ArticlePDF Available

Dissociation and misdiagnosis of schizophrenia in populations experiencing chronic discrimination and social defeat



As recently as the late 20th century, Schizophrenia, a category of mental illness with widely varying phenotypic symptoms, was believed by psychobiologists to be a genetically based disorder in which the environment played a limited etiological role. Yet a growing body of evidence indicates a strong correlation between schizophrenia and environmental factors. This theoretical paper explores the relationship between highly elevated rates of schizophrenia in some low-income minority communities worldwide and trauma-related dissociative symptoms that often mimic schizophrenia. Elevated rates of schizophrenia in racially and ethnically isolated, inner-city Black populations are well documented. This paper contains evidence proposing that this amplification in the rate of schizophrenia is mediated by childhood trauma, disorganized attachment, and social defeat. Further, evidence demonstrating how these three variables combine in early childhood to incubate dissociative disorders will also be conveyed. The misdiagnosis of dissociative disorders as schizophrenia is theorized to partially mediate the increased rate of schizophrenia in communities that experience high levels of racial/ethnic discrimination. It is argued that this misdiagnosis is often attributable to cultural misunderstanding and/or a lack of knowledge about dissociative disorders
Dissociation and Misdiagnosis of Schizophrenia in 1
Populations Experiencing Chronic Discrimination and Social 2
Defeat 3
Heather Hall 11 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
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
2 of 23
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
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
3 of 23
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
4 of 23
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
5 of 23
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
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 auditoryverbal hallucinations, and attachment-disrupting events 195
6 of 23
(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
7 of 23
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
8 of 23
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
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
9 of 23
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
10 of 23
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
11 of 23
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 selfother 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
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
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
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
References 505
1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. 2013: 507
Arlington VA. 508
2. Reinders, A, Marquand, AF, Schlumpf, YR, Chalavi, S, Vissia, EM, Nijenhuis, ERS, Dazzan, P, Jancke, L, 509
Veltman, DJ, Aiding the diagnosis of dissociative identity disorder: pattern recognition study of brain biomarkers. Br J 510
Psychiatry, 2019. 215(3): p. 536-544. 511
14 of 23
3. Lebois, LAM, Li, M, Baker, JT, Wolff, JD, Wang, D, Lambros, AM, Grinspoon, E, Winternitz, S, Ren, J, Gonenc, 512
A, Gruber, SA, Ressler, KJ, Liu, H, Kaufman, ML, Large-Scale Functional Brain Network Architecture Changes 513
Associated With Trauma-Related Dissociation. Am J Psychiatry, 2021. 178(2): p. 165-173. 514
4. Morgan, C, Knowles, G, Hutchinson, G, Migration, ethnicity and psychoses: evidence, models and future directions. 515
World Psychiatry, 2019. 18(3): p. 247-258. 516
5. Fearon, PMorgan, C, Environmental factors in schizophrenia: the role of migrant studies. Schizophr Bull, 2006. 517
32(3): p. 405-8. 518
6. Selten, JP, Termorshuizen, F, van Sonsbeek, M, Bogers, J, Schmand, B, Migration and dementia: a meta-analysis of 519
epidemiological studies in Europe. Psychol Med, 2020: p. 1-8. 520
7. Anglin, DM, Ereshefsky, S, Klaunig, MJ, Bridgwater, MA, Niendam, TA, Ellman, LM, DeVylder, J, Thayer, G, 521
Bolden, K, Musket, CW, Grattan, RE, Lincoln, SH, Schiffman, J, Lipner, E, Bachman, P, Corcoran, CM, Mota, 522
NB, van der Ven, E, From Womb to Neighborhood: A Racial Analysis of Social Determinants of Psychosis in the 523
United States. Am J Psychiatry, 2021. 178(7): p. 599-610. 524
8. Polanco-Roman, L, Danies, A, Anglin, DM, Racial discrimination as race-based trauma, coping strategies, and 525
dissociative symptoms among emerging adults. Psychol Trauma, 2016. 8(5): p. 609-17. 526
9. Keating, LMuller, RT, LGBTQ+ based discrimination is associated with ptsd symptoms, dissociation, emotion 527
dysregulation, and attachment insecurity among LGBTQ+ adults who have experienced Trauma. J Trauma 528
Dissociation, 2020. 21(1): p. 124-141. 529
10. Beatson, JA, Broadbear, JH, Duncan, C, Bourton, D, Rao, S, Avoiding Misdiagnosis When Auditory Verbal 530
Hallucinations Are Present in Borderline Personality Disorder. J Nerv Ment Dis, 2019. 207(12): p. 1048-1055. 531
11. Anglin, DM, Polanco-Roman, L, Lui, F, Ethnic variation in whether dissociation mediates the relation between 532
traumatic life events and attenuated positive psychotic symptoms. J Trauma Dissociation, 2015. 16(1): p. 68-85. 533
12. Anglin, DM, Espinosa, A, Barada, B, Tarazi, R, Feng, A, Tayler, R, Allicock, NM, Pandit, S, Comparing the Role 534
of Aberrant Salience and Dissociation in the Relation between Cumulative Traumatic Life Events and Psychotic-Like 535
Experiences in a Multi-Ethnic Sample. J Clin Med, 2019. 8(8). 536
13. Anderson RE, HS, Wilson MN, Shaw DS, Dishion TJ, Williams JL., Pathways to Pain: Racial Discrimination and 537
Relations Between Parental Functioning and Child Psychosocial Well-Being. J J Black Psychol., 2015. 41(6): p. 491-538
512. 539
14. van Ijzendoorn MH, SC, Bakermans-Kranenburg MJ. , Disorganized attachment in early childhood: meta-analysis 540
of precursors, concomitants, and sequelae. Dev Psychopathol. , 1999. Spring(2): p. 225-49. 541
15. Saha, S, Chant, D, Welham, J, McGrath, J, A systematic review of the prevalence of schizophrenia. PLoS Med, 2005. 542
2(5): p. e141. 543
16. Kate, MA, Jamieson, G, Dorahy, MJ, Middleton, W, Measuring Dissociative Symptoms and Experiences in an 544
Australian College Sample Using a Short Version of the Multidimensional Inventory of Dissociation. J Trauma 545
Dissociation, 2021. 22(3): p. 265-287. 546
17. Kirkbride, JB, Migration and psychosis: our smoking lung? World Psychiatry, 2017. 16(2): p. 119-120. 547
18. Cantor-Graae, ESelten, JP, Schizophrenia and migration: a meta-analysis and review. Am J Psychiatry, 2005. 162(1): 548
p. 12-24. 549
19. Kirkbride, JB, Morgan, C, Fearon, P, Dazzan, P, Murray, RM, Jones, PB, Neighbourhood-level effects on psychoses: 550
re-examining the role of context. Psychol Med, 2007. 37(10): p. 1413-25. 551
20. Golden, SA, Covington, HE, 3rd, Berton, O, Russo, SJ, A standardized protocol for repeated social defeat stress in 552
mice. Nat Protoc, 2011. 6(8): p. 1183-91. 553
15 of 23
21. Selten, JP, van der Ven, E, Rutten, BP, Cantor-Graae, E, The social defeat hypothesis of schizophrenia: an update. 554
Schizophr Bull, 2013. 39(6): p. 1180-6. 555
22. Trierweiler, SJ, Muroff, JR, Jackson, JS, Neighbors, HW, Munday, C, Clinician race, situational attributions, and 556
diagnoses of mood versus schizophrenia disorders. Cultur Divers Ethnic Minor Psychol, 2005. 11(4): p. 351-64. 557
23. Neighbors, HW, Trierweiler, SJ, Ford, BC, Muroff, JR, Racial differences in DSM diagnosis using a semi-structured 558
instrument: the importance of clinical judgment in the diagnosis of African Americans. J Health Soc Behav, 2003. 559
44(3): p. 237-56. 560
24. Morgan, CFearon, P, Social experience and psychosis insights from studies of migrant and ethnic minority groups. 561
Epidemiol Psichiatr Soc, 2007. 16(2): p. 118-23. 562
25. Bresnahan, M, Begg, MD, Brown, A, Schaefer, C, Sohler, N, Insel, B, Vella, L, Susser, E, Race and risk of 563
schizophrenia in a US birth cohort: another example of health disparity? Int J Epidemiol, 2007. 36(4): p. 751-8. 564
26. Hollander, AC, Dal, H, Lewis, G, Magnusson, C, Kirkbride, JB, Dalman, C, Refugee migration and risk of 565
schizophrenia and other non-affective psychoses: cohort study of 1.3 million people in Sweden. BMJ, 2016. 352: p. i1030. 566
27. Eack, SM, Bahorik, AL, Newhill, CE, Neighbors, HW, Davis, LE, Interviewer-perceived honesty as a mediator of 567
racial disparities in the diagnosis of schizophrenia. Psychiatr Serv, 2012. 63(9): p. 875-80. 568
28. Veling, W, Hoek, HW, Mackenbach, JP, Perceived discrimination and the risk of schizophrenia in ethnic minorities: a 569
case-control study. Soc Psychiatry Psychiatr Epidemiol, 2008. 43(12): p. 953-9. 570
29. Schwartz, RCBlankenship, DM, Racial disparities in psychotic disorder diagnosis: A review of empirical literature. 571
World J Psychiatry, 2014. 4(4): p. 133-40. 572
30. Tortelli, A, Errazuriz, A, Croudace, T, Morgan, C, Murray, RM, Jones, PB, Szoke, A, Kirkbride, JB, 573
Schizophrenia and other psychotic disorders in Caribbean-born migrants and their descendants in England: systematic 574
review and meta-analysis of incidence rates, 1950-2013. Soc Psychiatry Psychiatr Epidemiol, 2015. 50(7): p. 1039-575
55. 576
31. Paksarian, D, Merikangas, KR, Calkins, ME, Gur, RE, Racial-ethnic disparities in empirically-derived subtypes of 577
subclinical psychosis among a U.S. sample of youths. Schizophr Res, 2016. 170(1): p. 205-10. 578
32. Oluwoye, O, Stiles, B, Monroe-DeVita, M, Chwastiak, L, McClellan, JM, Dyck, D, Cabassa, LJ, McDonell, MG, 579
Racial-Ethnic Disparities in First-Episode Psychosis Treatment Outcomes From the RAISE-ETP Study. Psychiatr 580
Serv, 2018. 69(11): p. 1138-1145. 581
33. Neighbors, HW, Trierweiler, SJ, Munday, C, Thompson, EE, Jackson, JS, Binion, VJ, Gomez, J, Psychiatric 582
diagnosis of African Americans: diagnostic divergence in clinician-structured and semistructured interviewing 583
conditions. J Natl Med Assoc, 1999. 91(11): p. 601-12. 584
34. Harrison, G, Gunnell, D, Glazebrook, C, Page, K, Kwiecinski, R, Association between schizophrenia and social 585
inequality at birth: case-control study. Br J Psychiatry, 2001. 179: p. 346-50. 586
35. Solmi, F, Colman, I, Weeks, M, Lewis, G, Kirkbride, JB, Trajectories of Neighborhood Cohesion in Childhood, and 587
Psychotic and Depressive Symptoms at Age 13 and 18 Years. J Am Acad Child Adolesc Psychiatry, 2017. 56(7): p. 588
570-577. 589
36. O'Donoghue, B, Roche, E, Lane, A, Neighbourhood level social deprivation and the risk of psychotic disorders: a 590
systematic review. Soc Psychiatry Psychiatr Epidemiol, 2016. 51(7): p. 941-50. 591
37. van Os J, HM, Bijl RV, Vollebergh W. , Prevalence of psychotic disorder and community level of psychotic symptoms: 592
an urban-rural comparison. . Arch Gen Psychiatry. , 2001. July 58(7): p. 663-8. 593
38. Grech A, vOJ, Evidence That the Urban Environment Moderates the Level of Familial Clustering of Positive Psychotic 594
Symptoms. . Schizophr Bull. , 2017. March 1(2): p. 325-331. 595
16 of 23
39. Wagner, G, Glick, P, Khammash, U, Shaheen, M, Brown, R, Goutam, P, Karam, R, Linnemayr, S, Massad, S, 596
Exposure to violence and its relationship to mental health among young people in Palestine. East Mediterr Health J, 597
2020. 26(2): p. 189-197. 598
40. Clarke, A, Olive, P, Akooji, N, Whittaker, K, Violence exposure and young people's vulnerability, mental and 599
physical health. Int J Public Health, 2020. 65(3): p. 357-366. 600
41. Miguel, PM, Pereira, LO, Silveira, PP, Meaney, MJ, Early environmental influences on the development of children's 601
brain structure and function. Dev Med Child Neurol, 2019. 61(10): p. 1127-1133. 602
42. DeVylder, JE, Jun, HJ, Fedina, L, Coleman, D, Anglin, D, Cogburn, C, Link, B, Barth, RP, Association of 603
Exposure to Police Violence With Prevalence of Mental Health Symptoms Among Urban Residents in the United States. 604
JAMA Netw Open, 2018. 1(7): p. e184945. 605
43. Termorshuizen, F, Smeets, HM, Braam, AW, Veling, W, Neighborhood ethnic density and psychotic disorders 606
among ethnic minority groups in Utrecht City. Soc Psychiatry Psychiatr Epidemiol, 2014. 49(7): p. 1093-102. 607
44. Boydell, J, van Os, J, McKenzie, K, Allardyce, J, Goel, R, McCreadie, RG, Murray, RM, Incidence of schizophrenia 608
in ethnic minorities in London: ecological study into interactions with environment. BMJ, 2001. 323(7325): p. 1336-8. 609
45. Mezuk, B, Li, X, Cederin, K, Concha, J, Kendler, KS, Sundquist, J, Sundquist, K, Ethnic enclaves and risk of 610
psychiatric disorders among first- and second-generation immigrants in Sweden. Soc Psychiatry Psychiatr Epidemiol, 611
2015. 50(11): p. 1713-22. 612
46. Cicero, DCCohn, JR, The role of ethnic identity, self-concept, and aberrant salience in psychotic-like experiences. 613
Cultur Divers Ethnic Minor Psychol, 2018. 24(1): p. 101-111. 614
47. Flores, EC, Fuhr, DC, Bayer, AM, Lescano, AG, Thorogood, N, Simms, V, Mental health impact of social capital 615
interventions: a systematic review. Soc Psychiatry Psychiatr Epidemiol, 2018. 53(2): p. 107-119. 616
48. Fiorati, RC, Arcencio, RA, Segura Del Pozo, J, Ramasco-Gutierrez, M, Serrano-Gallardo, P, Intersectorality and 617
social participation as coping policies for health inequities-worldwide. Gac Sanit, 2018. 32(3): p. 304-314. 618
49. Castillo, EG, Chung, B, Bromley, E, Kataoka, SH, Braslow, JT, Essock, SM, Young, AS, Greenberg, JM, 619
Miranda, J, Dixon, LB, Wells, KB, Community, Public Policy, and Recovery from Mental Illness: Emerging Research 620
and Initiatives. Harv Rev Psychiatry, 2018. 26(2): p. 70-81. 621
50. De Silva MJ, MK, Harpham T, Huttly SR. , Social capital and mental illness: a systematic review. J Epidemiol 622
Community Health. , 2005. Aug(8): p. 619-27. 623
51. Ehsan, AMDe Silva, MJ, Social capital and common mental disorder: a systematic review. J Epidemiol Community 624
Health, 2015. 69(10): p. 1021-8. 625
52. Khazaeian, S, Kariman, N, Ebadi, A, Nasiri, M, The impact of social capital and social support on the health of 626
female-headed households: a systematic review. Electron Physician, 2017. 9(12): p. 6027-6034. 627
53. van Nierop M, LA, Myin-Germeys I, Collip D, Viechtbauer W, Jacobs N, Derom C, Thiery E, van Os J, van 628
Winkel R. , Stress reactivity links childhood trauma exposure to an admixture of depressive, anxiety, and psychosis 629
symptoms. Psychiatry Res. , 2018. Feb(260): p. 451-457. 630
54. Cantor-Graae, E, The contribution of social factors to the development of schizophrenia: a review of recent findings. 631
Can J Psychiatry, 2007. 52(5): p. 277-86. 632
55. Li D, LS, Andermann L. , Association between degrees of social defeat and themes of delusion in patients with 633
schizophrenia from immigrant and ethnic minority backgrounds. . Transcult Psychiatry. , 2012. Nov(5): p. 735-49. 634
56. Janssen, I, Hanssen, M, Bak, M, Bijl, RV, de Graaf, R, Vollebergh, W, McKenzie, K, van Os, J, Discrimination 635
and delusional ideation. Br J Psychiatry, 2003. 182: p. 71-6. 636
17 of 23
57. Berger, MSarnyai, Z, "More than skin deep": stress neurobiology and mental health consequences of racial 637
discrimination. Stress, 2015. 18(1): p. 1-10. 638
58. Eaton, S, Harrap, B, Downey, L, Thien, K, Bowtell, M, Bardell-Williams, M, Ratheesh, A, McGorry, P, 639
O'Donoghue, B, Incidence of treated first episode psychosis from an Australian early intervention service and its 640
association with neighbourhood characteristics. Schizophr Res, 2019. 209: p. 206-211. 641
59. Jaya, ES, Ascone, L, Lincoln, TM, Social Adversity and Psychosis: The Mediating Role of Cognitive Vulnerability. 642
Schizophr Bull, 2017. 43(3): p. 557-565. 643
60. McCutcheon, R, Bloomfield, MAP, Dahoun, T, Quinlan, M, Terbeck, S, Mehta, M, Howes, O, Amygdala 644
reactivity in ethnic minorities and its relationship to the social environment: an fMRI study. Psychol Med, 2018. 645
48(12): p. 1985-1992. 646
61. Sideli, L, Murray, RM, Schimmenti, A, Corso, M, La Barbera, D, Trotta, A, Fisher, HL, Childhood adversity and 647
psychosis: a systematic review of bio-psycho-social mediators and moderators. Psychol Med, 2020. 50(11): p. 1761-648
1782. 649
62. van de Beek MH, vdKL, Schoevers RA, Veling W. , . Social exclusion and psychopathology in an online cohort of 650
Moroccan-Dutch migrants: Results of the MEDINA-study. . PLoS One. , 2017. Jul 10(7): p. e0179827. 651
63. Oh, H, Jacob, L, Anglin, DM, Koyanagi, A, Perceived skin tone discrimination and psychotic experiences among 652
Black Americans: Findings from the National Survey of American Life. Schizophr Res, 2021. 228: p. 541-546. 653
64. Freyd, J, Betrayal trauma: The logic of forgetting childhood abuse. 1996, Cambridge MA: Harvard University Press. 654
65. Smith, CPFreyd, JJ, Institutional betrayal. Am Psychol, 2014. 69(6): p. 575-87. 655
66. Gómez, J, What's in a betrayal? Trauma, dissociation, and hallucinations among high-functioning ethnic minority 656
emerging adults. Journal of Aggression, Maltreatment & Trauma, 2019. 28(10): p. 1181-1198. 657
67. Garety, PA, Bebbington, P, Fowler, D, Freeman, D, Kuipers, E, Implications for neurobiological research of 658
cognitive models of psychosis: a theoretical paper. Psychol Med, 2007. 37(10): p. 1377-91. 659
68. Wallace, K, DeToma, A, Lewin, DN, Sun, S, Rockey, D, Britten, CD, Wu, JD, Ba, A, Alberg, AJ, Hill, EG, Racial 660
Differences in Stage IV Colorectal Cancer Survival in Younger and Older Patients. Clin Colorectal Cancer, 2017. 661
16(3): p. 178-186. 662
69. Myers, NAZiv, T, "No One Ever Even Asked Me that Before": Autobiographical Power, Social Defeat, and Recovery 663
among African Americans with Lived Experiences of Psychosis. Med Anthropol Q, 2016. 30(3): p. 395-413. 664
70. Trent, M, Dooley, DG, Douge, J, Section On Adolescent, H, Council On Community, P, Committee On, A, The 665
Impact of Racism on Child and Adolescent Health. Pediatrics, 2019. 144(2). 666
71. Clark, K, Clark. KM, The Development of Consciousness of Self and the Emergence of Racial Identification in Negro 667
Preschool Children. Journal of Social Psychology 1939. 10: p. 591-599. 668
72. McCarthy-Jones, S, Is Shame Hallucinogenic? Front Psychol, 2017. 8: p. 1310. 669
73. Laroi, F, Thomas, N, Aleman, A, Fernyhough, C, Wilkinson, S, Deamer, F, McCarthy-Jones, S, The ice in voices: 670
Understanding negative content in auditory-verbal hallucinations. Clin Psychol Rev, 2019. 67: p. 1-10. 671
74. Matos, M, Pinto-Gouveia, J, Duarte, C, Above and beyond emotional valence: the unique contribution of central and 672
traumatic shame memories to psychopathology vulnerability. Memory, 2012. 20(5): p. 461-77. 673
75. Arseneault L, CM, Fisher HL, Polanczyk G, Moffitt TE, Caspi A. , Childhood trauma and children's emerging 674
psychotic symptoms: A genetically sensitive longitudinal cohort study. Am J Psychiatry, 2011. 168(1): p. 65-72. 675
76. Varese, F, Smeets, F, Drukker, M, Lieverse, R, Lataster, T, Viechtbauer, W, Read, J, van Os, J, Bentall, RP, 676
Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional 677
cohort studies. Schizophr Bull, 2012. 38(4): p. 661-71. 678
18 of 23
77. Read, JBentall, RP, Negative childhood experiences and mental health: theoretical, clinical and primary prevention 679
implications. Br J Psychiatry, 2012. 200(2): p. 89-91. 680
78. Read, J, van Os, J, Morrison, AP, Ross, CA, Childhood trauma, psychosis and schizophrenia: a literature review with 681
theoretical and clinical implications. Acta Psychiatr Scand, 2005. 112(5): p. 330-50. 682
79. Gracie, A, Freeman, D, Green, S, Garety, PA, Kuipers, E, Hardy, A, Ray, K, Dunn, G, Bebbington, P, Fowler, 683
D, The association between traumatic experience, paranoia and hallucinations: a test of the predictions of psychological 684
models. Acta Psychiatr Scand, 2007. 116(4): p. 280-9. 685
80. Hardy, A, Fowler, D, Freeman, D, Smith, B, Steel, C, Evans, J, Garety, P, Kuipers, E, Bebbington, P, Dunn, G, 686
Trauma and hallucinatory experience in psychosis. J Nerv Ment Dis, 2005. 193(8): p. 501-7. 687
81. Holowka, DW, King, S, Saheb, D, Pukall, M, Brunet, A, Childhood abuse and dissociative symptoms in adult 688
schizophrenia. Schizophr Res, 2003. 60(1): p. 87-90. 689
82. Bentall RP, WS, Shevlin M, Varese F., Do specific early-life adversities lead to specific symptoms of psychosis? A 690
study from the 2007 the Adult Psychiatric Morbidity Survey. . Schizophr Bull. , 2012. 38(4): p. 734-40. 691
83. Schafer, IFisher, HL, Childhood trauma and psychosis - what is the evidence? Dialogues Clin Neurosci, 2011. 13(3): 692
p. 360-5. 693
84. Croft, J, Heron, J, Teufel, C, Cannon, M, Wolke, D, Thompson, A, Houtepen, L, Zammit, S, Association of 694
Trauma Type, Age of Exposure, and Frequency in Childhood and Adolescence With Psychotic Experiences in Early 695
Adulthood. JAMA Psychiatry, 2019. 76(1): p. 79-86. 696
85. Powers, A, Fani, N, Cross, D, Ressler, KJ, Bradley, B, Childhood trauma, PTSD, and psychosis: Findings from a 697
highly traumatized, minority sample. Child Abuse Negl, 2016. 58: p. 111-8. 698
86. Perry, BD, Childhood experience and the expression of genetic potential: What childhood neglect tells us about nature 699
and nurture. Brain & Mind, 3(1), 79100. . Brain & Mind 2002. 3(1): p. 79-100. 700
87. Joiner, TE, Hom, MA, Hagan, CR, Silva, C, Suicide as a derangement of the self-sacrificial aspect of eusociality. 701
Psychol Rev, 2016. 123(3): p. 235-54. 702
88. Tomassi, STosato, S, Epigenetics and gene expression profile in first-episode psychosis: The role of childhood trauma. 703
Neurosci Biobehav Rev, 2017. 83: p. 226-237. 704
89. Richetto, JMeyer, U, Epigenetic Modifications in Schizophrenia and Related Disorders: Molecular Scars of 705
Environmental Exposures and Source of Phenotypic Variability. Biol Psychiatry, 2021. 89(3): p. 215-226. 706
90. Read J, F, R Joskowitz, and Perry B, The traumagenic neurodevelopmental model of psychosis revisited 707
Neuropsychiatry, 2014. 4(1): p. 65-79. 708
91. Bentall, RP, de Sousa, P, Varese, F, Wickham, S, Sitko, K, Haarmans, M, Read, J, From adversity to psychosis: 709
pathways and mechanisms from specific adversities to specific symptoms. Soc Psychiatry Psychiatr Epidemiol, 2014. 710
49(7): p. 1011-22. 711
92. Bentall, R, "The environment and psychosis: Rethinking the evidence" in Trauma and Psychosis: New Directions for 712
Theory and Therapy, W. Larkin, & Morrison, A.P. , Editor. 2006, Routledge. 713
93. Dutta, R, Greene, T, Addington, J, McKenzie, K, Phillips, M, Murray, RM, Biological, life course, and cross-714
cultural studies all point toward the value of dimensional and developmental ratings in the classification of psychosis. 715
Schizophr Bull, 2007. 33(4): p. 868-76. 716
94. Insel, TR, Rethinking schizophrenia. Nature, 2010. 468(7321): p. 187-93. 717
95. Schiavone, FL, McKinnon, MC, Lanius, RA, Psychotic-Like Symptoms and the Temporal Lobe in Trauma-Related 718
Disorders: Diagnosis, Treatment, and Assessment of Potential Malingering. Chronic Stress (Thousand Oaks), 2018. 719
2: p. 2470547018797046. 720
19 of 23
96. Jaaskelainen, E, Haapea, M, Rautio, N, Juola, P, Penttila, M, Nordstrom, T, Rissanen, I, Husa, A, Keskinen, E, 721
Marttila, R, Filatova, S, Paaso, TM, Koivukangas, J, Moilanen, K, Isohanni, M, Miettunen, J, Twenty Years of 722
Schizophrenia Research in the Northern Finland Birth Cohort 1966: A Systematic Review. Schizophr Res Treatment, 723
2015. 2015: p. 524875. 724
97. Fang Z, LY, Xie L, Cheng M, Ma J, Li T, Li X, Jiang L. , Characteristics and outcomes of children with dissociative 725
(conversion) disorders in western China: a retrospective study. . BMC Psychiatry, 2021. 12;21(1): p. 31. 726
98. Putnam, F, Dissociative disorders in children: behavioral profiles and problems. . Child Abuse Negl. 1993 Jan-727
Feb;17(1):39-45. , 1993. Jan-Feb (1): p. 39-45. 728
99. Fonagy, P, The transgenerational transmission of holocaust trauma. Lessons learned from the analysis of an adolescent 729
with obsessive-compulsive disorder. Attach Hum Dev, 1999. 1(1): p. 92-114. 730
100. Davarinejad, O, Mohammadi Majd, T., Golmohammadi, F., Mohammadi, P., Radmehr, F., Alikhani, M., 731
Motaei, T., Moradinazar, M., Brühl, A., Sadeghi Bahmani, D., Brand, S., , Identification of Risk Factors to Predict 732
the Occurrences of Relapses in Individuals with Schizophrenia Spectrum Disorder in Iran. International journal of 733
environmental research and public health 2021. 18(2): p. 546. 734
101. Shaham Y., MJRSdISIP, Social defeat. , in Encyclopedia of Psychopharmacology. Springer, , S. I.P, Editor. 2010, 735
Springer, : Berlin, Heidelberg. 736
102. Unal, B, Akgul, O, T, BI, Alptekin, K, Akdede, BBK, Association of Wider Social Environment with Relapse in 737
Schizophrenia: Registry Based Six-Year Follow-Up Study. Noro Psikiyatr Ars, 2019. 56(4): p. 235-242. 738
103. O'Connor, RCNock, MK, The psychology of suicidal behaviour. Lancet Psychiatry, 2014. 1(1): p. 73-85. 739
104. Alameda, L, Ferrari, C, Baumann, PS, Gholam-Rezaee, M, Do, KQ, Conus, P, Childhood sexual and physical 740
abuse: age at exposure modulates impact on functional outcome in early psychosis patients. Psychol Med, 2015. 45(13): 741
p. 2727-36. 742
105. Bateson, G, Jackson, D. D., Haley, J., & Weakland, J. , Toward a theory of schizophrenia. . Behavioral Science, 1, 743
251–264., 1956. 1: p. 251-264. 744
106. Lyons-Ruth, K, The Two-Person Construction of Defenses: Disorganized Attachment Strategies, Unintegrated Mental 745
States, and Hostjle/Helpless Relational Processes. J Infant Child Adolesc Psychother, 2003. 2: p. 105-114. 746
107. Hesse, EMain, M, Disorganized infant, child, and adult attachment: collapse in behavioral and attentional strategies. J 747
Am Psychoanal Assoc, 2000. 48(4): p. 1097-127; discussion 1175-87. 748
108. Salter, MHall, H, Reducing Shame, Promoting Dignity: A Model for the Primary Prevention of Complex Post-749
Traumatic Stress Disorder. Trauma Violence Abuse, 2020: p. 1524838020979667. 750
109. Ford, JD, Complex PTSD: research directions for nosology/assessment, treatment, and public health. Eur J 751
Psychotraumatol, 2015. 6: p. 27584. 752
110. Bowlby, J, Attachment and loss: Attachment (Vol. 1). . 1969, New York: Basic. . 753
111. Duschinsky, RSolomon, J, Infant disorganized attachment: Clarifying levels of analysis. Clin Child Psychol 754
Psychiatry, 2017. 22(4): p. 524-538. 755
112. Riggs, S, Childhood emotional abuse and the attachment system across the life cycle: What theory and research tell us. 756
Journal of Aggression, Maltreatment & Trauma, 2010. 19(1): p. 5-51. 757
113. Zimmer-Gembeck, MJ, Haley J. Webb, Christopher A. Pepping, Kellie Swan, Ourania Merlo, Ellen A. Skinner, 758
Elbina Avdagic, and Michelle Dunbar. , Review: Is ParentChild Attachment a Correlate of Children's Emotion 759
Regulation and Coping?" International Journal of Behavioral Development 2017. 41(1): p. 74-93. 760
114. Cooke, JE, Kochendorfer, LB, Stuart-Parrigon, KL, Koehn, AJ, Kerns, KA, Parent-child attachment and children's 761
experience and regulation of emotion: A meta-analytic review. Emotion, 2019. 19(6): p. 1103-1126. 762
20 of 23
115. Moskowitz, AHeim, G, Eugen Bleuler's Dementia praecox or the group of schizophrenias (1911): a centenary 763
appreciation and reconsideration. Schizophr Bull, 2011. 37(3): p. 471-9. 764
116. Bucci, S, Emsley, R, Berry, K, Attachment in psychosis: A latent profile analysis of attachment styles and association 765
with symptoms in a large psychosis cohort. Psychiatry Res, 2017. 247: p. 243-249. 766
117. Harder, S, Attachment in schizophrenia--implications for research, prevention, and treatment. Schizophr Bull, 2014. 767
40(6): p. 1189-93. 768
118. Liotti, G, Trauma, Dissociation, and Disorganized Attachment: Three Strands of a Single Braid. Psychotherapy: 769
Theory, Research, Practice, Training 2004. 41(4): p. 472-486. 770
119. Vermetten E, DM, Spiegel D Traumatic Dissociation: Neurobiology and Treatment 2007: American Psychiatric 771
Publishing 772
120. Liotti, G, & Gumley, A. , "An attachment perspective on schizophrenia: The role of disorganized attachment, 773
dissociation and mentalization." in Psychosis, Trauma and Dissociation: Emerging Perspectives on Severe 774
Psychopathology, , S.I. Moskowitz A., & Dorahy M.J. , Editor. 2008, Psychosis, Trauma and Dissociation: 775
Emerging Perspectives on Severe Psychopathology, . 776
121. Paetzold, RL, Rholes, W. S., & Andrus, J. L, A Bayesian analysis of the link between adult disorganized attachment 777
and dissociative symptoms. Personality and Individual Differences, 2017. 107: p. 17-22. 778
122. Lyons-Ruth, K, Dissociation and the parent-infant dialogue: a longitudinal perspective from attachment research. J Am 779
Psychoanal Assoc, 2003. 51(3): p. 883-911. 780
123. Lyons-Ruth, K, Contributions of the Mother-Infant Relationship to Dissociative, Borderline, and Conduct Symptoms in 781
Young Adulthood. Infant Ment Health J, 2008. 29(3): p. 203-218. 782
124. Granqvist, P, Sroufe, LA, Dozier, M, Hesse, E, Steele, M, van Ijzendoorn, M, Solomon, J, Schuengel, C, Fearon, 783
P, Bakermans-Kranenburg, M, Steele, H, Cassidy, J, Carlson, E, Madigan, S, Jacobvitz, D, Foster, S, Behrens, K, 784
Rifkin-Graboi, A, Gribneau, N, Spangler, G, Ward, MJ, True, M, Spieker, S, Reijman, S, Reisz, S, Tharner, A, 785
Nkara, F, Goldwyn, R, Sroufe, J, Pederson, D, Pederson, D, Weigand, R, Siegel, D, Dazzi, N, Bernard, K, 786
Fonagy, P, Waters, E, Toth, S, Cicchetti, D, Zeanah, CH, Lyons-Ruth, K, Main, M, Duschinsky, R, Disorganized 787
attachment in infancy: a review of the phenomenon and its implications for clinicians and policy-makers. Attach Hum 788
Dev, 2017. 19(6): p. 534-558. 789
125. Felitti, VJ, The Relation Between Adverse Childhood Experiences and Adult Health: Turning Gold into Lead. Perm J, 790
2002. 6(1): p. 44-47. 791
126. Hesse, EMain, M, Frightened, threatening, and dissociative parental behavior in low-risk samples: description, 792
discussion, and interpretations. Dev Psychopathol, 2006. 18(2): p. 309-43. 793
127. Murphy, R, Goodall, K, Woodrow, A, The relationship between attachment insecurity and experiences on the 794
paranoia continuum: A meta-analysis. Br J Clin Psychol, 2020. 59(3): p. 290-318. 795
128. Bebbington, P, Jonas, S, Kuipers, E, King, M, Cooper, C, Brugha, T, Meltzer, H, McManus, S, Jenkins, R, 796
Childhood sexual abuse and psychosis: data from a cross-sectional national psychiatric survey in England. Br J 797
Psychiatry, 2011. 199(1): p. 29-37. 798
129. Tschöke, S, Uhlmann, C., Steinert ,T., Schizophrenia or trauma-related psychosis? Schneiderian first rank symptoms 799
as a challenge for differential diagnosis. Neuropsychiatry (2011) 1(4), 349–360, 2011. 1(4): p. 349-360. 800
130. Lyons-Ruth, K, & Block, D. , The disturbed caregiving system: Relations among childhood trauma, maternal 801
caregiving, and infant affect and attachment. Infant Mental Health Journal, 1996. 17(3): p. 257-275. 802
131. Schroeder K, LW, Fisher HL, Huber CG, Schäfer I. , Dissociation in patients with schizophrenia spectrum disorders: 803
What is the role of different types of childhood adversity? . Compr Psychiatry., 2016. Jul (68): p. 201-8. 804
21 of 23
132. Hébert M, LR, Charest F, Disorganized attachment and emotion dysregulation as mediators of the association between 805
sexual abuse and dissociation in preschoolers. J Affect Disord. 2020 Apr 15;267:220-228, 2020. April(267): p. 220-806
228. 807
133. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders 5th edition: DSM 5., ed. 808
American Psychiatric Association. 2013, Arlington VA. 809
134. Powers, A, Cross, D, Fani, N, Bradley, B, PTSD, emotion dysregulation, and dissociative symptoms in a highly 810
traumatized sample. J Psychiatr Res, 2015. 61: p. 174-9. 811
135. Kate, MA, Hopwood, T, Jamieson, G, The prevalence of Dissociative Disorders and dissociative experiences in college 812
populations: a meta-analysis of 98 studies. J Trauma Dissociation, 2020. 21(1): p. 16-61. 813
136. Dell, PF, A new model of dissociative identity disorder. Psychiatr Clin North Am, 2006. 29(1): p. 1-26, vii. 814
137. Rafiq S, CC, Varese F., The relationship between childhood adversities and dissociation in severe mental illness: a meta-815
analytic review. . Acta Psychiatr Scand. 138(6): p. 509-525. 816
138. Caroppo, E, Lanzotti, P, Janiri, L, Psychopathology in refugees subjected to the Dublin Regulation: an Italian study. 817
CNS Spectr, 2021. 26(1): p. 77-83. 818
139. Williams, J, Bucci, S, Berry, K, Varese, F, Psychological mediators of the association between childhood adversities and 819
psychosis: A systematic review. Clin Psychol Rev, 2018. 65: p. 175-196. 820
140. Braehler, C, Valiquette, L, Holowka, D, Malla, AK, Joober, R, Ciampi, A, Pawliuk, N, King, S, Childhood trauma 821
and dissociation in first-episode psychosis, chronic schizophrenia and community controls. Psychiatry Res, 2013. 822
210(1): p. 36-42. 823
141. Anglin, DMMalaspina, D, Ethnicity effects on clinical diagnoses compared to best-estimate research diagnoses in 824
patients with psychosis: a retrospective medical chart review. J Clin Psychiatry, 2008. 69(6): p. 941-5. 825
142. Gara, MA, Minsky, S, Silverstein, SM, Miskimen, T, Strakowski, SM, A Naturalistic Study of Racial Disparities in 826
Diagnoses at an Outpatient Behavioral Health Clinic. Psychiatr Serv, 2019. 70(2): p. 130-134. 827
143. Loewenstein, RJ, Dissociation debates: everything you know is wrong. Dialogues Clin Neurosci, 2018. 20(3): p. 229-828
242. 829
144. Sar, VRoss, C, Dissociative disorders as a confounding factor in psychiatric research. Psychiatr Clin North Am, 2006. 830
29(1): p. 129-44, ix. 831
145. Hansen, M, Ross, J, Armour, C, Evidence of the dissociative PTSD subtype: A systematic literature review of latent 832
class and profile analytic studies of PTSD. J Affect Disord, 2017. 213: p. 59-69. 833
146. van Huijstee J, VE, The Dissociative Subtype of Post-traumatic Stress Disorder: Research Update on Clinical and 834
Neurobiological Features. Curr Top Behav Neurosci. , 2018. 38: p. 229-248. 835
147. Frewen, PA, Brown, MF, Steuwe, C, Lanius, RA, Latent profile analysis and principal axis factoring of the DSM-5 836
dissociative subtype. Eur J Psychotraumatol, 2015. 6: p. 26406. 837
148. Ehlers, A, Maercker, A, Boos, A, Posttraumatic stress disorder following political imprisonment: the role of mental 838
defeat, alienation, and perceived permanent change. J Abnorm Psychol, 2000. 109(1): p. 45-55. 839
149. Evans, GJ, Reid, G, Preston, P, Palmier-Claus, J, Sellwood, W, Trauma and psychosis: The mediating role of self-840
concept clarity and dissociation. Psychiatry Res, 2015. 228(3): p. 626-32. 841
150. Morrison, AP, Frame, L, Larkin, W, Relationships between trauma and psychosis: a review and integration. Br J Clin 842
Psychol, 2003. 42(Pt 4): p. 331-53. 843
151. Bellido-Zanin G, P-GS, Senín-Calderón C, López-Jiménez AM, Rodríguez-Testal JF., Relationship between inner 844
dialog and ideas of reference and the mediating role of dissociation. . Scand J Psychol., 2017. 58(1): p. 100-106. 845
22 of 23
152. Griffin MG, RP, Mechanic MB. , Objective assessment of peritraumatic dissociation: psychophysiological indicators. . 846
Am J Psychiatry, 1997. Aug;154(8 847
): p. 1081-8 848
153. Sar, V, The many faces of dissociation: opportunities for innovative research in psychiatry. Clin Psychopharmacol 850
Neurosci, 2014. 12(3): p. 171-9. 851
154. Putnam, F, Dissociation in children and adolescents: A developmental perspective. , ed. G. Press. 1997, New York, 852
New York. 853
155. Sun, P, Alvarez-Jimenez, M, Simpson, K, Lawrence, K, Peach, N, Bendall, S, Does dissociation mediate the 854
relationship between childhood trauma and hallucinations, delusions in first episode psychosis? Compr Psychiatry, 855
2018. 84: p. 68-74. 856
156. Choi, JY, Posttraumatic stress symptoms and dissociation between childhood trauma and two different types of 857
psychosis-like experience. Child Abuse Negl, 2017. 72: p. 404-410. 858
157. Vogel, M, Braungardt, T, Grabe, HJ, Schneider, W, Klauer, T, Detachment, compartmentalization, and 859
schizophrenia: linking dissociation and psychosis by subtype. J Trauma Dissociation, 2013. 14(3): p. 273-87. 860
158. Lyssenko, L, Schmahl, C, Bockhacker, L, Vonderlin, R, Bohus, M, Kleindienst, N, Dissociation in Psychiatric 861
Disorders: A Meta-Analysis of Studies Using the Dissociative Experiences Scale. Am J Psychiatry, 2018. 175(1): p. 37-862
46. 863
159. Keller WR, FB, Carpenter WT Jr., Revisiting the diagnosis of schizophrenia: where have we been and where are we 864
going? . CNS Neurosci Ther. , 2011. 17(2): p. 83-8. 865
160. Freeman, DFowler, D, Routes to psychotic symptoms: trauma, anxiety and psychosis-like experiences. Psychiatry 866
Res, 2009. 169(2): p. 107-12. 867
161. Kluft, RP, First-rank symptoms as a diagnostic clue to multiple personality disorder. Am J Psychiatry, 1987. 144(3): p. 868
293-8. 869
162. Ross, CAJoshi, S, Schneiderian symptoms and childhood trauma in the general population. Compr Psychiatry, 1992. 870
33(4): p. 269-73. 871
163. Laddis, ADell, PF, Dissociation and psychosis in dissociative identity disorder and schizophrenia. J Trauma 872
Dissociation, 2012. 13(4): p. 397-413. 873
164. Bob, PMashour, GA, Schizophrenia, dissociation, and consciousness. Conscious Cogn, 2011. 20(4): p. 1042-9. 874
165. Dorahy, MJ, Shannon, C, Seagar, L, Corr, M, Stewart, K, Hanna, D, Mulholland, C, Middleton, W, Auditory 875
hallucinations in dissociative identity disorder and schizophrenia with and without a childhood trauma history: 876
similarities and differences. J Nerv Ment Dis, 2009. 197(12): p. 892-8. 877
166. Wearne, D, Curtis, G, Choy, W, Magtengaard, R, Samuel, M, Melvill-Smith, P, Trauma-intrusive hallucinations 878
and the dissociative state. BJPsych Open, 2018. 4(5): p. 385-388. 879
167. Longden, E, Madill, A, Waterman, MG, Dissociation, trauma, and the role of lived experience: toward a new 880
conceptualization of voice hearing. Psychol Bull, 2012. 138(1): p. 28-76. 881
168. Simon RJ, FJ, Gurland BJ, Stiller PR, Sharpe L, Depression and Schizophrenia in hospitalized black and white mental 882
patients. . Arch Gen Psychiatry., 1973. Apr(4): p. 509-12. 883
169. Adebimpe, VR, Overview: white norms and psychiatric diagnosis of black patients. Am J Psychiatry, 1981. 138(3): p. 884
279-85. 885
170. Patel K, HC, Institutional racism in psychiatry does not imply racism in individual psychiatrists: commentary on 886
Institutional racism in psychiatry. . Psychiatr Bull. , 2007. 31: p. 367-368. 887
23 of 23
171. Strakowski SM, HJ, Keck PE Jr, McElroy SL, West SA, Bourne ML, Sax KW, Tugrul KC., The effects of race and 888
information variance on disagreement between psychiatric emergency service and research diagnoses in first-episode 889
psychosis. . J Clin Psychiatry, 1997. 58(10): p. 457-63. 890
172. Allen, JG, Coyne, L, Console, DA, Dissociative detachment relates to psychotic symptoms and personality 891
decompensation. Compr Psychiatry, 1997. 38(6): p. 327-34. 892
173. Dillon, R, Self-Respect: Moral, Emotional, Political. Ethics 1997. 107(2): p. 226-249. 893
174. Brand, BL, McNary, S. W., Myrick, A. C., Classen, C. C., Lanius, R., Loewenstein, R. J., Pain,C., P, F. W., A 894
longitudinal naturalistic study of patients with dissociative disorders treated by community clinicians. . Psychological 895
Trauma: Theory, Research, Practice, and Policy, 2013. 5(4): p. 301-308. 896
175. Keyes KM, EN, Krueger RF, McLaughlin KA, Wall MM, Grant BF, Hasin DS., Childhood maltreatment and the 897
structure of common psychiatric disorders. . Br J Psychiatry. , 2012. 200(2): p. 107-15. 898
Schizophrenia (SCZ) is a severe mental disorder that affects approximately 1% general population worldwide and poses a considerable burden to society. Despite decades of research, its etiology remains unclear, and diagnosis remains challenging due to its heterogeneous symptoms. Exosomes play a crucial role in intercellular communication, and their contents, including nucleotides, proteins and metabolites, have been linked to various diseases. Recent studies have implicated exosome abnormalities in the pathogenesis of schizophrenia. In this review, we discuss the current understanding of the relationship between exosomes and schizophrenia, focusing on the role of exosomal contents in this disease. We summarize recent findings and provide insights into the potential use of exosomes as biomarkers for the diagnosis and treatment of schizophrenia.
Full-text available
The article is devoted to the analysis of the causes of overdiagnosis and misdiagnosis of schizophrenia from the standpoint of cognitive distortions in the process of cognition of clinical reality. Using the diagnosis of sluggish schizophrenia as an example, it is concluded that overdiagnosis is based on the false consensus effect, which in psychiatry reflects the diagnosticians solidarity with the position of the scientific school to which he belongs, and with the inability to resist the pressure of authorities. A clinical example of an erroneous diagnosis is given. In conclusion, it is stated that the overdiagnosis of schizophrenia and the unjustified prescription of antipsychotic therapy to patients leads to the discrediting of psychiatry and the stigmatization of the mentally ill. This trend should be reconsidered and the diagnosis of schizophrenia should be made solely on the basis of obvious, and not indirect, clinical phenomena.
Full-text available
Psychological models of the consequences of ostracism (i.e. being socially excluded and ignored) and negative symptoms in schizophrenia suggest that repeatedly experiencing ostracism can lead to elevated levels of amotivation, anhedonia, and asociality (i.e. negative symptoms). We tested this assumption in a prospective study, following up a large multi-national community sample from Germany, Indonesia, and the United States (N = 962) every four months over one year. At each of the four assessment points (T0 – T3), participants rated their recent ostracism experiences and negative symptoms. Using cross-lagged panel analyses we found a) that negative symptoms and experiences of ostracism were significantly associated in each of the four assessment points, b) that ostracism predicted negative symptoms over time (T2 to T3), and c) that negative symptoms increased ostracism (T0 to T1). The results are in line with the social defeat model of negative symptoms and suggest a bi-directional longitudinal relationship between ostracism and negative symptoms. Moving forward, it will therefore be important to gain an understanding of potential moderators involved in the mechanism.
Full-text available
Recent social movements have illuminated systemic inequities in U.S. society, including within the social sciences. Thus, it is essential that attachment researchers and practitioners engage in reflection and action to work toward anti-racist perspectives in the field. Our aims in this paper are (1) to share the generative conversations and debates that arose in preparing the Special Issue of Attachment & Human Development, “Attachment Perspectives on Race, Prejudice, and Anti-Racism”; and (2) to propose key considerations for working toward anti-racist perspectives in the field of attachment. We provide recommendations for enriching attachment theory (e.g. considering relations between caregivers’ racial-ethnic socialization and secure base provision), research (e.g. increasing the representation of African American researchers and participants), and practice (e.g. advocating for policies that reduce systemic inequities in family supports). Finally, we suggest two relevant models integrating attachment theory with perspectives from Black youth development as guides for future research.
Full-text available
Objective: Drawing on race-based trauma models, the present study examined common reactions to trauma exposure (i.e., stress sensitivity, dissociative symptoms, depressive symptoms), as potential explanatory factors in the relation between racial/ethnic discrimination and suicide-related risk among racial and ethnic minority young adults. Method: A group of racial and ethnic minority (N = 747; 61% women; 63% U.S.-born; 34% Asian American) young adults, ages 18–29 (M = 19.84; SD = 2.22), completed a battery of self-report measures online. Accounting for demographics and other trauma exposures, direct and indirect associations between racial/ethnic discrimination and suicide attempt (SA) through stress sensitivity, dissociative symptoms, depressive symptoms, and suicide ideation (SI) were examined using hierarchical linear regression models and bootstrapping methods. Results: There was a direct association between racial/ethnic discrimination and stress sensitivity, dissociative symptoms, and depressive symptoms, but not SI or SA, after accounting for demographics and trauma exposures. There was also an indirect association between racial/ethnic discrimination and SI and SA through stress sensitivity, dissociative symptoms, and depressive symptoms. Conclusion: Experiences of racial/ethnic discrimination may function as a source of traumatic stress in racial and ethnic minority young adults to confer risk for SI and SA via stress sensitivity, dissociation, and depressive symptoms. Addressing racial/ethnic discrimination may help reduce suicide-related risk by targeting stress-related exposures particularly relevant to racial and ethnic minority young adults.
Full-text available
Black populations are diagnosed with schizophrenia at a rate that is significantly higher than white populations. This elevated diagnostic rate is often the result of misdiagnosis. This article includes a brief literature review and case presentation highlighting the importance of understanding complex racial trauma when evaluating and treating Black clients.
Full-text available
The authors examine U.S.-based evidence that connects characteristics of the social environment with outcomes across the psychosis continuum, from psychotic experiences to schizophrenia. The notion that inequitable social and economic systems of society significantly influence psychosis risk through proxies, such as racial minority and immigrant statuses, has been studied more extensively in European countries. While there are existing international reviews of social determinants of psychosis, none to the authors' knowledge focus on factors in the U.S. context specifically-an omission that leaves domestic treatment development and prevention efforts incomplete and underinformed. In this review, the authors first describe how a legacy of structural racism in the United States has shaped the social gradient, highlighting consequential racial inequities in environmental conditions. The authors offer a hypothesized model linking structural racism with psychosis risk through interwoven intermediary factors based on existing theoretical models and a review of the literature. Neighborhood factors, cumulative trauma and stress, and prenatal and perinatal complications were three key areas selected for review because they reflect social and environmental conditions that may affect psychosis risk through a common pathway shaped by structural racism. The authors describe evidence showing that Black and Latino people in the United States suffer disproportionately from risk factors within these three key areas, in large part as a result of racial discrimination and social disadvantage. This broad focus on individual and community factors is intended to provide a consolidated space to review this growing body of research and to guide continued inquiries into social determinants of psychosis in U.S. contexts.
Full-text available
Experiencing psychological trauma during childhood and/or adolescence is associated with an increased risk of psychosis in adulthood. However, we lack a clear knowledge of how developmental trauma induces vulnerability to psychotic symptoms. Understanding the psychological processes involved in this association is crucial to the development of preventive interventions and improved treatments. We sought to systematically review the literature and combine findings using meta‐analytic techniques to establish the potential roles of psychological processes in the associations between developmental trauma and specific psychotic experiences (i.e., hallucinations, delusions and paranoia). Twenty‐two studies met our inclusion criteria. We found mediating roles of dissociation, emotional dysregulation and post‐traumatic stress disorder (PTSD) symptoms (avoidance, numbing and hyperarousal) between developmental trauma and hallucinations. There was also evidence of a mediating role of negative schemata, i.e. mental constructs of meanings, between developmental trauma and delusions as well as paranoia. Many studies to date have been of poor quality, and the field is limited by mostly cross‐sectional research. Our findings suggest that there may be distinct psy­chological pathways from developmental trauma to psychotic phenomena in adulthood. Clinicians should carefully ask people with psychosis about their history of developmental trauma, and screen patients with such a history for dissociation, emotional dysregulation and PTSD symptoms. Well conducted research with prospective designs, including neurocognitive assessment, is required in order to fully understand the biopsychosocial mechanisms underlying the association between developmental trauma and psychosis.
Full-text available
Background Dissociative (conversion) disorder in children is a complex biopsychosocial disorder with high rates of medical and psychiatric comorbidities. We sought to identify the characteristics and outcomes of children with dissociative (conversion) disorders in western China. Methods We conducted a retrospective cohort study of 66 children admitted with dissociative (conversion) disorders from January 2017 to July 2019, and analyzed their clinical characteristics, socio-cultural environmental variables, and personality and psychiatric/psychological characteristics. Binary logistic regression was used to analyze the variables associated with clinical efficacy. Results Of these 66 patients, 38 (57.6%) were male and 28 (42.4%) were female, 46 (69.7%) had an antecedent stressor, 30 (45.5%) were left-behind adolescents, and 16 (24.2%) were from single-parent families. In addition, 30 patients (45.5%) were not close to their parents, 38 patients (59.4%) had an introverted personality, and 34 (53.1%) had unstable emotions. Thirteen families (19.7%) were uncooperative with the treatment. Patients who had cormorbid anxiety or depression exhibited significantly lower cognitive ability ( P < 0.01). Logistic regression found that better treatment outcomes were positively associated with having a close relationship with parents, parental cooperation with treatment, and having a father with a lower level of education (i.e., less than junior college or higher). Conclusions The characteristics and outcomes of children with dissociative (conversion) disorders are related to socio-cultural environmental variables and psychiatric/psychological factors. Timely recognition and effective treatment of dissociative (conversion) disorders are important.
Background Black Americans face significant discrimination, which has been linked to risk for psychotic experiences. However, fewer studies have examined whether perceived skin tone discrimination is associated with psychotic experiences. Methods Drawing data from the National Survey of American Life (NSAL), we used multivariable logistic regression to examine the associations between perceived skin tone discrimination (from Blacks and Whites) and psychotic experiences, adjusting for sociodemographic covariates, common mental disorders, and major discriminatory events. Results In bivariate regression models, a one-unit increase in frequency of perceived skin tone discrimination from Blacks was associated with a 24% increase in odds of having any lifetime psychotic experience (AOR: 1.24; 95% CI: 1.11–1.38). A one-unit increase in frequency of perceived skin tone discrimination from Whites was associated with an 18% increase in odds of having any lifetime psychotic experience (AOR: 1.18; 95% CI: 1.03–1.34). When examining perceived skin tone discrimination from Blacks and Whites in the same models, only perceived skin tone discrimination from Blacks was significantly associated with lifetime psychotic experiences, adjusting for sociodemographic characteristics, common metal disorders, and major discriminatory events. Perceived skin tone discrimination was associated with lifetime hallucinatory experiences, but not lifetime delusional ideation. Conclusion A significant portion of the Black population reported skin tone discrimination from Blacks and Whites, which is related to lifetime psychotic experiences. Future longitudinal and qualitative studies can elaborate on these findings and further contextualize skin tone discrimination and its health effects.