Nasal drops

Chronic hallucinosis A 61-year-old man with a history of ~chizophtenic disorder and borderline mental retardation sought medical care for symptoms of psychosis, anxiety and nasal stuffiness. Over the years he was in the habit of using decongestant drops and sprays for 'nasal obstruction'. In the last 5 years, he had used ephedrine congeners (levodesoxyephedrine, menthol. methyl salicylate, camphor), phenylephrine hydrochloride and oxymetazoline (8 or more bottles per month) to relieve himself of an impending feeling of suffocation. The EEG, physical, laboratory and neurological examinations were normal. Chest x-rays showed emphysematous changes and mucosal thickening of (he left maxillary sinus was also noted. According to the Diagnostic and statistical Manual of Mental Disorders HI, the patient was schizophrenic. The National Institute of Mental Health Diagnostic Interview schedule suggested lifelong anxiety disorder. Nasal preparations were discontinued and trifluoperazine hydrochloride (I Omg/ day) and a combination of pseudoephedrine and lriprolidine hydrochloride (bid) were prescribed. Symptoms of anxiety, psychosis and nasal obstruction gradually decreased. However, 4 months later, all symptoms grew worse foHowing increased use of ephedrinetriprolidine and trifluoperazine during an attack of influenza. The neuroleptic and decongestant were rapidly tapered and discontinued On a suspicion of sympathomimetic psychosis. After I week, all hallucinations and delusions ceased. Amitriptyline hydrochloride (7 5mg/ day) and diazepam (15mg/day) were later prescribed for depressive symptoms which emerged after psychosis subsided. Follow-up evaluations showed a progressive improvement of effective and psychotic disturbances. SurpriSingly. inspite of the ready availability ofsympathomimetics, there are only a few reports of sympathomimetic related psychosis. The above report suggests that nasal drops used over a prolonged period could playa causal role in some psychoses. Escobar. J.I. and Karno, M.: Journal of the American Medical Association 247: I 8S9 (2 Apr 1982)

Comment: There are several possible reasons for the small number of previous reports on hallucinosis associated with long term use of sympathomimetic nasal drops. It could be that PSY<;:hiatric disorders go unrecognised in a basically medical sel up. Until 1970, psychiatrists failed to recognise nephrogenic diabetes insipidus in their lithium treated patients. A further problem is the difficulty of arriving at a cause-effect relationship. During chronic illnesses patients are exposed

6 Reactions 14 May 1982

to multiple drugs and to mUltiple preparations of the same type of drug, making differentiation more involved. Often clinicians are unaware oi side effects of a chronically used drug because these are unidentified in fairly brief prospective clinical trials that form the basis for clinical use of a drug. The association of chronic renal disorders with lithium carbonate was not recognised during 2 years of prospective clinical trials with lithium carbonate. Valid and easily administered psychiatric examination methods (Diagnostic Interview Schedule, Cognitive Capacity Screening Examination, Diagnostic and Statistical Manual of Mental Disorders Ill, Mini­Mental State Exam, General Health Questionnaire) should help clinicians to identify and quantitate psychiatric risks from long term medications. De Paulo. J.R.: Journal of the American Medical As.sociation 247; 1867 (2 Apr 1982)

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