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Treating the Trauma of First Episode Psychosis: a PTSD Perspective

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Treating the Trauma of First Episode Psychosis: a PTSD Perspective Journal of Mental Health ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20 Treating the trauma of first episode psychosis: A PTSD perspective Kim T. Mueser & Stanley D. Rosenberg To cite this article: Kim T. Mueser & Stanley D. Rosenberg (2003) Treating the trauma of first episode psychosis: A PTSD perspective, Journal of Mental Health, 12:2, 103-108 To link to this article: http://dx.doi.org/10.1080/096382300210000583371 Published online: 24 Oct 2011. Submit your article to this journal Article views: 93 View related articles Citing articles: 3 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijmh20 Download by: [Portland State University] Date: 26 January 2016, At: 13:06 Journal of Mental Health (2003) 12, 2, 103–108 Editorial Treating the trauma of first episode psychosis: A PTSD perspective KIM T. MUESER & STANLEY D. ROSENBERG New Hampshire-Dartmouth Psychiatric Research Center, Department of Psychiatry, Dartmouth Medical School, Lebanon, New Hampshire, USA Over the past decade there has been a huge In this same decade, a number of research growth of interest in identification and rapid studies have also begun to delineate a com- intervention for recent onset of psychosis plex set of inter-relationships between (Linszen & Dingemans, 2002; McGlashan et psychotic illness, trauma exposure and post- al., 2001; McGorry & Jackson, 1999). Effec- traumatic stress disorder (PTSD; Rosenberg tive treatment in the early years after the et. al., 2002). Consistent results suggest that: onset of psychosis is thought to be important 1) persons hospitalized for psychotic illness for several reasons. First, the duration of have unusually high rates of trauma exposure untreated psychosis in first episode patients prior to illness onset; 2) severe psychiatric is predictive of short- and long-term out- illness entails increased risk of trauma expo- comes (Lieberman et al., 2001). Second, sure, including violent victimization; and 3) deterioration in symptoms and psychosocial psychiatric disorder increases risk for PTSD functioning in schizophrenia occurs rapidly following exposure to trauma. However, after the first episode, usually within 2–5 important nosologic and conceptual ques- years (Birchwood et al., 1998; McGlashan, tions remain in regards to these findings. For Downloaded by [Portland State University] at 13:06 26 January 2016 1988). Third, adherence to treatment is espe- example, questions have been raised regard- cially problematic in recent onset psychosis ing the validity of patients’ reports of victimi- (Edwards & McGorry, 2002). These prob- zation, as well as the potential symptom lems suggest that if effective and engaging overlap between depression, schizophrenia interventions can be delivered in a timely and PTSD. These artifacts may conflate the fashion to individuals who have recently ex- apparent rates of PTSD in persons with re- perienced an onset of psychosis, the long- cent onset psychotic disorders (Franklin & term trajectory of the illness could be im- Zimmerman, 2001; Priebe et al., 1998). Al- proved. ternatively, PTSD associated with psychotic Address for Correspondence: Kim T. Mueser, NH-Dartmouth Psychiatric Research Center, Main Building, 105 Pleasant St., Lebanon, NH 03301, USA. Tel: +1 603-271-5747; Fax: +1 603-271-5265; E-mail: [email protected] ISSN 0963-8237print/ISSN 1360-0567online/2003/020103-06 © Shadowfax Publishing and Taylor & Francis Ltd DOI: 10.1080/09638230021000058337 104 Kim T. Mueser & Stanley D. Rosenberg symptoms may be misdiagnosed as a primary ogy. In addition, early treatment episodes are psychotic disorder (Hamner et al., 1999). frequently experienced by clients as even Even more controversial is an emerging set more traumatizing than the symptoms that of findings that first episode psychosis itself, precipitate intervention, putting clients at risk and patients’ associated treatment experi- for iatrogenic psychiatric morbidity (e.g. ences, may be traumatic for many persons. PTSD and depression), and very likely in- We will attempt to outline our rationale for creasing avoidance of helpful treatments. hypothesizing that interventions for recent Both the common finding of poor medication onset psychosis can be made more effective adherence, and the limited success of psy- if they begin to address the post-traumatic chosocial treatments for recent onset psycho- issues of these patients. sis, may be partly due to their failure to adequately address both the traumatizing ef- Treatment of recent onset psychosis fects of a psychosis on the sense of self, and the potentially traumatic components of treat- Despite the importance of treatment in re- ment, particularly the experiences associated cent onset psychosis, only antipsychotic medi- with first psychiatric hospitalization. cations have been shown to be effective (Gitlin We propose systematic experimentation et al., 2001), and these benefits are often with efforts, drawing on evidence-based strat- offset by medication non-adherence (Edwards egies from PTSD research and proven cogni- & McGorry, 2002). Controlled research on tive interventions for psychosis, aimed at: 1) psychosocial treatments, including family ameliorating the traumagenic aspects of early intervention, cognitively-oriented psycho- illness and treatment related events; 2) devel- therapy, and cognitive therapy for psychosis, oping specific interventions to help first epi- have yielded disappointing results (Jackson sode clients better understand and cope with et al., 2001; Lewis et al., in press; Linszen et the most stressful aspects of their illness and al., 1996). Thus, more effective psychoso- related treatment experiences; and 3) devel- cial treatments are needed for persons with a oping interventions for trauma/post-traumatic recent-onset psychosis. stress disorder (PTSD) that are suited for While a number of explanations have been clients with, or in recovery from, a first epi- offered to account for poor treatment engage- sode of psychosis. ment and outcomes of recent onset clients, we suggest that findings from multiple stud- Trauma, PTSD and severe mental Downloaded by [Portland State University] at 13:06 26 January 2016 ies support the importance of trauma-related illness issues in complicating the early course of illness in many, if not most, clients. There is Abundant research shows that people with growing evidence that the experience of a severe mental illnesses such as schizophre- psychotic episode can be understood as a nia, bipolar disorder, and severe major de- traumatic event (McGorry et al., 1991; Meyer pression are highly vulnerable to traumas et al., 1999; Shaner & Eth, 1989; Shaw et al., such as physical and sexual assault in both 1997). In this sense, post-traumatic symp- childhood and adulthood (Goodman et al., toms appear to represent an important sec- 1997). Considering that PTSD is the most ondary problem related to psychotic illness, common and well-established psychiatric with a significant group of first episode cli- consequence of trauma exposure, it is not ents reporting post-traumatic symptomatol- surprising to find that trauma exposure in Editorial 105 persons with severe mental illness is accom- lation, may improve the outcome of individu- panied by high rates of PTSD, with most als who have recently developed a psychosis estimates of current PTSD ranging between and/or are undergoing initial intensive treat- 28% and 43% (Cascardi et al., 1996; Craine ments. et al., 1988; McFarlane et al., 2001; Mueser et al., 1998, 2001, in press; Switzer et al., The psychological impact of 1999), as contrasted with the point preva- psychosis and its treatment lence rate of PTSD in the general population of approximately 2% (Stein et al., 1997). There are several arguments for consider- These rates of PTSD are also far in excess of ing the onset of psychosis, and its treatment, the lifetime rate of PTSD in the general as potentially ‘traumatic’ events. According population, with estimates ranging between to DSM-IV (American Psychiatric Associa- 7% and 12% (Breslau et al., 1991; Kessler et tion, 1994), a traumatic event is something al., 1995; Resnick et al., 1993). which presents a grave danger to the self or Trauma and PTSD are related to negative others and which results in severe negative outcomes in persons with severe mental ill- emotions at the time of the event. Such ness, including worse symptoms, more events are generally external to the person, hospitalizations, substance abuse, and health but may include internal events as well (e.g. problems (Goodman et al., 2001; Mueser et heart attack). Psychosis often involves se- al., in press; Switzer et al., 1999). Awareness vere perceptions of threat (e.g. paranoia, de- of the high rate of PTSD in this population lusions of control) accompanied by negative has led to a call for interventions to address emotions, and may therefore constitute a this problem (Frueh et al., 2002), and several traumatic event. In addition, social extrusion programs have recently been developed and stigma due to mental illness may be (Harris, 1998; Rosenberg et al., 2001). How- experienced as traumatic (or even more so) as ever, the major focus of these programs, and the psychotic symptoms themselves (Beale most other research on PTSD in severe men- & Lambric, 1995; Deegan, 1990; Fisher et tal illness, has been on the effects of life al., 1996). traumas such as physical
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