartin, 2011). These gures are very low when
compared to other countries. For example, one UK survey found a
prevalence of childhood sexual abuse of 11% in young adults (May-
Chahal and Cawson, 2005), and estimates from elsewhere in the world
have generally been in the same range (Dinwiddie et al., 2000;
Friedman et al., 2002; Pereda et al., 2009). In general terms, women
are more likely to suer sexual abuse than men, while males are more
frequently victims of physical abuse (Alvarez et al., 2011). In patients
with psychiatric disorders, the rate of any kind of abuse is high. A
review of 20 studies covering exclusively psychotic samples reported
that 28% of men and 42% of women had been sexually abused and that
50% of both sexes had been either sexually or physically abused as
children (Morgan and Fisher, 2007).
In the case of patients with BPD, symptoms associated with
psychosis have often been described, such as auditory hallucinations
and paranoia (Zanarini et al., 2004). We know that childhood trauma is
very common in subjects with BPD. Between 30% and 90% of these
patients have reported some kind of traumatic event in childhood
(Battle et al., 2004; Bornovalova et al., 2013; Lobbestael et al., 2010;
Zanarini, 2000). In fact, childhood trauma is considered the main
environmental factor associated to BPD development (Spataro et al.,
2004; Widom et al., 2009). In the case of BPD patients with psychotic
comorbidity, in just one study up to 44% reported severe sexual abuse.
Furthermore, there were some major similarities between schizophre-
nia and BPD patients in terms of their experience of voices (Kingdon
et al., 2010).
On the other hand, there is a possible association between parental
rearing styles and the onset of psychotic disorder (Parker et al., 1982;
Willinger et al., 2002). Parental bonding is a complex two-way process
in which the child becomes emotionally attached to its caregivers. The
parentchild bond will be broadly inuenced by characteristics of the
child (e.g. individual dierences in attachment behaviour), character-
istics of the parent or care-taking system (e.g. psychological and
cultural inuences) and by characteristics of the reciprocal, dynamic
and evolving relationship between the child and the parent (Parker
et al., 1979). In the Finnish prospective adoption studies, it was shown
that parental rearing styles interacted with genetic liability to increase
the risk of schizophrenia-related outcomes, but that genetic liability
itself was not associated with rearing style (Wahlberg et al., 1997). In a
more recent study, lower baseline care was strongly associated with
developing psychosis. However, when history of trauma was included
in the adjusted equation, the excess risk associated with low care was
greatly reduced, and no longer statistically signicant, at the expense of
a strong and signicant remaining main eect of trauma. The results
suggest that the association between a subject's representation of
parental rearing and psychosis may be an indicator of the eect of
earlier exposure to childhood trauma (Janssen et al., 2005).
The purpose of this study is twofold. Firstly, to study the rate of
childhood trauma and parental rearing styles in three groups of
subjects: borderline personality patients (BPD), rst episode psychosis
patients (FEP), and healthy controls (HC); and, secondly, to determine
the interaction between childhood trauma, parental rearing style and
positive psychotic symptomatology.
2. Material and methods
2.1. Ethical statement
The authors assert that all procedures contributing to this work
comply with the ethical standards of the relevant national and
institutional committees on human experimentation and with the
Helsinki Declaration of 1975, as revised in 2008. The local ethics
79
Psychiatry Research 251 (2017) 7884
committee (Ethics Committee of Clinical Research of Basurto
University Hospital) approved the study design and the patients
provided written informed consent.
2.2. Sample
The recruitment procedures for this study were described pre-
viously (Catalan et al., 2015). Controls were recruited from the general
population in the same catchment area of the patients through public
announcements. They were similar in age and sex to the patients, and
did not have rst degree family members with a psychotic disorder.
Inclusion criteria were the following (for the three groups): age
between 18 and 60 years, adequate ability to speak and understand
the Spanish language, IQ > 70; for FEP patients: treatment with
antipsychotic medication < 1 year. The psychotic episode fullled
DSM-IV-TR criteria for aective or non-aective psychotic disorder;
for BPD patients: meeting DSM-IV-TR criteria for BPD in the absence
of current psychotic disorder comorbidity (two of the patients had
previous history of psychotic symptoms). Exclusion criteria for three
groups were (a) current or past comorbid diagnosis of any neurological
disorder which could prevent neuropsychological task performance, (b)
history of severe head injury, (c) currently suering severe medical
conditions, (d) any current drug dependence and (e) unwillingness to
participate.
For FEP, the Operational Criteria Checklist for Psychosis (Williams
et al., 1996) was completed, based on clinical instruments and relevant
data in the medical history, and used to establish the diagnosis of the
patients using the associated OPCRIT computer programme (Craddock
et al., 1996).
Socio-demographic and clinical variables collected in the sample
have been detailed previously (Catalan et al., 2015).
2.3. Psychotic dimension
The Community Assessment of Psychic Experiences (CAPE) (Ros-
Morente et al., 2011; Stefanis et al., 2002) consists of 42 items that tap
into the psychotic phenotype. This scale was used to determine
positive, negative and depressive symptoms along a frequency scale
(1=never to 4=nearly always) and a distress scale (1=not distressed to
4=very distressed). The mean CAPE positive, negative, and depressive
score was the mean of the positive, negative, and depressive symptom
frequency scale, respectively.
2.4. Childhood trauma
The Childhood Trauma Questionnaire (CTQ-SF) validated to
Spanish (Hernndez et al., 2013) was used to establish the rate of
trauma retrospectively in three groups. This 25-item version was
derived from the original 70-item CTQ (Bernstein et al., 1998). This
questionnaire assesses ve aspects of abuse history: physical abuse,
emotional abuse, sexual abuse, physical neglect, and emotional neglect.
Each item uses a 5-point scale to identify the frequency or severity of
the experience. Scores for each type of trauma can be calculated
separately. The CTQ does not discriminate between current and past
experiences of abuse. It can be given to both clinical and non-clinical
respondents.
Cut-o scores for moderate to severe exposure were used to
classify the occurrence (presence or absence) of a specic trauma in
the three groups (emotional abuse > =13; physical abuse > =10; sexual
abuse > =8; emotional neglect > =15; physical neglect > =10). Scores
above this cut-o score correspond with rating most traumatic
experiences of that specic trauma as often true (Daalman et al.,
2012). The short form of the CTQ demonstrated good criterion related
validity in a subsample of adolescents and appeared to be viable across
diverse populations (Bernstein et al., 2003).
In order to improve statistical power we created three variables of
A. Catalan et al. Psychiatry Research 251 (2017) 7884

Table 1
Socio-demographic and clinical variables.

Variable Group

FEP patients BPD patients Controls

(n=61) (n=36) (n=173)

Age 36.1 (12.5) 37.5 (10.7) 31.9 (11.6)

Mean (SD)*** 36.1 (12.5) 37.5 (10.7) 31.9 (11.6)
Median (IQR)* 35 (2344) 36 (2942) 28 (2241)

Gender, n (%)*
Fig. 1. PBI categories. Male 36 (59%) 11 (30.6%) 94 (54.3%)
Female 25 (41%) 25 (69.4%) 79 (45.7%)

trauma: ctq1 being the existence of emotional abuse or negligence; ctq2 Partnership status, n
the existence of any kind of physical or sexual abuse; and ctq3 the (%)**
existence of any kind of abuse. Single 34 (55.7%) 20 (55.6%) 98 (56.7%)
Married/stable 20 (32.8%) 10 (27.8%) 72 (41.6%)
partnership
2.5. Parental rearing styles Divorced/separated 6 (9.8%) 6 (16.7%) 3 (1.7%)
Widowed 1 (1.6%) 0 0
A Parental Bonding Instrument (PBI) (Parker et al., 1979) was used
Housing, n (%)*
to establish parental rearing styles. This self-report questionnaire has
With original family 32 (52.5%) 16 (44.4%) 81 (46.8%)
25 items that are scored on a 4-point Likert-type scale ranging from With own family 20 (32.8%) 12 (33.3%) 81 (46.8%)
very unlikely to very likely. The Spanish PBI showed good internal Alone 9 (14.7%) 8 (22.2%) 11 (6.4%)
consistency for the four subscales, with Cronbach's ranging from 0.82
to 0.88 (Balls Creus, 1991; Gomez-Beneyto et al., 1993). This is a self- Employment status, n
(%)***
reporting questionnaire in which subjects were asked to rate their
Full-time employment 27 (44.3%) 5 (13.9%) 91 (52.9%)
parents on a variety of attitudes and behaviours related to two Unemployed 28 (45.9%) 24 (66.7%) 32 (18.6%)
dimensions (care and overprotection), referring to the period of their Student 3 (4.9%) 1 (2.8%) 44 (25.6%)
rst 17 years of life. There is one scale for each of the parents, one for Retired 3 (4.9%) 0 2 (1.2%)
Other 0 6 (16.7%) 3 (1.7%)
the mother and another one for the father. We chose parental bonding
IQ, mean (SD)*** 93.4 (16.2) 90.8 (14.8) 109.2 (14.6)
categories as shown in Fig. 1. Higher scores indicate less care and more
overprotection. Mean (SD) Mean (SD) Mean (SD)
CAPE positive 10.5 (6.9) 11.7 (8.1) 4.2 (2.9)
2.6. Statistical analysis CAPE negative 10.8 (5.4) 14.6 (7.9) 6.7 (4.1)
CAPE depressive 12.3 (5.8) 12.3 (5.8) 4.9 (2.7)

The description of the variables was carried out using frequency *

tables, means and standard deviations (SD), or median and interquar-
tile range (IQR). The socio-demographic and clinical variables were
compared between the three groups. The Chi-square or Fisher's exact
tests were used for the comparison of categorical variables, and the
non-parametric Kruskal-Wallis test for the continuous variables. The
association between trauma in childhood and parenting rearing styles
was studied by the Chi-square or Fisher's exact test. To examine the
association between each parenting rearing style with positive psycho-
tic symptoms (CAPE) the general linear model was used, considering
the CAPE Positive as the dependent variable, and the parenting rearing
style as the independent one. We also considered other adjusting
variables, such as age, sex, cannabis abuse, IQ, socio-demographic level
and group of each subject. Similarly, general linear models were also
used to study the association between trauma in childhood with CAPE
Positive. In this case, besides the previous adjusting variables, the
parenting rearing styles were also considered.
A result was considered statistically signicant at p < 0.05.
Statistical analyses were carried out with statistical software STATA
version 12 (StataCorp, 2011) and SAS for Windows, version 9.2 (SAS
Institute, 2010).
3. Results
Socio-demographic and clinical variables are detailed in Table 1.
CTQ rates of abuse and neglect were quite high in the three groups.
BPD patients had more frequently suered any of ve types of trauma
(p < 0.001). The most dramatic dierences were in relation with sexual
abuse (36% of BPD patients vs 8% of FEP patients and 2% of HC). BPD
patients reported 36% emotional abuse, 31% emotional neglect, 31%
physical abuse and 28% physical neglect. Although to a lesser degree,
p < 0.05.
**
p < 0.001.
***
p < 0.0001.
FEP patients also demonstrated to have suered higher emotional
abuse (15% vs 2% in HC, p=0.001), emotional neglect (13% vs 4% in
HC, p=0.013), physical abuse (8% vs 1% in HC, p=0.03), physical
neglect (18% vs 5% in HC, p=0.001) and sexual abuse (p=0.014) than
controls.
Regarding parenting rearing styles, an aectionless control parent-
ing style was the most frequent parental rearing style in the BPD group,
(51.4% vs 48.3% in FEP and 28.9% in HC in reference to mothers,
p=0.003; 52.9% vs 38.6% in FEP and 28.9% in HC in reference to
fathers, p=0.02) which at the same time had the lowest rate of optimal
parenting style (8.6% vs 16.7% in FEP and 28.9% in HC in reference to
mothers, p=0.013; 8.8% vs 26.3% in FEP and 30.2% in HC in reference
to fathers, p=0.036). There was no dierence between aectionate
constraint and neglectful parenting styles between groups.
In Table 2 we present data for the relation between trauma and
parental rearing styles. In general terms, both maternal and paternal
aectionless control conditions were more related with all kinds of
trauma than other parental care styles. As expected, optimal care was
related with a low probability of trauma. An aection constraint rearing
style was also associated with a low probability of suering emotional
abuse or neglect.
There was a strong relation between the mothers parenting styles
and positive psychotic symptomatology (Table 3), the relation was not
signicant for the fathers rearing styles (Table 4). An aectionless
control rearing style in mothers was related with positive symptoma-
tology while optimal care was inversely related to this symptomatology.
All sorts of trauma (emotional, physical and sexual) were associated

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A. Catalan et al. Psychiatry Research 251 (2017) 7884

Table 2
Relation between trauma in childhood and parenting rearing styles.

Trauma in childhood

ctq1 ctq2 ctq3

Parenting rearing styles No (n=233) Yes (n=37) p No (n=223) Yes (n=47) p No (n=213) Yes (n=57) p
Maternal aection constraint 66 (28.6) 2 (5.4) 0.0026 57 (25.7) 11 (23.9) 0.8026 57 (26.9) 11 (19.6) 0.2679
Maternal aectionless control 73 (31.6) 24 (64.9) < 0.0001 73 (32.9) 24 (52.2) 0.0132 68 (32.1) 29 (51.8) 0.0063
Maternal optimal 62 (26.8) 1 (2.7) 0.0013 60 (27.0) 3 (6.5) 0.0028 59 (27.8) 4 (7.1) 0.0012
Maternal neglect 30 (13.0) 9 (24.3) 0.0694 31 (13.9) 8 (17.4) 0.5485 28 (13.2) 11 (19.6) 0.2245
Paternal aection constraint 45 (20.1) 1 (2.8) 0.0115 41 (19.0) 5 (11.4) 0.2275 41 (19.9) 5 (9.3) 0.0681
Paternal aectionless control 67 (29.9) 22 (61.1) 0.0003 66 (30.6) 23 (52.3) 0.0057 59 (28.6) 30 (55.6) 0.0002
Paternal optimal 66 (29.5) 3 (8.3) 0.0077 63 (29.2) 6 (13.6) 0.0335 62 (30.1) 7 (12.9) 0.0111
Paternal neglect 46 (20.5) 10 (27.8) 0.3265 46 (21.3) 10 (22.7) 0.8333 44 (21.4) 12 (22.2) 0.8908

Data are given as frequency (percentage).

with positive psychotic symptomatology after adjusting by age, canna-
bis abuse, IQ, group of subjects and parental rearing styles (Table 5).
4. Discussion
Our gures of childhood abuse in HC are similar to these described
in previous studies from Spain (Sanmartin, 2011). In the case of
psychotic patients, we have found a rate of abuse lower than other
authors, especially with regard to sexual abuse (8%) (Morgan and
Fisher, 2007). More congruent with other studies (Zanarini, 2000) was
the rate of abuse reported by BPD patients, almost 40% of this group
reported sexual abuse and the percentage of emotional and physical
abuse was about 30%.
We also found a relationship between the existence of trauma in
childhood and an aectionless control parenting style in mothers and
in fathers. Moreover, subjects with a history of trauma showed the
lowest rate of optimal parenting style. This was true for any kind of
trauma and for both parents. Subjects with a history of emotional
trauma reported a less aectionate constraint rearing style (high
overprotection and high care), which can be congruent with the fact
that these kinds of parents may show an excessive preoccupation for
their children, which in fact can become protection against them
suering from emotional distress. In general terms, the aectionless
control parenting style was more prevalent in patients than in HC. This
style has been associated with harm avoidance personality traits in HC
(Otani et al., 2009) and with the development of anxiety. Other studies
have found signicant connections between lower parental care and
psychiatric disorders (Gerra et al., 2004; Heider et al., 2006; Torresani
et al., 2000).
We know that in some studies, inadequate parenting styles assessed
during childhood also increase the risk of subclinical psychotic
experiences (SPE) twenty years later (Galletly et al., 2011). This is
congruent with our results. In fact, a maternal aectionless control
parenting style was related to positive psychotic symptoms while an
optimal parenting style was inversely related to positive psychotic
symptoms in all groups. That is, subjects with maternal optimal rearing
style had a lower probability of suering positive psychotic symptoms
in adulthood. This did not happen in relation to paternal rearing styles.
One possible explanation is that in Spain during 70's, 80's and 90's
mainly mothers were in charge of parenting care in Spain, due to
socioeconomic and cultural causes. So their inuence over children
would be more decisive.
Furthermore, we demonstrated a link between existence of trauma
and positive psychotic symptoms in our sample. This relation main-
tained statistical signicance despite other possible confounding
factors, such as group, age, IQ, socio-economic level, sex and cannabis
abuse. This relation was found with all categories of trauma (emotional,
physical and sexual).
We could hypothesize that the fact that the trauma is related to the
positive psychotic symptomatology does not necessarily imply that FEP

Table 3
Maternal parental care and CAPE positive.

Variables Model with MPBIAC Model with MPBIAC1 Model with MPBIOP Model with MPBINP

p p p p

Sex male 0.17 0.7941 0.13 0.8377 0.16 0.8061 0.18 0.7776
THCa 0.84 0.2702 0.56 0.4572 0.57 0.4583 0.86 0.2614

Group
HC Ref. Ref. Ref. Ref.
FEP 5.56 < 0.0001 5.33 < 0.0001 5.49 < 0.0001 5.54 < 0.0001
BPD 6.81 < 0.0001 6.54 < 0.0001 6.58 < 0.0001 6.79 < 0.0001
IQ 0.03 0.2399 0.02 0.2621 0.02 0.3538 0.03 0.2293
Age 0.01 0.6749 0.02 0.4197 0.01 0.6171 0.01 0.6549
High socio-economic level 2 0.0170 2.09 0.0112 2.02 0.0146 2.04 0.0148
MPBIACb 0.10 0.8912
MPBIAC1c 1.85 0.0041
MPBIOPd 1.89 0.0093
MPBINPe 0.67 0.4349

Ref.: reference group.

a
THC: abuse of cannabis.
b
MPBIAC: maternal aection constraint.
c
MPBIAC1: maternal aectionless control.
d
MPBIOP: maternal optimal.
e
MPBINP: maternal neglect.

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A. Catalan et al. Psychiatry Research 251 (2017) 7884

Table 4
Paternal parental care and CAPE positive.

Variables Model with FPBIAC Model with FPBIAC1 Model with FPBIOP Model with FPBINP

p p p p

Sex male 0.34 0.5932 0.24 0.7050 0.28 0.6622 0.28 0.6652
THCa 0.93 0.2172 0.93 0.2211 0.80 0.2965 1.03 0.1786

Group
HC Ref. Ref. Ref. Ref.
FEP 5.53 < 0.0001 5.53 < 0.0001 5.60 < 0.0001 5.48 < 0.0001
BPD 6.28 < 0.0001 6.11 < 0.0001 6.11 < 0.0001 6.21 < 0.0001
IQ 0.02 0.2774 0.02 0.2478 0.02 0.2863 0.03 0.2387
Age 0.01 0.8536 0.003 0.9260 0.0003 0.9925 0.0003 0.9914
High socio-economic level 1.89 0.0219 1.98 0.0167 1.95 0.0182 1.95 0.0182
FPBIACb 1.11 0.1622
FPBIAC1c 0.59 0.3604
FPBIOPd 0.92 0.1814
FPBINPe 0.68 0.3593

Ref.: reference group.

a
THC: abuse of cannabis.
b
FPBIAC: paternal aection constraint.
c
FPBIAC1: paternal aectionless control.
d
FPBIOP: paternal optimal.
e
FPBINP: paternal neglect.

Table 5
Trauma in childhood and CAPE positive.

Variables Model with ctq1 Model with ctq2 Model with ctq3

P p p

Sex Male 0.32 0.6142 0.32 0.6134 0.39 0.5409

THCa 0.22 0.7745 0.29 0.6992 0.30 0.6883

Group
HC Ref. Ref. Ref.
FEP 5.13 < 0.0001 5.07 < 0.0001 4.92 < 0.0001
BPD 5.81 < 0.0001 5.55 < 0.0001 5.28 < 0.0001
IQ 0.02 0.2952 0.02 0.3793 0.02 0.2792
Age 0.02 0.4424 0.03 0.2791 0.03 0.3277
High socio-economic level 2.13 0.0091 2.10 0.0098 2.06 0.0111
MPBIAC1b 1.21 0.0837 1.36 0.0481 1.33 0.0536
MPBIOPc 1.17 0.1325 1.09 0.1593 1.04 0.1810
ctq1 1.94 0.0425
ctq2 2.21 0.0130
ctq3 2.32 0.0053

Ref.: reference group.

a
THC: cannabis abuse.
b
MPBIAC1: maternal aectionless control.
c
MPBIOP: maternal optimal.

patients should have more traumatic antecedents. It is clear that other
factors contribute to the aetiology of the psychosis, such as genetic
vulnerability. Positive psychotic symptoms are only a part of the
dimension of the psychotic illness, perhaps not even the most
important (negative symptoms, cognitive symptoms). However,
suering from a traumatic event in childhood may be more signicant
on the aetiology of BPD diagnosis (Bandelow et al., 2005; Belford et al.,
2012). Nevertheless, in our study, we found a clear relation between
trauma and positive psychotic symptomatology.
In fact, in literature any kind of trauma during childhood is
associated with an earlier diagnosis of mental illness, a higher number
of suicide attempts and negative outcomes, such as, drug abuse and
more severe positive psychotic symptoms (Alvarez et al., 2011; Conus
et al., 2010; Kilcommons and Morrison, 2005; Ross et al., 1994). The
relation between positive psychotic symptomatology and trauma has
been described not only in clinical samples but also in non-clinical
samples. Psychosis and its aetiological correlate therefore, may not be
conned to diagnostic extremes but emerge instead throughout the
general population. Median prevalence of SPE in the general popula-
tion is about 5% (van Os et al., 2009). Recent studies have shown that
exposure to physical or psychological trauma, including bullying and
sexual abuse, increases the risk of later SPE (Bak et al., 2005; Lataster
et al., 2006). In our sample, controls also showed this relationship was
signicant.
Some ndings (Varese et al., 2012) suggest that if trauma in
childhood was entirely removed from the population (with the assump-
tion that the pattern of the other risk factors remained unchanged), and
assuming causality, the number of people with psychosis would be
reduced by 33%. The association between childhood adversity and
psychosis accounted for the occurrence of psychotic symptoms in the
general population, as well as for the development of psychotic
disorder in prospective studies; the association remained signicant
when studies were included that corrected for possible demographic
and clinical confounders which is congruent with our study.
As in our study, literature demonstrates that all types of adversity
are related to an increased risk of psychosis, indicating that exposure to

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adverse experiences in general increases psychosis risk, regardless of
the exact nature of the exposure. Besides, one meta-analysis found no
evidence that any specic type of trauma is a stronger predictor of
psychosis than any other (Schreier et al., 2009).
Several theories have been suggested to explain the relation
between trauma and psychosis. First, it is possible that early abuse
may block eective social engagement and lead to an isolation that may
itself favour the development of psychotic symptoms (White et al.,
2000). These cognitive explanations state that traumatic experiences
enhance negative or maladaptive schematic models of the self, of others
and the world. Another possibility is the traumagenic neurodevelop-
mental model (TNM), which combines social, psychological and
biological factors (Read et al., 2001). This model suggests that
prolonged exposure to stressors leads to a chronic heightened gluco-
corticoid release. This could cause permanent changes in the hypotha-
lamicpituitaryadrenal axis, which in turn may induce increased
striatal dopamine turnover, rendering a person more vulnerable for
positive psychotic symptoms. A third possibility is that oered by
(Garety et al., 2001), who dene a central role for cognitive distur-
bances, leading to external appraisal errors. They hypothesized that
childhood trauma aects the appraisal of internal experiences as
coming from an external agent. Other cognitive models such as the
Threat Anticipation Model (Freeman et al., 2002) have proposed that
paranoid (persecutory) delusions may be interpreted as threat beliefs
which surface as a response to interpersonal trauma (Kilcommons and
Morrison, 2005). Attachment theory provides another valuable lens on
the relationship, (e.g. insecure attachment may be associated with
poorer interpersonal relationships and less integrative recovery styles
which predispose individuals to anomalous experiences and percep-
tions) (Read and Gumley, 2008). One recent article points out the
relation between stressors and alterations on presynaptic synthesis and
release of dopamine, as the major locus of dopaminergic dysfunction in
psychosis (Howes et al., 2016). As the aforementioned theories all
describe how psychotic symptoms can arise, it remains unclear whether
these are also applicable in non-psychotic individuals who experience
subclinical psychotic symptoms. Surely, the mediation of the link
between childhood abuse and psychosis is likely to be multifarious
and complex.
There have been specic concerns about the reliability of reports of
abuse in people aected by psychosis. However, in recent studies, such
disclosures have been shown to be reliable and the credibility of the
methodology has been established (Fergusson et al., 2000; Fisher et al.,
2011; Goldman and Padayachi, 2000; Goodman et al., 1999; Patton
et al., 2001). There is also evidence that the retrospective assessment of
childhood trauma tends to underestimate rather than over-report real
incidence rates (Hardt and Rutter, 2004).
On the other hand, our sample is quite heterogeneous. Nonetheless,
transdiagnostically we have demonstrated a relation between trauma
and positive psychotic symptoms and this can be important when
taking the importance of for assessing traumatic experiences in child-
hood into account in all kind of subjects who seek psychiatric help.
Moreover, the CAPE scale is used mainly in the population
vulnerable to psychosis in order to assess subclinical psychotic
symptoms in non-clinical samples. In any case, this scale has proved
itself reliable not only to report psychotic symptoms at subclinical
levels, but also in clinical samples (Fonseca-Pedrero et al., 2012; Moritz
et al., 2013). In any case, it is true that there is substantial stability in
the internal structure of the CAPE positive scale, with the exception of
the factors relating to magical thinking or grandiosity. A more valid
version of this scale has recently been developed (Capra et al., 2013).
4.1. Conclusions
It is possible that in vulnerable individuals, trauma may exacerbate
changes in brain structure and function leading to an increased risk of
psychosis with terrible consequences. Trauma in childhood and
83
Psychiatry Research 251 (2017) 7884
inadequate parenting styles seem to be related to positive psychotic
symptoms. If we bear in mind that trauma and parenting style are
modiable factors, we as clinicians should identify subjects at risk in
order to prevent future psychopathology.
This research did not receive any specic grant from funding
agencies in the public, commercial, or not-for-prot sectors.
Conicts of interest
None.
Acknowledgements
We would like to thank to our patients for their patience and
collaboration and to the sta of the Psychiatry Service at Basurto
University Hospital for their collaboration on this project.
References
Alvarez, M.J., Roura, P., Oses, A., Foguet, Q., Sola, J., Arrufat, F.X., 2011. Prevalence and
clinical impact of childhood trauma in patients with severe mental disorders. J. Nerv.
Ment. Dis. 199 (3), 156161. http://dx.doi.org/10.1097/NMD.0b013e31820c751c.
Bak, M., Krabbendam, L., Janssen, I., de Graaf, R., Vollebergh, W., van Os, J., 2005.
Early trauma may increase the risk for psychotic experiences by impacting on
emotional response and perception of control. Acta Psychiatr. Scand. 112 (5),
360366. http://dx.doi.org/10.1111/j.1600-0447.2005.00646.x.
Balls Creus, C., 1991. Adaptacin del Parental Bonding Instrument.
Bandelow, B., Krause, J., Wedekind, D., Broocks, A., Hajak, G., Ruther, E., 2005. Early
traumatic life events, parental attitudes, family history, and birth risk factors in
patients with borderline personality disorder and healthy controls. Psychiatry Res.
134 (2), 169179. http://dx.doi.org/10.1016/j.psychres.2003.07.008.
Battle, C.L., Shea, M.T., Johnson, D.M., Yen, S., Zlotnick, C., Zanarini, M.C., Sanislow,
C.A., Skodol, A.E., Gunderson, J.G., Grilo, C.M., McGlashan, T.H., Morey, L.C., 2004.
Childhood maltreatment associated with adult personality disorders: ndings from
the collaborative longitudinal personality disorders study. J. Pers. Disord. 18 (2),
193211.
Bebbington, P., 2009. Childhood sexual abuse and psychosis: aetiology and mechanism.
Epidemiol. Psichiatr. Soc. 18, 284293.
Bebbington, P., Bhugra, D., Bhugra, T., Singleton, N., Farrell, M., Jenkins, R., Meltzer,
H., 2004. Psychosis, victimisation and childhood disadvantage: evidence from the
second British National Survey of Psychiatric Morbidity. Br. J. Psychiatry 185,
220226.
Bebbington, P., Jonas, S., Kuipers, E., King, M., Cooper, C., Brugha, T., Meltzer, H.,
McManus, S., Jenkins, R., 2011. Childhood sexual abuse and psychosis: data from a
cross-sectional national psychiatric survey in England. Br. J. Psychiatry 199, 1937.
http://dx.doi.org/10.1192/bjp.bp.110.083642.
Belford, B., Kaehler, L.A., Birrell, P., 2012. Relational health as a mediator between
betrayal trauma and borderline personality disorder. J. Trauma Dissociation 13 (2),
244257. http://dx.doi.org/10.1080/15299732.2012.642750.
Bendall, S., Jackson, H.J., Hulbert, C.A., McGorry, P.D., 2008. Childhood trauma and
psychotic disorders: a systematic, critical review of the evidence. Schizophr. Bull. 34
(3), 568579. http://dx.doi.org/10.1093/schbul/sbm121.
Bernstein, D.P., Stein, J.A., Handelsman, L., 1998. Predicting personality pathology
among adult patients with substance use disorders: eects of childhood
maltreatment. Addict. Behav. 23 (6), 855868.
Bernstein, D.P., Stein, J.A., Newcomb, M.D., Walker, E., Pogge, D., Ahluvalia, T., Stokes,
J., Handelsman, L., Medrano, M., Desmond, D., Zule, W., 2003. Development and
validation of a brief screening version of the childhood trauma questionnaire. Child
Abus. Negl. 27 (2), 169190.
Bornovalova, M.A., Huibregtse, B.M., Hicks, B.M., Keyes, M., McGue, M., Iacono, W.,
2013. Tests of a direct eect of childhood abuse on adult borderline personality
disorder traits: a longitudinal discordant twin design. J. Abnorm. Psychol. 122 (1),
180194. http://dx.doi.org/10.1037/a0028328.
Capra, C., Kavanagh, D.J., Hides, L., Scott, J., 2013. Brief screening for psychosis-like
experiences. Schizophr. Res. 149, 104107. http://dx.doi.org/10.1016/
j.schres.2013.05.020.
Catalan, A., Simons, C.J., Bustamante, S., Olazabal, N., Ruiz, E., Gonzalez de Artaza, M.,
Penas, A., Maurottolo, C., Gonzlez, A., van Os, J., Gonzalez-Torres, M.A., 2015.
Data gathering bias: trait vulnerability to psychotic symptoms? PLoS One 10 (7),
113. http://dx.doi.org/10.1371/journal.pone.0132442.
Conus, P., Cotton, S., Schimmelmann, B.G., Berk, M., Daglas, R., McGorry, P.D.,
Lambert, M., 2010. Pretreatment and outcome correlates of past sexual and physical
trauma in 118 bipolar I disorder patients with a rst episode of psychotic mania.
Bipolar Disord. 12 (3), 244252. http://dx.doi.org/10.1111/j.1399-
5618.2010.00813.x.
Craddock, M., Asherson, P., Owen, M.J., Williams, J., McGun, P., Farmer, A.E., 1996.
Concurrent validity of the OPCRIT diagnostic system. Comparison of OPCRIT
diagnoses with consensus best-estimate life- time diagnoses. Br. J. Psychiatry 169,
5863.
Daalman, K., Diederen, K.M., Derks, E.M., van Lutterveld, R., Kahn, R.S., Sommer, I.E.,
2012. Childhood trauma and auditory verbal hallucinations. Psychol. Med. 42 (12),
24752484. http://dx.doi.org/10.1017/S0033291712000761.
Dinwiddie, S., Heath, A.C., Dunne, M.P., Bucholz, K.K., Madden, P.A., Slutske, W.S.,
A. Catalan et al.
Bierut, L.J., Statham, D.B., Martin, N.G., 2000. Early sexual abuse and lifetime
psychopathology: a co-twin-control study. Psychol. Med. 30 (1), 4152.
Fergusson, D.M., Horwood, L.J., Woodward, L.J., 2000. The stability of child abuse
reports: a longitudinal study of the reporting behaviour of young adults. Psychol.
Med. 30, 529544.
Fisher, H.L., Craig, T.K., Fearon, P., Morgan, K., Dazzan, P., Lappin, J., Hutchinson, G.,
Doody, G.A., Jones, P.B., McGun, P., Murray, R.M., Le, J., Morgan, C., 2011.
Reliability and comparability of psychosis patients' retrospective reports of
childhood abuse. Schizophr. Bull. 37 (3), 546553. http://dx.doi.org/10.1093/
schbul/sbp103.
Fonseca-Pedrero, E., Pano, M., Lemos-Girldez, S., Muiz, J., 2012. Validation of the
community assesment psychic experiences-42 (CAPE-42) in Spanish college
students and patients with psychosis. Actas Esp. Psiquiatr. 40 (4), 169176.
Freeman, D., Garety, P.A., Kuipers, E., Fowler, D., Bebbington, P., 2002. A cognitive
model of persecutory delusions. Br. J. Clin. Psychol. 41, 331347.
Friedman, S., Smith, L., Fogel, D., Paradis, C., Viswanathan, R., Ackerman, R., Trappler,
B., 2002. The incidence and inuence of early traumatic life events in patients with
panic disorder: a comparison with other psychiatric outpatients. J. Anxiety Disord.
16 (3), 259272.
Galletly, C., Van Hoo, M., McFarlane, A., 2011. Psychotic symptoms in young adults
exposed to childhood trauma a 20 year follow-up study. Schizophr. Res. 127 (13),
7682. http://dx.doi.org/10.1016/j.schres.2010.12.010.
Garety, P.A., Kuipers, E., Fowler, D., Freeman, D., Bebbington, P.E., 2001. A cognitive
model of the positive symptoms of psychosis. Psychol. Med. 31 (2), 189195.
Gerra, G., Angioni, L., Zaimovic, A., Moi, G., Bussandri, M., Bertacca, S., Santoro, G.,
Gardini, S., Caccavari, R., Nicoli, M.A., 2004. Substance use among high-school
students: relationships with temperament, personality traits, and parental care
perception. Subst. Use Misuse 39 (2), 345367.
Goldman, J.D.G., Padayachi, U.K., 2000. Some methodological problems in estimating
incidence and prevalence in child sexual abuse research. J. Sex Res. 37, 305314.
Gomez-Beneyto, M., Pedros, A., Tomas, A., Aguilar, K., Leal, C., 1993. Psychometric
properties of the parental bonding instrument in a Spanish sample. Soc. Psychiatry
Psychiatr. Epidemiol. 28 (5), 252255.
Goodman, L.A., Thompson, K.M., Weinfurt, K., Corl, S., Acker, P., Mueser, K.T.,
Rosenberg, S.D., 1999. Reliability of reports of violent victimization and
posttraumatic stress disorder among men and women with serious mental illness. J.
Trauma Stress 12 (4), 587599. http://dx.doi.org/10.1023/A:1024708916143.
Hardt, J., Rutter, M., 2004. Validity of adult retrospective reports of adverse childhood
experiences: review of the evidence. J. Child Psychol. Psychiatry 45 (2), 260273.
Heider, D., Matschinger, H., Bernert, S., Alonso, J., Angermeyer, M.C., 2006.
Relationship between parental bonding and mood disorder in six European
countries. Psychiatry Res. 143 (1), 8998. http://dx.doi.org/10.1016/
j.psychres.2005.08.015.
Hernndez, A., Gallardo-Pujol, D., Pereda, N., Arntz, A., Bernstein, D.P., Gaviria, A.M.,
Labad, A., Valero, J., Gutirrez-Zotes, J.A., 2013. Initial validation of the Spanish
childhood Trauma Questionnaire-Short Form: factor structure, reliability and
association with parenting. J. Interpers. Violence 28 (7), 14981518. http://
dx.doi.org/10.1177/0886260512468240.
Howes, O.D., McCutcheon, R., Owen, M.J., Murray, R.M., 2016. The role of genes, stress
and dopamine in the development of schizophrenia. Dopamine and the prodrome.
Biol. Psychiatry. http://dx.doi.org/10.1016/j.biopsych.2016.07.014.
Janssen, I., Krabbendam, L., Bak, M., Hanssen, M., Vollebergh, W., de Graaf, R., van Os,
J., 2004. Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatr.
Scand. 109 (1), 3845.
Janssen, I., Krabbendam, L., Hanssen, M., Bak, M., Vollebergh, W., de Graaf, R., van Os,
J., 2005. Are apparent associations between parental representations and psychosis
risk mediated by early trauma? Acta Psychiatr. Scand. 112 (5), 372375. http://
dx.doi.org/10.1111/j.1600-0447.2005.00553.x.
Kilcommons, A.M., Morrison, A.P., 2005. Relationships between trauma and psychosis:
an exploration of cognitive and dissociative factors. Acta Psychiatr. Scand. 112 (5),
351359. http://dx.doi.org/10.1111/j.1600-0447.2005.00623.x.
Kingdon, D.G., Ashcroft, K., Bhandari, B., Gleeson, S., Warikoo, N., Symons, M., Taylor,
L., Lucas, E., Mahendra, R., Ghosh, S., Mason, A., Badrakalimuthu, R., Hepworth, C.,
Read, J., Mehta, R., 2010. Schizophrenia and borderline personality disorder:
similarities and dierences in the experience of auditory hallucinations, paranoia,
and childhood trauma. J. Nerv. Ment. Dis. 198 (6), 399403. http://dx.doi.org/
10.1097/NMD.0b013e3181e08c27.
Lataster, T., van Os, J., Drukker, M., Henquet, C., Feron, F., Gunther, N., Myin-Germeys,
I., 2006. Childhood victimisation and developmental expression of non-clinical
delusional ideation and hallucinatory experiences: victimisation and non-clinical
psychotic experiences. Soc. Psychiatry Psychiatr. Epidemiol. 41 (6), 423428. http://
dx.doi.org/10.1007/s00127-006-0060-4.
Lobbestael, J., Arntz, A., Bernstein, D.P., 2010. Disentangling the relationship between
dierent types of childhood maltreatment and personality disorders. J. Pers. Disord.
24 (3), 285295. http://dx.doi.org/10.1521/pedi.2010.24.3.285.
May-Chahal, C., Cawson, P., 2005. Measuring child maltreatment in the United
Kingdom: a study of the prevalence of child abuse and neglect. Child Abus. Negl. 29
(9), 969984. http://dx.doi.org/10.1016/j.chiabu.2004.05.009.
Morgan, C., Fisher, H., 2007. Environment and schizophrenia: environmental factors in
schizophrenia: childhood trauma a critical review. Schizophr. Bull. 33 (1), 310.
http://dx.doi.org/10.1093/schbul/sbl053.
Moritz, S., Van Quaquebeke, N., Lincoln, T.M., Kther, U., Andreou, C., 2013. Can we
trust the internet to measure psychotic symptoms? Schizophr. Res. Treat., 15.
http://dx.doi.org/10.1155/2013/457010.
Otani, K., Suzuki, A., Oshino, S., Ishii, G., Matsumoto, Y., 2009. Eects of the
"aectionless control" parenting style on personality traits in healthy subjects.
84
Psychiatry Research 251 (2017) 7884
Psychiatry Res. 165 (12), 181186. http://dx.doi.org/10.1016/
j.psychres.2007.10.018.
Parker, G., Tupling, H., Brown, L.B., 1979. A parental bonding instrument. Br. J. Med.
Psychol. 52, 110.
Parker, G., Fairley, M., Greenwood, J., Jurd, S., Silove, D., 1982. Parental representations
of schizophrenics and their association with onset and course of schizophrenia. Br. J.
Psychiatry 141, 573581.
Patton, G.C., Coey, C., Posterino, M., Carlin, J.B., Wolfe, R., 2001. Parental
'aectionless control' in adolescent depressive disorder. Soc. Psychiatry Psychiatr.
Epidemiol. 36 (10), 475480.
Pereda, N., Guilera, G., Forns, M., Gomez-Benito, J., 2009. The prevalence of child sexual
abuse in community and student samples: a meta-analysis. Clin. Psychol. Rev. 29
(4), 328338. http://dx.doi.org/10.1016/j.cpr.2009.02.007.
Read, J., Gumley, A., 2008. Can attachment theory help explain the relationship between
childhood adversity and psychosis? Attachment 2, 135.
Read, J., Perry, B.D., Moskowitz, A., Connolly, J., 2001. The contribution of early
traumatic events to schizophrenia in some patients: a traumagenic
neurodevelopmental model. Psychiatry 64, 319345.
Read, J., van Os, J., Morrison, A.P., Ross, C.A., 2005. Childhood trauma, psychosis and
schizophrenia: a literature review with theoretical and clinical implications. Acta
Psychiatr. Scand. 112 (5), 330350. http://dx.doi.org/10.1111/j.1600-
0447.2005.00634.x.
Read, J., Fink, P., Rudegeair, T., Felitti, V., Whiteld, C., 2008. Child maltreatment and
psychosis: a return to a genuinely integrated bio-psycho-social model. Clin.
Schizophr. Relat. Psychoses 2, 235254.
Ros-Morente, A., Vilagr-Ruiz, R., Rodriguez-Hanse, G., Wigman, J.H., Barrantes-Vidal,
N., 2011. Process of adaptation to Spanish of the community assesment of psychic
experiences (CAPE). Actas Esp. Psiquiatr 39 (2), 95105.
Ross, C.A., Anderson, G., Clark, P., 1994. Childhood abuse and the positive symptoms of
schizophrenia. Hosp. Community Psychiatry 45 (5), 489491.
Sanmartin, J., 2011. Maltrato infantil en la familia de Espaa. Ministerio de Sanidad,
Poltica Social e Igualdad, Madrid.
SAS Institute, I., 2010. SAS Procedures Guide, Version 9. author, Cary, NC.
Schreier, A., Wolke, D., Thomas, K., Horwood, J., Hollis, C., Gunnell, D., Lewis, G.,
Thompson, A., Zammit, S., Duy, L., Salvi, G., Harrison, G., 2009. Prospective study
of peer victimization in childhood and psychotic symptoms in a nonclinical
population at age 12 years. Arch. Gen. Psychiatry 66 (5), 527536. http://
dx.doi.org/10.1001/archgenpsychiatry.2009.23.
Spataro, J., Mullen, P., Burgess, P.M., Wells, D., Moss, A., 2004. Impact of child sexual
abuse on mental health: prospective study in males and females. Br. J. Psychiatry
184, 416421.
Spauwen, J., Krabbendam, L., Lieb, R., Wittchen, H.U., van Os, J., 2006. Impact of
psychological trauma on the development of psychotic symptoms: relationship with
psychosis proneness. Br. J. Psychiatry 188, 527533. http://dx.doi.org/10.1192/
bjp.bp.105.011346.
StataCorp, 2011. StataCorp (2011) Stata Statistical Software: Release12. version release
12.
Stefanis, N.C., Hanssen, M., Smirnis, N.K., Avramopoulos, D.A., Evdokimidis, I.K.,
Stefanis, C.N., Verdoux, H., van Os, J., 2002. Evidence that three dimensions of
psychosis have a distribution in the general population. Psychol. Med. 32, 347358.
Torresani, S., Favaretto, E., Zimmermann, C., 2000. Parental representations in drug-
dependent patients and their parents. Compr. Psychiatry 41 (2), 123129.
Ucok, A., Bikmaz, S., 2007. The eects of childhood trauma in patients with rst-episode
schizophrenia. Acta Psychiatr. Scand. 116 (5), 371377. http://dx.doi.org/10.1111/
j.1600-0447.2007.01079.x.
van Os, J., Linscott, R.J., Myin-Germeys, I., Delespaul, P., Krabbendam, L., 2009. A
systematic review and meta-analysis of the psychosis continuum: evidence for a
psychosis proneness-persistence-impairment model of psychotic disorder. Psychol.
Med. 39 (2), 179195. http://dx.doi.org/10.1017/S0033291708003814.
Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., Read, J.,
van Os, J., Bentall, R.P., 2012. Childhood adversities increase the risk of psychosis: a
meta-analysis of patient-control, prospective- and cross-sectional cohort studies.
Schizophr. Bull. 38 (4), 661671. http://dx.doi.org/10.1093/schbul/sbs050.
Wahlberg, K.E., Wynne, L.C., Oja, H., Keskitalo, P., Pykalainen, L., Lahti, I., Moring, J.,
Naarala, M., Sorri, A., Seitamaa, M., Laksy, K., Kolassa, J., Tienari, P., 1997. Gene-
environment interaction in vulnerability to schizophrenia: ndings from the nnish
adoptive family study of Schizophrenia. Am. J. Psychiatry 154 (3), 355362. http://
dx.doi.org/10.1176/ajp.154.3.355.
White, R., Bebbington, P., Pearson, J., Johnson, S., Ellis, D., 2000. The social context of
insight in schizophrenia. Soc. Psychiatry Psychiatr. Epidemiol. 35 (11), 500507.
Widom, C.S., Czaja, S.J., Paris, J., 2009. A prospective investigation of borderline
personality disorder in abused and neglected children followed up into adulthood. J.
Pers. Disord. 23 (5), 433446. http://dx.doi.org/10.1521/pedi.2009.23.5.433.
Williams, J., Farmer, A., Ackenheil, M., Kaufmann, C., McGun, P., 1996. A multicentre
inter-rater reliability study using OPCRIT computerized diagnostic system. Psychol.
Med. 26, 775783.
Willinger, U., Heiden, A.M., Meszaros, K., Formann, A.K., Aschauer, H.N., 2002.
Maternal bonding behaviour in schizophrenia and schizoaective disorder,
considering premorbid personality traits. Aust. N. Z. J. Psychiatry 36 (5), 663668.
Zanarini, M.C., 2000. Childhood experiences associated with the development of
borderline personality disorder. Psychiatr. Clin. North Am. 23 (1), 89101.
Zanarini, M.C., Frankenburg, F.R., Hennen, J., Reich, D.B., Silk, K.R., 2004. Axis I
comorbidity in patients with borderline personality disorder: 6-year follow-up and
prediction of time to remission. Am. J. Psychiatry 161 (11), 21082114. http://
dx.doi.org/10.1176/appi.ajp.161.11.2108.