Delirium Trihexyphenidyl Hydrochloride

Dr. Andres and Dr. Jaime Solis Heerlein

 

Summary
For a patient of 17 years old, single, student, who is taken by her parents to consult the emergency service by behavioral problems, disorientation, paranoid and suicidal ideation, secondary use of trihexyphenidyl hydrochloride associated with consumption is presented alcohol and marijuana. Diagnosis of Substance-Induced Delirium, responsive to the administration of haloperidol and lorazepam intramuscular, with complete remission of symptoms arise. It also presents history of alcohol and marijuana, which is not achieved by treating abandonment of ambulatory controls. Keywords: psychosis, delirium, trihexyphenidyl hydrochloride.
Introduction
The study of the different etiologies of a psychotic disorder remains a challenge for psychiatry. Multiple causes and the heterogeneity of its presentation make it necessary to know them in detail for a proper diagnostic approach and indicate the appropriate treatment. Among them, the pictures related to substance use have become an important differential diagnosis in the emergency room of the general hospital and particularly in the initial psychiatric evaluation. Among the paintings produced as a result of substance are described, among others, psychotic disorders and delirium.
Various causes, through different mechanisms, have been involved in the production of delirium and psicóticos.1 disorders traditionally substances are included They described as abuse: alcohol, hallucinogens, amphetamines, cannabis and cocaine. Also various drugs used in general medical practice, higher than the prescribed dose individuals with idiosyncratic reactions, can trigger psychotic symptoms, including anesthetics, analgesics, anticonvulsants, antihistamines, antihypertensives, steroids, muscle relaxants, nonsteroidal anti-inflammatory, antimicrobial and antiparkinsonian agents such as trihexyphenidyl hydrochloride (CTHF). These tables have also been associated with the use of toxic products: organophosphate insecticides, nerve gases, carbon dioxide and volatile substances such as fuel or paint. The CTHF is widely used in neurological and psychiatric practice by its anticholinergic properties to reduce symptoms of Parkinson’s disease and various types of Parkinsonism, as it occurs with the use of antipsychotics (neuroleptics) typical.
In psychiatry The most common use is among schizophrenic patients, indications, dosage and time of use which are still the subject of discussion. Probably so prolonged use in this group was described where, decades ago, the risk of abuse and other anticholinergic drugs CTHF 1 for its euphoric effect. There is little information in the international literature to quantify the extent of this abuse. A Zemishlany et al 2 study attempted to determine the rate of abuse among the population of schizophrenic patients and found an incidence of 6.5%. When trying to determine the distinguishing characteristics of this group of patients found no significant differences in demographic variables or comorbidity with a personality disorder in particular. Only he managed to define a trend to more negative schizophrenic symptoms among drug abusers. In relation to its effect on the profile of symptoms, some case reports have it raised a possible benefit to some patients, the intensity of negative symptoms by adding in controlled drug dose anticolinérgicas.3,4 Moreover, it is known for several years that subjects who have not been prescribed the drug can be transformed into consumers and potentially develop abuse or dependence trihexyphenidyl hydrochloride. No estimates of the incidence of abuse in non-schizophrenic population of subjects.
verbal reports many Latinoamerica emergency psychiatrists refer an increasing number of cases of consumers CTHF without medical indication, particularly among young people, who use in conjunction with other drugs of abuse such as alcohol and marijuana, and alucinótico for its euphoric effect. This situation is facilitated by its low cost, ease of purchase and the lack of controls for sale, which makes it possible to acquire large dose at a low price.
In psychiatric practice the doses used typically range between 2 and 15 mg / day ; at higher doses (usually about 20 to 25 mg / day) has been reported to cause delirium CTHF with various symptoms such as euphoria, visual hallucinations, confusion, disorientation, aggressive behavior, agitation, paranoid ideas and
anterógrada.4 amnesia, 5 also can cause tachycardia and occasionally arrhythmias, hypertension, mydriasis, peripheral vasodilation, convulsion and urinary retention. Discontinuation of the drug results in complete recovery of symptoms with no residual effects. Adverse effects may occur even in patients who are receiving some other antipsychotic agents, suggesting a possible additive action of the anticholinergic action on the central nervous system, and also a possible reduction in the absorption of antipsychotics in concomitant use with the drug . Regarding the risk of dependence likely CTHF, they have published some cases of longstanding users with symptoms of drug withdrawal such as irritability, sweating, tachycardia and cefalea.6
Clinical description
Anamnesis next
GFC, female, 17 years old , single, childless, student of 2nd half, with no history of psychiatric consultation. Driven by her parents to consult the Emergency Service of the Hospital of the University of Chile, which indicate that, while on holiday, had gone to the beach with a group of friends. At dawn the day before consultation is given to police officers from the city of San Antonio for the inhabitants of a house to which the patient is admitted after jumping the wall. In that situation, he was disoriented, referring to the time you leave the police station says not recognize his mother and brother who come to remove it “trying to escape from a group that sought to kill her.” “Are not they, are about double that are suplantándolos, are also in contact with those who want to kill me. “Then moving it to the young Santiago spends the night at home under the supervision of his family, because he wanted to escape from your home. The next day consultation in the Emergency Service said, where it is evaluated by internist seeking psychiatric evaluation.
On examination the patient impresses distraught, looking older than the chronological, with diminished psychomotility, careless in his personal appearance, clothes disorderly, without makeup and disheveled. With distrustful attitude towards the interviewer, cooperates poorly at the beginning of the interrogation, but after repeatedly explaining where you are and the aim of progressively access the clinical interview to tell their story. Regarding awareness vigil is partially disoriented in time and space, “I just know I’m in a hospital or clinic but do not know what &.
rdquo; With regard to the date says “September 10,” being in fact 12 of the same month. With communicative, coherent, slightly slowed language, no neologisms, or stereotypes are appreciated. No alterations formal course of thought. Centric content paranoid ideas: “I was on a bus from San Antonio to Santiago, and I realized that everyone who came up were purchased and wanted to kill me. The driver the whole trip was looking in the mirror and spoke to me copilot. The person sitting next to me had a syringe with morphine and I was going to bury and when I realized I asked the driver to stop, got out and ran, I came to a house to ask for help but there was the guy who sent all, it was the father of the girls that came in the beach photos. He had a stick in his hand and showed my leg, arm, knee, those were the places where I had to shoot. ”
She reports that about 36 hours before the interview, with some friends, consumed about
500 cc of wine a “beep” of marijuana and 6-7 tablets 2 mg CTHF. According to the story of people who were with her ​​at the time of consumption approximately three hours after the patient began to wander the beach, avoiding contact with others. Then boarded a bus would “escape with machine gun cocks were up a bridge and wanted to kill me. All this was because I had taken them a photo of little girls, where it all started because I wanted to remove the roll and the type of the house, which was in charge to others, sent to kill me. “It is seen distraught He says not understand why the photos are so important: “I’m sure they want to kill me, so I had to start.”
He does not remember precisely the hours that the events had passed. When questioning about its status prior to consumption does not mood disorders, behavioral problems, hallucinations or delusions are evident. Parents confirm that there had behaviors that attract their attention, in addition to good social and family presetting. Suspected of possible alcohol on previous occasions, but not other drugs. Since wake up the day of the interview the patient adequately recognize their relatives, but keeps the fear that tells suicidal ideation in the last hours, but no actual “this group of people find her and kill.”: “Here I thought I to kill himself, but he was so scared I was. “The rest of the group with whom he shared on the beach tells others consumed, but only she presented such alterations. Also, they confirm that there was no violence or persecution against him.
Anamnesis Remote
biological aspects
Normal pregnancy and childbirth; normal psychomotor development. No significant medical or surgical history. Gynecological and obstetric history: menarche at age 12; menstruation IV / 29-30 without pregnancy.
Habits
Snuff: 2-3 cigarettes a day since age 13. Alcohol: 400-500 cc of beer and / or wine, every 15-20 days, from 15 years. Drugs: Marijuana 1-2 “whistles” the month 15 years. Denies consumption trihexyphenidyl hydrochloride prior to the current episode.
Family history
lives with mother 46, father of 48 and 21 brothers and 15 years. All without psychiatric history or medical importance.
physical and neurological examination in Emergency Service
Hydrated, normotensive (120/70 mmHg), without fever (36, 50 axillary), heart rate 78 per minute, sinus rhythm. Isochoric, reactive pupils. Cranial nerves were normal. Strength and muscle tone maintained. Reflexes were normal. Segmental examination without pathological findings. Laboratory tests:. Blood count, chemistry profile and complete urine normal
treatment and evolution
After contain verbally allows the administration of haloperidol 5 mg plus 4 mg intramuscular lorazepam, which, after about 90 minutes decreases anxiety and paranoid ideation. But continue with a partial view of the facts underlying the request. It states: strict surveillance by
their parents, lorazepam 2 mg every 8 hours, provided by third parties and control clinic at the University Psychiatric Clinic in 48 hours. In this evaluation the patient is seen noticeably worried about her appearance, cooperative during the interview, aimed temporoespacialmente, euthymic without trouble; contacted and adequate affective modulation; relates not paranoid ideas, without suicidal ideation and adequately prosecuted after the events in recent days. She says: “I think it was pure hallucinations, pure things I got in the head because of the pills, that never happened; luckily my parents helped me. . Now I have no desire to kill me, and all I want is to live in peace “Without awareness of the risks of alcohol and marijuana, the patient says:” Those I will I control and I have been never flown like this. ”
lorazepam dose reduction is indicated to the suspension and control at 7 days in the Drug Unit of the Clinic, which however does not concur. After 15 days he speaks by telephone with his mother, who said that the patient finished his holiday and rejoined their education without difficulty. He would not have wanted to attend enforcement over the insistence of the need for further evaluation and psychiatric treatment; states that seek time soon, which however no. is performed
Discussion
By altering consciousness, expressed in the ability to pay attention and adequately perceive the environment, disorientation, the presence of hallucinations, the time course and a history of consumption The case is an induced delirium trihexyphenidyl hydrochloride. It is difficult to tell if the patient has an individual predisposition to develop the picture with lower doses than usually described in the literature, or additive effect and / or enhancer of concomitant use of alcohol and marijuana. However, the amount used of the latter drugs and their effects characteristic profile, seems to correspond to the main action of trihexyphenidyl hydrochloride.
With regard to treatment responsive to the administration of haloperidol is observed, an antipsychotic with
low profile anticholinergic effects, along with a benzodiazepine. However, it is important to differentiate the pharmacological effect compared to the natural evolution of intoxication. It is possible that the indicated therapy has enabled rapid behavioral adjustment in the early hours, with marked decrease in anxiety and outpatient care by the family. There are data in the literature to support the idea of not using antipsychotics with greater anticholinergic effect, because they can be ineffective and eventually enhance the effect on the nervous system central.6 The state of the patient in the evaluation practiced 72 hours after consumption matches described in the literature, that said the CTHF induced delirium evolves to full remission of symptoms between 2-7 days after the drug suspended without residual effects.
The clinical case illustrates clearly raised about the risk of use and abuse potential trihexyphenidyl hydrochloride in young people, often associated with the use of alcohol, marijuana and cocaine. Must be interrogated
dirigidamente on its use in the examination of a patient with recent onset psychosis because, in some cases, the only manifestation of intoxication is the psychotic symptoms, without systemic involvement agregado.5 This may be due to low dose within the range of poisoning, with which one can demonstrate this effect. In an opposite sense, there are reports in the literature of patients who have suffered a progressive tolerance to the drug, which leads them to consume doses up to 100 mg / day and show no symptoms of acute importance.
With regard to the damage to the patient, with medical complications that can cause overdose have to consider the risk of their conduct during the period of intoxication such as amnesia, auto or hetero-risk and suicidal behavior consistent with deliriosas ideas. All this implies that the psychiatrist determined very carefully to what the patient, how long and how much will prescribe the drug, assessing the potential risk of addictive behavior, aspect of particular importance due to the high percentage of schizophrenic patients with a history of substance abuse. The frequency of these cases, moreover, should lead to a rethink by the health authorities in terms of control mechanisms for sale. In several Latin American markets today is possible to buy a tablet CTHF for less than US $ 0.01 retained without prescription. Most stores sold even with the simple request of the user, which implies having available a drug with serious potential effects, clearly demonstrated history of use as a drug of abuse and use apparently common in our population, particularly among young.
References
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2. Zemishlany Z, Aizenberg D, Z Weiner, Weiazman A. Trihexyphenidyl (Artane) abuse in schizophrenic patients. Int Clin Psychopharmacol. 1996; 1: 199-202.
3. Buhrich N, Weller A, Kevans P. Misuse of anticholinergic drugs by People with Mental illness serious. Psychiatr Serv. 2000; 51: 928-929.
4. Deutsch A, Eyma J. Massive ingestion of trihexyphenidyl. Am J Psychiatry. 1992; 149: 574-575.
5. Kaminer And Munitz H, H. Wijsenbeek Trihexyphenidyl (Artane) abuse: euphoriant and anxiolytic. Br J Psychiatry. 1982; 140: 473-474.
June. Tune L. The role of antipsychotics in treating delirium. Curr Psychiatry Rep 2002; 4:. 209-212