Exposure to ‘The Troubles’ in Northern Ireland influences the presentation of Schizophrenia

The article reviewed here is By Dr Ciaran Mulholland and colleagues based at the Queen’s University of Belfast in Northern Ireland. The paper examines the relationship between presentation in schizophrenia and the suffering that has taken place in Northern Ireland during ‘the troubles’. This suffering can be seen from some of the quoted research showing that since the troubles began in 1968, in a population of 1.68 million, that more than 3700 people have been killed and 40,000 people injured. This suffering extends into other areas, not reflected in these figures. The aim of the paper is to look at one area in particular – the presentation of people with schizophrenia.

All patients with Schizophrenia in the Newtownabbey outpatient clinic were approached to take part in the study. This comprehensive approach reduces the risk of selection bias although this still remains as the patients themselves self-select when choosing to participate. 82/92 outpatients agreed to participate which is a high proportion further minimising self-selection bias and meaning the results should be more representative of a real-world clinical population.

Research psychiatrists looked through the case notes and discussed cases with the research lead whilst a research psychologist administered a number of clinical scales (Beck Depression Inventory, Beck Anxiety Inventory, Beck Hopelessness Scale, The Trauma History Questionnaire and the Dissociative Experiences Scale). Research psychiatrists administered the Brief Psychiatric Scale, the Calgary Depression Scale and the SANS (Scale for the Assessment of Negative Symptoms). Needless to say, this produced a large and very useful dataset.

There was a preponderance of men in the study (76.8% of the sample) which itself was quite a striking finding. Three-quarters of the group reported trauma of any type. These were categorised into five groups with 55% of the sample experiencing trauma in childhood. In adulthood, 52% experienced ‘general disaster related trauma’ whilst 41.5% experienced trauma related to ‘The Troubles’.

Both groups with ‘Troubles’ related trauma and non-Troubles related trauma scored higher on measures of anxiety, depression and the Dissociative Experiences Scale (all of these results were highly significant and involved using the Mann-Whitney test or chi-squared test). Intriguingly those with ‘Troubles-related’ trauma had more hospital admissions than those without any type of trauma. The authors conclude that this study is the first to look at the effects of civil strife on schizophrenia. The other interpretation was about the role of trauma in schizophrenia, which I believe to be a very important topic for future exploration. Previous research in the 1960’s has shown the importance of life events in precipitating psychosis and the authors draw attention to research showing that trauma can precipitate depression instead of a deterioration in psychosis.

I found the results of the study very interesting. There has to be some caution in interpreting the results given that this is a cross-sectional study (although the notes are examined retrospectively to confirm the  diagnosis). This means that the results are suggestive of association rather than causation. Nevertheless the results on the Dissociative Experiences Scale, if causal, would suggest that this type of response (dissociation) is proportional to a person’s history of traumatic experiences rather than being an innate mechanism of coping with anxiety. The other curious finding was that the history of ‘Troubles-related’ Trauma was more likely to lead to hospital admission when compared to ‘non-Troubles’ related trauma. Perhaps in these instances, the hospital environment is removed from ongoing trauma.

Another point is that there is emerging evidence to suggest that PTSD can result from small trauma accumulated over a period of time. This might include for instance hostility in the family or community and is probably more difficult to measure. Accounting for this may influence the comparison of the Trauma and non-Trauma groups in either direction. Other types of trauma may have occured pre-verbally (during development) although the trauma identified in the scales may be a general marker for the overall trauma experienced by the individual.

This is a good paper which drives forward the debate about the relationship of trauma and dissociation to schizophrenia as well as the impact of civil strife.


The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.


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