national comorbidity study found a 7.8 percent
prevalence of PTSD in the general population (1).
The following case illustrates an interesting
pattern of comorbidity.
Mr. A., a 42-year-old Caucasian married male with
no prior psychiatric history, presented symptoms
of PTSD (Posttraumatic Stress Disorder) which
occurred after he sustained a gunshot wound to
his left arm while he was parking his car in front
of a fast food restaurant where he was working
as a manager. While he was approaching the parking
lot at 5:00 A.M., he noticed a small crowd of
what seemed to be gang members in the empty parking
lot. One of the men in the crowd pointed a handgun
at Mr. A. The patient made a fast turn and sped
away but was shot in his left deltoid area. He
was able to drive himself to a nearby hospital.
He underwent outpatient surgical removal of the
bullet from his left arm. After recovering from
general anesthesia, Mr. A. developed obsessive
recollections of the event, with occasional flashbacks
of different images of the shooting, insomnia,
a fear of approaching the geographical area of
the restaurant, a withdrawn reclusive attitude,
and nightmares. He developed a fear and avoidance
of fast food restaurants. Over the next few days,
symptoms of severe generalized anxiety, irritability,
and hypervigilance when spending time at home
alone set in. Approximately six weeks following
the shooting, Mr. A. developed severe dysphoria
and progressive psychomotor retardation. The diagnoses
of Posttraumatic Stress Disorder and Major Depression
were made. Mr. A.ís father was a World War II
veteran who served in the European war theater
and suffered from "traumatic war neurosis."
Mr. A.ís paternal grandfather had a history of
Manic Depressive illness. Treatment with Paroxetine
10 mg po q am was started. On Paroxetine 40 mg
per day the patient experienced a significant
improvement of affect/mood, sleep (six hours per
night), and a subsidence of dysphoria. Over the
next eighteen months the patient presented a fluctuating
clinical picture: while off Paroxetine he showed
a relapse of PTSD. After discontinuing Paroxetine
for the third time, the patient presented a rapid
onset of full depressive symptoms and a recurrence
of PTSD. Treatment with Paroxetine was reinstituted.
Three weeks later no significant response was
noted. Given the fact that a recurrent pattern
of the clinical picture was noticed, lithium carbonate
1200 mg per day was instituted. A blood level
of 0.85 was reached. On this combination of medications,
most symptoms cleared within two weeks. Symptoms
recurred on one occasion when the patient discontinued
Discussion: Fifty to ninety percent of patients
with PTSD (2,3) present comorbid anxiety, depressive,
substance abuse, or other psychiatric disorders.
However, a rather unusual pattern was noted in
Mr. A.ís case. He developed recurrent depression,
a condition known to be part of a "bipolar
spectrum," with a very endogenous pattern
of recurrence. In this case, the symptoms of PTSD
exhibited a periodicity that paralleled the cycles
of the depressive disorder, recurrent type.
Mr. A. has a family history of trauma. Prior contributions
(4) suggest that growing up with a family member
who suffered from PTSD or had a history of trauma
resulted in specific vulnerability to traumatic
stress. Mr. A. was able to resume function only
after long-term maintenance treatment with an
SSRI (known to be effective for symptoms of PTSD)
(5), and lithium. This case further supports the
current understanding of PTSD as a complex psychiatric
disorder. Alternative pathways in the formation
of memory (6), endocrine abnormalities (7) and
lifetime accumulation of stress (8) have all been
the subject of current research on this disorder.
A recent contribution suggests that anticonvulsants
may be effective in patients who are suffering
from Posttraumatic Stress Disorder (9). Mr. A.ís
case suggests that in certain predisposed individuals,
PTSD may involve a "phasic mechanism"
known to be at play in bipolar affective disorder
and depressive disorder, recurrent type. The possibility
that traumatic stress may open non-specific neurotransmitter
"gateways" that would render an individual
vulnerable to a number of psychiatric disorders
has to be further explored. The confirmation of
such a hypothesis would favor an early course
of preventive and broad spectrum (i.e., antidepressants,
mood stabilizers, beta blockers) psychopharmacological
intervention in traumatized individuals. Further
controlled studies on the effect of antidepressants
associated with mood stabilizers in PTSD, as maintenance
treatment, are necessary.
1. Kessler, R; Sonnega, A; Bromet, E; et al: Post
Traumatic Stress Disorder in the national comorbidity
survey. Arch J Psy 1995; 52: 1048-1060.
2. Freedy, J; Shaw, D; Jarrell, M: Towards an
understanding of the psychological impact of natural
disaster: An application of the conservation sources
stress model. J Traumatic Stress 1992; 5: 441-454.
3. Kulka, R; Schlenger, W; Fairbanks, J; et al:
Trauma and the Vietnam War generation: Report
of findings from the National Vietnam Veterans
Readjustment Study. New York, Bruner Marzel, 1990.
4. Nader, K: Effect of parents of previous trauma
on currently traumatized children. In: Danieli,
Y (ed): Handbook on Multigenerational Legacy of
Trauma, Plenum Press, in press.
5. Marshall, R; Stein, D; Liebowitz, M: A pharmacotherapy
algorithm in the treatment of post traumatic stress
disorder. Psychiatric Ann 1996; 26: 217-226.
6. Van der Kolk, B: Trauma and memory. In: Van
der Kolk, B; McFarlane, A; Waisaeth, L: Traumatic
stress. The effect of overwhelming experience
on mind, body, and society. The Gilford Press,
1996, New York.
7. Yehuda, R; Kahana, B; Binder-Brynes, K: Low
urinary cortisol excretion in Holocaust survivors
with Post Traumatic Stress Disorder. Am J Psychiatry
1995; 152: 982-986.
8. Yehuda, R; Kahana, B; Schmeidler, J: Impact
of cumulative life time trauma and recent stress
on current Post Traumatic Stress Disorder symptoms
in Holocaust survivors. Am J Psychiatry 1995;
9. Ford, N: The use of anticonvulsants in Post
Traumatic Stress Disorder: Case study and overview.
J of Traumatic Stress 1996; 4: 857-863.
©1997 by The American Academy
of Experts in Traumatic Stress, Inc.