Persistent paranoid delusions following the September 11 terrorist attacks in a man with no pre-existing mental illness.

Abstract: The effects of modern day terrorism on mental health are not well understood. Described here is a 51-year-old male with no pre-existing mental illness who developed paranoid delusions related to the September 11, 2001, terrorist attacks shortly after they occurred. After about two years of treatment with quetiapine the patient was no longer delusional about terrorism but experienced extensive paranoid delusions about commonly encountered persons, requiring treatment which continues to the current time. Clinicians should be aware of the possible impact of tertorist activities on the mental health of vulnerable individuals.

Key Words: terrorism, mental health, psychosis, delusional disorder 

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The terrorist attacks of September 11, 2001, shocked the world and had a devastating effect on many people, including individuals with and without mental illness. As would be expected, many of those directly exposed to the traumatic events had increased rates of post traumatic stress disorder (PTSD) symptomatology and anxiety (1,2) and those who lost friends or family experienced increased rates of depression. (3) Brief psychotic episodes occurred in rare instances (4) and at least one patient with a pre-existing mental illness was temporarily worsened by the attacks. (5) Presented here is a patient with no prior mental illness who developed persistent paranoid delusions secondary to the September 11 terrorist attacks.

Case Report

Our patient, a 51-year-old male, was brought by his wife for evaluation on October 22, 2001, because of increasing paranoia for about a month. He related that several days after the September 11 terrorist attacks he began thinking that his small rural town was the intended site of the next attack. His sleep decreased to about three hours per night and he became hypervigilant. He worked for a trucking firm and started thinking that the trucks were carrying hidden weapons or explosives. When a new trainee was hired, the patient believed that he was part of an attack plot. Occasionally he complained of smelling strange odors which he believed were poisonous gases or toxic substances produced by terrorists.

The patient's medical history was unremarkable and he was on no medications. He had no history of any psychiatric problems. He denied use of drugs or alcohol except for occasionally drinking beer at social events. He had no family history of mental illness. He had grown up in a rural area and described his childhood as happy. After completing high school he spent two years in the Army with an honorable discharge. He had been married to his wife for over 20 years and both of them described the marriage as satisfactory. He had been employed by the same employer for over 12 years preceding his presentation.

Treatment was started with quetiapine 25 mg b.i.d. with gradual increases in dosage. However he became increasingly paranoid. He climbed trees to use binoculars to monitor suspicious vehicles in his town and talked about buying guns and ammunition. He was eventually unable to continue working and had to be hospitalized.

He expressed great relief when admitted to a psychiatric unit because he felt the hospital was relatively safe. Examination revealed him to be cooperative and polite. He was anxious. Mood was euthymic or mildly depressed. His thought processes were coherent and cognitive functioning was within normal limits. He was paranoid and preoccupied with paranoid delusions of his town being the site of a terrorist attack as noted above. He believed that a number of individuals were involved in plots, that he was a specific target, and that a variety of everyday events were somehow related to the activities of terrorists. Physical and neurologic examinations were within normal limits. Laboratory studies, EEG, and MRI of the brain with gadolinium were unremarkable. Psychological testing included a Mini Mental State Examination (6) score of 30/30. His score on the Hamilton Rating Scale for Depression (7) was 13, not suggestive of a primary depressive process. On the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) (8) he scored 22 (of a possible 49) in the positive scale, 13 (of a possible 49) on the negative scale, and 26 (of a possible 112) on the general psychopathology scale. Although he was anxious, he did not have any other symptoms of post traumatic stress disorder (PTSD). He met criteria for an initial diagnosis of psychotic disorder not otherwise specified. (9)

The dosage of quetiapine was gradually increased and titrated to control his paranoia. Improvement was slow and ultimately 300 mg b.i.d. was required. After a few weeks in the hospital he expressed discouragement about his life and the future in general and was thought to be having some depressive symptoms and sertraline 50 mg daily was started. A month after admission he was discharged on these medications.

Although he had concerns about his symptoms of insomnia and anxiety, the patient was unaware of having any kind of psychotic or delusional disorder, even after this was discussed with him. He did not consider his beliefs about terrorist attacks as delusions but actual facts and could not be convinced to attribute his unusual thoughts to a mental disorder. He was unaware of potential social consequences of his mental disorder, although it had already impaired his relationship with his employer and coworkers. The patient perceived quetiapine as being prescribed for anxiety, not for delusional thoughts, and was unaware of its effects on those thoughts.

With time his paranoia began to gradually lessen and after about two years, attempts were made to wean the quetiapine. He tolerated initial decreases, but dosages of less than 100 mg b.i.d. resulted in recurrence of paranoia and he had to remain on the medication. However his delusions had shifted from ideas related to the terrorist attacks to other generalized persecutory thoughts about different individuals (such as his neighbors and the local police) wanting to harm him, spying on him, and telling harmful lies about him. Although his paranoia was significant, at this point none of his delusions were bizarre and he fulfilled DSM-IV-TR criteria for a diagnosis of delusional disorder, persecutory type. (9) His mood was moderately improved and he also remained on sertraline. As of August 2005 he continued to require treatment.

Discussion

Our patient's lack of insight about his mental disorder undoubtedly interfered with his improvement. Many reports indicate that a majority of patients with psychotic disorders have poor insight. Such patients appear to deny, fail to acknowledge, or in essence, lack awareness of having a mental disorder or symptoms of a mental disorder. (10, 11) A body of literature has developed which suggests that poor insight may play an important role in the course of psychotic disorders. Such would appear to be the case with our patient. Why such a phenomenon occurs is unclear. Parallels have been drawn between lack of insight in psychosis and the loss of self awareness that often accompanies frontal lobe dysfunction or anosognosia related to lesions of the right parietal lobe. Alternatively, lack of insight early in the course of illness may be a psychological defense. (12)

Not enough is known about the mental health effects of modern day terrorism. Patients with elevated rates of PTSD symptomatology following the September 11 attacks have not been followed longitudinally and the longterm psychological consequences for these individuals are unknown. It was anticipated that veterans with pre-existing PTSD would have exacerbations of symptoms by the attacks. However, analysis of symptom levels and service utilization data in samples of veterans with PTSD have failed to demonstrate exacerbations of PTSD symptoms or increases in service utilization after September 11 and have even documented the opposite effect in some samples. (13-15) On the other hand, one sample of veterans demonstrated a significant increase in PTSD symptom severity directly after the terrorist attacks, followed by a return to baseline functioning. (16) Thus, what clinicians might anticipate in terms of chronic PTSD symptomatology related to terrorist attacks on the United States is not yet clear.

Similarly, only limited reports are available concerning the relationship of the terrorist attacks and other mental illnesses. Residents who lived in the neighborhood of the World Trade Center were surveyed immediately after September 11 and five months later; prevalent anxiety was found in general community residents and additional depression in those who lost family or friends. (3) Clinicians also identified individuals who developed psychotic symptoms after heavy exposure to the media coverage of the attacks. Their symptoms resolved with time. (4) A patient with a pre-existing mental illness with psychotic symptoms who had to be evacuated from the World Trade Center did not receive any specialized treatment during the ensuing months as his mental state deteriorated, and he eventually required psychiatric hospitalization for a full blown psychotic episode. He had not needed hospitalization previously and the trauma of the terrorist attack was felt to have precipitated the psychotic episode leading to his first admission. He improved after 42 days in the hospital. (5)

Our patient appears to have developed a persistent mental disorder other than PTSD secondary to the stress of the September 11 attack, or at least to have experienced precipitation of a latent, previously unrecognized condition. This case demonstrates that certain individuals may be particularly vulnerable to the effects of events of this nature. Acts of terrorism are particularly stressful because they lead to continuing uncertainty of future terrorist acts. Literature on disaster mental health has frequently described important differences between "natural" and "man-made" disasters. (17) Natural disasters typically have an identifiable low point, after which the worst is over and the process of recovery can begin. (18) In contrast, a man-made disaster typically poses continuing uncertainty about when it began, when it will end, and what continuing effects victims may yet encounter. (19) The fact that Americans are unaccustomed to such a manifest threat on their own soil and the possibility that global terrorism may be entering a dangerous escalating phase creates an environment which may have a significant impact on vulnerable individuals. Cases such as that of our patient and the others mentioned above suggest that clinicians should be aware of the possible impact of terrorism on certain people, with possible worsening of some patients who already have mental illness and precipitation of symptoms in certain individuals who have no history of pre-existing mental illness.

References

1. Gales S, Ahearn J, Resnick H, et al. Psychological sequelae of the September 11 terrorist attacks in New York City. N Engl J Med 2002; 346:982-987.

2. Schlenger WE, Caddell JM, Ebert L, et al. Psychological reactions to terrorist attacks: findings from the national study of Americans' reactions to September 11. JAMA 2002;288:581-588.

3. Chen H, Chung H, Chen T, et al. The emotional distress in a community after the terrorist attack on the World Trade Center. Community Ment Health J 2003;39:157-165.

4. Rushing SE, Jean-Baptiste M. Two cases of brief psychotic disorder related to media coverage of the September 11, 2001 events. J Psychiatr Pract 2003;9:87-90.

5. Ellick JD, Paradis CM. The effects of the September 11 World Trade Center attack on a man with preexisting mental illness. Psychiatr Serv 2004;55:1313-1314.

6. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the state of patients for the clinician. J Psychiatr Res 1975;12:189-198.

7. Hamilton A. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.

8. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 1987;13:261-276.

9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

10. Amador XF, Strauss DH, Yale SA, et al. Awareness of illness in schizophrenia. Schizophr Bull 1991;17:113-132.

11. Amador XF, Strauss DH, Yale SA. Assessment of insight in psychosis. Am J Psychiatry 1993;150:873-879.

12. Thompson KN, McGorry PD, Harrigan SM. Reduced awareness of illness in first-episode psychosis. Compr Psychiatry 2001;42:498-503.

13. Reeves RR, Liberto V. Reactions of Veterans Administration psychiatric patients to the September 2001 terrorist attacks (letter). South Med J 2001;94:1139.

14. Rosenheck R, Fontana A. Use of mental health services by veterans with PTSD after the terrorist attacks of September 11. Am J Psychiatry 2003;160:1684-1690.

15. Rosenheck RA, Fontana A. Post-September 11 admission symptoms and treatment response among veterans with posttraumatic stress disorder. Psychiatr Serv 2003;54:1610-1617.

16. Niles BL, Wolf EJ, Kutter CJ. Posttraumatic stress disorder symptomatology in Vietnam veterans before and after September 11. J Nerv Ment Dis 2003;191:682-684.

17. Ofman PS, Mastria MA, Steinberg J. Mental health response to terrorism: the World Trade Center bombing. J Ment Health Counseling 1995;17:312-320.

18. Baum A, Davidson LM. A suggested framework for studying factors that contribute to trauma in a disaster. In Sowder BJ (ed): Disasters and Mental Health: Selected Contemporary Perspectives. Washington, DC, US Department of Health and Human Services, 1985, pp 29-30.

19. Bollin R. Disaster characteristics and psychosocial impacts. In Sowder BJ (ed): Disasters and Mental Health: Selected Contemporary Perspectives. Washington, DC, US Department of Health and Human Services, 1985, pp 2-27.

Roy R. Reeves, DO, PHD and John J. Beddingfield, MD

From the G.V. (Sonny) Montgomery VA Medical Center and the University of Mississippi School of Medicine, Jackson, MS.

Reprint requests to Roy R. Reeves, DO, PhD, Chief of Mental Health (11M), VA Medical Center, 1500 E. Woodrow Wilson Drive, Jackson, MS 39216. Email: [e-mail]

Accepted December 2, 2005.

RELATED ARTICLE: Key Points

* Acts of terrorism are particularly stressful because they lead to continuing uncertainty about when they will end and what continuing effects victims may yet encounter.

* The potential effects of modern day terrorist activities on mental health are poorly understood.

* Clinicians should be aware of the possible impact of terrorism on the mental health of vulnerable individuals.