Early Psychosis and Trauma-Related Disorders: Clinical Practice Guidelines and Future Directions

Abstract

Despite high rates of trauma-related disorders among individuals with early psychosis, no clinical practice guidelines for the treatment of comorbid early psychosis and trauma-related disorders exist to date. Indeed, the routine exclusion of individuals with past and current psychosis from participation in trauma research and practice has limited the accumulation of research that could support such clinical practice guidelines. While preliminary research evidence suggests that traditional, evidence-based treatments for trauma-related disorders can be safely and effectively employed to reduce symptoms of posttraumatic stress and chronic psychosis, it remains unclear whether such treatments are appropriate for individuals in the early stages of psychotic illness. Clinical experts (N = 118) representing 121 early psychosis programs across 28 states were surveyed using the expert consensus method. Forty-nine clinical experts responded and reached consensus on 46 of 49 expert consensus items related to the treatment of comorbid early psychosis and trauma-related disorders. Conjoint or family therapy and individual therapy were rated as treatment approaches of choice. Anxiety or stress management and psychoeducation were rated as treatment interventions of choice for addressing both trauma symptoms and psychotic symptoms. In addition, case management was rated as a treatment intervention of choice for addressing psychotic symptoms. No consensus was reached on expert consensus items regarding the appropriateness of a parallel treatment approach exposure interventions for addressing psychotic symptoms, or sensorimotor or movement interventions for addressing trauma symptoms. In areas where expert consensus exists and is supported by current research, preliminary clinical practice guidelines for the treatment of comorbid early psychosis and trauma-related disorders are offered. In areas where expert consensus does not exist, recommendations for future research are offered. The results of this study are intended to serve as a launching point for scientists and practitioners interested in advancing appropriate treatment for high-risk and underserved individuals with comorbid early psychosis and trauma-related disorders.

Childhood trauma and clinical high risk for psychosis

“…Our results here also specifically highlight the need to screen for all forms of trauma, not only abuse and neglect. Unfortunately, there are a lack of evidence-based interventions for trauma in the CHR syndrome with only recent attention to PTSD treatment in schizophrenia, and many clinicians express discomfort with addressing trauma in psychotic-spectrum conditions (Cragin et al, 2017;Gairns et al, 2015). Thus, our current treatment recommendations are limited to individual adaptations of trauma-informed and trauma-focused treatments (Swan et al, 2017), pointing to a substantial clinical need and direction for future research.…”

A Randomized Controlled Trial on Mutual Support Group Intervention for Families of People With Recent-Onset Psychosis: A Four-Year Follow-Up

“…Nevertheless, the positive effects found in the psychoeducation group were not as large (effect sizes) and substantive as those in the FMSG. While psychoeducation group programs for families of people with schizophrenia and psychotic disorders are widely accepted and implemented in Western countries (8–10) and China (52), recent systematic reviews on family interventions (8–11) concluded that this approach can produce moderate but inconsistent benefits in families' burden, stress and illness management and well-being, especially in a longer term (>18 months) of follow-up. The findings of this study support a conclusion that family psychoeducation groups may be less likely to demonstrate sustainable benefits on family functioning at ≥12 months follow-up, as well as lower effects on different aspects of family and patient outcomes over 48 months post-intervention.…”

“…In this study, the consistent and substantive symptom reduction (PANSS scores) and lower number of re-hospitalizations among the patients in the FMSG over the 4 years of follow-up may suggest much better illness/symptom management than those in both the TAU and psychoeducation group. While there have been increasing amounts of case controlled and prospective evaluation studies favoring the use of mutual support groups for patients with severe mental illness and their families, only few randomized controlled trials have been conducted to evaluate its effects or cost-benefits in community mental healthcare services (8–10, 15). In addition, the FMSG also demonstrated a stable or slightly reduced demand for community mental health services for patients and/or families and thus this approach might not result in any additional service needs or costs in the community.…”

“…Secondly, the patients were young, relatively mentally stable with low to moderate doses of anti-psychotic medications; and most families were supportive to their patients and were receiving an adequate monthly income. Lastly, the families might have been particularly motivated to attend because there are only few structured family intervention programs for recent-onset psychosis available in Hong Kong, or indeed worldwide (6, 10, 29, 55).…”

“…A few randomized controlled trials in Western countries (e.g., in the U.S. and U.K.) indicated significant positive results of psychoeducation and other family interventions for psychosis in reducing relapse rates and improving social functioning over 1–2 years post-intervention (8, 9). Practice guidelines for early psychosis (6, 10, 11) and related systematic reviews (8, 12) also recommend that the families should be provided with family-oriented psychosocial interventions to support their caregiving endeavors and improve functioning, mental health, and well-being for themselves. However, the effects of family interventions on caregivers' outcomes are less established in comparison to those of the patients.…”