Mrs. T.P. is a 36-year-old woman who was employed from the age of 25 to 33 as a welder, using styrene, in a plastic tank factory. Approximately one year after starting work, she became pregnant and was on sick leave until the age of 27, as required by law. As the patient was exposed to styrene again for professional reasons, she began to enjoy the subjective effects of volatile solvents, including styrene and acetone. When the patient was 32 years old, the company doctor recommended that she be removed from her job, after urine tests showed elevated levels of styrene metabolites. After a year, the patient decided to leave the factory. However, her addictive behaviours had not only persisted but had extended to alcoholic household detergents, hair sprays and motor fuels. Acute anxiety symptoms first appeared suddenly at work when the patient was 28 years old. Her first panic-like attack included dizziness, trembling, leg weakness and paraesthesias. Acute episodes of anxiety recurred and resulted in frequent absences from work for several days to recover from residual symptoms, such as headache and vertigo. After leaving work she was depressed for a few months and was treated with antidepressant medication. Although she recovered from her affective disorder, the residual anxiety symptoms were complicated by agoraphobia. Finally, the patient developed duodenal ulcer at the age of 35 years.

The main chronological relationships between occupational exposure, substance abuse behaviour, anxiety symptoms and life events are shown in Figure 1.

At the time of consultation, the patient was unemployed and separated from her husband, lived with her son in her mother's house, presented with fluctuating anxiety and persistent symptoms of mild depression and, although inhalant abuse was sporadic, the patient reported withdrawal from volatile substances in recent days. The most prominent mental disorders on examination included vertigo, psychic and somatic tension, paraesthesias, weakness in the legs and mild agoraphobia. The patient was dissatisfied with her prescribed antidepressant treatments (i.v. maprotiline, v.o. paroxetine) and was dependent on anxiolytic drugs (mainly alprazolam).

Psychiatric and psychological assessment

Table I refers to the SCL-90-R scores and indices. Specifically, the patient scored positive on all symptoms listed in the anxiety dimension in the last 7 days, and all but two (palpitations and tremor) obtained maximum scores; in contrast, the patient scored low on chest discomfort (which is an item of the somatization dimension).

We also administered the WAIS and the Rorschach test, since abnormalities in performance on these instruments had been found among workers exposed to medium-low concentrations of styrene (Jégaden et al. 1993, Lindstrom & Martelin 1980). Our patient showed an uneven profile of intellectual abilities on the Wechsler scale, with obviously lower scores on two subtests: arithmetic and number series (mainly on the inverse series); apart from possible organic damage, the loss of ability to concentrate may be due to anxiety. The Rorschach revealed a personality prone to emotional pain, somatisation, insecurity and depressive mood; the ego structure, although fragile, was well preserved; possible organic signs were below the threshold. Overall, psychological assessment was consistent with neuroticism, but did not demonstrate brain damage.

Neuroimaging

Axial and coronal magnetic resonance (MR) images were obtained after injection of medium contrast (gadolinium-DTPA). Previous MRI scans in inhalant abusers showed: a variable degree of brain atrophy, poor differentiation between grey and white matter, increased periventricular signal intensity and moderate hypointensity of the thalamus and basal ganglia on T2-weighted images (Yamanouchi et al. 1995). In our patient, no signs of intraparenchymal intensity alterations or intracranial areas of hypersignal were observed, so it was concluded that there was no brain alteration.