Furthering our understanding of PTSD is essential to exploring the link between trauma and psychosis. While the experience of traumatic events is unfortunately common, the majority of individuals who are exposed to trauma do not go on to develop PTSD. Of interest are the questions of why some people develop PTSD and whether it is possible to identify these individuals at an early stage to aid earlier targeted intervention. Increasing our understanding of the neurobiological mechanisms implicated in the development of PTSD can aid in this process. In this Research Topic, Wang et al. examine electrophysiological data to establish the presence of a physiological prodrome of PTSD in an attempt to identify possible markers that could identify opportunities for early treatment. Lee et al. address the question of the role of dopamine in the development of PTSD and propose the Rebound-Excitation Theory to explain the variability in stress resilience. Considering that dopamine has been hypothesized to play a central role in the pathophysiology of schizophrenia for over 50 years (13–15), further insight into the role of dopamine in PTSD may aid our understanding of the link between trauma and psychosis.

Conceptualizing PTSD across the time course is necessary to understand the development and maintenance of mental health problems over time. In this Research Topic, Ibrahim and Hassan examine data from Syrian Kurdish refugees living in a refugee camp and exposed to torture and other traumatic events, while Bovin et al. report on the longitudinal associations between PTSD severity and personality disorder features. Both these studies have important implications for when treatment is provided and its likely impact. Ibrahim and Hassan highlight the need for psychological services for Syrian Kurdish refugees that would potentially occur shortly after the traumatic event. Bovin et al., on the other hand, draw on their longitudinal data to demonstrate that improvements in PTSD symptoms are associated with improvements in characterological features (and vice versa), suggesting that targeting PTSD symptoms in individuals with a personality disorder may result in improvements in both psychopathology and comorbid personality traits over time. This time course (from shortly after the trauma to years later) indicates the need to conceptualize PTSD as longitudinal, and offer ongoing assessment and targeted treatments at different stages.

Of critical importance in this Research Topic is the inclusion of a first-person account of trauma and psychosis written from the perspective of someone with “lived experience” (Britz). The voices of persons with lived experience has been essential in our understanding of psychosis at multiple levels, but has been less widely explored in relation to trauma and psychosis (16). Britz writes eloquently, and with disarming honesty, about her experience of trauma and psychosis, and developing an understanding of the interface between the two while also drawing upon current discourse to highlight the importance of meaningful collaboration with people with lived experience. Adding to this lived experience perspective is Lu et al.’s qualitative analysis of posttraumatic reactions to psychosis that provides a narrative description of the key themes of the traumatizing nature of psychosis, including symptoms, treatment, and the corresponding emotional reactions to these.

As previously mentioned, although a clear link between trauma and psychosis has been established, the specific mechanisms involved are still unknown. Two papers in this research topic examine potential explanatory models. Berry et al. focus on a model specific to understanding the development of auditory hallucinations. This paper is the first to propose a theoretical link between early childhood attachment and dissociative processing as mechanisms to explain the origin, and maintenance of distressing voice hearing. Hardy proposes a comprehensive, theoretically informed model of posttraumatic stress in psychosis that encompasses emotion regulation and autobiographical memory to understand the pathway between victimization and psychosis and provides case vignettes to illustrate how this model informs case formulation and treatment. Brand et al. highlight the ethical challenges associated with experimental manipulation of possible causal pathways to scientifically establish links between trauma exposure, PTSD, and psychosis and propose an interventionist-causal paradigm to better understand this relationship. This approach examines the impact of an intervention on a proposed causal mechanism compared with a control intervention while observing the impact on the symptom of interest. The authors propose several potential mechanisms, including memory processing, negative posttraumatic beliefs, dissociation, and posttraumatic avoidance with connected interventions. This interventionist-causal paradigm has already been applied in psychosis research (17) and offers a model to better understand proposed mechanisms in trauma and psychosis.

Recognizing the debate regarding schizophrenia as a unitary diagnostic category, Stevens et al. propose four subgroups of trauma in psychosis in order to elaborate on symptom-specific conceptualizations of distress and propose corresponding interventions for these four subtypes. The concept of psychosis on a continuum, rather than as a discrete entity, is also of importance to the paper presented by Mayo et al., who address the role of psychosis and stressful life events in individuals determined to be at-risk of developing psychosis. This population is important to this topic in that they are a group of individuals who have not yet developed full psychosis, and may indeed not do so, but who are typically experiencing attenuated psychotic symptoms and are distressed and help seeking. Alarmingly, this population reports high levels of childhood trauma and the paper reviews these data while providing clinical recommendations on the assessment, treatment, and future research directions.

As previously discussed, there are concerns in the field about the under-detection of trauma in persons with psychosis or other severe mental illnesses. Under-detection due to professionals failing to screen for trauma and PTSD can be overcome by routine screening of individuals receiving services (18). Church et al. examine another potential factor contributing to poor identification of trauma history and its consequences in this population—the minimization or denial of childhood trauma by individuals themselves. In line with this theme of the importance of accurate assessment, Rosen et al. explored cumulative exposure of traumatic life events. In particular their use of qualitative analysis in the study highlights the importance of careful and sensitive assessment to understanding the time course and impact of trauma on individuals and their mental health.

The recovery literature has changed how recovery from mental illness is understood, with a shift from traditional medical definitions that emphasize symptom remission to conceptualizing recovery as a personally meaningful process that involves the development of meaning and a sense of purpose despite symptoms or other challenges (19, 20). In this Research Topic, Mazor et al. examine the experience of posttraumatic growth as mediated by meaning making and coping self-efficacy adding a much needed focus on resiliency in this population.

Interventions specifically for PTSD in individuals with a psychotic disorder are not as well established as for psychosis (e.g., cognitive behavioral therapy for Psychosis) or PTSD (e.g., cognitive processing therapy, eye movement desensitization and reprocessing therapy, prolonged exposure), although some recent progress has been made (21–23). Further work continues in this area with growing awareness of the link between trauma and psychosis and the need to provide targeted interventions that address the PTSD. In this Research Topic, Swan et al. provide a systematic review of interventions supporting the evidence that trauma-focused psychological interventions can be applied safely and effectively in individuals with psychosis. A range of interventions have been studied for trauma and psychosis and in this Research Topic Prolonged Exposure (Grubaugh et al.), Trauma Focused CBT (Keen et al.), and interventions specific to trauma and voices (Steel) are all discussed. However, despite emerging evidence that these interventions are safe and effective, there remains a challenge of dissemination. Cragin et al. begin to address this through the development of clinical practice guidelines to aid clinicians working with early psychosis and comorbid trauma-related disorders.

The articles in this Research Topic demonstrate the breadth of current research being conducted in this field. The authors of the included articles further the discussion around the interface between trauma, psychosis, and PTSD and provide cogent arguments for future research and clinical application of the data presented. They collectively highlight the need to identify, assess, and address trauma in this population which for too long has been overlooked and under treated.

KH and KM co-edited this Research Topic and co-wrote the editorial.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.