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An investigation of a new diagnostic sub-type: Post traumatic stress disorder with psychotic features

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Content ©2003
AN INVESTIGATION OF A NEW DIAGNOSTIC SUB-TYPE:
POST TRAUMATIC STRESS DISORDER
WITH PSYCHOTIC FEATURES
by
Leslie Ann Kaye
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
EDUCATION - COUNSELING PSYCHOLOGY
August 2003
Leslie Ann Kaye
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UMI Number: 3116724
Copyright 2003 by
Kaye, Leslie Ann
All rights reserved.
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UNIVERSITY OF SOUTHERN CALIFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 90089-1695
This dissertation, written by
Les \ \ < 5 A v \v \
dissertation committee, and
approved by all its members, has been presented to and
accepted by the Director o f Graduate and Professional
Programs, in partial fulfillment o f the requirements for the
degree o f
DOCTOR OF PHILOSOPHY
Director
Date A u gu st 1 2 . 2003
under the direction o f h f C
Dissertation Committee
Chair
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DEDICATION
To My Beloved Family,
Dad, Mom, Melissa, Carl, and Dan Pesta,
And, as well, the Entire Extended Pesta-McGowen-Nicholson Clan,
For Unflinching Love, Unending Laughs, Unbridled Song,
Undying Connection...
I am so blessed...
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iii
ACKNOWLEDGEMENTS
With appreciation to...
My committee,
Donald Polkinghome, Rodney Goodyear and Barbara Solomon,
For their expertise,
The USC Counseling Psychology Cohort, USC Presidential Fellows and Faculty,
Montreal General Clinical Interns and Faculty, Boston University CPAR Faculty,
Massachusetts General Clinical Fellows and Faculty,
For helping me learn with such pleasure and with such esteemed colleagues,
Mark Zimmerman,
For the use of the outstanding database,
Michael Posternak and Naureen Attiullah,
For steadfast integrity and friendship,
My Los Angeles Girls,
Libby DuBay, Margaret Romero, and Sidney Peck,
For being my soul sisters and opening your loving hearts and homes,
In times of joy or need, for almost twenty years,
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My Boston Girls,
Teresa Martinez, Meg Carley, Belinda Boardman Maggioli,
And Our Amazing Thursday Night Club,
For the words of love, insight, and encouragement,
And for helping me learn, that actually, I am a Puerto Rican Girl,
My Marblehead Girl,
Maren Falck,
For every day, every hour, spent in company,
My Dublin Girl,
Sharon Murphy,
For moving into our futures, in lock step,
My Detroit Girl,
Laurie Kuta,
For truly, truly, being a direct descendant of the Queen of Sheba!,
And Finally, The Boys,
Bart Bauer, Lawrence Baisch, Keith Wiesman, and James Fligdon,
For loving me no matter what.
And Eric... for trying to...
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V
TABLE OF CONTENTS
Page
DEDICATION........................................................................................................ ii
ACKNOWLEDGEMENTS................................................................................... iii
LIST OF TABLES....................................................................... viii
ABSTRACT............................................................................................................ x
PREFACE............................................................................................................... xii
CHAPTER
1. INTRODUCTION............................................................................... 1
Purpose and Significant of the Study.......................................... 5
My Experiences and Underlying Assumptions........................... 6
Definitions of Term s..................................................................... 9
2. LITERATURE REVIEW.................................................................... 11
The History of the Trauma Research.......................................... 12
Early Observations of Traumatized Patients..................... 12
Major Thinkers of the Twenties: Battling Theories 15
The World Wars and Beyond: Still Living the
Trauma of W ar..................................................... 16
Post World War II: Integration and Aftermath................ 18
The Seventies: Building Knowledge from Tragedies 19
The State of the DSM and Trauma Research.............................. 20
Introduction of the Term PTSD: The Splitting of
Symptoms............................................................. 20
Debates and Development................................................... 20
Field Trials for the DSM-IV for PTSD.............................. 21
Today’s Major Thinkers: Moving Forward................................ 22
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vi
The Nineties and Beyond: Differing Focuses,
Differing Views.................................................... 22
Classification, Terminology, and Symptoms.................... 25
The DSM in Comparison to the ICD.................................. 27
The Current Study in Context of Recommended
Future Research.................................................... 27
Subtyping of PTSD ............................................................. 28
Recent Empirical Studies in Psychosis and Trauma.................. 29
Veteran Studies..................................................................... 29
Torture Survivors, Refugees and Vicarious
Traumatization of Targeted Groups................... 33
Psychodynamic Case Studies.............................................. 34
Other Single Case Studies................................................... 35
Adolescents ................................................................... 36
Medication Studies.............................................................. 37
Inmates 39
Accident Survivors.............................................................. 39
Hospital and Clinical Patients............................................. 40
Measurement of PTSD Assessment Tools........................ 43
Measures Used in the Assessment of Trauma............................. 44
The Life Stressor Checklist................................................. 44
Trauma Center Modified PTSD Symptom
Scale Self-Report................................................................. 44
Structured Interview for Disorders of
Extreme Stress...................................................... 45
The Traumatic Antecedents Questionnaire....................... 46
The Impact of Events Scale................................................. 46
Rorschach Cards................................................................... 47
Childhood Trauma Questionnaire...................................... 47
Other Measures ................................................................... 49
Summarizing Critique of the Literature...................................... 50
Weaknesses of Prior Research............................................ 50
Strengths of Prior Research................................................. 51
How the Proposed Study Builds on Prior Work................ 51
How the Proposed Study is Different than
Prior Work............................................................ 51
Theories and Selected Research Guiding the Hypotheses 52
The Diathesis-Stress Model................................................. 52
Biological/Neurological/Genetic Theories........................ 53
Psychodynamic Drive Theory............................................ 54
Cognitive Science Theories................................................. 55
Embodiment and Gender Theories..................................... 56
Complex Adaptations to Trauma....................................... 58
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vii
Integrating Theories with Clinical Experiences................ 58
Limits on Testable Hypotheses.......................................... 59
Hypotheses Resulting from the Literature
Review and Clinical Knowledge........................................ 60
The Independent Variable and the Research
Hypotheses Tested................................................ 60
Research Hypothesis One.......................... 61
Research Hypothesis Two................................................... 61
Research Hypothesis Three................................................. 61
Research Hypothesis Four................................................... 62
Research Hypothesis Five................................................... 62
Research Hypothesis Six..................................................... 63
Research Hypothesis Seven................................................. 63
Research Hypothesis Eight.................................................. 64
Research Hypothesis Nine................................................... 64
Research Hypothesis Ten.................................................... 65
Research Hypothesis Eleven............................................... 65
Tables of Variables ................................................................... 66
3. METHOD 71
Participants 71
Raters 71
Measures 72
The Structured Clinical Interview for DSM-IV................. 72
Clinical Global Impressions Scale...................................... 74
Global Assessment of Functioning..................................... 74
Procedure 75
Ethics 75
4. RESULTS 77
Descriptive Statistics and Hypotheses......................................... 77
Research Hypothesis One.................................................... 77
Research Hypothesis Two................................................... 79
Research Hypothesis Three................................................. 79
Research Hypothesis Four................................................... 81
Research Hypothesis Five................................................... 81
Research Hypothesis Six..................................................... 81
Research Hypothesis Seven................................................. 81
Research Hypothesis Eight.................................................. 82
Research Hypothesis Nine................................................... 83
Research Hypothesis Ten.................................................... 83
Research Hypothesis Eleven............................................... 83
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viii
5. DISCUSSION 85
Explanations for the Findings............................................................ 85
Non-Significant Findings: Etiological Validity Hypotheses 85
Significant Findings ....................................................................... 87
Concurrent V alidity Findings.................................................. 87
Predictive Validity Findings.................................................... 88
Convergence and Divergence with Existing
Research............................................................... 89
Theoretical Implications.................................................................... 93
Research Implications................................................................... 96
Applied Implications ....................................................................... 97
Treatment Strategies................................................................. 98
Clinical Vigilance................................................................. 99
Implications during Times of W ar..................................... 99
Innovative Programs in the Treatment
of Trauma................................................................. 101
Refugee Trauma Program................. 102
Domestic Violence Program 103
Limitations of the Study................................................................... 104
Design and Internal Validity.................................................. 105
External Validity and Generalizability............................... 105
Measurement........................................................................... 106
Statistical Problems................................................................. 106
Directions for Future Research......................................................... 107
Theories ................................................................................ 107
Research ................................................................................ 108
Practice ................................................................................ 108
6. CONCLUSION ............................................................................ 110
Problems with the Diagnosis of PTSD........................................ 110
Problems of Classification in the Human Sciences.................... 112
The Social Construction of Mental Disorders............................. 114
The Invention of Neurosis................................................................ 115
Types of Errors in the Study of Social Problems....................... 118
The Researcher’s Biases and Evolution of Thinking................. 120
REFERENCES........................................................................................................... 124
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LIST OF TABLES
Table Page
1. Independent Variable to be Analyzed in the Database..................... 66
2. Dependent Variables to be Analyzed in the Database..................... 67
3. T Test Results....................................................................................... 78
4. Chi Square Results............................................................................... 80
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X
ABSTRACT
This dissertation presented an empirical study that asked the question: do
significant differences in etiology, concurrent symptoms, and outcomes exist,
warranting a new diagnostic subtype of Post-Traumatic Stress Disorder (PTSD),
PTSD with Psychotic Features. The literature review traced the historical
development of trauma research, the diagnosis of PTSD from its inception through
its controversies, the current literature on PTSD with co-occurring psychosis, the
measures used in trauma assessment, and the theories guiding research.
The Rhode Island Methods to Improve Diagnostic and Assessments Services
(MIDAS) project database was used. It consisted of a population of 1500 patients,
20% (300) of whom had PTSD. Patients were diverse in terms of gender, race and
trauma code. The study compared the 18.7%, or 56 psychiatric outpatients with
PTSD with Psychotic Features, with the 81.3%, or 244 psychiatric outpatients with
PTSD without Psychotic Features.
Testable portions of the etiological hypotheses of PTSD with Psychotic
Features were rejected. Data analysis did not reveal a significantly different clinical
profile in terms of potential risk factors such as interpersonal trauma code, early age
of onset of PTSD, greater number of trauma symptoms, female gender, nor minority
status. Conversely, concurrent validity hypotheses were accepted. Data analysis
revealed that patients with PTSD with Psychotic Features had a greater number of
symptoms or disorders outside of PTSD. These included a greater number of suicide
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xi
attempts within the last year, higher CGI scores for Depression, and more co-morbid
Axis I disorders. Patients co-morbid with psychotic disorders accounted for 76.7%
of the variance, but could not account for the other 23.3% of patients co-morbid with
only non-psychotic disorders, including Bulimia, Obsessive Compulsive Disorder
and Alcohol Dependence. Predictive validity hypotheses were accepted. Data
analysis revealed that patients with PTSD with Psychotic Features were associated
with poorer outcomes, either episodically or overall. Patients showed a greater
number of hospitalizations, poorer past and present social functioning, poorer work
functioning, and lower GAF scores.
The inclusion of the subtype PTSD with Psychotic Features could lead to
greater diagnostic clarity, less diagnostic co-morbidity, and more homogenous
research groups to guide future treatment studies and recommendations.
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xii
Preface
Today we face not only war, but also the probability of treating and dealing
with after affects of repeated, ongoing interpersonal trauma to international troops
and civilians alike. And yet, extreme stress is not unique to the war scenario. Events
like the impact of witnessing domestic violence, experiencing racial bullying or
religious persecution, withstanding long-term childhood neglect, sustaining repeated
sexual assaults, enduring chaos that reigns during and after political unrest are
current day problems at home and across the globe. The cost to communities and
families of those traumatized is profound. Graver still is the continued toll on the
individual psyche of the sufferer.
Trauma is challenging to discuss, study, and treat for many reasons. It puts
us in touch with some of the most distressing aspects of being human. While natural
disasters and accidents can somehow be comprehended, interpersonal trauma can
make us see the darkest side of human deeds. Trauma can threaten our worldview,
feelings of safety, and hopes that the world is a bright and interesting place.
Trauma survivors can behave in complicated ways that either mimic past
traumas or encompass means of coping that reflect shattered patterns of relating.
Often trauma manifests itself in symptoms and metaphors that fall between the
cracks of regular language or concrete recall. Trauma survivors can act impulsively
or inappropriately, and sometimes, as in the cases that were examined here, break
from the consensual reality that most patients can sustain.
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xiii
This dissertation examined the differences between PTSD patients with and
without Psychotic Features. Specifically, results were conceptualized as supporting
or not supporting one of three kinds of validity: etiological, concurrent, and
predictive. I expect it will be a significant contribution to the literature.
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CHAPTER 1
The dissertation that follows uses a standard format: an Introduction to the
study, a Review of the relevant literature, a description of the Method of the
empirical study, a Results section presenting the analysis of the research data, a
Discussion of the meaning of those results, and the Conclusions drawn from the
study.
INTRODUCTION
Research Informing Practice: The Problems of Traditional Research
This section specifically explores the place of research in the practice of
counseling psychology, and the types of knowledge that inform it, with their pros
and cons. As counseling psychologists we are trained in the scientist-practitioner
tradition. But what type of science informs the treatment of our patients? Some
(Polkinghorne, 1999) would argue that course and outcome in individual human
affairs are primarily not predictable due to the highly context dependent and dynamic
nature of human affairs. For example, psychotherapy practitioners operate in such a
context of changing and deepening ties with patients that focusing on diagnostic
judgment is less important, perhaps even problematic. Clinical decisions “are
tentative and need to be altered or abandoned depending on the effects they produce.
. . . Therapists consider what has worked in similar situations and weigh the
possibility that it might be successful in the present situation” (Polkinghorne, 1999,
p. 1432).
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Is it helpful or useful to diagnostically categorize the patient who has
experienced a trauma beyond his or her capacity to cope into those who are and are
not experiencing psychosis? Polkinghorne (1999) puts forward Heidegger’s idea
that technification, the “ascendency of values favoring scientific, bureaucratic, and
technological solutions to human problems” (p. 1430) is on the rise in recent years,
and that such an orientation by necessity loses some of the unique aspects of being
human. Both diagnosis and empirically validated treatments would appear to do so.
“When technification is substituted for epistemic thinking in theorizing, theoretical
and research thinking is replaced by a simple set of algorithmic rules” (p. 1431).
Scientist practitioners are guided by a knowledge base of their own
experiences, the lore of the discipline, and the vicarious experiences of others
reported to them or in descriptive research (Polkinghorne, 1999). This knowledge
base of psychologists provides an organizing scheme “that converts the fuzziness of
experience into various sharply focused categories.. . . However, when background
knowledge operates to bring into focus certain aspects of a situation it causes other
aspects to recede into the background and to become marginalized” (p. 1433). Some
of the most human aspects of experiences fade into the background when the focus is
on determining what type of instance something is. This loss is certainly true in
determining a patient’s category in the Diagnostic and Statistical Manual of
Psychiatric Disorders (DSM).
The types of knowledge that inform counseling psychology have been
explored, as well as what is lost in such a process. But what are the steps of
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traditional research as they are performed? Is it actually useful in the human
sciences? The following section will lay out the argument for a study such as this
and explicate the steps of traditional research.
The Steps of Traditional Research
First of all, the DSM is not necessarily the clinician’s “bible” as it is
sometimes purported, but is rather a guide and presentation of one particular type of
knowledge at one point in time. It follows an outline of advancement within which
this dissertation falls. It is known that there are losses with simplifying the complex
questions of human behavior and emotion that we deal with in counseling
psychology. But there is also recognition that such research is useful in its way. The
steps of traditional are discussed in this section.
Proponents of traditional research argue valid classification is a critical step
in science, in both natural sciences and human sciences such as psychology.
Proponents of traditional research propose such classifications “provide common
ground for different research groups so that diagnostic definitions can be emended
constructively as further studies are completed” (Feighner, et al., 1972, p.57). They
argue that this first taxonomic step can allow “prediction of course and outcome,
allow planning for both immediate and long-term treatment” (p.57) as well as
communication among patients, clinicians and researchers. Taxonomy development
literature has grown in the field of psychology (Gangstad & Snyder, 1985) with Paul
Meehl leading in the development of sophisticated statistical techniques for that
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purpose. While that literature is beyond the scope of the present study, it can guide
discussion in later chapters on the nature of discrete and continuous variables.
In traditional psychological and psychiatric research there are five recognized
steps to diagnostic validity (Robbins & Guze, 1970, Feighner, et al., 1972). The
process begins with clinical description of the illness. This goes beyond merely
cataloguing symptoms but determines if race, sex, age at onset, precipitating factors,
or any other striking feature can help us “delineate the clinical picture more
precisely” (Robins, E. & Guze, 1970, p. 983).
This step is followed by laboratory studies. This can involve tests such as
“chemical, physiological, radiological, and anatomical (biopsy and autopsy)”
(p.983). For psychology, empirically validated tests, i.e., those that are reliable and
reproducible, are included in this category. This step is considered more precise than
clinical description alone, and yet without a matching clinical picture such results are
much less useful.
The third step is the ruling out of other disorders. For example, to look at
psychosis in relation to trauma we must note how this differs from schizophrenia and
the flashbacks commonly associated with PTSD. So here one must include “specific
exclusion criteria” (p.984) that permits exclusion of cases on the borderline “so that
index groups are as homogenous as possible” (p.984).
Follow-up study is the fourth step. It can reveal whether initial diagnostic
groups were indeed homogenous, whether some have an entirely different disorder
that explains the clinical picture or whether “marked differences in outcome, such as
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5
between complete recovery and chronic ” (p.984) disability can challenge the
validity of the original diagnosis. For example, if the prognosis for a particular set of
symptoms of a disorder is significantly different, then this may be considered a
different subset of the disorder or warrant a completely different diagnostic category.
Finally, the study of immediate families of patients is the fifth step. “The
finding of increased prevalence of the same disorder among the close relatives of the
original patients strongly indicates that one is dealing with a valid entity” (p. 984).
This has been borne out in delineating schizophrenia, different subtypes of
depression, and other clinical disorders.
Now that the steps of traditional research are understood, why undertake such
a study at this time and for what purpose?
Purpose and Significance of the Study
The research question for this project was whether the analysis of the MIDAS
clinical database of PTSD patients supported PTSD with Psychotic Features as a
separate subtype of the disorder distinct from typical Post Traumatic Stress Disorder
(PTSD). This study reviews the historical development of the diagnosis of PTSD,
the empirical data available on the relationship between psychosis and trauma, and
proposed and tested hypotheses that grew out of the literature and the researcher’s
clinical experience.
This was important because it pointed the direction for further research
whether it be, “genetic, psychodynamic, clinical, social, chemical, physical or
therapeutic” (Robins, E. & Guze, 1970, p.987). However, the research was not an
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end in itself. Most importantly, it can contribute to addressing specific clinical
treatment of one type of human suffering.
This specificity of treatment is critically important today because many of our
most challenged patients are placed outside of psychiatric care facilities and into our
communities, and twelve sessions have replaced ongoing psychotherapy. As
diagnostic capacity is refined, clinicians are better able to serve patients according to
their specific symptoms and the outcomes associated with that profile. They can
then select the most time-effective and comprehensive treatments possible, given the
limited resources and conditions under which they most often work.
The significance and purpose of the study have been expressed. The next
section explores how I came to understand the importance of the study and the
interests and beliefs that I brought as a researcher.
My Experiences and Underlying Assumptions
My orientation and supervision throughout much of my training has been
toward the unconscious processes that reflect the archetypal themes and patterns of
human behavior. I have paid attention to dream and imagery as meaning-based
knowledge representation or “proceduralized knowledge” (Anderson, 1990),
thinking of images as various bits of knowledge, collapsed or connected into
representational pictures, problem representations and solutions. I am interested in
the meaning-making processes of humans.
The importance to me of understanding different types of traumatized
patients began with early readings about the cyclical nature of violence, crystallized
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within my clinical work, and later presented itself in others I saw in the world. As
early as 1996 during my practicum at the Didi Hirsch Clinic in Venice Beach,
California, I encountered my first patient with psychosis. Later that same summer I
encountered a second patient with psychosis. Both were ethnic minorities, one a man
and one a women. This dissertation grew out of that experience in the clinical
setting, as well as later encounters with people actively psychotic, and concern about
how effectively to help them. While I had worked with trauma patients’ imagery
before, a focus on the mental imagery or delusional system of psychosis proved more
problematic than abreactive, analyzable, or helpful.
Particularly influential on my thinking was counseling psychologist Clara
Hill’s (1996) model for work with mental imagery. Her work explored not only
having the patient gain insight on the imagery in question but also change the
imagery and let it guide changes in other relevant areas of their life by outlining this
in an action plan. Other recent studies (Krakow, Hollifield et al., 2001, Krakow,
Johnston et al., 2001) showed re-scripting of problematic imagery effective in the
treatment of chronic nightmares in those with PTSD. Today my interest in mental
imagery and thought systems remains, as does my confidence in the benefits of
traumatic imagery analysis and re-scripting for PTSD patients. However, it is
tempered by my understanding of the limitations when the extent of perceptual
disturbance is as great as in those experiencing psychosis.
For this reason and others, the differentiation of PTSD, with and without
Psychotic Features, felt responsible and ethically sound given this
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8
scientist/practitioner’s experience and interest. Through the good fortune of an
introduction through my friend Dr. Michael Posternak, Dr. Mark Zimmerman
offered the use of the MIDAS database. Initially I hoped to look at gender
differences and the impact on Axis I and Axis II diagnoses, of the witnessing
domestic violence, and the lesser known childhood traumas of emotional and verbal
abuse. That project is saved for another day. Our conversations and mutual interest
in trauma led to deciding on exploring differences in trauma patients with and
without Psychotic Features. I then had what would become my completed
dissertation topic. What follows is a traditional research study involving the
preliminary taxonomic step of parsing out a different type of PTSD with Psychotic
Features that has perhaps different origins, outcomes and treatment
recommendations.
The previous section provided an overview of the reasons why this study is
being undertaken at this time. It explored the types of knowledge informing
counseling psychologists, the problems of traditional research, and the argument for
continued traditional research and its steps. It explained how I came to understand
the differences in clinical treatment of patients who have PTSD with Psychotic
Features, how I came to the MIDAS database, as well as the underlying assumptions
of my work, and the plan to move forward.
The next section reviews the relevant literature that informs the study of
PTSD. It begins with trauma research history, PTSD and DSM debates, current
thinkers and their recommendations for diagnostic clarification, current literature
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relating to Psychotic Features, and an overall critique of the literature to determine
where the present empirical study fits in.
Definition of Terms
For the purposes of this study, PTSD was defined as it is in the DSM-IV
(APA, 1994) and as it is operationalized in the Structured Clinical Interview for Axis
I DSM-IV Disorders (SCID) (Spitzer, Williams, Gibbon, & First., 1992) section F.
There are six criteria for diagnosis that are labeled A-F in diagnosing PTSD.
Criterion A is that the person has been exposed to a traumatic event in which the
person experienced either horror or threatened death or injury of self or other.
Criterion B is that the event is re-experienced in one of several ways: intrusive
imagery or perceptions, recurrent dreams, feeling of reliving the trauma, intense
distress at cues of the trauma, and or physiological reactivity at indicators of the
trauma. Criterion C is that the person persistently avoids and numbs in three or more
of the following ways: avoids thoughts, activities related to the trauma, has an
inability to recall aspects of the trauma, has diminished interest, feeling of
detachment, restricted affect, and or sense of a foreshortened future. Criterion D is
that there is persistent arousal indicated by two or more symptoms such as difficulty
sleeping, anger, difficulty concentrating, hypervigilance, and or exaggerated startle
response. Criterion E is that the disturbance has lasted more than 1 month. Criterion
F is that the disturbance causes significant distress or impairment in social,
occupational or other important areas of functioning. A full definition can be found
under the category of Anxiety Disorders in the DSM-IV.
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10
Psychotic Features was defined as having at least one or more symptoms of
psychosis. It was operationalized as it is in the SCID (Spitzer, Williams et al., 1992)
section B. The positive symptoms of psychosis are as follows: paranoid ideation,
delusions of reference, visual hallucinations, tactile hallucinations, other
hallucinations such as olfactory or gustatory, grandiose delusions, persecutory
delusions, auditory hallucinations, somatic delusions, religious delusions, delusions
of guilt, jealous delusions, erotomanic delusions, delusions of being controlled,
thought insertion, thought withdrawal, thought broadcasting, delusion of mind
reading, and bizarre phenomenon delusion. The other symptoms of psychosis are
catatonic behavior, grossly disorganized behavior, grossly inappropriate affect,
and/or disorganized speech. The negative symptoms of psychosis are avolition (and
inability to initiate and persist in goal directed activity), alogia (impoverishment in
thinking), and/or affective flattening.
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1 1
CHAPTER 2
LITERATURE REVIEW
This review of literature guides the reader through a historical account of
trauma research. Interestingly, trauma research itself has a long and turbulent
history. Present era research goes back to the early observations at France’s
esteemed Salpetrierre, winds through the World Wars and Vietnam, and goes on to
current advances in the knowledge of complex adaptations to ongoing trauma such
as witnessing domestic violence. For clarity, the Literature Review is broken into six
sections. The first section begins by presenting the early evolution of the clinical
understanding, observations, and early diagnostic names of trauma-related disorders
and the major thinkers who have given their time and attention to trauma research.
The second section follows with the state of diagnostic debates at present, the
introduction of the term PTSD, what the Field Trials for DSM-IV revealed and what
the PTSD sub workgroup for the DSM-IV recommended that was tabled for future
editions. The third section is what that same sub workgroup proposed so that
research might move forward in the coming years and where this study fits into that
progress. The fourth section presents the research literature from 1998 to the
present that highlights what has been written and observed about PTSD and
psychosis. The fifth section is a summarizing critique of that literature. The sixth
section presents the theories that guided the hypotheses and the hypotheses that
resulted from the integration of theory and practice. This format thereby lays the
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12
groundwork for the present study. This integrated, historical approach was
undertaken to give the reader a sense of the progression of thought, the stops, starts
and forgetting of previous knowledge that marked and distinguished trauma
literature. It also allows the reader to understand what thinking has come before this
study, and builds on the knowledge already gained by the psychologists that have
come before me.
The History of the Trauma Research
This first section begins by presenting the early evolution of the clinical
understanding and observations, early diagnostic names of trauma-related disorders
and the major thinkers who have given their time and attention to trauma research.
Early Observations o f Traumatized Patients
Only recently has the diagnosis of PTSD entered the clinician’s repertoire of
categorization. However, prior to this, descriptions of those suffering with reactions
to extreme stress appeared in classic mythology, drama and the earliest records of
battle and recorded history. Prior to being called the disorder we know today as
PTSD, “hysteria” was the term used to describe such symptoms, primarily in women,
at the turn of the century. Later terms such as “shell shock,” “combat fatigue,”
“traumatic neurosis,” or “soldiers heart” were used for men who had been in battle.
Several comprehensive histories (Brett, 1996; Davidson & Foa, 1991; Doehring,
1993; van der Hart, 1996; van der Kolk, Herron, & Hosgtetler, 1994; van der Kolk,
Pelcovitz et al., 1996; van der Kolk, Weisaeth) were useful in the preparation of the
history that follows.
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Early on, clinicians attempted make sense of the chaotic existence of patients
with this disorder. Many of them were located in France and started with simple
observations of the symptoms of their patients. Briquet (1859), a French
psychiatrist, made some of the first observations about the connection between
hysterical symptoms and childhood trauma. However Erichsen (1866a, 1886b), a
surgeon in England, felt that badly injured accident victims with psychological
difficulties had an organic problem that was totally different from hysteria. Debate
ensued when Erichsen’s colleague Page (1885), also a surgeon, disagreed. He
argued that the fright alone from an accident could cause psychological problems.
Other systematic observations and contributions came from a French forensic
researcher and professor, Tardieu (1878), who documented sexual abuse of children
in France. As occurs in the present day debate, he was quickly confronted by critics
who thought that the children were falsely accusing their parents of incest.
In France, at Salpetrierre, “hysterics” were patients who were observed to
have odd reactions to stress. Charcot (1887), a neurologist, observed that a traumatic
shock or “choc nerveux” could put a person into a state similar to that of hypnosis.
The idea of suggestibility after shock or while hypnotized gave him the idea that
“hystero-traumatic autosuggestion” was possible when a patient was in a dissociated
state. Pierre Janet, a psychiatrist directing the laboratory at Salpetriere in the 1880s,
was inspired by Charcot. He observed patients’ outbursts toward self or others, their
psychosomatic illnesses and the stereotypical movements, emotions, ideas and
imagery in traumatized patients who had dissociated. He came to understand this as
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representing “derivations of emotional and behavioral responses to frightening past
events” (van der Kolk, Pelcovitz et al., 1996, p. 84) that were in fact split off from
ordinary consciousness due to faulty information processing in extreme stress. He
postulated that they would continue to haunt the patient as obsessions,
preoccupations and symptoms. His clinical observations “provided the first
convincing evidence that trauma caused some individuals to develop two or more
separate, dissociated streams of consciousness” (p. 84).
Babinsky (1901,1909), another student of Charcot, later took over at
Salpetrierre and focused his work on hysteria as a strictly neurological disease.
Charcot’s ideas of trauma at hysteria’s origin were thrown out, and it was thought of
as a disease of will. Babinsky and German psychiatrists during World War I put
their efforts toward what they called “simulation” and employed “causal will
therapies.”
Outside of the clinical setting, Steirlin, a Swiss psychiatrist, studied disasters,
e.g., an earthquake in Messina, Italy, in 1907, and a mining disaster in 1906. He
found that 25% of the survivors of the earthquake that killed 70,000 had nightmares
and sleep disturbances. In Germany, psychiatrist Bonhoeffer (1926) regarded
traumatic neurosis as a social illness that revealed the patient’s inherent weakness,
motivated by the secondary gain of compensation. The National Health insurance
policy of Germany supported this position. Thus Traumatic Neurosis would not be
compensated unless it was in the first days post-shock.
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By making observations of patients, each clinician group began to formulate
theories as to the origin and processes of disorders and how to handle them. The
next section will explain how some of the major clinician groups came to understand
what later became Post-Traumatic Stress Disorder.
Major Thinkers o f the Twenties: Battling Theories
Major thinkers in psychology came to have a similar understanding of
humans reacting to trauma as Janet and Charcot. Freud soon came to visit
Salpetriere, agreeing with Janet and Charcot that dissociation was at the heart of
hysteria. “The neurotic turns away from reality because he finds it unbearable -
either the whole or parts of it. The most extreme type of this alienation from reality
is shown in certain cases of hallucinatory psychosis” (Freud, 1950, p. 13). Freud and
Breuer felt that something becomes traumatic because it is dissociated. Later Freud
turned around his views that childhood trauma and hypnoid states were at the core of
hysteria. He instead put forward his original idea that it was instead the unacceptable
wishes primarily from the oedipal crisis that were at the core of hysteria. He led the
movement to focus on the intrapsychic reality over the interpersonal reality. His two
models, unbearable trauma and unacceptable impulse, remained at odds.
Ferenczi, spoke at the 1929 Psychoanalytic Conference about the damage
done when someone responsible for another’s growth uses their “vulnerability and
need for affection to gain sexual gratification” (van der Kolk, Weisaeth et al., 1996,
p. 56). William James, too, paid special heed to Janet’s concepts. He added that
traumatic events precipitated “the throwing of certain functional brain-tracts out of
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gear with others, so as to dissociate their consciousness from that of the remaining
brain, throws them out for both sensorial and ideational service” (James, 1890,
p.682).
Just after completing his own analysis in 1923 with Freud, Abram Kardiner
tried to create a theory of war neurosis based on early psychoanalytic theory. His
attempts were largely unsuccessful. Major thinkers could not agree about important
aspects of traumatization. Soon, the impact of wide spread exposure to, and
observations of, war trauma moved the field forward to some cohesion.
The World Wars and Beyond: Still Living the Trauma o f War
In an attempt to address his own frustrations with Freud’s analytical theories,
Kardiner pursued his own clinical work. Kardiner’s (1941) descriptions in “The
Traumatic Neurosis of War” grew out of his treatment of WWI veterans and later
revisions of his clinical observations as WWII was breaking out. He stated that
veterans “developed amnesia about the trauma, while continuing to behave as if they
were in the middle of it” (van der Kolk, Pelcovitz et al., 1996, p. 85) and that they
were “fixated on a traumatic experience which was reenacted during dissociative
fugue states” (p. 85).
Many researchers have noted that in times of war there was a great interest in
trauma. However, afterwards, interest generally fell off. Insights gained during
those times were collectively forgotten (dissociated?). Still, the International
Statistical Classification of the Diseases, Injuries and Causes of Death (ICD-6) from
the World Health Organizations (WHO) (1948) made the decision to include mental
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disorders in the classification manual. In 1952, when the American Psychiatric
Association (APA) revised its understanding from the 193 3 criteria, both the ICD and
the DSM had similar understanding of the disorder. The psychiatrists devoting their
time and attention to the understanding of war neurosis thought of it as “short-lived
responses in essentially normal individuals” (Brett, 1996, p. 118). In the ICD-6
(WHO, 1948) it was called “acute situational adjustments.” In the DSM-I (APA,
1952) it was called “transient situational personality disturbances.”
After World War II (WWII), clinicians put their work into understanding the
biologically conditioned response after trauma, and “they reintroduced, for the first
time in 4 decades, hypnosis and narcosynthesis to help patients “remember” and
abreact the trauma. They also confirmed Janet’s observation that abreaction without
transformation and substitution did not help” (van der Kolk, Weisaeth et al., 1996,
p.59). This is a particularly interesting to note in that it points to current research
that employs methods to transform and re-script traumatic imagery. The
observations of WWII clinicians grew out of their attempts at treatment and the
unusual finding that patients could remember bodily sensations from their trauma
during altered states of consciousness.
Group psychotherapy was thought to be the ideal unit of treatment after wars
and disasters. Both Menninger (1985) in the United States and Bion (1974) at the
Tavistock Clinic in London worked in this way, gleaning experiences from their war
time treatments and research. Interestingly, much was quiet on the research front for
the next 25 years.
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WWII served as an impetus for a flood of new knowledge. The progress in
clinical work led to consensus in some areas and renewed attention to earlier
research. The understanding of the power of groups in the treatment of trauma
disorders was discovered. While a period of quiet followed the war, it allowed
researchers and clinicians to synthesize their knowledge and to follow the after
effects over time on traumatized populations.
Post World War II: Integration and Aftermath
The synthesis of knowledge and following of different trauma groups
followed two strains and that emerged post WWII. One was the integration of
observations made during wartime. Grinker and Spiegel (1945) wrote on the lasting
impression left by experiences such as war on the soldier’s life. The other line of
research was on survivors of the Holocaust by Krystal (1968), a psychoanalyst. Not
only were the usual symptoms of trauma noted, but also the significant personality
changes effected by such long-term ongoing trauma. He felt personality change
results from a movement from states of ongoing hyper-arousal to a deadening of
emotions and behavior, in essence a giving up, but beyond that an inability to use
bodily sensations as signals. What can results are affect storms, anger outbursts and
an inability to know what one is feeling (alexithymia).
More wars and more tragedies such as Vietnam were to force the learning
curve of clinician-researchers. With full knowledge of the after effects of war,
clinicians walked into the next phase of knowledge.
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The Seventies: Building Knowledge from Tragedies
The term “transient situational disturbance” was used in both the DSM-II
(APA, 1968) and the ICD-8 (WHO, 1969). The ensuing seventies were marked by
the work of four major thinkers. Horowitz (1978) built on Lindemann’s (1944)
observations after the Cocoanut Grove nightclub fire in Boston, noting the intrusion
and numbing that are now consider classic to PTSD. Terr (1979) noted the
developmental impact on children following the Chowchilla school bus kidnapping
in California. The inability to verbalize one’s inner life, the impairment in the ability
to utilize symbolism and the resulting post-traumatic somatization were laid out by
the psychoanalyst Krystal (1978). Figley (1978) contributed his own experiences as
a Vietnam war veteran and his editing of other writers on the Vietnam War.
Later, domestic violence, rape, and incest became more widely and
systematically studied and reported. It was not until 1974 that Burgess and Holstrom
at Boston City Hospital first described the “rape trauma syndrome” similar to the
symptoms seen in war veterans in terms of nightmares and flashbacks. Kempe and
Kempe (1978) studied battered children, and Judith Herman (1981) studied incest.
Hayley (1974) wrote first person accounts of being both a daughter of a war veteran
and a victim of incest. She was an instrumental proponent of PTSD being accepted
into the DSM III.
Vietnam and domestic violence, community tragedies and incest, informed
the knowledge base of trauma researchers. Still, PTSD was thought to be a
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temporary disturbance. Research questions were about to deepen, and so too was the
split between European and American conceptualizations.
The State of the DSM and Trauma Research
What follows will be the introduction of the term PTSD, the state of
diagnostic debates at present, and what the Field Trials for DSM-IV revealed.
Introduction o f the Term PTSD: The Splitting o f Symptoms
When did the term PTSD first enter the clinician’s lexicon? The ICD- 9
(WHO, 1977) used the term “acute reaction to stress” but PTSD as a diagnostic name
first appeared in the DSM III (APA, 1980). Here the symptoms that were once
comprehensively understood to occur together now appeared to be dispersed over
several diagnoses. This caused diagnostic comorbidity when in fact it may be that
the symptoms are split, not because they are not clinically linked, but rather because
the DSM has approached the classification of disorders phenomenologically.
DSM-III, in an attempt to be atheoretical, [has] almost entirely abandoned the
psychodynamic understanding of psychiatric phenomenon.. . . The
traditional concept of hysteria as a disorder with both sensorimotor and
mental manifestations have been split apart by assigning the mental
symptoms of hysteria to the “Dissociative Disorders” and by allocating the
sensorimotor symptoms to the different category of “Somatoform Disorder”
(van der Kolk, Pelcovitz, et al., 1996, p. 83).
Debates and Development
In contrast to perceptions of short-term disability, new strides in
understanding introduced the idea of longer-term adaptations to trauma. The DSM-
III (APA, 1980) and the ICD-10 (WHO, 1992) both incorporated the idea that stress
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disorders can be chronic and can occur with other disorders both current and
previous ones. However, it was an American phenomenon to classify PTSD as an
anxiety disorder. Americans also had a more inclusive approach to the anxiety
disorders by including Obsessive Compulsive Disorder together with PTSD while
Europeans conceptualized anxiety as a more common feature of multiple disorders.
The sub workgroup for DSM-III (APA, 1980) PTSD debated strongly
whether it should be classified as a dissociative or an anxiety disorder. The
unanimous recommendation of both subcommittes to merge the two groups was not
heeded. In the end it was classified as an anxiety disorder with rape, battered
woman, Vietnam veteran, and abused child syndromes condensed into one heading,
considerably diminishing the differentiation trauma type in the DSM III (APA,
1980).
While Europe and America came to different diagnostic conclusions, the
debates were helpful in determining that systematic study was necessary for growth.
Field Trials for the DSM-IV for PTSD
Systematic study was incorporated into the field trials for the DSM-IV (APA,
1994). In the field trials, 395 treatment-seeking patients, and 125 non-treatment-
seeking patients were compared. Data on age of onset, PTSD, dissociation,
somatization, and affect dysregulation and age of onset were collected. In the study
of PTSD, dissociation, somatization and affect dysregulation were highly
intercorrelated (van der Kolk, Pelcovitz, et al., 1996). PTSD that developed after
interpersonal trauma was correlated with a great number of symptoms, with
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childhood interpersonal trauma being the most highly correlated. The field trials
were designed to “define symptom constellations operationally and to investigate
their interrelationships, as well as their relation to the diagnostic construct of PTSD
itself’ (p. 86).
The DSM-IV (APA, 1994) did include a list of “Associated Features and
Disorders” for PTSD which integrated dissociation, somatization, affect
dysregulation, and permanent character changes. These associated features still do
not allow for comprehensive classification of a patient with PTSD when the
symptoms move beyond flashbacks to psychotic breaks, hallucinations or delusions.
The field trials for the DSM-IV (APA, 1994) gave an understanding of the
cluster of symptoms that occur together. These associated features were
incorporated as a compromise to some of the losses in the DSM-III (APA, 1980).
The sub workgroup also had specific recommendations for moving forward.
Today’s Major Thinkers: Moving Forward
The following section describes the current major thinkers in the field of
trauma research, lays out the PTSD DSM-IV sub workgroup’s recommendations for
future research and determines where this study fits in the development of thinking.
The Nineties and Beyond: Differing Focuses, Differing Views
As the field of trauma research moved into the present day, progress was
made in the area of developmental impact of trauma and other divergent streams of
research. During the nineties, significant attention was paid to the developmental
impact of trauma. Cicchetti & White (1990) highlighted that abused children tend to
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act, not reflect, and have difficulty naming what they feel. Herman (1992) noted that
one’s sense of self is formed by one’s interaction with caregivers; thus abused
children end up with difficulties of identity. She highlighted the frequency of
traumatized individuals diagnosed with borderline personality disorder or
dissociative disorders.
In recent history, van der Kolk stated Boston has been “for the study of
trauma what Vienna once was for the composition of music” (van der Kolk,
McFarlane, et al., 1996d, p.xx). Bessel van der Kolk, one of the principal
investigators for the PTSD field trials for PTSD in DSM-IV, today holds yearly
conferences each spring that present state of the art trauma research to the interested
scholars and students. Most recently he has introduced attention to the body as a
critical piece of the comprehensive treatment of PTSD that is missing from most
treatment strategies. As well, he has focused recent attention on Eye Movement
Desensitization and Reprocessing. His work on the complex adaptations to trauma
inspires and informs current researchers.
David Barlow (2002), new to Boston University’s Clinical Psychology
Program, is one of the leaders of anxiety disorder research and the major proponent
of including PTSD in the category of the Anxiety Disorders. His reasoning rests on
the similarity between the anxiety disorders in terms of the hypervigilance,
hyperarousal, affect dysregulation and narrowed attention.
As highlighted earlier, children and women’s perspectives were missing until
very recently. Several clinicians and researchers have attempted to address that gap
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in the literature. Judith Herman’s (1992) critical work entitled “Trauma and
Recovery” in part remedied the oversight. Her placement at Harvard Medical
School’s teaching hospitals allows her to contribute not only to the literature on
PTSD but also the training and supervision of the next generation of trauma
clinicians and researchers.
Terence Keane directs the Behavioral Science Division at the National Center
for PTSD at the Boston Veterans Administration (VA) Medical Center. He and
colleagues across the VA system are current leaders in PTSD research and treatment.
Others like Edna Foa (Foa, Cashman, Jaycox, & Perry, 1997) and Donald
Meichenbaum (1994) lead in evaluating measures of assessing PTSD and
categorizing the most effective treatments for PTSD.
Rachel Yehuda is Director of the Traumatic Stress Studies Division at the
Mount Sinai School of Medicine and Bronx Veteran’s Affairs Medical Center and is
recognized for her outstanding work with Holocaust survivors.
Researchers at Massachusetts General Hospital are using the technological
advances of Positron Emission Tomography to indicate increased blood flow to
certain areas of the brains of traumatized individuals. Principal researchers there are
Roger Pitman and Scott Orr. Jose Saporta has received awards and outstanding
notice for his work in synthesizing psychoanalytic and biological approaches to
trauma.
Outside of the psychiatry and psychology fields, book contributors in history
have made significant and vital contributions to a broad based view of trauma.
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Burkett and Whitley’s (1998) “Stolen Valor” is one essential reference, as is Micale
and Lemer’s “Traumatic Pasts” (2001). Philosophical contributions of Ian
Hacking’s (1999) book on the social construction of mental illness is valuable, as is
Leys’ “Trauma: A geneology” (2000). Highly regarded is Scott’s (1993) “The
politics of readjustment: Vietnam veterans since the war” from the field of sociology,
and from anthropology, Young’s (1995) “Harmony of illusions” on the history and
“invention” of PTSD.
Enormous contributions in research have been made in trauma literature.
Those who have devoted their careers, considerable talent, and vested interests to the
study of trauma are too numerous to mention. While the next generation of
researchers moves to the forefront, how to progress was put forward by the leaders in
the field.
Classification, Terminology, and Symptoms
How a diagnosis is classified has a large impact on how future researchers
conceptualize the disorder. The words chosen should be precise and well thought
out. Despite the unanimous recommendations of the sub workgroup for PTSD to be
classified in a new Stress Response category, the DSM-IV Task Force did not
support the position, kept it classified as an anxiety disorder, and decided to table
that discussion for future research (Brett, 1996, p.l 17). The sub workgroup based
their recommendations for a new classification in part on the fact that classification
based on etiology is favored in the medical sciences due to its importance to public
health. Stressors or traumas, rather than anxiety, are to be prevented. Beyond that,
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“re-experiencing disorder” as opposed to “stress disorder” is supported because of
both the psychological and physiological re-experiencing as it differs from anxiety
(Pitman, 1993).
DSM-IY (APA, 1994) reintroduced the dissociative symptoms for PTSD in
Associated Features. And yet overt psychosis, while observed by clinicians and
raters, still creates confusion within the diagnosis of PTSD and has no
comprehensive diagnostic correlate as currently listed. Today the DSM-IY (APA,
1994) splits PTSD symptoms in the following way: Number one, it describes
Dissociative Disorders as “a disturbance or alteration in the normally integretive
function of identity memory or consciousness.” Number two, Somatization Disorder
is listed in the DSM as bodily complaints for which there is no medical explanation.
Such somatization is thought to occur because of alexithymia, an inability to name
what one is feeling, in particular in states of extreme arousal. Amnesia is one of
Somatization Disorders diagnostic criteria. Difficulty modulating “anger, chronic
self-destructive, and suicidal behaviors,. . . sexual involvement and impulsive and
risk-taking behaviors” (van der Kolk, Pelcovitz, et al., 1996, p.86) is known in the
symptom clusters as “affect dysregulation.” Further refinement is needed for the
unique characteristics presented by patients with PTSD with Psychotic Features.
Classification and terminology differences have left the DSM-IV in a state of
discord with the some of the top American researchers in the field. But the rest of
the world outside of the United States has handled the dilemma differently. Their
advances can help deepen American researchers’ next steps.
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The DSM in Comparison to the ICD
The ICD-10 (WHO, 1992) appears to be a step ahead in that it has more
variety in the diagnosis of trauma reactions, and it includes strong and enduring
personality changes that occur post traumatically. Future research must address and
move beyond oversimplifying the complex interrelationships of “specific traumas,
secondary adversities, environmental chaos and neglect, nature of pre-existing and
subsequent attachment patterns, temperament, special competencies, and other
contributions to the genesis of these problems” (van der Kolk, 1996, p. 183).
While the ICD-10 appears to have incorporated a more comprehensive
understanding of the complex adaptations to trauma, the DSM, as a work in progress,
is poised to also move forward with new developments. This research study expects
to be a part of the improvements as described below.
The Current Study in Context o f Recommended Future Research
This study used the knowledge gained by the sub workgroup for the DSM-IV
(APA, 1994) in its proposed new Stress Response or Trauma Re-Experiencing
category. It also incorporated the variety and differing manifestations of PTSD as
outlined in the ICD-10 (WHO, 1992). It moves beyond this to propose a Psychotic
Features subtype of PTSD.
The sub workgroup for PTSD in the DSM-IV identified five areas that are
critical to understanding the diagnosis of PTSD and moving research beyond the
DSM-IV. They are identified: (a) as increasing our understanding of the clinical
phenomenon of the disorder, (b) studying specific trauma groups, (c) epidemiology,
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(d) further research into where and how PTSD should be classified, and (e) the
relationship between PTSD and other disorders (Davidson & Foa, 1991).
The present study contributes to increasing clinical understanding of PTSD
and proposes the possible subtyping of PTSD with Psychotic Features. The study of
specific trauma groups, epidemiology, and the relationship between PTSD and other
disorders is beyond the scope of this paper other than parsing out the specific
psychotic symptoms. The potential re-classification of PTSD under the heading of
Stress Response or Trauma Re-Experiencing Disorders is taken upon the
recommendation and reasoning of the sub workgroup and yet is addressed to some
degree in the discussion of this paper.
Subtyping o f PTSD
The goal of this project was to show how the research literature and the
empirical study supported the subtyping of PTSD. However, it was not the first time
that subtypes have been proposed or incorporated, incorrectly or not. Clinical
experience in the recent past had informed and supported the subtyping of PTSD into
the DSM-III categories of acute, chronic and delayed onset (Rothbaum & Foa,
1992). Psychoanalytic descriptions of conscious and unconscious defenses were
used to explain the delayed onset of PTSD. Still subsequent research literature did
not support any significant differences between acute and delayed onset PTSD being
related to severity of trauma, severity of symptoms, repression, or previous stress
history (Watson et al., 1988). Emotional response also did not differ between the
two groups (Kolb & Mutalipassi, 1982). This project puts forward the idea that the
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more appropriate subtyping may be to include a phenomenological symptom subtype
of PTSD with Psychotic Features within the sub workgroup’s proposed new Stress
Response or Trauma Re-Experiencing category.
Since a subtype of Post Traumatic Stress Disorder with Psychotic Features
does not yet exist, the following section of the Literature Review will look at
empirical studies within “psychlNFO” that include PTSD and psychosis during the
period from 1998 to present.
Recent Empirical Studies in Psychosis and Trauma
This literature review examines current literature (1998 to present) that
encompasses and increases our understanding of current research in psychosis and
PTSD. It synthesizes the studies and gathers them moving from veteran studies to
torture survivors and refugees, from psychodynamic and other case studies to
adolescent research, from medication studies to inmate psychosis, from accident
survivors to hospital and clinic patients. Finally an article that reviews several
assessment tools for PTSD is followed by the hypotheses that grew out of the
research review and the clinical experiences of the researcher.
Veteran Studies
Of all the trauma groups available, veterans still are the population most often
studied in the PTSD literature (David, Kutcher, Jackson, & Mellman; 1999; David &
Mellman, 1999; Hamner et al., 2000; Hamner & Gold, 1998; Monnier, Elhai, Frueh,
Sauvageot, & Magruder, 2002; Petty et al., 2001; Pies, 1999; Sautter, Brailey et al.,
1999; Zelenova, Lazebnaia, & Tarabrina, 2001;). However, being that the sample is
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predominantly male, it hampers the ability to generalize it to a gender diverse
population.
Defining psychosis in PTSD is subject to debate as to the broadness or
stringency of criteria used. In an interplay of article (David et al., 1999), comment
(Pies, 1999), and response (David & Mellman, 1999), the volley debated the subject
of whether to define as psychosis the primarily auditory hallucinations. In the
sample of 53 male combat veterans with PTSD, excepting one case, auditory
hallucinations (within the last 6 months) were present in 40% of those 53 (David et
al., 1999). These psychotic symptoms reflected themes of combat and guilt, were
non-bizarre, and not associated with flat or inappropriate affect or formal thought
disorder. The objective of this study was to examine the psychotic symptoms in this
group and note their relationship to ethnicity and psychiatric co-morbidity. While
the study did find that psychotic symptoms were significantly associated with current
major depression and minority status, the greater part of the comment was the
suggestion that the criteria for psychosis in PTSD be more stringent. The response
noted the complexity of such issues.
A larger sample distinguished some veteran studies of PTSD (Monnier,
2002). However, other PTSD veteran studies that could have proven, useful omit
those patients with psychosis (Zelenova, Lazebnaia, & Tarabrina, 2001) for
diagnostic clarity. The study of 111 veterans (71 Caucasians, 40 African Americans)
in an outpatient PTSD treatment program (Monnier t al., 2002), contradicted earlier
studies that pointed to racial differences in the experience of PTSD. There were no
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significant differences for the two groups on demographic variables, on measures of
depression, anxiety and PTSD symptoms, nor on measures of dissociation,
schizophrenia and paranoia. African Americans differed on the MMPI-2 alone in
terms of bizarre mentation.
In another veteran study PTSD and co-morbid psychotic disorder were
assessed in three groups of veterans (Sautter, Brailey et al., 1999). The following
were based on DSM diagnosis: (a) 24 had psychotic disorder and war related PTSD,
(b) 22 had war-related PTSD without psychosis, and (c) 16 had psychosis without
PTSD. Those with co-morbid psychosis and PTSD had significantly higher positive
symptoms of psychosis, paranoia, violent thoughts, feelings, behaviors, and overall
psychopathology than the other two groups. This level of cognitive, behavioral and
emotional disturbance differs drastically from the other two groups. It led me to
postulate that this in fact may be a separate subtype classification of PTSD.
In one study of 40 veterans with chronic PTSD and well-defined Psychotic
Features, the subjects were compared with 40 veterans with chronic schizophrenia
(Hamner et al., 2000). Subjects with schizophrenia had both higher PANSS scores
and positive symptom scores, and slightly more intense delusions and conceptual
disorganization. But otherwise, both negative symptoms and psychopathology were
comparable in both groups. Positive symptoms and hallucinations were also
comparable.
In a biological and genetic study of 19 male combat veterans (age 41-60)
with PTSD, altered dopamine beta-hydroxylase (DBH) was found to be significantly
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higher in patients with PTSD with psychotic features (Hamner & Gold, 1998).
Plasma DBH may differentiate between psychotic and non-psychotic subtypes of
PTSD. Current research supports that DBH may be a genetic marker that can reveal
individual vulnerabilities to developing psychosis in the context of trauma.
Olanzapine, an antipsychotic psychotropic drug, was explored in an 8 week
open label study on 46 veterans with PTSD (Petty et al., 2001). The drug was
selected due to the high number of PTSD patients with intrusive “psychotic-like
symptoms.” Of the 46, 30 completed the protocol and significant improvement was
noted in the psychotic symptoms. As well, significant improvement was noted on all
outcome measures: the Hamilton Rating Scales for Depression and Anxiety, the
Clinician Administered PTSD Scale and the Clinical Global Impressions
Improvement Scale.
Overall, many of the veteran studies point to the possible subtyping of PTSD
with Psychotic Features. In fact, either by omitting those patients with co-morbidity
or highlighting the different clinical profile of those with psychosis or by showing
the sheer frequency of this type of occurrence, much of the groundwork is laid for
the study. The current research question begs to be asked. This proposed study is
different and perhaps better than other studies for the purposes of moving forward
diagnostic research clarity and possible subtype treatment specificity in a concrete,
researchable way.
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Torture Survivors, Refugees and Vicarious
Traumatization o f Targeted Groups
Veterans are a large study group. However, other groups are equally
significant in the literature. Torture survivors, refugees and those related to the
targeted group are another division in the literature (Saraceno et al., 2002; Silverman
et al., 1999; Wenzel, Griengl, Stompe, Mirzaei, & Kieffer, 2000; Wenzel, Sibitz,
Kieffer, & Strobl, 1999). There is evidence in some studies of a genetic
predisposition to the depressive syndrome, in conjunction with PTSD (Wenzel,
Griengl et al., 2000). This study speculated on the need to look beyond a simple
PTSD diagnosis toward a broader conceptualization of PTSD like the axial
syndromes. Here in a larger sample size of 44 torture survivors, 40 met the
diagnostic criteria of present PTSD, with 34 survivors still meeting the criteria for
other psychiatric disorders, primarily major depression and dysthymia (26). Four
survivors met criteria for functional psychosis.
In an earlier study of two torture survivors (age 31 and 37) with Capgras
Syndrome and psychosis (Wenzel, Sibitz et al., 1999), researchers reported the
interaction of personal life experience and psychiatric disorder are factors resulting
in persistent changes in perception and affect. Refugees (Saraceno, Sazena, &
Maulik, 2002) were studied in terms of their mental health needs. Among the
problems such as depression, anxiety, adjustment and PTSD, the conditions of war
trauma were shown to exacerbate underlying illnesses such as psychosis.
Vicarious traumatization was studied in the context of visits to concentration
camps by a group of young people with similar ethnicity to the targeted group. A
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34
group of 87 Jewish-American adolescents (aged 15-19 years old) who participated in
a B’nai B’rith memorial visit to concentration camps in Poland were assessed for the
psychological impact of such a visit (Silverman et al., 1999). The adolescents
completed pretest, posttest, 6 month follow-up and 12 month follow up of the
Symptom Checklist 90-revised, the Mississippi Scale for PTSD, and the Impact of
events Scale for PTSD. On the SCL-90-R changes in somatization, interpersonal
sensitivity, obsessive-compulsive tendencies, depression, anxiety, and phobic anxiety
were observed over time, with peak symptoms scores at posttest and 6 month follow-
up. Scores on the Mississippi Scale for PTSD and the IES Intrusion scale also
increased at 6 months. Predictors of PTSD symptoms on the Mississippi Scale
included previous psychiatric treatment, and SCL-90-R symptoms of paranoia,
depression and psychosis. Elevated psychotic symptoms on the SCL-90-R predicted
PTSD symptoms on the IES.
Persistent changes in cognition and affect were noted in this population, as
were elevations and prevalence of psychotic symptoms post trauma. This further
points to the importance of the potential sub-typing of Psychotic Features.
Psychodynamic Case Studies
The backlash against psychodynamic thinking has somewhat subsided and
the value of case studies, both in the clinical practice setting and in literature, as an
adjunct to empirically validated treatment studies, is revealed in newer published
studies. Psychodynamic diagnosis of both patients and even characters in novels,
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along with some treatment recommendations for PTSD and psychosis are offered by
some researchers (Cramer, 2002; Gregory, 2002).
Hannibal Lecter of the Thomas Harris trilogy was “diagnosed” as having
PTSD (Gregory, 2002) due to the childhood trauma of witnessing the cannibalization
of his small sister and the killing of his family. Using theories of Melanie Klein,
Gregory suggested Lecter to be in the paranoid schizoid position with schizoid
defenses, and during psychotic breaks immersed in the repetition compulsion.
In three psychodynamic clinical case studies atypical psychotic disorder
amongst other disorders accompanied the PTSD of women with substance abuse
problems (Cramer, 2002). The author emphasized the primacy of the treatment
alliance, the examination of the counter transference and the importance of process
supervision. All women were described as suicidal, with childhood sexual, physical,
and emotional abuse.
Though case studies give only a part of the picture, these more in-depth
descriptions of psychosis and trauma related psychotic breaks further indicate
evidence of a gap in our diagnostic nomenclature
Other Single Case Studies
Beyond psychodynamic case studies, other single case studies add to
observations. In the non-veteran, non-torture-survivor clinical population, small
sample sizes and anecdotal case studies hamper the ability to generalize from
observations. Still, we can note the observations and gather clinical data as vicarious
experience. In a case study of PTSD (Lustig, Srhrz, Sladen, Sellers, & Heilman,
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2000) a 30 year old single female art student was treated in a team treatment center.
This patient had a history of sexual abuse, and hospitalizations for depression,
psychosis, PTSD and borderline personality disorder. The team treatment approach
was thought to potentiate the other modalities. In particular, the patient benefited
significantly from dialectical behavioral therapy, eye-movement desensitization and
reprocessing, and psychopharmacology after an extensive battery of psychological
tests. Another case study noted that hypnosis has been used effectively in treating
both PTSD and psychosis amongst other disorders (Godoy, & Araoz, 1999).
A set of case studies of the medically ill in a bum unit included children and
adults (Ilechukwu, 2002). It showed that the trauma associated with bums can lead to
drastic permanent body image changes and psychosis along with other clinical
syndromes.
These case studies highlight that outside of psychodynamic thinking, other
types of clinicians also note the prevalence of psychosis and complexity of treating
the permanent and severe changes that can accompany severe ongoing trauma.
Adolescents
Aside from a sprinkling of adolescents in the case study literature,
adolescents are an under-represented group. In one child and adolescent study, a
drug free period of 4 weeks for 31 patients admitted with treatment resistant
schizophrenia was used to help determine a revised diagnosis (Kumra et al., 1999).
At the completion of this 4 week “washout” period, seven patients (23%) were
allowed to continue and were diagnosed with another illness because of their lack of
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schizophrenic symptoms. Of the 7, four were diagnosed with atypical psychosis
were labeled “multi-dimensionally impaired,” two had personality disorders and one
had PTSD.
An additional adolescent study involving PTSD and psychosis was reported
in a study of motiveless fire-setting (Pontius, 1999). In a group of 23 boys, three
previously nondestructive young men were reported not to fit into traditional
diagnostic categories. Each had fleeting 20 minute symptoms of flat affect,
autonomic arousal, and delusions or hallucinations. It was proposed that a stimulus
specific to each boy had triggered their memories of events associated with fire,
smoke or matches. It was linked to one of the boys abnormal EEG in the temporal
lobe, and further linked to a study of 17 adult males who had committed bizarre
homicidal acts.
Other than calling adolescents “multi-dimensionally impaired” or noting
bizarre psychotic acts related to their traumatic histories, adolescent studies also
support the need for a clearer diagnostic name and category.
Medication Studies
Medication has become a major part of life for many and in the treatment of
clinical disorders particularly. There are several studies that related medications and
drugs to psychosis (Jansen, 2001; Katz, 1999; Warner, 2000). It appears both
methadone and antibiotic induced psychosis, has occurred in those with PTSD. In
one case, a child had witnessed severe domestic violence (Warner, 2000). In the
other, a woman had chronic PTSD (Katz, 1999). MDMA or Ecstacy use was
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associated with psychosis, PTSD and other anxiety disorders (Jansen, 2001). Such
findings, though limited, suggest that prior PTSD can predispose one to greater
vulnerability to psychosis.
Another set of medication case studies revealed a course of PTSD that over
time resulted in additional psychotic symptoms (Chan & Silove, 2000; Ivezic, Oruc,
& Bell, 1999). In treatment of three patients, all developed extra-pyramidal side
effects to the anti-psychotic medications prescribed, and discontinued drug treatment
(Chan & Silove, 2000). This article contradicts other studies that showed promising
results with such drug treatments. In another report, an ambulance driver and nurse
from the frontlines in Croatia were reported to experience psychotic symptoms.
These symptoms were related symbolically to the traumas they witnessed, and yet
the symptoms were clearly different than flashbacks and did not respond to anti
psychotic drugs (Ivezic et al., 1999).
Comprehensive management of the complex manifestations of PTSD is
suggested by some algorithmic proposals. They delineate the specific questions to
discern criteria for each sub category of PTSD including not only Psychotic Features,
but also Depressive, Anxiety/Dissociative, and Hypomanic/Manic symptoms.
Medication choice, dose, maintenance pharmacotherapy, alternative options, and
eventual outcomes are suggested in terms of pharmacological management (Alarcon,
Glover, Boyer, & Balon, 2000).
Response to medication, medication-induced psychosis, and medication
treatment algorithms all highlight the occurrence and differences between PTSD
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with Psychotic Features and other variations of PTSD. Some studies even point to
the problems of categorization of those who have experienced ongoing
traumatization.
The next section, though from the popular media, is noteworthy in terms of
its highlighting a case of a criminal/patient who developed psychosis while
incarcerated with the ongoing threat of the death penalty.
Inmates
Psychosis subsequent to prison trauma was the subject of a recent report on
National Public Radio’s “All Things Considered” (February 12, 2003). Charles
Singleton, inmate, was competent when he stood trial. However, while awaiting the
death penalty on death row, his clinicians reported he became psychotic,
hallucinating that Arnold Schwartzenegger and Sylvester Stallone were coming to
save him and that demons were possessing him. The trauma of waiting on death row
appears to have created the deterioration of his mental health and is the subject of a
grand jury trial evaluating whether to treat him with medication so that he can be
competent to receive the death penalty.
Ongoing emotional trauma is quite different than a one-time traumatic event.
What follows is a review of accident survivor literature.
Accident Survivors
Non-intentional, man-made trauma was studied in articles exploring
accidents involving planes, cars, and fire (Birmes, Arrieu, Payen, Warner, &
Schmitt., 1999; Maes, Mylle, Delmeire, & Altamura, 2000). In the study involving
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128 fire and 55 motor vehicle accident survivors (Maes et al., 2000) the data were
gathered 7-9 months after the traumatic event. For those with PTSD, 51% had
additional axis-I diagnosis. In this group, the incidence for new-onset major
depression was 26.2%, agoraphobia 21.0%, and generalized anxiety disorder was
24.6%. These were the most common disorders, much higher than those without
PTSD. The best predictors of new onset anxiety disorders other than PTSD were:
type and horror of the trauma, the extent of physical injury, the loss of control during
the traumatic event, contextual stimuli, younger age, and female sex. In the study
involving eight plane crash survivors, subjects had witnessed the death of relatives
and burning corpses. One subject experienced depersonalization with auditory
hallucinations followed by a reduction in awareness of his surroundings. Another
two survivors experienced dissociative symptoms (Birmes et al., 1999).
It is perhaps the ongoing physical injury or evidence thereof, which may
account for the additional traumatizing experience leading in part to psychosis.
Younger age of onset of trauma appears to alter sensory perception, and female sex
predictor supports additional hypotheses about young age of onset and women’s
vulnerability as an “at risk” group.
Hospital and Clinical Patients
Hospital and clinic patients represent another group available for
comprehensive study. Larger sample sizes in clinical hospital populations improve
the generalizability of certain studies such as the following. With first time
psychosis admission 426 patients were examined for the lifetime prevalence of
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trauma exposure (Neria, Bromet, Sievers, Lavelle, & Fochtmann, 2002). Risk
factors for trauma exposure in psychotic patients were female gender, substance
abuse, younger age and repeated and ongoing childhood victimization. This article
emphasizes the importance of gathering trauma history information in psychotic
patients.
Psychosis itself and the subsequent hospitalization have been studied in
association with PTSD (Frame & Morrison, 2001; Meyer, Taiminen, Vuori,
Aeijaelae, & Helenius, 1999). Involuntary hospitalization was hypothesized to be
associated with PTSD and was compared with the severity of distress related to the
psychosis itself in schizophrenic and delusional patients (Meyer et al, 1999). A
group of 46 schizophrenic and delusional patients were given the Positive and
Negative Syndrome Scale (PANSS), the Impact of Events Scale (IES), and the
Clinician Administered PTSD Scale (CAPS) at weeks 1 and 8 after acute psychosis
admission. Of the 11% with PTSD, 69% of traumatic symptoms were related to
psychosis and 24% were related to hospitalization. High PANSS scores at week 8
was the biggest risk factor for developing PTSD. Positive and depressive-anxious
symptoms were associated with psychosis related traumatic symptoms at weeks 1
and 8. Findings suggest that the schizophrenic and delusional symptoms were more
traumatic than the coercive measures used to control them. Another slightly larger
clinical sample backs up this study. Sixty patients hospitalized for psychotic
episodes were assessed (Frame & Morrison, 2001). The study showed that, in
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particular, the psychotic symptoms contributed significantly to the patients’ response
to traumatization.
In another clinical study (Zimmerman & Mattia, 1999) 500 outpatients were
interviewed with the SCID. Half of the 500 had non-bipolar major depressive
disorder, 45 of whom had PTSD, with 19 having psychotic depression, and 296 non
psychotic depression. Subjects with psychotic depression were nearly four times
more likely to have PTSD. Another clinical sample (Sautter, Cornwell et al., 2002)
showed patients with PTSD with psychosis had a higher incidence of family
depression. However, the presence of psychotic symptoms did not reflect the
presence of an underlying psychotic disorder.
The etiology of PTSD was examined in a clinical study of 42 patients
hospitalized after a psychotic episode (Shaw, McFarlane, Bookless, & Air, 2002).
Those with post psychotic PTSD had more intrusive memories, and higher scores for
anxiety and dissociative symptoms.
When it comes to diagnostic criteria, it appears there is confusion in
test/retest reliability for PTSD. In fact, the confusion arises when psychotic
symptoms are involved (Mueser, 2001). There is currently no subtype for PTSD
with Psychotic Features. Thus when PTSD and psychosis are co-occurring there is
confusion as to diagnosis. In one recent study of 426 patients initially hospitalized
for psychosis, 68.5% had trauma exposure while 14.3% had Post-Traumatic Stress
Disorder (Neria et al., 2002). Findings revealed that repeated and ongoing trauma or
childhood victimization, as well as younger age, were risk factors for psychosis.
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Test-retest confusion, differing symptoms, frequency of psychosis, and PTSD
co-occurring, and the trauma of psychosis itself, show the problems with diagnosis
and treatment that does not discriminate between PTSD and PTSD with Psychotic
Features. Repeatedly in the studies, younger age of onset, female gender, and
repeated ongoing trauma are associated with Psychotic Features. Risk factors for
exposure to trauma support several hypotheses of this study. Where does research
go from here?
Measurement o f PTSD Assessment Tools
The field moves forward when the measures used to assess trauma are
examined for reliability and validity and are then used consistently. Several
measures of PTSD were assessed for inter-rater reliability, internal consistency,
test/retest reliability and convergent validity (Mueser et al., 2001). The three
measures examined were the Clinician Administered PTSD Scale (CAPS), the PTSD
Checklist, and the Trauma History Questionnaire. Thirty subjects with severe mental
illness were assessed using all instruments. While reliability and validity were
moderate to high on all instruments, lowest levels of test-retest reliability for PTSD
diagnosis were related to those patients having psychotic symptoms. This points the
direction for further research into the possible clarification of a sub category of
PTSD with Psychotic Features for diagnostic, research and treatment purposes.
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Measures Used in the Assessment of Trauma
Trauma has been assessed in many ways. This brief review will examine
alternate measures in which trauma has been assessed and conclude with the measure
currently used by the MIDAS project.
The Life Stressor Checklist
Advancement in the measurement of PTSD has resulted in the development
of the Life Stressor Checklist Revised (Wolfe & Kimmerling, 1997) at the Women’s
Health Sciences Division, National Center for PTSD. This revised measurement tool
is particularly sensitive to gender issues as opposed to most other instruments that
were “developed in the context of the experiences of male combat veterans” (p.217).
While measuring a vast array of stressors, including many that may be unique to
women, the instrument uses a 5-point Lickert scale to assess level of upset at the
time of the traumatic incident, as well as current impact of the trauma on the
individual’s life within the last year. Psychometric refinement and norms were not
available currently.
Trauma Center Modified PTSD Symptom Scale
Self-Report (TC-MPSS-SR)
The TC-MPSS-SR is a 17 item self report instrument adapted from the
MPSS-SR (Falsetti, Resnick, H., Resnick, P., & Kilpatrick, 1993) to be used on
chronic trauma patients (Trauma Center Psychological Trauma Assessment Package,
Unpublished Manuscript). Minor adjustments were made to make language
consistent with the SIDES and TAQ, and to address the layered and chronic abuse
histories by the majority of chronic trauma patients. The instrument is designed to
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assess severity (on a 5-point scale) and frequency (on a 4-point scale) of PTSD
symptoms in the last 2 weeks. It also assesses lifetime prevalence of each PTSD
symptom with a yes or no which is not assessed by the original MPSS-SR. PTSD
symptom clusters are scored by summing severity and frequency scores for the
corresponding items to intrusions, avoidance/numbing and hyperarousal.
Psychometric properties of the more comprehensive modified version have not been
assessed.
Structured Interview for Disorders o f Extreme Stress (SIDES)
The SIDES (Pelcovitz et al., 1997) is a 45-item self report instrument that
asks patients to address functioning on six dimensions: disorders of affect regulation,
amnesia and dissociation , somatization, disruptions in self perception, disorders in
relationships with others, and disrupted systems of meaning. These dimensions
represent the Associated Features of PTSD as listed in the DSM-IV (APA, 1994). A
systematic review of the literature and a survey of 50 experts helped develop the list
of 27 criteria seen in response to extreme trauma. Each item is rated as to length of
symptom, lifetime presence as indicated by a yes or no, and presence during the last
month rated 0-3. A rating of 2 or more indicates a clinical level of severity. SIDES
was administered to 520 subjects as part of the DSM-IV PTSD field trials. Inter-rater
reliability, as measured by Kappa coefficients for lifetime Disorders of Extreme
Stress, was .81. Internal consistency using coefficient alpha ranged from .53-.96.
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Results indicate that the SIDES is a useful tool for investigation of response to
extremes stress.
The Traumatic Antecedents Questionnaire (TAQ)
The TAQ (van der Kolk, Spinazola, & Hopper, 2001) is a 42-item self report
instrument. The instrument gathers lifetime experience information in ten domains:
competence, safety, neglect, separations, family secrets, physical trauma, sexual
trauma, witnessing trauma, other traumas such as serious accidents and natural
disasters, and exposure to drugs and alcohol. While the last eight are assessing
trauma exposure, the first two examine adaptive functioning. These domains are
assessed at four life periods: 0-6 years, 7-12 years, 13-18, and 18 and up. During
each developmental period, the patient scores each item 0-3 based on the extent to
which they had a particular experience. Multiple “Don’t Know” responses are noted
as possibly indicating sensitive topics or memory disturbances in particular life
periods. While psychometric data are not yet available, 70 admissions to an
outpatient trauma clinic indicated scores on the TAQ were significantly related to
symptoms of PTSD (van der Kolk et al., 2001). Data from that study indicated that
particularly predictive of “complex” PTSD were trauma during 0-6 years, as were
types of trauma: sexual abuse, physical abuse, emotional abuse, and other traumas.
Other traumas were most associated with “typical” PTSD.
The Impact o f Events Scale
The Impact of Event Scale (Horowitz, Wilner, & Alverez, 1979) is a 15-item
self report measure that assesses the stress associated with traumatic events.
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However, it only accounts for the acute stage of trauma, i.e., when the trauma has
first occurred or when the trauma is being re-experienced. Its strength lies in the
measurement of intrusive phenomena such as feelings, nightmares and ideas, as well
as the avoidance of like phenomena that are associated with the trauma.
Rorschach Cards
Rorschach cards have been used to diagnose post-traumatic stress disorder.
“Utilizing Rorschach cards may have the advantage of bypassing conscious defenses
and revealing the presence of traumatic material” (Doehring, 1993, p.24). Van der
Kolk and Ducey’s (1989) study found that combat veterans relived traumatic
experiences in an unmodified fashion in response to the five colored cards (II,
III,VIII, IX, X).
Childhood Trauma Questionnaire
Another instrument used to assess trauma and soon to be encoded into the
MIDAS Project database is the Childhood Trauma Questionnaire (Bernstein et al.,
1994). Researchers developed this measure (ctQ) to address the need for
standardized, reliable, validated instruments that assess more than just physical and
sexual abuse and can be administered in a timely manner. It is a 70-item self-report
instrument that assesses aspects of the child rearing environment and retrospective
experience of abuse and neglect. It uses a 5-point Likert-type scale, with responses
ranging from “never true” to “very often true.” It requires 15 minutes to administer.
This questionnaire was developed with 322 subjects under treatment for
alcohol and/or drug dependence at the Mount Sinai Medical Center and the
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48
Veteran’s Affairs Medical Center, Bronx, New York. Thirty-six did not complete
the protocol, 286 did. Of this 244 were male (85.3%) and their mean age was 40.2
years (ranging from 24-68 years), 54% were African American, 30.9% were Latino,
14.8% were White and 3.1% were other. Of this sample 73.6% had a high school
education, 29.3% were employed full-time, 10.5% were employed part-time, 52.0%
were unemployed and 8.2% were other. Most of the patients had a lifetime history
of multiple kinds of substance abuse. Lifetime use included 79.2% for alcohol,
78.3% for cocaine, 59.3% for heroin, and 57% for cannabis.
This drug and alcohol dependent population was selected because of the high
expected prevalence of abuse and neglect, and the researchers’ interest in substance
use disorders in relationship to childhood trauma (Bernstein et al., 1994, p.l 132). At
the time of this reliability and validity study, patients were undergoing inpatient
detoxification (N = 106), rehabilitation (N = 83), and outpatient methadone
maintenance (N = 91). Very few were in drug free groups (V= 6).
The subjects in the reliability and validity study were given the Childhood
Trauma Questionnaire in part of a larger test battery. Forty were given the test again
after 2 to 6 months. The Childhood Trauma Interview, a structured interview
assessing for child abuse and neglect, was given to 68 of the patients. This too was
developed by the researchers.
Four factors emerged in a principal component analysis of responses:
physical and emotional abuse, emotional neglect, sexual abuse, and physical neglect.
Internal consistency was assessed though Cronbach’s alpha, factors ranged from .79
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to .94, meaning high internal consistency. Test-retest reliability was good over the
2-6 month interval (correlation = .88), as was convergence of the Childhood Trauma
Questionnaire with the Childhood Trauma Interview. Therefore patients’ reports of
their child abuse and neglect were highly stable across instruments and over time.
In discussion, the researchers noted the striking nature of these findings given
the unstable nature of this population, the uncontrolled setting where this study took
place (an outpatient methadone clinic) and the length of time between testing. They
noted its consistency with reviews (Brewin, Andrews, & Gotlib, 1993) that indicate
that retrospective histories of childhood experiences are stable over time, consistent
with other informants (e.g., siblings) and are often verifiable with archival data.
Other Measures
Several other frequently used measures to assess PTSD are: the Davidson
Trauma Scale (Davidson & Neale, 1996), the Breslau Short Screening Scale for
PTSD (Breslau, Peterson, Kessler, & Schultz, 1999), the Clinician Administered
PTSD Scale for DSM-IY (Blake et al., 1995), the Posttraumatic Diagnostic Scale
(Foa et al., 1997), the Mississippi Scale (Keane, Caddell, & Taylor, 1988), the PTSD
checklist (Weathers et al., 1996), the Startle, Physiological Arousal, Anger, and
Numbness Scale (Meltzer-Brody, Churchill, & Davidson, 1999), and the Penn
Inventory of PTSD (Hammarberg, 1992). These are all reviewed very well
elsewhere (Foa et al., 1997; Meichenbaum, 1994).
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Summarizing Critique of the Literature
Weaknesses o f Prior Research
Unfortunately, many of the studies reviewed were marked by extremely small
sample sizes. Such small samples made it difficult to generalize and to draw out
conclusions that were relevant and statistically significant enough to move the field
forward. The literature was also hindered by the number of studies that were
individual clinical case studies. While the case studies were important to the depth
of knowledge about particular cases, they provided only anecdotal evidence for a
subtype of PTSD with Psychotic Features.
Most of the studies were composed of men. It was late in the research
literature, not until the 1970s, that research on women was proposed at all! In fact,
any early researchers’ work proposing that women’s hysteria was based on
childhood sexual abuse, was summarily thrown out later by Freud and his followers.
Women’s trauma was given little space in the research literature after that and it
remains true in the current literature.
The bulk of the literature, both past and present, was based on veteran
studies. While this was an important group that had been subject to the unusual
trauma of battle, it is unusual to the clinical setting when nations are not at war.
Additionally, veteran groups are primarily composed of men, and the problem of
non-diversity of gender was the same as noted earlier.
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Strengths o f Prior Research
What can be applauded about previous research is that it was conducted at
all, given how it can be a strain on the clinicians and researchers that work with this
population. Prior research has clarified the clinical symptoms of PTSD, it has
provided initial categories, and possible subtypes that were useful to study, even
though later research proved those subtypes not significant. Clinical trauma groups
and single case studies clarified the particulars as seen by clinicians. Specific
treatment centers studied those they knew best, that being their patients, and shared
their findings with the research community.
Prior research, its successes and more often its failures, showed where the
field’s understanding needs work, where the instruments of research need
refinement, and where new researchers can contribute.
How the Proposed Study Builds on Prior Work
This study took what is known about trauma’s symptoms and tried to clarify
and further the outlines already made. Earlier studies pointed the direction, both by
omission, when diagnostic categories become too diffuse to be homogenous and
were thrown out, and by inclusion, of the intense differences in etiology and outcome
when trauma has been early, repeated and ongoing.
How the Proposed Study is Different than Prior Work
This study was unique to the literature, and debatably better than many other
studies for several reasons deemed important to traditional research studies. This
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52
study used a very large clinical sample. This was important in terms of
generalizability. Additionally, this study was diverse in terms of gender. Many prior
studies have been conducted on male combat veterans alone. Additionally, studies
of women have focused on sexual trauma, primarily rape or incest. This study
covered a wide spectrum of possible traumas that women may have experienced in
addition to those usually studied. By having a diverse gender make up, the
hypothesis were tested on men and women. This study was diverse in terms of race.
This study used a clinical sample, not a single trauma group, and specifically asked
the question implicit in the diagnostic confusion resulting from when PTSD co
occurs with psychosis. It used a clean database of patients diagnosed by highly
trained clinical raters, on empirically validated instruments.
This study provided an important and clear research question that has not
fully been addressed in the literature. The question not only grew out of the existing
literature but out of my clinical experience.
This study was different, precise, and debatably better in many important
areas: (a) the distinctive research question, (b) the sample size, (c) diversity of race
and gender, (d) use of trained diagnostic clinicians, (e) and with instruments that are
well-respected and well-tested in the field.
Theories and Selected Research Guiding the Hypotheses
The Diathesis-Stress Model
What follows is a review of the trauma theories that provided an overall
explanation for the findings and influenced the selection of hypotheses that were
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tested in this study. What was adopted was a general model of psychopathology that
is called the diathesis-stress model (Davison & Neale, 1996, p. 53). This model is
underlying most contemporary thinking, not aligning exclusively with any particular
theory, but informing them all. The biological, psychodynamic,
behavioral/leaming/cognitive science perspectives on psychopathology are thought
to interact with each other, and thus the model is often described as bio-psycho-
social. Neither predisposition, biologically or cognitively, nor stress alone, then
account for a mental disorder, but rather their interaction. What follows are the
selected bio-psycho-social components that drove my hypotheses, described in more
detail. Particularly helpful was Jose Saporta’s (in press) “Combining Psychoanalytic
and Biological Perspectives on Trauma” to be published in Neuro-Psychoanalysis:
An Interdisciplinary Journal for Psychoanalysis and the Neurosciences.
Biological/ Neurological/Genetic Theories
While advances are still accruing in medical sciences, there is thought that
eventually a complete bio-neuro-genetic explanation for PTSD with Psychotic
Features may be found. Genetic influences are thought to impact hippocampal
volume, and a smaller hippocampus may be at risk factors for PTSD in those that are
trauma exposed. This decreased volume can also be associated with impaired verbal
memory. Such compromised neuro-cognitive functioning might hinder one’s ability
to deal with traumatic stress (McNally, 2003) or properly encode it (Saporta, in
press). Overall functioning would therefore likewise be compromised, memory
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impaired, and psychic traumatization and psychosis more likely due to a
predisposition for disease, disorders, or distress.
Also, “neurobiologists observe how trauma alters the structure and function
of the brain and nervous system” (Saporta, in press, p. 3). For example, the hyper
arousal that is an essential feature of PTSD, can interfere with the ability of an
individual to symbolize. “Deactivation of left hemisphere cortical structures such as
Broca’s area” (Saporta, in press, p.8) occurs during re-experiencing of trauma. “The
left hemisphere is involved in linguistic processing or coding information into verbal
symbols” (Saporta, in press, p.8). As well, this region is also proposed to “organize
inchoate experience into a meaningful and coherent personal narrative” (Saporta, in
press, p. 8). With disruptions in cortisol levels that are released during extreme
stress, hippocampal neurons can be damaged, resulting in the inability to represent
and recall trauma, form declarative memories or order experiences in space and time
(Saporta, in press). Still, hippocampal difficulties are only part of the problem, as
the hippocampus maps experience within only a few second intervals, with the
frontal lobe and left hemisphere organizing experience into a larger personal
narrative (Saporta, in press).
Psychodynamic Drive Theory
Psychodynamic theory informs many hypotheses about the psychological
etiology of different disorders. Structural or Drive theory can explain the impact of
traumatic stressors in terms of intense stimuli flooding the psychic structures and the
ego’s ability to process it. Here, all attention of the sympathetic nervous system is
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focussed on the danger of the stressor, and the fight or flight impulse. Repressed
unconscious drives are thought to fuse with the overwhelming stimuli, and psychotic
perceptions can contain either material related to the trauma, or related to the
particular oral, anal or oedipal level of unresolved developmental conflicts. In effect,
stress has overwhelmed the ego’s ability for the regular defenses to cope, thus the
unconscious material breaks into consciousness (Doehring, 1993).
The unconscious therefore shapes the processing of traumatic material,
symbolically organizing subsequent experiences. Patterns of behavior or thought
repeat under stress, thus regression or alterations in consciousness, like psychosis,
can occur. Prior research has shown that “patients with PTSD or a history of
childhood trauma have an increased rate of psychotic symptoms” (Zimmerman &
Mattia, 1999, p.311). If dissociation and psychosis has occurred once, whether as a
means of coping, due to hallucinogenic substances or other means, later psychosis is
more likely. In fact, dissociation at the time of trauma is one of the greatest risk
factors for later dissociative processes.
Cognitive Science Theories
While intrapsychic disruptions are at the core level of representations and ego
functioning, thinking and behavior are also thought to be impacted profoundly by
trauma. In terms of the subjective impact of trauma on the cognitive capacity of
meaning making, “traumatic stress alters and even shatters one’s experience of
meaning and of self’ (Saporta, in press, p. 1). When trauma is severe enough, there
is an inability to represent or organize the experience on a symbolic or verbal level.
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Episodic memory that is conscious and verbal can only be recorded when they can
be encoded and organized symbolically. Thus “there are no words or linguistic
catagories to contain, organize, or articulate trauma” (Saporta, in press, p.2).
Cognitive science recognizes both symbolic and sub-symbolic encoding.
Non-verbal, sub-symbolic encoding of multiple sensory modalities is processed
continuously and not sequentially, and all on the same “chunked” perceptual channel
(Saporta, in press). On the other hand, “verbal symbolic information is processed in
a sequential, amodal, single channel format, as opposed to subsymbolic processing
which is in a multimodal (multi channel), parallel distributed format” (Saporta, in
press, p. 10). The hippocampal/entorhynal cortex is also the transmodal node that
looks up and binds sensory information for declarative memories” (Saporta, in press,
p. 12). Coherent binding of the information with linguistic symbols is impaired by
high cortisol levels during trauma that interfere with the transmodal nodes in
Wernicke and Broca’s area (Sapporta, in press). Psychotic breaks may, in fact, be
undigested somatic and perceptual fragments “chunked” together in a kind of
streaming audio or visual format, the best approximation of meaning making, and an
attempt at developing a healing narrative for that which has no words or coherent
meaning.
Embodiment and Gender Theories
For the question of how we experience trauma, and even life itself, “we
clearly live an embodied life. . . . But as psychoanalysis has shown us, there is
nothing self evident about biology. How anyone experiences, fantasizes about, or
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internally represents her or his embodiment grows from experience, learning, and
self-definition in the family and in the culture” (Chodorow, 1991, p. 101). This view
is favored by this researcher.
Today the primary infant caretakers are women, and that may also result in
gender differences in both PTSD and psychosis. “The infant constructs an internal
set of unconscious, affectively loaded representations of others in relation to its self,
and an internal sense of self in relationship emerges” (Chodorow, p. 105). These are
the “underlying metaphors that give rise to the larger schemata of self and the world”
(Doehring, 1993, p. 21). In an earlier study of gender differences of patients with
borderline personality disorder (BPD) in the MIDAS database, lifetime impulse-
related disorders and post-traumatic stress disorder were compared (Zlotnik,
Rothschild, & Zimmerman, 2002). Results of that study showed men with BPD had
significantly more lifetime substance abuse disorders, more antisocial personality
disorder and met criteria of intermittent explosive disorder that did not overlap with a
diagnosis of BPD. Women with BPD reported significantly more lifetime eating
disorders than men with BPD. Otherwise, their profiles were remarkably similar.
Possible gender differences in psychotic behavior may then involve more anti-social
acting out behavior for men, and more internalized, psychotic breaks for women
corresponding with more gender related social withdrawal, learned helplessness and
depression.
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Complex Adaptations to Trauma
More severe adaptations to trauma appear to occur when the traumas are
interpersonal in nature. They are “likely to have more profound effects than
impersonal ones” (van der Kolk, 1996, p. 184), and even more so when the traumas
are suffered as a child. For example “people who have been physically and sexually
molested as children may develop a host of distrustful, fearful, and dissociative
responses to a range of stimuli associated with intimacy, aggression, and the
negotiation of trust” (van der Kolk, 1996, p. 184). Children who have experienced
severe neglect “have a particularly poor long-term prognosis, compared with
traumatized individuals who had more secure attachment bonds as children” (van der
Kolk, 1996, p. 185). What follows is an integration of those theories with my
clinical experiences.
Integrating Theories with Clinical Experiences
Clinical experience has also driven these hypotheses. I have seen patients
and others have breaks with consensual reality, and subsequently tried to make sense
of the processes. Two notable clinical profiles of the types of trauma patients who
had psychosis, with whom I came in contact, were as follows:
1. The reported ongoing, violent, racial bullying of a young Black women in
a southern elementary school who “saw red” on the floor while talking to me. She
was unable to establish eye contact with me, her white therapist, since she said that
this was not a good idea in the south, and that she still found it difficult. She had a
history of severe depression.
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2. The reported ongoing, sexual assaults of a young Hispanic man by his
elder brother, with whom he had shared a bed in childhood. In a “review of
systems”, asking about his digestive and elimination systems, he reported that his
brother often entered his colon metaphysically, to this day.
The ongoing, interpersonal nature of these patients’ traumas was striking, as
were the early age of the traumas. These coalesce with psychodynamic and neuro-
cognitive processing theories that hypothesize that traumatized patients may be
unable to properly encode information. This might explain their psychosis involving
perceptual fragments related to the trauma, and their best attempt at meaning
making. This traumatic material is not “repressed” per se, but instead encoded in
perceptual fragments (Saporta, in press).
Limits on Testable Hypotheses
Only certain portions of the theories used to account for the diagnosis, PTSD
with Psychotic Features, could be examined in this study. Whether there is a bio-
neuro-genetic vulnerability is beyond the scope of this study, as there were not
accompanying lab tests, nor available magnetic resonance imaging of the brain that
might indicate abnormalities. Also beyond the scope of what was available, were
assessments of similar disorders in the family. Nor were there triangulated, third
party reports of the early life experiences of the individuals that may have
illuminated early attachment styles or their correspondence with endocrine,
neurologic or chemical changes. Therefore, what follows are the testable portions of
the differences proposed for the patients with PTSD with Psychotic Features.
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Hypotheses Resulting from the Literature Review
and Clinical Knowledge
The following hypotheses were based on the previously described research
and my own clinical experience. What follows is a description of how the
independent variable was operationalized, and what research hypotheses were used
to test the relationship between the independent variable and the dependent variables.
The Independent Variable and the Research Hypotheses Tested
The independent variable for this study, “with Psychotic Features” was
operationalized in the following way. Patients assessed with a coding of 3
(threshold), or 4 (present in the past month), on one or more psychotic symptom
items were placed in the “with Psychotic Features” research group. Patients who
were assessed with a coding of 1 (absent), 2 (sub-threshold) or 5 (due to a General
Medical Condition) on the psychotic symptom items were considered “without
Psychotic Features”. The psychotic symptom items in section B of the SCID were as
follows: delusions of reference, persecutory delusions, auditory hallucinations, a
voice keeping a running commentary, two or more voices conversing with each
other, visual hallucinations, tactile hallucinations, gustatory or olfactory
hallucinations, grandiose delusions, somatic delusions, religious delusions, delusions
of guilt, jealous delusions, erotomanic delusions, delusions of being controlled,
thought insertion, thought withdrawal, thought broadcasting, delusions of mind
reading, and bizarre delusions.
What follows are each hypothesis and the tests run on the various dependent
variables.
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61
Research Hypothesis One: Suicide Attempts
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of more suicide attempts. To test the
hypothesis, a sample t test was used to examine the dependent variable. A
significant difference in the mean scores of each independent variable group on the
continuous dependent variable of suicide attempts would have confirmed the
research hypotheses.
Research Hypothesis Two: Hospitalizations
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of more psychiatric hospitalizations.
To test the hypothesis, a sample t test was used to examine psychiatric
hospitalizations. A significant difference in the mean scores of each independent
variable group on the continuous dependent variable of hospitalizations would have
confirmed the research hypotheses.
Research Hypothesis Three: Axis I Co-Morbidity
PTSD patients with Psychotic Features differ significantly from PTSD
patients without Psychotic Features in terms of having more Axis I co-morbidity. To
test the hypothesis, an independent samples /-test was used. A significant difference
in the mean scores of lifetime Axis I co-morbidity (SCID/Total # of Codings on 2-
20, no duplications) would have confirmed the research hypothesis.
A chi-square analysis of each diagnosis separately revealed which diagnoses
had a significant association with the research groups.
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62
Research Hypothesis Four: Past and Present Social Functioning
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features, in terms of poorer past and present social
functioning and social relations. A chi-square test of independence was used.
Original categorical data 1-6 was re-coded in the following way: patients with poor
or grossly inadequate social functioning and social relations (Coded 5 or 6) were re
coded 1, patients with superior to fair social functioning and social relations (Coded
1 to 4) were re-coded 0. A significant difference in the proportion of persons with
poor or grossly inadequate past and current social functioning and social relations
(Coded 1) exceeding the proportion of patients with superior to fair past and current
social functioning and social relations (Coded 0) would have confirmed the research
. hypotheses.
Research Hypothesis Five: Workdays M issed
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of more workdays missed. To test
this hypothesis, a sample t test was used for disability time off and work missed.
Original categorical data coded 0 (not expected to work outside the home or school
or retirement), 1 (virtually no time out of work due to psychopathology), 2 (only a
few days to a month missed in past 5 years), 3 (10% missed), and 4 (20% missed)
were re-coded into 0 (for average amount of work missed). The next group coded 5
(40% missed), 6 (60% missed), 7 (80% missed), 8 (up to almost 5 years), and 9
(worked practically not at all due to psychopathology) were re-coded 1 (for
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63
significant amount of work missed). A significant difference in the mean scores of
each independent variable group on the continuous dependent variables of work
missed would have confirmed the research hypotheses.
Research Hypothesis Six: CGI and GAF
PTSD patients with Psychotic Features differ significantly from PTSD
patients without Psychotic Features in terms of higher CGI score for Depression and
lower GAF.
To test the CGI hypothesis, a sample t test was used. A significant difference
in the mean scores of each independent variable group on the continuous dependent
variables of CGI for Depression would have confirmed the research hypotheses.
An independent sample t test was used to test the GAF hypothesis. A
significant difference in the mean scores of each independent variable group on the
continuous dependent variable of GAF score would have confirmed the research
hypotheses.
Research Hypothesis Seven: Trauma Symptoms
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of more re-experiencing, avoiding,
arousal and total characteristics of traumatization. To test the hypothesis, a sample t
test was used to examine the dependent variables. Original data on all trauma
symptoms were grouped into four categories: re-experiencing (SCID/Total # of
Codings of 3 on Items FI 84 to FI 88), avoiding (SCID/Total # of Codings of 3 on
Items FI 90 to FI 96), arousal (SCID/Total # of Codings of 3 on Items FI 98 to F202),
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64
and total characteristics of traumatization (SCID/Total # of Codings of 3 on Items
F184 to F188, Items F190 to F196, Items F198 to 202). A significant difference in
the mean scores of each independent variable group on each of the continuous
dependent variables of re-experiencing (SCID/Total # of Codings of 3 on Items FI 84
to F188), avoiding (SCID/Total # of Codings of 3 on Items F190 to F196), arousal
(SCID/Total # of Codings of 3 on Items FI 98 to F202), and total characteristics of
traumatization (SCID/Total # of Codings of 3 on Items F184 to F188, Items F190 to
F196, Items F198 to 202), would have confirmed the research hypotheses.
Research Hypothesis Eight: Age o f Onset
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of a younger age of onset for PTSD.
To test the hypothesis, a sample t test was used to examine the dependent variable.
A significant difference in the mean scores of each independent variable group on
the continuous dependent variable of age of onset (SCID/F212), would have
confirmed that portion of the research hypotheses.
Research Hypothesis Nine: Trauma Code
PTSD patients with Psychotic Features differ significantly from PTSD
patients without Psychotic Features in terms of having an interpersonal trauma code.
To test the hypothesis, a chi-square test of independence was used. A significant
difference in the proportion of persons with an interpersonal trauma code (Coded 3,
4, 5, 6, 7, 8, 9, 10, or 12) exceeding the proportion of patients with non-interpersonal
trauma code (serious accident, natural disaster, or life threatening illness) (Coded 1,
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65
2 or 11) on the SCID F162, F164, F166, F168, F170, F172, F174, F176, F178, or
FI 80 would have confirmed the research hypotheses. Other Traumas (Coded 13)
were unable to be evaluated on an individual basis as to interpersonal trauma code
status.
Research Hypothesis Ten: Gender
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of gender. A chi-square test of
independence was used. A significant difference in the proportion of females
(Coded 0) and males (Coded 1) on P8 of the SCID, would have confirmed the
research hypotheses.
Research Hypothesis Eleven: Race
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of race. A chi-square test of
independence was used. Multiple races (White, Black, Hispanic, Asian, Portuguese,
other) were re-coded into a dichotomous variable, 0 (White) and 1 (minority status).
A significant difference in the proportion of persons of minority status (coded 1)
exceeding the proportion of whites (Coded 0) on P9 of the SCID, would have
confirmed the research hypotheses.
What follows are table so the independent variable and dependent variable
hypotheses can be looked at, at a glance.
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Tables of Variables
Tables for independent and dependent variables are summarized in Tables 1 and 2.
Table 1
Independent Variable to be Analyzed in the Database
Measure Type of Measure Independent
Variable
Range of
Scores/Factor
Levels
SCID/ Total # of
Codings of 3 in
Items: B1 to B21
Nominal-
Dichotomous
Total # of
Psychosis
Symptoms
0 (Re-Coded 0)
1-21 (Re-Coded 1)
0 Without
Psychotic Features
1 With Psychotic
Features
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67
Table 2
Dependent Variables to be Analyzed in the Database
Measure/Item #/
Hypothesis #
Type of Measure Dependent
Variable
Range of
Scores/Factor
Levels
SCID/P20/Hyp 1 Continuous # of Suicide
Attempts
0 - 2 0 (approx.)
SCID/ P21/Hyp 2 Continuous # of Psychiatric
Hospitalization
0 - 5 (approx.)
SCID/Total # of
Codings on 2-20,
no
duplications/Hyp 3
Continuous Lifetime Axis I Co-
Morbidity
1-19
SCID/P 16/Hyp 4 Ordinal-
Dichotomous
Past Social
Functioning
poor or grossly
inadequate social
functioning and
social relations
(Re-Coded 1)
superior to fair
social functioning
and social relations
(Re-Coded 0)
0 Good
1 Poor
SCID/P 17/Hyp 4 Ordinal-
Dichotomous
Present Social
Functioning
poor or grossly
inadequate social
functioning and
social relations
(Re-Coded 1)
superior to fair
social functioning
and social relations
(Re-Coded 0)
0 Good
1 Poor
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68
Table 2: continued
Measure/Item #/
Hypothesis #
Type of Measure Dependent
Variable
Range of
Scores/Factor
Levels
SCID/P 18/Hyp 5 Ordinal-
Dichotomous
Work Missed Due
to Psychopathology
0 Average
1 Significant
SCID/21/Hyp 6 Ordinal-
Dichotomous
CGI for Depression
severe to extreme
depression (Re-
Coded 1)
none, border, mild
or moderate
depression (Re-
Coded 0)
0 None to
Moderate
1 Severe
SCID/22/Hyp 7 Continuous Current GAF 1-100
SCID/Total # of
Codings of 3 on
Items F I84 to
FI 88/Hyp 8
Continuous Total # of Types of
Trauma Re-
experiencing
Characteristics
1-5
SCID/Total # of
Codings of 3 on
Items F I90 to
FI 96/Hyp 8
Continuous Total # of Types of
Trauma Avoidant
Characteristics
1-7
SCID/Total # of
Codings of 3 on
Items F I98 to
F202/Hyp 8
Continuous Total # of Types of
Post-Trauma
Arousal
Characteristics
1-5
SCID/Total # of
Codings of 3 on
Items F I84 to
F188,
Items F I90 to
FI 96,
Items F I98 to
202/Hyp 8
Continuous Total # of PTSD
Symptoms
1-17
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69
Table 2: continued
Measure Type of Measure Independent
Variable
Range of
Scores/Factor
Levels
SCID/F212/Hyp 9 Continuous age of onset of
PTSD
6-100
SCID/Hyp 10 Nominal Interpersonal
Trauma Code
serious accident,
natural disaster, or
life threatening
illness (Re-Coded
0)
interpersonal
trauma (Re-Coded
1)
0 non
interpersonal
trauma
1 interpersonal
trauma
2 other
SCID/P8/Hyp 11 Nominal-
Dichotomous
Gender 0 female
1 male
SCID/P9/Hyp 12 Nominal-
Dichotomous
Race
White (Re-Coded 0)
Black, Hispanic, Asian,
Portuguese, other (Re-
Coded 1)
0 white
1 minority status
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This Review of Literature has laid out the history of early trauma research,
the introduction of the term PTSD, followed the debates and future research
proposed by the sub workgroup for PTSD for the DSM-IV (APA, 1994). It
presented the current state of the literature on PTSD and psychosis, as well as the
measures used to assess PTSD. It has brought to light the problems encountered
while diagnosing patients with PTSD with Psychotic Features, as well as the theory
and practice that guided the current hypotheses. The proposed empirical study builds
on the previous research and is in fact different in the specific hypotheses tested.
The next section, Method, describes in detail the particulars of the proposed
empirical study.
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71
CHAPTER 3
METHOD
Participants
Participants in this study were patients who initially presented at the
outpatient practice of the Rhode Island Hospital Department of Psychiatry, a
teaching hospital department of Brown University. Of the 1500 patients assessed
and entered into the MIDAS database, the sample for this study was the 20% or 300
patients (82 male, 218 female) who were diagnosed with PTSD sometime in their
lifetime via the research instrument, the Structured Clinical Interview for Axis I
DSM-IV Disorders (SCID). Their mean age was 34.7, (SD=10.78). Of the 300
patients with PTSD, there existed a significant subgroup, 18.6%, or 56 of those 300
patients that were defined as “with Psychotic Features”. These were the patients of
interest, and for all the research hypotheses, were compared with the 81.4% or 244
other PTSD patients “without Psychotic Features”.
Raters
This study is part of the MIDAS project. Data were generated by highly
trained researchers who conducted extensive semi-structured interviews, and who
then assigned a thorough DSM diagnosis on most major Axis I and Axis II disorders
for each patient.
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72
Measures
The Structured Clinical Interview fo r DSM-IV
The primary measure used for assessing Post Traumatic Stress Disorder and
other psychiatric illnesses in the MIDAS Database was the Structured Clinical
Interview for DSM-IV (SCID) (First, et al., 1997). It was used because of its
comprehensive diagnosis of Axis I disorders and distinguished record in research
literature. It was selected initially by the designer and creator of the MIDAS
database, Mark Zimmerman, M. D.. Patients who consented to be part of the
MIDAS protocol were assessed using the SCID at baseline. All diagnoses were
made according to DSM-IV (APA, 1994) criteria. Diagnostic raters were
psychologists or college graduate research assistants who were trained extensively in
the research instrument.
Initially the SCID I assessed 33 of the Axis I DSM IIIR disorders in adults.
Prior to the publication of the DSM-III in 1980, the most widely used structured
interview was the Schedule for Affective Disorders and Schizophrenia (S ADS)
(Endicott & Spitzer, 1978), which gave diagnoses based on the Research Diagnostic
Criteria (Spitzer, Endicott, & Robbins, 1978). The Renard Diagnostic Interview
provided diagnosis based on other criteria (Feighner et al., 1972).
Upon the publication of the DSM-III the National Institute of Mental Health
Diagnostic Interview Schedule (DIS) (Robins, L. N., Helzer, Croughan, & Ratcliff,
1981) was created and designed for use by lay examiners with one week of training.
While used in many research studies, the limitations of having lay examiners soon
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became apparent; a person well trained in psychology and the assessment of
psychopathology was thought to be better able to tailor questions to a patient’s
understanding with an eye to differential diagnosis. “This is particularly true in the
diagnostic evaluation of subjects with psychotic symptoms who have little insight
and present with a complicated story from which the interviewer must discern the
symptom profile” (Spitzer, Williams et al., 1992). For this reason, the SCID was
developed under grant support from the NIMH (Spitzer, Williams et al., 1992).
While all the other, previously developed, measures fully assessed all
symptoms, the SCID used algorithms to test diagnostic hypothesis. If a criterion was
not met, then the examiner was instructed to skip the remaining items in that section.
The questions begin closed-ended and then are followed up with further description
to clarify. The presence or absence of each diagnostic criterion was coded as either 1
for absence or false, 2 for sub-threshold or almost meeting criteria, 3 for criteria met
or true, 4 for present in the past month, or 5 for due to a General Medical Condition.
. A confirmatory test/retest reliability study was done for the SCID I for
DSM-III-R on 592 subjects in four patient and non patient sites in the US and on one
in Germany (Williams, et al., 1992). Overall reliability was fair to good for patients,
(weighted kappa= .61), but poor for non-patients (weighted kappa= .37). Reliability
for the SCID I for DSM IV has not been determined. Few validity studies have been
relevant to the SCID I. “More than 85% of patients with known psychotic symptoms
revealed all or some of their symptoms during a SCID I interview” (APA, 2000,
p.52).
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74
Clinical Global Impressions Scale
The Clinical Global Impressions Scale (Guy, 1976) is a three-item measure
developed by the National Institute of Mental Health (NIMH) for use in
pharmacological treatment studies. It evaluates three concepts: Severity of Illness,
Global Improvement, and Efficacy. “Clinicians use separate 7-point scales to make
the Severity and Improvement ratings and a 2-variable grid to make the Efficacy
items” (Schutte & Malouff, 1995, p. 461). Therapeutic effects and side effects are
rated on a 1-4 scale. Therapeutic effects are then divided by side effects for an
Efficacy score between .25 and 4.0. Higher scores mean more therapeutic effects in
relation to side effects. Researchers often dichotomize the Improvement item into
non-responders and responders to treatment. In an 8 week, test-retest, rank-order
correlation for the German version of this test, correlations of .20 to .81 for Severity,
.15 to .78 for Improvement, and .21 to .80 for Therapeutic Effects and Side Effects
were found (Beneke & Rasmus, 1992). Validity was shown through intercorrelations
of change scores on Severity and Improvement and therapeutic effects items. These
were between .47 and .93 (Beneke & Rasmus, 1992). This suggests they “were
measuring the same construct” (Schutte & Malouff, 1995, p. 462). The Efficacy
item’s validity is more problematic. The matrix format is not analyzable statistically,
and is thus rarely mentioned in research literature (Beneke & Rasmus, 1992).
Global Assessment o f Functioning
The Global Assessment of Functioning (APA, 1994) is represented on Axis
V of the DSM IV multi-axial system. It is a clinician rating between 0 for
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75
inadequate information to 100 superior functioning measuring psychological, social
and occupational functioning. It is broken into deciles. It was operationalized by
Luborsky in 1962 in the Health-Sickness Rating Scale. The current instrument is a
modified version of the Global Assessment Scale (GAS) (Endicott, Spitzer, Fleiss, &
Cohen, 1976). Joint reliability of the GAS and GAF ranged from .61 to .91 (fair to
excellent agreement) (APA, 2000). Concurrent validity of the GAS was evaluated
by comparing GAS scores with a 7-point scale. On admission, the correlation was
.44, after 6 months the correlation was .62 (APA, 2000).
The previous section has described the measures used in this study. What
follows is a description of the exact methodology of the study.
Procedure
When patients presented to the outpatient practice, they were invited to
participate in a comprehensive diagnostic evaluation prior to meeting with their
clinician. They were then presented with the consent form, asked to sign it, and
assessed by their rater prior to seeing their clinician. Completion of the assessment
took approximately 2 hours. Only completed data sets were used in the final
statistical analysis. Non-English speakers, patients with PTSD in remission or partial
remission, and those patients who were cognitively impaired were excluded from
this study.
Ethics
The Rhode Island Hospital Institutional Review Board approved this research
protocol, and all patients provided informed written consent. The benefits and risks
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were explained in the consent form, as were the steps taken to assure confidentiality,
and the voluntary nature of the study. Data were gathered from the records of
subjects consenting to MIDAS research and coded by case number in order to ensure
confidentiality of the subjects. Although ethical concerns in the analysis of data are
minimal, and should pose no risk of physical or psychological harm, certain subjects
may have experienced distress in responding to items regarding traumatic life events.
All patients were encouraged to discuss this with their clinicians and were made
aware of other treatment and mental health services options, whether or not they
consented to this study.
This chapter has examined the method of the present study. The following
chapter, Results, presents the results of the analysis.
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CHAPTER 4
RESULTS
This section presents the results of the present study. What follows are each
hypothesis, the tests run, the acceptance or rejection of the research hypothesis, and a
table of the final results.
Descriptive Statistics
The 56 patients in the primary research group with Psychotic Features, were
primarily female («=41; 73.2%), white (n=46; 82.1%), never married (n= ,33.9%),
th
and had an education between at least 7 grade and some college (n= ,73.7%). Their
mean age was 32.7 (S D -9.9).
Research Hypothesis One: Suicide Attempts
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of more suicide attempts. The
serious suicide attempts in the past year, was the only suicide type that was
significantly different between research groups. Four types of suicide attempts were
examined: serious suicide attempts in past year, non-serious suicide attempts in the
past year, serious suicide attempts before the last year, and non-serious suicide
attempts before the last year.
For serious suicide attempts in the past year, the research hypothesis was
accepted via an independent sample t test (f=-l .736, df= 59, p< .05). The Levene’s
Test for Equality of Variances was conducted. Equal variances were not assumed
(F=27.292,/K.05). For non-serious suicide attempts in the past year, the research
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78
hypothesis was rejected via an independent samples t test (f=-.508, df=298, p>.05).
The Levene’s Test for Equality of Variances was conducted. Equal variances were
assumed (F= 994,/?>.05). For serious suicide attempts before the past year, the
research hypothesis was rejected via an independent sample t test (t=-.615, df=298,
p>.05). The Levene’s Test for Equality of Variances was conducted. Equal
variances were assumed (F =.35\,p>.05). For non-serious suicide attempts before the
past year, the research hypothesis was rejected via an independent sample t test (t=-
1.315, df=298, p>05). The Levene’s Test for Equality of Variances was conducted.
Equal variances were assumed (EK3.51 l,p>.05). (See Table 3.)
Table 3
T Tests
With Without
Psychotic Psychotic
Features Features
M SD M SD
Suicide Attempts
Serious in past year .25 .81 .06 .33
Non-serious in past year .09 .44 .06 .35
Serious before past year .64 1.79 .50 1.57
Non-serious before past
year .63 2.69 .32 1.14
Hospitalizations 1.25 1.7 .60 1.15
Axis-I Co-Morbidity 7.00 2.70 5.93 3.44
CGI for Depression 3.09 1.21 2.70 1.05
GAF 39.91 12.39 50.41 9.59
Trauma Symptoms
Re-experiencing 3.63 1.26 3.39 1.39
Avoidant 4.63 1.15 4.43 1.24
Arousal 3.77 1.08 3.63 1.09
Total 12.02 2.55 11.45 2.68
Age of onset 18.76 11.98 18.51 11.17
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Research Hypothesis Two: Psychiatric Hospitalizations
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of more psychiatric hospitalization.
The research hypothesis was accepted via an independent sample t test (/=-2.721,
df=61, p<.05). Levene’s Test for Equality of Variances was conducted. The equal
variances were not assumed (F=15.613,p<05). (See Table 3.)
Research Hypothesis Three: Axis-I Co-Morbidity
PTSD patients with Psychotic Features differ significantly from PTSD
patients without Psychotic Features in terms of having more lifetime Axis-I Co-
Morbidity. The research hypothesis was accepted via an independent sample t test
(f=-2.167, df=298, p<.05). Levene’s Test for Equality of Variances was conducted.
Equal variances were not assumed (F= 3.318, p > .05). (See Table 3.)
The chi square analysis of each diagnosis separately revealed the following
diagnoses with a significant association with the research groups. Approximately
76.7% of the patients with PTSD with Psychotic Features were co-morbid with other
disorders with Psychotic Features, but could not account for the other 23.3% who
qualified for the proposed diagnosis, PTSD with Psychotic Features, that were co-
morbid with other non-psychotic disorders. (See Table 4.)
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Table 4
Chi Square
With
Psychotic Features
Without
Psychotic Features
% # % #
Co-Morbidity by Diagnosis
Alcohol Dependence 52 29 36 87
Schizophrenia 2 1 0 0
Schizo-Affective Disorder 4 2 0 0
Delusional Disorder 4 2 0 0
Brief Psychosis 2 1 0 0
Psychotic Disorder, NOS 16 9 0 0
MDD, single, psychosis 25 14 0 0
MDD, single, no psychosis 5 3 33 81
MDD, recurrent, psychosis 16 9 0 0
MDD, recurrent, no
psychosis 5 3 48 117
Bi Polar, Manic 2 1 0 0
Bi Polar, Mixed 2 1 0 0
Bi Polar, Depressed,
psychosis 11 6 0 0
Bi Polar, Depressed, no
psychosis 5 3 1 3
Bi Polar Disorder, NOS 5 3 1 2
Obsessive Compulsive
Disorder 25 14 13 31
Bulimia 13 7 4 10
Social Functioning
Past Poor (versus Good) 25 14 10 25
Present Poor (versus Good) 32 18 9 21
Significant (versus Average)
Amount of Work Missed 32 18 16 40
Interpersonal Trauma Code 86 48 81 198
Female (versus Male) 73 41 73 177
Minority Status (versus White) 18 10 14 34
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Research Hypothesis Four: Past and Present Social Functioning
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features, in terms of past and present social
functioning. Overall, both research hypotheses were accepted. For the past
functioning the research hypothesis was accepted via a chi square test of
independence (chi square =8.766, d f= l,p = <.05). (See Table 4.) For the present
functioning, the research hypothesis was accepted via a chi square test of
independence (chi square =22.308, d f= \,p = <.05). (See Table 4.)
Research Hypothesis Five: Workdays M issed
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of more workdays missed on the
SCID. The research hypothesis was accepted via a chi square test of independence
(chi square =7.244, d f= \,p = <.05). (See Table 4.)
Research Hypothesis Six: CGI Score fo r Depression
PTSD patients with Psychotic Features differ significantly from PTSD
patients without Psychotic Features in terms of higher CGI score for Depression. The
research hypothesis was accepted via an independent samples t test (f=2.458, df=298,
p< .05). Levene’s Test for Equality of Variances was conducted. Equal variances
were assumed (F=2.779,/?<.05). (See Table 3.)
Research Hypothesis Seven: Global Assessment o f Functioning
PTSD patients with Psychotic Features differ significantly from PTSD
patients without Psychotic Features in terms of a lower GAF score. The research
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hypothesis was accepted via an independent samples t test (7=5.941, <77=70.866,
p<.05). Levene’s Test for Equality of Variances was conducted. Equal variances
were not assumed (F=5.851,/?<.05). (See Table 3.)
Research Hypothesis Eight: Trauma Symptoms
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of more re-experiencing, avoiding,
arousal and total characteristics of traumatization. Overall, none of the trauma
symptoms, or total number of trauma symptoms, was found to be significant. (See
Table 3.) For the re-experiencing symptom grouping the research hypothesis was
rejected via an independent samples t test (/=-1.325, df=298,p=>.05). Levene’s Test
for Equality of Variances was conducted. Equal variances were assumed (F=.559,
p> .05). (See Table 4.) For the avoidant symptom grouping the research hypothesis
was rejected via an independent samples t test (/=-1.048, <7/=298, p — >.05). Levene’s
Test for Equality of Variances was conducted. Equal variances were assumed
(F=.816, p> .05). For the arousal symptom grouping the research hypothesis was
rejected via an independent samples t test (/=-.871, <7/=298,/?=>.05). Levene’s Test
for Equality of Variances was conducted. Equal variances were assumed (F=.l 14,
p > .05). For the total trauma symptom grouping the research hypothesis was rejected
via an independent samples t test (7=-. 1.441, <77=298,/?=>.05). Levene’s Test for
Equality of Variances was conducted. Equal variances were assumed (F=.83,
p>.05).
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Research Hypothesis Nine: Age o f Onset o f PTSD
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of a younger age of onset for PTSD.
The research hypothesis was rejected via an independent samples t test (r=-.151,
df=291,p>.05). Levene’s Test for Equality of Variances was conducted. Equal
variances were assumed (F=.832,/?>.05). (See Table 3.)
Research Hypothesis Ten: Interpersonal Trauma Code
PTSD patients with Psychotic Features differ significantly from PTSD
patients without Psychotic Features in terms of having an interpersonal trauma code.
The research hypothesis was rejected via a chi square test of independence (chi
square =1.674, df=2,p>.95). Other Traumas (Coded 13) were unable to be evaluated
on an individual basis as to interpersonal trauma code status. (See Table 4.)
Research Hypothesis Eleven: Gender
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of gender. The research hypothesis
was rejected via a chi square test of independence (chi square = 01, d f= \,p = .9 \9
>.05). (See Table 4.)
Research Hypothesis Twelve: Race
Patients with PTSD with Psychotic Features differ significantly from patients
with PTSD without Psychotic Features in terms of minority status. The research
hypothesis was rejected via a chi square test of independence (chi square =.56, df= 1,
p > .05). (See Table4.)
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This section provided an overview of the results of the present study.
The next section, Discussion, presents summaries of the explanations for
finding in terms of those hypotheses that were rejected and those that were accepted.
Several alternate explanations for findings are given, as are explanations and
implications of the convergence or divergence with existing research. Limitations of
the study and directions for future research are explored.
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85
CHAPTER 5
DISCUSSION
The Discussion presents the explanations for the findings, the convergence or
divergence with existing literature, and explanations and implications of those
convergences or divergences. Limitations of the study are presented, first for design
and validity, then for the external validity and generalizability. Next is presented
measurement and statistical limitations. Finally, the general implications are
presented. The chapter will close with directions for future research.
Explanations for the Findings
From this research study, I have learned that of the 1500 clinical patients, 300
have PTSD, 20% in this study. Of those PTSD patients, 56 have Psychotic Features,
18% in this study. This may indicate common vulnerabilities between those patients
with PTSD and those with psychosis, or an underlying causal relationship between
trauma and psychosis, or psychosis and trauma. Noting prevalence levels in clinical
samples is important, in that diagnostic refinement will potentially impact a
substantial portion of clinical patients. Further discussion of the research results can
be broken into three types of validity: etiological, concurrent, and predictive.
Non-Significant Findings: Etiological Validity Hypotheses
The non-significant findings can be conceptualized as not supporting
etiological validity hypotheses. Etiological hypotheses that were testable showed no
significant associations that could assist in determining risk factors. Neither
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interpersonal trauma, early onset of PTSD symptoms, greater number of trauma
symptoms, gender nor race presented an increased association with psychosis.
Etiological hypotheses tested the potential “causal factors (that) must be
found in the people who constitute the diagnostic group” (Davison & Neale, 1996, p.
69). Not enough information existed in the present database to test the diathesis-
stress model and corresponding theory pertaining to the interaction of early life
vulnerabilities, psycho-social experiences, and neuro-endocrine changes.
Via the current database, there is no means to determine early bio-neuro-
genetic vulnerabilities or psycho-social stresses that may have impeded or disrupted
perceptual systems. This is due to lack of third party observations of early life
attachment interactions, lack of knowledge of health and disposition of the infant,
and lack of lab tests and brain imaging studies taken before, during, and after trauma,
in the life of the individual. In fact, much of this type of study is improbable. More
likely however, might be the tracking of high-risk groups, not unlike those typical of
schizophrenia research (Davison & Neale, 2001), and periodic evaluations on
multiple assessment tools.
No particular type of self-reported trauma that was “able to be remembered
or described” by the patient, was associated with PTSD with Psychotic Features. It
may be that traumas that are “able to be remembered,” or that are sequentially and
verbally encoded, are not the traumas affecting perception and psychosis. While the
findings do reject the research hypothesis, it does not confirm the null hypotheses. It
suggests that data is not available that might confirm other portions of the model.
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Interpersonal trauma within the family may be dissociated, due to lack of
validation within the family structure, or the need to preserve the image of “good
parent”. This non-registration of these particular kinds of trauma (Saporta, in press)
would make a link from early or interpersonal trauma to psychosis untraceable.
Also, the SCID may not capture the nature of certain types of trauma that is
not verbally encoded, or that is encoded on multi-modal channels of perception.
There may be mediating factors like strong, early attachment, social support at the
time of trauma, empathic parental response, and more benign, non-catastrophizing,
interpretive strategies of the individual at play that have blunted the report or impact
of these later traumas, while still laying the path for alterations in perception.
Significant Findings
The significant findings can be conceptualized as supporting two of the three
categories of validity: concurrent validity and predictive validity. Results showed
that PTSD patients with Psychotic Features were distinguishable from those without
Psychotic Features in terms of similar concurrent symptoms and similar prognostic
outcomes.
Concurrent Validity Findings
Concurrent validity notes the “other symptoms or disordered processes not
part of the diagnosis itself (that) are discovered to be characteristic of those
diagnosed (Davison & Neale, 1996, p. 69). In this study, data analysis showed that
patients with PTSD with and without Psychotic Features differ in statistically
significant ways, in terms of behaviors or disorders outside of the criteria for PTSD.
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88
These included more suicide attempts in the past year, more Axis I co-morbidity, and
higher CGI score for depression. This is notable in that comorbidity is not just
associated with Depression via the CGI, but also with other disorders both with, and
without, psychosis. The additional diagnoses of Alcohol Dependence, Bulimia, and
Obsessive Compulsive Disorder, support the concurrent validity, beyond that which
is accounted for via other psychotic disorders. These additional diagnoses may all be
methods of coping with the stress of trauma and psychosis, via alcohol, food control,
and repetitive thoughts and behaviors.
Predictive Validity Findings
Predictive validity hypotheses test “specific prognosis, or outcome” (Davison
& Neale, 1996, p. 69) associated with the disorder, or those patients with the
disorder. In this study, data analysis showed that patients with PTSD with and
without Psychotic Features differ in statistically significant ways in terms of more
hospitalizations, poorer past and present social functioning, more work missed, and
lower Global Assessment of Functioning scores. Intuitively, this makes sense.
Psychosis can be one of the most distressing life events. In fact, one would expect,
and indeed it is corroborative, to find multiple measure that confirm the impaired
functioning, namely the hospitalizations, the poorer social functioning, and the
greater amount of work missed and the lower GAF. Some would argue that this rests
on the supposition that past behavior predicts future behavior. However, another
interpretation of predictive validity is that one could expect subsequent clinical
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patients with PTSD with Psychotic Features to have a similar profile, or similarly
greater amounts of hospitalizations, functional impairment, and work missed.
Alternate explanations are that trauma and psychosis are simply co-occurring
phenomena, unexplainable, without link, or coherence. Further study, I believe will
refute this. Still, I expect that by recognizing and highlighting the differences of
PTSD with Psychotic Features from the more typical PTSD population, heuristic
advances in theory, research, and practice might ensue.
This section has described likely explanations for the findings. The next
section presents these explanations in the context of existing research.
Convergence and Divergence with Existing Research
This section presents the findings in the context of existing research. It is
presented in the following order. The divergence with my interpretation of
theoretical and etiological underpinnings of psychosis, and the convergence with re
reading of critical research that notes that repeated and ongoing trauma and early age
of trauma is associated with more trauma symptoms and a greater risk factor for
PTSD, respectively, but not necessarily psychosis. Next the divergence with
research that posits racial or gender associations with psychosis, the convergence
with the possible call for the new diagnostic subtype, the divergence with existing
subtypes, the divergence with the call for the subtype Severe PTSD, and the
divergence with the co-morbidity of “typical” PTSD.
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90
The findings of this study contradicted my hypotheses that ongoing and
repeated childhood trauma, or interpersonal trauma of any kind, would be associated
with psychosis.
In re-reading critical articles, it appears that those non-significant dependent
variables are, in fact, increased risk factors for PTSD (Neria et al., 2002), but not
necessarily psychosis. Interpersonal trauma has been shown, in other studies (van
der Kolk, 1996, p. 184), to be associated with a greater number of trauma symptoms
but not necessarily with psychosis. Childhood trauma has been associated with
dissociative responses (van der Kolk, 1996, p. 184), but not psychosis, per se.
This study diverges from literature that showed Black and Hispanic patients
have more psychotic symptoms and current major depression (David et al., 1999).
The present study showed that racial differences, and for that matter, gender
differences, were not significantly associated with the presence of PTSD with
Psychotic Features. It may be that the reverse is not true. PTSD patients with
Psychotic Features are not more likely to be from the minority populations. The
racial differences, in terms of the increased strain of being of targeted status in a
dominant culture, was the prediction for this study. The divergence from existing
research could mean that earlier results were an artifact of the co-morbidity with
depression, which is more common in female and minority samples.
Existing research studies on PTSD converge with the present study in noting
that a significant part of the PTSD population has psychosis, and that it may call for
a distinct subtype of PTSD (David & Mellman, 1999; Hamner et al., 2000; Neria et
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91
al., 2002; Sautter, Brailey et al., 1999). It appears that multiple clinicians and
research sites are noting differences in this population, a vital step in diagnostic
validity. This study converges with earlier studies that show PTSD with Psychotic
Features is not accounted for just by symptom overlap with MDD with Psychotic
Features (Franklin & Zimmerman, 2001).
The findings in this study diverge from the current DSM IV existing subtypes
of acute, chronic, and delayed onset PTSD. This may be because the existing
subtypes were based on clinical observations alone (Rothbaum & Foa, 1992). In
fact, there are no significant differences between acute and delayed onset PTSD, in
terms of severity of trauma, severity of symptoms, repression, or previous stress
history (Watson et al., 1988). Thus, the non-significant outcome subtypes could be
replaced by a construct such as PTSD with Psychotic Features, in that it does present
a statistically different clinical profile.
This study diverges from some clinicians who suggest that Severe PTSD or
Disorders of Extreme Stress, Not Otherwise Specified, would be a more appropriate
subtype name. While there may be good cause for such additional subtypes, such as
other patients who might have an equal or greater number of trauma symptoms (re-
experiencing, avoidant, and arousal) or severity of symptoms, or complex personality
adaptations to trauma, they may not be psychotic. Those patients may warrant those
other subtype names. However those names are ambiguous for this group. The
group with Psychotic Features did not have a significantly greater number of PTSD
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92
symptoms, as revealed in this study. Thus, the subtype name PTSD with Psychotic
Features more clearly delineates those with Psychotic Features.
This study’s patients with PTSD with Psychotic Features have some co
morbidity that diverges from the co-morbidity typically associated with PTSD.
“Typical” PTSD is associated with Major Depressive Disorder, Bipolar Disorder,
Anxiety Disorders, and Substance Abuse or Dependence (Foa et al., 1999). Bulimia
is not on the typical co-morbility list, and yet was significantly different for this
research group with Psychotic Features. One explanation may be that the clinical
population for this study includes more women than is usual for PTSD studies, and
that food is a more frequently used coping mechanism for this group. Another
explanation is that the Eating Disorders could be re-conceptualized and classified as
another group of Anxiety Disorders, a type that involved food. It could be that
Bulimia is emerging as a new expression of distress for the “moving target” that
describes PTSD patients. It would correspond with the epidemic of Bulimia in other
parts of the world, and in Argentina in particular (Hacking, 1999), and could reveal
an aspect of PTSD that is evolving under present social conditions.
While the preceding section explained the present study in the context of
existing research, what follows are more general implications for theory, research,
and practice.
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Theoretical Implications
The theoretical implications of this study will be explored in terms of: the
type of variable that psychosis and traumatic reactions are thought to be, where it fits
in the realm of human experiences, and how this diagnosis should be classified.
PTSD with Psychotic Features is a newly proposed diagnostic subtype. The
differences between it and “typical” PTSD have been presented in this study.
Taxometric models can guide conversation about what exactly has been revealed
here. In my opinion, PTSD with Psychotic Features is not distributed discretely to
categories of individuals, in what is called a class variable (Gangstad & Snyder,
1985). I believe it is measurable, rather, on a continuum of distribution, as what is
called a dimensional variable (Gangstad & Snyder, 1985) of dissociative, stress
induced, and imaginative processes that all humans experience. In other words, it is
a matter of degree to what extent individuals have had breaks with consensual
reality, rather than the dichotomous distinction used for diagnostic purposes.
Though I claim psychosis is on a continuum of normal human experiences,
that is not to say that the field may not find bio-neuro-genetic differences in those
who are susceptible to PTSD or psychosis. For example, there are findings that
propose there are genetic influences on hippocampal volume, and that a smaller
hippocampus may be a preexisting risk factor for PTSD in those that are trauma
exposed, and that compromised neuro-cognitive functioning might hinder one’s
ability to deal with traumatic stress (McNally, 2003). Another explanation might be
that the dissociation from trauma averts use of the apparatus of the verbal encoding
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94
portions of the brain, leading to atrophy and dying off, of the hippocampal cells
responsible for narrative encoding, thus accounting for the diminished volume.
Still, the potential re-classification of PTSD under the heading of Stress
Response or Re-Experiencing Disorders is taken upon the recommendation and
reasoning of the sub workgroup for PTSD. I also recommend that the proposed
Stress Response or Re-Experiencing Disorders, which is the preferred title, should be
merged with the Dissociative Disorders. This is my variation on the subgroup’s
recommendation to merge the Anxiety Disorders and Dissociative Disorders
categories. I feel the ambiguous nature of “trauma”, of exactly what is being
repetitively relived or re-experienced, is debatable. The nature of horrifying
thoughts, feelings or events is very open to individual interpretation. Re-
experiencing seems to be at the core of the phenomenon. I also propose this because
I see both re-experiencing and dissociation as processes that involve removal from
the “now” of being, and involve the enactment of symptoms in the space of being
removed from the present.
There are as many theories for phenomenon as there are people who have
bothered to think about them. Each theory is interpreted by later readers in ways the
theorist may, or may not, have intended. One portion of my etiological proposals
were testable. These hypotheses failed.
The wondrous thing is not that we are unable to have perfect knowledge, but
that we are able to have any knowledge at all. Even more wondrous is that
we are able to learn at a ll.. . . Since there is no final picture of the world that
is open to human beings, this establishes that the decision to pick a particular
picture on which to base one’s actions is ultimately a heroic act and not a
“logical” one. The choice of a human action and the associated belief in it
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95
are among the greatest risks humans ever face” (Mitroff & Linstone, 1993,
pp. 161-162).
The picture, that early life trauma and repeated and ongoing trauma might
lead to psychosis, ultimately failed to produce the predicted results. In Mitroff’s
“The Subjective Side of Science” (1974), he examined how research scientists
theories changed after data from the Apollo moon landing experiments came back.
Despite the data, theorists stuck to their theories. Mitroff proposed that it was the
very tenacity of the beliefs and theories of those scientists that drove science, as real
human beings pushed to prove their hypotheses and theories, despite the evidence.
One possible definition of theory could be the attempt to explain the cause
and nature of something by the proposed processes involved. This study may have
theoretical implications for the understanding and classification of psychotic
processes, and the classification, nature and outcome of psychological disorders in
general, and re-experiencing phenomenon in particular. For example, as more
disorders emerge that have Psychotic Features, the entire process of psychosis may
need to be rethought, and those disorders with Psychotic Features may be better
conceptualized together. In terms of PTSD, the theories and definition of the
disorder may have to shift to conceptualize the re-experiencing phenomenon on a
continuum, from avoidance, to hyper-arousal, to intrusive memories, to flashbacks,
to psychosis. Another possibility is that the Anxiety Disorders may need to shift to
encompass disorders categorized within it, by particular methods of coping with that
anxiety.
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Research Implications
This section presents implications of my study in the context of other
research. It explains the nature of the problem of non-homogenous research groups,
the importance of the advancement of differentiation of subtypes of a single disorder,
and prognostic implications.
This study was similar to other clinical or hospital based population studies,
and used a standard measurement tool, plus research design and procedures that are
not unlike other studies in the field. What was different, were the research questions,
independent variables and ramifications of the results. The findings of this study
converge with past literature that notes diagnostic confusion when psychosis occurs
within the PTSD population.
This non-homogeneity presents conflicts for the researcher. Researchers
have struggled with what to do with the noticeable findings of a group of PTSD
patients that have psychosis. This study has extended those earlier findings,
examining particular functioning variables and etiological variables, to see whether
this group with Psychotic Features was different, and warranted not just removal
from the “typical” PTSD groupings, but rather a new diagnostic subtype group. It
was found that the differences were significant enough to warrant a new diagnostic
sub-type that may alleviate the research problem of multiple co-morbidities. The
non-homogeneity of research or treatment groups provides an initial argument for
PTSD with Psychotic Features holding together as a valid new diagnostic subtype,
separate from “typical” PTSD.
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97
This research diverged from previous research in that it specifically proposed
and investigated a new subtype of PTSD, with Psychotic Features. This study
improved on the understanding of one of the different manifestations of PTSD, and
perhaps will contribute to refinement in the taxonomy of mental disorders in general,
and PTSD in particular.
In traditional psychological and psychiatric research, when the prognosis for
a particular set of symptoms of a disorder is significantly different, this may then be
considered a different subset of a disorder, or warrant a completely different
diagnostic category (Robins & Guze, 1970). The prognostic differences revealed in
this study are not small. They sweep across multiple areas of living, functioning,
behavior, and experiences. These differences are substantial and significant enough
to warrant, in my opinion, the possible inclusion of a new sub-type of PTSD with
Psychotic Features, to enhance research and diagnostic clarity, and treatment
specificity.
While research is critical, and is an important part of the work of counseling
psychologists, in the end, the research is there to fulfill our mission to foster health
and growth in the lives of patients. The next section presents some of the applied
implications in the context of other work of psychologists.
Applied Implications
In terms of practice implications for the potential subgroup of PTSD with
Psychotic Features, there are several. This section presents the treatment
recommendations integrating this research with clinical practice, the need for
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98
increased vigilance with this population, and the seriousness of PTSD with Psychotic
Features. Two innovative programs used for PTSD are examined.
Treatment Strategies
Though evaluation of treatment strategies is beyond the scope of this paper,
one can speculate on how it may impact the existing treatment recommendations.
The Expert Consensus Guidelines for Treatment of PTSD (Foa et al., 1999) shows
that psychotherapies such as Anxiety Management, Cognitive therapy, Exposure
therapy, Play therapy for children, and Psycho-education should be the first line of
treatment, with medication experts also recommending that medication be
implemented from the start, as well.
My own experience in practice revealed that focussing on the imagery as one
does for Exposure therapy, or Re-scripting for nightmares or intrusive thoughts or
memories, was not readily effective when dealing with psychosis. It may be that the
ego structure, in psychoanalytic terms, is too fragile, leading more to disintegration,
and that the bio-neuro-genetic make-up of these patients prohibits the synthesizing
and healing nature of narrative and imagery restructuring. Another explanation is
that traumatic imagery is not able to be analyzed for meaning, or lifted from
repression, because they are not decodable or repressed, but rather are perceptual
fragments that need to be brought into a coherent narrative (Sapporta, in press) once
psychosis is stabilized. First line treatment should, perhaps, include supportive
therapy to stabilize the patient, at least a short trial of the best medication available at
that time, cognitive management techniques, and reality orienting treatment. Once
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the patient is stabilized, then potential work with bringing perceptual fragments into
narrative, or exploring the content of psychosis, may or may not prove useful.
I should note that my challenges with working with the imagery of the PTSD
patients with Psychotic Features may have been related to several things. These
include the active psychosis of the patient, the particular nature of these patients,
their chronic PTSD, the junior level of my own clinical abilities, the time limited
setting, and my brief exposure to these patients.
Clinical Vigilance
PTSD patients with Psychotic Features show significantly more reasons for
the clinician to be more watchful of the well-being of these patients, and not just
because they are psychotic. Co-morbidity is present for a host of other disorders
such as Bulimia, Obsessive Compulsive Disorder and Alcohol Dependence.
Increased attention to these other co-occurring disorders within the clinical setting,
and implementing simultaneous, coordinated treatment of these disorders is critical.
An awareness of the increased risk of suicidal behavior should make a clinician more
vigilant, and hospitalization could be implemented more readily than for more
typical PTSD patients, for the safety of the psychotic patient.
Implications During Times o f War
Other practice implications involve the gravity of the diagnosis of PTSD with
Psychotic Features. First, PTSD with Psychotic Features is discussed for refugees of
political trauma. This is important for many reasons, but is also particularly timely,
given the fact that our nation has been so recently at war, and given the nature of the
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traumas that have emerged from the stories of refugees from Cambodia and Bosnia,
amongst others. The challenges of helping in cultures different from one own, is
discussed. Two particularly innovative programs are highlighted. Implications for
coordinated efforts in inner cities and rural outposts are outlined.
In times of war, the seriousness of PTSD with Psychotic features becomes
even more apparent. According to the director of the Harvard Program in Refugee
Trauma, patients with psychosis rarely exist in refugee settings. Traumatized people
with psychosis are the first to be killed by the occupying regime by virtue of their
behavior. (Richard Mollica, personal communication, May, 2003). They are
deemed too much trouble, not useful to the regime, and expeditiously done away
with. After political unrest, or in poor countries when there are not enough hospitals,
medication, support or guidance in how to care for people for people with psychosis,
such individuals may be chained in a backyard for the protection of the family,
community and the patients themselves (Unpublished Lecture, Massachusetts
General Hospital, May, 2003).
A natural implication of increased risk for this population, is the call for the
international community to come to aid as rapidly as possible, after or during conflict
for this particularly vulnerable group. Also important is training in what specifically
has been found to be helpful and not helpful after major traumas, and in particular
for psychotic patients. Yet, there are problems when the groups doing the helping
are vastly dissimilar from those in need of the help (McGill Trans-Cultural
Psychiatry Institute, Unpublished Seminar, 1999). Attention and training in the
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culture of the region of conflict is critical, as is sensitivity to the differing levels of
cultural acceptance of help seeking behavior. For example, a completely unused
psychological center, in the middle of a small Cambodian town, was later placed
within a medical facility. This allowed privacy for help-seekers, letting referrals for
psychological help be handled without the cultural shame of walking into a free
standing psychological clinic, but rather through the more acceptable means of
seeking medical care (Unpublished Lecture, Massachusetts General Hospital, May,
2003). Intensive study of refugee populations leads to the recommendation that
refugee policy makers create programs that support work, indigenous religious
practices, and culture-based altruistic behavior among refugees (Mollica et al.,
2002).
On the homefront, similar integrated helping behaviors must be coordinated
for inner cities and rural areas to maximize the wellbeing of those in disenfranchised
populations. What is needed in times of extreme community trauma, such as war
and civil unrest, is support and guidance by the international psycho-medical-
spiritual community. Volunteer efforts via organizations such as the Red Crescent
and Red Cross and others and the importance of also incorporating and assessing
spiritual resources cannot be underestimated in the face of life shattering trauma or
illness (Doehring, 1993).
Innovative Programs in the Treatment o f Trauma
In order to demonstrate how PTSD practice can contribute, I would like to
highlight two very innovative programs in working with trauma, that resonate with
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my background in the arts, and my interest in helping strategies for domestic
violence. I examine them in terms of possible treatment of PTSD with Psychotic
Features.
Refugee Trauma Program
New York University’s International Trauma Studies Program’s has a
multidisciplinary center called “Refuge”, that addresses the mental health and social
integration of individuals and families who have been damaged by state sponsored
violence. “Refuge” houses the “Theatre Artists Against Political Violence” program
that uses the arts and narrative in healing. Beyond reporting and working with
traumatic imagery, this program encourages refugees to tell their stories to trained
actors and dramaturges who then present the stories in the format of a play for the
survivors themselves, their communities, and interested others. Here clinical work
and social justice aims are integrated. Clinicians are present throughout the process.
Accounts of the moving and healing nature of these performances for the refugees
themselves or others, are stirring (Unpublished Lecture, Trauma Institute
Conference, Boston, 2001). This can help break the silent repetition of violence,
alcoholism, and private pain that can continue within survivor families for
generations. Whether psychotic processes could be expressed and tolerated by
formerly psychotic patients is yet to be determined. However, presenting such
stories for survivors and the community has benefits on many levels, not unlike the
power of the experiences presented, and the understanding fostered by the film “A
Beautiful Mind.” Family education as to the experiences and expectations possible
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of their psychotic family member, like that in schizophrenia treatment (Davison &
Neale, 2001), is a potentially important contribution.
Domestic Violence Program
Another remarkable program is called MANALIVE. Hamish Sinclair has
had outstanding success in helping change the lives of men who batter, and those
who have entered the prison system (Unpublished Lecture, Trauma Institute
Conference, Boston, 2001). Often the offenders have had ongoing verbal, emotional,
and physical abuse in their personal histories, or witnessed domestic violence in their
family of origin (Unpublished Lecture, Massachusetts General Hospital, Forensic
Psychology Program, May, 2002). That, according to Mr. Sinclair, has the idea of
manhood for these men integrally linked to being in control, and physically
enforcing their will. Acting in a near psychotic state to threats to their control, these
offenders have physically and psychologically harmed others. Mr. Sinclair uses a
process that focuses on body awareness and slowed response time. He begins with
stopping the escalation via identification of bodily locus of felt emotions, subsequent
softening of muscles and posture, and development of use of words to foster
connection with the individual’s own thoughts and affects, and then with those of
others. New physiological and psychological experiences are reinforced by
repetitive movement, and rehearsals of anxiety and control provoking situations.
Many would debate whether acting out in this way is psychotic, that it is
rather a conscious and deliberate desire to do harm. I would say that the processes of
such violence, if broken down, are psychotic, more resembling entrenched delusions
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of the essential nature of control. It is involving breaks with conscious awareness,
leading to lack of empathy for others, lack of respect for body and property rights,
lack of awareness of certain unacceptable affects of the man himself, and
dissociation from thoughts and signifiers of earlier stress or trauma, that are unable
to be tolerated.
This section has highlighted how patients with PTSD with Psychotic Features
are both amongst the most vulnerable of the world’s population, and the most
dangerous. They are comprised of those who have experienced both overwhelming
trauma and psychosis. As counseling psychologists we must use our knowledge not
only with the leaders of our largest organizations, but also the least well functioning
of our fellow humans. And where we don’t know what to do, we must think, and try,
and care. We will be distinguished by the size and magnitude of the problems we are
trying to solve.
This section has explored several overarching implications for the theories,
research, and practices that guided the hypotheses and sparked the research
questions. What follows is a discussion of the limitations of the study.
Limitations of the Study
The limitations of this study are presented below, first for the design and
internal validity, then for the external validity and generalizability, next for
measurement, and finally for statistical limitations.
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Design and Internal Validity
Limitations of this design included lack of random sampling. A random
sample of the patients could have been selected.
External Validity and Generalizability
While the value of this sampling plan was its accessibility and convenience,
large sample size, and normative sample of patients that present at a teaching hospital
outpatient clinic, it is not generalizable beyond other such outpatient clinics, and
perhaps only those in New England. Since the sample pool was diverse in terms of
gender, race, and trauma code, its external validity is questionable for clinics that
serve single populations like the veteran or women’s hospitals populations. As in
any natural mental health setting, patients chose to come to the department for a
variety of reasons (marketing efforts, referrals, interaction with referring faculty and
physicians, etc.). Threats to the validity of the study included the degree to which
subjects self-select in seeking treatment and participating. Sampling bias, in terms of
why and which patients self-selected to be studied, and which patients might have
chosen not to be assessed, also comes into play. Given the large commitment of time
involved for assessment, several hours, the potential for significant differences in the
groups was high. Still, the benefits of having a thorough exam were also explained
to the patient at time of assessment, so differences may have been balanced out. Data
on demographics could have been compared in terms of those patients who chose not
to be assessed with those patients that chose to undertake the full assessment.
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Meaurement
Measurement issues include the possibility that the sample for this study was
significantly different that the initial sample pool of the SCID. This study’s sample
norms could also have been compared to the data for the initial sample pool of the
SCID. Though highly trained raters were used, responses were still based on self-
report. Direct observations and family reports could have been used to triangulate
and confirm the self-report data. As well, there may have been reactivity on the part
of the patients to the process of being assessed, such as response sets for social
desirability. This too, could have been addressed by including a measure of social
desirability.
There was also a potential response bias, since the data were collected at the
time of their application to the clinic, rather than at other stages of their disorder.
Where available, subjects from the database could have been contacted and
reassessed at a later time. This would have revealed any response bias.
None of the measures used to assess trauma are ideal. Overall, the SCID is
less desirable for assessing trauma than many of the instruments designed
specifically for that purpose. The SCID does not capture social support, nor more
refined aspects of trauma. A more precise trauma instrument could have been
selected.
Statistical Problems
While the sample size was sufficient, a larger sample size would have
increased the power of the statistics to detect lesser effects. Also, this study did not
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use specific statistical methods used for taxonomy. The maximum co-variance
statistical method of taxometrics begins with a substantive theory, develops a set of
tests composed of indicators that discriminate between the dichotomous taxonomy,
then statistically observes whether these indicators behave in a predictable way, that
is not so of dimensional variables (Gangestad & Snyder, 1985). This model is
beyond my expertise at present, however given more time and resources, this could
have been undertaken.
The limitations of this study have been presented. The chapter closes with
recommendations for future research.
Directions for Future Research
Post-Traumatic Stress Disorder is not just a “bad day or “a tough stretch.” It
is a pattern of re-experiencing, avoiding and hyperarousal in reference to an event
that caused horror for the individual. The threshold for the diagnosis is to include
only those people who survive events where they experienced or witnessed loss of
life or limb, or the threat thereof. Sometimes it occurs in a repeated and ongoing
way, sometimes in a single event, with lasting implications.
This section will express the research needed to extend or clarify the findings
in terms of theory, research, and practice in order to move the field forward.
Theories
Theories of psychosis and traumatization can be clarified specifically in
terms of what the exact proposed processes are underlying them both, and whether or
when those two processes are related, in light of current findings. Genetic and brain
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imaging studies could be conducted to clarify some biological and etiological
hypotheses, as well as possible studies that explore attachment patterns and the
subsequent neuro-endocrine outcomes that may develop under different early life
experiences and stressors. Particular kinds of childhood traumas could be assessed
more thoroughly, via the Childhood Trauma Questionnaire, that is part of the
MIDAS protocol. It will be entered into the database this year.
Research
Research will likely continue to explore classification. However, the most
important missing pieces for this study may be the continued research into co
morbidity. Exploration of the plusses and minuses of using a classification like
PTSD with Psychotic Features, in terms of whether it helps or hinders diagnostic
specificity, and homogeneity of research groups, is critical. Replication of this study
could help confirm or disconfirm functioning outcomes for other populations, or
determine whether other large clinical databases have similar findings.
Practice
Practice was only touched passingly in this study, and was not part of the
design purpose, or database characteristics. Still, future research will need to
conduct outcome studies that examine the specific treatments for different symptoms
and functioning ability of patients with PTSD with Psychotic Features. Also,
whether direct exploration and treatment of the psychotic symptom’s content is ever
helpful or appropriate, how different treatment methods work, when and for how
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long should they be undertaken, what the best and worst practices are, and what
changes result from different treatments.
The preceding section has summarized and discussed both the significant and
non-significant findings in terms of explanations for those findings, the convergence
or divergence with existing literature, and the explanations and implications of those
convergences or divergences for theory, research and practice. The limitations of
this study and possible remedies have been explored, as have possible directions for
future research.
The final chapter, the Conclusion, will present the following subjects. It will
1) give an overview of current thinking on the social construction of mental disorders
and the history of PTSD in particular, 2) present problems with studies of this kind,
and 3) present the researcher’s own experiences in her evolution of thinking.
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CHAPTER 6
CONCLUSION
This final chapter begins with an overview of the problems with the construct
of PTSD, presents the problems of classification in the human sciences, the argument
of the social construction of mental disorders, and the idea of the invention of
neurosis. Finally it explores the types of errors common to the study of social
problems, and then shares the researcher’s evolution of thinking and biases.
Problems with the Diagnosis of PTSD
Current ideas about hearing voices, hallucinations and delusions, about PTSD
itself and the ramifications of trauma exposure or “psychic traumatization,” are
socially constructed. Yet, these social constructions attempt to represent something
real and observable about human behavior. PTSD has been called “the most socially
constructed” disorder of them all (McNally, 2003), as a construct used to explain bad
behavior, to gain a pension, or for some experts, to make an industry out of treating
it.
In fact, there exists a body of literature that calls into question the very
construction, ethics, and viability of PTSD (McNally, 2003, Micale & Lemer, 2001).
These researchers reveal that multiple controversies and discrepancies arise. For
example, the definition of the type of trauma that can cause PTSD is disputed. The
dose-response model of PTSD is viewed as unpredictable. As well, there are
secondary gains possible from a PTSD diagnosis. The guilt and shame of trauma
response can be more severe for the perpetrator of an atrocity than even for a
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survivor of it. There are risk factors associated with lower intelligence and
predisposing clinical and personality factors to trauma. There is confusion over the
glucocorticoid process in the atrophy of the hippocampus. Finally, the recollection
of trauma can be distorted, which creates controversy over the reliability of
recovered memories of sexual abuse (McNally, 2003).
The field of history provides a valuable contribution here. Paul Lemer is co
editor of, and contributor to, the historical text Traumatic Pasts: History, Psychiatry
and Trauma in the Modern Age (Micale & Lerner, 2001), a book that looks at trauma
as it occurs in the lives of individuals and in the lives of communities. Lemer points
out that what psychologists are observing at present, is not necessarily what has been
observed in the past. There are many disconnections with what may have been
called PTSD via revisionist history. Though writers cite early literature and
historical accounts of what appears to be PTSD, one cannot assume that earlier
cultures or writers have even remotely similar categories as we have today (personal
communication, May, 2003). Lemer also states that scientific arguments today about
trauma are not necessarily advancements in science, but rather mirror the competing
theories from the earliest days of psychiatry and psychology.
So today, not only must the construction of PTSD be questioned, but also the
idea that current conceptions are so much of an advancement to what has been
thought before. There are additional problems beyond loss of the complexity of
human experience that come with the classification of humans. The following
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section goes over differences and potential solutions to the problems of classification
of humans.
Problems of Classification in the Human Sciences
Ian Hacking (1999) uses the idea of “interactive kinds” and “indifferent
kinds” to explain differences in the human and natural sciences, respectively.
Categories of human symptoms can be considered “interactive kinds.” This means
“ways of classifying human beings interact with the human beings who are
classified” (Hacking, 1999, p.31). Thus, the category of particular “kinds” of
symptom types of people, necessarily shift and change by virtue of “how they have
been classified, what they believe about themselves and how they have been treated
as so classified” (p. 104). What he calls “looping” occurs. “Looping” is the idea that
“kinds” are a moving target in the human sciences, that once we name “what” is, that
“what” moves, partially in response to the naming.
In the natural sciences, “indifferent kinds” do not interact with the idea of
how they are classified. “That which we call a rose/ By any other name would smell
as sweet” (Shakespeare, as cited in Griffiths & Joscelyn, 1992, p.466). Hacking,
however, uses the example of plutonium, which is active as an element, but no
different because it is called such. Hacking puts forward that psychopathology is,
interestingly, both “interactive” and “indifferent.”
The idea that psychopathology, the categorization of symptoms in the DSM,
is both “interactive” and “indifferent” can be illustrated by the following parallel
argument in terms of whether something can be both psychologically and
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biologically based. There is the idea that underneath mental disorders are some bio-
neuro-genetic explanation. In fact, there are currently multiple disorders that have
bio-neuro-genetic abnormalities with medication therapies that have proven
effective. And yet, most mental disorders are also treated psychologically. While
there is a general understanding that one’s health affects one’s cognitions and
emotions, there is also the idea that one’s emotions and cognitions impact bodily
health. For example, an expert yoga practitioner can significantly lower his or her
heart rate or create alterations in brain wave functioning via psychological and
physical processes.
Hacking (1999) uses the example of depression. Let us, for our purposes, use
the diagnosis of PTSD with Psychotic Features to illustrate a concept he calls “bio
looping.” Say a patient diagnosed with this disorder undertakes a serious
psychological regimen of behavior modification to address symptoms of PTSD with
Psychotic Features. Repeated behaviors are used to counter distressing symptoms,
and over time, become ingrained. Alongside this, certain chemical conditions in the
body system, correlated with PTSD with Psychotic Features, begin to change and are
alleviated.
So the question, is depression or PTSD with Psychotic Features, biologically
based or psychologically based? It appears that it is both. The bio-neuro-genetic
basis may be one particular thing. The alterations of the person treated are another.
There “need be no clash between construction and reality” (Hacking, 1999, p.29),
research programs in bio-neuro-genetics AND psychology are valid. The same goes
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for the “indifferent” and “interactive” arguments. One is the directly observable: the
behaviors, or objects, current status of the entity, what is observed at present. The
other is the construction: how it is conceptualized, understood, thought about at a
particular time, in a particular matrix of social elements, and perhaps the best name
or term used to describe it at the present moment.
There are problems with constructs, with classification, with the moving
target of psychopathology. What follows is a section on the social construction of
mental disorders, from the lens of obscure and different points in history.
The Social Construction of Mental Disorders
In order to put current thinking into context, this section addresses different
ways phenomena considered mental disorders were conceptualized at different
historical times. For example, at other times in history, an essential part of aesthetic
theory was that “poetic and artistic creations were not the result of conscious and
deliberate thought acting according to an artist’s will. Rather, they were the outward
expression of forces within him over which he had no control” (Guthrie, 1961, p.3).
The perception of some force taking over one’s mind or actions is psychotic by
current clinical measures. While artists are given more license to interpret their
experience than the general public, eccentricity can walk to the edge of mental
disorders. Likewise, voice hearing and other forms of what we now call psychosis,
have been interpreted in very different ways in different places and times. The
ancient Greeks would visit Asclepieion dream sanctuaries, Oracles or Sybyls who
heard and repeated the “voices of the divine” that told them what the patient
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“lacked” (Meier, 1989, p. 128). These messages were then interpreted as sacred
missives for the individual. Today, hearing voices holds no such revered place in
contemporary society. One who reports to others that he or she is hearing voices and
is a messenger of the otherworldly is thought to be delusional. I have heard it said
that the difference between a mystic and a lunatic today is just a matter of who one
tells!
Does the medicalization and problematization cause or contribute to the
suffering of individuals who have such experiences? Does it guide the expression of
their symptoms? This study pointed to significantly poorer functioning, and more
hospitalization and suicide attempts in this population. If their experiences weren’t
interpreted as bad, traumatic, out of the range of “normal” experience, would they be
so troubled? What if they were told it was a blessing? What would it be like if they
didn’t know the rules? Today, groups, such as the “Hearing Voices Network”
(Blackman, 2001) try to use the experiences of voice hearers themselves to challenge
the validity and helpfulness of current psycho-medical conceptualizations and
interpretations of such experiences.
Other groups, other times, other places, have thought of what we now call
psychosis in very different ways. The next section explores the crystallization of
neurosis as a valid area for psychologists and psychiatrists to treat.
The Invention of Neurosis
This section exposes some of the more current ways mental disorders were
initially conceptualized, constructed and instituted. In the psychological and
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psychiatric disciplines the “problem of hallucination” has become a key test of
insanity in the adjudication of the distinction between neurotic and the psychotic
reaction type” (Blackman, 2001, pl51). Does the patient know the voices or images
aren’t real? This is another differentiation, insight or lack thereof, that has been
hotly debated in defining psychosis in PTSD (David & Mellman, 1999; Pies, 1999).
For the “normal population,” fever might produce simple anomalous phenomena
while delusional systems were thought to underlie more complex hallucinations.
During Freud’s time, neurotic “manifestations of the normal mind and its devious
workings” (Blackman, 2001, p. 155), were thought to become psychoses if left
untreated. Thus, neurosis and management of the deviations of the general
population, became part of the province of psychological and psychiatric disciplines.
The treatment of neuroses can be thought of as part of the inculcation of the
idea of “healthism,” that one can, and should, monitor aspects of the self for moral
reasons, and because that is the individual’s responsibility in civilized society
(Blackman, 2001). This is what Michel Foucault called “disciplinary power”. That
certain “truths” are put forward in the world to govern individuals. Here,
disciplinary power is not necessarily that of restraining others. It is rather the idea
that people become more governable when they are consistently “monitored,
assessed and compared with others in relation to norms of behavior and conduct”
(Blackman, 2001, p.212) and subsequently believe, for themselves, that it is
desirable to fit the norm. Thus diagnostic labels can be thought of as pathologizing
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those that might formerly be ungovernable, and central to the management of
humans.
Such labels can “transform people’s relationships to their own bodies and
sense of selfhood” (Blackman, 2001, p.211). The idea of embodiment, or of the
lived body, has been used get out of the conundrum of between ideas of essentialism
and constructionism. Here, essentialism is defined as “a set of beliefs that there are
essential building blocks of human nature, which can be classified, compared and
calibrated” (p.210). Constructionism is the concept that puts forward that “there is
nothing stable or pre-discursive which can act as a basis or recognition of
humanness” (p.210), that the “docile body” is always waiting to be written on by
culture. In Lacanian psychoanalysis, there is the idea that language is all there is,
that there is no subject, merely the language of the caretakers (with particular rules)
available to the growing child that both kills experience and shapes its recollection.
The idea of embodiment is that bodily processes, even psychological processes,
cannot be separated from the times, beliefs and “truths” of the matrix in which one
lives. The very strategies and theories that people use to understand their experience,
in turn, shape those experiences themselves. In the end, the body and the social
environment are inseparable.
Norms of society have become the markers for how humans should be, and
psychologists and psychiatrists have taken this as a valid area for their treatment.
Here and in other disciplines there are possible biases to the production of valid
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causes for action. The next section examines these problems and errors associated
with the diagnoses and study of social problems such as PTSD.
Types of Errors in the Study of Social Problems
Errors are present in any endeavor of humans. This section reviews the
differing rules of knowledge claims for communities that evaluate trauma. Using
Wilbur Scott’s (1993) “The Politics of Readjustment” as a guide, I examine
problems associated with the rules of evaluating traumatic disorders, via the
sciences, medicine, and the law. Additionally, I consider other potential errors and
unanswered questions that are present in the study of social problems.
In the arena of science, knowledge claims are purposefully made
conservatively. “By focusing on the null hypothesis, scientific research favors type
II errors (failure to reject a false null hypothesis) over type I errors (rejection of a
true null hypothesis)” (Scott, 1993, p.255). In other words, it is better to accept that
nothing significant is here, rather than to say something is significant, in error.
In the medical field, clinicians are generally taught that it is better to err on
the side of caution and diagnose a well person as possibly ill, than to fail to diagnose
and not treat a sick person, in error. Two factors mediate this. So as not be
considered a quack, the clinician’s work must be based in current medical and
scientific evidence based knowledge, thus providing conservatism. On the other
hand, working under the aegis of an organization where there may be responsibility
to provide care, like a Health Maintenance Organization, or a Veteran’s
Administration (VA) hospital, the directive to “suspect harm until doubt is removed”
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(Scott, 1993, p. 256) can be reversed. An organization’s ability to afford to treat
those it diagnoses, conies into play. The history of Agent Orange showed that while
the VA hospitals have a general policy that veterans should be given the benefit of
the doubt in cases of uncertainty, the VA adopted the scientific criteria for treating
and compensating claimants. It took a lawsuit by the National Veterans Law Center
and Vietnam Veterans of America to force the VAs to use their “benefit of the
doubt” clause.
In law, there is yet a third set of rules. In criminal courts, one is innocent
until proven guilty. Civil suits, however, are based on a preponderance of the
evidence, and can be tipped either in terms of erring toward compensating a non
deserving claimant, or denying a deserving one, depending on how the evidence
falls. These varying biases highlight the controversies possible surrounding PTSD.
In examining type I and type II error, I also keep in mind the concept coined
by Howard Raiffa and developed by Ian Mitroff s proposal that there is also a type
III error (Mitroff, 1998), which is solving the wrong problem precisely. This occurs
when the problem definition does not model correctly, or in its entirety, the
boundaries of the actual real life problem. Errors of this sort are thought to be the
most common errors in policy making. I wonder, have I phrased my questions
correctly? What am I overlooking? What happens when I give my time and
attention to this problem and not others? Can I expand the boundaries of this
problem to include all the various stakeholders? Am I managing the paradoxes
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inherent in any solution, have I thought systemically? These questions have guided
me and will continue to do so.
The Researcher’s Biases and Evolution of Thinking
As I review the multitude of ideas I have encountered and tried to absorb in
this dissertation, I implement them practically in this way. As a counseling
psychologist working in America, I must know the current rules for practice in
hospitals, schools and organizations. I must know the ethics of my chosen
profession, the existing work on diagnoses at present, and the best treatment
guidelines. These are expectations of those that might seek my help, and I could do
harm by ignoring the consensual rules of engagement. Still I must recognize, while
practicing by those rules, that there could be alternate ways of knowing,
experiencing and attending to a patient’s experience. As well, that by the very virtue
of calling them a patient, I shape their experience.
As I keep different communities’ bases for knowledge claims in mind, I
cannot help thinking that I may be solving the wrong problem precisely, trying to
determine a particular diagnostic category, deciding if its real or constructed, and
when and what treatment should be undertaken. I like thinking about James
Hillman’s ideas (1993) that we should look at the symptoms of our patients as
possibly mirroring social ills and trying to say something about the world. I reflect
on my time working with Carol Gilligan’s research group, the Psychology of
Women, Boys, and the Culture of Manhood. We examined the outbreak of Hysteria
in women at the turn of the century, comparing it to the outbreak of Attention Deficit
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121
Hyperactivity Disorder (ADHD) in boys today. We proposed that Hysteria was
saying something about the restrictive roles of women at that time. Similarly, we
proposed that ADHD was saying something about what our society is doing to our
boys, sedating and medicating their fidgetiness, and that it may reveal their
discomfort and confusion about the changing role of men. What is PTSD with
Psychotic Features, its symptoms and outcomes, saying about the world? What is
problematic about facing the world in full consciousness for these patients, what
makes re-experiencing and dissociating the particular symptoms? Could the
symptoms also be a political act, saying “I will not forget,” “I cannot accept this
present, this reality”? Is being psychotic and traumatized a way of being that is the
best option for these patients?
I tend, by nature or training, to avoid the “Fundamental Attribution Error.” I
more often attribute someone’s symptoms or behavior to what it may say about their
circumstances, rather than about their character or biology, although I’ve learned that
these all interact. Clinically, I abide by the conception that if a patient comes in and
is troubled, I believe that they are troubled, even if I do not necessarily believe the
veracity of their interpretation of their circumstances. If they speak of a trauma, I
tend to take their distress seriously and try to understand their construction of it as
true, to them. By this I mean “true” as in whether it happened in reality or in
metaphor. With this foundation, their distress can be addressed, and their patterns of
thinking, relating and behaving out in the world can be explored and enhanced.
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I have very particular ideas about the nature of trauma. I disagree with the
incredulity of some who disbelieve that someone could be re-traumatized by jokes at
the water cooler. If a woman has been sexually assaulted, the underlying current of
violence against women in sexist comments are confirmation that the sentiments that
allowed the assault to occur in the first place exist, and are in the culture, and could
erupt at anytime. This is not unlike the Holocaust survivors, or those who are
racially persecuted, who see and feel the hostile environment underlying reportedly
innocuous, anti-Semitic or racist jokes. It is the re-experiencing of horror and terror
that disrupts coherent attention and action, and is at the core of the construct we call
Post Traumatic Stress Disorder, and the clinical distress with which I am concerned.
Today, I believe that DSM diagnoses are one particular type of present day
knowledge. I am interested in observing and musing on how human beings work,
act, think, feel in their bodies, and ascribe meaning. I do not think I had nearly as
good an understanding of the depth of prior research, nor the controversy of PTSD,
when first I undertook this project, as I do now. I am more aware of the context in
which I study, the history of the thinking before me, the competing reasons for
different interpretations and arguments, and my own preferred way of looking at the
world. I will continue to wonder about experiences that fall between the cracks of
current descriptions, and question the definitional systems already in place.
I do not work in a Veteran’s Administration Hospital. I am not a biologist or
policy maker. I do not feel the need to treat only repressed memories. I suppose this
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is one of the benefits of doing a dissertation on something from which one is fairly
removed. Yet this topic has touched my life.
My exposure to patients, and others, whom I conceptualize as having PTSD
with Psychotic Features, was among the most fascinating and distressing experiences
of my life and clinical training. The memories of these people stay with me, and yet,
I still wonder about how best to help them. This dissertation did not settle that
mystery. So, I have new questions to ask, as well as different treatment and
conceptual possibilities to examine.
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Asset Metadata

Creator Kaye, Leslie Ann (author)

Core Title An investigation of a new diagnostic sub-type: Post traumatic stress disorder with psychotic features

School Graduate School

Degree Doctor of Philosophy

Degree Program Education (Counseling Psychology)

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,psychology, clinical

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Polkinghorne, Donald (committee chair), Goodyear, Rodney (committee member), Solomon, Barbara (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-639084

Unique identifier UC11340135

Identifier 3116724.pdf (filename),usctheses-c16-639084 (legacy record id)

Legacy Identifier 3116724.pdf

Dmrecord 639084

Document Type Dissertation

Rights Kaye, Leslie Ann

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA