Original Paper

Psychopathology 2010;43:33–40 Received: August 12, 2008

Accepted after revision: April 23, 2009
DOI: 10.1159/000255961
Published online: November 6, 2009

Childhood Trauma and Dissociation in

Schizophrenia
Vedat Sar a Okan Taycan b Nurullah Bolat c Mine Özmen b Alaattin Duran b
Erdinç Öztürk a Hayriye Ertem-Vehid d
a
Clinical Psychotherapy Unit and Dissociative Disorders Program, Department of Psychiatry, Istanbul Faculty of
Medicine, Departments of b Psychiatry and c Child and Adolescent Psychiatry, Cerrahpasa Faculty of Medicine, and
d
Department of Family Health, Institute of Pediatrics, Istanbul University, Istanbul, Turkey

Key Words ported. Childhood trauma is related to concurrent dissocia-

Schizophrenia ⴢ Dissociation ⴢ Childhood trauma ⴢ
Comorbidity ⴢ Psychosis
Abstract
Background: This study is concerned with relationships be-
tween childhood trauma history, dissociative experiences,
and the clinical phenomenology of chronic schizophrenia.
Sampling and Methods: Seventy patients with a schizo-
phrenic disorder were evaluated using the Structured Clin-
ical Interview for DSM-IV, Dissociative Experiences Scale,
Dissociative Disorders Interview Schedule, Positive and
Negative Symptoms Scales, and Childhood Trauma Ques-
tionnaire. Results: Childhood trauma scores were correlated
with dissociation scale scores and dissociative symptom
clusters, but not with core symptoms of the schizophrenic
disorder. Cluster analysis identified a subgroup of patients
with high dissociation and childhood trauma history. The
dissociative subgroup was characterized by higher numbers
of general psychiatric comorbidities, secondary features of
dissociative identity disorder, Schneiderian symptoms, so-
matic complaints, and extrasensory perceptions. A signifi-
cant majority of the dissociative subgroup fit the diagnostic
criteria of DSM-IV borderline personality disorder concur-
rently. Among childhood trauma types, only physical abuse
and physical neglect predicted dissociation. Conclusions: A
trauma-related dissociative subtype of schizophrenia is sup-
tion among patients with schizophrenic disorder. A duality
model based on the interaction of 2 qualitatively distinct
psychopathologies and a dimensional approach are pro-
posed as possible explanations for the complex relation-
ship between these 2 psychopathologies and childhood
trauma. Copyright © 2009 S. Karger AG, Basel
Introduction
Dissociative disorders are increasingly considered as a
chronic complex post-traumatic psychopathology closely
related to childhood abuse and/or neglect [1]. Subjects
with dissociative disorders frequently report childhood
traumas, both in clinical settings [2] and in the general
population [3]. Alongside clinical series [4, 5], the rela-
tionship between childhood trauma and dissociation has
been verified both in prospectively designed studies [6]
and using retrospective investigation of highly reliable
forensic documents [7]. Recent studies document that pa-
tients with schizophrenia [8–11] or psychosis [12–14] also
report childhood traumas more frequently than controls.
Ten out of eleven recent general population studies have
found, even after controlling for other factors (including
family history of psychosis), that child maltreatment is
significantly related to psychosis [15]. Although consid-

© 2009 S. Karger AG, Basel Vedat Sar, MD

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eration of psychological trauma as a direct cause of a per-
vasive mental illness like schizophrenia is controversial
[16], a traumagenic neurodevelopmental model has been
proposed to explain a potential relationship [17].
Patients with a schizophrenic disorder may come with
concurrent psychiatric conditions, such as major depres-
sion, obsessive-compulsive disorder, or substance use
disorder [18]. Although there are contradictory findings
[19], dissociative symptoms [8, 9, 20, 21] and disorders
[10] have also been reported in patients with schizophre-
nia. Based on clinical phenomenology and childhood
trauma history, Ross proposed a dissociative subtype of
schizophrenia [22]. In accordance with claims for a direct
relationship between schizophrenia and dissociation
[23], he also proposed that non-dissociative schizophre-
nia, the dissociative subtype of schizophrenia, schizo-
dissociative disorder, and dissociative identity disorder
(DID) constitute a spectrum.
There is convincing evidence that childhood trauma
history has at least an impact on the clinical phenomenol-
ogy of schizophrenia. For instance, in 1 study, severity
and frequency of childhood maltreatment were both pos-
itively correlated with hallucinations and delusions [24].
Another study demonstrated that child abuse was related
to hallucinations (auditory and tactile ones in particular),
but not to delusions, thought disorder, or negative symp-
toms, which are known to be the more robust symptoms
of schizophrenia [25]. Patients with schizophrenia not
only report childhood trauma frequently, but also have
trauma-related symptoms. Schizophrenic patients with a
childhood sexual abuse history had higher levels of dis-
sociation, intrusive experiences, and state and trait anxi-
ety than the non-abused schizophrenia group [26]. In a
study covering adult traumas as well, two thirds of the
patients reported clinically significant trauma symptoms
that included (at least) intrusive experiences, defensive
avoidance, or dissociation. Delusions were correlated
with intrusive experiences, dissociation, and number of
significantly elevated trauma scales, whereas hallucina-
tions were correlated with irritability and total number of
significantly elevated trauma scales [27]. Greater levels of
depression and disturbance of volition were significantly
correlated with greater levels of anxious arousal, intru-
sive experiences, defensive avoidance, dissociation, and
the total number of significantly elevated trauma scales.
In another study, schizophrenia itself seemed to be as-
sociated, independently of trauma and pathological post-
traumatic conditions, with a broad range of dissociative
symptoms [28]. Pronounced post-traumatic symptoms in
schizophrenia were associated with severe additional
34 Psychopathology 2010;43:33–40
psychopathological distress, whereas the increase in dis-
sociation in this group of patients was considered as sec-
ondary to the increase in symptom load. In a third study,
trauma and dissociation were associated with severer
symptoms of schizophrenia [29]. In particular, high dis-
sociation was associated with an increase in symptom
load, whereas traumatic events fitting PTSD criterion A
of DSM-IV and post-traumatic stress disorder (PTSD)
had little or no such effect.
Based on this accumulating evidence, the present
study was concerned with possible relationships between
childhood trauma, dissociative experiences, and the clin-
ical phenomenology of chronic schizophrenia. While in-
quiring into the characteristics of these associations, the
study also tried to determine if there was a trauma-re-
lated dissociative subgroup among patients with schizo-
phrenic disorder. Beside correlational analyses between
various scale scores, schizophrenic patients with high
and low dissociation levels were compared on various
clinical measures, including general psychiatric comor-
bidity and childhood trauma reports. As an examination
of the true subgroups derived from a combination of var-
ious measures, patients were also classified by an inde-
pendent cluster analysis directly.
Method
Participants
All patients with a DSM-IV schizophrenic disorder [30] who
were admitted consecutively to the Psychiatric Department of the
Istanbul University Cerrahpasa Medical Faculty Hospital during
the 2-month study period (December 2005 to January 2006) were
considered for participation. The diagnosis was confirmed by the
Structured Clinical Interview for DSM-IV (SCID-II) [31]. Ap-
proval for the study was obtained from the Ethical Committee of
the Cerrahpasa Faculty of Medicine. Patients who agreed to par-
ticipate in the study provided written informed consent after the
study procedures had been fully explained.
Reasons for exclusion were: severe cognitive impairment (n =
2), psychosis too severe to cooperate (n = 4), and having received
electroconvulsive treatment during the 3-month period prior to
the study interview (n = 2) . Among 79 patients who were eligible
for the study, 8 patients refused to participate and 1 patient was not
able to attend due to illiteracy. Seventy patients comprised the final
study group. All patients were receiving neuroleptic drug treat-
ment as prescribed by their attending psychiatrists. Inpatients
(n = 21) attended the study interview after a stabilization period
for an average duration of 14.9 days (SD = 6.5, range = 3–30).
Instruments
Structured Clinical Interview for DSM-IV. The SCID is a semi-
structured interview developed by First et al. [31]. This widely
used interview serves as a diagnostic instrument for DSM-IV axis
Sar /Taycan /Bolat /Özmen /Duran /
Öztürk /Ertem-Vehid
I psychiatric disorders, except for dissociative disorders. In order Table 1. Pearson correlations between DES, CTQ, and selected
to document the whole comorbidity spectrum on a phenomeno- clinical features (n = 70)
logical basis, all sections of the interview were conducted in the
present study, i.e., skipping parts of the interview due to the pres- Clinical characteristics DES score CTQ total score
ence of a supraordinate diagnostic category were not carried
r p r p
out.
Scales for the Assessment of Negative (SANS) and Positive
DES total score – – 0.38 0.001
(SAPS) Symptoms. Developed by Andreasen [32], the SAPS has 30
CTQ total score 0.36 0.002 – –
items, whereas the SANS has 20. Each item is scored on a 6-point
Secondary symptoms of DID 0.52 0.001 0.26 0.031
Likert-type scale by an interviewer. The SAPS has an interrater
Number of borderline
reliability of 0.84, whereas the SANS has an interrater reliability
personality disorder
of 0.60. Turkish versions of the scales have good reliability and
criteria (SCID-II) 0.48 0.001 0.31 0.009
validity as well [33, 34].
Extrasensory perceptions 0.40 0.001 0.34 0.004
Dissociative Experiences Scale (DES). The DES is a 28-item
Somatic complaints 0.33 0.005 0.29 0.025
self-report instrument developed by Bernstein and Putnam [35].
Schneiderian symptoms 0.29 0.002 0.06 0.644
It is not a diagnostic tool but serves as a screening device for
SCID diagnoses (lifetime) 0.41 0.001 0.19 0.125
chronic dissociative disorders with possible scores ranging from
SCID diagnoses (current) 0.33 0.005 0.07 0.546
0 to 100. The Turkish version of the scale has good reliability and
SANS 0.31 0.008 0.12 0.327
validity [36], with a cut-off score of 30 being useful for screening
SAPS 0.31 0.010 0.12 0.327
dissociative disorders [37].
Age –0.34 0.004 –0.05 0.668
Dissociative Disorders Interview Schedule (DDIS). The DDIS is
Age at onset of disorder –0.38 0.001 –0.05 0.667
a structured clinical interview consisting of 131 items. It was de-
Duration of disorder –0.08 0.509 –0.02 0.883
signed by Ross et al. [38] to diagnose somatization, major depres-
Education –0.15 0.227 –0.07 0.543
sion, borderline personality disorder, and 5 classes of dissociative
disorders according to DSM-IV. The schedule also inquires about
childhood abuse and neglect and a variety of features associated
with dissociative disorders including 11 Schneiderian symptoms,
16 secondary features of DID, and 16 extrasensory experiences.
The validity and reliability of the Turkish version has been re- a 4-group solution with the aim of having the opportunity to look
ported elsewhere [37]. into the distribution of both positive and negative symptoms of
Childhood Trauma Questionnaire (CTQ). The CTQ is a 28- schizophrenia among patients in each subgroup with high and
item self-report instrument developed by Bernstein et al. [39] that low dissociation. The subgroups derived by cluster analysis have
evaluates childhood emotional, physical, and sexual abuse and been compared on various clinical features using one-way ANO-
childhood physical and emotional neglect. Possible scores for VA and the Fisher’s exact test. For all statistical analysis, p values
each type of childhood trauma range from 5 to 25. The sum of the were two-tailed and the level of significance was set at p = 0.05.
scores derived from each trauma type provides the total score
ranging from 25 to 125. Cronbach’s ␣ for the factors related to
each trauma type ranges from 0.79 to 0.94, indicating high inter-
nal consistency [39]. The scale also demonstrated good test-retest
reliability over a 2- to 6-month interval (intraclass correlation = Results
0.88).
Mean age of the patients was 38.3 years (SD = 11.3,
Statistical Analysis range = 19–59); 38 (54.3%) of them were women. They
Two-group comparisons on continuous variables were con- had 10.1 years (SD = 3.5, range = 5–20) of education on
ducted using the Student’s t test. The relationships of the CTQ and
DES with other variables were evaluated with the Pearson correla- average. Mean duration of schizophrenic disorder was
tion test. Predictive power of various types of childhood trauma 13.8 (SD = 9.3, range = 1–38) years. The overall patient
on DES scores were evaluated with stepwise linear regression group had a mean CTQ score of 43.6 (range = 27.0–80.0,
analysis. In order to clarify a potential heterogeneity in the study SD = 11.6) and a DES score of 18.1 (range = 0.0–73.9,
group, we preferred a k-means cluster analysis which classifies SD = 16.6). There was no significant difference between
subjects directly without pursuing a difference between variables
as either dependent or independent [40]. The k-means algorithm women (mean = 18.9, SD = 18.8) and men (mean = 17.2,
assigns each point to the cluster whose center (also called cen- SD = 13.8) on DES scores (t = 0.42, d.f. = 68, p = 0.679).
troid) is nearest. The center is the average of all the points in the Female (mean = 43.7, SD = 11.9) and male (mean = 43.6,
cluster – that is, its coordinates are the arithmetic mean for each SD = 11.4) patients did not differ on CTQ scores either
dimension separately over all the points in the cluster. The pur- (t = 0.03, d.f. = 68, p = 0.974).
pose of this method is to demonstrate the presence of patient sub-
groups with homogenous variables within groups and heteroge- Table 1 documents the findings from correlational
neity between groups, where the number of subgroups is to be analyses between various clinical measures. Age and DES
decided by the investigator but not the method itself. We preferred scores correlated negatively. There were significant cor-

Trauma and Dissociation in Psychopathology 2010;43:33–40 35

Schizophrenia
relations not only between DES total scores and second- ary features of DID had significant correlations with
ary features of DID, but also borderline personality dis- CTQ total score, while Schneiderian symptoms did not.
order criteria, Schneiderian symptoms, extrasensory per- A stepwise linear regression analysis showed that among
ceptions, somatic complaints, number of lifetime and 6 variables (comprising age and 5 types of childhood
current SCID diagnoses, and negative and positive symp- traumas), only young age and childhood physical abuse
toms of schizophrenia. There were positive correlations and neglect predicted DES scores (table 2).
between CTQ and DES total scores. Among symptom We attempted to classify all patients through k-mean
groups, only borderline personality disorder criteria, ex- cluster analysis into 4 groups, while 11 variables entered
trasensory perceptions, somatic complaints, and second- the analysis: secondary features of DID, somatic com-
plaints, extrasensory perceptions, Schneiderian symp-
toms, borderline personality disorder criteria (SCID-II),
total numbers of current and lifetime SCID diagnoses,
Table 2. Stepwise linear regression analysis: types of childhood positive and negative symptom scores, total childhood
trauma as predictor of DES scores (F = 10.79, d.f. = 69, 3; p < trauma and DES scores (table 3). Group A (n = 13) and
0.001) group B (n = 5) consisted of patients with the most robust
dissociative symptomatology, such as secondary features
SE ␤ t p OR and 95% CI
of DID and elevated DES scores. They also had more
Childhood trauma scores Schneiderian symptoms, extrasensory perceptions, so-
Physical neglect 0.52 0.28 2.57 0.013 1.35 (0.30–2.39) matic complaints, and borderline personality disorder
Physical abuse 0.60 0.28 2.60 0.011 1.56 (0.36–2.76) criteria than the remaining groups. Both groups A and B
Age (younger) 0.15 0.37 3.63 0.001 0.54 (0.24–0.84)
had elevated childhood trauma scores, except for emo-
Constant 7.43 – 2.23 0.029 16.58 (1.75–31.41)
tional neglect (table 4). A significant majority of patients

Table 3. Differences between 4 patient groups derived through k-mean cluster analysis

Symptom clusters and scale scores High-dissociation groups Low-dissociation groups 1-way variance
analysis
group A group B group C group D F p
(n = 13) (n = 5) (n = 10) (n = 42) (d.f. = 3, 69)

Schneiderian symptoms (DDIS) 7.683.2 7.881.3 6.182.4 4.883.5 3.53 0.019

Somatic complaints (DDIS) 9.887.4 8.085.3 2.582.2 4.083.7 7.18 0.001
Secondary features of DID (DDIS) 5.883.3 7.283.4 3.582.8 3.182.2 6.38 0.001
Extrasensory perceptions (DDIS) 4.582.7 4.282.0 1.982.6 1.481.5 9.74 0.001
Borderline personality disorder criteria (SCID-II) 4.782.9 2.882.6 0.380.5 1.681.5 13.51 0.001
SCID diagnoses (current) 2.881.1 2.081.2 2.480.7 1.681.0 5.84 0.001
SCID diagnoses (lifetime) 3.581.3 2.880.8 2.681.0 2.381.0 4.47 0.006
SANS 51.7823.0 46.6814.0 80.0823.9 28.0813.7 26.32 0.001
PANS 40.5815.6 106.4817.9 61.1821.5 17.9816.2 52.02 0.001
DES total score 40.0815.8 38.5812.4 12.5811.0 10.388.7 31.59 0.001
Childhood trauma scores
Emotional neglect 13.885.1 13.885.6 13.484.3 12.983.8 0.17 0.914
Physical neglect 11.184.4 10.081.9 7.682.6 8.083.1 3.67 0.016
Emotional abuse 10.583.5 12.485.5 6.481.8 8.184.3 3.59 0.018
Physical abuse 8.884.5 7.482.8 5.580.8 6.382.5 3.37 0.024
Sexual abuse 8.183.9 6.481.9 5.481.0 6.182.1 2.84 0.044
CTQ total score 52.2810.4 50.0813.4 38.387.9 41.5811.1 4.72 0.005
Age, years 32.5810.1 34.6818.1 36.4813.6 41.089.7 2.33 0.083
Age of onset of the disorder, years 21.484.7 18.282.4 23.687.7 26.488.6 2.73 0.051
Duration of the disorder, years 11.188.8 16.4816.3 12.888.8 14.189.2 0.50 0.685
Education, years 9.283.2 10.283.4 9.083.7 10.683.5 0.96 0.418

36 Psychopathology 2010;43:33–40 Sar /Taycan /Bolat /Özmen /Duran /

Öztürk /Ertem-Vehid
who fit the DSM-IV criteria for borderline personality
disorder were in the dissociative group (table 4). Very few
patients had a current or lifetime diagnosis of PTSD or
substance abuse.
While the overall number of psychiatric comorbidities
was correlated with DES scores, none of the comorbid
psychiatric diagnoses was associated exclusively with the
dissociative subgroup. Although positive symptoms of
schizophrenia predominated in group B, group A was
characterized by both positive and negative symptoms.
Group A had the highest scores on childhood sexual and
physical abuse. They had more diagnoses of concurrent
mood and anxiety disorder than group B. On the other
hand, group B had the highest scores on childhood emo-
tional abuse. There was no relationship between tradi-
tional subtypes of schizophrenia and the subgroups de-
rived by cluster analysis (table 4), and gender also was not
related to any of them.
Discussion
As shown by correlations between symptoms and
mental health history items, and an independent cluster
analysis, the present study documented the existence of
a dissociative subgroup among schizophrenic patients.
Notwithstanding the need for further research to estab-
lish its validity, this finding supports a dissociative sub-
type of schizophrenia as proposed by Ross [22]. This sub-
group did not overlap with any of the classical subtypes
of schizophrenia (table 4). The relationship of positive
and negative symptoms of schizophrenia with a dissocia-
tive subtype was also heterogenous (table 3). Thus, the
dissociative subtype of schizophrenia represents a para-
digm different from previous ones.
Three previous studies documented that patients with
schizophrenic disorder and a high level of dissociation
report childhood traumas more frequently than non-dis-
sociative schizophrenic patients [8, 10, 21]. Indeed, there
were significant correlations between DES and CTQ total
scores in the present study. There were also significant
correlations between CTQ total score and secondary

Table 4. Differences between 4 patient groups derived through k-mean cluster analysis

High-dissociation groups Low-dissociation groups Fisher’s

exact test
group A (n = 13) group B (n = 5) group C (n = 10) group D (n = 42)
p
n % n % n % n %

Subtypes of schizophrenia (SCID-II)

Paranoid 6 46.2 2 40.0 4 40.0 18 42.9 1.000
Catatonic 0 0.0 0 0.0 0 0.0 1 2.4 1.000
Disorganized 2 15.4 2 40.0 2 20.0 3 7.1 0.102
Undifferentiated 3 23.1 1 10.0 1 10.0 7 16.7 0.873
Residual 2 15.4 0 0.0 3 30.0 13 31.0 0.453
Psychiatric Comorbidity (SCID-II)
Any adjustment disorder (current) 4 30.8 2 40.0 3 30.0 7 16.7 0.369
Any adjustment disorder (lifetime) 4 30.8 2 40.0 3 30.0 14 33.3 1.000
Any somatoform disorder (current) 2 15.4 1 20.0 1 10.0 0 0.0 0.023
Any somatoform disorder (lifetime) 2 15.4 1 20.0 2 20.0 0 0.0 0.023
Any anxiety disorder (current) 8 61.5 0 0.0 4 40.0 10 23.8 0.027
Any anxiety disorder (lifetime) 9 69.2 2 40.0 4 40.0 15 35.7 0.202
Any mood disorder (current) 8 61.5 1 20.0 6 60.0 8 19.0 0.005
Any mood disorder (lifetime) 11 84.6 3 60.0 7 70.0 24 57.1 0.334
PTSD (current) 1 7.7 0 0.0 0 0.0 0 0.0 0.400
PTSD (lifetime) 1 7.7 0 0.0 0 0.0 2 4.8 0.790
Substance use (current) 0 0.0 1 20.0 0 0.0 0 0.0 1.000
Substance use (lifetime) 1 7.7 0 0.0 0 0.0 4 9.5 0.877
Borderline personality disorder 7 53.8 2 40.0 0 0.0 2 4.8 0.001
Female 8 61.5 3 60.0 2 20.0 25 59.5 0.135

Trauma and Dissociation in Psychopathology 2010;43:33–40 37

Schizophrenia
symptoms of DID alongside somatic complaints, extra-
sensory perceptions, and borderline personality disorder
criteria (table 2), which are known to be part of dissocia-
tive disorders [38]. However, CTQ scores were not related
to positive or negative symptoms of schizophrenia and,
in contrast to a previous study [41], neither to Schneide-
rian symptoms. Unlike childhood trauma scores, disso-
ciative experiences were correlated with negative and
positive symptoms of schizophrenia and Schneiderian
symptoms as well (table 1). Thus, the present study sug-
gests that childhood trauma is related to concurrent dis-
sociation rather than to core features of schizophrenia,
while there was a more proximal relationship between
schizophrenia and dissociation [29].
Representing a nosological fragmentation, high gen-
eral psychiatric comorbidity is a phenomenon observed
among traumatized psychiatric populations in particular
[42]. In accordance with this observation, dissociation
scores were correlated with total number of current and
lifetime comorbid psychiatric disorders, while none of
the comorbid DSM-IV [30] axis-I diagnoses was associ-
ated exclusively with the dissociative subtype of schizo-
phrenia. Nevertheless, a statistically significant number
of patients with borderline personality disorder diagnosis
belonged to the high-dissociation group (table 4). Previ-
ous studies documented a large overlap between border-
line personality disorder and dissociative disorders, in-
cluding high frequencies of reported childhood trauma
[43]. In a previous study on patients with schizophrenia,
higher levels of borderline traits were uniquely related to
the report of childhood sexual abuse [44]. It is possible
that borderline personality disorder criteria represent a
trauma-related symptom pattern among patients with
schizophrenic disorder rather than a personality disorder
per se.
In the present study, young age and childhood physi-
cal abuse and neglect predicted dissociation. Dissociative
experiences are known to be negatively correlated with
age, both in clinical and non-clinical populations [36, 37].
While being the most frequently reported types of child-
hood adverse experiences in Turkey [45], physical abuse
and neglect also may start to take effect at an earlier age
compared to other types of childhood trauma. In support
of its culture-free impact, childhood physical neglect was
predictor of adult dissociation among schizophrenic pa-
tients in a recent study from Germany as well [46]. There
were no gender differences on childhood trauma and dis-
sociation scores, pointing to a common factor affecting
both genders in context of a severe mental illness.
38 Psychopathology 2010;43:33–40
Significant overlap between any of the disorders may
arise for several reasons. In addition to shared risk factors
or fuzzy boundaries between the diagnoses, one of the
disorders may itself be a risk factor for the other. While
the introduction of a dissociative subtype of schizophre-
nia has advantages in terms of clinical utility, it does not
necessarily suggest the validity of a categorical model and
the same solution may fit with a dimensional approach as
well. Notwithstanding the possibility of a clinical spec-
trum from dissociation to schizophrenia either, we also
consider a duality (interaction) model to explain complex
co-existence of 2 distinct but concurrent or subsequent
psychopathologies as a possibility [47].
In fact, the notion of a relatively healthy part of per-
sonality not affected by prevailing psychopathology is
not new in psychiatry, including Bleuler’s original con-
ceptualization of schizophrenia as ‘split mind’ (or split-
ting of psychological functions) and in contrast to the
‘dementia praecox’ of Kraepelin [48]. Most recently, this
notion has been revived under the rubric of the struc-
tural dissociation model of personality as its modern ver-
sion [49, 50]. In application of Bleuler’s notion about a
healthy part onto the structural dissociation model of
personality, the duality model assumes coexistence and
interaction between two qualitatively distinct psychopa-
thologies depending on whether dissociation functions
as a source of resilience against, a risk factor for, or a re-
sponse to a schizophrenic disorder. One of the assump-
tions is that dissociation may function as a defense against
or a facade before an intrapsychic threat of schizophren-
ic psychopathology becomes manifest, historically de-
scribed in diverse ways depending on prevailing concep-
tualizations such as pseudoneurotic schizophrenia [51].
Although this defense may prevent the progression of, or
encapsulate, the severe psychopathology for some sub-
jects, it may make the condition more complex for others
and even constitutes the pathway leading to a severer
mental illness [52]. In addition, coping with the lifelong
experience of having a chronic and devastating mental
illness may require adaptive dissociative mechanisms,
such as denial of the disorder, social detachment, mental
absorption, change of perception of the self and the envi-
ronment, and identity disturbances. A similar interac-
tion model has been proposed for PTSD and severe men-
tal illness by several authors [53, 54]. A psychotic episode
can itself be a cause of PTSD as well which may even lead
to suicide attempts [55]. Although in its infancy, we hope
that the duality hypothesis may serve as a starting point
for further research in this field of complex comorbid-
ity.
Sar /Taycan /Bolat /Özmen /Duran /
Öztürk /Ertem-Vehid
 The present study has several limitations. First of all,
the study group consisted of chronic patients with long-
term psychiatric history. Moreover, all patients were re-
ceiving neuroleptic drug treatment and the study assess-
ment was conducted after a stabilization phase for some
of them. A study on first-episode schizophrenia and
medication-free patients may lead to different results.
Second, the assessment instruments were not designed
specifically for identifying qualitative differences be-
tween symptoms which are common in both disorders,
e.g. Schneiderian symptoms and hallucinations [56].
Third, childhood trauma reports are of retrospective na-
ture; thus, they are subject to possible reinterpretation
and are also susceptible to distortions by psychopathol-
ogy. However, this may happen in both directions. As
aversive contents, childhood traumas can be subject to
minimization or denial as well [11]. Fourth, in consider-
ation of the multivariate statistical method used in this
study, the relatively small sample size may also be consid-
ered as a limitation. Nevertheless, k-means clustering
does not involve any significance testing, so issues of
power and sample size do not arise [57]. The only sample
size issue is whether or not the sample is representative
enough to allow generalizations to be made. Thus, as the
sample is representative only for chronic patients, the
present study does not allow generalizations to patients
in early stages of the disorder.
Conclusions
In support of an earlier proposal for a dissociative sub-
type of schizophrenia, the present study documented that
there is a subgroup of schizophrenic patients who have
dissociative symptoms and childhood trauma history
more frequently than the remaining patients. Overall,
childhood trauma seems to be related to concurrent dis-
sociation rather than to core features of schizophrenic
disorder. The complex relationship between 2 psychopa-
thologies and/or childhood trauma requires further study
based on diverse models of psychopathology.

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