Trauma, PTSD, and the course of severe mental illness: an interactive model
Section snippets
Trauma: definitions and prevalence
Psychological trauma refers to the experience of an uncontrollable event which is perceived to threaten a person's sense of integrity or survival (Horowitz, 1986, Herman, 1992, Van der Kolk, 1987). In defining a traumatic event as a criterion for PTSD, DSM-IV (American Psychiatric Association, 1994) adopts a narrower definition to include events involving direct threat of death, severe bodily harm, or psychological injury, which the person at the time finds intensely distressing or fearful.
Clinical correlates of trauma in SMI
Aside from the evidence linking childhood abuse, especially sexual abuse, to the later development of adult psychiatric disorders (Bagley and Ramsey, 1986, Browne and Finkelhor, 1986, Bushnell et al., 1992, Duncan et al., 1996, Polusny and Follette, 1995), trauma exposure is also related to the severity of psychiatric symptoms in the SMI population. Specifically, a history of sexual and physical abuse in persons with SMI is related to more severe symptoms such as hallucinations and delusions,
PTSD and SMI
PTSD is a disorder defined in DSM-IV by three types of symptoms, including re-experiencing of the trauma, overarousal, and avoidance of trauma-related stimuli, which are present at least one month after exposure to a traumatic event (American Psychiatric Association, 1994). Recent estimates of lifetime prevalence of PTSD in the general population range between 7.8 and 12.3% (Breslau et al., 1991, Kessler et al., 1995, Resnick et al., 1993). As discussed below, research on PTSD in patients with
An interactive model of trauma, PTSD, and SMI
Our model is an adaptation and extension of the stress-vulnerability model developed for schizophrenia and other SMIs (Falconer, 1965, Liberman et al., 1986, Zigler and Glick, 1986). The stress-vulnerability model assumes that symptom severity and other characteristic impairments of SMI have genetic and related biological bases (psychobiological vulnerability) determined early in life by a combination of genes and early environmental factors, such as the intrauterine hormonal environment and
Theoretical and clinical implications
We have proposed that PTSD mediates the negative effects of trauma on the severity and course of SMI through both direct and indirect mechanisms. To facilitate the evaluation of the model, we have taken care to operationalize our model in terms of specific, measurable constructs. This model has both theoretical and clinical implications for understanding factors which influence the course of SMI, and developing interventions designed to lessen the hypothesized effect of trauma on these
Methodological and nosological issues
Our model raises a number of methodological and nosological issues relevant to the assessment and hypothesized interactions between PTSD and SMI. The most important of these issues include PTSD as a continuum disorder and PTSD as a SMI. As these considerations are beyond the central scope of our theory, and are more speculative in nature, we discuss them only briefly below.
General conclusions and future directions
Our model posits that PTSD is a primary mechanism that is responsible for the frequently reported associations between trauma history and the severity and course of SMI. PTSD is but one of many concepts advanced to understand the psychological consequences of trauma (e.g. Finkelhor and Browne, 1985, Briere, 1984). Other writers have, for example, emphasized the chronicity and heterogeniety of symptoms observed in survivors of chronic trauma exposure, including dissociation, somatization, and
Acknowledgements
Preparation of this manuscript was supported by NIMH grant no. R24 MH56147. Portions of this paper were presented at the Fourteenth Annual Public Sector Psychiatry Conference on Treatment and Mistreatment of Women with Chronic Mental Illness, Worcester, MA in May, 1998, and the Fourteenth Annual Meeting of the International Society for Traumatic Stress Studies, Washington, DC in November, 1998. We thank Robert E. Drake, Julian Ford, and Mathew J. Friedman for their helpful discussions
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2022, Child Abuse and NeglectCitation Excerpt :One study using the Perceived Causal Relations scale also reported that participants perceived anxiety and intrusions of traumatic memories as greater causes of depression symptoms, rather than the opposite (i.e., depression causing anxiety and intrusions) (Frewen et al., 2013). Similarly, other scholars have proposed that PTSD symptoms (e.g., re-experiencing, avoidance) may directly influence other mental health symptoms, and have found that PTSD mediated the relationship between trauma exposure and symptom severity in people with severe mental illness (Mueser et al., 2002; Subica et al., 2012). Moreover, depression is commonly observed in trauma survivors with post-traumatic psychopathology (Flory & Yehuda, 2015; Fung, Chan, et al., 2020; Stander et al., 2014) and is also predicted by PTSD symptoms in longitudinal studies (An et al., 2019; Cheng et al., 2020).
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2021, Psychiatry ResearchCitation Excerpt :Moreover, the current revision of DSM-5 virtually stopped research on the traumatic effects of psychiatric hospitalization, resulting in a significant lack of current understanding about traumatization in hospital settings. In addition, PTSD is usually a missed diagnosis among patients with severe mental illness (SMI) in general (Mueser et al., 2002) and depression in particular (Kostaras et al., 2017), leading to worsening of prognosis and to suicidal behavior due to comorbidity (Sareen, 2014). To overcome the aforementioned problem and to produce comparable data to older studies, we used the term Nosocomial PTSD to define patients who met symptom criteria for DSM-5 due to external traumatizing conditions during hospitalization, but did not necessarily fulfill criterion A for traumatization.