Psychosomatics 42:525-527, December 2001
© 2001 The Academy of Psychosomatic Medicine
Persistent Psychosis After a Single Ingestion of ‘Ecstasy’
Janice Van Kampen, M.D., and
Mark Katz, M.D., FRCP(C)
Received July 2, 2001; accepted July 14, 2001. From the Department of Psychiatry, University of Toronto, and the Department of Psychiatry and Psychosocial Oncology Program, University Health Network-TGH/PMH/OCI, Toronto, ON, Canada. Address reprint requests to Dr. Katz, Princess Margaret Hospital, 5-634, 610 University Ave, Toronto, ON M5G 2M9.
Key Words: Ecstasy • Psychosis
Consultation-liaison psychiatrists are often called on to assist in the assessment and management of patients admitted to medical units with substance-induced psychiatric symptoms.
The recreational drug "ecstasy" (3,4-methylenedioxymethamphetamine, MDMA) has become increasingly popular within the youth culture.1,2 MDMA is a synthetic amphetamine that has both stimulant and hallucinogenic properties.2 Users of MDMA report subjective effects of euphoria, enhanced sense of well-being and closeness, and heightened sensory experiences.2 MDMA use has become extremely prevalent among young people at all-night dances or "raves."1
There is a widely held belief that MDMA is a "safe" drug, but a growing body of literature has documented both medical and psychiatric adverse reactions to MDMA.3 Medical consequences include renal failure, rhabdomyolysis, disseminated intravascular coagulation, hepatitis, cerebral infarction, seizures, delirium, and coma.4 In terms of psychiatric sequelae, MDMA use has been associated with depression, anxiety, panic attacks, flashbacks, perceptual changes, depersonalization, and derealization.5
Transient psychotic symptoms may occur during intoxication with MDMA, but persistent psychotic symptoms have occasionally been reported as well. In the existing literature, investigators have emphasized the occurrence of psychosis in either chronic heavy users or vulnerable individuals with history of mental illness. There are few reports, however, of persistent psychotic symptoms in previously healthy individuals who have used the drug on isolated or sporadic occasions.6,7 In addition, there is very little discussion in the literature about the treatment of persistent psychosis secondary to MDMA use.
In this paper, we describe an individual who developed prolonged psychosis after a single recreational use of MDMA.
Case Report
Ms. F., an 18-year-old female high school student was admitted to the internal medicine service of a university-affiliated teaching hospital for investigation of confusion and an altered level of consciousness. The previous night, she had smoked marijuana, drunk a small amount of tea containing psilocybin ("magic mushrooms"), and taken one tablet of ecstasy at an all-night party. The following day, Ms. F. returned to her parents' home in a confused and disoriented state. She was taken to the emergency department, where she displayed a fluctuating level of consciousness; disorientation to name, place, and time; marked loosening of associations; and bizarre, agitated, and sexually inappropriate behavior.
Ms. F.'s vital signs were normal; physical examination was unremarkable except for nystagmus. Results of extensive blood work, including complete blood count, electrolytes, and liver and renal function tests, were normal. Urine toxicology was positive for cannabis and MDMA. She was seen by the neurology service, where physicians recommended an electroencephalogram plus computed tomography and magnetic resonance imaging of the head; the results of these tests were normal. Initial psychiatric consultation obtained in the emergency department revealed her to be somnolent, difficult to rouse, uncooperative, and profoundly confused. A diagnosis of hallucinogenic (and possibly cannabis-induced) delirium was made.
Ms. F. had no psychiatric history and was physically healthy. There were no difficulties within the family. A maternal aunt suffered from anorexia nervosa and a maternal great grandmother may have had depression. The patient excelled academically and was involved in various extracurricular activities, including school clubs and enrichment courses, and held a part-time job. She had experimented with marijuana on approximately 10 occasions in the past and reported subjective effects of euphoria and increased talkativeness lasting for a few hours, but no other sequelae. She had taken a half-tablet of ecstasy on one occasion several months earlier and experienced heightened sensory acuity without lasting effects. This was her first experimentation with psilocybin, and consisted of one sip of psilocybin tea.
Over the first 3 days in the hospital, Ms. F.'s level of consciousness improved; she became more alert but remained disoriented to time and place. She continued to show inappropriate behavior at times. By the fifth day of hospitalization, she was alert and oriented but displayed disorganized thought form with delusional ideation involving misidentification and paranoia. Her mood was euphoric, and she denied experiencing visual or auditory hallucinations. On the eighth day of hospitalization, her thought disorder had improved, her mood was euthymic, and she denied any delusional ideation. She was discharged home to the care of her parents; her physicians believed that her improvement had been significant enough that psychiatric admission was not warranted.
Ms. F. was seen for a psychiatric follow-up evaluation 2 weeks after discharge. She reported feeling confused and perplexed and was having difficulty reintegrating at school. She described feeling overwhelmed by excessive noise and activity, particularly in the classroom, and being easily distracted. On assessment, her mood was normal. Her thought form showed mild loosening of associations. There were ideas of reference involving school and current events. She felt that teachers had been directing their lessons specifically for her benefit and that she could influence other students' motivation to learn if she felt motivated to learn. She believed that news events reported in the media had a special connection to her. She denied experiencing auditory hallucinations but reported a heightened visual perception of colors. The patient denied any ongoing drug abuse, and a urine drug screen was negative. A trial of antipsychotic medication was offered at this time and at subsequent appointments but was rejected by Ms. F. and her parents in the hope that her symptoms would clear spontaneously.
At 6 weeks after discharge, however, her psychotic symptoms had still not resolved, and the patient agreed to a trial of olanzapine (2.5 mg at bedtime). One week later, she reported fewer ideas of reference and was less bothered by situations that would have perplexed her before. There was more clarity to her thinking, and her thought form improved. She was able to focus more productively on her schoolwork. At 6 weeks after starting olanzapine, Ms. F. reported that she had returned to her normal self, with no symptoms of psychosis on mental status examination.
The patient and her psychiatrist agreed to a 2-month trial of olanzapine and then further evaluation after discontinuation of medication. By 3-month follow-up, the psychotic symptoms had not returned and Ms. F. had resumed her academic and extracurricular activities, with full return to her previous personality and level of functioning.
Discussion
Our patient developed a prolonged psychotic reaction to recreational use of MDMA that was treated successfully with olanzapine. Initially, she experienced an MDMA-induced intoxication delirium, as evidenced by the disturbance of consciousness and a change in cognition according to DSM-IV criteria.8 Delirium following MDMA ingestion has been reported previously.9 Once the delirium had cleared, prominent psychotic symptoms emerged, including disorganized thought form, delusional ideation, and ideas of reference that lasted approximately 12 weeks. The diagnosis of MDMA-induced psychotic disorder8 seemed most appropriate given the absence of any sustained mood disturbance and the lack of evidence of any prodromal symptoms, such as impaired role functioning, social withdrawal, anxiety, or lack of motivation, as typically seen in first-episode psychosis.10 In addition, there was no family history of mood disorders or psychosis among first- or second-degree relatives.
Although Ms. F. admitted to using marijuana and psilocybin in addition to MDMA, we believe that the clinical presentation was most consistent with a persistent psychosis attributable to MDMA. Ms. F. had used marijuana on several occasions in the past, with no lasting sequelae beyond the intoxication period. We could find no mention in the literature about persistent psychosis following psilocybin use; furthermore Ms. F. stated that she had taken only a sip of tea containing psilocybin, and her urine toxicology screen, while positive for cannabis and MDMA, was negative for psilocybin.
The case presented here is unusual because in most reported cases, the authors described persistent psychosis in individuals who were heavy MDMA abusers and who also chronically misused other illicit drugs.5,7,11–13 Some authors have described psychosis in individuals who had a genetic vulnerability to psychotic disorders in first-degree relatives.7,12 In contrast, Ms. F. did not have a personal or family history of psychotic disorders and had used MDMA previously on only one occasion. Cohen and Cocores4 reported an individual who developed a wide range of psychiatric symptoms, including depression, derealization, and memory lapses, after a single use of MDMA, whereas our patient developed primarily psychotic symptoms. Some investigators have described individuals who developed a persistent psychotic disorder who derived partial benefit from neuroleptic therapy.6,12,13 In contrast, Ms. F. recovered fully after taking short-term low-dose olanzapine.
The etiologic role of MDMA in causing psychotic symptoms is not clearly understood.6 Evidence from animal and human studies has shown that MDMA reduces levels of brain serotonergic activity and depletes serotonin stores.2 MDMA has a lesser direct agonist effect on dopamine receptors,2 although MDMA may induce psychosis through dopaminergic or serotonergic pathways.13
The treatment of persistent psychosis secondary to MDMA abuse has received little attention in the literature. The choice of psychopharmacologic agents for treatment has varied among the typical neuroleptics such as haloperidol,6,7,12 trifluoperazine,11 depot neuroleptics,7,11 diazepam,7 and carbamazepine.7 To our knowledge, this is the first report of using an atypical neuroleptic, olanzapine, to treat MDMA-induced persistent psychosis.
Given the increasing popularity of MDMA,1 it would be prudent for clinicians to routinely ask young people about ecstasy use and to include MDMA in toxicology screens. In this paper, we show that a single instance of recreational use of MDMA can precipitate a prolonged psychosis in someone who has no indications of elevated vulnerability to psychiatric difficulties. Further studies are needed to clarify the incidence of persistent psychosis after MDMA use and to address the role of atypical antipsychotics in the treatment of persistent psychosis.
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