Trauma, Psychosis and Dissociation

In a 1987 article titled “First-Rank Symptoms as a Diagnostic Clue to Multiple Personality Disorder,” Richard Kluft highlighted how first-rank symptoms could be a valuable clue to diagnosing dissociative identity disorder (DDI). Forty years after this article, although several pieces of research have shown that this symptomatology is more frequent in DDI pictures than in schizophrenia, few clinicians link their presence to a structural dissociation of personality. The DSM-IV highlighted how the presentation of one Schneiderian symptom was sufficient to make the diagnosis of schizophrenia; in the 2013 DSM-5 version, it is no longer possible to make the diagnosis of schizophrenia with only the presence of one among bizarre delusions, two or more voices conversing with each other or commenting on the patient’s behaviour and thoughts. Despite this change, between the two symptoms required to receive this diagnosis, it is enough for the patient to manifest delusions and hallucinations.

The evaluation of first-rate symptoms as pathognomonic of schizophrenia has, over time, resulted in many patients being misdiagnosed as schizophrenic. 

In this workshop, some of the leading international experts on dissociation will discuss the difference between these two diagnostic categories, highlight some of the most recent research, and illustrate the different clinical pathways that characterize these patients. 

In the first part of the workshop, Eli Somer will briefly review the “maladaptive daydreaming” construct, presenting the standard features and differences between this and other diagnostic categories and discussing the mechanisms underlying the disorder. 

During the following talk, Vedat Sar will discuss the similarities and differences between dissociative and schizophrenic psychoses. 

In the second part of the workshop, Colin Ross will present the dissociative subtype of schizophrenia, discuss how genetic aspects are overestimated, and present trauma-based therapeutic interventions for psychosis. 

In the last talk, Martin Dorahy will review studies that have compared psychotic symptoms characteristic of dissociative identity disorder with those of schizophrenic spectrum disorders.

This workshop is organized in collaboration with:

Program

This workshop will take place online on 25th November 2023.

Discussant: Giovanni Tagliavini

Chairman: Costanzo Frau

Maladaptive daydreaming is a dissociative disorder: Existing research evidence and future directions

Eli Somer | 09:30 a.m. – 11:30 a.m. CET (CLICK HERE TO SEE YOUR TIME ZONE)

Maladaptive daydreaming (MD) is a distinctive clinical condition characterized by an addictive-compulsive immersion in vivid fantasy scenarios, often accompanied by stereotypical movements while listening to evocative music. This behavior becomes maladaptive when it causes distress or interferes with daily functioning. While scientific research on this phenomenon is accumulating, countless internet users have embraced the term widely, highlighting the prevalence of individuals struggling with this mental activity.

This webinar aims to explore the existing research evidence on maladaptive daydreaming, its potential association with trauma, and its similarities to dissociative disorders, particularly Dissociative Identity Disorder (DID). While severe dissociative psychopathology, including DID, is strongly linked to extreme childhood trauma, evidence suggests that dissociation, in general, and dissociative absorption (DA), in particular, are closely related to MD but that past traumata are not a necessary precursor.

During daydreaming episodes, individuals with MD exhibit a unique duality in consciousness, remaining immersed in their inner world while retaining awareness of their external surroundings. Like individuals with DID, those with MD create internally-narrated characters, developing strong emotional connections with them. However, unlike DID, the inner protagonists never take control of the body. Unlike individuals with DID, people with MD often demonstrate stronger ego strength, better emotion regulation abilities, and more integrated self-concepts. The webinar will discuss comorbidities, implications for treatment, and future directions for research.

Dissociative and Schizophrenic Psychoses: Similarities and Differences

Vedat Şar | 11:30 a.m. – 1:30 p.m. CET (CLICK HERE TO SEE YOUR TIME ZONE)

Schizotypal and dissociative processes are qualitatively distinct. On the other hand, dissociation is increasingly considered as a transdiagnostic phenomenon. The overlap between dissociative and other psychopathologies is dispersed on a spectrum of frequency.  It is still unkown whether this overlap refers to a qualitative relationship between psychopathologies or whether the overlap is based on dissociation related to concurrent developmental traumatization regardless of the main diagnosis. As an intermediate solution to explain this relationship is proposed as the duality hypothesis which is based on interaction between concurrent but distinct psychopathologies including dissociation.  From clinical point of view, two syndromes will be presented:

1. Dissociative psychosis without schizoptypal psychopathology.
2. Schizophrenic disorder with dissociative psychopathology. The symptomatology, mechanisms, treatment response, clinical course, outcome and traumatic backgrounds of each syndrome will be discussed.

Learning Objectives:

1. Participants will be able to differentiate dissociative psychosis from schizophrenic psychosis with dissociative features
2. Participants will learn about trauma-related background and interaction of comorbid conditions

Trauma, Dissociation and Psychosis

Colin Ross | 03:00 p.m. – 05:00 p.m. CET (CLICK HERE TO SEE YOUR TIME ZONE)

In this talk, Dr. Ross will discuss the relationships between trauma, dissociation and psychosis, focusing on the similarities and differences between dissociation and psychosis. He will describe his model of a dissociative subtype of schizophrenia and a spectrum from negative symptom-predominant schizophrenia on the left end to dissociative identity disorder (DID) on the right end. As you moved right on the spectrum you get: fewer negative symptoms of psychosis; more positive symptoms; more trauma; more comorbidity; more dissociation and PTSD; more auditory hallucinations; more capacity for the voices to engage in therapy; more response to psychotherapy; and higher levels of hypnotizability.

Dr. Ross will review research data on the prevalence of dissociative disorders in schizophrenia, and vice versa, and on the frequency of severe trauma in schizophrenia. He will briefly review data on the genetics of schizophrenia that show that genetics are not the main risk factor for psychosis and also data showing that antipsychotic medications are overall not very effective. This then leads to a call for more research on the role of trauma-informed psychotherapy in the treatment of psychosis, which Dr. Ross will illustrate in terms of ‘talking to the voices’. 

Participants will be able to:

1. Describe the differences and similarities between dissociation and psychosis.
2. Describe the role of psychological trauma in psychosis.
3. Describe treating strategies for dissociation and psychosis including ‘talking to the voices’.

The nature of psychotic symptoms in dissociative identity disorder

Martin Dorahy | 05:00 p.m. – 07:00 p.m. CET (CLICK HERE TO SEE YOUR TIME ZONE)

The intersection between dissociative disorders and psychotic disorders has been generating growing interest. So called ‘psychotic symptoms’ have been noted to occur in dissociative identity disorder (DID) for well over a century, with clinically and empirically-focused scholars attempting to more systematically understand when and how such symptoms present in DID (Kluft, 1987; Ross, 2004; Ross, Miller, Reagor, Bjornson, Fraser, & Anderson, 1990). In times of crisis, where dissociative defenses may temporarily break down in DID so as to no longer organise internal experience, psychotic symptoms often manifest (Şar & Öztürk, 2019). Yet, at least some symptoms typically described as psychotic, appear to be commonly experienced during relatively stable functioning in DID, as if they a common presenting problem.

This presentation will explore some recent empirical studies that have directly compared psychotic symptoms in DID with those in schizophrenia-spectrum disorders (SSD). This work has examined different phenomenological features of voice hearing, how voices are interpreted, types of delusional thinking and formal thought disorder symptoms. Those with DID tend to have richer voice hearing experiences and fixed beliefs around mistrusting other, while not having the same severe disorganised mental processes that manifest in incoherent thinking or metaphysical interpretations of voices. 

Participants will learn:

• What psychotic symptoms are and which ones have been systematically explored in dissociative identity disorder (DID)
• How psychotic symptoms present in DID outside psychological crises
• Which psychotic symptoms may differentiate DID from schizophrenia spectrum disorders.