MJP Online Early 02-10-21

CASE REPORT

A Case Series Describing the Tale of ‘The Magic Mushroom’; An Increasing Trend of Psychedelic Misuse Among Substance Abusers in

Chong Siew Koon1, Tuan Sharipah bt Tuan Haji1, Izatt Syafieq bin Abd Rashad1, Ruzila bt Ali2

1Psychiatry and Mental Health, Hospital Sultanah Nur Zahirah, , Terengganu, 2Psychiatry and Mental Health, Hospital Hulu Terengganu, Kuala Berang, Terengganu, Malaysia

Abstract

Hallucinogens comprise of a vast amount of substances such as Lysergic Acid Diethylamide, Phenylcyclidine PCP, naturally occurring alkaloid like Belladona and even mushrooms such as psylocybins. Usage of these substances can be traced back to antiquity, serving various purpose such as spiritual rites or even recreational purposes. However, in the modern era, teenagers appear to be in favor of designer drugs such as amphetamine type stimulants and more addictive substances such as opiates. Recently, there has been a resurgence of such cases in Terengganu where several patients had been reported to be using psychedelic compounds in the form of hallucinogenic mushrooms.

Keywords: Mushroom, Psychedelic, Hallucinogen, Substance

Introduction other psychological consequences which may be potentially detrimental to its user. Hallucinogen use in Malaysia is relatively This case series aims to describe several rare compared to other forms of substances. similar cases of patients who have been International data gives varying information admitted into our psychiatric facility within ranging from 0.6% in regional Asian the first half of year 2021 for the misuse of countries to 9% in the United States [1]. hallucinogenic mushrooms as well as their Those in urban areas favor synthetic classes treatment and outcomes. of hallucinogens such as LSD and PCP which are readily available from shady Case Report 1 dealers hidden around the country. Hallucinogen is classified under the Mr A is a patient suffering from Bipolar Dangerous Drugs Act 1952 [2] which Mood Disorder Type I who was admitted prohibits production, use and distribution. It several times to our ward . His readmission is known to cause vivid hallucinations and rate was almost four instances last year. MJP Online Early 02-10-21

Each presentation was similar; He would be dependence or withdrawal seen during his brought by his family for aggressive multiple admissions. behavior. Despite being treated with various medications, including long acting depot Case Report 2 injections, Mr A had a difficulty in controlling his anger outbursts leading to This is a report of Mr B who is a young 20 irritability, brawls with his father and year old Malay male. He was still attending subsequent presentation to the hospital. The the local college in Kuala Terengganu when treating team was puzzled as he was the pandemic struck. He had no psychiatric compliant to his medications which comorbidities but started venturing into vape comprise of high dosage of mood stabilizers as a method to ameliorate his boredom and antipsychotics. He admitted to abusing during the lockdown period. He used to substance but was very guarded regarding its imbibe nicotine flavored vape but several intake. He also frequently tested negative for days prior to his first psychiatric contact substance although he did admit to the decided to test a new concoction. According occasional use of amphetamines on isolated to him, it was offered by an acquaintance instances. After much effort of rapport who claimed that this form of vape building via a combination of constant contained a special mushroom which offered cordiality, slight humor and indirect more pleasure and gratification than his questioning, he finally revealed that he was regular mix. Shortly after imbibing the new taking hallucinogenic mushrooms on a mixture in which he described as being dark regular basis. He eventually opened up and in color emanating a fishy odor, he started gave details on how he acquired mushroom becoming unwell. He was rambling from an acquaintance that he declined to incessantly when he was brought to the identify. According to him, the mushroom district hospital of Kemaman. Onset of was purchased in a dried form. Desiccation psychosis was very acute on a seemingly made it easy to slice the mushroom into tiny healthy young man. He was very aggressive pieces in which he would fit them into a and the treating doctor had to resort to a huge rounded glass container with a thin strong dosage of sedatives in order to keep tube attached to a funnel. The apparatus is him at bay prior to transport to our center. called a ‘bong.’ The mushroom would then He quickly regained consciousness and had be burned within the glass chamber which to be given physical and chemical restraint serves a dual purpose of facilitating on a regular basis as he was confused and combustion and concentrating the vapors agitated, spitting on the staffs who attended generated. He would then inhale the fumes to him. He was very paranoid and was via a small funnel which was directly convinced that people were indeed trying to attached to the main hub. Mr A added that capture him. ECG revealed premature he would feel a surge of euphoria after ventricular contraction (PVC) and his imbibing the fumes of the burnt mushroom thyroid profiles were slightly raised. Urine but did not report any forms of perceptual for drugs however was negative. Owing to disturbance. He refuses to quantify the his poor oral intake, aggression and poor amount and frequency of his intake, response to antipsychotics, the team was dismissing our questions by saying considering electroconvulsive therapy. ‘whenever he felt bored.’ There appears to However the next morning his psychosis had be no form of physical or psychological subsided. He was orientated to his bearings and could not provide an account on what MJP Online Early 02-10-21 had transpired. He vaguely remembered Discussion events that occurred prior to the event such as indulging in the new mysterious vape. He The use of hallucinogens amongst the local could also briefly remember being populace of Terengganu is on the rise and is surrounded by the concerned faces of a cause of worry. A common challenge attending doctors and jested that he faced by psychiatrists treating these cases is transiently believed himself to be of royal the fact that most hallucinogen users rarely blood. Miraculously, even the PVC on admit to their behavior let alone realize electrocardiogram recordings spontaneously consequences of their actions. normalized and he was discharged well. In addition, hallucinogens are not readily Case Report 3 detectable by rapid test kits, giving it an evasive nature both to the effort making a This is a report of Mr C who is a Malay diagnosis and to the law [3]. It is only male in his 30s who had multiple episodes detectable via more sophisticated measures of admission to our hospital. He was such as chromatography and detailed suffering from mild to moderate intellectual biochemical analysis; which is cumbersome disability and was only able to perform and not carried out in the event of a menial chores to earn a living. Although he psychiatric emergency [4]. lives with his family, he used to wander around the village where he got into bad Physicians and psychiatrists alike would be company. Each time, Mr C would be perplexed as these patients would present brought to us with sudden outbursts of with rapid onset of vivid hallucinations and anger. He would scream and smash things unexplained hostility, subsiding as quickly around his home. His family admits that he as it began [5]. Multidisciplinary team had an odd personality of being aloof most would then embark on a laborious endeavor of the time but rarely encountered such of elucidating the cause, ranging from a destructive behavior. Mr C admits that he barrage of blood investigations, urine for was experiencing vivid visual hallucinations drug tests to computerized imaging to rule which would make him confused. At times out more sinister differentials such as the he finds it difficult to orientate himself to his possibility of an epilepsy or meningitis. This surroundings as his perceptions was indirectly takes a toll on valuable resources distorted. His urine for drugs tested negative in the long run; resources better diverted to and other vital parameters were more important causes like rescuing a unremarkable. However, after several days genuinely ill patient. of being treated with antipsychotics, he recovered and admitted to the act of If its elusive nature was the first challenge, smoking mushroom. He gave details of how then the next would be the fact that several he prepared mushroom slices in which he hallucinogen abusers also carry a dual acquired from his friend. He would heat the diagnosis as with the case of Mr A who ingredients in a bong, similar to the suffers from bipolar mood disorder, and Mr technique described by Mr A. Unlike Mr A, C who suffers from intellectual disability. his hallucinations were more pronounced. Hallucinogens are known to aggravate He described being able to see disturbing psychosis from individuals who are already images of devils and vicious looking susceptible to them and aggravate mood animals that caused him great distress. symptoms. ‘Bad trips’ is a terminology MJP Online Early 02-10-21 coined for the paradoxical reaction to From a logistic point of view, Terengganu hallucinogens where the user feels an encroaches upon the southern border of unpleasant rush instead of their regular Thailand. There is a possibility of active euphoric state which may explain irritability substance trade ongoing within the vicinity in most mushroom users [6]. The current [9]owing to its close proximity and the mainstay of treatment is a combination of dense jungle surrounding the region further supportive treatment, antipsychotics and serves to conceal this ongoing sinister trade tranquilizers to reduce the levels of [10]. Other identified entry points are aggression and agitations besides facilitating neighboring states such as and the recovery from intoxication and Gerik at [11]. withdrawal periods [7]. The psychiatric team of Hospital Sultanah The authorities may have difficulty in Nur Zahirah is currently working with the curbing the distribution of hallucinogens as National Anti Drug Agency (AADK) to help well. Dried mushroom may resemble curb the usage of psychedelic compounds domestic herbs of trade and may be amongst the local populace. To examine the dismissed by authorities during raids. Some increase in trend of psychedelic mushroom are even powdered for ease of storage and usage over the past 6 months ranging from can be cut into paper thin slices which are January to June, refer appendix below. readily concealable yet conveniently smoked when the urge arises [8].

Table 1. Increase in total number admission per month due to psychedelic mushroom intoxication from January to June in year 2021

MJP Online Early 02-10-21

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Corresponding Author Dr Chong Siew Koon Psychiatry and Mental Health Hospital Sultanah Nur Zahirah Kuala Terengganu, Terengganu, Malaysia

Email: [email protected]