Psychosis, Trauma and Dissociation

Evolving Perspectives on Severe Psychopathology

Andrew Moskowitz, Martin J. Dorahy, Ingo Schäfer, Andrew Moskowitz, Martin J. Dorahy, Ingo Schäfer

• Publisher: Wiley-Blackwell
• Year: 2018
• Print ISBN: 9781119952855
• eBook ISBN: 9781118586020
• Edition: 2
• Topic: Médecine
• Subtopic: Psychiatrie et santé mentale

An invaluable sourcebook on the complex relationship between psychosis, trauma, and dissociation, thoroughly revised and updated

This revised and updated second edition of Psychosis, Trauma and Dissociation offers an important resource that takes a wide-ranging and in-depth look at the multifaceted relationship between trauma, dissociation and psychosis. The editors – leaders in their field – have drawn together more than fifty noted experts from around the world, to canvas the relevant literature from historical, conceptual, empirical and clinical perspectives. The result documents the impressive gains made over the past ten years in understanding multiple aspects of the interface between trauma, dissociation and psychosis.   

The historical/conceptual section clarifies the meaning of the terms dissociation, trauma and psychosis, proposes dissociation as central to the historical concepts of schizophrenia and borderline personality disorder, and considers unique development perspectives on delusions and the onset of schizophrenia. The empirical section of the text compares and contrasts psychotic and dissociative disorders from a wide range of perspectives, including phenomenology, childhood trauma, and memory and cognitive disturbances, whilst the clinical section focuses on the assessment, differential diagnosis and treatment of these disorders, along with proposals for new and novel hybrid disorders. This important resource:

•       Offers extensive updated coverage of the field, from all relevant perspectives

•       Brings together in one text contributions from scholars and clinicians working in diverse geographical and theoretical areas

•       Helps define and bring cohesion to this new and important field

•       Features nine new chapters on: conceptions of trauma, dissociation and psychosis, PTSD with psychotic features, delusions and memory, trauma treatment of psychotic symptoms, and differences between the diagnostic groups on hypnotizability, memory disturbances, brain imaging, auditory verbal hallucinations and psychological testing

Written for clinicians, researchers and academics in the areas of trauma, child abuse, dissociation and psychosis, but relevant for psychiatrists, psychologists and psychotherapists working in any area, the revised second edition of Psychosis, Trauma and Dissociation makes an invaluable contribution to this important evolving field.

Part I
Historical and Conceptual Perspectives

1
Defining Psychosis, Trauma, and Dissociation: Historical and Contemporary Conceptions

Andrew Moskowitz, Markus Heinimaa, and Onno van der Hart

Prior to considering the range of potential relationships between trauma, dissociation, and psychosis, to which the rest of this book is dedicated, it is important to spend some time considering how these terms have been used over time, and the advantages and disadvantages of each. In this chapter, we review the etymology and historical uses of the terms psychosis, trauma, and dissociation, emphasizing current popular uses. Each term has been used in a range of ways, some more problematic than others. While only limited effort has been expended in defining trauma in recent years, and hardly any effort has been expended for psychosis, the definition of dissociation has received considerable attention in the literature, with a number of different definitions proposed (see Dell & O'Neil, 2009 and Nijenhuis & Van der Hart, 2011, for extended discussion of this issue). Following an overview of current uses of these terms, we present our recommendations as to how they might be most usefully employed. The authors of other chapters in this book are not bound by our recommendations, but the following discussion should allow the reader to carefully consider the use of these concepts throughout this volume and elsewhere.

Consideration of the meaning of the terms psychosis, trauma, and dissociation illuminates several tensions. The most prominent involves the relation between the person and the world, including other individuals. The question is whether any of our terms of interest can be adequately defined by reference to only the person or only the world. For example, the disturbances seen as part of psychosis, such as delusions, have long been considered to reside in the individual. However, we will consider here whether the concept psychosis can really be used without reference to other persons. Likewise, trauma is increasingly being seen as a specific event or events to which an individual is exposed, but attempting to locate the meaning of this term in the ‘outside world’ without reference to an individual's interpretation of the specific spatiotemporal context, appears fraught with difficulty (Nijenhuis, 2017). A second, related, tension involves the grounding of these concepts in real life experiences. By definition, trauma requires exposure to a challenging event, which is central to its meaning. In contrast, psychosis has often been seen as behaviour or language that fundamentally cannot be understood – is incomprehensible. But if psychotic symptoms, such as delusions, actually arise from challenging life events in ways that can be understood, does that then make them not psychotic? These issues will be explored below.

Psychosis

Etymology and Historical Conceptions

Severe forms of psychological and behavioural dysfunction have been recognized since ancient times, leading to the development of concepts such as ‘insanity’, ‘mania’, and ‘dementia’. The term ‘psychosis’ was introduced as an alternative term in the mid‐nineteenth century by the Austrian physician Ernst von Feuchtersleben (Beer, 1995). In his 1845 book (von Feuchtersleben, 1845) Lehrbuch der Ärztlichen Seelenkunde (translated into English as The Principles of Medical Psychology), von Feuchtersleben used the term ‘psychosis’ – derived from the Greek ‘psyche’ for ‘mind or soul’ (literally, ‘animating spirit’), followed by the Latin suffix ‘'osis’ for ‘abnormal condition’ – to refer to an ailment where both the body and the soul were sick (i.e. a disease that affected ‘the whole person’). His coinage was a response to the early nineteenth‐century debate in German psychiatry between Psychiker and Somatiker – those who located mental disease in the ‘soul’ and those who located it in the ‘body’. Feuchtersleben's new term was an attempt to mediate between these two groups and reconcile their opposing views.

Late nineteenth‐century and early twentieth‐century nosologies largely shared this conception of personhood as the primary locus of psychoticism (and schizophrenia). For Kraepelin, for instance, Dementia Praecox involved a ‘destruction of personality’ (Berrios & Hauser, 1988) and Bleuler (1949) maintained that

A schizophrenic … is not … a sick personality due to alterations in single psychological functions. Quite to the contrary, we notice in him single altered functions because his personality as a whole is sick (p. 288).

As the twentieth century developed, two divergent major trends could be recognized. In Europe, and particularly England, Kraepelin's narrow concept of schizophrenia/dementia praecox held the day, but in the United States a much broader conception was in use. The latter was influenced by Bleuler's notion of disturbed associative processes as central to schizophrenia and Freud's view of psychosis as a defect in ‘reality testing’. These conceptions were common in settings where psychodynamic thinking was dominant, such as the psychiatric community in the United States in the mid‐twentieth century (Andreasen, 1989). Here, the boundaries of the concepts schizophrenia and psychotic were wide, with ‘borderlines states’ argued to manifest ‘reality distortion’ in subtle ways.

These conceptions figured heavily in the first American classificatory systems, the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐I, APA, 1952) and the DSM‐II (APA, 1968); the latter added the condition that psychosis had to ‘interfere grossly with an individual's capacity to meet the ordinary demands of life’ (APA, 1980, p. 368). By the late twentieth century, the corresponding international diagnostic system, the International Classification of Diseases (ICD), was defining psychosis in a similar way. For example, the ICD‐9 (WHO, 1977) defined ‘psychoses’ as mental disorders in which ‘impairment of mental function has developed to a degree that interferes grossly with insight, ability to meet some ordinary demands of life or to maintain adequate contact with reality’ (p. 410). Level of functioning, however, was not emphasized in the DSM‐III (APA, 1980) or DSM‐III‐R's (APA, 1987) definitions of ‘psychosis’, perhaps because the revised diagnosis of schizophrenia now required evidence that current level of functioning was ‘markedly below’ previous levels. The DSM‐III defined ‘psychotic’ as a ‘gross impairment in reality testing’ (APA, 1980, p. 367) while the DSM‐III‐R added ‘… and the creation of a new reality’¹ (APA, 1987, p. 404). The presence of specific psychotic symptoms was considered ‘direct evidence’ of psychosis.

Current Conceptions

In the DSM‐IV (APA, 1994), DSM‐5 (APA, 2013), and the ICD‐10 (WHO, 1992), the trend to emphasize psychotic symptoms in the conception of psychosis reached its apex. Here, psychosis is simply defined as the presence of certain psychotic symptoms. This is most clearly stated in the ICD‐10 (WHO, 1992).

‘Psychotic’ has been retained as a convenient descriptive term …. Its use does not involve assumptions about psychodynamic mechanisms...

Table of contents

• Cover
• Table of Contents
• About the Editors
• Foreword from the Trauma Field
• Foreword from the Psychosis Field
• Introduction
• Part I: Historical and Conceptual Perspectives
• Part II: Research Perspectives
• Part III: Clinical Perspectives
• Index
• End User License Agreement