Linking posttraumatic stress disorder and psychosis: a look at epidemiology, phenomenology, and treatment

Relationships between trauma types and psychotic symptoms: A network analysis of patients with psychotic disorders in a large, multi-country study in East Africa

BACKGROUND

The link between trauma exposure and psychotic disorders is well-established. Further, specific types of trauma may be associated with specific psychotic symptoms. Network analysis is an approach that can advance our understanding of the associations across trauma types and psychotic symptoms.

METHODS

We conducted a network analysis with data from 16,628 adult participants (mean age [standard deviation] = 36.3 years [11.5]; 55.8% males) with psychotic disorders in East Africa recruited between 2018 and 2023. We used the Life Events Checklist and the Mini International Neuropsychiatric Interview to determine whether specific trauma types experienced over the life course and specific psychotic symptoms were connected. We used an Ising model to estimate the network connections and bridge centrality statistics to identify nodes that may influence trauma types and psychotic symptoms.

RESULTS

The trauma type "exposure to a war zone" had the highest bridge strength, betweenness, and closeness. The psychotic symptom "odd or unusual beliefs" had the second highest bridge strength. Exposure to a war zone was directly connected to visual hallucinations, odd or unusual beliefs, passivity phenomena, and disorganized speech. Odd or unusual beliefs were directly connected to transportation accidents, physical assault, war, and witnessing sudden accidental death.

CONCLUSION

Specific trauma types and psychotic symptoms may interact bidirectionally. Screening for psychotic symptoms in patients with war-related trauma and evaluating lifetime trauma in patients with odd or unusual beliefs in clinical care may be considered points of intervention to limit stimulating additional psychotic symptoms and trauma exposure. This work reaffirms the importance of trauma-informed care for patients with psychotic disorders.

Functional Connectivity of the Auditory Cortex in Women With Trauma-Related Disorders Who Hear Voices

BACKGROUND

Voice hearing (VH) is a transdiagnostic experience that is common in trauma-related disorders. However, the neural substrates that underlie trauma-related VH remain largely unexplored. While auditory perceptual dysfunction is among the abnormalities implicated in VH in schizophrenia, whether VH in trauma-related disorders also involves auditory perceptual alterations is unknown.

METHODS

We investigated auditory cortex (AC)-related functional connectivity (FC) in 65 women with trauma-related disorders stemming from childhood abuse with varying severities of VH. Using a novel, computationally driven and individual-specific method of functionally parcellating the brain, we calculated the FC of 2 distinct AC subregions-Heschl's gyrus (corresponding to the primary AC) and lateral superior temporal gyrus (in the nonprimary AC)-with both the cerebrum and cerebellum. Then, we measured the association between VH severity and FC using leave-one-out cross-validation in the cerebrum and voxelwise multiple regression analyses in the cerebellum.

RESULTS

We found that VH severity was positively correlated with left lateral superior temporal gyrus-frontoparietal network FC, while it was negatively correlated with FC between the left lateral superior temporal gyrus and both cerebral and cerebellar representations of the default mode network. VH severity was not predicted by FC of the left Heschl's gyrus or right AC subregions.

CONCLUSIONS

Our findings point to altered interactions between auditory perceptual processing and higher-level processes related to self-reference and executive functioning. This is the first study to show alterations in auditory cortical connectivity in trauma-related VH. While VH in trauma-related disorders appears to be mediated by brain networks that are also implicated in VH in schizophrenia, the results suggest a unique mechanism that could distinguish VH in trauma-related disorders.

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

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

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.

Does Post-traumatic Stress Disorder Impact Treatment Outcomes within a Randomised Controlled Trial of Mitochondrial Agents for Bipolar Depression?

Objective

Bipolar disorder often co-occurs with post-traumatic stress disorder, yet few studies have investigated the impact of post-traumatic stress disorder in bipolar disorder on treatment outcomes. The aim of this sub-analysis was to explore symptoms and functioning outcomes between those with bipolar disorder alone and those with comorbid bipolar disorder and post-traumatic stress disorder.

Methods

Participants (n = 148) with bipolar depression were randomised to: (i) N-acetylcysteine alone; (ii) a combination of nutraceuticals; (iii) or placebo (in addition to treatment as usual) for 16 weeks (＋4 weeks discontinuation). Differences between bipolar disorder and comorbid bipolar disorder and post-traumatic stress disorder on symptoms and functioning at five timepoints, as well as on the rate of change from baseline to week 16 and baseline to week 20, were examined.

Results

There were no baseline differences between bipolar disorder alone and comorbid bipolar disorder and post-traumatic stress disorder apart from the bipolar disorder alone group being significantly more likely to be married (p = 0.01). There were also no significant differences between bipolar disorder alone and comorbid bipolar disorder and post-traumatic stress disorder on symptoms and functioning.

Conclusion

There were no differences in clinical outcomes over time within the context of an adjunctive randomised controlled trial between those with bipolar disorder alone compared to those with comorbid bipolar disorder and post-traumatic stress disorder. However, differences in psychosocial factors may provide targets for areas of specific support for people with comorbid bipolar disorder and post-traumatic stress disorder.

A narrative review of psychological theories of post-traumatic stress disorder, voice hearing, and other psychotic symptoms

BACKGROUND

Most voice hearers report childhood trauma. Many voice hearers report comorbid post-traumatic stress symptoms and that the content of their voices (auditory verbal hallucinations) is directly (voices repeat phrases spoken by perpetrators) or indirectly (voice content and trauma is thematically similar) related to their trauma. The factors that maintain trauma-related voices are unknown, and there is limited research in this area. This study aimed to identify potential maintaining factors of trauma-related voices by reviewing models of post-traumatic stress disorder (PTSD) and positive symptoms of psychosis.

METHOD

Models of PTSD and positive symptoms were reviewed to identify potential factors that are unique and common to both sets of symptoms.

RESULTS

We reviewed 10 models of PTSD, 4 models of positive symptoms, and 2 trauma-informed models of voice hearing. One model provided a theoretical explanation of different types of trauma-related voices. Twenty-one factors were extracted from 16 theoretical models. No existing model incorporated all these factors.

DISCUSSION

Existing PTSD and positive symptom models present a range of common and unique factors. There may be value in extending existing integrative models to include a broader range of potential factors that could explain different pathways to, and expressions of, trauma-related voices. A future research agenda is presented to investigate how such an extension could lead to more complete individualized case formulations and targeted treatments.

Factors associated with late-life psychosis in primary care older adults without a diagnosis of dementia

PURPOSE

The epidemiology of late-life psychosis (LLP) remains unclear comparatively to early-onset psychosis. The study aims to estimate the prevalence and incidence of LLP over a 3-year period and examine the correlates of LLP in community-living older adults aged ≥ 65 years recruited in primary care.

METHODS

Study sample included N = 1481 primary care older adults participating in the Étude sur la Santé des Aînés (ESA)-Services study. Diagnoses were obtained from health administrative and self-reported data in the 3 years prior and following baseline interview. The prevalence and incidence of LLP (number of cases) were identified in the 3-year period following interview. Participants with dementia or psychosis related to dementia were excluded. Logistic regressions were used to ascertain the correlates of LLP as function of various individual and health system factors.

RESULTS

The 3-year prevalence and incidence of LLP was 4.7% (95% CI = 3.64-5.81) and 2.8% (95% CI = 1.99-3.68), respectively. Factors associated with both prevalent and incident LLP included functional status, number of physical diseases, hospitalizations, continuity of care and physical activity. Older age and the presence of suicidal ideation were associated with incident LLP, while higher education, a depressive disorder and a history of sexual assault were associated with persistent cases.

CONCLUSIONS

Results highlight the importance of LLP in primary care older adult patients without dementia. Health system factors were consistent determinants of prevalent and incident LLP, suggesting the need for better continuity of care in at-risk primary care older adults.

Differentiating Childhood-Onset Schizophrenia From Other Childhood Disorders

Childhood-onset schizophrenia (COS) is a rare disorder in which symptoms of schizophrenia occur before the age of 13 years. This disorder often has a complicated presentation that can mimic other childhood disorders including post-traumatic stress disorder (PTSD), autism spectrum disorder (ASD), major depressive disorder (MDD) with psychosis, and generalized anxiety disorder (GAD) among others. This is further complicated by the low prevalence rate of COS which limits understanding of the disorder. Accurate and timely diagnosis is crucial as failure to do so has adverse implications for long-term treatment outcomes and prognosis. In this study, a rare case of a 12-year-old girl with childhood-onset schizophrenia and key findings that help differentiate it from other childhood disorders are reviewed to guide diagnosis and treatment.

A culturally adapted brief intervention for post-traumatic stress disorder in people with severe mental illness in Botswana: protocol for a randomised feasibility trial

BACKGROUND

Research consistently reports elevated rates of exposure to traumatic events and post-traumatic stress disorder (PTSD) in people with severe mental illness (SMI). PTSD may be adequately managed with psychotherapy; however, there is a gap when it comes to management in culturally diverse settings like Botswana. This paper describes a study protocol whose aim is to culturally adapt the BREATHE intervention, a brief psychological intervention for people living with comorbid PTSD and SMI that was developed and tested in the USA; assess the feasibility and acceptability of the adapted BREATHE intervention and explore its efficacy.

METHODS

The study will be conducted in three phases using a mixed methods approach. The first phase will identify and describe the most common traumatic experiences and responses to traumatic experiences, amongst patients with SMI, and patients' and mental health care providers' perceptions about suitable PTSD interventions for Botswana. The second phase will entail cultural adaption of the intervention using findings from phase 1, and the third phase will be a pilot trial to assess the feasibility and acceptability of the culturally adapted intervention and explore its efficacy. Quantitative and qualitative data will be analysed using basic descriptive statistics and thematic analysis, respectively.

DISCUSSION

Literature highlights cultural variations in the expression and management of mental illness suggesting the need for culturally adapted interventions. The findings of this feasibility study will be used to inform the design of a larger trial to assess the efficacy of an adapted brief intervention for PTSD in patients with SMI in Botswana.

TRIAL REGISTRATION

Clinicaltrials.gov registration: NCT04426448 . Date of registration: June 7, 2020.

Trauma―Focused Treatment for PTSD With Comorbid Psychosis: A Case Report

Post-traumatic stress disorder is often a condition left untreated in patients also meeting criteria for psychotic disorders. While many clinicians who treat patients with these co-occurring conditions choose to avoid treatment targeting symptoms of PTSD for fear of de-stabilizing these individuals or exacerbating psychotic symptomatology, little is currently known about how patients respond to treatment for PTSD in the context of ongoing psychotic symptoms. Additionally, research is scarce regarding the clinical profile of individuals who develop psychotic symptoms secondary to a traumatic stressor, in the absence of any premorbid symptomatology. The purpose of this case report is to outline the case of an individual, “Mary” who developed psychotic symptoms secondary to a traumatic stressor in her middle age and to describe her response to treatment targeting her symptoms of PTSD. Mary presented with core symptoms of PTSD that emerged following a traumatic car crash. She developed psychotic symptoms (auditory and visual hallucinations) several weeks later. Mary underwent a treatment course of Prolonged Exposure targeting her symptoms of PTSD, with careful work done to monitor any changes in psychotic symptomatology while engaging in this treatment. Standardized measures such as the Post-traumatic Stress Disorder Checklist-5 (PCL-5) and the Psychotic Symptom Rating Scales were administered to assess Mary’s progress throughout treatment. This case report provides a comprehensive summary of Mary’s 16-week course of Prolonged Exposure therapy, which resulted in a significant reduction in PTSD symptomatology as demonstrated by a 72% decrease in scores on the PCL-5 from the initiation to the conclusion of treatment.

Intimate Partner Violence Among Patients Diagnosed With Severe Mental Disorder

Intimate partner violence (IPV) has a remarkable impact on mental health and is common in people diagnosed with severe mental disorders (SMDs). Data of 102 outpatients were collected from clinical records and the Traumatic Life Events Questionnaire (TLEQ). Global estimation of lifetime IPV exposure was obtained by combining answers to selected TLEQ questions about physical, psychological, and sexual IPV. Overall, 24.5% of the participants reported at least one lifetime episode of IPV victimization. Female gender (odds ratio [OR] = 3.15, p = 0.016) and childhood trauma (OR = 4.7, p = 0.002) significantly increased the likelihood of IPV victimization. Conversely, posttraumatic stress disorder was not significantly increased in IPV victims. These findings are in line with current literature and suggest a remarkable and transdiagnostic prevalence of lifetime IPV victimization in SMD. Gender, childhood trauma, and SMD are relevant factors in IPV analysis and prevention. Diathesis of trauma, psychosocial vulnerability to revictimization and intersectional feminist theory help explain our results.

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

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

Victimization of People With Severe Mental Illness Outside and Within the Mental Health Care System: Results on Prevalence and Risk Factors From a Multicenter Study

We performed a cross-sectional study using a self-reporting survey to assess lifetime violent and non-violent victimization in people with severe mental illness experienced both inside (i.e., any service providing mental health care such as psychiatric hospitals, psychosocial rehabilitative programs, or outpatient care) and outside (i.e., in the personal life of the participants) of the mental health care system. We recruited 170 participants from 20 community mental health facilities. We built logistic regression models to assess potential risk factors for victimization inside the mental health care system. Outside of the mental health care system, the most commonly reported events were theft (n=93, 54.7%), physical violence without use of a weapon (n=87, 51.2%), and sexual harassment (n=82, 50.6%). Within the mental health care system, most commonly reported incidents were theft (n=68, 40.0%), sexual assault (n=18, 10.6%), and physical violence (n=47, 27.7%) by other patients or staff. Significant risk factors for specific victimization events inside the mental health care system were psychotic disorder, victimization in childhood and youth, female gender, number of hospitalizations, and duration of illness. Findings call for increased attention to victimization of people with severe mental illness, especially within the mental health care system as such victimization events may severely impact patients' trajectories.

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

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

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

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

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

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

Restless 'rest': intrinsic sensory hyperactivity and disinhibition in post-traumatic stress disorder

Post-traumatic stress disorder is characterized by exaggerated threat response, and theoretical accounts to date have focused on impaired threat processing and dysregulated prefrontal-cortex-amygdala circuitry. Nevertheless, evidence is accruing for broad, threat-neutral sensory hyperactivity in post-traumatic stress disorder. As low-level, sensory processing impacts higher-order operations, such sensory anomalies can contribute to widespread dysfunctions, presenting an additional aetiological mechanism for post-traumatic stress disorder. To elucidate a sensory pathology of post-traumatic stress disorder, we examined intrinsic visual cortical activity (based on posterior alpha oscillations) and bottom-up sensory-driven causal connectivity (Granger causality in the alpha band) during a resting state (eyes open) and a passive, serial picture viewing state. Compared to patients with generalized anxiety disorder (n = 24) and healthy control subjects (n = 20), patients with post-traumatic stress disorder (n = 25) demonstrated intrinsic sensory hyperactivity (suppressed posterior alpha power, source-localized to the visual cortex-cuneus and precuneus) and bottom-up inhibition deficits (reduced posterior→frontal Granger causality). As sensory input increased from resting to passive picture viewing, patients with post-traumatic stress disorder failed to demonstrate alpha adaptation, highlighting a rigid, set mode of sensory hyperactivity. Interestingly, patients with post-traumatic stress disorder also showed heightened frontal processing (augmented frontal gamma power, source-localized to the superior frontal gyrus and dorsal cingulate cortex), accompanied by attenuated top-down inhibition (reduced frontal→posterior causality). Importantly, not only did suppressed alpha power and bottom-up causality correlate with heightened frontal gamma power, they also correlated with increased severity of sensory and executive dysfunctions (i.e. hypervigilance and impulse control deficits, respectively). Therefore, sensory aberrations help construct a vicious cycle in post-traumatic stress disorder that is in action even at rest, implicating dysregulated triangular sensory-prefrontal-cortex-amygdala circuitry: intrinsic sensory hyperactivity and disinhibition give rise to frontal overload and disrupt executive control, fuelling and perpetuating post-traumatic stress disorder symptoms. Absent in generalized anxiety disorder, these aberrations highlight a unique sensory pathology of post-traumatic stress disorder (ruling out effects merely reflecting anxious hyperarousal), motivating new interventions targeting sensory processing and the sensory brain in these patients.

Psychological Interventions for Post-traumatic Stress Symptoms in Psychosis: A Systematic Review of Outcomes

Individuals with severe mental health problems, such as psychosis, are consistently shown to have experienced high levels of past traumatic events. They are also at an increased risk of further traumatisation through victimization events such as crime and assault. The experience of psychosis itself and psychiatric hospitalization have also been recognized to be sufficiently traumatic to lead to the development of post-traumatic stress (PTS) symptoms. Rates of post-traumatic stress disorder (PTSD) are elevated in people with psychosis compared to the general population. The current guidance for the treatment of PTSD is informed by an evidence base predominately limited to populations without co-morbid psychiatric disorders. The systematic review therefore sought to present the current available literature on the use of psychological treatments targeting PTS symptoms in a population with a primary diagnosis of a psychotic disorder. The review aimed to investigate the effect of these interventions on PTS symptoms and also the effect on secondary domains such as psychotic symptoms, affect and functioning. Fifteen studies were identified reporting on cognitive behavior therapy, prolonged exposure, eye movement desensitisation and reprocessing and written emotional disclosure. The review provides preliminary support for the safe use of trauma-focused psychological interventions in groups of people with severe mental health problems. Overall, the interventions were found to be effective in reducing PTS symptoms. Results were mixed with regard to secondary effects on additional domains. Further research including studies employing sufficiently powered methodologically rigorous designs is indicated.

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. .

Psychotic-like experiences in a conflict-affected population: a cross-sectional study in South Sudan

PURPOSE

This study investigates the prevalence of psychotic-like experiences (PLEs) and examines exposure to potentially traumatic events and other relevant risk factors for PLEs in the general population of a conflict-affected, low-income country.

METHODS

We conducted a cross-sectional community based study of four Greater Bahr el Ghazal States, South Sudan (n = 1200). The Harvard Trauma Questionnaire was applied to investigate exposure to potentially traumatic events. The Mini-International Neuropsychiatric Interview was used to detect PLEs.

RESULTS

The estimated prevalence of lifetime PLEs was 23.3 % and the rate of PLEs which were evaluated as bizarre was 9.5 %. Exposure to higher number of potentially traumatic events, younger age, rural residency, being unemployed, not having a regular income and having traditional religion were significantly associated with having PLEs. PLEs were significantly associated with reporting of psychological distress when controlling for other covariates.

CONCLUSIONS

The finding of association between traumatic exposure and PLEs calls for greater attention to the diversity of negative mental health outcomes in conflict-affected populations.

Improving classification of psychoses

Psychosis has been recognised as an abnormal state in need of care throughout history and by diverse cultures. Present classifications of psychotic disorder remain based on the presence of specific psychotic symptoms, relative to affective and other symptoms, and their sequence and duration. Although extant diagnostic classifications have restricted validity, they have proven reliability and most clinicians and some patients find them useful. Moreover, these classifications have yet to be replaced by anything better. We propose that an expansion of the subgrouping approach inherent to classification will provide incremental improvement to present diagnostic constructs-as has worked in the rest of medicine. We also propose that subgroups could be created both within and across present diagnostic classifications, taking into consideration the potential value of continuous measures (eg, duration of psychotic symptoms and intelligence quotient). Health-care workers also need to work with service users and carers to develop and adapt approaches to diagnosis that are seen as helpful.

Ginsenoside Rb1 rescues anxiety-like responses in a rat model of post-traumatic stress disorder

Single prolonged stress (SPS), a rat model of post-traumatic stress disorder (PTSD), induces alterations in the hypothalamic-pituitary-adrenal axis. Korean red ginseng, whose major active component is ginsenoside Rb1 (GRb1), is one of the widely used traditional anxiolytics. However, the efficacy of GRb1 in alleviating PTSD-associated anxiety-like abnormalities has not been investigated. The present study used several behavioral tests to examine the effects of GRb1 on symptoms of anxiety in rats after SPS exposure and on the central noradrenergic system. Male Sprague-Dawley rats received GRb1 (10 or 30 mg/kg, i.p., once daily) during 14 days of SPS. Daily GRb1 (30 mg/kg) administration significantly increased the number and duration of open-arm visits in the elevated plus maze (EPM) test, reduced the anxiety index, increased the risk assessment, reduced grooming behaviors in the EPM test, and increased the total number of line crossings of an open field after SPS. The higher dose of GRb1 also blocked SPS-induced decreases in hypothalamic neuropeptide Y expression, increases in locus coeruleus tyrosine hydroxylase expression, and decreases in hippocampal mRNA expression of brain-derived neurotrophic factor. These findings suggest that GRb1 has anxiolytic-like effects on both behavioral and biochemical symptoms similar to those observed in patients with PTSD.

Glutamate and GABA imbalance promotes neuronal apoptosis in hippocampus after stress

Background

People who experience traumatic events have an increased risk of post-traumatic stress disorder (PTSD). However, PTSD-related pathological changes in the hippocampus and prefrontal cortex remain poorly understood.

Material/Methods

We investigated the effect of a PTSD-like animal model induced by severe stress. The experimental rats received 20 inescapable electric foot shocks in an enclosed box for a total of 6 times in 3 days. The physiological state (body weight and plasma corticosterone concentrations), emotion, cognitive behavior, brain morphology, apoptosis, and balance of gamma-aminobutyric acid (GABA) and glutamate in the hippocampus and prefrontal cortex were observed. Cell damages were examined with histological staining (HE, Nissl, and silver impregnation), while apoptosis was analyzed with flow cytometry using an Annexin V and propidium iodide (PI) binding and terminal deoxynucleotidyl transferase mediated-dUTP nick end labeling (TUNEL) method.

Results

In comparison with the sham litter-mates, the stressed rats showed decreased body weight, inhibition of hypothalamic-pituitary-adrenal (HPA) axis activation, increase in freezing response to trauma reminder, hypoactivity and anxiety-like behaviors in elevated plus maze and open field test, poor learning in Morris water maze, and shortened latency in hot-plate test. There were significant damages in the hippocampus but not in the prefrontal cortex. Imbalance between glutamate and GABA was more evident in the hippocampus than in the prefrontal cortex.

Conclusions

These results suggest that neuronal apoptosis in the hippocampus after severe traumatic stress is related to the imbalance between glutamate and GABA. Such modifications may resemble the profound changes observed in PTSD patients.

Pharmacotherapy for post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a serious mental illness of considerable importance from a public health perspective. Management of PTSD may involve the use of various treatment modalities, involving both nondrug treatments and pharmacotherapy. Nondrug treatment is regarded as the first-line option for PTSD and should be routinely incorporated into management plans for patients with PTSD. However, some patients do not achieve a sufficient response to nondrug therapy or are left with disabling residual symptoms in one or more areas. Antidepressants are currently the preferred medication for PTSD, with the most substantial evidence available to support the use of the selective serotonin reuptake inhibitors. Many patients with PTSD have symptoms that are resistant to initial drug treatment, meaning that it is often necessary to explore additional pharmacotherapy options to achieve optimal symptom control: antipsychotics, anti-adrenergic drugs, anxiolytics and anticonvulsants have all been advocated as treatments for PTSD. In addition to the management of core PTSD symptoms, it is also necessary for clinicians to address important associated comorbidities, most notably, substance-use disorders and mood disturbances. Interpretation of research studies of the efficacy and safety of PTSD pharmacotherapy is often difficult owing to methodological limitations and factors such as inclusion bias. Further research in fundamental neurosciences and pharmacogenomics may help to elucidate optimal pharmacotherapy options for PTSD in the future.

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

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

Childhood trauma and psychosis

Childhood trauma is a common occurrence and has been associated with psychosis and suggested as a risk factor leading to psychosis and schizophrenia in adulthood. This article introduces the scope of the problem and discusses the evidence for causal relationships between childhood adversities and increased risk for psychosis. The relationship between specific types of trauma and their association with specific psychotic symptoms is described, as well as the manifestations of co-occurring trauma effects and psychosis in adolescents. Clinical presentations and the use of diagnostic instruments, diagnostic comorbidities, and evidence-based psychotherapeutic interventions to treat effects of trauma in youth with psychotic illnesses are discussed.

Trauma and posttraumatic stress disorder among transition-age youth with serious mental health conditions

There is little information on trauma, posttraumatic stress disorder (PTSD), and associated risk factors in transition-age youth with mental health conditions. This study aimed at understanding the correlates and predictors of PTSD in 84 transition-age youth, between 16 and 21 years old, residing in supported community housing. Chi-square analyses and t tests were used to compare youth with a diagnosis of PTSD to those without a PTSD diagnosis. Stepwise logistic regression analyses were performed to identify unique predictors of PTSD. Of the 84 individuals, 79 (94%) reported a history of trauma, of whom 30 (36%) had PTSD. Sexual abuse was significantly associated with a PTSD diagnosis (r = .47) and the only unique predictor of PTSD (Cox r(2) = .20). Transition-age youth in supported community housing had higher rates of trauma exposure and PTSD than the general adolescent population, suggesting the need for routine assessment and treatment of PTSD in this population.

Prevalence of interpersonal trauma exposure and trauma-related disorders in severe mental illness

BACKGROUND

Interpersonal trauma exposure and trauma-related disorders in people with severe mental illness (SMI) are often not recognized in clinical practice.

OBJECTIVE

To substantiate the prevalence of interpersonal trauma exposure and trauma-related disorders in people with SMI.

METHODS

We conducted a systematic review of four databases (1980-2010) and then described and analysed 33 studies in terms of primary diagnosis and instruments used to measure trauma exposure and trauma-related disorders.

RESULTS

Population-weighted mean prevalence rates in SMI were physical abuse 47% (range 25-72%), sexual abuse 37% (range 24-49%), and posttraumatic stress disorder (PTSD) 30% (range 20-47%). Compared to men, women showed a higher prevalence of sexual abuse in schizophrenia spectrum disorder, bipolar disorder, and mixed diagnosis groups labelled as having SMI.

CONCLUSIONS

Prevalence rates of interpersonal trauma and trauma-related disorders were significantly higher in SMI than in the general population. Emotional abuse and neglect, physical neglect, complex PTSD, and dissociative disorders have been scarcely examined in SMI.

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

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

Posttraumatic stress disorder comorbidity and clinical implications in patients with severe mental illness

Traumatic experiences and posttraumatic stress disorder (PTSD) are more frequent in patients with serious mental illness than in the general population. This study included 102 patients with schizophrenia, bipolar disorder, and schizoaffective disorder, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Epidemiological and clinical data were collected using the Brief Psychiatric Rating Scale and Traumatic Life Events and Distressing Event questionnaires. We found a high number of traumatic experiences, and 15.1% of the patients met all criteria for PTSD. We found no differences based on diagnosis or sex, although there was a nonsignificant trend toward greater PTSD comorbidity in women. Among patients with serious mental illness and PTSD, 64.3% had made some attempt at suicide at some point in life, compared with 37.4% of patients without PTSD.

Subjective distress associated with sudden loss in clients with severe mental illness

Data from interviews with 276 community mental health clients diagnosed with a severe mental illness were used to examine the association between clients' subjective distress from sudden loss of a close friend or loved one and PTSD symptoms. Over three-quarters of these clients reported sudden losses in their lives, and regression analysis showed that distress related to sudden losses accounted for significant and unique variance in PTSD symptoms when all other sources of traumatic distress were controlled. Practitioners should routinely assess interpersonal losses among clients with SMI and offer brief interventions specifically aimed at helping clients cope with such losses.

Co-morbid PTSD and suicidality in individuals with schizophrenia and substance and alcohol abuse

BACKGROUND

Suicide risk is high in schizophrenic patients and is further elevated in dual diagnosis patients. Suicide behaviour is a continuum from ideation, plans to attempts. Exposure to traumatic stress and co-morbid PTSD is elevated in schizophrenic patients. Suicide behaviour is also common in non-psychotic PTSD patients. This study aimed to investigate the effect of trauma and co-morbid PTSD on suicide behaviour in dual diagnosis patients and whether co-morbid PTSD would further elevate suicide risk.

METHOD

This was a cross-sectional study in which suicide behaviour was compared in those with and without co-morbid PTSD in 110 patients suffering schizophrenia and alcohol and/or substance abuse.

RESULTS

100 (91%) reported at least one traumatic event with an average of 4.3 events. 31 (28%) patients met criteria for full PTSD. Current suicidal ideation was reported by 39 (35%) and 23 (21%) reported plans and ideation, 69 (63%) reported at least one previous suicide attempt. Suicide behaviour was significantly associated with an increasing number of traumatic events. Suicidality was significantly associated and elevated with co-morbid PTSD. Analysis indicated that the effect of trauma on suicide behaviour appeared to be mediated by hopelessness.

CONCLUSIONS

Suicide behaviour was not associated with exposure to trauma per se but was associated with incremental exposure to traumatic experiences. Consistent with the study hypotheses, co-morbid PTSD further adds to the risk of suicide behaviour in an already vulnerable group.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Might the inability to feel pleasure (anhedonia) explain the symptoms of major depression and schizophrenia, including unmotivated anxiety, delusions and hallucinations?

Inability to enjoy normally pleasurable experiences (anhedonia) is a symptom common both to major depression and schizophrenia. It also regularly accompanies and follows stress, and its presence in the two mental illnesses could depend on the fact that both are facilitated and often preceded by stressful events. Anhedonia might possibly accompany stress because the loss of the pleasure of aiming for a goal and achieving it (including defending oneself and escaping from a danger) could lead to immobility, and immobility (playing dead) offers the extreme chance of safety when an animal is facing the worst possible stressful situation--being seized by a predator--as in this case any movement can further stimulate the predator's aggressiveness. Perceiving and connecting sensory information also gives pleasure, and this appears to enhance the clarity of sensations and is an important factor in learning. We propose that anhedonia, by reducing or eliminating the pleasure, might jeopardize the usual appearance of the environment, which must not only be clearly perceived but also continuously interpreted (for instance a foreshortening, or something far off seen as small, must not be seen as a real deformation; the same holds for words, where the meaning has to be grasped from the single letters, and so on). Consequently, anhedonia could in some cases make the environment's image strange, distorted and frightening, and this could cause anxiety, confusion, and give problems in contacts with people and things. As correct information about images and sounds can inhibit visual and auditory hallucinations (considering them, like delusions, as attempts to reconstruct and make sense again of a world that is becoming confused and alien), we propose that anhedonia, interfering with the correct perceiving and processing of sensations, may facilitate them.

The association between trauma and delusional-like experiences

Individuals exposed to childhood trauma are more likely to report delusional-like experiences (DLE). This study examined the association between trauma exposure and DLE in a large community sample, investigating different trauma types and age-at-first-exposure to trauma. Subjects were from the Australian National Survey of Mental Health and Wellbeing 2007. Associations between DLE and (i) exposure to different trauma types and (ii) age-at-first-exposure were assessed using logistic regression with adjustments for potential confounding factors. 8.4% of 8773 subjects reported DLE and almost 75% reported at least one traumatic event. Exposure to a traumatic event was significantly associated with more than twice the odds of delusional-like experiences and exposure to more types of trauma increased the likelihood of DLE in a dose dependent fashion. The majority of the individual trauma items were independently associated with any endorsement of DLE. First exposure of trauma in childhood, adolescence and adulthood was all associated with DLE. Further understanding of biological and cognitive pathways is required to unravel the association between trauma exposure and delusional-like experiences.

Trauma and comorbid posttraumatic stress disorder in individuals with schizophrenia and substance abuse

OBJECTIVES

The aim of this study was to investigate the occurrence of trauma and comorbid posttraumatic stress disorder (PTSD) in dual diagnosis patients and whether the trauma was related to the patient's behavior or illness.

METHOD

One hundred ten patients with schizophrenia and comorbid substance or alcohol abuse were assessed for PTSD using self-report and structured interview. Traumatic events were classified as independent or dependent upon the patient's behavior, illness, or symptoms.

RESULTS

One hundred patients (91%) reported at least 1 trauma (mean, 4.3). Sixty-three patients (57%) reported a traumatic event that met modified-criterion A for PTSD. Thirty-one patients (28%) met criteria for full PTSD, and 18 (16%) had a trauma directly related to their illness. Patients with PTSD had significantly higher scores on positive psychotic symptoms and depression.

CONCLUSIONS

Exposures to traumatic events and comorbid PTSD are high but are inflated by reactions to illness-related events such as hospitalization and psychotic symptoms.

The efficacy of psychotherapy in reducing post-psychotic trauma

There is now growing evidence to suggest that the experience of psychosis may be so traumatic for some that it can lead to Post Traumatic Stress Disorder (PTSD)-type symptoms or post-psychotic trauma symptoms (PPTS). There is, however, less knowledge about what psychological interventions may be helpful in reducing these symptoms. Evidence from the literature, to date, suggests that of the seven studies that have addressed this issue only four were randomized controlled trials (RCTs). However, all these studies included less than 100 patients with the vast majority reporting positive results. Overall, it seems that although cognitive-behavioural treatment (CBT)-based psychological interventions appear to be efficacious in the treatment of PPTS, the studies are too small to draw any firm conclusions and should be subjected to larger good-quality RCTs. Further research will also need to establish the role of mediating variables such as shame and depression in the treatment of PPTS.

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

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

Enduring sensorimotor gating abnormalities following predator exposure or corticotropin-releasing factor in rats: a model for PTSD-like information-processing deficits?

A deficit in prepulse inhibition (PPI) can be one of the clinically observed features of post-traumatic stress disorder (PTSD) that is seen long after the acute traumatic episode has terminated. Thus, reduced PPI may represent an enduring psychophysiological marker of this illness in some patients. PPI is an operational measure of sensorimotor gating and refers to the phenomenon in which a weak stimulus presented immediately before an intense startling stimulus inhibits the magnitude of the subsequent startle response. The effects of stress on PPI have been relatively understudied, and in particular, there is very little information on PPI effects of ethologically relevant psychological stressors. We aimed to develop a paradigm for evaluating stress-induced sensorimotor gating abnormalities by comparing the effects of a purely psychological stressor (predator exposure) to those of a nociceptive physical stressor (footshock) on PPI and baseline startle responses in rats over an extended period of time following stressor presentation. Male Sprague-Dawley rats were exposed (within a protective cage) to ferrets for 5 min or left in their homecage and then tested for PPI immediately, 24 h, 48 h, and 9 days after the exposure. The effects of footshock were evaluated in a separate set of rats. The effects seen with stressor presentation were compared to those elicited by corticotropin-releasing factor (CRF; 0.5 and 3 μg/6 μl, intracerebroventricularly). Finally, the effects of these stressors and CRF administration on plasma corticosterone were measured. PPI was disrupted 24 h after ferret exposure; in contrast, footshock failed to affect PPI at any time. CRF mimicked the predator stress profile, with the lowdose producing a PPI deficit 24 h after infusion. Interestingly, the high dose also produced a PPI deficit 24 h after infusion, but with this dose, the PPI deficit was evident even 9d later. Plasma corticosterone levels were elevated acutely (before PPI deficits emerged) by both stressors and CRF, but returned to normal control levels 24 h later, when PPI deficits were present. Thus, predator exposure produces a delayed disruption of PPI, and stimulation of CRF receptors recapitulates these effects. Contemporaneous HPA axis activation is neither necessary nor sufficient for these PPI deficits. These results indicate that predator exposure, perhaps acting through CRF, may model the delayed-onset and persistent sensorimotor gating abnormalities that have been observed clinically in PTSD, and that further studies using this model may shed insight on the mechanisms of information-processing deficits in this disorder. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

Exposure to trauma and the clinical presentation of first-episode psychosis in South Africa

OBJECTIVE

To evaluate the relationship between a history of traumatic experiences and the clinical features of first-episode psychosis (FEP).

METHOD

We tested associations between trauma variables and duration of untreated psychosis (DUP), age of onset (AO), PANSS-rated positive and negative symptoms and depressive symptoms (Calgary Depression Scale) in a sample of 54 FEP patients.

RESULTS

Mean DUP was 34.4 weeks, while mean AO was 24.7 years. Witnessing a seriously violent assault (49%) was associated with high positive symptoms (p = 0.002), while a significant personal experience of racism and discrimination (39%) was associated with high depressive (p = 0.042) symptoms. Previous sexual assault (44% of females) was associated with high positive (p = 0.028) and negative (p = 0.035) symptoms with a trend association with depressive symptoms (p = 0.092).

CONCLUSION

Our findings suggest that previous traumatic experience is associated with positive and affective symptoms in FEP.

Psychotic depression, posttraumatic stress disorder, and engagement in cognitive-behavioral therapy within an outpatient sample of adults with serious mental illness

Depression with psychotic features afflicts a substantial number of people and has been characterized by significantly greater impairment, higher levels of dysfunctional beliefs, and poorer response to psychopharmacologic and psychosocial interventions than nonpsychotic depression. Those with psychotic depression also experience a host of co-occurring disorders, including posttraumatic stress disorder (PTSD), which is not surprising given the established relationships between trauma exposure and increased rates of psychosis and between PTSD and major depression. To date, there has been very limited research on the psychosocial treatment of psychotic depression; and even less is known about those who also suffer from PTSD. The purpose of this study was to better understand the rates and clinical correlates of psychotic depression in those with PTSD. Clinical and symptom characteristics of 20 individuals with psychotic depression and 46 with nonpsychotic depression, all with PTSD, were compared before receiving cognitive-behavioral therapy for PTSD treatment or treatment as usual. Patients with psychotic depression exhibited significantly higher levels of depression and anxiety, a weaker perceived therapeutic alliance with their case managers, more exposure to traumatic events, and more negative beliefs related to their traumatic experiences, as well as increased levels of maladaptive cognitions about themselves and the world, compared with participants without psychosis. Implications for cognitive-behavioral therapy treatment aimed at dysfunctional thinking for this population are discussed.

Impact of traumatic and violent victimization experiences in individuals with schizophrenia and schizoaffective disorder

Individuals with schizophrenia or schizoaffective disorder (SZ) experience more violent victimization and noninterpersonal traumatic experiences than the general population. Earlier studies, however, have generally excluded one or grouped together victimization and trauma experiences into single outcome variables, which may obscure their contributory role to SZ symptoms. This issue is important because there is some evidence that intentionally induced violence produces higher rates of psychopathology than nonintentional traumatic experiences. We examined the independent contribution of both types of victimization experiences on SZ patients' symptomatology. We were also interested in determining whether SZ patients' pattern of acute symptom presentation could discriminate between SZ patients with and without posttraumatic stress disorder (PTSD) comorbidity. SZ inpatients (n = 70) were assessed for the presence of comorbid PTSD diagnosis, violent victimization, and noninterpersonal traumatic experiences. Patients were also rated on SZ symptom severity and general psychopathology measures. Past violent victimization experiences predicted severity of dysphoria and anxiety in SZ. Past traumatic experiences, however, predicted severity of psychosis. Victimization predicted severity of patients' autistic/cognitive symptoms. SZ patients with comorbid PTSD presented with significantly more anxiety and dysphoria symptoms and SZ illness chronicity than their non-PTSD counterparts. Discriminant function analysis revealed that the severity of positive, dysphoric, autistic/cognitive, and anxiety symptoms differentiated comorbid PTSD patients from their non-PTSD counterparts, with an overall 72.9% classification rate. Past traumatic and victimization experiences are significantly associated with SZ patients' symptom severity and illness course in partially overlapping domains. Use of common assessment strategies may be employed to increase detection of PTSD in SZ patients presenting for acute treatment.

High-risk behaviors and drinking-to-cope as mediators of lifetime abuse and PTSD symptoms in clients with severe mental illness

Face-to-face interviews with 276 community mental health clients (56.2% women; 42.8% men) diagnosed with schizophrenia spectrum disorders (44.6%) and major mood disorders (55.4%) were used to examine mediating relationships among physical and sexual abuse, high-risk behaviors, drink-to-cope motives, and posttraumatic stress disorder (PTSD) symptom severity. Structural equation modeling revealed that both high-risk behaviors and drinking-to-cope significantly mediated the relationship between lifetime abuse and PTSD symptom severity with an excellent fit of model to data. Alternative models using PTSD symptom level as mediator were also tested, but did not meet optimal goodness-of-fit standards. Implications of findings call for vigilant screening for trauma, substance abuse, and high risk behaviors in clients with severe mental illnesses to inform treatment, and the need for longitudinal studies to test causal pathways.

Childhood abuse and psychosis; a critical review of the literature

Childhood trauma has long been recognised as a potential cause for a range of affective mental health problems arising in adulthood. Only in recent years has the association between childhood abuse and psychosis begun to be investigated. This paper provides a critical review of the literature addressing the relationship between childhood abuse and psychosis. Implications for practitioners are discussed, including practice, policy, treatment and child protection issues. A significant proportion of people develop psychosis in adulthood following all types of childhood abuse, including people diagnosed with schizophrenia, major depressive disorders, dissociative identity disorder and post-traumatic stress disorder. Evidence suggests the possibility of a causal relationship between childhood abuse and psychosis in adulthood. Mental health nurses are ideally placed to offer help, care and support to those individuals who experience psychosis by acknowledging and listening to their life events, including experiences of childhood abuse.