Objectives

1. 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

2. 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

10. 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

16. Studies of Post-Psychotic PTSD

17. Frame, L. & Morrison, A.P. (2001) Causes of PTSD in psychosis. Archives of General Psychiatry, 58, 305-306.

18. Frame, L. & Morrison, A.P. (2001) Causes of PTSD in psychosis. Archives of General Psychiatry, 58, 305-306.

19. 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

20. 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

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

22. 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

27. 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).

28. 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

29. 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.

30. 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

31. 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

34. Cognitive & Behavioural 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

35. 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

36. Role of dissociation in model • Procedural beliefs about dissociation (positive and negative) • Evaluate accuracy and helpfulness • Development alternatives • Change bandwidth

38. 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?

40. 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

41. 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.

42. 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

44. 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

46. 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

48. 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

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

50. 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’