Trauma and Serious Mental Illness

Dr. Frederika Theus
Licensed Clinical Psychologist
January 27, 2026

Understanding Trauma

Traumatic Events
→Rape/Sexual Abuse
→Physical Abuse
→Robbery
→Accidents
→Human Trafficking
→Emotional Abuse
→Combat
→Natural Disasters
→Sudden Death or Traumatic Experience of Loved One

PTSD Criteria

→Exposure to Actual or Threatened Death, Serious Injury, or Sexual Violence
→Intrusive Symptoms (May not appear distressing in children; may be reenacted in play)
→Persistent avoidance of Stimuli Associated with the Traumatic Event(s)
→Negative Alterations in Cognitions and Mood Associated with the Traumatic Event(s)
→Alterations in Arousal and Reactivity
→Disturbance Causes Clinically Significant Distress or Impairment
Understanding Serious Mental Illness 
(SMI)
Severe or Serious Mental Illness (1)

→Diagnosable mental, behavioral, or emotional disorder
→Substantially interferers with person’s life and ability to function
→Within the past year
→Over 18 years old
→Under 18 years old: “Serious Emotional Disturbance”
Via SAMHSA

Severe or Serious Mental Illness (2)

Typically
→Bipolar Disorder
→Schizophrenia
→Schizoaffective Disorder 
→Treatment-Resistant Major Depression

Sometimes
→Some Personality Disorders (BPD and Schizotypal)
→Severe/Chronic Anxiety Disorders
→PTSD
SMI and Substance Use Disorders
→Substance Use Disorders
→Considered a “psychiatric disorder”
→Not typically included as an SMI when occurring alone
→Substance Use Disorder often co-occurs with SMI

Bipolar Disorder
→Clear shifts in mood, energy, activity levels, and 
concentration 
→Often experience periods of extremely “up,” 
elated, irritable or energized behavior and 
periods of feeling “down,” sad, indifferent or 
hopeless
→Psychotic symptoms (hallucinations and/or 
delusions) may or may not be present 

Schizophrenia
→Significant impairments in perception of reality and 
changes in behavior
→Disorganized Behavior
→Disorganized Thinking
→Negative Symptoms
→Extreme Agitation or Slow Movements
→Cognitive Difficulties
→Persistent Delusions
→Persistent Hallucinations 
→Experiences of Influence, Control, or Passivity

Treatment-Resistant Depression
→Subset of Major Depression that does not respond to traditional and first-line treatments 
→Symptoms may be more severe 
→Depressive episodes may last longer 
→May have more episodes throughout the lifetime 

Schizoaffective Disorder
→Delusions 
→Hallucinations 
→Disorganized Thinking 
→Depressed Mood 
→Manic Symptoms 
Prevalence Rates

What we know…
→14.6 million American adults or 5.7% reported having SMI in 
the past year. 
→Via SAMHSA 2023 National Survey on Drug Use and Health
→Prevalence of specific disorders can be difficult to determine 
→Symptom overlap
→Complexity of diagnoses
→Varying methods for determining diagnoses
Prevalence by Type
→Schizophrenia and Related Psychotic Disorders – 0.25% - 0.64% (NIMH)
→Schizoaffective - 0.3% (less common than Schizophrenia)
→Bipolar Disorder – 4.4%
→Major Depression – 8.3%
→30% Treatment Resistant Depression (Zhdanava et al 2021)
→Borderline Personality Disorder – 1.4% - 5.9%
→Schizotypal Personality Disorder – 0.6% to 4.6%

Trauma Prevalence Estimates
General Population
→50 – 70% have experienced at least one traumatic event
People with SMI
→Far exceeds the general population
→Multiple traumas
→People with Psychotic Disorder have experienced at least one traumatic event
Adult Trauma and SMI

SMI – Physical Abuse
→Women – 75% 
→Men– 79%
SMI – Sexual Abuse
→Women – 57%
→Men – 25%

Domestic Violence
→Both men and women with SMI receiving psychiatric services are 2 – 8 times more likely to experience sexual and domestic violence
→Khalifeh et al (2014)
→Both men and women with Bipolar Disorder are more than 8 times more likely to report ever experiencing partner violence than people with no mental disorder
→Trevillion et al (2012)
Relationship Between Trauma, Stress and Severe Mental Illness
Stress-Vulnerability
→Genetic or biological vulnerability to psychosis and BPD
→People can withstand a certain amount of stressors
→Once someone’s stress threshold is reached, stress influences 
their neural processes
→Possible increased risk of psychosis and BPD

Stress-Vulnerability Model
Image: Four squares in a row, with arrows leading to the next square. The squares read childhood trauma, increased stress, stress influences vulnerable neural processes, and increased risk of psychopathology.
Stress-Sensitization
→Genetic or biological vulnerability and major stress may cause 
psychosis or BPD to emerge
→CT may intensify preexisting neurobiological vulnerability
→Less stress needed for recurring psychopathology and/or 
increased severity

Stress-Sensitization Model
Image: Four squares in a row with arrows leading to the next square. The squares read prenatal and perinatal insults, increased vulnerability, higher risk for SMI to emerge, and risk of increased severity and/or recurrence.
Trauma and SMI
People with SMI
→Physical Abuse – 45%
→Sexual Abuse – 35%
General Population
→Physical Abuse – 21%
→Sexual Abuse – 23%
Childhood Trauma and SMI
SMI – Physical Abuse
→Women – 54%
→Men– 58%
SMI – Sexual Abuse
→Women – 49%
→Men – 29%

Childhood Trauma and Psychosis
→Childhood Trauma linked to:
→Increased occurrence of psychosis
→More persistent psychosis
→Subclinical psychotic experiences

Childhood Trauma and Bipolar
→Childhood Trauma linked to:
→Increased Occurrence
→Earlier Age of First Episode
→Increased Severity
→Increased Rapid Cycling
→More frequent shifts between mood episodes
→Increased Risk of Suicidal Behavior
Childhood Trauma and Major Depressive Disorder (MDD)
→Childhood Trauma may: 
→Produce symptoms earlier 
→Create cycles that last longer and happen more 
frequently 
→Increase risk of morbidity 

Increased Trauma Risk and SMI
→Social Isolation
→Impulsivity
→Emotional Instability 
→Emotional Vulnerability
→Homelessness
→Difficulty Recognizing Risks
→Substance Misuse
→Emotional and/or Financial Abuse Related to the SMI

Trauma of SMI
→Experiencing SMI may be traumatizing
→Family Distress and Loss of Friends
→Social Stigma and Discrimination 
→Interpersonal Challenges
→Unemployment 
→Treatment and Hospitalization
→Intersection of Systems of Oppression
Trauma – SMI Cycle
Image: Four squares in a cycle, with arrows leading clockwise to the next square. The squares read Trauma/Revictimization, Mental Health Crisis, Trauma/ Revictimization, Mental Health Crisis, and back to trauma/revictimization.
Trauma Assessment Challenges (1)
→Limited confidence in self-reports
→Fears of exacerbating SMI symptoms
→Individual may be retraumatized by initial trauma-related questions and shut down
→May avoid talking about traumatic experience unless directly asked
Trauma Assessment Challenges (2)
→Diagnostic Overshadowing
→Highly distressing symptoms of 
SMI may block the importance of 
trauma symptoms for the 
clinician
→Symptom Overlap/Misinterpretation
→Intersectionality, Bias, and Diagnostic Overshadowing
→Race/Ethnicity
→Ability
→Gender Identity
→Sexual Orientation
Symptom Overlap: PTSD vs. SMI (1)
PTSD
→Flashbacks
→Memories of traumatic events
→Avoidance of trauma 
stimuli/reminders
→Over-arousal
→Racing thoughts
→Easily startled
→Physical responses
SMI
→Hallucinations
→Delusions
→Negative symptoms
→Lack of interest/enjoyment
→Lack of motivation
→Lowered emotional expression
→Mania

Symptom Overlap: PTSD vs. SMI (2)
→Psychotic symptoms including hallucinations, delusions, and 
paranoia can occur secondary to PTSD
→Not considered a “Psychotic Disorder”

Trauma-Informed Care
→Evidence-based trauma treatments are not offered routinely to people with SMI, such as those with psychotic symptoms
→SAMHSA recommends all treatment programs implement a trauma-informed approach
→Recognizes signs of trauma
→May or may not include trauma-specific treatments
→Policies and practices geared to avoid retraumatization
Helping Survivors Cope with Symptoms

Deep Breathing
Image: Four squares in a cycle, with arrows leading clockwise to the next square. The squares read threat, fear/anxiety, deep breath, hyperventilate, fear/anxiety, and back to threat.
Breathing Retraining
→Unless preparing for a truly dangerous situation we do not really need deep breaths
→What we really need is less air and slow breathing
→Decreases negative thoughts by being mindful of the present moment
→Paranoia - “Clear your head so you can think straight” rather than “relax”
→Early step in the Cognitive Restructuring (CR) for PTSD program
→Mueser & Gottlieb (2025)
Benefits of Breathing Retraining
→Decreases arousal, anxiety and other PTSD symptoms 
→Focuses attention when not anxious
→Relaxes the body, decrease fight/flight/freeze response
→Can be use in the moment or preemptively 
How to Retrain Breathing
→Choose a word you find relaxing (usually one syllable, ex. “Calm”) 
→Take a regular breath (not deep)
→Exhale very slowly through the mouth while saying your relaxing word
→Pause before taking your next normal inhalation (count of four)
→Practice several times a day, 10 to 15 breaths

Let’s Practice

Retraining your breathing [video link and transcript shared in email]
Coping with SMI and Trauma Symptoms (1)
Non-stressful actions requiring concentration
→Reading/Studying
→Sub-Vocalizing (ex. reading aloud or singing under your 
breath)
→Household Repairs
→Crafts

Coping with SMI and Trauma Symptoms (2)
Engage the senses 
→Find and Point to 5 different objects in the room. Say the name out loud. 5 Rounds
→Hold a small object and focus on how it feels
→Sip a non-alcoholic beverage
→Listen to instrumental music
→Sensory Soothing – warm bath, weighted blanket
→Hum
→Insert one ear-plug

Coping with SMI and Trauma Symptoms (3)
→Distraction (ex. do an easy chore) 
→Does not tend to be effective long-term 
→Do something constructive/self-esteem building 
→Establish or re-establish structure and routine 
→Address sleep hygiene 
Coping with SMI and Trauma Symptoms (4)
→Build upon healthy coping strategies already or 
previously used
→Social contacts
→Spirituality
→Hobbies
→Exercise
Coping with SMI and Trauma Symptoms (5)
→If receiving mental health services, follow established 
action plan 
→Contact mental health provider or seek emergency 
services in accordance with action plan

Helping Others to Regulate (1)
→Acknowledge emotions without escalating them (ex. “It sounds like you are worried.”)
→Keep your language clear, simple and nonjudgmental 
→Do not over-engage
→Adjust the environment (ex. increase or decrease lighting, offer distractions, attend to noise)
Helping Others to Regulate (2)
→Avoid arguing or challenging delusions and hallucinations while not buying into them
→Respond honestly
→If they are frightened offer calm reassurance (ex. “I’m here with you.”)
→Offer comforting touch if appropriate and with consent
→Maintain clear emotional and physical boundaries 
Helping Others to Regulate (3)
→Encourage and assist in obtaining trauma-informed mental health care
→Assist in connecting with support groups through established organizations (ex. NAMI)
→ALWAYS seek emergency assistance if symptoms create danger to self or others

Q and A