Additional Case information

Thank you for your interest in this case. Below you will find further details and discussion of this patients course, as well as links to relevant references.

Additionally, it is the authors hope that the unique format of this presentation provides inspiration for how scholarly presentations can be improved by using digital multi-media, particularly in the age of social distancing. The author is admittedly a novice in this style of presentation, however is eager to discuss it’s potential with interested parties.

Case History

Additional presenting history:

At the time of admission to the psychiatric unit the patient had demonstrated significant mood swings, including making statements alluding to suicide. His speech was marked by tangential thoughts that bordered on flight of ideas which made ascertaining his history nearly impossible. His behavior had become disorganized and potentially dangerous, as evidenced numerous superficial lacerations he sustained from his pet cats when he insisted on attempting to bathe with them while nude. He was insistent that he had sustained scalding wounds to his genitals for that same bathing incident, however there was no physical sign of burns on exam. He insisted that this need to bathe the animals was the result of voices he was hearing coming from his walls and air conditioning vents. The animals sustained fatal injuries from this episode. This felicide resulted in police involvement from the outset of his hospitalization, as well as swift recommendation that the patient be treated with involuntary medications to preclude further violence.

Interval Change:

Over the course of several weeks on the inpatient unit the patient showed rapid resolution of symptoms. He was able to recount a significantly more detailed history, explaining that in the months prior to developing psychotic symptoms he had experienced inexplicable gastro-intestinal distress, with protracted nausea and vomiting. These symptoms forced him to be placed on LIMDU and removed from his infantry platoon. He explained that serving in the infantry had been a life long ambition, and the loss of that status had caused depression, though he denied outright suicidality. His attempts to treat his GI distress had led to use of numerous medications, comprehensive evaluation by both military and civilian gastroenterologists, yet no clear diagnosis and no resolution of his symptoms. Shortly after hospitalization his GI symptoms also began to resolve. However, his thought process and behaviors remained concrete, furthering concern for a burgeoning psychosis.

Collateral Suggesting Foul Play

Collateral information was obtained from the patients wife and parents during separate interviews. His wife appeared notably amused by her husbands condition and after a brief conversation in which she described the patient as being “definitely crazy”, she declined further interaction with the treatment team for the duration of his care. His parents provided substantially more information, explaining that their son had a learning deficit that had been un-diangosed but apparent to all since his childhood. They also noted deep concern that he was being abused by his spouse, explaining that he had eloped on short notice, become estranged from his otherwise close-knit family, and told friends that his wife would hit him. They described unverified rumors that his spouse was already a widow at the age of 21, having been previously married to another Marine who died of unknown causes. They acknowledged a lack of evidence, though were adamant that his wife may have been intentionally poisoning their son, leading to his GI symptoms. These concerns led the family to pursue implementation of a military protective order while the patient was hospitalized.

Discharge and Recovery

After several weeks on the inpatient service the patient was discharged to the Psychiatric Transition Program. That program provides care using a modified NAVIGATE model of comprehensive engagement for patients with first episode psychosis. Treatment continues on a daily basis while patients undergo PEB, as the vast majority of such cases are disqualifying for military service. This close observation requires patients remain in barracks in Building 26 with close follow up and access to ancillary care.

In the weeks that followed discharge his multidisciplinary care team noted gradual, progressive resolution of all physical and psychiatric symptoms. At his request, the medications used to treat his presumed psychosis were discontinued, in deference to his concerns regarding lethargy and weight gain. Sufficient rapport had been established by that time to allow diligent observation and clear reporting in the event that symptoms recurred, which was considered highly probable. However, after several weeks he continued to show gradual improvement, to the point of full recovery. Near the conclusion of his PEB. He was evaluated by a neruopsychologist who noted a deficit in learning and intellectual capacity, but no other psychiatric diagnoses.

Promethazine and Phenothiazines

Promethazine is a well established anti-histamine, (H1), with additional antagonistic effects at D2, ACh M1-4, and 5-HT2. It also causes NMDA-mediated membrane current disruption. The histaminergic and dopaminergic effects provide clinical relief from histamine mediated allergies, while the non-selective central and peripheral dopaminergic effects facilitate anti-emetic and “anti-psychotic” actions. The images above show the molecular similarity of Promethazine to the more traditional psychiatric phenothiazine class of medications. Promethazine itself is still occasionally used as an “anti-psychotic” overseas. Traditional psychiatric doctrine suggests that the dopamine blockade caused by these medications should explain their effect in managing psychotic conditions. However, review of medical literature from Psychiatric, Emergency Medicine, and Internal Medicine journals shows numerous case reports dating back over 70 years of paradoxical exacerbation of erratic behavior and occasional autonomic disruption from these medications.

The effect appears to be magnified in cases where there is pre-existing sensory disruption (neurologic injury) or when the medications are used in overdose. Many of these cases, particularly those with accompanying autonomic instability likely represent Neuroleptic Malignant Syndrome and it’s associated alteration of mental status. However there are clearly reported cases of development of unique psychotic features such as auditory and tactile hallucinations, occurring weeks after initiation of promethazine, in a manner that argues against a simple dose dependent response.

Social implications and case resolution

This case highlights the advantages of the use a modified NAVIGATE model of close observation and managed social environment for patients in the immediate post hospitalization period for a presumed psychotic illness. The NAVIGATE model is intended to provide patients suffering from thought disorders the comprehensive support needed to ensure easy access to care, but it also provides an excellent opportunity for diagnostic refinement in cases where psycho-social factors may be contributing to the presentation.

In this case the patient was was able to return to service rather than undergo medical retirement for a psychiatric condition in his early 20’s. He was also afforded the chance to rejoin the Marine infantry, and fulfill his lifelong ambition, likely preventing a substantial ego injury. At the time of this writing he was pending clearance from GI to demonstrate full resolution of his previous symptoms, and was anticipated to return to full duty.