326

British Journal of Clinical Psychology (2015), 54, 326–344

© 2015 The British Psychological Society
www.wileyonlinelibrary.com

Negative evaluations of self and others, and peer

victimization as mediators of the relationship
between childhood adversity and psychotic
experiences in adolescence: The moderating role
of loneliness
Siobhan Murphy, Jamie Murphy and Mark Shevlin*
School of Psychology and Psychology Research Institute, University of Ulster,
Londonderry, UK
Objective. Previous research has identified an association between traumatic expe-
riences and psychotic symptoms. Few studies, however, have explored the underlying
mechanisms and contingent nature of these associations in an integrated model. This
study aimed to test a moderated mediation model of negative childhood experiences,
associated cognitive processes, and psychotic experiences within a context of adolescent
loneliness.
Design. Cross-sectional survey.
Methods. A total of 785 Northern Irish secondary school adolescents completed the
survey. A moderated mediation model was specified and tested.
Results. Childhood experiences of threat and subordination were directly associated
with psychotic experiences. Analyses indicated that peer victimization was a mediator of
this effect and that loneliness moderated this mediated effect.
Conclusion. A new model is proposed to provide an alternative framework for
assessing the association between trauma and psychotic experience in adolescence that
recognizes loneliness as a significant contextual moderator that can potentially
strengthen the trauma–psychosis relationship.

Practitioner points
 Moderated mediation analyses poses an alternative framework to the understanding of trauma–
psychosis associations
 Adolescent loneliness is a vulnerability factor within this association
 Data are based on a Northern Irish sample with relatively low levels of loneliness
 Cross-sectional data cannot explore the developmental course of these experiences in adolescence.

Epidemiological studies have shown that psychotic symptoms are reported in the general
population and that the differences between clinical and non-clinical samples are
quantitative rather than qualitative (Johns et al., 2004; Linscott & van Os, 2013; Van Os,

*Correspondence should be addressed to Mark Shevlin, School of Psychology and Psychology Research Institute, University of
Ulster, Magee Campus, Londonderry BT48 7JL, UK (email: m.shevlin@ulster.ac.uk).

DOI:10.1111/bjc.12077
 Moderated mediation 327

Linscott, Myin-Germeys, Delespaul, & Krabbendam, 2009). Psychotic experiences (PEs)

are characterized predominantly by hallucinatory and delusional-like experiences in non-
clinical samples. They are distinguishable from psychotic symptoms observed in clinical
populations in a number of ways (e.g., associated distress, severity, intrusiveness, and
associated functional impairment; Johns & van Os, 2001; Linscott & van Os, 2013; Van Os
et al., 2009). However, they share similar risk profiles and PEs predict subsequent
psychotic disorders (Poulton et al., 2000; Welham et al., 2009).
Traumatic events have been implicated as a risk for both psychotic symptoms and
PEs (see Read, Fink, Rudegeair, Felitti, & Whitfield, 2008). Varese et al. (2012)
conducted a meta-analysis on a range of study designs to examine the association of
childhood trauma and psychotic outcomes. A total of 41 studies were included in the
analysis: Prospective cohort studies, population-based studies, and cross-sectional and
case–control designs. The results indicated that childhood trauma was significantly
associated with psychotic outcome, with an overall effect indicating approximately a
threefold increase in risk. A more recent meta-analysis (Beards et al., 2013) also
explored the relationship between negative life events and psychosis and found that 14
of 16 studies revealed positive and significant associations and reported an overall
weighted odds ratio of 3.19.
Further studies have explored the association between trauma, post-traumatic stress
disorder (PTSD), and psychotic outcomes (see Morrison, Frame, & Larkin, 2003).
Kilcommons and Morrison (2005) examined whether negative post-traumatic appraisals
and dissociation were associated with PTSD and positive psychotic symptoms in a clinical
sample of 32 individuals diagnosed with a psychotic disorder. They found that trauma
exposure was high; 94% reported at least one traumatic experience and 53% met the
diagnostic criteria for PTSD. The authors also reported a dose–response relationship.
Trauma severity was positively associated with the severity of psychotic symptoms and
PTSD. Additionally, negative appraisals were associated with PEs (particularly hallucina-
tions), suggesting that post-traumatic beliefs may confer vulnerability to psychotic
symptoms. PTSD has also been argued to moderate the trauma–psychosis relationship.
This comorbid association has resulted in poorer outcomes for individuals, for example,
exacerbated symptomology, greater relapse, higher dependency on acute healthcare
services, and additional substance abuse problems (Mueser, Rosenberg, Goodman, &
Trumbetta, 2002). Furthermore, Mueser et al. developed a model where PTSD could both
directly and indirectly influence psychotic outcomes. This model suggested that PTSD
symptom clusters (avoidance, arousal, and re-experiencing) could have both direct effects
on psychosis symptoms and indirect effects through traumatic sequelae such as substance
abuse, re-traumatization, and interpersonal difficulties.
Other models have attempted to explain these trauma–psychosis associations (Bentall
& Fernyhough, 2008; Selten & Cantor-Graae, 2005). Cognitive models suggest that there
may be numerous casual routes to the development and maintenance of psychotic
symptoms such as adverse experiences, social marginalization, and the experience of
childhood trauma (Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001; Morrison,
2001; Morrison et al., 2003). These experiences may induce a cognitive vulnerability to
psychosis characterized by negative self and world evaluations. One risk factor for the
development of these negative evaluations is the individual’s perceptions of their family
environment, which is central to an individual’s social and emotional development and
has both positive and negative influences on mental and physical well-being (Gonz
alez-
Pinto et al., 2011). Gilbert, Cheung, Grandfield, Campey, and Irons (2003) suggested that
recall of threatening parental behaviour may result in the adoption of submissive and low
328 Siobhan Murphy et al.

ranking defensive behaviours. Consequently, children may become overly attentive to

threats and vulnerable to a range of psychological adjustment problems and psychopa-
thology in later life.
Notably, studies investigating early memories of threat and subordination have
revealed associations with paranoia (Allan & Gilbert, 1997; Gilbert, Boxall, Cheung, &
Irons, 2005) and auditory hallucinations (Birchwood, Meaden, Trower, Gilbert, &
Plaistow, 2000; Birchwood et al., 2004) in clinical samples and non-clinical populations
(Murphy, Shevlin, Adamson, Cruddas, & Houston, 2012). An implication of early feelings
of threat and subordination is that these feelings may extend beyond the family
environment to other interpersonal relationships. It is therefore not surprising that these
children may be vulnerable to other adverse experiences such as peer victimization. Lopes
(2013) investigated this using a sample of individuals with a diagnosis of paranoid
schizophrenia and social phobia. This clinical sample was split into a bullied and non-
bullied group to investigate differences on experiences of childhood trauma, paranoid
ideation, aggression, and submissive behaviours. Results showed that 59.5% of partici-
pants with paranoid schizophrenia and 40.5% with social phobia, who reported a history
of having been bullied, also reported significantly higher feelings of threat and
subordination from their parents. Peer victimization has also been identified as a risk
factor for psychosis. In a meta-analysis of both clinical and non-clinical samples, exposure
to peer victimization was found to confer risk for later development of psychosis (see Van
Dam et al., 2012).
However, while the research literature demonstrates robust associations between
childhood adversity and psychotic outcomes, fewer studies have evaluated the underlying
mechanisms. This study attempts to explore and conceptualize the role of loneliness in
trauma–psychosis associations. Empirical research, until recently, has been relatively
limited on the links between loneliness and psychosis. Social withdrawal, a common
outcome of loneliness, has been linked to psychosis and has been proposed as a factor
associated with psychotic outcomes (Hoffman, 2007). Two large systematic reviews on
the role of childhood/adolescent social withdrawal in psychotic disorder found large
effects for social withdrawal as a risk factor for schizophrenia (Matheson et al., 2013;
Tarbox & Pogue-Geile, 2008).
Loneliness is a multi-faceted phenotype with myriad variables influencing its onset,
development, and course. Loneliness has been described as a universal experience
characterized by a fundamental need for social connection (Cacioppo & Patrick, 2008).
Loneliness is associated with a host of negative outcomes such as poor psychological
adjustment, mental and physical health problems, and poor social skills (Heinrich &
Gullone, 2006); lonely individuals perceive their social world as threatening, form more
negative social impressions of others, and remember social events more negatively
(Hawkley & Cacioppo, 2010). Cacioppo and Hawkley (2009) developed a model
proposing that loneliness could cause a heightened sense of social threat whereby
individuals perceive their social world as threatening. Underlying this ‘Hypervigilance to
Social Threat’ (HST) hypothesis is that loneliness may be maintained by social information
processing biases that reflect negative and dysfunctional perceptions of social relation-
ships. Consequently, these negative cognitive appraisals tend to induce more socially
withdrawn behaviours, which thereby limit the opportunity to experience positive social
relationships and interactions (Cacioppo & Hawkley, 2009; Qualter et al., 2013). This can
reduce opportunities to challenge and disconfirm negative social appraisals, which in turn
serve as further confirmation of a threatening and negative world view. Similar to the
cognitive models of psychosis and PTSD, the HST approach proposes that an individual’s
 Moderated mediation 329

negative social evaluations will potentially elicit behaviours from others that confirm their
negative social evaluations; they in turn will be more likely to engage in behaviours that
may cause others to avoid them. Lonely individuals may subsequently believe that they are
passive victims in their social world unaware that their behaviour contributes to their
perception of rejection through adopting self-protective and self-defeating interactions
with others (Cacioppo & Hawkley, 2009).
The primary aim of this study was to test a model of how negative childhood
experiences such as loneliness and victimization can interact with cognitive processes to
increase the risk of PEs. The study aimed to test the following hypotheses: (1) early
childhood memories of threat, subordination, and being under-valued were predicted to
be directly associated with PEs, (2) post-traumatic cognitions, peer victimization, and
negative social comparisons were expected to mediate this relationship, and (3) these
associations were expected to be heightened (moderated) by loneliness. The overarching
hypothesis was that loneliness would moderate the direct effect between early childhood
feelings of threat and subordination and PEs, and also the indirect associations via post-
traumatic cognitions, peer victimization, and negative social comparisons.

Methods
Participants were recruited from ten post-primary schools in Northern Ireland. An overall
sample of 785 pupils participated in the study with a response rate of 32.7%. The mean age
of the participants was 16.20 (SD = 1.06). The study was introduced to the principal of
the participating schools in a formal meeting where the aims and objectives of the study
and the recruitment procedures were discussed. After agreeing to participate, the
principal met with the teachers responsible for years 12, 13, and 14 and relayed the aims of
the study, data collection, and confidentiality procedures. The responsibility was
therefore on the school to administer the survey during form class, or conversely, pupils
were sent home to complete the survey in their own time once parental consent was
granted. Information packages were sent home with pupils for their parents to review and
provide their consent. This package included information pages that informed the
participants and parents of the main points of the study, the participants’ right to
withdraw at any time, and the right not to answer questions that they did not want to.
Pupils were informed that they could speak to their year head, parent, or health-care
professional if they had any concerns with the subject matter of the questionnaire. In
addition, separate information/takeaway leaflets were provided to both participants and
their parents that listed numerous organizations that could be contacted if either party felt
it was necessary. Seven of the ten schools chose to administer the questionnaires in form
class. The participating schools were given a 2-week period to administer and collect the
questionnaires. The completed questionnaires were stored in sealed containers in the
school office to await collection. The sample consisted of 345 males (43.9%) and 440
females (56.1%) aged between 15 and 18 years. Ethical permission to conduct the study
was obtained, from the local ethics committee.

Measures
Early Life Experiences Scale (ELES: Gilbert et al., 2003)
Early memories of familial threat and subordination were measured using the ELES. In this
study, a total scale score was used to represent memories of childhood threat and
330 Siobhan Murphy et al.

subordination. The scale is comprised of 15 items, and a Likert scale response format
(1 = completely untrue, 2 = very occasionally true, 3 = sometimes true, 4 = fairly
true, 5 = very true) was used where participants’ rated the combined frequency and
accuracy of each statement. The measure comprises three subscales (memories of threat,
subordination, and feeling undervalued), and this study used an overall scale score. Scores
ranged from 15 to 75 with higher scores indicating more frequent emotional memories
associated with feeling undervalued, threatened, and subordinate. The reliability estimate
for the overall scale was acceptable (a = .87).

Mediators
Social Comparison Scale (SCS: Allan & Gilbert, 1995)
The SCS assess negative self-comparisons (e.g., feelings of inferiority, incompetence, and
being disliked) and can be used as a multi-dimensional (rank, attractiveness and group) or
unidimensional construct. In this study, a total scale score was used to assess overall
negative social comparisons. The scale consists of 11 items and uses a semantic differential
response format: Participants rate their responses using a scale of 1–10 denoting ‘how
they feel in relation to others’. Possible scores range from 11 to 110 with lower scores
indicative of feelings of inferiority and general low rank self-perceptions. The utility of this
scale has been evidenced in numerous studies across clinical and non-clinical populations,
and the scores have shown good reliability (a = .88 to a = .96; Allan & Gilbert, 1995;
Gilbert & Allan, 1998). The reliability estimate for the overall scale was high (a = .91) in
this study.

The Posttraumatic Cognitions Inventory (PTCI: Foa, Ehlers, Clark, Tolin, & Orsillo, 1999)
This 36-item measure was designed to assess trauma-related thoughts and beliefs. It
consisted of three subscales: Negative cognitions about self, negative cognitions about
world, and self-blame. A brief description of what constitutes a traumatic experience was
provided to participants, and this included examples such as the loss of a relative, car
accident, and physical assault. Participants were not asked to record a specific
experience, rather they were asked to keep this experience in mind when completing
the questionnaire. In this study, a total scale score was used to assess negative self and
other evaluations. The participants were asked to rate each item on a 7-point Likert scale
(1 = totally disagree, 2 = disagree very much, 3 = disagree slightly, 4 = neutral,
5 = agree slightly, 6 = agree very much, 7 = totally agree). Possible scores range from
36 to 252 with higher overall scores representing elevated levels of negative cognitions.
This measure has previously been shown to produce reliable scores (a = .78–.95) using
an adolescent population (Campbell & Morrison, 2007). The reliability estimate for the
overall scale was high in this study (a = .95).

Peer Victimization Scale (PVS: Mynard & Joseph, 2000)

This 16-item self-report scale measures four different types of peer victimization: Physical,
verbal, social manipulation, and attacks on property. The items are presented and
participants are asked to rate ‘How often during the last school year has another pupil
done these things to you?’ on a 3-point Likert scale (0 = Not at All, 1 = Once, 2 = More
Than Once). Possible scores range from 0 to 32 with higher scores representing more
 Moderated mediation 331

frequent victimization experiences. In this study, a total scale sore was calculated. The
reliability estimate for the total scale was acceptable (a = .89).

The UCLA Loneliness Scale (UCLA: Russell, Peplau, & Cutrona, 1980)
The UCLA Loneliness Scale (UCLA: Russell et al., 1980) is a widely used self-report
measure of general loneliness. It consists of 20 items that are rated on a 4-point Likert scale
(Never = 1, Rarely = 2, Sometimes = 3, Often = 4). The instructions ask the participant
to ‘Indicate how often each of the statements below is descriptive of you’. The total score
is the sum of all 20 items that range from 20 to 80, with higher scores reflecting greater
feelings of loneliness. A dichotomous variable denoting lonely and non-lonely status was
created using the overall scale score. Different methods for identifying cases have
previously been used: Scores >40, 1 standard deviation greater than the mean, and the cut-
off score for the upper quintile. To attain a conservative estimate of loneliness in this
study, the highest value was used (in this case 49, which was the score one standard
deviation above the sample mean). Cronbach’s alpha for the measure in this study was
high (a = .91).

The Adolescent Psychotic-like Symptom Screener (APSS: Kelleher, Harley, Murtagh, & Cannon, 2011)
This measure incorporates seven items assessing hallucinatory and delusional experi-
ences (items are presented in Table 2) and is rated on a 4-point Likert scale (1 = Never,
2 = Sometimes, 3 = Often, 4 = Nearly Always) to give an overall score of frequency of
psychotic-like experiences ranging from 7 to 28. The APSS is a recent screening measure
for psychosis; however, Kelleher et al. (2011) have conducted tests of sensitivity,
specificity, and positive and negative predictive values (PPV and NPV) on each of the
seven items of the screener and follow-up clinical interview based on a sample of Irish
adolescents. The results demonstrated good predictive validity and good specificity and
sensitivity in its ability to identify psychotic-like experiences in an adolescent
population. The reliability estimate for the overall scale in this study was acceptable
(a = .86).

Analytic plan
The overall model was tested using conditional process analysis. This allowed multiple
mediators and a moderator to be included simultaneously within a single statistical model.
The model was tested using SPSS 21 running the PROCESS macro (Hayes, 2012). The
statistical significance of the mediated, moderated, and moderated mediated effects were
calculated using the bootstrapping (10,000 samples) method. This approach resampled
the data to create an empirical approximation of the sampling distribution of the statistic.
Consequently, point estimates and 95% confidence intervals were created for the
conditional indirect and direct effects (Affrunti, Geronimi, & Woodruff-Borden, 2013).
Statistical significance was determined when zero was not within the 95% confidence
intervals. The empirically based confidence intervals used in this study should therefore
avoid making incorrect inferences about statistical significance. The index of moderated
mediation test describes how the indirect effect of the independent variable on the
dependent variable through the mediator(s) is linearly related to the moderator. The
purpose of this inferential test is to confirm whether an indirect effect is in fact moderated
by estimating whether indirect effects (constructed by model coefficients) at different
332 Siobhan Murphy et al.

values of the moderator are statistically different from each other. The moderated
mediation model is presented in Figure 1.

Results
Descriptive statistics and bivariate correlations for all main variables in the analysis are
displayed in Table 1. All correlations were statistically significant and of moderate
strength. Table 2 shows the endorsement rates for the APSS items; 17.5% endorsed at least
one item ‘sometimes,’ and between 5.2% and 3.3% endorsed at least one item ‘often’ or
‘nearly always’. Paranoia was the most commonly reported PE with 40% of the sample
endorsing paranoid thoughts to a certain degree. Table 2 also reveals that among
persistent (nearly always) psychotic symptoms, the highest endorsed items were paranoia
(4.2%) and beliefs that others could read their mind (3.7%).
Table 3 shows the mean scale scores and correlations for the variables separately for
lonely and non-lonely adolescents; lonely adolescents reported significantly higher early
memories of childhood threat, negative self, and other evaluations and were also more
likely to experience peer victimization and PEs. Lonely adolescents also reported
significantly poorer social comparisons, indicating that they perceived themselves to be of
lower social rank. The correlations among the measures were all low to moderate and
statistically significant.
The unstandardized estimates from the mediation model are displayed in Table 4. The
results showed that the regression coefficients for the hypothesized mediation variables
social comparison (path a1), post-traumatic cognitions (path a2), and peer victimization
(path a3) on early life experiences were statistically significant. Loneliness was, however,
only significantly associated with post-traumatic cognitions (path w2). In examining the
interactions between early life experiences and each mediator again, loneliness only
moderated the relationship in terms of post-traumatic cognitions (path a2 9 w2).
Table 5 shows that the direct path (path c) from early life experiences to PEs was
statistically significant. The model also showed that for the mediators (negative self and
other evaluations and peer victimization), the regression coefficients, while controlling

Figure 1. A moderated mediation model of early life experiences, negative self and other evaluations,
peer victimization, loneliness, and psychotic experiences.
 Moderated mediation 333

Table 1. Descriptive statistics and correlations for study variables

Descriptives Correlations

Variables Mean SD 1 2 3 4 5

ELES 31.30 10.28 –

SCS 65.73 16.90 .306*** –
PTCI 89.73 36.80 .571*** .391*** –
PVS 10.35 7.80 .396*** .265*** .445*** –
APSS 9.62 3.61 .348*** .132*** .403*** .380*** –

Note. *p < .05; **p < .05; ***p < .001.

ELES, Early Life Experiences Scale; SCS, Social Comparison Scale; PTCI, Post-traumatic Cognitions
Inventory; PVS, Peer Victimization Scale; APSS, Adolescent Psychotic-Like Symptom Screener.

Table 2. Endorsement rates for the Adolescent Psychotic-Like Symptom Screener (APSS)

N (%) Endorsement of APSS items

Items Never Sometimes Often Nearly Always

Some people believe that their thoughts can be 484 (62) 200 (25.5) 71 (9.1) 29 (3.7)
read by another person. Have other people ever
read your mind?
Have you ever had messages sent just to you 613 (78.3) 128 (16.3) 28 (3.6) 14 (1.8)
through the TV or radio?
Have you ever thought people are following or 466 (59.5) 231 (30) 53 (6.8) 33 (4.2)
spying on you?
Have you ever heard voices or sounds that no one 548 (70) 156 (20.0) 54 (7.0) 24 (3.0)
else can hear?
Have you ever felt you were under the control of 668 (86) 62 (8.0) 24 (3.0) 23 (3.0)
some special power?
Have you ever seen things that people could not 596 (76.6) 125 (16.1) 31 (4.0) 26 (3.3)
see?
Have you ever felt like you had extra special 668 (85.5) 56 (7.2) 25 (3.2) 32 (4.1)
powers?

Table 3. Descriptive statistics and correlations among study variables comparing lonely and non-lonely
adolescents

Non-Lonely (N = 647, 83%) Lonely (N = 135, 17%) Correlations

Mean (SD) Mean (SD) t (df) with UCLA

ELES 29.47 (8.85) 39.78 (12.17) 11.44 (778)*** .380***

SCS 67.69 (15.39) 55.95 (20.16) 7.61 (780)*** .263***
PTCI 81.92 (32.17) 123.44 (38.26) 13.16 (772)*** .428***
PVS 9.07 (3.04) 16.61 (8.37) 10.98 (780)*** .366***
APSS 9.21 (3.04) 11.57 (5.23) 7.10 (780)*** .246***

Note. ***p < .001.

ELES, Early Life Experiences Scale; SCS, Social Comparison Scale; PTCI, Post-traumatic Cognitions
Inventory; PVS, Peer Victimization Scale; APSS, Adolescent Psychotic-Like Symptom Screener.
334 Siobhan Murphy et al.

Table 4. Estimates of direct effects and interactions from the moderated mediation

From path b (SE), p-value t LLCI ULCI

Mediating paths
ELES–SCS a1 0.34 (0.07), .000 4.88 0.48 0.21
ELES–PTCI a2 1.86 (0.13), .000 14.41 1.61 2.11
ELES–PVS a3 0.21 (0.03), .000 6.79 0.15 0.27
Moderating paths
UCLA–SCS w1 0.077 (5.15), .881 0.15 10.87 9.34
UCLA–PTCI w2 43.96 (9.43), .000 4.64 25.19 62.20
UCLA–PVS w3 3.02 (2.26), .182 1.33 1.42 7.46
Interaction
ELES–UCLA–SCS a1 9 w1 0.018 (0.13), .165 1.39 0.44 0.08
ELES–UCLA–PTCI a2 3 w 2 0.053 (0.24), .028 2.20 1.09 0.06
ELES–UCLA–PVS a3 9 w3 0.06 (0.05), .316 1.00 0.05 0.017

Note. Significant effects in bold.

ELES, Early Life Experiences Scale; SCS, Social Comparison Scale; PTCI, Post-traumatic Cognitions
Inventory; PVS, Peer Victimization Scale; UCLA, University of California, Los Angeles, Loneliness Scale;
APSS, Adolescent Psychotic-Like Symptom Screener.

Table 5. Direct and indirect effects from the moderated mediation model

Variable Path b (SE), p-value t LLCI ULCI

Direct effect
ELES–APSS c 0.051 (0.02), .003 2.94 0.16 0.08
ELES–UCLA c1 9 w4 0.18 (0.03), .569 0.56 0.08 0.04
Mediating paths to APSS
SCS–APSS b1 0.01 (0.01), .104 1.63 0.00 0.03
PTCI–APSS b2 0.21 (0.01), .000 4.42 0.01 0.03
PVS–APSS b3 0.07 (0.02), .000 3.84 0.04 0.11
Moderating path to APSS
UCLA–APSS w5 3.62 (1.95), .064 1.86 7.45 0.21
Interaction with APSS
SCS–UCLA b1 9 w5 0.02 (0.02), .305 1.03 0.02 0.05
PTCI–UCLA b1 9 w6 0.01 (001), .293 1.05 0.01 0.03
PVS–UCLA b1 3 w7 0.16 (0.04), .000 3.63 0.07 0.24

Note. Significant effects in bold.

ELES, Early Life Experiences Scale; SCS, Social Comparison Scale; HST, Post-traumatic Cognitions
Inventory; PVS, Peer Victimization Scale; PTCI, Posttraumatic Cognitions Inventory; UCLA, University of
California, Los Angeles, Loneliness Scale; APSS, Adolescent Psychotic-Like Symptom Screener.

for early life experiences, were also significantly associated with PEs. Social comparisons,
however, were not significantly associated with PEs. In terms of moderated mediators
(interactions), the only significant relationship was between loneliness and peer
victimization.
Table 6 presents the moderated mediation results for the conditional direct and
indirect effects at the value of the moderator. Conditional indirect effects are calculated as
the product of the unstandardized regression coefficient of pathway a (predictor to
Table 6. Conditional direct and indirect effects for lonely and non-lonely participants

ELES–PTCI–APSS ELES–PVS–APSS
ELES–APSS (direct effects) ELES–SCS–APSS (indirect effects) (indirect effects) (indirect effects)

b (SE) 95% CI b (SE) 95% CI b (SE) 95% CI b (SE) 95% CI

Non-Lonely 0.049 (0.02) 0.016 to 0.082 0.005 (0.00) 0.012 to 0.002 0.039 (0.01) 0.018 to 0.063 0.015 (0.01) 0.006 to 0.027
Lonely 0.032 (0.03) 0.019 to 0.082 0.017 (0.02) 0.059 to 0.009 0.042 (0.02) 0.008 to 0.083 0.062 (0.02) 0.026 to 0.107

Note. Significant effects in bold.

ELES, Early Life Experiences Scale; APSS, Adolescent Psychotic-Like Symptom Screener; SCS, Social Comparison Scale; PTCI, Posttraumatic Cognitions Inventory;
PVS, Peer Victimization Scale.
Moderated mediation
335
336 Siobhan Murphy et al.

Table 7. Index of moderated mediation

Mediator Index SE (Boot) 95% CI

SCS .012 0.018 0.055 to 0.014

PTCI .003 0.023 0.039 to 0.048
PVS .046 0.021 0.009 to 0.093

Note. Significant effects in bold.

SCS, Social Comparison Scale; PTCI, Posttraumatic Cognitions Inventory; PVS, Peer Victimization Scale.

mediator) and the unstandardized regression coefficient from pathway b (mediator to

outcome) separately for lonely and non-lonely adolescents. Table 6 reveals that the direct
effect was significant for non-lonely participants but not for lonely adolescents. The
results further show that the conditional indirect effects of early life experiences on PEs
were significant for both post-traumatic cognitions and peer victimization. These effects
were statistically significant for both lonely and non-lonely adolescents. In terms of
negative self and other evaluations, there was little difference between lonely and non-
lonely individuals in the size of the effect at the level of the moderator. Peer victimization,
conversely, indicated significant differences between lonely and non-lonely participants
with lonely adolescents displaying a much stronger effect.
The index of moderated mediation (Table 7) revealed that moderated mediation
occurred only for peer victimization, as there were significant differences between lonely
and non-lonely adolescents.

Discussion
The primary aim of this study was to delineate the mechanisms linking trauma and PEs by
moderating a series of proposed mediated paths by a measure of loneliness. The analysis
aimed to test associations between memories of early adverse life experiences and PEs
among adolescents via experiences of peer victimization, negative self-comparisons, and
negative evaluations of self and other, while also estimating whether these associations
differed for lonely adolescents. The results confirmed the first hypothesis. A direct
relationship between PEs and childhood feelings of threat and subordination was
observed. This finding supported previous studies that also found a direct relationship
between childhood feelings of threat and paranoid ideation in both clinical (Allan &
Gilbert, 1997; Gilbert et al., 2003) and non-clinical samples (Murphy et al., 2012).
The results also demonstrated that, although there was a significant relationship
between feelings of childhood threat and negative social comparisons, this relationship
did not extend to PEs. However, there was an indirect effect for traumatic cognitions that
was characterized by negative self-other evaluations and self-blame. These results
supported previous findings that revealed associations between negative self-appraisals
and insecure attachment (Pickering, Simpson, & Bentall, 2008). It is plausible to assume
that children who adopt submissive behaviours as a form of coping with parental threat
may also formulate negative self-other evaluations as they mature. Previous studies have
shown that early feelings of threat can be positively correlated with feelings of
incompetency and self-hatred among college students (Richter, Gilbert, & McEwan,
2009). Moreover, research has also evaluated the role of negative self-other evaluations
and their association with positive psychotic symptoms. For example, Gracie et al.
 Moderated mediation 337

(2007) found that negative schematic beliefs about the self and others acted as a mediating
role in the relationship between trauma and PEs. Furthermore, the results also support
Gilbert and colleagues who proposed that exposure to early feelings of threat can cause
children/adults to adopt these submissive defensive styles as a reaction to their perceived
hostile family environment and how this can increase vulnerability to psychological
problems (Gilbert et al., 2003). The current results also compliment findings from
Udachina and Bentall (2014) who investigated the role of early interactions with parents
and later persecutory thinking in a non-clinical student sample. They found that early
experiences with parents predicted negative self-evaluations and dysfunctional coping
mechanisms (e.g. experiential avoidance characterized as intolerance of unpleasant
mental experiences) which further predicted paranoia. The current analysis therefore
seems to be consistent with the extant research literature on the importance of early
experiences with parents and the development of both negative self-other evaluations and
PEs.
The results also support findings that highlight the role of cognitive processes in the
development of PEs. Cognitive models of psychosis suggest that childhood experiences of
adversity can affect belief systems that lead to the development of negative schematic
beliefs involving the self and the world, which can affect how individuals interpret and
interact with their environment. These dysfunctional negative self-other appraisals have
also been found to exacerbate experiences of auditory hallucinations and paranoid
ideation (Fowler et al., 2006; Garety et al., 2001; Kilcommons & Morrison, 2005;
Morrison, 2001). Such models suggest that beliefs which an individual develops following
a trauma may inform the content of later hallucinations and the thematic associations that
often occur between hallucinations and delusions (Fowler et al., 2006; Hardy et al., 2005;
Read et al., 2008). Heightened senses of threat, for example, that are consequential to
trauma may ultimately influence beliefs that others are dangerous and cannot be trusted,
which in turn may induce PEs such as paranoid ideation (Freeman, 2007).
Victimization (physical, emotional, sexual abuse, bullying by peers, etc.) is a common
experience for children and adolescents, which has been found to be associated with poor
social, psychological, and physical functioning. Finkelhor, Ormrod, Turner, and Hamby
(2005) explored child and youth victimization experiences over the course of 1 year, 71%
of the sample reporting at least one form of direct or indirect victimization. On average,
the youths experienced three different types of victimization within the year with only
31% reporting an isolated incident. The current findings further support the links between
early childhood memories of threat and subordination and PEs in non-clinical (Murphy
et al., 2012) and clinical samples (Allan & Gilbert, 1997; Gilbert et al., 2005) while
recognizing the mediating influence of peer victimization (Lopes, 2013). This may be
explained within a trauma–psychosis framework in two ways. First, while bullying does
not formally constitute a traumatic experience in current psychiatric nosology, the
current analysis showed that bullying is associated with psychotic symptomatology and
cognitive biases that are commonly present in individuals diagnosed with psychotic
disorder. Previous studies have reported similar findings across clinical (Addington et al.,
2013; Bebbington et al., 2004) and non-clinical samples (Lataster et al., 2006; Schreier
et al., 2009). The current findings are also consistent with evidence that exposure to
bullying was associated with a predisposition to PEs (Campbell & Morrison, 2007).
Second, it was observed that adolescents who experienced victimization by peers may
have grown up in hostile family environments where submissive behaviours were
adopted as a form of coping. This seems to be consistent with findings reported by Lopes
(2013), who studied patients with social phobia and paranoid schizophrenia, and Gilbert
338 Siobhan Murphy et al.

et al. (2005), who found associations between paranoid ideation and heightened feelings
of threat and submissive defence strategies.
The third hypothesis that loneliness would moderate the mediating effects of social
comparisons, traumatic cognitions, and peer victimization was partially supported.
Moderated mediation by loneliness was observed in relation to peer victimization. It
seemed that feelings of threat and subordination, adopted at an early age, may have led to
victimization experiences and PEs and that loneliness, notably, was important in
moderating this relationship. This analysis therefore potentially presents an alternative
and novel framework for conceptualizing trauma–psychosis associations, that is one that
recognizes the potential contextual importance of experiences such as loneliness before,
during, and after adversity. The model also supports the recent research that emphasizes
the clinical significance of loneliness during adolescence (Heinrich & Gullone, 2006). The
findings may also be interpreted in the light of other theoretical models of loneliness,
indicating that loneliness is maintained by a HST in both adults (Cacioppo & Hawkley,
2009) and adolescents (Qualter et al., 2013). This also lends support to findings by
Qualter et al. (2013) that demonstrated lonely adolescents show a distinct pattern of
attentional biases and heightened social threat when compared to non-lonely adolescents.
The current study showed that loneliness moderated the mediated effects of peer
victimization within trauma–psychosis associations. It is not surprising that loneliness
acted as a moderator in this relationship as loneliness has consistently been associated
with peer victimization and peer-related problems (Chen, DeSouza, Chen, & Wang, 2006).
However, the significant differences in effect sizes between lonely and non-lonely
adolescents in the current model have potential implications for adolescent intervention
programmes. The findings also emphasize the potential clinical significance of loneliness
in adolescence and suggest that it should be considered meaningful within a trauma–
psychosis paradigm.
The generalizability of the findings from this study depends, in part, on the
characteristics of the sample; the participants in this study were similar to participants
in other studies. The most commonly reported delusional-like experience was paranoia,
with 41% of the sample experiencing paranoid thoughts at least ‘sometimes’. This finding
is consistent with a study in a student population (Freeman et al., 2005) that found 30–
40% reported they believed negative thoughts were being spread about them. The results
are also comparable to a recent review that reported a mean prevalence of PEs of 7.5% for
adolescents aged 13–18 years (Kelleher et al., 2012). However, Wigman et al. (2011)
used two separate adolescent samples and found 43% and 39% of each sample endorsed at
least one PE ‘often’ or ‘nearly always’ which is much higher than in this study. A possible
explanation for the higher rates in Wigman et al. study is that PEs were assessed using the
Community Assessment of Psychic Experiences (CAPE: Stefanis et al., 2002), which
includes schizotypal items rather than symptom-based items. The overall rates of
victimization and trauma-related cognitions were moderate to low. However, in
comparison to studies using similar samples, the level of trauma-related cognitions were
higher than a U.S. college sample and, as expected, lower than a treatment seeking trauma
sample (Van Emmerik, Schoorl, Emmelkamp, & Kamphuis, 2006). Recalled memories of
childhood threat are also similar, albeit slightly lower, to rates in a college sample (Gilbert
et al., 2003). The rates of peer victimization were also lower than found in previous
studies (Mynard & Joseph, 2000). This finding, however, must be interpreted in the light
that previous studies have used younger participants and peer victimization is more
prevalent in early adolescence (Bradshaw, Waasdorp, & O’Brennan, 2013).
 Moderated mediation 339

This study is not without limitations. First, early experiences of childhood threat were
assessed in an adolescent population. This could be argued to be too early in terms of
cognitive development for some adolescents to process these experiences and attribute
them to feelings of threat and subordination. Second, the post-traumatic cognitions
reported by the adolescents in the current study were not anchored to a specific traumatic
experience. However, they were given a brief description of what a traumatic experience
may constitute and were asked to think of this when answering the questionnaire.
Consequently, the present analysis was unable to identify the type of trauma that may have
been responsible for inducing the reported cognitions. Finally, the cross-sectional nature
of the study limited inferences involving the temporality of the predictor, mediator,
moderator, and outcome variables. Several criticisms have been raised regarding the use of
mediation analysis on cross-sectional data, as by definition mediation analysis examines
mechanisms over time (Cole & Maxwell, 2003; Maxwell, Cole, & Mitchell, 2011). Maxwell
et al. argue that mediation analysis of cross-sectional data can lead to biased estimates of
longitudinal parameters and that strong mediators derived from cross-sectional data
analyses may not emerge when data are reliably ordered over time. The authors of the
current study do contend, however, that the individual parameters within the proposed
model (specifically those denoting time ordered associations between risk variables and
mediators and mediators and outcome) have been empirically defined and supported and
that the proposed model offers a strong, plausible, and evidence-based theoretical
framework from which future analyses may be developed.
To conclude, the current findings indicated that adolescents who report PEs also
experienced feelings of threat and subordination within the family environment,
victimization from peers, and heightened feelings of loneliness. Underlying each of these
experiences is the association with heightened threat perceptions. Therefore, one
implication of the current study is that intervention programmes for psychosis should
target possible threat beliefs. Through promoting self-soothing strategies and encourag-
ing adolescents to become more supportive and self-reassuring may help reduce negative
self and other evaluations. These principles are the foundations of Compassion-Focused
Therapy (CFT: Gilbert, 2009), which is designed to stimulate affect systems associated
with safeness and self-soothing as opposed to threat. CFT has also been applied to the
treatment of psychosis (Gumley, Braehler, Laithwaite, MacBeth, & Gilbert, 2010). Another
implication of the findings is that, given the role of loneliness within the trauma–psychosis
paradigm, interventions should target reducing loneliness in adolescence. Interventions
based on targeting maladaptive social cognition have been found to be more effective in
reducing loneliness than social skills training (Masi, Chen, Hawkley, & Cacioppo, 2010).
This finding supports the HST hypothesis as addressing an individual’s negative thought
patterns about their social environment, this may alleviate heightened threat perceptions.
Furthermore, this study has described complex processes including psychological,
environmental, and social factors that may confer risk to psychotic symptom expression.
It is important to note, however, that the retrospective accounts of childhood feelings of
threat in the current analysis may have been influenced by the adolescents’ existing
emotional states. This may be particularly relevant as research has suggested that lonely
individuals often perceive their social world to be more negative and threatening. This
raises the issue of potential reciprocal causality; for example, lonely adolescents’
heightened threat perceptions could negatively influence their perceptions (and
memories) of both family and peer interactions. The current study therefore can only
conclude that loneliness is associated with the trauma–psychosis paradigm; the direction
of this relationship remains yet to be unequivocally established. It is suggested therefore
340 Siobhan Murphy et al.

that longitudinal data and analyses be employed to assess these proposed mechanisms
over time.

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Received 1 May 2014; revised version received 12 January 2015