'Ecstasy' Psychosis and Flashbacks That the Use of Propranolol F.J

J

MANIA SECONDARY TO THYROTOXICOSIS 713

_rio, Canada L8N 3ZS; · No psychotropic medications were used. At nine-months superior to other beta-blockers which have a selective ,epartment of Psychiatry, follow-up, when kept on propylthiouracil (50 mg/day), she peripheral action, especially in hyperthyroid patients Harvard University, weighed 50 kg and was well. with conspicuous mental symptoms. )SA; Michael F. Mazurek, of Neurology, Depart- Discussion References zd Biomedical Sciences, The evidence for thyroid state playing a role in mood AMEmCANPSYCHIATRICASStX:_TXON(1987) Diagnostic and Statistical edical Centre, Hamilton, disorders has increased rapidly in recent years. Manual ofMentaIDisorders(3rd edn, revised)(DSM-III-R). Clinical manifestations of hyperthyroidism are Washington, DC: APA. generally believed to be due to a synergistic ENmcorr, J., SmTZEa, R. L., FLEISS,J. L., et al(1976) The Global Assessment Scale. A procedure for measuring overall severity interaction between increased serum levels of thyroid of psychiatric disturbance. Archivesof General Psychiatry, 33, hormones and excess catecholamine stimulation. 766-771. Whybrow & Prange (1981) hypothesised that thyroid H^MtLrON,M. (1959) The assessment of anxiety by rating scales. hormones modulate central adrenergic response to British Journal of Medical Psychology, 32, 50-55. catecholamines in a manner analogous to that in HONtaFELO, G., GILLIS, R. D. & KLETT, C. J. (1966) NOSIE-30: A treatment sensitive ward behaviour scale. Psychological peripheral tissues. Accordingly, hyperthyroidism is Reports,19, 180-182. believed to augment the ability of beta-adrenergic KLE,._.I., TRZ£VACZ, P. T. & LEVEr, G. S. (1988) A symptom receptors to receive stimulation by noradrenalin, and rating scale for assessing hyperthyroidism. Archives of Internal Medicine, 148, 387-390. J and CHAR-NIE CHEN predisposes an individual to mania in accordance w,v,aow, p, C. & PRANCE,A. J. (1981)A hypothesisof thyroid- with the catecholamine theory of mood disorders, catecholamine-receptor interaction. Archives of General This state of supersensitivity may have developed in Psychiatry,38, 106-113. ,lc 1 this patient because of the delay in treatment of her YOUNG,R. C., BIGGS, J. T., ZIEGLER, V· E., etal (1978) A rating scale for mania: reliability, validity and sensitivity. British ;e to drug therapy obscure thyroid disorder· The sequence of rapid Journal of Psychiatry,133,429-435. Off Pr0pranol01 Propyl- ; mental changes suggests central adrenergic blockade Zaou, H. H., KOSHAKJI, R. P., SILBERSTEIN, D. J., et al (1989) ropranolol thiouracil by propranolol, which readily penetrates the brain. Racial differences in drug response - altered sensitivity to and The presence of residual symptoms which only clearance of propranolol in men of Chinese descent as compared 1514 196 1800 cleared after antithyroid drug therapy indicates that with565-570.Americanwhites.New England Journal of Medicine, 320, 32 4 0 the therapeutic effect of beta-adrenergic blockade by 27 14 2 propranolol was incomplete. Full recovery required Sing Lee, MRCPsych, Lecturer, Department of 15 70 85 the addition of propylthiouracil, which acts more Psychiatry; Chun Chung Chow, MRCP, Senior 41 1 slowly by inhibiting the synthesis of thyroid hormones. Medical Officer, Department of Medicine; Y. K. Despite the obvious limitations of a single-case Wing, MRCP, Lecturer, Department of Psychiatry; Mania GeneraliSedanWellxiety study, this case underscores the clinical importance C.M. Leung, MRCPsych, Lecturer, Department of disorder of carefully excluding hyperthyroidism in psychotic Psychiatry; Helen Chiu, MRCPsych,Lecturer, Depart- patients. Even though very large doses of pro- merit of Psychiatry; Char-Nie Chert. FRCP,,ch. 3caletrange0-4-0,eumvro,O< 5t. pranolol (200-2000 mg) have been suggested for Professor, Department of Psychiatry Chinese effective antimanic therapy (Whvbrow & Prance. nge0-60) _¥ounget al, 1978). - - University of Hong Kong, Shatin, .¥T, Hong orAnx,etv(range0-561(Ham((ton, 1981), Chinese people may be more sensitive to the Kong drug (Zhou et al, 1989), and a relatively low dose

ale (range 0-901 {Endicott et al, , may be sufficient for considerable control of Correspondence: Dr S. Lee, Lecturer, Department of :ale for In-patient Evaluation (range [ symptoms before antithyroid drug therapy takes its Psychiatry, 1 I/F, Prince of Wales Hospital, Shatin, NT, full effect. Being lipid-soluble, propranolol may be Hong Kong

rding to DSM-III-R criteria; elation, 1987), rating scales

'dlyrbehaviotoxicoursis,ratedmania,byanxiety,nurses 'Ecstasy' Psychosis and Flashbacks that the use of propranolol F.J. CREIGHTON, D. L. BLACK and C. E. HYDE ;nificant improvement of her _t _vithout significant change in ,'hile re-emergence of severe We report three cases of flashbacks and one case of Methylenedioxymetamphetamine (MDMA) is a lowed its withdrawal. Re- recurrent psychosis experienced by three MDMA users, derivative of 3,4,methylenedioxyamphetamine emission of mania, although , We draw the attention of clinicians to the combination of (MDA) and classed as a hallucinogenic amphetamine isted. With antithyroid drug adverse effects observed with this drug of abuse and to (Gilman et al, 1985). As such it is controlled under 100mg t.d.s.) she became the advisability of prolonged treatment should they occur. Class A of the Misuse of Drugs Act 197I. Anecdotal , euthyroid in two months. _ British Journal of Psychiatry (1991), 159, 713-715 reports of the effects of MDMAin low doses speak 1 714 CREIGHTONETAL [ of a sense of well-being, promotion of aesthetic months, although his depot injections were stopped after Ir All three of our patients h; pleasures, and a reduction of social anxiety (Climko four months. Subsequently, over about a month he took [ the same area of Manchest_ druget al, ('ecstasy')1986/87), andin theit becameUS wherea popularit was alsorecreationalused by becamefour furtherrestlessdosesandof wandering,ecstasy. His andfamilyhisreportedspeech becamethat he I MDMArecent publicingestionconcern(Manchat , a some practitioners as an adjunct for psychotherapy incoherent with frequent mention of people plotting against i December 1989). The urine, most alarmingly, was making suicidal threats. He was In our clinical experience, have demonstrated single doses of MDMA cause admitted for a third time and displayed a full range of (Naranjo, 1973). Recently, however, investigators him. He had delusions of reference from the television and, / presumably taken after exc selective damage to serotonergic neurons in monkeys psychotic symptoms from which he made a recovery within ;- 'street' MDMA (which may (Ricaurte et al, 1985). While MDMA has been illicitly a week. Between psychotic episodes he is a warm, friendly [ most resemble those of LSD. ] experienceavailable inof thethe drugUK andfor itsseveraltoxicity years,is limited.clinicalWe deteriorationand sociable ormanresidualwithsymptoms,no evidence of personality I visualafter ingestionillusions twowhilepatientsthe t present a series of adverse psychological reactions paranoid psychosis durin_ to this drug in three subjects, none of whom had a Case 2 intense urges of self-destruc previous or family history of psychiatric illness. Dewhurst & Hatrick (197; A 22-year-old female art student was referred to the tinguishing feature of LSD psychiatric out-patient department by her general practitioner, impulse is sudden, compul,, Case reports She had taken ecstasy on two occasions during a single week, part of a typical depressivt one month before attendance, and at those times she had patients, without prompting Case I thought shewasGod and hadbeendancingwiththe Devil. She also experienced frightening visual illusions, describing delayed sequelae of their dru: ',, definedby Strassman(198 A ~,-year-old man was brought to casuahy in a very the faces of other people becoming evilly distorted. Over aroused state, having miured himself by twice umping into the subsequent weeks she experienced frequent flashbacks. _ taneous recurrences of p the path ot oncoming traffic. He was initially uncooperative lasting for less than a minute, during whicl_, laces again appearing after a period o with psychiatric examination and his dislocated shoulder became contorted and menacing, and she suffered intense psychedelic drug experience, required setting under general anaesthesia, after which he fear and somatic symptoms of anxiety, istic reaction to LSD and slept for nearly 24 hours. He then told us that for the past The patient had used cannabis regularly in the recent past of users (Strassman, 1984) four months he had been taking 'ecstasy' between four and and in her teens occasionally used lysergic acid diethylamide suffered a recurrence of his seven times a week. During the week before admission he (LSD), heroin and amphetamines, without experiencing free of symptoms and, allegt had come to believe that certain people with whom he had similar symptoms. She denied any substance abuse since a fight were trying to kilt him. He became increasingly taking the ecstasy tablets. At interview there were no mental- The occurrence of delayed p hostile towards his girlfriend, who reported he behaved state abnormalities, been highlighted by Dewhu,, bizarrely- stridingabout theflat nakedwithramblingand may well represent the actix incoherent speech. On the day of admission he said it had predisposition (Strassman, Ic suddenly occurred to him that it would be preferable to Case 3 the subsequent presentatio kill himself rather than be killed. A 17-year-old female student was referred to the psychiatric induced psychosis must sugt No definite abnormalities were found at mental state out-patient department by her general practitioner. She had Other aspects of our first c examination on the day after admission, although recall been given a tablet of ecstasy at a party which caused her amphetamine abuse- he usec for recent events was poor. He denied use of any other drugs to feel 'high' and to have visual illusions in which people's a long period for its euphori apart from moderate but prolonged use of cannabis. Our faces melted. On leaving the party she was abducted and psychosis responded rapidly ' diagnosis was of a drug-induced psychosis; we offered no raped by the man who had given her the drug. When she These clinical observatio_ specific treatment and the following day the patient took managed to reach a police station she felt people were his own discharge. A urine specimen (taken more than two laughing at her and that it was a false police station psychopharmacology of th days after his last reported dose of MDMA) failed to reveal belonging to her attacker. _ cations for treatment. Unlike amphetamine or its derivatives, but confirmed cannabis use. In the subsequent three months she had experienced which generally clears wit Two months later the patient presented again. Although frequent episodes in which she felt intense fear and the chosis may require prolonger he denied the use of any drugs except cannabis, he had features of people's faces melted and became horribly theuseofelectroconvulsivetl noticed the pleasurable effects of MDMA could spon- deformed. These flashbacks were accompanied by marked has been recommended in it taneously return for up to two hours. Additionally, after somatic symptoms of anxiety. Hatrick, 1972). However, fl four weeks entirely free of other symptoms, his ideas of There was no past history of substance abuse. She had bated by chlorpromazine persecution had gradually returned. These were accompanied a very disadvantaged upbringing and had been physically ameliorated by haloperidol by subjective confusion, bizarre ideas of reference, a sense and sexually abused by her father. However, at interview of guilt for a nameless crime, and the reappearance of ideas she presented as a cheerful and pleasant girl without the latter would, therefore, s, of self-harm. He looked more subdued and perplexed than abnormalities in the mental state relating to her sexual of choice (Gilman et al, 1c previously and his speech was vague, with long pauses, traumas and experiences. Threeseparateurinesampleswerefreeof any drugsof abuse. The patient was admitted to hospital and treated with Discussion trifluoperazine(5 mg b.d.). His symptomsremittedover I a few days and his mood improved. He accepted depot Our patients' description of the drug, its effects and '_ fiupenthixol and remained free of symptoms for eight price all corresponded with either MDA or MDMA. ( 'ECSTASY' PSYCHOSIS AND FLASHBACKS 715

)t injections were stopped after · All three of our patients had obtained the drug in Many young people may have used ecstasy but the y, over about a month he took the same area of Manchester where there has been number of reported serious adverse reactions is _sy.His family reported that he recent public concern at a death associated with relatively small, even in American studies (Petrouka, tering, and his speech became MDMA ingestion (Manchester Evening News, 8 1987). Further, clandestine drugs may have con- ention of people plotting against [ December 1989). The urine specimens in case 1 were taminants with separate toxic effects which cannot tking suicidal threats. He was fferenceand displayedfrom theatelevisionfull rangeand,of 1 presumablyIn our clinicaltakenexperience,after excretionthe unwantedwas complete,effects of beWe,ruledhowever,out inreportthese ourreportsexperience(Noggle fromet al,an1985).area a,hich he made a recovery within 'street' MDMA (which may well include contaminants) in which the use of ecstasy is common, which has : episodes he is a warm, friendly most resemble those of LSD. In the period immediately caused concern; this report does not aim to be no evidence of personality J after ingestion two patients experienced disturbing alarmist, but to stimulate further reports and ,ymptoms. visual illusions while the third suffered an acute research in a British context. paranoid psychosis during which he developed intense urges of self-destruction. This latter feature References Dewhurst &Hatrick (1972) mention as one dis- student was referred to the tinguishing feature of LSD psychosis: "the suicidal ASRA"AM,H. D. {1983) Visual phenomenology or' the LSD tment by hergeneral practitioner, impulse is sudden, compulsive and not necessarily tlashback. Archivesof GeneralP_vchiatrv.40. 884-889. n0ccoccasions, and at dufingathose timessinglesheweek,had · part of a typical depressive syndrome". All three tumid,Ecstasy:R.aP.,reviewROEHRICII.of MbAH.,andSWI_I_NE¥.MDMA.D.IntR..ernationalet al(1986Jou/rnal871 ad been dancing with the Devil. patients, without prompting, reported flashbacks as of Psychiatric Medicine,16,359-372. ming visual illusions, describing delayed sequelae of their drug use. These phenomena, Oew.uksr, K. & HArR_C'K,J. A. (1972)Differentialdiagnosisand _ecoming evilly distorted. Over defined by Strassman (1984) as "transient, spon- treatmentPractitionerof209,, ly_rgic327-332.acid diethylamide induced psychosis. _perienced frequent flashbacks, taneous recurrences of psychedelic drug effect G"MAN,A. G., Gt:<)DMAL.N,S., RAt_L,T., eta1(1985)Goodman rote, during which faces again appearing after a period of normalcy following a and Gilrnank ThePharmacological Basis of Therapeutics (7th _acing,and she suffered intense psychedelic drug experience," are a highly character- edn). New York: Macmillan. _s of anxiety, istic reaction to LSD and experienced by 15-77070 Mosbacks.Kowrrz,MilitaryD. {1987)MedicineUseof,136,Haloperid754. olto reduce LSD flash- aabis regularly in the recent past of users (Strassman, 1984). Finally, our first case N.\RANJO.C. (1973)'FheHealirtgJourney. NewYork: Pantheon. 'tamines,¢used lysergicwithoutacid experiencingdiethylamide suffered a recurrence of his psychosis after a period N,xlt;it_,F. T., CLARK,C. R.. DAVENI,I_Rr.F. W., et al (198q) fled any substance abuse since free of symptoms and, allegedly, further drug abuse. Synthesis and identificationof anti toxicityof alpha-benzy[ interviewthere were no mental- The occurrence of delayed psychosis due to LSD has phcnethylamine and alpha benzyl-n-methyl phenethylamine. Contaminants in clandestine prel_arations of amphetamine and been highlighted by Dewhurst &Hatrick (1972) and methamphetamine.Journal- .-Issociatioofrt Official..Irtalvttt'al may well represent the activation of an endogenous Chemists,68. 1213-1222. predisposition (Strassman, 1984), although in our case Ptlrat)uK,x,S. J. {1987)Incidenceof recreationaluse of MDMA the subsequent presentation with a further drug- 317,on an 1542.undergraduate campus. New En.eland Journal of Medictne, tt was referred to the psychiatric induced psychosis must suggest exogenous drug use. RWXuR'rE,G. A., Fo_tNo.L. S., WilsoN, M. A.. et al (1985_ er general practitioner. She had Other aspects of our first case were reminiscent of 3,4-Methylendioxymetamphetamine selectively damages central sV. at a party_ which caused her amphetamine abuse- he used the drug re_atedlv . over ,erotonergic rleurones m nonhuman pr:mates. 5'c'tence--."_), sual illusions in which people's a long period for its euphoriant effect and the initiai ,_16-989. <_IR-\5;SMAN, I_...1. 119841 &dverse reactions to osvcnetlclic drui/s. _egivenpartyhershethewasdrug.abducteWhend andshe t psvchosis' responded rapidly to the druc,_'s withdrawal. \ review ot the literature. Journal r_/ Xerl'ousaria Mental .' station she felt people were _ These clinical observations confirming the mixed Disease. 172,577-595. it was a false police station psychopharmacology of this drug also have impli- cations for treatment. Unlike amphetaminepsychosis, Francis J. Creighton, MRCP, MRCPsych, Senior months she had experienced which generally clears within a week, LSD psy- Registrar, Brindle House, 34 Church Street, Hyde, she felt intense fear and the ' ' chosis may require prolonged hospital admission, and Cheshire SK14 1JJ; Dawn L. Black, PhD, MRCPsych, melted and became horribly the use of electroconvulsive therapy or chlorpromazine Lecturer in Psychiatry, Manchester Royal Infirmary, were accompanied by marked has been recommended in its treatment (Dewhurst & Oxford Road, Manchester M13 9BX; *Clive E. yely.of substance abuse. She had Hatrick, 1972). However, flashbacks may be exacer- Hyde, MD, MRCPsych, Consultant Psychiatrist, nging and had been physically bated by chlorpromazine (Abraham, 1983) but University Hospital of South Manchester, West father. However, at interview ameliorated by haloperidol (Moskowitz, 1971) and Didsbury, Manchester M20 8LR 'ul and pleasant girl without the latter would, therefore, seem to be the neuroleptic ti state relating to her sexual of choice (Gilman et al, 1985, p. 564). *Correspondence

:ussion

t of the drug, its effects and ith either IvlDA or MDMA.