A systematic review and meta-analysis of the traumatogenic phenotype hypothesis of psychosis

BACKGROUND

Developmental trauma increases psychosis risk and is associated with poor prognosis. It has been proposed that psychosis in survivors of developmental trauma gives rise to a distinct 'traumatogenic' phenotype.

AIMS

Given the implications for personalised treatment, we sought to explore the traumatogenic psychosis phenotype hypothesis in a systematic review and meta-analysis of studies comparing psychotic presentations between adults with and without developmental trauma histories.

METHOD

We registered the systematic review on PROSPERO (CRD42019131245) and systematically searched EMBASE, Medline and PsycINFO. The outcomes of interests were quantitative and qualitative comparisons in psychotic symptom expression (positive, negative, cognitive) and other domains of psychopathology, including affect regulation, sleep, depression and anxiety, between adults with and without experience of developmental trauma.

RESULTS

Of 34 studies included (N = 13 150), 11 were meta-analysed (n = 2842). A significant relationship was found between developmental trauma and increased symptom severity for positive (Hedge's g = 0.27; 95% CI 0.10-0.44; P = 0.002), but not negative symptoms (Hedge's g = 0.13; 95% CI -0.04 to 0.30; P = 0.14). Developmental trauma was associated with greater neurocognitive, specifically executive, deficits, as well as poorer affect, dissociation and social cognition. Furthermore, psychotic symptom content thematically related to traumatic memories in survivors of developmental trauma.

CONCLUSIONS

Our findings that developmental trauma is associated with more severe positive and affective symptoms, and qualitative differences in symptom expression, support the notion that there may be a traumatogenic psychosis phenotype. However, underdiagnosis of post-traumatic stress disorder may also explain some of these findings. More research is needed to explore this further.

A Systematic Chart Review of Adults with Post-Traumatic Stress Disorder: Data from a Tertiary Care Psychiatry Center in India

BACKGROUND

Post-traumatic stress disorder (PTSD) is an understudied construct in the psychiatric setting. The majority of existing Indian studies on PTSD focus on the general population or disaster-stricken communities. Here, we present data from a five-year retrospective chart review from a tertiary care psychiatric center in India.

METHODS

Medical records of adult patients (≥18 years) who had attended psychiatry outpatient services between April 1, 2015 and March 31, 2020 (five years) and were diagnosed with PTSD, as per ICD-10 criteria, were reviewed (n = 113). The relevant sociodemographic and clinical details were extracted using a semistructured pro-forma.

RESULTS

The percentage of adult patients with PTSD diagnosis in the five years was 0.22%. PTSD was more common in females (n = 65, 57.5%). Most patients had interpersonal trauma (n = 85, 75.2%), specifically sexual abuse (n = 47, 41.6%). The median age of onset was 22 years. All the patients had re-experiencing symptoms, with an equally high rate of avoidance (n = 109, 96.5%) and arousal symptoms (n = 110, 97.3%). 82%(93) had a comorbid psychiatric disorder, with mood disorder being the most common (n = 44, 38.9%). Males had a higher rate of comorbid substance use disorder (n = 14, 29.2%) and depression (n = 20,42%), and females had a higher rate of comorbid dissociative disorder (n = 13,20%). Most of the patients received non-trauma-focused psychological interventions, and only 18% (20) received evidence-based trauma-focused psychological interventions.

CONCLUSION

Interpersonal trauma, specifically sexual abuse, largely contributes to PTSD among adults attending psychiatric services. The need for trauma-focused psychological interventions is underscored.

The HTQ-5: revision of the Harvard Trauma Questionnaire for measuring torture, trauma and DSM-5 PTSD symptoms in refugee populations

BACKGROUND

The Harvard Trauma Questionnaire (HTQ) was developed 25 years ago as a cross-cultural screening instrument to document trauma exposure, head trauma and trauma-related symptoms in refugees. This article aims to: (i) outline the process of revision of Part IV of the HTQ to (a) include the new DSM-5 diagnostic criteria for PTSD, and (b) separate out and more fully develop the refugee-specific functioning items; and (ii) promote a consistent approach to the validation of the HTQ-5 when adapted for use in other cultures and language groups.

METHODS

Our process involved item mapping; expert consultations; generating items according to the new DSM-5 criteria; and drafting, refinement and finalization of the revised measure focusing closely on issues of meaning, future translation into multiple languages and comprehension amongst groups with low literacy and little or no exposure to Western trauma concepts. Validity and reliability testing of the new HTQ-5 is underway.

RESULTS

The HTQ symptom checklist was modified consistent with current DSM-5 diagnostic criteria to identify those refugees at risk for mental health and other symptoms associated with traumatic life events, disability and dysfunction.

CONCLUSIONS

Accurate screening of post-traumatic distress and dysfunction enables those working with refugees to triage them more effectively to scarce health and mental health resources. When developing screening measures to inform public health policy and practice, it is vital that these measures can bridge the gap between western (etic) nosologies and indigenous (emic) understandings of traumatic stress.

What Therapies are Favored in the Treatment of the Psychological Sequelae of Trauma in Human Trafficking Victims?

Human trafficking is a major public health concern that brings about deleterious psychological consequences and sequelae. Although a number of risk and protective factors for the health consequences of human trafficking victims have been identified, there is a dearth of information in the area of treatment. Specifically, we found no articles comparing the different components of prevailing trauma treatment strategies, and the potential usefulness of these strategies in the treatment of human trafficking victims. To this end, we compared and contrasted the different therapeutic treatments typically implemented with victims of trauma (including domestic violence victims and torture victims), and discussed how the different components of these treatments may or may not be helpful for human trafficking victims. We assessed the impact of these treatments on the psychological consequences of trauma and, in particular on posttraumatic stress disorder. We also assessed the potential usefulness of these treatments with co-occurring problems such as substance use, psychosis, dissociation, and other mood and anxiety disorders. On the basis of the prevailing research, we highlighted cognitive therapies as being preferred in addressing the needs of human trafficking victims. Mental health providers who work with human trafficking victims should become aware of and practiced in the use of cognitive therapeutic approaches in treating this population. Efficacy and effectiveness studies are needed to validate our recommendations.

Is Shame Hallucinogenic?

Research into the causes of "hearing voices," formally termed auditory verbal hallucinations (AVH), has primarily focused on cognitive mechanisms. A potentially causative role for emotion has been relatively neglected. This paper uses historical and contemporary case studies of AVH to tentatively generate the hypothesis that shame can be a causal factor in the onset of AVH. Other sources of support for the generation of this hypothesis are then sought. First, evidence is examined for a role of shame in the etiology of post-traumatic stress disorder, a condition that is characterized by phenomena related to AVH (intrusions and dissociation) and in which a substantial minority of sufferers report AVH. Second, the effect on AVH of a psychological therapy specifically designed to counteract shame (Compassion Focused Therapy) is noted. The hypothesis generation process is then expanded to propose mechanisms that could mediate a relation between shame and AVH. It is proposed that employing absorbed or avoidant strategies to deal with shame may lead to AVH through mediating mechanisms such as rumination, suppression, and dissociation. Evolutionary reasons for a relation between shame and AVH are also proposed, including that AVH may be an evolved mechanism to encourage self-protective behaviors in the wake of trauma. It is concluded that existing research supports the generation of this paper's hypothesis, which is now worthy of dedicated empirical testing.

Role of neuroinflammation and sex hormones in war-related PTSD

The susceptibility to develop posttraumatic stress disorder (PTSD) is greatly influenced by both innate and environmental risk factors. One of these factors is gender, with women showing higher incidence of trauma-related mental health disorders than their male counterparts. The evidence so far links these differences in susceptibility or resilience to trauma to the neuroprotective actions of sex hormones in reducing neuroinflammation after severe stress exposure. In this review, we discuss the impact of war-related trauma on the incidence of PTSD in civilian and military populations as well as differences associated to gender in the incidence and recovery from PTSD. In addition, the mutually influencing role of inflammation, genetic, and sex hormones in modulating the consequences derived from exposure to traumatic events are discussed in light of current evidence.

Treatment Outcome in Depressed Latinos Predicted by Concomitant Psychosislike Symptoms

We compared treatment response (≥50 decrease in Nine-Item Patient Health Questionnaire total score) among 24 Latinos with major depressive disorder, presenting with and without specific psychosislike symptoms: A, hearing noises or house sounds, B, hearing voices calling one's name, C, seeing fleeting visions such as shadows, and D, symptoms more likely to be truly psychotic (e.g., poorly defined and short-lasting voices [other than B], fleeting paranoid ideation, or fleeting ideas of reference). 18 subjects (75%) endorsed symptoms of cluster A, 12 (50%) of cluster B, 10 (31%) of cluster C, and 12 (50%) of cluster D. Only subjects who reported symptoms from the D cluster exhibited significantly unfavorable depressive outcomes (compared to those with absence of D symptoms). The authors propose a phenomenological differentiation between benign psychosislike symptoms (clusters A-C) and the expression of the psychotic continuum (cluster D) in depressed Latinos.

Auditory verbal hallucinations in schizophrenia and post-traumatic stress disorder: common phenomenology, common cause, common interventions?

Auditory verbal hallucinations (AVH: ‘hearing voices’) are found in both schizophrenia and post-traumatic stress disorder (PTSD). In this paper we first demonstrate that AVH in these two diagnoses share a qualitatively similar phenomenology. We then show that the presence of AVH in schizophrenia is often associated with earlier exposure to traumatic/emotionally overwhelming events, as it is by definition in PTSD. We next argue that the content of AVH relates to earlier traumatic events in a similar way in both PTSD and schizophrenia, most commonly having direct or indirect thematic links to emotionally overwhelming events, rather than being direct re-experiencing. We then propose, following cognitive models of PTSD, that the reconstructive nature of memory may be able to account for the nature of these associations between trauma and AVH content, as may threat-hypervigilance and the individual’s personal goals. We conclude that a notable subset of people diagnosed with schizophrenia with AVH are having phenomenologically and aetiologically identical experiences to PTSD patients who hear voices. As such we propose that the iron curtain between AVH in PTSD (often termed ‘dissociative AVH’) and AVH in schizophrenia (so-called ‘psychotic AVH’) needs to be torn down, as these are often the same experience. One implication of this is that these trauma-related AVH require a common trans-diagnostic treatment strategy. Whilst antipsychotics are already increasingly being used to treat AVH in PTSD, we argue for the centrality of trauma-based interventions for trauma-based AVH in both PTSD and in people diagnosed with schizophrenia.

Distinguishing schizophrenia from posttraumatic stress disorder with psychosis

PURPOSE OF REVIEW

Co-occurrence of psychotic symptoms with symptoms typically thought of as posttraumatic stress disorder (PTSD) is well known, and there has been considerable debate whether this represents a psychotic subtype or a comorbid psychotic disorder.

RECENT FINDINGS

Psychotic symptoms typical of schizophrenia occur with a higher than expected frequency in PTSD. A large genome-wide association study (GWAS) has identified a collection of genes associated with PTSD, and these genes overlap with those identified as increasing the risk of developing schizophrenia.

SUMMARY

Up to 70% of returning veterans experience symptoms of PTSD. These individuals also fall within the peak age range for the onset of schizophrenia. PTSD with psychosis may occur for several reasons: trauma increases one's risk for schizophrenia and PTSD; patients with schizophrenia have a higher incidence of PTSD and may present with characteristic psychotic symptoms overlapping with psychosis in schizophrenia. Secondary to symptom overlap, there may be substantial misdiagnosis of psychotic disorders as PTSD, or nonidentification of a comorbid psychotic disorder. This overlap calls into question traditional diagnostic boundaries with implications for initial and long-term treatment of PTSD and psychosis. This review will discuss the recent literature relating to the association of PTSD with schizophrenia.

Narrative Exposure Therapy for Treating PTSD With Psychotic Features

Posttraumatic stress disorder (PTSD) with secondary psychotic features is a syndrome that comprises PTSD symptoms followed in time by the additional appearance of psychotic features. Although diagnostic criteria for this condition are not available, the clinical description of this condition has been described especially in individuals who have experienced severe, chronic, multiple traumatic events. This case study presents the treatment of a survivor of torture with severe PTSD and concomitant psychotic features using the psychosocial approach as a theoretical framework of the clinical presentation and narrative exposure therapy (NET) as a psychotherapeutic intervention. NET could be a useful psychotherapeutic tool in relieving symptoms related to severe PTSD with secondary psychotic features. The overall implications involved in working with survivors of torture are also discussed.

Psychological strains, salivary biomarkers, and risks for coronary heart disease among hurricane survivors

OBJECTIVE

To examine the associations of psychological strains, salivary biomarkers, and coronary heart disease (CHD) risks in hurricane survivors 2 years after Hurricane Ike in the United States.

BACKGROUND

Hurricane survivors often suffer from long-lasting posttraumatic stress disorder (PTSD) and other forms of psychological strain related to surviving a natural disaster and dealing with its aftermath. Psychological strains may be associated with biomarkers, which, in turn, may be associated with a higher incidence of CHD risks.

METHODS

Structured interviews were conducted with 19 hurricane survivors to assess psychological strains (PTSD, perceived stress, depression, and anxiety) and measure CHD risks. Saliva samples were collected by the passive drool method and analyzed for inflammatory cytokine (interleukin [IL]-1β, IL-6, and IL-10) and chemokine (monocyte chemotactic protein [MCP]-1) biomarkers.

RESULTS

The salivary level of MCP-1 was significantly associated with PTSD symptoms, depression (both p < .01), and anxiety (p < .05). There were significant associations between anxiety and hypertension (p < .01), perceived stress and blood glucose level (p < .05), and perceived stress and obesity (p < .05).

CONCLUSION

Our findings that long-lasting psychological strains are associated with major CHD risks and salivary MCP-1 levels suggest that the mechanism by which such strains play a role in the development of CHD involves recruitment of monocyte cells in response to chronic endothelial inflammation. Further studies are needed to advance our understanding of the underlying mechanisms by which the PTSD and other psychological strains contribute to the development of CHD.

Delusional versus nondelusional body dysmorphic disorder: recommendations for DSM-5

The core feature of body dysmorphic disorder (BDD) is distressing or impairing preoccupation with nonexistent or slight defects in one's physical appearance. BDD beliefs are characterized by varying degrees of insight, ranging from good (ie, recognition that one's BDD beliefs are not true) through "absent insight/delusional" beliefs (ie, complete conviction that one's BDD beliefs are true). The Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. (DSM-III-R) and The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) classified BDD's nondelusional form in the somatoform section of the manual and its delusional form in the psychosis section, as a type of delusional disorder, somatic type (although DSM-IV allowed double-coding of delusional BDD as both a psychotic disorder and BDD). However, little or no evidence on this issue was available when these editions were published. In this article, we review the classification of BDD's delusional and nondelusional variants in earlier editions of DSM and the limitations of their approaches. We then review empirical evidence on this topic, which has become available since DSM-IV was developed. Available evidence indicates that across a range of validators, BDD's delusional and nondelusional variants have many more similarities than differences, including response to pharmacotherapy. Based on these data, we propose that BDD's delusional and nondelusional forms be classified as the same disorder and that BDD's diagnostic criteria include an insight specifier that spans a range of insight, including absent insight/delusional BDD beliefs. We hope that this recommendation will improve care for patients with this common and often-severe disorder. This increased understanding of BDD may also have implications for other disorders that have an "absent insight/delusional" form.