Trauma and Stigma as Defeating Experiences Over the Life Course Interacting with Genetic Liability in Schizophrenia

Catherine van Zelst
European Psychiatric Review, 2010;3(1):35-38
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Abstract

Research suggests that many individuals with schizophrenia have been exposed to developmental trauma early in life, possibly representing a causal influence. In addition, schizophrenia is a syndrome in which stigma has a negative impact on the course and outcome of symptoms and associated disabilities. In combination, these two environmental risk factors are hypothesised to have a cumulative ‘defeating’ effect on the person over the life course. We suggest that the cumulative cascade of early trauma and later stigma interact with genetic vulnerability, producing onset and poor outcome of psychotic symptoms that subsequently may be interpreted as ‘diagnostic’ for the construct of schizophrenia. Research tracing the genetic origins interacting with the defeating effects of early and late adversity therefore represents the first step in unravelling the causal pathways of psychotic psychopathology and ultimately may feed personalised intervention strategies. It is argued that interventions focusing on education at the level of the individual, the group or the community may be most useful in breaking the defeating cycle induced by trauma–stigma-related adversity over the life course in vulnerable individuals. Interventions may also build on ‘salutogenic’ aspects associated with experience of life course adversity. In particular, personal education focusing on the concept of coping may be instrumental in bringing about changes in personal resources and providing a more empowered perspective in overcoming defeat.

Acknowledgements: The research leading to these results has received funding from the European Community’s Seventh Framework Programme under grant agreement No. HEALTH-F2-2009-241909 (Project EU-GEI). With thanks to Jim van Os for commenting on earlier versions of the manuscript.
Keywords
Schizophrenia, psychosis, stigmatisation, coping, trauma
Disclosure The author has no conflicts of interest to declare.
Received: August 10, 2009 Accepted November 30, 2009
Correspondence: Catherine van Zelst, Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University Medical Centre, European Graduate School of Neuroscience, PO Box 616 (location VIJV), Maastricht, 6200 MD, The Netherlands. E: c.vanzelst@sp.unimaas.nl

It is increasingly recognised that, in addition to the disorder itself, societal stigma and the self-stigma associated with it form a major source of chronic stress in schizophrenia. Stigma can be perceived as an environmental factor exerting major effects on anyone with a diagnosis of schizophrenia.1 The defeating nature of the experience of stigma closely resembles the effects of developmental trauma, an environmental risk factor that a proportion of people with schizophrenia have been exposed to and that may be of causal relevance.2,3 Although trauma exposure often occurs in childhood and adolescence, it can also occur in adulthood, e.g. as a consequence of experiencing psychosis. It is proposed that trauma and stigma in fact represent a cascade of related defeating experiences over the life course of the individual with a diagnosis of schizophrenia, occurring both before and after the onset of the illness. Given the fact that together they represent a major environmental source of adversity and that individual differences exist in the susceptibility to environmental adversity,4 research focusing on the interaction between individual vulnerability and environmental adversity is a natural and likely productive starting point of enquiry embodied by these two exposures. Another argument for studying stigma and trauma in the context of gene–environment (GxE) interactions is that both have effects resembling ‘defeat’, and genetic influences in schizophrenia have been linked to neurobiological mechanisms associated with experimental defeat, involving dopamine neurotransmission.5 Thus, GxE interactions underlying the effects of trauma and stigma require further elucidation. In this article, the links between schizophrenia on the one hand and trauma and stigma on the other are reviewed. Not only are the adverse consequences of these two exposures acknowledged; another perspective is presented that incorporates possible positive, ‘salutogenic’ consequences of stigmatisation as well as coping methods to overcome it.

The Concept of Differential Sensitivity and Gene–Environment Interactions

The concept of differential sensitivity is key in explaining the aetiology of psychotic disorders. According to this concept, some individuals may be more sensitive than others to the psychotogenic effects of environmental risks associated with defeat. The concept of differential sensitivity is close to the experience of users, as it offers an explanation of why a particular individual, given certain life circumstances, may develop symptoms and need for care.

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