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Diagnostic and therapeutic challenges involving patients with post-traumatic stress disorder and schizoaffective disorder depressive type

Post-traumatic stress disorder (PTSD) is typically characterised by intrusive recollections of a traumatic event, enhanced arousal and affective numbness. Other symptoms may occur, such as depressive, dissociative and psychotic symptoms, leading to a significant clinical heterogeneity. A 39-year-old man developed PTSD and schizoaffective disorder depressive type one year after a stressing event marked by extreme violence. He was prescribed with valproic acid 2 g per day and clozapine 800 mg per day, but because of the presence of a series of symptoms, such as anxiety, insomnia, anhedonia and blunted affect, lorazepam 6 mg per day and sertraline 50 mg per day were added. Despite the combination of drugs, the response was only partial and he evolved with progressive deterioration of intrusive and psychotic symptoms, including first-rank Schneiderian symptoms such as commanding voices and suicidal ideation. He was submitted to a comprehensive neuropsychological evaluation that was unrevealing. In our psychiatric outpatient clinic (Raul Soares Institute, Belo Horizonte, Brazil), there are other 11 cases with similar clinical features described for the above-mentioned patient. They include male gender, victim of physical aggression and history of other previous traumatic events, suicidality, poor insight, depressive symptoms with blunted affect. Interestingly, they had been diagnosed with a long series of psychiatric disorders, such as bipolar disorder, factitious disorder, dissociative disorder, borderline personality disorder and PTSD. They were also using similar pharmacological schemes, including mood stabilisers, atypical antipsychotics, benzodiazepines and serotonergic antidepressants. Despite treatment, these patients evolved with clinical deterioration marked by anhedonia, first-rank symptoms and social isolation. Some questions emerge from these clinical observations. First, why did these cases receive so many clinical diagnoses? We believe that this may not reflect poor clinical expertise considering that these diagnoses were performed by welltrained and experienced psychiatrists. Maybe they truly represent pure PTSD. Alternatively, cumulative traumatic events could have triggered psychosis. This is in line with the diathesis-stress model of schizophrenia, i.e. stress fostered a psychotic process in vulnerable subjects. In genetically predisposed individuals with dysfunctional hypothalamicpituitary axis, abnormal release of cortisol following a stressful situation would lead to dopaminergic activation and, as a consequence, to the development of psychotic symptoms (1). Indeed, there is a growing body of evidence establishing an association between PTSD and psychosis. For instance, associations were found between negative schematic beliefs, PTSD COMMENT & CRITIQUE