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On-line version ISSN 1809-452X
Rev. Bras. Psiquiatr. vol.26 no.2 São Paulo June 2004
LETTERS TO THE EDITORS
Use of fluoxetine in somatic delusional disorder
Lucas de Castro QuarantiniI; Maria Conceição do Rosário-CamposI; Susana Carolina Batista-NevesI; Ângela Miranda-ScippaI; Aline Santos SampaioII
IPsychiatric Service of the University
Hospital Professor Edgard Santos - Federal University of Bahia
IIDepartment of Psychiatry of the Medical School of the University of São Paulo
Delusional disorders are characterized by the presence of an unshakeable, circumscribed idea, with a non-bizarre content and without deterioration of personality. Delusions are monothematic and likely to occur in daily life such as treachery or being infected. The minimum period of the condition should be one month.1
Obsessive-compulsive disorder (OCD) is characterized by the occurrence of obsessions and/or compulsions. Obsessions are thoughts, impulses or recurrent, intrusive and unpleasant mental images, recognized as products of the subject's own mind and which cause anxiety. Compulsions are repetitive behaviors or mental acts which the individual is led to voluntarily perform in response to an obsession to reduce or prevent a determined event.1
The correlation between somatic delusional disorder (SDD) and OCD is scarcely known, but several similarities between them are noteworthy.2
IMS, 65 years old, maidservant, Black, Catholic, some elementary school. In 2001, she had been complaining for one year about generalized pruritus, which she attributed to the presence of little insects on her skin. She was referred by the dermatological service after the exclusion of physical causes of these complaints. She intensely undertook the cleaning of her home, fearing that her granddaughter and her son would be infested and she also avoided touching them. The patient presented delusional, monothematic thought, related to the infestation by insects. Senso-perception with signs of kinesthetic hallucinations. She had poor insight on her psychical disease. Without other psychopathological alterations or cognitive impairment. Normal neurological exam and brain tomography.
She received diagnosis of SDD and the treatment started. Pimozide 8 mg daily for seven months was used, trifluoperazine 10 mg for six months, and haloperidol 10 mg for five months. The raising of the dose of medications was limited due to the occurrence of extra-pyramidal side-effects. Risperidone 3 mg was also used and was discontinued after 15 days for non-compliance. She had no improvement with those medications. She started having new rituals in order to be sure of the condition of her skin, what decreased her anxiety. It was decided to start treatment with fluoxetine 40 mg daily, due to the successive failures with antipsychotics and based on some experiences reported in the literature.2 After two months of treatment, the patient was almost asymptomatic, with insight about being infested and not being worried with the transmission to her family members.
The resemblance between SDD and OCD is due to their clinical similarities such as the occurrence of intrusive and recurrent thoughts, non-deterioration of personality and behaviors of verification and corporal cleanliness. Some authors have proposed that OCD patients with poor insight would belong to a different subtype, within a schizo-obsessive spectrum, whereas others included SDD among the psychiatric conditions related to OCD.3
Up to the '80s, SDD treatment was based on the use of antipsychotics, preferably pimozide, which besides being a dopaminergic antagonist has an opiod antagonistic action.4 After this period, there have been reported cases with improvement using tricyclic antidepressants and, especially, clomipramine and selective serotonin reuptake inhibitors (SSRI).3 Although this case adds evidence of the association between SDD and OCD, further studies with a larger number of patients are needed for the better understanding of this association.
1. American Psychiatric Association. Diagnostic and Statistical Manual Of Mental Disorders, DSM-IV, 4th Edition, Washington DC, American Psychiatric Press; 1994. p. 886.
2. Torres AR. Hipocondria e Transtorno Delirante Somático. In: Miguel EC, editor. Transtornos do espectro obsessivo-compulsivo: diagnóstico e tratamento. Rio de Janeiro: Guanabara Koogan; 1996. p. 138-49.
3. Torres A. Diagnóstico diferencial do transtorno obsessivo-compulsivo. Rev Bras Psiquiatr 2001;23:21-3.
4. Reilly TM. Delusional infestation. Brit J Psychiatry 1988;153:44-6.