Abstract
Delusional halitosis has been well documented as a monosymptomatic delusional disorder [1,2]. Its treatment, however, has been less well documented. Given its classification under the psychotic spectrum, it follows logically that the treatment should primarily involve antipsychotic medication and/or adjunctive cognitive behavioural therapy (CBT) [3]. The evidence currently appears to favour the typical agent pimozide [4,5] and the atypical antipsychotics olanzapine and risperidone [4–6]. There is sparse information on the role of selective serotonin re-uptake inhibitors (SSRIs) in the treatment of delusional halitosis. This case report describes a patient's response to a combination of the SSRI sertraline and CBT. It explores possible explanations for why a delusional disorder may have responded to a non-antipsychotic intervention.
The patient was a 29-year-old software engineer who presented with a 2 year history of delusional halitosis that satisfied DSM-IV-TR criteria for the diagnosis of a delusional disorder–somatic type. Distress emanating from this delusional belief had significantly impacted on his lifestyle, occupational functioning and mood state. Treatment over a 2 year period with olanzapine, risperidone and CBT yielded partial results. Disabling side-effects with the atypical antipsychotics (weight gain with risperidone, sedation and weight gain with olanzapine) interfered with compliance. Distress was severe enough to lead to two suicide attempts. This led to his general practitioner prescribing sertraline (50 mg) as an antidepressant. Additionally, he had been prescribed benzodiazepines for short periods of time to control agitation. He reported little improvement with previous interventions at first contact. The patient was taken off the olanzapine, the sertraline was titrated up to 200 mg po mane and a programme of CBT was initiated to work through his delusions 3 weeks after the increased SSRI dosage. He reported significant resolution of these delusional beliefs over an 8 week period. This was reflected in increased social interaction without accompanying distress that had previously been a major concern. He subsequently returned to full time work as an instructor requiring extensive interaction with students at close quarters, an activity he had shied away from when unwell. He maintained improvement at 6 month follow up.
Monosymptomatic delusional disorders are a perplexing set of disorders with controversy about the appropriateness of their current taxonomic classification. Are these disorders indeed a delusional psychosis or are these an obsessive–compulsive disorder (OCD) with delusional beliefs or with ‘poor insight’? Proponents have argued on both sides of this argument [7]. Viewing this as an OCD with delusional beliefs could explain why this patient responded to SSRIs and CBT.
SSRIs have also been explored as prophylactic agents that work against the easy reactivation of psychotic states in patients with psychosis [8,9]. The exact serotonergic mechanism that mediates this is as yet poorly understood. One can argue that this patient's initial improvement may have been the result of previously used antipsychotic medication, although he was still symptomatic at first contact with the author. The higher dose of sertraline and CBT prevented a relapse of symptoms that might have been in partial resolution. One could also argue for spontaneous resolution of symptoms but the close temporal correlation with current treatment renders the possibility remote.
This case report emphasizes the availability of safer alternatives to currently accepted standard therapy for monosymptomatic hypochondrial psychosis. SSRIs alone or in combination with CBT are an alternative that offers considerable safety and side-effect advantages over antipsychotic (typical and atypical) medication.