Life events that occur during adulthood are defined as particularly significant experiences that result in substantial changes to personal circumstances. These changes may be positive or they may be negative changes and can occur across all aspects of life, including health, education, employment, relationships, bereavement, housing, legal, and financial issues.

What is the evidence for adult life events as risk factors for schizophrenia?

Moderate quality evidence finds a medium-sized increase in recent adverse life events in people with psychosis compared to people without psychosis, measured between 3 months and 3.6 years prior. There was a small association between increased rates of neighbourhood crime and increased rates of psychosis.

Moderate to low quality evidence suggests a small increase in prevalence, and a medium to large increase in incidence of subclinical psychotic symptoms in people reporting prior exposure to stress and trauma. There was a medium-sized increase in perceived stress, but not adverse events, in people at ultra high-risk for psychosis; those with attenuated psychotic symptoms or brief and limited intermittent psychotic symptoms, genetic risk, and functional deterioration.

April 2022

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Antecedents such as behavioural disturbances and psychopathology are subtle deviations in development that may become evident during childhood or adolescence. The presence of these deviations may foreshadow the later development of schizophrenia, however most children who exhibit these antecedents do not develop the disorder. Studies exploring antecedents are ideally based on representative, population-based samples that follow the group from birth through childhood and adolescence to adulthood. These studies can provide unique insights into the changes in developmental trajectories that may be associated with schizophrenia.

What is the evidence for behavioural disturbances and psychopathology as antecedents of schizophrenia?

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Childhood adversities encompass a range of childhood experiences, including loss of a close relative, parental separation, bullying, physical abuse, sexual abuse, emotional abuse, and neglect. The nature, timing, severity, and duration of exposure are likely to influence mental health, however any evidence that childhood adversity directly causes psychosis or schizophrenia is controversial. Firstly, psychotic disorders may be secondary to comorbid affective, substance use, personality, or post-traumatic stress disorders, all of which have been linked to early adversities, and all are common in those with a psychotic mental illness. Another difficulty is accurately measuring childhood adversity, as it is dependent on assessment of the experiences via information collected retrospectively. This is particularly problematic if having a psychotic disorder impacts on memory recall.

What is the evidence for childhood adversity?

Moderate to high quality evidence found a small to medium-sized increased risk of schizophrenia and other psychotic disorders following exposure to childhood adversities (abuse, neglect, bullying, or parental loss) compared to people without exposure to childhood adversities. Rates of childhood sexual abuse in people with psychosis was approximately 26.3%, childhood physical abuse was approximately 38.8%, and childhood emotional abuse was approximately 34%. Rates were highest in older studies, in studies with more females, in studies with older patients, and in studies of patients with comorbid substance abuse.

In people with a psychotic disorder, exposure to any childhood adversity was associated with more severe symptom severity and poor cognition. For increased positive symptoms, there were small associations with sexual abuse, physical abuse, emotional abuse, and emotional neglect, and no association with physical neglect. For increased negative symptoms, there were small associations with sexual abuse, physical abuse, physical neglect, and emotional neglect, and no association with emotional abuse. For increased depression, there were small to medium-sized associations with sexual abuse, physical abuse, emotional abuse, emotional neglect, and physical neglect.

Compared to people with anxiety disorders, there was a medium-sized increased risk of childhood adversity in people with schizophrenia. Compared to people with dissociative disorders or post-traumatic stress disorder, there was a large decreased risk of childhood adversity in people with schizophrenia. There were no differences in rates of childhood adversity between people with schizophrenia and people with depressive disorders or affective psychosis.

Moderate to low quality evidence finds mediation and moderating effects of other life events and stressors, social defeat, loneliness, and social support on the relationship between childhood adversity and psychosis. Mediation, but not moderating effects were found for negative cognitive schemas about the self, the world and others, attachment style and parental bonding, mood symptoms, emotional dysregulation, post-traumatic stress disorder, and dissociation. Mediators are mechanisms through which the relationship may be at least partly explained, while moderators were factors that changed the relationship.

April 2022

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Exposure to environmental toxins can cause problems to both physical and mental health. Pollutants of main public health interest involve organic and elemental carbons, metals such as lead, polycyclic aromatic hydrocarbons, carbon monoxide, ozone, nitrogen dioxide, sulphur dioxide, and perchloroethylene commonly used in dry cleaning. Being born or raised in an urban environment has been related to a higher incidence of schizophrenia, and air pollution could be one of the explanatory factors.

What is the evidence for environmental toxins as a risk factor for schizophrenia?

Moderate to low quality evidence suggests exposure to high levels of air pollution may be associated with increased risk for schizophrenia. Prenatal and early childhood exposure to perchloroethylene may also be associated with increased risk of schizophrenia.

April 2022

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Some ethnic groups may show more or less risk for schizophrenia than other ethnic groups. Incidence refers to how many new cases there are per population in a specified time period, while prevalence refers to how many existing cases there are at a particular point in time. Differences in the incidence and prevalence across various ethnic groups can provide clues to possible causes of schizophrenia.

What is the evidence for ethnicity as a risk factor for schizophrenia?

Moderate to high quality evidence suggests the incidence of any psychotic disorder is greater in ethnic minority groups living in the UK or the Netherlands than in the majority population in those areas. The incidence of psychotic disorders in ethnic minority groups is highest in areas with low own-group ethnic density than in areas with high own-group ethnic density. There was also a small increase in the prevalence and incidence of subclinical psychotic symptoms in people from ethnic minority groups. Small effects showed increased rates of psychotic symptoms and experiences in people with high perceived ethnic discrimination.

For schizophrenia in particular, there is a large increased risk in black Caribbean and black African migrants living in the UK, and also in their descendants and a medium-sized increased risk for Asian migrants compared to the white British population. In the USA, moderate quality evidence found a medium-sized increased risk of schizophrenia in Black people compared to White people. This effect was largest in studies with more males, more White participants, more young participants, in studies conducted in hospital and military settings, and in studies conducted in the Midwest, Southeast or national/multistate USA settings.

April 2022

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Familial expressed emotion involving hostility, emotional over-involvement and critical comments has been associated with increased psychotic relapse in people with schizophrenia, so these traits may contribute to the development of psychotic symptoms in vulnerable individuals. Negative parental affective style involving guilt induction, over-intrusiveness and personal criticism, and a lack of clarity in communication may also contribute to increased risk of schizophrenia.

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