اختصاصی بودن ناملایمات دوران کودکی و اثر دوز پاسخ در روان پریشی اپیزود اول غیرعاطفی

Background Reviews conclude that childhood and adolescence sexual, physical, emotional abuse and emotional and physical neglect are all risk factors for psychosis. However, studies suggest only some adversities are associated with psychosis. Dose-response effects of several adversities on risk of psychosis have not been consistently found. The current study aimed to explore adversity specificity and dose-response effects of adversities on risk of psychosis. Method Participants were 101 persons with first-episode psychosis (FEP) diagnosed with ICD-10 F20 – F29 (except F21) and 101 non-clinical control persons matched by gender, age and parents' socio-economic status. Assessment included the Childhood Trauma Questionnaire and parts of the Childhood Experience of Care and Abuse Questionnaire. Results Eighty-nine percent of the FEP group reported one or more adversities compared to 37% of the control group. Childhood and adolescent sexual, physical, emotional abuse, and physical and emotional neglect, separation and institutionalization were about four to 17 times higher for the FEP group (all p < 0.01). The risk of psychosis increased two and a half times for each additional adversity. All associations between specific adversities and psychosis decreased when they were adjusted for other adversities. Conclusion Our findings suggest that there is a large shared effect of adversities on the risk of psychosis. Contrary to the call for further research into specific adversities, we suggest a search for mechanisms in the shared effects of traumatization. Clinical implications are thorough assessment of adversities and their possible effects.

Childhood and adolescence adversities are now considered risk factors for psychosis (Matheson et al., 2012, Varese et al., 2012b, Bonoldi et al., 2013 and Van Nierop et al., 2014b). However, some researchers advise they might be indicators or proxies of social and environmental causal factors (Cutajar et al., 2010 and Murray et al., 2013), while others hold that they themselves are causal (Varese et al., 2012b and Carr et al., 2013). Some even suggest that only few adversities increase the risk of psychosis (Fisher et al., 2010). Prospective and case-control studies have found associations between psychosis and different childhood and adolescent adversities. These include sexual abuse (Fennig et al., 2005, Cutajar et al., 2010, Elklit and Shevlin, 2011, McCabe et al., 2012 and Varese et al., 2012a); emotional abuse (Whitfield et al., 2005, McCabe et al., 2012 and Varese et al., 2012a); physical abuse (Whitfield et al., 2005, Aas et al., 2011, McCabe et al., 2012 and Varese et al., 2012a); parental loss/separation (Agid et al., 1999 and Aas et al., 2011); and emotional and physical neglect (McCabe et al., 2012 and Varese et al., 2012a). Several of these studies found that the risk of psychosis was associated with some but not other adversities (Aas et al., 2011 and McCabe et al., 2012). There is no clear pattern of particular adversities increasing the risk of psychosis. Moreover, in these studies, the adversities in question were not adjusted for other adversities, making it impossible to draw conclusions about whether specific adversities confer a greater risk of psychosis. Several studies, however, have adjusted for other adversities. They find different adversities to be central for risk of psychosis: physical abuse from the mother (Fisher et al., 2010); physical abuse and violence at home (Shevlin et al., 2007); physical abuse and parental discord (Rubino et al., 2009); sexual and emotional abuse (Daalman et al., 2012) and sexual abuse and victim of serious injury, illness or assault (Bebbington et al., 2004). Additionally, a population study examining specificity between different adversities and psychotic outcomes found that emotional neglect as well as physical, sexual and emotional abuse were equally associated with hallucinations, delusions and paranoia (Van Nierop et al., 2014a). Thus, even studies with greater methodological rigor, regarding specificity, show mixed results as to which specific adversity drives the risk for psychosis. Further to this, adversities often appear together in persons with psychotic disorders (Rosenberg et al., 2007, Ramsay et al., 2011 and DeRosse et al., 2014). While the body of psychosis research has been focused upon a search for specific adversities as risk factors, research into mechanisms and phenomenology of childhood and adolescent adversity may provide clues as to why this approach has not found conclusive results. The focal point in this research has been that persistent adversities are considered traumatizing if they are overwhelming and prevent the organism's return to physiological homeostasis. This mechanism is irrespective of the specific acts or lack of acts, and any abuse or neglect is potentially traumatizing (De Bellis, 2001). There are many examples of unspecific effects of traumatization: the immediate brain response of increased locus coeruleus activity is seen in relation to both fight, flight and freeze responses (Perry and Pollard, 1998 and De Bellis, 2001); the stress of different adversities, which is suggested to exert similar effects on cortico-limbic development (Teicher, 2010); and findings of individuals exposed to abuse and/or neglect having changes in brain connectivity networks as a group when compared to persons with no such history (Teicher et al., 2014). Additionally, no trauma treatment targets single adversities, but rather the consequences caused by traumatization. CBT, which is considered the most validated treatment for children and adolescents with PTSD (Silverman et al., 2008) focuses upon the cognitive, emotional and social consequences of traumatization (Cohen et al., 2006). Likewise, neurodevelopmental treatments seek to improve brain function where it has been impeded by traumatization (Perry, 2006). An investigation of the construction of adversity assessment tools also calls into question the possibility that specific adversity subcategories tap discrete and encapsulated experiences. For example, in the construction of the Childhood Trauma Questionnaire (CTQ) the created subcategories were not discrete: physical abuse was associated with therapist observation of both physical and emotional abuse (Bernstein et al., 2003). The mixed findings of associations between different specific adversities and risk of psychosis together with correlations between specific adversities, may suggest that the adversities represent an integrated phenomenon. This raises the issue of whether the focus upon the influence of specific adversities in psychosis research is preventing us from seeing their full effect. Alongside the substantial overlap between different childhood and adolescence adversities, there are indications of a dose-response effect on the risk of psychosis (Whitfield et al., 2005, Anda et al., 2006, Lataster et al., 2006, Shevlin et al., 2007, Arseneault et al., 2011, Heins et al., 2011 and Fawzi et al., 2013). However, some studies have not found an effect (Fisher et al., 2010 and Sahin et al., 2013). A dose-response effect implies that each adversity adds extra risk or has an interactive effect in the development of psychosis. The current study aims, in a case-control design, to explore the relation between adversity specificity and dose-response effect in an epidemiological sample of persons with non-affective first-episode psychosis compared to a non-clinical control group.