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This study was supported by grants from the National Science Council, Taipei, Taiwan (NSC-95-2314-B-006-093 to Dr. Lin and NSC96-2314-B-384-007-MY2 to Dr. Lu), and the Department of Health of the Executive Yuan of Taiwan, Taipei (DOH96-TD-M113-049 to Dr. Lu). The authors report no additional financial or other relationship relevant to the subject of this letter.
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1. Liu KY, Beautrais A, Caine E, et al. Charcoal burning suicides in Hong Kong and urban Taiwan: an illustration of the impact of a novel suicide method on overall regional rates. J Epidemiol Community Health 2007 Mar;61(3):248253 2. Yip P, Lee D. Charcoal-burning suicides and strategies for prevention. Crisis 2007;28(suppl 1):2127 3. Lin JJ, Lu TH. Suicide mortality trends by sex, age and method in Taiwan, 1971-2005. BMC Public Health 2008 Jan;8:6 4. Kuo CJ, Conwell Y, Yu Q, et al. Suicide by charcoal burning in Taiwan: implications for means substitution by a case-linkage study. Soc Psychiatry Psychiatr Epidemiol 2008 Apr;43(4):286290 5. Lu TH, Sun SM, Huang SM, et al. Mind your manners: quality of manner of death certification among medical examiners and coroners in Taiwan. Am J Forensic Med Pathol 2006 Dec;27(4):352354 6. Chan KP, Yip PS, Au J, et al. Charcoal-burning suicide in posttransition Hong Kong. Br J Psychiatry 2005 Jan;186:6773
hallucinogenic effects, which in doses above 200 g rival the synthetic hallucinogen lysergic acid diethylamide (LSD) in doses of 50250 g.3 S. divinorum product abusers experience a psychic depersonalization condition, a unique sensation of being disconnected from ones body. When leaves of S. divinorum are chewed or smoked, exposed individuals describe an intensely positive hallucinogenic experience (e.g., altered depth perception, heightened sensual and aesthetic appreciation, a creative dream-like state). However, depending on the dose and the route of administration, the effects are sometimes extremely negative (overly-intense experiences; fear, terror, and panic; increased perspiration; and possible difficulty integrating experiences). Until now, the potential abuse of salvinorin A and especially concomitant psychiatric symptoms or diseases have been poorly investigated. We therefore report a case of an 18-year-old female patient who unwittingly ingested S. divinorum for the first time, leading to a severe toxic psychosis within a week after intake with devastating somatic consequences resulting in a long-lasting interdisciplinary medical treatment and physical impairment. Case report. Ms. A was an 18-year-old female patient admitted to our psychiatric emergency service with acute onset of agitation, disorganization, and hallucinating behavior after smoking cannabis. A few days after admission, her former boyfriend disclosed that she had also unknowingly smoked the leaves and leaf extracts of S. divinorum, which had been added to her marijuana cigarette, for the first time. The patient had a long history of use of cannabis but had never experienced a psychotic episode. Ms. A was admitted to a general psychiatric ward with the presumptive diagnosis of a substance-induced psychotic disorder (ICD-10 criteria) and subsequent schizophrenia-spectrum disorder. After showing more and more self-mutilating behavior, with massive disorganization, disorientation and the intention to quit treatment, she was legally committed to a closed ward for involuntary treatment. There was no response to antipsychotic treatment with intramuscular olanzapine (up to 30 mg/day) or intravenous haloperidol (up to 15 mg/day), and Ms. A remained highly psychotic, with disordered thinking, thought blocking, derealization or delusional perceptions, and slow speech. During one of the following nights, Ms. A showed a marked decrease of alertness that required an immediate transfer to an intensive care unit. Because of a developing toxic psychosis with stupor and catatonic excitement, potential neurolepticassociated elevation of creatine kinase to 2055 U/L, and the lack of efficacy of the ongoing antipsychotic medication, further treatment was required. Ms. A then underwent 2 rounds of emergency electroconvulsive therapy (ECT), but these were discontinued after she developed recurrent self-limited asystolias with a maximum duration of 5 seconds. Although there was no further ECT treatment, Ms. A experienced recurrent cardiac arrhythmias that required a temporary external cardiac pacemaker. A recurring acute agitation led to a traumatic amputation of a 1 cm 1 cm part of Ms. As tongue with a subsequent aspiration leading to a temporary intubation and ventilation. Shortly after that, Ms. A developed elevated temperature and a drop in blood pressure that required catecholamine treatment. Within hours, the abdomen became tense and inflated, and the ultrasound and x-ray showed signs of peritonitis and an atony of the bowels. A following explorative laparatomy showed multiple segmental necroses of the distal small intestine and the ascending colon, so that these parts had to be removed surgically. Thereafter we
Jin-Jia Lin, M.D. Department of Psychiatry Chi-Mei Medical Center Tsung-Hsueh Lu, M.D., Ph.D. Institute of Public Health College of Medicine National Cheng Kung University Tainan, Taiwan
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REFERENCES
1. Wasson WG. A new Mexican psychotropic drug from the mint family. Bot Mus Leaflets Harvard Univ 1962;20:7784 2. Roth BL, Baner K, Westkaemper R, et al. Salvinorin A: a potent naturally occurring nonnitrogenous kappa opioid selective agonist. Proc Natl Acad Sci U S A 2002 Sep;99(18):1193411939 3. Bucheler R, Gleiter CH, Schwoerer P, et al. Use of nonprohibited hallucinogenic plants: increasing relevance for public health? a case report and literature review on the consumption of Salvia divinorum (Diviners Sage). Pharmacopsychiatry 2005 Jan;38(1):15 4. Schmidt MD, Schmidt MS, Butelman ER, et al. Pharmacokinetics of the plant-derived kappa-opioid hallucinogen salvinorin A in nonhuman primates. Synapse 2005 Dec;58(3):208210 5. Willmore-Fordham CB, Krall DM, McCurdy CR, et al. The hallucinogen derived from Salvia divinorum, salvinorin A, has kappa-opioid agonist discriminative stimulus effects in rats. Neuropharmacology 2007 Sep;53(4):481486 6. Hunt D. Rise of Hallucinogen Use. National Institute of Justice Research in Brief: Washington, D.C.: U.S. Department of Justice; 1997. Publication NCJ 166607. Available at: http://www.ncjrs.org/pdffiles/ 166607.pdf. Accessed July 16, 2008 7. Halpern JH, Pope HG Jr. Hallucinogens on the Internet: a vast new source of underground drug information. Am J Psychiatry 2001 Mar;158(3):481483 8. Giroud C, Felber F, Augsburger M, et al. Salvia divinorum: an hallucinogenic mint which might become a new recreational drug in Switzerland. Forensic Sci Int 2000 Aug;112(23):143150 9. Sheffler DJ, Roth BL. Salvinorin A: the magic mint hallucinogen finds a molecular target in the kappa opioid receptor. Trends Pharmacol Sci 2003 Mar;24(3):107109
Michael Paulzen, M.D. Gerhard Grnder, M.D. Department of Psychiatry and Psychotherapy RWTH Aachen University Aachen, Germany
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