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Psychosis, Trauma and Dissociation: Emerging Perspectives on Severe Psychopathology

ISBN: 978-1-119-96522-0
380 pages
August 2011
Psychosis, Trauma and Dissociation: Emerging Perspectives on Severe Psychopathology (1119965225) cover image
In the 100 years since Eugen Bleuler unveiled his concept of schizophrenia, which had dissociation at its core, the essential connection between traumatic life events, dissociative processes and psychotic symptoms has been lost. Psychosis, Trauma and Dissociation is the first book to attempt to reforge this connection, by presenting challenging new findings linking these now disparate fields, and by comprehensively surveying, from a wide range of perspectives, the complex relationship between dissociation and psychosis.

A cutting-edge sourcebook, Psychosis, Trauma and Dissociation brings together highly-respected professionals working in the psychosis field with renowned clinicians and researchers from the fields of traumatic stress, dissociation and the dissociative disorders, and will be of interest to those working with or studying psychotic or dissociative disorders, as well as trauma-related conditions such as borderline personality disorder or complex post-traumatic stress disorder. It makes an invaluable contribution to the burgeoning literature on severe mental disorders and serious life events.  The book has three sections:

  • Connecting trauma and dissociation to psychosis - an exploration of the links between trauma, dissociation and psychosis from a wide range of historical and theoretical perspectives.
  • Comparing psychotic and dissociative disorders - a presentation of empirical and clinical perspectives on similarities and differences between the two sets of disorders.
  • Assessing and treating hybrid and boundary conditions - consideration of existing and novel diagnostic categories, such as borderline personality disorder and dissociative psychosis, that blend or border dissociative and psychotic disorders, along with treatment perspectives emphasising humanistic and existential concerns.
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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 Erdinc¸ 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

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"Overall, the book suggests an exciting, more integrated perspective on understanding psychopathology. Well written, thought provoking and intellectually challenging, it serves to question current approaches to our patients and outlines the need for arguably very different styles of working in the future." (International Journal of Culture & Mental Health, 27 May 2011)

"Editors Andrew Moskowitz, Ingo Schafer, and Martin J. Dorahy have amassed contributions from eminent scholars around the world who undertake a serious and thoughtful exploration of the backgrounds, development, and overlaps in the different perspectives of how the mind is disrupted by psychosis and dissociation ...Taken together, these papers demonstrate the complexity and depth of our understanding to date. Psychosis, Trauma and Dissociation: Emerging Perspectives on Severe Psychopathology is a rich resource to return to again and again. I recommend it for those who enjoy the challenge of reading some of the best thinkers to date. " (Journal of Trauma and Dissociation, October 2010)

"This book is an excellent source book for historians, researchers and clinicians in the field of psychiatry interested in learning more about how the concepts of dissociation, trauma and psychosis inform one another." (Psychiatric Rehabilitation Journal, January 2010)

"This very interesting book not only connects traumatic experiences with dissociative and psychotic consequences, but clarifies the research into the nature of these links." (Psychosis, July 2009)

"This useful and interesting book is well written and lays out its arguments for the connections between trauma/dissociation/psychosis clearly and cogently." (Doody's, April 2009)

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