Download The relationship between trauma and psychosis

The relationship
between trauma and
psychosis
Presenter: Ron Unger LCSW
541-513-1811
[email protected]
Psychosis: the last holdout for
those who deny the role of trauma
 In
1975 the Comprehensive Textbook
of Psychiatry, a respected source of
information, estimated the
prevalence of incest to be 1 in a
million
 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.
From an official “Illness
Management and Recovery”
handout:
 “What
causes schizophrenia?
 “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.”
Three levels of possible
relationship between trauma and
psychosis:
1 Trauma, especially childhood sexual trauma, can
cause psychosis later
2 Having psychotic symptoms can in itself be
traumatizing
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

Further trauma can cause more psychosis, in a
vicious circle
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.
The Evidence that Trauma can
Cause Psychotic Symptoms:





The high incidence of psychotic symptoms in
people who have been traumatized
The high incidence of trauma histories in people
who have psychotic symptoms
Studies that show the greater the severity of the
trauma, the greater likelihood of more, and more
intense, psychotic symptoms
Brain changes sometimes linked with psychotic
symptoms are also found in many children and
adults with PTSD
There are logical and meaningful connections
between psychotic symptoms and traumatic
experience
Why the mental health system fails
to see the connection

If biological and physical factors explain
some psychoses, it is then hoped they will
explain them all
– Especially by the drug companies!
Historical period where some practitioners
were too quick to assume abuse by
particular individuals
 The difficulty in understanding people with
psychosis

– And the fear by some that understanding
“crazy people” means that oneself is “crazy!”
Client: What's
causing these
weird
experiences?
Therapist: We can
diagnose you with the
illness called
schizophrenia because
you have weird
experiences.
Therapist: These
weird experiences are
being caused by your
illness, which is
schizophrenia
Client: How do you
know that I have an
illness called
schizophrenia?
How the Stress/Vulnerability model
was hijacked
 The
idea is that “vulnerable” people,
when subject to excess stress,
become psychotic
– Biological psychiatry quickly adopted
this model, with “vulnerability” assumed
to be always biological, such as genetic
etc.
 But
psychological trauma, as well as
certain other experiences, can also
lead to vulnerability
The PTSD model of how trauma
“makes psychosis worse”
 Argues
that “schizophrenia” is a real
illness independent of trauma, but
that trauma can make a mild case
much worse
 Problems of this model:
– Continues to discuss schizophrenia as if
it were a meaningful construct, when it
is not
– Ignores evidence that trauma can cause
psychosis
Understanding why trauma
causes much more than just
“PTSD”


A PTSD diagnosis requires symptoms that can be
identified as revolving around the trauma
There must be at least one of the following:
–
–
–
–

recurrent recollections, or
distressing dreams that relate to the trauma or
acting or feeling as though it's reoccurring,
or distress at exposure to external or internal cues that
symbolize or resemble the event.
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.
The dissociation model of
psychosis
 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
Speaker of the
thought
Hearer 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.
Speaker of the
thought:
an “alter”
Hearer of the
thought:
another
“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 sharing a body with other personalities or
selves.
Speaker of the
thought:
a “voice”
Hearer of the
thought:
Identified
“self”
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.
Basic split that happens with
trauma
 One
part of self wants to clearly see
the danger
 One part wants to block perception
of the danger in order to prevent the
over-arousal that will shut down the
system and make higher functioning
impossible
– This leads to the terror/numbing cycle
common in PTSD etc.
Two types of hallucinations
and/or delusions:

Those whose function is to get the person
to see the danger that they may have
been blocking out
– These are on a spectrum with “flashbacks” that
are common after trauma

Those whose function is to protect the
person from being overwhelmed by what
they are afraid of
– These are on a spectrum with dissociation, the
ability to separate from experience that is
overwhelming
 All
types of grandiosity can be understood as having
a protective function
Key Difference between a
flashback and a hallucination:

In a flashback, there is the recognition
that what one is experiencing now is
related to the past trauma
– But when a trauma has been especially
overwhelming or denied, this recognition itself
is blocked
– A hallucination is often just a “flashback” type
of experience where the connection to the past
is overlooked or denied.
Hypervigilant:
Afraid of not seeing
a threat that may be
present
Blocks out or
looks away
from signs of
danger
Anxious, aroused,
perceiving a threat
in the absence of
good evidence
Interprets self as overreacting: afraid of going
mad or appearing mad
Confusion caused by co-existence of hypervigilance and blocking perceptions
Dissociation, memory disturbance,
and delusions
 Implicit
memory that gets triggered
could lead to mistaken attributions to
the present context
– To someone who doesn’t understand the
context (which can include the client
when memory is not explicit) behaviors
can seem bizarre and disorganized
Bizarre delusions, such as thought
withdrawal and/or insertion,
delusions of control
 These
sort of “delusions” occur in
one-third to two-thirds of individuals
diagnosed with Dissociative Identity
Disorder
 Can easily be understood in terms of
interactions between “alters” or
subsystems created by dissociation
Paranoia can be seen as
hypervigilance around issues of
betrayal
 I’ve
seen most commonly in people
who were seriously abused at a
young age
– Their trust was never very strong, then
something shattered it
– Example
Is trauma responsible for all
psychotic symptoms?

Lots of factors, not just trauma, contribute to
vulnerability
– Most of these factors, like trauma, have a disorientating
effect



Such as drug use, lack of sleep, brain damage for some,
mistaken beliefs,
even lack of good social support can be understood to be
disorientating
But trauma also contributes to many of the above
factors
– Such as a traumatized person is more likely to use
substances, or to lose sleep, or to have damaged
support systems

And as vulnerability increases, stresses in the
environment become increasingly traumatizing,
which is what sends people “over the edge”
Catastrophic Interaction Model

That there are a number of routes by
which severe trauma may tip someone
toward psychosis
– When various processes occur together, then
there is a bifurcation into psychosis

For example:
– Intrusive trauma memories
– Processing biases like overestimation of
danger, or jump to conclusions
– Negative opinions about self lead to greater
distress about hallucinations that occur
The bottom line:
 We
need to study, rather than deny,
the connection between trauma and
psychosis
 We need to recognize that there is
generally a story to how people came
to be mentally troubled
 Then we can join with them in
creating a story of recovery, rather
than retraumatization and chronic
“illness”
Finding out about trauma
 Need
to ask
– Often clients won’t say if not asked
– Seldom harmful to ask, often harmful
not to ask
 How
to ask:
– Prepare person
– Make questions specific
– Know how to respond
Consider the possibility of selfimposed trauma
Where the clients beliefs and attitudes
caused a situation to be traumatic that
otherwise would not have been
 Physical trauma definitions allow for
possibility that trauma was self inflicted,
by accident or otherwise

– Why not psychological trauma definitions?

Seeing a story where the client adopted
beliefs that led to a trauma experience,
suggests client could adopt different
beliefs & handle situations differently in
the future
– Unlike in “mental illness” explanations
Integrating trauma and cognitive
theory

All psychological trauma can be
understood in terms of mistakes made in
responding to experiences
– Understandable, and difficult to avoid making,
but still mistakes
– Which accounts for why some are
“traumatized” and some not, by the same
experience

Recovery involves learning alternative
ways of seeing and responding
Trauma and extreme states
A
key mistake in responding to
trauma is going to an extreme
– Which may be necessary at the time,
but then a person may get stuck in it
 An
example: either trying to block out an
experience, or recalling it so vividly it seems
overwhelming in the present
 When both of these happen at once, the
person may make a psychotic interpretation
Mental Health System goes to
extremes in response…..
 When
clients are effective enough in
blocking out distress that its source
is no longer obvious, then the mental
health system often joins with them
in not seeing the source either
–
Giving in to, or
appeasing, the
voices
Mindfulness:
being aware of
the voices but
not responding
one way or the
other, or feeling
a clear ability to
choose how to
respond to them
based on
multiple factors
Fight or flight:
arguing with
voice or
running from
them, such as
through
distraction
Picture world
as good and
positive, to
comfort self
and feel
relaxed.
Notice dangers
that are
prominent but
also possible
areas of safety.
Try to picture
world accurately
in regards to
safety versus
danger.
Picture world
as dangerous,
so that one
won’t be
overwhelmed
by any risks
that weren’t
anticipated
Block out the
trauma or
distress…it
just doesn’t
exist…numb.
The trauma or
stress is
accepted as part
of the story, but
the story is still
ongoing and is
free to move in
positive
directions
The trauma or
stress
intrudes into
everything, it
seems to be
happening
right now and
is
overwhelming
I think or feel it
– therefore it
is true, even if
everyone else
says it isn’t.
I can check in
with myself and
with others, and
make a
conclusion
based on what I
notice. If I find
later there is a
problem with
my decision, I
will change my
mind.
My thoughts
and feelings
are unreliable,
and others
have so many
different
opinions –
there is no
way to decide
what is true
If something is
worthwhile, I
must keep
working
towards it no
matter how
much I suffer.
I can work
toward things
and see what
happens. If the
stress is too
much, I can let
go, at least for
awhile, then I
can resume
where I left off.
Working
towards
things leads
to disaster
and
impossible
stress, so it’s
better to give
up before I
start.
I define myself
completely
independently
of others. If I
say I am
captain of a
spaceship,
then I am.
I negotiate my
identity with
others. My
identity
emerges out of
the mix of what I
propose and
what I do, and
how others see
what I propose
and what I do.
I am mentally
ill or
incompetent, I
cannot define
myself.
Others tell me
who and how I
am.
I define myself
completely
independently
of others. I am
invulnerable.
I negotiate my
identity with
others. In
general I care
how others see
me but I am not
a captive of the
perspective of
others. I decide
what to make of
how they see
me.
I am
completely
vulnerable to
how others
see and
define me.
Often I can’t
stand to be
looked at
because of
what might
happen to me.
Consumer: I
think or feel it,
therefore it is
correct.
Cognitive
approach: let’s
share some
perspectives on
where the
distress here
may be coming
from & how to
resolve it. Each
of us may be
making some
mistakes ……
Mental Health
system: This
person is
wrong and
mentally ill,
therefore we
must take
control away
from her and
decide for her.
Totally
focused on
autonomy:
self defining,
others have no
input or
connection.
Some mix of
autonomy with a
sense of
belonging,
sometimes self
asserting, other
times relaxes
and lets others
define self.
Comfortable
intimacy with
coexisting
sense of
independence.
Totally
focused on
belonging:
has no self
definition,
completely
defined by
others.
External World
Impulse
That which
one
consciously
identifies
with
Emotion
Memories
Thought
Voice
Internal representations of others
Our culture expects us to define anything that is not “the external world” as part of our self.