A systematic review on mediators between adversity and psychosis: potential targets for treatment

The effect of trauma-focused therapy on voice-hearing: An experience sampling study

Trauma and post-traumatic stress are involved in the aetiology and maintenance of voice-hearing. It has been proposed that trauma-focused therapy (TFT) might affect voice-hearing, but previous studies are limited and remain undecided.

OBJECTIVES

We aimed to investigate the effect of TFT on voice-hearing in people with PTSD and psychosis using experience sampling method (ESM). A secondary aim was to explore how changes in voice-hearing are related to changes in PTSD.

DESIGN

This is an adjunct longitudinal ESM study of a sub-group of participants (N = 39) from a randomised controlled trial that compared TFT to a waiting-list control group.

METHODS

Voice-hearing participants filled in 10 daily voice-hearing-related questionnaires for six consecutive days at baseline and post-treatment at pseudo-random times during the day. PTSD symptom severity was assessed at baseline and post-treatment. Multilevel linear regression was used to test the effect of TFT on voice-hearing and to analyse the relationship between changes in voice-hearing and changes in PTSD.

RESULTS

The intention-to-treat analysis showed a significant interaction effect between time and treatment condition (p < .00001) with a small effect size (dppc2 = -0.27), indicating a larger decrease in voice-hearing in the TFT group than in the waiting-list control group. Also, a significant association was observed between changes in PTSD symptoms and changes in voice-hearing (p < .00001).

CONCLUSIONS

Our findings tentatively suggest that, even when voices are not targeted directly, TFT for PTSD can alleviate distressing voices.

"No one will come and help me make my life": Ecological-transactional model approach to resilience among people with a history of childhood adversity

Resilience refers to the ability to employ a collection of protective factors to return to or maintain positive mental health following an experience of disadvantage or adversity. Understanding why some children do well despite early adverse experiences is crucial because it can inform more effective policies and programs that help more children reach their full potential. This study aimed to explore and explain the development of resilience within an ecological-transactional framework. A qualitative case study approach was used recruiting participants with history of childhood adversity: six patients with a diagnosis of first-episode psychosis from the main referral psychiatric hospital in Kenya and eight healthy controls from a neighbouring community in Nairobi. The findings indicate that children and their contexts mutually influenced each other. Using the systemic perspective of the ecological-transactional model, our participants identified the home environment (microsystem) as an important enabler of trauma to children. Available social support at both the micro-and exosystem levels, including good caregiver-child relationships, acted as buffers to alleviate the negative influence of adversity, leading to successful adaptation. Our study highlights the significant impact of adversities during childhood and adolescence. In addition, it emphasizes the influence of multiple contexts, supporting the need for appropriate interventions at each level to mitigate the negative consequences.

The effect of polygenic risk score and childhood adversity on transdiagnostic symptom dimensions at first-episode psychosis: evidence for an affective pathway to psychosis

Childhood adversity is associated with various clinical dimensions in psychosis; however, how genetic vulnerability shapes the adversity-associated psychopathological signature is yet to be studied. We studied data of 583 First Episode Psychosis (FEP) cases from the EU-GEI FEP case-control study, including Polygenic risk scores for major depressive disorder (MDD-PRS), bipolar disorder (BD-PRS) and schizophrenia (SZ-PRS); childhood adversity measured with the total score of the Childhood Trauma Questionnaire (CTQ); and positive, negative, depressive and manic psychopathological domains from a factor model of transdiagnostic dimensions. Genes and environment interactions were explored as a departure from a multiplicative effect of PRSs and total CTQ on each dimension. Analyses were adjusted for age, sex, 10 PCA, site of recruitment and for medication. A childhood adversity and PRS multiplicative interaction was observed between A) the CTQ and MDD-PRS on the predominance of positive (β = 0.42, 95% CI = [0.155, 0.682], p = 0.004); and depressive (β = 0.33, 95% CI = [0.071, 0.591], p = 0.013) dimensions; B) between the CTQ and BD-PRS on the positive dimension (β = 0.45, 95% CI = [0.106, 0.798], p = 0.010), and C) with the CTQ and SZ-PRS on the positive dimension (β = -0.34, 95% CI = [-0.660, -0.015], p = 0.040). Bonferroni corrected p-value of significance was set at 0.0125. In conclusion, despite being underpowered, this study suggests that genetic liability for MDD and BD may have a moderating effect on the sensibility of childhood adversity on depressive and positive psychotic dimensions. This supports the hypothesis of an affective pathway to psychosis in those exposed to childhood adversity.

Systematic review of variables that moderate and/or mediate the relationship between child maltreatment and adverse outcomes: a study protocol

INTRODUCTION

Child maltreatment (CM) is associated with adverse cognitive, behavioural, physical and social outcomes that often continue until adulthood. Systematic reviews on mediators and moderators of this relationship mostly investigate childhood adversities in general or only with regard to an adult population, single outcomes or single forms of maltreatment. The purpose of this review is to synthesise the evidence of variables that mediate and/or moderate the relationship between CM and diverse outcomes.

METHOD

A systematic search will be performed in Scopus, PsychInfo, Medline and Web of Science until January 2022. Eligibility criteria include children under 18 years who have been maltreated and experienced adverse outcomes until the age of 21, moderators and/or mediators that influence the relationship between maltreatment and adverse outcomes must belong to the individual level and be amenable to change. After independent screening of studies by two reviewers, data extraction and study quality of included studies will be done using adapted checklists of similar reviews, the Strengthening the Reporting of Observational Studies in Epidemiology report, the COnsensus-based Standards for the selection of health Measurement INstruments checklist and Downs and Black Checklist. The results will be presented in narrative form and, if adequate, meta-analysis.

ETHICS AND DISSEMINATION

Ethics approval will not be required. The results of this systematic review will be submitted for publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022297982.

Complex PTSD symptoms predict positive symptoms of psychosis in the flow of daily life

BACKGROUND

Post-traumatic stress disorder (PTSD) has been shown to predict psychotic symptomology. However, few studies have examined the relative contribution of PTSD compared to broader post-traumatic sequelae in maintaining psychosis. Complex PTSD (cPTSD), operationalized using ICD-11 criteria, includes core PTSD (intrusions, avoidance, hyperarousal) as well as additional "disturbances of self-organisation" (DSO; emotional dysregulation, interpersonal difficulties, negative self-concept) symptoms, more likely to be associated with complex trauma histories. It was hypothesized that DSOs would be associated with positive psychotic symptoms (paranoia, voices, and visions) in daily life, over and above core PTSD symptoms.

METHODS

This study (N = 153) employed a baseline subsample of the Study of Trauma And Recovery (STAR), a clinical sample of participants with comorbid post-traumatic stress and psychosis symptoms. Core PTSD, DSO and psychosis symptoms were assessed up to 10 times per day at quasi-random intervals over six consecutive days using Experience Sampling Methodology.

RESULTS

DSOs within the preceding 90 min predicted paranoia, voices, and visions at subsequent moments. These relationships persisted when controlling for core PTSD symptoms within this timeframe, which were themselves significant. The associations between DSOs and paranoia but not voices or visions, were significantly stronger than those between psychosis and core PTSD symptoms.

CONCLUSIONS

Consistent with an affective pathway to psychosis, the findings suggest that DSOs may be more important than core PTSD symptoms in maintaining psychotic experiences in daily life among people with comorbid psychosis and cPTSD, and indicate the potential importance of addressing broad post-traumatic sequelae in trauma-focused psychosis interventions.

Influence of the typology and timing of childhood trauma in psychoticism

PURPOSE

Child maltreatment (CM) is associated with psychosis; however little is known about the frequency, type, and timing of abuse in the personality pathology domain of psychoticism (PSY) in the DSM-5. The purpose of this study was to analyze childhood trauma typology and frequency according to gender and to identify sensitive periods of susceptibility to CM in women with high PSY.

METHODS

The Maltreatment and Abuse Chronology Exposure (MACE) scale was used to evaluate the frequency, severity and timing of each type of maltreatment. The full sample consisted of 83 participants with different psychiatric diagnoses. Psychoticism was assessed with the DSM-5 Personality Inventory (PID-5). To identify the differences in CM exposure between the PSY+ (high psychoticism) and PSY- (low psychoticism) groups, the Mann-Whitney U test, the chi square test and random forest (RF) test were used.

RESULTS

Comparing PSY + and PSY-, revealed gender differences in the impact of abuse, with highly frequent and severe types of abuse, in women. In women, PSY + and PSY-, were differentiated especially in non-verbal emotional abuse, peer physical bullying and parental verbal abuse. Several periods with a major peak at age seven followed by peaks at age 17 and 12 years old were identified.

CONCLUSION

Increased exposure to CM occurs in women with PSY+. A sensitivity to CM exposure during early childhood and late adolescence could be a risk factor for psychoticism in women.

Mediators of Outcome in Trauma-Focused Psychotherapy with Youth: A Systematic Review

This article aimed to provide a systematic narrative synthesis of existing studies on the mediators of change in psychotherapy with adolescents (10-19 years) and transition age youth (TAY) (20-29 years) who have experienced trauma-related symptoms or posttraumatic disorder. Additionally, we were interested in identifying psychotherapy-, trauma type-, and clients' age- and gender-specific mediators of treatment outcome. Following the preferred reporting items for systematic reviews and meta-analyses, a total of 3,723 studies published in PubMed and PsycINFO databases were screened against inclusion criteria, revealing 15 eligible studies. No studies with only TAY were found; therefore, all results were limited to therapy with adolescents. Cognitive mediators were tested in 66% of selected studies, followed by parents/family-related, mental-health-related, therapy-related, and behavioral mediators. Moderate evidence was found for posttraumatic cognitions, whereas therapeutic alliance seemed to be a promising candidate for future research. Striking absence of non-cognitive-behavioral therapy interventions, emotional and adolescent-specific mediators, as well as studies with males and in non-Western societies was evident. Future original studies would benefit from applying methodological rigor in respect to mediation testing.

Gender differences in first episode psychosis: Some arguments to develop gender specific treatment strategies

INTRODUCTION

Some aspects of gender differences in patients with schizophrenia spectrum disorders (SSD) have been studied, especially in cross-sectional designs and with a short-term follow-up. However, only a few studies have considered the evolution during the follow-up of SSD patients according to their gender. In this study, we explore gender differences from the time of entry in an early intervention program for psychosis, up to three years follow-up.

METHODS

We conducted a prospective study including a cohort of 474 patients treated at the Treatment and Early Intervention in Psychosis (TIPP) program, 319 men and 155 women, having presented a first episode of psychosis (FEP). Data regarding premorbid and baseline sociodemographic, psychopathological and patient functioning, were collected. These data were reassessed longitudinally after 2, 6, 12, 18, 24, 30 and 36 months after entry in TIPP.

RESULTS

Regarding premorbid and baseline characteristics, woman developed threshold symptoms of a FEP 1 year later than men on average. Women were more likely to be married, men were more likely to live in pension or care home facility or to be homeless. Women displayed a higher rate of history of suicide attempts and exposure to childhood trauma, while men were more likely to have a forensic history, a history of abuse of alcohol and cannabis as well as a dependency to cannabis at the time of entry in TIPP. Regarding evolution, men were more prone to violent acts and were less likely to decrease their usage of substances. The longitudinal analysis highlighted that men displayed greater negative symptoms over the entire treatment period, lower functioning after 6 months and on all assessment points after. Both genders displayed similar rate of improvement in these 3 dimensions over time.

CONCLUSION

Our study confirms that there are some gender differences in the early phase of psychosis that may require differentiation of assessment and treatment to improve recovery.

Relationship between childhood trauma and postpartum psychotic experiences: the role of postnatal anxiety and depression as mediators

BACKGROUND

Postpartum psychosis (PP) is a psychological emergency requiring rapid intervention, hospitalization and psychiatric management. However, PP has been neglected in the postpartum literature. Understanding the detrimental consequences of childhood trauma across mother's life span is crucial to prevent this serious condition. The study's objectives were to demonstrate the relationship between childhood trauma and postpartum psychotic experiences (PPEs) and to look over the mediating role of postnatal depression (PD) and anxiety (PA) in this relationship.

METHODS

This cross-sectional study, which enrolled 438 postpartum females 4-6 weeks after delivery (mean age: 31.23 ± 5.24 years), was carried out from September 2022 to June 2023. The Arabic validated versions of the Postpartum Psychotic Experiences Scale, the Edinburgh Postnatal Depression Scale, the Perinatal Anxiety Screening Scale, and the Child Abuse Self Report Scale were used.

RESULTS

Both PD and PA partially mediated the correlation between psychological abuse and PPEs, and fully mediated the association between neglect and PPEs. Higher psychological abuse and neglect were significantly associated with higher PD (Beta = 1.11) and PA (Beta = 3.94), higher PD (Beta = 0.84) and PA (Beta = 0.26) were significantly associated with higher PPEs in both models, whereas greater child psychological abuse (Beta = 1.37) (but not neglect) was directly and strongly correlated with higher PPEs in all models.

CONCLUSION

The significant mediating effect of PA and PD on the association between childhood adversities and PPEs among postpartum females may offer additional therapeutic avenues to help attenuate various postpartum mental health issues and their potential serious risks on both mother and child.

A systematic review and meta-analysis of the traumatogenic phenotype hypothesis of psychosis

BACKGROUND

Developmental trauma increases psychosis risk and is associated with poor prognosis. It has been proposed that psychosis in survivors of developmental trauma gives rise to a distinct 'traumatogenic' phenotype.

AIMS

Given the implications for personalised treatment, we sought to explore the traumatogenic psychosis phenotype hypothesis in a systematic review and meta-analysis of studies comparing psychotic presentations between adults with and without developmental trauma histories.

METHOD

We registered the systematic review on PROSPERO (CRD42019131245) and systematically searched EMBASE, Medline and PsycINFO. The outcomes of interests were quantitative and qualitative comparisons in psychotic symptom expression (positive, negative, cognitive) and other domains of psychopathology, including affect regulation, sleep, depression and anxiety, between adults with and without experience of developmental trauma.

RESULTS

Of 34 studies included (N = 13 150), 11 were meta-analysed (n = 2842). A significant relationship was found between developmental trauma and increased symptom severity for positive (Hedge's g = 0.27; 95% CI 0.10-0.44; P = 0.002), but not negative symptoms (Hedge's g = 0.13; 95% CI -0.04 to 0.30; P = 0.14). Developmental trauma was associated with greater neurocognitive, specifically executive, deficits, as well as poorer affect, dissociation and social cognition. Furthermore, psychotic symptom content thematically related to traumatic memories in survivors of developmental trauma.

CONCLUSIONS

Our findings that developmental trauma is associated with more severe positive and affective symptoms, and qualitative differences in symptom expression, support the notion that there may be a traumatogenic psychosis phenotype. However, underdiagnosis of post-traumatic stress disorder may also explain some of these findings. More research is needed to explore this further.

Defining and distinguishing early life stress, trauma, adversity, toxic and chronic stress and allostatic load: a descriptive review

AIMS

Various concepts are used to study the impact of stress on childhood development. These concepts are often used inconsistently or interchangeably. Our main objectives were to determine how selected stress concepts (chronic stress, toxic stress, allostatic load, early life stress, childhood adversity, childhood trauma and adverse childhood experiences; ACEs) are defined, operationalized and described, and to provide a theoretical context to aid the choice for a preferred concept in public health research.

METHODS

For this descriptive review, we systematically searched for literature published before 4 August 2021, on PubMed, Embase and PsycInfo. Two independent reviewers included studies. Exclusion criteria were: no systematic review, not peer reviewed, not published in English, selected stress concepts were no predetermined variable or a substantial topic in the discussion, full text was unobtainable or study described non-human or non-childhood populations. Data extraction forms were used. Descriptives were gathered, publication fields were identified through Journal Citation Reports categories, and verbatim descriptions were ordered in text and Venn diagrams.

RESULTS

Of 264 screened studies, 124 were included. ACEs, childhood adversity and childhood trauma were used most. ACEs were the main concept used most frequently (47.6%). A total of 11 of 14 public and environmental health journals used ACEs. All concepts refer to prolonged, repeated, interpersonal stress from 0 to 18 years, that can alter physiological systems. Four concepts were stressor oriented, two concepts focused on stress response and effect and one on the state of challenged homeostasis.

CONCLUSIONS

ACEs seem most fitting for public health setting, due to their operationalizability, large set of core experiences and widespread use.

Childhood Adversity and Incident Psychotic Experiences in Early Adulthood: Cognitive and Psychopathological Mediators

BACKGROUND AND HYPOTHESIS

Childhood adversity is often described as a potential cause of incident psychotic experiences, but the underlying mechanisms are not well understood. We aimed to examine the mediating role of cognitive and psychopathological factors in the relation between childhood adversity and incident psychotic experiences in early adulthood.

STUDY DESIGN

We analyzed data from the Avon Longitudinal Study of Parents and Children, a large population-based cohort study. Childhood adversity was measured prospectively from birth to age 11 years, mediators (anxiety, depression, external locus of control [LoC], negative symptoms) were assessed at approximately 16 years of age, and incident psychotic experiences were assessed at ages 18 and 24 years. Mediation was examined via the counterfactual g-computation formula.

STUDY RESULTS

In total, 7% of participants had incident suspected or definite psychotic experiences in early adulthood. Childhood adversity was related to more incident psychotic experiences (ORadjusted = 1.34, 95% CI = 1.21; 1.49), and this association was partially mediated via all mediators examined (proportion mediated: 19.9%). In separate analyses for each mediator, anxiety, depression, external LoC, and negative symptoms were all found to mediate the link between adversity and incident psychotic experiences. Accounting for potential confounders did not modify our results.

CONCLUSIONS

Our study shows that cognitive biases as well as mood symptomatology may be on the causal pathway between early-life adversity and the development of psychotic experiences. Future studies should determine which mediating factors are most easily modifiable and most likely to reduce the risk of developing psychotic experiences.

Severe Dissociative Experiences beyond Detachment in a Large Clinical Sample of Inpatients with Post-Traumatic Stress Disorder: Diagnostic and Treatment Implications

INTRODUCTION

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains a dissociative subtype of post-traumatic stress disorder (PTSD) characterized by depersonalization and derealization. Yet, there is evidence that dissociative symptoms in PTSD go beyond this kind of detachment dissociation and that some patients present with additional compartmentalization dissociation in the form of auditory-verbal hallucination, amnesia, and identity alteration.

METHODS

Hence, in this study, we examined latent profiles of childhood trauma (Childhood Trauma Questionnaire), PTSD (Impact-of-Event Scale-Revised), and pathological dissociation (Dissociative Experiences Scale-Taxon; DES-T) in a large sample of severely traumatized inpatients with PTSD (N = 1,360).

RESULTS

Results support a three-class solution of the latent profile analysis with a PTSD class, a dissociative subtype class, and a third class characterized by more complex and more severe dissociative symptoms. Importantly, in our inpatient sample of patients with severe PTSD, the latter class was found to be the most prevalent. Both the exploratory character of our retrospective analysis of clinical routine data and the use of the DES-T limit the generalizability of our findings, which require methodologically more rigorous replication.

CONCLUSION

In severe PTSD, dissociative symptoms beyond detachment are highly prevalent. Diagnostic and treatment implications are discussed.

Association of gut dysbiosis with first‑episode psychosis (Review)

The gut‑microbiota‑brain axis is a complex bidirectional communication system linking the gastrointestinal tract to the brain. Changes in the balance, composition and diversity of the gut‑microbiota (gut dysbiosis) have been found to be associated with the development of psychosis. Early‑life stress, along with various stressors encountered in different developmental phases, have been shown to be associated with the abnormal composition of the gut microbiota, leading to irregular immunological and neuroendocrine functions, which are potentially responsible for the occurrence of first‑episode psychosis (FEP). The aim of the present narrative review was to summarize the significant differences of the altered microbiome composition in patients suffering from FEP vs. healthy controls, and to discuss its effects on the occurrence and intensity of symptoms in FEP.

The relationship between childhood trauma, psychotic symptoms, and cognitive schemas in patients with schizophrenia, their siblings, and healthy controls: results from the EU-GEI study

BACKGROUND

The relationship between childhood trauma (CT) and psychotic symptoms in patients with schizophrenia (SCZ), and subthreshold psychotic experiences in non-clinical populations is well-established. However, little is known about the relationship between subtypes of trauma and specific symptoms in patients, their siblings, and controls. It is also not clear which variables mediate the relationship between trauma and psychotic symptoms.

METHODS

Seven hundred and forty-two patients with SCZ, 718 of their unaffected siblings and 1039 controls from three EU-GEI sites were assessed for CT, symptom severity, and cognitive schemas about self/others. CT was assessed with the Childhood Trauma Questionnaire, and cognitive schemas were assessed by The Brief Core Schema Scale.

RESULTS

Patients with psychosis were affected by CT more than their siblings and controls in all domains. Childhood emotional abuse and neglect were more common in siblings than controls. CT was related to negative cognitive schemas toward self/others in patients, siblings, and controls. We found that negative schemas about self-mediated the relationship between emotional abuse and thought withdrawal and thought broadcasting. Approximately 33.9% of the variance in these symptoms was explained by the mediator. It also mediated the relationship between sexual abuse and persecutory delusions in SCZ.

CONCLUSIONS

Our findings suggest that childhood abuse and neglect are more common in patients with schizophrenia than their siblings and healthy controls, and have different impacts on clinical domains which we searched. The relationship between CT and positive symptoms seems to be mediated by negative cognitive schemas about self in schizophrenia.

Childhood abuse v. neglect and risk for major psychiatric disorders

BACKGROUND

Childhood maltreatment (CM) is a strong risk factor for psychiatric disorders but serves in its current definitions as an umbrella for various fundamentally different childhood experiences. As first step toward a more refined analysis of the impact of CM, our objective is to revisit the relation of abuse and neglect, major subtypes of CM, with symptoms across disorders.

METHODS

Three longitudinal studies of major depressive disorder (MDD, N = 1240), bipolar disorder (BD, N = 1339), and schizophrenia (SCZ, N = 577), each including controls (N = 881), were analyzed. Multivariate regression models were used to examine the relation between exposure to abuse, neglect, or their combination to the odds for MDD, BD, SCZ, and symptoms across disorders. Bidirectional Mendelian randomization (MR) was used to probe causality, using genetic instruments of abuse and neglect derived from UK Biobank data (N = 143 473).

RESULTS

Abuse was the stronger risk factor for SCZ (OR 3.51, 95% CI 2.17-5.67) and neglect for BD (OR 2.69, 95% CI 2.09-3.46). Combined CM was related to increased risk exceeding additive effects of abuse and neglect for MDD (RERI = 1.4) and BD (RERI = 1.1). Across disorders, abuse was associated with hallucinations (OR 2.16, 95% CI 1.55-3.01) and suicide attempts (OR 2.16, 95% CI 1.55-3.01) whereas neglect was associated with agitation (OR 1.24, 95% CI 1.02-1.51) and reduced need for sleep (OR 1.64, 95% CI 1.08-2.48). MR analyses were consistent with a bidirectional causal effect of abuse with SCZ (IVWforward = 0.13, 95% CI 0.01-0.24).

CONCLUSIONS

Childhood abuse and neglect are associated with different risks to psychiatric symptoms and disorders. Unraveling the origin of these differences may advance understanding of disease etiology and ultimately facilitate development of improved personalized treatment strategies.

Eye-movement desensitisation and reprocessing therapy (EMDR) to prevent transition to psychosis in people with an at-risk mental state (ARMS): mixed method feasibility study

BACKGROUND

Trauma plays an important role in the development of psychosis, but no studies have investigated whether a trauma-focused therapy could prevent psychosis.

AIMS

This study aimed to establish whether it would be feasible to conduct a multicentre randomised controlled trial (RCT) to prevent psychosis in people with an at-risk mental state (ARMS), using eye-movement desensitisation and reprocessing therapy (EMDR).

METHOD

This started as a mixed-method randomised study comparing EMDR to treatment as usual but, as a result of low participant recruitment, was changed to a single-arm feasibility study. The proposed primary outcome for an RCT was transition to psychosis at 12-month follow-up. Data on secondary outcomes were also collected. Qualitative interviews were conducted with patients and therapists.

RESULTS

Fourteen participants were recruited from the Early Intervention teams. Most people who expressed an interest in taking part attended an assessment to determine eligibility. All those eligible consented to take part. A total of 64% (7 of 11) of participants who were offered EMDR were followed up at 12 months. Of the 11 participants offered EMDR, one (11%, 95% CI: 0.2%, 48%) transitioned to psychosis. Nine patients and three therapists were interviewed. Participants who completed therapy (n = 4; mean 10.5 sessions) found EMDR helpful, but those who discontinued (n = 6; mean 5.2 sessions) said it had not benefitted them overall. Therapists said EMDR could be effective, although not for all patients.

CONCLUSIONS

Future studies recruiting people with an ARMS to an RCT may need to extend recruitment beyond Early Intervention teams. Although some individuals found EMDR helpful, reasons for discontinuing need to be addressed in future studies.

Belief Updating, Childhood Maltreatment, and Paranoia in Schizophrenia-Spectrum Disorders

BACKGROUND AND HYPOTHESIS

Exposure to childhood maltreatment-a risk factor for psychosis is associated with paranoia-may impact one's beliefs about the world and how beliefs are updated. We hypothesized that increased exposure to childhood maltreatment is related to volatility-related belief updating, specifically higher expectations of volatility, and that these relationships are strongest for threat-related maltreatment. Additionally, we tested whether belief updating mediates the relationship between maltreatment and paranoia.

STUDY DESIGN

Belief updating was measured in 75 patients with schizophrenia-spectrum disorders and 76 nonpsychiatric controls using a 3-option probabilistic reversal learning (3PRL) task. A Hierarchical Gaussian Filter (HGF) was used to estimate computational parameters of belief updating, including prior expectations of volatility (μ03). The Childhood Trauma Questionnaire (CTQ) was used to assess cumulative maltreatment, threat, and deprivation exposure. Paranoia was measured using the Positive and Negative Syndrome Scale (PANSS) and the revised Green et al. Paranoid Thoughts Scale (R-GPTS).

RESULTS

Greater exposure to childhood maltreatment is associated with higher prior expectations of volatility in the whole sample and in individuals with schizophrenia-spectrum disorders. This was specific to threat-related maltreatment, rather than deprivation, in schizophrenia-spectrum disorders. Paranoia was associated with both exposure to childhood maltreatment and volatility priors, but we did not observe a significant indirect effect of volatility priors on the relationship between maltreatment and paranoia.

CONCLUSIONS

Our study suggests that individuals with schizophrenia-spectrum disorders who were exposed to threatening experiences during childhood expect their environment to be more volatile, potentially facilitating aberrant belief updating and conferring risk for paranoia.

A systematic review of dramatherapy interventions used to support adults with psychosis

BACKGROUND

Psychiatric treatment of psychosis often comprises therapeutic and psychotropic combinations. Dramatherapy is often utilised in health services with this population, particularly when clients struggle to engage with talking therapies because of complex presentations, experience preverbal trauma, neurodiversity challenges and/or communication difficulties. Dramatherapy as a therapeutic intervention is recognised by health regulating bodies but as yet has not yet been systematically reviewed.

AIMS

To synthesise existing peer-reviewed empirical research literature and gather evidence regarding dramatherapy used to support adults with psychosis; To collate and understand the intervention methods of dramatherapy as a treatment to support adults experiencing psychosis; To assess the effect of dramatherapy on adults with psychosis, by collating qualitative and quantitative outcome measures, where reported in included research.

METHODS

Literature was sourced through database searches (CINAHL, EMBASE, COCHRANE, PsycINFO, PubMed, Scopus, and APA PsycNet) and hand searches. 8541 papers were screened, and 11 met inclusion criteria for synthesis. Findings related to aims were narratively synthesised, before being thematically analysed.

RESULTS

Participant characteristics of age, gender, ethnicity, and socio-economic background were heterogeneous. Participants across studies often had multiple diagnoses, and unknown complexities making recovery through standard treatment unachievable. Presentations included episodes of psychosis, schizophrenia, and dual-diagnoses of mental health challenges and intellectual difficulties. Positive effects found the use of dramatherapy include: New perspectives; Improved relationships; Ability to make choices with reduced anxiety; Understanding of self; Reduced psychotic symptoms. Quantitative data substantiated qualitative findings, and effect indicated changes in social functioning, behaviours, and symptoms following dramatherapy intervention.

IMPLICATIONS

Systematic findings will support practitioners to implement evidence-based practice and to improve treatment provision for adults with psychosis. Further methodologically sound research into the field is encouraged to advance understanding of dramatherapy interventions for adults with psychosis.

Forensic aspects of dissociative positive symptoms in trauma-related disorders and borderline personality disorder

A psychotically motivated act or an act committed under impaired insight and control of action in the midst of an acute psychosis is the standard for lack of criminal responsibility. There is now increasing evidence that positive symptoms, particularly in the form of hallucinations and delusions, in trauma-related disorders and borderline personality disorder (BPD) are comparable to positive symptoms in psychotic disorders, posing a challenge for differential diagnosis and forensic assessment of the relevance of positive symptoms to insight and self-control. Due to the indistinguishability of the phenomena, there is both a risk of misdiagnosis of a psychotic disorder and also trivialization with the use of pseudo-hallucinations or quasi-psychotic labels. Essential phenomenological differences that may be helpful in forensic assessments are the usually preserved reality testing in trauma-related disorders and BPD, as well as differences in psychopathological symptom constellations. Because of these differences relevant to forensic assessments, it seems useful to distinguish trauma-related disorders and BPD with positive symptoms from psychotic disorders.

Visualizing threat and trustworthiness prior beliefs in face perception in high versus low paranoia

Predictive processing accounts of psychosis conceptualize delusions as overly strong learned expectations (prior beliefs) that shape cognition and perception. Paranoia, the most prevalent form of delusions, involves threat prior beliefs that are inherently social. Here, we investigated whether paranoia is related to overly strong threat prior beliefs in face perception. Participants with subclinical levels of high (n = 109) versus low (n = 111) paranoia viewed face stimuli paired with written descriptions of threatening versus trustworthy behaviors, thereby activating their threat versus trustworthiness prior beliefs. Subsequently, they completed an established social-psychological reverse correlation image classification (RCIC) paradigm. This paradigm used participants' responses to randomly varying face stimuli to generate individual classification images (ICIs) that intend to visualize either facial prior belief (threat vs. trust). An independent sample (n = 76) rated these ICIs as more threatening in the threat compared to the trust condition, validating the causal effect of prior beliefs on face perception. Contrary to expectations derived from predictive processing accounts, there was no evidence for a main effect of paranoia. This finding suggests that paranoia was not related to stronger threat prior beliefs that directly affected face perception, challenging the assumption that paranoid beliefs operate on a perceptual level.

Trauma therapies for psychosis: A state-of-the-art review

BACKGROUND

Traumatic events, particularly childhood interpersonal victimisation, have been found to play a causal role in the occurrence of psychosis and shape the phenomenology of psychotic experiences. Higher rates of post-traumatic stress disorder (PTSD) and other trauma-related mental health problems are also found in people with psychosis diagnoses compared to the general population. It is, therefore, imperative that therapists are willing and able to address trauma and its consequences when supporting recovery from distressing psychosis.

METHOD

This paper will support this need by providing a state-of-the-art overview of the safety, acceptability and effects of trauma therapies for psychosis.

RESULTS

We will first introduce how seminal cognitive-behavioural models of psychosis shed light on the mechanisms by which trauma may give rise to psychotic experiences, including a putative role for trauma-related emotions, beliefs and episodic memories. The initial application of prolonged exposure and eye movement and desensitation and reprocessing therapy (EMDR) for treating PTSD in psychosis will be described, followed by consideration of integrative approaches. These integrative approaches aim to address the impact of trauma on both post-traumatic stress symptoms and trauma-related psychosis. Integrative approaches include EMDR for psychosis (EMDRp) and trauma-focused Cognitive-Behavioural Therapy for psychosis (tf-CBTp). Finally, emerging dialogic approaches for targeting trauma-related voice-hearing will be considered, demonstrating the potential value of adopting co-produced (Talking with Voices) and digitally augmented (AVATAR) therapies.

CONCLUSION

We will conclude by reflecting on current issues in the area, and implications for research and clinical practice.

Does affect mediate the relationship between interpersonal trauma and psychosis? A systematic review and meta-analysis

INTRODUCTION

The relationship between interpersonal trauma and psychosis is well established, and research is now focused on identifying mechanisms that may explain this relationship. Models of trauma and psychosis increasingly emphasize a broad range of affective processes, yet the overall effect of these affective processes is not well understood.

AIM

This review systematically examined the effect of any form of long-term affective dysfunction on the relationship between interpersonal trauma and psychosis. Where possible, it used meta-analytic techniques to quantify the overall magnitude of this effect.

METHOD

Searches were conducted using PsychINFO, MEDLINE and CINAHL databases, and eligible studies were appraised for methodological quality. Narrative synthesis and meta-analytic methods were used to evaluate evidence.

RESULTS

Twenty-nine studies met criteria for inclusion. Five affective mediators were found; depression, anxiety, affective dysregulation, loneliness and attachment. Findings from both the narrative synthesis (n = 29) and meta-analysis (n = 8) indicated that, overall, affect is a small but significant mediator of the relationship between interpersonal trauma and psychosis (pooled Cohen's d = 0.178; pooled 95 % CI: 0.022-0.334).

CONCLUSIONS

Overall, findings support affective pathways to psychosis, though highlight the need for further research on broader affective mediators (loneliness, shame). The small effect size found in the meta-analysis also points to the potential importance of non-affective mediators. Clinically, these findings highlight the value of treatment modalities that attend to multiple mechanisms in the relationship between interpersonal trauma and psychosis. Future research should focus on the interplay and causal sequence between these mechanisms to further understand pathways between interpersonal trauma and psychosis.

A Preliminary Longitudinal Analysis of Symptom Management, Post-traumatic Stress, and Depressive Symptoms in Chinese Adults with Dissociative Symptoms

People with dissociative symptoms are generally poly-symptomatic and require high levels of healthcare resources. Post-traumatic stress disorder (PTSD) and depressive symptoms are two major disabling comorbid symptoms in people with dissociative symptoms. While the sense of control over symptoms may be associated with PTSD and dissociative symptoms, the interplay among these factors over time remains unexplored. This study examined the predictors of PTSD and depressive symptoms in people with dissociative symptoms. Longitudinal data from 61 participants with dissociative symptoms were analyzed. Participants completed self-report measures of dissociative, depressive, and PTSD symptoms and the sense of control over symptoms two times (T1 & T2) with an interval of over one month. PTSD and depressive symptoms were not transient or time-specific, but they persisted over time in our sample. Hierarchical multiple regression analyses revealed that, after controlling for age, treatment usage and baseline symptom severity, T1 symptom management scores (β = -.264, p = .006) negatively predicted T2 PTSD symptoms, while T1 PTSD symptoms (β = .268, p = .017) positively predicted T2 depressive symptoms. T1 depressive symptoms (β = -.087, p = .339) did not predict T2 PTSD symptoms. The findings highlight the importance of improving symptom management skills and treating comorbid PTSD symptoms when working with people with dissociative symptoms.

Childhood Adversity and Emerging Psychotic Experiences: A Network Perspective

BACKGROUND AND HYPOTHESIS

Childhood adversity is associated with a myriad of psychiatric symptoms, including psychotic experiences (PEs), and with multiple psychological processes that may all mediate these associations.

STUDY DESIGN

Using a network approach, the present study examined the complex interactions between childhood adversity, PEs, other psychiatric symptoms, and multiple psychological mediators (ie, activity-related and social stress, negative affect, loneliness, threat anticipation, maladaptive cognitive emotion regulation, attachment insecurity) in a general population, adolescent sample (n = 865, age 12-20, 67% female).

STUDY RESULTS

Centrality analyses revealed a pivotal role of depression, anxiety, negative affect, and loneliness within the network and a bridging role of threat anticipation between childhood adversity and maladaptive cognitive emotion regulation. By constructing shortest path networks, we found multiple existing paths between different categories of childhood adversity and PEs, with symptoms of general psychopathology (ie, anxiety, hostility, and somatization) as the main connective component. Sensitivity analyses confirmed the robustness and stability of the networks. Longitudinal analysis in a subsample with Wave 2 data (n = 161) further found that variables with higher centrality (ie, depression, negative affect, and loneliness) better predicted follow-up PEs.

CONCLUSIONS

Pathways linking childhood adversity to PEs are complex, with multifaceted psychological and symptom-symptom interactions. They underscore the transdiagnostic, heterotypic nature of mental ill-health in young people experiencing PEs, in agreement with current clinical recommendations.

Trauma and Trauma-Informed Care in Early Intervention in Psychosis: State of Implementation and Provider Views on Challenges

OBJECTIVE

Although trauma is increasingly recognized as a major risk factor for psychosis and for its link to treatment outcomes, the landscape of trauma-related practices in specialized early psychosis services in the United States and other countries remains only poorly characterized. Research documenting the perspectives of frontline providers is also lacking. The primary goals of this study were to document the state of trauma-related policy implementation in early intervention in psychosis (EIP) programs and to gather provider perspectives.

METHODS

This was a mixed-methods project involving an international EIP provider survey, followed by in-depth provider interviews. The survey was disseminated in Australia, Canada, Chile, the United Kingdom, and the United States. In total, 164 providers, representing 110 unique sites, completed the survey. Frequencies were calculated for responses to survey items, and open-ended responses were analyzed with a systematic content analysis.

RESULTS

The survey findings suggested low implementation rates for a variety of assessment and support practices related to trauma and trauma-informed care. Coding of open-ended responses revealed numerous concerns and uncertainties among providers regarding the relationship between trauma and psychosis and the state of the EIP field.

CONCLUSIONS

An expansion of research and service development aimed at better meeting the trauma-related needs of young people with psychosis is essential, with implications for EIP outcomes and service user and staff experiences.

The co-occurrence of manic and depressive dimensions in early psychosis: a latent transition analysis

BACKGROUND

Frequently associated with early psychosis, depressive and manic dimensions may play an important role in its course and outcome. While manic and depressive symptoms can alternate and co-occur, most of the studies in early intervention investigated these symptoms independently. The aim of this study was therefore to explore the co-occurrence of manic and depressive dimensions, their evolution and impact on outcomes.

METHODS

We prospectively studied first-episode psychosis patients (N = 313) within an early intervention program over 3 years. Based on latent transition analysis, we identified sub-groups of patients with different mood profiles considering both manic and depressive dimensions, and studied their outcomes.

RESULTS

Our results revealed six different mood profiles at program entry and after 1.5 years follow-up (absence of mood disturbance, co-occurrence, mild depressive, severe depressive, manic and hypomanic), and four after 3 years (absence of mood disturbance, co-occurrence, mild depressive and hypomanic). Patients with absence of mood disturbance at discharge had better outcomes. All patients with co-occurring symptoms at program entry remained symptomatic at discharge. Patients with mild depressive symptoms were less likely to return to premorbid functional level at discharge than the other subgroups. Patients displaying a depressive component had poorer quality of physical and psychological health at discharge.

CONCLUSIONS

Our results confirm the major role played by mood dimensions in early psychosis, and show that profiles with co-occurring manic and depressive dimensions are at risk of poorer outcome. An accurate assessment and treatment of these dimensions in people with early psychosis is crucial.

A better understanding of the impact of childhood trauma on depression in early psychosis: A differential item functioning approach

BACKGROUND

Childhood trauma (CT) has been shown to impact depressive symptoms measured broadly in early psychosis patients. Beyond the broad intensity of such impact, less is known about which depressive features are more impacted.

METHODS

Patients of a specialized early intervention programme were evaluated after the first two and six months of treatment with the Montgomery-Asberg Depression Rating Scale (MADRS). We used the first assessment available. We estimated an Item-response model to reveal potential differential item functioning (DIF) in order to highlight depressive features that could be impacted differently than others by experiences of abuse (sexual physical and emotional) and neglect (physical and emotional).

RESULTS

Two hundred and sixty-two recent onset patients with psychosis were assessed. Results at the beginning of the Treatment and Early Intervention in Psychosis Program (TIPP) showed that abuse but not neglect was associated with more severe depression levels, measured at a global MADRS score. Concerning specific depressive symptoms, concentration difficulties were left largely unaffected by abuse in contrast with other aspects of depression.

CONCLUSIONS

The cognitive item of the depressive dimension assessed by the MADRS was not impacted by experiences of abuse, while the remaining subdomains involving anxiety, suicidality, somatic symptoms, and anhedonia were. Trials focusing on improving the impact of depression in traumatised individuals should account for the possible diluting effect of concentration when measuring the depression broadly. DIF is a promising method to better understand the impact many variables may have on various psychological dimensions at the item level.

Cannabis use as a potential mediator between childhood adversity and first-episode psychosis: results from the EU-GEI case-control study

BACKGROUND

Childhood adversity and cannabis use are considered independent risk factors for psychosis, but whether different patterns of cannabis use may be acting as mediator between adversity and psychotic disorders has not yet been explored. The aim of this study is to examine whether cannabis use mediates the relationship between childhood adversity and psychosis.

METHODS

Data were utilised on 881 first-episode psychosis patients and 1231 controls from the European network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) study. Detailed history of cannabis use was collected with the Cannabis Experience Questionnaire. The Childhood Experience of Care and Abuse Questionnaire was used to assess exposure to household discord, sexual, physical or emotional abuse and bullying in two periods: early (0-11 years), and late (12-17 years). A path decomposition method was used to analyse whether the association between childhood adversity and psychosis was mediated by (1) lifetime cannabis use, (2) cannabis potency and (3) frequency of use.

RESULTS

The association between household discord and psychosis was partially mediated by lifetime use of cannabis (indirect effect coef. 0.078, s.e. 0.022, 17%), its potency (indirect effect coef. 0.059, s.e. 0.018, 14%) and by frequency (indirect effect coef. 0.117, s.e. 0.038, 29%). Similar findings were obtained when analyses were restricted to early exposure to household discord.

CONCLUSIONS

Harmful patterns of cannabis use mediated the association between specific childhood adversities, like household discord, with later psychosis. Children exposed to particularly challenging environments in their household could benefit from psychosocial interventions aimed at preventing cannabis misuse.

Examining associations, moderators and mediators between childhood maltreatment, social functioning, and social cognition in psychotic disorders: a systematic review and meta-analysis

Childhood maltreatment (CM) has been related to social functioning and social cognition impairment in people with psychotic disorders (PD); however, evidence across different CM subtypes and social domains remains less clear. We conducted a systematic review and meta-analysis to quantify associations between CM, overall and its different subtypes (physical/emotional/sexual abuse, physical/emotional neglect), and domains of social functioning and social cognition in adults with PD. We also examined moderators and mediators of these associations. A PRISMA-compliant systematic search was performed on 24 November 2022 (PROSPERO CRD42020175244). Fifty-three studies (N = 13 635 individuals with PD) were included in qualitative synthesis, of which 51 studies (N = 13 260) with 125 effects sizes were pooled in meta-analyses. We found that CM was negatively associated with global social functioning and interpersonal relations, and positively associated with aggressive behaviour, but unrelated to independent living or occupational functioning. There was no meta-analytic evidence of associations between CM and social cognition. Meta-regression analyses did not identify any consistent moderation pattern. Narrative synthesis identified sex and timing of CM as potential moderators, and depressive symptoms and maladaptive personality traits as possible mediators between CM and social outcomes. Associations were of small magnitude and limited number of studies assessing CM subtypes and social cognition are available. Nevertheless, adults with PD are at risk of social functioning problems after CM exposure, an effect observed across multiple CM subtypes, social domains, diagnoses and illness stages. Maltreated adults with PD may thus benefit from trauma-related and psychosocial interventions targeting social relationships and functioning.

The impact of cumulative obstetric complications and childhood trauma on brain volume in young people with psychotic experiences

Psychotic experiences (PEs) occur in 5-10% of the general population and are associated with exposure to childhood trauma and obstetric complications. However, the neurobiological mechanisms underlying these associations are unclear. Using the Avon Longitudinal Study of Parents and Children (ALSPAC), we studied 138 young people aged 20 with PEs (n = 49 suspected, n = 53 definite, n = 36 psychotic disorder) and 275 controls. Voxel-based morphometry assessed whether MRI measures of grey matter volume were associated with (i) PEs, (ii) cumulative childhood psychological trauma (weighted summary score of 6 trauma types), (iii) cumulative pre/peri-natal risk factors for psychosis (weighted summary score of 16 risk factors), and (iv) the interaction between PEs and cumulative trauma or pre/peri-natal risk. PEs were associated with smaller left posterior cingulate (pFWE < 0.001, Z = 4.19) and thalamus volumes (pFWE = 0.006, Z = 3.91). Cumulative pre/perinatal risk was associated with smaller left subgenual cingulate volume (pFWE < 0.001, Z = 4.54). A significant interaction between PEs and cumulative pre/perinatal risk found larger striatum (pFWE = 0.04, Z = 3.89) and smaller right insula volume extending into the supramarginal gyrus and superior temporal gyrus (pFWE = 0.002, Z = 4.79), specifically in those with definite PEs and psychotic disorder. Cumulative childhood trauma was associated with larger left dorsal striatum (pFWE = 0.002, Z = 3.65), right prefrontal cortex (pFWE < 0.001, Z = 4.63) and smaller left insula volume in all participants (pFWE = 0.03, Z = 3.60), and there was no interaction with PEs group. In summary, pre/peri-natal risk factors and childhood psychological trauma impact similar brain pathways, namely smaller insula and larger striatum volumes. The effect of pre/perinatal risk was greatest in those with more severe PEs, whereas effects of trauma were seen in all participants. In conclusion, environmental risk factors affect brain networks implicated in schizophrenia, which may increase an individual's propensity to develop later psychotic disorders.

Links between trauma and psychosis (Review)

The relationship between trauma and psychosis is complex and multifaceted, with evidence suggesting that trauma can be both a risk factor for the development of psychosis and a consequence of psychotic experiences. The present review aimed to provide an overview of the current state of knowledge on the relationship between trauma and psychosis, including historical and conceptual considerations, as well as epidemiological evidence. The potential explanation of the link between trauma and psychosis is provided through available models and similarities in their neurobiological associations. Overall, the research confirms the relationship between trauma and psychosis, and suggests that individuals with a co-occurring history of trauma and psychosis may have increased symptom severity and worse functional outcomes compared with individuals with psychosis alone. Future research should focus on elucidating the underlying causal pathways between trauma exposure and psychosis in order to inform effective treatment approaches aiming to prevent the intensification of psychotic symptoms and processes.

Association of childhood trauma with cognitive domains in adult patients with mental disorders and in non-clinical populations: a systematic review

Although the association between cognitive performances and the onset of psychiatric disorders has been widely investigated, limited research on the role of childhood trauma or early life stress (CT/ELS), and whether this role differs between clinical and non-clinical cohorts is available. This systematic review aims at filling this gap, testing whether the occurrence of CT/ELS and its subtypes are associated with cognitive domains (general cognitive ability, executive functions, working memory, attention, processing speed, verbal/visual memory) in patients with psychiatric disorders and in non-clinical populations. This study followed the PRISMA 2020 guidelines and the Newcastle-Ottawa scale for quality assessment. The search was performed until May 2022. Seventy-four studies were classified as eligible. The graphical representations of the results reported an association between exposure to CT/ELS and worse general cognitive ability, verbal/visual memory, processing speed and attention in patients affected by anxiety, mood and psychotic disorders, and that specific CT/ELS subtypes (physical neglect, physical/sexual abuse) can differentially influence specific cognitive abilities (executive functions, attention, working memory, verbal/visual memory). In non-clinical cohorts we found associations between CT/ELS exposure and impairments in executive functions, processing speed and working memory, while physical neglect was related to general cognitive ability and working memory. Concerning the emotional abuse/neglect subtypes in both populations, the results indicated their involvement in cognitive functioning; however, the few studies conducted are not enough to reach definitive conclusions. These findings suggest an association of CT/ELS with specific cognitive deficits and psychopathology.

Psychosocial stress, interpersonal sensitivity, and social withdrawal in clinical high risk for psychosis: a systematic review

Stress has repeatedly been implicated in the onset and exacerbation of positive symptoms of psychosis. Increasing interest is growing for the role of psychosocial stress in the development of psychosis symptoms in individuals at Clinical High Risk (CHR) for psychosis. A systematic review was therefore conducted to summarize the existing evidence base regarding psychosocial stress, interpersonal sensitivity, and social withdrawal in individuals at CHR for psychosis. An electronic search of Ovid (PsychINFO, EMBASE, MEDLINE, and GLOBAL HEALTH) was conducted until February 2022. Studies that examined psychosocial stress in CHR were included. Twenty-nine studies were eligible for inclusion. Psychosocial stress, interpersonal sensitivity, and social withdrawal were higher in CHR individuals compared to healthy controls and there was some evidence of their association with positive symptoms of psychosis. Two types of psychosocial stressors were found to occur more frequently with CHR status, namely daily stressors, and early and recent trauma, while significant life events did not appear to be significant. Greater exposure to psychosocial stress, emotional abuse, and perceived discrimination significantly increased risk of transition to psychosis in CHR. No studies examined the role of interpersonal sensitivity on transition to psychosis in CHR. This systematic review provides evidence for the association of trauma, daily stressors, social withdrawal, and interpersonal sensitivity with CHR status. Further studies investigating the impact of psychosocial stress on psychosis symptom expression in individuals at CHR and its effects on transition to psychosis are therefore warranted.

Redox and Immune Signaling in Schizophrenia: New Therapeutic Potential

Redox biology and immune signaling play major roles in the body, including in brain function. A rapidly growing literature also suggests that redox and immune abnormalities are implicated in neuropsychiatric conditions such as schizophrenia (SZ), bipolar disorder, autism, and epilepsy. In this article we review this literature, its implications for the pathophysiology of SZ, and the potential for development of novel treatment interventions targeting redox and immune signaling. Redox biology and immune signaling in the brain are complex and not fully understood; in addition, there are discrepancies in the literature, especially in patient-oriented studies. Nevertheless, it is clear that abnormalities arise in SZ from an interaction between genetic and environmental factors during sensitive periods of brain development, and these abnormalities disrupt local circuits and long-range connectivity. Interventions that correct these abnormalities may be effective in normalizing brain function in psychotic disorders, especially in early phases of illness.

Exploring the mediation of DNA methylation across the epigenome between childhood adversity and First Episode of Psychosis-findings from the EU-GEI study

ABTRACT

Studies conducted in psychotic disorders have shown that DNA-methylation (DNAm) is sensitive to the impact of Childhood Adversity (CA). However, whether it mediates the association between CA and psychosis is yet to be explored. Epigenome wide association studies (EWAS) using the Illumina Infinium-Methylation EPIC array in peripheral blood tissue from 366 First-episode of psychosis and 517 healthy controls was performed. Adversity scores were created for abuse, neglect and composite adversity with the Childhood Trauma Questionnaire (CTQ). Regressions examining (I) CTQ scores with psychosis; (II) with DNAm EWAS level and (III) between DNAm and caseness, adjusted for a variety of confounders were conducted. Divide-Aggregate Composite-null Test for the composite null-hypothesis of no mediation effect was conducted. Enrichment analyses were conducted with missMethyl package and the KEGG database. Our results show that CA was associated with psychosis (Composite: OR = 1.68; p = <0.001; abuse: OR = 2.16; p < 0.001; neglect: OR = 2.27; p = <0.001). None of the CpG sites significantly mediated the adversity-psychosis association after Bonferroni correction (p < 8.1 × 10-8). However, 28, 34 and 29 differentially methylated probes associated with 21, 27, 20 genes passed a less stringent discovery threshold (p < 5 × 10-5) for composite, abuse and neglect respectively, with a lack of overlap between abuse and neglect. These included genes previously associated to psychosis in EWAS studies, such as PANK1, SPEG TBKBP1, TSNARE1 or H2R. Downstream gene ontology analyses did not reveal any biological pathways that survived false discovery rate correction. Although at a non-significant level, DNAm changes in genes previously associated with schizophrenia in EWAS studies may mediate the CA-psychosis association. These results and associated involved processes such as mitochondrial or histaminergic disfunction, immunity or neural signalling requires replication in well powered samples. The lack of overlap between mediating genes associated with abuse and neglect suggests differential biological trajectories linking CA subtypes and psychosis.

Characterization of early psychosis patients carrying a genetic vulnerability to redox dysregulation: a computational analysis of mechanism-based gene expression profile in fibroblasts

In view of its heterogeneity, schizophrenia needs new diagnostic tools based on mechanistic biomarkers that would allow early detection. Complex interaction between genetic and environmental risk factors may lead to NMDAR hypofunction, inflammation and redox dysregulation, all converging on oxidative stress. Using computational analysis, the expression of 76 genes linked to these systems, known to be abnormally regulated in schizophrenia, was studied in skin-fibroblasts from early psychosis patients and age-matched controls (N = 30), under additional pro-oxidant challenge to mimic environmental stress. To evaluate the contribution of a genetic risk related to redox dysregulation, we investigated the GAG trinucleotide polymorphism in the key glutathione (GSH) synthesizing enzyme, glutamate-cysteine-ligase-catalytic-subunit (gclc) gene, known to be associated with the disease. Patients and controls showed different gene expression profiles that were modulated by GAG-gclc genotypes in combination with oxidative challenge. In GAG-gclc low-risk genotype patients, a global gene expression dysregulation was observed, especially in the antioxidant system, potentially induced by other risks. Both controls and patients with GAG-gclc high-risk genotype (gclcGAG-HR) showed similar gene expression profiles. However, under oxidative challenge, a boosting of other antioxidant defense, including the master regulator Nrf2 and TRX systems was observed only in gclcGAG-HR controls, suggesting a protective compensation against the genetic GSH dysregulation. Moreover, RAGE (redox/inflammation interaction) and AGMAT (arginine pathway) were increased in the gclcGAG-HR patients, suggesting some additional risk factors interacting with this genotype. Finally, the use of a machine-learning approach allowed discriminating patients and controls with an accuracy up to 100%, paving the way towards early detection of schizophrenia.

Childhood Trauma As a Mediator of the Association Between Autistic Traits and Psychotic Experiences: Evidence From the Avon Longitudinal Study of Parents and Children Cohort

BACKGROUND

Little is known on whether associations between childhood autistic traits and psychotic experiences persist into adulthood and whether genetic confounding and childhood trauma influence them. Here we investigate the associations between childhood autistic traits and psychotic experiences until young adulthood and assess the influence of schizophrenia polygenic risk and childhood traumatic experiences, using the Avon Longitudinal Study of Parents and Children (ALSPAC) population-based birth cohort.

STUDY DESIGN

We used a measure of broad autistic traits (autism factor mean score), and four dichotomised measures of autistic traits capturing social communication difficulties (age 7), repetitive behaviours (age 5), sociability (age 3), and pragmatic language (age 9). Psychotic experiences were assessed at ages 18 and 24 using the semi-structured Psychosis-Like Symptoms interview (PLIKSi). Traumatic experiences between ages 5 and 11 were assessed with questionnaires and interviews administered to children and parents at multiple ages.

STUDY RESULTS

Broad autistic traits, as well as social communication difficulties, were associated with psychotic experiences that were distressing and/or frequent until age 24 (autism factor mean score, n = 3707: OR 1.19, 95%CI 1.01-1.39; social communication difficulties, n = 3384: OR 1.54, 95%CI 0.97-2.45). Childhood trauma mediated a substantial proportion of the identified associations (~28% and 36% respectively, maximum n = 3577). Schizophrenia polygenic risk did not appear to confound the associations. Multiple imputation analyses (maximum n = 13 105) yielded comparable results.

CONCLUSIONS

Childhood trauma may be an important, potentially modifiable pathway between autistic features and later onset of psychotic psychopathology.

Association of trauma, post-traumatic stress disorder and non-affective psychosis across the life course: a nationwide prospective cohort study

BACKGROUND

We aimed to examine the temporal relationships between traumatic events (TE), post-traumatic stress disorder (PTSD) and non-affective psychotic disorders (NAPD).

METHODS

A prospective cohort study of 1 965 214 individuals born in Sweden between 1971 and 1990 examining the independent effects of interpersonal and non-interpersonal TE on incidence of PTSD and NAPD using data from linked register data (Psychiatry-Sweden). Mediation analyses tested the hypothesis that PTSD lies on a causal pathway between interpersonal trauma and NAPD.

RESULTS

Increasing doses of interpersonal and non-interpersonal TE were independently associated with increased risk of NAPD [linear-trend incidence rate ratios (IRR)adjusted = 2.17 [95% confidence interval (CI) 2.02-2.33] and IRRadjusted = 1.27 (95% CI 1.23-1.31), respectively]. These attenuated to a relatively small degree in 5-year time-lagged models. A similar pattern of results was observed for PTSD [linear-trend IRRadjusted = 3.43 (95% CI 3.21-3.66) and IRRadjusted = 1.45 (95% CI 1.39-1.50)]. PTSD was associated with increased risk of NAPD [IRRadjusted = 8.06 (95% CI 7.23-8.99)], which was substantially attenuated in 5-year time-lagged analyses [IRRadjusted = 4.62 (95% CI 3.65-5.87)]. There was little evidence that PTSD diagnosis mediated the relationship between interpersonal TE and NAPD [IRRadjusted = 0.92 (percentile CI 0.80-1.07)].

CONCLUSION

Despite the limitations to causal inference inherent in observational designs, the large effect-sizes observed between trauma, PTSD and NAPD in this study, consistent across sensitivity analyses, suggest that trauma may be a component cause of psychotic disorders. However, PTSD diagnosis might not be a good proxy for the likely complex psychological mechanisms mediating this association.

Associations between exposure to early childhood adversities and middle childhood psychotic experiences in children at familial high risk of schizophrenia, bipolar disorder, and population-based controls: The Danish high risk and resilience study - VIA 7 and VIA 11

BACKGROUND

Exposure to adversities in early childhood is associated with psychotic experiences and disorders in adulthood. We aimed to examine whether early childhood adversities are associated with middle childhood psychotic experiences in a cohort of children at familial high risk of schizophrenia (FHR-SZ), bipolar disorder (FHR-BP) and population-based controls (controls).

METHODS

Four hundred and forty-six children from The Danish High Risk and Resilience Study - VIA7 and VIA11 participated in this study (FHR-SZ = 170; FHR-BP = 103; controls = 173). Exposure to early childhood adversities and psychotic experiences were assessed using face-to-face interviews. Having childhood adversities assessed at baseline (age 7) was used as predictor. Psychotic experiences assessed at follow-up (age 11) were used as outcome.

RESULTS

Across the sample, exposure to early childhood interpersonal adversities was associated with an increased risk for any middle childhood psychotic experiences and subclinical delusions when adjusting for relevant confounders (OR 1.8, 95% CI 1.0-3.1, p = 0.05; OR 3.0, 95% CI 1.6-5.6, p < 0.001). There was no significant dose-response effect of exposure to multiple types of childhood adversities on any psychotic experiences. There were no interaction effects between early childhood adversities and FHR on middle childhood psychotic experiences. Exploratory analyses revealed that experiencing domestic violence in early childhood was associated with any middle childhood psychotic experiences (OR 2.8, 95% CI 1.5-5.1, p = 0.001).

CONCLUSIONS

Exposure to interpersonal adversities during early childhood is associated with an increased risk for middle childhood psychotic experiences including specifically subclinical delusions. Future studies should examine associations between exposure to childhood adversities and conversion to psychosis within this cohort.

Childhood Trauma in Clozapine-Resistant Schizophrenia: Prevalence, and Relationship With Symptoms

Background and Hypothesis

The role of early adversity and trauma is increasingly recognized in psychosis but treatments for trauma and its consequences are lacking. Psychological treatments need to understand the prevalence of these experiences, the relationship with specific symptoms and identify potentially tractable processes that may be targeted in therapy. It was hypothesized that greater adversity, and specifically abuse rather than neglect, would be associated with positive symptoms and specifically hallucinations. In addition, negative beliefs would mediate the relationship with positive symptoms.

Study Design

292 Patients with treatment resistant psychosis completed measures of early adversity as well as current symptoms of psychosis.

Study Results

Early adversity in the form of abuse and neglect were common in one-third of the sample. Adversity was associated with higher levels of psychotic symptoms generally, and more so with positive rather than negative symptoms. Abuse rather than neglect was associated with positive but not with negative symptoms. Abuse rather than neglect was associated with hallucinations but not delusions. Abuse and neglect were related to negative beliefs about the self and negative beliefs about others. Mediation demonstrated a general relationship with adversity, negative-self, and other views and overall psychotic symptoms but not in relation to the specific experience of abuse and hallucinations. Females were more likely to be abused, but not neglected, than males.

Conclusions

Whilst most relationships were modest, they supported previous work indicating that adversity contributes to people with psychosis experiencing distressing symptoms especially hallucinations. Treatments need to address and target adversity.

Investigating Specific Associations Between Childhood Victimization Profiles and Positive Psychosis Symptoms: The Mediating Roles of Anxiety, Depression, and Schema

Background

Childhood trauma is a risk factor for psychosis. It is proposed this is due to traumatic events giving rise to psychological mechanisms that are implicated in the development and maintenance of symptoms. Investigation of the psychological mechanisms accounting for relationships between trauma and psychosis will be assisted by focusing on specific trauma profiles, hallucination modalities, and delusion subtypes.

Study Design

In 171 adults with schizophrenia-spectrum diagnoses and high-conviction delusions, associations between childhood trauma classes, and hallucination and delusion factors, were tested using structural equation models (SEMs). Anxiety, depression, and negative schema were examined as potential mediators of trauma class-psychosis symptom factor links.

Study Results

Significant associations were found between the emotional abuse/neglect and poly-victimization classes with persecutory delusions and delusions of influence, that were all mediated through anxiety (β = 1.24-0.23, P = < .05). There was an association between the physical abuse class and grandiose/religious delusions that was not explained by the mediators (β = 1.86, P = < .05). Trauma class was not significantly associated with any hallucination modality (β = 0.004-1.46, P = > .05).

Conclusions

In a sample of people with strongly held delusions, this study demonstrates that childhood victimization is associated with delusions of influence and grandiose beliefs, as well as with persecutory delusions in psychosis. Consistent with previous findings, the potent, mediating role of anxiety supports affective pathway theories and the utility of targeting threat-related processes when treating trauma effects in psychosis.

Disentangling the impact of childhood abuse and neglect on depressive affect in adulthood: A machine learning approach in a general population sample

BACKGROUND

Different types of childhood maltreatment (CM) are key risk factors for psychopathology. Specifically, there is evidence for a unique role of emotional abuse in affective psychopathology in children and youth; however, its predictive power for depressive symptomatology in adulthood is still unknown. Additionally, emotional abuse encompasses several facets, but the strength of their individual contribution to depressive affect has not been examined.

METHOD

Here, we used a machine learning (ML) approach based on Random Forests to assess the performance of domain scores and individual items from the Childhood Trauma Questionnaire (CTQ) in predicting self-reported levels of depressive affect in an adult general population sample. Models were generated in a training sample (N = 769) and validated in an independent test sample (N = 466). Using state-of-the-art methods from interpretable ML, we identified the most predictive domains and facets of CM for adult depressive affect.

RESULTS

Models based on individual CM items explained more variance in the independent test sample than models based on CM domain scores (R² = 7.6 % vs. 6.4 %). Emotional abuse, particularly its more subjective components such as reactions to and appraisal of the abuse, emerged as the strongest predictors of adult depressive affect.

LIMITATIONS

Assessment of CM was retrospective and lacked information on timing and duration. Moreover, reported rates of CM and depressive affect were comparatively low.

CONCLUSIONS

Our findings corroborate the strong role of subjective experience in CM-related psychopathology across the lifespan that necessitates greater attention in research, policy, and clinical practice.

Dissociation as a Mediator Between Childhood Abuse and Hallucinations: An Exploratory Investigation Using Dissociative Identity Disorder and Schizophrenia Spectrum Disorders

Previous research has shown that the relationship between childhood abuse and the presence of auditory hallucinations is mediated by dissociation, specifically depersonalization and absorption. The current study assessed dissociation as a mediator of the relationship between childhood abuse and auditory hallucination frequency, characteristics and associated distress in those with dissociative identity disorder (DID; n = 50) and schizophrenia spectrum disorders (SSD; n = 49). It also tested whether dissociation mediated the relationship between childhood abuse and the presence of non-auditory hallucinations. Participants completed measures of childhood abuse, dissociation, auditory hallucination frequency, characteristics, distress, and non-auditory hallucinations. With distress associated with auditory hallucinations as the outcome, depersonalization was a mediator in the DID group. For non-auditory hallucinations, in the DID group depersonalization and amnesia were mediators between childhood abuse and the presence of visual, tactile and olfactory hallucinations. In the SSD group absorption mediated between childhood abuse and visual, olfactory and gustatory hallucinations. Results suggest that the presence of non-auditory hallucinations in DID and SSD are associated with different dissociative experiences.

PTSD as a mediator of the relationship between trauma and psychotic experiences

BACKGROUND

Traumatic experiences are associated with a higher risk of psychotic illnesses, but little is known about potentially modifiable mechanisms underlying this relationship. This study aims to examine whether post-traumatic stress disorder (PTSD) symptoms mediate the relationship between trauma and psychotic experiences (PEs).

METHODS

We used data from the Avon Longitudinal Study of Parents and Children to examine whether: PTSD symptoms mediate the relationships between (a) childhood trauma and adolescent PEs (study of adolescent PEs; n = 2952), and (b) childhood/adolescent trauma and PEs in early adulthood (study of adult PEs; n = 2492). We examined associations between variables using logistic regression, and mediation using the parametric g-computation formula.

RESULTS

Exposure to trauma was associated with increased odds of PEs (adolescent PEs: OR_adjusted 1.48, 95% CI 1.23-1.78; adult PEs: OR_adjusted 1.57, 95% CI 1.25-1.98) and PTSD symptoms (adolescent PTSD: OR_adjusted 1.59, 95% CI 1.31-1.93; adult PTSD: OR_adjusted 1.50, 95% CI 1.36-1.65). The association between PTSD symptoms and PE was stronger in adolescence (OR_adjusted 4.63, 95% CI 2.34-9.17) than in adulthood (OR_adjusted 1.62, 95% CI 0.80-3.25). There was some evidence that PTSD symptoms mediated the relationship between childhood trauma and adolescent PEs (proportion mediated 14%), though evidence of mediation was weaker for adult PEs (proportion mediated 8%).

CONCLUSIONS

These findings are consistent with the hypothesis that PTSD symptoms partly mediate the association between trauma exposure and PEs. Targeting PTSD symptoms might help prevent the onset of psychotic outcomes.

The Association between Type of Dissociation and Psychotic Experiences in a Non-Psychotic Inpatient Sample

Robust evidence exists for the link between dissociation and psychotic positive symptoms. The extent to which various dissociative phenomena may contribute to this relationship is still unknown. This study aimed to investigate the association between different dissociative phenomena and psychotic experiences. For this purpose, we analyzed data from 118 consecutively admitted patients of an acute care unit for trauma-related disorders who completed the Childhood Trauma Questionnaire, the German version of the Dissociative Experiences Scale and the Symptom Check-List-90-Revised. Stepwise regression analyses revealed that derealization/depersonalization in combination with amnesia accounted for 44.5% of the variance of the psychoticism subscale of the Symptom Check-List-90-Revised. Absorption in combination with emotional abuse accounted for 24.9% of the variance of the paranoid ideation subscale of the Symptom Check-List-90-Revised. The results reveal that pathological and non-pathological types of dissociation that alter the perception of reality or memory procession may contribute to the development of psychotic experiences.

Childhood adversity and psychotic disorders: Epidemiological evidence, theoretical models and clinical considerations

While genetic factors play a critical role in the risk for schizophrenia and other psychotic disorders, increasing evidence points to the role of childhood adversity as one of several environmental factors that can significantly impact the development, manifestations and outcome of these disorders. This paper reviews the epidemiological evidence linking childhood adversity and psychotic disorders and explores various theoretical models that seek to explain the connection. We discuss neurobiological parallels between the impact of childhood trauma and psychosis on the brain and then explore the impact of childhood adversity on different domains of clinical presentation. Finally, implications for prevention and treatment are considered, both on individual and structural levels.

A Computational Analysis of Abnormal Belief Updating Processes and Their Association With Psychotic Experiences and Childhood Trauma in a UK Birth Cohort

BACKGROUND

Psychotic experiences emerge from abnormalities in perception and belief formation and occur more commonly in those experiencing childhood trauma. However, which precise aspects of belief formation are atypical in psychosis is not well understood. We used a computational modeling approach to characterize belief updating in young adults in the general population, examine their relationship with psychotic outcomes and trauma, and determine the extent to which they mediate the trauma-psychosis relationship.

METHODS

We used data from 3360 individuals from the Avon Longitudinal Study of Parents and Children birth cohort who completed assessments for psychotic outcomes, depression, anxiety, and two belief updating tasks at age 24 and had data available on traumatic events assessed from birth to late adolescence. Unadjusted and adjusted regression and counterfactual mediation methods were used for the analyses.

RESULTS

Basic behavioral measures of belief updating (draws-to-decision and disconfirmatory updating) were not associated with psychotic experiences. However, computational modeling revealed an association between increased decision noise with both psychotic experiences and trauma exposure, although <3% of the trauma-psychotic experience association was mediated by decision noise. Belief updating measures were also associated with intelligence and sociodemographic characteristics, confounding most of the associations with psychotic experiences. There was little evidence that belief updating parameters were differentially associated with delusions compared with hallucinations or that they were differentially associated with psychotic outcomes compared with depression or anxiety.

CONCLUSIONS

These findings challenge the hypothesis that atypical belief updating mechanisms (as indexed by the computational models and behavioral measures we used) underlie the development of psychotic phenomena.

Evidence of mediation of severity of anxiety and depressive symptoms between abuse and positive symptoms of psychosis

BACKGROUND

Considerable evidence on general population suggests that an "Affective pathway to psychosis", involving depression and anxiety dimensions, mediates the abuse-psychosis association. However, this has never been tested in Early Psychosis (EP) patients. We aim at testing whether severity of depressive and anxiety mediates the abuse-positive symptoms dyad in an EP prospective sample.

METHODS

330 EP subjects aged 18-35 were assessed for psychopathology after 2, 6, 12, 18, 24, 30, and 36 months of treatment. Abuse was considered as facing at least one experience of physical, sexual, or emotional abuse before age 16. Positive psychotic symptoms and anxiety were measured with the Positive and Negative Syndrome Scale and depressive symptoms with the Montgomery-Asberg Depression Rating Scale. Mediation analyses were performed to study whether the abuse-positive symptom's link was mediated by depressive, anxiety, and a combination of anxiety/mood symptoms.

RESULTS

Among the 330 EP patient included, 104 (31.5% of the total) were exposed to abuse. Analyses across the 36 months of follow-up showed that depression and anxiety partially mediated 26.7% of the total effect of the abuse-positive symptoms association (indirect effects (IE) = 0.392 and 0.421 respectively), while the combined anxiety/mood model mediated 28.9% (IE = 0.475). Subanalyses at two and 36 months revealed a consistent role of depression, while that of anxiety was only present at baseline.

CONCLUSION

Our work confirms a mediating role of mood and anxiety in the association between abuse and positive symptoms during the first three years of treatment.

A systematic review and meta-analysis investigating the impact of childhood adversities on the mental health of LGBT+ youth

Background

The presence of trauma as a backdrop to the lives of LGBT+ youth has been recognised in recent literature. LGBT+ youth report a higher frequency, severity and pervasiveness of adverse childhood experiences when compared to their heterosexual and cisgender counterparts. This exposure has been directly related to an increased risk of mental health problems.

Method

A systematic literature search of Medline, Embase, PsycINFO, PubMed and Web of Science was conducted from the date of their inception until the 1st September 2021. The study protocol was registered in PROSPERO (CRD42021240472).

Results

A total of 27 studies satisfied the inclusion criteria and were used in the systematic review, representing 199,285 participants, 26,505 of whom identified as LGBT+ (mean age 16.54). Female participants (ranging from 11% to 74%) and white participants (7.7%-96%) made up the largest percentage of most samples. Depressive symptoms were the most commonly described psychiatric outcome (n = 17, 63%), followed by anxiety symptoms (n = 6, 31.5%). 18 studies provided meta-analysable data, compromising 21,781 LGBT+ young people. LGBT+ youth reported a higher prevalence of adverse experiences in comparison to their heterosexual or cisgender counterparts (p < .001), with sexual abuse representing the most commonly reported experience (29.7%), followed by verbal abuse (28.7%), physical abuse (26.5%) and cyberbullying (19.1%). LGBT+ youth were also at a heightened risk of mental health disorders (p < .001), with 36.9% and 31.5% of sample meeting the clinical criteria for depression and anxiety, respectively.

Conclusions

Continued advocacy is needed from communities and Allies to support and empower LGBT+ youth in the face of adversity. Longitudinal and longer-term studies are required to further understand the relationship between adverse experiences in LGBT+ youth and the impact on mental health.