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
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
