PTSD and comorbid psychotic disorder: Comparison with veterans diagnosed with PTSD or psychotic disorder

Journal of Traumatic Stress, VOL 12, No. I, 1999

PTSD and Comorbid Psychotic Disorder: Comparison with Veterans Diagnosed with PTSD or Psychotic Disorder

Frederic J. Sa~tter,'-~ Kevin Brailey,'J Madeline M. Uddo,lP2 Michelle F. Hamilton: Marcia G. Beard: and Alicia H. Borges2

Symptoms of posttraumatic stress disorder (PTSD), psychosis, general psychopathology, role functioning, violence potential, and cognitive and emotional aspects of psychotic states were compared in three groups of veterans. Groups were defined on the basis of their DSM-IV diagnoses: Psychotic disorder and war-related PTSD, war-related PTSD without psychotic symptoms, and psychotic disorder without PTSD. Veterans with PTSD and a comorbid psychotic disorder showed significantly higher levels of positive symptoms of psychosis, general psychopathology, paranoia, and violent thoughts, feelings, and behaviors than the other two groups. These data show that patients with comorbid PTSD and psychotic disorder show levels of cognitive, emotional, and behavioral disturbance that far exceed the levels of disturbance seen in patients with PTSD without psychosis or in patients with psychotic disorder KEY WORDS PTSD; psychosis; violence potential; comorbidity.

Studies have revealed that high rates of comorbid psychiatric disorders are associated with the diagnosis of posttraumatic stress disorder (PTSD) among diverse traumatized populations (Kilpatrick, Saunders, Veronen, Best, & Von, 1987; Mellman, Randolph, Brawman-Mintzer, Flores, & Mi- lanes, 1992; Sierles, Chen, McFarland, & Taylor, 1983; Sutker, Uddo,

Heidi S. Resnick, Associate Editor, was the action editor for this manuscript. 'Psychology Service (116B). New Orleans Veterans Affairs Medical Center, 1601 Perdido Street, New Orleans, Louisiana 70146.

2Tulane University School of Medicine, Department of Psychiatry and Neurology, 1440 Canal St., Tidewater Bldg., TB-53, New Orleans, Louisiana 70112; e-mail: [email protected] lane.edu

3T0 whom correspondence should be addressed.

73

0894-9867/99,4l100-0073S16.00/1 0 1999 International Society for Traumatic Stress Studies

74 Sautter, Brailey, Uddq Hamilton, Beard, and Borges

Brailey, Vasterling, & Errera, 1994). Although frequently co-occurring diagnoses include mood, substance abuse, and other anxiety disorders, there have been few systematic attempts to investigate the relationship between psychotic symptoms and PTSD. Recently however, several investigators have reported that psychotic symptoms co-occur with PTSD.

While the first epidemiological studies of PTSD (Helzer, Robbins, & McEvoy, 1987; Kulka et al., 1990) did not include assessments for psychotic symptoms, Davidson, Hughes, Blazer, and George (1991) measured psychotic symptoms in their epidemiological study, and they report a lifetime comorbidity of 10.9% between PTSD and schizophrenia or schizophreniform disorder. Their data are consistent with a number of clinical studies that have shown that PTSD may co-occur with auditory hallucinations (Hamner, 1996; Mueser & Butler, 1987; Wilcox, Briones, & Suess, 1991), delusional thought processes (Pinto & Gregory, 1995), as well as auditory hallucinations occurring with delusional thought processes in clinical samples (Butler, Mueser, Sprock, & Braff, 1996; Jackson, Tremont, Kutcher, David, & Mellman, 1996; Kumar, Kutcher, & Mellman, 1994). Hryvniak and Rosse (1989), Wilcox et al. (1991), Jackson et al. (1996), and Hamner (1996) reported psychotic symptoms in 28-35% of their PTSD clinical samples.

Because standardized diagnostic assessments were not used in many of the previously identified studies to diagnose psychotic symptoms, it is difficult to identify the types of psychotic disorders that most frequently co-occur with PTSD. Butler et al. (1996), Mueser and Butler (1987), and Wilcox et al. (1991) did not include standardized assessments of psychotic disorders and they report that the patients that they studied did not meet criteria for a major psychotic disorder (although they would presumably meet DSM-IV criteria for psychotic disorder not otherwise specified). Other investigators (Kumar et al., 1994; Strakowski, Keck, McElroy, Lonczak, & West, 1995) have included standardized diagnostic assessments, and they report that the majority of the patients that they studied met DSM diagnostic criteria for an affective psychotic disorder. To further com- plicate the picture, other studies (HIyvniak & Rosse, 1989; McGany, et al., 1991) have not included standardized diagnostic assessments, and they indicate that patients with PTSD and psychotic symptoms may meet full diagnostic criteria for either an affective or nonaffective (i.e., schizophrenic) psychotic disorder.

While clinical studies demonstrate that a significant number of treatment-seeking patients with PTSD may also show psychotic symptoms, re- searchers have not attempted to assess the clinical impact of these psychotic symptoms in patients suffering with PTSD. Therefore, the present research used detailed standardized diagnostic instruments to assess the impact of psychotic symptoms on the functioning of PTSD patients. The impact on

Posttraumatic Stress Disorder with Cornorbid Psychotic Disorder 75

patient functioning of psychotic symptoms co-occurring with PTSD was assessed by comparing veterans in one of three diagnostic categories: (1) combat-related PTSD and a psychotic disorder (DSM-IV schizophrenia, schizoaffective disorder, major depressive disorder with psychotic features) (Psychotic PTSD group), (2) combat-related PTSD without evidence of psychosis (FTSD group), and (3) psychotic disorder without evidence of PTSD (DSM-IV schizophrenia, schizoaffective disorder, major depressive disorder with psychotic features) (psychotic group). The assessment protocol included measures in the following domains: demographic variables such as gender, ethnicity, and education; severity of war zone exposure; intensity of PTSD symptoms; intensity of positive and negative psychotic symptoms; measures of the cognitive and emotional aspects of psychotic states; general psychopathology; measures of violence potential; and measures of interpersonal and occupational role functioning.

Methods

Participants

All veterans were recruited from mental health programs at a VA Medical Center. Informed consent was obtained from all patients. Sixteen patients met DSM-IV criteria for a psychotic disorder (schizophrenia, schizoaffective disorder, or major depression with psychotic features) and did not evidence any PTSD symptoms; 22 patients met DSM-IV criteria for PTSD without evidence of psychotic symptoms; 24 patients met DSM-IV criteria for both a psychotic disorder and PTSD. Patients with current substance abuse or dependence were excluded from the study. All PTSD patients had been exposed to combat, and approximately 50% of the psychotic group had some combat exposure. Patients with PTSD and a psychotic disorder were consecutive outpatient admissions to the New Orleans VA PTSD Day Hospital Program; patients with psychotic disorder without PTSD were consecutive admissions to the New Orleans VA Inpatient Psy- chiatric Unit. Patients who received a diagnosis of PTSD alone were vol- unteers responding to an advertisement displayed in the PTSD outpatient program. Four patients recruited for the psychotic group from the Psychi- atric Inpatient Unit, refused to enter the study. Demographic characteristics of the three groups are shown in Table 1, and diagnostic information is shown in Table 2. Issues raised by varying levels of ethnicity across the three groups will be addressed in the Results section.

76 Sautter, Brailey, Uddo, Hamilton, Beard, and Borges

Table 1. Sample Demographic Characteristics

Group

Characteristic Psychotic FTSD Psychotic PTSD

Age w.1 45.7 (2.1) 42.8 (7.3) 48.5 (3.0) Education (yrs.) 12.0 (1.9) 12.2 (1.9) 12.8 (2.8) Caucasian (%) 4.2 12.5 54.5 African American (%) 95.8 87.5 455

n 24 16 22 Note. Standard deviations for means appear in parentheses.

Measures

Severity of war zone exposure. The Combat Exposure Scale (Keane, et al., 1989) was developed to assess exposure to war-related stressors. It was used in the current study to determine if group differences could be accounted for by differences in combat exposure. Subjects rate items that describe various types of combat-related experiences on a 5-point Likert scale. This scale has demonstrated good internal consistency (a = .8S), test-retest reliability (r = .97), and convergent validity with other measures of combat exposure (Fairbank, Schlenger, Caddell, & Woods, 1994; Keane et al., 1989).

Intensity of PTSD symptoms. The Mississippi Scale for Combat-Related Posttraumatic Stress Disorder (Keane, Caddell, & Taylor, 1988) was developed to provide a valid and reliable measure of combat-related PTSD symptomatology. This 35-item scale is derived from DSM-I11 PTSD diagnostic criteria and requires subjects to rate items on a 5-point Likert scale. The scale has been shown to possess good test-retest reliability (r = .97), internal consistency (a = .93), sensitivity (.93), and specificity (.89) (Keane, et al., 1988; Keane et al., 1989; Kulka et al., 1990).

Cognitive and emotional aspects of psychotic states. The Positive and Negative Syndrome Scale (PANSS) (Kay, Fiszbein, & Opler, 1987) is a cli-

Table 2. Frequency of DSM-IV Diagnoses as a Function of Diagnostic Group Group

Diagnosis Psychotic PTSD Psychotic PTSD

PTSD 24 0 22 Schizophrenia 6 5 0 Schizoaffective 12 6 0 Major depression with psychosis 6 5 0 Major depression without psychosis 0 0 12 Past ETOH/drug dependency 15 8 14 Phobia 4 2 2 Panic disorder 1 0 3

Posttraumatic Stress Disorder with Comorbid Psychotic Disorder 77

nician-administered rating scale that provides a standardized technique for measuring positive and negative symptoms of psychosis and other cognitive and emotional aspects of psychosis. It is a 30-itemY 7-point rating instrument. Of the 30 items, 7 are grouped to form a Negative Psychotic Symp- tom Scale, and 6 are grouped to form a Positive Psychotic Symptom Scale. Positive psychotic symptoms include symptoms of hallucinations, delusions, and conceptual disorganization; negative psychotic symptoms include symptoms of blunted affect, emotional withdrawal, and poor rapport. The two scales do not share any items. Five subscales may be extracted from the PANSS: anergia, thought disturbance, behavioral activation, paranoia, and depression. There is some overlap between items from the Positive and Negative Symptom Scales and the five subscales; there are no items included on both the Positive and Negative Symptoms Scales. Factor analytic studies have determined that those scales measure the basic dimensions of cognitive, emotional, and behavioral disturbance that typify the psychotic state (Kay, 1991). Alpha coefficient analyses indicate high internal reliability with coefficients ranging from .73 to 33; test-retest reliability for unre- mitted inpatients over a 3 to 6 month interval ranged from .78 to 39; and studies indicate that the construct, discriminative, convergent, and predic- tive validity of the scales is good (Kay, 1991). The Positive and Negative Scales Psychotic Symptom and the five subscales of the PANSS were all used in the current study.

General psychopathology. Gene r a1 psychopath ol ogy was assessed through administration of the 16-item General Psychopathology Scale of the PANSS. This scale measures the following symptoms: somatic concern, anxiety, guilt, tension, mannerisms and posturing, depression, motor retar- dation, uncooperativeness, unusual thought content, disorientation, poor at- tention, insight, volition, impulse control, preoccupation, and social avoidance. Studies indicate that both the reliability and validity of this scale are adequate (Kay, 1991).

Kolence. The Past Feelings and Acts of Violence Scale (PFAV) (Plutchik, Clement, & Ervin, 1976) is a self-report instrument that was designed to assess risk for violent behavior. It consists of 12 items rated on a 4-point scale and has been used to identify past violent behaviors, thoughts and feelings that discriminate between prisoners who have shown violent behavior and other groups (Plutchik et al., 1976). The instrument is correlated with history of violent behaviors in psychiatric inpatients (Plutchik, van Praag, & Conte, 1989), and has been shown to possess good internal reliability (a = .77) and test-retest reliability (r = .75) (Plutchik & van Praag, 1989). The Aggression Risk Profile, a supplementary scale of the PANSS (Kay, 1991), was also used to measure violence. Reliability data for the PANSS have been presented in a previous section. The ARP


contains four items and is organized according to the same format as the other PANSS scales.

Measures of interpersonal and occupational role functioning. The Quality of Life Scale (Heinrichs, Hanlon, & Carpenter, 1984) is a 21-item scale based on a semi-structured interview that was designed to quantify role- functioning in patients suffering from chronic psychotic disorders. It consists of an Interpersonal Role Functioning Scale, an Occupational Role Functioning Scale, and a Deficit State Scale. Only the Interpersonal and Occupational Role Functioning Scales were used in the current study. This instrument has been shown to possess excellent reliability (interrater reliability ranges from .84 to .94), excellent internal consistency (a ranges from .91 to .97), and factor analytic studies suggest adequate construct validity (Heinrichs et al., 1984).

Procedure

All subjects were assigned DSM-IV diagnoses (American Psychiatric Association [APA], 1994) on the basis of the Structured Clinical Interview for DSM-IV (SCID) (Spitzer, Williams, & Gibbon, 1994). The SCID was administered by either a licensed clinical psychologist or a psychology in- tern or psychology technician under the direct supervision of a licensed clinical psychologist. These individuals had been trained to administer the SCID by viewing a series of SCID training tapes and by having their SCID administration skills directly observed and evaluated by an experienced SCID diagnostician. Subjects were assigned to one of three groups on the basis of their SCID-based DSM-IV diagnosis: (1) psychotic disorder (schizophrenia, schizoaffective disorder, major depression with psychotic symptoms) and PTSD, (2) PTSD without evidence of psychosis, or (3) psychotic disorder without evidence of PTSD. Once data from the SCID indicated that the subject met the diagnostic criteria used to define one of the three study groups, the remaining instruments in the assessment battery were administered to the subject by raters who were blind to the group status of the patient.

Data analysis. Two sets of data analyses were then conducted. First, the two combat-exposed groups were compared for mean differences on the Combat Exposure Scale using ANOVA procedures. This analysis was conducted to determine if later findings could be accounted for by differences between the groups in degree of combat exposure. The two combat- exposed groups were then compared for differences in PTSD symptoms by using an ANOVA to compare their scores on the Mississippi Scale. The second set of analyses were conducted to identify differences between the


three groups in nonPTSD psychiatric symptoms. A MANOVA and follow- up ANOVA procedures were used to compare the three groups for mean differences on scale scores derived from the PANSS and PFAY The PANSS yielded nine scale scores: (1) positive psychotic symptoms, (2) negative psychotic symptoms, (3) anergia, (4) thought disturbance, (5) behavioral activation, (6) paranoia, (7) violent thoughts and behaviors (Aggression Risk Profile), (8) depression, and (9) general psychopathology. The PFAV yields a single score measuring the subject’s violent behaviors and feelings. A total of 14 variables were used as dependent variables in separate ANOVAs. When ANOVAs yielded significant group differences, post-hoc comparisons using Newman-Kuels pairwise t-tests were conducted. In the third set of analyses, ANOVA procedures were used to compare the three groups for mean differences on the Interpersonal Role Functioning and the Occupa- tional Role Functioning Scales. These analyses were conducted in order to determine if the three groups showed significant differences in their daily role functioning. When ANOVAs yielded significant differences between the three groups, post-hoc t-tests were administered to identify which pairs of groups showed significant differences.

Results

DSM-IV diagnoses of subjects from the psychotic PTSD group, the PTSD group, and the psychotic group are shown in Table 2. Fifteen of 24 patients in the Psychotic PTSD group, 14 of 22 patients in the PTSD Group, and 8 of 16 patients in the psychotic group met DSM-IV criteria for a comorbid substance dependence disorder. None of the patients in the psychotic group had ever met lifetime criteria for PTSD.

The two combat-exposed groups were then compared for differences in combat exposure by using ANOVA procedures to compare their scores on the Combat Exposure Scale (Keane et al., 1989). The patients from the psychotic PTSD group showed a mean of 28.0 and patients from the PTSD group showed a mean of 28.6. The comparison yielded an F-statistic of less than 1.0, indicating that there were no significant differences between the two groups. This suggests that any clinical differences between these two groups are not due to differences in combat exposure. Patients from the psychotic group who had been exposed to combat showed a mean of 24.5. Approximately 50% of the psychotic group had not been exposed to any combat.

The two groups who had been exposed to combat in Viet Nam and received diagnoses of PTSD (the psychotic PTSD group and the PTSD group) were compared for differences in intensity of PTSD-related symp-


Table 3. Mean Scores from the PANSS and Past Feelings and Acts of Violence Scale as a Function of Diagnostic Group

Psychotic Scale Score PTSD Psychotic PTSD F(2,59)

Positive symptoms Negative symptoms General psychopathology Anergia Depression Behavioral activation Paranoia Thought disorder Aggression Risk Profile Past Feelings and Acts of

Violence Scale

21.8(5.8), 14.5(5.2), 41.8(9.4),

7.3(2.9), 14.5(3.5), 6.9(2.2), 8.9(3.8),

11.6(3.6), 11.4(4.4), 16.3(6.6),

18.4(5.1)b

32.5(9.6))b

9.6(5.0))b 4.9(1.3))b 5.6(2.8))i,

5.4(2.7))b 8.5(3.5)),

14.8(5.0),

7.6(2.9),

11.8(3.7),

1 1.5(3.1)c 13.3(3.8),

6.7(1.6), 13.4(3.0), 6.0( LI),

33.3(5.7)),

5.6(2.4)), 4.9( 1.3))h 6.6(2.4)),

13.0(6.1),

27.64'' < 1.0

8.37'' <LO

8.37" 7.05' 8.29''

36.03'' 19.22" 8.87**

Note. Standard deviations for means appear in parentheses. The positive symptoms, negative symptoms, and general psychopathology scores are derived from the primary scales of the PANSS. All of the remaining scales, except Past Feelings and Acts of Violence Scales, are primary PANSS scales. Row means with different subscripts are significantly different under Newman-Keuls pairwise comparisons at p c .05.

*p < .01. ** p c ,001.

toms by comparing their means on the Mississippi Scale and PTSD Rating Scale by using t-test procedures. The two groups did not show significant differences on the Mississippi Scale, the psychotic PTSD group showed a mean of 138.9 (SD = 18.9) and the PTSD group showed a mean of 129.9 (SD = 20.9), p > -15.

The three groups were then compared for differences in intensity of psychotic symptoms as well as for differences in other dimensions of general psychopathology (see Table 3 for means, standard deviations, F values, and associated p values for PANSS scales). A MANOVA indicated that the three groups showed significant multivariate differences (using Wilks criterion, F(20, 100) = 5.86, p < .001). ANOVA procedures indicated that the three groups differed significantly in intensity of positive symptoms of psychosis, and post-hoc t-tests indicated that all three groups differed significantly from each other. The psychotic PTSD group showed the highest mean for positive psychotic symptoms; the psychotic group showed the second highest mean; and the PTSD group showed the lowest mean. The three groups did not differ significantly in intensity of negative symptoms of psychosis.

The three groups were then compared for differences on other dimensions of psychopathology. Comparison by t-tests of scores from the General Psychopathology Scale of the PANSS indicated that the three groups exhibited significant differences between the Psychotic PTSD group (M = 41.8) and both the psychotic group (M = 32.5) and the PTSD disorder group ( M = 33.3). ANOVA procedures were then used to compare the three groups for differences on the six subscales that were extracted from


the PANSS. These analyses indicated that the groups did not show significant differences on the Anergia Subscale. The three groups did show significant differences on the depression, behavioral/activation, paranoia, thought disorder, and Aggression Risk Profile Subscales of the PANSS (see Table 3). On the Depression and Behavioral Activation Subscales, the psychotic PTSD and PTSD group showed significantly higher means than the psychotic group; the Psychotic PTSD group showed significantly higher mean scores on the Paranoia and Aggression Risk Profile Subscales than both the PTSD group and the psychotic group; and the psychotic PTSD group and psychotic group showed higher mean scores than the PTSD group on the Thought Disorder Subscale. The groups also showed significant differences on the Past Feelings and Acts of Violence Scale; as the psychotic PTSD group and the PTSD group showed significantly higher means than the psychotic group.

The three groups were also compared in order to determine if they differed significantly in terms of their interpersonal and occupational role functioning. The groups were compared for differences on the Interper- sonal Role Functioning Scale and the Occupational Role Functioning Scale of the Quality of Life Scale (Heinrichs et al., 1984). Data from these ANO- VAs indicated that the three groups did not differ significantly (both Fs < 1.0). On the Interpersonal Role Functioning Scale, the psychotic PTSD group showed a mean of 18.1 (SD = 6.1); the psychotic disorder group a mean of 19.9 (SD = 9.8); and the PTSD group a mean of 20.4 (SD = 8.7). On the Occupational Role Functioning Scale the psychotic PTSD group showed a mean of 5.3 (SD = 5.9); the psychotic group a mean of 4.9 (SD = 4.3); and the PTSD group a mean of 7.0 (SD = 6.0).

Data in Table 1 suggest that Caucasian and African-American subjects are not distributed evenly across the three study groups. Both the psychotic PTSD group and the psychotic group are predominantly African-American, while the PTSD group is split relatively evenly between both racial groups. A chi-square analysis confirms that such a distribution is not likely to occur by chance; x2 (2, N = 62) = 17.49, p = .002. To examine the possibility that the African-Americans in our sample might exhibit a different pattern of results than those demonstrated by the rest of the sample, ANOVAs were performed comparing African-American subjects with the other subjects on all 14 of the dependent variables used in this study. These data indicated that the pattern of results shown by the African-American sub- sample was identical to the pattern exhibited by the rest of our sample. To examine the possibility that different ethnic groups might exhibit divergent patterns of PTSD responses, the PTSD group was divided into two sub- groups (African-American vs. Caucasian), and t-tests were performed on all 14 variables. Caucasians exhibited higher levels of psychopathology than

82 Sautter, Brailey, Uddq Hamilton, Beard, and Borges

African-Americans as measured by the general psychopathology subscale of the PANSS, F(1, 20) = 5.31, p = .032; mean scores of 35.6 (SD = 6.3) and 30.5 (SO = 3.3), respectively. None of the other measures of psychopathology reached statistical significance. Given that only 1 of 28 significance tests was positive, it is reasonable to conclude that ethnicity does not account for the group differences reported in this study.

Discussion

There have been relatively few empirical studies of psychotic symptoms in patients with FTSD. The paucity of empirical studies in this area is sur- prising because it would appear that a substantial number of Viet Nam veterans suffer from PTSD and also demonstrate psychotic symptoms. The only epidemiologic study to systematically assess psychotic symptoms in Viet Nam veterans reported a lifetime comorbidity of 11% between PTSD and schizophrenia (Davidson et al., 1991), but did not report the lifetime risk for schizoaffective disorder, major depression with psychotic symptoms, or the atypical psychotic disorders which are frequently reported to co-occur with PTSD in clinical studies. Studies of clinical populations indicate that as many as 29% to 35% of treatment-seeking PTSD patients may show psychotic symptoms (Hamner, 1996; Hryvniak & Rosse, 1989; Jackson et al., 1996; Wilcox et al., 1991).

Although these studies clearly document the presence of psychotic symptoms in a substantial number of patients who have sought treatment for their PTSD, investigators have not assessed the effect of psychotic symptoms on patient functioning when they co-occur with PTSD. The effect of the association of psychotic and PTSD symptoms was assessed in the present investigation by comparing patients who suffer from both a psychotic disorder and PTSD with patients who suffer from PTSD without evidence of psychotic symptoms or from a psychotic disorder without evidence of PTSD. This comparison allowed us to determine if the combination of PTSD and psychotic symptoms is more disruptive of patient functioning than PTSD or psychotic symptoms alone.

The data from this study indicate that patients with both PTSD and a psychotic disorder show significantly higher scores on PANSS scales that assess positive psychotic symptoms, paranoia, violence potential, and general psychopathology than patients who suffer primarily from PTSD or a psychotic disorder. The fact that outpatients with PTSD and psychotic symptoms showed higher levels of psychopathology than patients with psychotic disorders who had been recruited from a psychiatric inpatient unit demonstrates a high level of impairment in these psychotic PTSD patients.

Posttraumatic Stress Disorder with Cornorbid Psychotic Disorder 83

Normally, inpatients are expected to show higher levels of impairment than outpatients. These results suggest that PTSD and psychotic symptoms com- bine to produce much higher levels of positive psychotic symptoms, paranoid thinking, and violent thoughts, affects and behaviors, than are associated with PTSD or psychotic disorder when they occur alone. The psychotic PTSD group and the PTSD group did not differ significantly on the Past Feelings and Acts of Violence Scale (Plutchik et al., 1976) although the Psychotic PTSD Group did show a higher mean score (A4 = 16.3) than the PTSD group (M = 13.0) (see Table 3).

It is important to note that the somewhat different results from the two violence scales may be due to the fact that the Past Feelings and Acts of Violence Scale (PFAV) (Plutchik et al., 1976) is a self-report scale and patients may have attempted to minimize presentation of their violent thoughts, feelings, and behaviors. The Aggression Risk Profile (Kay, 1991) is an interview-driven rating instrument that is less likely to be influenced by the defensiveness of the patient than the PFAV It is also important to note that the psychotic PTSD and PTSD groups did not differ on scales designed to measure PTSD symptoms. This indicates that the increased intensity of psychotic symptoms and psychopathology in the psychotic PTSD group is not due to the presence of more severe PTSD symptoms.

The data from this study have important clinical implications. An ex- amination of the means of the PANSS subscales shown in Table 3 indicate that the psychotic PTSD patients demonstrated much higher levels of paranoid thinking and violent thoughts, feelings, and behaviors than the other two groups. These differences account for the significant group differences attained on the primary scales that assess positive psychotic symptoms and general psychopathology. This suggests that psychotic symptoms interact with PTSD symptoms to increase paranoid delusions and violent thoughts, feelings, and behaviors. The fact that outpatients with PTSD and psychotic symptoms show higher levels of paranoia and violent thoughts, feelings, and behaviors than either PTSD patients or psychotic patients on an inpatient psychiatric unit, underscore the importance of designing clinical interventions that address the extremely high levels of agitation and paranoia shown by these severely ill PTSD patients. The control of these symptoms will require the development of new pharmacological interventions that tar- get agitation and paranoid behavior. Behavioral approaches need to be developed for the control of agitation and suspiciousness in PTSD patients with psychotic thought processes. While there are considerable data regard- ing the utility of specific psychosocial interventions with both the chronic psychoses (Scott & Dixon, 1995) and PTSD (Fairbank et al., 1994), there have not been any published studies that have addressed the manner in


which these treatments could be combined to optimally treat individuals that suffer from both PTSD and a psychosis.

The results of this study showed that the three groups did not differ in their interpersonal and occupational role functioning. One reason the three groups do not show significant differences in interpersonal and occupational role functioning is because all three groups exhibit severe impairment in these behavioral domains. This severe functional impairment is expected in the Psychotic Group, the chronic psychoses have been associated with relatively enduring deficits in occupational and social functioning (TZSuang, Woolson, & Fleming, 1979). Severe functional deficits would be expected to be especially prominent in our psychotic group because these patients had been hospitalized for a psychotic episode even though most of them had been treated for their psychoses for over 20 years. Fur- ther, patients hospitalized on the Inpatient Psychiatric Unit at the New Orleans VAMC are typically required to be psychotic to the extent that they represent a danger to themselves or others. The finding that the PTSD and psychotic group showed similar levels of social and occupational role impairment indicates that PTSD is associated with similar levels of functional impairment as chronic major mental disorders such as schizophrenia and the psychotic affective disorders. These findings are consistent with a recent archival analysis of data from the National Vietnam Veterans Re- adjustment Study that showed that markedly diminished quality of life, im- paired occupational role functioning, and compromised physical health are associated with PTSD (Zatzick et al., 1997).

A noteworthy feature of the Psychotic PTSD group is their relatively high incidence of past alcohol or drug dependence. This comorbid disorder could potentially explain the high levels of psychopathology exhibited by this group. To investigate this possibility, correlations within the psychotic PTSD group were computed between level of lifetime alcohol or drug dependence (measured as a dichotomous variable in the SCID) and each of the psychopathology measures previously discussed. None of these correlations were significant, suggesting that level of past alcohol or drug dependence is not directly related to level of psychopathology within the psychotic PTSD group.

There are at least three theoretical explanations for the finding that psychotic PTSD patients show significantly higher levels of psychopathology than patients who receive a diagnosis of either psychotic disorder or PTSD. First, patients with both PTSD and psychotic symptoms may suffer from two etiologically independent disorders (PTSD and a psychotic disorder) which interact to exacerbate positive psychosis, paranoia and violent thoughts, feelings, and behaviors. The second theoretical explanation is that psychotic PTSD patients have a single disorder that is an especially severe


subtype of PTSD that is characterized by psychotic symptoms (Kumar et al., 1994; Mueser & Butler, 1987; Wilcox et al., 1991). A third theoretical explanation is that patients with PTSD and psychotic symptoms suffer from a primary psychotic disorder that lowers their threshold for subsequent epi- sodes of PTSD. This theory conceptualizes PTSD with comorbid psychosis as a “postpsychotic syndrome” (McGarry et al., 1991). There are undoubt- edly other theoretical explanations as well. There are insufficient data to currently test the validity of these theoretical explanations. Further research needs to be conducted in order to develop a better understanding of the etiology that underlies cases of comorbid PTSD and psychosis.

Many previous studies of PTSD with psychotic symptoms have not used standardized diagnostic methods to diagnose psychotic disorder (But- ler et al., 1996; Hryvniak & Rosse, 1989; McGarry et al., 1991; Mueser & Butler, 1987; Wilcox et al., 1991). The current study used standardized diagnostic assessments, and it was found that patients with PTSD and psychosis may meet DSM-IV criteria for either major depression with psychotic features, schizophrenia, or schizoaffective disorder. These findings reflect the fact that clinical samples with PTSD and psychosis are a diagnostically heterogeneous group. These findings are consistent with the idea that PTSD is a heterogeneous disorder (Yehuda & McFarlane, 1995). It is important that future studies in this area use standardized assessment tools to rigorously define more homogeneous study groups.

There are a number of problems with this investigation that should to be addressed in future studies in this area. First, patients were not systematically assessed for the presence of dissociative symptoms. Patients with dissociative identity disorder have been shown to evidence positive symptoms of psychosis (Ellason & Ross, 1995), and dissociative and psychotic symptoms often are very difficult to discriminate. Further studies in this area should include standardized assessments of dissociative symptoms. Second, there was considerable diagnostic heterogeneity in all three study groups. The psychotic PTSD group was heterogeneous in that it included patients with DSM-IV schizophrenia, schizoaffective disorder, and affective psychotic disorder; the psychotic groups contained patients with schizophrenia, schizoaffective disorder, and affective disorder; and the majority of the patients in the PTSD groups also met DSM-IV criteria for another comorbid disorder. In addition, a significant number of patients in all three study groups had met DSM-IV criteria for a past substance dependence disorder. We did not have a sufficient number of patients to form the number of more homogeneous groups necessary to conduct meaningful comparisons of patients receiving different diagnoses within each of the study groups. Future studies should use more homogeneous study samples. Third, we did not assess the potential role of trauma exposure, other than combat trauma,


that might be associated with the symptoms assessed in this study. For ex- ample, a patient may have been exposed to crime-related trauma and impairment from these trauma could account for some group differences. Fourth, the three groups in this study consisted of very modest numbers of patients who were entirely male, in their ~ O S , and whose PTSD was com- posed exclusively of combat- related PTSD. This limits the generalizability of the findings. These results should be interpreted conservatively.

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Documents

PTSD and comorbid psychotic disorder: Comparison with veterans diagnosed with PTSD or psychotic disorder