Homicidality and Psychosis Caused by an Over-the-Counter Performance-Enhancing Supplement Containing Dendrobium Extract and L-Dopa

Presentation

A 30-year-old Caucasian male presented to our hospital after he had walked off his job because of a strong urge to kill his boss and a customer while experiencing a visual hallucination of committing the act. During an assessment in the psychiatric emergency service, his mental-status examination showed a distressed, alert, and fully oriented male concerned about his violent thoughts and worried about the loss of his muscle volume. His affect was stable and congruent with his mood. His speech was underproductive and soft, with difficulty finishing sentences because of thought-blocking.

He reported hearing the voice of one of his halfway house housemates for the previous two to three weeks. The patient described the voice as commenting on his activities, except on the day of admission, when the voice instructed him to go to the hospital to get “locked up” to prevent him from hurting someone. The patient believed that one of his housemates had drugged him with methamphetamine because he knew the feeling from past methamphetamine use. For approximately three to four months, he was convinced that women from his gym and his hometown had created a secret group to treat his sexual repression by teasing him, wearing revealing clothes, and acting provocatively around him. In addition, he reported that his family was “after him,” but he couldn’t explain why.

His physical examination was normal except for bilateral gynecomastia and acne on his back. The admitting physician noted hypertrophic musculature consistent with bodybuilding. On admission, laboratory tests (i.e., comprehensive metabolic panel, complete blood count, urinalysis, urine drug screen, and thyroid-stimulating hormone test), a computed tomography scan of the patient’s head, an electrocardiogram, and vital signs were all within normal parameters.

Based on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), the patient’s psychiatric and substance-use histories were positive for oppositional defiant disorder and polysubstance dependence (methamphetamine, opiates, and alcohol) at the age of 13, leading to legal problems in his later teenage years. He graduated from an inpatient chemical-dependency treatment center approximately 18 months before his hospital presentation. For the previous five months, he had lived in a halfway house. The patient and his family reported that he occasionally used alcohol and marijuana after his dependency treatment; however, he had not used these substances for two months before his presentation. His medical and family histories were noncontributory. He was not taking any prescription medications before admission.

Hospital Course

After his admission to our hospital, the patient started taking dissolvable olanzapine 5 mg orally at bedtime to treat his hallucinations, delusions, and thought-blocking (Table 1). By the sixth day of his hospitalization, his symptoms had improved, and the olanzapine dose was increased to 10 mg at bedtime.

One day later, the patient reported using testosterone and human growth hormone (HGH) shortly after he had graduated from chemical-dependency treatment. He identified himself as a recreational bodybuilder who achieved his muscle bulk with exercise and with “cycles” of “testosterone boosters” combined with the “stacking” of HGH, both obtained from a street source. He alternated one month “on hormones” with one month “off hormones” for seven cycles (Table 2). While “on drug,” he felt “bulky” and energetic, was able to lift more weights, had an increased libido and appetite, and rated his self-esteem as “nine out of 10.” At the same time, however, he felt irritable, punched walls, had aggressive thoughts (not homicidal), and would isolate himself. While “off drug,” he experienced anabolic steroid withdrawal symptoms, including feelings of depression, anxiety, and fatigue; insomnia; appetite loss; the loss of self-esteem; a decreased libido; and a desire to restart steroid use.^3–7 After 14 months, he interrupted “cycling” of the hormones because of the cost, the development of bilateral nipple tenderness, and the discovery of a lump under his right nipple. His last “cycle” of testosterone occurred approximately four months before his presentation to our hospital.

Despite vigorous exercise and the occasional use of HGH, the patient felt that his muscle mass was decreasing, and he started using an OTC PES product derived from the dendrobium orchid and L-dopa. His family reported that his behavior dramatically changed during those four months of OTC PES use (Table 2). According to his sister, the patient became even more obsessed with exercise, withdrew from his family, and began to feel that they were conspiring against him. He also started to make bizarre statements about women and sexual repression, and expressed the feeling that somebody had “drugged” him with methamphetamine. Later, he started to complain about hearing a male voice commenting on his behavior. He began to develop aggressive thoughts and eventually experienced a visual hallucination along with an unprovoked urge to kill his boss and a customer at his workplace. At that point, the patient quit his job and presented voluntarily at our hospital. The patient stated that he had never experienced his psychotic and homicidal symptoms before he used OTC PES products.

During days 7 through 10 of his hospitalization, the patient’s psychosis continued to improve (Table 1). He occasionally went to the cafeteria and interacted with the staff and his peers. At this time, he informed the health care team of his OTC PES use, and his olanzapine dose was increased to 15 mg at night on hospitalization day 11. After two days on this regimen, the patient reported the resolution of his psychotic symptoms. He became more socially oriented, ate in the cafeteria, participated in group therapies, and interacted with his peers on the unit. During these last two days of hospitalization (days 12 and 13), the patient participated in psychoeducation regarding the health risks associated with the use of hormones and PES products, and improved his insight regarding their use.^7–11 However, he remained ambivalent about his own abstinence from these substances (the contemplation stage in the Stages of Change–Substance Abuse model).¹² In addition, extended discussion of this topic distressed him to the point of needing to take extra olanzapine. His dose was further increased to 20 mg at night.

Before his discharge, the patient’s psychosis and homicidality were fully resolved, and he no longer felt “drugged with methamphetamine.” His preoccupation with the state of his musculature also improved. Using DSM-5 criteria, his discharge diagnoses included substance (PES)-induced psychotic disorder (resolved); anabolic steroid use disorder in early sustained remission (per the patient’s verbal report); stimulant and opioid use disorders (severe) in full and sustained remission; and alcohol and marijuana use disorder (moderate) in full and early remission.

The patient’s discharge instructions were to continue taking olanzapine 20 mg orally at bedtime, and to follow up with outpatient psychiatric, chemical-dependency, and general medical providers.