***Originally posted on www.madinamerica.com***

Trauma, Psychosis, and Dissociation

Recent years have seen an influx of numerous studies providing an undeniable link between childhood/ chronic trauma and psychotic states. Although many researchers (i.e., Richard Bentall, Anthony Morrison, John Read) have been publishing and speaking at events around the world discussing the implications of this link, they are still largely ignored by mainstream practitioners, researchers, and even those with lived experience. While this may be partially due to an understandable (but not necessarily defensible) tendency to deny the existence of trauma, in general, there are also certainly many political, ideological, and financial reasons for this as well.

Many have called for the trauma and psychosis fields to join forces. So many valuable findings have come out of the trauma field that could inform practitioners and lay people alike in understanding how one might come to be so overwhelmingly distressed and behave in such seemingly strange ways (see Read, Fosse, Moskowitz, & Perry, 2014, for an informative overview of how trauma affects our bodies). Studies looking at how the non-disordered brain adapts to chronic stress, how cumulative adverse events affect how people perceive and react to the world around them, and how many creative ways people come up with to defend against their own awareness of their distress all can help others to understand the un-understandable. More importantly, the trauma field has shown time and again how trauma-informed care can help a person slowly heal from horrid life experiences.

Yet, the trauma and dissociation field often goes to great lengths in an apparent effort to draw a decisive line in the sand between “real” trauma “disorders” and “schizophrenia.” This largely is done by insinuating that “dissociation” is trauma-based and explains the bizarre behaviors of so many distressed individuals labeled with “borderline” or “dissociative identity disorder”, while some cognitive or brain-diseased factor contributes to “real” psychosis. Somebody with “schizophrenia” may have experienced trauma, but it is largely irrelevant to the present distress. Is this true? Is there any actual evidence for this beyond ideology? It may be helpful to look at the overlap and separation between “dissociation” and “psychosis” to get a better understanding.

Brief history of trauma research

Over 100 years ago, Pierre Janet became the first major figure to identify and treat the vast array of the effects of trauma.  In fact, he considered almost all “psychopathology” to be the result of childhood trauma and dissociation (Janet, 1919/25). Under the large umbrella term of “hysteria”, Janet identified the following symptoms: hallucinations in all senses, fugue states, amnesia, extreme suggestibility, an odd disposition, nightmares, psychosomatic and conversion symptoms, reenactments, flashbacks, paranoia, subjective experiences of possession, motor agitation, mutism, catatonia, thought disorder (or disorganized speech), and/or double personalities (Janet, 1907/1965). He believed that treatment consisted of a phase-based approach involving stabilization, trauma processing, and recovery. Fatefully, Janet’s use of hypnosis provided the main basis for his eventual expulsion from the psychiatric community. He responded to his exile by pointing out that the medical establishment denied the existence of trauma and its effects, to the point of focusing too much on the physiological and biological domain.

For the next 8 decades or so, the mental health field became more and more narrow in its focus on and recognition of trauma to the point of neglecting it completely in the more biological domains. It was not until the late1970’s, when a massive influx of veterans gained political clout and women began to speak out and be heard, that trauma was once again recognized as a major factor in extreme emotional distress. This also was the time when the DSM became psychiatry’s new bible; and so, while trauma was once again recognized, it was also separated into narrowly defined disorders that included PTSD, adjustment disorders, and dissociative disorders (including multiple personality disorder, as it was then known). It was then that the modern-day lines were drawn.

Dissociation

So what are people talking about when they speak of “dissociation”? Well, not too many people agree on this. It also appears as though the more professionals attempt to come to a consensus on what this term means, the more they do so in an effort to delineate it from any possible association with “psychosis”; their attempts to define dissociation are done by disassociating.

Wikipedia defines dissociation (in the broad sense) as: “an act of disuniting or separating a complex object into parts.” I do not believe that many mental health professionals, particularly dissociation researchers, would entirely disagree with this definition. Rather, it is the interpretation of this meaning that is a hotly debated topic within psychiatry (a general term I use to describe the entirety of the mental health field). In general, it may be used to describe a process, a multitude of symptoms, specific disorders, a division of the personality (or lack of integration), and/or a psychic defense. Many believe that it refers to disconnection from one’s thoughts, feelings, environment, self, others, etc. The term is also used to refer to a process of entering a trance-like state or extreme detachment. Most agree that dissociation lies on a continuum from “everyday dissociation” (i.e., losing track of time while driving, becoming absorbed in a book) to severe dysfunctional dissociation (i.e., “multiple personalities”). Lately, it appears as though trauma researchers and practitioners are interpreting dissociation as solely meaning a separation of identity states or ego functioning that is based in trauma and is clearly understandable (i.e., not psychosis).

If nobody agrees on what it means, then why do we really care? Because the political implications and resulting effects on treatment options are directly related to how one interprets this meaning. We can see by looking at the DSM how this might work…

DSM and all its fancy terms

Akin to many religions throughout time, psychiatry makes up many technical terms and then create circular and eccentric definitions to confuse lay people into believing that mental health issues can only be dealt with by an educated professional. Putting this political maneuvering aside, I would like to focus for a moment on key terms related to the topic at hand: trauma, dissociation, dissociative symptoms, psychosis, psychotic symptoms, dissociative disorders, and schizophrenia.

Trauma: Trauma is technically defined as an event that provokes death-related fears in an individual. It is also agreed upon that trauma is defined by the person’s response to such an event, rather than the event itself. But, what of the child whose parents are cold and over-protective? Or the child who is “only” bullied verbally? Or the child who is chronically invalidated? Or poverty? Or the person in existential crisis? Are these not a form of “trauma”? Certainly, they are shown to be chronically stressful which, physiologically, is not any different than “trauma” defined in the DSM-sense. Although it is understood that trauma is subjective, the DSM insists on narrowly defining it anyways.

Dissociation: As stated previously, very few professionals in psychiatry agree on what this term means. Instead of just saying “absorption”, “feeling unreal”, “feeling one’s surroundings are not real”, “lack of integrated sense of self”, or “detachment” (all considered in different circles as varied forms of dissociation), scholars instead argue over its meaning until it has no meaning at all. Often, it is an ideological term that is used to say “trauma” vs. “not trauma”, whether this is explicitly acknowledged or not. Therefore, when one’s “symptoms” are considered non-dissociative, the assumption generally tends to be that they also are not trauma-based.

Dissociative symptoms: Although dissociative symptoms are acknowledged as existing in a multitude of different DSM categories, they mostly are usurped by the dissociative disorder classifications. In this case, as I will discuss in a moment, dissociative symptoms often seem to take on the meaning of “not psychotic” rather than having any distinct meaning in and of themselves.

Psychosis: Psychosis is another technical term with no precise meaning. It tends to refer to a state in which a person appears to not be aware of or in touch with consensual reality. This can be for 5 minutes or 5 years, but the term itself is non-time specific. In practice, it tends to be used when the professional comes to a point where they say “I don’t understand you or agree with your interpretation of reality.”

Psychotic symptoms: Most people tend to think that psychotic symptoms clearly refer to things such as hearing voices, seeing visions, having strange beliefs, or disorganized thinking/speech. However, “psychotic symptoms” specifically refers to symptoms of psychosis. What is psychosis? Having psychotic symptoms. If you don’t have psychosis, then you may have “psychotic-like” symptoms or “quasi-” insert what you like here. What makes these symptoms psychotic-like instead of truly psychotic? Whether or not your therapist understands you.

Dissociative disorders: While there are 5 dissociative disorders, the one that is most intertwined with the idea of psychosis is dissociative identity disorder (DID). People who might meet the criteria for DID often experience what is inarguably the core of the term “dissociation”; namely, having a fragmented sense of self. In addition, they also experience periods where they cannot remember large gaps of time. This amnesia is certainly not an experience that is universal to many or even most individuals suffering extreme states; however, the other experiences common in DID are definitely non-specific to this classification. These include: hallucinations in all senses, incoherence, bizarre beliefs, impaired reality testing, lack of awareness of the present moment, paranoia, and paranormal experiences. However, these are reframed as: hearing voices of an “alter”, body memories, flashbacks, intrusions of trauma and/or “alters”, beliefs attributed to “alters”, not being grounded, and hypervigilence. These words do not necessarily indicate any difference in the lived-experience, but rather a difference in how psychiatry interprets the experience. And who wouldn’t rather say “I have body memories and intrusions” then “I have hallucinations and delusions”?

Schizophrenia: The category of schizophrenia, and all its sister disorders, is one that is assumed to be a largely biological, genetic brain disease. What differentiates it from DID? No one seems to be able to define where this distinction lies, but those in the dissociative disorder field will state that the difference is based on the existence of “delusions” and/or “thought disorder”. A delusion, of course, is a belief that society deems unacceptable. Yet, nobody seems to be able to explain where the line is separating a delusion from an acceptable belief. More specifically, nobody will explain what the difference is between believing “I have a bunch of people living inside of my body who are not me” (DID) and “I am God” (psychotic). But questionnaires that measure dissociation use this very distinction to say whether one has dissociation or not. And then they say “delusions are not related to dissociation” because they just ruled out dissociation by the fact that a person did not endorse an interpretation of their experience that the questionnaire makers deemed dissociative.

“Thought disorder” has been convincingly described by Richard Bentall as a problem in communication, rather than an indication of any true cognitive impairment (Bentall, 2003). Yet, the theory adopted by mainstream psychiatry remains that “thought disorder” is a neurological disease. And so, if one is considered to have DID, any indication of thought disorder is instead interpreted as “intrusions” or “rapid-switching” of altered identity states. Only those with “real” psychosis have a “real” thought disorder.

On the other hand, psychosis researchers solve the problem by simply saying DID just does not exist. People who present with altered identity states and memory problems (not attributed to an actual neurological problem) are considered as just “borderline” or “attention-seeking”. I honestly cannot think of much that is worse than experiencing such emotional turmoil and distress to the point of a break-down and then being told I am making it up for attention. But, then, of course, that is just my perspective.

In spite of these ideological battles, studies still have shown that individuals meeting criteria for schizophrenia endorse a greater level of dissociative symptoms than any other clinical group, discounting PTSD and dissociative disorders (Ross, Heber, Norton, & Anderson, 1989). Approximately two-thirds of individuals diagnosed with DID who are hospitalized also meet structured interview criteria for schizophrenia or schizoaffective disorder (Ross, 2007), 25-50% of anybody diagnosed with DID has received a previous diagnosis of schizophrenia (Ross & Keyes, 2004), and approximately 60% of those diagnosed with schizophrenia meet criteria for a dissociative disorder (Ross & Keyes, 2004). Up to 20% of individuals diagnosed with DID have been found to exhibit communication styles indicative of thought disorder (Putnam, Guroff, Silberman, Barban, & Post, 1986), and levels of dissociation are highly correlated with thought disorder (Allen, Coyne, & Console, 1997). Bizarre explanations for anomalous experiences are not rare in those diagnosed with DID; indeed, one study discovered that 41% of individuals diagnosed with DID have been found to believe they were possessed by demons, and 36% experienced possession by some other outer power or force not attributed to part of the self (Ross, 2011).  In addition, the original concept of ‘schizophrenia’ (as it was discussed by Kurt Schneider, Eugen Bleuler, Harry Stack Sullivan, and Harold Searles) appears to emphasize presentations indicative of a dissociative disorder.

On the other hand, it has been found that dissociatively detached individuals are not necessarily chronically psychotic and can function at a high level (Allen et al., 1997).  Individuals diagnosed with DID are often able to maintain reality testing despite experiencing “psychotic” phenomena (Howell, 2008).  Another difference is that persons diagnosed with DID also report higher levels of dissociation, and more child, angry, persecutory, and commenting voices (Dorahy et al., 2009; Laddis & Dell, 2012). They also generally report a higher rate of more severe childhood trauma than any other clinical group (Putnam et al., 1986).

What does this all mean???

It is often purported that “delusions” and “schizophrenia” are not dissociative, when using the narrow definition of dissociation; when dissociation means dis-integration of identity. I would argue that when one is so distressed so as to be labeled as having delusions or schizophrenia, the person has experienced such a high level of dissociation so as to have a completely shattered identity; dis-integration to the point of disintegrated oblivion. But, this is not acknowledged as dissociative, and so then is considered somehow something completely different and separate.

I do not believe it is possible to separate psychosis and dissociation; to me this is like attempting to separate a headache and a fever when I have the flu. Where does the headache begin and the fever end? And should I focus on “treating” my headache, fever, or maybe the virus that infected me and is creating an interconnected process of events in my body? While psychosis and dissociation are not the same thing, I believe that one does not have psychosis without dissociation or dissociation without psychosis. Often the difference simply boils down to: who can frame things the way that the professional wants to hear or agrees with.

Certainly not all those who experience altered identity states experience strange beliefs, voices, or incoherence, but most do. Not all those who experience extreme states also experience altered identity or memory loss, but some do. These experiences are not separate, even if they are different. Although one may appear more reality-based and “dissociative” while another may appear more out of touch with reality and incomprehensible, I believe both stem from the same underlying process of attempting to deal with overwhelming life experiences. And this is where “treatment” should be focused.

Of course, this belief comes with the caveat that some presentations of emotional distress (whether it is psychosis, depression, dissociation, or any other term or category one might like to think of) are dietary, biological, and/or neurologically based. These are not psychological or psychiatric problems, then, and should be dealt with in the medical realm. All individuals suffering from extreme states should evaluate their diet, exercise, and overall physical health; when these are shown to be a non-issue, however, it should be assumed that some difficulty with life has led to whatever the person is suffering through in the present rather than blaming a faulty brain or neurochemicals without any evidence to back up such assertions.

I do not have all the answers. But, I do ask why it is that mental health professionals do not start with just saying what they mean? We can talk about altered identity states, memory loss, feeling unreal, not knowing what is real or not, being terrified of others, etc. Mental health professionals can own the fact that “I do not understand this person” instead of taking this as equivocal evidence of some brain-diseased process of “psychosis.” Each of these experiences do not make a distinct disease. People are complex. People do not fit in nice, neat boxes. People suffer, and when they do this is not necessarily a disease. People adapt to unbearable life circumstances in a number of complex ways that cannot be categorized, no matter how much psychiatry insists that it can. And none of these labels can tell anybody much of anything about a person beyond the stereotypes and confirmation biases they elicit.

At the end of the day, extreme states and anomalous experiences are terrifying; they are terrifying to the people experiencing them and to all those around those people. Doctors are human beings (much as many might like to state otherwise) and they too often act out of that fear. Certainly, nobody wants to get labeled with being psychotic, and there is benevolence in the efforts of those who try to save many from being so doomed. Being recently labeled with “schizophrenia” appears to be enough to increase the likelihood somebody will commit suicide (Fleischhacker et. al, 2014).

Instead of trying to understand people through labeling and insisting on enforcement of an authoritarian dictation of what the experience “really” is, perhaps psychiatry can listen to those who have actually been there. The Hearing Voices Network has given us tools to work with voices and other anomalous experiences; the National Empowerment Center has given us tools on how to work with crises and extreme states; I am working to try to get first-person perspectives on how to work with altered identity states and memory loss; so many individuals (most famously Marsha Linehan) have given us tools on how to work with self-harm and suicidality.

Why does psychiatry then continue to insist on abiding by a broken and invalid system of disease mongering? Why do we not allow the experiencer to make sense of their experience through their own framework? Why must we be so evangelical and insist that they see things our way? There is NOTHING that truly, scientifically can say that one diagnosis is more “accurate” than another. All of these diagnoses are just checklists of behaviors- there is nothing that anybody “has” and until some biological test shows otherwise than nobody can claim that there is. What matters is being with a person in their world where they are at and understanding the MEANING behind the experience, not attempting to define the experience itself in a way that makes sense to us. This is nothing more than social control and perpetuation of the status quo, not science.

Even the most biologically-based medical doctor knows that treatment can only be effective when the underlying disease is recognized and addressed. In my opinion (and it is only that), the underlying “disease” is trauma, overwhelming emotions in reaction to an un-understandable and terrifying world, and/or fear of death/annihilation. If this is the issue, and logically then the issue that needs to be “treated”, then why do we spend so much time splitting hairs over differentiating what behaviors or beliefs belong in what technical categories? In the heart of the Hearing Voices Network, why are we not focusing all of our time on understanding what happened to the person, not what’s wrong with the person?

Disclaimer: The views presented here are constructed from my biased interpretation of the vast literature associated with the various topics discussed. This is based on my on-going dissertation work as well as personal and clinical experiences that influence my views. In no way is any of this meant as a criticism towards any individual organization or researcher. I have a great appreciation for the work done in both the trauma and psychosis fields, and recognize that we all cling to views that help us make sense of the world. I just hope that one day we might be able to move past some of these partialities and work towards improving options for people who are in extreme distress without further traumatizing them in the process.

References

Allen, J. G., Coyne, L., & Console, D. A. (1997). Dissociative detachment relates to psychotic symptoms and personality decompensation. Comprehensive Psychiatry, 38, 327-334.

Bentall, R. (2003). Madness explained: Psychosis and human nature. London: Penguin.

Dorahy, M. J., Shannon, C., Seagar, L., Corr, M., Stewart, K., Hanna, D., . . . Middleton, W. (2009). Auditory hallucinations in dissociative identity disorder and schizophrenia with and without a childhood trauma history: Similarities and differences. Journal of Nervous and Mental Disease, iii-x(12), 892-898.

Fleischhacker, W. W., Kane, J. M., Geier, J., Karayal, O., Kolluri, S., Eng, S. M., …Strom, B. L. (2014). Completed and attempted suicides among 18,154 subjects with schizophrenia included in a large simple trial. Journal of Clinical Psychiatry, 75(3), e184-190. doi: 10.4088/JCP.13m08563.

Howell, E. (2008). From hysteria to chronic relational trauma disorder: The history of borderline personality disorder and its links with dissociation and psychosis. In A. Moskowitz, I. Schafer & M. J. Dorahy (Eds.), Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology (pp. 105-115). West Sussex, UK: John Wiley & Sons, Ltd.

Janet, P. (1907/1965). The major symptoms of hysteria. New York: Hafner Publishing Company.

Janet, P. (1919/25). Psychological healing. New York: Macmillan.

Laddis, A., & Dell, P. F. (2012). Dissociation and psychosis in dissociative identity disorder and schizophrenia. Journal of Trauma & Dissociation, 13(4), 397-413.

Putnam, F. W., Guroff, J. J., Silberman, E. K., Barban, L., & Post, R. (1986). The clinical phenomenology of multiple personality disorder: A review of 100 recent cases. Journal of Clinical Psychiatry, 47, 285-293.

Read, J., Fosse, R., Moskowitz, A., & Perry, B. (2014). The traumagenic neurodevelopmental model of psychosis revisited. Neuropsychiatry, 4, 65-79.

Ross, C. A. (2007). The trauma model: A solution to the problem of comorbidity in psychiatry. Richardson, TX: Manitou Communications, Inc.

Ross, C. A. (2011). Possession experiences in dissociative identity disorder: A preliminary study. Journal of Trauma & Dissociation, 12(4), 393-400.

Ross, C. A., Heber, S., Norton, G. R., & Anderson, G. (1989). Differences between multiple personality disorder and other diagnostic groups on structured interview. Journal of Nervous & Mental Disease, 177(8), 487-491.

Ross, C. A., & Keyes, B. (2004). Dissociation and schizophrenia. Journal of Trauma & Dissociation, 5(3), 69-83.