I dealt last time with the long and difficult journey both women and soldiers have had to travel to get their way of behaving after combat or abuse properly recognised as the effect of the trauma they have undergone rather than as evidence of some despicable personal weakness.
Trauma in Relation to Psychosis
I’ll try to keep this section intelligible with as little neuro-scientific psychobabble as possible.
As we move through this evidence, we need to keep aware of how hard it must be for people who have been invalidated by the diagnosis of schizophrenia, to gain the necessary credibility to shift public and professional opinion from insisting they are the victims of an irrational disease of the mind, limited to those whose genes are against them, to seeing them as human beings like the rest of us, experiencing a comprehensible response to intolerable stress and emotional pain – much harder, I suspect, than anything that veterans labelled with combat fatigue had to face.
A good place to begin is with Richard Bentall’s examination of the issue in his 2003 edition of Madness Explained. This book, as will become clear, significantly predates most of the references I draw on in this section. He writes (page 277):
In this discussion of environmental influences on psychosis, I have left the contribution of trauma and until last because, for many psychologists and psychiatrists at least, even to raise this issue is to court to controversy.
Clearly Freud was not the last in the line of writers to find that pursuit of this line of reasoning could be inviting professional disaster.
Even so his conclusions on the basis of the best evidence at the time is (pages 478-79):
Despite difficulties, there is consistent evidence that a history of physical or sexual abuse is unusually common in psychotic women.
Comparable evidence of an association between trauma and psychosis has emerged from studies of men.
Even as late as 2010 there seemed to be persisting resistance to widespread acceptance of what should have by then have become obvious and widely accepted (The Impact of Early Life Trauma – page 9):
While biological factors undoubtedly play a significant role in many cases of psychosis, there is an abundance of evidence supporting the impact of early trauma on the development of psychosis . . . , yet biological accounts in isolation still dominate treatment and teaching on the aetiology of psychosis. . . . Just as the research findings do not support childhood abuse and neglect as the only pathway to psychosis, there is no compelling evidence to suggest that biological models satisfactorily account for all psychosis . . . . Acceptance and acknowledgement of explanations more consistent with empirical findings need to overcome what societal attention to child abuse and neglect has always had to overcome: society’s desire for minimisation and denial.
The existence and effect of child maltreatment is perpetually fighting for acceptance against powerful psychological and social processes set to deny, ignore or undermine it.
When we leap almost to the present day there is thankfully far less hesitation in many quarters. I’m not sure though that we have yet come to the end of the need to change the prevailing consensus.
Longden and Read’s treatment of the issue (The Role of Social Adversity in the Etiology of Psychosis – page 15) is where we can pick up the thread.
Childhood sexual abuse can definitely damage the brain in ways that may lead to psychosis. They quote a study comparing abuse exposure and brain volume in 60 patients and 26 matched controls which had found that ‘a significant amount of variance in grey-matter volume in psychotic disorders can be accounted for by a history of sexual trauma. The association was not significant for other types of childhood maltreatment, although rates of [childhood sexual abuse], physical abuse, emotional abuse and physical neglect were all higher in the patients with psychosis than the healthy controls.’ We will return to brain issues, or do I mean ‘tissues’, again in a later post.
Jamie Murphy, Mark Shevlin, James Edward Houston, and Gary Adamson dig somewhat deeper and uncover the true complexity of the problem (Modelling the co-occurrence of psychosis-like experiences and childhood sexual abuse –pages 1037-1043).
Evidence, in their view, has repeatedly shown that Childhood Sexual Abuse (CSA) is ‘significantly associated with psychosis at both clinical and sub-clinical levels (Psychotic-like Experiences – PLEs): the worse the CSA, the greater the risk, severity and duration of psychosis.’
My own clinical experience powerfully validates the link between sexual abuse and psychotic experiences. I have blogged about this in detail previously so a very brief summary as well as the poem above will have to suffice at this point.
In 1988 a young woman persuaded her GP to refer her to me. She had carried a diagnosis of schizophrenia since she was 16. Before that she had had a twelve year history of sexual abuse at the hands of her father which went undisclosed and unnoticed at the time.
It took more than a year for her to begin to describe the abuse, so painful was it for her. She could focus on it for no more than ten minutes in each hour at first. After that she became overwhelmed with terrifying hallucinations of her father, hallucinations which impinged upon all her senses – smell, touch, hearing, taste and vision. The only way she learned to determine afterwards that he had not really been there was to observe that she had no marks upon her body. Generally it would take the rest of the session to help her regain control of her own mind.
Sexual abuse is not the only trauma implicated in psychosis and does not always lead to psychosis as Murphy et al go on to explain:
Many individuals who experience CSA [Childhood Sexual Abuse] do not develop psychosis or PLEs [Psychotic-like Experiences]. Many individuals who also experience PLEs or who are diagnosed with a psychotic disorder have never experienced CSA.
What explanation might there be for that?
Clearly, and I feel not unexpectedly, Childhood Sexual Abuse, they found, does not lead to psychosis/ Psychotic-like Experiences, in all cases. Many who experience Childhood Sexual Abuse, for example, go on to develop Post-Traumatic Stress Disorder, depression, anxiety, substance abuse/dependence or other forms of psychological debilitation and distress. Many others, on the other hand, seem to demonstrate resilience or seem to be less affected by their abuse experiences. In the same way, people with Psychotic-like Experiences and psychotic disorder are not always the victims of previous Childhood Sexual Abuse. Many psychosis sufferers experience a wide range of non-sexual traumas and many experience traumas, stressors and adversities that occur throughout their lifetime, not just in childhood.
Ian is an example of this form of troubled trajectory.
His mother died of tuberculosis before he was 12 months old. His childhood was disrupted and then made even more stressful by a custody issue in which his estranged father sought to wrest the care away from his grandparents to whom he was firmly attached. He was five before the case was settled in favour of his grandparents. Two years later his much loved grandfather died. When he was nine he was walking to school through a farmyard and saw the farmer hanging in his barn. Benign voices, which comforted him, began soon afterwards.
To avoid going down the mines, as his grandfather had done, and to avoid the consequent damage to the lungs which killed his grandad, he joined the army. He was posted eventually to Hong Kong where being bullied by a sergeant major precipitated his first episode of psychosis.
In the military hospital, to escape its oppressive atmosphere and enforced treatment, he faked recovery and was trained as a sniper, something which the army felt he could cope with better as ‘schizophrenics work better alone.’ The trauma undergone during his army experiences left him wracked with guilt for the deaths he had caused, and led to his playing a kind of Russian roulette, in which he deliberately courted death as a way of determining whether or not he deserved to live. The last occasion he did this while still in the Army was when he deliberately walked towards a suspect bomb in Northern Ireland. The bomb exploded while he was close enough to incur lung damage from the blast but not close enough for it to kill him. He was invalided out.
A traumatic break with his alcoholic partner later precipitated the intense psychosis which led to my work with him. There are more details of that work on my blog so I won’t discuss it here.
He died sometime after our work ceased. The cause of death was emphysema, brought on by his heavy smoking, which exacerbated the lung damage from the bomb. A sad echo of his early life. The failure of his lungs, like that of his mother’s all those years before, was what killed him.
Next time I will be exploring other factors.
 The experience of the Falklands conflict has led to many well-documented examples of where what leads to PTSD is not seeing your comrades killed, but seeing what happens to the soldiers you shoot. Psychologists shamefully found it easy to train men to shoot to kill, but were not prepared for how the trauma of that would affect large numbers of combatants.