When Trauma and Psychosis Mix

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Outlines some of the relationships between trauma and psychosis and schizophrenia, which are usually ignored by the mental health establishment. This is a presentation that will be given at the Oregon State Hospital on April 22, 2009.
I also provide a 6 hour online course on this topic, with 6 CE credits, go to https://www.udemy.com/working-with-trauma-dissociation-and-psychosis/ for more information, to watch some free previews, and to register.

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When Trauma and Psychosis Mix

  1. 1. When Trauma and Psychosis Mix Presenter: Ron Unger LCSW 541-513-1811 [email_address]
  2. 2. Defining Psychological Trauma <ul><li>DSM focuses on perceived physical threat </li></ul><ul><ul><li>But this is somewhat arbitrary </li></ul></ul><ul><li>Psychological impact is key </li></ul><ul><ul><li>Trauma is created by a combination of sense of overwhelming threat, or terror, with helplessness </li></ul></ul><ul><ul><li>It’s not a specific type of event, but our appraisal of the event, which causes psychological trauma </li></ul></ul>
  3. 3. Psychosis: the last holdout for those who deny the role of trauma <ul><li>In 1975 the Comprehensive Textbook of Psychiatry, a respected source of information, estimated the prevalence of incest to be 1 in a million </li></ul><ul><li>Since then, a lot has changed regarding recognition of the existence and role of trauma, but not for those with psychosis, especially in the U.S. </li></ul>
  4. 4. From an official “Illness Management and Recovery” handout: <ul><li>“ What causes schizophrenia? </li></ul><ul><li>“ Schizophrenia is nobody’s fault. This means that you did not cause the disorder, and neither did your family members or anyone else. Scientists believe that the symptoms of schizophrenia are caused by a chemical imbalance in the brain.” </li></ul>
  5. 5. The Evidence that Trauma can Cause Psychotic Symptoms: <ul><li>The high incidence of psychotic symptoms in people who have been traumatized </li></ul><ul><li>The high incidence of trauma histories in people who have psychotic symptoms </li></ul><ul><li>Studies that show the greater the severity of the trauma, the greater likelihood of more, and more intense, psychotic symptoms </li></ul><ul><li>Brain changes sometimes linked with psychotic symptoms are also found in many children and adults with PTSD </li></ul><ul><li>There are logical and meaningful connections between psychotic symptoms and normal reactions to traumatic experience </li></ul>
  6. 6. Three levels of possible relationship between trauma and psychosis: <ul><li>1 Trauma, especially childhood sexual trauma, can cause psychosis later </li></ul><ul><li>2 Having psychotic symptoms can in itself be traumatizing </li></ul><ul><li>3 The response by others to one’s psychosis, such as the response of the mental health system, of friends, of family, and of society, can also be traumatizing </li></ul><ul><li>Further trauma can cause more psychosis, in a vicious circle </li></ul>
  7. 7. Trauma (involves perceived need to reorganize in a radical way.) Psychosis (disorganization or mistaken way of being organized.) Trauma (involves perceived need to reorganize in a radical way.) Psychosis (disorganization or mistaken way of being organized.)
  8. 8. Peter Bulimore’s story illustrates all three levels of trauma, as well as why it is so important for the mental health system to begin to understand these issues.
  9. 9. What is the impact when the possible link between trauma & psychosis is denied? <ul><li>Trauma is often not even asked about, much less discussed </li></ul><ul><ul><li>Potentially, through decades of treatment </li></ul></ul><ul><li>Understandable reactions to trauma may be defined as non-understandable </li></ul><ul><li>Psychotherapy for trauma is denied </li></ul><ul><li>Even self-understanding may be discouraged </li></ul>
  10. 10. Why is the role of trauma in causing psychosis commonly denied? <ul><li>It is hoped that since some psychosis has a biological explanation, all of it will prove to have a biological explanation </li></ul><ul><li>Evidence of genetic causation is commonly exaggerated </li></ul><ul><li>Tendency to believe that if biology is involved at all, it must be primary </li></ul><ul><li>If seen as not primarily biological, then power of psychiatrists & pharmaceutical companies would be reduced </li></ul><ul><li>Denial of trauma has lessened overall, but this hasn’t yet reached the field of psychosis </li></ul>
  11. 11. Why is the role of trauma in causing psychosis commonly denied? (continued) <ul><li>Past overly simplistic judgments and assumptions by some of those who did see a role for trauma in causing psychosis </li></ul><ul><li>Biological explanations seem much simpler </li></ul><ul><li>Biological model is easier for bureaucrats to deal with </li></ul><ul><li>Idea that if trauma causes a mental problem, it will be PTSD </li></ul>
  12. 12. The PTSD model of how trauma “makes psychosis worse” <ul><li>Argues that “schizophrenia” is a real illness independent of trauma, but that trauma can make a mild case much worse </li></ul><ul><li>Problems of this model: </li></ul><ul><ul><li>Ignores evidence that trauma can cause psychosis, not just make it worse </li></ul></ul><ul><ul><li>Leads to seeing “schizophrenia” as a a “thing in itself” separate from the response to trauma, when it may not be </li></ul></ul>
  13. 13. Understanding why trauma causes much more than just “PTSD” <ul><li>A PTSD diagnosis requires symptoms that can be identified as revolving around the trauma </li></ul><ul><li>There must be at least one of the following: </li></ul><ul><ul><li>recurrent recollections, or </li></ul></ul><ul><ul><li>distressing dreams that relate to the trauma or </li></ul></ul><ul><ul><li>acting or feeling as though it's reoccurring, </li></ul></ul><ul><ul><li>or distress at exposure to external or internal cues that symbolize or resemble the event. </li></ul></ul><ul><li>But if a person successfully avoids thinking about or processing the trauma in an obvious way, then there will be no symptoms that clearly revolve around the trauma. </li></ul>
  14. 14. Common factors in PTSD and psychosis: <ul><li>High arousal & hypervigilance </li></ul><ul><li>Sleep disturbance </li></ul><ul><li>Avoidance </li></ul><ul><li>Emotional numbing </li></ul><ul><li>Selective Attention </li></ul><ul><li>Safety behaviors </li></ul><ul><li>Dysfunctional thought control strategies </li></ul><ul><li>Expressed emotion causes relapse </li></ul><ul><li>Dissociation </li></ul><ul><li>Intrusive phenomena: thoughts, sensory, emotions </li></ul>
  15. 15. Is trauma responsible for all psychotic symptoms? <ul><li>Lots of factors, not just trauma, contribute to vulnerability </li></ul><ul><ul><li>Most of these factors, like trauma, have a disorientating effect </li></ul></ul><ul><ul><ul><li>Such as drug use, lack of sleep, brain damage for some, mistaken beliefs, </li></ul></ul></ul><ul><ul><ul><li>even lack of good social support can be understood to be disorientating </li></ul></ul></ul><ul><li>But trauma also contributes to many of the above factors </li></ul><ul><ul><li>Such as a traumatized person is more likely to use substances, or to lose sleep, or to have damaged support systems </li></ul></ul><ul><li>And as vulnerability increases, stresses in the environment become increasingly traumatizing, which is what sends people “over the edge” </li></ul>
  16. 16. Catastrophic Interaction Model <ul><li>That there are a number of routes by which severe trauma may tip someone toward psychosis </li></ul><ul><ul><li>When various processes occur together, then there is a bifurcation into psychosis </li></ul></ul><ul><li>For example: </li></ul><ul><ul><li>Intrusive trauma memories </li></ul></ul><ul><ul><li>Processing biases like overestimation of danger, or jump to conclusions </li></ul></ul><ul><ul><li>Negative opinions about self lead to greater distress about hallucinations that occur </li></ul></ul>
  17. 17. How the Stress/Vulnerability model was hijacked <ul><li>The idea is that “vulnerable” people, when subject to excess stress, become psychotic </li></ul><ul><ul><li>Biological psychiatry quickly adopted this model, with “vulnerability” assumed to be always biological, such as genetic etc. </li></ul></ul><ul><li>But psychological trauma, as well as certain other experiences, can also lead to vulnerability </li></ul>
  18. 18. Why trauma causes problems in integrating experiences <ul><li>Ordinarily, the h ippocampus serves to bind individual features of incoming information into a spatial/temporal context </li></ul><ul><ul><li>Then info goes to amygdala </li></ul></ul><ul><li>But when trauma is too intense, info goes straight to the amygdala </li></ul><ul><ul><li>Resulting in memory fragments that contain high affect </li></ul></ul><ul><ul><ul><li>With no context </li></ul></ul></ul>
  19. 19. Decontextualized trauma flashbacks can easily become psychosis <ul><li>Psychotic interpretations of the activation of trauma memories </li></ul><ul><ul><li>Like a voice that echoes meanings first encountered during trauma </li></ul></ul><ul><ul><li>Or “emotional flashbacks” </li></ul></ul><ul><ul><li>Even “body memories” </li></ul></ul>
  20. 20. Key Difference between a flashback and a hallucination: <ul><li>In a flashback, there is the recognition that what one is experiencing now is related to the past trauma </li></ul><ul><ul><li>But when a trauma has been especially overwhelming or denied, this recognition itself is blocked </li></ul></ul><ul><ul><li>A hallucination is often just a “flashback” type of experience where the connection to the past is overlooked or denied. </li></ul></ul>
  21. 21. Let the experience intrude so vividly it seems to be happening right now: The experience is so vivid I get retraumatized just by having it, and I still don’t put it in context. Refuse to let the experience intrude: I stop the experience from retraumatizing me right now, but I also fail to integrate it so I will run into problems with it later. I let the experience occur, but I have ways of reducing its intensity by changing my reaction to it: I can note that reduced intensity and remind myself it is not a current threat. I gradually put it into a context. Spectrum of ways de-contextualized experiences/memories can be dealt with
  22. 22. Focus on defending against external threat, guard against feeling too safe internally: to maintain vigilance. Focus on maintaining internal sense of safety, guard against perceiving too much external threat: to maintain stability. Guard against either ignoring threats or seeing exaggerated threat: I seek to be vigilant but not hypervigilant, to maintain a feeling of safety without being oblivious. Two Extremes in Seeking Safety, Not Very Compatible……
  23. 23. Two types of hallucinations and/or delusions: <ul><li>Those whose function is to get the person to see the danger that they may have been blocking out </li></ul><ul><ul><li>These are on a spectrum with “flashbacks” that are common after trauma </li></ul></ul><ul><li>Those whose function is to protect the person from being overwhelmed by what they are afraid of </li></ul><ul><ul><li>These are on a spectrum with dissociation, the ability to separate from experience that is overwhelming </li></ul></ul><ul><ul><ul><li>All types of grandiosity can be understood as having a protective function </li></ul></ul></ul>
  24. 24. Trauma reminder seen as current threat Over-react to trauma reminder Experience bad consequences from one’s over-reaction Prepare to react even more strongly to such “threats” in the future Attribute bad consequences to the perceived threat itself, not to the over-reaction
  25. 25. Vicious Circle of Trauma and Paranoia <ul><li>Interpersonal betrayal, trauma </li></ul><ul><li>Develop beliefs, self as weak, others as bad </li></ul><ul><li>Automatic thoughts and/or voices reinforce negative view of self </li></ul><ul><li>Hypervigilance for threat leads to seeing more of it </li></ul><ul><li>Efforts to defend self against perceived threat are seen as inappropriate by others, </li></ul><ul><li>Aggressive response by others is perceived as……. </li></ul>
  26. 26. Possible origin of some voices in effort to block trauma related intrusions Trauma Interpret trauma memories as a threat, attempt to block Voices form to overcome blocks & raise issues related to trauma Interpret voices as a threat, become emotionally distressed, attempt to block or distract from voices Voices increase in volume & frequency as emotional distress and blocking increases
  27. 27. It is the “blocking” itself that gives an intrusion its power <ul><li>Trying to get rid of the “madness” is actually part of the madness </li></ul><ul><li>“ The way out of hell is through the center” </li></ul><ul><ul><li>Just accepting the trauma, just accepting the intrusion or unwanted “psychotic” experience, allows us to put it into perspective for what it is </li></ul></ul><ul><ul><li>And it’s putting it into perspective, into context, that allows us to move on </li></ul></ul>
  28. 28. Trauma Seeking control & toughness to deal with trauma Voices appear as an internal representation of what cannot be controlled Voices are interpreted as a threat to sense of control, so attempts are made to control them Voices “feed” off the tension involved in efforts to control them: they increase Life goes increasingly out of control as preoccupation with the voices goes up
  29. 29. Effect of dissociation on self-organization of dissociated content <ul><li>Whatever is not integrated in some way may take on a life of its own </li></ul><ul><li>Content not yet integrated may be simple or complex </li></ul><ul><ul><li>From automatic thoughts, emotions, memory fragments </li></ul></ul><ul><ul><li>To mood states, perspectives, voices </li></ul></ul><ul><ul><li>To complex identity states seen as “alternate personalities” or alien entities </li></ul></ul>
  30. 30. Comparing “dissociative voices” with “psychotic voices” <ul><li>No significant reliable differences have been found between the voices of those diagnosed with “schizophrenia” and discussions between alters in those diagnosed with dissociative identity disorder </li></ul>
  31. 31. Hearer of the thought Speaker of the thought Normal identity in our culture: we see ourselves both as who is saying or “thinking” the thought to ourselves, and as the person who is registering or hearing the thought. Our identity is not centered in either saying or hearing the thought.
  32. 32. Hearer of the thought: another “ alter” Speaker of the thought: an “alter” Dissociative identity: person may have a conversation with “alternate personalities” within themselves. At any given moment, a person may see themselves as a particular personality or self listening to or talking to another personality or self that shares the same body.
  33. 33. Hearer of the thought: Identified “ self” Speaker of the thought: a “voice” Hearing voices: Person sees thought as coming from outside themselves. They may be “heard” as though spoken aloud, or just heard “inside one’s head” but there is the sense or the belief that they are coming from something completely outside the self.
  34. 34. Bizarre delusions, such as thought withdrawal and/or insertion, & delusions of control <ul><li>These sort of “delusions” occur in one-third to two-thirds of individuals diagnosed with Dissociative Identity Disorder </li></ul><ul><li>Can easily be understood in terms of interactions between “alters” or subsystems created by dissociation </li></ul>
  35. 35. My feelings and emotions tell me what is real:   if I'm feeling down then I'm doing terrible, if I feel scared, then I’m in danger, etc. My feelings and emotions are my enemy:   I need to block them out (or drug them away) My feelings and emotions give me suggestions about what may be real.  I decide whether they are accurate or not. If they are accurate, I act on them, if not, I just accept them and let them go. “ Emotional Reasoning” versus Not Tolerating Emotions
  36. 36. My voices tell me what is real:   if they tell me I’m doing terrible then I am, if they tell me I’m in danger then I am, etc. My voices are my enemy:   I need to block them out (or drug them away) My voices give me suggestions about what may be real.   I decide whether they are accurate or not. If they are accurate, I act on them, if not, I just accept them and let them go. Dominated by Voices vs. Overly Distressed by Voices
  37. 37. Excess focus on conflict: I am always ready to do battle with the voices, my goal is to drive them out of existence. Excess focus on appeasement: It’s better to give in to the voices, even when they are unreasonable, rather than risk upsetting them. Focus on living a good life: I don’t waste energy opposing the voices just for the sake of conflict, but if they push for something that will harm my life, I will stand firm against it. Excess focus on conflict vs. excess focus on appeasement
  38. 38. How can understanding the relationship between trauma & psychosis inform treatment? <ul><li>Cognitive therapy for psychosis is an evidence based approach that helps clients appreciate the impact of stressful events, including trauma, on their mental state </li></ul><ul><ul><li>This provides an alternative to either psychotic explanations or strictly medical model explanations that may induce helplessness </li></ul></ul>
  39. 39. Other trauma therapies can be integrated with CBT for psychosis <ul><li>First use CBT for psychosis to provide an alternative to psychotic interpretations </li></ul><ul><li>Then introduce a cognitive approach to trauma, to provide a framework for understanding </li></ul><ul><li>Then proceed to more experiential or desensitizing approaches </li></ul><ul><ul><li>Proceeding cautiously, being willing to go back to earlier stages when necessary </li></ul></ul>
  40. 40. When desensitization is effective: <ul><li>Trauma flashbacks and/or psychotic intrusions become simply memories or thoughts </li></ul><ul><ul><li>That are put into an understandable and manageable context </li></ul></ul><ul><ul><li>That are neither avoided nor overly attended to </li></ul></ul><ul><li>Once they are put into context no “illness” remains </li></ul>
  41. 41. Experiential Avoidance: Attempts are made to not have thoughts, emotions, impulses, perceptions etc. which are evaluated as “bad.” Emotional reasoning or fusion: Emotions and other mental content is just taken as true in itself, and allowed to determine the person’s direction, without rational criticism. Some ability to practice mindfulness: Willingness to experience whatever is in one’s mind, but also able to disengage from it and see other perspectives. Mindfulness as a middle ground between experiential avoidance and fusion
  42. 42. Temptation: to join conscious self in attempt to eliminate “the symptom” <ul><li>This applies to voices, alters, unwanted emotions, thoughts, and impulses </li></ul><ul><li>Integration, rather than elimination, is a better goal </li></ul><ul><ul><li>Though once integrated, “symptoms” can seem to “disappear” </li></ul></ul><ul><li>To start with, join with conscious self around goal of reducing distress </li></ul><ul><ul><li>Then you can evaluate elimination versus integration as two possible strategies </li></ul></ul><ul><ul><ul><li>Notice which is more helpful </li></ul></ul></ul>
  43. 43. The bottom line: <ul><li>We need to study, rather than deny, the connection between trauma and psychosis </li></ul><ul><li>We need to recognize that there is generally a story to how people came to be mentally troubled </li></ul><ul><li>Then we can join with them in creating a story of recovery, rather than retraumatization and chronic “illness” </li></ul>

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