Factor structure of posttraumatic stress disorder (PTSD) in persons with serious mental illness.

BACKGROUND: Trauma and posttraumatic stress disorder (PTSD) are common among individuals with serious mental illness (SMI; e.g., schizophrenia, schizoaffective disorder, bipolar disorder, treatment refractory major depressive disorder), with resultant functional impairment. Previous studies have not evaluated the factor structure of the PTSD Checklist (PCL) among persons with SMI. AIMS: This study evaluated the factor structure of the PCL in two large SMI samples from public mental health treatment sectors screened for PTSD using the PCL. METHODS: Four different models of PTSD were tested using confirmatory factor analyses. RESULTS: Results indicated that the DSM-5 4-factor model (intrusion, avoidance, numbing, and hyperarousal) had the best fit. Further, the DSM-5 4-factor model demonstrated measurement invariance. CONCLUSIONS: Results supported the suitability of the DSM-5 4-factor model of PTSD among people with SMI.

Diagnostic profiles and trauma history among treatment-seeking young adults with positive post-traumatic stress disorder screens: Findings and implications for public mental health care.

OBJECTIVES: This study examined diagnostic profiles and trauma history among treatment-seeking young adults with positive PTSD screens in public mental health care. METHODS: Screening for trauma history and PTSD symptoms was implemented in a community mental health service system. 266 treatment-seeking young adults (aged 18-35) endorsed trauma exposure with a score of at least 45 on the DSM-IV PTSD Checklist, indicating probable PTSD. RESULTS: Young adults with positive PTSD screens were predominantly female, minority, and diagnosed with mood disorders. Of those with positive screens, only 15% had a chart diagnosis of PTSD; 17.3% (ages 18-24) versus 14.1% (ages 25-35). Variables significantly associated with a decreased likelihood of PTSD detection included a diagnosis of schizophrenia or bipolar disorder, exposure to fewer types of traumatic events, male gender, and white race. CONCLUSION: Routine PTSD screening for young adults receiving public mental health care should be prioritized to address long-term impacts of trauma.

Who is afraid of Hermy and Jimmy? Relating to and normalizing psychosis through theater.

OBJECTIVE: Psychotic experiences, such as hearing voices that others do not hear, being afraid of threats that others do not perceive, or believing in ideas that others find implausible can be confusing for those who face them and challenging to relate to for those who do not, leading to alienation and social exclusion. The objective of this article is to discuss how immersion in theater can enhance our understanding of human nature and facilitate a social environment that supports the recovery of individuals with psychosis. METHODS: Drawing on theories of the psychology of art and narrative psychology, this conceptual article discusses a theatrical production, a play, titled "Voices," created by a person with lived experience of voice hearing. We apply Semenov's model of art as a social psychological system as a guiding framework to focus on the roles of the art product, artist-author, artist-performer, and recipient. RESULTS: Theater is a uniquely reciprocal art form where actors and spectators share emotional, intellectual, and cathartic experiences, which could foster interpersonal connection, personal growth, and empathy. This article brings new perspective on how theater can elucidate psychotic experiences, encourage dialogue about these experiences, and facilitate social integration and recovery of individuals living with psychosis. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Theater can promote social change, making space for a wider range of perspectives in society. Engaging individuals with lived experiences of psychosis in theatrical productions could lead to new insights about and acceptance of psychotic experiences, both for these individuals and for society at large. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Post-Traumatic Cognitions Inventory (PTCI): psychometric properties in clients with serious mental illness and co-occurring PTSD.

BACKGROUND: People with post-traumatic stress disorder (PTSD) exhibit negative cognitions, predictive of PTSD severity. The Post-Traumatic Cognitions Inventory (PTCI) is a widely used instrument measuring trauma-related cognitions and beliefs with three subscales: negative thoughts of self (SELF), negative cognitions about the world (WORLD), and self-blame (BLAME). AIMS: The current study attempted to validate the use of the PTCI in people with serious mental illness (SMI), who have greater exposure to trauma and elevated rates of PTSD, using confirmatory factor analysis (CFA) and examining convergent and divergent correlations with relevant constructs. METHOD: Participants were 432 individuals with SMI and co-occurring PTSD diagnosis based on the Clinician Administered PTSD Scale, who completed PTCI and other clinical ratings. RESULTS: CFAs provided adequate support for Foa's three-factor model (SELF, WORLD, BLAME), and adequate support for Sexton's four-factor model that also included a COPE subscale. Both models achieved measurement invariance at configural, metric and scalar levels for three diagnostic groups: schizophrenia, bipolar and major depression, as well as for ethnicity (White vs Black), and gender (male vs female). Validity of both models was supported by significant correlations between PTCI subscales, and self-reported and clinician assessed PTSD symptoms and associated symptoms. CONCLUSIONS: Findings provide support for the psychometric properties of the PTCI and the conceptualization of Sexton's four-factor and Foa's three-factor models of PTCI among individuals diagnosed with SMI (Foa et al., ).

Predictors of undocumented PTSD in persons using public mental health services.

Individuals diagnosed with serious mental illness (SMI) have greater trauma exposure and are at increased risk for posttraumatic stress disorder (PTSD). However, PTSD is rarely documented in their clinical records. This study investigated the predictors of PTSD documentation among 776 clients with SMI receiving public mental health services, who had probable PTSD as indicated by a PTSD Checklist score of at least 45. Only 5.3% of clients had PTSD listed as a primary diagnosis, and 8.4% had PTSD as a secondary diagnosis, with a total 13.7% documentation rate. PTSD documentation rate was highest for clients with major depression (18.8%) compared to those with schizophrenia (4.1%) or bipolar disorder (6.3%). Factors that predicted a lower likelihood of having a chart diagnosis of PTSD included being diagnosed with schizophrenia/schizoaffective disorder or bipolar disorder. Factors that predicted a higher likelihood of having a chart diagnosis of PTSD included being of non-white race, being female, and experiencing eight or more types of traumatic events. Findings highlight the need for PTSD screening and trauma informed care for clients with SMI receiving public mental health services.

Psychometric properties of post-traumatic stress disorder (PTSD) checklist for DSM-5 in persons with serious mental illness.

BACKGROUND: PCL-5 is a self-report measure consisting of 20 items that are used to assess the symptoms of Post-Traumatic Stress Disorder (PTSD) according to the DSM-5. OBJECTIVE: This study evaluated the factor structure of the Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) in people with serious mental illness. METHOD: The sample in Study 1 included 536 participants with serious mental illness who were receiving supported employment services through community mental health agencies or supported housing programmes. Confirmatory factor analysis assessed the fit of six different models of PTSD. RESULTS: Results indicated that Armour's Hybrid 7-factor model composed of re-experiencing, avoidance, dysphoria, dysphoric arousal, anxious arousal, negative affect, anhedonia, and externalizing behaviours demonstrated the best fit. Study 2 found support for convergent validity for PCL-5 among 132 participants who met criteria for PTSD. CONCLUSION: Findings provide support for the psychometric properties of the PCL-5 and the conceptualization of the 7-factor hybrid model and the 4-factor DSM-5 model of PTSD among persons living with serious mental illness.

Antecedentes:PCL-5 es una medida de autoinforme que consta de 20 ítems que se utilizan para evaluar los síntomas del TEPT de acuerdo al DSM-5.Objetivo:Este estudio evaluó la estructura factorial de la Lista de verificación de Trastorno de Estrés Postraumático (TEPT) para DSM-5 (PCL-5) en personas con enfermedades mentales graves.Método:La muestra del Estudio 1 incluyó a 536 participantes con enfermedad mental grave que estaban recibiendo servicios de empleo subvencionado a través de agencias comunitarias de salud mental o programas de vivienda subvencionados. El análisis factorial confirmatorio evaluó el ajuste de seis modelos diferentes de TEPT.Resultados:Los resultados indicaron que el modelo híbrido de 7 factores de Armour - compuesto de reexperimentación, evitación, disforia, excitación disfórica, excitación ansiosa, afecto negativo, anhedonia y conductas de externalización - demostró el mejor ajuste. El estudio 2 encontró sustento para la validez convergente de PCL-5 entre 132 participantes que cumplieron con los criterios para TEPT.Conclusión:Los hallazgos respaldan las propiedades psicométricas del PCL-5 y la conceptualización del modelo híbrido de 7 factores y el modelo DSM-5 de 4 factores de TEPT entre personas que viven con una enfermedad mentales graves.

Understanding explanatory mechanisms for racial and ethnic differences in mental health stigma: the role of vertical individualism and right-wing authoritarianism.

BACKGROUND: Mental health (MH) stigma is pervasive worldwide. Culturally sensitive stigma reduction programs are needed to reduce MH stigma. AIMS: To determine racial/ethnic and cultural predictors of stigma. METHOD: The current study examined the relationship between cultural orientation (individualism-collectivism beliefs), race/ethnicity, and political beliefs (right-wing authoritarianism [RWA]). Participants (N = 951) from the United States completed an online survey for this cross-sectional study. RESULTS: Findings indicated that vertical individualism is a consistent, though modest, predictor of multiple dimensions of MH stigma, controlling for other predictors. Contrary to what was hypothesized, vertical individualism did not mediate the relationship between Asian-American race/ethnicity and MH stigma, but was found to mediate the relationship between RWA and stigma. A novel finding was that RWA mediated the relationship between African-American race/ethnicity and multiple MH stigma domains. CONCLUSIONS: Findings therefore indicate that the endorsement of authoritarian views, rather than vertical-individualism (which advances the idea that everyone is in competition), is the primary mechanism of MH stigma differences between African-Americans and individuals from other racial/ethnic groups. A major implication from this study is that efforts to address MH stigma among specific cultural groups should incorporate a sensitivity to the role of both RWA and vertical individualism in facilitating stigma.

I feel frozen: Client perceptions of how posttraumatic stress disorder impacts employment.

Objective: There is evidence that posttraumatic stress disorder (PTSD) is a hidden barrier to employment among individuals with serious mental illnesses (SMI) among whom PTSD is highly prevalent. This study aimed to explore how PTSD interferes with achieving employment outcomes among persons with SMI. Methods: Participants included 119 individuals with SMI and co-occurring PTSD receiving Supported Employment services. Responses to the question, "In what ways are PTSD symptoms interfering with your work during the past month?" were analyzed. Results: Six themes emerged: (a) I don't like being around people, (b) I feel frozen and unable to get started, (c) troubling negative affect, (d) mind is scattered and all over the place, (e) feeling fatigued all the time, and (f) flashbacks and triggers can happen whenever. Conclusions and Implications for Practice: Findings provide insight into how PTSD symptoms impact work outcomes and suggest that there is a need for Supported Employment providers to screen clients for trauma exposure to identify those in need of additional support in order to improve work outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The impact of illness identity on recovery from severe mental illness: A test of the model.

OBJECTIVE: The Illness Identity model posits that self-stigma reduces hope and self-esteem among persons with severe mental illnesses, impacting a range of outcomes. The "insight paradox" anticipates that the negative effects of self-stigma are amplified by insight. This study tested these predictions using both cluster and path analyses. METHOD: A total of 117 participants meeting the criteria for schizophrenia-spectrum disorders completed measures of self-stigma, self-esteem, hopelessness, insight, social functioning, coping, and symptoms. RESULTS: Cluster analysis supported the insight paradox; persons with low self-stigma/high insight had fewer psychiatric symptoms and better interpersonal functioning than persons with high self-stigma/low insight. Path analysis did not support the insight paradox, but indicated that self-stigma and insight impact different outcomes. DISCUSSION: Findings suggest that support for the predictions of the Illness Identity model and insight paradox are supported may depend on analytic method. CONCLUSIONS: Finding suggest that the benefits of self-stigma reduction may be constrained by insight.

Where are all the psychologists? A review of factors impacting the underrepresentation of psychology in work with serious mental illness.

Over the last few decades, clinical psychologists have played a key role in the development of empirically-validated psychosocial interventions for those with serious mental illness (SMI). However, in contrast to these substantial contributions, clinical psychologists in the United States are grossly underrepresented in treatment provision with this population (Roe, Yanos, & Lysaker, 2006; Rollins & Bond, 2001). This review aims to highlight various factors contributing to the establishment and perpetuation of this underrepresentation. First, we highlight systemic factors (e.g., the emergence of managed care) through an examination of the evolving role of the clinical psychologist. Next, we review training-based factors (e.g., limitations to SMI specific training) through a review of training in clinical psychology. Through an examination of training factors, the role of mental health stigma amongst clinicians toward individuals with SMI is identified as a potential perpetuating factor of this underrepresentation. Factors associated with clinician stigma are then reviewed and the relationship between clinical training and clinician stigma is considered. Lastly, important future directions to further investigate and address this underrepresentation are suggested - namely, investigating factors (training and individual) that may impact clinical psychology doctoral students' attitudes toward those with SMI.

Trauma Exposure and Prolonged Grief Disorder Among Persons Receiving Community Mental Health Services: Rates and Correlates.

BACKGROUND: Persons with serious mental illnesses (SMIs) are at increased risk for exposure to trauma and posttraumatic stress disorder (PTSD). Prolonged Grief Disorder (PGD) may also impact this population but has been seldom studied. AIMS: The present study investigated the rate of both PTSD and PGD among clients receiving community mental health services, and the clinical correlates of co-occurring PTSD/PGD. METHODS: Trauma history, PTSD and PGD were assessed among 536 individuals receiving community mental health services (Study 1). A subsample of 127 individuals from Study 1 who met DSM-5 criteria for PTSD based on diagnostic interview completed measures of psychiatric symptoms (Study 2). RESULTS: In Study 1, 92.4% of participants receiving community mental health services had experienced a traumatic event, 49.6% met criteria for probable and provisional PTSD, 14.7% scored positive for probable PGD, and 11.9% met criteria for probable and provisional PTSD as well as probable PGD. In Study 2, participants meeting diagnostic DSM-5 criteria for PTSD and probable PGD had more self-reported PTSD symptoms, but did not differ on other outcomes. CONCLUSIONS: Findings highlight the need for trauma informed services including grief counseling for persons with SMI.

Pathways to aggression and violence in psychosis without longstanding antisocial behavior: A review and proposed psychosocial model for integrative clinical interventions.

There is a need for a clearer understanding of the factors associated with increased risk of aggression and violence (AV) among people with psychosis and other severe mental illness (SMI) to guide effective prevention and intervention. The current article (1) reviews the literature regarding psychosocial factors associated with AV among individuals with psychosis and other SMI who do not have longstanding antisocial behaviors, (2) proposes an integrative psychosocial model of AV that can be practically applied, and (3) proposes appropriate evidence-based clinical interventions to reduce AV and facilitate recovery. We propose that increased risk for AV among people with psychosis is driven by anger, which is affected by a range of factors including victimization and situational stressors, social rejection or experiences of discrimination, anxious arousal, and hostile attribution bias related to psychosis. The cumulative effect of these systems is exacerbated by co-occurring substance misuse and increased impulsivity, particularly negative urgency. In consideration of the current psychosocial model and existing evidence-based interventions for AV in individuals with psychosis, we propose that trauma-informed interventions that integrate skills training in emotion regulation, social and interpersonal situations, cognitive restructuring and remediation, and modified prolonged exposure may demonstrate the most promise for this population.

The impact of illness identity on recovery from severe mental illness: A review of the evidence.

The "Illness Identity" model proposed that self-stigma impacts hope and self-esteem and subsequently leads to a cascade of negative effects on outcomes related to recovery among people diagnosed with severe mental illnesses. The purpose of the present review is to take stock of research support for the model. The citation index SCOPUS was reviewed for all papers published in peer-reviewed journals in English between 2010 and 2019 citing one of the initial 3 articles discussing the model: 111 studies met inclusion criteria and were reviewed. The most frequently tested, and supported, aspects of the model were relationships between self-stigma and self-esteem, hope, psychiatric symptoms and social relationships. Least frequently studied areas were relationships with suicide, avoidant coping, treatment adherence and vocational functioning, although they were supported in the majority of studies. The "insight paradox" was also tested in a relatively small number of studies, with mixed results. Findings were robust to geographic location of study, method, and subpopulation studied. Findings indicate that a large body of research has tested, and largely supported, the various components of the Illness Identity model, although some components need further investigation and there is a need for more comprehensive tests of the model.

Cross-sectional and prospective correlates of associative stigma among mental health service providers.

OBJECTIVE: Preliminary research has suggested that mental health clinicians who work with people with severe mental illness may experience associative stigma, and the Clinician Associative Stigma Scale (CASS; Yanos, Vayshenker, DeLuca, & O'Connor, 2017) was recently developed and tested in a cross-sectional, online sample to examine this construct. The purpose of the present study was to further investigate the CASS's psychometric properties, examining associations with measures of burnout, job satisfaction, and "turnover intention" with service providers in a setting directly working with people with severe mental illness (i.e., a community mental health center). Furthermore, we examined these associations over a 6-month period to assess predictive validity of the measure. METHOD: Participants were 68 providers working in a large community mental health center in a midwestern city. Participants completed the CASS as well as measures of burnout, job satisfaction, and turnover intention at 2 points in time (baseline and 6 months later). RESULTS: The CASS significantly predicted burnout (emotional exhaustion and personal accomplishment) and job satisfaction when examined cross-sectionally, even after controlling for demographic characteristics. Longitudinal analyses showed that increased associative stigma was associated with increased burnout and lower job satisfaction over time. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Associative stigma may have negative consequences for mental health service providers, as well as the consumers they serve, and the CASS appears to be a useful tool to study this phenomenon. Associative stigma may be an appropriate target for interventions designed to reduce burnout among mental health providers. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A randomized-controlled trial of treatment for self-stigma among persons diagnosed with schizophrenia-spectrum disorders.

PURPOSE: A substantial body of research indicates that self-stigma is associated with poorer outcomes related to recovery among people with severe mental illnesses. Narrative Enhancement and Cognitive Therapy (NECT) is a structured, group-based approach which targets the effects of self-stigma. A randomized-controlled trial was conducted to examine the efficacy of NECT. METHODS: One hundred and seventy persons, recruited from both outpatient and comprehensive treatment settings, meeting criteria for schizophrenia-spectrum disorders and moderate-to-elevated self-stigma, were randomly assigned to NECT or supportive group therapy and assessed at four time points over the course of nearly a year. Participants completed measures of self-stigma, hope, self-esteem, functioning, psychiatric symptoms, coping with symptoms, and narrative insight. RESULTS: Analyses indicated that NECT participants in outpatient sites improved significantly more over time in self-stigma compared to supportive group therapy participants in outpatient sites, while NECT participants in comprehensive (including day treatment and psychiatric rehabilitation program) sites improved significantly more in hopelessness and narrative insight than other participants. NECT participants as a group showed decreases in the social withdrawal component of self-stigma, decreased in their use of avoidant coping strategies, and were more engaged in treatment than supportive group therapy participants. There was no evidence for effects of NECT on social functioning or psychiatric symptoms. CONCLUSIONS: Findings suggest that NECT primarily impacts self-stigma and related outcomes, and that the degree of its effects is partially dependent on the treatment context in which it is offered.

Internalized stigma in adults with early phase versus prolonged psychosis.

AIM: Although internalized stigma is associated with negative outcomes among those with prolonged psychosis, surprisingly little work has focused on when in the course of one's illness stigma is internalized and the impact of internalization on symptoms or social functioning over the course of the illness. Therefore, this study investigated whether (1) internalized stigma is greater among those later in the course of psychosis and (2) whether internalized stigma has a stronger negative relationship with social functioning or symptoms among those with prolonged compared to early phase psychosis. METHODS: Individuals with early phase (n = 40) and prolonged psychosis (n = 71) who were receiving outpatient services at an early-intervention clinic and a VA medical center, respectively, completed self-report measures of internalized stigma and interview-rated measures of symptoms and social functioning. RESULTS: Controlling for education, race and sex differences, internalized stigma was significantly greater among those with prolonged psychosis compared to early phase. Internalized stigma was negatively related to social functioning and positively related to symptoms in both groups. Furthermore, the magnitude of the relationship between cognitive symptoms and internalized stigma was significantly greater among those with early phase. Stereotype endorsement, discrimination experiences and social withdrawal also differentially related to symptoms and social functioning across the 2 samples. CONCLUSIONS: Findings suggest that internalized stigma is an important variable to incorporate into models of early psychosis. Furthermore, internalized stigma may be a possible treatment target among those with early phase psychosis.

Correlates and moderators of stigma resistance among people with severe mental illness.

Research on factors associated with stigma resistance among people with severe mental illness remains relatively scant. This study aimed to (1) replicate previous findings linking stigma resistance with variables associated with recovery; (2) explore associations between stigma resistance and coping strategies and psychiatric symptoms; (3) compare these associations among individuals with different levels of self-stigma; and (4) examine whether race, age and education moderate these relationships. Analyses of a sample (n = 353) and sub-sample (n = 177) of persons with severe mental illness examined associations between stigma resistance and self-stigma, functional and clinical outcomes, and the moderating impact of age, race, and education on these relationships. Stigma resistance was significantly negatively associated with self-stigma and positively associated with social functioning, self-esteem, problem-centered coping, and symptoms of hostility-excitement, but not other types of symptoms. Race significantly moderated the relationship between stigma resistance and self-stigma, age significantly moderated the relationships between hopelessness and both stigma resistance and self-stigma, and education significantly moderated the relationship between stigma resistance and social functioning. Findings suggest that social circumstances impact the benefit of stigma resistance in complex ways; future work should aim to understand how these experiences impact stigma resistance to inform intervention development.

Political attitudes as predictors of the multiple dimensions of mental health stigma.

BACKGROUND: Mental health (MH) stigma is multidimensional and remains common in the United States and throughout the world. While sociopolitical attitudes such as right-wing authoritarianism (RWA) have emerged as strong predictors of some aspects of MH stigma, no study has assessed the relationship between RWA and multidimensional components of MH stigma, or linked this relationship to a theory of stigma. AIMS: The association between RWA and multiple stigma outcomes, including stereotypes, attributions/negative affect, social distance, microaggressions and help-seeking self-stigma was assessed controlling for covariates, including education, age, social desirability, race/ethnicity, gender, geographic location and prior contact with mental illness. METHOD: A total of 518 US residents (from all geographic regions; convenience sample) completed an online survey. RESULTS: Findings indicated that RWA was significantly associated with all MH stigma dimensions analyzed, even after controlling for covariates. A hypothesized mediator for this relationship, dangerous world beliefs, was not supported as a theoretical explanation. CONCLUSION: Right-wing authoritarianism predicts various dimensions of mental health stigma, but more research is needed to determine the theoretical underpinnings. These current findings may guide research in this area and be used to target a variety of conservative audiences for stigma reduction.

Self-stigma in PTSD: Prevalence and correlates.

Self-stigma is the internalization of negative societal stereotypes about those with mental illnesses. While self-stigma has been carefully characterized in severe mental disorders, like schizophrenia, the field has yet to examine the prevalence and correlates of self-stigma in post-traumatic stress disorder (PTSD). Thus, we assessed self-stigma in veterans diagnosed with PTSD and compared with veterans with schizophrenia. We further examined associations between PTSD, depressive symptoms and self-stigma in the PTSD sample. Data came from two larger studies of people with PTSD (n = 46) and schizophrenia-spectrum disorders (n = 82). All participants completed the Internalized Stigma of Mental Illness Scale (ISMIS). Results revealed that people with schizophrenia report more experiences of discrimination as a result of stigma than do those with PTSD, but these diagnostic groups did not differ for other subscales. In the PTSD group, feelings of alienation positively correlated with PTSD and depressive symptoms; other subscales positively correlated with depressive symptoms only. Taken together, results suggest a significant level of self-stigma exists among veterans with PTSD, and that self-stigma has an effect on PTSD and commonly comorbid symptoms, like depression. Future work should investigate whether current self-stigma interventions for other groups could be applicable for those with PTSD.