MDPV in forensic routine cases: Psychotic and aggressive behavior in relation to plasma concentrations.

The new psychoactive substance 3,4-methylenedioxypyrovalerone (MDPV) belongs to the group of synthetic cathinones and is purchased mainly as "research chemical" or "bath salt" on the illegal drug market, also in South Bavaria. MDPV was detected in blood and urine samples from 2010 on in 50 authentic routine cases in a forensic setting. Plasma concentrations in 46 cases with available blood specimens ranged from approximately 1.0 to 301µg/L (median 23.7; mean 47.9µg/L), detected by a fully validated LC-MS/MS method. Subjects aged between 16 and 54 years (median 36; mean 35 years) and reflected experienced chronic drug users. Accused offences were mainly violent crimes such as bodily harm, robberies, homicides and acts of resistance. A lot of subjects showed highly aggressive and violent behavior with endangerment of self and others and/or psychotic symptoms as confusion, hallucinations or paranoia. The risk for such behavior rises with MDPV plasma concentrations above as low as 30µg/L, whereby a time interval of 1.5h on average between incident and/or observation of impairment and blood sampling has to be taken into account. Comprehensive toxicological analysis proved poly-drug use in almost all cases including opiates/opioids, benzodiazepines and other sedatives, antidepressants and other stimulants, also other new psychoactive substances. Alcohol was detected only in three cases. Co-consumed benzodiazepines seem not be able to completely prevent psychotic effects despite their use as first-line treatment for patients with synthetic cathinone poisonings. The study demonstrates that relatively low plasma concentrations of MDPV could be associated with mental impairment which is relevant in the assessment of forensic cases.

Hyperactive delirium following administration of intra-articular corticosteroid.

Intra-articular administration of corticosteroids is a commonly used treatment for osteoarthritis as well as other inflammatory disorders of the joints. It is well known that delirium and psychosis can arise following the administration of oral corticosteroids but there are few documented cases of the development of acute hyperactive delirium with psychosis following intra-articular administration. We describe a case of an 82-year-old female patient with moderate dementia who developed a delirium with psychosis which responded well to a first-generation antipsychotic.

Acute psychosis associated with recreational use of benzofuran 6-(2-aminopropyl)benzofuran (6-APB) and cannabis.

INTRODUCTION: There is evidence from around Europe of the availability and use of 6-(2-aminopropyl)benzofuran (6-APB) as a recreational drug. However, there is currently limited information on the acute toxicity of this compound. We describe here a case of acute toxicity associated with recreational use of legal high (6-APB) and cannabis, in which the comprehensive toxicological analysis confirmed the presence of a significant amount of 6-APB together with metabolites of both tetrahydrocannabinol and the synthetic cannabinoid receptor agonist (JWH-122). CASE REPORT: A 21-year-old gentleman with no previous medical and psychiatric history was brought to the emergency department (ED) after he had developed agitation and paranoid behaviour following the use of 6-APB purchased over the Internet. There was no obvious medical cause for his acute psychosis. He required diazepam to control his agitation and was subsequently transferred to a psychiatric hospital for ongoing management of his psychosis. Toxicological screening of a urine sample collected after presentation to the ED detected 6-APB, with an estimated urinary concentration of 2,000 ng/ml; other drugs were also detected, but at lower concentrations including metabolites of the synthetic cannabinoid receptor agonist JWH-122 and tetrahydrocannabinol. CONCLUSION: This is the first case of analytically confirmed acute toxicity associated with the detection of 6-APB which will provide some information on acute toxicity of this drug to help clinicians with the management of such patients and legislative authorities in their consideration for the need of its control.

Excited delirium following use of synthetic cathinones (bath salts).

Synthetic analogs of the cathinone molecule have seen increasing recreational use as substitutes for cocaine, 3,4-methylenedioxymethamphetamine (ecstasy) and methamphetamine. Repeated use of these drugs is associated with a paranoid hallucinatory delirium. A subset of patients using these substances develops a syndrome of extreme agitation and violent behavior that has been reported following the use of other stimulant drugs that also produce rapid changes in brain monoamines. This syndrome, characterized as "excited delirium," presents to the acute care setting with a challenging combination of paranoia, severe agitation and violent behavior. These patients frequently suffer from dehydration, skeletal muscle damage and renal failure that may lead to multiorgan failure and death. Management of these individuals requires careful consideration of the consequences of interventions commonly implemented in medical settings to control dangerous aggressive behavior.

Psychiatric and hostility factors related to use of anabolic steroids in monozygotic twins.

INTRODUCTION: Anabolic androgenic steroids (AAS) are derived by chemical manipulation of the testosterone molecule. The specified category of drugs produces anabolic, androgenic and psycho-active effects including elevated aggressive, hostile, violent and anti social behavior. OBJECTIVE: The objective of this case report observational study was to evaluate the possible psychological consequences of AS use in the twin user of each pair, compared with the non-user twin. METHODOLOGY: We studied two pairs of male monozygotic twins: one pair 24 years old and the other 31 years old, with absolute genome and phenotype similarity. One of the twins of each pair used AAS while the other did not. Both pairs lived in Hellenic provincial towns and followed a common training and nutrition regime. The psychometric instruments used were the Symptoms Check List-90 (SCL-90) and the Hostility and Direction of Hostility Questionnaire (HDHQ). The psychometric evaluations took place within a time interval of 6 months. RESULTS: The study found high levels of aggressiveness, hostility, anxiety and paranoid ideation in the twins who used AS. The non-user twins showed no deviation from their initial status. CONCLUSION: The use of AAS induced several important psychiatric changes in monozygotic twins which were not present in the twin who did not use AAS.

Psychiatric side effects induced by supraphysiological doses of combinations of anabolic steroids correlate to the severity of abuse.

OBJECTIVE: The objective of our study was to evaluate the psychological consequences of real-world AAS use in athletes abusing such agents, in comparison with a placebo and control group of comparable athletes, while correlating the severity of abuse with the side effects observed. The hypothesis tested by the study was that the use of AAS induces a wide range of psychological side effects whose impact and emergence is dependent upon the severity of the abuse. DESIGN: The study includes a substantial group of AAS abusing athletes and two more groups demographically similar to the first, one composed of athletes not using any substance and a placebo group. All athletes were stratified according to the severity of AAS abuse. Psychometric instruments were applied to all athletes in specific time intervals, dependent to the AAS abusers' regimens, providing us with a final psychological profile that was to be compared to the pre-study profile. All results were comparable (within and between groups) for statistically significant differences and correlated to the severity of the abuse. Homogeneity of all groups was safeguarded by random doping controls, monitoring of drug levels and analysis of all self obtained drugs by method of liquid chromatography/mass spectrometry. All athletes were provided with a common exercise and dietary regime, so common training and nutritional conditions were achieved. METHODS: We studied a cohort of 320 body-building, amateur and recreational athletes, of whom 160 were active users of AAS (group C), 80 users administering placebo drugs (group B) and 80 not abusing any substance (Group A). Group C athletes were stratified according to AAS abuse parameters, thus providing us with three subgroups of "light, medium and heavy abuse". Athletes of groups A and B were included in a "no abuse" subgroup. The psychometric instruments used were the Symptoms Check List-90 (SCL-90) and the Hostility and Direction of Hostility Questionnaire (HDHQ). The psychometric evaluations took place within a time interval of 13 months. Statistical analysis was performed by using the Mann-Whitney/Wilcoxon two-sample non-parametric test (Kruskal-Wallis test for two groups) for data that were not normally distributed and Linear regression analysis was used to ascertain the correlation between severity of use and escalation of side effects. RESULTS: The study showed a statistically significant increase in all psychometric subscales recorded in group C, and no statistically significant difference in group C and A. There was a significant increase in the scorings of group C for all subscales of SCL-90 and HDHQ. Correlation of abuse severity and side effects showed that there was a statistical significant increase in Delta values of all SCL-90 and HDHQ subscales that escalated from light abuse to medium and heavy abuse/consumption patterns. CONCLUSIONS: The results of the study suggest that the wide range of psychiatric side effects induced by the use of AAS is correlated to the severity of abuse and the force of these side effects intensifies as the abuse escalates.

Acute psychosis after anesthesia: the case for antibiomania.

We report the case of a teenager who developed a postanesthesia acute psychosis (delusions, paranoia, and hallucinations) caused by a reaction to antibiotic therapy (amoxicillin and clarithromycin), so called 'Hoigne's syndrome' or 'antibiomania.' The differential diagnosis and a review of literature are presented. Our patient illustrates the importance of adding antibiomania as part of the differential diagnosis when altered postanesthesia behavior is observed in pediatric patients.

Nonsteroidal anti-inflammatory drugs and severe psychiatric side effects.

OBJECTIVE: Nonsteroidal anti-inflammatory drugs (NSAIDS) are used extensively in the treatment of pain. This study explored the possibility that psychiatric side effects may be both more frequent and more severe than thought previously. METHOD: Four psychiatric outpatients, three with affective disorders and one with schizophrenia, were treated with NSAIDS for a complaint of pain. The NSAIDs were withdrawn, then restarted for three patients, and then withdrawn again one or more times. The patients were evaluated while on and off NSAIDs. RESULTS: All four patients developed moderate to severe depression and one became severely paranoid while on NSAIDs initially. When the NSAID was withdrawn there was remission of the depressive symptoms and in one case the accompanying paranoia. The depressive symptoms were reproduced when the NSAID was restarted in five instances (involving only 3 of the patients) and remitted when the NSAID was discontinued. One of these three patients also became paranoid in two instances. The paranoia remitted when the NSAID was discontinued. CONCLUSIONS: These findings suggest that NSAIDs can induce or exacerbate reproducible symptoms (depression, paranoia) in patients with either affective disorder or schizophrenia. These adverse effects may be more severe and frequent than thought previously. NSAID-treated patients should be studied for NSAID-induced psychiatric side effects.

Acute nutmeg intoxication.

Nutmeg is a common household spice sometimes abused for its hallucinogenic properties. This abuse is well reported in the medical literature over the last century. Ingestion of less than one tablespoon can produce symptoms similar to those of an anticholinergic toxic episode. Common presenting complaints are hallucinations, palpitations, and feelings of impending doom. We report a case of intentional nutmeg intoxication in a 23-year-old college student. As laboratory tests are usually normal, this diagnosis should be considered in patients presenting with an acute psychotic break accompanied by symptoms resembling an anticholinergic toxic episode. Treatment is primarily supportive once other life-threatening conditions have been ruled out.

A functional psychosis precipitated by quinidine.

A 62-year-old man with a syndrome of gradually progressive cognitive deterioration accompanied by paranoid features is described. He had been taking quinidine since 1974 for a recurring supraventricular tachyarrhythmia. Examination revealed a suspicious man with widespread patchy cognitive deficits but no focal neurological signs. An exhaustive range of investigations gave unremarkable results. Within 24 hours of cessation of quinidine there was a dramatic improvement in his mental state and, after a further four days, he had returned essentially to normal with no demonstrable cognitive deficits. Several months later he suffered a recrudescence with prominent paranoid and depressive features which gradually settled after commencement of pimozide and dothiepin. It is likely that these events reflect a recurring functional psychosis which was precipitated or exacerbated in the first instance by quinidine. This represents a significant complication of quinidine therapy which has been largely unrecognized. Therapy with quinidine should be considered as a potential contributing factor in any patient with dementia or a functional psychosis who is also taking this drug.