Figures
Abstract
Background
The evaluation of childhood trauma is essential for the treatment of schizophrenia. The short form of Childhood Trauma Questionnaire (CTQ-SF) is a widely used measure of the experience of childhood trauma in the general population. Nevertheless, data regarding the psychometric property of CTQ-SF for assessing childhood trauma of patients with schizophrenia are very limited.
Methods
Two hundred Chinese inpatients with schizophrenia completed the Chinese CTQ-SF, the Child Psychological Maltreatment Scale (CPMS), the Impact of Events Scale-Revised (IES-R), and the Dissociative Experiences Scale-II (DES-II). To assess test-retest reliability of the CTQ-SF, all patients completed the CTQ-SF again two weeks later. Concurrent and convergent validity was assessed by analyzing Pearson bivariate correlation coefficients between CTQ-SF and CPMS, IES-R, and DES-II.
Citation: Jiang W-J, Zhong B-L, Liu L-Z, Zhou Y-J, Hu X-H, Li Y (2018) Reliability and validity of the Chinese version of the Childhood Trauma Questionnaire-Short Form for inpatients with schizophrenia. PLoS ONE 13(12): e0208779. https://doi.org/10.1371/journal.pone.0208779
Editor: Maurizio Pompili, Sapienza University fo Rome, ITALY
Received: August 24, 2017; Accepted: November 26, 2018; Published: December 13, 2018
Copyright: © 2018 Jiang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be shared publicly because they contain identifying and sensitive information. The minimal anonymized data set is available upon request. Requests for data can be sent to the secretary of the Institutional Review Board of Wuhan Mental Health Center at: Dr. Yan-Qin Xu, E-mail: 85398645@QQ.com, Tel.: +862759372344.
Funding: This study was supported by Wuhan Health and Family Planning Commission [Grant No.: WG15C01, PI: Wen-Juan Jiang] and National Key Research and Development Program of China (Grant No.: 2018YFC1314303, PI: Xiang-Rong Zhang).
Competing interests: The authors have declared that no competing interests exist.
Introduction
There is convincing evidence that patients with schizophrenia are at elevated risk for childhood trauma, and the childhood trauma is significantly associated with negative health outcomes in this patient population, including severe psychotic symptoms, non-adherence to treatment, and poor psychosocial functions [1–2]. Childhood trauma is an important environmental factor that interacts with genetic predisposition to influence the expression of schizophrenia [3–4]. The role of childhood trauma is thought to be pivotal in the development of schizophrenia: influencing both the manifestation and progression of this disease [5–6]. Some authors have also argued that childhood trauma leads to excessive glucocorticoid production and subsequently causes neurotoxicity to the hippocampus, which, in turn, results in psychotic symptoms in schizophrenia [7–8].
Further evidence from recent studies has demonstrated significant predictive effects of childhood trauma on poor response to treatment with antipsychotics [9] and higher doses of medications, particularly psychotropic medications and mood stabilizers [10]. An increasing literature emphasizes the need for an accurate, early assessment of childhood trauma in schizophrenia and encourages a subsequent trauma-sensitive treatment plan [11].
Routine assessment of childhood trauma and an individualized bio-psycho-social formulation are necessary for personalized treatment of schizophrenia [12]. Therefore, when patients are diagnosed with schizophrenia, they should receive a proper childhood trauma assessment and be offered psychological treatments to address the sequelae of the childhood trauma or abuse. There is a pressing need to address childhood trauma in this patient population, which is required by a broadening range of available treatments [13].
One impediment to the acceptance and implementation of these recommendations for schizophrenia patients is the lack of a psychometrically sound tool. Some instruments have been developed to assess childhood abuse and neglect. The Short Form of Childhood Trauma Questionnaire (CTQ-SF) is one of the most widely used tools to assess the experience of childhood trauma of both general populations and clinical patients and has become a leading measurement in western countries [14,15]. It also has good performance in the validity and reliability of various language versions [16–21]. However, the psychometric literature regarding the CTQ-SF in schizophrenia is sparse. There is a meaningful beginning with the study to confirm the reliability and validity in both outpatients and inpatients with schizophrenia in Korea [22–23]. Due to cultural difference across countries, additional studies are necessary to assess the psychometric property of CTQ-SF in China.
To the best of our knowledge, to date, there have been no data regarding the reliability and validity of the Chinese CTQ for assessing the childhood trauma of patients with schizophrenia. This study explored whether the Chinese version of the CTQ-SF is applicable for the assessment of childhood trauma in Chinese inpatients with schizophrenia.
Methods
Ethics statement
The study protocol was reviewed and approved by the Institutional Review Board of Wuhan Mental Health Center. Before participating the study, all subjects were fully informed of the study’s objectives, content, and procedures, and confidentiality and declarations of anonymity had been made. Written consent was obtained from all subjects and their guardians (when necessary) prior to the study. For the compensation of time spent in participating in this study, each patient was given a gift valued at 15 US$.
Settings and subjects
Subjects were inpatients at Wuhan Mental Health Center, the largest psychiatric specialty hospital in south-central China. A convenient sample of inpatients with schizophrenia was recruited from September 2015 to March 2017. Patients were considered qualified for the study if they 1) met the diagnosis of schizophrenia according to the ICD-10 as assessed by experienced psychiatrists; 2) were clinically stable (total score of Positive and Negative Syndrome Scale [PANSS] ≤40); 3) aged between18 and 40 years; and 4) had an educational attainment of at least primary school. Patients were excluded if they had 1) a severe physical illness, drug abuse/dependence or other psychosis; 2) an intelligence quotient (IQ) score less than 80 or 3) difficulties in understanding questions of the study questionnaire.
Procedures and measures
Three trained attending psychiatrists screened patients for eligibility, and sought consent from eligible patients to participate in the study. Participants were instructed to independently and anonymously complete the study questionnaire and completed the CTQ-SF again two weeks later.
The study questionnaire consisted of a basic information form and four scales. The basic information form was used to collect data on patients’ demographics (age, sex, education level, and marital status) and clinical characteristics (family history of psychosis, number of previous admissions, and duration of illness). The four scales were described as below:
1) Chinese version of the CTQ-SF [24]
The CTQ is a retrospective self-report scale developed by David Bernstein and colleagues, which has 70 items [25,26]. The CTQ-SF consists of 28 items of the original version of CTQ: five items for each of the five types of neglect or abuse [emotional neglect (EN), physical neglect (PN), emotional abuse (EA), physical abuse (PA), and sex abuse (SA)] and three items for the tendency to minimize/deny. Each item assesses the frequency of trauma experience by using a 5-point Likert-type response, ranging from 1 = never to 5 = very often. The total score of each subscale ranges from 5 to 25. Cut-off scores for separating subjects with none, low, moderate, and severe degrees of trauma for each subscale was reported in an early publication [26]. The Chinese translated version of CTQ-SF, developed by Zhao and colleagues, has been confirmed to exhibit good psychometric properties and cultural equivalence in Chinese population [20,24], which was directly used in our study.
2) Child Psychological Maltreatment Scale (CPMS) [27]
The concurrent validity of the CTQ-SF was evaluated with the 23-item self-report CPMS. CPMS is developed to measure childhood neglect and abuse for adolescents in China and it has five subscales: terrorizing, ignoring, belittling, intermeddling, and corrupting. In this study, we used two subscales of CPMS only: neglect (ignoring and corrupting) and abuse (terrorizing, belittling, and intermeddling). Each item of the CPMS is rated using 5-point Likert-type scale, ranging from 0 = never happen to 4 = very often happen. This scale has an acceptable psychometric property in Chinese students [27,28].
3) The Chinese version of the Impact of Events Scale-Revised (IES-R-C) [29]
The self-report IES-R-C scale measures the symptoms of posttraumatic stress disorder (PTSD) [30]. Because the symptoms of PTSD are more prevalent among individuals who have experienced early trauma and abuse [31], and studies have shown the significant correlations between childhood trauma experiences were significantly correlated with the PTSD symptoms [17, 31–34], the 22-item IES-R-C scale was adopted to assess the convergent validity of the CTQ-SF. The Chinese version of the IES-R has adequate psychometric properties among junior and senior students [29,30].
4) The Chinese version of the Dissociative Experiences Scale-II (DES-II-C) [35]
The DES-II-C was also administered to assess the convergent validity of CTQ-SF, because dissociative experiences frequently occur in patients with early trauma [36,37], and childhood trauma experiences are significantly correlated with dissociative symptoms [21,38–40]. This self-report scale is used to measure the continuum of dissociation, ranging from normal to pathological dissociative symptoms. The DES-II-C has adequate reliability and validity in Chinese undergraduates and inpatients with mental illness [35,41].
Data analysis
The internal consistency of the CTQ-SF-C was evaluated using Cronbach’s α coefficient. Because scores of the CTQ-SF, CPMS, IES-R-C, and DES-II-C were not normally distributed, Spearman’s correlation coefficients were calculated for assessing test-retest reliability and concurrent and convergent validity. All data were analyzed by using SPSS (version 20.0) for Windows, and statistical significance was set at an alpha level of 0.05 (two-sided) for all tests.
Results
Demographic characteristics and prevalence of childhood trauma
A total of 300 inpatients were screened, among whom 243 were eligible for the study but 35 declined to participate. Finally, 208 agreed to participate and 200 completed the study questionnaires.
Demographic characteristics of the 200 subjects are presented in Table 1. The mean age of subjects was 28.3 years (standard deviation [SD] = 5.9). Medians of the duration of schizophrenia illness and total number of previous psychiatric hospitalizations were 60.1 months (range: 1 month–28 years) and 3 (range = 0–39), respectively.
The average total score of CTQ-SF was 43.4 (SD = 13.9). The average total scores of EN, PN, EA, PA, and SA subscales of CTQ-SF were 11.6 (SD = 5.0), 9.3 (SD = 3.6), 8.6 (SD = 3.6), 7.2 (SD = 3.1), and 6.6 (SD = 2.7), respectively. According to recommended cut-off scores for low-to-moderate severity of childhood trauma [26], EA (≤12) was the most common type of trauma (n = 155,77.5%), followed by EN (≤14) (n = 151, 75.5%), PN (≤9) (n = 131, 65.5%), PA (≤9) (n = 95, 47.5%), and SA (≤7) (n = 74,37%), while for moderate-to-severe trauma, PN (≥10) was the most common (n = 31,15.5%), followed by EN (≥15) (n = 19, 9.5%), SA (≥8) (n = 10, 5.0%), PA (≥10) (n = 5, 2.5%), and EA (≥13) (n = 2, 1.0%).
Internal consistency and re-test reliability
The Cronbach’s α coefficient of the CTQ-SF was 0.81, and the α coefficients for the five subscales ranged from 0.61 (PN) to 0.84 (PA). The two-week test-retest reliability coefficient of the CTQ-SF was 0.81, and corresponding coefficients for the five subscales ranged from 0.58 (SA) to 0.78 (PN). All these correlations were statistically significant (p<0.01) (Table 2).
Concurrent and convergent validity
The total CTQ-SF score was significantly correlated with the total CPMS score (r = 0.61). The five subscales of CTQ-SF and the two subscales of CPMS were also significantly correlated (abuse: 0.39–0.64; neglect: 0.22–0.43) (Table 3).
The total scores of CTQ-SF and its five subscales were all significantly correlated with IES-R-C and the DES-II-C (r = 0.23–0.51) (Table 3).
Discussion
The cross-cultural and cross-population validation of childhood trauma screening measures in schizophrenia is a necessary and important work for both clinical and research work. Findings from the present study provide the basis for applying this scale in clinical work, for example, the CTQ-SF may be particularly useful for patients with refractory schizophrenia given their nonresponse to antipsychotics: psychotherapy based on childhood trauma experiences provides one potential effective treatment choice [12,13].
Overall, the CTQ-SF had good reliability for Chinese inpatients with schizophrenia in terms of internal consistency and test-retest reliability coefficients. In general, the Cronbach’s α coefficient of a psychometrically sound scale should be greater than 0.7 [42]. The low internal consistency of the PN subscale (α = 0.61) of CTQ-SF is consistent with previous studies [19,23,42,43]. We consider that this phenomenon might be ascribed to the cultural differences in the definition of physical neglect across countries, for example, most Chinese people believe “spare the rod and spoil the child” but most people of western countries do not think so. Compared with a similar study in Korea, our study showed a better test-retest reliability of CTQ-SF [23], indicating the good stability of trauma experiences as measured by CTQ-SF in Chinese inpatients with schizophrenia.
In this study, the good concurrent validity of the CTQ-SF was confirmed by the significant correlation between CPMS and CTQ-SF. The good convergent validity of the CTQ-SF was also proved by the significant correlations between CTQ-SF and IES-R-C and the DES-II-C. Similar to previous reports [36,44,45], this study found that the five types of childhood trauma were all related to PTSD and pathological dissociation symptoms. Moreover, the low-to-moderate correlations between the CPMS neglect subscale and CTQ-SF subscales were consistent with findings from the inpatient sample of the Korean study [23].
Overall, the prevalence pattern of the five types of trauma experiences in Chinese patients with schizophrenia as measured by CTQ-SF is similar to some but not all previous reports [16,22,23,46–48]; the discrepancy might be explained by a variety of clinical factors, including the mean age of the patient sample and clinical settings (i.e., inpatient vs. outpatient).
This study has several limitations. First, participants were 200 inpatients of one large psychiatric hospital only, limiting the generalizability of the study findings. More studies are warranted to further examine the psychometric property with samples of patients from both outpatient and inpatient clinical settings, as well as patients from other institutions. Second, strictly speaking, the CPMS has no the construct of SA, therefore using CPMS to examine the concurrent validity of SA of the CTQ-SF might be problematic. Nevertheless, the CPMS was still adopted for this study because it is a widely used instrument for the assessment of childhood neglect and abuse in China, despite not specific to SA.
In summary, this study confirmed adequate reliability and validity of the CTQ-SF for assessing childhood trauma experiences in patients with schizophrenia in in Chinese inpatient settings. More studies are warranted to address the low internal consistency of PA subscale of CTQ-SF, as well as the definition of childhood trauma, particularly regarding neglect, in China’s unique culture. A precise and conformity definition would help develop a more culturally relevant version of the CTQ-SF, which is particularly necessary in psychiatric clinical settings of China.
Acknowledgments
The authors thank all the research staff for their team collaboration work and all the patients involved in this study for their cooperation and support.
References
- 1. Schenkel LS, Spaulding WD, DiLillo D, Silverstein SM. Histories of childhood maltreatment in schizophrenia: relationships with premorbid functioning, symptomatology and cognitive deficits. Schizophr Res. 2005 Jul;76(2–3):273–86. pmid:15949659
- 2. Conus P, Cotton S, Schimmelmann BG, McGorry PD, Lambert M. Pretreatment and outcome correlates of sexual and physical trauma in an epidemiological cohort of first-episode psychosis patients. Schizophr Bull. 2010 Nov;36(6):1105–14. pmid:19386579
- 3. Aas M, Djurovic S, Athanasiu L, Steen NE, Agartz I, Lorentzen S, et al. Serotonin transporter gene polymorphism, childhood trauma, and cognition in patients with psychotic disorder. Schizophr Bull. 2012 Jan;38(1):15–22. pmid:21908796
- 4. Lysaker PH, Beattie NL, Strasburger AM, Davis LW. Reported history of child sexual abuse in schizophrenia: associations with heightened symptom levels and poorer participation over four months in vocational rehabilitation. J Nerv Ment Dis. 2005 Dec;193(12):790–5. pmid:16319700
- 5. Jim VO, Kenis G, Rutten BP. The environment and schizophrenia. Nature. 2010 Nov;468(7321):203–12. pmid:21068828
- 6. Mueser KT, Salyers MP, Rosenberg SD, Goodman LA, Essock SM, Osher FC, et al. Interpersonal trauma and posttraumatic stress disorder in patients with severe mental illness: demographic, clinical, and health correlates. Schizophr Bull. 2004 Feb;30(1):45–57. pmid:15176761
- 7. Ruby E, Polito S, McMahon K, Gorovitz M, Corcoran C, Malaspina D. Pathways Associating Childhood Trauma to the Neurobiology of Schizophrenia. Front Psychol Behav Sci. 2014 Jan;3(1):1–17. pmid:25419548
- 8. Frodl T, O’Keane V. How does the brain deal with cumulative stress? A review with focus on developmental stress, HPA axis function and hippocampal structure in humans. Neurobiol Dis. 2013 Apr;52:24–37. pmid:22426398
- 9. Misiak B, Frydecka D. A history of childhood trauma and response to treatment with antipsychotics in first-episode schizophrenia patients: preliminary results. J Nerv Ment Dis. 2016 Oct;204(10):787–92. pmid:27441460
- 10. Schneeberger AR, Muenzenmaier K, Castille D, Battaglia J, Link B. Use of psychotropic medication groups in people with severe mental illness and stressful childhood experiences. J Trauma Dissociation. 2014 Mar;15(4):494–511. pmid:24678974
- 11. Read J, Van Os J, Morrison AP, Ross CA. Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatr Scand. 2005 Nov;112(5):330–50. pmid:16223421
- 12. Hassan AN, De Luca V. The effect of lifetime adversities on resistance to antipsychotic treatment in schizophrenia patients. Schizophr Res. 2015 Feb;161(2–3):496–500. pmid:25468176
- 13. Read J, Ross CA. Psychological trauma and psychosis: another reason why people diagnosed schizophrenic must be offered psychological therapies. J Am Acad Psychoanal Dyn Psychiatry. 2003 Mar;31(1):247–68. pmid:12722898
- 14. Baker AJL, Maiorino E. Assessments of emotional abuse and neglect with the CTQ: Issues and estimates. Child Youth Serv Rev. 2010 May;32(5):740–8.
- 15. Burgermeister D. Childhood adversity: a review of measurement instruments. J Nurs Meas. 2007 Jan;15(3):163–76. pmid:18232616
- 16. Dudeck M, Vasic N, Otte S, Streb J, Wingenfeld K, Grabe HJ, et al. Factorial validity of the short form of the childhood trauma questionnaire (CTQ-SF) in German psychiatric patients, inmates, and university students. Psychol Rep. 2015 Jun;116(3):685–703. pmid:25933042
- 17. Wingenfeld K, Spitzer C, Mensebach C, Grabe HJ, Hill A, Gast U, et al. The German version of the Childhood Trauma Questionnaire (CTQ): preliminary psychometric properties. Psychother Psychosom Med Psychol. 2010 Aug;60(8):442–50.
- 18. Garrusi B, Nakhaee N. Validity and reliability of a Persian version of the Childhood Trauma Questionnaire. Psychol Rep. 2009 Apr;104(2):509–16. pmid:19610481
- 19. Gerdner A, Allgulander C. Psychometric properties of the Swedish version of the Childhood Trauma Questionnaire-Short Form (CTQ-SF). Nord J Psychiatry. 2009 Jan;63(2):160–70. pmid:19021077
- 20. Zhao XF, Zhang YL, Zhou YF, Li Z, Yang SC. Reliability and validity of the Chinese version of childhood trauma questionnaire. Chin J Clin Rehabil. 2005;9:105–7.
- 21. Paivio SC, Cramer KM. Factor structure and reliability of the Childhood Trauma Questionnaire in a Canadian undergraduate student sample. Child Abuse Negl. 2004 Aug;28(8):889–904. pmid:15350772
- 22. Kim D, Park SC, Yang H, Oh DH. Reliability and validity of the Korean version of the childhood trauma questionnaire-short form for psychiatric outpatients. Psychiatric Investig. 2011 Dec;8(4):305–11.
- 23. Kim D, Bae H, Han C, Oh HY, MacDonald K. Psychometric properties of the Childhood Trauma Questionnaire-Short Form (CTQ-SF) in Korean patients with schizophrenia. Schizophr Res. 2013 Mar;144(1–3):93–8. pmid:23352775
- 24. Fu WQ, Yao SQ. Initial Reliability and Validity of Childhood Truama Questinnaire (CTQ-SF) Apllied in Chinese College Students. Chinese Journal of Clinical Psychology. 2005;13(1):40–2.
- 25.
Bernstein DP, Fink L. Childhood Trauma Questionnaire: A Retrospective Self-report: Manual. The Psychological Corporation, San Antonio TX;1998.
- 26. Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, et al. Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse Negl. 2003 Feb;27(2):169–90. pmid:12615092
- 27. Pan C, Deng YL, Guan BQ, Luo XR. Reliability and validity of child psychological maltreatment scale. Chinese Journal of Clinical Psychology. 2010;18(4):463–5.
- 28. Deng YL, Pan C, Tang QP, Yuan XH, Xiao CG. Development of child psychological abuse and neglect scale. Chinese Journal of behavioral medical science. 2007;16(2):175–7.
- 29. Guo SR, Xin ZQ, Geng L. Reliability and validity of Chinese version of the impact of event scale-revised. Chinese Journal of Clinical Psychology. 2007;15(1):15–7.
- 30. Guo L, Li GY, Liu Q. Research on Wuhan College Students' Psychological Trauma of Events and Impact Medicine and Society. 2013;26 (9):73–6.
- 31. Wu KK, Zhang YQ, Peter Tianzhi Chen. Development and Application of PTSD and IES in Survivors after Disaster. Advances in Psychological Science, 2009, 17(3):495–8.
- 32. Leeshaley PR, Price JR, Williams CW, Betz BP. Use of the Impact of Events Scale in theassessment of emotional distress and PTSD may produce misleading results. J Forensic Neuropsychol. 2001 Oct;2(2):45–52.
- 33. Powers A, Fani N, Cross D, Ressler KJ, Bradley B. Childhood trauma, PTSD, and psychosis: Findings from a highly traumatized, minority sample. Child Abuse Negl. 2016 Aug;58(8):111–8.
- 34. Sullivan TP, Fehon DC, Andres-Hyman RC, Lipschitz DS, Grilo CM. Differential relationships of childhood abuse and neglect subtypes to PTSD symptom clusters among adolescent inpatients. J Trauma Stress. 2006 Apr;19(2):229–39. pmid:16612815
- 35. Li F, Liu XH. Detection of the reliability and validity of dissociative experience scale II. Chin J Clin Rehabil. 2006;42(10): 1–4.
- 36. Draijer N, Langeland W. Childhood trauma and perceived parental dysfunction in the etiology of dissociative symptoms in psychiatric inpatients. Am J Psychiatry. 1999 Mar;156(3):379–85. pmid:10080552
- 37. Garcia M, Montalvo I, Creus M, Cabezas Á, Solé M, Algora MJ, et al. Sex differences in the effect of childhood trauma on the clinical expression of early psychosis. Compr Psychiatry. 2016 Jul;68(8):86–96.
- 38. Chen J, Shi QJ. Correlated Study on Dissociative Experience and Trauma Medicine and Society,2006;19(5);44–8.
- 39. Jiang WJ, Chen J, Tang J, Zhang H, Wen YS, Jiang GR. Research on relationship between trauma and dissociation experience with patients suffering from borderline personality disorder. Chinese Journal of Clinical Psychology. 2010;18(3):329–30.
- 40. Haug E, Øie M, Andreassen OA, Bratlien U, Nelson B, Aas M, et al. Anomalous self-experience and childhood trauma in first-episode schizophrenia. Compr Psychiatry. 2015 Jan;56:35–41. pmid:25458477
- 41. Zhang X, Yu JH, Zhang YW, Ross CA, Benjamin BK, Xiao ZP. The Reliability and Validity of the Chinese Version of the Dissociative Experience Scale. J Clin Psychiatry, 2011;21(5);308–11.
- 42.
Nunnally JC. Psychometric theory. 2nd ed. New York: McGraw-Hill Inc.;1978.
- 43. Lochner C, Seedat S, Allgulander C, Kidd M, Stein D, Gerdner A. Childhood trauma in adults with social anxiety disorder and panic disorder: a cross-national study. Afr J Psychiatry. 2010 Nov;13(5):376–81.
- 44. Scher CD, Stein MB, Asmundson GJ, McCreary DR, Forde DR. The childhood trauma questionnaire in a community sample: psychometric properties and normative data. J Trauma Stress. 2001 Oct;14(4):843–57. pmid:11776429
- 45. Irwin HJ. Pathological and nonpathological dissociation: the relevance of childhood trauma. J Psychol. 1999 Mar;133(2):157–64. pmid:10188264
- 46. Li XB, Liu JT, Zhu XZ, Zhang L, Tang YL, Wang CY. Childhood trauma associates with clinical features of bipolar disorder in a sample of Chinese patients. J Affect Disord. 2014 Oct;168(10):58–63.
- 47. Huang MC, Schwandt ML, Ramchandani VA, George DT, Heilig M. Impact of Multiple Types of Childhood Trauma Exposure on Risk of Psychiatric Comorbidity among Alcoholic Inpatients. Alcohol Clin Exp Res. 2012 Jun;36(6):1099–107. pmid:22420670
- 48. Schafer I, Fisher HL, Aderhold V, Huber B, Hoffmann-Langer L, Golks D, et al. Dissociative symptoms in patients with schizophrenia: relationship with childhood trauma and psychotic symptoms. Compr Psychiatry. 2012 May;53(4):364–71. pmid:21741038