Abstract
REFERRAL AND EARLY HISTORY
The patient was referred to our service at the age of 15 years by her school psychologist, who had concerns about learning difficulties and her behaviour in class (including difficulty relating to other students). Concerns were also raised that she was taking an antipsychotic medication that had been prescribed overseas, and there was uncertainty about the diagnostic illness being treated.
Information from her adoptive parents indicated that the patient experienced significant disruption, loss, and hardship in her early childhood. She was exposed to multiple traumas and loss, and was the victim of and witnessed much violence and abuse, all during a time of civil unrest. Her childhood was characterized by disruption, as she lost her mother (believed to have died from a womb infection following a termination of pregnancy) when she was about 2 years old, and she was removed from her home and siblings and raised in a convent for several years while her adoption was arranged. In addition, the patient suffered from malnourishment and had worm infestation, and was most likely anaemic, and these biological factors would have hindered her early brain development.
Upon joining her adoptive family in a developed country at the age of 5, the patient displayed in most contexts prominent disturbance in social relatedness, where she failed to initiate and respond to most social interactions (as evidenced by oppositional behaviour towards her step-parents, academic difficulties and difficulty interacting with her peers). This behaviour was on a background of previous pathogenic care (including disregard for emotional and physical needs, and repeated changes in caregiver), and these features on adoption are consistent with an attachment disorder. The patient's difficulties with attachment and previous traumatic experiences at the hands of adult figures no doubt made it difficult for her to accept the affection and care-giving attempts of her new family (i.e. there was resistance to comforting).
Her step-parents described discrete episodes from the age of 5 to the present time when she would become highly aroused, and be verbally and physically aggressive. They stated that sometimes when she was highly aroused she would start ‘tribal dancing’, as though ‘in a trance’, and it would be difficult to communicate with her at these times (of note is that in the patient's culture of origin, tribal dancing and the practise of inducing trance-like states are not uncommon social or religious practises). On further questioning, however, these episodes were more in keeping with possible dissociative episodes; there was no history of any rising feeling in the stomach, epigastric pain, lip smacking, mannerisms or post-ictal confusion, or generalized seizures. The patient experienced nightmares but declined to elaborate. Furthermore, she refused to talk about her early childhood. It was thought that these symptoms may have represented an anxiety disorder, such as post-traumatic stress disorder, and that she may have suffered from dissociative episodes.
HALLUCINATIONS ON ENTERING ADOLESCENCE
Psychological services were engaged from the age of 5, but it appears the patient's behaviour escalated as she entered adolescence, and at the age of 12 she was referred to a psychiatrist. The patient reported hearing a single derogatory and unknown female voice, with confusion as to whether it was an inner or outer experience. The voice included aspects of commentary and commands, and this experience was associated with feelings of agitation and anxiety. The hallucinations were also associated with paranoid ideation about people wanting to harm her, and feelings of something terrible happening to her step-parents. She was commenced on risperidone (2 mg daily). Despite ongoing hallucinations, the patient and her step-parents reported that her symptoms had improved since medication was commenced. The significance of her hallucinations posed a diagnostic dilemma, and we were uncertain whether they represented symptomatology in keeping with post-traumatic stress disorder, an organic disease, or early-onset psychosis, or perhaps a combination of these.
TAPEWORM INFECTION AND ITS RELATIONSHIP TO PSYCHOTIC SYMPTOMS
Cysticercosis is systemic infestation of the larval form of the tapeworm Taenia solium. It is estimated that fifty million people suffer from cysticercosis worldwide, 1 and it occurs endemically in rural areas of developing countries of Asia, Africa and Latin America. 2 In this condition, ingested eggs (most commonly from contaminated food and water) release embryos that penetrate the intestinal mucosa of the upper digestive system and spread haematogenously to other organs, most commonly the muscles, eyes and brain. In the case of neurocysticercosis, the embryo develops into a larva which becomes encysted in the brain, where it may live for 1–10 years without causing symptoms, by evading the host's immune response. The degeneration of the cysts may result from treatment with anti-parasitic medication, or may be spontaneous. Only when the parasite dies is there an acute inflammatory response with the formation of oedema and subsequent granuloma formation, which is the time most likely that neurological complications (e.g. seizures) may occur. Subsequently, the cyst may either be completely reabsorbed or calcify. 3 , 4 A systematic study using standardized psychiatric instruments looking at the psychiatric manifestations of neurocysticercosis was limited to adults, but reported psychiatric disease in 65% of 38 outpatients at an infectious disease clinic in Brazil, with 52% of patients depressed and 14% of patients suffering from psychosis. 2 Furthermore, a study in Ecuador from a community sample that included children from the age of 9 years demonstrated neuropsychological dysfunction in those who suffered from neurocysticercosis. 5
Our patient was diagnosed with a gastrointestinal parasitic infection when she was adopted at age 5, and treated for this and cleared at the time. We performed an organic screen at age 15, and her blood tests (FBC, UEC, TFT, LFT, B12, folate, STD screen) and a single awake EEG were normal. Her cerebral CT scan, however, was abnormal and suggested sequelae of healed parasitic disease. She then had an MRI scan, which showed calcific foci (left parietal and right inferior temporal); these appeared to be leptomeningeal in location, deep within sulci, and no brain parenchymal cystic lesion was identified. These lesions were felt to represent old healed neurocysticercosis. The patient was reviewed by infectious disease specialists, who performed further tests to exclude other causes for such lesions (including toxoplasmosis, cryptococcal disease, tuberculosis, schistosomiasis and hydatid disease) and all of these test results were normal. The infectious disease team did not consider further investigations or empirical treatment were warranted.
Although treatment at the age of 5 would have no doubt led to an acute inflammatory response and may have contributed to her psychiatric symptoms at the time, it was felt that an ongoing disease process or healed neurocysticercosis were unlikely to account for her hallucinations. Nonetheless, one would be concerned about the impact of this early infection on her brain and neurocognitive development, and the patient is awaiting formal neurocognitive testing.
TRAUMATIC CHILDHOOD AND RELATIONSHIP TO PSYCHOSIS
As outlined by van Os and colleagues, and others, 6 , 7 there is evidence outlining considerable overlap between the diagnostic constructs of schizophrenia, dissociative disorders and post-traumatic stress disorder, and perhaps symptoms which are “categorised as psychotic by clinicians … before trauma has been identified are re-categorised as somehow non-psychotic when the trauma history becomes known” (i.e. on the premise that abuse cannot cause psychosis).
There is controversy over whether childhood trauma is a causal factor in the development of psychosis. 6 , 8 Some studies that have large patient samples, are well designed and control for possible confounders, show that hallucinations (particularly commentary and command hallucinations) are at least as strongly related to childhood abuse and neglect as many other health problems, and that the relationship is a causal one with a dose-effect. These studies would suggest that understanding the mechanisms by which traumatic childhood leads to psychosis requires an integration of biological and psychological paradigms, which acknowledges that adverse events can alter brain wiring and functioning.
The question remained, in the case of our patient's reported hallucinations, were they memories of traumatic events identical to split-off flashbacks indicative of post-traumatic stress disorder, or were they trauma-based psychotic hallucinations involving confusion between inner and outer experience (i.e. faulty source monitoring)? Were her paranoid ideations attempts to make sense of her hallucinations, or part of her anxiety or attachment disorders? Can the initial benefit she obtained from antipsychotic medication be more of an effect on her level of agitation and arousal rather than be indicative of treating psychotic symptoms per se?
PROGRESS: THE IMPACT OF AN EMOTIONALLY AVAILABLE MOTHER-FIGURE
The family relocated to Australia when the patient was aged 15 (and shortly after this the patient was referred to our service). As a consequence of this emigration, there was a change in the family dynamic such that the patient's step-mother would now be available full-time at home, while the father continued to work full-time. Over several months that this was occurring, during which time the patient was being assessed and investigated at our clinic, the hallucinations ceased and, after another 6 months, had not returned. Her step-mother feels a warm and affectionate relationship has developed since coming to Australia. Nevertheless, the patient's oppositional and care-eliciting behaviours, although improved, persist, as do possibly her dissociative phenomena, and it is likely that these are a combination of ongoing post-traumatic symptoms and inability to integrate her experiences and emotional response to them as she migrates through adolescence. The patient will require ongoing psychological input to assist her throughout this process, as well as family therapy to address some of the wider issues that stem from a traumatic childhood and disordered attachment. With regard to her episodes of ‘tribal dancing’, these have decreased in frequency, and no longer occur at school. The patient has participated in a dance and music group as part of her therapy, and she has stated that she feels less anxious after this.
Currently, we are approaching the patient's experiences of hallucinations with caution. We have started decreasing her antipsychotic medication slowly, with a view to ceasing it after 1 year. We will continue to review the progress of her symptoms, in collaboration with the infectious disease specialists, and will arrange further neurocognitive testing.