Case Study
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Case Report:
A patient with refractory PTSD, anxiety, and substance abuse abuse
Ethan Kisch, M.D.
Ellen P. (not her real name) is a middle-aged woman with a history of post-traumatic stress disorder, dissociated identity disorder, severe
anxiety symptoms, refractory auditory hallucinations, and substance abuse (cocaine and alcohol). Her sleep was often disturbed by nightmares,
flashbacks, and hallucinations. She had proved very difficult to stabilize and has been hospitalized many times, ending up in
an inpatient unit or outpatient program nearly every month.
She has been treated successively with the classic mood stabilizers; lithium,
valproate (2500 mg/day), and finally carbamazepine (2000 mg/day). She was also treated with a succession of psychotropic agents,
including risperidone (up to 6 mg/day, reduced to 4 mg when tiagabine was started), olanzapine (up to 30 mg/day), and clozapine (up to 700 mg/day).
Unfortunately, she became very obese (305 lbs) as a side effect of her therapy. After she failed to respond to clozapine, she was switched to quetiapine (up to 800 mg/day, later reduced to 400-600 mg), which seemed to have a lesser tendency to cause weight gain.
On carbamazepine and quetiapine her response was less than optimal, so tiagabine was added to the regimen. The addition of
tiagabine produced a dramatic improvement. Her sleep pattern was normalized, with a marked reduction in nightmares, flashbacks,
and hallucinations. With the exception of a three-day relapse of cocaine use, her drinking and drug-taking ceased and she has now been
abstinent for 18 months. She is currently stabilized, and remains greatly improved, on her regimen of carbmazepine (2000 mg/day),
quetiapine (400-600 mg/day), and tiagabine (2 mg t.i.d. plus 16 mg at bedtime). Her weight has declined to 165 lbs.
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