Tuesday, February 18, 2014

Trauma, PTSD, and Psychosis


I posted a briefer version of this on my Facebook page yesterday, but I wanted to add some more depth to it here. This is part of my preparation for a talk I will be giving to Tucson Police Department (TPD) detectives to help them better understand the experience of sexual trauma survivors.

One of the cool things about the book I cite from below is that it is re-confirming the connection between childhood trauma, dissociation, and psychosis - something that has been lost in recent decades as many researchers sought to find a genetic link for psychosis, or a clearly dysfunctional brain region.
Over the last several decades, evidence has accumulated that childhood trauma is common in persons who later develop schizophrenia or other psychotic disorders (Morrison, Frame and Larkin, 2003; Neria et al., 2002; see Chapter 10, this volume), and, in prospective studies, that childhood trauma is a significant risk factor for the development of subsequent psychotic disorders, even after controlling for potentially mediating variables, such as familial psychopathology (e.g. Janssen et al., 2004). Importantly, the Janssen et al. (2004) study of over 4000 individuals found a ‘dose–response’ relationship between childhood trauma and subsequent psychotic symptoms, with the most severely abused group demonstrating a 48 times increased risk compared to non-abused subjects.

[cited in "Delusional atmosphere, the psychotic prodrome and decontexualized memories," by Andrew Moskowitz, Lynn Nadel, Peter Watts and W. Jake Jacobs, page 68 - in Psychosis, Trauma and Dissociation: Emerging Perspectives on Severe Psychopathology; 2008]
Aside from a few clues that psychosis has a genetic underpinning, it has become clear that those genes are triggered into activation by childhood trauma. In fact, I suspect we still do not fully know what happens to the developing brain as a result of traumatic experiences.

We do know that trauma memories often play a role in psychosis, although because of the extreme dissociation involves in psychosis, it's often hard to make that connection.

This is one of the clearest explanations I have seen of why traumatic memories are (1) so much more deeply encoded, (2) so intrusive long after the original trauma, and (3) not likely to contain the level of detail (and reliability) law enforcement expects when interviewing a survivor:
"When memories are formed under intense stress, a critical component of normal memory formation – the hippocampus – is disabled, and memories without spatiotemporal content are created. At the same time, another component of normal memory function – the amygdala – can be potentiated, leading to stronger-than-usual memory for highly charged emotional events. When a person retrieves a traumatic event memory, the retrieved information is bereft of spatiotemporal context. Instead of being bound firmly to the past, this ‘disembodied’ event memory is conflated with the ongoing spatiotemporal frame. (Nadel and Jacobs, 1996: 459)"  (p. 66-67)
The trauma state is similar in some ways to infancy, the 3 earliest years before autobiographical memory comes online with the hippocampus.
Memories lacking spatiotemporal context occur not only under experiences of extreme stress, but also, Jacobs and Nadel (1985) contend, during the first few years of life, before the hippocampus becomes active. The limited functionality of the hippocampus has been argued to be a possible neurobiological foundation for so-called ‘infantile amnesia’ (Nadel and Zola-Morgan, 1984). Thus, ‘decontextualized’ affective memories occur when the hippocampus is disabled, under conditions of extreme stress during adulthood, and in the first few years of life when the hippocampus has not yet come ‘online’. In contrast, the amygdala, crucial for learning about danger situations, is functional from the beginning of life. (p. 67)
Here is an expansion of how all of this relates to the early stages of psychosis, the prodrome stage during which the continuity and logic of mental function begin to deteriorate.
In previous publications, Jacobs and Nadel have argued that several anxiety disorders could be understood as stemming from early childhood experiences – memories unlinked to an autobiographical, spatiotemporal nexus (Jacobs and Nadel, 1985, 1999; Nadel and Jacobs, 1996). While their models of PTSD, phobias and the first panic attack all presuppose exposure to a discrete triggering stimulus or stimuli at a particularly point in time, in order to adapt their model to the psychotic prodrome we have to allow for a different etiology – a slow, insidious reinstatement of early life experiences – that is, of ‘taxon-based’ instead of ‘locale-based’ learning.

Delusional atmosphere (DA) could be seen as even more consistent with ‘taxon-based’ learning than the anxiety disorders already modelled by Jacobs and Nadel because, in addition to evidence of high anxiety, there is in DA also evidence of disturbed visual perception and an inability to identify relevant and irrelevant stimuli consistent with early, feature-based memory. In addition, the characteristics of ‘taxon-based learning’ noted to be true for phobias – context independence, generalization and prolonged extinction (Jacobs and Nadel, 1985) – are equally true for delusions. Indeed, in many ways, DA sounds like the world of the infant as described by Nadel and Jacobs (1996), ‘populated not with the familiar objects and events of conscious adult life, but with fragments and features, pieces and patches’ (p. 460). These ‘fragments and features, pieces and patches’ do not disappear with adulthood, but instead lie just under surface of our awareness; they are a ‘veritable stew of impressions that we would scarce recognize’ if they popped into our conscious awareness (Nadel and Jacobs, 1996: 460). Is this what happens in DA?
We contend that these early experiences may be released in the psychotic prodrome as the functioning of the vulnerable hippocampi (smaller in size than is normal) is undermined by the stressful experiences (and exaggerated response to stressors) common in early schizophrenia. And, because such learning involves the connection between features of objects and threatening events (as in panic disorder), the actual trigger to the anxiety cannot be identified. Alternatively, later traumatic events could be ‘recalled’ without a spatiotemporal context, which is particularly likely in persons with autobiographical memory deficits, such as in schizophrenia. According to Nadel and Jacobs (1996), when this occurs, the ‘disembodied event memory is conflated to the ongoing spatio/temporal frame’ (p. 459). (p. 74)
One of the ways the mind can be damaged such that psychosis becomes a possibility is through attachment failures. Beyond the three organized forms of attachment (secure, avoidant, and ambivalent) there is also a disorganized attachment. Such an experience for the infant seem likely to stem from "memories unlinked to an autobiographical, spatiotemporal nexus."

From Chapter 9 in the same book, "An attachment perspective on schizophrenia: The role of
disorganized attachment, dissociation and mentalization," by Giovanni Liotti and Andrew Gumley, attachment patterns are explored as a possible cause for later psychosis.
Bowlby (1973) proposed that infants’ experience of interactions with attachment figures becomes internalized and is carried forward into childhood and adulthood as implicit core relational schemata, also known as internal working models (IWM; Bretherton and Munholland, 1999). These implicit structures produce expectations about the self and others, and regulate cognitive, behavioural and affective responses in interpersonal interactions. Early attachment relationships thus come to form, together with the intersubjective experiences of play and companionship with the caregivers (Trevarthen, 2005), the prototype for interpersonal relationships and self-regulation throughout life. Most interpersonal schemata that regulate relationships throughout childhood, adolescence and adulthood are influenced by the IWM of self and others developed in the interaction with the primary caregivers.

Infant attachment research has shown that, by twelve months, infants develop different organized patterns of attachment behaviour toward their caregivers, according to the responses they receive to their requests for comfort, soothing and protective closeness (Ainsworth et al., 1978). A specific IWM corresponds to each of these patterns. Three main patterns of early organized attachment have been identified: secure, avoidant and resistant (or ambivalent). In addition, a substantial minority of infants (around 15%; Van IJzendoorn, Schuengel and Bakermans-Kranenburg, 1999) fail to develop any organized or coherent attachment pattern; their attachments are said to be disorganized (Main, 1991).
Attachment theory explains the origins of disorganized attachment behaviour in terms of conflict between two different inborn systems, the attachment system and the fight–flight (i.e. defence) system. The attachment and defence systems normally operate in harmony (i.e. flight from the source of fear to find refuge near the attachment figure). They, however, clash in infant–caregiver interactions where the caregiver is at the same time the source of, and the solution for, the infant’s fear (Liotti, 2004). Being exposed to frequent interactions with a helplessly frightened, hostile and frightening, or confused caregiver, infants are caught in a relational trap; their defence system motivates them to flee from the frightened and/or frightening caregivers, while at the same time their attachment system motivates them, under the influence of separation fear, to approach them. Thus, the disorganized infant is bound to the experience of ‘fright without solution’ (Cassidy and Mohr, 2001; Main and Hesse, 1990: 163). This experience may be understood as a type of early relational trauma, which exerts an adverse influence on the development of the stress-coping system in the infant’s brain (Schore, 2003).
The damage caused by disorganized attachment has been linked the Axis II Borderline Personality Disorder (BPD) in a lot of research articles. More accurately, in my opinion, it is a form of complex post-traumatic stress disorder (C-PTSD).

It is entirely possible to live within this dissociated space from childhood. It's a form of "reenactment" because the person is continually reenacting the original trauma in the current context. I see this a LOT in the population we serve at SACASA, most of whom had childhood trauma.

Some survivors are reenacting traumas that occurred before autobiographical memory (and the hippocampus) came online around age 3, so there is no way for them to conceptualize, or even verbalize, that it is their early trauma that makes the world so scary or produces so much anxiety in them that they can barely function as adults. 

As the authors pointed out above, early traumatic events can be ‘recalled’ (or re-experienced) without a spatiotemporal context, which is particularly likely in persons with autobiographical memory deficits, such as in psychosis. Their trauma experience is "unstuck in time," continually being re-experienced with little or no awareness on their part of what is happening to them.

So for these people, being "unstuck in time" (love the Vonnegut reference here, since it is so apt to what he went through as a survivor of Dresden, which he describes in Slaughterhouse Five) is the norm, it is how they live every day, although they will not know that until they get into counseling or begin a serious meditation practice. 

We all do this to some degree, but it is usually transient and brief. If one of our childhood ego wounds gets triggered, we will react almost exactly as we did as children unless we have developed some awareness around the wounding and the reaction we learned as a coping strategy. The Internal Family Systems model (Richard Schwartz) and the Voice Dialogue model (Hal and Sidra Stone) both offer ways for those of us without severe trauma to work on these issues - and I generally consider "parts work" a deep form of shadow work. 

For those with this early wounding that leads to "psychotic" features in trauma survivors, shadow work is beyond their capacity. They need to be with a therapist who understands trauma and its effects on the brain and the sense of self.
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