A 42-year-old man is brought to the emergency department by his wife after he assaulted her. She says that he has not slept or eaten for days; he became agitated and started accusing her of plotting with her former boyfriend to murder him. The patient also believes that the FBI is out to get him and that there are bugs crawling under his skin. He had a prior psychiatric hospitalization 8 months ago when he was admitted for paranoid delusions and visual hallucinations. The patient was a successful stockbroker but has been unemployed for the past 2 years. He is uncooperative with the evaluation, speaks rapidly and loudly, gets up to pace during the interview, and shouts, "I don't trust any of you; you're in this together." Examination shows a thin, diaphoretic man with poor grooming and dentition. He clenches his teeth, picks at his skin, and has multiple sores on his face and body. Temperature is 37.8 C (100 F), blood pressure is 140/90 mm Hg, pulse is 104/min, and respirations are 20/min. Which of the following is the most likely diagnosis in this patient?

Question

A 42-year-old man is brought to the emergency department by his wife after he assaulted her.  She says that he has not slept or eaten for days; he became agitated and started accusing her of plotting with her former boyfriend to murder him.  The patient also believes that the FBI is out to get him and that there are bugs crawling under his skin.  He had a prior psychiatric hospitalization 8 months ago when he was admitted for paranoid delusions and visual hallucinations.  The patient was a successful stockbroker but has been unemployed for the past 2 years.  He is uncooperative with the evaluation, speaks rapidly and loudly, gets up to pace during the interview, and shouts, "I don't trust any of you; you're in this together."  Examination shows a thin, diaphoretic man with poor grooming and dentition.  He clenches his teeth, picks at his skin, and has multiple sores on his face and body.  Temperature is 37.8 C (100 F), blood pressure is 140/90 mm Hg, pulse is 104/min, and respirations are 20/min.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This patient's paranoid delusions, tactile hallucinations (eg, bugs crawling under the skin), aggressive behavior, severe insomnia, and physical findings of poor dentition, bruxism (ie, teeth grinding), and skin sores are suggestive of chronic methamphetamine use disorder. Methamphetamine-also known as "meth," "crystal," "ice," and "glass"-is a highly addictive and very potent central nervous system stimulant. Heavy use frequently causes marked weight loss, psychotic symptoms, and excoriations due to chronic skin picking. Severe dental problems ("meth mouth") can include brown discoloration, tooth decay, and cracked teeth due to severe bruxism and dry mouth. Other features of intoxication include mood disturbances, anxiety, irritability, confusion, violent behavior, and signs of sympathetic overactivity (eg, elevated pulse and blood pressure, hyperthermia, sweating, pupillary dilation). Some chronic methamphetamine users can develop persistent psychosis that may be difficult to distinguish from primary psychiatric disorders. Visual and tactile hallucinations tend to be more common in substance-induced psychotic disorders. Long-term management includes both cognitive-behavioral treatment to prevent relapse and antipsychotic medication. (Choices A, C, and F) Methamphetamine intoxication can resemble a manic episode as users experience increased energy and talkativeness and can go for days without eating or sleeping. They may also experience psychotic symptoms (eg, delusions, paranoia, hallucinations) that are seen in primary psychotic disorders. However, this patient's physical findings (ie, sympathetic overactivity, skin sores due to picking, tooth decay, bruxism) and history of tactile and visual hallucinations make methamphetamine use disorder more likely than a primary mood or psychotic disorder. (Choice B) Alcohol withdrawal can present with hallucinations and elevated vital signs but is usually associated with marked tremulousness. The extent of this patient's paranoid delusions is more suggestive of chronic methamphetamine use disorder. (Choice E) Signs of opioid intoxication include slurred speech, sedation, and pinpoint pupils, which are not seen in this patient. Educational objective: Chronic methamphetamine use can cause psychotic symptoms, including paranoid delusions and auditory, visual, and tactile hallucinations (eg, bugs crawling under the skin). Other signs include marked weight loss, severe tooth decay, and excoriations due to skin picking. References: The profile of psychiatric symptoms exacerbated by methamphetamine use. (http://www.ncbi.nlm.nih.gov/pubmed/26874915) Methamphetamine psychosis: epidemiology and management. (http://www.ncbi.nlm.nih.gov/pubmed/25373627) Differences in clinical features of methamphetamine users with persistent psychosis and patients with schizophrenia. (http://www.ncbi.nlm.nih.gov/pubmed/27071042)

A 42-Year-Old Man Is Brought to the Emergency Department by His