British Journal of Medicine & Medical Research 15(8): 1-5, 2016, Article no.BJMMR.26114 ISSN: 2231-0614, NLM ID: 101570965

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Psychosis, Catatonia and Post-psychosis PTSD

Evita Rocha 1, Andrei Novac 2, Daniel Kirsten 1, Jiwon Shin 3, Diana Totoiu 4 and Robert G. Bota 3*

1Resident Psychiatry, UC, Irvine, USA. 2Department of Psychiatry, UC, Irvine, USA. 3UC Irvine, USA. 4Department of Psychology, Cal State Fullerton, USA.

Authors’ contributions

This work was carried out in collaboration between all authors. Author ER wrote the first draft of the case reports and helped with literature search and part of introduction. Author AN contributed the writing of the manuscript and formulated the theoretical frame of the psychopathology. Authors DK, JS, DT managed the literature searches, contributed to writing of the manuscript and edited the final versions. Author RGB designed the study, supervised the process and wrote parts of the manuscript. All authors read and approved the final manuscript.

Article Information

DOI: 10.9734/BJMMR/2016/26114 Editor(s): (1) Domenico De Berardis, Department of Mental Health, National Health Service, Psychiatric Service of Diagnosis and Treatment, “G. Mazzini” Hospital, Italy. Reviewers: (1) Sara Marelli, Vita-Salute San Raffaele University, Milan, Italy. (2) Takashi Ikeno, National Center of Neurology and Psychiatry, Japan. Complete Peer review History: http://sciencedomain.org/review-history/14521

Received 1st April 2016 nd Case Study Accepted 2 May 2016 Published 9th May 2016

ABSTRACT

We are describing the case of a 27-year-old female with no previous psychiatric history who developed post-psychotic PTSD after presenting with first episode catatonia and psychosis. The patient initially presented to the emergency department with increasingly disorganized behavior and paranoid thinking over the course of one week in the context of multiple life stressors. Soon after admission, the patient became catatonic; demonstrating mutism, stereotyped behaviors, and echolalia. After ruling out an organic cause for the catatonia, the patient was treated with Lorazepam, which minimaly improved her catatonia, but revealed active psychosis. In particular, she voiced a scenario that she was sexually assaulted by several men at her mother’s home in the time leading up to her admission. An investigation by law enforcement ruled out the occurrence of assault. However, the patient, expressed vivid dreams, nightmares, and distress centered on her assault. Various anti-psychotics were trialed with little effect (Risperidone, Olanzapine, Haloperidol, ______

*Corresponding author: E-mail: [email protected], [email protected];

Rocha et al.; BJMMR, 15(8): 1-5, 2016; Article no.BJMMR.26114

and Clozapine). Given that she exhibited several characteristics of PTSD, other agents inlucluding: Escitalopram, Prazosin, and Divalproic were initiated to target her PTSD-like symptoms. On this regimen, the patient showed significant improvement in her mental status and functioning. Thiothixene was added to target residual symptoms of her psychosis. She was discharged to home in the care of her mother and on follow-up remembered little of her psychosis and denied any trauma or occurrence of sexual assault in the past.

Keywords: Psychopathology; catatonia; PTSD; psychotic disorders; post-psychotic variant of PTSD.

1. INTRODUCTION A week prior to admission, she quit her job. She gave a lot of reasons including disagreements Post Traumatic Stress Disorder (PTSD) is with her mother and the repossession of her car, described as the development of a constellation which she was unable to make payments. of psychiatric symptoms in response to a According to her family, she became hyper- traumatic event [1]. While diagnostic criteria does focused on the previous check incident and not include psychotic symptoms, it is not reported it on the FBI website. She started uncommon for patients to present with comorbid complaining that the FBI was monitoring her and psychosis and PTSD [2]. The intuitive that the people involved in the check incident assumption is to link a traumatic event to the were out to get her. Ms A’s mother and sister development of PTSD as well as the also described what appeared to be Ms. A’s predisposition to psychosis. However, reports paranoid thinking: she believed that the FBI was have described the phenomenon of PTSD controlling electronic devices around her and secondary to psychosis, where the delusions and were listening to her through the Internet. Ms. A hallucinations act as the traumatic event [3]. told her mother that she was hearing multiple Among patients who developed a psychotic voices; however, she denied visual disorder, 52% developed post psychotic PTSD hallucinations. She reported a feeling that others [4]. In such instances, the trauma responsible for were present, when in fact, no one was there. the triggering of PTSD symptoms is inherently linked to the experience of psychosis, a known On arrival to the unit from the emergency and documented painful human experience [3]. department, she was unable to give a clear Here we present a case of PTSD in a patient history. She appeared preoccupied, exhibiting who suffered from catatonia and a subsequent significant latency in responses and responding psychotic disorder characterized by only intermittently to questions asked by the hallucinations and delusions. We propose that physician. She appeared suspicious, frightened, the development of her PTSD was due to the and guarded. She asked if she “would be put on psychological trauma experienced during her trial and if the children would be targeted”. She psychosis. was unable to give an explanation for her statements. She was able to give her son's 2. CASE REPORT name. However, most of the time she muttered nonsensical words. One day later, her condition Ms. A is a 27-year-old female with no previous further deteriorated. She exhibited catatonic psychiatric history brought in by her mother for symptoms of mutism, stereotypies, and echolalia. increasingly disorganized behavior and paranoid She was then transferred to a medical psychiatric thinking. The symptoms set in gradually over a unit for more intensive care due to low oral period of one week. intake, requirement for IV fluids, and the need of a sitter given her inability to maintain any of her One year prior to admission, she had reported activities of daily living. She had flat affect and a feeling sad with decreased energy and sleep blank stare. She was walking with small, fast difficulties. Three months prior to admission, Ms. steps, bumping into people and walls and at A had been involved in an online scam that times kneeling and rolling on the floor. involved a phony check and lost some money. In the month preceding admission, she endorsed She was diagnosed with catatonia and was having had symptoms of depression including started on Lorazepam with an extensive medical insomnia, feelings of anxiety, obsessive thinking workup to rule out any organic cause for her (“overthinking”), anhedonia, poor concentration, catatonia and psychosis. Neurology and decreased energy, and feelings of guilt. cardiology consults were made without any

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positive findings. Numerous investigations were mg per day was added to the regimen. She was performed, including, CT of the head, EEG, MRI given Propranolol 20 mg per day for akathisia. brain, Vitamin B12, Folate levels, ESR, CRP, CBC, PTH, Uric acid, Treponema pallidum On the combination of Divalproex, Escitalopram, Antibody, hepatitis panel, Anti-TPO antibodies, and Prazosin, Ms A showed a considerable Cortisol levels, paraneoplastic panel, anti NMDA improvement (during the first week on the receptor encephalitis, copper, ammonia, CT medication she showed improvement but the abdomen and chest to rule out any possible medications were stopped by the covering neoplasms, ECHO, numerous blood labs attending for a week, when she was of including Huntington’s assay. They all revealed medications she did deteriorate to the previous negative findings. level and when we restarted the same regimen she improved again at a fast and steady rate). Lorazepam was titrated up to seven mg, four Her thought process became linear, so she was times a day, with allowed limited improvement in able to engage staff in a meaningful manner, and catatonia but a gradual increase in sedation. At she was able to perform her activities of daily this point, she started mumbling some intelligible living independently with minimal prompting. She words and endorsed psychosis. She thought no longer needed a sitter. Later, she was there was a monster in her abdomen and that prescribed Thiothixene 10 mg for delusions that her legs belonged to a man. Given her psychotic she had a contagious virus. She tolerated symptoms, Ms. A was started on risperidone. Thiothixene, and her delusions cleared. At the Then, due to a lack of response, Risperidone time of discharge, she was smiling with adequate was discontinued and olanzapine was started grooming and hygiene, making eye contact, with and titrated up to 20 mg twice daily. She also had slow and monotone speech, but able to speak in no notable improvement in her symptoms with full sentences. Yet, her restricted affect olanzapine but it was noted that her behavior persisted. She was discharged to her family with improved in the days following administration of Escitalopram 20 mg, Prazosin 5 mg, Thiothixene haloperidol overnight, which had been given as a 10mg for psychosis, with 50 mg Benadryl for PRN medication. After a few weeks, based on extrapyramidal symptoms, Lorazepam 0.5 mg in that observation of documented behavioral the morning and 2 mg at night (decreased as she response to Haloperidol, Olanzapine was cross- stared having sedation as she was improving), titrated with Haloperidol. This intervention did not Melatonin 5 mg and Divalproex 500mg in the cause improvement or worsening in her morning and 750 mg at night. symptoms and she was started on Clozapine, which was initially titrated up to 250 mg. When At the time of this report, approximately 90 days she developed elevated CK and CKMB, the since her admission, she continues to improve, Clozapine was discontinued gradually monitoring can hold one hour conversation, take care of her the laboratory values. Although discussed many son, and helps her family. When questioned times before, electroconvulsive therapy was about her memory of the psychosis, she reported ultimately never administered because of some that she remembered a state of total withdrawal delays in the necessary legal procedures and and emotional numbness, distancing, symptoms inadequate insurance coverage. that highly suggestive of dissociative states. She denies any trauma, reporting that the rape never At this juncture, in one morning, she related that occurred. a week prior to her hospitalization she was sexually assaulted, choked and raped by five 3. DISCUSSION men. The assault allegedly occurred in her mother’s house. A period of intense investigation Ms. A’s unusual presentation can be summarized followed with law enforcement probing into the by the fact that she presented three separate possible assault. The investigation and collateral cycles of psychopathology: a) A prodromal history ruled out such an assault. Nevertheless, depressive phase; b) a psychotic/ catatonic Ms A did report symptoms of nightmares and phase; c) a PTSD phase. The relationship intense dreams of the rape. between PTSD symptoms and psychotic disorders including catatonia has been previously At that time, Escitalopram was started documented [5,6]. Others document a immediately after her report of the trauma and relationship between psychosis and dissociative titrated up to 20 mg daily. In addition, Prazosin disorders [7]. More recently, however, there have was tapered to 5 mg and Divalproex up to 1250 been reports pointing to specific relationship

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between the trauma of a psychotic episode and the abundance of evidence from the literature, the onset of PTSD. Brunet et al. [8] found that this case further supports the need for a more 49% of patients presented post-traumatic stress formalized diagnostic entity - that is, a “post- symptoms after a psychotic episode. psychotic” variant of PTSD. Abdelghaffar et al. [9] reported in his cohort that after recovery form psychotic episode, 42% of 4. CONCLUSION patients exhibited symptoms of PTSD and another 69.2% had PTSD “syndrome” or partial Whether or not a patient presents with symptoms symptoms of PTSD. Bendall et al. [10] reported that meet full criteria for PTSD, PTSD symptoms that childhood trauma may predispose certain are common after one of the most devastating individuals toward developing post-psychotic life experiences – that is, suffering through a PTSD after their first episode of psychosis. In a psychotic episode. Psychosis, with its profound more extensive study, Chisholm et al. [11] found change in internal perceptions and sense of that 61% of patients who recovered from fragmentation, exposes an individual to a psychosis had symptoms of trauma that were frightening and deeply unpredictable world. Such severe enough to qualify for the diagnosis of a change and a fear that such an experience PTSD. They identified risk factors for post- may reoccur, challenges the basic schema of psychotic traumatic stress including the following: safety and security of a person and can lead to Previous history of trauma; previous psychotic the onset of PTSD. This suggests that clinicians episodes; perceived helplessness and lack of ought to inquiry about post-traumatic symptoms control; persecutory hallucinations, among in all patients with psychosis and be prepared to others. Finally, Shiloh et al. [12] described a extend treatment modalities to address the patient with PTSD who developed recurrent traumatic sequelae of psychosis. catatonia, pointing to the existence of a link between these two disorders. CONSENT

Ms A’s clinical presentation was unusual in the It is not applicable. sense that she did not present a history of childhood trauma or previous psychosis. Yet ETHICAL APPROVAL during her hospitalization, she did present a severe psychotic episode with catatonia and It is not applicable. possible dissociative symptoms. She also had a history of trauma and losses in the months COMPETING INTERESTS leading up to the onset of her psychiatric symptoms. It should be noted that upon careful Authors have declared that no competing evaluation, Ms A’s nightmares seemed more interests exist. connected to her psychotic thought processes and not to the actual sexual and physical assault REFERENCES by strangers she thought had experienced about a week prior to hospitalization. This was 1. Association AP. Diagnostic and statistical confirmed by the patient after recovery from her manual of mental disorders (5th ed.). illness. Nonetheless, her nightmares of rape may Arlington, VA, American Psychiatric be viewed as a symbolic expression in dreams of Publishing; 2013. her overall sense of severe violation. 2. Bosson JV, Reuther ET, Cohen AS. The comorbidity of psychotic symptoms and Thus, she presented at least four conditions posttraumatic stress disorder: Evidence for (recent trauma, psychosis, paranoia, catatonia) a specifier in DSM-5. Clin Schizophr Relat that rendered her to be at significant risk for post- Psychoses. 2011;5:147-154. psychotic PTSD. The mechanisms underlying 3. Mueser KT, Lu W, Rosenberg SD, Wolfe her nightmares and post-psychotic PTSD may R. The trauma of psychosis: Posttraumatic have been triggered by the catecholamine stress disorder and recent onset overdrive associated with psychosis, a psychosis. Schizophr Res. 2010;116:217- phenomenon previously described in critically ill 227. individuals [13,14]. She did not meet full criteria 4. Shaw K, McFarlane A, Bookless C. The for PTSD (re-experiencing, avoidance, phenomenology of traumatic reactions to hyperarousal, negative alteration of cognition), psychotic illness. J Nerv Ment Dis. but she exhibited characteristics of PTSD. Given 1997;185:434-441.

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