LETTERS
TO THE
gradually
EDITOR
because
a 60
mg/day
binges
and
limic
symptoms
of continued
dose
was
vomiting
symptoms.
reached,
began
had
to
almost
One
the
frequency
decrease.
After
completely
week
after
skin
disappeared
and
disorder
trunk, vulva.
of eating 3 weeks, bu-
clinic dermal
the
patient was euthymic. One month after treatment at this dosage the patient developed amenorrhea and a preoccupation with weight gain; she began to restrict severely her caIonic intake. Fluoxetine had to be discontinued when the patient’s weight fell below SO kg. One month later, bulimic symptoms recurred, the patient’s weight increased, and the amenorrhea, as well as other anorexic signs, gradually disappeared.
and given necrolysis),
anorexia ologic
nervosa
on opposite
poles of a clinical
and pathophysi-
To our knowledge,
there
are no reports
of a fluoxetine-in-
duced anorexia nervosa-like syndrome in a bulimic patient. The case reported here illustrates the potential importance of the serotonergic system in eating disorders and supports the possibility of inverse pathophysiologic pathways between bulimia
and
anorexia
nervosa.
possible adverse effect in hulimic patients.
This
of S-HT
case
may
reuptake
also
highlight
inhibitors
when
blisters
painless
of
the
face,
a diagnosis of Lyell syndrome a rare severe toxic reaction
(toxic epito different
by epidersheets ( 1 ). All
psychotropic medication was withdrawn. High doses of steroid therapy (initial dose, methylprednisolone, 250 mg/ day) and supportive care were administered. After a few days Ms. A exhibited mixed bipolar disorder with moodcongruent psychotic features (DSM-III-R) that progressed
to full-blown
ening
disorder
lethal
catatonia
of psychomotor
(2), a rare
disturbances
and
life-threatautonomic
dysregulation. The patient was given six unilateral ECT treatments within 2 weeks and showed a remission of lethal catatonia
within
hours
and
a remission
of the
affective
drome within 2 weeks. Steroids were tapered the skin lesions disappeared within 4 weeks. ECT (2),
even
is an effective in high-risk
and safe patients.
treatment for Carbamazepine
most likely responsible for Lyell syndrome we were nevertheless reluctant to administer drugs,
which
ECT.
Steroid
choses
continuum.
multiple
drugs, including carbamazepine, characterized mal blistering and peeling of the skin in large
rapidly It has been proposed that the abnormal eating patterns that characterize bulimia nervosa could result from an imbalance between facilitatory a-noradrenergic and inhibitory serotonergic pathways (2). Thus, drugs that potentiate S-hydroxytnyptamine (S-HT) activity may reduce bulimic symptoms. Some authors have proposed that these drugs might induce anorexia through a stimulation of 5-HT receptors (3), which could enhance satiety (4). Although the neurobiology of anorexia ncrvosa still remains poorly understood, a serotonergic hyperactivity has been suggested to play a role. This could explain the appetite stimulant effect of S-HT antagonists such as cyproheptadine (5). This hypothesis would place bulimia nervosa and
with
arms, and mucosal surfaces of the mouth, eyes, and The patient was admitted to the local dermatology
are
also
therapy
less
may
(3), but steroid-related
effective
affective
catatonia
and
lethal catatonia was the drug
in our patient, but other neuroleptic
in lethal
cause
syn-
quickly
and
catatonia
than
paranoid
is apparently
psy-
very
rare
(4). Comticosteroids were advocated as a treatment modality for lethal catatonia in the preneuroleptic era (DSM-III-R). Continuous steroid therapy in our patient may have blunted the syndrome of lethal catatonia initially and may have contributed
to its rapid
remission
during
ECT.
the
used
REFERENCES 1 . Roujeau
JC, Chosidow 0, Saiag P, Guillaume JC: Toxic epider(Lyell syndrome). J Am Acad Dermatol 1990; 23:
mal necrolysis REFERENCES 1 . Walsh BT: Psychopharmacologic treatment of bulimia nervosa. J Clin Psychiatry 1991; 52:34-38 2. Leibowitz SF, Shor-Possner G: Brain serotonin and eating behavior. Appetite 1986; 7:1-13 3. Garattini 5, Mennini T, Samanin R: Reduction of food intake by manipulation of central serotonin: current experimental results. BrJ Psychiatry 1989; 11:41-51 4. Clifton PG, Barnfield AM, Philcox L: A behavioral profile of fluoxetine induced anorexia. Psychopharmacology (Berl) 1989; 97: 89-95 5. Mitchell JE: Psychopharmacology of anorexia nervosa, in Psychopharmacology: The Third Generation of Progress. Edited by Meltzer HY. New York, Raven Press, 1987
1039-1058 2. Mann SC, Caroff ashida M: Lethal 1381 3. Hall CW, Popkin
ER: Presentation 167:229-236 4. Grigg JR: Prednisone mood disorder associated with catatonia. Geriatr Psychiatry Neurol 1989; 2:41-44
the steroid
Madrid,
Lyell SIR:
Syndrome We would
and Lethal
Catatonia:
like to present
the
A Case following
M.D. PH.D. M.D. PH.D. Spain
for ECT case
report.
Fourteen
1114
days
later
she developed
a progressive
exfoliative
5K, Garner
of
J Nerv Ment Dis 1979;
MICHAEL JOHANNES
J
WELLER,
M.D.
Bethesda,
Md.
KORNHUBER, M.D. Wurzburg, Germany
in the Pisa Syndrome
SIR: The Pisa syndrome, a dystonic reaction that appears as a side effect of antipsychotic agents ( 1 ), is considered to be a subtype of tardive dystonia (2). It is usually difficult to treat this condition without discontinuation of antipsychotics (3).
However, we report a case where the patient dramatically recovered from the Pisa syndrome following a change in mcdication from haloperidol to pimozide, a selective dopamine D2 receptor agent, without any reduction in the clinical antipsychotic
Ms. A, a 43-year-old woman with a history of bipolar affective psychosis, had been prescribed carbamazepine, 200 mg/day, sulpinide, 600 mg/day, and perazine, 100 mg/day, for pending exacerbation of her psychiatric illness.
MK, Stickney
psychoses.
Use of Pimozide SERGIO C. OLIVEROS, LUIS M. IRUELA, M.D., LUIS CABALLERO, ENRIQUE BACA, M.D.,
SN, Bleier HR, Welz WKR, Kling MA, Haycatatonia. Am J Psychiatry 1986; 143:1374-
effects.
Mr. A, a 22-year-old Suzuki-Binet
Test),
with a diagnosis ceived haloperidol,
man with mental was
admitted
retardation
to a psychiatric
(IQ=44, hospital
of schizophrenia. The patient initially 9 mg/day; propericiazine, 75 mg/day;
Am
J
Psychiatry
1 49:8,
August
meand
1992
TO THE
gradually
EDITOR
because
a 60
mg/day
binges
and
limic
symptoms
of continued
dose
was
vomiting
symptoms.
reached,
began
had
to
almost
One
the
frequency
decrease.
After
completely
week
after
skin
disappeared
and
disorder
trunk, vulva.
of eating 3 weeks, bu-
clinic dermal
the
patient was euthymic. One month after treatment at this dosage the patient developed amenorrhea and a preoccupation with weight gain; she began to restrict severely her caIonic intake. Fluoxetine had to be discontinued when the patient’s weight fell below SO kg. One month later, bulimic symptoms recurred, the patient’s weight increased, and the amenorrhea, as well as other anorexic signs, gradually disappeared.
and given necrolysis),
anorexia ologic
nervosa
on opposite
poles of a clinical
and pathophysi-
To our knowledge,
there
are no reports
of a fluoxetine-in-
duced anorexia nervosa-like syndrome in a bulimic patient. The case reported here illustrates the potential importance of the serotonergic system in eating disorders and supports the possibility of inverse pathophysiologic pathways between bulimia
and
anorexia
nervosa.
possible adverse effect in hulimic patients.
This
of S-HT
case
may
reuptake
also
highlight
inhibitors
when
blisters
painless
of
the
face,
a diagnosis of Lyell syndrome a rare severe toxic reaction
(toxic epito different
by epidersheets ( 1 ). All
psychotropic medication was withdrawn. High doses of steroid therapy (initial dose, methylprednisolone, 250 mg/ day) and supportive care were administered. After a few days Ms. A exhibited mixed bipolar disorder with moodcongruent psychotic features (DSM-III-R) that progressed
to full-blown
ening
disorder
lethal
catatonia
of psychomotor
(2), a rare
disturbances
and
life-threatautonomic
dysregulation. The patient was given six unilateral ECT treatments within 2 weeks and showed a remission of lethal catatonia
within
hours
and
a remission
of the
affective
drome within 2 weeks. Steroids were tapered the skin lesions disappeared within 4 weeks. ECT (2),
even
is an effective in high-risk
and safe patients.
treatment for Carbamazepine
most likely responsible for Lyell syndrome we were nevertheless reluctant to administer drugs,
which
ECT.
Steroid
choses
continuum.
multiple
drugs, including carbamazepine, characterized mal blistering and peeling of the skin in large
rapidly It has been proposed that the abnormal eating patterns that characterize bulimia nervosa could result from an imbalance between facilitatory a-noradrenergic and inhibitory serotonergic pathways (2). Thus, drugs that potentiate S-hydroxytnyptamine (S-HT) activity may reduce bulimic symptoms. Some authors have proposed that these drugs might induce anorexia through a stimulation of 5-HT receptors (3), which could enhance satiety (4). Although the neurobiology of anorexia ncrvosa still remains poorly understood, a serotonergic hyperactivity has been suggested to play a role. This could explain the appetite stimulant effect of S-HT antagonists such as cyproheptadine (5). This hypothesis would place bulimia nervosa and
with
arms, and mucosal surfaces of the mouth, eyes, and The patient was admitted to the local dermatology
are
also
therapy
less
may
(3), but steroid-related
effective
affective
catatonia
and
lethal catatonia was the drug
in our patient, but other neuroleptic
in lethal
cause
syn-
quickly
and
catatonia
than
paranoid
is apparently
psy-
very
rare
(4). Comticosteroids were advocated as a treatment modality for lethal catatonia in the preneuroleptic era (DSM-III-R). Continuous steroid therapy in our patient may have blunted the syndrome of lethal catatonia initially and may have contributed
to its rapid
remission
during
ECT.
the
used
REFERENCES 1 . Roujeau
JC, Chosidow 0, Saiag P, Guillaume JC: Toxic epider(Lyell syndrome). J Am Acad Dermatol 1990; 23:
mal necrolysis REFERENCES 1 . Walsh BT: Psychopharmacologic treatment of bulimia nervosa. J Clin Psychiatry 1991; 52:34-38 2. Leibowitz SF, Shor-Possner G: Brain serotonin and eating behavior. Appetite 1986; 7:1-13 3. Garattini 5, Mennini T, Samanin R: Reduction of food intake by manipulation of central serotonin: current experimental results. BrJ Psychiatry 1989; 11:41-51 4. Clifton PG, Barnfield AM, Philcox L: A behavioral profile of fluoxetine induced anorexia. Psychopharmacology (Berl) 1989; 97: 89-95 5. Mitchell JE: Psychopharmacology of anorexia nervosa, in Psychopharmacology: The Third Generation of Progress. Edited by Meltzer HY. New York, Raven Press, 1987
1039-1058 2. Mann SC, Caroff ashida M: Lethal 1381 3. Hall CW, Popkin
ER: Presentation 167:229-236 4. Grigg JR: Prednisone mood disorder associated with catatonia. Geriatr Psychiatry Neurol 1989; 2:41-44
the steroid
Madrid,
Lyell SIR:
Syndrome We would
and Lethal
Catatonia:
like to present
the
A Case following
M.D. PH.D. M.D. PH.D. Spain
for ECT case
report.
Fourteen
1114
days
later
she developed
a progressive
exfoliative
5K, Garner
of
J Nerv Ment Dis 1979;
MICHAEL JOHANNES
J
WELLER,
M.D.
Bethesda,
Md.
KORNHUBER, M.D. Wurzburg, Germany
in the Pisa Syndrome
SIR: The Pisa syndrome, a dystonic reaction that appears as a side effect of antipsychotic agents ( 1 ), is considered to be a subtype of tardive dystonia (2). It is usually difficult to treat this condition without discontinuation of antipsychotics (3).
However, we report a case where the patient dramatically recovered from the Pisa syndrome following a change in mcdication from haloperidol to pimozide, a selective dopamine D2 receptor agent, without any reduction in the clinical antipsychotic
Ms. A, a 43-year-old woman with a history of bipolar affective psychosis, had been prescribed carbamazepine, 200 mg/day, sulpinide, 600 mg/day, and perazine, 100 mg/day, for pending exacerbation of her psychiatric illness.
MK, Stickney
psychoses.
Use of Pimozide SERGIO C. OLIVEROS, LUIS M. IRUELA, M.D., LUIS CABALLERO, ENRIQUE BACA, M.D.,
SN, Bleier HR, Welz WKR, Kling MA, Haycatatonia. Am J Psychiatry 1986; 143:1374-
effects.
Mr. A, a 22-year-old Suzuki-Binet
Test),
with a diagnosis ceived haloperidol,
man with mental was
admitted
retardation
to a psychiatric
(IQ=44, hospital
of schizophrenia. The patient initially 9 mg/day; propericiazine, 75 mg/day;
Am
J
Psychiatry
1 49:8,
August
meand
1992
