Social Adversity in the Etiology of Psychosis: A Review of the Evidence

Despite increasing evidence for the role of psychosocial factors in the onset and continuance of psychosis, the experiences involved are still largely considered the result of a biogenetic anomaly for which medication is the first-line treatment response. This review summarizes the extensive literature demonstrating that adverse events involving trauma, loss, stress, and disempowerment have a central etiological role in psychosis. Evidence is further presented to show that many neurological changes traditionally considered indicative of a disease process can in fact be accounted for as secondary effects to the physiology of stress or the residual of long-term neuroleptic prescription. Particular emphasis is given to the traumagenic neurodevelopmental model of psychosis, which illustrates how many of the structural and functional cerebral anomalies observed in adult patients with psychosis (including dopamine dysregulation, atrophy, hippocampal damage, and over-activity of the hypothalamic-adrenal-pituitary axis) closely correspond to those in the brains of abused children. Finally, research is discussed that demonstrates how trauma may manifest in characteristic symptoms of psychosis, particularly hallucinations and delusions. It is suggested that if social adversities are of central importance in psychosis, then psychotherapy that addresses the long term sequelae of those adversities should be considered an essential aspect of treatment.