The relationship between childhood trauma and later development of psychotic symptoms has received increasing attention in recent years. A new study published in Schizophrenia Bulletin Open examines this relationship further, specifically looking at cases of schizophrenia that are treatment-resistant. The authors found a correlation between childhood adversity and psychotic symptoms, especially hallucinations. They recommend that treatment for psychosis, which traditionally has avoided trauma-related work, incorporate approaches that directly address traumatic experiences.
The authors, led by Robert Dudley of the Early Intervention Psychosis Service, NHS Foundation Trust, and University of York, write:
“Early adversity such as childhood neglect (CN) or abuse is associated with an increased risk of a range of mental health issues including psychosis… early adversity was strongly associated with increased risk for psychosis and that people with schizophrenia are 2.72 times more likely to have experienced adverse childhood events than healthy individuals. Evidence supports a causal role as longitudinal studies indicate early adversity precedes the onset of psychosis.”
Childhood experiences of abuse and neglect have been shown to lead to increased risk for later development of psychotic symptoms, which can include “positive” symptoms, such as hallucinations and delusions, and “negative” symptoms, such as lack of emotional expression.
Existing research has shown that individuals experiencing psychosis with histories of childhood maltreatment are more likely to experience severe symptoms that are not responsive to medications or therapies. Psychiatric literature refers to these forms of psychosis as “Treatment Resistant Schizophrenia” (TRS) or “Treatment Resistant Psychosis” (TRP). They are defined in terms of lack of responsiveness to at least two forms of antipsychotic medication, with the atypical antipsychotic drug clozapine being offered as a last resort due to its potentially dangerous side effects.
Research literature interested in cognitive understandings of psychosis has also investigated the role that negative beliefs about self and others brought on by childhood adversity play in the development of symptoms such as paranoia and delusions. While some have found relationships between negative beliefs about self and others, childhood abuse and neglect, and paranoia or other psychotic symptoms later in life, the research findings so far have been inconsistent.
In an attempt to further the research base on the correlations between psychosis, childhood adversity, and negative beliefs, Dudley and colleagues collected data from 292 participants who were part of a larger trial aimed at assessing the efficacy of cognitive behavioral therapy (CBT) for Clozapine-Resistant Schizophrenia (CRS). The majority of participants were white (90%), male (approximately 72%), unemployed (83%), had a diagnosis of schizophrenia (87%), and 90% were prescribed clozapine.
The researchers used a variety of questionnaires and rating scales to gather information on participants’ experiences of childhood adversity, psychotic symptoms, and core beliefs about self and others. Then, they conducted statistical analyses to examine their data.
Dudley and colleagues found that the level of abuse and neglect endorsed by the participants was similar to levels reported in other research involving psychosis and childhood trauma, providing additional support for the connections between childhood trauma and later development of psychosis. Consistent with the research literature, female participants reported high levels of severe sexual and emotional abuse.
Overall, adversity was found to be related to higher levels of psychotic symptoms across the board. Looking closer, positive symptoms, such as hallucinations, were found to be more influenced by past experiences of childhood adversity. Researchers also found a relationship between childhood abuse and neglect and negative beliefs about self and others. Although most of the relationships found by researchers were modest correlations, their findings are broadly consistent with other research that has found that childhood trauma can lead to individuals with psychosis experiencing distressing symptoms.
Given the support for the relationship between childhood adversity and later development of treatment-resistant psychotic symptoms, Dudley and colleagues conclude by recommending that further exploration into the use of trauma-focused therapies, such as Eye Movement Desensitization and Reprocessing (EMDR), in the treatment of psychosis to address the underlying issues of trauma that contribute to it. Another recent study also arrived at similar conclusions, pointing to how trauma therapies, including EMDR, can be effectively used in the treatment of psychosis.
Limitations of the study include a lack of information regarding the specifics of the traumas experienced, such as nature, duration, and frequency, as well as how participants perceived the impact of trauma on their lives. Additionally, the sample consisted of predominantly white men, leading to questions about whether the results would be generalizable to other populations.
Further research involving more diverse populations, especially people of color, is necessary, especially given the impact that oppression and marginalization have been shown to have on the development and treatment of psychosis. Research elsewhere has pointed to the role that racism and structural inequalities play in the development and increased risk of psychosis, as well as how these systemic inequalities negatively affect psychosis treatment itself.
Current understandings of psychosis rely heavily on a biological model, which emphasizes brain and genetic-based understandings of psychosis and its symptoms. However, it has been critiqued for explaining very little about how a person comes to develop schizophrenia. Additionally, a recent study found that genetic risk for the development of schizophrenia becomes less important as more traumatic events are experienced, contradicting the diathesis-stress model, which assumes that genetic risk plus traumatic events can lead to psychosis.
The pushback and mounting research evidence against biological models of understanding has paved the way for alternative, less pathologizing ways of understanding psychosis through a recognition that experiences of psychosis are nuanced and vary for each individual. Others have urged for non-pathologizing and interdisciplinary approaches to understanding psychosis, and peer support groups such as Hearing Voices have been shown to hold many benefits, including fostering human connection and respecting lived experience.
Dudley and colleagues, alongside others, contribute to this growing and important body of work by providing further research support for the recognition of the role trauma plays in the development of psychosis, which allows for increased movement away from biological understandings.
Dudley, R., Turkington, D., Coulthard, N., Pyle, M., Gumley, A., Schwannauer, M., Kingdon, D., Morrison, A. P. (2023). Childhood trauma in clozapine-resistant schizophrenia: Prevalence, and relationship with symptoms. Schizophrenia Bulletin Open, 4(1). https://doi.org/10.1093/schizbullopen/sgad030 (Link)