CP_1106_CASES.FinalREV 10/17/06 4:14 PM Page 132 Current p SYCHIATRY CASES THAT TEST YOUR SKILLS Mr. J is disoriented and seeing ‘visions.’ His psychiatric history suggests a substance use disorder, but a drug screen is negative. How would you diagnose him? The consequences of sipping ‘tea’ Melissa Buboltz, MD ® SahanaDowden Misra, MD Health MediaLinda Ganzini, MD, MPH Resident Assistant professor Professor Department of psychiatry Associate residency training director Departments of psychiatry CopyrightForDepartment personal of psychiatry use only and medicine Oregon Health & Science University, Portland HISTORY: A 'NEGATIVE' VIEW trist, who has prescribed citalopram, 40 mg/d, for r. J, a 50-year-old native of Fiji, has had depres- depression and clonazepam, 1 mg three times daily, M sion and substance abuse disorder for more for related anxiety symptoms. than 10 years, marked by irritability, poor sleep, The patient is disoriented and inattentive during hopelessness, and suicidality. He also suffered a the mental status examination. His cognitive deficits traumatic brain injury in the military 25 years ago. fluctuate in severity; at times he is aware of his sur- Police bring Mr. J to the ER after they find him roundings, then suddenly loses this awareness. wandering near traffic and speaking incoherently. Vital signs are stable. Physical exam shows Mr. His feet and hands jerk on the way to the hospital, J is approximately 30 lb underweight (97 lb) with a leading police to suspect that Mr. J has suffered a body mass index of 16.9 kg/m2—nearly 2 kg/m2 grand mal seizure. below normal. He says he has been skipping meals In the ER, Mr. J appears confused, has visual because of poor appetite. He also has strikingly hallucinations, and moves his hands and feet invol- lizard-like, scaly skin. untarily. His head and arms move erratically during Urine drug screen shows no signs of recent the ER psychiatrist’s interview, and he says that his alcohol or substance abuse. Complete metabolic pelvis is arching forward and preventing him from profile shows elevated liver enzymes, suggesting walking steadily. The day before, he says, he saw alcohol or illicit substance toxicity, medication toxic- frightening “visions” of a being who looked “like a ity, hepatitis, thyroid disorder, muscle disease, or a photo negative.” rare liver condition. EEG shows mild encephalopa- Mr. J has been seeing an outpatient psychia- thy but no ictal activity. 132 VOL. 5, NO. 11 / NOVEMBER 2006 For mass reproduction, content licensing and permissions contact Dowden Health Media. CP_1106_CASES.FinalREV 10/17/06 4:14 PM Page 133 Current p SYCHIATRY Mr. J suffers from: a) substance intoxication/withdrawal How would you b) seizure disorder handle this case? c) depression with psychotic features d) substance-induced delirium Visit www.currentpsychiatry.com to input your answers and compare them with e) substance-induced psychotic disorder those of your colleagues The authors’ observations Although the test results narrow the differen- Our psychiatric differential diagnosis is broad: tial diagnosis, we still have to consider numerous • visual and auditory hallucinations are con- medical conditions that can cause delirium, such current in numerous disorders, including as trauma, cerebral vascular accident, intracerebral schizophrenia and depression masses, CNS infection, and inflammatory disease. • visual hallucinations alone suggest demen- tia, delirium, or psychosis resulting from a medical condition, medication, or sub- Which tools could help clarify Mr. J’s stance(s) of abuse1 diagnosis? • Mr. J’s past head injury increases his risk of a) additional laboratory testing dementia and delirium b) imaging • his abrupt symptom onset and inattention c) collateral information suggest delirium. Police feared that Mr. J suffered a seizure dur- ing transport to the ER, but EEG shows no ictal HISTORY: COLLATERAL CONTRIBUTIONS activity. Also, his abnormal motor movements e refer Mr. J for lumbar puncture to rule out appear choreoathetoid, alternating between brief, W CNS infection and MRI to rule out tumor, rapid, involuntary movements (chorea) and slow, abscess, or other structural brain abnormalities that continuous, writhing movements (athetosis). could cause seizure. Results are unremarkable. Choreoathetosis can result from: We then speak with Mr. J’s outpatient psychia- • medications such as stimulants and levodopa trist, who reports that Mr. J has had no residual • toxins cognitive impairment from his head injury. She • systemic diseases such as systemic lupus adds, though, that he often develops cognitive erythematosus, thyrotoxicosis, or stroke problems after consuming large amounts of a tradi- • degenerative brain diseases such as tional South Pacific beverage containing kava (Piper Huntington’s disease methysticum). She explains that Mr. J socializes • or focal brain diseases such as tumors.2 with fellow Fijians who drink kava at gatherings, Given Mr. J’s substance abuse history, we and that he often drinks kava to excess. She attrib- strongly suspect a substance-related disorder utes his dry, scaly skin to excessive kava use. despite the negative urine drug screen. Alcohol Upon questioning, Mr. J says he consumes withdrawal is unlikely because his vital signs are about a half-pound of kava root per day. He says he stable, and the negative drug screen rules out uses the root to make a tea-like beverage that, like benzodiazepine withdrawal. alcohol, induces euphoria and relaxation. He says VOL. 5, NO. 11 / NOVEMBER 2006 133 CP_1106_CASES.FinalREV3 10/19/06 9:27 AM Page 134 CASES THAT TEST YOUR SKILLS The consequences of sipping ‘tea’ • Mr. J’s cognitive symptoms are more severe Box than those caused by kava intoxication Kava: A popular alternative • his psychotic symptoms occur only when to prescription anxiolytics he is delirious • his disturbed consciousness, cognitive, Kava, extracted from the roots of Piper methysticum, acts as a muscle relaxant, and perceptual disturbances and the tem- anesthetic, and anxiolytic.5 It is among the poral relationship between symptom most commonly used alternative treatments onset and massive kava use match DSM- for psychiatric symptoms, with sales estimated IV-TR criteria for substance-induced at $17 million in the United States in 2004.6 delirium.4 Kava lactones, the pharmacologically Cultural use. Although Mr. J’s kava consumption active components of kava, might act via constitutes abuse, people in some cultures ingest several pathways, including GABA-A receptor herbal substances as part of spiritual or social ritu- 7 binding and dopaminergic antagonism. This als. Fijians, for example, commonly drink kava at GABAergic CNS activity affects similar receptors as do benzodiazepines and produces social gatherings or ceremonies. kava’s anxiolytic effects. Being aware of cultural customs and beliefs Kava is available in health food stores as in your practice area can alert you to herbal sub- capsules, tinctures, and fluid extracts and can stance use in various populations, such as kava be obtained without a prescription. The by patients from the South Pacific or echinacea, amount of active ingredient varies greatly goldenseal, and burdock by some Native from preparation to preparation. Americans (see Related resources). Medicinal use. Patients often use kava and other herbal supplements—including fatty acids, gink- he began doing this in his youth back in Fiji, and go biloba, ginseng, St. John’s wort, valerian, and now drinks “many cups” of kava per day. others—with or instead of prescription drugs to Mr. J states that his current episode of strange alleviate psychiatric symptoms. Complementary movements and visual hallucinations began hours and alternative medicine practitioners use kava to after he drank several cups of kava the day before treat anxiety, for example (Box). police brought him to the ER. He considers his Anxiety and depression are among the most new psychiatric symptoms Jesus’ punishment for common reasons persons seek complementary or drinking kava. alternative treatment. In a national survey, 57% of respondents who suffered “anxiety attacks” and 54% of those with “severe depression” The authors’ observations reported using such therapies.8 Nearly 1 in 5 per- Mr. J’s persecutory delusions suggest that he does sons who take prescription drugs also take herbs not fully associate his symptoms with excessive and/or high-dose vitamin supplements.9 kava use, but his abnormal movements, weight Herbal products have been shown to cause loss, skin changes, liver function abnormalities, adverse effects (Table 1).10 Kava, for example, has and mental status changes are known adverse been associated with hepatotoxicity, dermopathy, effects of kava.3 We diagnose substance-induced movement disorders, GI disturbance, and weight delirium rather than substance intoxication or loss. Standardized extracts such as capsules and substance-induced psychosis because: tinctures appear more likely to cause adverse 134 Current VOL. 5, NO. 11 / NOVEMBER 2006 p SYCHIATRY CP_1106_CASES.FinalREV3 10/19/06 9:27 AM Page 135 Current p SYCHIATRY Table 1 Possible adverse effects of herbal supplements used for psychiatric symptoms Medication Psychiatric uses Adverse effects Fatty acids Depression, mania GI upset 5-HTP Depression, anxiety Agitation, ataxia, blurred vision, bradycardia, (5-hydroxytryptophan) dyspnea, eosinophilia, headache, hypotension, insomnia, mania, psychosis, tremulousness Ginkgo Cognitive Bleeding, dizziness, GI upset, headache, (Ginkgo