Linking Posttraumatic Stress Disorder and Psychosis: A Look at Epidemiology, Phenomenology, and Treatment
Seedat S, Stein MB, Oosthuizen PP, Emsley RA and Stein DJ;
Commented by , 29 Oct 2003
Aim of the study
To review the evidence for potential links between posttraumatic stress disorder (PTSD) and psychosis.
A comprehensive MEDLINE search on epidemiological, clinical, and treatment aspects of comorbid PTSD and psychosis. The data are organized under four headings: 1) trauma, psychosis, and PTSD; 2) psychosis within PTSD; 3) PTSD within psychosis; 4) PTSD as a response to psychosis.
1) Trauma is associated not only with elevated rates of PTSD and general psychopathology, but also with high levels of psychotic features.
2) Veterans with combat-related PTSD often have comorbid psychotic features. This association may be influenced by cultural and racial factors.
3) The prevalence of PTSD is much higher in the severely mentally ill than in the general population, in particular in patients with psychotic major depression, and, although to a lesser degree, in patients with schizophrenia. 4) Psychosis or hospitalisation (especially when associated with seclusion and sedation) may precipitate the occurrence of PTSD.
Empirical data on patients with comorbid PTSD and psychotic features or psychotic disorders are sparse. Assessment is difficult owing to the severity and complexity of the psychopathology and the simultaneous or consecutive presence of signs and symptoms of the two disorders.
PTSD symptoms such as flashbacks and intrusive recollections or emotional numbing and avoidance may be difficult to differentiate from positive (hallucinations and delusions) as well as from negative (social withdrawal and avolition) symptoms of schizoprenia. Assessment may be complicated by issues of compensation seeking and malingering.
Although psychotic features such as delusions and hallucinations are mainly trauma-specific in PTSD, several investigators have reported delusions and hallucinations in PTSD that involved themes not related to the initial trauma. Finally, investigations trying to link the severity of PTSD with the occurrence of psychotic symptoms have led to contradictory results.
The occurrence of psychotic features in chronic PTSD is best documented in combat populations, with prevalence rates reaching 20 to 40%. Prevalence rates of PTSD in other populations are less well documented. In particular, highly different prevalence rates have been reported for PTSD in schizophrenia and other psychotic disorders. Additional research efforts are also needed to establish a more solid evidence base about the prevalence of PTSD as a response to psychosis and/or hospitalisation for psychotic disorder.
In spite of these limitations, this is an important review on a controversial topic. The review itself as well as the articles that are referenced will interest both clinicians and researchers who deal with PTSD and/or with psychotic disorders, and who try to better understand or research the association between the two types of disorders.
Although further studies are certainly needed to document the prevalence of the association between PTSD and psychotic disorder and to establish the nature of the association, clinicians as well as researchers would be well advised to pay closer attention to psychotic symptoms in patients with PTSD and look more closely for symptoms of PTSD in patients with schizophrenia or other psychotic disorders.