Delusional disorder, somatic type (DDST), also known as monosymptomatic hypochondriacal psychosis (MHP), is characterised by somatic delusions which are sustained over a considerable period, sometimes for many years (Reference Munro1,2). It has been suggested that the somatic delusions in DDST are so specific and stable, e.g. a worm delusion does not turn into a delusion of ugliness or smell (Reference Munro1). However, there have been very few objective data to support this characteristic of DDST. We report a DDST patient, in whom specificity and stability of somatic delusions for almost 30 years were confirmed objectively.
The case was a 79-year-old woman. She had been living alone since the death of her husband 19 years ago. In December of 2008, she was referred to our clinic from a psychiatric clinic. According to the referral form, she had been treated for delusional complaints on mouth and teeth during the last 11 years with little improvement, and from 2 months ago the somatic delusions rather deteriorated and depressive symptoms also developed.
On the examination, she complained that ‘I have a hole in my mouth', ‘My mouth is empty', and ‘My teeth hit other parts of body such as the lips and heart, and they ache'. She stated that she had been suffering from the distressing sensations on mouth and teeth for the last 30 years, and that during this period she had visited several psychiatric clinics including ours. The examination of her medical record revealed that she had actually visited our clinic 26 years ago when none of the authors was present with almost the same complaints on mouth and teeth. At that time the diagnosis of cenestopathy, corresponding to DDST or MHP (Reference Munro1), was given. After a few visits, she had left for unknown reasons.
Magnetic resonance imaging and single photon emission computed tomography using (99m) Tc-ethylene cycteinate dimer were within normal limits. The diagnoses of DDST and depressive disorder not otherwise specified were made according to the Diagnostic and Statistical Manual of Mental Disorders-IV (2). Paroxetine, which had been started in the former clinic, was increased from 10 mg/day to 30 mg/day, as we had experienced DDST patients with (Reference Hayashi, Akahane, Suzuki, Sasaki, Kawakatsu and Otani3) and without (Reference Hayashi, Oshino, Ishikawa, Kawakatsu and Otani4) secondary depression recovering after several months of paroxetine monotherapy. In the 14th week, there was no depressive symptom, while the somatic delusions were slightly improved. In the 17th week, she was referred to the former clinic on her request.
In this case, the theme of delusions always centred around mouth and teeth, and the content of delusions remained almost the same for 30 years, despite the major life event of her husband's death. These findings were confirmed by her medical record. One report (Reference Stein, Le Roux, Bouwer and Van Heerden5) referred to continuation of delusion of smell for 30 years, but this was based on patient's report. Therefore, this is the first report to provide objective data on long-term specificity and stability of somatic delusions, a hallmark of DDST (Reference Munro1).
In contrast to our previous patients who had somatic delusions for several months (Reference Hayashi, Akahane, Suzuki, Sasaki, Kawakatsu and Otani3,Reference Hayashi, Oshino, Ishikawa, Kawakatsu and Otani4), this patient showed only slight improvement in the somatic delusions after paroxetine treatment. Therefore, paroxetine may be of limited value for a DDST patient with an extremely long clinical course. However, we recently reported a patient of Alzheimer's disease whose somatic delusions on tongue and mouth improved after the addition of olanzapine to paroxetine (Reference Hayashi, Suzuki, Matsumoto and Otani6). Therefore, this case might have responded to the augmentation with olanzapine, if she had stayed at our clinic longer.
Yuzuru Shibuya 1 , Hiroshi Hayashi 1 , Akihito Suzuki 1 , Koichi Otani 1
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Delusional disorder, somatic type (DDST), also known as monosymptomatic hypochondriacal psychosis (MHP), is characterised by somatic delusions which are sustained over a considerable period, sometimes for many years (Reference Munro1,2). It has been suggested that the somatic delusions in DDST are so specific and stable, e.g. a worm delusion does not turn into a delusion of ugliness or smell (Reference Munro1). However, there have been very few objective data to support this characteristic of DDST. We report a DDST patient, in whom specificity and stability of somatic delusions for almost 30 years were confirmed objectively.
The case was a 79-year-old woman. She had been living alone since the death of her husband 19 years ago. In December of 2008, she was referred to our clinic from a psychiatric clinic. According to the referral form, she had been treated for delusional complaints on mouth and teeth during the last 11 years with little improvement, and from 2 months ago the somatic delusions rather deteriorated and depressive symptoms also developed.
On the examination, she complained that ‘I have a hole in my mouth', ‘My mouth is empty', and ‘My teeth hit other parts of body such as the lips and heart, and they ache'. She stated that she had been suffering from the distressing sensations on mouth and teeth for the last 30 years, and that during this period she had visited several psychiatric clinics including ours. The examination of her medical record revealed that she had actually visited our clinic 26 years ago when none of the authors was present with almost the same complaints on mouth and teeth. At that time the diagnosis of cenestopathy, corresponding to DDST or MHP (Reference Munro1), was given. After a few visits, she had left for unknown reasons.
Magnetic resonance imaging and single photon emission computed tomography using (99m) Tc-ethylene cycteinate dimer were within normal limits. The diagnoses of DDST and depressive disorder not otherwise specified were made according to the Diagnostic and Statistical Manual of Mental Disorders-IV (2). Paroxetine, which had been started in the former clinic, was increased from 10 mg/day to 30 mg/day, as we had experienced DDST patients with (Reference Hayashi, Akahane, Suzuki, Sasaki, Kawakatsu and Otani3) and without (Reference Hayashi, Oshino, Ishikawa, Kawakatsu and Otani4) secondary depression recovering after several months of paroxetine monotherapy. In the 14th week, there was no depressive symptom, while the somatic delusions were slightly improved. In the 17th week, she was referred to the former clinic on her request.
In this case, the theme of delusions always centred around mouth and teeth, and the content of delusions remained almost the same for 30 years, despite the major life event of her husband's death. These findings were confirmed by her medical record. One report (Reference Stein, Le Roux, Bouwer and Van Heerden5) referred to continuation of delusion of smell for 30 years, but this was based on patient's report. Therefore, this is the first report to provide objective data on long-term specificity and stability of somatic delusions, a hallmark of DDST (Reference Munro1).
In contrast to our previous patients who had somatic delusions for several months (Reference Hayashi, Akahane, Suzuki, Sasaki, Kawakatsu and Otani3,Reference Hayashi, Oshino, Ishikawa, Kawakatsu and Otani4), this patient showed only slight improvement in the somatic delusions after paroxetine treatment. Therefore, paroxetine may be of limited value for a DDST patient with an extremely long clinical course. However, we recently reported a patient of Alzheimer's disease whose somatic delusions on tongue and mouth improved after the addition of olanzapine to paroxetine (Reference Hayashi, Suzuki, Matsumoto and Otani6). Therefore, this case might have responded to the augmentation with olanzapine, if she had stayed at our clinic longer.
Yuzuru Shibuya 1 , Hiroshi Hayashi 1 , Akihito Suzuki 1 , Koichi Otani 1