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CLINICAL TOXICOLOGY 9( 4), pp. 529- 538 (1976)

Psychiatric Sequelae of Phencyclidine Abuse*

BEVERLY FAUMAN, M.D. Department of Psychiatry and Division of Emergency Medicine University of Chicago Hospitals & Clinics Chicago, Illinois GLENN ALDINGER, M.D. Division of Emergency Medicine University of Chicago Hospitals & Clinics Chicago, Illinois MICHAEL FAUMAN, M.D., Ph.D, Department of Psychiatry University of Chicago Hospitals & C l i n i c s Chicago, Illinois P E T E R ROSEN, M.D. Director, Division of Emergency Medicine University of Chicago Hospitals & C l i n i c s Chicago, Illinois

*Request f o r reprints: Beverly Fauman, M.D., University of Chicago Hospitals &Clinics, Division of Emergency Medicine, 950 E a s t 59th S t r e e t Box 448, Chicago, Illinois 60637. 52 9 Copyright 0 1976 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.

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Phencyclidine has become one of the most commonly abused drugs in the drug experimenting culture. Its pattern of use, effects and reports in the literature parallel the e a r l i e r courses of lysergic acid and marijuana. Phencyclidine use appears to follow a geographical pattern: as with other drugs, the East and West coasts are innovative, and the Midwest follows suit two to three years later. Thus, in California the dangers of ingesting o r "shooting" the drug are well-known, so that most users smoke it, whereas in Chicago, the serious overdoses we have been witnessing in the last couple of years are all ingestions and inhalations. We have not yet seen the pure phencyclidine chronic u s e r s that are being found in California. The names applied to this drug are also local: on the West Coast it was first known as the Peace Pill ( P C P ) [l], and is now referred to as crystal, o r crystal joints ( C J s ) [2]; on the East Coast it has been called Hog [3] and sheets. It is recognized everywhere as an animal tranquilizer, and masquerades everywhere a s tetrahydrocannabinol. It is also generally known as Angel Dust and PCP. In Chicago its s t r e e t name s e e m s to have evolved from THC to TAC, and then to TIC, apparently from the television jingle about the candy, "Put a Tic Tac in your mouth and get a bang out of life." The recognition that P C P is a "bad" drug, that often produces bad t r i p s and unpleasant side effects probably led to the r a s h of pseudonyms and fraudulent s t r e e t marketing, but only for a short time. Most phencyclidine u s e r s are aware of what they a r e taking o r , like other drug users, don't seem to c a r e [4]. For instance, heroin u s e r s seek out the dealer who has supplied a T'friend" with an overdose, not for revenge but because they can be s u r e he has the "real O.D." The recognition that LSD may produce a bad trip if the u s e r is depressed does not deter use [ 51, and there are reports of epidemic amphetamine abuse despite high morbidity [6]. We have observed several prolonged psychotic reactions in young adults, which appear in a number of ways, generally including severe anxiety, bizarre behavior, and alterations in the state of consciousness. Case 1 PB, a 19-rear-old female who came to the emergency department complaining of strange sensations in h e r muscles, and of acute anxiety. She stated that friends had made her "snort TAC." On examination h e r blood p r e s s u r e was 116/86, pulse 64. She looked anxious, but the remainder of the exam was normal. Premorbid history revealed unremarkable achievement, socially and academically; she was living with h e r parents and was unemployed. She was given diazepam orally, and was sent home with reassurance and some additional diazepam.

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53 1

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Case 2 SR, an 18-year-old female brought to the emergency department by her boyfriend, who said she just wasn't behaving right. She had smoked a "reefer" in an apparent attempt to calm h e r anxiety, which had persisted since taking a tablet of TAC four days earlier. She appeared restless, agitated, disoriented, and paranoid, and was unable to cooperate with the interviewer to answer questions. Blood p r e s s u r e was 150/80, pulse 84. She was given a small amount of chlorpromazine orally, which provided some relief, and sent home. Five days l a t e r she returned; her family said she had not been herself, and s h e was much too agitated to return to work. She was r e s t l e s s and appeared frightened, and was too agitated f o r vital signs o r any other examination to be c a r r i e d out. She was given chlorpromazine intramuscularly and admitted to the psychiatric unit. On examination there, pulse was 110, and there was no nystagmus o r ataxia. A routine urine drug screen was negative for opiates, barbiturates, and amphetamines. During the next few days she improved with treatment by phenothiazines and milieu therapy, and was discharged as recovered on no medication after 24 days. Case 3 KM, an 18-year-old male brought to the emergency department ''a few days after using LSD" because of extreme agitation. In the emergency department his agitation increased, he became paranoid, and leaped out a window. He was retrieved by security guards and sent home with his mother, who was advised on the handling of an LSD bad trip. Twenty-four hours later he was brought back because his agitation had increased. On examination his blood p r e s s u r e was 136/80, pulse 80. Premorbid history included multiple and prolonged drug use and alcohol ingestion. The patient was hospitalized on the psychiatric ward, where he improved on major tranquilizers and milieu therapy, and was discharged after 25 days on no medication. He was able then to give the information that the drug he had taken p r i o r to his hospitalization was PCP.

Case 4 AJ, a 20-year-old female brought to the emergency department by h e r parents, who noted "peculiar behavior." She had taken a pill three days earlier, after which she had run endlessly and aimlessly for several hours. There was a normal interval of two days, and then the onset of delusional ideas, marked anxiety, and difficulty sleeping. She

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was known to have taken TAC in the past. In the emergency department, examination revealed a blood pressure of 148/108, pulse 118. Neurologic exam revealed that she was ataxic and had poor coordination, performed calculations poorly, and had paranoid ideas. She was unable to abstract, and behaved bizarrely during the interview, at one point crawling on the floor and barking and snapping at her mother's heels. Permorbidly, she had recently been isolating herself, and been nonfunctional socially. She was hospitalized on the psychiatric ward. An admission drug screen was negative for opiates, barbiturates, and amphetamines. She reintegrated over the next 10 days on phenothiazines, which were then stopped. She relapsed, and was again placed on phenothiazines with rapid recovery. She was discharged after 35 days, still on trifluoperazine. Case 5 GE, a 19-year-old male brought to the emergency department by his brother, who reported that a day earlier the boy had smoked and eaten some PCP, had been found wandering in a dazed state several hours later, and was brought home and put to bed. He slept for the next 20 h r , and though apparently awake thereafter, seemed unresponsive to familiar people and his environment. In the emergency department he could walk, but h i s movements and sparse speech seemed purposeless. He was unwilling o r unable to answer questions. On examination h i s blood pressure was 150/90, pulse 120. He exhibited lateral nystagmus and poor coordination, although he could not cooperate for formal testing. Reflexes were brisk but normal. H i s premorbid history included increasing social isolation after he had dropped out of college a few months earlier. Shortly after admission he appeared catatonic, and was so immobile that he had to be transferred to a medical unit where his nutritional and nursing needs could be tended to. Over the next few days there was improvement in his responsiveness, on haloperidol. He became communicative at times, although with much bizarre and paranoid ideation. On the 11th hospital day he was transferred back to the psychiatric unit where he remained a little over two months, and was discharged improved, although still on haloperidol. His brother obtained a sample of the drug for us, which was found to contain phencyclidine and methaqualone.

Case 6

DS, a 22-year-old female brought to the emergency department in deep coma following several seizures. Friends reported s h e had sniffed an extraordinarily large amount of phencyclidine powder

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several hours earlier. She remained in deep coma f o r five days with absent gag and corneal reflex for the first 48 hr, then gradually recovered over the next nine days with catatonic posturing, staring, and stereotypic behavior. She was extubated on the eighth day, and discharged on the 18th day.

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Case 7 HM, a 16-year-old male brought to the emergency department in an "awake" but unresponsive state. Shortly after his arrival h e had left-sided seizures. Vital signs initially were unremarkable, although temperature was not obtained. He had two more focal seizures, was given diazepam intravenously to control these and was admitted to the intensive care unit. Here it was discovered that h i s temperature was 109 degrees F. H e then suffered a cardiac a r r e s t and could not be resuscitated. Of note, he had been seen in the emergency department a month earlier, because his parents were alarmed by his intermittently peculiar behavior; he admitted to occasional phencyclidine use. His parents and he were advised to seek psychiatric help, which they did not pursue. A week prior to his death, his best friend had suicided by overdose. The presentation and course of these patients is summarized in Table 1. The effect of PCP noted by other observers is quite similar to schizophrenia; psychologic testing of normal volunteers given P C P produces schizophrenic range scores [7], and sensory deprivation of normal volunteers given P C P produces relief, a s it does in schizophrenics, rather than anxiety, a s it does in normals [8]. In fact, sensory isolation is recommended treatment for the acute P C P psychosis [2, 91. Subjectively, phencyclidine produces distortions in perception of all sensory modes, including proprioception, so that the subject feels paralyzed, off-balance, o r restrained [7- 121. Objectively, one s e e s an unmoving patient described a s catatonic o r in an "awake coma," o r an ataxic patient [2, 131. One can only speculate how overwhelming it must be to feel captured inside one's body. In the experiments carried out before it was recognized how dangerous P C P is, it was observed that schizophrenics given PCP were made worse and appeared to suffer relapses; in fact all pathologic behaviors were exaggerated with P C P [7, 81. Thus, it seemed reasonable to assume that the effect of PCP was to "uncover" a latent psychosis [13]. More recently, PCP has again been considered to produce a mental state difficult to distinguish from schizophrenia, and as more likely to do so in the presence of underlying psychiatric illness [13, 141.

534

FAUMAN E T AL. TABLE 1. Presentation and Course of Phencyclidine Overdose

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Case number a Presentation and course

1

2

3

4

5

6

7

PCP taken 0-4 days prior to EDvisit Anxiety and/or agitation

*

*

*

*

*

*

*

*

* *

*

*

*

*

*

*

Paranoid and/or delusion

*

Coma and/or seizures Catatonia Discharged from ED Returned to ED 1- 5 days after 1st visit with increased symptoms Admitted to hospital for 2 i to 9 weeks Major tranquilizers a

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*, presentation o r course for a particular case; first day of hospitalization.

t

t, patient died on

A s in our experience, many observers note the absence of prior psychiatric history o r hospitalization, although characteristically there is poor premorbid functioning in the population of PCP u s e r s who suff e r prolonged psychoses [ 131. The difficulty in assessing psychedelic drug effect is that drug users a r e not scientists. They a r e not concerned about dose, route of administration, purity of the sample, o r drug-drug interactions. Further, the population involved is not a normal, well fed average one. Nonetheless, reports in the literature during the 1960s attempted to describe what s o r t of person suffered drug-induced psychosis, and what sort of psychosis appeared. The psychoses developing after marijuana were thought to be related to the u s e r ' s expectations and personalities, a s well a s dose, route, and setting. It was also felt that poor handling of the acute confusional state prolonged the psychosis [ 18, 191, Marijuana u s e r s who sought medical assistance were generally inexperienced at drug use and without much group o r social support, o r else they had underlying psychiatric difficulties. There a r e reports of long-term psychosis after cannabis use in India, in patients whose premorbid history in-

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cluded evidence of schizophrenic o r sociopathic relatives [20]. Descriptions of the marijuana- related psychosis included sudden onset, permanent amnesia for the illness, p r e s s u r e of thought with flight of ideas, paranoid and grandiose thought content, euphoria, motor slowing, and decreased sleep. In addition, t her e was long-term flattening of affect and a persistent thought di s or der [ 181. Patients reported symptoms of time disorganization, confusion, disorientation, paranoid delusions, and hallucinations. Unlike the functional schizophrenic, the patient usually evidenced normal o r increased affect [ 191. The descriptions of LSD u s e r s who developed psychosis include absence of schizophrenia in the subjects and their relatives, and absence of p r i o r psychiatric hospitalizations. However, t here was often a history of long periods of unemployment and a tendency to vagrancy. Freedman wrote that "users who end up in the hospital with prolonged and s er io u s psychoses are initially a quite unstable group. They are, in any event, a sm al l group" [17]. The prolonged psychosis seen with LSD has been described a s a thought disorder, with auditory hallucinations, violence, paranoid delusions, regression, and depression. Other symptoms commonly present include emotional lability o r inappropriate affect, insomnia, psychomotor retardation, hallucinations and distortions, lo s s of time sense, confusion, and apathy [21]. The amphetamine psychosis appears to be m ore distinctive than the others: it appears to be dose related, although it is felt that certain personalities seek out the stimulation of amphetamines, and som e authors describe a "predilection f or paranoia" [22]. T here are strong paranoid delusions, hallucinations, hyperactivity including hypersexuality, and changes in body image. It can be distinguished from a functional psychosis in that t her e is no disorientation and the delusions are fixed, and often convincing to an interviewer. It is felt by som e that persistent psychoses as long as two yea rs after amphetamine use might still be residual drug effect, r at her than proof of predisposition f o r psychosis in the patient [22]. Phencyclidine u s e r s described in the l i t erat ure have these characteri s tic s premorbidly: a small number have a p r i o r history of psychiatric difficulty [13, 15, 231, but f or the most par t , there is no recording of premorbid dysfunction. This is contrary to our experience [13] and o u r clinical impression currently. All of o u r patients requiring hospitalization have evidence of poor premorbid functioning: poor school work o r work adjustment, and particularly difficulties with interpersonal interactions. C as e two had never gotten along well with h e r mother, case three was an alcoholic as well a s a polydrug u s e r a t age 18. C a s e five was described as a loner, and a quiet, sensitive boy who had recently dropped out of college. Case s i x was an awkward, socially inept g i r l who was "snorting" P C P with some acquaintances in an attempt to be accepted by them, and took such a l ar ge dose out of ignorance and possibly a s the object of a hazing. Case seven had presented a month

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earlier with recognizable psychosocial difficulties, and his suicide was probably willful. Luisada also suggests that prolonged psychosis develops in a particularly vulnerable population, some of whom in his study went on to have recurrent psychosis not precipitated by drug, and were then classified as schizophrenic [23]. There a r e also reports of phencyclidine being used a s an agent for suicide [ 151. The phencyclidine psychosis presents a s bizarre behavior, confusion, and agitation; in addition, the patient is often staring blankly and is noncommunicative. In our experience, contrary to other reports, patients were often unresponsive to deep pain, even when obviously "awake," o r at least alive. A sleep disturbance is present if the patient presents some time after the drug exposure. There is usually evidence of cerebellar dysfunction: dysarthria, ataxia, and nystagmus. In Luisada' s series, there was a high incidence of violent, aggressive, o r threatening behavior, and a striking degree of fearfulness in all subjects. The patient may be correctly diagnosed a s having taken a hallucinogen, o r may be thought to be a schizophrenic. Thus, phencyclidine users who become psychotic share many characteristics of other hallucinogen users who suffer serious dysfunction. There a r e schizophrenics among them, and alienated, poorly functioning, o r sociopathic persons, a s well a s some with no evidence of poor premorbid functioning. The proportion who suffer severe psychiatric illness must be very small, a s the evidence is that PCP use is very common. Nevertheless, the consistent finding of an illness generally lasting four to six weeks suggests some sort of chemical interaction. Slight variations in effect and duration of illness may be related to dose, route, and addition of other drugs. With a turnover on our ward rarely exceeding 20 days, our PCP patients stayed four to five weeks. The notion that a drug-produced psychosis can persist this long has support in the literature: amphetamines and LSD have both been considered to have caused psychosis weeks to months after exposure [22, 241. Phencyclidine has a particular affinity for brain tissue, and physiologic evidence for prolonged CNS effect can be found; e.g., the nystagmus that often persists for two to three days. One must still explain why the psychosis is seen so rarely. With the extraordinarily widespread use of this drug there a r e only a small number of severe psychotic reactions. Our patient (case 6) was comatose for five days, and her spinal fluid contained a higher concentration of phencyclidine than the laboratory standard, yet she was only briefly psychotic. Thus, the phencyclidine psychosis seems to require both sufficient drug and deficient ego strength: only in combination is the psychosis produced.

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SUMMARY Phencyclidine use has been noted to produce a psychosis of several weeks' duration in a small fraction of users. Descriptions of the premorbid personalities of those who became psychotic resemble descriptions of LSD and marijuana u s e r s who experienced prolonged psychiatric difficulty. In addition, the psychosis produced can often be recognized as a "hallucinogen" psychosis. Certain features of the phencyclidine psychosis, namely the neurologic abnormalities, dose- related severity of symptoms, and regularity of the length of illness, a r e not noted with other psychedelic drugs, leading to the conclusion that P C P psychosis is a drug effect r a t h e r than a brief functional psychosis precipitated by the disintegrating P C P experience. However, the infrequent occurrence of psychosis in the (apparently) l a r g e exposed population still suggests that this is a combination of drug effect and vulnerable, pathologic personality. ACKNOWLEDGMENT The authors would like to acknowledge the generous cooperation of Dr. Kristen Kaista, IIT Research Laboratories, in analyzing the drug and spinal fluid samples. REFERENCES

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Psychiatric sequelae of phencyclidine abuse.

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