Should You Screen for Psychotic Illness in Sexually Abused Patients?

Australian researchers have suggested, based on the results of their recent study, that children who are sexually abused are at a higher risk for developing such psychotic disorders as schizophrenia later in life, especially if the abuse involves penetration.

In the November issue of Archives of General Psychiatry, the research team wrote that although previous studies have established a link between abuse during childhood and depression, anxiety, substance abuse, borderline personality disorders, PTSD, and suicidal behavior, "The possibility of a link between childhood sexual abuse and later psychotic disorders, however, remains unresolved despite the claims of some that a causal link has been established to schizophrenia," the authors wrote.

Led by Margaret C. Cutajar, DPsych, MAPS, Monash University, Victoria, Australia, the researchers took data from police and medical examinations of sexual abuse cases and linked it to a statewide register of psychiatric cases. Doing so allowed them to compare the rates of psychiatric disorders among 2,759 people who were sexually abused when age 16 years or younger to rated of nearly 5,000 people in a comparison group drawn from electoral records.

When looking at a period of more than 20 years, Cutajar and colleagues found that people who experienced sexual abuse in childhood had significantly higher rates of overall psychosis than did those in the comparison group (2.8% vs. 1.4%, respectively). Schizophrenia disorders were also more common in the former (1.9%) than the latter group (0.7%), with those in the former group experiencing their abuse at an average age of 10.2 years. Among 1,732 cases that involved penetration of a bodily orifice, 3.4% had psychosis and 2.4% had schizophrenia.

"The risks of subsequently developing a schizophrenic syndrome were greatest in victims subjected to penetrative abuse in the peripubertal and postpubertal years from 12 to 16 years and among those abused by more than one perpetrator," wrote the authors. "Children raped in early adolescence by more than one perpetrator had a risk of developing psychotic syndromes 15 times greater than for the general population."

However, Cutajar et al. note that their results show childhood sexual abuse to a risk factor for psychotic illness, not a cause.

"Establishing that severe childhood sexual abuse is a risk factor for schizophrenia does have important clinical implications irrespective of questions of causality and irrespective of whether those whose abuse is revealed are typical," they concluded. "Children who come to attention following childhood sexual abuse involving penetration, particularly in the peripubertal and postpubertal period, should receive ongoing clinical and social support in the knowledge that they are at greater risk of developing a psychotic illness…. Such treatment in our opinion should focus on improving their current functioning and adaptation to the demands of the transition from adolescent to adult roles rather than primarily on the abuse experience itself. Such an approach should benefit all victims, irrespective of whether they have the potential to develop a psychotic illness."

Would it not make sense, based on these results, to monitor patients with a know history of childhood sexual abuse for the development of psychotic illnesses, including schizophrenia? Are there any prophylactic measures that can be taken among this population to hopefully avoid development of these illnesses?