Psychosis-induced Posttraumatic Stress Disorder M I C H A E L S. L U N D Y , M . D . , M.S.* The course of psychiatric illness may he complicated by an individual's reaction to it. Psychosis, because of its unique ability to disrupt mental processing, may result in psychological trauma of considerable magnitude. We report the case of an adolescent male with schizophrenia who developed posttraumatic stress disorder (PTSD) due to his experience of psychosis. Even though there was a significant overlap of symptoms, PTSD was discernible in the presence of schizophrenia. Recognition of this secondary syndrome led to a more adequate understanding of the patient's illness. INTRODUCTION
Severe psychological trauma, defined as a personal experience "outside the range of usual experience and that would be markedly distressing to almost anyone," distinguishes posttraumatic stress disorder (PTSD) from other "reactive" disorders and from nonreactive anxiety disorders. The degree of stress necessary to give rise to P T S D is, by definition, extreme, even though such a stress is not always sufficient to cause PTSD. 1
I n spite of careful attempts to define psychological trauma and the provision of specific examples i n DSM-III-R, agreement about what might or might not induce P T S D is far from universal. For example, illness is specifically excluded from the category of events considered to be traumatic, although an empirical basis for this rationale is not evident. By default, this 1
"Teaching Child Psychiatrist, William S. Hall Psychiatric Institute; Assistant Professor, Department of Neuropsychiatry and Behavioral Science, University of South Carolina. Mailing address: W.S. Hall Psychiatric Institute, P.O. Box 202, Columbia, SC 29202-0202. A M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol. X L V I , No. 3, July
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position excludes a category of illness that is traditionally held to be one of the most traumatic of all experiences: psychosis. P T S D is a serious condition associated w i t h significant psychiatric comorbidity; its diagnosis may be critical. Recognition of the disorder is sometimes difficult, especially when the symptoms of P T S D overlap w i t h those from other psychiatric illnesses. I f psychological trauma is unrecognized because of premature diagnostic closure, then the diagnosis of P T S D and treatment of this comorbid condition may be neglected. A case is presented i n which P T S D arose from and complicated the course of schizophrenia. Diagnosis of this coexisting disturbance contributed to treatment of the primary illness. CASE REPORT
James was 16 years old when psychiatrically hospitalized. H e met full DSM-III criteria for schizophrenia, paranoid type, subchronic. H e reported thought broadcasting, heard repetitive songs i n his head, and believed he could cause objects to freeze or burn by waving his fingers at them. H e displayed diffuse paranoid ideation, was morbidly jealous of his mother's " w e a l t h " (she was a welfare recipient), and showed overly concrete thinking. Though the patient denied illness, he eventually agreed to take low dose thioridazine (Mellaril®, 50 mg/day). Positive symptoms of psychosis resolved after two months on this medication, but a rigid and idiosyncratic form of thinking remained prominent. H e was discharged as improved, but not recovered. H e discontinued medication and two months after discharge, was readmitted after threatening to kill his mother. Florid psychotic symptoms were absent upon readmission, but rigid thinking was pronounced. H i s ideation was idiosyncratic. Some paranoid features were present, but his clinical picture was suggestive of negative symptom or residual schizophrenia. H e evidenced gross neglect of personal hygiene, refused school, denied illness, and muttered to himself continually. His social functioning was grossly impaired; he was withdrawn and inept i n attempts to interact w i t h other people, much more so than during his first hospitalization. H e had been well liked, but upon readmission, the qualities which had endeared h i m to the staff were absent. James rejected medication of any k i n d , but he agreed to talk about why he refused it. H e spontaneously related memories of his first hospitalization, saying " I t ' s very painful for me to acknowledge, but I was really coming apart t h e n . " H e said he had been powerless to stop songs which played continuously inside his head. H e feared that the songs were "wearing o u t " his brain. H e believed that he was disintegrating, and feared that he w o u l d "vaporize" and be dispersed by the wind. A t times, he felt as i f he were on a precipice, 1
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about to fall or be pushed into an abyss. These experiences had terrified h i m , and his recounting of them induced obvious anxiety. H e had not previously described them to anyone. I n relating his experience of psychosis, the patient displayed a full range of affect, quite distinct from his usual constricted style. Also, his thinking was flexible and devoid of its usual idiosyncrasies. Talking about his experience was difficult for James, but he was eager to be understood. H e spontaneously interpreted some of his present symptoms i n light of his initial psychotic experience. For example, he related that while he had once enjoyed taking showers, he now actively avoided them, since that was the activity i n which he was engaged when music began playing i n his head. School refusal was also essential, he explained, i n order to keep the use of his brain to a m i n i m u m ; the repetitive mental activity of the classroom reminded h i m of the incessant music. H e feared that school w o r k might "damage" his brain as he believed the music d i d . H e acknowledged muttering to himself, and explained that while it made h i m seem "crazy," talking to himself Table I
Pyschologically distressing event outside the range of usual human experience. An extensive breech in the protective shield against stimuli. Markedly distressing to almost anyone.
Anxiety of an intensity and intolerability not encountered to any comparable degree in a normal life.
The highest degree of mental pain becomes manifest in the psychoses. A living nightmare. Going crazy is a traumatic experience. Severe panic. Helpless state. Loss of will, feelings of indifference. Disintegration of the self to the point of nothingness. Psychosis is a real danger to survival. The danger is that the self will disintegrate. Feeling of dying. Internal catastrophe. The loss of self is perceived as real and irreversible. 7
Associated with intense: fear, terror, helplessness, loss of control, threat of annihilation. 8
Most commonly involves a threat to life or self-image or loss of a loved one. 10
Extreme stressors are most readily linked t o P T S D . 11
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prevented the intrusion of thoughts that were frightening. Finally, he said his refusal of medication was an attempt to avoid reminders of the symptoms medication had been used to treat. I t was as i f thinking of psychosis would lead to a relapse. The most frightening prospect for this patient was a recurrence of his psychosis; he defended himself against this fear by means of thinking which was psychotic. This irony was not apparent to the patient. Following this interview, the patient once again accepted medication, and has responded to it. DISCUSSION
Before considering whether or not this patient had secondary P T S D , it must first be ascertained whether or not he actually experienced psychological trauma. Can an episode of psychosis be considered to be a traumatic event, as intended by the definition i n DSM-III-R? Even though diagnostic criteria for P T S D exclude illness from the definition of a traumatic event, a psychotic episode may meet the intent of the definition. A comparison of PTSD-type psychic trauma and psychosis illustrates this (Tab. I ) . I t is evident that our concepts of psychic trauma share much w i t h our notions about the experience of psychosis. There are striking parallels i n the language used to describe each. As Breslau has pointed out, theory about P T S D draws heavily upon psychoanalytic concepts of psychic function, so it is not surprising that such parallels are found. Well-established clinical observations regarding the nature of psychosis are consistent w i t h the DSM-III-R definition of stressors likely to result i n P T S D . I f we consider psychosis i n this context, our patient met diagnostic criteria for P T S D . First, he clearly had an experience which was terrifying, life-threatening (at least w i t h respect to the patient's expectations), and subjectively and objectively unusual. The psychosis was re-experienced i n the f o r m of intrusive and recurrent recollections of the event, and its symbolic reminders produced severe distress. Also, the patient persistently avoided stimuli that recalled the event. H e actively avoided thoughts, activities, and situations that he associated w i t h psychosis, displayed a restricted range of affect, and shied away from social interactions. I n addition, he was hypervigilant and scanned for reminders of his psychosis. H e was irritable and easily provoked. Conversely, the patient d i d not have recurrent nightmares or overt flashbacks, and had no inability to recall his experience. A n exaggerated startle response was absent, as were sleep disturbance and difficulty concentrating. The absence of these characteristic features of P T S D may have been due to predominance of the avoidant/numbing phase of the disorder. I t w o u l d be expected that the intrusive elements of P T S D w o u l d be relatively less 12
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evident, given the excessive use of avoidance displayed by this patient. O n the other hand, "atypical" presentations of psychiatric illness are not uncommon i n the face of multiple diagnoses. Identification of P T S D i n our patient facilitated his acceptance of both his illness and necessary medication. Talking about his fears w i t h h i m facilitated a desensitization, which was evident i n a reduction of phobic avoidance. The change i n this patient is consistent w i t h a shift from "sealing over" toward " i n t e g r a t i o n . " ' The striking feature of this case is the subjective meaning that the patient attached to what might otherwise have been interpreted as negative schizophrenic symptoms. I n particular, he indicated that the memory of a previous, florid psychotic episode was so frightening that he took steps to avoid reminders of it, yet continued to be plagued by intrusive recollections of the event, and fear of its return. The memory of an event, without external stimuli, has been noted as sufficient to provoke symptoms i n P T S D . A t the same time, the overall course of illness appears to have been determined by the primary disorder, schizophrenia. The marked overlap between negative schizophrenia and the avoidant/numbing phase of P T S D may have been serendipitous. However, i t is unusual to find patients w i t h negative symptoms showing such awareness of their clinical picture, and even more unusual for such patients to offer an interpretation such as set forth by this adolescent boy. 13
Comorbidity can make for diagnostic error and therapeutic difficulties. ' P T S D has been misdiagnosed as schizophrenia, and has also resulted from and complicated the course of organic psychosis. Schizophrenics are at increased risk for poor outcome, including suicide, and one of the associated risk factors is a secondary depressive syndrome. B r e i e r suggests that anxiety disorders could also be a "prodromal, incomplete, or residual manifestation of other psychiatric disorders." Alternatively, an anxiety syndrome, such as P T S D , may represent a distinct complication of a primary psychiatric illness, and might be expected to contribute to the overall course of illness. W i n o k u r notes that anxiety disorders might occur " i n response to the presence of other (psychiatric) illnesses." I t is conceivable that some of the heterogeneity seen i n major mental disorders is reflective of unrecognized secondary syndromes. The presence of one major psychiatric disorder should alert clinicians to the possibility of a complicating secondary syndrome, including P T S D . Such a complication, as we have presented, can significantly influence a patient's attitude toward his illness. Although attitude may either affect or reflect o u t c o m e , ' determinants of that attitude may help to understand denial of illness, treatment noncompli13,17
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ance, and may have value i n clinical decision making and i n establishing a therapeutic alliance w i t h difficult-to-treat individuals. Failure to consider a secondary diagnosis of P T S D may detract from a full understanding of the patient's disorder, adversely impacting upon treatment and o u t c o m e . ' 20
Conventional theories about stressors severe enough to lead to P T S D have focused on external events. Historically, however, psychosis has been considered one of the most severe stressors to which one can be subjected. The impact of psychosis, i n the case of schizophrenia, may be mistaken for the psychosis itself. The possibility of a comorbid, psychosis-induced P T S D should be considered i n persons who have experienced a psychotic illness. Recognition of the syndrome may lead to more effective and empathie clinical treatment of persons w i t h severe mental illness. Acknowledgement: Thanks to Russell Noyes, Jr., M.D. for his encouragement and editorial review of this manuscript.
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Psychosis-induced Posttraumatic Stress Disorder 17. Brett, E.A. and Ostroff, R. (1985). Imagery and Posttraumatic Stress Disorder: An Overview. American Journal of Psychiatry 142:417-424. 18. Sierles, F.S., Chen, J., McFarland, R.E., and Taylor, M.A. (1983). Posttraumatic Stress Disorder and Concurrent Psychiatric Illness: A Preliminary Report. American Journal of Psychiatry 140:1177¬ 1179. 19. Domash, M . D . and Sparr, L.F. (1982). Post-Traumatic Stress Disorder Masquerading as Paranoid Schizophrenia: Case Report. Military Medicine 141:112-114. 20. Mackenzie, T.B. and Popkin, M.K. (1980). Stress Response Syndrome Occurring After Delirium. American Journal of Psychiatry 137:1433-1435. 21. Black, D.W., Winokur, G., and Warrack, G. (1985). Suicide in Schizophrenia: The Iowa Record Study.JournalojClinicalPsychiatry 46[11, Sec.2]: 14-17. 22. Breier, A., Charney, D.S., and Heninger, G.R. (1985). The Diagnostic Validity of Anxiety Disorders and Their Relationship to Depressive Illness. American Journal of Psychiatry 142:787-797'. 23. Winokur, G. (1988). Anxiety Disorders. Relationships to other psychiatric illness. Psychiatric Clinics of North America 2(2):287-293. 24. Blank, K. and Perry, S. (1984). Relation of Psychological Process During Delirium to Outcome. American Journal of Psychiatry 141:843-847. 25. Jeffries, J J . (1977). The Trauma of Being Psychotic. Canadian Psychiatric Journal, 22:199-205. 26. Shaner, A. and Eth, S. (1989). Can Schizophrenia Cause Posttraumatic Stress Disorder? American Journal of Psychotherapy 43:588-597.