Links between trauma and psychotic symptoms: Integrating cognitive behavioural and neuropsychoanalytic models of psychosis.

purposeCognitive-behavioural therapy for psychosis (CBTp) achieves small to modest effect sizes, which invites the question, 'What clinical modifications might improve outcomes?' This paper proposes an integration of CBTp with a neuropsychoanalytic approach that in clinical practice might extend the gains achieved by CBTp alone.

methodsThe author conducted a focused review of CBTp research bearing on trauma as well as a review of neuropsychoanalytic conceptions of psychological symptoms ('neuropsychoanalytic' meaning principally psychoanalytic ideas about how the brain maintains affective homeostasis) to identify similarities and differences in these approaches relevant to clinical practice.

resultsCBTp-oriented research shows that not only is childhood trauma associated with psychosis, but psychotic symptoms often contain de-contextualized memories of trauma and embody narrative themes that echo the person's trauma history, findings that mark psychosis as a trauma-related disorder in which psychotic symptoms constitute disguised representations of a person's trauma history. This paper expands the definition of trauma to include the symbolic meaning of events and relates psychosis to a neuropsychoanalytic model of the mind in which affect plays a central role, a conceptual lens through which delusions can be seen as meaningful adaptive attempts to maintain affective homeostasis in the aftermath of traumatic experiences. The paper offers an explanation of the developmental origins of the cast of characters and plot lines often encountered in delusional narratives.

conclusionsThere is considerable potential conceptual overlap between CBTp and neuropsychoanalytic approaches to psychosis, which if integrated might lead to better clinical outcomes, in particular in a collaborative development of schema therapy for psychosis.