Expert answers from
Post traumatic stress disorder (PTSD) and psychosis
- What is post traumatic stress disorder?
- People who experience psychosis are more likely to have PTSD
- PTSD as a result of psychosis
- 'Post traumatic stress disorder with psychotic features'
- Similar symptoms and misdiagnosis
- Assessment and treatment
People can develop post traumatic stress disorder (PTSD) when they have been the victim of, or witness to, a traumatic event or a series of traumatic events. A traumatic event could be a serious accident, a natural disaster, a rape or other violent crime, combat, torture, a terrorist attack, physical or sexual abuse in childhood, domestic violence. This list is not exhaustive, and some people, including refugees and asylum seekers, may have experienced many different traumatic events over a period of time.
One of the main symptoms of PTSD is re-experiencing the trauma. People get vivid ‘flashbacks’ that can include seeing, smelling, hearing and feeling things that were part of the trauma. These intrusive memories feel real and as if they are happening now: if someone felt they were going to die at the time, they feel as if they are going to die every time they have a flashback memory. People can also experience vivid and terrifying nightmares in which they re-experience the trauma. They often thrash around in their sleep or cry out, and wake up feeling disorientated.
People who have PTSD may feel constantly threatened and permanently damaged. They may blame themselves for what happened, or think they didn’t do the right thing at the time, or feel shame because they didn’t resist an attack, or guilt because they didn’t stop what happened. They may find it hard to sustain relationships and withdraw from other people.
Another symptom is ‘avoidance.’ People who have PTSD often avoid talking or thinking about the trauma they have experienced, and may also avoid people, places or activities that might remind them of the event.
Some people become hyper-vigilant, constantly looking out for danger or threats, and may be more jumpy than usual.
Research has shown that torture and rape are the traumatic events that are most likely to lead to PTSD: both involve another human being inflicting deliberate harm and humiliation. PTSD is also more likely to develop if someone believes his or her life is threatened. Research has further demonstrated that the more traumatic events a person experiences, the more likely they are to have PTSD.
Researchers think people develop PTSD when the memory of the event is stored in a different way from most memories, making it impossible for them to put the trauma behind them.
Not everybody who experiences trauma goes on to develop PTSD: researchers don't fully understand why some people develop PTSD and others don't. They think people may be more likely to develop PTSD if mental health problems run in the family, or if they themselves have experienced anxiety or depression in the past. They also think people who have the support of family and friends are less likely to develop PTSD.
Many research projects have examined links between abuse and trauma in childhood and the development of a serious mental illness like schizophrenia. Researchers have shown that experiencing traumatic events in childhood substantially increases the risk of developing the symptoms of psychosis later in life.
The results of research studies indicate that between 50 and 98 per cent of people who have experienced the symptoms of psychosis have also experienced at least one traumatic event in their life, including physical, sexual and emotional abuse.
People who experience psychosis are therefore much more likely to develop PTSD than people who have no experience of psychosis. One study showed that 43 per cent of people who had a diagnosis of a mental illness like schizophrenia also qualified for a diagnosis of PTSD.
Researchers think some people may develop PTSD as a result of experiencing psychosis. The hallucinations and delusions that are symptoms of psychosis can be terrifying, and lead people to feel intensely frightened, horrified and helpless. People who experience distressing persecutory delusions – when they believe others are trying to harm them in some way – may believe their life is threatened.
Some researchers have also suggested that admission to a psychiatric hospital, particularly if it is a compulsory admission or involves seclusion or sedation, may, for some people, be a traumatic experience that could contribute to the development of PTSD.
Some health professionals and researchers think that some people who have PTSD can develop symptoms of psychosis but do not meet the diagnostic criteria for a mental illness such as schizophrenia.
They say the vivid flashbacks experienced by people with PTSD can go on to develop into the type of hallucinations that are associated with psychosis.
People may develop delusional beliefs and begin to experience paranoia, particularly if they have been tortured or attacked, because they are constantly reliving the event as a result of the intrusive memories of PTSD. Because the flashbacks are so realistic, so threatening and difficult to explain, people search for a meaning to understand what they are. They may come to believe that someone really is talking to them from the dead, or that they are really being followed, for example.
Some health professionals and researchers think there is a distinct type of psychosis that is trauma-induced in this way. Some have suggested there should be a separate diagnosis of ‘post traumatic stress disorder with psychotic features' to describe people who have PTSD who experience some of the symptoms of psychosis.
Those in favour of a new diagnosis say it would mean new treatments could be developed and tested to specifically meet the needs of this group of people and address the trauma they have experienced.
The symptoms of psychosis and the symptoms of PTSD are alike.
The vivid flashbacks of PTSD can be similar to, or the same as, hallucinations. The intense fear and 're-experiencing' symptoms of PTSD can be akin to delusions that people who have psychosis experience.
Both PTSD and psychosis can lead to disturbed sleep patterns, difficulty concentrating, personal neglect and withdrawal from other people. The paranoia (see Paranoia page) often associated with psychosis can mirror the hyper-vigilance that people with PTSD may experience.
If someone is hearing voices or other sounds, or seeing and smelling things that others cannot see or smell, they may be re-experiencing a trauma rather than experiencing the symptoms of psychosis. However, GPs and mental health professionals may attribute the voices and other symptoms to psychosis rather than consider PTSD as a possible explanation.
Researchers think people may sometimes be misdiagnosed, particularly if GPs and mental health professionals don’t ask about traumatic events an individual may have experienced in the past.
Misdiagnosis can lead to mistreatment: people may be prescribed antipsychotic medication, which is not the National Institute for Health and Care Excellence-recommended treatment for PTSD.
Guidance from the National Institute for Health and Care Excellence (NICE) published in 2014* says everyone who experiences the symptoms of psychosis should also be assessed for PTSD. The group of experts responsible for developing the guideline about the treatment of psychosis and schizophrenia* says it is particularly important to assess people who are experiencing psychosis for the first time.
People who have PTSD should be offered NICE-recommended treatment for PTSD as well as NICE-recommended treatment for the symptoms of psychosis.
NICE recommends two talking therapies for PTSD: cognitive behaviour therapy (CBT) developed specifically for PTSD and eye movement desensitization and reprocessing (EMDR). Both these therapies require that someone focus on the most difficult and troubling aspects of the traumatic event/s they experienced.
Some concern has been expressed about using CBT for PTSD for people who have experienced psychosis on the grounds that part of the therapy is ‘reliving the trauma’ and this may be detrimental and exacerbate the symptoms of psychosis. There is, however, no research evidence to support this view.
Research studies are beginning to trial new CBT-based treatment specifically designed for PTSD and psychosis, but this work is still in its infancy.
*Psychosis and Schizophrenia in adults, NICE Guideline on Treatment and Management, updated edition 2014, uses the term 'psychosis' to describe the symptoms of psychosis experienced by people who have a diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder or delusional disorder. Recommendations for supporting people who are having psychotic-like experiences that are distressing are also included. The guidance does not include recommendations about treatment for people who experience psychosis as a symptom of bipolar disorder, psychotic depression, dementia or Parkinson's disease. These recommendations are contained in other NICE guidance.
This page was updated on 4 September 2014
Links on this page last checked: 4 September 2014
Next links check due: December 2014
National Institute for Health and Care Excellence (NICE): guidance about the treatment of PTSD
National Institute for Health and Care Excellence (NICE): guidance about the treatment of psychosis and schizophrenia in adults