psychosis and developmental trauma

people with psychosis die earlier than those who do not have psychosis

• true

• death 20 years earlier

• life-limiting diagnosis

• huge progress in other disorders and illnesses

why may someone with psychosis have a lower life expectancy?q

• suicide

• cardiovascular disease and other comorbid physical health problems

• shared risk factors with psychosis: e.g. SE deprivation

• increased rates of health-damaging behaviour

• state of psychosis itself is very stressful and traumatic, and places strain on the body

what characterises schizophrenia spectrum disorders?

fundamental and characteristic distortions of thinking, perceptions and affect

what are the key symptoms of psychosis in schizophrenia?

• thought interference and sonorisation (thoughts being heard out loud)

• 3rd person hallucinatory voices

• passivity (somebody is controlling thoughts or actions)

• thought disorder

• negative symptoms

what are the characteristics of paranoid schizophrenia?

• clinical triad of paranoia (feeling very threatened, others are actively trying to harm me)

• delusions: beliefs held despite contrary evidence

• hallucinations

  • can be very negative content, distracting

how may hallucinations and delusions arise after trauma?

experience of childhood trauma alters the ability to tell what is coming from inside and outside the mind

what was hysteria characterised as in the past?

mix of medically unexplained physical symptoms and high levels of anxiety

the association between early life experiences and MHDs have been identified historically

• true

• Dr. Pierre Janet proposed that early life experiences were contributing to this (around the time of Freud)

• Freud: advanced the idea that sexual trauma can contribute to mental disorders in adulthood

• Ferenczi: first to suggest psychosis and sexual abuse are related

what do psychoanalytic theories suggest about the intrapsychic processes occuring between trauma and psychosis?

there may be a deficit in telling between reality and unconscious fantasy that occurs in psychosis

what do French psychoanalytic theories suggest about the intrapsychic processes occuring between trauma and psychosis?

psychosis results from a deficit in ability to learn how to symbolise

what do British psychoanalytic theories suggest about the interpsychic processes occuring between trauma and psychosis?

• there is a disruption in the connection between infant and mother in terms of the info flowing between them

• when the parent is abusive or neglectful, they respond to the infant with punishment or ignorance

what is the impact of developmental trauma on psychosis?

• more severe psychosis

• lowered response to standard treatments

• more hospital readmissions

• less engagement with services

• 30% of psychosis cases are attributable to developmental trauma

what percentage of psychosis cases can be attributed to developmental trauma?

30%

developmental trauma

• trauma during childhood and adolescence

• includes all forms of childhood abuse

• can be perpetrated by primary caregiver or family members

does developmental trauma fit the Bradford-Hill criteria for medical causation?

meets criteria for

• strength of association: strong association

• consistency: consistently found

• temporality: recent psychotic experiences can be predicted by preceding trauma exposure, stopping trauma reduces symptoms

• dose-response effects: more severe psychotic syptoms in prospective studies and poorer treatment response

• plausibility: biologically plausible

• coherence: association between childhood trauma and psychosis remains while controlling confounds and reverse causality

developmental trauma does not impact neurocognitive processes

• false

• developmental trauma impacts a range of neurocognitive processes in a way that produces underlying latent vulnerability to psychopathology

• there is evidence that experiencing childhood trauma alters brain connectivity, and this may relate to vulnerability to psychosis

there is high vulnerability during adolescence in hippocampal volume

• false

• there is high vulnerability during early life and adolescence

there is high vulnerability during adolescence in right amygdala grey matter volume

• true

• from 11-13 years old

there is high vulnerability during early childhood in PFC grey matter volume

• false

• high vulnerability during adolescence

what specific alterations are found in neurocognitive processing in individuals with psychosis?

• altered amygdala response during threat processing

• ACC hyperactivation during emotion regulation and executive functioning

• blunted striatal response during reward processing

the pathway from developmental trauma to psychosis is mediated by dopamine

• true

• dopamine is involved in psychosis and affected by developmental trauma

how does psychosis arise from developmental trauma?

• combined genetic vulnerability and developmental trauma leads to sensitisation to dopamine system → dopamine responds to both reward AND threat

• sociodevelopmental adversity on its own leads to biased cognitive schema, but is accelerated via dopamine sensitisation

summarise how acute psychosocial stress leads to psychosis

• psychosocial stress, more dopamine than normal

• information processing is biased

• paranoid interpretation is more readily accessible, leading to psychosis

• psychosis then leads to more psychosocial stress

how does stress relate to psychosis?

corticotropin releasing factor (HPA axis: stress response system) binds to dopaminergic neurons, modulating release of dopamine during threat in the ventral tegmental area

how does dopamine relate to trauma processing?

• the VTA is in the brainstem, where dopamine projections come from

• dopamine projections reach areas involved in trauma processing

  • amydala

  • PFC

  • hippocampus

when restrained, the animal experiences stress, dopamine is released and comes down again

• true

• dopamine has been found to become elevated in response to aversive stimuli such as restraint and pain (at least in animals)

how does dopamine alter long term potentiation?

• dopamine interacts with glutamate and GABA systems (neuromodulation: longer term effect of dopamine)

• dopamine has both immediate and long term neuromodulatory effect

• prediction errors are also dopamine activity dependent

when is there an update in prediction?

• when there is a mismatch prediction and experience

• this is the neurochemical basis of learning

• if this process is perturbed, there may be aberrant predictions of the outside world that do not match with reality

if there is a perterbation of learning processes, your learning would cease to match reality

• true

• if this process is perturbed, there may be aberrant predictions of the outside world that do not match with reality

there are different levels of hierarchy in information processing

• true

• different levels of hierarchy in information processing

• highest hierarchy can be considered to be schema

according to animal models, adolescent stress exposure leads to changes in dopaminergic function in adulthood

• true

• developmental stress can result in long term increases in dopaminergic function persisting into adulthood

• combination of footshock and restraint stress yielded long term changes

MAM developmental model of schizophrenia

• animal model of schizophrenia: developmental disruption model

• displays a number of histological, neurophysiological and behavioral deficits observed in schizophrenia patients

• increased sensitivity to stress during early development

there is lowered dopamine synthesis after childhood adversity in humans

• true

• there is a dampening of biological stress response

• there is lowered dopamine synthesis after high levels of adversity experience although there are high levels of threat experience/distress

• these individuals do not have psychosis, however

people with childhood trauma more readily release dopamine

• true

• greater dopamine release in response to amphetamine in those with childhood trauma

• also relates to positive symptom scores

a recent systematic review has found that there are many pathways from developmental trauma to psychotic experiences

• true

• pathways include:

  • dissociation

  • OCD-like phenomena

  • PTSD symptoms

  • emotional dysregulation

  • schemata and belief systems

  • attachment and social cognition

what factors mediate the relationship between developmental trauma and hallucinations?

• dissociative processes

• OCD-like phenomena

• PTSD symptoms

what factors mediate the relationship between developmental trauma and delusions?

• PTSD symptoms

• emotional regulation

• schemata and belief systems

what factors mediate the relationship between developmental trauma and paranoia?

• schemata and belief systems

• attachment and social cognition

what has meta-analytic findings shown about how much dissociation, emotional dysregulation, and PTSD symptoms contribute to hallucinations?

• dissociation: ES 0.35

• emotional dysregulation: ES 0.06

• PTSD symptoms: ES 0.12

what mediator of developmental trauma contributes highest to hallucinations?

dissociation

people with psychological trauma + psychosis have higher cortical thickness and hippocampal volume

• false

• people with psychological trauma + psychosis have lower cortical thickness and hippocampal volume

there are differences in clinical presentation between people with and without childhood trauma

• true

• more severe symptoms and links between hallucination content and trauma memory in pw psychosis + childhood trauma

how may trauma memories manifest in hallucinations in pw psychosis + trauma?

• auditory memories of trauma experiences

• voices relating to the perpetrator

• schematised negative content

• increased fear in response to voice

what do intervention studies of adult survivors of developmental trauma with psychotic and dissociative symptoms suggest are the mechanisms between developmental trauma and psychosis?

• emotional regulation

• attachment and social cognition

• memory processing

• dissociation e.g. ego disintegration

there are high rates of undetected PTSD in people with psychosis

• true

• around a third of pw psychosis have undetected PTSD

• high rates of undetected PTSD across conditions

schizotypy

traits that predispose to psychosis

schizotypy is not a vulnerability factor for trauma memory intrusions

• false

• schizotypy (proneness to psychosis) is a vulnerability factor for intrusive trauma memories

what does the cognitive behavioural model of psychosis suggest about the role of developmental trauma in psychosis?

there is an interaction between:

• underlying vulnerability

• the ways memories are processed

• how they are appraised and coped with

what are the rates of CPTSD in pw schizophrenia + developmental trauma?

• 70%

• meeting CPTSD predicted psychosis in individuals experienced childhood trauma

there are high rates of CPTSD in pw schizophrenia and no developmental trauma

• false

• rates of CPTSD are very low in pw schizophrenia without DT

what are the potential mechanisms of how developmental trauma contributes to psychosis?

• brain structure changes

• dopamine system changes

• hierarchical predictive coding changes

• memory processing changes

• social cognition and attachment changes

• mentalisation changes and dissociation

what are important social factors in psychosis?

• social isolation

• high stigma and marginalisation

• re-traumatisation from psychotic symptoms

• re-traumatisation by compulsory treatments