Sudden Traumatic Loss Precipitating Very Late Onset Schizophrenia Iris Mcintosh ,1 Giles W Story1,2
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Case report BMJ Case Rep: first published as 10.1136/bcr-2020-235384 on 28 January 2021. Downloaded from Psychotic PTSD? Sudden traumatic loss precipitating very late onset schizophrenia Iris McIntosh ,1 Giles W Story1,2 1Camden and Islington NHS SUMMARY contrary, he continued to believe his family were Foundation Trust, London, UK Early theories of schizophrenia considered the illness alive and that they were present with him. He also 2 Max Planck- UCL Centre for as a fragmentation of mental content in response to showed marked deterioration in his ability to care Computational Psychiatry and psychological trauma. Here we present a case of very for himself, requiring the assistance of his family Ageing Research, UCL Institute late onset schizophrenia in a previously high- functioning for washing, dressing and toileting, and constant of Neurology, London, UK man in his mid- 60s, precipitated by having lost his family supervision due to chaotic, distracted and disinhib- Correspondence to in a terrorist attack, while he was living in Africa. He ited behaviour. Dr Giles W Story; presented with symptoms consistent with post-tr aumatic His family reported that he showed symptoms g. story@ ucl. ac. uk stress disorder, however also exhibited visual and consistent with increased startle and hypervigilance, auditory hallucinations and marked deterioration in daily for example, if he heard loud noises he would jump Accepted 28 December 2020 functioning. He showed mild impairment on cognitive under the bed. His brother said that this is how the testing, however brain imaging and screening for family would have had to respond while in hiding reversible causes of cognitive impairment were normal. during the civil war several years previously. The The case highlights the need for a formulation- based patient also became distressed at the sight of poten- approach to understanding and managing responses tial weapons, such as knives. to severe trauma, from resolution through to psychotic The patient is the second eldest of nine children, disintegration. bought up in a stable family home in Africa with no birth or developmental problems. He completed his education to college level and worked as a security BACKGROUND officer and a salesman. He married and had nine It is known that post- traumatic stress disorder children. (PTSD) can manifest with secondary psychotic He had no previous mental health problems, and symptoms, for example, flashbacks and hypervig- premorbidly was described by his brother as reli- ilance can be associated with persecutory delu- able, kind and generous. All his siblings moved to sions.1 2 However, in clinical practice hallucinations the UK some years ago, however he remained in his and delusions that are readily understood as reac- home country, reportedly because he enjoyed life http://casereports.bmj.com/ tions to stress are liable to be labelled ‘pseudo- there. His family are wealthy and own several prop- psychotic’.3 4 To draw attention to the putative role erties, which he used to manage on behalf of his of trauma in the aetiology of psychosis, we describe siblings, indicating a relatively high level of social a case in which a more generalised psychotic illness, functioning premorbidly. with features of PTSD, followed a severe traumatic Several years before the incident that precipitated loss event in later life. his move to the UK, his country had experienced civil war, during which the patient’s family went into hiding. On occasion he was held captive by CASE PRESENTATION militants for several days. There was no history of We present a case of a 68- year- old man, of East his having endured torture. African ethnicity, who developed first episode He has no known history of substance or alcohol on October 1, 2021 by guest. Protected copyright. psychosis after he was involved in a terrorist attack misuse, and no notable medical history besides in his home country, which bereaved him of his treated hypertension. His maternal aunt developed wife and children. He was one of only a handful a psychosis when in her 60s, which manifested as of survivors. chaotic and disinhibited behaviour requiring resi- We have little information pertaining to the dential care. patient’s personal experience of the attack, since he was unable to give a coherent account of this. Several months after the attack his siblings, all of Mental state examination © BMJ Publishing Group whom were in the UK, heard reports from others Appearance and behaviour Limited 2021. Re- use that he was neglecting his personal care, eating out On initial assessment he presented with unkempt permitted under CC BY- NC. No commercial re-use . See rights of bins and living on the street, despite his having hair and beard, though was dressed appropri- and permissions. Published a home. Due to his relatives’ concern for his health ately, and his personal hygiene was adequate. He by BMJ. they organised a flight for him to come to the UK. was highly distracted, continually looking around He sought asylum on arrival and he has since been the room, and his manner fluctuated from passive To cite: McIntosh I, Story GW. BMJ Case living with his brother. indifference to a degree of social disinhibition, for Rep 2021;14:e235384. On arriving in the UK he was experiencing example, ‘high fiving’ the doctor. He showed some doi:10.1136/bcr-2020- florid visual and auditory hallucinations of his facial grimacing and made writhing movements of 235384 wife and children. Despite explanations to the his hands. McIntosh I, Story GW. BMJ Case Rep 2021;14:e235384. doi:10.1136/bcr-2020-235384 1 Case report BMJ Case Rep: first published as 10.1136/bcr-2020-235384 on 28 January 2021. Downloaded from Speech over the course of a year of follow-up the patient showed Even with the assistance of an interpreter, the patient was initially gradual improvement in his ability to manage his daily living electively mute, requiring prompting to vocalise his answers to skills, rather than a decline as might have been expected from questions, rather than miming with his hands. When vocalising, a dementia. However we note that a frontotemporal dementia, his speech was limited to short sentences, with little subjective which often presents with gradual decline and subtle imaging elaboration. changes,5 remains a possible differential. Our patient’s history and mental state were consistent with Mood PTSD. First, he had experienced a traumatic stressor, defined th He was objectively labile in affect, at times grinning. When asked according to the International Classification of Diseases, 10 for a subjective appraisal of his mood he gave a ‘thumbs up’. Revision (ICD-10) criteria for PTSD as a ‘a stressful event or His sleep was disturbed, with increased autonomic arousal and situation of exceptionally threatening or catastrophic nature, nightmares. He had normal appetite. He reportedly derived which would be likely to cause pervasive distress in almost 6 enjoyment from having a bath and going to a local café with his anyone’. Second, his deterioration followed a few weeks brother. to months after the trauma, in keeping with ICD-10 criteria. Finally, the patient showed symptoms of PTSD, namely flash- Thought backs (episodes of reliving trauma), nightmares, increased startle The form of his thought could not be fully assessed due to his reaction, insomnia and avoidance of reminders of the trauma. poverty of speech, however there was no de facto evidence of Notably some of these symptoms, for instance startle in response thought insertion, thought block or thought withdrawal nor of to sharp objects, related to earlier traumas experienced during a passivity phenomena. He reported a delusional belief that his civil war, rather than the attack in which he lost his family. Our wife and children were still be alive and with him. He expressed patient also appeared to lack an emotional numbness or anhe- no thoughts of harming himself or others. donia often seen in PTSD. Psychotic depression is another important differential. Collat- Perception eral history from his brother revealed that early on in his illness he was often tearful. Also, his delusions and hallucinations could He was seen to be responding to visual hallucinations, gesturing be considered congruent with depression and he had signif- to his wife to go away, smiling and laughing to himself. It was icant self- neglect. Yet during our consultations he presented also reported that he could hear sounds of people fighting, and with neither low mood nor flat affect, as would be expected for experienced tactile hallucinations of his children climbing on psychotic depression. Rather, his affect was labile with social him at night. disinhibition and he would often laugh and smile, at times in response to hallucinations. He also subjectively described his Insight mood with a ‘thumbs up’ gesture and did not exhibit biological He had no insight into his illness. symptoms of depression. Finally persistent visual hallucinations of the deceased, with Cognition associated delusional beliefs that his family were still alive, were Our patient was oriented in place and person, and remembered consistent with a pathological grief reaction. However, when http://casereports.bmj.com/ clinicians between visits. He was oriented to the time of day and taken together with his incongruent affect and significant decline season, though reported that the year was 2014, a date prior in his daily functioning lasting for over a year, these symp- to the traumatic event. He struggled to name objects without toms would also be sufficient for a diagnosis of schizophrenia prompting, tending to give approximate answers. On cognitive according to ICD-10 criteria. assessment using the Rowland Universal Dementia Assessment Scale, a cross- culturally valid tool, he scored 21/30, 23 is consid- ered to be the lower limit of normal; his predominant impair- TREATMENT ments were in left-right judgements and visuoconstructional ► Olanzapine and sertraline were started at low doses a year drawing.