Weekly Post-graduate Case Presentation Venue: Meeting Room, Psychiatric Clinic, HUSM Date: 04/07/2000

1. Case Presentation
substance-induced psychosis
4th of July 2000
supervisor: Dr Hasanah

2. Identification Data
 ZN
 24 years old Pakistani man
 year of birth: 1976
 Petty trader (sell carpet & electrical goods)
 married
 admitted on 24th June 2000
 discharged on 3rd July 2000

3. Reason for admission
One week history of:
Poor sleep
Poor appetite
Not working well
Refuse to talk
Talked and smiled to himself

4. History of Present Illness
 According to patient’s wife, he was apparently
well until 2 weeks before admission
 Came home after 2-3 hours, went to his bed and
lied down (not sleeping)
 He appeared restless
 He told wife that he felt afraid that somebody was
after him, wanted to kill him
 At night walked aimlessly and switched the lights
on & off

5. History of Present Illness
 He became preoccupied to himself
 Seldom talked to family members
 Occasionally he was noted to be smiling and
talking to himself

6. History of Present Illness
 According to patient, he first felt that people were
talking about him about 2 months before
admission
 About 3 weeks before admission, he started
hearing voices of birds chirping, and indistinct
male and females voices which talked about him.
 The voices gradually increased in frequency until
it became almost continuos through out the day
 He did not realize its connection to any of the
substances that he took

7. History of Present Illness
 Hearing the voices, he felt afraid that somebody
wanted to harm him
 He also had difficulty to sleep, usually drank
alcohol before going to bed
 3 consecutive nights before admission drank
alcohol, initial 2 nights drank 1 can of carlsberg
and the last night drank a bottle of Crocodile
brand liquor (alcohol content 20%)

8. History of Present Illness
 That night and the following day, felt very afraid
and the voices was a lot.
 He was brought to casualty at 1:30 p.m. By his
father-in law.

9. Substance Use
 Claimed had stopped cannabis 6 months ago, that
time consumption had reduced and he was usually
offered by friends (not buying it)
 Reason was he worried that he might fall from
m/bike during “high”
 Had not experienced any psychotic symptoms or
similar experiences that led to admission when
intoxicated with cannabis
 He denies morphine/heroin use

10. Alcohol Use
 Drink alcohol since he came to Kelantan in 1994
 Bought the drink at Chinese coffee shop, drank
with friends at coffee shop or at home (alone or
with 2-4 people)
 Drank at night
 Avoid taking it in the morning due to the smell in
the breath especially when he met the customers
 Variable amount of consumption

11. Alcohol Use
 Ranges from binges 10 cans of beer to 1 can
 frequency ranges from every night to once in 2-3
days
 Usually consumed 1-3 cans of Carlsberg per use;
RM 5 per can
 He denies early morning tremors, blackout
episodes,
 Consumption slightly reduced after he was
introduced to cough mixtures

12. Cough Syrup Use
 Took cough mixtures since about (less than) 1
year ago
 Bought from clinic, RM 5-10 per use
 Ranged from daily to once a week
 Substitute for alcohol, if he already took cough
mixtures he did not drink alcohol
 No psychotic symptoms or similar experiences
associated with cough mix consumption

13. Psychotropic Pill Use
 About 2 months before admission, he was
introduced to “Pil Kuda” by a siamese friend,
purported to enhance sexual performance.
 RM 10 per tablet, had taken about 20 tablets in 5
weeks period
 Last tablet was 1 or 2 days before emergence of
voices
 He felt that people were talking about him while
he was on “Pill Kuda”

14. Psychotropic Pill Use
 Also had poor appetite that resulted in loss of
weight
 1 month before admission, felt lethargic, less
energy and thus became lazy to work
 3 week before admission heard voices
 ? Still took a few tablet after the onset of the
voices (different version to other doctor)
 Frequent palpitation and fearfulness led to seeking
treatment from 2 GPs

15. ? Benzodiazepine
 Due to intense palpitation, he had sought treatment
from Klinik Faiz 2 weeks PTA, and Klinik Ziad 1
week PTA.
 He was given oval yellow tablets 1 tablets 3 times
per day, but he often took 5 tabs per day
 Mixed 2 tablets with alcohol the night before
admission.
 Pills helped to calm him down

16. 2 mo 1 mo 3 wk 2 wk 1 wk Adm D/C
Pil
Kuda
Voices
Persecutor
y delusion
Delusion of
reference
Longitudinal Events

17. Personal history
Completed primary (5 years) and secondary
(5 years) school in Pakistan
came to KL at 15 years old
stayed in KL for 3-4 months selling carpets
then went to East Malaysia 1.5 years
Claimed that he came to Kelantan in 1994
after he obtained blue I/C (AY 39 yrs old)

18. Past Psy & Medical History
No previous contact with psychiatric
services
No previous similar episode
No history of epilepsy, head injury or
thyroid disease
No family history of psy illness

19. Personal History
Married to a same village Pakistani girl in
1993.
Had 2 children. The first died at 3 months
old and the second still birth.
2nd marriage to local Kelantanese girl in
August 1998 (love marriage)
Had a daughter age 1 year

20. Personal History
Financial commitment to wife in Pakistan
RM 700 every 1or 2 month (equivalent to
10K rupee)
Has not came home since 2nd marriage
Planned to go home in near future
Not worried leaving wife in Pakistan, last
saw her in 1997

21. Psychosexual History
 Had regular sex with current wife
 Frequency ranges from every night to every other
night
 Used to twice per night in younger days
 Claimed has no difficulty in initiating/maintaining
erection or too fast.
 History of contact with prostitutes and other
women. He denies previous venereal disease.

22. Family tree
Sister
28 years old
married
stay separately
Patient
24 years old
Sister
21 years old
High School
Brother
19 years old
High School
Sister
17 years old
High School
Brother
14 years old
Secondary school
Brother
11 years old
Secondary school
Father
53 years old
farmer
Mother
53 years old
homemaker
rahimah:

23. Physical Examination
 BP 146/92
 T 37.2 C
 PR 90 bpm
 No injection mark
 CNS, CVS and GTI systems were normal
 no neck rigidity

24. Investigations
Urine for drugs
HIV / VDRL
HbTWCPlt normal

25. Mental Status Examination
On admission (26th of June 2000)
 eye contact present
 mutism
 sweat profusely
 unshaven face
 perplexed and fearful affect
 refused oral medication
 psychomotor retardation

26. Mental Status Examination
On 2nd of July 2000
 Good rapport and forthcoming
 well shaven face
 completely relevant, coherent and rational speech
 appropriate, broad-ranged affect
 normal psychomotor activity
 no persecutory or self-referential delusions
 infrequent auditory hallucinations

27. Formulation
ZN is a 24 years old, married, carpet trader Pakistani man with
long history of polysubstance abuse presented with sudden onset
of delusion of reference for 2 months, auditory hallucination for
3 weeks and persecutory delusion for 2 weeks. Onset of
psychotic symptoms were preceded by consumption of a new
substance i.e. “pil Kuda” which has other side effects such as
suppressing the appetite, weight loss, insomnia, palpitations and
lethargy. He also took pills from clinic for palpitations and
drank higher strength alcohol to help him sleep. On admission
his BP was 146/92. He showed mutism, psychomotor
retardation, fearful and perplexed affect. He responded within a
few days to antipsychotic treatment.

28. Provisional Diagnosis
DSM-IV multiaxial diagnosis:
Axis I : 292.1 Amphetamine-induced psychosis
304.80 Polysubstance dependence
Axis II: None
Axis III: None
Axis IV: None
Axis V: GAF 25 (on admission)
GAF 71 (at discharge)

29. Differential Diagnosis
Schizophreniform disorder
Alcoholic hallucinosis

30. Management
Abstinence from substance
Antipsychotic medication
– low dose haloperidol
– short term
Psychoeducation

31. DIAGNOSTIC AND
STATISTICAL MANUAL OF
MENTAL DISORDERS
DSM-IV

32. Diagnostic criteria for 292.89
Amphetamine Intoxication
A. Recent use of amphetamine or related
substances (e.g., methylphenidate).

33. B. Clinically significant maladaptive
behavioral or psychological changes (e.g.,
euphoria or affective blunting; changes in
sociability; hypervigilance; interpersonal
sensitivity; anxiety, tension, or anger;
stereotyped behaviors; impaired
judgement; or impaired social or
occupational functioning) that developed
during, or shortly after, use of
amphetamine or related substance.

34. • Two (or more) of the following, developing during,
or shortly after, use of amphetamine or related
substance:
tachycardia or bradycardia
pupillary dilatation
elevated or lowered blood pressure
perspiration or chills
nausea or vomiting
evidence of weight loss
psychomotor agitation or retardation
muscular weakness, respiratory depression, chest pain, or
cardiac arrythmias
confusion, seizures, dyskinesia, dystonias, or comas
• The symptoms are not due to general medical
condition and are not better accounted by another
mental illness.

35. Diagnostic criteria for 292.0
Amphetamine Withdrawal
A. Cessation of (or reduction in)
amphetamine (or related substance) use
that has been heavy and prolonged.

36. B. Dysphoric mood and two (or more) of the
following physiological changes, developing
within a few hours to several days after
criterion A:
fatigue
vivid, unpleasant dreams
insomnia or hypersomnia
increased appetite
psychomotor retardation or agitation

37. C. The symptoms in criterion
B cause clinically significant
distress or impairment in
social, occupational, or other
important area of
functioning.
D. The symptoms are not due
to general medical condition
and are not better accounted
by another mental disorder

38. Acute Amphetamine Intoxication is
sometimes associated with confusion,
rambling speech, headache, transient
ideas of reference, and tinnitus. During
intense Amphetamine Intoxication,
paranoid ideation, auditory
hallucinations in clear sensorium, and
tactile hallucination may be experienced.
Frequently, the person using the
substance recognizes these symptoms as
resulting from stimulants.

39. Extreme anger with treats or acting out of
aggressive behavior may occur. Mood
changes such as depression with suicidal
ideation, irritability, anhedonia,
emotional lability, or disturbances in
attention and concentration are common,
especially during withdrawal. Weight
loss, anemia, and other signs of
malnutrition and impaired personal
hygiene are often seen with
Amphetamine Dependence.

40. Amphetamine-related disorder and other
stimulant-related disorders are often
associated with dependence or abuse of
other substances, especially those with
sedative properties (such as alcohol or
benzodiazepines), which are usually
taken to reduce the unpleasant, “jittery”
feelings that result from stimulant drug
effects. Urine tests for substances in this
class usually remain positive for only 1-3
days even after a “binge”.

41. 304.80 Polysubstance
dependence
The diagnosis is reserved for behavior during the
same 12-month period in which the person was
repeatedly using at least three groups of
substance (not including caffeine and
nicotine), but no single substance
predominated. Further, during this period, the
Dependence criteria were met for substance as
a group but not for any specific substance

42. Diagnostic criteria of Substance-
Induced Psychotic Disorder
A. Prominent hallucinations and
delusions. Note: Do not include
hallucinations if the person has insight
that they are substance induced.

43. B. There is evidence from the history,
physical examination, or laboratory
findings of either (1) or (2):
(1) the symptoms in Criterion A
developed during, or within a
month of, Substance Intoxication
or Withdrawal
(2) medication use is etiologically
related to the disturbance

44. C. The disturbance is not better accounted for by Psychotic
Disorder that is not substance induced. Evidence that the
symptoms are better accounted for by a Psychotic Disorder that
is not substance induced might include the following: the
symptoms precede the onset of the substance use (or
medication use); the symptoms persist for a substantial
period of time (e.g., about a month) after the cessation of the
acute withdrawal or severe intoxication, or are substantially in
excess of what would be expected given the type or amount af
the substance used or duration of use; or there is other evidence
that suggest the existence of an independent non-substance-
induced Psychotic Disorder (e.g., history of recurrent non-
substance-related episodes)
D. The disturbance does not occur exclusively during a course of
a delirium.

45. Substance-Induced Psychotic
Disorder
Code:
292.11 Amphetamine-Induced Psychotic
Disorder, With Delusions
292.12 Amphetamine-Induced Psychotic
Disorder, With Hallucinations

46. Substance-Induced Psychotic
Disorder
Specify if:
With Onset During Intoxication: if criteria are met
for intoxication with the substance and the
symptoms develop during intoxication syndrome
With Onset During Withdrawal: if criteria are met
for withdrawal from the substance and the
symptoms develop during, or shortly after, a
withdrawal syndrome

47. The love of speed: An analysis
of the enduring attraction of
amphetamine sulphate for
British youth
Hillary Klee. Journal of Drug
Issues; Tallahassee; Winter 1998;
28(1):33-56

48. Early History:
Licit and Illicit Use
treatment of hyperactivity in children,
obesity, depression, narcolepsy, and nasal
congestion
WW-II:troops were supplied with
amphetamine to delay fatigue and enhance
alertness

49. Early History:
Licit and Illicit Use
 The `Swinging Sixties' was a period of
revolutionary social change and experimentation
with psychoactive drugs.
 Amphetamine was popular among them because
it provided the energy to perform all night and
survive periods on tour (see Shapiro 1988).
 1970s and 1980s decline due to popularity of
heroin

50.  1990s: methylenedioxyamphetamine (MDMA) or
ecstasy
 Cannabis has been first in the list for some time,
but amphetamine sulphate is second and rising
(Parker et al. 1995)
 The increasing use of amphetamine-type
stimulants has now assumed global importance
(Pietschmann 1996,1997; Yoshida 1997)

51. The Attractions
If amphetamine was marketed legally and
aimed at the young, it would need little
promotion, it has a range of effects and
positive attributes that make it particularly
alluring to young people

52. Energy and the ‘Buzz’
 The energy and sociability induced by amphetamine
 The energy and motivation, which were sustained over
several hours, were regarded as highly functional in a
variety of settings; for work and leisure.
 activity levels seemed to be increased by disinhibition that
was a result of their confidence and better mood
 Klee and Ruben 1993; males tended to nominate the
euphoric effect (the high), females were more likely to
identify the extra energy, the worry-free state, and the
avoidance of depression

53. The Paradoxes Induced by
Frequent Use
 Irritability and/or aggression is common when
`coming down' off the drug, when using heavily,
and when combined with alcohol
 Paranoia can lead to isolation
 Klee et al. 1996; Paranoid delusions, aggression,
and acute depression were the most frequent
symptoms prior to presenting to services

54. The Bonuses
 A variety of other psychoactive effects add value,
for example the euphoric 'high' when injecting,
acute perception (some claiming telepathic
powers), and sexual performance
 increased energy was reported by over half the
sample of men and women in one study (Klee
1992), leading to extended periods of intercourse
 39% of men said their performance was improved
by delaying ejaculation, nearly as many (33%) had
experienced a failure to get an erection

55. Are cannabis and psychosis linked?
The Lancet; London; Feb 27, 1999; Peter
Harrigan;
 Wayne Hall, executive director of National Drug and Alcohol Studies
at the University of New South Wales, Sydney, Australia, has re-
kindled the argument about whether heavy use of cannabis can cause
"cannabis psychosis", and whether the use of cannabis can precipitate
schizophrenia or exacerbate its symptoms.
 At the inaugural international conference on cannabis and psychosis
(Melbourne, Feb 16-17), Hall enlisted support for the "cannabis
psychosis" hypothesis. Apparent precipitation of acute psychotic
symptoms by heavy use of cannabis remit after abstinence, he noted.
But are these symptoms a "toxic psychosis" induced by cannabis,
rather than a functional psychosis, he asked? It is also possible, he
added, that concurrent use of amphetamines could cause a toxic
psychosis, mistakenly attributed to cannabis alone.

56.  "If cannabis-induced psychoses exist, it seems that they would
require very high doses of THC [tetrahydrocannabinol], the
prolonged use of highly potent forms of cannabis, or a pre-existing
vulnerability", Hall suggested. Cannabis might have a causal link
with psychosis in vulnerable people [eg, adolescents and young
adults], he said, but the nature of this vulnerability has yet to be
identified.
 Hall referred to research indicating a linear relation between the
frequency of use of cannabis before age 18, and the risk of being
diagnosed with schizophrenia by the age of 33. "It is unclear whether
this means that cannabis precipitates schizophrenia, whether it is a
form of self-medication [of an existing psychosis], or whether the
association is because of the use of other drugs, such as
amphetamines, which heavy cannabis users are more likely to use",
he reported.
 Although there is evidence that cannabis dependence is associated
with a some-time diagnosis of schizophrenia, there is better evidence
that cannabis use can exacerbate the symptoms of schizophrenia. The
onset of such symptoms are more likely to be acute rather than
insidious among heavy users of cannabis, said Hall.

57. Psychiatric complications of
Ma-Huang
Psychosomatics; Washington;
Jan/Feb 2000; 41(1):58Karl M
Jacobs; Kenneth A Hirsch;

58.  Ma-huang-containing products with names such as
"Herbal Ecstasy," "Nature's Sunshine,"
"Metabolift," and "Ripped Fuel" promise a
"natural" means to improve health, increase
energy and sexual functioning, obtain a legal
"high," and to lose weight and build muscle
 The psychiatric complications linked to Ma-huang
include psychosis and affective disturbances, akin
to reactions previously observed in patients who
misused asthma medications containing ephedrine

59. Reports of Ephedrine-Induced Psychosis
 Herridge and O'Brook (BMJ 1968) noted that ephedrine and
amphetamine induced a similar psychosis: paranoia with a clear
sensorium
 Roxanas (1996) reported the cases of one patient with auditory
hallucinations and "delusions of persecution and of grandeur" and
another patient with "markedly accelerated speech, tangential thinking,
and paranoid delusions." Affective change included "extreme anger
and hostility" and "depression with paranoid features”
 In a review of 20 cases of ephedrine-induced psychosis, Whitehouse
and Duncan (BJP 1987) noted that all patients experienced delusions,
90% had auditory hallucinations, and 45% visual hallucinations.
Affective disturbance was present in 30% of the patients, and agitation
with insomnia was present in 55% of the patients. Eighty-five percent
of the patients presented with a clear consciousness.

60. Ephedrine psychosis, however, is
time-limited
 In Herridge and O'Brook's original case description of a
65-year-old hostile and paranoid man, the psychosis
"evaporated" within 4 days of inpatient hospitalization.
There is no mention of pharmacotherapy
 A 26 year-old man, reported by Roxanas, was admitted
with paranoid delusions, auditory hallucinations, ideas of
reference, and "passivity feelings." Trifluoroperazine (5
mg po tid) and phenytoin sodium (100 mg po tid)
alleviated his symptoms within 5 days, and antipsychotics
were stopped