European Psychiatry 42 (2017) 111–119

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European Psychiatry
journal homepage: http://www.europsy-journal.com

Original article

Childhood trauma and psychotic experiences in a general population

sample: A prospective study on the mediating role of emotion
regulation
T.M. Lincoln, N. Marin, E.S. Jaya *
Clinical Psychology and Psychotherapy, Institute of Psychology, University of Hamburg, Hamburg, Germany

A R T I C L E I N F O A B S T R A C T

Article history: Background: The causal role of childhood trauma for psychosis is well established, but the mechanisms
Received 14 October 2016 that link trauma to psychosis are largely unknown. Since childhood trauma is known to cause difficulties
Received in revised form 13 December 2016 in emotion regulation (ER) and patients with psychosis show impaired ER, we hypothesize that impaired
Accepted 18 December 2016
ER explains why people with a background of trauma are prone to psychotic experiences.
Available online 2 January 2017
Methods: The study used a longitudinal cohort design based on a community sample (N = 562) from
Germany, Indonesia, and the United States. Childhood trauma was assessed at baseline. ER and psychotic
Keywords:
experiences (defined as positive symptom frequency and related distress) were measured repeatedly at a
Schizophrenia and psychosis
Symptom distress
4-, 8-, and 12-month follow-up. Cross-lagged panel and longitudinal mediation analyses with structural
Social adversity equation modeling were used to test the predictive value of ER on psychotic experiences and its
Mediation mediating role in the association of childhood trauma and psychotic experiences.
Structural equation modeling Results: The cross-lagged paths from impaired ER to symptom distress (but not frequency) were
Prospective design significant. However, there was also evidence for the reverse causation from symptom frequency and
distress to impaired ER. ER partially mediated the significant prospective paths from childhood trauma
to symptom distress.
Conclusion: The findings demonstrate that ER plays a role in translating childhood trauma into
distressing psychotic experiences in later life. Moreover, the findings point to a maintenance mechanism
in which difficulties in ER and symptom distress exacerbate each other. Thus, ER could be a promising
target for interventions aimed at prevention of psychosis.
C 2016 Elsevier Masson SAS. All rights reserved.

The risk of psychosis is almost threefold for people with a psychosis develops, it can also help us to intervene earlier and
background of childhood trauma (CT) [1]. About 26% to 34% of the more effectively.
people diagnosed with a psychotic disorder have experienced CT Several studies have found negative affect, such as anxiety and
[2] that commonly includes sexual abuse [3,4], emotional abuse depression, to link different types of trauma to positive symptoms
[5–8] and physical abuse [9]. CT is associated with frequency and [4,15–17]. It seems intuitive to assume that persistent negative
severity of positive symptoms [10–12] and with a ten-fold increase affect might result from difficulties in emotion regulation (ER),
in symptom related distress [13]. Moreover, it has been found to which has been defined as the ‘‘processes responsible for
predict transition to psychosis in high risk samples [14]. The monitoring, evaluating, and modifying emotional reactions,
increasingly clear evidence for a causal role of CT in the especially their intensive and temporal features, to accomplish
development of psychosis has begun to inspire research on the one’s goals.’’ [18]. Building on this definition and synthesizing
putative mediating mechanisms. Knowing these mechanisms is established ER theories [19], Berking and colleagues [20]
not only crucial to a comprehensive understanding of how conceptualized adaptive ER as the ability to consciously process
emotions, to support oneself in emotionally distressing situations,
to actively modify negative emotions, to accept and tolerate
emotions and to confront emotionally distressing situations in
* Corresponding author at: Clinical Psychology and Psychotherapy, Institute of
order to attain important goals.
Psychology, University of Hamburg, Von-Melle-Park 5, 20146 Hamburg, Germany.
Tel.: +49 40 42838 8087; fax: +49 40 42838 6170. Developmental and attachment theories point to various
E-mail address: jap.edo.sebastian.jaya@studium.uni-hamburg.de (E.S. Jaya). mechanisms underlying the development of ER, including

http://dx.doi.org/10.1016/j.eurpsy.2016.12.010
0924-9338/ C 2016 Elsevier Masson SAS. All rights reserved.
112 T.M. Lincoln et al. / European Psychiatry 42 (2017) 111–119

observational learning, modeling and social referencing [21], complete a follow-up survey after 4 (T1), 8 (T2), and 12 months
parenting style [22] and attachment relationships [23]. For (T3). The follow-up surveys were protected by password to ensure
instance, parental punishment or neglect of a child’s emotional that only participants who completed the baseline survey at T0
displays have been linked to maladaptive ER [24]. Prospective received the invitation for further participation. Recruitment was
studies show that early attachment predicts effective regulation conducted through Crowdflower and other websites (e.g. internet
strategies [25] and CT has been found to fundamentally disrupt forums and social networking websites). Crowdflower is a
attachment to the maltreating caregiver [26]. Unsurprisingly, thus, crowdsourcing Internet marketplace, similar to Amazon MTurk,
there is a bulk of research showing that CT compromises an on which people complete paid jobs. Participants recruited from
individual’s ability to regulate emotions effectively [27,28]. How- Crowdflower received 0.50 US$ for completing the baseline survey
ever, the causal inferences of these findings are limited due to the analog to the median hourly wage in Amazon MTurk [44]. In order
cross-sectional designs used. to motivate participants to complete the follow-up surveys, the
Psychosis has repeatedly been found related to difficulties in ER payment increased with each survey (T1, 0.60 US$; T2, 0.80 US$;
[29]. ‘‘Several studies have found psychosis to be associated with T3, 1.00 US$). Participants recruited from other websites were not
difficulties in being aware of [30,31], understanding, tolerating and given compensation for reasons of data security. Participants had
accepting one’s emotions [32–34], with using less functional to be at least 18 years old and provide written informed consent
strategies, such as reappraising the situation in a functional before entering the study. This study received ethical approval
manner [30,31,35,36] and with more avoidance or suppression of from the ethical commission of the German Psychological Society
emotions [33,34]. Moreover, difficulties in ER have also been (DGPs, TL062014_2).
associated with increased frequency of symptoms as well as There were 2501 completed baseline survey entries of which
exacerbated symptom distress [29,37]. It is noteworthy that these 151 were excluded due to duplicate entries (n = 98), longstring
difficulties are also prevalent in people at risk of psychosis, who (i.e. providing the same answer consecutively for 50 items,
have found to be characterized by lower emotion awareness n = 46 [45]), and inconsistent answers (n = 7). The baseline
[38,39], less use of reappraisal strategies [39,40] and more sample thus consisted of 2350 participants of whom 720 com-
suppression of emotions [39]. This indicates that difficulties in pleted the English, 786 the German and 844 the Indonesian
ER seem to precede the disorder and might contribute to its version of the survey. Of those participants, 432 completed
development. However, only few studies have looked into the first the follow-up (response rate = 18.4%), 300 completed the
temporal relationship between ER and psychosis. A small second follow-up (response rate = 12.8%), 256 completed the
community based study found maladaptive ER to prospectively third follow-up (response rate = 10.9%) and 139 completed all
predict psychotic symptoms from baseline to a 1-month follow-up follow-ups (response rate = 5.9%). A detailed participant flow-
assessment [36]. Moreover, ER-skills have been found to predict chart following the STROBE (Strengthening the Reporting of
increases in subjective distress and psychotic symptoms following Observational Studies in Epidemiology) guideline is available in
a stressor in individuals with psychosis [41]. Thus, there is Supplementary Fig. 1.
preliminary evidence for a causal role of ER in the development of There were 2501 completed baseline survey entries of which
psychosis, but longitudinal studies are needed to further corrobo- 151 were excluded due to duplicate entries (n = 98), longstring (i.e.
rate the postulated causal direction. providing the same answer consecutively for 50 items, n = 46 [45]),
To sum up: As CT appears to have a significant influence on ER and inconsistent answers (n = 7). The baseline sample thus
and difficulties in ER are evidently related to psychosis it seems consisted of 2350 participants of whom 720 completed the
reasonable to postulate that the ability to effectively regulate English, 786 the German and 844 the Indonesian version of the
emotions could at least partially explain the relationship between survey. Of those participants, 432 completed first follow-
CT and psychosis, especially as ER has been shown to mediate the up (response rate = 18.4%), 300 completed the second follow-up
association between CT and other psychopathologies (e.g. eating (response rate = 12.8%), 256 completed the third follow-
disorder [42] and depression [43]). Using a longitudinal design up (response rate = 10.9%) and 139 completed all follow-ups
with four assessment time-points we hypothesized that (1) CT will (response rate = 5.9%). A detailed participant flowchart following
significantly predict ER and psychotic experiences (defined as the STROBE (Strengthening the Reporting of Observational Studies
frequency of positive symptoms and related distress), (2) that the in Epidemiology) guideline is available in Supplementary Fig. 1.
inability to regulate emotions at one time-point will predict In total, 562 participants completed at least one follow-up
psychotic experiences at the following time-point, (3) and that the survey, fulfilled the inclusion criteria (i.e. complete entry, no
relationship between CT and psychotic experiences will be at least longstring, and ID match) and were included in the analyses.
partially mediated by ER.
1.2. Measures

1. Method The back-translation procedure and cultural adaptation of

measures was conducted with a native German or Indonesian.
1.1. Participants and procedure
1.2.1. Childhood trauma
To enable an interpretation of the findings free of issues Childhood trauma at T0 was assessed via a brief questionnaire
inherent to clinical populations (e.g. small samples, medication adapted from ‘‘The Netherlands Mental Health Survey and
effects) the data for this study was collected in a community Incidence Study’’ (NEMESIS) [46]. The questionnaire assesses
sample that covered the continuum of psychotic experiences any kind of emotional, physical, psychological or sexual abuse
including those that would be considered clinically relevant. before age 16 years according to the definition presented (e.g.
Moreover, the sample was recruited from three different sexual abuse, ‘‘How often were you sexually approached against
continents to increase the generalizability of findings beyond your will? This means: were you ever touched sexually by anyone
the western societies. against your will or forced to touch anybody? Were you ever
Participants from Germany, Indonesia, and the United States pressured into sexual contact against your will?’’). Frequency of
were requested to complete a 30-minute online survey anony- abuse is indicated on a six-point scale ranging from 1 = never to
mously (T0). Subsequently, they were invited via e-mail to 6 = very often.
 T.M. Lincoln et al. / European Psychiatry 42 (2017) 111–119 113

1.2.2. Psychotic experiences All analyses were conducted with structural equation modeling
Subthreshold and clinically relevant psychotic experiences at (SEM) using the sem function in lavaan ver. 0.5–20 [52] in R, version
T1 through T3 were assessed with the Community Assessment of 3.2.3. Reported path coefficients are completely standardized.
Psychic Experiences (CAPE) [47], a 42-item self-report question- Reported overall total effect, overall direct effect, and overall
naire. The CAPE assesses experiences related to positive symptoms, indirect effect coefficients are unstandardized. The following
negative symptoms, and depression. The 20-item positive symp- indices and cut-off criteria were used to assess the fit between
tom subscale was used for the purpose of this study. It assesses a hypothesized models and the data: CFI  0.90, SRMR  0.08 [53];
range of psychotic experiences, such as unusual or persecutory RMSEA  0.08 [54]. Maximum likelihood procedure with robust
beliefs (e.g. ‘‘Do you ever feel as if you are under the control of some standard errors and a scaled test statistic, asymptotically equaling
force or power other than yourself?’’, ‘‘Have you ever felt that you Yuan–Bentler test statistic, was used to correct for non-normal
were being persecuted in any way?’’) or hallucinatory phenomena distribution. As we found that the frequency of psychotic
(e.g. ‘‘Have your thoughts ever been so vivid that you were worried experiences across measurement points was not missing complete-
other people would hear them?’’, ‘‘Do you ever hear voices when ly at random (MCAR; x2(16) = 101.73, P < .001), subsequent
you are alone?’’) in the past four weeks on both a frequency scale analyses used full information maximum likelihood (FIML) with
(ranging from 1 = never to 4 = nearly always) and a distress scale a missing at random (MAR) assumption. Variable inter-correlations
(i.e. ‘‘Please indicate how distressed you are by this experience’’; and missing status are shown in Supplementary Table 1.
ranging from 1 = not distressed, 4 = very distressed). Previous Before testing the mediation hypotheses, we computed an
studies have demonstrated good convergent and discriminative autocorrelation model to test the precondition that CT, ER and
validity [48] and the positive symptom subscale has good retest psychotic experiences are correlated and within-construct auto-
reliability (r = 0.63) [49]. regressive models to test the precondition that the values of
variables at future time points depend at least in part on their
1.2.3. Emotion regulation respective values at earlier time points.
Functional ER-skills at T1 through T3 were assessed with the The mediation analysis was based on Baron and Kenny’s [55]
Emotion Regulation Skills Questionnaire (ERSQ) [50] derived from principles for mediation and followed suggestions by Cole and
the theoretical conceptualization by Berking et al. [20]. The ERSQ is Maxwell [56] for mediation testing in longitudinal designs. First,
a 27-item self-report measure that assesses the application of ER- we examined the prospective paths from CT at T0 to frequency and
skills during the previous week on a five-point Likert-type scale distress of psychotic experiences at T1–T3 (path c), CT to ER at T1–
(1 = not at all, 5 = almost always). It contains nine scales that T3 (path a), and ER at T1–T3 to frequency and distress of psychotic
correspond to the following nine skills: (a) consciously process experiences at T1–T3 (path b) in separate models. Specifically, we
emotions/be aware of emotions, (b) identify and label emotions, (c) examined path b with a cross-lagged panel model to take into
interpret emotion-related body sensations correctly, (d) under- account various sources of error such as the stability of the
stand the prompts of emotions, (e) support oneself in emotionally variables, cross-sectional associations, prior associations and the
distressing situations, (f) actively modify negative emotions in possibility of a reverse pathway.
order to feel better, (g) accept emotions, (h) be resilient to/tolerate According to Cole and Maxwell [56], path c (in this case the path
negative emotions, and (i) confront emotionally distressing from CT-PE to the final follow-up at T3) needs to be significant in
situations in order to attain important goals. Both the total score order to conduct the longitudinal mediation analysis and compute
and the subscales of the ERSQ show good internal consistencies the overall total, direct and indirect effect coefficients. These effect
(Cronbach’s a = 0.90, and 0.68–0.81, respectively) and adequate coefficients were considered significant if the bias-corrected
retest-reliability (rtt = 0.75 and 0.48–0.74, respectively). All scales bootstrap 95% confidence interval (BCa CI) did not include zero
have demonstrated convergent and discriminate validity, includ- [57]. ER was considered a significant mediator if the indirect effect
ing strong positive correlations with constructs related to ER [50]. coefficient was significant [58].

1.2.4. Substance use

Use of alcohol, cannabis and other substances was measured 2. Results
with self-report items based on the L section of the Composite
International Diagnostic Interview version 1.1 [51] using a scale 2.1. Participant characteristics
ranging from 1 (never) to 6 (nearly every day).
The participants were 24.31 years old on average and 49.3%
1.3. Analyses were female. Moreover, 32.6% (n = 183) reported a life-time mental
diagnosis, and 3.7% (n = 21) reported a current diagnosis of
All analyses were conducted with structural equation modeling psychotic disorder. Slightly more than half (60.1%, n = 338)
(SEM) using the sem function in lavaan ver. 0.5–20 [52] in R, version reported childhood abuse. Specifically, 45.9% (n = 258) of the
3.2.3. Reported path coefficients are completely standardized. participants reported to be victims of emotional neglect, 38.3%
Reported overall total effect, overall direct effect, and overall (n = 215) of psychological abuse, 31.1% (n = 175), and 18.5%
indirect effect coefficients are unstandardized. The following (n = 104) of sexual abuse. Detailed participant characteristics are
indices and cut-off criteria were used to assess the fit between provided in Table 1.
hypothesized models and the data: CFI  0.90, SRMR  0.08 [53];
RMSEA  0.08 [54]. Maximum likelihood procedure with robust 2.2. Preliminary analyses
standard errors and a scaled test statistic, asymptotically equaling
Yuan–Bentler test statistic, was used to correct for non-normal The autocorrelation model showed that CT, ER, and psychotic
distribution. As we found that the frequency of psychotic experiences (symptom frequency and distress) were significant-
experiences across measurement points was not missing complete- ly inter-correlated in the expected directions at all measurement
ly at random (MCAR; x2(16) = 101.73, P < .001), subsequent time points. The within-construct longitudinal models
analyses used full information maximum likelihood (FIML) with showed that ER and psychotic experiences at a given assessment
a missing at random (MAR) assumption. Variable inter-correlations time-point predicted the respective variable at the next time-
and missing status are shown in Supplementary Table 1. point, which demonstrates sufficient stability across time.
114 T.M. Lincoln et al. / European Psychiatry 42 (2017) 111–119

Table 1
Participants’ characteristics.

Characteristic Mean SD Possible range Study range

a
Gender, female (%) 227 (49.30%) – – –
Agea 35.99 12.77 18–99 18–74
Socio-economic statusa 10.30 3.81 3–21 3.00–21.00
Educationa 4.66 1.80 1–7 1.00–7.00
Job positiona 2.78 1.93 1–7 1.00–7.00
Incomea 2.86 1.58 1–7 1.00–7.00
T0 Childhood abusea
Emotional neglecta 1.54 0.50 0–5 0–5
Psychological abusea 1.62 0.49 0–5 0–5
Physical abusea 1.69 0.46 0–5 0–5
Sexual abusea 1.81 0.39 0–5 0–5
T1 Frequency of psychotic experiencesb 1.45 0.38 1–4 1.00–3.15
T1 Distress related to psychotic experiencesb 1.22 0.32 1–4 1.00–3.00
T1 Emotion regulationb 3.42 0.70 1–5 1.00–5.00
T2 Frequency of psychotic experiencesc 1.46 0.43 1–4 1.00–4.00
T2 Distress related to psychotic experiencesc 1.18 0.28 1–4 1.00–3.00
T2 Emotion regulationc 3.53 0.76 1–5 1.00–11.5
T3 Frequency of psychotic experiencesd 1.40 0.38 1–4 1.00–3.85
T3 Distress related to psychotic experiencesd 1.18 0.30 1–4 1.00–3.75
T3 Emotion regulationd 3.55 0.75 1–5 1.52–5.00
a
n = 562.
b
n = 432.
c
n = 300.
d
n = 256.

Table 2
Fit indices of the tested models.

Model Yuan–Bentler x2 RMSEA [90% CI] SRMR CFI AICa

2
x df P

CT on symptom frequency (T1) 25.76 13 0.02 0.04 [0.020–0.063] 0.02 0.99 7290
CT on symptom distress (T1) 21.19 13 0.07 0.03 [0.008–0.054] 0.04 0.99 6775
CT on symptom frequency (T2) 21.55 13 0.06 0.03 [0.004–0.057] 0.03 0.99 7194
CT on symptom distress (T2) 22.94 13 0.04 0.04 [0.014–0.057] 0.03 0.99 6644
CT on symptom frequency (T3) 26.33 13 0.02 0.04 [0.022–0.063] 0.02 0.99 7028
CT on symptom distress (T3) 21.85 13 0.06 0.04 [0.010–0.056] 0.03 0.99 6611
CT on ER (T1) 22.97 13 0.04 0.04 [0.010–0.060] 0.03 0.99 8005
CT on ER (T2) 25.69 13 0.02 0.04 [0.019–0.063] 0.03 0.99 7627
CT on ER (T3) 16.09 13 0.24 0.02 [0.000–0.046] 0.03 0.99 7441
ER and symptom frequency 517.93 124 <0.01 0.08 [0.069–0.082] 0.08 0.93 3554
ER and symptom distress 418.81 124 <0.01 0.07 [0.059–0.072] 0.09 0.95 2239
Longitudinal mediation model of CT, ER, and symptom frequency 611.55 193 <0.01 0.06 [0.057–0.068] 0.07 0.94 10 262
Longitudinal mediation model of CT, ER, and symptom distress 508.69 192 <0.01 0.05 [0.054–0.066] 0.08 0.95 8930

Note. CT: childhood trauma; ER: emotion regulation; T0: baseline; T1: month 4; T2: month 8; T3: month 12; RMSEA: Root Mean Square Error of Approximation; SRMR:
Standardized Root Mean Square Residual; CFI: Comparative Fit Index; AIC: Akaike Information Criterion; 90%CI: 90% confidence interval.
a
Rounded to the next integer.

Additionally, all fit indices were met, indicating that the significant path from CT to symptom distress (g = 0.11, P = .12) at T3
parameters can be interpreted (see Table 2). was now non-significant. Furthermore, there was a significant path
from ER (T2) to symptom distress (T3, b = 0.09, P < .01) indicating
2.3. Prospective association of childhood trauma, emotional a possible mediation of ER in the relationship between CT and
regulation, and psychotic experiences distress. Note, however, that there was also a significant path from
both symptom frequency (b = 0.12, P < .05) and distress
There were significant prospective paths from CT (as assessed at (b = 0.16, P < .01) at T1 to ER at T2, indicating that psychotic
T0) to symptom frequency and distress at T3, and thus a significant experiences do not just follow but also precede difficulties in ER.
path c (see Fig. 1a for details). Moreover, there was a significant Since the hypothesized paths from ER to symptom frequency
prospective path from CT to ER at T2, and thus a significant path a were not significant, the overall total, direct and indirect effect was
(see Fig. 1b for details). only computed for symptom distress. The overall total effect of CT
The prospective association between ER and psychotic expe- on symptom distress at final follow up was significant at 0.0747
riences was tested with a cross lagged panel model (see Fig. 1c). (95% BCa CI, 0.0311, 0.1184). This effect consisted of a significant
Here we found a significant prospective path from ER at T2 to overall direct effect of 0.0694 (95% BCa CI, 0.0269, 0.1119) and a
symptom distress at T3, but no significant prospective paths from significant overall indirect effect of 0.0053 (95% BCa CI, 0.0002,
ER to symptom frequency. Thus, the path b was only significant for 0.0104). The mediation proportion [59] showed that ER mediated
symptom distress. 7.1% of the overall total effect of CT on symptom distress.

2.4. Longitudinal mediation analysis 2.5. Additional exploratory analyses

In the longitudinal mediation model (see Fig. 2), which included In order to explore whether the associations of interest differ
all time-points and the putative mediator ER, the previously across symptoms, we repeated the analyses using the hallucination
 T.M. Lincoln et al. / European Psychiatry 42 (2017) 111–119 115

and paranoia subscale of the CAPE [60] as dependent variables. The

results are presented in Supplementary Figs. 2 and 3 for
hallucinations and paranoia, respectively. We found childhood
trauma to predict both frequency and distress of hallucinations
and paranoia over time. Moreover, ER predicted both frequency
and distress of paranoia, but not of hallucinations. Consequently,
we only conducted the longitudinal mediation analysis on
paranoia. The results of this analysis are presented in Supplemen-
tary Fig. 4. The overall total effect of CT on paranoia distress at final
follow up was significant 0.130 (95% CI, 0.075, 0.186). This effect
consists of a significant overall direct effect of 0.116 (95% CI, 0.062,
0.171) and a significant overall indirect effect of 0.014 (95% CI,
0.001, 0.027). The overall total effect of CT on paranoia frequency at
final follow up was also significant at 0.109 (95% CI, 0.059, 0.159),
which consists of a significant overall direct effect of 0.099 (95% CI,
0.049, 0.149) and a significant overall indirect effect of 0.010 (95%
CI, 0.001, 0.020). Thus, ER was a significant partial mediator in the
association between CT and paranoia frequency and distress.
In order to explore whether the associations of interest differ
across symptoms, we repeated the analyses using the hallucination
and paranoia subscale of the CAPE [60] as dependent variables. The
results are presented in Supplementary Figs. 2 and 3 for
hallucinations and paranoia, respectively. We found childhood
trauma to predict both frequency and distress of hallucinations
and paranoia over time. Moreover, ER predicted both frequency
and distress of paranoia, but not of hallucinations. Consequently,
we only conducted the longitudinal mediation analysis on
paranoia. The results of this analysis are presented in Supplemen-
tary Fig. 4. The overall total effect of CT on paranoia distress at final
follow up was significant 0.130 (95% CI, 0.075, 0.186). This effect
consists of a significant overall direct effect of 0.116 (95% CI, 0.062,
Fig. 1. Prospective association of childhood trauma, emotion regulation, and
psychotic experiences. Note. (distress); [frequencies]; path coefficients are 0.171) and a significant overall indirect effect at 0.014 (95% CI,
completely standardized; +P < .10, *P < .05, **P < .001. Dotted lines indicate 0.001, 0.027). The overall total effect of CT on paranoia frequency at
insignificant paths. CT: childhood trauma; ER: emotion regulation; PE: psychotic final follow up was also significant at 0.109 (95% CI, 0.059, 0.159),
experiences; T0: baseline; T1: month 4; T2: month 8; T3: month 12.
which consists of a significant overall direct effect of 0.099 (95% CI,

Fig. 2. Longitudinal mediation analysis of childhood trauma, emotion regulation, and psychotic experiences. Note. (distress); [frequencies]; path coefficients are completely
standardized; +P < .10, *P < .05, **P < .001. Dotted lines indicate non-significant paths. CT: childhood trauma; ER: emotion regulation; PE: psychotic experiences; T0:
baseline; T1: month 4; T2: month 8; T3: month 12.
116 T.M. Lincoln et al. / European Psychiatry 42 (2017) 111–119

0.049, 0.149) and a significant overall indirect effect at 0.010 (95% ties in which people appear to be getting caught up in a vicious
CI, 0.001, 0.020). Thus, ER was a significant partial mediator in the circle of psychotic experiences, negative affect and difficulties in
association between CT and paranoia frequency and distress. down-regulating negative emotions. This may explain symptom
Furthermore, we investigated differences between countries in exacerbation over longer time-periods.
our variables of interest. We did not find significant mean The significant overall indirect effect indicates that ER partially
differences between countries in regard to CT, ER, and symptom explains the link between CT and symptom distress. This has not
distress. However, we did find significant differences between been investigated in regard to psychosis so far and thus makes a
countries in symptom frequency (F(2,429) = 14.60, P < 0.01), with novel contribution to the field. However, the mediating effect was
post hoc t-tests with Bonferroni correction indicating psychotic only found for symptom distress, not for symptom frequency.
experiences to be significantly more frequent in participants from Taken together with research showing that ER also mediates
Indonesia (M = 1.60) than in those from Germany (M = 1.36) and between CT and other affective disorders [65] one could speculate
the United States (M = 1.44). that ER may be more relevant to the affective symptomatology
Finally, in order to rule out that ER was merely a proxy for associated with psychosis than to the specific psychotic symp-
substance abuse, we analyzed correlations between ER and the use tomatology as such. Thus, the specificity warrants further research.
of alcohol, cannabis, and other substances, which were all found to Moreover, the mediation was partial, explaining 7.1% of the total
be non-significant. relationship between trauma and symptom distress. This indicates
that other putative mediators should be considered, candidates
being negative schema [15,66], social cognition (e.g. impaired
3. Discussion theory of mind [67,68]), neurocognitive impairment [69], sub-
stance abuse [70], and ongoing social adversities [71]. In addition
3.1. Summary of findings and general discussion to the reduced functional ER strategies as assessed in this study
(e.g. acceptance, tolerance and clarity of emotions), increased
This study tested for a significant association of CT and dysfunctional ER strategies (e.g. rumination, suppression, or
psychotic experiences, a predictive effect of ER on psychotic avoidance), might also contribute to mediating the relationship
experiences and a mediating role of ER in the relationship of CT and of CT and symptom distress, in particular because these types of ER
psychotic experiences. As hypothesized, and in line with the have been found to be linked to CT [43,72] and to exacerbated
extensive literature highlighting maltreatment as a major risk symptom distress in psychosis [29,73,74]. Notably, the focus on
factor for later psychosis [9] we found CT to be significantly related functional rather than dysfunctional ER in our study might explain
to psychotic experiences. Confirming part of our second hypothe- why we did not find a significant correlation between substance
sis, we found that the ability to regulate emotions significantly and use and ER as has been found in other studies [70].
prospectively predicted fluctuations in symptom distress over Our additional analyses of the effects for paranoia and
time. Thus, the fewer ER skills an individual endorsed at a given hallucinations suggest that although CT was linked to both
time-point, the higher the likelihood that this individual would be paranoia and hallucinations the mediating role of ER may be
distressed by psychotic experiences at the next time-point. This specific to paranoia. However, the insignificant finding for
finding adds to the preliminary evidence indicating a covariation of hallucinations needs to be interpreted with caution because the
at risk-mental states and ER [38–40], a causal influence of ER on hallucination subscale only has four items. Thus, the question of
psychotic symptoms and distress [36,41], and suggests that the specificity warrants further research with more suitable measures
ability to effectively regulate emotions is crucial to arrive at low for this purpose.
levels of symptom distress.
Given the overwhelming evidence for affective pathways to 3.2. Limitations
psychosis [61,62], we were surprised by the absence of a significant
path from ER to symptom frequency. Possibly, the mere presence The participants were drawn from a pool of people with access
of non-distressing low-threshold delusional beliefs or perceptual to the Internet. These participants tended to be highly educated
phenomenon as assessed in the frequency domain of the CAPE and to have middle to low income. Similar sample characteristics
might not have sufficient pathological character to find significant have been reported by other researchers who used crowdsourcing
associations with putative risk factors for psychosis. Psychotic websites for recruitment [75]. Due to the slightly reduced
symptom distress has been found to be a better discriminator variability of the participants’ demographics, the strength of the
between clinical and non-clinical samples than frequency [63] and observed relationships might have been underestimated. Howev-
to improve the prediction of high risk status relative to frequency er, the sample was sufficiently heterogeneous in regard to the
of psychotic experiences on their own [64]. Thus, it appears to be a variables of interest: childhood trauma and psychotic experiences.
more valid indicator of relevant subclinical symptomatology. Moreover, the inclusion of individuals from three countries adds to
However, this assumption warrants further research that includes the representativeness of the sample.
measures of clinical relevance (e.g. functioning). Another limitation is that only 23% of the baseline-group
Moreover, interestingly, our test of the ‘‘reverse causation participated in the follow-ups and only 5.9% of the initial sample
model’’ revealed that symptom frequency and related distress at completed all assessments. Although we used FIML procedure in
one time-point also significantly predicted an impaired ability to all analyses to take into account the missing data, we cannot rule
regulate emotions at the next time-point. This could be explicable out that the high attrition rate influenced the results. The
by the fact that psychotic experiences demand attention, leaving correlates of missing data reported in Supplementary Table 1
less attentional capacity to deal with distressing emotions, an suggest that participants with more severe symptoms were more
effortful process it itself. Moreover, people who are feeling likely to miss follow-up assessments. Selective drop-out at the
distressed by psychotic symptoms are dealing with higher levels higher end of the symptom spectrum could have resulted in
of negative affect that are more difficult to down-regulate (causing reduced variability and thus in attenuated effect sizes [76].
them to report less success in ER) than the milder levels of Another limitation is that only 23% of the baseline-group
emotional distress people without disturbing psychotic experien- participated in the follow-ups and only 5.9% of the initial sample
ces are faced with. The longitudinal pattern of associations speaks completed all assessments. Although we used FIML procedure in
for reciprocal exacerbations of symptom distress and ER difficul- all analyses to take into account the missing data, we cannot rule
 T.M. Lincoln et al. / European Psychiatry 42 (2017) 111–119 117

out that the high attrition rate influenced the results. The pathway linking trauma to psychosis by heightened emotional
correlates of missing data reported in Supplementary Table 1 distress, anxiety and depression [16,17]. Our findings extend this
suggest that participants with more severe symptoms were more line of research by pointing to the role of ER as a possible
likely to miss follow-up assessments. Selective drop-out at the psychological mechanism involved in this process. Although this
higher end of the symptom spectrum could have resulted in mechanism is unlikely to be specific to psychosis, the fact that
reduced variability and thus in attenuated effect sizes [76]. difficulties in ER precede and follow from symptom distress render
Another issue is that the retrospective assessment of CT is prone ER a promising target for interventions aimed at increasing well-
to recall bias [77]. Similarly, the self-report diagnosis cannot be being and preventing psychotic symptom exacerbation.
externally verified. However, the minimal reward for survey
termination, the application of data verification procedures and
Disclosure of interest
the similarity of prevalence rates of life-time mental diagnosis
(32.1%) to representative samples from epidemiological studies
The authors declare that they have no competing interest.
(e.g. 29.4% [78]) speak for the validity of the data. Furthermore, the
mean CAPE scores for frequency of positive symptoms across all
assessment time-points are comparable to those found in a large
data set of previously published data [60]. People who reported no Appendix A. Supplementary data
mental disorder in our study had a mean score of M = 1.44
(compared to M = 1.41 in other population samples [60]) and those Supplementary data associated with this article can be found, in
who reported a psychotic disorder had a mean value of M = 1.52 the online version, at http://dx.doi.org/10.1016/j.eurpsy.2016.12.
(compared to a mean value of M = 1.73 for participants with a 010.
psychotic disorder in other studies [60]).
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