Trauma in relation to psychosis and hospital experiences in secure settings

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Trauma in relation to psychosis and hospital
experiences in secure settings

• Katherine Berry, Sarah Ford,
• Lorna-Jellicoe Jones and Gillian Haddock
• University of Manchester
• Lancashire Care NHS Foundation Trust

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Background

• Well-established that psychosis and
  hospitalisation can be distressing (e.g.
  Centofanti et al., 2005 Robins et al., 2005).
• These experiences conceptualised as events that
  could trigger PTSD (Mueser et al., 2010).
• PTSD in psychosis associated with a range of
  worse outcomes (e.g. Mueser et al., 2002).
• Rates of psychosis- or hospital-related PTSD
  range from 11-67.

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Background

• Past 30 years has seen the closure of long-stay
  institutions, but significant numbers still
  reside for long periods in secure settings
  (Schizophrenia Commission, 2012).
• This population have high levels of symptoms and
  risk (Berry Drake, 2010). Therefore possibly
  high rates of psychosis- or hospital-related
  PTSD.
• Secure populations also typically have histories
  of interpersonal trauma and attachment
  difficulties (Berry Drake, 2010).

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Background

• Well-established that past trauma can increase
  vulnerability to PTSD following subsequent trauma
  (e.g. Brewin et al., 2000).
• Some evidence for the role of past trauma in
  psychosis-related and hospital-related PTSD (e.g.
  Centofanti et al., 2005).
• Other moderating or mediating factors are equally
  important in the development of PTSD in the
  general literature (Brewin et al., 2000).
• But these have been less well researched in the
  context of psychosis-related and hospital-related
  PTSD.

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Background

• Earlier experiences of trauma are associated with
  insecure attachment styles in adulthood (e.g.
  Berry et al., 2009).
• Evidence of associations between insecure
  attachment and PTSD in people with psychosis and
  substance misuse (Picken et al., 2010), but no
  research looking specifically at psychosis- or
  hospital-related PTSD.
• Recovery from psychosis has been associated with
  attachment style (e.g. Tait et al., 2004).

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Background

• Internal secure base which enables integration
  and processing of experiences of psychosis
  (Birchwood, 2003).
• McGlashan et al (1976)
• Integration flexible thinking style which
  incorporates psychosis into everyday experience.
• Sealing over psychosis appraised as
  threatening and therefore recall avoided.

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Background

• Jackson et als (2004) first episode study found
  sealers were more likely to avoid intrusions. No
  relationship between recovery style and PTSD
  caseness, but only 9 sealers.
• Mueser et als (2010) first episode study found
  those with PTSD syndrome had a more integrative
  coping style than those who did not.
• Although sealing over may be adaptive in the
  short-term, it is associated with worse outcomes
  longer term (McGlashan, 1987).

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Aims and hypotheses

• To investigate rates of psychosis-related and
  PTSD-related psychosis in long-stay secure
  settings.
• To investigate potential moderators or mediators
  of PTSD symptoms. We predicted
• Positive correlations between trauma history and
  PTSD.
• Positive correlations between insecure attachment
  and PTSD.
• More secure attachments and more PTSD symptoms in
  those with an integrative recovery style compared
  to those with a sealing over recovery style.

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Method

• Measures
• PANSS (Kay et al., 1987)
• Impact of Event Scale-Revised (Weiss Marmar,
  1997)
• Trauma History Questionnaire (Green, 1996)
• Psychiatric Experiences Questionnaire (Cusack et
  al., 2005)
• Psychosis Attachment Measure (Berry et al., 2008)
• Recovery Style Questionnaire (Drayton et al.,
  1998)

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• Adult attachment dimensions
• High levels of attachment anxiety
• negative self-image
• an overly demanding interpersonal style
• fear of rejection
• tendency to exaggerate or be overwhelmed by
  negative affect
• High levels of attachment avoidance
• negative image of others
• interpersonal hostility
• social withdrawal
• defensive minimisation of affect and importance
  of social
• relationships

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Method

• Participants and procedure
• 50 patients recruited from low-secure and
  medium-secure sites in the North West.
• Diagnoses of schizophrenia or related disorders,
  18 years and inpatients for at least one month.
• Assessment measures completed as part of a
  structured interview.

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Results

• 24 met criteria for psychosis-related PTSD.
• 18 met criteria for hospital-related PTSD.
• 30 met criteria for psychosis-related or
  hospital related PTSD.

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Results

• Hypothesis Associations between previous trauma
  and psychosis-related or hospital-related PTSD

Psychosis-related PTSD Hospital-related PTSD
Total number of previous traumas .19 (.186) .23 (.108)
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Results

• Hypothesis Associations between adult attachment
  and psychosis-related or hospital-related PTSD

Psychosis-related PTSD Hospital-related PTSD
Attachment anxiety .56 (.001) .54 (.001)
Attachment avoidance .22 (.123) .21 (.148)
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Results

• Hypothesis Integrators will have lower levels of
  attachment anxiety and avoidance, but more PTSD
  symptoms

Integrators (n 40) Sealers (n 10)
Attachment Anxiety .68 (.54) .58 (.23)
Attachment Avoidance 1.25 (.45) 1.49 (.65)
Psychosis-related PTSD 21.30 (17) 17.80 (12.81)
Hospital-related PTSD 15.20 (12.37) 19.60 (12.56)
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Summary and discussion

• The 30 rate of PTSD are lower than expected.
• Participants may have habituated to symptoms and
  hospital experiences over time or actively
  developed ways of coping.
• No significant associations between previous
  trauma and psychosis-related or hospital-related
  PTSD.
• Mixed evidence of associations in the literature,
  with studies with smaller samples or less
  sensitive measures not finding effects (e.g.
  Beattie et al., 2009 Tarrier et al., 2007).
• PTSD literature suggests other factors may also
  be important.

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Summary and discussion

• Attachment anxiety characterised by negative
  self-image and a tendency to be overwhelmed be
  overwhelmed by affect may be vulnerability factor
  for PTSD.
• However, evidence to suggest that the defensive
  coping style associated with avoidant attachment
  can also breakdown under extreme distress
  (Mikulincer et al., 1993).
• No significant differences between integrators
  and sealers in terms of attachment or PTSD, but
  consistent with previous research we found
  relatively few sealers (e.g. Jackson et al.,
  2004).

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Selection of caveats

• Rates of PTSD or trauma over or underestimated
  due to sample selection or reporting biases.
• Reduced power due to small numbers, particularly
  a problem in analyses involving recovery style.
• Cross-sectional design, so cannot ascertain the
  direction of relationships or rule out third
  variables.

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Future implications

• Adds to growing literature on the distressing
  nature of psychosis and the iatrogenic effects of
  treatment.
• Highlights the need to routinely assess peoples
  reactions to their experiences and screen for
  PTSD.
• Some evidence that PTSD in the context of
  psychosis can be treated with CBT (Mueser
  Rosenberg, 2008).

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Future implications

• CBT should be routinely offered to those who want
  to engage and therapists should recognise the
  traumatic nature of psychosis.
• Although there have been reforms in mental health
  care, these findings highlight a need to do more.
• Findings of associations between attachment and
  PTSD, highlight the importance of considering
  attachment patterns in treatment, particularly
  given evidence that insecure attachments can have
  an adverse effect on therapy (e.g. Mallinckrodt
  et al., 2010).

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Contact

• Katherine.berry_at_manchester.ac.uk