The trauma of first episode psychosis:

the role of cognitive mediation

Chris Jackson, Claire Knott, Amanda Skeate, Max Birchwood

Objective: First episode psychosis can be a distressing and traumatic event which has
been linked to comorbid symptomatology, including anxiety, depression and PTSD symp-
toms (intrusions, avoidance, etc.).
However, the link between events surrounding a first episode psychosis (i.e. police involve-
ment, admission, use of Mental Health Act, etc.) and PTSD symptoms remains unproven.
In the PTSD literature, attention has now turned to the patient’s appraisal of the traumatic
event as a key mediator. In this study we aim to evaluate the diagnostic status of first episode
psychosis as a PTSD-triggering event and to determine the extent to which cognitive factors
such as appraisals and coping mechanisms can mediate the expression of PTSD (traumatic)
symptomatology.
Method: Approximately 1.5 years after their first episode of psychosis, patients were
assessed for traumatic symptoms, conformity to DSM-IV criteria for posttraumatic stress
disorder (PTSD), and their appraisals of the traumatic events and coping strategies.
Psychotic symptomatology was also measured.
Results: 31% of the sample of 35 patients who agreed to participate reported symptoms
consistent with a diagnosis of PTSD. Although no relationship was found between PTSD
(traumatic) symptoms and potentially traumatic aspects of the first episode (including place of
treatment, detention under the MHA etc.), intrusions and avoidance were positively related to
retrospective appraisals of stressfulness of the ward (i.e. the more stressful they rated it the
greater the number of PTSD symptoms) and the patient’s coping style (sealers were less
likely to report intrusive re-experiencing but more likely to report avoidance).
Conclusions: The results call into question whether it is possible to make claims for a
simple causal link between psychosis and PTSD. Instead patients’ appraisals of potentially
traumatic events and their coping styles may mediate the traumatic impact of a first episode
of psychosis.
Key words: appraisals, first episode psychosis, PTSD, recovery style, trauma.

Australian and New Zealand Journal of Psychiatry 2004; 38:327–333

Over the past few years a number of studies have been argued that a significant number of patients fulfil
suggested that the diagnosis and experience of psychosis the criteria for posttraumatic stress disorder (PTSD)
can be a devastating and traumatic event; indeed it has [1–4]. These studies claim that between a third and a half
of patients with psychosis can become so traumatized by
Chris Jackson, Senior Research Fellow and Consultant Clinical Psychologist the experience, that they meet DSM-IV or ICD-10 crite-
(Correspondence); Claire Knott, Research Assistant; Amanda Skeate,
Research Fellow and Clinical Psychologist; Max Birchwood, Service ria for a diagnosis of PTSD. Only Meyer et al. [5] using
Director and Research Professor a Finnish inpatient sample, found a significantly lower
University of Birmingham and Early Intervention Service, Harry rate at 11%.
Watton House, 97 Church Lane, Aston, Birmingham, B6 5UG, UK.
Email: [email protected] While both anecdotal [6] and empirical evidence [7]
Received 24 April 2003; revised 17 October 2003; accepted 20 December attest to the traumatic nature of psychosis, there is less
2003. support for its diagnostic status as a PTSD triggering

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328 THE TRAUMA OF FIRST EPISODE PSYCHOSIS

event [8]. In order to fulfil the DSM-IV criteria for a mechanisms [15,16] as there are often large individual
diagnosis of PTSD, an identifiable stressor which is differences in response to the same traumas. In relation
potentially life-threatening needs to be defined and the to psychosis, we have little knowledge about the mediat-
content of the symptoms should refer to the stressor [9]. ing effects on traumatic symptoms of the appraisal of
Posttraumatic stress disorder-type symptoms (intrusive psychosis and the objective events (e.g. the degree to
re-experiencing, avoidance, hyper-arousal, etc.) on their which the patient appraised an admission to hospital as
own, without a connection to the stressor (Criterion A in stressful and how she or he coped with it).
DSM-IV) would not qualify for a PTSD diagnosis [10]. Finally, there has been some debate as to the most
(They may, however, be indicative of other comorbid appropriate methods of sampling: Most studies, with the
emotional disorders such as depression or anxiety which exception of McGorry et al. [2], have used multiple
can overlap with PTSD [11].) According to DSM-IV episode samples. This may be problematic because it
[12], to qualify for a diagnosis of PTSD, the patient must confounds the impact of diagnosis and how it is appraised
have experienced an event defined by Criterion A: with the impact of multiple episodes of psychosis.
Mueser et al. [17], found high rates of PTSD (43%) in
The person has been exposed to a traumatic event in
275 patients with long psychiatric histories which were
which both of the following are present: (1) the person
linked directly to multiple trauma events such as assault.
experienced, witnessed, or was confronted with an event
This suggests that there may be a cumulative impact of
or events that involved actual or threatened death or
psychosis-related ‘traumatic’ events. Furthermore, for
serious injury, or a threat to the physical integrity of self
some groups (i.e. dual diagnosis of psychosis and sub-
or others; (2) the person’s response involved intense
stance misuse), the experience of everyday trauma may
fear, helplessness, or horror. (pp. 427–428)
be even higher [18]. In view of reports that non-psychosis-
Criterion A has recently been criticized for being too related trauma can be significantly lower in first admis-
restrictive [13] and not acknowledging the psychological sion samples than multiple episode samples [19], a first
impact of events such as psychosis [1] and interpersonal episode psychosis cohort was used in the present study
trauma such as childhood abuse [14] which are not to explore the impact of the diagnosis, the pathway to
themselves life-threatening, but traumatic nonetheless. care and the experience of treatment. In the only pro-
In Criterion A, the emphasis is clearly placed upon spective study to date, McGorry et al. [2] reported a
threats to physical and not psychological integrity. PTSD rate of 35%, 11 months after the first episode.
Given that the candidate traumas associated with psy- The aims of the present study were therefore threefold:
chosis are related either to the content of the psychotic (i) to establish the incidence of traumatic symptoms
symptoms [4], the pathways to care (e.g. police involve- (intrusions, avoidance etc.) in a sample of young people
ment, use of Mental Health Act, etc.; [2]), or experience with a first episode of psychosis (FEP), receiving help
of treatment, it is likely that the current operational from a community-based early intervention service which
definitions of PTSD will miss these potentially traumatic draws from a diverse multicultural, inner-city population
stressors entirely. It is still unknown at this stage base in the UK; (ii) to test the hypothesized link between
whether, apart from the diagnosis itself, non-life- objectively measurable and identifiable stressors such as
threatening, objective events such as police involvement, police involvement, involuntary admission and so on
compulsory admission and so on are actually related to and the presence of PTSD symptoms; (iii) to determine
the PTSD (traumatic) symptoms often observed in psy- whether traumatic symptoms which may follow an FEP
chotic populations. are mediated by coping style (e.g. sealing over versus
There is some evidence that this link may be tenuous. integration) and patients’ appraisals of the potency of
Priebe et al. [3] found no relationship between PTSD their trauma.
symptoms in 105 community care patients suffering
from multiple episode schizophrenia and a history of Method
involuntary admissions; nor did Frame and Morrison [4].
This would be important to establish because as pointed Participants
out above, it is difficult to make a case even for meeting
Patients with a first episode of nonaffective psychosis conforming to
the current criteria for PTSD diagnosis if there is no link
broad ICD-10 criteria (F20, F22, F23, F25) were approached to take part
between the PTSD type symptoms and the ‘objective’ in the study. These were incident cases from the inner city of Birming-
psychosis related events which are assumed to form part ham, UK, managed by protocol in a community-based early psychosis
of the trauma. assertive outreach service. There were no exclusion criteria. All patients
Current models of PTSD place at their heart the role of were assessed at intake using the PANSS [20] and were interviewed for
psychological appraisals of traumatic events and coping the study on average 18 months after their first episode.

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 C. JACKSON, C. KNOTT, A. SKEATE, M. BIRCHWOOD 329

Instruments of adaptation to psychotic illness. According to McGlashan et al. [27]

people who adopt a ‘sealing over’ recovery style tend to isolate their
Diagnosing PTSD psychotic experiences; they view them as alienating and incompatible
with their life goals and consequently seek to encapsulate them. The
individual is disinclined to any investigation of his symptoms. Once
Patients were interviewed using a modified version of the PTSD
free from psychosis, he maintains an awareness of its negative aspects
scale [21] as used by McGorry et al. [2]. This is a 15 item measure with
and fails to become emotionally invested with others in an exploration
questions linked directly to DSM-IV criteria for PTSD but excluding
of their experiences. ‘Integrators’ on the other hand, are characterized
the need for fulfilment of Criteria A. (i.e. exposure to an event or events
by an awareness of the continuity of their mental activity and person-
that involved actual or threatened death or serious injury or the threat to
ality before, during and after the psychotic experience. During ‘inte-
the physical integrity of self or others). It has demonstrated reliability
gration’ the psychotic experience is used as a source of information.
and validity and can be used to establish ‘caseness’ by comparing
The questionnaire can be scored in order to classify which of the two
symptoms with the relevant DSM-IV criteria (i.e. B, C and D). Post-
recovery styles the patient is predominantly adopting. Higher scores
traumatic stress disorder symptoms were assessed with respect to the
represent ‘sealing over’. Its excellent psychometric properties have
overall experience of the first episode of psychosis and its treatment.
now been consistently demonstrated in a number of studies [25,28].
This was to allow the client’s subjective experiences of the onset of
The Psychiatric Assessment Scale (KGV) [29] is a brief rating scale
psychosis to be taken into account.
consisting of eight symptom categories: depression, anxiety, hallucina-
tions, delusions, flattened incongruous affect, psychomotor retarda-
PTSD and related symptoms tion, incoherence and irrelevance of speech and poverty of speech.
Patients are assigned a score ranging from 0 (absent) to 4 (severe).
Impact of Events Scale (IES) [22] can be tailored to any specific life It has been widely used in research in psychosis [30,31] and has high
event and seeks to measure posttraumatic phenomena on two dimen- retest reliability.
sions: (i) intrusive re-experiencing of the event, ideas, images, feelings
and dreams; and (ii) avoidance of situations, thoughts and feelings that
remind the person of the event. In this instance, the event in question
Analysis
(i.e. a first episode of psychosis) was cued in memory by asking
Nonparametric Mann–Whitney and χ2 statistics were used to analyze
patients to think back to their ‘breakdown’, ‘illness’ or psychotic symp-
the relationship between traumatic symptoms, PTSD caseness, and
toms (depending on their own frame of reference) and providing them
specific event aspects of the first episode. For the purposes of statistical
with an approximate date. As for the PTSD diagnosis discussed above,
analysis, ‘high’ or ‘low’ intrusion and avoidance groups were calcu-
intrusions and avoidance on the IES were assessed for the overall
lated for the IES by splitting about the medians (intrusion = 12;
experience of the first episode of psychosis and its management to
avoidance = 13) and for the HADS depression and anxiety scales, the
allow for subjective appraisals of the traumatic determinants (i.e. symp-
‘caseness’ scores of = 8 were used to define two groups (depressed
toms, treatment etc.). This 15 item scale is scored from 0 to 5 indicating
versus not depressed; anxious versus not anxious [32].
the extent to which each item was experienced in the preceding 7 days.
The IES has been shown to have good test-retest reliability and con-
struct validity [22] and is widely used in research in PTSD. Results
The Hospital Anxiety and Depression Scale (HADS) [23] is a
14 item self-report scale, originally developed for use in populations Sample
with physical health problems. It has also been used with patients with
schizophrenia [24] and gives a score for both depression and anxiety Fifty individuals satisfying inclusion criteria were asked to take part
(i.e. range 0–21 for each subscale). in the study; of these 35 agreed to participate. The mean age of the
sample was 25.8 (SD = 5.09, range 18–35) and included 26 men (74%)
Symptoms, trauma and coping with psychosis and nine women (26%). Duration of untreated psychosis (DUP) was
calculated using multiple sources according to the protocol of Beiser
The Hospital Experiences Questionnaire [2] is a semistructured et al. [33] (i.e. from the onset of psychotic symptoms to the start of ade-
interview adapted for use in the present study. It includes open and quate treatment with neuroleptic medication). The mean DUP was
closed questions about admission to a hospital ward and/or home treat- 37.1 weeks (SD = 43.9; median 15 weeks). There were no significant
ment, compulsory detention, police involvement and stressfulness of differences (p > 0.05) with regard to sex, age and DUP between those
the experience. In addition to an open question about the circumstances participating in the study and those refusing.
of their ‘breakdown or illness’, patients are asked to respond to a
number of closed questions by: indicating either ‘yes’ or ‘no’ (‘Did you Caseness and severity of traumatic symptoms
spend time on a secure ward?’); choosing from a number of options
(‘Which services were involved in your care?: [a] home treatment, Using DSM-IV operational criteria, excluding the need to fulfil
[b] admitted to a psychiatric hospital, [c] both, [d] none’); or by rating Criteria A, 31% of the sample were assigned a diagnosis of PTSD
on a four point Likert scale (‘How stressful was your time spent on the approximately 18 months after their first episode of psychosis. Scores
ward? [a] not at all, [b] a little, [c] fairly or [d] extremely’). on the Impact of Events Scale (IES) revealed a high level of both intru-
Recovery Style Questionnaire (RSQ) [25] is a 39 item self-report sions (12.7, SD = 8.8) and avoidance (15.0, SD = 9.9) for the entire
measure of McGlashan’s [26] ‘integration’ versus ‘sealing over’ styles sample; these means significantly increased for those 31% fulfilling the

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330 THE TRAUMA OF FIRST EPISODE PSYCHOSIS

above criteria for a PTSD diagnosis (mean intrusions = 21.4, SD = 3.5, Traumatic symptomatology (as measured by the IES) was not
mean avoidance =19.5; SD = 8.8). HADS anxiety, but not depression related to DUP, place of first treatment (home versus ward), police
ratings (Table 1), were significantly higher in the PTSD group involvement, use of MHA, or admission to a secure ward.
(p < 0.05). According to a ‘caseness’ cut-off of 8 or above on HADS- However, participants’ perception of the stressfulness of the admis-
anxiety [32], seven (64%) of the PTSD sample could be considered sion ward was higher in those with a diagnosis of PTSD (p < 0.05) and
‘clinically anxious’ (versus 25% for the non-PTSD group), while 45% those re-experiencing a ‘high’ level of intrusions (p < 0.01) following
of both PTSD and non-PTSD diagnosed groups were ‘clinically their first episode of psychosis. Perceived stressfulness of the ward
depressed’. correlated with IES intrusions (r = 0.61, p = 0.002) and with IES
Note was made of what clients were recalling when they were refer- avoidance (r = 0.48, p = 0.03).
ring to their intrusive memories and avoidance of those memories on Trauma symptoms (as measured by the PTSD scale and IES) were
the IES: 46% of the total sample reported that they were thinking back not correlated with residual psychotic symptoms rated on the KGV.
to the time of their ‘breakdown’, 11% to their ‘psychotic’ episode, 17% While psychotic symptoms were in remission for the majority of the
to ‘the time when they were ill’, 9% to ‘their schizophrenia’ and 17% to sample, there was no correlation between hallucinations and delusions
a variety of descriptions such as ‘when things got on top of me’. and IES scores for intrusions (hallucinations r = 0.23; p = 0.18; delu-
sions r = 0.20; p = 0.25) or avoidance (hallucinations r = 0.19;
Candidate traumas and ‘PTSD’ diagnosis p = 0.27; delusions r = 0.09; p = 0.59).

Twenty-two people (63%) reported that the police had been involved PTSD, traumatic symptoms and coping style
in their pathway to care. Five (14%) had been treated solely by a home
treatment team, while 22 (63%) had been admitted to the ward of a psy- According to the scoring criteria of Drayton et al. [25] and Tait et al.
chiatric hospital; 13 (37%) had experienced both and seven (20%) had [28], nine (26%) of the sample were considered to have a ‘sealing over’
experienced neither. Ten (29%) had been sectioned under the UK recovery style. The remaining 26 (74%) were classified as ‘integrators’.
Mental Health Act and 14 (40%) had spent time on a secure ward Inspection of the means (Table 2) indicates that while ‘sealers’ had
during their first episode. Of those who spent time on a locked secure less frequent intrusions about their first episode of psychosis than
ward, the average length of stay was 32 days. Of the 22 people who ‘integrators’ on the IES, although this did not quite reach significance
were admitted to a psychiatric ward, 18 (82%) described this time as at the 5% level (p =0.09), it was found that ‘sealers’, were significantly
either ‘fairly’ or ‘extremely stressful’. Overall, in response to a question more likely to adopt cognitive strategies to avoid these intrusions
on the Hospital Experiences Questionnaire [2], 77% of the total sample (t = 2.08; p = 0.04). There were no differences between the two recov-
described their first episode as ‘extremely stressful’. ery styles with regard to PTSD diagnosis, anxiety or depression.

Table 1. Impact of Events Scale (IES) and Hospital Anxiety and Depression Scale (HADS) for PTSD groups

Scale range PTSD (n = 11) Non-PTSD (n = 24) p

Mean (SD) Mean (SD)
IES
Intrusion 0–35 21.4 (3.5) 8.7 (7.5) < 0.001
Avoidance 0–40 19.5 (8.8) 12.9 (9.9) 0.06
Total 0–75 40.9 (9.2) 21.6 (13.2) < 0.001
HADS
Depression 0–21 7.4 (4.7) 6.8 (4.4) NS
Anxiety 0–21 9.5 (5.4) 6.1 (3.4) < 0.05

Table 2. Trauma and recovery style

Sealing over Integrating t or χ2 p

n = 9 (26%) n = 26 (74%)
PTSD diagnosis 22% 35% χ2 = 0.48* 0.69
Total (IES) 29.0 (16.3) 27.2 (14.9) t = 0.31 0.76
Intrusion (IES) 9.3 (8.3) 14.2 (8.6) t = –1.76 0.09
Avoidance (IES) 20.7 (10.2) 13.1 (9.2) t = 2.08 0.04
Anxiety (HADS) 6.2 (4) 7.5 (4.5) t = –0.73 0.47
Depression (HADS) 6.7 (5) 7.1 (4.3) t = –0.26 0.80

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 C. JACKSON, C. KNOTT, A. SKEATE, M. BIRCHWOOD 331

Discussion significant even after controlling for time elapsed since

first episode (r = 0.64; p = 0.001). This points to the
The study has shown that approximately one-third of need for further research into the subjective factors that
patients with a first episode of psychosis fulfil DSM-IV personalize trauma during a first episode of psychosis.
criteria for a diagnosis of PTSD where that diagnosis Future research, however, should ideally look into the
is made on the basis of DSM-IV Criteria B, C, and D possibility of assessing appraisals during or just after
(intrusive re-experiencing, avoidance and increased the first episode (i.e. peri-traumatically) and use a
arousal) but in the absence of Criterion A (life-threatening prospective design to test the relationship between
trauma). This is consistent with the only other study of appraisals and subsequent PTSD symptomatology over
PTSD in first episode psychosis [2] and indicates that for time.
a significant minority of young patients, a first episode The importance of psychological processes is further
may give rise to traumatic symptoms of considerable highlighted by the link identified between recovery style
severity. and severity of traumatic symptoms. The most marked
The present study did not indicate, however, that these difference between these two recovery styles was the
traumatic symptoms are linked to the presence of any avoidance of intrusions in ‘sealers’. Sealers, by defini-
pathway or treatment event, including police involve- tion, avoid thinking about their first episode more than
ment, involuntary detention and presence on a secure integrators and appear therefore to use sealing strategies
ward. Nevertheless, it was clear that a first episode of to ‘ward off’ painful memories and thoughts from that
psychosis is distressing and traumatic as, in our sample, time. This supports McGlashan’s original hypothesis
the level of distress and perceived stressfulness of the that ‘sealers’ are often unable to access memories of
diagnosis and its treatment was high. The levels of their psychotic episode [26]. These findings are consist-
intrusive re-experiencing and avoidance in the present ent with models of assimilation and trauma [37–39]
study were comparable with non-psychotic traumatized which advocate that some people ward-off unwanted
clinical samples at a similar time point. For instance, thoughts and images because they anticipate the cata-
Joseph et al. [34] found intrusion and avoidance scores strophic consequences of recollection. Under some
of 11.2 and 11.8, respectively, for traumatized survivors circumstances experiences may even become inacces-
of the Jupiter Shipping Disaster, 19 months after the sible to memory retrieval altogether [40].
event (12.7 and 15.0, respectively, in the present sam- The present study does not elucidate what factors
ple). The degree of clinically significant anxiety (64%) motivate the warding-off and inhibition of unwanted
and depression (45%) in the PTSD group also confirms thoughts in the ‘sealing over’ group. We have argued
the extent of comorbid symptomatology often found in elsewhere that sealers are a particularly vulnerable group
PTSD and first episode samples [11,35,36]. psychologically [25] and that the onset of psychosis and
The finding that there is no direct relationship between its implications for future aspirations and identity [36],
traumatic symptoms and candidate traumas is consistent renders patients unable to deal with the diagnosis. In a
with some other studies [2,3]. Frame and Morrison [4] in recent study [28] we found that ‘sealers’ have a low level
their letter recently reported that ‘experience in hospital’ of engagement with services, suggesting perhaps that
explained only 6% of the variance in PTSD scores in they may wish to avoid further trauma.
their multiple episode sample. The initial process of ‘sealing over’ may be adaptive in
However, these findings point to the role of psycho- the short term, acting like an ‘emotional brake’ during
logical mediating factors as described by Ehlers and the recovery period following the first episode [8,41] and
Clark’s [16] model of PTSD. Those who were admitted subsequent psychotic episodes [28]. It may psycho-
to hospital and retrospectively perceived their admission logically protect the patient from the perceived negative
as particularly ‘stressful’, were significantly more likely ‘realities’ of psychosis and its implications for the self
to meet a diagnosis of PTSD (without Criterion A) and [8,42]. This is consistent with data from our recent study
to report higher levels of intrusions. This is consistent [28] which assessed the recovery style of a cohort of
with the idea that individual appraisals may be more young people with psychosis at three time-points follow-
important than more objective events. Perceived stress- ing an acute episode: baseline, 1 month and 6 months.
fulness of patients’ time on the ward correlated specifi- Here it was demonstrated that while the majority of
cally with intrusive memories about the first episode of patients could be initially classified as integrators at
psychosis (r = 0.61; p = 0.002) and although this finding baseline, as they gained insight and started to emotion-
should be treated with caution in view of the fact that ally process what had happened to them, the predomi-
appraisals were made approximately 18 months after nant recovery style changed toward sealing within
the first psychotic episode, this correlation remained 6 months.

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332 THE TRAUMA OF FIRST EPISODE PSYCHOSIS

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