Alternative Meanings of "Psychotic" Behavior: A Case Example Involving Dissociative Phenomena in a Woman With Mild Mental Retardation and a History of Severe Childhood Physical Abuse
by George Hromnak, MD
Psychiatric symptoms reported as psychotic in common use suffer from a lack of uniformity. This may lead to inaccurate diagnosis and inappropriate treatment. The case of a woman with mild mental retardation, a history of physical abuse as a child and probable sexual abuse as a young adult is presented. Prior to further investigation of her history and direct observation, her symptoms had been viewed as examples of psychotic states. She was treated accordingly with antipsychotic medication, with a working diagnosis of bipolar disorder, but she did not improve. Closer examination of her history and direct observation led to a diagnosis of posttraumatic stress disorder. Specific examples of her symptoms and their reinterpretation are discussed.
" 'When I use a word,' said Humpty Dumpty in a rather scornful tone, 'it means just what I choose it to mean - neither more nor less.'
'The question is,' said Alice, 'whether you can make words mean so many different things.'
'The question is,' said Humpty Dumpty, 'which is to be master - that's all.'" 1
During my residency in child psychiatry, a neurology resident (whose name I forget, unfortunately) would repeatedly ask me to explain what we meant when we said that a child was psychotic. I remember reciting explanations that had to do with disorganized thinking and capacity for reality testing, compared to other children of the same age, but neither he nor I was ever fully satisfied with my answers, and the question has continued to nag me throughout my career. Since I began working more intensively with people with mental retardation, I have found myself taking up the question again in my daily work. I often will hear or read about examples of behavior described as psychotic that, when examined more closely, do not really seem psychotic to me. Part of the problem relates to the linguistic phenomenon of extension in lexus, whereby a jargon word gets taken up in colloquial use and acquires a different meaning, with both the original jargon and the colloquial interpretation used as if they had one meaning. A good example of this is the word schizophrenic, which has a specific meaning to psychiatrists and an alternate definition of, " . . . relating to, or characterized by the coexistence of disparate or antagonistic elements." 2 The problem also involves the rather loose use of the word psychotic by psychiatrists, psychologists, and other mental health professionals to describe disorganized and problematic behavior of all sorts.
The problem has been addressed recently in an article by Myers3 that takes up the problem of psychiatric disorders that mimic psychotic disorders. She discusses depressive disorder, autistic disorder, stereotypy/habit disorder (now stereotypic movement disorder), aggressive behaviors, movement disorders, temporal lobe seizures, dissociative disorders, anxiety disorders, fantasies and imaginary playmates, semantic-pragmatic deficit disorder, obsessive-compulsive disorder, and hearing loss/deafness, and gives a number of examples.
Lapses in reality testing occur in the everyday lives of most people and often do not cause much concern. The child who believes in Santa Claus; the child who is afraid to sleep because there may be a monster under the bed; the child who wants to write in cursive script and submits a specimen of loopy scribbling as "real grown-up writing;" the child (or adult) who whistles in the dark while passing a graveyard to keep ghosts away; the child who strikes his brother after getting a hostile look and later claims "he hit me first;" all may be showing evidence of impaired reality testing, but would not ordinarily be thought of as psychotic. If, however, one were to be searching for examples of behavior that could be psychotic, all might qualify. This search for the possibly psychotic is encouraged by the structure of our mental health system, with its emphasis on brief assessment and immediate action based on limited information, without the opportunity for reflection or detailed exploration. The requirement that a diagnosis be given (and a billable one, no less) encourages practitioners to err on the side of over-diagnosis. My favorite (and also most horrifying) example of this is that of a six-year-old boy whom I saw for follow-up, after a psychiatric hospitalization that apparently was in response to a prolonged temper tantrum. His documentation from the hospital noted no disorganized thinking, loose associations, delusions, deterioration in functioning, or social withdrawal, but did describe a "hallucination:" at bedtime after dark the boy thought that a wolf was looking at him through a ground-level glass window and expressed this to a nurse. He was started on haloperidol the next day, and was discharged with a diagnosis of schizophrenia.
Individuals with mental retardation offer us examples of behavior analogous to those seen in childhood that may represent breakdowns in communication, reality testing, or the capacity to verbally express experiences that are emotionally charged, unusual, or both. I was recently asked to see a woman living at the facility where I work (henceforth referred to as "the Center") who was diagnosed with bipolar disorder and mild mental retardation. She had been treated with high doses of medication that could be prescribed for this disorder, but seemed to have become worse over the past year. Because I work at the facility full-time, I was able to see her during examples of what were being reported as psychotic episodes. This led to a different conceptualization of her problem, a different treatment plan, and a reduction of neuroleptic medication that had been increased to a high dose and had resulted in sedation, but no real improvement.
Ms. X was born in 1956, and her mother remarried shortly after her birth. At age two years, she was brought to the local hospital emergency room three times within a span of several months, first after falling from a window, next after being punched in the abdomen; and finally after having been beaten severely by her stepfather after soiling her diaper. She was described as having contusions all over her abdomen, there was concern about spleen and liver injury, and head injuries were noted. She was taken into protective custody and placed in foster care with a family who noted that she was difficult and often appeared frightened. She was moved to another foster home prior to being placed at the Center at age eight years; no mention is made of therapy for her traumatic experience. No special adjustment problems were noted at the Center, but she was prescribed chlorpromazine (Thorazine) for "behavior" throughout the rest of her childhood and into her adult years. She was noted to have intelligence in the mildly retarded range, but did learn to read and write to some extent. At age 16 years, she was transferred to a residential facility in another state after her mother (who had remarried and by then enjoyed a stable marriage) moved and requested her transfer. While there, she was described as a productive worker, who often helped less-able residents with job tasks, and who could capably perform a number of tasks related to cardboard box fabrication. No special behavioral or emotional problems were noted. After her mother died of cancer, when Ms. X was 18, she was transferred back to the Center to be closer to surviving relatives. She was placed in the community for a period of time, and during this time was psychiatrically hospitalized in an agitated state, accompanied by claims that she had been raped. These claims appear to have been seen as delusional, as she was unable to provide a detailed and consistent account of the alleged rape, and she was treated with a antipsychotic medication. She eventually was returned to the Center. Staff there who recall her return and knew her prior to community placement believe that she had in fact been raped or sexually molested, but they were unable to get her to talk about the details due to her avoidance of the subject. Later attempts to place her in the community were accompanied by increasing anxiety and agitation, and allegations of being sexually molested while at the Center. She was treated with fluoxetine (Prozac), which may have helped to some extent. A different psychiatric consultant saw her as meeting criteria for bipolar disorder and recommended treatment with valproic acid (Depakote), lithium, olanzapine (Zyprexa), and other medications. She seemed to worsen over time and had become sedated, inactive, and obese, probably due to the high dose of olanzapine used to treat episodes of what were seen as delusions, involving repeated allegations that she was being raped while asleep in bed.
The rape allegations were made against staff and another female resident, who was elderly and not likely to have bothered her at night. Each allegation required investigation and was accompanied by some anxiety on the part of the accused staff. These events all had the following features: she was asleep; she had the distinct impression that she had been vaginally penetrated; the events woke her up; she did not see anyone in her room on awakening but knew that someone had been in her room, because in her words "it was real and not a dream." When asked if anything like this had ever happened to her before, she said that she had been raped while living in the community and added that that was why she never wanted to leave the Center. She was unaware that in saying this she had made an implicit distinction between the probably real event in the community and the imaginary (but still in an important sense real) nighttime molestations that she believed were going on while at the Center. She became visibly upset when asked about what had happened in the community and would not talk about it further.
Occasionally, Ms. X would speak in a deeper-than-usual voice, as if simultaneously fending off and making accusations that might be directed towards a child by a hostile adult using obscene language. On one such occasion, occurring in the late afternoon, she was heard to exclaim, "I don't need no titty-bottle!" and, "I don't need no shitty diaper!" while appearing to be in a trance-like state. Her voice, in addition to being deeper in pitch, was more distinct than her usual tone, which is characterized by a lisp. A water bottle fitted with a sports "nipple" was in full view in front of her, and she had been drinking from it. Her awareness of others appeared reduced, and she was only minimally responsive to attempts to engage her, which we did not continue, so that we could observe her (she was not engaging in dangerous or potentially injurious behavior). This lasted for about 15 minutes, and after she regained her usual state she seemed to have no recollection of what she had been talking about. When pressed, she became evasive and seemed to become upset. The inquiry was, therefore, dropped so as not to distress her.
Ms. X regularly could be heard screaming and moaning, as if frightened, while showering. She avoided discussing this and would not elaborate on these events, but usually insisted that she was "okay." She did not seek out staff help at these times. Her screams led to the practice of having staff nearby during showers.
Ms. X's treatment has been ongoing, and interventions to date have focused on coming up with a more accurate diagnosis and reducing or eliminating medications that may not be helpful, or that may be causing side effects exceeding benefit. As of this writing, her dose of antipsychotic medication (olanzapine, Zyprexa) has been reduced from 25 to 5 mg/day, with markedly less sedation, some reduction in obesity, and no real change in the frequency of her accusations. She had a trial reduction in her dose of divalproex sodium (Depakote) which, within several weeks, led to significant worsening of depression without any evidence of mania. Resumption at its original dose led to clinical toxicity associated with elevated serum unbound VPA (valproic acid) levels, and the dose was again adjusted. A trial of treatment with low dose (5-10 mg/day) fluoxetine (Prozac) led to improvement of intensely irritable mood associated with the premenstrual phase and will be used intermittently for an extended trial. She was moved to a different living area, where it was hoped that greater privacy would decrease her anxiety about intruders. Plans are being made to develop regular individual psychotherapy as a treatment mode; her tendency to make accusations against those involved in her care will require that two individuals meet with her for these sessions.
Ms. X's symptoms satisfy the following criteria for the diagnosis of posttraumatic stress disorder: past experience of an event involving a threat to physical integrity, accompanied by intense fear and helplessness; intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; recurrent distressing dreams of the event (in her case dreams that resembled the event, in that she had the sensation of being vaginally penetrated); efforts to avoid conversations or places (the community) associated with the trauma; (possible) inability to recall important aspects of the trauma; difficulty staying asleep; and outbursts of anger.4 She also meets criteria for dissociative disorder NOS due to the presence of dissociative symptoms that resemble dissociative disorder, but do not clearly meet the full criteria for this disorder. The full criteria for dissociative identity disorder would include: the presence of two distinct personality states; at least two of these states recurrently take control of the person's behavior; inability to recall important information that cannot be explained by ordinary forgetfulness; the disturbance is not due to a substance or medical condition (such as complex partial seizures).5
The allegations of rape appear to have been based on a misinterpretation of either a vivid dream or sexual physical sensation while asleep, that seemed real and different in quality from a dream. As Ms. X put it, "I know what a dream is, and this was not a dream; it was real!" Dreams of a traumatic nature are outside the everyday experience of most people (or so we think) and hence are not as easily understood by others, as an ordinary nightmare might be. The ability to describe emotionally charged experiences is not a skill that can be taken for granted and can be conceptualized as a developmental achievement. One would expect, then, that persons with mental retardation might resort to more immature ways of describing difficult experiences, including coming to the conclusion that inner experiences represented real events. This is the essence of a reality testing impairment. It is probably different from reality testing problems associated with schizophrenia or acute mania, and may be less amenable to medication strategies that would be effective in either disorder.
Showering is one of the few times in ordinary life when a person is naked and therefore vulnerable and exposed (one need only think of Hitchcock's Psycho and DePalma's Dressed to Kill for referents in popular culture). One might expect on this basis that it could serve as a trigger for recollections that included the experience of helplessness and vulnerability and might lead to intrusive memories of traumatic experiences. Ms. X's avoidance of discussing the matter makes it difficult to say for certain, but we have speculated that her episodes of screaming in the shower may represent traumatic recollections triggered by the everyday experience of nakedness and exposure. Her screaming had previously been seen as inexplicable and was lumped with other examples of psychotic symptoms; the fact that it continued despite treatment was seen as evidence that her antipsychotic dose was inadequate.
The trance-like episode suggested an interaction between a child who was outgrowing diapers and bottles and a punitive adult. We know from the record that such an interaction did in fact take place between Ms. X and her stepfather, when she was about two years old, and was associated with life-threatening physical abuse resulting in her being hospitalized and then taken into protective custody. Although perhaps necessary, the resulting separation from her mother would probably have also been difficult, if not in itself traumatic, and would have further complicated the normal developmental problems that a child of that age would face. The use of a drinking bottle fitted with a nipple may have served as the trigger for this particular event, which I am conceptualizing as a dissociative episode accompanied by changes in voice and vocabulary, suggesting a somewhat modified personality organization. This event would also have been reported as an example of psychotic behavior and, under other circumstances, would have been treated with an increase in antipsychotic medication.
The case presented here does not include instances of trauma experienced within the institution or at the hands of institution staff. The putative rape occurred while in a community living arrangement and was seen as quite distinct from the range of experiences in the Center. This may explain the sense of safety that Ms. X experiences at the Center, despite her conclusion that she continues to be raped while she is living there.
Ms. X's response to medication treatment raises many questions that go beyond the intended scope of this article. My main focus here has been the excessive use of antipsychotic medication in the face of minimal benefit and clearly adverse effects. The role of premenstrual dysphoric disorder6 and its treatment will be assessed as treatment continues. The response of mood symptoms to valproex sodium (VPA) would at first glance seem to support a diagnosis of bipolar disorder; however, a number of disorders that are not bipolar disorder (most notably, epilepsy, which is the original indication for this medication) do sometimes respond to VPA. The question of whether combined lithium/VPA treatment is of benefit will be addressed at a future date. It remains possible that some of Ms. X's clinical problems may be usefully conceptualized as bipolar disorder, which I hope will become clearer with time.
Psychotherapy has been limited in part by the need to address Ms. X's tendency to make accusations against those who work with her, which will require the presence of a witness at sessions. The logistical details are being worked out, and we plan to implement regular therapy sessions in the near future.
Loose use of the term psychotic to cover a variety of examples of impaired reality testing can lead to inaccurate diagnosis and inappropriate treatment. Decreased time available for psychiatric evaluations, scant opportunity for direct observation of fleeting symptoms, the reliance on observations by relatively inexperienced or untrained staff, and the collapsing of psychiatric symptoms into checklists is likely to worsen the problem. The case presented here shows how inexplicable behavior, described generically as psychotic, became less mysterious following a careful review of past records and direct observation of so-called psychotic episodes. These episodes did indeed involve a breakdown in reality testing but were better explained as symptoms of posttraumatic stress disorder and dissociative disorder, rather than as brief mixed or manic episodes representing bipolar disorder. Greater general awareness of the range of psychiatric symptoms by direct care staff and psychiatrists may help to mitigate this problem to some extent. The trend away from opportunities for direct observation by psychiatrists is probably irreversible in the near future. More accurate diagnoses will therefore rest on the development of observational individuals with mental retardation.
George Hromnak, MD, is employed full-time as a psychiatrist at a residential facility run by the Pennsylvania Department of Public Welfare, Office of Mental Retardation, through the Columbus Organization.
1 Carroll L, Alice in Wonderland and Through the Looking Glass, Puffin Books, 1997, p. 237.
2 The American Heritage Dictionary of the English Language, Houghton Mifflin, 1996.
3 Myers BA, "Psychiatric Disorders Mimicking Psychotic Disorders in People With Mental Retardation," Mental Health Aspects Developmental Disability, 1999, 2:4, pp. 113-121.
4 DSM-IV-TR, American Psychiatric Association, 2000
5 DSM-IV-TR, American Psychiatric Association, 2000
6 DSM-IV-TR, American Psychiatric Association, 2000