LETTERS TO THE EDITOR
included grief counseling and referral to E.N.T. for refitting of her hearing aid. There are features of this case that resemble both cases reported by Fisman. The first of these is the relationship between use of medication and onset of symptoms. Our patient was on several medications, the adverse effects of which can include psychotic symptoms. Both methylprednisolone and oxazepam were possible culprits, but she had been taking these for many months without problem. Additionally, initiation and discontinuation of the benzodiazepine was not related to onset or cessation of the hallucinations as described by Fisman. Imipramine was started just before onset of the hallucinations suggesting a cause-effect relationship, but discontinuation had no impact on the symptoms.
MUSICAL HALLUCINATIONS: ANOTHER CASE REPORT Dear Sir: Fisman (l) recently reported two cases of musical hallucinations, the first precipitated by the administration of benzodiazepines and the second resembling Charles Bonnet syndrome. We would like to report another case. Case Report An 80 year old woman was admitted to a general hospital medical ward with a three week history of auditory hallucinations. These consisted primarily of hearing familiar love songs in her left ear, although she would also occasionally hear male or female voices speaking in her left ear. She could not make out the words but found these experiences both comforting and pleasurable. However, she remained aware that she was hallucinating and began to fear that she was going crazy. She became agitated and dysphoric, and it was at this point she was hospitalized.
In Fisman's second case, symptoms suggested that the patient was suffering from Charles Bonnet syndrome with musical hallucinations replacing the usual visual ones. This aptly describes ourcase. This woman had also suffered from bereavement and social isolation described in association with Charles Bonnet syndrome (3,4). Our case lends further support to the idea that Charles Bonnet syndrome may not be restricted to just visual hallucinations with underlying ocular pathology, but may include musical hallucinations with auditory disease as well. It also supports the importance of physician awareness of this condition so that a correct diagnosis is made and appropriate treatment prescribed.
She had experienced a number of recent stresses. Two months prior to presentation her husband had died suddenly from a myocardial infarction. She became depressed and exhibited sleep and appetite disturbances. Four weeks later, she was hospitalized briefly for chest pain, which was treated successfully with digoxin. She returned to five with her alcoholic son in an isolated rural setting, which she felt only added to her stress. Just prior to the onset of her auditory hallucinations, she began taking imipramine 10 mg hs as prescribed by her family doctor. Her other medications included methylprednisolone 2 mg od, indomethacin 25 mg tid (both for arthritis), and oxazepam 15 mg hs, all of which she had been taking for some time before onset of the hallucinations.
References I. Fisman M. Musical hallucinations: report of two unusual cases. Can J Psychiatry 1991; 36(8); 609-611. 2. Folstein MF, Folstein S, McHugh PR. Mini mental status: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189. 3. Gold K, Rabins PV. Isolated visual hallucinations and the Charles Bonnet syndrome: a review of the literature and presentation of six cases. Compr Psychiatry 1989; 30: 90-96. 4. Alroe CJ, McIntyre JNM. Visual hallucinations. The Charles Bonnet syndrome and bereavement. Med J Aust 1983; 2: 674675.
Significant in this patient's medical history was a long-standing bilateral hearing loss, with tinnitus in the right ear. She refused to wear a hearing aid because it caused her discomfort. She had no history of psychiatric illness, and her family history was negative for mental illness. Physical examination on admission to hospital was unremarkable. All investigations, including salicylate and alcohol levels, were normal. Except for digoxin and indomethacin, all medications were discontinued. Her sleep and appetite disturbances, agitation and depressed affect cleared rapidly. There was minimal improvement in the voices she was hearing but no change in the musical hallucinations.
A. Freeland, B.Sc., M.D. R. O'Reilly, M.D. London, Ontario BULIMIA NERVOSA AND ACNE Dear Sir:
A psychiatric consultation revealed an appropriately dressed and groomed lady who looked younger than her age. She had a moderate degree of hearing impairment. Her affect was bright except for becoming teary when discussing her husband's death. She was not experiencing any psychotic symptoms, other than the auditory hallucinations. She was oriented to time, place and person and scored 29 of 30 on the Mini Mental Status Examination (2). She was much reassured to hear that she was not "going crazy." Discharge plans
Drs. Gupta, Gupta, Ellis and Voorhees are to be congratulated on their astute observation that acne may have a role in the development and/or perpetuation of bulimia nervosa through its negative effect on self-esteem and body image (1). However, they are wrong in their assertion that the association of acne with eating disorders has not previously been reported, and their account is disappointingly incomplete in that they have failed to consider androgen excess, 731
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CANADIAN JOURNAL OF PSYCHIATRY
extrinsic or intrinsic, as a common etiological factor in both the acne and the eating disorder. In 1990, I reported the case of a young woman with bulimia nervosa and refractory acne who was shown to have an androgen excess syndrome of the polycystic ovary type (2). I suggested that the androgen excess syndrome had contributed to my patient's eating disorder through acne-related reinforcement of concerns about appearance and self-image, and through androgen-induced upper body fat predominance, the anabolic effect of the excess androgen causing defective autonomous function further reinforcing negative self-perception in a patient trying to control her weight. My patient's eating disorder responded promptly to a treatment plan that included an oral contraceptive with low androgenic activity. It would have been helpful to know if the patient reported by Dr. Gupta et al had been using an oral contraceptive and, if so, which brand, since a change to one with estrogen dominance and low androgenic activity could have benefits in acne improvement and reduction in anabolic effect. Additionally, I would dispute the authors' assertion that "an acute exacerbation of acne in a patient with an eating disorder may prove to be a cutaneous sign that the patient is bingeing" and would instead respectfully, but nonetheless vigorously, suggest that it indicates the need for serum androgen estimation.
References I. Gupta MA, GuptaAK, Ellis CN, et al. Bulimia nervosa and acne may be related; a case report. Can J Psychiatry 1992; (37(1): 58-61. 2. McSherry JA. Bulimia nervosa and polycystic ovary syndrome: evidence for an occasional causal relationship. The Medical Therapist 1990; 6: 10-11.
J. McSherry, M.B., Ch.B Kingston, Ontario
DR. GUPTA REPLIES
to be a cutaneous sign that the patient is bingeing. We would not expect such a patient to have an androgen excess syndrome (in the absence of other independent medical problems) and therefore there is no need for a serum androgen estimation. Many types of disorders that result in body image problems whether it be acne, another dermatologic condition, or some other disfiguring disease - would conceivably lead to exacerbation of an eating disorder in predisposed individuals. In our paper, we highlighted other clinical features that are both unique to acne and eating disorders in the absence of other medical problems, and this makes their association especially relevant. We did not obtain Dr. McSherry's case study in our original MEDLINE search. However, a larger study (3), comparing 152 patients with polycystic ovary syndrome (PCaS) and 109 patients with other endocrinopathies showed that over one-third of the patients with pcas had an abnormally high score on the Bulimia Investigation Test (BITE), compared with 14% of the controls. Interestingly, when specific symptoms from the BITE were considered, a positive relationship was found between both binge eating and fasting and the diagnosis of PCas, after controlling for the effect of body mass index. We have proposed that a similar eating pattern (i.e., binge eating alternating with fasting) can result in abnormal fluctuations of androgen levels (without necessarily leading to abnormally high androgen levels) and thereby lead to an exacerbation of acne.
References I. Pochi PE, Downing DT, Strauss JS. Sebaceous gland response in man to prolonged total caloric deprivation. J Invest Dermatol 1970; 55: 303-309. 2. Wheeler MJ, Crisp AH, Hsu LKG, et aI. Reproductive hormone changes during weight gain in male anorectics. Clin Endocrinol 1983; 18: 423-429. 3. McCluskey S, Evans C, Lacey JH, et al. Polycystic ovary syndrome and bulimia. Fertil Steril 1991; 55: 287-291.
M.A. Gupta, M.D. Ann Arbor, Michigan
Dear Sir: Dr. McSherry's observations regarding the relation between acne and bulimia nervosa in association with androgen excess is interesting but not relevant to our paper. We have discussed the possible association between eating disorders and acne in an otherwise healthy woman who was undergoing a topical treatment for acne. In most cases, acne is not associated with an androgen excess syndrome. This was the case in our patient, who had been carefully screened for the dermatologic study. The patient was not on oral contraceptives or other medications that can affect acne. The focus of our paper was four different factors that may explain the relation between acne and eating disorders. We discussed, for example, the fact that the abnormal eating behaviours in eating disorders, alone, can affect androgen metabolism, and this could theoretically lead to an exacerbation of acne when binge eating follows dietary restriction. Dietary restriction can result in decreased levels of androgens and thereby decreased sebaceous gland secretion (l ,2). Sebaceous gland overactivity is a key feature of acne, and rapid refeeding during a binge episode, following a period of dietary restriction, could presumably lead to increased sebaceous gland activity and a flare up of acne. We therefore propose that an acute exacerbation of acne in a patient with an eating disorder may prove
BENZODIAZEPINES AND ACUTE PSYCHOTIC AGITATION Dear Sir: Benzodiazepines can be used effectively in the treatment of acute psychotic agitation (I). We have recently shown in an open study (2) that intramuscular clonazepam, in doses of 2 mg to 3 mg every 30 to 60 minutes, can be effective,safe and relatively rapid for the control of acute psychotic agitation. We have now completed a second, open study on the effectiveness, rapidity of action and safety of a potentiated dosage schedule of 1M c1onazepam. We present the results of this study and we compare them with our previous findings. Twelve consecutive patients (six males, six females) admitted to a 16-bed acute psychiatric unit of a public general hospital and displaying acute psychotic agitation were treated with 1M clonazepam, 4 mg to 5 mg every 30 to 60 minutes, until tranquilization. Mean age was 36.9 years (SD = 14.9 years; range = 19 years to 72 years).' Five were diagnosed with schizophrenia, three with
included grief counseling and referral to E.N.T. for refitting of her hearing aid. There are features of this case that resemble both cases reported by Fisman. The first of these is the relationship between use of medication and onset of symptoms. Our patient was on several medications, the adverse effects of which can include psychotic symptoms. Both methylprednisolone and oxazepam were possible culprits, but she had been taking these for many months without problem. Additionally, initiation and discontinuation of the benzodiazepine was not related to onset or cessation of the hallucinations as described by Fisman. Imipramine was started just before onset of the hallucinations suggesting a cause-effect relationship, but discontinuation had no impact on the symptoms.
MUSICAL HALLUCINATIONS: ANOTHER CASE REPORT Dear Sir: Fisman (l) recently reported two cases of musical hallucinations, the first precipitated by the administration of benzodiazepines and the second resembling Charles Bonnet syndrome. We would like to report another case. Case Report An 80 year old woman was admitted to a general hospital medical ward with a three week history of auditory hallucinations. These consisted primarily of hearing familiar love songs in her left ear, although she would also occasionally hear male or female voices speaking in her left ear. She could not make out the words but found these experiences both comforting and pleasurable. However, she remained aware that she was hallucinating and began to fear that she was going crazy. She became agitated and dysphoric, and it was at this point she was hospitalized.
In Fisman's second case, symptoms suggested that the patient was suffering from Charles Bonnet syndrome with musical hallucinations replacing the usual visual ones. This aptly describes ourcase. This woman had also suffered from bereavement and social isolation described in association with Charles Bonnet syndrome (3,4). Our case lends further support to the idea that Charles Bonnet syndrome may not be restricted to just visual hallucinations with underlying ocular pathology, but may include musical hallucinations with auditory disease as well. It also supports the importance of physician awareness of this condition so that a correct diagnosis is made and appropriate treatment prescribed.
She had experienced a number of recent stresses. Two months prior to presentation her husband had died suddenly from a myocardial infarction. She became depressed and exhibited sleep and appetite disturbances. Four weeks later, she was hospitalized briefly for chest pain, which was treated successfully with digoxin. She returned to five with her alcoholic son in an isolated rural setting, which she felt only added to her stress. Just prior to the onset of her auditory hallucinations, she began taking imipramine 10 mg hs as prescribed by her family doctor. Her other medications included methylprednisolone 2 mg od, indomethacin 25 mg tid (both for arthritis), and oxazepam 15 mg hs, all of which she had been taking for some time before onset of the hallucinations.
References I. Fisman M. Musical hallucinations: report of two unusual cases. Can J Psychiatry 1991; 36(8); 609-611. 2. Folstein MF, Folstein S, McHugh PR. Mini mental status: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189. 3. Gold K, Rabins PV. Isolated visual hallucinations and the Charles Bonnet syndrome: a review of the literature and presentation of six cases. Compr Psychiatry 1989; 30: 90-96. 4. Alroe CJ, McIntyre JNM. Visual hallucinations. The Charles Bonnet syndrome and bereavement. Med J Aust 1983; 2: 674675.
Significant in this patient's medical history was a long-standing bilateral hearing loss, with tinnitus in the right ear. She refused to wear a hearing aid because it caused her discomfort. She had no history of psychiatric illness, and her family history was negative for mental illness. Physical examination on admission to hospital was unremarkable. All investigations, including salicylate and alcohol levels, were normal. Except for digoxin and indomethacin, all medications were discontinued. Her sleep and appetite disturbances, agitation and depressed affect cleared rapidly. There was minimal improvement in the voices she was hearing but no change in the musical hallucinations.
A. Freeland, B.Sc., M.D. R. O'Reilly, M.D. London, Ontario BULIMIA NERVOSA AND ACNE Dear Sir:
A psychiatric consultation revealed an appropriately dressed and groomed lady who looked younger than her age. She had a moderate degree of hearing impairment. Her affect was bright except for becoming teary when discussing her husband's death. She was not experiencing any psychotic symptoms, other than the auditory hallucinations. She was oriented to time, place and person and scored 29 of 30 on the Mini Mental Status Examination (2). She was much reassured to hear that she was not "going crazy." Discharge plans
Drs. Gupta, Gupta, Ellis and Voorhees are to be congratulated on their astute observation that acne may have a role in the development and/or perpetuation of bulimia nervosa through its negative effect on self-esteem and body image (1). However, they are wrong in their assertion that the association of acne with eating disorders has not previously been reported, and their account is disappointingly incomplete in that they have failed to consider androgen excess, 731
732
Vol. 37, No. 10
CANADIAN JOURNAL OF PSYCHIATRY
extrinsic or intrinsic, as a common etiological factor in both the acne and the eating disorder. In 1990, I reported the case of a young woman with bulimia nervosa and refractory acne who was shown to have an androgen excess syndrome of the polycystic ovary type (2). I suggested that the androgen excess syndrome had contributed to my patient's eating disorder through acne-related reinforcement of concerns about appearance and self-image, and through androgen-induced upper body fat predominance, the anabolic effect of the excess androgen causing defective autonomous function further reinforcing negative self-perception in a patient trying to control her weight. My patient's eating disorder responded promptly to a treatment plan that included an oral contraceptive with low androgenic activity. It would have been helpful to know if the patient reported by Dr. Gupta et al had been using an oral contraceptive and, if so, which brand, since a change to one with estrogen dominance and low androgenic activity could have benefits in acne improvement and reduction in anabolic effect. Additionally, I would dispute the authors' assertion that "an acute exacerbation of acne in a patient with an eating disorder may prove to be a cutaneous sign that the patient is bingeing" and would instead respectfully, but nonetheless vigorously, suggest that it indicates the need for serum androgen estimation.
References I. Gupta MA, GuptaAK, Ellis CN, et al. Bulimia nervosa and acne may be related; a case report. Can J Psychiatry 1992; (37(1): 58-61. 2. McSherry JA. Bulimia nervosa and polycystic ovary syndrome: evidence for an occasional causal relationship. The Medical Therapist 1990; 6: 10-11.
J. McSherry, M.B., Ch.B Kingston, Ontario
DR. GUPTA REPLIES
to be a cutaneous sign that the patient is bingeing. We would not expect such a patient to have an androgen excess syndrome (in the absence of other independent medical problems) and therefore there is no need for a serum androgen estimation. Many types of disorders that result in body image problems whether it be acne, another dermatologic condition, or some other disfiguring disease - would conceivably lead to exacerbation of an eating disorder in predisposed individuals. In our paper, we highlighted other clinical features that are both unique to acne and eating disorders in the absence of other medical problems, and this makes their association especially relevant. We did not obtain Dr. McSherry's case study in our original MEDLINE search. However, a larger study (3), comparing 152 patients with polycystic ovary syndrome (PCaS) and 109 patients with other endocrinopathies showed that over one-third of the patients with pcas had an abnormally high score on the Bulimia Investigation Test (BITE), compared with 14% of the controls. Interestingly, when specific symptoms from the BITE were considered, a positive relationship was found between both binge eating and fasting and the diagnosis of PCas, after controlling for the effect of body mass index. We have proposed that a similar eating pattern (i.e., binge eating alternating with fasting) can result in abnormal fluctuations of androgen levels (without necessarily leading to abnormally high androgen levels) and thereby lead to an exacerbation of acne.
References I. Pochi PE, Downing DT, Strauss JS. Sebaceous gland response in man to prolonged total caloric deprivation. J Invest Dermatol 1970; 55: 303-309. 2. Wheeler MJ, Crisp AH, Hsu LKG, et aI. Reproductive hormone changes during weight gain in male anorectics. Clin Endocrinol 1983; 18: 423-429. 3. McCluskey S, Evans C, Lacey JH, et al. Polycystic ovary syndrome and bulimia. Fertil Steril 1991; 55: 287-291.
M.A. Gupta, M.D. Ann Arbor, Michigan
Dear Sir: Dr. McSherry's observations regarding the relation between acne and bulimia nervosa in association with androgen excess is interesting but not relevant to our paper. We have discussed the possible association between eating disorders and acne in an otherwise healthy woman who was undergoing a topical treatment for acne. In most cases, acne is not associated with an androgen excess syndrome. This was the case in our patient, who had been carefully screened for the dermatologic study. The patient was not on oral contraceptives or other medications that can affect acne. The focus of our paper was four different factors that may explain the relation between acne and eating disorders. We discussed, for example, the fact that the abnormal eating behaviours in eating disorders, alone, can affect androgen metabolism, and this could theoretically lead to an exacerbation of acne when binge eating follows dietary restriction. Dietary restriction can result in decreased levels of androgens and thereby decreased sebaceous gland secretion (l ,2). Sebaceous gland overactivity is a key feature of acne, and rapid refeeding during a binge episode, following a period of dietary restriction, could presumably lead to increased sebaceous gland activity and a flare up of acne. We therefore propose that an acute exacerbation of acne in a patient with an eating disorder may prove
BENZODIAZEPINES AND ACUTE PSYCHOTIC AGITATION Dear Sir: Benzodiazepines can be used effectively in the treatment of acute psychotic agitation (I). We have recently shown in an open study (2) that intramuscular clonazepam, in doses of 2 mg to 3 mg every 30 to 60 minutes, can be effective,safe and relatively rapid for the control of acute psychotic agitation. We have now completed a second, open study on the effectiveness, rapidity of action and safety of a potentiated dosage schedule of 1M c1onazepam. We present the results of this study and we compare them with our previous findings. Twelve consecutive patients (six males, six females) admitted to a 16-bed acute psychiatric unit of a public general hospital and displaying acute psychotic agitation were treated with 1M clonazepam, 4 mg to 5 mg every 30 to 60 minutes, until tranquilization. Mean age was 36.9 years (SD = 14.9 years; range = 19 years to 72 years).' Five were diagnosed with schizophrenia, three with
