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