The Journal of Forensic Psychiatry & Psychology,

December 2005; 16(4): 660 – 670

Comorbidity of post traumatic stress disorder

and paranoid schizophrenia: A comparison
of offender and non-offender patients

JAYDIP SARKAR1, GILLIAN MEZEY2, ANDREA COHEN1,

SWARAN P. SINGH2, & OLUMUYIWA OLUMOROTI1
1
Forensic Service, Shaftesbury Clinic, Springfield Hospital, London, UK, and
2
St. George’s Hospital Medical School, Department of Mental Health, London, UK

Abstract
This study describes rates of trauma and posttraumatic stress disorder (PTSD) in
forensic and non-forensic psychiatric patients, with a primary diagnosis of paranoid
schizophrenia. Twenty-seven disordered offender patients (forensic) were compared
with 28 non-offender (general) psychiatric inpatients. Ninety-three percent of the
entire group reported previous trauma, with the forensic group reporting higher
rates of physical and sexual abuse. The forensic patients had also experienced more
multiple traumas then the general psychiatric patients, although the result was non-
significant. There was no difference between the groups with regard to the age of the
earliest trauma experienced. PTSD was common, with rates of 27% for current, and
40% lifetime diagnosis in the whole group. Forensic patients had higher rates of
both current (33% v 21%) and lifetime (52% v 29%) PTSD. Very few patients had
received a working diagnosis of PTSD, or were receiving trauma focussed
psychological therapy. Possible reasons for high rates of trauma and PTSD, and
implications for treatment are discussed.

Keywords: Psychotic, pogt traumatic stress disorder, mentally disordered, trauma

Introduction
Post traumatic stress disorder (PTSD) is a psychiatric disorder which may
be precipitated by exposure to a serious or life-threatening event.
Symptoms of post traumatic stress disorder include re-experiencing of
the traumatic event, avoidance, and hyperarousal, which are associated with
impairment in the individual’s social, interpersonal, or other important
areas of functioning (American Psychiatric Association, 1994).

Correspondence: Gillian Mezey St. George’s Hospital Medical School, Department of Mental Health
(Forensic), Jenner Wing, Cranmer Terrace, London SW17 ORE, UK. E-mail: gmezey@sgul.ac.uk

ISSN 1478-9949 print/ISSN 1478-9957 online ª 2005 Taylor & Francis

DOI: 10.1080/14789940500279836
 PTSD and paranoid schizophrenia 661
Epidemiological studies indicate that the lifetime prevalence of PTSD is
1 – 9% in the community (Davidson, Hughes, Blazer, & George, 1991;
Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). PTSD has high rates
of co-morbidity with other psychiatric disorders, most commonly major
depressive disorder and alcohol and substance misuse (Kessler et al., 1995).
Although some studies have reported an increased rate of schizophrenia
and schizophreniform psychosis (Davidson et al., 1991) as well as bipolar
affective disorder (Helzer, Robins, & McEvoy, 1987) in individuals
diagnosed with PTSD, others have failed to replicate these findings
(Kessler et al., 1995; Shore, Vollmer, & Tatum, 1988). There is a
suggestion that the level of PTSD symptoms found in patients with
psychotic disorders may be comparable to that of Vietnam War veterans
(Priebe et al., 1998) and victims of torture (Jeffries et al., 1977). Studies of
clinical populations suggest that 29 – 35% of treatment-seeking PTSD
patients may experience psychotic symptoms (Hamner, 1996; Hryvniak &
Rosse, 1989). One study reported the prevalence of PTSD in patients with
schizophrenia and schizoaffective disorder as 28% and 37% respectively
(Mueser et al., 1998).
High rates of PTSD have been reported in criminal offenders (Spitzer
et al., 2001), juvenile delinquents (Fondacaro, Holt, & Powell, 1999;
Gibson et al., 1999; Steiner, Garcia, & Matthews, 1997), and mentally
disordered offender patients suffering from mental illness (Gray et al.,
2003, Papanastassiou, Waldron, Boyle, & Chesterman, 2004) or
personality disorder (Spitzer et al., 2001). One might also anticipate
high rates of PTSD in individuals with mental disorder, given the fact
that psychiatric patients report high rates of abuse and trauma in
childhood (e.g., Bebbington et al., 2004) and adulthood (Walsh et al.,
2003). It is not clear what effect the combination of psychiatric illness
and offending behaviour might have on reported trauma and PTSD
development. Although a number of recent studies have examined the
prevalence of PTSD in mentally disordered offenders in a hospital setting
(e.g., Gray et al., 2003; Papanastassiou et al., 2004; Spitzer et al., 2001)
none of these have included a comparison group of non-offender
psychiatric patients.

Aims
This study aimed to compare a group of forensic patients with a primary
diagnosis of paranoid schizophrenia with a control group of non-forensic
patients with schizophrenia. We hypothesised that, compared to the general
psychiatric patients, forensic patients would have:

. higher rates of trauma experiences

. higher rates of current and lifetime PTSD
662 J. Sarkar et al.
We further hypothesised that the two groups would differ in terms of:

. the type and severity of trauma experienced

. the age at which earliest and index trauma were experienced

Method
Subjects
Between January 2002 and July 2003, male forensic psychiatric inpatients
with a primary diagnosis of paranoid schizophrenia were opportunistically
recruited to the study from a medium secure unit in south London. They
were then matched according to age band and ethnicity with patients with
schizophrenia on general psychiatric wards. Exclusion criteria were:
inability to communicate in English, organic brain disease, learning
disability, severe affective disorder, or being considered too unwell to be
interviewed. Patients were interviewed by JS, OO, and AC after giving
informed consent.

Data collection
All subjects were interviewed, their case notes were scrutinised, and the
following information was collected: socio-demographic details, years of
education, and legal status (e.g., if voluntary or detained under the
Mental Health Act). All patients were also administered the following rating
scales:

. Trauma History Questionnaire (Green, 1996). This is an interviewer-

rated instrument, which consists of 24 items that enquire about a range
of traumatic events, under the main categories of: crime-related events,
unwanted physical and sexual experiences, and general disasters/
trauma. An additional question asks about ‘any other extraordinarily
stressful event or situation that is not covered above’. The scale also
includes a rating for the frequency of each trauma experienced, as well
the severity of distress experienced at the material time and currently, on
a visual analogue scale.
. PTSD Symptom Scale (PSS-I; Foa, Riggs, Dancu, & Rothbaum,
1993). This is a semi-structured interview designed to assess current
symptoms of PTSD, as defined by the DSM-IV (APA, 1994). The
PSS-I consists of 17 items corresponding to the 17 symptoms of PTSD
and yields a total PTSD severity score, as well as re-experiencing,
avoidance, and arousal sub-scores. Each item is rated by the interviewer
for severity and frequency. Severity is determined by a Likert-type rating
scale of 0 to 3, where 0 denotes not experiencing a particular symptom
 PTSD and paranoid schizophrenia 663
at all and 3 denotes experiencing the symptom five or more times per
week or almost always. The scale has high internal consistency (a ¼ .85)
and inter-rater reliability (k ¼ .91), and correlates strongly with the
Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, &
Williams, 1995).
. Personality Disorder Questionnaire Version 4 (PDQ-4; Hyler, Skodol,
Kellman, & Oldham, 1990). The PDQ-4 is an 84-item self-report
questionnaire that generates DSM-IV Axis II personality disorder
diagnosis. It is based upon an earlier version and has adequate
psychometric properties (Hyler et al., 1988). It has been found to be
a useful screening instrument among personality-disordered individuals
(Shine & Hobson, 1997) and has been previously used in a comparative
study of prison inmates and NHS patients (Dolan & Mitchell, 1994).

Results
An opportunistic sample of 55 patients, 27 from a medium secure unit and
28 from general psychiatric wards, participated in the study (Table I).
There was no significant difference between the two groups on the
following socio-demographic variables: age, ethnic minority group, employ-
ment in previous three years, and length of education. With respect to

Table I. Characteristics of forensic and general cases (n ¼ 55).

Forensic General
(n ¼ 27) % (n ¼ 28) % p value

Sociodemographic details
Age 33 38 .149
Ethnic minority status 62 48 .328
Unemployed in past 3 years 69 92 .075
Education in years .494
Psychiatric details
Voluntary status 12 54 5.001
Co-morbid clinical diagnoses
Personality disorder 15 0 .051
Substance abuse 27 22 .691
Drug induced psychosis 15 0 .051
History of treatment for PTSD 19 0 .023
Forensic history
Self-reported violence against the person 88 50 .004
Self-reported violence to property 62 46 .266
Convictions
Violent offences 70 15 5.001
Sexual offences 8 0 .111
Property offences 39 4 .111
664 J. Sarkar et al.
self-reported violence, the forensic group was significantly more likely to
report having been violent as an adult (88% vs 50%, p ¼ .004), although the
difference in terms of property offences was insignificant (62% vs 46%).
The forensic patients were significantly more likely than general psychiatric
patients to have convictions for violent offences (77% vs 11%, p 5 .001)
and for property (12% vs 0%) and sexual offences (12% vs 0%), although
statistics could not be validly employed in the latter two cases.
All the patients had a primary psychiatric diagnosis of schizophrenia. The
forensic group was significantly more likely to be compulsorily detained
under the 1983 Mental Health Act (88% vs 46%, p 5 .001). With regard
to co-morbidity, only the clinical diagnoses of personality disorder and
drug-induced psychosis were exclusively found in the forensic group.
However, only one patient (in the general psychiatric group) met the
criteria for a personality disorder, as assessed by the PDQ-4.

Trauma history
In all, 51 (93%) patients reported a history of trauma on the THQ, most
commonly for both groups in the category of general disaster/trauma (93%
forensic vs 71% general), followed by crime-related events (71% forensic vs
57% general). The next most common trauma was physical and sexual
experiences (44% forensic vs 25% general) for the forensic group and the
‘other’ category for the non-forensic group. Although there was no
significant difference between the groups on any trauma category, a larger
proportion of forensic compared to general patients experienced traumas of
all types (see Table II).
A total of 31 (60%) patients had experienced multiple types of traumatic
events; 19 (61%) in the forensic and 12 (39%) in the general group.
Forensic patients ( x ¼ 12, SD ¼ 11.1) reported a significantly higher
number of trauma incidents (repeated exposure) than the general group
(x ¼ 6, SD ¼ 6.6; t ¼ 2.31, df ¼ 52, p ¼ .025, 95% CI ¼ .746, 10.736). This
difference was mainly accounted for by an excess of physical and sexual
abuse in the forensic group (x ¼ 3) compared to the general group (x ¼ 0.4;
t ¼ 2.61, df ¼ 53, p 5 .12, 95% CI ¼ .549, 4.218). See Table III.

Table II. Types of trauma reported by forensic and general cases.

Forensic group General group

Type of trauma n (%) n (%) p value

Crime-related events 19 (71) 16 (57) .308

General disaster and trauma 25 (93) 20 (71) .078
Physical and sexual experiences 12 (44) 7 (25) .130
Other traumatic events 9 (33) 9 (32) .925
 PTSD and paranoid schizophrenia 665
Table III. Mean number of traumatic events reported by forensic and general cases.

Type of trauma Forensic General Mean diff (95% CI) p value

Crime-related events 2 2 0.14 (71.194, 1.478) 0.833

General disaster and trauma 6 3 2.48 (70.944, 5.907) 0.152
Physical and sexual experiences 3 0.4 2.38 (0.549, 4.218) 0.012
Other traumatic events 1 0.7 0.72 (70.564, 2.022) 0.263
Total 12 6 5.74 (0.746, 10.736) 0.025

Information on age at first traumatic experience was available for 49

(96%) cases. The mean age at first trauma for both groups combined was
14 years (SD ¼ 7.5, min ¼ 2 years, max ¼ 35 years), without any
significant difference between the groups. A history of trauma was
recorded in the case notes of a large proportion of cases (58% forensic vs
32% general), although these rates were much lower than questionnaire-
generated trauma events.

PTSD diagnosis
There were 15 patients (27%) who met the criteria for current PTSD and
22 (40%) for lifetime PTSD according to the PSS-I. The prevalence of
current PTSD was 33% for the forensic and 21% for the general group.
The prevalence of lifetime PTSD was 52% and 29% respectively. There
was no significant difference between the groups. Patients were significantly
more likely to meet the criteria for a lifetime diagnosis of PTSD if they had
experienced multiple traumas than if they reported a single traumatic event.
(w2 ¼ 7.8, df ¼ 1, p 5 .005).
In terms of self-reported PTSD symptoms, the only significant difference
was found in lifetime re-experiencing symptoms in the forensic group (85%
vs 54%, p ¼ .011), although there was a trend towards the forensic patients
reporting more PTSD symptoms than the general group in all categories.
There was also no significant difference between the groups in terms of
severity of symptoms, although forensic patients were more likely to report
more severe hyperarousal symptoms than general patients. On average,
forensic patients reported more severe symptoms both over the previous
month (2 – 4 times/week vs once/week or less by general patients) and
lifetime (5 or more times/week vs 2 – 4 times/week) compared with general
patients.

Discussion
This is the first UK study to examine the prevalence of PTSD in psychiatric
inpatients with a primary diagnosis of paranoid schizophrenia. Earlier
666 J. Sarkar et al.
reports have either been case studies (Harry & Resnick, 1986; Kruppa,
1991; Rogers, Gray, Williams, & Kitchiner, 2000) or patients with multiple
diagnoses (Gray et al., 2003; Papanastassiou et al., 2004).
Limitations of the study include the opportunistic selection of patients
from the secure unit and hospital wards and the small sample size. In
addition, the identification of trauma, although carried out using a
standardised measure, nevertheless relied on the patient’s accurate retro-
spective recall, as did the recording of post traumatic stress symptoms.
However, we found no evidence that patients were fabricating or
exaggerating their experiences, but rather the opposite, in that a number
of patients reported that this was the first time they had been asked, or been
willing to admit to certain past traumatic experiences.

Comparison with other studies

The overall rate of trauma exposure in the entire sample is comparable to
studies of patients with severe mental illness (Mueser et al., 1998), but
substantially higher than rates of lifetime trauma in community studies
(Kessler et al., 1995) and a diagnostically mixed group of non-forensic
psychiatric inpatients (MacFarlane, Bookless, & Air, 2001). The most
common trauma was violent victimisation including burglaries, robberies,
and physical and sexual assault.
The prevalence of current PTSD for the entire group was significantly
higher than general population figures (Davidson et al., 1991; Kessler et al.,
1995), but similar to rates found in non-forensic patients with schizo-
phrenia (Mueser et al., 1998), prison inmates (Powell, Holt, & Fondocaro,
1997), and personality disordered (Spitzer et al., 2001) or mentally ill (Gray
et al., 2003) forensic inpatients.
The prevalence of lifetime PTSD for the forensic patients was similar to a
diagnostically mixed group of mentally ill patients whose index trauma was
either murder or manslaughter (Papanastassiou et al., 2004). Being the
perpetrator of homicide is thought to lead to significantly higher PTSD
symptoms than other violent offences (Pollock, 1999; Gray et al., 2003),
although only one person in our sample had committed homicide and did
not identify it as the index trauma.

Reasons for high rates of trauma exposure and PTSD

It is recognised that severe mental illness increases an individual’s
vulnerability to violent victimisation in the community. A number of social
and psychological factors underlie the increased risk, including home-
lessness, urban living, poverty, substance misuse, and comorbid personality
disorder (Walsh et al., 2003). Social drift, whereby patients with severe
mental illness tend to live in socially disorganised and crime infested areas,
 PTSD and paranoid schizophrenia 667
also increases their vulnerability to violent victimisation (Goldberg &
Morrison, 1963).
The forensic patients in this sample had experienced higher rates of all
types of trauma, including assault and sexual violence, than the general
patients, and this may, in part, explain the very high rates of PTSD in this
group. It is recognised that individuals become sensitised to trauma the
earlier it occurs (Breslau, Chilcoat, Kessler, & Davis, 1999) and that the
psychiatric response to trauma is cumulative (Follette, Polusny, Bechtle, &
Naugle, 1996). Early experiences of trauma and abuse increase an
individual’s risk of repeat victimisation and developing PTSD as an adult
(Breslau et al., 1999; Follette et al., 1996; Maerker et al., 2004). Most
patients in this study reported their first experience of trauma in their early
teens and the forensic patients, in particular, had thereafter been exposed to
multiple traumas before developing PTSD in their early adulthood.
Although the rates of sexual and physical abuse were similar for both the
forensic and general psychiatric patients, the forensic patients had
experienced more incidents of abuse, and were also more likely to have
experienced multiple traumas of all types than the general psychiatric
patients.

Violence and PTSD in psychotic patients

An unexpected finding was the high rate of self-reported violence by
patients in the non-forensic group, albeit of a lesser gravity than that of
the forensic patients. PTSD can be associated with violence (Cauffman,
Feldman, Waterman, & Steiner, 1998; Gray et al., 2003; Papanastassiou
et al., 2004; Powell et al., 1997; Spitzer et al., 2001, Steiner et al.,
1997). Psychotic patients with co-morbid PTSD have more positive
psychotic symptoms, heightened paranoia, and more self-reported violent
thoughts, feelings, and behaviours than patients with psychosis or PTSD
alone (Sautter et al., 1999). The hyperarousal and re-experiencing
symptoms of PTSD may interact with persecutory delusions, thereby
increasing the potential for violent thoughts and feelings being translated
into action.
While early victimisation is known to predict later violence independently
(Walsh et al., 2003), it is recognised that previous victimisation is associated
with heightened feelings of threat and unsafety, which may result in
violence (Dodge & Somberg, 1987). A number of studies have found an
association between childhood abuse and neglect and later delinquency,
adult criminality, and violence (Hiday et al., 2001; Maxfield & Widom,
1996), resulting in the so-called ‘cycle of violence’ (Widom, 1989). Violent
victimisation is also known to cause intense anger and shame (Andrews,
Brewin, Rose, & Kirk, 2000), emotions that have been implicated in
violence (Chemtob, Hamada, Roitblat, & Muraoka, 1994; Gilligan, 1992).
668 J. Sarkar et al.
It is also suggested that excessive alcohol and drug use, as an attempt by
individuals with PTSD to self-medicate, increases the vulnerability to
further victimisation as well as the risk of violent behaviour (Sautter et al.,
1999; Swanson, Holzer, & Ganju, 1990). Even if PTSD does not lead to
violence, the experience of early physical abuse leads to distortion of social
cognition and attribution (Dodge et al., 1987), such that there is heightened
threat perception and risk of pre-emptive violence (Adshead & Mezey,
1997).

Lack of identification
No patient had received a diagnosis of PTSD, suggesting under-recognition
of the extent of trauma and trauma-related psychiatric illness (MacFarlane
et al., 2001; Mueser et al., 1998). This under-recognition may be due to a
tendency to adopt a hierarchical approach to diagnosing mental disorders.
The diagnosis of paranoid schizophrenia may lead to premature diagnostic
closure (Lundy, 1992), whereby either the psychotic disorder effectively
trumps the diagnosis of PTSD or leads to symptoms of PTSD being
overlooked altogether. Identification of the disorder is important in that
failure to diagnose and treat co-morbid PTSD in patients with psychotic
illness may result in more severe illness presentation (MacFarlane et al.,
2001), poorer response to conventional treatment (Hamner, 1996), and a
worse prognosis (Mueser & Butler, 1987).

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