Trauma and Psychosis

The DSM-5 and ICD-11 sections for PTSD and C-PTSD don’t mention psychosis, aside from “auditory pseudo-hallucinations” (attributed to dissociation, not psychosis) and differentiating flashbacks from hallucinations and hypervigilance from paranoia.

But there is a link between the two, and researchers have even proposed a subtype of PTSD, psychotic PTSD (or PTSD-SP).

Not only is there psychosis caused by trauma, but there’s also trauma caused by psychosis (PTSD-PP). A person can have both trauma caused by psychosis and psychosis caused by trauma.

The difference lies in the reasons why they are experiencing the symptoms: in PTSD-PP, a person has trauma revolving around their psychotic symptoms (e.g., a person who had a psychotic episode involving the FBI spying on them through their TV is now triggered by their TV, even though they’re no longer psychotic), where in PTSD-SP, the psychosis is caused by their trauma (e.g., a person who was religiously abused now has a delusion that they’re a demon).

Is a psychotic episode a potentially traumatic event?

There is considerable evidence of a link between prior exposure to potentially traumatic events (PTEs) and psychosis. One question that has received increasing attention, however, is whether experiencing a first episode of psychosis can, itself, be considered a PTE. There is no doubt that it can be extremely frightening. A recent literature review on the subject reported that the most distressing symptoms were paranoid delusions or delusions of being controlled, threatening or critical voices, and the feeling of losing touch with reality. These internally generated experiences may be even more distressing than external events, as they are harder to objectify and understand, and they dramatically challenge the individual’s view of themselves as ‘sane’ and stable. The first episode is also likely to be associated with objectively frightening external experiences such as contact with the police and involuntary admission to a secure psychiatric facility. The same review reported that high levels of distress were associated with aspects of treatment such as restraint, seclusion, sedation, and being forced to take medication, as well as the threat of physical and sexual assault by other patients and staff.

Although clinicians can debate whether experience of a first psychotic episode strictly meets the DSM-5 Criterion A, there is widespread consensus that it can result in PTSD. If other criteria are met, and the focus of the traumatic memories is the psychotic episode, PTSD is an appropriate diagnosis to inform treatment.

- From ‘Managing trauma in early psychosis’, by Orygen.org