It has been suggested that sexual trauma in childhood may increase an individual's vulnerability to schizophrenia and exacerbate the effects of the disease over time (1). Studies have found that the incidence of childhood sexual trauma among adults with schizophrenia greatly exceeds that of the general population (1,2,3), and a history of sexual abuse has been linked to more severe levels of positive symptoms (4), graver levels of general psychopathology (5,6), greater use of services and higher cost of care (7), and possibly poorer outcomes (8).
Less clear is how childhood sexual trauma may affect psychosocial functioning among adults with schizophrenia. Deficits in functioning are a defining feature of schizophrenia. They are detectable early in the course of the illness, and they often persist after acute symptoms have been resolved (9). However, no published study has directly addressed the question of whether sexual trauma during childhood further erodes psychosocial functioning among adults with schizophrenia. In other words, does sexual trauma constitute an additional impediment to the ability of persons with schizophrenia to function socially and to function appropriately in a given role?
We hypothesized that persons with schizophrenia who had experienced childhood sexual trauma might demonstrate greater psychosocial deficits than those who had not for several reasons. First, from a psychological perspective, research has suggested that childhood sexual trauma can profoundly disrupt the ability to trust and to form attachments with others, thereby creating greater emotional instability and a lasting barrier to intimate relationships and role function (10,11,12). Second, from a biological perspective, exposure to sexual trauma may alter hormonal balance, resulting in maladaptive responses to stress and disrupting the ability to process and express painful affect (13,14,15). Thus it may be that the psychological and biological effects of sexual trauma among individuals with schizophrenia combine to reduce the ability to form attachments and cope effectively.
Consequently, in this study, we concurrently assessed psychosocial functioning and history of sexual trauma among adults who had been diagnosed as having schizophrenia. We hypothesized that individuals who had experienced trauma would exhibit poorer levels of role or work functioning, a pattern of less frequent social contact with others, lower levels of the psychological resources necessary for interpersonal relationships, and higher levels of vulnerability to emotional turmoil.
Participants were recruited from the outpatient psychiatry service of a Veterans Affairs Medical Center between 1999 and 2000. The initial sample comprised 54 persons who had been diagnosed with the Structured Clinical Interview for DSM-IV as having schizophrenia (N=36) or schizoaffective disorder (N=18). Individuals were excluded if they had a history of mental retardation or traumatic head injury. All of the participants were in a postacute phase of their illness, as defined by no hospitalizations or changes in medication or housing in the past month. The mean±SD age of the participants was 44±9.32 years, and they had 12±1.8 years of education. Fifty-two participants were male and two were female; 38 were Caucasian and 16 were African American. Their lifetime number of psychiatric hospitalizations was 7±7.9, with the first occurring on average at age 22.
The Quality of Life scale (QOL) (16) was used to assess the participants' current interpersonal and work functioning. The QOL is a 21-item scale that is completed by clinically trained staff after a chart review and a semistructured interview that is designed to elicit information about a patient's social and vocational functioning. The individual items of the QOL are scored on a 7-point Likert scale, with higher ratings indicating higher levels of functioning.
We used three subscales from the QOL: intrapsychic foundations, which measures the building blocks from which interpersonal functioning is derived and contains constructs such as "sense of purpose," "empathy," and "rapport"; interpersonal relations, which assesses various aspects of interpersonal and social functioning and contains items such as "social network," "social initiative," and "sociosexual function"; and instrumental role, which assesses functioning in a defined social role such as parent, student, or worker. Good to excellent interrater reliability ratings have been reported for the QOL (16,17). Although the QOL was originally designed to measure the deficit syndrome of schizophrenia, it has been widely used to study social functioning in general (16,17,18).
The NEO Five Factor Inventory (Form S) (NEO) (19) was used to examine personality dimensions that are relevant to social function. This test is a self-report assessment and is based on the five-factor model of personality. Participants are asked to rate on a 5-point Likert scale the degree to which individual statements are or are not true about themselves. Higher scores indicate greater levels of the personality dimension measured. The first two measures of the test—neuroticism and extroversion—were used for this study.
Neuroticism and extroversion represent temporally stable patterns of interrelated traits that have been widely studied in the general population. Extraversion involves such traits as gregariousness, warmth, and sociability; neuroticism involves such traits as emotional instability, self-consciousness, and vulnerability (20,21). Assessment of these two personality dimensions has been found to be reliable and stable among persons with schizophrenia (22,23,24), and both of these personality dimensions are related to role functioning (25). The NEO Five-Factor Inventory, which is the short form of the NEO Personality Inventory, has been used successfully in other studies of personality and schizophrenia (22).
Sexual trauma was determined by use of the Childhood Sexual Trauma Questionnaire (26), a true-false, self-report screening measure consisting of four items. The items ask whether respondents, as children, had experienced an adult exposing him- or herself and whether an adult had threatened them with intercourse, had touched their genitals, or had had intercourse with them. This questionnaire was developed for epidemiological research and has been used with psychiatric populations.
After the participants provided written informed consent and their diagnoses were confirmed, the research staff conducted the three tests under the supervision of a clinical psychologist. The QOL was conducted and scored by researchers who were blinded to responses to the NEO and the sexual trauma questionnaire. In a posttest interview at the conclusion of the assessment, participants were asked to describe the instructions of each questionnaire to determine whether they had accurately understood them.
In the posttest interview, all the participants demonstrated a basic understanding of the instructions on the sexual trauma questionnaire. Nineteen participants (35 percent) indicated that at least one item on the questionnaire was true for them and therefore were classified as having experienced sexual trauma. The other 35 participants (65 percent) denied any history of sexual trauma. No significant differences in age, gender, education, number of psychiatric hospitalizations, diagnostic classification, or race were found between the two groups.
Also in the posttest interview, four participants from the trauma group and six from the nontrauma group were unable to describe the instructions for completing the NEO. Their scores were excluded, leaving the NEO scores of 44 participants available for analysis.
Because multiple comparisons between the two groups were planned, multivariate tests were conducted before univariate analyses. A multiple analysis of variance comparing QOL and NEO scores revealed significant differences between the two groups (f=2.41, df=6, 37, p<.05). Subsequent analysis of variance indicated that the trauma group had significantly poorer ratings on the QOL instrumental role scale (f=4.37, df=1, 52, p<.05) and intrapsychic foundations scale (f=4.25, df=1, 52, p<.05). The mean±SD scores for participants in the trauma and nontrauma groups were 1.4±3.3 and 4.63±6.3, respectively, for instrumental role and 21±5.8 and 25.8±8.5 for intrapsychic foundations. Scores for interpersonal relations did not differ significantly between the two groups.
Participants in the trauma group also had significantly higher scores on the NEO neuroticism scale (f=4.38, df=1, 43, p<.05). The mean scores for participants in the trauma and nontrauma groups were 31.3±7 and 25.2±9.7, respectively, and t scores were 68 and 61. Scores on the extraversion scale did not differ significantly.
The results of this study support the hypothesis that sexual trauma in childhood is predictive of poorer psychosocial functioning in adulthood among individuals with schizophrenia. Participants who had a history of childhood sexual trauma had poorer role functioning, fewer of the psychological resources necessary for sustaining intimacy, and higher levels of emotional instability and turmoil.
Taken together, the results suggest that early sexual trauma among individuals with schizophrenia limits their ability to form attachments and to function in a socially defined role, such as a worker or a parent, and thus represents another form of insult that further compromises the ability of these individuals to have the quality of life they desire.
For clinicians, the results underscore the importance of assessing sexual trauma in this population. Because schizophrenia often involves severe and enduring psychosocial deficits, it is tempting to routinely attribute poor functioning to the global severity of illness. However, that view does not accurately capture the complexities of psychosocial dysfunction for persons with this illness. Overlooking the role of sexual trauma could also block or retard needed access to adjunctive treatments that have been shown to be effective for trauma survivors.
An unexpected finding was that the results of interpersonal relations and extroversion measures did not differ significantly between the trauma group and the nontrauma group. There is considerable overlap between the constructs these two measures assess, so the fact that we did not find any differences on either suggests that sexual trauma is not linked with frequency of socialization. It may be that deficits in socialization are so pervasive among persons with schizophrenia that socialization is infrequent regardless of trauma history. Sexual trauma may affect the quality but not the quantity of social relationships in this population.
Several limitations of this study should be noted. Most of the participants were male and in a postacute phase of illness. Our assessment of sexual trauma was brief; age at onset, severity, and frequency of sexual trauma were not assessed. It is also possible that some participants had the delusional belief that they had been victims when in fact they had not. Longitudinal studies that use more comprehensive assessments of sexual trauma history—both in childhood and in adulthood—are necessary. Studies should also be conducted among both men and women in the earlier phases of their illness.
The finding that childhood sexual trauma may compromise role and interpersonal functioning among adults with schizophrenia is intriguing, but it represents only a beginning. Many unanswered questions about the role of sexual trauma in the symptoms and outcomes of individuals with schizophrenia await future research. For instance, are impairments in work performance related to trauma history? If so, are these impairments global, or are they related to specific areas of work functioning, such as social interaction with coworkers? Even if general social activity is not affected, are certain types of relationships, particularly those that require greater intimacy, compromised? Additionally, is the relationship between sexual abuse and social functioning mitigated by other intervening variables, such as cognitive function, substance abuse, and medication compliance? Answers to these questions will help us to better understand the processes surrounding psychosocial dysfunction in schizophrenia and to develop and deliver more effective adjunctive treatments.
The authors acknowledge the considerable assistance and support of Brian O'Donnell, Ph.D.
Dr. Lysaker and Ms. Clements are with the Roudebush Veterans Affairs Medical Center and the Indiana University School of Medicine in Indianapolis. Ms. Meyers, Dr. Evans, and Ms. Marks are with Indiana University-Purdue University at Indianapolis. Send correspondence to Dr. Lysaker at Day Hospital 116H, 1481 West 10th Street, Roudebush VA Medical Center, Indianapolis, Indiana 46202 (e-mail, email@example.com).