Cases That Test Your Skills A case of returning psychosis Mallika Lavakumar, MD, Steven J. Garlow, MD, PhD, and Ann C. Schwartz, MD In the ER, Ms. Y is agitated, violent, and aggressive. She received care How would you for psychotic symptoms 30 years ago, but had been healthy until she handle this case? Visit CurrentPsychiatry.com had a similar episode 6 months ago. What triggered her psychosis? to input your answers and see how your colleagues responded CASE Agitated and violent forearms. She is cooperative but claims to have Police bring Ms. Y, age 42, to the emergency room no recollection of the events leading up to her (ER) after her boyfriend calls 911 because she is admission. Her speech is soft with a lack of spon- physically aggressive. The police note that the taneity, and she demonstrates substantial psy- home is in disarray and several windows are bro- chomotor retardation. Her mood is irritable and ken. Ms. Y is threatening and violent—she bites affect is restricted. She has a latency of thought and spits at her boyfriend and the police. The ER and difficulty recalling basic historic information. assessment reports that she is “agitated, confused, Ms. Y appears confused and frequently responds and not making sense.” She receives IV haloperi- to questions with “I don’t remember.” She seems dol, 5 mg, for agitation and aggressive behavior, frustrated and distressed by her inability to an- but does not improve and receives a second dose swer questions. She denies suicidal or homicidal of haloperidol approximately 1 hour later. ideation and auditory or visual hallucinations, al- On examination she is afebrile. Laboratory though she appears to be responding to internal results are notable for elevated blood urea nitro- stimuli. We cannot complete a Mini-Mental State gen (27 mg/dL) and creatinine (2.3 mg/dL), sug- Exam because she becomes uncooperative. Af- gesting renal failure. Her white blood cell (WBC) ter 10 minutes, Ms. Y ends the interview, stating count is elevated at 14.7 K/µL with increased that too much is being “demanded” of her. neutrophil count. Her creatine phosphokinase (CPK) also is elevated at 2,778 U/L. Other lab re- sults, including liver function tests and a rapid What is the likely cause of Ms. Y’s agitation? plasma reagin, are within normal limits. Urinaly- a) psychotic disorder sis reveals WBC >50 and leukocyte esterase 3+ b) drug intoxication WBC/µL. Urine drug screen is negative for barbi- c) delirium turates, benzodiazepines, opiates, and cocaine d) personality disorder and her blood alcohol level is <10 mg/dL. She is overweight, but not obese. Ms. Y is admitted to the medical service for workup of rhabdomyoly- The authors’ observations sis and altered mental status. Ms. Y’s acute-onset agitation and confusion When the psychiatric consultation-liaison could be caused by an infection, such as a (CL) service evaluates Ms. Y 12 hours after pre- sentation, she is disheveled, drowsy, and lying in Dr. Lavakumar is Chief Resident, Dr. Garlow is Associate Professor, and Dr. Schwartz is Assistant Professor, Department Current Psychiatry bed, with multiple superficial lacerations on her of Psychiatry, Emory University School of Medicine, Atlanta, GA. Vol. 10, No. 1 51 Cases That Test Your Skills Box Carnitine: Supplementation usually isn’t necessary arnitine is derived from an amino acid valproic acid and carbamazepine, can reduce Cand found in nearly all cells of the carnitine blood concentrations.2 body. “Carnitine” is used to refer to several Because of its role in fatty acid oxidation, compounds, including L-carnitine, acetyl-L- carnitine often is promoted as a weight loss carnitine, and propionyl-L-carnitine. The natural aid. In addition, it is purported to improve form and the only one with biologic activity exercise performance and enhance well-being.3,4 is the geometric isomer L-carnitine. Most However, there is no consistent evidence that endogenous L-carnitine is derived from diet— carnitine supplements can improve physical meat and dairy are the primary sources—and performance in healthy individuals.5 the remainder is synthesized.2-4 At doses of approximately 3 g/d, carnitine Carnitine transports long-chain fatty supplements can cause nausea, vomiting, acids into the mitochondria so they can be abdominal cramps, diarrhea, and a “fishy” body Clinical Point oxidized to produce energy and transports odor. Rare side effects include muscle weakness toxic compounds out of the mitochondria to in uremic patients and seizures in those with a Acute-onset agitation prevent them from accumulating. Carnitine is seizure disorder.2-4 concentrated in tissues that use fatty acids In animal studies, carnitine persistently and confusion could as a dietary fuel, such as skeletal and cardiac increases dopamine outflow in the nucleus muscle.2-4 The body makes enough carnitine to accumbens.6 Dopamine dysregulation in this be caused by a urinary meet most person’s needs and supplementation pathway has been shown to cause psychotic tract infection, a typically is not required. Some drugs, such as symptoms.7 frequent culprit in delirium or transient urinary tract infection, a frequent culprit Medical records reveal that Ms. Y was admit- psychosis in delirium or transient psychosis. Seizure ted to our hospital 6 months ago because she activity with postictal confusion also has was acting violently and combative. She was to be included in the differential, as well as “talking out of context,” “stated that she was an endogenous psychotic disorder such as God,” and had auditory hallucinations. She was schizophrenia or a manic bipolar episode. admitted to the medical service for rhabdomy- Ms. Y’s boyfriend of 16 months indicated olysis, which was thought to be caused by hyper- that Ms. Y uses alcohol but cannot quan- activity or exertion. Ms. Y indicated that she was tify the amount or frequency. We consid- taking food supplements, including L-carnitine, ered and ruled out other intoxicant use as to help lose weight. Her psychotic symptoms a potential cause of her transient psycho- cleared within 24 hours and she was discharged sis. An extended drug screen was negative without any psychiatric medications. Her behav- and her lab values did not suggest heavy ioral disturbance was attributed to ingesting ex- alcohol use. cessive amounts of carnitine supplements, and Ms. Y was counseled to abstain from them. HISTORY Past psychotic episodes Ms. Y’s boyfriend reports that she had 2 psychi- What is carnitine’s purported mechanism for atric hospitalizations approximately 30 years weight loss? ago, which were precipitated by psychotic a) increased energy expenditure symptoms that she developed while abusing b) increased satiety drugs. To the best of his knowledge Ms. Y had c) increased fat oxidation or reduced fat not used these agents recently. He stated that synthesis Ms. Y did not appear to have ongoing psychot- d) increased water elimination ic symptoms and had not received psychiatric treatment since she was a teenager until 6 The authors’ observations months ago. He describes the current hospi- Carnitine is a common dietary supplement Current Psychiatry 52 January 2011 talization as being “just like 6 months ago.” that is advertised as being safe and effec- continued on page 54 Cases That Test Your Skills continued from page 52 Table Psychiatric effects of common weight loss supplements Supplement Psychiatric effects Caffeine Depression, anxiety, agitation, aggression, psychosis10-12 Ephedra* Psychosis, severe depression, mania or agitation, hallucinations, sleep disturbance, suicidal ideation13 Panax (ginseng) Euphoria, mania14 Amino acid-containing drinks Euphoria, hypervigilance, insomnia, verbal and physical aggression, (taurine and inositol) impulsive behavior9,15 Hypericum (St. John’s wort) Mania,16 psychosis17 *FDA removed ephedra from the market in 2003 because of adverse events Clinical Point tive.1 It is purported to increase fat oxidation unclear reasons. At admission, she lives with Given Ms. Y’s personal or reduce fat synthesis; however, no trials her boyfriend, whom she plans on marrying. and family history demonstrate that L-carnitine is effective for Ms. Y says she was taking carnitine to im- of psychosis, we weight loss (Box, page 52).2-7 Evidence from prove her energy and lose weight. She recalls considered that well-designed randomized, controlled clini- that her physicians advised her to discontinue she may have an cal trials indicates that the safe upper limit carnitine supplements, but she continued to take “4 or 5 a day” in an ongoing attempt to lose endogenous psychotic of long-term intake is 2,000 mg/d of L-carni- tine equivalents.8 The data for doses >2,000 weight. When asked about other supplements, disorder mg/d are not sufficient to make a confident Ms. Y reports regularly consuming 16-ounce conclusion on long-term safety.8 energy drinks, including the day before admis- Further evaluation for possible causes sion. The label on this drink lists L-carnitine and of Ms. Y’s symptoms include a chest ra- caffeine as main ingredients. She denies regu- diography and blood and urine cultures, larly drinking other caffeine-containing bever- which are unremarkable. Results of a lum- ages, including coffee, tea, or soda. bar puncture are within normal limits. Computed tomography of the head re- veals confluent periventricular hypoden- The authors’ observations sities compatible with moderate to severe Supplements for weight loss may appeal non-specific white matter disease. to people’s desire for a “quick fix” that is less demanding than diets and increased physical activity. Supplements are available TREATMENT Rapid improvement without a prescription and despite reports Ms. Y’s renal dysfunction resolves within 24 of adverse reactions generally are perceived hours with aggressive hydration and support- as being safe and having few side effects. ive therapy.