Psychosis and Catatonia after Dancing with a Dangerous Partner

Mr. D, age 23, presents with new-onset psychosis with auditory and visual hallucinations and catatonia 10 days after taking 2C-B, a designer drug. How would you treat him? [CASE] Rigid, frightened, and mute Mr. D, age 23, presents for evaluation immediately after discharge from another hospital, where he had been treated for altered mental status. Ten days earlier, Mr. D's friends obtained 2C-B (2,5-dimethoxy-4-bromophenethylamine), from the "Darknet," an underground niche of the Internet. He ingested 20 mg of 2C-B in powder form. Although his friends recovered from a "safe trip," Mr. D decompensated rapidly over the next few days with persistent psychosis, experiencing both auditory and visual hallucinations. He is "acting strange" at work, and trying to find "hidden codes" in data. Mr. D also has persistent thought disorganization. He speaks of "connections" between people and things, and says that he is an alien in a spaceship. His friends and family report that he is talking rapidly and is sleeping only 2 or 3 hours each night. Mr. D abruptly quit his job as an analyst a few days after taking the drug. Mr. D is a single, Ivy League-educated man and is described as hardworking and analytical. His family denies any recent mood changes or life stressors. They report that 1 month ago, Mr. D began smoking marijuana daily. He has no significant medical or psychiatric history, and no family history of psychiatric disorders. What is your most likely diagnosis for Mr. D? a) delirium due to a general medical condition b) substance-induced psychotic disorder c) catatonia due to a general medical condition d) schizophrenia e) bipolar I disorder, currently manic, with psychosis The authors' observations Ring-substituted phenethylamines, commonly known as 2Cs, are designer drugs that are emerging as new substances of abuse. (1) 2C-B belongs to the phenethylamine subclass of monoamine alkaloids that includes more familiar drugs such as amphetamines, methamphetamines, and 3,4-methylenedioxy-methamphetamine (MDMA). (2) It was first synthesized in 1974 by Alexander Shulgin, later described in his book Phenethylamines I Have Known and Loved: A Chemical Love Story, and its hallucinogenic activity is reported to be similar to LSD, mescaline, and psilocybin. (3) The literature is scant on the acute effects of 2C intoxication or long-term sequelae of 2C ingestion. (1) Most available information regarding the pharmacology of 2C-B comes from users who have reported their drug experiences on blogs, Web sites and forums, and in the media. (4) 2C-B usually is taken orally in powder or tablet form, in a dose of 10 to 50 mg. (4) After an onset period of 20 to 90 minutes, the drug's effect reaches maximum effect in 15 to 30 minutes, then plateaus for 2 to 7 hours, and comes down within 1 to 2 hours. (4) 2C-B is known to be orally active, and its hallucinogenic effects are mediated by its actions as a partial serotonin 5HT-2A and 5HT-2C receptor agonist. (5) Entactogenic-stimulating effects have been reported at low doses (4 to 10 mg), whereas visual hallucinations with intense colors and object distortion have been reported at moderate doses (10 to 20 mg). (4) 2C-B, which users often take at parties or raves, appeared on the drug market in the mid 1980s and early 1990s under the names Nexus, Erox, Performax, Toonies, Bromo, Spectrum, and Venus and marketed as a replacement for MDMA after it became a Schedule I drug in the United States. (4,6) Some users consume 2C-B in combination with other illicit drugs, including MDMA (called a "party pack") or LSD (referred to as a "banana split"). (6) According to the U.S. Drug Enforcement Agency, law enforcement authorities first seized 2C-B laboratories in California in 1986 and Arizona in 1992. (6) Distribution of the drug has been sporadic since it became Schedule I in 1995, and it has been seized from several states, including Virginia, Nevada, Maine, Illinois, Missouri, South Dakota, and Kansas. …