Psychiatric Annals

Case Report 

A Case of Psychosis and Dissociation in a 38-Year-Old Woman

Navjot Brainch, MD; Sanya Virani, MD, MPH; Felix Torres, MD; Maria Bodic, MD; Deval Zaveri, MD

Abstract

The patient was a 38-year-old woman with an unknown past psychiatric history. She was brought to the emergency department (ED) via ambulance due to apparent psychotic decompensation in the context of medication noncompliance. In her initial interview she introduced herself as a 12-year-old girl, then claimed to be a different person (it was later concluded that she was alluding to her sister), and then stated that she had moved to New York 5 days prior to presentation to the ED to live with her family. She explained that she had arrived to help take care of a family member but, finding herself unable to do so, had handed the child over to a neighbor. She further reported that she was in the third grade and wanted to go back to school and eventually home to her mother. She claimed that she hailed from a town where there were “grass and snakes.”

The initial interview was conducted in both English and Spanish, with the assistance of an interpreter to ease the patient into the process of being triaged in the ED. Although known to be a native Spanish speaker, the patient claimed to not understand what the interpreter was conveying to her. Not only was collateral information unavailable, but no information could be obtained from two patient databases (the New York State Psychiatric Services Clinical Knowledge Enhancement System for Medicaid and the DrFirst MedHx medication history data source) either.

With a limited perspective about the patient's current presentation and no understanding of her functioning in the community, the team sought social work assistance to find her family or friends for more information and to confirm her demographic details. Coincidentally, staff from the inpatient unit that happened to be posted in the ED later that day recognized her from one of her past hospitalizations, during which she had presented in a similar fashion. Inpatient records were retrieved using what was known from staff about the patient's identity. Based on review of these records and conclusions by providers that the patient's current presentation was a deviation from the baseline, she was emergently hospitalized for her own safety and symptomatic stabilization.

At the time of her ED visit 2 years prior, a regular screen for urine pregnancy had come back positive but she had repeatedly denied being pregnant at the time. To rule out the possibility of a false-positive test result, a quantitative beta-human chorionic gonadotropin test was performed and the levels obtained were 32,108 mIU/mL, suggesting a viable pregnancy. Other routine laboratory results were within normal limits. An ultrasound performed by the obstetrics team on the inpatient unit revealed an intrauterine pregnancy of 16 weeks. When the patient reconciled with the fact that she was pregnant, she refused to clarify who fathered her child. She kept providing unconfirmed locations as her addresses. A family meeting was convened with her husband, who reported that the patient had been “depressed” for 2 months prior to the hospital visit and had been spending most of her day sleeping and eating. Around that time, she had allegedly started claiming that her children were not her own. A case was opened with Child Protective Services when she made statements about her not being the mother of her children. During this admission, she displayed prominent symptoms of psychosis, present for at least 2 months duration. Because her symptoms started approximately 17 months after giving birth, postpartum psychosis was ruled out.1 She was given haloperidol at a starting dose of 2.5 mg orally and the dose was titrated upwards; however, due to the emergence of extrapyramidal symptoms (EPS) the dose…

The patient was a 38-year-old woman with an unknown past psychiatric history. She was brought to the emergency department (ED) via ambulance due to apparent psychotic decompensation in the context of medication noncompliance. In her initial interview she introduced herself as a 12-year-old girl, then claimed to be a different person (it was later concluded that she was alluding to her sister), and then stated that she had moved to New York 5 days prior to presentation to the ED to live with her family. She explained that she had arrived to help take care of a family member but, finding herself unable to do so, had handed the child over to a neighbor. She further reported that she was in the third grade and wanted to go back to school and eventually home to her mother. She claimed that she hailed from a town where there were “grass and snakes.”

The initial interview was conducted in both English and Spanish, with the assistance of an interpreter to ease the patient into the process of being triaged in the ED. Although known to be a native Spanish speaker, the patient claimed to not understand what the interpreter was conveying to her. Not only was collateral information unavailable, but no information could be obtained from two patient databases (the New York State Psychiatric Services Clinical Knowledge Enhancement System for Medicaid and the DrFirst MedHx medication history data source) either.

With a limited perspective about the patient's current presentation and no understanding of her functioning in the community, the team sought social work assistance to find her family or friends for more information and to confirm her demographic details. Coincidentally, staff from the inpatient unit that happened to be posted in the ED later that day recognized her from one of her past hospitalizations, during which she had presented in a similar fashion. Inpatient records were retrieved using what was known from staff about the patient's identity. Based on review of these records and conclusions by providers that the patient's current presentation was a deviation from the baseline, she was emergently hospitalized for her own safety and symptomatic stabilization.

Information from Previous Admission

At the time of her ED visit 2 years prior, a regular screen for urine pregnancy had come back positive but she had repeatedly denied being pregnant at the time. To rule out the possibility of a false-positive test result, a quantitative beta-human chorionic gonadotropin test was performed and the levels obtained were 32,108 mIU/mL, suggesting a viable pregnancy. Other routine laboratory results were within normal limits. An ultrasound performed by the obstetrics team on the inpatient unit revealed an intrauterine pregnancy of 16 weeks. When the patient reconciled with the fact that she was pregnant, she refused to clarify who fathered her child. She kept providing unconfirmed locations as her addresses. A family meeting was convened with her husband, who reported that the patient had been “depressed” for 2 months prior to the hospital visit and had been spending most of her day sleeping and eating. Around that time, she had allegedly started claiming that her children were not her own. A case was opened with Child Protective Services when she made statements about her not being the mother of her children. During this admission, she displayed prominent symptoms of psychosis, present for at least 2 months duration. Because her symptoms started approximately 17 months after giving birth, postpartum psychosis was ruled out.1 She was given haloperidol at a starting dose of 2.5 mg orally and the dose was titrated upwards; however, due to the emergence of extrapyramidal symptoms (EPS) the dose of haloperidol was reduced to 5 mg orally every night at bedtime.

Over the next few days, she showed significant improvement and started recognizing her husband and children and consistently accepted her pregnancy. Her husband was supportive and agreed with a plan of outpatient psychiatric follow-up care. She was able to perform daily activities independently and mindfully continued to inquire about the well-being of her family. She was deemed to not be an acute risk to herself and was discharged with a plan to follow up with psychiatry and with perinatal care by the obstetrics team.

Current Admission

Repeated attempts were made to contact the family. The team spoke to the patient's sibling who confirmed that the patient had assumed her identity. The patient had been living with her for 2 months since she was estranged from her husband and children, who no longer lived in the United States.

On subsequent evaluations during her hospitalization, the patient continued to state her sister's name as her own and steadfastly held on to her complex delusional framework even when confronted with contradictory evidence like her passport. She did not score positive on the Dissociative Experiences Scale (DES) and the Dissociative Disorders Interview Schedule – Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DDIS-DSM-5).2 Repeated diagnostic interviews exemplified significant thought disorder with subtle inconsistencies in her stories, inappropriate affect, impaired reality testing, and poor judgment. Interestingly, during both hospitalizations, she identified herself as one of her siblings and used nonexistent but similar home addresses.

Treatment

The patient failed trials with perphenazine and aripiprazole in combination with fluoxetine, and from past admissions was known to have not tolerated haloperidol at oral doses of more than 5 mg orally once daily because of EPS. Olanzapine and risperidone were avoided because of their side effect profile, metabolic effects, and EPS.

Because of the patient's history of failed neuroleptic trials, she was started on a combination of clozapine and fluoxetine and showed some initial improvement. She started acknowledging herself by her original name but continued to believe that she was age 12 years. On one occasion, however, she gave yet another name, this time with the same first name but a different last name. A couple of weeks into the hospitalization, she also noted that these three names actually belonged to her sisters. Clozapine dosage was titrated up to 400 mg orally once daily. When clozapine levels were found to be supratherapeutic, possibly due to interaction with fluoxetine, the dosage was subsequently decreased to 200 mg orally once daily. Fluoxetine was tapered and replaced with escitalopram. After this change in medication, the patient slowly started displaying appropriate self-care in a supervised setting, was able to tolerate somewhat longer conversations, and even confrontations and clarifications, by her sister and providers.

However, she continued to identify herself by her sister's name, and expressed delusions that her sister, who looked similar to her, was actually admitted to another unit on another floor during the same time and that they were being mistaken for the other.

Given that she still warranted longer inpatient hospitalization for gradual and consistent improvement, she was transferred from our acute care facility to a state hospital

Discussion

An acute decompensation of a psychotic illness with assumptions of alternate identities after stressful events could be easily confused with dissociative disorders (DDs). In the DSM-5, schizophrenia spectrum disorders (SSDs) and DDs are two separate entities with no consideration for potential overlap or relatedness between these conditions.2 This article described an interesting case of SSD that presented with two long dissociative episodes.

Potential differential diagnoses included SSDs, DDs (dissociative identity disorder, dissociative amnesia), malingering, factitious disorder, postpartum psychosis, bipolar disorder with psychotic features, complex partial seizure, depressive disorder (atypical), borderline personality disorder, and posttraumatic stress disorder. The top four differential diagnoses for this case, as determined by the treatment team, are listed with their DSM-5 criteria2 in Table 1.

Four Possible Differential Diagnoses

Table 1:

Four Possible Differential Diagnoses

There was no report of manic or hypomanic symptoms currently or in the past, which excluded the diagnosis of bipolar disorder with psychotic features. Furthermore, no active or past medical comorbidities that could have contributed to her current psychotic presentation were identified.

It is not clear when the symptoms of psychosis (delusions, disorganization) started during this admission, but they were prominently noticed at least 12 months after childbirth. The blurred the timeline of the onset of symptoms makes it difficult to rule out postpartum psychosis.

She also did not meet criteria for DD because there was no concrete disruption of identity with two or more distinct personality states during the same time frame, and no obvious switch from one identity to another was noted. There was a distinct lack of sense of self and gaps in recall of significant events including important personal information. The patient instead met DSM-5 criteria of schizophrenia due to delusions of identity, disorganized speech, disorganized behavior, and inappropriate affect.2

A literature search yielded support for significant symptom overlap between SSDs and DDs.3–6 Between 25% and 50% of patients diagnosed with DDs had a previous diagnosis of schizophrenia,7 and between 9% and 50% of people diagnosed with SSDs8–10 met criteria for diagnosis of DDs. These findings have prompted recent proposals for a new diagnostic subtype. The strong linkage of childhood trauma to dissociative episodes in schizophrenia, which is considered strong antecedent for DDs, further supports the connection between the two diagnosis types.11–13 In this case, each long-lasting episode of dissociation occurred in the context of significant stressful events (unplanned pregnancy, marital discord, husband taking away her children). The results of the DES and the DDIS-DSM-5, together with the lack of alternation between distinct personalities and the predominantly disorganized behavior across both hospitalizations, pointed toward the dissociative symptoms occurring as manifestations of a SSD rather than a DD.

The differences in treatment choice, with a focus on psychotherapy (mainly cognitive-behavioral therapy and dialectical behavioral therapy) for DDs and on pharmacotherapy for SSDs, and the reports of emergence of dissociative episodes with antipsychotics14–16 further complicated the management of these types of cases. The literature bears evidence that selective serotonin reuptake inhibitors, beta-blockers, clonidine, atypical antipsychotics, prazosin, carbamazepine and other mood stabilizers, and naltrexone have achieved some success in reducing anxiety, aggression, intrusive symptoms, self-injurious behaviors, and mood symptoms without any direct effect on dissociation.16,17 In this case, patient engagement was limited to psychotherapeutic modalities, making the management strategy less than optimal.

Conclusion

We conclude that in cases of psychosis presenting somewhat less traditionally and with dissociative symptoms, it is important to be cognizant of all differential diagnoses, including DDs, and to perform thorough assessments to tease out factors contributing to underlying psychosis. Further research is warranted to document such unique cases to aide in diagnosing them confidently and determining appropriate management strategies to target these symptoms.

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision]. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  3. Renard SB, Huntjens RJ, Lysaker PH, Moskowitz A, Aleman A, Pijnenborg GH. Unique and overlapping symptoms in schizophrenia spectrum and dissociative disorders in relation to models of psychopathology: a systematic review. Schizophr Bull.2017;43(1):108–121. https://doi.org/10.1093/schbul/sbw063 PMID: doi:10.1093/schbul/sbw063 [CrossRef]
  4. Spitzer C, Haug HJ, Freyberger HJ. Dissociative symptoms in schizophrenic patients with positive and negative symptoms. Psychopathology. 1997;30(2):67–75. https://doi.org/10.1159/000285031 PMID: doi:10.1159/000285031 [CrossRef]
  5. Foote B, Park J. Dissociative identity disorder and schizophrenia: differential diagnosis and theoretical issues. Curr Psychiatry Rep. 2008;10(3):217–222. https://doi.org/10.1007/s11920-008-0036-z PMID: doi:10.1007/s11920-008-0036-z [CrossRef]
  6. Devillé C, Moeglin C, Sentissi O. Dissociative disorders: between neurosis and psychosis. Case Rep Psychiatry. 2014; 2014:425892. https://doi.org/10.1155/2014/425892 PMID:25405051
  7. Ross A. Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment of Multiple Personality. 2nd ed. New York, NY: John Wiley & Sons; 1997.
  8. Haugen MC, Castillo RJ. Unrecognized dissociation in psychotic outpatients and implications of ethnicity. J Nerv Ment Dis. 1999;187(12):751–754. https://doi.org/10.1097/00005053-199912000-00007 PMID: doi:10.1097/00005053-199912000-00007 [CrossRef]
  9. Moise J, Leichner P. Prevalence of dissociative symptoms and disorders within an adult outpatient population with schizophrenia. Dissociation. 1996;9:190–196.
  10. Ross CA, Keyes B. Dissociation and schizophrenia. J Trauma Dissociation. 2004;5(3):69–83. https://doi.org/10.1300/J229v05n03_05 doi:10.1300/J229v05n03_05 [CrossRef]
  11. Schäfer I, Harfst T, Aderhold V, et al. Childhood trauma and dissociation in female patients with schizophrenia spectrum disorders: an exploratory study. J Nerv Ment Dis. 2006;194(2):135–138. https://doi.org/10.1097/01.nmd.0000198199.57512.84 PMID: doi:10.1097/01.nmd.0000198199.57512.84 [CrossRef]
  12. Varese F, Smeets F, Drukker M, et al. Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophr Bull. 2012;38(4):661–671. https://doi.org/10.1093/schbul/sbs050 PMID: doi:10.1093/schbul/sbs050 [CrossRef]
  13. Harangozó J, Szita B, Bese B, et al. Trauma, dissociation, schizophrenia, and the split mind of professionals. Ann Psychiatry Ment Health. 2015;3(6):1044.
  14. Brauer R, Harrow M, Tucker GJ. Depersonalization phenomena in psychiatric patients. Br J Psychiatry. 1970;117(540):509–515. https://doi.org/10.1192/bjp.117.540.509 PMID: doi:10.1192/bjp.117.540.509 [CrossRef]
  15. Sarkar J, Jones N, Sullivan G. A case of depersonalization-derealization syndrome during treatment with quetiapine. J Psychopharmacol. 2001;15(3):209–211. https://doi.org/10.1177/026988110101500309 PMID: doi:10.1177/026988110101500309 [CrossRef]
  16. Sadock BJ, Sadock VA. Kaplan and Sadock's Comprehensive Book of Psychiatry. 7th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2000.
  17. Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL. Massachusetts General Hospital Comprehensive Clinical Psychiatry. Waltham, MA: Elsevier Health Sciences; 2008.

Four Possible Differential Diagnoses

Schizophrenia Dissociative identity disorder
<list-item>

Two or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): <list-item>

Delusions

</list-item><list-item>

Hallucinations

</list-item><list-item>

Disorganized speech

</list-item><list-item>

Grossly disorganized or catatonic behavior

</list-item><list-item>

Negative symptoms

</list-item>

</list-item><list-item>

The level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset

</list-item><list-item>

Continuous signs of the disturbance persist for at least 6 months. This must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A and may include periods of prodromal or residual symptoms

</list-item><list-item>

Not due to direct physiological effects of a substance or medical condition

</list-item><list-item>

With history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated)

</list-item>
<list-item>

Disruption of identity characterized by two or more distinct personality states. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning

</list-item><list-item>

Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that is inconsistent with ordinary forgetting

</list-item><list-item>

It causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

</list-item><list-item>

Not a normal part of accepted cultural or religious practice

</list-item><list-item>

Not due to the physiological effects of a substance or other medical condition.

</list-item>
Dissociative amnesia <list-item>

Unconsciously unable to recall autobiographical memory associated with a traumatic event

</list-item><list-item>

This inability to recall creates distress

</list-item><list-item>

Not due to a physiological cause

</list-item><list-item>

Dissociative identity disorder is excluded

</list-item><list-item>

Is not a result of substance abuse or other substance

</list-item>
Malingering <list-item>

The intentional production of false or grossly exaggerated physical or psychological problems

</list-item><list-item>

Motivation for malingering is usually external (eg, avoiding military duty or work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs)

</list-item>
Authors

Navjot Brainch, MD, is an Addiction Psychiatry Fellow, Mount Sinai Beth Israel. Sanya Virani, MD, MPH, is a Resident, Department of Psychiatry, Maimonides Medical Center. Felix Torres, MD, is the Vice Chair of Acute Care Services and the Director of Electroconvulsive Therapy Services, Department of Psychiatry, Maimonides Medical Center. Maria Bodic, MD, is a Psychiatrist, Department of Psychiatry, Maimonides Medical Center. Deval Zaveri, MD, is the Unit Director, Adult Psychiatry, Department of Psychiatry, Maimonides Medical Center.

Address correspondence to Navjot Brainch MD, Mount Sinai Beth Israel, 10 Nathan D. Perlman Place, Bernstein Pavilion, New York, NY, 10003; email: navjot.brainch@gmail.com.

Disclaimer: The Maimonides Institutional Review Board/Research Committee determined that this activity does not meet the definition of human research.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20190716-01

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