PTSD with psychosis

[whopper]

Anyone seeing this? I've rarely but occasionally seen a PTSD patient with auditory hallucinations of voices and it wasn't thoughts, they alleged to hear actual voices.

My first inclination was they were malingering, but the more I interviewed them, the more I believed they were telling the truth. Second inclination was there was some comorbid psychotic disorder, but there did not appear to be any of the criteria for schizophrenia or schizoaffective disorder with these patients aside from the hallucinations. They could clearly identify the voices were hallucinations, actively ignored them, were able to function (e.g. had jobs, active lifestyles) and did not have other significant signs or sx of psychosis that clearly would've allowed me to attach a comorbid disorder. The same people also didn't have depression or bipolar disorder.

It's gotten to the point where now I've seen a handful of these types of patients and I've seen some data suggesting a link.
http://ptsd.about.com/od/relatedconditions/a/Psychosis.htm
http://focus.psychiatryonline.org/data/journals/focus/4332/foc00311000278.pdf

And in all of the cases I've seen so far the patients were extremely young-under the age of 10 when they had their traumatic experiences and they were severe trauma. E.g. being raped repeatedly for years, living with a father who was the head of a motorcycle gang and very highly ranked drug manufacturer and dealer who killed several of his competitors.

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[OldPsychDoc]

Where's the line between psychosis and dissociation?

 

[thoffen]

This kind of thing is pretty much every other patient at one of my clinical sites with very high trauma rates. Tends to be more externalizing and similar to dissociation in that sense. I usually put PTSD and psychosis NOS for diagnosis. Unfortunately antipsychotics don't seem to be the answer. My treatment thought would be dynamic therapy but good luck finding patients who have the means and inclination to see it through.

 

[erg923]

Dynamic therpay for PTSD? Must have missed the boat on the evidence base for that one.

We see this alot in VA although its usually just more extreme dissociatation. Inpatient PTSD program to structure the enviornment? Is that an option? The imaginal exposures in PE would probably be contraidicated due to the psychosis, although that kinds depends.

 

[whopper]

Dissociation? Crossed my mind as well. I haven't ruled it out and on that issue it's hard to rule out dissociation, but on interviews, when I explain to the patient what dissociation is, they deny having any solid types of dissociation symptoms you usually see in dissociative disorders.

Could be dissociation. I'm not denying it.

 

[nitemagi]

Dissociative "pseudohallucinations" exist in many psychopathologies, which can but don't have to overlap with PTSD, including Borderline PD and conversion d/o's.

DBT teaches other skills to tolerate distress, as an alternative to dissociating when stressed. I've also done training with patients to identify the signs when they're dissociating, and to practice bringing it on and turning it off.

 

[Ceke2002]

Just chiming in from personal experience, so I'm not sure how helpful this will be (hopefully somewhat). Have you thought about asking him if the hallucinations ever feel like they have a different quality of experience or sensation to them? The reason I mention that is because my case is sort of similar in that I also experienced frequent and prolonged trauma before (and after) the age of 10, and I experience episodes of psychotic like symptoms where my insight remains intact, and for the majority of the time I'm able to deal with those symptoms through a variety of methods such as distraction, ignoring, reality checking, and so on. The thing is, I could have the exact same hallucination several times over, and depending on the actual underlying reason for the hallucination, despite it being the same, the actual inner experience of it feels very different. The hallucinations/psychotic type symptoms I experience due to emotional disregulation, feels different to the hallucinations/psychotic type symptoms I experience during suspected trauma flashbacks (we're still looking into that), which again feels different to the type of softer, more derealisation type stuff I experience during periods of intense anxiety, and the hallucinations/psychotic symptoms I experience during episodes of MDD-Psychotic Fx feel completely different to the first three scenarios. The first three scenarios in that list have a more emotive or emotional quality to them, the last one feels biological (don't ask me how something can feel 'biological' it just does). I think I've mentioned before that at least part of my therapy over the past 4-5 years has been learning to differentiate between the different types of hallucinatory et al experiences I get so that treatment can be tailored to match - emotionally based psychotic like symptoms (what I'd call 'soft' or 'pseudo-hallucinations) are dealt with and treated differently to the more biologically based/experienced hallucinations (which is where medication may or may not come into play depending on the severity of the symptoms). Like your patient as well, none of my hallucinatory/psychotic like experiences can be explained by disassociation.

A book title 'Treating Complex Traumatic Stress Disorders in Adults: An Evidence Based Guide' mentions Axis 1 disorders, such as bipolar, MDD with Psychotic Fx, Schizophrenia spectrum disorders, being co-morbid at a rate of one third up to one half, according to Mueser, Rosenberg, Goodman, and Trumbetta, 2002.

 

[Merovinge]

Dissociative "pseudohallucinations" exist in many psychopathologies, which can but don't have to overlap with PTSD, including Borderline PD and conversion d/o's.

DBT teaches other skills to tolerate distress, as an alternative to dissociating when stressed. I've also done training with patients to identify the signs when they're dissociating, and to practice bringing it on and turning it off.

Not my area of expertise but definitely agree with this. If we see borderline personality/complex trauma patients with pseudohallucinations or "micropsychosis" as Ive heard it described, certainly makes sense that PTSD individuals could fall in the same spectrum.

 

[smalltownpsych]

Thanks for the post on this. I am seeing the same thing in practice and when one of the patients initially told me they had schizophrenia because they heard voices, I thought no friggin' way. The patient was very clear and descriptive about this, which was also a reason to think they didn't have schizophrenia as those patients tend to have much more difficulty describing their internal world. Severe early childhood trauma, cutting, interpersonal instability, abandonment, dissociation, chronic suicidality, substance abuse - BPD. So have started working with my usual, DBT leading into Object Relations, so this info validates what I was thinking and seeing. Unfortunately, the NP who prescribes isn't much help with conceptualizing and diagnosing more complex cases and atypical presentations.

 

[Shikima]

Are we sure there isn't an unaddressed underlying mood disorder responsible for the psychosis?

 

[Ceke2002]

Thanks for the post on this. I am seeing the same thing in practice and when one of the patients initially told me they had schizophrenia because they heard voices, I thought no friggin' way. The patient was very clear and descriptive about this, which was also a reason to think they didn't have schizophrenia as those patients tend to have much more difficulty describing their internal world. Severe early childhood trauma, cutting, interpersonal instability, abandonment, dissociation, chronic suicidality, substance abuse - BPD. So have started working with my usual, DBT leading into Object Relations, so this info validates what I was thinking and seeing. Unfortunately, the NP who prescribes isn't much help with conceptualizing and diagnosing more complex cases and atypical presentations.

I definitely think different therapeutic modalities are somewhat under used when it comes to treating any flavour of psychosis (or psychotic like symptoms). Unfortunately a lot of people are (mis)educated by misrepresentations in the media and automatically jump to 'I must be Schizophrenic if I hear voices', potentially making them less likely to engage in therapy unless you can help them understand that 'hearing voices' =/= 'schizoprenia or related spectrum disorders'. I must admit that is a bit of an automatic red flag for me that something else is going on when I have friends contacting me in a panic, because 'OMG I heard my name being called last night, and I'm seeing shadow people out the corner of my eye, and the other day I felt a bit paranoid around my next door neighbour - I'm having a Psychotic break, I know it, I'm Schizophrenic!' My first thought tends to be 'You've never actually met anyone with Schizophrenia, have you?'.

Having said that though, this probably goes without saying, but having a patient who is clear and descriptive with his pathology/symptoms doesn't necessarily indicate they're not experiencing psychosis somewhere along the spectrum. I think for some patients it depends on the length of time they've experienced the symptoms, and I guess some of us just get used to them and it makes it easier to describe in more detached or matter of fact terms.

But going back to therapy - definitely needs more usage in treating cases of psychoses/symptoms resembling psychoses/whatever else the correct term is. I personally don't think it's utilised half as much as it should be.

 

[Ceke2002]

Oh darn it, I just had a thought - this topic is right up my Psychiatrist's alley, one of his major areas of interest, among several, is complex relationships between trauma and psychosis (it forms some of his psychotherapy work). He also sub specialises in Neuropsych so he can give lots of brain related explanation stuff too. I'm seeing him mid next week, so I could ask for him to send some stuff through if it would help, but the 'oh darn it' is in relation to the fact that he's also going to be away for the month of November looking after some family stuff, and then Christmas season coming up I think tends to be busy, so I don't actually know if he'll have the time to answer in a timely enough manner for your patient. I can at least ask though, just can't promise any sort of response.

 

[Ceke2002]

Anyone seeing this? I've rarely but occasionally seen a PTSD patient with auditory hallucinations of voices and it wasn't thoughts, they alleged to hear actual voices.

My first inclination was they were malingering, but the more I interviewed them, the more I believed they were telling the truth. Second inclination was there was some comorbid psychotic disorder, but there did not appear to be any of the criteria for schizophrenia or schizoaffective disorder with these patients aside from the hallucinations. They could clearly identify the voices were hallucinations, actively ignored them, were able to function (e.g. had jobs, active lifestyles) and did not have other significant signs or sx of psychosis that clearly would've allowed me to attach a comorbid disorder. The same people also didn't have depression or bipolar disorder.

It's gotten to the point where now I've seen a handful of these types of patients and I've seen some data suggesting a link.
http://ptsd.about.com/od/relatedconditions/a/Psychosis.htm
http://focus.psychiatryonline.org/data/journals/focus/4332/foc00311000278.pdf

And in all of the cases I've seen so far the patients were extremely young-under the age of 10 when they had their traumatic experiences and they were severe trauma. E.g. being raped repeatedly for years, living with a father who was the head of a motorcycle gang and very highly ranked drug manufacturer and dealer who killed several of his competitors.

I did a bit of digging - not sure if any of these are useful, or of interest:

Post-traumatic stress disorder: the neurobiological impact of psychological trauma

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182008/

Child Maltreatment and the Developing HPA Axis

http://www.trainingourprotectors.co..._maltreatment_and_the_developing_hpa_axis.pdf

The effects of child maltreatment on the hypothalamic-pituitary-adrenal axis

http://tva.sagepub.com/content/5/4/333.short

The Body Keeps the Score: Memory and the Evolving Psychobiology of Posttraumatic Stress

http://informahealthcare.com/doi/abs/10.3109/10673229409017088

Update on stress and depression: the role of the hypothalamic-pituitary-adrenal (HPA) axis

http://www.scielo.br/scielo.php?pid=S1516-44462003000400010&script=sci_arttext

Interaction of brain noradrenergic system and the hypothalamic–pituitary–adrenal (HPA) axis in man

http://www.psyneuen-journal.com/article/S0306-4530(05)00068-5/abstract

Cortical/hippocampal monoamines, HPA-axis changes and aversive behavior following stress and restress in an animal model of post-traumatic stress disorder

http://www.sciencedirect.com/science/article/pii/S003193840600059X

Modeling Cortisol Dynamics in the Neuro-endocrine Axis Distinguishes Normal, Depression, and Post-traumatic Stress Disorder (PTSD) in Humans

http://www.ploscompbiol.org/article/info:doi/10.1371/journal.pcbi.1002379#pcbi-1002379-g011

Integration of psychological and biological approaches to trauma memory: Implications for pharmacological prevention of PTSD

http://onlinelibrary.wiley.com/doi/10.1007/s10960-004-5797-5/abstract

Neuropsychiatric symptoms of complex posttraumatic stress disorder: A preliminary Minnesota Multiphasic Personality Inventory scale to identify adult survivors of childhood abuse.

http://psycnet.apa.org/journals/tra/1/1/49/