People with a psychotic disorder and post-traumatic stress disorder (PTSD) can benefit greatly from trauma therapy. Prolonged exposure therapy, EMDR and cognitive therapy all significantly reduce PTSD symptoms, according to new research by Vrije Universiteit Amsterdam and Parnassia Group.
People with psychosis have often experienced traumatic events. These experiences can lead to PTSD, with symptoms such as nightmares, flashbacks, sleep problems and a persistent sense of being unsafe. It is estimated that more than 230,000 people in the Netherlands currently have PTSD.
For a long time, however, clinicians have been reluctant to offer trauma therapy to people with psychotic disorders. Healthcare professionals fear that revisiting and processing traumatic memories could worsen psychotic symptoms, such as hearing voices or experiencing severe paranoia. As a result, people with psychotic disorders are still regularly excluded from trauma-focused treatment.
“We therefore wanted to investigate whether this reluctance was justified,” says clinical psychologist and lead researcher David van den Berg. Together with his colleagues, he followed 162 people with PTSD and a psychotic disorder. In addition to their usual treatment for psychosis, participants were randomly assigned to receive prolonged exposure therapy, EMDR or cognitive therapy. A fourth group did not receive trauma therapy during the study period. “This allowed us to investigate whether these treatments are also effective for a group of people for whom trauma therapy has long been far from routine.”
Significant in PTSD symptoms
The results are clear: all three trauma therapies reduced PTSD symptoms significantly more than in the group that did not receive trauma therapy. After six months, 45 per cent of participants who received prolonged exposure therapy no longer met the diagnostic criteria for PTSD. The figures were 44 per cent for EMDR and 56 per cent for cognitive therapy, compared with 25 per cent in the control group.
“That is a particularly striking difference,” says Van den Berg. “We are not only seeing a reduction in symptoms, but also that around half of those who received trauma therapy no longer met the diagnostic criteria for PTSD after six months.”
Other trauma-related difficulties also decreased. Participants reported fewer symptoms of low mood and dissociation, as well as fewer negative thoughts about their trauma. However, the treatments did not have a clearly demonstrable effect on psychotic symptoms such as paranoia and hearing voices.
Effective even after twenty years of symptoms
Notably, participants had been experiencing PTSD symptoms for an average of more than twenty years and psychotic symptoms for approximately nineteen years. This makes the treatment outcomes particularly significant: even among people with long-standing and complex mental health difficulties, a relatively short course of treatment involving no more than sixteen sessions proved capable of making a substantial difference.
“Many of these people have been receiving treatment for severe mental health difficulties for years. That makes it all the more remarkable that trauma therapy can still make such a significant difference. Seeing such clear improvements in this particular group demonstrates that people with long-standing and complex symptoms can also benefit greatly from trauma therapy,” says Van den Berg.
Psychosis should not be a barrier to trauma treatment
According to Van den Berg, the most important message for clinicians is that people with psychosis should not automatically be excluded from trauma therapy. “These treatments are effective and safe. Withholding them may actually be doing people a disservice.”
As prolonged exposure therapy, EMDR and cognitive therapy are all effective, he believes it is important that patients are involved in deciding which treatment is best suited to their needs.
Van den Berg also believes there is an important task for policymakers. Previous research by his team has shown that trauma treatment not only improves health outcomes but can also reduce healthcare costs, as people require less care afterwards. At the same time, there is a shortage of therapists working in psychosis services. “If we know these treatments work, we must also ensure there is sufficient capacity to provide them.”
The study was published in the scientific journal Psychological Medicine. VU researchers Simone Burger, Inez Verdaasdonk and Catherine van Zelst also contributed to the study.
