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Cases that Test Your Skills


Psychotic and in pain

Mrs. P, age 58, has a history of depression, suicide attempts, and chronic pain. Eight months ago she developed psychotic symptoms. How would you treat her?

Vol. 11, No. 04 / April 2012
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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

Bipolar depression

Borderline personality disorder

Brief psychotic disorder

Delirium

Delusional disorder

Dementia

Major depressive disorder

Psychotic disorder due to a general medical condition

Schizoaffective disorder

Schizophrenia

Shared psychotic disorder

Substance-induced psychosis

Source: Reference 3

Table 2

DSM-IV-TR criteria for major depressive episode

  1. ≥5 of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure
  2. Symptoms do not meet criteria for a mixed episode
  3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
  4. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, hypothyroidism)
  5. The symptoms are not better accounted for by bereavement, ie, after the loss of a loved one, the symptoms persist for >2 months, or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation

Source: Reference 4

Depression, psychosis, and pain

From the beginning of Mrs. P’s treatment, we considered psychotic depression worsened—if not completely explained—her pain. Her somatic complaints appeared to be subtly woven into her delusional constructs. For instance, she complained that a device had been implanted in her head and she had the scar to prove it, pointing to the scar from her microvascular decompression surgery. Research indicates that depressive illness and chronic pain syndromes are highly comorbid and depressive illness can worsen pain syndromes.6,7 In addition, Mrs. P failed several medical and 1 surgical interventions for her pain condition that had high success rates. Her husband notes that when her outpatient psychiatrist started olanzapine 3 months ago for emerging psychotic symptoms, her pain complaints initially decreased with her psychotic symptoms, and she used less opiate medication during that time. Several months later Mrs. P’s pain complaints increased as her psychotic symptoms worsened. Second-generation antipsychotics have been evaluated as treatment for chronic pain syndromes, and may exert a primary analgesic effect.8,9 However, because of the correlation between her fluctuating psychotic symptoms and pain complaints, the more plausible explanation for olanzapine’s initial efficacy in treating Mrs. P’s pain is a secondary analgesic effect from decreased psychotic somatic preoccupation.

TREATMENT: ECT

Mrs. P is admitted to the inpatient psychiatric unit and placed on suicide precautions. Oxycodone/acetaminophen and clonazepam are tapered and limited to twice daily as needed. Escitalopram is tapered and discontinued. Thiothixene is tapered and replaced by olanzapine, 5 mg/d. Mrs. P receives 3 bifrontal, brief pulse-width ECT treatments. These result in marked improvement in her depressive and psychotic symptoms. In addition, her pain complaints become minimal. She becomes less preoccupied with her sexual trauma and grows to trust many staff members whom she previously believed were part of her traumatic childhood events. Mrs. P is no longer suicidal and asks to continue ECT treatments as an outpatient. She is discharged on olanzapine, 5 mg/d, trazodone, 100 mg/d for insomnia, benztropine, 2 mg/d, clonazepam 0.5 mg twice daily as needed for panic attacks, and oxycodone/acetaminophen, 5 mg/325 mg twice daily as needed for pain.

The authors’ observations

According to the Harvard South Shore Algorithm, treatment strategies for psychotic depression include antidepressant and antipsychotic combinations, lithium augmentation, clozapine, and ECT.10 Several factors made ECT the best option for Mrs. P. She had failed multiple treatment strategies and was suicidal. ECT is an effective treatment for MDD with psychotic features, single or recurrent episode.11 ECT can be used as a primary treatment before psychotropic medications or secondarily when there has been lack of clinical response to medications, intolerable side effects, deterioration in psychiatric condition, or suicidality.11,12 In addition, when treated with ECT, psychotic depression has a significantly higher remission rate than major depression without psychosis.12 Delusional guilt, psychomotor retardation, hypochondriacal preoccupations, loss of insight, paranoia, and obsessive-compulsive symptoms predict a favorable response.12 ECT also has demonstrated efficacy for treating pain secondary to psychotic depression or melancholic depression.13 In addition, ECT has been shown to have analgesic properties beyond treating underlying depression.14 Our primary focus was not to treat Mrs. P’s pain syndrome with ECT; however, in treating her psychotic depression we had hoped that her pain tolerance would improve and she would rely less on opiates.

OUTCOME: Pain relief

As an outpatient, Mrs. P receives 11 bifrontal ECT treatments in her initial series, followed by 7 bifrontal maintenance treatments. Her speech is more spontaneous, her grooming and hygiene improve, and she exhibits a brighter and more reactive affect. Suicidal ideation has resolved. Pain improves from a “10 out of 10” to a “2 out of 10.” Mrs. P consistently requires less oxycodone/acetaminophen. She relates better to her family and begins exploring new hobbies such as pottery. In addition to monthly maintenance bifrontal ECT treatments, she is stable on citalopram, 60 mg/d, and trazodone, 50 mg/d as needed for insomnia.

The authors’ observations

The relationship between depressive illness and chronic pain is complex. Treating a primary depressive illness can lead to improved functional outcomes and decreased disability from chronic pain complaints.15 Patients with comorbid chronic pain and depressive illness are more likely to suffer from unremitting pain despite compliance with evidence-based treatment strategies.16 Mrs. P had 2 co-occurring disorders: psychotic depression and chronic pain disorder secondary to glossopharyngeal neuralgia. Our opinion is that Mrs. P’s psychotic depression worsened her experience of pain.

Treatment strategies that address both depressive symptoms and chronic pain are ideal.17 These treatment modalities include psychotherapeutic techniques such as cognitive-behavioral therapy, medications, and somatic treatments such as ECT.18 In Mrs. P’s case, ECT was an effective treatment that caused remission of psychotic depressive symptoms, which lead to improved pain control and restored social and occupational functioning.

Related Resources

  • Schreiber S, Shmueli D, Grunhaus L, et al. The influence of electroconvulsive therapy on pain threshold and pain tolerance in major depression patients before, during and after treatment. Eur J Pain. 2003;7(5):419-424.
  • Suzuki K, Ebina Y, Shindo T, et al. Repeated electroconvulsive therapy courses improved chronic regional pain with depression caused by failed back syndrome. Med Sci Monit. 2009;15(4):CS77-CS79.
  • Giesecke T, Gracely RH, Williams DA, et al. The relationship between depression, clinical pain, and experimental pain in a chronic pain cohort. Arthritis Rheum. 2005;52(5):1577-1584.

Drug Brand Names

  • Amitriptyline • Elavil
  • Benztropine • Cogentin
  • Carbamazepine • Tegretol
  • Citalopram • Celexa
  • Clonazepam • Klonopin
  • Clozapine • Clozaril
  • Escitalopram • Lexapro
  • Gabapentin • Neurontin
  • Lithium • Eskalith, Lithobid
  • Olanzapine • Zyprexa
  • Oxycodone/ acetaminophen • Vicodin
  • Phenytoin • Dilantin
  • Thiothixene • Navane
  • Trazodone • Desyrel, Oleptro
  • Ziprasidone • Geodon

Disclosures

Dr. Kugler reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Magid receives NARSAD grant support.

References

1. Kawashima M, Matsushima T, Inoue T, et al. Microvascular decompression for glossopharyngeal neuralgia through the transcondylar fossa (supracondylar transjugular tubercle) approach. Neurosurgery. 2010;66(6 suppl operative):275-280.

2. Ferroli P, Fioravanti A, Schiariti M, et al. Microvascular decompression for glossopharyngeal neuralgia: a long-term retrospective review of the Milan-Bologna experience in 31 consecutive cases. Acta Neurochir (Wien). 2009;151(10):1245-1250.

3. Stahl SM. Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. 3rd ed. New York NY: Cambridge University Press; 2008.

4. Diagnostic and statistical manual of mental disorders, 4th ed, text rev.Washington DC: American Psychiatric Association; 2000.

5. Rothschild AJ. Diagnosis and assessment. In: Rothschild AJ. Clinical manual for diagnosis and treatment of psychotic depression. Arlington VA: American Psychiatric Publishing Inc.; 2009:57-71.

6. Tunks ER, Crook J, Weir R. Epidemiology of chronic pain with psychological comorbidity: prevalence risk, course and prognosis. Can J Psychiatry. 2008;53(4):235-242.

7. Hooten MW, Shi Y, Gazelka HM, et al. The effects of depression and smoking on pain severity and opioid use in patients with chronic pain. Pain. 2011;152(1):223-229.

8. Rico-Villademoros F, Hidalgo J, Dominguez I, et al. Atypical antipsychotics in the treatment of fibromyalgia: a case series with olanzapine. Prog Neuropsychopharmacol Biol Psychiatry. 2005;29(1):161-164.

9. Seidel S, Aigner M, Ossege M, et al. Antipsychotics for acute and chronic pain in adults. J Pain Symptom Manage. 2010;39(4):768-778.

10. Hamoda HM, Osser DN. The Psychopharmacology Algorithm Project at the Harvard South Shore Program: an update on psychotic depression. Harv Rev Psychiatry. 2008;16(4):235-247.

11. American Psychiatric Association. Committee on Electroconvulsive Therapy, Weiner RD, eds. The practice of electroconvulsive therapy: recommendations for treatment, training and privileging. 2nd ed. Washington DC: American Psychiatric Association; 2001.

12. Petrides G, Fink M, Husain MM, et al. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. J ECT. 2001;17(4):244-253.

13. Rasmussen KG, Rummans TA. Electroconvulsive therapy in the management of chronic pain. Curr Pain Headache Rep. 2002;6(1):17-22.

14. Wasan AD, Artin K, Clark MR. A case-matching study of the analgesic properties of electroconvulsive therapy. Pain Med. 2004;5(1):50-58.

15. Teh FC, Zaslavsky AM, Reynolds CF, 3rd, et al. Effect of depression treatment on chronic pain outcomes. Psychosom Med. 2010;72(1):61-67.

16. Sertel Berk HO. The biopsychosocial factors that serve as predictors of the outcome of surgical modalities for chronic pain. Agri. 2010;22(3):93-97.

17. Bair MJ, Robinson RL, Katon W, et al. Depression and pain comorbidity. Arch Intern Med. 2003;163(20):2433-2445.

18. Veehof MM, Oskam MJ, Schreurs KM, et al. Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis. Pain. 2011;152(3):533-542.

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