A 17-Year-Old With Hallucinations About Martians and Paranoia

Raheel I. Shaikh; Neal T. Patel; Alexander Martinek; Imran Shaikh, MD

Disclosures

September 28, 2021

Discussion

The negative results of the urine test for drugs of substance abuse ruled out a drug-induced psychosis. Although the patient had previously smoked marijuana before the onset of his symptoms, he did not continue to use it. Thus, no evidence suggests a chronic substance abuse disorder, other than the use of tobacco. The patient's psychomotor agitation and delusions are not related to drug-seeking behavior.

Nicotine use disorder is characterized as dependence on the use of tobacco products to obtain the effects of nicotine. Nicotine is a central nervous system stimulant that, although stimulatory, does not result in bizarre and hallucinatory effects, as seen in this patient. In addition, nicotine withdrawal was not the cause of his symptoms because the patient was still regularly smoking cigarettes.

The normal CBC count, vitamin B12 levels, and liver and renal function test results eliminated pernicious anemia and elevated bilirubin levels as causes of the patient's psychosis. The normal TSH, T3, and T4 levels ruled out thyrotoxicosis and other forms of hyperthyroidism-induced psychosis. The copper panel revealed normal copper levels, which excluded Wilson disease as a cause of central nervous system dysfunction.

Head CT revealed no brain lesions, masses, or any abnormalities, thus ruling out glioma-induced psychosis. The CT scan also showed no evidence of head trauma that may have caused compression of the brain.

Ruling out the other substance and medical diagnoses in the differential involved close examination of the positive symptoms of psychosis that the patient was displaying. Because the delusions were predominantly psychotic ("martians are chasing me") instead of grandiose, the patient was not experiencing manic symptoms and thus did not have bipolar 1 disorder. In addition, the absence of a history of poor sleep or extremely high energy helped steer the diagnosis toward a psychotic disorder.

Schizophreniform disorder was ruled out primarily by looking at the timeframe in which the patient had been experiencing symptoms. The symptoms of schizophreniform disorder resemble those of schizophrenia but last only 1-6 months. Although schizophreniform disorder increases the risk for later development of schizophrenia, it can also be a one-time occurrence.

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