Traumatic Stress Disorders and Risk of Subsequent Schizophrenia Spectrum Disorder or Bipolar Disorder: A Nationwide Cohort Study

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.

Comparison of early risk factors between healthy siblings and subjects with schizophrenia and bipolar disorder

Introduction

The following work aims to compare the types and magnitude of risk events in patients with Schizophrenia and Bipolar Disorder and each of those groups with of a group of healthy siblings, exploring differences and similarities of the two psychotic disorders.

Methods

Retrospective interviews were conducted with 20 families to investigate maternal and obstetric health, social support and the presence of early trauma for the affected family members and healthy siblings. Mothers were interviewed with the Prenatal Psychosocial Profile and each family participant was assessed with the Early Trauma Inventory, Screening Questionnaire of the Genomic Psychiatry Cohort and the Diagnostic Interview for Psychosis and Affective Disorders.

Results

Obstetric and gestational history, pregnancy weight changes and early trauma were associated with offspring's mental illness, including statistically significant findings for complications of pregnancy, pregnancy weight changes, general trauma, physical punishment and emotional abuse.

Conclusion

These findings highlight the different risk factor exposures that occur within a family, which may increase the risk for severe mental illness.

The effectiveness and tolerability of trauma-focused psychotherapies for psychotic symptoms: A systematic review of trauma-focused psychotherapies

INTRODUCTION

Psychological trauma is an established risk factor for psychosis. Trauma-focused psychotherapies (TFPT) have been suggested as a potential treatment for reducing psychotic symptoms in those who have experienced trauma. We therefore sought to investigate the effectiveness, tolerability, and acceptability of TFPT for psychotic symptoms.

METHODS

We conducted a systematic review of studies of any form of TFPT that measured psychotic symptoms across a broad range of diagnoses.

RESULTS

From 2584 papers initially identified, 17 studies (857 participants) met eligibility criteria. TFPT were found to be well tolerated, with very few adverse events. Acceptability was also high, with a mean dropout rate of 20%.

CONCLUSIONS

Whilst the evidence of effectiveness for TFPT in reducing psychotic symptoms is weak, we found tentative evidence in favour of exposure-based interventions. Methodologically rigorous trials investigating the efficacy of TFPT for the treatment of psychotic symptoms are needed to assess this promising intervention.

Experience of traumatic events in people with severe mental illness in a low-income country: a qualitative study

BACKGROUND

This study describes the trauma experiences of people with severe mental illness (SMI) in Ethiopia and presents a model of how SMI and trauma exposure interact to reduce functioning and quality of life in this setting.

METHODS

A total of 53 participants living and working in a rural district in southern Ethiopia were interviewed: 18 people living with SMI, 21 caregivers, and 14 primary health care providers.

RESULTS

Many participants reported that exposure to traumatic and stressful events led to SMI, exacerbated SMI symptoms, and increased caregiver stress and distress. In addition, SMI symptoms and caregiver desperation, stress or stigma were also reported to increase the possibility of trauma exposure.

CONCLUSIONS

Results suggest it is incumbent upon health professionals and the broader health community to view trauma exposure (broadly defined) as a public health problem that affects all, particularly individuals with SMI.

An exploration of the relationship between voices, dissociation, and post-traumatic stress disorder symptoms

OBJECTIVES

Extensive research has shown voice hearing to be associated with symptoms of Post-Traumatic Stress Disorder (PTSD) and dissociation. However, most studies have adopted a quantitative design, using cross-sectional data sampling methods, precluding temporal relationships between variables from being defined.

DESIGN

Using a qualitative design, this study sought to identify potential symptom relationships by addressing the research question: what is the nature of the temporal relationship between voices, dissociation and PTSD symptoms?

METHODS

Seven voice hearers (aged 27 to 68 years) participated in a semi-structured interview exploring voice hearing, PTSD symptoms, and dissociation. The interviews were analysed using Interpretative Phenomenological Analysis.

RESULTS

One superordinate theme was identified in the data. Voices were observed to occur in dynamic interrelationship with PTSD symptoms and dissociation, and were frequently experienced before and after PTSD symptoms and dissociative episodes.

CONCLUSIONS

Implications for theoretical understandings of voice hearing and future research are discussed.

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 IRR_adjusted = 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 IRR_adjusted = 3.43 (95% CI 3.21-3.66) and IRR_adjusted = 1.45 (95% CI 1.39-1.50)]. PTSD was associated with increased risk of NAPD [IRR_adjusted = 8.06 (95% CI 7.23-8.99)], which was substantially attenuated in 5-year time-lagged analyses [IRR_adjusted = 4.62 (95% CI 3.65-5.87)]. There was little evidence that PTSD diagnosis mediated the relationship between interpersonal TE and NAPD [IRR_adjusted = 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.

Case series: Cariprazine in early-onset schizophrenia

Introduction

Negative symptoms are part of the clinical manifestations of schizophrenia and their presence is associated with a poorer prognosis, significantly limited vocational opportunities, impaired quality of life and social functioning. In the clinical practice, treatment of negative symptoms in patients with schizophrenia, is a challenge. Cariprazine is a novel partial agonist of D3 and D2 receptors, and shows a high affinity for D3, with good tolerability, good response to schizophrenic symptoms and limited side effects. We present two cases of young patients with predominantly negative symptoms during treatment with an atypical antipsychotic, administered in a stable dose and therapeutic range, and for at least 4 weeks prior to the Cariprazine switch.

Methods

Two patients (men aged 21 and 22) with schizophrenia, exhibiting predominantly negative symptoms, are presented. Their diagnosis was based on, DSM-5 criteria (295.10).Patients were treated with Cariprazine at a daily dose of 4.5 mg. They were followed for a period of 18 months and assessed with Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning (GAF) and Clinical Global Impression-Severity (CGI-S), at the fourth week of initiation of treatment with Cariprazine, at 6 months, at 12 months and at 18 months. Their mean initial value was 75.5 on PANSS, 4.0 on CGI-S, and 52.5 on GAF. Both patients were treated with stable doses of atypical antipsychotic-Risperidone at a daily dose of 4,5 mg. Cross-titration to Cariprazine was initiated, from 1.5 mg daily dose up to 4,5 mg daily dose, during a period of 2 weeks.

Results

After 18 months of treatment with Cariprazine at a daily dose of 4.5 mg, the following results were reported: mean value was 57.5 on PANSS, 3.0 on CGI-S, and 74.5 on GAF. The overall PANSS mean score decreased by 23.8%, the CGI-S mean score improved by 25% and the mean GAF score increased by 29.5%. The positive PANSS subscale score decreased minimally, from 20 to 16, while for the negative subscale the improvement was 29.8%.Cariprazine was well tolerated by patients and no side effects were observed from it during therapy.

Discussion

After 18 months Cariprazine succeeded in improving negative symptoms, global functioning, and global clinical impression. In young schizophrenic patients with a predominance of negative symptoms, the cariprazine may be a successful alternative.

Positive mental health framework of transdiagnostic protective factors in elucidating the association between adverse childhood experiences and severe mental disorders

OBJECTIVES

Transdiagnostic risk factors-disrupted processes common to psychopathology-link adverse childhood experiences to severe mental disorders (i.e. major depressive disorder, bipolar disorder, and schizophrenia spectrum disorders); however, transdiagnostic protective factors are understudied. The present study investigated the association between a positive mental health framework of protective intra- and interpersonal resources and severe mental disorders in individuals with adverse childhood experiences. We hypothesized that (1) individuals with adverse childhood experiences will experience more severe mental disorders and poorer intra- and interpersonal resources than those without adverse childhood experiences; (2) intrapersonal (e.g. general coping) and interpersonal resources (e.g. emotional support) will interact to predict severe mental disorders.

METHODS

A total of 1929 adults participated in this population-based study. Participants were assessed for adverse childhood experiences, severe mental disorders, and intra- and interpersonal resources (general coping, general affect, emotional support, interpersonal skills, spirituality, and personal growth and autonomy) via structured interviews and self-reports.

RESULTS

As hypothesized, individuals with adverse childhood experiences (62.6%) experienced more severe mental disorders and poorer intra- and interpersonal resources than those without adverse childhood experiences. Among those with adverse childhood experiences, emotional support interacted with general coping and general affect to predict severe mental disorders; general coping and general affect were negatively associated with severe mental disorders at high (+1 SD) and low (-1 SD) emotional support, respectively.

CONCLUSIONS

The present study identified interactions between specific intrapersonal (i.e. general coping and general affect) and interpersonal resources (i.e. emotional support); knowing among whom and when to intervene are essential for optimal treatment of adverse childhood experiences and severe mental disorders.

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.

Incidence rate of schizophrenia after the Tangshan earthquake in China: a 44-year retrospective birth cohort study

Preliminary evidence indicates that natural disasters are associated with an increased risk for schizophrenia. With few longitudinal studies on earthquakes, this retrospective cohort study examined exposure to the 1976 Tangshan earthquake and the subsequent risk of schizophrenia. Population counts and visits to all nine psychiatric hospitals in Tangshan city were collected. We created three cohort groups by earthquake exposure: infant (August 1972 to July 1976 births), fetal (August 1976 to May 1977 births), and unexposed (June 1977 to May 1981 births). The cumulative incidence of schizophrenia in each cohort was calculated by dividing the number of schizophrenia patients by total births in the corresponding period. Altogether, 6424 schizophrenia patients were identified, with 2786 in the infant group, 663 in the fetal group, and 2975 in the unexposed group. The crude cumulative incidence of schizophrenia in the infant, fetal and unexposed groups were 7.64 (95% confidence interval [CI] = 7.36-7.92), 9.07 (95% CI = 8.38-9.76), and 7.40 (95% CI = 7.13-7.66) per thousand population respectively. Adjusted for mortality, the corresponding figures were 7.73 (95% CI = 7.44-8.01), 9.30 (95% CI = 8.60-10.01) and 7.44 (95% CI = 7.18-7.71) per thousand population respectively. The mortality-adjusted risk ratio (aRR) was 1.25 (95% CI = 1.15-1.36) between fetal and unexposed groups (χ² = 27.31, P < 0.001). Males exposed as infants did not differ from the unexposed in cumulative schizophrenia incidence. People with fetal exposure to the 1976 earthquake had 25% higher risk of developing schizophrenia compared to unexposed counterparts.

Adverse childhood experiences and positive psychotic symptoms: A nationally representative study in Singapore

BACKGROUND

Epidemiological studies show that adverse childhood experiences (ACE) are associated with positive psychotic symptoms in Western populations; however, there is a lack of population-based data in multi-ethnic, Asian societies.

OBJECTIVE

We investigated the associations between ACE (type and dosage) and positive psychotic symptoms in a nationally representative study in Singapore.

PARTICIPANTS AND SETTING

A total of 4441 adult Singapore residents were recruited via door-to-door surveys; they were assessed for ACE and positive psychotic symptoms (i.e., hallucinations, delusions, thought insertion, thought control, and telepathic powers) on structured interviews.

METHODS

Lifetime experiences of positive psychotic symptoms were regressed on (1) the experience of any ACE; (2) cumulative ACE; and (3) the experience of either no ACE, interpersonal victimization only, dysfunctional home environments only, neglect only or multiple exposures to ACE in weighted and adjusted regression models.

RESULTS

5.2 % of the sample experienced positive psychotic symptoms during their lifetime. Individuals exposed to dysfunctional home environments (OR = 2.84, 95 % CI 1.26 to 6.37) and multiple adverse childhood experiences (OR = 3.31, 95 % CI 2.18 to 5.01) were at an elevated risk of experiencing positive psychotic symptoms. The exposure to three or more ACE was associated with a near five-fold higher risk of experiencing positive psychotic symptoms (OR = 4.51, 95 % CI 2.89 to 7.05).

CONCLUSIONS

Individuals exposed to dysfunctional home environments or multiple adverse childhood experiences are at an elevated risk of experiencing positive psychotic symptoms. Given the intrafamilial nature of these childhood adversities, dual-generation approaches and family-centered interventions are key.

Family history of psychosis in youth at clinical high risk: A replication study

Having a first-degree relative with a psychotic disorder increases an individual's risk for developing psychosis to 10% compared to 1% in the general population. The impact of being at family high-risk for psychosis (FHR) has been examined in samples of youth who are at clinical high-risk for psychosis (CHR). The second North American Prodrome Longitudinal Study (NAPLS-2) identified very few clinical differences between CHR individuals with and without FHR. This paper aims to confirm these results in a new CHR sample, NAPLS-3. The NAPLS-3 sample consisted of 703 CHR participants, of whom 82 were at FHR (CHR+FHR), and 621 were not (CHR+FHRneg). The Family Interview for Genetic Studies was used to determine the presence of a first-degree relative with a psychotic disorder. The groups were compared on social and role functioning, positive and negative symptoms, IQ, cannabis use, and trauma. At baseline, the CHR+FHR group reported a statistically significant increased severity of positive and negative symptoms, lower IQ scores, and increased reports of trauma, psychological and physical abuse. There were no differences in transition rates between the two groups. This study supports some of the already reported differences in trauma, physical and psychological abuse between CHR individuals with and without FHR.

Childhood trauma in children at familial high risk of schizophrenia or bipolar disorder: A longitudinal study. The Danish High Risk and Resilience Study - VIA 7 and VIA 11

OBJECTIVES

Childhood trauma increases the risk of developing mental illness as does being born to parents with schizophrenia or bipolar disorder. We aimed to compare prevalence of lifetime childhood trauma among 11-year-old children at familial high risk of schizophrenia (FHR-SZ) or bipolar disorder (FHR-BP) compared with population-based controls (PBCs).

DESIGN

The study is a longitudinal, prospective cohort study of children at FHR-SZ, FHR-BP, and PBCs.

METHODS

A cohort of 512 children at FHR-SZ (N = 199), FHR-BP (N = 118), and PBCs (N = 195) were examined at baseline (mean age 7.8, SD 0.2) and 451 children at FHR-SZ (N = 172), FHR-BP (N = 104), and PBCs (N = 175) were examined at four-year follow-up (mean age 11.9, SD 0.2, retention rate 87.3%). Childhood trauma was measured with a semi-structured interview.

RESULTS

Children at FHR-BP had an elevated risk of exposure to any lifetime trauma (age 0-11 years) compared with PBCs (OR 2.082, 95%CI 1.223-3.545, p = .007) measured with binary logistic regression. One-way ANOVA revealed that both FHR-groups had a higher lifetime prevalence of exposure to a greater number of types of trauma compared with PBCs (FHR-SZ: observed mean: 1.53, 95%CI 1.29-1.77; FHR-BP: observed mean: 1.56, 95%CI 1.26-1.85; PBCs: observed mean: 0.99, 95%CI 0.82-1.17; p < .001). Binary logistic regression showed that the lifetime risk of exposure to interpersonal trauma (age 0-11 years) was elevated for both FHR-groups (FHR-SZ: OR 3.773, 95%CI 2.122-6.710, p < .001; FHR-BP: OR 3.602, 95%CI 1.913-6.783, p < .001).

CONCLUSIONS

Children at FHR-SZ and FHR-BP are at increased risk for being exposed to childhood trauma compared with PBCs. This study underscores the need for early detection, support, and prevention of childhood trauma in children at FHR-SZ and FHR-BP.

Diagnostic progression to schizophrenia in 35,255 patients with obsessive-compulsive disorder: a longitudinal follow-up study

Evidence suggests a continuity between obsessive-compulsive disorder (OCD) and schizophrenia. However, the factors that may predict diagnostic progression from OCD to schizophrenia remain unclear. A total of 35,255 adolescents and adults with OCD (ICD-9-CM code: 300.3) were enrolled between 2001 and 2010 and followed up at the end of 2011 for the identification of de novo schizophrenia (ICD-9-CM code: 295). The Kaplan-Meier method was used to estimate incidence rates, and the Cox regression was used to determine the significance of candidate predictors. At the end of the 11-year follow-up period, the crude cumulative progression rate from OCD to schizophrenia was 6%, and the estimated progression rate totaled 7.80%. Male sex (hazard ratio: 1.23), obesity (1.77), autism spectrum disorder (1.69), bipolar disorder (1.69), posttraumatic stress disorder (1.65), cluster A personality disorder (2.50), and a family history of schizophrenia (2.57) also were related to an elevated likelihood of subsequent progression to schizophrenia in patients with OCD. Further study is necessary to elucidate the exact pathomechanisms underlying diagnostic progression to schizophrenia in patients with OCD.

Trauma and psychosis: a qualitative study exploring the perspectives of people with psychosis on the influence of traumatic experiences on psychotic symptoms and quality of life

BACKGROUND

Despite experiencing high rates of trauma and trauma-related conditions, people with psychosis are seldomly asked about possible traumatic events. While there are some barriers to discussing trauma in clinical services, research has shown that disclosure is not only possible but also beneficial to both psychotic and traumatic symptoms. The current study is the first to evaluate service users' perception of the influence of trauma on the development and maintenance of their psychotic symptoms, as well as their views on how their life and mental health have been affected by traumatic events and their disclosure (or lack of).

METHODS

Eleven participants with experiences of psychosis and trauma took part in semi-structured interviews.

RESULTS

Consistently with previous literature, our participants reported high rates of interpersonal trauma, but had rarely had the opportunity to discuss any of these events. Using thematic analysis, we identified three major themes that have important implications for healthcare: factors that facilitate or hinder talking about trauma; consequences of talking or not; and relationship between trauma and psychosis. Participants generally benefited from talking about trauma and concerningly often associated the prolonged lack of opportunities to discuss traumatic events with negative feelings towards the self and with a deterioration of their mental health. Participants also recognised direct links between past traumas and the content and characteristics of their psychotic experiences.

CONCLUSIONS

Our findings highlight the importance, as perceived by service users, of discussing trauma and looking at psychosis through a "trauma lens". These results stress the need to systematically assess trauma history and traumatic symptoms in psychosis and might potentially help to overcome clinicians' worries about discussing trauma with service users. Our findings underscore the need to change current practice and implement trauma-informed approaches to understand clients' difficulties and provide support.

High incidence of PTSD diagnosis and trauma-related symptoms in a trauma exposed bipolar I and II sample

BACKGROUND

Post-traumatic stress disorder (PTSD) is an established comorbidity in Bipolar Disorder (BD), but little is known about the characteristics of psychological trauma beyond a PTSD diagnosis and differences in trauma symptoms between BD-I and BD-II.

OBJECTIVE

(1) To present characteristics of a trauma-exposed BD sample; (2) to investigate prevalence and trauma symptom profile across BD-I and BD-II; (3) to assess the impact of a lifetime PTSD diagnosis vs. a history of trauma on BD course; and (4) to research the impacts of sexual and physical abuse.

METHODS

This multi-center study comprised 79 adult participants with BD with a history of psychological trauma and reports baseline data from a trial registered in Clinical Trials (https://clinicaltrials.gov; ref: NCT02634372). Clinical variables were gathered through clinical interview, validated scales and a review of case notes.

RESULTS

The majority (80.8%) of our sample had experienced a relevant stressful life event prior to onset of BD, over half of our sample 51.9% had a lifetime diagnosis of PTSD according to the Clinician Administered PTSD scale. The mean Impact of Event Scale-Revised scores indicated high levels of trauma-related distress across the sample, including clinical symptoms in the PTSD group and subsyndromal symptoms in the non-PTSD group. Levels of dissociation were not higher than normative values for BD. A PTSD diagnosis (vs. a history of trauma) was associated with psychotic symptoms [2(1) = 5.404, p = 0.02] but not with other indicators of BD clinical severity. There was no significant difference between BD-I and BD-II in terms of lifetime PTSD diagnosis or trauma symptom profile. Sexual abuse significantly predicted rapid cycling [2(1) = 4.15, p = 0.042], while physical abuse was not significantly associated with any clinical indicator of severity.

CONCLUSION

Trauma load in BD is marked with a lack of difference in trauma profile between BD-I and BD-II. Although PTSD and sexual abuse may have a negative impact on BD course, in many indicators of BD severity there is no significant difference between PTSD and subsyndromal trauma symptoms. Our results support further research to clarify the role of subsyndromic PTSD symptoms, and highlight the importance of screening for trauma in BD patients.

A network analysis of post-traumatic stress and psychosis symptoms

BACKGROUND

Understanding the interplay between trauma-related psychological mechanisms and psychotic symptoms may improve the effectiveness of interventions for post-traumatic stress reactions in psychosis. Network theory assumes that mental health problems persist not because of a common latent variable, but from dynamic feedback loops between symptoms, thereby addressing the heterogeneous and overlapping nature of traumagenic and psychotic diagnoses. This is a proof-of-concept study examining interactions between post-traumatic stress symptoms, which were hypothesized to reflect trauma-related psychological mechanisms, and auditory hallucinations and delusions.

METHOD

Baseline data from two randomised controlled trials (N = 216) of trauma-focused therapy in people with post-traumatic stress symptoms (87.5% met diagnostic criteria for PTSD) and psychotic disorder were analysed. Reexperiencing, hyperarousal, avoidance, trauma-related beliefs, auditory hallucinations and delusional beliefs were used to estimate a Gaussian graphical model along with expected node influence and predictability (proportion of explained variance).

RESULTS

Trauma-related beliefs had the largest direct influence on the network and, together with hypervigilance, were implicated in the shortest paths from flashbacks to delusions and auditory hallucinations.

CONCLUSIONS

These findings are in contrast to previous research suggesting a central role for re-experiencing, emotional numbing and interpersonal avoidance in psychosis. Trauma-related beliefs were the psychological mechanism most associated with psychotic symptoms, although not all relevant mechanisms were measured. This work demonstrates that investigating multiple putative mediators may clarify which processes are most relevant to trauma-related psychosis. Further research should use network modelling to investigate how the spectrum of traumatic stress reactions play a role in psychotic symptoms.

Impact of childhood trauma on positive and negative symptom remission in first episode psychosis

OBJECTIVE

Early life adversity is suspected to play an important role for onset and course of psychosis, but its relationship with longer-term clinical outcome is not entirely clear. In this longitudinal study, we investigated the impact of childhood trauma (CT) on positive and negative symptom remission in first episode psychosis (FEP) patients over two years.

METHODS

A total of 210 FEP patients were assessed with the Childhood Trauma Questionnaire. Patients reporting moderate to severe trauma (CT; N = 114; 54.3%) were compared to those without trauma (N-CT; N = 96; 45.7%). Positive (PSR) and negative symptom remission (NSR) were determined monthly over 24 months following established criteria using the Scale for Assessment of Positive Symptoms and the Scale for Assessment of Negative Symptoms. Global Functioning was evaluated at baseline and 24 months of follow-up.

RESULTS

Compared to N-CT patients, CT patients had achieved significantly lower rates of PSR at 12 months and significantly lower rates of NSR at 24 months. A dose-response relationship was observed between the number of trauma categories fulfilled and the number of patients not achieving PSR and NSR at these time points. Higher trauma scores were significantly associated with poor functioning and higher positive and negative symptom severity at 24 months, but not at baseline and 12 months of follow-up.

CONCLUSION

Differential effects of CT on clinical outcome may not be apparent at psychosis onset, but only become evident through poor symptomatic remission and general functioning over time. Targeted diagnostic and therapeutic efforts after illness onset might limit these detrimental consequences.

The Greater Houston Area Bipolar Registry-Clinical and Neurobiological Trajectories of Children and Adolescents With Bipolar Disorders and High-Risk Unaffected Offspring

The aims of this article are to discuss the rationale, design, and procedures of the Greater Houston Area Bipolar Registry (HBR), which aims at contributing to the effort involved in the investigation of neurobiological mechanisms underlying bipolar disorder (BD) as well as to identify clinical and neurobiological markers able to predict BD clinical course. The article will also briefly discuss examples of other initiatives that have made fundamental contributions to the field. This will be a longitudinal study with participants aged 6-17 at the time of enrollment. Participants will be required to meet diagnostic criteria for BD, or to be offspring of a parent with BD. We will also enroll healthy controls. Besides clinical information, which includes neurocognitive performance, participants will be asked to provide blood and saliva samples as well as to perform neuroimaging exams at baseline and follow-ups. Several studies point to the existence of genetic, inflammatory, and brain imaging alterations between individuals at higher genetic risk for BD compared with healthy controls. Longitudinal designs have shown high conversion rates to BD among high-risk offspring, with attempts to identify clinical predictors of disease onset, as well as clarifying the burden associated with environmental stressors. The HBR will help in the worldwide effort investigating the clinical course and neurobiological mechanisms of affected and high-risk children and adolescents with BD.

The lived experience of psychosis in Nicaragua: a qualitative examination of the views of service users

BACKGROUND

The experience of psychosis is individual and influenced by a complex intersection of identity, thought processes, perceptions and culture. Little is known about the lived experience of psychosis in Nicaragua.

AIM

To explore the subjective experience of psychosis in Nicaragua from the perspectives of service users.

METHODS

Focus groups with 28 service users with experience of psychosis. A qualitative analysis using both inductive and deductive approaches was used to analyse these data.

RESULTS

Participants mostly attributed the onset of psychosis to external factors such as physical or psychological trauma and highlighted the impact of long-term conflict in the area. Whilst medication was generally viewed positively where this was available participants foregrounded lay and community support networks and engagement in valued activities in their narratives about the management of psychosis. Religious and magical forces were salient in participants' accounts of causal pathways, wider Nicaraguan culture and management practices. Stigma, social exclusion and limited access to formal health services and psychological interventions in particular were the major barriers reported to recovery from psychosis.

CONCLUSION

Our findings point to the potential utility of culturally adapted psychological interventions in Nicaragua as well as the value of lay and community workforces in delivering such interventions.

Global emotion dysregulation and maladaptive cognitive emotion regulation strategies mediate the effects of severe trauma on depressive and positive symptoms in early non-affective psychosis

BACKGROUND

Previous research has shown that childhood trauma contributes to the onset and maintenance of psychosis. However, few studies have accounted for the effects of lifetime trauma and post-traumatic stress disorder (PTSD), and none have examined the mediating role of emotion dysregulation in symptom maintenance after severe trauma. The purpose of this study is to determine whether maladaptive cognitive emotion regulation strategies (CERS) and global emotion dysregulation mediate the effects of probable PTSD on depressive symptoms, and whether this pathway extends to influence positive symptoms in patients with early non-affective psychotic disorders.

METHODS

A total of 150 outpatients with early non-affective psychosis were assessed for trauma exposure, DSM-5 PTSD symptoms, CERS, global emotion dysregulation, and current depressive and positive symptoms. Parallel and serial mediation analyses based on ordinary least squares regressions were used to test the hypothesized models.

RESULTS

Mediation analyses controlling for gender, psychiatric comorbidities, antipsychotic medication dosage, duration of untreated psychosis (DUP), family history of mental illness, and cumulative trauma revealed that maladaptive CERS (rumination, catastrophic thinking, and self-blame) and global emotion dysregulation mediated the effects of probable PTSD on depressive symptoms (R² = 41%), while maladaptive CERS, global emotion dysregulation, and depressive symptoms mediated the effects of probable PTSD on positive symptoms (R² = 30%).

CONCLUSIONS

Our results demonstrate the indirect effects of maladaptive CERS and global emotion dysregulation on maintaining depressive and positive symptoms. Emotion dysregulation may be a potential transdiagnostic treatment target to alleviate depressive and positive symptoms in traumatized patients with early non-affective psychosis.

Reconceptualizing Psychosis: The Hearing Voices Movement and Social Approaches to Health

The Hearing Voices Movement is an international grassroots movement that aims to shift public and professional attitudes toward experiences-such as hearing voices and seeing visions-that are generally associated with psychosis. The Hearing Voices Movement identifies these experiences as having personal, relational, and cultural significance. Incorporating this perspective into mental health practice and policy has the potential to foster greater understanding and respect for consumers/survivors diagnosed with psychosis while opening up valuable avenues for future research. However, it is important that a focus on individual experiences of adversity not supersede attention to larger issues of social and economic injustice. Access to appropriate mental health care is a human right; this article will argue that the right to health additionally extends beyond individual-level interventions.

Traumatic loss and psychosis - reconceptualising the role of trauma in psychosis

Literature suggests that the occurrence of psychological trauma (PT) from various negative life experiences beyond events mentioned in the DSM-criterion A, receives little to no attention when comorbid with psychosis. In fact, despite research indicating the intricate interplay between PT and psychosis, and the need for trauma-focused interventions (TFI), there continue to be mixed views on whether treating PT would worsen psychosis, with many practitioners hesitating to initiate treatment for this reason. This study, therefore, aimed to understand patient perspectives on the role of PT in psychosis and related treatment options. A qualitative exploratory approach was adopted using in-depth interviews with individuals experiencing psychosis. The Global Assessment of Functioning (GAF) scale was administered on a predetermined maximum variation sample resulting in two groups of participants- those with moderate-mild disability (GAF 54-80; n = 10) and those experiencing moderate-severe disability (GAF 41-57; n = 10). With the former group, a semi-structured interview schedule was used, while with the latter, owing to multiple symptoms and difficulty in cognitive processing, a structured interview schedule was used. Results from interpretative phenomenological analysis (IPA) indicated that traumatic loss was central to experienced PT, but received no attention; this often contributed to the psychotic experience and/or depression, through maintenance factors such as cognitive distortions and attenuated affective responses. Further, the experience of loss seems to be more consequential to trauma-related symptoms than the event itself. Participants opined strongly the need for TFI and the role of it in promoting recovery from psychosis.

Post-traumatic stress burden in a sample of hospitalized patients with Bipolar Disorder: Which impact on clinical correlates and suicidal risk?

BACKGROUND

Increasing evidence suggests Bipolar Disorder (BD) to be frequently associated to a history of traumatic experiences and Post-traumatic Stress Disorder (PTSD), with consequent greater symptoms severity, number of hospitalizations and worsening in quality of life. The aim of the present study was to investigate the lifetime exposure to traumatic events and PTSD rates in-patients with BD and to analyze the relationships between PTSD symptoms, clinical characteristics and severity of the mood disorder.

METHODS

A consecutive sample of 212 in-patients with a DSM-5 diagnosis of BD was enrolled at the psychiatric unit of a major University hospital in Italy and assessed by the SCID-5 and MOOD Spectrum-Self Report lifetime version (MOODS-SR). Socio-demographic characteristics, clinical features, substance or alcohol abuse, history of suicide related behaviors were also collected.

RESULTS

Lifetime trauma exposure emerged in 72.3% subjects, with a DSM-5 PTSD diagnosis reported by 35.6%. Patients with PTSD showed more frequently a (hypo)manic episode at onset, alcohol or substance abuse, psychotic features, suicide behaviors, higher scores in almost all the MOODS-SR domains, compared to those without PTSD.

LIMITATIONS

Cross sectional study. Lack of data about the time since trauma exposure or PTSD onset.

CONCLUSIONS

Our findings show a history of multiple traumatic experiences in hospitalized patients with BD besides high rates of PTSD, with the co-occurrence of these conditions appearing to be related to a more severe BD. Detailed investigation of post-traumatic stress symptoms is recommended for the relevant implications on the choice of a tailored treatment and the prognosis assessment.

The psychosis risk timeline: can we improve our preventive strategies? Part 2: adolescence and adulthood

Current understanding of psychosis development is relevant to patients' clinical outcomes in mental health services as a whole, given that psychotic symptoms can be a feature of many different diagnoses at different stages of life. Understanding the risk factors helps clinicians to contemplate primary, secondary and tertiary preventive strategies that it may be possible to implement. In this second article of a three-part series, the psychosis risk timeline is again considered, here focusing on risk factors more likely to be encountered during later childhood, adolescence and adulthood. These include environmental factors, substance misuse, and social and psychopathological aspects.

LEARNING OBJECTIVES:

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DECLARATION OF INTEREST:

None.

Acute stress-induced change in polysialic acid levels mediated by sialidase in mouse brain

Stress is an important environmental factor influencing human behaviour and causing several mental disorders. Alterations in the structure of polysialic acid (polySia/PSA) due to genetic alterations in ST8SIA2, which encodes a polySia-synthesizing enzyme, are related to certain mental disorders. However, whether stress as an environmental factor leads to changes in polySia structure is unknown. Here we studied the effects of acute stress on polySia expression and found reductions in both the quantity and quality of polySia in the olfactory bulb and prefrontal cortex, even with short-term exposure to acute stress. The use of inhibitors for sialidase, microglia and astrocytes revealed that these declines were due to a transient action of sialidase from microglia and astrocytes in the olfactory bulb and prefrontal cortex, respectively. These data suggest that sialidase dynamically regulates polySia expression in a brain region-specific manner.

The role of a family history of psychosis for youth at clinical high risk of psychosis

AIM

On average, there is a 10% to 12% likelihood of developing a psychotic disorder solely based on being at familial high risk. However, the introduction of the criteria for clinical high risk (CHR) of psychosis suggested for CHR individuals, 20% to 30% will go on to develop a full-blown psychotic illness within 3 years. Several studies suggest a role for family history in conversion to psychosis among those at CHR. However, we know very little about those who meet the CHR criteria and have a positive family history for psychosis compared to those at CHR with no known family history. The aim of this study was to compare these 2 groups on demographics, clinical symptoms, social and role functioning, IQ, environmental factors and conversion to psychosis.

METHOD

A total of 762 participants met criteria for being at CHR, 119 of whom had a family history (CHR + FH) and 643 without (CHR-FH). Groups were compared on attenuated symptoms, role and social functioning, IQ, past trauma, perceived discrimination and cannabis use. Survival analysis was used to compare groups on conversion rates.

RESULTS

There were no major differences between the groups in symptoms, functioning, IQ, cannabis use or in the rate of conversion between the groups. The CHR + FH group reported increased amounts of early trauma.

CONCLUSION

There is a possibility that CHR + FH individuals believe that it is more difficult for them to cope with circumstances such as abuse or potential abuse. Future research on this subject should investigate family environment and its role in conversion to psychosis among CHR + FH individuals.

Bioinformatic analysis of long-lasting transcriptional and translational changes in the basolateral amygdala following acute stress

Stress profoundly impacts the brain and increases the risk of developing a psychiatric disorder. The brain’s response to stress is mediated by a number of pathways that affect gene expression and protein function throughout the cell. Understanding how stress achieves such dramatic effects on the brain requires an understanding of the brain’s stress response pathways. The majority of studies focused on molecular changes have employed repeated or chronic stress paradigms to assess the long-term consequences of stress and have not taken an integrative genomic and/or proteomic approach. Here, we determined the lasting impact of a single stressful event (restraint) on the broad molecular profile of the basolateral amygdala complex (BLC), a key brain region mediating emotion, memory and stress. Molecular profiling performed thirty days post-restraint consisted of small RNA sequencing, RNA sequencing and quantitative mass spectrometry and identified long-lasting changes in microRNA (miRNA), messenger RNA (mRNA) and proteins. Alignment of the three datasets further delineated the regulation of stress-specific pathways which were validated by qPCR and Western Blot analysis. From this analysis, mir-29a-5p was identified as a putative regulator of stress-induced adaptations in the BLC. Further, a number of predicted mir-29a-5p targets are regulated at the mRNA and protein level. The concerted and long-lasting disruption of multiple molecular pathways in the amygdala by a single stress event is expected to be sufficient to alter behavioral responses to a wide array of future experiences, including exposure to additional stressors.

The Contribution of Biofeedback Brain Boy Method to the Treatment of Anxiety Disorders

Introduction:

Anxiety management is one of the most important health issues which is being faced by humans today. Biofeedback, as a method of neurophysiology, has been added to the methods recommended for this purpose.

Aim:

The aim of the study was to measure the effectiveness of biofeedback method by using Brain Boy Universal Professional in the treatment of anxiety disorders.

Methods:

The sample of this research study consisted of 50 individuals, suffering from symptoms of anxiety, who underwent biofeedback therapy. For the purposes of this study, the self-administered questionnaire Hamilton Rating Scale for Anxiety was completed by the individuals both before the initiation of the therapy and after individuals had completed ten sessions of treatment with biofeedback.

Results:

Prior to biofeedback, 26% of the participants showed mild to moderate anxiety, 12% a medium severity of anxiety and the remaining 62% severe anxiety. After the completion of 10 sessions of biofeedback, 78% of the participants was found to experience mild to moderate anxiety, 12% a medium severity of anxiety and only 10% of severe anxiety.

Conclusion:

Biofeedback can be a therapeutic method for the treatment of anxiety disorders, giving treatment to patients who do not respond to drugs but also to patients who want to apply to undergo such treatment alongside other therapeutic methods including drugs.

Gender Differences and Comorbidities in U.S. Adults with Bipolar Disorder

Background: Past studies have evaluated the association of various comorbidities with bipolar disorder. This study analyzes differences in the prevalence and association of medical and psychiatric comorbidities in bipolar patients by gender. Methods: A retrospective analysis was conducted using the Nationwide Inpatient Sample (2010–2014). Using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, we narrowed the study population to comprise those with a primary diagnosis of bipolar disorder and then obtained information about comorbidities. The differences in comorbidities by gender were quantified using chi-square tests and the logistic regression model (odds ratio (OR)). Results: Hypertension (20.5%), asthma (12.5%) and hypothyroidism (8.1%) were the top medical comorbidities found in bipolar patients. Migraine and hypothyroidism were seen three times higher in females (OR = 3.074 and OR = 3.001; respectively). Females with bipolar disorder had higher odds of comorbid inflammatory disorders like asthma (OR = 1.755), Crohn’s disease (OR = 1.197) and multiple sclerosis (OR = 2.440) compared to males. Females had a two-fold higher likelihood of comorbid post-traumatic stress disorder (PTSD) (OR = 2.253) followed by personality disorders (OR = 1.692) and anxiety disorders (OR = 1.663) compared to males. Conclusion: Women with bipolar disorder have a much higher medical comorbidity burden than men and may highly benefit from an integrated team of physicians to manage their condition and improve their health-related quality of life.

Do trauma-focussed psychological interventions have an effect on psychotic symptoms? A systematic review and meta-analysis

There is growing recognition of the relationship between trauma, posttraumatic stress disorder (PTSD) and psychosis. There may be overlaps in causal mechanisms involved in the development of PTSD and psychosis following traumatic or adverse events. Trauma-focussed treatments found to be effective in treating PTSD may therefore represent a new direction in the psychological treatment of psychosis. This systematic review examined the literature on trauma-focussed treatments conducted with people with schizophrenia spectrum or psychotic disorders to determine effects on psychotic symptoms. Secondary outcomes were symptoms of PTSD, depression and anxiety. Twenty-five studies were included in the review, with 12 being included in the meta-analysis. Trauma-focussed treatments had a small, significant effect (g=0.31, CI [0.55, 0.06]) on positive symptoms immediately post-treatment, but the significance and magnitude of this effect was not maintained at follow-up (g=0.18, CI [0.42, -0.06]). Trauma-focussed treatments also had a small effect on delusions at both post-treatment (g=0.37, CI [0.87, -0.12]) and follow-up (g=0.38, CI [0.67, 0.10]), but this only reached significance at follow-up. Effects on hallucinations and negative symptoms were small and non-significant. Effects on PTSD symptoms were also small (post-treatment g=0.21, CI [0.70, -0.27], follow up g=0.31, CI [0.62, 0.00]) and only met significance at follow-up. No significant effects were found on symptoms of depression and anxiety. Results show promising effects of trauma-focussed treatments for the positive symptoms of psychosis, however further studies developing and evaluating trauma-focussed treatments for trauma-related psychotic symptoms are needed.

Child Maltreatment and Clinical Outcome in Individuals at Ultra-High Risk for Psychosis in the EU-GEI High Risk Study

BACKGROUND

Child maltreatment has been associated with a wide range of mental disorders in adulthood. Whether child maltreatment is specifically associated with psychosis risk in individuals at ultra-high risk (UHR) for psychosis, or leads to a general vulnerability for overall psychopathology in the UHR stage remains unclear. The present study examines the association between child maltreatment and transition to psychosis and other mental disorders.

METHODS

The sample consisted of 259 UHR individuals from the EUropean network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) study. Participants were followed-up for 2 years to assess clinical outcome. Clinical outcome was assessed at 6 months, 12 months, and 24 months after baseline. Child maltreatment before the age of 17 years was assessed at baseline.

RESULTS

Our findings show that a history of emotional abuse was associated with an increased risk for transition to psychosis (OR = 3.78, 95% CI = 1.17 to 12.39, P = .027). Apart from psychosis, a history of physical abuse was associated with depressive disorder (OR = 4.92, 95% CI = 2.12 to 11.39, P = .001), post-traumatic stress disorder (OR = 2.06, 95% CI = 1.10 to 3.86, P = .023), panic disorder (OR = 2.00, 95% CI = 1.00 to 3.99, P = .048) and social phobia (OR = 2.47, 95% CI = 1.18 to 5.16, P = .016) at follow-up.

CONCLUSION

Our findings suggest that in the UHR stage child maltreatment is a pluripotent risk factor for developing psychosis, depressive disorder, post-traumatic stress disorder (PTSD), panic disorder, and social phobia in adulthood.

[Patients assaulted in psychiatric institutions: Literature review and clinical implications]

BACKGROUND

The psychiatric ward is a place where all forms of violence are treated. Occasionally, this violence involves acts of aggression between patients in emergency psychiatric units or hospital wards. Such events can lead to the development or worsening of posttraumatic stress disorder.

METHODS

To establish the context, we first examined the epidemiology data concerning posttraumatic stress disorder in psychiatric patients who were frequently exposed to assaults. Secondly, we examined the issue of sexual and physical assaults between patients receiving treatment in a psychiatric ward. In this context, we studied possible occurrence of posttraumatic stress disorder associated with exposure to assaults of this kind.

RESULTS

In certain cases, potentially traumatic exposure to violence was unknown to the medical staff or not taken into consideration. This would induce a risk of later development of posttraumatic stress disorder that would not be treated during the stay in psychiatry.

CONCLUSION

To date, few scientific studies have focused on the proportion of patients assaulted by other patients during treatment in a psychiatric ward and the subsequent development of peritraumatic reactions and/or posttraumatic stress disorder associated with these assaults. We know that an insufficient number of public and private health institutions report the existence of such facts to the competent authorities. Also, a minority of clinicians and caregivers are trained in screening and management of trauma victims. Yet, these issues are particularly relevant in the scope of public health and health promotion.

The feasibility and clinical benefits of improving facial affect recognition impairments in schizophrenia: Systematic review and meta-analysis

BACKGROUND

People diagnosed with schizophrenia have significant difficulty accurately recognising emotions expressed by others. This may generate anomalous experiences which, if misinterpreted, could contribute to experiences of social defeat, psychotic symptoms and reduced social functioning. It remains unclear whether this impairment is responsive to non-pharmacological intervention, or what the effect of modifying it is.

METHODS

We did a systematic review and meta-analysis to examine whether and to what extent facial affect recognition impairments can be improved by psychological intervention and, if so, whether this leads to improvements in psychotic symptoms and social functioning.

RESULTS

A total of 8 randomised controlled trials (RCTs) consisting of 300 participants were included. Focused yet brief psychological interventions led to very large improvements in facial affect recognition ability in psychosis [k=8, N=300, g=1.26, 95% Confidence Interval (CI) 0.92, 1.60, I² 41%]. Early evidence suggests this may cause large improvements in social functioning (k=3, N=109, g=0.98, 95% CI 0.37, 1.36, I² 38%), but not psychotic symptoms.

CONCLUSIONS

Facial affect recognition difficulties in schizophrenia are highly responsive to psychological interventions designed to improve them, and there is early evidence that this may lead to large gains in social functioning for this group - but not symptoms. A large-scale high-quality RCT with longer-term follow-up period is now required to overcome the limitations of the existing evidence.

Pathways from Trauma to Psychotic Experiences: A Theoretically Informed Model of Posttraumatic Stress in Psychosis

In recent years, empirical data and theoretical accounts relating to the relationship between childhood victimization and psychotic experiences have accumulated. Much of this work has focused on co-occurring Posttraumatic Stress Disorder or putative causal mechanisms in isolation from each other. The complexity of posttraumatic stress reactions experienced in psychosis remains poorly understood. This paper therefore attempts to synthesize the current evidence base into a theoretically informed, multifactorial model of posttraumatic stress in psychosis. Three trauma-related vulnerability factors are proposed to give rise to intrusions and to affect how people appraise and cope with them. First, understandable attempts to survive trauma become habitual ways of regulating emotion, manifesting in cognitive-affective, behavioral and interpersonal responses. Second, event memories, consisting of perceptual and episodic representations, are impacted by emotion experienced during trauma. Third, personal semantic memory, specifically appraisals of the self and others, are shaped by event memories. It is proposed these vulnerability factors have the potential to lead to two types of intrusions. The first type is anomalous experiences arising from emotion regulation and/or the generation of novel images derived from trauma memory. The second type is trauma memory intrusions reflecting, to varying degrees, the retrieval of perceptual, episodic and personal semantic representations. It is speculated trauma memory intrusions may be experienced on a continuum from contextualized to fragmented, depending on memory encoding and retrieval. Personal semantic memory will then impact on how intrusions are appraised, with habitual emotion regulation strategies influencing people's coping responses to these. Three vignettes are outlined to illustrate how the model accounts for different pathways between victimization and psychosis, and implications for therapy are considered. The model is the first to propose how emotion regulation and autobiographical memory may lead to a range of intrusive experiences in psychosis, and therefore attempts to explain the different phenomenological associations observed between trauma and intrusions. However, it includes a number of novel hypotheses that require empirical testing, which may lead to further refinement. It is anticipated the model will assist research and practice, in the hope of supporting people to manage the impact of victimization on their lives.