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Delusion or Obsession: Implications for Treatment
663
LEITERS TO EDITOR
attorneys. Yet they continue to testify because of their concern for the child 's future and because they believe that the judicial system (for all its bumbling) is attempting to protect the child. In spite of the flak, psychiatrists can act as the child's advocate and educate the court about the needs of children. It is true that testimony based on an evaluation, with or without the anatomical dolls, can be discredited by a bright, "rhetorically apt" attorney, but it is also true that much of what occurs in the playroom stands on its own merit and that there is no one more competent to elicit this material and translate it in court than the child psychiatrist. It is also true that overly aggressive, disparaging attorneys often discredit themselves and generate sympathy for the child. Dr. Donovan states that there are good reasons to abandon the dolls apart from their use in court because the dolls are "potentially very countertherapeutic." He does not explain why this is the case but later he asserts that the child might wonder why adults have such strange doUs in their office and what they might do with them after hours. I suspect that Dr. Donovan shares the culture's bias against the genitals. Children could just as well wonder why everyday dolls come without genitals and what this means about how they should act in the playroom. My major concern about Dr. Donovan's letter has nothing to do with doU physiogamy. He views research in child psychiatry as inconsistent with concern for the child. The protection, care, and treatment of children and adolescents has somehow been compromised because science has " mesmerized the field for two decades. " Dr. Frankenstein is not dead . No good will come from establishing a dichotomy between the laboratory and the clinic: if children are to be well served it will be through the integration of concepts from each of these crucial areas. Alayne Yates, M.D. Chief of Child Psychiatry CoUege of Medicine University of Arizona Tucson, Arizona
surprising that the patient responded to clomipramine, which may have some beneficial effect in obsessive-compulsive disorder, as Dr. Sondheimer notes . Of course, without seeing the case itself, I can only express my reservations. However, Dr. Sondheimer should know that an international literature on MHP does appear to support very strongly the relative specificity of pimozide in the condition (Ungvari, 1984). In fact, in the United Kingdom it is now officially accepted that this medication be recommended as treatment for MHP. The literature from the United States does not reflect this because pimozide has so recently become available there, and because it is currently indicated onl y for Tourette's syndrome. I think Dr. Sondheimer's comment that pimozide has been " touted" for several years as the treatment of choice for MH [sic] is rather condescending. It is in fact an efficacious treatment for many cases of a very wretched illness. Also, his remark about "acute anticholinergic side effects common to the administration of highpotency neuroleptics" is a scatter-gun one. Pimozide, given carefuUy to adequately diagnosed cases whose symptoms are demonstrably psychotic, is relatively free of serious side effects. REFERENCES
Munro, A. (1980), Monosymptomatic hypochondriacal psychosis. British Journal ofHospital Medicin e, 24:34-38. Munro, A. & Chmara, J. (1982), Monosymptomatic hypochondriacal psychosis: a diagnostic checklist based on 50 cases. Can. J. of Psychiatry, 27:374-376. Sondheimer, A. (1988), Clomipramine treatment of delusional disorder-somatic type. J. Am. Acad. Child Adolesc. Psychiatry, 27: 188-192. Thomas, C. S. (1984), Dysmorphobia: a question of definition. Br. J Psychiatry, 144:513-516. Ungvari, Von G . & Vladar, K. (1984), Pimozid-Therapie des Dermatozoenwabns. Dermatol. Monat sschr., 170:443-447. Alistair Munro, M.D. , F.R.C.P.C. Professor and Head Dalhousie University Department of Psychiatry Halifax, Nova Scotia, Canada
Delusion or Obsession: Implications for Treatment To the Editor: I would be grateful to be allowed to make some comments on Dr. Sondheimer's recent paper, "Clomipramine Treatment of Delusional Disorder-Somatic Type" (1988). As a member of the Psychosis Committee for DSM-IlI-R whose particular interest was in the delusional disorders, I have to correct one particular emphasis made by Dr. Sondheimer. He says that, in DSM-IIl-R, Delusional Disorder, Somatic Type, and Body otsmorphic Disorder "subsume an illness formerly described as Monosymptomatic Hypochondriasis." In fact, Delusional Disorder, Somatic Type, is more or less analogous with the condition known as Monosymptomatic Hypochondriacal Psychosis (MHP) (Munroe, 1980), whose outstanding characteristic is a somatic delusion. Body Dysmorphic Disorder, on the other hand, is characterized by an overvalued idea about somatic configuration and the patient is not delusional; this condition corresponds to the concept of dysmorphophobia (Thomas, 1984). There is now a considerable literature on MHP, and a clear clinical description is available (Munroe and Chmara, 1982). Patients with this condition are insightlessly convinced their somatic complaint is real and almost invariably resent any suggestion to the contrary. They are usually prickly, potentially noncompliant, and angry at referral to a psychiatrist. Reading Dr. Sondheimer's description of his case, I think there is some room for doubt that his patient had a true delusional disorder. The patient had "an intruding obsessional belief," he "struggled vigorously to ignore or suppress the belief," and he had a "wistfully expressed wish that they [his beliefs] be without foundation. " These characteristics seem to be at least as likely obsessive-compulsive as delusional, and if this were the case, it would not be altogether
Dr. Sondheimer Replies: Dr. Munro's comments are appreciated and deserve particular respect in consideration of his extensive work in the description and treatment of psychogenic somatically-based ideations and related syndromes. Specifically, reiterations ofthe distinction made between Delus ional Disorder-Somatic Type (DD-ST) and Body Dysmorphic Disorder, and his citation of the medication pimozide as " relatively specific" for the treatment of MHP, demand attention. Several elements discussed in the case report bear repetition in light of Dr. Munro's statements. Although delusions in some individuals may emerge suddenly, fully formed, and unrelated comprehensibly to environmental circumstances, i.e., primary delusions (Jaspers , 1923), a thought that eventually develops into a delusion more likely first emerges as an irrational idea that, over time, becomes transformed into a systematized belief (Meissner, 1978). As it takes on increasing importance, the idea may assume obsessional properties. This gradual process would be similar to that described in an article written by an individual suffering from remitting schizophreniform episodes (Lovejoy, 1984). It is altogether conceivable for a clinician to come upon this phenomenon in a patient at any point along this developmental continuum, perhaps all the more so in a population of children. Delusional disorders are most often first diagnosed in adults who report having had their notions for many years before initial medical attention (Hay , 1970; Pryse-Phillips, 1971). As children their ideas may well have reflected differing degrees of fixity. The adolescent described in the case report progressively became convinced that his somatic complaint was real. He did not resent but did disregard suggestions to the contrary. A secondary paranoid belief directly related to the first subsequently developed, and the
LEITERS TO EDITOR
attorneys. Yet they continue to testify because of their concern for the child 's future and because they believe that the judicial system (for all its bumbling) is attempting to protect the child. In spite of the flak, psychiatrists can act as the child's advocate and educate the court about the needs of children. It is true that testimony based on an evaluation, with or without the anatomical dolls, can be discredited by a bright, "rhetorically apt" attorney, but it is also true that much of what occurs in the playroom stands on its own merit and that there is no one more competent to elicit this material and translate it in court than the child psychiatrist. It is also true that overly aggressive, disparaging attorneys often discredit themselves and generate sympathy for the child. Dr. Donovan states that there are good reasons to abandon the dolls apart from their use in court because the dolls are "potentially very countertherapeutic." He does not explain why this is the case but later he asserts that the child might wonder why adults have such strange doUs in their office and what they might do with them after hours. I suspect that Dr. Donovan shares the culture's bias against the genitals. Children could just as well wonder why everyday dolls come without genitals and what this means about how they should act in the playroom. My major concern about Dr. Donovan's letter has nothing to do with doU physiogamy. He views research in child psychiatry as inconsistent with concern for the child. The protection, care, and treatment of children and adolescents has somehow been compromised because science has " mesmerized the field for two decades. " Dr. Frankenstein is not dead . No good will come from establishing a dichotomy between the laboratory and the clinic: if children are to be well served it will be through the integration of concepts from each of these crucial areas. Alayne Yates, M.D. Chief of Child Psychiatry CoUege of Medicine University of Arizona Tucson, Arizona
surprising that the patient responded to clomipramine, which may have some beneficial effect in obsessive-compulsive disorder, as Dr. Sondheimer notes . Of course, without seeing the case itself, I can only express my reservations. However, Dr. Sondheimer should know that an international literature on MHP does appear to support very strongly the relative specificity of pimozide in the condition (Ungvari, 1984). In fact, in the United Kingdom it is now officially accepted that this medication be recommended as treatment for MHP. The literature from the United States does not reflect this because pimozide has so recently become available there, and because it is currently indicated onl y for Tourette's syndrome. I think Dr. Sondheimer's comment that pimozide has been " touted" for several years as the treatment of choice for MH [sic] is rather condescending. It is in fact an efficacious treatment for many cases of a very wretched illness. Also, his remark about "acute anticholinergic side effects common to the administration of highpotency neuroleptics" is a scatter-gun one. Pimozide, given carefuUy to adequately diagnosed cases whose symptoms are demonstrably psychotic, is relatively free of serious side effects. REFERENCES
Munro, A. (1980), Monosymptomatic hypochondriacal psychosis. British Journal ofHospital Medicin e, 24:34-38. Munro, A. & Chmara, J. (1982), Monosymptomatic hypochondriacal psychosis: a diagnostic checklist based on 50 cases. Can. J. of Psychiatry, 27:374-376. Sondheimer, A. (1988), Clomipramine treatment of delusional disorder-somatic type. J. Am. Acad. Child Adolesc. Psychiatry, 27: 188-192. Thomas, C. S. (1984), Dysmorphobia: a question of definition. Br. J Psychiatry, 144:513-516. Ungvari, Von G . & Vladar, K. (1984), Pimozid-Therapie des Dermatozoenwabns. Dermatol. Monat sschr., 170:443-447. Alistair Munro, M.D. , F.R.C.P.C. Professor and Head Dalhousie University Department of Psychiatry Halifax, Nova Scotia, Canada
Delusion or Obsession: Implications for Treatment To the Editor: I would be grateful to be allowed to make some comments on Dr. Sondheimer's recent paper, "Clomipramine Treatment of Delusional Disorder-Somatic Type" (1988). As a member of the Psychosis Committee for DSM-IlI-R whose particular interest was in the delusional disorders, I have to correct one particular emphasis made by Dr. Sondheimer. He says that, in DSM-IIl-R, Delusional Disorder, Somatic Type, and Body otsmorphic Disorder "subsume an illness formerly described as Monosymptomatic Hypochondriasis." In fact, Delusional Disorder, Somatic Type, is more or less analogous with the condition known as Monosymptomatic Hypochondriacal Psychosis (MHP) (Munroe, 1980), whose outstanding characteristic is a somatic delusion. Body Dysmorphic Disorder, on the other hand, is characterized by an overvalued idea about somatic configuration and the patient is not delusional; this condition corresponds to the concept of dysmorphophobia (Thomas, 1984). There is now a considerable literature on MHP, and a clear clinical description is available (Munroe and Chmara, 1982). Patients with this condition are insightlessly convinced their somatic complaint is real and almost invariably resent any suggestion to the contrary. They are usually prickly, potentially noncompliant, and angry at referral to a psychiatrist. Reading Dr. Sondheimer's description of his case, I think there is some room for doubt that his patient had a true delusional disorder. The patient had "an intruding obsessional belief," he "struggled vigorously to ignore or suppress the belief," and he had a "wistfully expressed wish that they [his beliefs] be without foundation. " These characteristics seem to be at least as likely obsessive-compulsive as delusional, and if this were the case, it would not be altogether
Dr. Sondheimer Replies: Dr. Munro's comments are appreciated and deserve particular respect in consideration of his extensive work in the description and treatment of psychogenic somatically-based ideations and related syndromes. Specifically, reiterations ofthe distinction made between Delus ional Disorder-Somatic Type (DD-ST) and Body Dysmorphic Disorder, and his citation of the medication pimozide as " relatively specific" for the treatment of MHP, demand attention. Several elements discussed in the case report bear repetition in light of Dr. Munro's statements. Although delusions in some individuals may emerge suddenly, fully formed, and unrelated comprehensibly to environmental circumstances, i.e., primary delusions (Jaspers , 1923), a thought that eventually develops into a delusion more likely first emerges as an irrational idea that, over time, becomes transformed into a systematized belief (Meissner, 1978). As it takes on increasing importance, the idea may assume obsessional properties. This gradual process would be similar to that described in an article written by an individual suffering from remitting schizophreniform episodes (Lovejoy, 1984). It is altogether conceivable for a clinician to come upon this phenomenon in a patient at any point along this developmental continuum, perhaps all the more so in a population of children. Delusional disorders are most often first diagnosed in adults who report having had their notions for many years before initial medical attention (Hay , 1970; Pryse-Phillips, 1971). As children their ideas may well have reflected differing degrees of fixity. The adolescent described in the case report progressively became convinced that his somatic complaint was real. He did not resent but did disregard suggestions to the contrary. A secondary paranoid belief directly related to the first subsequently developed, and the