Is Psychosis Meaningful? Trauma, Dissociation and Schizophrenia - Part II

so this is the middle of series of three lectures last week we covered trauma and dissociation tonight we're going to be focusing on psychosis and schizophrenia and next week specifically on delusions and hallucinations there's also a chair there so a brief summary because I know some of you were here last week and some of you weren't so what we covered last week was a few arguments against the notion that schizophrenia is a genetically caused biological brain disease we talked about some of the problems with the older genetic studies the twin studies the adoption studies some of the genetic analyses that have been used that have looked at abnormalities in gene structure really and argue that these predicted schizophrenia there's many problems with them I discovered something in this past week or I was reminded of something in terms of the adoption studies and these classically are children who come from families in which one or more parents has been diagnosed with schizophrenia or a psychotic disorder and are adopted into other families that don't have any evidence of a mental disease of mental disorders do they end up developing schizophrenia or not and the argument would have been that if they do in a relatively healthy adoptive family then this is a biological illness that's manifesting itself the best study that had been conducted was one out of Finland by a guy named canary and what he did which was quite unique really is he also bothered to take a look at the families into which these children were being adopted and what he found is that the children who came from with biological children of families with mental disease mental disorders schizophrenia only developed a mental disorder if their adoptive families were also disturbed and specifically if there was disturbances and communication patterns called communication deviance and we'll come back to this next week when we talk about delusions and this was actually the strongest predictor of problems and the children's later on have normal patterns of communication and the adoptive families and even more they found when the adoptive families were clearly quite healthy this was a strong protective factor so these children with this strong biological mm taint or weight on them would not become unwell many other problems in those in those studies that we won't go into today we talked about trauma and I suggested to you that the main tension the core tension within the concept of trauma is whether it's an event that occurs in the world whether it's a person's reaction to that event or whether it's really some combination and I also argued that it's more useful to think of trauma in terms of psychological threat to the integrity of the self rather than physical threat of course physical threat always involves also a psychological threat but you can have a psychological threat to the self that does not involve a physical threat we talked about the metaphor of trauma that it comes from the word the Greek word for being wounded particularly wounded by stabbing and I also spoke with you a bit about this metaphor of being overwhelmed the image of being in a boat in a body of water overturned and who would survive and who wouldn't survive such an event depends on many many factors individual factors and so forth we argue in in the chapter you know in our book that it's most useful to think of trauma as an inability to integrate or if you want to say to make sense of the implications of an event into the existing conceptions of oneself in one's worlds so we have ways of thinking about ourselves and other people in the world and trauma some people would say shatters those assumptions certainly its powerfully inconsistent with their assumptions and being traumatized means you cannot integrate this experience you cannot bring it into your existing conceptions and this this failure of integration occurs because the danger strategies that we've developed the our evolutionary based danger strategies don't work so we're in a situation fight-or-flight doesn't solve the problem freezing immobility all of these solutions and they're the only solutions we know as mammals they don't work and Judith Herman argued in a quote I showed you last week that in a sense our psyche doesn't know what to do in these situations and these strategies become internalized they become distorted they get manifested over and over again until we find some way of dealing with it or not and then we also talked about dissociation that dissociation is a concept that has changed radically since it was first to you psychologically about a hundred and twenty years ago the tensions within the concept of dissociation is does it refer to a wide range of alterations and consciousness narrowly focused on something in the environment being immersed in one's own experiences and not paying attention or is it a division of the personality is it only pathological or is there also normal dissociation and also I think importantly do we consider dissociation transient experiences of depersonalization or D realization or should have really only refer to ongoing personality changes when we think about how a concept should be defined there's many ways of weighing this how useful is it clinically what's their store historical background to the concept but I think probably what's most useful is to take the epitome of a concept clearly the most extreme form and to see how these lesser versions of the concept relate to it so the question would be dissociative identity disorder used to be called multiple personality disorder everyone agrees this is a severe manifestation of dissociation so the question then is what predicts this what is associated with this is it really just a narrowing of the focusing of consciousness or as we would argue it's some sort of a division of the personality these normal or transient experiences are very common and they do not predict associative disorders we've all had experiences of depersonalization or derealization so we would argue that dissociation is really best thought of as a sustained and ongoing division of the personality there are results from trauma and this division resulting from trauma has these two core components to it which themselves can be divided depending upon how disturbed the person becomes there's a part of the person that's stuck in the past feels as though the past is happening all over again and cannot get out of it and there's a part of the person that's desperately trying to function in the present trying to avoid all reminders of the past and because of this division the person's psychological energy is impaired their capacity to deal with other events to synthesize experiences because if you will they're using a lot of mental energy to keep feelings and memories of the trauma out of their awareness and that's one of the problems that occurs with trauma before I move on though I want to address one question that was raised quite a good question which I think I answered wrongly last week and the question was we were talking a bit about what can help prepare people for traumatic experiences and I was arguing that successfully dealing with an earlier trauma hood could make you stronger in some ways and could help you deal with with future things and I think that was probably wrong because you know let's say you in a relationship for a long period of time and your partner dies and that's always going to be a trauma and then yours lit and you deal with it successfully so it takes time but you deal with it you manage that you integrate it and then some years later you're in a relationship again and your partner another partner dies in a similar kind of a way would you be more successful at dealing with that I I'm not at all sure I mean I think I think we need to think of trauma as a wound that can then be reopened potentially or an Achilles heel right you could be vulnerable in the same way I think what's more useful to think about is if you have experienced less severe but somewhat similar stressful events and have successfully dealt with those then you might be better able to deal with the trauma later on in life so here's an example one of the things we know from early parent-infant interactions is that it's very important that well first of all this there's a myth of the perfectly attuned parent or mother who is constantly focused on their child's every needs and is always available right and that's that just doesn't happen that's impossible what happens instead is that there's there's miss attunements that occur quite frequently between parent and infant so the chat the infant gets overly excited for example and any emotional experience will be overly exciting for an infant and then will break eye contact and this is classic view what's done and what does the parent do then there are some parents who will pursue their children who will actually pursue them to re-engage them before the infant is actually ready for that and the healthier approach of course is to just watching wait see whether the infant is ready again for more contact and then eye contact is returned in that in that of cars and of course what's happening over and over again is the infant is learning in a way that you know something difficult happens and then it gets better right well how many of you've seen that great the great frozen still face paradigm right have you haven't seen it the rest of you haven't seen it just google it and watch it it's really great to watch it's a classic experiment in which a often mother doesn't have to be but let's say mother and one-year-old infant or so are playing and then the mother gets the instruction from the experimenter to become expressionless to stop all expression on her face and you can see in the video within a matter of seconds infants become quite distressed and also clearly the mother becomes distressed and also the viewer watching it is very distressful in fact I think this is a really good measure for psychopathy I would argue if you show this video to people and they don't get upset watching it really really you get one gets very district but the key point to this is that in the experiment the mother does this for about two minutes I think or so and then you also see what happens when she Rhian gauges and within a matter of 10 seconds the infant's right back in it again right so you can imagine that that kind of a thing happening once in a while is probably not a bad thing but if you think about that happening for hours or repeatedly during a day over and over again what kind of I won't affect does that happen an infant but actually that was alongside I think I have a more useful example of this many of us had pets as children dogs cats whatever what happens when that animal dies in a family right as a psychologist I feel the best thing to do is to help the children deal with the loss of this animal but what happens in some families we know is quite well parents go out and buy another dog often of the same background and don't allow their children to deal with the normal feelings of grief I would suspect I don't have any proof of this but I would suspect you come from a family where you've been able to deal with some feelings of loss the death of a grandparents and your parents allowed you to go to the funeral and deal with this and see how people deal with that I think you probably better equipped to deal with a significant loss of someone you care about later in life then if you come from the family where you were never allowed to do that right so that's part of what I'm talking about how you can have had earlier experiences that might prepare you better for dealing with with traumas okay so now we should move on to what today's talk is supposed to be about these are the sources of for what I'm going to talk about today so we're going to talk a bit about psychosis about the concept of psychosis and psychosis is kind of a funny term it's different from trauma and dissociation in some ways and one of the things is that if you work clinically you might think you know what this is because there isn't there's an assumption that people know what we mean when we say psychosis but I want to suggest to you it's not as easy as you might think we'll talk about the concept of schizophrenia which is now a hundred and ten years old how that concept came about the role of Carl Jung which was very important in this and its relation to dissociation and then we'll talk a little bit about some other ideas about schizophrenia through up til to now and what I think what kind of similarities I think there might be between schizophrenia and dissociative disorders and and differences as well and once again stop me if something is unclear or if you have some questions so trauma dissociation those are both metaphors trauma we talked about as being a physical wound originally dissociation is dropping out of a group and both were applied psychologically afterward now psychosis is different psychosis just literally means a sickness or an abnormal condition of the mind or really the soul psyche is the old word for soul literally animating spirit and this term was created custom-made for the purpose of replacing other terms that this fellow Freud dis Laban felt were inadequate and in the early 19th centuries the mid 19th centuries there was ongoing debating it's not so different from the debate today is what are these things we call insanity mental illness is it the soul that is sick is it the body that's sick what is this going on and back then there was no middle ground between the soul and the body but Freud is Laban in creating this term psychosis was trying to create a middle ground so he was trying to say these severe mental disorders are diseases of the whole personality really the whole person not just the body it's not just the mind it's the whole entity that is disturbed diseased some of you may know this in the beginning the term psychosis was less biological than neurosis neurosis meant diseases of the nerves and were considered more biological but that changed within a generation Vilhelm agree Zynga said mental diseases are brain diseases and psychosis came to mean an organically based mental disorder in the 20th century the term psychosis often meant really had a lot to do with level of functioning so people who were very impaired were often called psychotic not emphasizing so much of the symptoms they experienced but how impaired they were but also impaired reality testing which is an expression one still hears in English I don't know if there's anything comparable in German reality testing this is very problematic term because it implies that psychosis is due to an inaccurate perception of what's really real a distortion and that's not how most contemporary theorists think about reality is something existing out there that I simply have to more or less accurate comprehend accurately comprehend and actually when we start talking more about psychosis or about delusions people really don't often distort reality in in any really dramatic way what they do is they misinterpret things that occur the classic example would be somebody sees a yellow car or a series of yellow cars yellow in English can also mean cowardly and they feel as though these cars are sending a message that they are a coward right the cars are really there they're not distorting these images they're not creating these images but they're misinterpreting and this was similar the earlier official diagnosis ICD is the World Health Organization manual can is the DSM DSM three and nineteen eighty psychotic is gross impairment and reality testing and interestingly a kind of a holdover to psychoanalysis and some of Freud's ideas this was 1987 the revision of this talked about the creation of a new reality which is probably really more accurate than anything that went before and what is evidence of psychosis the specific psychotic symptoms now what's happened in the last few decades is that there has been essentially no attempt to define what psychosis is instead psychosis has been defined as the presence of psychotic symptoms so in the icd-10 psychotic means just hallucinations delusions gross excitement or overactivity dsm-4 says the same things and this is the ICD 11 will be coming out this year or next year again just delusions hallucinations experiences of passivity and control which we'll talk about more later this is very important so this is this is tautological this is a circular definition right psychosis means having psychotic symptoms and the question then becomes well what does that term mean then beyond a specific symptoms such as delusions what is it actually telling us but when when you work clinically a colleague Marcus Hyneman has argued strongly that termos psychosis is used when we we just can't make sense of what another person is doing we don't understand why they are behaving or talking the way that they are we consider that to be psychotic but this is very much dependent on the context and very much of our understanding of what the context is comedians for example in various countries are given a lot of leeway a lot of flexibility to act strange and in America in the 1980s there were a few comedians who would basically act as though they were crazy or scream and yell there was also what was that guy again who would engage in mud wrestling Andy Kalvin right some of the things that auntie Calculon would do now if you came across a person acting in some of these ways and you didn't know they were comedian or the space in which you were present was not defined as a theatre you might think they were psychotic you wouldn't know why they were acting the way they were and so we don't know why people are doing or saying the things that they are and we don't have an explanation for it and these these are actually considered they're called disorganized behavior and disorganized as though they have no organization right but do we know that do we really know that this what why a person is saying what they are saying is meaningless or lacks organization or do we simply not know what that organization is because we don't know what they're thinking about when they're talking how do we decide if the symptom is unconnected to a person's life history if we don't know what their history is or if they can't tell us what it is there was a very nice study done some years ago on thought disorder that red used proverbs as famous sayings in English things like people who live in glass houses shouldn't throw stones or the grass is always greener on the other side you can think of some other ones like this and in the old days it was fairly common to read people this and ask them what they thought it meant and if they interpreted it on in an abstract way in terms of describing people's behaviors that was considered well functioning or they described in a very concrete way so there was a study done in which people were read these proverbs and their answers were recorded and psychotic people often tended to say fairly bizarre things did they would they would respond in a way that the interviewer could not understand this in but after these were recorded about a week later a sensitive psychiatrist who was involved in the went back to the individuals played them their answers and got into a conversation with them and said what were you thinking about when you said these things what did you mean by blah blah blah and most of the time the person was able to tell them and very often they were thinking about an event or events in their past that they kind of the this the researcher called this intermingling that they mixed up something from the past with something from the present and importantly of course they didn't tell the interviewer where they were coming from what they were thinking about but they knew they they were triggered and stimulated in a certain way and this probably happens on some level quite often that there is a logic there is an organization to what people are doing but we don't know what that is we can't automatically dismiss it as being incomprehensible yes well somebody's screaming on a street right somebody is walking down the street looking at something screaming - no one in particular right that looks very strange and that would often be called psychotic but it's entirely possible that there is something in the environment or something that she thought about or something that happened to her that relates to earlier experiences in which she had every reason to scream right so that's I mean Carl Jung gave an example not a really of psychotic behaviour but a really nice example said he was watching somebody in a hotel lobby or some sort of rooming house with very wealthy people and a waiter came over and gave the daily newspapers who had - a gentleman and put it down on the left side of the gentleman where he had his cup of coffee and then the the the guy started yelling at him screaming at him what is that about it looked entirely bizarre but Jung said if you had been in this place for the past week or so you would have known that this fellow told this waiter time after time to put the newspaper on the right side I did say left side didn't know what's ever to put the newspaper on the right side over and over again so there's a whole history behind it that explains the behavior much much better yes no no no of course I'm just bizarre just unexplainable let me move on with this and then you can get some of it because I think some of these quotes are quite quite noisy mark so Marcus Hyneman argues that the concept and he's not the only one this there's a long history behind this notion that psychosis is incomprehensible right that what people are doing cannot be understood not only that we don't understand it but they cannot be understood it's incomprehensible but what Marcus says is that these are incomprehensible ability and consequently psychosis are relational concepts and any attempt to read these relational events into individuals is doomed to fail so when we say we're always saying I don't understand you not that you are understandable you are incomprehensible there's a relationship here and a little more poetically he says saying something is incomprehensible is not an explanation at all but just an expression of despair when our ordinary ways of comprehending people and situations elude us so clinically you will often see people use this term psychosis almost in a way of saying I don't know and I don't know what's going on and I don't want to know what's going on that it's a really a way of creating barriers between people and what happens when you can't understand why people are acting the way they do then you often see a reluctance to use the term psychosis so you will see people use terms like psychotic like or quasi delusional or pseudo hallucinations so when we know what the connection is to a person's life experiences we don't want to call them psychotic we don't want to call them schizophrenic because we know it comes from their life that comes from a trauma but that's also problematic because phenomenologically in terms of their self experience it can be identical when someone is paranoid and they feel like people are poisoning them we're about to kill them and we don't know why they feel that way we call it psychotic but if we know that they were in some war zone in which that was actually happening their experience is the same does it make sense to call one of them psychotic in one psychotic like I would argue no that that's really not very useful yes well they may the may the thing is we don't know and also particularly as I'll talk about next week it may derive from some very early life experiences that they can recall in any conscious way right right yes yeah but the thing is I think for now the term psychosis it's not very useful we can we can talk about delusions we can talk about hallucinations we can talk about some of these things with some reasonable validity but the way it's being used to I know the term psychosis does not tell us very much at all it really doesn't so I I would definitely bracket that whole experience but as I say here you know what does what does the term psychotic add to delusional I mean we have kind of a sense of what we mean by delusional and when talk more about that next week certainly clinically to finding psychotic is incomprehensible is what happens often but that still doesn't tell us very much about the the actual experience and this this core tension here is can we call it Canseco --ss be genuinely connected with one's life experiences and I would say yes but we still have a lot of work to do in terms of understanding best to use the term I maybe I'll come back to this a little bit later but we in the chapter we propose some possibilities but they're not very useful it's really quite a problematic term right now yeah yeah yeah well and and this sort of gets to the next point because one of the real problems that happens right now is for a long time psychosis has been associated with schizophrenia very strongly there's a little bit of movement in this now on but the diagnosis of schizophrenia is very heavily weighted with psychotic symptoms and people often think being psychotic means having schizophrenia and that's certainly not necessarily true so these I'm going to show you the official current diagnosis of schizophrenia and then we'll go back to the past and talk about the beginning the sm5 the American Diagnostic and Statistical Manual came out about five years ago now requires at least two of these symptoms for for at least a month and also a lower level of symptoms for six months and notice that one of them has to be one two or three and one two three and four are psychotic symptoms depending how the definition is certainly one and two and then at various negative symptoms as I talked about last week about negative being a withdrawal of something that's normal flattened affect lower emotional expression social withdrawal they may according to the criteria they may have this symptom they don't have to we could just have delusions and hallucinations and the ICD 11 which will be coming out again soon that schizophrenia has disturbances in multiple areas including thinking self-experience the the sense that impulses thoughts behavior are under the control of an external force this has often been considered to be a core symptom of schizophrenia problems with cognition problems with volition these are more than negative areas loss of motivation flattened effects so these are the the official definitions of schizophrenia and you can see how important the the positive or psychotic symptoms are but that's not how schizophrenia started out started out with this fellow named organ boiler who is a Swiss psychiatrist and he cut his teeth he began his career at this Asylum which was an old monastery in Switzerland and he worked there for 12 years and boiler very early on felt that his patients experiences were meaningful so he like Pierre Rene actually he always had a pencil and paper with him and he was constantly writing down what his patients were saying and doing and he also was a confirmed bachelor well into his 40s which is very unusual for back then so all of his time was spent with his patients he would he would go to social activities with him like dances they would have activities together there's and there's a funny vignette from this time where boiler wanted to take some of the patients out to chop wood in the forest you can see there was huge forest surrounded so he created a list to give to one of his assistants to for the patients who were not to be sent out on this trip because he was concerned that they were not stable enough potentially too violent and the guy got it all mixed up so these were the people that they he sent with blighter the ones who were potentially at risk and actually the trip went really well this was one of the things that convinced Euler of the importance of activity and work and employment and engagement and so forth boylar's parents-- lived outside of Zurich and in 1898 they were getting old and interestingly they were caring for boilers older sister who was psychotic who was apparently quite crazy catatonic yeah we don't know too much about her but she was really impaired boiler reluctantly decided to go to Burke Holt sleep the psychiatric hospital near Zurich so that he could take care of his sister as well and he became the director of this clinic in 1898 and Carla young went to join him this was Young's first clinical placement in 1900 and he worked very closely with Euler for eight or nine years Brook Holly is still there I was able to visit it about ten years ago and to do some research there so young young Carl young had a really powerful influence on this developing concept of schizophrenia and um was interested from very early on in dissociative States really he did his medical thesis under the supervision of boiler on a seances that he attended arguing that the people who came out in these sciences were parts of the personality of this of the medium he went to France and he attended lectures by Pierre Rene who as you know was the founder of the field of dissociation came back very influenced by this and he began developing this word-association task really one of the first projective psychological tests where people would be read a list of words and they would be asked to associate another word and Jung and his colleague his cousin actually friends rickland they would time how long did it take for the person to up with the words and where their responses normal responses are were these strange responses and then they went on to argue that these strange responses indicated there was some unresolved issues unresolved complexes in there and he called them emotionally charged complexes a year before boiler the year before the terms cancer-free Nia was first used boiler young published this book on the psychology of dementia praecox dementia praecox was the name of the disorder before schizophrenia was caused so in the years nineteen seven and nineteen eight is really quite a fascinating history going on human Freud get together and I'm sure you all know about that it's considered called an intellectual love story really it was a very passionate relationship for a period of time and this occurred in 1907 and Freud was wanted to Freud could not work with psychotic individuals with people with schizophrenia but he was determined that his ideas would explain everybody would explain all humanity really so he pressured Yonge and Bloor to apply his ideas to schizophrenic patients and these were ideas about infantile sexuality at this point because he had moved away from trauma fears but Freud but Jung was quite influenced by peers your name and peers Renee's ways of thinking about things and their tensions around this played out in a number of interesting ways so in in shortly after Jung and Freud met Freud Jung told Freud that he was going to visit jennae and as far as we know we he hadn't had a one-to-one meeting with Renee before and that he was going to discuss because he was trying to figure out how do i reconcile what phorid is saying to what I believe about Renee so he told Freud that he was going to visit him so Freud says well I hope you have an interesting Paris complex but I don't want to see it repress your Vienna complex and Freud was already using this term complex in a very narrow way so Jung goes off to visit janay we don't really know what happens there but he comes back and he tells Freud he didn't know what he was talking about actually he was a hollow cos or I think he says just a personality Freud immediately writes back the next day and this is what he is to say I'm really glad you're back at berg homes Lee and I'm delighted with your impressions of the trip you can imagine I would have been very sorry if your Vienna complex had been obliged to share the available cathexis with a Paris complex luckily as you tell me nothing of the sort happened you gain the impression that the days of the great Charcot are past and the new life of psychiatry is with us between Zurich and Vienna so we've emerged safe and sound from the first danger Wow it's like a really jealous husband or something just I could have understand if young sort of fleed and when he read that but he didn't yeah a couple it took some time okay so let's talk about schizophrenia 1908 as far as you know April 1908 boiler at a conference here in Berlin in April 24th 1908 oh that's what today is actually is a 110 years ago today or yesterday he said CREP Lynne's dementia praecox is not dementia praecox means really early deterioration so a blurter said it's not always going to be early deterioration and because of this I'm using the word schizophrenia to denote prevalence concept I believe that the tearing apart said it--some or splitting bottom of psychic functions is a prominent symptom of the whole group and I'll give my reasons for this elsewhere as far as we know there's the first official use of the term schizophrenia now a few days later there is the first International psychoanalytic Congress Congress of Freudian researches and Freud has been pressuring young to give a paper melding his ideas with notions of schizophrenia and Jung rebelled he and this was and this paper has never been published which is very unusual we think it was out of a desire not to offend so he says we borrowed from French psychology we borrowed from French psychology not Austrian psychology French psychology a similar concept which was true for Asteria namely dissociation and today the name means a splitting of the self history is primarily characterized by dissociation and because dementia praecox also shows splitting concept of dissociation seems to blend into the concept of schizophrenia so he's saying very clearly that hysteria it's associative disorders borderline personality disorder seems similar to schizophrenia and Jung was very consistent throughout his life in these kind of ideas he kept to this notion of schizophrenia being related to dissociation Bleuler published his big book in 1911 it was really written in 1908 but he says that I'm calling this schizophrenia because the splitting of the different psychic functions is one of its most important characteristics if the disease is marked the personality loses its unity at different times different psychic complexes seem to represent the personality one set of complexes dominates the personality for time all of the groups of ideas or drives are split off and see mother partly or completely impotent now we heard about dissociation last week I hope you'll agree this sounds really a bit like dissociation personality losing its unity complexes representing the personality and others are impotent at the same time but we have to know what did he mean by splitting and what did they mean by complexes splitting as you know has a long psychoanalytic tradition after this but back then I would argue that what boiler' meant by splitting was very much like what Jena meant by dissociation from an earlier paper dissociation of the personality is nothing other than splitting off of the unconscious Boyle used unconscious in a funny way basically to mean parts of the personality that were not active were suppressed or repressed really like dissociation and he talked about the splitting as being very much essential to the whole notion of schizophrenia one of the issues around schizophrenia and its understanding is that people are many people from the medical profession in particular are quite eager to minimize the whole schizos part of schizophrenia right you know the Apple Euler didn't really mean split personality it's nothing like multiple personality well he did sort of mean like that there's a there's a good reason why he named it this splitting was very central to what he was thinking well that's another possibility yeah I think he recognized that in some sense yeah I mean it's there for a reason it's ultimately it is adaptive so splitting is essentially dissociation no splitting later on in the 20th century it was used by many other psychoanalytic thinkers in different ways but for Bleuler it really was dissociation what about complexes this gets even more interesting so when Jung was doing his word Association task and some people would come up with strange word and often he would find that the next word he gave them they took a long time to respond as though they were still kind of caught in this matrix of thinking about things when he would talk with him he would invariably discover there was some unresolved issue which they called complexes and in his early book he described these as clusters of ideas now the word ideas back then didn't just mean thoughts ideas were really mental components or psychological components that are cemented together by powerful effects has body innovations in fact 1907 he said it's kind of like a being living its own life and hindering and disturbing the development of the ego complex and later on he was even much more clear that these are like small secondary minds they're really like separate personalities in a later article he said complexes are splinter psyches and they often come from a trauma an emotional shock this shock that splits off a bit of the psyche boiler essentially agreed with him in fact boiler and Jung wrote a paper together in 1908 on complexes in which they did not agree they disagreed on etiology boiler I wonder whether it was because of his sister always thought that schizophrenia had some organic basis and young very consistently talked about the psycho genesis of schizophrenia that it can be caused by life experiences so how young and boiler thought about splitting how they thought about complexes was very much the same and these are very dissociative these ideas laura did not emphasize delusions and hallucinations he also talked about loosening of associations but when we think of dissociation splitting really is dissociation of splitting of the self of the personality and complexes are very much like what janae would call fixed ideas associations that are occurring as the result of a trauma I'll briefly tell you about this even though I'm running a bit short on time janae had this idea again Rick's ty Diaz is about psychological components that are stuck that when you're traumatized the things you associated with a trauma become fixed ideas and those are the stimuli the the aspects of the room the people who were there something that occurs the loud bangs but he also argued that when you are traumatized your mind is weakened as we talked about earlier you can't hold things together as well as you normally should and this leads to the possibility of secondary fixed ideas which are symbolic associations so for example somebody believing that they are burning in hell as a symbol of their pathological jealousy or their pathological guilts right for a particular event let's say so Sojin a thought that you could make start making symbolic connections or really loose associations if you will on the basis of a trauma because your mind becomes weakened after you're traumatized so Blois to schizophrenia the original concept with schizophrenia very different from how it's used today clearly has connections to dissociation and dissociative disorders and some of the cases Blois Lee described do sound like dissociative disorders his concept of schizophrenia was very broad but that doesn't explain why he thought the core components of schizophrenia work dissociative okay now we're gonna jump forward about 30 or 40 years to talk about Kurt Schneider any of you familiar with first rank symptoms or schneid Aryan symptoms schizophrenia no okay all right these are these are very important for the contemporary diagnosis of schizophrenia because these symptoms and we'll tell you what they are in a few minutes formed a core of the diagnosis of schizophrenia from 1980 on and only recently had they been slightly de-emphasized Schneider wrote a book in 1939 in work in which he proposed that certain symptoms were strongly predictive of schizophrenia and that it would be most effective to distinguish between people with schizophrenia and other disorders on the basis of these symptoms and the English the English world found out about them in 1959 when they were translated and that these were simply specific so for example he says thought withdrawal is a first rank symptom if this symptom is present in a non-organic psychosis we call this person schizophrenic as opposed to reactive or cyclothymic psychosis I thought withdrawal is the belief that something is taking the thoughts out of my mind thought withdrawal and these are how machine Eider came up with nine originally nine and then ten symptoms that are called first-rank symptoms and they can be grouped in a certain way auditory experiences so hearing your thoughts aloud and then two particular types of auditory verbal hallucinations a voice commenting on your behavior he's standing up there in front of all these people with these funny slides right or two or more voices discussing or arguing passivity experiences feelings impulses oddly cinsay actions all of which feel like you're not in control these are being driven by an external force and disturbances of thinking thoughts put in your head thoughts pulled out of your head thought broadcasting everyone can hear what I'm thinking and then this funny thing delusional perception not emphasized so much which is when people immediately create a delusion based on an actual experience an actual perception now Richard Kluft was one of the first 20th century prominent clinicians working with dissociative disorders interestingly I didn't know it at the time but he worked in Pennsylvania Hospital which is where I had my first clinical experience as a psychiatric intern some interesting coincidence and klephts began to notice that he saw a lot of these symptoms in di D patients multiple personality disorder patients so for about ten years he systematically basically was a case series you know a number of patients that he saw he would collect information from and this is what he found how often were these symptoms found in his patients not schizophrenic dissociative identities in particular these passivity experiences the feelings that your actions emotions your thoughts are controlled by another force we're very very common very common also the voice is experiencing thoughts withdrawn thoughts inserted but not not thought broadcasting not this delusional perception not hearing one's thoughts but most of the others were very very common and we have found since then other studies have replicated this when you're working with people with dissociative disorders for example a voice hearing Martin door he's a very close colleague of mine from New Zealand hearing a voice commenting in your actions or two or more voices talking with each other I'm much more common in dissociative identity disorder than schizophrenia and when you find these symptoms in schizophrenia the prognosis appears to be better so it's less of a chronic disease when they have these funny symptoms why are they common why would these symptoms become an inter socio destroyes well you may remember last week we talked about dissociation as involving at least two parts of the personality that can intrude on each other one part can act on another part so this is very easy to explain from its association perspective intrusions and withdrawals thoughts being put in thoughts being taken out voice hearing very commonly occur and dissociative disorders Richard Clough says it common for people to say personality is to say I would say parts of personalities that they have made another see or hear something influencing others perceptions caused a sensation impulse action or some other or taking away some memory so when somebody says to you that thought is not did not come from me what's going on often they are simply describing what they are actually experiencing it doesn't feel like their own thought and that may be because it's coming from another part of them they don't identify with that thought or with that feeling but not thought broadcasting or delusional perception not sure if I come back to this but Schneider thought that these symptoms I think I do come back to it actually I see you know I'm not sure I do Schneider thought that what we have in schizophrenia and he's probably right was a breakdown in the public-private boundary that what belongs to me and what belongs to the world gets very confused so thought Broadcasting is where I feel that my thoughts can be heard by anybody that they're a part of the world I don't have this clear boundary where I stop and where their world begins but you don't see that so much in dissociative disorders so these symptoms are not common in dissociative disorders which Snyder apparently didn't realize is that all of these kind of symptoms can occur in a person who has more than one part of their personality because they're highly dissociated and what we've discovered I did some historical research was a colleague is that Schneider didn't believe in dissociative identity disorder so he didn't believe that these people exist like many psychiatrists today the experience of identity is never broken multiple personality is always suspect findell he used the word findell an alternating consciousness has never won our credence that a person is first a and then B and the memory of a only belongs to B so he didn't believe that this occurs so what happens when he sees people who claim things like this he describes them as schizophrenic also interestingly look at what his sample consisted of his research sample mainly acutely disturbed women not chronic male patients so I would strongly believe that a subgroup of these folks were actually traumatized and probably too so so what is this connection there between schizophrenia and dissociative disorders people with schizophrenia score kind of somewhat high-end Association measures but not as high as genuine dissociative disorders higher than anxiety and depression typically I firmly believe that one of the real problems is that any group of people diagnosed schizophrenia include a subgroup of people with dissociative disorders and you can understand that when the criteria for schizophrenia will be selecting people with dissociative disorders and this is rarely assessed when it is assessed we find at least 10% probably more at least 10% severe dissociative disorders Blair has this idea of double bookkeeping which is very interesting which we do see that people have this delusional system which is active or not active depending upon this situation and if they're not in their delusional system they can be very relaxed toward you can I borrow some cigarettes can you mail this letter for me in their delusional system they feel like you're trying to kill them but then they can also have this so he called a double bookkeeping like there's almost these parallel tracks which is sounds a little bit - supposed to do now I'm gonna argue next week that voice hearing is a dissociative symptom and voice hearing is common in schizophrenia we know that for sure so what is schizophrenia event well there are some things that don't appear to be the same between schizophrenia and dissociative disorders negative symptoms negative syndromes are not so common bethenny brand did a Rorschach study and we also know this clinically people with dissociative disorders are interested in other people they can relate to other other people they are engaged they are not as socially withdrawn working memory in dissociative di D is at least normal and possibly enhanced it's imperative schizophrenia executive functioning is clearly impaired but this is where things really get interesting whether there are disturbances in the sense of self a number of researchers including in Germany working on this question one of the problems is that there again not considering dissociation so there's something there this private-public boundary issue but they're not comparing it to schizophrenia Kristian char Fodor however who was a Swiss psychiatrist did this and here's what he wondered he wondered whether it's a very unusual idea schizophrenia is like the extreme of dissociation because he said what you have in schizophrenia is this fragmentation or annihilation of the self which is the most severe and the most associative in what he called multiple personality is somewhat less and he even thought and I agree with him on this that dissociation may to some extent protect against schizophrenia that is if you have the capacity to dissociate well you don't become schizophrenic he said I assume a highly unstable fluctuating Eagles ego self is less disposed to ego fragmentation and perhaps may even be schism entity' v' and then in schizophrenic dissociative ego disorder there's a more rigid ego disposed for fragmentation rather than fluctuation and then he uses this lovely metaphor which he did not originate that schizophrenia is like glass or a mirror you throw it down and it cracks whereas dissociative disorders are like Quicksilver and the English we call the mercury separate into little holes they can come together again and maybe this time or next time we can talk a little bit more about just how dissociative capacity might protect against psychosis or delusions I just discovered this recently but Carl Jung said something very similar the dissociation in schizophrenia is not only far more serious but often irreversible it's no longer fluid and changeable more like a mirror broken into splinters the unity of the personality which in the case of Asteria lends a humanely understandable character to its own secondary personalities is definitely shattered into fragments okay my final slide I told you before boiler he thought that schizophrenia was organically based he thought all the symptoms could be psychologically caused so all of the symptomatic manifestations of this disorder could be understandable explainable psychologically cause psychosis to him would be meaningful but the disease the disorder was somehow organic but even he sometimes wondered he says the stronger the effects the stronger the emotion that the less pronounced the dissociative tendencies need to be in order to produce the emotional desolation thus in many cases of severe disease we find only quite ordinary everyday conflicts of life have caused the mark mental impairment and indeed we know this that minor apparently minor stressors can precipitate psychotic episodes but in milder cases the acute episodes may have been released by powerful ethics and not infrequently we had to pose the question whether we're not merely dealing with the effect of a particularly powerful psychological trauma on a very sensitive person rather than with a disease and then our sense of the word thank you [Applause] okay so yes right yeah yeah you know they say there's a fascinating concept in recent years called differential susceptibility also called sensitivity to biological sensitivity to context there's a few people working on this or highly sensitive people as well which is a very interesting body of research but I don't know whether I mean I I'm very interested in this question this whole notion of sensitivity because the argument is that it's very evolutionarily adaptive for some people to be more sensitive than others and the and the basic argument is that if you're in a society or a culture or a group there are some people who act very quickly right they're the ones who very quickly are driven to action and there are others who sit back and watch and notice and don't act so quickly and in certain situations these people will do better and what the research which is really interesting is showing is that this differential susceptibility is not a bad thing not necessarily a bad thing that given the adverse environments they turn out quite poorly but given a very supportive environment they turn out very well they actually become stars in a way social stars you have a larger group of people sorry but you've hit on something I really like so forgive me a larger group of people are more numb in a sense more insensitive for good or for bad but some of these people and they may be the people who are if not becoming schizophrenic I'm not so sure but highly dissociative had they gotten different earlier experiences they may be super skilled with other people because of the sensitivity go ahead sure sure yeah yeah yeah yeah I mean it's a it's a difficult question because one of the things we always see developmentally with schizophrenia is this social withdrawal so one of the things that happens quite clearly is that the people withdraw and whenever you do that whenever you're you're limiting your contact with others you are increases the chances for strange ideas developing and strange thoughts and feelings and all that and that's a very important part of it well yeah sometimes very creative like well I mean this is another whole notion that I don't know very much about the connection between creativity and madness I mean there's a lot of stuff on that and this there's clearly there's clearly stuff there yes yep right they grow and they don't break off so what happens is that these very very adaptable almost fairies that kind of tell the system if itself or other it doesn't break off so for some reason their brain is not it's very interesting right yeah I mean the the I don't know that much about autism but the thing is is that you know do you know the work of boosts Perry at all psychiatrist was Perry wonderful child psychiatrist and and he also has a very interesting therapeutic approach to working with children he really talks a lot about repetitive emotional states over and over again that shaped the brain in very powerful ways I do know the work of a guy named Martin Teicher from Boston who has demonstrated that many forms of seizure disorder are probably related to adverse early experiences you know that when you have enough of these disturbing upsetting unusual things it affects the wiring of your brain in the profound way yes absolutely absolutely yeah I mean you know from a very simple perspective what Perry argues is that that why humans are so successful is their the mind particularly when we really want young is exquisitely sensitive to the environment that it adapts to what it what happens around them and sometimes that can have very negative consequences yes okay well we'll know well it's short the short answer to your question is very little but clinically when you work with people who are who have dissociative identity disorder it's pretty common to find that you're facing a very bright very creative person with superior skills in certain areas of their life and you don't really see that very much with schizophrenia now from a theoretical perspective you can understand that if if a child has this capacity to compartmentalize essentially so that and there's some famous cases where it's been written about this if the traumatic experiences can be put in a part of their mind that are segregated from other parts of their mind they can pay attention in school they can play with their friends they can develop skills in a whole range of areas because they're not intruded on as much now what if there are some kids who don't have that same ability you know they're trying to pay attention in school and what's happening is all of the feelings all the memories you know the smells all the things that have happened to them are affecting them they can't pay attention they can't do as well at school they withdraw from their friends and the evidence on this is not so clear but past their brain is more affected because of the constant stress than stress hormones that they're experiencing it's the evidence not so clear on that because in di D you often find significant evidence for structural brain impairment even though these people look quite good it's almost as though they can find a way of compensating for for that okay yeah anyone else cuz this guy's got another question okay oh yeah of course I mean the old there's another old there all the movie called king of Arts is anyone okay of hearts an old French movie which is a great movie but of the inmate in an asylum in the time of crazy war and all that and what happens there but old the old International Studies on schizophrenia demonstrated that people did better in developing countries typically ones that had less of a biological perspective on the illness so yeah there's there if you follow them over time they return to a higher level of functioning there the long-term course of people diagnosed schizophrenia was better in developing countries than in Western countries like Denmark no no the opposite I'm saying it in the yeah in the developing countries they're better than the developed countries so it's in the better in the developing countries than the developed countries right there those aren't the best words to use but yeah I think it has to do with cultural attitudes you know how yeah sure yep okay sorry could you say that again yeah that's a good question really you mean it whether because there's there's a lot of research on personality a normal personality and how does that relate to schizophrenia I don't know whether whether any of you you know know about that I don't think it's that well-established really well part of the problem it definitely comes from the definition of it but there's a Giovanni Leo T and people who have a chapter in our book argue from an attachment perspective that that what you see on the trajectory to schizophrenia is children who are responding largely to disorganized attachment experiences or difficult attachment experiences by trying to deactivate their attachment system or trying we're trying not to activate their attachment system by social withdrawal classically there are patterns that you see that are written about more often where children around age five or six become controlling of the relationship with their parent they'll become critical or more often helpful paren to fight we might say but he argues that there's another group of people in which the kids become socially withdrawn and that that's part of this trajectory that you see toward toward schizophrenia maybe okay two more yes the back yeah yeah well well that it might be it's more like Quicksilver or mercury you know in the old days you had them in thermometers and they would break apart but then come back together I mean it's not an ideal image because there's nothing like that in Indy ID it's not like the parts easily come back together but this notion of the self in schizophrenia being fragmented or being broken you know in a very fundamental ways is there's a very common way of thinking about schizophrenia and that does sound quite different than how people with the ID experience themselves yeah yes [Music] well yeah well people use that's how people often define delusions I mean part of how delusions are defined often is that they're held with very strong conviction and you can't argue people out of delusions that's one of the arguments although there's how to define delusions is also very problematic but you don't really you don't see that in the dissociative disorders you know classic delusions are not very common in dissociative disorders one of the problems is that people think what people may be calling delusional is simply them telling you accurately what their internal experience is I feel like I feel like the thoughts are being pulled out of my head well if you had that kind of personality structure that could well happen I feel like somebody else is making me do these things that can definitely happen if you have a very dissociative structure it's not a delusion but it can be interpreted as a delusion if you don't understand Association or believe in the Association yes yes yes and there's a ego States there's a whole group of people who talk about that as well yeah well this when we talk about voice hearing next week this is what we're going to talk about because I I believe and I have good colleagues I've done some work but I have good colleagues who's done a lot of work is that they're doing exactly this the voices are parts of the personality that you engage with 'we are trying to overcome them they just come back stronger but yet if you understand what is hurt they're hurt behind it exactly exactly okay okay Sokol one last question yeah I mean I don't know so much about bipolar disorder there are people who have done a lot of work on childhood trauma and bipolar disorder and there are there probably are some people who are being called bipolar disorder who are really dissociative disorders and there are some extreme people I don't agree with who think dissociative disorders are really bipolar disorders but that's that's another story but did you have a more specific question yeah sure sure absolutely why not I mean I think theoretically even if someone has psychotic symptoms due to brain injury right it doesn't mean that they're going to be meaningless it may it may well have a connection to their life experience but they are precipitated by the head injury in that case so I think in in bipolar disorder sure certainly with voice hearing well we'll see next week is there's there's no clear evidence that voice hearing in any disorder or even in people with no disorder is fundamentally different that it seems to be all pretty much the same okay great all right so I hope to see some of you next week you [Applause]

Channel: Stillpoint

Views: 18,874

Keywords: Psychology, Trauma, Dissociation, Schizophrenia, Psychosis

Id: blbmeaDy21Y

Length: 82min 46sec (4966 seconds)

Published: Fri Jan 25 2019