Betel Nut Induced Psychosis { Julia Shakh, BA, MD Case . 16 y/o (Shan) Burmese female, recent immigrant from Thai refugee camp, with no past psychiatric history. Family concerned about recent onset (2-3 weeks) behavioral changes, with the only stressor appearing to be Global Regents Examinations. She presented in a grossly disorganized fashion, which, due to her accent and simple use of English, initially appeared to be a significant language barrier. Patient and her family speak a Burmese dialect (Karan), which is seldom available by translator phone. Her brother helped interpret; an official interpreter sent by agency happened to be her neighbor and family friend, and was not fluent in the Karen dialect the patient’s family spoke. There was significant difficulty translating. Patient is a good student, but otherwise struggling to adapt to school and life in the US; struggling with making friends. Since failing her Global Regents examination in English (her only failed subject) her behavior changed. She began staying up all night to study more intensely. She had been refusing to eat, citing lack of appetite. She had been having difficulty sleeping, often staying up all night and leaving the house at 5 AM and returning shortly before sundown. Family reported that this usually obedient child became defiant and oppositional, becoming aggressive when family tried to prevent her from leaving the home in the middle of the night. She had cut her own hair prior to presentation. She had been frequenting the Buddhist temple at night, and was asked to refrain from coming by at night. She has been having command auditory hallucinations (identified as her deceased father), telling her to go swimming in an industrialized (and polluted) waterway near her house, which she would do (without disrobing) in her street clothing. Family report that the patient is the “glue” of the household. Her mother and siblings all work outside the home, and she is responsible for keeping the house tidy, cooking meals, and even wakes at 5AM to prepare breakfast for her family before everyone leaves for work. Family report that she has been neglecting her housework and has been “spitting” in her room such that it is a disgusting mess. Family adamant that the patient does not “do drugs”, ten panel urine toxicology is negative for substances of abuse. MSE . Very petite and appearing very young for her age (10). Wearing a hospital gown, and wrapped in a hospital blanket. Oriented only to herself. Not attentive, engrossed in a drawing she colored in, dripping water on it and smearing it on the table. Grossly disorganized and unable to answer basic questions, volunteering a word salad and smiling sweetly in response. She is not easily redirected, and cooperating very minimally with interview and care on the unit. Past History . Patient has no past psychiatric history. Patient and family deny any pertinent surgical or medical history, that she had developed appropriately as a child, and had never been hospitalized. They add that the patient has not been following with any physician, aside from mandatory immigration health screenings two years prior to presentation. Her father is deceased from complications of chronic alcohol use. She has an older (eldest) brother living in Thailand, who is currently in incarcerated for an unknown offense. He is said to have had similar symptoms as our patient in the past. He chronically uses Thai Stick. THAI STICK Social History . Patient is of Shan (Burmese) descent. She was born in a refugee camp in Thailand, where she lived with her parents and (older) siblings. She was born to married parents, was the byproduct of a healthy pregnancy. Her family speaks Karen, and Thai (with the exception of her mother). Her father passed away several years ago, prior to immigration to the US. His passing affected her disproportionately, as she had been the closest to her father (and had been the only daughter). She completed the 10th grade. She had always been a high achieving student until coming to the US, where her teaching material was taught in Burmese, but tested in English. She had difficulty assimilating and acculturating, had difficulty learning the English language, and despite being quite friendly and social, was having difficulty making friends at school. She lamented that even the Burmese and Burmese-American children did not think she was “cool” enough to make friends. Family continue to insist that the patient does not use any drugs or psychotropic substances, and that she is a “good girl” who upholds traditional values. What may cause tooth staining?... Certain foods (curry/spices , tea, coffee) Habitual chewing of betel nut or tobacco Tobacco smoking Medications (doxycycline) Chromogenic bacteria And further questioning revealed… . That her mother was at one time heavy betel nut user (as was her deceased father). Conflict over cessation of the use of betel, which was discouraged by a Thai Ministry of Health campaign, nearly caused the patient’s parents to divorce. The patient herself began using betel at an early age, and had been using it heavily (around the clock vs occasionally after socially important/ holiday meals) the weeks preceding her hospitalization. The “spitting” her mother had been annoyed and concerned about, was the red staining alkalinized saliva which is a byproduct of betel chewing. It is considered impolite and offensive to do so indoors. “Burmese Toba(s)cco” . It was quite difficult to question the patient about her use of Betel, as she continued to be disorganized and grossly psychotic, with episodes of acute agitation. It was several weeks before we were able to talk about her habits, and even then there was a significant language barrier, as she did not know the word “betel”. Eventual identification and clarification of her habit involved searching the various words/slang used for betel in various Burmese dialects, and matching this word to her use. She was also asked to describe the common use of this substance, which is easily available here in the US, as it is not a controlled substance. There are various ways to use Betel, and modern methods now include addition of tobacco and flavoring agents that make its use attractive to youth. Hospital Course . The patient is started on Zyprexa. Her hospital course is prolonged, and initially she draws very little benefit from the medication. She requires multiple PRN medications for agitation, aggression, bizarre and disorganized behaviors. She has a preoccupation with water; she tries to abscond from the unit, pleading to be discharged. Neuroimaging obtained is unimpressive. Labs are normal. Vital signs were not available until the last week of her hospitalization, due to agitation and non-cooperation. Patient began to improve into her fourth week in the hospital, and was discharged home. She and her family were counseled to avoid betel use. So, what is “Betel Nut” . An estimated 600 million people around the world chew betel quids, which, after tobacco, alcohol, and caffeine drinks, makes them the fourth most commonly used psychoactive substance internationally. It is the nut of Areca Catechu, the Areca Palm. The Areca nut is the source of a psychoactive alkaloid called Arecoline . Arecoline is a powerful muscarinic and nicotinic receptor agonist. In TCM and Ayurveda it is utilized as a powerful antihelminthic, and used to alleviate toothache. Betel Leaf . Piper betle is the leaf of a tropical vine belonging to the Piperaceae family, which also includes pepper and kava. Piper betle flower or leaf contains aromatic phenolic compounds which have been found to stimulate the release of catecholamines in vitro. Used in Ayurveda and TCM to treat headache. Also utilized as a breath freshener, and mouth antiseptic. Widely used in cooking, and believed to have a high nutritious value by many, and regarded as a medicinal herb. Why Chew? Who Chews? What may be found in a betel quid? . Areca nut . Betel leaf . Lime . Catechu (aka Catha) (extract of acacia tree bark used variously as a food additive, astringent, tannin, and dye) . Tobacco . flavorings Lime (Calcium Hydroxide) • Ca (OH)2 is a food additive, most commonly used to preserve/pickle foods. It is responsible for the bright red saliva coloration associated with Betel quid chewing. • Utilized to facilitate hydroxylation of active compounds into more readily absorbed alkaloid forms, particularly for sublingual absorption. • Often made from incineration of coral, even seashells. • Very caustic, and often causes mucosal chemical burns, which with persistent and chronic use cause mucosa to become fibrotic and pre-cancerous. Said to be the predominant carcinogen in Betel Quid. “Taiwanese Chewing Gum” https://www.youtube.com/watch?v=DyKI6UgI 1Jk Vietnam: “Matters of Betel and Areca”: • “Matters of Betel and Areca”: said to be a phrase that is synonymous with love and weddings. • This is due to the large part Areca and betel leaves have in Buddhist ceremonies (used as offerings), thus also marking their ceremonial importance in weddings. • A wedding cannot occur without the presence of Areca and Betel, and many elaborate arrangements of Areca and Betel leaves are made for weddings. Vietnam . Although less common today, marriages were typically arranged in Vietnam. For a traditional wedding, it is customary for the groom’s family to visit the bride’s home with a gift of Betel nuts, and officially ask permission to receive the bride. After introductions, socializing, and the groom’s and bride’s parents chewing betel and discussing arrangements, the wedding would finally be confirmed and announced. Betel chewing is an important social pastime, and clearly, in the case of arranged marriages, provides a way to make a stressful event more pleasant. Tan and Lang Tan and Lang were (twin) brothers. Lang was in love with a beautiful young woman named Lu, who was the most beautiful woman in the village, and also was in love with Lang.