#
2002 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 113 ± 116
113
Risperidone for the treatment of delusional disorder CHRISTOPHER F FEAR1 AND SUSAN E LIBRETTO2 1
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC San Diego on 01/13/15 For personal use only.
2
Wotton Lawn Hospital, Gloucester and Janssen-Cilag Ltd, High Wycombe, UK.
The overlap between diagnostic criteria for schizophrenia and delusional disorder (DD) may cause diagnostic confusion. 1,2 This is important if response to treatment differs. Risperidone, an atypical antipsychotic, is established in the treatment of schizophrenia, although less so in other psychotic conditions. INTRODUCTION:
We report the case of a woman who developed DD, persecutory type, at the age of 50 years. Treatment with sulpiride 200 ± 800 mg daily caused side-effects of drowsiness and `hangover ’ and, consequently, non-complianc e. Written informed consent was gained for a 24-week, randomized, double-blind, placebo-contr olled, crossover trial of risperidone, initiated at 1 mg daily and increasing to 2 mg daily. METHOD:
Correspondence Address Dr Susan E Libretto, Janssen-Cilag Limited, PO Box No. 79, Saunderton, High Wycombe, Buckinghamshire HP14 4HJ, UK. Tel: 01494 567873 Fax: 01494 567445 Email: [email protected]
Significant improvemen t was found, as assessed by the Brief Psychiatric Rating Scale, Positive and Negative Symptom Schedule and Maudsley Assessment of Delusions Schedule. RESULTS:
We believe that this is the first case study reporting the resolution of persecutory DD with risperidone. A controlled clinical trial of risperidone in the treatment of patients with DD is warranted. (Int J Psych Clin Pract 2002; 6: 113 ± 116) CONCLUSION:
Received 27 March 2001; revised 30 January 2002; accepted for publication 5 February 2002
Keywords delusiona l disorder risperidone atypicals
INTRODUCTION
T
he nosological distinctiveness of delusional disorder (DD) has been determined in genetic, cognitive, neuropsychologica l and other parameters.1,3,4 Clinical diagnosis remains problematic, with DSM-IV criteria distinguishi ng it from schizophreni a almost exclusivel y on the bizarrenes s of the delusions and prominence of other psychotic symptoms.2 The condition is said to account for 1 ± 2% of psychiatric admissions , but its secretive nature means that the stated prevalence of 0.03% is almost certainly an underestimat e, compounded by the potential for diagnostic confusion with schizophreni a.5 The subtle distinction between these illnesses would make a differenc e if responsivene ss to treatment differed. Declaration: Dr Libretto is a medical writer for Janssen-Cilag Ltd, the manufacturers of risperidone.
delusions antipsychotic
Conventional neuroleptics appear to be of limited efficacy in treating delusional disorders, although no clinical trials have been conducted to date. One trial conducted on the monosymptomatic delusional hypochondriasis subtype suggested the efficacy of pimozide,6,7 but recent studies have questioned its supremacy.8,9 The atypical antipsychotic , risperidone , a potent serotonin 5-HT2A- and dopamine D2-receptor antagonist,10 is indicated for the treatment of schizophreni a and other psychotic conditions in which positive and/or negative symptoms are prominent. Its action on serotonin receptors suggests its trial in DD, where there are often obsessive elements which may be predicated upon a serotonergic aetiology. 11 The few reported uses of risperidon e in delusional disorder have involved erotomanic12,13 and somatic subtypes.9,14 ± 19 To our knowledge, this paper reports the first case study of the use of risperidon e to treat the persecutory
114
CF Fear and SE Libretto
subtype of DD with the response monitored in a trial with a double-blin d crossover design.
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC San Diego on 01/13/15 For personal use only.
CASE REPORT Mrs X was aged 50 when first referred for psychiatric assessment . Twelve months before, she had experienced a stressful period prior to leaving employment in a clerical job. She began to believe that her former colleague s and employers were persecuting her, notice that objects were missing from, or relocated around, the house, and concluded that people were breaking into her home. The lack of evidence of entry was explained by her belief that a duplicate set of door keys had been cut: she therefore had the locks changed twice. She noticed ``suspicious ’’ behaviour by her postman and by people similar to those with whom she used to work, together with repeated activities around the house by strangers whom she surmised were watching her movements. Her precautions included taping the windows and covering the television, maintaining that the house was bugged. Mrs X became reluctant to leave her house unattended and her behaviour put a considerabl e strain upon her husband and teenage daughter. Her sleep was poor and she was hypervigila nt. In a letter to her sister-in-law, she confided ``I am frightened to death in my own home. I have to move . . . It is just impossible for me to live like this . . . ’’. Her desperation led her to conclude: ``I cannot bear it here ± I panic every time I cannot find my keys . . . ’’. Mr X saw no evidence for his wife’s beliefs and was clearly worried about her mental state. There was no previous history of psychiatric illness and no other symptoms of psychosis . She was taking no medication and did not abuse drugs or alcohol. The diagnosis of DD met DSM-IV criteria5 and she was initially prescribed sulpirid e 400 mg twice daily. After 3 months, her paranoia had improved considerably , and although she still had fleeting delusional thoughts they no longer troubled her. She was calmer, sleeping well and had returned to her normal social activities with no undue worries about leaving her home. She was encouraged to continue taking sulpiride, although she was not keen to do so, having experienced side-effect s that included drowsiness and waking with a `hangover’ . Seven months later, the dose of sulpirid e had been reduced to 200 mg daily, which she insisted upon taking only when feeling stressed, due to continuing side-effects . Her delusiona l ideas began to increase, putting more stress upon the family, and a neighbour complained to the GP of her strange behaviour. A further assessment , prompted by her husband’s concerns, was conducted at home with the television on to thwart eavesdroppe rs, and it was soon apparent that her persecutory delusions had returned to the point at initial presentation. She entirely lacked insight concern-
ing her beliefs and refused treatment. It was suggested to her that she should collaborate in a trial of antipsychotic medication versus placebo. The trial would be double-blin d and use objective measures, so that the end of the trial period the benefits, or not, of the active treatment would allow her to draw conclusions about her illness. Mrs X gave written informed consent for inclusio n in a 24-week, randomized, double-blind , crossover trial of risperidon e 1 ± 4 mg daily versus placebo. Blinding was assured through the use of identical tablets for the active and placebo phases. The trial had local research ethics committee (LREC) approval, and four patients were recruited, one of whom failed to keep any appointments after the first, and two dropped out during the placebo phase. The trial was terminated, due to failure to recruit sufficien t subjects in a reasonable time period. Treatment began with 1 mg of trial medication, which was continued for 2 weeks before titrating up to 2 mg according to response. Efficacy was assessed using the Brief Psychiatric Rating Scale,20 Positive and Negative Syndrome Scale21 and Maudsley Assessmen t of Delusions Schedule (MADS).22 After 8 weeks Mrs X had gained no benefit. She had changed the door locks for the fourth time, had been to the police about her fears and her husband was at his wits’ end. Study assessment s over the first 12-week period confirmed her delusional condition. But by the end of the 24 weeks, there had been a dramatic change in her behaviour; she noticed no incidents of persecution. Her family situation improved and she no longer set the burglar alarm when she went out. Evaluation of efficacy assessmen t scales confirmed reduction or absence of delusions , suspicions , anxiety, tension and depression (Table 1). The MADS results showed that this improvement had begun at least 4 weeks after trial crossover, and was substantial by 2 months. She experience d no adverse effects. Breaking the blind showed that the first 12 weeks were placebo, and during weeks 12 ± 24 she took risperidon e in a final trial dose of 2 mg at night. Five months on, she remains well, with no delusional ideas, a happy home life and a new job.
DISCUSSION There is an acknowledge d overlap in DSM-IV diagnostic criteria for schizophren ia and delusional disorder (DD).5 Mrs X’s symptoms, occurring in mid-life and in the absence of previous psychiatric history or other psychotic symptoms, were clearly those of DD, persecutor y subtype. Results of the PANSS indicate the severity of the delusional and persecutory phenomena, with the absence of scores on other scales distinguishi ng it from schizophrenia. The devastating effect on an otherwise happy, stable family is illustrated by the results of the MADS. Her constant search for evidence to support her delusions , affect,
Risperidone in delusional disorder
115
Table 1 Notable findings from psychiatric assessments
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC San Diego on 01/13/15 For personal use only.
Week Assessment
0
12
24
Brief Psychiatric Rating Scale Total score (range 18 ± 126) Over concerned for present/future Tension, `nervousness’ Depressed Suspicious
37 moderate moderate mild extreme
36 moderate moderate v. mild extreme
26 v. mild absent absent moderate
Positive and Negative Syndrome Scale Positive: Total score (range 7 ± 49) Positive: Delusions Positive: Suspicions/persecution Negative: Total score (range 7 ± 49) General: Total score (range 16 ± 112) General: Anxiety
22 severe extreme 7 (absent) 34 moderate
21 severe extreme 7 (absent) 32 moderate
12 mild mild 7 (absent) 25 minimum
Maudsley Assessment of Delusions Schedule Total scores: Certainty of belief (range 0 ± 4) Belief maintenance factors (range 0 ± 10) Affect relating to chosen belief (range 0 ± 5) Negative behaviour (range 0 ± 16) Idiosyncracy of belief (range 0 ± 8) Preoccupation with chosen belief (range 0 ± 4) Systematization of chosen belief (range 0 ± 3)
4 7 4 8 7 4 3
4 7 4 6 3 4 3
4 5 0 0 0 2 2
Improvement is denoted by a reduction in score.
negative behaviour, and preoccupation led to repeated family arguments and a curtailment to her employment and social life, as she was unwilling to leave the house unattended. A previous trial of sulpiride had been partially successfu l but ended due to side-effects and her lack of insight. Risperidone has a lower incidence of sideeffects and a serotonergi c action, which may be more effective in DD due to the obsessive characteristic s of DD patients. She was persuaded to take it through gaining her collaboration in a double-blin d trial with a placebo arm, to allow her to work with her key-worke r and determine whether she was better on or off medication. This approach, mirroring the open-minded approach to delusions used in cognitive therapy, promotes collaboration and measures improvemen t through a reduction in behavioural symptoms, related to the belief rather than extinction of the delusion. A good result is therefore the firm belief that the persecution happened in the past but is not happening now. The dramatic reduction in negative behaviour and affect related to the delusional system is of more consequence in terms of the quality of individua l and family life than a purist `cure’ for the delusions.
MADS scores indicated a marked reduction in most delusional parameters between weeks 12 and 24, corresponding with the period on active medication. Both Mrs X and her family reported that they were much more settled during this period. The collaborativ e approach, in which her delusions were not challenge d from the outset, allowed a rapport to develop and, although the certainty with which she held the beliefs did not alter, they were qualitatively different , in that she believed the persecution had happened but was not current. At 6-month follow-up she remained on risperidon e 2 mg daily, a low dose, consistent with the finding that DD patients require lower neuroleptic doses than schizophreni c patients.23,24 Pimozide was previously the treatment of choice for DD, on the basis of one clinical trial in a single subtype of the disorder.6 Recently, this drug was restricted in the UK due to its potential for causing cardiovascul ar problems.25 Furthermore , the problems of distressin g side-effect s from conventional neuroleptics affect compliance,26 a major consideratio n when treating DD, in which patients are reluctant to accept medication as they do not believe themselve s to be ill. Although more costly, the case for atypical antipsychotics is likely to be strengthened by the fact of the better complianc e with the low doses required,
116
CF Fear and SE Libretto
meaning that cost is unlikely to be a significan t disadvantage .
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC San Diego on 01/13/15 For personal use only.
CONCLUSION We believe this to be the first reported case study of persecutor y DD responding to risperidone . Generally, risperidon e seems well suited to the treatment of this disorder. In a retrospective study of patients prescribe d risperidone , the 18 elderly patients with late-onset delusional disorders were amongst those who showed the most improvement.23 A controlled clinical trial of risperidon e in the treatment of patients with delusional disorder is warranted.
KEY POINTS . Risperidone , an atypical antipsychotic , shows efficacy in the treatment of delusional disorder . Low doses of risperidon e can be used to control and maintain patients with delusiona l disorder . Treatment with risperidon e is well tolerated . A collaborative approach without challenge to the delusiona l system can be helpful in improving insight . A controlled clinical trial of risperidon e in delusiona l disorder is warranted to substantiate the findings of this case study
REFERENCES 1. Kendler KS (1980) The nosological validity of paranoia (simple delusional disorder). Arch Gen Psychiatry 37: 699 ± 706. 2. Fear CF, McMonagle T, Healy D (1998) Delusional disorder: boundaries of a syndrome. Eur Psychiatry 13: 210 ± 18. 3. Farmer AE, McGuffin P, Gottesman H (1987) Twin concordance for DSM-III schizophrenia: scrutinising the validity of the definition. Arch Gen Psychiatry 44: 634 ± 41. 4. Fear CF, Sharp H, Healy D (1996) Cognitive processes in delusional disorders. Br J Psychiatry 168: 61 ± 67. 5. American Psychiatric Association (1994) Delusional disorder. In: Diagnostic and Statistical Manual of Mental Disorders, 4th edn. (DSM-IV) APA, Washington DC. 6. Hamman K, Aunstorp C (1982) Delusions of infestation treated by pimozide: a double-blind crossover clinical study. Acta Derm Venereal (Stockh) 62: 55 ± 58. 7. Munro A, Mok H (1995) An overview of treatment in paranoia/ delusional disorder. Can J Psychiatry 40: 616 ± 22. 8. De Leon OA, Furmaga KM, Canterbury AL et al (1997) Risperidone in the treatment of delusions of infestation. Int J Psychiatry Med 27: 403 ± 409. 9. Silva H, Jerez S, Ramirez A et al (1998) Effects of pimozide on the psychopathology of delusional disorder. Prog Neuropsychopharmacol Biol Psychiatry 22: 331 ± 40. 10. Leysen JE, Gommeren A, Eens D et al (1988) The biochemical profile of risperidone, a new antipsychotic. J Pharmacol Exp Ther 247: 661 ± 70. 11. Fear CF, Sharp H, Healy D (2000) Obsessive-compulsive disorder with delusions. Psychopathology 33: 55 ± 61. 12. Atre-Vaidya N (1996) Reply to Ze’ev Levin and Michael Y Hwang (letter). Neuropsychiatry Neuropsychol Behav Neurol 9: 218 ± 219. 13. Mannion L, Carney PA (1996) Homosexual erotomania responding to risperidone (letter). Eur Psychiatry 11: 378. 14. Gallucci G, Beard G (1995) Risperidone and the treatment of delusions of parasitosis in an elderly patient. Psychosomatics 36: 578 ± 80.
15. Songer DA, Roman B (1996) Treatment of somatic delusional disorder with atypical antipsychotic agents (letter). Am J Psychiatry 153: 578 ± 79. 16. Kitamura H (1997) A case of somatic delusional disorder that responded to treatment with risperidone. Psychiatry Clin Neurosci 51: 337. 17. Safer DL, Wenegrat B, Roth W (1997) Risperidone in the treatment of delusional parasitosis: A case report (letter). J Clin Psychopharmacol 17: 131 ± 32. 18. Cetin M, Ebrinc S, Agargun MY et al (1999) Risperidone for the treatment of monosymptomatic hypochondriacal psychosis (letter). J Clin Psychiatry 60: 554. 19. Freyne A, Kenny E, Cooney C (1999) Delusions of infestation ± A case report of response to risperidone. Irish Med J 92: 435. 20. Overall JE, Gorham DR (1962) The Brief Psychiatric Rating Scale. Psychol Rep 10: 799 ± 812. 21. Kay SR, Fiszbein A, Opler LA (1987) The Positive-Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bull 13: 261 ± 76. 22. Wessely S, Buchanan A, Reed A et al (1993) Acting on delusions. I. Prevalence. Br J Psych 163: 69 ± 76. 23. Kiraly SJ, Gibson RE, Ancill RJ et al (1998) Risperidone: Treatment response in adult and geriatric patients. Int J Psychiatry Med 28: 255 ± 63. 24. Evans JD, Paulsen JS, Harris MJ et al (1996) A clinical and neuropsychological comparison of delusional disorder and schizophrenia.J Neuropsychiatr Clin Neurosci 8: 281 ± 86. 25. Medicines Control Agency/Commitee on Safety of Medicines (MCA/CSM) (1995) Cardiac arrhythmias with pimozide (Orap). MCA/CSM Curr Prob Pharmacovigilance 21: 2. 26. Kapur S, Remington G (2000) Atypical neuroleptics. Br Med J 321: 1361 ± 62.
2002 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 113 ± 116
113
Risperidone for the treatment of delusional disorder CHRISTOPHER F FEAR1 AND SUSAN E LIBRETTO2 1
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC San Diego on 01/13/15 For personal use only.
2
Wotton Lawn Hospital, Gloucester and Janssen-Cilag Ltd, High Wycombe, UK.
The overlap between diagnostic criteria for schizophrenia and delusional disorder (DD) may cause diagnostic confusion. 1,2 This is important if response to treatment differs. Risperidone, an atypical antipsychotic, is established in the treatment of schizophrenia, although less so in other psychotic conditions. INTRODUCTION:
We report the case of a woman who developed DD, persecutory type, at the age of 50 years. Treatment with sulpiride 200 ± 800 mg daily caused side-effects of drowsiness and `hangover ’ and, consequently, non-complianc e. Written informed consent was gained for a 24-week, randomized, double-blind, placebo-contr olled, crossover trial of risperidone, initiated at 1 mg daily and increasing to 2 mg daily. METHOD:
Correspondence Address Dr Susan E Libretto, Janssen-Cilag Limited, PO Box No. 79, Saunderton, High Wycombe, Buckinghamshire HP14 4HJ, UK. Tel: 01494 567873 Fax: 01494 567445 Email: [email protected]
Significant improvemen t was found, as assessed by the Brief Psychiatric Rating Scale, Positive and Negative Symptom Schedule and Maudsley Assessment of Delusions Schedule. RESULTS:
We believe that this is the first case study reporting the resolution of persecutory DD with risperidone. A controlled clinical trial of risperidone in the treatment of patients with DD is warranted. (Int J Psych Clin Pract 2002; 6: 113 ± 116) CONCLUSION:
Received 27 March 2001; revised 30 January 2002; accepted for publication 5 February 2002
Keywords delusiona l disorder risperidone atypicals
INTRODUCTION
T
he nosological distinctiveness of delusional disorder (DD) has been determined in genetic, cognitive, neuropsychologica l and other parameters.1,3,4 Clinical diagnosis remains problematic, with DSM-IV criteria distinguishi ng it from schizophreni a almost exclusivel y on the bizarrenes s of the delusions and prominence of other psychotic symptoms.2 The condition is said to account for 1 ± 2% of psychiatric admissions , but its secretive nature means that the stated prevalence of 0.03% is almost certainly an underestimat e, compounded by the potential for diagnostic confusion with schizophreni a.5 The subtle distinction between these illnesses would make a differenc e if responsivene ss to treatment differed. Declaration: Dr Libretto is a medical writer for Janssen-Cilag Ltd, the manufacturers of risperidone.
delusions antipsychotic
Conventional neuroleptics appear to be of limited efficacy in treating delusional disorders, although no clinical trials have been conducted to date. One trial conducted on the monosymptomatic delusional hypochondriasis subtype suggested the efficacy of pimozide,6,7 but recent studies have questioned its supremacy.8,9 The atypical antipsychotic , risperidone , a potent serotonin 5-HT2A- and dopamine D2-receptor antagonist,10 is indicated for the treatment of schizophreni a and other psychotic conditions in which positive and/or negative symptoms are prominent. Its action on serotonin receptors suggests its trial in DD, where there are often obsessive elements which may be predicated upon a serotonergic aetiology. 11 The few reported uses of risperidon e in delusional disorder have involved erotomanic12,13 and somatic subtypes.9,14 ± 19 To our knowledge, this paper reports the first case study of the use of risperidon e to treat the persecutory
114
CF Fear and SE Libretto
subtype of DD with the response monitored in a trial with a double-blin d crossover design.
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC San Diego on 01/13/15 For personal use only.
CASE REPORT Mrs X was aged 50 when first referred for psychiatric assessment . Twelve months before, she had experienced a stressful period prior to leaving employment in a clerical job. She began to believe that her former colleague s and employers were persecuting her, notice that objects were missing from, or relocated around, the house, and concluded that people were breaking into her home. The lack of evidence of entry was explained by her belief that a duplicate set of door keys had been cut: she therefore had the locks changed twice. She noticed ``suspicious ’’ behaviour by her postman and by people similar to those with whom she used to work, together with repeated activities around the house by strangers whom she surmised were watching her movements. Her precautions included taping the windows and covering the television, maintaining that the house was bugged. Mrs X became reluctant to leave her house unattended and her behaviour put a considerabl e strain upon her husband and teenage daughter. Her sleep was poor and she was hypervigila nt. In a letter to her sister-in-law, she confided ``I am frightened to death in my own home. I have to move . . . It is just impossible for me to live like this . . . ’’. Her desperation led her to conclude: ``I cannot bear it here ± I panic every time I cannot find my keys . . . ’’. Mr X saw no evidence for his wife’s beliefs and was clearly worried about her mental state. There was no previous history of psychiatric illness and no other symptoms of psychosis . She was taking no medication and did not abuse drugs or alcohol. The diagnosis of DD met DSM-IV criteria5 and she was initially prescribed sulpirid e 400 mg twice daily. After 3 months, her paranoia had improved considerably , and although she still had fleeting delusional thoughts they no longer troubled her. She was calmer, sleeping well and had returned to her normal social activities with no undue worries about leaving her home. She was encouraged to continue taking sulpiride, although she was not keen to do so, having experienced side-effect s that included drowsiness and waking with a `hangover’ . Seven months later, the dose of sulpirid e had been reduced to 200 mg daily, which she insisted upon taking only when feeling stressed, due to continuing side-effects . Her delusiona l ideas began to increase, putting more stress upon the family, and a neighbour complained to the GP of her strange behaviour. A further assessment , prompted by her husband’s concerns, was conducted at home with the television on to thwart eavesdroppe rs, and it was soon apparent that her persecutory delusions had returned to the point at initial presentation. She entirely lacked insight concern-
ing her beliefs and refused treatment. It was suggested to her that she should collaborate in a trial of antipsychotic medication versus placebo. The trial would be double-blin d and use objective measures, so that the end of the trial period the benefits, or not, of the active treatment would allow her to draw conclusions about her illness. Mrs X gave written informed consent for inclusio n in a 24-week, randomized, double-blind , crossover trial of risperidon e 1 ± 4 mg daily versus placebo. Blinding was assured through the use of identical tablets for the active and placebo phases. The trial had local research ethics committee (LREC) approval, and four patients were recruited, one of whom failed to keep any appointments after the first, and two dropped out during the placebo phase. The trial was terminated, due to failure to recruit sufficien t subjects in a reasonable time period. Treatment began with 1 mg of trial medication, which was continued for 2 weeks before titrating up to 2 mg according to response. Efficacy was assessed using the Brief Psychiatric Rating Scale,20 Positive and Negative Syndrome Scale21 and Maudsley Assessmen t of Delusions Schedule (MADS).22 After 8 weeks Mrs X had gained no benefit. She had changed the door locks for the fourth time, had been to the police about her fears and her husband was at his wits’ end. Study assessment s over the first 12-week period confirmed her delusional condition. But by the end of the 24 weeks, there had been a dramatic change in her behaviour; she noticed no incidents of persecution. Her family situation improved and she no longer set the burglar alarm when she went out. Evaluation of efficacy assessmen t scales confirmed reduction or absence of delusions , suspicions , anxiety, tension and depression (Table 1). The MADS results showed that this improvement had begun at least 4 weeks after trial crossover, and was substantial by 2 months. She experience d no adverse effects. Breaking the blind showed that the first 12 weeks were placebo, and during weeks 12 ± 24 she took risperidon e in a final trial dose of 2 mg at night. Five months on, she remains well, with no delusional ideas, a happy home life and a new job.
DISCUSSION There is an acknowledge d overlap in DSM-IV diagnostic criteria for schizophren ia and delusional disorder (DD).5 Mrs X’s symptoms, occurring in mid-life and in the absence of previous psychiatric history or other psychotic symptoms, were clearly those of DD, persecutor y subtype. Results of the PANSS indicate the severity of the delusional and persecutory phenomena, with the absence of scores on other scales distinguishi ng it from schizophrenia. The devastating effect on an otherwise happy, stable family is illustrated by the results of the MADS. Her constant search for evidence to support her delusions , affect,
Risperidone in delusional disorder
115
Table 1 Notable findings from psychiatric assessments
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC San Diego on 01/13/15 For personal use only.
Week Assessment
0
12
24
Brief Psychiatric Rating Scale Total score (range 18 ± 126) Over concerned for present/future Tension, `nervousness’ Depressed Suspicious
37 moderate moderate mild extreme
36 moderate moderate v. mild extreme
26 v. mild absent absent moderate
Positive and Negative Syndrome Scale Positive: Total score (range 7 ± 49) Positive: Delusions Positive: Suspicions/persecution Negative: Total score (range 7 ± 49) General: Total score (range 16 ± 112) General: Anxiety
22 severe extreme 7 (absent) 34 moderate
21 severe extreme 7 (absent) 32 moderate
12 mild mild 7 (absent) 25 minimum
Maudsley Assessment of Delusions Schedule Total scores: Certainty of belief (range 0 ± 4) Belief maintenance factors (range 0 ± 10) Affect relating to chosen belief (range 0 ± 5) Negative behaviour (range 0 ± 16) Idiosyncracy of belief (range 0 ± 8) Preoccupation with chosen belief (range 0 ± 4) Systematization of chosen belief (range 0 ± 3)
4 7 4 8 7 4 3
4 7 4 6 3 4 3
4 5 0 0 0 2 2
Improvement is denoted by a reduction in score.
negative behaviour, and preoccupation led to repeated family arguments and a curtailment to her employment and social life, as she was unwilling to leave the house unattended. A previous trial of sulpiride had been partially successfu l but ended due to side-effects and her lack of insight. Risperidone has a lower incidence of sideeffects and a serotonergi c action, which may be more effective in DD due to the obsessive characteristic s of DD patients. She was persuaded to take it through gaining her collaboration in a double-blin d trial with a placebo arm, to allow her to work with her key-worke r and determine whether she was better on or off medication. This approach, mirroring the open-minded approach to delusions used in cognitive therapy, promotes collaboration and measures improvemen t through a reduction in behavioural symptoms, related to the belief rather than extinction of the delusion. A good result is therefore the firm belief that the persecution happened in the past but is not happening now. The dramatic reduction in negative behaviour and affect related to the delusional system is of more consequence in terms of the quality of individua l and family life than a purist `cure’ for the delusions.
MADS scores indicated a marked reduction in most delusional parameters between weeks 12 and 24, corresponding with the period on active medication. Both Mrs X and her family reported that they were much more settled during this period. The collaborativ e approach, in which her delusions were not challenge d from the outset, allowed a rapport to develop and, although the certainty with which she held the beliefs did not alter, they were qualitatively different , in that she believed the persecution had happened but was not current. At 6-month follow-up she remained on risperidon e 2 mg daily, a low dose, consistent with the finding that DD patients require lower neuroleptic doses than schizophreni c patients.23,24 Pimozide was previously the treatment of choice for DD, on the basis of one clinical trial in a single subtype of the disorder.6 Recently, this drug was restricted in the UK due to its potential for causing cardiovascul ar problems.25 Furthermore , the problems of distressin g side-effect s from conventional neuroleptics affect compliance,26 a major consideratio n when treating DD, in which patients are reluctant to accept medication as they do not believe themselve s to be ill. Although more costly, the case for atypical antipsychotics is likely to be strengthened by the fact of the better complianc e with the low doses required,
116
CF Fear and SE Libretto
meaning that cost is unlikely to be a significan t disadvantage .
Int J Psych Clin Pract Downloaded from informahealthcare.com by CDL-UC San Diego on 01/13/15 For personal use only.
CONCLUSION We believe this to be the first reported case study of persecutor y DD responding to risperidone . Generally, risperidon e seems well suited to the treatment of this disorder. In a retrospective study of patients prescribe d risperidone , the 18 elderly patients with late-onset delusional disorders were amongst those who showed the most improvement.23 A controlled clinical trial of risperidon e in the treatment of patients with delusional disorder is warranted.
KEY POINTS . Risperidone , an atypical antipsychotic , shows efficacy in the treatment of delusional disorder . Low doses of risperidon e can be used to control and maintain patients with delusiona l disorder . Treatment with risperidon e is well tolerated . A collaborative approach without challenge to the delusiona l system can be helpful in improving insight . A controlled clinical trial of risperidon e in delusiona l disorder is warranted to substantiate the findings of this case study
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