A Cognitive Approach to Understanding Trauma, Dissociation and Psychosis: research evidence and clinical implications

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• A Cognitive Approach to Understanding Trauma,
  Dissociation and Psychosis research evidence and
  clinical implications
• Tony Morrison
• School of Psychological Sciences, University of
  Manchester
• Psychosis Research Unit, GMWMHFT
• www.psychosisresearch.com

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Objectives

• Understand the relationships between trauma,
  dissociation and psychosis utilising a cognitive
  model
• Have an awareness of current evidence supporting
  this approach to understanding these links
• Development of case formulations and outline of a
  treatment approach
• Consider the implications of this approach for
  own clinical practice

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Read, J., van Os, J., Morrison, A. P., Ross, C.
A. (2005). Childhood trauma, psychosis and
schizophrenia a literature review and clinical
implications. Acta Psychiatrica Scandinavica,
112, 330-350.
Females 36 studies from 1984-2001 total sample
2318 Males 23 studies from 1987-2001 total
sample 1234
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Studies of Post-Psychotic PTSD
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Frame, L. Morrison, A.P. (2001) Causes of PTSD
in psychosis. Archives of General Psychiatry, 58,
305-306.
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Frame, L. Morrison, A.P. (2001) Causes of PTSD
in psychosis. Archives of General Psychiatry, 58,
305-306.
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Criteria for PTSD

• 1. Individual exposed to a traumatic event and
  responded with intense fear/distress
• 2. Persistently re-experience the event
• Intrusive recollections
• Recurrent dreams
• Reliving
• Intense distress at reminders

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Criteria for PTSD

• 3. Avoid trauma linked thoughts feelings and
  conversations
• Avoid activities, places ,people that trigger
  reminders
• Fail to recall part of the trauma
• Diminished interest
• Feels detached from others
• Unable to feel emotions normally appropriate to
  sits

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Criteria for PTSD

• 4. Increased arousal
• Sleep disturbance
• Irritability/anger outbursts
• Difficulty concentrating
• Hypervigilance
• Increased startle response

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Symptom Overlap

• Both disorders can be divided into positive and
  negative symptoms
• Shared PS. (Halldel similar to intrusions,
  threat appraisals flashbacks)
• Shared NS. (Numbing, responsiveness,
  concentration, derealisation, detachment,
  self-neglect withdrawal)
• Paranoia arousal, hypervigilence sleep
  problems common to both

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Cognitive factors

• Cultural unacceptability of appraisals and the
  cognitive and behavioural consequences of trauma
  may make people vulnerable to psychosis
• Negative beliefs about self, world and others
  (such as I am vulnerable and Other people are
  dangerous) have been shown to be associated with
  psychosis (Garety, Kuipers, Fowler, Freeman,
  Bebbington, 2001 Morrison, 2001)
• Such beliefs specifically formed as a result of
  trauma are related to psychotic experiences
  (Kilcommons Morrison, 2005)
• Positive beliefs about psychotic experiences
  (such as Paranoia is a helpful survival
  strategy) may also be related to traumatic
  experience, and have been shown to be associated
  with the development of psychosis (Morrison,
  Gumley, Schwannauer et al., 2005).

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Cognitive factors

• Psychotic experiences are essentially normal
  phenomena that occur on a continuum in the
  general population (Johns van Os, 2001).
• It would seem that the occurrence of trauma in
  the life history of a person experiencing such
  phenomena may represent the difference between
  patients and non-patients (Honig et al., 1998).
• It appears that catastrophic or negative
  appraisals of psychotic experiences result in the
  associated distress (Chadwick Birchwood, 1994
  Morrison, Nothard, Bowe, Wells, 2004), and that
  such appraisals are more likely if people have a
  history of trauma

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Morrison, A.P., Beck, A.T., Glentworth, D., Dunn,
H., Reid, G., Larkin, W. Williams, S. (2002)
Imagery and Psychotic Symptoms A Preliminary
Investigation. Behaviour Research and Therapy,
40, 1053-1062.

• 74.3 (n 26) were able to identify an image in
  relation to their psychotic symptoms.
• For those patients who were able to identify
  idiosyncratic images experienced in conjunction
  with their hallucinations and delusions
• 69.2 (18 out of 26) reported that their images
  were recurrent
• 96.2 (n25) were able to link the image to the
  experience of a particular emotion and to a
  particular belief
• 70.8 (n17) were able to associate the image
  with a memory for a particular event in their
  past.

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Morrison, A.P., Beck, A.T., Glentworth, D., Dunn,
H., Reid, G., Larkin, W. Williams, S. (2002)
Imagery and Psychotic Symptoms A Preliminary
Investigation. Behaviour Research and Therapy,
40, 1053-1062.

• Feared catastrophes associated with delusions
• Being chopped up with axes
• Self being pushed into an oven
• Self being cut in two by man wielding large sword
• Being led away to prison by two large policemen
• Memories of real traumatic life events
• Self rocking in a psychiatric hospital
• Being assaulted

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Morrison, A.P., Beck, A.T., Glentworth, D., Dunn,
H., Reid, G., Larkin, W. Williams, S. (2002)
Imagery and Psychotic Symptoms A Preliminary
Investigation. Behaviour Research and Therapy,
40, 1053-1062.

• Perceived source of psychotic experiences
• Neighbours in bedroom talking about me
• Spirits of friends and relatives surrounding head
• Man with beard shouting
• Image of black sphere of energy close to head
• Content of the voices
• Sexually abusing young girls
• Picture of sharp instrument stabbing someone

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Role of dissociation in model

• Dissociative experiences as trauma generated
  intrusions
• Grounding strategies
• Uncontrollable / dangerous?
• Unusual (psychotic) appraisals?
• Dissociation as a strategy
• Pros and cons (and evidence for these)
• Develop alternative strategies for safety

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Role of dissociation in model

• Procedural beliefs about dissociation (positive
  and negative)
• Evaluate accuracy and helpfulness
• Development alternatives
• Change bandwidth

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• On the next slide carry out the following
  instructions
• Stare at the blue dots while you count slowly to
  30.
• Then close your eyes and tilt your head back. A
  circle of light will slowly appear. Keep looking
  at it.
• What do you see?

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Common Components of CBT for PTSD Psychosis

• Therapeutic relationship / safety
• Problem list and goal setting
• Normalising/education
• Individualised formulations (collaboratively
  produced)
• Attribution, meanings beliefs (re trauma
  symptoms)
• Modification of safety-seeking behaviours
• Modification of imagery

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Clinical Implications

• Assessment and formulation-based intervention
  should incorporate potential developmental and
  maintaining factors such as
• Dissociation
• Interpretation of intrusions (especially as
  external and/or madness)
• Thought control strategies
• Safety behaviours
• Biases in memory and attention
• Imagery
• Procedural beliefs about vigilance, dissociation
  etc.

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Principles of Cognitive Therapy

• A cognitive model is required from which to
  empirically derive effective treatments
• FORMULATE USING MODEL
• What are you concerned about?
• SHARE A GOAL
• You are not mad, your difficulties are
  understandable
• NORMALISING MESSAGES AND LANGUAGE
• How you appraise events contributes to distress
• EVENT HOW MAKE SENSE HOW I FEEL WHAT I DO
• Either it is real or you believe it to be real
• SIT ON A COLLABORATIVE FENCE
• Test it out drop your safety-seeking responses
  
• EXPERIMENT IN OUT OF SESSION

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Formulation

• Normalise psychotic experiences, PTSD symptoms
  and emotions to reduce distress
• Have a plausible understanding of the antecedents
• basic/horizontal includes maintenance by
  dysfunctional responses
• role of stress, life events and trauma in
  developmental formulation

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Normalising information to decatastrophise
experiences

• Administration of the Maastricht Interview
• Material drawn from Think you are crazy think
  again
• Presentation and discussion of the Spot the
  voice hearer game
• Presentation and discussion of Eleanor Longdens
  TED talk
• Recovery stories
• Normalising information about relative prevalence
  of trauma and dissociation
• Conducting surveys

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Managing Dissociation

• Normalise strategy and symptoms
• Identify triggers
• Consent for therapy yellow and red cards
• Hold the pen and take the notes
• Consider current pros and cons vs. past
• Beliefs about controllability and experiments
• Physical grounding strategies
• Grounding objects
• Grounding phrases
• External focus of attention
• Current sensory cues to remain in present

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Recontextualising trauma

• Re-examination of meaning
• Role plays
• Imagery work
• Visit sites
• Responsibility pie charts
• Surveys

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Re-examine meaning of trauma

• modifying the main problematic appraisals related
  to the trauma and its consequences
• Im not normal and never will be I might
  have struggled with these experiences, but they
  are normal reactions to severe trauma and I am
  learning to cope with them
• I should have stuck up for myself no one
  could have fought-off adults
• Im vulnerable Im no more vulnerable than
  anyone else in fact, Im a strong, resilient
  person who has been in the Navy

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ACTION Assessing Cognitive Therapy Instead Of
Neuroleptics(formerly North Of Britain Treatment
Without Antipsychotics Trial)

• Two site single blind RCT with two conditions (CT
  plus TAU vs. TAU) for people with psychosis not
  taking antipsychotic medication (due to refusal
  or discontinuation)
• Assessments are 3 monthly following the initial
  baseline assessment (i.e. at baseline, 3, 6, and
  9 months)
• Follow-up assessments are at 12, 15 and 18 months
• Recruitment target of n80 final n 74

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ES -0.46
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gt50 PANSS Change

• At 9 months
• 7/22 CBT 32
• 3/23 TAU 13
• At 18 months
• 7/17 CBT 41
• 3/17 TAU 18
• NB 1 deterioration in CBT at 9 18 months
• 2 deteriorations in TAU at 18 months

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For people with confirmed treatment-resistant
schizophrenia that is unresponsive to an adequate
trial of clozapine (or unable to tolerate such a
trial), is CBT clinically and cost effective and
acceptable?
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Demographics
Variable Mean (SD/)
Age 43.04 (10.53)
Male Female ratio 273 109
Duration of psychosis 235.17 (124.50)
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Attrition at 9 months

• CBT plus TAU
• 100 completed
• 4 withdrawals
• 2 lost to follow-up
• TAU
• 105 completed
• 5 withdrawals
• 1 lost to follow-up

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Case study

• 1-8
• Problems and goals (confidence, self-esteem, low
  mood and self-harm, voices, low motivation)
• Formulation
• Continuum for low self-esteem
• Evidential analysis of self-critical thoughts
• Positive imagery
• Survey / results (judged, relationship, employ)

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Experiences that worry me Social situations Voices
What I make of it I am not good enough I must
harm myself Voices are bullies Others will harm
me
What I make of the self / world I am different I
am unimportant and worthless Need to be alert for
danger Other people cannot be trusted Others will
leave and reject me
How I feel Low mood Hopeless Anxiety Anger
What I do Try to stay in control of thoughts
Isolate self and withdraw Negative
comparisons Rituals Daydreaming / dissociation
Early experiences Family criticism Never fit
in Severe bullying at school and work Wrongful
arrest and harassment
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Case study

• 9-11
• Revisit goals
• Negative comparisons
• Im a failure
• Activity for mood
• 12-15
• Daydreaming and dissociation (normalising
  pros/cons diary modified GAD model)
• Voices

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Case study

• 16-18
• PTSD (grounding, attentional focus, reconsider
  meaning)
• 19-22
• Social anxiety (stop post-mortems, anticipation gt
  event, stop safety behaviours, external focus,
  update image)

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trigger Social situations
Negative thought Others will judge me Others will
reject me
Image of self Weak Vulnerable Hunched Ugly Very
skinny Unconfident Shaky
How I feel Anxiety Tense Palpitations Sweaty Shak
y
What I do Arrive late Avoid eye contact Only
speak to people I know Speak with hand over
mouth Doodle/fidget Hunch up and try to disappear
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Case study

• Progress
• I am good enough 0 80
• Social confidence 10 70
• I am different 100 50 (neutral)
• Im as important as others 0 80
• No flashbacks, no self-harm, no suicidal thoughts
• Voices only at night and managable
• Getting married
• Doing postgraduate course

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Implications for Mental Health Services

• Collaborative, hope inspiring relationships with
  service users
• Minimise the harm professionals can cause
• Choice of treatments
• Provision of normalising, recovery-orientated
  information
• Involvement of service users in planning,
  delivery development of services
• Measurement of recovery instead of symptoms as
  primary outcome

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Phases of therapy

• Assessment and enagement phase (approx sessions
  1-4)
• Introduction of strategies targeting dissociative
  phenomena/processes (approx sessions 5-14)
• Longitudinal Formulation/Cognitive Behavioural
  Change strategies phase (approx sessions 14-22)
• Consolidation phase (final 2 sessions)

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Dissociative focus

• Emphasises training and practice of skills to
  manage dissociative responses and increase
  perceived controllability of dissociation
• Distress tolerance skills and low arousal
  strategies
• Refocusing Use of grounding objects, images,
  statements and words
• Other emotional regulation, arousal management
  strategies, sleep hygiene
• Attention Training Technique (ATT Wells, 2009)

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Trauma and psychosis focus

• Trauma-related work (e.g. exposure, imagery work,
  cognitive restructuring informed by CT for PTSD)
  
• Additional work targeting maladaptive appraisal
  of dissociation using CT strategies or techniques
  adapted from meta-cognitive approaches (e.g.
  controlled dissociation period) 
• Cognitive and/or behavioural change strategies
  targeting core appraisals of voices/visions
  leading to related distress (e.g. beliefs about
  the power of voices controllability of
  voices/voices as a sign of losing control)
• Consolidate understanding of a developmental /
  longitudinal formulation of difficulties, which
  links them (many becomes one problem)

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Conclusions

• Trauma-induced psychosis exists
• Psychosis can cause PTSD
• Assess trauma history and PTSD
• Incorporate trauma and trauma-related processes
  in the formulation
• Intervention strategies derived from PTSD work
  can be useful (guided by formulation)
• Minimise harm / additional trauma from services

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Objectives revisited

• Understand the relationships between trauma,
  dissociation and psychosis utilising a cognitive
  model
• Have an awareness of current evidence supporting
  this approach to understanding these links
• Development of case formulations and outline of a
  treatment approach
• Consider the implications of this approach for
  own clinical practice