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Dissociation and Misdiagnosis of Schizophrenia in 1
Populations Experiencing Chronic Discrimination and Social 2
Defeat 3
Heather Hall 11 heatherhallmd@gmail.com 4
* (650) 455-5507 5
Abstract: In the late 20th-century, psycho-socio-biologists determined that schizophrenia, a category of mental 6
illness with wildly varying phenotypic symptoms, was a genetically based disorder and that environment played a 7
limited role in the illness's etiology. However, a growing body of evidence indicates a strong correlation between 8
environmental factors and schizophrenia in children and adults. This theoretical paper hypothesizes a 9
relationship between highly elevated rates of schizophrenia in some low-income minority communities 10
worldwide and trauma-related dissociative symptoms that often mimic schizophrenia. It has been well 11
established that there are elevated rates of schizophrenia in racially and ethnically isolated, inner-city Black 12
populations. This paper will present evidence suggesting that this amplification in the rate of schizophrenia is 13
mediated by childhood trauma, disorganized attachment, and social defeat. Further, evidence will be shown that 14
demonstrates how these three variables combine in early childhood to create dissociative disorders. Thus, the 15
misdiagnosis of dissociative disorders as schizophrenia is theorized to partially mediate the increased rate of 16
schizophrenia in communities that experience high levels of racial/ethnic discrimination. This misdiagnosis is 17
often the result of cultural misunderstanding and/or a lack of knowledge regarding dissociative disorders. 18
19
Keywords: Dissociative Disorder; Psychotic; Disorganized Attachment; Discrimination; Social 20
Defeat; Childhood Trauma 21
Introduction 22
Discrimination and social defeat combined with early childhood trauma and 23
disorganized attachment drive the traumatized individual to dissociative coping strategies. 24
These strategies used chronically to distance the suffer from the painful environment lead to 25
dissociative disorders that are easily misunderstood as schizophrenia. The Diagnostic and 26
Statistical Manual (DSM) 5 [1] is intentionally phenomenological and atheoretical and has 27
stripped the meaning behind the symptoms from their diagnostic categories. With all the 28
meaning behind symptoms like auditory hallucinations and paranoia, ideation stripped 29
away, differentiating dissociation and schizophrenia using DSM criteria is very difficult. 30
Pattern recognition software and machine learning techniques demonstrated success in 31
separating dissociative disordered patients from control groups [2, 3]. And so, a 32
controversial diagnosis has become increasingly well validated. 33
Black communities worldwide are subjected to discriminatory social structures with a 34
direct impact on mental health [4-6]. Black skin has been associated with elevated rates of 35
schizophrenia. Anglin et al. 2021 [7] highlight neighborhood factors, cumulative trauma and 36
stress, and prenatal and perinatal complications as three key factors that reflect social and 37
environmental conditions that could lead to schizophrenia-like symptoms through a common 38
pathway shaped by structural racism. This increase is unlikely to be purely genetic [5-7]. This 39
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paper argues that some of the increase in the rate of schizophrenia in inner-city dark-skinned 40
minority populations is mediated by childhood trauma, social defeat, and dissociation. 41
Dissociation results from early childhood trauma and can mimic the symptoms traditionally 42
labeled as psychotic [8, 9]. Patients suffering from dissociative disorders have consistently 43
been given a diagnosis of schizophrenia [10, 11]. Anglin et al. 2019 demonstrated that 44
dissociation mediated the relationship between traumatic life events and psychosis in a non-45
clinical population of African Americans. [12] Chronic experiences of discrimination and social 46
defeat give rise to conditions in which dissociative illness is more likely [8, 9]. The resulting 47
alienation leads to dysfunctional families and internalizing behaviors in children [13]. The 48
combination of disorganized attachment suffered in the family home as well as discrimination 49
and social defeat in the community lead to dissociative coping strategies and ultimately 50
dissociative disorders [14]. 51
The prevalence rate of schizophrenia is 0.4%-0.7% [15], while the dissociative disorders' 52
prevalence rates are 11.4%[16]. This data indicates that dissociative disorders are about ten 53
times the rate of schizophrenia in the general population. As will be discussed in greater 54
detail later in the paper, the rate of schizophrenia in some dark-skinned minority populations 55
is roughly ten times the rate of schizophrenia in white populations [17]. In impoverished 56
inner-city environments, the rates of schizophrenia increase as the inhabitants' skin darkens 57
[6, 18, 19]. This paper seeks a deeper understanding of that statistic. Much has been written 58
about the biological determinants of elevated rates of schizophrenia in black populations. 59
This paper, therefore, will put that aside for the moment to seek a psycho-social explanation. 60
Three key factors will be explored - social defeat, childhood trauma, and dissociation to 61
explain the increased rates of schizophrenia in these underprivileged, minority communities. 62
63
Social Defeat and Psychosis 64
The first section will discuss the relationship between discrimination and social defeat 65
and psychosis. Social defeat was initially described in the laboratory in rodent experiments. In 66
these studies, a smaller rodent is introduced to the cage of a larger, aggressive rodent. The 67
more aggressive resident rodent attacks the smaller intruder until it manifests a submissive 68
stance. The mere presence of the resident rodent is enough to induce the same physiological 69
and behavioral stress response in the intruder rodent that was noted just after the initial 70
physical confrontation. This behavioral and physiological response is called "social defeat." 71
[20] The term social defeat has subsequently been used to define a similar condition in 72
humans who have been chronically subjugated. [21] The stress associated with social defeat 73
under conditions of chronic discrimination has been described in humans and has been 74
associated with increased rates of schizophrenia. 75
There is a well-documented elevation in the incidence of schizophrenia in black inner-76
city populations worldwide[6, 22-33]. These are populations that inhabit neighborhoods with 77
high levels of poverty and social unrest. Elevated levels of social inequality at birth are 78
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associated with an increased risk of schizophrenia ([34]). Prolonged and more severe 79
exposure to adverse social environments is associated with greater odds of developing 80
psychotic and depressive symptoms in late adolescence [35, 36]. Urban birth is a risk factor 81
for schizophrenia [4, 37]. Grech et al. 2017 [38] evaluated the familial correlation of 82
psychotic symptoms in sibling pairs with one member affected by a psychotic disorder. They 83
predicted that psychotic symptoms would be higher if the unaffected siblings were raised in 84
an urban environment until age 15. Their data revealed a strong sibling pair association in the 85
urban environment and an absence in the rural setting. This data indicates that the effects of 86
the genetic and environmental factors that determine familial clustering of psychotic 87
symptoms depend on if the individuals spend their early life in an urban environment. Urban 88
environments are associated with poverty and exposure to violence. This leads to a greater 89
risk of aggressive and delinquent behavior, exposing inhabitants to overly aggressive policing 90
and more violence. This increases violence occurs in the family home, the classroom, and the 91
community. Early exposure to violence is correlated with a lower level of mental health [39-92
41] and psychosis[42]. 93
Studies out of London produced evidence of a 3- fold increase in the rate of "non-94
affective psychosis" in the socially disadvantaged, immigrant Neighborhoods. Dark skin 95
increased the rate of schizophrenia 9-fold [19, 24, 43]. The rates of schizophrenia in the 96
countries of origin for these immigrants were not above normal. When these populations 97
immigrated to countries that were not predominantly white, there was also no increase in 98
rates of schizophrenia [5]. The incidence of schizophrenia in ethnic minorities is greater when 99
they comprise a smaller proportion of the local population[43-46]. Ethnic fragmentation and 100
voter turnout (both aspects of social capital) were the two of the most significant predictors 101
of what these authors called non-affective psychosis in London neighborhoods [19]. Tortelli 102
et al. 2015 [30] completed a systematic review and meta-analysis of the Caribbean 103
immigrants in London and their offspring. They found the elevated rates of schizophrenia in 104
this population date back 60 years with no increase in the rate of schizophrenia in the home 105
country or when those same populations emigrated to a country that Caucasians did not 106
dominate. Social capital was found to be the most significant predictor of non-affective 107
psychosis in the London neighborhoods [36, 47]. It was even more predictive than skin color 108
[19]. 109
Social capital supports both physical health, as well as subjective well-being. It results 110
from a strong network of interpersonal relationships based on reciprocity and social 111
cooperation [48]. A high level of neighborhood social capital is a protective factor against 112
mental illness [17, 49-52]. Conversely, social defeat and low levels of social capital have been 113
demonstrated to contribute to the increased incidence of schizophrenia in marginalized 114
communities [17, 21, 33, 53-61]. In addition, perceived discrimination was associated with 115
delusional ideation and contributed to the high observed rates of diagnosed schizophrenia in 116
exposed minority populations [28, 55, 56, 60, 62]. 117
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In combination, loneliness and social defeat were found to mediate the relationship 118
between childhood adversity and psychotic symptoms [61]. Oh et al. 2021 [63] demonstrated 119
that Black Americans who reported discrimination based on skin tone were significantly more 120
likely to get a schizophrenia diagnosis. "Individuals with darker skin are more often 121
discriminated against in Western societies. Experiences of discrimination may foster a 122
paranoid attributional style that facilitates the development of psychotic symptoms… A 123
mechanism for this development might be the long-term experience of social defeat, i.e., the 124
chronic stressful experience of outsider status[21]." Li et al. 2021 [55] studied a group of 125
ethnic minority immigrants. They noted that delusional themes of psychological persecution 126
were more prevalent in those diagnosed as schizophrenic who had experienced moderate to 127
high levels of social defeat. They also found that the higher the education level, the greater 128
the experience of social defeat. Thus, those who seek higher education may feel even more 129
disappointed in failure perceived to be based on race, ethnicity, or skin color. They are likely 130
to put more faith in the societal structures and feel a greater sense of betrayal in their failure. 131
Freyd 1996 p 62 [64] introduces the concept of betrayal trauma, a theory suggesting that the 132
traumatic events most likely to lead to dissociation are those where betrayal is a fundamental 133
component. Institutional betrayal occurs when the perpetrator of the betrayal is an institute 134
trusted to uphold basic standards such as a university[65]. Gomez 2019 [66] has taken the 135
concept further and has described cultural betrayal trauma. Cultural betrayal is trauma that 136
occurs at the hand of individuals from one's group. Her research demonstrated that betrayal 137
trauma, in general, was associated with symptoms of PTSD, and cultural betrayal trauma was 138
associated with dissociative symptoms. 139
Garety et al. 2007 [67]suggest that early social adversity, such as social 140
marginalization, childhood loss, and severe childhood trauma, may create an enduring 141
cognitive vulnerability characterized by negative schematic models of the self and the world 142
that facilitate appraisal biases and low self-esteem. The belief in the self as weak, vulnerable, 143
inadequate combined with the belief that others as devious, threatening, and bad were 144
explicitly associated with paranoia. The effects of racial discrimination on mental health are 145
cumulative over time [68]. Myers et al. 2016 [69] used ethnographic research with African 146
American males diagnosed with a psychotic disorder in a high-poverty urban area to 147
understand the ways public mental health services led them to experience a paralyzing 148
erosion of autobiographical power. They define autobiographic power as the ability to tell 149
one's own story. They identified points where the loss of autobiographical power perpetuated 150
social defeat during public mental health care interactions. Over time and across generations, 151
discrimination and social defeat erode the fundamental self-worth of those exposed to it [70]. 152
This is particularly true in children [71]. Shame and low self-worth are potent drivers of 153
dissociation and are also correlated with schizophrenia [71-74]. 154
Minority populations that suffer in disadvantaged neighborhoods experience social 155
defeat in the form of discrimination. In addition, they experience institutional and cultural 156
betrayal trauma. This potent combination of traumatic experiences that occur over time and 157
across generations has a profoundly harmful effect on the inhabitants of these 158
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neighborhoods, leading to a particularly disorganized form of dissociation that is more readily 159
misdiagnosed as schizophrenia by providers unfamiliar with the relationship between social 160
defeat and schizophrenia. 161
162
163
Trauma and Psychosis 164
Children who report symptoms of psychosis have high incidents of traumatization[75]. 165
Adults with psychosis also report childhood trauma in high numbers [76-85]. The effects of the 166
childhood environment interact with all the processes of neurodevelopment. Abuse studies 167
demonstrate that children need stable emotional attachments with and touch from primary adult 168
caregivers and spontaneous peer interaction. If these connections are lacking, damage to brain 169
development both of caring behavior and cognitive capacities is lasting[86, 87]. The relatively new 170
field of epigenetics (the role of the environment in gene expression) has demonstrated an 171
association between childhood trauma and its biological correlates in first-episode psychosis 172
[88]. There is data to suggest that in discordant twins reared apart, there is an epigenetic 173
change that is noted at age ten that is not present at age 5 [89]. This combined data strongly 174
suggests that psychotic symptoms that develop in adverse environmental conditions are 175
driven by the conditions themselves and not solely based on genetic vulnerability. Many 176
studies have now demonstrated the relationship between schizophrenia and over-reactivity 177
to stress of the HPA axis and the dopaminergic system. Severe early social adversity can 178
induce a cascade of long-term disturbances in the HPA axis. Patients diagnosed with 179
schizophrenia who experienced child abuse had more significant HPA axis dysregulation than 180
their non-abused counterparts. Significant associations were found between the cortisol 181
awakening response and both inadequate early-life paternal parenting and childhood sexual 182
abuse in those with first episode psychosis. The same study linked decreased cortisol 183
awakening to the severity of positive symptoms of schizophrenia. These studies suggest a 184
relationship between trauma and psychosis, and the connection cannot be attributed to the 185
fact that psychosis can be traumatizing [90]. 186
Varese et al. 2012 [76] found that childhood adversity and trauma substantially increases 187
the risk of psychosis. Their data indicated that removing childhood adversities decreased the 188
rate of psychosis by 33%. This was true in general population studies and prospective studies, 189
and it was true for sexual abuse, physical abuse, emotional abuse, bullying, and neglect. All of 190
these are traumas involving interpersonal violence both in the home and in the community. 191
Bental et al. 2014 [91] consider the pathways between specific types of adversity and 192
particular symptoms of psychosis. Their findings suggested communication deviance in 193
parents was related to the development of thought disorders in offspring. Childhood sexual 194
abuse was implicated in auditory–verbal hallucinations, and attachment-disrupting events 195
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(e.g., neglect, being brought up in an institution) had particular salience for the development 196
of paranoid symptoms." 197
The DSM 5 diagnostic category of schizophrenia likely represents syndrome rather than a 198
discrete diagnostic entity [92-94]. A meta-analysis by Schiavone et al., 2018 [95] concluded 199
that psychotic symptoms are common in trauma-related disorders and are frequently 200
misinterpreted and diagnosed as schizophrenia, leading to ineffective treatment. 201
Jääskeläinen et al., 2014 [96] a meta-analysis, indicated that, at the age of 34, outcomes for 202
patients who had been diagnosed with schizophrenia were heterogeneous. More than half 203
(56%) of the individuals with schizophrenia were on disability, with only 21% were in 204
symptomatic remission and only 3.4% having recovered. Worldwide the recovery rate for 205
schizophrenia was found to be 13.5%. Early age of onset was the best predictor of a poor 206
outcome. These authors combined this information with brain morphology studies to suggest 207
that at least two distinct etiological groups were diagnosed with schizophrenia. One group 208
with a later onset of symptoms responded to the traditional treatments for schizophrenia, 209
and a second group with an early onset of symptoms that did not respond to medication. In a 210
traumatic early childhood, dissociative symptoms can present as early as 7 [97] and are often 211
misdiagnosed as schizophrenia [98]. Dissociation has been noted in traumatized children as 212
young as three years old [99]. 213
Davarinejad et al. 2021 [100] Studied relapse rates in patients diagnosed with 214
schizophrenia in Iran. A higher relapse ratio was associated with an increased history of 215
suicide attempts and a gradual and earlier disease onset: identified loneliness and weak 216
family ties as more potent predictors of suicidal behavior than co-varying economic 217
factors[101]. Loneliness and weak family ties were identified as more robust predictors of 218
suicidal behavior than co-varying economic factors. Early maladaptive schemas of emotional 219
deprivation, social isolation, shame, and abandonment were related to a history of suicide 220
attempts among patients with major depressive disorders [102]. Unal et al. 2019 [103] 221
demonstrated that early childhood adversity was a significant predictor of suicidal behavior, 222
as were feelings of defeat, social rejection, entrapment, humiliation, and subjectively 223
perceived low social support. Suicidal behavior was also found to be a function of alienation. 224
That alienation was related to withdrawal, disgust, perceptions that one is a burden, as well 225
as overarousal symptoms, including agitation, marked irritability, nightmares, and insomnia 226
[87]. 227
Alameda et al., 2015 [104] also found that symptom severity and early age onset were 228
related to exposure to adverse childhood experiences. They noted that 1) Age at the time of 229
exposure to trauma impacts later functional outcomes. 2) The impact of childhood trauma in 230
the premorbid phase of psychotic disorders is restricted to social domains while academic 231
functioning remains like that of unexposed patients. 3) Early psychosis patients exposed to 232
severe trauma in childhood have poorer functional outcomes than non-exposed patients. 4) 233
Age at the time of first exposure influences the long-lasting effects of these deficits. 5) 234
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Compared to non-exposed patients, those exposed to sexual and physical abuse before age 235
11 displayed a functional impairment maintained at follow-up. In contrast, patients exposed 236
at a later age had improved over the treatment period. A decreased ability to "think about 237
thinking," social anxiety and attachment difficulties were potential etiological factors in the 238
early-onset group. 239
Early attachment trauma is key to this discussion as it highlights the relationship 240
between the theory of the double-bind scenario and the "schizophrenogenic mother" [105] 241
and the development of dissociative symptoms [106]. This concept resembles the "fright 242
without solution" theorized in Hesse and Main [107]. There is an entire social structure and 243
order that undergirds the mother-child relationship. Organized society has been reluctant to 244
take responsibility for the conditions under which mothers (and fathers) raise children. It is 245
increasingly clear that there is a considerable cost to society in ignoring its responsibility to 246
provide a social safety net to maximize all a society's inhabitants' potential. The cost of not 247
doing so is enormous and likely to be higher than the safety net cost itself [108, 109]. 248
Current-day conceptualizations of schizophrenia have evolved in isolation from the 249
growing body of work on attachment. This concept ignores the central role of emotion 250
regulation in understanding the development of psychotic symptoms. Attachment behavior 251
was defined in Bowlby 1969 [110] as seeking and maintaining proximity to another individual. 252
Attachment to the mother is exhibited earlier, more intensely, and more consistently. 253
Attachment theory highlights the infant's reaction to anxiety and fear consists of innate 254
behaviors aimed at increasing proximity to a central caregiving figure. Bowlby coined the 255
term "the attachment system" as "how a child's experiences with attachment figures come to 256
influence in particular ways the pattern of attachment he develops." (p 373) The attachment 257
system operates in the first several years of life and regulates attention, affect, and behavior. 258
It is driven by activities that include recruiting and coordinating expectations based on past 259
events to achieve the physical and attentional availability of the caregiver [111]. Disorganized 260
attachment is understood as the absence of an organized strategy of gaining proximity to the 261
primary attachment figure. This results from the presence of a frightening parent who is 262
simultaneously the source of fear and the only possible protective figure [112]. This is what 263
Hess and Main 2000 [107] termed "fright without solution." Those suffering from a 264
disorganized attachment style have difficulty regulating their emotions [112-114]. 265
The role of disorganized attachment, dissociation, and trauma, in the development of 266
psychotic symptoms is increasingly evident [67, 80, 81, 83, 84, 115-128]. Parental attachment 267
strongly predicts the quality of the parent-infant attachment relationship and predicts 268
responsiveness to infant attachment signals[107, 110, 129]. Parents who experience high 269
discrimination and social defeat are more likely to have difficulty parenting; many will parent 270
from their own disorganized attachment. Disordered attachment styles are transmitted 271
transgenerationally [99, 126, 130]. Schroeder et al. 2016 [131] noted elevated childhood 272
adversity and adult dissociation rates in psychotic patients who reported sexual abuse or 273
paternal dysfunction in childhood. Liotti 2004 [118] has conceptualized disorganized 274
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attachment as a condition prototypical of the development of dissociative disorders. Paetzold 275
et al., 2007 [121] demonstrated that disorganized attachment styles were associated with 276
dissociation in adults. Lyons-Ruth 2003 [122] determined that disorganized attachment 277
behavior in infancy is a precursor to dissociative symptoms later in life, and the vulnerability is 278
related to patterns or parent-infant effective communication. Lyons-Ruth 2008 [123] 279
demonstrated that the mother-infant relationship was a better predictor of dissociative 280
symptoms in early adulthood than the attachment behaviors exhibited by the infant. This was 281
true even when controlling for socioeconomic variables. Hebert et al. 2020 [132] indicated 282
that disorganized attachment and emotion dysregulation mediated the relationship between 283
childhood sexual abuse and dissociation. Harder 2014 [117] noted that disorganized 284
attachment was associated with heightened stress sensitivity and dissociation. The studies on 285
adverse childhood events indicate the many adversities that a child can experience inside and 286
outside the home [125]. Granqvist et al. 2007 [124] highlight the role of parental trauma and 287
loss in the development of insecure attachment in infants. Many of these children would not 288
be classified as victims of child abuse. Parental trauma and loss could lead a parent to display 289
subtly frightening, frightened, or dissociative behaviors toward their infant. Having parents 290
who are victims of their own adverse childhood experiences and who actively dissociate 291
magnifies the number and intensity of the maltreatment events that are then passed 292
transgenerationally [99, 126, 130]. 293
Paranoia is associated with both attachment anxiety and attachment avoidance [127]. 294
In disadvantaged minority communities, traumatized parents struggling with severely limited 295
resources have a limited ability to provide stable attachment figures for their children [112]. 296
Once those children reach school age, they go out into a world where discrimination and 297
social defeat compound the effects of attachment deficits. This combination of insecure 298
attachment, developed in the family home, and the accumulation of discrimination and social 299
defeat experiences create the environment where these elevated rates of dissociative 300
symptoms develop. This process deeply embeds this traumatic dysfunction into 301
disadvantaged minority communities [75, 99]. 302
303
Dissociation and Psychosis 304
This section questions whether schizophrenia is an accurate explanation for all of 305
the increases noted above and suggests that a trauma-related dissociative disorder is a more 306
precise way to understand these symptoms. The American Psychiatric Association has, for 307
the first time, included a diagnostic category known as PTSD- Dissociative Subtype. DSM-5 308
has defined dissociation as 'a disruption of and discontinuity in the normal integration of 309
consciousness, memory, identity, emotion, perception, body representation, motor control, 310
and behavior[1]. Those in this category experience significant symptoms of 311
depersonalization and derealization. This subtype can be differentiated from traditional 312
PTSD using functional brain imaging studies and symptom severity [133]. The addition of the 313
dissociative subtype of PTSD is an important step forward because it links dissociative 314
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symptoms directly to traumatic experiences. Powers et al. [134] studied the link between 315
childhood trauma and psychosis in an underrepresented minority sample. Both child abuse 316
and current PTSD predicted the presence of psychotic symptoms. The increased rate of 317
schizophrenia in dark-skinned, disadvantaged communities can be up to 9 times the average 318
rate of schizophrenia in local White populations. That number is more consistent with the 319
rates of dissociative disorders than it is with the rates of schizophrenia [15, 135]. Dissociative 320
symptoms overlap with psychotic symptoms almost wholly [136]. In ethnic minorities, the 321
relationship between dissociative symptoms and psychosis increases as traumatic life events 322
accumulate [12]. Rafiq et al. 2018 [137] demonstrated that exposure to childhood trauma 323
was associated with schizophrenia and that dissociation mediated that association. They 324
studied several types of severe mental illness and found that the association between 325
dissociation and schizophrenia was the most robust. Fisher et al. [138] demonstrated that 326
the history of childhood adversity obtained retrospectively from psychosis patients is 327
reliable. 328
Bleuler, who coined the term schizophrenia, meant a "split mind," did so because of 329
the patients' clear-cut dissociative symptoms under his observation. His observation 330
suggested schizophrenia led to "splitting of thinking and emotion[115]." A meta-analysis 331
found strong evidence that dissociation mediated the relationship between adverse 332
childhood events and psychosis [139]. Braehler et al., 2013 [140] found that more severe 333
trauma symptoms were related to higher levels of dissociation and that this was particularly 334
true in those with chronic symptoms. Emotional abuse seems to be particularly salient in 335
chronic illness. Those diagnosed with dissociative identity disorder experience more first 336
rank Schneiderian symptoms than those diagnosed with schizophrenia [136]. 337
Some have speculated that misdiagnosis based on racial bias is the reason for the 338
overdiagnosis of schizophrenia in disadvantaged minority communities [27, 141, 142]. Bias 339
is likely to play a role, but another critical factor is that dissociative disorders are rarely 340
included in the differential diagnosis when evaluating patients with psychiatric symptoms, 341
despite the ever-increasing evidence that dissociative symptoms are often misdiagnosed. 342
[143]. The failure to include dissociative disorders in psychiatric research is likely to be a 343
compounding factor in the research heterogeneity in the study of psychiatric disorders 344
[144]. Delusional beliefs are thought to have no specific meaning in the life of the sufferer. 345
Delusional material is only incomprehensible to the extent that the examiner and the patient 346
are unaware of the real-life context of the delusional material. Moskowitz, Heim 2011 [115] 347
point out that amnesia for the events, events that are stripped of their autobiographical 348
significance, and events that occur so early in life that verbal-based recall is impossible, leave 349
the sufferer in the dark as to the origin of their overwhelming emotional lability. These 350
authors suggest that delusions can serve several purposes, including containment of 351
overwhelming emotions, symbolic expression of actual events, assuring that traumatic 352
memories remain outside conscious awareness, and acting out of otherwise unacceptable 353
behaviors [115]. 354
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The avoidance and numbing symptoms of PTSD were uniquely associated with the 355
symptoms of psychosis [145, 146], and with depersonalization and derealization [147]. 356
Persistent PTSD may have cognitive processes that include idiosyncratic negative appraisals 357
of the traumatic event and its sequelae, creating a sense of severe current threat. The 358
threat can be internal or external and maintained by the negative appraisals combined with 359
intrusions, arousal, and strong negative emotions[148]. Evans et al., 2015 [149] suggest that 360
the relationship between a damaged self-concept (the totality of an individual's thoughts 361
and feelings concerning himself as an object) and psychosis is mediated through 362
dissociation. That same paper demonstrated that this loss of self mediated the relationship 363
between psychosis and total childhood trauma (emotional abuse, physical abuse, emotional 364
and physical neglect). Dissociation and the loss of self were strongly correlated. Alameda et 365
al., 2015 [104] found evidence that negative cognitive schemas about self, the world, and 366
others, mediated the relationship between child abuse and psychosis. Posttraumatic 367
symptoms (particularly dissociation) played an essential role in that association. Child abuse 368
falls by definition falls into the category of betrayal trauma[64]. Betrayal trauma is 369
associated with higher rates of psychosis spectrum disorder and with increased rates of 370
dissociative spectrum illness[66]. 371
Avoidance and emotional numbing (negative symptoms) may be used as a defense 372
against distress and provide the context for unconscious memories to intrude into conscious 373
awareness [8, 140]. Morrison et al. 2003 [150] demonstrated how traumatic experiences 374
shape the cognitive processes that create and maintain insufficient reality testing. The 375
authors describe how cognitive appraisals of traumatic experiences can lead to trauma-376
based symptoms that can be easily misunderstood as psychosis. Bellido-Zanin et al. 2017 377
[151] demonstrated that dissociation mediated the relationship between inner speech and 378
ideas of reference, a specific symptom of psychosis. Inner speech is the result of the 379
misattribution of internal dialogues to external sources. 380
Dissociation is a defense against a painful world [150, 152, 153]. It is the ability to 381
distance oneself from pain. This can be emotional or physical pain. Often it is both. 382
Children have a natural ability to dissociate and often use it in play [154]. There is ample 383
evidence linking dissociative disorders to childhood trauma [76, 98, 155-158]. If a child is in 384
pain and the adults in his or her world are unwilling to or incapable of mitigating the pain, 385
then the child is forced to use the innate ability to get lost in a world of their own making. In 386
this world, the child becomes someone else, also known as compartmentalization 387
(depersonalization), or is somewhere else, known as distancing(derealization), [157]. There 388
is evidence to indicate that dissociation is a form of autohypnosis[158]. The abused and 389
neglected child uses the ability to create an autohypnotic trance state. In this state, the pain 390
is diminished or even eliminated. Dissociation is related to past traumatic events, but it is 391
also a symptom of a present-day traumatic environment that demands the use of this 392
autohypnotic detachment from pain. In disadvantaged minority communities, the pain is 393
both past and present, leading many members to be actively dissociating. Parents who are 394
in and out of dissociated states often cannot protect their children and often hurt their 395
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children themselves [123]. There are elevated rates of childhood maltreatment in 396
disadvantaged communities, and many layers of disadvantage can add up to increasing 397
incidents of childhood maltreatment. These layers have disordered attachment at the core. 398
Polanco-Roman et al. 2016 [8] demonstrated an association between racial 399
discrimination and dissociative symptoms. Passive coping strategies employed in response 400
to racial discrimination were associated with the greatest increased dissociative symptoms. 401
Caroppo et al. 2021 [138] studied migrants in Italy and found a link between social defeat 402
and the dissociative subtype of PTSD. Sun et al. 2018 [155] noted that childhood trauma 403
positively correlated with dissociation, which mediated the relationship between childhood 404
trauma and delusions. Choi 2017 [156] determined that dissociation partially mediated the 405
relationship between childhood trauma and aberrant experience. Aberrant experiences 406
include bizarre sensitive and perceptual experiences. 407
The 2011 review paper by Keller et al. 2011 [159] followed the diagnosis of 408
schizophrenia over the past 100 years. That paper noted, "the importance placed upon 409
different symptoms and course types associated with schizophrenia has been as 410
heterogeneous as the disorder itself." Patients with dissociative disorders very often meet 411
the criteria for schizophrenia[129, 136, 160-162]. Patients with schizophrenia have fewer 412
first-rank symptoms than patients with DID [163]. Dissociation has been linked to positive 413
symptoms of schizophrenia [56, 164-167]. An explanation for the increase in psychotic 414
symptoms in struggling marginalized communities is that many clinicians involved in the 415
studies are misdiagnosing patients with dissociative disorders [141, 168-171]. Wearn et al. 416
2018 [166] demonstrated that among individuals with PTSD, trauma-intrusive hallucinations 417
are best predicted by the presence of derealization/depersonalization and the loss of self-418
awareness rather than the severity of the PTSD symptoms. Longden 2012 [167] provided 419
evidence suggesting visual hallucinations, including those in the context of schizophrenia, 420
can be most appropriately understood as dissociated or disowned components of the self 421
(or self– other relationships) resulting from trauma, loss, or other interpersonal stressors. 422
Allen 1997 [172] highlighted dissociative detachment as related to developing a psychotic-423
like process, noting that it robs individuals of internal and external anchors and a sense of 424
disconnection to one's own body, self or identity, and actions. This loss of the self leads to 425
impaired reality testing, confusion, disorganization, and disorientation [115]. 426
427
Discussion 428
This paper emphasizes the evidence linking discrimination and social defeat, childhood 429
trauma, and the resulting dissociative disorders to the increased rate of diagnoses of 430
schizophrenia in dark-skinned, disadvantaged neighborhoods worldwide. Discrimination, 431
social defeat, and childhood trauma are factors that lead to a severely diminished sense of 432
self-worth. Dillon 1999 [173] indicated that self-respect is "among the personally significant 433
dimensions of human life" She wrote, "Individuals who are blessed with confident respect 434
12 of 23
for themselves have something that is vital to living a satisfying, meaningful, flourishing life, 435
while those condemned to live without it or with damaged or fragile self-respect are thereby 436
condemned to live constricted, deformed, frustrating lives, cut off from possibilities for self-437
realization, self-fulfillment, and happiness. And that sentence is often served through 438
debilitating emotion. When the abiding flavor of your life is shame or self-contempt; when 439
you have a profound and pervasive sense of yourself as inadequate, pathetic, like dirt; when 440
your life feels meaningless, your activities of little value, your abilities minimal, your 441
character base; when feelings of worthlessness swamp everything else-when living feels like 442
this, living well is impossible." She refers to dignity as respect for oneself as a moral equal 443
and involves "an understanding of oneself as an equal person among persons." Child abuse 444
at the hand of one's caretakers makes developing this self-concept difficult. Experiencing 445
discrimination and social defeat in the world outside the home then further compounds the 446
sense of worthlessness. That pervasive worthlessness is excruciating and ever-present. 447
There is no way to escape it physically. When no physical avenues of escape are possible, 448
dissociation provides the only relief. The individual must find a way to alter their state of 449
consciousness to lessen the pain. 450
The combination of early childhood abuse in the family home and discrimination and 451
social defeat outside the home lead to a profound disintegration of the self that can be all-452
encompassing. It is in this state that detachment and compartmentalization of the self from 453
the painful world takes shape. The different parts of the self can begin to communicate with 454
one another, forming dissociative alters. This communication is often experienced as voices 455
inside or outside of the head. This usually begins in early childhood, as young as 3 or 4 years 456
old. The need to emotionally distance oneself from a painful world leads to distortions in 457
experience, leading to feelings of fear and persecution; this leads to disorganized behavior 458
and a distorted, mistrustful worldview. This combination of symptoms mimics schizophrenia. 459
Because these patients are often non-responsive or only partially responsive to 460
antipsychotic medication, they are called treatment non-responders and left to languish. 461
Dissociative disorders respond to trauma-informed treatment modalities, as demonstrated 462
in Brand et al., 2013 [174]. Still, the treatment is expensive and time-consuming, and 463
providers trained to treat these severely ill patients are in short supply. 464
465
Conclusion 466
The combination of factors highlighted in this paper, including transgenerational and 467
present-day discrimination, social defeat, attachment disorganization, and low self-worth, 468
create a chronic and persistent form of mental illness that has been poorly understood and 469
often misdiagnosed. The resulting dissociative disorder is then misunderstood and 470
misdiagnosed as schizophrenia or non-affective psychosis. As discussed earlier, self-worth 471
and self-concept issues are at the core of the psychotic-like symptoms of dissociation. Salter 472
and Hall 2020 [108] highlight the role of shame in the documented responses to childhood 473
13 of 23
trauma and recommend a primary prevention approach to complex trauma disorders that 474
would go a long way towards decreasing the prevalence of a condition with such devastating 475
consequences for individuals and communities. Salter and Hall 2020 also point out the 476
importance of dignity as a unifying principle when developing prevention strategies and 477
treatment programs for underserved populations. Prevention strategies could eliminate many 478
of the circumstances that lead to this type of human destruction. Polanco- Roman et al., 2016 479
[8] studied the relationship between racial discrimination and dissociative symptoms. Their 480
evidence indicated that racial and ethnic minorities who experienced racial discrimination as 481
traumatic could be more vulnerable to dissociation. This relationship was not explained by 482
exposure to other traumatic life events. They also noted that avoidant and passive coping 483
strategies were most likely to lead to dissociative symptoms. Discrimination and social defeat 484
can be prevented. Societies that preserve the dignity and self-respect of their most vulnerable 485
citizens could stem the tide of traumatization and avoid much of this suffering. Accurate 486
diagnosis and appropriate treatment combined with a primary prevention approach would go 487
a long way towards decreasing the chronic conditions that lead to many cases of severe mental 488
illness [108, 175]. There is hope that more research will be done to determine the incidence of 489
dissociative disorders amongst those who suffer from the stressors of attachment disruption 490
and long-term discrimination, and social defeat. 491
Supplementary Materials: none. 492
Author Contributions: The entire paper was written by Heather Hall. 493
Funding: No funding was provided 494
Institutional Review Board Statement: There were no human or animal subjects involved in the 495
paper production. 496
Informed Consent Statement: Not Applicable 497
498
Data Availability Statement: Not Applicable 499
Acknowledgments: Not Applicable 500
Conflicts of Interest: Not Applicable 501
Appendix A Not Applicable 502
Appendix B Not Applicable 503
504
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