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
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
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
80
Proportion experienced
69
70
61
60
50
53
49
50
40
36
Females
29
30
20
20
10
0
CSA
Males
CPA
EITHER
Type of abuse
BOTH
1
Studies of Post-Psychotic PTSD
Proportion meeting DSM-IV PTSD criteria
80
67
70
60
50
40
52
46
51
50
52
35
Initial
6m follow-up
30
20
10
0
McGorry Shaw et Priebe et Frame & Shaw et
et al.
al. (1997) al. (1998) Morrison al. (2002)
(1991)
N=45
N=105
(2001)
N=42
N=36
N=60
Frame, L. & Morrison, A.P. (2001) Causes of PTSD in
psychosis. Archives of General Psychiatry, 58, 305-306.
Percent meeting DSM-IV caseness
PTSD in Psychosis
80
70
67
60
50
50
40
30
20
10
0
Discharge (n=60)
Follow-up (n=18)
Frame, L. & Morrison, A.P. (2001) Causes of PTSD in
Percentage of DTS variance
psychosis. Archives of General Psychiatry, 58, 305-306.
60
52
50
40
30
20
13
6
10
0
PANSS:
Psychotic
symptoms
Impact of events:
psychosis
Measure
Impact of events:
hospital
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
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
Criteria for PTSD
• 4. Increased arousal
– Sleep disturbance
– Irritability/anger outbursts
– Difficulty concentrating
– Hypervigilance
– Increased startle response
Symptom Overlap
 Both disorders can be divided into positive
and negative symptoms
 Shared PS. (Hall&del similar to intrusions,
threat appraisals & flashbacks)
 Shared NS. (Numbing, responsiveness,
concentration, derealisation, detachment,
self-neglect & withdrawal)
 Paranoia & arousal, hypervigilence &
sleep problems common to both
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).
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
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% (n=25) were able to link the image to the
experience of a particular emotion and to a particular
belief
– 70.8% (n=17) were able to associate the image with a
memory for a particular event in their past.
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
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
Cognitive
Processes
&
PTSD
Psychosis
Selective attention to threat
Thrasher, Dalgleish
& Yule (1994)
Bentall & Kaney
(1989)
Safety-seeking behaviours
Ehlers & Clark
(2000)
Morrison (1998)
Unhelpful thought control strategies
(particularly punishment and worry)
Reynolds & Wells
(1999)
Morrison & Wells
(2000)
Biases in autobiographical memory
Brewin (1998)
Baddeley et al. (1996)
Imagery
Sleep deprivation
Arousal
Dissociation
Behavioural
Role of dissociation in model
• Dissociative experiences as trauma
generated intrusions
– Grounding strategies
– Uncontrollable / dangerous?
– Unusual (psychotic) appraisals?
• Dissociation as a strategy
– Pro’s and cons (and evidence for these)
– Develop alternative strategies for safety
Role of dissociation in model
• Procedural beliefs about dissociation
(positive and negative)
– Evaluate accuracy and helpfulness
– Development alternatives
– Change bandwidth
 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?
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
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.
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
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
Unwanted, intrusive memories
Voices and visions
Physical flashbacks
Interpretation of intrusions:
Government agents are putting thoughts into my mind
My body is being controlled
There is a conspiracy to kidnap and harm me
I am vulnerable
Others can’t be trusted
Dissociation and paranoia are useful
Dissociation
Hypervigilance
Thought suppression
Social withdrawal
Restrict expression
Fear
Anger
High arousal
Physical / Sexual abuse
Institutional care / prison
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 Longden’s TED
talk
 Recovery stories
 Normalising information about relative prevalence of
trauma and dissociation
 Conducting surveys
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
Recontextualising trauma
•
•
•
•
•
•
Re-examination of meaning
Role plays
Imagery work
Visit sites
Responsibility pie charts
Surveys
Re-examine meaning of trauma
• modifying the main problematic appraisals
related to the trauma and it’s consequences
– ‘I’m 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’
– ‘I’m vulnerable’ = ‘ I’m no more vulnerable than
anyone else; in fact, I’m a strong, resilient person who
has been in the Navy’
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 n=80 – final n = 74
PANSS Total
80
ES = -0.46
70
60
Cognitive Therapy
50
TAU
40
30
0
3
6
9
12
15
18
>50% 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
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?
Demographics
Variable
Mean (SD/%)
Age
43.04 (10.53)
Male: Female ratio
Duration of psychosis
273: 109
235.17 (124.50)
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
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)
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 do
Try to stay in control of thoughts
Isolate self and withdraw
Negative comparisons
Rituals
Daydreaming / dissociation
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
Early experiences
Family criticism
Never fit in
Severe bullying at school and work
Wrongful arrest and harassment
How I feel
Low mood
Hopeless
Anxiety
Anger
Case study
• 9-11
– Revisit goals
– Negative comparisons
– I’m a failure
– Activity for mood
• 12-15
– Daydreaming and dissociation (normalising;
pros/cons; diary; modified GAD model)
– Voices
Case study
• 16-18
– PTSD (grounding, attentional focus,
reconsider meaning)
• 19-22
– Social anxiety (stop post-mortems,
anticipation > event, stop safety behaviours,
external focus, update image)
trigger
Social situations
Negative thought
Others will judge me
Others will reject me
Image of self
Weak
Vulnerable
Hunched
Ugly
Very skinny
Unconfident
Shaky
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
How I feel
Anxiety
Tense
Palpitations
Sweaty
Shaky
Case study
• Progress:
– I am good enough
0% 80%
– Social confidence
10% 70%
– I am different
100% 50% (neutral)
– I’m 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
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
Phases of therapy
1)Assessment and enagement phase (approx
sessions 1-4)
2)Introduction of strategies targeting
dissociative phenomena/processes (approx
sessions 5-14)
3)Longitudinal Formulation/Cognitive
Behavioural Change strategies phase
(approx sessions 14-22)
4)Consolidation phase (final 2 sessions)
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)
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)
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
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