Abstract
Despite high rates of trauma in individuals with psychotic symptoms, post-traumatic stress symptoms are frequently overlooked in clinical practice. There is also reluctance to treat post-traumatic symptoms in case the therapeutic procedure of reprocessing the trauma exacerbates psychotic symptoms. Recent evidence demonstrates that it is safe to use reprocessing strategies in this population. However, most published studies have been based on treating post-traumatic symptoms in isolation from psychotic symptoms. The aims of the current case series were to assess the acceptability, feasibility, and preliminary effectiveness of integrating cognitive-behavioural approaches for post-traumatic stress and psychotic symptoms into a single protocol. Nine participants reporting distressing psychotic and post-traumatic symptoms were recruited from a specialist psychological therapies service for psychosis. Clients were assessed at five time points (baseline, pre, mid, end of therapy, and at 6+ months of follow-up) by an independent assessor on measures of current symptoms of psychosis, post-traumatic stress, emotional problems, and well-being. Therapy was formulation based and individualised, depending on presenting symptoms and trauma type. It consisted of five broad, flexible phases, and included imaginal reprocessing strategies (reliving and/or rescripting). The intervention was well received, with positive post-therapy feedback and satisfaction ratings. Unusually for this population, no-one dropped out of therapy. Post therapy, all but one (88% of participants) achieved a reliable improvement compared to pre-therapy on at least one outcome measure: post-traumatic symptoms (63%), voices (25%), delusions (50%), depression (50%), anxiety (36%), and well-being (40%). Follow-up assessments were completed by 78% (n = 7) of whom 86% (n = 6) maintained at least one reliable improvement. Rates of improvements following therapy (average of 44% across measures post therapy; 32% at follow-up) were over twice those found during the waiting list period (19%). No participant indicated a reliable worsening of any symptoms during or after therapy. The study shows that an integrative therapy incorporating reprocessing strategies was an acceptable and feasible intervention for this small sample, with promising effectiveness. A randomised controlled trial is warranted to test the efficacy of the intervention for this population.
Highlights
There are very high rates of trauma in individuals presenting with psychotic symptoms
This case-series study demonstrated that it is safe, feasible, and acceptable to integrate current cognitive-behavioural approaches for post-traumatic stress and psychotic symptoms into a single protocol, in individuals with current distressing symptoms of psychosis and post-traumatic stress presenting to a psychological therapies service
This study has important implications for the psychological treatment of post-traumatic stress symptoms in people presenting with psychotic symptoms
Summary
There are very high rates of trauma in individuals presenting with psychotic symptoms. If the trauma-memory-related intrusion is, for example, of the abuser, in combination with high levels of arousal, this may be experienced as an auditory hallucination of the voice of the abuser in individuals with an information processing style prone to weakened contextual integration (10). Maladaptive schema about self and others are closely related to the concept of metacognitive capacity (13), i.e., an integrated representation of the self and others, which is suggested to be a foundation for resilience (14) Both individuals with psychosis and with PTSD show poor metacognitive mastery, which is further associated with greater distress and hyperarousal in PTSD patients (15), suggesting that a limited understanding of mental states, especially others’ emotions (16), may be another possible shared mechanism between psychotic and post-traumatic stress symptoms
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