SCHRES-07150; No of Pages 10

Schizophrenia Research xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Schizophrenia Research

journal homepage: www.elsevier.com/locate/schres

The traumatic experience of first-episode psychosis: A systematic review

and meta-analysis
Rebecca Rodrigues a, Kelly K. Anderson a,b,⁎
a
Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
b
Department of Psychiatry, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: A psychotic episode may be sufficiently traumatic to induce symptoms of post-traumatic stress dis-
Received 9 December 2016 order (PTSD), which could impact outcomes in first-episode psychosis (FEP). The objectives of this systematic re-
Received in revised form 23 January 2017 view and meta-analysis were to estimate the prevalence of PTSD symptoms in relation to psychosis in FEP and to
Accepted 26 January 2017 identify risk factors for the development of PTSD symptoms.
Available online xxxx
Methods: We searched electronic databases and conducted manual searching of reference lists and tables of con-
tents to identify relevant studies. Quantitative studies were included if the population was experiencing FEP and
Keywords:
First-episode psychosis
if PTSD was measured in relation to psychosis. Prevalence of PTSD symptoms and diagnoses were meta-analyzed
Trauma using a random effects model. Potential risk factors for PTSD symptoms were summarized qualitatively.
Post-traumatic stress disorder Results: Thirteen studies were included. Eight studies assessed PTSD symptoms, three studies assessed full PTSD,
and two studies assessed both. The pooled prevalence of PTSD symptoms was 42% (95% CI 30%–55%), and the
pooled prevalence of a PTSD diagnosis was 30% (95% CI 21%–40%). Exploratory subgroup analyses suggest that
prevalence may be higher in affective psychosis and inpatient samples. Evidence from included studies implicate
depression and anxiety as potential risk factors for PTSD symptoms.
Conclusions: Approximately one in two people experience PTSD symptoms and one in three experience full PTSD
following a first psychotic episode. Evidence-based interventions to treat PTSD symptoms in the context of FEP
are needed to address this burden and improve outcomes after the first psychotic episode. Further studies are
needed to clarify the associated risk factors.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction this criterion, the subjective impact of psychosis may be sufficiently

The experience of a psychotic episode has been described as trau-
matic (Birchwood, 2003; Dunkley et al., 2015). Psychotic symptoms,
such as delusions and hallucinations, can cause intense fear and distress
(Shaner and Eth, 1989) and some people may experience coercive treat-
ments such as involuntary hospitalization, seclusion, restraints, or
forced treatment (Paksarian et al., 2014). Even the experience of hospi-
talization to an acute psychiatric ward has been noted as upsetting
(Dunkley et al., 2015).
According to the Diagnostic and Statistical Manual of Mental Disor-
ders, 5th edition (DSM-5), a traumatic event is defined as “exposure
to actual or threatened death, serious injury, or sexual violence”, and ex-
posure to such an event is required for a diagnosis of post-traumatic
stress disorder (PTSD; American Psychiatrc Association, 2013). Al-
though psychosis and associated treatment does not technically satisfy
⁎ Corresponding author at: Department of Epidemiology & Biostatistics, Western
University, Kresge Building, Room K213, 1151 Richmond Street, London, Ontario N6A
5C1, Canada.
E-mail address: kelly.anderson@schulich.uwo.ca (K.K. Anderson).
traumatic to result in symptoms of PTSD. Consequently, the primary
symptoms of PTSD—re-experiencing the trauma, avoidance of trauma-
related stimuli, and hyperarousal—have been observed in people with
psychosis in relation to their experience of symptoms or hospitalization
(Shaner and Eth, 1989).
PTSD in people with severe mental illness has been associated with
psychiatric symptom severity and comorbid conditions (Mueser et al.,
2004a, 2004b; Minsky et al., 2015; Ng et al., 2016), greater impairment
of functioning (Minsky et al., 2015; Ng et al., 2016; Seow et al., 2016),
and lower engagement and satisfaction with mental health services
(Minsky et al., 2015; Switzer et al., 1999). It has been hypothesized
that PTSD symptoms related to psychosis may impact treatment adher-
ence through avoidance of trauma-related stimuli (Mueser and
Rosenberg, 2003). In the context of first-episode psychosis (FEP), it
has been suggested that negative experiences with health services at
first contact initiate patients on a trajectory that may impact long-
term outcomes (Anderson et al., 2010). Considering the importance of
early treatment in FEP for reducing the consequences of untreated psy-
chosis (Marshall et al., 2005; Perkins et al., 2005), and the potential im-
pact of treatment experiences on adherence and health care utilization

http://dx.doi.org/10.1016/j.schres.2017.01.045
0920-9964/© 2017 Elsevier B.V. All rights reserved.

Please cite this article as: Rodrigues, R., Anderson, K.K., The traumatic experience of first-episode psychosis: A systematic review and meta-
analysis, Schizophr. Res. (2017), http://dx.doi.org/10.1016/j.schres.2017.01.045
2 R. Rodrigues, K.K. AndersonSchizophrenia Research xxx (2017) xxx–xxx
(Minsky et al., 2015; Mueser and Rosenberg, 2003), unrecognized PTSD
symptoms may have a particularly detrimental impact on recovery in
this population.
Many studies investigating PTSD symptoms related to psychosis re-
port mixed first- and multi-episode populations, and prevalence esti-
mates vary widely, ranging from 11% to 70% (Berry et al., 2013).
Although many factors are likely to influence varying prevalence
estimates—including the timing of PTSD assessment, the instrument
used, geographic location, or treatment setting—we hypothesize that
the chronicity of the sample may impact prevalence estimates (Berry
et al., 2013), as the novelty of the first episode of psychosis may be
more traumatic than recurrent episodes (Mueser and Rosenberg,
2003). Our primary objective was to systematically review the literature
to estimate the prevalence of PTSD symptoms after the first episode of
psychosis. Our secondary objective was to investigate potential risk fac-
tors for PTSD symptoms to determine whether there are subgroups of
patients particularly vulnerable to experiencing PTSD symptoms after
a first episode of psychosis.
2. Methods
2.1. Search strategy
We searched the following electronic databases (1980–2016, inclu-
sive): MEDLINE-Ovid, EMBASE-Ovid, PsycINFO-Ovid, Cochrane Library,
Web of Science, the Published International Literature on Traumatic
Stress (PILOTS) database, Theses Canada Portal, and the Networked Dig-
ital Library of Theses and Dissertations (NDLTD). No language restric-
tions were imposed. MEDLINE search terms (Supplementary
Appendix A) were adapted to other databases. The database searches
were updated regularly, with the last update occurring July 30, 2016.
We used forward and backward citation searching and manual
searching of tables of contents (British Journal of Clinical Psychology,
Journal of Consulting and Clinical Psychiatry, Early Intervention in Psychia-
try, Social Psychiatry and Psychiatric Epidemiology, and Journal of Trau-
matic Stress). We contacted authors of abstracts or unpublished
studies to determine whether the studies had subsequently been pub-
lished in a peer-reviewed journal. The search strategy was developed
in consultation with a medical librarian.
2.2. Study selection and data extraction
Two independent reviewers screened titles, abstracts, and full-texts,
and completed data extraction. Studies were included if: (i) the popula-
tion was FEP or presented stratified data for first- and multi-episode
cases; (ii) PTSD symptoms were measured in reference to psychosis or
associated treatment experiences; and (iii) the study design was quan-
titative. We assessed study quality using an adapted Newcastle-Ottawa
Scale (Table 1; Wells et al., 2013). The representativeness of sample do-
main was adapted to include options for a population-based sample,
mixed inpatient/outpatient sample (unrestricted), and restricted inpa-
tient sample. Ascertainment of exposure (i.e., psychosis) was adapted
to include clinical interview, clinical chart diagnosis, and self-report. As-
certainment of outcome (i.e., PTSD symptoms) was adapted to include a
clinical diagnosis and screening tool. Discrepancies between reviewers
were discussed and resolved by consensus. We contacted correspond-
ing authors when methodological questions arose or if more detailed
data were required for analysis.
2.3. Meta-analysis
We divided studies into two groups for the meta-analysis based on
whether studies used self-report scales to assess PTSD symptoms or
clinical interviews to diagnose PTSD, irrespective of DSM criteria for a
traumatic event. Studies reporting both PTSD symptom and diagnosis
prevalence were included in both analyses. Proportions of participants
Please cite this article as: Rodrigues, R., Anderson, K.K., The traumatic experience of first-episode psychosis: A systematic review and meta-
analysis, Schizophr. Res. (2017), http://dx.doi.org/10.1016/j.schres.2017.01.045
meeting scale cut-offs for clinically relevant PTSD symptoms, or meeting
diagnostic criteria for PTSD, were meta-analyzed to obtain pooled prev-
alence estimates and 95% confidence intervals (CI). We used the Free-
man-Tukey double arcsine transformation (Freeman and Tukey, 1950)
within a random effects model to account for methodological and clin-
ical heterogeneity, including sample characteristics, PTSD instruments,
and timing of assessments.
We used post-hoc exploratory subgroup analyses to examine the in-
fluence of factors hypothesized to affect PTSD symptom prevalence
(Berry et al., 2013). First, we meta-analyzed PTSD symptom prevalence
in subgroups containing affective versus non-affective psychosis using
two strategies—by contacting study authors to obtain stratified data,
and by dividing studies based on the median percentage of non-affec-
tive psychosis. We meta-analyzed the prevalence of PTSD symptoms
and diagnoses in studies with unrestricted inpatient/outpatient versus
restricted inpatient samples. We further explored these factors by re-
moving studies from the meta-analysis that contain both affective sam-
ples (i.e., below the median percentage of non-affective psychosis) and
restricted inpatient samples. We also conducted subgroup analysis to
investigate regional differences in PTSD symptom prevalence. We
used sensitivity analyses to examine the influence of individual studies
and quality criteria on pooled prevalence estimates. We assessed statis-
tical heterogeneity using the I2 statistic with cut-off values of 25%, 50%,
and 75% indicating low, moderate, and high heterogeneity (Higgins et
al., 2003). We evaluated publication bias using a funnel plot for propor-
tions and visually inspected the plots for asymmetry of study propor-
tions around the average (Spiegelhalter, 2005). Publication bias was
assessed only when there were at least ten studies in the meta-analysis
(Higgins and Green, 2011).
Meta-analyses were conducted in Stata 13.0 using the metaprop
command (Nyaga et al., 2014) and funnel plots were constructed in
SAS 9.4. Potential risk factors for PTSD (symptoms or a diagnosis)
were summarized qualitatively.
3. Results
The database search retrieved 1186 studies and 39 were reviewed at
the full-text stage (Fig. 1). Thirteen studies met the inclusion criteria
and reported prevalence of PTSD symptoms (n = 10) (Abdelghaffar et
al., 2016; Bendall et al., 2012; Bernard et al., 2006; Jackson et al., 2004;
Jackson et al., 2009; McGorry et al., 1991; Mueser et al., 2010; Pietruch
et al., 2012; Stubbins, 2014; Turner et al., 2013) and/or diagnoses
(n = 5) (Abdelghaffar et al., 2016; Brunet et al., 2012; Mueser et al.,
2010; Sin et al., 2010; Tarrier et al., 2007). Nine studies were included
in the qualitative synthesis of factors associated with PTSD symptoms/
diagnoses (Fig. 1). Study characteristics are summarized in Table 2.
Nine studies described aspects of psychosis and treatment partici-
pants found to be traumatic. These experiences included psychotic
symptoms (31% to 75% of patients), hospitalization/treatment (22% to
46% of patients), and experiences such as behaviour when ill, paranoia
and mental disturbance, police involvement, fear of other patients,
and negative staff attitudes (Table 2).
None of the studies satisfied all quality criteria domains (Table 1).
Problems included high non-participation rates and/or lack of a descrip-
tion of participation (n = 11), no adjustment for important confounding
factors (n = 11), no adjustment for additional confounding factors (n =
9), and non-representativeness of samples (n = 4).
3.1. Meta-analysis of PTSD prevalence
Across eight studies (pooled n = 398), 42% (95% CI = 30%–55%, I2 =
83.8%) of people with FEP displayed clinically relevant PTSD symptoms
related to psychosis up to 2.5 years following the first-episode (Fig. 2).
Across four studies (pooled n = 204), the prevalence of full PTSD was
30% (95% CI = 21%–40%, I2 = 53.9%) within two years of the first-epi-
sode (Fig. 2). The funnel plot for PTSD symptoms displayed no evidence
analysis, Schizophr. Res. (2017), http://dx.doi.org/10.1016/j.schres.2017.01.045
Please cite this article as: Rodrigues, R., Anderson, K.K., The traumatic experience of first-episode psychosis: A systematic review and meta-

Table 1
Adapted quality criteria based on the Newcastle-Ottawa scale and quality assessment of included studies.

Quality assessment of included studies

Abdelghaffar

Tarrier et al.

Turner et al.
Bernard et
et al. (2016)

Brunet et al.

McGorry et
al. (2006)
Bendall et

Pietruch et
Jackson et
al. (2012)

Jackson et

al. (1991)

Mueser et
al. (2004)

al. (2009)

al. (2010)

al. (2012)

Stubbins
Sin et al.

(2007)

(2013)
(2010)
(2012)

(2014)
Domain Quality criteria

1. Representativeness Population–based (+)

of sample Mixed outpatient/inpatient sample (•)
– • • • • • – – • • • – •
Restricted inpatient sample (–)
No description (–)

R. Rodrigues, K.K. AndersonSchizophrenia Research xxx (2017) xxx–xxx

2. Non–participation Low rate and differences
rate described (+)
High rate and differences
– – – • • – – – – – – – –
described (•)
High rate and no description (–)
No description (–)
3. Ascertainment of Clinical interview (+)
exposure Clinical chart diagnosis (•)
• + • + • + + • – + • • +
Self–report (–)
No description (–)
4. Demonstration that Yes (+)
outcome not present No (–) N/A N/A N/A – N/A N/A – N/A N/A N/A N/A N/A N/A
at start*

5. Adjustment of Yes (+)

important confounding No (–) – – – – – – – – – + – – –
factors No description (–)

6. Adjustment of Yes (+)

additional confounding No (–) – + – – – – – – + + – – +
factors No description (–)
7. Ascertainment of Clinical diagnosis (+)
outcome Screening tool (•) + • • + • • • + • + • + •
No description (–)
8. Same method of Yes (+)
ascertainment for No (–) + + + + + + + + + + + + +
entire sample
9. Follow–up long Yes (+)
enough for outcomes No (–)
N/A N/A N/A + N/A N/A + N/A N/A N/A N/A N/A N/A
to occur*

10. Adequacy of Complete follow–up (+)

follow–up of cohort* Subjects lost, unlikely to introduce
bias (•) N/A N/A N/A – N/A N/A – N/A N/A N/A N/A N/A N/A
Subjects lost, potential for bias (–)
No description (–)

+ Criteria satisfied, • criteria partially met, – criteria not met; *Criteria relevant to prospective cohort studies only

3
4 R. Rodrigues, K.K. AndersonSchizophrenia Research xxx (2017) xxx–xxx

Fig. 1. Flow chart of study identification and selection process for the systematic review.

of imbalance in prevalence suggestive of publication bias (data not
shown). A funnel plot for PTSD diagnosis prevalence could not be con-
structed because the number of studies in the meta-analysis did not
meet the minimum requirement.
The results did not change substantially in the sensitivity analysis in
which each study was removed in turn and the pooled proportion
recalculated (data not shown). We also conducted sensitivity analyses
in which studies not meeting the quality criteria that likely impact prev-
alence estimates were excluded, with a general trend towards reduction
in prevalence estimates when these studies were removed (Supple-
mentary Appendix A).
3.2. Exploratory subgroup analysis
A meta-analysis of stratified data provided by authors from two
studies and data from studies with restricted non-affective samples re-
vealed a higher prevalence of PTSD symptoms in affective FEP (59%, 95%
CI = 37%–80%, I2 = 95.1%, pooled n = 22, n = 2 studies) compared to
non-affective FEP (34%, 95% CI = 20%–48%, I2 = 75.6%, pooled n =
212, n = 6 studies). Due to the small number of studies in the affective
FEP subgroup, we further explored this trend by dividing subgroups
based on the median percentage of non-affective psychosis (90%). Sim-
ilarly, we observed a higher prevalence of PTSD symptoms in the mixed
affective/non-affective psychosis subgroup (53%, 95% CI = 37%–68%,
I2 = 70.3%, pooled n = 141, n = 4 studies) compared with the non-af-
fective subgroup (34%, 95% CI = 19%–51%, I2 = 84.8%, pooled n = 223,
n = 5 studies). We could not perform these analyses in the PTSD diag-
nosis group due to the small number of studies.
The prevalence of PTSD symptoms and diagnoses was higher in re-
stricted inpatient versus unrestricted inpatient/outpatient samples.
PTSD symptom prevalence in the restricted inpatient subgroup was
55% (95% CI = 33%–75%, I2 = 77.9%, pooled n = 105, n = 3 studies)
compared to 37% in the unrestricted subgroup (95% CI = 24%–50%,
I2 = 80.3%, pooled n = 293, n = 7 studies). PTSD diagnosis prevalence
was 39% (95% CI = 30%–48%, I2 = 0%, pooled n = 111, n = 3 studies) in
the restricted inpatient subgroup and 20% (95% CI = 13%–29%, I2 =
88.5%, pooled n = 93, n = 2 studies) in the unrestricted subgroup.
Additional analyses that removed studies with both a large propor-
tion of patients with affective psychosis and restricted inpatient sam-
ples and that stratified by geographic region did not yield substantial

Please cite this article as: Rodrigues, R., Anderson, K.K., The traumatic experience of first-episode psychosis: A systematic review and meta-
analysis, Schizophr. Res. (2017), http://dx.doi.org/10.1016/j.schres.2017.01.045
analysis, Schizophr. Res. (2017), http://dx.doi.org/10.1016/j.schres.2017.01.045
Please cite this article as: Rodrigues, R., Anderson, K.K., The traumatic experience of first-episode psychosis: A systematic review and meta-

Table 2
Characteristics of included studies (n = 13).a

Study Study Study n Source of sample Diagnostic Non– Mean Male PTSD Timing of PTSD Most distressing experiences
location design criteria for affective age, (%) instrument assessmentb
psychosis psychosis years
(%)

Studies assessing PTSD symptoms

1 Bendall et Australia Cross – 36 Outpatients from DSM–IV–TR 67 21.4 61 IES–R Within 18 months –
al. (2012) sectional one EI site Axis I
2 Bernard et UK Cross – 23 Outpatients from ICD–10 (F20, 100 24.73 61 IES–R Mean of 30.9 “Breakdown” (44%), illness (17%),
al. (2006) sectionalc one EI site F22, F23, F25) months psychosis (13%), or a range of
descriptions, including paranoia,
mental disturbance, and mental
imbalance (26%)
3 Jackson et UK Cross – 35 Outpatients from ICD–10 (F20, 100 25.8 74 PTSD Scale Mean of 18 “Breakdown” (46%), “psychotic”
al. (2004) sectional one EI site F22, F23, F25) months episode (11%), “the time when they

R. Rodrigues, K.K. AndersonSchizophrenia Research xxx (2017) xxx–xxx

were ill” (17%), “their schizophrenia”
(9%), or a variety of descriptions
such as “when things got on top of
me” (17%)
4 Jackson et UK Cross– 66 Four mental health ICD–10 (F20, 100 23.2 74 IES 6 to 18 months –
al. (2009) sectionalc services sites in F22, F23, F25)
defined catchment
area
5 McGorry Australia Prospective 36 Inpatients DSM–III 67 25.0 72 PTSD Scale 4 months and 11 Symptoms linked especially to the
et al. cohort monthsd experience of hospitalization and
(1991) less to the psychotic experience (eg,
recurrent nightmares involving
forced sedation or seclusion)
6 Pietruch et UK Cross– 34 Outpatients from – – 25.7 65 IES–R Mean of 9.8 –
al. (2012) sectional one EI site months
7 Stubbins UK Cross– 51 Outpatients from ICD–10 90 26.9 63 IES–R Mean of 10.1 –
(2014) sectional nine EI or months
community mental
health sites

8 Turner et UK Cross– 50 Outpatients from ICD–10 (F20, 100 24.5 – IES–R 1 to 12 months Positive symptom (52%),
al. (2013) sectional one EI site F22, F23, F25) hospitalization (22%), behaviour
when ill (22%), or other (4%)

Studies assessing a PTSD diagnosis

9 Brunet et UK Prospective 50 Inpatients and ICD–10 (F20, 94 22.4 66 PSS–I 18 months Admission related (42%), psychosis
al. (2012)e cohort outpatients from F22, F23, F25 symptoms (31%), or events prior to
one EI site or F30, F31, psychosis (27%)
F32 with
psychotic
symptoms)
10 Sin et al. Singapore Cross– 61 Inpatients and DSM–IV–TR 93 25.8 49 CAPS, Median 118 days Symptoms (75%), or hospitalization
(2010) sectional outpatients from Axis I excluding (25%)
one EI site criterion A
11 Tarrier et UK Cross– 35 Inpatients DSM–IV – 24.9 71 CAPS–S, Within 286 days Confused/scared by hospitalization
al. (2007) sectional excluding (31%), forced medication (31%),
criterion A police “insensitivity” (11%), fear of
other patients (9%), and adverse
staff attitudes (9%)
(continued on next page)

5
6 R. Rodrigues, K.K. AndersonSchizophrenia Research xxx (2017) xxx–xxx

changes in our findings. Results from all subgroup analyses are shown in
Supplementary Appendix A.

EI, early intervention; DSM, Diagnostic and Statistical Manual of Mental Disorders (TR: text revision), ICD, International Classification of Diseases; SD, standard deviation; PTSD, post traumatic stress disorder; IES, Impact of Events
3.3. Potential risk factors for PTSD symptoms/diagnosis

PTSD symptoms were defined as meeting criteria for PTSD symptoms on the CAPS, regardless of A1/A2 criterion, and a diagnosis was met when the traumatic event met the A1/A2 criteria (A1 criterion referring to a perceived
Most distressing experiences

Potential risk factors for PTSD symptoms or diagnoses investigated

experience (42%), or both (5%)

Symptoms (54%), treatment

Symptoms (53%), treatment

included socio-demographic factors, clinical factors, hospitalization/
treatment factors, other experiences related to psychosis, prior trauma,
coping styles, substance/alcohol use, and reactions to psychosis (Table
experience (46%)

3). For a detailed summary of methods used and associations found in

each study, refer to Supplementary Appendix A. There was a paucity
of evidence for potential risk factors for the development of PTSD symp-

PTSD symptoms were defined as meeting the cut–off score on the PDS, regardless of the A1/A2 criteria from the CAPS, and a diagnosis was met when the traumatic event met the A1/A2 criteria.
toms or diagnoses after a first psychotic episode, or the relationships

Scale (R: revised); PSS–I, PTSD Symptom Scale–Interview; PDS, Posttraumatic Diagnostic Scale; CAPS, Clinician Administered PTSD Scale (S: adapted for use with patients with schizophrenia).
were inconsistent across studies. Psychotic symptom severity was
assessed most often and only one of seven studies reported an associa-

This study assessed PTSD in relation to either the psychotic episode, or another traumatic event. The prevalence of PTSD in relation to psychosis only was included in the meta–analysis.
hospitalization for
Within 2 years of
Timing of PTSD

tion with PTSD symptoms (Mueser et al., 2010). Of exception, depres-

assessmentb

Within 6 weeks

sion was significantly associated with PTSD symptoms in four of five

studies (Abdelghaffar et al., 2016; Jackson et al., 2004; McGorry et al.,
the first

1991; Mueser et al., 2010; Turner et al., 2013), and with a diagnosis of
FEP

PTSD in two of three studies (Abdelghaffar et al., 2016; Mueser et al.,

2010; Sin et al., 2010). Anxiety was significantly associated with PTSD
instrument

symptoms in two of two studies (Jackson et al., 2004; Mueser et al.,

PTSD

CAPS +/–
criterion

criterion
CAPS for
PDS +/–

2010), and with a diagnosis of PTSD in one of two studies (Mueser et

A1/A2g
A1/A2f

al., 2010; Sin et al., 2010).

The meta–analysis for prevalence of PTSD symptoms included studies 1–8, 12, and 13 and prevalence of a PTSD diagnosis included studies 9–13.

4. Discussion
Male
(%)

52

68

This systematic review and meta-analysis found that approximately

one in two people experienced PTSD symptoms and one in three were
Mean

years
age,

diagnosed with PTSD following a first psychotic episode. Exploratory

This study measured PTSD symptoms at two follow–up time points. The 11–month time point is included in the meta–analysis.
27.6

22.5

subgroup analyses suggest that PTSD symptom and diagnosis preva-

lence may be higher in people with affective psychosis and inpatient
These studies were randomized controlled trials in which the baseline data were extracted as a cross–sectional study.

groups. Results from included studies indicate that depression and anx-
affective
psychosis
Non–

(%)

iety may be potential risk factors for the development of PTSD following
a first episode of psychosis.
73

26

Our finding that 42% of FEP patients experience PTSD symptoms and
that 30% meet diagnostic criteria for PTSD in relation to psychosis is sim-
criteria for
Diagnostic

ilar to a previous review of 16 studies including both chronic and first

psychosis

DSM–IV

episode populations, which found a median prevalence of 39% (Berry

et al., 2013). Similarly, a study estimating the prevalence of PTSD in a
–

multi-episode population found that 31% of patients met the diagnostic

criteria for PTSD (Lu et al., 2011). This suggests that the experiences of
Inpatients in acute
academic hospital
Source of sample

hospitals and two

academic centres

threat, and A2 criterion referring to feelings of intense helplessness or horror).

psychosis and related treatment may have a similar traumatic impact

care at two state
services at an

in both the first and subsequent episodes.

Outpatients

psychiatric

psychiatric
consulting

The quality of included studies likely influenced prevalence esti-

mates. Studies that were more inclusive in their recruitment of partici-
pants and were more rigorous in their ascertainment of exposure had a
lower pooled PTSD diagnosis and symptom prevalence, respectively.
52

38
n

Studies assessing PTSD symptoms and a PTSD diagnosis

Similarly, the lower prevalence in the PTSD diagnosis group compared

to the PTSD symptom group suggest that studies using lower quality
self-report symptom measures may inflate prevalence compared to
design
Study

sectional

sectional
Cross–

Cross–

clinical interview methods. Conversely, non-participation may be relat-

ed to higher levels of trauma and avoidance suggesting studies with
high non-participation may underestimate PTSD prevalence (Berry et
Following the psychotic episode.

al., 2013; Sin et al., 2010), however, we were unable to investigate the
location
Study

Tunisia

impact of non-participation since it was uniformly high across studies

USA

or not described. Overall these gaps in study quality suggest an overes-

timate of PTSD prevalence, however, most included studies were not
Table 2 (continued)

Abdelghaf–

designed and powered to estimate prevalence, highlighting the explor-

Mueser et
al. (2010)
Study

far et al.

atory nature of the estimates in our meta-analysis.

(2016)

We found that PTSD symptoms were more prevalent in samples

with affective psychosis, which is supported by previous studies of
12

13

PTSD in people with severe mental illness. Rates of PTSD have been ob-
d
b

g
e
a

served to be highest in people with depression, followed by bipolar dis-

order, schizoaffective disorder, and lowest in people with schizophrenia
(Mueser et al., 2004b, 1998; Seow et al., 2016). Although the

Please cite this article as: Rodrigues, R., Anderson, K.K., The traumatic experience of first-episode psychosis: A systematic review and meta-
analysis, Schizophr. Res. (2017), http://dx.doi.org/10.1016/j.schres.2017.01.045
 R. Rodrigues, K.K. AndersonSchizophrenia Research xxx (2017) xxx–xxx 7

mechanism underlying this phenomenon is unclear, certain defining
features of non-affective psychotic disorders have been suggested to
play a role. Memory impairment may be involved, as greater cognitive
impairment in schizophrenia may limit intrusive memories or avoid-
ance of trauma-related stimuli (Mueser et al., 1998). Negative symp-
toms in people with schizophrenia and schizoaffective disorder have
also been implicated by serving as an emotional buffer that helps miti-
gate the intense negative emotional response related to psychosis
(Seow et al., 2016). However, the role of negative symptoms is unclear,
as it has also been noted that negative symptoms of psychosis overlap
with avoidance symptoms in PTSD (Morrison et al., 2003), which
would be suggestive of higher levels of PTSD in those with non-affective
psychosis, contrary to our findings. Further investigation of the potential
mechanisms underlying differences in PTSD for affective and non-affec-
tive psychotic disorders is needed to elucidate these relationships.
We observed higher PTSD symptom prevalence in restricted inpa-
tient samples, which has been noted in a previous review of PTSD in re-
lation to psychosis across first- and multi-episode samples (Berry et al.,
2013). This difference was particularly evident in the PTSD diagnosis
group, as prevalence in the inpatient subgroup was twice that of the un-
restricted subgroup with no overlapping CIs. Given that clinical inter-
views provide a more rigorous assessment of PTSD, this suggests that
inpatient status may potentially be a strong risk factor for the develop-
ment of PTSD following FEP. It is unclear why PTSD symptoms may be
more prevalent among inpatients, however, people who are hospital-
ized for FEP tend to have more severe functional and behavioural
disturbances, and are more likely to be considered a risk to self or others,
which may increase the likelihood of exposure to traumatic events
(Castle et al., 1994; Wade et al., 2006).
We found a paucity of evidence on potential risk factors for the de-
velopment of PTSD following psychosis from included studies, with
the exception of comorbid depression or anxiety. Psychotic symptoms
were commonly investigated and findings largely did not support an as-
sociation, although few studies sought to understand the impact of spe-
cific symptoms, such as persecutory delusions and hallucinations.
Additionally, most studies did not assess severity of psychotic symp-
toms in acute psychosis, instead doing so during the recovery phase.
In contrast, most studies that investigated associations between depres-
sion or anxiety and PTSD reported significant associations. It should be
noted that the only study to account for confounding factors in their
analysis did not find a significant association between a diagnosis of
PTSD and depression or anxiety (Sin et al., 2010). Furthermore, due to
the cross-sectional design of most of the included studies, it is unclear
whether depression or anxiety symptoms preceded PTSD symptoms.
In the general PTSD literature, it has been observed that PTSD predicts
comorbid depression and anxiety, but not vice versa (Ginzburg et al.,
2010).
There are several possible mechanisms through which a first psy-
chotic episode could induce symptoms of PTSD. It may be a reaction
to the traumatic experiences of delusions or hallucinations, as many
participants from included studies identified psychosis-related symp-
toms as highly traumatic. However, reported associations between

Fig. 2. Forest plot of the prevalence and 95% confidence intervals (CIs) of PTSD symptoms (pooled n = 398) or a PTSD diagnosis (pooled n = 204) as a result of experiencing psychosis and
related treatment following a first episode of psychosis. Proportions of patients experiencing clinically relevant PTSD symptoms or exhibiting a diagnosis of PTSD were meta-analyzed
using a random effects model with a Freeman-Tukey double arcsine transformation. Estimates were back-transformed so proportions are shown. The shaded boxes indicate the
relative weights of each study in the meta-analysis.

Please cite this article as: Rodrigues, R., Anderson, K.K., The traumatic experience of first-episode psychosis: A systematic review and meta-
analysis, Schizophr. Res. (2017), http://dx.doi.org/10.1016/j.schres.2017.01.045
8 R. Rodrigues, K.K. AndersonSchizophrenia Research xxx (2017) xxx–xxx

Table 3
Summary of findings from included studies on factors associated with PTSD symptoms or a diagnosis of PTSD following FEP.

PTSD symptoms PTSD diagnosis

Potential risk factor
# of studies # of significant associations # of studies # of significant associations

Socio-demographics

Age 0 – 2 0
Sex 0 – 2 0
Education 0 – 2 0
Marital status 0 – 2 0
Employment status 0 – 2 0
Ethnicity (Chinese vs other) 0 – 1 1

Clinical factors

Positive psychotic symptoms 1 0 2 0

Negative psychotic symptoms 1 0 2 0
General psychopathology 0 – 2 0
Total psychotic symptom scores 3 1 3 0
Duration of untreated psychosis 2 0 3 0
Depression 5 4 3 2
Anxiety 2 2 2 1
Global functioning 1 0 1 0
Psychotic disorder diagnosis 0 – 2 0
Age of onset of psychosis 1 0 0 –
Suicidal ideation 0 – 1 0

Hospitalization and treatment experiences

Involuntary hospitalization 2 0 3 1
Admission to hospital 1 0 1 0
Police involvement 1 0 1 0
Use of restraints 1 1 2 1
Number of hospital admissions 1 0 0 –
Duration of hospitalization 0 – 1 0
Perceived stressfulness of the ward 1 1 0 –
Admission to secure ward 1 0
Medication side effects 0 – 1 0
Threat by other patients 0 – 1 0
Threat by treatment provider 0 – 1 0

Psychosis-related experiences

Violent or embarrassing behaviour 0 – 1 0

Frightening hallucinations 0 – 1 0
Physical harassment or violence 0 – 1 1

Prior trauma

Lifetime traumatic events 1 0 3 0

History of sexual abuse/assault 1 0 1 0
Childhood trauma 1 1 0 –
Childhood trauma-related PTSD 1 1 0 –

Coping styles

Maladaptive coping 1 1 1 1
Adaptive coping 1 0 1 0
Integration-sealing over coping style 2 1 1 0

Substance/alcohol use

Alcohol use (past 30 days) 1 0 1 0

Alcohol abuse (past 30 days) 2 0 2 0
Drug abuse (past 30 days) 2 1 2 0

Reactions to experiencing psychosis

External shame due to psychosis 1 1 0 –

Reluctance to talk and actual self-disclosurea 1 1 0 –
Afraid of losing touch with reality 0 – 1 0
Feeling persecuted 0 – 1 0
a
“Reluctance to talk” is a dimension of self-disclosure, defined as the resistance to tell others about the trauma. The other dimension of self-disclosure consisting of the “urge to talk,”
defined as the need to disclose the traumatic experience. Actual self-disclosure describes the actual amount that individuals talked about their experience of psychosis.

severity of psychotic symptoms and PTSD were largely negative, so fur-
ther exploration of this mechanism is warranted. Hospitalization and
treatment-related experiences were also highlighted as traumatic,
however evidence for hospitalization and treatment experiences (eg,
restraints) as potential risk factors were inconsistent across studies.
McGorry et al. (1991) noted that hospitalization is uniformly stressful
and there may be a ceiling effect in studies attempting to assess the
impact of involuntary hospitalization or other treatment experiences.
Our observation that PTSD prevalence is higher in inpatient groups sup-
ports this hypothesis. We also cannot rule out the possibility that PTSD
was pre-existing prior to the first psychotic episode. Few studies con-
sidered the relationship between prior trauma and PTSD following
FEP; of exception, one study reported a strong relationship between
childhood trauma and childhood trauma-related PTSD and PTSD

Please cite this article as: Rodrigues, R., Anderson, K.K., The traumatic experience of first-episode psychosis: A systematic review and meta-
analysis, Schizophr. Res. (2017), http://dx.doi.org/10.1016/j.schres.2017.01.045
 R. Rodrigues, K.K. AndersonSchizophrenia Research xxx (2017) xxx–xxx
symptoms following FEP (Bendall et al., 2012). Finally, our findings
could be due to overlap in symptomatology of psychosis and PTSD. Neg-
ative symptoms of psychosis may be difficult to distinguish from avoid-
ance symptoms in PTSD, and hallucinations in psychosis may present
similarly to intrusions in PTSD (Morrison et al., 2003; Shaner and Eth,
1989). However, the reliability of assessing PTSD in people with severe
mental illness using the CAPS has been demonstrated (Mueser et al.,
2001), suggesting that distinction of symptoms from each disorder is
possible.
4.1. Clinical implications
PTSD symptoms in FEP has implications in terms of treatment and
outcomes. A reciprocal relationship between schizophrenia and PTSD
has been described, in which trauma histories may lead to PTSD,
which then lead to increased symptom severity in pre-existing mental
illness, subsequent traumatic events, and worsened overall clinical pre-
sentation (Mueser et al., 1998). Despite the high prevalence of psycho-
sis-related PTSD in FEP, it largely goes unrecognized and untreated
(Álvarez et al., 2012; Mueser et al., 1998) and there is no established ev-
idence-based intervention currently used in practice (Bendall et al.,
2010). Trauma-focused psychological therapies have demonstrated effi-
cacy in reducing PTSD symptoms in people with psychosis (Sin and
Spain, 2016) and specifically in people with PTSD symptoms related to
FEP (Bernard et al., 2006; Jackson et al., 2009). There may be reluctance
among clinicians to treat trauma in people with psychosis due to con-
cerns of symptom exacerbation and relapse, however there is no evi-
dence that trauma-focused psychological treatment leads to
exacerbation of PTSD symptoms, paranoia, depression, hallucinations,
or re-victimization (van den Berg et al., 2016). Further research is need-
ed to establish an evidence-base for acceptable and effective interven-
tions to treat trauma in FEP.
An under-investigated aspect of trauma related to FEP is the poten-
tial positive impact of experiencing psychosis as assessed through post-
traumatic growth (Jordan et al., 2016; Levine et al., 2009, 2008), which
has important implications for treatment and recovery (Pietruch and
Jobson, 2012). Further understanding of how posttraumatic growth oc-
curs following the first episode of psychosis in those who experience
PTSD symptoms, and how this process can be facilitated, may inform in-
terventions to address the trauma of FEP and improve recovery.
4.2. Limitations
The findings of this systematic review and meta-analysis must be
considered in the context of the limitations of included studies. Most
studies were cross-sectional, therefore temporal relationships could
not be established. Sample sizes were small and likely underpowered
to detect significant associations between potential risk factors and
PTSD. Many studies recruited from early intervention services so results
may not be generalizable to people with FEP treated outside of these
settings. Most studies had high non-participation rates (20% or greater)
which may have resulted in biased samples. Most studies did not adjust
for confounding factors in their analysis of factors associated with PTSD.
Limitations to this systematic review include the small number of
studies for the meta-analyses and subgroup analyses. We imposed a
date restriction for studies published prior to 1980; however, this is un-
likely to impact the number of included studies because the diagnostic
criteria for PTSD was first introduced to the DSM-III in 1980
(American Psychiatrc Association, 1980). We used an adapted quality
assessment tool, which has not been validated. The results from our
meta-analyses show high amounts of statistical heterogeneity. We
attempted to explore this using subgroup analyses, but were unable to
conduct meta-regression analyses to explore this further, as we had
less than the suggested minimum of ten studies per group (Higgins
and Green, 2011). Another potential source of heterogeneity may have
been timing of PTSD assessment following psychosis, as PTSD
Please cite this article as: Rodrigues, R., Anderson, K.K., The traumatic experience of first-episode psychosis: A systematic review and meta-
analysis, Schizophr. Res. (2017), http://dx.doi.org/10.1016/j.schres.2017.01.045
9
symptoms may decrease over time following acute psychosis
(McGorry et al., 1991). However, the variation in time points within
and between studies precluded investigation of this. We were unable
to rule out the possibility of publication bias since the small number of
included studies may not be sufficient to accurately assess whether
the funnel plot distribution was a result of systematic under-reporting
or random chance (Macaskill et al., 2001). Furthermore, the primary ob-
jective of most included studies was not to assess the prevalence of
PTSD in relation to a first-psychotic episode, and our search strategy
will have missed studies that did not mention PTSD in their title or
abstract.
4.3. Conclusions
The experience of FEP—including symptoms, pathways to care, hos-
pitalization, and treatment—can be sufficiently traumatic, such that one
in two people may develop clinically significant PTSD symptoms, and
one in three people may be diagnosed with PTSD. This high burden
highlights the importance of PTSD symptoms as an underappreciated
consequence of FEP. People with FEP who experience PTSD symptoms
are more likely to have affective psychosis, to have been previously hos-
pitalized, and to be experiencing symptoms of depression or anxiety.
Future large-scale studies are needed to prospectively assess the timing
of and risk factors for PTSD symptoms. We need evidence-based inter-
ventions to treat PTSD symptoms in the context of FEP to address this
burden and improve outcomes after the first psychotic episode.
Role of funding source
This work was supported by a New Investigator Fellowship awarded to KKA from the
Ontario Mental Health Foundation.
Contributors
RR and KKA designed the study and search strategy. RR conducted the database
searches, manual searching, article screening, data extraction, data analysis and interpre-
tation, and wrote the first draft of the manuscript. KKA reviewed full-text articles, con-
ducted data extraction, was involved in data analysis and interpretation, and provided
critical revision of the manuscript. Both authors have approved the final manuscript.
Conflict of interest
None.
Acknowledgements
We thank Basmah El-Aloul for extensive work in screening of re-
trieved citations, Rohin Krishnan for assistance with the meta-analysis,
and John Costella and Monali Malvankar for assistance with developing
the search strategy. We also thank Dr. Kim Mueser and Dr. Sarah Bendall
for providing data.
Appendix A. Supplementary data
Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.schres.2017.01.045.
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