Attending physician’s mental notes: six months

At the time of this treatment, the CYP450 interaction was a notable concern but this patient was significantly overweight, which likely accommodated this higher end of normal approved dosing

Her depression appears well treated now but her PTSD residual symptoms continue to be problematic

As she had modest gains from her first two medications, an SSRI and an NDRI, stopping them might cause relapse

Adding another augmentation is likely warranted now, using a specific target symptom approach

Case outcome: interim follow-ups through nine months

The patient agrees to augmentation with the antiepileptic selective GABA reuptake inhibitor (SGRI) tiagabine (Gabitril)

This agent is not addictive, and in theory should elevate GABA availability, promote anxiolysis, and also protect against bupropion-induced seizures

This augmentation was supported at this time by open-label trials but had no sanctioned approvals

• – Titrated to 16 mg/d

• – Sleep improves, but no other clear effects on the PTSD reliving events

• – It should be noted that this drug failed in controlled monotherapy trials in the treatment of PTSD some years later, and was also given a warning that despite being an approved epilepsy treating medication, it could actually cause seizures in non-epileptics

• – This patient suffered no such complications, however

Case outcome: interim follow-ups through 12 months

The patient gradually presents with more difficulty as random social events trigger PTSD reliving and some mood lability occurs

• – There are increased psychosocial stressors and a return of depressive symptoms

• – Sobriety continues

• – PTSD symptoms increase

• – Outside her usual insomnia and nightmares, she now has “a little man watching her”

  • Upon investigation, it is determined that she has a visual hallucination of a small man staring down at her when she is on the verge of falling asleep (hypnagogic hallucination)

  • This hallucination is not related to any PTSD themes, but she finds it very disturbing

Clinically, what types of patients typically suffer hypnagogic hallucinations?

Narcolepsy patients

Narcoleptics also may suffer sleep paralysis, cataplexy (drop attacks), as well as their usual REM-onset sleep attacks

In this case, these hallucinations could also be related to a relapse into drug use or seizure activity (both of which were negative)

Case outcome: interim follow-ups through 12 months (continued)

Evaluated for sleep disorder

• – Found to have OSA

• – Prescribed a continuous positive airway pressure (CPAP) machine and is compliant with its use

The OSA appears to be unrelated to the hallucinations

There is no relapse into drug use to explain the hallucinations

She is not having seizures

Question

What would you do now?

Escalate the tiagabine (Gabitril)

Augment with a 5-HT1A receptor partial agonist

Augment with an anxiolytic or hypnotic agent that is not addictive

Add an atypical antipsychotic

Taper off the now ineffective medications and start a new regimen

Attending physician’s mental notes: 12 month follow-ups

Despite increasing progress on her initial three medication regimen (SSRI, NDRI, SGRI), this was thwarted by social stress and exposure to PTSD-triggering stimuli

Given her increased mood lability, irritability, potential for violence, flashbacks, and now limited hallucinations, an antipsychotic might be warranted

At this time, it was becoming known that the atypical antipsychotics could drive an increase in weight but it was unclear if they would increase the metabolic syndrome

This patient already has the metabolic syndrome, but it is very well controlled and followed very closely by her PCP