Trauma, Dissociation

1
Trauma, Dissociation Hallucinations A Critical
Review

• Barry Nurcombe, MD, FRANZCP
• James Scott, MBBS, FRANZCP
• Mary Jessop, MBBS, FRANZCP
• bnurcombe_at_uq.edu.au 5/6/07

2
Topics

• Hallucinations and pseudohallucinations
• Hallucinations in the general population
• The longitudinal course of hallucinations
• Hallucinations the diagnosis of Spn
• Borderline personality
• Complex PTSD DESNOS
• Hallucinosis in children adolescents
• Trauma Schizophrenia

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Topics (continued)

• Traumatic reactions to psychotic illness
• Summary
• Some hypotheses

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Hallucinations Pseudohallucinations
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Hallucinations

• If a man has the intimate conviction of
  actually perceiving a sensation for which there
  is no external object, he is in a hallucinated
  state.
• Jean Etienne Dominique Esquirol, 1817

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Hallucination

• The most frequent and complicated
  hallucinations affect hearing interlocutors
  address the patient in the third person, so that
  he is the passive listener in a conversation the
  number of voices varies, they come from all
  directions, and even can be heard only in one
  ear. Francois Baillarger, 1842

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A Modern Definition

• Hallucinations, or false perceptions, are
  diagnosed when someone hears, sees, smells or
  tastes something, or feels something on or in his
  body, for which other people can find no
  objective basis.
• Christian
  Scharfetter, 1976

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Pseudohallucinations

• Introduced by Hagen (1868) to refer to errors of
  the senses or illusions that are not real
  hallucinations
• More sensory content than representations but
  lacking the fullness, objectivity, and
  exteriority of true hallucinations (Jaspers, 1911)

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Pseudohallucinations

• Zward Polak (2001) conclude that
  pseudohallucinations cannot be reliably
  differentiated from other perceptual disturbances
  and recommend the term be dropped
• Instead, hallucinations should be described in
  terms of modality, interiority/exteriority,
  intensity, frequency, timing, clarity, content,
  associated affect, and conviction as to reality

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Hallucinations In The General Population
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Community Surveys

• Eastern Baltimore Model Health Survey 4 had
  hallucinations (Eaton et al, 1991)
• 21 of Japanese aged 11-12 yrs had had
  hallucinations (Yoshizumi et al, 2004)
• NEMESIS study (Bijl et al, 1998) 10 had
  hallucinations but only 0.4 had non-affective
  psychosis. Assoc. with females, low SES, urban
  res., living alone, young age (Van Os et al,
  2000)
• Hallucinations are associated with traumatic
  events (eg, Ross et al, 1994 Spauwen et al,
  2006)

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Longitudinal Course
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The Outcome Of Hallucinations

• Escher et al (2002) followed 80 Dutch
  hallucinating children aged 8-19 yrs for 3 yrs.
  Hallucinations ceased in 60, but recommenced in
  13
• Dhossche et al (2002) followed a Dutch cohort
  aged 11-18 yrs. 5 had auditory halls. After 8
  yrs 2 had auditory halls. Early hallucinations
  did not predict PTSD or Schizophrenia

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Outcome

• New Zealand cohort studied at ages 11 and 26 yrs.
  Schizophrenia and Anxiety Disorder (but not Mood
  Disorder) at 26yrs was predicted by
  hallucinations, delusions, and thought alienation
  
• at 11 yrs. (Poulton et al, 2000)

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Hallucinations And The Diagnosis Of Schizophrenia
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The Symptoms Of Schizophrenia (And Complex
PTSD)

• Thought echo, third-person discussions, running
  commentaries
• Thought insertion or withdrawal
• Thought broadcasting
• The perception of being under external control or
  of being a passive, reluctant recipient of body
  sensations
• Delusional perception Kurt Schneider,
  1959

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Early Intervention In Schizophrenia

• Advocates of early intervention
• (eg, McGorry et al, 1996 McGorry, 1998) may be
  mistaking some cases of Complex PTSD for
  Schizophrenia, based on the hallucinations,
  first-rank symptoms, and paranoid thinking also
  found in CPTSD
• (eg,Van der Hart et al, 2005 Hamner et al,
  2000 Sareen et al, 2005 Famularo et al, 1998
  Honig et al, 1998 Berenson, 1998)

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Borderline Personality Disorder And Hallucinations
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Borderline Personality

• Knight (1953) described borderline states in
  which apparently neurotic analysands become
  subject to transient psychotic episodes
• Kernberg (1975) described borderline personality
  organization as associated with distortion in
  reality testing and breakthrough of primary
  process thinking

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Borderline Personality

• Numerous studies have linked Borderline
  Personality Disorder to child sexual abuse
• (eg, Herman, Perry van der Kolk, 1989 Silk
  et al, 1990 Westen et al, 1990 Zanarini, 1997)

21
Complex PTSD DESNOS
22
Terr L (1991). Am J Psychiat 148 10-20

• Two types of traumatic stress
• Type 1. resulting from a single blow
• Type 2. after multiple blows
• Type 2 trauma is likely to lead to
• Massive denial, repression,
• dissociation, self-anaesthesia, self-hypnosis,
  chronic rage, self-injury

23
Herman JL (1992). J Traum Stress, 5 377-391

• Complex PTSD or Disorder of Extreme Stress NOS
  (DESNOS) is a sequela of prolonged, repeated,
  coercive, trauma. Associated with
• Episodes of trance, /- hallucinations, and the
  fragmentation of personality

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Hallucinations In Child Adolescent Patients
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Hallucinations In Child Patients

• Garralda (1986a,b), in a retrospective chart
  review, found hallucinations in conduct and mood
  disorders. Followed into adulthood, not at
  increased risk for psychosis.
• Ulloa et al (2000) Hallucinations common in
  mood disorder

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Hallucinations In Child Patients

• Altman et al (1997) 33 of adolescents in a
  residential / daycare program had auditory
  hallucinations associated with dissociative
  processes
• Hallucinations are associated with PTSD
• (Heins et al, 1990 Famularo et al, 1998
  Lipschitz et al, 1999 Nurcombe et al, 1996
  Kaufman et al, 1997)

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Hallucinations In Child Patients

• Hallucinations are associated with Dissociative
  Disorder (Hornstein Putnam, 1992 Dell
  Eisenhower, 1990 Coons, 1996 Putnam, 1993)
• And DID (Hornstein Putnam, 1992 Vincent
  Pickering, 1998 Coons, 1996)

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Hallucinations In Adult Patients

• Honig et al (1998) negative and helpful internal
  commentaries and dialogues are equally common in
  Schizophrenia and Dissociative Disorder
• Steinberg et al (1994), Middleton Butler
  (1998) internalized dialogues are characteristic
  of DID

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Nurcombe et al. (1996). In F Volkmar
(Ed),Psychoses Pervasive Developmental
Disorders of Childhood. APPI Press

• Dissociative Hallucinosis
• Acute onset
• Precipitated by threat of attack or abandonment
• Recurrent, brief episodes of trance,
  autohypnosis, terror, rage, impulsive
  self-injury, assaultiveness, and hallucinations
  reflecting trauma
• No cognitive or affective deterioration between
  episodes

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Dissociative Hallucinosis

• Premorbid personality borderline, histrionic,
  needy, care-eliciting
• Families chaotic, neglective, abusive
• On blind, retrospective chart review,
  Dissociative Hallucinosis was no different from
  PTSD (except re hallucinosis) but was distinct
  from Schizophrenia
• Conclusion Dissociative Hallucinosis is a form
  of CPTSD with salient hallucinations

31
Scott J, Nurcombe B, Jessop M (2007).Australian
Psychiatry, 1544-48

• 66 adolescents consecutively admitted to an
  inpatient unit structured interview PTSD
  compared to Psychotic Disorder (Spn)
• No difference in the modality, location, or form
  of hallucinations
• In 25 of PTSD, hallucinations directly reflected
  trauma (0 in Spn)

32
Jessop M, Scott J, Nurcombe B (2007).Unpublished
MS, Queensland Health

• 54 adolescents consecutively admitted to an
  adolescent unit
• Structured interviews for diagnosis and for
  nature of hallucinations
• Hallucinations highly prevalent in PTSD and Spn,
  but indistinguishable in form, location, and
  content except that patients with PTSD were more
  likely to refer them to trauma

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The Relationship Between Trauma And Schizophrenia
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Three Competing ModelsAndreason NC Carpenter
WT (1993). Schizophrenia Bull, 19 199-214

• Spn is a single etiological process with diverse
  manifestations
• Multiple etiological processes with a final
  common diagnostic endpoint
• Specific symptom clusters within the same disease
  that come together in different ways in different
  patients

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Cross-Sectional Correlational Studies

• Read et al (2005) found 45 papers linking
  childhood trauma to psychosis, to particular
  psychotic symptoms, or to Schizophrenia
• (eg, Ross et al, 1994 Read Argyle, 1999
  Read et al, 2003)
• Hallucinatory commentaries ideas of
  reference, thought insertion or mind-reading
  paranoid ideation visual hallucinations sexual
  delusions

36
Bebbington PE et al (2004). Brit J Psychiatry,
185 220-226

• 8580 subjects in British National Survey of
  Psychiatric morbidity
• All psychotic subjects (0.7) administered
  structured interview
• Greatest predictive odds ratio for psychosis
  sexual abuse

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Problems Inherent In Cross-Sectional Studies Of
Psychiatric Patients

• Representative sample?
• Size of sample?
• Choice of control?
• Validity of self-reported abuse?
• Appropriate method of diagnosis?
• Causal direction?

?
38
Longitudinal Studies
39
Janssen I et al (2004). Acta Psychiatr Scand,
109 38-45

• 4000 subjects 18-64 yrs followed for 2 years
• Report of a history of child abuse at Time 1
  predicted positive psychotic symptoms at Time 2
• After controlling for demographic, other risk,
  and diagnostic factors at Time 1

40
Spataro J et al (2004). Brit J Psychiatry, 184
416-421

• 1612 children lt17 yrs, substantiated as sexually
  abused, followed 9 yrs, compared with gen. popn.
  Controls
• Contact with MH Services monitored through case
  register
• 12.4 cases v. 3.1 controls had contact with
  services

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Spataro J et al (2004) (Cont.)

• The disorders most likely to be associated with
  sexual abuse were
• Personality Disorder
• Anxiety Disorder
• Acute Stress Disorder
• Major Mood Disorder
• Conduct Disorder

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Spataro J et al (2004) (Cont.)

• No increased incidence of Schizophrenia, Alcohol
  / Sub. Use Disorder, other Mood Disorders, or
  Somatoform Disorder
• ? Sub. Cases of abuse not represent.
• ? Failure to access MHS
• ? Abuse in controls
• ? Imperfect recording / data matching
• ? Not enough time

43
Spauwen J et al (2006). Brit J Psychiat, 188
527-533

• 2524 adolescents 14-24 yrs, followed for 42
  months
• At Time 1 self-report re lifetime trauma
  structured diag. interview
• questionnaire
• At Time 2 structured interview
• Dose-response effect of trauma for psychotic
  symptoms

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Traumatic Reactions To Psychosis
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Psychosis Causes Trauma

• Shaw et al (1997) found that 52 of patients
  recovered from psychotic illness had PTSD
• McGorry et al (1991) found PTSD in 35 of
  recovered psychotic patients
• ? Psychotic symptoms or coerced hospitalization
  can traumatize patients
• ? The psychosis was originally CPTSD

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Summary
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Summary

• Complex PTSD can be caused by severe child abuse
• CPTSD can present with acute episodes of
  hallucinosis, paranoid ideation, dissociation,
  and self-injury
• The auditory hallucinations of CPTSD are
  indistinguishable from those of Spn, except in
  reflection of trauma

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Summary (Cont.)

• Schneiderian first-rank symptoms can be found in
  both Spn and CPTSD
• Psychosis is used to refer to Spn alone or to
  conflate (and confuse) Spn and CPTSD
• Dissociative Hallucinosis is a form of CPTSD in
  which hallucinations are clinically salient

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Summary (Cont.)

• CPTSD is part of a Trauma Spectrum (PTSD, ASD,
  CPTSD, DD, DID, BPD, IED, Conversion Disorder,
  Somatoform Disorder)
• Studies of the relationship between trauma and
  Schizophrenia are complicated by uncertainty
  whether Schizophrenia is a unitary disorder

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Summary (Cont.)

• Cross-sectional studies link trauma to
  psychosis, psychotic symptoms, and
  Schizophrenia however, all are methodologically
  flawed
• Longitudinal studies link child trauma to PTSD,
  psychotic symptoms, but not schizophrenia

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Summary (Cont.)

• PTSD has been found after psychosis. Was it
  present at the outset (CPTSD) ? Or was it caused
  by the traumatizing experience of psychosis ?

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Hypotheses
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Hypotheses

• Complex PTSD with Dissociative Hallucinosis is
  distinct from Schizophrenia
• Complex PTSD with Dissociative Hallucinosis is
  distinct from Schizophrenia but the two
  conditions overlap

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Hypotheses (Cont.)

• 3.There is no difference between CPTSD and Spn.
  Psychosis applies to a condition which trauma
  may or may not predispose to or precipitate
• 4.Schizophrenia is a spectrum of conditions
  which trauma may or may not predispose to or
  precipitate

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Hypotheses (Cont.)

• PTSD symptoms in Spn stem from the
  psychologically traumatic nature of psychotic
  symptoms or coercive hospitalization

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Hypotheses Distinct Disorders

• CPTSD DH Spn

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Or ?
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Hypotheses Distinct But Overlapping

• CPTSD DH Spn

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Hypotheses One Psychotic Spectrum

• Traumagenic Genetic

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One Psychotic Group Different Factors

• Traumagenic Birth
  Injury
• Family
  Genetic
  

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Psychosis Causes PTSD ?

• Psychosis PTSD
• ?
  

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More Longitudinal Research

• Follow adolescents with CPTSD, Spn, and other
  disorders into adulthood to determine outcomes
• Follow sexually abused children into adulthood to
  determine outcome
• Follow a general population sample into
  adulthood, comparing abused with non-abused
  outcomes

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Why Bother?

• Because the treatments of CPTSD and Schizophrenia
  are different
• CPTSD requires protection, exploratory
  psychotherapy, group therapy, family therapy,
  antidepressant medication
• Spn requires antipsychotics, family education,
  not exploratory treatment

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If I have seen further it is by standing on the
shoulders of Giants. Sir Isaac
Newton, Letter
to Robert Hooke, 5 February,
1675
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