​1. Title: 

The relationship between traumatic experiences and PTSD with psychotic symptoms in trauma-affected refugees 

2. Project period: 

February 2016 – August 2016 

3. Investigator: 

Hannah Rathke (MSc. Psychology student, University of Copenhagen). 

4. Supervisors and collaborative partners: 

• Sabina Palic-Kapic, CTP. 
• Stig Poulsen, University of Copenhagen. 

5. Background 

There is a growing amount of research focusing on the association between adult trauma, PTSD and psychosis. Nevertheless, there is only little research about the nature of traumatic experiences and their specific relation to psychotic symptoms. There is no empirical research on the specific effects of torture on PTSD with secondary psychotic features. Childhood abuse is often characterised by interpersonal experiences of captivity and dependence, which can lead to more complex PTSD reactions (Herman, 2015) and the experience of psychotic symptoms (Seedat et al., 2003). The association between childhood abuse and psychosis is supported by empirical research (Read & Bentall, 2004). It can be argued that an adult experience of torture is characterised by similar interpersonal experiences of captivity, dependence and an alteration of one’s sense of self as in childhood abuse (Herman, 2015). Luhrmann (2007) and Selten & Canton-Graee (2007) describe how an experience of social defeat is associated with an increased likelihood of psychotic symptoms. An experience of torture can be understood as an extreme experience of physical, moral and social defeat. Mueser, Rosenberg, Goodman & Trumbetta (2002) showed that PTSD can mediate the relationship between trauma and psychosis and lead to more severe forms of mental illness. The project examinesthe relationship between adult trauma, PTSD and psychosis and whether different kinds of adult trauma are associated with different likelihoods of the occurrence of PTSD with secondary psychotic symptoms. 

6. Aim/s 

The aim of the study is to examine if different kinds of traumatic experiences are associated with different likelihoods of developing psychotic symptoms in a population of trauma-affected refugees with a diagnosis of PTSD. It is hypothesised that the experience of torture and captivity, as an interpersonal adversity, is particularly associated with psychotic symptoms in PTSD. 

7. Methods 

7.1 Number of participants (N) 

Approx. 700 patients from the research trials PTF 1, PTF 2 and PTF 3 will be included in the study. 

7.2 Population

The study is based on a population of trauma-affected refugees who were seeking treatment at Competence Centre for Transcultural Psychiatry (CTP) in Ballerup, Denmark. The sample includes patients from the earlier research projects PTF 1, PTF 2 and PTF 3. It represents consecutive patients over a 6-year period. All patients have a diagnosis of PTSD. Patients with psychotic disorders are excluded from the study. However, studies PTF1-PTF3 include individuals with PTSD and secondary psychotic features (PTSD-SP). 

7.3 Description of data and data collection 

Variables in the analyses are derived from the PTF1-3 studies (2008-2012). The study uses variables from the ‘trauma anamnesis’, ‘HTQ scores’, ‘Hamilton scores for depression and anxiety’, ‘PTSD diagnosis’, ‘HSCL scores’, ‘GAF scores’, ‘information about the patient's psychotic symptoms’ and ‘demographic data’ at baseline. 

7.4 Application/acceptance from the Danish Data Protection Agency, the National Committee on Health Research Ethics 

The data collection was approved by the Danish Data Protection Agency, the National Committee on Health Research Ethics when it was collected during the research trials PTF 1, PTF 2 and PTF 3. The pooling of data across the PTF1-PTF3 studies was granted in relation to the project “What works for whom? Identifying different treatment trajectories in trauma-affected refugees”. The present project is a sub-study under this larger project, and has the aim to clarify possible predictors of treatment outcome. 

7.5 Analysis 

The analyses include both descriptive methods for the demographic data and hierarchical logistic regressions, to examine the relation of different kinds of traumatic experiences and the diagnosis of PTSD-SP (PTSD with secondary psychotic features). 

8. Expected results 

It is expected that torture, as an interpersonal trauma, will show the strongest association with the experience of psychotic symptoms secondary to a diagnosis of PTSD (PTSD-SP). 

9. Dissemination of results 

In the first step the results are part of a master thesis at the University of Copenhagen. Thereafter the results will be submitted to a journal in the form of an article in collaboration with Sabina PalicKapic and Stig Poulsen. 

10. References 

• Herman, J. (2015). Trauma and Recovery: The Aftermath of Violence-From Domestic Abuse to Political Terror. New York: Basic Books. Retrieved from http://www.amazon.com/TraumaRecovery-Aftermath-Violence-From-Political/dp/0465061710
• Luhrmann, T. M. (2007). Social defeat and the culture of chronicity: Or, why schizophrenia does so well over there and so badly here. Culture, Medicine and Psychiatry, 31(2), 135–172. http://doi.org/10.1007/s11013-007-9049-z 
• Mueser, K. T., Rosenberg, S. D., Goodman, L. A., & Trumbetta, S. L. (2002). Trauma, PTSD, and the course of severe mental illness: An interactive model. Schizophrenia Research, 53(1-2), 123– 143. http://doi.org/10.1016/S0920-9964(01)00173-6 
• Read, J., Mosher, L. R., & Bentall, R. P. (Eds.). (2004). Models of Madness. Psychological, Social and Biological Approaches to Schizophrenia. East Sussex: Brunner-Routledge. Retrieved from http://www.isps.org/index.php/publications/book-series/item/86-models-of-madness 
• Seedat, S., Stein, M. B., Oosthuizen, P. P., Emsley, R. A., & Stein, D. J. (2003). Linking Posttraumatic Stress Disorder and Psychosis. A Look at Epidemiology, Phenomenology, and Treatment. October, 191(10), 675–681. http://doi.org/10.1097/01.nmd.0000092177.97317.26 
• Selten, J.-P., & Cantor-Graae, E. (2007). Hypothesis : social defeat is a risk factor for schizophrenia ? British Journal of Psychiatry, 191(51), 9–12. http://doi.org/10.1192/bjp.191.51.s9