Psychotic reactions

Chopra GS and Smith JW (1974). Psychotic reactions following cannabis use in East Indians. Archives of General Psychiatry, 30, 24-27. 

Zolpidem, chemically unrelated to benzodiazepines or barbiturates, acts selectively at the y-aminobutyric acidA (GABAA)-receptor and has minimal anxiolytic and no muscle relaxant or anticonvulsant effects. It is comparable in effectiveness to benzodiazepine hypnotics, and it has little effect on sleep stages. Its duration is approximately 6 to 8 hours, and it is metabolized to inactive metabolites. Common side effects are drowsiness, amnesia, dizziness, headache, and GI complaints. Rebound effects when discontinued and tolerance with prolonged use are minimal, but theoretical concerns about abuse exist. It appears to have minimal effects on next-day psychomotor performance. The usual dose is 10 mg (5 mg in the elderly or those with liver impairment), which can be increased up to 20 mg nightly. Cases of psychotic reactions and sleep-eating have been reported. 

Disulfiram is used as an adjunct in the management of alcohol dependence. It is contraindicated in patients with a history of cerebrovascular accident, cardiac failure, coronary artery disease, hypertension and psychosis. Side-effects that may be present include initial drowsiness and fatigue, nausea, vomiting, halitosis, reduced libido, psychotic reactions, allergic dermatitis, peripheral neuritis and hepatic cell damage. 

Possible adverse reactions include headache anorexia nausea vomiting diarrhea palpitations tachycardia angina pectoris toxic reactions (particularly the LE cell syndrome) lacrimation conjunctivitis dizziness tremors psychotic reactions rash urticaria pruritus fever chills arthralgia eosinophilia constipation paralytic ileus lymphadenopathy splenomegaly nasal congestion flushing edema muscle cramps hypotension paradoxical pressor response dyspnea urination difficulty ... 

CNS - Asthenia, confusion, depression, dizziness, drowsiness, headache, nystagmus, peripheral neuropathy (see Warnings), psychotic reactions, vertigo. Dermatologic Erythema multiforme (including Stevens-Johnson syndrome), exfoliative dermatitis (rare) transient alopecia. 

The mechanisms of action of phencyclidine and ketamine are complex (Gorelick Balster, 1995). The drugs are non-competitive antagonists at NMDA receptors, and also bind to associated phencyclidine/sigma opioid receptors. They also have agonist actions at dopamine receptors, complex interactions with both nicotinic and muscarinic acetylcholine receptors and poorly understood interactions with noradrenergic and serotonergic systems. These multiple actions may combine to produce delirium and psychotic reactions. 

Neuropsychiatric adverse reactions that can occur include anxiety, nervousness and depression but also serious psychotic reactions. Involuntary movements, sometimes of a disturbing and complex nature, are frequent in patients on long-term therapy. 

The acute effects of psychomotor stimulant overdoses are related to their CNS stimulant properties and may include euphoria, dizziness, tremor, irritability, and insomnia. At higher doses, convulsions and coma may ensue. These drugs are cardiac stimulants and may cause headache, palpitation, cardiac arrhythmias, anginal pain, and either hypotension or hypertension. Dextroamphetamine produces somewhat less cardiac stimulation. Chronic intoxication, in addition to these symptoms, commonly results in weight loss and a psychotic reaction that is often diagnosed as schizophrenia. 

Treatment with steroids may initially evoke euphoria. This reaction can be a consequence of the salutary effects of the steroids on the inflammatory process or a direct effect on the psyche. The expression of the unpredictable and often profound effects exerted by steroids on mental processes generally reflects the personality of the individual. Psychiatric side effects induced by glucocorticoids may include mania, depression, or mood disturbances. Restlessness and early-morning insomnia may be forerunners of severe psychotic reactions. In such situations, cessation of treatment might be considered, especially in patients with a history of personality disorders. In addition, patients may become psychically dependent on steroids as a result of their euphoric effect, and withdrawal of the treatment may precipitate an emotional crisis, with suicide or psychosis as a consequence. Patients with Cushing s syndrome may also exhibit mood changes, which are reversed by effective treatment of the hypercortisolism. 

Erard et al.25a,43 believe that the psychosis Is a special form of an acute schizophrenic episode activated by the drug In some susceptible persons. Luisada estimated that 1-5% of the population may be susceptible (Luisada, P.V. personal comunicatlon). Although the Army volunteers were psychologically screened, preschizophrenic test subjects may have been Included. As noted, the psychotic reactions associated with SNA typically occur Immediately or soon after consumption of the drug. If serious mental consequences were not observed during the Immediate followup period or during the later Army tour of duty, It seems unlikely that a delayed SNA psychosis occurred. 

Table 7.3 Drug-related psychotic reactions Condition...

Bromocriptine, apomorphine, lisoride, and other direct-acting DA agonists benefit Parkinson s disease and can also cause psychotic reactions at high doses. 

As noted above, large doses of amphetamine, cocaine, and other sympathomimetics can cause acute paranoid reactions, either spontaneously in abusers or experimentally in normal volunteers. An injection of a large amphetamine dose, for example, often produces a paranoid psychosis within hours. Frequent smaller doses over several days can also produce a paranoid psychotic reaction. An episode s duration usually parallels the length of time the drug remains in the body. 

Several psychotic reactions to zolpidem have been reported-two cases of amnestic psychotic reaction and a psychotic reaction with hallucinations in an anorectic patient (151). Zolpidem 5 mg was prescribed for a 34-year-old woman with chronic insomnia. Twenty minutes after taking the recommended adult dose (10 mg), she experienced feelings of objects in her environment. She then slept uneventfully and recalled the unusual experience in the morning. Zolpidem may also cause transient cognitive and behavioral problems similar to those of BZDs (152). 

Ansseau M, Pichot W, Hansenne M, et al. Psychotic reactions to zolpidem. Lancet 1992 339 809. 

Side-effects Adverse reactions in the therapeutic range are mild and include drowsiness, dizziness, sedation and nausea. Overdosage can induce serious adverse reactions including profound sedation, respiratory depression, cardiovascular disturbances, convulsions and psychotic reactions, often with fatal outcome (Lawson and Northridge, 1987). Oral dextropropoxyphene has a relatively low abuse liability. Abuse by injection is impeded by severe irritation at the injection side. 

Regarding legal experimental use of the psychedelics, it has often been observed that the language used by the guide will influence what the subject says later to describe his session. This observation is borne out by some of the early research studies. It was initially believed that LSD produced psychotic reactions, and the drug was termed "psychotomimetic" by psychiatrists and psychologists (Rinkel, 1956). 

For example, Pollard,., Uhr, L., and Stern, E. (1965) no "persistent ill effects in experiments with eighty subjects over a five-year period Masters, R. E. L., and Houston, J. (1966) no psychotic reactions or unfavorable aftereffects in 206 sessions over a combined fifteen years of research Unger, S., et al. (1966) one adverse reac-... 

Diseases such as schizophrenia and/or malvaria (Hoffer and Osmond, 1962), are contraindications for the use of psychedelics, because subjects who have them are unlikely to have psychedelic reactions and are much more likely to have prolonged depressions and other psychotic reactions. These can lead to severe anxiety or panic, to suicide, and, very rarely, to other violent acts. Recurrences may occur several months later, but it is difficult to decide whether this is a recurrence of the LSD reaction or a resurgence of schizophrenia. 

The management of a psychotic reaction in an Addisonian patient taking a glucocorticoid needs special care (SED-8, 820). Psychotic reactions that do not abate promptly when the glucocorticoid dosage is reduced to the lowest effective value (or withdrawn) may need to be treated with neuroleptic drugs occasionally these fail and antidepressants are needed (SEDA-18,387). However, in other cases, antidepressants appear to aggravate the symptoms. 

A 14-year-old African-American girl with acute lymphocytic leukemia was treated with dexamethasone 24 mg/day for 25 days. Four days after starting to taper the dose she had a psychotic reaction with visual hallucinations, disorientation, agitation, and attempts to leave the floor. Her mother refused treatment with haloperidol. Steroids were withdrawn and lorazepam was given as needed. Nine days later the symptoms had not improved. She was given risperidone 1 mg/day within 3 days the psychotic reaction began to improve and by 3 weeks the symptoms had completely resolved. 

Behavioral treatment of obesity has given good results in patients taking neuroleptic drugs (835). More dubious is the use of antiobesity drugs, as some of them can cause psychotic reactions. 

Psychedelics LSD Mescaline Phencyclidine (PCP] Psilocybin Hallucinogens Oral may also be smoked or inhaled Altered perception and insight distorted senses disinhibition Severe hallucinations panic reaction acute psychotic reactions ... 

Common adverse psychologic consequences of hallucinogenic drugs include panic reactions ("bad trips") and acute psychotic reactions with PCP. Treatment includes benzodiazepines for sedation and constant monitoring by a nondrugged companion for several hours. Acidification of the urine (see Chapter 59 Management of the Poisoned Patient) may hasten PCP excretion. 

Prolonged use or high doses of amphetamines can result in a psychotic reaction, with disturbed thinking, paranoia, depression, and violent, homicidal, or suicidal behavior. Although the mental symptoms usually disappear within a week after stopping the drug, some users are left with permanent mental problems. 

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