Psychosis Masquerading as PTSD

Don’t Mess with the 101st, by Peter Varisano, courtesy of the Army Art Collection, US Army Center of Military History.

The overlap between posttraumatic stress disorder and psychosis is marked and well documented [1]. Psychosis and psychotic disorders may be provoked by a traumatic event: patients with schizophrenia are four times more likely to have PTSD compared to the general US population [2]. The overlap also influences treatment, as patients with psychotic disorders have more difficultly processing trauma and are thus typically excluded from evidence-based therapies for PTSD [3]. Additionally, patients with PTSD and schizophrenia have high rates of substance abuse, a phenomenon that can complicate, and worsen, both conditions. A family history of a psychotic disorder confers both heritability risk for such disorders and vulnerability to traumatic childhood exposures with subsequent PTSD.

Differentiating the two diagnostically can also be a challenge, as several PTSD symptoms overlap with symptoms of psychosis :

The experience of a flashback is described as the patient believing that they are not just remembering a trauma, but are reexperiencing it. Although patients are often able to reality test such experiences after the fact, during a flashback they are convinced that the event is actually reoccurring; making it challenging to differentiate a flashback from a perceptual disturbance. The overlap between PTSD and psychosis is so profound that previous studies defend the use of antipsychotics like quetiapine for the off-label treatment of nonpsychotic trauma-related nightmares and flashbacks [4].
PTSD patients may avoid people and places out of fear that they will be re-traumatized. For military patients, this often includes avoiding large public areas or feeling panic when driving on the highway due to recollections of the combat environment. Depending on the level of their conviction, attempts to assure patients that these external reminders pose little threat to them may not reduce their concerns. Such vigilance may resemble delusional paranoia or represent transient delusional states.
Feeling emotionally detached and engaging in interpersonal avoidant behaviors are common PTSD findings, which can look surprisingly similar to a variety of negative symptomatology found in schizophrenics.

Teasing out the difference between trauma-related symptoms including PTSD-related psychosis and primary psychotic disorder-related psychosis requires a thoughtful approach. Further complicating matters is that the presence of schizophrenia confers vulnerability to trauma exposure and hence concurrent PTSD. Differentiating a psychotic PTSD flashback from schizophrenic psychosis can be accomplished by assessing a patient’s ability to return to reality after the flashback: did they realize the event was not real? A schizophrenic patient will likely maintain a prolonged disruption in reality testing relative to a PTSD flashback, especially early in course of their disease. However, patients with chronic perceptual disturbances of schizophrenia may eventually learn to recognize and maintain some degree of functionality despite their hallucinations. The content of the flashback can also be helpful—it is related to a specific trauma in the patient’s history, or is it a novel experience for the patient? Distinguishing schizophrenic paranoid delusions from PTSD hypervigilance and avoidant behaviors requires a similar approach. A delusional schizophrenic patient may not have insight into where their fears are coming from, or their answers may not be entirely logical. A hypervigilant PTSD patient with avoidant symptoms should be able to account for how the stimuli they are avoiding reminds them of their traumatic event in some way. Additionally, the modality of the false sensory experience can aid in differentiation. PTSD flashback perceptual disturbances often involve several perceptual modalities and are much more likely to include nonauditory disruptions, such as olfactory disturbances, as compared to schizophrenic psychosis which are typically limited to auditory hallucinations. Lastly, and perhaps most importantly, the emergence of schizophrenic psychosis occurs in the absence of a putative potentially traumatic exposure (PTE), which is the defining characteristic of PTSD that is requisite for a determination of PTSD-related symptomatology.

Unfortunately, patients with PTSD related to military trauma can have several additional diagnostic challenges. Multiple military (and non-military) traumatic experiences across their lifespan can coalesce, leaving the patient’s intrusion symptoms vague and difficult to connect to a specific event. Military patients who suffer from a traumatic brain injury (TBI) may have a difficult time recalling important events independent of potential PTSD-related memory avoidance. Such difficulties in recalling trauma exposures along with ongoing difficulties in processing can interfere with cognitive and exposure therapies—the standard of care treatments for PTSD. The very nature of their military service may bias a provider’s interpretation of symptoms toward PTSD and away from other considerations. The following case demonstrates some of the complexities in presentation and treatment of a military patient who, despite appearing to have PTSD, was ultimately determined to be suffering from schizophrenia.

18.1 Case Presentation

A 43-year-old African American Major in the US Air Force presented to the mental health clinic due to difficulty sleeping and concerns regarding his “routines.” He had been having difficulty maintaining asleep over the past few years, which he attributed to recurrent distressing dreams associated with previous deployments to Iraq and Afghanistan. He noted that somewhere during his seven deployments he started having nightmares of falling in a black void and waking up afraid of “something.” He recently started checking the locks on his house every night and walking the perimeter of his property due to concerns related to being attacked. He believed that these behaviors were also due to traumatic events that had occurred during his deployments. These symptoms appeared to worsen after he and his family moved out into the country a few months ago. Specifically, he admitted that his wife was concerned about the fact that he had cleared a 10 ft swath around the perimeter of their property and routinely watched the small country road they lived on, noting cars that “should not be there.”

On further exploration of the patient’s trauma, it was determined that the most distressing event during his deployments was being woken in the middle of the night with a Red Cross message alerting him that his elderly father had become ill. He felt helpless in that he could not return to his family during their time of need and, ultimately, felt guilty for not being present for his father’s death or funeral. He perceived waking up in the middle of the night as “re-living that terrible night.” He acknowledged that, although the event was traumatic for him, it did not seem to relate to his paranoia about being attacked in his home. He reflected that over his multiple deployments he had also been shot at, exposed to mortar attacks, had numerous friends die, and participated in convoys that were attacked. Although he denied that any of these events caused him distress, he felt that they might be the source of his safety concerns.

The Major also reported feeling uncomfortable in crowded places, to include his own office: “I’d rather work in my car, out in the parking lot.” He confirmed feeling disconnected from his emotions and his wife. He recognized that he avoided thinking about his deployments and the death of his father. He had never visited his father’s grave and was hesitant to attend extended family reunions due to fear people would talk about his father.

On psychiatric review of symptoms, the patient described some overlapping depressive symptoms with PTSD including anhedonia and reduced concentration. He associated his reduced energy to his sleep disturbances and his vigilant mind/behavior. Mania was not detected, given a lack of concurrent elevated/irritable mood with increased energy or goal-directed activity. He denied any other obsessions, compulsions, or anxiety symptoms. He denied perceptual disturbances and delusions.

Clinical Pearl

Clinicians should make longitudinal inquiries beyond the initial evaluation regarding the possible presence of PTSD-related psychosis because many victims of trauma exposure are either too embarrassed or have not yet established the prerequisite level of trust to disclose such symptoms early on in the treatment relationship [1].

Regarding his fear of being attacked, his ability to reality test these thoughts was inconsistent with delusional paranoia. He reported occasional use of alcohol, denied evidence of misuse, and denied use of any other substances. He denied any history of loss of consciousness or confusion due to being exposed to an explosion or mechanical injury. He denied any thoughts of death or suicidal ideation. He also denied any homicidal intent, but qualified his answer with, “unless someone attacked me—then I’d have to defend myself.”

On medical review of symptoms, he endorsed snoring at night and that his wife had told him that he often made gasping sounds. He also endorsed occasional morning headaches that required over the counter medication (ibuprofen), but otherwise denied any current signs or symptoms of a medical condition. Medically he was being treated for essential hypertension with hydrochlorothiazide and elevated cholesterol with simvastatin.

Clinical Pearl

Consider screening for organic causes in any patient experiencing disrupted sleep. Following up with a sleep study can confirm the diagnosis and guide treatment. Resolution of organic contributions can enhance the treatment of any remaining symptoms [5].

He denied any previous personal or family psychiatric history. He grew up in a stable home, denied abuse, had a good relationship with parents, and reported doing well in school. He had completed a master’s degree a few years ago and was doing well occupationally: He had been in the military for 16 years and was up for promotion to Lieutenant Colonel, he was getting along well with others at work and had recently been praised for performance by his commander. He described his job as section lead for operations where he helped plan missions. He had been married for 15 years and had four children. He denied any legal or financial issues.

Clinical Pearl

Military patients often define themselves occupationally. A brief military history can provide insight into the patient’s functional levels and put the remainder of their history in a contextual frame. For example, promoting to Lieutenant Colonel around 16 years of service infers that this military patient is “on track” [6].

In addition to routine screening tools, the patient completed a Beck Depression Inventory (BDI-II), which showed some symptoms of depression but was not positive for a depressive disorder. He also completed the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which did not reveal any additional obsessions or compulsions. The patient’s posttraumatic stress disorder check list (PCL-5) supported a diagnosis of PTSD and demonstrated moderate clinical distress.

Clinical Pearl

While routine screening tools are not diagnostic, they can help clarify and support your diagnosis. Repeat use can also assist with symptom monitoring to access for treatment response and/or success [7].

Based on the patient’s initial assessment, he was diagnosed with PTSD. As noted above, there was evidence of PTSD-related unipolar depressive difficulties and potentially, an independent organic sleeping disorder. Treatment options were discussed, and the patient agreed to routine blood work and a sleep study to identify any comorbid organic contributions. He also agreed to a trial of a selective serotonin reuptake inhibitor (SSRI) for his anxiety and depressive symptoms along with prazosin at night to assist with nightmares. It was also agreed that after the patient’s acute symptoms of distress were improved with medication that he would engage in an evidence-based psychotherapy for PTSD. After describing prolonged exposure (PE) therapy and cognitive processing therapy (CPT), the patient opted to start the latter.

Only gold members can continue reading. Log In or Register to continue