Post-traumatic stress disorder (PTSD) and psychosis

Mental health care


  1. What is post-traumatic stress disorder?
  2. People who experience psychosis are more likely to have PTSD
  3. PTSD as a result of psychosis
  4. ‘Post-traumatic stress disorder with psychotic features’
  5. Similar symptoms and misdiagnosis
  6. Assessment and treatment

What is post-traumatic stress disorder?

When people have been the witness to, or victim of, a single traumatic event or multiple traumatic events, they can develop PTSD – Post Traumatic Stress Disorder. This traumatic event could be something like a natural disaster, a serious accident, violent crime like rape, torture, combat, a terrorist attack, childhood physical or sexual abuse and domestic violence. This is not an exhaustive list and any people including asylum seekers and refugees might have had the experience of a number of traumatic events spanning a period of time.

One of PTSD’s main symptoms is the trauma ‘re-experience’. People who have PTSD have flashbacks that are very vivid. They can see, smell, hear and feel all of the things that formed part of the original trauma. These memories are highly intrusive and can feel very real as if they are occurring again. For example, if someone felt like they were about to die during the trauma, their flashback memory will make them feel this way again. Terrifying and vivid nightmares are also possible. Those with PTSD might cry out or thrash about in the sleep and might wake up disorientated.

PTSD sufferers might feel as if they are permanently damaged or constantly under threat. They might even blame themselves for the trauma or believe that they didn’t act how they should have at the time. They could even feel shame because they didn’t resist their attacker or might feel guilty because they didn’t stop the attack. Following their experiences, people often find it hard to keep up with their relationships and often become withdrawn from others.

Avoidance is another symptom. People with PTSD will often avoid thinking or talking about their experience and might also avoid activities, places and people that could remind them about what happened. Some become hyper-aware and are on a constant lookout for threats or danger and might be jumpier than usual. This can make it extremely challenging for people to claim compensation for PTSD in certain cases.

Research shows that rape and torture are the most likely of traumatic events to lead to PTSD since both of these involve deliberate humiliation and harm from another human being. Also, PTSD is more likely to come about if a person believes their life is in danger. Research has demonstrated that when a person has more and more traumatic events, they are more likely to develop PTSD.
It is believed that PTSD occurs when an event’s memories are stored differently from usual memories, which makes it impossible for the person to but the traumatic event behind them.

Not every person with traumatic exposure will go on to have PTSD and researches don’t know exactly why some people don’t get PTSD when others do. It is thought that PTSD is more likely to develop when mental health problems already run in a family or if the person has had depression or anxiety in the past. It is also likely that having the support of friends and family means PTSD is less likely to develop.

People who experience psychosis are more likely to have PTSD

There has been research that has examined how trauma and abuse during childhood can have an influence on a person’s chances of developing a serious mental illness such as schizophrenia. Research has also shown how traumatic events in childhood increases a person’s risk of getting psychosis symptoms later.

Research studies have indicated that between half to 98% of people with experience of psychosis have had at least one traumatic happening in their life. This includes emotional, physical and sexual abuse.

People who have experienced psychosis are much more likely, therefore, to have PTSD than those who have never experienced it. A study showed the 43% of those with a mental illness like schizophrenia also met the criteria for a PTSD diagnosis.

PTSD as a result of psychosis

Some experts believe that the experience of psychosis itself can lead people to develop PTSD. The delusions and hallucinations of psychosis can be traumatic and terrifying. They can lead people to feel helpless, horrified and intensely frightened. Those who have persecutory delusions i.e. they believe that someone (or everyone) is trying to harm them in one way or another, might really believe that their life is in danger.

Some experts also suggest that that being admitted to a psychiatric hospital, in particular, if the admission is compulsory or involves sedation or seclusion, might be an experience that could lead to PTSD.

‘Post-traumatic stress disorder with psychotic features’

Some researchers and health professionals believe that some of those with PTSD can also develop psychosis symptoms but they don’t meet the criteria for schizophrenia or other serious mental illness being diagnosed.

It is said that a person’s vivid flashbacks when they have PTSD can turn into the hallucinations that are linked to psychosis.

People might develop beliefs that are delusional and they may begin to be paranoid, in particular, if the person has been attacked or tortured since they are reliving the event constantly as a result of PTSD and intrusive memories. Since their flashbacks are so difficult to explain, so threatening and so realistic, people try to find a meaning behind them. They might then begin believing that someone who is dead is really talking to them or that they are being followed when they’re not, for example.

Some researchers and mental health specialists believe that psychosis induced by trauma is distinct. Some have even suggested a different diagnosis of ‘PTSD with psychotic features’ to describe these people with PTSD and psychosis symptoms together.

The people pushing for this new diagnosis say that it could lead to the development and testing of new treatments that will meet this group of people’s needs specifically and address their trauma.

Similar symptoms and misdiagnosis

The symptoms of PTSD and the symptoms of psychosis are alike.

Hallucinations are the same or similar to the vivid flashbacks people experience with PTSD. The ‘re-experiencing’ symptoms and the intense fear that comes with PTSD can be just like the delusions experienced by someone with psychosis.

Both psychosis and PTSD can mean disturbed sleep, personal neglect, difficulty concentrating and social withdrawal. The paranoia that comes with psychosis oftentimes can mirror the experience of hyper-vigilance of those with PTSD.

If someone is smelling, seeing or hearing things that other people cannot, the could be re-experiencing their trauma rather than experiencing psychosis. Mental health specialists and GPs, however, could attribute these occurrences to psychosis instead of considering whether the person has PTSD.

Experts believe that people can be misdiagnosed sometimes, in particular, if mental health specialists and GPs don’t ask them about any possible traumatic events in their past.

When there is a misdiagnosis, it can lead to the wrong treatment. People might be given anti-psychotic drugs, which is not the recommended treatment for Post Traumatic Stress Disorder by NICE (the National Institute for Health and Care Excellence).

Assessment and treatment

Guidance from NICe published in 2014, states that every person who has psychosis symptoms needs to be assessed to see if they have PTSD. Experts at NICE say that it is important to assess people who have their first experience of psychosis.

People with PTSD need to be offered treatment that is recommended by NICE for this condition as well as being offered treatment for their psychosis symptoms.

NICE has issued two recommendations for PTSD talking therapies. These include CBT (cognitive behavioural therapy) that has been specifically developed for PTSD and EMDR (Eye Movement Desensitization and Reprocessing). Both of these talking therapies will require the person to focus on the most troubling and difficult parts of their traumatic experiences.

There has been some concern raised about the use of CBT for the treatment of PTSD because part of this means the person has to relive the trauma, which could be detrimental to them and could exacerbate their psychosis symptoms. There isn’t any evidence that supports this view, however.

Studies are starting to trail new treatment for PTSD with psychosis that is based on CBT. This is still in its very early stages, though.