CLINICAL HANDBOOK OF SCHIZOPHRENIA

448 VI. SPECIAL POPULATIONS AND PROBLEMSpreexisting psychiatric disorder may increase vulnerability to the emergence or chronicityof posttraumatic symptoms following exposure. Research to date supports the likely contributionof these, and other possible mechanisms, linking trauma exposure, schizophrenia,and PTSD.Several other contributory factors have also been hypothesized. For example, psychosisand associated treatment experiences (e.g., involuntary commitment) may themselvesrepresent DSM-IV-TR Criterion A traumas. The potential symptom overlap betweenschizophrenia and PTSD (e.g., flashbacks being misinterpreted as hallucinations;extreme avoidance and anhedonia interpreted as negative symptoms), may conflate theapparent rates of PTSD in those diagnostic groups. Alternatively, PTSD associated withpsychotic symptoms may be misdiagnosed as a primary psychotic disorder.Clients and advocacy groups often point to posttraumatic symptoms as among themost troubling of these individuals’ life problems, and many U.S. states have prioritizedthe development of “trauma-sensitive services” as a key reform to mental health and substanceabuse service systems. Major elements of trauma-sensitive services include (1) increasedawareness by providers about trauma history and sequelae among clients; (2)better understanding of special requirements of survivors; and (3) knowledge of traumaspecificinterventions for persons requiring such services. We discuss these three topics inthis chapter, and provide tools and useful references to increase mental health providers’knowledge and competence in regard to trauma-related issues. Posttraumatic stress disordersare among the most treatable of psychiatric syndromes, and it is important to recognizeand treat PTSD symptoms in clients with schizophrenia.DEFINITIONSPsychological trauma refers to the experience of an uncontrollable event perceived tothreaten a person’s sense of integrity or survival. A traumatic event is defined by DSM-IV-TR as an event involving direct threat of death, severe bodily harm, or psychological injury,which the person at the time finds intensely distressing (i.e., the person experiencesintense fear, helplessness, or horror). Common traumatic experiences include sexual andphysical assault, combat exposure, and the unexpected death of a loved one. Negativepsychiatric and health outcomes are associated with the total number of exposures totraumatic events and with their intensity. Sexual assault and other forms of interpersonalviolence in which the victim suffers actual physical harm, along with childhood sexualabuse, represent the forms of trauma most likely to lead to persistent psychiatric disorders,including PTSD. PTSD is defined by three types of symptoms: (1) reexperiencing thetrauma; (2) avoidance of trauma-related stimuli; and (3) overarousal. These symptomsmust be related to the index trauma and persist, or develop at least 1 month after exposureto that trauma. Examples of reexperiencing include intrusive, unwanted memories ofthe event, nightmares, flashbacks, and distress when exposed to reminders of the traumaticevent (e.g., being in the vicinity of the traumatic event, meeting someone with similaritiesto the perpetrator). Avoidance symptoms include efforts to avoid thoughts, feelings,or activities related to the trauma; inability to recall important aspects of thetraumatic event; diminished interest in significant activities; detachment; restricted affect;and a foreshortened sense of one’s own future. Overarousal symptoms include hypervigilance,exaggerated startle response, difficulty falling or staying asleep, difficulty concentrating,and irritability or angry outbursts. DSM-IV-TR criteria require that a personmust have at least one intrusive, three avoidant, and two arousal symptoms to be diagnosedwith PTSD.