Integrating Psychosocial Treatment for PTSD and Severe Mental Illness

Patients with severe mental illness (SMI), such as schizophrenia, bipolar disorder, and major depression, are more likely to have experienced trauma in childhood, adolescence, and throughout their adult lives than the general population.^1,2 This high exposure to traumatic events such as physical and sexual abuse and assault takes a heavy toll. In addition to the immediate effects of victimization on an individual's quality of life, a history of trauma exposure in persons with SMI is associated with more severe symptoms, greater impairment of functioning, and higher levels of distress.³

During the past decade, research has firmly documented that one of the most common consequences of trauma in patients with SMI is their high vulnerability to posttraumatic stress disorder (PTSD). The lifetime prevalence of PTSD in the general population is 8% to 12%^4,5; in comparison, patients with SMI have much higher rates of PTSD, with most reported estimates ranging from 29% to 47%.^6-9

It has been hypothesized that PTSD mediates the negative effects of trauma on the course of SMI.¹⁰ For example, PTSD symptoms may directly exacerbate other symptoms of SMI. Or PTSD may indirectly worsen the course of illness through other problems related to PTSD, such as substance abuse, retraumatization, or a poor therapeutic alliance with treatment providers. However, despite the high comorbidity of PTSD in SMI, research and clinical services have only recently begun to address this problem.

In this article, we consider how comorbid PTSD can complicate the treatment of patients with SMI. Then we briefly summarize strategies for assessing PTSD in this population, and we describe treatment programs designed to address PTSD and related trauma consequences in patients with SMI. Finally, we discuss principles for integrating the treatment of PTSD and SMI.

Trauma exposure and PTSD complicate treatment in patients with SMI in a number of ways. Exposure to trauma is associated with more hospitalizations and severe psychiatric symptoms, substance abuse, aggression, homelessness, and poor health.^6,11 Engagement, diagnosis, and treatment of patients with SMI are all made more difficult by the failure, in routine psychiatric treatment, to recognize a history of trauma and PTSD. Studies that have systematically assessed PTSD in patients with SMI report that the disorder is document- ed in the charts of only a fraction of patients.¹⁰

The underdiagnosis of PTSD has 2 important clinical implications. First, poor detection naturally leads to insufficient treatment of PTSD and continued distress for patients. Second, the failure to recognize PTSD may lead to misinterpreting PTSD symptoms as caused by another disorder. For example, mild hallucinations and delusions are relatively common in primary PTSD^12,13 but can easily be mistaken for symptoms of schizophrenia. Similarly, the hyperarousal symptoms of PTSD (eg, autonomic arousal, hypervigilance, anger) can appear quite similar to the symptoms of hypomania or mania.

The presence of PTSD in patients with SMI can also hinder the development of a therapeutic alliance. DSM-IV describes most traumatic experiences as interpersonal in nature, which can lead to pervasive feelings of mistrust and difficulties with relationships. The working alliance between patient and clinician can influence the course of SMI.^14,15 Thus, trauma-related interpersonal distrust may pose a challenge to establishing a good working alliance with patients with SMI and PTSD and may lead to suboptimal treatment.

Traumatic experiences and PTSD can easily and quickly be assessed in persons with SMI through the use of standardized screening tools and assessment instruments developed for the general population.^16-18 The greatest obstacle to accurately diagnosing PTSD is simply not using the standard techniques when asking about trauma. Avoidance of trauma-related stimuli is a cardinal symptom of PTSD. Consequently, if clinicians do not ask about patients' traumatic experiences, most patients with PTSD will not spontaneously divulge them. Clinicians' concerns about probing for traumatic life experiences are usually related to worry about exacerbating symptoms or disentangling reports of trauma from delusional beliefs.

Contrary to the concern that talking about traumatic events will worsen psychiatric symptoms, abundant clinical experience shows that this occurs only rarely. Rather, most patients with SMI readily tolerate inquiries about traumatic experiences, and many are relieved to talk about them. Concerns that reports of trauma in patients with SMI will be delusional are inflated. Reports have shown that, first, patients are more likely to underreport than overreport traumatic experiences. Second, rates of undiagnosed PTSD tend to be highest in patients with severe mood disorders, such as major depression or bipolar disorder (ranging from 40% to over 50%), and somewhat lower in patients with psychotic disorders such as schizophrenia or schizoaffective disorder (ranging from 25% to 35%).^8,19

Occasionally, clinical judgment is required to evaluate whether a patient's delusions stem from a genuine traumatic experience (eg, "I hear my mother telling me I am worthless even though she has been dead for 7 years"), or whether the traumatic events reported are themselves delusional or substantially distorted, such as those indicated by lack of coherence, implausibility (eg, "the librarian ran toward me and began to pummel me while the crowd simply stood by and watched"), or reference to supernatural phenomena (eg, alien abduction).

Research demonstrates that reliable and valid assessments of trauma history and PTSD can be obtained from patients with SMI.^17,18 Furthermore, a history of trauma in a patient with SMI bears similar associations to PTSD as in the general population, such as childhood sexual abuse and number of lifetime traumas predicting a greater likelihood of PTSD.⁸ Tips for assessing trauma and PTSD in patients with SMI are summarized in Table 1.