Hayashi 2004

human psychopharmacology
Hum Psychopharmacol Clin Exp 2004; 19: 351–352.

Published online 27 May 2004 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hup.590
CASE REPORT
Paroxetine treatment of delusional disorder, somatic type

Hiroshi Hayashi, Shingo Oshino, Junichi Ishikawa, Shinobu Kawakatsu and Koichi Otani*
Department of Neuropsychiatry, Yamagata University School of Medicine, 2-2-2 Iidanishi, Yamagata 990-9585, Japan
A 77-year-old female showed delusion of infestation in the oral cavity. She was treated by paroxetine 20 mg/day, and the
hypochondriacal delusion disappeared after 8 weeks. Hypoperfusion in the left temporal and parietal lobes which was
observed when she had the delusion was normalized after resolution of the delusion. This report suggests that paroxetine
may be effective for delusional disorder, somatic type. It also supports the previous views that this disorder is associated with
serotonergic dysfunction and hypoperfusion in the temporal and parietal lobes. Copyright # 2004 John Wiley & Sons, Ltd.
key words — delusional disorder somatic type; paroxetine; serotonin; SPECT
INTRODUCTION CASE REPORT

Delusional disorder, somatic type (DDST) is charac- The case was a 77-year-old housewife. From April
terized by hypochondriacal delusions, and is also 2002, she felt that ‘Something like a membrane is
known as monosymptomatic hypochondriacal psy- sticking to the ceiling of my mouth’, ‘It is slimy, burn-
chosis (Munro, 1988). Munro (1988) has recom- ing and painful’, and ‘It swells and shrinks’. Because
mended pimozide as the first choice drug for this of these distressing sensations, she visited two inter-
disorder. However, there have been several reports nists, an otolaryngologist and a dentist, but no
on the efficacy of tricyclic antidepressants, especially abnormality was found. In August 2002, she was
clomipramine (Sondheimer, 1987; Fernando, 1988; referred to our department.
Kizu et al., 1994; Wada et al., 1999b). These reports She was admitted to our ward. On admission,
suggest that DDST is related to serotonergic dysfunc- depressive symptoms such as depressed mood and loss
tion (Wada et al., 1999b). Therefore, selective seroto- of interest or pleasure were not observed. She was
nin reuptake inhibitors, e.g., paroxetine, may also be given the diagnosis of DDST according to DSM-IV
effective for this disorder. (American Psychiatric Association, 1994). Paroxetine
Meanwhile, Wada et al. (1999a) reported on a treatment and single photon emission computed tomo-
patient with DDST whose hypoperfusion in the tem- graphy (SPECT) using Xe-133 were performed with
poral and parietal lobes improved in parallel with clin- the patient’s consent. The dose of paroxetine was
ical improvement. This report suggests that DDST has 10 mg/day in the first 7 days, and was increased to
some association with hypoperfusion in these brain 20 mg/day from day 8. From day 22 the hypochondria-
regions. cal delusion started to improve, and she said that ‘The
In this report, we present a patient with DDST slimy and painful sensations are less severe than
whose clinical symptoms and hypoperfusion in the before’. On day 53 the delusion was resolved, and
temporal and parietal lobes improved with paroxetine she said that ‘There is no membrane or distressing sen-
treatment. sation in my mouth’. On day 65 she was discharged. At
the time point of August 2003, she has no hypochon-
driacal delusion with the same dose of paroxetine.
* Correspondence to: Dr K. Otani, Department of Neuropsychiatry,
Magnetic resonance imaging on day 17 showed
Yamagata University School of Medicine, 2-2-2 Iidanishi, Yama- multiple small infarctions in the bilateral deep white
gata 990-9585, Japan. E-mail: otani@med.icl.yamagata-u.ac.jp matter, which were considered to be within normal
Received 29 August 2003

Copyright # 2004 John Wiley & Sons, Ltd. Accepted 9 March 2004
352 h. hayashi ET AL.
limits for her age. The SPECT on day 9 showed The present report and the previous report (Wada
reduced regional cerebral blood flow in the left tem- et al., 1999a) suggest that the augmentation of seroto-
poral and parietal lobes, which was normalized on nin function by paroxetine and clomipramine normal-
day 60 (Plate 1). izes hypoperfusion in the left temporal and parietal
lobes. In line with this, it has been reported that parox-
DISCUSSION etine normalizes hypometabolism in these brain
regions in depressed patients (Brody et al., 2001; Ken-
The present case complained that there was something nedy et al., 2001).
like a membrane in the oral cavity causing distressing In conclusion, this report suggests that paroxetine
sensations. Extensive physical examinations revealed may be effective for DDST. It also supports the pre-
no abnormality. Therefore, it was considered that she vious views that DDST is associated with serotonergic
had infestation delusion, and the diagnosis of DDST dysfunction and hypoperfusion in the temporal and
was given. Psychotic depression was ruled out, since parietal lobes.
she had no depressive symptom.
Although Munro (1988) has recommended pimozide
as the first choice drug for DDST, this antipsychotic
REFERENCES
drug has serious cardiovascular side effects such as
QTc prolongation (Haddad and Anderson, 2002). American Psychiatric Association. 1994. Diagnostic and Statistical
Notably, female sex and old age are the risk factors Manual of Mental Disorders, 4th edn. American Psychiatric
Association: Washington, DC.
for the fatal arrhythmias associated with this QTc pro- Brody AL, Saxena S, Stoessel P, et al. 2001. Regional brain meta-
longation (Haddad and Anderson, 2002). Meanwhile, bolic changes in patients with major depression treated with
there have been several reports suggesting that DDST either paroxetine or interpersonal therapy. Arch Gen Psychiatry
is related to serotonergic dysfunction (Sondheimer, 58: 631–640.
Fernando N. 1988. Monosymptomatic hypochondriasis treated with
1987; Fernando, 1988; Kizu et al., 1994; Wada et al., a tricyclic antidepressant. Br J Psychiatry 152: 851–852.
1999b). Therefore, the treatment was started with Haddad PM, Anderson IM. 2002. Antipyschotic-related QTc pro-
paroxetine, a selective serotonin reuptake inhibitor. longation, torsade de pointes and sudden death. Drugs
As expected, the present case responded favourably 62: 1649–1671.
to paroxetine treatment. The hypochondriacal delu- Kennedy SH, Evans KR, Kruger S, et al. 2001. Changes in regional
brain glucose metabolism measured with positron emission
sion started to improve from day 22, and disappeared tomography after paroxetine treatment of major depression. Am
on day 53. Therefore, this report suggests that parox- J Psychiatry 158: 899–905.
etine as well as clomipramine may be effective for Kizu A, Miyoshi N, Yoshida Y, Miyagishi T. 1994. A case with fear
DDST. However, paroxetine may be superior to clo- of emitting body odour resulted in successful treatment with clo-
mipramine. Hokkaido J Med Sci 69: 1477–1480.
mipramine because of its lower side effect profile, Klemm E, Danos P, Grunwald F, Kasper S, Moller H-J, Biersack
e.g. fewer anticholinergic effects and a lower inci- H-J. 1996. Temporal lobe dysfunction and correlation of regional
dence of withdrawal due to adverse events (Wagstaff cerebral blood flow abnormalities with psychopathology in schi-
et al., 2002). This report also supports the previous zophrenia and major depression—a study with single photon
emission computed tomography. Psychiatry Res Neuroimaging
view that DDST is related to serotonergic dysfunction Section 68: 1–10.
(Wada et al., 1999b). Min SK, An SK, Jon D-I, Lee JD. 1999. Positive and negative symp-
The first SPECT taken when she had the delusion toms and regional cerebral perfusion in antipsychotic-naive schi-
showed hypoperfusion in the left temporal and parietal zophrenic patients: a high-resolution SPECT study. Psychiatry
lobes. This hypoperfusion was normalized after reso- Res Neuroimaging Section 90: 159–168.
Munro A. 1988. Monosymptomatic hypochondriacal psychosis. Br
lution of the delusion. Therefore, the previous finding J Psychiatry 153(Suppl. 2): 37–40.
that DDST was associated with hypoperfusion in these Sondheimer A. 1987. Clomipramine treatment of delusional disor-
brain regions (Wada et al., 1999a) was replicated. der-somatic type. J Am Acad Child Adoles Psychiatry 27: 188–
The temporal and parietal hypoperfusion in the pre- 192.
sent case was localized on the left side, while that in Wada T, Kawakatsu S, Komatani A, Okuyama N, Otani K. 1999a.
Possible association between delusional disorder, somatic type
the previous case was predominant on the left side and reduced regional cerebral blood flow. Progr Neuro-Psycho-
(Wada et al., 1999a). This left-sided laterality may pharmacol Biol Psychiatry 23: 352–351.
not be accidental, in the light of the previous reports Wada T, Kawakatsu S, Nadaoka T, Okuyama N, Otani K. 1999b.
suggesting a relationship between positive symptoms Clomipramine treatment of delusional disorder, somatic type.
Int Clin Psychopharmacol 14: 181–183.
of schizophrenia and hypoperfusion in the left tem- Wagstaff AJ, Cheer SM, Matheson AJ, Ormrod D, Goa KL. 2002.
poral and parietal lobes (Klemm et al., 1996; Min Paroxetine. An update of its use in psychiatric disorders in adults.
et al., 1999). Drugs 62: 655–703.
Copyright # 2004 John Wiley & Sons, Ltd. Hum Psychopharmacol Clin Exp 2004; 19: 351–352.
Plate 1. The SPECT images on day 9 (above) and day 60 (below). OM, the orbitomeatal plane
Copyright # 2004 John Wiley & Sons, Ltd. Hum Psychopharmacol Clin Exp 2004; 19

Hayashi 2004

Uploaded by

Copyright:

Available Formats

Hayashi 2004

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Hayashi 2004

Uploaded by

Copyright:

Available Formats

human psychopharmacology

Hum Psychopharmacol Clin Exp 2004; 19: 351–352.

Paroxetine treatment of delusional disorder, somatic type

key words — delusional disorder somatic type; paroxetine; serotonin; SPECT

INTRODUCTION CASE REPORT

Received 29 August 2003

You might also like