Coentre and Power Journal of Medical Case Reports 2011, 5:97 http://www.jmedicalcasereports.com/content/5/1/97 multi-faceted approach with an emphasis on addressing her pre-existing PTSD. She did not develop any extra- pyramidal symptoms associated with the use of a typical anti-psychotic, however, Chan et al. report the cases of three patients with PTSD with psychotic features who developed severe extra-pyramidal side effects, namely akathisia, leading to the withdrawal of the anti-psychotic medication [22]. Several psychotherapeutic interventions have been stu- died in PTSD and psychotic illnesses, with a growing lit- erature suggesting that they are both feasible and effective. Waldfogel et al. report the case of a non- combat veteran with PTSD with psychotic symptoms who was not successfully treated with anti-psychotics and for whom exposure therapy was successful in treat- ing PTSD and psychosis [23]. Mueser et al. published a randomized controlled trial of the cognitive-behavioral treatment (CBT) of PTSD in severe mental illness, which includes breathing retraining, education about PTSD and cognitive restructuring. Results indicated that patients included in a 12- to 16-session CBT program showed a greater improvement of their PTSD symp- toms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance compared with treatment as usual, where patients continued to receive the usual treatments they had been undertaking in local mental health centers [24]. Frueh et al. report an open trial in adults with PTSD and either schizophrenia or schizoaf- fective disorder who were treated via an 11-week cogni- tive-behavioral intervention. The trial involved 22 group and individual sessions for PTSD consisting of anxiety management therapy, psycho-education, social skills training and exposure therapy. Participants showed a significant improvement of their PTSD symptoms and high treatment satisfaction [25]. Besides the psychophar- macological therapy, our patient could benefit from one of these psychotherapeutic programs targeting PTSD symptoms. As in the case report published by Waldfogel et al., patients presenting with PTSD with psychotic features who do not have a well established severe mental illness might also respond to conventional psychotherapeutic treatments with a demonstrated efficacy for the treat- ment of PTSD in the general population [23]. Due to the paucity of published systematic studies, this is a field for future research. Because our patient has no friends or family in the UK, our diagnosis was based only on self-reported infor- mation; a less rigorous approach than those using other sources of information to corroborate a patient’s account. A structured clinical interview and the use of specific measure instruments could also help in rating Page 4 of 5 symptoms and promoting an improvement in clinical daily routine. Conclusions There are many factors responsible for the symptoms that occur in response to a traumatic event, including cognitive, behavioral, physiological, affective and envir- onmental factors. These factors may predispose to the development of PTSD and/or psychotic disorders. The independent diagnosis of PTSD with psychotic features remains an open issue. Evidence seems to demonstrate that the two disorders - PTSD and psychosis - may both emerge from a traumatic experience, or that PTSD itself may increase the risk of subsequent psychotic illness. A psychological formulation addressing the potential causes of PTSD and psychosis that could be treated with specific interventions (such as CBT) is essential. Consent Written informed consent was obtained from the patient for publication of this case report and any accompany- ing images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Abbreviations CBT: cognitive-behavioral therapy; DSM-IV-TR: diagnostic and statistical manual of mental disorders, fourth edition, text revision; MRI: magnetic resonance imaging; NOS: not otherwise specified; PTSD: post-traumatic stress disorder; RCT: randomized, double-blind, placebo-controlled clinical trials; SSRIs: selective serotonin re-uptake inhibitors. Author details 1Lambeth Early Onset (LEO) Service, Lambeth Hospital, South London and Maudsley NHS Trust, 108 Landor Road, London SW9 9NT, UK. 2Institute of Psychiatry, King’s College, 16 De Crespigny Park, London SE5 8AF, UK. 3Department of Psychiatry, Faculty of Medicine, Hospital Santa Maria, University of Lisbon, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal. Authors’ contributions RC designed the study, reviewed the existing literature and drafted the manuscript. PP carried out the follow up on the patient, took part in the scientific discussion and helped to draft the manuscript. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 8 May 2010 Accepted: 10 March 2011 Published: 10 March 2011 References 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4 edition. Washington, DC: APA; 1994. 2. Kilcommons AM, Morrison AP: Relationships between trauma and psychosis: an exploration of cognitive and dissociative factors. Acta Psychiatr Scand 2005, 112:351-359. 3. Floros GD, Charatsidou IC, Lavrentiadis G: A case of PTSD presenting with psychotic symptomatology: a case report. Cases J 2008, 1:352. 4. Deering CG, Glover SG, Ready D, Eddleman HC, Alarcon RD: Unique patterns of comorbidity in posttraumatic stress disorder from different sources of trauma. Compr Psychiatry 1996, 37:336-346.