Psychotic and in pain

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CASE: Depressed and delusional

Mrs. P, age 58, is a retired art teacher who presents for inpatient psychiatric admission after an 8-month depressive and psychotic illness. She reports profound feelings of worthlessness, anhedonia, psychomotor retardation, daily spontaneous crying spells, and worsening suicidal ideation. She is unkempt, disheveled, and makes limited eye contact. She is floridly psychotic, exhibits hebephrenia at times, and appears to be having conversations with people who are not there. Mrs. P reports derogatory intracranial auditory hallucinations of her brother’s and father’s voices. She also describes a complex delusional system relating to sexual trauma she experienced as a child perpetrated by her brother. Her family corroborates some details of the trauma; however, she says her father, neighbors, pastor, and outpatient psychiatrist are involved. Mrs. P believes these individuals are members of a cult, she has been the victim of a satanic sexual rite, and a television news personality knows about this conspiracy and has been attempting to contact her.

Mrs. P suffers from severe, debilitating chronic pain experienced as shock-like pain lasting for several minutes that starts in her throat and radiates to her left ear. Her pain began several years ago and prompted a neurologic workup, including MRI of the head and somatosensory evoked potentials of the glossopharyngeal nerve. She was diagnosed with “probable” glossopharyngeal neuralgia and failed multiple medication trials, including carbamazepine, phenytoin, gabapentin, and amitriptyline. She underwent microvascular decompression surgery 3 years ago. The operation, which has an 80% to 90% success rate for neuralgias,^1,2 offered only brief symptomatic relief. She was maintained on immediate-release opiates until the pain became “unbearable” 8 months ago. This prompted a second neurologic workup, which was unremarkable. Mrs. P was diagnosed with pain disorder associated with psychological factors and a general medical condition.

Ten years ago she had 2 major depressive episodes with inpatient hospitalization and 2 suicide attempts within 1 year, but no history of psychosis before 8 months ago. Mrs. P’s husband says his wife has no history of manic or hypomanic episodes. Her medications are ziprasidone, 20 mg/d, thiothixene, 10 mg/d, benztropine, 3 mg/d, and escitalopram, 30 mg/d. She also receives oxycodone/acetaminophen, 5 mg/325 mg as needed for facial pain and headaches, and clonazepam, 1 mg as needed for panic attacks.

The authors’ observations

Psychosis can be a feature of any of the disorders listed in Table 1³; however, several features of Mrs. P’s illness led us to diagnose MDD, recurrent, severe with psychotic features.⁴ Mrs. P and her husband described several discreet episodes of major debilitating depression without alternating periods of hypomanic or manic symptoms (Table 2).⁴ Comorbid depressive symptoms and a timeline indicating persistence of psychotic symptoms make a brief psychotic episode less likely. Although uncommon, patients can develop psychotic or mood disorders as a result of opiate abuse or dependence. However, Mrs. P was taking opiates as prescribed and not asking for early refills, which makes substance abuse an unlikely cause of her psychosis. In addition, because Mrs. P had 2 major depressive episodes in the absence of opiate use, a primary mood disorder seemed the more appropriate diagnosis. Schizophrenia is ruled out based on history. Although Mrs. P was suffering from complex delusional constructs, auditory hallucinations, and grossly disorganized behavior, these symptoms occurred only within the context of her depressive episode. New-onset delusional guilt relating to her childhood sexual trauma and hypochondriacal preoccupations within the context of pain complaints make psychotic depression more likely.⁵

Table 1

Psychiatric diseases in which patients may present with psychotic symptoms

Table 2

DSM-IV-TR criteria for major depressive episode