Psychiatric Annals

CME Article 

Comorbid: Posttraumatic Stress Disorder and Schizophrenia

Kristina Muenzenmaier, MD; Dorothy M. Castille, PhD; Anne-Marie Shelley, PhD; Andrea Jamison, MA; Joseph Battaglia, MD; Lewis A. Opler, MD, PhD; Mary Jane Alexander, PhD

Abstract

In recent years, an increasing awareness of comorbid disorders with schizophrenia has largely overlooked posttraumatic stress disorder (PTSD) as a co-occurring disorder. Not only are traumatic experiences often ignored, but the symptoms associated with trauma also are rarely assessed in people with schizophrenia. The implication of this oversight is that people diagnosed with schizophrenia do not receive evidence-based treatment for symptoms of PTSD.

While the deleterious effects of trauma are widely known and documented, more recent studies have shown that the type and severity of the traumatic events in the clinical population differ from those in the general population. The percentage of individuals in the community exposed to at least one traumatic event is high;1 however, the rate among the seriously mentally ill (SMI) population is almost twice as high.2 Psychiatric patients experienced an average of 3.5 different types of traumatic events throughout the lifespan, whereas less than 30% of the general populace experienced more than one traumatic event.1,3

Furthermore, there is an elevated co-occurrence of different types of childhood trauma in people with SMI, as well as of revictimization in adulthood. Rates of childhood sexual or physical abuse among female psychiatric patients range from 31% to 77%.2,4,5 Among adult male psychiatric inpatients, rates of childhood sexual abuse were more than double that in the general male population.6 Women who were sexually abused in childhood are seven times more likely to be sexually revictimized in adulthood.5

With this increased rate and severity of trauma exposure, it is not surprising that the prevalence rate of PTSD in people with SMI also is elevated. PTSD is a condition often missed in people with SMI. Epidemiological studies suggest prevalence rates of PTSD in the general population range from 1% to 9.5%.7,8 Compared with prevalence rates of PTSD in people with SMI, which range from 29% to as high as 43%,4 these figures suggest that PTSD may be three times more prevalent in people with SMI than in the general population.

Of people with PTSD, 79% had one or more comorbid psychiatric disorders, underscoring the need for an examination of PTSD comorbidity in people with SMI.1 Moreover, 37% of people diagnosed with PTSD were also diagnosed with schizoaffective disorder and 28% with schizophrenia.3 Studies conducted with people who were diagnosed with schizophrenia alone found that rates of comorbid PTSD ranged from 6% to as high as 42%.9,10

People who have histories of trauma, particularly childhood sexual and physical abuse, have been shown to have increased rates of PTSD, depression, anxiety disorders, psychosis, dissociation, borderline personality disorder, somatization, self-destructive behaviors, alcohol and substance abuse, and HIV-risk behaviors.2,4,11–16 Also of greater likelihood are revicitimization,5,17 homelessness,5,18 more frequent psychiatric relapses, and greater use of high-cost mental health services.2,19 Within the limited literature, a diagnosis of comorbid schizophrenia and PTSD (SCZ-PTSD) was found to be associated with increased severity of PTSD symptoms, depression, anxiety, psychosis, paranoia, and violent thoughts, feelings, and behaviors.9,10,20

Proponents of an integrative, bio-psycho-social approach to understanding SCZ-PTSD use a vulnerability-stress model as a foundation on which to locate the role of traumatic experience in the psychogenic pathway.21 This model proposes that a genetic (chromosomal) or congenital (intra-uterine toxic or viral exposure) vulnerability forms the biological platform, making the person more sensitive to stressful experiences triggering psychotic symptoms. Mueser adds to this model by positing that in people with SMI, a trauma history may lead to PTSD, which can lead either directly to increased symptom severity of SMI or to substance abuse, exposure to further traumatizing events, or both, resulting indirectly in increased symptom severity.3 Thus, in Mueser's model, PTSD has a central role as…

In recent years, an increasing awareness of comorbid disorders with schizophrenia has largely overlooked posttraumatic stress disorder (PTSD) as a co-occurring disorder. Not only are traumatic experiences often ignored, but the symptoms associated with trauma also are rarely assessed in people with schizophrenia. The implication of this oversight is that people diagnosed with schizophrenia do not receive evidence-based treatment for symptoms of PTSD.

Prevalence of PTSD in People with Schizophrenia

While the deleterious effects of trauma are widely known and documented, more recent studies have shown that the type and severity of the traumatic events in the clinical population differ from those in the general population. The percentage of individuals in the community exposed to at least one traumatic event is high;1 however, the rate among the seriously mentally ill (SMI) population is almost twice as high.2 Psychiatric patients experienced an average of 3.5 different types of traumatic events throughout the lifespan, whereas less than 30% of the general populace experienced more than one traumatic event.1,3

Furthermore, there is an elevated co-occurrence of different types of childhood trauma in people with SMI, as well as of revictimization in adulthood. Rates of childhood sexual or physical abuse among female psychiatric patients range from 31% to 77%.2,4,5 Among adult male psychiatric inpatients, rates of childhood sexual abuse were more than double that in the general male population.6 Women who were sexually abused in childhood are seven times more likely to be sexually revictimized in adulthood.5

With this increased rate and severity of trauma exposure, it is not surprising that the prevalence rate of PTSD in people with SMI also is elevated. PTSD is a condition often missed in people with SMI. Epidemiological studies suggest prevalence rates of PTSD in the general population range from 1% to 9.5%.7,8 Compared with prevalence rates of PTSD in people with SMI, which range from 29% to as high as 43%,4 these figures suggest that PTSD may be three times more prevalent in people with SMI than in the general population.

Of people with PTSD, 79% had one or more comorbid psychiatric disorders, underscoring the need for an examination of PTSD comorbidity in people with SMI.1 Moreover, 37% of people diagnosed with PTSD were also diagnosed with schizoaffective disorder and 28% with schizophrenia.3 Studies conducted with people who were diagnosed with schizophrenia alone found that rates of comorbid PTSD ranged from 6% to as high as 42%.9,10

Reciprocal Increased Vulnerability

People who have histories of trauma, particularly childhood sexual and physical abuse, have been shown to have increased rates of PTSD, depression, anxiety disorders, psychosis, dissociation, borderline personality disorder, somatization, self-destructive behaviors, alcohol and substance abuse, and HIV-risk behaviors.2,4,11–16 Also of greater likelihood are revicitimization,5,17 homelessness,5,18 more frequent psychiatric relapses, and greater use of high-cost mental health services.2,19 Within the limited literature, a diagnosis of comorbid schizophrenia and PTSD (SCZ-PTSD) was found to be associated with increased severity of PTSD symptoms, depression, anxiety, psychosis, paranoia, and violent thoughts, feelings, and behaviors.9,10,20

Proponents of an integrative, bio-psycho-social approach to understanding SCZ-PTSD use a vulnerability-stress model as a foundation on which to locate the role of traumatic experience in the psychogenic pathway.21 This model proposes that a genetic (chromosomal) or congenital (intra-uterine toxic or viral exposure) vulnerability forms the biological platform, making the person more sensitive to stressful experiences triggering psychotic symptoms. Mueser adds to this model by positing that in people with SMI, a trauma history may lead to PTSD, which can lead either directly to increased symptom severity of SMI or to substance abuse, exposure to further traumatizing events, or both, resulting indirectly in increased symptom severity.3 Thus, in Mueser's model, PTSD has a central role as a comorbid disorder leading to the worsening of SMI.

Read's Traumagenic Neurodevelopmental Model21 proposes that stress and trauma, particularly early in life, can shape the neurodevelopmental pathways that underlie psychotic pathology by precipitating the biological dysregulation of the hypothalamic–pituitary axis (HPA), gamma-aminobutyric acid (GABA) pathways, and neurotransmitters. As a result, this produces brain structural changes and impaired learning and memory functioning.

Psychological stress and major life events may play a role in relapse as well as in the onset of schizophrenia by leading to longstanding changes in the neurobiology of the body.22 Traumatic experiences may cause decreased hippocampal volume,23,24 which increases the likelihood of developing PTSD.25 Decreased hippocampal volume also may increase the likelihood of developing schizophrenia.21 People with schizophrenia have been found to have both decreased volume26 and deformities27 of the hippocampus. In addition, PTSD may cause changes in the glutamate system28 and glutamatergic abnormalities may in turn lead to schizophrenia.29

In other words, neurobiological deficits associated with schizophrenia may predispose persons to PTSD, while neurobiological deficits associated with PTSD may increase the risk of developing schizophrenia. Adverse life events, especially in childhood, are seen as having a direct effect on the developing brain. This effect results in biological abnormalities that can lead to symptoms of psychosis and cognitive impairment.

Phenomenology

PTSD and schizophrenia may express themselves in symptoms that are difficult to distinguish. The hallmark symptoms of PTSD are re-experiencing the event (eg, flashbacks or nightmares), hyperarousal, and avoidance, particularly of trauma-related stimuli.30 While positive symptoms (eg, hallucinations, delusions, thought disorder) are seen as pathognomic for schizophrenia,30 some argue they may instead represent re-experiencing symptoms,31,32 paranoia due to extreme hypervigilance,20 or dissociative symptoms33 as a result of the trauma. Notably, combat veterans diagnosed with PTSD and psychosis experience more positive symptoms, such as hallucinations, delusions, and violent thoughts, feelings, and behaviors, than participants with either disorder alone.20

Flat affect may be part of the deficit syndrome of schizophrenia or may be indicative of the emotional numbing often seen in PTSD sufferers to combat overwhelming anxiety. Poor eye contact may reflect either apathetic social withdrawal, one of the negative symptoms associated with schizophrenia, or the active avoidance associated with PTSD.9 More research is needed to address the association as well as the overlap of positive and negative symptoms, PTSD-related symptoms, and dissociative symptoms (Figure 1, see page 52).

Overlapping symptoms of schizophrenia, posttraumatic stress disorder, and dissociation.

Figure 1.

Overlapping symptoms of schizophrenia, posttraumatic stress disorder, and dissociation.

Assessment and Differential Diagnosis

Despite high rates of severe traumatic exposure and PTSD, clinicians rarely assess trauma or diagnose PTSD comorbidity in people with psychosis.34 Among people with SMI and comorbid PTSD, only about 3% had a diagnosis of PTSD recorded in their charts.4 The assessment procedure often is complicated by psychotic elaborations of traumatic events. The underreporting of PTSD symptoms is due in part to clinicians questioning the validity of answers given by people diagnosed with SMI35 and the consequent lack of inquiry into traumatic experiences and any related symptoms. Decreased disclosure of those experiences as a result of shame and guilt also contributes to underreporting.4,5

However, studies that have assessed the reliability and validity of patient reports have found surprisingly high test–retest reliability and validity.4,9,36 Rather than probing for details of traumatic experiences, which may lead to revictimization of the patient, clinicians must probe for details and content of psychotic symptoms and the affect related to it (ie, What is the nature of the voices? Whose voices are they? Are the voices inside or outside of the head? Are they threatening or commanding? Are they derogatory?). Such detailed information may help differentiate psychotic from PTSD or dissociative symptoms and avoid misdiagnosis and serious treatment mistakes.19,21,37

Important issues in the assessment of SCZ-PTSD are the differentiation of acute versus chronic PTSD, simple versus complex PTSD, dissociative disorders, and comorbidities (eg, substance abuse) associated with PTSD. Complex PTSD, the result of prolonged childhood trauma, while recognized by many clinicians,17 was not included in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition.30 A range of instruments for assessment of trauma and trauma symptoms are listed in the Table. More information on these assessment instruments and others can be found on the National Center for Post-Traumatic Stress Disorder Web site38 and in the Handbook of Psychiatric Measures.39

Instruments for Assessing Trauma and Trauma Associated Disorders

Table.

Instruments for Assessing Trauma and Trauma Associated Disorders

Treatment

A comprehensive treatment approach that includes different modalities is key in treating people with SCZ-PTSD. Individual treatment, group treatment, family therapy, and milieu therapy, combined with psychotherapy, cognitive behavioral therapy, social support, and pharmacotherapy, are important therapeutic tools.

In the United States, treatment for schizophrenia has relied primarily on the use of antipsychotic drugs, with a de-emphasis on psychotherapy. A growing literature, however, suggests that cognitive and psychoeducational methods are effective adjuncts to pharmacotherapy.40,41 This has led to a move toward incorporating techniques such as cognitive-behavior therapy (CBT), psychoeducation, skills training, social cognition, and cognitive rehabilitation into treatment programs.

Although cognitive therapies originally were developed for the treatment of affective and anxiety disorders, an increasing number of clinicians have successfully applied these techniques to a wider range of psychiatric diagnoses,42 including SMI with a psychotic component. Cognitive techniques have been used with good results in these populations to treat “voices,”40 delusions,41 and other psychotic symptoms43 unresponsive to medication.

Psychosocial Interventions

Treatment approaches for PTSD include several cognitive-behavior therapy (CBT) methods,44,45 psychodynamic psychotherapy,17,46 and eye movement desensitization and reprocessing (EMDR) therapy.47 CBT approaches proven useful comprise stress inoculation training (SIT), cognitive therapy (CT), cognitive processing therapy (CPT), and prolonged exposure (PE) therapy.44,45

PE combines prolonged exposure with psychoeducation, whereas CPT uses brief exposure and cognitive therapy, asking the traumatized person to write down recollections of the trauma, including thoughts and feelings associated with it, in a paced approach.45 Both CPT and PE have been shown to be equally effective in the treatment of complex PTSD.45 Although there are no large-scale treatment outcomes in people with SCZ-PTSD, preliminary results of two pilot studies support the clinical effectiveness of CBT approaches in this population.

Mueser's CBT program includes psychoeducation, breathing retraining and cognitive restructuring,37 de-emphasizing exposure based elements that often lead to high attrition rates. Syndrome-specific group therapy (SSGT), originally designed to treat the five-symptom clusters of schizophrenia,42 has been extended to encompass the treatment of complex PTSD. SSGT uses a variety of cognitive, behavioral, and emotive techniques, as well as psychoeducation and specific coping skills training (eg, grounding, behavior scripts, identifying feelings, relaxation techniques, anger management, rescripting nightmares). SSGT has demonstrated efficacy for symptoms of schizophrenia,42 and preliminary data suggest it also is effective for the treatment of complex PTSD symptoms in people with schizophrenia.

Other programs, such as dialectical behavior therapy,48 trauma recovery and empowerment model (TREM),49 and the Sanctuary Model,50 have demonstrated clinical utility, emphasizing safety to self and safety of the environment. However, they do not address all PTSD symptoms. Only limited research is available regarding interventions for families of people with SCZ-PTSD, who need skills in dealing with that family member and support to reduce burden and grief.51

Pharmacologic Interventions

As previously mentioned, there is evidence for involvement of opioid, glutamatergic, GABAergic, noradrenergic, serotonergic, and neuroendocrine pathways in the pathophysiology of PTSD and schizophrenia. Excellent reviews for the pharmacotherapy of PTSD include selective serotonin reuptake inhibitors (SSRI), mood stabilizers, and anti-adrenergic drugs, and the consensus is that the SSRIs are the main agents used for treatment of PTSD.52–55 The alpha adrenergic drugs, like clonidine, target specific symptoms such as hyperarousal and sleep disturbances. However, little is known in the treatment of comorbid PTSD and schizophrenia.

In general, in addition to pharmacotherapy for psychosis, medication interventions are useful to target several specific symptom domains. These include:

  • Re-experiencing phenomena of the trauma, such as flashbacks, recurrent nightmares, and psychotic-like symptoms;
  • Avoidance/numbing phenomenon, in which patients avoid all stimuli and memories of the traumatic event, including symptoms that are consistent with dissociative symptoms and depression (avoidance, withdrawal, and sense of shortened future); and
  • The hyper-arousal cluster, consisting of increased autonomic discharge resulting in difficulties in sleep, concentration, anger, and chronic anxiety.

A variety of agents may be used to treat both PTSD and schizophrenia. While first-generation antipsychotics have not shown efficacy when used to treat SCZ-PTSD comorbidity,56 several second-generation antipsychotics (eg, clozapine, risperidone, olanzapine, quetiapine), although not approved for PTSD, have shown some promise. Two double-blind studies with risperidone56,57 involved combat-related PTSD. When looking at PTSD and comorbid psychotic symptoms, there was a modest reduction in the Positive and Negative Syndrome Scale (PANSS) scores and on the re-experiencing subscale of the Clinician-administered PTSD Scale (CAPS).58 In a double-blind controlled study of veterans with combat-related PTSD, olanzapine was associated with improvement of both depression and sleep disturbance in patients with PTSD that had not responded to treatment with SSRIs.59

In an open trial, the use of quetiapine reduced total CAPS scores as well as PANSS scores.41,60 In a retrospective chart review (also of veterans with combat-related PTSD), low-dose quetiapine was shown to be effective in improving symptoms of re-experiencing, avoidance, numbing, arousal, and sleep disturbance.61

There may be a specific role for lamotrigine, either alone or as an add-on agent to the antipsychotics listed above, given the role of glutamate in both illnesses. Lamotrigine, although not FDA approved, may be more effective for the re-experiencing and avoidance symptom clusters.62,63

Summary

The treatment of PTSD and schizophrenia remains complex and understudied. A comprehensive treatment approach is essential when one treatment modality is not helpful. In some cases, certain forms of psychosocial interventions succeed when pharmacotherapy is less successful. Recovery must include mutual collaboration and respect between client and therapist, as well as the development and maintenance of a strong therapeutic alliance to address attachment and empowerment issues in treatment. Discharge resistance needs to be reframed to consider the environment into which the patient will be discharged. A person returning to the same neighborhood of the initial traumatization can be expected to experience retraumatization upon discharge. In addition, complicated family dynamics need to be addressed in order to develop a sufficiently supportive environment and ensure successful re-integration into the community.

Recognition of the severity of traumatic experiences and the comorbidity of PTSD in people with schizophrenia requires careful assessment and informed interventions. Research must provide detailed descriptions of positive and negative symptoms and dissociative and PTSD symptoms, as well as analyze their overlap. Only careful examination of the correlation of symptoms, rather than classification of symptoms to fit into specific diagnostic categories, will lead to better understanding, accurate diagnosis, and more effective treatment of comorbid disorders.

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Instruments for Assessing Trauma and Trauma Associated Disorders

Area of AssessmentInstrument
Trauma AssessmentTraumatic Life Events Questionnaire (TLEQ)
Trauma History Questionnaire (THQ)

Diagnostic MeasuresClinician Administered PTSD Scale (CAPS)
Structured Clinical Interview Diagnostic Post-Traumatic
Stress Disorder subscale (SCID-PTSD)

Symptom MeasuresImpact of Event Scale (IES)
Posttraumatic Stress Diagnostic Scale (PDS)
PTSD Checklist (PCL)
Trauma Symptom Checklist (TSC-40)

Complex PTSDStructured Interview for Disorders of Extreme Stress-NOS (SIDES-NOS)
Symptoms of Trauma Scale (SOTS)

DissociationDissociative Experiences Scale (DES)
The Dissociative Disorders Interview Schedule (DDIS)
Somatoform Dissociation Questionnaire (SDQ-20)

Educational Objectives

  1. Identify the prevalence of traumatic events in people with schizophrenia.

  2. Discuss the comorbidity and neurobiology of schizophrenia and posttraumatic stress disorder.

  3. Describe a treatment recommendation for comorbid schizophrenia and posttraumatic stress disorder, including psychotherapeutic and psychopharmacologic approaches.

Authors

Dr. Muenzenmaier is assistant clinical professor of psychiatry, Albert Einstein College of Medicine, and supervising psychiatrist, Bronx Psychiatric Center, Bronx, NY. Dr. Castille is research scientist, Epidemiology of Mental Disorders Research Department, New York State Psychiatric Institute, New York, NY. Drs. Shelley and Battaglia are assistant clinical professors of psychiatry, Albert Einstein College of Medicine.Ms.Jamison is a doctoral candidate, Department of Psychology, Long Island University, Brooklyn, NY. Dr. Opler is clinical professor of psychiatry, New York University School of Medicine, New York, NY. Dr. Alexander is senior research scientist, Nathan Kline Institute for Psychiatric Research, Orangeburg, NY.

Address reprint requests to: Kristina Muenzenmaier, MD, Bronx Psychiatric Center, Waters Place, Bronx, NY 10461-2796.

The authors have no industry relationships to disclose.

Members of the Trauma Committee at Bronx Psychiatric Center and Janet Chassman, MBA, director of the trauma unit at the New York State Office of Mental Health, contributed to the research for this article.

10.3928/00485713-20050101-07

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