Citation

Montefiore D, Mallet L, Levy R, Allilaire JF, Pélissolo A. Encephale (1974) 2007; 33(3): 352-355.

Copyright

(Copyright © 2007, Masson Editeur)

DOI

10.1016/S0013-7006(07)92050-3

PMID

unavailable

Abstract

Background - Post-traumatic stress disorder (PTSD) is often associated with other psychiatric syndromes. However, studies exploring conversion and PTSD comorbidity are scarce. Case-report - This paper reports the case of a 45 year-old patient without medical or psychiatric history. In 2003, he suddenly started suffering from amnesia and symptoms of delirium : he was at his office with a cup of coffee but he did not remember why. Aphasia, trembling, behavioural disorders appeared over the next hours and days. Numerous neurological examinations and laboratory tests (including cerebral imagery) were performed without evidence of any physical disease. Three psychiatric examinations were also negative, even if a possible psychogenic origin was hypothesized. Neurological or psychiatric diagnoses were discussed but without definitive conclusion. One year later, the symptoms were unchanged until the patient watched a movie (" Mystic River ") that described the story of a man with sexual abuse in childhood. He suddenly remembered that he lived the same experience when he was 8 years old. At the end of the movie, his wife surprisingly noticed that he was walking and speaking normally. All the neurological symptoms disappeared. Unfortunately, symptoms of a severe PTSD appeared, as well as a major depressive disorder. The patient and his parents remembered that he had been more irritable, depressed and anxious at school and during the night, between 8 and 13 years of age, with a possible PTSD during this period. He always refused to talk with his parents about the traumatic event. When he was 13, the family moved house, the patient seemed to forget everything and the symptoms disappeared. About thirty years later, the symptoms were similar with the reexperien of the traumatic event through unwanted recollections, distressing images, nightmares, or flashbacks. He had also symptoms of hyperarousal with physiological manifestations, such as irritability, insomnia, impaired concentration, hypervigilance, and increased startle reactions. Hospitalisation became necessary because of a severe depressive disorder with suicidal ideation and suicidal attempt by hanging. After two failed treatments with SSRI antidepressants, the administration of clomipramine (200 mg/d) and a combined therapy with Eyes Movement Desensitization and Reprocessing (EMDR) led to a significant improvement of PTSD and depression symptoms.

DISCUSSION - Even if PTSD and conversion may share common dissociative mechanisms, the links between both syndromes have not yet been sufficiently explored. Our clinical case raises specifically the question of the initial manifestations of pseudo-dementia (why this type of symptoms, and why at this particular moment of his life, without any targeting events). Moreover, the case of this patient is particularly interesting because of the very long amnesia period between the traumatic event and the onset of PTSD.

CONCLUSION - The different phases of this case warrant more precise exploration of the links between PTSD and conversion, with clinical, epidemiological and cerebral imagery perspectives.; Indications:1 patient with refractory post-traumatic stress disorder, pseudo-dementia conversion disorder, and major depressive disorder.; Patients:One 45-year-old inpatient.; TypeofStudy:A case of post-traumatic stress disorder (PTSD) and pseudo-dementia conversion disorder that was successfully treated with combined therapy of Anafranil and eye movement desensitization and reprocessing (EMDR) was reported.; DosageDuration:150 mg daily. Duration not stated.; Results:Anafranil and EMDR led to a significant improvement of symptoms of PTSD and depression.; AdverseEffects:No adverse events were mentioned.; FreeText:The patient started to experience restlessness, amnesia, and symptoms of delirium in 2002. The symptoms worsened during the following days with fluctuating aphasia. Some motor symptoms appeared weeks later, marked by weakness, tremors, and ataxia. Neuropsychological test revealed deterioration of intelligence and an aphasic syndrome. The symptoms remain steady for about a year. Several psychiatric examinations revealed a depressive syndrome and anxiety disorder with a score of 26-60 in the Montgomery-Asberg Depression rating Scale (MADRS). In December 2003, the symptoms were unchanged until the patient watched a movie (Mystic River) that described the story of a man with sexual abuse in childhood. He suddenly remembered that he had the same experience when he was 8 years old. At the end of the movie, his wife surprisingly noticed that he was walking and speaking normally. All the neurological symptoms disappeared. Unfortunately, symptoms of a severe PTSD appeared, as well as a major depressive disorder. The patient and his parents remembered that he had been more irritable, depressed and anxious at school and during the night, between 8 and 13 years of age, with a possible PTSD during this period. He refused to talk with his parents about the traumatic event. When he was 13, the family moved to another place and the patient seemed to forget everything and the symptoms disappeared. About 31 years later, similar symptoms reappeared through recollection of the traumatic events, distressing images, nightmares, or flashbacks. He had also symptoms of hyperarousal with physiological manifestations, such as irritability, insomnia, impaired concentration, hypervigilance, and increased startle reactions. The patient was diagnosed with severe major depressive disorder with PTSD. The patient attempted suicide. He was treated with paroxetine and sertraline with only partial improvement. Anafranil was then started in combination with Eye Movement Desensitization and Reprocessing (EMDR).

Language: fr

Keywords

adult; human; sexual abuse; female; case report; insomnia; Sexual abuse; Post-traumatic stress disorder; suicidal ideation; depression; anxiety; school; suicide attempt; major depression; conversion disorder; hospitalization; comorbidity; disease severity; posttraumatic stress disorder; neuroimaging; article; behavior disorder; clomipramine; serotonin uptake inhibitor; age distribution; psychiatric diagnosis; alertness; irritability; delirium; neurologic disease; symptom; Conversion; amnesia; desensitization; laboratory test; intellectual impairment; neurologic examination; aphasia; drug treatment failure; pseudodementia; Amnesia; eye movement; bladder irritation