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Sexual abuse and psychotic phenomena: a directed acyclic graph analysis of affective symptoms using English national psychiatric survey data

Moffa, G., Kuipers, J., Kuipers, E. , McManus, S. ORCID: 0000-0003-2711-0819 & Bebbington, P. (2023). Sexual abuse and psychotic phenomena: a directed acyclic graph analysis of affective symptoms using English national psychiatric survey data. Psychological Medicine, 53(16), pp. 7817-7826. doi: 10.1017/s003329172300185x


Sexual abuse and bullying are associated with poor mental health in adulthood. We previously established a clear relationship between bullying and symptoms of psychosis. Similarly, we would expect sexual abuse to be linked to the emergence of psychotic symptoms, through effects on negative affect.

We analysed English data from the Adult Psychiatric Morbidity Surveys, carried out in 2007 (N = 5954) and 2014 (N = 5946), based on representative national samples living in private households. We used probabilistic graphical models represented by directed acyclic graphs (DAGs). We obtained measures of persecutory ideation and auditory hallucinosis from the Psychosis Screening Questionnaire, and identified affective symptoms using the Clinical Interview Schedule. We included cannabis consumption and sex as they may determine the relationship between symptoms. We constrained incoming edges to sexual abuse and bullying to respect temporality.

In the DAG analyses, contrary to our expectations, paranoia appeared early in the cascade of relationships, close to the abuse variables, and generally lying upstream of affective symptoms. Paranoia was consistently directly antecedent to hallucinations, but also indirectly so, via non-psychotic symptoms. Hallucinosis was also the endpoint of pathways involving non-psychotic symptoms.

Via worry, sexual abuse and bullying appear to drive a range of affective symptoms, and in some people, these may encourage the emergence of hallucinations. The link between adverse experiences and paranoia is much more direct. These findings have implications for managing distressing outcomes. In particular, worry may be a salient target for intervention in psychosis.

Publication Type: Article
Additional Information: This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited. Copyright © The Author(s), 2023. Published by Cambridge University Press
Publisher Keywords: Affective symptoms, DAGs, psychosis, sexual abuse
Subjects: B Philosophy. Psychology. Religion > BF Psychology
R Medicine > RC Internal medicine > RC0321 Neuroscience. Biological psychiatry. Neuropsychiatry
Departments: School of Policy & Global Affairs > Violence and Society Centre
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