Psychotic Symptoms in Rape Survivors: Signs of Trauma, not Psychosis

Andrew Moskowitz Clinical Department of Mental Health University of Aberdeen

ICRS November 2008

Objectives of talk
To indicate that a wide range of

psychotic symptoms are common in rape survivors To emphasise that these symptoms are usually trauma-based and not indicative of a schizophrenic or psychotic disorder

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Outline of talk
What are psychotic symptoms? What is dissociation? Immobility / catatonic peri-traumatic responses during

rape (which may be predictive of PTSD) PTSD and post-traumatic delusions in rape survivors Prevalence and significance of auditory hallucinations (hearing voices) in rape survivors Conclusion: Psychotic symptoms in rape survivors are likely signs of trauma, not schizophrenia

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Goals for presentation

To help those working with rape survivors to reduce stigma and shame in rape survivors who did not struggle or call out when those actions derived from an involuntary fear response (rape paralysis / tonic immobility / catatonia) fear of going crazy in rape survivors who interpret their post-traumatic responses as signs of becoming psychotic or schizophrenic bias in police officers / legal professionals toward discounting rape stories where the survivor did not (felt unable to) struggle or call out described the rape in a relatively unemotional fashion (often a sign of dissociation), or was experiencing psychotic symptoms.
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Current definition of psychosis

DSM-IV provides three definitions:
delusions and prominent hallucinations experienced without insight delusions and prominent hallucinations (with or without insight) the four Criterion A positive symptoms of schizophrenia (i.e., delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior)

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DSM-IV diagnosis of schizophrenia

2 of the following: Delusions Hallucinations Disorganised speech (e.g., frequent derailment or incoherence) Grossly disorganised or catatonic behaviour Negative symptoms (i.e., affective flattening, alogia, or avolition) or 1 of the following: Bizarre delusions Voices commenting on ones behaviour or two or more voices conversing with one another present for a significant portion of time during a 1-month period (or less if successfully treated)
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What is dissociation?
A response to a traumatic situation that

involves a disruption in the normally integrated functions of consciousness, memory, identity, or perception of the environment Dissociative symptoms include
Depersonalisation Derealisation Amnesia Identity alteration

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Paralysis/involuntary immobility/ catatonic stupor during rape

Reported by between 1/3 and 1/2 of rape survivors (Burgess &

Holmstrom, 1976; Galliano et al, 1993; Fus et al, 2007) Approximately 10% report severe immobility Characterised by Abrupt onset and termination An involuntary inability to move or call out A numbing to physical sensation / pain Subjective feeling of coldness Odd, stiff posture; staring or closed eyes Maintained or enhanced awareness / alertness Experiences of detachment from self / watching self Associated with Fear for ones life Physical restraint or the perception of no escape
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Mammalian fear responses and evolutionary psychology

Changes in evolutionary behaviour patterns -

particularly danger responses - lag far behind social and cultural changes

Pilo-erection (hair standing on end) Phobias to spiders and snakes (not guns and knives)

Fear-induced paralysis derived as a response to

attacks from predators Emotions felt in situations may serve to cue evolutionary-based response

human psychological mechanisms are orchestrated by emotions that frame present circumstances in terms of the evolutionary past (Tooby & Cosmides, 1990)
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Predator/prey distance, fear and defense reactions

Extreme

FEAR

unsuccessful Freezing Low Flight/Escape Fight/Struggle TI

successful FAR Proximity to Threat NEAR

Adapted from Marx et al (2008)

Tonic immobility (TI) in animals

The sudden onset of prolonged stillness and decreased responsivity in a previously active animal in the face of threatening stimulation. TI is an extreme fear reaction based on the way movement triggers attack by predators, in which the animal is scared stiff and unresponsive to even painful or other intense stimulation.
Isaac Marks (1987) Fears, Phobias, and Rituals

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Characteristics of TI
Bizarre, death-like postures Muscular rigidity No movement, no vocalisation Insensitivity to pain Alert and aroused

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A chick in a TI response

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Consequences of TI responses in Rape

Increased likelihood of PTSD TI is associated with peri-traumatic dissociation, which predicts PTSD TI itself is traumatic, very frightening and confusing Increased self-blame, decreased help-seeking Less likely authorities will believe rape or

successfully prosecute May lead to future episodes of TI or catatonic stupor under stress
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Delusions, trauma and PTSD (Scott et al, 2007)

PTSD is associated with delusions and hallucinations Content may not be clearly trauma-related 10,000+ Australians representatively sampled

(National Survey of Mental Health and Wellbeing)

Asked about delusional experiences over past year (delusions of reference, thinking, paranoia and grandiosity) and lifetime traumatic events Controlled for prior schizophrenia diagnosis, cannabis and alcohol dependence, and various demographic variables

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Delusions, trauma and PTSD

54% of sample experienced a trauma Delusional experiences endorsed by

2% with no trauma history 5% with trauma history (but not PTSD) 18% with PTSD

Exposure to trauma = 2x risk of developing

delusions PTSD = 6.5x risk of developing delusions

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Rape, PTSD and delusions

Delusions and specific traumatic events (rape, sexual

abuse (excluding rape), physical assaults, combat, accidents and natural disasters)

Rape (- PTSD) associated with 3.3x increase in delusions (2nd largest increase) Rape (+ PTSD) associated with 18x increase in delusions (substantially the largest increase)

Authors conclusion: Delusional experiences were

associated with all types of trauma (but) the association was especially strong in those who had reported rape (p. 341).
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Auditory hallucinations (voices) and trauma

Voices are common in general population between 2% and

9% have heard voices (excluding hypnogogic / hypnopompic or calling ones name) <1/3 have any psychiatric disorder or are clinically distressed More strongly associated with trauma than any other psychotic symptom 70% of voices start after a traumatic or highly emotional experience 14-25% Combat veterans with PTSD hear voices (outside of flashbacks) 85% of adolescents with PTSD heard voices (Scott et al, 2007) <1/3 content clearly related to trauma Few differences with AH in adolescents with psychosis Heavily weighted in schizophrenia diagnosis, but most likely dissociative in nature (Moskowitz & Corstens, 2007)
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Voices in rape survivors

Particularly common after childhood sexual abuse Shevlin et al (2007) 21% of women raped < age 16

heard voices Often take on characteristics of the perpetrator, taunting or blaming the survivor Or may have little apparent connection to trauma and can be supportive May be heard primarily inside the head Voices may appear only after rape even in persons sexually abused as children
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Summary
Psychotic symptoms associated with rape Immobility/Catatonia Delusions Hallucinations Should not be seen as indications of

schizophrenia, but of trauma/dissociation Rape survivors should be re-assured they are not going crazy Dealing with trauma, including with split-off emotions, may reduce symptoms
ICRS November 2008