In our case report, we describe the case of a patient with PTSD with psychotic symptoms. Her PTSD developed soon after a severe traumatic experience associated with a civil war twelve years ago: she witnessed the murder of her nuclear family. Eight years later she developed psychotic symptoms, which included auditory and visual hallucinations and persecutory delusions. She finally presented two years ago to mental health services in the context of major social stresses, an unwanted pregnancy, potential homelessness, and a rejected asylum claim. Symptomatically, her psychosis responded well to treatment but the PTSD features and stresses remain. Her follow-up is now directed towards dealing with these issues, as well as preventing a relapse.
We reviewed the scientific literature regarding the diagnosis and treatment of PTSD with psychotic symptoms. There are few case reports about the presence of PTSD with psychotic features, mainly involving war veterans, but none using trifluoperazine as a psychopharmacological treatment. In 2008, Floros et al. reported the case of a man with psychotic symptomatology after a traumatic event involving the accidental mutilation of his fingers. His treatment plan included pharmacotherapy and supportive psychotherapy with the establishment of a good doctor-patient relationship. This biopsychosocial approach was made to integrate all aspects relating to his history in a meaningful way [3].
In our case report, our patient had PTSD symptoms including experiencing recurrent distressing images of the traumatic event, with a markedly diminished interest and participation in significant activities and the avoidance of thoughts and conversations associated with the trauma. She also had persistent symptoms of increased arousal, with difficulty falling and staying asleep. PTSD with psychotic symptoms is associated with a clinically significant impairment in social and occupational functioning, including difficulties in getting a stable job and holding down relationships. According to the DSM-IV-TR, PTSD is classified as an anxiety disorder but expressions of the disorder may include obsessions, phobias, dissociations or depression [4]. Less characteristic and poorly studied, are the psychotic symptoms associated with PTSD. Our patient presented with visual and auditory hallucinations and persecutory delusions with content that mirrored her PTSD. In patients who do not have another established severe mental illness, the presence of psychotic symptoms in PTSD might be better captured as a dimension or sub-group of PTSD rather than psychosis NOS.
Mueser et al. have suggested that PTSD influences psychosis both directly, through the effects of specific PTSD symptoms including avoidance, over-arousal and re-experiencing the trauma, and indirectly, through the effects of common consequences of PTSD such as re-traumatization, substance abuse and difficulties with interpersonal relationships [5]. Our patient had both; she frequently "relived" the traumatic event through intrusive flashbacks and recurring dreams. Co-morbid psychosis has been described in approximately 20 to 40 percent of veterans with combat-related PTSD [6, 7]. The prevalence of PTSD in patients with a severe mental illness is at least three times higher (29 percent) than the general population [5]. In PTSD, the psychotic symptoms may be more pervasive or frequent than psychotic-like symptoms that occur during dissociative episodes or flashbacks [8]. PTSD with psychotic symptoms has also been reported in non-combat related cases of patients with PTSD but not schizophrenia-spectrum or bipolar disorders.
From a psychological point of view, there is a relationship between the individual's pre-existing cognitive schemas and thought patterns emerging after the traumatic event. A maladaptative cognitive processing style culminates in feelings of shame, guilt and worthlessness, which emerge during trauma acting as positive feedback to enhance symptom severity and keep the individual in a constant state of psychotic turmoil. It is possible that under certain individual-specific conditions, the defence and coping mechanisms break down at a level of psychotic manifestations in the form of delusions and hallucinations. It has been hypothesized that trauma may produce a psychological vulnerability leading to the development of psychotic experiences. In our patient, factors such as an unwanted pregnancy, potential homelessness and a rejected asylum claim may have contributed to and triggered the emergence of psychotic features in a preceding PTSD. Some authors underline the importance of both disorders being characterized by intrusions. In PTSD, the interpretation of intrusive symptoms such as flashbacks is seen as central to the maintenance of the disorder. In psychosis, hallucinations and delusional beliefs are interpretations of intrusions [9].
Unlike our case report, where there was clear evidence of a life-threatening trauma before psychotic symptoms, some authors identify psychosis itself as the source of trauma for patients with both conditions. There is some evidence suggesting that psychosis, hospitalization, or both may be sufficiently severe to precipitate PTSD and that psychological distress related to a psychotic episode may predict an evolution to PTSD [10].
Our patient was an immigrant from a black ethnic minority group. First- and second-generation black ethnic minority migrants are at a particularly high risk of psychosis in London. The explanation for these findings is uncertain, but social adversity, racial discrimination, family dysfunction, unemployment, poor housing conditions and urbanicity have been proposed as contributing factors [11–13]. It is possible that similar stresses contributed to the heightened risk of psychosis in our patient.
Some authors argue for a new condition called PTSD with psychotic symptoms, claiming that it should be included in the psychiatric classification systems to account for the high percentage of psychotic symptoms in patients with PTSD [14]. Our patient could fit into this category.
Establishing a correct diagnosis is imperative in developing an appropriate treatment strategy, particularly when the presence of psychotic symptoms necessitates the use of anti-psychotic medication. In addition to the demonstrated efficacy of selective serotonin re-uptake inhibitors (SSRIs), a range of other drugs, including second-generation anti-psychotics, have recently been investigated for the treatment of PTSD. The currently available evidence suggests that first-line pharmacotherapy is SSRIs and possibly the serotonin norepinephrine re-uptake inhibitor venlafaxine extended release [15]. Response rates are limited: approximately 60 percent of patients treated with SSRIs are reached [16]. Psychotic symptoms are associated with more severe symptomatology and their presence is also known to decrease the efficacy of conventional treatment [17], further indicating a possible role for an anti-psychotic treatment. We found a paucity of randomized, double-blind, placebo-controlled clinical trials (RCT) of anti-psychotics for the treatment of PTSD. However case reports, small RCTs and open-label studies have demonstrated the beneficial effect of this pharmacotherapy (add-on and monotherapy) for the treatment of PTSD patients with and without psychotic symptoms. Published case reports demonstrate the efficacy of clozapine [8] or amisulpride [3] in the treatment of both PTSD and psychotic symptoms. Fluphenazine, olanzapine, risperidone and quetiapine are anti-psychotics with demonstrated efficacy in open clinical trials as a monotherapy in PTSD with psychotic features [18–20].
Hamner described the case of a Vietnam veteran with a history of PTSD symptoms and psychotic symptoms including auditory hallucinations, visual hallucinations, thought disorder and paranoid ideation. He had a history of substance abuse (alcohol and cocaine) but had been in remission for one year prior to his evaluation. He was treated unsuccessfully with typical neuroleptics, electroconvulsive therapy, benzodiazepines and lithium. Clozapine was initiated and titrated to 600 mg/day leading to an improvement of his PTSD and psychotic symptoms [8].
However, to date, none of these agents has received registration status for use in PTSD in the USA or in Europe [21]. In the absence of guidelines relating to the condition of PTSD with psychosis, our patient's psychosis responded well to the standard anti-psychotic treatment but her co-morbid PTSD features remain. Given her complicated presentation, her recovery will require a multi-faceted approach with an emphasis on addressing her pre-existing PTSD. She did not develop any extra-pyramidal symptoms associated with the use of a typical anti-psychotic, however, Chan et al. report the cases of three patients with PTSD with psychotic features who developed severe extra-pyramidal side effects, namely akathisia, leading to the withdrawal of the anti-psychotic medication [22].
Several psychotherapeutic interventions have been studied in PTSD and psychotic illnesses, with a growing literature suggesting that they are both feasible and effective. Waldfogel et al. report the case of a non-combat veteran with PTSD with psychotic symptoms who was not successfully treated with anti-psychotics and for whom exposure therapy was successful in treating PTSD and psychosis [23]. Mueser et al. published a randomized controlled trial of the cognitive-behavioral treatment (CBT) of PTSD in severe mental illness, which includes breathing retraining, education about PTSD and cognitive restructuring. Results indicated that patients included in a 12- to 16-session CBT program showed a greater improvement of their PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance compared with treatment as usual, where patients continued to receive the usual treatments they had been undertaking in local mental health centers [24]. Frueh et al. report an open trial in adults with PTSD and either schizophrenia or schizoaffective disorder who were treated via an 11-week cognitive-behavioral intervention. The trial involved 22 group and individual sessions for PTSD consisting of anxiety management therapy, psycho-education, social skills training and exposure therapy. Participants showed a significant improvement of their PTSD symptoms and high treatment satisfaction [25]. Besides the psychopharmacological therapy, our patient could benefit from one of these psychotherapeutic programs targeting PTSD symptoms.
As in the case report published by Waldfogel et al., patients presenting with PTSD with psychotic features who do not have a well established severe mental illness might also respond to conventional psychotherapeutic treatments with a demonstrated efficacy for the treatment of PTSD in the general population [23]. Due to the paucity of published systematic studies, this is a field for future research.
Because our patient has no friends or family in the UK, our diagnosis was based only on self-reported information; a less rigorous approach than those using other sources of information to corroborate a patient's account. A structured clinical interview and the use of specific measure instruments could also help in rating symptoms and promoting an improvement in clinical daily routine.
