Weili Lu

A Randomized Controlled Trial of Cognitive-Behavioral Treatment for Posttraumatic Stress Disorder in Severe Mental Illness

A cognitive-behavioral therapy (CBT) program for posttraumatic stress disorder (PTSD) was developed to address its high prevalence in persons with severe mental illness receiving treatment at community mental health centers. CBT was compared with treatment as usual (TAU) in a randomized controlled trial with 108 clients with PTSD and either major mood disorder (85%) or schizophrenia or schizoaffective disorder (15%), of whom 25% also had borderline personality disorder. Eighty-one percent of clients assigned to CBT participated in the program. Intent-to-treat analyses showed that CBT clients improved significantly more than did clients in TAU at blinded posttreatment and 3- and 6-month follow-up assessments in PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance. The effects of CBT on PTSD were strongest in clients with severe PTSD. Homework completion in CBT predicted greater reductions in symptoms. Changes in trauma-related beliefs in CBT mediated improvements in PTSD. The findings suggest that clients with severe mental illness and PTSD can benefit from CBT, despite severe symptoms, suicidal thinking, psychosis, and vulnerability to hospitalizations.

Correlates of Adverse Childhood Experiences Among Adults With Severe Mood Disorders

OBJECTIVES Adverse childhood experiences have been found to be associated with poor physical and poor mental health, impaired functioning, and increased substance abuse in the general adult population. The purpose of this study was to examine the clinical correlates of these experiences among adults with severe mood disorders. METHODS Adverse childhood experiences (including physical abuse, sexual abuse, parental mental illness, loss of parent, parental separation or divorce, witnessing domestic violence, and placement in foster or kinship care) were assessed retrospectively in a sample of 254 adults with major mood disorders. The relationships between cumulative exposure to these experiences and psychiatric problems, health, substance use disorders, community functioning, trauma exposure in adulthood, and high-risk behaviors were examined. RESULTS Increased exposure to childhood adverse experiences was related to high-risk behaviors, diagnosis of a substance use disorder, exposure to trauma in adulthood, psychiatric problems (younger age at first hospitalization, number of suicide attempts, and diagnosis of posttraumatic stress disorder), medical service utilization, and homelessness. CONCLUSIONS The findings extend research in the general population by suggesting that adverse childhood experiences contribute to worse mental and physical health and functional outcomes among adults with severe mood disorders.

The trauma of psychosis: Posttraumatic stress disorder and recent onset psychosis

Clinical investigators have argued that the experience of a recent onset of psychosis is an event of such severity that it can lead to posttraumatic stress disorder (PTSD), or at least to PTSD symptoms. The traumagenic elements of the psychotic experience may relate to the distressing nature of psychotic symptoms, components of treatment, or both. However, this hypotheses has not been fully empirically evaluated. In particular, the importance of the DSM-IV A1 (perception of threat) and A2 (negative emotion at time of event) criteria for a traumatic event due to a psychotic episode has not been assessed. To address this question, 38 clients in treatment for recent onset of psychosis were interviewed to identify distressing experiences related to the episode, with PTSD assessed (including A1/A2 criteria) related to those events. More than one-half of the participants reported intense distress related to psychotic symptoms or treatment experiences, with 66% meeting symptom criteria for the PTSD syndrome (regardless of A1/A2), and 39% meeting full diagnostic criteria for PTSD (including A1/A2). Both participants with the PTSD syndrome and full PTSD reported more problems in daily functioning and more severe symptoms than those without PTSD. Participants with the PTSD syndrome were also more likely to have an integrative rather than sealing over coping style compared to those without the PTSD syndrome. The results suggest that individuals with PTSD symptoms related to a recent onset of psychosis may benefit from intervention designed to help them integrate their experience into their lives and address potentially stigmatizing beliefs that could contribute to distress and impaired functioning.

Self-efficacy and psychosocial functioning in schizophrenia: A mediational analysis

The construct of self-efficacy has been hypothesized to mediate the relationship between efforts at coping with psychiatric illness and functional outcome. This study examined whether self-efficacy mediated the relationships between psychosocial functioning and important predictors of functioning: premorbid functioning, negative symptoms, and cognitive functioning. Although self-efficacy was positively associated with psychosocial functioning, it did not mediate the relationships between functioning and the other established predictors. Rather, negative symptoms were the strongest predictor of functioning and mediated the relationship between self-efficacy and functioning. The findings suggest that negative symptoms, and not self-efficacy, are the most critical determinants of psychosocial functioning in schizophrenia, and that psychosocial treatment should focus on the amelioration of these symptoms.

Evaluation of cognitive restructuring for post-traumatic stress disorder in people with severe mental illness

BACKGROUND A cognitive-behavioural therapy (CBT) programme designed for post-traumatic stress disorder (PTSD) in people with severe mental illness, including breathing retraining, education and cognitive restructuring, was shown to be more effective than usual services. AIMS To evaluate the incremental benefit of adding cognitive restructuring to the breathing retraining and education components of the CBT programme (trial registration: clinicaltrials.gov identifier: NCT00494650). METHOD In all, 201 people with severe mental illness and PTSD were randomised to 12- to 16-session CBT or a 3-session brief treatment programme (breathing retraining and education). The primary outcome was PTSD symptom severity. Secondary outcomes were PTSD diagnosis, other symptoms, functioning and quality of life. RESULTS There was greater improvement in PTSD symptoms and functioning in the CBT group than in the brief treatment group, with both groups improving on other outcomes and effects maintained 1-year post-treatment. CONCLUSIONS Cognitive restructuring has a significant impact beyond breathing retraining and education in the CBT programme, reducing PTSD symptoms and improving functioning in people with severe mental illness.

Public Mental Health Clients with Severe Mental Illness and Probable Posttraumatic Stress Disorder: Trauma Exposure and Correlates of Symptom Severity

Individuals with severe mental illness (SMI) are at greatly increased risk for trauma exposure and for the development of posttraumatic stress disorder (PTSD). This study reports findings from a large, comprehensive screening of trauma and PTSD symptoms among public mental health clients in a statewide community mental health system. In 851 individuals with SMI and probable PTSD, childhood sexual abuse was the most commonly endorsed index trauma, followed closely by the sudden death of a loved one. Participants had typically experienced an average of 7 types of traumatic events in their lifetime. The number of types of traumatic events experienced and Hispanic ethnicity were significantly associated with PTSD symptom severity. Clients reported experiencing PTSD in relation to events that occurred on average 20 years earlier, suggesting the clinical need to address trauma and loss throughout the lifespan, including their prolonged after-effects.

Cognitive-Behavioral Treatment of PTSD in Severe Mental Illness: Pilot Study Replication in an Ethnically Diverse Population

Posttraumatic stress disorder (PTSD) is a common comorbid condition in persons with severe mental illnesses (SMI) such as bipolar disorder, schizophrenia, and major depression. A parent study conducted in New Hampshire examined the effects of a 12- to 16-week cognitive-behavioral therapy (CBT) intervention for PTSD among people with SMI. We conducted a pilot study examining the effects of this intervention with an ethnically diverse sample of 14 clients with PTSD and SMI in an urban setting in New Jersey. Results showed high levels of retention in treatment and improvement at three and six months posttreatment in PTSD. We discuss the importance of this intervention in this population.

Post-traumatic reactions to psychosis in people with multiple psychotic episodes

Psychotic symptoms, coercive interventions, and other negative treatment experiences have been found to lead to posttraumatic stress disorder (PTSD) symptoms. However, prior research has not examined the importance of the DSM-IV A1 (perception of threat) and A2 (negative emotion at time of event) criteria for a traumatic event due to a psychotic episode. To address this question, 50 clients with a history of multiple episodes of psychosis were interviewed to identify distressing experiences related to past episodes, with PTSD assessed (including A1/A2 criteria) related to those events, and other psychiatric symptoms, psychosocial functioning, and coping style. Participants reported intense distress related to psychotic symptoms (66%), treatment experiences (25%), and their combination (8%), with 69% meeting symptom criteria for PTSD (excluding A1/A2 criteria), and 31% meeting full diagnostic criteria for PTSD (including A1/A2 criteria). Clients meeting symptom criteria for PTSD, as well as those meeting full diagnostic criteria for PTSD were similar, with both groups reporting more severe symptoms and distress, and more problems in daily functioning, than clients with fewer or no PTSD symptoms. The results are similar to a previous study of PTSD in persons with recent onset of psychosis (Mueser et al., 2010), and suggest that individuals with PTSD symptoms related to psychosis and coercive treatment may benefit from interventions designed to help them integrate their experiences into their lives and reduce PTSD symptoms, regardless of whether the triggering event(s) meet DSM-IV A1/A2 criteria for a traumatic event.

Ethnicity and Clinical Psychiatric Diagnosis in Childhood

This paper focuses on whether a consistent difference by ethnicity existed in the clinical diagnosis of children and adolescents in two behavioral health service environments and reviews plausible explanations for such a difference. Key measures were clinical diagnosis and ethnicity, abstracted from the administrative dataset of a New Jersey behavioral health care organization during 2000–2002, and a data collection conducted for the State of Indiana during 1991–1992. Sample sizes were 5,394 and 10,437, respectively. Only primary diagnoses were used in this study, classified into externalizing versus internalizing disorders. Logistic regression was performed for the dependent variable of presence/absence of an externalizing disorder or internalizing disorder. A main effect for ethnicity was found; African American youth received more externalizing diagnoses than did European American youth (odds ratio 2.01 (CI: 1.73–2.33) in one sample and 1.67 (CI: 1.44–1.94) in the other); African American youth also received fewer internalizing diagnoses than European American youth (odds ratio 0.55 (CI: .48–.63) in one sample and 0.75 (CI:.64–.88) in the other. Potential explanations for these findings include: 1. Biopsychosocial origin; 2. Clinician bias; 3. Discordant normative behavioral expectations between parents and service providers; and 4. Interaction between differential expression of underlying pathology and tolerance for such expressions.

A study of the impact of social support development on job acquisition and retention among people with psychiatric disabilities

The current study examined the relationship between specific techniques for developing social support (i.e., Person Centered Planning) and job related outcomes among 110 individuals with psychiatric disabilities receiving Supported Employment (SE) services in a northeastern state. Seven SE programs participated. All individuals receiving SE services from any of the seven SE programs were eligible to enroll in the study. Participant data were collected on demographics, psychiatric history, work history, and social support over a period of two years. Data on the use of Person Center Planning practices were collected from SE staff every three months for the first 12 months of the study. This information was recorded in the Quality Indicators Survey, an instrument developed for this study. A positive relationship was found between total days employed and the number of non- paid supporters an individual reported having; a negative relationship existed between total days employed and number of paid supporters; and there was a positive correlation between total days employed and Person Centered Planning techniques used at nine and 12 months.