Sudden onset psychosis lasting months

[Poit]

Pt is a 20-something male. A few months ago, "something happened" at work that he can't expound upon. Within one day, he slumped into depression with minimal talking. He became paranoid, responds to internal stimuli, made references to "thought insertion" regarding aliens and demonstrates disorganized speech and behavior. MRI, syphillus and A/I workup wnl. This has been going on for months. What could this be? Can schizophrenia come on this suddenly?

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[Merely]

Yeah it could be schizophrenia, also could be drug induced if he’s taking like bath salts or some **** that doesn’t appear on tox screen

 

[hebel]

Does A/I mean autoimmune work-up? What have you been trying to treat him with, and how's the response been so far?

 

[lyla]

Agree with above. also... Any possibility of partial complex seizures or some other neurological condition?

 

[thumbz]

Caveat - I'm an internist and walking far outside of my wheelhouse here.

Did you screen CSF for anti-hu and anti-nmda? Although incredibly rare, limbic encephalitis can cause an acute psychosis and psychiatric disturbances from damage to the limbic system, and growing evidence seems to implicate the limbic system in some cases of schizophrenia. Did the patient have any evidence of memory loss?

 

[dl2dp2]

I would argue a substantial number of schizophrenia cases have relatively "rapid onset", but if you have good collateral there's usually a proceeding prodrome that's classic.

I would say this is a classic picture of schizophrenia. It's probably schizophrenia until proven otherwise. Obviously other things need ruling out before you can make a full diagnosis.

 

[jbomba]

How long can one conceivably still present psychotic after discontinuing substance (meth) abuse? Have a 30 something female who became psychotic right around the time she started using meth. Hasn't used in 3 months and still psychotic, though improving on SGA.

 

[Merely]

How long can one conceivably still present psychotic after discontinuing substance (meth) abuse? Have a 30 something female who became psychotic right around the time she started using meth. Hasn't used in 3 months and still psychotic, though improving on SGA.

I had a pt not on meth but on “pot” (urine tox positive only for thc) that was probably laced with some other random drugs that urine tox doesn’t test for and was psychotic for 1 month while on the unit being observed and not responding fully to antipsychotics..some of the drugs out there really f u up it seems..after 1 month he improved but damn

 

[clausewitz2]

I would argue a substantial number of schizophrenia cases have relatively "rapid onset", but if you have good collateral there's usually a proceeding prodrome that's classic.

I would say this is a classic picture of schizophrenia. It's probably schizophrenia until proven otherwise. Obviously other things need ruling out before you can make a full diagnosis.

Yeah usually when you have things appearing to go south this quickly you actually have someone who was struggling for a while and just couldn't keep it together any more.

Make some phone calls, they will be tremendously more informative and much cheaper than an MRI or exotic serologies. Find out from someone who knew him well if he had talked about being depressed or anxious. "Anxiety" is the number one chief complaint for people presenting to services who go on to develop frankly psychotic symptoms.

 

[Armadillos]

How long can one conceivably still present psychotic after discontinuing substance (meth) abuse? Have a 30 something female who became psychotic right around the time she started using meth. Hasn't used in 3 months and still psychotic, though improving on SGA.

I’ve seen younger folks get psychotic for several months after allegedly single use of bath salts, synthetic MJ substitutes or ecstasy. Now if only I could travel the multiverse to see what would have happened to them down the road if not for that single time drug use.

 

[splik]

If it walks like a duck, and quacks like a duck...

As mentioned, there could well have been a prodrome with less dramatic symptoms (e.g. withdrawal, day-night reversal, light sensitivity, perplexity, existential angst) as seen in so-called 'schizophreniform' illnesses. Abrupt onset is also seen in manic and mixed affective states where in some cases the level of paranoia and disorganization eclipse the affective disturbance. Also consider the possibility of catatonia. In the absence of catatonia, cognitive dysfunction, seizures, dyskinesias, focal neurology, a flu-like prodrome, or other systemic disturbance the likelihood of this being an autoimmune encephalopathy (does not even sound like he is encephalopathic) or some other neuromedical disorder is low. Abrupt onset is also not consistent with that, where onset is typically subacute. And if you are thinking about a paraneoplastic phenomena etc you better start with a testicular exam and not just doing an LP.

 

[clausewitz2]

How long can one conceivably still present psychotic after discontinuing substance (meth) abuse? Have a 30 something female who became psychotic right around the time she started using meth. Hasn't used in 3 months and still psychotic, though improving on SGA.

I have cited this before, but in the first studies of methamphetamine-induced psychosis from Japan in the 50s the median length of psychosis following last use was about 2 years. This was extremely pure military-grade meth being diverted to the black market and injected IV, but also most of these folks were not using other substances.

 

[FlowRate]

I've seen psychotic depressions (some might say these are usually BPAD) that were quite resistant to treatment. Sudden onset isn't out of the realm of possibility for that diagnosis.

 

[Stagg737]

I have cited this before, but in the first studies of methamphetamine-induced psychosis from Japan in the 50s the median length of psychosis following last use was about 2 years. This was extremely pure military-grade meth being diverted to the black market and injected IV, but also most of these folks were not using other substances.

That’s actually really interesting. I’ve had attendings day they’ve had patients with meth-induced psychosis that took over a year to resolve, but I haven’t heard of that long before (unless it was unmasking an underlying primary psychotic disorder). Are these studies relatively easy to find?

I've seen psychotic depressions (some might say these are usually BPAD) that were quite resistant to treatment. Sudden onset isn't out of the realm of possibility for that diagnosis.

How about when it happens in a 57 year old? I recently had a similar case but more atypical with a lot more ruled out.

 

[Armadillos]

That’s actually really interesting. I’ve had attendings day they’ve had patients with meth-induced psychosis that took over a year to resolve, but I haven’t heard of that long before (unless it was unmasking an underlying primary psychotic disorder). Are these studies relatively easy to find?



How about when it happens in a 57 year old? I recently had a similar case but more atypical with a lot more ruled out.

Is the 57yo a woman? I feel like I see later onset stuff for women enough that it’s not too surprising anymore.

 

[Stagg737]

Is the 57yo a woman? I feel like I see later onset stuff for women enough that it’s not too surprising anymore.

Male, went on a ~week long trip for work the next state over about 7 months ago and per GF came back a completely different person. Denied any events, drug use, illness, etc. on the trip and mentation changed so much that he was fired because he could no longer perform duties. No prodromal signs per GF. Showed up completely flat, suicidal, high anxiety, with paranoia but very specific delusion, and severe speech latency. Previous admission was tried on 2 antidepressants and has now been on 3 antipsychotics with no effect. Extensive labs, CT head, LP, and neuro exam per neuro (consulted) all pan-negative. Neuro psych testing a few months PTA was average for all domains. SLUMS was 23. Previously trialed on Benzos to r/o Catalonia and just made him more sedated. Initial diagnosis was MDD w/ psychosis vs. primary psychotic d/o, but started expanding the differential a lot after failed med trials.

 

[clausewitz2]

Male, went on a ~week long trip for work the next state over about 7 months ago and per GF came back a completely different person. Denied any events, drug use, illness, etc. on the trip and mentation changed so much that he was fired because he could no longer perform duties. No prodromal signs per GF. Showed up completely flat, suicidal, high anxiety, with paranoia but very specific delusion, and severe speech latency. Previous admission was tried on 2 antidepressants and has now been on 3 antipsychotics with no effect. Extensive labs, CT head, LP, and neuro exam per neuro (consulted) all pan-negative. Neuro psych testing a few months PTA was average for all domains. SLUMS was 23. Previously trialed on Benzos to r/o Catalonia and just made him more sedated. Initial diagnosis was MDD w/ psychosis vs. primary psychotic d/o, but started expanding the differential a lot after failed med trials.

What was the character of the delusion? The general theme might be helpful in clarifying. Is he slow-moving generally or just his speech? Sleep patterns? Eating? Does he do anything or just sit around being flat and reporting anxiety?

I recognize there are limits to what you can disclose.

 

[clausewitz2]

That’s actually really interesting. I’ve had attendings day they’ve had patients with meth-induced psychosis that took over a year to resolve, but I haven’t heard of that long before (unless it was unmasking an underlying primary psychotic disorder). Are these studies relatively easy to find?

Looking again at the literature, I find that the median in the earliest published studies in the English-language literature actually have a median duration of 6 months following abstinence, but another paper on a group of them had 49% continuing to experience spontaneous recurrence of acute psychotic symptoms over 15-20 months following last use. I knew I wasn't making up two years.

A place to start is Yui et al. (2000) "Studies of amphetamine or methamphetamine psychosis in Japan: relation of methamphtetamine psychosis to schizophrenia" Ann NY Acad Sci 914.

There is a very comprehensive chapter on stimulants and psychosis in Sachedv and Keshavan's Secondary Schizophrenia

 

[hebel]

Were any of those meds clozapine?

 

[dl2dp2]

You are also missing mental status exams.

I think most likely other differential is some kind of personality disorder, esp. if no evidence of substance use disorder. The psychosis from a neurological condition looks very different vis-a-vis primary psychotic illness.

Medical students typically think about zebras, and don't think about people LIE to you. Whenever symptoms don't fit into a syndrome a key parsimonious answer is the patient is lying. Lying doesn't necessarily need a secondary gain. I've had intakes where I thought okay this is a chronically psychotic person. Then I make a phone call and have the patient show up with parent with a completely different mental status. Final diagnosis: BPD. Some people are good at acting. Doesn't mean the prognosis for severe personality disorder is much better.

 

[calvnandhobbs68]

That’s actually really interesting. I’ve had attendings day they’ve had patients with meth-induced psychosis that took over a year to resolve, but I haven’t heard of that long before (unless it was unmasking an underlying primary psychotic disorder). Are these studies relatively easy to find?



How about when it happens in a 57 year old? I recently had a similar case but more atypical with a lot more ruled out.

Yeah the studies are pretty easy to find if you search online. Again though this was in the context of hardcore regular IV amphetamine use after WWII in Japan but if I remember right about 30% of these guys had pretty long term symptoms even after all amphetamine use was discontinued. Unclear how this relates to smoking meth though.

Edit: Just saw above, guess it was more like 50% haha. I looked this up myself bc we had a discussion of this while I was inpatient at the VA with one of our regular meth users who continued to have some psychotic symptoms for like a month+ after being admitted. Again, it's not clear if this hold with smoking amphetamines as its unclear how the dosages and routes compare.

 

[calvnandhobbs68]

Agree with a lot of people above though, many of these "sudden break" patients that are real deal psychosis are either 1) Drug induced 2) Have some prodromal sx (usually depression/anxiety when talking to family or gradually lower functioning) or 3) Lying.

Also the few months ago at work may have actually been the prodrome if he was just "depressed" at first.

 

[Mad Jack]

I've seen a couple of these and they were both related to synthetic drug use after which the patients never came back to baseline. We've got a lot of synthetics coming out of China into my region and a lot of the time we'll end up with batches of psychotic patients as whatever new batch of chemicals hits the streets. Most of them clear up, but every now and then you get a patient that is just fried

 

[Mad Jack]

That’s actually really interesting. I’ve had attendings day they’ve had patients with meth-induced psychosis that took over a year to resolve, but I haven’t heard of that long before (unless it was unmasking an underlying primary psychotic disorder). Are these studies relatively easy to find?



How about when it happens in a 57 year old? I recently had a similar case but more atypical with a lot more ruled out.

Meth-induced psychosis seems to initially resolve rather quickly, but each time a patient comes in it seems to last a little longer. We've got a few patients that take several days or weeks that used to resolve in a few hours. Probably the result of the accumulation of neurotoxic damage from each episode of psychosis chipping away at their cognitive reserve

 

[Crayola227]

I had an attending tell me that auditory hallucinations with alcoholism is fairly common as far as that goes, and that he'd seen that continue for years, 20+ or indefinitely.

I sort of take for granted that it's possible for any drug that can cause acute psychosis, to cause a more chronic psychosis. You would think the drug-induced psychosis would clear when the drug does, and it usually does, but it's not exactly a rule.