Results document the need to address the issues related to posttraumatic reactions to psychosis in people with multiple psychotic episodes. Our findings can inform the development of treatment that is sensitive to these issues. Specifically, findings suggest the need to validate the intense and negative emotional reactions people frequently experience during a psychotic episode and during treatment episodes. Reactions following the acute psychotic episode were more varied, with a small percentage of people reported relief that the worst part was over, while others remained traumatized about what happened. Psychotherapy can be offered to clients who show evidence of posttraumatic reactions and should address these reactions through validation to alleviate traumatic reactions to psychosis. Findings on aspects of symptoms that can cause traumatogenic reactions among clients could also inform the development of treatment protocols so that patients can know what to expect when going to a psychotic episode. Clients commonly reported negative, often traumatizing treatment experiences. The damaging effects of such experiences on client's trust of mental health professionals were evident in client interviews. Effective treatment of posttraumatic reactions to psychosis can potentially improve clients' ability to form more collaborative relationships with treatment providers and to play a more active role in the management of their psychiatric disorder (8, 58). Emerging research addressing post-psychotic depression indicates promising results for cognitive behavior therapy (CBT) as a treatment for traumatic reactions toward psychosis (59). Jackson et al. (59) evaluated a form of CBT in reducing trauma, depression, and low self esteem following a first episode of psychosis, in a randomized controlled trial among 66 patients who had recently experienced a first episode of psychosis. CBT has also been found to be effective in reducing hopelessness, when compared to treatment as usual, among a total of 66 participants recovering from FEP (28). In a third study (60), among 22 people recovering from psychosis, those who wrote about the most stressful aspects of their illness showed fewer traumatic symptoms than those who wrote about emotionally neutral topics. Findings suggest that narrative statements disclosing the most stressful aspects of psychosis may lessen the traumatic impact of psychosis (60). Future research on focused intervention for posttraumatic reactions toward psychosis is needed.

Findings from this study underline some of the complicated issues facing the mental health service system. On one hand, participants reported being traumatized by symptoms of mental illness such as distressing auditory hallucinations, bizarre behavior, and persecutory delusions. Simultaneously participants reported being traumatized by interventions (such as involuntary hospitalization, restraints, and forced medication) designed to alleviate these symptoms. However, in many cases, participants experienced these interventions as humiliating or violations of self. Trauma informed care (61) may offer alternatives to restraints and seclusion. Newer models of treatment that place an emphasis on "shared-decision making," such as the Open Dialog Model (62), have been recommended for people experiencing a first psychotic episode, but our findings suggest that these approaches may need to be offered for persons experiencing multiple psychotic episodes as well. Shared-decision making in medication management, which emphasizes "partnership between two experts: the client and the practitioner," provides a model for the client to "assess a treatment's advantages and disadvantages" in medication management [Ref. (63), p. 1636]. Commonground, a web-based application of shared decision making model, encourages the use of resilient self-care strategy in addition to the use of psychotropic medication. It has been found that when CommonGround is implemented, the use of self-management strategies among clients correlated with less concerns about medication side effect, increased perception that medicines were helping, and improved recovery (64). CommonGround has been implemented successfully in community mental health centers (65) while its implementation in psychiatric hospitals has not been reported in the literature. The adoption of shared decision model may reduce traumatic reactions during treatment and foster better trust between providers and clients.

The limitations of this study include sampling issues and the retrospective nature of the data collected. The inpatient participants in the present study were significantly younger (mean age was 33.78) than studies of multi-episode patients with severe mental illness [e.g., Ref. (44, 66–68)]. The participants also had a higher number of hospitalizations (8.55) upon the time of assessments compared to the participants in other studies of persons with severe mental illness. Participants also were more likely to be diagnosed with schizophrenia or schizoaffective disorders (54%), and to be non-white compared to other studies of persons with severe mental illness. These divergences with previous studies suggest that our findings may not be generalizable to a wider range of persons with psychotic disorders. Additionally, experiences of psychosis and contact with psychiatric services were reported retrospectively, recall bias may have affected the accuracy of people's recollections about their reactions to psychotic experiences and treatment. Finally, during a psychotic episode such as during the height of hallucinations or delusions, the patient may be unable to distinguish reality from non-reality, or even self from other. Therefore, technically, the experience of delusions or hallucinations may not be considered as a traumatic life event, to the same extent as events such as criminal victimization. For some patients with chronic schizophrenia, there is a possibility that these patients never experienced traumatic life events such as abuse or criminal victimization. While we would caution the distinction between a traumatic life event and a traumatic experience of psychosis, treatment however could be similar. Clinical experience has indicated that PTSD-like symptoms induced by delusions can be similarly treated using CBT. For example, a client experienced the delusion of police "shooting" and "killing" his best friend who "stalked" him. Client held onto this fixed delusion and blamed himself for causing the "death" of his best friend. He in turn suffered PTSD-like symptoms including avoidance, hypervigilance, and re-experiencing symptoms. He was successfully treated with CBT by treating his delusion as though the event was real. Once his beliefs in causing the "death" of his best friend were challenged, his PTSD-like symptoms went away. The fixed delusion no longer significantly impacted his life as his guilt for causing his friend's "death" went away (Lu, unpublished manuscript). Further research is needed in this regard for trauma informed care for persons with psychosis.

In summary, this qualitative study describes the experiences of people during the episodes of psychosis. We found multiple factors contributing to traumatic dimensions of the experience, including actual or perceived coercive aspects of psychiatric treatment. Further research is needed to determine how mental health services can be improved to reduce illness related trauma and facilitate recovery.

### REFERENCES

### ETHICS STATEMENT

This study was carried out in accordance with the recommendations of Rutgers RBHS Institutional Review Board (previously UMDNJ-Newark IRB) and Dartmouth College Institutional Review Board with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Rutgers RBHS Institutional Review Board (previously UMDNJ-Newark IRB) and Dartmouth College Institutional Review Board.

### AUTHOR CONTRIBUTIONS

WL was the site PI for this project. She supervised the operation the project, collected some of the data herself, supervised the data entry and data analysis. She contributed to the conception and the writing of the manuscript. KM obtained the grant. Was the PI of the grant. He supervised WL in the conduction of the research activities in this grant. He provided the research instruments, research ideas, and supervision for the original project. He also contributed to the writing of the manuscript. SR was the co-PI of the project. He provided the research instruments, research ideas, and supervision for the original project. He also contributed to the writing of the manuscript. PY contributed to the writing of the manuscript. NM contributed to the data analysis of the manuscript, composition of the tables, and the editorial assistance of the manuscript.

### FUNDING

This research was partially supported by a Distinguished Investigator Award to the second author from the National Alliance for Research on Schizophrenia and Depression (NARSAD) and by departmental funding to the first author from the Department of Psychiatric Rehabilitation at Rutgers University.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2017 Lu, Mueser, Rosenberg, Yanos and Mahmoud. This is an openaccess article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# The Role of Trauma and Stressful Life Events among Individuals at Clinical High Risk for Psychosis: A Review

*Danessa Mayo1 \*, Sarah Corey2 , Leah H. Kelly2 , Seghel Yohannes2 , Alyssa L. Youngquist2 , Barbara K. Stuart2 , Tara A. Niendam1 and Rachel L. Loewy2*

*1 Imaging Research Center, Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, CA, USA, 2Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA*

The experience of childhood trauma (CT) and stressful life events (SLEs) is associated with subsequent development of a variety of mental health conditions, including psychotic illness. Recent research identifying adolescents and young adults at clinical high risk (CHR) for psychosis allows for prospective evaluation of the impact of trauma and adverse life events on psychosis onset and other outcomes, addressing etiological questions that cannot be answered in studies of fully psychotic or non-clinical populations. This article provides a comprehensive review of the current emerging literature on trauma and adverse life events in the CHR population. Up to 80% of CHR youth endorse a lifetime history of childhood traumatic events and victimization (e.g., bullying). Several studies have shown that the experience of CT predicts psychosis onset among CHR individuals, while the literature on the influence of recent SLEs (e.g., death of a loved one) remains inconclusive. Multiple models have been proposed to explain the link between trauma and psychosis, including the stress-vulnerability and stress-sensitivity hypotheses, with emphases on both cognitive processes and neurobiological mechanisms (e.g., the hypothalamic–pituitary–adrenal axis). Despite the preponderance of CHR individuals who endorse either CT or SLEs, no clinical trials have been conducted evaluating interventions for trauma in CHR youth to date. Furthermore, the current process of formal identification and assessment of trauma, SLEs, and their impact on CHR youth is inconsistent in research and clinical practice. Recommendations for improving trauma assessment, treatment, and future research directions in the CHR field are provided.

Keywords: clinical high risk, trauma, early psychosis, stressful life events, ultra-high risk, schizophrenia

## INTRODUCTION

While a wealth of data has demonstrated indirect associations between childhood trauma (CT) and psychosis in adulthood, the role of CT in the etiology of psychosis and its potential underlying mechanisms are not yet well-understood (1–4). CT is the experience of a highly distressing event or situation during youth that is beyond one's capacity for coping and/or control (5, 6). Prospective studies of individuals who later develop psychosis provide a unique opportunity to examine potential risk factors, resilience factors, and mechanisms that may link CT and psychosis. Over the past

*Edited by: Kim T. Mueser, Boston University, USA*

#### *Reviewed by:*

*Lauren Gibson, Temple University, USA Craig Steel, University of Reading, UK*

> *\*Correspondence: Danessa Mayo<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Psychopathology, a section of the journal Frontiers in Psychiatry*

*Received: 15 December 2016 Accepted: 27 March 2017 Published: 20 April 2017*

#### *Citation:*

*Mayo D, Corey S, Kelly LH, Yohannes S, Youngquist AL, Stuart BK, Niendam TA and Loewy RL (2017) The Role of Trauma and Stressful Life Events among Individuals at Clinical High Risk for Psychosis: A Review. Front. Psychiatry 8:55. doi: 10.3389/fpsyt.2017.00055*

decade, the "clinical high risk" (CHR) paradigm has been used to identify adolescents and young adults at increased imminent risk for developing psychotic disorders. Thus, CHR research makes an important contribution to understanding the potential etiologic role of CT in the development of psychosis. In this paper, we review the emerging literature on trauma and stressful life events (SLEs) in CHR individuals, with a focus on both behavioral and neurobiological studies. This paper also provides a risk model that explains the trauma and psychosis relationship. Further, current and important future directions for assessment, research, and clinical care are highlighted.

### The CHR Syndrome

The CHR syndrome, also termed "ultra high risk" by some research groups, is typically diagnosed using one of two semistructured interviews—the Structured Interview for Psychosis Risk Syndromes (SIPS) or the Comprehensive Assessment of At-Risk Mental States (CAARMS) (7, 8). The interviews assess a variety of subthreshold psychotic-like experiences (i.e., positive, negative, and disorganized symptoms), general psychopathology (e.g., depression, anxiety), functioning, and family history. Despite slight differences in diagnostic criteria and terminology, both instruments diagnose three possible risk syndromes and have shown high agreement ratings (86%) (9). Other instruments are also used to diagnose individuals at elevated risk for psychosis based on subjective cognitive changes (10, 11). As such, these selected standardized measures have been utilized in international early psychosis (EP) clinics and research programs in an effort to reach diagnostic consensus and validity across sites.

### Psychosis Risk and Outcomes

Outcomes for CHR individuals are heterogeneous: proportion estimates of individuals who transition to full psychosis range from 10–70% due to ascertainment strategy, diagnostic instrument, and follow-up period used (12). The largest individual study using the SIPS demonstrated a conversion rate of 35% to full psychosis by 2.5 years (12, 13). The CHR syndrome confers higher and more immediate risk than heritability estimates of 10% risk among first-degree family members (i.e., parent-offspring; full siblings), although not as high as the 50% rate of psychosis among identical twins (14, 15). Several factors appear to increase the risk for developing psychotic disorders among those with CHR syndromes: poor premorbid functioning, severe positive symptoms (i.e., elevated unusual thought content, increased suspiciousness), increased anhedonia, poor cognition (i.e., impaired verbal learning, decision-making, memory), decline in social and role functioning, substance abuse history, and family history of psychosis (16–19).

It is important to note that approximately 65% of CHR individuals do *not* develop psychosis within the first 3 years after diagnosis of the syndrome. A significant proportion (46%) of non-converters experience remission of their attenuated psychosis (20). Yet, many of those who do not develop psychosis continue to experience psychiatric problems such as mood, anxiety, and substance use disorders (21, 22). By targeting individuals presenting with attenuated psychotic symptoms or other markers indicative of increased psychosis risk, CHR programs seek to identify factors that could be addressed in order to mitigate a variety of negative outcomes and support resilience. To date, a number of potential factors related to outcomes in CHR populations have been identified, including the role of trauma and stress.

### TRAUMA EXPERIENCES IN THE CHR POPULATION

The experience of CT leads to a cascade of negative effects on typical child and adult development (6, 23). A strong body of literature on the general population of adolescents and young adults (*via* school-wide samples, research and clinical settings, and longitudinal population studies) suggests that CT contributes to poor cognitive, social, medical, and developmental functioning; moreover, CT is a significant risk factor for later development of serious mental illness (SMI), including schizophrenia (24–34). The lifetime prevalence rate of trauma exposure is high among both men (60.7%) and women (51.2%) (35). Individuals ages 14–24 reported exposure to one or more traumatic experiences, such as physical abuse (50%), child abuse, or neglect (13%) (36); approximately 68% of youth by age 16 endorsed at least one trauma experience (37). CT is linked with a variety of adult psychopathology outcomes. Compared to adult participants with no history of CT, those with exposure to four or more traumas were at substantial risk (4- to 12-fold) for developing substance use, depression, and suicidality (38). Thus, several studies on stress and trauma posit that the experience of CT and prolonged early stressors may contribute to the increased risk of future SMI (24–34, 39–41).

To date, only 24 studies, representing 14 distinct samples, report on CT in CHR populations; of these, 11 followed the participants longitudinally to examine CT as a risk factor for developing psychosis (2, 34, 40, 42–62). Sixteen of these studies were included in a recent review and meta-analysis (5), which summarized the existing studies in a series of tables. We refer the reader to this paper by Kraan and colleagues (5) and have summarized more recent publications (8, 34, 45, 49, 51, 52, 55, 59) in a parallel table below (see **Table 1**).

The meta-analysis concluded that CT is a largely prevalent experience among the CHR population (86.8%) compared to healthy controls (HC) (5). Such alarmingly high rates of CT endorsed by the CHR population is comparable to the prevalence rate among individuals with schizophrenia (85%) (5). We expand upon the meta-analysis by reviewing different types of trauma in the CHR syndrome based on all current available information below.

### Associated Findings on Trauma in the CHR Population

Clinical high risk individuals may be at risk for experiencing various forms of traumatic experiences that are common within the general population. The meta-analysis by Kraan and colleagues (5) reported a mean prevalence rate of 86.8% CT in CHR studies (2, 40, 42, 51, 56). The range of rates (35.9–70%) may be partially explained by the type of trauma being examined and the gender sample distribution (e.g., sexual abuse) (40, 53) and type of

TABLE 1 | Studies on clinical high risk (CHR) individuals with trauma history and/or stressful life events.

*for Affective Disorders and Schizophrenia-Present and Lifetime; BPRS, Brief Psychiatric Rating Scale-expanded; SANS, Scale for the Assessment of Negative Symptoms; SAPS, Scale for the Assessment of Positive Symptoms; CAARMS, Comprehensive Assessment of At-Risk Mental State. Studies: NAPLS-2, North American Prodrome Longitudinal Study-2; NIHR, National Institute for Health Research Mental States; CHR, clinical high risk; EP, early psychosis; LR, low risk; HC, healthy control.*

assessment used (e.g., medical records review, semi-structured interview, self-report), with self-report measures associated with higher rates of trauma disclosure [e.g., Childhood Trauma Questionnaire (CTQ), Early Trauma Inventory] (40–91%) (40, 42, 44, 55, 59). Some measures assess narrowly defined trauma, while others are more broad, including major life events. Eight of the studies were based on small samples of less than 100 participants, with some as small as 25 subjects (40, 44, 46, 50, 53, 56, 58, 62). Smaller samples are more easily biased by sampling differences and thus contribute to heterogeneity of results and lack of reproducibility (63). The largest sample reported 46.2% of CHR individuals with CT (*n* = 764), a majority of those who endorsed severe to extreme rates of trauma on the brief CTQ (51, 52, 55). As a whole, these studies highlight the preponderance of CT experiences among the CHR population and the importance of such information for clinical consideration.

Four studies formally compared CT rates in CHR samples with HC populations matched on demographic variables (i.e., age, gender, socioeconomic status) and found higher rates of abuse among CHR groups (2, 50, 58). Research suggests that CHR individuals may be at greater risk for physical trauma than the general population (17%) (64). In a small study of 30 CHR participants, 83% reported a physical abuse history (56). A study on a CHR sample reported more violent (71.7%) and non-violent events (53.3%) than the low-risk group (48.4% violent; 33.9% non-violent events) (45). Physical trauma is also associated with poorer cognitive functioning, which is a significant concern for CHR individuals, as poor premorbid cognitive functioning may add to their psychopathology risk (59, 61).

Individuals with a sexual abuse history are at higher risk for developing mood and anxiety disorders, substance abuse, posttraumatic stress disorder (PTSD), eating disorders, suicidal behaviors, and psychosis (65–69). Across studies, approximately 22–31.1% of CHR individuals endorsed a sexual trauma history (34, 40, 44, 49, 52, 53, 56) compared to the lifetime prevalence rate in the general population (15–25%) (70).  This may indicate that previous experiences of sexual trauma contribute in part to the nature of CHR individuals' emerging positive psychotic symptoms. CHR youth showed even higher rates of emotional abuse (41.5–75%) and emotional neglect (59–100%) (56, 58, 59) compared to HC (33%) (58). Furthermore, emotional abuse and neglect among CHR individuals have also been associated with greater Schneiderian first-rank symptoms, more elevated Schneiderian total score, and depression severity level (2).

Bullying victimization is becoming increasingly recognized as an important form of adverse childhood experience (24). Bullying has been associated with a variety of poor outcomes, ranging from poor self-esteem, depression, suicidality, aggression, and psychosis being the most serious (71). CHR youth endorsed a lifetime history of physical and psychological bullying (30 and 60%, respectively) that was much higher than HC (14 and 36%, respectively) (42). Bullying history among CHR youth was significantly associated with poorer social functioning (42) and was more likely to persist into adult psychiatric disorders (71). As such, it is imperative that more research is conducted to examine the relationship between childhood bullying and psychosis symptoms.

Trauma is often experienced as a result of developing psychosis, due to the experience of frightening psychotic symptoms or hospitalizations, especially involuntary treatment. Prevalence of psychosis-associated trauma symptoms among individuals with full psychotic disorders varies from 11–67% (72, 73). They may be associated with factors such as trauma history prior to inpatient hospitalization (e.g., physical or sexual abuse) and other psychological factors (e.g., negative event appraisals, poor coping skills) (74, 75). However, some studies did not find any associations with psychosis-related trauma symptoms and the number of negative experiences from inpatient psychiatric hospitalizations (73, 76). It may be important to ascertain whether other patientlevel factors, such as the level of distress attributed to the inpatient hospitalization, legal status, and involuntary hospitalization may be associated with psychosis-related trauma symptoms (73, 75, 76). To date, there are no specific studies that focus on trauma symptoms associated with psychiatric hospitalization among CHR individuals. This is an important research area in need of further exploration and highlights the usefulness of examining the impact of CT in the CHR population, prior to the potentially traumatizing effects of involuntary hospitalization that can accompany the onset of a full psychotic disorder.

Only a few published studies have explored the demographic characteristics of trauma in CHR individuals. A study on gender differences showed that stress-sensitivity scores among CHR females (but not males) mediated the association between trauma and attenuated positive psychotic symptoms, which suggests that females cope with trauma differently and tend to internalize their experiences (77). While ethnic sample variability (i.e., majority Caucasian women) was a possible research limitation, this is consistent with the common finding that females with psychosis are more likely to endorse a trauma history (e.g., sexual abuse) than males (42, 53) and are more likely to have an affective disorder associated with their diagnosis (78). Similarly, limited studies regarding ethnicity (e.g., perceived discrimination, social adversity) and its relationship with trauma in CHR groups currently exist (51). The current collective studies on CHR groups with trauma experiences suggest the importance of continued research into its associated influence on psychosis risk.

### Trauma and CHR Conversion to Psychosis

Trauma has been repeatedly found to predict transition to psychosis in CHR samples. Sexual abuse is the most common form of CT associated with later psychosis conversion, followed by physical abuse (3, 40, 53, 55, 60). Moreover, emotional abuse and physical neglect have been identified as potential risk factors for psychosis conversion (58). Similar to findings on sexual abuse history, the increased severity and duration of individuals' bullying history has been linked to the emergence of psychosis symptoms (71). While elevated rates of trauma history were found among CHR individuals in the NAPLS sample and trauma history was a significant predictor of psychosis conversion in the univariate and multivariate analyses, it was not a statistically significant predictor after controlling for prodromal symptom severity, social functioning decline, verbal learning, and memory (16). Thus, the power of trauma to predict conversion must be examined in the context of other predictors in order to determine its relative impact and possible relationship to other predictive factors.

## SLEs IN THE CHR POPULATION

It is not yet clear whether the impact of trauma on individuals with CHR is specific to narrowly defined traumatic events or also includes the cumulative effects of adverse or SLEs that have also been linked with adult psychopathology, including psychosis risk (79, 80). In fact, many studies that purport to measure traumatic events include less severe SLEs, which consist of dangerous or life-changing experiences that have occurred for an individual (5) and may cause disruption in the typical developmental trajectory of youth through adulthood. Exposure to SLEs are associated with increased risk for depressed mood, anxiety, eating disorders, suicidality, substance use, and psychosis symptoms in later adolescence (29, 81–85). Current findings on the SLE–psychosis risk relationship are inconclusive; some cited a positive relationship (39, 51, 86, 87) while others did not (43, 47, 48, 57). Kraan and colleagues (5) indicated that recent SLEs were less commonly endorsed by CHR youth than HC, which may be due to increasing negative symptoms of psychosis (e.g., increased avolition, social withdrawal) that limit activities. Increased research efforts are underway to improve current understanding of the relationship between SLEs and psychosis.

### COMORBID DISORDERS AND DIFFERENTIAL DIAGNOSIS IN THE CHR POPULATION

The specificity of the relationship between trauma and CHR symptoms is muddied by the high level of comorbidity in this population (88–90). Around 73% of CHR individuals have at least one other Axis I disorder (89). Long-term studies show persistence of comorbid disorders such as mood (15–38%), anxiety (5–16%), substance use (11%), personality disorders (2.7%), and other diagnoses (43–52%) (91, 92). At a 6-year follow-up, approximately 56.8% of CHR patients endorsed at least one comorbid disorder and 61.5% of them reported continued comorbidity from baseline (91). Only a small group of CHR individuals (7–16%) reported no comorbid diagnoses at baseline or follow-up (91, 92). Clearly, comorbidity is the rule and not the exception when dealing with EP symptomatology. Since up to 65% of CHR individuals do *not* go on to develop psychotic disorders within 3 years after initial CHR diagnosis, such subthreshold psychotic symptoms experienced may have responded to treatment, resolved over time, or may be better explained by another psychiatric diagnosis. In a strict sense, these non-converters may be considered "false positive" diagnoses regarding a pre-psychotic phase of illness. Thus, the CHR syndrome may best be understood as a mixture of individuals identified prior to the onset of psychosis, along with adolescents/young adults who experience subthreshold positive symptoms in the context of a primary mood, anxiety or PTSD. Any relationships to trauma must be understood in this context, given the extensive literature that links trauma to later mood and anxiety disorders. In this section, we examine the various comorbid disorders within the CHR and other psychotic disorders and their symptom interaction with CT.

### Mood/Anxiety Disorders

Clinical high risk individuals with CT showed high comorbid mood (40–45%) and anxiety disorders (15.3%) (5, 42, 93), as did CHR individuals with SLEs [i.e., major depressive disorder (13%), bipolar disorder (8.7%), dysthymic disorder (4.3%), social phobia (17.4%), generalized anxiety disorder (8.7%), panic disorder (4.3%)] (57). However, a study on CHR samples was unable to show a relationship between CT and mood/anxiety disorders, possibly due to low sample size (*n* = 30) (56). Available studies on CHR and first-episode psychosis (FEP) individuals with CT show that both groups had higher rates of suicidal attempts, elevated rates of psychiatric hospitalization, and poorer clinical functioning (3, 59). Studies on individuals with schizophrenia suggest that CT is associated with increased severity of depression and anxiety disorders (94, 95). The small number of current findings related to comorbid mood and anxiety disorders among CHR groups with CT warrants additional research in this area to untangle whether trauma is specifically related to positive psychotic symptoms.

### Substance Use

Despite high rates of comorbid substance use in CHR populations, particularly tobacco (34.4%), alcohol (17–44%), and cannabis (3–54%) (96), there is currently limited research specifically focused on CHR individuals with trauma and substance use. However, there are well-documented links between trauma and substance use in the general population (97) and the role of substance use in triggering psychotic episodes (98, 99). While there is minimal support as of yet for the direct relationship between substance use and conversion to psychosis in the CHR group, there is stronger evidence for the relationship between substance use and increased severity of subthreshold psychosis symptoms among CHR individuals (96). School-aged youth showed an interaction effect between CT and cannabis use that accounted for 83% of their reported psychosis symptoms (100). Better understanding potential interactions between trauma and substance use as risk factors for psychosis is a critical need in the literature, as well as highly relevant to designing interventions for this population.

### Posttraumatic Stress Disorder

Most critical to comorbidity issues in our review of trauma and the CHR syndrome is the presence of PTSD in this population. A multisite CHR study reported a significantly higher prevalence rate of current (2.6%) and lifetime (4.1%) formal PTSD diagnosis than in HCs (101). Specifically, CHR youth with a CT history demonstrates PTSD rates of 15.2% (3). Similar to mood and other anxiety disorders, comorbid PTSD diagnoses with FEP individuals who have a trauma history are associated with longer treatment duration and more intensive treatment to address all presenting symptoms (3). A meta-analysis indicated that individuals who suffer from comorbid psychosis and PTSD endorse symptoms of faulty cognitive appraisals, feelings of helplessness, and lack of control (75). These are, of course, important targets for treatment with individuals who have comorbid PTSD and psychosis, and may be relevant for CHR treatment.

### Differential Diagnosis of PTSD and CHR Status

A common referral question posed by clinicians seeking evaluation for a consumer asks— "Is it trauma or EP?" Indeed, the symptoms associated with PTSD can create diagnostic uncertainty. There are a number of similarities between the symptoms of PTSD and psychosis (102). Hallucinations in psychosis are analogous to the experience of flashbacks and intrusive images and bodily sensations associated with PTSD as they both present in visual, auditory, or tactile modalities and are usually experienced as distressing and unbidden. Suspiciousness in psychosis resembles the hypervigilance in PTSD and avoidance behaviors, which are a hallmark of PTSD and can be similar to safety-seeking behaviors or negative symptoms in psychosis. Hallucinations in an adolescent sample were found to be highly prevalent in both PTSD and psychotic disorders, and the hallucinations of psychosis and PTSD could not be differentiated in terms of content, modality, location, or form (103, 104).

It may also pose additional difficulties when evaluating individuals with more severe symptoms. Data from the U.S. National Comorbidity Survey Part II indicated that all of the positive psychotic symptoms examined in the sample were more likely to be endorsed by respondents who met diagnostic criteria for PTSD than those without PTSD (105). A dose–response relationship was also found, such that with more PTSD symptoms endorsed, the higher likelihood for experiencing both symptoms of paranoia and hallucinations. Among the psychotic symptoms, auditory hallucinations had the greatest odds ratios with lifetime PTSD diagnosis. Several studies on non-clinical, community samples suggest that CT is a strong risk factor for visual, auditory, and tactile hallucinations (106, 107). Data from the National Comorbidity Survey indicated that a history of childhood rape was significantly associated with auditory hallucinations in a non-clinical adult (Age M = 32 years, SD = 10.59) sample (107).

Despite the substantial similarities, one study of adolescents suggests that command hallucinations and derogatory themes were more common in PTSD and were associated with higher emotional distress, self-injury, and suicidal ideation, compared to hallucinations in schizophrenia (103). Furthermore, the presence of PTSD in children and adolescents has been noted to confer a substantial likelihood of disturbances of reality testing. Maltreated and traumatized children with a PTSD diagnosis are more likely than children with a history of trauma with no PTSD diagnosis to also meet criteria for a brief psychotic episode or unspecified psychotic disorder with symptoms analogous to the CHR syndrome (108). However, children with PTSD rarely exhibited full-blown delusions or illogicality. Thus, perceptual disturbances and suspiciousness may be present both in the CHR syndrome and in PTSD while other types of delusional thinking, cognitive disorganization, and negative symptoms (differentiated from mood disturbance or avoidant behaviors) may be more specific to psychotic disorders.

### MECHANISMS OF TRAUMA AND STRESS IN THE CHR POPULATION

Multiple models have been cited to explain the link between trauma and later psychosis, including the stress-vulnerability and stress-sensitivity hypotheses, with emphases on both cognitive processes and neurobiological mechanisms (e.g., the hypothalamic–pituitary–adrenal axis). Consistent with a gene–environment interaction model, trauma history appears to contribute to psychosis in adulthood somewhat independent of genetics (109). A recent gene–environment interaction study supports the idea that genes associated with schizophrenia lead to changes in not only dopamine but also serotonin signaling pathways in the brain, thus suggesting an "affective pathway" to psychosis (110). Below, we address models that have been referenced in previous works to explain the potential interplay between trauma, stress, and psychosis. Following the discussion of currently identified relationship models of trauma and psychosis, we propose our own comprehensive model that conceptualizes a cyclical relationship between trauma and psychosis risk.

### Stress-Vulnerability Model

In an effort to understand the mechanism through which trauma and stress may lead to psychosis, Zubin and Spring (111) proposed the stress-vulnerability model. This model posits that individuals possess a genetic or biological vulnerability to psychosis that can withstand a certain amount of stressors due to genes and other biological risk factors. However, once the stress threshold is surpassed, psychosis may be at higher risk of development (see **Figure 1**) (111). From this perspective, the experience of trauma increases one's experienced stress and, therefore, leaves them at greater susceptibility to experiencing psychopathology. One way this has been examined biologically is through research on the functioning of the hypothalamic–pituitary–adrenocortical (HPA) axis (see **Figure 2**), one of the primary stress response systems in the human body.

### Stress-Sensitization Model

The impact of stress on psychopathology has also been discussed in the context of stress sensitization (112). The origins of this concept come from animal models that indicated individual differences in stress-sensitivity and -reactivity due to interactions between genes and environments. Similar to the stress-vulnerability model, the stress-sensitization theory hypothesizes that for a person to experience their first psychiatric illness, they may have a biological vulnerability, and then need to experience a major stressor. After the initial emergence of psychopathology, vulnerability increases, requiring less stress for the person to develop recurrent or more severe psychiatric issues (113). Thus, experience of CT may render an individual more susceptible to psychosis triggered by later stressors. Walker and Diforio (114) describe the connection of behavioral and biological stressors in

psychosis and how dysregulation of stress response in both of these capacities overtime can create even greater disturbances in the HPA axis, thereby creating even more damaging effects on one's functioning. Support for the concept of a dysregulated response to stress following trauma can be seen in other mental health conditions. In a study of 18,713 individuals without a psychiatric diagnosis prior to the September 11 attack in the US, those who reported a CT history and were either directly or indirectly affected by the attack were at significantly greater risk of experiencing an internalizing disorder and were more vulnerable to elevated stress in comparison to those that did not report CT (115). Within the CHR population, the stress-sensitization model has never been formally tested; that is, no study has examined the possibility of an interaction between CT or SLEs and raising the risk for psychosis onset. A very large sample would be required to test an interaction model to predict conversion to psychosis, which one would only expect for up to a third of CHR individuals. However, partial behavioral evidence for stress sensitization was reported from the NAPLS study, in which CHR individuals who converted to psychosis not only reported more SLEs but also experienced higher levels of self-reported stress than CHR participants whose symptoms remitted. Additionally, those who rated more SLE also indicated higher stress from daily hassles (116). However, they did not examine any relationship of CT to SLE response. We have begun to investigate this possible interaction in our own work as described below.

### Dysregulated Stress Response

Cortisol is a biological stress marker, the final product of activation of the HPA axis in response to stress and can be obtained through plasma, saliva, and urine (117). Cortisol has a standard diurnal rhythm that can be assessed when samples are collected throughout the day (118). In addition to quantifying its daily cycle, stress reactivity can be measured when cortisol is measured in saliva samples that have been collected when a person is undergoing a stressful task (119). Therefore, dysregulation of the HPA axis can be evaluated globally to address the underlying vulnerability to stress, and locally, sensitivity can be evaluated in response to a specific stress task. Findings within the schizophrenia population indicate elevated cortisol (a physiologic measure of stress responsivity) in many individuals with psychosis (120, 121), with some variable results indicating both hyper- and hypo-function of the HPA axis (122). Some of the heterogeneity in results could be due to the presence of antipsychotic medication, which has shown to decrease cortisol levels (122, 123) or potentially to the experience of trauma.

### Trauma and the HPA Axis

There is currently some evidence for the impact of trauma on the development of altered stress responses and psychopathology. Indeed, research has shown blunted cortisol secretion in patients with PTSD (124), and in women with a history of sexual trauma (125), as well as for patients with schizophrenia who reported CT. In a study of 14 individuals who met diagnostic criteria for DSM-IV schizophrenia, those who reported moderate to severe CT experiences had lower diurnal cortisol secretion, especially within the first hour of the waking, whereas those without the experience of CT exhibited higher levels of cortisol throughout the day (126). Following the same pattern, Phassouliotis and colleagues (127) found lower basal cortisol levels, in a sample of first-episode patients who reported significantly higher rates of CT than HC. However, due to the small sample size, within-group comparisons of first-episode patients with and without CT could not be explored. Within the CHR population, this theory has had a lack of attention, but one study has supported the idea. Although trauma was not explicitly assessed, decreased cortisol secretion as a response to Trier Social Stress Test administration was found in a small sample of CHR individuals who also reported higher levels of chronic stress compared to HCs (119). Further research evaluating CT history explicitly within the CHR population is necessary to understand its impact on cortisol secretion.

Evidence suggests that psychosocial stress activates the HPA axis and, in turn, the dopamine and serotonin systems, where exaggerated effects have been observed in individuals who experienced childhood adversity (110, 128). Neuroimaging studies (i.e., magnetic resonance imaging; functional magnetic resonance imaging; positron emission tomography; diffusion tensor imaging; multimodal) have revealed that in those CHR individuals who converted to psychosis, functional changes in striatal dopamine synthesis and release were observed (129–131). In addition, Oswald and colleagues (132) found that perceived stress partially mediated the association between childhood adversity and ventral striatal dopamine responses. A full exploration of the potential neurobiological mechanisms linking trauma and psychosis are beyond the scope of this paper, but we provide these examples of one possible relationship and highlight the need for further research in this area.

Overall, a majority of studies has demonstrated abnormalities in cortisol secretion in CHR samples compared to HC (133). In a large sample of 256 CHR patients and 141 HC, the CHR group exhibited significantly higher mean diurnal salivary cortisol levels (134). Participants who converted to full psychosis in the CHR group had higher mean daily cortisol levels than those who remitted. However, the specificity of this result to psychosis is unclear, as well as whether it is a cause or consequence of attenuated psychosis. It may be related to the high rates of mood and anxiety disorders in this group rather than be central to psychosis, specifically. Its relative contribution to psychotic transition in the context of other significant risk factors is also not yet fully understood. Additional research that follows HPA axis functioning overtime and relates it to symptom expression and other biomarkers, such as genetics and neuroimaging, are critical to understanding the role it may (or may not) play in psychosis risk. A dysregulated stress response with altered cortisol secretion may be evidence of a subgroup of CHR individuals who experience an affective/stress pathway to psychosis, and thus moderating the stress response at a biological or behavioral level could be an important target for intervention in those with a demonstrated dysregulated response.

### Cognitive Mechanisms

Several cognitive mechanisms may explain the associated link between trauma and psychotic disorders. For instance, it has been suggested that early adversity may lead to the formation of negative schemas of the self, others, and the surrounding environment (135). Such negative views may eventually contribute to greater external locus of control (54) and increased symptoms of suspicious or paranoia (136). CT may be associated with faulty responses to environmental stimuli, such as informational processing bias for negative or irrelevant stimuli (137, 138). Such focus on irrelevant or what may appear to be threatening stimuli has been thought to lead to reasoning bias (e.g., jumping into conclusions) (136, 139) and paranoid thinking (140). For a more detailed overview of cognitive and neurobiological mechanisms involving trauma and psychosis, we refer the reader to a recent review by Gibson and colleagues (141).

### The Cycle of Trauma, Psychosis, and Future Risk of Trauma

To comprehend the impact of CT and SLE on the development of psychosis, the synthesized findings point to the cyclical nature of trauma, psychosis risk, and increased vulnerability for future traumatic experiences. However, given the current weak findings associating SLE with CHR transition to psychosis, our conceptualized model focuses primarily on CT. Individuals exposed to CT are at elevated risk for abnormal childhood development in terms of neurocognitive, social, and emotional functioning. Depending on the form and severity of CT, some may have a more negative impact on learning and development. For instance, exposure to physical abuse or witness of domestic violence can create globally negative views of the self, others, and the world (142). Maladaptive behaviors (e.g., non-suicidal self-injury, suicidal behaviors, aggression), poor coping skills, and impaired emotional regulation may also arise out of CT experiences, increasing one's risk for developing mood and anxiety disorders (143). These same behaviors can result in poorer role and social functioning overtime (e.g., bullying, increased peer isolation), thus decreasing protective factors, such as social support and adaptive problem-solving skills. Several studies have also highlighted that the sole experience of trauma does not predict poor clinical functioning and CHR status (34, 52). Instead, as explained by the stress-sensitivity model, one's trauma history creates an initial level of elevated vulnerability for later psychopathology, such as SMI. Other risk factors (e.g., genetic, environmental) may add or interact with trauma to confer increased risk for psychosis. While the current evidence does not support SLE as a trigger for psychosis onset, they do lead to increased levels of depression in both episodes and severity (143). Severe mood disorders that are characterized with psychotic features are often more difficult to treat (144, 145). Thus, the dose–response relationship suggests that with increased CT experiences, the risk for later psychosis becomes greater.

Unfortunately, the negative impact of CT does not end at the onset of psychotic illness. For CHR individuals who endorsed CT, the emergence of psychosis creates a string of increased vulnerability for future traumatic experiences.  In general, increased psychosis risk is associated with a decline in global functioning (e.g., social, role), emergence of comorbid disorders (e.g., depressed mood and anxiety disorders, PTSD, substance use), poor treatment engagement, and increased maladaptive coping skills and behaviors (16–19). The influence of CT further adds to the complexity of their symptom presentation and severity. As a result, the cascade of abnormal development and increased psychopathology leads to the resurgence of future vulnerability to other trauma.

The trauma–psychosis risk relationship postulates that following an initial traumatic experience, an individual experiences an abrupt change in their normal developmental course, is weakened in various areas of functioning, and therefore, is made more vulnerable moving forward in development. Based on the interaction between an individual's genetic foundation and their interaction with environmental stressors, including increased stress sensitization, the risk of psychosis conversion escalates. With the onset of full psychosis, individuals are further weakened in their ability to adaptively respond to stressful situations and adverse events moving forward, leading to increased risk of experiencing additional future trauma/SLEs. Nevertheless, the findings which highlight no associations between trauma and transition to full psychosis offer hope that there may be strong protective factors that can be bolstered during treatment of early subthreshold psychotic symptoms or that there may be additional risk factors that can help identify a subgroup of CHR individuals at particular risk for worsening psychosis related to CT.

### TRAUMA ASSESSMENT IN THE CHR SYNDROME

To better understand the role of trauma in the CHR syndrome, current methods of trauma assessment must be harmonized. Although they are used regularly with individuals with psychosis or the CHR syndrome, no existing trauma or SLE measures have been developed or validated specifically with these populations. The National Child Trauma Stress Network (146) and the American Academy of Child and Adolescent Psychiatry (147) provide guidelines on the appropriate assessment and treatment of children and adolescent who may have experienced trauma. These guidelines stress the need to briefly screen all children in a given setting for the experience of traumatic events and, in the presence of a positive screen, to follow up with a more detailed assessment in order to appropriately guide treatment planning.

Trauma experiences and associated clinical consequences can be identified through a variety of methods. Brief self-report screening questionnaires retrospectively assess for the occurrence and reaction to a variety of traumatic events. Brief screening measures for assessing only exposure to traumatic events include the Brief Trauma Questionnaire (148) and the CTQ (149). Measures examining both the experience of trauma *and* its psychological impact (e.g., assesses symptoms and distress) include the Trauma Symptom Checklist for Children (150) and the Child Posttraumatic Symptom Scale (151). The UCLA PTSD Reaction Index for DSM-IV (152) is an example of a combined measure that starts with a brief questionnaire to assess for a history of traumatic events, which is then followed by a semi-structured interview to determine distress and impact of those events to support a diagnosis of PTSD. Some measures also include a collateral informant report, such as the Trauma Symptom Checklist for Young Children (153). Finally, semi-structured diagnostic interviews such as the Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID-I) (154) and the Kiddie Schedule for Affective Disorders and Schizophrenia (155) include sections to assess for a history of traumatic events and their clinical sequelae. Measures most commonly used in CHR research studies are the CTQ, Trauma History Screen, and the CT and Abuse Scale. For a comprehensive list of trauma experience and symptom measures, please refer to the National Child Traumatic Stress Network and the American Academy of Child and Adolescent Psychiatry resources (146, 147).

While various measures of traumatic experiences and SLEs are available, there may be concerns about using them with CHR individuals. For instance, if there are concerns about early trauma experiences being distorted by the delusional thinking (e.g., suspiciousness), collateral reports from family, previous treatment providers, and school staff can clarify the validity of the individual's reported experience. Conversely, it may be difficult to determine if certain attenuated symptoms (e.g., suspiciousness) are associated with reality-based experiences of victimization and better accounted for by a trauma reaction than a psychoticspectrum symptom. However, a previous study that has examined the reliability of reported CT experiences by individuals with psychotic disorders found that they were retrospectively accurate and stable over time irrespective of current psychopathology (156). Patients may tend to underreport CT while in treatment for psychosis and could be more forthcoming when experiencing more severe psychotic symptoms. Nevertheless, studies have tackled this issue by enforcing other measures for additional precaution. A UK study on a national sample of (*n* = 2,172) 12-year-old twin children showed that research protocol can easily be structured to determine credibility of children's reporting in clinical interviews, such as enforcing a rating system that codes from 0 (i.e., not a symptom), 1 (i.e., a likely symptom), to 2 (i.e., definite symptom); and enlisting the clinical judgment of various professionals who are familiar with the CHR group/symptoms within the psychosis spectrum or whose area of specialization is with youth (41). Additionally, clinicians may worry that discussing trauma as part of an evaluation can trigger worsening of psychotic symptoms, which may lead to avoidance of appropriate assessment. Contrary to this belief, research suggests that appropriate and sensitive evaluation of trauma does not increase subjective distress (157, 158).

One significant challenge of concordant trauma and SLE assessment in this population is that the age of individuals often ranges from 12–30, and instruments are often designed for either children, adolescents, or adults. The types of trauma and SLEs experienced by these different age groups vary considerably, with school and family-related stressors (e.g., divorce of parents) relevant for children and work and romantic relationship-related stressors (e.g., one's own divorce) more relevant for young adults. The measurement of trauma and stressors overtime in the same individual creates challenges in the consistent use of instruments. While a variety of appropriate measures exists to aide in the identification of trauma, there is currently no standardized trauma evaluation protocol for CHR groups as part of research or clinical practice. This lack of detailed information related to trauma or SLE that can be compared across clinics and research precludes our ability to effectively target treatment or elucidate relationships in research.

### CHR and Trauma Interventions

Given the high prevalence and relevance of trauma in the CHR syndrome, which we have outlined above, the next step is translating this knowledge to improve interventions for this population. Trauma and psychosis are two of the most difficult clinical symptoms to target and manage in psychiatric treatment; combined, they are considered by most mental health providers to be one of the most complex forms of mental illness, usually requiring a greater level of care. Typically, when individuals present to clinical treatment settings for either symptoms of trauma or psychosis, they are often referred to clinics with an expertise in one of the two areas of concern because few programs provide integrated care for both issues (159). Consequently, there is a growing need for treatment settings that provide clinical expertise on both trauma and psychosis. Given the complex interplay of symptoms, the current model of the trauma-psychosis cycle (see **Figure 3**) suggests that CHR individuals who present with trauma history do not share the same expected course of treatment and recovery as those without a history of trauma. As shown by Cragin and colleagues (159), there is a growing need to address trauma in EP care. Recent research on trauma treatment in psychosis has shown the impact of prolonged exposure, an evidence-based trauma treatment, on reducing trauma symptoms and psychosis in individuals with chronic schizophrenia and comorbid trauma (160). However, many clinicians are concerned that addressing trauma in treatment may trigger worsening of psychosis (161). Given the lack of attention to trauma-focused treatments in psychosis, it is no surprise that even less has been developed in EP, despite the preponderance of first episode and CHR individuals who endorse CT. To date, no clinical trials have been published evaluating interventions for trauma in CHR youth. Currently, many CHR clinics utilize treatment based on cognitive–behavioral therapy (CBT) methods for individual treatment and family-based treatments [e.g., multi-family group (MFG) or functional family therapy (FFT)] to address social stress and support. The addition of components from Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) represent a potential approach to providing trauma-informed care for CHR individuals that is consistent with prominent treatment models for this population. Both CBTp and TF-CBT start with providing psychoeducation and enhancing coping skills, then introduce methods of cognitive coping, before providing opportunities to address psychotic symptoms, or trauma symptoms *via* exposure. Similar to MFG and FFT, TF-CBT also integrates family members to maintain support for the individual and ensure generalization outside of the therapeutic context. While TF-CBT is a promising approach for the CHR population, it has not yet been fully developed nor evaluated. This is a critical area of future research.

### IMPLICATIONS AND FUTURE DIRECTIONS

Overall, recent findings continue to provide supporting evidence for higher rates of trauma among CHR individuals compared to HC, consistent with Kraan and colleagues (5). Emerging studies

continue to show a strong relationship between CT and severity of psychosis symptoms in the CHR population (34, 45, 51). Studies of CHR individuals with CT also repeatedly demonstrate a negative relationship with cognitive, clinical, and social functioning outcomes overtime (34, 59). Trauma appears to predict conversion to psychosis, but may not function independently of other known risk factors such as more severe positive symptoms, cognition, and functioning (16). While CHR individuals may demonstrate heightened stress reactivity at the clinical and biological levels (119, 134), the role of SLEs in triggering transition to psychosis has not been clearly substantiated. As a result, the current proposed model of the trauma-psychosis cycle (**Figure 3**) focuses solely on CT and not SLE. However, SLE may be an important area to consider when refining the proposed trauma–psychosis model when additional studies provide a richer understanding of its influence on psychosis risk. Finally, the mechanisms underlying the relationship of trauma to psychosis onset in CHR individuals are not fully understood, although there is some evidence for both cognitive and biological (HPA axis, gene–environment interaction) models (111, 141). Most importantly, no appropriate interventions have been developed and validated specifically for trauma in CHR individuals, despite an enormous need for such an approach. The overall findings

suggest that the study of trauma, stress, and psychosis risk is still in its early stages and requires continued work. Several suggestions are provided to further research and clinical interventions in addressing the role of trauma and SLEs in psychosis among CHR individuals.

### Recommendations for Future Research

First, larger sample sizes in CHR trauma studies would support stronger inferences in research findings *via* increased statistical power that allows for testing of interaction models, mechanistic mediation models, and simultaneous testing of multiple predictors of outcomes. Adequate representation of minority groups and more international research would help to evaluate potential demographic differences. Second, inclusion of a psychiatric control group (e.g., mood and anxiety disorders without psychotic-like experiences) would prove useful in delineating what is unique to CHR individuals and what is shared with other symptom domains. Third, a standardized measure, validated for the adolescent/young adult population would help to compare across studies and assess cohorts longitudinally. The measure should assess both the number and age of occurrence of traumatic events in order to investigate whether there is a "critical period" for CT and to test stress-sensitization models.

Moving forward, the research definitions for trauma types and SLEs should be consistent and specific in order to facilitate comparison of research results across studies. For instance, some measures assess narrow definitions of trauma while other "trauma" measures also include events that are less severe and are better categorized as SLE. As another example, there is great disparity between individuals and families concerning the definition of childhood physical abuse. Researchers would benefit by providing participants with an operational definition of childhood physical abuse to help increase their responses' internal validity. Similarly, differences in the definitions of abuse across cultures should also be investigated to clarify the constructs that are measures as part of a study. In addition, the current studies examined suggest that sexual abuse history is a prominent area that demands greater focus and consideration in CHR population research, given the psychological cost of illness that may follow. Based on the current review's proposed conceptualization of trauma and psychosis risk occurring in a cyclical and repeated pattern, it is suggested that future studies on CHR individuals should consider examining the influence of complex trauma (i.e., multiple types of trauma) on psychosis risk. Additional variables to consider would be the severity and duration of trauma experiences as well as differentiating between a single traumatic event and chronic abuse, with the latter potentially conferring greater risk. Furthermore, research should delve deeper into gender differences among CHR individuals with trauma, given evidence of differential rates and effects in psychosis (42, 53).

### Recommendations for Treatment and Interventions

For clinical recommendations and improved delivery of service, it would be important for clinicians to determine a treatment plan that considers both trauma and psychosis symptoms. A decision-tree process that decides primary areas to initially target would be helpful and should be a focus of future clinical research (90). Clinicians should be able to determine whether trauma is a significant centerpiece of the presenting problem or a complicating factor that aggravates the individual's psychosis symptoms. Case conceptualizations should also consider modifications of standard treatment when necessary in order to better address the client's needs. During intake and clinical evaluations, it may be useful to create a timeline of CHR individual's trauma and SLEs in relation to their other clinical symptoms and associated functional decline. This documented information may prove imperative use for case conceptualization and treatment planning. In reference to the trauma-psychosis cycle (**Figure 3**), the timeline of events in a CHR individual's life may give helpful information into the nature of their trauma history, its severity, and the level of treatment required.

The accumulated knowledge on trauma and psychosis thus far highlights that children and youth who experience CT and/ or SLEs should be referred for immediate clinical evaluation and intervention. In particular, youth who report early bullying experiences should be taken seriously, as it can be one of the earliest forms of social stress that persists and influences various domains of functioning and well-being. Individuals experiencing psychotic-like symptoms should be encouraged to seek treatment to boost their cognitive and behavioral coping skills in order to help them combat increased vulnerability to future trauma. Families and parents have a pivotal role in increasing the effectiveness of any treatment intervention. As demonstrated by the trauma-psychosis cycle (**Figure 3**), the experience of trauma can be pervasive and persistent. Clinicians are strongly urged to involve parents, family members, or other significant people in treatment with CHR youth dealing with trauma and psychosis to enhance their social support system and buffer them against additional stressors.

A particular challenge is that many clinicians working with adolescents have not received sufficient training regarding psychotic-spectrum conditions, and specialists in EP may not have sufficient training in trauma treatment (159). Broad availability of training across clinical degree programs in the US regarding assessment and treatment of psychosis would help to improve community providers' accurate detection of potential CHR syndromes in traumatized youth. Further, training for coordinated specialty care programs that treat EP should include training modules on the appropriate assessment and treatment of trauma.

As advocated by previous research (61, 142), a standard protocol for CT or SLE assessment during all initial patient evaluations should be used in pediatric and behavioral health settings. Due to the sensitive nature of the assessment questions, clinicians and other medical providers should recognize the appropriate format of assessing trauma history in youth (i.e., separately or with their parents/caregivers in the room). Akin to training on suicide risk screening, clinical staff should be knowledgeable on how to identify and assess for trauma when working with CHR youth.

Most importantly, based on the current collective knowledge on trauma and stress in EP, we conclude that evidence-based treatments addressing trauma symptomology in the CHR population is desperately needed. Without a targeted and evidence-based treatment for a large number of CHR youth with trauma history and/or SLE, current interventions may not always be successful in impacting their illness trajectory. Yet, the preliminary outcomes from current studies show promising evidence; with improved understanding of the mechanisms that perpetuate the cycle of trauma among CHR individuals, we can promote resilience and mitigate the vulnerability of CHR individuals to developing a psychotic disorder and improve their chances of recovery from the CHR syndrome.

### AUTHOR CONTRIBUTIONS

All the authors participated in the writing of the manuscript. DM was the lead author and primary writer. SC and AY contributed in the writing of Section "Mechanisms of Trauma and Stress in the CHR Population." LK conducted a wide literature review of CHR studies and contributed in the writing of Section "Trauma Experiences in the CHR Population." SY coauthored Section "Trauma Experiences in the CHR Population" and Section "Recommendations for Future Research." BS coauthored the "Differential Diagnosis of PTSD and CHR Status" subsection. TN coauthored Sections "Trauma Assessment in the CHR Syndrome" and "Implications and Future Directions" and provided overall feedback on the manuscript. RL was the senior author of the manuscript and provided overall guidance and feedback on topic of trauma, stress, and psychosis risk

### REFERENCES

in CHR group. All authors approved the final version of the manuscript.

### FUNDING

No funding source is associated with the current manuscript submission.

maternal care: a positron emission tomography study using [11C]raclopride. *J Neurosci* (2004) 24(11):2825–31. doi:10.1523/JNEUROSCI.3422-03.2004

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2017 Mayo, Corey, Kelly, Yohannes, Youngquist, Stuart, Niendam and Loewy. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Early Psychosis and Trauma-Related Disorders: Clinical Practice Guidelines and Future Directions

*Casey A. Cragin1 \*, Martha B. Straus1 , Dawn Blacker 2 , Laura M. Tully3 and Tara A. Niendam3*

*1Department of Clinical Psychology, Antioch University New England, Keene, NH, USA, 2CAARE Diagnostic and Treatment Center, Department of Pediatrics, University of California, Davis, Sacramento, USA, 3UC Davis Imaging Research Center, Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, USA*

### *Edited by:*

*Kate Hardy, Stanford University, USA*

#### *Reviewed by:*

*Craig Steel, University of Reading, UK Sara Freedman, Bar-Ilan University, Israel*

> *\*Correspondence: Casey A. Cragin<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Psychopathology, a section of the journal Frontiers in Psychiatry*

*Received: 12 November 2016 Accepted: 16 February 2017 Published: 06 March 2017*

#### *Citation:*

*Cragin CA, Straus MB, Blacker D, Tully LM and Niendam TA (2017) Early Psychosis and Trauma-Related Disorders: Clinical Practice Guidelines and Future Directions. Front. Psychiatry 8:33. doi: 10.3389/fpsyt.2017.00033*

Despite high rates of trauma-related disorders among individuals with early psychosis, no clinical practice guidelines for the treatment of comorbid early psychosis and trauma-related disorders exist to date. Indeed, the routine exclusion of individuals with past and current psychosis from participation in trauma research and practice has limited the accumulation of research that could support such clinical practice guidelines. While preliminary research evidence suggests that traditional, evidence-based treatments for trauma-related disorders can be safely and effectively employed to reduce symptoms of posttraumatic stress and chronic psychosis, it remains unclear whether such treatments are appropriate for individuals in the early stages of psychotic illness. Clinical experts (*N* = 118) representing 121 early psychosis programs across 28 states were surveyed using the expert consensus method. Forty-nine clinical experts responded and reached consensus on 46 of 49 expert consensus items related to the treatment of comorbid early psychosis and trauma-related disorders. Conjoint or family therapy and individual therapy were rated as treatment approaches of choice. Anxiety or stress management and psychoeducation were rated as treatment interventions of choice for addressing both trauma symptoms and psychotic symptoms. In addition, case management was rated as a treatment intervention of choice for addressing psychotic symptoms. No consensus was reached on expert consensus items regarding the appropriateness of a parallel treatment approach exposure interventions for addressing psychotic symptoms, or sensorimotor or movement interventions for addressing trauma symptoms. In areas where expert consensus exists and is supported by current research, preliminary clinical practice guidelines for the treatment of comorbid early psychosis and trauma-related disorders are offered. In areas where expert consensus does not exist, recommendations for future research are offered. The results of this study are intended to serve as a launching point for scientists and practitioners interested in advancing appropriate treatment for high-risk and underserved individuals with comorbid early psychosis and trauma-related disorders.

Keywords: early psychosis, trauma, posttraumatic stress disorder, clinical practice guidelines, expert consensus method

### INTRODUCTION

Rates of PTSD among individuals in the early stages of psychotic illness are high: in a study of Cincinnati psychiatric services, nearly 23% of first episode psychosis individuals presented with comorbid PTSD (1) versus an estimated 15% lifetime prevalence in individuals with chronic psychotic illness (2–4) and 6.8% prevalence in the general population (5). These high rates of comorbidity have prompted research on the effectiveness of interventions for comorbid psychosis and PTSD, with recent conceptual frameworks posing a reciprocal relationship between trauma and psychosis in the context of the cognitive model (6, 7). Empirically supported treatments for PTSD predominantly include trauma-focused treatments that provide direct exposure to traumatic events in order to combat the role of avoidance in the maintenance of PTSD (8, 9). Findings suggest these traditional evidence-based treatments for trauma-related disorders can be safely and effectively employed to reduce symptoms of posttraumatic stress and chronic psychosis (3, 10–12); however, it remains unclear whether such treatments are appropriate for individuals with early psychosis (i.e., within the first 5 years of illness onset). The early stages of psychotic illness are a critical period for intervention. With onset typically occurring between 15 and 25 years of age, psychosis symptoms disrupt important developmental trajectories in social, academic, and vocational domains. Combined with high rates of relapse (13) and comorbid trauma-related disorders (1), early intervention using evidencebased practices is necessary to prevent a long-term trajectory of accumulating disability (14). Yet, despite the burgeoning number of early psychosis treatment programs across the United States (15, 16), no clinical practice guidelines for treating comorbid early psychosis and trauma-related disorders currently exist.

The effect of exposure interventions on PTSD symptoms in adults with PTSD and chronic psychotic disorders has been explored in four studies to date. In an open trial study of 20 adults with PTSD and either schizophrenia or schizoaffective disorder, Frueh and colleagues (10) found cognitive behavioral therapy (CBT) that included imaginal exposure interventions integrated with treatment-as-usual (TAU) approaches significantly decreased PTSD symptoms and anger, as well as increased general mental health, compared to TAU alone. In another open pilot trial, van den Berg and van der Gaag (12) found eye movement desensitization and reprocessing (EMDR) plus TAU significantly decreased posttraumatic stress symptoms, psychotic symptoms (i.e., auditory verbal hallucinations and delusions), and other psychiatric symptoms (i.e., depression and anxiety), as well as increased self-esteem, after treatment compared to TAU alone. Similarly, in a withingroup controlled study, de Bont and colleagues (3) found both prolonged exposure (PE) and EMDR decreased PTSD severity and diagnosis. Subsequently, in a randomized control trial, van den Berg and colleagues (17) found both PE and EMDR significantly decreased PTSD symptoms and diagnosis compared to waiting list (WL); however, PE, but not EMDR, resulted in full remission of PTSD compared to WL.

Two randomized control trials (RCTs) have examined the effect of CBT that did not include exposure interventions on PTSD symptoms in adults with PTSD and schizophreniaspectrum disorders. Mueser and colleagues (11) found CBT integrated with TAU significantly decreased PTSD, mood, and anxiety symptoms, negative trauma-related cognitions, other psychiatric symptoms, and health-related concerns compared to TAU alone. Additionally, CBT participants endorsed increased knowledge of PTSD and client-case manager working alliance. The observed effects were significantly more robust for individuals with severe PTSD compared to those with mild or moderate PTSD. More recently, Steel and colleagues (18) found CBT without exposure, conducted in the context of TAU, did not significantly decrease trauma-related cognitions, severity of PTSD symptoms, positive symptoms of psychosis, severity of hallucinations and delusions, depression, or anxiety, or increase functioning or quality of life. Steel and colleagues concluded that exposure interventions focused on processing emotions related to traumatic memories may be needed in order for CBT to be effective in individuals with comorbid PTSD and psychotic disorders. Both studies also recommended future research include exposure interventions in treatment protocols in order to increase their effectiveness.

Collectively, these findings demonstrate that CBT, PE, and EMDR can be employed safely and effectively to reduce both PTSD and psychotic symptoms in adults with comorbid chronic psychosis and PTSD (3, 10–12); however, the inclusion of exposure interventions may result in more robust effects compared to non-exposure interventions in this population. There is, however, no available literature to guide the treatment of comorbid early psychosis and trauma-related disorders. As a result, additional research is needed to clarify which treatments are appropriate for individuals in the early stages of psychotic illness.

### The Current Study

Well-constructed clinical practice guidelines have the potential to improve the consistency, efficiency, value, and outcome of health care, as well as to empower patients and practitioners to make more informed health-care decisions, protecting both parties from the negative influences of uncertainty and antiquity; however, poorly constructed clinical practice guidelines have the potential to reduce the quality, efficiency, availability, and flexibility of health care (19). It is, therefore, important to use empirical methods to promote guideline development, ideally rooted in a strong foundation of carefully conducted RCTs on multiple large, independent, well-defined samples; however, RCTs often require years to conduct and the adoption of original research into clinical practice can take up to two decades (20); other methods can be used to generate preliminary guidelines and inform clinical practice in the interim.

One such method is the expert consensus method, which is designed to allow researchers to collect consensus evidence in cases where the outcome literature is unclear, incomplete, or absent, and must be supplemented with expert opinion (21). The expert consensus method has been used to develop clinical practice guidelines for dementia (22), obsessive–compulsive disorder (23), bipolar disorder (24), schizophrenia (25), PTSD (9), and complex PTSD (26). Here, we use the expert consensus method to develop preliminary clinical practice guidelines as a first step toward addressing the needs of individuals with comorbid early psychosis and trauma-related disorders.

We conducted a survey of clinical experts responsible for overseeing the clinical services provided in early psychosis programs across the United States. This survey elicited their expert opinions about treatment appropriateness for individuals with comorbid early psychosis and trauma-related disorders. In areas where expert consensus existed and was supported by current research, preliminary clinical practice guidelines for comorbid early psychosis and trauma-related disorders are offered. In areas where expert consensus does not exist, recommendations for future research are offered. The results of this study are intended to serve as a launching point for scientists and practitioners interested in advancing appropriate treatment for high-risk and underserved individuals with comorbid early psychosis and trauma-related disorders. To this end, the current study is designed to address the following research questions:

### MATERIALS AND METHODS

### Participants

Participants included clinical directors or persons in comparable positions responsible for overseeing the clinical services of early psychosis programs in the United States. Given the specialized nature of evidence-based care for early psychosis populations (14), these individuals were presumed to have the knowledge and experience needed to offer expert clinical opinions about the treatment of individuals with comorbid early psychosis and trauma-related disorders in the United States. There were no *a priori* exclusion criteria for this study.

### Procedures

Early psychosis program directories, located through an Internet search and consultation with experts in the field, were reviewed in order to identify potential recruitment sites (15, 16, 27, 28). This resulted in the identification of 121 early psychosis programs across 28 states (see Supplementary Material). Clinical directors or persons in comparable positions were identified for all 121 early psychosis programs in the United States. In some cases, one person fulfilled this role at multiple early psychosis programs. As a result, the total number of prospective participants (*N* = 118) was slightly lower than the total number of early psychosis programs (*N* = 121). No early psychosis programs or prospective participants were excluded.

Participants were recruited *via* email, including a brief description of the study and a link to the anonymous online survey. No identifying information was collected or attached to survey responses to allow the participants to respond as honestly as possible. Reminder emails were sent to all prospective participants 2 and 4 weeks after the initial recruitment email. Participants were offered two optional participation incentives: optional entry into a raffle for one of four \$25 Amazon gift cards and optional receipt of study results. In order to ensure that survey responses remained anonymous, prospective participants were instructed to opt-in to one or both optional participation incentives by emailing the principle investigator with "RAFFLE" and/or "RESULTS" in the subject line. This study was reviewed and approved by the Institutional Review Board (IRB) of Antioch University New England (AUNE). The IRB of AUNE granted this study exempt status under 45 CFR 46.101(b)(2) exemption from 45 CFR part 46 requirements.

### Measure

Participants completed an anonymous 15–20 min online survey, administered *via* the Qualtrics secure web-based platform. The online survey contained 24–30 questions (the exact number varied depending on six conditional response questions) about participant characteristics, program characteristics, and expert consensus questions regarding modalities, approaches, interventions, treatments, developmental considerations, treatment barriers, and treatment improvements. Definitions of key terms and interventions were provided. See Supplementary Material for the complete survey and definitions.

The expert consensus questions were modeled after prior studies (22, 26, 29). Participants were instructed to use a 9-point scale to rate the appropriateness of modalities, approaches, interventions, and treatments. Scores in the 7–9 range indicate a degree of appropriateness, scores in the 4–6 range indicate a degree of equivocal opinion, and scores in the 1–3 range indicate a degree of inappropriateness with the following anchors: 9 = extremely appropriate: your modality, approach, intervention, or treatment of choice (TOC) (you may have more than one per question); 7–8 = appropriate: a first-line modality, approach, intervention, or treatment you would often use; 4–6 = equivocal: a second-line modality, approach, intervention, or treatment you would sometimes use (e.g., after first-line modalities, approaches, interventions, or treatments failed); 2–3 = usually Inappropriate: at most, a third-line modality, approach, intervention, or treatment you would rarely use; and 1 = extremely inappropriate: a modality, approach, intervention, or treatment you would never use.

### Data Analysis

Expert consensus data were analyzed using procedures identical to those described in Frances and colleagues (29). First, the mean and confidence interval (95%) was calculated for each expert consensus item. The confidence interval for each expert consensus item was used to assign a categorical rating based on the range into which the lowest confidence limit (LCL) fell. A categorical rating of first-line was assigned to modalities, approaches, interventions, and treatments with a LCL that fell into the 6.50–9.00 range; a categorical rating of second-line was assigned to modalities, approaches, interventions, and treatments with a LCL that fell into the 3.50–6.49 range; and a categorical rating of third-line was assigned to modalities, approaches, interventions, and treatments with a LCL that fell into the 1.00–3.49 range. The distribution of responses for each expert consensus item was then analyzed for consensus. The categorical ratings for each expert consensus item were coded (i.e., first-line = 1, second-line = 2, and thirdline = 3), and a non-parametric chi-square test was conducted for each expert consensus item in order to determine whether or not expert consensus existed. Consensus was defined as when the response distribution of categorical ratings was statistically different from chance (*p* ≤ 0.05) (29). Finally, expert consensus items rated a 9 by 50% or more of participants were determined to represent a TOC for modalities, approaches, interventions, and treatments. Participant and program characteristics data are reported in Supplementary Material. Qualitative data were analyzed using a general inductive approach (30).

## RESULTS

Online survey responses were collected from June 27 to August 5, 2016. Of the 118 clinical experts invited to participate, 66 (56%) responded. Seventeen (26%) of the 66 responses were omitted due to discontinuation of the survey prior to reaching the expert consensus items. The remaining 49 (42%) survey responses were included and analyzed to yield the following results.

## Quantitative Results

### Participant Characteristics

Twenty-six (53%) participants identified a master's degree and 23 (47%) identified a doctorate or professional degree as their highest level of completed education. Forty-three (88%) participants reported providing treatment to individuals with early psychosis and 35 (71%) reported providing treatment to individuals with comorbid early psychosis and trauma-related disorders in the last 12 months. Forty-nine (100%) participants reported receiving formal training or supervised clinical experience in the treatment of early psychosis: 35 (73%) reported receiving both formal training and supervised clinical experience, while 13 (27%) reported receiving formal training only. Thirty-nine (80%) participants reported also receiving formal training or supervised clinical experience in the treatment of trauma-related disorders: 23 (62%) reported receiving both formal training and supervised clinical experience, while 11 (30%) reported receiving formal training only and 3 (8%) reported receiving supervised clinical experience only. See Supplementary Material for specific early psychosis and trauma treatments in which participants reported receiving formal training and supervised clinical experience.

### Program Characteristics

Participants represented early psychosis programs from 18 states (see Supplementary Material). Twenty-eight (57%) programs were based in the community, 11 (22%) programs were based in a university, and 2 (4%) programs were based in a hospital. The remaining 8 (16%) programs were based in a combination of community, hospital, or university settings. Thirty-eight (95%) programs served clients under age 18 and 28 (70%) served clients over age 25. Forty-two (86%) participants reported that their programs offered coordinated specialty care for early psychosis, the primary evidence-based model for outpatient treatment of early psychosis (14). See Supplementary Material for types of services offered.

Forty-eight (98%) programs provided staff members with formal training or supervised clinical experience in the treatment of early psychosis: 39 (85%) provided staff members with both formal training and supervised clinical experience, while 5 (11%) provided formal training only and 2 (4%) provided supervised clinical experience only. Twenty-three (47%) programs also provided staff members with formal training or supervised clinical experience in the treatment of trauma-related disorders: 33 (68%) provided staff members with both formal training and supervised clinical experience, while 7 (14%) provided formal training only and 9 (18%) provided supervised clinical experience only. See Supplementary Material for early psychosis and trauma treatments in which programs provided formal training and supervised clinical experience.

### Treatment Modalities

Participants were asked to rate the appropriateness of individual therapy (i.e., seeing client alone), consultation (i.e., seeing family members or support persons alone), and conjoint or family therapy (i.e., seeing client and family members or support persons together) for clients aged 18–25 with comorbid early psychosis and trauma-related disorders. Conjoint or family therapy (LCL = 7.98), individual therapy (LCL = 7.73), and consultation (LCL = 6.87) were all rated as first-line treatment modalities. Conjoint or family therapy (TOC = 57.14%) and individual therapy (TOC = 53.06%), however, were rated as the treatments of choice. See **Table 1** for expert consensus ratings of treatment modalities.

### Treatment Approaches

Participants were asked to rate the appropriateness of singlediagnosis (i.e., treating either early psychosis or trauma-related disorder only), sequenced (i.e., treating early psychosis before treating trauma-related disorder or *vice versa*), parallel (i.e., different providers treating early psychosis and trauma-related disorder at the same time), and integrated (i.e., the same provider treating early psychosis and trauma-related disorder at the same time) treatment approaches for clients aged 18–25 with comorbid early psychosis and trauma-related disorders. Integrated treatment (LCL = 8.10) was rated as a first-line treatment approach. Sequenced treatments, beginning with either the treatment of

#### TABLE 1 | Expert consensus ratings of treatment modalities and approaches.

*a TOC.*

*bFirst-line.*

*c Second-line.*

*dThird-line.*

*ncNo consensus.*

*EPEarly psychosis.*

*TRDTrauma-related disorder.*

early psychosis (LCL = 5.52) or the treatment of the traumarelated disorder (LCL = 4.11), were rated as second-line treatment approaches. Single-diagnosis treatments, only treating early psychosis (LCL = 2.92) or the trauma-related disorder (LCL = 2.60), were rated as third-line treatment approaches. No consensus was reached on the appropriateness of parallel treatment. See **Table 1** for expert consensus ratings of treatment approaches.

### Treatment Interventions

Participants were asked to rate the appropriateness of treatment interventions for addressing either psychotic symptoms or trauma symptoms for clients aged 18–25 with comorbid early psychosis and trauma-related disorders. These various treatment interventions are often components of broader treatment protocols for early psychosis and/or trauma-related disorders. See Supplementary Material for definitions of interventions.

### *Psychotic Symptoms*

Anxiety or stress management (LCL = 8.10), psychoeducation (LCL = 7.97), cognitive restructuring (LCL = 7.48), case management (LCL = 7.43), interpersonal effectiveness (LCL = 7.16), meditation or mindfulness (LCL = 6.66), and emotion-focused (LCL = 6.52) interventions were rated as first-line treatment interventions for addressing psychotic symptoms. Anxiety or stress management (TOC = 73.91%), psychoeducation (TOC = 73.91%), and case management (TOC = 50.00%) interventions were rated as treatment interventions of choice. Sensorimotor or movement (LCL = 4.86) and bilateral stimulation (LCL = 4.00) interventions were rated as second-line treatment interventions. No consensus was reached on the appropriateness of exposure interventions for addressing psychotic symptoms. See **Table 2** for expert consensus ratings of treatment interventions for addressing psychotic symptoms.

### *Trauma Symptoms*

Anxiety or stress management (LCL = 8.13), psychoeducation (LCL = 7.78), meditation or mindfulness (LCL = 7.45), cognitive restructuring (LCL = 7.42), interpersonal effectiveness (LCL = 6.99), emotion-focused (LCL = 6.98), and case management (LCL = 6.81) interventions were rated as first-line treatment interventions for addressing trauma symptoms. Anxiety or stress management (TOC = 68.89%) and psychoeducation (TOC = 61.36%) interventions were rated as treatments of choice. Exposure (LCL = 6.00) and bilateral stimulation (LCL = 4.69) interventions were rated as second-line treatment interventions. No consensus was reached on the appropriateness of sensorimotor or movement interventions for addressing trauma symptoms. See **Table 2** for expert consensus ratings of treatment interventions for trauma symptoms.

### Trauma-Focused Treatment

Trauma-focused treatment addresses exposure to traumatic events directly by asking clients to recall or encounter thoughts, images, feelings, or situations related to traumatic events. Participants were asked to rate the appropriateness of trauma-focused treatment for clients aged 18–25 with comorbid early psychosis and trauma-related disorders overall, at each stage of psychosis, and under specific current and past clinical and psychosocial conditions. Given that participants were previously asked to rate various treatment interventions that are often components of specific trauma-focused treatments, here, participants were asked to rate the appropriateness of trauma-focused treatment in general. Overall, trauma-focused treatment (LCL = 6.97) was rated as a

#### TABLE 2 | Expert consensus ratings of interventions to address psychotic symptoms and trauma symptoms.

*a TOC. bFirst-line.*

first-line treatment for clients aged 18–25 with early psychosis and comorbid trauma-related disorders. See **Table 3** for expert consensus ratings of trauma-focused treatment.

### *Stage of Psychosis*

Stages of psychosis included genetic risk and deterioration (i.e., family history of psychosis and decline in functioning without attenuated or threshold psychotic symptoms), ultra-high or clinical high risk (i.e., attenuated psychotic symptoms), firstepisode psychosis (i.e., onset of threshold psychotic symptoms less than 5 years ago), and established or chronic psychosis (i.e., onset of threshold psychotic symptoms more than 5 years ago). Trauma-focused treatment (LCL = 6.97) was rated as a first-line treatment for clients at all stages of psychosis: first-episode psychosis (LCL = 7.21), genetic risk and deterioration (LCL = 7.19), chronic or established psychosis (LCL = 7.14), and ultra-high risk or clinical high risk (LCL = 7.07). See **Table 3** for expert consensus ratings of trauma-focused treatment at each stage of psychosis.

### *Current Clinical and Psychosocial Conditions*

Trauma-focused treatment was rated as a first-line treatment for clients with current attenuated or residual psychotic symptoms (LCL = 7.12). It was rated as a second-line treatment for clients with current comorbid personality disorders (LCL = 6.29), other comorbid psychiatric disorders (LCL = 6.35), low involvement of family members or support persons (LCL = 6.09), and significant life stressors (LCL = 6.00). See **Table 3** for expert consensus ratings of trauma-focused treatment given current conditions.

### *Past Clinical and Psychosocial Conditions*

Trauma-focused treatment was rated as a first-line treatment for clients with a history of multiple traumas (LCL = 6.99), single trauma (LCL = 6.71), and long-duration psychotic symptoms (LCL = 6.69). It was rated as a second-line treatment for clients with a history of poor functioning (LCL = 6.49) and severe psychotic symptoms (LCL = 6.37), as well as a history of hospitalization (LCL = 5.95), substance use (LCL = 6.34), non-suicidal self-injury (LCL = 6.38), high suicide risk (LCL = 5.54), and high violence risk (LCL = 5.14). See **Table 3** for expert consensus ratings of trauma-focused treatment given past conditions.

### Qualitative Results

### Developmental Considerations

Because the expert consensus items asked specifically about clients aged 18–25, participants who reported serving clients under age 18 or over age 25 were asked if and how the appropriateness of modalities, approaches, interventions, or treatments differ for these other age groups. Of those participants who reported serving clients under age 18 and over age 25, respectively, 19 (50%) and 6 (21%) agreed that the appropriateness of modalities,

*c Second-line.*

*ncNo consensus.*

#### TABLE 3 | Expert consensus ratings of trauma-focused treatment.

*a First-line.*

*bSecond-line.*

approaches, interventions, or treatments differs for the specified age group.

#### *Family Involvement*

Participants acknowledged both the ethical (e.g., consent) and supportive functions of the family, noting that they work harder to engage family members in treatment in general and in decision-making specifically when working with clients under age 18. One participant, for example, noted the increased importance of family consent and engagement for clients with comorbid early psychosis and trauma-related disorders due to the perception of "increased risk with trauma treatment." In cases where family involvement is low, another participant reported wanting "to ensure the individual had […] other identified support persons." For clients over age 25, participants noted alternative support persons like close friends or partners might be more apt to be involved in treatment than members of the client's family of origin.

#### *Modification of Treatment Materials or Interventions*

Participants noted the importance of "using age appropriate materials, language, and consideration of developmental tasks." Participants noted cognitive interventions might be less appropriate or require additional assessment or modification for clients under age 18 compared to older clients. In addition, participants noted the importance of skill building for clients under age 18. For example, one participant responded, "Ensure [the] young person has skills to manage [a] potential increase in symptoms prior to commencing trauma work."

### Treatment Barriers

Participants were also asked if they were aware of any barriers their early psychosis programs encountered in attempting to treat clients with comorbid early psychosis and traumarelated disorders and, if so, to describe those barriers. Twenty-eight (78%) participants reported being aware of such barriers.

#### *Differentiating Trauma Exposure from Psychotic Experiences* Participants noted high endorsement of traumatic events and

other stressful life experiences or difficulty determining whether traumatic events and other stressful life experiences were real or delusional. In addition, participants reported difficulty determining how to handle reports of the first episode of psychosis as a traumatic event. Participants described attempts to overcome these barriers by focusing on educating clients about stressful experiences in general and helping clients develop and utilize strategies to cope with stressful experiences in lieu of educating clients specifically about trauma or helping clients to directly process the reported traumatic events. One participant noted that inclusion of collateral information can help to clarify the validity of the experiences that are being reported.

### *Symptom Interference and Exacerbation*

One participant, for example, noted impairment associated with either early psychosis or trauma-related disorders can impede recovery from the other disorder. This participant described trauma as a major source of stress that can worsen psychotic symptoms. Another participant noted that psychotic symptoms interfere with the processing of traumatic events, especially in cases where the first episode of psychosis was experienced as traumatic.

### *Inadequate Training and Supervision*

One participant noted that programmatic training, as well as available tools and interventions, focus only on early psychosis treatment despite a clearly identified need to be able to integrate early psychosis and trauma treatment. This participant also noted individual efforts to obtain training in trauma treatments on the part of clinicians have not been effective due to a lack of structured supervision and technical support. Another participant noted programmatic efforts to provide training in trauma treatments have not been effective due to a lack of available funding.

### *Discomfort Treating Both Trauma and Psychosis*

Some participants reported not treating clients with comorbid trauma-related disorders due to specializing in early psychosis. In contrast, one participant noted clients are often misdiagnosed in the community as a result of practitioners specializing in trauma treatment incorrectly conceptualizing psychotic symptoms as trauma symptoms. Another participant noted difficulty identifying referral sites that are comfortable providing both early psychosis and trauma treatment.

### Improving Treatment

Finally, participants were asked to provide any additional information they thought would help to improve the treatment of clients with comorbid early psychosis and trauma-related disorders. Eleven (22%) participants offered such suggestions.

### *Increase Training in Trauma Assessment and Treatment*

Participants suggested increased training in trauma assessment and treatment would improve the treatment of clients with comorbid early psychosis and trauma-related disorders. For example, one participant noted, "We have addressed a lot of training but never trained in the context of comorbidity with trauma and psychosis." Another participant suggested "early identification of trauma or stressful experiences using a[n] evidence-based scale to evaluate need for further treatment."

### *Increase Trauma Research and Treatment Planning Guidance*

Participants also suggested increased trauma research in general and related to treatment planning in particular. For example, one participant responded, "I wish that there were more data comparing treatments to guide decisions about what treatment options would be best for a specific individual." Another participant noted a need for greater consistency in how trauma-related disorders are treated in early psychosis programs; however, participants noted that research-based treatment protocols would also need to allow treatment to be tailored to client symptoms and client and family preferences.

### *Increase Funding for Multidisciplinary Programs*

Finally, participants suggested increased funding for programs that treat clients with a wider range of presenting problems including early psychosis, rather than for programs that specialize in treating early psychosis only, would improve the treatment of clients with comorbid early psychosis and trauma-related disorders.

### DISCUSSION

With the growing number of early psychosis programs in the United States and abroad, this study represents an essential first step toward addressing the needs of individuals with comorbid early psychosis and trauma-related disorders. The development of clinical practice guidelines has been limited historically by the routine exclusion of individuals with past and present psychosis from participation in trauma research and practice (31–33), as well as trauma symptoms not being adequately addressed in psychosis research and practice. Using a comprehensive online survey of clinical experts who are responsible for overseeing the clinical services provided in early psychosis programs, we investigated the current opinions and intervention practices that are guiding the treatment of individuals with comorbid early psychosis and trauma-related disorders in the United States. Based on these responses and preliminary evidence that traditional evidencebased treatments for trauma-related disorders can be safely and effectively employed to reduce symptoms of posttraumatic stress and chronic psychosis (3, 10–12), we offer preliminary clinical practice guidelines and recommendations for future research.

### Preliminary Clinical Practice Guidelines and Suggestions for Future Research Selecting a Treatment Modality

More than half of the clinical experts surveyed in this study rated conjoint or family therapy and individual therapy as their treatment modalities of choice when working with individuals with comorbid early psychosis and trauma-related disorders. This suggests that practitioners should see the client and family members or alternative support persons together with client consent or see the client alone at the start of treatment. This is consistent with current treatment guidelines for psychosis, which support the use of individualized and integrated family interventions (34–36). Additionally, the clinical experts surveyed in this study believed involving family members in the client's treatment is particularly important for individuals under age 18; however, practitioners should also consider the benefits of involving alternative support persons, such as friends or romantic partners, when other family involvement is low or when treating individuals over age 25.

Consultation with family or support persons (without the client present) was also rated as a first-line treatment modality. In cases in which conjoint or family therapy or individual therapy is ineffective, seeing family members or alternative support persons alone with client consent could be an appropriate alternative treatment modality. Family members often experience significant burden when caring for individuals with serious mental illness (37). Therefore, family support may be helpful in protecting the family system if the client refuses to engage; however, current practice models suggest that engagement of family alone would likely not be sufficient in promoting recovery in the client (38).

#### Selecting a Treatment Approach

Integrated treatment was rated as a first-line treatment approach and sequenced treatments were rated as second-line treatment approaches for the treatment of comorbid early psychosis and trauma-related disorders. The first-line rating of an integrated treatment approach is somewhat surprising given that inadequate training and supervision, as well as inadequate institutional and financial support, were cited as barriers to integrated treatment in these open response data. Integrated treatment may represent the ideal approach that clinical experts recognize as most appropriate and often strive to provide even if they are ill equipped to do so. Funding should be provided to develop innovative programs that strive to address the complex needs of the early psychosis population through staff training and additional program supports.

The second-line rating of sequenced treatment approaches is consistent with participants' report that the exacerbation of early psychosis by a comorbid trauma-related disorder, or visa versa, is a potential barrier to treatment. Clinical experts gave examples of psychotic symptoms interfering with or worsening as a result of treatment of a comorbid trauma-related disorder, as well as the traumatic nature of psychotic symptoms for some clients interfering with treatment of early psychosis. In such cases, sequenced treatment (i.e., treating the exacerbating disorder first in part or in entirety) may be more appropriate than integrated treatment. Practitioners who elect to use a sequenced treatment approach, however, should clearly delineate the client's treatment goals and carefully monitor client progress in the initial phase of treatment. A sequenced approach carries with it the risk that treatment will ultimately focus disproportionately on a single-diagnosis if the provider never feels the client is stable enough to shift to the second phase of treatment (39). Importantly, single-diagnosis treatment was rated as a third-line treatment approach, indicating that the clinical experts surveyed in this study believe that treating only early psychosis or only a trauma-related disorder when both conditions are present is inappropriate.

No consensus was reached regarding the appropriateness of a parallel treatment approach. This is consistent with current recommendations that suggest coordinating parallel treatment by different providers, often in different treatment settings, may fail to address the overlapping aspects of the comorbid psychiatric conditions or work at cross-purposes (39). Parallel treatment may, however, have merits in addressing barriers related to practitioner discomfort treating both trauma and early psychosis. Successful parallel treatment may be possible in the context of the early psychosis coordinated specialty care model, in which multiple practitioners from different specialties work together as a team to address the various needs of early psychosis clients (14). If practitioners specializing in the treatment of trauma-related disorders were added to these multidisciplinary teams, clients could access appropriate treatment for trauma-related disorders without compromising their access to evidence-based early psychosis care. In addition, working within a multidisciplinary team with specialty in early psychosis care would likely increase the competence and comfort of these trauma specialists with treating clients with early psychosis.

### Selecting Treatment Interventions to Address Psychotic and Trauma Symptoms

First-line treatment interventions for addressing both psychotic and trauma symptoms included: anxiety or stress management, psychoeducation, case management, cognitive restructuring, emotion-focused interventions, interpersonal effectiveness, and meditation or mindfulness interventions. Bilateral stimulation was rated as a second-line treatment intervention for addressing both psychotic and trauma symptoms. When addressing trauma symptoms in the context of psychosis, exposure interventions were rated as second-line interventions. Sensorimotor or movement interventions were also rated as second-line treatment interventions for addressing psychotic symptoms.

Based on these ratings and consistent with evidence-based cognitive behavioral models for treating psychosis (35, 40) and PTSD (8, 9), we make the following recommendations. Practitioners should begin by providing psychoeducation about early psychosis and trauma. This should include descriptions of psychotic and trauma symptoms and information about treatment rationale and efficacy in order to help the client and their support persons understand the client's problems as surmountable over time with appropriate treatment. Practitioners should then use anxiety and stress management interventions to help individuals develop coping skills to reduce stress and stress-related difficulties. Throughout treatment, practitioners should also provide case management to coordinate services and identify resources needed by the client. Finally, practitioners should select from first-line interventions (e.g., cognitive restructuring, emotionfocused, interpersonal effectiveness, and meditation or mindfulness) to address any residual psychotic and trauma symptoms.

#### Using Trauma-Focused Treatments and Exposure

Clinical experts surveyed here rated trauma-focused treatment (i.e., treatments that address exposure to traumatic events directly by asking individuals to recall or encounter thoughts, images, feelings, or situations related to traumatic events) as a first-line treatment for individuals aged 18–25 with comorbid early psychosis and trauma-related disorders in general and at all stages of psychosis. Trauma-focused treatment was rated as a first-line treatment for individuals presenting with current attenuated or residual psychotic symptoms, as well as a history of both single and multiple traumas and long-duration psychotic symptoms.

Furthermore, trauma-focused treatment was rated as a second-line treatment for individuals presenting with additional comorbidities and complexities, including: comorbid personality disorders, low involvement of support persons, significant life stressors, as well as a history of poor functioning, severe psychotic symptoms, substance use, non-suicidal self-injury, high suicide risk, high violence risk, and/or hospitalization. This indicates that the clinical experts surveyed in this study believe trauma-focused treatment may be appropriate for such individuals if more appropriate alternatives, not explored in this study, have failed. Notably, there were no current or past conditions for which trauma-focused treatment was rated as inappropriate. Practitioners should, therefore, diligently monitor areas of risk when utilizing trauma-focused treatment with individuals with comorbid early psychosis and trauma-related disorders; however, these risk factors should not be viewed as contraindications for trauma-focused treatment.

These findings contradict the experts' ratings of exposure and bilateral stimulation, two interventions considered to be key components of trauma-focused treatments, as second-line interventions. It may be the case that clinical experts believe trauma-focused treatments that include interventions of choice (e.g., psychoeducation, anxiety, and stress management) and first-line interventions (e.g., cognitive restructuring, emotionalfocused) before or in addition to exposure, for example, are more appropriate for individuals with comorbid early psychosis and trauma-related disorders than exposure interventions alone. Conversely, clinical experts may worry about the possible negative impact of exposure interventions on the recovery process, such as the exacerbation of psychotic symptoms, and may hesitate to use them. To date, the positive effect of exposure interventions on chronic psychotic symptoms in adults has been reported as effective in one published study (12), and two other studies have noted that the exclusion of exposure may have decreased the observed effectiveness of their treatment protocols (11, 18).

Exposure interventions are a primary component of all cognitive and behavioral interventions, including cognitive behavioral therapy for psychosis (CBTp), the early psychosis treatment in which participants received and programs provided training and supervision most often. It is possible that clinical experts are not utilizing recommended exposure components of CBTp in their practice despite evidence that doing so is beneficial, which is a phenomenon commonly seen in trauma treatment as well (31). It is also possible that clinical experts are utilizing exposure interventions without recognizing they are doing so, including psychoeducation about psychotic or trauma symptoms and behavioral experiments. This study asked participants to rate the appropriateness of component interventions, as opposed to combinations of interventions, in order to guide the composition of treatment for comorbid early psychosis and trauma-related disorders. Had participants been asked to consider the use of exposure in the context of broader treatment approaches (e.g., CBT), they might have responded more favorably to exposure interventions.

While the clinical experts surveyed in this study were unable to agree on the appropriateness of exposure interventions for addressing psychotic symptoms in individuals with comorbid trauma-related disorders, they agreed that exposure interventions are appropriate for addressing trauma symptoms in this population when first-line interventions have proved to be ineffective. Nonetheless, because exposure is such an important part of trauma treatment, expert attitudes toward exposure therapy for this population merit greater exploration. Research is needed to determine whether practitioners are either not utilizing or not recognizing their use of exposure interventions. Similarly, future studies should determine which exposure interventions are considered most appropriate when treating individuals with early psychosis in general, versus individuals with comorbid early psychosis and trauma-related disorders in particular.

### Using Sensorimotor and Movement Interventions to Address Trauma Symptoms

Sensorimotor and movement interventions were included in the current study to reflect the wide range of evidence-based interventions used in clinical practice, despite not being included in the expert consensus study of PTSD conducted over a decade ago (9) and being rated as second-line treatment interventions in the expert consensus study of complex PTSD. Sensorimotor and movement interventions are used to assist individuals with trauma-related disorders regulate their autonomic nervous system, think more clearly, and derive information from emotional states more accurately by processing dissociated, incomplete, or ineffective sensorimotor reactions (e.g., trauma-related images, sounds, smells, and physical sensations) (41). Individuals with early psychosis are frequently vulnerable to excessive autonomic arousal in response to stress (42) and may misinterpret anomalous cognitive or perceptual experiences resulting in emotional arousal and behavioral withdrawal (7) secondary to trauma exposure (43). While mind-body interventions, like sensorimotor and movement interventions, are important to contemporary trauma treatment, their utility for the treatment of psychosis alone has not been well investigated (44). The experts' rating of these approaches as second-line for the treatment of psychotic symptoms may represent growing interest in the integration of mind-body practices into psychosis care, but more well-controlled studies are needed before conclusions can be drawn (45). Currently, these approaches are not seen as core interventions for individuals with psychosis (34). Therefore, additional research is needed to determine whether sensorimotor and movement interventions could be beneficial for individuals with only early psychosis, as well as for individuals with comorbid early psychosis and trauma-related disorders.

### Understanding Reports of Trauma in the Context of Psychosis

Open response data indicated that practitioners are often concerned about the validity of high rates of trauma exposure and other stressful life experiences reported by individuals with comorbid early psychosis and comorbid trauma-related disorders, particularly when trauma-related content is mixed with delusional content. As a result, clinical experts surveyed in this study reported program-wide efforts to address this issue by focusing on psychoeducation about stress in general and on developing and using coping skills to manage stress in daily life rather than providing psychoeducation about trauma and processing traumatic events. Auditory hallucinations and non-bizarre delusions of guilt, paranoia, or persecution occur in up to 40% of individuals with severe PTSD (46, 47). The content of these psychotic symptoms are often, though not always, trauma-related (48), and the relationship between trauma and psychosis is extraordinarily complex both causally and diagnostically (42, 43). Future research should aim to provide clearer guidance on how to safely and effectively address the mixture of trauma-related content and the content of delusions/hallucinations in treatment. In the meantime, practitioners should obtain collateral information to understand the temporal relationship between reported traumatic events and psychotic symptom development and conceptualize psychotic symptoms with trauma-related content as an indication that trauma-focused treatment, including psychoeducation about trauma, may be appropriate.

### Limitations

A limitation of all studies utilizing the expert consensus method is that the opinion of experts may be wrong (29). As a result, it is recommended that practitioners consider the results of this study in conjunction with the results of existing and emerging literature on the treatment of comorbid early psychosis and trauma-related disorders. In addition, the outcomes associated with implementation of these preliminary clinical practice guidelines should be evaluated to determine whether they are efficacious and effective.

Additionally, the survey utilized in this study was anonymous to encourage participants to respond as honestly as possible about their personal and programmatic clinical decision-making and intervention practices in the course of treating individuals with comorbid early psychosis and trauma-related disorders. As a result, we were not able to evaluate potential differences between those individuals who were contacted and responded versus those who did not respond.

Finally, the response rate for this study (42%) is lower than the typical response rates of other expert consensus method studies; however, the number of participants included in this study (*N* = 49) is comparable (29). While the expert consensus method is appropriate for use with clinical experts, it has been used primarily with preselected groups of research experts, which tends to increase the response rate (29). To yield the largest possible sample of respondents for this study, we consulted multiple published resources and available clinical and research experts and invited individuals from across the United States to participate. As research in this area increases, future endeavors to develop more comprehensive practice guidelines should include clinical and research experts in psychosis, as well as trauma, treatment to incorporate a variety of perspectives and sources of knowledge.

### CONCLUSION

This study addresses a gap in the existing outcome literature on the treatment of comorbid early psychosis and trauma-related disorders by supplementing it with consensus evidence obtained from a national survey of clinical experts. The clinical experts reached consensus on 46 (94%) of the 49 expert consensus items. In areas where expert consensus existed, preliminary clinical practice guidelines for comorbid early psychosis and traumarelated disorders were offered. Recommendations for future research were also proposed in areas in which expert consensus did not exist.

Perhaps most important is what this study did not find: the clinical experts surveyed in this study did *not* rate the use of trauma-focused treatment, or any component intervention including exposure interventions, as inappropriate for individuals with comorbid early psychosis and trauma-related disorders under any condition. In contrast, the clinical experts agree that not treating early psychosis and trauma-related disorders when both conditions are present is inappropriate. As a result, practitioners should use existing research evidence, clinical expertise and judgment, and client preferences and values to treat comorbid early psychosis and trauma-related disorders in individuals presenting with both conditions (49).

### AUTHOR CONTRIBUTIONS

CC contributed to conception and design of the study, acquired, analyzed, and interpreted these data, and drafted and revised the manuscript. MS, DB, and LT contributed to conception and design of the study, as well as to revisions of the manuscript. TN contributed to conception and design of the study, acquisition and interpretation of these data, and revisions of the manuscript. All authors approved the final version of the manuscript to be published. In addition, all authors agreed to be accountable for all aspects of the work, including ensuring that all questions related to the accuracy and integrity of the work are appropriately investigated and resolved.

### ACKNOWLEDGMENTS

The content of this article first appeared in the dissertation of the first author (CC), submitted in partial fulfillment for the degree of Doctor of Psychology in the Department of Clinical Psychology at Antioch University New England. The authors thank William Slammon, Ph.D., Adjunct Faculty at Antioch University New England, for his feedback on the conception and design of the study provided as a dissertation committee member. The authors also thank Divya Kumar, Junior Specialist at the UC Davis Imaging Research Center, for assistance with managing data collection.

### FUNDING

This research was supported by HRSA D40HP26868 (Multidisciplinary training in evidence-based assessment and treatment of children and youth with trauma and serious mental illness).

### SUPPLEMENTARY MATERIAL

The Supplementary Material for this article can be found online at http://journal.frontiersin.org/article/10.3389/fpsyt. 2017.00033/full#supplementary-material.

### REFERENCES

**Conflict of Interest Statement:** This research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.