Child Abuse & Neglect 99 (2020) 104243

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Child Abuse & Neglect

journal homepage: www.elsevier.com/locate/chiabuneg

Research article

Childhood trauma and coping in patients with psychotic disorders

T
and obsessive-compulsive symptoms and in un-affected siblings
Tristan C. Renkemaa, Lieuwe de Haana,b,1, Frederike Schirmbecka,b,*,1, GROUP
Investigators (Behrooz Z. Alizadehc,r, Therese van Amelsvoorti,
Agna A. Bartels-Velthuisc, Nico J. van Beverend,e,f, Richard Bruggemanc,n,
Wiepke Cahng,m, Lieuwe de Haanh,q, Philippe Delespauli, Jurjen J. Luykxg,o,
Inez Myin-Germeysj, Rene S. Kahng,p, Frederike Schirmbeckh,q, Claudia J.P. Simonsi,k,
Jim van Osg,l, Ruud van Winkeli,j)
a
Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Location AMC, Meibergdreef 9, 1105AZ, Amsterdam, the Netherlands
b
Arkin Institute for Mental Health, Klaprozenweg 111, 1033 NN, Amsterdam, the Netherlands
c
University of Groningen, University Medical Center Groningen, University Center for Psychiatry, Rob Giel Research Center, the Netherlands
r
University Medical Center Groningen, Department of Epidemiology, Groningen, the Netherlands
i
Maastricht University Medical Center, Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht, the
Netherlands
d
Antes Center for Mental Health Care, Rotterdam, the Netherlands
e
Erasmus MC, Department of Psychiatry, Rotterdam, the Netherlands
f
Erasmus MC, Department of Neuroscience, Rotterdam, the Netherlands
n
University of Groningen, Department of Clinical and Developmental Neuropsychology, Groningen, the Netherlands
g
University Medical Center Utrecht, Department of Psychiatry, Brain Centre Rudolf Magnus, Utrecht University, Utrecht, the Netherlands
m
General Menthal Health Care, Utrecht, the Netherlands
h
Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam, the Netherlands
q
Institute for Mental Health, Amsterdam, the Netherlands
o
University Medical Center Utrecht, Department of Translational Neuroscience, Brain Center Rudolf Magnus, Utrecht, the Netherlands
j
KU Leuven, Department of Neuroscience, Research Group Psychiatry, Leuven, Belgium
p
Dept of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States
k
GGzE Institute for Mental Health Care, Eindhoven, the Netherlands
l
King’s College London, King’s Health Partners, Department of Psychosis Studies, Institute of Psychiatry, London, United Kingdom

ARTICLE INFO ABSTRACT

Keywords: Background: Research on environmental and individual risk-factors in patients with a psychotic
Childhood trauma disorder and co-occurring obsessive-compulsive symptoms (OCS) is limited.
Abuse Objective: This study aimed to examine the role of childhood trauma and coping on the occur-
Coping rence of OCS in patients with a psychotic disorder and on a subclinical level in siblings.
Psychosis
Participants and setting: 626 patients and 638 siblings from the Genetic Risk and Outcome of
Obsessive compulsive
Psychosis (GROUP) study were included in the current study.
Methods: Differences between patients and siblings with and without OCS were analyzed with
between-group comparisons. Mediation analyses investigated the effect of coping on the asso-
ciation between trauma and OCS severity.
Results: Patients and siblings with OCS reported more childhood traumatic events, particularly
sexual (OR = 1.62 / 3.26) and emotional (OR = 1.47 / 2.04) abuse compared to those without

⁎
Corresponding author at: Department of Psychiatry, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
E-mail address: [email protected] (F. Schirmbeck).
1
Both last authors contributed equally.

https://doi.org/10.1016/j.chiabu.2019.104243
Received 15 April 2019; Received in revised form 18 September 2019; Accepted 17 October 2019
0145-2134/ © 2019 Elsevier Ltd. All rights reserved.
T.C. Renkema, et al. Child Abuse & Neglect 99 (2020) 104243

OCS. Both patients (d = 0.69) and siblings (d = 0.49) with co-occurring OCS showed a higher
tendency for dysfunctional passive coping strategies compared to the group without OCS. The
tendency for passive coping mediated the association between sexual and emotional abuse and
OCS severity in patients.
Conclusions: Results imply that childhood trauma is associated with the presence of co-occurring
OCS. Enhancing active coping strategies might have a beneficial effect in the prevention and
treatment of co-occurring OCS in patients with psychotic disorders.

1. Introduction

Patients with psychotic disorders (PD) often experience co-occurring obsessive-compulsive symptoms (OCS). Meta-analyses show
that the prevalence rate of OCS in patients with a PD is 30.3% and that about 13% meet the criteria for an obsessive-compulsive
disorder (OCD) (Achim et al., 2011; Swets et al., 2014). It has been reported that co-occurrence of OCS and PD increases the risk of
developing a more persistent form of psychosis (Van Dael et al., 2011). Moreover, the comorbidity is associated with more severe
positive, negative and affective symptoms (Cunill, Castells, & Simeon, 2009; Schirmbeck, Konijn, Hoetjes, Zink, & de Haan, 2018),
increased suicidality (Sevincok, Akoglu, & Kokcu, 2007; Szmulewicz, Smith, & Valerio, 2015), more social dysfunction (de Haan,
Sterk, & van der Valk, 2013; Hunter & Lysaker, 2015), a lower socioeconomic status, and significantly earlier onset of schizophrenia
compared with patients without comorbid OCS (Owashi, Ota, Otsubo, Susa, & Kamijima, 2010).
Research investigating possible underlying mechanisms suggests shared individual and environmental risk factors for PD and
OCD/OCS. However, these risk factors have mainly been investigated for primary OCD and PD separately. Childhood trauma has
been described as a risk factor for psychosis, and psychotic-like experiences (Morgan & Gayer-Anderson, 2016; Varese et al., 2012).
Trauelsen et al. (2015) reported that with each additional adversity, the chance of developing a psychosis increases by two and a half
(Trauelsen et al., 2015). Additionally, childhood trauma has been associated with OCD (Briggs & Price, 2009; Mathews, Kaur, & Stein,
2008). A recent meta-analysis including 24 studies found an association between four types of trauma (e.g. emotional and sexual
abuse) and OCS severity (Miller & Brock, 2017). The relationship between childhood adversities and comorbid OCS in patients with a
PD remains relatively unknown. To our knowledge, only two recent studies investigated this association and revealed a modest effect
of childhood trauma on comorbid OCS severity (Schreuder, Schirmbeck, Meijer, & de Haan, 2017). Lindgren et al. (2017) recently
reported that the severity of childhood adversity was associated with increased anxiety and OCS in young adults with a first-episode
psychosis (Lindgren et al., 2017).
Another factor that seems to play a role in the development and maintenance of OCD and psychotic disorders is the use of
dysfunctional coping strategies (Moritz et al., 2016). To the best of our knowledge, only one study has investigated the association
between coping and OCS in patients with a PD (Lysaker, Whitney, & Davis, 2006). This study revealed that patients with schizo-
phrenia and OCS showed a higher preference for avoidant coping strategies in comparison to those without OCS (Lysaker et al.,
2006). Furthermore, dysfunctional coping and experiential avoidance have been reported to function as a mediator in the re-
lationship between traumatic life events, perceived stress and psychotic-like experiences (Ered, Gibson, Maxwell, Cooper, & Ellman,
2017), and in the relation between trauma and OCS (Kroska, Miller, Roche, Kroska, & O’Hara, 2018).
Taken together, findings suggest that childhood trauma and dysfunctional coping strategies play a role in the development and
maintenance of both OCD and PD and may also influence their co-occurrence. So far, the association between different types of
childhood traumatic experiences and co-occurring OCS in patients with PD and a possible mediating effect of coping on these
associations has not been investigated.
Previous research reported an increased risk for first-degree relatives of patients with a PD and co-occurring OCS to also develop
psychotic and obsessive-compulsive symptoms (Poyurovsky et al., 2005). By including a sample of unaffected siblings in the current
study, more can be learned about potential associations between childhood trauma, coping strategies and a dimensional liability for
the co-occurrence of OCS and psychosis.

1.1. Aims of the study

The aim of the current study was to investigate the association between experienced childhood trauma, coping preferences and
the occurrence of OCS in patients with a PD and in unaffected siblings. We expect that participants with OCS have experienced more
childhood trauma, and use more dysfunctional coping strategies (e.g. avoidance) than those without OCS. We further hypothesize
that dysfunctional coping strategies mediate the association between (different types of) childhood trauma and OCS.

2. Material and methods

2.1. Study design and participants

For this study, data was obtained from the multicenter Genetic Risk and Outcome of Psychosis (GROUP) study (Korver, Quee,
Boos, Simons, & de Haan, 2012). This is a naturalistic longitudinal cohort study with baseline, three- and six-year follow-up as-
sessments. Assessment was done by trained clinicians consisting of psychologists, research assistants, psychiatrists, nurses and PhD

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students who received training and supervision for all measures. For a detailed description of procedures of recruitment, we refer to
Korver et al. (2012). In short, inclusion criteria for this study for patients and siblings were (1) age ranging from 16 to 50 years and
(2) a good command of the Dutch language. Patients had to meet the criteria of a non-affective psychotic disorder according to DSM-
IV (Association, A. P., 2013), which was assessed with the Comprehensive Assessment of Symptoms and History (CASH; (Andreasen &
Flaum, 1992)) or the Schedules for Clinical Assessment for Neuropsychiatry version 2.1 (SCAN; (Wing, Babor, & Brugha, 1990)),
whereas siblings were included when they did not meet these criteria. The present study has a cross-sectional design, only using data
from the 6-year follow-up assessment, except for childhood trauma, which was retrospectively assessed at the 3-year follow-up
assessment. In the 6-year follow-up assessment 677 patients and 699 siblings participated. In the present study data of 626 patients
and 638 siblings were included, who provided data on co-occurring OCS from GROUP data release 7.0. Most but not all of the siblings
were related to included patients. In several cases patients did not have their sibling included and in other cases siblings took part in
the study although their affected brother or sister did not participate. In some cases multiple siblings and/or patients took part from
the same family. Of note, coping preferences were only investigated in subsamples of 333 patients and 351 siblings. All participants
received verbal and written information about the study and informed consent was obtained before the start of the first assessment.
The study was approved by the Ethical Review Board of the University Medical Centre of Utrecht.

2.2. Measures

Sociodemographic information was assessed through self-reports of participants. Antipsychotic use during the last 3 years was
also mainly recorded through self-report of the patient. If unknown, the professional caregiver was contacted.
The severity of obsessions and compulsions was measured with the Dutch version of the Yale-Brown Obsessive-Compulsive Scale
(Y-BOCS; (Goodman, Price, Rasmussen, & Mazure, 1989)). This instrument has been reported as reliable when assessed in patients
with schizophrenia (Boyette, Swets, Meijer, Wouters, & GROUP Investigators, 2011). The interview assesses the distress and time
associated with the obsessions and/or compulsions individuals experienced during the prior week up until the interview on a 5-point
Likert scale (0–4). Total scores range from 0 to 40. To measure the presence of childhood trauma, the Dutch version of the Childhood
Trauma Questionnaire (CTQ; (Bernstein et al., 1994) was administered. This self-report version consists of 25 items that measure
childhood abuse (emotional, physical or sexual) and neglect (emotional and physical) in 5 subscales on a 5-point Likert scale (1–5).
The validity and reliability of the CTQ is supported within both the general population (Bernstein et al., 1994) and patients diagnosed
with schizophrenia (Kim, Lindenmayer, & Hwang, 2013). Because scores on trauma were highly skewed, this variable was dichot-
omized into high and low scores. In previous literature the cutoff was defined at the 80 th percentile of the subscale scores in healthy
controls (Heins et al., 2011). Because this cut-off score led to an insufficient distinction of dichotomous groups in the current patient
sample, the cutoff score was changed to the 90th percentile of the scores of healthy controls per subscale. See Supplement Table 1 for
an overview of the cut-offs at both percentiles. The Utrechtse Coping List (UCL; (Schreurs, van de Willige, Brosschot, Tellegen, &
Graus, 1993) is a Dutch self-report questionnaire examining different coping strategies generally preferred by the participant in
different situations. The survey consists of 47 items measuring seven independent coping styles: proactive action, palliative reaction,
avoidance, seeking social support, passive reaction, expression of emotions, and calming thoughts. Examples for items describing
different coping preferences are:” see problems as a challenge”, “avoiding difficult situations as much as you can”, “share your
concerns with someone else” or “await what will happen”). Each item is scored on a 4-point Likert scale from rarely or never (1) to
very often (4). (1–4). Schreurs et al. (1993) found that Cronbach’s alphas of the subscales vary from α = .45 to α = .85 (Schreurs
et al., 1993). Cronbach’s alphas for the subscales in present study varied from α = .77 to α = .88.
To measure the severity of psychotic symptoms of patients, the Positive and Negative Syndrome Scale (PANSS; (Kay, Fiszbein, &
Opler, 1987) was administered. The scale consists of 30 items measuring the severity of positive and negative symptoms and general
psychopathology rated on a scale ranging from 1 (absent) to 7 (extreme). Only the estimates of positive and negative symptoms will
be examined. Index scores vary from 7 to 49 for both subscales. The PANSS is identified to have a good validity and reliability (Kay
et al., 1987). Calculations in our sample show Cronbach’s alphas of α = .76 for the positive symptom scale and α = .80 for the
negative symptom scale.
The presence of subclinical symptoms in siblings was assessed with the Community Assessment of Psychic Experiences (CAPE;
(Konings, Bak, Hanssen, Van Os, & Krabbendam, 2006). The CAPE is a self-report questionnaire, developed to measure the prevalence
of subclinical positive, negative, and depressive symptoms in the general population. The current study will only use the frequency
scales of the positive and negative symptom scales, ranging from 0.00 - 0.85 for positive symptoms and from 0.00 to 2.36 for negative
symptoms. Items of the CAPE are rated on a scale from 0 (absent) to 3 (severe). A mean total score was calculated for the subscales
positive and negative symptoms respectively, if at least 70% of the item-scores were available. The CAPE has been recognized to be a
reliable and valid instrument for the measurement of psychotic experiences in the general population (Konings et al., 2006). Analysis
of reliability in this study shows Cronbach’s alphas of α = .92 for the positive symptom scale and α = .91 for the negative symptom
scale.

2.3. Statistical analysis

In order to evaluate differences between participants with and without OCS regarding sociodemographic characteristics in-
dependent t-tests were performed for continuous variables, whereas chi-square tests were used for dichotomous variables. For group-
comparisons patients and siblings with a score of zero on the Y-BOCS were assigned to the OCS- group (Y-BOCS = 0), whereas all
other subjects were included in the OCS + group (Y-BOCS > 0). This categorization, which includes subclinical OCS severity in a

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T.C. Renkema, et al. Child Abuse & Neglect 99 (2020) 104243

OCS + group has been applied in other relevant studies on this subject (Meijer et al., 2013; Ntouros et al., 2014; Tonna et al., 2015).
Furthermore, it accounts for a dimensional perspective were e.g. the exposure to a traumatic event has already been associated with
an increased risk to endorsed at least one obsessive-compulsive symptom (Barzilay et al., 2019).
To account for the nested data structure where some patients and siblings were coming from the same family, we analyzed
between group differences for all outcome variables using mixed effect models including random intercepts for family level. Linear
mixed effect models were analyzed for continuous outcomes and binominal logit link-functions for the dichotomous outcomes of
trauma subtypes. Models with continuous outcome variables were fitted with restricted maximum likelihood (REML) under the
assumption of data missing at random, which we tried to make tenable by comparing individuals with missing data to those providing
complete data sets.
In addition, effect sizes were calculated according to Cohens d (1988) for continuous variables and odds ratio for categorical data.
Subsequently, to examine a possible mediating role of coping on the association between trauma and OCS severity as measured with
the YBOCS total score, maximum likelihood regression mediation analyses were conducted using PROCESS version 2.0 (Preacher &
Hayes, 2008). PROCESS is a tool for moderation and mediation analysis using path based analysis, and generates coefficients of the
effects and confidence intervals estimates based on bootstrapping (Preacher & Hayes, 2008). With regard to the calculated path-ways:
the a-path represents the path from the predictor variable to the mediator and the b-path from the mediator to the outcome variable,
the c’-path represents the direct pathway between the predictor and the outcome variable. For the indirect effects of trauma on co-
occurring OCS severity through coping (ab-path), a bootstrapping approach was used, taking the mean of 10.000 estimates of ab and
the 95% confidence interval. The presented path coefficients are unstandardized. To account for the possible confounding effect of
between-group differences, covariates were added to the model. For all analyses a two-tailed significance level of p = < .05 was
applied. All analyses were performed using Statistical Package for the Social Sciences (IBM SPSS Statistics 24).

3. Results

Between-group comparisons on sociodemographic characteristics and relevant outcome variables in patients are shown in
Table 1. Both groups did not differ in age, gender, IQ or DSM diagnosis. We additionally analyzed whether the OCS + group was
more likely treated with olanzapine or clozapine, as antipsychotic medication with strong antiserotonergic properties have been
proposed to induce or aggravate OCS (Schirmbeck & Zink, 2015) and found significant group differences. In addition, illness duration

Table 1
Sample characteristics and differences between patients with and without co-occurring obsessive-compulsive symptoms.
Variable OCS- (N = 471) OCS+ (N = 155) Test Statistic p-value OR Cohen’s d

Age in years, mean (SD) 33.52 (7.40) 33.90 (9.90) t = -.568 .570
Gender, male n (%) 359 (76.22%) 114 (73.54%) χ2 = .251 .617
Illness duration in years, mean (SD) 11.31 (4.46) 12.19 (4.63) t = -1.992 .047
IQ, mean (SD) 101.16 (17.94) 100.94 (18.07) t = .132 .895
Years of education, mean (SD) 15.48 (4.00) 15.73 (4.00) t = .065 .513
Antipsychotic medication 85 (61.15%) 202 (50.12%) χ2 = 5.044 .025
Clozapine/Olanzapine, n (%)
DSM-IV diagnosis, n (%) χ2 = 4.601 .102
Schizophrenia 319 (67.72%) 118 (76.13%)
Schizoaffective disorder 99 (21.01%) 27 (17.42%)
Unspecified psychotic disorder 53 (11.25%) 10 (6.45%)
PANSS, mean (SD)
Positive symptoms 11.36 (6.12) 14.69 (6.80) t = -5.405 < .001
Negative symptoms 12.22 (5.87) 12.89 (5.30) t =−1.336 .182
CTQ, high/lowa
emotional abuse 109/310 43/83 t = 1.738 .083 1.47
physical abuse 122/297 46/80 t = 1.558 .120 1.40
sexual abuse 88/331 38/88 t = 2.075 .038 1.62
emotional neglect 99/319 27/99 t = -0.517 .605 0.88
physical neglect 99/310 23/103 t = -1.266 .206 0.72
UCL, M (SD)b
proactive action 2.53 (0.51) 2.38 (0.48) t = 1.738 .018 .30
palliative reaction 2.23 (0.45) 2.33 (0.44) t = -1.885 .060 .22
avoidance 2.16 (0.41) 2.28 (0.40) t =-2.435 .015 .30
seeking social support 2.27 (0.50) 2.26 (0.60) t = 0.330 .742 .02
passive reaction 1.89 (0.54) 2.26 (0.54) t = -5.760 < .001 .69
expression of emotion 1.94 (0.50) 1.95 (0.55) t = -0.191 .849 .02
calming thoughts 2.38 (0.51) 2.41 (0.55) t = -0.553 .580 .06

Abbreviation: OCS- = patients without comorbid obsessive-compulsive symptoms; OCS+ = patients with comorbid obsessive-compulsive symp-
toms; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders 4th edition; PANSS = Positive and Negative Syndrome Scale;
CTQ = Childhood Trauma Questionnaire; OR = Odds Ratio; UCL = Utrechtse Coping List.
a
Subsample: OCS- = 419 OCS+ = 126.
b
Subsample: OCS- = 245 OCS+ = 88.

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T.C. Renkema, et al. Child Abuse & Neglect 99 (2020) 104243

and means of PANSS positive symptoms were significantly higher in the OCS + group and were therefore also considered as potential
confounders. Table 2 represents an overview of characteristics of the siblings. The OCS- and OCS + groups in the sibling sample did
not significantly differ in age, gender and IQ, but the OCS + group showed higher means on the CAPE positive and negative subscale.
We compared patients and siblings with complete data to those showing missing values on the JTV or UCL. Neither patient nor
sibling groups significantly differed in age, gender, estimated IQ, years of education or antipsychotic medication. Patients with
missing data regarding trauma showed significantly shorter illness duration (t=-3.976, t= < .001, d = .52), whereas those with
missing data regarding coping showed significantly longer illness duration (t = 2.411, p = .016, d = .20), respectively.

3.1. Between-group differences in childhood trauma and coping strategies

Association between OCS status and outcome variables were first assessed by fitting logit link and linear mixed models for all
participants with participant-status (patient / sibling) as fixed effect and accounting for familiar clustering by including an extra
random intercept for family level. Significant differences between patients and siblings emerged for all outcome variables, except for
UCL calming thoughts. For this reason and to be able to compare findings in patients and siblings, we subsequently reported analyses
fitted for each group separately. Again, mixed effect models were applied including random intercept for family level to account for
the fact that some patients and siblings were coming from the same family. Patients in the OCS + group reported a significant higher
level of experienced sexual abuse when compared to patients in the OCS- group (OR: 1.62) (see Table 1). In the sibling sample, similar
and more substantial group-differences were found. Siblings in the OCS + group were 3.26 times more likely to have experienced
sexual abuse and in addition also reported an increased risk for emotional abuse (OR: 2.04). Regarding differences in coping stra-
tegies, patients in the OCS + group scored significantly higher on the UCL subscales avoidance and passive reaction and lower on the
subscale proactive action (see Table 1). Accordingly, In siblings, the OCS + group showed more passive reaction and a tendency for
less proactive action compared to the OCS- group (see Table 2).

3.2. The mediating effect of coping

To explore the potential mediating effect of coping on the relationship between trauma and OCS severity, subsequent analyses
were conducted with the dichotomous variables high/low sexual and emotional abuse as independent variables and the YBOCS total
score as the dependent variable. Based on significant between-group differences, proactive action, avoidance and passive reaction
were included as potential mediators in patients. In siblings, the same coping strategies were kept in the model to enable compar-
ability with the patient sample. Table 3 shows the result of the mediation analyses performed in patients and siblings.
The associations between emotional and sexual abuse and OCS severity in patients were mediated by passive reaction as shown in
significant a- and b-paths. These indirect effects were also tested using bootstrapping procedures with confidence intervals (95% CI).
Both upper and lower estimates of the effect of passive reaction in the model of sexual abuse, CI [0.20, 1.31], and emotional abuse, CI
[0.22, 1.26], were larger than 0, indicating significance (Table 3). To account for potential confounding effects, positive symptoms

Table 2
Sample characteristics and differences between siblings with and without subclinical obsessive-compulsive symptoms.
Variable OCS- (N = 582) OCS+ Test Statistic p OR Cohen’s d
(N = 56)

Age in years, mean (SD) 34.21 (8.16) 33.31 (7.68) t = .809 .419
Gender, male n (%) 262 (45.02) 24 (51.78) χ2 = 0.771 .380
IQ, mean (SD) 112.04 (17.43) 112.18 (19.31) t =-.056 .956
CAPE
Positive, mean (SD) 0.08 (0.11) .14 (0.15) t = -3.404 .001
Negative, mean (SD) 0.45 (0.40) .78 (0.50) t = -4.598 < .001
CTQ, high/lowa
emotional abuse 74/477 13/41 t = 2.001 .046 2.04
physical abuse 124/427 19/35 t = 1.874 .061 1.87
sexual abuse 68/483 17/37 t = 3.687 < .001 3.26
emotional neglect 98/453 10/44 t = 0.180 .857 1.05
physical neglect 76/475 9/45 t = 0.558 .558 1.25
UCL, M (SD)b
proactive action 2.76 (0.46) 2.60 (0.52) t = 1.841 .067 0.33
palliative reaction 2.13 (0.44) 2.20 (0.31) t = -1.389 .166 0.18
avoidance 1.98 (0.37) 2.06 (0.48) t = -1.051 .294 0.18
seeking social support 2.39 (0.57) 2.28 (0.55) t = 1.119 .264 0.20
passive reaction 1.55 (0.45) 1.81 (0.61) t = -2.507 .013 0.49
expression of emotion 2.08 (0.50) 2.07 (0.54) t = 0.045 .964 0.02
calming thoughts 2.39 (0.48) 2.35 (0.36) t = 0.610 .542 0.09

Abbreviation: OCS- = siblings without obsessive-compulsive symptoms; OCS+ = siblings with obsessive-compulsive symptoms; CAPE =
Community Assessment of Psychic Experiences; UCL = Utrechtse Coping List.
a
Subsample: OCS- = 551, OCS+ = 54.
b
Subsample: OCS- = 312, OCS+ = 39.

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Table 3
Mediating effect of dysfunctional and proactive coping on the association between sexual/emotional abuse and OCS severity in patients (n = 261)
and siblings (n = 298).
X to M M to Y Direct effect Indirect effect
X M Y a b c’ (95%CI) ab (95% CI)
CTQ UCL

Patients sexual abuse proactive action OCS 0.07 −0.10 −0.36 (-2.01-1.30) −0.01 (-0.22-0.11)
avoidance 0.11 0.04 −0.05 (-0.24-0.27)
passive reaction 0.26** 2.34*** 0.61 (0.20-1.31)*
emotional abuse proactive action 0.05 −0.22 1.21 (-0.31-2.72) −0.01 (-0.22-0.07)
avoidance 0.19** −0.08 −0.02 (-0.47-0.32)
passive reaction 0.30*** 2.08** 0.62 (0.22-1.26)*
Siblings sexual abuse proactive action OCS −0.11 −0.41 0.78 (-0.19-1.77) 0.05 (-0.03-0.27)
passive reaction 0.27*** 0.72* 0.20 (-0.01-0.68)
avoidance 0.17** −0.33 −0.06 (-0.28-0.10)
emotional abuse proactive action −0.08 −0.42 0.65 (-0.39-1.69) 0.04 (-0.03-0.29)
passive reaction 0.24** 0.76* 0.20 (0.01-0.63)*
avoidance 0.16* −0.32 −0.05 (-0.27-0.08)

Abbreviation: CTQ = Childhood Trauma Questionnaire; UCL = Utrechtse Coping List; OCS = obsessive-compulsive symptoms.
*** p < 0.001.
** p < 0.01.
* p < 0.05.

were added to the models as covariates, considering they were significantly associated with predictor and outcome variables, unlike
illness duration and antipsychotic treatment with clozapine or olanzapine. The mediating effect of passive reaction on the association
between sexual abuse and OCS severity, as well as the mediating effect on the association between emotional abuse and OCS
remained significant (see Supplement Table 2). Mediation analyses in siblings also revealed significant effects of passive reaction on
both the relation between sexual and emotional abuse and OCS severity (Table 3). After accounting for subclinical positive and
negative symptoms, the mediating effects on the association between sexual and emotional abuse and OCS severity lost significance
(Supplement Table 2).

4. Discussion

This study aimed to examine the association between childhood trauma and the occurrence of OCS and possible mediating effects
of coping strategies in patients with a PD and on a subclinical level in unaffected siblings. Results show that patients with comorbid
OCS experienced more sexual abuse than patients who reported no OCS. Accordingly, the OCS + group in siblings also reported more
sexual and emotional abuse. No differences were found regarding the occurrence of childhood neglect in both groups. With regard to
coping we found that patients in the OCS + group showed a higher preference for avoidance and passive coping and less proactive
action in comparison to patients in the OCS- group. The sibling group with OCS again was more likely to apply dysfunctional passive
coping. Subsequent analysis revealed mediating effects of passive coping on the relation between sexual and emotional abuse and
OCS severity in patients and siblings, which remained significant in patients when controlling for positive symptom severity, but lost
significance in siblings.
So far, studies investigating the association between individual and environmental risk-factors and co-occurring OCS in patients
with a PD have been scarce. The present study adds to previous findings (Schreuder et al., 2017) by investigating different types of
traumatic experiences and expanding the focus to a sample of unaffected siblings. Results showed that particularly higher levels of
sexual abuse were related to the presence of OCS in patients and siblings, whereas no differences were found with regard to childhood
neglect. These findings stand in line with reported associations between childhood adversities and OCS in the general population
(Mathews et al., 2008) and primary OCD (Miller & Brock, 2017). Meta-analytic findings in primary OCD patients also showed a
moderately stronger association between childhood sexual and emotional abuse and OCS severity than between neglect and OCS
severity (Miller & Brock, 2017). Comparable results have been reported in the association between childhood abuse/neglect and
psychotic symptoms (van Dam et al., 2015).
Regarding differences in coping preferences, in line with previous findings of Lysaker et al. (Lysaker et al., 2006), patients with PD
and OCS showed a preference for dysfunctional passive and avoidant coping compared to patients without OCS (Lysaker et al., 2006).
This tendency to withdraw when being confronted with stressors and the belief of being unable to do something about the situation
(Schreurs et al., 1993) has been found associated with several psychopathological syndromes, including primary OCD (Moritz et al.,
2016). Moreover, dysfunctional coping has been described to function as a mediator in the relation between trauma and OCS (Briggs
& Price, 2009; Kroska et al., 2018), but also between traumatic experiences and psychotic symptoms (Ered et al., 2017). This suggests
an interplay between childhood trauma, dysfunctional coping strategies and co-occurring symptoms of psychosis and OCS. Re-
maining mediating effects of passive coping on OCS severity in patients when controlling for severity of psychotic symptoms however
suggest that early traumatic experiences add to the explanation of variance in co-occurring OCS. Recent findings on the prospective
course and interaction of OCS and symptoms of psychosis showed persistent associations between severity of symptom domains on
the between-subject level but also significant variation in symptom severity on the within-subject level, suggesting shared underlying

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vulnerability factors, but also time-varying maintenance factors (Schirmbeck et al., 2018). Traumatic experiences could represent
such a shared vulnerability factor increasing the risk to develop both symptom clusters.
In line with previous findings (Abdelghaffar, Ouali, Jomli, Zgueb, & Nacef, 2016; Hassija, Luterek, Naragon-Gainey, Moore, &
Simpson, 2012) our results suggest that the experience of early childhood adversity (particularly emotional and sexual abuse) is
related to the preference of avoidant and passive coping strategies. In turn, these maladaptive coping strategies in everyday life
situations might lead to a more severe experience of stress and distress and increase the risk to aggravate or maintain both psychotic
symptoms and comorbid OCS. Prospective studies are needed to investigated these proposed causal associations.
Our findings might have implications for the prevention and treatment of co-occurring OCS and psychotic symptoms. Increased
diagnostic attention should focus on the exploration of early adverse experiences and strategies to cope with stressful events.
Cognitive-behavioural interventions aiming to increase the ability to use more adaptive strategies in managing stressful situations
might show beneficial effect on the course of co-occurring symptoms.

4.1. Strengths and limitations

This is the first study investigating the role of coping in the relation between trauma and OCS in patients with a PD in a relatively
large sample of the representative cohort GROUP study (Korver et al., 2012). By including a sample of unaffected siblings, we were
able to investigate similar associations in participants with an increased liability for psychosis and OCS without illness related
confounding effects of for instance medication. Several limitations of the current study should be noted. This study has a cross-
sectional design; therefore no causal conclusions can be drawn and bi-directional associations should be considered. For instance the
presence of OCS might also have an effect on coping preferences and the recollection or judgement of childhood trauma. However,
prospective studies support the assumption that childhood experiences and life events significantly predict subsequent psycho-
pathology and found more consistent relations for coping as a mediator of the link from stress to symptoms than from symptoms to
stress (Evans et al., 2015; Kim, Neuendorf, Bianco, & Evans, 2016). Participants who took part in the GROUP study may differ from
individuals who declined participation or those who dropped out during the course of the study. As a result, generalizability of our
findings is limited to a relatively high functioning group of patients with a PD and could potentially underestimate associations in
more severely ill patients. Furthermore, some participants had missing data on the JTV and particularly UCL questionnaire. Non-
significant comparisons between completers and non-completers supported the assumption that data were mainly missing at random.
However, differences emerged with regard to illness duration. We tried to account for these differences by including illness duration
as a potential confounder. Nevertheless, missing data resulted in smaller subsample of participants to examine differences and
possible mediating effects of coping, with less power to detect effects. Finally, the decision to group participants according to a
YBOCS total score > 0, acknowledging a dimensional perspective on OCS severity, might have led to underestimations of group
differences. Future studies should investigate findings by dividing participants according to no versus more severe, clinically relevant
OCS.

Ethical standards

Al participants provided written informed consent prior to their inclusion in the current study. The study was approved by the
accredited Medical Ethics Review Committee (METC) and has therefore been performed in accordance with the ethical standards laid
down in the Declaration of Helsinki.

Declaration of Competing Interest

All authors declare no conflict of interest regarding the present study.

L. de Haan has received speakers-bureau honoraria from Eli Lilly, Janssen-Cilag Pharmaceuticals and AstraZeneca BV and an
investigator initiated unrestricted research grant from Eli Lilly.

Acknowledgements

This work was supported by the Geestkracht programme of the Dutch Health Research Council (Zon-Mw, grant number 10-000-
1001), and matching funds from participating pharmaceutical companies (Lundbeck, AstraZeneca, Eli Lilly, Janssen Cilag) and
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, 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, OPZ Rekem. Utrecht: University Medical Center
Utrecht and the mental health institutions Altrecht, GGZ Centraal and Delta).
We are grateful for the generosity of time and effort by the patients, their families and healthy subjects. Furthermore we would
like to thank all research personnel involved in the 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.

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T.C. Renkema, et al. Child Abuse & Neglect 99 (2020) 104243

Appendix A. Supplementary data

Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.chiabu.2019.
104243.

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