Identifying potential predictors of traumatic reactions to psychotic episodes

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.

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.

Posttraumatic Stress Disorder in First-Episode Psychosis: Prevalence and Related Factors

INTRODUCTION

The experience of psychosis or related treatment can be conceptualized as a traumatic event, which might lead to posttraumatic stress disorder (PTSD) or PTSD syndrome (which is defined as the presence of PTSD symptoms irrespective of the DSM-IV criterion A definition of a traumatic event as an actual or threatened harm). Few studies explored the subject so far.

METHODS

This cross-sectional study included 52 clinically stabilized patients who were hospitalized for a first-psychotic episode during the two years preceding the study. Sociodemographic and clinical information were collected including past trauma history and drug and alcohol use. Patients were administered the Clinician-Administered PTSD Scale (CAPS), the Major Depression Inventory (MDI), the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning scale (GAF), and the Brief COPE.

RESULTS

A total of 22 patients (42.3%) met full PTSD criteria and 36 patients (69.2%) met PTSD syndrome criteria. Full PTSD as well as PTSD syndrome were both associated with physical restraint, higher scores on the MDI and its maladaptive coping scales. The most distressing symptoms were paranoid delusions, and the most distressing treatment experiences involved physical restraint and problems with other hospitalized patients.

DISCUSSION/CONCLUSIONS

Our data showed high rates of psychosis-related PTSD. To prevent PTSD, conditions of hospitalization should be optimized and the use of coercive treatments should be limited. Subjects with recent-onset psychosis should be screened for PTSD symptoms. Improving coping abilities with a well-fitted therapy would be useful in these patients.

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.

Trauma in relation to psychosis and hospital experiences: the role of past trauma and attachment

OBJECTIVES

We investigated rates of psychosis-related and hospital-related post-traumatic stress disorder (PTSD) in people with psychosis in secure settings. We also investigated relationships between PTSD symptoms and previous experiences of trauma and adult attachment.

METHOD

Using a cross-sectional design, 50 participants from medium-secure and low-secure settings were interviewed to identify distressing experiences related to psychosis and hospitalization. PTSD symptoms related to those experiences, past trauma and attachment were assessed using self-report measures.

RESULTS

The combined rate of psychosis-related and hospital-related PTSD was 30%. Twenty-four percent and 18% met criteria for psychosis-related and hospital-related PTSD, respectively. Severity of psychosis was associated with both psychosis-related and hospital-related PTSD symptoms. The prevalence of previous trauma was high, but previous trauma was not significantly correlated with psychosis-related or hospital-related PTSD symptoms. Anxiety in attachment relationships was significantly associated with both psychosis-related PTSD symptoms and hospital-related PTSD symptoms.

CONCLUSIONS

This study adds to the growing body of research highlighting the distressing nature of psychosis and the iatrogenic effects of treatments. It also highlights the potentially important role of attachment styles in PTSD in psychosis.

PRACTITIONER POINTS

30% of patients met criteria for psychosis- or hospital-related PTSD. Severity of psychosis was associated with PTSD symptoms. Anxiety in attachment relationships was positively correlated with PTSD symptoms.

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.

How do people with persecutory delusions evaluate threat in a controlled social environment? A qualitative study using virtual reality

BACKGROUND

Environmental factors have been associated with psychosis but there is little qualitative research looking at how the ongoing interaction between individual and environment maintains psychotic symptoms.

AIMS

The current study investigates how people with persecutory delusions interpret events in a virtual neutral social environment using qualitative methodology.

METHOD

20 participants with persecutory delusions and 20 controls entered a virtual underground train containing neutral characters. Under these circumstances, people with persecutory delusions reported similar levels of paranoia as non-clinical participants. The transcripts of a post-virtual reality interview of the first 10 participants in each group were analysed.

RESULTS

Thematic analyses of interviews focusing on the decision making process associated with attributing intentions of computer-generated characters revealed 11 themes grouped in 3 main categories (evidence in favour of paranoid appraisals, evidence against paranoid appraisals, other behaviour).

CONCLUSIONS

People with current persecutory delusions are able to use a range of similar strategies to healthy volunteers when making judgements about potential threat in a neutral environment that does not elicit anxiety, but they are less likely than controls to engage in active hypothesis-testing and instead favour experiencing "affect" as evidence of persecutory intention.

Association between traumatic experiences and psychosis among incarcerated men

The possible influence of traumatic experiences on subsequent manifestations of psychosis has been the subject of intense scientific debate in the last decade. Whereas some authors have found a clear association between trauma and psychosis, others have pointed out methodological deficiencies in the research or have found only weak associations. Others found no association between trauma and psychosis in exclusive samples of men and recommend the use of studies stratified by sex. This article uses the data from an epidemiological study of a random sample of 500 male inmates in two prisons in Andalusia (Spain) to analyze the association between psychosis and trauma. The inmates were diagnosed using The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) interviews by teams of experienced clinicians. The results show a clear association between traumatic events and some functional psychosis or some psychosis, including induced psychoses. These associations resist the possible effect of confusing variables such as the origin of the inmates, educational level, or having an addictive disorder. We discuss the need to pay special attention to traumatic experiences such as witnessing extreme violence against others or participating in acts of violence, particularly in men. Our results are compatible with different theories that defend the association between trauma and psychosis.

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.

The role of cognitive appraisal in adaptation to traumatic stress in adults with serious mental illness: a critical review

A compelling body of literature suggests that negative appraisal may be associated with adverse reactions to traumatic stress. However, very few studies have examined how appraisal influences posttraumatic adaptation in people with serious mental illness (SMI) despite evidence of disproportionately high prevalence rates of trauma exposure and Posttraumatic Stress Disorder (PTSD) in this population. The purpose of this article is to provide a critical analysis of the theoretical and empirical literature on cognitive appraisal and psychological adaptation to traumatic stress with a specific focus on individuals diagnosed with SMI. It will be argued that appraisal is a key correlate that may partially account for higher rates of PTSD in people diagnosed with major mood and schizophrenia-spectrum disorders, meriting special consideration for future research.

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.

Post-traumatic reactions to psychosis in people with multiple psychotic episodes

Psychotic symptoms, coercive interventions, and other negative treatment experiences have been found to lead to posttraumatic stress disorder (PTSD) symptoms. However, prior research has not examined 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. To address this question, 50 clients with a history of multiple episodes of psychosis were interviewed to identify distressing experiences related to past episodes, with PTSD assessed (including A1/A2 criteria) related to those events, and other psychiatric symptoms, psychosocial functioning, and coping style. Participants reported intense distress related to psychotic symptoms (66%), treatment experiences (25%), and their combination (8%), with 69% meeting symptom criteria for PTSD (excluding A1/A2 criteria), and 31% meeting full diagnostic criteria for PTSD (including A1/A2 criteria). Clients meeting symptom criteria for PTSD, as well as those meeting full diagnostic criteria for PTSD were similar, with both groups reporting more severe symptoms and distress, and more problems in daily functioning, than clients with fewer or no PTSD symptoms. The results are similar to a previous study of PTSD in persons with recent onset of psychosis (Mueser et al., 2010), and suggest that individuals with PTSD symptoms related to psychosis and coercive treatment may benefit from interventions designed to help them integrate their experiences into their lives and reduce PTSD symptoms, regardless of whether the triggering event(s) meet DSM-IV A1/A2 criteria for a traumatic event.

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.

Postpsychotic posttraumatic stress disorder: associations with fear of recurrence and intolerance of uncertainty

Experiencing psychosis can be sufficiently distressing to precipitate symptoms of postpsychotic posttraumatic stress disorder (PP-PTSD). The current research sought to investigate potential associations that PP-PTSD had with the Fear of Recurrence Scale and the Intolerance of Uncertainty Scale. Twenty-seven individuals diagnosed with DSM-IV Schizophrenia and adjudged to be distressed by their experience of psychosis were recruited by referral to the study. The Clinician Administered PTSD Scale was used to assess participants for PP-PTSD. Clinical rating scales (PANSS, HADS, and IES-R) and measures assessing appraisals of paranoia and hallucinatory voices (BAPS and IVI) were also employed. The prevalence rate of PP-PTSD in the sample was 37%. PP-PTSD caseness was associated with being fearful about psychosis recurring, being intolerant of uncertainty, and making negative appraisals of paranoia. Logistical regression analyses indicated that fear of recurrence was a significant predictor of PP-PTSD caseness. The implications of these results for understanding how fear and worry processes might influence emotional adaptation following psychosis are discussed.

Predictors of PTSD symptoms in response to psychosis and psychiatric admission

The experiences of psychosis and psychiatric admission have the potential to act as events precipitating posttraumatic stress disorder (PTSD) symptoms. Known risk factors for the development of PTSD symptoms in adults were identified. These included childhood trauma, current psychiatric symptoms, perceived coercion, and relationships with mental health service providers. These factors were analyzed to determine if they were important in the development of PTSD symptoms in response to psychosis and admission. We used a cross-sectional design with a sample of 47 participants recruited from a service in Northern Ireland who had experienced psychosis and been discharged from inpatient treatment within 12 months of data collection. The main outcome measure was the impact of events scale-revised. Data was subject to correlation analyses. A cut-off point of r = +/- 0.25 was used to select variables for inclusion in hierarchical regression analyses. Forty-five percent and 31% of the sample had moderate to severe PTSD symptoms related to psychosis and admission, respectively. The majority of participants identified positive symptoms and the first admission as the most distressing aspects of psychosis and admission. Childhood sexual and physical traumas were significant predictors of some PTSD symptoms. Strong association was found between current affective symptoms and PTSD symptoms. A reduced sense of availability of mental health service providers was also associated with PTSD symptoms and depression. Awareness of risk factors for the development of PTSD symptoms in response to admission and psychosis raises important issues for services and has implications for interventions provided.

Suspicious minds: The psychology of persecutory delusions

At least 10-15% of the general population regularly experience paranoid thoughts and persecutory delusions are a frequent symptom of psychosis. Persecutory ideation is a key topic for study. In this article the empirical literature on psychological processes associated with persecutory thinking in clinical and non-clinical populations is comprehensively reviewed. There is a large direct affective contribution to the experience. In particular, anxiety affects the content, distress and persistence of paranoia. In the majority of cases paranoia does not serve a defensive function, but instead builds on interpersonal concerns conscious to the person. However, affect alone is not sufficient to produce paranoid experiences. There is also evidence that anomalous internal experiences may be important in leading to odd thought content and that a jumping to conclusions reasoning bias is present in individuals with persecutory delusions. Theory of mind functioning has received particular research attention recently but the findings do not support a specific association with paranoia. The threat anticipation cognitive model of persecutory delusions is presented, in which persecutory delusions are hypothesised to arise from an interaction of emotional processes, anomalous experiences and reasoning biases. Ten key future research questions are identified, including the need for researchers to consider factors important to the different dimensions of delusional experience.