Author's Accepted Manuscript
Delusional Infestation Following Misuse of Prescription Stimulants Corneliu N. Stanciu MD, Thomas M. Penders MD, Heather N. Oxentine MD
PII: DOI: Reference:
S0033-3182(14)00051-6 http://dx.doi.org/10.1016/j.psym.2014.03.004 PSYM451
To appear in:
Psychosomatics
Cite this article as: Corneliu N. Stanciu MD, Thomas M. Penders MD, Heather N. Oxentine MD, Delusional Infestation Following Misuse of Prescription Stimulants, Psychosomatics, http://dx.doi.org/10.1016/j.psym.2014.03.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Delusional Infestation Following Misuse of Prescription Stimulants Corneliu N. Stanciu MD, Resident, Thomas M. Penders MD, Associate Professor, Heather N. Oxentine MD, Resident Department of Psychiatric Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Suite 400E, Greenville, North Carolina 27834 [email protected] Abstract Delusional parasitosis is an uncommon disorder that has been described as a primary disorder and also in association with a variety of psychiatric disorders. There are only a few descriptions of delusional parasitosis in association with misuse of mixed amphetamine salts (Adderall). Increasing misuse of prescription stimulants place greater numbers at risk for consequent psychiatric morbidities including, rarely, delusional parasitosis. A description of a case of a somatic delusion following chronic use of mixed amphetamine salts is detailed alerting clinicians to the probability of causation and rapid resolution following elimination of the misused stimulant. Keywords: Dermatology - PSY0280, Primary Care - PSY0530, Somatization - PSY0680, Alcohol/Drug Abuse - PSY0030, Consultation Liaison Psychiatry - PSY0230
INTRODUCTION Delusional Parasitosis (Ekbom’s syndrome) is a fixed, false belief that one is infested with parasites. Imaginary infestation is reported as a perception of pruritis, a tactile hallucination, experienced as insects crawling on the skin, also known as formication. Affected individuals, preoccupied with the perceived infestation, interpret any skin marking as evidence. Sufferers often gather “evidence” compulsively and display it to medical providers, as proof of their infestation, the “baggie sign” (1). Delusional parasitosis is uncommon, the true prevalence being uncertain. While present in all demographic groups, it is most common in Caucasian women in late middle-age or older (2). It can be categorized as a primary (delusional disorder, somatic type), secondary functional (in context of schizophrenia, psychotic depression) or secondary organic (occurring in the context of a medical condition or substance use) (3). Repeated use of psychostimulants has been associated with this disorder in both children and adults (2,3). Case reports detailing such presentations have implicated mixed amphetamine salts, methamphetamine, ephedrine, cathinones, and other substituted amphetamine-type-drugs. Affected individuals often resist psychiatric referral and present most frequently to 1
primary care, dermatology, or emergency department settings (4). We present a case of delusional infestation following misuse of mixed amphetamine salts that remitted rapidly and completely after withdrawal of the offending agent. Mixed amphetamine salts (Adderall) are highly effective and approved by the US Food and Drug Administration (FDA) for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). ADHD has an estimated prevalence of 8% among children and adolescents and 4.4% in adults (5). While effective when used as prescribed for ADHD, stimulant drugs are often diverted for use recreationally for cognitive enhancement or to reduce fatigue. Recent surveys find that 5.3% of young adults have used these agents for reasons other than their intended prescriptive use. Also, recent evidence suggests that nonmedical use of Adderall has been found to be more common in adults than in schoolaged individuals (6). Prescription drugs are the most commonly abused substances among Americans age 14 and older, after alcohol and marijuana. Mixed amphetamine salts are among those most commonly misused (7). Psychiatric consequences of such use include anxiety, aggression, paranoia, insomnia and hyperactivity (8). CASE REPORT A married, Caucasian female, mother of three, age in her late 30s, presented to the Emergency Department of an academic medical center with the chief complaint that: “a huge tape worm came out of my vagina last night”. She offered a “specimen” in a small plastic bag. She had been sleepless for three days while conducting internet searches for information about various worms that might be involved. She revealed that two days before she visited the Emergency Department of a General Hospital in a nearby community presenting with the same complaint that had appeared for the first time approximately six weeks before. She was released with a prescription for Cephazol and Hydroxyzine and an indicated diagnosis of “psychogenic skin disorder”. She appeared anxious, agitated and was somewhat pressured in speech. She reported being otherwise generally healthy without medical or psychiatric conditions. She described having no prescribed medications and had never been prescribed medication for treatment of ADHD. Despite reassurance, she was insistent that further investigation be conducted as she had been seeing worms underneath her skin for the prior three days. She pointed to an engorged vein on her left arm, a hyperpigmented area in the interdigital fold and a wrinkle extending from her nasolabial fold. She indicated that she could feel the worms. Neither family members, nor medical personnel were able to appreciate evidence of infestation. The patient displayed various skin lacerations located on her hips, thighs, and jaw line where she attempted to extract the worms with tweezers. Examination by emergency physicians, including a gynecological exam, was unremarkable except for toilet paper residue similar to the “specimen” found in the plastic bag. Laboratory analysis, including microscopic examination for ova and parasites, was also unremarkable. The patient acknowledged a history of use of crack cocaine since age twelve with her last use greater than two years prior. She denied a history of seizures, head trauma or obsessive characteristics. Despite never having been diagnosed with ADHD she reported use of Adderall daily. She defended this illicit use as it was her
2
belief that it assisted her in managing overwhelming household responsibilities. She used as much as 120 mg a day (three times the FDA approved limit) for the last three years taking a minimum of 40 mg per day. Drug testing was positive only for amphetamines. Both she and her family denied any recent use of other illicit drugs or pharmaceuticals. Hospital admission was arranged after the patient showed persistent symptoms of agitation and severe irritability. She was treated with risperidone 2 mg twice daily. The morning after she was drowsy and irritable. Beginning the second hospital day she denied any perception of bugs on her or under her skin. Her preoccupation with infestation by worms rapidly remitted. The day prior to discharge she was completely euthymic and free of the severe obsession preoccupation that led to her initial presentation. She was discharged with a Diagnostic and Statistical Manual 5 (DSM-5) diagnosis of stimulantinduced perceptual disorder. The positive and negative syndrome scale (PANSS) score on admission was 93, and 44 at discharge three days later. Six weeks after discharge, the patient she reported feeling well and free of any somatic preoccupation. Risperdone had been discontinued two weeks after discharge. he reported that she had ceased illicit use of stimulant drugs. DISCUSSION Chronic use of various amphetamines has long been recognized to produce a psychosis that mimics the symptoms of schizophrenia. (9). Psychotic symptoms are also common with repeated use of cocaine. With repeated use of stimulant drugs, sensitization to subsequent use may occur making the appearance of psychotic symptoms more likely. (10). Individuals who use prescription stimulants commonly have a history of prior misuse of other substances both prescribed and illicit. Illicit use of prescription amphetamines, however does not necessarily serve as a gateway to other drugs of abuse. (11). Most reported cases of delusional parasitosis are of the primary type where the delusion present without an associated psychiatric or medical condition. When presenting with a co-occuring disorder it is considered to be a secondary. (3). Reports of cases involving association with amphetamines are unusual despite the increasing prevalence of misuse of prescription stimulants. Among the psychotic symptoms associated with excessive stimulant use is the illusion of infestation that can become a delusional preoccupation (12). Pathogenesis appears to involve dysregulation of striatal dopamine systems subserving attention, reward and motor coordination (8,10). Since amphetamines exert their primary action by increase in levels of dopamine within the central nervous system this case provides evidence consistent with involvement of dopaminergic circuits in the pathogenesis of delusional parasitosis. Management involving use of a variety of newer antipsychotic agents has shown varying degrees of efficacy. The greatest body of evidence supports use of risperidone (13). SUMMARY AND CONCLUSION This report adds to evidence of an association between excessive use of psychostimulants and development of delusional parasitosis. Like a similar case reported by Buscarino et
3
al., somatic delusions remitted soon after discontinuing stimulant use (14). This patient had a rapid, dramatic and complete remission of symptoms. She left the hospital with no residual psychotic or affective symptoms. Six weeks after stopping amphetamines the patient remained free of delusions or any somatic concerns. Given the increasing use of stimulant drugs for the treatment of ADHD, and their common misuse, clinicians should be aware of the potential for these agents to induce delusions of infestation when used in amounts exceeding those recommended. Discontinuing the amphetamine and use of short-term, low dose antipsychotics led to rapid and complete remission of the symptoms in this patient. Clinicians would be well advised that screening for risk of abuse or misuse might lead to early recognition and intervention to avoid complications such as described here.
REFERENCES 1. Hinckle CN. Ekbom Syndrome: A delusional condition of “bugs in the skin”. Current Psychiatry Reports 2011:13:178–86. 2. Mosholder AD, Gelperin K, Hammad, TA et al. Hallucinations and Other Psychotic Symptoms Associated with the Use of Attention Deficit/Hyperactivity Disorder in Children. Pediatrics;2009:123:611-16. 3. Foster AA, Hylwa SA, Bury EJ, Davis MD, Pittelkow MR, Bostwich MJ. Delusional infestation: Clinical presentation in 147 patients seen at Mayo Clinic. Journal of American Academy of Dermatology 2012; 67:673 e1-10. 4. Mercan S, Altunay IL, Taskintuna N, Ogutcen O. Atypical antipsychotic drugs in the treatment of delusional parasitosis. International Journal of Psychiatry in Medicine , 2007: 37:1:29-37 5. Kessler RC, Berlund P, Demler O et al Lifetime Prevalence and Age of Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry. 2005;62:593-602. 6. Substance Abuse and Mental Health Administration. National Survey on Drug Use and Health. October 2, 2013. http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/Index.aspx (accessed March 9, 2014). 7. National Institute on Drug Abuse. Drug Facts 2013; May: http://www.drugabuse.gov/publications/drugfacts/prescription-over-countermedications (accessed February 15, 2014). 8. Bramness GJ, Gundersen, OH, Guterstam, J, Rognlil, EB. Amphetamine-induced psychosis - a separate diagnostic entity or primary psychosis triggered in the vulnerable? BioMed Central 2012: 12:221 9. Harris D, Batki SL. Stimulant Psychosis: Symptom Profile and Acute Clinical Course. American Journal on Addictions. 2000;9:28-37. 10. Huber M, Karner M, Kircher E, Lepping P, Freudenmann RW. Striatal lesions in delusional parasitosis revealed in magnetic resonance imaging. Progress in Neuropsychopharmachology and Biological Psychiatry. 2008:32:1967-1971 11. Sweeney CT, Sembower MA, Ertischek MD, Shiffman S, Schnoll SH. Nonmedical
4
use of prescription ADHD stimulants and preexisting patterns of drug abuse. Journal of Addictive Disease: 2013: 32:1-10. 12. deLeon J, Antelo RE, Simpson G. Delusional Parasitosis or Chronic Tactile Hallucinations: Hypothesis about Brain Physiopathology. Comprehensive Psychiatry. 1993;33(1):25-33. 13. Elmer KB, George RM, Peterson K. Therapeutic update: use of risperidone for the treatment of monosymptomatic hypochondriacal psychosis. Journal of the American Academy of Dermatology 2000:43:683–686. 14. Buscarino M, Saal J, Young JL. Delusional Parasitosis in a Female Treated with Mixed Amphetamine Salts: A Case Report and Literature Review. Case Reports in Psychiatry 2012: 10:1-3.
5
Delusional Infestation Following Misuse of Prescription Stimulants Corneliu N. Stanciu MD, Thomas M. Penders MD, Heather N. Oxentine MD
PII: DOI: Reference:
S0033-3182(14)00051-6 http://dx.doi.org/10.1016/j.psym.2014.03.004 PSYM451
To appear in:
Psychosomatics
Cite this article as: Corneliu N. Stanciu MD, Thomas M. Penders MD, Heather N. Oxentine MD, Delusional Infestation Following Misuse of Prescription Stimulants, Psychosomatics, http://dx.doi.org/10.1016/j.psym.2014.03.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Delusional Infestation Following Misuse of Prescription Stimulants Corneliu N. Stanciu MD, Resident, Thomas M. Penders MD, Associate Professor, Heather N. Oxentine MD, Resident Department of Psychiatric Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Suite 400E, Greenville, North Carolina 27834 [email protected] Abstract Delusional parasitosis is an uncommon disorder that has been described as a primary disorder and also in association with a variety of psychiatric disorders. There are only a few descriptions of delusional parasitosis in association with misuse of mixed amphetamine salts (Adderall). Increasing misuse of prescription stimulants place greater numbers at risk for consequent psychiatric morbidities including, rarely, delusional parasitosis. A description of a case of a somatic delusion following chronic use of mixed amphetamine salts is detailed alerting clinicians to the probability of causation and rapid resolution following elimination of the misused stimulant. Keywords: Dermatology - PSY0280, Primary Care - PSY0530, Somatization - PSY0680, Alcohol/Drug Abuse - PSY0030, Consultation Liaison Psychiatry - PSY0230
INTRODUCTION Delusional Parasitosis (Ekbom’s syndrome) is a fixed, false belief that one is infested with parasites. Imaginary infestation is reported as a perception of pruritis, a tactile hallucination, experienced as insects crawling on the skin, also known as formication. Affected individuals, preoccupied with the perceived infestation, interpret any skin marking as evidence. Sufferers often gather “evidence” compulsively and display it to medical providers, as proof of their infestation, the “baggie sign” (1). Delusional parasitosis is uncommon, the true prevalence being uncertain. While present in all demographic groups, it is most common in Caucasian women in late middle-age or older (2). It can be categorized as a primary (delusional disorder, somatic type), secondary functional (in context of schizophrenia, psychotic depression) or secondary organic (occurring in the context of a medical condition or substance use) (3). Repeated use of psychostimulants has been associated with this disorder in both children and adults (2,3). Case reports detailing such presentations have implicated mixed amphetamine salts, methamphetamine, ephedrine, cathinones, and other substituted amphetamine-type-drugs. Affected individuals often resist psychiatric referral and present most frequently to 1
primary care, dermatology, or emergency department settings (4). We present a case of delusional infestation following misuse of mixed amphetamine salts that remitted rapidly and completely after withdrawal of the offending agent. Mixed amphetamine salts (Adderall) are highly effective and approved by the US Food and Drug Administration (FDA) for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). ADHD has an estimated prevalence of 8% among children and adolescents and 4.4% in adults (5). While effective when used as prescribed for ADHD, stimulant drugs are often diverted for use recreationally for cognitive enhancement or to reduce fatigue. Recent surveys find that 5.3% of young adults have used these agents for reasons other than their intended prescriptive use. Also, recent evidence suggests that nonmedical use of Adderall has been found to be more common in adults than in schoolaged individuals (6). Prescription drugs are the most commonly abused substances among Americans age 14 and older, after alcohol and marijuana. Mixed amphetamine salts are among those most commonly misused (7). Psychiatric consequences of such use include anxiety, aggression, paranoia, insomnia and hyperactivity (8). CASE REPORT A married, Caucasian female, mother of three, age in her late 30s, presented to the Emergency Department of an academic medical center with the chief complaint that: “a huge tape worm came out of my vagina last night”. She offered a “specimen” in a small plastic bag. She had been sleepless for three days while conducting internet searches for information about various worms that might be involved. She revealed that two days before she visited the Emergency Department of a General Hospital in a nearby community presenting with the same complaint that had appeared for the first time approximately six weeks before. She was released with a prescription for Cephazol and Hydroxyzine and an indicated diagnosis of “psychogenic skin disorder”. She appeared anxious, agitated and was somewhat pressured in speech. She reported being otherwise generally healthy without medical or psychiatric conditions. She described having no prescribed medications and had never been prescribed medication for treatment of ADHD. Despite reassurance, she was insistent that further investigation be conducted as she had been seeing worms underneath her skin for the prior three days. She pointed to an engorged vein on her left arm, a hyperpigmented area in the interdigital fold and a wrinkle extending from her nasolabial fold. She indicated that she could feel the worms. Neither family members, nor medical personnel were able to appreciate evidence of infestation. The patient displayed various skin lacerations located on her hips, thighs, and jaw line where she attempted to extract the worms with tweezers. Examination by emergency physicians, including a gynecological exam, was unremarkable except for toilet paper residue similar to the “specimen” found in the plastic bag. Laboratory analysis, including microscopic examination for ova and parasites, was also unremarkable. The patient acknowledged a history of use of crack cocaine since age twelve with her last use greater than two years prior. She denied a history of seizures, head trauma or obsessive characteristics. Despite never having been diagnosed with ADHD she reported use of Adderall daily. She defended this illicit use as it was her
2
belief that it assisted her in managing overwhelming household responsibilities. She used as much as 120 mg a day (three times the FDA approved limit) for the last three years taking a minimum of 40 mg per day. Drug testing was positive only for amphetamines. Both she and her family denied any recent use of other illicit drugs or pharmaceuticals. Hospital admission was arranged after the patient showed persistent symptoms of agitation and severe irritability. She was treated with risperidone 2 mg twice daily. The morning after she was drowsy and irritable. Beginning the second hospital day she denied any perception of bugs on her or under her skin. Her preoccupation with infestation by worms rapidly remitted. The day prior to discharge she was completely euthymic and free of the severe obsession preoccupation that led to her initial presentation. She was discharged with a Diagnostic and Statistical Manual 5 (DSM-5) diagnosis of stimulantinduced perceptual disorder. The positive and negative syndrome scale (PANSS) score on admission was 93, and 44 at discharge three days later. Six weeks after discharge, the patient she reported feeling well and free of any somatic preoccupation. Risperdone had been discontinued two weeks after discharge. he reported that she had ceased illicit use of stimulant drugs. DISCUSSION Chronic use of various amphetamines has long been recognized to produce a psychosis that mimics the symptoms of schizophrenia. (9). Psychotic symptoms are also common with repeated use of cocaine. With repeated use of stimulant drugs, sensitization to subsequent use may occur making the appearance of psychotic symptoms more likely. (10). Individuals who use prescription stimulants commonly have a history of prior misuse of other substances both prescribed and illicit. Illicit use of prescription amphetamines, however does not necessarily serve as a gateway to other drugs of abuse. (11). Most reported cases of delusional parasitosis are of the primary type where the delusion present without an associated psychiatric or medical condition. When presenting with a co-occuring disorder it is considered to be a secondary. (3). Reports of cases involving association with amphetamines are unusual despite the increasing prevalence of misuse of prescription stimulants. Among the psychotic symptoms associated with excessive stimulant use is the illusion of infestation that can become a delusional preoccupation (12). Pathogenesis appears to involve dysregulation of striatal dopamine systems subserving attention, reward and motor coordination (8,10). Since amphetamines exert their primary action by increase in levels of dopamine within the central nervous system this case provides evidence consistent with involvement of dopaminergic circuits in the pathogenesis of delusional parasitosis. Management involving use of a variety of newer antipsychotic agents has shown varying degrees of efficacy. The greatest body of evidence supports use of risperidone (13). SUMMARY AND CONCLUSION This report adds to evidence of an association between excessive use of psychostimulants and development of delusional parasitosis. Like a similar case reported by Buscarino et
3
al., somatic delusions remitted soon after discontinuing stimulant use (14). This patient had a rapid, dramatic and complete remission of symptoms. She left the hospital with no residual psychotic or affective symptoms. Six weeks after stopping amphetamines the patient remained free of delusions or any somatic concerns. Given the increasing use of stimulant drugs for the treatment of ADHD, and their common misuse, clinicians should be aware of the potential for these agents to induce delusions of infestation when used in amounts exceeding those recommended. Discontinuing the amphetamine and use of short-term, low dose antipsychotics led to rapid and complete remission of the symptoms in this patient. Clinicians would be well advised that screening for risk of abuse or misuse might lead to early recognition and intervention to avoid complications such as described here.
REFERENCES 1. Hinckle CN. Ekbom Syndrome: A delusional condition of “bugs in the skin”. Current Psychiatry Reports 2011:13:178–86. 2. Mosholder AD, Gelperin K, Hammad, TA et al. Hallucinations and Other Psychotic Symptoms Associated with the Use of Attention Deficit/Hyperactivity Disorder in Children. Pediatrics;2009:123:611-16. 3. Foster AA, Hylwa SA, Bury EJ, Davis MD, Pittelkow MR, Bostwich MJ. Delusional infestation: Clinical presentation in 147 patients seen at Mayo Clinic. Journal of American Academy of Dermatology 2012; 67:673 e1-10. 4. Mercan S, Altunay IL, Taskintuna N, Ogutcen O. Atypical antipsychotic drugs in the treatment of delusional parasitosis. International Journal of Psychiatry in Medicine , 2007: 37:1:29-37 5. Kessler RC, Berlund P, Demler O et al Lifetime Prevalence and Age of Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry. 2005;62:593-602. 6. Substance Abuse and Mental Health Administration. National Survey on Drug Use and Health. October 2, 2013. http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/Index.aspx (accessed March 9, 2014). 7. National Institute on Drug Abuse. Drug Facts 2013; May: http://www.drugabuse.gov/publications/drugfacts/prescription-over-countermedications (accessed February 15, 2014). 8. Bramness GJ, Gundersen, OH, Guterstam, J, Rognlil, EB. Amphetamine-induced psychosis - a separate diagnostic entity or primary psychosis triggered in the vulnerable? BioMed Central 2012: 12:221 9. Harris D, Batki SL. Stimulant Psychosis: Symptom Profile and Acute Clinical Course. American Journal on Addictions. 2000;9:28-37. 10. Huber M, Karner M, Kircher E, Lepping P, Freudenmann RW. Striatal lesions in delusional parasitosis revealed in magnetic resonance imaging. Progress in Neuropsychopharmachology and Biological Psychiatry. 2008:32:1967-1971 11. Sweeney CT, Sembower MA, Ertischek MD, Shiffman S, Schnoll SH. Nonmedical
4
use of prescription ADHD stimulants and preexisting patterns of drug abuse. Journal of Addictive Disease: 2013: 32:1-10. 12. deLeon J, Antelo RE, Simpson G. Delusional Parasitosis or Chronic Tactile Hallucinations: Hypothesis about Brain Physiopathology. Comprehensive Psychiatry. 1993;33(1):25-33. 13. Elmer KB, George RM, Peterson K. Therapeutic update: use of risperidone for the treatment of monosymptomatic hypochondriacal psychosis. Journal of the American Academy of Dermatology 2000:43:683–686. 14. Buscarino M, Saal J, Young JL. Delusional Parasitosis in a Female Treated with Mixed Amphetamine Salts: A Case Report and Literature Review. Case Reports in Psychiatry 2012: 10:1-3.
5
