Abstract
Stefan Kropp, Jann Schlimme, Udo Schneider, Department of Clinical Psychiatry and Psychotherapy, Hanover Medical School, Germany:
We report the case of a 79-year-old, white married patient, who on admission revealed that she was weary of life. On mental state examinations she was alert, clearthinking and orientated. Formal thinking was coherent, the contents of which showed a marked delusion of poverty without any indication of hallucination. The patient suffered a severe lack of motivation and showed only fleeting signs of emotion. Psychomotor inhibition was prominent. She admitted to continual suicidal thoughts, although lacked the drive to carry out such an attempt. Hamilton Depression Rating Score (HAMD) was 41 points on admission. Relatives reported her screaming out in terror while asleep. Medical history included chronic obstructive lung disease, hyperthyroidism (now stable) and osteoporosis. A subcortical arteriosclerotic encephalopathy was apparent in magnetic resonance imaging.
Throughout World War II, the patient was in hiding in Germany because she was Jewish, and was in constant fear of being detected and deported. Her father and all other members of the family except her mother did not survive the war and the extermination of the Jews.
Despite initial treatment with 30 mg mirtazapine and 2 mg risperidone her condition worsened. The patient became distraught, withdrew into herself, refused to accept any form of liquid or nourishment and became incontinent. She lost orientation as to time, place or person. She was preoccupied with the thought that someone was waiting to kill her. This disturbance of consciousness was most likely associated with flashbacks which occur in patients with posttraumatic stress disorder (PTSD; meeting DSM-IV criteria) and which is common in Holocaust survivors [1, 2]. This was probably triggered off by dehydration, exacerbating the subcortical arteriosclerotic encephalopathy. Due to her poor health, all medication was discontinued. She received medical care and her condition stabilized. Then further treatment was started with 75 mg of sertraline due to its proven efficacy on delusional symptoms in depression [3], combined with a kava-extract containing product. After 2 weeks of symptoms such as anxiety and delusions improved, while no severe side-effects were observed. She regained her sense of orientation and no longer had suicidal ideas. She still suffered with a mild degree of delusion of poverty; however, HAMD dropped to 12 points and the patient was discharged home in a satisfactory condition. In conclusion, selective serotonin re-uptake inhibitor (SSRI) treatment of PTSD-associated major depression seems to be effective and further study might clarify the role of SSRIs in the treatment of this disease.