Elsevier

Schizophrenia Research

Volume 53, Issues 1–2, 1 January 2002, Pages 123-143
Schizophrenia Research

Trauma, PTSD, and the course of severe mental illness: an interactive model

https://doi.org/10.1016/S0920-9964(01)00173-6Get rights and content

Abstract

Traumatic life events, as defined by DSM-IV, are common among persons with severe mental illnesses (SMI) such as schizophrenia. Limited evidence suggests concomitantly high rates of posttraumatic stress disorder (PTSD) in this population. However, conceptual models do not exist for understanding the interactions between trauma, PTSD, and SMI. We propose a model, which is an extension of the stress-vulnerability model, in which PTSD is hypothesized to mediate the negative effects of trauma on the course of SMI. Our model posits that PTSD influences psychiatric disorders both directly, through the effects of specific PTSD symptoms including avoidance, overarousal, and re-experiencing the trauma, and indirectly, through the effects of common correlates of PTSD such as retraumatization, substance abuse, and difficulties with interpersonal relationships. We discuss the evidence supporting this model, and consider several intervening variables that are hypothesized to moderate the proposed relationships between PTSD and SMI, including social support, coping and competence, and antisocial personality disorder. Theoretical and clinical implications of the model are considered, as well as several methodological and nosological issues. We conclude with a brief discussion of directions for future research aimed at evaluating components of the 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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