Opening Pandora’s Box: The Importance of Assessing and Treating Trauma in Individuals Experiencing Psychosis

Case Vignette

“Sasha” is a 23-year-old nonbinary Asian American individual. Sasha is a survivor of childhood emotional and physical abuse by their parents. In addition, Sasha was physically assaulted when they were a freshman in college as they were walking back to their dorm late at night. Soon after this experience, they started having nightmares and flashbacks about the assault. They became easily startled and hypervigilant and no longer felt safe in lecture halls and on campus, which led them to drop out of college. Sasha also believes that strangers on the street intend to harm them physically, and they let Sasha know this by making eye contact with Sasha or by touching their faces. Sasha also reports seeing shadowy figures that seem threatening and hearing voices—both of their abusers from the past and strangers. These voices say degrading things about Sasha, which they interpret as a sign that there is a larger plot against them. Sasha no longer feels safe leaving the house or socializing, is disengaged from loved ones, is unable to return to college or work, and is currently on a leave of absence from their job at a daycare center. In the context of reduced sleep, concerns about financial stressors, and worsening voices, Sasha presents to the emergency department, where they disclose their voices, the shadowy figures, and fears that others in their neighborhood are threatening them. They are commenced on antipsychotic medication and are connected with their local early psychosis service for follow-up.

Trauma and Psychosis

Per the Substance Abuse and Mental Health Services Administration (SAMHSA), “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” Posttraumatic stress disorder (PTSD) refers to a cluster of symptoms often experienced by individuals who have experienced trauma. Whether a person who has experienced a traumatic event will go on to qualify for a diagnosis of PTSD depends on the event, the person’s experience of the event, and the long-lasting adverse effects of the event.¹

Sasha’s presentation with comorbid symptoms of psychosis and PTSD is not unusual. Individuals experiencing psychosis often have also been exposed to traumatic life events,^2,3 with some estimates suggesting that all individuals with a psychotic disorder have experienced at least 1 traumatic event.² In addition, the experience of psychosis, as well as some aspects of mental health treatment including police involvement in admission, seclusion, and restraint, can also be traumatic.⁴ The rates of PTSD in those experiencing psychosis range from 10% to 30%, and approximately 40% of individuals with PTSD experience psychosis.^3,5-8 Psychosis-related PTSD, or PTSD directly related to having a psychotic episode, varies from 14% to 47%.⁹ Comorbid PTSD/psychosis is associated with increased health care use and worse clinical outcomes.^8,10 Hence, when planning for effective care, it is important to assess for trauma and PTSD in anyone presenting with symptoms of psychosis.

Clinical Pearl: Traumatic experiences are very common for those who report symptoms of psychosis. Trauma may be a result of early childhood experiences or later traumatic experiences linked to psychosis symptoms or treatment for psychosis. Psychosis symptoms can also occur in the context of PTSD and posttraumatic stress. 

Assessment of Trauma in Individuals Experiencing Psychosis

Trauma is often overlooked in individuals with psychosis, resulting in an inadequate assessment of traumatic or adverse life events and, therefore, limited access to gold standard, evidence-based trauma treatments. Assessing for trauma should occur routinely, and access to these treatments should be made available for all individuals as needed. If Sasha is asked specific questions assessing past traumas, they will likely report childhood abuse and the more recent physical assault. Structured assessments commonly used to assess PTSD symptoms include the PTSD Checklist for DSM-5 (PCL-5),¹¹ PTSD Symptom Scale – Interview for DSM-5 (PSS-I-5),¹² and Clinician-Administered PTSD Scale for DSM-5 (CAPS-5).¹³ During an initial assessment, it is vital for clinicians assessing potential traumatic experiences to gather only the information necessary to determine whether a trauma history is present and whether trauma interventions are appropriate, which does not require a full account of traumatic experiences. Requiring individuals to disclose a detailed account of their trauma history during the initial assessment poses a risk for retraumatization and may limit what the individual feels comfortable sharing. PTSD assessments only ask clients to, at most, share a brief description of the traumatic event and PTSD symptoms.

Assessment is an essential component of understanding, and addressing, trauma as part of a psychosis presentation. In our clinical example, if Sasha is only assessed for psychosis and not asked questions about past traumas, they will likely receive a diagnosis of a psychotic disorder (such as schizophrenia) and be prescribed antipsychotic medications to reduce the occurrence of the voices and shadowy figures. Sasha may also be offered supportive psychotherapy and case management. If the clinic has trained staff, Sasha may be offered an evidence-based psychotherapeutic intervention such as cognitive behavioral therapy for psychosis (CBTp). However, the traumatic experiences would go untreated, thus limiting the potential for recovery.

Clinical Pearl: As clients do not often report trauma experiences unless asked about them explicitly, assessment of trauma in individuals presenting with psychosis symptoms is essential. Assessing for the types of trauma experienced and PTSD symptoms, as opposed to a full account of traumatic events, is sufficient at this stage of care.

Trauma-Informed Care

SAMHSA recommends that all treatment programs take a trauma-informed approach.¹ This incorporates key principles into the organizational culture of the program. These include acknowledging the widespread impact of trauma and the path to recovery, recognizing the signs of trauma in individuals, and responding by making sure policies and practices are geared toward not retraumatizing the individual. A trauma-informed approach may or may not include trauma-specific treatments. Some fundamental principles in a trauma-informed approach are ensuring a sense of physical and psychological safety for all served; building and maintaining individuals’ trust in the program by those accessing services and their families; welcoming mutual self-help from those with lived experience of trauma and recovery from trauma; adopting a nonhierarchical, collaborative stance where the expertise of individuals accessing services is understood and respected; keeping individuals accessing services front and center, and believing in their resilience and ability to recover from trauma; and providing care that actively moves away from stereotypes and biases.

Clinical Pearl: Programs should consider how to implement trauma-informed care and ensure staff are trained in this approach to best meet the needs of individuals accessing services.

Addressing Trauma

Clinicians are often concerned about the increased sensitivity to stress in those experiencing psychosis and can be hesitant to use evidence-based treatments for PTSD.^14,15 As a result, evidence-based trauma treatments are not offered routinely to individuals seeking treatment for psychosis in the United States.¹⁶ However, Grubaugh et al, in a meta-analysis of PTSD treatments for individuals diagnosed with PTSD and a “severe and persistent comorbid mental illness,” which included psychotic spectrum disorders or mood disorders, found that PTSD treatment can be used safely in this population.⁵

In addition, a growing evidence base suggests that standard protocols for trauma treatments in psychosis are effective.¹⁷ These treatment protocols include trauma-focused CBTp,¹⁸ prolonged exposure,¹⁹ and eye movement desensitization reprocessing.²⁰ However, adapting these protocols may be necessary to ensure the needs of an individual experiencing psychosis symptoms are thoroughly addressed; for example, ensuring the individual has sufficient coping skills in place to tolerate the trauma intervention while not prolonging access to exposure-based therapies (“as much as needed, but as little as necessary”) and supporting the individual around psychosis symptoms if these are intrusive and may impact the trauma treatment. Developing an initial formulation to understand the trauma timeline, subsequent symptoms (both trauma and psychosis focused), and impact of these on core beliefs will aid the clinician in determining where to focus psychosocial interventions.

Clinical Pearl: Treatment options and pacing are guided by the immediate needs of the individual and should support the reduction of distress and movement toward meaningful goals.

Concluding Thoughts

Traumatic life events are common among individuals who experience psychosis. Often, when an individual presents with psychosis, past traumas are not assessed. This could be due to the individual’s hesitancy to talk about these events or the clinician’s fear that asking about trauma will exacerbate symptoms. We now know that trauma-informed care leads to better outcomes. This systemwide approach begins with creating safe spaces for individuals to speak about past experiences in a way that is not retraumatizing and incorporates the impact of these experiences into a formulation that guides treatment. Evidence-based trauma interventions have been shown to be effective in addressing trauma in individuals experiencing psychosis and should be made routinely available. Further research on effective trauma intervention adaptations for individuals with psychosis would be meaningful. We encourage all clinicians who support individuals experiencing psychosis to provide trauma- informed care across treatment settings.

Dr Chari is the assistant psychosocial director and didactic lead of the INSPIRE Clinic and a clinical associate professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in California. Dr Lee is a clinical assistant professor and a California-licensed clinical psychologist in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine. Dr Olson is a clinical associate professor and licensed psychologist in the INSPIRE Clinic and dialectical behavior therapy program at Stanford University. Dr Hardy is the codirector of the INSPIRE Clinic, the co–section chief of INSPIRE Section, and a clinical professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine.

References

1. Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Substance Abuse and Mental Health Services Administration; 2014. HHS Publication No. (SMA) 14-4884. Accessed September 25, 2024. https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf

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