Kim T. Mueser, PhD

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.

 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.

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%

; in comparison, patients with SMI have much higher rates of PTSD, with most reported estimates ranging from 29% to 47%.

It has been hypothesized that PTSD mediates the negative effects of trauma on the course of SMI.

 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.

Complicating issues of PTSD in the treatment of 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.

 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.

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

 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. 

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.

 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.

Assessment of PTSD in severe mental illness

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.

 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%).

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.

 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.

 Tips for assessing trauma and PTSD in patients with SMI are summarized in 

Although substantial research has demonstrated effective psychotherapeutic interventions for PTSD in the general population,

 controlled trials have routinely ruled out patients with common features of SMI, such as psychotic symptoms, suicidal ideation and self-harming behavior, and cognitive impairment. The exclusion of patients with these problems from clinical trials has led to a call for interventions that can address the broad range of patients with PTSD,

Two approaches have predominated in developing programs for SMI. First, some interventions focus specifically on PTSD by adapting treatment approaches shown to be effective in the general population for patients with SMI, such as cognitive restructuring

 Second, some interventions are more broad-based and address a wide range of trauma sequelae, such as poor self-esteem and body image, dysregulated behavior, and problematic relationships.

 Pharmacological treatments are often included as important components of treatment.

The characteristics of several recently developed programs for trauma and PTSD in SMI are summarized in 

. Research on the effects of programs specifically developed to address trauma in patients with SMI is still in its infancy. However, clinical reports from early trials of these programs indicate that patients with SMI can be successfully engaged and treated, and that outcomes often improve.

 Only 1 randomized controlled trial of a treatment for trauma in SMI has been completed (K. T. Mueser et al, unpublished data, 2007). The results of the trial indicate that participation in the 12- to 16-week cognitive-behavioral therapy program was associated with improvements in PTSD symptoms, other symptoms such as depression, and trauma-related beliefs about oneself and the world. The following clinical vignette illustrates the use of this program.

Elizabeth is a 46-year-old woman with schizophrenia and PTSD. As a child she experienced significant physical abuse from her mother and, in an attempt to escape the abuse, frequently ran away from home. As a result, she spent much of her adolescence in a children's home. At 17, she left the home and moved in with her stepfather, who was separated from her mother. She lived with him for about a year, during which time he sexually abused her. At one point she became pregnant by him; she told no one, but suffered a painful and confusing miscarriage. Shortly thereafter, she withdrew from people and stopped taking care of herself, which was followed by signs of psychosis, including paranoia, hallucinations, and conceptual disorganization.

Elizabeth was hospitalized, treated, and discharged free of psychotic symptoms. She began to work as a store clerk, married, and had 2 children. Although her husband physically abused her, she remained fairly stable until he sought a divorce and took custody of their children. Following this, Elizabeth's condition worsened, and she spent several years cycling in and out of hospitals, interspersed with periods of homelessness. During a stay at a halfway house, she met a man and fell in love. Despite his drug abuse, they forged a relationship that lasted several years, during which time Elizabeth's symptoms and functioning stabilized, and she began working part-time. Then one day she found him dead, which was followed by a deterioration in her functioning.

Several years later, an evaluation confirmed that Elizabeth had severe PTSD. She reported that the death of her boyfriend was her most distressing traumatic experience. She said that she felt extremely guilty because she had not been able to prevent his death. She also talked about how her history of abuse made it difficult for her to trust anyone. The therapist described the 12- to 16-session treatment plan that included breathing retraining, psychoeducation, and cognitive restructuring to Elizabeth, who agreed to participate. Elizabeth was unkempt and restless but arrived promptly for all of her therapy sessions. Gradually, over time, she became more consistent in completing her homework.

The first session focused on teaching breathing retraining to manage her anxiety. During a homework review the following week, Elizabeth stated that she only felt comfortable practicing breathing retraining with her eyes open, but that she found it very helpful. The next 2 sessions focused on discussing the symptoms of PTSD, including how they differ from the symptoms of schizophrenia, and how the 2 affected each other. Elizabeth expressed relief in learning that her PTSD symptoms were common reactions to traumatic experiences.

During the fourth session cognitive restructuring was introduced. Elizabeth was able to understand the connection between thoughts and feelings but struggled with the related homework. She noted that she was afraid of becoming too overwhelmed when trying to do her homework alone. After more sessions in which the therapist helped her use cognitive restructuring to examine and challenge thoughts related to her upsetting feelings, Elizabeth began to practice using the skill on her own to deal with negative feelings. She described the therapy program as helpful and agreed to a joint session with her case manager at the end of treatment so that she and her therapist could teach her case manager the skills that Elizabeth had developed in therapy.

A recurring concern that was addressed with cognitive restructuring was Elizabeth's fear that nobody would claim her body at her death. She felt abandoned by her children, depressed and isolated, and preoccupied by worry about rejection. She was eventually able to identify several core beliefs, including the thoughts that "you cannot trust anybody" and "anyone that you do trust will abandon or mistreat you." Over the course of treatment she was able to recognize that there were some people who had stood by her (eg, her therapist, her psychiatrist, her case manager, her son). She was able to gain a more balanced perspective on her feelings of guilt over her boyfriend's death, realizing she was not to blame. As Elizabeth's symptoms gradually improved, she began to reach out to others. She started having brief conversations with people (eg, at the library), reconnected with a neighbor, and renewed her relationship with her son.	

Integration of PTSD and other treatment for SMI

There are several principles of effective treatment of patients with SMI and PTSD. Patient advocates, consumers, and trauma experts have argued that provider organizations usually require some degree of systemic change if appropriate services are to be provided for this common comorbid array. Such change, known as the implementation of trauma-sensitive services,

 entails provider and consumer education about trauma, general awareness of the needs of trauma survivors, and the introduction of the services that traumatized clients need and can best tolerate.

Accurate identification of traumatic life experiences and their consequences is critical in order to know which patients have PTSD and who would benefit from additional treatment. Patients who are motivated for treatment of PTSD need to be supported in undertaking that work. Such support can either be through directly working on PTSD in the context of the clinician's relationship with the patient, or by finding another clinician who can provide the treatment. In the latter case, the primary clinician can still play an important role by supporting the patient's participation in treatment and helping him or her review information and practice skills related to the program.

In addition, the pharmacological management of SMI should be sensitive to the nature of any PTSD treatment program in which patients are participating as well as to potential changes in needs over time. For example, some treatment programs for PTSD involve teaching skills for managing anxiety (such as breathing retraining or cognitive restructuring), suggesting that minimal and judicious use of benzodiazepines may be necessary in order not to interfere with learning those skills. With effective treatment leading to reductions in PTSD symptoms, depression, anxiety, nightmares, and hallucinations, many clients may require lower doses of medication or may be able to stop some medications altogether.

Trauma and PTSD are common in patients with SMI, but despite their impact on the course of psychiatric illness they are not routinely detected or treated. Advances during the past decade have shown that trauma and PTSD can be reliably and validly assessed in patients with SMI, and preliminary work suggests that specially designed treatment programs may also be effective. This progress bodes well for clinicians who recognize the importance and consequences of trauma in the lives of their patients with SMI and who seek treatment for PTSD and associated problems in this population. Given the building momentum in the field, there are good reasons to believe that clinical challenges such as psychosis, self-injurious behavior, or cognitive impairment will not be obstacles to effective treatment of PTSD in the future.

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Articles

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. This high exposure to traumatic events such as physical and sexual abuse and assault takes a heavy toll.

Author | Kim T. Mueser, PhD

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Integrating Psychosocial Treatment for PTSD and Severe Mental Illness