Psychosis is defined as a gross impairment that is characterized by severe distortions of perception and thought as manifested by delusions. Psychosis cause by the use of bath salts is a non-specific condition that is associated with a variety of diagnoses and states including delirium and toxic states (Ries, Miller & Fiellin, 2002). Psychosis symptoms include delusions, hallucinations, disorganized speech or behavior negative symptoms and catatonia. Ries, Miller & Fiellin (2002) noted that negative symptoms greatly impact interpersonal communication and include flat affect, lack of motivation, poor attention, indifference and social withdrawal.
Bath salts are sold at stores or on the Internet, and they were first found in the United States in 2009. Oltvai (2012) says that buyers of bath salts are aware that they are buying stimulant drugs promoted in a way designed to skirt laws and avoid legislative interference. Trevouledes & Grieger (2012) say that bath salts is a relative newcomer to the drug scene with critical numbers of negative reports to poison control centers noted beginning in 2011. As a synthetic derivative of cathonine, a plant grown in Africa, bath salts has been banned in New Jersey, and other states are rapidly following the suit. Oltvai (2012) further asserts that the two common ingredients of bath salts are 3.4 methylenedioxypyrovalerone and 4-methylcathinone (nephedrone, similar to the cathinone that naturally occurs in the leaves of khat).
Because of the nature of chemical, composition in bath salts act as amphetamine analogs, altering the proper transmission of dopamine, norepinephrine and serotonin. Oltvai (2012) says that as amphetamine analogs, the components of bath salts can produce undesirable cardiac and psychiatric side effects inducing death. According to Oltvai (2012), the number of bath salt-related calls to the US poison control centers increased from 303 in 2010 to 4720 by August 31, 2011. The majority of the calls were related to tachycardia, hypertension, agitation and delusions.
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Psychosis symptoms are associated with recreational anabolic use of bath salts. Use and abuse of bath salts can cause psychosis rarely during intoxication but more often during withdrawal, such as delirium tremens (Lake, 2012). Persistent psychosis, such as bath salt hallucinations, occurs with chronic abuse of bath salts. Bath salts can be detected in urine and gastric samples providing confirmation of exposure. However, quantitative serum levels do not closely correlate with the severity of clinical effects and are not generally available (Lake, 2012). Bath salt derivatives and adrenergic amines may cross react in immunoassays, and distinguishing the specific drug requires confirmatory testing. Selegiline and clobenzorex are metabolized to bath salts and can produce a positive result for amphetamines on urine and blood tested with immunoassays (Lake, 2012).
Bath salts are potentially dangerous drugs. They have been sold at gas stations, mini marts and head shops under such brand names as Ivory Wave, Blue Wave and Red Dove. Trevouledes & Grieger (2012) say that they are reputedly used primarily by adolescents and young adults. Bath salts produce methamphetamine and hallucinogenic effects similar to LSD. Trevouledes & Grieger (2012) indicated that these products have been reported to produce negative side effects such as psychosis. Bath salts are substances that can be snorted, injected or smoked and re being viewed as an emerging health threat by poison control centers.
When an individual persists in using bath salts, psychosis and other psychiatric symptoms may present early in the course of medical disorders. Goetz (2007) says that the clinician must consider this in the differential diagnosis. It is important to note that there is significant link between temporal lobe tumors and psychosis even if patients with epilepsy are not considered. Patients with bath salt cause of psychosis have a higher amount of insight into the illness and are distressed by their symptoms. Clinicians must be aggressive in pursuing a medical or neurological cause of psychosis in patients with no diagnosed psychiatric disease, particularly if there are unusual symptoms such as altered consciousness, concomitant medical or neurological signs (Goetz, 2007). In addition, bath salt cause of psychosis condition may cause an exacerbation or recrudescence of psychosis in patients with an established psychiatric disease.
Bath salts are manufactured from cathinone. Methcathinone and mephedrone are chemically related drugs and major components of bath salts with amphetamine-like effects. New synthetic analogs, such as 3,4 methylenedioxypyrovalerone and various derivatives of methcathinone, are becoming popular drugs of abuse often sold on the Internet as bath salts with names such as “Mad Cow” (Olson, 2011).
Bath salts cause psychosis in that they activate the sympathetic nervous system via CNS stimulation, peripheral release of catecholamines, inhibition of neuronal reuptake of catecholamines and inhibition of monoamine oxidase. The use of bath salts also causes serotonin release and blocks neuronal serotonin uptake. Various categories in this group have different profiles of catrecholamine and serotonin action resulting in different levels of CNS and peripheral stimulation.
Olson (2011) noted that bath salts cause acute CNS effects of intoxication including signs of psychosis. Chronic effects of bath salts abuse include paranoid psychosis in which psychiatric disturbances may persist for days or weeks. After cessation of habitual use, patients may experience fatigue, hypersomnia and depression lasting several days (Olson, 2011).
According to Lake (2012), bath salt psychosis patients can present a diagnostic dilemma. The first diagnostic task in approaching a psychosis patient once the patient and medical personnel are safe is to determine the type of bath salt used. All patients presenting with a new onset psychosis warrant a thorough medical and laboratory evaluation that excludes medical and toxic causes of the psychosis. Neurologic and cognitive evaluations along with a comprehensive laboratory and possibly brain imaging are basic. Lake (2012) says that repeated serial cognitive testing may reveal a delirium or toxic psychosis.
Ries, Miller & Fiellin (2002) indicated that the most reported psychosis symptoms related to bath salts are paranoia and hallucinations. Auditory hallucinations are most common and are often associated with paranoid delusions. Visual hallucinations are the next most common followed by tactile hallucinations. Ries, Miller & Fiellin (2002) further indicated that visual hallucinations have been associated with chronic mydriatic pupils and the appearance of geometric shapes. It is important to note that nearly all hallucinations are associated with bath salt use. Stereotypic behavior also can be associated with psychosis. Such behavior occasionally continues after the intoxication subsides.
It is very difficult to assess the pre-morbid evidence of psychotic thinking in individuals who go on to use large repeated doses of bath salts and to forecast the likelihood that they will develop psychotic symptoms (Ries, Miller & Fiellin, 2002). Researchers measured the level of psychotic thinking in the abstinent patient who is prone to bath salt induced psychosis. Whether this is evidence of proneness to the development of persistent neurobiological changes concurrent with the onset of bath salt induced psychosis remains unclear.
Psychosis associated with bath salt has been described as a three-stage illness. Ries, Miller & Fiellin (2002) say that initially it is marked by the increased curiosity and repetitive examining, searching and sorting behaviors. In the second stage, these behaviors are followed by increased paranoia. Ries, Miller & Fiellin (2002) say that in the final stage, paranoia leads to the ideas of reference persecutory delusions and hallucinations which are marked by a fearful, panic stricken, agitated, overactive state.
The appearance of psychotic-like symptoms in bath salt users became more prevalent in the 2000s, and it fits what we now know about the pattern of amphetamine use associated with these symptoms. Ries, Miller & Fiellin (2002) say that “bath salt induced psychosis develops over time in association with large amounts of the drug, delivered by any route of administration” (p. 1198).
In addition, a common presentation of the psychotic bath salt intoxicated patient entails paranoia, delusional thinking and hypersexuality. Ries, Miller & Fiellin (2002) say that “the hallucinatory symptoms may include visual, auditory, olfactory or tactile sensations”. Ries, Miller & Fiellin (2002) noted that “research shows that the patient’s orientation and memory usually remain intact” (p. 1198). Typically, this altered mental state lasts only during the period of intoxication although there are reports of it persisting for days to weeks.
Treatment should be initiated by providing a safe, secure place for the patient and should reduce external environmental stimuli. Ries, Miller & Fiellin (2002) established that physical restrains should be avoided or used in a time-limited fashion so as not to complicate the presentation with worsening hyperthermia, dehydration rhadomyolysis and possible renal failure. Individuals should be cautioned that the potential of bath salt for lowering seizure threshold, inducing hyperpyrexia and stimulating cardiovascular compromise, particularly in the patient who is using large amounts of bath salts in a chronic pattern (Ries, Miller & Fiellin, 2002).
In patients who have been in prolonged use of bath salts, cholopromazine (Thorazine) should be avoided because of its potential to lower seizure threshold and worsen hyperthermia. Benzodiazepines can be helpful in the treatment of these symptoms (Ries, Miller & Fiellin, 2002). A common initial dose is diazepam (Valium) 10mg, either intramuscularly or intravenously then titrated to the level that sufficiently sedates the patient. Patients should be closely watched for respiratory depression. When using benzodiazepines intramuscularly, the clinician should wait at least 1 hour between doses to avoid inadvertent overdose.
The question of how long the psychosis caused by bath salt will last and how likely the patient is to develop a long-term psychotic illness as a result of bath salt use is not clear. Ries, Miller & Fiellin (2002) say that therapists and clinical experience have found out that bath salt psychosis can last from 3 to 6 months in extreme cases of high-dose use. Antipsychotic medications are an important component of the treatment of psychosis caused by bath salts. These types of medications are instrumental in reducing the long-term positive symptoms of the illness. Despite the advantages of these atypical agents, clinicians should have realistic expectations.
Psychosis patients who present with active bath salt abuse, psychotic symptoms and noncompliance can be difficult to mange as outpatients. Ries, Miller & Fiellin (2002) argue that improving medication compliance is an outpatient setting can be enhanced by reducing positive and negative symptoms, providing psycho-education and social skills training in medication management using motivational enhancement techniques to improve compliance and switching the route of administration of the medications if patients are unable or refuse to take oral medications. In addition, Ries, Miller & Fiellin (2002) found out that individuals with bath salt induced psychosis will benefit from medications as well as a supportive treatment team and environment.
The presence of bath salt use and psychotic symptoms poses special diagnostic and treatment challenges for clinicians in all treatment settings including mental health, addiction, and primary care settings. Psychosocial treatment requires the awareness of the perceived self-medication aspects of why individuals with psychosis believe they continue to use bath salts (Ries, Miller & Fiellin, 2002). When dealing with bath salts induced psychosis patients, it is important to establish and develop a working alliance, help the patient evaluate the cost benefit ratio continued bath salt use, help the patient develop individual goals, help the patient build a supportive environment and a lifestyle that is conducive to abstinence and help the patient learn to anticipate and cope with crises (Ries, Miller & Fiellin, 2002).
Tisdale & Miller (2005) noted that bath salts induced psychosis often requires medical attention to protect the safety of a patient or those around them although harm due directly to the psychosis state is relatively uncommon. Essentially keeping a patient in a safe environment until the psychosis resolves is all that is important. More severe cases may require the short-term use of antipsychotic medications. In the context of bath salt related psychosis, death is rarely directly related to psychosis.
Bath salt induced psychosis may be prevented by minimizing risk factors. Tisdale & Miller (2005) say that a thorough history of past and current psychiatric and medical illness should be completed. There are no specific parameters for the prevention of bath salt related psychosis. It is important to educate the family and caregivers regarding the signs and symptoms of bath salt related psychosis which may help in early treatment (Tisdale & Miller, 2005). The choice of medication should be based on efficacy, patient acceptability and the adverse effect profile of the drug. The anxiolytic and sedative effects of benzodiazepines make them a useful option for the treatment of acute agitation and anxiety (Tisdale & Miller, 2005).
In conclusion, psychosis as a result of bath salt is often a preventable disease. This implies that careful inquiry regarding all medications that a patient is taking, including nonprescription drugs and complementary therapies should be completed before making recommendations. Diligent assessment of medication profiles can help clinicians identify and prevent bath salt related psychosis. Familiarity with those bath salts commonly implicated in drug interactions could help reduce the risk of bath salt induced psychosis.
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