Trauma and delirium: what relationship

In the book “Decoding delusions: a guide for the clinician on how to work with delusions and other extreme beliefs”, of Hardy and Turkington (2023) there is an interesting chapter, edited by Charles Heriot-Maitland entirely dedicated to relationship between trauma and deliriumbriefly summarized below.

The author offers a very different perspective compared to the traditional approaches of mental health services dedicated to psychosis: if in fact, in general, the therapeutic approach has been the one aimed at reducing/removing symptoms (think of “antipsychotic” drugs, literally “anti” – against – the symptoms), following the author’s proposal we are stimulated to change rational, putting attention on the trauma as a promoter of the delusional belief. Let’s see how and with what implications.

Traumatic paths to delusions

The evidence of a causal link between trauma and psychosis are manifold, so much so that Bentall et al. (2014) They suggest both comparable “to causal evidence that connects smoking to lung cancer”.

The trauma in childhood It increases the probability of psychosis (Varese et al. 2012) and there are evidence of a cumulative relationship such that the greater the trauma, the greater the probability of psychosis (Shevlin et al. 2008).

There are research that also show that different types of trauma can lead to different psychotic symptoms: for example, Bentall et al. (2014) They say that childhood sexual abuse could be more linked to feeling the voices (hallucinations) and that the events that impact on attachment could be more related to paranoia.

However, this consequentiality is not so clear since there are also contrary evidence, such as the one that connects thesexual abuse to paranoia (Murphy et al. 2012) or the trauma of the attachment to hearing the voices (Pilton et al. 2016).

Interventions focused on trauma for people with delusions

Psychoeducation

It is important that an intervention focused on trauma for people with delusions is built on one solid psychoeducation. What are the key messages to be transmitted to this type of patient?

1. The brain has an integrated threat system that has an important evolutionary function. His task is very simple: to detect danger and react to it. The threat system does not work for our happiness or mental health, but for our survival.
2. The more the threat system is activated, the more sensitized and reactive it becomes. Similarly to the training of a muscle in the gym: the more we exercise it, the more strong and dominant it becomes. If someone had to use a lot the threatening system In his life (for example through prolonged experiences of trauma) then the threat system has become stronger and dominant and is activated more promptly.
3. It is not the patient’s fault if the brain has evolved in this way, nor if social experiences have modeled the way in which his threat system has been exercised over time.

Formulate delusions and their possible functions in the context of trauma

The delusional beliefsin the author’s proposal, are conceived as strategies instead of like symptoms: strategies that the brain could adopt in situations of extreme adversity or trauma.

There are several ways in which delusions could work as (functional) strategies for people in the context of trauma.

• A conviction of threat (in paranoid deliriumfor example) can help support the oriented threat system (Heriot-Maitland, 2022), and therefore capable of protecting a person from external or internal threats. A delusional belief can, for example, arouse answers such as “guard”, “keep the distances from the others” or “close to the doors and windows”: it does not necessarily have importance what the real is content of the deliriumthe important thing, as regards protection from threat and survival, is the mental, physical and behavioral response aroused by delirium.
• There function of delusions To protect themselves from threats it can apply not only to potential external threats, but also to internal threats (from one’s emotions, memories and feared mental states). An example of a relevant internal threat for trauma survivors is the fear of one’s own feelings of helplessness. In this case, it can be functional to maintain a delirium that keeps the mind oriented towards a current threat in the outside world when the alternative (to meet their internal states and memories of impotence and helplessness) can be much more difficult.

Therapeutic opportunities

Build an intervention focused on trauma starting from a formulation that considers i delusions as strategies rather than as symptoms It can open a series of therapeutic opportunities:

• Moving the patient’s relationship with delirium from a conflict and anguish relationship (“This delusion is a threat to me”) to one of curiosity and exploration (“This delusion can reflect something from which my mind is trying to protect me, communicate or resolve me. What is this something? What is the threat, the emotion or conflict that could be behind?”);
• Identify the therapeutic objectives (for example, experiences of threats and memories) for the I work on trauma and feared or avoided emotions which could be behind the delusions;
• Preparing the patient at what intense feelings and conflicts could begin to emerge as the delusions begin to reduce or weaken;
• Setting the path for work on trauma (for example, gradual exposure to memories, emotions and conflicts so that they can be accessible and integrated safely).

Bibliography

• Unger, R. (2024). Decoding disappointments: A Clinician’s Guide to Working with Disput and Other Extreme Beliefs: Edited by Kate V. Hardy and Douglas Turkington, Washington, DC, American Psychiatric Association Publishing.
• Bentall, RP, Wickham, S., Shevlin, M., Varese, F. (2012) Do Specific Early Life Adversities Lead to Specific Sympoms of Psychosis? A Study from the 2007 The Adult Psychiatric Morbidity Survey. Schizophrenia Bulletin38 (4): 734–740.
• Bentall, RP, De Sousa, P., Varese, F. (2014) from Adversity to Psychosis: Pathways and Mechanisms from Specific Adversities to Specific Sympoms. Social Psychiatry and Psychiatric Epidemiology49 (7): 1011–1022.
• Heriot-Maitland, C. (2022) Compassion Focused Therapy for Voice-Hearing and Disappointment in Psychosis, in Compassion Focused Therapy: Clinical Practice and Applications. Edited by Gilbert, P., Simos, G. London, Routledge, 2022, pp 549–564.
• Heriot-Maitland, C., Longden, E. (2022) Safety and Safeness, in Relating to Voices Using Compassion Focused Therapy: A Self-Help Companion. London, Routledge, pp 43–62.
• Heriot-Maitland, C., Peters, E. (2015) Dimensional approaches to disappointment beliefs, in schizotypy: new dimensions. Edited by Mason Oj, Claridge G. London, Routledge, pp 165–179.
• Murphy, J., Shevlin, M., Houston, J., Adamson, G. (2012) Sexual Abuse, Paranoia, and Psychosis: a Population-Based Mediation Analysis. Traumatology 18 (1): 37–44.
• Pilton, M., Bucci, S., Mcmanus, J. (2016) Does Insecure Attachment Mediate The Relationship Bethaeen Trauma and Voice-Hearing in Psychosis? Psychiatry Research246: 776–782.
• Shevlin, M., Houston, Je, Dorahy, MJ, Adamson, G. (2008) Cumulative Traumas and Psychosis: An Analysis of the National Comorbider Survey and the British Psychiatric Morbidity Survey. Schizophrenia Bulletin 34 (1): 193–199.
• Turner, MH, Bernard, M., Borchwood, M. (2013) The contribution of shame to post-Psychotic trauma. British Journal of Clinical Psychology 52 (2): 162–182.
• Varese, F., Smeets, F., Drukker, M. (2012) Childhood Adversities Incasse The Risk of Psychosis: A Meta-Aalysis of Patient-Control, Prospective and Cross-Sectional Cohort Studies. Schizophrenia Bulletin 38 (4): 661–671.