Feature Article Psychotic Symptoms in Posttraumatic Disorder By Steven E. Lindley, MD, PhD, Eve Carlson, PhD, and Javaid Sheikh, MD, MPH

ABSTRACT hyperarousal symptoms, including intense psychological or Recent data suggest that the presence of psychotic symp physiologic reactivity in response to cues that are reminders toms in suffering from posttraumaticstress disorder of the event (eg, , exaggerated startle, and (PTSD) may represent an underrecognized and unique sub disturbances). PTSD rarely occurs in isolation; the core type of PTSD. Among combat veterans with PTSD, 30% to symptoms are often associated with the presence of comor 40% report auditory or visual hallucinationsand/or delu bid conditions. Those that cooccur with high frequency sions. The presence of psychotic symptoms in PTSD is associ include major depressive disorder, personality disorders, ated with a more severe level ofpsychopathology, similar to and and .[2,3] that of chronic . In this review, the differential Psychotic symptoms have also been reported to occur diagnosis of psychotic symptoms in PTSD is discussed, with high frequency in patients with chronic PTSD. The including possible comorbid schizophrenia,psychotic depres presence of in PTSD has been reported for a sion, substance-inducedpsychosis, and . number of years,[4-6]but the frequency and characteristics of A recent biologic study supporting the existence of a unique psychotic symptoms had not been systematically studied subtype of PTSD with psychoticfeatures is also addressed, as until recently. Among combat veterans with PTSD, 30% to are the similarities between PTSD with psychoticfeatures 40% report psychotic symptoms in the absence of comorbid and psychotic disorder.Finally data on the treat psychotic conditions, such as schizophrenia or bipolar dis ment implications of psychotic symptoms in PTSD are pre order,[7,8]compared with a rate of 15% of persons with senwd. The intriguingrecent filings on psychotic symptoms depression.[9]The rate of psychotic symptoms in persons who in PTSD need further investigation in noncombat-related have PTSD from noncombat-related traumas is unknown. PTSD populations before findings can he generalized to all In addition to being a relatively common finding in PTSD, individualswith PTSD. the presence of psychotic features is linked to more severe CNS Spectrums 2000;5(9):52-57 ;[10 ]therefore, a greater understanding of this condition may have important clinical implications for the INTRODUCTION treatment of PTSD. This article reviews the recent findings Hallucinations and have been reported to on the psychological and biologic characteristics of patients sometimes occur after an individual has experienced a with PTSD with psychotic features (PTSD-P), discusses severely stressful eveut. In the Diagnostic and Statistical issues concerning the of the psychotic Manual of Mental Disorders, Fourth Edition, (DSM-IV)1 symptoms, and addresses clinical treatment implications. In stress-induced reactions with psychotic symptoms are the four case studies presented below, the diversity of included in the brief psychotic disorders. Until recently, presentation of psychotic features in PTSD is illustrated. little attention has been given to the presence of psychotic symptoms in more prolonged reactions to severe stress, CASE DESCRIPTIONS including postraumatic stress disorder (PTSD). Recent Case 1 findings suggest that hallucinations and delusions are A 46-year-old, African-American truck driver frequently overlooked symptoms in a significant number of presented with a history of having his life threatened by PTSD patients. Furthermore, evidence suggests that the police when he was a teenager. He was evaluated for presence of psychotic symptoms in PTSD may have treatment for intrusive , anger, important implications for clinical treatment and outcome. avoidance, and hyperarousal symptoms that had PTSD is an disorder that can develop in a person worsened in the past year due to family and work who has been exposed to a traumatic event. The symptoms stressors. In addition to symptoms of PTSD, he occasionally comprising PTSD are divided into three symptom clusters: that he heard news commentators discussing the (1) the reexperiencing of phenomena, including thoughts, events of his life, and he heard his name being called at images, and dreams associated with the trauma; (2) avoid night. His wife complained of his . He had ance symptoms, including numbing and behavioral avoid significant symptoms of depression, but denied any his ance of stimuli associated with the trauma; and (3) tory of alcohol or use.

Dr. Lindley is associate directorfor research, Dr. Carlson is research science specialist, and Dr. Sheikh is chief ofpsychiatry at the National Centerfor PTSD at Palo Alto VA Health Care System in Menlo Park, CA. Dr. Sheikh is also associate professor of at Stanford University in Palo Alto, CA. Volume 5 - Number 9 * September 2000 52 C n s S P E c T R U M s Feature Article

Case 2 toms of are the most commonly A 53-year-old, Caucasian man presented reported. Among the combat veterans with for treatment of PTSD symptoms upon the PTSD-P studied to date, almost all reported encouragement of a social worker. He was an auditory hallucinations.[7,8]Most of these hallu unemployed factory worker with a history of cinations related to their traumatic experi severe social isolation since his service in ence (eg, the voice of a dead enemy Vietnam. The had a strict religious calling to them), although many patients also upbringing. When in Vietnam, he was hazed report nontrauma-specific auditory hallucina "Individuals with by his fellow enlisted men by being placed in tions (eg, hearing their name being called). a body bag while intoxicated for the first time. Delusions are also reported in as many as PTSD-P have He volunteered for work in tile morgue for the 86% of patients with PTSD-P and can rest of his tour of duty. include nontrauma-specific content (eg, the levels of general On presentation to the clinic, he exhibited belief that one is being poisoned).[7,8,11]These intrusive thoughts (particularly concerning symptoms are not confined only to known psychopathology the dead bodies he had seen), hyperarousal, flashback episodes. and avoidance symptoms, as well as ideas of When present, psychotic symptoms are similar to those of reference, , and occasional odd associated with an increased severity of a beliefs. (For example, he believed that the number of other symptoms. Among veterans patients suffering from electricity in the building had an effect on with PTSD-P, significantly higher levels of his body.) None of the beliefs were clearly general psychopathology, paranoia, violent chronic schizophrenia." bizarre or disorganized. He also exhibited an thoughts, feelings, and behaviors have been odd, restricted affect. He denied auditory or reported, as well as greater degrees of depres visual hallucinations. sion, anxiety, and .[8,10,11](General psychopathology includes symptoms of Case 3 somatic concerns, anxiety, guilt, tension, man A 54-year-old, Hispanic, homeless Vietnam nerisms, posturing, depression, motor retarda combat veteran presented with PTSD symp tion, uncooperativeness, unusual thought toms associated with his combat experiences, content, disorientation, poor attention, lack of including intrusive thoughts, , , low volition, poor impulse control, avoidance symptoms, and hyperarousal. He preoccupation, and social avoidance.) had also used up until Individuals with PTSD-P have levels of gen 3 months before his evaluation. In addition to eral psychopathology similar to those of symptoms of PTSD, he occasionally heard his patients suffering from chronic name being called at night outside his window, schizophrenia.[12]This high level of impairment and heard the voice of a dead comrade calling in PTSD-P vs PTSD without psychotic fea to him. tures is similar to the greater levels of social impairment reported in depressed patients Case 4 with psychotie features vs those without psy A 49-year-old, divorced Caucasian man chotic features.[9]It is interesting that the presented with anger, isolation, and thoughts severity of PTSD symptoms, as measured by of . He was a Vietnam combat vet the Clinician-Administered PTSD Scale eran. In addition to symptoms of PTSD, he (CAPS), does not appear to he greater in reported feeling "like everyone is trying to patients with psychotic features.[7,13]This sug screw me over." He had a history of hearing gests that PTSD-P may reflect a distinct sub footsteps walking behind him and seeing group of patients, rather than simply very snakes on the ground. He became convinced severe PTSD. Likewise, the presence of psy that someone had poisoned his Christmas chotic symptoms in depression is not assoei dinner. His belief that he had been poisoned ated with more severe levels of depression.[9] declined when nothing happened to him after The number of veterans with noncombat the passage of time. related PTSD who report psychotic symptoms appears to vary across ethnic groups. The SYMPTOM ChARACTERISTICS AND highest rates are among African-American GLOBAL IMPAIRMENT and Hispanic populations.[6,8,13,14]It is not As illustrated by the above ease examples, known what factors account for these ethnic there can be a diverse presentation of symp differences, but ethnic and cultural differ toms in PTSD-P. Nonbizzare, positive symp- ences are also noted in acute and brief reac-

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tive diagnoses where a disproportionately high of a diagnosis of PTSD may be useful in the rate of reporting is observed in individuals in treatment of these patients. developing countries.[15]These ethnic differ ences suggest a social factor in the reporting Psychotic Major Depression of stress-related psychotic reactions. As noted above, depression occurs with a Likewise, there may be ethnic differences in high frequency in chronic PTSD, with even the risk factors for the expression of some psy higher rates observed when psychotic features "...when depression chotic symptoms. For example, it has been are present. Because the rate of psychotic observed that minorities exposed to racist and symptoms in depressed patients is as high as is present in discriminatory behaviors may tend to be more 15%,[9]it can be argued that the presence of vigilant and suspicious about others in society, psychotic features in those with comorbid patients with which may contribute to a higher rate of para PTSD and depression may be better classified noid symptoms.[15] as psychotic dcpression. This does not appear PTSD-P, both the to account for all cases of PTSD-P, however, DIFFERENTIAL DIAGNOSIS since as many as 32% of PTSD patients with psychotic and PTSD AND RELATIONSHIP TO psychotic features do not meet the criteria for OTHER DISORDERS either current or lifetime major depressive symptoms are disorder.[13]It is interesting to note that when Schizophrenia Spectrum Disorders depression is present in patients with PTSD-P, more severe." Persons who present with PTSD and psy both the psychotic and PTSD symptoms are ehotic features need to be carefully evaluated more severe.[14]This suggests that depression is to determine if they meet the criteria for schiz an important factor in the pathophysiology of ophrenia or schizoaffective spectrum disor psychosis in PTSD. ders. Delusions and hallucinations associated The reported increase in general psy with the presence of disorganized speech, chopathology in persons with PTSD-P is simi grossly disorganized behavior, or negative lar to that reported in persons with psychotic symptoms (eg, affective flattening, , or depression. Specifically, the presence of psy ), in addition to social and/or occupa chotic symptoms in depressed patients is tional dysfunction, suggest a schizophrenia associated with higher rates of guilt, psy . Those who meet these eri chomotor disturbance, morbidity, and residual teria and suffer from PTSD are classified as impairment.[9]Similar to PTSD-P, the presence having schizophrenia with comorbid PTSD. of psychotic features in depression is not sim The PTSD rate in patients suffering from ply associated with more severe depression. schizophrenia and other chronic psychotic ill Psychotic major depression has a poorer nesses may be quite high. Because of their response to either placebo or tricyclic antide , patients suffering from schizo pressants than nonpsychotic major depres phrenia have a greater chance of being trau sion.[9]It may be that PTSD-P also has a poorer matized (eg, homeless patients are at a greater response rate to standard treat risk of assault). In addition to -based ment alone. traumas, it has also been suggested that the A further relationship between psychotic experience of psychosis itself, which subjects major depression and PTSD-P is suggested by the individual to a terrifying inner life experi the history of PTSD in psychotic major depres ence, may induce PTSD symptoms.[16-21It ] is sion. In a study of first psychotic hreaks, there also possible that traumatic experiences could was a significantly higher rate of PTSD pre precipitate a psychotic deeompensation in ceding psychotic major depression than either patients at risk for schizophrenia. The PTSD bipolar psychotic depression or nonaffective rate in individuals with either schizophrenia psychotic illnesses.[22]In addition, in a study of or a has been reported to outpatients with major depressive disorder, be as high as 46% to 56%.[17,19]The traumatic those with psychotic features were nearly four experiences described in these studies have times more likely to have PTSD than those been the psychotic experience itself or the without psychotic features.[23]These findings experience of subsequent forced hospitaliza indicate a possible link between PTSD and an tion and treatment. It has been suggested that increased risk of developing psychotic symp the symptoms of PTSD, resulting from psy toms. They also suggest that PTSD may be an chosis, may be mistaken for the symptoms of underrecognized, comorbid condition in indi schizophrenia. For this , consideration viduals with psychotic depression.

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Bipolar Disorder personality disorder (BPD) may exhibit Unlike depression, is normally not transient, stress-related, paranoid ideation associated with PTSD.' The presence of and reality distortions, such as a belief that , a decreased need for sleep, the treatment staffis conspiring against them. pressured speech, the flight of ideas, or other Because BPD is also associated with an symptoms of mania in the presence of PTfSD-P increased rate of and are most consistent with a comorbid bipolar neglect, there is an overlap between the disorder as the primary source of the diagnoses of BPD and chronic PTSD. There is "...in addition psychotic symptoms. some evidence that childhood trauma is associated with a higher rate of psychotic to possessing an Substance-induced Psychosis symptoms, as well as with a higher probability Rates of comorbid alcohol and drug abuse of PTSD and BPD.[31,32]It is possible that increased sensitivity are high in chronic PTSD. Therefore, it is similar etiologic factors may be involved in possible that the majority of persons with the production of the psychotic symptoms in to future substance psychotic symptoms in PTSD are suffering PTSD and BPD. from alcohol hallucinosis, paranoia, Patients with schizotypal or paranoid induced psychoses, or another substance-induced psychosis. personality disorder may also experience Evidence suggesting the unlikelihood of this psychotic decompensation under stress; individuals who possibility includes the similar rates of therefore, individuals with premorbid cluster A alcohol or other drug use reported in PTSD personality disorders may he overrepresented have experienced patients with and without psychotic features.[8] in the population of persons with PTSD who In addition, PTSD-P patients with alcohol develop psychotic symptoms. The patient stimulant-induced abuse histories have a lower intensity of psy described in the second case example chotic features, as measured by the Positive appeared to have a cluster A personality disor psychosis may and Negative Scale (PANSS), than der. The rate of character pathology in PTSD those without alcohol abuse histories[13] patients with psychotic symptoms vs those experience a It is possible that, despite similar substance without psychotic symptoms is unknown. use histories, there are some PTSD-P patients stress-induced with an increased sensitivity to substance Flashbacks Associated With PTSD induced psychosis. Greater stimulant con Reexperiencing is one of the three psychosis when sumption is related to an increased probability symptom clusters of PTSD. Reexperiencing of developing a substance-induced psychosis; phenomena can include intrusive distressing abstinent from ." however, there are significant individual recollections of the event, including images, differences in the susceptibility to thoughts, or , as well as feeling or psychosis.[24,26]In addition, once substance even acting as if the traumatic event were induced psychosis has occurred, the patient recurring. These experiences can range from a has an increased sensitivity to developing a vague of reliving the experience to substance-induced psychosis in the future. It , hallucinations, and flashback has also been reported that, in addition to episodes. It has been argued that the possessing an increased sensitivity to future psychotic symptoms in PTSD are simply substance-induced psychoses, individuals who flashback experiences, but most of the have experienced stimulant-induced psychosis research to date has excluded patients whose may experience a stress-induced psychosis psychotic symptoms occurred in response to when abstinent from drugs.[27-30] Therefore, some traumatic cues. Psychotic symptoms that are instances of PTSD with psychotic symptoms not related to traumatic events appear to may represent the existence of a substance differentiate more clearly PTSD-P from flash induced, psychosis-sensitive population. backs. In addition, it has been reported that the severity of psychotic symptoms, as measured Personality Disorders by the PANSS, is not correlated with the High rates of character pathology occur in severity of reexperiencing symptoms, as mea persons with chronic PTSD. These include sured by the CAPS. This would be expected if borderline, schizotypal, and paranoid PTSD-P were secondary to flashbacks.[13] personality disorders.[1]The presence of a per The distinction between a psychotic sonality disorder may be a contributing factor symptom and a reexperiencing symptom is to the development of psychotic symptoms in not always clinically clear, and the relationship PTSD. For example, those with horderline needs to be investigated further. Clinically, it

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is important to remember that psychotic tribute to the production of psychotic symptoms, by definition, involve grossly symptoms. The physiologic significance of an impaired , in which the increased plasma level of Db H activity is individual makes incorrect inferences about unclear; however, this finding suggests that external reality, even in the face of contrary significant biologic differences may exist evidence.[15]This is distinct from how most between PTSD patients with psychotic patients describe flashback episodes (in features vs those without psychotic features. "...patients which external reality testing is only briefly This is the case for depression: The presence impaired, if at all). of psychosis in depression is associated with with PTSD with significant differences in a number of biologic Factitious/MalingeringDisorders markers, including greater elevations in corti psychotic features had As with all disorders in psychiatry, it is sol, increased nonsuppression of cortisol by necessary to be attuned to the possible inten , differences in sleep measures, nearly twice as much tional production or feigning of psychological and increased ventricle-to-brain ratios.[35,36] signs or symptoms either for or DBH enzyme activity material gain. The rate of factitious disorders TREATMENT and malingering is increased in chronically The only published report on the treatment intheplasma disabled patient populations in which housing of PTSD-P is a case report of a 44-year-old and/or financial incentives can be gained by Vietnam veteran with PTSD and auditory and as those without having the disorder. Additionally, the need for visual hallucinations, as well as a thought social support through the production of disorder, paranoid ideation, and alcohol and psychotic features..." symptoms may be higher in socially disabled abuse. The patient demonstrated populations. A factitious or malingering marked improvement with therapy.[37 ] disorder is suggested by inconsistency In addition to this case report, Hamner and between the symptoms that the patient reports colleagues[38]reported good responses to the and his or her observed behaviors. In atypical antidepressant in an addition, the report of psychotic symptoms open-label trial of patients with PTSD-P. that are rarely observed outside of general The recognition of psychotic symptoms in medical conditions or substance abuse, such PTSD could have important clinical implica as vivid visual hallucinations, increases the tions for medication treatments. In depression, probability of a factitious or malingering com the presence of psychotic symptoms is ponent to the patient's condition. associated with a poorer response to tricyclic alone, compared with BIOLOGIC FACTORS IN PTSD depression without psychotic symptoms. The WITH PSYCHOTIC FEATURES treatment response is significantly improved There is only one report in the literature with the addition of an .[8,39,40] examining biologic differences between PTSD patients with or without psychotic features. CONCLUSION beta-hydroxylase (DBH) is the The available data suggest that the enzyme that converts the catecholamine presence of psychotic features in persons with dopamine to norepinephrine PTSD may represent an underrecognized, in norepinephrine-containing neurons. It has unique subtype of PTSD; however, comorbid been reported that plasma levels of DBH are psychotic depression, substance-induced psy reduced in patients suffering from psychotic chosis, personality disorder, or a factitious dis major depression.[33] order must be carefully excluded as the source Although the significance of plasma DBH of psychotic symptoms. Further investigation is uncertain, it is released along with of psychotic symptoms in noncombat-related norepinephrine from synaptic vesicles in both PTSD populations is needed before findings the adrenal gland and sympathetic neurons. can be generalized to all individuals with Hamner and Gold[34]reported that patients with PTSD. The only published biological study[34]in PTSD with psychotic features had nearly this area suggests that patients with PTSD-P twice as much DBH enzyme activity in the may possess unique biologic traits or states. plasma as those without psychotic features The intriguing similarities between PTSD-P (whose enzyme activity levels were similar to and psychotic depression suggest that recogni controls). They proposed that this might tion of psychotic symptoms in PTSD may have represent a trait difference that could con- important clinical implications.

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