Recognizing Trauma and Posttraumatic Stress Disorder Symptoms in Individuals With Psychotic Disorders

When an individual with a psychotic disorder seeks counseling, there are a number of complicating factors for both the counselor and client to address. As evidenced by the diagnosis, these individuals often have histories of very distressing symptoms, including hallucinations and delusions, functional problems in work or school, disorganized thought and behavior, and other frightening and confusing experiences (American Psychiatric Association [APA], 2000). Psychotic disorders include schizophrenia, bipolar and major depressive disorders in cases with psychotic symptoms, schizoaffective disorder, brief reactive and unspecified psychosis, and schizophreniform disorder (Lu et al., 2011). Given the significance of the features of these disorders, counselors may tend to focus on prominently displayed psychiatric symptoms and inadvertently fail to identify a client's trauma history and the often unrecognized symptoms of posttraumatic stress disorder (PTSD; Davidson & Smith, 1990; Mueser et al., 1998). Examining the relationship between traumatic events and psychosis is vital to understanding the lack of recognition of PTSD symptoms in individuals with psychotic disorders. The first step in this process is developing an awareness of the significant overlap between traumatic events and psychotic disorders. In research with those who had recently experienced their first episode of psychosis, participants reported considerable rates of exposure to sexual and physical assault (Mueser, Lu, Rosenberg, & Wolfe, 2010). Specifically, 29% were victims of sexual assault and 45% were victims of physical assault by someone related to them (Mueser et al., 2010). Equally concerning, 21% of those in the study had suffered sexual assault and 26% suffered physical assault by someone of no relation (Mueser et al., 2010). Furthermore, there is evidence that the majority of those with psychotic disorders were victims of childhood abuse. More than half (53%) of those in a study of patients hospitalized for the first time with psychosis or bipolar disorder were victims of childhood sexual and/or physical abuse (Greenfield, Strakowski, Tohen, Batson, & Kolbrener, 1994). These exposure rates show that even for those having experienced only a single episode of psychosis, there is reason to consider the possibility of a trauma history. For those who have experienced multiple psychotic episodes, the rates of exposure to trauma are magnified. In a follow-up study to the one conducted by Mueser et al. (2010), 40% of patients with a mean of 10 hospitalizations and 11 psychotic episodes were sexually assaulted and 60% were physically assaulted by a family member. Thirty-four percent were sexually assaulted and 52% were physically assaulted by someone they did not know (Lu et al., 2011). Despite this connection between both recent onset psychosis and long-term psychotic histories and trauma, there is evidence that this relationship is not well recognized by clinicians (Cusack, Grubaugh, Knapp, & Frueh, 2006). One way to evaluate the degree to which clinicians recognize trauma history is via chart review. In one such chart review with community mental health clients with at least one prior psychiatric hospitalization, 28% of clients had a charted trauma history. However, when the clients' trauma histories were independently assessed by the researchers, an actual exposure rate to trauma of 87.2% was discovered (Cusack et al., 2006). This indicates a sizable difference between the trauma identified by providers and the actual life experiences of this population. This lack of identification of trauma during treatment can prove dehumanizing to clients who may not know how to introduce these painful experiences into counseling or be familiar with the connections that exist between psychosis and earlier traumatic experiences (Boevink, 2006). This prior trauma should not be the only concern for providers. Another major component of trauma in relation to psychosis is the traumatic effect of psychotic experiences themselves. …