The relationship among cognitive appraisal, posttraumatic stress reactions and the experience of psychosis

Abstract

The experience of psychosis (e.g. threatening symptoms such as persecutory delusion and terrifying hallucinations) and its treatment (e.g. coercive measures such as involuntary admission and seclusion) are distressing. In view of the potential severity of the distress associated with psychosis, previous research has applied the trauma model to understand the experience of psychosis and its treatment and found that 11-67% of psychotic patients presented with clinically significant PTSD reactions in response to their psychosis and treatment experience. This phenomenon is termed as post-psychotic PTSD (PP-PTSD). However, previous research generally failed to find consistent relationship between PP-PTSD reactions and objective psychotic and treatment experiences (except for positive psychotic symptoms). Cognitive conceptualization of PTSD opines that it is the cognitive appraisal of the traumatic event, rather than the trauma per se, that is related to the development of PTSD. The present study aims to contribute to a better understand of PP-PTSD through a cognitive perspective. The present study applies Ehlers and Clark’s cognitive model of PTSD in understanding PP-PTSD. It explores the roles of fear of relapse and perceived risk of relapse, attribution of the causes of psychosis, perceived stigma and rejection and perceived consequence of the psychotic illness in PP-PTSD. The present study was a cross-sectional study and recruited 38 patients with schizophrenia-spectrum disorders. Semi-structured interview was used to determine whether the patients met the PP-PTSD diagnosis. The patient’s positive psychotic symptoms and social and occupational functioning were assessed by semi-structured interview while their PP-PTSD symptoms, trauma history and cognitive appraisals were measured using self-report questionnaires. Results showed that 15.8% of patients meet the full criteria of PP-PTSD and more than 50% of patients demonstrated some PP-PTSD reactions, which provides support for the application of the PP-PTSD construct in the local context. Treatment experiences were found to induce more severe PP-PTSD reactions than psychotic experience. Cognitive appraisals were found to be associated with PP-PTSD and there was some support for the application of Ehlers and Clark’s model in PP-PTSD. Specially, the present study found that fear of relapse, higher perceived risk of relapse, perceived helplessness and self-blame of causing the onset of psychosis, stable attribution of the cause of psychosis onset, perceived stigma, perceived large and chronic consequence of psychosis were all associated with more severe PP-PTSD reactions. Fear of relapse was also found to predict PP-PTSD severity. Clinical implications on the prevention, assessment and treatment with reference to the present results are discussed.