Cases That Test Your Skills

A young man’s ‘trips’ to heaven and hell

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Mr. F hears voices from Jesus and Satan. He has schizophrenia and is addicted to dextromethorphan in cold medications. Which problem is causing his auditory hallucinations?


 

References

CASE: The man from Betelgeuse

Mr. F, age 33, has been hospitalized repeatedly for psychotic episodes after abuse of dextromethorphan in cold medications.

Approximately 1 week before presenting to us, Mr. F stormed out of his house after his father, with whom he lived, confronted him about spending his allowance on cold medications. He spent the week living on the streets, abusing dextromethorphan whenever he could get it.

One night, Mr. F approached a police officer at an accident scene and exclaimed, “Dude, I’m from the planet Betelgeuse.” He appeared disorganized as police questioned him, and officers transported him to the county hospital’s psychiatric emergency service.

At presentation, Mr. F is at times silly, irritable, and sleepy, and chants incantations during the intake interview. Alternately, he hears Jesus Christ and aliens from Betelgeuse telling him “everything is going to be cool” and voices of aliens threatening to abduct him.

We admit Mr. F to the inpatient psychiatric unit, start risperidone at 2 mg nightly, and titrate it to 6 mg nightly over 3 days, after which he is significantly more organized with reduced auditory hallucinations. At discharge 6 days later, he still occasionally hears Jesus but has partial insight into his obsession with aliens and no paranoid delusions. We continue risperidone, 6 mg nightly, and refer him to an outpatient mental health program. He visits the clinic once but avoids the attending psychiatrist.

Five days later, Mr. F begins hallucinating at home and his father brings him back to the emergency psychiatry unit. At presentation, the patient claims to be an agent of Satan and waves his arms wildly while performing “black magic.” He believes he is damned and that previous messages he thought came from Jesus and extraterrestrials were instead from the devil.

Mr. F’s father reports that over the weekend his son ingested 6 boxes of cold medicine—each with 16 tablets containing 30 mg of dextromethorphan. Peeling skin on the lower part of Mr. F’s forehead, the bridge of his nose, and under his eyes suggests chronic cold tablet abuse. We re-admit the patient after extended urine drug screen shows traces of chlorpheniramine.

The authors’ observations

Routine urine drug screens based on radio-immunoassay detect many substances, but an extended or comprehensive urine drug screen based on gas chromatography-mass spectrometry is needed to detect dextromethorphan.1 Tertiary hospitals and reference laboratories usually offer these tests.

An extended urine screen will not detect dextromethorphan 24 hours after use because the agent has a 3- to 11-hour half-life. The test can, however, detect other active cold preparation compounds with longer half-lives, such as chlorpheniramine.

If extended urine screening is not available, clinical findings discussed later in this article can confirm recent cold medication abuse. Blood testing can reveal dextromethorphan levels, but a 3- to 6-mL sample may be needed.

HISTORY: ‘Sick’ at 16

Mr. F began abusing dextromethorphan at age 16, when friends would “turn him on” to 8-ounce bottles of cough syrup every other week. He later tried marijuana, cocaine, phencyclidine, methamphetamine, morphine, and LSD. Soon after graduating from high school, he stopped using substances and remained clean for several years.

At age 25, Mr. F suffered his first psychotic break, after which a psychiatrist diagnosed schizophrenia. Initial symptom control with antipsychotics helped him finish college.

Mr. F worked as a restaurant manager for about 4 months but found the job stressful and constantly argued with staff. He resumed abusing cough syrup to relieve his stress but soon became hooked on its dissociative and hallucinogenic effects. One night he ingested enough cough syrup to remain “high” until the next morning. He was hallucinating when he reported to work that day and was fired.

Since then, Mr. F’s cold medication abuse has escalated from biweekly to almost daily at presentation. He switched to tablets because the syrup induced cold symptoms and he finds the “buzz” from the tablets easier to control.

He typically dresses in black (in keeping with his satanic obsessions) and wears a long black overcoat with several pockets, that allows him to carry boxes of cold capsules, books, and other items.

Mr. F’s father has repeatedly tried to stop his son’s cold tablet abuse by cutting off his allowance. Dextromethorphan-containing cold medications are inexpensive, however—a box of 16 30-mg tablets costs as little as $1.50. Also, Mr. F often would get money for cold capsules by going to malls and participating in market research surveys.

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