CLINICAL HANDBOOK OF SCHIZOPHRENIA

454 VI. SPECIAL POPULATIONS AND PROBLEMSally abused in childhood might, for example, allude to this experience as being assaultedby the devil, expressing both confusion about the event and the common desire of childrento protect the actual perpetrator, who might even be a primary caretaker. Whateverthe sources of diagnostic ambiguity, including lack of provider awareness of traumarelateddisorders and lack of standardized screening for clients, multiple studies have nowreported that only about 5% of clients with severe mental illness and PTSD have the latterdiagnosis even listed in their charts, and almost none currently receive trauma-specifictreatment.ASSESSMENT OF TRAUMA AND PTSDProviders should be aware that there are simple, straightforward techniques for assessingtrauma history and PTSD in clients with schizophrenia and other severe mental illnesses.Several studies, and much recent clinical experience, have now shown that clients respondreliably and coherently to straightforward questions about trauma exposure (both earlyand more recent), and can be assessed for PTSD symptoms with brief symptom inventories.These tests have been used successfully in paper-and-pencil format, as interviews,and in computerized formats. They generally take about 10 minutes to complete. Despiteearlier concerns, these assessments rarely lead to increased distress (even in acutely ill clients),and are often appreciated by clients as indicators of provider concern about the issuesthat really trouble them, yet have not been a focus of traditional mental health care.One note of caution is worthy of mention: Providers who ask clients to participate inthese assessments, or who conduct them, may be uncomfortable themselves with some ofthe topics covered (e.g., childhood sexual abuse or recent sexual assault experiences).When this is the case, the providers may need some information and supervision on howto conduct these assessments in a neutral, matter-of-fact, supportive way to ensure clientcomfort and accurate, open reporting.We have discussed how clients with both schizophrenia and PTSD may differ fromclients with schizophrenia alone. It is also important to observe that clients with both disorderstend to present with many of the same issues as people with so-called “complexPTSD,” as described by Herman (1992) and others. Complex PTSD has been observed inpeople exposed to early or extreme stress, to neglect or abuse, and to multiple trauma experiences.In addition to the core symptoms of PTSD, which may be expressed in very intenseform, complex PTSD involves dissociation, relationship difficulties, somatization,revictimization, affect dysregulation, and disruptions in sense of self. Experts have arguedthat people with complex PTSD are often diagnosed as having borderline personality disorder,and this sometimes appears as a secondary diagnosis in clients with schizophreniawho have extremely adverse life histories.CURRENT TREATMENT APPROACHESAt this point in time, no published studies exist of treatment for clients with bothschizophrenia and posttraumatic stress syndromes. To our knowledge, none of the drugtrials for PTSD have included clients with schizophrenia or other psychotic disorders,so we do not discuss pharmacological treatments in this chapter. Instead, we describeseveral psychotherapeutic treatment models designed for the broader category of peoplewith severe mental illness. The list is not comprehensive, but it is representative ofwhat is being developed, assessed, and implemented in the field. Developmental work