Comorbidity of Post-traumatic Stress Disorder and Psychosis in Children: Diagnostic and Management Considerations: A Case Report

Abstract

The association of post-traumatic stress disorder (PTSD) with psychosis has important diagnostic and treatment implications. We present a case of a 13-year-old girl with illness duration of 3 months characterized by decreased social interaction, anger outbursts, decreased self-care, and separation anxiety with fearfulness and self-muttering behavior on serial observations pointing towards a possible psychotic disorder, which improved with risperidone 6 mg. Persistence of separation anxiety with possibility of trauma sequalae leads to diagnosis of PTSD. Attempt to taper antipsychotic resulted in the resurfacing of psychotic symptoms. She attained stable improvement with a combination of sertraline 150 mg and aripiprazole 20 mg.

Introduction

Early life trauma is a risk for development of both psychotic symptoms and post-traumatic stress disorder (PTSD). Traumatic events may include serious harm to self or others, accidents, natural disasters, sexual or physical trauma or violence. ¹ Children and adolescents react differently to stressful life events and thus their clinical presentation and experiences differ from those of adults. ² Evidence suggests that potentially traumatic events are more likely to go unnoticed and without receiving proper treatment in children than adults, thus could contribute to masquerading. Overlapping phenomena such as psychotic symptoms and perceptual abnormalities in trauma sequelae could be challenging to delineate.

Most of the studies about the association of PTSD and psychotic symptoms have been done in adult population.^3-6 Here, we present a case of a 13-year-old girl who presented with initial psychotic symptoms and later emergence of PTSD and describe key aspects of management in similar presentations.

Case Details

A 13-year-old female child presented with an illness duration of 3 months and subacute onset, characterized by decreased social interaction, hearing voices, suspiciousness about being harmed and her food being poisoned by someone, frequent anger outbursts, decreased self-care, and sleep disturbances. Intense separation anxiety was noted, and she often reported suicidal ideations and had one suicidal attempt. There was history of slow to warm up temperament, uneventful perinatal period, typical developmental milestones, family history of probable psychosis in maternal grandmother, past history of obsessive-compulsive symptoms for a period of 2 years that resolved spontaneously along with premorbid age-appropriate social interaction and functioning. She was given trials of multiple psychotropic medications including risperidone 2 mg, escitalopram up to 10 mg, fluoxetine up to 20 mg, clobazam 5 mg, and oxcarbamazepine up to 300 mg, all for inadequate duration, prior to current consultation.

On initial mental status examination, she was noncooperative, restless, and fearful, with poor eye contact, and decreased speech output. On serial observations over the next week, she was observed laughing inappropriately without any reason, talking, and gesturing to herself, fearful of new places and persons, along with periods of intense anxiety and suspiciousness and secondary avoidance behaviors. Most of the above symptoms along with the gradual academic decline suggested a possibility of psychosis due to which risperidone titrated up to 6 mg guided by clinical response. Blood work up (Complete hemogram, liver function test, renal function test, serum electrolytes, serum folate levels, serum vitamin B12 levels, thyroid function test, serum calcium, serum homocysteine. Evaluation for organic causes is routinely done in cases of suspected early onset psychosis.) and magnetic resonance imaging of brain were within normal limits. ⁷ Oxcarbamazepine and clobazam were stopped in view of no clear indications. The child improved in terms of speech output, self-care with decrease in anger outbursts and suspiciousness.

The psychotherapeutic interventions were based on an eclectic and integrated approach informed by principles of behavioral and developmental interventions. The initial 4–5 sessions were aimed at building rapport and engagement. She was predominantly self-absorbed, and at times refused engagement. Visual cues and activities such as drawing and coloring tasks were used as she was not verbally expressive, and parents were present in the sessions to help the child feel comfortable. Gradually she could be engaged in story and paragraph reading, listening to music, and brief discussions about “self.” Over the next 2 weeks, her reactivity improved. During this phase, she was amenable for further exploration of her fearfulness and anxiety. She reported of seeing a road traffic accident of her neighbor in front of her house that was later corroborated by her parents to have a temporal correlation with her symptoms. The person was run over by a truck while he was crossing the road ultimately leading to his death. Following the accident, she was fearful of going outside, especially on main roads and extending to not allowing her family members to go out. Even when taken outside by her parents, she would hold them tightly, walking on the extreme edge of road, and the behavior continued during the inpatient care. She was fearful of seeing blood during instances of phlebotomy for her and other kids in the ward. These symptoms explained the presence of anxiety on being separated from family members. She was noted to be highly sensitive to sounds and had frequent sleep disturbances due to nightmares, a repeated theme was seeing blood. Considering the possibility of comorbid PTSD, sertraline was added and gradually increased to 150 mg.

Following sessions were aimed at improving the child’s involvement in age-appropriate group activities. Graded separation from family members, managing anxious arousal, and engagement in age-appropriate activities was attempted. The child improved in terms of her fearfulness and clingy behavior with parents and brother. Sessions with parents focused on facilitating understanding about their child’s psychiatric illness and attuned responding to her anxiety. In view of risperidone induced hyperprolactinemia (52.5 ng/ml) dose-reduction was planned. On tapering risperidone, she had major worsening of symptoms of smiling to herself and inappropriate laughter, decrease in speech output, social withdrawal, and poor self-care. Risperidone was cross-tapered with aripiprazole on which she showed gradual improvement and was discharged on a combination of aripiprazole 20 mg and sertraline 150 mg. Improvement was noted in all dimensions over the next few months with the child returning back to school and had improved interaction with her peers.

Discussion

In this case, predominant psychotic symptoms along with decreased verbal expressivity, difficulty in engagement at presentation were challenges faced in exploring the psychopathology in the initial phase. Treatment with antipsychotics resulted in initial improvement of psychotic symptoms with persisting symptoms of separation anxiety, hypervigilance, and temporal correlation with a traumatic event, warranting consideration of PTSD. The separation anxiety was mainly triggered by the traumatic events, subsequently leading to avoidance of trauma reminders. Studies have reported separation anxiety to be a predictor for PTSD and also having a strong association as a comorbidity. ⁸ Though sertraline improved the anxiety symptoms, an attempt to reduce antipsychotic resulted in worsening/resurfacing of psychotic symptoms, indicating psychosis as a comorbidity. Decisions related to long-term pharmacotherapy posed a challenge in this case.

A number of models have been proposed to highlight the connection between trauma, PTSD, and psychotic disorder. One model suggests that PTSD and psychotic disorder are seen as distinct disorders that interact with one another creating compounded risk for increased psychotic and PTSD symptoms. ⁹ Another model proposes that PTSD and psychosis are similar entities that are part of a broader spectrum of reactions to trauma. ¹⁰ Thus, the identification of psychotic symptoms and their classification may be important for treatment considerations. If the psychotic symptoms are secondary to PTSD, then treating the PTSD may decrease the psychotic symptoms. ¹¹ If the symptoms of PTSD occur along with the psychotic symptoms, then a course of antipsychotic along with management of PTSD symptoms by means of medication or psychotherapy may be needed. PTSD comorbidity in early onset psychosis is high. ¹² Hence, such presentations call for continued exploration and longitudinal approach to diagnosis and management.