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LETTER TO EDITOR |
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| Is pheniramine dependence associated with secondary psychiatric syndrome? A case report |
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Puneet Kumar Soni1, Ajay Kumar2
1 Junior Resident, Department of Psychiatry, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
2 Assistant Professor, Department of Psychiatry, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
Click here for correspondence address and email
| Date of Submission | 23-Apr-2022 |
| Date of Acceptance | 15-May-2022 |
| Date of Web Publication | 14-Jul-2022 |
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Sir,
The indiscriminate use of antihistamines is a significant public health problem.[1],[2],[3] A range of physical and psychological symptoms have been documented with these over-the-counter antihistaminic.[1],[2],[3],[4],[5] Pheniramine, the most abused antihistaminic, is known for its euphoric effect, memory disturbance, slurring, ataxia, and generalized weakness if used acutely. In contrast, chronic use shows withdrawal symptoms of irritability, lethargy, forgetfulness, and low mood.[2],[6] Its overdose can be complicated as seizure, delirium or psychosis, rhabdomyolysis, and even death.[6]
The association of psychosis with pheniramine has been documented poorly as case reports only, where pheniramine is abused with a combination of other antihistaminic or substances.[6] Here we discuss a unique case of chronic use of pheniramine in dependence pattern in the absence of different substances and developed psychosis.
A 31-year-old male, with a secondary level of education, from lower socioeconomic status and urban background, premorbid well-adjusted, has a family history of cannabis-induced psychosis in younger brother. He presented with chief complaints of using pheniramine tablets for three years; smiling, muttering to himself, irritability, and social withdrawal for the past year.
The patient began using 1–2 tablets of pheniramine (25 mg) per day, which gradually increased up to 20 pills over 18 months to get the desired effect. He reported difficulty sleeping, intense urges, and irritability on weaning off pheniramine. Family members noticed strange behavior in the patient, characterized by muttering and smiling to himself, looking self-absorb and inattentive, visits the temple multiple times a day, unlike his usual self. He gradually started neglecting his care, applying nail paints on his toe and thumbnails, remaining confined to his room, express anger on perusing for food and other routine maintenance. His mental status examination revealed increased response time, shallow effect, preservation, and derailment of thoughts with poor insight. Patient blood investigations and noncontrast computed tomography of the brain were within the normal limits. The patient was started on oral risperidone 2 mg later, and 2 mg trihexyphenidyl was added as the patient developed mild extrapyramidal symptoms on increasing risperidone to 4 mg. A satisfactory improvement was observed in patient psychopathology.
Pheniramine is relevant to psychiatry owing to its abuse potential and prevalent use by psychiatric patients.[2],[3],[4] Pheniramine is commonly abused by patients with depression and opioid dependence due to its sedative property and euphoric effect.[7],[8],[9]
Another reason why pheniramine is relevant to psychiatry is its questionable potential to develop secondary psychotic symptoms.[7] The pheniramine has been present in the market for many years and is safe in prescribed doses. There are sparse reports of psychotic symptoms during intoxication and withdrawal when used indiscriminately. The chronic use of pheniramine can cause secondary psychosis, as reported by Pal et al. (2005)[7] in two cases. One had the delusion of infidelity with chlorphenamine use, and another reported an unusual experience with heavy pheniramine use in the background of alcohol dependence.[7] In another case report, intravenous use of dexamethasone and pheniramine was found to have secondary psychosis, characterized by hypochondriasis.[10]
In the index case, the patient used 20 tablets of 25 mg per day for around 3 years in a dependence pattern, presented with smiling and muttering to self, inappropriate affect, deterioration in social functioning, and personal care. The index case used reported having only pheniramine dependence, unlike other issues that have used other substances or used pheniramine to act out on hypochondriasis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Jun I, Yoshiko Y, Mitsukuni M. Abuse of “BRON”: A Japanese OTC cough suppressant solution containing methylephedrine, codeine, caffeine and chlorpheniramine. Prog Neuropsychopharmacol Biol Psychiatry 1991;15:513-21.  |
| 2. | Buckley NA, Whyte IM, Dawson AH, Cruickshank DA. Pheniramine – A much abused drug. Med J Aust 1994;160:188-92. |
| 3. | Cooper RJ. Over-the-counter medicine abuse – A review of the literature. J Subst Use 2013;18:82-107. |
| 4. | Kocamer Sahin S. Pheniramine dependence: A case report. Dusunen Adam J Psychiatry Neurol Sci. 2020;32:281-2. |
| 5. | Feldman MD, Behar M. A case of massive diphenhydramine abuse and withdrawal from use of the drug. JAMA 1986;255:3119-20. |
| 6. | Saatcioglu O, Evren C. A case of pheniramine dependence. Subst Abus 2005;26:45-7. |
| 7. | Pal H, Kumar R, Bhushan S, Berry N. Psychiatric co-morbidity associated with pheniramine abuse and dependence. Indian J Psychiatry 2005;47:60. [Full text] |
| 8. | Rao MG, Varambally S, Venkatasubramanian G, Gangadhar BN. Hazards of antihistamine dependence in psychiatric patients: A case report. Int J Risk Saf Med 2015;27:153-7. |
| 9. | Balhara YP, Jain R, Dhawan A, Mehta M. Assessment of abuse liability of pheniramine among opioid-dependent human subjects. J Subst Use 2011;16:484-95. |
| 10. | Prakash S. A case of hypochondriasis with dexamethasone and pheniramine dependence. J Subst Use 2015;20:73-5. |
Correspondence Address:
Ajay Kumar,
Department of Psychiatry, All India Institute of Medical Sciences, Raipur - 492 099, Chhattisgarh
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/amh.amh_63_22
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