Psychosis, Trauma and Dissociation – Emerging Perspectives on Severe Psychopathology

Dr. Andrew Moskowitz, Clinical Senior Lecturer, University of Aberdeen, UK Ingo Schafer, M.D., Klinik fur Psychiatrie und Psychotherapie, Universitatsklinikum Hamburg-Eppendorf, Germany Martin Justin Dorahy, Department of Psychology, University of Canterbury, Christ Church, New Zealand

Foreword xiii List of contributors xvii Introduction 1 Andrew Moskowitz, Ingo Schafer and Martin J. Dorahy PART 1 Connecting trauma and dissociation to psychosis: Historical and theoretical perspectives 7 1 Historical conceptions of dissociation and psychosis: Nineteenth and early twentieth century perspectives on severe psychopathology 9 Warwick Middleton, Martin J. Dorahy and Andrew Moskowitz 1.1 Dissociation: Mesmerism, multiple personalities and hysteria 10 1.2 Psychosis: Insanity, dementia praecox and schizophrenia 12 1.3 Dissociation, psychosis and schizophrenia: The merging of constructs 15 1.4 Conclusion 17 2 Hysterical psychosis: A historical review and empirical evaluation 21 Eliezer Witztum and Onno van der Hart 2.1 Early literature on hysterical psychosis 22 2.2 Hysterical psychosis in Pierre Janet's dissociation theory 22 2.3 The decline of hysteria 24 2.4 The return of the diagnosis of hysterical psychosis 25 2.5 Systematic and empirical studies 27 2.6 Hysterical psychosis and reactive psychosis 28 2.7 Integration and concluding remarks 29 3 Association and dissociation in the historical concept of schizophrenia 35 Andrew Moskowitz 3.1 The birth of schizophrenia 37 3.2 Splitting, dissociation and the unconscious 39 3.3 Complexes and fixed ideas 41 3.4 Loosening of associations 43 3.5 Summary and conclusions 45 4 Ego-fragmentation in schizophrenia: A severe dissociation of self-experience 51 Christian Scharfetter 4.1 Schizophrenic syndromes as self-disorders 52 4.2 The construct of ego-pathology 52 4.3 Clinical elaboration of ego-pathology 53 4.4 Empirical assessment of ego-pathology 57 4.5 Ego-fragmentation, association and the dissociation model 59 4.6 Dissociative mechanisms: What and where? 60 4.7 The continuum of dissociative mechanisms: The spectrum of dissociation 62 5 Delusional atmosphere, the psychotic prodrome and decontextualized memories 65 Andrew Moskowitz, Lynn Nadel, Peter Watts and W. Jake Jacobs 5.1 Multiple memory systems and the hippocampus 66 5.2 Phobias, panic attacks and post-traumatic stress disorder 67 5.3 A summary of relevant research findings in schizophrenia 68 5.4 The psychotic prodrome 70 5.5 Delusional atmosphere, the psychotic prodrome and decontextualized memories 74 5.6 Freud's 'The Uncanny' (1919) 75 5.7 Summary and conclusion 75 6 The complex overlap between dissociation and schizotypy 79 Timo Giesbrecht and Harald Merckelbach 6.1 Introduction 79 6.2 Overlap between measures of dissociation and schizotypy 80 6.3 Why dissociation and schizotypy overlap 81 6.4 Conclusion 85 7 Pierre Janet on hallucinations, paranoia and schizophrenia 91 Andrew Moskowitz, Gerhard Heim, Isabelle Saillot and Vanessa Beavan 7.1 Historical overview 92 7.2 Important Janetian concepts 93 7.3 Schizophrenia 95 7.4 Paranoia 97 7.5 Hallucinations 98 8 From hysteria to chronic relational trauma disorder: The history of borderline personality disorder and its links with dissociation and psychosis 105 Elizabeth Howell 8.1 Historical overview 106 8.2 Theoretical analysis 109 8.3 Summary 113 9 An attachment perspective on schizophrenia: The role of disorganized attachment, dissociation and mentalization 117 Giovanni Liotti and Andrew Gumley 9.1 Attachment disorganization and dissociation 118 9.2 Trauma and loss in the lives of primary caregivers of psychiatric patients 120 9.3 Dissociation, schizotypy and psychotic experiences 122 9.4 Metacognition and mentalization deficits 124 9.5 Summary and theoretical integration 126 9.6 Concluding remarks 127 PART 2 Comparing psychotic and dissociative disorders: Research and clinical perspectives 135 10 Childhood trauma in psychotic and dissociative disorders 137 Ingo Schafer, Colin A. Ross and John Read 10.1 Childhood trauma in patients with psychotic disorders 138 10.2 Childhood trauma in patients with dissociative disorders 141 10.3 The relationship between dissociation and psychosis 142 11 Dissociative symptoms in schizophrenia 151 Ingo Schafer, Volkmar Aderhold, Harald J. Freyberger and Carsten Spitzer 11.1 Empirical studies on dissociation in patients diagnosed with schizophrenia 153 11.2 Dissociation and psychosis - what is the relationship? 158 11.3 Conclusion 160 12 Psychotic symptoms in complex dissociative disorders 165 Vedat Sar and ErdincC Ozturk 12.1 Hallucinations 166 12.2 Grossly disorganized behaviour 167 12.3 Impairment in reality-testing: Trance-logic or psychotic breakdown? 168 12.4 Conditions mimicking formal thought disorder 169 12.5 Schneiderian symptoms: Are they nonspecific? 169 12.6 Psychopathogenesis of psychotic symptoms in dissociative disorders 170 12.7 An interaction (duality) model 171 12.8 Conclusions and recommendations for future research 172 13 Advances in assessment: The differential diagnosis of dissociative identity disorder and schizophrenia 177 Marlene Steinberg and Harold D. Siegel 13.1 Dissociative identity disorder and schizophrenia: Overlapping and diagnostically distinct symptoms 178 13.2 Distinguishing between schizophrenia and dissociative identity disorder: Assessment of dissociation 181 13.3 Clinical implications 185 14 Cognitive perspectives on dissociation and psychosis: Differences in the processing of threat? 191 Martin J. Dorahy and Melissa J. Green 14.1 Trauma and threat in dissociative and psychotic individuals 192 14.2 Attention and working memory 194 14.3 Conclusion 201 15 Depersonalization disorder and schizotypal personality disorder 209 Daphne Simeon and Holly K. Hamilton 15.1 Phenomenology of depersonalization and schizotypy 210 15.2 Neurocognitive profiles of depersonalization and schizotypy 211 15.3 Neurobiology of depersonalization and schizotypy 212 15.4 Clinical vignettes 215 15.5 Conclusion 216 16 Contributions of traumatic stress studies to the neurobiology of dissociation and dissociative disorders: Implications for schizophrenia 221 Eric Vermetten, Ruth Lanius and J. Douglas Bremner 16.1 Introduction 221 16.2 Differentiation of abnormal thought processes in dissociative disorders and schizophrenia - vignettes 222 16.3 Schizophrenia research: From psychosocial events to traumatic stress 223 16.4 Effects of traumatic stress on psychobiological systems 224 16.5 Pharmacologically induced dissociation 226 16.6 Neurotransmitters in dissociation and psychosis 227 16.7 Different neural circuits in schizophrenia and dissociative disorders 228 16.8 Heterogeneity of trauma response: Neural circuits in dissociative disorders and other trauma-related disorders 230 16.9 Vulnerable phenotypes 231 16.10Concluding remarks 232 17 Treating dissociative and psychotic disorders psychodynamically 239 Valerie Sinason and Ann-Louise S. Silver 17.1 Historical background 240 17.2 Clinical vignettes 242 17.3 Treating dissociative states 248 17.4 The role of trauma in creating psychopathology 249 17.5 Conclusion 251 PART 3 Assessing and treating hybrid and boundary conditions: Clinical and existential perspectives 255 18 Dissociative psychosis: Clinical and theoretical aspects 257 Onno van der Hart and Eliezer Witztum 18.1 Dissociative psychosis and Pierre Janet's dissociation theory 258 18.2 Dissociative psychosis and the theory of structural dissociation of personality 259 18.3 Discussion and conclusion 267 19 Trauma-based dissociative hallucinosis: Diagnosis and treatment 271 Barry Nurcombe, James G. Scott and Mary E. Jessop 19.1 Psychotic symptoms in post-traumatic stress disorder (PTSD) and complex PTSD 272 19.2 Hallucinations in children and adolescents 272 19.3 Clinical vignettes 274 19.4 Dissociative hallucinosis 275 19.5 The treatment of dissociative hallucinosis 276 19.6 Conclusion 277 20 Dissociative schizophrenia 281 Colin A. Ross 20.1 A dissociative structural model of the psyche 283 20.2 The dissociative subtype of schizophrenia 287 20.3 A clinical case example of dissociative schizophrenia 289 20.4 Research data supporting the existence of dissociative schizophrenia 292 20.5 Research and clinical implications of dissociative schizophrenia 293 21 The role of double binds, reality-testing and chronic relational trauma in the genesis and treatment of borderline personality disorder 295 Ruth A. Blizard 21.1 The effects of relational trauma on reality-testing 297 21.2 Caregiver pathology, double binds, disorganized attachment and dissociated self-states 298 21.3 Treating the effects of dissociative, psychotic or sociopathic caregivers on reality-testing 301 21.4 Conclusion: Borderline psychotic traits stemming from relational trauma require relational treatment 303 22 Pharmacotherapy in the collaborative treatment of trauma-induced dissociation and psychosis 307 Thom Rudegeair and Susie Farrelly 22.1 A brief overview of psychopharmacologic philosophy 308 22.2 The complex presentation of people who dissociate 309 22.3 Overview of a 'good enough' medical approach to the treatment of dissociative/psychotic phenomena 310 22.4 Some specific recommendations for the use of psychotropic medications in the treatment of persons with dissociative symptoms 312 22.5 Summary 317 23 Accepting and working with voices: The Maastricht approach 319 Dirk Corstens, Sandra Escher and Marius Romme 23.1 The history of the Maastricht approach and of the hearing voices movement 320 23.2 Relevant research findings 320 23.3 Assessment: The Maastricht hearing voices interview 321 23.4 Formulation: Making the construct/breaking the code 325 23.5 Case vignette: Maureen 327 23.6 Making a treatment plan 328 23.7 Talking with the voices 329 23.8 Recovery 330 23.9 Summary 331 24 Dissociation, psychosis and spirituality: Whose voices are we hearing? 333 Patte Randal, Jim Geekie, Ingo Lambrecht and Melissa Taitimu 24.1 A cosmic battle: Patte's story 335 24.2 Maori perspectives 336 24.3 Shamanic crisis 337 24.4 A cosmic battle - Part 2 338 24.5 The subjugation of other cultural perspectives 339 24.6 Dissociation and psychosis as states of consciousness 340 24.7 A cosmic battle - Part 3 341 24.8 From victim to victor - a new model 342 24.9 Conclusion 343 References 343 Index 347