Loneliness and the psychosis continuum: a meta-analysis on positive psychotic experiences and a meta-analysis on negative psychotic experiences

Abstract

There is an increase in interest in the relationships between loneliness and psychosis. The notion of psychosis continuum implies that psychotic experiences extend from clinical populations with psychotic disorders to non-clinical populations. This meta-analytic review aimed to examine the respective associations of loneliness with positive and negative psychotic experiences along the psychosis continuum. A systematic database search was conducted and a total of 30 studies were included in the first meta-analysis and 15 studies were included in the second meta-analysis. There was a medium association between loneliness and positive psychotic experiences (r?=?0.302, p?<?0.001). In particular, the association between loneliness and paranoia was robust (r?=?0.448, p?<?0.001). The second meta-analysis revealed a medium association between loneliness and negative psychotic experiences (r?=?0.347, p?<?0.001). The associations between loneliness and both positive and negative psychotic experiences were found to be smaller among clinical than non-clinical samples. The above findings provided evidence for the associations between loneliness and the two core dimensions of psychotic experiences along the phenomenological continuum. Future research should examine the dynamics of these relationships in both clinical and non-clinical samples, preferably using a single-symptom approach.     

Psychotic symptoms in non-clinical populations and the continuum of psychosis

A growing body of evidence suggests that delusional or hallucinatory experiences are much more frequent in subjects from the general population than the prevalence of cases of psychotic disorders, thereby suggesting the existence of a symptomatic continuum between subjects from the general population and clinical cases of psychosis. Exploring the risk factors modulating the expression of psychosis-like signs in non-clinical populations may better contribute to elucidate the etiology of psychosis than research restricted to subjects at the endpoint of the distribution of the psychotic dimension. The aim of this paper is to briefly review research investigating the distribution of psychotic symptoms in non-clinical populations, the developmental aspects of psychosis proneness, and the outcome characteristics of psychosis-prone subjects.     

Paracingulate Sulcus Length Is Shorter in Voice-Hearers Regardless of Need for Care

Hallucinations—while often considered an indication of mental illness—are commonly experienced by those without a need for clinical care. These nonclinical voice-hearers offer an opportunity to investigate hallucinations in the absence of confounds inherent to the clinical state. Recent work demonstrates an association between auditory verbal hallucinations (AVH) and structural variability in paracingulate sulcus (PCS) of medial prefrontal cortex in a clinical population. However, before PCS length may be considered a biomarker for clinical hallucination risk, it is necessary to investigate PCS structure in a nonclinical population of voice-hearers with AVH phenomenology similar to those of their clinical counterparts. In the current study, PCS length was measured from T1-weighted structural MRI scans of four groups of participants: (1) voice-hearers with a psychotic disorder (n = 15); (2) voice-hearers without a psychotic disorder (n = 15); (3) nonvoice-hearers with a psychotic disorder (n = 14); and (4) nonvoice-hearers without a psychotic disorder (n = 15). There was a main effect of AVH status—but not psychosis—on right PCS length, with no interaction of AVH and psychosis. Participants with AVH exhibited reduced right PCS length compared to participants without AVH (mean reduction = 8.8 mm, P < 0.05). While past studies have demonstrated decreased PCS length in clinical voice-hearers, ours is the first demonstration that shorter right PCS extends to nonclinical voice-hearers. Our findings support the hypothesis that differences in PCS length are related to the propensity to hear voices and not to illness, consistent with a continuum model of voice-hearing.     

The impact of aversive personality traits on the psychotic-spectrum of disorders

ObjectivesThough relatively unexplored in clinical populations, aversive personality traits have been shown to impact the expression, the management, and the outcomes of psychotic disorders. This paper seeks to gather and organize existing evidence of the complex interplay linking social ethics, personality and experiences of psychosis through the lens of the so-called Dark Triad personality model, comprising the three multidimensional constructs Machiavellianism, narcissism and psychopathy.MethodsA semi-systematic review of major literature databases was conducted; search terms aimed at capturing each of the Dark Triad dimensions and their known relations with both clinical (with single-symptom approach) and non-clinical psychotic experiences.ResultsReviewed studies suggest that all the components of the Dark Triad model present significant clinical implications in the management of psychotic disorders.ConclusionsAversive personality traits interact with and modulate the experiences of psychosis. They can be shown to influence the clinical and functional outcomes of psychotic patients. Therefore, further research on this theme seems justified in that it may inform rehabilitative efforts.     

Dermatoglyphic asymmetries and fronto-striatal dysfunction in young adults reporting non-clinical psychosis

Mittal VA, Dean DJ, Pelletier A. Dermatoglyphic asymmetries and fronto‐striatal dysfunction in young adults reporting non‐clinical psychosis. Objective: Growing evidence indicates that non‐clinical psychotic‐like experiences occur in otherwise healthy individuals, suggesting that psychosis may occur on a continuum. However, little is known about how the diathesis for formal psychosis maps on to individuals at the non‐clinical side of this continuum. Our current understanding of the pathophysiology of schizophrenia implicates certain key factors such as early developmental abnormalities and fronto‐striatal dysfunction. To date, no studies have examined these core factors in the context of non‐clinical psychosis. Method: A total of 221 young adults were assessed for distressing attenuated positive symptoms (DAPS), dermatoglyphic asymmetries (a marker of early developmental insult), and procedural memory (a proxy for fronto‐striatal function). Results: Participants reporting DAPS (n = 16; 7.2%) and no‐DAPS (n = 205; 92.7%) were split into two groups. The DAPS group showed significantly elevated depression, elevated dermatoglyphic asymmetries, and a pattern of procedural learning consistent with other studies with formally psychotic patients. Conclusion: The results indicate that the non‐clinical side of the psychosis continuum also shares key vulnerability factors implicated in schizophrenia, suggesting that both early developmental disruption and abnormalities in fronto‐striatal function are core aspects underlying the disorder.     

Ethnicity and variability of psychotic symptoms

This review addresses the influence of ethnicity on the expression of psychotic symptoms and the implications for evaluating and treating patients of diverse backgrounds. Growing clinical and population research from Europe and the United States supports a dimensional interpretation of psychosis, yet the evidence suggests that psychotic symptoms place individuals at higher risk for a range of severe psychiatric conditions and adverse outcomes, such as suicidality. Ethnocultural diversity challenges clinicians to accurately interpret the clinical significance of patients’ symptom presentations. Disproportionate psychotic symptoms and higher rates of psychotic disorders have been found in some ethnic groups, particularly among immigrants and their offspring, but profound inconsistencies in these patterns remain. More cultural research on the clinical implications of ethnic variation in psychosis is needed. Developing awareness and requisite skills is a priority for clinicians who evaluate and recommend treatments to ethnically diverse patients.     

Identification de marqueurs sociaux et émotionnels associés à l’hallucination acoustico-verbale (HAV) en population pédiatrique : étude Physalis

ObjectivesAuditory-verbal hallucinatory experiences (AVH) represent a prevalence of 12% in the general pediatric population. They are most often considered as a transient and benign developmental phenomenon, associated with mood and anxiety disorders. The persistence of AVHs for several years and into adolescence would represent a poor prognosis of progression into a psychiatric disorder, and more particularly psychotic disorder. The alteration of social and emotional cognitive markers are described as prodromal of this unfavorable progression which should be considered within the continuum between subclinical and clinical signs of the “psychosis phenotype”. The objective of this study was to assess these markers in children and adolescents with AVH and their correlation with the presence and persistence of hallucinations.MethodsMulticenter prospective case-control study, longitudinal over 6 months. Patients were included based on the presence of HAV on clinical examination. Forty subjects aged 8 to 16 years from a clinical pediatric population were included. They were divided into two groups according to the Diagnostic Interview Schedule for Children-Child version (DISC-C): a group with AVH (“AVH+”), and a group without HAV (“AVH?”). A diagnosis of schizophrenia spectrum disorder was a non-inclusion criterion according to the criteria of DSM-5 (K-SADS-PL). This group was matched to the control group without AVH (AVH?) according to sex, age (± 6 months) and associated psychiatric diagnoses assessed by the MINI-Kid. The marker of social cognition was assessed with the NEPSY II test. The emotional marker was assessed with the self-questionnaires: EED IV, which highlights the emotions currently being felt by the subject, and the BAVQ-R, which categorizes the child's emotions in reaction to AVH.ResultsNo significant link was found between the social and emotional cognition markers and the presence of AVH at T0. At 6 months, 50% of subjects in the AVH+ group suffered from persistent AVH and 18% progressed to a diagnosis of schizophrenia spectrum disorder. The persistence of AVH was not significantly correlated with the marker of social cognition, but it was significantly correlated with the presence of negative emotions (sadness, fear, hostility and anger) and inversely correlated with emotions of joy.ConclusionIn this study, AVH experiences in the pediatric population are not linked to markers of social cognition, but negative emotions appear as early markers of AVH persistence.ClinicalTrials.gov IdentifierNCT02567500.     

Auditory hallucinations elicit similar brain activation in psychotic and nonpsychotic individuals

While auditory verbal hallucinations (AVH) are most characteristic for schizophrenia, they also occur in nonpsychotic individuals in the absence of a psychiatric or neurological disorder and in the absence of substance abuse. At present, it is unclear if AVH in these nonpsychotic individuals constitute the same phenomenon as AVH in psychotic patients. Comparing brain activation during AVH between nonpsychotic and psychotic individuals could provide important clues regarding this question. 21 nonpsychotic subjects with AVH and 21 matched psychotic patients indicated the presence of AVH during 3T functional magnetic resonance imaging (fMRI) scanning. To identify common areas of activation during the experience of AVH in both groups, a conjunction analysis was performed. In addition, a 2-sample t-test was employed to discover possible differences in AVH-related activation between the groups. Several common areas of activation were observed for the psychotic and nonpsychotic subjects during the experience of AVH, consisting of the bilateral inferior frontal gyri, insula, superior temporal gyri, supramarginal gyri and postcentral gyri, left precentral gyrus, inferior parietal lobule, superior temporal pole, and right cerebellum. No significant differences in AVH-related brain activation were present between the groups. The presence of multiple common areas of AVH-related activation in psychotic and nonpsychotic individuals, in the absence of significant differences, implicates the involvement of the same cortical network in the experience of AVH in both groups.     

Explaining transitions over the hypothesized psychosis continuum

OBJECTIVES: It is crucial to understand the psychological mechanisms that mediate transition from having one or two psychotic symptoms to becoming a patient with a psychotic disorder. This study investigated whether: (i) a delusional interpretation and/or a depressed response to hallucinatory experiences predicts the later onset of clinical psychotic disorder; and (ii) the presence of need for care in relation to psychotic disorder was associated with the use of particular coping strategies. METHOD: A general population sample of 4672 individuals with no lifetime evidence of any psychotic disorder were interviewed with the Composite International Diagnostic Interview Schedule (CIDI) at baseline and 1 and 3 years later. At year 3, individuals with CIDI evidence of psychotic symptoms were interviewed by clinicians to identify onset of psychotic disorder with need for care. Coping, subjective distress with and perceived control over the psychotic experience were assessed using the Maastricht Assessment of Coping Strategies (MACS). RESULTS: Given the presence of hallucinatory experiences at baseline, the increase in risk on the additive scale of having the psychosis outcome at T2 was higher in the group with delusional ideation at T1 than in those without delusional ideation at T1. Similarly, presence of depressed mood at T1 increased the risk of having the psychosis outcome at T2, but this effect overlapped partly with the risk-increasing effect of delusional ideation. Individuals with a need for care were much more likely to display symptomatic coping, whereas the presence of the other coping types was not different across the groups with and without need for care. CONCLUSION: Transitions over the psychosis continuum are, at least in part, driven by the emotional, cognitive and behavioural responses to the initial psychotic or psychosis-like experiences. Individuals who react with a delusional interpretation, negative emotional states and/or a symptomatic coping style have an increased risk for developing clinical psychosis.     

Childhood traumatic events and types of auditory verbal hallucinations in first-episode schizophrenia patients

ObjectiveEvidence is accumulating that childhood trauma might be associated with higher severity of positive symptoms in patients with psychosis and higher incidence of psychotic experiences in non-clinical populations. However, it remains unknown whether the history of childhood trauma might be associated with particular types of auditory verbal hallucinations (AVH).MethodWe assessed childhood trauma using the Early Trauma Inventory Self-Report — Short Form (ETISR-SF) in 94 first-episode schizophrenia (FES) patients. Lifetime psychopathology was evaluated using the Operational Criteria for Psychotic Illness (OPCRIT) checklist, while symptoms on the day of assessment were examined using the Positive and Negative Syndrome Scale (PANSS). Based on ETISR-SF, patients were divided into those with and without the history of childhood trauma: FES(+) and FES(−) patients.ResultsFES(+) patients had significantly higher total number of AVH types and Schneiderian first-rank AVH as well as significantly higher PANSS P3 item score (hallucinatory behavior) in comparison with FES(−) patients. They experienced significantly more frequently third person AVH and abusive/accusatory/persecutory voices. These differences remained significant after controlling for education, PANSS depression factor score and chlorpromazine equivalent. Linear regression analysis revealed that the total number of AVH types was predicted by sexual abuse score after controlling for above mentioned confounders. This effect was significant only in females.ConclusionOur results indicate that the history of childhood trauma, especially sexual abuse, is associated with higher number AVH in females but not in males. Third person AVH and abusive/accusatory/persecutory voices, representing Schneiderian first-rank symptoms, might be particularly related to childhood traumatic events.     

Latent profile analysis of healthy schizotypy within the extended psychosis phenotype

Converging evidence suggests that psychosis exists on a continuum, and that even mentally “healthy” individuals may experience subclinical psychotic experiences. However, little research has examined the subjective and psychological well-being of individuals in the putatively healthy end of the continuum. This study explored the latent profile structure of schizotypy in a non-clinical sample and compared subjective and psychological well-being across schizotypy profiles. Latent profile analysis was conducted on participants' responses (N=420) to the Oxford-Liverpool Inventory of Feelings and Experiences. Six latent profiles emerged: Low Schizotypy, Average, High Schizotypy, High Unusual Experiences (UE), High Introvertive Anhedonia, and High Introvertive Anhedonia/Cognitive Disorganization. Individuals in the profile characterized by high UE without negative, disorganized or impulsive features tended to endorse similar levels of well-being as the Average and Low Schizotypy profiles. With some exceptions, all three profiles also demonstrated significantly greater subjective and psychological well-being when compared to negative/disorganized schizotypy profiles. The UE profile most closely aligns with previous conceptualizations of “healthy schizotypy.” Future research should investigate how individuals in this profile make sense of unusual or ambiguous experiences that may lead to distress in clinical populations.     

Hallucinations in the general population

Although hallucinations occur in a range of organic and psychiatric conditions, they are not invariably a sign of illness and also occur in “normal“ individuals. Evidence indicates that psychotic hallucinations lie on a continuum with normal experiences, and many more people experience hallucinations than meet criteria for clinical psychosis. In addition to a symptomatic continuum between normal individuals and patients with psychosis, there is evidence that hallucinatory experiences in nonclinical and clinical samples may share the same underlying etiologic influences, including sociodemographic risk factors and neurocognitive mechanisms. Predictors of patient status include beliefs about hallucinations, negative mood, and perceived lack of control.     

Circuit-Based Approaches to Understanding Corticostriatothalamic Dysfunction Across the Psychosis Continuum

Dopamine is known to play a role in the pathogenesis of psychotic symptoms, but the mechanisms driving dopaminergic dysfunction in psychosis remain unclear. Considerable attention has focused on the role of corticostriatothalamic (CST) circuits, given that they regulate and are modulated by the activity of dopaminergic cells in the midbrain. Preclinical studies have proposed multiple models of CST dysfunction in psychosis, each prioritizing different brain regions and pathophysiological mechanisms. A particular challenge is that CST circuits have undergone considerable evolutionary modification across mammals, complicating comparisons across species. Here, we consider preclinical models of CST dysfunction in psychosis and evaluate the degree to which they are supported by evidence from human resting-state functional magnetic resonance imaging studies conducted across the psychosis continuum, ranging from subclinical schizotypy to established schizophrenia. In partial support of some preclinical models, human studies indicate that dorsal CST and hippocampal-striatal functional dysconnectivity are apparent across the psychosis spectrum and may represent a vulnerability marker for psychosis. In contrast, midbrain dysfunction may emerge when symptoms warrant clinical assistance and may thus be a trigger for illness onset. The major difference between clinical and preclinical findings is the strong involvement of the dorsal CST in the former, consistent with an increasing prominence of this circuitry in the primate brain. We close by underscoring the need for high-resolution characterization of phenotypic heterogeneity in psychosis to develop a refined understanding of how the dysfunction of specific circuit elements gives rise to distinct symptom profiles.     

The psychosis continuum in the general population: findings from the São Paulo Epidemiologic Catchment Area Study

The aim of the study was to examine the psychosis continuum in a Latin-American community setting. Data were from the Brazilian São Paulo Epidemiologic Catchment Area Study, a cross-sectional survey conducted in two boroughs of the city of São Paulo. The Composite International Diagnosis Interview (version 1.1) was applied to a probabilistic sample of 1,464 adults, who were interviewed in their household, in order to identify the presence of psychotic symptoms. A subsample was assessed with Schedules for Clinical Assessment in Neuropsychiatry interview. We described the occurrence of psychotic symptoms, categorized into subgroups according to their clinical impact, disability, and help-seeking behavior. The correlation of socio-demographic variables, depressive symptoms, and alcohol and substance use disorders with those psychotic subgroups was analyzed. Polychotomic logistic regression tested the associations between subgroups of psychosis (clinical and subclinical) and the correlates. Of the total sample, 38.0% presented at least one lifetime psychotic symptom, 1.9% met the criteria for an ICD-10 diagnosis of non-affective psychosis, 5.4% presented clinically relevant psychotic symptoms, and 30.7% endorsed clinically non-relevant symptoms. The most common psychotic symptom was delusion with a plausible explanation (in 18.6%). The presence of any psychiatric diagnosis was associated with the presence of psychotic symptoms (OR range, 1.9–8.9). Subclinical psychosis subgroups were found to be associated with the 18–24 year age bracket, chronic depressive mood, and alcohol use disorder. Our results support the concept of a psychosis continuum in Latin-American populations, suggesting that different risk factors influence their manifestation across the continuum.     

Childhood victimisation and developmental expression of non-clinical delusional ideation and hallucinatory experiences

Background Victimisation in childhood may be associated with adult psychosis. The current study examined this association in the crucial developmental period of early adolescence and investigated whether (1) unwanted sexual experiences, and (2) being bullied, were associated with non-clinical delusional ideation and hallucinatory experiences in a general population sample of 14 year olds. Methods Data were derived from standard health screenings of the Youth Health Care Divisions of the Municipal Health Services in Maastricht, the Netherlands. A self-report questionnaire was filled out by a total of 1290 adolescents to assess non-clinical psychotic experiences, as well as experiences of being bullied and sexual trauma. Results Non-clinical psychotic experiences were strongly and independently associated with both bullying (OR=2.9, 95% CI 1.8–4.8) and sexual trauma (OR=4.8, 95% CI 2.3–10.1). Conclusions The results suggest that reported associations between childhood victimisation and adult psychosis can be understood in a developmental framework of onset of at-risk mental states in early adolescence. In addition, the data suggest that the traumatic experience of being bullied may also feed the cognitive and biological mechanisms underlying formation of psychotic ideation.     

Working memory predicts presence of auditory verbal hallucinations in schizophrenia and bipolar disorder with psychosis

Objective: The recent dramatic increase in research investigating auditory verbal hallucinations (AVHs) has broadened the former narrow focus on schizophrenia to incorporate additional populations that experience these symptoms. However, an understanding of potential shared mechanisms remains elusive. Based on theories suggesting a failure of top-down cognitive control, we aimed to compare the relationship between AVHs and cognition in two categorical diagnoses of psychosis, schizophrenia and psychotic bipolar disorder. Method: A total of 124 adults aged 21–60 participated, of whom 76 had present-state psychosis (schizophrenia, n = 53; bipolar disorder with psychosis, n = 23), and 48 were non-clinical controls. Diagnosis and hallucination presence was determined using the Structured Clinical Diagnostic Interview for DSM-IV TR. AVHs severity was assessed using the Positive and Negative Syndrome Scale. Participants also completed the MATRICS cognitive battery. Results: The bipolar disorder with psychosis group performed better than the schizophrenia group for cognitive domains of Processing speed, Attention, Working memory (WM), and Visual memory. Hierarchical binary logistic regression found that WM significantly predicted presence of AVHs in both psychotic groups, but diagnosis did not significantly increase the predictive value of the model. A hierarchical multiple linear regression found that schizophrenia diagnosis was the only significant predictor of hallucination severity. Conclusions: The findings of this study—the first, to our knowledge, to compare the relationship between AVHs and MATRICS domains across schizophrenia and bipolar disorder with psychosis—support theories that deficits in WM underly the genesis of AVHs. WM potentially represents a shared mechanism of AVHs across diagnoses, supporting dimensional classifications of these psychotic disorders. However, non-cognitive factors predictive of hallucination severity may be specific to schizophrenia.     

Cognitive endophenotypes of psychosis within dimension and diagnosis

This study sought to characterize the psychosis phenotype, contrasting cognitive features within traditional diagnosis and psychosis dimension in a family sample containing both schizophrenia and psychotic bipolar I disorder. Seventy-six probands with psychosis [44 probands with schizophrenia, 32 probands with psychotic bipolar I disorder] and 55 first-degree relatives [30 relatives of schizophrenia probands, 25 relatives of bipolar probands] were recruited. Standardized clinical and neuropsychological measures were administered. No differences in cognitive performance emerged between probands with schizophrenia and probands with psychotic bipolar disorder, or between relatives of probands with schizophrenia and relatives of probands with bipolar disorder in the domains of working and declarative memory, executive function and attention. Relatives overall showed higher cognitive performance compared to probands, as expected. However, when we segmented the probands and relatives along a psychosis dimension, independent of diagnostic groups, results revealed lower cognitive performance in probands compared to relatives without psychosis spectrum disorders, whereas relatives with psychosis spectrum disorders showed an intermediate level of performance across all cognitive domains. In this study, cognitive performance did not distinguish either probands or their first-degree relatives within traditional diagnostic groups (schizophrenia and psychotic bipolar disorder), but distinguished probands and relatives with and without lifetime psychosis manifestations independent of diagnostic categories. These data support the notion that schizophrenia and psychotic bipolar disorder present a clinical continuum with overlapping cognitive features defining the psychosis phenotype.     

Aberrations in the arcuate fasciculus are associated with auditory verbal hallucinations in psychotic and in non‐psychotic individuals

The pathophysiology of auditory verbal hallucinations (AVH) is still unclear. Cognitive as well as electrophysiological studies indicate that a defect in sensory feedback (corollary discharge) may contribute to the experience of AVH. This could result from disruption of the arcuate fasciculus, the major tract connecting frontal and temporo‐parietal language areas. Previous diffusion tensor imaging studies indeed demonstrated abnormalities of this tract in schizophrenia patients with AVH. It is, however, difficult to disentangle specific associations with AVH in this patient group as many other factors, such as other positive and negative symptoms, medication or halted education could likewise have affected tract integrity. We therefore investigated AVH in relative isolation and studied a group of non‐psychotic individuals with AVH as well as patients with AVH and non‐hallucinating matched controls. We compared tract integrity of the arcuate fasiculus and of three other control tracts, between 35 non‐psychotic individuals with AVH, 35 schizophrenia patients with AVH, and 36 controls using diffusion tensor imaging and magnetization transfer imaging. Both groups with AVH showed an increase in magnetization transfer ratio (MTR) in the arcuate fasciculus, but not in the other control tracts. In addition, a general decrease in fractional anisotropy (FA) for almost all bundles was observed in the patient group, but not in the non‐psychotic individuals with AVH. As increased MTR in the arcuate fasciculus was present in both hallucinating groups, a specific association with AVH seems plausible. Decreases in FA, on the other hand, seem to be related to other disease processes of schizophrenia. Hum Brain Mapp, 2013. © 2011 Wiley Periodicals, Inc.     

Toward a unified theory of childhood trauma and psychosis: A comprehensive review of epidemiological,clinical, neuropsychological and biological findings

There is a growing body of research focused on the relationship between childhood trauma and the risk of developing psychosis. Numerous studies, including many large-scale population-based studies, controlling for possible mediating variables, provide persuasive evidence of a dose-response association and are indicative of a causal relationship. Existing evidence supports the specificity model, showing differential associations between particular adversities and clinical symptoms, with cumulative adversity causing less favorable clinical and functional outcomes in psychotic patients. To date, several psychological and biological models have been proposed to search for underlying developmental trajectories leading to the onset of psychosis, influencing psychopathological manifestation and negative functional outcomes due to a history of childhood trauma. In this article, we provide a unified review on the relationship between childhood trauma and psychosis by integrating results of epidemiological, clinical, neuropsychological and biological studies. The question whether psychosis with a positive history of childhood trauma should be considered as a new psychotic phenotype, requiring specific therapeutic interventions, warrants further investigation.