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
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%.
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).
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.
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).
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.
Background
 Jackson et al’s (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 al’s (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).
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.
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)
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
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.
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.
Results
Hypothesis: Associations between previous trauma
and psychosis-related or hospital-related PTSD
Psychosisrelated PTSD
Total number of .19 (.186)
previous traumas
Hospital-related
PTSD
.23 (.108)
Results
Hypothesis: Associations between adult attachment
and psychosis-related or hospital-related PTSD
Attachment
anxiety
Attachment
avoidance
Psychosisrelated PTSD
.56** (.001)
Hospital-related
PTSD
.54** (.001)
.22 (.123)
.21 (.148)
Results
Hypothesis: Integrators will have lower levels of
attachment anxiety and avoidance, but more PTSD
symptoms
Attachment
Anxiety
Attachment
Avoidance
Psychosis-related
PTSD
Hospital-related
PTSD
Integrators
(n = 40)
.68 (.54)
Sealers
(n = 10)
.58 (.23)
1.25 (.45)
1.49 (.65)
21.30 (17)
17.80 (12.81)
15.20 (12.37)
19.60 (12.56)
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.
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).
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.
Future implications
 Adds to growing literature on the distressing
nature of psychosis and the iatrogenic effects of
treatment.
 Highlights the need to routinely assess people’s
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).
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).
Contact
Katherine.berry@manchester.ac.uk