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

Several recent studies have provided direct evidence for the link between posttraumatic stress disorder (PTSD) and psychosis. Patients with psychotic disorders are known to be at a higher risk of traumatization and PTSD. Additionally, preclinical and clinical data suggest that the effects of trauma exposure on neural networks may provide a common diathesis for disorders like PTSD and schizophrenia. This article reviews evidence on a) the magnitude of association between PTSD and psychosis, b) the causal mechanisms implicated, and c) treatment considerations relevant to this association. A comprehensive MEDLINE search was conducted, and articles pertinent to epidemiological, clinical, and treatment aspects of comorbid PTSD and psychosis were identified. High rates of PTSD characterize patients with severe mental illness. Psychotic phenomena may also be a relatively common manifestation in patients with chronic PTSD. However, in clinical settings, the diagnosis is often missed, and few systematic guidelines exist for the identification and treatment of these comorbidities. Future neurobiological and treatment studies may be useful in better informing the clinical management of these subgroups.     

Prevalence of post-traumatic stress disorder in first-episode psychosis

Background: Psychosis can be considered one of the most severe stressors that an individual may face. Previous studies have suggested that the traumatic experience of psychotic symptoms and hospitalization may provoke a post-traumatic type reaction. Aim: The aim of this study was to establish the point prevalence of post-traumatic stress disorder (PTSD) among patients recovering from a first-episode of psychosis in Singapore, and to elucidate the factors associated with it. Methods: Patients from the Early Psychosis Intervention Programme in Singapore, who were recovering from their first psychotic episode, participated in this study. Diagnoses were made using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) – Text Revised Axis I Disorders. The Clinician-Administered PTSD Scale, an interviewer-rated semi-structured interview, was used to diagnose PTSD. Results: Sixty-one patients (30 males, 31 females) were recruited. Twelve (19.7%) patients were diagnosed with PTSD. Hospitalization for treatment, whether compulsory or otherwise, did not increase the rate of PTSD. The Chinese ethnic group had lower risk of developing PTSD (adjusted odds ratio 0.14, P = 0.018). Conclusions: There was a high prevalence of PTSD in patients recovering from their first psychotic episode. This study raises awareness among clinicians and hopes to promote early recognition and treatment of PTSD so as to potentially improve outcome.     

Reciprocal Association between Psychological Distress and PTSD and Their Relationship with Pre-Displacement Stressors among Displaced Women

It is established in the psychological literature that pre-displacement stressors, PTSD symptoms, and psychological distress are associated among internally displaced persons. However, existing studies have not demonstrated the mechanism underlying these associations. This study compared two explanatory models; one with PTSD symptoms severity explaining the indirect association between pre-displacement stressors and psychological distress, and the other with psychological distress explaining the indirect relationship between pre-displacement stressors and PTSD symptoms severity. In a cross-sectional design, 631 women (Mean age = 31.18 ± 8.59) were conveniently and purposely selected from the displaced women harboured in two camps in Borno State, Nigeria, due to the Boko-Haram insurgency. Data were collected utilizing structured questionnaires and subjected to path analyses. Results demonstrated that PTSD symptoms severity and psychological distress indirectly explained their respective and independent association with pre-displacement stressors. However, PTSD symptoms had a statistically larger standardized indirect effect size, greater indirect effect percentage, and bigger kappa-squared (k2) effect size than psychological distress. PTSD symptoms and psychological distress may have a reciprocal influence on each other from pre-displacement stressors. However, PTSD symptoms can better explain the association between pre-displacement stressors and psychological distress than the other way around. These outcomes have important implications for the psychological treatment of displaced persons.     

Psychosis and trauma. Theorical links between post-traumatic and psychotic symptoms

Introduction

The co-occurrence between post-traumatic symptoms and psychotic symptoms is well described in the immediate suites of a trauma but can also be chronic. This symptomatic co-occurrence, rarely studied in the literature, is often approached under the sole angle of a primary post-traumatic stress disorder (PTSD) or of a primary psychosis, without federative will to unify the psychotic and post-traumatic symptoms within the same nosological framework. Individuals with schizophrenia or schizoaffective disorder report higher rates of trauma and assault than the general population.

Literature findings

High rates of PTSD have been noted in severe mental illness cohorts. Psychotic phenomena may be a relatively common manifestation in patients with chronic PTSD.

Aim

The purpose of this paper is to expose the various theorical psychopathological aspects between the symptoms of psychosis and PTSD. In populations of veterans, positive and negative symptoms of psychosis in PTSD are described as delusional thoughts and hallucinations often combat-specific.

Clinical findings

When a PTSD becomes established at a subject to the personality of neurotic structure, the intensity of the PTSD's symptoms lead to a psychotic expression which constitutes a factor of seriousness. Besides, PTSD often induces a risk of substance use disorder supplying psychotic symptoms. Cannabis increases the hallucinations, cocaine strengthens an underlying paranoid tone, and alcohol implies withdrawal hallucinosis. Moreover, such consumption could be a risk factor for the future development of chronic psychosis. From another point of view, by basing themselves on the plasma dopamine beta-hydroxylase activity, some authors made the analogy between psychotic major depression and PTSD with psychotic features (also characterized as a distinct psychotic subtype of PTSD). However, other studies found no correlation between PTSD with psychotic features and family predisposition for schizophrenia or schizoaffective disorder.

Discussion

The determination of the structure of personality seems fundamental in the understanding of the symptoms. A personality of psychotic structure increases the risk of traumatization and PTSD. At the same time, the fragility of this structure causes an increased sensitivity to the trauma, which takes on a particular echo. Moreover, a trauma can test a latent psychotic structure to reveal its existence. The experience of psychosis may be traumatic in itself for patients with, notably, seclusion and sedation during hospitalization. Lastly, the symptoms of this post-traumatic psychosis will be differentiated from neurological confusion caused by a traumatic brain injury. Clinicians often fail to screen routinely for trauma and PTSD symptoms in patients with severe mental illness because few systematic guidelines exist for the identification and treatment of this comorbidity.

Conclusion

The links between psychotic and psycho-traumatic symptoms are complex and multidirectional; this co-occurrence is a factor of seriousness. The clinician, while paying attention to these symptoms, has to distinguish the structure of the personality of the subject to articulate the psychotherapy and the pharmacological treatment. Further investigational studies may determine whether antipsychotics will enhance treatment response in PTSD patients with psychotic features.     

Interpersonal trauma and posttraumatic stress disorder in patients with severe mental illness: demographic, clinical, and health correlates

This study's purpose was to evaluate the prevalence and correlates of posttraumatic stress disorder (PTSD) in persons with severe mental illness. Standardized assessments of interpersonal trauma and PTSD were conducted in 782 patients with severe mental illness receiving services in one of five inpatient and outpatient treatment settings. Analyses examined the prevalence of PTSD and the demographic, clinical, and health correlates of PTSD diagnosis. The overall rate of current PTSD in the sample was 34.8 percent. For demographic characteristics, the prevalence of PTSD was higher in patients who were younger, white, homeless, and unemployed. For clinical and health variables, PTSD was more common in patients with major mood disorders (compared to schizophrenia or schizoaffective disorders), alcohol use disorder, more recent psychiatric hospitalizations, more health problems, more visits to doctors for health problems, and more nonpsychiatric hospitalizations over the past year. The results support prior research documenting the high rates of PTSD in patients with severe mental illness and suggest that PTSD may contribute to substance abuse, psychiatric and medical comorbidity, and psychiatric and health service utilization.     

Untreated PTSD in schizophrenia - unrecognized risk factor for recovery and course of illness?

More recently research has focused on post-traumatic stress disorder (PTSD) as comorbide condition of schizophrenia. Current literature focussing the relationship between PTSD and schizophrenia is reviewed. Evidence is found in support of psychosis as a precondition for development of PTSD, PTSD as vulnerability factor for psychosis as well as psychosis and PTSD both as part of a spectrum of responses to a traumatic event. PTSD may be regarded as risk factor for worse outcome in schizophrenia: Internal stress of reexperiencing the trauma may enhance vulnerability to relapse of illness and proneness to anxiety avoiding coping style with psychosis by adoption of a "sealing over" style, lowering service utilization and compliance. Risk for development of alcohol misuse, cannabis misuse or benzodiazepine misuse and depression may be higher, also worsening the course of schizophrenia. Methodological shortcomings of current studies, ongoing debates on extending DSM-IV criterion A1 definition to psychotic or treatment experiences and implications for clinical assessment and cognitive-behavioural treatment of PTSD in schizophrenia are discussed.     

Corticotropin-releasing factor in posttraumatic stress disorder (PTSD) with secondary psychotic symptoms, nonpsychotic PTSD, and healthy control subjects.

BACKGROUND: Recent studies have reported a high comorbidity between posttraumatic stress disorder (PTSD) and psychotic symptoms, and it has been hypothesized that PTSD with comorbid psychosis is a severe form of PTSD. Few studies have examined the neurobiology of PTSD with comorbid psychosis. If PTSD with secondary psychotic symptoms (PTSD-SP) is a severe form of PTSD, then it might be expected to show more extreme perturbations in the neuroendocrine patterns that characterize PTSD. METHODS: Patients with PTSD with secondary psychotic symptoms (PTSD-SP), PTSD without psychosis, and healthy comparison subjects were compared for differences in cerebrospinal fluid concentrations of corticotropin-releasing factor (CRF) and somatotropin-release-inhibiting hormone (SRIF). RESULTS: The PTSD-SP subjects had significantly higher mean levels of CRF than either the PTSD or control subjects (p <.01). The three groups showed similar SRIF levels. CONCLUSIONS: These data implicate abnormalities in the secretion of CRF with the production of secondary psychotic symptoms in PTSD. This finding supports the validity of PTSD-SP as a PTSD subtype and as a severe form of PTSD.     

PTSD Following Bereavement

Until quite recently, the only stressor considered consistent with the diagnosis of PTSD was a catastrophic, out of the ordinary, trauma that almost anyone could be expected to have a severe reaction to. Thus, PTSD was considered relatively rare among non-military populations. More recently, epidemiologic surveys have suggested that PTSD may be much more prevalent than heretofore recognized, and the DSM-IV has opened the door to a much larger variety of stressors (the A criterion). Yet, bereavement is not considered the type of stressor capable of producing PTSD. In this study, 350 newly bereaved widows and widowers were assessed for the prevalence of PTSD, its chronicity, comorbidity, and consequences. The diagnosis of PTSD was made on the basis of questionnaire items approximating the DSM-IV criteria for PTSD. At 2 months after the spouse's death, 10% of those whose spouses died after a chronic illness met criteria for PTSD, 9% of those whose spouses died unexpectedly met criteria, and 36% of those whose spouses died from unnatural causes (suicide or accident) had PTSD. Symptoms tended to be chronic in at least 40% of the subjects, almost always were associated with comorbid depression, and created substantial morbidity. The results suggested that PTSD may occur after bereavement, and, by extension, other stressors not recognized by official diagnostic systems. The A criterion needs further examination.     

An examination of stress and coping among adults diagnosed with severe mental illness

The present study explored the types of major life and chronic stressors that people with severe mental illness experience, and the coping strategies that are used in response to them. Twenty-eight adults with severe mental illness completed qualitative interviews focused on stress and coping in the prior six months. Participants reported experiencing disruptive major life events including the sudden death of a loved one, loss of housing, and criminal victimization, as well as chronic stressors such as psychiatric symptoms and substance abuse issues, substandard living conditions, legal problems, and health concerns. Results suggested that persons with severe mental illness frequently use problem-centered coping strategies in response to most types of stressors, including major life events, although this occurred after the initial application of avoidant coping strategies. Future research should explore whether or not the identified stressors and the coping strategies used in response to them are unique to this population.     

The stressor criterion in DSM-IV posttraumatic stress disorder: an empirical investigation.

BACKGROUND: The DSM-IV two-part definition of posttraumatic stress disorder (PTSD) widened the variety of stressors (A1) and added a subjective component (A2). The effects of the revised stressor criterion on estimates of exposure and PTSD in a community sample are evaluated. METHODS: A representative sample of 2181 persons in southeast Michigan were interviewed about lifetime history of traumatic events and PTSD. The evaluation of the revised two-part definition is based on a randomly selected sample of events that represents the total pool of traumatic events experienced in the community. RESULTS: The enlarged definition of stressors in A1 increased the total number of events that can be used to diagnose PTSD by 59%. The majority of A1 events (76.6%) involved the emotional response in A2. Females were more likely than males to endorse A2 (adjusted odds ratio = 2.66; 95% confidence interval 1.92, 3.71). Of all PTSD cases resulting from the representative sample of events, 38% were attributable to the expansion of qualifying events in A1. The identification of exposures that lead to PTSD were not improved materially by A2 however, events that did not involve A2 rarely resulted in PTSD. CONCLUSIONS: Compared to previous definitions, the wider variety of stressors in A1 markedly increased the number of events experienced in the community that can be used to diagnose PTSD. Furthermore, A2 might be useful as a separate criterion, an acute response necessary for the emergence of PTSD, and might serve as an early screen for identifying a subset of recently exposed persons at virtually no risk for PTSD. The utility of A2 as a screen must be tested prospectively.     

Posttraumatic stress disorder among Hispanic Vietnam veterans

OBJECTIVE: The purpose of this study was to examine posttraumatic stress disorder (PTSD) among Hispanics who served in the Vietnam War. METHOD: The authors conducted secondary data analyses of the National Vietnam Veterans Readjustment Study, a national epidemiologic study completed in 1988 of a representative sample of veterans who served during the Vietnam era (N=1,195). RESULTS: After adjustment for premilitary and military experiences, the authors found that Hispanic, particularly Puerto Rican, Vietnam veterans had significantly more severe PTSD symptoms and a higher probability of experiencing PTSD than nonminority veterans. However, they had no greater risk for other mental disorders, and their greater risk for PTSD was not explained by acculturation. Despite their more severe symptoms, Hispanic veterans, especially Puerto Rican veterans, showed no greater functional impairment than non-Hispanic white veterans. CONCLUSIONS: Hispanic Vietnam veterans, especially Puerto Rican Vietnam veterans, have a higher risk for PTSD and experience more severe PTSD symptoms than non-Hispanic white Vietnam veterans, and these differences are not explained by exposure to stressors or acculturation. This high level of symptoms was not accompanied by substantial reduction in functioning, suggesting that the observed differences in symptom reporting may reflect features of expressive style rather than different levels of illness.     

Relationships between trauma and psychosis: an exploration of cognitive and dissociative factors

OBJECTIVE: There is a growing awareness of the relationship between trauma and psychosis. Studies have found associations between traumatic life experiences and the development of psychosis. METHOD: This study examined the prevalence of trauma exposure and post-traumatic stress disorder (PTSD) in 32 people with psychotic diagnoses and investigated associations between specific traumas and psychotic symptoms. The role of dissociation and cognitive factors was also explored. RESULTS: The prevalence of lifetime trauma was high (94% of the sample reported at least one traumatic event). The prevalence of current PTSD was 53%. Severity of trauma was associated with severity of PTSD and psychotic experiences. Physical abuse was associated with positive psychotic symptoms and sexual abuse was specifically related to hallucinations. Dissociative processes and negative beliefs formed as a result of trauma were associated with psychotic experiences (particularly hallucinations). CONCLUSION: These findings are consistent with the suggestion that psychosis may be trauma-induced, and other implications are considered.     

Psychological mechanisms in acute response to trauma.

Traumatic events are common, but posttraumatic stress disorder (PTSD) is relatively rare. These facts have prompted several questions: What variables increase risk for PTSD among trauma-exposed people? Can we distinguish between pathologic and nonpathologic responses to traumatic stressors? If so, what psychobiological mechanisms mediate pathologic responses? Prospective studies have identified certain individual difference variables as heightening risk (e.g., lower intelligence, negative personality traits). Studies on peritraumatic and acute-phase response have identified certain dissociative symptoms (e.g., time slowing, derealization) and cognitive appraisal (e.g., belief that one is about to die) as harbingers of later PTSD. Negative appraisal of acute symptoms themselves may foster chronic morbidity (e.g., that symptoms signify shameful moral weakness or prefigure impending psychosis). Further attempts to elucidate pathologic mechanisms in the cognitive psychology laboratory and via biological challenges are warranted.     

Posttraumatic stress symptomatology and cancer

The extant nosological formulations of the American Psychiatric Association denotes that Posttraumatic Stress Disorder (PTSD) maybe predicated upon some life threatening experience. Historically, combat, robbery, rape, and serious accidents have been included as traumatogenetic stressors. Only recently has life-threatening illness been considered as a traumatogenetic stressor. This paper reviews the relativity between cancer and posttraumatic stress.     

Cannabis and psychosis

There has been considerable debate about the reasons for the association observed between cannabis use and psychosis in both clinical and general population samples. Among the hypotheses proposed to explain the association are the following: 1) common factors explain the cooccurrence; 2 cannabis causes psychosis that would not have occurred in the absence of cannabis use; 3) cannabis precipitates psychosis among persons who were vulnerable to developing the disorders; 4) cannabis use worsens or prolongs psychosis among those who have already developed the disorder; and 5) that persons with psychosis are more likely to become regular or problematic cannabis users than persons without psychosis. This article evaluates the evidence on each of these hypotheses, including recent research on the role of the cannabinoid receptor system in schizophrenia. The evidence suggests that common factors do not explain the comorbidity between cannabis use and psychosis, and it is unlikely that cannabis use causes psychosis among persons who would otherwise not have developed the disorder. The evidence is more consistent with the hypotheses that cannabis use may precipitate psychosis among vulnerable individuals, increase the risk of relapse among those who have already developed the disorder, and may be more likely to lead to dependence in persons with schizophrenia.     

Non-participation may bias the results of a psychiatric survey

Objective A major reason for limited validity of research is non-participation. Subjects with severe mental illness tend to cumulate in the group of non-participants, causing selection bias. We tested the hypothesis that severe psychosis is linked to non-participation in a field survey including magnetic resonance imaging (MRI) of the brain, psychiatric interviews and cognitive testing among subjects with psychosis. Furthermore, we wanted to explore other associative factors expected to affect non-participation. Methods Members of the Northern Finland 1966 Birth Cohort with a lifetime diagnosis of psychosis (N = 145) were invited to participate in the survey conducted in 1999–2001. Non-participation was determined by refusal or loss of contact. Data were gathered in earlier phases of the follow-up study or using register data. Results Ninety-one (63%) subjects attended the study. Compared to participants, non-participants were more often patients with schizophrenia and had more psychiatric hospitalisations, they had more positive psychosis symptoms during their illness course and they were more often on disability pension. Married subjects participated more often than those who were not married. Conclusion This study suggests that among subjects with psychosis, particularly those subjects who have the most severe course of illness are less willing to participate. This may lead to biased estimates when studying subjects with severe mental disorders.     

Three strategies for changing attributions about severe mental illness

The effects of three strategies for changing stigmatizing attitudes--education (which replaces myths about mental illness with accurate conceptions), contact (which challenges public attitudes about mental illness through direct interactions with persons who have these disorders), and protest (which seeks to suppress stigmatizing attitudes about mental illness)--were examined on attributions about schizophrenia and other severe mental illnesses. One hundred and fifty-two students at a community college were randomly assigned to one of the three strategies or a control condition. They completed a questionnaire about attributions toward six groups--depression, psychosis, cocaine addiction, mental retardation, cancer, and AIDS--prior to and after completing the assigned condition. As expected, results showed that education had no effect on attributions about physical disabilities but led to improved attributions in all four psychiatric groups. Contact produced positive changes that exceeded education effects in attributions about targeted psychiatric disabilities: depression and psychosis. Protest yielded no significant changes in attributions about any group. This study also examined the effects of these strategies on processing information about mental illness.     

Coping strategies and social support in old age psychosis

BACKGROUND: According to vulnerability-stress models of psychosis, cognitive and behavioural coping strategies can help mediate the potentially negative effects of daily stressors. The nature, frequency and effectiveness of coping have been studied in people with psychosis under 65 years of age. However, these findings may not generalise to older people with the diagnosis, as the nature of stressors and coping strategies may change with increasing age. This study therefore aimed to explore coping in older patients with psychosis. METHODS: A total of 48 older patients with psychosis (F20-29, ICD-10) and 25 non-clinical elderly controls were compared using self-report measures of stressors, perceived control over stressors, coping strategies, perceived coping efficacy and social support. A regression analysis was used to explore predictors of dysfunctional coping in the patient group. RESULTS: Patients used a significantly higher proportion of problem-focused coping strategies, but they were more dysfunctional copers and rated their coping as less effective compared to controls. They also had fewer friends and less emotional support. Severity of symptoms was a significant predictor of dysfunctional coping when depression, cognitive impairment and functional disability were controlled. CONCLUSIONS: Patients with psychosis coped less well with daily stressors than controls and patients with more severe symptoms were more dysfunctional copers. The findings highlight the potential benefit of psychosocial interventions in old age psychosis.     

Insight among people with severe mental illness,co-occurring PTSD and elevated psychotic symptoms: Correlates and relationship to treatment participation

BackgroundThere is a dearth of research on what factors are predictive of insight among people with severe mental illness and co-occurring PTSD.MethodData were drawn from 146 participants with severe mental illness, co-occurring PTSD and elevated psychotic symptoms participating in a randomized controlled trial comparing two interventions for PTSD among people with severe mental illness. We examined the clinical and demographic correlates of insight at baseline, the relationship between baseline insight and treatment participation, the relationship between treatment participation and post-treatment insight, and the relationship between change in insight and change in other clinical variables.ResultsImpaired insight was relatively common, with roughly half the sample demonstrating mild or moderate impairment at baseline. Baseline insight was associated with fewer psychotic and disorganized symptoms, and greater emotional discomfort and PTSD knowledge, but was not associated with negative symptoms, PTSD symptoms, depression/anxiety, or treatment participation. Participation in PTSD treatment was associated with increased insight at post-treatment. Improved insight was associated with improvements in disorganization and negative symptoms, but not with knowledge of PTSD or positive symptoms.DiscussionThe findings suggest that engagement in treatment that includes educating people about PTSD may lead to improvements in insight and related improvements in other psychiatric symptoms.     

A person-centered analysis of posttraumatic stress disorder symptoms following a natural disaster: Predictors of latent class membership

The present study applied latent class analysis to a sample of 810 participants residing in southern Mississippi at the time of Hurricane Katrina to determine if people would report distinct, meaningful PTSD symptom classes following a natural disaster. We found a four-class solution that distinguished persons on the basis of PTSD symptom severity/pervasiveness (Severe, Moderate, Mild, and Negligible Classes). Multinomial logistic regression models demonstrated that membership in the Severe and Moderate Classes was associated with potentially traumatic hurricane-specific experiences (e.g., being physically injured, seeing dead bodies), pre-hurricane traumatic events, co-occurring depression symptom severity and suicidal ideation, certain religious beliefs, and post-hurricane stressors (e.g., social support). Collectively, the findings suggest that more severe/pervasive typologies of natural disaster PTSD may be predicted by the frequency and severity of exposure to stressful/traumatic experiences (before, during, and after the disaster), co-occurring psychopathology, and specific internal beliefs.