Remission of schizophrenia after an EMDR session.

We present a case study of the remission of a chemically resistant schizophrenia disorder after a single session of EMDR. Our patient had been followed-up for schizophrenia according to DSM5 criteria, since 4 years. During our subject's fourth hospitalization for major delirious decompensation, a single EMDR session, according to the standard protocol, resulted in a complete and total remission of the delirious disorder and the disorganization/dissociative syndrome in 8 weeks. This allowed us to interrupt the patient's antipsychotic treatment without relapse at 18 months. This case study allows us to highlight, as many authors have previously done, the necessity of researching the traumatic history of patients diagnosed with schizophrenia in order to provide therapies focused on traumatic dissociation. It also questions the relevance of our diagnostic criteria for schizophrenia and other dissociative disorders.

Introduction

The concept of schizophrenia is nowadays controversial: it is accepted that schizophrenia gathers under the same name very heterogeneous clinical presentations (Lasalvia, Penta, Sartorius, & Henderson, 2015; Os, 2016). In recent years, several meta-analyses have focused on demonstrating the link between psychotic symptomatology and a history of childhood trauma (Varese et al, 2012; Bortolon, Seillé, & Raffard, 2017).

While we found evidence in the literature of the effectiveness on psychotic symptoms of trauma-focused therapies (Van den Berg et al., 2018; Adams, Ohlsen, & Wood, 2020), we did not find any mention of the complete remission of schizophrenia with a discontinuation of all psychotropic treatment without relapse over 18 months.

Mr K was 35 years old when he was hospitalized for the fourth time in 4 years in psychiatry for delirious decompensation of schizophrenia.

He has no somatic history apart from asthma, his family psychiatric history consists of an older brother being treated for schizophrenia. His psychiatric history consists of three forced hospitalizations over the past 4 years with a partial response to Olanzapine, Amisulpririne and then Clozapine introduced during his last hospitalization. Clozapine was stopped by the patient a few months after his discharge from hospital a year ago because hallucinations persisted and the patient felt too sedated.

This period had social consequences. In 3 years our patient went from being a father and a senior executive greatly appreciated by his employer, to being divorced, homeless, unemployed and without any income.

On a paraclinical level, the biological tests, the MRI and the EEG are normal. The anti NMDA antibodies are negative.

On entry, Mr K presents acoustical-verbal, visual and cenesthetic hallucinations which have been evolving for more than 6 months. These symptoms prevent him from moving or doing things. He also describes that he sees images: often pornographic images, murders, or the devil. When he looks in the mirror he sees himself transforming into a devil and feels horns growing on both sides of his forehead. He says he threw himself under a bus in a feeling of well-being. He stopped about a metre away from the bus before going to the emergency room.

According to the DSM 5, (American Psychiatric Association, 2013) Mr K presents the diagnostic criteria of schizophrenia with 4 A criteria: delusions, hallucinations, disorganized speech, disorganized behaviour. His social, professional and family integration has totally deteriorated since the onset of the disorder (criterion B). The symptoms have been evolving for more than six months (criterion C). He does not present any element allowing us to retain the diagnosis of schizoaffective disorder or bipolar disorder (criterion D), he does not take any toxins (criterion E) and has no history of psychiatric care before the age of 33 (criterion F).

In the absence of identity disturbance, dissociative amnesia, or complaints evoking a picture of derealization or depersonalization, we did not evoke the diagnosis of dissociative disorder (DSM 5).

Medication strategy: After ineffectiveness of Olanzapine, reintroduction of Clozapine and anxiolysis: the treatment associates Clozapine 400 mg/day, Lamotrigine 75 mg/day in increasing dosage, Diazepam, 20 mg/day, Loxapine 150 mg/day, Zolpidem7,5 and 50 mg of Alimemazine.

This treatment has little effect on the hallucinatory syndrome and the psychic disorganization. The PANSS is at 113 with treatment.

During his fourth hospitalization, Mr K mentions for the first time that he was a victim of paternal incest and that he witnessed the paternal rape of his little sister when he was 6 years old. We propose an EMDR session focused on these memories.

This EMDR session follows the standard protocol: the target is the rape of his little sister in front of him by his father. The negative cognition is ‘I am an accomplice’, the emotion is disgust. During the alternating bilateral stimulations, Mr K connects to his own rape by his father, then to the memory of having intervened to not leave his little brother alone with his father, then to the memory of having called his mother for help. He then feels anger towards his mother who stopped the aggression of his sister but who stayed living with his father and therefore ‘sold them like cattle since she did not intervene to protect her children’. Cognitions are modified: ‘I was manipulated, it was easy, this little boy, I take care of him, I like him’.

He ends this session calmed (SUD at 0 and VOC at 7).

No other EMDR session will be necessary.

The evolution is rapidly favourable: the patient declares 8 days after this EMDR session that he ‘reconnects with himself’. At the same time, we observe a progressive decrease in the intensity and frequency of the acoustic-verbal and visual hallucinations. He gradually manages to better identify what is reality and what is his hallucination. We suggest to the patient to rate the intensity and frequency of his auditory and visual hallucinations on a scale every week. We adapt the treatment to this symptomatic improvement by gradually reducing the sedative psychotropic drugs over a month until they are stopped. Lamotrigine, Diazepam, Loxapine, Zolpidem7,5 and Alimemazine were stopped.

Once this sedative treatment was stopped, we noted a further decrease in the hallucinatory and dissociative syndrome without any anxiety reactivation. We then decided to progressively reduce the clozapine by 50 mg every week until complete cessation in February 2020. This gradual discontinuation did not trigger any delusional or dissociative symptomatic reactivation. Because of the March 2020 confinement, we keep Mr K in hospital and he does not take any psychotropic medication for another 6 months. On the social level we find him a place in a community flat when he is discharged from hospital.

Since then, he has not taken any more treatment, and we gave him a PANS at 12 months, which was down to 35.

At the time of writing this article, 22 months after stopping the psychotropic drugs, he remains psychiatrically asymptomatic: he sleeps 8 hours a night, says he has no voice or vision, he has no flashbacks, no symptoms of hyper vigilance.

From a psychological point of view:

The interviews are an opportunity to revisit his childhood history and to identify the psychological defences he has put in place within a family described as dominated by a tyrannical father who set up a system of widespread denunciation and surveillance: “trusting was impossible, all the interactions we had with our brothers and sisters were traced back to my parents who humiliated us. My parents would spy on us, go through our things … Sometimes I wondered if they had bugged us when in fact it was my sister who told them everything. No relationship was possible between my 7 brothers and sisters, everything had to go through our parents”.

The patient is able to identify his old cognitive defensive patterns: ‘Now I have the word danger coming up when I think of the phrase “trust”, but at the time I was avoiding it. The word trust was just an empty word that saved appearances. Now I realise what it means, I try but, in fact, I don’t trust anyone’.

He manages to describe his own traumatic dissociation: ‘In my final year, I wondered how I was going to live, I was always out of my mind, I was like a robot, an automaton. I’m learning now that it’s the same person, I was functioning like an animal with my ability to speak but the words didn’t really make sense to me. I realized that I was saying words thinking I meant them but I didn’t. It also took time for me to accept a certain form of fragility. Now I don’t feel more fragile, I feel stronger. Vulnerability is now acceptable. I think it was made acceptable and possible by care. Otherwise, I think I would have clearly gone through life not knowing I was not of myself, not experiencing my real emotions.’

The patient can also identify his traumatic amnesia and understand the onset of delusional disorders: ‘So I was a victim of incest and witnessed an attempted rape of my little sister but I had put it aside during my adult life. It came back gradually with the birth of my son when I saw what it was like to have a child … I started to have doubts, images, it had also been reactivated by my brother who had spoken to me about it … it took a little while until I searched my memory, until I saw some things’.

While he had been out of care for 4 years because he interrupted his treatment and did not attend the outpatient appointments proposed after each forced hospitalization, he comes regularly for monthly consultations. He does not receive any psychotropic treatment and we have not had to perform any new EMDR session.

Discussion

This total remission led us to the following question: Had an EMDR session cured schizophrenia or, more modestly, had we made the wrong diagnosis?

It is now accepted that childhood trauma can play a crucial role in the development and maintenance of psychotic symptoms (Bell, Foulds, Horwood, Mulder, & Boden, 2018; Gomez et al, 2017a; Longden, Sampson, & Read, 2015; Kelleher et al., 2013; Hardy et al., 2016).

In France, a recent epidemiological survey of traumatic event screening in a general psychiatric population estimated exposure to a DSM 5, defined traumatic event in this population to be over 70% (Fossard, 2018).

The value of trauma-focused therapies in psychotic pati-ents who have been exposed to trauma has been demonstrated. Among these, EMDR has shown its therapeutic effects in psychosis: it has no adverse effects, is associated with a reduction in delusional and negative symptoms, a reduction in the need for care and a reduction in the prescription of psychotropic drugs. (Adams et al., 2020; Van den Berg et al., 2018).

The history of dissociation parallels the history of psychiatry: dissociation was at the heart of the representations and explanatory models of mental pathologies of 19th century alienists (Janet, 2007; Moskowitz, Heim, Saillot, & Beavan, 2008).

Today, dissociation appears to be an adaptive mechanism of the human psyche when confronted with trauma (Hardy et al., 2016, Longden et al., 2015, Waters et al., 2020, Wearne et al., 2020). A recent meta-analysis of the cognitive mechanisms involved in the genesis of hallucinations in early trauma patients (Bloomfield et al., 2021) suggests that dissociation is an automatic coping mechanism for traumatic exposure: “dissociation may contribute to the development of hallucinations by diminishing a subject’s ability to judge the reality of internal experiences, presumably in the form of source attribution error”.

Concerning positive symptoms (delusions and hallucinations): Several studies have shown the relationship between acoustic-verbal or visual hallucinations and childhood trauma, with a cumulative dose-response effect (Bortolon et al., 2017; Longden et al., 2015; Muenzenmaier et al., 2015; Rosen, McCarthy-Jones, Jones, Chase, & Sharma, 2018).

The role of dissociation appears to be central to the occrrence of hallucinations in trauma subjects (Bloomfield et al., 2021; Wearne et al., 2020; Bortolon et al., 2017). In a recent meta-analysis, Longden et al. (2015) show that ‘dissociative phenomena are not only strongly linked to hallucinations, but also to multiple positive symptoms, and less strongly linked to negative symptoms’. These authors conclude that some psychotic symptoms might be better conceptualized as dissociative and point to the value of addressing dissociation in the treatment of psychotic experiences (Steele, Boon, Hart, & van der Hart et al., 2018).

Our main hypothesis concerning this remission of schizophrenia is that even though Mr K presented all the DSM5 or ICD 10 criteria for schizophrenia, he was not schizophrenic. His hallucinatory disorders and psychic disorganization can be justified as the noisy expression of a traumatic dissociation linked to a childhood trauma. The dissociative depersonalization and derealization were such that their symptomatic expression led to the false diagnosis of schizophrenia. An EMDR session treated this dissociation, which explains the complete remission and the total cessation of psychotropic drugs. We note, however, that Mr K did not present criteria suggestive of dissociative disorders according to the DSM5: neither identity disturbance, nor dissociative amnesia, nor complaints evoking a picture of derealization or depersonalization. We therefore did not mention this diagnosis. On the other hand, he presented all the criteria associated with schizophrenia as we previously specified in our observation.

In this case study the EMDR session, by reprocessing memories of childhood rape, seems to have interrupted a process of traumatic psychic dissociation which, according to the patient, was invading 90% of his thought field.

Conclusions

The link between trauma, dissociation, delusions and hallucination is robust and further investigation is needed to determine with certainty the neurophysiological mechanisms involved in the development of these symptoms (Bloomfield et al., 2021).

This case study demonstrates the need to look for a history of trauma but also the existence of dissociation in all patients who are involved in psychiatric care. A more systematic consideration of the traumatic dimension of psychotic disorders would reveal a double diagnostic but also therapeutic interest, as so far, trauma-focused therapies have had a positive impact on all psychotic symptoms (Adams et al., 2020; Van den Berg et al., 2018).

Concerning our patient, an EMDR session was followed by complete remission of psychic disorganization and hallucinations without any psychotropic treatment nor relapse at 18 months.

It is clear that the diagnostic criteria (DSM5 and ICD10) without taking into account the potential influence of post-traumatic symptoms, which may mimic the symptoms of other disorders, can mislead us with maladaptive therapeutic consequences that are harmful to our patients’ future.