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1.<br /> 100 word minimum<br /> <br /> After reading the article’s first five paragraphs, in the space below answer these two questions: What previous research has been conducted on the article authors’ same or similar topics? What were their explanations for why their study was needed?<br /> <br /> 2.<br /> 100 word length minimum<br /> In the space below, describe in narrative form (lists and sentence fragments cannot be used) the characteristics of the participants involved in the research study conducted by the article authors. What was the number of persons who participated; where were they recruited from; what were the participant demographics; were any participant screening procedures conducted; what criteria were used to determine who participated in the study and who didn’t; were participants paid or did they receive any other type of compensation for being involved in the study; etc.

Journal of Traumatic Stress
April 2013, 26, 266–273
Public Mental Health Clients with Severe Mental Illness and
Probable Posttraumatic Stress Disorder: Trauma Exposure and
Correlates of Symptom Severity
Weili Lu,1 Philip T. Yanos,2 Steven M. Silverstein,3 Kim T. Mueser,4 Stanley D. Rosenberg,4
Jennifer D. Gottlieb,4 Stephanie Marcello Duva,5 Thanuja Kularatne,1 Stephanie Dove-Williams,5
Danielle Paterno,5 Danielle Hawthorne,5 and Giovanna Giacobbe5
1Department of Psychiatric Rehabilitation and Counseling Professions, University of Medicine and Dentistry of New Jersey,
Scotch Plains, New Jersey, USA
2John Jay College of Criminal Justice, Department of Psychology, CUNY, New York, New York, USA
3Division of Schizophrenia Research, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New
Jersey, Piscataway, New Jersey, USA
4Department of Psychiatry, Dartmouth Medical School, Concord, New Hampshire, USA
5University Behavioral Health Care, University of Medicine and Dentistry of New Jersey, Piscataway, New Jersey, USA
Individuals with severe mental illness (SMI) are at greatly increased risk for trauma exposure and for the development of posttraumatic
stress disorder (PTSD). This study reports findings from a large, comprehensive screening of trauma and PTSD symptoms among public
mental health clients in a statewide community mental health system. In 851 individuals with SMI and probable PTSD, childhood sexual
abuse was the most commonly endorsed index trauma, followed closely by the sudden death of a loved one. Participants had typically
experienced an average of 7 types of traumatic events in their lifetime. The number of types of traumatic events experienced and Hispanic
ethnicity were significantly associated with PTSD symptom severity. Clients reported experiencing PTSD in relation to events that occurred
on average 20 years earlier, suggesting the clinical need to address trauma and loss throughout the lifespan, including their prolonged
after-effects.
Over the past two decades, a growing body of research has
shown that individuals with severe mental illness (SMI) are
at greatly increased risk for trauma exposure (see Grubaugh,
Zinzow, Paul, Egede, & Frueh, 2011, for a review). Although
national surveys indicate that more than half of people in the
general population report exposure to at least one event that
according to the Diagnostic and Statistical Manual of Mental
Disorders (4th ed., DSM-IV; American Psychiatric Association,
1994) meets criteria for trauma (Kessler, Sonnega, Bromet,
Hughes,&Nelson, 1995), studies of peoplewith a SMI (such as
This research was supported by National Institute of Mental Health grant R01
MH064662. We wish to thank the following individuals for their assistance
with this project: Edward Kim, Lee Hyer, Rachael Fite, Kenneth Gill, Rosemarie
Rosati, Christopher Kosseff, Karen Somers, John Swanson, Avis Scott,
Rena Gitlitz, John Markey, Zygmond Gray, Marilyn Green, Alex Shay, Leila
Hosseini, and Yetunde Adetona.
Correspondence concerning this article should be addressed to Philip Yanos,
445 W. 59th St., New York, NY 10019. E-mail: pyanos@jjay.cuny.edu
Copyright C  2013 International Society for Traumatic Stress Studies. View
this article online at wileyonlinelibrary.com
DOI: 10.1002/jts.21791
schizophrenia, bipolar disorder, or major depression) suggest
that trauma exposure is nearly universal, with multiple traumas
being the norm (Goodman, Rosenberg, Mueser, & Drake,
1997; Mueser et al., 1998; Mueser, Essock, Haines, Wolfe, &
Xie, 2004). Violent victimization, a particularly toxic class of
trauma, is unusually common in people with SMI, with 34%–
53% reporting child abuse, and 43%–81% reporting lifetime
victimization (Mueser et al., 1998).
The high rates of trauma exposure among people with SMI,
combined with possibly increased vulnerability to the effects
of trauma, are associated with an increased prevalence of
PTSD in this population (Grubaugh, Elhai, Cusack, Wells, &
Frueh, 2007). Specifically, in most studies, the current prevalence
of PTSD among persons with SMI has been found
to range from 28%–43% (Cascardi, Mueser, DeGiralomo, &
Murrin, 1996; Craine, Henson, Colliver, & MacLean, 1988;
Cusack, Grubaugh, Knapp, & Frueh, 2006; Goldberg & Garno,
2005; Howgego et al., 2005; McFarlane, Bookless,&Air, 2001;
Mueser et al., 1998, 1998, 2004; Picken & Tarrier, 2011),
although a few studies have reported lower, but nevertheless
increased rates ranging from 16%–18% (Fan et al., 2008;
Lommen & Restifo, 2009; Neria, Bromet, Sievers, Lavelle,
266
PTSD Severity 267
& Fochtmann, 2002). This contrasts with an estimated current
rate of 3.5% for PTSD in the general population (Kessler,
Chiu, Demler, & Walters, 2005). Despite evidence that PTSD
is a significant clinical problem among people with SMI, many
questions remain regarding the nature of PTSD in this population
(Grubaugh et al., 2011). Although the types of traumatic
exposure commonly experienced by people with SMI
have been previously reported (e.g., Mueser et al., 1998; Mc-
Farlane et al., 2001; Goldberg & Garno, 2005; Goodman et al.,
2001), limited data are available on which events are most
distressing and most likely to lead to PTSD. In a survey of
trauma exposure and associated distress and PTSD symptoms
in people with SMI, O’Hare and Sherrer (2011) reported that
the most distressing event was sexual assault (either in childhood
or adulthood), followed by physical assault, and the sudden
unexpected death of a loved one; sexual assault was the
strongest predictor of PTSD symptoms, followed by unexpected
death. Another study of individuals with SMI reported
that exposure to childhood sexual abuse was more uniquely
predictive of PTSD than any other types of trauma (Mueser
et al., 1998), whereas Goldberg and Garno (2005) found that a
history of adult sexual assault or a history of suicide or homicide
in a close friend or relative were more strongly related
to PTSD.
No studies that we know of have evaluated the relationship
between exposure to different types of traumatic events and
PTSD symptom severity among people with SMI and probable
PTSD. A better understanding of which traumatic events
clients with SMI and PTSD find most distressing, and which
events are most strongly related to PTSD symptom severity,
could inform specific trauma interventions for this population.
The experience of traumatic events and their relationship to
PTSD symptom severity tends to differ by gender (Breslau,
Davis, Andreski, & Peterson, 1991; Kessler, et al., 1995;
Norris, Foster, & Weishaar, 2002), so the differential impact
of traumatic events on PTSD among people with SMI also
needs to be examined. Consistent with research in the general
population, studies suggest that women with SMI are significantly
more likely to experience sexual violence than men,
both in childhood and adulthood (see Grubaugh et al., 2011 for
a review).
In addition to evaluating the importance of exposure to different
types of traumatic events in people with SMI, there is a
need to further examine the role of ethnicity in the experience of
these events and their effects on PTSD symptoms. Some have
suggested that culture may have an influence on the impact of
traumatic events (Carlson, 2005; Fontes, 1995), for example, by
moderating the relationship between trauma exposure and development
of psychopathology (Garcia-Coll & Garrido, 2000).
Studies in the general population have found that Hispanic
individuals are more vulnerable to developing PTSD when exposed
to sexual, assaultive, or combat-related traumatic events
and among those with PTSD,Hispanics experience more severe
symptoms than persons from other ethnic backgrounds (Marshall,
Schell, &Miles, 2009). Although one study found higher
rates of PTSD among Hispanic individuals with SMI (Mueser,
Saylers, et al., 2004), we know of no other studies that have examined
the relationship between ethnicity and PTSD symptom
severity in this population.
To address these gaps in the literature, this study reports
findings from a comprehensive screening of trauma and PTSD
symptoms in public mental health clients in a statewide community
mental health system. Among a large group of individuals
with SMI and probable PTSD, we examined the types of trauma
experienced; which traumatic events were most distressing to
participants; and the association between traumatic events, demographic
and clinical characteristics, and PTSD symptom
severity.
Method
Participants and Procedures
Study participants were clients with SMI (defined by the
State of New Jersey) receiving services at the University of
Medicine and Dentistry of New Jersey-University Behavioral
HealthCare (UMDNJ-UBHC). UBHC serves approximately
15,000 clients annually, and is one of the largest mental health
specialty providers in theUnited States. In addition to outpatient
clinics and partial hospitalization clinics (five of which participated
in the study), UBHC is also equipped with programs such
as intensive case management services, residential programs, an
emergency room, and an inpatient unit. UBHC serves clients on
Medicaid/Medicare (56%) as well as uninsured/self-pay clients
(20%).
Acceptance into services at UMDNJ-UBHC requires meeting
New Jersey criteria for SMI, which include a DSM-IV diagnosis;
disability within the past 3–6 months from the mental
disorder which has resulted in functional limitations in major
life activities that would be appropriate for the client’s developmental
stage; and that during the past 2 years the mental
disorder led to two or more treatment episodes of greater intensity
than outpatient services, such as inpatient, emergency, or
partial hospitalization care, or a single episode lasting 3 months
or more or that the normal living situation was disrupted to the
point that supportive services were required to maintain the
client in that home or residence or housing, or law enforcement
officials intervened. Although these criteria are similar to
broad criteria for SMI that have been discussed in the literature
(e.g., Ruggieri, Leese, Thornicroft, Bisoffi, & Tansella, 2000),
we removed participants with no Axis I diagnosis other than
substance use, as this is a further criterion for SMI in other
jurisdictions.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
268 Lu et al.
Study sites included five outpatient and partial hospitalization
programs located in three different cities in central and
northern New Jersey. A comprehensive screening of trauma exposure
and PTSD symptoms was implemented at these sites
as part of a research study aimed at evaluating two different
treatments for PTSD in people with SMI. Clients were not paid
for their participation in the screening. This screening sought to
identify clients with SMI and probable PTSD, who were then
approached for participation in a treatment study. The study
protocol, informed consent, and all study-related materialswere
reviewed and approved by the Institutional Review Boards at
Dartmouth Medical School and the University of Medicine
and Dentistry of New Jersey (UMDNJ)-Robert Wood Johnson
Medical School.
Within a 31-month period, 851 clients endorsed at least one
traumatic event on the Traumatic Life Events Questionnaire
(TLEQ), had a total PCL score of at least 45 indicating probable
PTSD, had a chart diagnosis of an Axis I diagnosis other
than substance use disorder, and expressed an interest in the
study. Data are not available on screened individuals who did
not show evidence of likely PTSD, as clinicians were instructed
to seek consent for release of the information to the research
team only if the participant showed evidence of likely PTSD
and would be a candidate for targeted PTSD treatment. We
note, however, that the ethnic and diagnostic characteristics of
the study sample were similar to the characteristics of clients
at the participating sites of UBHC: demographic information
available for participants from these four sites was the following:
30% European Americans, 47% African Americans,
14% Hispanic, 8% other; 17% with schizophrenia-spectrum
disorders.
Table 1 summarizes the demographic and clinical characteristics
of the study sample. The participants were predominantly
female (64%), in their early 40s, and had completed high school.
Participants were ethnically diverse, with most self-identifying
as African American (44%) or European American (33%); 14%
identified themselves as Hispanic. The most common principal
Axis I diagnoses in clients’ charts were major depressive disorder
and other depressive disorders (46%), schizophrenia and
other psychotic disorders (17%), and bipolar disorders I and II
(22%). Of note, only 5% of the sample had PTSD listed as a
primary diagnosis in their medical record. The average age was
40.4 years (SD = 11.2) and average education was 12.0 years
(SD = 2.0).
From January 12, 2007 to August 2, 2010, clinicians conducted
routine screening (using the aforementioned measures)
of trauma history and PTSD with their clients, either at the
second intake session for new clients or at regular sessions for
clients who were already in treatment (treatment participants
were receiving was routine mental health treatment and not the
specific treatment targeting PTSD for which they were being
screened). When clients were grossly psychotic or suicidal, the
screening was deferred until a later time when the person was
more clinically stable.
Table 1
Demographics and Clinical Characteristics Participants
Variable n %
Gender
Male 298 35.2
Female 548 64.4
Missing 5 0.6
Race/ethnicity
African American 371 43.6
Native American 2 0.2
Asian/Pacific Islander 8 0.9
European American 282 33.1
Hispanic 117 13.7
Other 62 7.3
Missing 9 1.1
Psychiatric diagnoses
Schizophrenia/schizoaffective 123 14.5
Major depressive disorder 245 28.8
Bipolar I disorder 116 13.6
Bipolar II disorder /other bipolar 78 9.2
Other mood disorders 156 18.3
Anxiety disorder 27 3.2
PTSD 43 5.1
Other psychotic disorders 23 2.7
Adjustment disorders / acute stress 8 0.9
Other (e.g., eating disorder) 16 1.9
Missing 16 1.9
Note. N = 851. PTSD = posttraumatic stress disorder.
Measures
An abbreviated 16-item version of the Traumatic Life Events
Questionnaire (TLEQ; Kubany et al., 2000) was as described
above to screen lifetime trauma history for all clients at one of
the five sites. For each event on the scale, the client indicated
whether he or she had ever experienced it over their lifetime in a
binary (yes/no) format (e.g., “Has anyone threatened to kill you
or seriously hurt you?”). The TLEQ asks about the experience
of traumatic events using wording that corresponds with the
DSM-IV Criterion A for PTSD. This version of the TLEQ was
used to screen for trauma exposure in previous studies with
persons with SMI (Mueser et al., 2008).
The PTSD Checklist (civilian version) (PCL; Blanchard,
Jones-Alexander, Buckley, & Forneris, 1996) was used to
screen and identify cases with probable PTSD, as well as to
assess PTSD symptom severity. The PCL includes one question
for each DSM-IV PTSD symptom, requiring the respondent
to rate the severity of each symptom over the past month on
a 5-point Likert scale (range: 17–85). The PCL has good testretest
reliability and convergent validity in people with SMI
(Grubaugh et al., 2007; Mueser et al., 2001). A total score
of 45 or greater on the PCL was used to identify cases of
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
PTSD Severity 269
Table 2
Traumatic Events Reported on Abbreviated Traumatic Life Events Questionnaire (TLEQ) by Gender
Total (N = 851) Male (n = 299) Female (n = 552)
Variable n % n % n % ?2
Car accident 327 38.4 115 38.4 212 38.5 0.00
Other accident 240 28.2 99 33.1 141 25.5 5.48*
Warfare 50 5.9 35 11.7 15 2.7 28.33***
Sudden death of loved one 667 78.4 238 79.6 429 77.7 0.41
Robbery 367 43.1 164 54.8 203 36.8 25.83***
Stranger assault 414 48.6 192 64.2 222 40.2 44.71***
Seeing stranger violence 402 47.2 164 54.8 238 43.1 10.71***
Being threatened 534 62.7 202 67.6 332 60.1 4.56*
Childhood physical abuse 420 49.4 152 50.8 268 48.6 0.41
Witnessing domestic violence 534 62.7 167 55.9 367 66.5 9.38**
Experiencing domestic violence 527 61.9 140 46.8 387 70.1 44.60***
CSA by Adult 457 53.7 117 39.1 340 61.6 39.36***
CSA by peer 339 39.8 77 25.8 262 47.5 38.15***
CSA 491 57.7 122 40.8 369 66.8 53.90***
Adult sexual abuse 310 36.4 52 17.4 258 46.7 72.13***
Being stalked 396 46.5 98 32.8 298 54.0 35.07***
Other 351 41.2 141 47.2 210 38.0 6.65**
Note. N = 851. CSA = childhood sexual abuse.
*p < .05. **p < .01. ***p < .001.
probable PTSD during the initial screening (Blanchard et al.,
1996). A mean imputation procedure whereby the scale mean
for the participant was substituted for missing items was used
in cases where individual items were missing for participants.
Across the 14,467 responses, 89 items (or less than .01%) were
replaced using this procedure.
Clients first completed the TLEQ. If they indicated yes to
any of the 16 items, they then completed the PCL, based on the
most upsetting event identified on the TLEQ (only two clients
in the current study were unable to identify one most distressing
event, and data were noted as “missing” for these participants).
Clients with probable PTSD (PCL = 45) were then asked if
they were willing to have their screening data, and other pertinent
clinical information, provided to the research team for
possible participation in a treatment study. Clients who agreed
then completed a consent form, and the results of the screening
and other clinical information were then provided to the research
team. Data on primary psychiatric diagnoses, ethnicity,
education level, and age were drawn from participants’ medical
records after they had provided consent.
Data Analysis
Descriptive data were calculated and bivariate correlations between
events and symptoms were derived. Differences between
men and women were tested via chi-square or t test. Finally,
we used linear regression to examine which combination of
demographic and trauma variables was most strongly associated
PTSD symptom severity. For this analysis, we used a
step-wise regression approach and included all variables that
showed a significant bivariate relationshipwith PCL total score.
Thus, variables included TLEQ total score, all TLEQ items with
the exception of warfare and car accidents, ethnicity (dummy
coded so that Hispanic participants were contrasted to all other
race/ethnic groups), and years of education. We confirmed that
PCL scores were normally distributed in the sample, despite
our sample being restricted to persons with high scores.
Results
Table 2 lists the types of traumatic events reported by the participants
on the TLEQ by gender. The most common traumatic
event was the sudden death of a loved one, which did not
differ in frequency by gender. Car accidents and childhood
physical abuse were also reported at similar frequencies by
both men and women. Men, however, more frequently experienced
robbery, stranger assault, and being threatened, and were
significantly more likely than women to report experiencing
combat and other accidents. Women more often experienced
domestic violence, childhood sexual abuse, adult sexual assault,
and stalking than men. Average total events was 7.43
(SD=3.47) for the total sample, but the difference between men
(M = 7.18, SD = 3.33) and women (M = 7.57, SD = 3.55) was
not significant.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
270 Lu et al.
Table 3
Traumatic Events Identified as Most Distressing by Gender
Total (N = 851) Male (n = 299) Female (n = 552)
Variable n % n % n %
Car accidents 16 1.9 10 3.3 6 1.1
Other accidents 13 1.5 8 2.7 5 0.9
Warfare 7 0.8 6 2.0 1 0.2
Sudden death of loved one 166 19.5 63 21.1 103 18.7
Robbery 13 1.5 7 2.3 6 1.1
Stranger assault 34 4.0 27 2.7 14 2.5
Witnessing stranger violence 16 1.9 9 3.0 7 1.3
Childhood physical abuse 33 3.9 14 4.7 19 3.4
Witnessing domestic violence 5 0.6 1 0.3 4 0.7
Experiencing domestic violence 60 7.1 11 3.7 49 8.9
Childhood sexual abuse 189 22.2 40 13.4 149 27.0
Adult sexual abuse 31 3.6 3 1.0 28 5.1
Other 134 15.7 59 19.7 75 13.6
Not specified/ missing 120 14.1 45 15.1 75 13.6
Note. N = 851.
Table 3 lists the traumatic events identified by participants
as most distressing on the TLEQ, upon which the PCL was
based. The most frequently endorsed distressing event, across
gender, was childhood sexual abuse (22%), followed by the
sudden death of a loved one/friend (20%). Inspection of the
specific nature of the sudden death of a loved one/friend found
the following causes: murder (12%), suicide (9%), witnessing
death/finding someone dead (7%), car accident/fire (4%), drug
overdose (1%), or unspecified (68%). Among women, the next
most common most distressing events were childhood sexual
abuse (27%), sudden death of a loved one (19%), and being
a victim of domestic violence (9%). Among men, the next
most common most distressing events were the sudden death
of a loved one (21%), childhood sexual abuse (13%), and robbery/
stranger assault (10%). On average and across gender, the
reported index trauma had occurred almost 19 years prior to the
screening (mean = 18.71, SD = 14.30, range: 0–54.71).
Table 4 reports correlations between endorsement of specific
traumatic events on the TLEQ and PCL total score. The
overall number of types of trauma exposed to as reported in the
TLEQwasmoderately and significantly correlated with PCL total
score (r = .27, p < .001), and specific traumatic experiences
(with the exception of car accidents and warfare) were also significantly
correlated with PTSD symptom severity. To evaluate
diagnostic and demographic correlates of overall trauma exposure
and PTSD symptom severity we also performed t tests
or one-way analyses of variance (for categorical variables),
or computed Pearson correlations (for continuous variables).
Hispanic participants had significantly higher PCL total scores
than participants of other ethnic groups, F(3, 838) = 5.19, p =
.001. Education level was modestly negatively correlated with
PCL total score (r = -.09, p = .008). Age, gender, diagnosis
(psychotic vs. other), and index trauma identified as most
distressing were not significantly related to PTSD symptom
severity.
The overall linear regression equation was significant, R2 =
.09, F(4, 824) = 20.99, p < .001. The final equation included
four variables: TLEQ total (ß = .17, t = 3.80, p < .001), Hispanic
ethnicity (ß = .09, t = 2.66, p = .008), being threatened
Table 4
Correlations Between Endorsement of Trauma on the TLEQ and
PCL Scores
Variable r
Total .27***
Car accident .09
Other accident .14***
Warfare .05
Sudden death of loved one .09**
Robbery .13***
Hit by stranger .10**
Witnessing stranger violence .17***
Threatened with death .21***
Childhood physical abuse .13***
Witnessing domestic violence .11**
Adult domestic violence .14***
CSA .08*
CSA by peer .12**
Adult sexual abuse .08*
Note.N=851. TLEQ=traumatic life events questionnaire; PCL=posttraumatic
stress disorder checklist; CSA = childhood sexual abuse.
*p < .05. **p < .01. ***p < .001.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
PTSD Severity 271
to be killed (ß = .10, t = 2.46, p = .014). and being stalked
(ß = .09, t = 2.42, p = .016).
Discussion
The present study represents the first effort (to our knowledge)
to examine the correlates of PTSD symptom severity among a
large sample of persons with SMI and probable PTSD. Findings
provide important implications for the targeting of traumabased
interventions for this population, in that they identify
factors associated with risk for greater levels of PTSD symptoms.
One important finding was that exposure to more types
of traumatic events was a strong correlate of PTSD symptom
severity in this sample. These findings extend previous research
showing that exposure to a number of types of trauma is correlated
with PTSD diagnosis and symptom severity in clients
with SMI (Goldberg & Garno 2005; McFarlane et al., 2001;
Mueser et al., 1998; O’Hare & Sherrer, 2009), by demonstrating
a similar association within the subgroup of clients with
probable PTSD.
Among the range of traumatic events experienced, childhood
sexual abuse was the most commonly endorsed index trauma
leading to PTSD symptoms. This is consistent with previous
research showing that childhood sexual abuse is uniquely associated
with PTSD in people with SMI (Mueser et al., 1998).
The findings support the growing evidence documenting the
significant public health burden of childhood sexual abuse in
the public sector (Gilbert et al., 2009; Talbot et al., 2009), and
considering the increased rate of such abuse in SMI, underscore
the importance of treating the most common sequelae of abuse,
PTSD. Although the most frequently endorsed index trauma
was childhood sexual abuse, however, it is interesting to note
that the traumatic events that were associated with the most
severe PTSD symptoms in the regression equation were being
stalked and being threatened. This indicates that although these
events were not most frequently identified by clients as most
distressing, the experience of these events was associated with
significantly elevated PTSD symptoms above and beyond the
effect of experiencing a number of different types of traumatic
events.
The traumatic eventmost frequently experienced in this sample
was the sudden unexpected death of a loved one, reported
by 78% of the sample. This finding is consistent with other
research on the SMI population showing that unexpected death
is the most commonly reported traumatic event (Mueser et al.,
1998; O’Hare & Sherrer, 2009), and supports Goldberg and
Garno’s (2005) assertion that childhood sexual abuse and severe
interpersonal loss may sensitize individuals with SMI to
the development of PTSD.
The high frequency of unexpected death in this sample of
clientswith SMI, and its associationwith PTSD symptom severity,
raises the question of the related disorder of complicated
grief (Horowitz et al., 1997). There is significant overlap between
PTSD, complicated grief, and depression (Bonanno et al.,
2007; Burke, Neimeyer, & McDevitt-Murphy, 2010; Craig,
Sossou, Schnak, & Exxex, 2008; Pivar & Field, 2004), and
recent trials report the success of cognitive–behavioral therapy
in treating grief reactions in the general population (de Groot
et al., 2007; Shear, Frank, Houck, & Reynolds, 2005). The
findings from this study support O’Hare and Sherrer’s (2011)
suggestion that clients with SMI may benefit from counseling
that targets complicated grief reactions.
Despite a more ethnically diverse population in this study,
consistent with previous findings among clients with SMI (Kilcommons
& Morrison, 2005; Mueser et al., 1998), men were
more likely to have experienced warfare, robbery, stranger assault,
witnessing stranger assault, and being threatened.Women
were more likely to have experienced sexual abuse in childhood
and adulthood, domestic violence, being stalked, and
witnessing domestic violence. Men and women did not differ
on exposure to childhood physical abuse, and sudden death
of loved ones, and had comparable rates of traumatic event
exposure, consistent with previous findings with SMI clients
(Kilcommons & Morrison, 2005; Mueser et al., 1998). Hispanic
ethnicity was also found to be significantly associated
with PTSD symptom severity, a finding that remained significant
with education level and TLEQ score in the model. The
finding of more severe PTSD symptoms among Hispanic individuals
is consistent with Marshall et al.’s (2009) findings
that Hispanic individuals with PTSD tend to report more severe
symptoms. This result is also consistent with one previous report
that Hispanics with SMI were more likely to have PTSD
than non-Hispanic clients (Mueser, Saylers, et al., 2004). Although
the mechanisms underlying this relationship remain unclear
(Marshal et al., 2009), the finding suggests that clinicians
should be aware of the risk for increased PTSD symptoms in
Hispanic clients.
Although the type of trauma identified as most distressing
was not found to be associated with PTSD symptom severity,
the number of types traumatic events experienced was in line
with previous research showing that cumulative trauma exposure
is related to PTSD diagnosis in people with SMI (Mueser
et al., 1998). Of particular note, clients with SMI reported experiencing
PTSD symptoms related to events that had occurred
on average almost 20 years earlier. These findings highlight the
need to routinely assess trauma exposure, and to address the
prolonged effects of trauma and loss throughout the lifespan of
individuals with SMI.
Some limitations of the present study should be noted. Diagnoses
were based on clinical charts and therefore may be less
reliable than research-based diagnoses conducted using interview
schedules such as the Structured Clinical Interview for
the DSM-IV. Furthermore, though the sample was drawn from
a large community mental health center as part of a comprehensive
screening effort, data may not be generalizable to other
groups of individuals with SMI living in less urban settings,
with larger numbers of individuals with psychotic disorders,
and with fewer individuals from African American and Hispanic
backgrounds. Finally, although data from the TLEQ give
us a sense of the range of exposure to different types of trauma
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
272 Lu et al.
which participants experienced, we are unable to determine
the number of traumatic experiences that participants had (e.g.,
repeated experience of multiple traumatic events of the same
type). Future research needs to be conducted to more accurately
assess the relationship between the number and severity
of types of traumatic events experienced by people with SMI
and PTSD symptom severity.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual
of mental disorders (4th ed.). Arlington, VA: Author.
Blanchard, E. P., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996).
Psychometric properties of the PTSD Checklist. Behavior Research and
Therapy, 34, 669–673. doi:10.1016/0005-7967(96)00033-2
Bonanno, G. A., Neria, Y., Mancini, A., Coifman, K. G., Litz, B., & Insel,
B. (2007). Is there more to complicated grief than depression and posttraumatic
stress disorder? A test of incremental validity. Journal of Abnormal
Psychology, 116, 342–351. doi:10.1037/0021-843X.116.2.342
Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic
events and posttraumatic stress disorder in an urban population of young
adults. Archives of General Psychiatry, 48, 216–222. Retrieved from
http://archpsyc.ama-assn.org
Burke, L. A., Neimeyer, R. A., & McDevitt-Murphy, M. E. (2010). African
American homicide bereavement: Aspects of social support that predict
complicated grief, PTSD, and depression. Omega (Westport), 61, 1–24.
doi:10.2190/OM.61.1.a
Carlson, B. E. (2005). The most important things learned about violence and
trauma in the past 20 years. Journal of Interpersonal Violence, 20, 119–126.
doi:10.1177/0886260504268603
Cascardi, M., Mueser, K. T., DeGiralomo, J., & Murrin, M. (1996).
Physical aggression against psychiatric inpatients by family members
and partners. Psychiatric Services, 47, 531–533. Retrieved from
http://psychservices.psychiatryonline.org
Craig, C.D., Sossou, M. A., Schnak, M.,&Essex, H. (2008).Complicated grief
and its relationship to mental health and well-being among Bosnian refugees
after resettlement in the United States: Implications for practice, policy, and
research. Traumatology, 14, 103–115. doi:10.1177/1534765608322129
Craine, L. S., Henson, C. E., Colliver, J. A., & MacLean, D. G. (1988). Prevalence
of a history of sexual abuse among female psychiatric patients in a
state hospital system. Hospital and Community Psychiatry, 39, 300–304.
Retrieved from http://psychservices.psychiatryonline.org
Cusack, K. J., Grubaugh, A. L., Knapp, R. G., & Frueh, B. C. (2006). Unrecognized
trauma and PTSD among public mental health consumers with
chronic and severe mental illness. Community Mental Health Journal, 42,
487–500. doi:10.1007/s10597-006-9049-4
de Groot, M., de Keijser, J., Neeleman, J., Kerkhof, A., Nolen, W., & Burger,
H. (2007). Cognitive behaviour therapy to prevent complicated grief among
relatives and spouses bereaved by suicide: Cluster randomised controlled
trial. BMJ, 334(7601), 994. doi:10.1136/bmj.39161.457431.55
Fan, X., Henderson, D. C., Nguyen, D. D., Cather, C., Freudenreich, O.,
Evins,A. E., . . . Goff,D.C. (2008). Posttraumatic stress disorder, cognitive
functioning and quality of life in patients with schizophrenia. Psychiatry
Research, 159, 140–146. doi:10.1016/j.psychres.2007.10.012
Fontes, L. A. (1995). Sexual abuse in nine North American cultures: Treatment
and prevention. Thousand Oaks, CA: Sage.
Garcia-Coll, C., & Garrido, M. (2000). Minorities in the United States: Sociocultural
context for mental health and developmental psychopathology.
In A. J. Sameroff, M. Lewis, & S. M. Miller (Eds.), Handbook of developmental
psychopathology (2nd ed., pp. 177–195). Dordrecht, Netherlands:
Kluwer.
Gilbert, R.,Widom, C. S., Browne, K., Fergusson, D., Elspeth,W. F.,&Janson,
S. (2009). Burden and consequences of child maltreatment in high-income
countries. The Lancet, 373, 68–81. doi:10.1016/S0140-6736(08)61706-7
Goldberg, J. F., & Garno, J. L. (2005). Development of posttraumatic
stress disorder in adult bipolar patients with histories of severe
childhood abuse. Journal of Psychiatric Research, 39, 595–601.
doi:10.1016/j.jpsychires.2004.11.002
Goodman, L. A., Rosenberg, S. D., Mueser, K. T., & Drake, R. E. (1997).
Physical and sexual assault history in women with serious mental illness:
Prevalence, correlates, treatment, and future research directions. Schizophrenia
Bulletin, 23, 685–696. doi:10.1093/schbul/23.4.685
Goodman, L. A., Salyers, M. P., Mueser, K. T., Rosenberg, S. D., Swartz,
M., Essock, S. M., . . . 5 Site Health and Risk Study Research Committee.
(2001). Recent victimization in women and men with severe mental illness:
Prevalence and correlates. Journal of Traumatic Stress, 14, 615–632.
doi:10.1023/A:1013026318450
Grubaugh, A. L., Elhai, J. D., Cusack, K. J., Wells, C., & Frueh, B. C. (2007).
Screening for PTSD in public-sector mental health settings: The diagnostic
utility of the PTSD checklist. Depression and Anxiety, 24, 124–129.
doi:10.1002/da.20226
Grubaugh, A. L., Zinzow, H. M., Paul, L., Egede, L. E., & Frueh, B. C. (2011).
Trauma exposure and posttraumatic stress disorder in adults with severe
mental illness: A critical review. Clinical Psychology Review, 31, 883–899.
doi:10.1016/j.cpr.2011.04.003
Horowitz, M. J., Siegel, B., Holen, A., Bonanno, G. A., Milbrath, C.,
& Stinson, C. H. (1997). Diagnostic criteria for complicated grief disorder.
American Journal of Psychiatry, 154, 904–910. Retrieved from
http://ajp.psychiatryonline.org
Howgego, I. M., Owen, C., Meldrum, L., Yellowlees, P., Dark, F., & Parslow,
R. (2005). Posttraumatic stress disorder: An exploratory study examining
rates of trauma and PTSD and its effect on client outcomes in community
mental health. BMC Psychiatry, 5, 21. doi:10.1186/1471-244X-5-21
Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence,
severity, and comorbidity of 12-month DSM-IV disorders in the National
Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617–
627. doi:10.1001/archpsyc.62.6.617
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995).
Posttraumatic stress disorder in the National Comorbidity Survey. Archives
of General Psychiatry, 52, 1048–1060. Retrieved from http://archpsyc.amaassn.
org
Kilcommons, A. M., & Morrison, A. P. (2005). Relationship between
trauma and psychosis: An exploration of cognitive and dissociative factors.
Acta Psychiatrica Scandinavica, 112, 351–359. doi:10.1111/j.1600-
0447.2005.00623.x
Kubany, E. S., Haynes, S. N., Leisen, M. B., Owens, J. A., Kaplan, A. S.,
Watson, S. B., & Burns, K. (2000). Development and preliminary validation
of a brief broad-spectrum measure of trauma exposure: The Traumatic
Life Events Questionnaire. Psychological Assessment, 12, 210–224.
doi:10.1037/1040-3590.12.2.210
Lommen,M. J.,&Restifo, K. (2009). Trauma and posttraumatic stress disorder
(PTSD) in patients with schizophrenia or schizoaffective disorder. Community
Mental Health Journal, 45, 485–496. doi:10.1007/s10597-009-9248-x
Marshall, G. N., Schell, T. L., & Miles, J. N. V. (2009). Ethnic differences
in posttraumatic distress: Hispanics’ symptoms differ in kind and
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
PTSD Severity 273
degree. Journal of Consulting and Clinical Psychology, 77, 1169–1178.
doi:10.1037/a0017721
McFarlane, A. C., Bookless, C., & Air, T. (2001). Posttraumatic stress disorder
in a general psychiatric inpatient population. Journal of Traumatic Stress,
14, 633–645. doi:10.1023/A:1013077702520
Mueser, K. T., Essock, S. M., Haines, M., Wolfe, R., & Xie, H. (2004). Posttraumatic
stress disorder, supported employment, and outcomes in people
with severe mental illness. CNS Spectrums, 9, 913–925. Retrieved from
http://www.cnsspectrums.com
Mueser, K. T., Goodman L. A., Trumbetta, S. L., Rosenberg, S. D., Osher, F.
C., Vivader, R., Foy, D.W. (1998). Trauma and posttraumatic stress disorder
in severe mental illness. Journal of Consulting and Clinical Psychology, 66,
493–499. doi:10.1037/0022-006X.66.3.493
Mueser,K. T., Saylers, M. P., Rosenberg, S.D., Goodman, L.A., Essock, S.M.,
Osher, F. C., Butterfield, M. (2004). Interpersonal trauma and posttraumatic
stress disorder in clients with severe mental illness: Demographic, clinical,
and health correlates. Schizophrenia Bulletin, 30, 45–57. Retrieved from
http://schizophreniabulletin.oxfordjournals.org
Mueser, K. T., Rosenberg, S. R., Xie, H., Jankowski, M. K., Bolton, E. E.,
Lu, W., . . . Wolfe, R. (2008). A randomized controlled trial of cognitivebehavioral
treatment of posttraumatic stress disorder in severe mental
illness. Journal of Consulting and Clinical Psychology, 76, 259–271.
doi:10.1037/0022-006X.76.2.259
Mueser, K. T., Salyers, M. P., Rosenberg, S. D, Ford, J. D., Fox, L., & Carty,
P. (2001). A psychometric evaluation of trauma and PTSD assessments in
persons with severe mental illness. Psychological Assessment, 13, 110–117.
doi:10.1037//1040-3590.13.1.110
Norris, F. H., Foster, J. D., &Weishaar, D. L. (2002). The epidemiology of sex
differences in PTSD across developmental, societal, and research contexts.
In R. Kimerling, P. Ouimette, & J. Wofle (Eds.), Gender and PTSD (pp.
3–42). New York: Guilford Press.
Neria, Y., Bromet, E. J., Sievers, S., Lavelle, J., & Fochtmann, L. J. (2002).
Trauma exposure and posttraumatic stress disorder in psychosis: Findings
from a first-admission cohort. Journal of Consulting and Clinical Psychology,
70, 246–251. doi:10.1037/1040-3590.13.1.110
O’Hare, T., & Sherrer, M. V. (2009). Impact of the most frequently
reported traumatic events on community mental health clients. Journal
of Human Behavior in the Social Environment, 19, 186–195.
doi:10.1080/10911350802687158
O’Hare, T., & Sherrer, M. (2011). Subjective distress associated with sudden
loss in clientswith severe mental illness. Community Mental Health Journal,
47, 646–653. doi:10.1007/s10597-011-9382-0
Picken, A., & Tarrier, N. (2011). Trauma and comorbid posttraumatic
stress disorder in individuals with schizophrenia and substance abuse.
Comprehensive Psychiatry, 52, 490–497. doi:10.1016/j.comppsych.2010.
10.008
Pivar, I., & Field, N. P. (2004). Complicated grief as distinct from PTSD and
depression in Vietnam combat veterans. Journal of Anxiety Disorders, 18,
745–755. doi:10.1016/j.janxdis.2003.09.005
Ruggeri, M., Leese, M., Thornicroft, G., Bisoffi, G., & Tansella, M.
(2000). Definition and prevalence of severe and persistent mental illness.
British Journal of Psychiatry, 177, 149–155. doi:10.1192/bjp.177.2
.149
Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. (2005). Treatment of
complicated grief: A randomized controlled trial. JAMA, 293, 2601–2608.
doi:10.1001/jama.293.21.2601
Talbot, N. L., Chapman, B., Conwell, Y., McCollumn, K., Franus, N.,
Cotescu, S., & Duberstein, P. R. (2009). Childhood sexual abuse is associated
with physical illness burden and functioning in psychiatric patients
50 years of age and older. Psychosomatic Medicine, 71, 417–422.
doi:10.1097/PSY.0b013e318199d31b
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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