Dissertation Title: Childhood Sexual Abuse (CSA) and Psychosis in Later Life

Chapter 3: Critical Review of the Literature

To critically evaluate and analyse the chosen studies related to the topic in discussion, i.e.,
childhood sexual abuse (CSA) and psychosis is the main aim of this chapter. For this literature
review, six pieces of primary research studies were chosen due to their relevance to the research
questions and statement of purpose identified in chapter one. To make reasoned judgements
regarding the rigour and quality of the research, an assessment of the trustworthiness of the
literature will be conducted by using the key concepts of transferability, auditability,
confirmability and credibility. These reasoned judgments will assure that recommendations made
in discussion chapter have resulted from systematic appraisal of the best evidence available.
3.1 What is the relationship between childhood sexual abuse (CSA) and psychosis?
I will be focusing on the following two research studies by Sara et al (2013) and Paul et al
(2011) in order to answer the above question. Childhood sexual abuse and psychosis were the
emerging themes that were covered in both studies. Clear titles were maintained by both papers.
Abstracts that present rational summaries of the key points of the studies and the focus of the
phenomenon under examination were indicated by the titles of the papers.
To test theories of the relationship between selective attention, posttraumatic intrusions,
delusions and hallucinations, childhood sexual abuse (CSA) in first-episode psychosis (FEP) was
the main aim of the study by Sara et al (2013). According to Sara et al (2013), one of a risk
factor of psychosis is the childhood traumatic experiences, although the link between common
mental disorders and childhood trauma (CT) has long been established. A connection between
hallucinations and CT has been found by studies in groups with psychosis. According to
different theories, in psychosis one of the factors integral to the relationship between delusions,
hallucinations and CT is posttraumatic intrusive symptoms. Selective attention, intrusions,
posttraumatic stress disorder, hallucinations, first-episode psychosis and childhood trauma were
the elements that were focused throughout within this study.
In this study, a convenience sample of forty people with FEP participated. Into two groups, i.e.,
those who reported no CT and those who reported CSA the participants were divided. However,
for posttraumatic and psychotic and CT stress symptoms, around twenty-one non-clinical
controls and twenty-eight people with FEP were assessed. Through use of words related to CSA,
an emotional Stroop test was also completed by those twenty-eight people. Furthermore, to
determine the presence of heteroscedacity, heterogeneity of variance, and presence of non-
normality data screening was conducted.
The main outcomes of the study were that in comparison to those without CSA and with FEP,
severe delusions and hallucinations were found within those with CSA and FEP. For related
words to CSA selective attention was displayed by them and posttraumatic intrusions were also
reported at clinical levels. However, with the posttraumatic intrusions account of delusions and
hallucinations in those with psychosis and CSA there were consistent results. The theory that
severe delusions and hallucinations characterize psychosis with CT as an etiological factor was
supported by the results of this study.
Small sample size was the main weakness of this study as due to it the within-group analysis got
limited. Through a larger sample size, theoretically and clinically meaningful conclusions could
have been drawn. Another major weakness of this study was the possibility of biased or
inaccurate reporting of traumatic experiences that was introduced by the use of retrospective
reports of CT. For the widely theorized idea that post-traumatic intrusions may be involved in the
relationship between delusions and hallucinations and CSA in psychosis the empirical support
was provided by this study. For clinical practice, important implications were derived from this
study. It informs clinicians about the importance of assessment for the symptoms of PTSD in
people with psychosis and for CT. It suggests that for clinical interventions new avenues may be
provided by conceptualizing delusions and hallucinations.
Comparatively, to test hypotheses that there is a relationship between psychosis and sexual abuse
and with mediation by depression, anxiety, heavy cannabis use, and re-victimisation experiences
the relationship is consistent was the main study of Paul et al (2011). According to Paul et al
(2011), childhood sexual abuse is one of the bad experiences experienced by a child. Relatively
non specific effects connected with many psychiatric manifestations are exerted by childhood
sexual abuse. The mechanisms by which symptoms of psychosis are maintained and emerged are
illuminated by the relationship between psychosis and childhood sexual abuse.
In a representative cross-sectional survey of the adult household population of England the
prevalence of psychosis was established operationally within this study. A history of various
forms of sexual abuse was established through use of computer-assisted self-interview. Detailed
clinical and socio-demographic information was collected in the interview phase. With the
Clinical Interview Schedule (revised) (CIS-R) the non-psychotic psychiatric disorder was
assessed during the interview phase. For obtaining separate overall scores for depressive and
anxiety symptoms the facility of the CIS-R was employed within this study.
In childhood an earlier event in comparison to the development of psychosis is sexual abuse in
childhood. According to the theoretical perspective, experiential variables, such as, mental
dispositions and representations led directly by childhood sexual abuse is easily conceivable, as
an even a more complex mental disorder, like, psychosis is developed by them subsequently. An
association between anxiety and abuse was found that reflected that more severe symptoms,
including the persistence and development of positive symptoms of psychosis were involved.
The main outcome of this study was that in case of involved sexual intercourse a strong
relationship was found between childhood sexual abuse and psychosis. By re-victimisation
experiences or by heavy cannabis the relationship was not mediated. On the relationship between
psychosis and childhood sexual intercourse, there was little impact from re-victimisation,
however, the contact sexual abuse was magnified by it. A strong relationship between re-
victimisation and childhood sexual abuse is already provided by the existing literature. Higher
rates of mental illness, particularly schizophrenia has been found within people that are abused
as adults and higher levels of adult abuses are significantly suffered by psychiatric patients.
Therefore, the repetition and severity of abuse is strongly linked with the relationship between
psychosis and sexual abuse. However, for severity of abuse the re-victimisation may merely be a
marker. No relationship was found between psychosis or childhood sexual abuse or heavy use of
cannabis.
One of the main strengths of this study was that important implications for health and social
policy were maintained by its findings. The criminal justice system and the Social Services do
identify those people that have experienced sexual abuse. In primary care and in schools, there is
also increasing awareness. Through dealing with the psychological consequences of abuse there
are opportunities for targeted secondary and primary prevention. An important component of
psychiatric management and treatment is both sensitive and direct questioning. Besides strength
one of the main weaknesses of this study was its use of a random sample of the population as the
prevalence of sexual abuse and psychosis was distorted by it.
Both of the studies were based on CSA and psychosis. Sara et al (2013) revealed that in
comparison to those without CSA and with FEP, severe delusions and hallucinations were found
within those with CSA and FEP. For related words to CSA selective attention was displayed by
them and posttraumatic intrusions were also reported at clinical levels. However, with the
posttraumatic intrusions account of delusions and hallucinations in those with psychosis and
CSA there were consistent results. The theory that severe delusions and hallucinations
characterize psychosis with CT as an etiological factor was supported by the results of the study.
On the other hand, Paul et al (2011) revealed that in childhood an earlier event in comparison to
the development of psychosis is sexual abuse in childhood. According to the theoretical
perspective, experiential variables, such as, mental dispositions and representations led directly
by childhood sexual abuse is easily conceivable, as an even a more complex mental disorder,
like, psychosis is developed by them subsequently. An association between anxiety and abuse
was found that reflected that more severe symptoms, including the persistence and development
of positive symptoms of psychosis were involved. The main outcome of this study was that in
case of involved sexual intercourse a strong relationship was found between childhood sexual
abuse and psychosis. By re-victimisation experiences or by heavy cannabis the relationship was
not mediated. On the relationship between psychosis and childhood sexual intercourse, there was
little impact from re-victimisation, however, the contact sexual abuse was magnified by it. A
strong relationship between re-victimisation and childhood sexual abuse is already provided by
the existing literature. Higher rates of mental illness, particularly schizophrenia has been found
within people that are abused as adults and higher levels of adult abuses are significantly
suffered by psychiatric patients. Therefore, the repetition and severity of abuse is strongly linked
with the relationship between psychosis and sexual abuse. However, for severity of abuse the re-
victimisation may merely be a marker. No relationship was found between psychosis or
childhood sexual abuse or heavy use of cannabis.
3.2 What interventions are available in order to treat those who had experienced childhood
sexual abuse?
I will be focusing on the following two research studies by Jennifer and Elisa (2013) and Andrew
(2013) in order to answer the above question. Childhood sexual abuse, treatment practices for
CSA and interventions for CSA were the emerging themes that were covered in both studies.
Clear titles were maintained by both papers. Abstracts that present rational summaries of the key
points of the studies and the focus of the phenomenon under examination were indicated by the
titles of the papers.
According to Jennifer and Elisa (2013) for many young individuals one of the bitter realities is
childhood sexual abuse (CSA). In the communitys clinical settings the evidence-based
psychological interventions are not used frequently. For adolescents/children that have
experienced CSA, the evidence-based intervention is trauma-focused cognitive behaviour (TF-
CBT) and cognitive behaviour therapy. The main aim of this study was to examine the extent to
which evidence-based practices (EBP) are used by community-based psychologists for identified
predictors of EBP use and CSA. Dissemination, empirically supported intervention, adolescents,
children and sexual abuse were the main elements that were focused throughout this study.
Through the first census of adolescent and child psychology clinicians registered with the
College of Psychologists of Ontario the psychologists were identified. CSA treatment services to
adolescents and children in Ontario were provided by these psychologists. These psychologists
were the main participants of this study. A questionnaire related to attitudes toward EBP,
treatment provision, work setting, socio-demographics, and treatment strategies was completed
by these participants.
It was found that the use of an empirically based intervention for CSA was predicted by
attitudes, continuing education, theoretical orientation and age factors and this statement was
indicated by multiple regressions. In the EBP of trauma-focused cognitive behaviour therapy,
training was received by only five percent of psychologists. However, in specific treatment
approaches training was never received by majority of psychologists that were providing services
related to CSA. In specific treatment approaches for victims of CSA the training was received by
few community-based psychologists. Regarding the practice of psychologists who are
unsupervised and untrained, ethical concerns were also found. This study highlighted the
necessity for translation of continuing education, supervision and training into clinical practice.
One of the main strengths of this study is that it emphasized on the importance of understanding
the factors that impact the use of EBP and current treatment practices. This study identified that
in the area of interventions for adolescents/children that experienced sexual abuse there is a
significant disconnect between practice and research. The necessity to move beyond clinical
theories and guidelines was highlighted overall within this study. It emphasized on the
importance of having such a service approach that is more focused on cohesion and
accountability amongst the realms of practice and research. However, one of the main
weaknesses of this study is that in terms of observable behaviour it failed to address the validity
of self-reported actions as it relied on self-report measures. Secondly, the availability of
validated assessment instruments and previous research was limited.
Comparatively, Andrew (2013) investigated the overall physical and mental health functioning,
forced sexual trauma on severity of depression and posttraumatic stress disorder (PTSD) and the
adverse effects of CPA. According to Andrew (2013) the physical and mental impacts of forced
sexual trauma, CSA, and childhood physical abuse (CPA) on persons remain unevaluated
although with serious mental illness PTSD and trauma does take place frequently. Among
individuals with serious mental illness the sexual and physical abuse during childhood are
commonly reported. It has been found from previous studies that diathesis of serious mental
illness is contributed and on the developing bran a neuropathological influence is exerted by
childhood abuse. In comparison to adulthood trauma, one of the stronger predictors of PTSD is
childhood abuse. Increasing rates of chronic medical conditions and health issues and reduced
physical health is associated with increased exposure to traumatic events.
The main outcome of this study was that it found a direct relationship between physical health
issues, depression and PTSD and reduced physical and mental health functioning with CSA and
exposure of sexual trauma connected with heightened depression and PTSD. These clinical
domains were less significantly affected by CPA. It also concluded that increased treatment and
screening of sexual traumas is required as in the physical and mental health outcomes of
individuals with serious mental illness were influenced negatively due to sexual traumas.
My Articles:
3.3 What role does the nurse play in helping those who have been sexually abused?
My Articles: Do mental health professionals enquire about
childhood sexual abuse during routine mental
health assessment in acute mental health settings?
A substantive literature reviewj pm_1939 473. .483
My Themes: