Letters to the Editor
Gabapentin is a relatively new antiepileptic agent structurally similar to gamma-aminobutyric acid (GABA), with unclear mechanisms of action and a good safety profile. It has been used in psychiatric practice with promising results for the treatment of several disorders (for example bipolar disorder [BD], schizoaffective disorder, obsessivecompulsive disorder [OCD], social phobia, somatization disorder, and behavioural agitation in dementia) (1,2). With regard to aggressive behaviour, a few studies have reported significant improvement in behavioural and psychological symptoms among dementia patients (3,4). In one study, a young patient affected by intermittent explosive disorder, attention-deficit hyperactivity disorder (ADHD), organic mood disorder secondary to a closed head injury, and simple partial seizure disorder was treated with gabapentin 1200 mg daily. After treatment, a decrease in frequency and intensity of violent episodes was observed (5). We report a case of successful gababentin treatment of chronic impulsive-aggressive behaviour in a patient with severe borderline personality disorder (BPD).
A 30-year-old man with a DSM-IV diagnosis of severe BPD was admitted to our residential psychiatric program because his clinical condition progressively worsened secondary to the abrupt breakup of the relationship with his girlfriend. At psychiatric examination he reported unstable interpersonal relationships, chronic feelings of loneliness, affective instability, impulse dyscontrol with periodic drug and alcohol abuse and bulimic episodes, recurrent self-mutilating acts, and chronic impulsivity and violence. He also showed intense depressive symptoms, with suicidal ideation, suspiciousness, and visual egodistonic hallucinations. Brain CT scan revealed mild diffused atrophy without defined focal damage, while EEG and laboratory tests were in the normal range. From the first day of hospitalization, treatment was started with paroxetine 40 mg daily and lorazepam 7.5 mg daily . In the next 3 weeks a progressive improvement of mood was observed, with full remission of suicidal ideation and visual hallucinations, but the impulsive-aggressive behaviour remained unchanged. In fact, he showed frequent episodes of violence against objects and people. He broke plates and glasses in the dining room almost every day, he slammed and kicked doors and furniture, he flung chairs along the corridors, and he hit other people. The episodes, usually related to the patients frustration when his excessive requests to staff and other patients were not met, caused a worsening in the ward atmosphere. Other patients, feeling fearful and hostile toward him, started to avoid him, and he went around the ward alone. For that reason, during the fourth week of admission, we added divalproex 1500 mg daily (plasma level 61 mg/L) to the treatment; however, in the following month there was no improvement in the his behavioural dyscontrol. We therefore discontinued divalproex and started a trial with gabapentin 900 mg daily. Within 48 hours of gabapentin initiation, a quick and dramatic improvement in the impulsive-aggressive behaviour was observed, and a complete remission of symptoms was reported in the following 2 weeks. Gabapentin was well tolerated by the patient, and he did not show any side effects. The ward atmosphere and the interpersonal relationships among the patients improved. Forty-five days after gabapentin initiation, the clinical benefit was unchanged, and it was possible to refer the patient to the rehabilitation program for supported employment. In 2 months, no further episode of impulse dyscontrol was registered, and the patient was discharged. In the last psychiatric interview he stated, Since I started taking this new drug I no longer lose control, and Im sure that its because of this drug.
In treating impulsive-aggressive behaviour in patients with BPD, the efficacy of the neuroleptics, monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and mood stabilizers (for example, carbamazepine, lithium carbonate, and divalproex) has been reported (6,7). However, a Medline search between October 1, 1966, and October 31, 2001, did not yield any references to gabapentin use.
The following observations support the hypothesis that the improvement in this patients chronic behavioural dyscontrol is associated with gabapentin use: first, his behaviour did not benefit from previous treatments, including divalproex; second, gabapentin initiation was followed a quick and steady improvement in the disorder. However, because different drugs were used to treat the patients psychiatric disturbances (that is, lorazepam and paroxetine), it is difficult to ascertain if the amelioration was directly related to gabapentin alone or to possible pharmacologic interaction, especially with the SSRI (paroxetine). SSRIs have been reported to reduce violent behaviour in psychiatric patients (8,9). Although further studies are necessary to confirm our observation, this report suggests that gabapentin is a possible last-line alternative adjunct in the treatment of impulsive-aggressive behaviour in patients with BPD.
1. Letterman L, Markowitz JS. Gabapentin: a review of published experience in the treatment of bipolar disorder and other psychiatric conditions. Pharmacotherapy, 1999;19:56572.
2. Garcia-Campayo J, Sanz-Carrillo C. Gabapentin for the treatment of patients with somatization disorder [letter]. J Clin Psychiatry 2001;62:474.
3. Herrmann N, Lanctôt K, Myszak M. Effectiveness of gabapentin for the treatment of behavioral disorders in dementia. J Clin Psychopharmacol 2000;20:903.
4. Miller LJ. Gabapentin for treatment of behavioral and psychological symptoms of dementia. Ann Pharmacother 2001;35:42731.
5. Ryback R, Ryback L. Gabapentin for behavioral dyscontrol [letter]. Am J Psychiatry 1995;152:1399.
6. Soloff PH. Psychopharmacology of borderline personality disorder. Psychiatr Clin North Am 2000;23:6992.
7. Hollander E. Managing aggressive behavior in patients with obsessive-compulsive disorder and borderline personality disorder. J Clin Psychiatry 1999;60 (Suppl 15):3844.
8. Fuller RW. The influence of fluoxetine on aggressive behavior. Neuropsychopharmacology 1996;14:7781.
9. Goodman M, New A. Impulsive aggression in borderline personality disorder. Curr Psychiatry Rep 2000;2:5661.
Bruno Biancosino, MD
Assessment, differential diagnosis, and management of compulsive scratching (CS) in medically ill patients with psychiatric disorders can be very complicated. This is because it is difficult to pinpoint the underlying mechanism, which is crucial for the treatment. We present the case of Mr A, a 48-year-old man with an established diagnosis of schizophrenia and chronic renal failure secondary to focal segmental glomerulosclerosi, who was admitted to our inpatient unit suffering mainly with the following 2 conditions: extreme CS that had led to missing skin-patches and bleeding from his scalp and the front part of his legs, and orthostatic hypotension so severe that he was unable to stand up and walk unaided safely.
Given his severe uremic medical status, a wide range of psychopathology was expected (1) but not detected. On admission, his medications for renal failure were bumetanide 5 mg once daily, metalozone 2.5 mg on alternate days, chlorpheniramine 4 mg 3 times daily, and ferrous sulphate 200 mg twice daily. His psychotropic medications were fluphenthixol decanoate (depot) 50 mg weekly IM and chlorpromazine 50 mg at night. His medical status was poor (hemoglobin 81 g/L, creatinine 877 umol/L, urea 50.9 mmol/L).
We explored 4 possible causes of the CS:
1. We considered whether the CS was an obsessivecompulsive spectrum phenomenon, for which the patient had already been started on paroxetine (40 mg daily, over 6 months), with no or minimal improvement.
2. We considered whether the symptom represented somatic hallucinationrelated CS, in which a patient may scratch in response to somatic hallucinations. We excluded this possibility because a detailed assessment of the patients mental state revealed no evidence of psychotic symptoms. Further, there was no evidence of CS prior to the development of his renal failure, despite prior treatment for schizophrenia.
3. We considered whether the patient was experiencing uremic CS (pruritis). The precise underlying mechanism of this condition is poorly understood but may relate to secondary iron deficiency anaemia, associated electrolyte imbalance, or accumulations of toxins (2).
4. We considered whether the CS was due to other causes, including dermatological, allergic, and cholestatic hepatic disease.
We felt that possibility 3 was the most likely. We tapered down and discontinued chlorpromazine to improve orthostatic hypotension. We made no other changes or additions to the patients pharmacotherapy. Mr A required an urgent fresh blood transfusion (1 L) in the nephrology unit. After 72 hours, he returned to the psychiatric unit with almost complete resolution of the CS, together with improvement of his medical status. However, his urea (49.5 mmol/L) and creatinine (896 umol/L) levels were only marginally altered. The improvement in CS remained during his stay in the inpatient unit. He was discharged with no further change in his pharmacotherapy because his mental state was stable, with no evidence of psychosis or other psychopathology.
The precise mechanism of improvement in CS after blood transfusion remains unclear. However, we suggest 2 possibilities: the chemical(s) which caused CS may have been diluted or destroyed after blood transfusion, or significantly improved anaemia led to the improvement in CS (3).
With such patients, it is first important to investigate and try to pinpoint the mechanism of CS. Therefore, clinicians should consider several possible causes, as listed above. Second, clinicians should choose the appropriate treatment option, depending on the CS mechanism identified. Third, if there is severe anemia, we suggest an early-admission-nephrology consultation and fresh blood transfusion.
1. Lishman AL, editor. Uraemia. In: Organic psychiatry. London: Blackwell Sci Press; 1998. p 5558.
2. Roberston KE, Mueller BA. Uremic pruritus. Am J Health Syst Pharm 1996;18:215970.
3. Staubli M. Pruritisa little known iron-deficiency symptom. Schweiz Med Wochenschr 1981;111:13948.
P Strickland, Bsc, MB, ChB, PhD, MRCPsych
Internet psychosis is likely more common than has been reported in the literature (13). We present a patient with delusions in which the Internet is the central component. To better understand the role the Internet can play in a patients delusional structure, we characterized these delusions using the Rating Scale for Psychotic Symptoms (RSPS) (4,5).
Mr A is a 26-year-old man with DSM-IV diagnosis of schizophrenia. He states that people follow his activities via Internet chat rooms devoted to him and that several Web sites dedicated to him are named according to a variation on his first name. For example, he feels that Altavista.com®, a popular search engine, is used to track his activities, because it starts with Al, the first 2 letters of his first name. Other psychotic symptoms include paranoid ideas of reference received from the television and radio and occasional auditory hallucinations of messages from the devil and angels.
Using the RSPS, we noted 8 types of delusions (that is, delusions of wealth, fame, special powers, reference, religion, extraterrestrial beings, paranormal experiences, and persecution) with 5 in the largest system. Further, the RSPS revealed that his Internet psychosis is associated with a loss of attentional focus (that is, thought blocking, sensory negativism, and catatonia), rated moderate 3/6 to moderately severe 4/6; and attentional intrusions (that is, thought insertion, external control of movements, and external control of speech), rated severe 5/6 to extreme 6/6. These symptoms have been present for at least the last 6 months. The overall clinical global impression (CGI) of psychosis is moderately severe.
With combined risperidone 4 mg daily and olanzapine 15 mg daily, this Internet psychosis delusional system remains intact, but with less active elaboration. The patient complies with treatment, as evidenced by weekly attendance at his appointments and elevation of prolactin (91.24 ug/ml; normal = 0 to 10 ug/ml for men), likely secondary to risperidone treatment.
As with previously reported cases (13), our patient has little experience with the Internet or computers. In the RSPS rating, Mr As Internet delusions fall within the second of 3 groups of delusions (ideas with intellectual attractiveness, as opposed to ideas associated with explicit reward or ideas with negative affect: unpleasant or frightening ideas). This may reflect the fact that things one does not know about fall within the RSPS description of ideas with very fluid and uncertain logical relationships, becoming akin to the occult or paranormal. As the Internet becomes more central to human interactions, Internet psychosis will likely become more common because many patients with schizophrenia may not logically understand it.
1. Kobayashi T, Okada Y, Nisijima K, Kato S. Internet Delusion in a patient with a schizoaffective disorder [letter]. Can J Psychiatry 2001;46:8990.
2. Tan S, Shea C, Kopala L. Paranoid schizophrenia with delusions regarding the Internet [letter]. J Psychiatry Neurosci 1997;22:143.
3. Catalano G, Catalano MC, Embi CS, Frankel RL. Delusions about the Internet. South Med J 1999;92:60910.
4. Chouinard G, Miller R. A rating scale for psychotic symptoms (RSPS) part I: theoretical principles and subscale 1: perception symptoms (illusions and hallucinations). Schizophr Res 1999;38:10122.
5. Chouinard G, Miller R: A rating scale for psychotic symptoms (RSPS) part II: subscale 2: distraction symptoms (catatonia and passivity experiences subscale 3: delusions and semi-structured interview (SSCI-RSPS). Schizophr Res 1999;38:12350.
Howard C Margolese, MD, CM, FRCPC
Changes in the status of psychiatric patients are characteristic of and inherent in the treatment process that includes hospitalization (1) and their eventual release and return to the community (2,3). The trend in recent years has been to close down large psychiatric hospitals (4) and to transfer the patients to rehabilitation facilities (5). In our centre, an entire ward was transferred in a single day from an old building to a new modern one. We describe here the process that we followed.
The subjects included 36 hospitalized patients and 19 staff members. Preparatory discussions were held, the new ward was visited, and a questionnaire was given pior to the move. Both patients and staff had chiefly positive expectations about the move to the new ward. Most of the patients anticipated an improvement in their physical condition (74%), in the staffpatient relationships (60%), and in their mental condition (60%). One month later, most patients and staff felt that their expectations had been fulfilled, although the staff expectations were higher than those of the patients (P < 0.05).
Transferring patients from one place to another has many difficulties. While most of the patients and staff enjoyed and were grateful for the improved physical conditions of the ward, some felt insecure in the transfer, and even asked to return to the old ward, because they felt that the demands put on them in the new building were more than they could cope with (for example, new smoking regulations and increased ward space). However, the overall feeling was festive.
An added bonus of transferring the ward in a single day and as an entity was the strengthening of the relationship between the patients and the staff, as all worked together to deal with the task in hand. The move to the new ward also had the impressive effect of achieving, over time, the complete cessation of smoking within the ward among both staff and patients.
Our observations during the 2 years following the move indicate that there has indeed been a change in the patients. The nature of their illnesses has not changed, nor has the length of hospitalization; however, there have been real gains in their sense of satisfaction and quality of life.
1. Smith AD. Humphreys M. Characteristics of in-patients transferred to a locked ward of a Scottish psychiatric hospital. Health Bull (Edinb) 1997;55:7782.
2. Okin RL. Testing the limits of deinstitutionalization. Psychiatr Serv 1995;46:56974.
3. Okin RL, Borus JF, Baer L, Jonas AL. Long-term outcome of state hospital patients discharged into structured community residential settings. Psychiatr Serv 1995;46(6):738.
4. Craig CQ. Do not go gentle into that good night: when a psychiatric hospital closes. Psychiatr Serv 1998;48:5412.
5. Thornicroft G, Boocock A, Strathdee G. Transfer between psychiatric hospitals: symptom, social functioning and patient attitude changes in long-term patients. Soc Psychiatry Psychiatr Epidemiol 1991;26:21720.
Yuval Melamed, MD
Female orgasmic disorder is common and there appear to be many etiologic factors associated with its development (1). Comer has reported that 20% to 30% of women have never reached, or rarely reach, orgasm during intercourse (2). There are several case reports and 1 small study discussing the role of sildenafil citrate for the treatment of anorgasmia induced in women by selective serotonin reuptake inhibitors (SSRIs) (36). However, we found no published data regarding the use of sildenafil to treat the disorder in cases unrelated to SSRI therapy. We report such a case of acquired female orgasmic disorder successfully treated with sildenafil.
Ms B is a 42-year-old woman who was anorgasmic for 15 years. Her anorgasmia commenced after the birth of her last child, but she continued to have a robust libido. Ms B had no history of sexual dysfunction prior to this time. Eight years after she became anorgasmic, Ms B was diagnosed with major depressive disorder (MDD). This was initially treated with paroxetine, with good clinical effect. Five years later, the antidepressant was changed to venlafaxine because of worsening mood. After several years of stable mood, Ms B reported dissatisfaction with her ongoing anorgasmia. The venlafaxine was gradually reduced from 300 mg to 75 mg daily, with no change in either mood or ability to reach orgasm, despite vigorous sexual activity. Subsequently, Ms B was prescribed 25 mg sildenafil and instructed to take the medication orally about 1 hour before expected sexual activity. The treatment was unsuccessful in correcting her anorgasmia. The sildenafil was increased to 50 mg, with the result that Ms B regained her ability to reach orgasm. She reported no side effects from the sildenafil. Discontinuation of sildenafil resulted in anorgasmia.
This case is not a controlled study, and it is possible that the response was due to placebo. However, Ms Bs failure to respond to 25 mg sildenafil makes the possibility of placebo effect less likely. It is also possible that her anorgasmia was a well-recognized side effect of antidepressant therapy (7). This, however, also seems somewhat unlikely, because her anorgasmia predated antidepressant therapy by 8 years. Given the prevalence of female orgasmic disorder and the lack of good treatment, plausible new therapies should be considered. Further study of sildenafil for treatment of female orgasmic disorder is warranted.
1. Kaplan HI, Sadock BJ. Concise textbook of clinical psychiatry. Baltimore (WA): Williams and Wilkins; 1996.
2. Comer RJ. Abnormal psychology. 2nd ed. New York: Freeman; 1995.
3. Nurnberg HG, Hensley PL, Lauriello J, Parker LM, Keith SJ. Sildenafil for women patients with antidepressant-induced sexual dysfunction. Psychiatr Serv 1999;50:10768.
4. Ashton AK. Sildenafil treatment of paroxetine-induced anorgasmia in a woman. Am J Psychiatry 1999;156:800.
5. Nurnberg HG, Hensley PL, Lauriello J, Parker LM, Keith SJ. Sildenafil for iatrogenic serotonergic antidepressant medication-induced sexual dysfunction in 4 patients. J Clin Psychiatry 1999;60 (1):335.
6. Rosenburg KP. Sildenafil citrate for SSRI-induced sexual side effects. Am J Psychiatry 1999;156.
7. Montejo AL, Llorca G, Izquierdo JA, Rico-Villademoros F. Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients. Spanish working group for the study of psychotropic-related sexual dysfunction. J Clin Psychiatry 2001;62 (Suppl 3):1021.
Jonathan Gamble, BSc
In a recent report, the World Health Organization (WHO) drew world attention with its statement that suicide and tuberculosis are the highest cause of mortality in Asian countries. Among immigrants to British Columbia born outside Canada, those from India stand just behind England, the US, and Germany in terms of suicide rates (1). Although no study has been done in Canada regarding suicide among immigrants from the Indian subcontinent, studies from other countries report more suicides among young Indian women (aged 15 to 24 years) than among indigenous women in the same age group. Further, suicides are disproportionately higher in young married women than in single women. Suicide rates are lower among Indian men, compared with Indian women, but higher than among the indigenous men (26). Hanging is the most common method of suicide among both male and female Indian-subcontinent immigrants (2,4). Burning is the second most common method of suicide by women, followed by poisoning using insecticides or fertilizer and benzodiazepines (2,7,8).
Traditionally, Indian family structure is an extended family unit with grandparents, parents, brothers, and sisters all living together. The man is the head of the family, the earner, and the decision maker. Preference is given to male children. The elderly are respected. In India, arranged marriages are common practice. Men expect to marry a girl who is a virgin; therefore, girls are very well protected.
A woman who migrates to marry a local Indo-Canadian man may experience emotional and physical stress in a new country, with a new language, new culture, new in-laws, and a husband who is also still a stranger to her. If she gives birth to a girl, the problem is made worse by taunting from in-laws who want a male child (4). In the new country, children get little attention if both parents are working. These children get caught between 2 cultures and develop 2 identitiesan identity for home and an identity for school. They oppose arranged marriage and may have unrealistic expectations of getting a higher education. As well, it is easier for women to find jobs than it is for men, resulting in role reversal. At the same time, the family and the community reject an unmarried pregnant girl.Professionals from India with degrees and experience of many years find themselves worthless in Canada, with implications for the fathers status and authority. Similarly, the elderly lose their traditional status and, with no knowledge of the new language and culture, end up in a dependent role.
Most immigrant Indian communities have maintained their cultural identity and traditions even after generations of overseas residence. Interpersonal disputes in relation to marriage and life styles, economic competition, and anxiety attached to nonconformist behaviour, especially in young women, may be the causes of self-harm. Because of these factors, I believe there is a correlation between suicides among immigrants from the Indian subcontinent and the clash of their traditional culture with Western culture in Canada.
Further research should be done to ascertain the rate of suicide among immigrants from the Indian subcontinent, with a focus on the effects of migration and culture. Counselling services should be organized within the local community, using appropriate language and culture. To educate the community, workshops, articles in local newspapers, and talk shows on the local TV and radio should be arranged.
This paper was previously presented in part at the 11th Annual Conference of the Canadian Association for Suicide Prevention; October 1114, 2000; Vancouver (BC).
1. The report of the National Task Force on Suicide in Canada. Ottawa: Department of National Health and Welfare; 1987. p 15.
2. Soni Raleigh V, Balusu L, Balarajan R. Suicide among immigrants from the Indian subcontinent. Br J Psychiatry 1990;156:4650.
3. Patel SP, Gaw Albert C. Suicide among immigrants from the Indian subcontinent, a review. Psychiatr Serv 1996;47:517521.
4. Hayness,RH. Suicide in Fiji: a preliminary study. Br J Psychiatry 1984;145:4338.
5. Wyndham CH: Cause and age specific mortality rates from accidents, poisoning, and violence. S Afr Med J 1986;69:55962.
6. Ree GH. Suicide in Macuata Province. Fiji. Practitioner 1971;207:66971.
7. Khan MM, Reza H. Suicide and life threatening behavior. Crises 1998;28 (1):628.
8. Adityanjee DR. Suicide attempts and suicides in India: cross cultural aspects. Int J Soc Psychiatry 1986;32 (2):6473.
Kala Singh, MBBS
The relation between sexual motives and fire has been reported (1), and fire fetishism has been reported in male subjects (2). To our knowledge, such a case has never been reported in female subjects.
A 29-year-old heterosexual woman charged with 28 counts of arson was sent for a forensic psychiatric assessment by the courts. The product of a normal pregnancy and delivery, her growth and milestones were unremarkable. Medical screening was also mostly unremarkable. She was sexually abused at age 8 years. Adolescence was marked by some experimentation with substances, cruelty to animals, and setting small fires. She had some college education.
In a typical fire, the accused scouted opportunities while walking. She would return in the early morning hours and set a fire in a garbage or recycling container, using matches or a lighter. She would hide and watch the aftermath. She kept a detailed diary of the fires. Upon returning home, she would masturbate, thinking about the various aspects of the fire and the aftermath. Over time her behaviour escalated, resulting in approximately 175 fires with no injuries. The motives were described as an outlet for anger, sexual motivation and satisfaction, and an intense preoccupation with fire, together with tension and affective arousal that was relieved by setting fires. There was no correlation between the fires and her menstrual cycle or substance abuse.
Past psychiatric history revealed depressive episodes resulting in psychiatric admissions and trials of antidepressants. Currently, she is being treated with nefazadone. A mental status assessment showed that she was euthymic and without evidence of anxiety, substance abuse, or psychotic symptoms.
Two cases of male subjects with fire fetishism and a case of pyrophilia have been reported (2,3). These cases usually involve masturbation while watching the fire. Fetishism, initially thought of as a male activity has been reported in female subjects (46). This case report describes an arsonist who meets the diagnostic criteria for pyromania and may also meet criteria for fetish (7). To meet criteria for fetish, the behaviour must occur over a period of 6 months. Most of the fires were set within a period of 5 months. To our knowledge, this is the first description of a possible case of fire fetishism in a female.
1. Lewis NDCL, Yarnell H. Pathological firesetting (pyromania). Nerv Ment Dis Monographs 1951;82.
2. Bourget D, Bradford J. Fire fetishism, diagnostic and clinical implications: a review of two cases. Can J Psychiatry 1987;32:45962.
3. Litman C. A case of pyrophilia. CPA Bulletin 1999;February:1820.
4. Zavitzianos G. The perversion of fetishism in women. Psychoanal Q 1982;51:40525.
5. Richards AK. Female fetishes and female perversions: Hermine Hug-Hellmuths a case of female foot or more properly boot fetishism reconsidered. Psychoanalytic Review 1990;77(1):1123.
6. Raphling D. Fetishism in a woman. J Am Psychoanal Assoc 1989;37;46591.
7. Diagnostic and statistical manual of mental disorders. 4th ed.Text revision. Washington (DC): American Psychiatric Association; 2000.
Krishna Balachandra, MD