Toward a new paradigm of psychopathology:

The importance of trauma, dissociation and attachment

Andrew Moskowitz

Aarhus University

EMDR and Dissociation

Metz, 17 November 2015

Paradigms and psychopathology Current paradigm of mental illness, emphasizing

genetics and brain pathology, has failed An emerging trauma/dissociation/attachment paradigm

shows real promise Such a paradigm may be supplemented by

conceptualizing individuals not as vulnerable to negative influences, but as sensitive or susceptible to environmental influences - for better or worse

Such ideas must be couched within a process/ relational worldview, which rejects the Cartesian/Newtonian metaphor of the person as machine

Thomas Kuhn and The Structure of Scientific Revolutions (1962)

Kuhn’s argument Science does not advance in a linear fashion

Myth: More and more accurate data collected over time so that reality or truth is more and more closely approximated

Rather, science always progresses under the influence of a dominant paradigm Paradigm means

a specific past scientific achievement held up as a model or exemplar and the generally accepted beliefs and attitudes of a particular scientific community

A paradigm exerts an organizing influence on a field, determining to a large extent what types of research questions are considered legitimate and what sorts of answers are considered acceptable. Ultimately, what is seen and what is not seen

Dissociative disorders field DID is caused by

overwhelming severe, sadistic childhood trauma

Treatment is intensive psychotherapy

Symptoms have meaning and can be linked to life events

Opposing paradigms in psychopathology

Schizophrenia field Genetic/biologically

caused brain disease Treatment is medications

or biomedical technologies

Symptoms are meaningless (unconnected to life contexts)

DID almost never (and PTSD rarely) considered in any type of schizophrenia research

Paradigmatic interpretation of voices

To schizophrenia field Voices (auditory verbal

hallucinations) are biologically-generated signs of brain disease

Content is meaningless Treatment is medications

or distraction techniques

To dissociative disorders field Voices are psychologically-

generated indications of unresolved loss or trauma

Content is meaningful (split off aspects of the self/ parts of the personality)

Treatment involves engaging these parts (which can be challenging)

Basic assumptions of the neo-Kraepelinian paradigm

Over the past 40 years, psychiatry’s perspective has been heavily biological/genetic

This has been associated with an idealization of Emil Kraepelin - the German psychiatrist who distinguished Schizophrenia (which he called Dementia Praecox) from Manic-Depressive Illness

According to Klerman (1978), the neo-Kraepelinian credo contains 9 propositions, 4 of which are:

Psychiatry is a branch of medicine There is a boundary between the normal and the sick There are discrete mental illnesses… There is not one, but many mental

illnesses The focus of psychiatric physicians should be particularly on the

biological aspects of mental illness

The idealization of Kraepelin Neo-Kraepelinian’s image of Kraepelin as an objective

scientist is flawed His early clinical work was in Estonia, where he had to use

translators to speak with patients Preferred to spend time instead sorting through his diagnostic

cards, which contained information on patient’s signs and symptoms But these were not truly objective, serving only to ‘supplement and

reinforce [Kraepelin’s] preconceived (diagnostic) concepts’ (Weber & Engstrom, 1987, pp. 382-383)

What were these concepts based on? The disease Dementia Paralytica or General Paresis of the Insane

Emil Kraepelin and Dementia Paralytica (General Paresis)

General Paresis of the Insane A life threatening condition, rampant in early 19th century

Europe, that primarily struck young men, combining psychotic symptoms (often grandiosity and impaired judgment) with physical symptoms (including paralysis)

Suggested by Bayle (1822) to be linked to syphilis By the late 19th century, when Kraepelin was developing his

ideas, this was largely confirmed By early 20th century, link between syphilis and GPI

confirmed by biological studies, leading to the only Nobel Prize for a psychiatrist (Wagner-Jauregg) Who proposed malaria as a treatment!

General Paresis as the central paradigm for Kraepelin

‘All his life, he (Kraepelin) had a preoccupation, if not obsession, with syphilis… He had no doubt an organic cause would be found for psychiatric illnesses and saw general paresis of the insane as a template for the other illnesses’ (Kaplan, 2010, p.24).

‘General paresis was taken by Kraepelin to be the model disease entity and he hoped that both schizophrenia and manic-depressive disorder would follow suit’ (Jablensky, 1995, p. 186).

Post-mortem brain of a General Paresis of the Insane (GPI) patient

Model disease entity for Kraepelin (and neo-Kraepelinians) is Dementia Paralytica (GPI) caused by advanced syphilitic infections

A genuine neuro-psychiatric disorder!

The importance of Kraeplin’s fundamental dichotomy The neo-Kraepelinians championed Kraepelin’s

greatest achievement - the distinction between dementia praecox (schizophrenia) and manic-depression (bipolar disorder) - as the cornerstone of their diagnostic system

‘…if the twin pillars of manic-depressive psychosis and schizophrenia are disturbed before there is anything better to put in their place, the roof will come crashing down’ (Kendell, 1987, p. 500)

Paradigms and Anomalies According to Kuhn, problems arise for paradigms

when no acceptable answers are generated for issues considered fundamental This, along with too many or too important anomalies,

pushes a paradigm toward a crisis Anomalies

Results not compatible with dominant paradigm occur usually ignored or adjustments made to keep fit with

paradigm

Scientific Revolutions A scientific revolution occurs when an

alternative paradigm is proposed that explains some of the anomalies as well as most previous findings Revolutions do not occur in the absence of a

suitable alternative paradigm Kuhn suggests that for some revolutions to

occur, the ‘old guard’ (‘power elite’) has to ‘die out’!

Failures of the neo-Kraepelinian paradigm: schizoaffective disorder Evidence now suggests that schizoaffective disorder

is a valid disorder (Marneros & Akiskal, 2007) A disorder between schizophrenia and bipolar

disorder was not predicted by Kraepelin, and poses a major challenge for the paradigm

A dimension is implied, on the basis of family studies and many other factors

Paradigm response? Calls to eliminate schizoaffective disorder. DSM-5

criteria for schizoaffective disorder are even narrower than the DSM-IV.

Failures of the neo-Kraepelinian paradigm: problems with boundaries

Substantial comorbidity for almost every disorder a serious problem for a categorical paradigm Kraepelinian credo: ‘There are many mental

illnesses’ Maybe, but they overlap and blend into one another

Failures of the neo-Kraepelinian paradigm: non-specificity of schizophrenic (psychotic) symptoms Increasing evidence that psychotic symptoms are common in the

‘normal’ population and do not differ in nature from those found in schizophrenia (Murphy et al, 2010;Van Os et al, 2008,) Other factors determine symptom persistence and psychiatric diagnosis

Psychotic symptoms are common in many disorders, including PTSD (Shevlin et al, 2010), and are not always clearly related in content to the trauma (Scott et al, 2007).

‘Psychotic experience is to the diagnosis of mental illness as fever is to the diagnosis of infection – important but non-decisive in differential diagnosis’ (Fischer & Carpenter, 2009, p. 2081)

Failures of the neo-Kraepelinian paradigm: antipsychotic medications Are less effective than previously believed,

have more serious side effects and do not act directly on psychotic symptoms ‘(A)ntipsychotics do not primarily change thoughts

or ideas; instead, they provide a neurochemical mileau wherein new aberrant saliences are less likely to form and previously aberrant saliences are more likely to extinguish… antipsychotics lessen the salience of the concerns, and the patient “works through” her symptoms toward a psychological resolution’ (Kapur, 2003, p. 17)

Failures of the neo-Kraepelinian paradigm: genetic findings

Significant overlap between schizophrenia and bipolar disorder ‘new work provides compelling support for the… evidence that

schizophrenia and bipolar disorder partially share a common genetic etiology’ (Craddock et al, 2008, p. 483)

‘genetic studies point to a shared neurobiology across the two disorders’ (Thaker, 2008, p. 720)

Questionable validity of previously cited genetic findings A large scale, well-designed study found ‘none of the (genetic)

polymorphisms were associated with the schizophrenia phenotype at a reasonable threshold for statistical significance’ (Sanders et al, 2008, p. 421)

‘The project to ground our messy psychiatric categories in genes… may be in fundamental trouble’ (Kendler, 2006, p. 1145).

So the dominant paradigm is in crisis. Is there an alternative to take its place?

The emerging attachment/trauma/dissociation paradigm

Insecure attachment patterns, and particularly disorganized attachment, greatly increases the likelihood of a range of mental disorders, including schizophrenia (Liotti & Gumley, 2008) The emotional foundation of some delusions may be in early attachment experiences (Moskowitz,

Nadel, Watts and Jacobs, 2008) Childhood trauma, and aversive childhood experiences, change the structure and functioning

of the brain in powerful ways – ways that have previously been seen as evidence for a neurobiological disorder (Read, Fosse, Moskowitz and Perry, 2014)

Childhood trauma strongly predicts a wide range of mental disorders A prominent psychiatric geneticist, Kenneth Kendler, concluded from a large-scale twin study that

childhood sexual abuse was ‘causally related’ to the development of psychiatric and substance abuse disorders (Kendler et al, 2000, p. 953), and that this relationship (at least for major depression) was ‘much stronger’ than for any gene linked to schizophrenia or bipolar disorder (Kendler, 2006, p. 1140)

In addition, there is now extensive evidence, from a range of studies, that childhood trauma specifically predicts psychotic symptoms

Dissociation plays a central role not only in DID, but also in PTSD, BPD and possibly schizophrenia (certainly in auditory hallucinations) There may be ‘dissociative’ and ‘non-dissociative’ disorders, or ‘cohesive’ and ‘non-cohesive’

The emerging attachment/trauma/dissociation paradigm: Dissociation and Voice Hearing

Pilton et al (2015) Meta-analysis of auditory verbal hallucinations and dissociation

Review of 4 databases identified 18 studies 10 with clinical populations 8 with non-clinical voice hearers

Overall correlations were .52 (clinical) and .49 (non-clinical) No significant differences in strength of the relationship between clinical

and non-clinical voice hearers Voice hearing appears broadly similar in clinical and non-clinical groups

Dissociation explains 25% of variance in voice hearing in all populations Relationship between dissociation and voice hearing is stronger than that

between voice hearing and delusions

The emerging attachment/trauma/dissociation paradigm: genetics and brain development Family patterns of psychosis formerly attributed to genetics may be

explained by trauma. A large scale case-control and case-sibling comparison concluded:

‘Discordance in psychotic illness across related individuals can be traced to differential exposure to trauma.… Positive psychotic symptoms in vulnerable individuals may arise as a consequence of the level and frequency of exposure to abuse’ (Heins, et al, 2011, American Journal of Psychiatry)

Plus the limited genetic evidence that exists is at least partly gene x environment evidence. The field of epigenetics emphasizes the powerful impact of the environment on the expression of genes.

‘(R)odent and non-human primate studies replicate the vulnerability of the prefrontal cortex, amygdala, hippocampus, and HPA axis to early-life adversity…’ (Roth And Sweatt, 2011a)

‘To the extent that an increased incidence of schizophrenia is associated with early-life adversity, epigenetic changes triggered in early prenatal or postnatal developments might predispose the development of schizophrenia later in life’ (Roth and Sweatt, 2011a)

The emerging attachment/trauma/dissociation paradigm: treatment

Psychotherapy is effective treatment for psychotic symptoms And can prevent the development of psychotic disorders, including

schizophrenia (French et al, 2007, Lemos-Giráldez, 2009) Trauma-based therapies, including EMDR, are particularly important for

psychosis Van der Berg & Van der Gaag (2012) found that EMDR reduced delusions

and auditory hallucinations (mostly) in persons with comorbid PTSD and psychosis - even without psychotic symptoms being directly targeted

In a larger study, Van der Berg et al (2015) found significant improvement in delusions but not auditory hallucinations (Van der Gaag, personal communication, 9 March 2015)

As noted, voices have a much stronger relation to dissociation and may require alternative EMDR protocols (i.e., Dolores Mosquera and Anabel Gonzales’ work)

Paradigms, vulnerability and sensitivity The current paradigm sees individuals as

having genetic based vulnerabilities (or diatheses) that become expressed under stress But the vulnerability may be due to childhood

trauma Any may not even be a specific vulnerability, but

a general sensitivity

Vulnerability to harm vs sensitivity to influence A number of researchers are now suggesting, on the basis of

evolutionary theory and empirical research, that some people are more sensitive, for better or for worse, than others.

Certain gene alleles (dopamine, serotonic, etc.) may predispose to this Differential susceptibility (Belsky)

Differences within families are normal Biological sensitivity to context (Boyce & Ellis)

Highly supportive or highly aversive environments (including prenatal) increase stress sensitivity/physiological reactivity

Sensory processing sensitivity (Aron & Aron) Evolutionary-based personality type processes sensory information deeply

before acting

Differential sensitivity

Classic diathesis (vulnerability) – stress model

‘Beyond Diathesis Stress: Differential susceptibility to environmental influences’ (Belsky & Pluess, 2009)

‘The central thesis in this paper… is that those putatively “vulnerable” individuals most adversely affected by many kinds of stressor may be the very same ones who reap the most benefit from environmental support and enrichment, including the absence of adversity’. (p. 886) This appears to apply not only to children with a difficult temperament,

but also to those with genetic variants of the serotonergic and dopaminergic systems (linked to sensitivity to stress), previously seen as indicators of vulnerability to psychosis.

Interventions to improve parenting differentially affect the behavior of the more sensitive children (with a specific dopamine gene allele). Poor parenting led to most ‘externalizing behavior’ and sensitivity to stress, while good parenting led to the least. (Van IJzendoorn et al, 2008)

From Bakermans-Kranenburg & Van IJzendoorn (2011)

Differential susceptibility (sensitivity) model (Ellis et al, 2011)

Changing one’s worldview? Attachment, trauma and dissociation are

environmental influences that have been overlooked And the notion of sensitivity turns the notion of

predispositions for pathology on its head But it is important to go further -- and not see these

as environmental mechanisms or factors that can interact with and be added to biological or genetic ones A change in worldview is also required

World views and metaphors The dominant medical paradigm in psychiatry arises from a

Cartesian/Split/Mechanistic world view Where humans are passive responders to stimuli, and all activity

can be reduced to brain functioning Information processing and the computer metaphor

(input/output) arise from the same worldview ‘The insertion between input and output of a computing

mechanism or a neural network is merely an updating of Descartes’ cogs and wheels, yielding a more complicated relation between input and output; from a push-pull machine or a wind-up clock to the telegraph system, telephone switchboard, hydraulic pump, and the digital computer, this idea has been constant.’ (Overton, 2015, p. 24)

The relation between genes and environment In the neo-Kraepelinian paradigm, genes are privileged over

environment But ‘not a single risk-factor [gene] allele has been identified for either

the most prevalent mental illnesses (schizophrenia, autism, bipolar disorder and depression) or for behavioral variation within a ‘normal’ range (i.e., intelligence and personality)’ (Charney, 2014, p. 1)

And can genes even be treated as a separate ‘factor’ from environment? ‘The character of any contemporary behavior is 100% nature because

it is 100% nurture; 100% biology because it is 100% culture. There is no origin to [any] behavior that was not some other percentage -- regardless of whether we climb back into the womb, back into the cell, or back into the DNA’ (Overton, 2015)

An alternative paradigm? Process/relational world view argues against reductionism

and the reification of concepts ‘The focus of understanding is not on things but on the relations

among things. Unity is found in multiplicity and not by reducing the many to the one’. (Overton, 2015, p. 33)

Instead of reducing all activity to ‘behavior’ or ‘brain functioning’ ‘these become standpoints, points-of-view, or lines-of-sight, in recognition that they do not reflect absolute foundations but perspectives in a multiperspective world… although explicitly recognizing that any behavior is both 100% biology and 100% culture, alternative points of view permit the scientist to analyze the acts of the person from a biological or from a cultural standpoint.… the unity that constitutes nature, the organism, and development becomes discovered only in the diversity of multiple interrelated lines of sight’. (Overton, 2015, p. 43).

How can a new paradigm of psychopathology fit into this worldview? Current ‘medical’ model, neo-Kraepelinian paradigm has

explained little and been faced with numerous ‘anomolies’ Is in a current state of crisis

New paradigm emphasizing sensitivity (not vulnerability) and adverse life experiences - trauma, attachment - and dissociation, better explains current findings - including biomedical ones

Psychopathology must fit into this worldview, by denying any hard line between normality and abnormality, and by seeing humans as inherently active, meaning-making organisms - not as machines, even ‘information processing’ ones

Time to put Kraepelin to bed? And remember Jung?

Jung in Zürich public lecture (Jan 1908)

‘Though we are far from being able to explain all the relationships in that obscure world, we can maintain with complete assurance that in dementia praecox there is no symptom which could be described as psychologically groundless or meaning-less. Even the most absurd things are nothing other than symbols for thoughts which are not only understandable in human terms, but dwell in every human breast. In insanity, we do not discover anything new and unknown; we are looking at the foundations of our own being, the matrix of those vital problems on which we are all engaged.’