Neurosis and Psychosis
I attended an interesting conference organised by the Royal College of Psychiatrists in early 2022. The focus of the discussion was on trauma, PTSD (post traumatic stress disorder where sufferers have flashbacks, nightmares, etc) and complex PTSD (where sufferers experience additional difficulties). The speakers also discussed how trauma could be linked to psychosis, a condition characterised by delusions (false fixed belief) and hallucinations (seeing or hearing things that are not there).
Broadly speaking, mental health conditions can be separated into the two main categories - psychosis (as described above) and neurosis (anxiety, depression, PTSD, etc). This separation has been going on for a long time and it has some practical benefit, for instance in designing services and pathways.
However, in clinical terms, the overlap between psychosis and neurosis is more considerable than what clinicians tend to think. This makes sense to me when I think about how the psychiatric diagnostic system always struggles when the experiences of the patient do not neatly fit into a particular category.
In my clinical practice, I have seen many patients who have had traumatic experiences and subsequently hear voices in the context of their traumas. These voices can be difficult to manage but do not have the characteristics of psychosis. These post trauma voices experienced are “dissociative” (from dissociation) in nature which means they are rooted in trauma experiences.
Dissociation is a consequence of trauma and can be described as a process that serves to protect the individual by creating distance between the trauma and the individual. It works well in short term but can become problematic if it carries on long term.
The conference also discussed that Schizophrenia (a psychotic condition with delusions, hallucinations, etc) currently thought of as a genetic disorder appears to have a significant trauma connection. There is no single gene implicated in Schizophrenia and recent research suggests that childhood trauma can predispose individual to develop Schizophrenia.
The “first rank symptoms” (synonymous with Schizophrenia) are in fact more common in Dissociative Identity Disorder (a condition related to significant trauma).
In summary, it is important to pay attention to the past experiences of an individual and think of trauma as a mediator in the development of mental health difficulties. Classification systems are helpful but primarily for the clinician. The core objective of all clinicians working in mental health should be to understand what is going on for the patient (and what they have been through) as this can help with treatment planning.