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All rights reserved ACTA PSYCHIATRICA SCANDINAVICA
DOI: 10.1111/acps.12041
Significant outcomes
• No significant differences were observed between the groups in cognitive test performance.
• Schizophrenia patients with trauma and post-traumatic stress disorder (PTSD) had significantly more
current depression than the non-traumatized group.
Limitations
• Given the nature of the cross-sectional design, causal relationships between traumatization/PTSD,
schizophrenia, and functional measures cannot be drawn.
• Some questionnaires have a low response rate Calgary Depression Scale for Schizophrenia (CDSS).
• Heterogeneity within the trauma group with regard to the type and age when the traumatic event
happened complicates the interpretation of our results.
455
Peleikis et al.
456
PTSD in Schizophrenia patients
457
Peleikis et al.
458
PTSD in Schizophrenia patients
Table 1. Demographical and clinical characteristics of patients with schizophrenia: No trauma, trauma and PTSD groups
*ANOVA, P < 0.05, PTSD > no trauma, trauma statistically sign. by post hoc test (Tukey’s test). Mean and Standard Deviation (M, SD). Positive and Negative Syndrome Scale
(PANSS). Global Assessment of Functioning (GAF), Symptom-(GAF-S) and Function-(GAF-F) subscale.
†Chi-squared test, two-sided for categorical variables, ANOVA one-way analysis for scaled variables.
‡Fisher’s exact test.
§Use of tablets, alcohol, cannabis, amphetamine, ecstasy, or cocaine during the last 2 weeks before inclusion.
¶The Calgary Depression Scale (CDSS) (item 8): Any current suicidal thoughts, plans, or attempts (score 1).
**The psychopathology mean score from the three-factor model of Kay et al. (43) (Item G1–G16).
††Dysphoric mood factor from five-factor PANSS model of White et al. (56) (Item G1, G2, G3, G4, and G6).
‡‡Intelligence Quotient (IQ) assessed by the Wechsler Abbreviated Scale of Intelligence (WASI).
Table 2. Type of trauma in relation to age between the groups on the current IQ measure,
Trauma (not PTSD) (n = 54) PTSD (n = 21)
consisting of the subtests Vocabulary, Similarities,
Block Design, and Matrix Reasoning of the WASI,
Age where the patients with SZ in no trauma, trauma,
Type of trauma Child* Adult unknown Total Child* Adult Total and PTSD performed equally (P = 0.377).
Violence 3 0 0 3 0 0 0
Child sexual 6 0 0 6 0 0 0
abuse (CSA) Discussion
Neglect 3 0 0 3 1 0 1
CSA+ violence 5 0 0 5 4 0 4
The main finding of the current study was no sig-
Violence + neglect 4 0 0 4 3 0 3 nificant differences in cognitive functioning
CSA+ neglect 8 0 0 8 4 0 4 between schizophrenia (SZ) spectrum disorder
CSA+ neglect 14 0 0 14 8 0 8 patients with trauma, post-traumatic stress disor-
+ violence
Accident 1 1 0 2 0 0 0
der (PTSD), or no trauma, but clear psychopatho-
Trauma, not 6 0 3 9 0 1 1 logical differences. The study of Duke et al., 2010
specified (38), did not find any association between PTSD
*Child of age <16 years.
and cognitive abnormalities already present in
patients with SZ. This result was in line with our
main findings where no significant differences in
norms of healthy controls, except for psychomotor cognitive functioning between SZ patients with
speed or processing speed (Digit Symbol from the trauma, PTSD, or no trauma were seen. However,
WAIS) with performances 1 SD below the mean in some studies have found an association of comor-
all groups. Because no significant differences were bid PTSD with cognitive dysfunction in schizo-
found regarding age, education, and positive and phrenia (14, 57). Fan and colleagues (14) suggest
negative symptoms, there was no need for adjust- that patients with comorbid PTSD (n = 15) suffer
ments in the further analyses (Table 3). As can be more cognitive impairments especially in the
seen in this table, there is no significant difference domains of attention, working memory, and
459
Peleikis et al.
Table 3. Cognitive test performance for Schizophrenia between patients with no regarded as a result of abnormal neurodevelop-
trauma, trauma, and PTSD
ment. Trauma seems more related to mood symp-
Trauma (without toms, which are generally regarded as a state
Neuropsychological No trauma PTSD) PTSD measure. To our knowledge, our study provides
tests Mean (SD) Mean (SD) Mean (SD) P the most extensive evaluation of cognitive function
Verbal memory in the largest traumatized SZ sample to date.
WMS-III LM I 8.26 (2.89) 8. 30 (3.05) 8.24 (3.33) 0.996 As assumed, we found a significantly higher level
CVLT-II 46.72 (11.84) 46.89 (13.34) 46.76 (13.57) 0.997 of depression in the SZ group with PTSD com-
Total A1-5
CVLT-II LDR 0.44 (1.27) 0.52 (1.37) 0.36 (1.35) 0.883
pared with both the no trauma and the trauma
Attention group (Table 1). Our findings of current depres-
Digit span 5.85 (1.06) 5.71 (1.08) 5.33 (1.46) 0.121 sion (CDSS total) were in line with a recent study
forward (38), which shows that trauma and PTSD have
Working
memory
been related to a variety of adverse outcomes in
Digit span 4.15 (1.07) 3.98 (1.10) 4.19 (1.21) 0.611 patients with SZ. Patients with PTSD tend to have
backward more severe psychotic symptoms (58), increased
Psychomotor suicidality (59), and to use more psychiatric ser-
speed
Digit symbol 6.36 (2.14) 6.78 (2.29) 6.76 (2.81) 0.456
vices (60). Our study, however, did not find any
Executive significant differences between the groups concern-
functioning ing psychotic symptoms, suicidality, or the use of
Inhibition 7.38 (3.68) 6.82 (3.93) 7.19 (4.25) 0.688 psychiatric services.
Letter fluency 8.92 (3.94) 8. 23 (4.02) 8.40 (3.44) 0.544
Category 8. 62 (4.15) 8.18 (4.22) 8.05 (3.59) 0.729 A series of studies have been conducted on the
fluency prevalence of PTSD in patients with SZ (7, 37,
Inhibition 7.81 (3.61) 7.43 (3.46) 7.52 (4.08) 0.809 61–64), with some discrepancies in the prevalence
/Switching
estimates. Apparently, 20–29% of psychological
WASI
Vocabulary 47.06 (12.35) 45.55 (12.91 43.81 (16.86) 0.493 traumatization results in the development of PTSD
Similarities 48.92 (11. 32) 47.89 (11.30) 46.65 (12.10) 0.653 (2, 3, 64, 65). In our study, we found a prevalence
Block design 50.33 (10.41) 49.23 (11.73) 46.25 (11.93) 0.275 of trauma in the total SZ group of 25%, of which
Matrix 51.08 (11.63) 48.76 (12.54) 45.57 (12.73) 0.102
reasoning
only 7% had current PTSD. The prevalence of
WASI VIQ 97.39 (16.59) 95.52 (17.13) 94.80 (20.29) 0.707 PTSD in our study was low, but comparable to
WASI PIQ 101.52 (15.82) 98.77 (16.96) 94.40 (16.81) 0.160 Neria and coworkers (8) who found a prevalence
WASI FIQ 99.54 (16.48) 97.30 (17.51) 94.35 (19.64) 0.377 of PTSD in their sample of patients with schizo-
4 subtests
phrenia of approximately 10%.
WMS-III LM I, Wechsler’s Memory Scale-III Logical Memory I; CVLT-II, California There are several limitations in the present
Verbal Learning Task-II; LDR, long delay–free recall. study. Given the nature of the cross-sectional
All neuropsychological values were converted to z (or t) score (mean 10; SD 3), design, causal relationships between traumatiza-
except the CVLT-II Total (number of correct words recollected) and Digit Span For-
ward and Backward (raw scores).
tion/PTSD, SZ, and functional measures cannot
be drawn. Our sample size with the groups con-
taining 292 participants with SZ, 75 traumatized
executive functioning, compared with those who patients, and 21 with a comorbid PTSD may lack
have not developed PTSD. adequate power to detect between-group differ-
Previous studies of cognitive function in SZ ences. Also some questionnaires have a low
patients with traumatization/PTSD have some lim- response rate (CDSS). The reason for CDSS not
itations including a small number of participants being used for the total sample is that CDSS was
with limited evaluation of cognitive abilities and first included in the protocol after the first phase of
reliance of clinical diagnoses of SZ and PTSD. It the TOP recruitment; thus, it is missing in 164
may be speculated whether the cognitive deficits patients. However, there is no selection bias in
associated with traumatization are sufficiently these two subsamples, because there is no reason
severe to be differentiated from those associated to believe that patient characteristics changed over
with SZ development. There is also a large varia- time in Oslo. There were no significant differences
tion in cognitive functioning in SZ, which suggests in clinical or sociodemographic characteristics
that some of the discrepant findings in this field between the CDSS and no CDSS groups (data not
could be due to differences in statistical power. shown).
Due to the correlation design, the current findings A limitation of the method for assessing trauma
cannot be used for causative inferences. However, was that the approach probably led to underre-
it may be speculated that trauma has less effect porting of traumatic events that are common in
on neurocognitive functioning, which is often the general population (66), such as the sudden,
460
PTSD in Schizophrenia patients
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