Coentre and Power Journal of Medical Case Reports 2011, 5:97 http://www.jmedicalcasereports.com/content/5/1/97 intrusive flashbacks and recurring dreams. Co-morbid psychosis has been described in approximately 20 to 40 percent of veterans with combat-related PTSD [6,7]. The prevalence of PTSD in patients with a severe men- tal illness is at least three times higher (29 percent) than the general population [5]. In PTSD, the psychotic symptoms may be more pervasive or frequent than psy- chotic-like symptoms that occur during dissociative epi- sodes or flashbacks [8]. PTSD with psychotic symptoms has also been reported in non-combat related cases of patients with PTSD but not schizophrenia-spectrum or bipolar disorders. From a psychological point of view, there is a rela- tionship between the individual’s pre-existing cognitive schemas and thought patterns emerging after the trau- matic event. A maladaptative cognitive processing style culminates in feelings of shame, guilt and worthless- ness, which emerge during trauma acting as positive feedback to enhance symptom severity and keep the individual in a constant state of psychotic turmoil. It is possible that under certain individual-specific condi- tions, the defence and coping mechanisms break down at a level of psychotic manifestations in the form of delusions and hallucinations. It has been hypothesized that trauma may produce a psychological vulnerability leading to the development of psychotic experiences. In our patient, factors such as an unwanted pregnancy, potential homelessness and a rejected asylum claim may have contributed to and triggered the emergence of psychotic features in a preceding PTSD. Some authors underline the importance of both disorders being characterized by intrusions. In PTSD, the inter- pretation of intrusive symptoms such as flashbacks is seen as central to the maintenance of the disorder. In psychosis, hallucinations and delusional beliefs are interpretations of intrusions [9]. Unlike our case report, where there was clear evidence of a life-threatening trauma before psychotic symptoms, some authors identify psychosis itself as the source of trauma for patients with both conditions. There is some evidence suggesting that psychosis, hospitalization, or both may be sufficiently severe to precipitate PTSD and that psychological distress related to a psychotic episode may predict an evolution to PTSD [10]. Our patient was an immigrant from a black ethnic minority group. First- and second-generation black eth- nic minority migrants are at a particularly high risk of psychosis in London. The explanation for these findings is uncertain, but social adversity, racial discrimination, family dysfunction, unemployment, poor housing condi- tions and urbanicity have been proposed as contributing factors [11-13]. It is possible that similar stresses con- tributed to the heightened risk of psychosis in our patient. Page 3 of 5 Some authors argue for a new condition called PTSD with psychotic symptoms, claiming that it should be included in the psychiatric classification systems to account for the high percentage of psychotic symptoms in patients with PTSD [14]. Our patient could fit into this category. Establishing a correct diagnosis is imperative in devel- oping an appropriate treatment strategy, particularly when the presence of psychotic symptoms necessitates the use of anti-psychotic medication. In addition to the demonstrated efficacy of selective serotonin re-uptake inhibitors (SSRIs), a range of other drugs, including sec- ond-generation anti-psychotics, have recently been investigated for the treatment of PTSD. The currently available evidence suggests that first-line pharmacother- apy is SSRIs and possibly the serotonin norepinephrine re-uptake inhibitor venlafaxine extended release [15]. Response rates are limited: approximately 60 percent of patients treated with SSRIs are reached [16]. Psychotic symptoms are associated with more severe symptoma- tology and their presence is also known to decrease the efficacy of conventional treatment [17], further indicat- ing a possible role for an anti-psychotic treatment. We found a paucity of randomized, double-blind, placebo- controlled clinical trials (RCT) of anti-psychotics for the treatment of PTSD. However case reports, small RCTs and open-label studies have demonstrated the beneficial effect of this pharmacotherapy (add-on and monother- apy) for the treatment of PTSD patients with and with- out psychotic symptoms. Published case reports demonstrate the efficacy of clozapine [8] or amisulpride [3] in the treatment of both PTSD and psychotic symp- toms. Fluphenazine, olanzapine, risperidone and quetia- pine are anti-psychotics with demonstrated efficacy in open clinical trials as a monotherapy in PTSD with psy- chotic features [18-20]. Hamner described the case of a Vietnam veteran with a history of PTSD symptoms and psychotic symptoms including auditory hallucinations, visual hallucinations, thought disorder and paranoid ideation. He had a his- tory of substance abuse (alcohol and cocaine) but had been in remission for one year prior to his evaluation. He was treated unsuccessfully with typical neuroleptics, electroconvulsive therapy, benzodiazepines and lithium. Clozapine was initiated and titrated to 600 mg/day lead- ing to an improvement of his PTSD and psychotic symptoms [8]. However, to date, none of these agents has received registration status for use in PTSD in the USA or in Europe [21]. In the absence of guidelines relating to the condition of PTSD with psychosis, our patient’s psycho- sis responded well to the standard anti-psychotic treat- ment but her co-morbid PTSD features remain. Given her complicated presentation, her recovery will require a