psychosis case study quizlet

Mental Health and Psychiatric Nursing NCLEX Practice Questions Nursing Test Bank (700+ Questions)

Welcome to your ultimate NCLEX practice questions and nursing test bank for mental health and psychiatric nursing. For this nursing test bank, test your knowledge on the concepts of mental health and psychiatric disorders. This quiz aims to help students and registered nurses grasp and master mental health and psychiatric nursing concepts.

Mental Health and Psychiatric Nursing Test Banks

In this section, you’ll find the NCLEX practice questions and quizzes for mental health and psychiatric nursing. This nursing test bank set includes 700+ practice questions divided into comprehensive quizzes for mental health and psychiatric nursing and a special set of questions for common psychiatric disorders. Use these nursing test banks to augment or as an alternative to ATI and Quizlet.

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Recommended Resources

Recommended books and resources for your NCLEX success:

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Saunders Comprehensive Review for the NCLEX-RN Saunders Comprehensive Review for the NCLEX-RN Examination is often referred to as the best nursing exam review book ever. More than 5,700 practice questions are available in the text. Detailed test-taking strategies are provided for each question, with hints for analyzing and uncovering the correct answer option.

Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items Next Generation NCLEX®-style practice questions of all types are illustrated through stand-alone case studies and unfolding case studies. NCSBN Clinical Judgment Measurement Model (NCJMM) is included throughout with case scenarios that integrate the six clinical judgment cognitive skills.

Saunders Q & A Review for the NCLEX-RN® Examination This edition contains over 6,000 practice questions with each question containing a test-taking strategy and justifications for correct and incorrect answers to enhance review. Questions are organized according to the most recent NCLEX-RN test blueprint Client Needs and Integrated Processes. Questions are written at higher cognitive levels (applying, analyzing, synthesizing, evaluating, and creating) than those on the test itself.

NCLEX-RN Prep Plus by Kaplan The NCLEX-RN Prep Plus from Kaplan employs expert critical thinking techniques and targeted sample questions. This edition identifies seven types of NGN questions and explains in detail how to approach and answer each type. In addition, it provides 10 critical thinking pathways for analyzing exam questions.

Illustrated Study Guide for the NCLEX-RN® Exam The 10th edition of the Illustrated Study Guide for the NCLEX-RN Exam, 10th Edition. This study guide gives you a robust, visual, less-intimidating way to remember key facts. 2,500 review questions are now included on the Evolve companion website. 25 additional illustrations and mnemonics make the book more appealing than ever.

NCLEX RN Examination Prep Flashcards (2023 Edition) NCLEX RN Exam Review FlashCards Study Guide with Practice Test Questions [Full-Color Cards] from Test Prep Books. These flashcards are ready for use, allowing you to begin studying immediately. Each flash card is color-coded for easy subject identification.

Recommended Links

An investment in knowledge pays the best interest. Keep up the pace and continue learning with these practice quizzes:

• Nursing Test Bank: Free Practice Questions UPDATED ! Our most comprehenisve and updated nursing test bank that includes over 3,500 practice questions covering a wide range of nursing topics that are absolutely free!
• NCLEX Questions Nursing Test Bank and Review UPDATED! Over 1,000+ comprehensive NCLEX practice questions covering different nursing topics. We’ve made a significant effort to provide you with the most challenging questions along with insightful rationales for each question to reinforce learning.

37 thoughts on “Mental Health and Psychiatric Nursing NCLEX Practice Questions Nursing Test Bank (700+ Questions)”

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I am in doubt of 43rd question of anxiety disorder question asking the side effect of Ritalin- the correct answer here is increased attention span and concentration. This is actually the therapeutic effect of this medication. As far as I know, the main side effect is sleeplessness. therefore, this medication should be given before noon to avoid sleeping problems. please check and let me know too thank you

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You can print these questions or the webpage by clicking on the Quiz Summary > Finish Quiz > View Questions > Then go to File > Print > Save as PDF.

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May I clarify the question in number 65, is it asking for the therapeutic effects or side effects of RITALIN? thank you!

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Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

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Understanding Psychosis

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What is psychosis?

Psychosis refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality. During an episode of psychosis, a person’s thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not.

Who develops psychosis?

It is difficult to know the number of people who experience psychosis. Studies estimate that between 15 and 100 people out of 100,000 develop psychosis each year.

Psychosis often begins in young adulthood when a person is in their late teens to mid-20s. However, people can experience a psychotic episode at younger and older ages and as a part of many disorders and illnesses. For instance, older adults with neurological disorders may be at higher risk for psychosis.

What are the signs and symptoms of psychosis?

People with psychosis typically experience delusions (false beliefs, for example, that people on television are sending them special messages or that others are trying to hurt them) and hallucinations (seeing or hearing things that others do not, such as hearing voices telling them to do something or criticizing them). Other symptoms can include incoherent or nonsense speech and behavior that is inappropriate for the situation.

However, a person will often show changes in their behavior before psychosis develops. Behavioral warning signs for psychosis include:

• Suspiciousness, paranoid ideas, or uneasiness with others
• Trouble thinking clearly and logically
• Withdrawing socially and spending a lot more time alone
• Unusual or overly intense ideas, strange feelings, or a lack of feelings
• Decline in self-care or personal hygiene
• Disruption of sleep, including difficulty falling asleep and reduced sleep time
• Difficulty telling reality from fantasy
• Confused speech or trouble communicating
• Sudden drop in grades or job performance

Alongside these symptoms, a person with psychosis may also experience more general changes in behavior that include:

• Emotional disruption
• Lack of motivation
• Difficulty functioning overall

In some cases, a person experiencing a psychotic episode may behave in confusing and unpredictable ways and may harm themselves or become threatening or violent toward others. The risk of violence and suicide decreases with treatment for psychosis, so it is important to seek help. If you find that you are experiencing these changes in behavior or notice them in a friend or family member and they begin to intensify or do not go away, reach out to a health care provider.

The National Institute of Mental Health (NIMH) has information on ways to get help and find a health care provider or access treatment . If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide and Crisis Lifeline   at 988 or chat at 988lifeline.org   . In life-threatening situations, call 911 .

What causes psychosis?

There is no one cause of psychosis. Psychosis appears to result from a complex combination of genetic risk, differences in brain development, and exposure to stressors or trauma. Psychosis may be a symptom of a mental illness, such as schizophrenia, bipolar disorder, or severe depression. However, a person can experience psychosis and never be diagnosed with schizophrenia or any other disorder.

For older adults, psychosis symptoms can be part of a physical or mental illness that emerges later in life. Psychosis can also be a symptom of some diseases of older age, including Parkinson's disease, Alzheimer’s disease, and related dementias.

Other possible causes of psychosis include sleep deprivation, certain prescription medications, and the misuse of alcohol or drugs. A mental illness, such as schizophrenia, is typically diagnosed by excluding these other causes.

A qualified mental health professional (such as a psychologist, psychiatrist, or social worker) can provide a thorough assessment and accurate diagnosis. Find tips to help prepare for and get the most out of your visit . For additional resources, including questions to ask your health care provider, visit the Agency for Healthcare Research and Quality  .

How is psychosis treated?

Studies have shown that it is common for a person to have psychotic symptoms for more than a year before receiving treatment. Reducing this duration of untreated psychosis is critical because early treatment often means better recovery. A qualified psychologist, psychiatrist, or social worker can make a diagnosis and help develop a treatment plan.

Treatment of psychosis usually includes antipsychotic medication. There are several different types of antipsychotic medications, and they have different side effects, so it is important to work with a health care provider to determine the medication that is most effective with the fewest side effects.

Treatment also often includes other elements. There is substantial research support for coordinated specialty care, which is a multi-element, recovery-oriented team approach to treating psychosis that promotes easy access to care and shared decision-making among specialists, the person experiencing psychosis, and family members. People experience better outcomes from coordinated specialty care if they begin treatment as soon as possible after psychotic symptoms emerge.

Coordinated specialty care is now the standard of care for early psychosis, according to “ The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia  .”

NIMH research on coordinated specialty care

The Recovery After an Initial Schizophrenia Episode (RAISE) research project, supported by NIMH, established coordinated specialty care as an effective treatment for early psychosis and identified important elements for helping people lead productive, independent lives. Learn more about the RAISE studies .

NIMH continues to prioritize research on and expansion of treatments for early psychosis with the launch of the Early Psychosis Intervention Network (EPINET) in 2019. Through EPINET, NIMH funded awards to establish a national data coordinating center and regional scientific hubs connected to more than 100 coordinated specialty care programs that provide early psychosis treatment in 17 states. The EPINET website   provides resources for researchers, health care providers, administrators, and people experiencing psychosis and their families.

Coordinated specialty care consists of multiple components:

• Individual or group psychotherapy is tailored to a person’s recovery goals. Cognitive and behavioral therapies focus on developing the knowledge and skills necessary to build resilience and cope with aspects of psychosis while maintaining and achieving personal goals.
• Family support and education programs teach family members about psychosis as well as coping, communication, and problem-solving skills. Family members who are informed and involved are more prepared to help loved ones through the recovery process.
• Medication management (also called pharmacotherapy) means tailoring medication to a person’s specific needs by selecting the appropriate type and dose of medication to help reduce psychosis symptoms. Like all medications, antipsychotic medications have risks and benefits. People should talk with a health care provider about side effects, medication costs, and dosage preferences (daily pill or monthly injection).
• Supported employment and education services focus on return to work or school, using the support of a coach to help people achieve their goals.
• Case management provides opportunities for people with psychosis to work with a case manager to address practical problems and improve access to needed support services.

Learn more about the components of coordinated specialty care .

People with psychosis should be involved in their treatment planning and consulted in making decisions about their care. Their needs and goals should drive the treatment programs, which will help them stay engaged throughout the recovery process.

It is important to find a mental health professional who is trained in psychosis treatment and who makes the person feel comfortable. With early diagnosis and appropriate treatment, it is possible to recover from psychosis. Some people who receive early treatment never have another psychotic episode. For other people, recovery means the ability to lead a fulfilling and productive life, even if psychotic symptoms sometimes return.

Clinical trials studying psychosis and related disorders

NIMH supports a wide range of research, including clinical trials that look at new ways to prevent, detect, or treat diseases and conditions, such as psychosis and disorders that involve psychosis (like schizophrenia). The goal of a clinical trial is to determine if a new test or treatment works and is safe. Although people may benefit from being part of a clinical trial, they should know that the primary purpose of a clinical trial is to gain new scientific knowledge so that others can be better helped in the future.

Researchers at NIMH and around the country conduct clinical trials with people experiencing psychosis and healthy volunteers. Talk to a health care provider about clinical trials, their benefits and risks, and whether one is right for you. Learn more about  participating in clinical trials .

How can I find help?

NIMH does not endorse specific psychosis clinics or evaluate individual practitioners’ professional qualifications or competencies. However, several organizations are available to assist in finding a treatment program in your area. The following is not a comprehensive list of all programs, and a program’s inclusion on the list does not constitute an endorsement by NIMH.

• Early Assessment and Support Alliance (EASA )   : EASA offers a National Early Psychosis Directory   that lists early psychosis programs across the United States.
• Early Psychosis Intervention Network (EPINET)   : EPINET’s Early Psychosis Intervention Network Clinics   provide treatment and services to individuals with early psychosis across 17 states.
• Calling 1-800-950-NAMI (6264)
• Texting “HelpLine” to 62640
• Emailing [email protected]
• Psychosis-Risk and Early Psychosis Program Network (PEPPNET)   : PEPPNET supports an Early Psychosis Program Directory   that provides services to people at risk for or experiencing early psychosis.
• Substance Abuse and Mental Health Services Administration (SAMHSA)   : SAMHSA has an Early Serious Mental Illness Treatment Locator  for finding mental health treatment facilities and programs.

The information in this publication is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

For more information

MedlinePlus   (National Library of Medicine) ( en español  ) ClinicalTrials.gov   ( en español  ) National Institutes of Health NIH Publication No. 23-MH-8110

• Open access
• Published: 24 March 2022

Trauma and psychosis: a qualitative study exploring the perspectives of people with psychosis on the influence of traumatic experiences on psychotic symptoms and quality of life

• Carolina Campodonico 1 ,
• Filippo Varese 2 , 3 &
• Katherine Berry 2 , 3  

BMC Psychiatry volume  22 , Article number:  213 ( 2022 ) Cite this article

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Despite experiencing high rates of trauma and trauma-related conditions, people with psychosis are seldomly asked about possible traumatic events. While there are some barriers to discussing trauma in clinical services, research has shown that disclosure is not only possible but also beneficial to both psychotic and traumatic symptoms. The current study is the first to evaluate service users’ perception of the influence of trauma on the development and maintenance of their psychotic symptoms, as well as their views on how their life and mental health have been affected by traumatic events and their disclosure (or lack of).

Eleven participants with experiences of psychosis and trauma took part in semi-structured interviews.

Consistently with previous literature, our participants reported high rates of interpersonal trauma, but had rarely had the opportunity to discuss any of these events. Using thematic analysis, we identified three major themes that have important implications for healthcare: factors that facilitate or hinder talking about trauma; consequences of talking or not; and relationship between trauma and psychosis. Participants generally benefited from talking about trauma and concerningly often associated the prolonged lack of opportunities to discuss traumatic events with negative feelings towards the self and with a deterioration of their mental health. Participants also recognised direct links between past traumas and the content and characteristics of their psychotic experiences.

Conclusions

Our findings highlight the importance, as perceived by service users, of discussing trauma and looking at psychosis through a “trauma lens”. These results stress the need to systematically assess trauma history and traumatic symptoms in psychosis and might potentially help to overcome clinicians’ worries about discussing trauma with service users. Our findings underscore the need to change current practice and implement trauma-informed approaches to understand clients’ difficulties and provide support.

Peer Review reports

Introduction

People with experiences of psychosis report high rates of trauma [ 1 ] and are often diagnosed with trauma-related conditions such as post-traumatic stress disorder (PTSD) [ 2 ]. Repeated childhood trauma, which is particularly prevalent in people with psychosis [ 3 ], has frequently been associated with the new diagnosis of complex PTSD (CPTSD) [ 4 ], although research on psychosis and CPTSD is still in its early stages. Research has shown that exposure to adverse life events not only can result in these trauma-related conditions, but it can increase vulnerability to psychotic disorders and psychotic-like experiences [ 5 ], with a dose-response relationship where a greater number of exposures results in stronger risk for psychotic outcomes [ 6 ]. Aiming to clarify the relationship between trauma and psychosis, researchers have proposed different mechanisms that might explain this association.

The “affective pathway to psychosis” [ 7 ] suggests that mood-related symptoms such as emotional dysregulation, anxiety and depressive symptoms, might be determining factors for paranoid thinking. According to this hypothesis, anticipation of threat might result from anxiety, while precursors of psychotic symptoms, such as negative schemas about the self and self-esteem, can be negatively affected by depressive symptom [ 8 ]. These mood-related symptoms not only precede the psychotic onset, but can also negatively impact functioning [ 9 ] and precipitate relapse [ 10 ] in people experiencing psychosis and with a hystory of trauma. Recent evidence supports the idea that anxiety and moods might mediate the association between adversities and psychosis [ 11 ], while meta-analytic data found that, in people with psychosis, neglect and abuse positively associate with higher severity of depressive symptoms, further stressing the role played by mood symptoms in those with trauma [ 12 ].

Offering a different perspective, Morrison et al. [ 13 ] suggest that psychotic and traumatic symptoms are caused and maintained by similar psychological mechanisms and fall on a continuum of trauma-related reactions. In support of this theory, research has shown that hallucinations can be considered a form of post-traumatic intrusion, where the content of psychotic symptoms relates to the traumatic experiences or to the feelings of humiliation, fear and guilt associated with them [ 14 , 15 ]. Hallucinations and other positive symptoms of psychosis have also been linked to dissociation [ 16 , 17 ], another trauma-related response, with researchers suggesting that several symptoms of psychosis are in fact a dissociative phenomenon [ 18 , 19 ]. Another type of psychotic symptoms that have been associated with traumatic reactions are delusional beliefs, as paranoia and PTSD following trauma have been found to share similar cognitive underpinnings [ 20 ]. Some authors have recently suggested that some people with psychosis might also experience a particular traumatic reaction described as “psychosis-related PTSD” (PR-PTSD), where the symptoms of PTSD are caused by events related to the diagnosis and treatment of psychosis (e.g. sectioning) or by the psychotic symptoms themselves [ 21 ]. However, despite increasing evidence about the existence of PR-PTSD [ 22 ], this is yet to be accepted as an official diagnostic sub-type.

The evidence of a relationship between trauma and psychosis has led to the inclusion of recommendations to assess PTSD in national clinical guidelines for the management of psychosis [ 23 , 24 ]. However, trauma-history and traumatic stress symptoms are often unrecognised [ 25 , 26 ] and inconsistently treated [ 27 ], possibly due to a lack of trauma screening within routine services or to a minimisation of trauma by the individuals themselves [ 2 ]. A systematic review found that most people who use mental health services are never asked about traumatic experiences such as childhood abuse and neglect, and that people diagnosed with psychotic disorders are asked even less than other service users [ 28 ]. Practitioners’ reluctance to enquire about trauma has been attributed to workload pressures and poor client engagement [ 29 ], and to concerns about offending or distressing the clients [ 30 , 31 ].

However, clinicians’ worries about investigating trauma are not the only barriers to trauma disclosure in psychosis. A descriptive study investigating victimization found that 11% of participants with experience of psychosis would not report any type of victimization to anyone, and that in 57% of the cases patients would not report any victimization even when the psychiatrists thought that their patients had been victimised [ 32 ]. These findings follow those of Jansen et al.’s [ 25 ], who conducted a qualitative study to examine service users' experience of childhood trauma in the early phase of psychosis. The results showed that many traumatic experiences that participants previously reported in questionnaires, were not discussed when interviewed about their life story. The authors suggest that participants did not recognise the traumas in their personal narratives because such events had been dissociated or were not seen as something that should be discussed with others. Not being able to recognise and discuss traumatic stress in people with psychosis is a cause of great concern, as traumatic life events and their consequences can lead to more severe clinical profiles, worse overall functioning, and lower remission rates when compared to patients who did not experience such events [ 33 ]. Further negative consequences include drugs misuse [ 34 ], suicidal ideation [ 35 ] and the creation of barriers to people’s engagement in mental health services that would otherwise facilitate recovery [ 36 ].

Despite clinicians’ concerns and individuals’ reluctance to disclose trauma, different treatments are available that specifically target traumatic symptoms in people who experience psychosis, such as trauma-focused cognitive behavioural therapy for psychosis (TF-CBTp) [ 37 ], eye movement desensitization and reprocessing (EMDR) [ 38 ] and trauma exposure therapy [ 39 ]. Recently published systematic reviews suggest that these interventions for PTSD in psychosis not only are safe [ 40 , 41 ], but they effectively reduce negative beliefs associated with traumatic memories, intrusive images and thoughts, hypervigilance and avoidance [ 42 ]. Treating PTSD in psychosis not only addresses the traumatic symptoms, but can also improve self-esteem and decrease delusions, hallucinations, anxiety, and depression (van den Berg & van der Gaag, 2012). Consensus has been recently reached about 16 essential principles of trauma-informed care in psychosis, including training on trauma-informed care for all staff, the adoption of a person-centred approach and the creation of an empathetic and non-judgmental environment [ 43 ]. This consensus might facilitate the consistent delivery of these interventions [ 43 ].

In support of these findings, qualitative research shows that promoting discussion of traumatic events in people with psychosis, even when individuals are hesitant, is possible. A study conducted with participants with first-episode of psychosis (FEP) and PTSD found that, although people might initially experience difficulty acknowledging that a trauma has occurred, it is possible to enhance their willingness to talk about trauma by giving them enough time and control over how trauma memories are shared [ 44 ]. Another study investigating the perspectives of young people with PTSD and FEP found that 86% of the participants showed improvement in both their PTSD and psychotic symptoms after talking about trauma, and reported that all participants found disclosure to be beneficial and worthwhile [ 45 ]. These qualitative studies offered privileged access to service users’ experiences of trauma and disclosure, providing a unique depth of understanding which is difficult to gain from closed question surveys, and offering descriptive rather than predictive results [ 46 ]. These findings, although promising, need to be further supported by additional research looking at patients’ perspectives of trauma.

Considering the high prevalence of trauma research in FEP, investigating the experiences of service users who have been diagnosed for a longer time would offer a more complete understanding of patients’ perspective on the relationship between trauma and psychosis. Also, many qualitative studies in psychosis have so far focused on disclosure and recovery from psychotic symptoms, rather than specifically on traumatic symptoms or people’s beliefs around the role played by trauma in influencing the development and maintenance of psychosis. Although the debate about what kind of events can be classified as traumatic is still ongoing, a recent meta-analysis has found that events currently recognised as traumatic by diagnostic manuals (e.g., involving actual or threatened death, serious injury, or sexual violence) are associated with only slightly higher PTSD symptoms than non-traumatic stressors [ 47 , 48 ]. In the present study, we explore service users’ experiences of trauma (without limitation to what participants could describe as traumatic), and we discuss their perspectives on how trauma and disclosure have affected participants’ life and current mental health condition.

A qualitative approach was chosen to explore participants’ individual views, feelings and authentic experiences. Semi-structured interviews were used as they allow participants to freely disclose their thoughts without constraint and elaborate on their answers, and offer the researcher the opportunity to follow up on answers given by respondents in real-time, generating valuable conversation around a subject [ 46 ].

Participants

A sample of eleven participants was purposively recruited to complete semi-structured interviews as part of a larger quantitative research on post-traumatic reactions in people with psychosis. Participants were recruited if: 1) aged 16 or above; (2) able to provide informed consent; (3) experiencing psychosis as confirmed by relevant mental health professional; (4) experienced at least a difficult life event as defined by the Trauma and Life Events Checklist [TALE; 49]. Participants were excluded if: 1) experiencing dementia and/or other organic disorders; (2) had insufficient English to understand and complete the assessment; (3) had an intellectual disability which would impact the ability to complete the assessment. To create a group as heterogeneous as possible, the subsample of participants for this study was systematically recruited to differ in terms of: 1) age; 2) gender; 3) ethnicity; 4) levels of trauma symptoms as measured by the International Trauma Questionnaire [ITQ; 50]; 5) type of trauma anchored to the ITQ.

The Trauma And Life Events Checklist [TALE; 49] is a 22-item self-report measure specifically designed for routine trauma screening in psychosis services. It includes a list of common traumatic or stressful life events, as well as an item where participants can discuss traumas not covered previously. For each event that is endorsed, participants are asked if it occurred more than once and at what age(s). Three additional items ask participants which events are still affecting them and to what extent, using a scale from “not at all (0)” to “extremely (10)”. Currently, the TALE is the only trauma checklist including psychosis-specific potentially traumatic events (e.g. traumatic reactions to psychotic symptoms, hospitalisations or unusual behaviours), showing moderate psychometric acceptability overall, with excellent convergent validity and reliability for sexual abuse [ 49 ].

The International Trauma Questionnaire [ITQ; 50] is a self-report assessment tool that evaluates whether someone meets the criteria for ICD-11 PTSD and CPTSD. It includes 12 items, 6 measuring PTSD symptoms (re-experiencing, avoidance, and sense of current threat) and 6 measuring DSO symptoms (negative self-concept, affective dysregulation, and disturbances in relationship). Each item is scored on a 5-point Likert scale ranging from “Not at all” (0) to “Extremely” (4), with possible totals for the PTSD and DSO symptoms subscales varying from 0 to 24. Impairment caused by PTSD and DSO symptoms is investigated through three items each. The criteria for PTSD are met when each relevant symptom scores at least 2 (moderately), and when functional impairment is also observed (at least one of the three items scores ≥2). The criteria for possible CPTSD are met when in addition to PTSD, the participant also presents at least moderate scores across each DSO symptom, as well as functional impairment. The ITQ has good diagnostic and psychometric properties and has been shown to effectively capture the distinction between PTSD and CPTSD [ 50 ].

This research was carried out in accordance with the Declaration of Helsinki. Participants were invited from a pool of individuals with lived experience of psychosis, recruited as part of a larger study that had received NHS Research Ethics Committee and Health Research Authority approval (reference number: 18/NW/0469). After completing the previous study, participants were contacted via phone and offered the possibility to take part in this research. The researcher explained the study and agreed with them on a mutually convenient time and location (e.g., charity or Trust premises, private room at the University of Manchester, the participant’s home) to take informed written consent and complete the interview. The semi-structured interviews lasted between 50 to 90 minutes and were conducted using a topic guide ( Appendix A ). The questions were developed in collaboration with the research team. The topic guide was piloted with service users to ensure it was worded in a way that was easy to understand and not too distressing, and that the content was meaningful and relatable for people with lived experience of psychosis. Due to the iterative process of data collection and analysis, it became apparent during the research process that it was necessary to explore ideas not originally on the topic guide, like participants’ opinion on what causes unusual experiences such as hearing voices. Interviews were audio-recorded using a digital recording device and then transcribed verbatim and anonymised at the earliest opportunity. Transcription was carried out by psychology students on placement who had been provided appropriate training and were then double-checked by the first author. Interviews were conducted until data adequacy was reached [ 51 ].

The data were input in NVivo 12. The six steps of thematic analysis were systematically followed during data management, coding, and theme development, to allow the recognition of patterns across data as well as the production of findings easily accessible to different audiences [ 46 ]. After transcription, the researcher familiarised herself with the data by reading through the interviews and making notes about items of interest. At this stage, similar content was grouped into codes. The first author conducted line-by-line coding using a mixed deductive and inductive analytical process, allowing for theoretical assumptions to be interpreted from previous research and to be grounded from the data [ 52 ]. CC coded several portions of interviews under the supervision of the other members of the research team, who have extensive qualitative and clinical experience. Three interviews were double coded by the other two authors (FV and KB) to make sure that the codes identified were valid, and new lines of enquiry were considered to combine the insight of the author handling the data (CC) and the authors with extensive methodological and clinical experiences (FV and KB). Emerging codes and categories, as well as the interpretation of key texts and potential new lines of enquiry, were discussed between the authors. This process allowed a combined insight of the researcher handling the data closely and members of the team with wider methodological and clinical perspectives. Provisional themes were created by grouping similar codes and by discussing them within the research team [ 53 ]. The overarching themes “factors that facilitate or hinder talking about trauma”, “consequences of talking or not” and “relationship between trauma and psychosis” were driven by assumptions and abstract concepts underpinning the data, according to a latent interpretative approach [ 52 ]. Codes and themes were repetitively revised as new data was collected and coded. Up to the point when no new codes were identified and data adequacy was reached, which in our study meant that all codes relating to the study questions had appeared at least once in two different transcripts, recruitment, data collection, and analysis occurred concurrently [ 46 , 51 ].

Reflexivity statement

The first author (CC) is a white, middle-class, non-disabled female PhD student with an interest and background in working with trauma and people experiencing psychosis. CC believes that psychotic symptoms are strongly influenced by life experiences, especially by those events which have a traumatic nature. CC does not consider all psychotic manifestations as something intrinsically negative that need to be eradicated, but rather as meaningful attempts, conscious or not, to deal with a previous trauma. The other members of the research team (KB and FV) are also white, middle-class academics conducting research looking at the impact of trauma on psychosis, which might have influenced CC’s understanding of the relationship between these two conditions. Although this study has been designed to investigate participants’ point of view on the relationship between trauma and psychosis, CC was aware that some participants’ might not think that such a relationship exists and she made sure to choose participants in a way that made the sample as heterogeneous as possible, rather than choosing participants depending on their perspective around trauma and their current mental health.

During both the data collection and analysis, CC attempted to acknowledge her preconceptions and personal feelings through constant discussion with the other team members. As mentioned above, all the participants in this study had previously taken part in previous research so CC had the opportunity to develop a positive working relationship with them. These relationships have given CC privileged access to people’s stories, as they may have felt more confident in mentioning traumatic events or personal opinions that they had never spoken about before. As a result of their past experiences, some participants had strong negative feelings towards professionals. The existing relationship between CC and the participants, as well as the fact that CC has no experience as a clinician, made it difficult in the beginning to look at all the stories with impartiality. This was also affected by the fact that CC knows that trauma should be routinely assessed in clinical practice, but it is not. However, the other two authors have extensive clinical experience and offered their points of view during the analysis phase.

A critical realist [ 54 ] approach was used to analyse the data, which combines ontological realism and epistemological relativity. In other terms, we appreciate that the world has a concrete reality besides human constructions of it, but we also recognise that our understanding of the world is necessarily limited by our perspectives and standpoints within it. We acknowledge that our interpretations of what participants discussed are influenced by concepts that are socially constructed (e.g., schizophrenia and PTSD), and that complete objectivity is impossible.

The demographics of the participants are displayed in Table 1 . While Table 1 . presents the traumatic event to which the ITQ was anchored, it is important to note that all participants reported complex and repeated trauma histories. On the TALE, participants reported having experienced an average of thirteen different traumatic events. Most of these events were repeated experiences of interpersonal abuse both in childhood and adulthood, including bullying, discrimination, aggression, or insults by a close person, or feeling unsafe and unloved during childhood. More than half of the participants had experienced childhood sexual abuse and two participants reported having experienced sexual abuse as adults. Almost all participants reported feeling scared or threatened by psychosis-related symptoms or by contact with mental health services. As observed in Table 1 ., most of the sample had ITQ scores suggestive of a PTSD or CPTSD diagnosis.

After conducting thematic analysis, three major themes were identified: 1. Factors that facilitate or hinder talking about trauma; 2. Consequences of talking or not; and 3. Relationship between trauma and psychosis. The following themes describe participants’ experiences and their perspectives on what has facilitated or hindered trauma disclosure in the past and what could help to create the right environment in the future for discussing traumatic experiences. This is followed by a description of the most common consequences both in relation to talking and not talking about trauma, where disclosure normally resulted in positive outcomes and failure to discuss trauma led to isolation and the development of negative feelings towards the self. The last theme describes the relationship between trauma and psychosis as identified by the participants, in that participants recognised that not having the chance to share their traumatic stories aggravated their overall mental health and described how the content of their psychotic symptoms related to past traumas.

Factors that facilitate or hinder talking about trauma

Of the many factors that played a role in participants’ willingness to talk about trauma, having people in their life that were trusted and considered willing to listen, played the most important role in terms of disclosure. Participants who had the opportunity to discuss trauma usually confided in family and support groups or tried to approach a professional . Disclosure to family and support groups was facilitated by perceiving a safe environment and being around someone trustworthy or who had been through similar events. Discussing trauma was also facilitated by having a supportive professional, who participants described as a person who is kind, patient and interested, who asks questions without being perceived as judgemental. Sylvia describes which characteristics in a professional facilitate trauma disclosure:

“I think the good ones are kind. I think they take the time to understand what you are saying, and they don’t rush you and they just try and- personally I like when people ask me questions because I can go on- so I feel like when they ask you questions they are trying to understand, they are trying to make the effort. My new CPN is lovely, because she doesn’t make it feel like I am a burden.”

Most participants revealed that on many occasions they wished somebody had asked them about their difficult life events, as this was often the only push they needed to be able to share their stories and feeling less alone. However, when they felt ready to talk about trauma, they often did not have the opportunity to do so, or other people seemed distracted and not interested. Disclosure to family was often met by negative reactions including anger, disbelief and dismissal, while disclosure to support groups was sometimes regarded as disappointing or insufficient. Daniel describes his mother violent reaction to his attempt at disclosing a sexual abuse:

“I think I said to you, when I was trying to tell me mum about the sexual assault I said, I told her about the worst bit, and she came down and kicked the Jesus out of us.”

During hospital admissions, participants felt that they had no opportunity to disclose because of a range of negative views of professionals (perceived as too busy or as “ the enemy ”). Similarly, two participants reported not having the opportunity to talk when they were on probation following a prison sentence, as people around them already had a negative opinion of them and were not interested in listening. Sylvia describes how she felt when she got sectioned and realised that staff in the hospital was not interested in investigating deeper causes for her behaviour:

“it’s just weird cause you think you are getting into the hospital to be helped, but when you get there the only thing they are doing is just keeping you alive. They don’t talk to you about… they give you the medication and otherwise they sit in their office and do- whatever they do.”

Among those patients who did not experience rejection, the fear that people would not believe them or would not understand the trauma or the participants’ ways of coping with it, was enough to prevent them from discussing the event. At other times participants were simply not ready to talk about trauma as they had not processed it themselves, either because they were unable to recall the traumatic events or because they had spent too much time denying what happened. Another common hindering factor consisted in being too scared of possible consequences of talking about trauma. Participants often believed that bad things would happen if they spoke about the traumatic event (e.g., threat to them or family members), either because the voices (i.e. auditory verbal hallucinations) or the perpetrator of the abuse told them so. Vanessa explains she never spoke about trauma as she feared negative repercussions on her parents:

“He said if I ever told mum and dad, he’d make sure the police found out about their illegal poker game. They’d lose the house; they’d go to jail, and I’d end up in the orphanage. That is what he threatened. Well, when you’re nine years old you’d believe it.”

Consequences of talking or not

Participants identified many outcomes related to talking or not about trauma. Those who had the opportunity to discuss trauma reported experiencing positive consequences both for themselves and others. Many participants said that although talking about trauma is hard, when they were able to do so they felt as if a weight had been lifted off their chest. Similarly, some people remarked that discussing past experiences offers a chance of releasing negative emotions that would normally bottle up and become ‘negative energy’. Walter acknowledges the difficulties of discussing trauma, but appreciates the benefits that might come from it:

“I think it’s helpful... like, it’s not nice reliving past pain, but when you talk through it, when you can talk through it and work your way through it maybe, it’s better than just remembering stuff and going through it every time.”

Participants also found value in sharing their stories to help others feeling less lonely and desperate, and reported experiencing positive feelings when they thought they had been useful to someone else. In this respect, participants noted that knowing that someone else went through similar events, experienced similar feelings and survived, could be inspirational. For example, a participant said that the reason why they agreed to participate in this research, was that they hoped that their story would reach more people in similar situations. Luca explains his motivation for sharing his story:

“But see… me, when I do this in here, in me own tinpot way, it’s my way of tryna give something back to somebody else’s. If from what I say, somebody else can make sense of it, and they go, ‘oh my god, that’s the way I think, that’s what I’ve heard’. It might just be one life or two lives or whatever, but it’s not just me. Because I’ve been through it, you know, like I’ve lost my daughter, I’ve lost my – you know – lost my best friend.”

Some participants who had not yet had the chance to talk about trauma, said that they would welcome the possibility to do so as it could potentially help them changing perspective on what happened and fully understand the consequences trauma had on their lives. Participants reported that not having the opportunity to discuss trauma mostly impacted the way they made sense of it. Not having anyone to talk to influenced their understanding of the reasons behind their maltreatment, which meant that for a long time they felt like they were to blame. Self-blame and guilt added to the wide range of negative emotions that they were already experiencing in relationship to trauma. For example, not being able to discuss trauma also led to feelings of shame, as participants considered themselves weak for feeling scared, angry or lonely, especially if they thought that abuse was ‘normal’ or deserved and they had no reason to be feeling that way. It was proposed that this way of thinking about trauma and themselves might have eventually led to the inability to cope with the traumatic event. Vanessa describes how she felt when she was blaming herself for her mother’s death, and the relief she experienced when she could finally forgive herself:

“It was anger, more than anything. I blamed myself when my mother died, I didn’t know her heart had burst. I just thought she died of a heart attack. I blamed myself for not calling the doctor, I blamed myself for not staying up all night later. But when I found out five years later that her heart had burst and there was nothing I could have done, I finally forgave myself. If they only had been honest, I wouldn’t have gone through all that grief.”

Participants reported that not being able to discuss trauma had long-lasting consequences on their lives. They reported not feeling in control, because they often had to give up work and education, as trauma and its consequences affected their motivation and their ability to cope with daily tasks and be among other people. The idea of not having accomplished anything in life led to feelings of sadness and depression. Vanessa describes how the consequences of trauma made it impossible for her to hold on to a job:

“I couldn’t work, because I’ll tell you why- I never know when I wake up what mood I’m going to be in, or when I’m going to wake up. Yesterday I had twelve hours sleep, the day before I had fifteen hours sleep! How can you go to work when you are like that? And if somebody looked at me the wrong way when I was upset, I’d burst into tears, and I couldn’t cope.”

Interpersonal trauma was more frequently associated with avoidance of social contact, as participants considered their loneliness a result of their past life events. Not being able to discuss traumas resulted in being cautious around other people and keeping distance for fear of being hurt or losing someone they cared about, leading to increasing isolation. Participants said they suffered because of their social withdrawal, and even when they wanted to connect with others, they reported not knowing how to do it, as interpersonal traumas resulted in difficulty expressing and feeling emotions, and confusion around the meaning of love and affection. Mary explains that she realises that she is the one keeping people distant, but she does not know how to stop doing that:

“And I can tell myself, I understand that I am- I’m doing it, I don’t let people inside in my heart. It’s because I feel like they’re gonna hurt me. I have got that and my head saying “They’re gonna hurt ya, they’re gonna hurt ya” or something. That is how I feel. Like I do not know how to not do that […] and I have no friends now, not a friend, and it’s pretty sad that – it makes me really lonely when I think about it.”

Relationship between Trauma and Psychosis

While almost all participants agreed that trauma impacted their whole life and that they were largely still affected by it, they had different thoughts around how it influenced their current mental health. While a few participants were unsure, many believed that trauma was the cause of their psychotic symptoms and psychosis-related diagnosis, and that if they had had the chance to discuss trauma earlier this could have prevented their current condition. One participant thought that professionals diagnosed them with psychosis only because they did not believe their trauma disclosure, and they were convinced that their life would have been much better if only they had received help when they were looking for it. Participants’ mental health slowly or suddenly deteriorated as a direct consequence of trauma, or as a result of ignoring the event and its effects for too long. Symon explains how having the chance to discuss trauma when it first happened, could have prevented their current mental health status:

“I think the best time was in 1992 when it first happened. If I would’ve had someone to speak to then, perhaps I wouldn’t have the- I wouldn’t have the psychological damage.”

Even when the trauma did not cause traumatic or psychotic symptoms, it shattered the participants’ confidence, coping abilities and mood, until they could not deal with daily tasks anymore and felt useless and hopeless. Feeling constantly scared as a consequence of trauma, as well as feeling continuously on the edge of a mental breakdown, wore participants down until something else traumatic happened and they could not cope anymore. Mary offers an example of how her everyday activities eventually became unmanageable:

“Every tiny little thing that I did I- I’d phone my husband when he was at work like- I’d spill, do you know the tipp-ex, that white thing that you take the pen off… and I’d start panicking.”

Participants recognised specific links between trauma and the content and characteristics of psychotic symptoms. For example, memories of the trauma faded into visual hallucinations, and voices that screamed and cried often sounded like the participants at the time the trauma happened. They sometimes recognised that feelings of suspiciousness and ‘paranoia’ were also linked to their trauma, and so were some voices warning them off every time they left the house. Deborah explains her understanding of the relationship between her past traumatic experiences and current mental health:

“I think that’s why I hear voices, it’s because I was sexually abused […] and I can see how these different mental health experiences are really clearly linked to what happened to me, through like the content of my voices.”

However, the voices were not always perceived negatively. Despite being daunting, some participants recognised that the voices were probably just trying to keep them safe and to avoid new traumas. The voices would get anxious when the participants tried to talk about trauma, or they would directly order the participants to not talk about the traumatic events. On the other hand, a participant reported appeasing the voices to be able to cope with trauma, and that once they started dealing with the traumatic memories the voices also got better. Walter described the protective role played by his voices:

“I think they try to keep me safe. They’re not very nice, they tell me to hurt people or cars... how are you supposed to hurt a car I don’t know, but... psychosis could very well be linked to my troubled history... they’re just… the things I hear are trying to keep me safe from what... going through the pain again, I guess.”

This study investigated service users’ perception of the role played by trauma in influencing the development and maintenance of their psychotic symptoms and their views on how traumatic experiences and their disclosure (or lack of) have affected their life and mental health. The study found that participants had high rates of interpersonal traumas and that discussion of these traumas could be facilitated by having appropriate conditions to do so. When provided with the right opportunity, mostly referring to having somebody trusted and interested in listening, talking about trauma usually led to positive outcomes for the participant and the people around them. On the other hand, not being able to discuss traumatic life experiences, together with feeling scared or not ready to disclose, affected the way participants made sense of the trauma and often led to negative feelings towards the self. Most participants believed that the prolonged lack of opportunities to talk about trauma aggravated their difficulties, and they recognised direct links between past traumas and the content and characteristics of their psychotic experiences.

Consistently with what found in the literature [ 2 , 28 ], our participants reported seldomly being asked about trauma history or traumatic stress symptoms, despite national clinical guidelines recommend trauma assessment in psychosis [ 23 , 24 ]. Our research provided a richer description of the personal implications of not having the occasion to talk about trauma, grounded in participants’ testimonies and personal experiences. In line with Tong et al.’s [ 44 ] qualitative research on FEP, our participants agreed that conversations about trauma can be uncomfortable, yet they welcomed the idea of a professional asking them about their experiences, as long as they felt safe and not judged. This supports the evidence that rates of disclosure are not influenced by patient characteristics [ 32 ], but rather by external factors such as the reactions of those to whom the traumas are disclosed. Our results not only further stress the importance of routine assessment of trauma in psychosis, but also match meta-analytical evidence that trauma disclosure is ultimately beneficial [ 55 ]. Negative reactions are particularly detrimental as not only they influence willingness to disclose, but they can also increase PTSD symptoms [ 56 ]. In our sample participants agreed that not talking was largely influenced by not having people in their life that were trusted and considered willing to listen, by previous negative reactions from family members or by poor relationships with professionals. Overall, our findings reflect and support the conclusions from qualitative research on trauma and FEP, suggesting that discussing trauma in psychosis is possible and beneficial.

Our findings that discussing trauma often resulted in positive consequences for the participants and others are in line with previous research suggesting that trauma disclosure can improve overall well-being [ 57 ]. For example, participants felt that telling their stories allowed them to process some of the associated memories and being able to use their experiences to help others get through similar events increased their self-esteem. These findings have important clinical implications as they suggest the value of using client narratives within services. By normalising and sharing positive experiences of patients who decided to talk about trauma, professionals can encourage disclosure. As both clinicians and service users gain confidence in the safety and benefits of discussing trauma, routine trauma inquiry initiatives would be facilitated.

The fact that participants who did not talk about trauma often blamed themselves for what was happening in their lives and felt weak for being scared or lonely, also finds support in the literature, which suggests that not being able to discuss trauma in psychosis can result in negative outcomes [ 33 ]. The role of self-blame here is particularly important, as research has found that in people with a history of trauma, internalising feelings of blame contributes to psychological distress [ 58 ] and has a deleterious impact on physical health [ 59 ]. Studies around self-blame in psychosis have so far focused mostly on caregivers rather than on service users [ 60 ]. Further research is needed to investigate the role of self-blame in relation to trauma and psychosis, to understand if self-blame arises as a result of prolonged non-disclosure or if the relationship is possibly more complex (e.g., bi-directional).

Similarly to previous research, participants reported that the content of psychotic symptoms was often related to their traumatic events and the negative feelings associated to them [ 14 , 15 ]. When interviewed, participants reported experiencing many psychosis-related traumas, including being scared because unable to distinguish reality from fantasy, by their hallucinations or by going through several negative hospital experiences. These findings stress the need to move away from what is currently considered traumatic within the diagnostic classifications systems and adopt a wider and more ideographic understanding of what constitutes a traumatic experience. Events currently recognised as traumatic by diagnostic manuals (e.g., involving actual or threatened death, serious injury, or sexual violence) are associated with only slightly higher PTSD symptoms than non-traumatic stressors [ 47 , 48 ]. Widening the definition of trauma could affect who is treated for trauma-related disorders, how treatment is understood and could reduce the risk of invalidating people’s attempts of disclosing trauma. If more people who experience psychosis were treated for trauma, it might impact how their symptoms are conceptualised, as we know that flashbacks of an event can be difficult to distinguish from hallucinations [ 14 , 15 ] and that the way these intrusive experiences are labelled determines the diagnostic interpretation of these symptoms as either a function of psychosis or PTSD [ 61 ].

While there is extensive quantitative evidence on the potential links between trauma and psychosis, including re-victimisation [ 62 ], our findings indicate that the views of people with psychosis are sometimes, although not always, congruent with these research findings. Consistently with studies that found that re-victimization increases the likelihood of having psychotic experiences [ 63 ], our results suggest that feeling constantly scared as a consequence of trauma, or feeling continuously on the edge of a mental breakdown, led participants to a point where they were so worn down that they could not cope with anything anymore.

Our findings on the relationship between trauma and psychosis, and the fact the participants reported wanting to discuss trauma rather than just be treated for the psychotic symptoms, fit well within the recovery movement that advocates for a broader and more individualised understanding of what recovery in mental health means [ 64 ], as well as with increased calls for the implementation of trauma-informed approaches within mental health care [ 65 ]. In the context of trauma in psychosis, this would not only mean reducing the psychotic symptoms, but also trying to understand these symptoms as potential reactions to traumatic life experiences, and therefore benefit from general support consistent with trauma-informed care as well as, in some cases, trauma-focused therapy. Trauma-informed care in psychosis, based on knowledge and understanding of how trauma affects people's lives, have widely agreed on principles [ 43 ]. Trauma-focused therapy has shown promising results [ 66 ], with no evidence that it could lead to re-victimization or the exacerbation of PTSD or psychotic symptoms [ 67 ]. For our participants, not being able to discuss trauma was potentially related to the development of their psychotic experiences, which has been found to be the case in other mental health conditions, as non-disclosure has been associated with higher PTSD symptoms and depression [ 68 ]. Trauma-informed approaches and trauma-focused interventions could be particularly useful and more acceptable for these participants who already see a connection between their past traumatic experiences and their symptoms of psychosis. TF-CBTp in particular, has been found to have promising effectiveness, as supported by case-series [ 37 ] and feasibility trials [ 69 ]. Prolonged exposure and EMDR have also been found to be effective in reducing both symptoms of PTSD and psychotic symptoms in people with experiences of psychosis [ 70 ]. These types of interventions have shown to improve both service users' experiences and working environments for staff, as they foster understanding, respect and trust between patients and professionals and avoid the risk of service users being retraumatised by ‘trauma-uninformed’ staff [ 65 ].

Limitations

It is important to remember that participants in this study had already contributed to previous research about trauma and were, therefore, more likely to be interested in the topic and willing to discuss their experiences, even if for the first time. This could potentially mean that those individuals who would not even consider discussing a traumatic event may not be represented and that additional challenges to disclosure could exist. It might also mean that the series of positive consequences associated with discussing trauma reported by our participants do not necessarily apply to all service users. Additionally, due to the diverse sample, potential moderating characteristics were not adequately represented to allow the exploration of subgroup differences (e.g., ethnicity and gender). As evidence indicates that minority ethnicities have a higher chance to experience coercive and potentially traumatic pathways into care [ 71 ], future qualitative research is needed to further our understanding of the experiences of trauma in minorities. Finally, while our results contribute to existing literature suggesting that many people with traumatic experiences and psychosis attribute their psychotic experiences to their traumas, we recognise that this study was not designed to test this putative mechanism nor any causal relationships. Although trauma seems to be one pathway to psychosis, there are people with experiences of psychosis who do not report any trauma [ 72 ].

The findings from this research highlight the importance, as perceived by service users, of discussing trauma. Our results suggest that similarly to findings in non-clinical populations, people with psychosis are willing to discuss trauma and think that disclosure might be associated with positive outcomes. On the other hand, not being able to discuss trauma was normally associated with negative outcomes. Despite not having the opportunity to discuss trauma previously, service users welcome the idea of discussing trauma and even hope that doing so might improve psychotic symptoms. Future research is needed to systematically investigate the connection between trauma and psychotic symptoms and explore the benefits of discussing trauma also with service users who have been diagnosed for a long time. By looking at psychosis through a “trauma lens” and implementing trauma-informed approaches to understand clients’ difficulties and provide support, we might be able to see faster recovery and overall improved functioning and wellbeing.

Availability of data and materials

The dataset generated and analyzed during this study are not publicly available as interview transcripts contain sensitive and potentially identifying information but are available from the corresponding author on reasonable request.

Abbreviations

Community psychiatric nurse

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The authors are grateful to all participants who took time to share their invaluable thoughts and experiences.

This review was supported by a doctoral research grant from the University of Manchester. The sponsors had no role in the study design, collection, analysis, or interpretation of the data, or the preparation and approval of the manuscript.

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Campodonico, C., Varese, F. & Berry, K. Trauma and psychosis: a qualitative study exploring the perspectives of people with psychosis on the influence of traumatic experiences on psychotic symptoms and quality of life. BMC Psychiatry 22 , 213 (2022). https://doi.org/10.1186/s12888-022-03808-3

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• v.14(7); 2022 Jul

Adderall-Induced Persistent Psychotic Disorder Managed With Long-Acting Injectable Haloperidol Decanoate

Saral desai.

1 Department of Psychiatry, One Brooklyn Health, Brookdale University Hospital Medical Center, Brooklyn, USA

Erika L Santos

Anca e toma, andrés a henriquez, adeel anwar.

Adderall is one of the most commonly prescribed stimulant medications for attention deficit hyperactivity disorder (ADHD). Although safe and effective when clinically indicated at the appropriate dose, stimulant misuse may lead to serious adverse effects. We report a 29-year-old male with a diagnosis of ADHD who took more than the recommended therapeutic dose of Adderall prescribed by his psychiatrist. He subsequently presented with persistent psychotic symptoms, which responded to oral haloperidol. Due to treatment non-compliance with multiple recurring psychiatric hospitalizations, long-acting injectable haloperidol decanoate was considered to improve compliance and prognosis. The patient’s psychosis remained in remission while on the long-acting injectable. In this case study, we highlight the need for future research to identify stimulant misuse risk factors. Randomized clinical trials are needed to determine the effectiveness of long-acting injectable antipsychotic medication in the management of persistent psychosis secondary to stimulant misuse.

Introduction

Adderall (mixed amphetamine salts) is one of the most commonly used stimulant drugs in the management of attention deficit hyperactivity disorder (ADHD). Stimulant medications such as Adderall can increase levels of the neurotransmitter dopamine in the brain, and over time lead to the phenomenon of “sensitization.” Amphetamines can mimic psychosis, especially when taken recreationally above the approved therapeutic doses. Stimulants when used in therapeutic dosage for treatment of ADHD have been shown to reduce the risk of substance abuse in these patient populations [ 1 ]. Additionally, there is imaging evidence to support that stimulant use among individuals with ADHD has differential effects as opposed to those without ADHD [ 2 ].

A recent meta-analysis suggests that childhood ADHD might increase the risk of developing subsequent psychotic disorders during adulthood [ 3 ]. There might also be a shared genetic susceptibility between childhood ADHD and adult schizophrenia [ 4 ]. Although, stimulant use for the treatment of ADHD is safe and effective, whether prolonged stimulant use/misuse contributes to the development of a subsequent psychotic disorder in genetically susceptible individuals remains unknown. Additionally, this relationship might be further complicated by overdiagnosis and treatment of ADHD as well as a rise in prescription stimulant misuse [ 5 , 6 ].

While acute amphetamine intoxication can present as a substance-induced psychotic disorder, some may go on to develop a psychotic disorder with onset during intoxication that persists [ 7 ]. In the young adult patient population, it poses a unique challenge in separating first onset psychosis from a stimulant-induced psychotic disorder and subsequent transition to schizophrenia-like illness, leading to diagnosis and treatment dilemmas. We describe such a case of a 29-year-old male with a stimulant-induced persistent psychotic disorder that responded well to oral haloperidol. In light of the patient’s recurrent hospitalizations and history of non-compliance to the treatment, a clinical decision was made to try a long-acting injectable for haloperidol decanoate.

Case presentation

Mr. X is a 29-year-old Caucasian male who was brought to the emergency department (ED) for altered mental status. Mr. X was pulled over on the highway and was found to be agitated, incoherent, and responding to internal stimuli. Emergency medical services (EMS) were then called to bring Mr. X to the ED to be evaluated for altered mental status. Mr. X has a past psychiatric history of ADHD, anxiety disorder, and stimulant-induced psychosis. He has no known medical history. There is no known psychiatric history in Mr. X’s family. Mr. X is single and lives with his mother. Mr. X holds a bachelor's degree in computer science and plans to attend law school. Mr. X has no known history of illicit substance use. Mr. X was diagnosed with ADHD as an adult when he started college, and he was first prescribed Adderall at the age of 19 and has taken a dosage of up to 90 mg per day. Mr. X had been hospitalized twice in an inpatient psychiatric unit for a similar symptomatic presentation that was attributed to Adderall use above the approved therapeutic dosage (90 mg/day). During his past presentations, he was prescribed olanzapine and risperidone for the management of psychosis, but he was non-compliant with treatment for unspecified reasons. Following his last discharge from an inpatient unit, Mr. X continued to see different psychiatrists over the telemedicine platform and continued to obtain Adderall.

En route to the hospital, his blood pressure was noted to be 150/90 mmHg, with a pulse rate of 112 beats per minute, and he was given 10 mg of midazolam. The initial medical workup was negative, which included a negative head CT scan and infectious disease workup. Urine toxicology was not possible initially as Mr. X refused to give a urine sample. However, based on vitals, physical examination, and Mr. X's confession, it was determined that Mr. X took multiple pills of prescription stimulant Adderall before the presentation. Mr. X was soon medically cleared, and a psychiatric consult was placed for further evaluation. Upon initial psychiatric evaluation in the ED, Mr. X was noted to be guarded and had an intense stare with bloodshot eyes and dilated pupils. He displayed elevated mood, bizarre behavior, and grandiose delusions of being a supreme court judge. He was perseverating with legal terms and speaking circumstantially and rapidly. He was transferred to emergency psychiatry (Comprehensive Psychiatric Emergency Program (CPEP)) for further observation. In CPEP, Mr. X became more agitated, verbal de-escalation was unsuccessful, and he refused oral medications. He was given intramuscular medications of haloperidol 5 mg, diphenhydramine 50 mg, and lorazepam 2 mg for acute agitation as a result. He agreed to give a urine sample on the third day of his initial presentation, and the results were negative. After considering a differential diagnosis of bipolar disorder, schizoaffective disorder, and schizophrenia, based on history, collateral information (diagnosis of ADHD, history of Adderall abuse, seeking different psychiatrists to obtain Adderall, and history of previous hospitalizations/ER visits) from his mother, and clinical presentation, he was given a diagnosis of stimulant-induced psychosis. His behavioral symptoms failed to remit after three days of observation in CPEP, prompting a decision to admit the patient to an inpatient unit under involuntary status for further stabilization based on criteria that he would not be able to take care of himself in that state if he was discharged from hospital.

In the inpatient unit, the patient was initially started on oral risperidone 1 mg twice a day (BID); however, Mr. X continued to refuse medications. Mr. X’s mother was actively involved in the treatment plan. After discussing all the available treatment options in a family meeting in the presence of Mr. X’s mother, Mr. X agreed to take oral Haldol 5 mg BID that was later up titrated to 7.5 mg BID. Mr. X provided reasoning that he had tried risperidone in the past and he did not like how it made him feel. Initially, Mr. X was only partially compliant with oral Haldol, but with repeated counseling and the active involvement of Mr. X’s mother in the treatment plan, he eventually became compliant. Throughout his inpatient stay, he continued to remain insistent on getting Adderall or Vyvanse for his ADHD without specifying dosage. In light of his two inpatient psychiatric hospitalizations in the past six months and his continuation of Adderall abuse as well as non-compliance with prescribed antipsychotic treatment, a clinical decision was made to offer long-acting Haldol to the patient. After discussing with Mr. X and his mother, with the agreement of Mr. X, he was given two injections of Haldol Decanoate 50 mg and 100 mg intramuscularly as per the manufacturer’s guidelines. Additionally, Mr. X was prescribed clonidine 0.1 mg daily for the management of his ADHD. Mr. X tolerated the prescribed treatment without any adverse effects. Toward the end of his hospitalization, he no longer exhibited grandiose delusions of being a supreme court justice. His bizarre and disorganized behaviors were reduced significantly, and he was safely discharged (two weeks of hospitalization) to be followed up in a partial hospitalization program. Following the discharge, he remained compliant with the treatment plan for a follow-up period of six months.

The endogenous sensitization hypothesis suggests that first-episode psychosis patients have a heightened response to acute amphetamine administration, causing excessive dopamine release when compared to healthy volunteers [ 8 ]. At the same time, healthy volunteers given amphetamine for a prolonged period of time develop similar sensitization as seen in first-episode psychosis patients [ 8 ].

Stimulant medications have been used for decades in the treatment of ADHD with a good safety record when used in the therapeutic dosage range. Additionally, treatment with stimulant medications has been shown to reduce the risk of subsequent illicit substance use by 60% in ADHD patients compared to untreated ADHD patients [ 1 ]. With evidence of differential effects of stimulants in ADHD patients, it is possible that sensitization occurring with prolonged stimulant use might be beneficial to these patients, correcting the dopamine deficit in the prefrontal cortical regions of the brain. Whereas in the non-ADHD population, prolonged amphetamine exposure and subsequent excessive dopamine release from amphetamine might make them prone to developing psychotic disorders. The increasing trend of overdiagnosing ADHD and treatment with stimulants may explain the psychotic presentation in healthy individuals after prolonged stimulant use [ 5 , 6 ]. At the same time, epidemiological studies suggest an increasing trend of non-medical Adderall use, primarily obtained from friends and family members, contributing to increased ED visits [ 9 ].

Although it remains challenging to separate first onset psychosis from stimulant-induced psychosis that persists, there are some studies that suggest different symptom presentations in the case of amphetamine-induced persistent psychosis. For example, a study by Yang et al. suggests that methamphetamine-induced psychosis is marked by less paranoia and negative symptoms compared to patients with primary schizophrenic psychosis [ 10 ].

Besides the obvious predictors of amphetamine-induced psychosis that include the dosage and duration of amphetamine use, some studies have highlighted the additional role of gamma-aminobutyric acid (GABA) dysfunction resulting in a heightened risk of stimulant-induced psychosis. A study done by Ahn et al. suggests that pre-existing GABA deficits increased vulnerability to stimulant-induced psychosis in healthy subjects [ 11 ].

Treatment of stimulant-induced psychosis seems to be similar to that of treatment of psychotic disorders and schizophrenia. A recent systematic review by Fluyau et al. found that aripiprazole, haloperidol, quetiapine, olanzapine, and risperidone were able to reduce or control stimulant-induced psychosis with comparable efficacy, and all treatments were well tolerated [ 12 ]. A systematic review by Coles et al. found long-acting injectable antipsychotics to be an effective option for the treatment of dual diagnosis schizophrenia and substance use disorder [ 13 ].

We described a case of Adderall-induced psychosis that persisted long after a negative urine drug test. We described the diagnostic dilemma as a result. Based on the above-mentioned history, collateral information, and clinical judgment, we diagnosed Mr. X with stimulant-induced psychosis. Although not FDA approved for the treatment of stimulant-induced psychosis, we successfully used a long-acting injectable for haloperidol decanoate in light of Mr. X’s two inpatient hospitalizations within the past six months and history of non-compliance with antipsychotic treatment.

Conclusions

Adderall, when used above the therapeutic dosage, can lead to psychotic episodes that may persist. There is a pressing need to identify individuals at a higher risk of prescription stimulant abuse. Additionally, further research is needed to identify individuals that are at increased risk of developing persistent psychosis from Adderall abuse. Alpha-2-adrenergic agonists may be a safer alternative for the management of ADHD in such cases. Long-acting Haldol provided a great response in our case; however, further research is required to assess long-acting injectables as a definitive treatment for stimulant-induced psychotic disorders, especially in patients with a history of non-compliance and recurrent hospitalizations.

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The authors have declared that no competing interests exist.

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Consent was obtained or waived by all participants in this study