Aripiprazole treatment in a case of amphetamine-induced delusional infestation

Drug-induced Delusional Infestation

It is considered that certain drugs might induce delusional infestation, yet, to date, no studies have been performed to identify the pharmacodynamics associated with these treatments. The aim of this review is to summarize current available knowledge of drug-induced delusional infestation. A literature search was performed for primary studies on suspected drugs reported to induce delusional infestation. Included articles were evaluated systematically using the Naranjo criteria. In addition, drug mechanisms of action were compared. The final selection included 31 studies, in which a total of 26 classes of drugs were identified. Anti-Parkinson drugs were most frequently associated with delusional infestation, followed by antidepressants, antiepileptics, antibiotics, prescription stimulants, and a few other drug groups. The current available literature suggests that the onset of delusional infestation is initiated by drug-induced alterations in neurotransmitter levels, predominantly dopamine, in the central nervous system.

Adverse psychocutaneous effects of prescription stimulant use and abuse: A systematic review

Although rare, psychocutaneous disorders induced by prescription stimulants have been reported throughout the literature. A systematic review was conducted to identify all case reports and case series of prescription stimulant-induced trichotillomania, tactile hallucinations, and delusional infestation. A total of 22 case reports were identified and relevant information was analyzed. Patients presenting with trichotillomania and tactile hallucinations induced by prescription stimulants were typically pediatric male patients being treated for attention deficit hypersensitivity disorder. Symptoms resolved after discontinuation of the offending medication. Patients presenting with delusional infestation secondary to stimulant use or abuse were typically adults who were misusing or abusing stimulant medication. Although symptoms typically improved or resolved after decreasing or discontinuing medication, several patients required the use of antipsychotic medication. While the observational nature of case reports and small number of patients limits meaningful analysis of trends and comparison, this study demonstrates that physicians, especially dermatologists and psychiatrists, should be aware of the potential for prescription stimulants to precipitate adverse psychocutaneous disorders in a minority of individuals.

The effects of alcohol and illicit drug use on the skin

Early identification of cutaneous manifestations of alcohol and illicit drug use can aid in the diagnosis and management of these uses, as well as their sequelae. In addition, the effects of alcohol and illicit drug use on the skin can result in significant morbidity. Alcohol misuse can present with jaundice, pruritus, pigmentary alterations, urticaria, hair and nail changes, and oral changes. It is also a risk factor for skin cancer and infections. Vascular disturbances associated with alcohol misuse include telangiectasias, palmar erythema, caput medusae, and flushing. Diseases related to alcohol misuse include nutritional deficiencies, porphyria cutanea tarda, psoriasis, seborrheic dermatitis, nummular dermatitis, and rosacea. Other conditions seen in alcohol misuse include Dupuytren contracture, Peyronie disease, and pancreatitis. Dermatologists should also be aware of hepatotoxic medications that are commonly prescribed for skin diseases so as to avoid initiating hepatoxicity in patients who use alcohol. Illicit drug use can manifest with cutaneous fibrosis, scarring, granulomas, ulceration, pruritus, infections, cocaine-levamisole-induced vasculitis, tooth decay, and oral disease. By recognizing the cutaneous stigmata of alcohol and illicit drug use, dermatologists can aid in the identification and treatment of patients suffering from these addictions.

Stimulant use in patients presenting with psychocutaneous disorders

BACKGROUND

Psychocutaneous disorders are often attributed to stimulant medications, yet this relationship has never been fully elucidated. Literature on psychocutaneous disorders largely focuses on clinical presentation and treatment rather than disease etiology or exacerbation.

OBJECTIVE

To determine whether patients presenting with psychocutaneous disorders display high rates of stimulant use and psychiatric comorbidity.

METHODS

We undertook a retrospective cohort study of patients with psychocutaneous disorders presenting to a single center. It was hypothesized that these patients would have high rates of stimulant use and psychiatric comorbidity. Following analysis of baseline demographics, the patients were assigned to 1 of 2 groups: those with a psychotic disorder and those with a neurotic disorder.

RESULTS

Sixty percent of the patients (n = 317) with psychocutaneous disease had recently used a stimulant and more than 80% (270 of 317) carried an additional psychiatric diagnosis. The neurotic disorder group (n = 237) was younger and had higher rates of stimulant use. The psychotic disorder group (n = 80) had higher rates of psychosis, medical comorbidity, and illicit stimulant drug use.

LIMITATIONS

The predominantly Caucasian population may limit generalizability of findings as may the retrospective nature.

CONCLUSIONS

Patients with psychocutaneous disease have high rates of stimulant use and most have at least 1 psychiatric comorbidity.

Historical and clinical considerations on Ekbom's syndrome

Ekbom's syndrome represents a relatively uncommon neuropsychiatric condition characterized by the recurrent and bizarre fixed delusional belief to be infested by small organisms or even unanimated materials ('Morgellons disease'), without any objective evidence of infestation/parasitosis. The condition, mainly diagnosed in a nonpsychiatric setting, is supposed to be largely underestimated and, hence, undermanaged. The present comprehensive review aims at investigating Ekbom's syndrome, from a historical, epidemiological, clinical and therapeutic perspective, by providing diagnostic-treatment strategies in managing this condition in routine psychiatric clinical settings. The prototypical patient is a middle-aged woman (or a younger subject in those cases in which substance and/or alcohol abuse is implicated), often single, divorced or widowed (loneliness component and social withdrawal), who has already consulted several specialists due to skin lesions associated with a firm and delusional belief to be infested. The identification and diagnosis are challenging due to poor patient's insight, poor knowledge and collaboration between specialists and differential diagnoses to be considered before asking for a psychiatric referral. Management and treatment strategies mainly derive from isolated case reports or observational studies with a small sample size. Further randomized clinical trials should be performed to evaluate the efficacy of newer antipsychotic drugs, including long-acting injectable formulations.

Reframing delusional infestation: perspectives on unresolved puzzles

Delusional infestation (DI), a debilitating psychocutaneous condition, featured as a false fixed belief of being infested accompanied by somatosensory abnormality, behavior alteration, and cognitive impairment. Although management of primary causes and pharmacotherapy with antipsychotics and/or antidepressants can help to alleviate symptoms in most patients, the underlying etiology of DI still remains unclear. Morgellons disease (MD), characterized by the presence of cutaneous filaments projected from or embedded in skin, is also a polemic issue because of its relationship with spirochetal infection. This review aims to discuss the following topics that currently confuse our understandings of DI: 1) the relationship of real/sham “infestation” with DI/MD; 2) behavior alterations, such as self-inflicted trauma; 3) neuroimaging abnormality and disturbance in neurotransmitter systems; and 4) impaired insight in patients with this disease. In discussion, we try to propose a multifactorial approach to the final diagnosis of DI/MD. Future studies exploring the neurobiological etiology of DI/MD are warranted.

Treatment of toxicity from amphetamines, related derivatives, and analogues: a systematic clinical review

BACKGROUND

Overdose of amphetamine, related derivatives, and analogues (ARDA) continues to be a serious worldwide health problem. Patients frequently present to the hospital and require treatment for agitation, psychosis, and hyperadrenegic symptoms leading to pathologic sequelae and mortality.

OBJECTIVE

To review the pharmacologic treatment of agitation, psychosis, and the hyperadrenergic state resulting from ARDA toxicity.

METHODS

MEDLINE, PsycINFO, and the Cochrane Library were searched from inception to September 2014. Articles on pharmacologic treatment of ARDA-induced agitation, psychosis, and hyperadrenergic symptoms were selected. Evidence was graded using Oxford CEBM. Treatment recommendations were compared to current ACCF/AHA guidelines.

RESULTS

The search resulted in 6082 articles with 81 eligible treatment involving 835 human subjects. There were 6 high-quality studies supporting the use of antipsychotics and benzodiazepines for control of agitation and psychosis. There were several case reports detailing the successful use of dexmedetomidine for this indication. There were 9 high-quality studies reporting the overall safety and efficacy of β-blockers for control of hypertension and tachycardia associated with ARDA. There were 3 high-quality studies of calcium channel blockers. There were 2 level I studies of α-blockers and a small number of case reports for nitric oxide-mediated vasodilators.

CONCLUSIONS

High-quality evidence for pharmacologic treatment of overdose from ARDA is limited but can help guide management of acute agitation, psychosis, tachycardia, and hypertension. The use of butyrophenone and later-generation antipsychotics, benzodiazepines, and β-blockers is recommended based on existing evidence. Future randomized prospective trials are needed to evaluate new agents and further define treatment of these patients.