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April 2017 | Volume 8 | Article 571
ORIGINAL RESEARCH
published: 19 April 2017
doi: 10.3389/fpsyt.2017.00057
Frontiers in Psychiatry | www.frontiersin.org
Edited by:
Kate Hardy,
Stanford University, USA
Reviewed by:
Timo Partonen,
National Institute for Health and
Welfare, Finland
Sérgio Saraiva,
Centro Hospitalar Psiquiátrico de
Lisboa, Portugal
*Correspondence:
Cherise Rosen
crosen@psych.uic.edu
†Co-rst author.
Specialty section:
This article was submitted
to Psychopathology,
a section of the journal
Frontiers in Psychiatry
Received: 14October2016
Accepted: 29March2017
Published: 19April2017
Citation:
RosenC, JonesN, LongdenE,
ChaseKA, ShattellM, MelbourneJK,
KeedySK and SharmaRP (2017)
Exploring the Intersections of Trauma,
Structural Adversity,
and Psychosis among a Primarily
African-American Sample:
AMixed-Methods Analysis.
Front. Psychiatry 8:57.
doi: 10.3389/fpsyt.2017.00057
Exploring the Intersections of
Trauma, Structural Adversity,
and Psychosis among a Primarily
African-American Sample:
A Mixed-Methods Analysis
Cherise Rosen1*†, Nev Jones2†, Eleanor Longden3, Kayla A. Chase4, Mona Shattell5,
Jennifer K. Melbourne1, Sarah K. Keedy6 and Rajiv P. Sharma1,7
1 Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA, 2 Felton Institute, San Francisco, CA, USA,
3 Greater Manchester West Mental Health NHS Foundation Trust, Psychosis Research Unit, Manchester, UK, 4 Department of
Psychiatry, University of California San Diego, La Jolla, CA, USA, 5 Department of Community, Systems, and Mental Health
Nursing, Rush University, Chicago, IL, USA, 6 Department of Psychiatry, University of Chicago, Chicago, IL, USA,
7 Department of Psychiatry, JesseBrown Veterans Affairs Medical Center, Chicago, IL, USA
Traumatic life events (TLEs) have been associated with multiple psychiatric diagnoses,
including anxiety disorders, major depression, PTSD, and psychosis. To advance our
understanding of the complex interactions between forms of adversity as they manifest
across the lifespan, psychosis, and symptom content, we undertook a mixed-methods
investigation of TLEs and psychosis. Our research explored the association between
cumulative exposures, type of TLE, and proximity to the traumatic event and psychosis;
the association between TLEs and clinical symptomology including specic types of
delusions and/or hallucinations; and how qualitative data further inform understanding
of complex relationships and patterns of past trauma and symptoms as they unfold
over time. There were a total of 97 participants in the quantitative study sample, 51
participants with present state psychosis and 46 non-clinical. There were a total of 34
qualitative study participants, all of whom were experiencing psychosis. The quantitative
analysis showed that when comparing persons with psychosis to the non-clinical group,
there were no group differences in the overall total score of TLEs. However, there was
a signicant difference in cumulative TLEs that “Happened,” demonstrating that as the
number of TLEs increased, the likelihood of clinical psychosis also increased. We also
found a correlation between lifetime cumulative TLEs that “Happened” and PANSS
ve-factor analysis: positive, excitement, depression, thought disorder, activation, and
paranoia scores. The qualitative analysis further built on these nding by providing rich
narratives regarding the timing of trauma-related onset, relationships between trauma
and both trauma-related and religious–spiritual content, and trauma and hallucinatory
modality. Analysis of participant narratives suggests the central role of localized cultural
and sociopolitical inuences on onset, phenomenology, and coping and contributes to a
growing literature calling for strengths-based, client-driven approaches to working with
distressing voices and beliefs that centers the exploration of the personal and social
meaning of such experiences including links to life narratives. Findings also underscore
the clinical importance of trauma assessment and trauma-informed care.
Keywords: psychosis, traumatic life events, delusions, hallucinations, mixed methods
2
Rosen et al. Intersections of Trauma, Structural Adversity, and Psychosis
Frontiers in Psychiatry | www.frontiersin.org April 2017 | Volume 8 | Article 57
INTRODUCTION
Traumatic life events (TLEs) have been associated with multiple
psychiatric diagnoses, including anxiety disorders, major depres-
sion, PTSD, and psychosis (1–3). In a recent epidemiological
study, the World Mental Health Survey Consortium found that
over 70% of respondents in the general population endorsed
exposure to at least one TLE, while 30.5% endorsed four or
more lifetime exposures to TLEs (4). Recent meta-analyses have
found that persons with TLE exposure are three times more
likely to experience psychosis than persons with no past trauma
(2) and that TLEs signicantly increase the risk for subclinical
psychosis (5).
In addition to research linking trauma to psychosis, multiple
studies have examined the associations between traumatic
experiences and specic symptom domains, including auditory
hallucinations (voices), paranoia and delusions (6, 7), as well as
non-auditory hallucinations (8, 9). Links between trauma and
auditory hallucinations (and to a lesser extent other psychotic
symptoms) have also been investigated in combat and non-com-
bat-related PTSD (10–12), borderline personality disorder (13),
and dissociative identity disorder (14). Several studies have also
sought to unpack the relationship between past trauma exposure
and the content of delusions and hallucinations, consistently nd-
ing strong direct and/or indirect links between dominant content,
themes, and past experiences of adversity (15–18). Structural and
community adversity, including migration and ethnic density, are
also signicant risk factors for psychosis (19, 20).
In spite of a large body of research linking TLEs to psychosis
and specic symptom domains, mechanisms of action and the
interrelationships between multiple social and environmental
risk factors are still not well understood (17, 21–23). Childhood
adversity, as well as broader lifetime trauma, tends to be
correlated with additional environmental factors, including
prenatal insults [such as alcohol exposure during gestation
(24), poverty/structural adversity1, and personal substance
use (25)]. Muenzenmaier etal. (26), have described “complex
trauma reactions” triggered by cumulative social adversities
and TLEs leading to a broad range of presenting psychotic or
psychotic-like symptoms, including dissociation, ashbacks,
hallucinations, and paranoid ideation. Recent debates have
centered on the dierences and overlap between dissociative
phenomena, including hallucinations, and psychotic symptoms
as they manifest across traditional diagnostic boundaries [e.g.,
Ref. (15, 27, 28)].
While a number of studies have investigated the role of
migration, far fewer have addressed the relationship between
race, non-migration-related racism, trauma, and psychosis (29)
and found that dissociation only fully mediated the relation-
ship between trauma and psychotic experiences for African-
American (not Hispanic or Asian) young adults; while another
investigation found that rates of adversity were substantially
higher among ethnic minority participants with psychosis
1 Jones N, Godzikovskaya J, Zhao Z, Vasquez A, Davidson L. Intersecting disad-
vantage: unpacking sub-optimal outcomes within early intervention in psychosis
services. Early Interv Psychiatry (under review).
and that adversity partially mediated the relationship between
ethnicity and psychosis (30). A recent set of analyses utilizing
the National Survey of American Life found that multiple types
of adversity increased psychosis risk in African-Americans,
including neighborhood diculties and lack of quality edu-
cational options (31). To our knowledge, no previous qualita-
tive studies have explored the intersections between trauma,
psychosis, and symptom content among African-Americans in
the US, although historical and ethnographic work has drawn
attention to signicant disparities in diagnosis, treatment, and
social responses [e.g., Ref. (32, 33)].
To advance our understanding of the complex interactions
between forms of adversity as they manifest across the lifespan,
psychosis, and symptom content, we undertook a mixed-methods
investigation of TLEs and psychosis. Coding and analysis of a
separate qualitative sample followed initial analyses of a quantita-
tive sample. A majority of participants were African-Americans,
and the qualitative analyses explicitly focused on the experiences
of African-Americans participants. Our research questions were
as follows:
(1) Is there an association between cumulative exposure, type of
TLE, proximity to the traumatic event, and psychosis?
(2) Is there an association between TLEs and clinical sympto-
mology including specic types of delusions and/or hal-
lucinations and in what ways are trauma and past adversity
reected in the form and content of participant’s symptoms?
(3) How does qualitative data further inform our understand-
ing of the complex relationships and patterns of past trauma
and adversity and symptoms as they unfold over time?
MATERIALS AND METHODS
is study reports the analyses from a novel mixed-methods
investigation into the intercept of TLEs and psychosis. e rst
set of analyses (n=97) focuses on quantitative data from a sample
of individuals with and without psychotic disorders recruited
from a large urban university medical center, private referrals,
and community treatment facilities from January 2013 through
January 2015 in Chicago, IL, USA. Participants were recruited
using yers and direct communication with clinical sta regard-
ing study information from a convenience sample. Participants in
the quantitative arm of the study were administered standardized
measures that are described in detail in Section “Measures Used
to Assess Psychosis and TLEs in the Quantitative Sample.”
e second set of analyses (n=34) focuses on a set of indi-
vidual interviews (n= 10) and group interviews (n= 24; two
focus groups) conducted with individuals reporting experiences
of psychosis. e majority of these participants were recruited
from a public mental health agency, which serves individuals
with serious mental illness and signicant, established disability
also located in Chicago, Illinois during the same time period.
Researchers queried participants about the circumstances sur-
rounding the onset of psychosis; their understanding of the
causes and origins of their experiences; and the content, develop-
ment, and phenomenology of positive symptoms, including the
characterological qualities of any voices.
TABLE 1 | Demographic characteristics of quantitative sample.
Demographic
measure
Schizophrenia
(n=35)
Bipolar
disorder with
psychosis
(n=16)
Non-clinical
control
(n=46)
p Value
Sex (male/female) 19/16 7/9 16/30 n.s.
Race 0.02*
African-American 26 13 20
Caucasian 3 3 11
Hispanic 4 0 5
Other 2 0 10
Mean SD Mean SD Mean SD p Value
Current age 42 12.31 47 12.19 38 12.27 0.04*
n.s., not signicant.
*p<0.05.
TABLE 2 | Demographic characteristics of qualitative sample.
Demographic measure Focus groups
percent (n)
Individual interviews
percent (n)
Sex (male/female) 16/8 4/6
Race
African-American 18 5
Caucasian 2 3
Hispanic 2 0
Other/mixed 2 2
Mean Mean
Current age 41.4 49.1
3
Rosen et al. Intersections of Trauma, Structural Adversity, and Psychosis
Frontiers in Psychiatry | www.frontiersin.org April 2017 | Volume 8 | Article 57
Qualitative interviews and focus groups employed broad,
open-ended questions regarding the onset of psychosis or voices;
psychosocial context preceding onset; and current symptoms,
symptom content, and treatment experiences. Formal diagnostic
instruments were intentionally avoided to avoid “clinicalizing”
the interviews, and so diagnosis was only recorded through
self-report. Background information on past trauma was col-
lected with the demographics. Qualitative data were analyzed
using a grounded theory approach (34), which involves focused
interview sampling, transcription and summary, coding of data,
development of conceptual categories, analytic memoing, and
summary of emerging constructs.
Participants
ere were a total of 97 participants in the quantitative study
sample, of whom 51 reported present state psychosis consisting
of 35 (36%) persons diagnosed with schizophrenia and 16 (17%)
diagnosed with bipolar disorder with psychotic features, per
consensus diagnosis. Consensus diagnosis was determined by
reviewing all research data and collateral information by the study
personnel that included an Attending Physician, Psychologists,
and a Mental Health Nurse Practitioner. Inclusion criteria for
the study included participants between the ages of 21 and 60.
e clinical sample must have met criteria for schizophrenia or
bipolar disorder/psychosis. A group of 46 (47%) non-clinical
controls, with no history of DSM-IV-TR Axis 1 diagnosis per
the SCID, were also recruited. Exclusion criteria for both groups
included current substance dependence, seizure disorders, and
neurological conditions. All participants, clinical and non-clin-
ical, were reimbursed equally for their time and transportation.
Demographic characteristics for the sample (Ta b l e 1 ) and clinical
metrics were obtained at the study evaluation.
ere were a total of 34 qualitative study participants, all
of whom reported either schizophrenia spectrum diagnosis
or bipolar disorder with psychotic features. e majority also
reported past or comorbid diagnoses of PTSD, dissociative
identity disorder, anxiety disorders, and/or major depression.
All participants described current hallucinations and/or delu-
sions during interviews and groups. Demographics are listed in
Ta b l e 2 . e majority of participants were African-Americans
(23/34; 68%). All participants signed consent forms and agreed to
be audiotaped for research purposes. Interviews and focus groups
lasted from 1.5 to 3h and were led by an interviewer–facilitator
with personal experience of psychosis, which was intentionally
disclosed as a part of the interview process.
Measures Used to Assess Psychosis and
TLEs in the Quantitative Sample
Multiple clinical measures were employed to examine the rela-
tionship between TLEs and psychosis. e evaluation of forms of
delusions and hallucination was based on the SCID and scored
for lifetime exposure as absent (score of “1”), subthreshold (“2”),
and threshold or present (“3”). e SCID includes an assessment
of forms of delusions (referential, persecutory, grandiose, somatic,
religious, guilt, jealous, erotomanic, control, thought insertion,
thought withdrawal, and thought broadcasting) and hallucina-
tions (auditory, visual, tactile, gustatory, and olfactory) (35).
e Life Events Checklist consists of 17 items that measure
exposure to various TLEs (36). e items consisted of exposure
to (1) natural disaster, (2) re or explosion, (3) transportation
accident, (4) serious physical accident, (5) exposure to toxic sub-
stance, (6) physical assault, (7) assault with a weapon, (8) sexual
assault, (9) other unwanted or uncomfortable sexual experiences,
(10) combat or exposure to a war zone, (11) captivity, (12) life-
threatening illness or injury, (13) severe human suering, (14)
sudden violent death, (15) sudden unexpected death of someone
close, (16) serious injury, and (17) harm or death you caused to
someone else or any other very stressful event. For each event,
participants were asked to select one or more event by checking
all that applied along the following continuum: (a) happened to
me, (b) witnessed it, (c) learned about it, (d) not sure, and (e)
doesn’t apply.
e PANSS was scored along a continuum of severity between
one (asymptomatic) to seven (extreme symptom severity).
Analysis was conducted via data reduction strategies guided
by prior empirical studies of symptom domains assessed by
the PANSS (37). Scores were calculated for ve factors: positive
symptoms (delusions, grandiosity, suspiciousness/persecution,
and unusual thought content), negative symptoms (blunted
aect, emotional withdrawal, poor rapport, passive/apathetic
social withdrawal, lack of spontaneity and ow of conversation,
and active social avoidance), cognitive disorganization (concep-
tual disorganization, diculty in abstract thinking, mannerisms
and posturing, disorientation, and poor attention), excitement
(excitement, hostility, tension, and poor impulse control), and
TABLE 3 | Correlations between “Happened” traumatic life events (TLEs)
and clinical symptomology.
Variables Life Events Checklist (LEC)
1. LEC ~
2. PANSS positive 0.241*
3. PANSS negative 0.113
4. PANSS cognitive 0.180
5. PANSS excitement 0.302**
6. PANSS depression 0.310**
7. PANSS anergia 0.131
8. PANSS thought disorder 0.216**
9. PANSS activation 0.266**
10. PANSS paranoia 0.224*
11. PANSS prosocial 0.139
Spearman’s correlations between “Happened” TLE and forms of delusions.
*p<0.05.
**p<0.01.
4
Rosen et al. Intersections of Trauma, Structural Adversity, and Psychosis
Frontiers in Psychiatry | www.frontiersin.org April 2017 | Volume 8 | Article 57
depression (somatic concern, anxiety, guilt feelings, depres-
sion, and preoccupation). Second, PANSS items that have been
shown to identify related symptom domains in cluster analyses
that assess anergia (blunted aect, emotional withdrawal, motor
retardation, and disorientation), thought disturbance (conceptual
disorganization, hallucinatory behavior, grandiosity, and unusual
thought content), activation (excitement, hostility, tension, poor
impulse control), paranoia (suspiciousness/persecution, hostility,
and uncooperativeness), and prosocial (active social avoidance,
passive social withdrawal, emotional withdrawal, suspiciousness\
persecution, stereotyped thinking, and hallucinations) were also
obtained. Items were pooled in this way based on previous factor
analytic ndings (38, 39). Coecient alpha, for interrater reli-
ability, was between 0.83 and 0.87.
Data Analyses
Demographic data were analyzed using chi-square tests and
analyses of variance (ANOVA). For ANOVAs that yielded sig-
nicant results (alpha level <0.05), Newman–Keuls posthoc tests
were used to identify signicant pairwise group dierences. We
conducted a binary logistic regression to examine the probability
that cumulative TLEs increased the likelihood of psychosis.
An independent sample t-test was conducted to compare the
association of TLEs and aspects of psychosis. Bivariate spearman
correlations were conducted to determine separate associations
between TLEs and clinical symptomology with particular atten-
tion to forms of delusions and hallucinations between persons
with psychosis and the non-clinical group. All quantitative data
were analyzed using SPSS soware version 24.
For the qualitative component of the project, apriori codes
were generated following the associations identied as signicant
and/or unexplained in the quantitative analyses. For example, we
explicitly sought to identify and unpack cumulative associations
between diverse traumatic events and broader adversity, a topic
that the trauma measure utilized in the quantitative study could
not address. We also coded the content of participant’s symptoms,
looking for associations between past adversity, trauma, and the
themes of voices and/or unusual beliefs. Transcripts were inde-
pendently coded at dierent time points to establish reliability.
RESULTS
Quantitative Analyses
Demographic characteristics of the quantitative sample are
presented in Tab l e 1. Group comparisons revealed a signicant
dierence in race between diagnostic groups, with a larger pro-
portion of African-American participants in the schizophrenia
group relative to both the bipolar/psychosis and non-clinical
groups (χ2=15.38, df = 6, p< 0.02). In total, just over three
quarters (77%) of clinical participants were African-American.
We also found a signicant dierence in age across diagnostic
groups, showing that participants with bipolar/psychosis were
older than participants with schizophrenia and non-clinical
controls (F2,94=3.282, p<0.04). ere was no signicant sex
dierence between diagnostic groups or the non-clinical group.
When comparing persons with psychosis (n= 51) to the
non-clinical group (n=46), there were no group dierences in
the overall total score of TLEs exposure (t95=0.43, p=0.67).
However, we did nd a signicant group dierence in the expo-
sure of TLEs that “Happened” to the individual (as opposed to
those who “Witnessed” or “Learned” about the event), showing
that as lifetime cumulative TLEs exposures that “Happened” to
the individual increased, the more likely the individual was to
exhibit symptoms of psychosis (t95= 2.42, p=0.02). We also
examined dierences in exposure of TLEs that “Happened” and
race and found a signicant increase in TLEs that “Happened” in
the African-Americans sample (F3,93=3.03, p=0.03) (M=4.27,
SD=3.19). In addition, we found a signicant eect of cumulative
TLEs on psychosis (OR=1.174; p<0.02). us, as the number
of TLEs increased by one unit, the likelihood of the presence of
psychosis also increased.
Spearman’s correlations between the number of exposures
of TLEs that “Happened” to the individual and clinical symp-
tomology as measured by the PANSS are presented in Ta b l e 3 .
We found a positive correlation between lifetime cumulative
TLEs that “Happened” to the individual and several, but not
all, PANSS symptom domains, showing that as the number of
TLE exposures that “Happened” increased, the severity of clini-
cal symptomology increased. ere was a positive correlation
between the number of TLEs and the following PANSS factor
and composite scores: positive (r= 0.241, n= 97, p= 0.02),
excitement (r=0.302, n=97, p=0.003), depression (r=0.310,
n=97, p=0.002), thought disorder (r=0.216, n=97, p=0.03),
activation (r=0.266, n=97, p=0.008), and paranoia (r=0.224,
n=97, p=0.03). However, there was no correlation between the
number of TLEs and negative, cognitive, anergia, or prosocial
symptom domains.
We also examined the correlations between the number of
exposures of TLEs that “Happened” to the individual and hal-
lucinations (Tab l e 4 ). With the exception of gustatory hallucina-
tion, signicant positive correlations were found between TLCs
exposure that “Happened” to the individual and all hallucination
modalities: auditory hallucinations (r=0.196, n=97, p=0.05),
commenting hallucinations (r=0.254, n= 97, p= 0.01), con-
versing hallucinations (r=0.255, n=97, p=0.012), visual hal-
lucinations (r=0.257, n=97, p=0.011),; tactile hallucinations
TABLE 5 | Correlations between “Happened” TLEs and delusions.
Variables Life Events Checklist (LEC)
1. LEC ~
2. Delusions of reference 0.145
3. Persecutory delusions 0.191
4. Grandiose delusions 0.156
5. Somatic delusions 0.109
6. Religious delusions 0.196*
7. Delusions of guilt −0.023
8. Jealous delusions −0.025
9. Erotomanic delusions −0.013
10. Delusions of control 0.196*
11. Delusions of thought insertion 0.147
12. Delusions of thought withdrawal 0.092
13. Delusions of thought broadcasting 0.164
Spearman’s correlations between “Happened” TLE and delusions.
*p<0.05.
TABLE 4 | Correlations between “Happened” TLEs and hallucinations.
Variables Life Events Checklist (LEC)
1. LEC ~
2. Auditory hallucinations 0.196*
3. Voices commenting 0.254**
4. Voices conversing 0.255**
5. Visual hallucinations 0.257**
6. Tactile hallucinations 0.420***
7. Gustatory hallucinations 0.125
8. Olfactory hallucinations 0.296**
Spearman’s correlations between “Happened” TLE and hallucinations.
*p<0.05.
**p<0.01.
***p<0.001.
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(r= 0.420, n= 97, p= 0.000), and olfactory hallucinations
(r=0.296, n=97, p=0.003).
Correlations between the number of TLEs that “Happened”
to the individual and forms of delusions are reported in Tab l e 5 .
We found positive associations between the number of TLE expo-
sures that “Happened” to the individual and 12 specic forms
of delusions, indicating that as the number of TLE exposures
that “Happened” increased, the more likely they were to experi-
ence specic forms of delusions. However, only associations
between the number of TLEs and religious delusions (r=0.196,
n=97, p= 0.05) and delusions of control (r=0.196, n=97,
p=0.05) were statistically signicant, with an additional trend
in persecutory delusions (r=0.191, n=97, p=0.06). ere was
no correlation between the number of TLEs that “Happened”
and delusions of reference, grandiosity, somatic, guilt, jealous,
erotomanic, thought insertion, thought withdrawal, and thought
broadcasting.
Given the highly correlated ndings between TLEs in both
religious delusions and tactile hallucinations, we conducted an
independent sample t-test to explore associations between spe-
cic TLEs involving physical and/or sexual assault, unwanted or
uncomfortable sexual experiences, and religious delusions and
tactile hallucination. Interestingly, we found a positive relation-
ship between tactile hallucinations and physical assault (t95=3.95,
p=0.000), sexual assault (t95=4.65, p=0.000), and unwanted
or uncomfortable sexual experiences (t95=3.18, p=0.003). We
also found a positive association between religious delusions
and unwanted or uncomfortable sexual experiences (t95=1.98,
p=0.05).
Qualitative Analyses
Interviews and focus groups were transcribed verbatim, and a
modied grounded theory approach was used to identify themes
related to the intersections of race, trauma, and psychosis.
Transcripts were comprehensively coded and recoded aer a
3-month interval to establish reliability (kappa>0.90). Findings
revolve around four major thematic umbrellas: (1) developmental
relationships between multiple, intersecting adverse experiences;
(2) variations in the timing of onset related to trauma; (3) trauma,
spirituality, and religious symptom content; and (4) trauma and
hallucinatory modalities.
Developmental Relationships between Multiple
Adversities
Virtually all participants, and all African-American participants,
described some form of trauma and, in the majority of cases,
multiple forms of adversity, including structural discrimination
and racism that interacted synergistically over the course of child-
hood, adolescence, and early adulthood. Many participants also
reported family members with serious mental illness, poverty,
unstable home environments, neglect, verbal and/or physical
abuse, and disruption of attachment relationships.
• “e voices that I heard was bad ones for the most part. I came
from an abusive background, meaning that my family was
abusive physically, emotionally and sexually. I was raped and
I just heard all these voices. at’s why the doctors thought
initially I had schizophrenia.”
• “I would get very mad at my mother for being gone. For having
passed away. My mother put me in the hospital kind of like my
dad. He was in the same hospital, too. He had a mental illness.
My father was also in jail. He was put into a hospital in the
past too. He was a patient there. He had voices. He oen talked
to himself and I would wonder why is he talking to himself?
Who is he talking to? My dad heard voices. I caught him in
that, too, many times talking to himself. Sometimes I would
go to church and people were talking like they heard voices.
Sometimes I would see my father talking about [voices] and
ready to beat me up and he got very angry. He would say, ‘Just
get out of here. Go on back home.’ He would just get really
agitated….”
• “Since I was like 12, 13years old, I used to talk to myself,
caught my voices. I didn’t know what it was then. I assumed
it was me, cuz I heard it very early. I came introverted some-
what cuz there’s a lotta violence in the streets. I was more of a
homebody. I think, for me being a homebody, that’s when the
voices got brought up. I just had to entertain myself with the
voices and talking.”
Narratives of gangs, substance use, and drug tracking were
oen woven throughout. One participant described learning
(as an older teen) that his mother had been drinking heavily
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Rosen et al. Intersections of Trauma, Structural Adversity, and Psychosis
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while pregnant with him, while others described parents with
severe addictions throughout their childhoods, as well as parents
incarcerated for drug-related oenses. Still others indicated pres-
sure from siblings or peers to start using drugs, as well as more
complicated entanglements of money, gangs, and drug use.
• “e kids I hanging with. ey got me on drugs. I think it was
a negative factor, negative inuence on my life, the kids I was
with. Other than that, I probably wouldn’t be doing drugs.
Yeah, denitely drugs is a factor in [my diagnosis].”
• “I was just getting angry, depressed, sad. My parents, I heard
my mother say—she was drinking. She was drinking when
she […] was pregnant with me. I heard my father was on my
marijuana. Other than them, my mental illness is from both
sides of my family, my father and mother’s side. ey both
have mental illness. I’m just sure that I get—I see it in my
auntie, too, on my mother’s side. I see some mental illness with
her and everything. It runs in the family.”
• “My mother, she was a heroin addict. I had a problem with
her ‘cause people wanna take advantage of her. at’s where
most my problems start. ey pissed me o ‘bout my mother. I
started stickin’ up, stealin’ to start supplyin’ my mother’s heroin
so she wouldn’t have to go out there in the streets. at caused
conict between me and my brother. Me and him got in a ght
one time. e second time I shot him in the foot. All that’s to
say is that I never had no chance at life—childhood or life.”
Among African-American men, a strong subtheme was bully-
ing and/or verbal abuse (oen from male members of the house-
hold or male peers) related to perceptions of eeminate behavior.
For example, several participants reported having been bullied
due to perceived homosexuality. Several participants reported
responding to such accusations by engaging in stereotypically
masculine behaviors such as joining a gang or drinking, while
others, publicly or in private, embraced gender minority identi-
ties, with one engaging in same-sex sex work as a teen.
• “I was bullied, too, in high school and grammar school. I was
bullied. People messing with me and everything, beating me
up. I got jumped on by some gang bangers. Used to pick on me
a lot like I don’t know how to defend myself or something. Pick
on me and everything. I know how to protect myself, though.
I ain’t gonna let too many people try to mess me up. My father
said that I was gay. He said, ‘People think you gonna be gay
cuz you don’t have many women around. [But] I wasn’t gay….
I’m not gay.’ ”
e above experiences virtually all unfolded in racially seg-
regated neighborhoods and housing projects with high rates of
poverty, gang violence, and limited access to quality job and/
or secondary education. About half the participants remained
in such neighborhoods and explicitly foregrounded the risks of
violence in their communities as a major factor in their experi-
ences of ongoing treatment and recovery. Just 2weeks before,
a focus group held at a Chicago South Side drop-in center, for
example, participants noted that, only a few blocks away at a
public park, over a dozen community members (including chil-
dren) had been killed or seriously injured in a day-time drive-by
shooting.
Timing of Trauma-Related Onset
In discussing the relationship between traumatic events and the
onset of psychosis, most participant accounts fell into one of
two categories: childhood onset of voices in the midst of acute
traumatic experiences (e.g., sexual abuse) and older adolescent
or adult onset following a series of adversities (as well as drug or
alcohol use) but that was nevertheless temporally disconnected
from any single traumatic event.
e content and characteristics of voices arising during acute
traumatic events in childhood were generally much more likely
to mirror real-life abusive gure(s). For instance, voices that
began during episodes of severe sexual or physical abuse were
typically verbally abusive, telling participants that they “deserved
what [they] got,” were “whores” or “sluts,” would never amount to
anything and/or never succeed.
• “ere’s a lot of voices that I hear. All grown men saying the
same thing over and over. I’m no good, I’m worthless. Kill
yourself. Just repeatedly over and over and over and over by
men.”
• “…they keep telling me to kill myself. I’m no good. I’m worth-
less. To kill myself repeatedly.”
• “A lot of negative remarks, they ain’t gonna amount to being
nothing, they gonna grow up to be nothing, you’re a failure,
and all that stu.”
One participant with trauma-onset voices described her voices
as “glued to your experience through childhood experience.” In
spite of hearing voices from an early age—typically beginning in
early to mid-childhood within this subgroup—most participants
reported not receiving a diagnosis of (or treatment for) a psychotic
disorder until a much later time point. It was generally ambiguous
whether these later diagnoses were exclusively tied to voices, or
in fact stemmed from the addition of later onset symptoms and/
or functional disability.
For those with later onset and multiple forms of adversity
and associated risk taking (substance use, drug tracking, and
participation in street gangs, as described above), connections
between psychotic symptoms and particular experiences were
less clear—e.g., it was far less common for participants to report
voice or symptom contact that amplied or re-played a particular
event and associated interpersonal exchanges (such as the mes-
sages of an abusive gure). emes consistent with participants’
lives and broad experiences of individual and community adver-
sity and discrimination were nevertheless common, for example,
delusions involving gangs or pimps or demonic voices tempting
participants to use drugs or engage in illegal activities.
Trauma and Religious–Spiritual Content
e majority of participants described multiple entanglements
between religious faith, spiritual beliefs, and their experiences
of psychosis and adversity. Examples ranged from distinct voices
that reected demonic forces, or a G-d or Jesus-like messianic
gure, ostensible delusions of reference involving messages from
G-d or the devil, automatic thoughts related to participants’
addictions, and perceived temptations as attributable to the devil
while automatic protective thoughts were attributed to G-d; and
the involvement of pastors or other religious gures who helped
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participants make sense of their experiences and distinguish
between those that were divine versus demonic in origin.
• “Well, there are voices from above. I label it as G-d. It’s a
noise, but it’s a feeling of ‘I must something.’ It is like a voice of
something talking. Sometimes it’s sort of like an amen kind of
a noise. Like a church music kind of noise. at kind of noise.
ere are voices within that.”
• “I think they’re demons. I think that G-d talks to you and I
think that demons talk to you. When I was drinking and using
drugs, they was always telling me to kill myself. at I wasn’t
worthy, that I didn’t amount to nothing. When I gave my life to
G-d and turned my life over, the devil still tried to come at me.
I would hear his voice, but I also read the bible and I believe
in the word of G-d. I had to choose G-d’s word over what the
devil was tellin’ me. e bible tells me that the devil is a liar.
Whatever he’s tellin’ me that’s negative, he’s tellin’ me to kill
myself, that’s not something that G-d would want me to do.”
• “When I go to church and all, they teaches me to tell me why
the voices are talking like that. [Interviewer: Your pastor at
church does?] Yeah, tells me not to listen to the voices telling
me to hurt yourself.”
• “I said that I’ll be listening to the preacher preaching, and he’s
telling me which one is—why you shouldn’t listen to the bad
side. e bad side try to get you to hurt yourself. He be talking
about teaching ’em [voices] how to do good things, too, but
he be telling why the bad things be happening, like getting
jumped on or getting beat up a lot. ey tell you what spirit
that is telling you to hurt yourself.”
Trauma was oen tied to these experiences in both direct and
indirect ways. For example, demonic “temptations” (whether
communicated through voices or non-auditory messages) oen
involved risk behaviors deeply interwoven with neighborhood
poverty and a lack of supports and access to child and family
services such as drug use, drug tracking, gang involvement, and
survival sex. Positive voices, even when not explicitly religious or
spiritual in nature, were not infrequently described as forces or
entities, which would protect the participant against adversity or
violence or to reassure them of their core morality or humanity
in spite of “immoral” activities and events they had been exposed
to (or previously participated in).
• “One time I go outside at 2:00 a.m. Somethin’ tells me that
somethin’ ain’t right. Like you talkin’ to me like it’s a warning
sign. Like you talkin’ to me, that’s the way—that’s how I hear
it. Like you talkin’ to me. I changed my mind. I’m not gonna
catch the bus. I turned around and went upstairs. Where I live
there’s a park across the street. One of the bus stops is right
there. About 2-min long up the steps I heard some shootin’. As
I look out the window, I saw a body layin’ down and a couple
guys runnin’. e very same bus stop I was gonna catch the
bus at. at’s why I say it’s a good voice and a bad voice. e
voice that I heard, I feel it was comin’ from G-d. If it was an evil
voice, I feel that I wouldn’t got that notice.”
Several participants whose narratives involved accusations
and/or internalized concerns about sinful behavior and/or
stigmatized gender or sexual identit(ies) described various uses
of religious faith or spiritual practice to address their concerns or
reassure themselves that they were (in fact) good, ethical people.
• “Jesus [described as a voice earlier in the interview] reassures
me…that He loves everyone. Regardless of sexual orientation.”
• [Reporting what her voices say]: “I get, ‘at’s not the right
thing to do, Carol [pseudonym].’” [Pause] “You can get through
this day without thinking about going back and using drugs.”
Trauma and Hallucinatory Modality
While participants most frequently described, and spent the most
time discussing, ostensible delusions (particularly paranoia) and
auditory hallucinations (“voices”), altered perceptual or somatic
experiences in other modalities were common. Participants’
descriptions generally revolved less around literal “hallucinatory”
experiences than they did around more existential alterations of
experience and/or “felt presences,” which tended to be subtler and
harder to describe. In many cases, participants reported that such
presences represented ghosts or spirits, generally of deceased
loved ones.
• “A smell like, let’s see—maybe it tastes like you wanna drink
some water cuz I’m dizzy. Almost like a shocking feeling, but
the smell it’s like maybe more like a taste. Maybe it smells like
air, like air.” [Q: In some way that’s dierent from the air that’s
already there?] “Right, it’s not the same. It’s dierent.”
• “I can see my [deceased] aunt and my uncle and you see, I
see them. Yeah, I see a lot of people up there when I look up
[toward the voices].”
• “I feel like, like it’s a liing, sort of like a liing feeling, like of
something being lied.”
• “For me it’s more like a feeling, too. Like something that makes
me turn my head. Like something that’s there that I—almost
like a buzz or a tone or something.”
A number of participants connected non-auditory–verbal
experiences directly to G-d or spirituality. For example:
• “It’s bothersome and there’s noise, but then it’s like this singing
like this noise, and I feel like G-d, you know, G-d makes these
noises [‘voices’].”
In contrast to the previous themes, direct links between these
non-verbal experiences and trauma were unclear, and no partici-
pant in this sample explicitly described non-auditory experiences
as sexual or violent in nature.
DISCUSSION
e urban experience for African-Americans living in segregated
neighborhoods and/or housing projects oen involves exposure
to high rates of poverty, gang violence, and limited access to qual-
ity secondary education and job opportunities (40, 41). Increased
exposure to TLEs tends to be more frequent in low SES and racial
minorities groups (42, 43). In comparison to Caucasians, African-
Americans have reported increased exposure to violent assaults
(44, 45) including gun-related violence (46, 47). Although racial
disparities in access and outcomes are well documented [e.g., Ref.
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(48, 49)], relatively little empirical research has focused on the
complex relationships between trauma and the subjective experi-
ence and phenomenology of psychosis, including symptom con-
tent, within specic ethnic/racial/cultural minority communities
[for exceptions, see Ref. (33, 50)].
e mixed-methods data reported here replicate existing
ndings in identifying strong and signicant links between
cumulative trauma exposure and psychosis that cut across
traditional diagnostic boundaries (2, 3, 51, 52). We extend
this literature by demonstrating that these ndings hold in
our predominantly African-American US sample, where the
relationship between TLE and psychosis may be particularly
relevant due to higher likelihood of TLEs among ethnic
minorities. Increased and more nuanced understanding of the
role that such environmental factors play in the development of
psychotic disorders helps parse the heterogeneous etiology of
these illnesses and possibly points toward more personalized
treatment conceptualizations.
Beyond demonstrating a general link of greater TLEs and
psychosis, we found specic types of psychosis symptoms asso-
ciated with TLEs, including multiple types of hallucinations,
religious delusions, and delusions of control. We further found
that tactile hallucinations and religious delusions were signi-
cantly correlated with history of unwanted sexual experiences
and, for tactile hallucinations, with past physical and sexual
assault. We discuss these ndings and their implications in the
sections that follow.
Our qualitative analyses were designed to further unpack,
potentially conrm, and deepen the ndings from the quantita-
tive study. e qualitative ndings underscore the complex and
synergistic relationships between multiple forms of individual
trauma (including bullying, harassment, and abuse) as they
unfold against a backdrop of racial segregation, poverty, drug
tracking, gang violence, and neighborhood disadvantage. In
addition, we report multiple ways in which both individual-level
and neighborhood-level themes and dynamics are reected in
the form and content of both voices and unusual beliefs. For
example, we found that an array of themes related to participants’
childhood experiences and associated attempts to cope with these
experiences were reected in both the content of voices and sub-
ject’s interpretations of their meaning and signicance.
Cumulative Exposure, Type, and Proximity
to the Traumatic Event and Psychosis
National comorbidity studies and meta-analysis have reported
a potentially causal relationship between cumulative TLEs
exposure and psychosis (26, 53, 54). Our data are consistent
with other studies that show that the overall lifetime TLE
exposure is signicantly higher in the African-American
population (47, 55, 56). In turn, our nding that cumulative
TLE exposures that “Happened” to the individual increased
relative to reporting psychotic symptoms is consistent with
existing research, highlighting the likelihood of multiple
exposures amplifying the risk of psychosis beyond individual
stressors alone (5, 25, 57). For example, analysis of the United
States National Comorbidity Survey (NCS; n=5,782) and the
British Psychiatric Morbidity Survey (BPMS; n=8,580) found
that aer adjusting for demographic confounds, substance use,
and depression, experiencing two TLEs increased psychosis
risk by 3.37 times (NCS) and 4.31 times (BPMS), respectively,
compared to 30.16 times (NCS) and 192.97 times (BPMS) for
individuals reporting ve TLEs (58).
e nature of the relationship between collective trauma and/
or socioenvironmental adversity and psychosis indicates that the
urban environment may increase the likelihood of exposure to
TLE in persons who later develop psychosis (59). Our qualitative
ndings underscore the synergistic eects of both individual-
and neighborhood-level adversity, with both psychological and
biological components, including exposure to illicit substances
(prenatal and during childhood/adolescence) and chronic back-
ground stress. We suggest that future research needs to more
explicitly model both biological and (ongoing) psychological
mechanisms and associated (adaptive or maladaptive) coping
into early adulthood. Participant narratives also suggest that
neighborhood adversity, particularly threat of gang-related vio-
lence, may be an important maintaining factor for both paranoid
beliefs and voices.
TLEs and Participant’s Symptoms in Form
and Content
Associations between trauma and delusions have been reported
in multiple studies (23, 57, 60). A study conducted by Scott etal.
(12), examining the association between trauma and delusions
found that persons who endorsed any type of delusion were sig-
nicantly more likely to have been exposed to a traumatic event
and that as the exposure to trauma increased, the relative risk
of experiencing delusions increased signicantly. Exposure to an
urban environment has been shown to increase anxiety, negative
belief about others, and jumping to conclusions in persons with
persecutory delusions when compared to a non-clinical group
(61). Interactions amongst discrimination, deprivation, stress,
mistrust, social inequality, and lack of social support were pro-
posed as predictors of both aective and non-aective psychosis
(62). Likewise, auditory hallucinations across diagnoses have
been strongly linked to childhood adversity, particularly sexual
abuse (63, 64).
In line with previous research, we also found multiple direct
and/or indirect emotional and thematic links between adversity
exposure and the content of voices and delusions, including
voices that mimicked the sentiments of abusive gures, and
paranoia that reected community contexts characterized by
poverty, gang, police activity, and near constant background
threat of violence (15, 16, 18). Rather than nding that voices
and delusional beliefs predominantly reected negative trauma-
linked content, many of our participants reported positive and/
or protective content, including voices perceived to originate
from G-d, Jesus, or protective spirits, ndings which are consist-
ent with Jones etal. (65). Our nding that several participants
reported voices as a source of comfort and support also highlights
the need for sensitivity amongst healthcare workers in not treat-
ing hallucinations as unilaterally negative experiences, which
need to be eradicated.
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TLEs, Psychosis, and Spiritual
Experiences
In the existing literature, religious beliefs have been reported as
a source of strength, comfort, and encouragement in manag-
ing psychiatric diculties related to traumatic events (66, 67).
Religion or spirituality may also provide a framework to under-
stand or bring meaning to the individual who experienced a TLE
(68, 69). Religious practices such as prayer or meditation, worship,
and participation in religious services can engender hope and
increased social support among individuals with serious mental
illness (70–72). While not universal, religious/spiritual explana-
tions of psychotic experiences, religious themes, and/or content
(such as hearing the voices of G-d), and faith-based coping and
healing practices (including explicit discussions regarding the
navigation of voices with pastors or preachers) were common.
For many participants, positive religious or spiritual beliefs,
including those entangled directly in their voices and psychotic
experiences, were described as oering advice, guidance, moral
reassurance, and/or fortication against temptations or demonic
intrusions. For at least some clients, these temptations or intru-
sions (for example, commands such as “take drugs,” “shoot him,”
“have sex,” or delusions involving similar themes) were directly
associated with past adversity.
Relationship and Patterns of Past Trauma
and Symptoms over Time
e causative evidence of the association between trauma and
psychosis is the strongest for the manifestation of hallucinations
(73). Experiencing trauma has been shown to increase the likeli-
hood of verbal hallucination vefold (74). e phenomenological
associations between trauma and hallucinations have shown that
hallucinations with content related to trauma are not only found
in psychosis they may actually shape the themes of the halluci-
natory experience (16, 73, 75). In a recent systematic literature
review of studies investigating voices, the association between
trauma and voices has been explored in multiple realms includ-
ing phenomenology, causal link, neurobiological hypotheses, and
treatment interventions (76). Much of the research emphasis has
focused on the associations between trauma and verbal hallucina-
tions with much less emphasis between trauma and other types
of hallucinations, including tactile or olfactory (77). Our research
examined the association of trauma and all forms of hallucina-
tions. Interestingly, the strongest association was found between
TLE’s that “Happened” and tactile hallucinations, although there
was a positive correlation between TLE and most types of halluci-
nations. Our qualitative data further link the association between
a specic traumatic event such as sexual assault and the onset
of psychosis and draws attention to a potentially traumatogenic
subgroup of patients whose voices began in the midst of acute
trauma in childhood but were later diagnosed with a psychotic
disorder, and a subgroup who, in spite of signicant trauma, did
not develop psychosis until early adulthood. is nding further
supports the clinical need of evaluating current and past trauma
throughout the lifespan as symptoms associated with a TLE may
occur during or in close time proximity the event or may not
manifest until much later in life (78).
ere are limitations of this study in that both quantitative
and qualitative datasets reported here are cross-sectional and
can only establish correlations and perceived causal connections
rather than empirical causality. In addition, our sample was
predominantly African-Americans living in a particular, notori-
ously segregated urban environment; our qualitative analyses are
meant to deepen our understanding of the interplay of trauma,
psychosis, and spirituality within a particular group and associ-
ated sociogeographic context, not to generalize. We also had no
mechanism for verifying TLE, although it should be noted that
retrospective accounts of adversity amongst psychosis popula-
tions have consistently been shown to be reliable and valid and
are more likely to underreport than overreport TLEs (79–81).
Finally, our ndings echo the extant literature in foreground-
ing the importance of childhood adversity, neighborhood
characteristics, and cumulative adversity with response to both
the epidemiology of psychosis and the process of recovery and
healing. Experiences described by qualitative participants were
far from unilaterally negative, and participants consistently
linked the content of symptoms to an array of life events and chal-
lenges. Taken together, these ndings foreground the importance
of trauma assessment and conversations aimed at understanding
the role that traumatic experiences have played in clients’ lives, in
the genesis of their mental health challenges, and in the content of
these experiences. From a public health perspective, they add fur-
ther fuel to calls for both research and preventative interventions
aimed at addressing the negative impacts of childhood structural
adversity and neighborhood disadvantage.
ETHICS STATEMENT
e quantitative analysis was conducted and approved by
University of Illinois at Chicago Institutional Review Board
(IRB). e University of Illinois at Chicago Institutional Review
Board approved the study, and signed consent was obtained from
all participants in accordance with the Declaration of Helsinki
before initiation of study procedures. e qualitative analysis by
DePaul University’s Institutional Review Board where two of the
researchers were employed at the time the study was approved
and data were collected.
AUTHOR CONTRIBUTIONS
CR, NJ, and RS designed the study. CR and NJ collected the data.
CR, NJ, KC, and RS developed the methodology and performed
the analysis. CR, NJ, EL, KC, MS, JM, SK, and RS wrote, edited,
and approved the nal version of the manuscript.
ACKNOWLEDGMENTS
e authors would like to thank all the individuals who partici-
pated in this study.
FUNDING
is work was supported in part by PHS grant (NIH)
R01MH094358 (RS).
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Conict of Interest Statement: e authors declare that the research was con-
ducted in the absence of any commercial or nancial relationships that could be
construed as a potential conict of interest.
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