Psychiatry · Medical Literature
Symptom networks of therapy-seeking individuals with comorbid psychosis and PTSD.
Abstract
Post-traumatic sequelae are theorized to contribute to and maintain psychotic symptoms. The relative contribution of core posttraumatic stress disorder (PTSD) symptoms and those of complex PTSD are understudied. Network analysis was used to examine interactions between psychosis, core PTSD, and complex post-traumatic symptoms. Based on previous evidence, it was predicted that trauma-related beliefs would have the greatest predictability. It was also hypothesized that the association between voices and trauma-related beliefs would be greater than the association between voices and re-experiencing. Baseline data from the Study of Trauma and Recovery (STAR), a randomized controlled therapy trial of people with schizophrenia-spectrum disorder who experience distressing delusions and/or hallucinations and comorbid PTSD (N = 305). A network was estimated using a Bayesian Gaussian graphical model, comprised of psychosis symptoms (delusions and voices), posttraumatic stress symptoms (re-experiencing, avoidance, and sense of threat), complex posttraumatic stress symptoms (affective dysregulation, negative self-concept, disturbed relationships), and trauma-related beliefs (negative cognitions about the self and world, self-blame). A direct acyclic graph was plotted to estimate the potential directionality of associations between symptoms. The hypotheses were not supported. All symptoms had similar predictability scores. There was no evidence for conditionally dependent relations between re-experiencing and voices nor between trauma-related beliefs and voices. However, self-blame was associated with delusions, and affective dysregulation was found to predict voices. Affective dysregulation and self-blame may maintain voices and delusions, respectively. Heterogeneity in trauma-related psychosis could explain inconsistent findings; future research should identify symptom presentation subgroups to improve network reliability.
Clinical relevance
This study addresses a critical gap in understanding the mechanistic relationships between PTSD, complex PTSD, and psychotic symptoms in individuals with schizophrenia-spectrum disorders — a highly vulnerable and often treatment-refractory population. With comorbid PTSD prevalent among psychosis patients, clarifying which specific symptom domains drive and maintain psychotic experiences is essential for optimizing trauma-focused therapeutic targets. These findings are timely given the growing implementation of trauma-informed care models in psychosis services and ongoing debates about whether PTSD and psychosis share transdiagnostic maintaining mechanisms.
Key findings
1. Sample comprised N=305 therapy-seeking individuals with schizophrenia-spectrum disorder experiencing distressing delusions and/or hallucinations with comorbid PTSD, drawn from the Study of Trauma and Recovery (STAR) RCT baseline data. 2. A Bayesian Gaussian graphical model (network analysis) was used to map interactions across psychosis symptoms (delusions, voices), core PTSD symptoms (re-experiencing, avoidance, sense of threat), complex PTSD symptoms (affective dysregulation, negative self-concept, disturbed relationships), and trauma-related beliefs (negative cognitions about self/world, self-blame). 3. Contrary to the primary hypothesis, all symptom nodes demonstrated similar predictability scores; no single symptom cluster — including trauma-related beliefs — emerged as disproportionately central to the network. 4. The pre-specified hypothesis that the association between voices and trauma-related beliefs would exceed the association between voices and re-experiencing was not supported; no conditionally dependent relationship was detected between re-experiencing and voices, nor between trauma-related beliefs and voices. 5. Self-blame showed a specific association with delusions, and affective dysregulation was identified via directed acyclic graph (DAG) analysis as a potential directional predictor of voices — suggesting these two complex PTSD features may serve as maintaining mechanisms for psychotic symptoms. 6. The authors note that heterogeneity in trauma-related psychosis presentations may account for inconsistent findings across the literature, highlighting the need for future subgroup analyses to improve network reliability and replicability.
Practice implications
Clinicians treating comorbid psychosis and PTSD should prioritize assessment and targeted intervention for affective dysregulation and self-blame, as these complex PTSD features — rather than core PTSD re-experiencing — may be the proximal maintaining mechanisms for voices and delusions, respectively, making them candidate targets for transdiagnostic interventions (e.g., Imagery Rescripting, Compassion-Focused Therapy, or Dialectical Behavior Therapy skills within trauma-focused protocols). The absence of a privileged role for re-experiencing or trauma-related beliefs challenges the assumption that direct trauma processing alone will reduce psychotic symptoms, suggesting that emotion regulation and shame-focused components should be explicitly integrated into trauma therapies for this population. Given the substantial clinical heterogeneity suggested by these findings, individualized network-informed case formulation and future efforts to identify symptom-presentation subgroups are warranted to guide personalized treatment selection and improve therapeutic outcomes.