Aripiprazole in difficult-to-treat delusional disorder with co-morbid epilepsy.

Abstract

Our current understanding of the psychopharmacological treatment of persistent delusional disorder is limited by scanty scientific data that mostly consist of individual case reports and series only. A reasonable pharmacological treatment approach for patients with delusional disorder is a standard trial of an antipsychotic or, for somatic delusions, selective serotonin reuptake inhibitor.1 A 22-year-old man was brought to the Institute of Human Behaviour and Allied Sciences (a tertiary neuropsychiatric care centre) with a 2-year history of persistent persecutory belief. Examination revealed a well systematized delusion of reference and persecution with occasional transitory auditory hallucinations. Collateral history obtained included use of sodium valproate for episodes of generalized tonic clonic seizures (GTCS) for the last 3 years. There was no history of substance abuse and his family history was negative for any neuropsychiatric illness. The laboratory investigations and brain imaging, including electro-encephalogram, showed no abnormality and no cause could be ascertained for multiple episodes of GTCS. During the last 2 years, the patient was unsuccessfully treated with adequate dose and duration trials of three different atypical (risperidone, olanzapine, ziprasidone) and two typical (haloperidol, trifluoperazine) antipsychotic drugs (APD). He had mild extrapyramidal side-effects on typical APD and suffered one episode of GTCS on atypical APD, risperidone, at 4 mg/day. The patient was diagnosed as a case of delusional disorder as per ICD-10 and started on tab aripiprazole 5 mg/day, which was gradually increased to 20 mg/day over a period of 6 weeks, along with tab sodium valproate 1 g/day. The patient started showing improvement in psychotic symptoms at the end of 4 weeks and is currently maintaining well. Limited data exist on the psychopharmacological treatment of delusional disorder and no controlled studies have been published to date. Aripiprazole is a new-generation atypical APD that is a partial agonist at dopamine D2 and serotonin1A (5-HT1A) receptors and has antagonist activity at the 5-HT2 receptor.2, 3 There are case reports demonstrating that delusional disorder (persecutory type) was successfully treated with aripiprazole monotherapy.4 We selected aripiprazole based on its reported qualities of being well-tolerated with low potential for extrapyramidal symptoms and lowering of seizure threshold. The risk of seizures with aripiprazole is reported to be 0.1%, the lowest among atypical agents.3 Duvar et al.5 reported a case of delusional disorder (jealous type), which did not respond to different atypical antipsychotic agents previously but showed a prognostic improvement with aripiprazole of 30 mg/day. This case presentation highlights the efficacy of aripiprazole in difficult-to-treat persistent delusional disorder (persecutory type) with co-morbid epilepsy that did not respond previously to three different atypical and two typical antipsychotic agents. The subject gave informed consent and patient anonymity was preserved. None of the authors has anything to disclose.