The psychosis was characterized by delusions of persecution, grandiosity, and thought broadcast, as well as erotomania, aggression, apathy, blunted affect, and disturbed biological functions. His substance abuse worsened after he developed schizophrenia and, according to him, was apparently an effort on his part to control (self-medicate) his schizophrenic symptoms. There was no family or past history of mental illness. He had not sought treatment prior to contact with us. The patient received a trial of olanzapine 20 mg daily for a period of 6 weeks, with no beneficial effects on either illness. We then initiated risperidone up to 4 mg daily, and the psychopathology (the delusions and aggression) subsided over the subsequent 3 weeks. Concomitant substance use also subsided; the patient reported simultaneous diminution of craving and relief from psychopathology-related anxiety. For the last 10 months, he has maintained an asymptomatic state.

To our knowledge, this is the first report of beneficial risperidone use for dual-diagnosis schizophrenia with opioid and stimulant abuse. Atypical antipsychotics exert their beneficial effects of reduced psychopathology, low incidence of extrapyramidal effects, and possible attenuation of craving by action on the mesolimbic dopaminergic neurons and antagonism of central serotonergic receptors (2,3). Risperidone may have acted via these mechanisms. It has previously been reported to reduce cue-elicited craving in patients abusing cocaine (4). Risperidone has a safe side-effect profile, requires relatively little mandatory clinical and laboratory

monitoring, and is easily administered, compared with clozapine. Further research is warranted to investigate risperidone’s utility in treating such dual-diagnosis patients and to understand the biological basis of its effect on attenuating craving.

References

1. Zimmet SV, Strous RD, Burgess ES, Kohnstamm S, Green AI. Effects of clozapine on substance use in patients with schizophrenia and schizoaffective disorder: a retrospective survey. J Clin Psychopharmacol 2000;20:94–8.
2. Buckley PF. Substance abuse in schizophrenia: a review. J Clin Psychiatry 1998;59 (Suppl 3):26–30.
3. Green AI, Zimmet SV, Strous RD, Schildkraut JJ. Clozapine for comorbid substance use disorder and schizophrenia: do patients with schizophrenia have a reward-deficiency syndrome that can be ameliorated by clozapine? Harv Rev Psychiatry 1999;6:287–96.
4. Smelson DA, Roy A, Roy M. Risperidone diminishes cue-elicited craving in withdrawn cocaine- dependant patients. Can J Psychiatry 1997;42:984.

Nitin Gupta, MD
Debasish Basu, MD, DNBE, MAMS
Chandigarh, India

Dear Editor:

I read the article on developmental disability training in Canadian psychiatry residency programs published in the March 2001 edition (1). I was quite impressed by the authors’ attempt to identify the need for residency training in this neglected area. I have worked as a psychiatrist

both in the UK and in Canada, and I have observed a big difference in the importance which each country assigns to this particular area of psychiatry. As the authors have indicated, people with developmental disabilities have a higher risk of associated Axis I diagnosis than does the general population. Thus, it is appropriate and important that we pay more attention to this special client group by making future residents in Canadian programs more aware of it and providing them with more experience in this field. In the UK, developmental disability is considered to be a subspeciality within psychiatry, and exclusive specialist registrar training exists that leads to consultant posts in developmental psychiatry. I fully support the conclusions and recommendations of this article; we should try to do something about this before it becomes too late.

Reference

1. Lunsky Y, Bradley E. Developmental disability training in Canadian psychiatry residency programs. Can J Psychiatry 2001;46:138–43.

D Natarajan, MBBS, DPM, MRCPsych (UK), DPM (RCP and SI), FRCPC
Regina, Saskatchewan

Dear Editor:

Perfectionism is proverbial; an anthology of English proverbs has a host of reflections and aphorisms on the subject from the 16th and 17th centuries (1). Lately, perfectionism has been embraced as an important psychological construct.