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For personal use. Only reproduce with permission from The Lancet Publishing Group.THE LANCET • Vol 361 • February 22, 2003 • www.thelancet.com 705
CORRESPONDENCE
3 Honer WG, Smith GN, MacEwan GW, et al.Diagnostic reassessment and treatmentresponse in schizophrenia. J Clin Psychiatry1994; 55: 528–32.
4 Haskett R. Diagnostic categorization ofpsychiatric disturbance in Cushing’ssyndrome. Am J Psychiatry 1985; 142:911–16.
5 Walkup JT, McAlpine DD, Olfson M, et al.Patients with schizophrenia at risk forexcessive antipsychotic dosing. J Clin Psychiatry 2000; 61: 344–48.
a disorder that would fulfil the DSM IVor ICD 10 criteria for schizophrenia ifthe organic cause is overlooked andcould be easily misdiagnosed asschizophrenia.
Before the patient came to ourdepartment, an experienced seniorpsychiatrist from another psychiatrichospital had diagnosed hebephrenicschizophrenia, given the schizophrenia-like psychopathological findings and thechronicity of the patient’s symptoms (>4 years). This colleague hadoverlooked the clinical signs ofCushing’s disease, paradoxically due tothe outbursts of rage and the non-compliance of the patient otherwiseindicative of Cushing’s disease. Thepersisting severe persecutory ideas andnegative symptoms could not beexplained by the diagnosis of delirium.These symptoms are unspecific and canoccur in many other psychiatricdisorders besides delirium andschizophrenia.
Although we agree with Raj’s generalcautioning of the use of neuroleptics incases of organic psychosis, we stronglydisagree with his labelling of its use inour case as “improper”. Our patient wastreated with a low dose of flupentixol inan attempt to achieve symptomatic reliefin a very difficult clinical situation.Neuroleptic treatment can lead to greatsymptomatic benefit and is definitelynot contraindicated in organicpsychoses. There is no question that thetreatment of choice for an organicpsychosis is treatment of the underlyingmedical condition. However, a treatingpsychiatrist must still find ways toimprove the patient’s condition duringthe often lengthy diagnostic phase. Inour case, the problem of non-compliance was severe and delayeddiagnosis substantially.
We presented this case to emphasisethat even long-standing schizophrenia-like and negative symptoms can becaused by rare organic disorders and canrespond promptly to the appropriatesomatic treatment.*Jürgen Zielasek, Martin Lauer
Deparment of Psychiatry, Julius-Maximilians-University, D-97080 Würzburg, Germany(e-mail: [email protected])
1 Zielasek J, Bender G, Schlesinger S, et al. A woman who gained weight and becameschizophrenic. Lancet 2002; 360: 1392.
2 WHO. The ICD-10 Classification of Mentaland Behavioural Disorders: clinicaldescriptions and diagnostic guidelines,Geneva: World Health Organization, 1992.
3 American Psychiatric Association. Diagnosticand Statistical Manual of Mental Disorders,fourth edn, text revision. Washington, DC:American Psychiatric Association, 2000.
4 Beckmann H. Classification of endogenouspsychoses and their differentiated etiology, 2.Revised and enl. edn. Wien: Springer; 1999.
Sir—The new rules1 for publishingletters in The Lancet are commendablefor attempting to expedite publicationof correspondence about recently-published articles, but the provision ofonly 2 weeks after publication of amanuscript for correspondence may beburdensome for some authors. For example, we received the Jan 4issue of The Lancet—in which the newrules were printed—on Jan 10.Already, a week had passed beforereceiving the issue on which we arecommenting.
A week or two may seem like plentyof time to write a letter, but thedemanding obligations of life can easilymake this deadline daunting orunrealistic for some authors. Considerthat one might have to go to the libraryor internet to research a topic beforebeginning correspondence. If collabo-rating with a colleague in another city,authors will have to fax or e-mailmaterials back and forth to oneanother. All the tasks associated withwriting a letter must be accomplishedin addition to clinical duties, teachingschedules, administrative obligations,family functions, and attempting to geta few hours of much-needed sleep.And it is assumed that one is not onvacation or at a conference within the2-week period after an article’spublication.
Old letters, new rules
Sir—I am glad that I happened to peruse the online edition of The Lancet today, and so have anopportunity to reply to Zoë Mullan’sCommentary (Jan 4, p 12).1 IfI had waited for the paper version ofthe journal, I would not have been ableto reply under the new 2-week rule.
My paper version of The Lancetusually takes about 3 weeks to arriveby mail to this, not too remote, part ofCanada. I suspect that many of yourreaders are like me in that they mightbriefly scan The Lancet online for theheadlines each week, but prefer toread the paper version of the journal.Some of the more remote readersmight have to wait as long as I for thepaper version and might not haveinternet access. Are their voices nownot to be heard? Did The Lancetreview the time to delivery of thepaper version before introducing thesenew rules?Michael O’ConnorDepartment of Laboratory Medicine, MedicineHat Regional Hospital, Medicine Hat, Alberta T1A 4H6, Canada(e-mail: [email protected])
1 Mullan Z. Lancet Correspondence: oldletters, new rules. Lancet 2003; 361: 12.
Sir—Jürgen Zielasek and colleagues1
report the case of a woman withCushing’s syndrome and schizophrenia-like symptoms. In our experience ofabout 400 cases of Cushing’s syndromeof pituitary, adrenal, and ectopic origin,psychiatric disorders were not at all rare.The most frequent was depression,which was seen in 78 of 111 cases ofadrenal hyperfunction.2 In fulminantCushing’s syndrome, manic disorderswere more frequent.
The risk of suicide is high in these patients owing to depression or schizophrenia-like symptoms,hallucinations, and illusions. In ourgroup of patients, we saw attemptedsuicide by drug intoxication, hanging,3
and venous incision. All psychiatricdisorders improved after successfultreatment of adrenal hyperfunction. Toprevent suicide attempts, all patientswith Cushing’s syndrome should bemonitored carefully for the appearanceof psychiatric disorders.*Anna A Kasperlik-Zaluska, Jadwiga Slowinska-Srzednicka, Wojciech ZgliczynskiDepartment of Endocrinology, Centre forPostgraduate Medical Education, Ceglowska 80,01-809 Warsaw, Poland(e-mail: [email protected])
1 Zielasek J, Bender G, Schlesinger S, et al. Awoman who gained weight and becameschizophrenic. Lancet 2002; 360: 1392.
2 Kasperlik-Zaluska A, Hartwig W,Nielubowicz J, et al. Clinical analysis of 111cases of adrenocortical hyperfunction: resultsof surgical treatment. Endokrynol Pol 1978;29: 273–88.
3 Kasperlik-Zaluska A, Nielubowicz J,Migdalska B, et al. Association ofadrenocortical hyperactivity with renalcarcinoma. Nowotwory 1980; 30: 195–99.
Authors’ reply
Sir—Our patient showed severalsymptoms that fulfil the generaldiagnostic criteria of schizophreniaaccording to ICD 10 and DSM IV:formal thought disorder with breaks inthe train of thought, persecutory ideas,social withdrawal, loss of interest, lack ofinitiative, and aimlessness.1–3 However,we never diagnosed our patient ashaving an endogenous schizophrenicpsychosis.4 We diagnosed an organicschizophrenia-like disorder (ICD 10:F06.2), the term being used to describe
