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CASE STUDY Clomipramine Treatment of Delusional Disorder-Somatic Type
CASE STUDY Clomipramine Treatment of Delusional Disorder-Somatic Type ADRIAN SONDHEIMER. M.D .
Abstract. Clomipramine was used to succe ssfully treat a 17-year-old adolescent male who had developed. 2 years earlier. an ego-dystonic. circumscribed. somatic delusion presenting with dist inct ohsessional features. The development o f Delusional Disorders among ad olescents is described . along with problems raised for accurate diagnosis when attempting to determine precise positions on the continua of belief-obsession-delusion. nonpsychosis-psychosis, and syntonicity-dystonicity . A relationship between childhood Obsessive-compulsive Disorder and Delusional Disorder is posited. with conseq uent implicat ions for fun her research in the treatment of the latter disorder with clomipramine. I Am, Acad Child Adole sc . Psvchiatrv, 19l!8, 27. 2: 1l!8-192. Key Words: Delusi onal Disorder. Monosymptomatic Hypoch ondriasis. Obsessive-compulsive Disorder. clomipramine, d yskinesia (Gelcnberg, 1985). treatments with alternative psychotropic medications were pursued. Several case reports describing partially or fully successful outcomes of the treatment of M H with haloperidol (Andrews et al., (986). doxepin, imipramine (Brotman and Jenike, 1984; Cashman and Pollock. 1983). nortript yline (Pylko and Sicignan, 1985). and tran ylcypromine (Jen ikc, 1984) have appeared . An article by Akiskal et al. (1983) described five patients with the diagnosis of Atypical Paranoid Disorder. These individuals shared a delusional belief in common with patients carrying the diagnosis of MH, but somatic complaints were phasi c or absent. These patients also responded well to various tric yclic medications and poorly to neuroleptics. It is intriguing that many of these reports described suc cessful resolutions of the illness following treatment with one of the medications cited above after trials with others of those mentioned above, or of structurally similar compounds, had failed. Material pertinent to somatic delusional disorders appears essentially nonexistent in the child and adolescent psychiatric literature. The case described below, one of several seen by this author. illustrates important features of this syndrome in a male adolescent. In addition to a description of the disorder manifesting itself during childhood, the obsessional nature of the delusional belief can be so striking a feature of the syndrome as to also demand emphasis of itself. Frequent or constant awareness of the affliction, with consequent functional impairment. is commonly described by the patient. despite intentional attempts to shut the inimical thought out of consciousness. Rapoport et al. 's study (198 I). describing data derived from nine adolescents with a diagnosis of Childhood Obsessive-compulsive Disorder. suggests features shared by patients suffering from obsessional and delusional disorders. None of their patients, however. appear to have suffered exclusively from a solitary somatically-based obsessional delusion . For that matter. their study appears to have excluded patients in whom evidence for a delusional system or other thought disorder was present. Clomipramine. a tricyclic compound, commonly emerges as superior to other medications in the pharmacological treatment of obsessional disorders (Ananth et al.. 1981: Inset et al., 1983; Thoren et al., 1980). In light of the obsessional nature of the delusional belief. and in the absence of other primary symptomatology, a marginally novel pharmacological approach to the treatment of this delusional disorder was employed. i.e.. the use of clomipramine. as described below.
DSM-III-R has defined two syndromes. Delu sional Disorder-Somatic Type and Body Dysmorphic Disorder. that subsume an illness formerly described as Monosymptomatic Hypochondriasis (MH). The symptomatology of MH was defined by a somatically-based. encapsulated. and fixed delusion unaccompanied by other gross manifestations of thought disorder or organic impairment (Bishop. 1980: Munro, (978). Secondary or reactive anxiety. depression. neurovegetative symptoms, compulsive behaviors, and /or phobic avoidance were often noted to develop as accompaniments to the condition (Andrews et al., 1986). The illness required differentiation from primary schizophreniform. affective. conversion. or histrionic personality disorders and organic brain syndromes. Atypical Somatoform Disorder and Atypical Paranoid Disorder were the DSM-III diagnoses most commonly employed to approximate this entity, but they barely suggested the essential nature of the dysfunction . Inasmuch as both earlier and very recent literature referred to this disorder as MH . that terminology will occasionally be used below . although the word hyp ochondriasis. as currently defined . is somewhat of a misnomer, In the absence of psychotropic intervention . the majorit y of individuals suffering from this disorder remained considerably disturbed and behaviorally impaired but generally did not develop other profound pathology. Reports describing two cases culminating in suicide (Bebbington, 1976) and two others developing schizophreniform illness (Munro and Pollock, (981) appeared to be exceptions. Pimozide, a butylpiperidine neuroleptic structurally and pharmacologically similar to haloperidol. recently received approval for use in the United States under orphan drug legislation. This medication had been touted for several years as the treatment of choice for MH (Riding and Munro, 1975). In light of acute anticholinergic side effects common to the administration of high-potency neuroleptics. and possibly in response to concerns about the potential for cardiotoxic effects and the theoretical possibility of the development of tardi ve
Accepted Octob er 29, IWi 7, Dr, Sondheimer is Clinical Assistant Professor ot Psvchiatrv and Director. Child Psychiatry Tra ining, Di\'isi()~ olChitd m;d Adol;'sccl/I Psychiatry. V AtDNJ - Ne ..... Jersey Medical School, 215 S outh Orang e Al'e.. Ne wark , NJ U710J-2 770, Reprint requests to the auth or, 01l90-11567/ 1l1l/270 2-0 188 $02.00 /0 f(~ \ 488 by the American Academy of Child and Adolescent Psychi atry. IHH
CLOMIPRAMINE AND DELUSIONAL DISORDER-SOMATIC
Case History
History ofOnset The patient was referred by his general practitioner and first seen as an outpatient at the age of 17, when beginning his senior year of high school. While serving at age 15 as a summer camp counselor, his school-age charges teased him about his genitalia after the unexpected and momentary extrusion of his testicles from his shorts. Consequently, during the subsequent 2 years, the patient was unable to rid himself of the always unwanted but progressively more intense and frequently intruding obsessional belief that his genitalia were of insufficient size. He struggled vigorously to ignore or suppress the belief, which dominated his thinking and whose truth he accepted. Although he had several heterosexual encounters during those years that included completed sexual intercourse, the patient subsequently developed the conviction that his sexual partners were aware of his small genital size and that they shared this information with their friends . Consequently, he interpreted passing remarks innocently made by friends concerning genitalia as reflecting their knowledge of his inadequacy. After 1112 years of maintaining an embarrassed and tortured silence, he unburdened himself to his mother. Shortly there after, an examination was performed by his physician. which revealed no physical abnormalities, and the patient was specifically informed that genital size and morphology were normal. The intruding and now apparently groundless obsessional thoughts nevertheless continued unabated. and referral was subsequently made for psychiatric intervention. In addition to the above information, the initial meetings revealed chronic feelings of low self-esteem and dysthymia. subjectively experienced as intermittently related to the obsessional phenomena. The patient also reported an average of once weekly alcohol and/or marijuana use in the company of peers, which inevitably momentarily heightened the intensity of what he termed his "paranoid" beliefs. Academically, socially, and vocationally the patient functioned in largely unremarkable fashion. He masturbated three times per week, and the activity was accompanied by heterosexual fantasies; he reported no homosexual fantasies or encounters. Characterologically evident were mild to moderate passive and avoidant traits, and he experienced extreme discomfort from the ego-dystonic nature of the constantly intrusive delusional beliefs. Results of complete blood count and urinalysis determinations performed at the time of the physical examination were within normal limits. as were the results of SMA 20. T " T., and thyroid-stimulating hormone determinations performed at a later date. The sole laboratory abnormality: DST. 10 ~g/dl (4:00 P.M.).
Family History The patient, an only child , lived in the United States with his mother and father until his parents' divorce , which occurred at 10 years of age. Shortly thereafter, his father returned to his country of origin in Western Europe. Erratic and sporadic contact between the patient and his father has since ensued. The patient remained with his mother through the
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senior year of high school and currently attends college several hundred miles from home . The father was a bartender. his mother is a secretary. Family history for psychiatric disorder is reported by mother as negative on the maternal side: father and a paternal uncle are both described as frequent but episodic alcohol abusers without vocational impairment, and lacking overt affective or other psychiatric symptomatology. The patient describes his relationships with his parents as having been essentially satisfactory and appropriately close with his mother since the divorce.
Treatment During the first month, data gathering was pursued. and it became clear that the patient's beliefs were deeply ingrained despite his wistfully expressed wish that they be without foundation. Behavioral psychotherapeutic approaches. including thought-stopping and relaxation exercises, and a brief attempt at a psychodynamic understanding of the problem. were initially introduced. These methods, however, although experienced as supportive, proved ineffective at symptom alleviation. Consequently, pharmacotherapy was initiated. with haloperidol 0.5 mg b.i.d. Over a 3-week period. the patient reported a mild reduction in the frequency of the original intrusive belief. but shortly thereafter. complaints emerged of sedation, general malaise . and muscle tightness. attributed to the neuroleptic. He therefore discontinued further use of both medication and treatment. After a 2-month hiatus from psychiatric care. the patient began treatment with clomipramine. At dosages of 100 mg b.i.d, and, later, 250 mg q.d. in divided doses. he reported a considerable decrease in both the frequency of intrusion and the intensity of the delusions concerning inadequate genital size and the distorted perceptions of other's awareness of this deficit. Thus both the somatic and referential delusional beliefs continued. but their presence was experienced as considerably less onerous. No simultaneous subjective change in the frequency or extent of the intermittent dysthymia, and no significant medication side effects, other than that of dry mouth, were noted. Late in the course of treatment. when the patient was receiving a dose of 150 mg q.d. while maintaining clinical improvement. plasma levels of clomipramine (42 ng/ ml) and its primary metabolite desmethylclomipramine (120 ng/rnl) were determined . After one-half year of treatment with clomipramine. an unanticipated exhaustion of the patient's supply of medication occurred, and for a period of less than I month. he was medication-free. Very mild medication withdrawal effects were initially reported. but within I week a notable progressive resumption of the intensity and frequency of the earlier delusional symptoms commenced. With the subsequent readmin istration of clomipramine. the intensity and frequency of the thoughts returned to the former ameliorated level. The patient's improvement in condition has lasted I I months. and it is monitored by telephone conversations from college averaging I to 2 calls per month . During treatment with clomipramine he graduated from high school. received average grades during the freshman year of college. socialized actively with fellow students. worked part-time. and has been
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occasionally sexuall y active. In sum . th e patient is functioning reasonabl y well. Discussion This rep ort is based on a patient-physician contact that encouraged subjective reporting and clinical observatio n. and little ut ilization of objective or "blind" me asures. Despite these ca veats. the case raise s and the report outlines several intriguing issues . AJ?e of Onset
The de scription of this patient illu strates the commencement during adolescence of a somati c delusional disorder. This age of onset is generally given no more than occasional reference in the bulk of the MH literature. and Hay (1970) reports that individuals average 30 years of age at the time of first addressing a complaint of dy smorphophobia to a physician. That no reference to this entity in recent child and adolescent psychiatric literature could be located is therefore not unexpected. To the extent that delusional disorders ma y share features in common with Ob sessive-compulsive D isor der (OCD). howe ver. Black (1974 ) rep orted that the symptomatology of more than one third o f adult case s of OCD was expressed initiall y during childhood . This author has to date treated four male st udents with thi s disorder. including the patient descri bed abov e. Age of on set of the illnes s has va ried from sch ool-ag e in one case. midadolescence in two others. and late -adolescence in the fourth. Two of the cases did not come to m edi cal attention until ages 20 and 25 (ages of onset 15 a nd 19. respecti vely) when the patients reported their d ysfunctions in the co n tex t of uni versit y health services. Patients' profound embarrassment co ncerning self-pe rceived strange but circ u ms cribed symptom atology, frequently combined with a fear of rid icule or dismissal by adult professionals. appear to hav e commonly dictated a delay in the divulging of the illn ess until many years after adolescent onset.
Diagnostic Issues MH cannot be easily pigeon-holed in th e current diagnostic nomenclature. This entity po ses a va rie ty o f perplexing questions that incl ude the potential uses o f th e co ncept of psychosis; th at hazy area where a n overvalued idea becomes a fixed delusion (see Brotman a nd Jcnike, 19X5); th e features th at d ist inguish between circ umscribed and more gen eralized delu sion s; the degree of d ystonicity of an obsessio na l beli ef versus that o f the sy nto n icity o f a delusion ; and the po ssibl y sh ifting relat ionships between so m ato form complaints, obs essional ideation, dysth ymia, and paran oia. In the current case the patient presented with a so m atic a lly-based dystonic circumscribed delusion and a secondary d ystonic paranoid referential delusion. with no other m anifestations of psychosis but acc o m pa nied by d ysth ymi c elem ents. The adve nt of DSM-III-R a nd its inclusio n of th e syndromes Delusional Disorder-Somati c T ype (D DST) and Bod y D ysmorphic Disorder (BDD) defin itel y facil itates the sorting out of so me of the above questi on s in a m ore useful diagnostic and nosological fashion . The primary demarcation between DDST and BDD is the degree o f intensity concerning the
beli ef abo ut the somatic di sturbance. That is. the d iagnosis of delu sional di sorder implies th at th e person cannot acknowledge the possibility th at th e exte nt of th e defect may be exaggerated. Similarly. a feature that d istinguishes obsessional from delusional disorders in DSM-III-R is the emphasis o n th e intrusive and senseless nature o f the former. Although th e att em pt to thus co m part m entalize and isolate specific sy ndromes is o f major value. o ne must keep in mind that the expression of pathology in human be ing s can be fluid and co ntai n elements o f seve ra l syndromes. In this case . the pa tient was clearl y preoccupied with an im agined defect in ph ysical appearance; he expe rie nce d frequent intrusive and phasic thoughts. which he unsuccessfully attempted to ignore a nd suppress; these thoughts became of delusional intensity such that although he acknowledged the rationality of his physician's views. the delusion rem ained unaffected; and he de veloped a secondary unshakeabl e referential delusion. This case would seem to suggest that th e degree of intensity of a single o vervalued idea or delusional belief and the degree to wh ich th e patient feels that others a re aware of the symptoms exist along a co nti nu u m of in tensi ty. intrusiveness. emphasis. and sy nto nicity . The ca se also illustrates that at tempts at an accurate diagnosis. despite the welcome refinem ents of DSM-III-R. may still rem ain a subjective matter because of the lack of a vailab ilit y of consistently reliable biological markers (Pylk o and Sicignan, 1985) . As de scribed in th e co nce ivably related illn ess of OCD by Insel and Akiska l (19 86 ), it appears that the un ita ry syndrome formerly described as MH presents at different points along the continuum of nonpsychotic d isorder th rough psychotic manifestation . It should be noted th at thi s pati ent d id not meet criteria for othe r psychiatric d isorders as hallucination s; other delusions; and serious affective. an xiet y. substa nce abuse, or organic m ental disorders were ab sent. The degree to which this adolescent's weekly use of alcohol and/or marijuana may have pre cipitated the onset of his syndrome is an open question . At no time during treatment d id he cease his recreational. although risky and symptom exac erbating. use of these substa nc es.
Pharmu cological Intcrvcnt ions The literature of the past 15 yea rs co nc ern ing the ph armaco logica l treatment of MH in itiall y em phasized the util ization of th e neuroleptic pimozide. Recently. the effectiveness of a variety o f other medications incl udi ng a related neuroleptic. tri cyclic compounds a nd a m on oam ine oxidase inhibitor, wer e described. The literature appears to illustrate responsivity o f th is synd ro me to several cla sses of psychotropic medications. but. co m m on ly. th e respon sivit y of individual patients a ppea rs limited to a specific m ed icat ion withi n a clas s. One co uld in fer that sim ilar symptomat ology may mask d iffering biological responsive capacities. Thus a varie ty of medication s appear se nsib ly usable in the treatment of a somatic d elu sional d isorder. but given th e prominence o f the obsessional nature of th e belief it appeared reason abl e to attempt treatment o f this patient with the tricyclic clo mi pram ine. currently th e recommended treatment of cho ice for OCD (Insel and Mueller , 1984).
CLOMIPRAMINE AND DELUSIONAL DISORDER-SOMATIC
A double-blind controlled study by F1ament ct al. (19 85. 1987) found clomipramine su pe rio r to placebo in the treatment of ch ildhood OCD. sim ila r to findings reponed with adult pat ients. The apparentl y succ essfu l treatment with clo mipram ine of an adolescent patient ca rry ing the diagnosis of a Delusional Di sorder lends itself to spe c ula tio n about the possibilit y of related or similar biological mechanisms med iating both illnesses. Such a not ion is intriguing. as subjects whose symptom presentation included delusional ideation appear to ha ve been excluded from Flarnent et al.ts study. In light of the prominent features that aspects of this di sorder and OCD sha re in common. and the a p pa re nt effecti veness of clomipramine in this case. it follows that systematic research regarding the use of this medication as a potential treatment for the DSM-III-R equivalents of MH appears warranted. One report describing the treatment o f MH with clornipramine was located (Bebbington, 1976). In that account. a patient rec eived an unspecified dosage of clomipramine as part o f a regimen that included treatment with neurolcptics, anx iolyt ics. a monoamine oxidase in hi bi tor. other tric yclics, and electroconvulsive therapy. The patient wa s reported to ha ve had a response to this pharmacotherapeutic approach o f "at least transient improvement." a lt ho ugh. obviousl y. the degree o f improvement and its relationsh ip specifica lly to th e adm inistration of clomipramine ca n not be determined.
Clomipramine: Antidepressant
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Ant iobsessionai E tjixts
The freq ue nt coe xiste nce in th e same patient of both obsessive-compulsive and depressive sy m pto mato logy ha s rece ived extensi ve d iscussion (Goodwin et a l., 1969: Vaughan . 1976). The indexed patient wa s cle arl y ex pe rie nc ing d ysth ymia a nd associated symptoms of low sel f-estee m and indecisiveness at the onset of treatment. concurrent with those features of the delusional disorder sha re d in common with those of OCD. Marks (1983) and Marks et al. (1980) have argued the possibility that clomipramine. a tricyclic agent structurally similar to imipramine. e xe rt s an antidepressant effect that indirectly reduces th e su bj ective experience of obsessional pathology. This patient's co urse of treatment with clom ipramine. however. did not notabl y alter the depressive symptomatology. Rather. this ca se would see m to offer co nfirmat ion of the findings of o thers (Fla rne nt et al ., 198 5: Mavissakalian et al. , 198 5: Montgome ry. 1980 ) that clomipramin e appears to ha ve an effec t directly o n obsessional phenomena. independent of possible a ntide pressa nt effects.
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metaphorical level. there see ms to be little indication o f an o rie nta tio n other than heterosexu al. and the patient read ily a nd co ns cio usly acknowledged the d ifficulties of ha ving grown up an only ch ild with a single fem ale parent for a significant period of his adolescence. G iven the specific anatom ic su bjec ts of his concern. it is unfortunate that the patient's first name lends itself to a d im inutive that may ha ve re inforced the pathology. When tea sed by friends who o cca sionall y usc th is moniker. he find s it very diffi cult not to co ncl ude th at they " k no w" about his problem . That his first name plays an etiological role is at best a very remote possibility: th at its in fe licito us usc oc casi ons sym pto m exacerbation. howev er. is a regrettable realit y. Conclusion This discussion and description o f a case of somatic delusio na l disorder will. hopefully. lead to the compilation of a larger number of cases that have th eir onset in childhood and ad ol escence. Increased knowl edge o f demographic and symptom characteristics . as well as the a tt e nda nt implications for treatment and prognosis. a re the o bvio us benefit s. In add it ion . a nothe r potentially therapeutic use for clomipramine in the c hild a nd ado lescen t population is suggested by its apparentl y s uc cessfu l usc here. The po ssib ilit y that this tri cyclic m a y be o f help in the treatment of pat ients fitting the criteria for th e gen eral category of delusion al di sorder is a sim ila rly intriguing noti on rai sed by this ca se . References Akiskal. H. S.. Arana. G . W.. Baldessarini. R. J . & Barreira. P. J . (19l!3). A clinical report of th yrnolepti c-responsi ve atypical paranoid psychoses. Am . J. Psychiatry. 140:1187-1190. Ananth. J .. Pccknold, J. C . Van Den Steen. N. & Englesmann. F. (198 1). Double-bl ind comparative study of clomipramine and amitriptyline in obsessive neurosi s. Pm K. Neuropsvchop harmacot . Bioi. Psvchiatrv, 5:257-264. A nd ~ews. E'.. Bellard. J . & Walter-Ryan . W. G . (19l!6). Monos ymptomatic hypochondriacal psychosis manifesting as delusions of infestation: case studies of treatm ent with haloperidol. 1. Clin. Ps\'chialr\' .47:188-190. Bebbington , P. E. (1976). Mon osympt omatic hypochondriasis. abnormal illness behavior and suicide. Br. 1. Psychiatry. 128:475478 .
Bishop. Jr ., E. R. (1980). Monosympt omat ic hypochondriasis. 1'.101'chosom aiics. 21:73 1- 747. Black. A. (1974 ). The natural history of obsessional neu rosis. In: Obsessional States. cd. H. R. Beech. Londo n: Methuen & Co. Brotma n. A. W. & Jcnikc , M. A. (19!l4). Mon osymptomatic hypochondriasis treated with tricyclic antidepressants. Am. 1. Psvchiatry, 141: 160 l!-1609.
Psychodynamic Issues It is a give n that one of th e major task s o f adolesce nc e is the co nso lida tio n of one's sexual id entity. wh ich comm onl y in vol ve s e ngage m e nt in se xua l ac tiv ity . One might suspect that the development of a focu s on a bod y part whose form is perce ived as pathological would ha ve psychod ynamic significance . It is therefore of interest to not e that. other than th e incident in volving testicles mentioned a bov e. no unusual experiences occurred for this patient in the genital area. Furthermore. he had been sexuall y acti ve both before and after the onset of the illness. without this activity affecting the intensity or frequency of his obsessional thoughts. On a more
- - Jcn ikc, M. A. ( 1985). Dysmorph oph ohia and mon osympt om atic hypochondriasis: reply to letter from C S. Thomas . Am . 1. 1'.1'.1'chiut ry.
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1 1~ I .
Cashman. F. E. & Pollock. B. ( 19l!3). Treatment of monosympt omat ic hypochondriacal psychosis with imipramine. Can. 1. 1'.101'chia trv. 28:85. Flam eni. M. F.. Rapoport. J . L.. Berg. C J.. et al. ( 1985). Clom ipramine treatment of childhood obsessive-compulsive disorde r. Arch. (je ll. Psvch iatr v, 42 :977- 983. - - - - ·Murph y. D. L.. Berg. C. J.. Lake. C. R. ( 19!l7). Biochemi cal changes during clom ipram ine treatm ent of childhood ob sessivecompulsive disorder. Arch. Gen. Psvchiat rv, 44:219-22 5. Gelenberg, A. cd. (1985). Pimozide for parasites'? In: Biological Therapies in Psychiatrv Vol. !l. Littleto n. Mass.: PSG. pp. 6- 7. Goo dwin. 0 .. Guze, S.. Robin s, E. (1969). Follow-up studi es in
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obsessional neurosis. Arch. Gen. Psychiatry. 20:182-187. Hay, G . G. (1970), Dysmorphophobia. Br. J. Psychiatry, 116:399406. Insel, T. R., Murphy, D. L., Cohen, R. M., Alterman, I., Kitts, C, Linnoila, M. (1983), Obsessive-compulsive disorder: a double-blind trial of clomipramine and clorgyline. Arch. Gen. Psychiatry, 40:605-612. - - Mueller , A. E. (1984 ). Pharmacologic treatment of obsessivecompulsive disorder. In: New Findings In Obsessi ve-Compulsive Disorder, ed. T . R. Insel. Washington, D.C.: American Psychiatric Press. - - Akiskal, H. S. (1986), Obsessive-compuls ive disorder with psychotic features: a phenomenologic anal ysis. Am . 1. Psychiatry, 143:1527-1533. Jenike, M. A. (1984 ), A case report of successful treatment of dysmorphophobia with tranylcypromine. Am . 1. Psychiatry. 141:1463-1464. Marks, I. M., Stem, R. S., Mawson, D. (1980), Clomipramine and exposure for obsessive-compulsive rituals, I. Br. J. Psychiatry, 136:1-25 . - - (1983), Are there anticompulsive or antiphobic drugs? Review of the evidence . Br. J. Psychiatry, 143:338-347 . Mavissakalian, M., Turner, S. M., Michelson , L., Jacob , R. (1985).
Tricyclic ant idepressants in obsessive-compulsive disorder: antiobsessional or antidepressant agents? II. Am . J. Psychiatry, 142:572576. Montgomery, S. A. (1980), Clomipramine in obsessional neurosis: a placebo controlled trial. Pharmacological M edicine, I: 189-192. Munro, A. (1978), Monosymptomatic hypochondriacal psychosis. Canadian Psychiatric Association Journal, 23:497-500. - - Pollock, B. ( 198 1), Monosymptomatic psychoses which progress to schizophrenia. J. Clin. Psychiatry, 42:474-476. Py1ko, T. & Sicignan , J. (1985), Nortriptyline in the treatment of a monosymptomatic delusion . Am. J. Psychiatry, 142:1223. Rapoport, J. L., Elkins, R., Langer, D. H., et al. (1981), Childhood obsessive-compulsive disorders . J. Am. Acad. Child Psychiatry, 138:1545-1554. Riding , J. & Munro, A. (1975), Pimozide in the treatment of monosymptomatic hypochondriacal psychosis. Acta. Psychiatr. Scand. 52:23-30. Thoren, P., Asberg, M., Cronholm, B., Jornestedt, L., Traskrnan, L. (1980), Clomipramine treatment of obsessive-compulsive disorder: a controlled clinical trial . Arch. Gen. Psychiatry , 37: 1281-1285. Vaughan , M. (1976), The relationship between obsessional personality, obsession in depression and symptoms of depression. Br. J. Psychiatry, 129:36-39 .
Abstract. Clomipramine was used to succe ssfully treat a 17-year-old adolescent male who had developed. 2 years earlier. an ego-dystonic. circumscribed. somatic delusion presenting with dist inct ohsessional features. The development o f Delusional Disorders among ad olescents is described . along with problems raised for accurate diagnosis when attempting to determine precise positions on the continua of belief-obsession-delusion. nonpsychosis-psychosis, and syntonicity-dystonicity . A relationship between childhood Obsessive-compulsive Disorder and Delusional Disorder is posited. with conseq uent implicat ions for fun her research in the treatment of the latter disorder with clomipramine. I Am, Acad Child Adole sc . Psvchiatrv, 19l!8, 27. 2: 1l!8-192. Key Words: Delusi onal Disorder. Monosymptomatic Hypoch ondriasis. Obsessive-compulsive Disorder. clomipramine, d yskinesia (Gelcnberg, 1985). treatments with alternative psychotropic medications were pursued. Several case reports describing partially or fully successful outcomes of the treatment of M H with haloperidol (Andrews et al., (986). doxepin, imipramine (Brotman and Jenike, 1984; Cashman and Pollock. 1983). nortript yline (Pylko and Sicignan, 1985). and tran ylcypromine (Jen ikc, 1984) have appeared . An article by Akiskal et al. (1983) described five patients with the diagnosis of Atypical Paranoid Disorder. These individuals shared a delusional belief in common with patients carrying the diagnosis of MH, but somatic complaints were phasi c or absent. These patients also responded well to various tric yclic medications and poorly to neuroleptics. It is intriguing that many of these reports described suc cessful resolutions of the illness following treatment with one of the medications cited above after trials with others of those mentioned above, or of structurally similar compounds, had failed. Material pertinent to somatic delusional disorders appears essentially nonexistent in the child and adolescent psychiatric literature. The case described below, one of several seen by this author. illustrates important features of this syndrome in a male adolescent. In addition to a description of the disorder manifesting itself during childhood, the obsessional nature of the delusional belief can be so striking a feature of the syndrome as to also demand emphasis of itself. Frequent or constant awareness of the affliction, with consequent functional impairment. is commonly described by the patient. despite intentional attempts to shut the inimical thought out of consciousness. Rapoport et al. 's study (198 I). describing data derived from nine adolescents with a diagnosis of Childhood Obsessive-compulsive Disorder. suggests features shared by patients suffering from obsessional and delusional disorders. None of their patients, however. appear to have suffered exclusively from a solitary somatically-based obsessional delusion . For that matter. their study appears to have excluded patients in whom evidence for a delusional system or other thought disorder was present. Clomipramine. a tricyclic compound, commonly emerges as superior to other medications in the pharmacological treatment of obsessional disorders (Ananth et al.. 1981: Inset et al., 1983; Thoren et al., 1980). In light of the obsessional nature of the delusional belief. and in the absence of other primary symptomatology, a marginally novel pharmacological approach to the treatment of this delusional disorder was employed. i.e.. the use of clomipramine. as described below.
DSM-III-R has defined two syndromes. Delu sional Disorder-Somatic Type and Body Dysmorphic Disorder. that subsume an illness formerly described as Monosymptomatic Hypochondriasis (MH). The symptomatology of MH was defined by a somatically-based. encapsulated. and fixed delusion unaccompanied by other gross manifestations of thought disorder or organic impairment (Bishop. 1980: Munro, (978). Secondary or reactive anxiety. depression. neurovegetative symptoms, compulsive behaviors, and /or phobic avoidance were often noted to develop as accompaniments to the condition (Andrews et al., 1986). The illness required differentiation from primary schizophreniform. affective. conversion. or histrionic personality disorders and organic brain syndromes. Atypical Somatoform Disorder and Atypical Paranoid Disorder were the DSM-III diagnoses most commonly employed to approximate this entity, but they barely suggested the essential nature of the dysfunction . Inasmuch as both earlier and very recent literature referred to this disorder as MH . that terminology will occasionally be used below . although the word hyp ochondriasis. as currently defined . is somewhat of a misnomer, In the absence of psychotropic intervention . the majorit y of individuals suffering from this disorder remained considerably disturbed and behaviorally impaired but generally did not develop other profound pathology. Reports describing two cases culminating in suicide (Bebbington, 1976) and two others developing schizophreniform illness (Munro and Pollock, (981) appeared to be exceptions. Pimozide, a butylpiperidine neuroleptic structurally and pharmacologically similar to haloperidol. recently received approval for use in the United States under orphan drug legislation. This medication had been touted for several years as the treatment of choice for MH (Riding and Munro, 1975). In light of acute anticholinergic side effects common to the administration of high-potency neuroleptics. and possibly in response to concerns about the potential for cardiotoxic effects and the theoretical possibility of the development of tardi ve
Accepted Octob er 29, IWi 7, Dr, Sondheimer is Clinical Assistant Professor ot Psvchiatrv and Director. Child Psychiatry Tra ining, Di\'isi()~ olChitd m;d Adol;'sccl/I Psychiatry. V AtDNJ - Ne ..... Jersey Medical School, 215 S outh Orang e Al'e.. Ne wark , NJ U710J-2 770, Reprint requests to the auth or, 01l90-11567/ 1l1l/270 2-0 188 $02.00 /0 f(~ \ 488 by the American Academy of Child and Adolescent Psychi atry. IHH
CLOMIPRAMINE AND DELUSIONAL DISORDER-SOMATIC
Case History
History ofOnset The patient was referred by his general practitioner and first seen as an outpatient at the age of 17, when beginning his senior year of high school. While serving at age 15 as a summer camp counselor, his school-age charges teased him about his genitalia after the unexpected and momentary extrusion of his testicles from his shorts. Consequently, during the subsequent 2 years, the patient was unable to rid himself of the always unwanted but progressively more intense and frequently intruding obsessional belief that his genitalia were of insufficient size. He struggled vigorously to ignore or suppress the belief, which dominated his thinking and whose truth he accepted. Although he had several heterosexual encounters during those years that included completed sexual intercourse, the patient subsequently developed the conviction that his sexual partners were aware of his small genital size and that they shared this information with their friends . Consequently, he interpreted passing remarks innocently made by friends concerning genitalia as reflecting their knowledge of his inadequacy. After 1112 years of maintaining an embarrassed and tortured silence, he unburdened himself to his mother. Shortly there after, an examination was performed by his physician. which revealed no physical abnormalities, and the patient was specifically informed that genital size and morphology were normal. The intruding and now apparently groundless obsessional thoughts nevertheless continued unabated. and referral was subsequently made for psychiatric intervention. In addition to the above information, the initial meetings revealed chronic feelings of low self-esteem and dysthymia. subjectively experienced as intermittently related to the obsessional phenomena. The patient also reported an average of once weekly alcohol and/or marijuana use in the company of peers, which inevitably momentarily heightened the intensity of what he termed his "paranoid" beliefs. Academically, socially, and vocationally the patient functioned in largely unremarkable fashion. He masturbated three times per week, and the activity was accompanied by heterosexual fantasies; he reported no homosexual fantasies or encounters. Characterologically evident were mild to moderate passive and avoidant traits, and he experienced extreme discomfort from the ego-dystonic nature of the constantly intrusive delusional beliefs. Results of complete blood count and urinalysis determinations performed at the time of the physical examination were within normal limits. as were the results of SMA 20. T " T., and thyroid-stimulating hormone determinations performed at a later date. The sole laboratory abnormality: DST. 10 ~g/dl (4:00 P.M.).
Family History The patient, an only child , lived in the United States with his mother and father until his parents' divorce , which occurred at 10 years of age. Shortly thereafter, his father returned to his country of origin in Western Europe. Erratic and sporadic contact between the patient and his father has since ensued. The patient remained with his mother through the
189
senior year of high school and currently attends college several hundred miles from home . The father was a bartender. his mother is a secretary. Family history for psychiatric disorder is reported by mother as negative on the maternal side: father and a paternal uncle are both described as frequent but episodic alcohol abusers without vocational impairment, and lacking overt affective or other psychiatric symptomatology. The patient describes his relationships with his parents as having been essentially satisfactory and appropriately close with his mother since the divorce.
Treatment During the first month, data gathering was pursued. and it became clear that the patient's beliefs were deeply ingrained despite his wistfully expressed wish that they be without foundation. Behavioral psychotherapeutic approaches. including thought-stopping and relaxation exercises, and a brief attempt at a psychodynamic understanding of the problem. were initially introduced. These methods, however, although experienced as supportive, proved ineffective at symptom alleviation. Consequently, pharmacotherapy was initiated. with haloperidol 0.5 mg b.i.d. Over a 3-week period. the patient reported a mild reduction in the frequency of the original intrusive belief. but shortly thereafter. complaints emerged of sedation, general malaise . and muscle tightness. attributed to the neuroleptic. He therefore discontinued further use of both medication and treatment. After a 2-month hiatus from psychiatric care. the patient began treatment with clomipramine. At dosages of 100 mg b.i.d, and, later, 250 mg q.d. in divided doses. he reported a considerable decrease in both the frequency of intrusion and the intensity of the delusions concerning inadequate genital size and the distorted perceptions of other's awareness of this deficit. Thus both the somatic and referential delusional beliefs continued. but their presence was experienced as considerably less onerous. No simultaneous subjective change in the frequency or extent of the intermittent dysthymia, and no significant medication side effects, other than that of dry mouth, were noted. Late in the course of treatment. when the patient was receiving a dose of 150 mg q.d. while maintaining clinical improvement. plasma levels of clomipramine (42 ng/ ml) and its primary metabolite desmethylclomipramine (120 ng/rnl) were determined . After one-half year of treatment with clomipramine. an unanticipated exhaustion of the patient's supply of medication occurred, and for a period of less than I month. he was medication-free. Very mild medication withdrawal effects were initially reported. but within I week a notable progressive resumption of the intensity and frequency of the earlier delusional symptoms commenced. With the subsequent readmin istration of clomipramine. the intensity and frequency of the thoughts returned to the former ameliorated level. The patient's improvement in condition has lasted I I months. and it is monitored by telephone conversations from college averaging I to 2 calls per month . During treatment with clomipramine he graduated from high school. received average grades during the freshman year of college. socialized actively with fellow students. worked part-time. and has been
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SONDHEIM ER
occasionally sexuall y active. In sum . th e patient is functioning reasonabl y well. Discussion This rep ort is based on a patient-physician contact that encouraged subjective reporting and clinical observatio n. and little ut ilization of objective or "blind" me asures. Despite these ca veats. the case raise s and the report outlines several intriguing issues . AJ?e of Onset
The de scription of this patient illu strates the commencement during adolescence of a somati c delusional disorder. This age of onset is generally given no more than occasional reference in the bulk of the MH literature. and Hay (1970) reports that individuals average 30 years of age at the time of first addressing a complaint of dy smorphophobia to a physician. That no reference to this entity in recent child and adolescent psychiatric literature could be located is therefore not unexpected. To the extent that delusional disorders ma y share features in common with Ob sessive-compulsive D isor der (OCD). howe ver. Black (1974 ) rep orted that the symptomatology of more than one third o f adult case s of OCD was expressed initiall y during childhood . This author has to date treated four male st udents with thi s disorder. including the patient descri bed abov e. Age of on set of the illnes s has va ried from sch ool-ag e in one case. midadolescence in two others. and late -adolescence in the fourth. Two of the cases did not come to m edi cal attention until ages 20 and 25 (ages of onset 15 a nd 19. respecti vely) when the patients reported their d ysfunctions in the co n tex t of uni versit y health services. Patients' profound embarrassment co ncerning self-pe rceived strange but circ u ms cribed symptom atology, frequently combined with a fear of rid icule or dismissal by adult professionals. appear to hav e commonly dictated a delay in the divulging of the illn ess until many years after adolescent onset.
Diagnostic Issues MH cannot be easily pigeon-holed in th e current diagnostic nomenclature. This entity po ses a va rie ty o f perplexing questions that incl ude the potential uses o f th e co ncept of psychosis; th at hazy area where a n overvalued idea becomes a fixed delusion (see Brotman a nd Jcnike, 19X5); th e features th at d ist inguish between circ umscribed and more gen eralized delu sion s; the degree of d ystonicity of an obsessio na l beli ef versus that o f the sy nto n icity o f a delusion ; and the po ssibl y sh ifting relat ionships between so m ato form complaints, obs essional ideation, dysth ymia, and paran oia. In the current case the patient presented with a so m atic a lly-based dystonic circumscribed delusion and a secondary d ystonic paranoid referential delusion. with no other m anifestations of psychosis but acc o m pa nied by d ysth ymi c elem ents. The adve nt of DSM-III-R a nd its inclusio n of th e syndromes Delusional Disorder-Somati c T ype (D DST) and Bod y D ysmorphic Disorder (BDD) defin itel y facil itates the sorting out of so me of the above questi on s in a m ore useful diagnostic and nosological fashion . The primary demarcation between DDST and BDD is the degree o f intensity concerning the
beli ef abo ut the somatic di sturbance. That is. the d iagnosis of delu sional di sorder implies th at th e person cannot acknowledge the possibility th at th e exte nt of th e defect may be exaggerated. Similarly. a feature that d istinguishes obsessional from delusional disorders in DSM-III-R is the emphasis o n th e intrusive and senseless nature o f the former. Although th e att em pt to thus co m part m entalize and isolate specific sy ndromes is o f major value. o ne must keep in mind that the expression of pathology in human be ing s can be fluid and co ntai n elements o f seve ra l syndromes. In this case . the pa tient was clearl y preoccupied with an im agined defect in ph ysical appearance; he expe rie nce d frequent intrusive and phasic thoughts. which he unsuccessfully attempted to ignore a nd suppress; these thoughts became of delusional intensity such that although he acknowledged the rationality of his physician's views. the delusion rem ained unaffected; and he de veloped a secondary unshakeabl e referential delusion. This case would seem to suggest that th e degree of intensity of a single o vervalued idea or delusional belief and the degree to wh ich th e patient feels that others a re aware of the symptoms exist along a co nti nu u m of in tensi ty. intrusiveness. emphasis. and sy nto nicity . The ca se also illustrates that at tempts at an accurate diagnosis. despite the welcome refinem ents of DSM-III-R. may still rem ain a subjective matter because of the lack of a vailab ilit y of consistently reliable biological markers (Pylk o and Sicignan, 1985) . As de scribed in th e co nce ivably related illn ess of OCD by Insel and Akiska l (19 86 ), it appears that the un ita ry syndrome formerly described as MH presents at different points along the continuum of nonpsychotic d isorder th rough psychotic manifestation . It should be noted th at thi s pati ent d id not meet criteria for othe r psychiatric d isorders as hallucination s; other delusions; and serious affective. an xiet y. substa nce abuse, or organic m ental disorders were ab sent. The degree to which this adolescent's weekly use of alcohol and/or marijuana may have pre cipitated the onset of his syndrome is an open question . At no time during treatment d id he cease his recreational. although risky and symptom exac erbating. use of these substa nc es.
Pharmu cological Intcrvcnt ions The literature of the past 15 yea rs co nc ern ing the ph armaco logica l treatment of MH in itiall y em phasized the util ization of th e neuroleptic pimozide. Recently. the effectiveness of a variety o f other medications incl udi ng a related neuroleptic. tri cyclic compounds a nd a m on oam ine oxidase inhibitor, wer e described. The literature appears to illustrate responsivity o f th is synd ro me to several cla sses of psychotropic medications. but. co m m on ly. th e respon sivit y of individual patients a ppea rs limited to a specific m ed icat ion withi n a clas s. One co uld in fer that sim ilar symptomat ology may mask d iffering biological responsive capacities. Thus a varie ty of medication s appear se nsib ly usable in the treatment of a somatic d elu sional d isorder. but given th e prominence o f the obsessional nature of th e belief it appeared reason abl e to attempt treatment o f this patient with the tricyclic clo mi pram ine. currently th e recommended treatment of cho ice for OCD (Insel and Mueller , 1984).
CLOMIPRAMINE AND DELUSIONAL DISORDER-SOMATIC
A double-blind controlled study by F1ament ct al. (19 85. 1987) found clomipramine su pe rio r to placebo in the treatment of ch ildhood OCD. sim ila r to findings reponed with adult pat ients. The apparentl y succ essfu l treatment with clo mipram ine of an adolescent patient ca rry ing the diagnosis of a Delusional Di sorder lends itself to spe c ula tio n about the possibilit y of related or similar biological mechanisms med iating both illnesses. Such a not ion is intriguing. as subjects whose symptom presentation included delusional ideation appear to ha ve been excluded from Flarnent et al.ts study. In light of the prominent features that aspects of this di sorder and OCD sha re in common. and the a p pa re nt effecti veness of clomipramine in this case. it follows that systematic research regarding the use of this medication as a potential treatment for the DSM-III-R equivalents of MH appears warranted. One report describing the treatment o f MH with clornipramine was located (Bebbington, 1976). In that account. a patient rec eived an unspecified dosage of clomipramine as part o f a regimen that included treatment with neurolcptics, anx iolyt ics. a monoamine oxidase in hi bi tor. other tric yclics, and electroconvulsive therapy. The patient wa s reported to ha ve had a response to this pharmacotherapeutic approach o f "at least transient improvement." a lt ho ugh. obviousl y. the degree o f improvement and its relationsh ip specifica lly to th e adm inistration of clomipramine ca n not be determined.
Clomipramine: Antidepressant
\ '.1'.
Ant iobsessionai E tjixts
The freq ue nt coe xiste nce in th e same patient of both obsessive-compulsive and depressive sy m pto mato logy ha s rece ived extensi ve d iscussion (Goodwin et a l., 1969: Vaughan . 1976). The indexed patient wa s cle arl y ex pe rie nc ing d ysth ymia a nd associated symptoms of low sel f-estee m and indecisiveness at the onset of treatment. concurrent with those features of the delusional disorder sha re d in common with those of OCD. Marks (1983) and Marks et al. (1980) have argued the possibility that clomipramine. a tricyclic agent structurally similar to imipramine. e xe rt s an antidepressant effect that indirectly reduces th e su bj ective experience of obsessional pathology. This patient's co urse of treatment with clom ipramine. however. did not notabl y alter the depressive symptomatology. Rather. this ca se would see m to offer co nfirmat ion of the findings of o thers (Fla rne nt et al ., 198 5: Mavissakalian et al. , 198 5: Montgome ry. 1980 ) that clomipramin e appears to ha ve an effec t directly o n obsessional phenomena. independent of possible a ntide pressa nt effects.
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metaphorical level. there see ms to be little indication o f an o rie nta tio n other than heterosexu al. and the patient read ily a nd co ns cio usly acknowledged the d ifficulties of ha ving grown up an only ch ild with a single fem ale parent for a significant period of his adolescence. G iven the specific anatom ic su bjec ts of his concern. it is unfortunate that the patient's first name lends itself to a d im inutive that may ha ve re inforced the pathology. When tea sed by friends who o cca sionall y usc th is moniker. he find s it very diffi cult not to co ncl ude th at they " k no w" about his problem . That his first name plays an etiological role is at best a very remote possibility: th at its in fe licito us usc oc casi ons sym pto m exacerbation. howev er. is a regrettable realit y. Conclusion This discussion and description o f a case of somatic delusio na l disorder will. hopefully. lead to the compilation of a larger number of cases that have th eir onset in childhood and ad ol escence. Increased knowl edge o f demographic and symptom characteristics . as well as the a tt e nda nt implications for treatment and prognosis. a re the o bvio us benefit s. In add it ion . a nothe r potentially therapeutic use for clomipramine in the c hild a nd ado lescen t population is suggested by its apparentl y s uc cessfu l usc here. The po ssib ilit y that this tri cyclic m a y be o f help in the treatment of pat ients fitting the criteria for th e gen eral category of delusion al di sorder is a sim ila rly intriguing noti on rai sed by this ca se . References Akiskal. H. S.. Arana. G . W.. Baldessarini. R. J . & Barreira. P. J . (19l!3). A clinical report of th yrnolepti c-responsi ve atypical paranoid psychoses. Am . J. Psychiatry. 140:1187-1190. Ananth. J .. Pccknold, J. C . Van Den Steen. N. & Englesmann. F. (198 1). Double-bl ind comparative study of clomipramine and amitriptyline in obsessive neurosi s. Pm K. Neuropsvchop harmacot . Bioi. Psvchiatrv, 5:257-264. A nd ~ews. E'.. Bellard. J . & Walter-Ryan . W. G . (19l!6). Monos ymptomatic hypochondriacal psychosis manifesting as delusions of infestation: case studies of treatm ent with haloperidol. 1. Clin. Ps\'chialr\' .47:188-190. Bebbington , P. E. (1976). Mon osympt omatic hypochondriasis. abnormal illness behavior and suicide. Br. 1. Psychiatry. 128:475478 .
Bishop. Jr ., E. R. (1980). Monosympt omat ic hypochondriasis. 1'.101'chosom aiics. 21:73 1- 747. Black. A. (1974 ). The natural history of obsessional neu rosis. In: Obsessional States. cd. H. R. Beech. Londo n: Methuen & Co. Brotma n. A. W. & Jcnikc , M. A. (19!l4). Mon osymptomatic hypochondriasis treated with tricyclic antidepressants. Am. 1. Psvchiatry, 141: 160 l!-1609.
Psychodynamic Issues It is a give n that one of th e major task s o f adolesce nc e is the co nso lida tio n of one's sexual id entity. wh ich comm onl y in vol ve s e ngage m e nt in se xua l ac tiv ity . One might suspect that the development of a focu s on a bod y part whose form is perce ived as pathological would ha ve psychod ynamic significance . It is therefore of interest to not e that. other than th e incident in volving testicles mentioned a bov e. no unusual experiences occurred for this patient in the genital area. Furthermore. he had been sexuall y acti ve both before and after the onset of the illness. without this activity affecting the intensity or frequency of his obsessional thoughts. On a more
- - Jcn ikc, M. A. ( 1985). Dysmorph oph ohia and mon osympt om atic hypochondriasis: reply to letter from C S. Thomas . Am . 1. 1'.1'.1'chiut ry.
1 4~:
1 1~ I .
Cashman. F. E. & Pollock. B. ( 19l!3). Treatment of monosympt omat ic hypochondriacal psychosis with imipramine. Can. 1. 1'.101'chia trv. 28:85. Flam eni. M. F.. Rapoport. J . L.. Berg. C J.. et al. ( 1985). Clom ipramine treatment of childhood obsessive-compulsive disorde r. Arch. (je ll. Psvch iatr v, 42 :977- 983. - - - - ·Murph y. D. L.. Berg. C. J.. Lake. C. R. ( 19!l7). Biochemi cal changes during clom ipram ine treatm ent of childhood ob sessivecompulsive disorder. Arch. Gen. Psvchiat rv, 44:219-22 5. Gelenberg, A. cd. (1985). Pimozide for parasites'? In: Biological Therapies in Psychiatrv Vol. !l. Littleto n. Mass.: PSG. pp. 6- 7. Goo dwin. 0 .. Guze, S.. Robin s, E. (1969). Follow-up studi es in
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obsessional neurosis. Arch. Gen. Psychiatry. 20:182-187. Hay, G . G. (1970), Dysmorphophobia. Br. J. Psychiatry, 116:399406. Insel, T. R., Murphy, D. L., Cohen, R. M., Alterman, I., Kitts, C, Linnoila, M. (1983), Obsessive-compulsive disorder: a double-blind trial of clomipramine and clorgyline. Arch. Gen. Psychiatry, 40:605-612. - - Mueller , A. E. (1984 ). Pharmacologic treatment of obsessivecompulsive disorder. In: New Findings In Obsessi ve-Compulsive Disorder, ed. T . R. Insel. Washington, D.C.: American Psychiatric Press. - - Akiskal, H. S. (1986), Obsessive-compuls ive disorder with psychotic features: a phenomenologic anal ysis. Am . 1. Psychiatry, 143:1527-1533. Jenike, M. A. (1984 ), A case report of successful treatment of dysmorphophobia with tranylcypromine. Am . 1. Psychiatry. 141:1463-1464. Marks, I. M., Stem, R. S., Mawson, D. (1980), Clomipramine and exposure for obsessive-compulsive rituals, I. Br. J. Psychiatry, 136:1-25 . - - (1983), Are there anticompulsive or antiphobic drugs? Review of the evidence . Br. J. Psychiatry, 143:338-347 . Mavissakalian, M., Turner, S. M., Michelson , L., Jacob , R. (1985).
Tricyclic ant idepressants in obsessive-compulsive disorder: antiobsessional or antidepressant agents? II. Am . J. Psychiatry, 142:572576. Montgomery, S. A. (1980), Clomipramine in obsessional neurosis: a placebo controlled trial. Pharmacological M edicine, I: 189-192. Munro, A. (1978), Monosymptomatic hypochondriacal psychosis. Canadian Psychiatric Association Journal, 23:497-500. - - Pollock, B. ( 198 1), Monosymptomatic psychoses which progress to schizophrenia. J. Clin. Psychiatry, 42:474-476. Py1ko, T. & Sicignan , J. (1985), Nortriptyline in the treatment of a monosymptomatic delusion . Am. J. Psychiatry, 142:1223. Rapoport, J. L., Elkins, R., Langer, D. H., et al. (1981), Childhood obsessive-compulsive disorders . J. Am. Acad. Child Psychiatry, 138:1545-1554. Riding , J. & Munro, A. (1975), Pimozide in the treatment of monosymptomatic hypochondriacal psychosis. Acta. Psychiatr. Scand. 52:23-30. Thoren, P., Asberg, M., Cronholm, B., Jornestedt, L., Traskrnan, L. (1980), Clomipramine treatment of obsessive-compulsive disorder: a controlled clinical trial . Arch. Gen. Psychiatry , 37: 1281-1285. Vaughan , M. (1976), The relationship between obsessional personality, obsession in depression and symptoms of depression. Br. J. Psychiatry, 129:36-39 .