Case Reports

References I. Marlowe RI: Effective treatment of tinnitus through hypnotherapy. Am J C/in Hypn 15: 162-165. 1973 2. House JW: Treatment of severe tinnitus with biofeedback training. Laryngoscope 88:4Q6.412. 1978 3. Sullivan M. Dobie R. Sakai C. et al: Treatment of depressed tinnitus patients with nonriptyline. Ann Otol Rhinol LarynKol 98:867-872. 1990

4. Meyerhoff WL. Cooper JC: Tinnitus. in Otolaryngology. Volume II. The Ear. 2nd Edition. edited by Paparella ED. Shuymrick DA. Philadelphia, WB Saunders. 1980. pp 1861-1862 5. France RD, Houpt JL. Ellinwood EH: Therapeutic effects of antidepressants in chronic pain. Gen Hosp Psychiatry 6:55~3, 1984

Organic Delusional Disorder on a Consultation-Liaison Psychiatry Service Report and Review STEPHEN

T

A.

GOLDMAN,

he diagnostic category and underlying philosophical concept of the organic mental disorders have been the focus of recent discussion and examination. In a progress report by members of the DSM-IV Work Group on Organic Mental Disorders. many felt the term "organic" should be eliminated because this distinction implied other psychiatric diagnoses were not organically based and "thus perpetuated a false dichotomy and obstructed. rather than facilitated, a truly integrated approach to diagnosis."1 Lipowski,2 in a later perspective. felt the organic concept is not yet obsolete and cited the International Classification of Disease. 10th Revision (ICD-IO) formulation to the effect that "the term •organic' means no more and no less than that the syndrome so classified can be attributed to an independently diagnosable cerebral or systemic disease"3 (p. 30). Lipowski 2 stated that the organic distinction has clinical utility and that the cited formulation does not suggest that all other psychiatric disorders are unrelated to "cerebral processes." The consultation-liaison (C-L) psychiatry setting provides an appropriate context in which to examine the organic mental disorders. given VOLUME 33· NUMBER 3· SUMMER 1992

M.D.

the Col patient populations. Moreover. Col psychiatry would almost assuredly be affected by a major revision of the organic diagnostic designation.l.2.4 This article seeks to evaluate. through clinical case reports. data presentation. and literature review. the general question of the organic mental disorders on a Col psychiatry service and. more specifically. the viability of the organic delusional disorder diagnosis.

Methods For the purposes of this article. the caseload of the Col service of an urban university teaching hospital in the Midwest was used. DSM-III-R diagnoses of 379 patients seen in consultation Received October 19. 1990; revised February 18. 1991; accepted March I I. 1991. From the Depanment of Psychiatry and Division of Consultation-Liaison Psychiatry. Indiana University School of Medicine. Indianapolis. Address reprint requests to Dr. Goldman. Henry Ford Hospital. Department of Psychiatry, CFP-3. 2799 West Grand Blvd. Detroit. MI 48202. Copyright © 1992 The Academy of Psychosomatic Medicine.

343

Case Reports

over a 13-month period (1989-1990) were reviewed. An organic mental disorder was the primary diagnosis in 158 (41.7%) cases. Table I outlines the diagnostic distribution of the organic mental disorders. As can be seen, organic mood disorder, depressed (37.3%), delirium (32.3%), and dementia (13.9%) were the three leading diagnoses, accounting for over 80% of the organic mental disorders. DSM-III-R diagnostic requirements for organic delusional disorder include the presence of an organic etiology, absence of delirium, and delusional symptomatology. 5 Eight patients were diagnosed with organic delusional disorder; in two other patients delirium and organic delusional disorder could not confidently be differentiated. The medical records of these 10 patients were carefully reviewed; these last two case were excluded due to the inability to eliminate delirium as delusion causation. The following case histories are illustrative of organic delusional disorder.

Case Reports Case I. A 20-year-old white man was admitted to a university hospital neurology service for evaluation of headache, decreased visual acuity, and seizures. He had a significant past medical history ( I year prior) of optic neuritis that resolved with steroid therapy. He had residual optic atrophy and poor

vision. He had been well until 2 months prior to admission when he experienced headache and back pain. Subsequently he had diplopia, bizarre behavior, and a tonic-clonic seizure. Right VII cranial nerve involvement was noted prior to admission. as were mood changes and agitated behavior. On admission. the patient was noted to have headache, bilateral decrease in visual acuity, bilateral VI nerve palsy, bilateral Babinski signs. and right V nerve sensory changes. Right VII nerve palsy. seizures. and papilledema were all of acute onset. Col psychiatry was consulted within 3 days of the patient's admission for reported paranoid ideation. On examination. the patient was alert and fully oriented. On bedside assessment, he was able to perform cognitive tasks with minor deficits (i.e.. recalled only two of three items at 3 minutes, exhibited concrete similarities between given word pairs. and had nonabstract interpretation of one of two proverbs). There was no evidence of overt delirium. No symptoms of mood disorder or hallucinations were elicited. and no history of past psychiatric illness was reported. The patient manifested delusions of marital infidelity. and he had called others about a perceived doctors' error. Treatment with haloperidol (I mg po qam and 2 mg po qpm) had been initiated I day prior to psychiatric consultation. and dosage was increased (10 a maximum of 5 mg po bid) as evaluation and treatment continued. He was maintained on haloperidol (8 mg po qhs) for approximately 2 weeks. with gradual decrease in delusional ideation. He was begun on methylprednisolone (I g iv qd) 5 days after initial psychiatric consultation. and many of his neurologic symptoms improved. A trial off steroids resulted in

TABLE I. Distribution of organic mental disorder diagnoses on a consultation-liaison psychiatry service Diagnosis Organic mood disorder. depressed Delirium Dementia (senile. pre-senile. or with delirium) Organic delusional disorder (ODD) Organic hallucinosis Organic personality disorder Organic anlliety disorder Delirium vs. ODD Organic amnestic disorder Organic mood disorder. manic Lupus cerebritis Total

344

Total Diagnosed

Percentage of Organic Mental Disorders

Percentage of Total Consults

59 51 22 8 5 4 4 2 I I I 158

37.3 32.3 13.9 5.1 3.2 2.5 2.5 1.3 0.6 0.6 0.6 99.9

15.6 13.5 5.8 2.1

1.3 1.1 1.1

0.5 0.3 0.3 0.3 41.9

PSYCHOSOMATICS

Case Reports

the development of tenosynovitis and recurrence of cranial neuropathies. including VI and VII. Methylprednisolone was reinstituted. and these symptoms resolved within 48 hours. Delusions did not exacerbate during the period the patient was off steroids. With the patient on prednisone (60 mg po qd). haloperidol was tapered and eventually discontinued. The patient's wife reported that he had returned to his usual baseline mental state (including cognition). Although the patient later had a generalized seizure and the diagnostic workup continued. delusions did not recur with the patient off haloperidol. Included in the diagnostic studies performed were head CT and MRI. both of which were normal. and SPECT, which showed perfusion deficits in the left temporoparietal, right parietal, and right perisagittal regions. No definitive diagnosis was made despite extensive investigation. The differential diagnosis included vasculitis, sarcoidosis. Behcet's syndrome, demyelinating disorder, or infectious process. The patient was discharged with a diagnosis of steroid responsive encephalopathy. Case 2. A 67-year-old white man was admitted to a university hospital infectious disease service after having traveled from another state for treatment. The patient reported that he had come to the hospital because of an article he had read about experimental treatment for a specific cancer being done at the facility. Available history revealed that the patient had been hospitalized recently in his home state for cellulitis and treated with intravenous antibiotics and whirlpool with improvement. The patient reported a past history of non-insulin-dependent diabetes mellitus and foot ulcers. The admitting medical staff noted rambling. tangential speech with paranoid ideation concerning others trying to obtain his money. He described insomnia of several days' duration. X rays revealed osteomyelitis and pathologic fracture of the right fifth metatarsal. with clear destruction of metatarsophalangeal and head/base of phalanx I. Additionally. osteoporosis of both feet was noted. Physical exam revealed a surrounding cellulitis in addition to radiologic findings. The patient was seen by the CoL psychiatrist within the first 24 hours of admission, having received one 2-mg dose of haloperidol 12 hours earlier. The patient was alert, oriented in all spheres. pleasant, and cooperative. There was no evidence of pressured speech, flight of ideas. hallucinations. tangentiality, or suicidalitylhomicidality. He reported only 2 hours sleep per day because of foot pain. not because he did not go to sleep or did not need it. The VOLUME 33· NUMBER 3· SUMMER 1992

patient denied anhedonia. mood swings. decreased appetite. fatigue, or any past psychiatric history. Drug and alcohol use were denied. and he was not agitated or anxious. He was neatly groomed. and his behavior was appropriate. The patient reported that thoughts were put into his head by God and that these led to hunches that he would find could be true. He felt God had kept him alive to develop projects such as an enormous farm to help the poor or the use of electricity and other factors from space to help the U.S. economy. He denied other special powers. paranoid ideation, or ideas of reference. Mental status exam (including elements of the 6 Modified Mini-Mental State Exam ) revealed good performance on tests of short- and longer-term recall, abstraction, construction, concentration. and object and body part naming. The only deficits noted were inability to name the vice president or home state governor, inability to name presidents beyond the latest two. and impaired ability to fully provide information about one specific historic event. The diagnostic impression was that of an organic delusional disorder. and workup for organic etiology was recommended. EEG revealed left anterior-temporal seizure focus with very frequent sharp activity and occasional right temporal sharp activity. MRI of the head revealed periventricular and left posterior temporoparietal white matter lesions consistent with ischemic injury. Empiric treatment with phenytoin (300 mg/d) was initiated. During this workup interval of a few days, the patient did not manifest symptomatology suggestive of mania (beyond grandiosity) and was not administered any neuroleptic medication. The patient was started on haloperidol (2 mg po tid) almost concurrently with phenytoin (100 mg po tid), and gradually became less delusional with improved sleep. He underwent surgical amputation of his right fifth toe and subsequently did well at physical therapy. When seen on day of discharge. he did not manifest delusions and was felt to be showing some distance from those thoughts. He was realistic and optimistic about his health and volunteer work plans and was discharged on haloperidol and phenytoin.

Results The eight cases of organic delusional disorder are outlined in Table 2. Table 3 summarizes pertinent demographic and clinical data. 345

Case Reports

The majority of delusions were of a paranoid nature; grandiosity and other delusional themes were less frequent. An underlying dementing iIIness/organic mental syndrome was identified in three of the patients. None of the patients manifested halIucinaTABLE 2.

Clinical descriptions or patients with organic delusional disorder

Patient Age Sex Race

346

tions as part of their clinical picture. Patient 5, when delirious as his clinical condition worsened, appeared to be having visual halIucinations. This was distinct from the nondelirious delusional state earlier in the course of his admission. Cognitive status varied significantly among

Delusional Content

Contributing Organic Etiology

Treatment

Outcome

20

M

W

I. Wife unfaithfulness Steroid-responsive 2. Doctors' mistake encephalopalhy 3. PanlRoid ideation about slaff member

Haloperidol eventually I. Haloperidol (8 mg poqhs) stopped with no re2. Steroids: currence of delusions a. Methylpredni solone (I g ivss qd), then b. Prednisone (60 mg po qd)

2

67

M

W

I. Grandiose ideation 2. Thoughl insenion

EEG abnormalilies MRlofhead abnormalities

I. Haloperidol (2 mg po tid) 2. Phenyloin (100 mg po tid)

3

76

M

W

I. Paranoid ideation (plouing of others) 2. Grandiose ideation 3. Delusional somatic preoccupation

Organic mental syndrome: conical atrophy on head IT (by history) and clinical exams

Transferred 10 Not available accepling facility (medical service. later psychialric unill

4

34

M

W

Paranoid ideation: I. Harassment by olhers 2. Illness caused by health worker

Recommended neuroleptic; patient refused

Continuing paranoid ideation

5

52

M

W

Paranoid ideation: I. Being recorded 2. Being talked about by others 3. Staff members related

Past head trauma with the following results: a. Right temporal slowing on EEG b.Complex panial seizures AIDS-dementia complex

I. Haloperidol (0.5 mg po bid) 2. Swilched to thioridazine (25 mg po bid)

6

29

M

W

Paranoid ideation: Afraid of olhers wanting/trying to hun patient

Abrupt diazepam discontinuation (3 days duration)

Reinslilule diazepam

I. Haloperidol showed efficacy, but 2. Clinical consideralions led to switch to thioridazine; condition worsened and patient expired Delusions resolved within 24 hours

7

59

F

W

I. Paranoid ideation: Other person stealing from patienl 2. Threatening behavior

Presenile dementia of Alzheimer's type

I. Inpalient psychialric care 2. Haloperidol (evenlual dose. 5 mgpoqpm) 3. Diazepam taper

Delusions resolved on haloperidol

8

70

M

W

I. Rei igious preoccupation! rumination 2. Obsession with legal matter

Mild hypercalcemia felt secondary to squamous cell CA of lung

Calcitonin and hydralion

Delusions resolved

On haloperidol and phenytoin, delusions resolved

PSYCHOSOMATICS

Case Reports

the patients. Patients 5 and 7 had findings/histories consistent with dementing disorders, and Patient 3 showed mild cognitive deficits. Patient I showed minor deficits and returned to baseline during the hospitalization. Patient 8 showed mild to moderate item recall deficits reported as baseline mental status after delusions resolved. Patients 2, 4, and 6 showed few to no deficits on examination. None of the patients had a history of past psychiatric illness that was unrelated to the contributing organic etiology. Delusions completely resolved in five of the patients (I, 2, 6, 7, and 8), and clinical improvement occurred in one other (Patient 5). Full folTABLE 3. Clinical data of patients with organic delusional disorder Number Percentage Gender Male Female Race White Delusional content Paranoid ideation Grandiose ideation Somatic preoccupation Religious preoccupation Thought insenion Obsession with legal matter Hallucinations Contributing organic etiology Dementia/organic mental syndrome (by history. exam. and/or investigational findings) EEG abnormalities/seizure disorder Steroid-responsive encephalopathy Diazepam withdrawal Metabolic (hypercalcemia) Past psychiatric history unrelated to organic etiology Outcome Delusions resolved Clinical improvement Treatment refused (neuroleptic) Not available Use of haloperidol Clinical response while on haloperidol

7 I 8

87.5 12.5 100

6 2 I I I I

75 25 12.5 12.5 12.5 12.5

0

0

3

37.5

2

25 12.5 12.5 12.5

0

o

5 I I I

4 4

Note: Total patient sample. N =8; age range years (mean 50.9).

VOLUME 33· NUMBER 3· SUMMER 1992

100 (of4)

=20-76

low-up outcome information was not available for Patient 3, and Patient 4 refused neuroleptic treatment. Haloperidol efficacy is noted in Tables 2 and 3. Patient I did not show recurrence of delusions while off steroids and on haloperidol, and neuroleptic therapy was eventually discontinued without relapse. In Patient 2, haloperidol and phenytoin were used concurrently with subsequent resolution of delusions; thus, one cannot definitively determine the individual contribution of either agent to symptom resolution. The two other patients (5 and 7) placed on haloperidol improved on the agent. In summary, the patients widely ranged in ages, and none had a past psychiatric history unrelated to the contributing organic etiology. The cognitive examinations showed variations, but all patients had a clear sensorium and none manifested hallucinations. Delusional content was predominantly paranoid in nature, but there was heterogeneity in the organic etiologies. There was good clinical response to treating the organic etiology, neuroleptic therapy, or both. Discussion

Comparison to Other Studies Literature review by MEDLINE and Index Medicus (1980-1990) does not reveal any earlier studies specifically addressing organic delusional disorder on a psychiatric C-L service. However, the literature of organic mental disorders affords comparisons with the present study. McKegney et al. 7 reported a 27% organic mental disorder diagnosis rate on a teaching hospital C-L service, and a 17.1 % rate was found by Hales et al. B in a military general hospital. Both studies7•B used DSM-III diagnostic nomenclature. McKegney et al. 7 did not include organic affectivedisorders in their data. Without organic mood disorder, depressed/manic, the present study shows a 25.9% rate for primary organic mental disorder diagnosis based on DSM-III-R criteria and is consistent with the results of McKegney et al. 7 Hales et al. B found dementia (44.5%), delirium (30.8%), and organic affective syndrome 347

Case Reports

( 11.5%) to account for over 80% of the organic mental disorder diagnoses, closely approximating the findings of the present report. However. whereas the percentages for delirium are almost identical, the relative percentages for dementia and organic affective syndrome/organic mood disorder. depressed are essentially reversed in the two studies. K In their study ofshort-term general hospitals, Wallen et al.~ found that 23.6% of patients who had psychiatric consultation were diagnosed with depression. Similarly. Moffic and Paykel 'O reported that 24% of mixed medical inpatients met depression criteria as assessed by the Beck Depression Inventory. Depression (organic mood disorder. depressed/major depression) was the primary diagnosis in 99 of 379 patients in the present study: this 26.1 % rate is thus consistent with previous investigations. Cummings' 1985 study I I of 20 patients with organic delusions referred for neurobehavioral assessment bears comparison with the present article. He found the average age at time of delusion onset to be 63.7 years ll vs. 50.9 years for the average patient age in the present research. This disparity may be a function of differences between the two clinical services from which patients were drawn. Absence of hallucinations in the present report contrasts with the Cummings' cohort. " in which 7 of 20 patients with organic delusions manifested hallucinations. As in the present study, none of his patients had a past history of psychiatric illness. I I Delirium vs. Organic Delusional Disorder Delusional ideation in the setting of organic illness is a long-recognized phenomenon in the medical literature. In 1985, Cummings II outlined the great variety of metabolic and central nervous system (CNS) disorders that produce delusions. The imperative need to eliminate delirium as the causative agent of delusion must be stressed. As Lipowski l2 has pointed out, the main cognitive functions of attention, perception, thinking. and memory are all adversely affected when delirium is present. Disordered sleep-wake cycle and altered psychomotor behavior are also common 348

features of delirium. '2 . D Delusions, usually of a persecutory nature, can often occur with delirium but are not believed to be as well organized or well maintained as those seen in other conditions (schizophrenia. mania, paranoid psychosis). 12 Many cases of organic delusional disorder reported in the literature may have been delirium. Alarcon and Franceschini, 14 for example, in their review of the literature of hyperparathyroidism and paranoid psychosis. contend that some of the published cases of paranoid psychosis were actually delirium. occurring as they did with altered consciousness. lethargy, agitation, and affected cognition. Hallucinations can often occur as part of a delirious stateD and are usually visual or visual plus auditory, although other sensory hallucinations are possible.' 2 In the present study. no patient manifested hallucinations as part of the delusional picture. These considerations, coupled with DSMII1-R mandate, necessitate careful screening for delirium before the diagnosis of organic delusional disorder can be made. Contributing Organic Etiologies The contributing organic etiologies in these cases are worth reviewing. In Patient I. steroidresponsive encephalopathy. though nonspecific, best classified the CNS disorder; sarcoidosis was a strong consideration. Stoudemire et al. 15 described a case of presumptive CNS sarcoidosisrelated delirium that rapidly (within 72 hours) resolved with chlorpromazine and prednisone, with the patient remaining asymptomatic off chlorpromazine. Patient I's delusions showed similar sustained response to steroids. Systemic lupus erythematosus (SLE), a collagen vascular disease with associated vasculitis, may produce delusions. '6 In two previously reported cases, delusions co-occurred with confusion, disorientation. and hallucinations; 16 thus, delirium was a likely etiology. Feinglass et al.,l? in their description of the neuropsychiatric manifestations of SLE, found that 22 of 24 patients with secondary psychiatric manifestations showed some organic component, with paranoia PSYCHOSOMATICS

Case Reports

noted in six. In the clinical outcome data, 84% (56/67) of the episodes of neuropsychiatric disease improved; the majority (47/56) improved with either initiation or increased dosage of steroids. J7 Patient 2 in the present study had EEG abnormalities consistent with a seizure disorder, and Patient 4 had a history of complex partial seizures. Slater and Beard,18 in their landmark article on the "schizophrenia-like psychoses of epilepsy," concluded that there was an etiologic relationship between epilepsy and this psychosis. Schwartz and Cummings l9 found that 3 of 21 epileptic outpatients referred to an outpatient C-L service had psychoses. Trimble 20 proposed that the epileptic psychoses be divided into periictal and interictal psychoses. The former, attributable to the acute CNS disturbances seen with seizures, necessitates better seizure control as treatment, whereas the latter type are independent of the acute CNS electrical disturbances and should be treated with conventional antipsychotic agents. 20 Under this system, Patient 2 might be classified as having a periictal disorder and Patient 4 as having an interictal psychosis. Delusions in association with dementing processes are well documented 21.22 and are implicated in three of the cases in the present study. Patient 7 manifested a delusion of someone stealing from her, a symptom that Reisberg et al. 23 found to be the most frequent delusional manifestation in symptomatic Alzheimer's disease (AD) patients, occurring in 48%. Among less frequent symptoms were the delusions of one's house not being one's home (21 %), delusion of abandonment (21 %), paranoia (21 %), unspecified delusions (12%), and the delusion of one's spouse being an impostor (9%).23 Both Patient 7 (with an AD diagnosis) and Patient 3 (with strong consideration of dementing illness) manifested such delusional symptoms. Similarly, the association of AIDS dementia complex (Patient 5's contributing organic etiology) with delusions has been well documented. 24 .25 Price et al. 26 noted organic psychosis as both an early and late manifestation of AIDS dementia. VOLUME 33· NUMBER 3· SUMMER 1992

Sudden benzodiazepine withdrawal (Patient 6) as an etiology of delusion without delirium is not common. In Fruensgaard's27 study of withdrawal psychosis, all patients abruptly withdrawn from "drugs that can lead to physical dependence" (including benzodiazepines) manifested psychosis in the setting of a delirium. Petursson and LaderH reported "paranoid reaction" in 2 of 16 patients gradually withdrawn from long-term, therapeutic-dose benzodiazepine treatment. Bleich et al. 29 reported a case of paranoid ideation without delirium that occurred during gradual withdrawal of alprazolam with symptom alleviation after dose increase, a scenario that parallels Patient 6. Most revealing is Preskom and Denner'sJO examination of three cases of acute psychosis following sudden benzodiazepine withdrawal. Whereas their Cases I and 3 had features suggestive of delirium-related psychosis, Case 2 manifested acute paranoid delusions with intact orientation and memory occurring within 3 days of abrupt diazepam discontinuation; the paranoid ideation resolved within 24 hours of diazepam reinstitution. JO The contributing organic etiology in Patient 8 was hypercalcemia secondary to squamous cell carcinoma of the lung. The literature of psychiatric manifestations in hyperparathyroidism and other hypercalcemic disorders was reviewed by Alarcon and Franceschini. 14 They concluded that severity of psychiatric symptoms was not directly related to the degree of hypercalcemia. 14 Jobom et al.JI found the following: I) the majority of patients with primary hyperparathyroidism manifest psychiatric symptoms; 2) parathyroid surgery reversed the symptoms; 3) the severity of symptoms did not seem to be related to the degree of hypercalcemia. Numann et al. 32 felt neuropsychologic dysfunction in hyperparathyroidism may relate to calcium level, parathyroid hormone (PTH), or disease-associated metabolic abnormalities. They noted that patients with secondary hyperparathyroidism with high PTH and low calcium levels frequently have neuropsychologic manifestations, suggesting a role for PTH in producing the symptomsY In Patient 8, delusional symptomatology re349

Case Reports

solved with calcium-lowering measures of calcitonin and hydration. Similarly, Weizman et al. 33 found that psychiatric symptoms resolved in seven patients with malignant disease and hypercalcemia when the calcium levels normalized after treatment. Assessment(freatment of Organic Delusional Disorder The investigational search for contributing etiologies is crucial to treatment of organic delusional disorder. A comprehensive evaluation may include neuroimaging as well as serum laboratory studies. Tanridag and Kirshner~ found that the anatomic lesions demonstrated on both CT and MRI in six patients with neurobehavioral syndromes correlated well with the behavioral symptomatology. They also concluded that MRI has superiority to CT in "anatomic detection and localization offocal cerebrallesions."J.l Similarly, Ostrow et a1.3~ considered MRI more sensitive than CT for imaging structural lesions in the setting of human immunodeficiency virus (HIV)-associated brain involvement. SPECT and PET, brain imaging techniques that provide functional information, may also have important roles in assessing organic delusional disorder. Holman and Tumeh 36 report that SPECT's applications in dementia, stroke, and epilepsy make this modality an important form of medical imaging. They note SPECT is less expensive and more readily accessible than PET. 36 It is well established that there can be major biochemical alterations demonstrated by SPECT without clear structural lesions on either CT or MRI or when there are lesions apparently too small to account for the degree of symptomatology.37 Patient I illustrates this point: his CT and MRI were normal, but a SPECT showed perfusion abnormalities indicative of an underlying organic CNS etiology of his delusional symptoms. Thus, obtaining SPECT when there is a clinical index of suspicion of contributing organic etiology to delusions may be considered, even if (or perhaps, particularly when) anatomic imaging studies are not revealing. 350

Treatment of an organic delusional disorder is determined by the organic factor(s) found on assessment. Neuroleptic medication was not required for delusion resolution in Patients 6 and 8; treatment for sudden benzodiazepine withdrawal and malignancy-associated hypercalcemia, respectively, was required. All four patients treated with haloperidol had a clinical response while on the neuroleptic agent. Patient I required temporary treatment with haloperidol and more sustained therapy with steroids. Patient 2 remained on both haloperidol and phenytoin, with delusion resolution. Both Patients 5 and 7 were treated with haloperidol in the setting of underlying dementing illness; clinical improvement was noted in Patient 5 and delusion resolution was noted in Patient 7. The effective haloperidol doses ranged up to 8 mg/d, with no significant side effects reported. Cummings3K noted that the same neuroleptics are used to treat organic psychosis as "idiopathic psychotic disorders," but patient age and (if applicable) preexisting basal ganglia disease are special concerns in organic psychosis. With the organic etiologies that cause organic psychosis more common in the elderly,3K the psychogeriatric and dementia literature have applicability in the pharmacologic treatment of organic delusional disorder. Jenike 39 acknowledged the efficacy of neuroleptics in managing psychosis in the elderly, but also noted the numerous possible side effects that can occur, including tardive dyskinesia. He thus advised that cautious use of high-potency neuroleptics in low dosage could lessen the possibility of extrapyramidal side effects.-19 Steele et al. 40 found both haloperidol and thioridazine, used in low doses, to be effective in managing behavioral symptoms in AD patients. High-potency neuroleptics were recommended by Ostrow et a1.3~ for psychotic episodes associated with HIV -related organic brain disorder, reporting that patients with this condition are responsive to very low doses. Psychotherapeutic clarification techniques were used in addition to psychopharmacology in the present study. Educating both the families (if available) and the patients themselves about the diagnosis, assessment, treatment, and prognosis PSYCHOSOMATICS

Case Reports

of the organic delusional disorder aided management. Liaison with the individual treatment teams directly responsible for these patients was also crucial to treatment effectiveness.

Conclusions The organic etiologies and associated cognitive exams of the patients included here were variable but clinical features were not. They showed striking similarities in delusional content, absence of hallucinations, and clearness of sensorium. None had a past psychiatric history unrelated to the underlying organic etiology, and there was good clinical response to treatment. An objective of this article was to examine the DSM-III-R diagnosis of organic delusional disorder through clinical cases and data and Iiter-

ature review. A diagnosis should classify a disorder as a distinct entity. This study's findings clearly support the conclusion that the present organic delusional disorder diagnostic criteria fulfill this requirement. The criteria contain the crucial need to eliminate delirium as the delusional causation, and, just as importantly, mandate the determination of specific organic etiology. The diagnostic mandate to assess each patient for specific organic causation has been shown in this article to have significant treatment implications.

The author acknowledges Dr. Virginia Streusand Goldman, Dr. Jeffrey L. Cummings, and Dr. Vicki Burdine for their editorial contributions, and Nancy Haworth for manuscript preparation.

References I. Popkin MK. Tucker G. Caine E, et al: The fate of organic mental disorders in DSM-IV: a progress repon. Psychosomatics 30:438--441. 1989 2. Lipowski ZJ: Is "organic" obsolete? Psychosomatics 31 :342-344. 1990 3. World Health Organization: World Health Organization /989 Draft ofChapter 5: Menial and Behavioral Disorders. Geneva. World Health Organization. 1989 4. Goldman SA: Concerns and issues of the diagnostic category of organic mental disorders in the DSM-IV (letter). Psychosomatics 32: 112. 1991 5. American Psychiatric Association: Diagnostic and Statistical Manual of Menial Disorders. 3rd Edition, Rel·ised. Washington, DC, American Psychiatric Association, 1987 6. Teng EL, Chui HC: The Modified Mini-Mental State (3MS) Examination. J Clin Psychiatry 48:314-318. 1987 7. McKegney FP. McMahon T. King J: The use of DSM-IU in a general hospital consultation-liaison service. Gen HospPsychiatry5:115-12I,1983 8. Hales RE, Polly S. Bridenbaugh H. et al: Psychiatric consultations in a military general hospital: a repon on 1065 cases. Gen Hosp Psychiatry 8: 173-182. 1986 9. Wallen J. Pincus HA. Goldman HH. et al: Psychiatric consultations in shon-term general hospitals. Arch Gen Psychiatry 44: 163-168. 1987 10. Moffic HS. Paykel ES: Depression in medical inpatients. Br J Psychiatry 126:346-353. 1975 II. Cummings JL: Organic delusions: phenomenology. anatomical correlations. and review. Br J Psychiatry 146:184-197.1985

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12. Lipowski ZJ: Delirium (acute confusional states). JAMA 258:1789-1792.1987 13. Lipowski ZJ: Delirium: Acute Brai" Failure in Man. Springfield. IL. Charles C Thomas. 1980 14. Alarcon RD. Franceschini JA: Hyperparathyroidism and paranoid psychosis: case repon and review of the literature. Br J Psychiatry 145: 477-486. 1984 15. Stoudemire A. Linfors E. Houpt JL: Central nervous system sarcoidosis. Gen Hosp Psychiatry 5: 129-132. 1983 16. MacNeill A. Grennan DM. Ward D. et al: Psychiatric problems in systemic lupus erythematosus. Br J Psychiatry 128:442--445. 1976 17. Feinglass EJ, Arnett FC. Dorsch CA. et al: Neuropsychiatric manifestations of systemic lupus erythematosus: diagnosis. clinical spectrum, and relationship to other features of the disease. Medici"e 55:323-339. 1976 18. Slater E. Beard AW: The schizophrenia-like psychoses of epilepsy. Br J Psychiatry 109:95-150. 1963 19. Schwanz J. Cummings JL: Psychopathology and epilepsy: an outpatient consultation-liaison experience. Psychosomatics 29:295-300. 1988 20. Trimble MR: The psychoses of epilepsy and their treatment. Clin NeuropharmacoI8:211-220. 1985 21. Cummings JL. Miller B. Hill MA. et al: Neuropsychiatric aspects of multi-infarct dementia and dementia of the Alzheimer type. Arch Neurol44:389-393. 1987 22. Morriss RK, Rovner BW. Folstein MF. et al: Delusions in newly admitted residents of nursing homes. Am J Psychiatry 147:299-302. 1990 23. Reisberg B. Borenstein J. Salob SP. et al: Behavioral symptoms in Alzheimer's disease: phenomenology and

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33. Weizman A. Eldar M. Schoenfeld Y. et al: Hypercalcemia-induced psychopathology in malignant diseases. Br } Psychiatry 135:363-366. 1979 34. Tanridag O. Kirshner HS: Magnetic resonance imaging and CT scanning in neurobehavioral syndromes. Psychosomatics 28:517-528. 1987 35. Ostrow D. Grant I. Atkinson H: Assessment and management of the AIDS patient with neuropsychiatric disturbances.} Clin Psychiatry 49(suppl): 14-22. 1988 36. Holman BL. Tumeh SS: Single-photon emission computed tomography (SPECT): applications and potential. }AMA 263:561-564.1990 37. Devous MD Sr: Imaging brain function by single-photon emission computer tomography. in Brain Imaging: Applications in Psychiatry, edited by Andreasen NC. Washington. DC. American Psychiatric Press. 1989. pp 147-234 38. Cummings JL: Organic psychosis. Psychosomatics 29: 16-26.1988 39. Jenike MA: Handbook of Geriatric Psychopharmacol010'. Littleton. MA. PSG Publishing Co. 1985 40. Steele C. Lucas MJ. Tune L: Haloperidol versus thioridazine in the treatment of behavioral symptoms in senile dementia of the Alzheimer's type: preliminary findings. } Clin Psychiatry 47:310-3 12. 1986

Pemoline

An Alternative Psychostimulantfor the Management of Depressive Disorders in Cancer Patients WILLIAM BREITBART, M.D. HINDI MERMELSTEIN, M.D.

P

sychostimulants (e.g.• methylphenidate. dextroamphetamine. pemoline) have been shown to be effective antidepressants in cancer patients and other medically ill populations. I- 3 Methylphenidate and dextroamphetamine have been shown to reduce sedation secondary to opioid analgesics and provide adjuvant analgesia in cancer patients. 4 These psychostimulants have also been shown to improve attention, concentration. and overall performance on neuropsychological testing in the medically ill and specifically in AIDS patients. s 352

Pemoline is a unique psychostimulant that is only remotely similar to amphetamine in chemical structure. It is a comparatively mild central nervous system stimulant with minimal sympathomimetic activity and low abuse potential. 6 Received February 8. 1991; revised April 30. 1991; accepted May 3.1991. From the Psychiatry Service. Depanment of Neurology. Memorial Sloan-Kettering Cancer Center, 1275 York Ave .• Box421. New York. NY 10021. Address reprint requests to Dr. Breitban. Copyright © 1992 The Academy of Psychosomatic Medicine.

PSYCHOSOMATICS