(152) Use of Vitamin Supplementation for Inhalant-Induced Psychosis

Abstract: -Background/Significance– Use of nitrous oxide (NO2) as a recreational dissociative agent commonly presents with neuropsychiatric symptoms mimicking first-break psychosis, leading to frequent misdiagnosis and lower efficacy treatment. A common means of inhalant intoxication, NO2 cannisters (“whippits”) can lead to vitamin B12 deficiency secondary to the inhalant’s effects on B12’s metabolic pathway. This deficiency can present as persistent psychotic symptoms. In this case report, we demonstrate the use of intramuscular B12 supplementation for treatment of NO2-induced psychosis.

-Methods- A 32-year-old male with past history significant for polysubstance use disorder, but no primary psychotic disorder history, presented to the emergency department, and subsequently the behavioral health unit, with several days of disorganized speech & behavior, blunted affect, thought blocking, intermittent agitation, and paranoia. The patient agreed to oral olanzapine treatment, but he continued to exhibit psychotic symptoms despite therapeutic dosage. The patient became acutely agitated and threatened violence, necessitating behavioral interventions and unlocked seclusion. Additional collateral information revealed the patient’s recent acute use of whippits, and laboratory work-up showed Vitamin B12 deficiency. Daily intramuscular injections of B12 were started for the suspected metabolic defect.

-Results– Within 24 hours of adding B12 supplementation to scheduled olanzapine, the patient exhibited clinically significant improvements in positive and negative psychosis symptoms. The patient became less disorganized, blunted, and paranoid and provided a more reliable history. After 6 days of B12 supplementation, the patient returned to his previous baseline, was no longer a threat to others, cared for his own needs, and demonstrated improved insight. He was discharged home to family on continued nightly olanzapine. The patient followed up with his primary care physician 1 week later with a continued full remission of psychiatric symptoms.

-Discussion– This case illustrates the need for a holistic approach to substance use disorder diagnosis and treatment, considering the significant role of nutritional etiologies in neuropsychiatric symptoms. Second-generation antipsychotics and behavioral interventions contributed to the patient’s initial safety while hospitalized, but he did not return to baseline until after receiving nutritional supplementation. Clinicians may be tempted to discount the efficacy of nutritional supplementation in cases that do not fit classic malnutrition pictures, but integrating metabolic correction with evidence-based antipsychotic treatment proved invaluable in this case of NO2-induced B12 deficiency.

-Conclusion/Implications– This case contributes valuable evidence to a sparsely researched topic in substance use disorder treatment, and it illustrates the critical nature of addressing nutritional derangement in inhalant-induced psychosis patients, due to the metabolic effects of those substances.

-References-

1. Sood R, Parent T. Peripheral polyneuropathy and acute psychosis from chronic nitrous oxide poisoning: A case report with literature review. Medicine (Baltimore). 2022 Aug 5;101(31):e28611. PMID: 35945749; PMCID: PMC9351869.

2. Sethi NK, Mullin P, Torgovnick J, Capasso G. Nitrous oxide "whippit" abuse presenting with cobalamin responsive psychosis. J Med Toxicol. 2006 Jun;2(2):71-4. PMID: 18072118; PMCID: PMC3550053.

3. Wong SL, Harrison R, Mattman A, Hsiung GY. Nitrous Oxide (N2O)-Induced Acute Psychosis. Can J Neurol Sci. 2014 Sep;41(5):672-4. PMID: 25373825.

Presentation Eligibility: Not previously published or presented.

Diversity, Equity, and Inclusion: Consult liaison psychiatrists should be equipped to provide excellent, holistic care to substance use disorder patients, who have been historically marginalized in the quality of care and access to care they receive. Part of holistic care includes thorough nutritional evaluation of these patients and appropriate interventions to address clinically significant deficiencies, which may, in turn, affect the course of their psychiatric symptoms. This case report demonstrates how one such nutritional intervention may be used to benefit NO2-induced psychosis patients.