Psychiatry Research 189 (2011) 121–127

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Psychiatry Research
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

Differential effects of childhood abuse and neglect: Mediation by posttraumatic

distress in neurotic disorder and negative symptoms in schizophrenia?
Matthias Vogel a,⁎, Johanna Meier b, Stephanie Grönke a, Marco Waage a, Wolfgang Schneider a,
Harald Jürgen Freyberger c, Thomas Klauer c
a
Department of Psychosomatic Medicine and Psychotherapy, University of Rostock, Germany
b
Department of Child and Adolescent Psychiatry, University of Leipzig, Germany
c
Department of Psychiatry and Psychotherapy, University of Greifswald, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Dissociation, though understood as a response to trauma, lacks a proven etiology. The assumption of a dose–
Received 29 April 2010 response relationship between trauma, dissociation and Schneiderian symptoms led to the proposal of a
Received in revised form 5 January 2011 dissociative subtype of schizophrenia characterized by severe child maltreatment, dissociation and psychosis.
Accepted 10 January 2011
Child maltreatment and dissociation are common features of neurotic disorders as well, and the link between
trauma, dissociation, and hallucinations is not specific for schizophrenia. This study compares childhood
Keywords:
Childhood trauma
abuse and neglect, posttraumatic distress and adult dissociation in patients with psychotic vs. non-psychotic
Dissociation disorder. Thirty-five participants with non-psychotic disorder and twenty-five with schizophrenia were
PTSD analyzed using the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of
Psychotic disorder Negative Symptoms (SANS), the Montgomery–Åsberg Depression Rating Scale (MADRS), the Posttraumatic
Non-psychotic disorder Stress Diagnostic Scale PDS (PDS), the Childhood Trauma Questionnaire (CTO) and the Arbeitsgemeinschaft
Methodik und Dokumentation in der Psychiatrie (AMDP)-module on dissociation. Trauma and clinical
syndromes were compared by means of T-testing and logistic regression between 1) the diagnoses and
2) groups with and without post-traumatic stress disorder (PTSD), marked dissociation and psychotic symptoms.
While non-psychotic disorder was related to abuse, schizophrenia showed an association with neglect. Childhood
trauma predicted posttraumatic symptomatology and negative symptoms. Childhood abuse and neglect may
effectuate different outcomes in neurotic and psychotic disorder. The underlying mechanisms, including
dissociation, dovetail with cognitive, emotional and behavioural changes involved in depression, posttraumatic
distress and chronic schizophrenia symptoms rather than being directly linked to trauma.
© 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction and trauma. Referencing a factual review of the literature, Bremner

Dissociation is defined as the disruption of the usually integrated
functions of memory, consciousness, identity and perception of the
environment (American Psychiatric Association, 2000). Dissociative
symptoms are commonly understood as manifestations of an
automatic defence mechanism that serves to mitigate the impact of
highly aversive or traumatic events (van IJzendorn and Schuengel,
1996). Despite this generally accepted understanding of symptom-
atology, dissociation continues to lack a proven etiology, and the
disagreement about its causation is echoed in recent controversy. Case
in point, Giesbrecht et al. (2008) state that fantasy proneness,
cognitive failures, and suggestibility co-occur with dissociative syn-
dromes, and may thus artificially create the link between dissociation
⁎ Corresponding author. Klinik für Psychosomatik und Psychotherapie, Der Universität
Rostock, Gehlsheimer Str.20, D-18147 Rostock, Germany. Tel.: +493814949661; fax: +49
3814949603.
E-mail address: matthias.vogel@uni-rostock.de (M. Vogel).
(2010) contradicts Giesbrecht's explanations vigorously, concluding
that there would be no proof of a relationship between these cognitive
constructs and dissociation, whereas the trauma theory of dissocia-
tion would in fact be “stronger than ever”.
Etiology aside, there is little dispute that dissociative features differ
widely in their expression. Symptoms and disorders of dissociation
are each said to represent a continuum ranging from common
experiences such as daydreaming and lapses in attention, through
déjà vu phenomena, to a pathological failure to integrate thoughts,
feelings, and actions (Atchison and McFarlane, 1994). Yet, given the
phenomenological differences between the single symptoms, some
authors have criticized the notion of dissociation as a unitary con-
ceptual domain. Accordingly, trauma might not be an absolute pre-
requisite of any dissociative symptom (Hacking, 1995; Holmes et al.,
2004; Jureidini, 2003), but rather one of several potential underlying
causes. Clinicians encounter dissociative features along with various
psychiatric disorders, certainly not only those explicitly linked to
trauma (i.e. PTSD), but also others such as: depression (Saxe et al.,

0165-1781/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2011.01.008
122 M. Vogel et al. / Psychiatry Research 189 (2011) 121–127
1993; Molina-Serrano et al., 2008), obsessive compulsive disorder
(Fontenelle et al., 2007), anxiety disorders (Michal et al., 2005),
substance abuse disorder (Evren and Evren, 2006), somatisation
disorder (Brown et al., 2005), borderline personality disorder
(Merckelbach et al., 2005), and also severe mental illness, such as
schizophrenia (Ross and Keyes, 2004b; Vogel et al., 2009a). Therefore,
the high prevalence of dissociative disorders, found to be 25–30% in
in- and outpatient psychiatric populations, does not come as a sur-
prise (Saxe et al., 1993; Foote et al., 2006).
Similarly, adverse childhood experiences are common not only
among individuals suffering from post-traumatic stress disorder
(PTSD) (Mulder et al., 1998) and dissociative disorder (Tutkun et al.,
1998) but also among those with mood disorder (Johnstone et al.,
2009), substance use disorder (Tucci et al., 2010), anxiety (Hovens et
al., 2010; Simon et al., 2009), somatoform disorder (Spitzer et al.,
2008) and schizophrenia (Vogel et al., 2009b). More specifically,
childhood neglect has been associated with depression (Harkness and
Monroe, 1997; Bernet and Stein, 1999), substance abuse disorder
(Singer et al., 2004; Evren and Evren, 2006), obsessive–compulsive
disorder (Lochner et al., 2004), eating disorder (Grilo and Masheb,
2001; Mitchell and Mazzeo, 2005), anxiety in obsessive–compulsive
disorder (Matthews et al., 2008), depression (Moskvina et al., 2007)
and schizophrenia (Vogel et al., 2009a; Sar et al., 2010).
Incidence of childhood abuse has been correlated to depression
(Brown et al., 2005; Hovens et al., 2009; Tucci et al., 2010), anxiety
disorder (Simon et al., 2009), somatisation disorder (Spitzer et al.,
2008) and severe mental illness, i.e. bipolar disorder (McIntyre et al.,
2008) and schizophrenia (Ross and Keyes, 2004). Moreover, there are
associations of childhood sexual abuse with multiple personality
disorder (Ross and Ness, 2010) and of childhood emotional abuse
with depersonalization disorder (Simeon et al., 2001, 2008), which
might serve as an indication of a specific trauma-related pathome-
chanism linking childhood trauma to severe dissociation as seen in
these dissociative disorders.
Taken together, the aforementioned studies point to the relevance
of trauma, childhood trauma in particular, and of dissociative
symptoms for a variety of psychiatric diseases, thereby suggesting
that trauma and dissociation may be influential on psychopathology
not only in dissociative disorders but also across categories and syn-
dromes. For example, we see that dissociative symptoms are asso-
ciated with an increased severity of positive and negative (Vogel et al.,
2009a) symptoms in patients with schizophrenia. Conversely,
psychotic symptoms do not only occur in dissociative identity dis-
order (DID), but their average prevalence in patients with DID is
reported even higher than in patients with schizophrenia (Ellason and
Ross, 1997; Honig et al., 1998). Dorahy et al. (2009b) in their
examination of the different aspects of auditory hallucinations in DID
and schizophrenia, challenge clinical wisdom with their finding that
the most serious hallucinations in terms of earlier onset, involvement
of several senses and greater intensity of the misperception, are found
in those patients with DID and not with schizophrenia. Yet, in line
with the aforementioned theory of Giesbrecht et al. (2008), one
should not suppress the notion that dissociation may as well be
enhanced by the symptoms with which it appears associated and
emerged in connection with other mediating factors, such as cognitive
alterations. Indeed, research suggests a high degree of phenomeno-
logical overlap and functional interplay between schizophrenic
syndromes, posttraumatic conditions and dissociative disorders
(Ross and Keyes, 2004; Jessop et al., 2008; van der Hart et al., 2006).
Not only does this pose the question of differential diagnosis and
comorbidity, but it may also be accounted for by shared risk factors,
fuzzy boundaries between the overlapping diagnoses or a mutual
effect on the respective vulnerability. Accordingly, Sar and Öztürk
(2008) propose a duality (interaction) model to explain the complex
co-existence of two qualitatively distinct but interactive, concurrent
or subsequent psychopathologies as a possibility. Contrarily, Ross
(2004a) contends that trauma, especially early and chronic childhood
trauma and dissociation, is the most important contributing factor to
mental illness. Consequently, Ross (2004) proposes a dissociative
subtype of schizophrenia and contends that non-dissociative schizo-
phrenia, dissociative subtype of schizophrenia, schizo-dissociative
disorder, and dissociative identity disorder constitute a psychopath-
ological spectrum. Since this hypothesis is based on comorbidity,
elevated trauma rates and concurrent dissociative symptoms, the
question arises as to what extent patients that dissociate in the
schizophrenia spectrum differ from maltreated dissociators outside
this diagnostic range. Notably, an intriguing difference between these
clinical populations pertains to their reaction to PTSD, which seems to
induce psychotic symptoms in non-schizophrenic populations, but
not to accentuate psychotic symptoms in those with schizophrenia
(Hamner et al., 2000; Vogel et al., 2009a).
The present study aims at the investigation of the differences in the
experience of dissociation, psychotic features and posttraumatic
stress symptoms as potential responses to trauma between psychotic
vs. non-psychotic disorders. Both these clinical domains are known to
exhibit high degrees of dissociation, childhood trauma and PTSD, but
differ substantially in the expression of symptoms, raising the
question whether different histories of childhood trauma may
account for their respective clinical appearances in adulthood. In
addition, the present study is concerned with the association of
trauma and dissociation with different psychopathological syn-
dromes, in particular negative symptoms of schizophrenia, as they
may lend support to claims of a complex causation of dissociation as a
result of cognitive alterations, which are a hallmark of these negative
symptoms.
2. Methods
2.1. Participants
Participants were recruited after written informed consent in two clinics in
Northern Germany, one psychiatric (Stralsund) and the other psychosomatic
(Rostock). Twenty-five patients with paranoid schizophrenia were compared to 45
patients in psychotherapeutic treatment. Ten participants at the latter site did not
complete the self-rating of childhood trauma and had to be excluded from the analysis.
Of the remaining 35 participants, 15 were diagnosed with depressive disorder
excluding major depression, two with agoraphobia, two with agoraphobia and panic
disorder, two with social phobia, three with panic disorder, two with adjustment
disorder, and nine with somatoform disorder. Diagnoses were made or confirmed
according to DSM-IV criteria by experienced specialists in psychiatry and psychoso-
matic medicine, respectively. Psychiatric patients were in outpatient treatment for pre-
diagnosed schizophrenia and included only on the condition of stable remission under
atypical neuroleptics and of regular contacts deemed sufficient to establish sound
patient–psychiatrist relational bonds. Psychosomatic patients were recruited from an
inpatient setting, where they were receiving psychoanalytical psychotherapy.
Admission to this psychotherapeutic ward is typically attained after waiting periods
of several weeks. Given this prerequisite, patients are affected significantly enough by
their index disorder to be in need of in-patient psychotherapy, but stable inasmuch as
they are able to cope with the waiting period. Participants with non-psychotic
disorders were consecutively admitted to the inpatient setting, whereas those with
schizophrenia represented one author's client-ship in the psychiatric outpatient
department without further conscious selection. Five patients (two with pain disorder,
two with moderate depression, and one with panic disorder) at the psychosomatic site
refused to participate for unspecific reasons. Five participants reported former cannabis
use, however the only explicitly adopted exclusion criterion was current substance
abuse. Two with a primary anxiety disorder were mildly depressed. Among patients
with a primary diagnosis of depression 11 had a comorbid disorder (3× agoraphobia,
2× panic disorder, and one obsessive compulsive disorder), and two had a pain
disorder.
The sample is described in Table 1.
2.2. Instruments
Symptoms were assessed in interviews using the Scale for the Assessment of
Positive Symptoms (SAPS; Andreasen, 1984), the Scale for the Assessment of Negative
Symptoms (SANS; Andreasen, 1983), the Montgomery–Åsberg Depression Rating Scale
(MADRS; Montgomery and Åsberg, 1979), the German version (Ehlers et al., 1996) of
the Posttraumatic Stress Diagnostic Scale (PDS) (Foa et al., 1997) and the
Arbeitsgemeinschaft Methodik und Dokumentation in der Psychiatrie (AMDP) module
“dissociation”, hereafter referred to as AMDP-Dis (Freyberger and Moller, 2004) by
 M. Vogel et al. / Psychiatry Research 189 (2011) 121–127 123

thoroughly trained raters. The PDS is assigned good to very good internal consistence
(Cronbach's alpha = 0.92) and retest reliability (kappa = 0.74). Convergent validity at
comparison with the corresponding SCID section is moderate (Cohen's Kappa = 0.59).
The SAPS has 30 items while its companion, SANS, has 20. Each item is scored on a six-
point Likert-type scale; the interrater-reliabilities are 0.84 and 0.60, respectively. The
AMDP scale for dissociation and conversion is a 30 item rating scale (english translation
in Vogel et al., 2009b) with good psychometric properties: its high correlation with the
German version of the dissociative experiences scale (r = 0.8; FDS) suggests strong
concordant validity (Spitzer et al., 2004), and the interrater-reliability of the AMDP
system is judged to be high, in general (Bobon et al., 1985). The score for each item is
either 0 (not at all) or one (mild) or two (moderate) or three (severe). The present
study made use of the 15 items pertaining to psychological dissociation, only.
The 28 item version of the Childhood Trauma Questionnaire (CTQ) was used for the
self-report of child maltreatment (Bernstein et al., 2003). It is a brief, reliable and valid
screening device for histories of childhood trauma including emotional, sexual and
physical abuse (CEA, CSA, and CPA), as well emotional and physical neglect (CEN, and
CPN) with good reliability and validity (Bernstein and Fink, 1998). For the intended
analyses, the group as a whole was split according to the means of AMDP-Dis, SAPS and
SANS measures into groups scoring high and low on dissociation, high and low on SAPS,
and high and low on SANS, respectively. It should be noted that PTSD was treated
both as a category (for the purpose of investigating its impact on the variables of
interest) and dimensionally (based on the assumption that the number of PTSD
symptoms would indicate severity of posttraumatic distress independently from the
fulfilment of all formal requirements on which the diagnosis is based by definition). For
the purpose of this study, participants were asked to respond to the full scope of the
Post-Traumatic Distress Scale (PDS) questionnaire. In this respect, the authors deviated
from the standard diagnostic procedure, which would have, in some cases, stopped the
interview based on the non-fulfilment of certain PTSD criteria. The rationale behind
utilizing the full scope of the PDS scale was to obtain the most comprehensive and
multi-dimensional evaluation of post-traumatic distress and ensure that no single
symptom was overlooked. In order to ensure a consistent and objective rating of each
participant, the PDS was observer-rated as opposed to self-rated. The dimensional
measures of PTSD symptoms are referred to as PTSD-Dim, and the categorical measures
shall hereafter be referred to as the secondary category. Additionally, the sample was
divided in terms of those with and without a history of childhood abuse and neglect on
the CTQ. Any score above low trauma rendered the participant positive for childhood
trauma. This procedure was adopted from Dorahy et al. (2009b).
2.3. Statistical analyses

Multivariate analysis of variance (MANOVA) and χ2-testing served to investigate

sociodemographic variables and comorbidity between the primary categories, i.e.
Table 1
schizophrenia vs. non schizophrenia. These and the secondary categories (PTSD vs. non-
Sociodemographic characterisation of the sample.
PTSD), as well as the groups (any childhood trauma vs. no childhood trauma; high vs. low
Psychotic disorder Non psychotic disorder T, p/χ2, p dissociation; high vs. low scores on SAPS and SANS, respectively), were compared by
Mean (S.D.) or n (%) Mean (S.D.) or n (%) means of t-testing using CTQ and clinical symptom measures as test variables. For further
analyses, stepwise forward binary logistic regression was chosen, with the secondary
Age 36.0 (12.4) 37.43 (10.28) T = − 0.5, category and groups (except for any childhood trauma vs. no childhood trauma) being
p = 0.62 entered as dependent variables. Statistics were calculated using SPSS 17.
Female 7 (28.0) 25 (71.4) χ2 = 11.5,
Male 18 (72.0) 10 (28.6) p = b 0.01
Marital status χ2 = 5.26; 3. Results
p = 0.15
Single 17 (68.0) 16 (45.7)
Socio-demographic data are shown in Table 1. Gender distribution
Married 4 (16.0) 13 (37.1)
Divorced 4 (16.0) 4 (11.4)
was unequal among the diagnostic groups and among groups scoring
Widow 0 2 (5.7) high and low on the SAPS (cf. Table 2). The prevalence of PTSD was
School χ2 = 10.5, 40.0% (n = 10) in patients with schizophrenia vs. 45.7% (n = 16) in
p = 0.03 patients with neurotic or affective disorder (cf. Table 2). The mean
No school 2 (8.7) 0
(S.D.) score of AMDP-Dis was 14.65 (7.14). The mean (S.D.) score of
b 8 classes 1 (4.3) 0
8 classes 5 (21.7) 2 (5.7) SAPS was 33.00 (24.64), and that of SANS was 40.92 (25.23). Table 2
10 classes 12 (52.2) 20 (57.1) shows the distribution of high and low dissociators among subjects
12 classes 3 (13.0) 13 (37.1) with and without a history of childhood maltreatment, those with and
Education χ2 = 8.16, without PTSD, and those with high and low scores on SAPS and SANS,
p = 0.15
Apprenticeship, 1 (4.3) 2 (5.9)
respectively. As shown in Table 3, the primary categories differed only
ongoing with respect to positive and negative symptoms of schizophrenia.
Apprenticeship, 9 (39.1) 20 (58.8) Mean childhood-trauma scores ranged between none to moderate in
complete almost all categories and groups. CPN scores classified as severe only
University 3 (13.0) 8 (23.5)
in patients with schizophrenia who also scored high on SAPS and
No degree 6 (26.1) 2 (5.9)
Other 4 (17.9) 2 (5.9) SANS. Furthermore, mean CEN scores were severe in those individuals
No information 1 (4.3) 2 (5.9) without PTSD and those with low dissociation. SAPS and SANS scores
Accommodation χ2 = 6.64, differed significantly among participants in the primary category. The
p = 0.15 CEA, CPA, CSA, CTQ total, MADRS, AMDP-Dis, PTSD-dim and nPTE
Individual home 13 (54.1) 28 (80.0)
Community home 4 (16.7) 0
scores varied among participants in the secondary category. The
With parents 4 (16.7) 5 (14.1) scores for CEA, CPA, SAPS, MADRS, and PTSD-dimensions differed
Other 3 (12.5) 2 (5.9) significantly among groups with high vs. low dissociation. Groups
Unknown 1 (4.3) 0 with high and low scores on SAPS and SANS differed only with respect
Occupation χ2 = 22.6,
to the SAPS and SANS scores. Additionally, those with high scores on
p b 0.01
Full-time 1 (4.2) 8 (24.4) SAPS also had higher scores on MADRS and AMDP-Dis. The presence
Part-time 1 (4.2) 7 (21.2) of any childhood-trauma was significantly associated with CEA, CPN,
Other 2 (8.4) 3 (9.1) CTQ-total and SANS, and in addition showed a trend towards an
Industrial training 1 (4.2) 2 (6.1) association with nPTE.
Rehabilitation 1 (4.2) 0
Housewife 2 (8.3) 0
In the next stage of analysis, stepwise forward binary regression
Jobless 3 (12.5) 8 (24.2) was used to determine if child abuse and symptom measures
Pension 13 (54.1) 3 (9.1) improved the prediction of categories (schizophrenia vs. nonschizo-
Unknown 0 2 (6.1) phrenia; PTSD vs. non-PTSD) and groups (high dissociation vs. low
No comorbidity 21 (84.0) 26 (57.8) χ2 = 16.81,
dissociation; high vs. low scores on SAPS; high vs. low scores on
p = 0.01
Substance abuse 4 (16.7) 1 (2.9) SANS). Step 1 consisted of age and gender. Step 2 of CEA, CPA, CEN and
(currently abstinent) CPN, on condition that previous t-testing had shown an association
Anxiety 0 6 (17.14) between CTQ-subscales and the respective group; if this condition
Somatoform disorder 0 2 (5.9) was not met, the dichotomised childhood trauma variable (present/
Dysthymia 0 2 (5.9)
absent) was entered instead. Symptom measures were entered in
124 M. Vogel et al. / Psychiatry Research 189 (2011) 121–127

Step 3, so far as they were not defining the dependent variable. For
example, SAPS scores were omitted in the prediction of high scores on
SAPS, AMDP-Dis scores omitted in the prediction of high dissociation,
and nPTE/PTSD-Dim scores omitted in the prediction of PTSD. Block 3
also contained the primary diagnostic category as a covariate.
As shown in Table 4, gender and SANS were significant predictors
of the diagnostic category but lost significance when AMDP-Dis was
entered as covariate. CEA and AMDP-Dis predicted PTSD. Only MADRS
predicted high dissociation significantly, but CPA increased the odds
ratio (OR) of belonging to the high dissociatiors' group to a similar
extent (17% vs. 16%) as MADRS. By choice of forward stepwise
methods, further variables were excluded from the model due to lack
of significance. Scoring highly on SAPS was better predicted by SANS
than by AMDP-Dis. Negative symptoms were predicted by SAPS,
AMDP-Dis and the presence of any childhood trauma.
4. Discussion
The purpose of the present study was to explore differences in the
association of childhood trauma, PTSD and dissociation with psychotic
and non-psychotic disorder. As reported in previous studies (Vogel
et al., 2009b), severe CPN has been associated with schizophrenia.
Although childhood trauma among participants in the present study
was predominantly low and did not differ markedly between the
categories, the results have interesting implications. Firstly, all forms
of childhood abuse showed significant associations with PTSD and
dissociation. Secondly, at the symptom level, a link between
dissociation and positive symptoms apparently holds in one direction,
with dissociation predicting high scores on SAPS, but high scores on
SAPS not necessarily predicting high dissociation. Thirdly, PTSD and
high dissociation showed similar associative patterns with each of
their respective defining variables (PTSD-Dim, nPTE and AMDP-Dis)
and also with MADRS scores. Lastly, positive symptoms, as measured
by SAPS, were more closely related to dissociation than to PTSD and
were not specific to schizophrenia. Surprisingly, negative symptoms
of schizophrenia were not only linked to their counterpart with
schizophrenia and to dissociation but also to the presence of child-
hood trauma.
4.1. Childhood adversities and adult susceptibility to symptoms of
posttraumatic distress and schizophrenia
disorder. Likewise, child abuse and MADRS seem to synergistically
increase the risk of dissociation. Interestingly, a key difference is
evident among participants in the primary categories, namely that
the elevated severity of childhood neglect in patients with schizo-
phrenia stands in sharp contrast to the relative elevation of child-
hood abuse in the non-schizophrenia group. This result corroborates
previous findings (Vogel et al., 2009a; Sar et al., 2010), which
establish a relationship between CPN and high dissociation in
schizophrenia. However, rather than linking neglect to dissociation,
the present study yields evidence for a link between negative
symptoms and childhood trauma, which is more relevant for chronic
psychosis given the specificity of negative syndromes for schizo-
phrenia (Schennach-Wolff et al., 2009; Wobrock et al., 2009).
Negative symptoms tend to be associated with higher levels of
physical neglect, lower levels of abuse and the presence of any
childhood trauma. Notwithstanding the small sample size, regres-
sion analysis suggests the presence of childhood trauma and
dissociation to be protective against negative symptoms in those
patients with neurotic disorder, but the presence of any childhood
trauma was positively correlated with negative symptoms in
patients with schizophrenia. Given the contrast between high levels
of abuse in the non-psychotic category and high levels of neglect in
the schizophrenia category, a factual increase in the odds of negative
symptoms may originate in neglect but be disguised by opposite
effects of different childhood trauma domains in the distinct diag-
nostic categories. Research has found an impact of dissociation on
positive and, to a lesser extent, on negative symptoms of schizo-
phrenia (Ross and Keyes, 2004; Vogel et al., 2009a). Negative
symptoms of schizophrenia, however, have been disregarded within
the heuristic models of the interplay between psychosis and dis-
sociation, probably due to the lack of an apparent overlap between
these negative symptoms and dissociative syndromes. Hence, the
results of the present study may point to an innovative new path of
research: instead of causing dissociation, childhood abuse and
neglect may engender disruptions of cognitive, emotional, motiva-
tional, and social functioning which map onto the construct of
negative symptoms. This is a cogent assertion, given that repeated
and long-lasting experiences of neglect could intuitively be dis-
couraging to relational engagement.
4.2. Negative symptoms may function as a cognitive and emotional defence

The prediction of PTSD by dissociation holds obvious implications Dorahy et al. (2009a) observed interpersonal disconnectedness
for the concept of PTSD, which perhaps unjustly excludes dissoci- and childhood neglect were linked to complex PTSD, a chronic
ation within its definition. Moreover, the stepwise results suggest posttraumatic condition characterized by somatisation, impaired
that CEA and dissociation could increase an individual's propensity affect regulation, altered consciousness, self-perceptions and systems
to encounter posttraumatic distress, meaning that child abuse, of meanings, as well as distorted relations to others (Herman, 1992).
dissociation and trauma appear to co-participate in the mediation of Negative symptoms in schizophrenia could be as effective a mecha-
PTSD, without categorical specificity for either psychotic or neurotic nism for the elusion of adverse cognitive and emotional stimulation as
avoidance is in the fields of anxiety and posttraumatic distress. This
interesting, albeit tentative, proposal is empirically supported by an
Table 2 association of amnesia with negative symptoms and of CPN with
Distribution of PTSD and groups classified according to low and high expression of the dissociation in patients with schizophrenia (Vogel et al., 2009a,b). A
defining characteristic among the diagnostic categories. putative overlap of negative symptoms and PTSD dimensions might
N (%/%females) Schizophrenia Neurotic disorder χ2 p
also lend an explanation to the finding that a concurrent diagnosis of
PTSD and schizophrenia is not associated with a dramatic increase in
No CHT 21 (84.0/28.6) 33 (94.3/72.7) 1.71 0.2
schizophrenia symptoms (Vogel et al., 2009a), as PTSD may simply
CHT 4 (16.0/25.0) 2 (5.7/50.0)
No PTSD 15 (60.0/33.3) 19 (54.3/78.9) 0.19 0.79 amalgamate with schizophrenic syndromes in terms of functional and
PTSD 10 (40.0/20.0) 16 (45.7/62.5) phenomenological similarities. Moreover, linking negative syndromes
Low dissociation 14 (56.0/35.7) 16 (45.7/56.3) 0.62 0.6 to dissociation is in-line with claims of a significant contribution of
High dissociation 11 (44.0/18.2) 19 (54.3/84.2)
cognitive failures to the etiology of dissociation (Giesbrecht et al.,
Low SAPS 8 (32.0/37.5) 30 (85.7; 73.3) 18.12 b0.01
High SAPS 17 (68.0/23.5) 5 (14.3/60.6) 2008). Whether an individual's diagnosis is neurotic or psychotic
Low SANS 3 (12.0/33.3) 32 (8.6/71.9) 40.26 b0.01 disorder, vulnerability to posttraumatic distress and adult dissociation
High SANS 22 (88.0/27.3) 3 (91.4/100.0) may originate in childhood experiences of abuse and neglect and be
CHT: childhood trauma; SAPS: Scale for the Assessment of Positive Symptoms; SANS: mediated by adult trauma and cognitive alterations in later life. By
Scale for the Assessment of Negative Symptoms. contrast, Schneiderian symptoms may be less relevant in this context,
 M. Vogel et al. / Psychiatry Research 189 (2011) 121–127 125

Table 3
t-testing statistics.

Mean (S.D.) CEA CPA CSA CEN CPN CTQ-total SAPS SANS MADRS AMDP-Dis PTSD-Dim nPTE

Psychotic (n = 25) 8.88 7.20 6.17 16.17 12.46 38.36 51.48 65.00 25.72 13.52 10.48 1.84
4.10a 3.35b 3.23a 5.56c 3.36d 16.93 25.95 19.96 9.28 7.84 11.66 1.46
Neurotic (n = 35) 10.23 7.54 5.89a 17.20 11.63 39.00 19.80 24.29 26.14 15.46 13.34 1.65
5.30a 3.89a 2.84 5.86c 1.63c 868 12.17 9.12 8.89 6.59 13.85 1.51
t − 1.05 − 0.36 0.35 − 0.68 1.12 − 0.17 5.67 9.49 − 0.18 − 1.04 − 0.84 0.47
p 0.3 0.72 0.73 0.5 0.27 0.86 b0.01 b0.01 0.9 0.3 0.4 0.64
No CHT (n = 54) 9.07 7.13 5.72 16.78 11.61 35.83 32.15 39.28 25.59 14.53 11.33 1.61
4.31a 3.66b 2.36a 5.79c 2.11c 9.03 24.68 24.42 9.11 7.18 12.87 1.47
CHT (n = 6) 16.20 9.83 9.00 16.80 15.80 64.83 40.67 61.50 29.33 15.67 19.50 2.83
6.06d 2.79c 6.52c 5.31c 3.27d 10.83 25.11 22.39 7.47 7.34 12.34 1.17
t − 3.42 − 1.75 − 1.11 − 0.01 − 4.05 − 7.33 − 0.80 − 2.13 − 0.97 − 0.37 − 1.45 − 1.96
p b0.01 0.09 0.33 0.99 b 0.01 b 0.01 0.43 0.04 0.34 0.72 0.14 0.06
No PTSD (n = 34) 7.82 6.21 5.18 17.91 11.68 34.06 28.65 40.58 23.65 11.94 3.47 1.00
3.57b 2.74b 0.52b 5.25d 2.42c 9.94 24.81 26.27 9.24 6.76 7.37 1.18
PTSD (n = 26) 12.20 8.9 7.12 15.24 12.36 44.85 38.69 42.77 29.00 18.19 23.50 2.69
5.28a 4.13a 4.33a 6.06c 2.58c 13.37 23.69 3.68 7.78 6.07 9.37 1.29
t − 3.59 − 2.94 − 2.23 1.81 − 1.04 − 3.59 − 1.58 − 0.33 −2.38 − 3.71 − 8.98 −5.29
p b0.01 b 0.01 0.04 0.08 0.3 b 0.01 0.12 0.74 0.02 b0.01 b 0.01 b 0.01
LD (n = 30) 6.47 8.34 5.41 17.69 11.90 36.90 24.60 36.83 21.03 8.80 8.10 1.47
2.80b 3.70a 1.09b 5.43d 2.50c 13.68 19.35 24.04 7.73 4.69 10.61 1.33
HD (n = 30) 8.33 10.97 6.57 15.90 12.03 40.57 41.40 45.00 30.90 20.50 16.20 2.00
4.18b 5.51c 3.99a 5.93c 2.53c 11.48 26.75 26.13 7.33 3.30 13.96 1.60
t − 2.03 − 2.15 − 1.53 1.21 − .209 − 1.13 − 2.79 − 1.26 − 5.07 −11.18 − 2.53 − 1.40
p 0.05 0.04 0.14 0.23 0.84 0.27 0.01 0.21 b 0.01 b0.01 0.01 0.12
LP (n = 38) 7.63 10.12 5.70 16.59 11.46 39.12 17.21 28.39 23.95 12.95 10.16 1.68
3.75b 5.23c 2.67a 5.67c 1.85c 11.96 9.24 16.34 9.04 6.63 12.28 1.56
HP (n = 22) 7.00 8.95 6.50 17.09 12.82 38.09 60.27 62.55 29.45 17.59 15.59 1.82
3.52b 4.16a 3.45a 5.90c 3.17d 14.05 18.04 23.34 7.88 7.17 13.64 1.37
t 0.64 0.88 − 1.00 −0.32 − 1.83 0.30 − 10.43 −6.06 − 2.38 − 2.54 − 1.59 − 0.34
p 0.52 0.38 0.32 0.75 0.08 0.77 b0.01 b0.01 0.02 0.01 0.12 0.74
LN (n = 35) 7.40 10.06 5.46 17.43 11.49 37.91 20.54 23.26 25.94 14.97 11.83 1.60
3.77b 4.72c 1.07a 5.44c 1.72c 8.12 11.81 7.07 8.70 6.62 13.65 1.44
HN (n = 25) 7.50b 9.30 6.87 15.48 12.65 39.96 52.54 68.21 26.83 14.79 13.00 1.96
3.59 5.11a 4.51a 5.95c 3.30d 17.64 25.89 15.76 8.75 7.51 12.27 1.57
t − 0.10 0.57 −1.48 1.29 − 1.56 − 0.53 − 5.67 − 13.10 − 0.39 0.10 − 0.91 −0.34
p 0.92 0.57 0.15 0.20 0.13 0.60 b0.01 b0.01 0.70 0.92 0.37 0.74

Footnotes denote corresponding levels of severity according to CTQ-classifications; CEA: childhood emotional abuse; CPA: childhood physical abuse; CSA: childhood sexual abuse;
CEN: childhood emotional neglect; CPN: childhood physical neglect; CTQ-total: total CTQ-score; SAPS: scale for the assessment of positive symptoms; SANS: scale for the assessment
of negative symptoms; MADRS: Montgomery–Asberg depression rating scale; AMDP-Dis: AMDP-dissociation; PTSD-Dim: PTSD symptoms; nPTE: number of potentially traumatic
events. CHT: childhood trauma; LD: low dissociation, HD: high dissociation, LP: low scores on SAPS; HP: high scores on SAPS; LN: low scores on SANS; HN: high scores on SANS.
a
Low.
b
None.
c
Moderate.
d
Severe.

inasmuch as they are more closely linked to negative symptoms than
to trauma and dissociation.
4.3. Synergism of current syndromes and distal causes to shape a
phenomenology of similarities?
One can infer from the present results that inter-syndromal inter-
actions and dose–response relationships between trauma, posttraumatic
distress, dissociation and psychotic symptoms cross the borders of
schizophrenic, depressive and neurotic disease in the studied sample.
Dissociation holds a central role within this interplay as it functions as a
mediator of posttraumatic distress and, to a lesser degree, also of
psychotic symptomatology but is itself engendered by current symp-
toms of depression and – more distally – by childhood abuse.
Contrary to previous findings, this study does not confirm the
close relationship between childhood trauma and adult dissociation,
which many authors have described for both psychotic (Ross,
2004a; Vogel et al., 2009b; Sar et al., 2010) and non-psychotic
disorder (Tutkun et al., 1998; Gershuny and Thayer, 1999). Apart
from the heterogeneity of symptoms among individuals with
schizophrenia on one hand, and among patients with neurotic and
affective disorder on the other, this inconsistency may also be
substantiated by the design of the present study in which the
distinct categories were merged and underwent regression analyses
as a whole, enabling a trauma-related phenomenology of both,
partial similarities and distinctive features to become apparent by
direct comparison. Thus, we see a lack of specific interactions
between a) the diagnostic categories, b) dissociation, c) psychotic
features, and d) PTSD. Both categories exhibit psychotic features and
dissociation in coping with trauma. Furthermore, high dissociators
very likely involve a high degree of psychotic features as well,
suggesting an essential link between dissociation and Schneiderian
symptoms, regardless of whether or not the clinical diagnosis is
schizophrenia. However, in this study, pronounced Schneiderian
symptoms are limited to conditions which accumulate negative and
not dissociative symptoms. Hence, severe psychosis does not appear
to be a result of dissociation, particularly since dissociation is
equally present in non-psychotic and psychotic disorders. The
present study is not consistent with a linear dose–response
relationship between childhood trauma and psychotic or dissocia-
tive symptoms. Rather, it points to an interaction between avoidant
behaviour, cognitive impeding, emotional numbing, and dissocia-
tion, that is mediated by the recurrence of trauma and which is
shown to originate in childhood neglect if the clinical appearance is
characterized by negative symptoms and in childhood abuse if the
clinical appearance is characterized by a lack of negative symptoms.
The present study clearly warrants replication as the results may
encourage researchers to not preclude negative symptoms from their
126 M. Vogel et al. / Psychiatry Research 189 (2011) 121–127

Table 4
Logistic regression statistics (d.f. = 1).

Dependent variable (model) Predictor B SE Wald p OR 95% C.I. for exp

(B) lower/upper

Schizophrenia (χ2 = 11.38; d.f. = 1; p b 0.01; Nagelkerke R2 = 0.23) Gender − 2.52 1.24 4.14 0.04 0.08 0.07/0.9
SANS 0.17 0.05 11.28 0.001 1.18 1.1/1.3
Gender − 7.43 5.47 1.85 0.17 0.01 0.01/26.87
SANS 0.65 0.4 2.57 0.11 1.91 0.87/4.21
AMDP-Dis − 1.18 0.78 2.28 0.13 0.3 0.07/1.42
PTSD (χ2 = 26.75; d.f. = 3; p b 0.01; Nagelkerke R2 = 0.50) CEA 0.17 0.08 5.08 0.02 1.19 1.02/ 1.37
CSA 0.44 0.37 1.29 0.26 1.53 0.73/ 3.19
AMDP-Dis 0.15 0.06 5.76 0.02 1.16 1.03/1.32
Dissociation (χ2 = 23.16; d.f. = 3; p b 0.01; Nagelkerke R2 = 0.43) CPA 0.15 0.10 2.23 0.14 1.16 0.95/1.42
MADRS 0.16 0.04 12.87 b0.01 1.17 1.08/1.28
SAPS (χ2 = 39.61; d.f. = 3; p b 0.01; Nagelkerke R2 = 0.66) Gender − 0.93 0.73 1.60 0.21 0.40 0.09/1.67
SANS 0.07 0.017 15.46 b0.01 1.07 1.03/1.10
Gender − 1.07 0.82 1.71 0.19 0.34 0.07/1.71
SANS 0.092 0.03 11.00 b0.01 1.10 1.04/1.16
AMDP-Dis 0.21 0.08 6.01 0.01 1.23 1.04/1.45
SANS (χ2 = 43.42; d.f. = 4; p b 0.01; Nagelkerke R2 = 0.7) Gender −0.095 0.78 1.48 0.22 0.39 0.08/1.78
Any CHT − 2.83 1.42 3.96 0.05 0.06 0.04/1.0
SAPS 0.08 0.02 11.91 b0.01 1.08 1.04/1.14
Gender − 0.76 0.86 0.79 0.37 0.47 0.09/2.5
Any CHT − 3.33 1.62 4.24 0.04 0.04 0.01/0.85
AMDP-dis − 0.19 0.08 5.76 0.02 0.83 0.71/0.97
SAPS 0.12 0.04 12.08 b0.01 1.13 1.05/1.21

CHT: childhood trauma; CEA: childhood emotional abuse; CPA: childhood physical abuse; CSA: childhood sexual abuse; SAPS: Scale for the Assessment of Positive Symptoms; SANS:
Scale for the Assessment of Negative Symptoms; MADRS: Montgomery–Åsberg Depression Rating Scale; AMDP-Dis: AMDP-dissociation.

endeavours to explore the complex relationships between trauma and
dysfunctional outcomes. Despite the strength of its interview-based
assessment of symptoms and the advantage of its case–control design,
the present study holds two potential shortcomings. The first is the
unbalanced distribution of genders and the poor matching of socio-
demographic characteristics in the psychotic vs. non-psychotic
groups. Although, given the similarities of the variables of interest
in this study, one could also argue that the process of coping with
childhood trauma and PTSD is not influenced by sociodemographic
factors. The second potential shortcoming is that the generalizibility
of the results is somewhat limited by the small sample size of
heterogenous individuals and by the small sizes of the distinct
subgroups within the sample. Nevertheless, the results of this study
reinforce the notion that childhood development plays a critical role
in the prediction of neurotic as well as severe mental illness in later
phases of life.
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