CLINICAL HANDBOOK OF SCHIZOPHRENIA

CHAPTER 43TRAUMA AND POSTTRAUMATICSTRESS SYNDROMESSTANLEY D. ROSENBERGKIM T. MUESERNATURE OF THE SPECIAL POPULATIONIn the wake of 9/11 and Hurricane Katrina, mental health providers and the general publichave become increasingly aware of the emotional and psychiatric consequences of exposureto traumatic events—consequences that can persist for many years after thetrauma. It is important that providers who work with clients with schizophrenia also beaware of the presentation of posttraumatic stress syndromes and their treatment. Whatwe have discovered in recent years is that trauma exposure is close to universal in clientswith schizophrenia and other severe mental illnesses, and multiple traumatization overthe lifespan is the rule rather than the exception in this population. For example, studiesof the prevalence of interpersonal trauma in women with severe mental illness indicate especiallyhigh exposure to violent victimization (a particularly toxic form of trauma), withrates ranging as high as 77–97% for episodically homeless women.Approximately one-third of all clients with schizophrenia spectrum disorders enrolledin treatment services also meet diagnostic criteria for current posttraumatic stressdisorder (PTSD), making it perhaps the most common psychiatric comorbidity in thisgroup. Moreover, trauma exposure and PTSD in clients with schizophrenia spectrum diagnosesare associated with more severe symptoms, substance abuse, higher service utilization(including medical and psychiatric hospitalizations), increased medical problems,overall distress, and increased high-risk behaviors.Why do we see so much trauma and trauma-related impairment in clients withschizophrenia and other severe mental illnesses? Several models have been put forth toaccount for these relationships. First, because there is abundant evidence that stress canprecipitate psychotic episodes, negative life events have long been thought to act as stressorsthat contribute to an underlying vulnerability to psychotic symptoms. Second, schizophreniaand severe mental illness generally may increase the likelihood of trauma exposurethrough associated correlates such as homelessness and substance abuse. Third, a447