Relationship between childhood trauma and level of insight in schizophrenia: A path-analysis in the national FACE-SZ dataset

Abstract

Introduction

This study aimed was to investigate the relationship between different types of childhood trauma and the level of insight (i.e., awareness of having a psychiatric disorder) in subjects suffering from schizophrenia, as well as the putative role of clinical mediators.

Methods

294 community-dwelling subjects with stable schizophrenia were included into FACE-SZ, a multicentre cross-sectional study. All patients were assessed by specialized multidisciplinary teams. The level of insight was assessed by the Scale to assess Unawareness of Mental Disorder (SUMD), and childhood trauma by the Childhood Trauma Questionnaire (CTQ).

Path analyses from the five CTQ subscales (physical abuse and neglect, emotional abuse and neglect, and sexual abuse) and the SUMD, with current symptomatology (i.e., positive, negative, global psychopathology and depression) as mediator, was performed.

Results

Physical neglect (β = 0.14) and abuse (β = 0.13) were significantly associated with poor insight. Negative symptoms were a clinical mediator of the relationship between physical neglect and poor insight. Moreover, positive (β = 0.21) and negative (β = 0.30) symptoms were associated with poor insight, whereas depression (β = −0.14) was associated with higher levels of insight.

Discussion

For the first time, this study shows a significant relationship between childhood trauma, specifically physical neglect and abuse, and poor insight. The level of insight was linked to different clinical dimensions. Among subjects with schizophrenia, these results provide support for a role of childhood trauma in poorer management outcomes, and the need to provide treatment, including psycho-education that better targets the consequences of childhood trauma.

Introduction

Poor insight is defined as the presence of an impaired awareness of having a psychiatric disorder, as well as of its symptoms and implications. Poor insight has been reported in 50 to 80% of patients with schizophrenia (Lincoln et al., 2007). A low level of insight is associated with negative attitudes towards taking antipsychotic medication, and to the decision to decline treatments (Lysaker et al., 2018). Similarly, it is associated with higher rates of rehospitalisation and poor global functioning (Lysaker et al., 2018; Pousa et al., 2017). Moreover, several studies have shown that poor insight is associated with the overall severity of schizophrenia, and in particular with positive, negative and disorganisation symptoms (Amador et al., 1994; Brohan et al., 2010; Mintz et al., 2003; Zhou et al., 2015). Conversely, high levels of insight are associated with depression, self-stigma, and suicidality (Misdrahi et al., 2014; Schrank et al., 2014). Finally, insight appears to be temporally stable (Cuesta et al., 2000; Smith et al., 2004), with cognitive-behavioural and psycho-education therapies having a significant (but small to moderate) positive effect on insight levels (Pijnenborg et al., 2013).

Childhood trauma (CT) is defined by a range of severe adverse experiences, including physical, sexual and emotional abuse, neglect, or bullying. These experiences may affect approximately one-third of the general population (Kessler et al., 2010; Scher et al., 2004). There is an accumulating body of evidence suggesting an association between such CT experiences and a range of negative social and health outcomes, including higher gastrointestinal disorders, chronic pelvic pain, and cardiometabolic disorders, as well as several psychiatric disorders (McLaughlin et al., 2010; Paras et al., 2009; Tebeka et al., 2016; Wickrama et al., 2015). Moreover, CT is a well-known risk factor for psychotic disorders, in interaction with genetic risk, and in an addition of other environmental risk factors, such as urbanicity, or cannabis use (Guloksuz and van Os, 2018; Kraan et al., 2018; Pries et al., 2018; Varese et al., 2012). Some studies have even suggested a dose-dependent relationship between CT and psychosis (Schäfer and Fisher, 2011). More specifically, sexual and physical abuse (Fisher et al., 2009; Shevlin et al., 2008), separation from the parents (Baudin et al., 2017; Morgan et al., 2007), and peer-victimisation or bullying (Trotta et al., 2013) are associated with future psychotic disorders. Moreover, among patients with psychotic disorders, CT are identified as modifier factors, i.e., factors that are associated with specific clinical features or specific course of the disease (Misiak et al., 2017). For instance, several studies showed associations between CT history and more severe positive symptoms (Duhig et al., 2015; McCabe et al., 2012; Read et al., 2005; Schalinski et al., 2015), in particular auditory-verbal hallucinations (Bailey et al., 2018; Bentall et al., 2012). Interestingly, among patients with bipolar disorders, childhood abuse was also associated with the presence of auditory-verbal hallucinations (Smith et al., 2017). Consistent with these results, recent studies in the FACE-SZ dataset show CT to be associated with the number of hospitalizations, and worse overall outcome, as well as positive, and negative psychotic symptoms, and low global functioning (Andrianarisoa et al., 2017; Baudin et al., 2016; Roux et al., 2018).

CT may have a negative impact on insight levels, and clinical mediators may be involved. However, the specific impact of CT on the level of insight has never been studied. Moreover, studying the associations between CT, clinical dimensions and insight could help to define subsets of patients for whom specific interventions, such as psychotherapy, may be of utility. This study uses path-analysis methods to investigate factors modulating insight levels. We hypothesise that CT could be negatively associated with insight in schizophrenia. This association may be both direct and indirect, and partly mediated by positive and negative symptoms dimensions. As such, this study aims was to analyse the relationship between CT and insight, in association with several clinical dimensions, in a sample of patients with schizophrenia.