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Psychosis in an 18-year-old male

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Contemporary PEDS Journal, November/December 2022,

Alex, an 18-year-old male, presented to the emergency department with a 4-day history of paranoia, agitation, and disorganized behavior. He had no psychiatric history or prior mental health contact and no known medical conditions.

The case:

Alex, an 18-year-old male, presented to the emergency department with a 4-day history of paranoia, agitation, and disorganized behavior. He had no psychiatric history or prior mental health contact and no known medical conditions.

History and examination:

Alex was admitted to the psychiatry unit due to agitation and violent behavior in the context of new-onset psychosis. In the week leading up to his hospitalization, he had attempted to assault family members and punched holes in the walls. He believed that his father had hacked into his bank account and had been responsible for starting the COVID-19 pandemic. Alex had been sleeping approximately 4 hours per night. Concerned about his escalating agitation, his parents called for EMS to take him to the hospital to be evaluated. Alex had been working out regularly, using pre-workout supplements and occasional marijuana. He had no previous mental status changes, functional decline, or psychiatric contact.

On examination, he appeared afraid and was posturing and yelling loudly. He had no visible lesions, track marks, or skin rashes. Overall, his physical examination was unremarkable. He was tachycardic to 110 bpm, with a temperature of 101 °F and blood pressure within normal limits.

Laboratory Testing:

Due to sudden new-onset mental status changes, a workup for reversible causes of mental status change was performed. A CT scan of his head was unremarkable, and laboratory testing was negative for infectious etiologies, malignancy, or thyroid disease. Urine toxicology was positive for marijuana. Alex was seen by internal medicine and psychiatry in the emergency department, from where he was medically cleared, and subsequently admitted to the psychiatry unit on an involuntary basis owing to psychosis and violent behavior.

Differential Diagnosis:

The differential for new-onset psychosis in an adolescent is broad and can be divided into psychiatric and nonpsychiatric causes. Psychiatric illnesses that present with psychotic symptoms include depression or bipolar disorder, schizophrenia, schizoaffective disorder, and brief psychotic illness. Alex’s presentation is less typical of primary psychotic illness because it had an abrupt onset. Other differentials include metabolic abnormalities, infectious etiologies, malignancy, and substance use (Table 1).

Metabolic abnormalities

Infection

Malignancy

Possible causes of substance-induced psychosis

Autoimmune disorders

  • Hyponatremia/ hypernatremia
  • Hypokalemia
  • Hyperammonemia
  • Hypoglycemia/hypoglycemia
  • Hypercalcemia
  • Neurosyphilis
  • HIV/AIDs
  • Herpes simplex virus
  • Lyme Disease
  • COVID-19
  • Epstein Barr virus
  • Cytomegalovirus
  • Bacterial, viral, fungal meningitis
  • Brain tumor
  • Paraneoplastic syndrome
  • Psychiatric illness
  • Major depressive disorder
  • Bipolar disorder
  • Schizophrenia/schizoaffective disorder
  • Brief psychotic illness
  • Stimulants: cocaine, methamphetamine, amphetamine salts, methylphenidate
  • Cannabis or synthetic cannabis
  • Hallucinogens
  • Caffeine
  • Supplements
  • Lupus
  • Hashimoto thyroiditis
  • Graves disease
  • Sjogren syndrome
  • Anti-NMDA receptor encephalitis

Hospital course:

Upon admission to the inpatient psychiatry unit, Alex was started on oral risperidone due to his level of distress regarding his psychosis. On day 2 of hospitalization, the inpatient psychiatry team spoke with him and his mother and screened him for possible ingestions or changes in behavior. For the past 4 months, Alex had been working out regularly and had begun using a pre-workout supplement powder containing caffeine, branched-chain amino acids, vitamins, and minerals. Two weeks before presentation, he had begun dry scooping (consuming without diluting in water) pre-workout supplement, which is a trend on Tik-Tok. He was consuming up to 2 scoops at a time, which equals 800 mg caffeine. He had used marijuana socially for the previous 3 years, but neither his frequency of use nor supplier had changed during the previous year.

One month after hospitalization, Alex’s mother reported that he had no periods of disorganized thoughts, anger, or paranoia. After discharge, he had stopped all supplements, marijuana, caffeine, and risperidone. At a 3-month follow-up visit, both he and his mother denied that he was having mood or psychotic symptoms. Alex’s cannabis use may have been a contributing factor, but because he had been using cannabis 1 to 2 times per month for 3 years before presentation and there had been no changes in the frequency and quantity of his use or in his supplier, we felt that his psychosis was attributable to dry scooping the pre-workout supplement.

Discussion:

Alex developed substance-induced psychosis in the setting of dry scooping a pre-workout supplement, a trend circulating on TikTok. Pre-workout supplements are sold over the counter and used to enhance anaerobic exercise performance by decreasing fatigue and increasing endurance.1 These supplements contain caffeine, amino acids, B vitamins, and other additives. Case reports and review articles have implicated caffeine as a trigger for psychosis,2 and we believe this resulted in Alex’s presentation.

Only 8% of TikTok videos involving pre-workout supplements show people consuming the supplements according to the instructions.3 Cases of cardiac strain and arrhythmia secondary to pre-workout supplement use have been reported,4 but to our knowledge, this is the first report of a person who developed pre-workout supplement–induced psychosis. Overall, the regulation of these supplements is limited, and active ingredients can vary. Due to ease of access, uncertainty of ingredients, and the possible physical and mental health consequences of use, physicians, teachers, and family members should consider counseling young adults on the risks of pre-workout supplement use. We had discussions with Alex and later with him and his mother and recommended talking about social media trends with physicians during routine health maintenance visits.

In addition to dry scooping pre-workout supplements,3 there are many other potentially dangerous trends circulating on TikTok. The “Benadryl challenge” encourages viewers to take at least 12 tablets of Benadryl (a total of more than 300 mg) and stay awake to hallucinate,5 and there have been numerous reports of adolescents requiring hospitalization afterwards.6 L-tyrosine, an over-the-counter amino acid, has been promoted on TikTok as a “natural Adderall” to improve energy and focus.7 Videos also encourage the use of 5-HTP, a naturally occurring amino acid the body uses to create serotonin, to curb appetite and improve sleep and mood.7 Some TikTok users also encourage the consumption of large quantities of nutmeg to induce hallucinations.8 See Table 2 for other TikTok trends that may impact adolescent mental health. Although some social media trends may decrease the stigma surrounding mental health through discussion and normalization, many trends may promote self-diagnosis and self-treatment.

Trend

What is it?

Dangers

Dry Scooping Pre-Workout3

Consuming scoops of pre-workout without mixing it with water to get a more intense effect.

Cardiac arrythmias and ischemia, gastrointestinal upset, dehydration, and mental status changes, including psychosis.

5-HTP8

This is an amino acid that is converted into serotonin in the body. TikTok users are touting it as an over-the-counter way to treat depression, curb appetite, and improve sleep.

This is not regulated by the FDA and may encourage self-medication for an underlying mood disorder that would warrant psychiatric treatment. If taken with other serotonergic agents, it could cause serotonin syndrome.

Benadryl Challenge5,6

Consuming >300 mg Benadryl and then attempting to stay awake to experience an altered sense of reality.

Overdose can result in dry mouth, nausea, vomiting, seizures, and even coma, along with impaired judgement, reaction time, and coordination.

Natural Adderall7

L-tyrosine supplementation to increase focus and productivity. This is an amino acid that is produced by the body.

This could make an underlying thyroid disorder worse. If a person thinks they have ADHD, they should be seen by a psychiatrist.

Nutmeg Challenge8

Consuming large quantities of nutmeg in an effort to hallucinate.

Ingestion can result in dizziness, dry mouth, hallucinations, and seizures.

Headphone or Earphone Waist Challenge

Users see how many times they can wrap their headphone cords around their waist.

This can trigger disordered eating and body dissatisfaction and promote unrealistic body standards.

As the use of social media sites becomes increasingly common among teenagers, health care providers must be aware of the potential spread of misinformation via these sites. TikTok in particular is an algorithm-based platform where users share brief videos with keywords, or hashtags. “Fitness and sports” is now the fourth most popular hashtag.9 Within this category, people share tips on diet and exercise, like dry scooping pre-workout supplements, weight-loss changes, meal plans, and related matters. Rapid and accessible dissemination of information, opinions, and trends through social media platforms may result in the spread of misinformation, self-diagnosis, and self-treatment.10 Some worrisome trends include supplement use as the primary treatment for mental health conditions7 and the promotion of unrealistic body standards.11 On the other hand, these trends offer an opportunity for providers to engage adolescents and decrease the stigma around mental health.

When dealing with this population, it is important to remain up to date on trends likely to impact them. With new-onset personality and behavioral changes, supplement use should remain on the differential. Providers should educate family members on social media trends and exposure and offer appropriate treatment and support for this demographic.

Reference

1. Beckner ME, Pihoker AA, Darnell ME, et al. Effects of multi-ingredient preworkout supplements on physical performance, cognitive performance, mood state, and hormone concentrations in recreationally active men and women. J Strength Cond Res. 2022;36(9):2493-2501. doi:10.1519/JSC.0000000000003660

2. Wang HR, Woo YS, Bahk W-M. Caffeine-induced psychiatric manifestations: a review. Int Clin Psychopharmacol. 2015;30(4):179-182. doi:10.1097/YIC.0000000000000076

3. Nelson Chow. Dry scooping and other dangerous pre-workout consumption methods: a quantitative analysis. Presented at: American Academy of Pediatrics Annual Meeting; October 9, 2021; Lynbrook, NY.

4. Wang SSY. Pre-workout supplement induced cardiac ischemia in a young female. J Sports Sci. 2020;38(2):187-191. doi:10.1080/02640414.2019.1689598

5. Minhaj FS, Leonard J. Dangers of the TikTok Benadryl challenge. Contemp Pediatr. 2021;38(1). https://www.contemporarypediatrics.com/view/dangers-of-the-tiktok-benadryl-challenge

6. Scott C. Updated: Most dangerous, foolish, mean Tiktok trends and challenges. Parentology. Published online July 26, 2021.

7. Miller K. People On TikTok Are Calling These Supplements “Natural Adderall”—Here’s Why That’s Not OK. Shape.com. Published online March 15, 2021. https://www.shape.com/lifestyle/mind-and-body/l-tyrosine-adderall-tiktok

8. Atherton RR. The ‘Nutmeg Challenge’: a dangerous social media trend. Arch Dis Child. 2021;106(5):517-518. doi:10.1136/archdischild-2020-319407

9. Freer A. These are the top 10 hashtag categories on TikTok. BusinessofApps. August 10, 2020. https://www.businessofapps.com/news/these-are-the-top-10-hashtag-categories-on-tiktok/

10. Koeck P. Viral TikTok challenge highlights stress, depression, anxiety test.

11. de Vries DA, Peter J, de Graaf H, Nikken P. Adolescents’ social network site use, peer appearance-related feedback, and body dissatisfaction: testing a mediation model. J Youth Adolesc. 2016;45(1):211-224. doi:10.1007/s10964-015-0266-4