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Exposure to childhood trauma is associated with an increased risk of developing and maintaining psychotic symptoms later in life. Self-esteem might be an important psychological process underlying the association between childhood trauma and psychosis, but there is only limited evidence to support this claim, especially in daily life.
In this study, we aimed to investigate whether exposure to childhood trauma (physical, emotional, and sexual abuse and physical and emotional neglect) moderates the cross-sectional and temporal associations between self-esteem and psychotic experiences in patients with psychotic disorders, their first-degree relatives, and controls.
We assessed momentary self-esteem and psychotic experiences in daily life using the experience sampling method in 139 patients with psychotic disorders, 118 first-degree relatives of patients with psychotic disorders, and 111 controls. Childhood trauma was measured using the Childhood Trauma Questionnaire. We fitted linear mixed models and added two-way and three-way interaction terms to test the hypotheses.
The association between momentary self-esteem and psychotic experiences in daily life was modified by prior exposure to high versus low levels of several types of childhood trauma, that is, physical (
The association between self-esteem and psychotic experiences in daily life was found to be stronger in those exposed to high versus low levels of several types of childhood trauma (ie, physical abuse, sexual abuse, and physical neglect).
Exposure to childhood trauma can have persistent adverse effects on an individual’s well-being, social development, and physical and mental health [
Evidence for familial liability to psychosis [
Several putative psychological mechanisms and processes have been posited to be involved in the association between childhood trauma and psychosis [
Self-esteem and psychotic experiences are often assessed using cross-sectional measures, with global scores [
Overall, there is limited evidence that exposure to childhood trauma moderates the association between self-esteem and psychotic experiences, especially in daily life. Exposure to childhood trauma plays an important role in the development and maintenance of psychosis [
Therefore, we aimed to investigate whether cross-sectional and temporal associations of momentary self-esteem and psychotic experiences in daily life were modified by prior exposure to childhood trauma (ie, physical, emotional, and sexual abuse and physical and emotional neglect) in patients with enduring psychotic disorders, their first-degree relatives, and controls. Specifically, using data from the Genetic Risk and Outcome in Psychosis (GROUP) study [
In patients, their first-degree relatives, and controls, the magnitude of associations of self-esteem and psychotic experiences in daily life (both measured with the ESM) is stronger in individuals exposed to high levels of each type of childhood trauma (ie, physical, emotional, and sexual abuse and physical and emotional neglect) than in those exposed to low levels of childhood trauma (measured using the Childhood Trauma Questionnaire [CTQ]; hypothesis 1).
The difference in the magnitude of associations of self-esteem and psychotic experiences in daily life between those exposed to high levels of childhood trauma and those exposed to low levels of childhood trauma is (1) greater in patients than in controls, (2) greater in relatives than in controls, and (3) greater in patients than in relatives (hypothesis 2).
In patients, their first-degree relatives, and controls, the temporal association (1) between self-esteem at tn-1 and psychotic experiences at tn and (2) between psychotic experiences at tn-1 and self-esteem at tn in daily life (both measured with the ESM) is stronger in individuals exposed to high levels of each type of childhood trauma than those exposed to low levels of childhood trauma (measured using the CTQ; hypothesis 3).
The difference in the magnitude of temporal associations of (1) self-esteem and psychotic experiences and (2) psychotic experiences and self-esteem in daily life between those exposed to high levels of childhood trauma and those exposed to low levels of childhood trauma is (1) greater in patients than in controls, (2) greater in relatives than in controls, and (3) greater in patients than in relatives (hypothesis 4).
A sample of patients with psychotic disorders, their first-degree relatives, and controls without a family history of psychotic disorders was recruited in the GROUP study [
Ethics approval was provided by the Ethical Review Board of the University Medical Centre Utrecht (METC: 0 4/003- O), and all participants gave written informed consent. For this analyses, only participants who completed the CTQ and, in line with previous ESM studies [
Using a sociodemographic schedule, data on age, gender, ethnicity, marital status, and educational level (adapted from the Dutch Standard Classification of Education) [
The Dutch version of the 25-item CTQ-short version [
The ESM was used at the 6-year follow-up assessment to collect data on self-esteem and psychotic experiences in daily life. Participants were offered an ESM briefing session that provided detailed instructions on the ESM procedure. Participants received a dedicated digital device (ie, PsyMate, ECS International B.V.), which emitted a beep at 10 semirandom times a day, within 90-minute time blocks, between 7:30 AM and 10:30 PM for 6 consecutive days. Each time the PsyMate emitted a beep, the participants were asked to complete an ESM questionnaire immediately after the beep. A debriefing session was scheduled after 6 days. Research has shown that the ESM in samples of patients with psychosis and their relatives is feasible, reliable, and valid [
To assess momentary self-esteem, the mean score of the following 2 ESM items was used: “I like myself” and “I doubt myself” (reversed) [
For this analyses, we used release 7.0 of the overall GROUP database and release 2.0 of the ESM data. The “mixed” command in Stata 13.0 (StataCorp) was used to fit linear mixed models. Because ESM data include multiple observations within each participant, they were treated as nested within participants and participants nested within families. Restricted maximum likelihood estimation was used to fit the models and estimated the associations between momentary self-esteem as the continuous independent variable and psychotic experiences as the outcome variable. We controlled for the potential confounders of age, gender, ethnicity (people of color or White), level of education, and marital status.
We then added two-way (self-esteem × abuse, self-esteem × group, and abuse × group) and three-way (self-esteem × abuse × group) interaction terms to test whether associations between self-esteem and psychotic experiences were modified by prior exposure to high (mean + 1 SD of continuous CTQ scores) versus low levels (mean − 1 SD of continuous CTQ scores) [
The third-wave (6-year follow-up) data of the GROUP study was completed by 486 participants (patients: n=194, 39.9%; relatives: n=169, 34.8%; and controls: n=123, 25.3%). Participants who did not complete the CTQ in the first wave (30/486, 6.2%) and a minimum of one-third of the ESM assessments in the third wave (88/486, 18.1%) were excluded from the analysis, resulting in a sample of 368 participants (patients: n=139, 37.8%; relatives: n=118, 32.1%; and controls: n=111, 30.2%). The basic characteristics of the excluded participants of the third-wave sample were broadly similar to those of the included participants (
Basic characteristics.
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Patients (n=139) | Relatives (n=118) | Controls (n=111) | Test statistics | ||||||||||||
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Age (years), mean (SD) | 34.5 (8.3) | 35.5 (8.7) | 41.0 (11.5) | 15.87 (2) | N/Aa | <.001 | ||||||||||
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N/A | 34.8 (2) | <.001 | |||||||||||||
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Men | 88 (65.2) | 47 (39.8) | 33 (29.7) |
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Women | 47 (34.8) | 71 (60.2) | 78 (70.3) |
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N/A | 5.2 (2) | .08 | |||||||||||||
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White | 123 (88.5) | 107 (90.7) | 107 (96.4) |
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People of color | 16 (11.5) | 11 (9.3) | 4 (3.6) |
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N/A | 42.2 (4) | <.001 | |||||||||||||
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Low | 35 (25.2) | 8 (6.8) | 3 (2.7) |
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Middle | 60 (43.2) | 45 (38.1) | 42 (37.8) |
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High | 44 (31.6) | 65 (55.1) | 66 (59.5) |
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N/A | 71.1 (4) | <.001 | |||||||||||||
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Not married | 101 (72.7) | 37 (31.4) | 25 (26.9) |
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Married or living together | 28 (20.1) | 76 (64.4) | 62 (66.7) |
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Divorced | 10 (7.2) | 5 (4.2) | 6 (6.4) |
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Current antipsychotic use (patients: n=100), n (%)d | 98 (98) | N/A | N/A | N/A | N/A | N/A | ||||||||||
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Emotional abusee | 9.5 (4.2) | 7.5 (3.1) | 7.1 (3.4) | 15.51 (2) | N/A | <.001 | |||||||||
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Physical abusee | 6.6 (2.9) | 5.7 (2.2) | 5.5 (1.6) | 8.53 (2) | N/A | <.001 | |||||||||
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Sexual abusee | 6.3 (3.1) | 5.6 (2.6) | 5.9 (3.0) | 1.93 (2) | N/A | .15 | |||||||||
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Emotional neglectf | 11.4 (4.1) | 10.6 (4.1) | 9.2 (3.9) | 9.25 (2) | N/A | <.001 | |||||||||
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Physical neglect | 7.2 (2.4) | 6.6 (2.5) | 6.0 (1.9) | 9.16 (2) | N/A | <.001 |
aN/A: not applicable.
bMissing values: 4/368, 0.01%.
cMissing values: 18/368, 4.9%.
dMissing values: 39/139, 28.1%.
eMissing values: 2/368, 0.5%.
fMissing values: 3/368, 0.8%.
Categorical Childhood Trauma Questionnaire severity scores by group.
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Patients (n=139), n (%) | Relatives (n=118), n (%) | Controls (n=111), n (%) | |||||
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32.8 (6) | <.001 | ||||||
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Severe to extreme | 13 (9.3) | 4 (3.4) | 3 (2.8) |
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Moderate to severe | 19 (13.7) | 2 (1.7) | 6 (5.5) |
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Mild to moderate | 34 (24.5) | 22 (18.6) | 13 (11.9) |
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None | 73 (52.5) | 90 (76.3) | 87 (79.8) |
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15.5 (6) | .02 | ||||||
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Severe to extreme | 8 (5.8) | 3 (2.5) | 3 (2.7) |
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Moderate to severe | 11 (8) | 2 (1.7) | 1 (0.9) |
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Mild to moderate | 7 (5.1) | 5 (4.3) | 2 (1.8) |
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None | 112 (81.1) | 108 (91.5) | 104 (94.6) |
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15.5 (6) | .02 | ||||||
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Severe to extreme | 9 (6.5) | 4 (3.4) | 5 (4.6) |
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Moderate to severe | 14 (10.0) | 2 (1.7) | 6 (5.5) |
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Mild to moderate | 19 (13.7) | 11 (9.3) | 6 (5.5) |
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None | 97 (69.8) | 101 (85.6) | 92 (84.4) |
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17.6 (6) | .01 | ||||||
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Severe to extreme | 10 (7.2) | 9 (7.6) | 6 (5.5) |
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Moderate to severe | 20 (14.5) | 11 (9.3) | 4 (3.7) |
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Mild to moderate | 60 (43.5) | 44 (37.3) | 35 (32.1) |
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None | 48 (34.8) | 54 (45.8) | 64 (58.7) |
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15.9 (6) | .01 | ||||||
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Severe to extreme | 6 (4.3) | 6 (5.1) | 2 (1.8) |
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Moderate to severe | 18 (13.0) | 6 (5.1) | 4 (3.6) |
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Mild to moderate | 21 (15.1) | 13 (11.0) | 9 (8.1) |
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None | 94 (67.6) | 93 (78.8) | 96 (86.5) |
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aMissing values: 2/368, 0.5%.
bMissing values: 3/268, 0.8%.
Differences in scores of Childhood Trauma Questionnaire severity between groups.
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Patients versus controls | Relatives versus controls | Patients versus relatives | |||||
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Adjusted |
Adjusted |
Adjusted |
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Emotional abuse | .67 (0.42 to 0.92) | <.001 | .09 (−0.14 to 0.32) | .44 | .58 (0.35 to 0.80) | <.001 | ||
Physical abuse | .30 (0.09 to 0.51) | .005 | .05 (−0.14 to 0.25) | .58 | .25 (0.06 to 0.44) | .01 | ||
Sexual abuse | .42 (0.19 to 0.66) | <.001 | .01 (−0.21 to 0.23) | .92 | .41 (0.20 to 0.63) | <.001 | ||
Emotional neglect | .51 (0.25 to 0.78) | <.001 | .30 (0.05 to 0.54) | .02 | .22 (−0.02 to 0.46) | .07 | ||
Physical neglect | .26 (0.03 to 0.50) | .03 | .19 (−0.02 to 0.40) | .08 | .08 (−0.13 to 0.29) | .47 |
aCI adjusted for age, gender, ethnicity, education, and marital status.
As shown in
Associations between momentary self-esteem and psychotic experiences by childhood trauma in patients, relatives, and controlsa.
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Outcome: psychotic experiences | ||||||||||||||
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Patients | Relatives | Controls | Wald test for interaction | |||||||||||
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Adjusted |
Adjusted |
Adjusted |
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9.0 (2) | .01 | |||||||||||||
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High (mean + 1 SD) | −.20 (−0.25 to −0.15) | <.001 | −.29 (−0.32 to −0.27) | <.001 | −.15 (−0.19 to −0.12) | <.001 |
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Average (mean) | −.17 (−0.20 to −0.14) | <.001 | −.27 (−0.29 to −0.25) | <.001 | −.18 (−0.20 to −0.15) | <.001 |
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Low (mean − 1 SD) | −.14 (−0.18 to −0.10) | <.001 | −.25 (−0.28 to −0.22) | <.001 | −.20 (−0.24 to −0.16) | <.001 |
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High versus low | −.06 (−0.13 to 0.01) | .12 | −.04 (−0.08 to −0.01) | .03 | .05 (−0.00 to 0.10) | .07 |
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Momentary SE × emotional abuse × groupe | 5.4 (2) | .07 | |||||||||||||
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24.9 (2) | <.001 | |||||||||||||
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High (mean + 1 SD) | −.16 (−0.22 to −0.10) | <.001 | −.32 (−0.35 to −0.30) | <.001 | −.08 (−0.12 to −0.04) | <.001 |
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Average (mean) | −.16 (−0.18 to −0.13) | <.001 | −.26 (−0.29 to −0.24) | <.001 | −.11 (−0.14 to −0.08) | <.001 |
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Low (mean − 1 SD) | −.16 (−0.21 to −0.11) | <.001 | −.21 (−0.24 to −0.17) | <.001 | −.14 (−0.18 to −0.09) | <.001 |
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High versus low | 0 (−0.09 to 0.09) | .99 | −.12 (−0.15 to −0.08) | <.001 | .06 (−0.00 to 0.12) | .058 |
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15.9 (2) | <.001 | |||||||||||||
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High (mean + 1 SD) | −.11 (−0.17 to −0.06) | <.001 | −.29 (−0.32 to −0.27) | <.001 | −.08 (−0.12 to −0.04) | <.001 |
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Average (mean) | −.15 (−0.18 to −0.13) | <.001 | −.27 (−0.29 to −0.25) | <.001 | −.11 (−0.14 to −0.08) | <.001 |
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Low (mean − 1 SD) | −.19 (−0.24 to −0.15) | <.001 | −.25 (−0.28 to −0.22) | <.001 | −.13 (−0.17 to −0.09) | <.001 |
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High versus low | .08 (−0.01 to 0.16) | .07 | −.05 (−0.08 to −0.02) | .001 | .05 (0.00 to 0.10) | .049 |
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Momentary SE × emotional neglect × group | 1.8 (2) | .41 | |||||||||||||
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116.7 (2) | <.001 | |||||||||||||
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High (mean + 1 SD) | −.23 (−0.28 to −0.19) | <.001 | −.29 (−0.32 to −0.27) | <.001 | −.08 (−0.12 to −0.04) | <.001 |
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Average (mean) | −.17 (−0.20 to −0.14) | <.001 | −.28 (−0.30 to −0.25) | <.001 | −.11 (−0.14 to −0.08) | <.001 |
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Low (mean − 1 SD) | −.11 (−0.14 to −0.07) | <.001 | −.26 (−0.29 to −0.23) | <.001 | −.13 (−0.17 to −0.09) | <.001 |
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High versus low | −.13 (−0.19 to −0.07) | <.001 | −.03 (−0.07 to 0.01) | .14 | .05 (−0.01 to 0.11) | .11 |
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aAdjusted for age, gender, ethnicity, level of education, and marital status.
bAdjusted
cFamily-wise error-corrected
dSE: self-esteem.
eThree-way interaction included in the following model (with yij psychotic experiences as the outcome variable): yij =
Lower levels of momentary self-esteem were associated with more intense psychotic experiences in relatives exposed to high levels of childhood trauma in general compared with those exposed to low levels of childhood trauma (adjusted
Next, we examined the differences in the magnitude of associations of self-esteem and psychotic experiences between those exposed to high versus low levels of childhood trauma in general, physical and sexual abuse, and physical neglect across groups. These differences in magnitude were only examined if both groups showed significant (
Difference in associations in those exposed to high versus low levels of childhood trauma across groups (Δ high vs low).
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Outcome: psychotic experiences | |||||||||||||
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Patients versus controls | Relatives versus controls | Patients versus relatives | |||||||||||
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Adjusted |
Adjusted |
Adjusted |
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Δ High versus low childhood trauma across groups | N/Aa | N/A | N/A | N/A | N/A | N/A | |||||||
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Δ High versus low physical abuse across groups | N/A | N/A | N/A | N/A | N/A | N/A | |||||||
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Δ High versus low sexual abuse across groups | N/A | N/A | −.10 (−0.16 to −0.04) | <.001 | N/A | N/A | |||||||
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Δ High versus low physical neglect across groups | N/A | N/A | N/A | N/A | N/A | N/A |
aN/A: not applicable.
Findings regarding the temporal associations between momentary self-esteem and psychotic experiences in patients, relatives, and controls are shown in
Effect of self-esteem and psychotic symptoms at tn-1 on psychotic experiences at tn by group and modified by childhood traumaa.
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Patients | Relatives | Controls | Wald test for interaction | |||||||||||||||||
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Adjusted |
Adjusted |
Adjusted |
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0.07 (2) | .80 | ||||||||||||||||||
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High (mean + 1 SD) | −.04 (−0.10 to 0.03) | .28 | −.11 (−0.14 to −0.08) | <.001 | −.02 (−0.07 to 0.03) | .48 |
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Average (mean) | −.03 (−0.07 to −0.00) | .05 | −.13 (−0.16 to −0.11) | <.001 | −.02 (−0.06 to 0.01) | .17 |
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Low (mean − 1 SD) | −.03 (−0.08 to 0.02) | .20 | −.15 (−0.19 to −0.11) | <.001 | −.03 (−0.07 to 0.02) | .20 |
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High versus low | −.00 (−0.10 to 0.09) | .92 | .04 (−0.01 to 0.08) | .10 | .01 (−0.06 to 0.08) | .77 |
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0.58 (2) | .45 | ||||||||||||||||||
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High (mean + 1 SD) | .01 (−0.07 to 0.09) | .82 | −.14 (−0.17 to 0.11) | <.001 | −.02 (−0.06 to 0.03) | .49 |
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Average (mean) | −.03 (−0.06 to 0.01) | .14 | −.12 (−0.14 to −0.09) | <.001 | −.02 (−0.06 to 0.01) | .15 |
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Low (mean − 1 SD) | −.06 (−0.11 to −0.00) | .03 | −.10 (−0.13 to −0.06) | <.001 | −.03 (−0.08 to 0.01) | .17 |
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High versus low | .07 (−0.05 to 0.18) | .25 | −.04 (−0.09 to 0.00) | .06 | .02 (−0.05 to −0.08) | .60 |
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0.01 (2) | .91 | ||||||||||||||||||
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High (mean + 1 SD) | −.03 (−0.09 to 0.03) | .32 | −.12 (−0.14 to −0.09) | <.001 | −.02 (−0.06 to 0.02) | .34 |
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Average (mean) | −.03 (−0.06 to −0.00) | .046 | −.13 (−0.15 to −0.10) | <.001 | −.02 (−0.06 to 0.01) | .14 |
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Low (mean − 1 SD) | −.03 (−0.08 to 0.01) | .15 | −.14 (−0.17 to −0.10) | <.001 | −.03 (−0.07 to 0.01) | .19 |
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High versus low | 0 (−0.08 to 0.09) | .93 | .02 (−0.01 to 0.05) | .27 | .01 (−0.04 to 0.06) | .72 |
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0.04 (2) | .83 | ||||||||||||||||||
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High (mean + 1 SD) | −.02 (−0.07 to 0.02) | .29 | −.11 (−0.14 to −0.08) | <.001 | −.02 (−0.07 to 0.03) | .40 |
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Average (mean) | −.03 (−0.06 to −0.00) | .04 | −.13 (−0.15 to −0.10) | <.001 | −.02 (−0.06 to 0.01) | .15 |
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Low (mean − 1 SD) | −.04 (−0.08 to 0.00) | .07 | −.15 (−0.19 to −0.11) | <.001 | −.03 (−0.07 to 0.02) | .22 |
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High versus low | .01 (−0.05 to 0.07) | .64 | .04 (−0.0 to 0.09) | .11 | 0 (−0.06 to 0.07) | .89 |
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0.18 (2) | .67 | ||||||||||||||||||
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High (mean + 1 SD) | −.02 (−0.07 to 0.03) | .41 | −.11 (−0.14 to.08) | <.001 | −.03 (−0.08 to 0.02) | .29 |
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Average (mean) | −.03 (−0.06 to 0.00) | .05 | −.13 (−0.15 to −0.10) | <.001 | −.03 (−0.06 to 0.01) | .13 |
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Low (mean − 1 SD) | −.04 (−0.08 to 0.00) | .07 | −.14 (−0.18 to −0.10) | <.001 | −.02 (−0.07 to −0.02) | .32 |
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High versus low | .02 (−0.05 to 0.09) | .60 | .03 (−0.02 to 0.08) | .28 | −.00 (−0.08 to 0.07) | .94 |
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aAdjusted for age, sex, ethnicity, level of education, and marital status.
bAdjusted
cFamily-wise error-corrected
Effect of self-esteem and psychotic symptoms at tn-1 on self-esteem at tn by group and modified by childhood traumaa.
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Patients | Relatives | Controls | Wald test for interaction |
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Adjusted |
Adjusted |
Adjusted |
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0.52 (2) | .47 | |||||||||||||||||||||||
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High (mean + 1 SD) | −.09 (−0.22 to 0.05) | .20 | −.09 (−0.12 to −0.06) | <.001 | −.13 (−0.27 to 0.00) | .06 |
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Average (mean) | −.09 (−0.14 to −0.04) | .001 | −.11 (−0.14 to −0.08) | <.001 | −.08 (−0.15 to −0.02) | .02 |
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|
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Low (mean − 1 SD) | −.09 (−0.19 to −0.00) | .046 | −.13 (−0.18 to −0.09) | <.001 | −.03 (−0.13 to −0.07) | .51 |
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High versus low | .01 (−0.20 to 0.21) | .96 | .04 (−0.01 to 0.10) | .09 | −.10 (−0.29 to −0.10) | .33 |
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0.04 (2) | .84 | |||||||||||||||||||||||
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High (mean + 1 SD) | −.07 (−0.21 to 0.07) | .32 | −.10 (−0.13 to −0.07) | <.001 | −.04 (−0.15 to 0.07) | .46 |
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|
||||||||||||||||
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Average (mean) | −.09 (−0.14 to −0.03) | .002 | −.10 (−0.13 to −0.08) | <.001 | −.07 (−0.13 to −0.01) | .03 |
|
|
||||||||||||||||
|
|
Low (mean − 1 SD) | −.10 (−0.20 to −0.01) | .03 | −.11 (−0.15 to −0.07) | <.001 | −.10 (−0.20 to −0.00) | .04 |
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|
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High versus low | .03 (−0.17 to 0.24) | .75 | −.01 (−0.03 to 0.06) | .48 | .06 (−0.11 to 0.22) | .48 |
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0.02 (2) | .88 | |||||||||||||||||||||||
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High (mean + 1 SD) | −.07 (−0.19 to 0.05) | .24 | −.10 (−0.13 to −0.07) | <.001 | −.06 (−0.15 to −0.02) | .15 |
|
|
||||||||||||||||
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Average (mean) | −.09 (−0.14 to −0.04) | <.001 | −.10 (−0.13 to −0.07) | <.001 | −.07 (−0.13 to −0.01) | .03 |
|
|
||||||||||||||||
|
|
Low (mean − 1 SD) | −.11 (−0.20 to −0.01) | .03 | −.10 (−0.14 to −0.07) | <.001 | −.08 (−0.16 to 0.00) | .055 |
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|
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High versus low | .03 (−0.16 to 0.23) | .72 | .00 (−0.04 to 0.04) | .85 | .02 (−0.09 to 0.13) | .75 |
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|
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0.00 (2) | .99 | |||||||||||||||||||||||
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|
High (mean + 1 SD) | −.10 (−0.17 to −0.02) | .01 | −.10 (−0.14 to −0.06) | <.001 | −.08 (−0.19 to 0.04) | .18 |
|
|
||||||||||||||||
|
|
Average (mean) | −.09 (−0.14 to −0.04) | <.001 | −.10 (−0.13 to −0.08) | <.001 | −.07 (−0.14 to −0.01) | .03 |
|
|
||||||||||||||||
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|
Low (mean − 1 SD) | −.08 (−0.15 to −0.02) | .01 | −.11 (−0.15 to −0.06) | <.001 | −.07 (−0.16 to −0.03) | .18 |
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|
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High versus low | −.02 (−0.12 to 0.08) | .76 | .01 (−0.05 to 0.07) | .83 | −.01 (−0.18 to 0.15) | .87 |
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0.48 (2) | .49 | |||||||||||||||||||||||
|
|
High (mean + 1 SD) | −.09 (−0.16 to −0.01) | .02 | −.10 (−0.13 to −0.07) | <.001 | −.00 (−0.19 to 0.18) | .96 |
|
|
||||||||||||||||
|
|
Average (mean) | −.09 (−0.14 to −0.04) | <.001 | −.11 (−0.14 to −0.08) | <.001 | −.06 (−0.13 to 0.02) | .12 |
|
|
||||||||||||||||
|
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Low (mean − 1 SD) | −.09 (−0.16 to −0.03) | .006 | −.12 (−0.16 to −0.07) | <.001 | −.11 (−0.22 to 0.00) | .05 |
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|
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High versus low | .01 (−0.09 to 0.11) | .89 | .02 (−0.03 to 0.07) | .41 | −.11 (−0.16 to 0.37) | .43 |
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aAdjusted for age, sex, ethnicity, level of education, and marital status.
bAdjusted
cFamily-wise error-corrected
Using an experience sampling design, the results of this study showed strong evidence that associations between momentary low self-esteem and increased intensity of psychotic experiences in daily life were modified by several types of childhood trauma, that is, physical and sexual abuse and physical neglect. For physical abuse, this was only the case for relatives of patients with psychotic disorders, and for physical neglect, this was only the case for patients. Sexual abuse modified the association in relatives and controls, but not in patients. Emotional abuse and emotional neglect did not modify the association between self-esteem and psychotic experiences in any group. When investigating temporal order, we found no evidence that childhood trauma modified the temporal associations between self-esteem at tn-1 and psychotic experiences at tn or those between psychotic experiences at tn-1 and self-esteem at tn.
Several limitations of this study should be considered when interpreting its findings. First, only a selection of the baseline sample made it through the third wave. For our analyses, we had to exclude 118 individuals because they did not complete either a sufficient number of ESM assessments or the CTQ. Possibly, these assessments were too burdensome and, therefore, might have led to selection bias. However, when comparing the excluded individuals with those in the analytical sample, who participated in the third wave of GROUP assessments, in terms of basic sample characteristics, the included and excluded participants were comparable to a great extent, except for ethnicity (included participants were more often White in all 3 groups). Second, the CTQ, which was used to measure exposure to several types of trauma during childhood, is a retrospective self-report measure. It has been argued that the CTQ is prone to recall bias and that the manifestation of psychotic symptoms might affect the ratings of this measure [
Moreover, momentary self-esteem was measured using only 2 items. Using fewer items in ESM research is quite common because it minimizes reactivity to the assessment method [
Next, we controlled for potential a priori confounders, such as age, gender, ethnicity, education level, and marital status. We did not include medication use as a confounder because 98% (98/100) of the patients were using medication. Nevertheless, unmeasured confounders, such as other childhood adversities, comorbidities, the impact of illness chronicity, and molecular genetic measures, were not considered and may have, therefore, influenced the findings.
Finally, we standardized the continuous childhood trauma variables because it allowed us to interpret associations at higher versus lower levels of childhood trauma [
There is well-established evidence that exposure to childhood trauma is a risk factor for developing a psychotic disorder [
As hypothesized (hypothesis 1), and extending previous findings [
On the basis of previous literature [
In addition, relatives have a familial liability to psychosis [
Overall, the cross-sectional findings indicate that it might possibly be relevant to develop and implement early and low-level interventions that directly target self-esteem, especially for individuals exposed to physical and sexual abuse and physical neglect. Thus, the intensity of psychotic experiences in daily life can be reduced. We are currently evaluating the ecological momentary intervention (EMI) “SELFIE” [
Previous research has investigated the temporal order of self-esteem and psychotic experiences in daily life and found that self-esteem preceded psychotic symptoms only in controls and psychotic experiences had a temporal effect on self-esteem in patients with psychotic disorders, their first-degree relatives, and controls [
Taken together, our findings suggest that the association between self-esteem and psychotic experiences in daily life is stronger in those exposed to high versus low levels of several types of childhood trauma. Hence, self-esteem might be a psychological process that links childhood trauma to psychosis. The results showed that this is especially the case in first-degree relatives and, to a lesser extent, in patients with psychotic disorders. Although we did not find evidence of temporal associations, the cross-sectional results indicate that improving self-esteem may potentially reduce the intensity of psychotic experiences in daily life. This underlines the importance of developing and evaluating early and low-level EMIs that directly target self-esteem to reduce the intensity of psychotic experiences in daily life. We currently evaluate such an intervention in the SELFIE study [
Basic characteristics of the excluded participants (participants with less than one-third experience sampling method assessments or no Childhood Trauma Questionnaire results were excluded).
Associations between self-esteem psychotic experiences at high (mean + 1 SD) versus low (mean − 1 SD) levels of physical abuse, sexual abuse, and physical neglect in patients, relatives, and controls.
Childhood Trauma Questionnaire
ecological momentary intervention
experience sampling method
Genetic Risk and Outcome in Psychosis
The authors are grateful for the generosity of the time and effort of the patients, their families, and control participants. The authors would also like to thank all research personnel involved in the Genetic Risk and Outcome in Psychosis (GROUP) project, in particular Joyce van Baaren, Erwin Veermans, Ger Driessen, Truda Driesen, Karin Pos, Erna van ’t Hag, Jessica de Nijs, and Atiqul Islam.
This work was supported by a research grant from the Netherlands Organization for Health Research and Development (ZonMw; grant 60-63600-98-346) and a Heisenberg Professorship from the German Research Foundation (grant 389624707) to Ulrich Reininghaus (UR). The infrastructure for the GROUP study is funded through the Geestkracht program of the Dutch Health Research Council (Zon-Mw; grant 10-000-1001) and matching funds from participating pharmaceutical companies (Lundbeck, Astra Zeneca, Eli Lilly, and Janssen-Cilag), universities, and mental health care organizations (Amsterdam: Academic Psychiatric Centre of the Academic Medical Center and the mental health institutions GGZ Ingeest, Arkin, Dijk en Duin, GGZ Rivierduinen, Erasmus Medical Centre, and GGZ Noord Holland Noord. Groningen: University Medical Center Groningen and the mental health institutions Lentis; GGZ Friesland; GGZ Drenthe; Dimence; Mediant; GGNet Warnsveld; Yulius Dordrecht; and Parnassia psycho-medical center, The Hague. Maastricht: Maastricht University Medical Centre and the mental health institutions GGzE, GGZ Breburg, GGZ Oost-Brabant, Vincent van Gogh voor Geestelijke Gezondheid, Mondriaan, Virenze riagg, Zuyderland GGZ, MET ggz, Universitair Centrum Sint-Jozef Kortenberg, CAPRI University of Antwerp, PC Ziekeren Sint-Truiden, PZ Sancta Maria Sint-Truiden, GGZ Overpelt, and OPZ Rekem. Utrecht: University Medical Center Utrecht and the mental health institutions Altrecht, GGZ Centraal, and Delta).
The members of the
Therese van Amelsvoorta, Agna A Bartels-Velthuisb, Richard Bruggemanb,c, Wiepke Cahnd,e, Lieuwe de Haanf,g, Frederike Schirmbeckf,g, Claudia J P Simonsa,h, Jim van Osd,i
aDepartment of Psychiatry and Neuropsychology, Maastricht University Medical Center, School for Mental Health and Neuroscience, Maastricht, The Netherlands
bUniversity of Groningen, University Medical Center Groningen, University Center for Psychiatry, Rob Giel Research center, Groningen, The Netherlands
cDepartment of Clinical and Developmental Neuropsychology, University of Groningen, Groningen, The Netherlands
dDepartment of Psychiatry, University Medical Center Utrecht, Brain Centre Rudolf Magnus, Utrecht University, Utrecht, The Netherlands
eAltrecht, General Mental Health Care, Utrecht, The Netherlands
fDepartment of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
gArkin Institute for Mental Health, Amsterdam, The Netherlands
hGGzE Institute for Mental Health Care, Eindhoven, The Netherlands
iDepartment of Psychosis Studies, King’s College London, King’s Health Partners, Institute of Psychiatry, London, United Kingdom
None declared.