PTSD? Schizoaffective? Does it matter?

Bryan crouched on the edge of his chair, hands poised on his knees. He looked wary, about to leap up and attack whatever danger faced him.

He was in my office at an outpatient substance abuse program for formerly incarcerated individuals on state parole. Not usually considered a dangerous place, unless you're afraid to talk about your feelings. (I'm rather proud that many strong men have felt safe crying in my office.)

“I'm paranoid,” he said. Bryan had survived a lifetime of trauma: a physically and emotionally abusive father; a dangerous stint of selling drugs on the street; seeing rivals and friends killed; and several years in prison, including long stretches in “the box” (solitary confinement).

When he neared the end of his time, he was transferred to special pre-release barracks where psychiatric medication was forbidden, which fortunately is no longer state policy. Diagnosed with schizoaffective disorder, Bryan endured the return of harrowing symptoms: anxiety that he was going to be attacked, hurt or killed; nightmares in which he relived prior traumas and awoke sweating and crying; and vicious auditory hallucinations.

“I can't live like this,” he said. “I'm no good to anyone.”

“Or to yourself,” I said. “You look like you're in a lot of pain.”

“I have to be on my guard,” Bryan clarified. “When I take the subway, I always scan the car before I get in. If I see anyone who looks dangerous, I wait for the next train. When I get in, I have to sit or stand near the middle so I can see what's going on in the whole car.”

“Do you really think someone's going to attack you on the subway?” I asked.

He winced. “I know it sounds stupid,” he said. “I know I shouldn't think that way, but I do.”

Hypervigilance is a symptom of PTSD. As are nightmares. I started to wonder about his diagnosis. Could he be suffering from PTSD instead of schizoaffective? He was eloquent and articulate; often people with schizoaffective disorder suffer cognitive symptoms and have difficulty expressing themselves lucidly. He also recognized that his fear of fellow subway riders was irrational.

I wasn't familiar of any cases of PTSD that involved auditory hallucinations. “What voices do you hear?” I asked him. “What are they saying?”

“It's my father's voice,” he said, looking at the floor and speaking softly. “I can hear him screaming at me. Telling me I'm lazy, I'm no good, I'm a failure. He always used to say that to me when I was growing up.”

What's the difference between a vivid memory and a hallucination? I wondered. Between reliving the verbal abuse and hallucinating?

“What does your father say to you now?” I asked.

“Same things he always said to me when he was alive,” Bryan responded.

“Does he comment on your current life?” I asked. “He died before you went to prison. When you were in prison, did he yell at you about that?”

Bryan shook his head. “He just says the same things he always said.”

“I'm a little surprised that he hasn't... updated his abuse,” I said. “Usually hallucinations are in the moment, like someone's talking to you now. Do you hear him now?” I asked.

Bryan hesitated, then nodded.

“What is he saying?” I asked. “Is he telling you not to trust me?” Sometimes people who experience auditory hallucinations will hear messages that reinforce what they're feeling. A person with paranoia might be advised by the voices not to trust his counselor.

“He's not talking about you at all,” said Bryan. “Just the same old 'you piece of shit, you worthless sack of garbage' stuff.”

Our program had a wonderful psychiatrist, who met with Bryan and prescribed an antipsychotic and an antidepressant. I asked her if she thought he'd been misdiagnosed.

“Maybe,” she said. “But it really doesn't matter. I'm interested in symptom relief. If the medications stop him from hearing his father, and help him feel less anxious, that's all that matters.”

After trying a few different combinations—not all psychiatric medications work for all people, so it's always a trial-and-error process—Bryan reported that he was sleeping better, felt less anxious, and gradually stopped hearing his father's voice screaming abuse. He enrolled in a training program to become a credentialed alcohol and substance use counselor. On his discharge date, he leaned back in the chair in my office, arms crossed blithely behind his head, completely at ease.