Coentre and Power Journal of Medical Case Reports 2011, 5:97 http://www.jmedicalcasereports.com/content/5/1/97 Her background history suggested co-morbid PTSD. Twelve years ago, she saw her family (parents, sisters and brother) being killed during the civil war in her birth country in Africa. Her clinical PTSD symptoms, such as the recurring nightmares, hyper-arousal, and initial and middle insomnia, began shortly afterwards. Eight years later, she came to the UK as an asylum see- ker. During her first few years in the UK, she had no social support, was unable to speak English, experienced homelessness and was unsuccessful in gaining asylum. Her auditory and visual hallucinations and persecutory delusions started at this time. A few months before her first contact with mental health services, her psychotic symptoms and PTSD features became more frequent and intense. With no stable relationship she became pregnant and visited her general practitioner who referred her to our first-episode psychosis unit. Upon admission, she presented as well kempt yet she appeared distressed. She was withdrawn and quiet and there was some delay in her responses to questions. She was tearful and her mood was low but reactive. She described vivid and clear auditory and visual hallucina- tions and persecutory delusions. Her medical psychia- tric, personal, and family histories were unremarkable. A physical examination, neurological examination and brain magnetic resonance imaging (MRI) scan were nor- mal. The results of our routine blood investigations were in the normal range, and a pregnancy test was positive. At our clinical interview, she clearly fulfilled the DSM-IV-TR criteria for PTSD and psychotic disor- der not otherwise specified (NOS). Because of the intensity of her symptoms, her distress and suicidal ideation, our mental health team recom- mended ongoing hospitalization. She was started on tri- fluoperazine (5 mg/day) and cognitive-behavioral therapy for psychosis. She also started a prenatal follow- up. She self-reported a partial improvement in her clini- cal picture and her psychotic symptoms gradually resolved over a three-week period, although they occa- sionally resurfaced when she was under stress or when- ever her medication compliance lapsed. She was discharged from hospital and is now living in temporary accommodation funded by local services and waiting for her asylum re-application to be processed. She continues to have ongoing PTSD symptoms associated with the initial tragic event as persistent remembering of the stressor event with recurring and vivid memories, night- mares, hyper-arousal and initial insomnia. She also avoids circumstances resembling the initial stressor event, such as wars and violence. Discussion In our case report, we describe the case of a patient with PTSD with psychotic symptoms. Her PTSD Page 2 of 5 developed soon after a severe traumatic experience asso- ciated with a civil war twelve years ago: she witnessed the murder of her nuclear family. Eight years later she developed psychotic symptoms, which included auditory and visual hallucinations and persecutory delusions. She finally presented two years ago to mental health services in the context of major social stresses, an unwanted pregnancy, potential homelessness, and a rejected asy- lum claim. Symptomatically, her psychosis responded well to treatment but the PTSD features and stresses remain. Her follow-up is now directed towards dealing with these issues, as well as preventing a relapse. We reviewed the scientific literature regarding the diagnosis and treatment of PTSD with psychotic symp- toms. There are few case reports about the presence of PTSD with psychotic features, mainly involving war veterans, but none using trifluoperazine as a psychophar- macological treatment. In 2008, Floros et al. reported the case of a man with psychotic symptomatology after a traumatic event involving the accidental mutilation of his fingers. His treatment plan included pharmacotherapy and supportive psychotherapy with the establishment of a good doctor-patient relationship. This biopsychosocial approach was made to integrate all aspects relating to his history in a meaningful way [3]. In our case report, our patient had PTSD symptoms including experiencing recurrent distressing images of the traumatic event, with a markedly diminished interest and participation in significant activities and the avoidance of thoughts and conversations associated with the trauma. She also had persistent symptoms of increased arousal, with difficulty falling and staying asleep. PTSD with psy- chotic symptoms is associated with a clinically significant impairment in social and occupational functioning, includ- ing difficulties in getting a stable job and holding down relationships. According to the DSM-IV-TR, PTSD is clas- sified as an anxiety disorder but expressions of the disor- der may include obsessions, phobias, dissociations or depression [4]. Less characteristic and poorly studied, are the psychotic symptoms associated with PTSD. Our patient presented with visual and auditory hallucinations and persecutory delusions with content that mirrored her PTSD. In patients who do not have another established severe mental illness, the presence of psychotic symptoms in PTSD might be better captured as a dimension or sub- group of PTSD rather than psychosis NOS. Mueser et al. have suggested that PTSD influences psychosis both directly, through the effects of specific PTSD symptoms including avoidance, over-arousal and re-experiencing the trauma, and indirectly, through the effects of common consequences of PTSD such as re- traumatization, substance abuse and difficulties with interpersonal relationships [5]. Our patient had both; she frequently “relived” the traumatic event through