Paroxetine HCL and Lithium in the Treatment of PTSD
with Comorbid Depressive Disorder Recurrent Type
Andrei Novac, M.D.


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of different images of the shooting, insomnia, a fear of approaching the geographical area of the restaurant, a withdrawn reclusive attitude, and nightmares.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.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 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.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.


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.