whether 5-HT₂ antagonism potentiated the effect of paroxetine on other 5-HT receptors in the hypothalamus is not clear. A literature search failed to find any reported cases of galactorrhea associated with trazodone treatment.

Galactorrhea is an uncommon side effect of antidepressants that occurs weeks after treatment initiation, with the result that neither patients nor physicians may recognize the association. In addition, it is a rather unusual and potentially embarrassing adverse side effect that patients may not report to their physician.

References

1. Klein JJ, Segal RL, Pichel Warner RR. Galactorrhea due to imipramine. N Engl J Med 1964;271:510–2.
2. Anand VS. Clomipramine-induced galactorrhoea and amenorrhoea. Br J Psychiatry 1985;147:87–8.
3. Arya DK, Taylor WS. Lactation associated with fluoxetine treatment [letter]. Aust N Z J Psychiatry 1995;29:697.
4. Bonin B, Vandel P, Vandel S. Fluvoxamine and galactorrhea. A case report [letter]. Therapie 1994;49:149–51.
5. Jeffries J, Bezchlibnyk-Butler K, Remington G. Amenorrhea and galactorrhea associated with fluvoxamine in a loxapine-treated patient [letter]. J Clin Psychopharmacol 1992;12:296–7.
6. Bronzo MR, Stahl SM. Galactorrhea induced by sertraline [letter]. Am J Psychiatry 1993;150:1269–70.
7. Bonin B, Vandel P, Sechter D. Bizouard P. Paroxetine and galactorrhea. Pharmacopsychiatry 1997;30:133–4.
8. Nicholas L, Dawkins K, Golden RN. Psychoneuroendocrinology of depression. Prolactin. Psychiatric Clin North Am 1998;21:341–57.
9. Arya DK. Extrapyramidal symptoms with selective serotonin reuptake inhibitors. Br J Psychiatry 1994;165:728–33.
10. Halman M, Goldbloom DS: Fluoxetine and neuroleptic malignant syndrome. Biol Psychiatry 1990;28:518–21.

Jason Morrison, Bsc
Kingston, Ontario
Ronald A. Remick, MD, FRCPC
Marianna Leung, BS (Pharm)
Katherine J. Wrixon, MD, FRCPC
Richard A. Bebb, FRCPC
Vancouver, British Columbia

Dear Editor

There have been a few reports in the literature of obsessive–compulsive symptoms secondary to methlyphenidate treatment (1,2). We  report the following case of a child who developed compulsive stealing while taking large doses of methylphenidate.

Case Report

Ms D was initially seen at age 10 years. She had a history of attention-deficit hyperactivity disorder (ADHD) for which she was receiving methylphenidate that had been increased gradually to 90 mg daily, sertraline 50 mg nightly, and clonidine 0.025 mg nightly (her weight was 29.5 kg). Ms D was brought in by her mother, a nurse, for assessment of her 2-year history of uncontrollable stealing from peers, teachers, neighbours, and stores. She would steal a vast array of things, from small objects and food to full outfits of clothing. The stealing was occurring on an almost-daily basis, despite intense monitoring by her mother and regular consequences for her behaviour. She would hoard stolen goods in her bedroom; eventually, she had to hide them in other people’s homes—for example her babysitter’s—so that her vigilant mother would not discover that she had been stealing. Her mother reported that Ms D had told her that she had become unable to stop the urge to steal. Ms D also acknowledged retrospectively that her stealing behaviour coincided with the increase of methylphenidate to high doses.

In treatment, methylphenidate was gradually reduced to 30 mg daily. The uncontrollable stealing soon began to subside, and the child reported that “the thought to steal” did not cross her mind anymore. Occasional instances of stealing, however, did continue to occur; she called these “borrowing” from friends. Four months later, Ms D was admitted to the psychiatric ward of a pediatric hospital so that methylphenidate could be discontinued under observation. Sertraline was also discontinued. No major behaviours characteristic of ADHD were observed upon withdrawal of methylphenidate, and episodes of stealing decreased further.

One year later the child is free of stealing. She is not hyperactive or impulsive, but she still experiences some attentional and academic difficulties (she is about 1˝ years below the expected level). Her current medications are clonidine 0.05 mg 3 times daily and venlafaxine 37.5 mg each morning, prescribed independently by her family doctor.

This case further supports the evidence associating methylphenidate with obsessive–compulsive spectrum disorders (OCSD) (1,2). We do not know of another case in the literature that describes compulsive stealing as a side effect of stimulants. In Ms D’s case, the symptoms of compulsive stealing were triggered and maintained by doses of methylphenidate well above those recommended by researchers (3). The current understanding of the mechanism of action of stimulants involves norepinephrine and dopamine (4). Experimental evidence suggests that stimulants in high doses may also affect the serotonergic pathways (5) that are considered to be involved in OCSD. In this case, a link between a stimulant and compulsive behaviour may explain stealing. This, obviously, is only a hypothesis that requires further investigation.

References

1. Kozumi HM. Obsessive-compulsive symptoms following stimulants. Biol Psychiatry 1985;20:1332–7.
2. Kouris S. Methylphenidate-induced obsessive-compulsiveness. J Am Acad Child Adolescent Psychiatry 1998;37(2):135.
3. The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention deficit/hyperactivity disorder. Arch Gen Psychiatry 1999;56:1073–86.
4. Solanto M. Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivitydisorder: a review and integration. Behav Brain Res 1998;94:127–52.
5. Kankaanpaa A, Meririnne E, Lillsunde P, Seppala T. The acute effects of amphetamine derivatives on extracellular serotonin and dopamine levels in rat nucleus accumbens. Pharm Biochem Behav 1998;59:1003–9.

Sotiris Kotsopoulos, MD
Mitchell Spivak, MD
Calgary, Alberta

Dear Editor

Delusions, especially in patients with schizophrenia, often reflect the sociocultural characteristics of the epoch: delusions regarding demons and spirits were succeeded in the industrial era by delusions regarding electromagnetic waves and televisions.