Cultural factors impacting misdiagnosis of PTSD in a Puerto Rican female Lorangelly Rivera, MD and Telva Olivares, MD

Department of Psychiatry, University of Rochester Medical Center

• Hispanics are the fastest growing ethnic group

in the US and are expected to make up more

than 20% of the US population by 2060

• Several studies have shown that 10–25% of

the general (non-psychiatric) Latino population

have had hallucinatory experiences, both visual

and auditory, with no identified underlying

psychiatric issue 1

• Despite high prevalence of psychotic symptoms in this population most

patients do not meet criteria for a thought disorder 2

• Various factors including language barrier, difference in beliefs, tendency to

under report certain symptoms, racial bias, and decreased access to care are

some of the factors that complicate formulation of a correct assessment and

accurate diagnosis in this population

• We will discuss factors leading to an initial diagnosis of Schizophrenia in a

Puerto Rican female later found to have PTSD

Case report• This is the case of a 79 year old Puerto Rican woman with a medical history

significant for SCC of the lung (s/p radiation tx) , PVD, T2DM and HTN and a

psychiatric history of Depression and Schizophrenia who presented with a

chief complaint of depression. She was referred by her PCP who was

prescribing Quetiapine 800mg nightly and Fluoxetine 20 mg daily.

• Psychiatric ROS:

• + : depressed mood, sleep disturbances, persistent feelings of guilt, low energy,

low appetite, low concentration, anhedonia, hopelessness, anxious mood, racing

thoughts, ruminations and intermittent suicidal ideation without intent. She auditory,

visual and tactile hallucinations (felt that she was held while in bed, heard a male voice,

heard whispers during the day, sees shadows in the corner of her eye) that occur

independent of mood symptoms and do not improve with Quetiapine.

• - : paranoid delusions, ideas of reference, thought insertion/broadcasting, symptoms of

mania, flashbacks, trauma related nightmares, panic attacks, violent/homicidal ideation,

intent or plan.

• Medical ROS: Constitutional: positive for fatigue, Musculoskeletal: positive

for stiff joints and tongue movements. Neurological: positive for memory

problems

• Past History: Multiple hospitalizations in Puerto Rico for depression. Trauma

history of childhood physical, emotional and verbal abuse from her mother and

domestic violence from ex husband. One episode of suicidal attempt with low

lethality where she wrapped a rope around her neck but did not attempt to

hang herself and had no medical repercussions. Family history was non-

contributory.

Interventions and results

• MSE: Appears stated age, Well-groomed, Casual. Cooperative with interview.

Motor activity was within normal limits. Direct eye contact. Slurred speech.

Affect was depressed with decreased range. Mood was depressed. Thought

process was linear, logical and goal oriented. Though content was normal

without unusual themes. Perception was within normal limits and there was no

evidence of internal preoccupation. She endorsed vague passive thoughts of

suicide. Concentration was initially impaired but improved as interview

progressed. Remote memory was intact and recent memory was impaired.

Orientation was intact to person and place but not to time. Cognitive function

was average Judgement and Insight were intact.

• Week 1: Quetiapine was

discontinued. Fluoxetine was

increased to 40mg. Trazodone

was started at 50mg nightly.

• Week 3: Trazodone was

increased to 100mg. Resolution

of tremors and tongue

movements was seen.

• Week 4: Visible improvement in

mood. Fluoxetine 40mg and

Trazodone 100mg were

continued. Intermittent AVH

endorsed without changes to

thought content.

References

Differential diagnosis

• Hispanics with depression and anxiety commonly describe atypical auditory

and visual hallucinations in the context of an otherwise unremarkable mental

status exam

• Approximately one in ten Latinos in a US national probability sample endorsed

at least one lifetime psychotic symptom on the CIDI screener. Diagnostic

evaluation, however, revealed that only 7% of Latinos in the NLAAS who

endorsed psychotic symptoms met SCID criteria for psychotic disorder 4

• Examples of psychosis-like symptoms include hearing “someone calling”,

“knocking at the door” or the “phone ringing in the house”

• Symptoms are commonly based around religion and family (eg seeing a dead

relative) and occur independently of disorganization of thought

• Limited data has shown that neuroleptics are not more efficacious at treating

these attenuated psychotic symptoms when compared to antidepressants or

anxiolytics 5

• Non psychotic hallucinations can be easily misinterpreted as a symptom of a

thought disorder by clinicians who lack cultural training or experience with

latinx population

• Patients may minimize trauma related symptoms and multiple evaluations may

be necessary to make accurate diagnosis

• Non psychotic experiences should be considered in all cases where symptoms

occur independently of a progressive cognitive process

• Though not related to a primary thought disorder NPH increase risk of poor

social functioning and suicide

• Even in patients with co-morbid mood or anxiety disorders, NPH can occur

during moments of stabilization and interview should focus on patient’s

reported experience of symptoms

• Antipsychotics may have a role in treatment of NPH in certain patients but do

not appear to have an impact on outcomes

Discussion

1. Moreira-Almeida, A., & Koss-Chioino, J. D. (2009). Recognition andtreatment of psychotic symptoms: Spiritists compared to mental health

professionals in Puerto Rico and Brazil. Psychiatry: Interpersonal and Biological Processes, 72(3), 268–283.

2. Geltman D, Chang G. Hallucinations in Latino psychiatric outpatients: a preliminary investigation. Gen Hosp Psychiatry.

2004;26(2):153-157. doi:10.1016/j.genhosppsych.2003.09.002

3. Olfson M, Lewis-Fernández R, Weissman MM, et al. Psychotic symptoms in an urban general medicine practice. Am J Psychiatry.

2002;159(8):1412-1419. doi:10.1176/appi.ajp.159.8.1412

4. Lewis-Fernández R, Horvitz-Lennon M, Blanco C, Guarnaccia PJ, Cao Z, Alegría M. Significance of endorsement of psychotic symptoms

by US Latinos. J Nerv Ment Dis. 2009;197(5):337-347. doi:10.1097/NMD.0b013e3181a2087e

5. Mischoulon D, Lagomasino IT, Harmon C. Atypical psychotic symptoms in a Hispanic population: diagnostic dilemmas and implications for

treatment. Psychiatry (Edgmont). 2005;2(10):38-46.

6. Cassano P, Chang T, Trinh NH, Baer L, Fava M, Mischoulon D. Differential impact of isolated psychotic symptoms on treatment outcome

of major depressive disorder in the STAR*D cohort of Whites, Blacks and Latinos. J Affect Disord. 2013;150(2):578-584.

doi:10.1016/j.jad.2013.02.012

7. Lewis-Fernández R, Gorritz M, Raggio GA, Peláez C, Chen H, Guarnaccia PJ. Association of trauma-related disorders and dissociation

with four idioms of distress among Latino psychiatric outpatients. Cult Med Psychiatry. 2010;34(2):219-243. doi:10.1007/s11013-010-

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Non psychotic hallucinations Introduction

Schizoaffective disorderMDD with psychotic features

Complex PTSDSchizotypal personality

disorder

MDD with anxious distress

Schizophrenia MDD with psychotic features and PDD

PTSD and GAD

Figure 1. Relational representation of pertinent diagnosis

0

2

4

6

8

10

12

14

16

18

20

0 5 10 15 20 25

PHQ 9

1816

3

1 2 3 4 5 6 7 8 9 10

PHQ 9PHQ 9

Weeks

• Week 10: Gains maintained with no

psychotropic changes.

• Month 9: PHQ 9 remains negative.

Intermittent non distressing AVH

endorsed. Medication adherence

endorsed