Psychometric evaluation of trauma and posttraumatic stress disorder assessments in persons with severe mental illness

Factor structure of posttraumatic stress disorder (PTSD) in persons with serious mental illness

BACKGROUND

Trauma and posttraumatic stress disorder (PTSD) are common among individuals with serious mental illness (SMI; e.g., schizophrenia, schizoaffective disorder, bipolar disorder, treatment refractory major depressive disorder), with resultant functional impairment. Previous studies have not evaluated the factor structure of the PTSD Checklist (PCL) among persons with SMI.

AIMS

This study evaluated the factor structure of the PCL in two large SMI samples from public mental health treatment sectors screened for PTSD using the PCL.

METHODS

Four different models of PTSD were tested using confirmatory factor analyses.

RESULTS

Results indicated that the DSM-5 4-factor model (intrusion, avoidance, numbing, and hyperarousal) had the best fit. Further, the DSM-5 4-factor model demonstrated measurement invariance.

CONCLUSIONS

Results supported the suitability of the DSM-5 4-factor model of PTSD among people with SMI.

Multilayer depressive symptom networks in adults with bodily pain living in precarious housing or homelessness

Housing insecurity is associated with co-occurring depression and pain interfering with daily activities. Network analysis of depressive symptoms along with associated risk or protective exposures may identify potential targets for intervention in patients with co-occurring bodily pain. In a community-based sample of adults (n = 408) living in precarious housing or homelessness in Vancouver, Canada, depressive symptoms were measured by the Beck Depression Inventory; bodily pain and impact were assessed with the 36-item Short Form Health Survey. Network and bootstrap permutation analyses were used to compare depressive symptoms endorsed by Low versus Moderate-to-Severe (Mod + Pain) groups. Multilayer networks estimated the effects of risk and protective factors. The overall sample was comprised of 78% men, mean age 40.7 years, with 53% opioid use disorder and 14% major depressive disorder. The Mod + Pain group was characterized by multiple types of pain, more persistent pain, more severe depressive symptoms and a higher rate of suicidal ideation. Global network connectivity did not differ between the two pain groups. Suicidal ideation was a network hub only in the Mod + Pain group, with high centrality and a direct association with exposure to lifetime trauma. Antidepressant medications had limited impact on suicidal ideation. Guilt and increased feelings of failure represented symptoms from two other communities of network nodes, and completed the shortest pathway from trauma exposure through suicidal ideation, to the non-prescribed opioid exposure node. Interventions targeting these risk factors and symptoms could affect the progression of depression among precariously housed patients.

Validity of mental and physical stress models

Different stress models are employed to enhance our understanding of the underlying mechanisms and explore potential interventions. However, the utility of these models remains a critical concern, as their validities may be limited by the complexity of stress processes. Literature review revealed that both mental and physical stress models possess reasonable construct and criterion validities, respectively reflected in psychometrically assessed stress ratings and in activation of the sympathoadrenal system and the hypothalamic-pituitary-adrenal axis. The findings are less robust, though, in the pharmacological perturbations' domain, including such agents as adenosine or dobutamine. Likewise, stress models' convergent- and discriminant validity vary depending on the stressors' nature. Stress models share similarities, but also have important differences regarding their validities. Specific traits defined by the nature of the stressor stimulus should be taken into consideration when selecting stress models. Doing so can personalize prevention and treatment of stress-related antecedents, its acute processing, and chronic sequelae. Further work is warranted to refine stress models' validity and customize them so they commensurate diverse populations and circumstances.

The Impact of Parental Mental Health Diagnoses, Trauma, and Coping Mechanisms on Their Children's Well-Being

The transgenerational effects of parental diagnoses, trauma and coping mechanisms on children's internalizing symptoms are not well understood. In a population-based study of 933 families combining data from a web-based survey and the Danish registers, we used an online survey of parents to examine how parental diagnoses, trauma and coping mechanisms affect the development of internalizing symptoms in children aged 6 to 18 years. To account for attrition, we used inverse probability weights in our regression models. Children of parents diagnosed with depression or anxiety displayed more internalizing symptoms than children of controls. Similarly, children of parents who experienced multiple trauma had significantly more internalizing symptoms. In contrast, we observed significantly fewer internalizing symptoms among children of parents who felt they could cope well. The protective effect of parental coping persisted even after adjusting for parental diagnoses or trauma. Interventions boosting parental coping mechanisms might help to prevent the development of internalizing symptoms in children even among patients who have been diagnosed with depression or anxiety or experienced a high trauma load.

When Trauma Survivors with Psychosis Accuse Staff of Sexual Assault in Inpatient Psychiatric Care

Inpatient psychiatric settings are now known settings in which sexual assault can occur. When a trauma survivor with psychosis makes an accusation of sexual assault within an inpatient setting, staff and the institution are frequently not well equipped in how to respond. While there is scant literature on how to proceed in such dilemmas there is even more of a dearth on how to effectively provide mental health services, trauma- and culturally informed care, and how to best engage with the individual so that safety can be maintained, and treatment continue. This article seeks to convey some basic supports for institutional response, theoretical frameworks to enhance understanding and clinical skill, and shifts in care so that trauma-informed and culturally informed care can take place within these complex dynamics. The goal of this paper is to support mental health services and interdisciplinary teams in becoming more effective in navigating these complex situations so that they can honor and respect the trauma survivor and continue to be effective at providing a healing environment.Public Significance Statement: This article offers enhanced understanding of managing risk and balancing trauma-informed care at an institutional and multi-systemic level when inpatients make allegations of sexual assault. Included in this is enhancing understanding from a theoretical framework of the traumatic experiences of clients, assessing needs and offering safety, treatment, and care, while also managing the complex dynamics and services of the organization.

Feasibility and Preliminary Impact of a Community-Based Intervention for Maternal PTSD and Parenting: Parenting-STAIR Pilot

Trauma exposure and post-traumatic stress disorder (PTSD) impact emotional and physical well-being, social functioning, and parent-child relationship quality. The effect of parental trauma on parenting and child maltreatment is often overlooked by current child welfare (CW) services. The novel intervention, Parenting-STAIR, was created to address maternal mental health, parenting skills, and child well-being outcomes. Parenting-STAIR is a combination of Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy and Parent-Child Care (PC-CARE). This open pilot study aimed to examine the feasibility and preliminary impact of Parenting-STAIR in reducing maternal PTSD and increasing positive parenting skills for mothers and families involved in the child welfare system. Parenting-STAIR was delivered to 111 mothers receiving family preservation services in New York City. Of these, 70 completed treatment; statistical and clinically significant changes were observed for maternal PTSD and depression as well as in parenting stress, parenting skills, and child behaviors. These findings provide encouraging initial evidence for the feasibility and impact of this novel PTSD intervention. An evaluation of maltreatment recidivism is needed, as well as implementation of a randomized controlled trial to establish efficacy of the intervention.

Predictors of undocumented PTSD in persons using public mental health services

Individuals diagnosed with serious mental illness (SMI) have greater trauma exposure and are at increased risk for posttraumatic stress disorder (PTSD). However, PTSD is rarely documented in their clinical records. This study investigated the predictors of PTSD documentation among 776 clients with SMI receiving public mental health services, who had probable PTSD as indicated by a PTSD Checklist score of at least 45. Only 5.3% of clients had PTSD listed as a primary diagnosis, and 8.4% had PTSD as a secondary diagnosis, with a total 13.7% documentation rate. PTSD documentation rate was highest for clients with major depression (18.8%) compared to those with schizophrenia (4.1%) or bipolar disorder (6.3%). Factors that predicted a lower likelihood of having a chart diagnosis of PTSD included being diagnosed with schizophrenia/schizoaffective disorder or bipolar disorder. Factors that predicted a higher likelihood of having a chart diagnosis of PTSD included being of non-white race, being female, and experiencing eight or more types of traumatic events. Findings highlight the need for PTSD screening and trauma informed care for clients with SMI receiving public mental health services.

Dynamic networks of psychotic symptoms in adults living in precarious housing or homelessness

BACKGROUND

People living in precarious housing or homelessness have higher than expected rates of psychotic disorders, persistent psychotic symptoms, and premature mortality. Psychotic symptoms can be modeled as a complex dynamic system, allowing assessment of roles for risk factors in symptom development, persistence, and contribution to premature mortality.

METHOD

The severity of delusions, conceptual disorganization, hallucinations, suspiciousness, and unusual thought content was rated monthly over 5 years in a community sample of precariously housed/homeless adults (n = 375) in Vancouver, Canada. Multilevel vector auto-regression analysis was used to construct temporal, contemporaneous, and between-person symptom networks. Network measures were compared between participants with (n = 219) or without (n = 156) history of psychotic disorder using bootstrap and permutation analyses. Relationships between network connectivity and risk factors including homelessness, trauma, and substance dependence were estimated by multiple linear regression. The contribution of network measures to premature mortality was estimated by Cox proportional hazard models.

RESULTS

Delusions and unusual thought content were central symptoms in the multilevel network. Each psychotic symptom was positively reinforcing over time, an effect most pronounced in participants with a history of psychotic disorder. Global connectivity was similar between those with and without such a history. Greater connectivity between symptoms was associated with methamphetamine dependence and past trauma exposure. Auto-regressive connectivity was associated with premature mortality in participants under age 55.

CONCLUSIONS

Past and current experiences contribute to the severity and dynamic relationships between psychotic symptoms. Interrupting the self-perpetuating severity of psychotic symptoms in a vulnerable group of people could contribute to reducing premature mortality.

Communal mastery and associations with depressive and PTSD symptomatology among urban trauma-exposed women

Objective: Racial and ethnic minority women from low-resource urban communities experience disproportionately high rates of trauma exposure. Higher rates of lifetime trauma exposure are strongly associated with subsequent psychological sequela, specifically depression and posttraumatic stress disorder (PTSD). Communal mastery is the ability to cope with challenges and achieve goals by being closely interconnected with friends, family, and significant others. Yet, it is unknown if communal mastery is protective specifically against PTSD and depressive symptoms. Method: Participants (N = 131) were Black and Latina women (88.5% Black, mean monthly income: < $750) recruited from an urban outpatient obstetric-gynecological clinic at an academic medical center. Participants completed an online questionnaire that assessed trauma history, PTSD and depressive symptoms, types of individualistic coping, social support, and communal mastery. Results: Hierarchical multiple regression models demonstrated that communal mastery is uniquely associated with fewer PTSD symptoms (β = -.23, p = .003). More severe trauma history, more use of passive coping skills, and poorer social support were also significantly associated with PTSD symptoms, explaining over half of the variance in PTSD symptoms. Although significantly correlated, communal mastery was not uniquely associated with fewer depressive symptoms (β = -.13, p = .201). Conclusions: These findings suggest that connectedness as assessed through communal mastery serves as an important shield against the effects of traumatic stress for Black and Latina women. Future research would benefit by exploring interventions that aim to increase communal mastery in order to help highly trauma-exposed racial and ethnic minority women in low-resource environments. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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.

A network analysis of post-traumatic stress and psychosis symptoms

BACKGROUND

Understanding the interplay between trauma-related psychological mechanisms and psychotic symptoms may improve the effectiveness of interventions for post-traumatic stress reactions in psychosis. Network theory assumes that mental health problems persist not because of a common latent variable, but from dynamic feedback loops between symptoms, thereby addressing the heterogeneous and overlapping nature of traumagenic and psychotic diagnoses. This is a proof-of-concept study examining interactions between post-traumatic stress symptoms, which were hypothesized to reflect trauma-related psychological mechanisms, and auditory hallucinations and delusions.

METHOD

Baseline data from two randomised controlled trials (N = 216) of trauma-focused therapy in people with post-traumatic stress symptoms (87.5% met diagnostic criteria for PTSD) and psychotic disorder were analysed. Reexperiencing, hyperarousal, avoidance, trauma-related beliefs, auditory hallucinations and delusional beliefs were used to estimate a Gaussian graphical model along with expected node influence and predictability (proportion of explained variance).

RESULTS

Trauma-related beliefs had the largest direct influence on the network and, together with hypervigilance, were implicated in the shortest paths from flashbacks to delusions and auditory hallucinations.

CONCLUSIONS

These findings are in contrast to previous research suggesting a central role for re-experiencing, emotional numbing and interpersonal avoidance in psychosis. Trauma-related beliefs were the psychological mechanism most associated with psychotic symptoms, although not all relevant mechanisms were measured. This work demonstrates that investigating multiple putative mediators may clarify which processes are most relevant to trauma-related psychosis. Further research should use network modelling to investigate how the spectrum of traumatic stress reactions play a role in psychotic symptoms.

Exposure to traumatic events, emotion regulation, and traumatic stress among infertility patients: a moderation analysis

Exposure to traumatic events and emotion regulation were examined as predictors of posttraumatic stress symptoms (PTSS) among women seeking medical treatment for infertility. Emotion regulation difficulties were hypothesized to moderate the association between traumatic events and PTSS severity. Sixty-six participants completed the Trauma History Questionnaire, Posttraumatic Check List for DSM-5, and Difficulties in Emotion Regulation Scale. Regression analyses were conducted. Emotion regulation difficulties predicted PTSS. The interaction between lifetime exposure to traumatic events and emotion regulation significantly predicted PTSS (b = 0.02, p = 0.002) and the model accounted for 31% of the variance in symptoms. Among women pursuing medical fertility treatment with past exposure to traumatic events, brief interventions that enhance emotional regulation skills may decrease PTSS.

The invisible scars of emotional abuse: a common and highly harmful form of childhood maltreatment

BACKGROUND

Childhood maltreatment (CM) is unfortunately widespread globally and has been linked with an increased risk of a variety of psychiatric disorders in adults, including posttraumatic stress disorder (PTSD). These associations are well established in the literature for some maltreatment forms, such as sexual and physical abuse. However, the effects of emotional maltreatment are much less explored, even though this type figures among the most common forms of childhood maltreatment. Thus, the present study aims to investigate the impact of each type of childhood maltreatment, both individually and conjointly, on revictimization and PTSD symptom severity using a nonclinical college student sample.

METHODS

Five hundred and two graduate and undergraduate students participated in the study by completing questionnaires assessing lifetime traumatic experiences in general, maltreatment during childhood and PTSD symptoms. Bivariate and multivariate negative binomial regressions were applied to examine the associations among childhood maltreatment, revictimization, and PTSD symptom severity.

RESULTS

Our results showed that using bivariate models, all types of CM were significantly associated with revictimization and PTSD symptom severity. Multivariate models showed that emotional abuse was the type of maltreatment associated with the highest incidence rates of revictimization and PTSD symptom severity.

CONCLUSIONS

These data provide additional evidence of the harmful effects of childhood maltreatment and its long-term consequences for individuals' mental health. Notably, the findings highlight the importance of studying the impacts of emotional abuse, which seems to be a highly prevalent, understudied, and chronic form of maltreatment that is as toxic as other maltreatment forms.

Temporal Stability of Self-Reported Trauma Exposure on the Life Events Checklist for DSM-5

The Life Events Checklist for DSM-5 (LEC-5) is a comprehensive screening instrument used to detect exposure to a range of potentially traumatic events. Despite its widespread use, research assessing the psychometric properties of scores on the LEC-5-and trauma exposure more broadly-is scarce. Using a large sample of undergraduate students (N = 1,013), we sought to evaluate the reliability of trauma exposure reporting on the LEC-5 across 8- (N = 379) and 12-week (N = 343) intervals. Reliability estimates were examined for trauma exposure type (e.g., experiencing, witnessing), traumatic event type (e.g., sexual assault), and index trauma (i.e., "worst event") reporting. Reliability was more stable for events that were directly experienced, intraclass correlation coefficients (ICCs) = .62-64, than events that were witnessed, ICCs = .47-.52, or learned about, ICCs = .48-.53. Test-retest agreement was fair to good for reports of sexual assault, physical assault, transportation accidents, natural disasters, and other sexual experiences, κs = .49-.72, but only when individuals directly experienced these events. By contrast, across both assessment intervals, the agreement was attenuated, all κs < .40, for events that individuals witnessed or learned about regardless of event type. For index events, only sexual assault and sudden accidental or violent deaths were consistently reported with a fair or better agreement, κs = .42-.64. These findings suggest that reliable trauma reporting varies largely based on the nature of the traumatic event, yielding important implications for the assessment of DSM-5 Criterion A and posttraumatic stress disorder.

Peer delivery of a brief cognitive-behavioral treatment for posttraumatic stress disorder: A hybrid effectiveness-implementation pilot study

OBJECTIVE

Posttraumatic stress disorder (PTSD) treatment delivery by peer specialist providers could increase access to and engagement with PTSD treatment in low resource settings. The current pilot study tested the feasibility, acceptability, and initial effectiveness of a peer-delivered, brief cognitive-behavioral therapy for PTSD.

METHOD

Four certified peer specialists delivered the intervention to 18 participants with probable PTSD. We assessed PTSD symptoms weekly and administered surveys and interviews at baseline and posttreatment.

RESULTS

Our mixed-methods approach suggests that the intervention was feasible and acceptable, demonstrating high client satisfaction. We also found significant improvements in PTSD, depressive, anxiety, and general stress symptoms.

CONCLUSIONS

Peer-delivered interventions may be a good fit for addressing posttraumatic stress symptoms for people accessing care in low resource settings. Future research should evaluate peer-delivered PTSD treatment as a strategy for both reducing symptoms and improving access and engagement in professional care.

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.

Associations of substance use, psychosis, and mortality among people living in precarious housing or homelessness: A longitudinal, community-based study in Vancouver, Canada

BACKGROUND

The "trimorbidity" of substance use disorder and mental and physical illness is associated with living in precarious housing or homelessness. The extent to which substance use increases risk of psychosis and both contribute to mortality needs investigation in longitudinal studies.

METHODS AND FINDINGS

A community-based sample of 437 adults (330 men, mean [SD] age 40.6 [11.2] years) living in Vancouver, Canada, completed baseline assessments between November 2008 and October 2015. Follow-up was monthly for a median 6.3 years (interquartile range 3.1-8.6). Use of tobacco, alcohol, cannabis, cocaine, methamphetamine, and opioids was assessed by interview and urine drug screen; severity of psychosis was also assessed. Mortality (up to November 15, 2018) was assessed from coroner's reports and hospital records. Using data from monthly visits (mean 9.8, SD 3.6) over the first year after study entry, mixed-effects logistic regression analysis examined relationships between risk factors and psychotic features. A past history of psychotic disorder was common (60.9%). Nonprescribed substance use included tobacco (89.0%), alcohol (77.5%), cocaine (73.2%), cannabis (72.8%), opioids (51.0%), and methamphetamine (46.5%). During the same year, 79.3% of participants reported psychotic features at least once. Greater risk was associated with number of days using methamphetamine (adjusted odds ratio [aOR] 1.14, 95% confidence interval [CI] 1.05-1.24, p = 0.001), alcohol (aOR 1.09, 95% CI 1.01-1.18, p = 0.04), and cannabis (aOR 1.08, 95% CI 1.02-1.14, p = 0.008), adjusted for demographic factors and history of past psychotic disorder. Greater exposure to concurrent month trauma was associated with increased odds of psychosis (adjusted model aOR 1.54, 95% CI 1.19-2.00, p = 0.001). There was no evidence for interactions or reverse associations between psychotic features and time-varying risk factors. During 2,481 total person years of observation, 79 participants died (18.1%). Causes of death were physical illness (40.5%), accidental overdose (35.4%), trauma (5.1%), suicide (1.3%), and unknown (17.7%). A multivariable Cox proportional hazard model indicated baseline alcohol dependence (adjusted hazard ratio [aHR] 1.83, 95% CI 1.09-3.07, p = 0.02), and evidence of hepatic fibrosis (aHR 1.81, 95% CI 1.08-3.03, p = 0.02) were risk factors for mortality. Among those under age 55 years, a history of a psychotic disorder was a risk factor for mortality (aHR 2.38, 95% CI 1.03-5.51, p = 0.04, adjusted for alcohol dependence at baseline, human immunodeficiency virus [HIV], and hepatic fibrosis). The primary study limitation concerns generalizability: conclusions from a community-based, diagnostically heterogeneous sample may not apply to specific diagnostic groups in a clinical setting. Because one-third of participants grew up in foster care or were adopted, useful family history information was not obtainable.

CONCLUSIONS

In this study, we found methamphetamine, alcohol, and cannabis use were associated with higher risk for psychotic features, as were a past history of psychotic disorder, and experiencing traumatic events. We found that alcohol dependence, hepatic fibrosis, and, only among participants <55 years of age, history of a psychotic disorder were associated with greater risk for mortality. Modifiable risk factors in people living in precarious housing or homelessness can be a focus for interventions.

Trauma history in a high secure male forensic inpatient population

There is an increasing focus on trauma within forensic services. This study aimed to investigate exposure to trauma among a high secure male forensic population. Based on the Childhood Trauma Questionnaire (CTQ) and the Trauma History Questionnaire (THQ) data capture sheets were developed. Patients' own offending behaviour was included as a source of potential trauma. Records for all patients placed within the hospital (n = 194) were reviewed. All patients had been exposed to a traumatic event over the lifespan, with 75% having been exposed to trauma during childhood. Sixty-five percent of patients had experienced more than one type of trauma during childhood; the mean number of trauma types experienced during this period being 2.31. In adulthood 63% had been exposed to one trauma type while 29% had been exposed to two or more trauma types. No significant difference was found between those with and those without childhood trauma histories on hospital variables including admission length, seclusion and incidents. The implications of these results in the context of adopting a trauma informed care approach to treatment in forensic settings are discussed, and recommendations for future clinical and research directions are made.

Direct and indirect relationships among posttraumatic stress disorder, depression, hostility, anger, and verbal and physical aggression in returning veterans

Hostility, anger, and aggression are conceptually related but unique constructs found to occur more often among veterans with posttraumatic stress disorder (PTSD) than among civilians or veterans without PTSD. However, the pathways between PTSD, depression, hostility, anger, and aggression have not been comprehensively characterized. Therefore, drawing on a sample of returning Operation Enduring Freedom/Operation Iraqi Freedom combat veterans ( N = 175; 95% male; mean age 30 years), this study sought to examine the direct and indirect relationships among PTSD, depression, hostility, anger, and four types of aggression: verbal, and physical toward self, others, and objects. Functional modeling of direct effects was done using multiple least-squares regression and bootstrapped mediation analyses were carried out to test indirect effects. Results indicate that PTSD is not the overall direct contributor to different forms of aggression, supporting the mediating role of depression and trait anger. Depression symptoms explain part of the relationships between PTSD and verbal aggression, physical aggression toward objects, and physical aggression toward self and trait anger explains part of the relationships between PTSD and verbal aggression, physical aggression toward objects, and physical aggression toward others. Our findings support the importance of assessing for anger, depression, and different types of aggression among veterans presenting for PTSD treatment to develop individualized treatment plans that may benefit from early incorporation of interventions.

The Temporal Relationship Between Coping Self-Efficacy and Dissociation in Undergraduate Students

Dissociation is a lack of information integration resulting from a process that ranges on a continuum from normative experiences (e.g., daydreaming) to a pervasive traumatic response involving alterations and/or fragmentation in mental processes such as memory, emotion, and perception. Perceived coping self-efficacy (CSE) is a cognitive appraisal ability utilized to regulate internal and external stressors that arise from traumatic events, and is crucial for effective adaptation after extreme stress or trauma. Thus, CSE may be a critical component in decreasing dissociative experiences following a traumatic event. In the present study, 136 undergraduate students (M age = 22.36 years, SD = 6.27; 81% female, 69.1% Caucasian, 77.2% attended some college) completed self-report measures of trauma, dissociation, and coping self-efficacy. All measures were completed by the same participants at two different time points (Time 1 and Time 2) two months apart; all participants reported a history of exposure to at least one Criterion A traumatic event (according to the DSM-5) at Time 1. We hypothesized that CSE for posttraumatic coping demands at Time 2 would mediate the relationship between dissociation at Time 1 and dissociation at Time 2, and subsequently found evidence of significant mediation, 95% CI [.02, .18]. These findings suggest that initial levels of persistent dissociation negatively predict CSE, which in turn directly and negatively influence persistent dissociation at a later time point. This highlights how CSE may serve as a protective factor against persistent dissociation.

The Relationship Between Childhood Trauma and Poor Sleep Health in Adulthood

OBJECTIVE

Childhood trauma has been related to adverse behavioral, mental, and health outcomes later in life. Sleep may be a potential mechanism through which childhood trauma is related to adverse health. The current retrospective study aimed to characterize the relationship between childhood trauma exposure and sleep health, a novel multidimensional measure of sleep.

METHODS

Participants (N = 161; mean [standard deviation] age = 59.85 [9.06] years; 67.7% female) retrospectively reported trauma exposure using the Trauma History Questionnaire. Childhood trauma was defined as the number of reported traumatic events before 18 years of age. Trauma exposure after 18 years of age and across the life-span was also recorded. Sleep health was derived both from diary- and actigraphy-assessed measures of sleep regularity, timing, efficiency, and duration, subjective sleep satisfaction, and daytime sleepiness from the Epworth Sleepiness Scale. The relationships between childhood trauma exposure and sleep health were examined using hierarchical linear regression, controlling for relevant covariates.

RESULTS

In unadjusted models, a greater number of childhood trauma exposures were associated with poorer diary- and actigraphy-measured sleep health in adulthood. After adjustment for current stress, depression history, and other sociodemographic covariates, greater childhood trauma remained significantly associated with poorer sleep health (diary: β = -0.20, ΔR = 0.032; actigraphy: β = -0.19, ΔR = 0.027). Trauma exposure after 18 years of age and across the life-span did not relate to diary- or actigraphy-based sleep health.

CONCLUSIONS

Childhood trauma may affect sleep health in adulthood. These findings align with the growing body of evidence linking childhood trauma to adverse health outcomes later in life.

TF-CBT and EMDR for young people with trauma and first episode psychosis (using a phasic treatment approach): two early intervention service case studies

The relationship between trauma and psychosis is well established with a large amount of overlap between the ICD/DSM (International Classification of Diseases/Diagnostic and Statistical Manual of Mental Disorders) diagnostic criteria for post-traumatic stress disorder (PTSD) and psychosis and/or schizophrenia. In spite of co-morbidity and evidence of the links and underlying mechanisms, trauma is rarely a focus of intervention in psychosis. Psychosis has often been on the list of exclusion criteria for PTSD research studies. There is a lack of literature on the impact of trauma work with people experiencing psychosis. The National Institute for Health and Care Excellence (NICE) (2014) suggests that Early Intervention in Psychosis (EIP) service users should be assessed for PTSD, and PTSD guidelines (NICE, 2005) followed for those who show signs of post-traumatic stress. There is a need to evaluate the effectiveness of therapeutic approaches for people with PTSD and co-morbid psychosis. These case studies aim to provide initial evidence of how two EIP clients experienced and responded to NICE-recommended psychological therapy for trauma. This study aims to test the feasibility of trauma work delivered via a phasic approach in a novel population. Two EIP clients received psychological therapy [including trauma-focused cognitive behavioural therapy (CBT) and eye movement desensitization and reprocessing (EMDR)] for identified traumatic experiences. Assessment outcome measures were utilized to establish the effectiveness of the interventions. Both clients reported significant improvements following therapy, including reduced trauma-related distress, reduced distress from symptoms of psychosis and improved quality of life. Clients with co-morbid PTSD and symptoms of psychosis are likely to benefit from recommended psychological treatments for PTSD. Further research is required to address generalizability to a larger population.

The Trauma and Life Events (TALE) checklist: development of a tool for improving routine screening in people with psychosis

Background: Best practice guidelines recommend traumatic events should be assessed in psychosis to support the identification and, when indicated, treatment of post-traumatic stress reactions. However, routine assessment in frontline services is rare, and available tools are not tailored to psychosis. Assessment obstacles include lengthy measures, a focus on single, physically threatening events, and the exclusion of psychosis-related traumas. Objective: To develop and validate a brief trauma screening tool for the identification of clinically significant traumas in people with psychosis. Method: The Trauma and Life Events (TALE) checklist was developed in conjunction with people with lived experience of trauma and psychosis, and specialist clinicians and researchers. The psychometric properties (i.e. test-retest reliability, content validity, construct validity) of the TALE were evaluated in a sample of 39 people with psychosis diagnoses. Results: The TALE displayed moderate psychometric acceptability overall, with excellent reliability and convergent validity for sexual abuse. High rates of psychosis-related trauma and childhood adversity were reported, in particular bullying and emotional neglect. A dose-response relationship between cumulative trauma, post-traumatic stress and psychosis was found. Conclusions: The TALE is the first screening tool specifically designed to meet the needs of routine trauma screening in psychosis services. The psychometric limitations highlight the challenge of developing a measure that is both sufficiently brief to be useful in clinical settings and comprehensive enough to identify all relevant adverse events. Validation of the TALE is now required across the spectrum of psychosis.

[Patients assaulted in psychiatric institutions: Literature review and clinical implications]

BACKGROUND

The psychiatric ward is a place where all forms of violence are treated. Occasionally, this violence involves acts of aggression between patients in emergency psychiatric units or hospital wards. Such events can lead to the development or worsening of posttraumatic stress disorder.

METHODS

To establish the context, we first examined the epidemiology data concerning posttraumatic stress disorder in psychiatric patients who were frequently exposed to assaults. Secondly, we examined the issue of sexual and physical assaults between patients receiving treatment in a psychiatric ward. In this context, we studied possible occurrence of posttraumatic stress disorder associated with exposure to assaults of this kind.

RESULTS

In certain cases, potentially traumatic exposure to violence was unknown to the medical staff or not taken into consideration. This would induce a risk of later development of posttraumatic stress disorder that would not be treated during the stay in psychiatry.

CONCLUSION

To date, few scientific studies have focused on the proportion of patients assaulted by other patients during treatment in a psychiatric ward and the subsequent development of peritraumatic reactions and/or posttraumatic stress disorder associated with these assaults. We know that an insufficient number of public and private health institutions report the existence of such facts to the competent authorities. Also, a minority of clinicians and caregivers are trained in screening and management of trauma victims. Yet, these issues are particularly relevant in the scope of public health and health promotion.

Observed Relationship Behaviors and Sleep in Military Veterans and Their Partners

BACKGROUND

Emerging research has begun to examine associations between relationship functioning and sleep. However, these studies have largely relied on self-reported evaluations of relationships and/or of sleep, which may be vulnerable to bias.

PURPOSE

The purpose of the study was to examine associations between relationship functioning and sleep in military couples. This is the first research to examine associations between observed relationship behaviors and subjective and polysomnographically measured sleep in a sample at-risk for both sleep and relationship problems.

METHODS

The sample included 35 military veterans and their spouses/partners. Marital functioning was coded from a videotaped conflict interaction. Analyses focused on behavioral codes of hostility and relationship-enhancing attributions. Sleep was assessed via self-report and in-home polysomnography.

RESULTS

Greater hostility was associated with poorer sleep efficiency for oneself (b = -0.195, p = .013). In contrast, greater relationship-enhancing attributions were associated with higher percentages of stage N3 sleep (b = 0.239, p = .028). Partners' hostility was also positively associated with higher percentages of stage N3 sleep (b = 0.272, p = .010). Neither hostility nor relationship-enhancing attributions was associated with self-reported sleep quality, percentage of REM sleep, or total sleep time.

CONCLUSIONS

Both partners' positive and negative behaviors during conflict interactions were related to sleep quality. These findings highlight the role that effective communication and conflict resolution skills may play in shaping not only the marital health of veterans and their spouses but also the physical health of both partners as well. Understanding the links between relationship functioning and sleep may be important targets of intervention in the aftermath of war.

The traumatic experience of first-episode psychosis: A systematic review and meta-analysis

INTRODUCTION

A psychotic episode may be sufficiently traumatic to induce symptoms of post-traumatic stress disorder (PTSD), which could impact outcomes in first-episode psychosis (FEP). The objectives of this systematic review and meta-analysis were to estimate the prevalence of PTSD symptoms in relation to psychosis in FEP and to identify risk factors for the development of PTSD symptoms.

METHODS

We searched electronic databases and conducted manual searching of reference lists and tables of contents to identify relevant studies. Quantitative studies were included if the population was experiencing FEP and if PTSD was measured in relation to psychosis. Prevalence of PTSD symptoms and diagnoses were meta-analyzed using a random effects model. Potential risk factors for PTSD symptoms were summarized qualitatively.

RESULTS

Thirteen studies were included. Eight studies assessed PTSD symptoms, three studies assessed full PTSD, and two studies assessed both. The pooled prevalence of PTSD symptoms was 42% (95% CI 30%-55%), and the pooled prevalence of a PTSD diagnosis was 30% (95% CI 21%-40%). Exploratory subgroup analyses suggest that prevalence may be higher in affective psychosis and inpatient samples. Evidence from included studies implicate depression and anxiety as potential risk factors for PTSD symptoms.

CONCLUSIONS

Approximately one in two people experience PTSD symptoms and one in three experience full PTSD following a first psychotic episode. Evidence-based interventions to treat PTSD symptoms in the context of FEP are needed to address this burden and improve outcomes after the first psychotic episode. Further studies are needed to clarify the associated risk factors.

Childhood physical and sexual abuse experiences associated with post-traumatic stress disorder among pregnant women

PURPOSE

We sought to evaluate the extent to which childhood physical and/or sexual abuse history is associated with post-traumatic stress disorder (PTSD) during early pregnancy and to explore the extent to which the childhood abuse-PTSD association is mediated through, or modified by, adult experiences of intimate partner violence (IPV).

METHODS

In-person interviews collected information regarding history of childhood abuse and IPV from 2,928 women aged 18-49 years old prior to 16 weeks of gestation. PTSD was assessed using the PTSD Checklist-Civilian Version. Multivariate logistic regressions were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Compared to women with no childhood abuse, the odds of PTSD were increased 4.31-fold for those who reported physical abuse only (95% CI, 2.18-8.49), 5.33-fold for sexual abuse only (95% CI, 2.38-11.98), and 8.03-fold for those who reported physical and sexual abuse (95% CI, 4.10-15.74). Mediation analysis showed 13% of the childhood abuse-PTSD association was mediated by IPV. Furthermore, high odds of PTSD were noted among women with histories of childhood abuse and IPV compared with women who were not exposed to either (OR = 20.20; 95% CI, 8.18-49.85).

CONCLUSIONS

Childhood abuse is associated with increased odds of PTSD during early pregnancy. The odds of PTSD were particularly elevated among women with a history of childhood abuse and IPV. Efforts should be made to prevent childhood abuse and mitigate its effects on women's mental health.

Single-nucleotide polymorphisms in genes related to the hypothalamic-pituitary-adrenal axis as risk factors for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a common psychiatric disorder. The etiology of PTSD is multifactorial, depending on many environmental and genetic risk factors, and the exposure to life or physical integrity-threatening events. Several studies have shown significant correlations of many neurobiological findings with PTSD. Hypothalamic-pituitary-adrenal (HPA) axis dysfunction is strongly correlated with this disorder. One hypothesis is that HPA axis dysfunction may precede the traumatic event, suggesting that genes expressed in the HPA axis may be involved in the development of PTSD. This article reviews molecular genetic studies related to PTSD collected through a literature search performed in PubMed, MEDLINE, ScienceDirect, and Scientific Electronic Library Online (SciELO). The results of these studies suggest that several polymorphisms in the HPA axis genes, including FKBP5, NR3C1, CRHR1, and CRHR2, may be risk factors for PTSD development or may be associated with the severity of PTSD symptoms.

Exploring the gold-standard: Evidence for a two-factor model of the Clinician Administered PTSD Scale for the DSM-5

OBJECTIVE

The latent factor structure of posttraumatic stress disorder (PTSD) remains a source of considerable variability. The current study compared several a priori factor structures, as well as a novel 2-factor structure of posttraumatic psychological distress as measured by the Clinician Administered PTSD scale for the DSM-5 (CAPS-5). In addition, variability in diagnostic rates according to the divergent DSM-5 and ICD-11 criteria were explored.

METHOD

The setting for this study was a Level 1 trauma center in a U.S. metropolitan city. Data were pooled from 2 studies (N = 309) and participants were administered the CAPS-5 at 1 (n = 139) or 6 months postinjury (n = 170). Confirmatory factor analysis (CFA) was used to compare several factor models, and prevalence rates based on DSM-5 and ICD-11 criteria were compared via z tests and kappa.

RESULTS

CFAs of 5 factor structures indicated good fit for all models. A novel 2-factor model based on competing models of PTSD symptoms and modification indices was then tested. The 2-factor model of the CAPS-5 performed as well or better on most indices compared to a 7-factor hybrid. Comparisons of PTSD prevalence rates found no significant differences, but agreement was variable.

CONCLUSIONS

These findings indicate that the CAPS-5 can be seen as measuring 2 distinct phenomena: posttraumatic stress disorder and general posttraumatic dysphoria. This is an important contribution to the current debate on which latent factors constitute PTSD and may reduce discordance. (PsycINFO Database Record

Therapeutic effect of increased openness: Investigating mechanism of action in MDMA-assisted psychotherapy

A growing body of research suggests that traumatic events lead to persisting personality change characterized by increased neuroticism. Relevantly, enduring improvements in Post-Traumatic Stress Disorder (PTSD) symptoms have been found in response to 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy. There is evidence that lasting changes in the personality feature of "openness" occur in response to hallucinogens, and that this may potentially act as a therapeutic mechanism of change. The present study investigated whether heightened Openness and decreased Neuroticism served as a mechanism of change within a randomized trial of MDMA-assisted psychotherapy for chronic, treatment-resistant PTSD. The Clinician-Administered PTSD Scale (CAPS) Global Scores and NEO PI-R Personality Inventory (NEO) Openness and Neuroticism Scales served as outcome measures. Results indicated that changes in Openness but not Neuroticism played a moderating role in the relationship between reduced PTSD symptoms and MDMA treatment. Following MDMA-assisted psychotherapy, increased Openness and decreased Neuroticism when comparing baseline personality traits with long-term follow-up traits also were found. These preliminary findings suggest that the effect of MDMA-assisted psychotherapy extends beyond specific PTSD symptomatology and fundamentally alters personality structure, resulting in long-term persisting personality change. Results are discussed in terms of possible mechanisms of psychotherapeutic change.

The Symptoms of Trauma Scale (SOTS): Psychometric evaluation and gender differences with adults diagnosed with serious mental illness

A new clinician rating measure, the Symptoms of Trauma Scale (SOTS), was administered to adult psychiatric outpatients (46 men, 47 women) with severe mental illness who reported a history of trauma exposure and had recently been discharged from inpatient psychiatric treatment. SOTS composite severity scores for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, posttraumatic stress disorder (PTSD), complex PTSD (cPTSD), and total PTSD/cPTSD severity had acceptable internal consistency reliability. SOTS scores' construct and convergent validity was supported by correlations with self-report measures of childhood and adult trauma history and PTSD, dissociation, and anger symptoms. For men, SOTS scores were associated with childhood sexual and emotional abuse and self-reported anger problems, whereas for women SOTS scores were most consistently and strongly associated with childhood family adversity and self-reported PTSD symptoms. Results provide preliminary support for the reliability and validity of the SOTS with adults with severe mental illness and suggest directions for replication, measure refinement, and research on gender differences.

The PCL as a brief screen for posttraumatic stress disorder within schizophrenia

OBJECTIVES

To assess the utility of using the posttraumatic checklist (PCL) as a screening measure for identifying posttraumatic stress disorder (PTSD) in individuals diagnosed with a psychotic disorder.

METHODS

The PCL was administered to 165 participants as part of a clinical trial. Those scoring 44 or above on the PCL underwent further assessment using the clinician administered PTSD scale (CAPS).

RESULTS

Overall 18.2% of the sample exhibited a diagnostic level of PTSD symptoms, as indicated by the CAPS assessment. Only 29.7% of those who scored above the PCL threshold were diagnostic of PTSD.

CONCLUSIONS

The use of PCL for identifying PTSD within this population is not recommended.

Seeking Safety Group Therapy for Co-Occurring Substance Use Disorder and PTSD among Transgender Women Living with HIV: A Pilot Study

Transgender women living with HIV experience high rates of substance use, violence, and post-traumatic stress disorder (PTSD). Seeking Safety is a manualized, present-focused, cognitive-behavioral therapy program designed to address co-occurring substance use and PTSD. Seeking Safety has evidence of efficacy in a variety of populations but had not been evaluated specifically with people living with HIV or transgender women. We pilot-tested a 12-session Seeking Safety program with a group of transgender women living with HIV who reported substance use and a history of violence. Seven transgender women living with HIV were recruited from two HIV primary care clinics in San Francisco and completed pre- and post-intervention assessments. Participants attended an average of 8 of the 12 sessions. Mean scores for all three outcome measures improved: PTSD symptom scores declined 17.5%, alcoholism screening scores declined 23.9%, and drug abuse screening scores declined 68.8%, on average. Despite the small sample, this pilot study showed Seeking Safety to be a promising intervention among transgender women living with HIV. The findings are encouraging and justify larger studies of Seeking Safety among transgender women and other people living with HIV who experience high rates of substance use and PTSD.

Validity of the posttraumatic stress disorders (PTSD) checklist in pregnant women

BACKGROUND

The PTSD Checklist-civilian (PCL-C) is one of the most commonly used self-report measures of PTSD symptoms, however, little is known about its validity when used in pregnancy. This study aims to evaluate the reliability and validity of the PCL-C as a screen for detecting PTSD symptoms among pregnant women.

METHODS

A total of 3372 pregnant women who attended their first prenatal care visit in Lima, Peru participated in the study. We assessed the reliability of the PCL-C items using Cronbach's alpha. Criterion validity and performance characteristics of PCL-C were assessed against an independent, blinded Clinician-Administered PTSD Scale (CAPS) interview using measures of sensitivity, specificity and receiver operating characteristics (ROC) curves. We tested construct validity using exploratory and confirmatory factor analytic approaches.

RESULTS

The reliability of the PCL-C was excellent (Cronbach's alpha =0.90). ROC analysis showed that a cut-off score of 26 offered optimal discriminatory power, with a sensitivity of 0.86 (95% CI: 0.78-0.92) and a specificity of 0.63 (95% CI: 0.62-0.65). The area under the ROC curve was 0.75 (95% CI: 0.71-0.78). A three-factor solution was extracted using exploratory factor analysis and was further complemented with three other models using confirmatory factor analysis (CFA). In a CFA, a three-factor model based on DSM-IV symptom structure had reasonable fit statistics with comparative fit index of 0.86 and root mean square error of approximation of 0.09.

CONCLUSION

The Spanish-language version of the PCL-C may be used as a screening tool for pregnant women. The PCL-C has good reliability, criterion validity and factorial validity. The optimal cut-off score obtained by maximizing the sensitivity and specificity should be considered cautiously; women who screened positive may require further investigation to confirm PTSD diagnosis.

Factors Affecting Resilience and Development of Posttraumatic Stress Disorder in Critical Care Nurses

BACKGROUND

Job stress and cumulative exposure to traumatic events experienced by critical care nurses can lead to psychological distress and the development of burnout syndrome and posttraumatic stress disorder. Resilience can mitigate symptoms associated with these conditions.

OBJECTIVE

To identify factors that affect resilience and to determine if the factors have direct or indirect effects on resilience in development of posttraumatic stress disorder.

METHODS

Data from 744 respondents to a survey mailed to 3500 critical care nurses who were members of the American Association of Critical-Care Nurses were analyzed. Mplus was used to analyze a mediation model.

RESULTS

Nurses who worked in any type of intensive care unit other than the medical unit and had high scores for resilience were 18% to 50% less likely to experience post-traumatic stress disorder than were nurses with low scores. Nurses with a graduate degree in nursing were 18% more likely to experience posttraumatic stress disorder than were nurses with a bachelor's degree.

CONCLUSION

Because of their effects on resilience, working in a medical intensive care unit and having a graduate degree may influence the development of posttraumatic stress disorder. Future research is needed to better understand the impact of resilience on health care organizations, development of preventive therapies and treatment of posttraumatic stress disorder for critical care nurses, and the most appropriate mechanism to disseminate and implement strategies to address posttraumatic stress disorder.

The Connor-Davidson Resilience Scale in Critical Care Nurses: A Psychometric Analysis

OBJECTIVE

(a) To investigate the factor structure of the Connor-Davidson Resilience Scale (CD-RISC) in critical care nurses, using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) and (b) to assess reliability and known group differences of the CD-RISC on critical care nurses.

METHODS

CD-RISC surveys were collected on 744 critical care nurses across the United States. An abridged version of the CD-RISC was used for the EFA and CFA. Further reliability and known group differences were also tested.

RESULTS

EFA identified 3 factors with eigenvalues >1.0 and an explained variance of 59%. The factors were labeled personal competence, perseverance, and leadership, and each factor had salient loadings. The 3-factor CFA provided good fit to the data, χ(2) = 243.1, p < .001; RMSEA = .062; CFI = .935, although correlations among the 3 factors were high (.78-.86). A 1-factor model was subsequently tested but did not produce a better fit, and model comparison analyses supported retention of the 3-factor model. Known group differences was supported as intensive care unit (ICU) nurses with a diagnosis of posttraumatic stress disorder (PTSD) had significantly lower total resilience scores (M = 75.43) compared to those without a diagnosis of PTSD (M = 83.21; t = 5.01; p < .001).

DISCUSSION

The current investigation found that the 3-factor structure provided the best fit for the data on the abridged version of the CD-RISC in a population of ICU nurses. Analyses also supported the reliability and known group differences of the 16-item measure. Further research is needed to examine trait and capacity features of resilience as it relates to this population.

Severe Mental Illness and Acute Stress: A Study of Service Utilization in a Conflict Zone

Patients suffering from severe mental illness (SMI) are considered especially vulnerable to stress. In this study, their use of acute stress services in a military context affecting civilian populations was assessed, using naturally occurring data. The proportion of patients with a previously known SMI, defined as any chronic psychotic disorder or bipolar disorder, among all civilians examined at a center for treatment of stress during a military conflict versus at the ER in usual times, was compared, using the Chi square statistical test. Among 354 subjects examined at the center for treatment of stress, 12 had a SMI diagnosis. Among 404 subjects examined at the ER in usual times, 16 had a SMI diagnosis. Patients with SMI were under-represented, but not in a statistically significant manner, at the center for treatment of stress (χ² = 0.31, p = ns). Although these results may imply that patients with SMI are not more vulnerable to external stress than the general population, we believe that they may have difficulties in seeking immediate help in such traumatogenic contexts. In order to reduce the occurrence of PTSD and gain efficacy in the treatment of the primary disorder, psychiatric services should perhaps make a reaching out effort to identify and examine these patients in the community. .

Cognitive-behaviour therapy for post-traumatic stress in schizophrenia. A randomized controlled trial

BACKGROUND

There is limited evidence for effective interventions in the treatment of post-traumatic stress symptoms within individuals diagnosed with schizophrenia. Clinicians have concerns about using exposure treatments with this patient group. The current trial was designed to evaluate a 16-session cognitive restructuring programme, without direct exposure, for the treatment of post-traumatic stress symptoms specifically within individuals diagnosed with schizophrenia.

METHOD

A multicentre randomized controlled single-blinded trial with assessments at 0 months, 6 months (post-treatment) and 12 months (follow-up) was conducted. A total of 61 participants diagnosed with schizophrenia and exhibiting post-traumatic stress symptoms were recruited. Those randomized to treatment were offered up to 16 sessions of cognitive-behaviour therapy (CBT, including psychoeducation, breathing training and cognitive restructuring) over a 6-month period, with the control group offered routine clinical services. The main outcome was blind rating of post-traumatic stress symptoms using the Clinician Administered PTSD Scale for Schizophrenia. Secondary outcomes were psychotic symptoms as measured by the Positive and Negative Symptom Scale and the Psychotic Symptom Rating Scale.

RESULTS

Both the treatment and control groups experienced a significant decrease in post-traumatic stress symptoms over time but there was no effect of the addition of CBT on either the primary or secondary outcomes.

CONCLUSIONS

The current trial did not demonstrate any effect in favour of CBT. Cognitive restructuring programmes may require further adaptation to promote emotional processing of traumatic memories within people diagnosed with a psychotic disorder.

Serum brain-derived neurotrophic factor (BDNF) concentrations in pregnant women with post-traumatic stress disorder and comorbid depression

There is accumulating evidence for the role of brain-derived neurotrophic factor (BDNF) in the pathophysiology of depression. However, the role of BDNF in the pathophysiology of post-traumatic stress disorder (PTSD) remains controversial, and no study has assessed BDNF concentrations among pregnant women with PTSD. We examined early-pregnancy BDNF concentrations among women with PTSD with and without depression. A total of 2928 women attending prenatal care clinics in Lima, Peru, were recruited. Antepartum PTSD and depression were evaluated using PTSD Checklist-Civilian Version (PCL-C) and Patient Health Questionnaire-9 (PHQ-9) scales, respectively. BDNF concentrations were measured in a subset of the cohort (N = 944) using a competitive enzyme-linked immunosorbent assay (ELISA). Logistic regression procedures were used to estimate odds ratios (OR) and 95 % confidence intervals (95 % CI). Antepartum PTSD (37.4 %) and depression (27.6 %) were prevalent in this cohort of low-income pregnant Peruvian women. Approximately 19.9 % of participants had comorbid PTSD-depression. Median serum BDNF concentrations were lower among women with comorbid PTSD-depression as compared with women without either condition (median [interquartile range], 20.44 [16.97-24.30] vs. 21.35 [17.33-26.01] ng/ml; P = 0.06). Compared to the referent group (those without PTSD and depression), women with comorbid PTSD-depression were 1.52-fold more likely to have low (<25.38 ng/ml) BDNF concentrations (OR = 1.52; 95 % CI 1.00-2.31). We observed no evidence of reduced BDNF concentrations among women with isolated PTSD. BDNF concentrations in early pregnancy were only minimally and non-significantly reduced among women with antepartum PTSD. Reductions in BDNF concentrations were more pronounced among women with comorbid PTSD-depression.

Trauma-Focused Treatment in PTSD Patients With Psychosis: Symptom Exacerbation, Adverse Events, and Revictimization

OBJECTIVES

Most clinicians refrain from trauma treatment for patients with psychosis because they fear symptom exacerbation and relapse. This study examined the negative side effects of trauma-focused (TF) treatment in patients with psychosis and posttraumatic stress disorder (PTSD).

METHODS

Analyses were conducted on data from a single-blind randomized controlled trial comparing TF treatment (N = 108; 8 sessions prolonged exposure or eye movement desensitization) and waiting list (WL; N = 47) among patients with a lifetime psychotic disorder and current chronic PTSD. Symptom exacerbation, adverse events, and revictimization were assessed posttreatment and at 6-month follow-up. Also investigated were symptom exacerbation after initiation of TF treatment and the relationship between symptom exacerbation and dropout.

RESULTS

Any symptom exacerbation (PTSD, paranoia, or depression) tended to occur more frequently in the WL condition. After the first TF treatment session, PTSD symptom exacerbation was uncommon. There was no increase of hallucinations, dissociation, or suicidality during the first 2 sessions. Paranoia decreased significantly during this period. Dropout was not associated with symptom exacerbation. Compared with the WL condition, fewer persons in the TF treatment condition reported an adverse event (OR = 0.48, P = .032). Surprisingly, participants receiving TF treatment were significantly less likely to be revictimized (OR = 0.40, P = .035).

CONCLUSIONS

In these participants, TF treatment did not result in symptom exacerbation or adverse events. Moreover, TF treatment was associated with significantly less exacerbation, less adverse events, and reduced revictimization compared with the WL condition. This suggests that conventional TF treatment protocols can be safely used in patients with psychosis without negative side effects.

Intrusive prospective imagery, posttraumatic intrusions and anxiety in schizophrenia

Trauma exposure and intrusive thoughts are commonly reported in both schizophrenia and posttraumatic stress disorder (PTSD). Information processing accounts suggest that intrusions occur in the two conditions as a result of insufficient state and/or trait contextual processing in long-term memory. Most research has focused on intrusions about past events, while growing evidence suggests that intrusions about prospective imagined events warrants further investigation. Prospective intrusive imagery has yet to be examined in psychotic disorders but could provide crucial information regarding the aetiology and maintenance of psychotic symptoms. The current study examines the role of prospective intrusive imagery, posttraumatic intrusions and anxiety in schizophrenia. Fifty-seven participants (30 patients and 27 healthy controls) completed measures of trauma, PTSD, anxiety, general non-affective use of imagery, and intrusive prospective imagery. Patients reported significantly more intrusive prospective imagery relative to control participants but, importantly, not greater use of general non-affective imagery. Intrusive prospective imagery was associated with posttraumatic intrusions and anxiety in schizophrenia. The findings are consistent with information processing models of intrusions and psychosis, and provide novel insights for theoretical accounts, clinical formulation and therapeutic targets for psychotic symptoms in schizophrenia.

Epidemiology of trauma: Childhood adversities, neighborhood problems, discrimination, chronic strains, life events, and daily hassles among people with a severe mental illness

Trauma during childhood and adolescence is a common event among people with a serious psychological disorder. Few studies assess a wide range of stressors for this population. This is surprising given that these stressful events are implicated in poorer outcomes related to course and treatment of mental health problems. This study of 214 people with serious mental illness examines the prevalence of childhood traumas, perceived neighborhood problems, discrimination, chronic strains, negative life events, and daily hassles. We use regression analyses to determine if these stressors are associated with quality of life. Results show that 95% of the sample report at least one childhood adversity. Perceived neighborhood problems, experiences of discrimination, chronic strains, life events, and daily hassles were also common. Examining the relationship between demographic factors and stressors suggests that older respondents, Whites, those who have never been married, and people diagnosed with Schizophrenia reported fewer stressors compared to those who are older, non-White, ever married, or suffering from other types of mental health problems. Finally, three of the six types of stressors were related to lower quality of life and depression. We discuss the implications of these findings for the treatment of severe psychological problems.