Childhood Trauma, Delusions and Memory

Childhood Trauma, Delusions and Memory Trauma, Dissociation and Psychosis conference 23 May 2019 Kristiansand, Norway

Based on Moskowitz, A. & Montirosso, R. (2019) Childhood experiences and delusions: Trauma, memory and the double bind. in Psychosis, Trauma, and Dissociation (2nd ed) Moskowitz, A., Dorahy, M. J. and Schäfer, I. Chichester, UK: Wiley, pp. 117-139.

Disorganized Attachment (DA) and the double bind –Apologies! • Many parallels between the historic double bind theory of schizophrenia and recent theories and research on connections between DA and dissociation • Child must maintain relationship with attachment figure at all costs • Which includes the denial/repression/dissociation of its reality • These denied/repressed/dissociated aspects can be re-experienced later on and form the basis for delusions • The model presented here would apply to very early childhood experiences, except that (probably) narrative memories have never been formed

Other sychotic symptoms in relation to trauma and dissociation • Disorganized speech and behavior • Catatonia and other apparently irrational behaviors • Thought disorder? • from Michael Robbins’ ‘The language of schizophrenia’ (2002) • ‘But why do you talk [write] this way [and not more clearly]?’ • ‘Some people try to intimidate people; I intimate people. Relationships are too difficult, so I word my way into a relationship with letters. I’d like to work my way into your hearts without working my way in, and without mentioning things that would work my way out of your hearts’ (p. 392).

Outline • The tragic case of Judge Daniel Schreber • Delusions – definitions and models • Connections between trauma and delusions • Memory and the relation between trauma and delusions • The retrieval in adulthood of implicit/body childhood memories • Interpretations of Schreber, and Schreber’s father • What purposes do delusions serve? • How can delusions be treated?

Judge Daniel Paul Schreber (1842-1911) • German judge hospitalized 2 months after being made the highest judge in the German state of Saxony (in 1893) • 1st hospitalized in 1884, but recovered • Very bright, rapidly promoted in the legal profession • After a10-year hospitalization, he pub-lishedMemoirs of my Nervous Illness (1903), partly in an attempt to argue for his freedom (he was successful) • He reports extraordinary delusions and experiences in a remarkable clear and detailed way • The most famous autobiography of a psychotic person, analyzed many times, including by Freud in 1911

What are delusions? • Defined in DSM-5 glossary as • ‘false beliefs’ based on ‘incorrect inference’ about ‘external reality’, not consistent with the typical beliefs of one’s culture or subculture, that are ‘firmly held’ despite ‘incontrovertible and obvious proof or evidence to the contrary’ • All aspects of this definition have been criticized, however

Contemporary psychological models of delusions • Delusions as explanations for strange or ‘anomalous’ experiences (Maher, 1974, 1988) • Garety & Freeman (2001, 2002) developed an influential model which argues that delusions are ‘attributions’ or ‘causal explanations’ for events, deriving from a ‘search for meaning’ • Strong emotions, particularly anxiety, before the onset of delusions, play an important causal role • anxiety and depression decrease with the development of psychosis (Cunningham Owens et al, 2005) • Trauma is important • Delusions ‘consistently occur in the context of a history of trauma: bullying, physical abuse, and sexual abuse’ (Bebbington & Freeman, 2017, p. 278).

Trauma and delusions • Many large scale studies now, some prospective, link trauma and delusions • Scott et al, 2007 • 10,000+ Australians representatively sampled (National Survey of Mental Health and Wellbeing) • Asked about delusional experiences over past year (delusions of reference, thinking, paranoia and grandiosity) and lifetime traumatic events • Controlled for prior schizophrenia diagnosis, cannabis and alcohol dependence, and various demographic variables

Delusions, trauma and PTSD • 54% of sample experienced a trauma • Delusional experiences endorsed by • 2% with no trauma history • 5% with trauma history (but not PTSD) • 18% with PTSD • Exposure to trauma = 2x risk of developing delusions • PTSD = 6.5x risk of developing delusions • PTSD from Rape associated with 18x increase in delusions (substantially the largest increase) • Authors’ conclusion: ‘Delusional experiences were associated with all types of trauma (but) the association was especially strong in those who had reported rape’ (p. 341).

Is the association between trauma and delusions related to memory? • Amy Hardy’s (2017) model • psychotic symptoms may be due to trauma-based perceptual memory intrusions which ‘may occur in the absence of any episodic context, such that they are experienced as occurring in the “here and now” with no recollection of their link to past trauma’ (Hardy, 2016, p. 9). • A very similar position was proposed by us in 2008 (Moskowitz et al., Delusional atmosphere, the psychotic prodrome and decontextualized memories) • Support for these models can also be found in the extensive evidence for autobiographical and working memory deficits in schizophrenia (Galletly & McFarlane, 2019; Moskowitz et al, 2008)

Clinical examples of trauma/delusion/memory links • Could ‘flashbacks’, not recognized as such, form the basis for delusions? • Snakes in the bed • Keeping the trauma memories, and the ‘vehement emotions’ associated with them, out of conscious awareness, may be one of the main purposes of delusions • Scorsese’s (2010) ‘Shutter Island’ • Highly dissociative individuals (i.e., those who develop DID) keep the trauma away through compartmentalization (creation of dissociative parts) • Others may have to develop delusions to serve the same purpose

Trauma, memory and delusions • Traumatic memories are encoded without an autobiographical narrative (implicit perceptual & emotional memories) or body and emotional memories are disconnected (dissociated?) from narrative memories • In either case, body/emotional memories can be re-experienced without any link to narrative reconstructions (specific time & place) • This makes them ripe for delusional interpretations

Adult retrieval of early life memories in therapy • John Bowlby (1979) On knowing what you are not supposed to know, and feeling what you are not supposed to feel • Children who find a parent attempting or having committing suicide • And then have their reality denied • ‘choking’ vignette • William Niederland • Patient with the ‘North Pole’ dream • Memories stored non-verbally, in the body

Schreber’s delusions • Shortly before his hospitalization, Schreber reports that he awoke from a dream with the thought that it would be ‘nice’ to be a woman and for a man to have sexual intercourse with him. • Central to his delusional system was the belief that ‘God’ was slowly turning him into a woman, and that the success of this process was essential in order to save the world • He referred to this as ‘unmanning’ or, strikingly, ‘soul murder’ (‘Seelenmord’) • Also believed that God did not understand the living, only the dead • He also had a whole series of delusions involving odd bodily sensations, which he called ‘miracles’, which were caused by God’s ‘rays’ (‘Strahlen’ in German) • For example, there was the ‘compression-of-the-chest-miracle’, where ‘my whole chest wall being compressed, so that the state of oppression caused by the lack of breath was transmitted to my whole body’ (Schreber, 1903/1955, p. 133).

Freud’s interpretation (1911) • Schreber’s paranoia and delusions seen as deriving from ‘repressed homosexual’ wishes toward his father, represented by God and his psychiatrist, Dr. Flechsig • his ‘fantasy’ of being transformed into a woman was a more direct representation of his desire for his father • Bleuler (1912) criticized Freud’s interpretation • “Couldn’t it be that (Schreber’s) recurrent fantasy of the end of the world developed through the loss of the usual coherence of perceptions and memories, which certainly plays a role in schizophrenia, rather than through the retraction of libido?” (p. 347)

Schreber’s father • Freud interprets this man’s delusions and persecution complex as the manifestation of his warded-off homosexual love for his father without bothering to find out what his father had done to his child earlier… In his essay about Schreber, Freud was actually describing merely the last act of a drama about whose plot… he seemed to know nothing (Alice Miller, 1984, p. 71). • (T)hese findings give support to the hypothesis advanced by Niederland that the paranoid delusions of Judge Schreber, on which Freud based his theory of paranoia, were distorted versions of the extraordinary pedagogic regime to which the patient’s father had subjected him from the early months of life (Bowlby,1988, p. 117).

Dr. Daniel Gottlob Moritz Schreber (Schreber’s father) 1808-1861 • Highly influential physician, educator and pedagogue • Emphasized gymnastics, gardening (Schreber ‘Verein’, gardens) • He published a series of pamphlets and books about the proper way to raise children, which were enormously influential • These included techniques to instill complete obedience, procedures for ensuring proper posture, attention, etc.

Moritz Schreber’s guidelines for raising children • ‘Such a procedure [for dealing with a crying child] is necessary only once or at most twice and – one is master of the child forever. From now on a glance, a word, a single threatening gesture, is sufficient to rule the child’ (M. Schreber, 1858, pp. 60-61) • ‘The most generally necessary condition for moral will power and character is the unconditional obedience of the child.” (p. 135) • Publications fiercely opposed masturbation, and designed contraptions to try to prevent adolescent males from masturbating • M. Schreber invented many physical contraptions for correcting a child’s posture, which he believed must be perfectly straight at all times • For example, the Geradhalter(‘straight holder’) was an iron cross-bar which pressed against the collar bones and front of the shoulders to correct a child’s posture

Dr. Schreber’s posture devices Father described in Schreber’s patient records as having ‘compulsive ideas’ and ‘murderous impulses’

Niederland and Schatzman’s interpretations • Connecting Schreber’s childhood to his delusions • Starting with Niederland, many researchers have noted striking parallels between Schreber’s delusions and the experiences of his childhood • Schatzman (1971, 1973) presented numerous examples of these • Schreber believed that ‘fleetingly improvised men’ were compressing his chest, prying open his eyelids, etc. • Many of this replicate closely contraptions that his father invented

De Mause’s (1987) reversal of Freud • Lloyd de Mause contends, through his historical research, that sexual and physical abuse of ‘little children’ was quite common in Germany in the mid-19th century • Partly because parents believed early life experiences had no impact on children • Schreber’s delusions are implicitly and sometimes explicitly sexual • For example, Schreber defines ‘soul murder’ as being ‘unmanned’ for the ‘sexual satisfaction of a human being’, of having ‘female buttocks on my body… whenever I bend down’

Was Schreber sexually abused? • ‘I received souls… in my mouth, of which I particularly remembered distinctly the foul taste and smell which such impure souls cause in the body of the person… On some nights, the souls finally dripped down on to my head… The nerves of my head… were covered with a sort of paste… If I wiped them off my eyes with a sponge, it was considered by the rays as a sort of crime against God’s gift’ • We have no direct evidence Schreberwas sexually abused by his father, but the above passage is one of many that not only replicates details of sexual abuse, but also the perpetrator-victim dynamic • Heard voices saying calling him a ‘slut’; he would yell ‘The Sun is a whore!’ • At least with regard to M. Schreber’s physical contraptions, we have strong evidence that some delusions were based on unrecognized memories

Schreber and the double bind • ‘Schreber suffers from reminiscences. His body embodies his past. He retains memories of what his father did to him as a child; although part of his mind knows they are memories, “he” does not… It is as if Schreber is forbidden by a rule to see the role his father has played in his suffering, and is forbidden by another rule to see that there is anything he does not see’ (Schatzman, 1971, p. 188). • Why did he get sick after promotion? • What purposes do his delusions serve?

Why delusions? • May serve multiple psychological purposes • Binding overwhelming affect • Keeping traumatic memories out of awareness • Allowing for the symbolic expression of actual events • Allowing for the experience of denied affect • And the expression of forbidden actions

Schreber’s beginning… and his end • What happened in Schreber’s childhood? • We do not know – brutal childrearing experiences – yes; sexual abuse – maybe • But his delusions tell the story of a child desperately longing for a father who had no use for him except as an object of sadistic impulses and perverse desires • Since God only understands dead people, if my soul is murdered, he will understand me, and the world will be saved

Schreber’s sad end • Judge Daniel Schreber successfully argued for his release from the hospital in 1902 • He recovered partly, enjoyed life with his wife, and considering returning to legal work • In 1907 his mother died, and a few months later his wife suffered a serious stroke • Schreber stopped sleeping, was rehospitalized and his delusions returned – he felt he was ‘eternally damned’ and ‘already dead’. In the end, he became catatonic. • In 1911, he developed a chest infection. The doctors decided against surgery, as prolonging his psychic suffering seemed, to them, inhumane. He died on 14 April 1911.

Summary • Delusions are frequently memory-based, deriving from decontextualized body or emotional memories that are not recognized as such, often related to traumatic experiences • These memories may derive from childhood, or even the 1st years of life • Delusions serve multiple purposes, including to keep actual memories of the trauma from consciousness • But may also be a creative solution to the double bind • Painful early attachment experiences may provide the foundation for common delusions such as paranoia and grandiosity • And the terrifying sense of foreboding that underpins many delusions

Winnocott on the treatment of psychosis • Fear of Breakdown (1974) • The purpose of this paper is to draw attention to the possibility that the breakdown has already happened, near the beginning of the individual's life. The patient "heeds to ' remember ' this but it is not possible to remember something that has not yet happened, and this thing of the past has not happened yet because the patient was not there for it to -happen to. The only way to ' remember' in this case is for the patient to experience this past thing for the first time in the present, that is to say, in the transference. (p. 105) • What happened in the past was death as a phenomenon... Many men and women spend their lives wondering whether to find a solution by suicide, that is, sending the body to death which has already happened to the psyche. (p. 106)

Childhood experiences and delusions: Trauma, memory and the Double Bind • ‘By continuing to insist that delusions represent nothing other than the expression of a diseased brain, biologically-oriented psychiatry is only serving those in society who do not wish to face the pain and suffering experienced by very young children. As raised here, there is the very real possibility that at least some delusions are symbolic crystallizations, serving multiple purposes, of chronic distressing experiences between parents and their children; to call the extreme end of such experiences 'soul murder' is, perhaps, not a delusion at all.’ (p. 139)

Childhood Trauma, Delusions and Memory