Trauma, PTSD, and the course of severe mental illness: an interactive model

Trauma and mental health in Pacific Islanders

BACKGROUND

Little is known about trauma and its mental health impact on Native Hawaiians/Pacific Islanders (NH/PI), an understudied Indigenous-colonized population that endures severe mental health disparities.

AIMS

This novel investigation assessed trauma prevalence and its mental health and substance use correlates in NH/PIs in the U.S.

METHOD

Using community-based participatory research methods, survey data on NH/PI trauma, depression, anxiety, substance use, and treatment need were collected from 306 NH/PI adults using online, telephone, and in-person methods. Descriptive statistics and adjusted regression models were employed.

RESULTS

Sixty-nine percent of participants experienced lifetime trauma, reporting mean exposure to 2.5 different trauma types. Childhood physical and sexual abuse, and lifetime forced sexual assault rates were 34%, 25%, and 27%, respectively, exceeding general population rates. Women and men reported equivalent total mean exposure to different trauma types, as well as equal prevalence for every trauma type examined (e.g. sexual abuse/assault). Confirming hypotheses, after controlling for key demographic and mental health risk factors, increased exposure to multiple trauma types uniquely associated with greater depression, anxiety, alcohol symptomology, and greater likelihood for needing treatment and using illicit substances.

CONCLUSIONS

Trauma is prevalent in NH/PI populations and significantly impacts NH/PI mental health; serving as an important but overlooked contributor to NH/PI mental health disparities. Current findings fill critical gaps in our knowledge of NH/PI trauma and mental health while revealing the importance of screening and treating NH/PIs for trauma exposure to alleviate existing mental health disparities.

Violence Increases Psychological Distress Among Women Trafficking Survivors in Ghana

Human trafficking is a crime that is often shaped by violence, particularly for women who are trafficked. Additionally, trafficking survivors often report severe psychological distress, though research on the causes of this psychological distress is lacking, as there is little longitudinal data available on trafficking survivors. Informed by past literature on the links between violence and mental health among other traumatized groups of women, we investigate how experiences of violence influence posttraumatic stress, depression, and suicide ideation among a unique longitudinal sample of 116 labor-trafficked women in Ghana. We find that experiencing sexual violence while being trafficked is associated with higher levels of both depression and posttraumatic stress years after the trafficking period ended. This indicates both the long-term effects of stress and the enduring nature of psychological distress among the women in this study. Our analytic account of how violent experiences while trafficked impact mental health over the period of reintegration contributes to the general literature on violence and mental health among women, as well as to literature on the health implications of human trafficking.

Experience of traumatic events in people with severe mental illness in a low-income country: a qualitative study

BACKGROUND

This study describes the trauma experiences of people with severe mental illness (SMI) in Ethiopia and presents a model of how SMI and trauma exposure interact to reduce functioning and quality of life in this setting.

METHODS

A total of 53 participants living and working in a rural district in southern Ethiopia were interviewed: 18 people living with SMI, 21 caregivers, and 14 primary health care providers.

RESULTS

Many participants reported that exposure to traumatic and stressful events led to SMI, exacerbated SMI symptoms, and increased caregiver stress and distress. In addition, SMI symptoms and caregiver desperation, stress or stigma were also reported to increase the possibility of trauma exposure.

CONCLUSIONS

Results suggest it is incumbent upon health professionals and the broader health community to view trauma exposure (broadly defined) as a public health problem that affects all, particularly individuals with SMI.

A dyadic session-by-session assessment of therapeutic alliance and short-term outcome among clients with schizophrenia in comparison with clients with emotional disorders

OBJECTIVE

Although the clinical significance of the therapeutic alliance (TA) is well documented, the literature regarding the establishment of TA and the relation between client-therapist agreement on it to short-term outcome among various diagnostic groups-and specifically among clients diagnosed with serious mental illness (SMI)-is sparse. The aim of the present study was to examine the effect of client diagnosis on the abovementioned TA characteristics.

METHOD

Dyadic analyses of session-by-session (SBS) data were used to compare clients diagnosed with schizophrenia and clients diagnosed with emotional disorders (based on a clinical interview) in their TA characteristics.

RESULTS

TA as initially rated by clients was stronger in the emotional disorders group than in the schizophrenia group. Higher TA ratings, regardless of whether these were provided by the therapist or the client, predicted better subsequent functioning in the emotional disorders group, whereas in the schizophrenia group, this association was observed only among good-outcome cases.

CONCLUSIONS

Establishing TA, having client-therapist agreement on it, and having clients derive therapeutic benefit from it might be more challenging with clients with schizophrenia than with clients with emotional disorders. Special attention should be given to specific challenges and needs regarding clients' diagnosis in order to enhance favourable therapy outcomes.

Are Sexual Assaults Related to Functional Somatic Disorders? A Cross-Sectional Study

An increasing number of sexual assaults (SAs) are being reported. This study investigated associations between SA and FSD, conceptualized as bodily distress syndrome (BDS), and five functional somatic syndromes (FSSs): chronic widespread pain (CWP), irritable bowel (IB), chronic fatigue (CF), multiple chemical sensitivity (MCS), and whiplash-associated disorder (WAD). Participants (n = 7493) from the population-based cohort Danish Study of Functional Disorders (DanFunD) completed questionnaires on FSD, emotional distress, SA, and sociodemographics. Risk ratios (RRs) for each FSD and emotional distress were calculated in nine models with SA as the primary exposure using generalized linear models with binomial family and log link and were adjusted for other potential risk factors. The results showed that SA was associated with single-organ FSD (RR = 1.51; 95% CI = 1.22-1.87), multi-organ FSD (RR = 3.51; 95% CI = 1.89-6.49), CWP (RR = 1.28; 95% CI = 0.83-1.98), IB (RR = 2.00; 95% CI = 1.30-3.07), CF (RR = 1.81; 95% CI = 1.42-2.32), WAD (RR = 2.62; 95% CI = 1.37-5.03), MCS (RR = 3.04; 95% CI = 1.79-5.17), emotional distress (RR = 1.75; 95% CI = 1.21-2.54), and health anxiety (RR = 1.65; 95% CI = 1.10-2.46). Overall, SA victims experienced significantly more somatic symptoms than individuals not exposed to SA. Adjusting for physical and emotional abuse did not change the observed associations. Our results suggest a large impact of SA on the overall somatic and mental health of SA victims. Due to the cross-sectional study design, further studies are required.

Physical and sexual victimization of persons with severe mental illness seeking care in central and southwestern Uganda

Purpose

This study established the prevalence of physical and sexual victimization, associated factors and psychosocial consequences of victimization among 1,201 out-patients with severe mental illness at Butabika and Masaka hospitals in Uganda.

Methods

Participants completed structured, standardized and locally translated instruments. Physical and sexual victimization was assessed using the modified adverse life events module of the European Para-suicide Interview Schedule. We used logistic regression to determine the association between victimization, the associated factors and psychosocial consequences.

Results

The prevalence of physical abuse was 34.1% and that of sexual victimization was 21.9%. The age group of > = 50 years (aOR 1.02;95% CI 0.62-1.66; p = 0.048) was more likely to have suffered physical victimization, while living in a rural area was protective against physical (aOR 0.59; 95% CI 0.46-0.76; p = <0.001) and sexual (aOR 0.48, 95% CI 0.35-0.65; p < 0.001) victimization. High socioeconomic status (SES) (aOR 0.56; 95% CI 0.34-0.92; p = <0.001) was protective against physical victimization. Females were more likely to have been sexually victimized (aOR 3.38; 95% CI 2.47-4.64; p = <0.001), while being a Muslim (aOR 0.60; 95% CI 0.39-0.90; p = 0.045) was protective against sexual victimization. Risky sexual behavior was a negative outcome associated with physical (aOR 2.19; 95% CI 1.66-2.90; p = <0.001) and sexual (aOR 3.09; 95% CI 2.25-4.23; p < 0.001) victimization. Mental health stigma was a negative outcome associated with physical (aOR 1.03; 95% CI 1.01-1.05; p < 0.001) and sexual (aOR 1.03; 95% CI 1.01-1.05; p = 0.002) victimization. Poor adherence to oral anti-psychotic medications was a negative outcome associated with physical (aOR 1.51; 95% CI 1.13-2.00; p = 0.006) and sexual (aOR 1.39; 95% CI 0.99-1.94; p = 0.044) victimization.

Conclusion

There is a high burden of physical and sexual victimization among people with SMI in central Uganda. There is need to put in place and evaluate complex interventions for improving detection and response to abusive experiences within mental health services. Public health practitioners, policymakers, and legislators should act to protect the health and rights of people with SMI in resource poor settings.

Long-Term Consequences of War Captivity in Military Veterans

Numerous studies on the health and functioning of veterans and former prisoners of war have shown that the experience of war captivity is one of the most difficult human experiences. Captivity is often characterized by extremely difficult and inhumane conditions, as well as exposure to various forms of both psychological and physical abuse. Such traumatic experiences can lead to serious psychological consequences that can last for years, even decades after release from captivity. The aim of this paper is to present a brief overview of research that points to the specifics of wartime captivity and the long-term psychological consequences in veterans of former camp detainees, as well as the consequences suffered by their families and factors that, apart from the intensity of the trauma, contribute to the emergence and persistence of psychological disorders. From the presented research, it can be concluded that former prisoners of the camp represent an extremely vulnerable group of the social community and require long-term appropriate treatment, while the needs of veterans' families should not be neglected, with the necessity of including spouses and children in psychological and psychosocial treatments.

Association of trauma, post-traumatic stress disorder and non-affective psychosis across the life course: a nationwide prospective cohort study

BACKGROUND

We aimed to examine the temporal relationships between traumatic events (TE), post-traumatic stress disorder (PTSD) and non-affective psychotic disorders (NAPD).

METHODS

A prospective cohort study of 1 965 214 individuals born in Sweden between 1971 and 1990 examining the independent effects of interpersonal and non-interpersonal TE on incidence of PTSD and NAPD using data from linked register data (Psychiatry-Sweden). Mediation analyses tested the hypothesis that PTSD lies on a causal pathway between interpersonal trauma and NAPD.

RESULTS

Increasing doses of interpersonal and non-interpersonal TE were independently associated with increased risk of NAPD [linear-trend incidence rate ratios (IRR)_adjusted = 2.17 [95% confidence interval (CI) 2.02-2.33] and IRR_adjusted = 1.27 (95% CI 1.23-1.31), respectively]. These attenuated to a relatively small degree in 5-year time-lagged models. A similar pattern of results was observed for PTSD [linear-trend IRR_adjusted = 3.43 (95% CI 3.21-3.66) and IRR_adjusted = 1.45 (95% CI 1.39-1.50)]. PTSD was associated with increased risk of NAPD [IRR_adjusted = 8.06 (95% CI 7.23-8.99)], which was substantially attenuated in 5-year time-lagged analyses [IRR_adjusted = 4.62 (95% CI 3.65-5.87)]. There was little evidence that PTSD diagnosis mediated the relationship between interpersonal TE and NAPD [IRR_adjusted = 0.92 (percentile CI 0.80-1.07)].

CONCLUSION

Despite the limitations to causal inference inherent in observational designs, the large effect-sizes observed between trauma, PTSD and NAPD in this study, consistent across sensitivity analyses, suggest that trauma may be a component cause of psychotic disorders. However, PTSD diagnosis might not be a good proxy for the likely complex psychological mechanisms mediating this association.

Trauma-focused therapies for post-traumatic stress in psychosis: study protocol for the RE.PROCESS randomized controlled trial

INTRODUCTION

Many people with psychotic disorders experience symptoms of post-traumatic stress disorder (PTSD). In recent years, several trauma-focused therapies (TFTs), including cognitive restructuring (CR), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR) have been studied and found to be safe and effective in reducing PTSD symptoms in individuals with psychosis. However, studies were conducted in different countries, with varying inclusion criteria, therapy duration, control groups, and trial outcomes. RE.PROCESS will be the first study to compare the impact of CR, PE, and EMDR with a waiting list control condition within the same context.

METHODS AND ANALYSIS

This is the protocol of a pragmatic, single-blind, multicentre, superiority randomized controlled trial, in which CR, PE, and EMDR are compared to a waiting list control condition for TFT (WL) in a naturalistic treatment setting. Inclusion criteria are as follows: age ≥ 16 years; meeting full DSM-5 diagnostic criteria for PTSD on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), with a total CAPS score ≥ 23; and a psychotic disorder in the schizophrenia spectrum confirmed by the Structured Clinical Interview for DSM-5 (SCID-5). Participants (N=200) will be randomly allocated to 16 sessions of one of the TFTs or WL, in addition to receiving treatment as usual (TAU) for psychosis. The primary objective is to compare the effects of CR, PE, and EMDR to WL on researcher-rated severity of PTSD symptoms over time from baseline to 6-month follow-up. Secondary objectives are to examine these effects at the separate time-points (i.e., mid-treatment, post-treatment, and at 6-month follow-up) and to test the effects for clinician-rated presence of PTSD diagnosis, and self-rated severity of (complex) PTSD symptoms.

DISCUSSION

This is the first RCT to directly compare the effects of CR, PE, and EMDR within the same context to TAU on PTSD symptoms in individuals with psychosis and PTSD. Secondary effects on clinical and functional outcomes will be investigated both directly after therapy and long term.

TRIAL REGISTRATION

ISRCTN ISRCTN56150327 . Registered 18 June 2019.

Prevalence and factors associated with relapse and long hospital stay among adult psychiatric patients with a history of childhood trauma

This cross-sectional multicentre-based study determined the magnitude of relapse, long hospital stay and factors of mental illness associated with a history of childhood trauma. We assessed 335 adult psychiatric patients and living in conflict areas, using a questionnaire established from items of the Adverse Childhood Experience International Questionnaire, Multidimensional Scale of Perceived Social Support, Rosenberg Self-esteem Questionnaire, Relapse Assessment Tool, and Self-report of hospital stay. Logistic regression analyses were used to determine associations between predictors and relapse and long hospital stay. 298 participants (88.9%) had experienced childhood adversities, among which 44.4% reported more than five childhood traumas. Relapse occurred in 40.9% of participants, whereas long hospital stay occurred in 71.1% of cases. Predictors of long hospital stay were emotional abuse, substance use and living in rural settings. Being an employed and experiencing a childhood trauma committed by a parent increase the likelihood risk of relapse of mental illness associated with childhood trauma. Being treated by childhood trauma-focused interventions decreases the risk of relapse and shorter the length of hospital stay. Building a mental health capacity should be centered on detecting patients with childhood trauma committed by the parent, those with low-self esteem, and victims of emotional abuse.

Trauma exposure and co-occurring ICD-11 post-traumatic stress disorder and complex post-traumatic stress disorder in adults with lived experience of psychiatric disorder

OBJECTIVE

To establish factors associated with ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) in a large sample of adults with lived experience of psychiatric disorder and examine the psychiatric burden associated with the two disorders.

METHODS

One thousand three hundred and five adults were recruited from the National Centre for Mental Health (NCMH) cohort. ICD-11 PTSD/CPTSD were assessed with the International Trauma Questionnaire (ITQ). Binary logistic regression was used to determine factors associated with both PTSD and CPTSD. One-way between-groups analysis of variance was conducted to examine the burden associated with the two disorders in terms of symptoms of anxiety, depression, and psychological wellbeing. For post-hoc pairwise comparisons, the Tukey HSD test was used, and the magnitude of between-group differences assessed using Cohen's d.

RESULTS

Probable ICD-11 CPTSD was more common than PTSD within the sample (PTSD 2.68%; CPTSD 12.72%). We found evidence that PTSD was associated with interpersonal trauma and household income under £20,000 a year. CPTSD was also associated with interpersonal trauma, higher rates of personality disorder, and lower rates of bipolar disorder. Those with probable-CPTSD had higher levels of current anxiety and depressive symptoms and lower psychological wellbeing in comparison to those with probable-PTSD and those with neither disorder.

CONCLUSIONS

CPTSD was more prevalent than PTSD in our sample of people with lived experience of psychiatric disorder. Our findings indicate a need for routine screening for trauma histories and PTSD/CPTSD in clinical settings and a greater focus on the need for interventions to treat CPTSD.

The mediating role of post-traumatic stress disorder symptoms in the relationship between childhood adversities and depressive symptoms in two samples

BACKGROUND

Childhood adversities have been increasingly recognized as a significant risk factor for depression. However, the underlying mediating mechanism between childhood adversities and depression requires further investigation. The literature shows that childhood adversities are also closely associated with post-traumatic stress disorder (PTSD) symptoms and that PTSD symptoms can predict depressive symptoms. It remains unexplored whether PTSD symptoms can act as a mediator between childhood adversities and depression.

OBJECTIVES

The primary goal of this study was to examine whether PTSD symptoms would mediate the relationship between childhood adversities and depressive symptoms.

PARTICIPANTS AND SETTING

We examined in a convenience sample of Hong Kong adults aged 18 or above (N = 418) whether PTSD symptoms would mediate the relationship between childhood adversities and depressive symptoms. We then examined and compared the results with those in another convenience sample of Chinese-speaking young adults (mainly from Taiwan and Hong Kong) aged between 18 and 24 (N = 205). Participants in both samples completed online surveys that included measures of childhood adversities, PTSD symptoms and depressive symptoms.

RESULTS

Childhood adversities were significantly associated with depressive symptoms; and this relationship was mediated by PTSD symptoms in both samples.

CONCLUSION

This study is one of very few studies demonstrating that PTSD symptoms mediate the relationship between childhood adversities and depressive symptoms. Our findings suggest that addressing unresolved PTSD symptoms for adults with childhood adversities may help in preventing or treating depressive symptoms. Therefore, PTSD symptoms should be taken into account in the prevention and management of depression.

Psychological adjustment following mechanical restraint in individuals with schizophrenia

AIM

While it is known that being mechanically restrained during hospitalization can, in severe cases, lead to PTSD in individuals with mental illness, less is known about why some develop posttraumatic stress reactions following restraint while others do not. This study examined whether the amount of exposure to mechanical restraint and patients' interpretations of the episodes' centrality to their identity were related to symptoms of PTSD in individuals with schizophrenia.

METHODS

We asked 20 individuals to recall mechanical restraint episodes and rate them on centrality to identity. They also completed scales measuring symptoms of posttraumatic stress, depression, trauma history, and were rated on positive and negative symptoms. Objective information about the number of times they had been restrained was obtained through Danish health registries.

RESULTS

Amount of exposure to mechanical restraint was not significantly related to PTSD symptoms, potentially due to limitations of our small sample. However, interpreting episodes as more central to identity was. This relationship remained significant when controlling for trauma history, positive symptoms, and depression.

CONCLUSION

The results suggest that clinically significant levels of PTSD are common in this population, and that considering patients' subjective interpretations of restraint episodes, and not merely the objective facts surrounding them is important for patients' psychological adjustment.

Investigating the Efficacy and Experiences With Narrative Exposure Therapy in Severe Mentally Ill Patients With Comorbid Post-traumatic Stress Disorder Receiving Flexible Assertive Community Treatment: A Mixed Methods Study

BACKGROUND

Patients with severe mental illness with repeated interpersonal trauma and post-traumatic stress disorder (PTSD) have a negative illness progression. Traumas are often not treated because of their vulnerability. Narrative exposure therapy (NET) is an effective trauma therapy. It is unknown whether NET is effective and tolerable in these patients receiving community mental healthcare.

OBJECTIVES

The objectives of this study are (1) to gain insights into patients' experiences before, during, and after NET concerning changes in PTSD, dissociative and severe mental ill symptoms, care needs (CAN), quality of life, and global functioning; (2) to identify factors that influence diagnostic changes after NET as compared to patients' experiences. These insights will help to decide whether NET should be incorporated in usual care for these patients.

DESIGN

A mixed methods convergent design consists of a grounded theory approach with thematic analysis followed by a merged analysis, comparing quantitative, and qualitative data for each participant and by means of a joint matrix.

PARTICIPANTS

Adult psychiatric outpatients (age, 21-65) with post-traumatic stress disorder (PTSD) related to repeated interpersonal trauma were indicted for the study.

METHODS

Baseline demographics and clinical characteristics were assessed. Qualitative data were collected 3 months after NET using individual semi-structured in-depth interviews. The merged analysis compared quantitative and qualitative results for each participant.

RESULTS

Twenty-three outpatients (female, 82%) with a mean age of 49.9 years (SD 9.8) participated in the study. Participants experienced NET as intensive, and most of them tolerated it well. Afterward, eighteen participants perceived less symptoms. Mixed analysis showed substantial congruency between quantitative scores and participants' perceptions of PTSD, dissociative symptoms, and CAN (Cohen's kappa > 0.4). Remission of PTSD was associated with sufficient experienced support.

CONCLUSION

Outpatients with severe mental illness underwent intensive NET, and most of them tolerate it well. This therapy is clearly efficacious in this group.

CLINICAL TRIAL REGISTRATION

[www.ClinicalTrials.gov], identifier [NL5608 (NTR5714)].

Psychiatric admission as a risk factor for posttraumatic stress disorder

Psychiatric hospitalization poses a risk for Posttraumatic Stress Disorder (PTSD), partly because of coercion. However, the role of legal status is less clear, while factors like insight, exposure to violence and affective disorders have not been addressed adequately. The present study aims at assessing PTSD rates after hospitalization and evaluating the potential role of these factors. 98 inpatients were assessed for PTSD, insight, main diagnosis, adverse events during hospitalization and legal status. Assessment took place at discharge (T1) and three months later (T2). Three months after discharge, 74.2% of patients with affective disorders met symptom-criteria for PTSD. Voluntarily hospitalized patients had more severe PTSD-symptoms. This relation vanished after controlling for affective disorders. The latter, as well as exposure to violence were the most significant risk factors at T2. Female gender, marital status (not married) and employment status (not employed), were additional risk factors at T1, while involuntary medication had a negative effect on PTSD-symptoms. Voluntarily hospitalized patients are more vulnerable to PTSD, due to higher rates of affective disorders. Females suffering from affective disorders who are not married and not employed should be monitored for PTSD symptoms during and after hospitalization, especially if exposed to violence.

Serious physical assault and subsequent risk for rehospitalization in individuals with severe mental illness: a nationwide, register-based retrospective cohort study

BACKGROUND

Victimization is associated with worse social and clinical outcomes of individuals with severe mental illness (SMI). A relapse of SMI may be one of the clinical consequences of assaultive trauma. As far as we know, there is no published study that analyzes nationwide health registers to assess the risk of SMI rehospitalization following assault.

AIM

We aimed to assess whether exposure to assault is associated with an increased risk of psychiatric hospitalization in those with SMI.

METHODS

We utilized data from the Czech nationwide registers of all-cause hospitalizations and all-cause deaths. We defined exposed individuals as those discharged from a hospitalization for SMI between 2002 and 2007, and hospitalized for serious injuries sustained in an assault in the subsequent 7 years. For each assaulted individual, we randomly selected five counterparts, matched on SMI diagnosis, age and sex, who were not assaulted in the examined time period. We used mixed effect logistic regression to assess the effect of assault on the risk of SMI rehospitalization within the following 6 months. We fitted unadjusted models and models adjusted for the number of previous SMI hospitalizations and drug use disorders.

RESULTS

The sample consisted of 248 exposed and 1 240 unexposed individuals. In the unadjusted model, assaulted individuals were almost four times more likely to be rehospitalized than their non-assaulted counterparts (odds ratio (OR) = 3.96; 95% CI 2.75; 5.71). After adjusting for all covariates, the OR remained threefold higher (OR = 3.07; 95% CI 2.10; 4.49).

CONCLUSION

People with a history of SMI hospitalization were approximately three times more likely to be rehospitalized for SMI within 6 months after an assault than their non-assaulted SMI counterparts. Soon after a person with SMI is physically assaulted, there should be a psychiatric evaluation and a close follow-up.

Adapting the Trauma History Questionnaire for use in a population of homeless people with severe mental illness in Tamil Nadu, India: qualitative study

BACKGROUND

The Trauma History Questionnaire (THQ) is one of the most widely used traumatic event inventories, but its lack of validation makes it unsuitable for the millions of homeless people with severe mental illness in India, who are particularly vulnerable to trauma exposure.

AIMS

To translate and culturally adapt the THQ for use in a population of homeless people with severe mental illness in Tamil Nadu, India.

METHOD

We used Herdman et al's model of cultural equivalence to conduct an in-depth qualitative assessment of the cultural validity of the THQ. Following several translations, conceptual, item, semantic and operational equivalence of the THQ was assessed through four focus groups with user-survivors (n = 20) and two focus groups with mental health professionals (n = 11).

RESULTS

Several adaptations, including the addition of 18 items about relationships, homelessness and mental illness, were necessary to improve cultural validity. Three items, such as rape, were removed for reasons of irrelevance or cultural insensitivity. Items like 'adultery' and 'mental illness' were reworded to 'extramarital affair' and 'mental health problem', respectively, to capture the cultural nuances of the Tamil language. Findings revealed a divergence in views on tool acceptability between user-survivors, who felt empowered to voice their experiences, and mental health professionals, who were concerned for patient well-being. Providing a sense of pride and autonomy, user-survivors preferred self-administration, whereas mental health professionals preferred rater administration.

CONCLUSIONS

Culture significantly affects what types of events are considered traumatic, highlighting the importance of cultural validation of instruments for use in novel populations and settings.

Child Sexual Abuse and Age at Onset of Psychotic Disorders: A Matched-cohort Study: L'âge d'apparition des troubles psychotiques chez les victimes d'agression sexuelle à l'enfance: Une étude prospective de cohortes appariées

OBJECTIVE

Victims of child sexual abuse (CSA) present with a higher risk of psychotic disorders. However, the developmental course of psychosis following CSA, such as the age at onset, remains unknown. This study aimed to determine whether the age at onset of psychotic disorders was influenced by sexual abuse, sex, and confounding factors (substance misuse, intellectual disability, and socioeconomic status).

METHOD

A prospective matched-cohort design was used, with administrative databases from a child protection agency (CPA) and a public health system. Children who received a substantiated report of CSA at the CPA and whose health data could be retrieved were selected (n = 882) and matched with children from the general population using their date of birth, sex, and geographical area. Survival analysis was performed to estimate the association between sexual abuse, sex, and confounding factors and the age at onset of psychotic disorders.

RESULTS

Sexual abuse and substance misuse are significantly associated with the age at onset of psychotic disorders. In the sexually abused group, only substance misuse is associated with the age at onset of psychotic disorders, but this was not significant for the general population.

CONCLUSIONS

These findings highlight the importance of prevention of psychotic disorders among sexually abused youth, especially those with a substance misuse diagnosis.

Victimisation of individuals with serious mental illness living in sheltered housing: differential impact of risk factors related to clinical and demographic characteristics

BACKGROUND

Sheltered housing is associated with quality-of-life improvements for individuals with serious mental illness (SMI). However, there are equivocal findings around safety outcomes related to this type of living condition.

AIMS

We aimed to investigate raw differences in prevalence and incidence of crime victimisation in sheltered housing compared with living alone or with family; and to identify groups at high risk for victimisation, using demographic and clinical factors. We do so by reporting estimated victimisation incidents for each risk group.

METHOD

A large, community-based, cross-sectional survey of 956 people with SMI completed the Dutch Crime and Victimisation Survey. Data was collected on victimisation prevalence and number of incidents in the past year.

RESULTS

Victimisation prevalence was highest among residents in sheltered housing (50.8%) compared with persons living alone (43%) or with family (37.8%). We found that sheltered housing was associated with increased raw victimisation incidence (incidence rate ratio: 2.80, 95% CI 2.36-3.34 compared with living with family; 1.87, 95% CI 1.59-2.20 compared with living alone). Incidence was especially high for some high-risk groups, including men, people with comorbid post-traumatic stress disorder and those with high levels of education. However, women reported less victimisation in sheltered housing than living alone or with family, if they also reported drug or alcohol use.

CONCLUSIONS

The high prevalence and incidence of victimisation among residents in sheltered housing highlights the need for more awareness and surveillance of victimisation in this population group, to better facilitate a recovery-enabling environment for residents with SMI.

Intergenerational Trauma and Its Relationship to Mental Health Care: A Qualitative Inquiry

Intergenerational trauma is a discrete form of trauma which occurs when traumatic effects are passed across generations without exposure to the original event. This qualitative study aimed to explore how psychiatrists understand intergenerational trauma in respect to their practice, for the purposes of identifying interventions for addressing intergenerational trauma in public mental health services. Findings revealed that psychiatrists observe intergenerational trauma frequently in their roles and try to opportunistically promote awareness of trauma with adults, and refer families to external services for supportive interventions. They feel powerless when faced with directly intervening with intergenerational trauma and required restructuring of their roles to adequately address it in public settings. Findings have implications for training, advocacy and research on the relationship between trauma and mental illness. Alongside this, there is an indicated need for examination of how systems can ensure access to appropriate services once organisations become trauma-informed.

Elucidating the Impact of Childhood, Adulthood, and Cumulative Lifetime Trauma Exposure on Psychiatric Symptoms in Early Schizophrenia Spectrum Disorders

Cumulative lifetime trauma has a profound impact on the development of schizophrenia spectrum disorders. However, few studies have determined participants' most distressing (i.e., "worst") life event in childhood or adulthood or examined whether this event contributes to poorer clinical outcomes. The present study aimed to (a) determine the associations between the worst life event and demographic/clinical variables and (b) examine the associations between the worst life event and psychiatric symptoms (i.e., positive, negative, depressive, and anxiety symptoms). Participants (N = 150) were outpatients newly diagnosed with schizophrenia spectrum disorders who were assessed for lifetime trauma exposure, positive and negative symptoms of schizophrenia, and symptoms of depression and anxiety. Multinomial logistic regression analysis was conducted to examine the associations between demographic and clinical variables and worst life events (none, childhood, or adulthood). Multiple linear regression analyses were performed to examine the associations between worst life events and psychiatric symptoms. More participants reported that their worst life event occurred during adulthood (31.1%) than childhood (21.3%). Adulthood trauma was associated with male gender, older age, non-Chinese ethnicity, and psychiatric comorbidities; childhood trauma was associated with a family history of depression/anxiety. Adulthood trauma was significantly associated with more severe positive psychotic symptoms, f² = 0.19, whereas childhood and adulthood trauma exposure were both significantly associated with more severe depressive and anxiety symptoms, f² s = 0.19 and 0.25, respectively. Our findings underscore the importance of conducting assessments for worst life events and the associated risk factors to develop meaningful formulations and appropriate trauma-focused treatment plans.

Psychotic PTSD? Sudden traumatic loss precipitating very late onset schizophrenia

Early theories of schizophrenia considered the illness as a fragmentation of mental content in response to psychological trauma. Here we present a case of very late onset schizophrenia in a previously high-functioning man in his mid-60s, precipitated by having lost his family in a terrorist attack, while he was living in Africa. He presented with symptoms consistent with post-traumatic stress disorder, however also exhibited visual and auditory hallucinations and marked deterioration in daily functioning. He showed mild impairment on cognitive testing, however brain imaging and screening for reversible causes of cognitive impairment were normal. The case highlights the need for a formulation-based approach to understanding and managing responses to severe trauma, from resolution through to psychotic disintegration.

A systematic review of PTSD to the experience of psychosis: prevalence and associated factors

BACKGROUND

Psychosis can be a sufficiently traumatic event to lead to post-traumatic stress disorder (PTSD). Previous research has focussed on the trauma of first episode psychosis (FEP) and the only review to date of PTSD beyond the first episode period was not systematic and is potentially outdated.

METHODS

We searched electronic databases and reference lists using predetermined inclusion criteria to retrieve studies that reported prevalence rates and associated factors of psychosis-related PTSD across all stages of the course of psychosis. Studies were included if they measured PTSD specifically related to the experience of psychosis. Risk of bias was assessed using an adapted version of the Newcastle Ottawa Scale. Results were synthesised narratively.

RESULTS

Six papers met inclusion criteria. Prevalence estimates of psychosis-related PTSD varied from 14 to 47%. Studies either assessed first-episode samples or did not specify the number of episodes experienced. Depression was consistently associated with psychosis-related PTSD. Other potential associations included treatment-related factors, psychosis severity, childhood trauma, and individual psychosocial reactions to trauma.

CONCLUSIONS

Psychosis-related PTSD is a common problem in people with psychosis. There is a lack of published research on this beyond first episode psychosis. Further research is needed on larger, more generalizable samples. Our results tentatively suggest that prevalence rates of psychosis-related PTSD have not reduced over the past decade despite ambitions to provide trauma-informed care. Prospero registration number: CRD42019138750.

Mental health disorders as cooccuring and predictive factors of psychotic disorders in sexually abused children

BACKGROUND

Little is known about the factors associated with psychosis in sexually abused children. Many factors have been associated with both sexual abuse and psychosis, and some mental health disorders have been identified as implied in the relationship between childhood trauma and psychosis.

OBJECTIVES

This study aims to identify factors cooccurring with psychotic disorders in sexually abused youth and to determine which predict the development of psychosis in this population.

PARTICIPANTS AND SETTING

Children with a corroborated report of sexual abuse (n = 882) at a Child Protection Agency (CPA) between 2000 and 2010 and whose health data could be retrieved from public health databases were selected for this study.

METHODS

A prospective matched-cohort design was used, with administrative databases from a CPA and a public health system. Logistic regressions were performed to determine which mental health diagnoses were associated with, and which predicted, psychotic disorders.

RESULTS

Logistic regressions revealed that personality disorders were significantly associated with psychotic disorders whereas substance misuse disorders and intellectual disability significantly predicted psychotic disorders.

CONCLUSIONS

Psychotic disorders and personality disorders appear concomitantly in sexually abused youth. Having received a substance misuse disorder diagnosis increases the risk of developing a psychotic disorder in sexually abused youth. Health professionals should be aware of those risk factors to help reduce the severity of youth sexual abuse consequences and, ultimately, prevent psychosis.

Traumatic life events as risk factors for psychosis and ICD-11 complex PTSD: a gender-specific examination

BACKGROUND

Numerous studies found robust associations between psychosis and posttraumatic stress disorder (PTSD), but few have examined the relationships between psychosis and recently formulated ICD-11 Complex PTSD (CPTSD). Further, no known study has examined the effects of different traumatic life events on CPTSD and psychotic-like symptoms in a manner that permits gender-specific effects to be identified.

OBJECTIVE

Using a nationally representative sample of 1,020 Irish adults, we examined gender-differences in (a) psychotic-like symptoms, CPTSD, and exposure to 21 different traumatic life events, and (b) the unique associations between different traumas with CPTSD and Psychosis.

METHOD

Bivariate analyses and structural equation modelling were performed.

RESULTS

Consistent with the literature, no gender differences were observed in psychotic-like symptoms. Females reported slightly higher levels of CPTSD and were more likely to be exposed to sexual and emotional abuse, whereas men reported greater exposure to physical violence, accidents, and disasters. Psychosis symptoms were explained by trauma exposure to a considerate degree and at a level similar to CPTSD; a moderate correlation was also found between CPTSD and Psychosis. Physical/emotional neglect was the only traumatic life event that significantly and most strongly predicted both conditions. Two gender-specific associations between different traumatic life events and CPTSD and Psychosis were identified out of the 42 possible effects modelled.

CONCLUSIONS

The present investigation provides initial evidence that psychotic-like symptoms and CPTSD are moderately correlated constructs in the general population. Results also highlight the importance of conducting a detailed assessment of trauma history for all clients presenting with symptoms of CPTSD, psychosis, or both.

A frog in boiling water? A qualitative analysis of psychiatrists' use of metaphor in relation to psychological trauma

OBJECTIVE

Tensions about the definition, diagnostics, and role of psychological trauma in psychiatry are long-standing. This study sought to explore what metaphor patterns in qualitative interviews may reveal about the beliefs of psychiatrists in relation to trauma.

METHOD

A qualitative inquiry using systematic metaphor analysis of 13 in-depth interviews with Australian psychiatrists.

RESULTS

Three themes were identified: a power struggle between people, trauma, and psychiatry; trauma is not a medical condition; and serving the profession to protect society.

CONCLUSIONS

Metaphors present trauma as a powerful force that people can manage in different ways. Psychiatrists may view trauma as a social rather than medical issue. Psychiatrists experience role pressure associated with trauma including incongruence with risk management expectations of their roles.

Childhood Adversity, Proximal Stressors and PTSD Among People with Severe Mental Illness: An Exploratory Study

The purpose of this exploratory study is to: (1) assess prevalence of childhood adversities and posttraumatic stress disorder (PTSD); (2) assess their association, and; (3) explore whether proximal sources of stress affect this relationship and/or have an association with PTSD among people with severe and persistent psychological disorders. Using data from 141 respondents, we assess the extent to which individuals in this population experienced 17 PTSD symptoms, various correlates to probable PTSD, and the most relevant of these factors in a multivariate logistic regression. Overall, 27% of the participants met study criteria for probable PTSD and each symptom was reported by at least 18% of the sample. Multivariate logistic regression models indicated that interpersonal conflict and being a victim of a crime were significantly related to probable PTSD. We discuss these findings in relation to treatment and course of disease for people suffering from severe and persistent mental illness experiencing a traumatic event.

Pathways to aggression and violence in psychosis without longstanding antisocial behavior: A review and proposed psychosocial model for integrative clinical interventions

There is a need for a clearer understanding of the factors associated with increased risk of aggression and violence (AV) among people with psychosis and other severe mental illness (SMI) to guide effective prevention and intervention. The current article (1) reviews the literature regarding psychosocial factors associated with AV among individuals with psychosis and other SMI who do not have longstanding antisocial behaviors, (2) proposes an integrative psychosocial model of AV that can be practically applied, and (3) proposes appropriate evidence-based clinical interventions to reduce AV and facilitate recovery. We propose that increased risk for AV among people with psychosis is driven by anger, which is affected by a range of factors including victimization and situational stressors, social rejection or experiences of discrimination, anxious arousal, and hostile attribution bias related to psychosis. The cumulative effect of these systems is exacerbated by co-occurring substance misuse and increased impulsivity, particularly negative urgency. In consideration of the current psychosocial model and existing evidence-based interventions for AV in individuals with psychosis, we propose that trauma-informed interventions that integrate skills training in emotion regulation, social and interpersonal situations, cognitive restructuring and remediation, and modified prolonged exposure may demonstrate the most promise for this population.

Global emotion dysregulation and maladaptive cognitive emotion regulation strategies mediate the effects of severe trauma on depressive and positive symptoms in early non-affective psychosis

BACKGROUND

Previous research has shown that childhood trauma contributes to the onset and maintenance of psychosis. However, few studies have accounted for the effects of lifetime trauma and post-traumatic stress disorder (PTSD), and none have examined the mediating role of emotion dysregulation in symptom maintenance after severe trauma. The purpose of this study is to determine whether maladaptive cognitive emotion regulation strategies (CERS) and global emotion dysregulation mediate the effects of probable PTSD on depressive symptoms, and whether this pathway extends to influence positive symptoms in patients with early non-affective psychotic disorders.

METHODS

A total of 150 outpatients with early non-affective psychosis were assessed for trauma exposure, DSM-5 PTSD symptoms, CERS, global emotion dysregulation, and current depressive and positive symptoms. Parallel and serial mediation analyses based on ordinary least squares regressions were used to test the hypothesized models.

RESULTS

Mediation analyses controlling for gender, psychiatric comorbidities, antipsychotic medication dosage, duration of untreated psychosis (DUP), family history of mental illness, and cumulative trauma revealed that maladaptive CERS (rumination, catastrophic thinking, and self-blame) and global emotion dysregulation mediated the effects of probable PTSD on depressive symptoms (R² = 41%), while maladaptive CERS, global emotion dysregulation, and depressive symptoms mediated the effects of probable PTSD on positive symptoms (R² = 30%).

CONCLUSIONS

Our results demonstrate the indirect effects of maladaptive CERS and global emotion dysregulation on maintaining depressive and positive symptoms. Emotion dysregulation may be a potential transdiagnostic treatment target to alleviate depressive and positive symptoms in traumatized patients with early non-affective psychosis.

Discharge and post-discharge outcomes of psychiatric inpatients with a lifetime history of exposure to interpersonal trauma: A population-based study

OBJECTIVE

To examine discharge and post-discharge outcomes for psychiatric inpatients with a history of exposure to physical, sexual, or emotional trauma.

METHODS

In this population-based cohort study using health-administrative data, adult psychiatric inpatients in Ontario, Canada (2009-2016) with and without self-reported lifetime exposure to interpersonal trauma were compared on their likelihood of: discharge against medical advice; post-discharge outpatient follow-up; and post-discharge emergency department (ED) visits, rehospitalization, deliberate self-harm and suicide. Modified Poisson regressions generated relative risks (aRR) and 95% confidence intervals (CI), adjusted for age, sex, income, medical comorbidities, and psychiatric diagnosis.

RESULTS

Psychiatric inpatients with a history of interpersonal trauma (n = 50,832/160,436, 31.7%) were at elevated risk for discharge against medical advice (5.6% vs. 4.6%; aRR = 1.27, 1.21-1.33), and for 1-year post-discharge psychiatric ED visits (31.0% vs. 28.3%, aRR = 1.04, 1.02-1.06), and deliberate self-harm (5.5% vs. 3.7%, aRR = 1.30, 1.23-1.36). Post-discharge 30-day follow-up with primary care was slightly more common among those with a trauma history (37.6% vs. 34.5%, aRR = 1.06, 1.04-1.08); psychiatrist follow-up was less common (35.1% vs. 37.1%, aRR = 0.87, 0.86-0.89). Elevations in risk were observed for those with primary diagnoses of psychotic, mood and anxiety disorders, but not for those with a primary diagnosis of substance-related disorders. Risk elevations were specifically observed in those without a diagnosis of post-traumatic stress disorder.

CONCLUSION

Implementing supports and services during and after inpatient hospitalization that take into account a history of interpersonal trauma may help reduce certain undesirable discharge and post-discharge outcomes in this slightly higher-risk group.

"If somebody could just understand what I am going through, it would make all the difference": Conceptualizations of trauma in homeless populations experiencing severe mental illness

Exposure to violence, vulnerability due to lack of shelter, alienation due to stigma, the experiences of severe mental illness (SMI) and subsequent institutionalization, make homeless persons with SMI uniquely susceptible to trauma exposure and subsequent mental health consequences. This study aims to contribute to the development of culturally sensitive interventions for identifying and treating trauma in a population of homeless persons with SMI in Tamil Nadu, India by understanding the manifestations of trauma and its associated consequences in this population. Free-listing exercises followed by in-depth interviews were conducted with a convenience sample of 26 user-survivors who have experienced homelessness or were at risk of homelessness, and suffered from SMI. Topics explored included events considered to be traumatic, pathways to trauma, associated emotional, physical and social complaints, and coping strategies. Results indicate discrepancies in classification of traumatic events between user-survivors and the Diagnostic and Statistical Manual of Mental Disorders. Traumatic experiences, particularly relating to social relationships and poverty, mentioned by user-survivors did not match traditional conceptualizations of trauma. Positive coping strategies for trauma included being mentally strong, knowledge and awareness, whereas the main negative coping strategy is avoidance. User-survivors attributed their experiences of homelessness and SMI to past traumas. Differing views of trauma between user-survivors and mental health professionals can lead to misdiagnosis and under-recognition of trauma in this population of homeless persons with SMI.

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.

Traumatic experiences, ICD-11 PTSD, ICD-11 complex PTSD, and the overlap with ICD-10 diagnoses

OBJECTIVES

This study investigated the frequency of traumatic experiences, prevalence rates of ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD), and overlap with ICD-10 classified disorders in outpatient psychiatry.

METHOD

Overall, 165 Danish psychiatric outpatients answered the International Trauma Questionnaire, the Life Event Checklist, and the World Health Organization Well-being Index. ICD-10 diagnoses were extracted from the hospital record. Chi-square analysis, t-tests, and conditional probability analysis were used for statistical analysis.

RESULTS

Nearly, all patients (94%) had experienced at least one traumatic event. CPTSD (36%) was more common than PTSD (8%) and had considerable overlap with ICD-10 affective, anxiety, PTSD, personality, adjustment and stress-reaction disorders, and behavioural and emotional disorders with onset usually occurring in childhood and adolescence. ICD-11 PTSD overlapped with ICD-10 anxiety, PTSD, adjustment and stress-reaction disorders, and behavioural and emotional disorders with onset usually occurring in childhood and adolescence. A subgroup of patients with ICD-10 PTSD (23%) did not meet criteria for ICD-11 PTSD or CPTSD.

CONCLUSION

Traumatic experiences are common. ICD-11 CPTSD is a highly prevalent disorder in psychiatric outpatients. One quarter with ICD-10 PTSD did not meet criteria for either ICD-11 PTSD or CPTSD. PTSD and CPTSD had considerable overlap with ICD-10 disorders.

Traumatic loss and psychosis - reconceptualising the role of trauma in psychosis

Literature suggests that the occurrence of psychological trauma (PT) from various negative life experiences beyond events mentioned in the DSM-criterion A, receives little to no attention when comorbid with psychosis. In fact, despite research indicating the intricate interplay between PT and psychosis, and the need for trauma-focused interventions (TFI), there continue to be mixed views on whether treating PT would worsen psychosis, with many practitioners hesitating to initiate treatment for this reason. This study, therefore, aimed to understand patient perspectives on the role of PT in psychosis and related treatment options. A qualitative exploratory approach was adopted using in-depth interviews with individuals experiencing psychosis. The Global Assessment of Functioning (GAF) scale was administered on a predetermined maximum variation sample resulting in two groups of participants- those with moderate-mild disability (GAF 54-80; n = 10) and those experiencing moderate-severe disability (GAF 41-57; n = 10). With the former group, a semi-structured interview schedule was used, while with the latter, owing to multiple symptoms and difficulty in cognitive processing, a structured interview schedule was used. Results from interpretative phenomenological analysis (IPA) indicated that traumatic loss was central to experienced PT, but received no attention; this often contributed to the psychotic experience and/or depression, through maintenance factors such as cognitive distortions and attenuated affective responses. Further, the experience of loss seems to be more consequential to trauma-related symptoms than the event itself. Participants opined strongly the need for TFI and the role of it in promoting recovery from psychosis.

The experience of living after ECT: a qualitative meta-synthesis

BACKGROUND

Electroconvulsive therapy (ECT) is a controversial treatment. Research has predominantly focused on clinician assessment of short-term efficacy and, occasionally, on participant experiences of the treatment itself. While service user accounts of the long-term impacts of ECT are reported, they are dispersed throughout the literature and typically tangential to studie's main foci.

AIM

The aim of this study was to synthesise service-user accounts, within peer-reviewed literature, of long-term impacts of ECT in their daily lives.

METHODS

A qualitative meta-synthesis was conducted. A systematic literature search identified qualitative articles meeting the inclusion criteria. Results sections of eligible papers were analysed thematically.

RESULTS

From 16 eligible papers, the review identified 11 long-term impacts, four social influences and five strategies that people employed to navigate these long-term impacts.

CONCLUSION

Limited research has examined long-term experiences of ECT from service-user perspectives. These lived experience perspectives are required to facilitate peer-to-peer learning and assist future service delivery to align with needs of people living with long-term ECT impacts.

UP'S: A Cohort Study on Recovery in Psychotic Disorder Patients: Design Protocol

Recovery is a multidimensional concept, including symptomatic, functional, social, as well as personal recovery. The present study aims at exploring psychosocial and biological determinants of personal recovery, and disentangling time-dependent relationships between personal recovery and the other domains of recovery in a sample of people with a psychotic disorder. A cohort study is conducted with a 10-year follow-up. Personal recovery is assessed using the Recovering Quality of Life Questionnaire (ReQoL) and the Individual Recovery Outcomes Counter (I.ROC). Other domains of recovery are assessed by the Positive and Negative Symptom Scale Remission (PANSS-R), the BRIEF-A and the Social Role Participation Questionnaire-Short version (SRPQ) to assess symptomatic, functional and societal recovery, respectively. In addition, multiple biological, psychological, and social determinants are assessed. This study aims to assess the course of personal recovery, and to find determinants and time-dependent relationships with symptomatic, functional and societal recovery in people with a psychotic disorder. Strengths of the study are the large number of participants, long duration of follow-up, multiple assessments over time, extending beyond the treatment trajectory, and the use of a broad range of biological, psychological, and social determinants.

Psychiatric comorbidity and co-occurring opioid misuse: Depression mediates the relationship between post-traumatic stress disorder and opioid misuse in community pharmacy settings

AbstractsBackground: Individuals who misuse opioids frequently have comorbid psychiatric issues, including post-traumatic stress disorder (PTSD) and depression. However, little is known about the mechanisms by which these disorders are associated with opioid misuse and specifically in community pharmacy settings. The current study examined whether depression mediated the relationship between PTSD and opioid misuse in patients filling opioid prescriptions. Methods: We administered a health survey in four community pharmacies among patients filling opioid medications in southwestern Pennsylvania. Univariate statistics were used to assess relationships among demographic and clinical characteristics of PTSD, depression, and opioid misuse behaviors. We then examined whether depression mediated the relationship between PTSD and opioid misuse using ordinary least squares path analysis with bootstrapping. Results: A total of 333 participants completed the health survey. Opioid misuse was reported among 15.9% of all participants, 33.3% among those with a positive PTSD screen, and 29.3% of those who screened positive for depression. Depression significantly mediated the relationship between PTSD and opioid misuse. Specifically, there was a statistically significant indirect effect (ab) of PTSD on opioid misuse through a pathway mediated by depression (ab = .06, SE_ab = .02, 95% CI = .02-.10). The direct effect (c') of PTSD on opioid misuse was also significant (c' = .12, SE_c' = .05, P = .01, 95% CI = .03-.22), suggesting partial mediation. Conclusions: Results suggest an indirect pathway by which clinical intervention may help ameliorate outcomes in patients with PTSD. Further, there is an increased need for screening, assessment, and intervention protocols for this patient population in which community pharmacy is a novel setting to expand future efforts within the patient population.

What is the relationship between post-traumatic stress disorder, extreme appraisals of internal state and symptoms in bipolar disorder?

BACKGROUND

It is important to understand the factors associated with more severe mood symptoms in bipolar disorder. The integrative cognitive model of bipolar disorder proposes that extreme appraisals of changes to internal states maintain and exacerbate mood symptoms.

AIMS

The current study aimed to investigate if post-traumatic stress disorder (PTSD) is related to current depressive and manic bipolar symptoms, and whether this relationship is mediated by appraisals of internal state.

METHOD

Participants with bipolar disorder (n = 82) from a randomized controlled trial of cognitive therapy for bipolar disorder (the TEAMS trial) completed self-reported questionnaires assessing appraisals of internal state, generalized anxiety symptoms, and self-reported and observer-rated depressive and manic symptoms. Clinical interviews assessed PTSD co-morbidity.

RESULTS

Participants with bipolar and co-morbid PTSD (n = 27) had higher depressive symptoms and more conflicting appraisals than those without PTSD. Regression analyses found PTSD to be associated with depressive symptoms but not manic symptoms. Conflicting appraisals were found to be associated only with manic symptoms meaning that the planned mediation analysis could not be completed.

CONCLUSIONS

Findings provide partial support for the integrative cognitive model of bipolar disorder and highlight the need for transdiagnostic treatments in bipolar disorder due to the prevalence and impact of trauma and co-morbidity. Working on trauma experiences in therapy may impact on depressive symptoms for those with bipolar disorder and co-morbid PTSD.

Childhood abuse and psychotic experiences - evidence for mediation by adulthood adverse life events

AIMS

We have previously reported an association between childhood abuse and psychotic experiences (PEs) in survey data from South East London. Childhood abuse is related to subsequent adulthood adversity, which could form one pathway to PEs. We aimed to investigate evidence of mediation of the association between childhood abuse and PEs by adverse life events.

METHODS

Data were analysed from the South East London Community Health Study (SELCoH, n = 1698). Estimates of the total effects on PEs of any physical or sexual abuse while growing up were partitioned into direct (i.e. unmediated) and indirect (total and specific) effects, mediated via violent and non-violent life events.

RESULTS

There was strong statistical evidence for direct (OR 1.58, 95% CI: 1.19-2.1) and indirect (OR 1.51, 95% CI: 1.32-1.72) effects of childhood abuse on PEs after adjustment for potential confounders, indicating partial mediation of this effect via violent and non-violent life events. An estimated 47% of the total effect of abuse on PEs was mediated via adulthood adverse life events, of which violent life events made up 33% and non-violent life events the remaining 14%.

CONCLUSIONS

The association between childhood abuse and PEs is partly mediated through the experience of adverse life events in adulthood. There is some evidence that a larger proportion of this effect was mediated through violent life events than non-violent life events.

The role of substance use and adult sexual assault severity in the course of schizophrenia: An epidemiological catchment study of sexual assault victims

BACKGROUND

Childhood trauma increases the risk of schizophrenia, yet the role of adult sexual assault in the course of schizophrenia is unknown. This study aims to examine the associations between substance use and sexual assault severity characteristics with the course of schizophrenia among adult sexual assault victims using an epidemiologic study design.

METHODS

Sexual assault data on all individuals received from 2000 to 2010 (N = 2147) at the Center for Care of Sexual Assault Victims at Wolfson Medical Center, the largest medical center for sexual assault victims in the country, were merged with the Israel National Psychiatric Case Registry, that consisted of lifetime psychiatric hospitalizations of schizophrenia (birth to 6 years post-assault). The associations between substance use and adult sexual assault severity characteristics with hospitalizations were quantified using recurrent events Cox modeling.

RESULTS

Schizophrenia with sexual assault survivors occurred in 117 persons. Cox modeling showed that recurrent psychiatric hospitalizations were associated with younger age, sexual assault at older age, previous diagnosis of psychosis, and drug use shortly before or during the assault. Other assault characteristics (number of assailants, means of subdual, penetration type, perpetrator violence, physical injury of the victim) and immediacy of seeking help had a null association with the course of psychiatric hospitalization. These results replicated in two sensitivity analyses.

CONCLUSIONS

Substance use among victims of sexual assault was associated with an exacerbated course of schizophrenia, pointing to a possibly modifiable risk factor that should be targeted in prevention, assessment, treatment formulation and implementation.

Not recognized enough: The effects and associations of trauma and intellectual disability in severely mentally ill outpatients

Background:

Little is known about the association between trauma and intellectual disability in SMI patients.

Aim:

To establish the prevalence of trauma and its association with intellectual functioning in SMI outpatients.

Methods:

A cross-sectional study was conducted in two mental health trusts in the Netherlands. We used the Trauma Screening Questionnaire (TSQ) to screen for trauma and PTSD, and the Screener for Intelligence and Learning disabilities (SCIL) for suspected MID/BIF. Chi-square and t-tests were used to test differences in outcome over patient characteristics. Post-hoc analysis was used to investigate gender differences between patients with and without MID/BIF on trauma and sexual trauma.

Results:

Any trauma was found in 86% of 570 patients and 42% were suspected for PTSD. The SCIL suggested that 40% had Borderline Intellectual Functioning (BIF), half of whom were suspected of having Mild Intellectual Disability (MID). These patients had more traumatic experiences (1.89 in BIF, 1.75 in MID, against 1.41 in SCIL-negative patients). Female MID/BIF patients (61%) had experienced significantly more sexual abuse than male MID/BIF patients (23%).

Conclusions:

Significantly more SMI outpatients who screened positive for MID/BIF reported having experienced traumatic events than those who screened negative. Rates of all trauma categories were significantly higher in the screen-positive group, who were also more likely to have PTSD. Sexual abuse occurred more in all females but the SCIL positive women are even more often victim. Clinical practice has to pay more attention to all of these issues, especially when they occur together in a single patient.

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.

Psychodrama's Role in Alleviating Acute Distress: A Case Study of an Open Therapy Group in a Psychiatric Inpatient Ward

Numerous studies point to the acute distress associated with experiencing severe mental illness and psychiatric hospitalization. Another strand of research describes how the unique features of psychodrama group therapy are useful in fostering spontaneity and creativity, and their benefits in treating particularly difficult populations where traditional psychotherapy is limited. This paper provides a framework for understanding the potential of psychodrama group therapy to alleviate the experience of loneliness and distress in psychiatric inpatients. A case study of an open inpatients psychodrama group in a psychiatric hospital in Israel demonstrates the role of therapeutic means such as the doubling technique and group sharing phase in creating and reinforcing empathy, relatedness, and support, which may offer at least partial relief of the distress and loneliness of psychiatric inpatients. The unique contribution of this study is the intimate encounter that it provides to researchers and practitioners with the processes that take place within the setting of inpatients therapy group.

Psychotic disorders in sexually abused youth: A prospective matched-cohort study

Child sexual abuse has been identified as a potential risk factor for developing a psychotic disorder. However, little is known about the prevalence of psychotic disorders in youth who were sexually abused during adolescence and young adulthood. Gender differences also remain unclear. This study used administrative databases from a Child Protection Agency and a public health care system. It aimed to investigate the prevalence of psychotic disorders in sexually abused youth between the first substantiated report of sexual abuse and the beginning of adulthood. A second objective was to assess gender differences. Administrative health data for 882 sexually abused youth were compared with 882 matched controls from the general population over a 13-year period using conditional generalized linear mixed models. Stratified analyses by gender (group comparison) and group (gender comparison) were also performed. Sexually abused youth were 10 times more at risk of receiving a diagnosis of psychotic disorder than youth from the general population. There was no gender difference in the prevalence of psychotic disorders among sexually abused youth. These results highlight the importance of targeted prevention of psychotic disorders among sexually abused youth. Future studies should investigate risk factors and developmental trajectories of psychotic disorders in this population.

Characteristics of Sexual Abuse Among Individuals With Serious Mental Illnesses

The deleterious effects of sexual abuse (SA) are well documented, as many studies have found that SA can increase the risk for psychiatric disorders. While SA has been examined in multiple samples, no studies have examined the characteristics of SA in individuals with severe mental illnesses (SMI). This study examined the prevalence rate and characterized the nature of SA among individuals with SMI who were under psychiatric care in three different inpatient facilities. Utilizing data from the MacArthur Violence Risk Assessment Study, 1,136 individuals with SMI were assessed for SA histories, psychiatric diagnoses, and other demographics. Nearly half of this sample ( n = 511) identified SA histories, with almost half indicating that the person was a stranger or someone outside of the family unit. One third reported SA occurred "too many times to count," and approximately a third indicated the abuse consisted of intercourse, occurring at a mean age of 11.22 years. Results found that individuals with SA histories were often never married, Caucasian, female, had children, described themselves as psychologically unwell, and were commonly voluntary psychiatric admissions. Those with SA histories had significantly higher psychopathology and lower functioning, and were more likely to be diagnosed with depression but less likely to be substance dependent. Identifying SA characteristics in individuals with SMI is a critical component to successful treatment. Thorough screening and assessment of this common problem can help clinicians identify accompanying issues that may exacerbate SMI symptomology, and improve the prognosis for long-term outcomes.

Acceptance and Commitment Therapy for Psychosis and Trauma: Investigating Links between Trauma Severity, Attachment and Outcome

BACKGROUND

Although Acceptance and Commitment Therapy (ACT) may be effective for individuals with psychosis and a history of childhood trauma, little is known about predictors of treatment response among such patients.

AIMS

The current study examined: (1) whether severity of trauma predicted treatment response, and (2) profiles of patients with regard to their responses to treatment.

METHOD

Fifty participants with psychosis and childhood trauma history were recruited and randomized to take part in either eight sessions of group-based ACT, or to be on a waiting list for the ACT group (i.e. treatment as usual group). The entire sample was used for the first part of the analyses (aim 1), whereas subsequent subsample analyses used only the treatment group (n = 30 for aim 2).

RESULTS

It was found that trauma severity did not moderate the effectiveness of ACT on symptom severity, participants' ability to regulate their emotional reactions, or treatment compliance with regard to help-seeking. In addition, among those receiving ACT, the results revealed three distinct and clinically relevant change profiles. Avoidant attachment style and number of sessions attended were predictive of belonging to the different clusters or profiles. Patients in the profile representing the least amount of clinical change attended an average of two sessions less than those in the other change profiles.

CONCLUSION

ACT offered in a group format appears to be a promising treatment for those with psychosis and history of trauma regardless of trauma severity. Given the brevity of the intervention, patients should be encouraged to attend each session to obtain maximum benefit.