Tuesday, January 25, 2011

Sydenham chorea and psychosis

Tijdschr Psychiatr. 2010;52(4):265-9.
[Article in Dutch]
Mengde W, Jessurun AY.
Caprileskliniek, Willemstad, Curacao. W.Mengde@ggzbreburggroep.nl


Sydenham chorea (SC) is a complication of a group A beta-haemolytic streptococcal infection which is characterised by involuntary, choreatic movements. There is a definitive link between SC and psychoses. Furthermore, patients with SC seem to run a greater risk of developing neuroleptic-induced movement disorders. In this case-study of a 19-year-old psychotic male with a history of SC, the authors illustrate that this complicates the treatment of a psychotic episode.

PMID: 20503168 [PubMed - indexed for MEDLINE]

Promethazine-Induced Psychosis in a 16-Year-Old Girl

Charles Timnak, M.D., and Ondria Gleason, M.D., Tulsa, Okla.

TO THE EDITOR: Promethazine is a phenothiazine derivative and an H1 receptor antagonist that is commonly used for symptomatic relief of nausea and vomiting and for allergic conditions. Some clinicians also use promethazine as a cough suppressant. Promethazine is known to cause CNS side effects, including confusion, nervousness, disorientation, and hallucinations.1

There are currently few case reports of promethazine-induced psychosis. A report in the Medical Journal of Australia indicated two cases involving promethazine-induced psychosis in children.2 A case study of a 3-year-old patient reported severe visual hallucinations and agitation after treatment with promethazine.3 One case involved a middle-aged woman, who overdosed on promethazine and was disoriented and agitated and experienced hallucinations.4 A geriatric patient also developed psychosis after intramuscular administration of promethazine.5 We now report on a 16-year-old African American girl who developed psychotic symptoms after receiving treatment with promethazine.

Case Report

Alice, a 16-year-old African American girl with no prior psychiatric history, came to the emergency room with a chief complaint of hallucinations. Her symptoms had developed 5 days previously and included fever and a cough. She was taken to a local emergency room, diagnosed with an upper respiratory infection, and given azithromycin. Her condition worsened over the next 2 days. She was again taken to the emergency room, given an injection of promethazine, and discharged with a prescription for oral promethazine with codeine.

[Acute psychotic disorders related to bupropion: review of the literature].

Encephale. 2010 Dec;36(6):461-71. Epub 2010 Mar 15.

[Article in French]
Javelot T, Javelot H, Baratta A, Weiner L, Messaoudi M, Lemoine P.

Service "Les Hortensias", centre psychothérapique Nord Dauphiné, 100, avenue du Médipôle, 38307 Bourgoin-Jallieu cedex, France. javelot.thierry@cp-nord-dauphine.fr


RATIONALE AND OBJECTIVES: Bupropion, or amfebutamone, is an atypical antidepressant also used during tobacco cessation. From a structural standpoint, it resembles amphetamine drugs with psychostimulant effects, and endogenous monoamines. From a pharmacological standpoint, bupropion, and two of its most important active metabolites, inhibit dopamine and norepinephrine reuptake. It has recently been discovered that bupropion may act as a non-competitive cholinergic nicotinic receptor antagonist, and that it may inhibit the activation of reward systems triggered by nicotine. Buproprion's efficacy as a smoking cessation aid has been demonstrated by numerous clinical trials that have compared its effects with those of placebo and other nicotinic substitutes. In 2001, buproprion SR received marketing authorization in France as a smoking cessation aid, under the name ZYBAN®. Tobacco addiction indeed remains a major public health issue. Among patients with psychiatric conditions, chronic tobacco consumption is frequent. The development of non-nicotinic drugs may therefore enhance therapeutic possibilities. However, the psychotropic effects of these molecules should be taken into account. We have recently reported the case of a patient with schizoaffective disorder, who presented two acute bupropion-induced psychotic episodes. We have also undertaken an exhaustive bibliographical research on this subject. The aim of the present study is to present the information available to us, in order to suggest aetiopathogenic hypotheses and therapeutic proposals.

Acute psychosis due to the interaction of legal compounds--ephedra alkaloids in 'vigueur fit' tablets, caffeine in 'red bull' and alcohol.

Med Sci Law. 2001 Oct;41(4):331-6.
Tormey WP, Bruzzi A.
Department of Chemical Pathology, Beaumont Hospital, Dublin, Ireland.


A short-lasting episode of acute psychosis in a 32-year-old male which followed the consumption of alcohol, caffeine and 'vigueur fit' tablets containing ephedra alkaloids is reported. Less than two days after the event, a urine sample contained 22 microg/ml of ephedrine and 5 microg/ml of pseudoephedrine. Despite detailed pharmacological evidence being given at a jury trial, he was convicted of assault and trespass and was fined pounds sterling 16,000. An earlier incident involving misbehaviour on an aircraft again involving alcohol and ephedrine resulted in a conviction and a court order to provide twice weekly urine tests for alcohol for a period of six months. He stopped taking the alkaloid tablets after the second incident. There was no history of aberrant behaviour in this man outwith the period when taking these tablets. Ephedra alkaloids may cause psychosis and their effects can be exaggerated by interaction with caffeine and ethanol. To protect the public, the use of stimulant drugs in over-the-counter weight control programmes should be prescription only and the package insert should include a warning on the dangers of concomitant use of ethanol.

PMID: 11693229 [PubMed - indexed for MEDLINE]

Caffeine and psychiatric symptoms: a review.

J Okla State Med Assoc. 2004 Dec;97(12):538-42.
Broderick P, Benjamin AB.
University of Oklahoma, 2312 North Indiana Avenue, Oklahoma City, Oklahoma 73106, USA.


Caffeine is a widely used psychoactive substance that has the potential to contribute to many psychiatric symptoms. This review article aims to address the specific research studies and case reports that relate caffeine to psychiatric symptoms. Caffeine can cause anxiety symptoms in normal individuals, especially in vulnerable patients, like those with pre-existing anxiety disorders. Caffeine use is also associated with symptoms of depression due to either a self-medication theory, or a theory that caffeine itself causes changes in mood. Psychosis can be induced in normal individuals ingesting caffeine at toxic doses, and psychotic symptoms can also be worsened in schizophrenic patients using caffeine. Sleep and symptoms of ADHD may be altered by caffeine as well. Prevention of caffeine-induced psychiatric symptoms is possible by recognizing, educating, and treating patients using a tapering approach.

PMID: 15732884 [PubMed - indexed for MEDLINE]

Caffeine-induced psychosis.

CNS Spectr. 2009 Mar;14(3):127-9.
Hedges DW, Woon FL, Hoopes SP.
Department of Psychology, Neuroscience Center, Brigham Young University, Provo, UT, USA. dawson_hedges@byu.edu


As a competitive adenosine antagonist, caffeine affects dopamine transmission and has been reported to worsen psychosis in people with schizophrenia and to cause psychosis in otherwise healthy people. We report of case of apparent chronic caffeine-induced psychosis characterized by delusions and paranoia in a 47-year-old man with high caffeine intake. The psychosis resolved within 7 weeks after lowering caffeine intake without use of antipsychotic medication. Clinicians might consider the possibility of caffeinism when evaluating chronic psychosis.

PMID: 19407709 [PubMed - indexed for MEDLINE]

Psychiatric side effects attributed to phenylpropanolamine.

Pharmacopsychiatry. 1988 Jul;21(4):171-81.
Lake CR, Masson EB, Quirk RS.
Dept. of Psychiatry, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.


Phenylpropanolamine (PPA) is a sympathomimetic drug similar in structure to amphetamine which, in the United States, is present in over 130 medications, primarily decongestants, cough/cold remedies, and anorectic agents. We have reviewed 37 cases (published in North America and Europe since 1960) that received diagnoses of acute mania, paranoid schizophrenia, and organic psychosis and that were attributed to PPA product ingestion. Of the 27 North American case reports, more reactions followed the ingestion of combination products than preparations containing PPA alone; more occurred after ingestion of over-the-counter products than those obtained by prescription or on-the-street; and more of the cases followed ingestion of recommended doses than overdoses. Groups at particular risk appear to be those with a past or family psychiatric history, children under the age of 6 and post-partum women. Failure to recognize PPA as an etiological agent in the onset of symptoms usually led to a diagnosis of schizophrenia or mania, lengthy hospitalization, and treatment with substantial doses of neuroleptics or lithium. While generally safe at recommended doses, PPA can be hazardous to susceptible individuals and we urge physicians to be alert to the potential for PPA related psychiatric reactions. We have compiled an alphabetized table (Table 1: Prescription and Over-the-Counter Products Containing Phenylpropanolamine) allowing busy clinicians quick access to those drugs containing PPA.

PMID: 3060884 [PubMed - indexed for MEDLINE]

Organic affective psychosis associated with the routine use of non-prescription cold preparations

Br J Psychiatry. 1990 Apr;156:572-5.
Brown TM, Golden RN, Evans DL.
Department of Psychiatry, University of North Carolina, School of Medicine, Chapel Hill 27599.


A patient experienced an organic affective psychosis on three separate occasions after taking recommended doses of non-prescription cold/sinus preparations. The possible underlying pharmacological mechanisms of this clinical reaction lend support to the cholinergic-adrenergic balance hypothesis of affective disorders. Recognition of this acute drug-induced state can lead to appropriate short-term pharmacotherapy and can prevent misdiagnosis of a major affective disorder or schizophrenia.

PMID: 2386871 [PubMed - indexed for MEDLINE]

Dextromethorphan- and pseudoephedrine-induced agitated psychosis and ataxia: case report.

J Emerg Med. 1999 Mar-Apr;17(2):285-8.
Roberge RJ, Hirani KH, Rowland PL 3rd, Berkeley R, Krenzelok EP.
Department of Emergency Medicine, Western Pennsylvania Hospital, Pittsburgh 15224, USA.


Pseudoephedrine and dextromethorphan are therapeutic constituents of numerous commonly used, over-the-counter cough and cold preparations. Although this drug combination is generally considered quite safe if utilized in recommended doses, overmedication or overdose can result in serious neurologic and cardiovascular abnormalities that occasionally can be life-threatening. We present a case of a 2-year-old child who developed hyperirritability, psychosis, and ataxia after being overmedicated with a pseudoephedrine/dextromethorphan combination cough preparation, and discuss probable mechanisms of toxicity and risk factors for adverse events.

PMID: 10195488 [PubMed - indexed for MEDLINE]