Does shame mediate the influence of trauma on psychosis? A systematic review and meta-analytic structural equation modelling approach

BACKGROUND

Meta-analytic evidence has linked shame separately to both potentially traumatic events (PTEs) and psychosis, but the influence of shame on the relationship between PTEs and psychosis has not yet been examined. This study used meta-analytic structural equation modelling (MASEM) to examine whether shame plays a mediatory role between PTEs and experiences of psychosis.

METHODS

A nested search was conducted within a previous systematic review on psychosis and shame to identify articles that contained a measure of PTEs. Included studies reported a quantitative association between psychosis and shame, and additionally a quantitative relationship between either i) PTEs and psychosis; or ii) PTEs and shame.

FINDINGS

Of the 40 articles initially included, 14 met criteria and 13 were included in the analyses. Overall, shame partially mediated the relationship between PTE's and psychosis, observed through a significant indirect effect (β = 0.15, 95 % CI: 0.11-0.19) and a reduction in the direct path that remained significant (β = 0.13, 95 % CI: 0.06-0.20). Indirect paths through shame between childhood PTEs and psychosis (β = 0.07, 95 % CI: 0.03-0.11), and between lifespan PTEs and psychosis (β = 0.09, 95 % CI: 0.03-0.11), were both small but significant. Both direct paths remained significant, suggesting that shame acts a partial mediator for both types of PTE.

CONCLUSIONS

Shame is one path through which potentially traumatic events may influence the experience of psychosis and should be considered alongside other affective types in future modelling of psychosis. Qualitative research may aid further understanding of the mechanisms by which shame operates in this relationship.

Experiencing Psychosis and Shame: A Systematic Review and Meta-analysis of the Strength and Patterns of Association

BACKGROUND AND HYPOTHESIS

Shame has been linked to the experience of psychosis, with implications for clinical outcomes, however, a meta-analysis of the relationship has not yet been conducted. This systematic review and meta-analysis aimed to examine the strength of the association between shame and psychosis, and any variations between clinical and non-clinical populations and shame type (internal vs external shame).

STUDY DESIGN

Searches were conducted in CINAHL, EMBASE, PsycInfo, PubMed, Scopus, and Web of Science from the inception of the e-databases until July 2023. For inclusion, studies reported a quantitative association between psychosis and shame, or data that could be used to identify a relationship. From 11 372 unique retrieved records, 40 articles met the inclusion criteria and 38 were included in the meta-analyses.

STUDY RESULTS

A significant large pooled estimate of the psychosis-shame association was identified (Zr = 0.36, [95% CI: 0.28, 0.44], P < .001), indicating that higher levels of shame were associated with greater severity of psychotic symptoms. The strength of the association was similar across clinical and non-clinical populations, however, differed by type of shame and psychosis symptom measured. External shame was strongly associated with paranoia suggesting possible confounding. Only a minority of studies met the highest quality criteria.

CONCLUSIONS

Shame is strongly associated with the severity of psychotic symptoms in clinical and non-clinical populations. Given the overlap with paranoia, measurement of external shame alone is not advised. Larger studies in clinical populations, with measures of a range of psychosis symptoms, are needed to better understand the relationship between shame and specific symptoms.

Position paper - CFT for psychosis

PURPOSE

This paper outlines the theoretical and empirical basis for compassion focused therapy (CFT) for psychosis, the gaps in the current knowledge and research, as well as some of the challenges for addressing gaps. It will guide the direction of future work and the steps needed to develop and advance this approach.

METHOD

This paper reviews evidence of how evolutionary models such as social rank theory and attachment theory have greatly contributed to our understanding of psychosis and provide a clear rationale and evidence base for the mechanisms of change in CFT for psychosis. It reviews the evidence for outcomes of compassion training more generally, and early feasibility evaluations of CFT for psychosis.

RESULTS

The process evidence shows that people with psychosis have highly active social rank and threat systems, and the benefits of switching into attachment and care systems, which can support emotion regulation and integrative mind states. The outcomes evidence shows that compassion training impacts not only psychological outcomes, but also physiological outcomes such as neural circuits, immune system, and the autonomic nervous system. Within the psychosis field, outcomes research is still in the early days, but there are good indications of feasibility and a clear path forward for the next steps.

CONCLUSIONS

CFT for psychosis is an approach that integrates biopsychosocial processes, an integration that's evidenced across each aspect of the model, from theoretical foundations (evolution-informed) to interventions (e.g., body/breath training and relational techniques), to evaluation. Future RCTs are required to understand the effects on biopsychosocial outcomes for people with psychosis.

Post-Psychotic Depression: An Updated Review of the Term and Clinical Implications

BACKGROUND

Post-psychotic depression (PPD) is an important and frequent clinical phenomenon featuring controversial complexity in its nosological and aetiopathogenic cataloguing.

OBJECTIVES

The main objective of this research was to review the published literature on PPD. The second objective was to indicate its clinical importance, either comorbid or as an entity of its own. To answer these questions, a historical review of the term is made and a search about the clinical, evolutionary, predisposal, and prognostic variables that characterize the PPD.

METHODS

The international recommendations were followed according to the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses (PRISMA). The databases used were Web of Science and PubMed, with the deadline for the inclusion of articles in November 2019. The MeSH used were the following: "post" AND "psych *" AND "psich" AND "depr."

RESULTS

The search resulted in 64 articles. Only 19 of these met the pre-specified inclusion criteria and were finally included in the review. One article found that reading this literature was added due to its relevance. Despite its high prevalence (around 30%), there is little research about the term PPD. Nevertheless, results show data to improve the description of the syndrome, revealing differential characteristics from other depressive symptoms in chronic psychosis due to its clinical implications.

CONCLUSIONS

Coinciding with the latest classification manuals that do not include the term, there appears to be an abandonment of its use despite its high prevalence. Data suggest that PPD is a nosological entity different from a secondary effect to antipsychotics, the negative symptoms of psychosis, and other clinical disorders that combine psychotic and depressive symptoms such as bipolar disorder, schizoaffective disorder, or depression with psychotic symptoms. PPD also has differential characteristics concerning further depressive symptoms, especially important clinical implications such as higher suicide risk and poorer quality of life.

Self-compassion and posttraumatic growth mediate the relations between social support, prosocial behavior, and antisocial behavior among adolescents after the Ya'an earthquake

Background: Previous studies indicate that social support, self-compassion, and posttraumatic growth (PTG) can affect prosocial behaviour and antisocial behaviour, but few studies have examined their combined role in prosocial and antisocial behaviour among adolescents who have experienced traumatic events. Objective: This study examined the mediating roles of self-compassion and PTG in the relationship between social support and prosocial and antisocial behaviour among Chinese adolescents after the Ya'an earthquake. Method: Four and a half years after the Ya'an earthquake, 492 students aged 13 to 18 in Lushan County (98.6% of the 499 students surveyed) were assessed using the following system: Measures of Trauma Exposure Questionnaire, Social Support Questionnaire, Self-Compassion Scale, Posttraumatic Growth Inventory, and Child Behaviour Problems Questionnaire. Results: When we controlled for gender, age, and traumatic exposure, social support had a positive effect on prosocial behaviour. Moreover, social support had an indirect and positive effect on prosocial behaviour via positive self-compassion and PTG, as well as via an indirect path from positive self-compassion to PTG, but social support had a negative effect on antisocial behaviour via PTG, as well as via an indirect path from positive self-compassion to PTG on antisocial behaviour. Social support also had a positive effect on antisocial behaviour via negative self-compassion. Conclusion: Findings suggest that increased support may be beneficial for prosocial behaviour and reduce antisocial behaviour. Self-compassion and PTG play a significant mediating role between social support, prosocial behaviour, and antisocial behaviour.

A systematic review of PTSD to the experience of psychosis: prevalence and associated factors

BACKGROUND

Psychosis can be a sufficiently traumatic event to lead to post-traumatic stress disorder (PTSD). Previous research has focussed on the trauma of first episode psychosis (FEP) and the only review to date of PTSD beyond the first episode period was not systematic and is potentially outdated.

METHODS

We searched electronic databases and reference lists using predetermined inclusion criteria to retrieve studies that reported prevalence rates and associated factors of psychosis-related PTSD across all stages of the course of psychosis. Studies were included if they measured PTSD specifically related to the experience of psychosis. Risk of bias was assessed using an adapted version of the Newcastle Ottawa Scale. Results were synthesised narratively.

RESULTS

Six papers met inclusion criteria. Prevalence estimates of psychosis-related PTSD varied from 14 to 47%. Studies either assessed first-episode samples or did not specify the number of episodes experienced. Depression was consistently associated with psychosis-related PTSD. Other potential associations included treatment-related factors, psychosis severity, childhood trauma, and individual psychosocial reactions to trauma.

CONCLUSIONS

Psychosis-related PTSD is a common problem in people with psychosis. There is a lack of published research on this beyond first episode psychosis. Further research is needed on larger, more generalizable samples. Our results tentatively suggest that prevalence rates of psychosis-related PTSD have not reduced over the past decade despite ambitions to provide trauma-informed care. Prospero registration number: CRD42019138750.

Trauma and Social Pathways to Psychosis, and Where the Two Paths Meet

The pathways from trauma-via dissociation-to psychosis have been thoroughly tested and evidenced, but what has received less attention has been the social pathways-via dissociation-to psychosis. Often social factors are more commonly linked to other influences, e.g., to appraisals and the creation of negative schema in cognitive models, or to unsupportive caregiving experiences where there is high "expressed emotion." However, evidence is now emerging that negative social rank experiences, such as being excluded or shamed, may themselves have dissociative properties, which poses intriguing questions as to how trauma pathways and social pathways might interact. This article reviews the state of knowledge in trauma and social pathways to psychosis and then considers the potential mechanisms and the relationships between them, specifically (i) dissociation, (ii) attachment, and (iii) social rank. Recommendations are suggested for future modeling and testing of three-way interactions (dissociation × attachment × social rank) in the pathway from trauma to psychosis.

Shame and the psychosis continuum: A systematic review of the literature

OBJECTIVES

Shame is increasingly implicated in the development and maintenance of several psychological problems including psychosis. The aim of the current paper was to review the research literature concerning the relationship between shame and the psychosis continuum, examining the nature and direction of this relationship.

METHOD

Systematic searches of databases PsycINFO, Medline, Scopus, and Web of Science (from the earliest available database date until November 2016) were undertaken to identify papers that examined the relationship between shame and psychosis or psychotic experiences.

RESULTS

A total of 20 eligible papers were identified. Risk of bias assessment identified methodological shortcomings across the research in relation to small, unrepresentative samples and failure to control for confounding variables. Narrative synthesis suggested positive associations between shame and paranoia (n = 10, r = .29-.62), shame and psychosis (n = 1, r = .40), and shame and affiliation with voices (n = 1, β = .26), and suggested that shame was greater in those with psychosis compared to controls (n = 4, d = 0.76-1.16).

CONCLUSIONS

Overall, several studies provide partial support for the theory that shame is an important factor in relation to psychotic experiences in both clinical and non-clinical populations, particularly paranoia. However, the predominance of cross-sectional designs prevents any conclusions being drawn concerning the temporal nature of associations. Additional research is necessary to further delineate the role of shame in relation to specific psychotic experiences such as voice-hearing. Longitudinal research is particularly needed to help establish the directionality and temporal aspects of effects.

PRACTITIONER POINTS

Research indicates moderate-to-strong positive associations between shame and psychotic experiences in the existing literature. The results provide preliminary evidence that shame may play a role in relation to psychosis and, more specifically, paranoia. Findings should be interpreted with caution due to many disparities across the studies reviewed and methodological shortcomings (e.g., small sample sizes). It is not currently possible to determine causality or direction of effect due to the cross-sectional design of all existing studies.

Post-psychotic depression: Paranoia and the damage done

To mitigate the often chronic course of schizophrenia and improve functional outcome, researchers are increasingly interested in prodromal states and psychological risk factors that may predict the outbreak of psychotic symptoms, but are also amenable to change. In recent years, depressive symptoms have been proposed as precursors of psychosis and some interventional studies indicate that the amelioration of depressive symptoms and depression-related thinking styles (e.g., worrying) improves positive symptoms, thereby "killing two birds with one stone". Yet, in a prior study, we were unable to find a strong specific predictive role of depression on paranoia over three years, which may have been due to the use of a nonclinical sample with minimal/mild symptom fluctuations. To address this further, in the present study we adopted a similar methodological approach but assessed a large patient sample with a schizophrenia spectrum disorder at three assessment points; baseline (N = 250), 6 weeks later (n = 207, 82.8% retention) and 6 months after baseline (n = 185, 74% retention). Using cross-lagged modeling, we assessed paranoia with the respective items from the Positive and Negative Syndrome Scale (PANSS) and the Psychosis Rating Scales (PSYRATS) delusions subscale. Depression was measured using the Patient Health Questionnaire-9 (PHQ-9) and the Calgary Depression Scale for Schizophrenia (CDSS). We could identify a significant pathway from depression to paranoia from baseline to post (negative association) but not from post to follow-up. Paranoia significantly predicted depressive symptoms for both intervals. Our findings do not refute claims that depression may precede or even predict psychosis, but such a linkage does not seem to be ubiquitous.

On shame and voice-hearing

Hearing voices in the absence of another speaker-what psychiatry terms an auditory verbal hallucination-is often associated with a wide range of negative emotions. Mainstream clinical research addressing the emotional dimensions of voice-hearing has tended to treat these as self-evident, undifferentiated and so effectively interchangeable. But what happens when a richer, more nuanced understanding of specific emotions is brought to bear on the analysis of distressing voices? This article draws findings from the 'What is it like to hear voices' study conducted as part of the interdisciplinary Hearing the Voice project into conversation with philosopher Dan Zahavi's Self and Other: Exploring Subjectivity, Empathy and Shame to consider how a focus on shame can open up new questions about the experience of hearing voices. A higher-order emotion of social cognition, shame directs our attention to aspects of voice-hearing which are understudied and elusive, particularly as they concern the status of voices as other and the constitution and conceptualisation of the self.

The traumatic experience of first-episode psychosis: A systematic review and meta-analysis

INTRODUCTION

A psychotic episode may be sufficiently traumatic to induce symptoms of post-traumatic stress disorder (PTSD), which could impact outcomes in first-episode psychosis (FEP). The objectives of this systematic review and meta-analysis were to estimate the prevalence of PTSD symptoms in relation to psychosis in FEP and to identify risk factors for the development of PTSD symptoms.

METHODS

We searched electronic databases and conducted manual searching of reference lists and tables of contents to identify relevant studies. Quantitative studies were included if the population was experiencing FEP and if PTSD was measured in relation to psychosis. Prevalence of PTSD symptoms and diagnoses were meta-analyzed using a random effects model. Potential risk factors for PTSD symptoms were summarized qualitatively.

RESULTS

Thirteen studies were included. Eight studies assessed PTSD symptoms, three studies assessed full PTSD, and two studies assessed both. The pooled prevalence of PTSD symptoms was 42% (95% CI 30%-55%), and the pooled prevalence of a PTSD diagnosis was 30% (95% CI 21%-40%). Exploratory subgroup analyses suggest that prevalence may be higher in affective psychosis and inpatient samples. Evidence from included studies implicate depression and anxiety as potential risk factors for PTSD symptoms.

CONCLUSIONS

Approximately one in two people experience PTSD symptoms and one in three experience full PTSD following a first psychotic episode. Evidence-based interventions to treat PTSD symptoms in the context of FEP are needed to address this burden and improve outcomes after the first psychotic episode. Further studies are needed to clarify the associated risk factors.

Is Shame Hallucinogenic?

Research into the causes of "hearing voices," formally termed auditory verbal hallucinations (AVH), has primarily focused on cognitive mechanisms. A potentially causative role for emotion has been relatively neglected. This paper uses historical and contemporary case studies of AVH to tentatively generate the hypothesis that shame can be a causal factor in the onset of AVH. Other sources of support for the generation of this hypothesis are then sought. First, evidence is examined for a role of shame in the etiology of post-traumatic stress disorder, a condition that is characterized by phenomena related to AVH (intrusions and dissociation) and in which a substantial minority of sufferers report AVH. Second, the effect on AVH of a psychological therapy specifically designed to counteract shame (Compassion Focused Therapy) is noted. The hypothesis generation process is then expanded to propose mechanisms that could mediate a relation between shame and AVH. It is proposed that employing absorbed or avoidant strategies to deal with shame may lead to AVH through mediating mechanisms such as rumination, suppression, and dissociation. Evolutionary reasons for a relation between shame and AVH are also proposed, including that AVH may be an evolved mechanism to encourage self-protective behaviors in the wake of trauma. It is concluded that existing research supports the generation of this paper's hypothesis, which is now worthy of dedicated empirical testing.

Negative cognitions about the self in patients with persecutory delusions: An empirical study of self-compassion, self-stigma, schematic beliefs, self-esteem, fear of madness, and suicidal ideation

There has been growing awareness of the high prevalence of negative cognitions about the self in patients with persecutory delusions, and it has been proposed that paranoid fears build upon these perceived vulnerabilities. This study aimed to investigate for the first time a wide range of different conceptualisations of the negative self, and to examine associations with suicidal ideation, in patients with persecutory delusions. Twenty-one patients with persecutory delusions and twenty-one non-clinical individuals completed measures relating to negative self cognitions. The delusions group also completed a measure of suicidal ideation. It was found that the patients with persecutory delusions had low self-compassion, low self-esteem, increased fears of being mad, beliefs of inferiority to others, negative self-schemas, and low positive self-schemas when compared to the non-clinical control group. The effect sizes (Cohen's d) were large, and the different conceptualisations of negative self cognitions were highly associated with one another. Self-stigma did not differ between the two groups. Furthermore, suicidal ideation was highly associated with low self-compassion, low self-esteem, fears of madness, and negative self-schema but not self-stigma. This study shows marked negative self cognitions in patients with persecutory delusions. These are likely to prove targets of clinical interventions, with patient preference most likely determining the best conceptualisation of negative self cognitions for clinicians to use.

Narrowing the focus on the assessment of psychosis-related PTSD: a methodologically orientated systematic review

BACKGROUND

Posttraumatic stress disorder (PTSD) in response to psychosis and associated experiences (psychosis-related PTSD, or PR-PTSD) is the subject of a growing field of research. However, a wide range of PR-PTSD prevalence rates has been reported. This may be due to definitional and methodological inconsistencies in the assessment of PR-PTSD.

OBJECTIVE

The focus of the review is two-fold. (1) To identify factors that enhance, or detract from, the robustness of PR-PTSD assessment and (2) to critically evaluate the evidence in relation to these identified criteria, including the impact on PR-PTSD prevalence rates.

METHOD

Four quality criteria, whose development was informed by mainstream PTSD research, were selected to evaluate findings on PR-PTSD prevalence. Two criteria related to assessment of psychosis-related stressors (participant identification of worst moments of discrete threat events; psychometrically robust trauma measure) and two focussed on PR-PTSD symptom measurement (adequate time elapsed since trauma; use of validated PTSD interview) in the context of psychosis.

RESULTS

Twenty-one studies of PR-PTSD, with prevalence rates ranging from 11 to 51%, were evaluated. Fourteen studies (67%) used robust PTSD measures but PR-trauma was not specifically defined or assessed with validated measures. Eleven studies (52%) assessed PTSD before sufficient time had elapsed since the trauma. Due to significant methodological limitations, it was not possible to review PR-PTSD rates and provide a revised estimate of prevalence.

CONCLUSIONS

Methodological limitations are common in existing studies of PR-PTSD prevalence. Specific recommendations for improving assessment of psychosis-related trauma are made to guide the development of this new and emerging field. The review concludes with a proposed conceptualisation of PR-PTSD in the context of current diagnostic systems. The utility of the PR-PTSD term and its theoretical underpinnings are discussed.

Self-Compassion and Self-Criticism in Recovery in Psychosis: An Interpretative Phenomenological Analysis Study

OBJECTIVE

To increase understanding of the internal processes of recovery in psychosis, with particular consideration given to self-compassion and self-criticism.

METHOD

Qualitative data were collected by semistructured interviews, from 10 participants with psychosis, and analyzed using interpretative phenomenological analysis.

RESULTS

Five superordinate themes emerged: (a) "my mind can't take the load": the "curse" of psychosis; (b) the "trap" of self-criticism; (c) "coming to terms" with psychosis in my life to "move on"; (d) "on my own two feet"; and (e) "an opportunity" for growth. The themes included a reciprocal relationship between psychosis and self-criticism, processes of acceptance, empowerment, and posttraumatic growth.

CONCLUSIONS

The internal process of self-to-self relating contributed to 2 maintenance cycles: self-criticism maintained distressing experiences of psychosis and compassionate self-acceptance resulted in empowered action and promoted recovery and growth. The dual process of acceptance and change in relationship to self was central to recovery.

Is good insight associated with depression among patients with schizophrenia? Systematic review and meta-analysis

Among patients with schizophrenia, better insight may be associated with depression, but the findings on this issue are mixed. We examined the association between insight and depression in schizophrenia by conducting a systematic review and meta-analysis. The meta-analysis was based on 59 correlational studies and showed that global clinical insight was associated weakly, but significantly with depression (effect size r=0.14), as were the insight into the mental disorder (r=0.14), insight into symptoms (r=0.14), and symptoms' attributions (r=0.17). Conversely, neither insight into the social consequences of the disorder nor into the need for treatment was associated with symptoms of depression. Better cognitive insight was significantly associated with higher levels of depression. The exploratory meta-regression showed that methodological factors (e.g. the instrument used to assess depression and the phase of the illness) can significantly influence the magnitude of the association between insight and depression. Moreover, results from longitudinal studies suggest that the relation between insight and depression might be stronger than what is observed at the cross-sectional level. Finally, internalized stigma, illness perception, recovery attitudes, ruminative style, and premorbid adjustment seem to be relevant moderators and/or mediators of the association between insight and depression. In conclusion, literature indicates that among patients with schizophrenia, better insight is associated with higher levels of depressive symptoms. Thus, interventions aimed at promoting patients' insight should take into account the clinical implications of these findings.

Shame amplifies the association between stressful life events and paranoia amongst young adults using mental health services: Implications for understanding risk and psychological resilience

Shame is associated with a range of psychological disorders, and is a trans-diagnostic moderator of the association between stressors and symptoms of disorder. However, research has yet to investigate shame in relation to specific psychotic symptoms in clinical groups. In order to address this, the present study investigated shame in young adults with mental health problems, to test whether shame was i) directly associated with paranoia, a prevalent psychotic symptom, and ii) a moderator of the association between stress and paranoia. Sixty participants completed measures of stressful events, paranoia, shame, depression and anxiety. Results from a cross-sectional regression analysis suggested that shame was associated with paranoia after the stressful life event measure was entered into the model, and shame moderated the association between stress and paranoia. For individuals scoring high on shame, shame amplified the association between stress and paranoia, but for low-shame individuals, the association between stress and paranoia was non-significant. These findings suggest that high levels of shame could confer vulnerability for paranoia amongst clinical groups, and that resistance to experiencing shame could be a marker of resilience.

A meta-analysis and theoretical critique of oxytocin and psychosis: prospects for attachment and compassion in promoting recovery

OBJECTIVES

There is now considerable evidence that affiliative processes are linked to oxytocin (OXT), which is linked to a range of social-cognition competences underpinning interpersonal functioning. There is evidence that OXT circuitry is involved in psychosis and emerging evidence for OXT in treatment. Therefore, this study explored studies investigating OXT and improvements in symptoms and social cognition among individuals diagnosed with psychosis.

METHOD

We conducted a systematic review of randomized controlled trials investigating OXT and psychosis. Specifically we asked, (1) what is the evidence that OXT is associated with improved overall, positive, negative and general symptoms and (2) what is the evidence that OXT is associated with improved social cognition?

RESULTS

There were seven randomized controlled trials that met the inclusion criteria for this review. We conducted an exploratory meta-analysis of data from four of these studies on a total sample size of n = 105. For overall symptoms, using a random-effects model OXT versus placebo was associated with an effect size of d = 0.52 (95% CI = 0.34-0.70; z = 5.66; p < .01). There was evidence of significant heterogeneity (Q = 96.4, p < .001; I(2) = 96.5%). Similar patterns of findings were observed for positive, negative, and general symptoms. We found significant evidence of high risk of bias across all studies. We also identified that one particular study had an undue effect on overall effect size estimates. Finally, evidence regarding OXT was linked to improved social cognition was inconsistent.

CONCLUSIONS

There are significant problems in interpreting the current evidence base for OXT in psychosis. However, OXT may provide a useful biomarker for exploring mechanisms of change occurring in psychological therapies including compassion-focused therapy (CFT), which through its engagement of the attachment system may directly influence OXT.