Dayanand Medical College,. Ludhiana - 141001 (Pb). The Malleus Maleficarum and its. Psychopathology of Sex. Sir,. The honesty of Kramer was dubious. He.
Indian Journal of Psychiatry, July 1985, 27(3), pp. 267-268
Letters to the Editor Acute Abdomen Following Abrupt Cessation o f Imipramine - A Case R e p o r t Sir, Psychotropic drugs appear to produce significant biochemical changes in the physiological system during their long term administration, that often become manifest only after their withdrawal. Various clinical states described are : rebound insomnia following discontinuation of benzodiazepines (Kale et al 1980) and mania after antidepressant withdrawal (Mirin et al 1981). Such a switch process may be result of shifts in the balance between intracellular production, synaptic reuptake and metabolic degradation of monoamines (Schildkrautt et al 1976).
Her treatment was continued in the form of Lithium (900 mg/day) and Imipramine (100 mg/day) for another one month. Latter she was brought to clinic with symptoms of euphoria, increased talk, irritability, insomnia and doing household work hurriedly. Imipramine was stopped abruptly. Her daily dose of Lithium was increased to 1200 mg/day and hypnotic was added for sleep. After 36 hours of imipramine stoppage she attended medical emergency with symptoms of vomiting and severe generalized abdominal colieky pain. She was managed with antiemitic and antispasmodic drugs. Detailed physical examintion and investigations did not suggest any pathology. She could not be given any diagnosis for her acute abdomen. Her physical condition was attributed to abrupt withdrawal from imipramine.
Case Report
On follow up she had experienced similar abdominal symptoms when imipramine had to be withdrawn again when she developed symptoms of manic psychosis on a combination of Lithium and Imipramine. Such two experiences were quite convincing to suggest that her acute abdomen resulted from abrupt cessation imipramine.
Mrs. A. a 45 years old woman was referred with symptoms of sadness, anxiety, insomnia, feelings of inadequacy and guilt feelings of 2 months duration, in the absence of a precipitating factor. She had one attack of mania and two attacks of depressive psychosis in the last 3 years and was diagnosed as bipolar major affective disorder with present episode of endogenous depression. She had been taking Lithium (900 mg/day) for the past 9 months. In addition she was started on 150 mg of imipramine in 3 divided doses. She came out of depression in a period of 5 weeks.
Many of the symptoms that have been considered side effects of imipramine treatment, e.g. nausea, vomiting, abdominal pain, drowsiness, decreased appetite, headache, agitation might actually be secondary to withdrawal of imipramine and may be result of cholinergic rebound (Petti et al 1981). Compliance in taking medicines is a major problem in medicine and psychiatry. It is important for the physicians and psychiatrists to be aware of the symptoms reported as side effects which may actually indicate that the patient or family have discontinued medication.
There have been reports of gastrointestinal withdrawal symptoms like nausea, vomiting and abdominal discomfort with abrupt cessation of imipramine (Petti et al 1981). We present a case of affective disorder who developed acute abdomen following abrupt withdrawal of imipramine.
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References KALE, A., SCHARF, M.E. & KALES, J.D. (1978), Rebound insomnia: a new clinical syndrome, Science, 201, 1039-1041. MIRIN, S.M., SCHATZBERG, A.F. & CREASEY, D. E. (1971), Hypomania and mania after withdrawal of tricyclic antidepressants. American Journal of Psychiatry, 138, 87-88. PETTI, T. A. & LAW, W. (1981), Abrupt cessation of high-dose imipramine treatment in children, JAMA, 246, 768-769. ' SCH1LDKRAUTT, J.J. ROFMANN, M. & ORSULAK PJ. et al, (1976), Effects of Short and Long term administration of tricyclic antidepressants and Lithium on norepinephrine turn over in the brain, Science, 199, 197. RAJEEV G U P T A R.L. N A R A N G Deptt. of Psychiatry, Dayanand Medical College, Ludhiana - 141001 (Pb).
T h e M a l l e u s M a l e f i c a r u m a n d its P s y c h o p a t h o l o g y of Sex Sir, T h e honesty of Kramer was dubious. H e used to torture witches in Tyrol and was expelled by the local Bishop. Kramer could win a sympathetic hearing by Pope Innocent VIII. The Bull was issued subsequently. 'Reports' elicited by torture w e r e recorded as 'facts' (Hall and Kingston 1979). Despite such criticism of the man and his method, the Mallens seems to make sense (Somasundaram 1985) and we need it. REFERENCE Hall, Angus and Kingston, J (1979) Great Mysteries : Mysterious Cults. Enlarged edition. London: Aldus Books. Somasundaram, O (1985), The Mallens maleflcarum and its psychopathology of sex, Indian Journal of Psychiatry, 27, 123-126. A. R A M A N A T H A N Institute of Mental Health Kilpauk, Madras.
