I found this book an incredibly interesting read and at points even relatable to my own experiences. Many times when I posted about
it while I was reading it people seemed to agree that its theories and propositions made sense, and found value in the facts it brought
forward. I personally found the proposition that delusions could be rooted in childhood trauma very relatable as someone who's held the
belief that my first delusion was a trauma response, and it made me happy to see the point argued in psychological literature. I also
found its criticism of some studies as well as the actual practice of psychiatry and its incongruence with current research welcome. I
absolutely adored how it acknowledged and went into detail on how psychosis is a traumatizing experience and criticized the DSM definitions
of trauma! I did notice the book was a bit heavy on the psychosis side, but I'm not complaining about that since that's what I picked it
up for. I really enjoyed the end of the book, which explored other culture's perspectives from people actually in those cultures. Really,
the only bad part of the book was the ableism and stigma from one of chapter 26's authors towards plurals/systems which was pretty hard to
get through, but didn't impede on the rest of the book since it was from a different author.
The information following is only the parts of the book I found personally relevent to the topic of psychosis, followed by miscellaneous
facts (some of which are not related to psychosis, but I still want to post because they're interesting). There is much more on dissociation
and trauma in the book, and if you are interested in any of the three I would highly recommend checking out the book. Overall, it was a wonderful read.
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The term 'psychosis' was first used as an alternative to terms like 'insanity' and 'lunacy.' It was coined by the Austrian physician
Ernst von Feuchtersleben, taken from the Greek word 'psyche' (meaning mind or soul) and the Latin suffix '-osis' (meaning an abnormal
condition). It referred to a sickness where both the body and the soul were sick, or a disease that affected 'the whole person.' The coining
of this term was in response to a German psychiatry debate between mental disease located in the 'soul' and disease located in the 'body'
- /Psychiker/ and /Somatiker./
Modernly, 'psychosis' is used to mean 'having psychotic symptoms.' However, psychosis is often used related to incomprehensibility.
It's not new - Jaspers argued more than a century ago that 'genuine psychotic delusions' are 'not understandable.' Often, terms like
"quasi-psychotic" and "psychotic-like" are used when the behavior can be made sense of in some way.
The book then argues that a useful conception of the word psychosis would be one where it means that a) an alteration in the 'hierarchy
of reality' has occured, and b) the person as a whole has been changed in a fundamental way.
Thomas Sydenham (1624-1689) used the term 'hysteria' to denote any mental disorder short of 'frank alienation' (outright psychosis), while
Thomas Willis (1621-1675) outlined a picture in 1672 of a condition what two centuries later would be called 'dementia praecox' by Emil Kraepelin.
In 1808, the term 'psychiatry' was first used by Johann Reil to refer to the treatment of the mind. Now, larger scale scientific observations
could be brought to what used to be isolated accounts of individual observers.
John Haslam (1766-1844) provided cases that would be consistent with what would later be called 'schizophrenia', and his 1810 book /Illustrations
of madness/ detailed a single case of insanity. It was of a paranoid psychotic man, James Tilly Matthews, who believed an 'infernal machine' was
controlling his life and torturing him. Haslam also recognized that in some people there were states of excitement and depression that alternated
- an early recognition of bipolar disorder.
In the mid-nineteenth century, the term 'psychosis' was first proposed by Ernst von Feuchtersleben to replace 'insanity' or 'lunacy.' Ironically
though, he considered 'hysteria' to be a neurosis (a term proposed for any disease caused by the functioning of the nerves), and as such it was more
'biological' than psychosis...
Less than a generation later, Wilhelm Griesinger helped the somaticists win the soul versus soma dispute and 'psychosis' became a term for
'organically based mental disorders.' Under Griesinger's influence, psychosis came to mean organic (caused by organic processes) and neurosis
came to mean non-organic (by-products of psychological development.)
Karl Ludwig Kahlbaum (1828 - 1899) labelled the disorders hebephrenia (with his student Ewald Hecker), to mean a psychosis of young adoloscents
characterized by mental disorientation, and catatonia, a condition where the patient had no reactivity, was mute, and physically immobile.
Emil Kraepelin (1856 - 1926), while he wrote about every major psychiatric disorder, psychosis was a major interest of his. He built upon the ideas
of Griesinger and Kahlbaum, observing many patients and outlined a classification of psychosis that is still very evident in the DSM-5.
Kraeplin grouped together disorders that had a poor outcome - 'catatonia', 'hebephrenia', and 'dementia paranoides.' On the sixth edition of his textbook,
he outlined 'manic depressive psychosis' (bipolar disorder) and 'dementia praecox' (schizophrenic disorders.' Kraeplin claimed that on top of progressive and
inevitable decline, essential features were a discrepany between thought and emotion, negativism, stereotypical behaviors, hallucinations, delusions, and
disordered thought. His focus on 'inherent bodily defects' in psychiatric disorders and rapid decline led to a pessimisstic outlook on the treatment of dementia praecox.
Kraepelin also described 'paranoia,' a chronic illness characterized by delusional beliefs, in the absence of personality changes. He believed paranoia was
less severe and associated with partial recovery.
The first use of the term 'schizophrenia' was by Eugen Bleuler (1908/1987). Over 10 years, Bleuler developed his ideas on schizophrenia in close
cooperation with Carl Jung. Bleuler criticized Kraepelin's idea of dementia praecox, by saying that not all cases began early (praecox) and not all cases
ended in full mental deterioration (dementia.) He proposed the term 'schizophrenia' in a Berlin psychiatry conference. The word literally means
'split mind' as he thought that /tearing apart/ ('Zerreissung') and /splitting/ ('Spaltung') were central to the disorder.
Schneider's first-rank symptoms of schizophrenia had a powerful influence on the diagnostic criteria for schizophrenia, from the 1970s onwards. They
were considered sufficient but not necessary for a diagnosis of schizophrenia to be made. They were (In German, followed by their english translations):
Gedankenlautwerden (audible thoughts), Stimmen in Form von Rede und Gegenrede (voices conversing or arguing), Begleitung des Tuns mit halluzinierten
Bemerkungen (voices commenting on one’s behaviour), körperliche Beeinflussung (somatic influences), Gedankenentzug, Gedankeneingebung und ‐beeinflussung
(thought insertion, thought withdrawal and thought influences/‘made’ thoughts), echter Wahn als Beziehungssetzung ohne Anlaß (delusional perception).
Psychosis has forever been associated with incomprehensibility, but the authors contend that delusions may be ways to cope with adverse life
experiences or heavily influenced by said adverse experiences.
Psychosis may be a way to contain overwhelming emotions, as evidenced by how anxiety and depression are very common in people who develop
psychosis, and anxiety/depression actually decreased with the onset of psychosis. Delusions are also explainable as "explanations for anomalous
experiences, associated with strong emotions", with delusions meaning to bear the overwhelming affect the experiences have on the person.
There is clear evidence in and outside of therapy of the body's ability to remember early traumatic experiences in forms other than memories
(such as bodily sensations and dreams.) Basically, early memories could still influence later functioning even if they can't be recalled by the person. This is
especially true of trauamtic memories. The authors propose that these types of experiences are the basis for delusions.
Most theories of delusions today view delusions as a person's attempt to make meaning and explain strange things they are experiencing. Delusions may be misguided
explanations for early experiences, for example: paranoid delusions may be founded in the idea that "a powerful, unknown danger is present", grandiose delusions
in the idea that "I, who have caused such fear in my mother (or saved her), must have extraordinary powers." Other delusions that relate to the blurring of
public/private boundaries (thought broadcasting, delusions of reference) could be related to boundary violations in childhood like invalidation of emotional
experiences and being told what one is thinking or feeling.
Delusions may provide the ability to express genuine emotions/actions that for some external or internal reason can't otherwise be expressed. All of this
raises the question: Can delusions be treated by reconnecting the to the life experiences they came from? At the very least, the "incomprehensibility" of
psychosis needs to be re-examined.
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Childhood trauma has been associated with a wide array of mental health problems, including psychosis. This will overview the findings on childhood
trauma in relation to those diagnosed with psychotic disorders.
In a comprehensive review, the majority of patients of both sexes experienced some kind of trauma. Sexual abuse was reported by 48% of female patients
and 28% of male patients, physical abuse by 48% of female patients and 50% of male patients. In a later review, the rate of sexual abuse in females was only
slightly lower, the same in males, and physical abuse was lower for both. At least one form of abuse was found in half of patients diagnosed with schizophrenia,
regardless of sex. In studies of people living with psychosis, high rates of emotional abuse and neglect were found in addition to physical/sexual abuse. In
people diagnosed with schizophrenia, the weighted average of childhood emotional abuse was 47%, emotional neglect at 51%, and physical neglect at 41%. However,
the rates varied between studies because of the difference in definitions used.
A meta-analysis of the literature including 41 studies had found that people who had adverse childhood experiences were 2.78 times more likely to develop
psychosis than those who had not. All in all, those diagnosed with psychotic disorders show high rates of all forms of childhood maltreatment. Several population-based
studies suggest that childhood trauma is likely a factor in the development of psychosis; even if definitive conclusions can't be drawn, it is highly likely.
On childhood trauma affecting the characteristics of psychosis: those that have a psychotic illness and had experienced childhood trauma show more severe form
of illness than those that do not have childhood trauma. They tend to show an earlier age of onset, more hospitalizations, a more 'severe clinical course', were more
likely to be re-victimized, had more current PTSD, more current or lifetime substance abuse, more lifetime episodes of major depression and depression/anxiety in
general, had more positive psychotic symptoms, and more dissociative symptoms. In a study of patients with schizophrenia, abused patients frequently report more suicidal
ideation and suicide attempts.
There are also differences in the type and content of psychotic symptoms - Ross, Anderson, and Clark (1994) found that people diagnosed with schizophrenia who had
suffered physical/sexual abuse had significantly more hallucinations, ideas of reference, and thought insertion. Findings about the relationship between trauma and
delusions, thought disorder, and negative symptoms have been inconsistent while the association between trauma and hallucinations has been replicated multiple times.
Out of all, auditory hallucinations - specifically voices commenting on things - could be the most strongly related of all psychotic symptoms. Early findings of current
research show a link between sexual abuse and hallucinations, and bullying/neglect and paranoid delusions.
There may be a spectrum of psychotic disorder where trauma as a cause is important. The book proposes that on one end of the spectrum is those who have a clear
dissociative disorder, and at the other end of the spectrum is those who have a neurodevelopmental disposition towards psychosis that in some cases arise from childhood
adversity/trauma/neglect. Further research is absolutely needed as studies directly comparing both psychotic and dissociative disorders that focus on childhood trauma are
dated, lacking, biased, and unstandardized.
Regardless, whatever one's diagnosis is, there seems to be an importance in routinely being asked about childhood adverse experiences so meaningful and appropriate
treatment plans can be made.
Recent animal and human studies shows that early life adversity can change the developing brain, in ways similar to psychotic disorders. Early life adversity can alter
brain development (it modifies process like methylation and acetylation, changing gene expression and as such the structure and functioning of neurons and neural networks.)
Because of this, the brain's systems work differently.
This will outline the way brains of people with psychosis will differ, with a focus on schizophrenia. It will go over the hippocampus, amygdala, prefrontal cortex,
and insula - and then the relationships between them. (It's gonna get real sciency - I tried my best to paraphrase to simpler terms, but it's kinda hard to do that
when we're talking the structure of the brain.)
Hippocampus: The center of a variety of functions, from memory to spatial nagivation to cognitive maps.
Structural changes to the hippocampus were first identified in schizophrenia more than 35 years ago. Needless to say, it's pretty common. It has, bilaterally, 5-10%
smaller volume, with the smallest volumes reported in chronic states and elderly patients. Decreased volume was correlated with childhood adversity. All hippocampal
subfields were affected, with some studies finding changes in the anterior parts, CA1 and the subiculum while others found stronger results in the posterior parts,
CA2-3 and CA4-dendate gyrus. The reduced volume correlates with both positive and negative psychotic symptoms, and increased sensitivity to stress.
Cellularly, changes in schizophrenia were decreased mRNA expression of GR receptors (in all hippocampal subfields), decreased # of apical dendrite spines and spine
density in subicular internal pyramidal neurons, reduced size of pyramidal neuron cell bodies, and reduced interneuron activity containing parvalbumin and interneuron
density and number. Overall the cellular changes are highly consistent with those found after early adversity (in animal research.)
Amygdala: Made of many different nuclei, it is also involved in a variety of functions - fear conditioning, memory, perception, attention...
The results of studies looking at first epsiode psychosis and schizophrenia have been relatively consistent with lower amygdala volume. There was some evidence of
progressively reduced volume in schizophrenia. Some authors argued the sizes were rather small and that large sample sizes were needed for differences to appear
in a significant manner.
Earlier studies suggested that reductions in volume were not there in first episode psychosis, but more recent studies contradict that, also noting that the smaller
amygdala volume correlated with childhood trauma. In a contrast, one study reported increased amygdala size in adolescents - the mean age at 14 years - with schizophrenia.
In response to the range of findings, the book proposes that one explanation could be that the age of which the adversity was experienced and the age at which brain
scans were performed differed.
Frontal Lobes: The ones in control of higher order executive functions, from working memory, goal-directed thinking, problem solving, cognitive flexibility, mental
representations, to the control of feelings and behavior.
Psychotic disorders have consistently found abnormal frontal lobe functioning. The frontal and prefrontal regions show widespread reduced volume (middle and inferior
frontal regions, anterior cingulate, and orbitofrontal and dorsolateral prefrontal cortices.) The volume loss is particularly prominent in the inferior and medial frontal
gyrus, and anterior cingulate. In patients with schizophrenia, there is a significant association between sexual abuse and volume loss of the prefrontal cortical.
The following interneuron changes may be significant to the aberrant cortical gamma oscillations and compromised cognitive functions in psychotic disorders: a decrease
in GR mNRA expression, reduced dendritic spine density in deep layer three pyramidal cells, and in the anterior cingulate, altered density, size, and shape of pyramidal
cells and interneurons. In individuals with schizophrenia, the subpopulation of GABA interneurons expressing parvalbumin are altered - reduced density in the anterior
cingulate and reduced activity in the dorsolateral prefrontal cortex. GAD67 expression is reduced in frontal cortical regions.
Frontal lobe volume loss in psychotic disorders is consistent with the fact that the frontal lobes are sensitive to stress, leading to volume loss and a myriad
of changes in pyramidal cells and interneurons. It seems to match that of detailed changes seen after early life stressed.
Insula: This piece is involved with the functions like intereoception - awareness of the body and of feelings, saliency detection, integration of external
stimuli, self-consciousness, the experience of identity, and individual personality.
In individuals at a very high risk for psychosis, reduced insula volume has been reported. In patients that developed schizophrenia, there was a highly consistently
reported reduction in insular volume - right and left, anterior and posterior parts all included - with the mean reduction being 5.2%. Reduced insular volume has been
associated with positive symptoms and negative symptoms in those with schizophrenia. Overall, reduced insula volume is a common finding.
Relationships between the different parts: The parts of the brain don't work independently, so of course, this has to be touched on too.
Altered functional connectivity between the amygdala and prefrontal cortex has been found in psychosis, as well as between several other brain regions like
the hippocampus, amygdala, insula, and prefrontal cortex. The several findings in psychotic disorders include an increased baseline level of cortisol, cortisol
sensitization to new stressors and cortisol habituation to known stressors, as well as dopamine hyperactivity in the striatum and hypoactivity in the prefrontal cortex.
All of these changes are also seen after early life stress! This can suggest that the mechanisms behind the brain's structural alterations seen in psychosis
could be the same as those involved with brain changes after early life stress. This raises the question of whether or not adversity is what causes the neurological
anomalies in psychotic disorders.
Overall, the book says it can be argued that the experiences of early adversity could be a cause, even a primary cause, for most brain abnormalities in psychotic disorders.
While it has been established that depersonalization occurs in a wide variety of mental disorders, most authors agree that it's a little different in schizophrenia.
Meyer (1956) would note that patients with schizophrenia would interpret depersonalization experiences as threatening or uncanny.
There is solid evidence that people with schizophrenia experience dissociation more often and more intensely, but with lower intensity of those with BPD, PTSD, and DID.
There is some difference in the results - probably because what stage the disorder is in plays a role. Those in remission show less dissociation, and in a study of
inpatients found that there was a decrease in score from admission to the second interview that took place when the patient stabilized. There is also a close association
between positive symptoms and dissociative symptoms, as patients with predominantly positive symptoms had higher scores than patients with predominantly negative symptoms.
Findings related to the link between negative symptoms and dissociation are inconsistent.
There needs to be more research and clarification on the association between schizophrenia and dissociation. For example, is there a highly dissociative subgroup
of patients with schizophrenia, or do psychotic symptoms simply have a dissociative underpinning?
In patients with psychotic disorders, there may be delusional elaborations of what is actually a dissociative experience, like feelings of passivity or being
influenced by something outside. The book proposes delusional interpretations of dissociative experiences may be a core of many psychotic symptoms - one obvious example
being delusions of possession.
NOTE: In chapter 12, about psychotic symptoms in dissociative disorders, since there was a high prevalence of both dissociative symptoms in schizophrenia and a
high prevalence of psychotic symptoms in dissociative disorders, the book authors mention a proposal that it may be a continuum. The continuum would be from schizophrenia,
to a dissociative subtype of schizophrenia, to a "schizo-dissociative disorder", to DID.
For the longest time, hearing voices has been seen as the end-all-be-all sign of madness, and a key part to the diagnosis of schizophrenia. In both the DSM-III and DSM-IV,
certain forms of hearing voices were the only symptom required to meet a diagnosis of schizophrenia. Keep in mind these manuals were in use for a third of a century!
And, despite it now not being present in the DSM-5, it is still emphasized in the ICD-10 and ICD-11.
It was first proposed that hearing voices could be dissociative in nature by Moskowitz and Corstens in 2007 and elaborated upon by Longden and colleagues in 2012.
This will overview the research in support of this proposal.
Statistics suggest that WAY more people hear voices than there are people with psychotic disorders - 40% of adolescents/young adults and 13% of adults hear voices,
while the lifetime prevalence of clinically identified psychosis ranges from 0.2-0.7%. Several large-scale studies report that only a minority of respondants
- between a third and a fifth - sought any kind of psychiatric help for their voices.
On voice phenomenology: because of the prevalence of voice hearing outside of psychotic disorders, some theorists propose a dichotomy between "true hallucinations"
and "pseudo-hallucinations." In this, true hallucinations are said to be from psychosis and pseudo-hallucinations coming from dissociative disorders, PTSD, BPD,
and other trauma-related disorders. However, this classification has been unsuccessful due to the inability to distinguish between the characteristics of the voices
in different groups. There's a general held belief that voices that are external and heard through the ears are 'more psychotic' than internal voices heard inside the
head, but the location of voices has been reviewed to be highly non-specific in diagnostics or the prognosis.
Not only can this perceived location of the voices change over time, there's also no evidence that external voices are more associated with schizophrenia than
they are not. Other features like "controllability", "mood-incongruent content" and whether voices comment on things or argue are also found to be similar between
groups. So, this symptom that seems to be so indicative of schizophrenia is actually common in non-psychotic disorders and even in some non-disordered people.
The only significant distinction between clinical voice hearers and non-clinical is that clinical voice hearers tend to perceive their voices as more omnipotent,
malicious, controlling, and aggravating.
Even if PTSD and psychotic disorders are classified as seperate, there's increasing evidence that they could be related. Because of co-occurances
of each disorders' symptoms, researchers are beginning to question if one could lead to the other. There's two main paths: a) Psychosis may be traumatizing
enough to cause PTSD, and b) psychotic experiences are more common in severe PTSD. This will overview A and then B.
On the trauma of psychotic symptoms themselves, and hospitalization: Shaner and Eth (1989) were the first to document that schizophrenia can lead to
future PTSD. Since then, many other studies have been done on this topic. Bendall, McGorry, and Krstev (2006) examined some personal accounts of psychosis
and came to the conclusion that half of them would meet the criteria for PTSD. Further research concludes that psychotic experiences puts you at risk for
developing PTSD, such as a) the fear and terror of psychotic symptoms themselves like paranoia and voices, b) the constant fear of a psychotic relapse,
and c) a low tolerance for uncertanties that they have to face.
Though, despite this, researches have debated if psychotic experiences and involuntary hospitalization procedures can be considered 'traumatic enough'
for PTSD. The debate was mainly about whether or not psychotic experiences qualified as "actual threatened death or serious injury, or a threat to the physical
integrity of the self or others." In addressing this, Shaw et al. (1997) proposed that the definition of trauma should be revised to include "a threat to the
psychological integrity to the self", which clearly encompasses the psychotic experience. The current DSM-5 definition - "death, threatened death, actual or
threatened serious injury, or actual or threatened sexual violence" - does not allow psychotic experiences or their associated hospitalizations to be 'traumatic enough' for PTSD.
Regardless of problems associated with definitions, in a recent review of literature it was suggested that across all studies high levels of distress with
both symptoms and hosptializations were apparent. In one study, 69% of PTSD symptoms were reported as being directly attributable to psychotic experiences.
Hospitalization and the associated procedures accounted for 24%. Mueser et al. (2002) asked patients to identify the most upsetting aspects of their psychotic
episodes, where 66% identified the psychotic experiences themselves, 26% naming hospitalization, and 8% a combination of the two. This shows how the definitions
may be problematic: despite hospitalizations fitting the DSM-IV and DSM-5 definitions of trauma more, psychotic experiences happen to be more traumatizing...
On the flip side, several recent studies have suggested that severe PTSD could result in psychotic experiences. Much of the earlier work relies on veteran
samples, but more recent work includes non-veteran samples too. Hamner and Fossey (1993) reviewed clinical charts of 214 veterans who previously recieved treatment
for PTSD, noting that 15% of the sample had psychotic experiences. This showed that the rate of psychotic experiences in PTSD was higher than originally thought.
A later study showed that veterans who received a PTSD diagnosis showed a higher rate of psychotic experiences than veterans not diagnosed with PTSD. Another study
confirmed that auditory hallucinations were the most common psychotic experience in those who had PTSD.
For non-veteran studies, once again the presence of psychotic experiences was related to the severity of PTSD symptom severity. In a study of Northern Irish
participants that had trauma related to the Northern Irish political trauma, 20 of 40 participants that had PTSD experienced auditory verbal hallucinations.
Most of the hallucinations were concluded to be trauma related. Overall there have been similar findings in non-veteran studies as in veteran studies.
As a whole the body of research suggests a psychotic subtype of PTSD.
Dissociation has the potential to play a role in the development of this psychotic subtype of PTSD - dissociation has been associated with PTSD for a
long time, after all, to the point where some suggest it could be classified as a dissociative disorder. Recently, a dissociative subtype of PTSD has been
introduced in the DSM-5, and this subtype could overlap with the proposed psychotic subtype. Brewin and Patel (2010) found that auditory hallucinations are
common in both veteran and civilian PTSD samples and is correlated with dissociation scores. Blevins and colleagues found that their dissociative PTSD group
scored higher than the PTSD-only group on a variety of mental health experiences, including psychotic experiences. Overall, more research is needed to explore
the association between dissociative PTSD and psychotic symptoms.
The book argues that a psychotic subtype of PTSD would look like this: the presence of hallucinations and delusions, of which the former are more prevalent;
the subtype being pervasive, chronic, and severe; the disorder must be differentiated from related disorders - the subtype can be differentiated in that its
delusions are often paranoid and persecutory while schizophrenia's delusions are often more bizarre and complex; the subtype presents without the thought disorder
which is common in schizophrenia; the psychotic subtype has a typical course that does lessen in severity over time; the subtype has a typical response to treatment,
and distinctive biological characteristics of the disorder should be apparent, such as increased levels of serotonin production and increased monoamine oxidase
B activity compared to individuals suffering PTSD alone.
This will focus on the cognitive processing of perceived or actual threat. Both dissociative and psychotic experiences are characterized by the
presence of frightening memories, thoughts, and beliefs. Regardless of how 'real' the threat is, a terrifying internal world renders the external
world unsafe and dangerous. However, research differs between dissociation and psychosis - work in psychosis has often focused on specific symptoms
(particularly paranoid delusions) while dissociation has been viewed as a process that reduces the impact of a threat. The question asked by
dissociation researchers tends to be "What cognitive mechanisms are associated with the process of dissociation?", while the question by
psychosis researchers is "What cognitive mechanisms underlie, or lead to, psychotic symptoms?"
Studies on encoding and retrieval have produced interesting results, but the most fruitful for comparison between the disorders is in attention
and working memory studies. The primary findings of these studies is that divided attention is a feature of dissociation, but not psychosis. Weakness
in cognitive inhibition is evident in thos ewith dissociative disorders in the context of a threat, but not when an overt threat is absent. Weakness
in cognitive inhibition is evident in acude illness episodes of paranoia, but not when symptoms remit. In psychotic and psychosis-prone individuals,
there is evidence for biased attentional processing of threats. These results point towards a similar process of increased internal salience and perception
of threat in both dissociation and paranoid ideation.
The book has a running theme in that dissociation may be a putative mechanism to explain psychotic symptom outcomes. The book states this proposal has yet
to be falsified. The final question raised in this chapter is: can the cognitive processes that are associated with dissociation provide an empirical account
of psychotic symptoms?
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Although not currently recognized as a diagnostic category, specialists in trauma-related dissociation have argued that treating Dissociative
Psychosis as such has clinical value. It was originally called 'hysterical psychosis'; it is a syndrome that has been documented in a wide variety
of disorders from PTSD to DID. It's proposed that for something to be Dissociative Psychosis, it has to be trauma related and embedded in a structural
dissociation of the personality. Goal-directed actions that the person cannot control should be present in the psychosis, along with dissociative symptoms.
The acceptability of dissociative psychosis as a term hinges on the fact that 'psychosis' is so broadly defined. For example, according to Jackson (2001),
psychosis is "a broad category of mental disorders that are characterized by severe abnormalities of thought process. These are associated with disturbance
of the sense of reality and often with delusions, hallucinations, and disruptions in the sense of personal identity". When a diagnosis of dissociative
psychosis is in order, the person's /hierarchy of degrees of reality/ is severely compromised. Normally, the orientation of place, time, and identity has
the highest 'degree of reality', but when threatening inner voices, or dissociative parts of the personality re-experiencing traumatizing events, or related
terrifying fantasies are accorded to a higher 'degree of reality' (experienced as more real) than the present environment, the diagnosis of a dissociative psychotic
episode may be appropriate.
This will first present Pierre Janet's original analysis of hysterical psychosis' dissociative nature, then a description of Dissociative Psychosis in terms
of the modern theory of structural dissociation of the personality. It then presents a number of forms of dissociative psychosis, and discusses clinical applications.
Janet (1907) defined hysteria as a malady of /personal synthesis/, 'a form of mental depression characterized by the retraction of the field of consciousness
and a tendency to the dissociation and emancipation of ideas and functions that constitute personality.' Although he wasn't always explicit about it, Janet
thought that the dissociative 'systems of ideas and functions' had their own sense of self and their own range of affect and behavior. The most obvious of
these dissociative system are ones that contain traumatic memories, which Janet originally describes as 'primary idées fixes' or 'primary emotional states.'
These systems consisted of a 'psychological and physiological phenomena, of images and movements of a multiform character', each with its own sense of self.
When these systems reactivate, whether in nightmares or in a waking state, persons are 'continuing the action, or rather the attempt at action, which began when
the [trauma] happened; and they exhaust themselves in these everlasting recommencements.'
'Secondary idées fixes' or 'secondary emotional states' are related to primary idées fixes (traumatic memories). These secondary idées fixes are not based
on actual events, but are related to them, and may manifest as fantasies or dream elaborations. A person might hallucinate being in hell, secondarily related
to an extreme sense of guilt during or following a traumatic experience. For Janet, these secondary idées fixes, forming the basis of secondary dissociative
states, were required for hysterical psychosis. Even when traumatic memories completely dominated consciousness and behavior, Janet would not speak of
hysterical psychosis unless secondary idées fixes developed. However, the book authors believe a wider range of phenomena deserve the label dissociative psychosis.
According to Janet, the more traumatized someone is, the more fragmented their personality. This implies that dissociative psychosis may be part of a
relatively simple or a more complex truama-related dissociation of the personality. The theory of structural dissociation is essentially an extension
of Janet's theories.
According to the theory of trauma-related structural dissociation, trauma-related disorders involve insufficient integration among two or more
dissociative parts of the personality. Basically, the person functioning as one type of dissociative part may try to go on with life as if the
trauma has not affected them. Since Myers (1940), this part has been named the 'apparently normal part' or ANP. The other type of dissociative part,
'emotional parts' or EPs, is fixated in traumatic memories, and re-experiences them often.
The primary and prototypical form of structural dissociation is related to the lack of integration between one ANP and EP. An ANP will fulfill
functions in daily life, avoiding traumatic memories, but as an EP the person's actions are essentially mediated by the mammalian defense system
and attachment cry. An EP is highly motivated to engage in defensive actions against perceived threat due to their fixation on traumatic memories.
Secondary structural dissociation is a more complex version, involving more than one EP and thus a lack of coherence among flight, freeze, fight, and fawn.
In tertiary structural dissociation - the most complex - there is also a lack of integration among different action systems for daily life as well
as among EPs. Clinical observations indicate that dissociative psychosis is usually embedded in secondary or tertiary structural dissociation.
The book defines dissociative psychosis as 'a syndrome involving one or more EPs that seem to be characterized by psychotic experiences, which
either obtain executive ontrol or heavily intrude upon ANP.' However, the book contends that the question of what defines the EPs as 'psychotic'
is difficult to answer. A person who is really an ANP suffering from voices belonging to perpetrator imitating-parts may be diagnosed as psychotic
or schizophrenic and receive heavy doses of antipsychotics or even ECT whereas a dissociative specialist would likely recognize the dissociative
nature of the phenomena and make a diagnosis of OSDD or DID, and offer psychotherapy. Even so, the book authors believe that dissociative psychotic
episodes may require 'specific interventions not typically used with dissociative disorders, including, potentially, short-term inpatient admissions
or mdication.' However, they also advise caution with the use of antipsychotics. They contend that focusing exclusively on the dissociative disorder
and ignoring the dissociative psychotic episode could be counterproductive. In short. dissociative psychosis could be a window into understanding
complex dissociative disorders.
The book says that the following dissociative conditions could be considered instances of dissociative psychotic episodes: a) an ANP feeling
overwhelmed by threatening and/or imperative voices, b) an EP(s) in executive control re-experiencing traumatizing events, c) an EP(s) in
executive control (re)experiencing terrifying hallucinations derived from traumatic experiences, d) rapid switching among EPs because of
reactivated traumatic experiences, and e) the phemonemon of double emotion, in particular instances in which current traumatization reactivates
past traumatization. These various forms of dissociative psychosis are not mutually exclusive.
The chapter concludes by acknowledging the highly theoretical nature of the previously discussed topics, stating that studies regarding
dissociative psychosis and the effectiveness of its treatment are strongly needed.
The term Schizophrenia, meaning 'split mind', was coined by Bleuler in his 1911 text, /Dementia Praecox or the Group of Schizophrenias./
Bleuler stated that "the splitting is the fundamental prerequisite condition of most of the complicated phenomena of the disease. It is the
splitting which gives the peculiar stamp to the entire symptomatology." He went on to say that "the term 'dissociation' has already been in
use for a long time to designate similar observations."
'Splitting' and 'dissociation' were synonyms to Bleuler. In Bleuler's conception of schizophrenia, splitting-dissociation is pervasive,
and in his text he provides clinical examples of the splitting of attention, personality, touch, ideas, somatic sensations, will, memory,
emotion, voice, hallucinations, movement, pain, arousal, personal names, and physiological functions such as heart rate. Bleuler's description
of many of his schizophrenia cases is similar to the modern description of DID, saying that his patients typically had amnesia for periods of
time when different identities take control of their bodies. He says that one part of the person refers to other parts in the third person,
describing changes in voice, mannerisms, posture, and identity when there is a switch, that the different identities often have different names.
Serious consideration of the link between dissociation and psychosis has existed in the dissociative disorders field for over 30 years, whereas
in schizophrenia literature it has only begun to be acknowledged within the past 5 years. The book author proposes a dissociative subtype of
schizophrenia to encourage collaboration between the dissociation and schizophrenia fields. This will describe the features of dissociative
schizophrenia, and describe the research data supporting its existence.
A modified version of the theory of structural dissociation can account for a wide range of mental disorders, and for the comorbidity of
them within a person. Disorders in this group include DID, PTSD, somatic symptom disorder, BPD, many cases of schizophrenia, impulse control
disorders, many paraphilias, and OCD. The book presents a modification of the theory of structural dissociation of the personality, with a
particular interest in using the extended model in solving the problem of extensive comorbidity in survivors of extreme trauma. Van der Hart et al. (2006)
require the existence of an emotional part (EP) with at least a rudimentary sense of separate selfhood for structural dissociation of the
personality to be occuring. This is the case in DID and OSDD, but the book author doesn't think that the presence of an EP is required for a
disorder to be dissociative in nature. Rather, they theorize that 'a dissociated compartment may house a feeling, impulse, memory, or other psychic
content without an EP being present.' The book proposes using "structural dissociation" instead of "structural dissociation of the personality" to be
used for this, as it is based on compartmentalization rather than a structural dissociation of the /personality/ as defined by Van der Hart et al. (2006).
With this modification the chapter author (Ross, 2013) argues that a wide range of DSM-5 disorders, many of which are commonly present as comorbid
disorders in DID, can be considered dissociative. They call it "structural dissociation" to acknowledge that while it overlaps with
Van der Hart et al. (2006)'s theory for DID and OSDD, it extends the domain of dissociation by not requiring the presence of an EP in every dissociated
compartment. The basic point is, an EP is not needed for all cases of dissociative schizophrenia.
In clinical practice few (if any) schizophrenia experts consider DID in their diagnostic assessments. In the dissociative disorders field, DID and
schizophrenia are viewed as separate disorders and the problem is to decide which is present. A diagnosis of DID leads to primarily psychotherapy
with adjunctive medication, while a diagnosis of schizophrenia leads to a primarily psychopharmological treatment with adjunctive or no psychotherapy.
However, there are still several unresolved problems.
Most people with DID would meet the DSM-5 criteria for schizophrenia. That is, only two symptoms - one of which must be hallucinations, delusions,
or disorganized speech - need to be met, along with a duration of six months and a deterioration in occupational or social function, with exclusion
criteria for schizoaffective disorder and mood disorder and for substance/general medical condition. And an additional exclusion criteria for that
autistic people either delusions or hallucinations must be present in order to make the additional diagnosis of schizophrenia. Most people with DID
meet this criteria because they experience auditory hallucinations, the disorder is chronic, it interferes with function, and the exclusion criteria
are not met. If th belief that other people live inside one's body is classified as a delusion - as it can be based on the DSM-5 definition of delusions
- then most people with DID would meet the criteria for schizophrenia. This confusion between the two disorders has been present ever since Bleuler's
coining of schizophrenia.
So, a proposed subtype of dissociative schizophrenia serves several purposes. It is an operationalized, scientifically testable hypothesis.
The proposed DSM diagnostic criteria are:
A type of schizophrenia in which the clinical picture is dominated by at least three of the following
1) dissociative amnesia
2) depersonalization
3) the presence of two or more distinct identities or personality states
4) auditory hallucinations
5) extensive comorbidity
6) severe childhood trauma
Because some cases of dissociative schizophrenia could be genetic or physiological in origin, childhood trauma is not an absolute requirement.
Also, because of the complex multi-faceted relationship between psychosis, trauma, and dissociation, the type of trauma contributing to dissociative
schizophrenia is likely to vary from case to case. In practice, however, almost everyone with DID will meet criteria for dissociative schizophrenia,
and the criteria are set up this way on purpose.
By the current rules of the DSM, a clinician has the option to diagnose DID, schizophrenia, or both. The purposes of the proposed dissociative
schizophrenia are to help schizophrenia experts recognize that dissociatve symptoms are common in schizophrenia, to stimulate consideration of DID
in the differential diagnosis of schizophrenia, to open up the possiblity of a truama-driven subtype of or at least a trauma contribution to
schizophrenia, and to open up the possibility of trauam-informed psychotherapy for a subgroup of people with schizophrenia. Broadening the structural
dissociation model to include dissociated compartments that do not house an EP was with the intent of getting clinicians and researchers to consider
the possibility that the psychological structure and processes in DID and a subset of cases of schizophrenia are similar, if not the same.
Laferre-Simard et al. (2014) have studied this subtype of schizophrenia - they administered several scales and structured interviews to
15 individuals with a psychotic disorder scoring above 15 on the Dissociative Experiences Scale, selected out of an initial sample of 50.
They found that 24% of these 15 patients met the criteria for dissociative schizophrenia, showing that the criteria do apply to a subset of cases.
On the research data supporting its existence: there are severeal basic findings in literature - in different case series, between 25 and 50%
of people in treatment for DID have received past diagnoses of schizophrenia, and about half have been prescribed antipsychotics. This shows that
it depends on who's doing the assessment whether some people have schizophrenia or DID. It's not limited to clinical practice - structured
interview for dissociative disorders have diagnosed chronic CDDs in 24% or more of people with long-term, stable clinical diagnoses of schizophrenia.
Haugen and Castillo (1999) diagnosed DID or DDNOS in 28% of 50 psychotic out-patients at a community mental health centre in Hawaii using the SCID-D.
Steinberg, Cicchetti, Buchanan, Rakfeldt, and Rounsaville (1994) reported that 32.1% of 28 individuals with psychotic diagnoses reported moderate to
severe identity alteration on the SCID-D. Yu et al. (2010) made clinical diagnoses of a dissociative disorder in 29.2% of 96 individuals with
schizophrenia, Ross and Keyes (2004) diagnoses DID in 26.4% of 60 patients with schizophrenia they interviewed with the DDIS.
On the other side of things, two thirds of people in long-term psychotherapy for DID meet structured interview criteria for schizophrenia or
schizoaffective disorder. And similarly, a subgroup of people with schizophrenia have high scores on measures of dissociation and people with DID,
on average, score higher on measures of psychosis than people with schizophrenia do.
This shows that clinicians, DSM-IV or DSM-5 criteria, structured interviews, or self-report measures can not adequately separate DID and schizophrenia
into two dichotomous categories. Clinicians on both sides of the DID/schizophrenia divide comonnly believe they can make reliable differential diagnoses,
but this is just not true. It can't be true because of the core features shared between the disorders.
The clinical implications of dissociative schizophrenia: a) dissociative symptoms are common in schizophrenia and have to be considered in treatment,
b) some cases of schizophrenia could be treatable with psychotherapy, c) the environment can be a major factor in many cases of schizophrenia, and d)
psychological trauma is a major theme in schizophrenia. The next paragraph in the book words it too well for me to paraphrase it: "In the current ideological
climate, the pendulum has swung from the extreme of the schizophrenogenic mother to the opposite extreme; it is now politically forbidden to ‘blame’ or
‘stigmatize’ the family. Why it should be politically unacceptable to blame a physically violent, inconsistent, emotionally neglectful, and sexually
abusive parent for his or her adult child’s mental health problems is unclear."
Now for the research implications: a) measures of trauma and dissociation should be included on most research of psychosis, b) dissociative symptoms
may define a valid subtype of schizophrenia with a distinct treatment response, c) psychological trauma should be controlled for in all
twin/family/adoption/genetic studies of psychosis, and d) a truly integrated biopsychosocial model of schizophrenia is possible - one that
would pay more lip service to psychosocial factors.
Behaviorally - and symptomatically - individuals with dissociative disorders are difficult to distinguish from those with psychotic disorders. This
chapter reviews how a range of psychological instruments can inform us on the differences between these two sets of disorders - with the dissociative
disorders in focus being DID and OSDD.
Certain forms of voice hearing and experiencing 'made' thoughts and feelings, as in the Schneiderian first-rank symptoms, are more commonly reported
in patients with dissociative disorders than in patients with schizophrenia - even though these first-rank symptoms have long been emphasized in the
diagnosis of schizophrenia. It's suggested by some authors that psychotic symptoms could be driven by dissociative mechanisms, while others go so
far as to question whether dissociation is a 'distinct nosological category' from schizotypy. The clinical and theoretical importance comes from the
fact that these two groups are often given different treatments.
The following is a comparison of results between dissociative disorders and psychotic disorders on the following kinds of measures: a) cognitive
testing, b) structured personality tests/broad psychiatric symptom measures, c) trauma-focused measures, and d) projective tests like the Rorschach Inkblot Test.
On cognitive testing: People with dissociative disorders did 'remarkably unremarkable', with an average of 100 IQ with normally distributed scores
ranging from the lower to high ends. There was nothing out of the ordinary. Meanwhile, people with schizophrenia typically showed low overall scores
on intelligence tests, as well as deficits in verbal and delayed memory. Unfortunately there have been no studies that have directly compared dissociative
and psychotic disorders in cognitive or neuropsychological testing.
On structured personality tests/broad symptom measures: There are some validity issues here! The MMPI-2 has several 'validity' scales,
of which the F scale is notable as it is often elevated to such a degree in dissociative disorder patients that the profile is considered
invalid. The F scale is essentially meant to assess if the individual is "bad at faking." Patients with a psychotic disorder are often less
likely to provide an invalid profile on the MMPI, but it can still happen sometimes. There's a similar pattern on the MCMI-III, with
psychotic patients reporting less symptoms than dissociative patients, while dissociative patients often provide a profile that would often
be considered 'exaggerated.'
The MMPI - Scores in the paranoid, schizophrenia, and bizarre thoughts scales are often elevated in patients with psychotic disorders, but
scores in the schizophrenia scale are also elevated in people with a dissociative disorder. In addition, elevations on the hypochondriasis
scale can be seen in dissociative disorders where it isn't in psychotic disorders.
The MCMI - Using the MCMI-II, a study found that dissociative disorder individuals were characterized by avoidant and self-defeating
personality features. However they also showed high levels of borderline, passive-aggresive, schizotypal, schizoid, and even paranoid personality
disorder pathology. Contrary to expectations, high scores on the schizotypal and thought disorder scale on the MCMI-III may be more indicative of
a dissociative disorder than a psychotic disorder. There seems to be a reasonably consistent pattern of both psychotic disorder and dissociative disorder
patients reporting high schizophrenia scores using the MCMI, which is somewhat replicated on the MCMI-III on the schizotypal and thought disorder scales.
The SCL-90 and BSI - Patients with a dissociative disorder score higher on many scales on these, including somatization, obsessive-compulsive, interpersonal
sensitivity, depression, anxiety, anger-hostility, phobic anxiety, paranoid ideation, psychoticism, and the general symptom index. A substantial correlation
between the subscales of psychoticism and paranoid ideation has been made with the SCL-90 and Dissociative Experiences Scale. The Global Symptom Inventory
(a summary score for the SCL-90) is also obviously elevated in people with dissociative disorders. Allen et al. (1996) found significant correlations
between the Dissociative Experiences Scale total and all nine BSI scales, except interpersonal sensitivity.
On trauma-focused symptom measures: There is a lack of research in the TSI/TSI-2 profiles in patients with DID and psychotic disorders. The only
study of psychotic disorder patients with the TSI found that in those with trauma histories, TSI elevations were positively correlated with the
severity of hallucinations and delusions. The psychotic disorder patients had a mean score of 62.47 compared to a mean score on the Dissociation
scale of 81.45 in a sample of patients diagnosed with DID. Note that the latter study used the TSI-2 while the first used the TSI, however! In
summary, many psychotic disorder patients suffer from trauma-related experiences, but not as pronounced as among severely dissociative patients.
On projective testing: Interestingly, distinctions come to light on projective testing like the Rorschach Inkblot Test. Dissociative disorder
patients show a greater capacity to be self-reflective, to modulate affect, to think logically, and to see others as potentially collaborative
despite traumatic flooding than psychotic diorder patients. Both groups misperceive others and manifest some perceptual inaccuracies. Dissociative
disorder patients show a greater level of self-reflection combined with a desire to actively seek change, which is not prominent in psychotic disorders.
But, there is a clear need for more research.
A new approach to dealing with voices, emphasizing accepting and making sense of the experience, has been being developed for the past
three decades in Maastricht, the Netherlands, by psychiatrist Marius Romme and researcher Sandra Escher. This framework, 'the Maastricht
appoach', has grown progressively more influential in Europe, North America, Australasia, and elsewhere. It has led to voice hearers organizing
themselves in networks to empower themselves and fight stigma, as well as find new constructive ways of working towards recovery. The idea is
that people hearing voices can learn to cope with the experience, benefiting from psychosocial interventions, based on three core tenets: a) the
phenomena of hearing voices is more common in the population than previously believes, b) the phenomena of hearing voices can be understood as a
personal reaction to life stress, and c) the phenomena of hearing voices is better understood as a dissociative experience in nature than a
psychotic symptom.
On the history of this all - it started with one patient who insisted their voices should be taken seriously. Romme and Escher worked in
close collaboration with voice hearers to conduct research projects and organize meetings for voice hearers and professionals. Bringing
together professionals and non-professionals in this early work brought to light the fact that there was a relative lack of difference between
the experiences of the two groups at the time. The striking difference was that non-patients were more likely to have a subjectively meaningful
framework for their voices, and were able to cope with them successfully. Sharing the stories of voice hearers who had recovered and non-patient
voice hearers generally gave hope to distressed voice hearers.
Their narratives were widely shared in conferences, media work, and network meetings in the Netherlands - effectively, accepting and making
sense of voices became a new paradigm, making ways for new treatment approaches and ways of recovery. This has lead to - starting in the UK
and spreading out - voice hearers coming together to make collectives and networks of support outside of mental health services. These activities
became embedded in what is known today as the International Hearing Voices Movement. Today there are Hearing Voices networks in 32 ountries across
the world, whose activities are supported and coordinated via Intervoice (www.intervoiceonline.org), which is the organizational body of the
international movement. In addition to the administrative role, Intervoice also gives out messages of hope, promotes training and research,
and offers practical support for distressed individuals that are trying to make sense of their experiences.
Since Romme and Escher's (1989, 1993, 2000) initial work, substantial empirical evidence has been provided for the Maastricht approach.
It has moved from heresy to certainty, for example, that hearing voices and psychosis generally is heavily associated with trauma and adversity.
Data likewise confirms that hearing voices is by no means solely a "mentally ill thing," rather being a part of the spectrum of human difference
and diversity. On top of that the difference in hearing voices between non-patients, patients with non-psychotic diagnoses, and patients with
a formal diagnosis of schizophrenia have been shown to be surprisingly small aside from the fact that non-patients feel their voices to be
less powerful and are less afraid of them overall. In fact, it is the person's /reaction/ to their voices and the way that they cope that determines clinical need.
With psychiatrists tending to view hearing voices as something pathological and in need of medication, the Maastricht approach gives an alternative to
medication in understanding and making sense of voices. A clinical strategy associated with this is the Maastricht Hearing Voices Interview
or MHVI, an assessment instrument for exploring the links between voice content/characteristics and the psychosocial circumstances that a
person is in. The MHVI encourages the voice hearer to emotionally distance from the voices and explore their own experiences, which can
highlight important information.
The MHVI is structured like this:
1. The Nature of the Experience: Establish if the person actually hears voices or if they are more like intrusive thoughts, if they
hear the voices inside or outside the head, as well as other unnatural sensory experiences and how they may relate to the voices.
2. Characteristics of the Voices: Factors like name, age, and gender (if known or applicable), frequency, duration, speaking tone,
and ways in which different voices may relate to one another and the voice hearer.
3. Personal History of Voice Hearing: The voice hearer's circumstances when each voice appeared for the first time, and how the voices may have developed.
4. Triggers: What things trigger the voices, and how they respond to these.
5. What do the Voices Say?: The content of each voice, preferably in whole sentences or exact words.
6. Explanations for th Origin of the Voice(s): The person's perspective on why they are hearing voices.
7. Impact of the Voices on Daily Life: The effect of voice hearing on the person's daily goals, as well as 'strategies' the voices
use on the person like giving advice, commanding, 'blackmailing,' threatening, punishment are also examined.
8. Balance of the Relationship: The ways which the voice hearer relates to and communicates with the voices.
9. Coping strategies: How the voice hearer already copes with the experience, categorized into cognitive, behavioural, and physiological.
10. Childhood Experiences: Significant developmental events, particularly exposure to adversity and trauma.
11. Treatment History: What support the person has received as well as its effectiveness.
12. Social Network: An inventory of the presence, or absense, of a supportive social network for the person.
It usually takes about 90 minutes to complete the MHVI, although it can be used more extensively over several sessions.
It's important to establish rapport by showing a broader interest in the person and their problems first, combined with positive
examples of other voice hearer's experiences of coping/recovery to motivate the person to talk about the voices. When the interview is
done the interviewer writes an accessible report of the information. The voice hearer is then asked to read the report, and comment on
it and correct misunderstandings - encouraging the person to engage in discussing new strategies for dealing with voices and emotions.
Hearing voices is typically seen as the end result of this sequence: a) trauma leads to b) over-whelming emotions which provoke c)
dissociation or repression. At this point, d) coping fails and e) voice hearing starts. Voice hearing can be shocking and stressing,
and since in Western culture it's so heavily associated with mental instability the person may be ashamed of the experience. Many voice
hearers don't relate hearing their voices to their life history due to these factors.
Two key questions are explored from the information in the report in order to formulate an understanding of the purpose of the voices.
Who or what do the voices represent?: The identity, content, and characteristics of the voices and their origin can often indicate who
or what they represent. Traumatic events often involve other individuals and the powerful emotions that the survivor finds difficult to
cope with. How the voices relate to the voice hearer can reveal the identity and characteristics of significant individuals related to the
trauma, in either a literal or metaphorical way. For example, the voice could have the same name or characteristics like gender and age as
the perpetrator. In some cases the voice could be a direct re-experiencing of the original traumatic events, or maybe they just thematically
reflect the words said by the original aggressors. Sometimes collaboration and imagination is needed to discover the 'who' behind the voices
- tone and content of the voice may not be congruent, like a male voice repeating the words of the real-life male perpetrator.
What problems do the voices represent?: Generally, problems, conflicts, and traumatic events that were so overwhelming that they exceeded
the individual's ability to cope are the circumstances that lie at the root of the voice-hearing experience. Many voice hearers have been
emotionally inhibited in childhood by their caregivers or other significant adults like teachers. As a consequence, they may have low self-esteem;
the more vulnerable a person is the more hard it is to learn to endure and negotiate stressful events. So, in addition to trauma/abuse,
other root problems can be like severe workplace conflict, domestic tension, sexual identity confusion, loyalty conflict, etc...
All in all the Maastricht approach rejects the idea that hearing voices is a meaningless pathological symptom, supporting voice hearers
to develop more positive and empowered relationships with their voices. The focus is not clinically 'curing' and eliminating voices, but on
healing, restitution, and emotional exploration. Empowerment and recovery are key objectives.
Eye Movement Desensitization and Reprocessing (EMDR) therapy is a psychotherapeutic approach with a broad and growing empirical
support for it. It's the internationally recommended approach for PTSD, its efficacy and efficiency recognized in many national and
international treatment guidelines, including those of the World Health Organization, American Psychiatric Association, International
Society for Traumatic Stress Studies, and British National Institute for Clincal Excellence. The application of EMDR to psychotic disorders,
however, is a just emerging area of research, with several studies that will be covered here.
The most obvious use of EMDR in this case is to treat comorbid traumatic experiences as well as the trauma of psychotic experiences
themselves. The process of being psychotic can be an overwhelming experience due to the primary symptoms, the treatment process often
including hospitalizations and physical restraint and isolation, and the consequences of having a chronic and disabling disease. The
conception of psychosis is a genetic brain disorder in needing of medication has left many psychotic patients without the option for
therapy. Evidence for the safety and efficacy of CBT for psychosis remains mixed, and in many countries interventions are limited.
The role of trauma in psychotic disorders probably goes beyond just having the disorder, however, as the interaction between trauma,
dissociatoon, and psychosis can't be understood from only a simplistic point of view. Traumatic experiences can be related to triggering
psychotic episodes, they can influence the content of hallucinations and delusions, they can modify brain structure and function promoting
the development of psychotic symptoms. Could EMDR help with all of these areas? By working on the 'traumatic layer' to psychosis with EMDR
we could develop a new understanding of the interaction between trauma and psychosis.
There are several descriptions of positive results in single cases of EMDR treatment for psychotic symptoms in a range of disorders from
PTSD to depression. In 2006, Miller described a series of clinic cases of schizophrenia, severe depression with psychosis, and delusional
dysmorphophobia (excessive dislike for a part of one's body) that were successfully treated with EMDR therapy. In a follow up report, the
patient with schizophrenia remained off medications and symptom-free. Based on his clinical experiences Miller (2010) proposed a specific
EMDR protocol for psychosis, called ICoNN for "Indicating Cognitions of Negative Networks." It focused on more positive cognitions than
negative ones or somatic sensations.
Van der Berg and Van der Gaag (2012) conducted an uncontrolled open trial pilot study, of EMDR treatment of comorbid PTSD in psychotic
disorders, based on the argument that having a psychotic disorder should not shut the door for therapeutic treatment of PTSD symptoms. After
a max of six sessions of EMDR, they found EMDR to be highly effective in alleviating PTSD symptoms with no evidence for adverse affects. Also,
despite not being directly targeted, auditory verbal hallucinations and delusions also increased along with anxiety and depression, while patient's
self-esteem improved.
De Bont, Van Minnen, and De Jongh (2013) studied 10 patients with comorbid PTSD and psychotic disorders to examine the efficacy and safety
of EMDR and prolonged exposure in treating PTSD. The two therapies were equally effective and safe. 8 of the 10 patients completed the full
course of treatment, and 7 no longer met the criteria for PTSD at the follow-up. The study was limited in some ways however - by not screening
for dissociative disorders, small sample size, only using bilateral auditory tones rather than bilateral eye movements which have shown to be
more efficient, etc.
McGoldrick, Begum, and Brown (2008) reported EMDR treatment for olfactory reference syndrome, a subtype of delusional disorder where
there is a persistent, false belief about emitting abnormal body odours which are foul and offensive to others. Their article describes
brief EMDR treatment for four cases of ORS, whose pathological symptoms had persisted from 8 to 48 years - EMDR therapy resulted in a
complete resolution of symptoms in all four cases which was maintained in follow-up. While four cases is a very small sample, ORS is
a rare diagnosis with a poor prognosis, so these results are impressive.
Kim et al. (2010) presented a pilot study with 45 acutely psychotic schizophrenia inpatients. They were assigned to three groups -
treatment as usual, treatment as usual + three sessions of EMDR, or progressive muscle relaxation. They found that even during the acute
phase, EMDR focusing on targets related to traumatic memories or disturbing consequences for psychotic symptoms themselves was well-tolerated.
The test results however failed to confirm the effectiveness of EMDR compared to the other two groups. It would make sense that EMDR would be
less effective when the brain is overly disturbed in the acute phase of psychosis however, where processing of information is disturbed.
Overall, results from EMDR therapy offer a different perspective for understanding how some 'psychotic' symptoms have their roots in
trauma. Auditory verbal hallucincations can reflect either psychotic cognitive processes or dissociated parts of the personality. EMDR
targeting traumatic experiences or even directly psychotic symptoms themselves has been shown to reduce the symptoms of psychosis. Exploring
the effectiveness of EMDR and other trauma-oriented psychotherapies with psychotic patients could help with a number of questions. Can EMDR
and trauma therapies offer an effective alternative to medication for psychosis? If EMDR treatment leads to a reduction in hallucinations
or delusions by processing adverse life experiences, wouldn't this support the causal importance of adverse environmental situations for
the development of psychosis? While more research is needed, the results we already have appear promising.