Voice phenomenology as a mirror of the past

The effect of trauma-focused therapy on voice-hearing: An experience sampling study

Trauma and post-traumatic stress are involved in the aetiology and maintenance of voice-hearing. It has been proposed that trauma-focused therapy (TFT) might affect voice-hearing, but previous studies are limited and remain undecided.

OBJECTIVES

We aimed to investigate the effect of TFT on voice-hearing in people with PTSD and psychosis using experience sampling method (ESM). A secondary aim was to explore how changes in voice-hearing are related to changes in PTSD.

DESIGN

This is an adjunct longitudinal ESM study of a sub-group of participants (N = 39) from a randomised controlled trial that compared TFT to a waiting-list control group.

METHODS

Voice-hearing participants filled in 10 daily voice-hearing-related questionnaires for six consecutive days at baseline and post-treatment at pseudo-random times during the day. PTSD symptom severity was assessed at baseline and post-treatment. Multilevel linear regression was used to test the effect of TFT on voice-hearing and to analyse the relationship between changes in voice-hearing and changes in PTSD.

RESULTS

The intention-to-treat analysis showed a significant interaction effect between time and treatment condition (p < .00001) with a small effect size (dppc2 = -0.27), indicating a larger decrease in voice-hearing in the TFT group than in the waiting-list control group. Also, a significant association was observed between changes in PTSD symptoms and changes in voice-hearing (p < .00001).

CONCLUSIONS

Our findings tentatively suggest that, even when voices are not targeted directly, TFT for PTSD can alleviate distressing voices.

Trauma therapies for psychosis: A state-of-the-art review

BACKGROUND

Traumatic events, particularly childhood interpersonal victimisation, have been found to play a causal role in the occurrence of psychosis and shape the phenomenology of psychotic experiences. Higher rates of post-traumatic stress disorder (PTSD) and other trauma-related mental health problems are also found in people with psychosis diagnoses compared to the general population. It is, therefore, imperative that therapists are willing and able to address trauma and its consequences when supporting recovery from distressing psychosis.

METHOD

This paper will support this need by providing a state-of-the-art overview of the safety, acceptability and effects of trauma therapies for psychosis.

RESULTS

We will first introduce how seminal cognitive-behavioural models of psychosis shed light on the mechanisms by which trauma may give rise to psychotic experiences, including a putative role for trauma-related emotions, beliefs and episodic memories. The initial application of prolonged exposure and eye movement and desensitation and reprocessing therapy (EMDR) for treating PTSD in psychosis will be described, followed by consideration of integrative approaches. These integrative approaches aim to address the impact of trauma on both post-traumatic stress symptoms and trauma-related psychosis. Integrative approaches include EMDR for psychosis (EMDRp) and trauma-focused Cognitive-Behavioural Therapy for psychosis (tf-CBTp). Finally, emerging dialogic approaches for targeting trauma-related voice-hearing will be considered, demonstrating the potential value of adopting co-produced (Talking with Voices) and digitally augmented (AVATAR) therapies.

CONCLUSION

We will conclude by reflecting on current issues in the area, and implications for research and clinical practice.

The Diagnostic Spectrum of Sexual Hallucinations

ABSTRACT

Sexual hallucinations are little known, yet often extremely burdening, phenomena. In this systematic review, we summarize what is known about their phenomenology, prevalence, etiopathology, ensuing distress, and treatment options. Sexual hallucinations can be experienced as genital or orgasmic sensations, although other sensory modalities can also be involved. With the notable exception of orgasmic auras in the context of epilepsy, sexual hallucinations tend to be distressing and embarrassing in nature. Our analysis of 79 studies (together describing 390 patients) indicates that sexual hallucinations are more frequent in women than in men, with a sex ratio of 1.4:1, and that they are most prevalent in schizophrenia spectrum disorders, with rates ranging from 1.4% in recently admitted patients to 44% in chronically hospitalized patients. Other underlying conditions include epilepsy, the incubus phenomenon (possibly the most prevalent cause in the general population, associated with sleep paralysis), narcolepsy, and sedative use. As regards the sedative context, we found more medicolegal than purely medical cases, which sadly underlines that not all sexually explicit sensations experienced in anesthesia practice are indeed hallucinations. In the absence of evidence-based treatment protocols for sexual hallucinations, practice-based guidelines tend to focus on the underlying condition. Further research is needed, especially in the fields of substance abuse, posttraumatic stress disorder, and borderline personality disorder, where only anecdotal information on sexual hallucinations is available. Moreover, awareness of sexual hallucinations among health professionals needs to be improved in order to facilitate counseling, diagnosis, and treatment.

Making meaning of trauma in psychosis

Background

Finding new meaning and identity in the aftermath of trauma has been identified as a key process of mental health recovery. However, research indicates that this meaning-making process is compromised in people with psychosis. Considering the high prevalence, yet under-treatment of trauma in people with psychosis, it is urgent to gain insight into how their meaning-making process can be supported.

Aim

To gain insight into how people with psychosis make meaning of trauma and identify barriers and facilitators in their meaning-making process.

Methods

Qualitative inquiry of N = 21 interviews transcripts from the Dutch Psychiatry Storybank. We included interviews of people who (a) lived through multiple psychotic episodes, and (b) spontaneously addressed traumatic experiences in a low-structured interview. Storyline analysis was performed to gain insight into the meaning-making of trauma within their self-stories. Psychosocial conceptualizations of narrative identity were used to inform the analysis. A data-validation session with four experts-by-experience was organized to check and improve the quality of our analysis.

Results

We identified four different story types: (1) Psychiatry as the wrong setting to find meaning; (2) The ongoing struggle to get trauma-therapy; (3) Exposure to trauma as a threat to a stable life, and (4) Disclosure as the key to resolving alienation. Each story type comprises a different plot, meaning of trauma withing the self-story, (lack of) integration and barriers and facilitators in the meaning-making process. Overall, barriers in the meaning-making process were mostly situated within mental healthcare and stigma-related. People felt particularly hindered by pessimistic ideas on their capacity to develop self-insight and cope with distress, resulting in limited treatment options. Their process of adaptive meaning-making often started with supportive, non-judgmental relationships with individuals or communities that offered them the safety to disclose trauma and motivated them to engage in a process of self-inquiry and growth.

Conclusion

The outcomes illuminate the social context of the meaning-making challenges that people with psychosis face and illustrate the devastating influence of stigma. Our outcomes offer guidance to remove barriers to adaptive meaning-making in people with psychosis, and can help clinicians to attune to differences in the meaning-making of trauma.

[A Transtheoretical Model and Treatment of Dissociative Identity Disorder: A Case Report]

Dissociative identity disorder is the most severe of the dissociative disorders and neither the trauma model nor the sociocognitive model provide a satisfactory account of its complexity. Transtheoretical models propose an interaction of traumatic experiences as well as cultural, cognitive, and social factors in the development of the disorder. This perspective has important implications for the treatment which should encompass a reprocessing of traumatic memories, emotional regulation skills, and a modification of dysfunctional beliefs about memory. An elaboration of dissociative identities should be prevented. A corresponding inpatient treatment approach is described.