Exploring the Intersections of Trauma, Structural Adversity, and Psychosis among a Primarily African-American Sample: A Mixed-Methods Analysis

Meaning in Psychosis: A Veteran's Critique of the Traumas of Racism, Sexual Violence, and Intersectional Oppression

This clinical case study presents the case of a Latina Veteran experiencing psychosis and draws on eclectic theoretical sources, including user/survivor scholarship, phenomenology, meaning-oriented cultural psychiatry & critical medical anthropology, and Frantz Fanon's insight on 'sociogeny,' to emphasize the importance of attending to the meaning within psychosis and to ground that meaning in a person's subjective-lived experience and social world. The process of exploring the meaning and critical significance of the narratives of people experiencing psychosis is important for developing empathy and connection, the fundamental prerequisite for developing trust and therapeutic rapport. It also helps us to recognize some of the relevant aspects of a person's lived experiences. To be understood, this Veteran's narratives must be contextualized in her past and ongoing life experience of racism, social hierarchy, and violence. Engaging in this way with her narratives pushes us towards a social etiology that conceptualizes psychosis as a complex response to life experience, and in her case, a critical embodiment of intersectional oppression.

Structural Racism and Inequities in Incidence, Course of Illness, and Treatment of Psychotic Disorders Among Black Americans

Psychotic disorders (e.g., schizophrenia, schizoaffective disorder) are a leading cause of morbidity and premature mortality and an overlooked health inequity in the United States. European data indicate inequities in incidence, severity, and treatment of psychotic disorders, particularly for Black communities, that appear to be primarily attributable to social adversities. The dominant US narrative is that any observed differences are primarily a result of clinician bias and misdiagnosis. We propose that employing the framework of structural racism will prompt European and US research to converge and consider the multifaceted drivers of inequities in psychotic disorders among Black Americans. In particular, we describe how historical and contemporary practices of (1) racialized policing and incarceration, and (2) economic exploitation and disinvestment, which are already linked to other psychiatric disorders, likely contribute to risks and experiences of psychotic disorders among Black Americans. This framework can inform new strategies to (1) document the role of racism in the incidence, severity, and treatment of psychotic disorders; and (2) dismantle how racism operates in the United States, including defunding the police, abolishing carceral systems, and redirecting funds to invest in neighborhoods, housing, and community-based crisis response and mental health care. (Am J Public Health. 2022;112(4):624-632. https://doi.org/10.2105/AJPH.2021.306631).

Clients' Preferences for Family Involvement and Subsequent Family Contact Patterns Within OnTrackNY Early Psychosis Services

OBJECTIVE

Little is known about clients' preferences for family involvement and subsequent family contact in naturalistic, community-based coordinated specialty care (CSC) settings. The study's primary goal was to characterize clients' preferences and longitudinal patterns of family contact with providers across the OnTrackNY network in New York.

METHODS

Clinical administrative data collected at 3-month intervals and spanning 21 OnTrackNY CSC sites were used to analyze the preferences of 761 clients at baseline (unconditional involvement, conditional involvement, or no involvement) and patterns of family contact with program staff (always, sometimes, never, or early discharge) and their correlates during the initial 12-month service period. Data from clients discharged before 12 months were included for comparison.

RESULTS

At baseline, most clients requested some form of family involvement (unconditional, 59%; conditional, 35%; and none, 6%). Within each 3-month assessment period, rates of family contact ranged from 73% to 84%. Variables associated with both client preferences and contact patterns included baseline insurance status, housing status, race, frequency of family contact, and employment. Clients' preferences for no or conditional family involvement were associated with higher rates of early discharge (i.e., before 1 year).

CONCLUSIONS

Structuring family involvement around clients' preferences did not appear to negatively affect family contact, and for some clients, it seemed to bolster such contact. Additional mixed-methods research is needed to deepen the understanding of the contexts and reasoning underlying both client preferences for family involvement and subsequent levels of family contact.

Structural Disadvantage and Culture, Race, and Ethnicity in Early Psychosis Services: International Provider Survey

OBJECTIVE

Little is known about provider perspectives on programmatic responses to structural disadvantage and cultural differences within early intervention in psychosis (EIP) services, programs, and models. The primary objective of this study was to investigate providers' perspectives on the impacts of disadvantage and minority race, ethnicity, and culture and to describe current practices and perceived gaps and concerns.

METHODS

An online survey of specialized EIP providers was disseminated in the United Kingdom, United States, Canada, Australia, and Chile. A total of 164 providers, representing 110 unique sites, completed the survey. Closed-ended questions gathered demographic and program data, including information on formal assessment of trauma or adversity, integration of trauma-informed care, integration of formal cultural assessment tools, training focused on culture, programmatic changes to address culture-related issues, and consultation with cultural insiders. Open-ended questions addressed the demographic mix of the program's client population; the perceived role and influence of trauma, structural disadvantage, and cultural differences; and concerns and needs related to these topics. Frequencies were examined for closed-ended items; open-ended responses were systematically coded.

RESULTS

Overall, survey findings suggested low levels of implementation of a variety of assessment and support practices related to cultural diversity in EIP programs. Coding of open-ended responses revealed numerous concerns regarding the impacts of disadvantage and cultural difference on clients and perceived gaps in policy and implementation.

CONCLUSIONS

An expansion of research and service development aimed at better meeting the disadvantage- and culture-related needs of young people with early psychosis and their families should be a priority for the field.

Behind the opaque curtain: A 20-year longitudinal study of dissociative and first-rank symptoms in schizophrenia-spectrum psychoses, other psychoses and non-psychotic disorders

BACKGROUND

Depersonalization and derealization are currently considered diagnostically distinct from first-rank symptoms (FRS) seen in schizophrenia-spectrum psychoses. Nevertheless, the lived experiences of these symptoms can be very similar phenomenologically.

AIMS

To investigate the interrelationships between depersonalization, derealization and FRS in individuals with different types of psychotic and non-psychotic diagnoses.

METHODS

The Chicago Follow-up Study was a prospective longitudinal research program designed to study psychopathology and recovery in psychiatric disorders consisting of 555 participants, who were recruited at index hospitalization and studied over six follow-up timepoints at approximately 2, 4.5, 7.5, 10, 15, and 20 years later. The primary clinical indices were depersonalization, derealization and Schneiderian FRS that were measured at index hospitalization and at each subsequent follow-up.

RESULTS

62.8% of participants had at least four follow-ups. There were significant differences in the course and chronicity of depersonalization, derealization and first-rank symptoms across the three diagnostic groups. For the whole sample, derealization was significantly associated with FRS at 2-, 4.5- and 7.5-year follow-up timepoints whereas depersonalization was related to FRS from 10-year follow-up to 20-year follow-up. In participants with schizophrenia, overall depersonalization was more often associated with passivity phenomena whereas derealization was more often associated with overall delusions. There was also a significant effect of time on the associations between depersonalization, derealization and FRS across follow-ups.

CONCLUSIONS

Depersonalization and derealization should be viewed as transdiagnostic phenomena that are associated with FRS psychopathology along a continuum, although they are more closely associated with schizophrenia-spectrum psychoses.

The role of inner speech on the association between childhood adversity and 'hearing voices'

Adverse childhood experiences are associated with later development of psychosis, particularly auditory verbal hallucinations and delusions. Although auditory hallucinations have been proposed to be misattributed inner speech, the relation between childhood adversity and inner speech has not been previously investigated. The first aim was to test whether childhood adversity is associated with inner speech in persons with psychosis. The second aim was to test for the influence of inner speech on the association between childhood adversity and auditory hallucinations. Our final aim was to test for evidence that would falsify the null hypothesis that inner speech does not impact the relationship between childhood adversity and delusions. In persons with psychosis, we found a positive association between childhood adversity and dialogic inner speech. There was a significant total effect of childhood adversity on auditory hallucinations, including an indirect effect of childhood adversity on auditory hallucinations via dialogic inner speech. There was also a significant total effect of childhood adversity on delusions, but no evidence of any indirect effect via inner speech. These findings suggest that childhood adversities are associated with inner speech and psychosis. The relation between childhood adversity and auditory hallucination severity could be partially influenced by dialogic inner speech.

Traumagenics: At the intersect of childhood trauma, immunity and psychosis

Early childhood trauma, including physical, sexual or emotional abuse, neglect, harm or threat of harm, is associated with adulthood dysregulation of the immune system. Trauma can induce chronic immune system activation. Associations between a chronic pro-inflammatory state and schizophrenia are an enduring finding of psychiatry, with elevated cytokine concentrations correlated with psychotic symptom severity. Most importantly, persons with schizophrenia and a history of childhood trauma demonstrate increased cytokine levels. Specific types of childhood trauma can also differentially impact the expression of unique immune markers. This study tested the hypotheses that levels of adverse childhood experiences (ACEs) would be associated with levels of peripheral immune activity assessed by IL6, IFNG, CXCL10, IRF1, STAT1 and TLR4 mRNA expression, and that there would be an association between ACEs and psychosis along a continuum from non-clinical controls (NCC) to psychotic disorders such as schizophrenia. These hypotheses were tested in 20 schizophrenia, 20 NCC. We found correlations between ACEs scores and immune markers, specifically IL6. We also found a positive association between ACEs and positive symptoms. Childhood trauma, through its effects on IL6, may be a risk factor for schizophrenia.

Hallucinations Beyond Voices: A Conceptual Review of the Phenomenology of Altered Perception in Psychosis

Recent psychiatric research and treatment initiatives have tended to move away from traditional diagnostic categories and have focused instead on transdiagnostic phenomena, such as hallucinations. However, this emphasis on isolated experiences may artificially limit the definition of such phenomena and ignore the rich, complex, and dynamic changes occurring simultaneously in other domains of experience. This article reviews the literature on a range of experiential features associated with psychosis, with a focus on their relevance for hallucinations. Phenomenological research on changes in cognition, perception, selfhood and reality, temporality, interpersonal experience, and embodiment are discussed, along with their implications for traditional conceptualizations of hallucinations. We then discuss several phenomenological and neurocognitive theories, as well as the potential impact of trauma on these phenomena. Hallucinations are suggested to be an equifinal outcome of multiple genetic, neurocognitive, subjective, and social processes; by grouping them together under a single, operationalizable definition, meaningful differences in etiology and phenomenology may be ignored. It is suggested that future research efforts strive to incorporate a broader range of experiential alterations, potentially expanding on traditional definitions of hallucinations. Relevance for clinical practice, including emphasizing phenomenologically responsive techniques and developing targeted new therapies, is discussed.

Negative voice-content as a full mediator of a relation between childhood adversity and distress ensuing from hearing voices

A key predictor of whether or not an individual who hears voices (auditory verbal hallucinations; AVH) meets criteria for a psychiatric diagnosis is the level of negative content of the voices (e.g., threats, criticism, abuse). Yet the factors that contribute to negative voice-content are still not well understood. This study aimed to test the hypotheses that levels of childhood adversity would predict levels of negative voice-content, and that negative voice-content would partially mediate a relation between childhood adversity and voice-related distress. These hypotheses were tested in a clinical sample of 61 patients with formally diagnosed psychotic disorders (48 schizophrenia, 13 bipolar). We found evidence consistent with negative voice-content fully (not partially) mediating the relation between childhood adversity and voice-related distress. Although bivariate analyses found depression to be associated with both negative voice-content and voice-related distress, we found no evidence of an indirect effect of childhood adversity on either negative voice-content or voice-related distress via depression. Alternative study designs are now needed to test if our findings are replicable and causal. Should they be, it will be necessary for psychological therapies to devise ways to reduce negative voice-content itself, rather than just changing beliefs about voices. A number of techniques are discussed (Avatar Therapy, Compassion Focused Therapy, voice-dialogue) that already show promise for this.