Childhood Maltreatment Associated With Increased Risk of Psychosis in Ultra-High Risk Individuals

Young girl with curly hair sits on grass and cries into her arms.
Young girl with curly hair sits on grass and cries into her arms.
Child maltreatment is significantly more prevalent in young individuals who present with UHR symptoms compared with controls.

Researchers have found that in individuals at ultra-high risk (UHR) for psychosis, childhood abuse and neglect are pluripotent risk factors for developing psychosis, depressive disorder, post-traumatic stress disorder (PTSD), panic disorder, and social phobia in adulthood. The findings were published in Schizophrenia Bulletin.1

Mark van der Gaag, PhD, from the department of psychosis research at Parnassia Psychiatric Institute in The Hague, The Netherlands and colleagues assessed 259 UHR individuals from the EU-GEI study (EUropean network of national schizophrenia networks studying Gene-Environment Interactions), a naturalistic, prospective, multicenter study aiming to identify the interactive genetic, clinical, and environmental determinants of schizophrenia.

“In the last 2 decades, research has increasingly focused on early detection of psychosis,” the researchers wrote. “As 70% of individuals meeting UHR criteria will not go on to develop a psychotic episode, it is important to search for additional factors that may contribute to psychosis risk.”

Maltreatment in childhood was assessed at baseline with the Child Trauma Questionnaire (CTQ), and clinical outcome was assessed at 6, 12, and 24 months with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). Subclinical psychotic symptoms in the year before the study were assessed with the Comprehensive Assessment of At-Risk Mental States (CAARMS), and cannabis use or abuse was assessed with a modified version of the Cannabis Experience Questionnaire.

The researchers found that despite previous research showing the strongest associations between sexual abuse and psychosis, findings from this study showed that a history of emotional abuse was associated with an increased risk for transition to psychosis (odds ratio [OR] 3.78; 95% CI, 1.17 to 12.39; P =.027). However, this effect was only present when controlling for the effects of other types of maltreatment.

“Interestingly, emotional neglect significantly protected against transition to psychosis,” they wrote. “It might be that childhood without emotional comfort or protection teaches the child that he can stand being neglected and survive on [his] own. However, it should also be noted that different types of child maltreatment are likely to co-occur, and further research is needed to explore the effects of child maltreatment.”

A history of physical abuse was associated with depressive disorder (OR 4.92; 95% CI, 2.12 to 11.39; P =.001), post-traumatic stress disorder (OR 2.06; 95% CI, 1.10 to 3.86; P =.023), panic disorder (OR 2.00; 95% CI, 1.00 to 3.99; P =.048) and social phobia (OR 2.47; 95% CI, 1.18 to 5.16; P =.016).

“Our findings could be explained by the fact that adverse events during [childhood], a period of significant brain maturation, probably impacted neurodevelopment,” the researchers wrote. “Exposure to adverse events may result in an overactive stress regulation system and permanent changes in the hypothalamicpituitary-adrenal (HPA) axis. An overactive HPA-axis causes increased cortisol levels in the brain, leading to increased distress in reaction to environmental stressors.”

They also noted that psychological processes may also explain the association between child maltreatment and psychopathology. Child maltreatment may lead to the formation of negative self-schemas, which could lead to depressive symptoms. Negative self-schemas may also trigger suspiciousness and hypervigilance, which could lead to psychosis.2,3

Summary & Clinical Applicability

“In congruence with earlier reports, our findings clearly indicate that child maltreatment is significantly more prevalent in young individuals who present with UHR symptoms compared [with] controls,” the researchers wrote. “However, significant associations were only found for emotional abuse and it might be that child maltreatment is a risk factor for UHR status but that its additional effect on transition to psychosis in the UHR stage is limited.”

These findings emphasize the importance of reducing the harmful effects of emotional and physical childhood abuse.

“Because in particular the combination of child maltreatment and the presence of attenuated psychotic symptoms seems a precursor for severe and complex psychopathology, it is warranted to screen for UHR status and childhood abuse in mental healthcare settings,” they concluded.


  • There is the possibility of recall bias with the child trauma questionnaire (CTQ)
  • The CTQ does not examine details of the trauma
  • Depressive symptoms may have contributed to an overrepresentation of child maltreatment
  • The transition rate to psychosis may have been underrepresented since the 24-month assessment was incomplete when data was being analyzed
  • The study did not control for risk factors for psychosis such as ethnicity or socioeconomic status
  • Other forms of childhood maltreatment such as bullying or witnessing domestic violence were not analyzed
  • Recent life events, which have been shown to affect transition to psychosis, were not analyzed4
  • The control group was small compared with the UHR group; therefore results should be interpreted with caution
  • Current cannabis use was assessed, but type or quality of cannabis was not analyzed; frequent cannabis use has been associated with risk of psychosis5

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1. Kraan TC, Velthorst E, Themmen M, et al. Child maltreatment and clinical outcome in individuals at ultra-high risk for psychosis in the EU-GEI high risk study [published online June 28, 2017]. Schizophr Bull. doi:10.1093/schbul/sbw162

2. Garety PA, Kuipers E, Fowler D, Freeman D, Bebbington PE. A cognitive model of the positive symptoms of psychosis. Psychol Med. 2001;31:189-195.

3. Kilcommons AM, Morrison AP. Relationships between trauma and psychosis: an exploration of cognitive and dissociative factors. Acta Psychiatr Scand. 2005;112:351-359.

4. Beards S, Gayer-Anderson C, Borges S, Dewey ME, Fisher HL, Morgan C. Life events and psychosis: a review and metaanalysis. Schizophr Bull. 2013;39:740-747.

5. Di Forti M, Marconi A, Carra E, et al. Proportion of patients in south London with first-episode psychosis attributable to use of high potency cannabis: a case-control study. Lancet Psychiatry. 2015;2:233-238.