Predictors of PTSD symptoms in response to psychosis and psychiatric admission

Psychiatric admission as a risk factor for posttraumatic stress disorder

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

Effect of standardized post-coercion review session on symptoms of PTSD: results from a randomized controlled trial

OBJECTIVE

Post-coercion review is increasingly regarded as a mean to reduce the negative consequences of coercive interventions, including the development of posttraumatic symptoms. However, the efficacy of this intervention in preventing posttraumatic symptoms or PTSD has not been sufficiently studied. The objective of this study is to examine the influence of a single, standardized post-coercion review session on the development or exacerbation of PTSD symptoms in patients with psychotic disorders.

METHODS

In a multi-center, two-armed, randomized controlled trial, patients who experienced coercive interventions during current hospitalization were either randomized to standard treatment or an intervention group receiving a guideline-based, standardized reflecting review session. Factorial MANCOVA and subsequent ANCOVAs investigated the effects of the post-coercion reflecting review session on post-traumatic symptoms as measured by the subscales of the Impact of Events Scale-Revised (IES-R). Similarly, the effect of the intervention on the intensity of the peritraumatic reactions measured by the Peritraumatic Distress Inventory (PDI) was analyzed by conducting a factorial ANCOVA.

RESULTS

N = 82 patients were included in an intention-to-treat analysis. MANCOVA and post hoc ANCOVAs revealed a significant main effect of the intervention for the IES-R subscales intrusion and hyperarousal, when controlling for levels of peritraumatic distress, whereby intervention group participants presented lower respective mean scores. There was no significant difference regarding the intensity of the peritraumatic reaction.

CONCLUSION

Standardized post-coercion review contributes to a reduction of the burden of PTSD symptoms in patients with psychotic disorders experiencing coercive interventions in acute settings and shall be recommended as a measure of trauma-informed care. The trial was registered at ClinicalTrials.gov (ID NCT03512925) on 01/30/2018 (retrospectively registered).

Treating mental health crises at home: Patient satisfaction with home nursing care

WHAT IS KNOWN ON THE SUBJECT?: Most studies have focused on whether hospital admissions have been reduced by the introduction of crisis services, rather than focusing on how these services are employed. Research has also shown that home assistance decreases costs and increases the level of patient satisfaction, thereby being more efficient in terms of the cost/effectiveness ratio than is traditional hospital care. Patient satisfaction with nursing care has long been identified as a key element of quality of care; however, satisfaction with nursing care among patients and families receiving crisis resolution at home has not been studied yet. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: There is limited research on patient satisfaction with CRHTTs. This study provides new insights and data including that on relationships between patient satisfaction and the teams' attention to person-centred mental health care. The difference between this study and other studies on patient satisfaction with crisis resolution home treatment teams is that this study focused on patients' and families' satisfaction with the nursing care provided by crisis resolution home treatment teams rather than with the general service provided. This study is the first of its kind with such a focus. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This research has both academic and clinical implications. Patients' and their families' satisfaction with nursing care is an integral aspect for evaluating mental health services, and this is especially important regarding services provided by crisis resolution home treatment teams because such teams are currently being introduced in countries such as Spain. Closely examining patients and families' satisfaction with nursing care can also foster improvements in current practices. Nurses in crisis teams might need to focus on equalizing power relations, which the data gathered in this study suggests is most important to patient satisfaction. ABSTRACT: Introduction Crisis resolution home treatment teams (CRHTT) provide short-term, intensive home treatment to people experiencing mental health crises. Patient satisfaction has long been identified as a key element of quality of care; however, satisfaction with nursing care as part of this service has not been studied yet. Aim To assess patients' and their families' satisfaction with the nursing care provided through a home care program offered by a hospital in Catalonia which administers person-centred care. Method A mixed methods research design was conducted. A cross-sectional study including quantitative survey data and qualitative interview data with a phenomenological focus was conducted. Results Twenty interviews were conducted. Patients and relatives reported high satisfaction that seems to be related to the person-centred nature of the care. Discussion The findings provide new insights, including how home treatment tends to equalize power relations between nurses and patients/the patient's family members, and how nurses increase sensitivity when focusing on service users' needs and priorities, leading to high patient and family satisfaction. Implications for practice This research has both academic and clinical implications. It highlights what mental health patients and their families value most about home care and interactions with nurses, and also drives improvements in current practices.

A Multicenter Phase II RCT to Compare the Effectiveness of EMDR Versus TAU in Patients With a First-Episode Psychosis and Psychological Trauma: A Protocol Design

Background

Patients with a first episode psychosis (FEP) who are admitted for the first time to a psychiatric hospital frequently have experienced prior psychological trauma. Additionally, 40-80% develop posttraumatic stress symptoms, which are summarized as a post-psychotic post-traumatic syndrome (PPS). Eye Movement Desensitization and reprocessing (EMDR) therapy could be an effective psychotherapy to treat a PPS and prior psychological traumas in this population.

Objectives

To assess if EMDR therapy leads to: 1) a reduction of relapses after intervention, 2) an improvement of trauma-related, psychotic and affective symptoms, 3) an improvement of overall functioning, and 4) an improvement in quality of life.

Methods

This is a multicenter phase II rater-blinded randomized controlled trial in which 80 FEP patients with a history of psychological trauma will be randomly assigned to EMDR (n = 40) or to TAU (n = 40). Traumatic events will be measured by the Global Assessment of Posttraumatic Stress Questionnaire, the Cumulative Trauma Screening, the Impact of Event Scale-Revised, the Dissociative Experiences Scale, the Childhood Trauma Scale, the Holmes-Rahe Life Stress Inventory, and the Dissociative Experiences Questionnaire. Clinical symptomatology will be evaluated using the Suicide and Drug Consumption module of the International Neuropsychiatric Interview, Structured Clinical Interview for Positive and Negative Syndrome Scale, Young's Scale for Mania Evaluation, and Beck Depression II Questionnaire. Functionality will be assessed with the Global Assessment of Functioning and the Quality of Life with the Standardized Instrument developed by the EuroQol Group. The cognitive insight and adherence to the treatment will be assessed with the Beck Cognitive Insight Scale and the Drug Attitude Inventory. All variables will be measured at baseline, post-treatment and at 12-month follow-up.

Conclusion

This study will provide evidence of whether EMDR therapy is effective in reducing trauma and clinical symptoms, reducing relapses and in improving functionality and quality of life in patients with FEP and a history of trauma.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier: NCT03991377.

Posttraumatic growth among people with serious mental illness, psychosis and posttraumatic stress symptoms

Recent research has shown high rates of exposure to trauma among people with serious mental illness (SMI). In addition, studies suggest that psychosis and mental illness-related experiences can be extremely traumatic. While some individuals develop posttraumatic symptomatology related to these experiences, some appear to experience posttraumatic growth (PTG). Little is known, however, about PTG as a possible outcome among people who experienced psychosis as well as posttraumatic stress symptoms (PTSS). For further understanding of the relationship between PTSS and PTG among people with SMI who experienced psychosis, 121 participants were recruited from community mental health rehabilitation centers and administered trauma and psychiatric questionnaires. Results revealed that while high levels of traumatic exposure were common, most participants experienced some level of PTG which was contingent upon meaning making and coping self-efficacy. In addition, posttraumatic avoidance symptoms were found to be a major obstacle to PTG. The range of effect sizes for significant results ranged from η²=0.037 to η²=0.144. These findings provide preliminary evidence for the potential role of meaning making and coping self-efficacy as mediators of PTG in clinical, highly traumatized populations of people with SMI and psychosis. Implications of these findings for future research and clinical practice are discussed.

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.

Posttraumatic Reactions to Psychosis: A Qualitative Analysis

The current study aimed to evaluate the potentially traumatic aspects of psychotic symptoms and psychiatric treatment of psychosis using qualitative methods. Participants included 63 people with first episode psychosis or multiple psychotic episodes recruited from an inpatient psychiatric unit and an urban state psychiatric hospital in the North East region of the United States. Quasi-structured interviews were used to explore those aspects of symptoms and treatment that were perceived as traumatic Emotional reactions to the most traumatic aspect of symptoms and treatment, during and after the event, were also examined. Participants described a number of traumatogenic aspects of psychotic symptoms, including frightening hallucinations; suicidal thought/attempts, thoughts/attempts to hurt others; paranoia/delusions and bizarre/disorganized behavior or catatonia. Traumatic aspects of psychosis elicited emotions including anger, sadness and confusion, anxiety, and numbness at the time of event. Furthermore, many participants found aspects of treatment to be traumatic, including: being forced to stay in the hospital for a long time; experiencing upsetting side-effects; coercive treatments, including involuntary hospitalization, use of restraints, and forced medication; being exposed to aggressive patients; and mistreatment by professionals. These experiences elicited emotions of anger, sadness, distrust, and a sense of helplessness. Study findings suggest that the experiences both of psychotic symptoms and psychiatric treatment, potentially traumatic, can be a powerful barrier to engaging people in mental health services and facilitating recovery. Clinical implications were discussed.

Narrowing the focus on the assessment of psychosis-related PTSD: a methodologically orientated systematic review

BACKGROUND

Posttraumatic stress disorder (PTSD) in response to psychosis and associated experiences (psychosis-related PTSD, or PR-PTSD) is the subject of a growing field of research. However, a wide range of PR-PTSD prevalence rates has been reported. This may be due to definitional and methodological inconsistencies in the assessment of PR-PTSD.

OBJECTIVE

The focus of the review is two-fold. (1) To identify factors that enhance, or detract from, the robustness of PR-PTSD assessment and (2) to critically evaluate the evidence in relation to these identified criteria, including the impact on PR-PTSD prevalence rates.

METHOD

Four quality criteria, whose development was informed by mainstream PTSD research, were selected to evaluate findings on PR-PTSD prevalence. Two criteria related to assessment of psychosis-related stressors (participant identification of worst moments of discrete threat events; psychometrically robust trauma measure) and two focussed on PR-PTSD symptom measurement (adequate time elapsed since trauma; use of validated PTSD interview) in the context of psychosis.

RESULTS

Twenty-one studies of PR-PTSD, with prevalence rates ranging from 11 to 51%, were evaluated. Fourteen studies (67%) used robust PTSD measures but PR-trauma was not specifically defined or assessed with validated measures. Eleven studies (52%) assessed PTSD before sufficient time had elapsed since the trauma. Due to significant methodological limitations, it was not possible to review PR-PTSD rates and provide a revised estimate of prevalence.

CONCLUSIONS

Methodological limitations are common in existing studies of PR-PTSD prevalence. Specific recommendations for improving assessment of psychosis-related trauma are made to guide the development of this new and emerging field. The review concludes with a proposed conceptualisation of PR-PTSD in the context of current diagnostic systems. The utility of the PR-PTSD term and its theoretical underpinnings are discussed.

Understanding the trauma of first-episode psychosis

AIM

This study examined the distress of first-episode psychosis (FEP) beyond the acute episode. It focused on how people understand the experience of FEP and its negative impact and how this relates to the traumagenic phenomena.

METHODS

This research was a longitudinal qualitative study including interpretative phenomenological analysis of interview data. Ten people who had experienced FEP were interviewed 3-6 months following their psychotic episode (time one) and again 3 months after their initial interview (time two). Clinicians and significant others were interviewed at time two.

RESULTS

Interpretative phenomenological analysis of the interview data supported a conceptualization of recovery from FEP within a broad trauma framework. The traumatic nature of FEP was found to be extended beyond the acute episode and was not linked to symptoms of post-traumatic stress disorder (PTSD) but included impact on identity, relationships and worldview.

CONCLUSIONS

The diagnosis of PTSD does not appear to capture all aspects of the distress of FEP. Traumagenic distress appears explained by incorporating a range of negative emotions, viewing the impact of FEP as ongoing rather than contained to the acute episode, and recognizes disruption of the individual's views of the self, others and the world.

Determinants of patient satisfaction with hospital health care in psychiatry: results based on the SATISPSY-22 questionnaire

BACKGROUND

The aim of our study was to identify patient- and care-related factors that are associated with patients' satisfaction with psychiatric hospital care, using a specific, self-administered questionnaire based exclusively on the patient's point of view: the Satisfaction with Psychiatry Care Questionnaire-22 (SATISPSY-22).

METHODS

This cross-sectional study was conducted in the psychiatric departments of two French public university teaching hospitals. The data collected included sociodemographic information, clinical characteristics, care characteristics, and the SATISPSY-22. A multivariate analysis using multiple linear regressions was performed to determine the variables potentially associated with satisfaction levels.

RESULTS

Two hundred seventy patients were enrolled in our study. Only one moderate association was found between satisfaction and sociodemographic characteristics: the personal experience dimension with age (β=0.15). Clinical improvement was moderately associated with higher global satisfaction (β=-0.15), higher satisfaction with quality of care (β=-0.19), and higher satisfaction with food (β=-0.18). Stronger associations with satisfaction were found for care characteristics, particularly the therapeutic alliance with all of the satisfaction dimensions (β, 0.20-0.43) except food, and for seclusion with global satisfaction (β=-0.33) and personal experience (β=-0.32). Patients with previous hospitalization also had a higher level of satisfaction with quality of care compared with patients who were admitted for the first time (β=-0.15).

CONCLUSION

This study has identified a number of potential determinants of satisfaction. The therapeutic relationship and seclusion were the most important features associated with a patient's satisfaction. These factors might be amenable through intervention, which, in turn, might be expected to improve satisfaction, patients' management, and health outcomes in psychiatric hospitals.

Association between childhood physical abuse, unprotected receptive anal intercourse and HIV infection among young men who have sex with men in Vancouver, Canada

Introduction

The association between childhood sexual abuse and HIV risk among men who have sex with men (MSM) is well established. However, no studies have examined the potential impact of other forms of childhood maltreatment on HIV incidence in this population.

Methods

We explored the impact of child physical abuse (CPA) on HIV seroconversion in a cohort of gay/bisexual men aged 15 to 30 in Vancouver, Canada. Cox proportional hazard models were used, controlling for confounders.

Results

Among 287 participants, 211 (73.5%) reported experiencing CPA before the age of 17, and 42 (14.6%) reporting URAI in the past year. After a median of 6.6 years follow-up, 16 (5.8%) participants HIV-seroconverted. In multivariate analysis, CPA was significantly associated with HIV seroconversion (adjusted hazard ratio [AHR] = 4.89, 95% confidence interval (CI): 1.65–14.48), after controlling for potential confounders.

Conclusion

Our study uncovered a link between childhood physical violence and HIV incidence. Results highlight an urgent need for screening of young gay and bisexual men for histories of violence, and social and structural supports to prevent HIV transmission in this population.

Prevalence of self-reported childhood abuse in psychosis: a meta-analysis of retrospective studies

There is extensive clinical literature reporting traumatic childhood experiences in patients with psychosis. A quantitative meta-analysis addressing the prevalence of self-reported childhood sexual (CSA), physical (CPA) and emotional abuse (CEA) in psychotic patients has yet to be done. We conducted, a systematic literature search to identify retrospective studies addressing self-reported childhood abuse in patients with DSM/ICD psychosis. Demographic, clinical, and methodological variables were extracted from each publication, or obtained directly from its authors. Quantitative meta-analysis of CSA, CPA, CEA in the sample of patients was performed. Statistical heterogeneity and publication bias were assessed and meta-regressions performed to control for different moderators. Twenty-three studies were retrieved and included a total of 2017 psychotic patients. The prevalence of self-reported CSA, CPA, CEA were respectively of 26%, 39% and 34%. Age, publication year, gender and substance abuse moderated CSA, while age, clinical setting and substance abuse moderated CPA. Results indicated that CEA was moderated by gender and publication year of the study. According to our meta-analysis, psychotic patients have a consistently high self-report of childhood traumatic events which are sexual, physical and emotional in nature. It is our opinion that clinicians should be trained and skilled to carefully investigate childhood abuse in psychosis.

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.

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

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

Suicidal thoughts are associated with platelet counts in adolescent inpatients

OBJECTIVE

Platelets (PLT), which serve as the primary hemostatic indicator, can be used as a peripheral model for studying monoamine turnover in the brain. Therefore, they are attractive targets as circulatory biomarkers for the detection of psychiatric disorders. However, PLT counts have not been utilized as a peripheral biomarker of psychopathology.

METHODS

This study was a retrospective analysis of PLT counts upon admission of 108drug-naïve adolescents hospitalized in an inpatient psychiatric department. PLT counts of patients with suicidal ideation (SI) were compared with those of nonsuicidal in patients (NSI) and those of 77 healthy adolescents, serving as a control group. The patients' disorders were diagnosed and classified by one of four American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM IV) diagnoses, that is, unipolar depression, bipolar depression, schizophrenia, and a pooled group of conduct and borderline personality disorders.

RESULTS

Significantly higher PLT counts were observed in SI patients, as compared with NSI patients (300,200±53.3/mL vs. 253,900±53.2/mL, respectively; p=0.0001). A significant difference in PLT counts in SI patients, relative to the control group, was also noted (300,200±53.3/mL vs. 254,000±52/mL, respectively; p=<10(-26)). Finally, a significant difference in PLT counts was observed between conduct/borderline personality disorders patient with and without suicidal ideation (292,000±55/mL vs. 246,000±64/mL, respectively; p=0.001).

CONCLUSIONS

PLT counts are higher in suicidal hospitalized adolescents than in nonsuicidal inpatients, as well as than in controls.

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.

The varying impact of type, timing and frequency of exposure to childhood adversity on its association with adult psychotic disorder

BACKGROUND

Childhood adversity has been associated with onset of psychosis in adulthood but these studies have used only general definitions of this environmental risk indicator. Therefore, we sought to explore the prevalence of more specific adverse childhood experiences amongst those with and without psychotic disorders using detailed assessments in a large epidemiological case-control sample (AESOP).

METHOD

Data were collected on 182 first-presentation psychosis cases and 246 geographically matched controls in two UK centres. Information relating to the timing and frequency of exposure to different types of childhood adversity (neglect, antipathy, physical and sexual abuse, local authority care, disrupted living arrangements and lack of supportive figure) was obtained using the Childhood Experience of Care and Abuse Questionnaire.

RESULTS

Psychosis cases were three times more likely to report severe physical abuse from the mother that commenced prior to 12 years of age, even after adjustment for other significant forms of adversity and demographic confounders. A non-significant trend was also evident for greater prevalence of reported severe maternal antipathy amongst those with psychosis. Associations with maternal neglect and childhood sexual abuse disappeared after adjusting for maternal physical abuse and antipathy. Paternal maltreatment and other forms of adversity were not associated with psychosis nor was there evidence of a dose-response effect.

CONCLUSIONS

These findings suggest that only specific adverse childhood experiences are associated with psychotic disorders and only in a minority of cases. If replicated, this greater precision will ensure that research into the mechanisms underlying the pathway from childhood adversity to psychosis is more fruitful.

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.