The
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a withdrawn reclusive attitude, and nightmares.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.’s father
was a World War II veteran who served in the
European war theater and suffered from "traumatic
war neurosis." Mr. A.’s 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 the medication.
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.’s 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.’s 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.
References
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;
152: 1815-1818.
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. |
