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dateTime="2024-11-12T16:00:00.000">November 12, 2024</time></div><div class="flex items-center"><p class="text-gray-500 mt-[1px]">Psychiatric Times</p></div><div class="flex flex-wrap max-h-[24px] text-gray-500 mb-2"><span class="text-gray-500">Vol 41, Issue 11<div class="inline-block h-[16px] border-l-2 border-gray-400 mt-1 mx-1 relative top-[3px]"></div>Volume<span class="font-bold "></span></span></div><h1 class="text-[26px] font-medium leading-8">Opening Pandora’s Box: The Importance of Assessing and Treating Trauma in Individuals Experiencing Psychosis</h1><div class="py-3 text-gray-600 md:flex flex-col md:justify-between"><div class="flex flex-col xs:flex-row"><p class="mr-1 self-start">Author(s):</p><div class="flex flex-col xs:flex-row mb-3 md:mb-0"><div class="flex flex-wrap"><span class="text-md mr-2"><a class="text-author text-gray-500 hover:text-primary underline hover:no-underline decoration-gray-400" href="/authors/sripriya-chari-phd">Sripriya Chari, PhD</a><span class="mx-1">,</span></span><span class="text-md mr-2"><a class="text-author text-gray-500 hover:text-primary underline hover:no-underline decoration-gray-400" href="/authors/grace-eun-lee-phd">Grace Eun Lee, PhD</a></span></div><button class="text-xs text-gray-500 flex items-center mt-2 xs:mt-0 xs:ml-2">+2 More<span class="ml-1"><svg stroke="currentColor" fill="currentColor" stroke-width="0" viewBox="0 0 512 512" height="1em" width="1em" xmlns="http://www.w3.org/2000/svg"><path d="M256 294.1L383 167c9.4-9.4 24.6-9.4 33.9 0s9.3 24.6 0 34L273 345c-9.1 9.1-23.7 9.3-33.1.7L95 201.1c-4.7-4.7-7-10.9-7-17s2.3-12.3 7-17c9.4-9.4 24.6-9.4 33.9 0l127.1 127z"></path></svg></span></button></div></div><div class="max-w-full"><div class="flex flex-wrap sm:flex-nowrap items-center w-fit "></div><div class="w-full flex flex-col sm:flex-row justify-between mt-2"><div class="block md:hidden "><div class="mt-2 flex items-center max-w-fit"><button title="Opening Pandora’s Box: The Importance of Assessing 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d="M5 1a2 2 0 0 0-2 2v2H2a2 2 0 0 0-2 2v3a2 2 0 0 0 2 2h1v1a2 2 0 0 0 2 2h6a2 2 0 0 0 2-2v-1h1a2 2 0 0 0 2-2V7a2 2 0 0 0-2-2h-1V3a2 2 0 0 0-2-2H5zM4 3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1v2H4V3zm1 5a2 2 0 0 0-2 2v1H2a1 1 0 0 1-1-1V7a1 1 0 0 1 1-1h12a1 1 0 0 1 1 1v3a1 1 0 0 1-1 1h-1v-1a2 2 0 0 0-2-2H5zm7 2v3a1 1 0 0 1-1 1H5a1 1 0 0 1-1-1v-3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1z"></path></svg></a></div><style> .print-wrap { width: 32px; height: 32px; background: #7F7F7F; border-radius: 100%; } .print { background: #7F7F7F; color: white; padding: 2px; border-radius: 100%; } </style></div><style> video::cue { display: inline; background-color: #b8dcf6; padding: 2px 2px; } audio { height: 40px; } .rhap_container { width: 300px !important; border-radius: 100px !important; height: 40px !important; box-shadow: 0px 0px 2px 2px rgba(0,0,0,0.1); } .rhap_progress-section { width: 150px; margin-left: 35px; } .rhap_controls-section { position: relative; bottom: .75rem; } .rhap_time { font-size: 12px; color: rgb(0,55,103); } .rhap_progress-bar { color: rgb(0,55,103) !important; } .rhap_progress-filled { background-color: rgb(0,55,103) !important; } .rhap_progress-indicator { height: 15px; width: 5px; top: -5px; margin-left: 1px; background-color: rgb(0,55,103) !important; } .rhap_repeat-button { display: none; } .rhap_volume-bar, rhap_volume-button, .rhap_volume-indicator { background: rgb(0,55,103) !important; } .rhap_volume-bar { height: 2px; width: 35px; position: relative; left: 22px; bottom: 21px; } .rhap_volume-button { // width: 5px; // height: 5px; flex: 0 0 26px; position: relative; left: 22px; bottom: 21px; } .rhap_volume-button svg { height: 18px; width: 18px; } .rhap_volume-indicator { height: 8px; width: 8px; top: -2.75px } .rhap_button-clear { color: rgb(0,55,103) !important; } .rhap_play-pause-button { color: rgb(0,55,103) !important; font-size: 30px !important; width: 30px !important; height: 30px !important; position: relative; right: 90px; bottom: 22px; } .rhap_main-controls button { color: rgb(0,55,103) !important; } audio::-webkit-media-controls-play-button, video::-webkit-media-controls-play-button { -webkit-appearance: media-play-button; color: #b8dcf6; } audio::-webkit-media-controls-panel { background-color: white !important; color: #000; } audio::-webkit-media-controls-current-time-display, audio::-webkit-media-controls-time-remaining-display { font-size: 12px; } </style></div></div></div><div class=" lg:w-full flex flex-col lg:flex-row lg:items-center lg:justify-end"></div><div class="w-full flex flex-col px-4 py-4 border-t border-b border-solid border-gray-400 my-4 "><h3 class="text-primary text-xl font-semibold">Key Takeaways</h3><ul class="list-disc px-8"><li class="py-2 "> Trauma and psychosis frequently co-occur, necessitating comprehensive assessments to identify trauma in individuals presenting with psychosis symptoms. </li><li class="py-2 "> Trauma-informed care, incorporating safety, trust, and collaboration, is crucial for effective treatment and recovery in individuals with psychosis. </li><li class="py-2 hidden"> Evidence-based PTSD treatments, including trauma-focused CBTp, can be safely and effectively used in individuals with comorbid psychosis and PTSD. </li><li class="py-2 hidden"> Clinicians should adapt trauma interventions to address both trauma and psychosis symptoms, ensuring adequate coping skills and minimizing retraumatization.</li></ul><span class="text-xs font-bold text-primary underline cursor-pointer mt-2 ml-4">SHOW MORE</span></div><p class="py-2 mb-2 text-sm italic text-gray-600">Traumatic life events are common among individuals who experience psychosis. Here's how best to assess and treat. </p><div class="py-2"><div class="blockText_blockContent__TbCXh"><div class=""><div style="width:52%;float:left;max-width:525px;margin:0 1.5rem 1.5rem 0;clear:both;cursor:" class=" figure"><div class="flex-none relative text-center"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%277280%27%20height=%274080%27/%3e"/></span><img alt="trauma" title="trauma" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="trauma" title="trauma" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3baa097f1742d64c9afda10b2c6f7deda469f1dc-7280x4080.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 1x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3baa097f1742d64c9afda10b2c6f7deda469f1dc-7280x4080.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span></div><div id="image-caption" class="text-gray-500 italic"><div class="blockText_blockContent__TbCXh"><p class="pb-2">necropos12/AdobeStock</p></div></div><div class="top-[-100%] block w-[1px] transition-opacity duration-500 ease-in-out opacity-0 overflow-hidden"><img class="m-auto absolute inset-0 max-w-[0%] max-h-[0%] border-[3px] border-solid border-white shadow-[0px_0px_8px_rgba(0,0,0,0.3)] box-border transition ease-in-out duration-500" src="https://cdn.sanity.io/images/0vv8moc6/psychtimes/3baa097f1742d64c9afda10b2c6f7deda469f1dc-7280x4080.jpg?fit=crop&auto=format"/></div></div><style> #image-caption p{ font-size: 12px; max-width: 525px; margin: 0 auto; text-align: center; } </style></div><p class="pb-2"><strong>Case Vignette </strong></p><p class="pb-2">“Sasha” is a 23-year-old nonbinary Asian American individual. Sasha is a survivor of childhood emotional and physical abuse by their parents. In addition, Sasha was physically assaulted when they were a freshman in college as they were walking back to their dorm late at night. Soon after this experience, they started having nightmares and flashbacks about the assault. They became easily startled and hypervigilant and no longer felt safe in lecture halls and on campus, which led them to drop out of college. Sasha also believes that strangers on the street intend to harm them physically, and they let Sasha know this by making eye contact with Sasha or by touching their faces. Sasha also reports seeing shadowy figures that seem threatening and hearing voices—both of their abusers from the past and strangers. These voices say degrading things about Sasha, which they interpret as a sign that there is a larger plot against them. Sasha no longer feels safe leaving the house or socializing, is disengaged from loved ones, is unable to return to college or work, and is currently on a leave of absence from their job at a daycare center. In the context of reduced sleep, concerns about financial stressors, and worsening voices, Sasha presents to the emergency department, where they disclose their voices, the shadowy figures, and fears that others in their neighborhood are threatening them. They are commenced on antipsychotic medication and are connected with their local early psychosis service for follow-up. </p><p class="pb-2"><strong>Trauma and Psychosis</strong></p><p class="pb-2">Per the Substance Abuse and Mental Health Services Administration (SAMHSA), “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” <a target="_blank" href="https://www.psychiatrictimes.com/topics/ptsd">Posttraumatic stress disorder</a> (PTSD) refers to a cluster of symptoms often experienced by individuals who have experienced trauma. Whether a person who has experienced a traumatic event will go on to qualify for a diagnosis of PTSD depends on the event, the person’s experience of the event, and the long-lasting adverse effects of the event.<sup class="text-inherit">1</sup></p><p class="pb-2">Sasha’s presentation with comorbid symptoms of psychosis and PTSD is not unusual. Individuals experiencing psychosis often have also been exposed to traumatic life events,<sup class="text-inherit">2,3</sup> with some estimates suggesting that all individuals with a psychotic disorder have experienced at least 1 traumatic event.<sup class="text-inherit">2</sup> In addition, the experience of psychosis, as well as some aspects of mental health treatment including police involvement in admission, seclusion, and restraint, can also be traumatic.<sup class="text-inherit">4</sup> The rates of PTSD in those experiencing psychosis range from 10% to 30%, and approximately 40% of individuals with PTSD experience psychosis.<sup class="text-inherit">3,5-8</sup> Psychosis-related PTSD, or PTSD directly related to having a psychotic episode, varies from 14% to 47%.<sup class="text-inherit">9</sup> Comorbid PTSD/psychosis is associated with increased health care use and worse clinical outcomes.<sup class="text-inherit">8,10</sup> Hence, when planning for effective care, it is important to assess for trauma and PTSD in anyone presenting with symptoms of psychosis.</p><p class="pb-2"><strong><em>Clinical Pearl:</em> </strong>Traumatic experiences are very common for those who report symptoms of psychosis. Trauma may be a result of early childhood experiences or later traumatic experiences linked to psychosis symptoms or treatment for psychosis. Psychosis symptoms can also occur in the context of PTSD and posttraumatic stress. </p><p class="pb-2"></p><p class="pb-2"><strong>Assessment of Trauma in Individuals Experiencing Psychosis</strong></p><p class="pb-2">Trauma is often overlooked in individuals with psychosis, resulting in an inadequate assessment of traumatic or adverse life events and, therefore, limited access to gold standard, evidence-based trauma treatments. Assessing for trauma should occur routinely, and access to these treatments should be made available for all individuals as needed. If Sasha is asked specific questions assessing past traumas, they will likely report childhood abuse and the more recent physical assault. Structured assessments commonly used to assess PTSD symptoms include the PTSD Checklist for DSM-5 (PCL-5),<sup class="text-inherit">11 </sup>PTSD Symptom Scale – Interview for DSM-5 (PSS-I-5),<sup class="text-inherit">12</sup> and Clinician-Administered PTSD Scale for DSM-5 (CAPS-5).<sup class="text-inherit">13</sup> During an initial assessment, it is vital for clinicians assessing potential traumatic experiences to gather only the information necessary to determine whether a trauma history is present and whether trauma interventions are appropriate, which does not require a full account of traumatic experiences. Requiring individuals to disclose a detailed account of their trauma history during the initial assessment poses a risk for retraumatization and may limit what the individual feels comfortable sharing. PTSD assessments only ask clients to, at most, share a brief description of the traumatic event and PTSD symptoms.</p><p class="pb-2">Assessment is an essential component of understanding, and addressing, trauma as part of a psychosis presentation. In our clinical example, if Sasha is only assessed for psychosis and not asked questions about past traumas, they will likely receive a diagnosis of a psychotic disorder (such as <a target="_blank" href="https://www.psychiatrictimes.com/topics/schizophrenia">schizophrenia</a>) and be prescribed antipsychotic medications to reduce the occurrence of the voices and shadowy figures. Sasha may also be offered supportive psychotherapy and case management. If the clinic has trained staff, Sasha may be offered an evidence-based psychotherapeutic intervention such as cognitive behavioral therapy for psychosis (CBTp). However, the traumatic experiences would go untreated, thus limiting the potential for recovery.</p><p class="pb-2"><strong><em>Clinical Pearl: </em></strong>As clients do not often report trauma experiences unless asked about them explicitly, assessment of trauma in individuals presenting with psychosis symptoms is essential. Assessing for the types of trauma experienced and PTSD symptoms, as opposed to a full account of traumatic events, is sufficient at this stage of care.</p><p class="pb-2"></p><p class="pb-2"><strong>Trauma-Informed Care</strong></p><p class="pb-2">SAMHSA recommends that all treatment programs take a trauma-informed approach.<sup class="text-inherit">1</sup> This incorporates key principles into the organizational culture of the program. These include acknowledging the widespread impact of trauma and the path to recovery, recognizing the signs of trauma in individuals, and responding by making sure policies and practices are geared toward not retraumatizing the individual. A trauma-informed approach may or may not include trauma-specific treatments. Some fundamental principles in a trauma-informed approach are ensuring a sense of physical and psychological safety for all served; building and maintaining individuals’ trust in the program by those accessing services and their families; welcoming mutual self-help from those with lived experience of trauma and recovery from trauma; adopting a nonhierarchical, collaborative stance where the expertise of individuals accessing services is understood and respected; keeping individuals accessing services front and center, and believing in their resilience and ability to recover from trauma; and providing care that actively moves away from stereotypes and biases.</p><p class="pb-2"><strong><em>Clinical Pearl: </em></strong>Programs should consider how to implement trauma-informed care and ensure staff are trained in this approach to best meet the needs of individuals accessing services.</p><p class="pb-2"></p><p class="pb-2"><strong>Addressing Trauma</strong></p><p class="pb-2">Clinicians are often concerned about the increased sensitivity to stress in those experiencing psychosis and can be hesitant to use evidence-based treatments for PTSD.<sup class="text-inherit">14,15</sup> As a result, evidence-based trauma treatments are not offered routinely to individuals seeking treatment for psychosis in the United States.<sup class="text-inherit">16</sup> However, Grubaugh et al, in a meta-analysis of PTSD treatments for individuals diagnosed with PTSD and a “severe and persistent comorbid mental illness,” which included psychotic spectrum disorders or mood disorders, found that PTSD treatment can be used safely in this population.<sup class="text-inherit">5</sup></p><p class="pb-2">In addition, a growing evidence base suggests that standard protocols for trauma treatments in psychosis are effective.<sup class="text-inherit">17</sup> These treatment protocols include trauma-focused CBTp,<sup class="text-inherit">18</sup> prolonged exposure,<sup class="text-inherit">19</sup> and eye movement desensitization reprocessing.<sup class="text-inherit">20</sup> However, adapting these protocols may be necessary to ensure the needs of an individual experiencing psychosis symptoms are thoroughly addressed; for example, ensuring the individual has sufficient coping skills in place to tolerate the trauma intervention while not prolonging access to exposure-based therapies (“as much as needed, but as little as necessary”) and supporting the individual around psychosis symptoms if these are intrusive and may impact the trauma treatment. Developing an initial formulation to understand the trauma timeline, subsequent symptoms (both trauma and psychosis focused), and impact of these on core beliefs will aid the clinician in determining where to focus psychosocial interventions.</p><p class="pb-2"><strong><em>Clinical Pearl:</em></strong> Treatment options and pacing are guided by the immediate needs of the individual and should support the reduction of distress and movement toward meaningful goals.</p><p class="pb-2"></p><p class="pb-2"><strong>Concluding Thoughts</strong></p><p class="pb-2">Traumatic life events are common among individuals who experience psychosis. Often, when an individual presents with psychosis, past traumas are not assessed. This could be due to the individual’s hesitancy to talk about these events or the clinician’s fear that asking about trauma will exacerbate symptoms. We now know that trauma-informed care leads to better outcomes. This systemwide approach begins with creating safe spaces for individuals to speak about past experiences in a way that is not retraumatizing and incorporates the impact of these experiences into a formulation that guides treatment. Evidence-based trauma interventions have been shown to be effective in addressing trauma in individuals experiencing psychosis and should be made routinely available. Further research on effective trauma intervention adaptations for individuals with psychosis would be meaningful. We encourage all clinicians who support individuals experiencing psychosis to provide trauma- informed care across treatment settings.</p><p class="pb-2"></p><p class="pb-2"><strong>Dr Chari</strong> <em>is the assistant psychosocial director and didactic lead of the INSPIRE Clinic and a clinical associate professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in California. </em><strong>Dr Lee</strong> <em>is a clinical assistant professor and a California-licensed clinical psychologist in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine.<strong> </strong></em><strong>Dr Olson</strong><em> is a clinical associate professor and licensed psychologist in the INSPIRE Clinic and dialectical behavior therapy program at Stanford University.</em> <strong>Dr Hardy</strong><em> is the codirector of the INSPIRE Clinic, the co–section chief of INSPIRE Section, and a clinical professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine.</em></p><p class="pb-2"><strong></strong></p><p class="pb-2"><strong>References</strong></p><p class="pb-2">1. Substance Abuse and Mental Health Services Administration. <em>SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach</em>. Substance Abuse and Mental Health Services Administration; 2014. HHS Publication No. (SMA) 14-4884. Accessed September 25, 2024. <a rel="nofollow noreferrer noopener" target="_blank" href="https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf">https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf</a></p><p class="pb-2">2. Kessler RC, Birnbaum H, Demler O, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/16023620/">The prevalence and correlates of nonaffective psychosis in the National Comorbidity Survey Replication (NCS-R).</a> <em>Biol Psychiatry</em>. 2005;58(8)668-676.</p><p class="pb-2">3. Achim AM, Maziade M, Raymond E, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/19959704/">How prevalent are anxiety disorders in schizophrenia? A meta-analysis and critical review on a significant association.</a> <em>Schizophr Bull</em>. 2011;37(4):811-821.</p><p class="pb-2">4. Hardy KV, Mueser KT. Editorial: <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/29163239/">trauma, psychosis and posttraumatic stress disorder.</a> <em>Front Psychiatry</em>. 2017;8:220.</p><p class="pb-2">5. Grubaugh AL, Brown WJ, Wojtalik JA, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/34033709/">Meta-analysis of the treatment of posttraumatic stress disorder in adults with comorbid severe mental illness.</a> <em>J Clin Psychiatry</em>. 2021;82(3):20r13584.</p><p class="pb-2">6. de Bont PAJM, van den Berg DPG, van der Vleugel BM, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/25792693/">Predictive validity of the Trauma Screening Questionnaire in detecting post-traumatic stress disorder in patients with psychotic disorders. </a><em>Br J Psychiatry</em>. 2015;206(5):408-416.</p><p class="pb-2">7. Mueser KT, Goodman LB, Trumbetta SL, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/9642887/">Trauma and posttraumatic stress disorder in severe mental illness.</a> <em>J Consult Clin Psychol</em>. 1998;66(3):493-499.</p><p class="pb-2">8. Seow LSE, Ong C, Mahesh MV, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/27230289/">A systematic review on comorbid post-traumatic stress disorder in schizophrenia.</a> <em>Schizophr Res</em>. 2016;176(2-3):441-451.</p><p class="pb-2">9. Buswell G, Haime Z, Lloyd-Evans, B, Billings J. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/33413179/">A systematic review of PTSD to the experience of psychosis: prevalence and associated factors.</a> <em>BMC Psychiatry</em>. 2021;21(1):9.</p><p class="pb-2">10. Hassan AN, De Luca V. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/25468176/">The effect of lifetime adversities on resistance to antipsychotic treatment in schizophrenia patients.</a><em> Schizophr Res.</em> 2015;161(2-3):496-500.</p><p class="pb-2">11. Blevins CA, Weathers FW, Davis MT, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/26606250/">The posttraumatic stress disorder checklist for DSM‐5 (PCL‐5): development and initial psychometric evaluation.</a> <em>J Trauma Stress</em>. 2015;28(6):489-498.</p><p class="pb-2">12. Foa EB, McLean CP, Zang Y, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/26691507/">Psychometric properties of the Posttraumatic Stress Disorder Symptom Scale Interview for DSM–5 (PSSI–5). </a><em>Psychol Assess</em>. 2016;28(10):1159-1165.</p><p class="pb-2">13. Weathers FW, Bovin MJ, Lee DJ, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/28493729/">The Clinician-Administered PTSD Scale for DSM–5 (CAPS-5): development and initial psychometric evaluation in military veterans.</a> <em>Psychol Assess</em>. 2018;30(3):383-395.</p><p class="pb-2">14. Lataster T, Valmaggia L, Lardinois M, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/23111055/">Increased stress reactivity: a mechanism specifically associated with the positive symptoms of psychotic disorder.</a> <em>Psychol Med</em>. 2013;43(7):1389-1400.</p><p class="pb-2">15. Meyer JM, Farrell NR, Kemp JJ, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/24530499/">Why do clinicians exclude anxious clients from exposure therapy?</a> <em>Behav Res Ther</em>. 2014;54:49-53.</p><p class="pb-2">16. Cusack J, Deane FP, Wilson CJ, Ciarrochi J. <a rel="nofollow noreferrer noopener" target="_blank" href="https://www.researchgate.net/publication/224856492_Emotional_expression_perceptions_of_therapy_and_help-seeking_intentions_in_men_attending_therapy_services">Emotional expression, perceptions of therapy, and help-seeking intentions in men attending therapy services.</a> <em>Psychol Men Masc</em>. 2006;7(2):1-14.</p><p class="pb-2">17. Swan S, Keen N, Reynolds N, Onwumere J. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/28352239/">Psychological interventions for post-traumatic stress symptoms in psychosis: a systematic review of outcomes.</a> <em>Front Psychol</em>. 2017;8:341.</p><p class="pb-2">18. Peters E, Hardy A, Dudley R, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/35606886/">Multisite randomised controlled trial of trauma-focused cognitive behaviour therapy for psychosis to reduce post-traumatic stress symptoms in people with co-morbid post-traumatic stress disorder and psychosis, compared to treatment as usual: study protocol for the STAR (Study of Trauma And Recovery) trial.</a> <em>Trials</em>. 2022;23(1):429.</p><p class="pb-2">19. Foa EB, Hembree EA, Rothbaum BO. <em>Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide.</em> 1st ed. Oxford University Press; 2007.</p><p class="pb-2">20. Shapiro F, Forrest MS. <em>EMDR: The Breakthrough “Eye Movement” Therapy for Overcoming Anxiety, Stress, and Trauma.</em> Basic Books; 1998.</p><p class="pb-2"> </p></div></div><div class="flex items-center lg:w-3/4 mb-4 pb-12"><div class="flex sm:inline"><a target="_blank" class="mr-[5px] md:mr-2 p-[.56rem] border rounded-md bg-primary text-white" href="https://cdn.sanity.io/files/0vv8moc6/psychtimes/e10ffe3e89a70766afa190f65812cbcf1744c8eb.pdf/PSY1124_eZine.pdf">Download Issue PDF</a></div></div><div class="mb-6"><div class="jsx-19ede9f0a5a45918 py-4 relative bg-primary md:px-8 pl-2 -ml-6 xs:ml-0 w-screen xs:w-full mb-4 "><div class="jsx-19ede9f0a5a45918 px-4 sm:px-0"><div class="jsx-19ede9f0a5a45918 text-white text-2xl md:text-3xl pb-2 md:pb-1">Articles in this issue</div><hr class="jsx-19ede9f0a5a45918 -mr-2"/></div><div style="scroll-snap-type:none" class="jsx-19ede9f0a5a45918 flex items-start overflow-x-auto space-x-4 py-4 relative mx-auto w-full pl-4'"><div 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Sasha is a survivor of childhood emotional and physical abuse by their parents. In addition, Sasha was physically assaulted when they were a freshman in college as they were walking back to their dorm late at night. Soon after this experience, they started having nightmares and flashbacks about the assault. They became easily startled and hypervigilant and no longer felt safe in lecture halls and on campus, which led them to drop out of college. Sasha also believes that strangers on the street intend to harm them physically, and they let Sasha know this by making eye contact with Sasha or by touching their faces. Sasha also reports seeing shadowy figures that seem threatening and hearing voices—both of their abusers from the past and strangers. These voices say degrading things about Sasha, which they interpret as a sign that there is a larger plot against them. Sasha no longer feels safe leaving the house or socializing, is disengaged from loved ones, is unable to return to college or work, and is currently on a leave of absence from their job at a daycare center. In the context of reduced sleep, concerns about financial stressors, and worsening voices, Sasha presents to the emergency department, where they disclose their voices, the shadowy figures, and fears that others in their neighborhood are threatening them. They are commenced on antipsychotic medication and are connected with their local early psychosis service for follow-up. \n\nTrauma and Psychosis\n\nPer the Substance Abuse and Mental Health Services Administration (SAMHSA), “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” Posttraumatic stress disorder (PTSD) refers to a cluster of symptoms often experienced by individuals who have experienced trauma. Whether a person who has experienced a traumatic event will go on to qualify for a diagnosis of PTSD depends on the event, the person’s experience of the event, and the long-lasting adverse effects of the event.1\n\nSasha’s presentation with comorbid symptoms of psychosis and PTSD is not unusual. Individuals experiencing psychosis often have also been exposed to traumatic life events,2,3 with some estimates suggesting that all individuals with a psychotic disorder have experienced at least 1 traumatic event.2 In addition, the experience of psychosis, as well as some aspects of mental health treatment including police involvement in admission, seclusion, and restraint, can also be traumatic.4 The rates of PTSD in those experiencing psychosis range from 10% to 30%, and approximately 40% of individuals with PTSD experience psychosis.3,5-8 Psychosis-related PTSD, or PTSD directly related to having a psychotic episode, varies from 14% to 47%.9 Comorbid PTSD/psychosis is associated with increased health care use and worse clinical outcomes.8,10 Hence, when planning for effective care, it is important to assess for trauma and PTSD in anyone presenting with symptoms of psychosis.\n\nClinical Pearl: Traumatic experiences are very common for those who report symptoms of psychosis. Trauma may be a result of early childhood experiences or later traumatic experiences linked to psychosis symptoms or treatment for psychosis. Psychosis symptoms can also occur in the context of PTSD and posttraumatic stress. \n\n\n\nAssessment of Trauma in Individuals Experiencing Psychosis\n\nTrauma is often overlooked in individuals with psychosis, resulting in an inadequate assessment of traumatic or adverse life events and, therefore, limited access to gold standard, evidence-based trauma treatments. Assessing for trauma should occur routinely, and access to these treatments should be made available for all individuals as needed. If Sasha is asked specific questions assessing past traumas, they will likely report childhood abuse and the more recent physical assault. Structured assessments commonly used to assess PTSD symptoms include the PTSD Checklist for DSM-5 (PCL-5),11 PTSD Symptom Scale – Interview for DSM-5 (PSS-I-5),12 and Clinician-Administered PTSD Scale for DSM-5 (CAPS-5).13 During an initial assessment, it is vital for clinicians assessing potential traumatic experiences to gather only the information necessary to determine whether a trauma history is present and whether trauma interventions are appropriate, which does not require a full account of traumatic experiences. Requiring individuals to disclose a detailed account of their trauma history during the initial assessment poses a risk for retraumatization and may limit what the individual feels comfortable sharing. PTSD assessments only ask clients to, at most, share a brief description of the traumatic event and PTSD symptoms.\n\nAssessment is an essential component of understanding, and addressing, trauma as part of a psychosis presentation. In our clinical example, if Sasha is only assessed for psychosis and not asked questions about past traumas, they will likely receive a diagnosis of a psychotic disorder (such as schizophrenia) and be prescribed antipsychotic medications to reduce the occurrence of the voices and shadowy figures. Sasha may also be offered supportive psychotherapy and case management. If the clinic has trained staff, Sasha may be offered an evidence-based psychotherapeutic intervention such as cognitive behavioral therapy for psychosis (CBTp). However, the traumatic experiences would go untreated, thus limiting the potential for recovery.\n\nClinical Pearl: As clients do not often report trauma experiences unless asked about them explicitly, assessment of trauma in individuals presenting with psychosis symptoms is essential. Assessing for the types of trauma experienced and PTSD symptoms, as opposed to a full account of traumatic events, is sufficient at this stage of care.\n\n\n\nTrauma-Informed Care\n\nSAMHSA recommends that all treatment programs take a trauma-informed approach.1 This incorporates key principles into the organizational culture of the program. These include acknowledging the widespread impact of trauma and the path to recovery, recognizing the signs of trauma in individuals, and responding by making sure policies and practices are geared toward not retraumatizing the individual. A trauma-informed approach may or may not include trauma-specific treatments. Some fundamental principles in a trauma-informed approach are ensuring a sense of physical and psychological safety for all served; building and maintaining individuals’ trust in the program by those accessing services and their families; welcoming mutual self-help from those with lived experience of trauma and recovery from trauma; adopting a nonhierarchical, collaborative stance where the expertise of individuals accessing services is understood and respected; keeping individuals accessing services front and center, and believing in their resilience and ability to recover from trauma; and providing care that actively moves away from stereotypes and biases.\n\nClinical Pearl: Programs should consider how to implement trauma-informed care and ensure staff are trained in this approach to best meet the needs of individuals accessing services.\n\n\n\nAddressing Trauma\n\nClinicians are often concerned about the increased sensitivity to stress in those experiencing psychosis and can be hesitant to use evidence-based treatments for PTSD.14,15 As a result, evidence-based trauma treatments are not offered routinely to individuals seeking treatment for psychosis in the United States.16 However, Grubaugh et al, in a meta-analysis of PTSD treatments for individuals diagnosed with PTSD and a “severe and persistent comorbid mental illness,” which included psychotic spectrum disorders or mood disorders, found that PTSD treatment can be used safely in this population.5\n\nIn addition, a growing evidence base suggests that standard protocols for trauma treatments in psychosis are effective.17 These treatment protocols include trauma-focused CBTp,18 prolonged exposure,19 and eye movement desensitization reprocessing.20 However, adapting these protocols may be necessary to ensure the needs of an individual experiencing psychosis symptoms are thoroughly addressed; for example, ensuring the individual has sufficient coping skills in place to tolerate the trauma intervention while not prolonging access to exposure-based therapies (“as much as needed, but as little as necessary”) and supporting the individual around psychosis symptoms if these are intrusive and may impact the trauma treatment. Developing an initial formulation to understand the trauma timeline, subsequent symptoms (both trauma and psychosis focused), and impact of these on core beliefs will aid the clinician in determining where to focus psychosocial interventions.\n\nClinical Pearl: Treatment options and pacing are guided by the immediate needs of the individual and should support the reduction of distress and movement toward meaningful goals.\n\n\n\nConcluding Thoughts\n\nTraumatic life events are common among individuals who experience psychosis. Often, when an individual presents with psychosis, past traumas are not assessed. This could be due to the individual’s hesitancy to talk about these events or the clinician’s fear that asking about trauma will exacerbate symptoms. We now know that trauma-informed care leads to better outcomes. This systemwide approach begins with creating safe spaces for individuals to speak about past experiences in a way that is not retraumatizing and incorporates the impact of these experiences into a formulation that guides treatment. Evidence-based trauma interventions have been shown to be effective in addressing trauma in individuals experiencing psychosis and should be made routinely available. Further research on effective trauma intervention adaptations for individuals with psychosis would be meaningful. We encourage all clinicians who support individuals experiencing psychosis to provide trauma- informed care across treatment settings.\n\n\n\nDr Chari is the assistant psychosocial director and didactic lead of the INSPIRE Clinic and a clinical associate professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in California. Dr Lee is a clinical assistant professor and a California-licensed clinical psychologist in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine. Dr Olson is a clinical associate professor and licensed psychologist in the INSPIRE Clinic and dialectical behavior therapy program at Stanford University. Dr Hardy is the codirector of the INSPIRE Clinic, the co–section chief of INSPIRE Section, and a clinical professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine.\n\n\n\nReferences\n\n1. Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Substance Abuse and Mental Health Services Administration; 2014. HHS Publication No. (SMA) 14-4884. Accessed September 25, 2024. https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf\n\n2. Kessler RC, Birnbaum H, Demler O, et al. The prevalence and correlates of nonaffective psychosis in the National Comorbidity Survey Replication (NCS-R). Biol Psychiatry. 2005;58(8)668-676.\n\n3. Achim AM, Maziade M, Raymond E, et al. How prevalent are anxiety disorders in schizophrenia? A meta-analysis and critical review on a significant association. Schizophr Bull. 2011;37(4):811-821.\n\n4. Hardy KV, Mueser KT. Editorial: trauma, psychosis and posttraumatic stress disorder. Front Psychiatry. 2017;8:220.\n\n5. Grubaugh AL, Brown WJ, Wojtalik JA, et al. Meta-analysis of the treatment of posttraumatic stress disorder in adults with comorbid severe mental illness. J Clin Psychiatry. 2021;82(3):20r13584.\n\n6. de Bont PAJM, van den Berg DPG, van der Vleugel BM, et al. Predictive validity of the Trauma Screening Questionnaire in detecting post-traumatic stress disorder in patients with psychotic disorders. Br J Psychiatry. 2015;206(5):408-416.\n\n7. Mueser KT, Goodman LB, Trumbetta SL, et al. Trauma and posttraumatic stress disorder in severe mental illness. J Consult Clin Psychol. 1998;66(3):493-499.\n\n8. Seow LSE, Ong C, Mahesh MV, et al. A systematic review on comorbid post-traumatic stress disorder in schizophrenia. Schizophr Res. 2016;176(2-3):441-451.\n\n9. Buswell G, Haime Z, Lloyd-Evans, B, Billings J. A systematic review of PTSD to the experience of psychosis: prevalence and associated factors. BMC Psychiatry. 2021;21(1):9.\n\n10. Hassan AN, De Luca V. The effect of lifetime adversities on resistance to antipsychotic treatment in schizophrenia patients. Schizophr Res. 2015;161(2-3):496-500.\n\n11. Blevins CA, Weathers FW, Davis MT, et al. The posttraumatic stress disorder checklist for DSM‐5 (PCL‐5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489-498.\n\n12. Foa EB, McLean CP, Zang Y, et al. Psychometric properties of the Posttraumatic Stress Disorder Symptom Scale Interview for DSM–5 (PSSI–5). Psychol Assess. 2016;28(10):1159-1165.\n\n13. Weathers FW, Bovin MJ, Lee DJ, et al. The Clinician-Administered PTSD Scale for DSM–5 (CAPS-5): development and initial psychometric evaluation in military veterans. Psychol Assess. 2018;30(3):383-395.\n\n14. Lataster T, Valmaggia L, Lardinois M, et al. Increased stress reactivity: a mechanism specifically associated with the positive symptoms of psychotic disorder. Psychol Med. 2013;43(7):1389-1400.\n\n15. Meyer JM, Farrell NR, Kemp JJ, et al. Why do clinicians exclude anxious clients from exposure therapy? Behav Res Ther. 2014;54:49-53.\n\n16. Cusack J, Deane FP, Wilson CJ, Ciarrochi J. Emotional expression, perceptions of therapy, and help-seeking intentions in men attending therapy services. Psychol Men Masc. 2006;7(2):1-14.\n\n17. Swan S, Keen N, Reynolds N, Onwumere J. Psychological interventions for post-traumatic stress symptoms in psychosis: a systematic review of outcomes. Front Psychol. 2017;8:341.\n\n18. Peters E, Hardy A, Dudley R, et al. Multisite randomised controlled trial of trauma-focused cognitive behaviour therapy for psychosis to reduce post-traumatic stress symptoms in people with co-morbid post-traumatic stress disorder and psychosis, compared to treatment as usual: study protocol for the STAR (Study of Trauma And Recovery) trial. Trials. 2022;23(1):429.\n\n19. Foa EB, Hembree EA, Rothbaum BO. Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide. 1st ed. Oxford University Press; 2007.\n\n20. Shapiro F, Forrest MS. EMDR: The Breakthrough “Eye Movement” Therapy for Overcoming Anxiety, Stress, and Trauma. Basic Books; 1998.\n\n ","description":"Traumatic life events are common among individuals who experience psychosis. Here's how best to assess and treat. ","author":[{"@type":"Person","name":"Sripriya Chari, PhD"},{"@type":"Person","name":"Grace Eun Lee, PhD"},{"@type":"Person","name":"Nichole D. Olson, PhD"},{"@type":"Person","name":"Kate V. 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This case highlights the frequent overlap of trauma and psychosis, emphasizing the need for trauma-informed care. Trauma is often overlooked in psychosis assessments, leading to inadequate treatment. Implementing trauma-informed approaches and evidence-based PTSD treatments, such as trauma-focused CBTp, can improve outcomes. Clinicians should routinely assess trauma in psychosis patients and adapt interventions to address both trauma and psychosis symptoms effectively, supporting recovery and reducing distress.","factCheckAuthorMapping":null,"drugMentions":"{\"drug_mentions\": [\"antipsychotic medication\"]}","url":{"_type":"slug","current":"opening-pandoras-box-the-importance-of-assessing-and-treating-trauma-in-individuals-experiencing-psychosis"},"articleType":"Publication","contentCategory":{"_id":"8bdaa7fc-960a-4b57-b076-75fdce3741bb","name":"Articles"},"_createdAt":"2024-11-11T21:23:30Z","_updatedAt":"2024-11-11T21:23:40Z","issueSection":null,"filter":null,"summary":"Traumatic life events are common among individuals who experience psychosis. Here's how best to assess and treat. ","ExcludeFromPubMedXML":false,"_type":"article","pdfUrl":null,"body":[{"disableTextWrap":false,"alt":"trauma","_key":"ea3d94bb02c1","_type":"figure","upload_doc":null,"medias":null,"imgcaption":[{"style":"normal","_key":"c7587d8ba6a0","markDefs":[],"children":[{"_type":"span","marks":[],"text":"necropos12/AdobeStock","_key":"01fe0f8049d20"}],"_type":"block"}],"asset":{"_ref":"image-3baa097f1742d64c9afda10b2c6f7deda469f1dc-7280x4080-jpg","_type":"reference"},"alignment":"left","widthP":52,"disableLightBox":true,"uploadAudio":null},{"children":[{"_key":"3923afc8f8ae","_type":"span","marks":["strong"],"text":"Case Vignette "}],"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"9cfae10a87c3","markDefs":[]},{"_key":"6f0a120a970f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"“Sasha” is a 23-year-old nonbinary Asian American individual. Sasha is a survivor of childhood emotional and physical abuse by their parents. In addition, Sasha was physically assaulted when they were a freshman in college as they were walking back to their dorm late at night. Soon after this experience, they started having nightmares and flashbacks about the assault. They became easily startled and hypervigilant and no longer felt safe in lecture halls and on campus, which led them to drop out of college. Sasha also believes that strangers on the street intend to harm them physically, and they let Sasha know this by making eye contact with Sasha or by touching their faces. Sasha also reports seeing shadowy figures that seem threatening and hearing voices—both of their abusers from the past and strangers. These voices say degrading things about Sasha, which they interpret as a sign that there is a larger plot against them. Sasha no longer feels safe leaving the house or socializing, is disengaged from loved ones, is unable to return to college or work, and is currently on a leave of absence from their job at a daycare center. In the context of reduced sleep, concerns about financial stressors, and worsening voices, Sasha presents to the emergency department, where they disclose their voices, the shadowy figures, and fears that others in their neighborhood are threatening them. They are commenced on antipsychotic medication and are connected with their local early psychosis service for follow-up. ","_key":"ae86b87ed1ba"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Trauma and Psychosis","_key":"2d2c4984cef80"}],"_type":"block","style":"normal","_key":"19df16d351eb","upload_doc":null,"uploadAudio":null,"medias":null},{"_type":"block","style":"normal","_key":"68f22e6675d4","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/ptsd","_key":"478472b25997"}],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_type":"span","marks":[],"text":"Per the Substance Abuse and Mental Health Services Administration (SAMHSA), “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” ","_key":"f449939cd7920"},{"_type":"span","marks":["478472b25997"],"text":"Posttraumatic stress disorder","_key":"f67cd3fc6889"},{"_type":"span","marks":[],"text":" (PTSD) refers to a cluster of symptoms often experienced by individuals who have experienced trauma. Whether a person who has experienced a traumatic event will go on to qualify for a diagnosis of PTSD depends on the event, the person’s experience of the event, and the long-lasting adverse effects of the event.","_key":"a3b6e2739dbe"},{"_type":"span","marks":["superscript"],"text":"1","_key":"92582eb60ccd"}]},{"_key":"863374d0a5fa","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_key":"ee6a2b1559200","_type":"span","marks":[],"text":"Sasha’s presentation with comorbid symptoms of psychosis and PTSD is not unusual. Individuals experiencing psychosis often have also been exposed to traumatic life events,"},{"_type":"span","marks":["superscript"],"text":"2,3","_key":"a27c7b8ee84a"},{"text":" with some estimates suggesting that all individuals with a psychotic disorder have experienced at least 1 traumatic event.","_key":"dcb93fc61fa0","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"2","_key":"99c0afb0ecfe"},{"marks":[],"text":" In addition, the experience of psychosis, as well as some aspects of mental health treatment including police involvement in admission, seclusion, and restraint, can also be traumatic.","_key":"dd679da3dd71","_type":"span"},{"_type":"span","marks":["superscript"],"text":"4","_key":"65573a220790"},{"_key":"212019e0ea47","_type":"span","marks":[],"text":" The rates of PTSD in those experiencing psychosis range from 10% to 30%, and approximately 40% of individuals with PTSD experience psychosis."},{"_key":"5097ee08e0cc","_type":"span","marks":["superscript"],"text":"3,5-8"},{"marks":[],"text":" Psychosis-related PTSD, or PTSD directly related to having a psychotic episode, varies from 14% to 47%.","_key":"360632143304","_type":"span"},{"_type":"span","marks":["superscript"],"text":"9","_key":"3ffe271492c2"},{"_type":"span","marks":[],"text":" Comorbid PTSD/psychosis is associated with increased health care use and worse clinical outcomes.","_key":"e02108a5ca10"},{"_type":"span","marks":["superscript"],"text":"8,10","_key":"797dc58322e8"},{"_type":"span","marks":[],"text":" Hence, when planning for effective care, it is important to assess for trauma and PTSD in anyone presenting with symptoms of psychosis.","_key":"69351212f915"}],"_type":"block","style":"normal"},{"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_type":"span","marks":["strong","em"],"text":"Clinical Pearl:","_key":"56654ffc90760"},{"_type":"span","marks":["strong"],"text":" ","_key":"8c35cc633a2d"},{"marks":[],"text":"Traumatic experiences are very common for those who report symptoms of psychosis. Trauma may be a result of early childhood experiences or later traumatic experiences linked to psychosis symptoms or treatment for psychosis. Psychosis symptoms can also occur in the context of PTSD and posttraumatic stress. ","_key":"12f9523c581a","_type":"span"}],"_type":"block","style":"normal","_key":"ecb3ce78093d","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"2a2bedb339b7"}],"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"31d6921130a7"},{"_key":"68cd91cd5237","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Assessment of Trauma in Individuals Experiencing Psychosis","_key":"d92720c7ab3b0"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null},{"upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal","_key":"10d1823d4bc6","markDefs":[],"children":[{"text":"Trauma is often overlooked in individuals with psychosis, resulting in an inadequate assessment of traumatic or adverse life events and, therefore, limited access to gold standard, evidence-based trauma treatments. Assessing for trauma should occur routinely, and access to these treatments should be made available for all individuals as needed. If Sasha is asked specific questions assessing past traumas, they will likely report childhood abuse and the more recent physical assault. Structured assessments commonly used to assess PTSD symptoms include the PTSD Checklist for DSM-5 (PCL-5),","_key":"85ece899cd910","_type":"span","marks":[]},{"text":"11 ","_key":"9741bccf172c","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":"PTSD Symptom Scale – Interview for DSM-5 (PSS-I-5),","_key":"719f8a0d30ef"},{"text":"12","_key":"a8dfabe13e7d","_type":"span","marks":["superscript"]},{"text":" and Clinician-Administered PTSD Scale for DSM-5 (CAPS-5).","_key":"e2d96d86b540","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"13","_key":"1fc5c376246c"},{"_type":"span","marks":[],"text":" During an initial assessment, it is vital for clinicians assessing potential traumatic experiences to gather only the information necessary to determine whether a trauma history is present and whether trauma interventions are appropriate, which does not require a full account of traumatic experiences. Requiring individuals to disclose a detailed account of their trauma history during the initial assessment poses a risk for retraumatization and may limit what the individual feels comfortable sharing. PTSD assessments only ask clients to, at most, share a brief description of the traumatic event and PTSD symptoms.","_key":"942804615eb4"}],"_type":"block"},{"_key":"a6b8aeb9f68e","markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/topics/schizophrenia","_key":"d8214a5a9350","nofollow":true,"blank":true}],"children":[{"text":"Assessment is an essential component of understanding, and addressing, trauma as part of a psychosis presentation. In our clinical example, if Sasha is only assessed for psychosis and not asked questions about past traumas, they will likely receive a diagnosis of a psychotic disorder (such as ","_key":"a3c19acd92eb0","_type":"span","marks":[]},{"_key":"77604a39a007","_type":"span","marks":["d8214a5a9350"],"text":"schizophrenia"},{"_type":"span","marks":[],"text":") and be prescribed antipsychotic medications to reduce the occurrence of the voices and shadowy figures. Sasha may also be offered supportive psychotherapy and case management. If the clinic has trained staff, Sasha may be offered an evidence-based psychotherapeutic intervention such as cognitive behavioral therapy for psychosis (CBTp). However, the traumatic experiences would go untreated, thus limiting the potential for recovery.","_key":"3559fd194365"}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal"},{"_key":"21cd01287ce4","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Clinical Pearl: ","_key":"fd9eb8545e9c0"},{"_key":"ecfb99764e01","_type":"span","marks":[],"text":"As clients do not often report trauma experiences unless asked about them explicitly, assessment of trauma in individuals presenting with psychosis symptoms is essential. Assessing for the types of trauma experienced and PTSD symptoms, as opposed to a full account of traumatic events, is sufficient at this stage of care."}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null},{"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"_key":"33f834148e7a","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"9c9613896724","upload_doc":null},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Trauma-Informed Care","_key":"9765ab1dd28b0"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null,"_key":"d1e421b5bec3"},{"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"7e446c9a1681","markDefs":[],"children":[{"_type":"span","marks":[],"text":"SAMHSA recommends that all treatment programs take a trauma-informed approach.","_key":"b67d570f20860"},{"_type":"span","marks":["superscript"],"text":"1","_key":"8d86306d3ac6"},{"_type":"span","marks":[],"text":" This incorporates key principles into the organizational culture of the program. These include acknowledging the widespread impact of trauma and the path to recovery, recognizing the signs of trauma in individuals, and responding by making sure policies and practices are geared toward not retraumatizing the individual. A trauma-informed approach may or may not include trauma-specific treatments. Some fundamental principles in a trauma-informed approach are ensuring a sense of physical and psychological safety for all served; building and maintaining individuals’ trust in the program by those accessing services and their families; welcoming mutual self-help from those with lived experience of trauma and recovery from trauma; adopting a nonhierarchical, collaborative stance where the expertise of individuals accessing services is understood and respected; keeping individuals accessing services front and center, and believing in their resilience and ability to recover from trauma; and providing care that actively moves away from stereotypes and biases.","_key":"ba8723c5431d"}]},{"_key":"d6b894b68ec2","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Clinical Pearl: ","_key":"22aeea7450c00"},{"_type":"span","marks":[],"text":"Programs should consider how to implement trauma-informed care and ensure staff are trained in this approach to best meet the needs of individuals accessing services.","_key":"4cb2122c8799"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null},{"style":"normal","_key":"a1504d8d40cc","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"marks":[],"text":"","_key":"6ad611286096","_type":"span"}],"_type":"block"},{"upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"text":"Addressing Trauma","_key":"88f3e6fa02c30","_type":"span","marks":["strong"]}],"_type":"block","style":"normal","_key":"e9c37a269cc3"},{"uploadAudio":null,"medias":null,"style":"normal","_key":"bf19bb1c869d","markDefs":[],"children":[{"_key":"f20c8abcc6470","_type":"span","marks":[],"text":"Clinicians are often concerned about the increased sensitivity to stress in those experiencing psychosis and can be hesitant to use evidence-based treatments for PTSD."},{"_type":"span","marks":["superscript"],"text":"14,15","_key":"d2744bce97f2"},{"marks":[],"text":" As a result, evidence-based trauma treatments are not offered routinely to individuals seeking treatment for psychosis in the United States.","_key":"3701106caee7","_type":"span"},{"_type":"span","marks":["superscript"],"text":"16","_key":"35b05d027c71"},{"marks":[],"text":" However, Grubaugh et al, in a meta-analysis of PTSD treatments for individuals diagnosed with PTSD and a “severe and persistent comorbid mental illness,” which included psychotic spectrum disorders or mood disorders, found that PTSD treatment can be used safely in this population.","_key":"1444440872d4","_type":"span"},{"_type":"span","marks":["superscript"],"text":"5","_key":"2fd90c84cf85"}],"_type":"block","upload_doc":null},{"children":[{"_type":"span","marks":[],"text":"In addition, a growing evidence base suggests that standard protocols for trauma treatments in psychosis are effective.","_key":"af52c57198d70"},{"_type":"span","marks":["superscript"],"text":"17","_key":"844c511b2b18"},{"_type":"span","marks":[],"text":" These treatment protocols include trauma-focused CBTp,","_key":"b806af46327e"},{"_type":"span","marks":["superscript"],"text":"18","_key":"961c7f1dc092"},{"_type":"span","marks":[],"text":" prolonged exposure,","_key":"761eaf8e1bed"},{"_type":"span","marks":["superscript"],"text":"19","_key":"533e62e1f515"},{"_type":"span","marks":[],"text":" and eye movement desensitization reprocessing.","_key":"bd1e88d694b7"},{"_type":"span","marks":["superscript"],"text":"20","_key":"a40fb0106e08"},{"text":" However, adapting these protocols may be necessary to ensure the needs of an individual experiencing psychosis symptoms are thoroughly addressed; for example, ensuring the individual has sufficient coping skills in place to tolerate the trauma intervention while not prolonging access to exposure-based therapies (“as much as needed, but as little as necessary”) and supporting the individual around psychosis symptoms if these are intrusive and may impact the trauma treatment. Developing an initial formulation to understand the trauma timeline, subsequent symptoms (both trauma and psychosis focused), and impact of these on core beliefs will aid the clinician in determining where to focus psychosocial interventions.","_key":"b559930bfda4","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"87c3e1c1e9d9","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null},{"uploadAudio":null,"medias":null,"style":"normal","_key":"3d54d81ab544","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Clinical Pearl:","_key":"b5b3e14824a50"},{"_type":"span","marks":[],"text":" Treatment options and pacing are guided by the immediate needs of the individual and should support the reduction of distress and movement toward meaningful goals.","_key":"09df86fc96fc"}],"_type":"block","upload_doc":null},{"children":[{"_type":"span","marks":[],"text":"","_key":"ceadb6aed9cd"}],"_type":"block","style":"normal","_key":"c6ba35812f68","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[]},{"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal","_key":"04c89206a160","markDefs":[],"children":[{"marks":["strong"],"text":"Concluding Thoughts","_key":"6c96206f90d20","_type":"span"}]},{"upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"marks":[],"text":"Traumatic life events are common among individuals who experience psychosis. Often, when an individual presents with psychosis, past traumas are not assessed. This could be due to the individual’s hesitancy to talk about these events or the clinician’s fear that asking about trauma will exacerbate symptoms. We now know that trauma-informed care leads to better outcomes. This systemwide approach begins with creating safe spaces for individuals to speak about past experiences in a way that is not retraumatizing and incorporates the impact of these experiences into a formulation that guides treatment. Evidence-based trauma interventions have been shown to be effective in addressing trauma in individuals experiencing psychosis and should be made routinely available. Further research on effective trauma intervention adaptations for individuals with psychosis would be meaningful. 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He explained that the most serious cases occur within the first 18 weeks and that the risk decreases over time, becoming almost negligible after 2 years. “Long-term risk excess is small compared with advantages of clozapine in outcomes, including life expectancy,” he reported. ”Relaxing long-term monitoring could favor the advantages of clozapine use, without incurring risk of neutropenia.”","_key":"18e22a4b3fd30","_type":"span"},{"_type":"span","marks":["superscript"],"text":"2","_key":"7b77547d7ad1"}],"_type":"block"},{"_type":"block","style":"normal","_key":"2d2f1b8ac65e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Meanwhile, Cotes addressed prescriber, patient, and caregiver concerns, including challenges working with some pharmacies in submitting information. He discussed the results of a study that found 60% of clinicians prescribing clozapine said that “The safe use requirements have often caused delay in my patients receiving medication.” Cotes added that missed doses due to this bureaucracy can lead to the need for re-titration, psychological distress for patients, physical discomfort/withdrawal, symptom exacerbation, and can even lead to hospitalization.","_key":"c565c799b74a0"},{"_type":"span","marks":["superscript"],"text":"2","_key":"17530ad78640"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"In addition to expert testimony, patients, caregivers, clinicians, and advocates were given an opportunity to speak before the committee voted.","_key":"6a316006ab240"}],"_type":"block","style":"normal","_key":"2a455930a838"},{"style":"normal","_key":"e6a2b1f72b3b","markDefs":[],"children":[{"_type":"span","marks":[],"text":"“The REMS program, while well-intentioned and -designed, does create a barrier to prescribers and patients using clozapine,” said Kathryn K. Erickson-Ridout, MD, a member of APA’s Council on Quality Care who testified on behalf of APA.3 Erickson-Ridout, who is also an inpatient psychiatrist and researcher for Kaiser Permanente, told the committee, ““I have been treating patients with treatment-resistant schizophrenia for 12 years and have seen the life-transforming benefit of this medication—controlling otherwise treatment-resistant psychotic symptoms and providing cognitive clarity.” ","_key":"51e90a4d955f0"}],"_type":"block"},{"_type":"block","style":"normal","_key":"cdb1d8cd1e2d","markDefs":[],"children":[{"_type":"span","marks":[],"text":"She added the disruptions in care resulted from the REMS protocol can lead to “disastrous results.”","_key":"aa3cc47443430"}]},{"children":[{"_type":"span","marks":[],"text":"Similarly, epidemiologist and panelist Sascha Dublin, MD, PhD, emphasized the need for monitoring and support without “a punitive and technocratic approach.”","_key":"25820974114e0"},{"_type":"span","marks":["superscript"],"text":"3","_key":"3c7ed08f4587"}],"_type":"block","style":"normal","_key":"27d6c40b2c46","markDefs":[]},{"style":"normal","_key":"0b6c6a7ff083","markDefs":[],"children":[{"text":"“I do not believe that the REMS’ approach to documenting and enforcing is serving the health of the patients or the needs of the community,” she said.","_key":"4a3dfec9d2bf0","_type":"span","marks":[]}],"_type":"block"},{"style":"normal","_key":"5366de8a504a","markDefs":[],"children":[{"text":"Although the committee overwhelmingly decided the REMS was no longer appropriate, Walter Dunn, MD, PhD disagreed. Dunn, Health Sciences Assistant Clinical Professor in the department of psychiatry at UCLA David Geffen School of Medicine, director of the Mood Disorders Clinic at West Los Angeles Veterans Affairs Medical Center, preferred monitoring when the risk was the greatest—during the first 18 weeks—instead of completely getting rid of the REMS. He did, however, suggest a more streamlined program without ANC levels.","_key":"7fee48f1814e0","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"1","_key":"acfaadd1cdfd"}],"_type":"block"},{"markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/view/clozapine-rems-regulatory-discrimination-against-psychiatrists","_key":"5a7bf474edb0","nofollow":true,"blank":true}],"children":[{"_type":"span","marks":[],"text":"In a recent article for ","_key":"80b8b91534900"},{"_type":"span","marks":["em","5a7bf474edb0"],"text":"Psychiatric Times","_key":"80b8b91534901"},{"_type":"span","marks":[],"text":", Gilbert Honigfeld, PhD, detailed the onerous process and the delays in treatment that result from REMS, even referring to it as a discriminatory practice against psychiatric clinicians.","_key":"80b8b91534902"},{"marks":["superscript"],"text":"4","_key":"880f2a14f95c","_type":"span"}],"_type":"block","style":"normal","_key":"8ca00f559ec5"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"“From the point of view of professional equity alone then, clozapine REMS is clearly discriminatory and should be eliminated immediately,” he wrote.","_key":"8abb61a4f7330"},{"_type":"span","marks":["superscript"],"text":"4","_key":"c06c83f1b504"},{"_type":"span","marks":[],"text":" “Psychiatrists are physicians first, specialists second. They are as capable of monitoring the health and well-being of their patients as physicians in all other medical specialties. No medicine is free of significant adversity, and clozapine’s low overall rate of fatal outcomes turns out to be quite comparable to other antipsychotic medicines, if not better.”","_key":"9bd3b0140e8e"}],"_type":"block","style":"normal","_key":"376432600a8e"},{"_type":"block","style":"normal","_key":"35ddcc57aa61","markDefs":[],"children":[{"_type":"span","marks":[],"text":"“As well intended as it might once have seemed, the federal REMS program is now one of the primary obstacles standing in the way of patients receiving their medicine on time,” he added.","_key":"4bd19ff897f00"},{"_type":"span","marks":["superscript"],"text":"4","_key":"2cd84761ed9c"},{"_key":"ad08774ba85f","_type":"span","marks":[],"text":" “It is a major factor limiting access to clozapine for individuals with serious mental illnesses whose very lives might well depend on it. Solution? Eliminate FDA’s clozapine REMS program and allow psychiatrists to practice medicine just like their peers in all other medical specialties.”"}]},{"children":[{"_type":"span","marks":["em"],"text":"What do you think of this decision and how will it impact your prescribing strategy and patients? Share your thoughts with us via PTEditor@mmhgroup.com.","_key":"a2cacd160e480"}],"_type":"block","style":"normal","_key":"aaf11f441454","markDefs":[]},{"style":"normal","_key":"208fc07548d6","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"References","_key":"e5f5da6c57440"}],"_type":"block"},{"_type":"block","style":"normal","_key":"d6c3935bc857","markDefs":[{"_type":"link","href":"https://insights.citeline.com/pink-sheet/product-reviews/us-advisory-committees/clozapine-rems-a-barrier-to-treatment-and-unnecessary-for-safe-use-us-fda-adcomms-say-KDK6ICJKNBHPTBGVFFL3C6ME7U/","_key":"1fc3d61f6408"}],"children":[{"_type":"span","marks":[],"text":"1. Sutter S. Clozapine REMS A Barrier To Treatment And Unnecessary For Safe Use, US FDA Adcomms Say. ","_key":"f2fa6ed975360"},{"_type":"span","marks":["em"],"text":"The Pink Sheet. ","_key":"f2fa6ed975361"},{"_type":"span","marks":[],"text":"November 20, 2024. Accessed November 20, 2024. ","_key":"f2fa6ed975362"},{"_type":"span","marks":["1fc3d61f6408"],"text":"https://insights.citeline.com/pink-sheet/product-reviews/us-advisory-committees/clozapine-rems-a-barrier-to-treatment-and-unnecessary-for-safe-use-us-fda-adcomms-say-KDK6ICJKNBHPTBGVFFL3C6ME7U/","_key":"f2fa6ed975363"}]},{"style":"normal","_key":"23601345cdbd","markDefs":[{"_key":"fcf608efde8c","_type":"link","href":"https://www.fda.gov/media/183655/download"}],"children":[{"_key":"774434e85b970","_type":"span","marks":[],"text":"2. FDA Advisory Committee Meeting Clozapine Risk Evaluation and Mitigation Strategy. November 19, 2024. Accessed November 20, 2024. 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states overlap with PTSD, GAD, ADD, and borderline personality disorder, complicating differential diagnosis.\n\n• Comprehensive data collection, including family history and antidepressant reactions, aids in distinguishing bipolar depression.\n\n• Digital therapeutics and psychotherapy offer effective alternatives to medication, with new CPT codes proposed for reimbursement.\n\n• Patient involvement and education, supported by reliable internet resources, are crucial in managing diagnostic uncertainty.","published":"2024-11-19T15:00:00.000Z","_updatedAt":"2024-11-11T20:29:41Z","authorMapping":[{"_type":"author","_id":"pst_author_323669","_updatedAt":"2020-08-21T07:23:47Z","url":{"current":"james-phelps-md","_type":"slug"},"displayName":"James Phelps, MD","_createdAt":"2020-02-21T11:23:21Z","_rev":"pI9SawGKsTP14Lioy52fLS"}],"ExcludeFromPubMedXML":false,"authors":[{"displayName":"James Phelps, 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With these symptoms, bipolar mixed states overlap almost completely with those of ","_key":"4e5ff86c7daf0","_type":"span"},{"_type":"span","marks":["1ea498eb1a16"],"text":"posttraumatic stress disorder","_key":"67ebf2a933fc"},{"text":" (PTSD) with depression, generalized anxiety disorder (GAD) with depression, attention deficit disorder (ADD) with depression, and ","_key":"e2ed83948b3e","_type":"span","marks":[]},{"_type":"span","marks":["6364a9ec098f"],"text":"borderline personality disorder","_key":"329ff50803c8"},{"_type":"span","marks":[],"text":".","_key":"2f62088f407c"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"7a378520683c0"}],"_type":"block","style":"normal","_key":"a579010d1481"},{"_key":"409bec3037da","markDefs":[],"children":[{"_type":"span","marks":[],"text":"This essay presents 4 means of coping with the diagnostic uncertainty that results from this overlap.","_key":"f35dc399e7a80"}],"_type":"block","style":"normal"},{"style":"normal","_key":"08be638e487c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"f8b63e5eab280"}],"_type":"block"},{"_key":"49aed91bd7ef","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"1. Gather More Data","_key":"157db4f44a590"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"While the ","_key":"673de9b6e6260"},{"_type":"span","marks":["em"],"text":"symptoms","_key":"673de9b6e6261"},{"_type":"span","marks":[],"text":" of these conditions overlap almost completely, 4 other domains of information do statistically differentiate bipolar depressions from depression (including when comorbid with PTSD, GAD, ADD and borderline): (1) a family history of ","_key":"673de9b6e6262"},{"text":"bipolar disorder","_key":"5f9908842445","_type":"span","marks":["9eccebc8b2af"]},{"_type":"span","marks":[],"text":"; (2) early age of depression onset (teens/early 20s); (3) episodic illness course or postpartum onset; and (4) highly adverse reactions to antidepressants.","_key":"d70ee928bfbb"},{"_type":"span","marks":["superscript"],"text":"1,2","_key":"e1eeaf92b272"}],"_type":"block","style":"normal","_key":"f6e8277fc7c1","markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/topics/bipolar","_key":"9eccebc8b2af","nofollow":true,"blank":true}]},{"children":[{"_type":"span","marks":[],"text":"","_key":"83ecad4bc2e20"}],"_type":"block","style":"normal","_key":"00e73dda9a13","markDefs":[]},{"_key":"4ec84dbf939c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Therefore, one way of coping with the difficult differential posed by depression with 1 or more of the mixed state symptoms described in Part 1 (including anxiety, anger, agitation, attention problems; and extreme insomnia) is to make sure to gather all relevant data. No diagnosis should be proffered until they are obtained and evaluated.","_key":"06da9a469a8d0"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"a35b7b0349e60"}],"_type":"block","style":"normal","_key":"7e8f74f43677"},{"markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/view/efficient-assessment-20-questions-about-bipolarity-moodcheck","_key":"1d4afd973797","blank":true}],"children":[{"_key":"3d648a40293e0","_type":"span","marks":[],"text":"But the sheer volume of information one is expected to gather in an initial interview can interfere with establishing trust and rapport through open-ended questions and accurate reflective listening. Using questionnaires to gather some of this information is efficient but can be cumbersome: how much can you ask a patient to divulge before meeting you in person? For a short questionnaire designed to capture mood symptoms "},{"_key":"3d648a40293e1","_type":"span","marks":["em"],"text":"and"},{"_type":"span","marks":[],"text":" family history, age of onset, illness course, and response to antidepressants, consider “MoodCheck”, described in ","_key":"3d648a40293e2"},{"_type":"span","marks":["em"],"text":"Psychiatric Times","_key":"3d648a40293e3"},{"_type":"span","marks":[],"text":" in ","_key":"3d648a40293e4"},{"_type":"span","marks":["1d4afd973797"],"text":"2017","_key":"3d648a40293e5"},{"_type":"span","marks":[],"text":" and available for direct download (no profit or industry connections).","_key":"3d648a40293e6"},{"_type":"span","marks":["superscript"],"text":"3","_key":"fb27cc7d34d6"}],"_type":"block","style":"normal","_key":"424ec05c9df6"},{"children":[{"_type":"span","marks":[],"text":"","_key":"24f6d130b6200"}],"_type":"block","style":"normal","_key":"c6bfafb49464","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"2. Recruit the Patient (And Perhaps Family)","_key":"4193a52422500"}],"_type":"block","style":"normal","_key":"e5f882a4b647"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Shared decision-making involves more than simply explaining treatment pros and cons. It includes understanding the patient’s beliefs and fears and social milieu. For example, is PTSD a preferred diagnosis because it places causality outside the patient? Is ADD preferred because it is a simple explanation for struggling in school? How much stigma is attached to the word bipolar, in the patient’s mind, and their family’s, and their community?","_key":"ee2c5548804d0"}],"_type":"block","style":"normal","_key":"9c1deae87048"},{"style":"normal","_key":"04848dcbb3b0","markDefs":[],"children":[{"text":"","_key":"d44a0069a4170","_type":"span","marks":[]}],"_type":"block"},{"_key":"08d4d5af8095","markDefs":[],"children":[{"_type":"span","marks":[],"text":"With these insights in hand or in development, a good clinician helps the patient (and perhaps family) understand the diagnostic challenge of mixed states. One might say “There are a couple of ways to explain your symptoms. No single diagnosis is obvious. We have to consider several” (enumerating those most likely, including bipolar without mania). Another variation: “You do not have bipolar disorder, but you do not have plain depression either. You may be somewhere in between.”","_key":"ffb23894da5a0"}],"_type":"block","style":"normal"},{"style":"normal","_key":"3f9b3c10f471","markDefs":[],"children":[{"marks":[],"text":"","_key":"e364a4bc28500","_type":"span"}],"_type":"block"},{"_key":"b9ae5a9e4f8c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"When time is limited, especially in an initial interview, it is almost impossible to be this deliberate explaining a complex differential. But many patients, if they leave with limited information, will turn to the internet. Unguided searching can easily lead to misimpressions. You could create your own website, or a handout of recommended sites to direct your patients’ searches. For that list, consider a site built recently for patients with depression that emphasizes all the themes in the essay you are reading now (no profit, no advertising).","_key":"bd5f7bd5e02f0"},{"marks":["superscript"],"text":"4","_key":"16497d1efc3e","_type":"span"}],"_type":"block","style":"normal"},{"style":"normal","_key":"3c1600dc27b5","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"01062a9426d70"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"3. 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Psychotherapies have lower risks than medications, even if targeting the “wrong” diagnosis; indeed, several are likely to help even when misdirected.","_key":"1ac8ffc40373"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"a8990d1b4beb0"}],"_type":"block","style":"normal","_key":"1a57a9fa4813"},{"markDefs":[],"children":[{"_key":"627ba31e9a3a0","_type":"span","marks":[],"text":"In the face of diagnostic uncertainty, you can offer or refer the patient to a psychotherapy specific for the most likely diagnosis, or therapy likely to benefit any of several diagnostic possibilities. For example, some therapies are PTSD-specific, focusing on trauma, while basic cognitive-behavioral therapy (CBT) may still be of benefit in PTSD through components such as stress management and mindfulness skills. Similarly, CBT is likely to help a patient whose depression is mixed, or even bipolar II depression. A meta-analysis of 409 trials found CBT equally effective as medications for depression in the short term, and better in the long term."},{"_type":"span","marks":["superscript"],"text":"5","_key":"d38313e2c465"}],"_type":"block","style":"normal","_key":"9c7e13d94e00"},{"_key":"f9396c3b2c78","markDefs":[],"children":[{"marks":[],"text":"","_key":"aa3bb1c3ab200","_type":"span"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"4c21870797ce","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Unfortunately, unless you have a solid referral network, it can be difficult to confidently refer patients for psychotherapy. The best local therapists are often not routinely taking new patients. For online therapy, some websites allow a patient to choose a particular kind of therapy, but you cannot control the quality.","_key":"69922eaa370b0"}]},{"_key":"f8599a3ed871","markDefs":[],"children":[{"marks":[],"text":"","_key":"46b370ff497e0","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Digital therapeutics (DTX) include websites and apps that provide a kind of psychotherapy. Web-based versions of CBT have been shown to be nearly as effective as a live therapist, particularly if guided with some minimal support.","_key":"ae7378618d4e0"},{"marks":["superscript"],"text":"6","_key":"af6584f9cf3c","_type":"span"},{"marks":[],"text":" Online therapies for PTSD also have shown efficacy, although patients are more likely to drop out if the intervention focuses on stabilization (as do the majority of such programs) when they are looking for trauma-focused work.","_key":"b5daf72142f6","_type":"span"},{"_type":"span","marks":["superscript"],"text":"7","_key":"57dc2804b8da"}],"_type":"block","style":"normal","_key":"c3ad4a1af5f9"},{"_key":"e6ed0303cf28","markDefs":[],"children":[{"_key":"c750da621e810","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"c2840482743d","markDefs":[],"children":[{"marks":[],"text":"Some of the best studied versions of online CBT rely on patient motivation to work through the modules.","_key":"6e1078fed0820","_type":"span"},{"_type":"span","marks":["superscript"],"text":"8","_key":"7a43e9df9599"},{"_key":"0d6304d98299","_type":"span","marks":[],"text":" Completion rates have been as low as 10% in some of these studies."},{"marks":["superscript"],"text":"9","_key":"0597a5194280","_type":"span"},{"text":" By contrast, newer DTX programs “push” adherence with programmed messages and limited text-based support. With these, 1 industry-sponsored study demonstrated almost 90% adherence after 12 of 16 sessions.","_key":"fe48900dd3f1","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"10","_key":"e95681bcae79"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"ee4b5841248b0"}],"_type":"block","style":"normal","_key":"07943f40613a"},{"children":[{"_type":"span","marks":[],"text":"In that industry-sponsored study, the absolute difference in the primary outcome measure (MADRS) vs an active control condition was small. But all patients were already on an antidepressant and the control was a very plausible version of the treatment app, perhaps limiting improvement and separation. Data from further research will be of great interest. In the meantime, it appears that the push technology represents a major advance vs older DTXs.","_key":"beaeefab38d60"}],"_type":"block","style":"normal","_key":"a8cd0a74de9d","markDefs":[]},{"_key":"7152a1da38ba","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"679b26ba5e450"}],"_type":"block","style":"normal"},{"style":"normal","_key":"c496c3cbbf2f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"As a final reason to more deeply consider adding DTX to your toolkit, note that Medicare and Medicaid Services have proposed new CPT codes that would pay for prescribing and managing these tools. (In an important twist, only “FDA-approved” programs would be allowed, thus excluding several existing programs that have not sought such approval). Code GMBT1 would allow clinicians to bill for giving DTX to patients and teaching them how to use it. The idea is to make DTX rather like giving a vaccine. Code GMBT2 covers the first 20 minutes of “monthly management services,” such as reviewing the data from the DTX device.","_key":"8f248968726f0"},{"_type":"span","marks":["superscript"],"text":"11","_key":"de7dab8a8bfb"}],"_type":"block"},{"children":[{"marks":[],"text":"","_key":"5fa46fc4153c0","_type":"span"}],"_type":"block","style":"normal","_key":"3305fa1be214","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"4. Compare Treatment Risks","_key":"2fb32e6222360"}],"_type":"block","style":"normal","_key":"1a9e9ab3e57a"},{"children":[{"_type":"span","marks":[],"text":"If beginning with a medication treatment rather than a psychotherapy, a fourth means of coping with diagnostic uncertainty is to help the patient compare the risks of treatment options associated with possible diagnoses. This approach is detailed in Part 3 of this series.","_key":"709ecdf704770"}],"_type":"block","style":"normal","_key":"0e1e0631dfde","markDefs":[]},{"_key":"340b73a3e070","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"50f0439333cd0"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"ec6f1eb38e1b","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Concluding Thoughts","_key":"6029913f51c40"}]},{"_type":"block","style":"normal","_key":"bceb3730b6f6","markDefs":[],"children":[{"_key":"e692eaca9ba70","_type":"span","marks":[],"text":"Because of overlapping symptoms, distinguishing mixed states from other common presentations of depression can be nearly impossible. This essay describes 4 means of coping with that uncertainty, including respective clinical tools: "},{"_type":"span","marks":["em"],"text":"gathering data","_key":"e692eaca9ba71"},{"_type":"span","marks":[],"text":" using a broad but brief questionnaire; ","_key":"e692eaca9ba72"},{"_type":"span","marks":["em"],"text":"patient education","_key":"e692eaca9ba73"},{"_key":"e692eaca9ba74","_type":"span","marks":[],"text":", augmented with reliable internet sources; starting with a "},{"_type":"span","marks":["em"],"text":"psychotherapy","_key":"e692eaca9ba75"},{"text":", including DTX; and patient education ","_key":"e692eaca9ba76","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"comparing treatment risks","_key":"e692eaca9ba77"},{"_type":"span","marks":[],"text":".","_key":"e692eaca9ba78"}]},{"_key":"52e6fed7438a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"56939e5608990"}],"_type":"block","style":"normal"},{"children":[{"marks":["strong"],"text":"Dr Phelps","_key":"ec89bee9541f0","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"ec89bee9541f1"},{"_key":"ec89bee9541f2","_type":"span","marks":["em"],"text":"is retiring from 30 years of treating complex mood disorders, and recently founded another website, DepressionEducation.org. He is the bipolar disorder section editor for "},{"_type":"span","marks":[],"text":"Psychiatric Times®","_key":"ec89bee9541f3"},{"_type":"span","marks":["em"],"text":" and the author of","_key":"ec89bee9541f4"},{"_type":"span","marks":[],"text":" ","_key":"ec89bee9541f5"},{"_type":"span","marks":["ca2683fb96a4"],"text":"A Spectrum Approach to Mood Disorders","_key":"ec89bee9541f6"},{"_type":"span","marks":["em"],"text":" for clinicians and","_key":"ec89bee9541f7"},{"_type":"span","marks":[],"text":" ","_key":"ec89bee9541f8"},{"_type":"span","marks":["c778ff5bea03"],"text":"Bipolar, Not So Much","_key":"ec89bee9541f9"},{"_type":"span","marks":[],"text":" ","_key":"ec89bee9541f10"},{"_type":"span","marks":["em"],"text":"for patients and their families","_key":"ec89bee9541f11"},{"marks":[],"text":".","_key":"ec89bee9541f12","_type":"span"}],"_type":"block","style":"normal","_key":"7805dc0c6f64","markDefs":[{"blank":true,"_type":"link","href":"https://wwnorton.com/books/A-Spectrum-Approach-to-Mood-Disorders/","_key":"ca2683fb96a4"},{"_key":"c778ff5bea03","blank":true,"_type":"link","href":"https://wwnorton.com/books/Bipolar-Not-So-Much/"}]},{"_type":"block","style":"normal","_key":"28abf4f6a063","markDefs":[],"children":[{"text":"","_key":"2f6e7f2155cb0","_type":"span","marks":[]}]},{"children":[{"marks":["strong"],"text":"References","_key":"67ddc72426800","_type":"span"}],"_type":"block","style":"normal","_key":"bf014d87bba7","markDefs":[]},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/18199233/","_key":"c0d37f0aac4a"}],"children":[{"_key":"7a240a9e93da0","_type":"span","marks":[],"text":"1. 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Coombs, MD","url":"angela-coombs-md"},{"displayName":"Jennifer Sotsky, MD, MS","url":"jennifer-sotsky-md-ms"}],"targeting":{"content_placement":["topics/traumatic-stress-disorders","topics/anxiety","topics/covid-19","topics/emergency-psychiatry"],"document_url":["teamwork-trauma"],"document_group":null,"rootDocumentGroup":[],"issue_url":"","publication_url":""},"relatedArticles":[{"title":"Multidisciplinary Inpatient Care for Medically Compromised Youth and Young Adults With Eating Disorders","url":{"current":"multidisciplinary-inpatient-care-for-medically-compromised-youth-and-young-adults-with-eating-disorders","_type":"slug"},"thumbnail":{"_type":"mainImage","alt":"eating disorders","caption":"Wanlee/AdobeStock","asset":{"_ref":"image-75e054327354fd399f1c1b0d16066577da5800d1-5000x3500-jpg","_type":"reference"}},"published":"2024-11-22T17:00:00.488Z"},{"title":"4 Ways to Cope With Bipolar Uncertainty","url":{"current":"4-ways-to-cope-with-bipolar-uncertainty","_type":"slug"},"thumbnail":{"_type":"mainImage","alt":"bipolar","caption":"Vector Tradition/AdobeStock","asset":{"_type":"reference","_ref":"image-404e1c0468b1b692448c95b34c56c94c7d55a7bd-462x451-jpg"}},"published":"2024-11-19T15:00:00.000Z"},{"title":"Newly FDA-Cleared TMS for Major Depressive Disorder, Obsessive-Compulsive Disorder, and Anxious Depression","url":{"current":"newly-fda-cleared-tms-for-major-depressive-disorder-obsessive-compulsive-disorder-and-anxious-depression","_type":"slug"},"thumbnail":{"alt":"brain electric","caption":"LuckyStep/AdobeStock","asset":{"_ref":"image-fe4aecdda8576865763573dc3fea3f22023851dc-600x375-jpg","_type":"reference"},"_type":"mainImage"},"published":"2024-11-12T19:37:30.544Z"},{"title":"Opening Pandora’s Box: The Importance of Assessing and Treating Trauma in Individuals Experiencing Psychosis","url":{"current":"opening-pandoras-box-the-importance-of-assessing-and-treating-trauma-in-individuals-experiencing-psychosis","_type":"slug"},"thumbnail":{"asset":{"_ref":"image-3baa097f1742d64c9afda10b2c6f7deda469f1dc-7280x4080-jpg","_type":"reference"},"_type":"mainImage","alt":"trauma","caption":"necropos12/AdobeStock"},"published":"2024-11-12T16:00:00.000Z"},{"title":"Differential Diagnosis of Mixed States is Nearly Impossible. 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","url":{"current":"differential-diagnosis-of-mixed-states-is-nearly-impossible-heres-how-to-cope","_type":"slug"},"thumbnail":{"_type":"mainImage","alt":"questions","caption":"sergign/AdobeStock","asset":{"_ref":"image-0ed42755e5073b545ec9cabf17e17101c1af23d2-4000x2667-jpg","_type":"reference"}},"published":"2024-11-12T15:00:00.000Z"},{"title":"Time to Think of Aggression as a Treatment Target Symptom, Independent of Diagnosis ","url":{"_type":"slug","current":"time-to-think-of-aggression-as-a-treatment-target-symptom-independent-of-diagnosis"},"thumbnail":{"_type":"mainImage","alt":"aggression","caption":"Stranger ManAdobeStock","asset":{"_ref":"image-986628c7bb80dae06a08a56503356ed45edbefbb-4017x3734-jpg","_type":"reference"}},"published":"2024-11-08T16:00:00.000Z"}]},{"gptTakeaways":"• Bipolar mixed states share symptoms with depression comorbid with PTSD, GAD, or ADD, complicating differential diagnosis.\n\n• The DSM-5's mixed features specifier broadens the bipolar spectrum, increasing symptom overlap with other conditions.\n\n• Diagnostic certainty is challenging; a tentative approach to diagnoses is recommended, considering alternative explanations.\n\n• Managing uncertainty involves gathering patient data, shared decision-making, psychotherapy, and comparing treatment risks.","articleType":"News","_updatedAt":"2024-11-11T20:11:59Z","gptSummary":"Bipolar mixed states are challenging to distinguish from depression comorbid with PTSD, GAD, or ADD due to overlapping symptoms. The DSM-5's mixed features specifier broadens the bipolar spectrum, complicating differential diagnosis. Common symptoms include anxiety, irritability, agitation, and attention problems. Diagnostic certainty is difficult, necessitating a tentative approach to diagnoses. Strategies to manage uncertainty include gathering comprehensive patient data, engaging in shared decision-making, considering psychotherapy, and comparing treatment risks. These steps aim to improve diagnostic accuracy and treatment outcomes in complex mood disorders.","authorMapping":[{"displayName":"James Phelps, MD","_createdAt":"2020-02-21T11:23:21Z","_rev":"pI9SawGKsTP14Lioy52fLS","_type":"author","_id":"pst_author_323669","_updatedAt":"2020-08-21T07:23:47Z","url":{"current":"james-phelps-md","_type":"slug"}}],"is_visible":true,"summary":"How can you distinguish bipolar mixed states? Stay tuned in this short series. ","thumbnail":{"_type":"mainImage","alt":"questions","caption":"sergign/AdobeStock","asset":{"_ref":"image-0ed42755e5073b545ec9cabf17e17101c1af23d2-4000x2667-jpg","_type":"reference"}},"contentCategory":{"_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Articles","_id":"8bdaa7fc-960a-4b57-b076-75fdce3741bb","_updatedAt":"2020-02-25T09:35:56Z","_createdAt":"2020-02-06T09:15:47Z"},"ExcludeFromPubMedXML":false,"authors":[{"displayName":"James Phelps, MD","url":"james-phelps-md"}],"documentGroup":null,"_rev":"bcxmLYb4HqB4YfW9fqdbqK","published":"2024-11-12T15:00:00.000Z","title":"Differential Diagnosis of Mixed States is Nearly Impossible. Here’s How to Cope. ","url":"differential-diagnosis-of-mixed-states-is-nearly-impossible-heres-how-to-cope","factCheckAuthorMapping":null,"factCheckAuthors":null,"documentGroupMapping":null,"_type":"article","body":[{"alignment":"left","disableLightBox":true,"_type":"figure","disableTextWrap":false,"alt":"questions","_key":"e018e0b3ac21","asset":{"_ref":"image-0ed42755e5073b545ec9cabf17e17101c1af23d2-4000x2667-jpg","_type":"reference"},"imgcaption":[{"style":"normal","_key":"427f5aada048","markDefs":[],"children":[{"_type":"span","marks":[],"text":"sergign/AdobeStock","_key":"74efa4830b5e0"}],"_type":"block"}],"widthP":50},{"style":"normal","_key":"1fb026c784ca","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/ptsd","_key":"6feebe99dafd"}],"children":[{"_type":"span","marks":[],"text":"This first of 3 articles will demonstrate that bipolar mixed states are nearly impossible to differentiate from depression that is comorbid with ","_key":"44f622088b110"},{"_type":"span","marks":["6feebe99dafd"],"text":"posttraumatic stress disorder","_key":"fdd2b88018b6"},{"_key":"60436d9e5985","_type":"span","marks":[],"text":" (PTSD), or generalized anxiety disorder (GAD), or attention-deficit disorder (ADD). Parts 2 and 3 will present 4 ways of coping with uncertainty when faced with this difficult differential."}],"_type":"block"},{"style":"normal","_key":"894b98c5e77b","markDefs":[],"children":[{"text":"","_key":"9deb883f27580","_type":"span","marks":[]}],"_type":"block"},{"markDefs":[],"children":[{"marks":["strong"],"text":"The Mixed Features Specifier","_key":"6127deb56eea0","_type":"span"}],"_type":"block","style":"normal","_key":"097dc5f3b014"},{"style":"normal","_key":"61b36b70f904","markDefs":[{"href":"https://www.psychiatrictimes.com/topics/major-depressive-disorder","_key":"c3f6fe514229","nofollow":true,"blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"In 2013, the ","_key":"30bf705385c30"},{"_type":"span","marks":["em"],"text":"DSM-5","_key":"30bf705385c31"},{"_key":"30bf705385c32","_type":"span","marks":[],"text":" extended the bipolar spectrum all the way to “unipolar” ("},{"_type":"span","marks":["c3f6fe514229"],"text":"major depressive disorder","_key":"c91cebd0f16c"},{"marks":[],"text":", MDD). The mixed features specifier means that individuals who do not have bipolar disorder can have manic symptoms. But which symptoms and how many? Broadening the answer broadens overlap with other conditions.","_key":"80056bfa6b54","_type":"span"}],"_type":"block"},{"_type":"block","style":"normal","_key":"0f4f2c7bf720","markDefs":[],"children":[{"_key":"3680c918333d0","_type":"span","marks":[],"text":""}]},{"children":[{"_type":"span","marks":["strong"],"text":"Which Symptoms?","_key":"48637dc11e5b0"}],"_type":"block","style":"normal","_key":"3f53cb9fc7d5","markDefs":[]},{"_key":"49751ce53d5c","markDefs":[],"children":[{"text":"In the words of some of the of the ","_key":"5fac634596b20","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"DSM-5 ","_key":"5fac634596b21"},{"marks":[],"text":"crafters: “The mixed features specifier, it was decided, would define clinical entities … that merited clear and more precise definition—especially in order to ","_key":"5fac634596b22","_type":"span"},{"text":"establish clear entities for future outcome studies","_key":"5fac634596b23","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":".”","_key":"5fac634596b24"},{"marks":["superscript"],"text":"1","_key":"a78fdb3fb139","_type":"span"},{"_type":"span","marks":[],"text":" [emphasis mine] In other words, the new criteria were more a research guideline than a clinical guideline.","_key":"440b4b104242"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"marks":[],"text":"","_key":"bf3aa43e992a0","_type":"span"}],"_type":"block","style":"normal","_key":"762764c75e70"},{"_type":"block","style":"normal","_key":"59d2c6a123d3","markDefs":[],"children":[{"_type":"span","marks":[],"text":"This helps explain the exclusion of some of the high-energy symptoms commonly observed in research on mixed states since 2013. According to three such studies,","_key":"90a8ddb8e7830"},{"marks":["superscript"],"text":"2-4","_key":"f07d368f97d2","_type":"span"},{"_type":"span","marks":[],"text":" common symptoms of mixed states include:","_key":"20bf79f2973d"}]},{"style":"normal","_key":"52313093d9a2","listItem":"bullet","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Agitation, both psychic (anxiety) and physical","_key":"ec326abfbaf20"}],"level":1,"_type":"block"},{"listItem":"bullet","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Irritability","_key":"53ef1f4683b30"}],"level":1,"_type":"block","style":"normal","_key":"436f140cdb65"},{"level":1,"_type":"block","style":"normal","_key":"a912666c4707","listItem":"bullet","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Nonstop ideas and distractibility","_key":"87be4f9619ed0"}]},{"listItem":"bullet","markDefs":[],"children":[{"text":"Decreased sleep","_key":"91e2439ba3430","_type":"span","marks":[]}],"level":1,"_type":"block","style":"normal","_key":"dee860043232"},{"_type":"block","style":"normal","_key":"a5b2bbb9b57e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"d02f5f26a0960"}]},{"style":"normal","_key":"175235fd3736","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Roger McIntyre, coauthor of one of those studies4 suggests these be remembered as “The 4 A’s”: anxiety, anger, agitation and attention problems. 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This overlap is shown in the ","_key":"3988f7f80a0e0"},{"_type":"span","marks":["strong","00e550146000"],"text":"Table","_key":"3988f7f80a0e1"},{"_type":"span","marks":[],"text":" (symptoms of MDD are shown in blue).","_key":"3988f7f80a0e2"}],"_type":"block","style":"normal","_key":"c3bff32ee2fd","markDefs":[{"_key":"00e550146000","nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fd030bfc505bdc5e912f1a3d8da755ba41dc254b9-624x304.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=1920\u0026q=75"}]},{"asset":{"_ref":"image-d030bfc505bdc5e912f1a3d8da755ba41dc254b9-624x304-png","_type":"reference"},"imgcaption":[{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Table. 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Response to previous treatments may be illuminating, but you might be the first provider."}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"3cc206c717580"}],"_type":"block","style":"normal","_key":"dcb9e1884977"},{"style":"normal","_key":"023ad74e5dc9","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Is this “farewell to differential diagnosis,” as one author lamented?9 Not necessarily; rather, one can simply acknowledge that diagnostic certainty is almost impossible to attain in the face of depression with anxiety or anger or agitation or attention problems. When dealing with these symptoms, one must think of diagnoses in this context as ","_key":"ce646d5f4c280"},{"_type":"span","marks":["em"],"text":"tentative","_key":"ce646d5f4c281"},{"_type":"span","marks":[],"text":", holding open the possibility of alternative explanations until a good outcome is obtained.","_key":"ce646d5f4c282"}],"_type":"block"},{"style":"normal","_key":"161a6beed092","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"108c8aea94a00"}],"_type":"block"},{"children":[{"_type":"span","marks":["strong"],"text":"Coping With Diagnostic Uncertainty","_key":"213c27ec64940"}],"_type":"block","style":"normal","_key":"82b770c020ff","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Here are 4 steps to take or consider before initiating treatment that can help manage diagnostic uncertainty.","_key":"3fed91887d020"}],"_type":"block","style":"normal","_key":"99f8b3e29e2b"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"1. ","_key":"a474ebbea0ed0"},{"marks":["em"],"text":"Routinely gather data","_key":"a474ebbea0ed1","_type":"span"},{"text":" that differentiate bipolar and unipolar depressions: family history, age of onset of depression, illness course (episodic or postpartum), and response to treatment (especially adverse responses to antidepressants).","_key":"a474ebbea0ed2","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"dd7ae6e4c1fd"},{"children":[{"_type":"span","marks":[],"text":"2. ","_key":"ca62a65d4c200"},{"_key":"ca62a65d4c201","_type":"span","marks":["em"],"text":"Engage the patient"},{"_type":"span","marks":[],"text":" (and perhaps family) in shared decision-making through psychoeducation. 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Ostacher MJ, Suppes T. ","_key":"88282183e0c40","_type":"span","marks":[]},{"_type":"span","marks":["2c8fd933df1b"],"text":"Depression with mixed features in major depressive disorder: a new diagnosis or there all along?","_key":"88282183e0c41"},{"_type":"span","marks":[],"text":" ","_key":"b73176a99cbb"},{"_type":"span","marks":["em"],"text":"J Clin Psychiatry","_key":"88282183e0c42"},{"_type":"span","marks":[],"text":". 2018;79(2):17ac11974.","_key":"88282183e0c43"}],"_type":"block","style":"normal","_key":"656d46b79976"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/25830457/","_key":"22e363f239c1"}],"children":[{"_type":"span","marks":[],"text":"2. Perugi G, Angst J, Azorin JM, et al; BRIDGE-II-Mix Study Group. ","_key":"bb70ea9e19d00"},{"_key":"bb70ea9e19d01","_type":"span","marks":["22e363f239c1"],"text":"Mixed features in patients with a major depressive episode: the BRIDGE-II-MIX study."},{"text":" ","_key":"30309c178daf","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"J Clin Psychiatry","_key":"bb70ea9e19d02"},{"_type":"span","marks":[],"text":". 2015;76(3):e351-8.","_key":"bb70ea9e19d03"}],"_type":"block","style":"normal","_key":"adde073c18c0"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/24856547/","_key":"6629083cb256"}],"children":[{"marks":[],"text":"3. Sani G, Vöhringer PA, Napoletano F, et al. ","_key":"a2b13eeaad8e0","_type":"span"},{"_type":"span","marks":["6629083cb256"],"text":"Koukopoulos׳ diagnostic criteria for mixed depression: a validation study.","_key":"a2b13eeaad8e1"},{"_key":"25e1302ea172","_type":"span","marks":[],"text":" "},{"text":"J Affect Disord","_key":"a2b13eeaad8e2","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":". 2014;164:14-18.","_key":"a2b13eeaad8e3"}],"_type":"block","style":"normal","_key":"4f98d29c5d13"},{"style":"normal","_key":"956106c51fbf","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/29105003/","_key":"449447e433cc"}],"children":[{"_type":"span","marks":[],"text":"4. Suppes T, Eberhard J, Lemming O, et al. ","_key":"3c1157fd88500"},{"text":"Anxiety, irritability, and agitation as indicators of bipolar mania with depressive symptoms: a post hoc analysis of two clinical trials.","_key":"3c1157fd88501","_type":"span","marks":["449447e433cc"]},{"_type":"span","marks":[],"text":" ","_key":"3c195e27f4e6"},{"_type":"span","marks":["em"],"text":"Int J Bipolar Disord","_key":"3c1157fd88502"},{"_type":"span","marks":[],"text":". 2017;5(1):36.","_key":"3c1157fd88503"}],"_type":"block"},{"markDefs":[{"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/34599629/","_key":"153b4a361101","blank":true}],"children":[{"marks":[],"text":"5. Yatham LN, Chakrabarty T, Bond DJ, et al. ","_key":"8d5906efe0d90","_type":"span"},{"_type":"span","marks":["153b4a361101"],"text":"Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) recommendations for the management of patients with bipolar disorder with mixed presentations.","_key":"8d5906efe0d91"},{"_type":"span","marks":[],"text":" ","_key":"baf6282be962"},{"_type":"span","marks":["em"],"text":"Bipolar Disord","_key":"8d5906efe0d92"},{"_type":"span","marks":[],"text":". 2021;23(8):767-788.","_key":"8d5906efe0d93"}],"_type":"block","style":"normal","_key":"dce2df9373dc"},{"_key":"08a349bde045","markDefs":[{"_key":"db6729198ab2","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/28421980/"}],"children":[{"_type":"span","marks":[],"text":"6. Stahl SM, Morrissette DA, Faedda G, et al. ","_key":"efbfab06b65c0"},{"text":"Guidelines for the recognition and management of mixed depression.","_key":"efbfab06b65c1","_type":"span","marks":["db6729198ab2"]},{"_type":"span","marks":[],"text":" ","_key":"d811fae8a8bc"},{"_type":"span","marks":["em"],"text":"CNS Spectr","_key":"efbfab06b65c2"},{"text":". 2017;22(2):203-219.","_key":"efbfab06b65c3","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"cc2ee191ef6e","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/33353391/","_key":"3e03d96b5676"}],"children":[{"_type":"span","marks":[],"text":"7. Malhi GS, Bell E, Bassett D, et al. ","_key":"c027b560b8960"},{"_type":"span","marks":["3e03d96b5676"],"text":"The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders.","_key":"c027b560b8961"},{"_type":"span","marks":[],"text":" ","_key":"1628de8f3e8d"},{"_type":"span","marks":["em"],"text":"Aust N Z J Psychiatry","_key":"c027b560b8962"},{"_type":"span","marks":[],"text":". 2021;55(1):7-117.","_key":"c027b560b8963"}]},{"_key":"d76acb9c4dbe","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/27866502/","_key":"0a4d108911ef"}],"children":[{"_type":"span","marks":[],"text":"8. McElroy SL, Keck PE. ","_key":"a31cb06f95000"},{"marks":["0a4d108911ef"],"text":"Dysphoric mania, mixed states, and mania with mixed features specifier: are we mixing things up?","_key":"a31cb06f95001","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"702013efc487"},{"_type":"span","marks":["em"],"text":"CNS Spectr","_key":"a31cb06f95002"},{"marks":[],"text":". 2017;22(2):170-176.","_key":"a31cb06f95003","_type":"span"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"b4bdb24555cf","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/25830464/","_key":"68a4a6ba8fdf"}],"children":[{"_type":"span","marks":[],"text":"9. Goldberg JF. 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Here’s How to Cope. ","url":{"current":"differential-diagnosis-of-mixed-states-is-nearly-impossible-heres-how-to-cope","_type":"slug"},"thumbnail":{"_type":"mainImage","alt":"questions","caption":"sergign/AdobeStock","asset":{"_ref":"image-0ed42755e5073b545ec9cabf17e17101c1af23d2-4000x2667-jpg","_type":"reference"}},"published":"2024-11-12T15:00:00.000Z"}]},{"factCheckAuthorMapping":null,"documentGroup":null,"url":"emraclidine-for-schizophrenia-fails-to-meet-primary-endpoints-in-phase-2-empower-trials","summary":"Emraclidine once-daily, oral monotherapy treatment for adults with schizophrenia experiencing acute psychotic symptoms, failed to meet the primary endpoints in the 2 phase 2 EMPOWER trials. ","body":[{"_key":"293bf97aef07","asset":{"_ref":"image-b8ef2680390810316525d823173ed9dd8cb09f10-6000x4000-jpg","_type":"reference"},"widthP":50,"_type":"figure","alt":"failed endpoint","imgcaption":[{"_type":"block","style":"normal","_key":"7cbace250830","markDefs":[],"children":[{"_key":"f3920f2fbc1b0","_type":"span","marks":[],"text":"MasterSergeant/AdobeStock"}]}],"alignment":"left","disableTextWrap":false,"disableLightBox":true},{"_type":"block","style":"normal","_key":"dc89a3acdb9f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"AbbVie announced that 2 of its phase 2 EMPOWER trials investigating emraclidine as a once-daily, oral monotherapy treatment for adults with schizophrenia experiencing acute psychotic symptoms, did not meet their primary endpoint of a statistically significant improvement in the change from baseline in the Positive and Negative Syndrome Scale (PANSS) total score compared with the placebo group at week 6.","_key":"16851d87e6dd0"},{"marks":["superscript"],"text":"1","_key":"e124624b43e4","_type":"span"}]},{"children":[{"_type":"span","marks":[],"text":"","_key":"af49d3c36db6"}],"_type":"block","style":"normal","_key":"de4221a4897a","markDefs":[]},{"_type":"block","style":"normal","_key":"76ea9f898794","markDefs":[],"children":[{"_type":"span","marks":[],"text":"\"While we are disappointed with the results, we are continuing to analyze the data to determine next steps,\" said Roopal Thakkar, MD, executive vice president of research and development and chief scientific officer at AbbVie. \"We would like to extend our gratitude to the study participants and their loved ones as well as to our network of clinical investigative sites for their participation in these trials. We are confident that our innovative pipeline will continue to bring meaningful therapies to patients, and we remain committed to finding better treatments for people living with psychiatric and neurological disorders.\"","_key":"e61321d0a9850"}]},{"style":"normal","_key":"7fbbc26db3cd","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"9451b4ddd123"}],"_type":"block"},{"style":"normal","_key":"b3fbea7bac84","markDefs":[],"children":[{"text":"According to new data from EMPOWER-1, those receiving placebo (n= 127), who had a baseline PANSS of 98.3 (8.16), saw an LS Mean (95% CI) change of -13.5 (-17.0, -10.0). Those receiving emraclidine 10 mg QD (n = 125), who had a baseline of 97.6 (7.65), saw an LS Mean change of -14.7 (-18.1, -11.2). Those receiving emraclidine 30 mg QD (n = 127), who had a baseline of 97.9 (7.89), saw an LS Mean change of -16.5 (-20.0, -13.1).","_key":"96edc9aa373c0","_type":"span","marks":[]}],"_type":"block"},{"style":"normal","_key":"d5c45246fb3b","markDefs":[],"children":[{"marks":[],"text":"","_key":"dae9248e5094","_type":"span"}],"_type":"block"},{"_type":"block","style":"normal","_key":"d934a826c1d9","markDefs":[],"children":[{"_type":"span","marks":[],"text":"\"Although understandably AbbVie is disappointed about the emraclidine negative phase 2 studies, the results are important for our continued understanding of how the muscarinic cholinergic receptors (mAChRs) interface with the symptoms of schizophrenia. There are several receptor binding differences between emraclidine and xanomeline, the active molecule in Cobenfy that was just FDA approved in September to treat individuals with schizophrenia. Specifically, emraclidine is a positive allosteric modulator of only one of the 5 mAChRs, M4. Xanomeline is an agonist at 2 specific mAChRs, M1 and M4. The emraclidine results suggest that M1 agonism contributes to the improvement in symptoms of schizophrenia, but this remains to be established,\" said John J. Miller, MD, Editor in Chief of ","_key":"4d50a6f331df"},{"_type":"span","marks":["em"],"text":"Psychiatric Times","_key":"9f56a7f9cbbd"},{"_type":"span","marks":[],"text":". ","_key":"fd876d05de92"}]},{"markDefs":[],"children":[{"text":"","_key":"70ced2180fea","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"711a9fdceffd"},{"_type":"block","style":"normal","_key":"431c127dd825","markDefs":[],"children":[{"text":"In EMPOWER-2, those receiving placebo (n = 128), who had a baseline PANSS of 97.4 (8.22), saw an LS Mean change of -16.1 (-19.4, -12.8). Those receiving emraclidine 15 mg QD (n = 122), who had a basline of 98.0 (8.49), saw an LS Mean change of -18.5 (-22.0, -15.0). Those receiving emraclidine 30 mg QD (n = 123), who had a baseline of 97.2 (7.75), saw an LS Mean change of -14.2 (-17.6, -10.8).","_key":"40fd83a9a36a0","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"text":"","_key":"d732ebfc8ff3","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"e8b385914e9e"},{"_key":"a0e90faef18e","markDefs":[],"children":[{"text":"In the EMPOWER trials, emraclidine was well-tolerated. Its safety profile is comparable to that observed in the phase 1b trial. 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