Andrew Moskowitz

The Contribution of Early Traumatic Events to Schizophrenia in Some Patients: A Traumagenic Neurodevelopmental Model

Abstract The current diathesis-stress model of schizophrenia proposes that a genetic deficit creates a predisposing vulnerability in the form of oversenstivity to stress. This model positions all psychosocial events on the stress side of the diathesis-stress equation. As an example of hypotheses that emerge when consideration is given to repositioning adverse life events as potential contributors to the diathesis, this article examines one possible explanation for the high prevalence of child abuse found in adults diagnosed schizophrenic. A traumagenic neurodevelopmental (TN) model of schizophrenia is presented, documenting the similarities between the effects of traumatic events on the developing brain and the biological abnormalities found in persons diagnosed with schizophrenia, including overreactivity of the hypothalamic-pituitary-adrenal (HPA) axis; dopamine, norepinephrine, and serotonin abnormalities; and structural changes to the brain such as hippocampal damage, cerebral atrophy, ventricular enlargement, and reversed cerebral asymmetry. The TN model offers potential explanations for other findings in schizophrenia research beyond oversensitivity to stress, including cognitive impairment, pathways to positive and negative symptoms, and the relationship between psychotic and dissociative symptomatology. It is recommended that clinicians and researchers explore the presence of early adverse life events in adults with psychotic symptoms in order to ensure comprehensive formulations and appropriate treatment plans, and to further investigate the hypotheses generated by the TN model.

Auditory Hallucinations: Psychotic Symptom or Dissociative Experience?

SUMMARY While auditory hallucinations are considered a core psychotic symptom, central to the diagnosis of schizophrenia, it has long been recognized that persons who are not psychotic may also hear voices. There is an entrenched clinical belief that distinctions can be made between these groups, typically, on the basis of the perceived location or the ‘third-person’ perspective of the voices. While it is generally believed that such characteristics of voices have significant clinical implications, and are important in the differential diagnosis between dissociative and psychotic disorders, there is no research evidence in support of this. Voices heard by persons diagnosed schizophrenic appear to be indistinguishable, on the basis of their experienced characteristics, from voices heard by persons with dissociative disorders or by persons with no mental disorder at all. On this and other bases outlined in this article, we argue that hearing voices should be considered a dissociative experience, which under some conditions may have pathological consequences. In other words, we believe that, while voices may occur in the context of a psychotic disorder, they should not be considered a psychotic symptom.

Replication of dissociation-psychosis link in New Zealand students and inmates.

To assess the relationship between dissociative and psychotic experiences, New Zealand university students (N = 119) and prison inmates (N = 42) were administered the Dissociative Experiences Scale (DES) and Symptom Checklist-90-Revised (SCL-90-R). Strong correlations were found between DES scores and the psychoticism and paranoid ideation subscales of the SCL-90-R (students: r = .520, .517, respectively; inmates: r = .637, .649, respectively). While other correlations were also significant (but smaller), these results are consistent with previous studies that have used a range of measures of psychosis or schizotypy with a variety of clinical and nonclinical populations. Such consistent findings in the face of methodological diversity offer strong support for the validity of a link between the concepts of dissociation and psychosis. While this relationship has previously been interpreted indirectly, as dissociative experiences predisposing to psychotic symptoms, we suggest a direct route: that dissociative experiences of various forms may underlie some (or even all) psychotic symptoms.

The role of mental illness in homicide-suicide in New Zealand, 1991 – 2000

Abstract Prior studies of homicide-suicide (H-S) have largely glossed over the relevance of mental illness (MI), either ignoring the issue outright or defining H-S cases as intrinsically related to MI or not. While such positions have methodological or theoretical justifications, it was felt that a finer-grained analysis was possible and might prove fruitful. As part of a large population study on homicide and MI in New Zealand, all H-S cases over a 10-year period were identified through a police database and their Coronial Services files reviewed. Thirty-three H-S cases (0.08 per 100,000 prevalence) were identified. Fourteen perpetrators (42.4%) were classified as MI; among these were all five of the female perpetrators and 32% of the male; 20% had not previously been in treatment. Most of the MI perpetrators killed their children and then themselves. In contrast, only a few of the H-S perpetrators who killed a current or former partner were MI. It is concluded that H-S events in New Zealand appear broadly similar to such events in other countries, and that MI plays a significant role in some forms of H-S. However, the relationship between gender, H-S motivation, and mental illness is clearly complex and in need of further study.

Dissociative Pathways to Homicide: Clinical and Forensic Implications

ABSTRACT In a earlier review, dissociation was found to be linked to violence in a wide range of populations, including college students, young mothers, psychiatric patients, and criminal offenders, and was often expressed in the violent act itself, in the form of depersonalization or subsequent amnesia (Moskowitz, 2004). While that review focused on “state” dissociation–i.e., dissociation during an act of violence, this paper looks at links between “trait” dissociation and violence–evidence that long-term dissociative processes may predispose vulnerable individuals to violent behavior, and even homicide. Specifically, it is argued that dissociation is related to the development of four “types” (probably not mutually exclusive) of homicide offenders: (1) violent individuals suffering from dissociative identity disorder, whose violence is expressed through certain dissociated personality states, (2) fantasy-driven violence, often accompanied by some form of identity alteration, (3) paroxysms of “dissociative rage” in individuals normally presenting as polite or meek, characterized as “overcontrolled hostile” (Megargee, 1966), and (4) persons designated as psychopathic, whose emotional numbing may be trauma-based and similar to that seen in depersonalization disorder. While the last three areas are somewhat speculative, research findings supporting each proposed link are presented. In conjunction with Moskowitz (2004), this review strongly suggests a significant role for dissociation not only in the commission of certain violent acts, but also in the development of some violent individuals; the clinical and forensic implications of this are discussed. Further research systematically exploring the role of dissociative processes in violent and homicidal behavior is called for.

Profiles of DES Performance in Inmate and Student Samples

ABSTRACT Despite the finding of a recent review of the literature (Moskowitz, 2004) that at least 25% of offenders demonstrated pathological levels of dissociation, very little empirical research has been conducted that examines dissociation in samples of prison inmates. This study examined the profiles of dissociative experiences reported in a sample of 42 prison inmates, when compared to 119 students on the Dissociative Experiences Scale. Profile analysis indicated that overall DES performances differed significantly for the two samples. Using Hotellings criterion, DES items were found to deviate significantly from flatness, and using Wilkss criterion, the profiles also found to differ significantly from parallelism (p < .01). Specific items contributing to these differences were examined. It is hypothesized that some of these items may be reflective of past criminal activities rather than dissociation. As DES-taxon item content reflects less susceptibility to alternative interpretations, it is recommended that both researchers and clinicians consider using the DES-taxon, rather than DES total scores when examining dissociation in forensic samples.