The psychiatrist-woman patient relationship.

Dear Sir: There have been recent descriptions in the psychiatric literature of the use of Pimozide as an effective, specific treatment in the often refractory condition known as "monosymptomatic hypochondriacal psychosis" or MHP (2, 3,4). It has been suggested that this is a form of paranoia, and Kenyon (I) has suggested that not all cases need have hypochondriacal delusions. In particular, the possibility that delusional jealousy might, in some cases, be an analogous disorder, has been mooted. Monosymptomatic psychoses are to be distinguished from neurotically determined dysmorphophobias, as well as from affective illness, schizophrenia and organic brain syndromes. Patients with MHP typically suffer from a chronic somatic delusional system, with little deterioration of thinking or of personality. I would like to report on the successful use of Pimozide in a patient who presented with a monosymptomatic paranoid psychosis which took the form of pathological jealousy. I am not aware of a previous report of this nature. The patient, a 56-year-old, Italian-speaking housewife, suffered from the belief that her husband had been unfaithful to her over a six-year period, and that he intended to marry another woman. This belief was delusional in nature, and could not be altered by the protestations of her husband and family, or by all evidence to the contrary. The symptom had begun abruptly when the patient heard a woman speaking on the radio about her husband's betrayal of her. Thereafter, the patient consistently misinterpreted comments on radio and television, and remarks of relatives, as evidence of her husband's infidelity. Otherwise, she functioned well and coped with everyday activities, although her suspicions seriously interfered with the marital relationship. During the few months prior to admission she had increasingly withdrawn from society because she believed that other people knew of her plight. When admitted to the Toronto General Hospital, the patient was markedly anxious. She was garrulous, with circumstantiality and overinclusiveness, but had no evidence of depressive symptoms, hallucinations or cognitive impairment. On the grounds that she was suffering from a paranoid illness similar to a monosymptomatic psychosis, we decided to initiate treatment with Pimozide, 4 mg once daily. Within a few days the patient became very cheerful, socialized much more freely, and reported a greatly diminished preoccupation with her delusion. One week after treatment was started, she was virtually symptom-free and said she had been mistaken about her husband. She was discharged to a delighted family and her improvement has been sustained over a two-month period. Her social and marital relationships are now quite normal and she continues to take Pimozide 4 mg daily. It therefore seems that Pimozide has been a specific and rapidly effective treatment in a condition which can sometimes be intractable. I would commend a trial of this medication in such cases and would be interested to know if anyone else can report similar results.