The relationship between trauma and psychosis

1. The relationship between trauma and psychosis Presenter: Ron Unger LCSW 541-513-1811 ronunger@efn.org

2. 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.

3. 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.”

4. 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

5. 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.

6. 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

7. 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!”

9. 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

10. 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

11. 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.

12. 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

13. 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.

14. 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.

15. 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.

16. 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.

17. 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

18. 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.

20. 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

21. 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

22. 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

23. 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”

24. 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

25. 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”

26. 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

27. Consider the possibility of self-imposed 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

28. 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

29. 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

30. 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

31. 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 Giving in to, or appeasing, the voices Fight or flight: arguing with voice or running from them, such as through distraction

32. 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 good and positive, to comfort self and feel relaxed. Picture world as dangerous, so that one won’t be overwhelmed by any risks that weren’t anticipated

33. 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 Block out the trauma or distress…it just doesn’t exist…numb. The trauma or stress intrudes into everything, it seems to be happening right now and is overwhelming

34. 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. I think or feel it – therefore it is true, even if everyone else says it isn’t. My thoughts and feelings are unreliable, and others have so many different opinions – there is no way to decide what is true

35. 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. If something is worthwhile, I must keep working towards it no matter how much I suffer. Working towards things leads to disaster and impossible stress, so it’s better to give up before I start.

36. 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 define myself completely independently of others. If I say I am captain of a spaceship, then I am. I am mentally ill or incompetent, I cannot define myself. Others tell me who and how I am.

37. 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 define myself completely independently of others. I am invulnerable. 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.

38. 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 …… Consumer: I think or feel it, therefore it is correct. Mental Health system: This person is wrong and mentally ill, therefore we must take control away from her and decide for her.

39. 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 autonomy: self defining, others have no input or connection. Totally focused on belonging: has no self definition, completely defined by others.

40. 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.