Instead, Mr. M may have had complex PTSD secondary to 10 years of abuse by a partner and lifelong abuse by his mother, with drug-induced psychotic symptoms. PTSD can mimic schizoaffective disorder and schizophrenia (Table), and DSM-IV trains us to manage the differential diagnosis first. Mr. M’s revelation about his abusive mother could have raised suspicion of PTSD, but I was targeting apparent psychotic symptoms.
Mr. M’s shame over being gay and his inability to discuss his guilt with family and friends likely contributed to his isolation and perpetuated both the abuse and psychiatric symptoms. Although his ex-partner’s death ended an abusive relationship, his mother’s ongoing abuse prolonged its emotional effects.
If Mr. M. had not revealed his mother’s aggression—in response to a question about his abusive behavior—his psychiatric symptoms may have continued unabated. For years, despite many psychiatric consultations and hospitalizations, Mr. M kept his abusive relationships a secret.
Ask patients about ongoing physical, sexual, and emotional abuse as part of the initial evaluation. Even if the patient denies abuse at first, he or she may reveal this information as the therapeutic alliance develops. As treatment continues—particularly when the patient seems more stressed—ask again about abuse by or toward the patient. If necessary, be direct: “Is anyone hitting or hurting you in any way? Are you hurting someone else in any way?”
Building an alliance
Although clinicians often harbor low expectations for chronically ill patients, I believe that recovery from major psychiatric illness is possible.
Whatever his diagnosis, a strong therapeutic alliance hastened Mr. M’s recovery. Respecting his treatment goals, enhancing motivation to change, being his advocate, and considering alternate diagnoses helped me gain his trust (Box). Because I accepted responsibility for Mr. M’s prescription problems, for example, he sensed that I was on his side. This trust may have ultimately encouraged him to share secrets with me that he had not told other psychiatrists.
Related resources
- National Center for Post-Traumatic Stress Disorder. www.ncptsd.org
- Heim C, Meinlschmidt G, Nemeroff CB. Neurobiology of early-life stress. Psychiatric Annals 2003;33(1):18-26.
- Yehuda R. Post-traumatic stress disorder. N Engl J Med 2002;346:108-14.
Drug brand names
- Bupropion • Wellbutrin
- Divalproex • Depakote
- Lorazepam •Ativan
- Olanzapine • Zyprexa
- Ziprasidone • Geodon
Disclosure
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
The author thanks Mr. M for permission to publish this case report.