The association between early traumatic experiences and the five domains of negative symptoms in participants at clinical high risk for psychosis

Youth at clinical high risk (CHR) for psychosis have high rates of early life trauma, but it is unclear how trauma exposure impacts later negative symptom severity in CHR. The current study examined the association between early childhood trauma and the five domains of negative symptoms (anhedonia, avolition, asociality, blunted affect, alogia).


| INTRODUCTION
Trauma is an important risk factor for developing psychotic disorders and severe mental illnesses (Gibson et al., 2016).Studies have found that individuals with psychotic disorders endorse higher rates of childhood trauma than healthy controls (Kraan et al., 2015).Exposure to traumatic events has also been associated with greater delusions and hallucinations in individuals with psychosis (Bailey et al., 2018).
Research has begun to explore the role of trauma in those at clinical high risk (CHR) for psychosis, which reflects a clinical syndrome characterized by attenuated positive symptoms, functional decline, and distress.Like schizophrenia, CHR individuals report higher trauma rates than healthy controls (Kline et al., 2016;Mayo et al., 2017), with a meta-analysis by Kraan et al. (2015) finding an average trauma prevalence rate of 86.8% for those at CHR.These traumatic experiences can precipitate events that impact neurocognitive, emotional, and functional development (Mayo et al., 2017), which can contribute to clinical consequences.Most critically, higher trauma rates in CHR have been linked to greater positive symptomatology (Grivel et al., 2018;Loewy et al., 2019) as well as increased anxiety, depression, and suicidal ideation (Addington et al., 2013;Grivel et al., 2018).
Although these findings point to a link between trauma, positive symptoms, and general psychopathology, the link between trauma and negative symptoms is unclear.In those with psychotic disorders, some studies have found an association between specific childhood trauma, such as emotional neglect, and higher negative symptoms, while others have not (Kraan et al., 2015;Isvoranu et al., 2016).In CHR, little work has examined the association between trauma and negative symptoms, but similar to schizophrenia, the extant work is mixed (Kraan et al., 2015).Among CHR youth, the Structured Interview of Psychosis-Risk Syndromes (SIPS; Miller et al., 2003) negative symptom subscale is often used; however, this subscale does not comprehensively assess negative symptoms in accordance with contemporary theoretical conceptualizations (Strauss et al., 2020), which may explain mixed findings.This scale also does not assess the five core negative symptom domains (anhedonia, avolition, asociality, alogia, blunted affect) put forth by the NIMH consensus conference on negative symptoms (Kirkpatrick et al., 2006) and found to represent the latent structure of negative symptoms in CHR (Chang, Strauss, Ahmed, Wong, Chan, Lee, et al., 2021).
This study aimed to build on prior research by examining the association between childhood trauma and the five negative symptom domains in CHR using the Negative Symptom Inventory-Psychosis Risk (NSI-PR, Strauss et al., in press).Greater understanding of the mechanisms underlying the five domains can allow for tailored treatment approaches, which is critical because negative symptoms are highly predictive of conversion, functional decline, initial access to care, and subjective well-being among CHR (Strauss & Cohen, 2017).Although findings are mixed, prior studies have found associations between early trauma history and decreased expressed emotions (Grivel et al., 2018), social isolation in adulthood (Copeland et al., 2018), and reduced motivation (Miu et al., 2017).Therefore, we hypothesized that greater childhood trauma would be associated with greater negative symptoms due to the impact trauma may have on motivational, social, and emotional functions.

| Participants
Participants included 89 CHR individuals (see Table 1) initially recruited for studies examining reward processing mechanisms underlying negative symptoms and psychosis risk (Bartolomeo et al., 2019(Bartolomeo et al., , 2021;;Clay et al., 2021;Strauss et al., 2023).Participants were included if they met criteria for an at-risk syndrome on the SIPS and did not meet lifetime criteria for a DSM-5 psychotic disorder on the SCID-5 (First et al., 2015).et al., 2013;Janssen et al., 2004), which is a semi-structured interview that assesses whether participants experienced one or more of six types of trauma before the age of 16.The CTAS was chosen due to its prior use in large scale CHR studies (Addington et al., 2013) and inclusion of trauma types (e.g., bullying) that may be especially relevant to CHR youth.Participants were monetarily compensated for their participation.

| Data analysis
We first examined sex differences in the number of traumas endorsed; due to a non-normal distribution in the sample, the Wilcoxon rank sum test was used.Spearman correlations were conducted to examine associations between overall negative symptoms and trauma levels, as well as the severity of the five negative symptom domains and the types of traumas endorsed.Finally, to determine whether negative symptom severity was associated with childhood trauma beyond the effects of positive symptom severity, a hierarchical regression was conducted.Trauma was regressed onto positive symptom severity in the first step, followed by negative symptom severity in the second step.

| RESULTS
The means and frequency of traumatic experiences are reported in Table 2. Males and females did not significantly differ in overall (i.e., CTAS total score) traumatic experiences (W = 1256, p = .77,r = À.01).
Several significant correlations were found between traumatic experiences and negative symptoms in CHR (see Table 3).More severe avolition and total negative symptoms were associated with larger CTAS total scores and emotional neglect.Severity of negative symptoms increased with greater rates of psychological and physical bullying, psychological abuse, and physical abuse.More severe avolition and asociality were associated with more exposure to physical bullying.More severe avolition was associated with increased exposure to emotional neglect.
Regression analyses (see Table 4) indicated that negative symptom severity accounted for an additional 5% of the variance in trauma beyond that accounted for by positive symptom severity, R 2 Δ = .05,F(1,86) = 4.66, p = .034.

| DISCUSSION
This study examined the association between childhood trauma and negative symptoms.We found that greater severity of negative symptoms broadly defined was associated with childhood traumatic experiences, including physical bullying, emotional neglect, psychological abuse, and physical abuse.
These findings suggest that early adversity and childhood trauma may contribute to the emergence of negative symptoms.It may be that childhood trauma leads to a vulnerability in the neural systems responsible for negative symptoms, for example, corticostriatal circuitry (Dandash et al., 2014).Alternatively, in line with the cognitive model of negative symptoms (Beck et al., 2011), early adverse experiences may contribute to the development of cognitive processes core to avolition, anhedonia, and asociality, like dysfunctional beliefs (Clay et al., 2021;Perivoliotis et al., 2009).Similarly, in line with attachment theory (Berry et al., 2007), trauma may negatively influence social interaction patterns and interpersonal beliefs about oneself and others, which may contribute to negative symptoms.Finally, the experience of trauma may also result in greater secondary negative symptoms through its impact on positive symptoms.
Furthermore, greater avolition and asociality severity in early adulthood were specifically associated with greater experiences of physical bullying, and greater avolition was associated with emotional neglect.This is the first study to suggest that these experiences may be associated with increased negative symptoms.Similarly, emotional neglect has been associated with greater positive symptoms (Ackner et al., 2013); however, we do not know when this develops.Future longitudinal research is needed to identify the direction of this association.Importantly, we also found that negative symptom severity explained additional variance in trauma beyond the effects of positive symptom severity.This suggests that the link between negative T A B L E 2 CTAS mean and frequency scores (N = 89).

Mean scores
Trauma endorsement frequency  (Bernstein et al., 1995) or Brief Betrayal Trauma Survey (Goldberg & Freyd, 2006).Additionally, our sample size was largely female and did not permit examining racial differences.Finally, longitudinal data were not available to compare psychosis converters versus non-converters.

| Clinical implications
The associations between negative symptom and childhood trauma indicate that trauma may be an essential yet under- Participants were recruited from three sites across the United States: the Georgia Psychiatric Risk Evaluation Program (G-PREP) in Athens, GA, the Northwestern University Adolescent Development and Preventative Treatment (ADAPT) research program in Evanston, IL, and the Mental Health and Development (MHAD) Program at Emory University in Atlanta, GA.All three programs are designed to perform evaluations for youth displaying early psychosis.
All participants provided written informed consent for a study approved by local institutional review boards and following the ethical standards outlined in the 1964 Declaration of Helsinki and its later amendments.Participants completed clinical interviews conducted by the site PIs or examiners trained to reliability standards (>0.80) using gold standard training videos.Participants completed the SCID-5, SIPS, NSI-PR, which assesses the five domains of negative symptoms, and the Childhood Trauma and Abuse Scale (CTAS; Addington considered mechanism of avolition and asociality.The high trauma prevalence in the CHR population indicates the need for trauma screening when treating CHR individuals.Incorporating components of trauma-informed care in extant negative symptom treatments such as Cognitive-Behavioural Social Skills Training (Kelsven et al., 2022) may offer a novel approach to treating negative symptoms in CHR.CONFLICT OF INTEREST STATEMENT Gregory P. Strauss is one of the original developers of the brief negative symptom scale (BNSS) and receives royalties and consultation fees from Medavante-ProPhase LLC in connection with commercial use of the BNSS and other professional activities; these fees are donated to the Brain and Behaviour Research Foundation.Gregory P. Strauss has received honoraria and travel support from ProPha-seLLC for training pharmaceutical company raters on the BNSS.Gregory P. Strauss has consulted for minerva neurosciences, acadia and lundbeck.All other authors have no relevant disclosures.
T A B L E 1 Study demographics.Note: CHR, clinical high risk.73 CHR participants were not on any psychiatric medications, 13 were prescribed an antidepressant, four were prescribed an anxiolytic, two were prescribed an anticonvulsant, one was prescribed a mood stabilizer, one was prescribed a stimulant, and two were prescribed an antipsychotic.All CHR participants met SIPS criteria for prodromal syndromes: (1) attenuated positive symptom syndrome (APSS; n = 46 progression; n = 41 persistence; n = 2 partial remission); (2) genetic risk and deterioration syndrome (GRD; n = 1 progression); and (3) brief intermittent psychotic syndrome (BIPS; n = 1 full remission, participant has additional diagnosis of APSS current persistence).
%) Correlations between CTAS variables and negative symptoms.