Psychotic features and illness severity in combat veterans with chronic posttraumatic stress disorder

Can computational models help elucidate the link between complex trauma and hallucinations?

Recently, a number of predictive coding models have been proposed to account for post-traumatic stress disorder (PTSD)'s symptomatology, including intrusions, flashbacks and hallucinations. These models were usually developed to account for traditional/type-1 PTSD. We here discuss whether these models also apply or can be translated to the case of complex/type-2 PTSD and childhood trauma (cPTSD). The distinction between PTSD and cPTSD is important because the disorders differ in terms of symptomatology and potential mechanisms, how they relate to developmental stages, but also in terms of illness trajectory and treatment. Models of complex trauma could give us insights on hallucinations in physiological/pathological conditions or more generally on the development of intrusive experiences across diagnostic classes.

[Recent developments in the modeling and psychological management of persecutory ideation]

Persecutory ideas are a major clinical problem and are associated with impaired functioning, reduced compliance with medication and increased risk of hospitalization. Persecutory ideation is defined as the false conviction that others are threatening or conspiring against one. Although persecutory delusions are mainly described and experienced in schizophrenia spectrum disorders, they also occur in other neurological and psychiatric diagnoses including Alzheimer disease, epilepsy, depression, mania, dementia and post-traumatic stress disorder. Moreover, epidemiological data from general and clinical populations indicated that paranoid beliefs occur on a hierarchy of severity and are present to a lesser degree in the general population, with paranoid delusions representing the severe end of a continuum. In this review we focus on the important advances following a decade of research from psychological sciences, and more particularly the work of Daniel Freeman and Philippa Garety in England. Their work has demonstrated that a range of causal factors are involved in the development and maintenance of delusions beyond the traditional cognitive and behavioural models. Indeed, there is now well-validated evidence that sleep disturbances, worry proneness, reasoning biases, such as failure to consider alternative explanations or belief confirmation bias, abnormal experiences such as hallucinations, negative self-beliefs, and safety behaviours, are central factors that contribute to the paranoid phenomenon. In this review, we describe each of these causal factors in detail as well as the clinical interventions developed by Freeman and his collaborators, including the integrative and modular "Feeling Safe" intervention. Broadly speaking, the aim of this psychological intervention is for patients to relearn safety by exposing them to situations they consider as potentially dangerous after reduction of the influence of the maintenance factors described above. A recent publication showed that the Feeling Safe program led to recovery in persecutory delusions for 50% of patients having poor response to antipsychotic medication, making the intervention as the most effective psychological treatment for persecutory delusions. Finally, we will critically discuss the efficacy data from the numerous clinical studies validating its effectiveness. Prospects for the implementation of the Feeling Safe program in France also is discussed.

A Neuroanatomic and Pathophysiologic Framework for Novel Pharmacological Approaches to the Treatment of Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a debilitating disorder inflicting high degrees of symptomatic and socioeconomic burdens. The development of PTSD results from a cascade of events with contributions from multiple processes and the underlying pathophysiology is complex, involving neurotransmitters, neurocircuitry, and neuroanatomical pathways. Presently, only two medications are US FDA-approved for the treatment of PTSD, both selective serotonin reuptake inhibitors (SSRIs). However, the complex underlying pathophysiology suggests a number of alternative pathways and mechanisms that may be targets for potential drug development. Indeed, investigations and drug development are proceeding in a number of these alternative, non-serotonergic pathways in an effort to improve the management of PTSD. In this manuscript, the authors introduce novel and emerging treatments for PTSD, including drugs in various stages of development and clinical testing (BI 1358894, BNC-210, PRAX-114, JZP-150, LU AG06466, NYV-783, PH-94B, SRX246, TNX-102), established agents and known compounds being investigated for their utility in PTSD (brexpiprazole, cannabidiol, doxasoin, ganaxolone, intranasal neuropeptide Y, intranasal oxytocin, tianeptine oxalate, verucerfont), and emerging psychedelic interventions (ketamine, MDMA-assisted psychotherapy, psilocybin-assisted psychotherapy), with an aim to examine and integrate these agents into the underlying pathophysiological frameworks of trauma-related disorders.

User-Centered Development of STOP (Successful Treatment for Paranoia): Material Development and Usability Testing for a Digital Therapeutic for Paranoia

BACKGROUND

Paranoia is a highly debilitating mental health condition. One novel intervention for paranoia is cognitive bias modification for paranoia (CBM-pa). CBM-pa comes from a class of interventions that focus on manipulating interpretation bias. Here, we aimed to develop and evaluate new therapy content for CBM-pa for later use in a self-administered digital therapeutic for paranoia called STOP ("Successful Treatment of Paranoia").

OBJECTIVE

This study aimed to (1) take a user-centered approach with input from living experts, clinicians, and academics to create and evaluate paranoia-relevant item content to be used in STOP and (2) engage with living experts and the design team from a digital health care solutions company to cocreate and pilot-test the STOP mobile app prototype.

METHODS

We invited 18 people with living or lived experiences of paranoia to create text exemplars of personal, everyday emotionally ambiguous scenarios that could provoke paranoid thoughts. Researchers then adapted 240 suitable exemplars into corresponding intervention items in the format commonly used for CBM training and created 240 control items for the purpose of testing STOP. Each item included newly developed, visually enriching graphics content to increase the engagement and realism of the basic text scenarios. All items were then evaluated for their paranoia severity and readability by living experts (n=8) and clinicians (n=7) and for their item length by the research team. Items were evenly distributed into six 40-item sessions based on these evaluations. Finalized items were presented in the STOP mobile app, which was co-designed with a digital health care solutions company, living or lived experts, and the academic team; user acceptance was evaluated across 2 pilot tests involving living or lived experts.

RESULTS

All materials reached predefined acceptable thresholds on all rating criteria: paranoia severity (intervention items: ≥1; control items: ≤1, readability: ≥3, and length of the scenarios), and there was no systematic difference between the intervention and control group materials overall or between individual sessions within each group. For item graphics, we also found no systematic differences in users' ratings of complexity (P=.68), attractiveness (P=.15), and interest (P=.14) between intervention and control group materials. User acceptance testing of the mobile app found that it is easy to use and navigate, interactive, and helpful.

CONCLUSIONS

Material development for any new digital therapeutic requires an iterative and rigorous process of testing involving multiple contributing groups. Appropriate user-centered development can create user-friendly mobile health apps, which may improve face validity and have a greater chance of being engaging and acceptable to the target end users.

The Role and Clinical Correlates of Complex Post-traumatic Stress Disorder in People With Psychosis

Traumatic experiences and post-traumatic stress are highly prevalent in people with psychosis, increasing symptom burden, decreasing quality of life and moderating treatment response. A range of post-traumatic sequelae have been found to mediate the relationship between trauma and psychotic experiences, including the "traditional" symptoms of post-traumatic stress disorder (PTSD). The International Classification of Diseases-11th Edition recognizes a more complex post-traumatic presentation, complex PTSD (cPTSD), which captures both the characteristic symptoms of PTSD alongside more pervasive post-traumatic sequelae known as 'disturbances in self-organization' (DSOs). The prevalence and impact of cPTSD and DSOs in psychosis remains to be explored. In the first study of this kind, 144 participants with psychosis recruited from North West United Kingdom mental health services completed measures assessing trauma, PTSD and cPTSD symptoms and symptoms of psychosis. Forty-percent of the sample met criteria for cPTSD, compared to 10% who met diagnostic criteria for PTSD. PTSD and DSOs mediated the relationship between trauma and positive symptoms, controlling for dataset membership. Both PTSD and DSOs mediated the relationship between trauma and affective symptoms but did not explain a significant proportion of variance in negative symptoms. Cognitive and excitative symptoms of psychosis did not correlate with trauma, PTSD or DSO scores. These findings indicate the possible value of adjunct therapies to manage cPTSD symptoms in people with psychosis, pending replication in larger epidemiological samples and longitudinal studies.

Psychotic Depression: Diagnosis, Differential Diagnosis, and Treatment

Psychotic depression was initially considered to be at one end of a continuum of severity of major depression. Subsequent experience demonstrated that psychosis is an independent trait that may accompany mood disorders of varying severity. While much has been learned about the impact of severe mood congruent delusions and hallucinations on the course and treatment response of depression, less is known about fleeting or mild psychosis, mood incongruent features, or psychotic symptoms that reflect traumatic experiences. Acute treatment of psychotic unipolar depression generally involves the combination of an antidepressant and an antipsychotic drug or electroconvulsive therapy. There is inadequate information about maintenance treatment of unipolar psychotic depression and acute and chronic treatment of psychotic bipolar disorder. Decision-making therefore still must rely in part on clinical experience.

[Psychotic disorders in the veterans of local wars]

OBJECTIVE

To determine the frequency of the key psychopathological syndromes, the dynamics and comorbidity of schizophrenia and other psychoses in Russian veterans of local wars receiving hospital treatment.

MATERIAL AND METHODS

The study included 685 patients of a psychiatric department of a military hospital, including 264 veterans of the local wars (the main group), 296 people (career military servicemen and retirees), who do not take part in combat actions (the first comparison group) and 125 people matched for the middle age and the age distribution curve with the main group (the second comparison group).

RESULTS AND CONCLUSION

The frequency of psychoses appeared to be slightly less in veterans (7.2%) compared to patients of comparison groups (14.5% and 8.8%, respectively). In all groups, most patients were diagnosed with schizophrenia (ICD-10 F20): 3.8% in the main group, 4.4% in the first comparison group and 4.0% in the second comparison group. Other acute and chronic psychotic disorders (F22-F23) were diagnosed in 0.8, 5.4 and 3.2% patients, respectively. Organic delusion disorders were diagnosed in 1.5% patients of the main group, 3.7% patients of the first comparison group and were not detected in the second comparison group. Comorbidity of posttraumatic stress disorder (PTSD) and psychosis was about 2% in the main group in whole and 26.3% in those with schizophrenia and other delusional disorders. The degree of incidence of symptoms of PTSD in veterans diagnosed with psychosis was significantly less than their frequency among all veterans (20% and 46.9%, respectively). Military stress factors do not influence the development of hallucinations and delusions in the main group. In the majority of veterans, psychotic symptoms manifested for the first time after stopping combat stress, the subsequent development and recurrence of psychotic symptoms happened regardless of the influence of combat stress factors.

PTSD with secondary psychotic features among trauma-affected refugees: The role of torture and depression

This cross-sectional study examined the prevalence of PTSD with secondary psychotic symptoms (PTSD-SP), its comorbidities, and its association with torture and depression in treatment-seeking refugees. Data were pooled from the Danish Database on Refugees with Trauma (DART). The sample represents approximately 90% of trauma-affected refugee-patients (N = 627) attending a Danish psychiatric outpatient clinic from 2008 to 2013. PTSD, secondary psychotic symptoms, and comorbidities were assessed with structured and routine clinical interviews. The association of PTSD-SP with torture and depression was investigated using hierarchical logistic regression. The prevalence of PTSD-SP in treatment-seeking refugees with PTSD was 30%. Among these, 44% fulfilled the criteria for Enduring Personality Change After Catastrophic Experience (EPCACE). Psychotic symptoms comprised hallucinations and persecutory delusions, often reflecting trauma-related themes. Comorbidity with depression was high (79%). Neither torture, nor other war-trauma (ex-combatant, imprisonment, civilian war trauma) predicted PTSD-SP, but comorbid depression did. Depression only explained a small amount of the total PTSD-SP variance. Results indicate that PTSD-SP is common in treatment-seeking refugees. However, its etiology is poorly understood. This highlights the need for further research to improve diagnosis and treatment for this patient group.

Assessing Voice Hearing in Trauma Spectrum Disorders: A Comparison of Two Measures and a Review of the Literature

Voice hearing (VH) can occur in trauma spectrum disorders (TSD) such as posttraumatic stress disorder (PTSD) and dissociative disorders. However, previous estimates of VH among individuals with TSD vary widely. In this study, we sought to better characterize the rate and phenomenology of VH in a sample of 70 women with TSD related to childhood abuse who were receiving care in a specialized trauma program. We compared the rate of VH within our sample using two different measures: 1) the auditory hallucination (AH) item in the Structured Clinical Interview for DSM-IV-TR (SCID), and 2) the thirteen questions involving VH in the Multidimensional Inventory of Dissociation (MID), a self-report questionnaire that comprehensively assesses pathological dissociation. We found that 45.7% of our sample met threshold for SCID AH, while 91.4% met criteria for MID VH. Receiver operating characteristics (ROC) analyses showed that while SCID AH and MID VH items have greater than chance agreement, the strength of agreement is only moderate, suggesting that SCID and MID VH items measure related but not identical constructs. Thirty-two patients met criteria for both SCID AH and at least one MID VH item ("unequivocal VH"), 32 for at least one MID VH item but not SCID AH ("ambiguous VH"), and 6 met criteria for neither ("unequivocal non-VH"). Relative to the ambiguous VH group, the unequivocal VH group had higher dissociation scores for child voices, and higher mean frequencies for child voices and Schneiderian voices. Our findings suggest that VH in women with TSD related to childhood abuse is common, but that the rate of VH depends on how the question is asked. We review prior studies examining AH and/or VH in TSD, focusing on the measures used to ascertain these experiences, and conclude that our two estimates are consistent with previous studies that used comparable instruments and patient samples. Our results add to growing evidence that VH-an experience typically considered psychotic or psychotic-like-is not equivalent to having a psychotic disorder. Instruments that assess VH apart from psychotic disorders and that capture their multidimensional nature may improve identification of VH, especially among patients with non-psychotic disorders.

Reframing PTSD for computational psychiatry with the active inference framework

Introduction: Recent advances in research on stress and, respectively, on disorders of perception, learning, and behaviour speak to a promising synthesis of current insights from (i) neurobiology, cognitive neuroscience and psychology of stress and post-traumatic stress disorder (PTSD), and (ii) computational psychiatry approaches to pathophysiology (e.g. of schizophrenia and autism). Methods: Specifically, we apply this synthesis to PTSD. The framework of active inference offers an embodied and embedded lens through which to understand neuronal mechanisms, structures, and processes of cognitive function and dysfunction. In turn, this offers an explanatory model of how healthy mental functioning can go awry due to psychopathological conditions that impair inference about our environment and our bodies. In this context, auditory phenomena-known to be especially relevant to studies of PTSD and schizophrenia-and traditional models of auditory function can be viewed from an evolutionary perspective based on active inference. Results: We assess and contextualise a range of evidence on audition, stress, psychosis, and PTSD, and bring some existing partial models of PTSD into multilevel alignment. Conclusions: The novel perspective on PTSD we present aims to serve as a basis for new experimental designs and therapeutic interventions that integrate fundamentally biological, cognitive, behavioural, and environmental factors.

Ziprasidone Augmentation of SSRI Antidepressants in Posttraumatic Stress Disorder: A Randomized, Placebo-Controlled Pilot Study of Augmentation Therapy

BACKGROUND

Posttraumatic stress disorder (PTSD) is often a chronic, disabling illness for which antidepressant medications (ie, SSRI) are considered the primary psychopharmacological treatment. However, many patients remain refractory to antidepressants alone or in combination with psychotherapy. Safe and effective treatments for individuals with refractory PTSD are needed. This study aimed to examine ziprasidone augmentation of SSRI treatment of PTSD.

METHODS

This was a 2-phase study. In phase 1, subjects were treated with paroxetine or sertraline for 8 weeks. Individuals refractory to the SSRI treatment then entered into phase II of the study and were randomized, in a double-blind fashion, to 8 weeks of treatment with either ziprasidone or placebo. The primary outcome measure was change in Clinician Administered PTSD Scale total scores with the intent-to-treat sample. Secondary outcome measures included Positive and Negative Syndrome Scale scores, measures of depression and anxiety, and safety measures.

RESULTS

No significant differences were observed on the Clinician Administered PTSD Scale, Positive and Negative Syndrome Scale, or other outcome measures between ziprasidone and placebo groups. No significant differences were observed for safety measures including metabolic profiles, extrapyramidal symptoms/movement disorder rating scales, nor study dropout.

CONCLUSIONS

Although no significant differences were noted in efficacy or safety measures between ziprasidone and placebo in this pilot study, the small sample size prevents definitive conclusions.

Reductions in reported persecutory ideation and psychotic-like experiences during exposure therapy for posttraumatic stress disorder

While psychotic-like experiences (PLEs), including persecutory ideation and auditory or visual hallucinations, are common in PTSD, questions remain about their relationships to core PTSD symptoms and responsiveness to treatment. This study examined data from a waitlist (WL) controlled clinical study of the effect of virtual reality (VR) and prolonged exposure (PE) in a sample of active-duty service members with deployment-related trauma (n = 161). PLEs were assessed and examined with regard to their responsiveness to trauma focused treatment (combining conditions) relative to the WL, as well as their relationships to PTSD symptoms. Persecutory ideation symptoms, which were most closely related to PTSD Cluster C (avoidance and numbing) symptoms, were reduced post-treatment in the trauma-focused condition relative to WL. Auditory and visual hallucinations-which were most closely associated with PTSD re-experiencing-decreased from baseline to post-treatment assessments for WL and exposure therapy participants. The presence of PLEs at baseline did not predict a reduced PTSD symptom response to treatment. Trauma-focused treatments appear effective in addressing psychotic-like experiences that can emerge in individuals with PTSD.

Posttraumatic stress disorder with secondary psychotic features (PTSD-SP): Diagnostic and treatment challenges

Trauma exposure leads to various psychiatric disorders including depression, anxiety, bipolar disorders, personality disorders, psychotic disorders, and trauma related disorders, especially posttraumatic stress disorder (PTSD). There are some overlapping symptoms of both PTSD and psychosis that make diagnosis challenging. Despite this overlap, the evidence of PTSD with comorbid psychosis as a distinct entity lies in the research showing biologic, genetic and treatment management differences between psychotic PTSD, non-psychotic PTSD, psychotic disorders and healthy controls. There is emerging evidence that PTSD with secondary psychotic features (PTSD-SP) might be a discrete entity of PTSD with known risk factors that increase its prevalence. This review has presented evidence for individuals with PTSD-SP being distinct in genetics and neurobiological factors. Individuals with PTSD and comorbid psychosis can benefit from evidence based psychotherapy (EBT). There is not enough evidence to recommend second generation antipsychotics (SGA) for PTSD-SP given that risperidone and quetiapine are the only SGAs studied in randomized controlled trials. Hence, developing an operational diagnostic criteria and treatment framework for clinical and research use is critical.

Prevalence of auditory pseudohallucinations in adult survivors of physical and sexual trauma with chronic post-traumatic stress disorder (PTSD)

Auditory Verbal Hallucinations (AVHs) are commonly associated with psychosis but are also reported in post-traumatic stress disorder (PTSD). Hearing voices after the experience of stress has been conceptualised as a dissociative experience. Brewin and Patel's (2010) seminal study reported that hearing voices is relatively common in PTSD, as hearing voices was associated with PTSD in half and two thirds of military veterans and survivors of civilian trauma, respectively. The authors conceptualised these voices as "auditory pseudohallucinations." To build upon this work, we administered Brewin and Patel's' interview to adult survivors (n = 40) of physical and sexual trauma with chronic PTSD, and healthy controls (n = 39). In contrast to previous findings, only 5% (n = 2) of our PTSD sample reported recently hearing a voice that was consistent with an auditory pseudohallucination, with no reports in our control group. Thus, no support was provided for auditory pseudohallucinations as a significant symptom in this population.

The Impact of Irrational Beliefs on Paranoid Thoughts

BACKGROUND

Although the ABC model proposed by cognitive behavioral theory has strong empirical support for a wide range of psychological problems, little is known about the role of irrational beliefs (IBs), a central concept of the ABC model, in the aetiology of paranoid thoughts, one of the most common psychotic symptoms.

AIMS

The present study aimed to investigate the impact of IBs on paranoid thoughts and people's perceptions of others.

METHOD

Eighty-one non-clinical participants (m age = 21.21 years, SD = 2.72, range 18-33; 83.95% female) recruited for this study were randomly assigned to one of the two conditions: IBs or rational beliefs (RBs). In a role-play paradigm, subjects were asked to imagine holding a list of IBs or RBs, respectively, while being exposed to a neutral social context in a virtual reality environment.

RESULTS

In line with the ABC model, results indicate that IBs lead to significantly higher levels of state paranoid thoughts and more negative perceptions of others than RBs, even after controlling for participants' baseline irrationality and trait paranoia [F (5,68) = 11.23, p < .001, Wilk's λ = .54, partial η2 = .45].

CONCLUSIONS

The findings of this paper suggest that IBs might play an aetiological role in the occurrence of paranoid thoughts. Practical and theoretical implications of these results are also considered.

Birth experiences, trauma responses and self-concept in postpartum psychotic-like experiences

The frequency of psychotic-like experiences (PLEs) amongst new mothers is beginning to be explored but the mechanisms underlying such experiences are yet to be understood. First time mothers (N=10,000) receiving maternity care via the UK National Health Service were contacted postnatally via Emma's Diary, an online resource for mothers. Measures assessed birth experience, trauma appraisals, post-traumatic stress symptoms, adjustment to motherhood, self-concept clarity and PLEs (in the form of hallucinations and delusions). There was a 13.9% response rate (N=1393) and 1303 participants reported experiencing at least one PLE (93.5%). Three competing nested path models were analysed. A more negative birth experience directly predicted delusions, but not hallucinations. Trauma appraisals and poorer adjustment to motherhood indirectly predicted PLEs, via disturbed self-concept clarity. Post-traumatic stress symptoms directly predicted the occurrence of all PLEs. PLEs in first time mothers may be more common than previously thought. A key new understanding is that where new mothers have experienced birth as traumatic and are struggling with adjustment to their new role, this can link to disturbances in a coherent sense of self (self-concept clarity) and be an important predictor of PLEs. Understanding the development of PLEs in new mothers may be helpful in postnatal care, as would public health interventions aimed at reducing the sense of abnormality or stigma surrounding such experiences.

Post-traumatic psychiatric disorders: PTSD is not the only diagnosis

Traumatic events and their consequences are often hidden or minimised by patients for reasons linked to the post-traumatic stress disorder itself (inexpressibility, shame, depressive thoughts, fear of stigmatisation, etc.). Although post-traumatic stress disorder (PTSD) remains the most widely known disorder, chronic post-traumatic psychiatric disorders are many and varied. After a trauma, the practitioner has to check for the different clinical forms of post-traumatic psychological consequences: PTSD is not the only diagnosis. Based on our own clinical experience compared to the international literature, we think necessary to build a didactic classification describing chronic post-traumatic symptoms and syndromes. Post traumatic depressions and bereavement lead to high risk of suicidal crisis and self-harm behaviours. Re-experiencing are felt with anxiety, hyper arousal increases anxious reactivity, and avoidance strategies increase anticipatory anxiety, indicating post-traumatic anxiety disorders (agoraphobia, specific phobia, obsessive compulsive disorder, separation anxiety, social phobia). Characterising an often-severe clinical picture, the co-occurrence of post-traumatic and chronic psychotic symptoms is not unusual (post-traumatic schizophrenia, post-traumatic depression with mood-congruent psychotic features, non-schizophrenic post-traumatic psychotic disorder, and bipolar reaction to trauma). A physical injury occurring at the same time as a traumatic exposure increases the risk of developing post-traumatic stress disorder later which, in turn, afflicts the subjective perception of the physical health (development of somatoform and psychosomatic disorders, comorbidity with a post-concussion syndrome). The trauma may cause a rupture in the biography of a person, also in his/her internal physiological functioning as in his/her social activities (impacts of instinctive functions and behaviours, personality changes, and adjustment difficulties on professional and personal life). Although a nomenclature is necessary for semiological descriptions, a thorough analysis of the patient's general psychological functioning must also be conducted.

Auditory hallucinations and PTSD in ex-POWS

Literature has suggested that auditory hallucinations might be prevalent in the general population and could be linked to the experience of trauma. This prospective study examines the prevalence of auditory hallucinations in trauma survivors and its association with posttraumatic stress disorder (PTSD) symptoms, over time. Former prisoners of war (ex-POWs) from the 1973 Yom Kippur War (n = 99) with and without PTSD and comparable veterans (n = 103) were assessed twice, in 1991 (T1) and 2003 (T2) in regard to auditory hallucinations and PTSD symptoms. Findings indicated that ex-POWs who suffered from PTSD reported higher levels of auditory hallucinations at T2 as well as increased hallucinations over time, compared to ex-POWs without PTSD and combatants who did not endure captivity. The relation between PTSD and auditory hallucinations was unidirectional, so that the PTSD overall score at T1 predicted an increase in auditory hallucinations between T1 and T2, but not vice versa. Assessing the role of PTSD clusters in predicting hallucinations revealed that intrusion symptoms had a unique contribution, compared to avoidance and hyperarousal symptoms. The findings suggest that auditory hallucinations might be a consequence of the posttraumatic reaction among veterans.

Cognitive Bias Modification for paranoia (CBM-pa): study protocol for a randomised controlled trial

BACKGROUND

Persecutory delusions are the most common type of delusions in psychosis and present in around 10-15% of the general population. Persecutory delusions are thought to be sustained by biased cognitive and emotional processes. Recent advances favour targeted interventions, focussing on specific symptoms or mechanisms. Our aim is to test the clinical feasibility of a novel psychological intervention, which manipulates biased interpretations toward more adaptive processing, in order to reduce paranoia in patients.

METHODS

The 'Cognitive Bias Modification for paranoia' (CBM-pa) study is a feasibility, double-blind, randomised controlled trial (RCT) for 60 stabilised outpatients with persistent, distressing paranoid symptoms. Patients will be randomised at a 50:50 ratio, to computerised CBM-pa or a text-reading control intervention, receiving one 40-min session per week, for 6 weeks. CBM-pa involves participants reading stories on a computer screen, completing missing words and answering questions about each story in a way that encourages more helpful beliefs about themselves and others. Treatment as Usual will continue for patients in both groups. Patients will be assessed by a researcher blind to allocation, at baseline, each interim session, post treatment and 1- and 3-month follow-up post treatment. The primary outcome is the feasibility parameters (trial design, recruitment rate and acceptability) of the intervention. The secondary outcomes are clinical symptoms (including severity of paranoia) as assessed by a clinical psychologist, and 'on-line' measurement of interpretation bias and stress/distress. The trial is funded by the NHS National Institute for Health Research.

DISCUSSION

This pilot study will test whether CBM-pa has the potential to be a cost-effective, accessible and flexible treatment. If the trial proves feasible and demonstrates preliminary evidence of efficacy, a fully powered RCT will be warranted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN: 90749868 . Retrospectively registered on 12 May 2016.

Early Psychosis and Trauma-Related Disorders: Clinical Practice Guidelines and Future Directions

Despite high rates of trauma-related disorders among individuals with early psychosis, no clinical practice guidelines for the treatment of comorbid early psychosis and trauma-related disorders exist to date. Indeed, the routine exclusion of individuals with past and current psychosis from participation in trauma research and practice has limited the accumulation of research that could support such clinical practice guidelines. While preliminary research evidence suggests that traditional, evidence-based treatments for trauma-related disorders can be safely and effectively employed to reduce symptoms of posttraumatic stress and chronic psychosis, it remains unclear whether such treatments are appropriate for individuals in the early stages of psychotic illness. Clinical experts (N = 118) representing 121 early psychosis programs across 28 states were surveyed using the expert consensus method. Forty-nine clinical experts responded and reached consensus on 46 of 49 expert consensus items related to the treatment of comorbid early psychosis and trauma-related disorders. Conjoint or family therapy and individual therapy were rated as treatment approaches of choice. Anxiety or stress management and psychoeducation were rated as treatment interventions of choice for addressing both trauma symptoms and psychotic symptoms. In addition, case management was rated as a treatment intervention of choice for addressing psychotic symptoms. No consensus was reached on expert consensus items regarding the appropriateness of a parallel treatment approach exposure interventions for addressing psychotic symptoms, or sensorimotor or movement interventions for addressing trauma symptoms. In areas where expert consensus exists and is supported by current research, preliminary clinical practice guidelines for the treatment of comorbid early psychosis and trauma-related disorders are offered. In areas where expert consensus does not exist, recommendations for future research are offered. The results of this study are intended to serve as a launching point for scientists and practitioners interested in advancing appropriate treatment for high-risk and underserved individuals with comorbid early psychosis and trauma-related disorders.

Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future

Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.

Childhood trauma, PTSD, and psychosis: Findings from a highly traumatized, minority sample

Trauma, especially early life trauma, is a risk factor for the development of both posttraumatic stress disorder and psychosis. The goal of the present study was to determine specific associations between exposure to childhood abuse, PTSD symptoms, and current psychotic disorder. Subjects were recruited from a public, urban hospital (N=328, >90% African American). Psychotic disorders were measured using the MINI International Neuropsychiatric Interview, PTSD was measured using the Clinician Administered PTSD Scale, child abuse was measured with the Childhood Trauma Questionnaire, and lifetime trauma exposure was measured with the Traumatic Events Inventory. Logistic regression analyses showed that both child abuse and current PTSD were statistically significant predictors of psychotic disorder beyond the effects of lifetime trauma load. When PTSD symptom clusters were examined, avoidance and numbing symptoms showed unique association with psychotic disorder independent of demographic variables and trauma exposure. Using bootstrapping techniques, we found a full indirect effect of PTSD on the association between child abuse and, suggesting a particularly important role of PTSD symptoms in relation to psychotic disorder in the presence of early life trauma. Because this is a cross-sectional study, continued research is needed to determine causality of such models. Identifying co-occurring psychosis and PTSD, particularly in populations with high levels of trauma exposure, is critical and will likely aid in more successful treatment interventions.

The epidemiology of substance use disorders in US Veterans: A systematic review and analysis of assessment methods

BACKGROUND

Substance use disorders (SUDs), which encompass alcohol and drug use disorders (AUDs, DUDs), constitute a major public health challenge among US veterans. SUDs are among the most common and costly of all health conditions among veterans.

OBJECTIVES

This study sought to examine the epidemiology of SUDs among US veterans, compare the prevalence of SUDs in studies using diagnostic and administrative criteria assessment methods, and summarize trends in the prevalence of SUDs reported in studies sampling US veterans over time.

METHODS

Comprehensive electronic database searches were conducted. A total of 3,490 studies were identified. We analyzed studies sampling US veterans and reporting prevalence, distribution, and examining AUDs and DUDs.

RESULTS

Of the studies identified, 72 met inclusion criteria. The studies were published between 1995 and 2013. Studies using diagnostic criteria reported higher prevalence of AUDs (32% vs. 10%) and DUDs (20% vs. 5%) than administrative criteria, respectively. Regardless of assessment method, both the lifetime and past year prevalence of AUDs in studies sampling US veterans has declined gradually over time.

CONCLUSION

The prevalence of SUDs reported in studies sampling US veterans are affected by assessment method. Given the significant public health problems of SUDs among US veterans, improved guidelines for clinical screening using validated diagnostic criteria to assess AUDs and DUDs in US veteran populations are needed.

SCIENTIFIC SIGNIFICANCE

These findings may inform VA and other healthcare systems in prevention, diagnosis, and intervention for SUDs among US veterans.

Failed efficacy of ziprasidone in the treatment of post-traumatic stress disorder

Background

Post-traumatic stress disorder (PTSD) is a chronic anxiety disorder that is often difficult to treat. Patients suffering from PTSD often fail to respond to antidepressants and may have a high incidence of positive symptoms of psychosis, though antipsychotic medications have been minimally studied in this population. The aim of this study was to assess the impact of the atypical antipsychotic ziprasidone (Geodon) on PTSD symptom clusters, as well as comorbid major depressive disorder. To our knowledge, this is the first completed randomized controlled trial investigating the potential efficacy and tolerability of ziprasidone in patients with chronic PTSD.

Methods

We conducted a 9-week prospective, randomized, double-blind, placebo-controlled trial of ziprasidone in 30 patients diagnosed with PTSD and comorbid depression. After screening and randomization, patients completed nine weekly study visits at which treatment safety and efficacy were evaluated. Primary measures of efficacy included total and subscale scores from the Clinician-Administered PTSD Scale (CAPS), while the Hamilton Rating Scale for Depression (HAM-D), Hamilton Anxiety Scale (HAM-A), Clinical Global Impression (CGI), and Treatment Outcome PTSD Scale (TOP-8) were implemented as secondary efficacy measures.

Results

We observed no significant effect of treatment on reduction of PTSD or depression symptoms from pre- to post-treatment.

Conclusions

Our findings suggest that ziprasidone treatment may not significantly improve symptoms of PTSD or comorbid depression, though further study is needed.

Rate and predictors of psychotic symptoms after Kashmir earthquake

Psychotic symptoms are more common in general population than validated diagnosis of psychosis. There is evidence to suggest that these symptoms, hallucinations, paranoia, elated mood, thought insertion, are part of a spectrum of psychosis and may have association with the same risk factors that determine development of psychosis. These symptoms have an association with exposure to psychological trauma, post-traumatic stress disorder, anxiety and depression. The aim of this study was to explore the prevalence of psychotic symptoms in the population affected by a natural disaster, earthquake in this case and possible correlates of these symptoms. We conducted a cross-sectional survey of a population sample affected by the disaster, comprising of 1,291 individuals, 18 months after 2005 earthquake in Northern Pakistan and Kashmir to look at the prevalence of these symptoms and their correlates. Screening Instrument for Traumatic Stress in Earthquake Survivors and Self-Reporting Questionnaire and Psychosis Screening Questionnaire were used as tools. We examined association between the symptoms of anxiety, depression, PTSD and psychotic symptoms. We performed logistic regression analysis where hallucinations and delusions were dependent variables and demographic and trauma exposure variables were independent variables. The prevalence of psychotic symptoms ranged between 16.8 and 30.4 %. They were directly correlated with symptoms of post-traumatic stress disorder as well as concurrent symptoms of anxiety and depression. Lower level of education had a strong association in all the regression models. For hallucinations, living in a joint family had a negative association and participation in rescue, history of exposure to previous trauma and past psychiatric history had positive association. Paranoia was associated with female gender. Any psychiatric symptom was associated death of a family member, history of past psychiatric illness and living in a tent at the time of interview. Pattern of association of psychotic symptoms is consistent with prior literature and can be understood in the light of stress vulnerability model.

Life Stressors and Posttraumatic Stress Disorder in a Seriously Mentally Ill Jail Population

Inmates represent a vulnerable population with increased rates of trauma and posttraumatic stress disorder (PTSD). However, little is known about the rates of trauma and PTSD among male inmates with acute psychiatric illness. This prospective, randomized study was conducted to assess the current rates of trauma and PTSD in this population. The sample consisted of 48 patients admitted to a hospital jail psychiatry service in New York City. Subjects were administered the Life Stressor Checklist-Revised and the Structured Clinical Interview for DSM-IV-TR Disorders, PTSD Module (SCID-I). The rate of PTSD diagnosis via SCID-I was 46.2% as compared to 2.1% diagnosis via clinical interview. All participants reported a history of at least one stressful and/or traumatic event, and many of these events occurred during incarceration. These results demonstrate that a great deal of trauma and PTSD goes unrecognized and untreated in this population, indicating the need for more effective treatment interventions.

PTSD and substance use disorder among veterans: characteristics, service utilization and pharmacotherapy

OBJECTIVE

While there has been considerable concern about veterans with dually diagnosed posttraumatic stress disorder (PTSD) and comorbid substance use disorders, a national study of clinical characteristics, service utilization, and psychotropic medication use of such veterans in Veterans Affairs (VA) has yet to be conducted. We hypothesized that veterans having both PTSD and substance use disorder would have lower socioeconomic status, greater medical and psychiatric comorbidity, higher medical service utilization, and more psychotropic pharmacotherapy fills.

METHODS

National VA data from fiscal year 2012 were used to compare veterans with dually diagnosed PTSD and substance use disorder to veterans with PTSD without substance use disorder on sociodemographic characteristics, psychiatric and medical comorbidities, mental health and medical service utilization, and psychotropic pharmacotherapy. Comparisons were based on bivariate and Poisson regression analyses.

RESULTS

The sample included all 638,451 veterans who received the diagnosis of PTSD in the VA in fiscal year 2012: 498,720 (78.1%) with PTSD alone and 139,731 (21.9%) with dually diagnosed PTSD and a comorbid substance use disorder. Veterans with dual diagnoses were more likely to have been homeless and to have received a VA disability pension. Medical diagnoses that were more strongly associated with veterans with dual diagnosis included seizure disorders, liver disease, and human immunodeficiency virus (HIV). Psychiatric comorbidities that distinguished veterans with dual diagnoses included bipolar disorder and schizophrenia. Veterans with dually diagnosed PTSD and substance use disorder also had a greater likelihood of having had mental health inpatient treatment. There were no substantial differences in other measures of service use or prescription fills for psychotropic medications.

CONCLUSIONS

Several substantial differences were observed, each of which represented more severe medical and psychiatric illness among veterans with dually diagnosed PTSD and substance use disorder compared to those with PTSD alone. However, effective treatments are available for these disorders and special efforts should be made to ensure that veterans with dual diagnoses receive them.

Trauma Management Therapy for a Veteran With Co-Occurring Combat PTSD and Hallucinations

Despite the development of evidence-based treatment protocols for posttraumatic stress disorder (PTSD), many clinicians are hesitant to begin trauma-focused treatment for individuals presenting with co-occurring conditions, particularly disorders with psychotic features. The current clinical case describes the treatment of a male veteran with PTSD with hallucinogenic features and recurrent depression who was treated with Trauma Management Therapy, a comprehensive treatment program for combat-related PTSD incorporating virtual-reality assisted exposure therapy and group therapy. Following treatment, the veteran demonstrated clinically significant decreases in overall PTSD symptoms as well as combat-themed hallucinations. Treatment gains were maintained at the 3-month follow-up. This case illustrates how exposure therapy can safely and effectively be delivered to individuals with complex co-occurring conditions.

Symptom structure and severity: a comparison of responses to the positive and negative syndrome scale (PANSS) between patients with PTSD or schizophrenia

OBJECTIVES

To describe and compare the structure and relative severity of symptoms in clinical trial patients diagnosed with Post Traumatic Stress Disorder (PTSD) or schizophrenia using the Positive and Negative Syndrome Scale (PANSS), developed originally to evaluate symptoms of schizophrenia.

METHOD

This secondary data analysis used baseline PANSS symptom ratings (n=267) from a six-month multicenter randomized placebo-controlled trial of adjunctive risperidone in patients with chronic military-related PTSD. First, using a split-half design, Exploratory Factor Analysis (EFA) was employed to identify independent factors which were then compared to published factor structures for schizophrenia. Next, Confirmatory Factor Analysis (CFA) was applied to the second half of the sample to compare the results of the EFA and published factor structures. Finally, T-tests were used to compare the severity of factor scores between the PTSD sample and the baseline PANSS ratings from the Clinical Antipsychotic Trial for Intervention Effectiveness (CATIE) schizophrenia sample (n=1460).

RESULTS

EFA suggested five factors similar to those identified in a summary of 29 schizophrenia studies by Wallwork (Schizophrenia Research, 137:246-250). CFA showed that the five factor Wallwork model fit the data better than the EFA, although both had relatively high goodness of fit. T-tests showed that the PTSD sample had more severe symptoms on the Depressive factor, and the schizophrenia sample on the Positive, Negative, and Disorganized factors, with no significant difference on the Excited factor.

CONCLUSION

Veterans with PTSD had similar symptom structure to patients with schizophrenia on the PANSS, but were less symptomatic on psychosis-related factors and more symptomatic on depression. Dimensional symptom factors can be virtually the same across diagnoses.

Psychotic-like experiences, symptom expression, and cognitive performance in combat veterans with posttraumatic stress disorder

Apparent psychotic symptoms are often associated with posttraumatic stress disorder (PTSD), but these symptoms are poorly understood. In a sample of 30 male Vietnam combat veterans with severe and chronic PTSD, we conducted detailed assessments of psychotic symptom endorsement, insight, symptom severity, neurocognitive function, and feigning. Two thirds of the subjects endorsed a psychotic item but did not believe that the experiences were real. Those endorsing psychotic items were higher in PTSD severity, general psychopathology, and dissociation but not depression, functional health, cognitive function, or feigned effort. Severity of psychotic symptoms correlated with dissociation, combat exposure, and attention but not PTSD, depression, or functional health. Those endorsing psychotic items scored higher on a screen but not on a detailed structured interview for malingering. Endorsement of psychotic experiences by combat veterans with PTSD do not seem to reflect psychotic symptoms or outright malingering.

Pharmacotherapy of post-traumatic stress disorder: a family practitioner’s guide to management of the disease

Post-traumatic stress disorder is a difficult to treat, yet common disorder, which is associated with significant morbidity, mortality and societal burden. Comprehensive management of post-traumatic stress disorder must include both psychotherapeutic and pharmacologic components. The current evidence-based pharmacologic management approaches to post-traumatic stress disorder, suggests that first-line treatments for monotherapy are the selective serotonin reuptake inhibitors, sertraline, paroxetine and fluoxetine. Other potential options include other monotherapies including venlafaxine, mirtazapine, tricyclic antidepressants, monoamine oxidase inhibitors, as well as adjunctive usage of atypical antipsychotics, lamotrigine, trazadone and a number of adrenergic agents. A trial of therapy should be at least 8 weeks and continue for at the very least 12 months, but is likely to be much longer. In light of the risks of untreated post-traumatic stress disorder (e.g., suicide and impaired psychosocial functioning), therapy may need to be continued for 2 years or more. Pharmacologic therapy instituted at the time of acute psychologic trauma shows promise for the prevention of post-traumatic stress disorder in the future and warrants further study.

Emerging roles for atypical antipsychotics in chronic post-traumatic stress disorder

Post-traumatic stress disorder is an anxiety disorder that may occur after the individual is exposed to severe psychologic trauma such as combat, sexual assault, or childhood physical or sexual abuse. Chronic post-traumatic stress disorder may result in considerable psychologic pain and suffering for the individual in addition to significant functional impairment. In addition to the heterogeneity of symptoms that occur in post-traumatic stress disorder, there may also be extensive comorbidity with other anxiety disorders, mood disorders, psychotic disorders, and other psychiatric disorders. This complicates the treatment picture. Currently, accepted treatments for post-traumatic stress disorder include psychotherapy, in particular cognitive behavioral-based approaches and antidepressant medication. However, many patients are refractory to these initial treatments or have only a partial response. In light of this, may clinicians combine additional classes of psychotropic agents and different psychotherapeutic approaches to enhance treatment response. This article reviews the literature on the use of atypical antipsychotics in the treatment of post-traumatic stress disorder. Most of the research to date has involved combat veterans partially responsive or refractory to treatment, namely with antidepressants. Studies have shown improvement across post-traumatic stress disorder symptom clusters, as well as improvement in comorbid psychotic symptoms or disorders. More research is needed to confirm these recent findings and further delineate the role of atypical antipsychotics in the treatment of post-traumatic stress disorder. Currently, possible indications for their use include treatment-resistant post-traumatic stress disorder and post-traumatic stress disorder with comorbid psychotic features.

Testing a model of the relationship between childhood sexual abuse and psychosis in a first-episode psychosis group: the role of hallucinations and delusions, posttraumatic intrusions, and selective attention

Several theories suggest that posttraumatic intrusive symptoms are central to the relationship between childhood trauma (CT) and hallucinations and delusions in psychosis. Biased selective attention has been implicated as a cognitive process underlying posttraumatic intrusions. The current study sought to test theories of the relationship between childhood sexual abuse (CSA), hallucinations and delusions, posttraumatic intrusions, and selective attention in first-episode psychosis (FEP). Twenty-eight people with FEP and 21 nonclinical controls were assessed for CT and psychotic and posttraumatic stress symptoms and completed an emotional Stroop test using CSA-related and other words. Those with FEP and CSA had more severe hallucinations and delusions than those with FEP and without CSA. They also reported posttraumatic intrusions at clinical levels and showed selective attention to CSA-related words. The results are consistent with the posttraumatic intrusions account of hallucinations and delusions in those with CSA and psychosis.

The psychotic mummified hand: an unusual hand injury complication

The authors report the case of a patient with psychotic symptoms secondary to a posttraumatic stress disorder following a work-related hand injury. The somatic presentation was a "mummified" hand neglected for several years in a splint without any care. The psychiatric analysis concluded that this was part of a delusion of persecution expressing a conflict against the patient's employer and insurance company. Surgical treatment was limited to a hand cleaning with hardware removal. Despite 3 years of antipsychotic medication the patient was still suffering from delusion and the hand remained neglected at the last follow-up.

The prevalence of full and partial posttraumatic stress disorder among people with severe mental illness in Israel

Research has shown higher rates of trauma exposure and posttraumatic stress disorder (PTSD) among persons with severe mental illness (SMI). The aim of this study was to assess the prevalence of traumatic events and full and partial PTSD among people with SMI and their associations with trauma-related cognitions and depressive symptoms. A total of 122 persons with SMI were assessed for trauma exposure and PTSD. A subsample of 40 participants, 20 with PTSD and 20 without PTSD, were randomly selected, and their posttraumatic cognitions and depressive symptoms were assessed. The prevalence of traumatic events was 90%, and 19% met full diagnostic criteria for PTSD, and 20% had partial PTSD. The people with PTSD had more depressive symptoms and negative cognitions. PTSD in SMI is highly prevalent and underdiagnosed.

PTSD symptoms associated with the experiences of psychosis and hospitalisation: a review of the literature

There is evidence of high rates of PTSD in people with psychosis, but the influence that symptoms or hospitalisation have on PTSD in individuals with psychosis is less clear. This paper reviewed studies investigating the prevalence of PTSD induced as a result of the experience of psychosis and hospitalisation and factors that might influence its development. The review included 24 studies, published between 1980 and 2011. Studies showed high levels of PTSD resulting from the trauma of symptoms and/or hospitalisation, with prevalence rates for actual PTSD resulting from these traumas varying from 11% to 67%. In line with studies of PTSD related to other traumatic events, there were inconsistent associations between PTSD and severity of positive and negative symptoms, but there were consistent associations between affective symptoms and PTSD. There were also inconsistent associations between hospital experiences and PTSD. Consistent with the general PTSD literature, there was some evidence that psychosis-related PTSD was associated with trauma history. There was also some emerging evidence that psychological variables, such as appraisals and coping style may influence psychosis-related PTSD. The review highlights the need for further research into psychological mechanisms that could increase vulnerability to psychosis-related PTSD and treatment approaches.

Etiopathogenic perspectives on chronic psycho traumatic and chronic psychotic symptoms: the hypothesis of a hyperdopaminergic endophenotype of PTSD

Post traumatic stress disorder (PTSD) is a complex and heterogeneous disorder, which specific symptoms are re-experiencing, increased arousal and avoidance of stimuli associated with the trauma. PTSD has much comorbidity like depression, substance abuse, somatic complaints, repeated dissociative phenomena and transitory or chronic psychotic reactions. PTSD can manifest itself in different clinical forms: some patients present higher symptoms in one domain as compared to another, probably because of abnormalities in different neurobiological systems. Hyposerotonergic and hypernoradrenergic PTSD endophenotypes have been previously identified and the purpose of this paper is to focus on the hypothesis of a hyperdopaminergic endophenotype. The current review discusses several entities: PTSD with psychotic features with or without depression, the comorbide use of psychoactive substances that increase psychotic symptoms and traumatic brain injuries as agents of psycho traumatic and psychotic features. For all of these nosographic entities, the dopaminergic neuromodulation may play a central role. The hypothesis of a hyperdopaminergic endophenotype of PTSD opens up new research and therapeutic perspectives. Although antipsychotics are frequently used for people with PTSD further studies are needed to develop a consensus on the guidelines for treating the psychotic forms of PTSD.

Evidence for a psychotic posttraumatic stress disorder subtype based on the National Comorbidity Survey

PURPOSE

This study assessed the distribution of posttraumatic stress disorder (PTSD) symptoms and psychosis indicators among a large sample of individuals with a lifetime diagnosis of PTSD. The identification of a psychotic PTSD subtype was also predicted.

METHOD

Using data from the National Comorbidity Survey a latent class analysis was conducted on the PTSD symptoms of intrusion, avoidance, and hyperarousal and the psychosis hallucination and delusion indicators.

RESULTS

Results indicated four latent classes, two of which had relatively high probabilities of endorsing the hallucination and delusion indicators. These classes were associated with a broad range of traumatic experiences. One particular class had high probabilities of endorsing both the psychosis indicators and the PTSD symptoms and was associated with a broad range of comorbid psychiatric disorders.

CONCLUSION

There was a candidate class that met the characteristics expected to be evident in a psychotic PTSD subtype.

The psychosis continuum in the general population: findings from the São Paulo Epidemiologic Catchment Area Study

The aim of the study was to examine the psychosis continuum in a Latin-American community setting. Data were from the Brazilian São Paulo Epidemiologic Catchment Area Study, a cross-sectional survey conducted in two boroughs of the city of São Paulo. The Composite International Diagnosis Interview (version 1.1) was applied to a probabilistic sample of 1,464 adults, who were interviewed in their household, in order to identify the presence of psychotic symptoms. A subsample was assessed with Schedules for Clinical Assessment in Neuropsychiatry interview. We described the occurrence of psychotic symptoms, categorized into subgroups according to their clinical impact, disability, and help-seeking behavior. The correlation of socio-demographic variables, depressive symptoms, and alcohol and substance use disorders with those psychotic subgroups was analyzed. Polychotomic logistic regression tested the associations between subgroups of psychosis (clinical and subclinical) and the correlates. Of the total sample, 38.0% presented at least one lifetime psychotic symptom, 1.9% met the criteria for an ICD-10 diagnosis of non-affective psychosis, 5.4% presented clinically relevant psychotic symptoms, and 30.7% endorsed clinically non-relevant symptoms. The most common psychotic symptom was delusion with a plausible explanation (in 18.6%). The presence of any psychiatric diagnosis was associated with the presence of psychotic symptoms (OR range, 1.9-8.9). Subclinical psychosis subgroups were found to be associated with the 18-24 year age bracket, chronic depressive mood, and alcohol use disorder. Our results support the concept of a psychosis continuum in Latin-American populations, suggesting that different risk factors influence their manifestation across the continuum.

Aripiprazole augmentation in the treatment of military-related PTSD with major depression: a retrospective chart review

BACKGROUND

In this chart review, we attempted to evaluate the benefits of adding aripiprazole in veterans with military-related PTSD and comorbid depression, who had been minimally or partially responsive to their existing medications.

METHODS

A retrospective chart review of patients who received an open-label, flexible-dose, 12- week course of adjunctive aripiprazole was conducted in 27 military veterans meeting DSM-IV criteria for PTSD and comorbid major depression. Concomitant psychiatric medications continued unchanged, except for other antipsychotics which were discontinued prior to initiating aripiprazole. The primary outcome variable was a change from baseline in the PTSD checklist-military version (PCL-M) and the Beck Depression Inventory (BDI-II).

RESULTS

PTSD severity (Total PCL scores) decreased from 56.11 at baseline to 46.85 at 12-weeks (p < 0.0001 from Wilcoxon signed rank test) and the depression severity decreased from 30.44 at baseline to 20.67 at 12-weeks (p < 0.0001 from Wilcoxon signed rank test). Thirty seven percent (10/27) were considered responders, as defined by a decrease in total PCL scores of at least 20 percent and 19% (5/27) were considered as responders as defined by a decrease in total BDI score of at least 50%.

CONCLUSIONS

The addition of aripiprazole contributed to a reduction in both PTSD and depression symptomatology in a population that has traditionally demonstrated poor pharmacological response. Further investigations, including double-blind, placebo-controlled studies, are essential to confirm and further demonstrate the benefit of aripiprazole augmentation in the treatment of military related PTSD.

Trauma exposure and posttraumatic stress disorder in adults with severe mental illness: a critical review

There is a great deal of research on the prevalence, correlates, and treatment of PTSD in the general population. However, we know very little about the manifestation and consequences of PTSD in more complicated patient populations. The purpose of the current paper is to provide a comprehensive review of PTSD within the context of severe mental illness (SMI; i.e., schizophrenia spectrum disorders, mood disorders). Extant data suggest that trauma and PTSD are highly prevalent among individuals with SMI relative to the general population, and both are associated with adverse clinical functioning and increased healthcare burden. However, trauma and PTSD remain overlooked in this population, with low recognition rates in public-sector settings. Additionally, there are few data on the clinical course and treatment of PTSD among individuals with SMI. Particularly lacking are longitudinal studies, randomized controlled treatment trials, and studies using ethno-racially diverse samples. Furthermore, there is a need to better understand the interplay between trauma, PTSD, and severe forms of mental illness and to further develop and disseminate evidence-based PTSD treatments in this population. The current state of the literature and future directions for practice are discussed.

[Psychosis and trauma. Theorical links between post-traumatic and psychotic symptoms]

INTRODUCTION

The co-occurrence between post-traumatic symptoms and psychotic symptoms is well described in the immediate suites of a trauma but can also be chronic. This symptomatic co-occurrence, rarely studied in the literature, is often approached under the sole angle of a primary post-traumatic stress disorder (PTSD) or of a primary psychosis, without federative will to unify the psychotic and post-traumatic symptoms within the same nosological framework. Individuals with schizophrenia or schizoaffective disorder report higher rates of trauma and assault than the general population.

LITERATURE FINDINGS

High rates of PTSD have been noted in severe mental illness cohorts. Psychotic phenomena may be a relatively common manifestation in patients with chronic PTSD.

AIM

The purpose of this paper is to expose the various theorical psychopathological aspects between the symptoms of psychosis and PTSD. In populations of veterans, positive and negative symptoms of psychosis in PTSD are described as delusional thoughts and hallucinations often combat-specific.

CLINICAL FINDINGS

When a PTSD becomes established at a subject to the personality of neurotic structure, the intensity of the PTSD's symptoms lead to a psychotic expression which constitutes a factor of seriousness. Besides, PTSD often induces a risk of substance use disorder supplying psychotic symptoms. Cannabis increases the hallucinations, cocaine strengthens an underlying paranoid tone, and alcohol implies withdrawal hallucinosis. Moreover, such consumption could be a risk factor for the future development of chronic psychosis. From another point of view, by basing themselves on the plasma dopamine beta-hydroxylase activity, some authors made the analogy between psychotic major depression and PTSD with psychotic features (also characterized as a distinct psychotic subtype of PTSD). However, other studies found no correlation between PTSD with psychotic features and family predisposition for schizophrenia or schizoaffective disorder.

DISCUSSION

The determination of the structure of personality seems fundamental in the understanding of the symptoms. A personality of psychotic structure increases the risk of traumatization and PTSD. At the same time, the fragility of this structure causes an increased sensitivity to the trauma, which takes on a particular echo. Moreover, a trauma can test a latent psychotic structure to reveal its existence. The experience of psychosis may be traumatic in itself for patients with, notably, seclusion and sedation during hospitalization. Lastly, the symptoms of this post-traumatic psychosis will be differentiated from neurological confusion caused by a traumatic brain injury. Clinicians often fail to screen routinely for trauma and PTSD symptoms in patients with severe mental illness because few systematic guidelines exist for the identification and treatment of this comorbidity.

CONCLUSION

The links between psychotic and psycho-traumatic symptoms are complex and multidirectional; this co-occurrence is a factor of seriousness. The clinician, while paying attention to these symptoms, has to distinguish the structure of the personality of the subject to articulate the psychotherapy and the pharmacological treatment. Further investigational studies may determine whether antipsychotics will enhance treatment response in PTSD patients with psychotic features.

The differential effects of child abuse and posttraumatic stress disorder on schizotypal personality disorder

OBJECTIVE

Previous findings suggest a relation between trauma exposure and risk for schizotypal personality disorder (SPD). However, the reasons for this relationship are not well understood. Some research suggests that exposure to trauma, particularly early trauma and child abuse, as well as posttraumatic stress disorder (PTSD) may play a role.

METHODS

We examined subjects (n = 541) recruited from the primary care clinics of an urban public hospital as part of an National Institute of Mental Health-funded study of trauma-related risk and resilience. We evaluated childhood abuse with the Childhood Trauma Questionnaire and the Early Trauma Inventory and SPD with the Schedule for Nonadaptive and Adaptive Personality. We assessed for lifetime PTSD using the Clinician-Administered PTSD Scale.

RESULTS

We found that of the 3 forms of abuse analyzed (emotional, physical, and sexual), only emotional abuse significantly predicted SPD (P < .001, R = 0.28) when all 3 abuse types were simultaneously entered into a regression model. Lifetime PTSD symptoms also significantly predicted SPD (P < .001, R = 0.26). Posttraumatic stress disorder was specifically predictive of 4 of the 8 SPD symptoms (P ≤ .001): excessive social anxiety, a lack of close friends or confidants, unusual perceptual experiences, and eccentric behavior or appearance. Using a Sobel test, we also found a partial mediation effect of PTSD on the relation between emotional abuse and SPD (z = 3.45, P < .001).

CONCLUSIONS

These findings point to the important influence of emotional abuse on SPD and suggest that PTSD symptoms may provide a link between damaging childhood experiences and SPD symptoms in traumatized adults.