It cannot be overemphasised that PTSD is not the only problem that survivors of trauma face. ‘Pure’ PTSD after trauma is comparatively rare and comorbidity is the norm. Full-blown PTSD is also relatively uncommon and partial PTSD (Stein et al, 1997), in which there are fewer than the required number of DSM–IV avoidance phenomena or hyperarousal phenomena, might be more likely, particularly in a chronic form.
Comorbid Axis I disorders
Depression is the most common co-diagnosis and might be the most common disorder post-trauma. Other psychiatric illnesses post-trauma include anxiety disorders, such as panic disorder or phobic disorders, and substance misuse.
These can all lead to more chronic PTSD if not detected and addressed. In particular, the co-occurrence of substance use and anxiety disorders can dramatically reduce the chances of remission (Jacobsen et al, 2001; Zlotnick et al, 2004). Substance misuse might be the primary presenting problem, masking intrusive symptoms of PTSD.
There is now good evidence that PTSD is common in people with severe mental illness such as schizophrenia. Histories of childhood adversity and adult trauma have been commonly reported in people with psychotic disorders (Bebbington et al, 2004). Studies of traumatic experience in community samples have found similar results, which suggests that many people with Axis I disorders might also have either full-blown PTSD or symptoms of PTSD, both of which will amplify other pathology and increase treatment resistance (Mueser et al, 1998). These studies suggest that psychiatrists should look for history of trauma and possible post-traumatic pathology in people presenting with severe mental illness or who appear to be making a poor recovery from psychotic episodes.
Comorbid Axis II disorders
Marked changes in personality, in terms of personal interaction with others, might cause more problems than any other disorder post-trauma, especially when this is accompanied by substance misuse or violent behaviour (Southwick & Giller, 1993). The relationship between personality disorder and PTSD is complicated and the diagnosis of complex PTSD can be seen as an attempt to bring together the dichotomy of Axis I (state) and Axis II (trait) symptoms (McClean & Gallop, 2003). A history of childhood trauma is common in adults with personality disorder, particularly borderline or paranoid personality disorder, but is by no means universal.
Childhood abuse appears to be a risk factor for PTSD independently of personality disorder and early trauma (<12 years of age) and confers an equal risk of depression (Spataro et al, 2004). Adults with these personality disorders are more likely to develop PTSD, through a combination of increased exposure to adult trauma (paranoid personality disorder only) and psychological and social vulnerability (Golier et al, 2003).
References
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Gwen Adshead and Scott Ferris
Gwen Adshead is Consultant Forensic Psychotherapist at Broadmoor Hospital (Dadd Centre, Crowthorne, Berkshire RG45 7EG, UK. Email: gwen.adshead@wlmht.nhs.uk). Her research interests include psychiatric ethics, moral reasoning in psychiatry and attachment histories in abusive parents. Scott Ferris is Specialist Registrar in Psychotherapy at Forest House, Walthamstow, London and was previously Specialist Registrar in Forensic Psychiatry working in the trauma service at St George’s Hospital, London. His other research interests include attachment and offence representations.
