The trauma of being psychotic: a neglected element in the management of chronic schizophrenia?

Identifying potential predictors of traumatic reactions to psychotic episodes

OBJECTIVES

The experience of a psychotic episode can sometimes lead to post-traumatic stress disorder (PTSD) symptoms. The objective of the research was to identify candidate predictors of such negative reactions for future prospective study. We examined six predictors identified from the PTSD and psychosis literatures in a retrospective study: a history of previous trauma, a history of previous episodes of psychosis, perceived helplessness and uncontrollability at the time of the index psychotic episode, the content of persecutory delusions at episode and the perceived presence of crisis support after the psychotic episode.

DESIGN

The design was a cross-sectional self-report and interview study of people with recently remitted symptoms of psychosis.

METHOD

36 individuals with delusions and hallucinations that had remitted in the past year were assessed for the presence of PTSD symptoms in reaction to their most recent psychotic episode. Measures of the potential predictors were also taken at this point and associations with PTSD symptoms tested.

RESULTS

61% of the individuals with remitted positive symptoms had a reaction to their psychotic episode that was potentially severe enough to receive a PTSD diagnosis. Higher levels of PTSD symptoms were associated with all six predictors tested.

CONCLUSIONS

The study provides further evidence that negative reactions to psychotic episodes are relatively common. Clinicians may wish to assess for such symptoms. The study extended these findings by identifying a number of candidate psychological predictors of PTSD reactions such as perceptions of uncontrollability and absence of support. Prospective longitudinal studies are required to test the causal significance of these factors. More broadly, the findings indicate that traumatic stress in response to intra-psychic events such as delusions can be understood in similar ways to traumatic stress arising from physical traumas such as disasters.

The trauma of psychosis: posttraumatic stress disorder and recent onset psychosis

Clinical investigators have argued that the experience of a recent onset of psychosis is an event of such severity that it can lead to posttraumatic stress disorder (PTSD), or at least to PTSD symptoms. The traumagenic elements of the psychotic experience may relate to the distressing nature of psychotic symptoms, components of treatment, or both. However, this hypotheses has not been fully empirically evaluated. In particular, the importance of the DSM-IV A1 (perception of threat) and A2 (negative emotion at time of event) criteria for a traumatic event due to a psychotic episode has not been assessed. To address this question, 38 clients in treatment for recent onset of psychosis were interviewed to identify distressing experiences related to the episode, with PTSD assessed (including A1/A2 criteria) related to those events. More than one-half of the participants reported intense distress related to psychotic symptoms or treatment experiences, with 66% meeting symptom criteria for the PTSD syndrome (regardless of A1/A2), and 39% meeting full diagnostic criteria for PTSD (including A1/A2). Both participants with the PTSD syndrome and full PTSD reported more problems in daily functioning and more severe symptoms than those without PTSD. Participants with the PTSD syndrome were also more likely to have an integrative rather than sealing over coping style compared to those without the PTSD syndrome. The results suggest that individuals with PTSD symptoms related to a recent onset of psychosis may benefit from intervention designed to help them integrate their experience into their lives and address potentially stigmatizing beliefs that could contribute to distress and impaired functioning.

[Psychosis-induced posttraumatic stress disorder. A rarely diagnosed symptom]

Patients with severe mental disorders encounter a rather high risk of also evolving symptoms of posttraumatic stress disorder (PTSD) as a result of psychotic experience. A wide overlap of symptoms makes the differentiation between "psychosis-induced PTSD" and "psychotic warning signs" difficult; nevertheless, the distinction is important as different therapy strategies must be envisaged. A case report of a psychosis-induced PTSD is given.

The social construction of disability in schizophrenia

Chronicity and disability can accompany a diagnosis of schizophrenia, but long-term follow-up studies are demonstrating that these outcomes are not inevitable. There is growing awareness that characteristics of long-term illness previously understood to be part of the disorder can be partially constructed through a convergence of physical, psychological, and social processes. In this study, the potential for social construction of disability was explored through secondary analysis of qualitative data. Findings suggest that family, consumers, professionals, and society each have a role in shaping a person with schizophrenia's perceptions of his or her worth, competence, and place in society but that the individuals are not passive recipients of this input.

Posttraumatic stress disorder symptoms related to psychosis and acute involuntary hospitalization in schizophrenic and delusional patients

The aims of this study were: a) to assess the prevalence of posttraumatic stress disorder (PTSD) after an acute psychotic episode in schizophrenic and delusional patients, b) to explore which psychotic symptoms and aspects of treatment were associated with traumatization, and c) to compare the extent of the traumatic impact of psychosis and involuntary hospitalization. Forty-six schizophrenic and delusional patients were assessed with the Positive and Negative Syndrome Scale (PANSS), the Impact of Event Scale-Revised (IES-R), and the Clinician-Administered PTSD Scale (CAPS) at weeks 1 and 8 after acute psychiatric admission. Traumatic symptoms related to psychosis and coercive measures were scored separately. The prevalence of PTSD was found to be 11%. Sixty-nine percent of traumatic symptoms were related to psychosis and 24% to hospitalization. High PANSS score at week 8 was the strongest risk factor for the development of PTSD. Particularly positive and depressive/anxious symptomatology were associated with psychosis-related traumatic symptoms at both weeks 1 and 8. These data suggest that, in general, schizophrenic and delusional symptoms are more traumatic than the coercive measures used to control them.

Defining new frameworks for psychosocial intervention

The personal experiences of individuals with schizophrenia have been neglected in the psychiatric literature. Disappointingly, ideas about the impact of the illness on the experience of "self" have either been devalued or based primarily on the impressions of theorists rarely collaborating with individuals with the illness. Rather than making assumptions about the subjective experience of mental illness, we must enter a meaningful dialogue with our clients so that they can tell us about their situations using their own voices. This study presents life-history interviews with 15 individuals diagnosed with schizophrenia and describes the explanatory models they use to give coherence to their experiences of psychosis. The struggle for control emerges as a central theme with effects on the management of symptoms, self-image, feelings of social competence, and dealing with others' expectations. Respondents speak about the possibility of recovery from illness through engaging in a process of internal and external reorganization. These individuals echo the assertions in the literature generated by consumers and other investigators of subjective experience and advocate for recovery-based models of care including therapeutic discourse with clients.

Involuntary admission and posttraumatic stress disorder symptoms in schizophrenia patients

In a sample of 105 community-care patients suffering from schizophrenia, the relationship between reports of involuntary admission in the past, current posttraumatic stress disorder (PTSD) symptoms, and other aspects of psychopathology was examined. PTSD symptoms were obtained on the PTSD interview, and psychopathology was rated on the Brief Psychiatric Rating Scale (BPRS) and on the Present State Examination (PSE). Fifty-seven percent of the patients reported they had experienced involuntary admissions in the past. The degree of PTSD symptoms was high--51% fulfilled the criteria for a PTSD diagnosis. PTSD symptoms were not correlated with reports of involuntary admissions. They were, however, significantly correlated with the BPRS subscale anxiety/depression, and with PSE subscores for specific and nonspecific neurotic syndromes. Because of an overlap of symptom scores, a diagnosis of PTSD according to DSM criteria appears to be very difficult in schizophrenia patients.

Intravenous sedation of involuntary psychiatric patients in New South Wales

OBJECTIVE

Intravenous sedation of involuntary psychiatric patients is practised in almost all hospitals in New South Wales. Despite its widespread use, little has been published about the medications used or their safety and efficacy. The present study reports the frequency and reasons for intravenous sedation, the medications used, and the incidence of adverse effects.

METHOD

Eighteen of 21 acute psychiatric admission units in the State were reviewed. The medical records of a random sample of 495 patients admitted involuntarily during 1990 were examined and information from the progress notes, drug charts and physical observations was recorded and subjected to statistical analysis.

RESULTS

Of the 495 patients, 132 (27%) were intravenously sedated. Eighty-six percent (86%) of patients received a combination of haloperidol or diazepam, usually 20 mg of each drug. The threat of violence was the most significant patient characteristic predicting the use of intravenous sedation. Patients with mania or intoxication were relatively more likely to be intravenously sedated than other diagnostic categories. Patients admitted via accident and emergency departments and those admitted to teaching and metropolitan general hospitals compared to rural and large psychiatric hospitals were significantly more likely to receive intravenous sedation. The most common complications of intravenous sedation were dystonia (37%), hypotension (8%) and confusion (5%). The incidence of phlebitis and other extrapyramidal side-effects was probably under-reported.

CONCLUSION

About one in four involuntary psychiatric patients receive intravenous sedation in NSW. Intravenous sedation is more likely when patients are admitted through accident and emergency departments to teaching or metropolitan hospitals, and pose a threat of violence. Intravenous sedation was shown to be a safe procedure given certain precautions.

The clinical boundaries of posttraumatic stress disorder

Three sets of clinical boundaries exist for posttraumatic stress disorder (PTSD), as for all concepts of psychiatric disorder. The first involves the border with normal psychology in general, and with the normal psychology of stress response in particular. This boundary can be surveyed from a number of vantage points and the maps which result will not necessarily correspond. The second boundary issue involves internal boundaries between psychiatric disorders, specifically between PTSD and other concepts of disorder. The high level of comorbidity documented in PTSD has ensured that this aspect of boundary setting is particularly contentious. The third set of boundaries is concerned with subtyping within the global construct of PTSD. The validity and extent of subtyping would be based on the degree to which phenomenological differences exist in relation to PTSD syndromes occurring in the wake of certain types of traumatic events. Such clinical subtyping might however need to be buttressed by external validity indicators such as differential treatment responses or outcome. A final boundary issue of major significance to therapists involves the need to place oneself unambiguously on the side of the trauma survivor in the struggle to resolve the traumatic experiences. The pivotal position of PTSD in the psychopathological arena is discussed.

Nursing model of psychoeducation for the seriously mentally ill patient

The purposes of this paper are to describe a nursing model for psychoeducation that is being implemented in the psychiatric unit of a Veterans Administration (V.A.) Hospital and to report baseline descriptive data for 19 seriously mentally ill patients. The data were collected as part of a larger study of patient, family, and treatment variables associated with community adjustment of seriously ill psychiatric patients. A convenience sample of 19 consenting patients with DSM-III-R diagnoses of schizophrenia, schizoaffective disorder, or bipolar disorder were interviewed and assessed by a clinical nurse specialist. Nine consenting family members, identified by the patient as a key family member, were also interviewed. The baseline data reported here were generated in these interviews. These data were also used to develop psychoeducational plans to meet individual patient/family needs. The patients had had an average of 12 prior hospitalizations. Their mean age was 38 years; 74% were African-American and 89% were male. Patients reported a variety of understandings of the reason for their hospitalization and techniques for management of their symptoms. The most common ways of managing symptoms were categorized as physical activity, decreasing stimuli, and use of alcohol/drugs/smoking. Practical problems arising in association with the conduct of clinical research in a V.A. psychiatric setting by a research team are also discussed.

How do they see themselves? Self-perception and functioning for people with chronic schizophrenia

In a supervised living situation, 15 individuals whose physical health was considered stable and who had diagnoses of chronic schizophrenia expressed varying perceptions of their mental health. Most perceived themselves as mentally well. This is in opposition to findings reported by Estroff (1981) and Dzurec (1986) that suggested that clients with schizophrenia tended to have negative self-perceptions. The author posits that this positive self-perception might be a function of respondents' expressed satisfaction with their housing situation. This is an area in which ongoing research is being conducted (Bininger, 1989; Dzurec, 1989). Housing satisfaction is thought by some researchers to precede successful community adaptation for the severely mentally disabled (Blanch, 1988). Respondents' perceptions of their mental health, as expressed in response to the interview protocol, appeared to be couched within primarily mundane, day to day issues. This finding is consistent with Estroff's conclusion that clients "seemed to have less control of their time, space, resources, and information than did outside and inside normals" (Estroff, 1981). The respondents gave themselves higher than average scores (ie, 3 or above on a five-point scale) overall on the PES, an instrument that measured aspects of their daily functioning. Their caretakers gave them somewhat lower overall scores on the PES. There was a moderate association between individual pairs of respondent-caretaker scores on the PES. Personal mental health perception did not appear to influence daily functioning.(ABSTRACT TRUNCATED AT 250 WORDS)