DSM-III: problems in diagnosis of paranoia and obsessive-compulsive disorder

Delusional disorders: boundaries of a concept

In 1987, DSM-III introduced the term delusional disorder. In so doing they gave new life to a concept that had predated but was delineated in its modern form by Kraepelin and developed most notably in France in the second and third decades of this century. While the current concept of delusional disorder is defined in a manner that distinguishes it from schizophrenia, a consideration of the evolution of thinking about delusional syndromes in France suggests that current distinctions are based on descriptive convenience rather than any understanding of the mechanisms that might produce phenotypic variations. If the purpose of accurate descriptions is to assist research, this state of affairs would seem unsatisfactory.

Olfactory reference syndrome: demographic and clinical features of imagined body odor

OBJECTIVE

Olfactory reference syndrome (ORS) - preoccupation with a false belief that one emits a foul or offensive body odor - has been described around the world for more than a century. However, only a few small studies have systematically assessed ORS's clinical features.

METHOD

Twenty patients with ORS were systematically assessed using semistructured measures.

RESULTS

Subjects' mean age was 33.4±14.1; 60% were female. Preoccupation most often focused on the mouth (75%), armpits (60%) and genitals (35%). Bad breath (75%) and sweat (65%) were the most common odor descriptions. Currently, 85% of subjects had delusional ORS beliefs, 77% had referential thinking and 85% reported actually smelling the odor. Ninety-five percent of subjects reported performing one or more ORS-related repetitive behaviors (e.g., excessive showering). Forty percent had been housebound for at least 1 week because of ORS symptoms, 68% had a history of suicidal ideation, 32% had attempted suicide and 53% had been psychiatrically hospitalized. Forty-four percent of subjects had sought nonpsychiatric medical, surgical or dental treatment for the perceived odor, and one third had received such treatment, which was ineffective in all cases.

CONCLUSION

ORS appears to be characterized by high morbidity and seeking of nonpsychiatric treatment.

Olfactory reference syndrome: issues for DSM-V

The published literature on olfactory reference syndrome (ORS) spans more than a century and provides consistent descriptions of its clinical features. The core symptom is preoccupation with the belief that one emits a foul or offensive body odor, which is not perceived by others. This syndrome is associated with substantial distress and disability. DSM-IV and ICD-10 do not explicitly mention ORS, but note convictions about emitting a foul body odor in their description of delusional disorder, somatic type. However, the fact that such symptoms can be nondelusional poses a diagnostic conundrum. Indeed, DSM-IV also mentions fears about the offensiveness of one's body odor in the social phobia text (as a symptom of taijin kyofusho). There also seems to be phenomenological overlap with body dysmorphic disorder, obsessive-compulsive disorder, and hypochondriasis. This article provides a focused review of the literature to address issues for DSM-V, including whether ORS should continue to be mentioned as an example of another disorder or should be included as a separate diagnosis. We present a number of options and preliminary recommendations for consideration for DSM-V. Because research is still very limited, it is unclear how ORS should best be classified. Nonetheless, classifying ORS as a type of delusional disorder seems problematic. Given this syndrome's consistent clinical description across cultures for more than a century, substantial morbidity and a small but growing research literature, we make the preliminary recommendation that ORS be included in DSM-Vs Appendix of Criteria Sets Provided for Further Study, and we suggest diagnostic criteria.

Event-related potential and clinical correlates of neurodysfunction in obsessive-compulsive disorder

The current study confirmed with increased sample sizes our preliminary findings of event-related potential (ERP) abnormalities in obsessive-compulsive disorder (OCD) (Towey et al., 1990) and examined their relationship to symptom severity, treatment response, and neurological soft signs. Unmedicated patients (n = 17) showed larger negativities in N200 and slow wave regions than normal control subjects (n = 16) to correctly detected auditory "oddball" stimuli. N200 amplitude was larger over left than right hemispheres of OCD patients, but not normal control subjects. Greater N200 amplitude correlated with less severe obsessions, better response to subsequent treatment with serotonin reuptake blockers, and fewer neurological soft signs in OCD. With increased task difficulty, N200 and P300 latencies lengthened for normal subjects, but not for OCD patients. The abnormal ERP pattern in OCD supports hypotheses of cortical hyperarousal and overfocused attention.

Monosymptomatic hypochondriacal psychosis: belief of contracting rabies

The authors describe a forty-one-year-old female with possible monosymptomatic hypochondriacal psychosis (MHP): a delusional belief that she had contracted rabies. This is the first report of this type of delusion in MHP. The patient failed to respond to multiple somatic therapies and finally made a serious suicide attempt. The authors discuss the reasons for the failed treatment and suggest a sequential protocol for treatment of MHP based on the current literature.

The treatment of monodelusional psychosis associated with depression

This is a report of the treatment of four patients suffering from a syndrome consisting of a single delusion in association with depression. The tendency of monodelusional syndromes to respond to a pimozide provides a rationale for nosological organisation.

Diagnosis and treatment of monosymptomatic hypochondriacal psychosis in chronic renal failure

The authors describe a case of a patient who presents with a delusional interpretation of a somatic symptom, uremic pruritus. The literature on the diagnosis and treatment of monosymptomatic hypochondriacal psychosis (MHP) is reviewed and discussed. There is an effective treatment available for this disabling condition--a neuroleptic agent called pimozide, which appears to have a selective ability to block central dopaminergic receptors.

Delusional (paranoid) disorders: etiologic and taxonomic considerations. II. A possible relationship between delusional and affective disorders

Paranoid (delusional) disorders are usually thought to overlap with schizophrenic disorders, and there may be a continuum, especially with paranoid schizophrenia. There is also some recent evidence of an overlap with affective disorders. This article refers to the author's series of monodelusional disorders, emphasizing certain mood concomitants, and discussing the implications of these for delusional disorders in general.