Trauma    

Trauma  before  PTSD  

•  PTSD  included  in  DSM  3  (1980)  •  Prior  to  that,  trauma  recognised  as  producing  emoAonal  numbness,  followed  by  a  period  of  anxiety,  poor  sleep,  nightmares,  painful  recollecAons  and  avoidance,  which  gradually  fades,  with  return  to  baseline  mental  health.  

•  Occurrence  and  course  influenced  by  temperament,  predisposiAon.  

Trauma  

“mental  shock”  Something  overwhelming.  Sudden  fright.  An  event  that  shaMers  peoples  assumpAons.  

1800’s  

•  American  Civil  War.    Soldiers  heart.  •  AQer  Franco  Prussian  war  of  1871,  wards  for  treatment  of  hysterical  men  were  opened  

Spinal  concussion  

•  19th  century.  Disturbances  in  nervous  system  may  be  produced  by  the  physical  impact  of  e.g.  Railway  accidents  

Charles  Dickens  

•  1865  train  crash.  •  A  year  later                    “I  have  sudden  vague  rushes  of  terror  even  when  riding  in  a  Hanson  cab,  which  are  perfectly  unreasonable  but  quite  insurmountable”  

Herbert  Page  1885  

“it  could  be  an  advantage  to  the  vicAm  to  have  actually  experienced  physical  injury  …  the  bodily  injury  saAsfies  the  requirements  of  the  paAent  himself  in  seeking  an  explanaAon  of  the  symptoms  present  aQer  the  accident”  

Railway  Spine                      “a  strong  and  healthy  man  reduced  by  apparently  inadequate  causes  to  a  state  in  which  all  control  of  the  emoAons  is  well  nigh  gone;  who  cannot  sleep  because  he  has  before  his  mind  an  ever-­‐  present  sense  of  the  accident;  who  starts  at  the  least  noise;  who  lies  in  bed  almost  afraid  to  move;  whose  heart  palpates  when  ever  he  is  spoken  to,  and  who  cannot  hear  or  say  a  word  about  his  present  condiAon  and  his  future  prospects  without  bursAng  into  tears”                  

                                                                                                                       (Herbert  Page,  1883)  

Charcot  

•  Saw  vicAms  of  Railway  spine  and  other  accidents  as  affected  by  hysteria  

•  Influenced  Freud,  considered  hysteria  due  to  repressed  memories  of  traumaAc  events  

Pierre  Janet  

DissociaAon  •  Predisposed  personaliAes,  if  traumaAsed,  their  ideas  and  behaviours  get  separated  from  consciousness.  PaAents  present  with  hysteria,  and  loss  of  memory  for  the  incident  

SeducAon  Theory  

Breuer  and  Freud  1885  “  hysterical  symptoms  are  residues  of  profoundly  moving  experiences,  which  have  been  withdrawn  from  everyday  consciousness  …  their  form  is  determined  by  details  of  the  traumaAc  effects  of  the  experiences  …  therapeuAc  prospects  lie  in  the  possibility  of  gebng  rid  of  their  “repression”  to  allow  part  of  the  unconscious  psychical  material  to  become  conscious  and  thus  to  deprive  it  of  pathogenic  power”  

World  War  1  Shell  Shock  

•  80  000  BriAsh  soldiers.  •  IniAal  uncertainty.  Is  shell  shock  psychogenic,  or  a  organic  result  of  close  proximity  to  explosions?  

•  Undermined  the  idea  that  mental  Disorder  was  the  result  of  an  unsound  personality.  

•  “forward  psychiatry”  pioneered,  aQer  it  was  noAced  that  removal  of  soldiers  to  the  rear  didn’t  help  them  return.  

WW  2  

•  US  screened  out  the  poorly  adjusted  •  SAll  had  10%  psychiatric  casualAes  in  Europe,  oQen  affecAng  the  bravest  of  soldiers.  

•  WW  2  “PIE”,  “Forward  Psychiatry”  

DSM  1  

“Gross  stress  reacAon”  

1960’s  

•  Vietnam.  Few  psychiatric  casualAes  in  1965-­‐7  (before  the  anA-­‐war  movement)  

•  DSM  2  –  1968,  didn’t  include  trauma  syndromes  

The  Stress  Response  Syndrome  

Mardi  Horowitz,  1976  •  Intrusive  experiencing  •  Avoidance  •  EmoAonal  numbing  

1970’s  

PoliAcal  lobbying  for  a  new  diagnosis  •  Vietnam  vets  •  BaMered  women’s  groups.  

Birth  of  PTSD  

•  USA  draQees  involved  in  an  unpopular  war.  •  Much  poliAcal  interest  in  vicAm  veterans.  •  “Post  –  Vietnam  syndrome”  •  Growing  incenAves  (excuse,  enAtlement)  in  70’s  for  distressed,  maladjusted  individuals  to  aMribute  their  difficulAes  to  the  Vietnam  war.  

AQer  PTSD  described  

•  Massive  increase  in  traumatology.  •  1988  study  of  Vietnam  veterans,  479  000  had  PTSD  15  years  aQer  the  war,  nearly  a  million  (31%)  had  “full  blown”  PTSD  at  some  stage.  Only  300  000  had  been  aMached  to  combat  units.  

•  Massive  increase  in  skepAcal  accounts  of  validity  of  PTSD  diagnosis  and  therapy.  

US  Comorbidity  study  of  PTSD  

•  7.8%  lifeAme  prevalence.  •  Comorbid  with  alcohol  dependence,  depression  and  other  anxiety  disorders.  

DSM  5  

Trauma  and  Stress  Related  Disorders  •  ReacAve  aMachment  disorder.  •  Disinhibited  social  engagement  disorder.  •  Post  traumaAc  stress  disorder.  •  Acute  Stress  Disorder.  •  Adjustment  Disorder.  •  Other  and  unspecified.  

Acute  Stress  Disorder  

•  Symptoms  typically  begin  immediately  aQer  the  trauma.  

•  Diagnose  if  symptoms  last  3  days  to  1  month  aQer  trauma.  

•  Guilt,  panic,  reckless  behaviour:  v  common.  •  Predicts  later  PTSD.  

DSM  5  PTSD  

•  Contains  subjecAve  and  objecAve  elements.  •  4  symptom  clusters.  Many  paAents  do  not  have  all  4  clusters.  

DSM  4        PTSD            A  

 •  Directly  experiences  the  traumaAc  event.  •  Or  witnesses  it.  •  Or  learns  of  it  happening  to  a  close  family  member  or  close  friend.  (but  death  from  natural  causes  doesn’t  count)  

•  Or  repeated  and  extreme  exposure  to  aversive  details  (e.g.  first  responders,  police  officers).  (doesn’t  apply  to  exposure  through  electronic  media,  television  …  Unless  this  exposure  is  work  related)  

 

DSM  5          PTSD          B  

One  or  more  Intrusion  symptoms  •  Recurrent  and  intrusive  distressing  recollecAons.  •  Recurrent  distressing  dreams.  •  DissociaAve  reacAons.  E.g.  flashbacks.  •  Intense  or  prolonged  distress  at  exposure  to  cues  that  symbolize  or  resemble  an  aspect  of  the  traumaAc  event.  

•  Marked  physiological  reacAvity  on  exposure  to  cues.  

DSM  5            PTSD          C  

Persistent  Avoidance  of  sAmuli  associated  with  the  trauma.  One  or  both  of:  

•  Avoidance  of  distressing  memories,  thought  or  feelings  about  or  closely  related  to  the  traumaAc  event.  

•  Avoidance  of  external  reminders  that  arouse  distressing  memories,  thought  or  feelings  about    the  traumaAc  event.  

DSM  5      PTSD            D  

NegaAve  alteraAons  in  cogniAons  and  mood  associated  with  the  traumaAc  event.  Two  or  more  of:  

•  Inability  to  remember  an  important  part  of  the  event.  

•  Perssitetn  and  exaggerated  negaAve  beliefs  about  self  or  world.  

•  Persitent  disotorted  ogniAons  abut  the  cause  or  consequences  of  the  event.  

DSM  5    PTSD      D  conAnued  

•  Persistent  negaAve  emoAonal  state  •  Markedly  diminished  interest  or  parAcipaAon  in  significant  acAviAes  

•  Feelings  of  detachment  or  estrangement  from  others  

•  Persistent  inability  to  experience  posiAve  emoAons  

DSM  5        PTSD        E  

Marked  alteraAons  in  arousal  and  reacAvity.  Two  or  more  of:  •  Irritable  behaviour  and  angry  outbursts.  •  Reckless  or  self  destrucAve  behaviour.  •  Hypervigilance  •  Exaggerated  startle  •  Problems  with  concentraAon  •  Sleep  disturbance.  

DSM  5    PTSD  

•  DuraAon  of  disturbance  is  over  1  month.  •  ~  50%  start  with  Acute  Stress  Disorder.  •  Causes  clinically  significant  distress  or  impairment  

•  Different  criteria  for  children  

Traumas  

•  Gunfire  •  Explosions  •  Combat  •  Assault  •  Handling  dead  bodies  •  Witnessing  events  •  Witnessing  events  on  

television.  •  Giving  birth  •  Hearing  bad  news  •  Learning  of  spouse’s  affair  •  Being  stalked  

•  Rape  •  RTA  •  Accident  •  Natural  disaster  •  Bereavement  •  Illness  •  Injury  •  Psychiatric  admission  •  Restraint  &  Seclusion  •  Hostage  •  Bullying  •  Work  stress  •  Witnessing  RTA  

Measuring  trauma  

•  ObjecAve  severity  •  SubjecAve  severity  

trauma  

•  Accidental  or  deliberate:  important?  Yes.  •  Anger  •  Trust  •  Self  blame  •  compensaAon  

Severity  of  trauma,  means?  

•  DuraAon  •  Surprise  •  Injury  •  Threat  •  A  quesAon  of  appraisal  

Risk  factors  for  PTSD  In  order  of  importance...  •  Lack  of  social  support  •  Post  traumaAc  life  stress  •  SubjecAve  Trauma  severity    •  Other  Adverse  child  experience  •  Low  IQ  •  Low  socioeconomic  status  •  Childhood  abuse  •  Female  •  Psychiatric  Hx  •  Lack  of  educaAon    

Age  and  ethnicity  appear  unimportant  (  Brewin    et  al,  2000,  a  meta  analysis  of  77  studies)  

Before  the  trauma  

•  Temperament:  childhood  emoAonal  problems,  mental  disorder.  

•  Environmental.  •  Low  socioeconomic  status,  previous  trauma,  family  dysfuncAon.  

•  Physiological.  Female,  youth.  

During  the  trauma  

•  Severity  of  trauma.  •  ProspecAve  studies  indicate  dissociaAve  experiences  at  the  Ame  of  the  truama  predict  later  PTSD.  

•  For  soldiers:  killing,  perpetraAng  atrociAes  

AQer  the  trauma  •  Subsequent  life  stress  and  poor  social  support  predict  PTSD  (  in  prospecAve  studies  –  although  many  PTSD  symptoms  may  provoke  these)  

•  ProspecAve  studies  of  early  social  support  suggest  it  is  a  cause,  not  just  an  effect.  

•  NegaAve  reacAons  of  others.  •  Acute  stress  disorder.  •  Subsequent  financial  or  other  trauma  related  stressors.  

•  Poor  family  support.  •  Avoidance  of  unwanted  thoughts.  

ShaMered  illusions  

•  If  shaMered  illusions  about  a  kind  world  is  important  in  genesis  of  PTSD,  we  might  expect  childhood  trauma  to  protect:  but  it  does  not.  

Course  •  AQer  a  severe  trauma,  most  meet  cross  secAonal  PTSD  criteria.  

•  Most  resolve  over  ~  3  months.  •  Those  with  enduring  distress  aQer  ~  6  months  need  intervenAon.  

•  Some  have  delayed  onset,  months  or  years  later.  •  Can  be  recurrent:  when  a  person  has  powerful  reminders  or  major  life  changes.  

•  High  levels  of  anger,  and  negaAve  interpretaAon  of  symptoms  predict  slower  recovery  

Comorbidity  

•  Seen  in  >50%  •  Depression,  drug  abuse,  anxiety,  dissociaAve  disorders,  psychosomaAc  disorders,  personality  disorder.  

•  Psychosis.  •  A  consequence,  or  predaAng  the  PTSD?  US  NaAonal  comorbidity  survey  suggests  depression  and  addicAon  are  likely  consequences  of  PTSD.  Anxiety  may  be  more  independent.  

CriAcizing  PTSD  

•  DiagnosAc  criteria  are  broad  and  imprecise.  •  Discourages  broad  clinical  assessment  and  formulaAon  that  takes  account  of    biography,  temperament,  social  circumstances,  and  values  independent  informants.  

•  The  normal  response  to  fear,  which  tends  to  be  prompt  and  acute,  has  morphed  into  something  delayed,  and  chronic.  

McHugh  &  Treisman  2007  J  of  Anxiety  Dis,  21,  211-­‐222  

   “  Of  all  the  faddish  postulates  that  cluMer  the  contemporary  diagnosAc  landscape  of  psychiatry,  none  is  more  pervasive  than  PTSD.  Its  themes  and  alleged  psychopathology  fill  the  journals  and  are  discussed  incessantly  in  the  clinics.  Grief  and  trauma  ‘counselors’  now  flock  to  every  disaster  and  intrude  upon  the  survivors,  jusAfying  their  acAons  as  prevenAng  PTSD”  

•  Soldiers  in  warAme  made  worse  by  diagnosis  of  mental  disorder.  

Stolen  Valour  

BurkeM  &  Whitley,  1998  •  Vietnam  vets  no  more  at  risk  of  problems  than  veterans  of  other  conflicts  

•  Lots  of  people  make  up  their  combat  history  

DissociaAon  and  PTSD  •  PTSD  “Flashbacks”    originally  considered    dissociaAve.  •  now  more  an  emoAve  term  for  unpleasant  recollecAon.  •  DissociaAon  someAmes  defined  as  any  temporary  

breakdown  in  the  relaAvely  conAnuous,  interrelated  processes  of  perceiving  the  world.    

•  Mild  dissociaAve  reacAons  are  common  under  stress,  •  e.g.  96%  of  soldiers  undergoing  survival  training.  •  DissociaAve  symptoms  commonly  encountered  in  

trauma        -­‐  emoAonal  numbing,    derealizaAon,    depersonalizaAon,  and  ‘out-­‐of-­‐body’  experiences  -­‐  related  to  the  severity  of  the  trauma,  fear  of  death,  and  feeling  helpless.    

Complex  PTSD  

•  Herman  1992  •  PTSD  oQen  has  associated  features  –  personality  disturnabce,  somaAsaAon,  mood  disturbance,  dissociaAve  symptoms.  

•  Argued  to  result  from  repeated  and  severe  childhood  trauma.  

“Complex  PTSD”  Marked  by  •  Altered  self  capaciAes:  regulaAon  of  affect,  interpersonal  relaAons,  concept  of  self  

•  Poor  self  esteem,  self  blame,  expectaAons  of  rejecAon  

•  Disturbed  mood:anger,  irritability,  aniety  depression.  

•  Avoidance:  dissociaAon,  drug  missuse.  •  Somatoform  distresss  •  And  more  convenAonal  PTSD  symptoms  

Complex  PTSD  

       Herman  J  (  1992)  Complex  PTSD:  a  syndrome  in  survivors  of  prolonged  and  repeated  trauma.  Journal  of  TraumaAc  Stress,  5,  377-­‐391.  

 -­‐  Argues  that  trauma  is  the  origin  of  borderline  personality  

What  counts  as  trauma  

•  Depends  greatly  on  social  context  

Many  different  Kinds  of  events.  •  RTA  

A  trauma  is  not  a  single  event  •  Injury  •  Painful  rehabilitaAon  •  Police  interview  •  Court  appearance  •  Anger,  self  blame  •  Hurxul  comments  •  Loss  of  work  and  income  •  loss  of  role  •  Incapacity  •  Bereavement  •  Uncertainty  about  outcome  •  Disputes  about  liability  

CompensaAon  

•  ResoluAon  of  court  case  or  compensaAon  claim  is  not  generally  followed  by  recovery  

Lies?  

•  13%  of  combat  veterans  referred  to  the  UK  defence  psychiatric  service  make  facAAous  claims  of  combat  exposure  or  military  service.  

•  US  NaAonal  Vietnam  Veterans  Readjustment  study.  30%  of  Veterans  have  PTSD  –  twice  as  may  as  saw  combat.  

•  Freuh  et  al  (2005)  100  Vietnam  veterans  seeking  Rx  for  combat  trauma:  32  hadn’t  seen  combat.  5%  hadn’t  been  in  Vietnam.    

SkepAcs  

•  Not  an  independent  enAty  different  from  anxiety  or  depression.  

•  Diagnosis  lacks  specificity.  •  Individual  symptoms  are  not  unique  to  PTSD.  

Allan  Young,  1997  

“The  disorder  is  not  Ameless,  nor  does  it  possess  an  intrinsic  unity.  Rather  it  is  glued  together  by  the  pracAces,  technologies  and  narraAves  with  which  it  is  diagnosed,  studied,  treated  and  represented  and  by  the  various  interests,  insAtuAons  and  moral  arguments  that  mobilise  these  efforts  and  resources”  

Blame  

•  Groups/individuals  felt  to  be  culpable  are  seen  as  less  deserving  of  diagnosis  or  compensaAon.  

Sympathy  for  vicAms  

•  OQen  prominent,  early  on.  •  But  can  wear  out.  •  Onlookers  can  feel  helpless.  VicAms  can  be  discomforAng:  responses  include  the  sympatheAc,  and  also  distancing.  

Mental  defeat  (Anke  Ehlers)  

~  helplessness  •  Perceived  loss  of  autonomy  •  Giving  up  efforts  to  maintain  ones  own  idenAty  

Common  experiences  

•  Experiencing  powerlessness  •  Feeling  inferior  •  Self  blame,  guilt  (  survivor  uilt)  •  Feeling  stupid  •  Lacking  a  future,  feeling  permanently  damaged  •  Other  do  not  understand  •  A  sense  of  betrayal  •  PosiAve  change:  Feeling  stronger,  more  appreciaAve  of  life  

Flashbacks  

•  Vivid  •  Full  of  sensory  detail  •  OQen  fragmented  •  The  horror  is  re-­‐experienced  •  Normal  sensaAons  are  excluded.  The  person  is  relaAvely  unresponsive  to  the  social  situaAon  

•  Usually  follow  triggers,  which  become  objects  of  avoidance.  

Recovered  memory  

•  Some  paAents  recover  memories  of  abuse  in  therapy.  

•  Some  therapists  seek  this,  may  have  joint  moAvaAon  and  theoreAcal  commitment  to  recovered  memory.  

•  “You  remember  this,  but  what  happened  next,  what  do  think  happened,  why  do  you  think  you  can’t  remember”  

Recovered  memory  

•  Based  on  idea  of  repression  –  we  forget  what  is  too  horrible  to  remember.  The  forgoMen  events  enter  consciousness  in  disguised  forms  and  cause  apparently  unrelated  problems,  which  can  be  treated  by  rediscovering  the  forgoMen  event  

memory  

•  Strong  emoAons  are  responsible  for  beMer  or  worse  memory  (studies  conflict).  

•  Flashbulb  memory  –  seems  to  improve  recall.  •  EmoAons  that  narrow  aMenAon  are  likely  to  worsen  memory.  

•  Weapon  focusing  –  recall  of  other  aspects  suffer.  

Freud  

•  Repression:  a  defence  mechanism.  •  The  purpose  of  analyses  was  to  liQ  the  repression  of  unacceptable  mental  content  that  was  excluded  from  awareness.  

•  1893  Freud  and  Breuer.  Trauma  is  repressed  –  bring  it  to  consciousness  and  so  heal  hysteria.  

Freud  

•  1896.  Early  sexual  trauma  causes  later  psychological  disturbance  (the  seducAon  theory).  

•  Later.  Repression  is  of  infanAle  drives  and  wishes,  rather  than  of  events  

Freudian  repression  

•  Referred  to  an  unconscious  process,  not  under  voluntary  control,  and  to  a  “turning  way”  from  things  that  have  already  had  some  conscious  processing  (  AKA  suppression”,  and  “moAvated  forgebng”).  This  may  be  commonplace,  and  allow  for  accurately  recovered  memory  

Forgebng  Trauma?  

Q.  Surely,  if  it  really  was  “traumaAc”,  people  wouldn’t  forget  it?  

A.  No  one  knows.  And  it  might  depend  on  what  is  meant  by  traumaAc  

Memory  

•  Amnesia  for  traumaAc  events  noted  in  ww1  shell  shock  –  in  absence  of  brain  injury.  

•  From  what  age  can  people  form,  for  later  recovery,  memories?  

Repression  

•  Unfalsifiable.  •  A  record  of  events  is  not  accurately  stored  in  the  brain.  

•  Memory  is  sketchy,  reconstrucAve,  decays  over  Ame,  is  corrupted  by  current  bias,  incorporates  post  event  informaAon  that  becomes  indisAnguishable  from  the  actual  event.  

1990’s  Memory  wars  

•  1980’s  increasing  recogniAon  of  prevalence  of  CSA,  and  service  provision.  

•  Some  paAents  recalled  previously  forgoMen  memories.  

•  Linked  to  MulAple  personality  •  Much  angry  rhetoric  

•  Some  therapists  did  assume  recovered  memory  were  likely  to  be  accurate.  

•  Some  use  age  regression  techniques  and  hypnosis  –  in  a  suggesAble  compliant  paAents  

•  Much  rhetoric  about  needing  to  believe  the  vicAm  

Elizabeth  LoQus  •  Recovered  memories  are  oQen  highly  unusual.  •  Events  oQen  occur  at  an  age  too  young  for  veridical  memory.  

•  Typically  no  corroboraAon.  •  Some  therapists  had  a  fixed  idea  about  the  ubiquitous  influence  of  CSA.  

•  Techniques  such  as  guided  imagery  likely  to  reveal  whatever  memory  was  assumed  to  be  there.  

•  i.e.  False  memories  do  occur.  

The  courage  to  heal  

Bass  and  Davis  (1988)  •  “for  many  survivors,  remembering  is  the  first  step  in  healing”  

•  “if  your  memories  are  incomplete,  even  if  your  family  insists  nothing  ever  happened,  you  sAll  must  believe  yourself”  

•  “If  you  think  you  were  abused  and  your  life  shows  the  symptoms,  then  you  were.”  

False  Memory  

•  How  common?  Data  comes  from  surveys,  and  from  False  memory  socieAes.  

•  Can  memories  of  Sex  abuse  be  forgoMen,  and  then  recovered?  Several  studies  say  so.  –  Perhaps  they  just  needed  to  be  asked.  

Recovered  Memory  

•  Content  someAmes  bizarre.  •  Memories  are  someAmes  corroborated.  •  TherapeuAcally  helpful?  

Child  sex  abuse  

•  Is  necessarily  harmful?  •  If  we  assume  so,  we  begin  examinaAon  of  an  abused  person  in  search  of  a  mental  injury  already  assumed  to  be  present  

Child  sex  abuse  

•  A  risk  factor  for  later  mental  disorder  

Notes  for  assessment  •  Pre  trauma  Hx.  What  is  baseline  funcAoning.  •  Immediate  pretrauma  psychosocial  context.  •  The  traumaAc  event.  Single  or  mulAple.  Degree  of  danger.  Injury.  DuraAon.  

•  The  meaning  of  the  trauma.  •  Post  trauma  psychosocial  context.    •  Responses  of  family  and  social  agencies  •  Evidence  of  exaggeraAon  or  zricaAon  •  comorbidity  •  secondary  gain  

Drug  treatment  of  PTSD  

•  Some  evidence  for  SSRI  and  Venlafaxine.  •  Effect  not  rapid.  Persist  for  3  months.  •  Less  good  evidence  for  Phenelzine,  Lamotrigine,  &  Mirtazapine.  

•  Olanzapine  or  Risperidone  if  other  approaches  fail.  

Psychological  Rx  

•  Trauma  focused  CBT.  •  Exposure,  (an  hour,  daily  or  more,  habituaAon.  Can  be  imaginal  exposure  or  real  life  exposure  to  avoided  sAmuli)  

•  Anxiety  management/stress  inoculaAon.  •  CogniAve  therapy.  Address  fear,  shaMered  assumpAons  and  negaAve  schemata  

Psychological  Rx  

•  Anxiety  management  (educaAon  on  nature  of  anxiety,  muscle  relaxaAon,  controlled  diaphragmaAc  breathing,  thought  stopping,  cogniAve  restructuring,  guided  self  dialogue,  problem  solving  –  breaking  difficulAes  into  their  components,  role  playing)  

•  Does  rediscovering  old  memories  help?  

Debriefing  

•  Mitchell  model/criAcal  incident  stress  debriefing.  

•  A  prevenAon  approach,  originally  for  emergency  workers.  

•  Talking  about  the  incident  and  feelings  about  it  is  promoted  in  group.  

•  RCT’s  demonstrate  ineffecAve.  

Psychodynamics  

5  defences  commonly  considered.  •  Denial  •  DissociaAon  (  argued  to  account  for  amnesia  and  flashbacks)  

•  Splibng  (  lose  holisAc  view  of  others,  e.g.  all  men  are  bad).  

•  IdenAficaAon  with  the  aggressor.  •  ProjecAon(  unacceptable  feelings  aMributed  to  others)  

“Psychogenic  Psychosis”  

DSM  4  

Brief  PsychoAc  Disorder  •  Sudden  onset.  •  The  disturbance  is  less  than  one  month.  •  The  individual  recovers  fully.  •  OQen  occurs  in  response  to  marked  stressors.  (DSM  3  R  category  -­‐  “brief  reacAve  psychosis”  

DSM  4  Brief  psychoAc  episode  

•  Typically  emoAonal  turmoil  or  overwhelming  confusion.  

•  Personality  disorder  may  predispose.  

Jaspers  1913  PrecipitaAon  Psychoses  –  where  the  psychoAc  content  is  unrelated  to  the  precipitaAng  factor.  

 Contrasted  with…    

ReacAve  psychoses.    •  The  content  is  understandable  reflecAon  of  the  cause.  

•  The  psychosis  would  not  have  occurred  without  it.  

•  Removal  of  the  stressor  resolves  the  psychosis.  

Psychogenic  Psychosis  August  Wimmer,  1916        “Psychogenic  psychoses…  generally  on  a  predisposed  terrain…  are  caused  by  psychic  factors…  decisive  for  the  Ame  of  erupAon  of  the  psychosis,  its  movements  (remissions,  intermissions,  exacerbaAons,  terminaAon).  Likewise,  in  form  and  content  the  psychosis  directly  and  completely  reflects  the  precipitaAng  psychic  casual  factor…  to  these  criteria  we  may  further  add  the  predominant  tendency  to  recovery”.  

“hysterical”  psychosis  

•  Some  brief  psychoAc  episodes  give  impression  of  intent  and  dissociaAon.  

•  No  consensus  on  how  dissociaAon  relates  to  psychosis.  

 

CSA  and  schizophrenia  

•  Parallels  between  SZP  symptoms  and  PTSD  symptoms?  

•  An  associaAon  

DissociaAon  

•  AlteraAons  in  conscious  awareness  that  are  defensive  changes  in  otherwise  integrated  thoughts,  feelings,  memories,  and  behaviours.  

•  Argues  to  reduce  the  distress  of  trauma.  •  A  hypothesis  masquerading  as  a  descripAon.