CLINICAL HANDBOOK OF SCHIZOPHRENIA - PART 8 docx

preexisting psychiatric disorder may increase vulnerability to the emergence or chronicity of posttraumatic symptoms following exposure. Research to date supports the likely con - tribution of these, and other possible mechanisms, linking trauma exposure, schizophre - nia, and PTSD. Several other contributory factors have also been hypothesized. For example, psy - chosis and associated treatment experiences (e.g., involuntary commitment) may them - selves represent DSM-IV-TR Criterion A traumas. The potential symptom overlap be - tween schizophrenia and PTSD (e.g., flashbacks being misinterpreted as hallucinations; extreme avoidance and anhedonia interpreted as negative symptoms), may conflate the apparent rates of PTSD in those diagnostic groups. Alternatively, PTSD associated with psychotic symptoms may be misdiagnosed as a primary psychotic disorder. Clients and advocacy groups often point to posttraumatic symptoms as among the most troubling of these individuals’ life problems, and many U.S. states have prioritized the development of “trauma-sensitive services” as a key reform to mental health and sub - stance abuse service systems. Major elements of trauma-sensitive services include (1) in - creased awareness by providers about trauma history and sequelae among clients; (2) better understanding of special requirements of survivors; and (3) knowledge of trauma- specific interventions for persons requiring such services. We discuss these three topics in this chapter, and provide tools and useful references to increase mental health providers’ knowledge and competence in regard to trauma-related issues. Posttraumatic stress disor- ders are among the most treatable of psychiatric syndromes, and it is important to recog- nize and treat PTSD symptoms in clients with schizophrenia. DEFINITIONS Psychological trauma refers to the experience of an uncontrollable event perceived to threaten a person’s sense of integrity or survival. A traumatic event is defined by DSM-IV- TR as an event involving direct threat of death, severe bodily harm, or psychological in- jury, which the person at the time finds intensely distressing (i.e., the person experiences intense fear, helplessness, or horror). Common traumatic experiences include sexual and physical assault, combat exposure, and the unexpected death of a loved one. Negative psychiatric and health outcomes are associated with the total number of exposures to traumatic events and with their intensity. Sexual assault and other forms of interpersonal violence in which the victim suffers actual physical harm, along with childhood sexual abuse, represent the forms of trauma most likely to lead to persistent psychiatric disor - ders, including PTSD. PTSD is defined by three types of symptoms: (1) reexperiencing the trauma; (2) avoidance of trauma-related stimuli; and (3) overarousal. These symptoms must be related to the index trauma and persist, or develop at least 1 month after expo - sure to that trauma. Examples of reexperiencing include intrusive, unwanted memories of the event, nightmares, flashbacks, and distress when exposed to reminders of the trau - matic event (e.g., being in the vicinity of the traumatic event, meeting someone with simi - larities to the perpetrator). Avoidance symptoms include efforts to avoid thoughts, feel - ings, or activities related to the trauma; inability to recall important aspects of the traumatic event; diminished interest in significant activities; detachment; restricted affect; and a foreshortened sense of one’s own future. Overarousal symptoms include hypervig - ilance, exaggerated startle response, difficulty falling or staying asleep, difficulty concen - trating, and irritability or angry outbursts. DSM-IV-TR criteria require that a person must have at least one intrusive, three avoidant, and two arousal symptoms to be diag - nosed with PTSD. 448 VI. SPECIAL POPULATIONS AND PROBLEMS How do clients with both schizophrenia and PTSD present differently from those with schizophrenia alone? First, it is important to recognize that most of these clients do not spontaneously talk about their trauma experiences and related symptoms. Clinicians generally believe that they know their client well enough to be aware when a particular client has experienced a very adverse event. Thus, providers are often surprised when they systematically inquire about trauma history in clients they have know for years, and learn for the first time about traumatic events clients have experienced. The reality is that a central feature of PTSD is avoidance. The last thing that most trauma survivors are likely to do is to discuss spontaneously or describe past traumatic events, or associated problems such as nightmares and avoidance (e.g., fear of going back to a setting where a sexual assault occurred). Because clients with PTSD tend to appear more fearful, avoidant, and distrustful of others, they are more difficult to engage. On average, they are more likely to abuse substances (often to avoid memories of their traumatic experiences), to experience revictimization, and to be assaultive toward others, including providers. In general, clients with PTSD tend to be more impaired, low function, and symptomatic than individuals without PTSD. For example, one client reported believing that others could see into his mind, and he frequently heard persecutory voices when he was out in public, which made him very wary of leaving his house. Only when he was assessed for PTSD symptoms did his pro - viders become aware that the voices referred both to childhood incidents of being sexu- ally abused and his own subsequent abuse of other, younger children. He believed that people on the street knew about his past actions and were highly critical of him. The voices were a form of expressing guilt and shame (common among abuse survivors), and of reexperiencing the trauma. What was somewhat unusual in terms of PTSD (although not unknown in severe cases) was that this client utilized psychotic mechanisms to ex- press these symptoms and associated distorted cognitions. However, once he was treated for PTSD, the voices essentially disappeared, and the client became less psychotic. An- other client frequently relapsed into substance abuse when exposed to reminders of her past trauma (so-called “triggers”). These slips also tended to lead to more general de- creases in her ability to function independently, including unstable housing, inability to hold a job, and frequent rehospitalizations. Treatment for PTSD helped this client de - velop alternative strategies to alcohol use in response to trauma-related stressors, and a period of relative stability followed. The trauma-related problems described in these cli - ents represent either the primary or associated symptoms of PTSD. An understanding of this disorder is crucial to clinicians’ ability to recognize the behaviors, attitudes, and symptoms that people with schizophrenia and PTSD present. POSTTRAUMATIC STRESS SYNDROMES: THE EVOLUTION OF THE CONCEPT Recognition of the psychiatric complications associated with extreme forms of trauma exposure has a long history, dating back at least to the U.S. Civil War. In the last half of the 19th century, the concept of Da Costa syndrome, or irritable heart, appeared in the medical literature. Seen first in combat veterans, it was characterized by anxiety (fearful - ness, chest pain mimicking heart attack), extreme fatigue, and arousal symptoms (palpi - tations, sweating). By the end of the 19th century, Breuer and Freud had recognized and described the role of trauma in various neurotic disorders, particularly so-called “hyste - ria,” and Freud continued for many years to theorize about the role of traumatic events in personality formation and disruption of functioning. Throughout the 20th century, 43. Trauma and Posttraumatic Stress Syndromes 449 posttraumatic reactions were recognized in psychiatry and military medicine, and gener - ally conceptualized under various labels that suggested organic etiologies (e.g., “shell shock” in World War I, and “combat fatigue” in World War II). Psychiatry has also long recognized that civilian traumas (e.g., dramatic changes in life circumstances; car acci - dents) can produce similar emotional reactions. In more recent years, the psychological and psychophysiological components of posttraumatic disorders have been better characterized through empirical studies, and the affective, cognitive, and interpersonal alterations associated with trauma exposure have been extensively researched and described in the literature. Neuroimaging techniques have more recently allowed the field to examine the neurobiological alterations in persons who develop PTSD, including hippocampal changes (atrophy) and alterations in amygdala function. Both lines of research have been associated with advances in treating PTSD. A variety of psychotherapeutic interventions (primarily based on cognitive-behavioral tech - niques) have become well established through multiple clinical trials, and effective treat - ments are available for a variety of trauma populations, including children, combat veterans, sexual assault survivors, and women who experienced abuse in childhood. Biological treatments, which build on the similarities between the neurobiology of PTSD and depression, have also shown utility in reducing symptoms. Systematic reviews of these treatments and their relative efficacy are available (see References and Recommended Readings). However, until very recently, no proven treatments for clients with both schizophrenia spectrum disorders and PTSD have been available. Several clinical research groups are now actively addressing this gap in services, and promising treatment models are described below. TRAUMA, SCHIZOPHRENIA, AND PTSD Unfortunately, until the last decade, theory and practice regarding severe mental illnesses, such as schizophrenia, and posttraumatic stress syndromes were quite separate and dis- tinct. Much of the seminal work on trauma-related psychiatric disorders focused on combat- related stress responses, and scant research—and almost no treatment models in the field—explicitly considered the intersection of trauma-related disorders with other major DSM Axis I disorders. Following the inclusion of PTSD as a diagnosis in DSM-III, re - search on trauma-related disorders accelerated. The field became increasingly aware that many forms of civilian trauma exposure, including childhood physical and sexual abuse, are not only common events but also are frequently comorbid and possible contributory factors in a variety of other psychiatric disorders. Exposure to traumatic events in general population studies is associated with increased psychiatric morbidity, substance abuse, in - creased medical utilization, and generally poor health and functional outcomes. These re - lationships are often mediated by PTSD. TRAUMA EXPOSURE AND SCHIZOPHRENIA Limited systematic research has investigated trauma exposure in clients with schizophre - nia spectrum disorders. Most studies have looked at the broader category of severe men - tal illness (typically including both schizophrenia spectrum and bipolar disorders, and chronic and disabling major depression). These studies have reported overwhelmingly high levels of trauma exposure, both prior to illness onset and throughout the course of illness. In those few studies looking specifically at clients with schizophrenia, the same re - 450 VI. SPECIAL POPULATIONS AND PROBLEMS lationships are evident. For example, in a recently completed study of adverse childhood events in a large sample of clients with schizophrenia receiving public mental health ser - vices (Rosenberg, Lu, Mueser, Jankowski, & Cournos, 2007), rates of childhood physical abuse were much higher than those found in the National Comorbidity Study: 56.4% abused versus 3.3% in the general population. Sexual abuse in childhood (33.6 versus 10.1%) was also elevated in the schizophrenia sample. These rates are consistent with the larger set of studies looking at the combined group of people with severe mental illness. These studies report almost universal (e.g., 98%) exposure to any or all types of trauma over the lifetime. Although there are many types of civilian trauma, the most common of which is the sudden, unexpected death of a loved one, 87% of clients report more severe and less common traumas, including either physical or sexual assault in childhood, in adulthood, or in both. Indeed, more than one- third of clients living in the community report either physical or sexual assault in the last year alone. By all accounts, being a person with schizophrenia or other severe mental ill - ness is generally a frightening and dangerous way to live, at least in the United States. Often confined to low-income urban areas, likely to be intermittently homeless and incar - cerated, sometimes forced by circumstance into sex trading, and disproportionately likely to abuse drugs in unsafe places such as crack houses, clients live in the most dangerous spaces in a society where violence is rather common. In addition, it seems likely that these clients’ common isolation and vulnerability make them likely targets of opportunity for predators in such environments. CORRELATES OF TRAUMA EXPOSURE What happens to people following exposure to extreme, life-threatening events? For many people, the hours and days following exposure are filled with anxiety, agitation, and distress. Clients may feel emotionally numb, lose focus on the immediate environ- ment, and feel as if they or events are “unreal” or “in a daze.” They may be unable to stop thinking about the events, even though thinking about them is highly distressing. People in the United States as a whole had at least an indirect experience of these symp - toms following 9/11, when, for example, people were horrified by the television footage of the Twin Towers but could not help ruminating about the event. People found them - selves unable to concentrate on work or school. Some reported watching the news replays over and over; others tried to avoid any news or mention of the attack. When these reac - tions become clinically significant and last for more than 2 days, they are called acute stress disorder. For an unfortunately high percentage of trauma survivors, acute stress dis - order persists beyond 30 days, and progresses to PTSD. Other people exposed to trauma may not meet criteria for acute stress disorder, but have instead delayed response to the events and develop symptoms later. In either sequence, PTSD is the most common and di - rectly attributable psychiatric disorder to develop following trauma exposure, although depression and substance use disorders may also ensue, with or without diagnosable PTSD symptoms. The steps by which PTSD develops after a trauma exposure have been well docu - mented. During and immediately following the event, the survivor experiences an intense emotional response, including fear, anxiety, grief, helplessness, and often a complex mix - ture of all of these. Memories of the event are associated with reexperiencing all of these emotions and, subsequently, elaborated emotions and ideas (e.g., guilt, sense of loss) as the person continues to process the implications of the trauma. Because these recollec - tions are so emotionally charged and distressing, the person attempts to avoid memories 43. Trauma and Posttraumatic Stress Syndromes 451 or situations that are reminders of the trauma, which leads to further vigilance and avoidant behavior. In addition, some traumatic events are so overwhelming that survi - vors’ assumptions about the world (e.g., “People are mostly OK”) and themselves (“I know how to look out for danger as well as the next person”) can be shattered. They may construct new cognitive frames or internal scripts that keep them locked in aspects of the traumatic moment (e.g., “I could be attacked at any moment” or “No one can be trusted”). The severity of the trauma, the number of traumas to which persons have been ex - posed in their lifetime, the nature of available social supports, and the quality known as psychological hardiness, or resilience, all influence the likelihood of developing PTSD fol - lowing exposure, as well as the severity and chronicity of this disorder. All these factors seem to conspire to make people with schizophrenia highly vulnerable to developing chronic PTSD. Recent estimates of lifetime prevalence of PTSD in the general population range be - tween 8 and 12%, and the few available, community-based studies reporting point preva - lence of PTSD (the number of people who meet diagnostic criteria on any given day) sug - gest rates of approximately 2%: 2.7% for women and 1.2% for men. Studies of clients with severe mental illness suggest much higher rates of PTSD. Seven studies have reported current rates of PTSD ranging between 29 and 43% (Mueser, Rosenberg, Goodman, & Trumbetta, 2002), yet PTSD, as discussed earlier, was rarely documented in clients’ charts. In the few studies with samples large enough to assess PTSD in clients by diagno- sis, clients with schizophrenia spectrum diagnoses had slightly lower rates (33%) than cli- ents with mood disorders (45%), but rates in both groups were nevertheless much higher than those in the general population. Another study reported that among persons hospi- talized for a first episode of psychosis, 17% met criteria for current PTSD. This study, in combination with the others, suggests that childhood trauma exposure and PTSD not only occur more often in persons who develop schizophrenia and other forms of severe mental illness, but that having severe mental illness also increases subsequent risk for trauma and PTSD. As in the general population, PTSD severity in clients with severe mental illness is related to severity of trauma exposure, and the high rates of PTSD in this population are consistent with clients’ increased exposure to trauma. These rates also suggest an elevated risk for developing PTSD given exposure to a traumatic event. For example, in a sample of clients drawn from a large health maintenance organization, Breslau, Davis, Andreski, and Peterson (1991) reported that the prevalence of PTSD among those exposed to trauma was 24%. This rate of PTSD following trauma exposure is approximately half the rate (47%) found in studies of trauma and PTSD in persons with severe mental illness. The high PTSD rate in this population and its correlation with worse functioning suggests that PTSD may interact with the course of co-occurring severe mental illnesses, such as schizophrenia and major mood disorders, worsening the out - come of both disorders. We developed a model to help us understand how trauma and PTSD may interact with schizophrenia and other severe mental illnesses (see Figure 43.1). TRAUMA, PTSD, AND THE COURSE OF SCHIZOPHRENIA This model describes how PTSD directly and indirectly mediates the relationships among trauma, more severe psychiatric symptoms, and greater utilization of acute care services in clients with schizophrenia (Mueser et al., 2002). Specifically, we suggest that the symp - toms of PTSD may directly worsen the severity of schizophrenia due to clients’ avoidance of trauma-related stimuli (resulting in social isolation), reexperiencing the trauma (resulting 452 VI. SPECIAL POPULATIONS AND PROBLEMS in chronic stress), and hyperarousal (resulting in increased vulnerability to stress-induced relapses). In addition, the model suggests that common clinical correlates of PTSD might indirectly worsen schizophrenia, including increased substance abuse (leading to substance- induced relapses), retraumatization (leading to stress-induced relapses), and poor working alliance with case managers. It is important to treat PTSD in clients with schizophrenia to reduce the suffering related to the disorder, and because PTSD may exacerbate the course of schizophrenia, contributing to worse outcomes and greater utilization of costly ser- vices through a number of mechanisms. PTSD AND SCHIZOPHRENIA PTSD is frequently chronic, often ebbs and wanes in intensity, and is characterized by both clear biological changes and psychological symptoms. PTSD is also complicated by the fact that it frequently occurs in conjunction with related disorders, such as depres - sion, substance abuse, problems of memory and cognition, and other physical and mental health problems. The disorder is also associated with impairment of the person’s ability to function in social or family life, including occupational instability, marital problems and divorces, family discord, and difficulties in parenting. Given this cluster of primary and secondary symptoms, it is readily apparent how some PTSD symptoms might be overlooked in clients with schizophrenia, who frequently have problems in these life spheres. Possible symptom overlap may lead to masking of PTSD in clients with a pri - mary psychotic disorder. For example, concentration and memory problems are common in schizophrenia, as are restricted or blunted affect and sleep difficulties associated either with the primary illness or with medication side effects. As with a client described earlier in this chapter, PTSD may be expressed in psychotic terms, or in psychotic distortion of actual traumatic events by clients with schizophrenia diagnoses. A client who was sexu - 43. Trauma and Posttraumatic Stress Syndromes 453 FIGURE 43.1. Heuristic model of how trauma and PTSD interact with schizophrenia to worsen the course of illness. From Mueser, Rosenberg, Goodman, and Trumbetta (2002). Copyright 2002 by Elsevier. Reprinted by permission. Trauma Substance Abuse Trauma History PTSD: • Reexperiencing trauma • Overarousal • Avoidance of trauma- related stimuli Symptom Severity, Relapses, and Use of Acute Care Services Working Alliance Illness Management Services ally abused in childhood might, for example, allude to this experience as being assaulted by the devil, expressing both confusion about the event and the common desire of chil - dren to protect the actual perpetrator, who might even be a primary caretaker. Whatever the sources of diagnostic ambiguity, including lack of provider awareness of trauma- related disorders and lack of standardized screening for clients, multiple studies have now reported that only about 5% of clients with severe mental illness and PTSD have the lat - ter diagnosis even listed in their charts, and almost none currently receive trauma-specific treatment. ASSESSMENT OF TRAUMA AND PTSD Providers should be aware that there are simple, straightforward techniques for assessing trauma history and PTSD in clients with schizophrenia and other severe mental illnesses. Several studies, and much recent clinical experience, have now shown that clients respond reliably and coherently to straightforward questions about trauma exposure (both early and more recent), and can be assessed for PTSD symptoms with brief symptom invento - ries. These tests have been used successfully in paper-and-pencil format, as interviews, and in computerized formats. They generally take about 10 minutes to complete. Despite earlier concerns, these assessments rarely lead to increased distress (even in acutely ill cli- ents), and are often appreciated by clients as indicators of provider concern about the is- sues that really trouble them, yet have not been a focus of traditional mental health care. One note of caution is worthy of mention: Providers who ask clients to participate in these assessments, or who conduct them, may be uncomfortable themselves with some of the topics covered (e.g., childhood sexual abuse or recent sexual assault experiences). When this is the case, the providers may need some information and supervision on how to conduct these assessments in a neutral, matter-of-fact, supportive way to ensure client comfort and accurate, open reporting. We have discussed how clients with both schizophrenia and PTSD may differ from clients with schizophrenia alone. It is also important to observe that clients with both dis- orders tend to present with many of the same issues as people with so-called “complex PTSD,” as described by Herman (1992) and others. Complex PTSD has been observed in people exposed to early or extreme stress, to neglect or abuse, and to multiple trauma ex - periences. In addition to the core symptoms of PTSD, which may be expressed in very in - tense form, complex PTSD involves dissociation, relationship difficulties, somatization, revictimization, affect dysregulation, and disruptions in sense of self. Experts have argued that people with complex PTSD are often diagnosed as having borderline personality dis - order, and this sometimes appears as a secondary diagnosis in clients with schizophrenia who have extremely adverse life histories. CURRENT TREATMENT APPROACHES At this point in time, no published studies exist of treatment for clients with both schizophrenia and posttraumatic stress syndromes. To our knowledge, none of the drug trials for PTSD have included clients with schizophrenia or other psychotic disorders, so we do not discuss pharmacological treatments in this chapter. Instead, we describe several psychotherapeutic treatment models designed for the broader category of peo - ple with severe mental illness. The list is not comprehensive, but it is representative of what is being developed, assessed, and implemented in the field. Developmental work 454 VI. SPECIAL POPULATIONS AND PROBLEMS with these treatment models has included some (but not necessarily a majority) of cli - ents with schizophrenia. Assessment of the treatment models has involved either open or randomized clinical trials of varying levels of rigor (e.g., uniform implementation; good characterization of clients served; use of well-validated, standard outcome mea - sures). Like trauma and PTSD treatments designed for the general population, these inter - ventions have relied on a relatively small set of therapeutic ingredients, often combining with or employing somewhat different mixes and emphases. Common therapeutic ele - ments include psychoeducation, stress management techniques, teaching strategies and resources to enhance personal safety, prolonged exposure to trauma-related stimuli (e.g., memories, safe but fear-eliciting situations), cognitive restructuring, group support, skills training, and empowerment. Of these elements, the empirical literature on PTSD treat - ment in the general population has shown that prolonged exposure and cognitive restruc - turing are the most effective treatments. Interventions designed for more vulnerable pop - ulations, including those with psychotic disorders, have used both group and individual formats (with some models combining the two), and intervention length has ranged from 12 weeks to 1 year or more. Some models have been developed specifically for women, particularly women survivors of sexual abuse, whereas other, more general models are for all types of trauma exposure (in either childhood or adulthood) leading to PTSD. Several models focus on PTSD per se, whereas others attempt to address a broader array of prob- lems associated with chronic victimization. These models, and the level of evidence sup- porting them, are summarized in Table 43.1. TREATMENT GUIDELINES 1. All clients with schizophrenia spectrum disorders should be assessed with stan- dardized instruments for trauma exposure and for PTSD. 2. Providers working with these clients should be trained to understand post- traumatic stress syndromes, and to recognize their symptom presentation in schizophre- nia. 3. Services for such clients should be trauma-aware (e.g., housing recommendations; gender of providers; guidelines for use of restraints for abused clients that factor in trauma-related issues). 4. Clients should receive psychoeducation about trauma and posttraumatic stress syndromes, including how to recognize PTSD symptoms, how PTSD might exacerbate psychotic illness, and what treatments might be available. 5. Trauma-specific treatments (with different levels of empirical support) are avail - able and well described in the literature. Service systems that provide care for clients with schizophrenia should choose trauma interventions best suited for their clients and set - tings, and train staff in providing these treatments. 6. Providers should learn who in their area is able to provide trauma-specific treat - ments for clients with both schizophrenia and PTSD symptoms. 7. Given the high level of ongoing trauma in clients with schizophrenia, periodic re - assessment for trauma exposure and PTSD should be part of standard care. 8. PTSD symptoms can persist over many years, and symptoms ebb and wane, often in response to external stressors. Providers should be aware that clients’ PTSD may reemerge, and follow-up treatments or “booster” sessions may be required when clients undergo stress. 43. Trauma and Posttraumatic Stress Syndromes 455 456 VI. SPECIAL POPULATIONS AND PROBLEMS TABLE 43.1. Treatment Approaches for PTSD and Other Posttraumatic Syndromes in Persons with Schizophrenia and Other Severe Mental Illnesses Intervention name (developer) Target population Format and length Therapeutic elements Level of evidence Reference Beyond Trauma (Covington) Women abuse survivors Both group (11 sessions) and individual and group (16–28 sessions) Strengths-based approach; empowerment oriented Pre–post trial under way (150 participants) Beyond Trauma Manual (S. Covington; 858-454-8528) Seeking Safety (Najavits) Clients with substance abuse and PTSD or partial PTSD 25 topics (variable length); group and individual Establish safety. Teaches 80 safe coping skills for relationships, substances, self- harm, etc. Several RCTs; multiple open trials (none with identified SMI clients) Najavits (2002) Target (Ford) Multiple- trauma- exposed populations Group and individual versions; variable length, 3–26 sessions Strengths-based; teaches symptom monitoring and self-regulatory skills, experiential exercises Multiple open trials (none for SMI); one RCT completed for substance abuse population www.ptsdfreedo m.org for updates Trauma Recovery and Empowerment (TREM; Harris) Women trauma survivors Group format, 24–33 sessions Skills training, psychoeducation, peer support, elements of CBT Multiple open trials, RCT under way (women with SMI) Harris (1998) CBT for PTSD among Public Sector Consumers (Frueh) People with SMI and PTSD Group (10–14) and individual (6–12) sessions Anxiety management, exposure, coping and skills enhancement Treatment development phase (open trial under way) Frueh et al. (2004) CBT for PTSD in SMI (Mueser, Rosenberg) Clients with SMI and PTSD Individual (12–16) sessions Psychoeducation, relaxation One open trial and one RCT completed Mueser et al. (2004); Rosenberg et al. (2004) Atrium (Miller & Guidry) Abuse survivors with related problems (substance abuse, self- injury, violence, severe psychiatric disorders) 12-session individual, group, or peer-led program Psychoeducation, relaxation, mindfulness, expressive modalities, elements of CBT Participated in multisite, open trial (women and violence study) www.dusty miller.org Syndrome- Specific Group Therapy for Complex PTSD (Shelley & Munzenmeier) People with complex PTSD and SMI 12 sessions, group intervention Psychoeducation, skills training, and social support Pilot data only Syndrome- Specific Treatment Program for SMI Manual (Vols. I–VI) (shelleybpc @aol.com) Note. CBT, cognitive-behavioral therapy; RCT, randomized controlled trial; SMI, severe mental illness. KEY POINTS • Trauma exposure is ubiquitous in clients with schizophrenia, as is PTSD, but trauma history and posttraumatic syndromes are rarely assessed and treated in this population. • Trauma history and PTSD are associated with more severe symptoms (especially depres - sion, anxiety, and psychosis), worse functioning, and a more severe course of illness in cli - ents with schizophrenia. • Reliable and valid evaluations of trauma exposure and PTSD can be obtained in clients with schizophrenia through the use of standardized assessment instruments, including inter - view, self-report, and computer-administered formats. • The assessment of traumatic experiences and PTSD in schizophrenia rarely leads to symp - tom exacerbations or other untoward clinical effects. • Treatment programs for trauma and PTSD in schizophrenia, based on effective interven - tions for posttraumatic syndromes in the general population, have recently been developed and are being evaluated. • Preliminary experience with these treatment programs suggests that people with schizo - phrenia can be engaged and retained in treatment, and experience benefits from their par - ticipation. REFERENCES AND RECOMMENDED READINGS Blanchard, E. P., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric proper- ties of the PTSD Checklist. Behavior Therapy, 34, 669–673. Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216– 222. Cusack, K. J., Frueh, B. C., & Brady, K. T. (2004). Trauma history screening in a community mental health center. Psychiatric Services, 55, 157–162. Da Costa, J. M. (1871). On irritable heart: A clinical study of a form of functional cardiac disorder and its consequences. American Journal of the Medical Sciences, 61, 17–52. Frueh, B. C., Buckley,T.C., Cusack, K. J., Kimble, M.O.,Grubaugh, A. L., Turner, S. M., et al.(2004). Cognitive-behavioral treatment for PTSD among people with severe mental illness: A proposed treatment model. Journal of Psychiatric Practice, 10, 26–38. Harris, M. 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Trauma and Posttraumatic Stress Syndromes 457 [...]... in DSM-IV-TR (American Psychiatric Association, 2000) for adults Also, though autism and schizophrenia are separate disorders, they share symptom overlap of disturbances in social-cognitive development This chapter is divided into two parts The first part focuses on the clinical and neurobiological aspects of early-onset psychotic disorders, and the second part focuses on the general principles of treatment,... referred to as childhood-onset schizophrenia (COS) In contrast, the incidence of the disorder sharply increases after puberty, and when schizophrenia occurs before age 18 it is referred to as early-onset schizophrenia (EOS) The assessment of a child or adolescent with possible psychosis involves obtaining a careful history and assessment of mental status over multiple sessions 481 482 VI SPECIAL POPULATIONS... with adult-onset schizophrenia However, the rate of language impairments and transient, autistic-like symptoms appears higher in children and adolescents with schizophrenia relative to their adult counterparts, potentially suggesting that a more disturbed neurodevelopmental course is associated with an earlier onset of schizophrenia The few studies to examine the phenomenology of COS using DSM-III (American... early onset of schizophrenia, but whether this usage is involved in the etiopathogenesis of the disorder remains a topic of future research In such cases, it may be very important to clarify whether the usage of cannabis preceded the onset of psychotic symptoms, because many adolescents may attempt to self-medicate with cannabis Also, for a diagnosis of schizophrenia, a careful assessment of affective... correlated with risk of child maltreatment in parents with SMI 45 Parenting 473 THE IMPACT OF PARENTAL SCHIZOPHRENIA ON CHILDREN Offspring of mothers with schizophrenia are more likely to have developmental, emotional, social, behavioral, and cognitive problems This is due in part to genetics and in part to adverse childhood experiences, perhaps exacerbated by common correlates of serious mental illness... women with schizophrenia may not define motherhood as an option; consequently, they may need to grieve the loss of this life role 474 VI SPECIAL POPULATIONS AND PROBLEMS The major reason for loss of the parenting role among adults with schizophrenia appears to be loss of custody of children Although there are no nationally representative data on the prevalence of parents’ ultimate loss of custody... reviews of comorbidity and its management are given by Donald, Dower, and Kavanagh (2005); Drake, Mercer-McFadden, Mueser, McHugo, and Bond (19 98) ; Graham, Copello, Birchwood, and Mueser (2003); Kavanagh, Mueser, and Baker (2003); and Kavanagh and Mueser (2007) Castle and Murray (2004) offer an overview of the effects of cannabis, the use of cannabis by people with psychosis, and the management of comorbidity... research since the publication of Schizophrenia and Other Psychotic Disorders” (Tsai & Champine, 2004) The reader is referred to this chapter and to other sources (see References and Recommended Readings) for additional information regarding the care of children and adolescents with psychotic disorders CLINICAL AND NEUROBIOLOGICAL ASPECTS OF EARLY-ONSET PSYCHOTIC DISORDERS Onset of schizophrenia before age... versus non-integrated management and care for clients with co-occurring mental health and substance use disorders: A qualitative systematic review of randomised controlled trials Social Science and Medicine, 60, 1371–1 383 Drake, R E., Mercer-McFadden, C., Mueser, K T., McHugo, G J., & Bond, G R (19 98) Review of integrated mental health and substance abuse treatment for patients with dual disorders Schizophrenia. .. drinkers Journal of General Internal Medicine, 12, 274– 283 C H A P TE R 45 PARENTING JOANNE NICHOLSON LAURA MILLER EPIDEMIOLOGY AND SOCIAL CONTEXT Parenthood is a desired life goal and meaningful role for many adults with schizophrenia An analysis of national prevalence data indicated that 62% of women and 55% of men with schizophrenia spectrum disorders are parents Parents with schizophrenia spectrum . and individual and group (16– 28 sessions) Strengths-based approach; empowerment oriented Pre–post trial under way (150 participants) Beyond Trauma Manual (S. Covington; 85 8- 4 5 4 -8 5 28) Seeking Safety (Najavits) Clients. be - tween 8 and 12%, and the few available, community-based studies reporting point preva - lence of PTSD (the number of people who meet diagnostic criteria on any given day) sug - gest rates of. course of schizophrenia, contributing to worse outcomes and greater utilization of costly ser- vices through a number of mechanisms. PTSD AND SCHIZOPHRENIA PTSD is frequently chronic, often ebbs