Dissociation mediates the relationship between childhood trauma and hallucination-proneness

An online survey on clinical and healthy individuals with auditory verbal hallucinations: Abuse did not lead to more negative voice content

Despite the clinical and theoretical importance of the negative content in auditory verbal hallucinations (AVHs), little research has been conducted on the topic. A handful of studies suggest that trauma or adverse life events contribute to negative content. The findings are somewhat inconsistent, however, possibly due to methodological limitations. Moreover, only trauma occurring in childhood has been investigated so far. In the present study, we studied the effect of abuse, experienced in either child- or adulthood, and clinical status on negative content of AVHs in four groups of participants that were assessed as part of a large, previously published online survey: Individuals with a psychotic disorder and AVHs (total n = 33), who had experienced abuse (n = 21) or not (n = 12) as well as a group of healthy individuals with AVHs (total n = 53), who had experienced abuse (n = 31) or not (n = 22). We hypothesized that having experienced abuse was associated with a higher degree of negative content. The clinical group collectively reported significantly higher degrees of negative AVHs content compared to the healthy group, but there was no effect of abuse on the degree of negative AVHs content. The presence of AVHs was more common amongst individuals who reported a history of abuse compared to individuals with no history of abuse, both in clinical and healthy participants with AVHs. This implies that at group level, being subjected to traumatic events increases an individual's vulnerability to experiencing AVHs. However, it does not necessarily account for negative content in AVHs.

Linking childhood trauma to the psychopathology of schizophrenia: the role of oxytocin

Childhood trauma has been linked to schizophrenia, but underlying biological mechanisms remain elusive. This study explored the potential role of plasma oxytocin as a mediator in the relationship between childhood trauma and the psychopathology of schizophrenia. 160 patients with schizophrenia and 80 age- and sex-matched healthy controls were assessed for childhood trauma experiences using the Childhood Trauma Questionnaire and structured interviews. Psychopathology was evaluated using the Positive and Negative Syndrome Scale and plasma oxytocin levels were measured. Results showed that patients with schizophrenia had lower oxytocin levels and higher childhood trauma scores than healthy controls. There was a significant correlation between childhood trauma scores and psychopathology, with plasma oxytocin levels being inversely associated with psychopathology, except for positive symptoms. Hierarchical regression analysis indicated that both childhood trauma scores and plasma oxytocin levels significantly predicted psychopathology. Plasma oxytocin levels partially mediated the relationship between childhood trauma and schizophrenia psychopathology. This study underscores the potential role of oxytocin in bridging the gap between childhood trauma and schizophrenia.

Trauma exposure and disclosure in Hispanic youth at clinical high risk for psychosis: A retrospective review study

AIM

This exploratory study aimed to examine differences in rates of self and clinician-reports of trauma in youth at clinical high risk for psychosis (CHR) and whether rates of reporting differed by ethnicity.

METHODS

Self-reported history of trauma was collected at intake amongst youth at CHR enrolled in Coordinated Specialty Care (CSC) services (N = 52). A structured chart review was conducted for the same sample to identify clinician-reported history of trauma throughout treatment in CSC.

RESULTS

For all patients, frequency of self-reported trauma at intake to CSC (56%) was lower compared to clinician-reports of trauma throughout treatment (85%). Hispanic patients self-reported trauma at intake (35%) less frequently than non-Hispanics (69%) (p = .02). No differences were found in clinician reported exposure to trauma by ethnicity throughout treatment.

CONCLUSION

Whilst further research is needed, these findings suggest the need for formalised, repeated, and culturally appropriate assessments of trauma within CSC.

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.

Does disorganised attachment lead to auditory hallucinations via dissociation? An experimental study with an analogue sample

OBJECTIVES

Auditory hallucinations (such as hearing voices) are common in clinical and non-clinical populations. Many people who hear voices also report early adversity and have an insecure attachment style. Current cognitive models suggest that dissociation mediates an association between disorganised attachment and auditory hallucinations, but this has not been tested experimentally.

DESIGN

We recruited a non-clinical analogue sample highly predisposed to auditory hallucinations and utilised an experimental design to examine the impact of disorganised attachment imagery on hallucinatory experiences, and whether dissociation mediates an expected association.

METHODS

Participants completed self-report measures of state auditory hallucinations and dissociation before and after random allocation to secure or disorganised attachment conditions.

RESULTS

Attachment imagery did not affect auditory hallucinations. Both secure and disorganised attachment conditions increased state dissociation. Secure attachment imagery reduced paranoia, but state dissociation did not mediate this effect. An exploratory analysis found that trait dissociation fully accounted for the association between trait-disorganised attachment and hallucinatory experience while controlling for paranoia.

CONCLUSIONS

Secure attachment imagery reduces paranoia but not auditory hallucinations and the impact on paranoia is not mediated by dissociation. Secure attachment imagery may be useful in reducing fears and distress associated with voices, rather than the frequency or severity of hallucinations. Disorganised attachment may increase hallucinatory experiences for people vulnerable to dissociation. Trait dissociation should be assessed in clinical settings and addressed where indicated as a means of targeting vulnerability to distressing voices.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Neurocognitive bases of self-monitoring of inner speech in hallucination prone individuals

Verbal hallucinations in schizophrenia patients might be seen as internal verbal productions mistaken for perceptions as a result of over-salient inner speech and/or defective self-monitoring processes. Similar cognitive mechanisms might underpin verbal hallucination proneness in the general population. We investigated, in a non-clinical sample, the cerebral activity associated with verbal hallucinatory predisposition during false recognition of familiar words -assumed to stem from poor monitoring of inner speech-vs. uncommon words. Thirty-seven healthy participants underwent a verbal recognition task. High- and low-frequency words were presented outside the scanner. In the scanner, the participants were then required to recognize the target words among equivalent distractors. Results showed that verbal hallucination proneness was associated with higher rates of false recognition of high-frequency words. It was further associated with activation of language and decisional brain areas during false recognitions of low-, but not high-, frequency words, and with activation of a recollective brain area during correct recognitions of low-, but not high-, frequency words. The increased tendency to report familiar words as targets, along with a lack of activation of the language, recollective, and decisional brain areas necessary for their judgement, suggests failure in the self-monitoring of inner speech in verbal hallucination-prone individuals.

Childhood trauma, antipsychotic medication, and symptom remission in first-episode psychosis

BACKGROUND

To what extent psychotic symptoms in first-episode psychosis (FEP) with a history of childhood interpersonal trauma (CIT) are less responsive to antipsychotic medication is not known. In this longitudinal study, we compare symptom trajectories and remission over the first 2 years of treatment in FEP with and without CIT and examine if differences are linked to the use of antipsychotics.

METHODS

FEP (N = 191) were recruited from in- and outpatient services 1997-2000, and assessed at baseline, 3 months, 1 and 2 years. Inclusion criteria were 15-65 years, actively psychotic with a DSM-IV diagnosis of psychotic disorder and no previous adequate treatment for psychosis. Antipsychotic medication is reported as defined daily dosage (DDD). CIT (<18) was assessed with the Brief Betrayal Trauma Survey, and symptomatic remission based on scores from the Positive and Negative Syndrome Scale.

RESULTS

CIT (n = 63, 33%) was not associated with symptomatic remission at 2 years follow-up (71% in remission, 14% in relapse), or time to first remission (CIT 12/ no-CIT 9 weeks, p = 0.51). Those with CIT had significantly more severe positive, depressive, and excited symptoms. FEP with physical (N = 39, 20%) or emotional abuse (N = 22, 14, 7%) had higher DDD at 1 year (p < 0.05). Mean DDD did not excerpt a significant between-group effect on symptom trajectories of positive symptoms.

CONCLUSION

Results indicate that antipsychotic medication is equally beneficial in the achievement of symptomatic remission in FEP after 2 years independent of CIT. Still, FEP patients with CIT had more severe positive, depressive, and excited symptoms throughout.

Speech Illusions in People at Clinical High Risk for Psychosis Linked to Clinical Outcome

BACKGROUND AND HYPOTHESIS

Around 20% of people at clinical high risk (CHR) for psychosis later develop a psychotic disorder, but it is difficult to predict who this will be. We assessed the incidence of hearing speech (termed speech illusions [SIs]) in noise in CHR participants and examined whether this was associated with adverse clinical outcomes.

STUDY DESIGN

At baseline, 344 CHR participants and 67 healthy controls were presented with a computerized white noise task and asked whether they heard speech, and whether speech was neutral, affective, or whether they were uncertain about its valence. After 2 years, we assessed whether participants transitioned to psychosis, or remitted from the CHR state, and their functioning.

STUDY RESULTS

CHR participants had a lower sensitivity to the task. Logistic regression revealed that a bias towards hearing targets in stimuli was associated with remission status (OR = 0.21, P = 042). Conversely, hearing SIs with uncertain valence at baseline was associated with reduced likelihood of remission (OR = 7.72. P = .007). When we assessed only participants who did not take antipsychotic medication at baseline, the association between hearing SIs with uncertain valence at baseline and remission likelihood remained (OR = 7.61, P = .043) and this variable was additionally associated with a greater likelihood of transition to psychosis (OR = 5.34, P = .029).

CONCLUSIONS

In CHR individuals, a tendency to hear speech in noise, and uncertainty about the affective valence of this speech, is associated with adverse outcomes. This task could be used in a battery of cognitive markers to stratify CHR participants according to subsequent outcomes.

The Indirect Effect of Peritraumatic Dissociation on the Relationship Between Childhood Maltreatment and Schizotypy

Schizotypy is a multidimensional personality construct that is understood as a vulnerability for schizophrenia, often manifesting as more subtle and attenuated symptoms, referred to as schizotypic psychopathology. It has many well-established environmental risk factors, including experiencing childhood maltreatment (CM), but the intermediary mechanisms that relate CM to schizotypic psychopathology are unclear. Prior studies have demonstrated that trait dissociation may indirectly affect the relationship between CM and schizotypic psychopathology. However, less is known about the importance of peritraumatic dissociative experiences during CM and how it relates to schizotypic symptom manifestations in young adulthood. Therefore, the present study explored the independent contributions of peritraumatic and trait dissociation in the relationship between CM and schizotypy. Participants (N = 346) were undergraduate students who completed online self-report measures on CM, trait dissociation, peritraumatic dissociation experienced during CM, and schizotypic symptoms. The indirect effect of peritraumatic dissociation and trait dissociation on the relationship between CM and schizotypy was examined using mediational analyses. Correlational analyses revealed significant associations between self-reported CM, schizotypy, trait dissociation, and peritraumatic dissociation. In addition, mediational analyses indicated a significant indirect effect of peritraumatic dissociation (β = .06, 95% confidence interval (CI) [0.01, 0.12]), but not trait dissociation (β = .05, 95% CI [-0.02, 0.12]), on CM and schizotypy. These results highlight peritraumatic dissociation as an important mechanism driving the expression of schizotypic symptoms among individuals with a history of CM. Understanding how trauma sequelae lead to schizotypic psychopathology may be crucial in assessing and treating individuals with maltreatment histories or those on the psychosis spectrum.

Dissociation as a Mediator of Traumatic Childhood Experiences and Ideas of Reference

Ideas of reference (IR) - self-attributions about what happens in the social environment are a frequent phenomenon present in a wide variety of people with mental health disorders as well as in the nonclinical population. The purpose of this study was to find out the relationship between traumatic childhood experiences, IR and dissociative states in the nonclinical population, emphasizing the potential mediating role of dissociation between traumatic experiences and IR. The sample was comprised of 337 participants from the general population (58.8% women) with a mean age of 33.20 years (SD = 14.08). They filled in the Juvenile Victimization Questionnaire (JVQ), the Dissociative Experiences Scale-II (DES-II) and the Referential thinking Scale (REF). The results supported the original hypotheses and showed that the participants with higher frequency of IR reported more childhood traumatic (χ² (2) = 64.33, p < .001, f = .39, 1- β = .99) and dissociative experiences (χ² (2) = 50,414, p < .001, f = .38, 1- β = .99), and that dissociative states (β = .12, p < .05; 95%CI [.07, .19]; c´ = .26, p < .001), specifically absorption (β = .09, p < .05; 95% CI [.03, .15]; c´ = .26, p < .001), mediated between traumatic childhood experiences and referential thinking. It was concluded that the relationship between traumatic experiences and IR is complex and may be mediated by variables such as dissociation.

Dissociation, trauma and the experience of visual hallucinations in post-traumatic stress disorder and schizophrenia

Dissociative behaviours and hallucinations are often reported in trauma-exposed people with schizophrenia spectrum disorders and post-traumatic stress disorder (PTSD). Auditory hallucinations are the most commonly reported type of hallucination, but often co-occur with experiences in other sensory modalities. The phenomenology and the neurobiological systems involved in visual experiences are not well characterised. Are these experiences similar in nature, content or severity among people with schizophrenia and/or PTSD? What are the neurobiological bases of these visual experiences and what is the role of dissociative behaviours in the formation of these experiences? A study by Wearne and colleagues in BJPsych Open aimed to characterise these phenomenological systems in groups of people with PTSD, schizophrenia or both (schizophrenia + PTSD).

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

Background

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

Study Design

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

Study Results

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

Conclusions

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

Childhood Maltreatment and Its Association with Cognitive Ability in Young People Suspected to Be at Clinical High Risk of Psychosis

INTRODUCTION

Childhood maltreatment is associated with both reduced cognitive functioning and the development of psychotic symptoms. However, the specific relationship between childhood maltreatment, cognitive abilities and (pre)psychotic symptoms remains unclear. Therefore, the aim of this study was to investigate the association between childhood maltreatment and tasks of verbal memory and processing speed in a help-seeking sample of an early detection of psychosis service.

METHODS

A total of 274 participants consisting of 177 clinical high risk (CHR) for psychosis subjects and 97 clinical controls (CC) with subthreshold CHR underwent a battery of neurocognitive assessments measuring the latent variables verbal memory and processing speed. Additionally, the Trauma and Distress Scale (TADS) was administered to assess varying childhood maltreatment subtypes. Structural equation modeling (SEM) was used to examine associations between verbal memory, processing speed, and maltreatment subtypes. Other factors in the model were age, gender, clinical group (CHR or CC), and the presence of different CHR criteria.

RESULTS

Physical abuse was associated with lower scores in verbal memory and processing speed. The explained variance in the SEM reached up to 9.5% for verbal memory and 24.9% for processing speed. Both latent variables were each associated with the presence of cognitive-perceptive basic symptoms. Lower verbal memory was additionally associated with the clinical high-risk group, and processing speed capacity was associated with higher age and female gender.

CONCLUSION

Childhood physical abuse in particular was associated with poorer performance on verbal memory and processing speed across both groups of CHR and CC with subthreshold CHR symptoms. This adds to the current literature on reduced cognitive abilities when childhood maltreatment had occurred, albeit subtype dependent. Our findings, together with high prevalence rates of childhood maltreatment in patients with psychosis or CHR states, along with the presence of cognitive deficits in these patients, highlight the importance of not only assessing cognition but also childhood maltreatment in managing these patients. Future research should investigate the specific biological mechanisms of childhood maltreatment on verbal memory and processing speed in CHR subjects, as neurobiological alterations might explain the underlying mechanisms.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Network Approach to Trauma, Dissociative Symptoms, and Psychosis Symptoms in Schizophrenia Spectrum Disorders

BACKGROUND

Dissociative experiences commonly occur in schizophrenia spectrum disorders (SSD). Yet little is known about how dissociative experiences in SSD are related to SSD symptoms. Accordingly, we investigated the relations between dissociative experiences and SSD symptoms, focusing on symptoms bridging these 2 symptom clusters as well as their relation to reported trauma history.

STUDY DESIGN

Network analyses were conducted on the responses of 248 individuals with an SSD who enrolled from multiple mental health centers in The Netherlands. Dissociative experiences were assessed via the Dissociative Experience Scale, SSD symptoms using the Positive and Negative Syndrome Scale, and trauma history through the Trauma History Questionnaire.

STUDY RESULTS

The results indicated that dissociative symptoms in SSD are mostly independent of other symptoms, but that emotional distress bridges between the dissociative and SSD symptom clusters. Furthermore, results revealed associations between positive and negative SSD symptoms and trauma through emotional distress, whereas dissociative symptoms remained relatively isolated.

CONCLUSION

Because SSD symptoms and dissociative experiences clustered relatively independent from each other, our findings promote the idea of tailored treatment approaches for individuals with an SSD with frequent dissociative experiences, specifically targeting these symptoms.

The Relationships Between Childhood Abuse and Neglect, Sub-clinical Symptoms of Psychosis and Self-harm in a Non-clinical Community Sample

There is now substantial evidence that childhood adverse events are a significant risk factor for symptoms of psychosis in both clinical and community samples. Both childhood trauma and positive symptoms of psychosis are associated with an increased risk of self-harming behaviours. Therefore the current study aimed to consider the relationship between retrospective reports of childhood adversity, sub-clinical positive symptoms of psychosis and self-harm in a non-clinical community sample. The study employed a cross-sectional survey design, distributed online. Participants were asked to complete psychometric assessments relating to: demographic characteristics including past-year substance misuse; childhood adversity; sub-clinical symptoms of psychosis (delusions and hallucinations) and self-harming behaviours. The results found that, after controlling for substance misuse, childhood adversity predicted significant variance in sub-clinical delusions and hallucinations in the general population. Both symptoms of psychosis and childhood adversity increased the risk of self-harming behaviours. Positive symptoms partially mediated the relationship between early adversity and self-harming behaviours. For some people, the sequelae of early adversity including sub-clinical delusions and hallucinations may increase the risk of self-harming behaviours. Future research would benefit from considering the role of dissociation in these relationships and the affective impact of pseudo-psychotic experiences. Practitioners should consider the impact of childhood adversity, unusual perceptual experiences and distorted beliefs when working with people who self-harm. The current research was limited by the cross-sectional survey design and non-random sampling methodology.

Can We Predict Dissociative Experiences Based on Inner Speech in Nonclinical Population by Mediating Role of Sleep Disturbance?

ABSTRACT

Dissociative experiences include various experiences and behaviors that can cause people to feel disturbed and disconnected from reality. Individuals with dissociative experiences may exhibit various symptoms, particularly in their inner speech. The present study examined how we can predict dissociative experiences based on inner speech in nonclinical populations by mediating the role of sleep disturbance. In this cross-sectional study, data were collected from university students aged 18 to 40 years ( N = 400). They were asked to complete online self-report questionnaires: Varieties of the Inner Speech Questionnaire, Dissociative Experiences Scale, and Pittsburgh Sleep Quality Index. Results showed that there was a relationship between dissociative experiences and sleep disturbance ( r = 0.29, p < 0.001), dialogic inner speech ( r = 0.39, p < 0.001), condensed inner speech ( r = 0.31, p < 0.001), other people's inner speech ( r = 0.46, p < 0.001), evaluative/motivational inner speech ( r = 0.28, p < 0.001), and total inner speech score ( r = 0.48, p < 0.001). Thus, the current study showed a significant relationship among inner speech, dissociative experiences, and sleep disturbances. Inner speech was found to predict dissociative experiences by mediating sleep disturbances in the nonclinical population. Individuals with strong dissociative experiences had high scores for inner speech and sleep disturbance. The present study highlights a new area of research and its relationship to inner speech and dissociation. Future studies could further explore this new area to validate the findings reported here and support the authors' theoretical interpretation.

Neighbourhood effects on psychotic and depressive symptoms in the context of religious sectarianism in Northern Ireland: A data linkage study

BACKGROUND

The incidence of psychotic disorders is higher in ethnic minorities groups. The 'ethnic density effect', in which living in a neighbourhood with a low own-group proportion increases the risk of psychosis, is one explanatory factor. The density effect in the ethno-religious and sectarian context of Northern Ireland has been found to be reversed, particularly for Catholics, in which there is harmful effect of high own-group density areas. This is partly explained by high urbanicity, deprivation and unemployment, but is otherwise not well understood.

AIMS

This study aimed to examine the density effect at the level of symptomology (positive and negative psychosis symptoms and depressive symptoms) in a representative sample of people with a first episode of psychosis in Northern Ireland.

METHOD

Data linkage methodology was used drawing on data from the Northern Ireland First Episode Psychosis Study (NIFEPS) and the 2001 Census of Northern Ireland.

RESULTS

In total, 223 people between the ages of 18 to 64 were included in the study. A significant density effect was found for Catholics for total psychosis scores, but not for positive, negative and depressive symptoms, nor for general psychopathology, after adjusting for individual and area characteristics. The model accounted for just over 12% of the variance. No effect was found for Protestants.

CONCLUSION

The findings suggest that the density effect for Catholics is unrelated to the core features of psychosis (hallucinations, delusions and anhedonia) but rather to broader cognitive and emotional disturbances and area deprivation. Explanations of exposure to social adversity and inequality are proposed, with implications for public mental health and social policy.

Effects of childhood trauma on facial recognition of fear in psychosis

INTRODUCTION

Childhood trauma has been reported as a risk factor for psychosis. Different types of traumatic experiences in childhood could lead to different clinical manifestations in psychotic disorders.

METHODS

We studied differences in social cognition (emotion recognition and theory of mind) and clinical symptoms in a sample of 62 patients with psychosis (less than five years of illness) and childhood trauma, analysing performance by trauma type.

RESULTS

Psychotic patients with a history of childhood trauma other than sexual abuse were more capable of recognizing fear as a facial emotion (especially when facial stimuli were non-degraded) than participants with a history of sexual abuse or with no history of childhood trauma (P = .008). We also found that the group that had suffered sexual abuse did not show improvement in fear recognition when exposed to clearer stimuli, although this intergroup difference did not reach statistical significance (P = .064). We have not found other differences between abuse groups, neither in clinical symptoms (PANSS factors) nor in Hinting Task scores.

CONCLUSION

We have found differences in fear recognition among patients with psychotic disorders who have experienced different types of childhood trauma.

Dissociative Model in Patients With Resistant Schizophrenia

BACKGROUND

Schizophrenia is a severe mental illness in which, despite the growing number of antipsychotics from 30 to 50% of patients remain resistant to treatment. Many resistance factors have been identified. Dissociation as a clinical phenomenon is associated with a loss of integrity between memories and perceptions of reality. Dissociative symptoms have also been found in patients with schizophrenia of varying severity. The established dispersion of the degree of dissociation in patients with schizophrenia gave us reason to look for the connection between the degree of dissociation and resistance to therapy.

METHODS

The type of study is correlation analysis. 106 patients with schizophrenia were evaluated. Of these, 45 with resistant schizophrenia and 60 with clinical remission. The Positive and Negative Syndrome Scale (PANSS) and Brief Psychiatric Rating Scale (BPRS) scales were used to assess clinical symptoms. The assessment of dissociative symptoms was made with the scale for dissociative experiences (DES). Statistical methods were used to analyze the differences in results between the two groups of patients.

RESULTS

Patients with resistant schizophrenia have a higher level of dissociation than patients in remission. This difference is significant and demonstrative with more than twice the level of dissociation in patients with resistant schizophrenia.The level of dissociation measured in patients with resistant schizophrenia is as high as the points on the DES in dissociative personality disorder.

CONCLUSION

Patients with resistant schizophrenia have a much higher level of dissociation than patients in clinical remission. The established difference between the two groups support to assume that resistance to the administered antipsychotics is associated with the presence of high dissociation in the group of resistant patients. These results give us explanation to think about therapeutic options outside the field of antipsychotic drugs as well as to consider different strategies earlier in the diagnostic process.

Associations between PTSD symptoms and other psychiatric symptoms among college students exposed to childhood sexual abuse: a network analysis

Background: Childhood sexual abuse (CSA) is one of the prevalent forms of trauma experienced during childhood and adolescence. Previous research underscores its associations with depression, anxiety, post-traumatic stress disorder (PTSD), and psychosis. Objective: This study examined symptom connections between depression, anxiety, PTSD, and psychosis while simultaneously investigating whether these connections differed by gender among CSA survivors. Methods: A large-scale, cross-sectional study among 96,218 college students was conducted in China. Participants' CSA was measured by the Childhood Trauma Questionnaire-Short Form (CTQ-SF). Participants' PTSD, psychosis, depression, and anxiety were measured by the Trauma Screening Questionnaire (TSQ), the Psychosis Screener (PS), the nine-item Patient Health Questionnaire (PHQ-9), and the 7-item Generalized Anxiety Disorder Scale (GAD-7), respectively. Network analysis was used to explore the potential associations between these symptoms and to compare the sex differences in the symptoms model. Results: Among participants who suffered from CSA, females were more likely from left-behind households, while males were more likely from households with a high annual income (P < .001, Cohen's W = 0.07). In addition, compared to male victims, female victims were more likely to report depression, anxiety, and PTSD (P < .001, Cohen's d≈0.2), while male victims were more likely to report psychosis (P < .001, Cohen's d = 0.36). Results from network estimation showed that psychosis, depression, anxiety, and PTSD symptoms were positively correlated. Moreover, psychosis had a stronger connection with PTSD symptoms, including hypervigilance, intrusive thoughts, and physiological and emotional reactivity. Conclusions: The current study explores the associations between PTSD symptoms and psychiatric symptoms among college students exposed to CSA using a network analysis approach. These crucial symptoms of PTSD may have potential connections to psychosis. Target intervention and strategy should be developed to improve mental health and quality of life among these CSA victims. Furthermore, longitudinal studies are warranted to advance our understanding of PTSD and psychosis.

Hallucinations and Other Psychotic Symptoms in Patients with Borderline Personality Disorder

BACKGROUND

Psychotic symptoms in BPD are not uncommon, and they are diverse and phenomenologically similar to those in schizophrenia spectrum disorders. Despite their prevalence in BPD patients, knowledge about the characteristics and severity of hallucinations is limited, especially in modalities other than auditory.

AIM

This review summarises the causes, phenomenology, severity, and treatment options of hallucinations and other psychotic symptoms in BPD.

METHODS

The PubMed database was used with the following key terms: "borderline personality disorder" and 'hallucinations' and "psychotic symptoms". Articles were selected between January 1990 and May 2021. The primary keyword search yielded a total of 545 papers, of which 102 articles met the inclusion criteria and were fully screened. Papers from the primary source reference lists were also screened, assessed for eligibility, and then added to the primary documents where appropriate (n = 143). After the relevance assessment, 102 papers were included in the review. We included adult and adolescent studies to gather more recent reviews on this topic.

RESULTS

Hallucinations are significantly prevalent in BPD, mainly auditory, similar to schizophrenia spectrum disorders. The relationship between hallucinations and depression, anxiety, suicidality, schizotypy, and loneliness in BPD has been discovered but requires more research. Studies for treatment options for hallucinations in BPD are lacking.

CONCLUSION

Recognition of psychotic symptoms in patients with BPD as distinguished psychopathological phenomena instead of diminishing and overlooking them is essential in the clinical assessment and can be useful in predicting complications during treatment. More focused research in this area is needed.

Pharmacological modelling of dissociation and psychosis: an evaluation of the Clinician Administered Dissociative States Scale and Psychotomimetic States Inventory during nitrous oxide ('laughing gas')-induced anomalous states

RATIONALE

A significant obstacle to an improved understanding of pathological dissociative and psychosis-like states is the lack of readily implemented pharmacological models of these experiences. Ketamine has dissociative and psychotomimetic effects but can be difficult to use outside of medical and clinical-research facilities. Alternatively, nitrous oxide (N₂O) - like ketamine, a dissociative anaesthetic and NMDAR antagonist - has numerous properties that make it an attractive alternative for modelling dissociation and psychosis. However, development and testing of such pharmacological models relies on well-characterized measurement instruments.

OBJECTIVES

To examine the factor structures of the Clinician Administered Dissociative States Scale (CADSS) and Psychotomimetic States Inventory (PSI) administered during N₂O inhalation in healthy volunteers.

METHODS

Secondary analyses of data pooled from three previous N₂O studies with healthy volunteers.

RESULTS

Effect sizes for N₂O-induced dissociation and psychotomimesis were comparable to effects reported in experimental studies with sub-anaesthetic ketamine in healthy volunteers. Although, like ketamine, a three-factor representation of N₂O-induced dissociation was confirmed, and a more parsimonious two-factor model might be more appropriate. Bayesian exploratory factor analysis suggested that N₂O-induced psychosis-like symptoms were adequately represented by two negative and two positive symptom factors. Hierarchical cluster analysis indicated minimal item overlap between the CADSS and PSI.

CONCLUSION

N₂O and ketamine produce psychometrically similar dissociative states, although parallels in their psychosis-like effects remain to be determined. The CADSS and PSI tap largely non-overlapping experiences under N₂O and we propose the use of both measures (or similar instruments) to comprehensively assess anomalous subjective states produced by dissociative NMDAR antagonists.

Item-specific overlap between hallucinatory experiences and cognition in the general population: A three-step multivariate analysis of international multi-site data

Hallucinatory experiences (HEs) can be pronounced in psychosis, but similar experiences also occur in nonclinical populations. Cognitive mechanisms hypothesized to underpin HEs include dysfunctional source monitoring, heightened signal detection, and impaired attentional processes. Using data from an international multisite study on non-clinical participants (N = 419), we described the overlap between two sets of variables - one measuring cognition and the other HEs - at the level of individual items. We used a three-step method to extract and examine item-specific signal, which is typically obscured when summary scores are analyzed using traditional methodologies. The three-step method involved: (1) constraining variance in cognition variables to that which is predictable from HE variables, followed by dimension reduction, (2) determining reliable HE items using split-halves and permutation tests, and (3) selecting cognition items for interpretation using a leave-one-out procedure followed by repetition of Steps 1 and 2. The results showed that the overlap between HEs and cognition variables can be conceptualized as bi-dimensional, with two distinct mechanisms emerging as candidates for separate pathways to the development of HEs: HEs involving perceptual distortions on one hand (including voices), underpinned by a low threshold for signal detection in cognition, and HEs involving sensory overload on the other hand, underpinned by reduced laterality in cognition. We propose that these two dimensions of HEs involving distortions/liberal signal detection, and sensation overload/reduced laterality may map onto psychosis-spectrum and dissociation-spectrum anomalous experiences, respectively.

Eye movement desensitization and reprocessing therapy for psychosis (EMDRp): Protocol of a feasibility randomized controlled trial with early intervention service users

AIM

Traumatic events are involved in the development and maintenance of psychotic symptoms. There are few trials exploring trauma-focused treatments as interventions for psychotic symptoms, especially in individuals with early psychosis. This trial will evaluate the feasibility and acceptability of conducting a definitive trial of Eye Movement Desensitization and Reprocessing for psychosis (EMDRp) in people with early psychosis.

METHODS

Sixty participants with first episode psychosis and a history of a traumatic/adverse life event(s)will be recruited from early intervention services in the North West of England and randomized to receive16 sessions of EMDRp + Treatment as Usual (TAU) or TAU alone. Participants will be assessed at baseline, 6 and 12 months post-randomization using several measures of psychotic symptoms, trauma symptoms, anxiety, depression, functioning, service-user defined recovery, health economics indicators and quality of life. Two nested qualitative studies to assess participant feedback of therapy and views of professional stakeholders on the implementation of EMDRp into services will also be conducted. The feasibility of a future definitive efficacy and cost-effectiveness evaluation of EMDRp will be tested against several outcomes, including ability to recruit and randomize participants, trial retention at 6- and 12-month follow-up assessments, treatment engagement and treatment fidelity.

CONCLUSIONS

If it is feasible to deliver a multi-site trial of this intervention, it will be possible to evaluate whether EMDRp represents a beneficial treatment to augment existing evidence-based care of individuals with early psychosis supported by early intervention services.

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.

Symptom variability in depersonalization-derealization disorder: A latent profile analysis

OBJECTIVE

Depersonalization-derealization disorder (DDD) is characterized by diverse symptomatology overlapping with anxiety and dissociative disorders, but the sources of this variability are poorly understood. This study aims to determine whether symptom heterogeneity is attributable to the presence of latent subgroups.

METHOD

We applied latent profile analysis to psychometric measures of anxiety, depersonalization-derealization, and dissociation in 303 DDD patients.

RESULTS

The analysis yielded evidence for five discrete subgroups: three of varying severity levels and two moderate-to-severe classes characterized by differential dissociative symptoms. The five classes reliably differed on several nondissociative symptoms, comorbidities, and factors precipitating their diagnosis but did not significantly differ in other symptoms including anxiety.

CONCLUSION

These results suggest the presence of three distinct DDD subtypes in the upper severity range that are distinguished by differential expression of detachment and compartmentalization symptoms. Further elucidation of these subtypes has potential implications for the etiology, mechanisms, and treatment of DDD.

Trauma exposure and posttraumatic stress disorder in a large community sample of Chinese adults

BACKGROUND

This study investigated the prevalence and related factors of trauma exposure and probable posttraumatic stress disorder (PTSD) in adults from a Chinese community sample.

METHODS

Participants were 7218 adults recruited from Jiangxi and Hunan provinces in China. Life Events Checklist and Posttraumatic Stress Disorder Checklist for DSM-5 were used to screen lifetime trauma exposure and PTSD symptoms, respectively. Participants' adverse and positive childhood experiences, behavioral inhibition, depression, insomnia, psychotic-like experiences (PLEs) and ADHD symptoms were also measured. Multiple regressions were performed to examine the correlates of PTSD.

RESULTS

Approximately 67.1% of participants reported one traumatic event; 27.1% experienced four or more. Participants recruited from private school, male, young age, low socioeconomic status, and poor physical health were associated with more trauma-exposure. The prevalence of PTSD was 2.1% in the total sample and 3.1% among the trauma-exposed. Among participants with PTSD, 53.6% were screened as depression, 54.3% had insomnia, 65.6% had one to three PLEs, 12.6% had four to seven PLEs, and 26.5% were screened as likely ADHD, and 5.3% highly likely ADHD. Younger age, being less educated, poor marriage quality and physical health, more adverse childhood experiences, behavioral inhibition and less positive childhood experiences were associated with increased risk of PTSD among the trauma exposed. After adjustment of these related factors, depression, insomnia, PLEs and ADHD were related to PTSD.

CONCLUSIONS

PTSD is relatively prevalent among Chinese community population. Childhood experiences, behavioral inhibition, and concurrent mental health account for individual differences in vulnerability to PTSD.

Traumatic events and psychotic experiences: a nationally representative study in Thailand

AIMS

Most research exploring the link between traumatic events and psychotic experiences has focused on either Australia, Europe or North America. In this study, we expand the existing knowledge to Thailand and investigate the impact of the type and the number of traumatic events on psychotic experiences in Thailand.

METHODS

We used data from the nationally representative 2013 Thai National Mental Health Survey (TNMHS), including questions on traumatic events and psychotic experiences. We regressed the lifetime experience of hallucinations or delusions against the following independent variables: the experience of any traumatic event during lifetime (dichotomous; hypothesis 1); the experience of either no traumatic event, one interpersonal, one unintentional or both interpersonal and unintentional traumatic events (categorical; hypothesis 2) and the number of traumatic events experienced during lifetime (categorical; hypothesis 3). We adjusted the regression models for sociodemographic indicators and psychiatric disorders, and considered survey weights.

RESULTS

About 6% (95% confidence interval: 4.9-7.0) of the respondents stated that they had either hallucinatory or delusional experiences during their lifetime. The risk of reporting such experiences was more than doubled as high among respondents who had experienced at least one traumatic event during their lifetime than among those who had not yet experienced one, with higher risks for interpersonal or multiple traumatic events. Our results further indicated an increase in the risk of psychotic experiences as the number of traumatic events increased, with up to an eight-fold higher risk for people exposed to five or more traumatic events in their lifetime, compared to those with no traumatic events.

CONCLUSIONS

Individuals reporting interpersonal or multiple traumatic events face much higher risk of psychotic experiences. Effective and widely accessible secondary prevention programmes for people having experienced interpersonal or multiple traumatic events constitute a key intervention option.

Targeting dissociation using cognitive behavioural therapy in voice hearers with psychosis and a history of interpersonal trauma: A case series

OBJECTIVES

Previous studies have suggested that dissociation might represent an important mechanism in the maintenance of auditory verbal hallucinations (i.e., voices) in people who have a history of traumatic life experiences. This study investigated whether a cognitive behavioural therapy (CBT) intervention for psychosis augmented with techniques specifically targeting dissociative symptoms could improve both dissociation and auditory hallucination severity in a sample of voice hearers with psychosis and a history of interpersonal trauma (e.g., exposure to sexual, physical, and/or emotional abuse).

DESIGN

Case series.

METHODS

A total of 19 service users with psychosis were offered up to 24 therapy sessions over a 6-month intervention window. Participants were assessed four times over a 12-month period using measures of dissociation, psychotic symptoms severity, and additional secondary mental-health and recovery measures.

RESULTS

Sixteen participants engaged in the intervention and were included in last-observation-carried-forward analyses. Dropout rates were in line with those of other CBT for psychosis trials (26.3%). Repeated measures ANOVAs revealed large and significant improvements in dissociation (d_rm  = 1.23) and hallucination severity (d_rm  = 1.09) by the end of treatment; treatment gains were maintained 6 months following the end of therapy. Large and statistically significant gains were also observed on measures of post-traumatic symptoms, delusion severity, emotional distress, and perceived recovery from psychosis.

CONCLUSIONS

The findings of this case series suggest that the reduction of dissociation represents a valuable and acceptable treatment target for clients with auditory verbal hallucinations and a trauma history. Future clinical trials might benefit from considering targeting dissociative experiences as part of psychological interventions for distressing voices.

PRACTITIONER POINTS

Practitioners should consider the role of dissociation when assessing and formulating the difficulties of voice hearers with a history of trauma. Techniques to reduce dissociation can be feasibly integrated within psychological interventions for voices. Voice hearers with histories of trauma can benefit from psychological interventions aimed at reducing dissociation.

Absence of negative associations of insular and medial frontal gray matter volume with dissociative symptoms in schizophrenia

BACKGROUND

Dissociative symptoms have been constantly found in schizophrenia (SCZ). Traumatic experience seems to relate to dissociative symptoms and brain volume alterations in SCZ. The current study aimed to clarify the inter-relations of dissociative symptoms, traumatic experience, and brain volume in SCZ.

METHODS

We employed voxel-based morphometry to compare the distributions of gray matter volumes (GMV) in 37 SCZ patients and 26 healthy volunteers (HV). All participants underwent T1-weighted images on a 1.5 T MRI system. Traumatic experience was examined by the Brief Betrayal Trauma Survey. Pathological and non-pathological dissociation were measured by the Dissociative Symptoms Scale and the Dissociative Experiences Scale, respectively.

RESULTS

A GMV reduction was found in SCZ patients in the right thalamus. Importantly, a significant group by pathological dissociation interaction was observed in the medial frontal cortex (MFC), bilateral anterior insular area, and precuneus. A negative correlation between MFC/insular GMV and pathological dissociation was observed in HV; higher non-pathological dissociation and smaller volume in MFC/insula were associated with pathological dissociation. In contrast, higher traumatic experience, higher non-pathological dissociation, and larger volume in MFC/insula were associated with pathological dissociation in SCZ.

CONCLUSION

The negative association between MFC/insula GMV and pathological dissociation in HV was not observed in SCZ patients. The absent negative association in SCZ suggests a unique neural underpinning in SCZ with dissociative pathology, in which medial frontal and temporal regions play crucial roles.

Dissociation as a causal pathway from sexual abuse to positive symptoms in the spectrum of psychotic disorders

BACKGROUND

Although numerous studies have supported the role of childhood maltreatment in the etiology of psychosis, underlying mechanisms have not been well understood yet. The present study aimed to investigate the mediating role of particular forms of dissociation in the relationship between five major types of childhood abuse and psychotic symptoms among patients with schizophrenia spectrum and other psychotic disorders.

METHODS

In this cross-sectional correlation study, 70 first-episode psychotic patients and 70 chronic psychotic patients were selected by systematic random sampling (with the sampling interval of 3) from among inpatients and outpatients referring to Baharan Psychiatric hospital, Zahedan, Iran, and were matched based on age, gender, and education level. Moreover, 70 age-, gender-, and education level-matched community controls were recruited from hospital staff and their relatives and friends. All of the participants completed a research interview and questionnaires. Data on experiences of childhood maltreatment, psychosis, dissociation, and demographics were collected and analyzed by SPSS V25 software.

RESULTS

The obtained results revealed that the mean scores of sexual abuse, emotional abuse, and physical abuse were higher in psychotic patients than community controls (without any significant difference between first-episode psychotic patients and chronic psychotic patients). Furthermore, the highest mean scores of dissociative experiences belonged to chronic psychotic patients. Multiple-mediation also indicated that absorption and dissociative amnesia played a mediating role in the relationship between sexual abuse and positive symptoms. Moreover, this study demonstrated the role of physical abuse in predicting psychotic symptoms even in the absence of sexual abuse.

CONCLUSIONS

This study illustrated specific associations among childhood maltreatment, dissociative experiences, and psychotic symptoms in the clinical population. Thus, to provide appropriate interventions, patients with schizophrenia spectrum and other psychotic disorders were asked about a wide range of possible adverse childhood experiences and dissociative experiences. Nevertheless, further studies using prospective or longitudinal designs need to be carried out to realize the differential contribution of various forms of childhood maltreatment and their potential interactions, more precisely.

Pivotal mental states

This paper introduces a new construct, the 'pivotal mental state', which is defined as a hyper-plastic state aiding rapid and deep learning that can mediate psychological transformation. We believe this new construct bears relevance to a broad range of psychological and psychiatric phenomena. We argue that pivotal mental states serve an important evolutionary function, that is, to aid psychological transformation when actual or perceived environmental pressures demand this. We cite evidence that chronic stress and neurotic traits are primers for a pivotal mental state, whereas acute stress can be a trigger. Inspired by research with serotonin 2A receptor agonist psychedelics, we highlight how activity at this particular receptor can robustly and reliably induce pivotal mental states, but we argue that the capacity for pivotal mental states is an inherent property of the human brain itself. Moreover, we hypothesize that serotonergic psychedelics hijack a system that has evolved to mediate rapid and deep learning when its need is sensed. We cite a breadth of evidences linking stress via a variety of inducers, with an upregulated serotonin 2A receptor system (e.g. upregulated availability of and/or binding to the receptor) and acute stress with 5-HT release, which we argue can activate this primed system to induce a pivotal mental state. The pivotal mental state model is multi-level, linking a specific molecular gateway (increased serotonin 2A receptor signaling) with the inception of a hyper-plastic brain and mind state, enhanced rate of associative learning and the potential mediation of a psychological transformation.

Psychological processes mediating the association between developmental trauma and specific psychotic symptoms in adults: a systematic review and meta-analysis

Experiencing psychological trauma during childhood and/or adolescence is associated with an increased risk of psychosis in adulthood. However, we lack a clear knowledge of how developmental trauma induces vulnerability to psychotic symptoms. Understanding the psychological processes involved in this association is crucial to the development of preventive interventions and improved treatments. We sought to systematically review the literature and combine findings using meta-analytic techniques to establish the potential roles of psychological processes in the associations between developmental trauma and specific psychotic experiences (i.e., hallucinations, delusions and paranoia). Twenty-two studies met our inclusion criteria. We found mediating roles of dissociation, emotional dysregulation and post-traumatic stress disorder (PTSD) symptoms (avoidance, numbing and hyperarousal) between developmental trauma and hallucinations. There was also evidence of a mediating role of negative schemata, i.e. mental constructs of meanings, between developmental trauma and delusions as well as paranoia. Many studies to date have been of poor quality, and the field is limited by mostly cross-sectional research. Our findings suggest that there may be distinct psy-chological pathways from developmental trauma to psychotic phenomena in adulthood. Clinicians should carefully ask people with psychosis about their history of developmental trauma, and screen patients with such a history for dissociation, emotional dysregulation and PTSD symptoms. Well conducted research with prospective designs, including neurocognitive assessment, is required in order to fully understand the biopsychosocial mechanisms underlying the association between developmental trauma and psychosis.

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.

Cognitive and phenomenological characteristics of hallucination-proneness across the lifespan

INTRODUCTION

The impact of age on hallucination-proneness within healthy adult cohorts and its relation to underlying cognitive mechanisms is underexplored. Based on previously researched trends in relation to cognitive ageing, we hypothesised that older and younger adults, when compared to a middle adult age group, would show differential relations between hallucination-proneness and cognitive performance.

METHODS

A mixed methods, between-groups study was conducted with 30 young adults, 26 older adults, and 27 from a "middle adulthood" group. Participants completed a source memory task, jumbled speech task, Launay-Slade hallucination scale, unusual experiences schedule, and control measures of delusion-proneness and attitudes to mental health.

RESULTS

Compared to older age-groups, younger participants demonstrated better scores on the source memory task, and reported hearing more words in jumbled speech. Additionally, younger cohorts rated higher on hallucination-proneness and disclosed more unusual experiences on a customised schedule designed to gather further qualitative data. Jumbled speech scores positively correlated with hallucination-proneness scores, particularly for the "middle" age group. Source memory performance unexpectedly correlated positively with hallucination-proneness, although this may be the product of age differences in task performance.

CONCLUSIONS

Age differences in hallucination-proneness are evident on self-report and cognitive measures. Implications are discussed for potentially non-overlapping cognitive mechanisms underlying hallucination-proneness in non-clinical groups.

The Relationship Between Dissociation and Symptoms of Psychosis: A Meta-analysis

Evidence suggests that dissociation is associated with psychotic experiences, particularly hallucinations, but also other symptoms. However, until now, symptom-specific relationships with dissociation have not been comprehensively synthesized. This is the first prospectively registered (CRD42017058214) meta-analysis to quantify the magnitude of association between dissociative experiences and all symptoms of psychosis. MEDLINE, PsycINFO, PubMed, and Scopus databases were searched using exhaustive terms denoting dissociation and psychotic symptoms. We included both nonclinical (58 studies; 16 557 participants) and clinical (46 studies; 3879 patient participants) samples and evaluated study quality. Ninety-three eligible articles considering 20 436 participants were retained for analysis. There was a robust association between dissociation and clinical and nonclinical positive psychotic symptoms (r = .437; 95%CI: .386 -.486), with the observed effect larger in nonclinical studies. Symptom-specific associations were also evident across clinical and nonclinical studies, and included significant summary effects for hallucinations (r = .461; 95%CI: .386 -.531), delusions (r = .418; 95%CI: .370 -.464), paranoia (r = .447; 95%CI: .393 -.499), and disorganization (r = .346; 95%CI: .249 -.436). Associations with negative symptoms were small and, in some cases, not significant. Overall, these findings confirm that dissociative phenomena are not only robustly related to hallucinations but also to multiple positive symptoms, and less robustly related to negative symptoms. Our findings are consistent with proposals that suggest certain psychotic symptoms might be better conceptualized as dissociative in nature and support the development of interventions targeting dissociation in formulating and treating psychotic experiences.

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

Various psychological and biological pathways have been proposed as mediators between childhood adversity (CA) and psychosis. A systematic review of the evidence in this domain is needed. Our aim is to systematically review the evidence on psychological and biological mediators between CA and psychosis across the psychosis spectrum. This review followed PRISMA guidelines. Articles published between 1979 and July 2019 were identified through a literature search in OVID (PsychINFO, Medline and Embase) and Cochrane Libraries. The evidence by each analysis and each study is presented by group of mediator categories found. The percentage of total effect mediated was calculated. Forty-eight studies were included, 21 in clinical samples and 27 in the general population (GP) with a total of 82 352 subjects from GP and 3189 from clinical studies. The quality of studies was judged as 'fair'. Our results showed (i) solid evidence of mediation between CA and psychosis by negative cognitive schemas about the self, the world and others (NS); by dissociation and other post-traumatic stress disorder symptoms; and through an affective pathway in GP but not in subjects with disorder; (iii) lack of studies exploring biological mediators. We found evidence suggesting that various overlapping and not competing pathways involving post-traumatic and mood symptoms, as well as negative cognitions contribute partially to the link between CA and psychosis. Experiences of CA, along with relevant mediators should be routinely assessed in patients with psychosis. Evidence testing efficacy of interventions targeting such mediators through cognitive behavioural approaches and/or pharmacological means is needed in future.

Understanding individuals' subjective experiences of negative symptoms of schizophrenia: A qualitative study

OBJECTIVES

Individuals with a diagnosis of schizophrenia often experience both positive and negative symptoms. Negative symptoms can be disabling and have a serious impact on everyday functioning. Despite the range of clinician-rated measurement tools used to assess negative symptoms, very little is known about how individuals subjectively experience these symptoms. This study sought to examine, using qualitative methods, how people living with a diagnosis of schizophrenia subjectively experience negative symptoms.

DESIGN

Qualitative study.

METHOD

Semi-structured interviews were carried out with individuals with a diagnosis of schizophrenia who were experiencing negative symptoms. The sample was recruited from community and inpatient National Health Service mental health settings in the United Kingdom. Interviews were analysed using thematic analysis.

RESULTS

Twenty individuals took part. Individuals highlighted the persistent and enduring nature of their negative symptoms. Two central themes were identified: What it is like to experience negative symptoms and where have my negative symptoms come from? Within the first theme, four sub-themes emerged: loss of concentration, loss of motivation, withdrawal, and 'feeling but not feeling'. Within the second theme, four sub-themes emerged related to the causes of negative symptoms: impact of traumatic life events, positive psychotic symptoms, impact of social network, and recreational and prescribed drug use.

CONCLUSION

Individuals, who experience negative symptoms, were able to articulate the persistent and disabling nature of negative symptoms and clearly described factors which they believed contributed to the onset, exacerbation, and amelioration of the experiences.

PRACTITIONER POINTS

Negative symptoms for people diagnosed with schizophrenia are persistent and enduring and impact an individual's life. There has been little research conducted qualitatively on individuals' subjective experiences of negative symptoms. Individuals who experience negative symptoms attribute these to a number of factors, including adverse life events, recreational and prescribed drug use, an absence of social support, and positive psychotic symptoms. Understanding negative symptoms is important for services, clinicians, and family members, where misattributions made about negative symptoms can lead to such experiences being dismissed.

An integrative framework for perceptual disturbances in psychosis

Perceptual disturbances in psychosis, such as auditory verbal hallucinations, are associated with increased baseline activity in the associative auditory cortex and increased dopamine transmission in the associative striatum. Perceptual disturbances are also associated with perceptual biases that suggest increased reliance on prior expectations. We review theoretical models of perceptual inference and key supporting physiological evidence, as well as the anatomy of associative cortico-striatal loops that may be relevant to auditory perceptual inference. Integrating recent findings, we outline a working framework that bridges neurobiology and the phenomenology of perceptual disturbances via theoretical models of perceptual inference.

Pareidolia-proneness, reality discrimination errors, and visual hallucination-like experiences in a non-clinical sample

Introduction: It has been proposed that hallucinations occur because of problems with reality discrimination (when internal, self-generated cognitions are misattributed to an external, non-self source) and because of elevated levels of top-down processing. In this study, we examined whether visual reality discrimination abilities and elevated top-down processing (assessed via face pareidolia-proneness) were associated with how often non-clinical participants report visual hallucination-like experiences.Methods: Participants (N = 82, mean age = 23.12 years) completed a visual reality discrimination task and a face pareidolia task, as well as self-report measures of schizotypy and of the frequency of visual hallucination-like experiences.Results: Regression analysis demonstrated that the number of false alarms made on the visual reality discrimination task and the number of hits made on the face pareidolia task were independent predictors of the frequency of visual hallucination-like experiences. Correlations between performance on the tasks and levels of schizotypy were not statistically significant.Conclusions: These findings suggest that weaker visual reality discrimination abilities and elevated levels of top-down processing are associated with visual hallucination-proneness and are discussed in terms of the idea that clinical visual hallucinations and non-clinical visual hallucination-like experiences share similar cognitive mechanisms.

Assessing Voice Hearing in Trauma Spectrum Disorders: A Comparison of Two Measures and a Review of the Literature

Voice hearing (VH) can occur in trauma spectrum disorders (TSD) such as posttraumatic stress disorder (PTSD) and dissociative disorders. However, previous estimates of VH among individuals with TSD vary widely. In this study, we sought to better characterize the rate and phenomenology of VH in a sample of 70 women with TSD related to childhood abuse who were receiving care in a specialized trauma program. We compared the rate of VH within our sample using two different measures: 1) the auditory hallucination (AH) item in the Structured Clinical Interview for DSM-IV-TR (SCID), and 2) the thirteen questions involving VH in the Multidimensional Inventory of Dissociation (MID), a self-report questionnaire that comprehensively assesses pathological dissociation. We found that 45.7% of our sample met threshold for SCID AH, while 91.4% met criteria for MID VH. Receiver operating characteristics (ROC) analyses showed that while SCID AH and MID VH items have greater than chance agreement, the strength of agreement is only moderate, suggesting that SCID and MID VH items measure related but not identical constructs. Thirty-two patients met criteria for both SCID AH and at least one MID VH item ("unequivocal VH"), 32 for at least one MID VH item but not SCID AH ("ambiguous VH"), and 6 met criteria for neither ("unequivocal non-VH"). Relative to the ambiguous VH group, the unequivocal VH group had higher dissociation scores for child voices, and higher mean frequencies for child voices and Schneiderian voices. Our findings suggest that VH in women with TSD related to childhood abuse is common, but that the rate of VH depends on how the question is asked. We review prior studies examining AH and/or VH in TSD, focusing on the measures used to ascertain these experiences, and conclude that our two estimates are consistent with previous studies that used comparable instruments and patient samples. Our results add to growing evidence that VH-an experience typically considered psychotic or psychotic-like-is not equivalent to having a psychotic disorder. Instruments that assess VH apart from psychotic disorders and that capture their multidimensional nature may improve identification of VH, especially among patients with non-psychotic disorders.

Oligodendrocytes as A New Therapeutic Target in Schizophrenia: From Histopathological Findings to Neuron-Oligodendrocyte Interaction

Imaging and postmortem studies have revealed disturbed oligodendroglia-related processes in patients with schizophrenia and provided much evidence for disturbed myelination, irregular gene expression, and altered numbers of oligodendrocytes in the brains of schizophrenia patients. Oligodendrocyte deficits in schizophrenia might be a result of failed maturation and disturbed regeneration and may underlie the cognitive deficits of the disease, which are strongly associated with impaired long-term outcome. Cognition depends on the coordinated activity of neurons and interneurons and intact connectivity. Oligodendrocyte precursors form a synaptic network with parvalbuminergic interneurons, and disturbed crosstalk between these cells may be a cellular basis of pathology in schizophrenia. However, very little is known about the exact axon-glial cellular and molecular processes that may be disturbed in schizophrenia. Until now, investigations were restricted to peripheral tissues, such as blood, correlative imaging studies, genetics, and molecular and histological analyses of postmortem brain samples. The advent of human-induced pluripotent stem cells (hiPSCs) will enable functional analysis in patient-derived living cells and holds great potential for understanding the molecular mechanisms of disturbed oligodendroglial function in schizophrenia. Targeting such mechanisms may contribute to new treatment strategies for previously treatment-resistant cognitive symptoms.

Affective and cognitive factors associated with hallucination proneness in the general population: the role of shame and trauma-related intrusions

Introduction: Feelings of shame may be an important factor implicated in the onset and maintenance of hallucination (or hearing voices). Shame has been shown to increase trauma-related intrusions and avoidance and may reinforce negative beliefs about the self, which in turn may contribute to hallucinations in clinical and non-clinical populations. To our knowledge, no study has so far explored the role of shame in hallucination-proneness. Therefore, the main goal of the present study is to explore the mediation role of shame, trauma-related intrusions and avoidance in the association between childhood trauma and hallucination-proneness.Methods: Self-report questionnaires were used to assess past traumatic experiences, trauma-related symptoms, shame, and hallucination proneness in 175 participants from the general population.Results: Mediation analyses (joint-significance test and Monte Carlo test) showed that both shame and intrusions mediated the association between childhood trauma and hallucination-proneness.Conclusions: Our results reinforce the importance of considering previous experiences of trauma and trauma-related symptoms, including feelings of shame in individuals experiencing hallucinations. Moreover, this study reinforces previous studies showing some preliminary evidence that compassion-focused therapy, whose primary goal is to reduce shame by increasing self-compassion, could have a significant effect on voices whose content is hostile.

Clinical and non-clinical hallucinations are similarly associated with source memory errors in a visual memory task

Hallucinations have been found to be associated with various types of source memory failure in both schizophrenia patients and hallucination-prone healthy individuals. We investigated the associations of clinical and non-clinical hallucinations with source memory errors in a visual memory task that involved the remembering of picture presentation context. 59 schizophrenia patients and 61 healthy individuals took part in the study. Pictures were presented either at different locations or in association with different visual stimuli. The participants were required afterwards to recognize the target pictures among distractors, and then to remember their spatial location or the visual stimulus that was associated with them. Liberal response bias in picture recognition was associated with hallucination proneness and auditory-verbal hallucinations in subsamples of participants with significant non-clinical or clinical hallucinations. After controlling for overall memory performance, failure to remember the spatial location of the pictures was associated with visual hallucinations in male patients; failure to remember the associated visual stimulus was related to auditory-verbal hallucinations in female patients and to hallucination proneness in healthy women. The findings suggest that both clinical and non-clinical hallucinations are associated with loss of contextual information relative to the acquisition of events.

Childhood maltreatment and treatment outcome in psychotic disorders: a systematic review and meta-analysis

OBJECTIVE

Childhood maltreatment (CM) plays an important role in the aetiology and course of psychotic disorders and is associated with characteristics that could be relevant for treatment. We aimed to conduct a systematic review and meta-analysis on the association between CM and treatment outcome in psychotic disorders.

METHODS

Treatment outcome was defined as change in psychotic symptoms or in social or occupational functioning between first and last reported measurement in the course of a pharmacological and/or psychological treatment.

RESULTS

Twelve treatment results from seven studies (636 patients, average treatment duration: 59.2 weeks) were included. CM was related to poorer treatment outcomes in psychotic disorders (OR = 1.51, 95% CI = [1.08, 2.10]). There is evidence that this association might increase with illness duration and increasing age and might be stronger in schizophrenia samples.

CONCLUSIONS

Childhood maltreatment is highly understudied with regard to treatment outcome in psychotic disorders. The need for more studies is emphasized by the fact that this meta-analysis reveals evidence for a poorer treatment response in patients with CM. If this association is confirmed, the identification of patients with CM and the consideration of associated clinical and biological conditions could contribute to improve treatment outcome in psychotic disorders.