Psychotic-like experiences in help-seeking adolescents: Dimensional exploration and association with different forms of bullying victimization – A developmental social psychiatry perspective

Abstract

Background:

Psychotic-like experiences (PLEs) are common in the general population and increase the risk of psychotic disorders. Adolescents are a high-risk group of this condition. Stressful events, such as bullying, have a role in the onset of PLEs. This study has several aims: (1) to assess PLEs in adolescents seeking help from a Child and Adolescent Mental Health Service, (2) to assess the association of PLEs with specific bullying victimization and (3) to assess difference in PLEs and victimizations by sex and age.

Methods:

Participants were help-seeking (HS) adolescents initially screened for PLEs. They completed an assessment including characteristics of PLEs and bullying victimization. We paid particular attention to different kinds of PLEs and victimization.

Results:

In total, 50 PLE-positive adolescents screened from 324 HS adolescents (15.4%) constituted the sample. Paranoia and verbal bullying were the PLEs and form of victimization most represented, respectively. Verbal bullying was strongly associated with paranoia (odds ratio (OR): 4.40, confidence interval (CI): 2.8−5.9, p < .001). Results remained significant after controlling for confounder (socio-demographic, anxiety, depression and for the latter analysis also other forms of victimization). Furthermore, social manipulation showed a strong association of paranoia and physical bullying with grandiosity. Verbal bullying was also associated with psychotic negative symptoms, but controlling for emotional symptoms and other victimization led to a reduction in the effect. Men were more involved in physical victimization and experienced grandiosity; on the contrary, late adolescents were most involved in social victimization and negative psychotic symptoms

Conclusion:

PLEs are relevant in HS adolescents. Bullying victimization interacts with the onset of these phenomena. In particular, verbal bullying predicted paranoia onset significantly.

Keywords

Psychosis bullying social paranoia development

Introduction

Psychotic symptoms experienced by a part of the healthy population without frank disorder are named psychotic-like experiences (PLEs). The prevalence of PLEs was found to be 7.2% in the general population, and in adolescence, it is higher (Kelleher & Cannon, 2011; Linscott & van Os, 2013). PLEs have been described as ‘continuous’ and dimensional, and hence in opposition to traditional categorical means of structuring symptoms and disorders (Daneluzzo et al., 2009).

Several dimensions of psychotic experiences have been examined in community samples, such as paranoia, hallucinations and thoughts problems (Bebbington et al., 2013; Dominguez, Wichers, Lieb, Wittchen, & van Os, 2011; Gritti et al., 2014; Sharifi, Sajjadifar, & Amini, 2008); recently, this has been extended also for other psychotic dimensions (i.e. negative symptoms, cognitive disorganization) (Taylor, Freeman, & Ronald, 2016). Several studies have demonstrated that PLEs experienced in childhood or adolescence may increase the risk of developing psychotic disorders subsequently (Poulton et al., 2000; Wong, Freeman, & Hughes, 2014). PLEs have been described largely as transitional and time-limited, but 20% of people could experience persistence and 7% could develop psychotic disorder (Kaymaz et al., 2012). In adolescence, specific PLEs have been found to be distinct, separated in two components (positive vs negative), and quite heterogeneous in type and combination displayed (Ronald et al., 2014). Several studies demonstrated that PLEs tend to decrease with age (Bartels-Velthuis, van de Willige, Jenner, van Os, & Wiersma, 2011; De Loore et al., 2011; Dominguez et al., 2011; Mackie, Castellanos-Ryan, & Conrod, 2011); in fact, self-report psychotic experiences have been found to be higher in childhood (9–12 years) than in adolescence (13–18 years) and adult age (Kelleher et al., 2012). Many studies reported that females were more likely to experience psychotic symptoms, especially paranoid ideation, conceptual disorganization and perceptual anomalies (Armando et al., 2010; Brandizzi et al., 2014). Moreover, PLEs have been largely described, such as associated with anxiety and depression symptoms (Johns et al., 2004; Varghese et al., 2011).

Socio-environmental factors are associated with the extended psychotic phenotype; for example, stress exposure has been associated with the persistence of PLEs (Wigman et al., 2012). Bullying is a specific stressful event that has been repeatedly associated with mental health complaints (Kim, Koh, & Leventhal, 2005; Zwierzynska, Wolke, & Lereya, 2013) and has been repeatedly associated with the onset of psychotic continuum manifestations in a social/psychological informed perspective (Catone et al., 2015; Moffa et al., 2017). In fact, a social event with the feature of stress may lead to the development of psychotic symptoms.

Bullying is defined as a repeated aggressive behavior against a victim who cannot easily defend himself. Different types of bullying were described: direct (verbal, physical) and indirect (social, covert) (Espelage & Swearer, 2004). Direct bullying such as physical acts (punching, kicking, shoving) and verbal acts (insults, threats, intimidation) have been largely studied, whereas indirect forms were less investigated. Covert victimization refers to social manipulation and includes exclusion of peers from a group or activity, spreading rumors or inciting someone to bullying toward a victim (Marini, Dane, Bosacki, & Ylc, 2006). Large epidemiological surveys have examined the reduction in physical aggression over time with the possibility that aggression was replaced by covert form of victimizations. Moreover, physical aggression was classically associated with males, whereas relational forms of aggression were attributed mainly to females (Juvonen & Graham, 2014).

Studying PLEs could add information to the understanding of psychosis, and PLEs are more evident in children and adolescents. Several prior studies have addressed this in community samples (Yung et al., 2009). However, few studies have focused on a clinical young sample. Brandizzi et al. described attenuated PLEs in 171 help-seeking (HS) adolescents. They found four dimensions of psychotic symptoms (‘Conceptual Disorganization and Suspiciousness’, ‘Perceptual Abnormalities’, ‘Bizarre Experiences’, and ‘Magical Ideation’), alternatively age and/or psychopathology and functioning related (Brandizzi et al., 2014), while Kline et al. studied the association between PLEs and clinical distress in 66 adolescents and young adults receiving mental health services (Kline et al., 2014). Ames et al. found a high prevalence of PLEs in a sample of 40 children (aged 8–14 years), referred to a community Child and Adolescent Mental Health Service; PLEs were associated with several factors, such as emotional problems, cognitive biases and negative life events (Ames et al., 2014). In Italian samples, Pontillo et al. found that children aged 8−17 years with PLEs had more impairment in global, social and role functioning (Pontillo, De Luca, Pucciarini, Vicari, & Armando, 2016). Armando et al. examined 1,882 undergraduate students, and they found different subtypes of PLEs in this sample (bizarre experiences, perceptual abnormalities, persecutory ideas and grandiosity) associated with depression, distress and low functioning (Armando et al., 2010), and in another study, the same research group associated a specific psychotic experiences with socio-demographic variables or alcohol and drug misuse (Armando et al., 2012). Furthermore, to the best of our knowledge, no studies have attempted to investigate which kind of bullying (direct or indirect) is most pertinent to the risk of developing specific PLEs (positive, negative), a potentially important step on the path to frank disorder and impairment of function. Findings may have important theoretical and clinical/preventive implication.

Therefore, the first aim of this study was to accurately describe PLEs in a clinical sample of HS adolescents, and the second aim was to test for a specific association between specific types of bullying and specific psychotic experiences. In detail, we tested the hypothesis that PLEs were common in this age period and that the individual PLEs weakly correlate with one another; thus, they could present independently of each other (Ronald et al., 2014). Moreover, we examined the hypothesis that specific types of bullying may be independently associated with specific type of PLEs. Finally, the third aim was to observe differences in PLEs and bullying victimization by gender and age band (early adolescence–late adolescence; please see the ‘Methods’ section for further details). We would test the hypotheses that physical bullying is more prevalent in males and early childhood, whereas relational bullying is more prevalent in females and late childhood. We would also test the hypotheses that PLEs were more frequent in early adolescence and in female participants.

Methods

Study design, setting and participants

The study design was observational and cross-sectional. The setting was the Complex Unit (CU) of Child and Adolescent Neuropsychiatry of the Department of Mental Health, Physical and Preventive Medicine, University of Campania ‘Luigi Vanvitelli’ (ex Second University of Naples), Naples, Italy (please see the Supplementary Material for further information). Participants were consecutive HS adolescents referred to the CU. They were included in this study if they were aged between 12 and 18 years and found to suffer from PLEs after the administration of a screening instrument. Exclusion criteria were (1) diagnosis of intellectual disability, autism spectrum disorder or the patient had a known diagnosis of psychosis or schizophrenia; (2) the presence of genetic, neurological or sensory disease; and (3) adolescents who were taking psychotropic drugs. All the participants and their parents gave their written informed consent before starting the interviews. Their participation was voluntary and they could cancel their participation at any time without justification. Data collection was carried out by self-interviews and questionnaires scales, supervised by G.C. and R.M. Interviews took place during in-depth psychiatric assessment with the participant and their parents. The ethical committee of the University of Campania ‘Luigi Vanvitelli’ (ex Second University of Naples) approved the study (N.499/29 April 2016).

Measures

Screening instrument

We used the Adolescent Psychotic-Like Symptom Screener (APSS) as a screening instrument for PLEs. The APSS is a ‘rapid’, 7-item questionnaire with three possible answers: No (0), Maybe (0.5) and Yes (1). The cut-off to be at risk for PLEs was a score >2. The APSS had good sensitivity and specificity in identifying young adolescents with PLEs. In particular, the questions relating to auditory hallucinations, visual hallucinations and paranoid thoughts have demonstrated a good predictive power for PLEs (Kelleher, Harley, Murtagh, & Cannon, 2011).

Bullying

Bullying victimization was assessed using the Multidimensional Peer Victimization Scale (MPVS). The MPVS is a 16-item questionnaire with three possible answers: Not at all (0), Once (1) and More than once (2). MPVS constituted four subscales: (1) physical victimization scale, (2) verbal victimization scale, (3) social manipulation scale and (4) attacks on property scale. Total score and scale scores are computed by summing item responses. Scores on the total scale have a possible range of 0–32; scores on each of the four subscales have a possible range of 0–8. Higher scores reflect more victimization. The MPVS showed a good reliability and validity to measure bullying victimization (Mynard & Joseph, 2000). This tool has been already used and validated in an Italian sample (Carraro, Scarpa, Paggiaro, & Ventura, 2011; Scarpa, Carraro, Gobbi, & Nart, 2012).

PLEs

We used the Specific Psychotic Experiences Questionnaire (SPEQ) to assess the PLEs in the sample. Six types of psychotic experiences compose the SPEQ: paranoia, hallucinations, cognitive disorganization, grandiosity and anhedonia (all assessed via self-report), and negative symptoms (via parent report). All subscales demonstrated good to excellent internal consistency (r = .77–.93) and test–retest reliability (r = .65–.74) after 9 months of follow-up in a general population sample of monozygotic and dizygotic twins (Twins Early Development Study – TEDS) (Pisano et al., 2015; Ronald et al., 2014).

Depression

The Children’s Depression Inventory (CDI) was used to assess depression in the sample. The CDI is composed of 27 items within a score of 0−2 points. Cut-off score is settled on 19 points. The CDI is widely used for assessing depressive symptoms in children and adolescents aged 8–17 years and has good internal consistency (Cronbach’s α = .80) (Kovacs, 1985).

Anxiety

Multidimensional Anxiety Scale for Children (MASC) was used to evaluate anxiety in the sample. The MASC is composed of 39 items with four possible answers: Never true for me (0), Rarely true for me (1), Sometimes true for me (2) and Often true for me (3). Higher score reflects higher level of anxiety. MASC provides a reliable and valid depiction of the configuration of anxiety, showing good internal reliability (March, Parker, Sullivan, Stallings, & Conners, 1997).

Statistical analysis

Data processing was done using software for statistical analysis: The Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 20.0; IBM Corp, Armonk, NY) and STATA (Version 11.2; StataCorp, College Station, TX).

Descriptive statistics (mean values, standard deviations, ranges and frequency distributions) were used to describe the sample and to assess its socio-demographic and clinical characteristics. Univariate analysis of variance (ANOVA) was used to assess significant mean variations in bullying victimization total scores and subscales and PLEs subscales; the covariate were (a) sex (1: male; 2: female) and (b) age bands (1: early adolescence 144–168 months; 2: late adolescence 169–211 months). A series of Bravais-Pearson correlations within (1) the PLE scales and between (2) the PLE scales and the victimization subscales were performed. Linear regression models were used to test the predictive power of the type of bullying victimization on the type of PLEs, with regressions being performed only between variables (PLEs: dependent variables (DVs); Victimizations: independent variables (IVs)), with correlation coefficient ranging from .3 to .7 (moderate correlation) and from .7 to 1 (strong correlation), with a significant p value (in the previous correlation analyses). The results were crude coefficients that have been controlled for by several confounders: sex, age, depression and anxiety symptoms and other types of victimization (beyond the independent variable) (for regressions diagnostics, see Supplementary Material).

Results

Descriptive statistics

The sample consisted of 50 patients, 24 males (48%) and 26 females (52%); the total number of people screened to obtain 50 participants was 324 (15.4%). HS not positive to PLEs did not differ significantly in terms of age and gender from those PLE positive. The mean age was 170 (±18.4) months. Figures 1 and 2 show the distribution of the different PLEs and the different types of bullying victimization in our sample. The mean of total MPVS was 17.1 (±7.5); the four MPVS subscales showed the following means: verbal bullying 6.1 (±2.5), social manipulation 4.6 (±2.2), attack property 3.8 (±2.2) and physical bullying 2.4 (±2.4). SPEQ scale means were as follows: paranoia 34.6 (±17.5, range: 0–62), hallucinations 15.5 (±8.9, range: 2−36), grandiosity 7.4 (±5.8, range: 0−24), cognitive disorganization 7.1 (±2.7, range: 1−11), anhedonia 25.2 (± 9.4, range: 6−46) and negative symptoms 13.3 (±6.9). CDI mean was 17.6 (±7.2, range: 3−32), whereas the MASC mean was 49.8 (±19.7). Other descriptive statistics are provided in the Supplementary Material (please Tables 1 and 2 of the Supplementary Material).

Figure 1.

PLE distribution (x-axis: type of PLEs; y-axis: arithmetical mean of scales of the Specific Psychotic Experience Questionnaire: paranoia, grandiosity, hallucinations, cognitive disorganization, anhedonia and negative symptoms).

Figure 2.

Bullying victimization distribution (x-axis: type of victimizations; y-axis: arithmetical mean of subscales of the Multidimensional Peer Victimization Scale: physical bullying, verbal bullying, social manipulation and attack on property).

Correlation between PLEs and types of victimizations and PLEs

The first correlation analysis among the six PLE dimensions is shown in Table 1. As hypothesized, the various psychotic symptoms tend to correlate weakly to moderately with each other. The only moderate correlations (>.3) were between auditory verbal hallucinations (AVHs) and cognitive symptoms (.334, p < .05), anhedonia and cognitive symptoms (.339, p<.05), paranoia and negative symptoms (.336, p < 05) and AVHs and negative symptoms (.382, p < .01). Interestingly, grandiosity correlated negatively with all other psychotic dimensions. The second correlation analysis between PLE scales and victimization scales is shown in Table 2. Paranoia shows moderate and significant correlations with verbal bullying (.628, p < .01) and social manipulation (.477, p < .01); grandiosity is significantly correlated with physical bullying (.376, p < .01), whereas negative symptoms showed moderate and significant correlation with verbal bullying (.341, p < .05); A significant correlation is also found for social manipulation and negative symptoms (p < .05) but with weak correlation coefficient (.287). Total bullying was correlated with paranoia and negative symptoms.

Table 1.

Correlation between PLE subscales.

	Paranoia	Grandiosity	AVHs	Cognitive	Anhedonia
Paranoia	–	–	–	–	–
Grandiosity	–.052	–	–	–	–
AVHs	.299*	–.063	–	–	–
Cognitive	.298*	–.296*	.334*	–	–
Anhedonia	.244	–.289*	.193	.339*	–
Negative	.336*	–.322	.382**	.249	.163

AVHs: auditory verbal hallucinations.

<.05; **<.01.

Table 2.

Correlation between PLE subscales and MPVS total scale and subscales.

	Paranoia	Grandiosity	AVHs	Cognitive	Anhedonia	Negative
Physical bullying	.261	.376 **	.230	–.098	–.329*	.092
Verbal Bullying	.682 **	.060	.203	.229	–.010	.341 *
Social Manipulation	.477 **	.115	.137	.217	–.036	.287*
Attack on property	.186	.205	.232	–.041	–.359*	.110
Total bullying	.557 **	.254	.290*	.121	–.232	.313 *

Italic values denote correlation coefficient ranging from 0.3-0.7 (moderate correlation) or from 0.7-1 (strong correlation).

PLE: psychotic-like experience; MPVS: Multidimensional Peer Victimization Scale.

<.05; **<.01.

Association of PLEs by type of victimization

Linear regressions between verbal bullying and paranoia (C = 3.45, confidence interval (CI) = 1.48−5.43, p < .001) and social manipulation and paranoia (C = 2.34, CI = 0.20 −4.49, p < .01) show significant association, which remains after controlling for confounders (sex, age, anxiety, depression and other forms of victimization, except for verbal bullying in the regression between social manipulation and paranoia) (see Table 3). The linear regression performed between physical bullying and grandiosity displays a positive unadjusted coefficient, but controlling for other victimizations reduced the significance of the association (C = 0.67, CI = 0.28−1.63, p > .05) (Table 3 of the Supplementary Material). The linear regression between verbal bullying and negative symptom showed a positive crude coefficient, but the significance of this association receded after controlling for depression and other victimizations (C = 0.78, CI = 0.15−1.71, p > .05) (Table 4 of the Supplementary Material). Finally, Tables 5 and 6 of the Supplementary Material showed positive and significant regressions between total scale of bullying and paranoia (C = 1.41, CI = 0.80−2.92, p < .01) and negative symptoms (C = 0.31, CI = 0.03−0.59, p < .05) as outcome.

Table 3.

Regression analyses between verbal and social bullying and paranoia.

Paranoia	Verbal bullying	Social manipulation
Paranoia	Coefficient (CI)	Coefficient (CI)
Unadjusted	4.40 (2.81–5.98)**	3.66 (1.70 to 5.62)**
Controlling for socio-demographics	4.46 (2.79–6.04)**	4.13 (2.02 to 6.24)**
Controlling for above + anxiety	4.28 (2.67–5.88)**	3.85 (1.65 to 6.06)**
Controlling for above + depression	4.29 (2.65–5.94)**	3.97 (1.75 to 6.19)**
Controlling for above + physical bullying	3.85 (2.00–5.70)**	3.36 (1.18 to 5.55)**
Controlling for above + verbal bullying	–	2.09 (−0.02 to 4.21)
Controlling for above + social manipulation	3.15 (1.23–5.08)**	–
Controlling for above + attack on property	3.45 (1.48–5.43)**	2.34 (0.20 to 4.49)*

CI: confidence interval.

<.05; **<.01.

Variance for sex and age band

Table 4 shows the mean differences within the sample divided for sex and age band (age band 1, early adolescence (24 subjects, 48%): 144−168 months; age band 2, late adolescence (26 subjects, 52%): 169−211 months) for MPVS total score and subscales and SPEQ subscales. Men were more likely to experience physical bullying and suffer from grandiosity. Late adolescents were more likely to be involved in social manipulation victimization and suffer from psychotic negative symptoms, whereas those in early adolescents suffer from grandiosity.

Table 4.

Bullying victimization and PLEs: difference for sex and age band.

	Mean (SD)		Mean (SD)		Mean (SD)		Mean (SD)
MPVS total				SPEQ paranoia
M	16.9 (7.1)	Age band 1	16.3 (7.7)	M	31.29 (16.2)	Age band 1	33.8 (20.4)
F	17.3 (6.7)	Age band 2	17.9 (6)	F	37.73 (18.3)	Age band 2	35.3 (14.7)
MPVS physical				SPEQ grandiosity
M	3.1 (2.4)*	Age band 1	2.5 (2.6)	M	9.6 (5.8) *	Age band 1	9.3 (6.4)*
F	1.7 (2.1)	Age band 2	2.2 (2.1)	F	5.5 (5)	Age band 2	5.7 (4.4)
MPVS verbal				SPEQ AVHs
M	5.6 (2.6)	Age band 1	5.9 (2.7)	M	17.5 (8.7)	Age band 1	15.2 (7.9)
F	6.5 (2.3)	Age band 2	6.3 (2.2)	F	13.6 (8.9)	Age band 2	15.7 (9.9)
MPVS social manipulation				SPEQ cognitive disorganization
M	4 (2.2)	Age band 1	3.8 (2.1)	M	6.7 (2.7)	Age band 1	7 (3)
F	5 (2.2)	Age band 2	5.2 (2.2)*	F	7.4 (2.6)	Age band 2	7.1 (2.3)
MPVS attack on property				SPEQ anhedonia
M	3.9 (2.5)	Age band 1	3.8 (2.2)	M	24.8 (9.6)	Age band 1	25 (9.2)
F	3.7 (1.9)	Age band2	3.8 (2.2)	F	25.5 (9.4)	Age band 2	25.4 (9.8)
				SPEQ negative symptoms
				M	12.3 (6.4)	Age band 1	11.1 (6.5)
				F	14.1 (7.4)	Age band2	15.3 (6.7)*

PLEs: psychotic-like experiences; SD: standard deviation; MPVS: Multidimensional Peer Victimization Scale; SPEQ: Specific Psychotic Experiences Questionnaire; AVHs: auditory verbal hallucinations.

Age band 1 (24, 48%): 144−168 months; age band 2 (26, 52%): 169−211 months.

Discussion

This is one of the few studies that have selected an HS population from a child psychiatry service. It confirms that PLEs are quite common in an HS population, independent of presenting complaint and reason for referral (derived by the fact that the screening procedure was conducted in a heterogeneous and transversal way to specialized clinics). Our data showed that paranoia was the psychotic experience most common, followed, in turn, by anhedonia, AVHs, negative symptoms, grandiosity and cognitive disorganization. Comparing these data with those that emerged from other studies using the SPEQ, paranoia and anhedonia were again the most common experience (Our study means of paranoia (p) and anhedonia (a): (p) 34.6 and (a) 25.2 vs Angelica Ronald’s means of paranoia and anhedonia, 2014: (p) 12,1 and (a) 16, 3). Our figures were higher than those found in other studies (Ronald et al., 2014; Shakoor et al., 2016; Sieradzka et al., 2014). This was probably due to the different nature of the sample (clinical HS vs community, epidemiological sample). Second, we confirmed the hypothesis that PLEs did not strongly correlate between themselves. Therefore, in an adolescent HS population, having one type of psychotic experience did not necessarily mean having other kinds of experiences; there was heterogeneity in type and combination of experiences manifested (Ronald et al., 2014).

Our regression analyses have indicated that particular types of bullying predicted different PLEs. We used a study design with post hoc analyses, without baseline hypothesis. This was due to the lack of previous studies on the topic. The foremost result concerned paranoia that was strongly predicted by verbal bullying and social manipulation. Recently, paranoia ideation and suspiciousness have been associated with both psychological and physical bullying (Masillo et al., 2017), and our results put in detail that verbal and social victimization were mostly linked to paranoia. Therefore, both direct and indirect bullying were associated with persecutory ideas, and this result could be expected given the presence of numerous studies that have testified this association (Catone et al., 2015). Verbal victimization refers to name-calling, teasing, insults and threats. Social manipulation included the spreading of rumors or social exclusion. They usually represent the most common forms of victimization. It is somewhat intuitive that all types of bullying determine low personal efficacy, distress, mistrust and poor peer relationship, but it is more likely that verbal threats and social exclusion are more prone to cause feelings of rejection, derision and judgment. Recent theories of psychosis suggest the role of emotional factors as the substrate from which the paranoia emerges, in particular from interpersonal worry and social anxiety (Bebbington et al., 2013). Interpersonal sensitivity, the concern about rejection from others, has been recognized hierarchically as a precursor of paranoia, and several studies have noted the association between social anxiety and paranoid thoughts in young adults and adolescents (Armando et al., 2013; Pisano et al., 2015). Indeed, one of the most frequent symptoms of paranoia is precisely the idea that others are talking about them (ideas of reference). Intense and repetitive bullying victimization (in particular verbal bullying and social manipulation) may elicit or reinforce negative ideas about the self, the others and the world. The particular associations that emerged from our data could support the hypothesis of a link between the content of stressful experiences and psychotic symptoms (the thematic link) (Catone et al., 2016).

Physical bullying was associated with ideas of grandiosity (in association with other victimizations). Physical victimization refers, for example, to being kicked and/or punched. Men were classically more involved in these actions and were more likely to suffer from grandiosity. In addition, both factors are more common in younger age. However, this kind of bullying involves an imbalance of power, especially in physical strength. It is likely that the victims tend to develop a sense of inferiority related to the concepts of strength, recognition of one’s limits and a sense of low self-efficacy and importance. Compensatory psychological mechanisms could occur to cope with these feelings, for example, the developing of an ‘elevated sense of self’ (Falukozi & Addington, 2012). In this regard, we could recall the psychodynamic concept of the ‘denial’ that is a well-recognized psychotic defense mechanism of reconstruction of outer reality. Furthermore, from the psychodynamically and developmentally informed perspective, physical abuse has an extremely high traumatic potential, and this interacts with developmental stage (in adulthood, the effects appear to be different). We could speculate about the possibility that some individuals, victims of physical bullying, may shift from one dimension of narcissistic¹ vulnerability toward a narcissistic grandiosity (Pincus, Cain, & Wright, 2014). However, further studies are needed to reach such conclusions with the need to include in the assessment questionnaires or interviews focused on the analysis of defense mechanisms.

Verbal bullying predicted negative symptoms and the onset of lack of energy and interests and social isolation behaviors. However, controlling for depressive symptoms and other victimizations reduced the significance of the association. It is difficult to disentangle this kind of relationship because the parent-rated negative symptoms scale showed a positive moderate correlation with parent-rated depression in the SPEQ validation sample (Ronald et al., 2014). Verbal bullying and depression may act synergistically or as links on a causal chain in determining the onset of negative symptoms of psychosis. Certainly, a decline in psychosocial functioning is a consequence of bullying (Nansel et al., 2004; Scholte, Engels, Overbeek, de Kemp, & Haselager, 2007) and precedes and accompanies the negative symptoms of psychosis (Kim et al., 2013). Verbal bullying can have a damaging effect, such as low self-esteem, chronic stress, anxiety and dislike of school. Therefore, these factors, together with depression, could be considered as risk factors for psychotic negative symptoms.

A dissonant result concerns the anhedonia dimension, which correlates negatively with all the domains of bullying both direct and indirect. Previously, anhedonia has been found to be slightly correlated with bullying victimization (Shakoor et al., 2016), but surprisingly in our study the two dimension correlated in inverse fashion. Probably, the construct of anhedonia is more closely linked to endogenous factors rather than environmental events, but further studies are needed to shed light on this association.

Data on the differences for gender and age band showed interesting results. As previously described in the literature, men were more involved in physical bullying behaviors (Espelage, Bosworth, & Simon, 2001). We did not find any difference for relational victimization regarding gender. Knight et al. showed that sex difference in verbal victimization was less consistent than physical (Knight, Guthrie, Page, & Fabes, 2002), and other studies found no differences between males and females in indirect bullying (Crick & Grotpeter, 1995; Prinstein, Boergers, & Vernberg, 2001). Conversely, social manipulation was higher in the late adolescence group. From a developmental perspective, this result could be interpreted in terms of considering personal and environmental aspects. First, relational bullying involves heightened cognitive and perspective-taking abilities and knowledge of interpersonal dynamics. Second, the development of more high social cognition, from childhood to adolescence, may explain the increase in indirect bullying with age. In addition, with age, there is a change in the nature of social interactions and importance and function of the peer group (greater intimacy, self-disclosure) (Espelage & Swearer, 2004).

We have shown that, among PLEs, grandiosity was more likely in males and in early adolescence. Conversely, older adolescents were more prone to suffer from negative psychotic symptoms. Ziermans also found that grandiosity was higher in males and negative symptoms were more likely experienced with increasing age, highlighting symptom clusters that could vary by sex and age and the progressive impairment in neuropsychological domains with age (Ziermans, 2013). In our sample, older adolescents may experience more severe psychological impairment and association with anxiety or depressive problems that could enhance negative symptoms.

Conclusion

We would emphasize the theoretical and clinical implications of this study. Understanding that the various forms of victimization may be differently associated with particular psychotic symptoms could help to unravel which psychological mechanisms underlie the relationship between a traumatic event, such as bullying and dimensional PLEs, and to clarify the pathogenesis of some very common symptoms, such as paranoia, hallucinations and negative symptoms of psychosis. In fact, several pathways may be involved, and an indirect effect (via affective dimensions or symptoms) has been suggested (Fisher et al., 2013; Moffa et al., 2017). Therefore, a careful study of the psychological impact of physical or verbal aggression or covert forms of bullying is needed. In a psychotherapeutic setting, specialists should focus on the content of the verbal offenses or the consequences of the evaluation of self and others after a physical dispute, social exclusion or an attack on property in the treatment of psychosis. It is indeed not impossible that different beliefs, feelings or defensive mechanisms evolve from different types of victimizations. From a preventive perspective, mental health prevention program, including detection of psychotic risk, should include both primary community and school-based intervention for bullying phenomena and secondary and selective effective interventions for adolescents involved in bullying episodes.

Finally, we would outline the limitations of this study. First, the lack of a control group precluded us to draw firm conclusions on the prevalence and relationship between PLEs and bullying. Second, the cross-sectional design of the study provided information on characteristics associated with the outcome and no indication of the sequence of events and whether exposure occurred before, after or during the onset of the outcome. Data were collected by self-report questionnaires, and it is known that the prevalence of PLEs tends to increase with this way of data gathering (van Os & Reininghaus, 2016). Furthermore, people with PLEs may have been less accurate in recalling incidents of bullying or exaggerate the same. We tried to overcome these difficulties with a one-to-one assessment and using multiple item questionnaires and scales of intensity rather than the single questions. However, other studies are needed to confirm our results.

Footnotes

Acknowledgements

G.C., R.M. and S.P. contributed equally to this work. A.P. and M.R.B. are joint last authors.

Authors’ note

Author Simone Pisano is now affiliated to Department Medicine and Surgery, Child and Adolescent Neuropsychiatry Unit, University of Salerno, Baronissi, SA, Italy.

Availability of data and materials

The dataset used will be available from the corresponding author on reasonable request.

Consent for publication

All authors read and approved the study. The manuscript is original and has not already been published. It is not currently under review by another journal.

Ethical approval

The study was in accordance with the 1964 Helsinki declaration and its later amendments. The ethical committee of the University of Campania ‘Luigi Vanvitelli’ (ex Second University of Naples) approved the study (N.499/29 April 2016)

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Maudsley Philosophy Group Charitable Trust supported this research project with a small grant to G.C.

Supplementary material

Supplementary material is available for this article online.

Notes

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