Psychosis is a collection of symptoms where someone perceives reality in a very different way from those around them. Psychotic experiences may involve hallucinations, delusions, or disorganised thinking or speech. People often experience their first psychotic episode in young adulthood, usually preceded by small, gradual changes to their experiences and behaviours.
In recent years, research has focused on how social and environmental factors affect the development of psychosis. A meta-analysis of 30 years of studies found that psychosis was significantly associated with childhood trauma, including sexual, physical, emotional, and psychological abuse, neglect, parental death, and being bullied (Varese et al. 2012). Young people who experience adversity as they grow up are more likely to experience persistent psychotic symptoms.
Bullying is one of the most common forms of adversity that children face. Around 25% of young people may have been bullied during their school years, experiencing repeated aggressive behaviour that they are unable to defend against. Bullying can take different forms and can cause serious distress, anxiety, low self-esteem, and in some cases, suicidal ideation and attempts.
While research on the specific link between bullying and the continuum of psychosis is still limited, several studies have found significant relationships between them. Research has also explored how bullying may interact with developmental pathways of psychosis and developed other cognitive and biological explanations.
Exploring the link between bullying and psychosis is important, helping to both prevent psychotic symptoms and support young people with psychosis to find alternative explanations for their experiences.
This article offers a summary of research on the link between bullying and psychosis and outlines some key theoretical explanations. It also explores how our understanding of the relationship can help prevent young people who have experienced bullying from developing full-blown psychosis and support others to manage the disorder.
What Is The Relationship Between Bullying and Psychosis?
Several studies have found that young people on the psychotic continuum are more likely to have experienced bullying than those without any psychosis-like experiences. Equally, children who are bullied are more likely to develop psychotic symptoms later on in life.
Research has looked into different types of psychotic experiences, from pre-clinical psychotic symptoms to first-case psychotic episodes and full-blown psychotic disorders.
Pre-clinical Psychotic Symptoms
Arseneault et al., 2011 found that children who experience bullying were almost 3 times more likely to report psychotic symptoms by the age of 12 than those who didn’t experience any traumatic events. They found that this relationship remained significant even after taking into account other confounding variables, including gender, genetic liability, and social-economic situation.
Another study interviewed 14 to 16-year-olds about their experiences of bullying and their predisposition to key psychotic symptoms, including auditory hallucinations, delusions, and paranoia (Campbell and Morrison, 2007). There was a significant association between bullying and these psychotic phenomena.
The authors concluded that bullying may contribute to the development of psychosis while acknowledging that psychosis-like symptoms could also make it more likely that young people are bullied.
In their meta-analysis, van Dam et al., 2012 found that children who had been bullied were almost twice as likely to develop non-clinical psychotic symptoms. The likelihood increased when children were bullied for longer, more severely, or more frequently.
A similar meta-analysis four years later had similar results, suggesting that bullying does predict the later development of psychotic symptoms (Cummingham et al. 2016).
First-Case Psychosis and Clinical Disorders
The research surrounding clinical cases of psychosis offers less clear results. While data from the British Adult Psychiatric Morbidity Surveys found that bullying increased the risk of a psychosis diagnosis, the effect disappeared after controlling for other traumas and sexual abuse (Catone et al., 2015). Notably, there was still a significant relationship between bullying and psychotic symptoms even after controlling for variables.
In 2013, Fisher et al. explored this relationship further, this time focusing on first clinical presentation for psychotic disorders, rather than diagnoses of psychosis. They found that psychotic cases were almost twice as likely to report bullying than others. The effect stayed significant even when other life events were taken into account.
How Bullying Leads to Psychosis: Theoretical Explanations
Research over the past decades clearly shows a link between bullying and psychotic symptoms, and possibly also psychotic disorders. The next question is why this relationship exists – what are the pathways and mechanisms between bullying and psychotic experiences?
There are many different models and theoretical explanations that attempt to understand this relationship. Some of the explanations may work in conjunction with one another: in most young people, psychosis probably develops from a combination of different factors.
Some of the most relevant theoretical explanations are laid out below.
Empathy and Mentalisation
Empathy – the ability to feel or think about the mental states of others – is an important prerequisite for effective social skills. People can empathise both cognitively (by understanding how a person might be feeling) and emotionally (by experiencing the same emotion as them).
Mentalisation refers to both the understanding of another person’s mental state and of your own: that is, understanding the mental states and processes that lie behind your own emotions, impulses, and actions.
Studies have found that adolescents at ultra-high risk of psychosis may struggle to identify their emotions and interact with others (van Rijn et al., 2011). Individuals with psychotic symptoms may also be unable to mentalise as much as other people (Sprong, 2007).
Some evidence suggests that children who experience relational bullying may have lower emotional or cognitive empathy skills or misunderstand the intentions of others (Woods et al., 2009).
Moreover, young people who have experienced maltreatment may be more inclined to expect aggression from other people, even in new settings, and misjudge the thoughts and feelings of others. These characteristics may put children and adolescents who have been bullied at a greater risk of developing symptoms of psychosis.
Social Withdrawal
Children and teenagers who are bullied are usually socially isolated. Social isolation prevents young people from developing fundamental social skills that are necessary to form healthy relationships with others. It also affects the way that young people see themselves, perceive the world around them, and perform in other areas of life, such as in school work.
Research has found that impaired social functioning makes it more likely for young people at a high risk of psychosis to develop a psychosis disorder (Cornblatt 2012). Social withdrawal is also a key feature of prodromal schizophrenia, a phase that precedes schizophrenia in around 75% of people.
Social withdrawal and isolation may mediate the relationship between bullying and psychosis in various ways, particularly as social isolation can be both a cause and consequence of bullying. It’s possible that young people at risk of psychosis may be more likely to be socially isolated, increasing the chance that they are bullied.
Alternatively, children and adolescents who are bullied may withdraw socially, affecting their social and functional skills and putting them at a greater risk of developing psychosis. In some cases, both pathways may work at once, reinforcing one another.
Stress and Stress Responses
Humans’ stress responses are regulated by a central nervous system pathway known as the Hypothalamic-Pituitary-Adrenal (HPA) axis. When someone experiences a stressful event, the pituitary gland in the brain releases certain hormones which, in turn, cause adrenal glands to release cortisol. Cortisol is an important stress hormone that affects many parts of the body, including muscles, the digestive system, and the brain.
Research has found that bullying may interact with this system, causing weakened cortisone responses to stress (Ouellet-Morin et al., 2011).
Interestingly, disrupted HPA activity is also linked to the development of attenuated psychotic symptoms and psychotic disorders, but involves hyperactive (rather than blunted) reactions (Aiello et al., 2012). Increased stress also leads to higher levels of dopamine in the brain, something that may contribute to psychotic experiences like hallucinations and delusions.
Negative Schematic Beliefs
Research has found that negative schematic beliefs about the self and others are associated with both positive (such as hallucinations and delusions) and negative (such as loneliness) symptoms of psychosis.
Negative beliefs may also increase the distress of hallucinations and delusions by affecting the way they are interpreted. Someone who is distrustful of others may be more likely to interpret internal voices as something threatening or scary.
Young people who have been bullied may be more likely to hold negative schematic beliefs than other people. They may view those around them as aggressive or threatening while struggling with their own self-esteem.
Anilmis et al., 2015 found that negative beliefs about the self and others were associated with both bullying and unusual distressing experiences in childhood, as well as mediating the relationship between the two.
Shared Risk Factors
Bullying and psychosis share many risk factors. That is, personal and environmental factors that make young people more likely to be bullied also make them more likely to develop psychosis. These risk factors include poor performance at school, being autistic, and emotional problems like anxiety or depression. Among shared environmental factors, social-economic disadvantage and living in urban settings increase the risk of both psychosis and being bullied.
These shared risk factors can make it more complicated to identify and understand fundamental developmental processes and potential pathways between bullying and psychotic symptoms.
It can be hard to ascertain when the experience of bullying itself has contributed to the development of psychosis and when there is another factor that has caused someone to both be bullied and to develop psychosis. While the task is not impossible, disentangling the influence of different variables may require further specific and carefully planned research.
Moving Forward: Preventing and Treating Psychosis
Research connecting bullying and psychosis can teach us several valuable things. Firstly, it underlines the importance of interventions that help to prevent bullying among young people, including interventions in schools and parental training.
Secondly, it highlights children and adolescents who have been bullied as a group who are at risk of developing psychotic symptoms, as well as other mental health conditions. These young people may benefit from extra support, screening, and, where necessary, early preventative treatment to reduce the likelihood of psychotic disorders developing.
Mental health assessments should include bullying and other stressful life events, paying particular attention to experiences during childhood and adolescence.
Thirdly, psychotherapeutic treatments can support young people to cope with the consequences of bullying and change negative thoughts and beliefs about themselves and others that may have developed from their experiences.
Behavioural therapies like CBT (cognitive-behavioural-therapies) may help people with psychosis to understand what is happening by linking psychotic symptoms with emotions, beliefs, life events, and past traumas.
These pychotherapeutic and trauma-focused treatments are valuable both in reducing the potential of bullying to cause psychotic symptoms and in treating individuals who already experience psychosis.
