Expert answers from
Post traumatic stress disorder (PTSD) and psychosis
- What is post traumatic stress disorder?
- Post traumatic stress disorder and psychosis
- Developing psychosis after trauma
- Diagnosis and treatment
- Similar symptoms and misdiagnosis
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 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.
Not everybody who experiences trauma goes on to develop PTSD. Researchers think some 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.
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, 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 with 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, 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 with 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 most likely to lead to PTSD as both involve another human being inflicting deliberate harm and humiliation. PTSD is also more likely to develop if someone believes their life is threatened. Research has further demonstrated that the more traumatic events a person experiences, the more likely they are to have PTSD.
People who have experienced the symptoms of psychosis are much more likely to have post traumatic stress disorder than people who have no experience of psychosis. Studies have shown that up to half the people who participated in the research had PTSD in addition to a diagnosis of schizophrenia or bipolar disorder.
Researchers believe that trauma may play a part in the development of psychosis: there have been a large number of studies looking at the relationship between physical, sexual and emotional abuse and neglect in childhood with the development of a mental illness like schizophrenia in later life. They therefore think trauma may lead to the development of PTSD and/or psychosis.
However, they also 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.
Researchers think traumatic experiences might contribute to the development of psychosis (regardless of whether people also develop PTSD), and particularly if people experience many traumatic events over a long period of time, or at a young age.
Some studies have shown 70 to 90 per cent of people who have experienced the symptoms of psychosis have also experienced at least one traumatic event in their life. These childhood adversities include sexual and other kinds of abuse, bullying and being raised in institutional care. Many research projects have examined links between abuse and trauma in childhood and the later development of schizophrenia. Researchers think the more traumatic events a person experiences, the more likely they are to develop a serious mental illness, particularly if the events occurred in childhood.
Other studies of people who have experienced psychosis and abuse in childhood have shown that about half of them have hallucinations that relate to the trauma from their past.
Some researchers think that the vivid flashbacks experienced by people with PTSD can go on to develop into the hallucinations 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.
Mental health professionals and researchers are currently discussing whether there is a distinct type of psychosis that is trauma-induced in this way. Some have suggested that there should be a separate diagnosis of ‘post traumatic stress disorder with psychotic features' which would describe people who have PTSD and then go on to develop 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.
Experts in the field say everyone who experiences psychosis should also be assessed for PTSD to ensure it is detected and treated. One study found that 43 per cent of people qualified for a diagnosis of PTSD as well as a diagnosis of a mental illness like schizophrenia, but mental health professionals had spotted PTSD in only two per cent of them.
Some research suggests that helping people to understand that some of their hallucinations and delusions are memory-based might make them easier to cope with, and lessen the amount of distress these symptoms cause.
However, people who experience psychosis and have PTSD are likely to be treated for the symptoms of psychosis alone, and not offered treatment for post traumatic stress disorder. This is partly because mental health professionals may not diagnose the PTSD, but also because they are not sure about the best way to treat someone who has been given a diagnosis of a serious mental illness ike schizophrenia and has PTSD: there is little research evidence available about what treatment is most effective.
Cognitive behaviour therapy (CBT) developed specifically for PTSD is well-established and proven to be successful by research. The National Institute for Health and Care Excellence (NICE) recommends CBT for PTSD as well as another talking therapy shown to be effective – eye movement desensitisation and reprocessing (EMDR). Both these therapies require that someone focus on the most difficult and troubling aspects of the traumatic event/s they experienced.
There is some concern 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 for PTSD and psychosis, designed to take account of these concerns, but this work is still in its infancy.
If people are having CBT for psychosis (see Cognitive behaviour therapy page), their therapist might be able to offer CBT for PTSD as well. If you think your relative may have PTSD, he or she could ask their mental health team for a referral for treatment. However, psychosis specialists sometimes don’t think they have the experience to treat trauma, and trauma services may think they don’t have the expertise to treat someone who has experienced psychosis (although there is evidence that shows this situation is improving). In addition, there are not many specialist trauma services in the UK.
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 an appropriate treatment for PTSD.
However, if people are referred to early intervention services for psychosis (see Early intervention services page), mental health professionals should be looking for all possible reasons for the unusual experiences, and should ask about and consider trauma and PTSD as a potential cause.
Department of Health policy says that staff working in mental health services should routinely ask people if they have experience of abuse. It says staff should be trained to raise the issue, and to offer appropriate support and care if people choose to disclose past or current experiences to them. The policy was introduced to acknowledge and address links between violence, abuse and mental ill health. Mental health professionals should be asking about any traumatic events individuals are experiencing, or have experienced in the past, not just abuse.
This page was updated on 20 May 2012.
(NICE name change incorporated 19 April 2013)
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Links on this page last checked: 4 December 2013
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National Institute for Health and Care Excellence Guideline