Dear Editor

Labbate and Douglas recently described the use of olanzapine to treat a patient with posttraumatic stress disorder (PTSD)(1). The mood and anxiety symptoms were controlled, but the patient suffered from nightmares and sleep disturbances. We present 2 cases wherein olanzapine was used early in the pharmacological treatment of PTSD.

Patient 1 is a 25-year-old woman, diagnosed at age 23 years with PTSD, who as a child was sexually assaulted by an older woman. Her sexual orientation was exclusively heterosexual, and her sexual relationship with her husband was described as fulfilling. Her condition had been managed successfully with cognitive-behavioural therapy with a community social worker, but she suffered a relapse while undergoing treatment for infertility. Most disturbing to her were intrusive, ego-dystonic thoughts and images of a homosexual nature. Treated as an outpatient with fluvoxamine up to 400 mg daily for 2 weeks by her family physician, her distress increased to the point where she became suicidal and required admission. In response to the increasing intensity of her ego-dystonic images, she was started on a trial of olanzapine 2.5 mg at bedtime. Within 2 days she reported that both the frequency and intensity of the images had decreased, and she was discharged 10 days after starting olanzapine. She continues to take fluvoxamine 400 mg daily and to attend for psychotherapy.

Patient 2 is a 45-year-old woman who was sexually assaulted as a 12-year-old by her then 18-year-old brother. After her daughter was sexually assaulted, she developed symptoms that included flashbacks, emotional numbing, derealization, marked hypervigilence, avoidance of men who resembled her brother, and suicidal ideations. Until her

daughter’s assault, she had no symptoms and no recollection of her own assault. She saw a psychologist in the community for depression, but she did not disclose her PTSD symptoms at that time. She took a leave of absence from work and was admitted after a suicide attempt. She was treated with paroxetine, reaching 40 mg daily 2 days before admission. After admission, she disclosed the history of the sexual assault and her symptoms and was started on olanzapine 2.5 mg at bedtime. Two days after starting olanzapine, she reported a decrease in her PTSD symptoms and was no longer suicidal. She was able to discuss her assault openly and resumed therapy with her outpatient psychologist.

These cases demonstrate that olanzapine, along with other second-generation antipsychotics, may have efficacy in treating not only those  patients with PTSD who experience chronic residual symptoms (1–3) but also those in the acute phase of pharmacological treatment. An analogous protocol is the use of benzodiazepines in the treatment of other anxiety disorders while serotonin-specific reuptake inhibitors (SSRIs) are being titrated and during the period before clinical effects are noted. It is possible that the response seen in these patients reflects the actions of the SSRIs, but the rapid and temporal relation between the initiation of olanzapine and the decrease within days in intrusive thoughts and visual imagery described by the patients strongly suggests that this medication was involved.

References

1. Labbate LA, Douglas S. Olanzapine for nightmares and sleep disturbance in post-traumatic stress disorder (PTSD). Can J Psychiatry 2000;45:667–8.
2. Krashin D, Oates EW. Risperidone as an adjunct therapy for post-traumatic stress disorder. Mil Med 1999;164:605–6.
3. Leyba CM, Wampler TP. Risperidone in PTSD. Psychiatr Serv 1998;49:245–6.

Trevor I Prior, BSc(Hons), MD, PhD, FRCP(C)
Edmonton, Alberta

Dear Editor

We read with interest the case reports written by Dr Prior. The salutary effect of olanzapine on the re-experiencing symptoms of posttraumatic stress disorder (PTSD) in these 2 acute cases comports with our finding of similar improvement in a patient with chronic PTSD. These compelling cases suggest that olanzapine may be a useful adjunct in the complex treatment of PTSD, although placebo-controlled trials are needed to determine the short- and long-term efficacy of olanzapine on re-experiencing symptoms.

Lawrence A Labbate, MD
Susan Douglas, MD
Charleston, South Carolina

Dear Editor

I report the first case of a woman with schizoaffective disorder (depressive type) who had an episode of hypomania associated with the atypical antipsychotic quetiapine (no similar reports were  found on MEDLINE).

A 43-year-old woman diagnosed with DSM-IV schizoaffective disorder (depressive type) at age 27 years had for years had a stable clinical picture (negative symptoms) while taking fluoxetine 20 mg daily, chlorpromazine 100 mg daily, and diazepam 5 mg daily. During a follow-up visit, she complained of mild insomnia and weight gain. Her mood was normal, and she was not psychotic. Chlorpromazine was discontinued, and quetiapine 100 mg daily was added at night. Over the course of 1 week, quetiapine was increased to 300 mg daily. During the following 4 weeks, she had increased difficulty sleeping,