1. Relationship between Trauma and Psychosis in Older Adults with Schizophrenia Nikhil J Palekar, M.D. PGY 1V

2. Outline Clinical Scenario Clinical Scenario Introduction Introduction Study Hypothesis Study Hypothesis Methodology Methodology Results Results Discussion Discussion Clinical Implications Clinical Implications

3. Clinical Scenario Mr. Smith a 67 yr old single A. A male with a Hx of Schizophrenia, Chronic Paranoid type diagnosed at age 25 currently lives with his daughter in Brooklyn. Mr. Smith a 67 yr old single A. A male with a Hx of Schizophrenia, Chronic Paranoid type diagnosed at age 25 currently lives with his daughter in Brooklyn. Medical Hx : HTN, DM, Hypercholesterolemia Medical Hx : HTN, DM, Hypercholesterolemia Substance abuse Hx : Alcohol Dependence Substance abuse Hx : Alcohol Dependence Nicotine Dependence Nicotine Dependence Psycho-social Hx : Gang member at age 15 Psycho-social Hx : Gang member at age 15 No close friends/family members No close friends/family members Financial stressors Financial stressors  Trauma Hx: Multiple physical assaults Witness to murder Witness to murder Nightmare’s and Flashbacks Nightmare’s and Flashbacks

4. Questions for the Audience 1) Is there an association between Mr. Smith’s positive psychotic symptoms and his history of trauma? □ Yes □ No □ Maybe □ Yes □ No □ Maybe 2) Which of these factors could be most associated with Mr. Smith’s history of trauma and current psychosis compared to those without Hx of trauma? A. ETOH use A. ETOH use B. Social isolation B. Social isolation C. Financial Strain C. Financial Strain D. Physical Illness D. Physical Illness E. PANSS negative symptoms E. PANSS negative symptoms F. All of the Above F. All of the Above G. None of the Above G. None of the Above

5. Introduction No documented data has been found on the relationship between trauma and psychosis in the elderly schizophrenic population. No documented data has been found on the relationship between trauma and psychosis in the elderly schizophrenic population. Trauma has been shown to have a significant relationship with psychosis in younger persons with schizophrenia particularly with positive symptoms. Trauma has been shown to have a significant relationship with psychosis in younger persons with schizophrenia particularly with positive symptoms. Prior research has suggested that many individuals with schizophrenia have been exposed to significant trauma, not only after but also prior to the onset of illness. Prior research has suggested that many individuals with schizophrenia have been exposed to significant trauma, not only after but also prior to the onset of illness.

6. Psycho-Analytic Perspective Charcot's "traumatic hysteria" Charcot's "traumatic hysteria"

7. Eugene Bleuler Eugene Bleuler ‘The Schizophrenias’ (Bleuler E. Dementia praecox or the group of schizophrenias. New York, NY: International Universities Press, 1911/1950.) ‘The Schizophrenias’ (Bleuler E. Dementia praecox or the group of schizophrenias. New York, NY: International Universities Press, 1911/1950.)

8. Trauma: Trauma: "An event in the subject's life, defined by its intensity, by the subject's incapacity to respond adequately to it and by the upheaval and long-lasting effects that it brings about in the psychical organization". "An event in the subject's life, defined by its intensity, by the subject's incapacity to respond adequately to it and by the upheaval and long-lasting effects that it brings about in the psychical organization". Repetition Compulsion: Repetition Compulsion:

9. Object Relations Theory: Object Relations Theory: Paranoid-Schizoid Paranoid-Schizoid ↕ Depressive Depressive

10. Cognitive-Behavioral Perspective Negative beliefs about self, world and others (such as ‘I am vulnerable’ and ‘Other people are dangerous’) have been shown to be associated with the development of psychotic experiences. Negative beliefs about self, world and others (such as ‘I am vulnerable’ and ‘Other people are dangerous’) have been shown to be associated with the development of psychotic experiences. Read et al (2004), Garety et al (2001) Read et al (2004), Garety et al (2001) A more recent study has shown that such beliefs specifically formed as a result of trauma are related to psychotic experiences in patients. A more recent study has shown that such beliefs specifically formed as a result of trauma are related to psychotic experiences in patients. KilCommons et al (2005) KilCommons et al (2005)

11. There have been several suggestions that there is a sub-group of schizophrenia that is trauma- induced and characterized by a predominance of positive symptoms. There have been several suggestions that there is a sub-group of schizophrenia that is trauma- induced and characterized by a predominance of positive symptoms. Kingdom, Turkington (2004) and Ross (2004) Kingdom, Turkington (2004) and Ross (2004)  “Traumatic Psychosis” is described as an entity in which trauma has a distinct and specific role in terms of the onset and content of psychotic symptoms. Kingdom, Turkington (2004) Kingdom, Turkington (2004)

12. Biological Perspective Diathesis-Stress Model: Diathesis-Stress Model: Genetic Vulnerability  Hypersensitivity to Stress Genetic Vulnerability  Hypersensitivity to Stress  Traumagenic Neurodevelopmental Model: Read et al (2001) Read et al (2001) Trauma  HPA activation  ACTH   Glucocorticoids Trauma  HPA activation  ACTH   Glucocorticoids     Impaired negative feedback  Changes in Hippocampus Impaired negative feedback  Changes in Hippocampus HPA Activation  Augments DA synthesis and receptors

13. Similarities between effects of traumatic events on the developing brain and the biological abnormalities in Schizophrenia Overactivity of HPA Overactivity of HPA Dopamine, Norepinephrine & Serotonin Abnormalities Dopamine, Norepinephrine & Serotonin Abnormalities Hippocampal damage Hippocampal damage Cerebral atrophy Cerebral atrophy Ventricular enlargement Ventricular enlargement Reversed cerebral asymmetry Reversed cerebral asymmetry

14. Exploring the relationship between trauma and psychosis in Younger Population  A research in Netherlands study involving 4045 subjects aged 18–64 found that those who had experienced emotional, physical, or sexual abuse or neglect before the age of 16 were more likely to report experiencing psychotic symptoms during a 3-year follow-up period. Janssen et al (2004) Janssen et al (2004) A British study of 8580 subjects aged 16–74 found that those who met criteria for a definite or probable psychotic disorder were over 15 times more likely to have been sexually abused at some point in their lifetime. A British study of 8580 subjects aged 16–74 found that those who met criteria for a definite or probable psychotic disorder were over 15 times more likely to have been sexually abused at some point in their lifetime. Bebbington et al (2004) Bebbington et al (2004)

15.  A large population-based study (n = 17,337) found that respondents reporting a history of hallucinations were more likely to have been both physically and sexually abused during childhood. Whitfield at al (2005) Whitfield at al (2005)  A more recent study on 2524 subjects aged 14–24 found that the experience of any lifetime trauma, not restricted to childhood was associated with the development of 3 or more psychotic symptoms. Spauwen et al (2006)  In the schizophrenia group a history of trauma was significantly related to poor communication skills and depressive symptoms. Spence et al (2006) Spence et al (2006)

16. PTSD and Schizophrenia: Similarities and Differences Psychotic Features in Chronic Posttraumatic Stress Disorder and Schizophrenia: Comparative Severity Psychotic Features in Chronic Posttraumatic Stress Disorder and Schizophrenia: Comparative Severity Hamner et al (2000) Hamner et al (2000) 1)Schizophrenic patients had more severe delusions and conceptual disorganization. 1)Schizophrenic patients had more severe delusions and conceptual disorganization. 2)Severity of hallucinations and suspiciousness/persecution were identical between the two groups. 2)Severity of hallucinations and suspiciousness/persecution were identical between the two groups. 3)PANSS negative symptoms and global psychopathology subscales were comparable between the two groups. 3)PANSS negative symptoms and global psychopathology subscales were comparable between the two groups.

17. Study Hypothesis Primary Primary There is an association between trauma and positive symptoms in elderly Schizophrenic patients. There is an association between trauma and positive symptoms in elderly Schizophrenic patients.  Secondary The associated socio-demographic and clinical factors continue to have a significant impact on the relationship between trauma and positive symptoms in the elderly Schizophrenic population. The associated socio-demographic and clinical factors continue to have a significant impact on the relationship between trauma and positive symptoms in the elderly Schizophrenic population.

18. Methods Schizophrenia (S) Group Schizophrenia (S) Group -198 person’s age 55 + who developed schizophrenia before age 45. -198 person’s age 55 + who developed schizophrenia before age 45. -39 % Living Independently -39 % Living Independently -61 % Living in supported community residences -61 % Living in supported community residences Community (C )Comparison Group Community (C )Comparison Group -113 persons derived from random block sampling. -113 persons derived from random block sampling. -Well matched with schizophrenia sample for age, gender and race. -Well matched with schizophrenia sample for age, gender and race.

19. Exclusion : Persons with substantial cognitive impairment. Exclusion : Persons with substantial cognitive impairment. Scales Used: Scales Used: 1) Trauma and Victimization scale (12 Items) - Measures frequency of trauma ( 0 to 3) - Measures frequency of trauma ( 0 to 3) - Stress caused due to trauma ( 0 to 3) - Stress caused due to trauma ( 0 to 3) 2) Other Scales PANNS, DRS, CESD, IADL, Acute Stressor’s Scale,Religiosity Scale, Social network (NAP) PANNS, DRS, CESD, IADL, Acute Stressor’s Scale,Religiosity Scale, Social network (NAP)

21. Dependant variables Dependant variables The Trauma score was computed by multiplying the frequency of traumatic events with the degree of stress. The Trauma score was computed by multiplying the frequency of traumatic events with the degree of stress. Using a median cut-off score on the trauma scale, the trauma group was dichotomized into persons scoring in the Low Trauma Group(3 and below)and High Trauma Group(4 +). Using a median cut-off score on the trauma scale, the trauma group was dichotomized into persons scoring in the Low Trauma Group(3 and below)and High Trauma Group(4 +).  Independent variables 17 independent variables were used in the study based on literature review and earlier findings. 17 independent variables were used in the study based on literature review and earlier findings. Demographic Biological Biological Psychological Psychological Social Social Gender Gender PANSS + PANSS + Use of Spiritualists Use of Spiritualists Prop of Intimate Contacts Age Age PANSS - PANSS - ψ / Therapist Use Financial Strain Financial Strain Race Race PANSS Anxiety PANSS Anxiety Acute Stressors Acute Stressors Education Education IADL IADL Total Meds Total Meds Syndromal Depression Syndromal Depression ETOH Amount ETOH Amount Physical Illness Physical Illness

22. Results Table 1. C Group(n = 113) V/S S Group (n = 198) t df df p Community (C) Schizophrenia (S) 3.5 (6.1) 8.1 (10.7) -4.79 -4.79 308 308 0.001 0.001

23. Table 2. Bivariate Analysis of Trauma among older adults with Schizophrenia Variable Variable Low Trauma High Trauma t / x2 t / x2 df df p Demographic Gender (female) Age Race (white) Education 44.6 % 44.6 % 62.1 62.1 54.5 % 54.5 % 12.8 12.8 53.6 % 53.6 % 60.8 60.8 58.8 % 58.8 % 12.8 12.8 1.62 1.62 1.66 1.66 0.37 0.37 -0.007 -0.007 1 193 193 1 190 190 0.20 0.20 0.10 0.10 0.54 0.54 0.99 0.99 Biological PANSS + PANNS – PANSS anxiety IADL Total Psych Meds Physical Illness Syndromal Dep. ETOH Amount 11.5 11.5 12.3 12.3 1.6 1.6 21.8 21.8 1.9 1.9 1.1 1.1 25.7 % 25.7 % 0.6 0.6 13.6 13.6 11.5 11.5 2.1 2.1 22.5 22.5 2.3 2.3 1.6 1.6 39.2 % 39.2 % 1.8 1.8 -2.45 -2.45 0.92 0.92 -2.69 -2.69 -1.31 -1.31 -1.63 -1.63 2.69 2.69 4.08 4.08 -2.5 -2.5 180 180 196 196 173 173 194 194 184 184 173 173 1 142 142 0.015 0.015 0.36 0.36 0.008 0.008 0.19 0.19 0.10 0.10 0.008 0.008 0.043 0.043 0.013 0.013 Psychological Use of Spiritualists Use of ψ / Therapists Acute Stressors 30.7 % 30.7 % 55.4 % 55.4 % 6.9 6.9 55.7 % 55.7 % 52.6 % 52.6 % 10.4 10.4 12.6 12.6 1.6 1.6 -3.4 -3.4 1 1 191 191 0.001 0.001 0.20 0.20 0.001 0.001 Social Prop. of Intimate Contacts Financial Strain 0.20 0.20 7.7 7.7 0.27 0.27 6.8 6.8 -1.9 -1.9 2.0 2.0 183 183 196 196 0.049 0.049 0.046 0.046

24. Bivariate Analysis Significant variables: High Trauma Group Significant variables: High Trauma Group 1)Higher PANSS positive scores 2)Higher PANSS anxiety scores 3)Higher CESD scores (syndromal depression) 4)Higher ETOH consumption 5)Greater amount of Physical Illnesses 6)Greater use of Spiritualists 7)More Acute Stressors 8)Higher proportion of intimate contacts 9)Increased financial strain

25. Table 3. Logistic Regression Analysis: 17 independent variables High Trauma Group Independent Variable Independent Variable Odds Ratio Odds Ratio 95% Conf Int. 95% Conf Int. p Gender 1.48 1.48 0.73-3.0 0.73-3.0 0.28 0.28 Age 0.99 0.99 0.92-1.06 0.92-1.06 0.82 0.82 Race (white) 1.96 0.93-4.21 0.93-4.21 0.79 0.79 Education 0.99 0.99 0.96-1.03 0.96-1.03 0.76 0.76 PANSS + 1.08 1.08 1.01-1.17 1.01-1.17 0.036 0.036 PANSS - 0.96 0.96 0.88-1.04 0.88-1.04 0.26 0.26 Syndromal Depression 0.64 0.64 0.28-1.49 0.28-1.49 0.31 0.31 Prop. Of Intimate Contacts 2.10 2.10 0.35-12.25 0.35-12.25 0.42 0.42 IADL 1.1 1.1 0.98-1.19 0.98-1.19 0.11 0.11 Total psych meds 1.23 1.23 0.94-1.60 0.94-1.60 0.13 0.13 Use of Psychiatrist/Therapist 0.65 0.65 0.32-1.33 0.32-1.33 0.24 0.24 PANSS anxiety 1.23 1.23 0.89-1.77 0.89-1.77 0.26 0.26 Physical illness 1.23 1.23 0.97-1.72 0.97-1.72 0.083 0.083 Use of Spiritualists 1.77 1.77 0.82-3.85 0.82-3.85 0.15 0.15 Financial strain 0.98 0.98 0.87-1.11 0.87-1.11 0.76 0.76 Stressor 1.03 1.03 0.98-1.10 0.98-1.10 0.23 0.23 ETOH Amount 1.18 1.18 1.03-1.34 1.03-1.34 0.018 0.018

26. Logistic Regression Significant Variables: High Trauma Group Significant Variables: High Trauma Group 1) Higher PANSS positive symptoms 2) Higher ETOH consumption

27. Right Answers 1) Is there an association between Mr. Smith’s positive psychotic symptoms and his history of trauma? YES YES 2) Which of these factors could be most associated with Mr. Smith’s history of trauma and current psychosis compared to those without Hx of trauma? A. ETOH use A. ETOH use B. Social isolation B. Social isolation C. Financial Strain C. Financial Strain D. Physical Illness D. Physical Illness E. PANSS negative symptoms E. PANSS negative symptoms F. All of the Above F. All of the Above G. None of the Above G. None of the Above

28. Discussion The strong association between trauma and positive symptoms exists in elderly persons with Schizophrenia. The strong association between trauma and positive symptoms exists in elderly persons with Schizophrenia. Ongoing and continuing trauma seems to have a significant impact on positive symptoms in schizophrenia in later life, although it is possible that increased positive symptoms may lead to more traumatic events. Ongoing and continuing trauma seems to have a significant impact on positive symptoms in schizophrenia in later life, although it is possible that increased positive symptoms may lead to more traumatic events. The increased alcohol consumption significant in the study has been reported in studies done in younger populations. However, its impact on the elderly with multiple co-morbid medical illnesses merits serious considerations. The increased alcohol consumption significant in the study has been reported in studies done in younger populations. However, its impact on the elderly with multiple co-morbid medical illnesses merits serious considerations.

29.  Patients may be prone to exacerbation and maintenance of their psychotic experiences through being traumatized by the subjective experience of psychosis or through subsequent victimization in the community. Being in the high trauma group pre-disposes the individuals to a greater burden of psychopathology, increased ETOH consumption and possibly increased anxiety, depression, physical illnesses, social isolation and financial strain. Being in the high trauma group pre-disposes the individuals to a greater burden of psychopathology, increased ETOH consumption and possibly increased anxiety, depression, physical illnesses, social isolation and financial strain.

30. In Bivariate analysis, Syndromal depression was significantly higher in high trauma group (39%)as compared to low trauma group (25%). In Bivariate analysis, Syndromal depression was significantly higher in high trauma group (39%)as compared to low trauma group (25%).  PANSS negative symptoms did not achieve significance in this study.

31. Strengths and Limitations Strengths: Strengths: 1) Multivariate Analysis 2) Multiracial Sample 3) Bio-psycho-social model  Limitations: 1) Cross sectional design 2) Self report of trauma 3) One geographic location

32. Clinical Implications Biological Interventions: Biological Interventions:  SSRIs  Second Generation Anti-psychotics  Anti-convulsants  Monitoring ETOH and Substance abuse  Monitoring co-morbid medical illnesses

33.  Psychological Interventions:  Cognitive Behavior Therapy for Psychosis -Psycho-education -Psycho-education -Identify links between traumatic experience and current psychotic symptoms  Normalize their experience, reduce distress and increase perceived control. -Identify links between traumatic experience and current psychotic symptoms  Normalize their experience, reduce distress and increase perceived control. -Voice Dairies, coping strategies and rational responding to critical hallucinations  reduces symptom burden and depression. -Voice Dairies, coping strategies and rational responding to critical hallucinations  reduces symptom burden and depression.  Eye Movement Desensitization and Reprocessing (EMDR)  Group Therapy

34. Social Interventions: Social Interventions:  Family Therapy  Educating staff at Residential Programs

35. Summary There is a strong association between trauma and positive psychotic symptoms in older adults with Schizophrenia. There is a strong association between trauma and positive psychotic symptoms in older adults with Schizophrenia. The study results underscore the value of a thorough review of current and lifetime trauma in older persons with schizophrenia. The study results underscore the value of a thorough review of current and lifetime trauma in older persons with schizophrenia. The findings of this study suggest more targeted psychotherapeutic and pharmacological interventions may be required for persons in the high trauma group. The findings of this study suggest more targeted psychotherapeutic and pharmacological interventions may be required for persons in the high trauma group.

36. Acknowledgments Dr. Cohen Dr. Cohen Dr. Garrett Dr. Garrett Dr. Berkowitz Dr. Berkowitz Dr. Goldfinger Dr. Goldfinger Dr. Schooler Dr. Schooler Dr. Weiden Dr. Weiden Dr. Coplan Dr. Coplan Dr. S. Friedman Dr. S. Friedman Dr. Selzer Dr. Selzer Dr. Kawi Dr. Kawi Dr. Dailey Dr. Dailey Catherine Cozzolino & Kino James Catherine Cozzolino & Kino James SUNY Downstate Residents and Medical Students SUNY Downstate Residents and Medical Students

37. THANK – YOU THANK – YOU