The distribution of psychosis, ICD-11 PTSD and complex PTSD symptoms among a trauma-exposed UK general population sample

Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR): A New Modular Treatment for ICD-11 Complex Posttraumatic Stress Disorder (CPTSD)

ICD-11 Complex Posttraumatic Stress Disorder (CPTSD) is a relatively new condition; therefore, there is limited available evidence for its treatment. Prior to the recognition of CPTSD as a separate trauma condition, people who met criteria were often diagnosed with multiple co-morbid conditions such as PTSD, anxiety, depression, and emotional dysregulation difficulties. In the absence of a coherent evidence base, treatment tended to involve multiple treatments for these multiple conditions or lengthy phase-based interventions, often delivered in an integrative fashion, which was not standardized. In this paper, we present Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR), a new flexible multi-modular approach for the treatment of CPTSD and its transdiagnostic symptoms. ESTAIR is consistent with trauma-informed and patient-centered care, which highlights the importance of patient choice in identification and sequencing in targeting CPTSD symptoms. Directions for future research are discussed.

Prevalence, service use and clinical correlates of hallucinations and delusions in an out-patient population from India

BACKGROUND

Despite the persistent public health problem of positive psychotic symptoms, understanding of symptom specific prevalence rates, clinical correlates and service utilisation are sparse.

AIMS

The current study aimed to establish prevalence, clinical and service utilisation correlates of hallucinations and delusions in people accessing outpatient clinics in Tamil Nadu, India.

METHODS

Secondary patient data from outpatient clinics, over a 12-month period, in 2016, was used for analysis (N = 917). Based on the presence of positive psychotic symptoms (PPSx), the sample was divided into four groups for analysis- hallucinations-only (H), delusions-only (D), both hallucinations and delusions (HD) and neither PPSx (N-PPSx).

RESULTS

Findings indicate that the most prevalent PPSx were hallucinations (10.7%) however, barriers to service utilisation and clinical correlates were associated predominantly with the D and the HD group; as was severe work impairment. Yet, this group was most likely to remain with psychiatric services. Lastly, diagnostic challenges were apparent within the sample.

CONCLUSIONS

The study revealed that despite more barriers to service utilisation, persons with PPSx remain in contact with services. Yet prognosis remains only moderate at best, indicating other mediating and underlying factors impeding recovery may be interplaying and, therefore, a need for enhanced biopsychosocial approaches.

Suicidality in patients with post-traumatic stress disorder and its association with receipt of specific secondary mental healthcare treatments

BACKGROUND

Post-traumatic stress disorder (PTSD) is a risk factor for suicidality (suicidal ideation, and suicide attempt). This study described the prevalence of suicidality amongst a representative sample of individuals with PTSD and the association between suicidality and receipt of five PTSD treatments.

METHODS

We analysed deidentified data for patients being treated for PTSD at Camden and Islington NHS Foundation Trust between 2009 and 2017 obtained via the Clinical Record Interactive Search tool. We described the sample's sociodemographic and clinical characteristics and used stepwise logistic regression to investigate the association between suicidality and receipt of four, specific PTSD treatments: psychotherapy, antidepressant/antianxiety medication, antipsychotics, benzodiazepines. We used Cox proportional hazards regression to investigate the association between suicidality and hospital/crisis team admission.

RESULTS

Of 745 patients diagnosed with PTSD, 60% received psychotherapy and 66% received psychotropic medication. Those who reported suicidality (6%) were no more likely than those who did not to be prescribed antidepressant/antianxiety medication, but were more likely to receive antipsychotics (AOR = 2.27, 95% CI 1.15 - 4.47), benzodiazepines (AOR 2.28, 95% CI 1.17 - 4.44), psychotherapy (AOR 2.60, 95% CI 1.18 - 5.73) and to be admitted to hospital/crisis team (AOR 2.84, 95% 1.82 - 4.45).

CONCLUSION

In this sample, patients with PTSD and suicidality were more likely to receive psychiatric medication, psychotherapy and psychiatric admission than those who were not suicidal. Overall patients were more likely to receive psychotropic medication than psychotherapy. Adherence to clinical guidelines is important in this population to improve treatment outcomes and reduce the risk of suicide.KEY POINTSNICE guidelines recommend psychological therapy be first line treatment for PTSD, yet we identified that fewer people diagnosed with PTSD received therapy compared to psychotropic medication.Patients with suicidality were more likely to receive antipsychotics and benzodiazepines, yet not antidepressant/antianxiety medication although given that suicidality is characteristic of severe depression, it might be assumed from stepped care models that antidepressant/antianxiety medication be prescribed before antipsychotics.The high proportion of patients prescribed antipsychotics suggests a need for better understanding of psychosis symptoms among trauma-exposed populations.Identifying which combinations of symptoms are associated with suicidal thoughts could help tailor trauma-informed approaches to discussing therapy and medication.

Complex post-traumatic stress disorder

Complex post-traumatic stress disorder (complex PTSD) is a severe mental disorder that emerges in response to traumatic life events. Complex PTSD is characterised by three core post-traumatic symptom clusters, along with chronic and pervasive disturbances in emotion regulation, identity, and relationships. Complex PTSD has been adopted as a new diagnosis in the ICD-11. Individuals with complex PTSD typically have sustained or multiple exposures to trauma, such as childhood abuse and domestic or community violence. The disorder has a 1-8% population prevalence and up to 50% prevalence in mental health facilities. Progress in diagnostics, assessment, and differentiation from post-traumatic stress disorder and borderline personality disorder is reported, along with assessment and treatment of children and adolescents. Studies recommend multicomponent therapies starting with a focus on safety, psychoeducation, and patient-provider collaboration, and treatment components that include self-regulatory strategies and trauma-focused interventions.

Exploring complex-PTSD comorbidity in trauma-exposed Northern Ireland veterans

BACKGROUND

Complex posttraumatic stress disorder (CPTSD) describes the results of complex, prolonged, and/or inescapable trauma, and is typified by avoidance, re-experiencing, sense of threat, affect dysregulation, negative self-concept, and interpersonal disturbances. Additionally, CPTSD is highly comorbid with other common psychopathologies.

OBJECTIVES

A study was conducted in a trauma-exposed UK Armed Forces Veteran population resident in Northern Ireland (N = 638, NI) to determine the prevalence of CPTSD and comorbid associations.

METHODS

Data from the Northern Ireland Veterans Health and Wellbeing Study (NIVHWS), including self-report data describing traumatic stress, depression, anxiety, and suicidality, were used in a latent class analysis to identify distinct profiles of symptomology in the sample, and in a multinomial logistic regression to identify comorbidities associated with class membership.

RESULTS

Three distinct classes emerged: a low endorsement 'baseline' class (36%), a 'Moderate Symptomatic' class (27%), and a high endorsement 'Probable CPTSD' class (37%). Both the Moderate Symptomatic and CPTSD classes were predicted by cumulative trauma exposure. Depression was highly comorbid (OR = 23.06 in CPTSD), as was anxiety (OR = 22.05 in CPTSD) and suicidal ideation (OR = 4.32 in CPTSD), with suicidal attempt associated with the CPTSD class (OR = 2.51).

CONCLUSIONS

Cases of probable CPTSD were more prevalent than cases of probable posttraumatic stress disorder (PTSD) without Difficulties in Self-Organisation (DSO) symptoms in a UK Armed Forces veteran sample, were associated with repeated/cumulative trauma, and were highly comorbid across a range of psychopathologies. Findings validate previous literature on CPTSD and indicate considerable distress and thus need for support in UK Armed Forces veterans resident in NI.

Protective Factors Associated With Post-traumatic Outcomes in Individuals With Experiences of Psychosis

Trauma and trauma-specific mental health difficulties (e.g., post-traumatic stress disorder) are highly prevalent in people with psychosis. However, not everyone develops post-traumatic symptoms, and some people even experience post-traumatic growth (PTG) following trauma. It is important to identify which protective factors are associated with less severe trauma symptoms and/or positive outcomes to inform the development and implementation of interventions fostering these variables. Eighty-five patients with experiences of psychosis took part in a cross-sectional study. They were administered questionnaires measuring exposure to traumatic events, symptoms of PTSD and complex PTSD and potential protective factors assumed to be associated with lower vulnerability for post-traumatic symptoms and higher post-traumatic growth (trait resilience, secure attachment, social support, adaptive coping, optimism, general self-efficacy). Multiple hierarchical regression showed that some of these protective factors, in particular optimism, were associated with lower post-traumatic symptoms, explaining 21% of the variance in complex PTSD symptoms and 16% of the variance in PTSD symptoms. However, the hypothesized protective factors, in particular resilience and adaptive coping, explained a considerably larger proportion of variance in PTG (44%). Our results suggest that whilst these variables provide only moderate protection from the vulnerability to experience post-traumatic stress, they may play an important role in allowing people to find meaning despite multiple traumas and subsequently lead more fulfilling lives. Therapies targeting the emotional and psychological consequences of trauma in people with psychosis might benefit from the integration of intervention strategies to enhance these additional psychological protective factors, which in turn may lead to positive treatment outcomes beyond the mere reduction of post-traumatic stress symptoms.

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.

A systematic literature review of factor analytic and mixture models of ICD-11 PTSD and CPTSD using the International Trauma Questionnaire

The 11th version of the International Classification of Diseases (ICD-11; WHO, 2018) describes two distinct trauma related disorders, Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD). This review aims to summarise and synthesize evidence from factor analytic and mixture modelling studies that have investigated the latent structure of the International Trauma Questionnaire. A systematic search of PsycInfo, Web of Science, Scopus and Pubmed databases was conducted to identify relevant articles. Thirty-three studies met the inclusion criteria for this systematic review. The latent structure of the ITQ was best represented by two models; a correlated six-factor model (Re-experiencing, Avoidance, Threat, Affect Dysregulation, Negative Self Concept, and Disturbed Relationships) and a two-factor second-order model (PTSD and Disturbances in Self-Organization). Mixture model studies consistently identified distinct classes representing those displaying PTSD and CPTSD symptoms. Numerous studies demonstrated support for the factorial and discriminant validity of PTSD and CPTSD when analysed in conjunction with other variables. Overall, support was found for the conceptual coherence of PTSD and CPTSD as empirically distinguishable disorders, as measured by the ITQ. The available evidence demonstrates that the ITQ is a valid measure of ICD-11 PTSD and CPTSD. Recommendations for future research are included.

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.

Five Applications of Narrative Exposure Therapy for Children and Adolescents Presenting With Post-Traumatic Stress Disorders

Narrative exposure therapy (NET) is an individual therapeutic approach that has an emerging evidence base for children. It was initially trialed with refugee and asylum seeking populations, in low, middle and high-income settings, utilizing either lay or professional therapists. The results of treatment trials for PTSD in refugee children with NET (or the child "KIDNET" adaptation) demonstrates how this is an effective intervention, is scalable and culturally dexterous. This paper describes, in five cases from clinical practice settings, the applicability of NET into broader, routine practice. The cases outlined describe the use of NET with adolescents with: autism spectrum disorders, psychotic symptoms, and intellectual disabilities; histories of forced abduction into child soldiering; complex physical health problems needing multiple interventions; and victims of childhood sexual abuse. The cases are discussed with regards to how the NET lifeline facilitated engagement in treatment, practical adaptations for those with intellectual disabilities and how NET, with its relatively short training for health professionals, can be modified to different contexts and presentations. The importance of improving access to care is discussed to ensure that young people are supported with their most complex and disruptive memories.