CASE REPORT
Successful Treatment by Paroxetine of Delusional
Disorder, Somatic Type, Accompanied by Severe
Secondary Depression
Hiroshi Hayashi, MD, PhD, Takaki Akahane, MD, Haruyoshi Suzuki, MD, Tetsuya Sasaki, MD,
Shinobu Kawakatsu, MD, PhD, and Koichi Otani, MD, PhD
Abstract: The case of a 42-year-old woman with delusional disorder,
somatic type (DDST), with infestation delusion and delusions of body
odor and halitosis accompanied by severe secondary depression is pre-
sented. These somatic delusions and depressive symptoms responded
favorably to treatment with paroxetine 10 to 30 mg/d. Hypoperfusion in
the left temporal and parietal lobes observed when she had marked
clinical symptoms was improved at near recovery. The present report
suggests that paroxetine is effective and a reasonable drug for DDSTwith
secondary depression. It also supports previous observations that DDST
is associated with hypoperfusion in the temporal and parietal lobes.
Key Words: delusional disorder, somatic type, secondary depression,
paroxetine
(Clin Neuropharm 2010;33: 48Y49)
D elusional disorder, somatic type (DDST), also known as
monosymptomatic hypochondriacal psychosis, is charac-
terized by somatic delusions.1,2 There has been no randomized
controlled trial on the treatment of DDST. Munro1 has recom-
mended pimozide as the first-choice drug for DDST based on his
clinical experience. On the other hand, some case reports have
shown the efficacy of antidepressants, especially clomipramine3
and paroxetine4 for this disorder.
Munro1 has reported that secondary depression, often se-
vere, was present in more than half of his DDST patients, and
suicide thoughts and/or suicide attempts were observed in not a
few of them. However, the treatment of DDST with secondary
depression has never been discussed.
We present the case of a patient with DDST accompanied
by severe secondary depression, who responded favorably to
paroxetine treatment.
CASE REPORT
The patient was a 42-year-old unmarried woman. She
had no history or family history of psychiatric disorders. Her
social and occupational histories were quite normal. For the last
3 years, she had been feeling that her back was oily from early
From the Department of Psychiatry, Yamagata University School of Medi-
cine, Yamagata, Japan.
Address correspondence and reprint requests to Hiroshi Hayashi, MD, PhD,
Department of Psychiatry, Yamagata University School of Medicine,
2-2-2 Iidanishi, Yamagata 990-9585, Japan; E-mail: hhayashi@
med.id.yamagata-u.ac.jp
The authors did not receive any funding for this study.
None of the authors have any actual or potential conflict of interest including
any financial, personal, or other relationships with other people or
organizations that could inappropriately influence, or be perceived to
influence, this work.
Copyright * 2010 by Lippincott Williams & Wilkins
DOI: 10.1097/WNF.0b013e3181c1cfe4
48 www.clinicalneuropharm.com Clinical Neuropharmacology
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
summer to autumn. In September 2006, she felt that oils were
welling out or oozing out from her back. In December, the
body part from which oils welled out spread to the breast and
head. To get rid of the oils, she frequently and excessively
washed her body and head. Also, she started to hear that people
passing by were saying, Bit stinks[ or Bawful smell,[ and
became to believe that she was emitting a foul odor from her
body and mouth. She tended to limit her public appearance
and wore a flu mask when she had to go out. She gradually
developed depressive symptoms such as depressed mood,
markedly diminished interest and pleasure, decreases in appetite
and body weight, insomnia, loss of energy, feelings of worth-
lessness, concentration difficulty, and recurrent suicidal thoughts,
for example, jumping down from a tall building. In March 2007,
she had to quit her job. In May, she visited a dermatologist, in-
ternist, and gynecologist, but no abnormality was found. Then,
she was referred to our outpatient clinic.
On the first examination, she had multiple somatic delu-
sions and severe depressive symptoms, but no other psychiatric
symptom. Hallucinations, disorganized speech, disorganized or
catatonic behavior, affective flattening, and alogia were not
observed. The diagnoses of DDST and depressive disorder not
otherwise specified were made according to the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition.2
Olanzapine was initiated at 5 mg/d and increased to 10 mg/d
12 weeks later, with no improvement. In September, olanzapine
was switched to paroxetine 10 mg/d, and the dose was increased
to 20 mg/d 4 weeks later. In October, there was a slight im-
provement, and she said that BThe oils and foul odor have
decreased 30%. Now I think in a positive way and have started
to go shopping and go to a driving school.[ The dose of par-
oxetine was further increased to 30 mg/d. Subsequently, the
depressive symptoms and somatic delusions improved gradu-
ally. In May 2008, there were mild somatic delusions left, but no
depressive symptom, and she said that BI have recovered 90%.[
There was no adverse effect of paroxetine. In November, she
started to look for work.
Her magnetic resonance imaging and electroencephalo-
graphy were within normal limits. The single photon emission
computed tomography using technetiumYethyl cysteinate dimer
was also performed twice with the patient’s consent (Fig. 1).
The single photon emission computed tomography taken in
June 2007 when she had marked clinical symptoms showed
reduced regional cerebral blood flow in the left temporal and
parietal lobes. The hypoperfusion was normalized in January
2008 when she was at near recovery.
DISCUSSION
The patient in the present case was convinced that oils were
welling out or oozing out from her skin and therefore had in-
festation delusion,1,2 although the symptoms may be somewhat
atypical. She also had a belief that she was emitting a foul odor
& Volume 33, Number 1, January/February 2010
Clinical Neuropharmacology & Volume 33, Number 1, January/February 2010 Paroxetine for Delusional Disorder, Somatic Type

Notwithstanding the importance of secondary depression

in DDST stressed by Munro1 and in this report, the treatment
of DDST with secondary depression has never been discussed.
The present report suggests that paroxetine is effective and a
reasonable drug for such a case. Comparison studies between
paroxetine and other drugs, especially pimozide, for DDST
with secondary depression are warranted.
Finally, this report supports previous observations3,4 that
DDST is associated with hypoperfusion in the temporal and
parietal lobes, which are associated with somatic sensation.5

REFERENCES
1. Munro A. Monosymptomatic hypochondriacal psychosis. Br J
Psychiatry 1988;153(suppl 2):37Y40.
2. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 4th ed. Washington, DC: American
Psychiatric Association; 1994.

FIGURE 1. Tc-99m ECD SPECT images on June of 2007 (above)
and January of 2008 (below). OM; orbitomeatal plane.
from her body and mouth, that is, delusions of body odor and
halitosis.1,2 Organic brain diseases and schizophrenia were un-
likely. It was apparent that the severe depressive symptoms
were a reaction to the multiple and deteriorating somatic delu-
sions. Taken together, it is reasonable to consider that she was
experiencing DDST and secondary depression.
3. Wada T, Kawakatsu S, Komatani A, et al. Possible association
between delusional disorder, somatic type and reduced regional
cerebral blood flow. Prog Neuropsychopharmacol Biol Psychiatry
1999b;23:353Y357.
4. Hayashi H, Oshino S, Ishikawa J, et al. Paroxetine treatment of
delusional disorder, somatic type. Hum Psychopharmacol
2004;19:351Y352.
5. Gloor P. The Temporal Lobe and Limbic System. Oxford, UK: Oxford
University Press; 1997.

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Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.