Trauma, Dissociation & Hallucinations: A Critical Review

1. Trauma, Dissociation & Hallucinations: A Critical Review Barry Nurcombe, MD, FRANZCP James Scott, MBBS, FRANZCP Mary Jessop, MBBS, FRANZCP bnurcombe@uq.edu.au5/6/07

2. Topics • Hallucinations and pseudohallucinations • Hallucinations in the general population • The longitudinal course of hallucinations • Hallucinations & the diagnosis of Spn • Borderline personality • Complex PTSD & DESNOS • Hallucinosis in children & adolescents • Trauma & Schizophrenia

3. Topics (continued) • Traumatic reactions to psychotic illness • Summary • Some hypotheses

4. Hallucinations & Pseudohallucinations

5. Hallucinations If a man has the intimate conviction of actually perceiving a sensation for which there is no external object, he is in a hallucinated state. Jean Etienne Dominique Esquirol, 1817

6. Hallucination The most frequent and complicated hallucinations affect hearing; interlocutors address the patient in the third person, so that he is the passive listener in a conversation; the number of voices varies, they come from all directions, and even can be heard only in one ear. Francois Baillarger, 1842

7. A Modern Definition Hallucinations, or false perceptions, are diagnosed when someone hears, sees, smells or tastes something, or feels something on or in his body, for which other people can find no objective basis. Christian Scharfetter, 1976

8. Pseudohallucinations • Introduced by Hagen (1868) to refer to errors of the senses or illusions that are not real hallucinations • More sensory content than representations but lacking the fullness, objectivity, and exteriority of true hallucinations (Jaspers, 1911)

9. Pseudohallucinations • Zward & Polak (2001) conclude that pseudohallucinations cannot be reliably differentiated from other perceptual disturbances and recommend the term be dropped • Instead, hallucinations should be described in terms of modality, interiority/exteriority, intensity, frequency, timing, clarity, content, associated affect, and conviction as to reality

10. Hallucinations In The General Population

11. Community Surveys • Eastern Baltimore Model Health Survey: 4% had hallucinations (Eaton et al, 1991) • 21% of Japanese aged 11-12 yrs had had hallucinations (Yoshizumi et al, 2004) • NEMESIS study (Bijl et al, 1998): 10% had hallucinations; but only 0.4% had non-affective psychosis. Assoc. with females, low SES, urban res., living alone, young age (Van Os et al, 2000) • Hallucinations are associated with traumatic events (eg, Ross et al, 1994; Spauwen et al, 2006)

12. Longitudinal Course

13. The Outcome Of Hallucinations • Escher et al (2002) followed 80 Dutch hallucinating children aged 8-19 yrs for 3 yrs. Hallucinations ceased in 60%, but recommenced in 13% • Dhossche et al (2002) followed a Dutch cohort aged 11-18 yrs. 5% had auditory halls. After 8 yrs 2% had auditory halls. Early hallucinations did not predict PTSD or Schizophrenia

14. Outcome • New Zealand cohort studied at ages 11 and 26 yrs. Schizophrenia and Anxiety Disorder (but not Mood Disorder) at 26yrs was predicted by hallucinations, delusions, and thought alienation at 11 yrs. (Poulton et al, 2000)

15. Hallucinations And The Diagnosis Of Schizophrenia

16. The Symptoms Of Schizophrenia (And Complex PTSD) • Thought echo, third-person discussions, running commentaries • Thought insertion or withdrawal • Thought broadcasting • The perception of being under external control or of being a passive, reluctant recipient of body sensations • Delusional perception Kurt Schneider, 1959

17. Early Intervention In Schizophrenia • Advocates of early intervention (eg, McGorry et al, 1996; McGorry, 1998) may be mistaking some cases of Complex PTSD for Schizophrenia, based on the hallucinations, first-rank symptoms, and paranoid thinking also found in CPTSD (eg,Van der Hart et al, 2005; Hamner et al, 2000; Sareen et al, 2005; Famularo et al, 1998; Honig et al, 1998; Berenson, 1998)

18. Borderline Personality Disorder And Hallucinations

19. Borderline Personality • Knight (1953) described “borderline states” in which apparently neurotic analysands become subject to “transient psychotic episodes” • Kernberg (1975) described “borderline personality organization” as associated with distortion in reality testing and breakthrough of primary process thinking

20. Borderline Personality • Numerous studies have linked Borderline Personality Disorder to child sexual abuse (eg, Herman, Perry & van der Kolk, 1989; Silk et al, 1990; Westen et al, 1990; Zanarini, 1997)

21. Complex PTSD & DESNOS

22. Terr L (1991). Am J Psychiat 148: 10-20 • Two types of traumatic stress: Type 1. resulting from a single blow Type 2. after multiple blows Type 2 trauma is likely to lead to: Massive denial, repression, dissociation, self-anaesthesia, self-hypnosis, chronic rage, self-injury

23. Herman JL (1992). J Traum Stress, 5: 377-391 • Complex PTSD or Disorder ofExtreme Stress NOS (DESNOS) is a sequela of prolonged, repeated, coercive, trauma. Associated with: • Episodes of trance, +/- hallucinations, and the fragmentation of personality

24. Hallucinations In Child & Adolescent Patients

25. Hallucinations In Child Patients • Garralda (1986a,b),in a retrospective chart review, found hallucinations in conduct and mood disorders. Followed into adulthood, not at increased risk for psychosis. • Ulloa et al (2000) : Hallucinations common in mood disorder

26. Hallucinations In Child Patients • Altman et al (1997) : 33% of adolescents in a residential / daycare program had auditory hallucinations associated with dissociative processes • Hallucinations are associated with PTSD (Heins et al, 1990; Famularo et al, 1998; Lipschitz et al, 1999; Nurcombe et al, 1996; Kaufman et al, 1997)

27. Hallucinations In Child Patients • Hallucinations are associated with Dissociative Disorder (Hornstein & Putnam, 1992; Dell & Eisenhower, 1990; Coons, 1996; Putnam, 1993)… • And DID (Hornstein & Putnam, 1992; Vincent & Pickering, 1998; Coons, 1996)

28. Hallucinations In Adult Patients • Honig et al (1998): negative and helpful internal commentaries and dialogues are equally common in Schizophrenia and Dissociative Disorder • Steinberg et al (1994), Middleton & Butler (1998): internalized dialogues are characteristic of DID

29. Nurcombe et al. (1996). In F Volkmar (Ed),Psychoses & Pervasive Developmental Disorders of Childhood. APPI Press Dissociative Hallucinosis • Acute onset • Precipitated by threat of attack or abandonment • Recurrent, brief episodes of trance, autohypnosis, terror, rage, impulsive self-injury, assaultiveness, and hallucinations reflecting trauma • No cognitive or affective deterioration between episodes

30. Dissociative Hallucinosis • Premorbid personality borderline, histrionic, needy, care-eliciting • Families chaotic, neglective, abusive • On blind, retrospective chart review, Dissociative Hallucinosis was no different from PTSD (except re hallucinosis) but was distinct from Schizophrenia • Conclusion: Dissociative Hallucinosis is a form of CPTSD with salient hallucinations

31. Scott J, Nurcombe B, Jessop M (2007).Australian Psychiatry, 15:44-48 • 66 adolescents consecutively admitted to an inpatient unit; structured interview; PTSD compared to Psychotic Disorder (Spn) • No difference in the modality, location, or form of hallucinations • In 25% of PTSD, hallucinations directly reflected trauma (0% in Spn)

32. Jessop M, Scott J, Nurcombe B (2007).Unpublished MS, Queensland Health • 54 adolescents consecutively admitted to an adolescent unit • Structured interviews for diagnosis and for nature of hallucinations • Hallucinations highly prevalent in PTSD and Spn, but indistinguishable in form, location, and content except that patients with PTSD were more likely to refer them to trauma

33. The Relationship Between Trauma And Schizophrenia

34. Three Competing ModelsAndreason NC & Carpenter WT (1993). Schizophrenia Bull, 19: 199-214 • Spn is a single etiological process with diverse manifestations • Multiple etiological processes with a final common diagnostic endpoint • Specific symptom clusters within the same disease that come together in different ways in different patients

35. Cross-Sectional Correlational Studies • Read et al (2005) found 45 papers linking childhood trauma to “psychosis”, to particular psychotic symptoms*, or to Schizophrenia (eg, Ross et al, 1994; Read & Argyle, 1999; Read et al, 2003) *Hallucinatory commentaries; ideas of reference, thought insertion or mind-reading; paranoid ideation; visual hallucinations; sexual delusions

36. Bebbington PE et al (2004). Brit J Psychiatry, 185: 220-226 • 8580 subjects in British National Survey of Psychiatric morbidity • All psychotic subjects (0.7%) administered structured interview • Greatest predictive odds ratio for psychosis: sexual abuse

37. Problems Inherent In Cross-Sectional Studies Of Psychiatric Patients • Representative sample? • Size of sample? • Choice of control? • Validity of self-reported abuse? • Appropriate method of diagnosis? • Causal direction? ?

38. Longitudinal Studies

39. Janssen I et al (2004). Acta Psychiatr Scand, 109: 38-45 • 4000 subjects 18-64 yrs followed for 2 years • Report of a history of child abuse at Time 1 predicted positive psychotic symptoms at Time 2 • After controlling for demographic, other risk, and diagnostic factors at Time 1

40. Spataro J et al (2004). Brit J Psychiatry, 184: 416-421 • 1612 children <17 yrs, substantiated as sexually abused, followed 9 yrs, compared with gen. popn. Controls • Contact with MH Services monitored through case register • 12.4% cases v. 3.1% controls had contact with services

41. Spataro J et al (2004) (Cont.) • The disorders most likely to be associated with sexual abuse were: • Personality Disorder • Anxiety Disorder • Acute Stress Disorder • Major Mood Disorder • Conduct Disorder

42. Spataro J et al (2004) (Cont.) • No increased incidence of Schizophrenia, Alcohol / Sub. Use Disorder, other Mood Disorders, or Somatoform Disorder • ? Sub. Cases of abuse not represent. • ? Failure to access MHS • ? Abuse in controls • ? Imperfect recording / data matching • ? Not enough time

43. Spauwen J et al (2006). Brit J Psychiat, 188: 527-533 • 2524 adolescents 14-24 yrs, followed for 42 months • At Time 1: self-report re lifetime trauma; structured diag. interview; questionnaire • At Time 2: structured interview • Dose-response effect of trauma for psychotic symptoms

44. Traumatic Reactions To Psychosis

45. Psychosis Causes Trauma • Shaw et al (1997) found that 52% of patients recovered from psychotic illness had PTSD • McGorry et al (1991) found PTSD in 35% of recovered psychotic patients • ? Psychotic symptoms or coerced hospitalization can traumatize patients • ? The psychosis was originally CPTSD

46. Summary

47. Summary • Complex PTSD can be caused by severe child abuse • CPTSD can present with acute episodes of hallucinosis, paranoid ideation, dissociation, and self-injury • The auditory hallucinations of CPTSD are indistinguishable from those of Spn, except in reflection of trauma

48. Summary (Cont.) • Schneiderian first-rank symptoms can be found in both Spn and CPTSD • “Psychosis” is used to refer to Spn alone or to conflate (and confuse) Spn and CPTSD • Dissociative Hallucinosis is a form of CPTSD in which hallucinations are clinically salient

49. Summary (Cont.) • CPTSD is part of a Trauma Spectrum (PTSD, ASD, CPTSD, DD, DID, BPD, IED, Conversion Disorder, Somatoform Disorder) • Studies of the relationship between trauma and Schizophrenia are complicated by uncertainty whether Schizophrenia is a unitary disorder

50. Summary (Cont.) • Cross-sectional studies link trauma to “psychosis”, psychotic symptoms, and Schizophrenia; however, all are methodologically flawed • Longitudinal studies link child trauma to PTSD, psychotic symptoms, but not schizophrenia