Community Ment Health J (2015) 51:5462

DOI 10.1007/s10597-014-9755-2

ORIGINAL PAPER

Cumulative Effects of Childhood Traumas: Polytraumatization,

Dissociation, and Schizophrenia
lvarez Helga Masramon
Mara-Jose A
Carlos Pena Marina Pont Caroline Gourdier
Pere Roura-Poch Francesc Arrufat

Received: 29 December 2012 / Accepted: 6 July 2014 / Published online: 15 July 2014
 Springer Science+Business Media New York 2014

Abstract The study objective was to measure and compare the presence of childhood trauma and dissociative
symptoms in a convenience sample of healthy controls and
a probabilistic sample of outpatients with a diagnosis of
schizophrenia. Patients reported more childhood trauma
and more polytraumatization than the controls, and had a
higher average dissociation score. In both cases and controls, the presence of childhood trauma was related to the
intensity of the dissociation observed. Childhood trauma,
clinical dissociation and schizophrenia are closely related,
particularly when the patient has been the victim of more
than one type of abuse.

lvarez (&)
H. Masramon
C. Pena
C. Gourdier

M.-J. A
F. Arrufat
Mental Health Department, Vic Hospital Consortium, 1,
Francesc Pla Street, 08500 Vic, Barcelona, Spain
e-mail: Mlaalonso@hotmail.com
H. Masramon
e-mail: helga.masramon@gmail.com
C. Pena
e-mail: cmpena@chv.cat
C. Gourdier
e-mail: globe__c@hotmail.com
F. Arrufat
e-mail: farrufat@chv.cat
M. Pont
P. Roura-Poch
Clinical epidemiology and Research Department, Vic Hospital
Consortium, 1, Francesc Pla Street, 08500 Vic, Barcelona, Spain
e-mail: marina_pont@hotmail.com
P. Roura-Poch
e-mail: proura@chv.cat

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Keywords Schizophrenia
Dissociation
Childhood

trauma
Severe mental illness

Introduction
Childhood Trauma and Psychosis
There is now a broad consensus that confirms schizophrenia as a neurodevelopmental disease caused by the
interaction of genetic and environmental factors. Childhood trauma is one of the non-hereditary factors intimately
related to the development of schizophrenia in adulthood.
In a review of 51 studies of psychotic patients completed
between 1987 and 2005 (Read et al. 2005), a history of
sexual abuse was documented in 47.7 % of women and
28.3 % of men, of physical abuse in 47.8 and 50.1 %, and
of at least one type of abuse in 68.8 and 58.1 %,
respectively.
In 2004, two studies in large populations were published
(Bebbington et al. 2004; Janssen et al. 2004), both of which
reported a significant relationship between childhood abuse
and the development of psychosis in adulthood.
Although the consideration of childhood trauma as the
only cause of some types of schizophrenia is not yet confirmed and awakens controversies, a traumagenic neurodevelopment (TN) model has been proposed that could
explain this relationship (Read et al. 2001). The TN model
is based on central nervous system (CNS) similarities
encountered between individuals severely traumatized in
childhood and those affected by schizophrenia, with
respect to structural and neurobiological anomalies (dysregulation of the hypothalamicpituitaryadrenal axis,
abnormalities in dopaminergic transmission, hippocampal damage, brain atrophy and ventricular asymmetry).

Community Ment Health J (2015) 51:5462

Therefore, this model suggests that very severe trauma

constitutes a vulnerability factor in the biological stressvulnerability system, independent of genetic predisposition.
Polytraumatization
On the other hand, having experienced more than one type
of trauma in childhood (polytraumatization) was predictive
of retraumatization and related to more symptoms of rage
and depression in children and adolescents (Turner et al.
2006; Finkelhor et al. 2007), and in adults was related to
increased post-traumatic stress symptoms (Clemmons et al.
2007), chronic depression (Tanskanen et al. 2004), and
symptoms of psychosis (Shevlin et al. 2008).
Researchers are currently analyzing the impact of
cumulative traumas in childhood on mental health, and
whether the effect is more than a mere summation. In a
very broad sample of 51,945 individuals from 21 countries,
nine classified as high income, six as high-middle income,
and six as low/lower-middle income, a 2010 study of
World Health Organization mental health surveys observed
a universal impact of accumulated adversities in childhood
on the development of Axis I disorders of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV);
psychotic disorders were not studied. Childhood adversities
often co-occurred, and these clusters were associated with
maladaptive family functioning and linked with the highest
risk of mental disorders. Subadditive adversities were also
associated with maladaptive family functioning (Kessler
et al. 2010).
Along the same lines, an earlier study with a smaller
sample had observed a relationship between childhood
trauma and the development of depressive disorders, drug
abuse, and antisocial behaviors in young adults. The study
also concluded that this was more attributable to the
severity of the individual traumas experienced by these
patients with multiple childhood adversities than to the
accumulation of traumas per se (Schilling et al. 2008).
Trauma, Schizophrenia, and Dissociation
The concept of dissociation or dissociative symptomatology is widely associated with childhood trauma. Van der
Harts theory of structural dissociation suggests that the
personality of highly traumatized human beings dissociates
into parts that coexist and alternate, each maintaining its
own basic psychobiology (Van der Hart et al. 2011). This
theory would explain a whole spectrum of psychiatric
conditions related to traumatization, including post-traumatic stress disorder, somatoform and dissociative disorders, and borderline personality disorders.

55

Studies published over the past decade have reported

significant relationships between the different types of
childhood trauma and the development of dissociative
symptoms. In women from a general population, emotional
abuse, sexual abuse, and physical neglect were related to
the presence of dissociative pathology (S ar et al. 2007). In
patients with disorders along the schizophrenic spectrum,
in clinically stable patients with schizophrenia a relationship has been observed between adversity in early stages of
development and dissociation, specifically physical abuse
(Sar et al. 2010), emotional abuse (Holowka et al. 2003;
Schafer et al. 2006), physical negligence (Vogel et al.
2009; Schafer et al. 2012), and sexual abuse (Ross and
Keyes 2004).
Some studies indicate that the relationship between
childhood trauma and psychotic symptoms, especially
hallucinations, in patients on the schizophrenic spectrum is
mediated by dissociation (Perona-Garcelan et al. 2012;
Varese et al. 2012).The mediating effect of depersonalization could facilitate attribution of events (thoughts and
intrusive memories) to external sources, which is probably
how the hallucinations surface (Perona-Garcelan et al.
2012). The explanations given for these findings suggest
the possibility that hallucinations could be more a dissociative than a psychotic symptom (Moskowitz and Corstens
2007).Hearing voices, a common hallucination in schizophrenia, is also very common in patients with dissociative
identity disorder (DID) (Ross et al. 1990).
This overlap between some schizophrenias and DID,
which exists in the definition and even the name given to
dementia praecox by Bleuler (schizophrenia, meaning split
mind). This indefinition persists to the present day in the
DSM-IV (American Psychiatric Association 2000), in
which the diagnosis of schizophrenia requires only one
item from criterion A: if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the persons behavior or thoughts, or two or
more voices conversing with each other. This criterion is
met by many patients with DID (Ross et al. 1990).
Ross and Keyes (2004) propose the concept of dissociative schizophrenia, which is included in the model
explaining structural dissociation. This is a useful and
plausible hypothesis that could help to clarify the intricate
relationship between the two disorders. The study from
which this concept evolved included a sample of 60
patients with schizophrenia, divided into two groups based
on Dissociative Experience Scale (DES) scores. The study
established that patients with high dissociation had more
history of severe childhood trauma, more positive and
negative symptomatology, and more comorbidity with
other psychiatric pathologies at Axis III of the DSM-IV
(American Psychiatric Association 2000). The existence of

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Community Ment Health J (2015) 51:5462

this subtype of schizophrenia was later corroborated by Sar

et al. (2010).
Based on the theoretical framework and the various
studies mentioned above, the present study of patients with
psychosis tested the hypothesis that childhood trauma and,
more specifically the cumulative effect of different types of
abuse, is related to the development of schizophrenia in
adulthood and that having experienced trauma, and particularly polytraumatization, would be related to more
dissociative symptomatology in patients on the psychotic
spectrum.
The study objectives were the following:
1.

2.

3.
4.

To quantify the prevalence of childhood trauma in the

healthy population and in patients with psychotic
spectrum disorders and analyze any differences
between the two groups.
To measure dissociation as a continuous variable and
test its relationship with the different types of childhood trauma reported in patients and controls.
To compare the prevalence of polytraumatization in
patients and controls.
To determine for each group whether there is a
relationship between the level of dissociation and
childhood polytraumatization.

Methods
Design and Participants
This retrospective casecontrol study assessed 123 individuals, including 45 individuals with a serious mental
disorder and 78 healthy controls. Patients were consecutively recruited from the outpatient population of the Osona
Mental Health Center (Consorci Hospitalari de Vic). All
patients 18 years of age with a diagnosis of schizophrenia
or schizoaffective disorder according to DSM-IV criteria
were invited to participate when they visited their outpatient clinic. Patients were excluded if they declined to
participate or if the severity of their clinical profile was
likely to compromise their responses to questionnaires
administered by interviewers. The threshold for exclusion
was defined as severe disorganized speech, delusional
ideation, and/or hallucinations.
The control group was composed of a convenience
sample of volunteers older than 18 years from the general
population, recruited from university students and colleagues. Exclusion criteria were any report of current or
previous mental disease and/or psychopharmacologic
treatment.

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Instruments

CTQ-SF (Bernstein et al. 1994): The short form of the

Childhood Trauma Questionnaire (CTQ-SF) was
used to assess childhood trauma. This questionnaire is
widely used internationally for the study of traumatic
experiences in childhood. Its 28 items are grouped into
two types of trauma and five specific factors (abuse:
physical, emotional, sexual; neglect: physical, emotional). It has high temporal stability (r = 0.80) and
good internal consistency (Cronbach a = 0.620.92).
In general terms, this questionnaire has acceptable
validity, particularly convergent and discriminant
validity. The response format is based on a 5-point
Likert-type scale (1-never to 5-very often). Each area is
evaluated by five items and there are three control items
to determine possible minimization of responses. Each
dimension was assessed for the presence or absence of
the trauma described and the scores achieved, which
did not follow a normal distribution (Kolmogorov
Smirnov, p \ 0.05). Validation of the Spanish-language edition of the instrument was recently published
(Hernandez et al. 2013).
DES-II (Carlson and Putnam 1993): An adapted
Dissociative Experiences Scale (DES-II) was used to
assess dissociative symptomatology. The scale consists
of 28 items, which measure the frequency of three
dimensions of dissociation (abstraction, amnesia, and
depersonalization/derealization). Each item is quantified for each person using a 100-point scale with
10-point intervals (0-never to 100-always). There is no
cutoff point indicating pathology because the scale is
oriented toward the quantitative measurement of
dissociative symptoms. With respect to psychometric
properties, the original scale has high testretest
reliability (r = 0.96 after 4 weeks) and high internal
consistency (Cronbach a = 0.95). It also has good
construct validity and high sensitivity and specificity to
appropriately identify individuals with dissociative
symptomatology and exclude those with no dissociative
symptoms (74 and 80 %, respectively). The Spanish
adaptation used in this study has been validated and has
psychometric properties similar to the original (Icaran
et al. 1996).

Procedures
The diagnosis of schizophrenia or schizoaffective disorder,
according to DSM-IV criteria, was confirmed for all participating patients prior to their inclusion in the study. Data
collection and interviews were completed between May

Community Ment Health J (2015) 51:5462

2011 and May 2012 by evaluators not involved with the

patients clinical follow-up.
Demographic data were recorded for all participants,
including age, sex, education level, and employment. Cases
and controls were matched by age (5 years) and sex.
The CTQ and DES were administered to both groups of
participants. In the control group, both questionnaires were selfadministered; a team of researchers obtained informed consent
and collected the study questionnaires. In the patient group, the
CTQ was self-administered but the interviewer read aloud the
various options for responding to the DES. They intervened
occasionally, as requested by respondents, to explain any
concept that required clarification. This protocol was suggested
by the authors who validated the DES in Spanish: The
majority of patients opted for the interview approach to completing the scale when this was offered in response to doubts
they expressed after reading the items or concerning the scoring
of the prevalence of their experiences (Icaran et al. 1996).
Difficulty in focusing attention (inherent in many of these
patients) was another factor in designing our alternative
approach to administration of the scale.
Retrospective studies are frequently criticized for the
potential unreliability of traumatic memories in patients with
psychotic disorders. However, a recent study (Fisher et al.
2011) applied rigorous methods and corroborated reasonably
good reliability of traumatic memories in this patient population. Specifically, their descriptions of the trauma
remained stable over time (testretest reliability) and the
patients mental health status at the time of the interview was
unrelated to any change in traumatic memories. Furthermore, the abuses described in patient narratives coincided
with those reported in the surveys (convergent validity).
Definition of Polytraumatization
We defined polytraumatization in two different ways to
analyze the impact of more than one type of childhood
trauma. The first definition was dichotomous, distinguishing participants with no history of trauma or only one type
of traumatic experience (the reference category) from those
who had experienced two or more types of trauma (polytraumatization). The second definition had three categories:
no polytraumatization (no trauma or only one type),
moderate polytraumatization (two or three trauma types),
and extreme polytraumatization (four or five trauma types).
Statistical Analysis
Using SPSS 19.0, we described the sociodemographic
variables of the cases and controls included in the study.
Scores were calculated for the specific questionnaires; the
average and median values are presented. The number of
traumas and the dissociation scores were analyzed. Chi

57

square was used for bivariate analysis of the qualitative

variables and odds ratios for risk assessment, Student T test
to compare the averages of two independent groups of
quantitative variables, and analysis of variance (ANOVA)
for k independent groups. For variables with non-normal
distribution, the corresponding non-parametric tests were
used: MannWhitney U test to compare the median values
of two independent groups or KruskalWallis for k independent samples. Significance was set at p \ 0.05.

Results
Descriptive Statistics
Age, Sex, Education, and Employment
Males constituted 55.5 % of the patients and 43.6 % of
controls. Chi square test showed no significant differences
by sex between cases and controls (p [ 0.05).
The average age of participants was 37.9 years (95 % CI
35.940.0), 41.1 for cases (95 % CI 38.343.9) and 36.1
for controls (95 % CI 33.338.9). There was a significant
age difference between cases and controls (Student T,
p \ 0.05).
Among controls, 11.5 % had not completed mandatory
secondary education and 71 % had completed upper secondary or university studies. Among patients (cases),
26.6 % had not completed mandatory secondary education
and 40 % had completed secondary school or university
studies. Most of the controls (71.8 %) were actively
employed, compared to 66.3 % of patients, who were
unemployed due to their chronic illness. The differences in
educational and employment status were in line with
expectations for individuals with serious mental illness
originating in their youth.
Childhood Trauma Questionnaire
The presence and type of trauma was assessed (yes/no) in
each dimension of the CTQ. Table 1 presents the results for
cases and controls on each dimension. There was a significantly greater presence of physical neglect and abuse
and of sexual abuse among cases, compared to controls.
Patients scored more highly than healthy controls on all
dimensions of trauma. Using the MannWhitney U test, the
difference was significant for physical neglect, physical
abuse and sexual abuse (Table 2).
Dissociative Experience Scale
The contrast between cases and controls in DES scores on
dissociative symptoms (which did not follow a normal

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Community Ment Health J (2015) 51:5462

Table 1 Distribution of the presence of trauma (by CTQ dimensions)

between cases and controls
CTQ dimensions
(Types of trauma)

Controls (%)

Cases (%)

Physical neglect

30.7

75.6

p \ 0.05

Emotional neglect

87.1

91.1

Not significant

Emotional abuse
Physical abuse

60.2
20.5

68.9
42.2

Not significant
p \ 0.05

Sexual abuse

15.3

45

p \ 0.05

distribution; KolmogorovSmirnov, p \ 0.05) was significant (MannWhitney U test, p \ 0.05). Cases, with an
average score of 13.21 points, had significantly more dissociation than controls, with an average score of 5.54
points.
For both cases and controls, we assessed the relationship
between the different dimensions of the CTQ (type of
trauma) and the total scores obtained on DES-II (Table 3).
In the control group, the presence of any of the five types of
childhood trauma increased the dissociation score. The
increase was significant for participants who had experienced physical neglect and/or emotional abuse (Mann
Whitney U test, p \ 0.05).
The patient group also had higher dissociation scores in
the presence of any form of trauma. The scores obtained
were significantly higher when there had been sexual,
physical, or emotional abuse (MannWhitney U test,
p \ 0.05).
Polytraumatization in Cases and Controls
Classified Dichotomously When the presence of polytraumatization was studied as a dichotomy (no trauma or
one type vs. two or more trauma types), 73.9 % of participants88.9 % of cases and 65.4 % of controlshad
experienced polytraumatization (Table 4). Chi square test
showed a significant relationship between polytraumatization and a diagnosis of schizophrenia (p \ 0.05), and the
odds ratio (OR) was 4.24 (95 % CI 1.5011.98); this allows

Table 2 Distribution of scores

(by CTQ dimension) between
cases and controls

x Mean, SD Standard deviation,

Mdn Median, Min Minimum,
Max Maximum

123

us to conclude that cases were four times more likely than

controls to have experienced two or more traumas.
Classified into Three Groups Maintaining the same category of non-polytraumatization (0 or 1 trauma) and
reclassifying polytraumatization as moderate (2 or 3 traumas) or extreme (4 or more traumas), 48.0 % of the participants (51.3 % of controls vs 42.2 % of cases) had
experienced moderate polytraumatization and 26.0 %
(14.1 % of controls vs. 46.7 % of cases) extreme polytraumatization (Table 5). The Chi square test remained significant (p \ 0.05) and OR expresses the strength of this
relationship. When we compared non-polytraumatization
with moderate polytraumatization, we obtained a non-significant OR of 2.57 (95 % CI 0.857.70). The OR was significant for the comparison of non-polytraumatization with
extreme polytraumatization (OR 10.30 [95 % CI
3.1034.27]) and of moderate polytraumatization with
extreme polytraumatization (OR 4.01 [95 % CI 1.1610.0]).
In other words, individuals with extreme polytraumatization
were 10 times more likely to have a diagnosis of schizophrenia than those without polytraumatization and four times
more likely than those with moderate polytraumatization.

Polytraumatization and Dissociation

We compared the DES scores of participants who reported
polytraumatization (2 or more traumas), averaging 10
points (range 1.0776.79), to those with no polytraumatization (average of 4.11, range 0.3616.07). MannWhitney
U test identified significant differences (p \ 0.05). Table 6
presents the dissociation scores for cases and controls, with
and without polytraumatization; both cases and controls
with polytraumatization scored significantly higher on
dissociation. Comparative analysis of polytraumatization
using three categories to assess dissociation in cases and
controls produced the same results and the same significant
difference between categories: those with higher polytraumatization scored higher on dissociation (Fig. 1).

Type of trauma
(point scores)

Controls

Cases

SD

Mdn

Min

Max

Physical neglect

5.92

2.23

5.00

4.00

20.00

7.93

2.89

Emotional neglect

9.38

3.60

9.00

5.00

24.00

11.67

Emotional abuse

7.45

3.46

6.00

4.00

19.00

Physical abuse

5.94

2.49

5.00

4.00

Sexual abuse

5.46

1.70

5.00

5.00

p
SD

Mdn

Min

Max

7.00

5.00

17.00

p \ 0.05

5.44

10.00

4.00

24.00

Not
significant

9.89

5.32

8.00

5.00

24.00

Not
significant

17.00

7.60

4.17

5.00

5.00

20.00

p \ 0.05

16.00

7.98

5.13

5.00

5.00

25.00

p \ 0.05

Community Ment Health J (2015) 51:5462

Table 3 Distribution of
dissociation scores and
relationship to CTQ dimensions
of trauma

Diagnosis

59

Type of trauma

DESII average dissociation scores

x

SD

Mdn

Min

Max

p \ 0.05

Physical neglect
Controls
Cases

No

54

6.18

4.49

4.82

1.07

21.07

Yes

24

10.24

7.95

7.86

2.50

30.71

No

11

11.04

6.79

8.57

0.36

25.00

Yes

34

21.00

17.79

14.29

2.14

76.79

Not significant

Emotional neglect
Controls
Cases

No

10

4.50

3.13

4.11

1.07

11.07

Yes

68

7.86

6.25

5.71

1.07

30.71

No

3.03

19.66

5.18

0.36

42.50

Yes

41

9.08

16.16

13.21

2.14

76.79

Physical abuse
Controls
No
Cases

62

6.52

4.94

5.00

1.07

24.29

Yes

16

10.94

8.43

9.82

1.07

30.71

No

26

15.73

17.02

9.82

0.36

76.79

Yes

19

22.46

14.90

18.21

7.50

65.71

No

31

5.17

3.43

3.93

1.07

1.71

Yes

47

8.91

6.90

7.14

1.07

30.71

No

14

9.03

6.78

7.32

0.36

26.43

Yes

31

22.88

17.59

16.79

2.14

76.79

Not significant
Not significant

Not significant
p \ 0.05

Emotional abuse
Controls
Cases

p \ 0.05
p \ 0.05

Sexual abuse
Controls
N Number of subjects, x Mean,
SD Standard deviation, Mdn
Median, Min Minimum, Max
Maximum

Table 4 Polyvictimization, two

values. Distribution of cases and
controls

Cases

No

66

7.28

5.71

5.36

1.07

24.29

Yes

12

8.24

7.84

6.79

1.79

30.71

No

27

12.49

10.08

8.57

0.36

42.50

Yes

18

2.70

19.69

20.37

0.36

76.79

Polyvictimization

Controls
N

Cases
%

Total
%

No

27

34.61

11.11

32

Yes

51

65.39

40

88.89

91

Total

78

100

45

100

123

Not significant
p \ 0.05

p
%
26.01
73.99

p \ 0.05

100

Discussion

Dissociation in Cases and Controls

Childhood Trauma in Patients and in Healthy Controls

Individuals affected by a psychotic disorder present with

more dissociative symptoms than do those with no psychiatric pathology. The average of 18.5 points on the DES
scored by the group of patients with schizophrenia concurs
with the findings of other studies that range from 11.9 to 21
points (Sar et al. 2010; Schafer et al. 2006, 2012; Vogel
et al. 2009). In two of those studies (Schafer et al. 2006,
2012), Schafer reports a decrease in acute DES scores once
the patients are stabilized. Our study included outpatients
who attended scheduled visits, which excludes recruitment
of the most severe cases. This may have decreased the

Our work corroborates previous studies (Read et al. 2005;

Bebbington et al. 2004; Janssen et al. 2004) that have
related childhood trauma to schizophrenia. In our study,
patients had more history of physical neglect, physical
abuse, and sexual abuse than controls. Experiencing some
type of childhood trauma doubled the risk of developing
psychosis as an adult. These results support the study
hypothesis that traumatic experiences early in life are
related to the development of schizophrenia.

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Table 5 Polyvictimization,
three values. Distribution of
cases and controls

Polyvictimization

Controls
N

Cases
%

Total
%

p
%

No polyvictimization

27

34.6

11.1

32

26.0

Moderate polyvictimization

40

51.3

19

42.2

59

48.0

p \ 0.05

Extreme polyvictimization

11

14.1

21

46.6

32

26.0

p \ 0.05

Total

78

100.0

45

100.0

123

100.0

Table 6 Points scored for dissociation and polyvictimization by cases and controls
Polyvictimization

Dissociation points
N

Controls
Cases

SD
4.94

3.38

Mdn
3.92

Min

Max

1.07

15.71

p \ 0.05

0 or 1 trauma

27

2 or [ traumas

51

8.75

6.71

7.14

1.07

30.71

0 or 1 trauma

6.64

5.92

6.43

0.36

16.07

2 or [ traumas

40

20.06

16.63

13.75

2.14

76.79

p \ 0.05

N Number of subjects, x Mean, SD Standard deviation, Mdn Median, Min Minimum, Max Maximum

and in patients. Emotional, physical, and sexual abuse seem

to be closely related to dissociation in schizophrenic
patients. Our study concurs with previous reports that
related dissociation in patients with schizophrenia to
physical abuse (Sar et al. 2010; Ross and Keyes 2004),
emotional abuse (Holowka et al. 2003; Schafer et al. 2006),
and sexual abuse (Schafer et al. 2012; Ross and Keyes
2004).

30
28

CONTROLS

26

CASES

24

Average DES Score

22
20
18
16

Polytraumatization in Patients and Controls

14

In agreement with a recent study (Shevlin et al. 2008), we

observed that being the victim of more than one type of
childhood trauma is related to increased presence of psychosis in adulthood. The risk of developing a disorder on
the schizophrenic spectrum is 4.23 times greater in the
presence of polytraumatization. This risk was 10 times
greater in patients who had experienced more than four
types of abuse, compared to controls.

12
10
8
6
4
2
0
NO POLYVICTIMIZATION

MODERATE
POLYVICTIMIZATION

EXTREME
POLYVICTIMIZATION

Fig. 1 Dissociation score and degree of polyvictimization in cases

and controls

presence of dissociative symptoms that overlap acute

symptoms of psychosis. We found only one study that
reports similar dissociation in controls and schizophrenic
patients (17.2 and 14 points, respectively); the higher dissociation score in the control group is remarkable (Brunner
et al. 2004).
As in previous studies, we report a relationship between
having experienced childhood trauma and the intensity of
dissociative symptomatology, both in healthy individuals

123

Dissociation and Polytraumatization

Most (89 %) of the patients had experienced multiple types
of abuse and these same patients had an average dissociation score of 20 points. The literature associates this value
with disorders that have a major dissociative component,
such as borderline personality disorder (Brunner et al.
2004; Putnam et al. 1996). Patients without multiple traumas had an average DES score of 6.64 points, coinciding
with that of controls (7.43 points). In patients who had
experienced four or five types of trauma, or extreme
polytraumatization (almost half of all cases), dissociation
shot up to an average DES of 27.27. This score is higher

Community Ment Health J (2015) 51:5462

than the averages of the borderline patients in other studies

and coincides with those of patients with post-traumatic
stress disorder (Zanarini et al. 2000).
The sharp increase in the intensity of dissociative
symptoms and in the risk of developing a psychotic disorder observed in extreme polytraumatization, but not in
the context of moderate polytraumatization, leads to the
conclusion that even though trauma is involved in the etiopathogenic mechanisms of the psychosis, extreme polytraumatization could be a determining factor for risk as
well as for the later clinical profile. These findings support
the concept of dissociative schizophrenia proposed by Ross
and Keyes (2004), who reports that 60 % of schizophrenic
patients are high dissociators (DES [ 25) and had suffered
more physical and sexual abuse. Therefore, the relationship
between childhood maltreatment and dissociation in
schizophrenic patients could be mediated by polytraumatization. One possible explanation could be that resiliency
factors are diminished as the number of types of trauma
increase and the environment becomes increasingly hostile
on multiple fronts.

61

the victim of more than one type of trauma. The importance of assessing possible trauma events and the presence
and intensity of dissociative symptoms in all patients with
schizophrenia is increased by the possibility of supplementing normal treatment with validated psychological
therapy to integrate the dissociated parts of the personality
(Guidelines for Treating Dissociative Identity Disorder in
Adults 2011).
On the other hand, this study suggests new hypotheses
about the role of more than one type of abuse during
childhood in the development of schizophrenia in adults.
Our work shows that patients with extreme polytraumatization in childhood not only have a 10 times higher risk of
schizophrenia but also have very high dissociation compared to patients with no history of polytraumatization.
Future research is needed that takes into account not only
the number of types of traumas but also their frequency and
intensity and their relationship to adult schizophrenia and
its clinical characteristics.
Acknowledgments To Elaine Lilly, Ph.D., for her invaluable
assistance not only with the English language but also with thoughtful
questions that have helped us to clarify the presentation of our work.

Limitations
References
The 5-year difference in age between the patient group
(41 years) and the control group (36 years) is a potential
study limitation. Although there are no studies showing
that age affects the recollection of childhood trauma, we
consider it important to note this possible source of bias.
Another limitation is the small number of patients (45) on
the schizophrenic spectrum.
We would also point out the very high rate of emotional
neglect encountered in both patients and healthy controls
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CTQ discrimination between emotional neglect and situations that might be construed as within normal limits
because of their very high frequency.
We have focused on the number and type of traumas,
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is part of the nuclear family or not. We recognize that
greater dissociation has been reported when the perpetrator
of sexual aggression is a member of the childs family
(Plattner et al. 2003).

Conclusions
Childhood trauma, clinical dissociation and schizophrenia
are closely related, particularly when the patient has been

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