Early Psychosis and Trauma-Related Disorders: Clinical Practice

99 Pages·2017·1.47 MB·English

Antioch University
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Dissertations & Theses
2017
Early Psychosis and Trauma-Related Disorders:
Clinical Practice Guidelines and Future Directions
Casey A. Cragin
Antioch University, New England
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Cragin, Casey A., "Early Psychosis and Trauma-Related Disorders: Clinical Practice Guidelines and Future Directions" (2017).
Dissertations & Theses. 340.
http://aura.antioch.edu/etds/340
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Running head: EARLY PSYCHOSIS AND TRAUMA-RELATED DISORDERS
Early Psychosis and Trauma-Related Disorders:
Clinical Practice Guidelines and Future Directions
by
Casey A. Cragin
B.A., College of the Holy Cross, 2010
M.S., Antioch University New England, 2014
DISSERTATION
Submitted in partial fulfillment for the degree of
Doctor of Psychology in the Department of Clinical Psychology
at Antioch University New England, 2017
Keene, New Hampshire
EARLY PSYCHOSIS AND TRAUMA-RELATED DISORDERS ii

Department of Clinical Psychology

DISSERTATION COMMITTEE PAGE

The undersigned have examined the dissertation entitled:

EARLY PSYCHOSIS AND TRAUMA-RELATED DISORDERS:
CLINICAL PRACTICE GUIDELINES AND FUTURE DIRECTIONS

presented on February 10, 2017

by

Casey A. Cragin
Candidate for the degree of Doctor of Psychology
and hereby certify that it is accepted*.

Dissertation Committee Chairperson:
Martha B. Straus, PhD

Dissertation Committee members:
William Slammon, PhD
Tara Niendam, PhD

Accepted by the

Department of Clinical Psychology Chairperson
George Tremblay, PhD
on 2/10/17

* Signatures are on file with the Registrar’s Office at Antioch University New England.
EARLY PSYCHOSIS AND TRAUMA-RELATED DISORDERS iii
Table of Contents
Acknowledgements ......................................................................................................................... v
Abstract ........................................................................................................................................... 1
Review of Relevant Literature .................................................................................................... 2
Significance ............................................................................................................................... 10
Conceptual Framework ............................................................................................................. 15
Objectives and Rationale .......................................................................................................... 16
Summary and Research Questions ............................................................................................ 17
Methodology ................................................................................................................................. 19
Participants ................................................................................................................................ 19
Procedures ................................................................................................................................. 20
Results ........................................................................................................................................... 24
Quantitative Results .................................................................................................................. 24
Qualitative Results .................................................................................................................... 38
Discussion ..................................................................................................................................... 44
Clinical Practice Guidelines ...................................................................................................... 44
Recommendations for Future Research .................................................................................... 48
Implications for Clinical Practice ............................................................................................. 52
Limitations ................................................................................................................................ 54
Conclusions ............................................................................................................................... 55
References ..................................................................................................................................... 58
Appendix A: Early Psychosis Programs in the United States ....................................................... 67
Appendix B: Email to Prospective Participants ............................................................................ 71
Appendix C: Survey ...................................................................................................................... 72
Appendix D: Definitions of Key Terms ........................................................................................ 89
Appendix E: Definitions of Interventions ..................................................................................... 90
Appendix F: Institutional Review Board Approval for Exempt Status ........................................ 92
EARLY PSYCHOSIS AND TRAUMA-RELATED DISORDERS iv

List of Tables
Table 1 .......................................................................................................................................... 26
Table 2 .......................................................................................................................................... 27
Table 3 .......................................................................................................................................... 29
Table 4 .......................................................................................................................................... 30
Table 5 .......................................................................................................................................... 30
Table 6 .......................................................................................................................................... 32
Table 7 .......................................................................................................................................... 33
Table 8 .......................................................................................................................................... 34
Table 9 .......................................................................................................................................... 36
EARLY PSYCHOSIS AND TRAUMA-RELATED DISORDERS v
Acknowledgements
Thank you to Antioch University New England and University of California Davis
faculty, staff, and students for all you have taught me, the culmination of which this project
represents. Especially, to my dissertation committee—Martha Straus, PhD, Tara Niendam, PhD,
and William Slammon, PhD— for everything you have done along the way to help this project
and me shine. Also to Gina Pasquale, PsyD for D.L.S. and cloth monkeys, and to Brian
Denietolis, PsyD, for footballs and seashells.
Thank you also to those who helped to improve the outcome of this project despite
having no obligation to do so. To Dawn Blacker, PhD and Laura Tully, PhD for contributions to
the conception of this project and assistance with editing. To Satinder Gill, PsyD, Rachel Loewy,
PhD, and Laura Tully, PhD for assistance with survey development. To Divya Kumar for
assistance with managing data collection. To Brandi Hawk, PhD, for assistance with data
analysis.
Finally, thank you to my family and friends for continued interest in this project—and
me—despite intermittently being met with overwhelming enthusiasm and irritability throughout.
To Ed, Tracey, Dottie, and Kait for cuddling our little guy during the home stretch. To Beth for
full-friendship and half-cupcakes. Most of all, to my husband, Dylan, for endless love and
support. I likely would not have started this journey, or completed it, without your
encouragement.
EARLY PSYCHOSIS AND TRAUMA-RELATED DISORDERS vi

To the courageous young people who have inspired this work
EARLY PSYCHOSIS AND TRAUMA-RELATED DISORDERS 1
Abstract
Despite very 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 evidence that could inform such clinical practice guidelines. While preliminary research
evidence suggests that traditional, empirically supported 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 interventions of choice for addressing
both trauma symptoms and psychotic symptoms. In addition, case management was rated as an
intervention of choice for addressing psychotic symptoms. No consensus was reached on expert
consensus items regarding the appropriateness of a parallel treatment approach for the treatment
of comorbid early psychosis and trauma-related disorders, sensorimotor or movement
interventions for addressing trauma symptoms, or exposure interventions for addressing
psychotic symptoms. In areas where expert consensus exists, clinical practice guidelines for the
treatment of comorbid early psychosis and trauma-related disorders are offered in accordance
with the expert consensus method. In areas where expert consensus does not exist,
EARLY PSYCHOSIS AND TRAUMA-RELATED DISORDERS 2
recommendations for future research are proposed. 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.
Keywords: early psychosis; trauma; posttraumatic stress disorder;
clinical practice guidelines; expert consensus
EARLY PSYCHOSIS AND TRAUMA-RELATED DISORDERS 3
Psychosis and Trauma-Related Disorders: Clinical Practice Guidelines and Future Directions
Rates of trauma-related disorders are higher among individuals with early psychosis (i.e.,
less than five years since the onset of threshold psychotic symptoms) than would be expected
based on general population estimates (Achim et al., 2011; Strakowski, Keck, McElroy,
Lonczak, & West, 1995), yet no clinical practice guidelines exist for treating comorbid early
psychosis and trauma-related disorders. The collection of research evidence that could inform
such clinical practice guidelines has been limited historically by the routine exclusion of
individuals with past and present psychosis from participation in trauma research and practice
(Becker, Zayfert, & Anderson, 2004; Litz, Blake, Gerardi, & Keane, 1990; Ronconi, Shiner, &
Watts, 2014). 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 (de Bont, van Minnen, & de Jongh, 2013; Frueh et al.,
2009; Mueser et al., 2008; van den Berg & van der Gaag, 2012); however, it remains unclear
whether such treatments are appropriate for individuals with early psychosis.
Review of Relevant Literature
Here, the relevant literature on trauma, psychosis, and related disorders is briefly
reviewed before describing the significance, conceptual framework, and objectives and rationale
of the current study.
Trauma and related disorders. A traumatic event is defined as a situation in which an
individual is exposed to “actual or threatened death, serious injury, or sexual violence”
(American Psychiatric Association, 2013, p. 217). Exposure includes directly experiencing the
traumatic event, witnessing the traumatic event occur to another person, learning about the
traumatic event occurring to a close family member or friend, or directly experiencing repeated