Transcript Auditory hallucinations and pseudo

The convergence of the trauma
and personality disorders fields
Dr Andrew Moskowitz
Department of Mental Health
NHS Grampian Specialist Psychotherapy Services
My background
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Trauma and dissociation - and psychosis
Knowledge of PD comes primarily from
trauma and forensic fields
Talk more appropriate called ‘relevance
of trauma field for PD’
Overview of talk
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A bit about PD
An outline of trauma and PTSD
Borderline Personality Disorder and
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Complex PTSD - Herman and others
Structural dissociation - Van der Hart & Nijenhuis
The dissociative nature of PD? - Bromberg
Attachment
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Secure
Insecure
Disorganised/disoriented
What I know about PD
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Historical background
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‘moral insanity’ - psychopathy, narcissism
Hysteria - BPD
Bleuler’s ‘simple’ schizophrenia - schizoid,
schizotypal PD (US:UK study)
BPD same as other PDs?
Nosological approach becoming dimensional?
Adaptive in nature
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Attachment perspective: disorganised in infancy,
controlling in childhood, unstable in adulthood
(HH)
Analyst Bromberg -- all PDs dissociative, adaptive
What does the word ‘trauma’ mean?
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Derives from the Greek word for ‘wound’
Used for over 300 years to describe
medical wounds
First used in a psychological sense about
100 years ago, by William James
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“Certain reminiscences of the shock fall into
the subliminal consciousness… If left there,
they act as permanent ‘psychic traumata’,
thorns in the spirit, so to speak”.
History of PTSD
‘faking it’ vs ‘breaking it’
 Soldier’s heart, shell shock, railway
spine
 1970s: The Vietnam War, battered
women’s syndrome, rape, natural
disasters
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The Trauma component of PTSD
(DSM-IV Diagnosis)
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PTSD is a disorder involving ‘stress’ – a
disturbed stress response, which occurs after
(’post’) a traumatic event
The ‘A’ criterion – definition of trauma – is quite
broad:
The person has been exposed to a traumatic event in
which both of the following were present:
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the person experienced, witnessed, or was confronted with
an event or events that involved actual or threatened death
or serious injury, or a threat to the physical integrity of self
or others and
the person's response involved intense fear, helplessness, or
horror
Trauma overwhelms one’s capacity to process it producing dissociation?
The Symptom components of
PTSD (DSM-IV Diagnosis)
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One (1) Re-experiencing symptom, such as
flashbacks and nightmares
Three (3) Avoidance and Numbing symptoms,
such as avoiding things that remind one of
the trauma, and feeling detached or
estranged from others
Two (2) Hyperarousal symptoms, such as
hypervigilance or sleep difficulties
Clearly linked to one (1) trauma and lasting
at least one (1) month
Shattered assumptions
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Traumatic events shatter the assumptions people
hold about the world, other people, and themselves –
assumptions needed in order to feel safe, deal
comfortable with others, and have confidence in
themselves.
Natural disasters shatter assumptions of the world
being a safe place – earthquakes in particular shatter
assumptions of the world being stable – the ground
is not supposed to move beneath one’s feet.
Violent crimes, particularly committed by strangers,
shatter the assumption that people can be trusted.
Certain other interpersonal traumas may affect views
of oneself – an inability to protect oneself and/or
loved ones affects feelings of competence and
confidence.
Problems with PTSD diagnosis
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Significant co-morbidity and subthreshold PTSD
All symptoms must originate with the
trauma and relate to only one trauma
Aftermath of ongoing or chronic trauma
does not conform to PTSD diagnosis
Borderline Personality Disorder
and child abuse
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Childhood trauma, particularly sexual abuse
is, in BPD samples:
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very common (60-75%)
more frequent and begins earlier than in other
PDs (Yen et al, 2002)
often severe (at least 1/week for at least 1 year Zanarini et al, 2002)
associated with increased symptomatology
increases the risk of suicide 10-fold in BPD
populations (Soloff et al, 2002)
Symptom criteria (DSM-IV) for
BPD (‘stable instability’)
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Frantic efforts to avoid real or imagined abandonment
A pattern of unstable and intense interpersonal
relationships characterised by alternating between
extremes of overidealisation and devaluation
Identity disturbance
Impulsivity
Recurrent suicidal behaviour, gestures, or threats, or selfmutilating behaviour
Affective instability
Chronic feelings of emptiness
Inappropriate, intense anger (or difficulty controlling
anger)
Transient, stress-related paranoid ideation or severe
dissociative symptoms
‘Voices’ in BPD
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Common
‘Not transient’
Not pseudo-hallucinations (no such
thing)
Not a psychotic symptom
1. Complex PTSD
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Coined by Judith Herman (1992) Trauma and Recovery
Core feature of ongoing trauma is captivity.
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‘A history of subjection to totalitarian control over a
prolonged period (months to years). Examples include
hostages, prisoners of war, concentration-camp
survivors, and survivors of some religious cults.
Examples also include those subjected to totalitarian
systems in sexual and domestic life, including survivors
of domestic battering, childhood physical or sexual
abuse, and organised sexual exploitation’
Chronic abuse in childhood same as in adulthood?
Developing brain, adaptation to environment, usedependent organisation (‘states become traits’, Bruce
Perry)
Complex PTSD (or DESNOS)
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Alterations in emotional regulation
This may include symptoms such as persistent sadness, suicidal thoughts,
explosive anger, or inhibited anger
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Alterations in consciousness
This includes things such as as forgetting traumatic events, reliving traumatic
events, or having episodes in which one feels detached from one's mental
processes or body
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Changes in self-perception
This may include a sense of helplessness, shame, guilt, stigma, and a sense
of being completely different than other human beings
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Alterations in the perception of the perpetrator
For example; attributing total power to the perpetrator or becoming
preoccupied with the relationship to the perpetrator, including a
preoccupation with revenge
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Alterations in relations with others
Variations in personal relations including isolation, distrust, or a repeated
search for a rescuer
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Changes in one's system of meanings
This may include a loss of sustaining faith or a sense of hopelessness and
despair
2. Structural dissociation (Van der Hart,
Nijenhuis, & Steele, 2006)
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Simple PTSD involves one central
split/dissociation in the personality
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one part that is immersed in the trauma (the
‘Emotional’ part of the personality or EP) and
One part that tries to avoid reminders of the
trauma at all costs (the ‘Apparently normal’ part of
the personality -- AP).
Originally coined by C.S. Myers in WWI
EP is typically organised around evolutionarybased animal defence systems
AP is organised around daily activities
‘Secondary’ structural
dissociation and BPD
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One AP, though often very constricted
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Many areas of daily life associated with
traumas triggers (eating, sexuality),
particularly interpersonal relations
EP is split into several, often organised
around animal defence systems (fight,
flight, freeze, submission)
3. Philip Bromberg
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Interpersonal analyst
PDs involve ‘ego-syntonic dissociation’.
Essential rigidity is dissociative in nature.
Defines PDs as:
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‘the characterological outcome of the inordinate use of
dissociation in the schematization of self-other mental
representation’
Independent of type, PD reflects a mental structure
organised in part as a protective protection against the
potential repetition of early trauma
The distinctive personality traits of each type of PD are
embodied within a mental structure that allows each
trait to be always ‘on-call’ for the trauma that is seen
as inevitable.
4. Attachment
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Bowlby, Ainsworth, Main (Fonagy)
Secure and insecure attachment
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Evolutionary basis - seeking comfort in a person,
not a place
Darwin & the sea lizard
Conditioned fear to guns
Strange situation
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Secure attachment
Insecure (when parental figure is inadequate)
Disorganised attachment
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‘fright without solution’
When parent is the source of danger (as well
as its only solution - approach/avoidance
conflict
As a result of severe trauma
But also as a result of
frightened/frightening/dissociative faces (2nd
generation unresolved loss/trauma)
Become controlling children
(punitive/parentified or solicitous) -aggressive, BPD/DD adults?
Adult attachment interview
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Secure/autonomous
Ward et al, 2006
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Dismissing - idealised caretakers, contradictory &
impoverished memories (high PD) - ANP?
Preoccupied - overly detailed, anger and affect
over past events - (anxious/depressed disorders)
EP?
Unresolved losses, traumas - high
psychopathology when alternate classification not
secure
Treatment approaches
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Reconceptualise ‘bad’ and ‘good’ objects
into ‘victim’, ‘perpetrator’ and ‘rescuer’
identities - all relationships viewed in
such terms
Advantages of multiple treaters
Utilise AAI in treatment outcome
studies