Connection between psychosis, trauma and dissociation: an exploratory study involving patients in forensic mental health settings

Abstract

Background: High levels of dissociation have been found in recent studies involving psychiatric inpatients. Proponents of the ‘dissociative psychoses’ have found that trauma-focused intervention strategies can improve outcomes of patients with major mental illness. Despite this, levels of dissociation have not been measured in forensic inpatients in Scotland. This study investigates levels of dissociative symptoms (DES-II) within a sample of male patients in secure forensic psychiatry settings in Scotland. It explores levels of psychosis (PANSS) and self-reported childhood trauma (CTQ), current PTSD symptoms (IES-R), levels of depression (BDI-II) and broad attachment style (RQ). Four groups were arbitrarily defined based on presence or absence of psychosis and childhood trauma. It was hypothesised that levels of dissociation would be predicted by presence of childhood trauma. Methods: A quantitative cross-sectional design was used in which 56 mentally disordered offenders were interviewed across three different secure hospitals in Scotland: The State Hospital – a maximum security psychiatric hospital, and two medium secure facilities. Attempts are made to clarify the relationship of dissociation with different types of childhood trauma and psychosis symptom clusters. By splitting the data into groups the study seeks to discern whether the groups differ significantly on dissociation scores in relation to the childhood experiences they reported and presence of psychosis they are experiencing. Results: Childhood traumatic experiences were frequent where median CTQ total score = 47.0 (IQR: 42-70.5). Physical neglect was reported by 58.9% of the sample closely followed by emotional neglect (55.4%). 46.4% of the sample reported physical abuse of significant levels, 44.6% reported being emotionally abused and almost a third reported being sexually abused (28.6%). DES-II (dissociation) scores were significantly associated with delusions and hallucinatory behaviour from PANSS. Emotional abuse and sexual abuse were significantly associated with dissociation scores. Mann Whitney tests revealed that dissociation was significantly higher in the groups which reported childhood trauma. Kruskal-Wallis results indicated no significant differences between groups within the data and dissociation scores. Conclusion: Patients with clinically significant levels of dissociative symptoms were identified. This indicates that dissociation is a key characteristic, warranting further consideration in this sample. Levels and severity of reported childhood trauma were higher than expected. The findings add weight and support to the importance of dissociation and trauma in formulations of male, mentally disordered offenders. Clinical implications of these findings are considered and further directions are discussed.