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Psychotic Symptoms in Post Traumatic Stress Disorder: a Case Illustration and Literature Review

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Psychotic Symptoms in Post Traumatic Stress Disorder: a Case Illustration and Literature Review CASE REPORT SA Psych Rev 2003;6: 21-24 Psychotic symptoms in post traumatic stress disorder: a case illustration and literature review Adekola O Alao, Laura Leso, Mantosh J Dewan, Erika B Johnson Department of Psychiatry, State University of New York, Syracuse, NY, USA ABSTRACT Posttraumatic stress disorder (PTSD) is a condition being increasingly recognized. The diagnosis is based on the re-experiencing of a traumatic event. There have been reports of the presence of psychotic symptoms in some cases of PTSD. This may represent in- creased severity or a different diagnostic clinical entity. It has also been suggested that psychotic symptoms may be over-represented in the Hispanic population. In this manuscript, we describe a case to illustrate this relationship and we review the current literature on the relationship of psychotic symptoms among PTSD patients. The implications regarding diagnosis, treatment, and prognosis are discussed. Keywords: Psychosis; PTSD; Trauma; Hallucinations; Delusions; Posttraumatic stress disorder. INTRODUCTION the best of our knowledge is the first report of psychotic symp- Posttraumatic stress disorder (PTSD) is a psychiatric illness for- toms in a non-veteran adult with PTSD. mally recognized with the publication of the third edition of the Diagnostic and Statistical Manual of the American Psychiatric CASE ILLUSTRATION Association in 1980.1 Re-experiencing of traumatic events as A 37 year-old gentleman was admitted to a state university hos- recurrent unpleasant images, nightmares, and intrusive feelings pital inpatient setting after alerting his wife of his suicidal is a core characteristic of PTSD.2 Most PTSD research has oc- thoughts and intent to slit his throat with a kitchen knife. At the curred among veteran populations exposed to traumatic images time of initial presentation, he felt the “weight of the whole and events during combat and the presence of psychotic symp- world was on him” and stated that he had “always felt this way” toms has been described among some combat veterans with since he was a young boy. He recounted that there had never chronic PTSD. It has been suggested that this presentation may been a time when he had not wanted to kill himself. He re- either reflect a distinct subtype of the disorder or indicate an ported hearing a man’s voice, which he believed could be that increased severity of PTSD symptoms.3 David et al described of his father. The voices were telling him that”: he was good for 53 combat-related PTSD patients, 40% of whom were said to nothing.” He was admitted to the inpatient unit for further evalu- have “psychotic” symptoms of which 95% were auditory hallu- ation and management. He described initial and terminal in- cinations.4 The prevalence of auditory hallucinations seems somnia with nightmares of previous physical and sexual abuse greater among Hispanic populations suffering from PTSD.2 The by his father. He admitted to having panic attacks and graphic identification of psychotic symptoms in PTSD may have impli- flashbacks to the episodes of abuse. During these flashbacks cations regarding diagnosis, treatment, and prognosis. This the patient reported” I could smell his sweat.” He would often manuscript reviews the literature regarding the occurrence of avoid situations that he believed would initiate a flashback. He psychotic symptoms in PTSD. We also describe a case of an avoided watching violent television programs, as these would Hispanic gentleman with non-combat related PTSD which, to precipitate a flashback. On further questioning, he admitted that he had experienced auditory and visual hallucinations since the age of seven. At Correspondence: nine years of age, he recalled seeing a transparent muscular white Prof AO Alao, Division of Consultation Liason Psychiatry, Department male, two feet tall, running in circles around his bed and laugh- of Psychiatry, State University of New York, Upstate Medical ing at him. He felt protected by this man. Since the age of four- University, 750 East Adams Street, Syracuse. NY 13210, USA. teen, he recalls seeing transparent, black, male figures, two feet e-mail [email protected] tall, circling his bed, tormenting and kicking him, saying “you South African Psychiatry Review - February 2003 21 PTSD.PM6 21 7/5/2003, 1:03 pm CASE REPORT SA Psych Rev 2003;6: 21-24 are no good for nothing” and “it is time to end it.” He also sees DISCUSSION silver-gray fanged snakes that rattle while preparing to attack In describing the criteria for posttraumatic stress disorder, him. He reports delusions of reference involving people on tele- DSM-IVdoes not indicate that psychotic symptoms may be a vision and people in public talking about him. component of PTSD.5 It also does not recognize the proposed There had been three previous psychiatric hospitalizations diagnostic category of complex posttraumatic stress disorder between 1993 and 1997. In 1993, he was diagnosed with a suggested by Herman.6 Under recognition of this entity may “psychotic disorder not otherwise specified” and was treated be the result of the under-reporting of psychotic symptoms by with risperidone. patients with PTSD,the misdiagnosis of psychotic symptoms,or As a teenager, he abused alcohol, cannabis, cocaine, heroin, the less bizarre presentation of psychosis with PTSD. Prior to and amphetamines. However, he had not used any illicit sub- 1980,individuals with PTSD were frequently diagnosed with stances in the ten years preceding this hospitalization. There schizophrenia. Although, auditory and visual hallucinations was a medical history significant for asthma, for which he uses may occur within the content of flashbacks, patients with PTSD an albuterol inhaler. He had been married for ten years with frequently report the presence of psychotic symptoms when three school aged children. A family history of drug and alco- they are not having flashbacks.7 hol use was elicited but not for any other psychiatric disorders. We do recognize that there are cultural differences regarding Previously he had been employed as a janitor. but was currently the significance and interpretation of psychotic symptoms. What receiving social security disability as a result of the current psy- is psychotic in one’s culture can be normal behavior in another chiatric illness. Physical examination was normal,except for culture. However, we believe this patient was experiencing psy- faint scars on his left forearm from a past suicide attempt in chotic symptoms since we examined his symptoms within a cul- 1997. A urine drug screen on admission was negative. tural context during family meetings with relatives. Mental status examination on admission revealed a coopera- It is important to assess co-morbidity in many patients with tive Hispanic gentleman with poor grooming, little eye contact PTSD. PTSD and schizophrenia may co-occur in the same in- during the interview, and psychomotor retardation. His speech dividual, and the amount of traumatic exposure experienced by was of slow rate and decreased volume. He described his mood chronically psychotic patients can be extremely high. In addi- as depressed. His affect was noted to be flat. His thought pro- tion, PTSD may co- occur with borderline personality and ma- cess was logical and coherent, without tangential or circum- jor affective disorders. As we did in this patient, careful evalu- stantial thinking. He experienced auditory hallucinations as de- ation using the DSM criteria may help in making an accurate scribed above. His thought content was significant for suicidal diagnosis It has been suggested that about 40% of patients with ideation without intent or plan. His insight and judgement into PTSD may have psychotic symptoms.4 Such psychotic symp- his current illness were limited. toms may occur in those with a more severe form of PTSD. Our diagnostic impression on admission was that this pa- There have been several reports of psychotic symptoms occur- tient was suffering from PTSD. We did consider the diagnosis ring in patients with PTSD.8,9 (Table I) However, these reports of childhood onset of schizophrenia or schizoaffective disorder have generally been in patients with combat related PTSD. The because of the early onset of psychosis, with a delusion of mo- patient described in this manuscript had severe PTSD symp- lestation persisting into adulthood. We however felt this to be toms resulting from domestic sexual and physical abuse. He unlikely,given the collateral information from the family that also demonstrated psychotic symptoms such as delusions, along the described sexual and physical abuse did occur. We consid- with auditory and visual hallucinations. These psychotic symp- ered a major depressive illness, especially as he has had epi- toms occurred outside the context of flashbacks. It can be ar- sodes of depressed mood with suicide attempts in the past. The gued that his psychotic symptoms were secondary to a depres- patient was screened but did not meet the criteria for a major sive illness, since there is significant co-morbidity between de- depressive illness. We also considered schizophrenia and schizo- pression and PTSD. However, the fact that this patient contin- affective disorder. The patient met criteria for PTSD according ued to have psychotic symptoms during those periods when he to the fourth edition of the Diagnostic and Statistical Manual was not clinically depressed argues against this. It can also be (DSM IV),but did not meet the criteria for any other major psy- argued that his psychotic symptoms were the result of a concur- chiatric disorder.5 rent psychotic illness,such, as, schizophrenia or schizoaffective He was started on risperidone 2 mg twice daily, sertraline disorder. However,again, after careful consideration and review 100mg daily, and trazodone 50mg at bedtime for insomnia. In of diagnostic criteria in DSM-IV, the patient was felt to meet addition, he received individual and group supportive psycho- the criteria for PTSD and no other psychiatric illness.5 therapy similar to other patients in the unit.
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