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Zorluk: Çok zorSubstance-Related and Addictive Disorders

A 24-year-old man is brought to the emergency department by his parents due to bizarre and erratic behavior over the past 3 weeks. He has barricaded himself in his bedroom, claiming that foreign intelligence agents have implanted a device in his head and are monitoring his thoughts. His parents report that he has slept less than 2 hours per night over this period and has been continuously pacing and speaking at a rapid pace. The patient has a history of major depressive disorder, for which he was started on citalopram 6 weeks ago. Vital signs are temperature 37.8°C (100.0°F), pulse 122/min, respirations 18/min, and blood pressure 162/98 mmHg. Physical examination reveals bilateral pupillary dilation, marked diaphoresis, and multiple linear excoriations on his face and forearms. Neurologic examination reveals normal muscle tone and absent clonus. Routine urine toxicology screen results are pending. Which of the following is the most likely diagnosis?

  1. A
    Brief psychotic disorder
  2. B
    Bipolar I disorder with psychotic features
  3. Substance/medication-induced psychotic disorderCevap
  4. D
    Schizophreniform disorder
  5. E
    Serotonin syndrome

Cevap

Substance/medication-induced psychotic disorder
The correct diagnosis is substance/medication-induced psychotic disorder. This patient's presentation of acute paranoia, delusions, rapid speech, and decreased need for sleep must be interpreted in the context of his physical examination. The presence of significant sympathetic overactivity (tachycardia, hypertension, bilateral pupillary dilation, marked diaphoresis) combined with multiple linear excoriations on his face and forearms is classic for methamphetamine intoxication. The excoriations ('meth sores') result from chronic skin picking due to tactile hallucinations of bugs crawling under the skin (formication). Because the psychotic symptoms are the direct physiological consequence of substance intoxication, a primary psychotic or mood disorder cannot be diagnosed.

Adım Adım Çözüm

1
Analyze the patient's psychiatric symptoms and timeline.
The patient has a 3-week history of acute paranoia, delusions, decreased need for sleep, and rapid speech.
To establish the primary psychiatric differential, which includes mania, primary psychosis, or a substance-induced etiology.
2
Evaluate the patient's physical examination and vital signs.
The patient exhibits a sympathomimetic toxidrome (tachycardia, hypertension, mydriasis, diaphoresis) along with skin excoriations and normal muscle tone.
To identify physiologic clues that distinguish a medical or toxicological cause from a primary psychiatric disorder.
3
Synthesize the findings to reach a definitive diagnosis.
The combination of severe sympathetic overactivity, formication (excoriations), and acute psychosis in the absence of neuromuscular rigidity points to methamphetamine intoxication rather than SSRI-induced mania or serotonin syndrome.
To accurately rule out competing diagnoses and confirm that the psychosis is secondary to a substance.

Anahtar Kavram

Substance-induced psychotic disorder must be differentiated from primary psychotic and mood disorders by recognizing the associated toxidrome (e.g., sympathetic overactivity and formication in methamphetamine use).
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Konular

Substance-Related and Addictive Disorders

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